Because the cribriform plate may be disrupted, avoid nasotracheal intubation in patients with midface trauma. Nasotracheal intubation can result in nasocranial intubation or dramatic nasal hemorrhage. Admittedly, these complications are rare, and some patients have successfully intubated via the nasotracheal route. 7 Nonetheless, orotracheal intubation is often successful even with severely distorted facial anatomy.
Rapid-sequence intubation carries particular risk in facial trauma. These dangers include the failure to intubate and subsequent failure to ventilate with a bag-valve mask. Before paralyzing any patient, evaluate the degree of difficulty anticipated for mask ventilation. Patients with distortion of the maxilla or mandible may be impossible to bag, because the mask will not fit tightly on an unstable face.
In such cases, consider an awake intubation. Options include sedation with a benzodiazepine, droperidol, or other induction agent in a dose that minimizes respiratory depression. If a patient with severe maxillofacial trauma is given paralytics, prepare for immediate backup cricothyroidotomy. Preparation in this case implies more than locating a surgical tray: it extends to povidone-iodine on the neck, a ready blade, an opened cricothyroidotomy tray, and a tracheostomy tube at the bedside.
Some authors describe creative approaches to intubation in facial trauma. Fiberoptic intubation with patients in the semiprone position may be useful in penetrating injuries of the face.8 The traditional supine intubating position may be impossible with a ruined maxilla that falls into the airway. Such airways may clear when a patient lies on his or her side (although this may be both awkward and disconcerting to the physician). The Bullard intubating blade and the laryngeal mask airway are all used to manage a difficult airway in patients with a crushed face.
Other alternatives include percutaneous transtracheal ventilation and retrograde intubation as a temporizing measure. Both require considerable preparation, and the most dependable alternative airway is surgical. Emergency cricothyroidotomy, being faster and associated with fewer complications, is preferable to emergency tracheostomy.
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