Maxillofacial – Management

Last Updated on by frcemuser

Mechanisms of airway obstruction in Facial Injuries

  • Posteroinferior displacement of a fractured maxilla may block the nasopharyngeal airway
  • A bilateral fracture of the anterior mandible may cause the fractured symphysis to slide posteriorly cause oropharyngeal obstruction in the supine patient
  • Fractured or exfoliated teeth, bone fragments, vomitus and blood as well as foreign bodies may cause airway obstruction
  • Hemorrhage ( distinct vessels in open wounds or severe nasal bleeding) may cause airway obstruction
  • Soft tissue swelling and edema may cause delayed airway compromise
  • Trauma to the larynx and trachea may cause swelling and displacement of structures
  • Loss of pharyngeal tone due to loss of consciousness from TBI or shock

Issues in Maxillofacial Injuries Management :

  • poor visualisation of the airway due to deformity and debris
  • difficult ventilation e.g. poorly fitting mask, traumatic airway leak
  • the requirement for cervical spine immobilization
  • full stomach and aspiration risk
  • need for emergent intubation due to airway obstruction or hypoxia

Immediate ED Management:

  • Call for help (anesthetic technician, senior anesthetist, ENT specialist, maxillo-facial specialist)
  • Assess and secure airway (may require cricothyroidotomy/tracheostomy)
  • Escalate from simple to advanced techniques as required.
    • Suction and Magill’s forces should be immediately available.
    • Employ simple airway maneuvers – jaw thrust and chin lift. Head tilt inappropriate with cervical spine control.
    • Use airway adjuncts – oropharyngeal airway usually only a temporizing measure if tolerated usually requires definitive airway.
    • Nasopharyngeal airways are inappropriate in the head and facial trauma due to the risk of intracranial passage.
  • Stop bleeding (nasal tampons)

Recommended equipment for management of unanticipated difficult intubation

  • DAS guidelines algorithm flowcharts
  • Equipment list for restocking
  • At least one alternative blade(e.g. straight, McCoy)
  • Intubating LMA (Size 3,4,5 with dedicated tubes and pushers)
  • Flexible fibreoptic laryngoscope (with portable/battery light source)
  • Aintree Intubation Catheter
  • Proseal LMA / Supreme LMA
  • Cricothyroid cannulae with High pressure jet ventilation system (Manujet) OR
  • Large bore cricothyroid cannulae (e.g. Cuffed Melker) OR
  • Surgical Cricothyroidotomy kit

Reading :

Airway in Maxillofacial Trauma

 

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