Airway Management in Facial Trauma

7/28/2019 Airway Management in Facial Trauma

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AIRWAY MANAGEMET IN FACIAL

TRAUMA

OLA WAHBA,

MDConsultant Anesthetist

Lecturer in Anaesthesiology

Asyut UniversityEgypt


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AETIOLOGY

Road traffic accident (RTA): 35 60% Rowe and Killey (1968);

Vincent Towned and Shepherd (1994)

Fight and assault (interpersonal violence)Most in economically prosperous countries

Beek and Merkx (1999)

Sport and athletic injuries

Industrial accidents

Domestic injuries and falls


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INCIDENCE

Associated with:

facial fracture

Higher incidence of TBI

Cervical spine injury

Carotid artery injury

Eye injury: blindness may occur with facial fractures


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FACIAL FRACTURES: MANDIBULAR


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SEQUEL OF FACIAL INJURY

Airway obstruction

Asphyxia

Cerebral hypoxia

Brain damage


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AIRWAY LOSS AFTER FACIAL INJURY

CAUSES:

Anatomical disruption of the larynx or trachea. Soft tissue impaction

Foreign body, blood, vomitus, teeth or bone Soft tissue edema Associated burn or smoke inhalation


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AIRWAY MANAGEMENT: AIM

Oxygenation

Oxygenation

Oxygenation


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AIRWAY MANAGEMENT AFTER FACIAL INJURY

IMMEDIATE MANAGEMENT

Airway management during the resuscitation phase

LATE MANAGEMENT

Airway management during operative fixation of facial fracture.


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IMMEDIATE MANAGEMENT:IMPORTANT CONSIDERATIONS

Securing the airway is challenging Be ware: head injury are common.

cervical spine injury are common.

Trauma patient: other serious injuries may coexist.

Full stomach


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Securing the airway is challenging


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Be ware: head injury

Many of facial injury patients sustain head injury in particular the mid face injuries

Closed open

Ranges from mild concussion to serious injury

Airway problems aggravates secondary cerebral insults resulting in a poor outcome.


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Be ware: cervical spine injury

Should be considered in any injury above the clavicle = facial injury

Airway management may result in spinal cord injury

The consequences are devastating.

Cervical spine stabilization during airway management are mandatory.


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Be ware: Other serious injuries many coexist

Should not be distracted by the facial injury

Follow the structured algorithm:Primary survey: Ac, B, C, D, ESecondary survey

Continuous reassessment.


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Be ware: you should conceder full stomach

Should be considered in all trauma patients

Large volume of blood may have already been swallowed

Vomiting can

result

in:

Obscuring

the

field

already

difficult

airwayPulmonary aspiration.

Rapid sequence intubation + cricoid pressure (Sellicks maneuver)


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AIRWAY MANAGEMENT

First step in the primary survey: Ac, B, C, D, E

Ac = airway management + C. spine stabilization

Be prepared

PPE: to avoid cross infection. Equipment: laryngoscopes, video laryngoscopes, blades, tubes, Magill forceps, fiberoptic laryngoscope, cricothyrotomykit, LMAs, Combitubes, powerful suction, monitoring and

resuscitation equipment Medications: for RSI and resuscitation Personnel; skilled anesthesia assistants, trauma team and

surgeons capable of performing tracheostomy


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AIRWAY MANAGEMENT

1. Assess consciousness:

Awake and alert: Airway still safe

Disturbed conscious level: Airway at risk

Unconscious: Airway is potentially obstructed


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Hard Collar and spine board Head blocks


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AIRWAY MANAGEMENT

3. Open the airway:

Jaw thrust maneuver

Jaw fracture OR No jaw


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AIRWAY MANAGEMENT4. Clear the airway:

Blood clots, mucous, foreign body, broken teeth


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AIRWAY MANAGEMENT

5. Administer high flow oxygen :

Breathing well:

Face mask with a reservoir bag

Well fitted mask

Beware; facial hair, edema, jaw fracture

Not breathing well: Self inflating bag


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AIRWAY MANAGEMENT OPTIONS

Simple adjuncts to buy time

Have plans: A, B and C

Ask for senior advice/help earlier than late


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Plan

A


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ET intubation with RSI:

Adequate preparation.

Consider different blades (McCoy) and videaolaryngoscopes.

Bougie and stylets

Trained assistants

MIL Powerful suction


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Large IV bore catheters (already in place).

IV fluids running.

Full monitoring.

Consider anticolinergics (Neurogenic shock)

Beware of induction agent induced hypotension


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Cricoid pressure.

Avoid nasal intubation

Confirm correct placement:Auscultation

Capnography (6 breaths)Esophageal detector device


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Awake fiberoptic intubation:

Patient is awake, alert and can cooperate

Anticipated difficulty

High risk cervical spine injury

Needs experienced operatorAnatomy disturbed ?Field is bloody ?


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Plan

B

Failed intubation

AIRWAYMANAGEMENTOPTIONS


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supraglottic airway devicesLaryngeal mask airway

Classic LMAProseal LMA


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Combitube:

?

N o . 1

1 0 0 m l

N o . 2 1 5

m l

N o .

2 N

o .

1


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Laryngeal tube Single lumen tube with both an oesophageal

and pharyngeal cuff A single pilot balloon inflates both cuffs

simultaneously Successful insertion and airway pressure

generated are comparable to LMA


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Plan

C

Complete upper airway obstruction


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Surgical cricothyrotomy:

Indicationsabsolute need for a definitive airway ANDunable to perform ETT due for structural or anatomic

reasons, AND risk of not intubating is > than surgical airway riskORunable to clear an upper airway obstruction, ANDmultiple unsuccessful attempts at ETT, ANDother methods of ventilation do not allow for effective ventilation and respiration


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Retrograde intubation:


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Percutaneous trans tracheal jet ventilation

(needle cricothyrotomy):

Requires high pressure equipment Ventilate 1 sec then allow 35 sec pause Hypercarbia likely Temporary: 20 30 mins High risk for barotrauma

Tracheostomy:

Urgent


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AIRWAY MANAGEMENT AFTER FACIAL INJURY

IMMEDIATE MANAGEMENT

Airway management during the resuscitation phase

LATE MANAGEMENT

Airway management during operative fixation of facial fracture.

LATEMANAGEMENT


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LATE MANAGEMENT:IMPORTANT CONSIDERATIONS

Securing the airway is challenging Anatomical difficulty Cervical spine mobility may be restricted Limited mouth opening

The need to wire the jaws.

LATEMANAGEMENT


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1Anatomical difficulty

LATEMANAGEMENT


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LATE MANAGEMENT:IMPORTANT CONSIDERATIONSSecuring the airway is challenging

2Cervical

spine

mobility

may

be

restricted

due

to

:

Immobilization devices in place

Hard collar

Halo traction device

Range of C. spine movement should be assessed preoperatively.

Maintain immobilization ? MIL.

LATEMANAGEMENT


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3 Limited mouth opening

Muscle spasm (reversible by relaxants)

Bony impingement (not reversed by relaxants)

LATEMANAGEMENT:


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The need to wire the jaws.

Neither nasal nor oral tube (even RAE tube) is suitable.



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Plan

A



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Endotracheal intubation:

Awake Fibreoptic

Asleep

consider difficultyBe prepared have alternative plans



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JAW WIRING IS NEEDED OPTIONS:

submandibular tubeSumental tube


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Curtsey of Prof. Abdel Raheem



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Plan

B



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ILMA ??

Plan


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Plan

c

Tracheostomy Awake under LA Asleep

KEYPOINTS


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KEY POINTS

Airway management of patients with facial trauma is challenging

Adequate preparation and experience are essential

It is mandatory to follow the structured approach of trauma management.

Carefully consider the associated injuries especially head and cervical spine injury.


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THANK YOU

Airway Management in Facial Trauma

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