Hiking Injury to the Face: Airway Adjuncts and Techniques to Consider for Evacuation

by | Aug 13, 2020 | Evacuation, Treating injuries, Wilderness Medicine Case Studies | AWLS

RW is a 70 year old male hiking on a well traversed trail head. He falls on loose gravel resulting in a 15 foot fall down a steep pitch. He rolls down the pitch, hitting his face on a boulder at the bottom of the slope. There is no known loss of consciousness and he is able to hike the mile out to the aid station.

On initial assessment: he is tolerating secretions, is mildly tachypneic, and his pulses are equal and symmetric. His chief complaint is that his face hurts. He has a history of hypertension, takes blood pressure medications consisting of a beta-blocker. No other allergies to medications, no illicit substances, and he takes no other medications or over the counters, to include blood thinners.

On secondary survey, there is an obvious deformity to his nose with bruising along the left face. His eyes are PERRL. On upward gaze, his right eye is not able to fully look up and RW complains of diplopia. There is no proptosis. His tympanic membranes are clear bilaterally. On palpation of his face, his forehead is normal. His left face has significant tenderness to palpation and crepitus along the zygoma with mild deformity present. His right face is tender along the maxilla. He has malocclusion of his jaw. Upon moving his upper dentition, a significant portion of his midface moves anteriorly as well. There is scant blood in the anterior nares without septal hematoma or central clearing surrounding the blood as it drips. There is blood in the oropharynx of undetermined etiology. Aside from some superficial abrasions and ecchymosis, there are no other injuries appreciated.

Winds are particularly severe, making air evacuation unobtainable. The nearest hospital is approximately 1 hour by ALS ground unit.

In preparation for departure, you look at your airway equipment: you have an NPA, a MAC 4, an 8-0 ETT, a scalpel, a trach hook, and 6-0 ET tube. Regarding medications, you have rocuronium, versed and fentanyl. The accident happened approximately 1 hour prior to initial evaluation and it will take another 40 minutes for the ambulance to reach you. He has had no worsening airway swelling, is still alert and appropriate.

What concerns do you have regarding this patient’s airway? Are there other airway adjuncts or techniques would you consider using? Consider the risks/benefits of each of the following:

A. NPA
B. CPAP/BiPAP during transport
C. Video laryngoscopy/Glide scope/fiberoptic
D. Supraglottic devices
E. Bougie
F. Rapid Sequence Intubation (RSI)
G. Awake intubation
H. Cricothyrotomy

 

A. NPA

Not an option in this patient. He had an obvious nasal fracture, as well as an inferior orbital fracture on the right extending through the midface on the left. One of the few contraindications with an NPA is the nasal fracture. What about the OPA? Not a bad option for an adjunct, however, this patient was still alert with a gag reflex. If he had been unconscious, an OPA would be a reasonable adjunct to assist with bag-mask ventilation.

B. CPAP/BiPAP

This could be problematic on multiple fronts. First, the patient has multiple facial fractures, so fitting a mask in a way that would allow both comfort and appropriate seal is unlikely. In reviewing the literature, there are also a number of case reports of pneumocephalus, pneumomediastinum, significant worsening of subcutaneous emphysema as a result of using continuous positive pressure ventilation in the setting of facial fractures, particularly of the zygomaticomaxillary complex.

C. Video laryngoscopy

Does it really make a difference? Training in the age of improved electronics, it is easy to be complacent on the comfort that is added with simple video laryngoscopy. One study recently published looked at the first-pass success of direct laryngoscopy versus video laryngoscopy specifically in the setting of patients with potentially difficult airways. Those with even a single risk factor for difficult airway had a first pass rate decline from 82% to 69.4% with use of direct laryngoscopy compared to 90.8% to 85.1% with video laryngoscopy. The criteria included in this study consisted of airway edema, cervical immobility, facial/neck trauma, large tongue, obesity, short neck, small mandible, and blood/vomit in the airway. This patient had at least 3, possibly 4 criteria. With three or more criteria, the first pass rate of intubation with direct laryngoscopy was 54% compared to 68.9% with video laryngoscopy. In the setting of potential airway edema second to trauma, often the first look is the best look you will have. In this setting, if at all possible, a video laryngoscopy could definitely be of benefit.

Video laryngoscpy may be of benefit, but is it feasible? There are a multitude of optical laryngoscopes. There are multi-use devices with blades that need to be sterilized, as well as single use scopes that make use of light, mirrors, and a magnifying lens to achieve similar outcomes. There are also portable lighted stylets that are inexpensive, single use, and while not the same visualization as an optical device, may be of assistance in intubating when direct laryngoscopy provides no view.

D. Supraglottic Devices

For ease of use, there are many studies that show the utility in LMA use as an adequate back-up method. As such, it is in the paramedic difficult airway algorithm throughout Europe and the US. There are many case reports in the EMS world as well as anesthesia in the utility and ease of use of LMA when direct laryngoscopy has failed. What about the trauma patient? Patients with facial trauma have a particular risk of intubation failure second to distorted anatomy and poor visualization. Despite mandibular fractures and cervical spine injury, LMA insertion can be easily achieved with minimal training in the most difficult anatomic variances. Combitubes are also utilized, though less widespread. Part of this is related to advancing LMA technology that now allows for potentially intubating through an LMA that is already in place, eliminating the potential loss of airway temporarily while attempting to switch to an endotracheal tube. There is also a benefit in relation to c-spine injured patients. The LMA has less associated motion along the cervical spine when compared to direct laryngoscopy on biomechanical models and cadaveric studies. Another benefit is that while some familiarization is necessary to become competent, far less is necessary to become adequate at placing an LMA compared to direct laryngoscopy. This leads to lives saved in the field because less familiar individuals take longer to place an ET tube under direct laryngoscopy. That time often results in hypoxia, which may have significant clinical consequences.

E. The Bougie

It’s lightweight, inexpensive, malleable, and easy to pack. This piece of equipment is one of my favorite difficult airway adjuncts. It does not require batteries or other high tech gear that may fail in the wilderness. The theory behind this device is that using the angled beak to slip into the vocal cords, one can then confirm placement by feeling the transmitted bumps or clicks as one passes the tracheal rings.

The sensitivity by feel alone is touted to be 90%8 suggesting that if one does not feel the rings, there is a high chance of an esophageal intubation. Despite how many times I have used the bougie, I have not consistently felt tracheal rings. Perhaps my hands are not adept at it, perhaps when I have needed to use the bougie, the adrenaline had been too overwhelming to allow my hand to perceive small clicks. Regardless, I was trained to also make use of the “hold-up” sign. The hold up sign is the increased resistance as one passes the bougie approximately 45cm. The idea is that if one has passed the bougie into the esophagus, no significant resistance is felt regardless of depth of insertion compared to the continually narrowing airway when passed endotracheally. One recent study by Marson et al suggests that this method of confirmation of endotracheal placement may result in significant force to the airway which may result in trauma. Despite an extensive literature search, there is a paucity of data resulting clinical complications solely related to the use of the bougie. Martin et al did a nice review of over three thousand difficult airways and associated complications ranging from dental injuries, aspiration, esophageal intubations, and pneumothorax. This paper suggests that 0.1% of the difficult airway cases were complicated by pneumothorax. Unfortunately, it is not mentioned what intubation technique was utilized on those cases, nor does it specify if it was potentially related to direct trauma via bougie or from aggressive oxygenation. If the concern is increased force resulting in airway trauma, one would anticipate a higher percentage of pneumothorax complication when a bougie is utilized. Still, the multitude of prehospital protocols, both nationally and internationally, that utilize the bougie as part of the protocol with such a paucity of complications from such techniques related to direct trauma suggest that while in vitro studies may show a risk, in vivo the risk is not clinically apparent. I will definitely continue to review the literature, however, will likely continue to use the “hold-up” sign to assist with confirmation until a more obvious clinical correlation is apparent.

F. Rapid Sequence Intubation

Who wants to RSI this potentially difficult airway? With which medications? During the initial evaluation of this patient, as initially stated, you have rocuronium, versed, and fentanyl at your disposal. There are a lot of wonderful aspects of nondepolarizing neuromuscular blockers such as rocuronium, vecuronium, pancuronium, atracurium, and cisatracurium. There is limited associated cardiovascular effect or hemodynamic instability. It is paramount to ensure adequate dosing of sedation when utilizing paralytics, but generally they are well tolerated as long as the patient is appropriately sedated. One significant downfall is the length of action. This class of drugs takes longer to reach adequate intubating conditions than depolarizing neuromuscular blockers, and the duration of activity is significantly longer. One fear with this patient in particular, with the limited resources available, is that if this patient is paralyzed, one is committed to obtaining an airway. With the facial fractures, one can anticipate that bagging this patient for oxygenation and ventilation may be inadequate. Let us imagine that one can bag-valve mask this patient adequately. If one utilizes the vecuronium and then fails to intubate, one is committed to bagging the patient until the medication wears off, which may be up to 45 minutes. Even with the rapidity of onset of the depolarizing agents, namely succinylcholine in the US, would the patient survive a failed intubation attempt without being able to bag him for 3-5 minutes if he is unable to be adequately ventilated via BVM? All of these are significant considerations in and of themselves. Add in being in the wilderness with limited resources, and the risks multiply.

What about apneic oxygenation or delayed sequence intubation? Apneic oxygenation is the use of nasal cannuli, NPA, nonrebreather facemask in order to ensure high flow oxygen is available from the pharynx to the glottis. Multiple studies have shown that even in a paralyzed and apneic person, patients may not desaturate if high flow oxygen is continued. This method of oxygenation during apneic periods is increasing in use in the ED. If the supplies were available, I would highly consider utilizing this technique where added minutes of oxygenation could significantly decrease morbidity/mortality of a difficult airway. Delayed sequence intubation is a method of sedating a patient who may be delirious from hypoxia, making pre-oxygenation difficult and at times, inadequate. This is more relevant in the patient who prior to attempting an airway, one cannot get an O2 sat above 84%, confounded by the patient continually removing facemasks or other airway adjuncts. While not necessarily relevant for this case, I thought I would mention it because this topic has become much more widely discussed as an alternative management strategy in the past few years.

G. Awake intubation

If medications and equipment to support this technique were available, and airway collapse was anticipated, this method would be my preferred method of obtaining a definitive airway in this patient. There are many different medication combinations to utilize for adequate anesthesia to allow for good visualization. Nebulized 5% lidocaine can significantly reduce the sensation and gag reflex of the patient. One can use topical lidocaine gel in the nares if one is planning to do nasotracheal intubation. With this patient’s likely nasal fractures, I would avoid that method in this instance. One can also make use of versed for anxiolysis. If at your disposal, Haldol, droperidol, ketamine, and dexmedetomedine (precedex) may all serve to assist with anxiolsys or mild sedation. Once the upper airway is adequately anesthetized, one can gently insert the blade of your choice. The benefit of an awake intubation is that if necessary, the patient can remain upright to ensure the soft tissues remain out of the airway compared to a supine patient that is paralyzed. Another benefit being that if unable to obtain an adequate view, one is not committed to bagging the patient while coming up with plan B. Once an adequate view of the cords is obtained, one can use more topical lidocaine to numb the cords prior to insertion of the tube or you can then push a higher dose of sedating medication. Once the tube is inserted, the patient can then be adequately sedated and given pain medication as necessary to tolerate the intubation.

H. Cricothyrotomy

Over the past two decades, the use of surgical cricothyrotomy in the ED has decreased. This is in part second to the improvement in supraglottic devices resulting in improved ventilation without surgical intervention. One study quoted as low as 0.17% incidence in the time period from 1997 to 2002.16 This is less than the 1.7-2.7% rate from previous studies in the hospital setting and much less than the 2.1-14.9% incidence in the pre-hospital setting. Most of the literature discussing cricothyrotomy in the austere setting refers to the battlefield. As a tenuous airway is one of the three most common preventable deaths in the battlefield, extensive training to improve airway techniques in the battlefield has helped to improve mortality over the past decade of war. With all of the abundant literature showing the utility of obtaining a definitive airway via cricothyrotomy in an austere environment, many pre-hospital difficult airway protocols now involve performing cricothyrotomy by pre-hospital personnel. Last year, a case was published that showed the utility of performing a cricothyrotomy in the wilderness setting, not associated with the battlefield. This case is the only report of a stateside backcountry cricothyrotomy published to my knowledge. The patient in the case is similar to the patient proposed in the scenario above. While significant facial fractures and blood may limit the utility of direct laryngoscopy, the anatomic landmarks along the anterior neck remain obvious. This patient had reasonable anatomy to consider cricothyrotomy as another way to obtain a definitive airway. As cricothyrotomy is not without inherent risk, my preference would be to prepare the neck and mark the appropriate landmarks prior to attempting a direct laryngoscopy first with the intention to use cricothyrotomy as needed if oral intubation failed.

 

Outcome:

As it was, this patient remained stable during the evaluation with limited swelling prior to the arrival of the ambulance. The decision was made to defer intubation as limited resources were available, knowing that this patient’s airway could be particularly difficult. Follow up obtained for this patient showed he arrived to the hospital after an uneventful evacuation, where he was prepared for surgery and intubated without difficulty in the OR.

We love a case study,  but a wilderness hands-on continuing medical education (CME)  provides a unique opportunity to hone skills out of doors.  Check our upcoming courses list to see where our classes are held.

 

References:
1. Klopfenstein CE, Forster A, Suter PM. Pneumocephalus. A complication of continuous positive airway pressure after trauma.Chest. 1980 Oct;78(4):656-7.
2. Yildiz A, Duce MN, Ozer C, Apaydin FD, Eğilmez H, Kara E. Disseminated pneumocephalus secondary to an unusual facial trauma. Eur J Radiol. 2002 Apr;42(1):65-8.
3. Fangman B, Penna KJ. Pneumomediastinum, pneumopericardium, orbital subcutaneous emphysema as consequence of low energy impact facial trauma. N Y State Dent J. 2012 Nov;78(6):25-8.
4. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med. 2014 Feb;9(1):93-8. doi: 10.1007/s11739-013-0995-x. Epub 2013 Sep 4.
5. Grier G1, Bredmose P, Davies G, Lockey D. Introduction and use of the ProSeal laryngeal mask airway as a rescue device in a pre-hospital trauma anaesthesia algorithm. Resuscitation. 2009 Jan;80(1):138-41. 6. Brimacombe J, Keller C, Künzel KH, Gaber O, Boehler M, Pühringer F. Cervical spine motion during airway management: a cinefluoroscopic study of the posteriorly destabilized third cervical vertebrae in human cadavers. Anesth Analg. 2000 Nov;91(5):1274-8.
7. Mason A. Use of the intubating laryngeal mask airway in pre-hospital care: a case report. Resuscitation. 2001 Feb;51:91-95.
8. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Use of the gum elastic bougie. Anesthesia 1988;43:437-8.
9. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia 2014;69:219-223.
10. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 Emergency Tracheal Intubations at a University Hospital: Airway Outcomes and Complications. Anesthesiology 2011;114:42-48.
11. Abdulla S, Abdulla S, Schwemm KP, Eckhardt R, Abdulla W. Making endotracheal intubation easy and successful, particularly in unexpected difficult airway. Int J Crit Illn Inj Sci. 2014 Jan;4(1):24-8.
12. Weingart S. Preoxygenation, reoxygenation, and delayed sequence intubation in the emergency department. J Emerg Med. 2011 Jun;40:661-7.
13. Dhasmana SC. Nasotracheal fiberoptic intubation: patient comfort, intubating conditions and hemodynamic stability during conscious sedation with different doses of dexmedetomidine. J Maxillofac Oral Surg. 2014 Mar;13(1):53-8.