Maxillofacial trauma airway management

Meet the patient

An assault victim arrives with bilateral mandibular fractures, blood pooling in the oropharynx, a hard collar in place, and an oxygen saturation of 91 percent on a non-rebreather. He is drooling because he cannot swallow, his voice is muffled, and the registrar is reaching for the laryngoscope — while the floor of his mouth is quietly swelling.^[1]

The single question that decides this case is the one examiners reward: is the airway getting worse on a clock? A manageable airway at presentation does not stay manageable. Progressive voice change, drooling, stridor, tripod posture, or a rising oxygen requirement are hard indications to secure the airway now — before a CT delay converts a controllable airway into CICO.^[1]

References5ShowHide

1. [1]Frerk C et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
2. [2]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
3. [3]Neal JM et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017 Reg Anesth Pain Med, 2018.PMID 29356773
4. [4]Cook TM, Woodall N, Frerk C, et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth, 2011.PMID 21447488
5. [5]Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia, 2012.PMID 22321104