Emergency management of life-threatening associated conditions is described in Chapter 12.
Evaluate the patient's entire airway with direct visualization while maintaining immobilization of the cervical spine (C-spine) with a cervical collar. The patient should remain fully immobilized until spinal column injury is ruled out.
Diligent continuous monitoring of the airway should be performed for any patient with significant maxillofacial or neck trauma, as airway compromise can be abrupt. Keep a low threshold for intubation of any patient with impending airway obstruction. Soft tissue swelling and edema may result in delayed airway compromise. Warning signs include hoarseness, subcutaneous emphysema of the neck, laryngeal pain, visible edema, or the presence of an expanding hematoma.
Perform a jaw thrust to allow for ventilation while aggressively clearing and suctioning the obscuring material. The chin lift maneuver is contraindicated in any patient with potential cervical spinal trauma. Rapid-sequence intubation (RSI) with in-line C-spine stabilization is the preferred method of securing an airway in any patient without contraindications. Avoid using paralytics if the patient's facial trauma might preclude successful bag-valve-mask ventilation. Intubation with sedatives alone is an alternative. Fiberoptic and videolaryngoscopic intubations are difficult in maxillofacial trauma patients secondary to poor visualization resulting from blood, secretions, and vomitus in the airway. LMA should only be considered as a bridging device when immediate ventilation is needed and only used until a definitive airway can be established. Surgical airways and direct laryngoscopy are still the best options for definitive airway management. Nasogastric (NG) or orogastric tube placement if facial trauma is present, should be performed after intubation for gastric decompression.
Hoarseness, dysphonia, edema, persistent pain below the hyoid bone or crepitance over the thyroid cartilage implies a laryngeal injury. Presence of these signs necessitates a definitive airway. Endotracheal intubation is not contraindicated but may be difficult in this situation secondary to disruption and displacement of normal anatomic structures. If direct laryngoscopy is impossible, a cricothyroidotomy with prompt revision to a tracheostomy is the preferred alternative.
Tension pneumothorax or persistent air leak from chest tube may indicate a tracheal or bronchial injury. A chest X-ray may demonstrate signs of an occult upper airway injury by demonstration of mediastinal air. Bronchoscopy may be necessary for definitive diagnosis. Endotracheal intubation is not contraindicated in injury to the trachea below the cricothyroid membrane and should be attempted. Preparations for a surgical airway should be ongoing simultaneously. Tracheotomy below the trauma is the preferred alternative and should be performed immediately after the initial attempt at endotracheal intubation fails. Endotracheal or tracheostomy tubes may also be placed during diagnostic bronchoscopy if necessary.
Intubation through a Traumatic Opening
Dashboard trauma to the neck in motor vehicle accidents and “clothes-line” injuries from motorcycle or skiing injuries can sever the soft tissue ...