Stab Mouth

[dwgkennedy at aol.com]

Sorry for the delay in replying, I’m a single finger typist.

Maxillofacial trauma is an area not covered by many surgical training programmes. Unfortunately the injuries are relatively common. For example 30% of injuries of conflict are to the face and head. This is similar in civilian practice where handguns are prevalent. Another good example of the need for facial trauma experience is that the surgical component at the Multinational Medical Unit in Kandahar consists of 2 general surgeons, 2 orthopaedic surgeons and a Maxfac surgeon, (with a neurosurgeon recently added.) Serious facial trauma isn’t that rare in civilian practice. In the UK, blunt interpersonal violence and road trauma predominate.

Normally this lack of exposure is not too much of a problem where the specialists are immediately available – I didn’t appreciate Sa’ad’s geographical isolation and clearly this makes managing the case described very difficult. I fully empathise with his predicament and am sure the last thing he needed was to have to persuade someone to come and help.

Stab wounds in the mouth, however, are not especially common but I think that some basic principles would still apply. With the active bleeding described, I would want the airway secured as quickly as possible. I would convert this to a tracheostomy when practical. I would tackle the active bleeding surgically. Pressure and packing would be used as required. The first choice would be by extending the wounds and approaching vessels directly and secondly by opening the neck. This would apply to most wounds in other parts of the body. I would almost certainly be using temporary splintage to hold all of the fractures together prior to definitive fixation.  As elsewhere, relocating the bones will reduce bleeding .This is when wiring loose fragments of bone comes into its own. There are descriptions of these wiring techniques in most maxfac trauma books; however, it is a practical skill that needs to be learned. Bleeding from the midface often comes out through the nose and there are a variety of tamponade techniques to use for that bleeding. When using nasal tamponade techniques it is important not to distract the fractured maxillae and mouth props will stop that.

I am not aware of anyone using haemostatic agents in this type of situation and would not see a role unless there was absolutely zero surgical management available. I am aware of the use of these agents in conflict wounds at present – indeed I have seen them used and washed them out of some wounds in theatre myself. I think the case for these agents prehospital is easily made – in hospital these wounds should be opened up surgically. The alvogyl material mentioned is just a dry socket dressing and not for wounds – it contains lignocaine, eugenol and iodoform. (By the way, it is extremely good for post extraction dry socket.)

Of course, all wounds and circumstances differ and generalisations of management are only that.

Now, I mentioned my top tips. There is really only one – it has to be getting some exposure to this type of trauma. Especially if practising in an isolated environment. For Sa’ad in particular, South Africa has some of the busiest Maxfac units in the world and I quite sure that they would welcome a visitor for a couple of weeks. I am sure that you would see the management of bleeding and quickly learn useful temporary fixation techniques. There are a few courses available that teach this type of thing – for example the British Army run a maxfac workshop that lasts one day. Regrettably I can’t name a civilian workshop – maybe that should be a project for me!

My advice would be to approach your nearest unit – otherwise you’ll be getting your experience the hard way as before.

Regards to all,

Doug 

 

 

 



-----Original Message-----
From: Matthew Reeds <mgreeds at reeds.uk.com>
To: 'Trauma &amp; Critical Care mailing list' <trauma-list at trauma.org>
Sent: Wed, 7 May 2008 19:46
Subject: Stab Mouth



Doug,
 
I know of a number of situations where the use of haemostatic agents has
roved lifesaving and I also know that the military use them regularly to
ave both life and limb. Whilst I fully agree that their use would certainly
ot be the preferred option, if all other options have failed, you should
ot waste time repeatedly trying methods that have already failed but
nstead move one quickly and try a different method which may work. I
ecognise your comment about antiseptic dressing use for dry sockets - but
hat is a completely different subject. The HemCon dressings have worked for
e in the past with good effect - in fact our local Max-Fax unit confirmed
hat they were a good idea! Given what you have said though, I shall
ertainly await your practical tips with keen interest.
 
 
Matthew 
 
 
-----Original Message-----
rom: DWGKENNEDY at aol.com [mailto:DWGKENNEDY at aol.com] 
ent: 05 May 2008 19:18
o: trauma-list at trauma.org
ubject: Re: stab mouth
 
Stop this now!
 
Alvogyl is an antiseptic dressing used for post extraction 'dry sockets' -  
NOTHING ELSE.
 
I'll write some practical tips later when people stop stuffing things in  
this wound!
 
Doug
 
 
 
   
 
 
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