will be useful for anesthesia interns regarding various methods available for securing airway in patients with severe facio-maxillary injuries

1. ANESTHETIC MANAGEMENT OF
FACIO-MAXILLARY TRAUMA
Presented by : Dr. Madhanmohan
Guidance : Dr. Basant dindor sir

2. Introduction
• Patients with maxillofacial trauma present
unique airway management challenges
1. Emergency
2. Operative
3. Postoperative settings.

3. Etiology
△ Road traffic accident (RTA)- 35-60%
△ Fight and assault (interpersonal violence)
△ Sport and athletic injuries
△ Industrial accidents
△ Domestic injuries and falls

4. Facial Anatomy

5. Fractures of facial bones
• Mandible (61%)
• Maxilla (46%)
• Zygoma (27%)
• Nasal (19.5%)

6. I II III

7. 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

8. 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

9. MILS

10. 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

11. 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

12. 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

13. 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.

14. Equipment required for intubation
Multiparamonitor
ETT of proper size
Nasal decongestant
spray
Laryngocope
Magill’s forceps
2% Lignocaine gel
Suction apparatus

15. 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.

16. 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

17. • c
Direct Laryngoscopy and Magill’s forceps assisted NTI

18. Lightwand assisted & Blind NTI
Light source visible in larynx

19. Flexible Fibreoptic Bronchoscope
• FFB is the ideal equipment for intubation in pt
with facio-maxillary #. Nasal / oral route as per
requirement

20. 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.

21. • 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.

22. Retrograde intubation

23. or Tracheostomy

24. 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

25. CRICOTHYROITOMY KIT

26. 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 .

27. 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.

28. Combitube
• Esophageal/tracheal double lumen airway (Combitube,
Tyco Healthcare Group LP, Pleasanton, CA),

29. 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

30. 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.

31. Submental intubation

32. Retro molar intubation

33. • 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

34. 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.

35. • 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.

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

37. Airway exchange catheter (Cook)

38. Sheridan JETTX™ Exchanger
Jet Ventilation/Tracheal Tube Exchanger

39. 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.

40. Thank You
• Next class : Journal club
• To be presented by : Dr. Rekha