DOI: 10.5272/jimab.2013192.

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ISSN: 1312-773X (Online)

Journal of IMAB - Annual Proceeding (Scientific Papers) 2013, vol. 19, book 2

MAXILLOFACIAL TRAUMA MANAGEMENT IN

POLYTRAUMATIZED PATIENTS - THE USE OF
ADVANCED TRAUMA LIFE SUPPORT (ATLS)
PRINCIPLES
Elitsa G. Deliverska, Lachesar P. Stefanov.
Department of Oral and Maxillofacial surgery , Faculty of Dental Madicine,
Medical University, Sofia, Bulgaria.

ABSTACT:
Management of the multiply injured patient requires
a co-ordinated multi-disciplinary approach in order to
optimise patients outcome. A working knowledge of the sort
of problems these patients encounter is therefore vital to
ensure that life-threatening injuries are recognised and
treated in a timely pattern and that more minor associated
injuries are not omitted. This article outlines the
management of polytraumatized patients using the Advanced
Trauma Life Support (ATLS) principles and highlights the
areas of specific involvement of the engaged medical team.
Advanced Trauma Life Support is generally regarded as the
gold standard and is founded on a number of well known
principles, but strict adherence to protocols may have its
drawbacks when facial trauma co-exists. These can arise in
the presence of either major or minor facial injuries, and oral
and maxillofacial surgeons need to be aware of the potential
problems.
Key words: ATLS; fractures; maxillofacial; trauma
Maxillofacial trauma is without doubt a most
challenging area within the specialty of oral and
maxillofacial surgery. Despite the many advances in our
understanding of tissue healing, biomaterials and surgical
techniques, the initial assessment and the timing and
undertaking of management of facial injuries in the early
stages have remained a difficult area of patients care.
Appropriate and timely management of facial injuries
becomes even more challenging following high velocity
trauma, when significant injuries elsewhere may, or may not,
take priority.(5)
This reinforces the concept of the mechanism of
injury, which supports screening for the following injuries.
1. High-velocity impacts (e.g. motor vehicle collision
at a pedestrian, ejection from vehicle, airbag deployment,
fatalities or severe injuries to other vehicle occupants).
2. Falls from a height (typically greater than the
height of the individual or >6 feet).

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3. In patients with pelvic fractures or lower limb

long-bone fractures. (6)
Familiarity with an algorithm for the assessment and
initial treatment of traumatized patients provides the treating
physician with the confidence to competently manage
polytrauma, and ensures optimal outcome for the patient.
Advanced trauma life support (ATLS) is a system of
simultaneous assessment and treatment of multiple trauma
patients.1 It is based on identification and safe initial
management of all injuries.
In particular, it prioritizes diagnosis and effective
management of life-threatening injuries. Having originally
been conceived in Nebraska in the 1970s, its principles are
now taught in courses all over the world and form the
cornerstone of management of the patient with multiple
trauma. Since its inception in 1978, the Advanced Trauma
Life Support (ATLS) (1, 2, 3) system of care has generally
become accepted as the gold standard in the initial
management of the multiply injured patient and is now
taught in over 40 countries worldwide. This approach is
based on the three well established principles of:
1. ABCDEs of assessment (Airway maintenance with
cervical spine protection, Breathing with ventilation,
Circulation with haemorrhage control, Disability;
neurological status, and Exposure/ Environment);
2. "primum non nocere" (first, do no harm); and
3. treatment of life-threatening injuries within the
golden hour. The aim of the following information is to
outline the acute assessment and treatment of polytraumatized patients, with an added emphasis on the
management of MF injuries(6).
Initial evaluation and treatment
In the setting of a major trauma unit, the management
of seriously injured patients involves the coordinated
approach of a multidisciplinary team with simultaneous
assessment and treatment of a variety of life-threatening
conditions.
The care of the patient after hospital admission is

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divided into the following phases(7):

1. Primary survey.
2. Adjuncts to primary survey and resuscitation.
3. Secondary survey (head-to-toe evaluation and
history).
4. Adjuncts to the secondary survey.
5. Continued post-resuscitation monitoring and reevaluation.
6. Definitive care.
A history of the accident and the circumstances may
provide important clues to the likely pattern of injury, but
in many multiple trauma patients a standard medical history
cannot be obtained, due to the severity of the injuries and a
reduced level of consciousness. However, it is usually
possible to obtain some important items of information from
relatives or paramedics if the patient is unable to provide
information. The following key points of information should
be obtained if possible (the ATLS mnemonic is AMPLE).
Allergies.
Medications.
Past illnesses/pregnancy.
Last meal.
Events/environment of injury.
The ATLS system divides the initial assessment into
a primary and secondary survey. The primary survey aims
to identify immediate life-threatening injuries. The
secondary survey aims to identify all other injuries that will
require treatment but are not immediately life-threatening.
The mnemonic for the primary survey is given by the letters
ABCDE.
Airway maintenance with cervical spine protection.
Breathing and ventilation.
Circulation with haemorrhage control.
Disability: neurological status.
Exposure/environmental control undress the
patient but prevent hypothermia.
Airway with cervical spine immobilization
If a patient is not able to maintain their own airway,
for whatever reason, irreversible cerebral damage can occur
in as little as 4 minutes. It is therefore essential that a safe
and secure airway is established as the first step. In
maxillofacial trauma or other conditions associated with
immediate difficulty in gaining an airway, an emergency
cricothyroidotomy can be carried out as a temporary
measure. In 1015% of poly-traumatized patients there will
have been an associated spinal injury, of which 55% occur
in the cervical spine.(7) A proportion will be unstable and
injudicious manipulation of the spine, as may be done to
secure an airway, runs the risk of spinal cord injury.
Therefore an equal priority must be given to the in-line
traction applied by hand on either side of the head to
maintain stabilization of the cervical spine while trying to
secure an airway.
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If there is no evidence of airway compromise, or once

an airway breathing is spontaneous, the usual procedure
moves attention to next issue. The lungs are vital for
maintaining oxygenation of the body tissues as well as
removing waste carbon dioxide and helping to maintain acidbase balance. There are six causes of life-threatening
respiratory compromise: upper airway obstruction, tension
pneumothorax, open pneumothorax, flail chest, massive
haemothorax and cardiac tamponade.(7)
Initial treatment consists of removing the mechanical
problem (insertion of an intercostal drain for haemo/
pneumothorax; application of an occlusive dressing for
sucking chest wound), providing high-flow oxygen and
providing mechanical ventilator support if necessary. In
patients with a suspected spinal injury, it is always important
to remember the possibility of spinal shock. This occurs in
patients who have a cord injury above the level of the
thoracic sympathetic outflow. The haemodynamic result is
hypotension and bradycardia. It is the bradycardia that tends
to differentiate spinal shock from hypovolaemic shock,
although patients on -blockers or with cardiac arrhythmias
may also have bradycardia. Treatment of spinal shock
involves the judicious use of intravenous fluids combined
with vasopressors to increase the resting vascular tone.
ATLS teaches that trauma occurring above the
clavicle should raise a high index of suspicion for a potential
cervical spine injury and strict application of this principle
means all patients with maxillofacial or craniofacial trauma
must be included in this group.(6)
Accordingly, maxillofacial trauma patients must be
initially managed with a :
- cervical spine collar until clinical and radiological
clearance is confirmed,
- comprehensive neurological examination including
cranial nerves
- specific assessment for cerebrospinal fluid
rhinorrhea.(4)
Circulation
Maintaining adequate tissue perfusion and hence
oxygenation requires an adequate circulating blood volume,
adequate vascular tone and a normally functioning heart. In
the vast majority of trauma victims, the main reason for
circulatory compromise is acute blood loss leading to
haemorrhagic shock. However, some other causes of shock
do occur and should also be considered. These include:
cardiogenic shock
tension pneumothorax
neurogenic shock
septic shock.
Haemorrhagic shock: while some bleeding may be
obvious, frequently the exact source may not be readily
apparent. The common sites for major occult loss are:
the chest, in cases of haemothorax

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 the abdomen, from ruptured viscera

the pelvis, from an unstable pelvic fracture
from multiple closed long bone fractures.
The key early signs of haemorrhagic shock are
tachycardia and cutaneous vasoconstriction. In healthy
young adults, hypotension occurs later and signifies a blood
loss in excess of 15002000 ml. The initial fluid bolus is
12 litres for an adult and 20 ml/kg for a child. This is
followed by blood transfusion. Fully cross-matched blood
tests is preferable, but in an urgent situation type-specific
(ABO and Rh matched blood) can be used. In lifethreatening hypotension, O negative packed cells can be
used. The return of blood pressure and pulse to normal are
encouraging signs. Restoration of urinary output to 0.5 ml/
kg/hr suggests that adequate renal perfusion has been
restored.(7)
Disability (neurological status)
The possibility of brain injury is assessed next. A
decrease in a patients level of consciousness may be due
to a primary brain injury. This is assessed very quickly by
examining the pupil size and reactivity and by assessing
whether the patient is alert, responds to verbal stimuli,
responds only to pain or is unresponsive. Unequal pupillary
responses may be indicative of local trauma to the eye
(traumatic mydriasis) or, more worryingly, an expanding
intracranial haematoma. The Glasgow Coma Scale(GCS) is
a useful clinical method of monitoring the status of patients
following head injury. This gives a score out of 15 based
on the patients best motor, verbal and eye responses. A
score of 15 would indicate a fully alert, cooperative and
comprehensible patient, and a score of 8 or less usually
indicates the presence of serious cranial trauma.
A decreased level of consciousness, particularly in the
absence of any signs of external head injury, may represent
inadequate cerebral oxygenation and perfusion, prompting
a swift re-assessment of A, B and C. (5)
Exposure/environment
To facilitate a thorough whole body examination, all
clothing should be removed from a patient. Frequently this
requires clothing to be cut off. This allows an adequate
assessment of the spinal column, the posterior aspects of the
limbs and the perineum.
Once the appropriate examinations have been
performed, it is important that the patient is covered with
blankets to prevent hypothermia. Additional preventative
measures include the warming of intravenous fluids and the
maintenance of a warm environment in the resuscitation
room.(7) It is vitally important that progress through the

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assessment and resuscitation sequence does not occur until

problems of higher priority are appropriately dealt with.
There is no point in trying to put on a pelvic external fixator
if the patient cannot maintain his own airway. Equally, the
condition of a traumatized patient is constantly changing and
frequent reassessment is required to ensure there has been
no deterioration.
Maxillofacial surgeons should be an integral part of
the trauma team for those patients where facial injuries are
evident. This involvement is particularly relevant during the
management of:
1. the airway,
2. hypovolaemia including facial bleeding
3. craniofacial injuries
4. in the assessment of the eyes.(5)
If the patients blood alcohol levels are high, they are
unlikely to fall in the next 1224 h and the following
hangover will almost certainly be associated with vomiting.
If the patients consciousness level is of concern, intubation
is necessary; also, in these circumstances a CT scan of the
brain is indicated.(8)
SUMMARY
The management of polytraumatized patients
remains a significant challenge, requiring a multidisciplinary
approach.
Initial assessment and treatment should follow a
structured approach (ATLS), which prioritizes lifethreatening injuries.
Due to the high frequency of maxillofacial trauma,
the maxillofacial surgeon is an integral part of the trauma
team. During and immediately after the golden hour,
maxillofacial surgeons may need to provide an advisory
service or to intervene in some way.
Definitive repair procedures will depend on a
number of factors related to the patients general status,
overall prognosis and other planned procedures
Specific injury patterns are now well known to be
associated with high- velocity mechanisms of injury
Maxillofacial surgeons managing multiply injured
patients should always maintain a high degree of suspicion
for associated injuries, the negligence of which can have a
drastic effect on outcome.
From a maxillofacial perspective, although it is the
gold standard in trauma care, ATLS does have its limitations,
and strict adherence to its principles in patients with facial
injuries brings its own set of problems. With a greater
understanding of trauma mechanisms, a multidisciplinary
approach and advances in technology, many of our concerns
can now be anticipated and addressed in a timely manner.

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REFERENCES:
1. American College of Surgeons
Committee on Trauma (2004)
Advanced trauma life support program
for doctors, 7th edn. American College
of Surgeons, Chicago.
2. American College of Surgeons
Committee on Trauma Advanced
trauma life support program for
doctors, 6th edn. American College of
Surgeons, Chicago.
3. Carmont MR. The Advanced
Trauma Life Support part1 course: a
history of its development and review
of related literature. Postgrad Med J.
2005 Feb;81(952):8791. [PubMed]
[CrossRef]

4. Grover RS, Antonyshyn OM.

(iv) Care of maxillofacial injuries in
multiple trauma. Orthopaedics and
Trauma. 2003 Aug;17(4)274-286
5. Perry M. Advanced Trauma Life
Support (ATLS) and facial trauma: can
one size fit all? Part 1: dilemmas in the
management of the multiply injured
patient with coexisting facial injuries.
Int J Oral Maxillofac Surg. 2008 Mar;
37(3):209-14. [PubMed] [CrossRef]
6. Perry M, Morris C. Advanced
trauma life support (ATLS) and facial
trauma: can one size fit all? Part 2:
ATLS, maxillofacial injuries and
airway management dilemmas. Int J

Oral Maxillofac Surg. 2008 Apr; 37(4):

309-20. [PubMed] [CrossRef]
7. Simpson P, Keating JF. The
multiply injured patients, Acute trauma,
The foundation years 4:8, Published by
Elsevier Ltd. 2008; p.314-318
8. Head Injury: triage, assessment,
investigation and early management of
head injury in infants, children and
adults. National Collaborating Centre
for
Acute
Care.
Guideline
commissioned by the National Institute
for Clinical Excellence; June 2003;
http://www.nice.org.uk/nicemedia/pdf/
headinjury_full_version_completed.pdf

Address for correspondence:

Elitsa Georgieva Deliverska,
Department of Oral and Maxillofacial Surgery,
Faculty of Dental Medicine, Medical University - Sofia.
1, St. Georgi Sofiiski boul., 1431 Sofia, Bulgaria
E-mail: [email protected];
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