A 70-year-old depressed man presents after attempted suicide by shooting himself with a handgun held under his jaw. He is seated upright and leaning forward when paramedics arrived on the scene and refuses to lie supine due to facial bleeding. He is kept in position so as to optimize airway patency and expeditiously transported to the nearest emergency department (ED).

The patient presents to the ED in tripod position with obvious bleeding from his mouth. His anterior mandible is missing, and he is holding a non-rebreather oxygen mask in front of his face. His oxygen saturation is 95% and has been stable during transport. Vital signs include a pulse of 85 beats per minute, a blood pressure of 175/90 mm Hg, a respiratory rate of 22 breaths per minute, and a temperature of 37°C. Upon initial examination (Figure 27–1), he had ongoing oral hemorrhage and completely missing anterior mandible. The patient is awake and has a Glasgow Coma Scale (GCS) of 15. In light of his injuries, he was kept upright on the gurney in anticipation of tracheal intubation (for airway protection).

What Are the Airway Evaluation Considerations in This Patient?

This patient presents with multiple clinical issues that may influence his airway management. The missing anterior mandible is a dramatic presentation, but standard trauma management principles apply.^1,2 His airway does require management, as indicated for airway protection and anticipated clinical course. However, this is not a “crash” intubation situation (because his oxygen saturation is >90% and stable). Therefore, a rapid evaluation of the airway for anticipated difficulty is possible.³ If this was a “crash” scenario (e.g., vital signs become unstable or patient becomes hypoxic), an awake cricothyrotomy might be the most appropriate initial approach.^1,3

The presence of oro-facial disruption will likely hinder bag-mask-ventilation (BMV) due to a poor mask seal. Similarly, with the associated hemorrhage, soft tissue edema, and the presence of foreign bodies (teeth, clots, etc.), the use of an extraglottic device (EGD) may be difficult. Laryngoscopy will likely be complicated by the presence of blood, tissue edema, and possible airway disruption. However, the absence of mandibular resistance might actually make visualization easier. While it is always wise to consider cervical spine injury in the setting of head injury, this case is special as the patient is neurologically intact and this places him in a low-risk category for spine injury. To date, there have been no cases reported of isolated penetrating injury to the face that have resulted in an unstable cervical spine fracture in an awake, alert, neurologically intact patient.^4,5 Maintenance of strict cervical spine precautions in this instance, such as lying the patient supine or placing the patient in a cervical collar could result in aspiration and obstruction of the airway.² In this instance, maintaining the patient in a position of relative comfort in an upright, sitting position allows the patient to keep their airway open, manage bleeding, and provides the clinician an opportunity for further assessment in planning their approach. This airway is classified as “difficult,” specifically for potential challenges that may be encountered during laryngoscopy and mask-ventilation.

How Does Airway Assessment Proceed in the Setting of Disrupted Anatomy?

Significant penetrating facial injuries can present significant difficulties isolating landmarks. A “look, listen, feel” approach to airway evaluation is wise. Critical structures to identify include the tongue, the hypopharynx, and the larynx. The tongue frequently remains present in penetrating facial injuries, but can also be disrupted by the trauma. Key to airway evaluation is identification of the glottis at the base of the tongue. Hence, sequential visualization of the anatomy from the base of the tongue can direct the airway practitioner to the glottis. Airway sounds, such as gurgling, pose a potential aspiration threat usually from bleeding. More concerning is stridor or the inability to phonate which may indicate impending compromise. Palpation of airway anatomy might allow for identification of otherwise unrecognizable structures, such as the grossly abnormal tongue, mandible, etc., and will also allow the practitioner to identify the position of the larynx in the neck to localize the target for cricothyrotomy if it is necessary.

How Is Airway Hemorrhage Managed in This Circumstance?

Patient positioning is paramount.² Severe hemorrhage requires consideration of sitting the patient upright or rolling the patient into a lateral decubitus position to allow gravity to assist moving blood out of the airway. It merits emphasizing that gravity can also work against the airway practitioner if the patient is forced to lie flat when hemorrhage is severe. Adequate suction is a necessity; plan to have at least two devices available to allow for adequate suction. Direct pressure with 4 × 4 gauze might be of use if the bleeding site is within reach. Topical vasoconstricting medications will most unlikely be successful. Injected lidocaine with epinephrine is an occasional consideration once airway stability is confirmed.

How Often Is a Penetrating Facial Injury Associated with Cervical Spine Injury?

The incidence of associated cervical spine fracture with severe blunt facial trauma ranges from 1% to 6% of patients.^2,6–9 While incidence of cervical spine fracture with penetrating facial wounds can be relatively high (8.1%–23%),^4,5 there are no case reports of penetrating facial/head injury in a neurologically intact patient that has resulted in an unstable cervical spine fracture. Immediately forcing a patient into a cervical collar or supine positioning, however, might result in catastrophe. Caution and common sense should guide emergency medical service (EMS) personnel and the emergency airway practitioner. If no concomitant trauma issues exist (e.g., a fall from a height after the penetrating wound), allowing the patient to stay in a position of comfort can be lifesaving.

What Other Concerns Do You Have for This Patient?

Denitrogenation will be difficult, as any mask device will not provide a good seal and will also serve to pool blood and further compromise the airway.¹ Alternatives to non-rebreather masks or bag-mask devices include blow-by oxygen with a non-rebreather mask held in front of the airway, and nasal oxygen by a high-flow nasal cannula. If nostrils are intact, both might be employed simultaneously.

If induction of anesthesia is deemed necessary, a cerebroprotective sedative (e.g., propofol, benzodiazepines, or barbiturates) is warranted, but care must be taken not to induce or exacerbate hypotension. Etomidate may be attractive because of its associated “hemodynamic stability,” and is neutral in its effects on ICP.^10–14 Based on patient assessment an awake approach would be the preferred method of managing this patient’s airway. Ketamine may allow “facilitated cooperation,” provide analgesia, and allow further assessment of the patient’s airway.^15–17 Recent evidence supports the use of ketamine even in the instance of head trauma as the concern for ICP rise with the use of ketamine is offset by the increase in cerebral perfusion pressure.^18,19 The choice of agents is of particular importance when caring for patients with a diminished cardiac reserve, such as those with severe cardiac disease, those who are critically ill, or patients who are elderly. These patients are more prone to a hypotensive response than are healthier patients with similar injuries. As this is not a “crash” intubation situation, an evaluation of the airway for anticipated difficulty is possible.

What Investigations Are Warranted for This Patient Before Proceeding to Airway Management?

A priority in managing patients with trauma is adequate oxygen delivery. Airway intervention usually takes precedence over any further investigation or intervention. Some may argue that plain film imaging of the face and neck may give additional information related to the destructive path of the projectile, which may help plan the approach to the airway. However the value of such imaging is questionable and is insufficient in its ability to exclude a potential spinal injury and should not delay airway management.^1,2 Concurrent resuscitation and evaluation is key to trauma care, meaning that relevant investigations are underway at the same time airway intervention is undertaken and do not delay management.

What Are the Airway Management Considerations One Needs to be Aware of?

The initial plan should anticipate difficult laryngoscopy, difficult EGD placement, and difficult BMV. The practitioner should also consider how the patient ought to be positioned for laryngoscopy, as the volume of bleeding and the mechanical stability of the airway might preclude supine positioning.² The preferred method in such a patient would be awake with the patient seated upright.³ An RSI would not be considered as a primary approach, in part as it would require the patient to lie flat. It must be recognized that failure of intubation and BMV is a significant possibility in this patient.³ In such a circumstance, the efficacy of many of the common alternative devices would also be compromised. The EGDs such as the intubating laryngeal mask, the King LT, and Combitube™ airway require intact hypopharyngeal structures to seat correctly, and so might be difficult to place. Vision with video-laryngoscopy, such as the GlideScope^®, C-MAC^®, or flexible bronchoscope may be obscured in the presence of blood.^1,20 Regardless of approach, preparation for a surgical airway as part of a double setup requires that cricothyrotomy equipment be readily available.

What Procedure Should be Used to Intubate the Trachea of This Patient?

Timing and positioning in anticipation of airway management is an important consideration. The patient is able to maintain his airway as he is sitting up. This positioning allows blood, bone fragments, and macerated tissue to be displaced away from the airway. In contrast, immediately placing the patient supine strictly for concern of cervical spine injury or reflexively resorting to typical airway management positioning, could place his already tenuous airway at undue risk.² Given the soft tissue disruption and continued hemorrhage, one would anticipate that he would quickly obstruct his airway in a supine position. Denitrogenation should take place in the patient’s original position of comfort. Help should be summoned from other experienced airway practitioners and surgical colleagues to be immediately available to assist in managing this patient.³ Once all preparations for the difficult airway have been made, the practitioner needs to determine what plan to employ for airway management.

Penetrating facial trauma has a potential to cause a difficulty directly, from disruption of the upper airway or secondarily cause challenges related to problems maintaining airway patency from the disrupted soft tissues, or protecting the airway from significant bleeding. Plan A in this case would include an awake look/intubation, which is best achieved through the nose if the patient’s anatomy allows this. A nasopharyngoscope may allow visualization of the airway and bypass much of the pathology, but as discussed above, it may be challenging in the presence of blood. Better option is the use of a flexible bronchoscope after placement of an endotracheal tube (ETT) through a topicalized nose (advance the ETT to 14 to 16 cm for an average size adult). This allows protection of the scope from blood and should provide a good view of the glottis as the bronchoscope exits the supraglottically positioned ETT. Additional topical anesthetic can be delivered through the functioning channel of the bronchoscope before tracheal intubation with the patient seated upright facilitated by procedural sedation doses of an intravenous sedative agent.² An awake oral approach may also be considered but will be challenging as displacement pressure on disrupted and bloody soft tissue with inadequate topicalization may be very difficult.