This case report describes the anesthetic management of a patient with severe facial trauma from a car accident. The patient experienced cardiac arrest after induction with fentanyl and propofol. Resuscitation was performed including external cardiac massage, adrenaline, bicarbonate, and lidocaine. Sinus tachycardia was achieved. The patient was found to have pneumothorax requiring chest tube insertion and developing subcutaneous emphysema in the neck requiring surgery. In the ICU, the patient required inotropic support with dobutamine before being weaned. The report concludes with lessons around securing the airway in facial trauma and managing compromised airways.

1. A Case Report of Facial Trauma
Gholamreza
Ghamatzadeh M.D
Boardman of Anesthesiology
Poursina Hospital - Rasht

2. Presentation
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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

9. Fentanyl 50 µgr/stat
+
TPN 50mg/stat
↓↓
Cardiac arrest + Gasping respiration

10. CPR 1
Direct Laryngoscopy + Oral intubation
↓
O2 100%
↓
External Cardiac Massage
↓
Adrenaline 100µg (3 times)
↓

11. CPR 2
Bicarbonate Na 50 meq
↓soon
Adrenaline 1mg (3 times)
↓↓
Bradycardia
↓
Atropine 0.5mg (2 times)
↓↓
VT

12. CPR 3
VT
↓↓
Lidocaine 100mg
↓↓
Sinus Tachycardia
(BP=140/70, PR=143/min)

15. Maintenance of Anesthesia
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Fentanyl 50µg
Cisatracurium 4mg
O2 100%
Ventilation rate= 12/min

16. ABG 1
PH: 6.97
Pco2: 67 mmHg
Hco3: 15.5
Po2: 242
O2 sat: 99%
BE: -15
↓↓
Bicarbonate Na 2 vials
Rate: 18/min

17. ABG 2 (40 min. later)
PH: 7.06
Pco2: 73.9 mmHg
Hco3: 20.5
Po2: 114
O2 sat: 95%
BE: -11
↓↓
Bicarbonate Na 1 vial

18. CBC result
In this time:
Hgb: 9.1
Hct: 27
Plt: 425000

19. New Problem
In this time:
BP decreased (60/30-40)
↓↓
Ephedrine 10mg (2 times)
(Tachycardia)↓soon
Dobutamine infusion 20µg/kg/min

20. Another Problem
Because of ↓respiratory sounds:
CXR
↓↓
Right side Pneumothorax
↓
Surgical Consultation for Chest Tube insertion
↓
Chest Tube

23. In this time:
O2 50%
+
N2O 50%

24. 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

26. In the end of surgery:
BP: 80/50 mmHg
PR: 140 beats/min
Urine out put: 1500 ml for 4 hours
Transportation to ICU

27. Received Fluids
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Packed cell: 3 units
N/S: 3000ml

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

30. ABG 3 (60 min. later in ICU)
PH: 7.31
Pco2: 37.2 mmHg
Hco3: 18.2
Po2: 227 mmHg
O2 sat: 99.7%
BE: -6.8
↓↓
FIO2 = 30%

31. In ICU
BP=160/80, PR=140/min
↓↓
Dobutamine 10µg/kg/min
30 min. later:
BP=140/80, PR=140/min
↓↓
Dobutamine 5µg/kg/min
45 min. later:
BP=130/80, PR=136/min

32. Conclusion

33. Compromised Airway 1
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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.

34. 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 anesthetic
3.
Awake fiberoptic evaluation of the airway
4.
Tracheostomy under local anesthesia
5.
If necessary, lifesaving TTJV through a cricothyroid
puncture with a large-caliber(14-gauge) needle, or an
emergency cricothyroidotomy.

35. Facial Injury
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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.

36. Contraindications of Nasal Intubation
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Coagulopathy
Severe intranasal disorder
Basilar skull fracture
Presence of a CSF leak

37. Asystol Management

40. Thanks