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).
A photograph of the patient shortly after presentation to the ED.
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).