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CASE PRESENTATION

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A 70-year-old depressed man presents after attempted suicide by shooting himself with a handgun held under his jaw. He is seated upright and leaning forward when paramedics arrived on the scene and refuses to lie supine due to facial bleeding. He is kept in position so as to optimize airway patency and expeditiously transported to the nearest emergency department (ED).

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The patient presents to the ED in tripod position with obvious bleeding from his mouth. His anterior mandible is missing, and he is holding a non-rebreather oxygen mask in front of his face. His oxygen saturation is 95% and has been stable during transport. Vital signs include a pulse of 85 beats per minute, a blood pressure of 175/90 mm Hg, a respiratory rate of 22 breaths per minute, and a temperature of 37°C. Upon initial examination (Figure 27–1), he had ongoing oral hemorrhage and completely missing anterior mandible. The patient is awake and has a Glasgow Coma Scale (GCS) of 15. In light of his injuries, he was kept upright on the gurney in anticipation of tracheal intubation (for airway protection).

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FIGURE 27–1.

The picture shows that patient arrived at the emergency department sitting on a stretcher with a non-rebreather oxygen mask.

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PATIENT ASSESSMENT

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What Are the Airway Evaluation Considerations in This Patient?

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This patient presents with multiple clinical issues that may influence his airway management. The missing anterior mandible is a dramatic presentation, but standard trauma management principles apply.1,2 His airway does require management, as indicated for airway protection and anticipated clinical course. However, this is not a “crash” intubation situation (because his oxygen saturation is >90% and stable). Therefore, a rapid evaluation of the airway for anticipated difficulty is possible.3 If this was a “crash” scenario (e.g., vital signs become unstable or patient becomes hypoxic), an awake cricothyrotomy might be the most appropriate initial approach.1,3

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The presence of oro-facial disruption will likely hinder bag-mask-ventilation (BMV) due to a poor mask seal. Similarly, with the associated hemorrhage, soft tissue edema, and the presence of foreign bodies (teeth, clots, etc.), the use of an extraglottic device (EGD) may be difficult. Laryngoscopy will likely be complicated by the presence of blood, tissue edema, and possible airway disruption. However, the absence of mandibular resistance might actually make visualization easier. While it is always wise to consider cervical spine injury in the setting of head injury, this case is special as the patient is neurologically intact and this places him in a low-risk category for spine injury. To date, there have been no cases reported of isolated penetrating injury to the face that have resulted in an unstable cervical spine fracture in an awake, alert, neurologically intact patient.4,5 Maintenance ...

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