Airway Management in Severe Combat Maxillofacial Trauma

Airway Management for Penetrating Neck Trauma: A Case Report

Penetrating neck injuries comprise 5-10% of traumatic injuries in adults and can cause immediate life-threatening compromise. Performing awake fibreoptic intubation in cooperative patients when airway management is not time critical has been suggested as a method of securing these potentially complicated airways. We report a case of a male in his 20s who presented to the emergency service with neck trauma following a bicycle road accident. With the exception of a wound in the neck region, there were no alarming distress signs or symptoms of airway endangerment. Imagiological evaluation revealed a rupture of the right lateral tracheal wall. He was referred for urgent surgery. We performed intubation with video laryngoscopy assisted by a neck surgery team, keeping the patient breathing spontaneously and under deep sedation. After advancing the tube through the vocal cords, the surgeon explored the cervical wound, guiding the tube through the trachea. Keeping spontaneous ventilation and advancing the tracheal tube beyond the lesion under visualization is essential when managing a traumatized airway. Tracheal intubation using video laryngoscopy, assisted by a neck surgeon guiding the tube, and avoiding creation of a false passage can be a safe alternative to fibreoptic intubation in selected cases of tracheal laceration.

The Difficult Airway Redefined

There is no all-encompassing or universally accepted definition of the difficult airway, and it has traditionally been approached as a problem chiefly rooted in anesthesiology. However, with airway obstruction reported as the second leading cause of mortality on the battlefield and first-pass success (FPS) rates for out-of-hospital endotracheal intubation (ETI) as low as 46.4%, the need to better understand the difficult airway in the context of the prehospital setting is clear. In this review, we seek to redefine the concept of the “difficult airway” so that future research can target solutions better tailored for prehospital, and more specifically, combat casualty care. Contrasting the most common definitions, which narrow the scope of practice to physicians and a handful of interventions, we propose that the difficult airway is simply one that cannot be quickly obtained. This implies that it is a situation arrived at through a multitude of factors, namely the Patient, Operator, Setting, and Technology (POST), but also more importantly, the interplay between these elements. Using this amended definition and approach to the difficult to manage airway, we outline a target-specific approach to new research questions rooted in this system-based approach to better address the difficult airway in the prehospital and combat casualty care settings.

The New Face of War: Craniofacial Injuries from Operation Inherent Resolve

INTRODUCTION

During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices has resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve.

METHODS

Data was collected for patients treated at Role 1, Role 2, and Role 3 facilities in Iraq and Syria over a one-year period. During this time, a specialized Head & Neck surgical augmentation team was deployed and co-located with the central Role 3 facility. Data included for this cross-sectional study: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed.

RESULTS

Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in forty-six patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (Figure, all p < 0.05). While IEDs had the highest rate of cranial and truncal injuries, GSW and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local healthcare system.

CONCLUSION

Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located Head & Neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both U.S. and local national patients.

LEVEL OF EVIDENCE

Level 4, retrospective study.

Spectral Reflectance as a Unique Tissue Identifier in Healthy Humans and Inhalation Injury Subjects

Tracheal intubation is the preferred method of airway management, a common emergency trauma medicine problem. Currently, methods for confirming tracheal tube placement are lacking, and we propose a novel technology, spectral reflectance, which may be incorporated into the tracheal tube for verification of placement. Previous work demonstrated a unique spectral profile in the trachea, which allowed differentiation from esophageal tissue in ex vivo swine, in vivo swine, and human cadavers. The goal of this study is to determine if spectral reflectance can differentiate between trachea and other airway tissues in living humans and whether the unique tracheal spectral profile persists in the presence of an inhalation injury. Reflectance spectra were captured using a custom fiber-optic probe from the buccal mucosa, posterior oropharynx, and trachea of healthy humans intubated for third molar extraction and from the trachea of patients admitted to a burn intensive care unit with and without inhalation injury. Using ratio comparisons, we found that the tracheal spectral profile was significantly different from buccal mucosa or posterior oropharynx, but the area under the curve values are not high enough to be used clinically. In addition, inhalation injury did not significantly alter the spectral reflectance of the trachea. Further studies are needed to determine the utility of this technology in a clinical setting and to develop an algorithm for tissue differentiation.

A Market Review of Available Airway Suction Technology

INTRODUCTION

Airway injuries are the second leading cause of potentially survivable battlefield death and often require airway management strategies. Airway suction, the act of using negative pressure in a patient's upper airway, removes debris that can prevent respiration, decreases possible aspiration risks, and allows clearer viewing of the airway for intubation. The most important characteristics for a portable airway suction device for prehospital combat care are portability, strong suction, and ease of use.

METHODS

This market review searched academic papers, military publications, Google searches, and Amazon to identify devices. The search included specific characteristics that would increase the likelihood that the devices would be suitable for battlefield use including weight, size, battery life, noise emission, canister size, tubing, and suction power.

RESULTS

Sixty portable airway suction devices were resulted, 31 of which met inclusion criteria - 11 manually powered devices and 20 battery-operated devices. One type of manual suction pump was a bag-like design with a squeezable suction pump that was extremely lightweight but had limited suction capabilities (vacuum pressure of 100mmHg). Another type of manual suction pump had a trigger-like design which is pulled back to create suction with a firm collection canister that had increased suction capabilities (vacuum pressures of 188-600mmHg), though still less than the battery operated, and was slightly heavier (0.23-0.458kg). Battery-operated devices had increased suction capabilities and were easier to use, but they were larger and weighed more (1.18-11.0kg).

CONCLUSION

Future research should work to lighten and debulk battery-operated suction devices with high suction performance.

Portable Medical Suction and Aspirator Devices: Are the Design and Performance Standards Relevant?

Airway clearance refers to the clearing of any airway blockage caused due to foreign objects such as mud, gravel, and biomaterials such as blood, vomit, or teeth fragments using the technology of choice, portable suction devices. Currently available devices are either too heavy and bulky to be carried, or insufficiently powered to be useful despite being in accordance with the ISO 10079-1 standards. When applied to portable suction, the design and testing standards lack clinical relevancy, which is evidenced by how available portable suction devices are sparingly used in pre-hospital situations. Lack of clinical relevancy despite being in accordance with design/manufacturing standards arise due to little if any collaboration between those developing clinical standards and the bodies that maintain design and manufacturing standards. An updated set of standards is required that accurately reflects evidence-based requirements and specifications, which should promote valid, rational, and relevant engineering designs and manufacturing standards in consideration of the unique scenarios facing prehospital casualty care. This paper aims to critically review the existing standards for portable suction devices and propose modifications based on the evidence and requirements, especially for civilian prehospital and combat casualty care situations.

Underestimated Craniomaxillofacial Fractures Due to Firework

BACKGROUND

Iranian people celebrate the last Wednesday of the year also known as Chahar Shambeh Soori (CSS) using low explosive pyrotechnics classified as fireworks. Mishaps and accidents are common and maxillofacial fractures may occur which have a negative impact on the quality of life. This study aimed to assess maxillofacial fractures (fx) caused by explosive agents.

METHODS

This cross-sectional descriptive study assessed 283 patients suffering maxillofacial fxs caused by explosive agents during CSS ceremonies between 2009 and 2019 referred to our craniomaxillofacial (CMF) surgery center. The data assessed included age, sex, cause, type, site, and severity of injury, fracture patterns, treatment modalities, and complications. All maxillofacial injuries were evaluated and treated by Craniomaxillofacial staff surgeons.

RESULTS

Among 283 patients, 72.8% (206) and 27.2% (77) were men and women, respectively. The mean age of patients was 17.35 years. The most common maxillofacial fracture was in the mid-face; with the distribution of fractures being: 39.9% zygomatic fractures, 32.1% nasal bone fractures, 63.2% dentoalveolar fracture, 43.1% Le Fort (Le Fort I, Le Fort II, Le Fort III), 31.4% orbital, and 43.1% mandible fractures. The most frequent type of treatment was Open Reduction and Internal Fixation (ORIF) (77.4%).

CONCLUSION

The most common site of maxillofacial fractures and most frequent treatment used were similar to military or ballistic injuries. ORIF was common treatment.

An Analysis of Airway Interventions in the Setting of Smoke Inhalation Injury on the Battlefield

INTRODUCTION

The Committee on Tactical Combat Casualty Care and Capabilities Development and Integration Directorate cite airway burn injuries as an indication for prehospital cricothyrotomy. We sought to build on previously published data by describing for the first time the incidence of prehospital airway interventions in combat casualties who received airway management in the setting of inhalational injuries.15,26 We hypothesized that (1) airway interventions in combat casualties who suffered inhalational injury would have a higher mortality rate than those without airway intervention and (2) prehospital cricothyrotomy was used with greater incidence than endotracheal intubation.

MATERIALS AND METHODS

Using a previously described Department of Defense Trauma Registry dataset from January 2007 to August 2016, unique casualties with documented inhalational injury were identified.

RESULTS

Our predefined search codes captured 28,222 (72.8% of all encounters in the registry) of those subjects. A total of 347 (1.2%) casualties had a documented inhalational injury, 27 (7.8%) of those with at least 1 prehospital airway intervention inhalational injuries (0.09% of our dataset [n = 28,222]). Within the subset of patients with an inhalation injury, 23 underwent intubation, 2 underwent cricothyrotomy, 3 had placement of an airway adjunct not otherwise specifically listed, and 1 casualty had both a cricothyrotomy and intubation documented. No casualties had a supraglottic, nasopharyngeal, or oropharyngeal airway listed. Contrary to our hypotheses, of those with an airway intervention, 74.0% survived to hospital discharge. In multivariable regression models, when adjusting for confounders, there was no difference in survival to discharge in those with an airway intervention compared to those without.

CONCLUSIONS

Casualties undergoing airway intervention for inhalation injuries had similar survival adjusting for injury severity, supporting its role when indicated. Without case-specific data on airway status and interventions, it is challenging to determine if the low rate of cricothyrotomy in this population was a result of rapid transport to a more advanced provider capable of performing intubation or cricothyrotomy may not be meeting the needs of the medics.

Airway Clearance Using Suction Devices in Prehospital Combat Casualty Care: A Systematic Review

Airway management is at the forefront for combat medics dealing with battlefield trauma. For military service members, compromised airways are the second leading cause of potentially survivable death on the battlefield, accounting for one in ten preventable combat deaths. Effective suction is a critical component of airway clearance. However, currently available devices are too heavy and bulky to be carried by combat medics and are insufficiently powered. The industry has not responded to the need, with companies continuing to produce models using 1970s technology. A literature review was completed with the assistance of a librarian. The databases searched included: Biomedical Research Database (BRD), Computer Retrieval of Information of Scientific Projects (CRISP), Federal Research in Progress (FEDRIP), Defense Technical Information Center (DTIC), Pub Med/Medline, and OVID. Additionally, a Google Scholar search was performed to identify nonstandard sources. After screening, a total of 40 articles were used. There were no randomized controlled trials or other high-quality evidence that addressed the issues; there was limited peer-reviewed literature on the use, effectiveness, adverse effects, and safety of suction for use in combat casualty care. A review of the available literature revealed no standards, either proposed, validated, or accepted, for the safety or avoidance of adverse effects for portable suction device use in combat casualty care. Similarly, there are no accepted standards to guide the safe use and anticipated adverse effects of suction for use in prehospital combat or emergency care. Nevertheless, there are meaningful data that can be extracted from the few studies available combined with non-clinical studies, narrative reviews and case reports, and expert opinions.

Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities

Supplemental digital content is available in the text.

The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.

Prehospital airway procedures performed in trauma patients by ground forces in Afghanistan

BACKGROUND

Airway management is of critical importance in combat trauma patients. Airway compromise is the second leading cause of potentially survivable death on the battlefield and accounts for approximately 1 in 10 preventable deaths. Reports from the Iraq and Afghanistan wars indicate 4% to 7% incidence of airway interventions on casualties transported to combat hospitals. The goal of this study was to describe airway management in the prehospital combat setting and document airway devices used on the battlefield.

METHODS

This study is a retrospective review of casualties that required a prehospital lifesaving airway intervention during combat operations in Afghanistan. We obtained data from the Prehospital Trauma Registry that was linked to the Department of Defense Trauma Registry for outcome data for the time period between January 2013 and September 2014.

RESULTS

Seven hundred five total trauma patients were included, 16.9% required a prehospital airway management procedure. There were 132 total airway procedures performed, including 83 (63.4%) endotracheal intubations and 26 (19.8%) nasopharyngeal airway placements. Combat medics were involved in 48 (36.4%) of airway cases and medical officers in 73 (55.3%). Most (94.2%) patients underwent airway procedures due to battle injuries caused by explosion or gunshot wounds. Casualties requiring airway management were more severely injured and less likely to survive as indicated by Injury Severity Score, responsiveness level, Glascow Coma Scale, and outcome.

CONCLUSION

Percentages of airway interventions more than tripled from previous reports from the wars in Afghanistan and Iraq. These changes are significant, and further study is needed to determine the causes. Casualties requiring airway interventions sustained more severe injuries and experienced lower survival than patients who did not undergo an airway procedure, findings suggested in previous reports.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level III.

An Experience of Improvised Laryngoscopy

Airway management in the wilderness runs the gamut from basic airway support to endotracheal intubation. Fortunately, direct laryngoscopy is a seldom called upon skill in expedition medicine. However, the medical skills required during a mission or expedition are never truly known in advance. Improvisation during evolving medical events is a mainstay of expedition medicine education and practice. It is unlikely, given constraints of weight and size of expedition medical kits, that a conventional laryngoscope would find its way into a standard "go bag." Faced with the real but rare event of needing to intubate a patient in an austere environment, how can improvisation be used? Multiple ideas for improvised laryngoscopes can be found in the wilderness medicine literature, but which, if any, of these devices have true clinical utility? To this end, participants of a recent Wilderness Medical Society preconference in medical elements of light search and rescue were given the opportunity to devise and construct their own improvised laryngoscopes and attempt intubation of a training mannequin. Participants with varying degrees of intubating experience improvised effective laryngoscopes from provided materials and successfully intubated an airway mannequin.

Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma

INTRODUCTION

Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns.

METHODS

A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763).

RESULTS

A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns.

CONCLUSIONS

The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety.

Analysis of cases managed by the otolaryngology service in the Chinese military peacekeeping level 2 medical treatment facility in Mali

OBJECTIVES

As part of the UN peacekeeping mission in Mali, the People's Republic of China have deployed a level 2 medical treatment facility (CHN L2). The aim of this study was to review the cases managed by the otolaryngology service within this facility.

METHODS

The medical records of all patients treated by the otolaryngology service at the CHN L2 from 1 March 2015 to 1 March 2018 were retrospectively assessed.

RESULTS

614/10189 (6%) of all cases seen in the hospital during this period were referred to the otolaryngology service. 7/614 cases required admission to hospital (1.14%) and 40/614 cases required surgery (6.51%). 3/40 cases requiring surgery (7.5%) were performed under general anaesthesia and 37 cases (92.5%) were under local anaesthesia. The most common surgical treatment was facial soft-tissue injury debridement and closure. Acute rhinosinusitis was the most common diagnosis, followed by acute pharyngitis and allergic rhinitis. Four patients required medical evacuation to a level 3 medical treatment facility.

CONCLUSIONS

Disease non-battle injury in the form of ear disease was the most common presentation. Maxillofacial soft-tissue injury was the most common cause of traumatic injury. There were limits that the service could provide in terms of medical equipment and consumables, necessitating increased training of otolaryngologists prior to deployment.

Our Treatment Approaches in Severe Maxillofacial Injuries Occurring After Failed Suicide Attempts Using Long-Barreled Guns

Maxillofacial traumas with long-barreled guns may sometimes cause catastrophic results by means of smashing in facial structures. In these patients, reconstruction strategies of both fragmented/lost soft and hard tissues still remain controversial. In their clinic, the authors treated 5 patients with severely injured face after failed suicide attempt between 2008 and 2013. In this study, the authors aimed to present their clinical experiences on these severely injured maxillofacial gunshot traumas and offer a treatment algorithm to gain a result as possible as satisfactory in terms of functionality and appearance.

Management and reconstruction of blast wounds of the head and neck

PURPOSE OF REVIEW

The purpose of this review is to highlight recent literature related to the initial management and reconstruction of blast injuries to the head and neck.

RECENT FINDINGS

An increasing percentage of combat-related injuries are caused by blast trauma. Management of blast trauma over the last 10 years has improved understanding of the unique nature of these injuries and the importance of thoughtful management and reconstruction. Blast trauma is associated with an increased need for definitive airway management. As a result, initial triage principles of airway management and hemorrhage control are extremely important in the acute setting. Blast trauma results in high-velocity injuries that can lead to extensive soft tissue damage, which has important implications for reconstruction. Staging reconstruction is an important consideration for more extensive injuries.

SUMMARY

Experience on the battlefield with blast injuries over the last decade has led to efficient triage with focus on hemorrhage and airway control. The lessons learned in Iraq and Afghanistan with the unique physiology of blast trauma have improved the casualty care of service members and can be used both in future military conflicts and in civilian trauma care.

Percutaneous dilatational tracheostomy (PDT) in trauma patients: a safe procedure

PURPOSE

Percutaneous dilatational tracheostomy (PDT) is a standard procedure routinely performed on intensive care units. While complication rates and long-term outcomes have been studied in different patient populations, there are few studies known to these authors involving PDT in trauma patients and the complications which may result.

METHODS

Between March 2007 and August 2013, all instances and peri-procedural complications during PDT occurring on the trauma intensive care unit, a unit specialized in the care of injured patients and especially polytrauma patients, were documented. PDTs were performed by a surgeon with the assistance and supervision of another, using bronchoscopic guidance performed by the respiratory medicine department.

RESULTS

289 patients were included in the study, 225 men and 64 women with a mean age of 49 ± 21 years. Complications occurred in 37.4 % of cases. The most common complication, bleeding, occurred in 26.3 % of patients ranging from little to severe bleeding. Fracture of tracheal cartilage occurred in 6 % of PDT cases. Additional complications such as dislocation of the guidewire, hypotension, and oxygen desaturation were observed. Most complications did not require treatment. The second tracheal intercartilaginous space was successfully intubated in 82 % of cases.

CONCLUSIONS

PDT is a safe procedure in trauma patients. When considering the severity of complications such as major blood loss, pneumothorax, or death, this evidence suggests that PDT is safer in trauma patients compared to other patient cohorts.