ANESTHETIC MANAGEMENT OF FACIO-MAXILLARY TRAUMA

Presented by : Dr. MadhanmohanGuidance : Dr. Basant dindor sir

Introduction

• Patients with maxillofacial trauma present unique airway management challenges

1. Emergency 2. Operative 3. Postoperative settings.

Etiology

△ Road traffic accident (RTA)- 35-60%

△ Fight and assault (interpersonal violence)

△ Sport and athletic injuries

△ Industrial accidents

△ Domestic injuries and falls

Facial Anatomy

Fractures of facial bones

• Mandible (61%)• Maxilla (46%)• Zygoma (27%)• Nasal (19.5%)

I II III

Primary Survey in Facio-maxillary Trauma

Ⓐ Airway maintenance with cervical spine control

Ⓑ Breathing and ventilation

Ⓒ Circulation with hemorrhage control

Ⓓ Disability assessment of neurological status & rule out head injury

Ⓔ Exposure and complete examination of the patient

Airway management

• Satisfactory airway signifies the implication of breathing and ventilation and cerebral function

• Management of maxillofacial trauma is an integral part in securing an unobstructed airway

• Immobilization in a natural position by a semi-rigid collar until damaged spine is excluded

• MILS

MILS

Sequel of facial injury

10

Is the patient fully conscious? And able to maintain adequate airway?

Semiconscious or unconscious patient rapidly suffocate because of inability to cough and tongue fall.

Obstruction of airway

asphyxia

Cerebral hypoxia

Brain damage/ death

Immediate treatment of airway obstruction in facial injured patient

△Clearing of blood clot and mucous of the mouth and nares and head position that lead to escape of secretions (sit-up or side position)

△ Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaled and ensuring the patency of the mouth and oropharynx

△ Controlling the tongue position in case of symphysial bilateral fracture of mandible and when voluntary control of intrinsic musculature is lost

△ Maintaining airway using artificial airway in unconscious patient with maxillary fracture or by nasophryngeal tube with periodic aspiration

Advanced airway management• Endotracheal intubation Needed with multiple injuries, extensive soft tissue

destruction and for serious injury that require artificial ventilation

• Tracheostomy Surgical establishment of an opening into the trachea Indications: 1. when prolonged artificial ventilation is necessary 2. to facilitate anesthesia for surgical repair in certain cases 3. to ensure safe postoperative recovery after extensive surgery 4. following obstruction of the airway from laryngeal edema 5. in case of serious hemorrhage in the airway

• Needle Cricothyroidectomy , new generation SAD

Anesthetic management during emergency

• Anesthesiologist role is vital during the emergency management of facio-maxillary trauma patients.

• Securing the airway in unconscious & hypoxic pts can be done by various techniques available.

• Nature, site of injury, associated complications and further surgical management and equipment available decides the technique of airway securement.

Equipment required for intubation

Multiparamonitor

ETT of proper size

Nasal decongestant spray

Laryngocope

Magill’s forceps

2% Lignocaine gel

Suction apparatus

Orotracheal intubation• Intubation through oral route using D/L can be

done if there is no contraindication for it like C-spine injury, grossly fragmented # mandible, extensive oral cavity edema, multiple broken and loose teeth.

• During oral intubation in these pt, skilled person should attempt it along with various shape, size blades and tubes along with stylet.

Nasotracheal intubation (NTI)• If there is contraindication for oral intubation as mentioned

earlier, nasal intubation can be proceeded with.

• Main advantage of NTI (blind, FOI & Lightwand) is in associated C-spine injury

Contraindication for NTI 1. Midface instability (Le fort II & III)2. Suspected basilar skull #3. CSF rhinorrhea (Target sign)4. Coagulopathy

• c

Direct Laryngoscopy and Magill’s forceps assisted NTI

Lightwand assisted & Blind NTI

Light source visible in larynx

Flexible Fibreoptic Bronchoscope • FFB is the ideal equipment for intubation in pt

with facio-maxillary #. Nasal / oral route as per requirement

Retrograde intubation• This technique is carried out in pt where there is

restricted mouth opening such that only ETT can be inserted and no room for laryngoscopy.

• In this a guide wire or epidural catheter is threaded thru a touphy needle or 16G cannula which is punctured intra tracheally between 1-3 tracheal rings.

• The guide wire is then taken out orally or nasally as per the route of intubation and the ETT is rail roaded over the wire. Once ETT position is confirmed guide wire is removed & dressing applied.

Retrograde intubation

or Tracheostomy

Cricothyroidotomy• When attempts at intubation or ventilation have

failed, cricothyroidotomy is considered the procedure of choice.

• The relative ease in locating the cricothyroid membrane and its proximity to the skin allow more expedient dissection compared with emergent tracheostomy

CRICOTHYROITOMY KIT

Tracheostomy• A tracheostomy is a surgical procedure to

create an opening through the neck into the trachea.

• A tracheostomy tube is usually placed through this opening to provide an airway and to remove secretions from the lungs also an ET tube can be passed and ventilated .

Additional choices for managing the emergent airway

• Intubating laryngeal mask airway (LMA Fastrach, LMA North America, San Diego, CA)

• Successful emergent use of the ILMA has been described in a patient with maxillofacial trauma. Its ease of insertion and subsequent ability to blindly intubate the trachea may be advantageous when direct laryngoscopic intubation fails.

Combitube• Esophageal/tracheal double lumen airway (Combitube,

Tyco Healthcare Group LP, Pleasanton, CA),

A.M for Facio-maxillary -Elective surgery

• Intraoperative airway management of patients with maxillofacial trauma is complicated by competing needs for airway and surgical access.

• Airway is secured with various techniques as mentioned earlier

OPERATIVE MANAGEMENT

• For patients with severe panfacial injuries, intraoperative endotracheal tube changes and tracheostomy remain common means of managing the airway.

• However, techniques such as submental and retromolar intubation have recently been espoused to eliminate the morbidity associated with tracheostomy as well as the risk of intraoperative tube repositioning.

Submental intubation

Retro molar intubation

• Maxillomandibular fixation is often employed intraoperatively when correcting both mandibular and maxillary fractures, and, therefore, nasotracheal intubation remains the preferred technique in these patients.

• Preformed curved nasotracheal tubes may be used to minimize operative field interference

Strategies for difficult airway extubation

• a) extubate when the patient awake.

• b) extubate in a deep plane of anesthesia followed by the placement of a laryngeal mask airway to decrease the risk of laryngospasm or bronchospasm.

• extubation over a fibreoptic bronchoscope

• long hollow catheters which may include connections for jet and/or manual ventilation.

• Placing various equipment available in the airway and using it for re-intubation if needed.

Endotracheal Tube Exchanger (TTX) METTRO (Mizus Endotracheal Tube Replacement Obturator)

Airway exchange catheter (Cook)

Sheridan JETTX™ ExchangerJet Ventilation/Tracheal Tube Exchanger

Recommended Technique by the ASA for Extubation of the Difficult Airway

1. Administer 100% oxygen.2. Suction the oropharynx & trachea. 3. Deflate cuff of the endotracheal tube for cuff leakage

check. 4. Insert an airway exchange catheter through the

endotracheal tube to a predetermined depth. 5. Extubate the patient over a jet ventilation catheter.6. Apply oxygen by face mask or insufflation through a jet

ventilation catheter. 7. Tape the proximal end to stabilize it.8. Remove the jet ventilation catheter after 30 to 60

minutes if no obstruction appears.

Thank You• Next class : Journal club

• To be presented by : Dr. Rekha