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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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IMMEDIATE MANAGEMENT:IMPORTANT CONSIDERATIONS
Securing the airway is challenging
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IMMEDIATE MANAGEMENT:IMPORTANT CONSIDERATIONS
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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AIRWAY MANAGEMENT OPTIONS
Plan
A
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AIRWAY MANAGEMENT OPTIONS
ET intubation with RSI:
Adequate preparation.
Consider different blades (McCoy) and videaolaryngoscopes.
Bougie and stylets
Trained assistants
MIL Powerful suction
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AIRWAY MANAGEMENT OPTIONS
ET intubation with RSI:
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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AIRWAY MANAGEMENT OPTIONS
ET intubation with RSI:
Cricoid pressure.
Avoid nasal intubation
Confirm correct placement:Auscultation
Capnography (6 breaths)Esophageal detector device
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AIRWAY MANAGEMENT OPTIONS
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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AIRWAY MANAGEMENT OPTIONS
Plan
B
Failed intubation
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
supraglottic airway devicesLaryngeal mask airway
Classic LMAProseal LMA
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AIRWAY MANAGEMENT OPTIONS
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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AIRWAY MANAGEMENT OPTIONS
Plan
C
Complete upper airway obstruction
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AIRWAY MANAGEMENT OPTIONS
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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AIRWAY MANAGEMENT OPTIONS
Retrograde intubation:
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AIRWAY MANAGEMENT OPTIONS
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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LATE MANAGEMENT:IMPORTANT CONSIDERATIONS
Securing the airway is challenging
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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LATE MANAGEMENT:IMPORTANT CONSIDERATIONS
Securing the airway is challenging
3 Limited mouth opening
Muscle spasm (reversible by relaxants)
Bony impingement (not reversed by relaxants)
LATEMANAGEMENT:
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LATE MANAGEMENT:IMPORTANT CONSIDERATIONS
The need to wire the jaws.
Neither nasal nor oral tube (even RAE tube) is suitable.
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
Plan
A
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
Endotracheal intubation:
Awake Fibreoptic
Asleep
consider difficultyBe prepared have alternative plans
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
JAW WIRING IS NEEDED OPTIONS:
submandibular tubeSumental tube
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Curtsey of Prof. Abdel Raheem
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
Plan
B
AIRWAYMANAGEMENTOPTIONS
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AIRWAY MANAGEMENT OPTIONS
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
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