An summary of a Krausz et al (2009) article discussing the importance of effective airway management in the maxillofacial trauma patient and the complexities that such an injury presents. Only points relevant to UK paramedics have been included. For more details, please read the original article. Any additions made by Article 999 are in square brackets [].

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The Key Points

• Remember to follow ATLS protocol [and/or your local guidance and JRCALC guidelines]
• Use cervical spine control along with effective airway management
• ‘The most common critical care errors are related to airway and respiratory management. Gruen et al studied 25 trauma mortality patients […] [and] found that failure to intubate, secure or protect the airway was […] responsible for 16% of inpatient deaths’ [and that was in a trauma centre, albeit in 1996-2004!] (Gruen et al, 2006)

Hutchinson et al (1990) (in Krausz et al, 2009) found 6 potential ways maxillofacial trauma might prevent effective airway management.

These, from the top of the head downwards, can be summarised as:

Head and soft tissue trauma
– These risk ‘delayed airway compromise’

Nasal bleeding/open wounds causing obstruction

Mandible fractures
– Leading to the tongue to drop back, blocking the oropharnyx
– Leading to blockage of the nasopharnygeal airway

Mouth obstructions
– From loose items & bodily fluids

Tracheal trauma
– Leading to swelling and displacement of essential airway structures behind them.

C-spine injury
– Leading to the need for “in-line stablization”. This can cause a reduced view during intubation
– The act of intubating might increase neck movements, potentially worsening this injury

Stomach
– [All patients ambulance personnel intubate in the prehospital environment might realistically have a full stomach]
– Note the risk of regurgitation
– Consider cricoid pressure – but also consider that this might ‘worsen the larnygeal view’
– Other tips noted in this section are not relevant to UK paramedics. Please read the full article for more information

These cause:
– Difficulties fitting a mask
– Less ‘efficient air transferring from the mask to the lungs’
– A ‘difficulty in visualizing the vocal cords’ when intubating due to fluids & obstructions

Final points

• Consider all of the above and ‘avoid future complications’. Then address other injuries.
• Emergency intubation is fraught with risks
• Consider your expertise and experience. Ensure the trauma patient can access ‘the most experienced personnel’ where possible. This would reduce one of the risks.
• Ensure prompt treatment
• Consider the patient’s GCS, breathing level & risk to aid your decision making about transport
• Check the ‘extent, the composition and the anatomy of the injury’. Is it possible to ventilate with a mask?
• ‘Is there a limitation in mouth opening? Is that limitation the result of pain’ only? [In a prehospital environment, this may be difficult to ascertain]
• An LMA may ‘not be suitable for managing trauma patients. However, it could enable ventilating the patient until definitive airway is achieved’

References

Gruen, R.L. et al. 2006. Patterns of Errors Contributing to Trauma Mortality: Lessons Learned from 2594 Deaths, Annals of Surgery, 244 (3): 371-380, Available Online:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856538/

Krausz, A. et al. 2009. Maxillofacial trauma patient: coping with the difficult airway, World Journal of Emergency Surgery, 4: 21, Available Online: https://wjes.biomedcentral.com/articles/10.1186/1749-7922-4-21

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Remember to follow ATLS protocol [and your local guidelines], use cervical spine control and focus on airway management.

Head and soft tissue trauma, nasal bleeding or open wounds, mandible fractures, mouth obstructions, tracheal trauma, c-spine injury and the patient’s stomach contents can all make airway management more challenging (Hutchinson et al, 1990 in Krausz et al, 2009).

Top tips?

• Consider cricoid pressure but bear in mind it may actually worsen your view during intubation.
• Ensure rapid transport and treatment of the patient and consider your own expertise.
• What level of experience do you really need to deal with this patient, who has it, and where are they?
• The patient’s GCS, breathing level and risk should all support this decision.
• You can use an LMA, but it’s a time-stop measure [Article 999 interpretation; see full summary].
• Consider the ‘extent’ of the patient’s injuries and how they are going to make it difficult to use a mask and intubate if required.

(Krausz et al, 2009)

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