Lefort and anesthesia
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Trauma patients with facial fractures, lefort fractures, difficult airway, via aerea dificil, trauma facial, intubacion
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Lefort and anesthesia
- 2. MAXILLO-FACIAL INJURIES Challenges for the ED and Anesthesia team. Airway obstruction Pulmonary aspiration Face mask ventilation Direct tracheal access Surgical airway access Infections Mediatinitis Surgical team involved Critical Care & Pain j Volume 12 Number 5 2012
- 3. MECHANISMS OF TRAUMA Penetrating Injury: Gunshot Knife wounds Blunt Trauma: MVC Falls Violent crimes Chemical Electrical Burns Essentials or Trauma Anesthesia, 2nd ed. 2018
- 4. MOST COMMON CAUSES OF FACIAL INJURIES Interpersonal Violence 52% Road Traffic Accidents 16% Sports Injuries 19% Falls 11% Industrial accidents 2% Children 17% 3 millon of Facial traumas AA Critical Care & Pain j Volume 12 Number 5 2012
- 5. MAXILLO-FACIAL INJURIES Male: Female 2:1 Mean age 25.3 years Dental and Tissue Injuries TBI 15-48 % AIRWAY COMPROMISE: Dyspnea, stridor. Drooling, Odynophagia Tracheal Deviation Trismus Bleeding Emphysema Voice changes Burns Critical Care & Pain j Volume 12 Number 5 2012
- 6. FACIAL SKELETON Crumple zone Distribute energy Minimizing damage Points of weakness Strong dense bone areas. Comminution Mandible fracture. Tongue – genioglossi Muscles Mid-face fracture
- 8. Hemorrhage Little impact on the airway. U shape.
- 9. Maxilla – zygoma Naso – Orbito – Ethmoidal complex Crumple zone for TBI Hemorrhage
- 10. Frontal – Sphenoid Naso – Orbito – Ethmoidal complex Eyes Paranasal sinuses Dural tears CSF leak C- Spine condylar Fract
- 11. Anesthetic Briefing Airway evaluation Mechanism – extent injuries Skills of the Provider Available equipment Pre-oxygenation IV access Mouth opening Neurologic Assessment Critical Care & Pain j Volume 12 Number 5 2012
- 12. Anesthetic Briefing Muscle relaxation Ability to preserve airway patency Jaw thrust or traction Cricoid pressure Manual In-line immob Rescue Technique Transtracheal jet ventilation Antibiotics Anti-inflammatory drugs. Critical Care & Pain j Volume 12 Number 5 2012
- 14. Postoperative Management Decision to extubate Anticipating Planning Cuff down leak Equipment for re-intubation. Strategy in case extubation fails
- 15. COMPLICATIONS Failed intubation Esophageal intubation Hypoxia Neurological Injury Death Needs of: Open Cricothyroidoctomy Needle Cannula Tracheostomy FACTORS: Trained Staff Level of assistance Working environment ICU 61% ED 31% Failure to use capnography Delayed recognition Failed rescue Failure of capnography interpret British Journal of Anaesthesia, Volume 106, Issue 5, 1 May 2011,
- 16. ED and ICU British Journal of Anaesthesia, Volume 106, Issue 5, 1 May 2011,
- 17. ED and ICU British Journal of Anaesthesia, Volume 106, Issue 5, 1 May 2011,
Editor's Notes
- Penetrating: loss the landmarks secondary to broken bones and teeth Hemorrhage edema
- American Association of Oral and Maxillofacial Surgeons
- The facial skeleton is composed of many bones inter-digitating with each other at suture lines. It is designed to perform several functions but in the context of trauma, they act as a crumple zone to evenly distribute energy transferred to the face whilst minimizing damage occurring to the skull and brain. There are natural points of weakness in the facial skeleton as well as areas of very strong dense bone called buttresses (Fig. 3). Facial fractures occur in characteristic points where the bones are weakest, and when the buttresses break, it is less usual for the break to be comminuted. Comminution implies greater energy transfer. There are further points of weakness where the facial bones are penetrated by vital structures forming ‘holes’ in the bony cortex. An example of this is the infra-orbital foramen carrying branches of maxillary nerve (second branch of trigeminal nerve, V2) and infra-orbital vessels. The tongue is tethered forward to the mandible by the paired genioglossi muscles that insert into the genial tubercles on the lingual aspect of the anterior mandible (symphysis). Bilateral anterior fractures of the mandible may cause the tongue to fall back into the oropharynx and a conscious patient with this injury will sit up and forwards to protect his own airway. In an unconscious supine patient without airway protection, this fracture is fatal. The face has an extremely good blood supply and facial fractures, particularly of the mid-face, can cause catastrophic haemorrhage. A significant portion of this may go unnoticed in an unconscious supine patient as it can accumulate in the airway, pharynx, and stomach
- In the early 20Th century rene lefort classified the mid midface fractures as lefort I –III Lefort I : horizontal fractures separates the tooth bearing of the maxilla from the rest of the maxilla
- Pyramid shape fracture, separating the tooth maxilla and the nose from upper lateral midface and zygoma Rise suspicion of a skull base fx
- Condylar fracture significantly limit mouth opening Midface is separated and often displaced posteriorly. This type of fracture is often associated with fx of the skull base. Blind attempts at nasotracheal intubation or nasogastric tube placement may result in intracranial penetration of the tube, face mask ventilation is often difficult or impossible.
- Anaesthetic technique The choice of anaesthetic technique will be influenced by the airway evaluation, the skills of the anaesthetist and surgeon, and the available equipment. Conventional i.v. induction of general anaesthesia with muscle relaxation, inhalation route without muscle relaxation, insertion of trans-tracheal catheter under local anaesthesia before induction, awake fibreoptic intubation or tracheostomy under local anaesthesia have been techniques described in the literature.2 Adequate pre-oxygenation, i.v. access, and monitoring are paramount irrespective of the technique used. Trismus secondary to infection might not improve with induction of anaesthesia.3 In cases where mouth opening is limited and swelling is confined to the oral cavity, there should be a low threshold for the use of awake nasal fibreoptic intubation. In the recently published NAP 4 report, failure to consider awake fibreoptic intubation as the primary airway technique led to direct harm in a proportion of reported patients. The avoidance of muscle relaxation when a difficult laryngoscopy is also anticipated, by using either a gaseous induction or a TIVA technique led to a feeling of false reassurance and contributed to adverse outcome in some cases.2 This, however, should be balanced against those cases where these techniques were used successfully and so, were not included in the project. It should be recognized that all primary techniques may fail and that clear rescue plans are in place before commencing anaesthesia. The location of anaesthetic management also needs consideration. The NAP 4 report recommends the anaesthetic management of any case which may involve surgical tracheostomy as a rescue technique should start in the operating theatre.2 Once a secure airway is established, anaesthesia can be maintained by either gaseous or i.v. routes. A saline-soaked throat pack is placed in the oropharynx, if possible, to absorb pus, secretions, and blood. Antibiotics are given according to local microbiology guidance. I.v. dexamethasone may also be required. The operating table may need to be rotated to 908 or 1808 with regards to the anaesthetic machine. Pain relief can be provided by paracetamol, non-steroidal anti-inflammatory drugs, intra- oral local anaesthesia, and long acting opioids.
- Anaesthetic technique The choice of anaesthetic technique will be influenced by the airway evaluation, the skills of the anaesthetist and surgeon, and the available equipment. Conventional i.v. induction of general anaesthesia with muscle relaxation, inhalation route without muscle relaxation, insertion of trans-tracheal catheter under local anaesthesia before induction, awake fibreoptic intubation or tracheostomy under local anaesthesia have been techniques described in the literature.2 Adequate pre-oxygenation, i.v. access, and monitoring are paramount irrespective of the technique used. Trismus secondary to infection might not improve with induction of anaesthesia.3 In cases where mouth opening is limited and swelling is confined to the oral cavity, there should be a low threshold for the use of awake nasal fibreoptic intubation. In the recently published NAP 4 report, failure to consider awake fibreoptic intubation as the primary airway technique led to direct harm in a proportion of reported patients. The avoidance of muscle relaxation when a difficult laryngoscopy is also anticipated, by using either a gaseous induction or a TIVA technique led to a feeling of false reassurance and contributed to adverse outcome in some cases.2 This, however, should be balanced against those cases where these techniques were used successfully and so, were not included in the project. It should be recognized that all primary techniques may fail and that clear rescue plans are in place before commencing anaesthesia. The location of anaesthetic management also needs consideration. The NAP 4 report recommends the anaesthetic management of any case which may involve surgical tracheostomy as a rescue technique should start in the operating theatre.2 Once a secure airway is established, anaesthesia can be maintained by either gaseous or i.v. routes. A saline-soaked throat pack is placed in the oropharynx, if possible, to absorb pus, secretions, and blood. Antibiotics are given according to local microbiology guidance. I.v. dexamethasone may also be required. The operating table may need to be rotated to 908 or 1808 with regards to the anaesthetic machine. Pain relief can be provided by paracetamol, non-steroidal anti-inflammatory drugs, intra- oral local anaesthesia, and long acting opioids.
- Every year about 3 million people are treated for facial trauma according to the American Association of Oral and Maxillofacial Surgeons. Soft tissue trauma includes any cuts to the face or gums. Avulsed, or knocked out teeth are another type of injury, and must be dealt with immediately to increase the chances for reimplantation. Bone injuries, such as fractured jaws, cheekbones, and noses can also occur as well as damage to the nerves in the eyes, face and salivary glands. It is extremely important to have facial trauma assessed and treated by an expert in facial trauma.
- Postoperative management The decision to extubate post-surgery should be taken on a case-by-case basis and after discussion with the surgeon. For patients with significant swelling and stridor at presentation, it may be necessary to keep them sedated and ventilated until extubation becomes safe to do so. Some patients are likely to develop further postoperative swelling, particularly those with Ludwig’s angina or parapharyngeal involvement. The Difficult Airway Society is currently drafting guidelines for extubation. Anticipating, planning, and preparing for what could be an equally dangerous time of anaesthesia should include checking for a ‘cuff down’ leak, having airway equipment for re-intubation on standby, appropriate anaesthetic drugs drawn up in the required doses, and a management strategy in case extubation fails. The surgical team should remain in the operating theatre until successful extubation has been established. A period of observation in theatre should follow before transfer to recovery
- Study conducted in the ED and ICU Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments Abstract Background The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and the emergency department (ED). Methods Reports of major complications of airway management (death, brain damage, emergency surgical airway, unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of 1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management. Results A total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography contributed to 74% of cases of death or persistent neurological injury. Conclusions At least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED. Active airway management takes place most frequently in anaesthetic practice, but is often required outside the operating theatre. Several studies of airway management outside the operating theatre have identified higher rates of complications, including failed intubation, oesophageal intubation, hypoxia, and cricothyroidotomy. These include studies in intensive care units (ICU)1–4 and emergency departments (EDs).4–8 Differences in factors such as case mix, availability of skilled and trained staff, levels of assistance, and working environment all likely contribute. Recent data from analysis of the National Reporting and Learning System (NRLS) of the National Patient Safety Agency (NPSA) indicated that ICU may be an area where airway complications are relatively frequent,9 but the data were limited by the nature of NRLS reporting, which numerically focuses on low impact events.9,10 The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) had the primary aim of identifying the incidence of major complications of airway management during anaesthesia. At an early stage in planning NAP4, it was decided that it would be important to study similar complications in the environments of ICUs and EDs for the reasons stated above. This paper describes the major findings of this section of the NAP4 project. For reasons of space, this paper cannot explore many facets of events that were reported. This paper should be read in conjunction with the accompanying paper11 and the full report of the project is available on