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Critical Conditions (Perioperative and Emergency Care) 103
https://t.me/med1917
●
Elective management? (based on CT/MRI ndings) –
angiography, ow scanning to get idea of cerebral blood ow/
circle of Willis, then trial balloon occlusion:
●
Pass (low risk), permanently occlude and heparinise,
resection 2 weeks later
●
Fail (moderate risk), bypass and carotid reconstruction
(7% mortality, 5% stroke)
NECROTISING FASCIITIS (NF)
NF is a rare but potentially fatal infection involving the subcutaneous tissue and fascia. Four dierent causes of infection are
described.
1. Polymicrobial (more common in abdomen/perineum)
2. Group A Streptococcus/Staphylococcus aureus (H&N, limbs)
3. Vibrio vulnicus from sea water
4. Fungal organisms
NEUROLOGICAL OBSERVATIONS
For patients presenting with head injury, regular assessment
of the GCS, power, reexes, sensation and cranial nerves may
be warranted. is is guided by neurosurgical discussion and
advice.
●
If imaging anomaly is present, GCS less than 15 aer imaging, CT cannot be done, symptoms
●
Normal pupillary diameter should be 2.6–3.6mm with
torchlight
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Half-hourly until GCS 15, then
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Half-hourly for 2hours
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Hourly for 4hours
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Every 2hours thereaer
●
Consists of normal observation plus GCS, pupils and limb
movements
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NATIONAL INSTITUTE FOR HEALTH AND
CARE EXCELLENCE (NICE) HEAD CT CRITERIA
FOR ADULTS
e following guidelines are applied to individuals who sustain a
head injury and meet any of the criteria listed. For those who meet
these criter ia, a head CT is indicated within eithe r 1hour or 8hours.
1-hour scan:
●
GCS < 13 on admission, <15 2hours aer injury
●
Suspected fracture
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Seizure
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Amnesia (>30 min prior to head injury)
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Vomit (two times or more)
8-hour scan:
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Loss of consciousness (LOC) or amnesia + (65+ years/coagulopathy/mechanism – fall 1m/5 stairs)
●
If patient on warfarin/anticoagulants
NICE HEAD CT CRITERIA FOR CHILDREN
e following guidelines are applied to individuals who sustain a
head injury and meet any of the criteria listed. For those who meet
the criteria, a head CT is indicated within either 1hour or 8hours.
1-hour scan:
●
GCS < 14 on arrival/<15 if under 1year old/<15 2hours post
head injury
●
NAI suspected
●
Suspected fracture
●
Seizure
●
5cm so tissue injury and under 1year old
1-hour scan if two of the following; if one, patient
ismonitored for 4hours (and if GCS < 15/further
vomiting/drowsy, a scan within an hour):
●
LOC > 5 min
●
Drowsy
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Critical Conditions (Perioperative and Emergency Care) 105
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●
Vomits three or more times
●
Mechanism (high-speed RTA/fall 3m)
●
Amnesia ≥5 min duration before or aer
8-hour scan:
●
Children on warfarin should have 8-hour scan like adults
REFEEDING SYNDROME RISK FACTORS
AND MANAGEMENT
Increased nutrition following a prolonged period of starvation can result in refeeding syndrome. Refeeding syndrome
is dened as medical complications that result from uid
and electrolyte shis as a result of aggressive nutritional
supplementation.
Any one of (or less severe but combination of):
●
Inadequate (<60% expenditure) intake for 10 days (same as
criteria for NG feeding)
●
Low phosphate/K/Mg
●
15% weight loss in 3–6 months
●
BMI < 16
NICE guidelines suggest:
●
Start at 10 kcal/kg/day then increase to 30 (normal, plus 1.2 g/
kg/day protein) by 4–7 days
●
Supplement potassium, phosphate, magnesium, thiamine and
multi-B vitamins
●
Daily bloods rst week, 3× per week thereaer
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106 Classifications and Lists in Oral and Maxillofacial Surgery
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SEPSIS SIX
Individuals presenting with sepsis, dened as a systemic inammatory response syndrome plus an infective source, should have
the following interventions conducted immediately (can be
abbreviated as LABOUR).
●
Lactate
●
Antibiotics
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Blood cultures
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Oxygen
●
Urine output
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Resuscitation with uids
SYSTEMIC INFLAMMATORY RESPONSE
SYNDROME (SIRS)
SIRS is an exaggerated defence response of the body to a noxious
stressor. It is diagnosed with the presence of in or more of the following criteria.
●
WCC < 4 or >12 × 109/litre
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Temperature (<36 or >38 degrees Celsius)
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Pulse (>90 bpm)
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RR (>20 or PaCO2 < 4.3)
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Severe sepsis is dened as SIRS plus organ dysfunction
STAGES OF HAEMORRHAGIC SHOCK
Shock is a life-threatening manifestation of circulatory failure. With
the Advanced Trauma Life Support (ATLS) algorithm, the degree of
blood loss may be predicted on the basis of physiological parameters.
1. <15% blood loss (approx. 750 mL) – slightly anxious, pulse
pressure normal or increased
2. 15–30% (up to 1500 mL) – pulse 100–120 bpm, pulse pressure
reduced, RR 20–30 per min, mildly anxious
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Critical Conditions (Perioperative and Emergency Care) 107
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3. 30–40% (up to 2 L) – pulse 120–140 bpm, RR 30–40 per min,
BP NOW REDUCED, patient confused
4. >40% (>2 L) – pulse > 140 bpm, RR > 40 per min, BP LOW,
lethargic
1 and 2 need crystalloid; 3 and 4 need blood and crystalloid.
FURTHER READING
Ferzli G, Sukato DC, Mourad M, Kadakia S, Gordin EA, Ducic Y.
Aggressive necrotizing fasciitis of the head and neck resulting
in massive defects. Ear Nose Throat J. 2019;98(4):197–200.
Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the
head, neck and adjacent regions. Am J Anat. 1938;63:367–408.
Hotchkiss RS, Moldawer LL, Opal SM, Reinhart K, Turnbull IR,
Vincent JL. Sepsis and septic shock. Nat Rev Dis Primers.
2016;2:16045. doi: 10.1038/nrdp.2016.45.
Mehanna HM, Moledina J, Travis J. Refeeding syndrome:
What it is, and how to prevent and treat it. BMJ.
2008;336(7659):1495–8.
NICE. Overview | Head injury: Assessment and early manage-
ment | Guidance. NICE [online]. 2023. www.nice.org.uk/
guidance/ng232.
SDCEP. Anticoagulants and Antiplatelets. [online]. www.sdcep.
org.uk/published-guidance/anticoagulants-and-antiplatelets/.
Suárez C, Fernández-Alvarez V, Hamoir M, etal. Carotid blowout
syndrome: Modern trends in management. Cancer Manag
Res. 2018;10:5617–28.
Tins BJ. Imaging investigations in Spine Trauma: The value of
commonly used imaging modalities and emerging imaging
modalities. J Clin Orthop Trauma. 2017;8(2):107–15.
t.me/Dr_Mouayyad_AlbtousH
13
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Miscellaneous
RESEARCH
Phases of Clinical Research
Clinical research involves the trial and testing of new treatments;
this can be divided into phases. Earlier phases look at whether
drugs are safe to be used, whilst later phases look specically at
comparisons with existing treatments. e phases of clinical trials are depicted in the following.
●
Preclinical – animal models and trials, etc.
●
Phase 0 – pharmacokinetics on a few people
●
Phase 1 – dosing (tens of people)
●
Phase 2 – ecacy and side eects (hundreds of people with
disease)
●
Phase 3 – therapeutic eect (thousands of people with disease)
●
Phase 4 – post-marketing surveillance
DOI: 10.1201/9781003156895-13 109
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110 Classifications and Lists in Oral and Maxillofacial Surgery
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Oxford Centre for Evidence-Based Medicine
(CEBM) Levels of Evidence (2011)
Within clinical research, hierarchies of evidence exist. It is a key
concept in evidence-based medicine. e levels of evidence are
depicted in the following.
1a. Systematic review of randomised controlled trials (RCTs)
1b. RCTs
1c. All or none studies (intervention gives radical change in
outcome)
2a. Systematic review of cohort
2b. Cohort
2c. Outcomes/ecological
3a. Systematic review of case/control
3b. Case control
4. Case series
5. Opinion/anecdotal/benchtop
ANATOMY
e next section of this chapter will focus on various aspects of
head and neck and craniofacial anatomy, with memory aids
and useful mnemonics to help with retention.
Branchial Arches
1. Mandibular (trigeminal nerve branches V2 and V3 only),
terminal branch maxillary artery – bones: from MECKEL’S
cartilage or incus& malleus, zygoma/maxilla/mandible/squamous temporal and upper auricle; muscles: masticators plus
anterior belly digastric, tensors, mylohyoid
2. Hyoid (facial nerve), stapedius artery – bones: from
REICHERT’S cartilage or stapes, lesser horns hyoid, lower
auricle; muscles: facial expression, posterior belly digastric,
mylohyoid and stapedius
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3. (Glossopharyngeal nerve) common carotid – bone: greater
horn hyoid; muscle: stylopharyngeus
4. (Vagus) arch aorta on le, right subclavian on right (superior
laryngeal nerve) – bone: larynx; muscle: cricothyroid, levatorveli palatine, pharyngeal constrictors
5. (Vagus) ductus arteriosus and pulmonary artery (recurrentlaryngeal nerve – right under subclavian, le under
arch)– bones: larynx; muscles: all other intrinsic muscles
oflarynx
Cartilage Derivatives of First Pharyngeal Arch
(‘I’m a Super Strong Guy or Girl’)
●
Incus
●
Malleus
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Anterior ligaments of malleus
●
Spine of sphenoid
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Sphenomandibular ligament
●
Genial tubercule of mandible
Cavernous Sinus Contents (‘O TOM CAT’)
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Lateral wall contents superior to inferior (O TOM)
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Oculomotor nerve
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Trochlear nerve
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Ophthalmic nerve (V1)
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Maxillary nerve (V2)
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Medial components (CAT)
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Carotid artery
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Abducens (or abducent) nerve
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Trochlear nerve (carotid artery ends at this level)
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External Carotid Branches (‘Some
AnatomistsLike Freaking Out Poor
Medical Students’)
●
Superior thyroid artery
●
Ascending pharyngeal artery
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Lingual artery
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Facial artery
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Occipital artery
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Posterior auricular artery
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Maxillary artery
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Supercial temporal artery
Infratemporal Fossa Boundaries and Contents
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Anteriorly – maxilla
●
Posteriorly – styloid/tympanic plate
●
Superomedially – greater wing of sphenoid
●
Superolaterally – temporalis fascia
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Medially – lateral pterygoid plate/pharynx
●
Laterally – ramus of mandible
●
Contents – FIRST and SECOND parts of maxillary artery,
pterygoid plexus, mandibular division of trigeminal, chorda
tympani, otic ganglion
Maxillary Artery First and Second Parts
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First part – mandibular (condyle to sphenomandibular ligament, along lower edge of lateral pterygoid)
●
Deep auricular
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Anterior tympanic
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Middle meningeal and accessory middle meningeal
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Inferior alveolar artery
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Second part – pterygoid
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Deep temporals
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Pterygoid
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Masseteric
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Buccal
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Maxillary Artery Third Part
●
ird part – pterygopalatine
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Posterior superior alveolar
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Infraorbital
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Greater palatine
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Sphenopalatine
●
Pharyngeal
●
Pterygoid canal
Pterygopalatine Fossa Boundaries
●
Anterior – maxilla
●
Posterior – pterygoid plates
●
Superior – orbit
●
Inferior – oral cavity
●
Medial – nasal cavity
●
Lateral – infratemporal fossa
Three ways into the pterygopalatine fossa:
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Pterygomaxillary ssure (maxillary artery)
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Pterygoid canal (greater petrosal nerve bres in vidian nerve/
sphenopalatine ganglion)
●
Foramen rotundum (maxillary division of trigeminal nerve)
Three ways out of the pterygopalatine fossa:
●
Sphenopalatine foramen (sphenopalatine artery, nasopalatine
nerve, bres to nasal mucosa)
●
Greater palatine foramen (descending palatine artery, greater
and lesser palatine nerves, bres to palate mucosa)
●
Inferior orbital ssure (maxillary division of trigeminal,
infraorbital artery, bres to lacrimal)
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