SAQ 309 – Airway – severe midface trauma and haemorrhage control

Airway – severe midface trauma and haemorrhage control.

a. Initial priorities

• Secure the airway.
• Control haemorrhage.
• Provide volume/blood resuscitation as required.

b. Laryngoscopy problem

• Haemorrhage obscures the view and can make laryngoscopy ineffective; airway geometry is not usually the main problem.

c. RSI modifications

• Position awake patients sitting up if possible; if GCS is reduced, use supine or left lateral positioning if blood pools.
• Pre-oxygenation may be limited by blood pooling and poor mask seal.
• Prepare active suctioning, including a SALAD-style approach if needed.
• Use dose-reduced induction if shocked; ketamine is a suitable induction agent.

d. Midface haemorrhage control

• Use a cuffed endotracheal tube and confirm the airway is protected first.
• Clear clots and blood with suction.
• Insert posterior nasal packs or Foley catheters through the nares, inflate, and pull anteriorly to tamponade posterior bleeding.
• Pack the anterior nasal cavities firmly with ribbon gauze or commercial nasal packs.
• Pack the oropharynx around the tube with gauze to tamponade ongoing oral bleeding while protecting the tube.
• Secure packs/catheters, reassess bleeding, and urgently involve ENT/maxillofacial surgery or interventional radiology for definitive control.