A Case Report of Facial Trauma

Gholamreza Ghamatzadeh M.DBoardman of Anesthesiology

Poursina Hospital - Rasht

Presentation

Male 25 years old BW ≈ 80kg Severe facial trauma due to car accident Agitated & Disoriented GCS = 8/15 Left side chest tube ↓ Respiratory sounds in right side of the chest → suspect to

right side pneumothorax SBP=60mmHg, DBP=non sense, HR=140/min, RR=25/min

Fentanyl 50 µgr/stat

+

TPN 50mg/stat

↓↓

Cardiac arrest + Gasping respiration

CPR 1

Direct Laryngoscopy + Oral intubation↓

O2 100%↓

External Cardiac Massage↓

Adrenaline 100µg (3 times)↓

CPR 2

Bicarbonate Na 50 meq↓soon

Adrenaline 1mg (3 times)↓↓

Bradycardia↓

Atropine 0.5mg (2 times)↓↓VT

CPR 3

VT

↓↓

Lidocaine 100mg

↓↓

Sinus Tachycardia

(BP=140/70, PR=143/min)

Maintenance of Anesthesia

Fentanyl 50µg Cisatracurium 4mg O2 100% Ventilation rate= 12/min

ABG 1

PH: 6.97Pco2: 67 mmHg

Hco3: 15.5Po2: 242

O2 sat: 99%BE: -15

↓↓Bicarbonate Na 2 vials

Rate: 18/min

ABG 2 (40 min. later)

PH: 7.06Pco2: 73.9 mmHg

Hco3: 20.5Po2: 114

O2 sat: 95%BE: -11

↓↓Bicarbonate Na 1 vial

CBC result

In this time:

Hgb: 9.1

Hct: 27

Plt: 425000

New Problem

In this time:

BP decreased (60/30-40)

↓↓

Ephedrine 10mg (2 times)

(Tachycardia)↓soon

Dobutamine infusion 20µg/kg/min

Another Problem

Because of ↓respiratory sounds:

CXR

↓↓

Right side Pneumothorax

↓

Surgical Consultation for Chest Tube insertion

↓

Chest Tube

In this time:

O2 50%

+

N2O 50%

New Problem

In the end of surgery:

Emphysema in left side of upper chest and neck + Air bubbling from left side wound of

neck

↓

Second Surgical Consultation

In the end of surgery:

BP: 80/50 mmHg

PR: 140 beats/min

Urine out put: 1500 ml for 4 hours

Transportation to ICU

Received Fluids

Packed cell: 3 units N/S: 3000ml

In ICU

Full Support Cisatracurium 4mg/PRN SIMV: VT→700 ml Rate→14/min FIO2→40% PS→20 cmH2O PEEP→0 Dobutamine 20µg/kg/min

ABG 3 (60 min. later in ICU)

PH: 7.31Pco2: 37.2 mmHg

Hco3: 18.2Po2: 227 mmHgO2 sat: 99.7%

BE: -6.8↓↓

FIO2 = 30%

In ICU

BP=160/80, PR=140/min↓↓

Dobutamine 10µg/kg/min30 min. later:

BP=140/80, PR=140/min↓↓

Dobutamine 5µg/kg/min45 min. later:

BP=130/80, PR=136/min

Conclusion

Compromised Airway 1

Unlike difficult intubations in normal airways, patients with compromised airways must not be given GA or muscle relaxants unless control of airway is ensured.

Attempt at awake intubation should not be done “blindly” in patients with uncertain pathologic processes.

Compromised Airway 2

Safe techniques for managing compromised airways include:

1. Awake direct laryngoscopy after careful topical laryngeal block

2. Spontaneous breathing using an inhaled anesthetic3. Awake fiberoptic evaluation of the airway4. Tracheostomy under local anesthesia5. If necessary, lifesaving TTJV through a cricothyroid

puncture with a large-caliber(14-gauge) needle, or an emergency cricothyroidotomy.

Facial Injury

The most common fractures involve the mandible and midface (Le fort I,II,III)

A first priority is to secure the airway by placing the patient in the lateral position, pulling the mandible or maxilla forward and clearing the oropharynx of blood or loose teeth.

If this action is not successful, endotracheal intubation or emergency tracheostomy should be considered.

These patients may also have head trauma or fractures of the cervical spine.

Contraindications of Nasal Intubation

Coagulopathy Severe intranasal disorder Basilar skull fracture Presence of a CSF leak

Asystol Management

Thanks