Post on 22-May-2015
A Case Report of Facial Trauma
Gholamreza Ghamatzadeh M.DBoardman of Anesthesiology
Poursina Hospital - Rasht
Presentation
Male 25 years old BW ≈ 80kg Severe facial trauma due to car accident Agitated & Disoriented GCS = 8/15 Left side chest tube ↓ Respiratory sounds in right side of the chest → suspect to
right side pneumothorax SBP=60mmHg, DBP=non sense, HR=140/min, RR=25/min
Fentanyl 50 µgr/stat
+
TPN 50mg/stat
↓↓
Cardiac arrest + Gasping respiration
CPR 1
Direct Laryngoscopy + Oral intubation↓
O2 100%↓
External Cardiac Massage↓
Adrenaline 100µg (3 times)↓
CPR 2
Bicarbonate Na 50 meq↓soon
Adrenaline 1mg (3 times)↓↓
Bradycardia↓
Atropine 0.5mg (2 times)↓↓VT
CPR 3
VT
↓↓
Lidocaine 100mg
↓↓
Sinus Tachycardia
(BP=140/70, PR=143/min)
Maintenance of Anesthesia
Fentanyl 50µg Cisatracurium 4mg O2 100% Ventilation rate= 12/min
ABG 1
PH: 6.97Pco2: 67 mmHg
Hco3: 15.5Po2: 242
O2 sat: 99%BE: -15
↓↓Bicarbonate Na 2 vials
Rate: 18/min
ABG 2 (40 min. later)
PH: 7.06Pco2: 73.9 mmHg
Hco3: 20.5Po2: 114
O2 sat: 95%BE: -11
↓↓Bicarbonate Na 1 vial
CBC result
In this time:
Hgb: 9.1
Hct: 27
Plt: 425000
New Problem
In this time:
BP decreased (60/30-40)
↓↓
Ephedrine 10mg (2 times)
(Tachycardia)↓soon
Dobutamine infusion 20µg/kg/min
Another Problem
Because of ↓respiratory sounds:
CXR
↓↓
Right side Pneumothorax
↓
Surgical Consultation for Chest Tube insertion
↓
Chest Tube
In this time:
O2 50%
+
N2O 50%
New Problem
In the end of surgery:
Emphysema in left side of upper chest and neck + Air bubbling from left side wound of
neck
↓
Second Surgical Consultation
In the end of surgery:
BP: 80/50 mmHg
PR: 140 beats/min
Urine out put: 1500 ml for 4 hours
Transportation to ICU
Received Fluids
Packed cell: 3 units N/S: 3000ml
In ICU
Full Support Cisatracurium 4mg/PRN SIMV: VT→700 ml Rate→14/min FIO2→40% PS→20 cmH2O PEEP→0 Dobutamine 20µg/kg/min
ABG 3 (60 min. later in ICU)
PH: 7.31Pco2: 37.2 mmHg
Hco3: 18.2Po2: 227 mmHgO2 sat: 99.7%
BE: -6.8↓↓
FIO2 = 30%
In ICU
BP=160/80, PR=140/min↓↓
Dobutamine 10µg/kg/min30 min. later:
BP=140/80, PR=140/min↓↓
Dobutamine 5µg/kg/min45 min. later:
BP=130/80, PR=136/min
Conclusion
Compromised Airway 1
Unlike difficult intubations in normal airways, patients with compromised airways must not be given GA or muscle relaxants unless control of airway is ensured.
Attempt at awake intubation should not be done “blindly” in patients with uncertain pathologic processes.
Compromised Airway 2
Safe techniques for managing compromised airways include:
1. Awake direct laryngoscopy after careful topical laryngeal block
2. Spontaneous breathing using an inhaled anesthetic3. Awake fiberoptic evaluation of the airway4. Tracheostomy under local anesthesia5. If necessary, lifesaving TTJV through a cricothyroid
puncture with a large-caliber(14-gauge) needle, or an emergency cricothyroidotomy.
Facial Injury
The most common fractures involve the mandible and midface (Le fort I,II,III)
A first priority is to secure the airway by placing the patient in the lateral position, pulling the mandible or maxilla forward and clearing the oropharynx of blood or loose teeth.
If this action is not successful, endotracheal intubation or emergency tracheostomy should be considered.
These patients may also have head trauma or fractures of the cervical spine.
Contraindications of Nasal Intubation
Coagulopathy Severe intranasal disorder Basilar skull fracture Presence of a CSF leak
Asystol Management
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