Chapter 25. Airway Management for Blunt Facial Trauma

A 40-year-old officer was thrown from his police boat causing him to strike his face on a concrete bridge abutment. He was found lying face down and unconscious by other officers on the scene. Upon paramedic arrival, his initial Glasgow Coma Scale (GSC) score was 9, with facial bleeding, and a tenuous airway. He was positioned so as to optimize airway patency and expeditiously transported to the nearest emergency department (ED).

The patient presented to the ED with sonorous respirations and an oxygen saturation of 95%, despite an inspired oxygen concentration (FiO2) of 0.7. Vital signs included a pulse of 65 beats per minute (bpm), a blood pressure (bp) of 155/90 mm Hg, a respiratory rate of 12 breaths per minute, and a temperature of 37°C. Upon initial examination (Figure 25-1), he had ongoing oral and nasal hemorrhage; periorbital, nasal, and lip ecchymoses; mobility of his maxilla; and multiple broken teeth. The patient appeared somnolent and his GCS score was 9. In light of his injuries, and their mechanisms, cervical spine precautions were initiated in anticipation of tracheal intubation (for airway protection).

25.2.1 What Are the Airway Evaluation Considerations in This Patient?

This patient presents with clinical issues that may influence his airway management. In addition to airway protection and maintenance, strategic management of his ventilation will likely be required. As this is not a crash intubation situation, an evaluation of the airway for anticipated difficulty is possible.

The presence of mid-face instability and orofacial disruption will likely hinder the success of bag-mask-ventilation (BMV) due to a poor mask seal. Similarly, in the presence of soft tissue edema and foreign bodies (teeth, clots, etc.), 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. In addition, the use of cervical spine precautions limits the ability to position the head and neck optimally during laryngoscopic intubation. His airway is classified as difficult, requiring the difficult airway algorithm to be employed.

25.2.2 What Is the LeFort Classification System?

Significant mid-face injuries that involve the maxilla and pterygoid plates can be categorized by the LeFort system (Figure 25-2). While fractures can be of mixed type, they are generally classified as follows: the fracture lines of a LeFort I fracture follow the course of the overlying nasolabial folds (ie, involve the maxilla inferior to the nose only); LeFort II fractures involve a larger portion of the maxillae, triangulating from the premolar region on both sides to the nasal bones; and LeFort III fractures include the zygomatic arches, thereby allowing for total mobility of the facial structures (craniofacial disjunction).

By definition, LeFort fractures require that the maxilla be fractured in two separate places, leaving an essentially free-floating segment of bone. This alters the structural integrity of the face and potentially complicates airway visualization. LeFort II and III fractures can significantly impair the airway practitioner's ability to ventilate the patient using a bag-mask, due to poor mask fit and associated obstruction of the nares.1-3

25.2.3 How Is a Basilar Skull Fracture Different from a LeFort Fracture?

Blunt facial and head trauma are often associated with other injuries, including basilar skull and cervical spine fractures. Basilar skull fractures most commonly involve the petrous portion of the temporal bone. However, the sphenoid and ethmoid bones can also be involved. The possibility of ethmoid fracture may be of particular concern, as a free passage may ensue between the nasal and intracranial cavities. Inadvertent intracranial placement of nasally introduced tubes and catheters has been reported, making the blind insertion of nasal airway devices contraindicated.4,5

25.2.4 How Often Is a Major Facial Fracture Associated with Cervical Spine Injury?

The incidence of associated cervical spine fracture with severe blunt facial trauma ranges from 1% to 2.6% of patients.6-9 This potential for associated cervical spine injury requires that, in the absence of the C-spine that has been fully cleared, the airway practitioner makes every effort to maintain the cervical spine in a neutral position. An assistant will be needed to maintain in-line cervical immobilization during attempts at laryngoscopy.

25.2.5 What Other Concerns Do You Have for This Patient?

There are other issues for this patient. The patient has sustained a head injury that is moderately symptomatic. An increase in intracranial pressure (ICP), or even an intracranial hematoma, is possible. The principles of management for the brain-injured patient include the avoidance of hypotension and hypoxemia, as both are independently associated with aggravating secondary brain injury and higher patient mortality. In addition, gratuitous intracranial engorgement due to patient coughing should be controlled. Modulation of the patient's cerebral metabolic oxygen demand is desirable to mitigate increases in cerebral blood flow to areas of normal brain with the potential to cause an increase in ICP. Pretreatment with intravenous lidocaine and fentanyl should be considered prior to induction and paralysis in an effort to blunt further ICP rise with laryngoscopy. For induction, a cerebroprotective sedative (eg, propofol, benzodiazepines, or barbiturates) is warranted, but care must be taken not to induce hypotension that could exacerbate the patient's brain injury. Etomidate may be attractive because of its associated hemodynamic stability, and is neutral in its effects on ICP.10-14 The choice of agents is of particular importance when caring for patients with a diminished cardiac reserve, such as those with severe cardiac disease, those who are critically ill, or patients who are elderly. These patients are more prone to a hypotensive response than are healthier patients with similar injuries. As this is not a crash intubation situation, an evaluation of the airway for anticipated difficulty is possible.

25.2.6 What Investigations Are Warranted for This Patient before Proceeding to Airway Management?

The priority in managing patients with trauma is adequate gas exchange and oxygenation. Clearly, airway intervention takes precedence over any further investigations. Some may argue that a cross-table lateral cervical spine x-ray ought to precede airway intervention. However, since such an investigation would not alter the manner in which the airway is managed (in-line stabilization during laryngoscopy), it ought not delay airway management. Concurrent resuscitation and evaluation is the hallmark of trauma management, meaning that relevant investigations are underway at the same time intubation is undertaken and do not delay management.

25.3.1 What Are the Airway Management Considerations One Needs to Be Aware of?

The initial plan should anticipate both difficult laryngoscopy and difficult BMV. This is at least in part related to the potential for an unstable cervical spine prohibiting proper positioning of the airway by neck flexion or extension with the potential for spinal cord injury. The practitioner should also consider how the patient ought to be positioned for laryngoscopy, as the volume of bleeding and the mechanical stability of the airway might preclude lying the patient flat. An induction with full paralysis might be desirable, although it must be recognized that failure of both intubation and BMV is a significant possibility in this patient. In such a circumstance, the efficacy of many of the common alternative devices would also be compromised. Transillumination with the lightwand (eg, Trachlight™) could be problematic. The intubating laryngeal mask airway might be difficult to place. Vision with the Bullard™ laryngoscope, GlideScope®, or bronchoscope would be clouded in the presence of blood. Basic backups, such as the Combitube™, or surgical airway, would have to be available.

25.3.2 What Procedure Should Be Used to Intubate the Trachea of This Patient?

Timing of positioning in anticipation of airway management is an important consideration. Upon arrival, the patient is able to maintain his airway as he is sitting up. This positioning allows blood and bone fragments to be somewhat displaced away from the airway. However, immediately placing the patient in a supine position strictly for concern of his cervical spine places his tenuous airway at undue risk. Given his mental status and host of injuries, one would anticipate that he would begin to obstruct his airway upon supine positioning. As such, consider denitrogenation in his original position of comfort. Manual in-line cervical immobilization can be quickly initiated in the sitting position. Once all preparations for the difficult airway have been made, the patient should be placed supine immediately preceding laryngoscopy.

With a deteriorating neurological status and a possible increase in ICP, Plan A is a standard approach to rapid-sequence intubation (RSI) with in-line cervical spine stabilization. Alternatively, if the airway is determined to be too difficult to proceed with RSI, an awake look may be employed as Plan A, realizing that the topical anesthesia will most likely fail due to the amount of blood in the airway. Paralysis and intubation would be indicated upon viewing glottic structures. Plan B would be an EGD and Plan C a surgical airway—in other words a "triple setup." Preparation begins by assembling standard intubating equipment, alternative airway devices, and a surgical airway kit. Denitrogenation with a non-rebreather oxygen mask should be initiated well in advance of induction. Uncontrolled epistaxis may impede this process, can lead to aspiration, and may require immediate packing, or cauterization. Adequate suctioning is essential.

Pretreatment with lidocaine, and an opioid should be given 3 minutes prior to intubation, time permitting. RSI will ordinarily include propofol or etomidate, followed by succinylcholine. Anti-aspiration maneuvers, such as Sellick maneuver, ought to be employed, although cautiously to avoid internal jugular vein compression and impeded venous return from the cranial vault. Dosages of the opioids and the induction agents should be moderated to avoid hypotension, particularly in the face of substantial sympathetic nervous system activation.

A sequence of predetermined steps should be employed if failure with laryngoscopy or oxygenation occurs. The alternative airway device of choice should be the one with which the practitioner has the most experience. An intubating LMA has particular advantage, as it may circumvent the problem of a traditional mask seal on top of a mobile maxilla. It can also be manipulated by the guiding handle to best fit the hypopharynx. As an additional backup, the patient's neck should be prepped, and cricothyrotomy equipment should be opened and ready for use, in the event that the preceding steps fail to secure the airway.

25.4.1 What Other Issues Should Be Considered Following Tracheal Intubation?

Stable hemodynamics, as well as intracranial dynamics with adequate cerebral perfusion, together with adequate oxygenation and ventilation, are mandatory for this patient. Serial arterial blood gas measurements to monitor for hypo- or hyperventilation are recommended. Continuous capnography, if available, can be useful in this setting. Importantly, during the time of initial evaluation in the ED, the patient should be adequately sedated and paralyzed to limit the possibility of accidental extubation.

A maxillofacial injury can significantly impair both the ability to bag-mask-ventilate a patient and perform laryngoscopy. Careful consideration must be given to approach this difficult airway, which is complicated further by the significant risk of cervical spine injury, as well as brain injury. The lesson from this patient is to have multiple backup devices ready to use, along with a predetermined plan on how to employ them, in the event that the trachea cannot be intubated orally.