Presentation 1

Panfacial Trauma
■ Panfacial fractures are defined as multiple fractures of the facial

bones that usually affect the upper, middle, and lower areas of the
face.
■ Airway management in maxillofacial injuries presents with a unique
set of problems. Compromised airway is still a challenge to the
anesthesiologist in spite of all modalities available.
■ Maxillofacial injuries are the result of high-velocity trauma arising
from road traffic accidents, sport injuries, falls and gunshot
wounds. Any flaw in airway management may lead to grave
morbidity and mortality in prehospital or hospital settings and as
well as for reconstruction of fractures subsequently..
Airway management in case of trauma can be
Challenging
Difficult Needs Disrupted

Airway Rapid Action Anatomy
Failure or delay = high morbidity and

mortality
When planning to secure the airway,
the physician has to consider
several aspects:
■ the nature of the trauma and its effect on the airways,
■ potential difficulties in mask ventilation or endotracheal
intubation,
■ possible trauma of the cervical spine,
■ the risk of regurgitation and aspiration of gastric contents,
■ significant bleeding that precludes view of airway anatomy and
may cause circulatory deterioration, and
■ the type of maxillofacial operation that is to be done and
whether the oral cavity needs to be empty for performing the
procedure and closed with maxilla-mandibular fixation (MMF) at
the end of surgery.
Hutchison et al., there are six specific
situations associated with maxillofacial
trauma, which can adversely affect the airway.
Anatomical considerations
Cribriform plate may be fractured so in the presence of basal skull fractures
nasogastric tube insertion or nasotracheal intubation is contraindicated
Trauma – Initial Assessement
■ Prehospital – control airway, external haemorrhage, rapid

transport.
■ Primary Survey - initial assessment and resuscitation of vital
functions, prioritization (based on ABCDE)
■ The primary focus of ATLS is on the first hour of trauma
management - rapid assessment and resuscitation (THE
GOLDEN HOUR)
Indications of Definitive Airway
Strategy
How Will You Assess Airway?
o ‘BONES’ for assessing difficulty at mask ventilation
(Beard, obesity, no teeth, elderly, snorer)
o ‘LEMON’ for assessing difficulty during laryngoscopy
& intubation(Look externally, examine 3-3-2,MMP,
obstruction, neck mobility)
o ‘RODS’ for assessing difficult placement of SAD
(Restricted mouth opening, obstruction, disrupted
upper airway, stiff lung)
o ‘BANG’ to predict difficult surgical airway (Bleeding
tendency, agitation, neck scarring, growth or
vascular abnormalities in region)
Oral Vs Nasotracheal Intubation
In general, oral intubation is preferable to nasal intubation in the
emergency setting because
■ Epistaxis.
■ Risk for sinusitis in a patient who will be mechanically ventilated for >
24 hours.
■ use of a smaller-diameter tube will also increase the difficulty of
subsequent airway suctioning and fiberoptic bronchoscopy. of the
risk of injury to the brain in the presence of a basilar skull or
cribriform plate fracture.
■ However, If nasal intubation is most likely to be successful in a given
situation, then prefer nasal, Change to an oral tube once the patient's
condition has stabilized.
Role Of Rapid Sequence
Induction(RSI)?
■ Still considered hazardous.
■ However, if the situation justifies the risk of administering these drugs, one
should assure that skilled personnel are available to perform tracheal intubation.
Following steps should be strictly adhered to while carrying out rapid sequence
intubation:
1. Ensure the presence of a person with skills to perform surgical airway in the
event of failed intubation.
2. Ensure that suction and device to ventilate the patient is readily available.
3. Pre-oxygenate with 100% oxygen and apply cricoid pressure (Sellick's
maneuver).
4. Administer i.v. induction agent & then administer 1-2 mg/kg succinylcholine
intravenously.
5. Perform intubation after the patient relaxes.
6. Inflate the cuff of the endotracheal tube and confirm correct tracheal tube
placement by auscultation and presence of CO2 in exhaled air.
7. Release cricoid pressure.
8. Ventilate the patient.
9. Secure the tracheal tube firmly.
Alternative to the Airway of the
Patient with Maxillofacial
Trauma
■ Fiber-optic intubation under local anesthesia
■ Retrograde Intubation
■ Awake Laryngoscopy
■ Supraglottic Airway devices
■ The Surgical Airway
ASA Algorithm for Difficult Airway
The surgical Airway
■ Definitions
■ Tracheotomy:Surgical opening of the trachea.
■ Tracheostomy : Creation of a stoma at the skin surface which
leads into the trachea.
History
 The Tracheostomy is one of the oldest surgical
procedure.
 It can be traced back to Egyptian tablets from 3600
B.C.
 1546 : first well-documented tracheostomy by
Antonius Musa Brasavola,
 1921: Chevaliar Jackson – standardized the
technique of the tracheostomy .
 Modern percutaneous tracheostomy (PCT)
developed by Toye and Weinstein in 1969
Types of tracheostomy
■ Depending on time Elective /routine Emergency
■ Depending on the cause Permanent/Temporary
■ Depending on site
High
Mid
Low
■ Technique –
■ Cricothyroidotomy,
■ open tracheostomy ,
■ Percutaneous procedure
Paediatric tracheostomy
■ Better done under general anesthesia
■ Neck shoudnt be extended too much
■ Always divide the thyroid isthmus
■ Vertical incision in trachea b/w 2nd and 3rd
ring.
■ No excision of ant. Wall of trachea
■ Margins of tracheal incision sutured to skin
Percutaneous Dilational
Tracheostomy
Submental Intubation
■ Submental orotracheal intubation was developed in order to avoid
the need for tracheotomy and to permit unfettered access to the oral
region.
■ This type on intubation is done
a) in patients with comminuted fracture of the midface or the nose,
where nasal intubation is contraindicated,
b) in patients who require restoration of the occlusion, and
c) In patients whose condition permits extubation at the end of
surgery.
However, this type of intubation is contraindicated in patients with

comminuted mandibular fractures.
Retromolar
intubation
■ The retromolar space is a potential space for ETT placement

bounded anteriorly by the last molar and posteriorly by the
anterior edge of ascending ramus of mandible. Adequacy of this
space can be confirmed by placing finger behind the distal molar.
■ Hence, it is a feasible alternative to the invasive methods
described, cheaper, associated with fewer complications and less
time-consuming.
■ However, when the space is insufficient due to
impacted/erupting third molar, its use may be limited.

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Panfacial Trauma

■ Panfacial fractures are defined as multiple fractures of the facial

Difficult Needs Disrupted

Failure or delay = high morbidity and

■ Prehospital – control airway, external haemorrhage, rapid

However, this type of intubation is contraindicated in patients with

■ The retromolar space is a potential space for ETT placement

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