A 40 year old man who met with a motor vehicle catastrophe came to the casualty hospital in an hour with severe maxillofacial trauma. His Pulse rate was 120/min, BP was 100/70 mm Hg, Sp02 - 80% with oxygen. What would be the immediate management -
B i.e. Orotracheal intubation - ABCDE of trauma care includes Airway maintenance and cervical spine protection, Breathing and ventilation, Circulation with haemorrhage control, Disability and neurological assessment and Exposure (undress) to assess for other injures. So option C is excluded. And decreased 02 saturation (80%) with oxygen (most probably through mask or nasal tube) indicate that patient needs tracheal intubation. The tube in trachea can be put nose (nasotracheal), oral cavity (orotracheal) or trachea itself (tracheostomy). - Ideally tracheostomy should be performed under GA. And technically tracheostomy with an awake local anesthetic in a patient with severe airway compromise is difficult because the ideal positioning with an extended head and supine is often not tolerated by patient, and the procedure is to be undeaken in a semi upright sitting position. Because tracheostomy is a relatively time taking procedure in comparison to intubation, it does not have much role in emergency airway managementQ. Tracheostomy is usually done when immediate 02 requirements are taken care of by rapid intubation and prolonged intubation is plannedQ (>1 to 2-3 weeks). However, if intubation is impossible, cricothyroidotomy is an emergency procedure. So option D is excluded. Orotracheal intubation using rapid sequence induction is the technique of choice for resuscitationQ. And nasotracheal intubation is preferred in awake patients. But it is impoant to understand that in case of maxillary fracture, awake intubation is not possible. Nasotrached intubation is contraindica in severe mid facial injuryQ. So for maxillary fracture, orotracheal intubation is method of choice for immediate management of hypoxia.
Nasotracheal intubation
Orotracheal intubation
Intravenous fluid
Tracheostomy