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Maxillofacial Injury—Not Always a Difficult Airway

Published online by Cambridge University Press:  21 May 2015

John Glasheen ,
David Hennelly  and
Stephen Cusack
John Glasheen*
Affiliation:
Emergency Department, Cork University Hospital, Cork, Ireland
David Hennelly
Affiliation:
Clinical Development, National Ambulance Service, Limerick, Ireland
Stephen Cusack
Affiliation:
Emergency Department, Cork University Hospital, Cork, Ireland
*
Correspondence: John Glasheen, MB, BCh, BAO, MScEMS Emergency Department Cork University Hospital Cork, Ireland E-mail: Jglash@hotmail.com
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Abstract

The optimal method for securing the airway in injured patients is controversial. Maxillofacial injury has been shown to be a marker for difficult airway management; however, a delay in intubation may result in deterioration of intubating conditions due to further airway bleeding and swelling. Decisions on the timing and method of airway management depend on multiple factors, including patient characteristics, the skill set of the clinicians, and logistical considerations. This report describes the case of a multi-agency response to a motor-vehicle collision in a rural area in Ireland. One young male patient had sustained significant maxillofacial injuries, multiple limb injuries, and had a decreased level of consciousness. Further airway compromise occurred following extrication. Difficult intubation was predicted; however, abnormal jaw mobility from bilateral mandibular fractures enabled easy laryngoscopy and intubation. Although preparation must be made for difficult airway management in the setting of maxillofacial injury, appropriately trained and experienced practitioners should not be deterred from performing early intubation when indicated.

Glasheen J, Hennelly D, Cusack S. Maxillofacial Injury—Not Always a Difficult Airway. Prehosp Disaster Med. 2015;30(4):1 –4.

Keywords

maxillofacialprehospital caretrauma
Type
Case Report
Information
Prehospital and Disaster Medicine , Volume 30 , Issue 4 , August 2015 , pp. 421 - 424
Copyright
© World Association for Disaster and Emergency Medicine 2015 

Introduction

Failure to protect the airway has been shown to be an error contributing to mortality in 16% of in-patient deaths from trauma in a Level I regional trauma center.Reference Gruen, Jurkovich, McIntyre, Foy and Maier 1 Patients with maxillofacial injury may present with airway compromise,Reference Tung, Tseng, Chen, Lai and Chen 2 and management of this subset of trauma patients particularly can be challenging.

In the hospital setting, endotracheal intubation is considered standard practice for patients with potential or actual airway compromise. Prehospital airway management of these patients may take the form of basic maneuvers and adjuncts (positioning, jaw thrust, oropharyngeal airway, and nasopharyngeal airways), supraglottic devices, or endotracheal intubation. The percentage of trauma patients undergoing endotracheal intubation in ground-based Emergency Medical Service (EMS) varies from 2%-37%Reference Mayglothling, Duane and Gibbs 3 and depends on the protocols of individual EMS systems.

Although effective airway management is a key component of prehospital care, the ideal approach to achieving this remains controversial.Reference Boer, Franschman and Loer 4 Patients who are intubated without drugs following trauma have increased mortality when compared to patients undergoing basic airway management,Reference Evans, Brison, Howes, Stiell and Pickett 5 and prehospital rapid sequence intubation (RSI) has been associated with worse outcomes in traumatic brain injury.Reference Karamanos, Talving and Skiada 6 In the United States, Cudnik et al showed that there was no statistical difference in survival of trauma patients who underwent prehospital intubation compared to patients who were not intubated.Reference Cudnik, Newgard, Daya and Jui 7 An Australian study of paramedic provided prehospital RSI found a survival benefit in patients with isolated head trauma.Reference Bernard, Nguyen and Cameron 8 No published data exist on the benefit of prehospital RSI in patients with a combination of maxillofacial injury and compromised airway.

Despite the conflicting evidence base, prehospital RSI is considered standard of care in many jurisdictions, and several high-performing prehospital services have shown that prehospital RSI can be performed safely by well-trained doctor-paramedic teams.Reference McQueen, Crombie and Hulme 9 - Reference Crewdson and Lockey 13

A decision on the optimal method of airway management should be made for each individual patient, and this decision may vary due to local factors of geography, transport time, transport modality (ground vs air), patient characteristics, and the availability of experienced emergency teams with the capability to perform prehospital RSI.Reference Boer, Franschman and Loer 14

Case Report

Written informed consent to write and publish this case report was obtained from Patient 2. Consent was not required from Patient 1 as his case was not discussed in detail.

A multi-agency response was dispatched to a motor-vehicle collision in rural County Tipperary, Ireland. A small car with two male occupants had been involved in a high-speed, frontal impact with a tree.

The initial response included an advanced paramedic in a rapid response vehicle, an Advanced Life Support ambulance, and a Basic Life Support ambulance. Fire and Rescue personnel and Police were also dispatched. At 2:52 am, a critical care doctor was requested and arrived on scene at 3:21 am.

Patient 1

Patient 1 was a 19-year-old male who was the unrestrained passenger and was ejected from the vehicle. He was alert and complaining of abdominal pain. On examination, he was tachycardic and hypotensive and had a soft but tender right upper quadrant. Ultrasound equipment was not available, so enhanced Focused Assessment with Sonography in Trauma was not performed.

He was packaged rapidly, and tranexamic acid (1 g) was administered for presumed intra-abdominal hemorrhage. He was transported from the scene in the care of an advanced paramedic. Blood products were not available, so intermittent boluses of crystalloid were administered en route to maintain a radial pulse.

Computerized tomography (CT) scans subsequently showed that he had sustained a liver laceration, which was managed conservatively and he made a complete recovery.

Patient 2

Patient 2 was also 19 years old and was the restrained driver of the vehicle. On arrival of EMS, he was trapped in the driver’s seat, haemodynamically stable (heart rate 96; blood pressure 114/72), but with a reduced level of consciousness (Glasgow Coma Score 7; Eye response 1, Verbal response 2, and Motor response 4). He had obvious severe facial injuries with active airway hemorrhage, as well as multiple limb fractures. During his entrapment, his airway was maintained with a combination of an oropharyngeal airway, suction, and jaw thrust.

Due to the reduced level of consciousness and airway compromise, it was decided that a prehospital RSI would be performed immediately after extrication. Equipment (including failed intubation and surgical airway equipment) was set up and drugs were prepared using the RSI checklist (Appendix 1), as per standard operating procedure. Due to adverse weather conditions, it was decided to perform the procedure in the ambulance.

During the prolonged and difficult extrication from the vehicle, the patient was placed on a long spine board and had a cervical collar in situ. When he was positioned supine, the airway became compromised further despite basic adjuncts, and he required assisted ventilation with a bag-valve-mask to maintain oxygen saturation >94%. Facial swelling and mobile anatomical structures made mask seal difficult. Significant intra oral hemorrhage was noted from a tongue laceration and this required frequent suctioning.

Fentanyl 200 mcg, ketamine 100 mg, and rocuronium 100 mg were administered during the prehospital RSI. A Cormack and LehaneReference Cormack and Lehane 15 Grade I view was achieved and the patient was intubated successfully with an 8.0 mm endotracheal tube on first pass. Apneic diffusion oxygenation was provided with nasal prongs, and there was no desaturation or hypotension. Correct tube placement was confirmed both clinically and with continuous capnography. After securing the endotracheal tube, intraoral bleeding was controlled easily with direct pressure on the tongue laceration.

Anesthesia was maintained with boluses of morphine and midazolam, and ongoing muscle relaxation was ensured with a further 50 mg of rocuronium. The patient was ventilated manually using a Mapleson C-circuit (Intersurgical; Berkshire, United Kingdom), and a target EtCO2 range of 35 mmHG-45 mmHg was maintained. A single episode of hypotension during transport was responsive to a 250 ml bolus of crystalloid, and vacuum splints were applied to his limbs en route. Significantly increased facial swelling was noted on arrival at the receiving facility at 4:43 am.

Subsequent CT imaging showed multiple facial fractures, including bilateral medial and lateral orbital wall fractures, bilateral medial and lateral pterygoid plate fractures, fractures to the lateral walls of the maxillary sinuses bilaterally, a fracture of the medial wall of the right maxillary sinus and bilateral mandibular fractures, as well as a comminuted nasal bone fracture.

He also sustained multiple fractures of all four limbs and focal intracerebral hemorrhages, which did not require neurosurgical intervention. Following extensive surgery and rehabilitation, the patient made a full recovery.

Discussion

Due to the injuries identified on assessment of Patient 2, the team anticipated difficulty in managing his airway. Bag-valve-mask ventilationReference Perry and Morris 16 and endotracheal intubation has been reported to be more difficult in the presence of maxillofacial injury,Reference Combes, Jabre and Jbeili 17 - Reference Breckwoldt, Klemstein, Brunne, Schnitzer, Mochmann and Arntz 20 and trauma courses with an in-hospital 21 and a prehospital 22 focus list maxillofacial trauma as a marker for difficult airway management. This may be due to distorted or mobile maxillofacial anatomy resulting from the loss of bony integrity associated with bilateral maxillary or mandibular fractures.Reference Hutchison, Lawlor and Skinner 23

Airway swellingReference Morrissette and Chewning 24 , Reference Ardekian, Rosen, Klein, Peled, Michaelson and Laufer 25 and hemorrhageReference Chase, Hebert and Farnham 26 can further obscure the view during laryngoscopy,Reference King 27 and a combination of these factors may lead to a delay in securing the airway. In patients with maxillofacial injuries, intubating conditions can deteriorate with the passage of time due to increased swelling, and intubation of these patients in the prehospital phase may be optimal.Reference Bredmose, Rock and Lockey 28

Multiple attempts at intubation are associated with an increased rate of complications,Reference Mort 29 and for this reason, many prehospital services advocate optimization of the first intubation attempt. 30 The strategies for maximizing first-pass success include optimizing patient positioning, removal of the cervical collar prior to laryngoscopy (with maintenance of manual in-line stabilization), ensuring that the patient is paralyzed pharmacologically and sedated adequately, ensuring the availability of multiple suction devices in the event of massive airway hemorrhage, external laryngeal manipulation and the routine use of a bougie, as well as performing a challenge-response checklist and team briefing prior to commencing the prehospital RSI. In the event of failed intubation, a backup plan (ie, supraglottic device and surgical airway technique) should be in place and discussed during the team brief. Following intubation, hemorrhage from the mid-face may be controlled by the use of McKesson props and balloon tamponade.Reference Murphy, Doran, O'Sullivan, Sleeman and Cusack 31

In this case of maxillofacial trauma following a motor-vehicle collision, intra-oral hemorrhage and abnormal posterior movement of the tongue and fractured mandible resulted in airway compromise when the patient was placed supine on extrication from the vehicle. This same abnormal jaw mobility also facilitated laryngoscopy and led to an easier than anticipated intubation. This phenomenon may contribute to the finding that maxillofacial injury is not associated with difficult airway management in some series.Reference Cobas, De la Peña, Manning, Candiotti and Varon 32

Conclusion

It was considered that early definitive airway management was a key factor in a successful outcome for Patient 2. While the presence of maxillofacial trauma may, in some cases, make airway management more challenging, this should not deter appropriately trained and equipped providers from performing early prehospital RSI when indicated.

Appendix 1. RSI Checklist.

Abbreviation: RSI, rapid sequence intubation.

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