7.1 Facial Fractures in uncooperative patient Flashcards
A 23-year-old man is brought to the emergency department following an assault in a nightclub. He
appears to have suffered significant mid-face fractures and is uncooperative with staff. You are asked
to accompany him to the CT scanner.
a) Outline the immediate management plan for this patient. (25%)
b) List the options for securing the airway in this case and any advantage or disadvantage of the
methods. (25%)
c) What problems should be anticipated before securing the airway? (50%)
Immediate management
Primary survey
A - assess if it is at risk secondary to blood loss or injury
B - 100% via NRB FM
C - Check vital signs
establish wide bore iv access
check fbc - anemia / coag - coagulopathy / group and x match
D
patient is uncooperative with staff
what is the reason for this - is he drunk? has he consumed drugs
try to reason with him
if he is danger to self and staff he may require sedation to reduce risk of further injury
Exposure
assess for any other injuries
May need intubation along with sedation if low gcs
b) List the options for securing the airway in this case and any advantage or disadvantage of the
methods. (25%)
1 Direct laryngoscopy
Ease access / familiarity
Provides direct view
- unsuitable if difficutly suspected
2 Video Laryngoscopy
Useful if difficult airway susepected
Assistant can see on screen
camera may become blocked with blood if present
3 AFOI
If anticipated difficult airway expected is safest option to secure airway prior to induction of anaesthesia
Requires cooperative patient
4 Intubating bronchoscope
if difficulty suspected / for body
Require familiary
- Intubating LMA
rescue technique
c) What problems should be anticipated before securing the airway? (50%)
- Combatative patient - may not be able to adequately pre o2 patient
may not cooperate with afoi - Facial fractures
may cause pain on pre o2 holding tight fitting fm
3 Anatomy distortion
secondary to injury
- blood in field
due to injury - may affect view on VL
5 difficult airway - may have difficulty with mouth opening
inserting laryngoscope
6
A 23-year-old man is brought to the emergency department following an assault in a nightclub. He
appears to have suffered significant mid-face fractures and is uncooperative with staff. You are asked
to accompany him to the CT scanner.
a) Outline the immediate management plan for this patient. (25%)
A
This is an emergency trauma situation and so I would assess and manage the patient simultaneously following an ABCDE approach.
Call for help (senior anaesthetic and ODP support, maxillofacial or ENT colleague) and a difficult airway trolley.
Airway:
» Allow the patient to adopt a position that is comfortable for breathing.
> > Oxygen 15 l/min via non-rebreathe bag.
> > Check for airway obstruction by blood, teeth, displaced bone. If posteriorly displaced midface fracture causes loss of airway, then pull
midface forward.
> > Assess for indications for immediate intubation: dyspnoea, stridor, drooling, voice change.
C-spine control: if the patient is uncooperative, it is not safe to force them
into collar and blocks, but bear in mind the possibility of associated injury.
A 23-year-old man is brought to the emergency department following an assault in a nightclub. He
appears to have suffered significant mid-face fractures and is uncooperative with staff. You are asked
to accompany him to the CT scanner.
a) Outline the immediate management plan for this patient. (25%)
B+C
Breathing:
» Assess for associated injuries: auscultate and palpate chest, assess for
bilateral chest movement with respiration, palpate trachea.
» Monitor oxygen saturations and respiratory rate.
Cardiovascular:
» Large-bore intravenous access, take blood for cross-match, full blood
count, urea and electrolytes, blood glucose.
» Major midface fractures rarely cause significant hypovolaemia, but the
patient may have other injuries causing blood loss.
A 23-year-old man is brought to the emergency department following an assault in a nightclub. He
appears to have suffered significant mid-face fractures and is uncooperative with staff. You are asked
to accompany him to the CT scanner.
a) Outline the immediate management plan for this patient. (25%
D+E
Disability:
> > Patient is uncooperative. Possible causes: alcohol; illicit drug use; brain injury; hypoxia due to airway compromise.
> > Check GCS and pupils and assess for any obvious lateralising signs that may indicate an associated brain injury.
Exposure:
» Check for signs of other major and immediately life-threatening injuries and manage appropriately.
b) List the options for securing the airway in this case and any advantage or disadvantage of the
methods. (25%)
Rapid sequence induction:
> > Preferred option due to low likelihood of cooperation and full stomach.
> > Requires videolaryngoscope and full difficult airway trolley availability, skilled assistance, presence of maxillo-facial/ENT colleague if considered
necessary.
> > Plan B supraglottic airway device, plan C surgical cricothyroidotomy/ emergency tracheostomy.
Advantages:
» Rapidly secures the airway.
» Minimal patient cooperation required.
» Maximum protection of airway from contamination by blood or full stomach.
Disadvantages:
» Potential for difficulty intubating once the patient is rendered apnoeic.
Depending on gas exchange and level of consciousness, it may not be possible to wake the patient up again, hence the need for full
range of airway adjuncts (remembering that nasopharyngeal airway contraindicated due to risk of base of skull fracture).
b) List the options for securing the airway in this case and any advantage or disadvantage of the
methods. (25%)
Other options:
Awake fibreoptic:
• Advantages: maintenance of spontaneous ventilation, useful in the presence of distorted anatomy.
• Disadvantages: specific skills required, does not protect airway from contamination, requires patient cooperation, requires transfer to theatre of potentially unstable patient, view would be obscured if there
is airway bleeding.
Awake tracheostomy:
• Advantages: avoids a potentially difficult airway.
• Disadvantages: requires skilled surgeon, patient cooperation, skilled anaesthetist
c) What problems should be
anticipated before securing the
airway? (50%)
> > Preoxygenation: uncooperative patient, mask may not fit well/cause pain
due to fracture. May be done sitting for patient comfort. Consider highflow
nasal oxygen.
> > Difficult laryngoscopy: distorted anatomy, obscured view due to blood,
neck immobilisation, hence the need for difficult airway trolley, senior
anaesthetic assistance and, possibly, ENT or maxillofacial assistance.
> > Airway contamination: blood, teeth, full stomach.
> > Tube: smaller diameter tube should be available and leave uncut – potential for significant swelling.
c) What problems should be
anticipated before securing the
airway? (50%)
> > Cardiovascular stability: may be compromised by other injuries.
Resuscitation drugs, fluid boluses, full monitoring should all be ready.
> > Drugs: consideration of potential interactions of anaesthetic agents with
alcohol and illicit drugs.
> > Comorbidities: awareness that history may be limited due to patient’s lack of ability to cooperate.
