How would you manage the airway of a Road Traffic Accident (RTA) patient with multiple mandibular fractures, severe bleeding, and unconsciousness?

From the Guidelines

The most appropriate method for managing the airway of an unconscious RTA patient with multiple mandibular fractures and severe bleeding is rapid sequence intubation (RSI) with preparation for a potential difficult airway, and if orotracheal intubation fails, proceeding to a surgical airway via cricothyroidotomy. This approach is based on the principles outlined in the most recent guidelines for airway management in critically ill adults 1. The patient's condition, with severe bleeding and unconsciousness, necessitates immediate and secure airway management to prevent further complications such as hypoxia and aspiration.

Given the presence of multiple mandibular fractures, basic airway maneuvers like jaw thrust or chin lift should be avoided to prevent exacerbating the injuries. Instead, proceeding directly to RSI allows for rapid control of the airway. The use of etomidate or ketamine for induction, followed by succinylcholine or rocuronium for paralysis, is recommended as part of the RSI protocol.

It is crucial to be prepared for a difficult airway scenario, given the facial trauma and potential for bleeding to obscure visualization. Having alternative devices ready, such as video laryngoscopy, can aid in securing the airway. If orotracheal intubation is unsuccessful after a limited number of attempts, transitioning to a surgical airway via cricothyroidotomy is the next step to ensure timely and secure airway management.

Throughout the process, maintaining oxygenation with high-flow oxygen and continuous monitoring of vital signs are essential. After securing the airway, placing an orogastric tube can help decompress the stomach and prevent aspiration, further minimizing the risk of complications in this critically injured patient. This approach aligns with the emphasis on prioritizing oxygenation, using modern equipment, and applying technical expertise as outlined in the guidelines for managing tracheal intubation in critically ill adults 1.

Key considerations include:

• Immediate intervention with a stepwise approach
• Avoidance of basic airway maneuvers that could worsen mandibular fractures
• Preparation for a difficult airway scenario
• Use of RSI with appropriate induction and paralysis agents
• Readiness to transition to a surgical airway if necessary
• Maintenance of oxygenation and monitoring of vital signs
• Placement of an orogastric tube after securing the airway

This management strategy is supported by the most recent and highest quality evidence available, emphasizing the importance of timely, effective, and safe airway management in critically ill patients 1.

From the Research

Airway Management in RTA Patient with Multiple Mandibular Fractures

• The patient's airway management is crucial, especially with severe bleeding and unconsciousness 2, 3.
• Initial airway management can be achieved through endotracheal intubation in most patients, but alternative methods may be necessary in cases of severe bleeding or difficult airway access 2, 4.
• In patients with maxillofacial injuries, nasotracheal intubation can be considered, and intraoperative change to orotracheal intubation can be performed to avoid tracheostomy or submental intubation 4.
• If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach, and cricothyroidotomy or tracheostomy may be necessary in cases where traditional airway management is impossible 3, 5.

Airway Management Options

• Endotracheal intubation: can be used as initial airway management in most patients 2.
• Nasotracheal intubation: can be considered in patients with maxillofacial injuries, with possible intraoperative change to orotracheal intubation 4.
• Cricothyroidotomy: may be necessary in cases where traditional airway management is impossible, especially with severe bleeding or difficult airway access 3, 5.
• Tracheostomy: may be required in some cases, especially with extensive airway injury or failure to intubate using direct laryngoscopy 2, 3.

Considerations for Airway Management

• Severe bleeding in the airway can render traditional airway management impossible, and alternative techniques such as flexible video-/optical-scope-guided intubation or cricothyroidotomy may be necessary 5.
• The choice of airway management technique depends on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment 3.