SAQ 394 – Maxillofacial – severe facial trauma airway and haemorrhage

Maxillofacial – severe facial trauma airway and haemorrhage.

a. Analgesia approach

• Give judicious analgesia in appropriate doses to relieve pain while maintaining airway tone, respiratory drive, and cardiorespiratory physiology; avoid hypoxia and hypotension.
• Prefer fentanyl over morphine because it is short acting and haemodynamically favourable.
• Ketamine may be used, but sub-dissociative behavioural disturbance and physiological instability remain possible.
• Use adjunctive antiemetics.

b. Airway plan

• Treat this as a difficult airway.
• Optimise positioning and consider cervical-spine precautions.
• Anticipate worsening haemorrhage after induction and paralysis; set up two suctions.
• Use a double-airway setup: laryngoscopy plus immediate readiness for front-of-neck access.
• Direct laryngoscopy may be superior to video laryngoscopy because blood obscures the camera.
• Bag-mask ventilation and LMA rescue are high risk for failure, so move early to CICO/FRONA if required.

c. Further haemostasis

• CT imaging including arterial phase to assess for interventional radiology.
• Damage-control surgery or theatre.

d. Mid-face fracture classification

• Le Fort classification; fractures may be unilateral or bilateral.
• Le Fort I: floating palate/horizontal maxillary fracture separating the teeth from the upper face; through the alveolar ridge, lateral nose, and inferior wall of the maxillary sinus.
• Le Fort II: floating maxilla/pyramidal fracture with teeth at the base and nasofrontal region at the apex; through posterior alveolar ridge, lateral maxillary sinus walls, inferior orbital rim, and nasal bones.
• Le Fort III: floating face/transverse craniofacial disjunction through nasofrontal and maxillofrontal sutures, orbital wall, and zygomatic arch or zygomaticofrontal suture.