Maxillofacial trauma patient: coping with the difficult airway

Abstract

Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.

Figure 1

A woman who sustained a single gunshot injury. She arrived at the hospital conscious and breathing spontaneously. Impossible mask ventilation and diffucult intubation were anticipated. Direct laryngoscopy was performed and oro-tracheal intubation was successful.

Figure 2

A patient with high velocity long distance injury, with severe soft tissue damage of the right chick. 3 dimensions CT shows comminuted fracture of the right orbit, zygoma and right mandible.

Figure 3

Male patient who sustained low velocity missile injury to the left chick. Lateral radiography demonstrates the bullet location. Note the patent airway on the lateral view (white arrow).

Figure 4

Male patient who sustained high velocity injury to the lower face. Tracheostomy was performed in the Shock-Trauma Unit. Lateral x-ray shows comminuted fracture of the mandible with huge soft tissue swelling of the neck and narrowing of the airway (white arrow).