key: cord-0783714-e1mnkzyd
authors: Sahni, Dr Vaibhav
title: A protocol for the management of Maxillofacial Injuries in the wake of the COVID-19 Pandemic
date: 2020-06-25
journal: Injury
DOI: 10.1016/j.injury.2020.06.037
sha: 4209975cd3fdecd7fcce2dbd8ded75ebb879e200
doc_id: 783714
cord_uid: e1mnkzyd

The oral & maxillofacial region and by that virtue surgery of the same is correlated to an increased risk of the transfer of the SARS CoV-2. In times of a pandemic it is imperative to institute a protocol based management of maxillofacial injuries based on currently available literature which is suggestive, simplistic, executable and amenable to modifications should the rapidly changing situation demand the same. The author, in the present study conducted a review of literature to undertake the task of forming a simplistic protocol which is readily applicable for the management of maxillofacial injuries which would not only provide the clinician guidance on what to do now but caution towards the future implications of his/her present decision.

A protocol for the management of Maxillofacial Injuries in the wake of the COVID-19 Pandemic

The oral & maxillofacial region and by that virtue surgery of the same is correlated to an increased risk of the transfer of the SARS CoV-2. In times of a pandemic it is imperative to institute a protocol based management of maxillofacial injuries based on currently available literature which is suggestive, simplistic, executable and amenable to modifications should the rapidly changing situation demand the same. The author, in the present study conducted a review of literature to undertake the task of forming a simplistic protocol which is readily applicable for the management of maxillofacial injuries which would not only provide the clinician guidance on what to do now but caution towards the future implications of his/her present decision.

Keywords: Maxillofacial, Trauma, COVID-19

Sir,

The COVID-19 pandemic, caused by the novel coronavirus has had health authorities and healthcare professionals scurrying for resources be it in terms of equipment, personal protective or otherwise, conserving or for lack of a better word judiciously utilizing the available infrastructure. The fatality rate of COVID-19 reportedly seems to increase with age and like other illnesses is affected by comorbidities. A very real concern is however, the inordinate proportion of health workers at risk of contracting the disease, to the tune of 29% of the initially reported cases. 1 This seriously draws attention to a modification of healthcare practices being routinely followed. An unfortunate fallout of this situation is that a number of patients who would otherwise have been treated promptly are facing delays which is piling on the agony in the face of an already overburdened system. It is further a major concern that this virus, in its novel nature has stymied a number of otherwise smoothly running protocols. The oral & maxillofacial region and by that virtue surgery of the same is correlated to an increased risk of the transfer of the SARS CoV-2. The unique nature of spread of this virus renders a unique conundrum to the speciality, although not an airbourne infection, the viral particles if aerosolized, tend to remain for protracted periods of time in the environment, further, oral & maxillofacial surgery procedures deal with the oral cavity, it is in the saliva and at the level of the naso-and oropharynx that the virus has been recovered in its highest titres. So much so that these form bases of testing methodology.

In times of a pandemic, wherein the entire healthcare system of a country may be overwhelmed or might be gearing up to face a massive wave of patients, it is imperative to have protocols in place in order to eliminate errors, maintain the flow of healthcare and provide effective management of the presenting patients, both those part of the pandemic and the ones without as after all, a patient not affected by the COVID-19 is also a patient. The author aimed to collate evidence in all its forms as this is the need of the hour in the author's opinion, to provide a protocol for the management of maxillofacial trauma patients in both the emergent, urgent and delayed frames of time.

On the basis of this collated literature, the author aims to provide a suggested protocol for the triage and/or management of maxillofacial injuries during the pandemic. This communication aims to concentrate on making suggestions pertaining to the management of maxillofacial injuries alone without confounding the same by making it a part of a holistic view of the entire specialty of maxillofacial surgery, the suggestions are aimed to be simplistic and readily executable along with being amenable to suitable modifications as, specially, in many parts of the developing world, injuries of the maxillofacial region are not always attended by a specialist, a dynamic situation requires protocols which are simple and capable of being as dynamic as the challenges being faced. The algorithmic workflow and accompanying interpretation table aim to serve as a general framework within which units can adapt their specific protocols without having to commit to a particular set of guidelines as many a times guidelines being issued do not match the realities of units all over the world. Protocols tend to be rigid and rightfully so, however we are faced with a disease without an evidence base which is constantly evolving both in terms of its pathophysiology and the logistics it entails and hence it is the author's sincere hope that a more fluid, adaptable framework for the management of injuries of the maxillofacial region would aid units in functioning. A few points to be kept in mind: 1,2, 3 1. Relatively easy to differentiate between emergency and elective procedures, those who can wait should be allowed to do so. 2. Grey area between urgent and potentially delayed procedures needs to be addressed. 3. If a conservative methodology exists to manage a potentially surgical correction, that should be preferred (atleast for the time being) 4. Aerosol Generating Procedures (AGPs) need to be identified in maxillofacial surgery unit (airway care, irrigation, handpieces such as piezoelectric, ultrasonic, high-speed, abscess drainage) and coordination for identifying the same with allied specialities. 5. All decisions should be made in the backdrop of conserving resources, as it is simply not the procedure but the ancillary support that it requires which needs to be conserved 6. In light of all such decisions, a case to case dynamic decision making process preferably, at the consultant level needs to be established 7. It should also be bourne in mind that current decision making would impact healthcare burden once the pandemic passes and would also potentially complicate or increase the surgical difficulty of relatively straightforward cases presenting at this time.

The merits of these recommendations would be effectively streamlining triage, reducing the risk of healthcare workers contracting the disease, ensuring patients with injuries of a life threatening nature or those with injuries entailing significant functional impairment are provided care regardless of their COVID status. It would also serve to convey a reassuring message to the public in general that hospitals are not just for COVID patients and thereby serve to reaffirm trust in our institutions. The perceived limitations of this protocol would be those paralleling the postponement of care such as increasing the number of patients awaiting surgery post the pandemic, less than optimal results in some cases necessitating a possibly more complicated second surgical procedure and the psychological toll on the patient for living with an injury and awaiting treatment. In a parting remark, it would serve us well to append every recommendation and every guideline calling for deferring of treatment or suggesting a so-called substandard procedure with the word 'empathise'. This is the need of the hour, after all, we are all in this together.

Approaches to the management of patients in oral and maxillofacial surgery during COVID-19 pandemic

Lamontagne F, Angus DC: Toward universal deployable guidelines for the care of patients with COVID-19

COVID-19): Emerging and Future Challenges for Dental and Oral Medicine. Meng L, Hua F, Bian Z

The author has no financial interests to disclose. The author does not perceive any conflicts of interests financially or in terms of publication of this manuscript.