From the Guidelines
For a patient with road traffic accident (RTA) with mandibular fracture, surgical cricothyrotomy (option C) is the recommended approach to protect the airway, specifically using a scalpel-bougie-tube cricothyroidotomy technique, as it provides a fast and reliable technique with a high success rate and enables confirmation of success by waveform capnography 1. This technique is preferred because it allows for a definitive airway, offering a degree of protection against aspiration, facilitates exhalation, and enables application of PEEP. Key steps in this procedure include:
- Maximum neck extension
- A horizontal incision with a wide scalpel blade for those with a palpable cricothyroid membrane, or an initial large vertical midline skin incision if the cricothyroid membrane is impalpable
- Insertion of a bougie as a guide for a 5.0-6.0 mm tracheal tube
- Ensuring the smaller tracheal tube size fits over the type of bougie used in the unit. Orotracheal intubation (option A) and nasotracheal intubation (option B) may not be suitable in all cases, especially if there are concerns about the patient's airway anatomy or potential for complications. Needle cricothyrotomy (option D) is not recommended as a first-line approach due to the high risk of failure and complications associated with transtracheal jet ventilation 1. Surgical cricothyrotomy, on the other hand, provides a more reliable and secure airway, making it the preferred choice for patients with RTA and mandibular fracture.
From the Research
Airway Protection in Patients with Mandibular Fractures
To protect the airway in a patient with a mandibular fracture due to a road traffic accident (RTA), several options can be considered:
- Orotracheal intubation: This is a common method for securing the airway in patients with maxillofacial injuries, including mandibular fractures 2.
- Nasotracheal intubation: This approach can be used in patients with mandibular fractures, but it may be contraindicated in cases with suspected basal skull fractures or severe nasal injuries.
- Surgical cricothyrotomy: This is an emergency procedure that can be performed to establish an airway in patients with severe maxillofacial trauma, including mandibular fractures 3.
- Needle cricothyrotomy: This is a temporary measure to establish an airway in emergency situations, but it is not a definitive solution for airway management in patients with mandibular fractures.
Considerations for Airway Management
When managing the airway in patients with mandibular fractures, it is essential to consider the following factors:
- The severity of the fracture and the potential for airway compromise
- The presence of other injuries, such as cervical spine fractures or head injuries
- The need for surgical intervention to stabilize the fracture and restore occlusion
- The patient's overall medical condition and any underlying health issues
Evidence from Studies
While the provided studies do not directly address the question of airway protection in patients with mandibular fractures, they do provide information on the management of mandibular fractures and the importance of considering the individual patient's needs and circumstances 4, 5, 6, 3, 2.