What is the best approach for managing a 15-year-old female's multiple physical injuries, including a complex lacerated wound, multiple abrasions, and possible maxillofacial fracture, with a GCS score of 15?

Anesthetic Management for Wound Debridement and Suturing in Adolescent Trauma Patient

For this 15-year-old with GCS 15 and multiple facial injuries requiring wound debridement under sedation, your proposed combination of propofol TCI and ketamine is appropriate, but you must prioritize airway protection, hemodynamic stability, and cervical spine precautions given the mechanism of injury (motor vehicle collision). 1, 2

Pre-Procedural Priorities

Immediate Assessment Requirements

• Complete cervical spine clearance is mandatory before any procedure, as 11% of facial trauma patients have concomitant cervical spine injury 3
• Maintain manual in-line stabilization during any airway manipulation until cervical spine is definitively cleared 1
• Obtain CT maxillofacial without contrast and CT head without contrast immediately - this is the gold standard imaging for facial trauma and will identify any occult intracranial injury present in up to 68% of facial fracture patients 3, 2
• Ensure systolic blood pressure remains >100 mmHg throughout the procedure, as hypotension significantly worsens outcomes in trauma patients 4, 1

Critical Pre-Sedation Evaluation

• Perform comprehensive facial examination including palpation for step-offs and crepitus, visual acuity testing, extraocular movement assessment, cranial nerve evaluation, and assessment for cerebrospinal fluid leak 3, 2
• Evaluate for signs suggesting maxillofacial fractures: malocclusion, pain overlying zygoma, facial asymmetry, or infraorbital nerve paresthesia 3, 2
• Mandatory ophthalmology consultation for any orbital involvement given the temporal location of the laceration 3
• Consider neurosurgery consultation given 68% incidence of concomitant cerebral injury in facial fracture patients 3

Anesthetic Technique

Sedation Protocol

• Your combination of propofol TCI and ketamine is reasonable for this procedure, as ketamine provides analgesia while maintaining airway reflexes, and propofol allows titration of sedation depth 1
• Avoid hypotensive agents - even a single episode of SBP <90 mmHg worsens neurological outcomes in trauma patients 2
• Maintain mean arterial pressure >80 mmHg throughout the procedure 4
• Have vasopressors (phenylephrine or norepinephrine) immediately available for rapid correction of any hypotension rather than waiting for fluid resuscitation 2

Airway Management Considerations

• Prepare for potential difficult airway - maxillofacial trauma frequently compromises the airway through hemorrhage, soft-tissue edema, and loss of facial architecture 2
• Have equipment ready for emergency intubation including video laryngoscopy 1
• Maintain continuous end-tidal CO2 monitoring to prevent hypocapnia-induced cerebral vasoconstriction 2
• Apply cricoid pressure if needed to prevent aspiration 1

Positioning and Monitoring

• Position patient with 20-30° head-up tilt if cervical spine is cleared to reduce any potential intracranial pressure 1
• Maintain continuous monitoring of vital signs and neurological status throughout procedure 1
• Ensure adequate oxygenation with PaO2 ≥13 kPa 1

Wound Management During Procedure

Irrigation and Debridement

• Thoroughly irrigate the complex temporal laceration with large volumes of warm or room temperature potable water until no foreign matter remains in the wound 4
• This is a Class I recommendation with Level A evidence for superficial wounds and abrasions 4
• Perform adequate debridement of devitalized tissue while preserving viable structures 4

Wound Closure and Dressing

• After suturing, cover the wound with antibiotic ointment or cream and a clean occlusive dressing - this improves healing and reduces infection (Class IIa, Level A evidence) 4
• Ensure hemostasis is achieved before final closure 4

Post-Procedure Management

Immediate Recovery

• Maintain blood pressure goals (SBP >100 mmHg, MAP >80 mmHg) during emergence 4, 1
• Continue neurological monitoring including pupillary assessment 1
• Maintain glucose levels between 6-10 mmol/L 1

Definitive Care Planning

• Await CT results before determining need for neurosurgical intervention - any life-threatening brain lesion requires urgent neurosurgical consultation 1
• Coordinate with maxillofacial surgery for definitive management of any identified fractures 3
• Delayed repair of maxillofacial injuries (>3 days) yields comparable results to early repair in stable patients, so fracture management can be staged appropriately 5

Critical Pitfalls to Avoid

• Do not allow the severe facial injuries to distract from potential life-threatening injuries - maintain systematic ATLS approach 2
• Do not miss associated injuries - 75% of significant facial fractures have additional injuries, and head injury is the most common associated injury 2, 6
• Do not proceed without cervical spine clearance given the collision mechanism 3
• Do not induce hypotension with sedatives - have vasopressors ready for immediate use 2
• Do not delay intubation if airway compromise develops - facial trauma can rapidly progress to airway obstruction 1, 2