EMS Trauma Emergencies - Le Fort Fractures

EMS Providers should be familiar with Le Fort fractures as they are severe injuries to the facial bones that require immediate attention.

There are three main types of Le Fort fractures, each affecting different parts of the face. Here's what EMS providers should know about them:

Le Fort I Fracture (Horizontal Maxillary Fracture):

This fracture involves a horizontal separation of the maxilla (upper jaw) from the rest of the face.

Mechanism of injury often involves a blow to the front of the face, such as a dashboard impact in a motor vehicle accident.

Signs and symptoms may include:

- Pain and tenderness in the upper jaw region.

- Mobility or instability of the teeth.

- Numbness or tingling in the upper lip or gums.

Complications can include airway compromise due to displacement of the maxilla.

Le Fort II Fracture (Pyramidal Fracture):

This fracture involves separation of the central portion of the face from the skull, including the nasal bones, ethmoid bone, and maxilla.

Mechanism of injury often involves a high-energy impact to the middle third of the face, such as a direct blow to the nose or cheekbones.

Signs and symptoms may include:

- Swelling and deformity of the mid-face.

- Crepitus (grinding sensation) upon palpation.

- Periorbital ecchymosis (bruising around the eyes).

- CSF (cerebrospinal fluid) rhinorrhea or otorrhea, if there is associated skull base fracture.

Complications can include orbital and ocular injuries, as well as CSF leakage which may lead to increased risk of meningitis.

Le Fort III Fracture (Transverse Fracture):

This fracture involves separation of the entire facial skeleton from the skull, including the zygomatic arches, orbits, and nasal bones.

Mechanism of injury often involves a severe, high-velocity impact to the face, such as a fall from height or a significant blunt force trauma.

Signs and symptoms may include:

- Gross facial deformity with flattening of the mid-face.

- Bilateral periorbital ecchymosis (raccoon eyes).

- Subconjunctival hemorrhage.

- Epistaxis (nosebleed).

Complications can include severe facial disfigurement, orbital compartment syndrome, and optic nerve injuries leading to visual impairment or blindness.

The concept of Le Fort fractures was developed by a French surgeon named René Le Fort. René Le Fort conducted extensive anatomical studies on the human skull in the early 20th century. 

In 1901, he published his findings on patterns of fractures involving the mid-face region, which came to be known as Le Fort fractures. His work laid the foundation for understanding and classifying these severe injuries to the facial bones.

For EMS providers, prompt recognition and stabilization of patients with Le Fort fractures are crucial. Management typically involves securing the airway, controlling bleeding, and providing pain management while transporting the patient to an appropriate medical facility for further evaluation and treatment by a maxillofacial surgeon or a trauma specialist. 

Additionally, EMS providers should be vigilant for associated injuries, particularly to the cervical spine and head, given the mechanism of injury typically associated with these fractures.

Further Reading:

Alexander, M. & Belle, R (2012) Advanced EMT: A Clinical Reasoning Approach (2nd Ed). New Jersey: Pearson. 

Bledsoe, B. E., Cherry, R. A. & Porter, R. S. (2023) Paramedic Care: Principles and Practice Volume 1 (6th Ed). New Jersey: Pearson. 

Brown, C. A., III., & Walls, R. M. (2023) The Walls Manual of Emergency Airway Management (6th Ed). Pennsylvania: Lippincott Williams & Wilkins. 

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care (11th Ed). New Jersey. Pearson Education. 

EMS Trauma Assessment - Index of Suspicion & Mechanism of Injury

 

EMS Providers play a crucial role in assessing and managing trauma emergencies. Two important concepts they need to understand are the Index of Suspicion and Mechanism of Injury. These concepts help EMTs make quick and informed decisions about the care of trauma patients.

Index of Suspicion (IOS):

The IOS is an essential element in the assessment of trauma patients. It refers to the level of concern or suspicion an EMS Providers should have regarding potential injuries or conditions.

EMS Providers must maintain a high index of suspicion, especially in trauma situations, because injuries are not always immediately evident. This means considering the possibility of severe injuries even when there are no obvious signs or symptoms.

A high index of suspicion should be maintained for patients involved in high-impact mechanisms of injury, such as car accidents, falls from heights, or severe blows.

EMS Providers should consider the mechanism of injury, the patient's presentation, and the nature of the incident to determine the likelihood of hidden injuries. A high index of suspicion prompts a thorough assessment and treatment.

Mechanism of Injury (MOI):

The MOI is an important aspect of the assessment process for trauma patients. It involves understanding how the injury occurred, the forces involved, and the potential for damage to specific body parts or systems.

EMTs should gather information about the MOI from the scene, bystanders, and the patient whenever possible. Common mechanisms of injury include:

Motor Vehicle Accidents: Speed, type of collision, airbag deployment, seat belt use, intrusion into the vehicle, etc.

Falls: Height of fall, landing surface, position of the body during the fall, and age of the patient.

Assaults: The type of weapon or force used, number of assailants, and locations of injuries.

Penetrating injuries: The object causing the injury, its size, and depth of penetration.

Understanding the MOI helps EMS Providers predict potential injuries. For example, if a patient was involved in a high-speed car crash with significant vehicle damage, the EMT should be highly suspicious of head, neck, and chest injuries even if the patient is alert and without immediate complaints.

Combining the MOI with the patient's presentation and a high index of suspicion guides EMTs in making critical decisions regarding patient care, such as spinal immobilization, oxygen therapy, and the need for rapid transport to a trauma center.

EMS Providers need to maintain a high index of suspicion, especially in trauma cases, and carefully assess the mechanism of injury. These concepts, when used together, allow EMTs to provide timely and appropriate care to trauma patients, even when injuries may not be readily apparent.

Bibliography

Alexander, M. & Belle, R. (2017) Advanced EMT: A Clinical Reasoning Approach. 2nd Ed. Hoboken, New Jersey: Pearson Education

Limmer Education (2021) What Does Mechanism Of Injury Tell Us? https://limmereducation.com/article/trauma-assessment-mechanism-of-injury/ Accessed on October 15, 2023

Mistovich, J. J. & Karren, K. J. (2014) Prehospital Emergency Care. 11th Ed. Hoboken, New Jersey: Pearson Education  

#EMS #IndexofSuspicion #MechanismofInjury #PatientAssessment #TraumaAssessment #MotorVehicleAccidents

The Glasgow Coma Scale

The Glasgow Coma Scale (GCS) was developed by Graham Teasdale and Bryan Jennett, neurosurgeons at the University of Glasgow, Scotland, in 1974. They designed the scale as a standardized method to assess and communicate the level of consciousness in patients with traumatic brain injuries (TBIs).

Teasdale and Jennett recognized the need for a simple and reliable tool that could be used by healthcare professionals across different settings to evaluate a patient's neurological status. They aimed to create a system that could provide a common language for describing levels of consciousness and facilitate communication among healthcare providers.

The GCS was based on observations and analysis of patients admitted to the neurosurgical unit at the Southern General Hospital in Glasgow. Teasdale and Jennett identified three key components of neurological function—eye-opening response, verbal response, and motor response—and assigned scores to each category based on the observed range of responses.

Their work resulted in the development of the GCS, which quickly gained acceptance and became widely used not only in the field of neurosurgery but also in emergency medicine, intensive care, and other healthcare specialties worldwide. The GCS has undergone revisions and refinements over the years to enhance its clinical utility, but the fundamental principles and scoring system established by Teasdale and Jennett remain the foundation of the scale.

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EMS providers should have a good understanding of the Glasgow Coma Scale (GCS) as it is a vital tool for assessing a patient's level of consciousness. Here are a few key points about the GCS:

1. The GCS assesses three aspects of neurological function: eye-opening response, verbal response, and motor response. Each of these aspects is assigned a score ranging from 1 to 4 or 5, depending on the specific category.

2. The scores from each category are added together to give a total GCS score, which can range from 3 (indicating deep unconsciousness) to 15 (indicating full consciousness).

3. The GCS is commonly used to assess patients with TBIs or altered mental status. It provides a standardized and objective way to assess the severity of neurological impairment and monitor changes over time.

4. EMS providers should be familiar with the criteria for assigning scores in each category. For example, eye-opening response ranges from spontaneous (4) to no response (1), verbal response ranges from oriented conversation (5) to no verbal response (1), and motor response ranges from following commands (6) to no motor response (1).

5. The GCS score can help guide treatment decisions, determine the need for immediate intervention, and provide a baseline for assessing the patient's progress. Lower GCS scores generally indicate more severe neurological injury or impairment.

Remember, the GCS is just one tool among many that EMS providers utilize to assess and manage patients. It's important to consider other factors and clinical findings in conjunction with the GCS score to make informed decisions about patient care.

#EMS #GlasgowComaScale #PreHospitalCare #TraumaAssessment