IMMEDIATE MANAGEMENT OF LIFE-THREATENING CONDITIONS
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 or in-line stabilization with cervical collar temporarily removed to allow full visualization. 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. Watch for “hard signs” which indicate the need for early airway intervention and operative exploration. These include air bubbling from the wound, expanding hematoma, hematemesis, shock, diminished radial pulse(s), and/or neurologic deficits. Although close monitoring should continue, when “soft signs” are present (including subcutaneous emphysema, dysphagia, dyspnea, chest tube air leak, paresthesias, and/or a stable, nonexpanding hematoma), securing an airway may be delayed to obtain imaging, such as computed tomography angiography (CTA). Soft tissue swelling and edema may result in delayed airway compromise. Warning signs include hoarseness, subcutaneous emphysema of the neck, laryngeal pain, visible edema, stridor, or sonorous respirations.
Perform a jaw thrust to allow for ventilation while aggressively clearing and suctioning the obscuring material. The chin lift maneuver may be performed as long as stabilization of the cervical spine is maintained, being careful not to hyperextend the neck. 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. Laryngeal mask 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 (OG) tube placement should be performed after intubation for gastric decompression. Contraindications for NG tube placement include suspected or confirmed basilar skull fractures, as insertion may result in intracranial placement and death. Instead, in cases where basilar skull fractures are suspected or confirmed, an OG tube should be placed.
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 (ET) 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.