In the management of emergencies, all the trauma patients had anti-tetanus prophylaxis, analgesics were prescribed in 101 patients (95.3%) and 102 patients (96.2%) were given antibiotics while dexamethasone was prescribed in 36 patients or 34 per cent. Sixty-eight (64.2%) out of the 88 patients that required a surgical procedure were operated in the Accident and Emergency, 13 (12.3%) were operated in the main operating theatre and the rest were referred to the outpatient clinic. The outcome for all the patients is presented in Figure 3.

Almost half of the patients were admitted into the ward (49 or 46.2%), 41 patients (38.7%) were discharged home from the Accident and Emergency unit, 4 died (3.8%), 4 discharged themselves against medical advice, 1 (0.9%) absconded and 3 were referred to other hospitals. The outcome was not recorded in three patients. Cross tabulations were computed to determine the effect of the patients’ age, time and day of presentation on the outcome, no

statistically significant relationship was demonstrated.

The pattern and presentation of maxillofacial emergencies have been studied in many parts of the world and maxillofacial injuries constitute an important component in the management of multiple trauma victims^3,5,6,11. This study has concentrated on the emergencies seen during the call hours of 4pm to 8am on weekdays and 24 hours on weekends and it is by no means a reflection of all the patients seen by the unit. Other conditions that constitute emergencies such as pulpitis, failed root canal treatments, fractured teeth or dentures and other maxillofacial emergencies, which present to the dental hospital during the day are not included. It is also probable that many emergencies are being seen by quacks and some private clinics, despite the fact that our hospital is a major referral centre in the environ. Patients may have patronized other clinics due to financial constraints.

The mean age of 31.3 years for our patients averages for the third and fourth decades of life, the age of activity. It is therefore not surprising that most of the patients are students and traders who are constantly traveling for one reason or the other. Such individuals are very prone to road traffic accidents, which accounted for the majority of the patients presenting as emergencies. This observation is supported by previous studies in Nigeria where road traffic accidents were the major cause of facial hard and soft tissue injuries and such individuals usually require emergency care¹⁴,¹⁵. A recent study from northern Nigeria however has demonstrated that facial injuries due to assault have been on the increase¹⁶. The gunshot injuries recorded were due to armed robbery attacks, a deviation from a previous study conducted in our hospital where sport related activities (hunting) were mainly responsible¹⁷. The recent communal clashes in Ile-Ife and Modakeke with an attendant influx of arms and unemployment may be responsible for this trend. Weekends (Friday evening to Sunday) recorded many patients because of the twenty-four hour coverage and the fact that most social functions that necessitate traveling are also done on weekends. It is also a well-documented fact that emergencies present more frequently at the weekends¹⁸.

It is not surprising that approximately a third of the patients were only able to reach the hospital within the first hour which is usually the ‘golden hour’ in an emergency¹⁸. A situation where ambulance services are almost non-existent and patients have to be transported to the hospital in commercial vehicles or private cars (Figure 1) allows for this. Apart from the delay in conveying patients to the hospital, such vehicles are not designed for such functions and in some cases may worsen the condition of the patient. In spite of this limitations, the fact that 87.2% presented within 24 hours is an improvement over previous studies where only a third of patients managed to get to the hospital within a similar time frame^14,16. The observation that more Nigerians in recent time have acquired private vehicles may contribute to this. In the trauma victims, soft tissue injuries predominated a fact that has been well documented³. The pattern of soft tissue injuries, which is highlighted in Figure 2, contrasts with a similar study among children from our center in which the upper third of the face was most commonly injured¹⁹. The larger ratio of the upper third of the face in children may explain the differences, especially in falls (which is common in children) where the head impacts on the floor and other objects. Additionally, our observation that mandibular fractures are the most commonly fractured bone of the facial skeleton agrees with reports form different parts of the world^16,20,21.

The importance of associated injuries in patients with facial injuries has been emphasized in a previous report from our institution where more that 20% had one form or the other¹⁴. While head injuries have been described as the most commonly associated concomitant injury with facial fractures^13,20, it ranked second after limb injuries in this study. Eye injuries were the third most frequently observed injury and this is important due to the possibility of visual loss. The incidence of eye involvement is high in midface fractures and with the absence of an obligatory seat belt law²², a situation which existed in Nigeria until January 2003 when the seat belt law was enforced by the Federal Road Safety Corps.

The role of computed tomographic scanning in the management of trauma related emergencies have been emphasized²³. This is especially relevant in patients with head injuries, which has been reported to be the most commonly associated injury in facial trauma²⁴. It is however unfortunate that only very few patients in this study had this mode of investigation carried out for the reason that they could not afford the cost. Good Samaritans, police or other voluntary organizations usually bring in many trauma victims and there is usually no relative to pay for this very important

investigation when the patients need it most. It is suggested that government should make this investigation available for all trauma victims during the initial phase of treatment and relatives could then pay for the services whenever they show up. The observation that not all the patients who needed a surgical intervention could be managed in the theatre is a reflection of the facilities available. While this study was being conducted, there was no functioning Accident and Emergency theater. This situation, which has since changed with the construction of a new Accident, and Emergency complex which has a functioning theatre.

It is obvious from this study that trauma victims, especially as a result of road traffic accident constitute the bulk of emergencies seen by the maxillofacial unit of the Obafemi Awolowo University Teaching Hospital, Ile-Ife, especially on weekends. There is therefore a need for every member of the unit to be versed in the management of trauma victims. There is also a need to be on the lookout for associated injuries such as limb injuries and head injuries which may sometimes be a greater threat to the patients’ life than the maxillofacial condition. In addition, there is an urgent need for the provision of ambulance services round the clock and free CT scans for all emergency victims in order to reduce morbidity and mortality. While this study has provided an insight into the nature of maxillofacial emergencies presenting to our hospital, it is by no means exhaustive and there is a need for larger surveys which is not only necessary for auditing the services provided but will also help in the appropriate planning and allocation of human and material resources. There is also a need for an oral and maxillofacial trauma registry at different locations in the country. This will ensure a long-term data collection for the development and evaluation of preventive measures³.