Question 24

Created on Tue, 05/12/2015 - 22:48
Last updated on Tue, 06/14/2016 - 18:33
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Highest mark: ?

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An 18-year-old male presents following a bicycle crash with obvious facial injuries. He has profuse bleeding from the mouth and nose and insists on sitting up at 90 degrees. He has bruising under both eyes, his face is significantly swollen and his mid-face is mobile. His breathing is “noisy”.

His vital signs are as follows:

  • HR 105 beats/minute;
  • BP 115/60 mmHg;
  • RR 30 breaths/min;
  • SpO2 92% on room air.

His GCS is 15. He has no cervical spine injury and no other significant injuries.

List the possible techniques for securing the airway in this patient, and the pros and cons of each.

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College Answer

Rapid Sequence Induction:

Pro:

Rapid technique - may be only option if patient peri – arrest No special expertise required 
May be best technique with ENT/Surgical backup at bedside to perform immediate tracheostomy if intubation fails.

Con:

Obscured / absent landmarks (potential to lose airway with RSI)

  1. Airway swelling
  2. Haematomata and ongoing haemorrhage
  3. Bony and soft tissue trauma

Co-existing upper airway / tracheal injuries Patient unable to lie flat 
Left lateral position may be preferred but increases degree of difficulty Limited respiratory reserve 
Pre-oxygenation, bag-mask ventilation problematic

Likely to become haemodynamically unstable with sedation

Cricothyroidotomy / Awake tracheostomy:

Pro:

Safe – no risk of losing airway

Patient breathing throughout

Con:

May be difficult without sedation Positioning may be problematic

May be technically challenging in the setting of local tissue damage and haemorrhage

Fibreoptic intubation:

Pro:

No risk of losing airway 
Patient breathing throughout

Con:

Likely to be extremely challenging in the setting of ongoing haemorrhage

Attempted nasotracheal intubation could result in nasocranial passage of tube and/or severe nasal haemorrhage 
Need expert/experienced airway assistance

Awake direct laryngoscopy / intubation:

Pro:

Quick – no time wastage

Reduced risk of losing airway 
Patient breathing throughout 
Uses standard intubating equipment 
May be method of choice with senior operator

Allows easy transition to a back-up technique

Con:

Technically challenging 
Needs adequate local anaesthesia 
Positioning patient problematic

Credit given to discussion of any sensible technique and any relevant introductory or concluding statement giving a summary of the issues.

Discussion

This patient is suffering from fractures of the mid-face.

There are several options for securing the airway in this patient.

Firstly, does he need intubation? It seems he does, as his respiratory rate is rapid, and his oxygenation is poor. Likely, he has inhaled some blood. And NIV is absolutely contraindicated in such people. So yes, he does need intubation - largely for airway protection, to prevent vast quantities of blood and snot from seeping into his lungs.

And the savvy candidate will have arrived at this conclusion without a half a page of introductory gibberish.

So, the question asked by the college really is "how do you intubate a hypoxic patient with facial injuries".

They ask for pros and cons, which lends itself well to a tabulated answer.

Technique Advantages Disadvantages
Rapid sequence induction
  • requires less skill
  • requires little preparation
  • If the airway is difficult, it may be disastrous
  • This airway is likely to be difficult
  • pre-oxygenation is going to be interesting (the patient cant lie flat)
  • bag-mask ventilation is impossible (facial fractures)
Fibreoptic intubation
  • patient is awake and breathing throughout the procedure
  • gold standard for difficult airways
  • Requires skilled staff
  • Takes time to prepare
  • Might be difficult if blood and debris is in the airway
  • cannot be performed nasally (fractured face)
Percutaneous cricothyroidotomy
  • patient is awake and breathing throughout the procedure
  • Little chance of airway loss
  • Hghly invasive procedure, may be poorly tolerated
  • cannot lie flat

Then, the college asks for a sensible concluding statement, without demonstrating what one should look like.

In summary, this patient requires intubation by skilled technicians, with backup equipment available. If the patient is peri-arrest, there is not time for any technique other than RSI. Ideally, a videolaryngoscope should be available. Otherwise, the first attempt should be an awake fiberoptic orotracheal intubation, with the opportunity to convert to RSI. In the event that both techniques fail, a percutaneous cricothyroidotomy should be the approach of last resort.

In addition to this "model answer" (pfft) I have also found unusual trivia around the medical literature. There are many ways to approach intubation in the patient with midfacial injuries.

For instance, a submental approach is a well-recognised approach. Retrograde intubation may be attempted, which might be even bloodier than the cricothyroidotomy. These techniques and others are discussed in a good 2009 review article of airway management in facial trauma.

References

Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.

Barriot, P. A. T. R. I. C. K., and B. R. U. N. O. Riou. "Retrograde technique for tracheal intubation in trauma patients." Critical care medicine 16.7 (1988): 712-713.

Mohan, Raja, Rajiv Iyer, and Seth Thaller. "Airway management in patients with facial trauma." Journal of Craniofacial Surgery 20.1 (2009): 21-23.