What is the recommended approach for intubation in a patient with a LeFort 2 fracture?

Airway Management in Patients with LeFort II Fractures

For patients with LeFort II fractures, rapid sequence induction with endotracheal intubation is recommended as the primary approach for securing the airway, with preparation for potential difficult airway management including videolaryngoscopy and surgical airway backup.

Understanding LeFort II Fractures and Airway Implications

LeFort II fractures involve the midface with a pyramidal fracture pattern extending across the nasal bones, medial orbital walls, and pterygoid plates. These fractures present significant airway management challenges due to:

• Potential midface instability
• Risk of oropharyngeal airway obstruction
• Possible associated bleeding and edema
• Distorted anatomy affecting conventional airway management

Primary Approach to Airway Management

Initial Assessment

• Evaluate for signs of immediate airway compromise: stridor, dyspnea, desaturation
• Assess for associated injuries (particularly cervical spine)
• Determine the extent of facial fractures and midface mobility

Recommended Technique

1. Rapid Sequence Induction (RSI) with Orotracheal Intubation

   • Position patient in a ramped position to optimize laryngoscopy 1
   • Pre-oxygenate thoroughly with 100% oxygen 1
   • Use a modified RSI technique with manual in-line stabilization if cervical spine injury is suspected 1
   • Consider videolaryngoscopy as first-line approach for better visualization with minimal manipulation 1
   • Have bougie readily available to assist with tube placement 1

2. Drug Selection for Induction

   • High-dose fentanyl (3-5 μg/kg) or alfentanil (10-20 μg/kg) 1
   • Ketamine 1-2 mg/kg is preferred in hemodynamically unstable patients 1
   • Rocuronium 1 mg/kg for neuromuscular blockade 1
   • Have vasopressors (ephedrine or metaraminol) immediately available 1

Special Considerations

Avoid Nasotracheal Intubation

• Contraindicated in LeFort II fractures due to risk of:
  • Inadvertent intracranial placement through fracture lines
  • Worsening bleeding
  • Creating false passages 2

Difficult Airway Preparation

• Always have difficult airway equipment immediately available
• Second-generation supraglottic airway device should be available as rescue 1
• Be prepared for surgical airway access if needed 1
• Consider awake fiberoptic intubation in cooperative patients with anticipated extremely difficult airway 1

Cervical Spine Precautions

• Maintain cervical spine precautions if trauma mechanism suggests potential injury
• Remove anterior portion of cervical collar to facilitate mouth opening while maintaining manual in-line stabilization 1
• Videolaryngoscopy is particularly valuable in these cases 1

Post-Intubation Management

• Secure the endotracheal tube carefully to prevent dislodgement
• Consider using an uncut endotracheal tube to accommodate for potential facial swelling 1
• Avoid nasal gastric tube placement initially; insert orogastric tube after airway is secured 1
• Perform recruitment maneuvers if hypoxemia persists post-intubation 1

Pitfalls to Avoid

1. Delaying definitive airway management - Early control of the airway is essential as progressive swelling can make later attempts more difficult 3

2. Underestimating the difficulty - LeFort II fractures are associated with higher rates of airway complications compared to LeFort I 3

3. Excessive manipulation - Minimize manipulation of fracture fragments during laryngoscopy to prevent worsening injury or bleeding

4. Inadequate preparation - Always have surgical airway equipment and personnel immediately available 1

5. Relying on clinical signs alone - Clinical signs may underestimate the severity of airway compromise; maintain high vigilance 1

By following this structured approach to airway management in patients with LeFort II fractures, clinicians can minimize complications and optimize patient outcomes in these challenging scenarios.