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AIRWAYMANAGEMETINFACIAL TRAUMA

OLAWAHBA,MD ConsultantAnesthetist LecturerinAnaesthesiology AsyutUniversity Egypt

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

Cerebral hypoxia Brain damage

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

AIRWAYMANAGEMENTOPTIONS supraglottic airwaydevices


Laryngealmaskairway

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

Plan C Completeupperairway obstruction

AIRWAYMANAGEMENTOPTIONS

Nightmarescenario Cannotintubate Cannotventilate

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.

THANKYOU

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