Control the airway in a patient with signs of maxillofacial trauma

The article is professionally consulted by Master, Doctor Tong Van Hoan - Emergency Medicine Doctor - Emergency Department - Vinmec Danang International Hospital. Doctor with 10 years of experience in the field of Emergency Resuscitation.

Maxillofacial trauma is defined as an injury that is limited from the lower part by the mandible, the upper part to the scalp and ears. Signs of maxillofacial trauma vary widely, depending on the type of injury. Maxillofacial trauma can be:
Soft tissue trauma such as: Injury to cheeks, lips, tongue with lesions of different depth, length. The maxillofacial software has many clinging muscle groups, so it's difficult to treat the wound, if you don't pay attention to the landmarks that can disturb the face. In addition, the maxillofacial region has nerves and salivary ducts that, if not handled properly, can cause complications later on such as facial numbness, saliva leakage into the skin,... Jawbone trauma: Possible trauma to the upper or lower jaw. In particular, the upper jaw is a spongy bone that is softer than the lower jaw, so it is more prone to injury, but it is easier to heal. Trauma to teeth: May leave the consequences that the teeth are dead pulp leading to inflammation of the apex, tooth abscess, tooth extraction.

Along with the development of urban traffic, dense population, maxillofacial injuries are more and more common. Maxillofacial trauma such as jaw fracture can cause collapse of soft tissues in the oropharynx, laryngeal trauma causing airway obstruction. In addition, trauma can cause a hematoma or a foreign object to fall into the airway. In the management of maxillofacial trauma, airway control is the first step, followed by treatment of shock (shock) if present and management of specific injuries. The airway assessment will be done thoroughly and quickly. The doctor will examine, understand all the details of the injury to choose the best method of airway control for the patient.

Safe and optimal airway management for patients with maxillofacial trauma requires careful assessment of the nature of the injury. There are a number of severe maxillofacial injuries that require immediate treatment, particularly acute upper airway involvement and/or heavy bleeding. There are six specific situations associated with maxillofacial trauma, which can adversely affect the airway (Hutchison I, 1990):
(1) Mandibular fracture displaced posteriorly and downward parallel to the inclined plane of the floor of the skull can obstruct the nasopharyngeal airway.
(2) Bilateral anterior mandibular fractures may result in fractured symphysis and posterior tongue slip and oropharyngeal obstruction in supine patients.
(3) Tooth loss/loss or broken teeth, broken bones, vomiting, blood, secretions as well as foreign bodies such as dentures, debris, and sharp fragments that can obstruct the airway anywhere along the mouth pharynx and larynx.
(4) Bleeding from blood vessels in open wounds or heavy nosebleeds due to the complicated blood supply of the nose can also contribute to airway obstruction.
(5) Soft tissue swelling and edema due to head and neck trauma can lead to late airway complications.
(6) Trauma to the larynx and trachea can cause edema and displacement of structures such as the epiglottis, arytenoid cartilages, and vocal cords, thereby increasing the risk of airway obstruction neck area.
High suspicion, meticulous examination and close follow-up of the patient can help detect such situations early and facilitate proper and timely management to avoid future complications. Once the airway is controlled and bleeding is controlled at all sites, a CT scan of the patient's head and neck should be performed with contrast, to examine the vascular structures surrounding the sites of injury and Provides detailed information on the type and extent of injury, for thorough control of bone and soft tissue injuries. Radiological imaging and radical maxillofacial surgery may be delayed until all life- and/or organ-threatening lesions are well controlled.
2.1. Techniques for opening the airways Correction of the patient's position (when the patient is unresponsive): If the patient is lying on his side or on his stomach, use the head, trunk, and limbs to be turned over at the same time. log flipping technique) to return the patient to the supine position. Open the airway by tilting the head or holding the jaw, depending on the specific injury. Tongue enema is one of the common causes of airway obstruction, applying posture corrections helps to pull the tongue forward and open the airway.

If the patient has partial airway obstruction, is awake and coughing, encourage the patient to cough to clear the airway. If the patient is unable to speak, cough, or breathe, has failed to correct posture, or has a foreign body in the mouth or pharynx, apply abdominal compressions (Heimlich maneuver) or back blows and chest compressions. The Heimlich maneuver: Using pressure on the epigastrium to push the diaphragm upwards causes an increase in thoracic pressure, creating a strong airflow to expel the foreign body from the airway. Back pats and chest compressions: Often used for young children. Place the baby on his or her arms in a prone position along the axis of the arms and with the baby's head low. Using the brake of your hand, give 5 quick and 5 quick pats between the shoulder blades. If patting the back does not push the object, turn the child over and apply chest compressions. Between back blows and chest compressions, examine the oral cavity for foreign bodies if found. 2.2. Some protective techniques for airway control in maxillofacial trauma patients Canuyn placement: Helps maintain airway patency by separating the tongue from the pharyngeal wall. Canuyn provides adequate ventilation especially when using Ambu balloons and masks. Properly placed cannulas also make it easier to aspirate sputum. There are two types of cannula: oropharyngeal cannula and nasopharyngeal cannula. Nasopharyngeal catheters are indicated when oropharyngeal catheters cannot be placed, contraindicated in children (due to small nostrils) and in cases of trauma and foreign bodies in the nasal area. Laryngeal mask: Is a means of opening the upper airway with a structure consisting of a large barrel, the lower end has an elliptical ball. After the laryngeal mask is placed on the patient and inflated, the balloon insert is closed over the entrance to the larynx, forming a mask-like layer. Laryngeal mask is convenient and easier to perform than intubation.

Intubation to control airway in patients with maxillofacial trauma: Intubation is an effective method to help maintain airway patency, provide high-concentration oxygen, and facilitate suction of viscous sputum. secretions and help prevent aspiration of secretions from the stomach, throat, and mouth. However, intubation is a difficult technique and should be performed by an experienced physician. Airway surgery: Airway surgery is considered a last resort in airway management. Cricoidotomy or tracheostomy under local anesthesia is a life-saving procedure in the situation of “cannot intubate nor ventilate” especially in fluid airways where the patient is in a comatose state. Urgent emergency tracheostomy is required to both ventilate and aspirate the airway. When needed, you can take the initiative to give controlled respiration (ventilator or balloon pump). During the emergency, it is necessary to pay attention to protect the cervical spine. and coordinate with the same emergency department to treat the patient in the most comprehensive way when there are coordinated injuries.
Airway control is a procedure performed in emergency, surgical,... routine cases at Vinmec. Accordingly, the airway control process at Vinmec is carried out methodically and in accordance with the process standards by a team of highly skilled medical doctors and modern machinery. Thanks to that, many patients have escaped danger and limited complications after the process of controlling the airway.