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Case Report: Facial Trauma

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Submitted by: Patricia N. Sommer, RN, BSN.

Pre hospital:
The patient is a 15 year old female with no significant medical history who was struck by a motor vehicle and sustained significant crush injuries to the face. On initial exam her eyes were swollen shut, and there was a significant amount of bleeding from her mouth as well as facial swelling. Multiple attempts at intubation with etomidate and fentanyl by ems were unsuccessful. The patient arrived to the trauma bay with ventilations by BVM in progress.

ER Course:
Level 1 trauma was initiated pre-arrival and the trauma team was present upon arrival. The patient's airway was considered unstable upon arrival; she was normotensive and tachycardic with a HR of 145. GCS was 6 and she was groaning, combative, and actively moving all extremities. Anesthesia was present for intubation with 6.0 fr ETT via LMA with use of fiber optic guidance. After intubation, oxygen saturation remained poor with sat at 50%. Bilateral chest tubes were placed with eventual improvement to 90%. Chest x-ray was performed which showed ETT high in the trachea, subsequently moved 2 cm by anesthesia. A left tibial IO was placed and two units PRBCS were transfused in the trauma room. Upon secondary survey, no other obvious injuries or deformities were noted. The patient was transported for head, c-spine, face, chest, abdomen and pelvis CT. Imaging showed significant facial fractures and possible dural tears relating to frontal sinus fractures. She was transferred immediately to PICU from CT with requested consults from OMFS, PRS, dental, optho and ENT.

PICU course:
On the night of admission, the patient was taken to OR for ICP monitor placement and ENT- guided emergent tracheostomy due to the severity of facial fractures and inability to remain safely intubated via ETT. She remained on a mechanical vent until day 16 of hospital stay. Intracranial pressure remained in the range of 4-20. On day three of hospital stay, the ICP monitor was removed, and the patient underwent stage 1 of cranial repair and dural tears without complication. On day 10 of admission, she was taken to the OR for maxillofacial reconstruction with plastic surgery. During the course of her PICU admission, the patient was placed on keppra for seizure prophylaxis, and morphine and precedex for pain and sedation- both of which she was weaned off of by admission day 17. Gabapentin was given for neuropathic pain, as well as a methadone taper for withdrawal prophylaxis. Due to hemodynamic instability, in total she received 4 units of PRBCs and required epinephrine intermittently until day 3 of hospital stay. She was placed on Ceftriaxone and vancomycin at meningitis dosing for CSF rhinorrhea per IDís recommendation.

Floor course and disposition:
The patient was transferred to a med/surg floor from PICU on day 21 of admission. She received feeds via g-tube due to the severity of facial fractures. She was transferred to a rehab facility post admission day 29 tolerating feeds and ambulating with assistance. Discharge instructions included plans to follow up with pediatric surgery, neurosurgery, ophthalmology, plastic surgery, orthopedic surgery and ENT.

Topic Review: Facial trauma and airway management.

Approximately 22 million children in the United States suffer traumatic injury yearly. Evaluation and management of facial trauma in the pediatric population differs due to differences in anatomy in relation to adult patients. The ratio of cranial mass to the body is increased in children, leaving them at increased vulnerability to craniofacial injury. Maxillofacial injury also presents a unique set of challenges for providers due to compromised airway prior to and during reconstruction. This trauma can have significant impact on future growth and development. It is therefore essential that treating physicians are aware of these variants as well as proper techniques and procedures for stabilizing airway while managing significant injuries.

Maxillofacial injuries are the result of high velocity trauma from motor vehicle traffic accidents, sport injuries, falls and gunshot wounds. These injuries can compromise airway stability and ventilation due to excessive bleeding, fractures, tissue edema, and deranged anatomy. Once stabilized, considerations must be also made between providers to ensure airway stability while competing with space for surgical intervention. During facial reconstruction, airway secured by nasal intubation by direct visualization of the vocal cords and oral intubation are the most common methods used to secure the airway. Intraoperatively, fracture patterns will ultimately dictate the route of intubation. Postoperative management focuses on avoidance of reintubation of the difficult airway. Techniques including fiber optic bronchoscopic intubation, and submental or retromolar intubation may reduce the instance of tracheostomy. However, a standard tracheostomy prior to surgical intervention provides a safe, stable airway without interfering with the surgical field and protects against post-operative airway obstruction. The decision to perform cricothyroidotomy must be made on an individual basis and is in some cases required as the initial emergent intervention.

Resources:

Kellman, R. M., & Losquadro, W. D. (2008). Comprehensive airway management of patients with maxillofacial trauma. Craniomaxillofacial trauma & reconstruction, 1(1), 39-47.

Raval, C. B., & Rashiduddin, M. (2011). Airway management in patients with maxillofacial trauma - A retrospective study of 177 cases. Saudi journal of anaesthesia, 5(1), 9-14.

Ryan, Et al. (2011). Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department. Journal of craniofacial surgery 22(4):1183-9.

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