Professional Documents
Culture Documents
AETIOLOGY
Roadtrafficaccident(RTA):3560% RoweandKilley (1968); VincentTowned andShepherd(1994) Fightandassault(interpersonalviolence) Mostineconomicallyprosperouscountries Beek andMerkx (1999) Sportandathleticinjuries Industrialaccidents Domesticinjuriesandfalls
INCIDENCE
Withmultisysteminjury2050%. Nasalandmandibular fracturesmostcommoninEDs. Midface andzygomatic injuriesmostcommoninTraumacenters. 25%ofwomenwithfacialtraumaresultofdomesticviolence
INCIDENCE
Associatedwith: facialfracture HigherincidenceofTBI Cervicalspineinjury Carotidarteryinjury Eyeinjury:blindnessmayoccurwithfacialfractures
FACIALFRACTURES:MANDIBULAR
FACIALFRACTURES:LeFORT
SEQUELOFFACIALINJURY
Airway obstruction
Asphyxia
AIRWAYLOSSAFTERFACIALINJURY
CAUSES: Anatomicaldisruptionofthelarynxortrachea. Softtissueimpaction Foreignbody,blood,vomitus,teethorbone Softtissueedema Associatedburnorsmokeinhalation
AIRWAYMANAGEMENT:AIM
Oxygenation
Oxygenation
Oxygenation
AIRWAYMANAGEMENTAFTER FACIALINJURY
IMMEDIATEMANAGEMENT
Airwaymanagementduringtheresuscitationphase
LATEMANAGEMENT
Airwaymanagementduringoperativefixationoffacialfracture.
IMMEDIATEMANAGEMENT:
IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging Beware:headinjuryarecommon. cervicalspineinjuryarecommon. Traumapatient:otherseriousinjuriesmaycoexist. Fullstomach
IMMEDIATEMANAGEMENT:
IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging
IMMEDIATEMANAGEMENT:
IMPORTANTCONSIDERATIONS
Beware:headinjury Manyoffacialinjurypatientssustainheadinjuryinparticularthe midfaceinjuries Closed open Rangesfrommildconcussiontoseriousinjury Airwayproblemsaggravatessecondarycerebralinsultsresultingin apooroutcome.
Beware:cervicalspineinjury
Shouldbeconsideredinanyinjuryabovetheclavicle=facialinjury Airwaymanagementmayresultinspinalcordinjury Theconsequencesaredevastating. Cervicalspinestabilizationduringairwaymanagementare mandatory.
Beware:Otherseriousinjuriesmanycoexist
Shouldnotbedistractedbythefacialinjury Followthestructuredalgorithm: Primarysurvey:Ac,B,C,D,E Secondarysurvey Continuousreassessment.
Beware:youshouldconcederfullstomach
Shouldbeconsideredinalltraumapatients Largevolumeofbloodmayhavealreadybeenswallowed Vomitingcanresultin:Obscuringthefield alreadydifficultairway Pulmonaryaspiration. Rapidsequenceintubation+cricoid pressure(Sellicks maneuver)
AIRWAYMANAGEMENT
Firststepintheprimarysurvey:Ac,B,C,D,E Ac =airwaymanagement+C.spinestabilization Beprepared PPE:toavoidcrossinfection. Equipment:laryngoscopes,videolaryngoscopes,blades, tubes,Magillforceps,fiberoptic laryngoscope,cricothyrotomy kit,LMAs,Combitubes,powerfulsuction,monitoringand resuscitationequipment Medications:forRSIandresuscitation Personnel;skilledanesthesiaassistants,traumateamand surgeonscapableofperformingtracheostomy
AIRWAYMANAGEMENT
1.Assessconsciousness:
Awakeandalert:Airwaystillsafe Disturbedconsciouslevel:Airwayatrisk Unconscious:Airwayispotentiallyobstructed
AIRWAYMANAGEMENT
2.Stabilizethecervicalspine:
Highlyessential Shouldbemaintainedthroughout Spineboard cervicalcollar headblocks straps. MIL=manualinlinestabilization.
HardCollarandspineboard
Headblocks
AIRWAYMANAGEMENT
3.Opentheairway:
Jawthrustmaneuver JawfractureORNojaw
AIRWAYMANAGEMENT
4.Cleartheairway:
Bloodclots,mucous,foreignbody,brokenteeth
AIRWAYMANAGEMENT
5.Administerhighflowoxygen:
Breathingwell: Facemaskwithareservoirbag Wellfittedmask Beware;facialhair,edema,jawfracture Notbreathingwell: Selfinflatingbag
AIRWAYMANAGEMENTOPTIONS
Simpleadjunctstobuytime Haveplans:A,BandC Askforsenioradvice/helpearlierthanlate
AIRWAYMANAGEMENTOPTIONS
Plan A
AIRWAYMANAGEMENTOPTIONS
ETintubationwithRSI:
Adequatepreparation. Considerdifferentblades(McCoy)andvideaolaryngoscopes. Bougie andstylets Trainedassistants MIL Powerfulsuction
AIRWAYMANAGEMENTOPTIONS
ETintubationwithRSI:
LargeIVborecatheters(alreadyinplace). IVfluidsrunning. Fullmonitoring. Consideranticolinergics (Neurogenic shock) Bewareofinductionagentinducedhypotension
AIRWAYMANAGEMENTOPTIONS
ETintubationwithRSI:
Cricoid pressure. Avoidnasalintubation Confirmcorrectplacement: Auscultation Capnography (6breaths) Esophagealdetectordevice
AIRWAYMANAGEMENTOPTIONS
Awakefiberoptic intubation:
Patientisawake,alertandcancooperate Anticipateddifficulty Highriskcervicalspineinjury Needsexperiencedoperator Anatomydisturbed? Fieldisbloody?
AIRWAYMANAGEMENTOPTIONS
Plan B Failedintubation
Proseal LMA
ClassicLMA
AIRWAYMANAGEMENTOPTIONS
Combitube:
. No 2
No. 1
No . 2 15 ml
No. 1 100 ml
Laryngealtube
Singlelumentubewithbothanoesophageal andpharyngealcuff Asinglepilotballooninflatesbothcuffs simultaneously Successfulinsertionandairwaypressure generatedarecomparabletoLMA
AIRWAYMANAGEMENTOPTIONS
AIRWAYMANAGEMENTOPTIONS
AIRWAYMANAGEMENTOPTIONS
Surgicalcricothyrotomy: Indications
absoluteneedforadefinitiveairwayAND unabletoperformETTdueforstructuraloranatomic reasons,ANDriskofnotintubating is>thansurgical airwayrisk OR unabletoclearanupperairwayobstruction,AND multipleunsuccessfulattemptsatETT,AND othermethodsofventilationdonotallowforeffective ventilationandrespiration
AIRWAYMANAGEMENTOPTIONS
Surgicalcricothyrotomy: Contraindications(relative)
Norealdemonstratedindication Risks>benefits Age<8years(somesay10) evidenceoftraumatolarynxorcricoid cartilage evidenceoftrachealtransection
AIRWAYMANAGEMENTOPTIONS
Retrogradeintubation:
AIRWAYMANAGEMENTOPTIONS
Percutaneous transtrachealjetventilation (needlecricothyrotomy): Requireshighpressureequipment
Ventilate1secthenallow35secpause Hypercarbia likely Temporary:2030mins Highriskforbarotrauma
Tracheostomy:
Urgent
AIRWAYMANAGEMENTAFTER FACIALINJURY
IMMEDIATEMANAGEMENT
Airwaymanagementduringtheresuscitationphase
LATEMANAGEMENT
Airwaymanagementduringoperativefixationoffacialfracture.
LATEMANAGEMENT: IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging Anatomicaldifficulty Cervicalspinemobilitymayberestricted Limitedmouthopening Theneedtowirethejaws.
LATEMANAGEMENT: IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging 1Anatomicaldifficulty
LATEMANAGEMENT: IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging 2Cervicalspinemobilitymayberestricteddueto: Immobilizationdevicesinplace Hardcollar Halotractiondevice RangeofC.spinemovementshouldbeassessedpreoperatively. Maintainimmobilization?MIL.
LATEMANAGEMENT: IMPORTANTCONSIDERATIONS
Securingtheairwayischallenging 3 Limitedmouthopening Musclespasm(reversiblebyrelaxants) Bonyimpingement(notreversedbyrelaxants)
LATEMANAGEMENT: IMPORTANTCONSIDERATIONS
Theneedtowirethejaws. Neithernasalnororaltube(evenRAEtube)issuitable.
AIRWAYMANAGEMENTOPTIONS
Plan A
AIRWAYMANAGEMENTOPTIONS
Endotracheal intubation: AwakeFibreoptic
Asleep considerdifficulty Beprepared havealternativeplans
AIRWAYMANAGEMENTOPTIONS
JAWWIRINGISNEEDED OPTIONS:
submandibular tube Sumental tube
CurtseyofProf.AbdelRaheem
AIRWAYMANAGEMENTOPTIONS
Plan B
AIRWAYMANAGEMENTOPTIONS
ILMA??
Plan c
Tracheostomy
AwakeunderLA Asleep
KEYPOINTS
Airwaymanagementofpatientswithfacialtraumais challenging Adequatepreparationandexperienceareessential Itismandatorytofollowthestructuredapproachof traumamanagement. Carefullyconsidertheassociatedinjuriesespeciallyhead andcervicalspineinjury.
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