International journal of oral and maxillofacial surgery
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Int J Oral Maxillofac Surg · May 2008
ReviewAdvanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient.
Hypovolaemic shock is a common cause of morbidity and mortality following trauma, accounting for approximately 30% to 40% of trauma deaths. Life-threatening blood loss from the maxillofacial region is uncommon, but represents one of a number of possible sites which must be rapidly identified and controlled. Bleeding from the face may not be obvious especially in awake, supine patients and it poses an obvious threat to the unprotected airway. ⋯ The concepts of the 'lethal triad' and 'biologic first hit' have resulted in new strategies in managing the profoundly shocked patient, although some of these remain controversial. Debate continues over the optimal blood pressure, fluid administration and role of surgical intervention in the actively bleeding patient. These may have an impact on the timing and extent of any proposed maxillofacial repairs, and are discussed.
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A new technique of surgical tracheostomy is described. Prior to performing the tracheostomy, the endotracheal tube (ETT) is advanced further down the trachea so that the end of the tube is positioned just above the carina. Using the flexible endoscope within the ETT the positioning can be done with precision. ⋯ Following the creation of an opening in the trachea, the patient continues to have a definitive airway. In this controlled environment, time is taken to obtain haemostasis at the tracheostomy site, place a rescue stitch and also suction above the cuff of the ETT. A study was carried out in a series of 15 patients by recording various measurements during the procedure to confirm the accuracy of this technique.