Orotracheal Intubation in Trauma Patients With Cervical Fractures-Reply

AbstractIntroduction:Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial.Purpose:This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma.Hypothesis:The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma.Methods:The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway—CSF—breathing spontaneously, stable vital signs; 2) Urgent airway—CSF—breathing spontaneously, unstable vital signs; and 3) Emergent airway—CSF—apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures.Results:Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81 %, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%.The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation.Conclusion:The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.

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Intubação submentoniana na cirurgia bucomaxilofacial: relato de casos clínicos

ARCHIVES OF HEALTH INVESTIGATION ◽

10.21270/archi.v8i9.4738 ◽

2020 ◽

Vol 8 (9) ◽

Author(s):

Breno dos Reis Fernandes ◽

Darah Ligia Marchiori ◽

Oswaldo Belloti Neto ◽

Patrese Pereira de Bella ◽

Gabriel Mulinari dos Santos ◽

...

Keyword(s):

Airway Management ◽

Orotracheal Intubation ◽

Maxillofacial Trauma ◽

Facial Trauma ◽

Trauma Patients ◽

Maxillofacial Injuries ◽

Short Term ◽

Submental Intubation ◽

Randomized Control ◽

Panfacial Fractures

A manutenção das vias aéreas em pacientes com lesões maxilofaciais complexas é um desafio para os cirurgiões e anestesiologistas. A intubação submentoniana é uma técnica útil que é menos invasiva que a traqueostomia na proteção das vias aéreas, onde a intubação orotraqueal e nasotraqueal são contraindicadas. Este procedimento evita o uso de traqueostomia e suas complicações, visto que a intubação submentoniana demonstra baixo indice de complicações. Um tubo endotraqueal reforçado flexível e resistente a dobras com conector universal destacável é comumente usado para intubação submental. São apresentados dois casos clínicos utilizando a intubação submentoniana em pacientes com lesões maxilofaciais complexas.Descritores: Intubação; Ferimentos e Lesões; Cirurgia Bucal.ReferênciasRodrigues WC, Melo WM, Almeida RS, Pardo-Kaba SC, Sonoda CK, Shinohara EH. Submental intubation in cases of panfacial fractures: a retrospective study. Anesth Prog. 2017;64(3):153-61.Cheong Y, Kang SS, Kim M, Son HJ, Park J, Kim J. Submental intubation in patients with complex maxillofacial injuries. J Lifestyle Med. 2016; 6(2):68-71.Kumar RR, Vylopilli S, Sayd S, Thangavelu A, Joseph B, Ahsan A. Submental intubation: alternative short-term airway management in maxillofacial trauma. J Korean Assoc Oral Maxillofac Surg. 2016;42(3):151-56.Kaiser A, Semanoff A, Christensen L, Sadoff D, Digiacomo J. Submental intubation: an underutilized technique for airway management in patients with panfacial trauma. J Craniofac Surg. 29(5):1349-51.Akbari H, Heidari-Gorji MA, Poormousa R, Ayyasi M. Submental intubation in maxillofacial fracture: a case report. J Korean Assoc Oral Maxillofac Surg. 2016;42(3):166-68.González-Magaña F, Malagón-Hidalgo HO, García-Cano E, Vilchis-López R, Fentanes-Vera A, Ayala-Ugalde FA. Airway management through submental derivation: a safe and easily reproduced alternative for patients with complex facial trauma. J Korean Assoc Oral Maxillofac Surg. 2018;44(1):12-17.Kita R, Kikuta T, Takahashi M, Ootani T, Takaoka M, Matsuda M et al. Efficacy and complications of submental tracheal intubation compared with tracheostomy in maxillofacial trauma patients. J Oral Sci.2016;58(1):23-8.Lim D, Ma BC, Parumo R, Shanmuhasuntharam P. Thirty years of submental intubation: a review. Int J Oral Maxillofac Surg. 2018;47(9):1161-65.Savitha KS, Kujur AR, Vikram MS, Joseph S. A modified submental orotracheal intubation. Anesth Essays Res. 2016;10(1):132-35.Ujam A, Perry M. Minimally traumatic submental intubation: a novel dilational technique. Eur J Trauma Emerg Surg, 2017;43(3):359-62.Ali S, Athar M, Ahmed SM, Siddiqi OA, Badar A. A randomized control trial of awake oral to submental conversion versus asleep technique in maxillofacial trauma. Ann Maxillofac Surg. 2017;7(2):202-6.Shivpuri A. Sub-mental Intubation in Oral and Maxillofacial Trauma Patients. Indian J Surg. 2015;77(Suppl 3):1450-52.

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Cervical Computed Tomography Angiography Rarely Leads to Intervention in Patients With Cervical Spine Fractures

Global Spine Journal ◽

10.1177/2192568219885897 ◽

2019 ◽

Vol 10 (8) ◽

pp. 992-997

Author(s):

Conor John Dunn ◽

Stuart Changoor ◽

Kimona Issa ◽

Jeffrey Moore ◽

Nancy J. Moontasri ◽

...

Keyword(s):

Computed Tomography ◽

Cervical Spine ◽

Computed Tomography Angiography ◽

Neurological Deficits ◽

Cervical Region ◽

Trauma Patients ◽

Spine Fractures ◽

Cervical Fractures ◽

Cervical Spine Fractures ◽

The Impact

Study Design: Retrospective cohort study. Objectives: To evaluate the impact of computed tomography angiography (CTA) in the management of trauma patients with cervical spine fractures by identifying high-risk patients for vertebral artery injury (VAI), and evaluating how frequently patients undergo subsequent surgical/procedural intervention as a result of these findings. Methods: All trauma patients with cervical spine fractures who underwent CTA of the head and neck at our institution between January 2013 and October 2017 were identified. Patients were indicated for CTA according to our institutional protocol based on the modified Denver criteria, and included patients with cervical fractures on scout CT. Those with positive VAI were noted, along with their fracture location, and presence or absence of neurological deficit on physical examination. Statistical analysis was performed and odds ratios were calculated comparing the relationship of cervical spine fracture with presence of VAI. Results: A total of 144 patients were included in our study. Of those, 25 patients (17.4%) were found to have VAI. Two patients (1.4%) with VAI underwent subsequent surgical/procedural intervention. Of the 25 cervical fractures with a VAI, 20 (80%), were found to involve the upper cervical region (4.2 OR, 95% CI 1.5-12.0; P = .007). Of the 25 who had a VAI, 9 were unable to undergo reliable neurologic examination. Of the remaining 16 patients, 5 (31.3%) had motor or sensory deficits localized to the side of the VAI, with no other attributable etiology. Conclusions: Cervical spine fractures located in the region of the C1-C3 vertebrae were more likely to have an associated VAI on CTA. VAI should also be considered in cervical trauma patients who present with neurological deficits not clearly explained by other pathology. Despite a finding of VAI, patients rarely underwent subsequent surgical or procedural intervention.

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