Perimortem intracranial orogastric tube insertion in a pediatric trauma patient with a basilar skull fracture

Novel alternative for submental intubation - A case report

Background

Submental intubation is commonly used during general anesthesia for maxillofacial surgeries as it provides a safe unrestricted surgical access compared to tracheostomy. During submental intubation, soft tissues and blood clots can become lodged in the endotracheal tube. To overcome this problem, we used a laparoscopic trocar.

Case

A 52-year-old male with maxillofacial injury was scheduled to undergo an open reduction and internal fixation. We performed submental intubation using laparoscopic trocar, which created sufficient space for the insertion of the endotracheal tube. Unlike conventional methods, our method did not require any blunt dissection and caused significantly less soft tissue damage and required significantly less time.

Conclusions

Submental intubation with laparoscopic trocar is a one-step method and is quick and easy-to-perform technique with less complications.

A rare complication of Epistats

We report a 53-year-old man who sustained severe facial and base of skull fractures. At the scene of his accident he had Epistats (Medtronic Sofamor Danek, Memphis, TN, USA) placed for control of his severe nasal haemorrhage, subsequently resulting in the migration of one Epistat into the anterior cranial fossa. There are numerous reports of inadvertent intracranial placement of medical equipment, predominantly in association with complex facial and skull trauma. Other factors that can predispose to aberrant location include previous anterior cranial base surgery and lesions affecting structures in that area.

Submental intubation: a retrospective review of 45 cases

BACKGROUND

Airway management in patients undergoing maxillofacial surgery requires special consideration. A number of options including oro- or naso-tracheal intubation and tracheostomy are available. Submental intubation is now a recognised method of airway control during maxillofacial surgery. It provides a secure airway and does not interfere with maxillomandibular fixation or access to naso-orbito-ethmoid fractures. It avoids potential complications associated with nasotracheal intubation and tracheostomy in patients with multiple facial fractures, and obviates the need to alternate between oral and nasal intubation intra-operatively.

METHODS

This is a ten year retrospective review of patients who underwent submental intubation in a Regional Oral and Maxillofacial Surgery Department. The following variables were recorded: patient gender and age, preoperative diagnosis, duration of intubation, and complications associated with the intubation technique.

RESULTS

Submental intubation was performed 45 times on 45 patients. There were no complications relating to the submental intubation procedure.

CONCLUSION

Submental intubation should be considered as an option for airway management in selected cases of craniomaxillofacial surgery. It is a quick and safe technique with minimal morbidity and a low complication rate. It allows access to the maxillofacial skeleton intra-operatively and does not preclude the use of intermaxillary fixation.

Submental tracheal intubation in oromaxillofacial surgery

BACKGROUND

Oromaxillofacial surgical procedures present a unique set of problems both for the surgeon and for the anesthesist. Achieving dental occlusion is one of the fundamental aims of most oromaxillofacial procedures. Oral intubation precludes this surgical prerequisite of checking dental occlusion. Having the tube in the field of surgery is often disturbing for the surgeon too, especially in the patient for whom skull base surgery is planned. Nasotracheal intubation is usually contraindicated in the presence of nasal bone fractures seen either in isolation or as a component of Le Fort fractures. We utilized submental endotracheal intubation in such situations and the experience has been very satisfying.

MATERIALS AND METHODS

The technique has been used in 20 patients with maxillofacial injuries and those requiring Le Fort I approach with or without maxillary swing for skull base tumors. Initial oral intubation is done with a flexo-metallic tube. A small 1.5 cm incision is given in the submental region and a blunt tunnel is created in the floor of the mouth staying close to the lingual surface of mandible and a small opening is made in the mucosa. The tracheal end of tube is stabilized with Magil's forceps, and the proximal end is brought out through submental incision by using a blunt hemostat taking care not to injure the pilot balloon. At the end of procedure extubation is done through submental location only.

RESULTS

The technique of submental intubation was used in a series of twenty patients from January 2005 to date. There were fifteen male patients and five female patients with a mean age of twenty seven years (range 10 to 52). Seven patients had Le Fort I osteotomy as part of the approach for skull base surgery. Twelve patients had midfacial fractures at the Le Fort II level, of which 8 patients in addition had naso-ethomoidal fractures and 10 patients an associated fracture mandible. Twelve patients were extubated in the theatre. Eight patients had delayed extubation in the post-operative ward between 1 and 3 days postoperatively.

CONCLUSION

In conclusion, the submental intubation technique has proved to be a simple solution for many a difficult problem one would encounter during oromaxillofacial surgical procedures. It provides a safe and reliable route for the endotracheal tube during intubation while staying clear of the surgical field and permitting the checking of the dental occlusion, all without causing any significant morbidity for the patient. Its usefulness both in the emergency setting and for elective procedures has been proved. The simplicity of the technique with no specialized equipment or technical expertise required makes it especially advantageous. This technique therefore, when used in appropriate cases, allows both the surgeon and the anesthetist deliver a better quality of patient care.

Submental intubation in panfacial injuries: our experience

Panfacial fractures present a unique set of problems to the anaesthesiologist and surgeon. Airway management in panfacial fractures is still a challenge to the anaesthesiologist as all modalities available such as orotracheal intubation, nasotracheal intubation, tracheostomy, etc., have their own advantages and disadvantages. When all the conventional modalities to secure airway seem unsuitable then submental route offers an excellent alternative to manage airway in such patients. Here we describe our experience with submental intubation technique in 10 patients with panfacial injuries over a period of two years.

Traumatic brain injury: an integrated clinical case presentation and literature review. Part I: assessment and initial management

Holistic nursing care of critically ill patients continues to be a challenge for all levels of critical care clinicians. Patients with multi-system dysfunction in particular, present complicated clinical challenges that demand care based on sound knowledge and understanding of physiological, psychosocial and spiritual needs. Experiential learning through exposure to a range of patient presentations enables incremental development of professional practice and excellence in nursing care. Case study learning enhances understanding through application of theory to practice in complex clinical presentations. This two-part paper outlines the assessment, interventions and outcome of a person who sustained multiple trauma including severe traumatic brain injury (TBI). Part I explores assessment and initial management from pre-hospital care through to the Emergency Department (ED) and operating theatre. Part II describes the intensive care period as an integral component of the continuum of care. Key issues in the case are presented sequentially with relevant literature integrated and applied to clinical progress, focussing on the complex physiological, psychosocial, spiritual and environmental needs of the patient and his family. The purpose of the paper is to therefore provide a comprehensive learning resource for critical care nurses, particularly for those beginning their practice.

Emergency care in facial trauma--a maxillofacial and ophthalmic perspective

Facial trauma, with or without life- and sight-threatening complications, may arise following isolated injury, or it may be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. Although the American College of Surgeons Advanced Trauma Life Support (ATLS) system of care is generally accepted as the gold standard in trauma care, it has potential pitfalls when managing maxillofacial injuries, which are discussed. Management of facial trauma can arguably be regarded as "facial orthopaedics", as both specialities share common management principles. This review outlines a working approach to the identification and management of life- and sight-threatening conditions following significant facial trauma.

Retrograde Submental Intubation by Pharyngeal Loop Technique in a Patient with Faciomaxillary Trauma and Restricted Mouth Opening

Submental intubation is useful for airway management during maxillofacial surgery when both nasal and orotracheal intubation are deemed unsuitable and to avoid a tracheostomy, especially when long-term ventilatory support is not required in the postoperative period. Adequate mouth opening is a prerequisite for all the techniques described for submental intubation, as the initial step is orotracheal intubation. Hence, this procedure has never been reported in a patient with the inability to open the mouth. We describe the technique of retrograde submental intubation with the help of a pharyngeal loop assembly for the first time in a patient with maxillofacial trauma and restricted mouth opening in whom oral and nasal intubations were not possible and tracheostomy was the only alternative. In this case report, with successful retrograde submental intubation, the potential complications associated with a short-term tracheostomy were avoided, as there was no indication for keeping a tracheostomy during the postoperative period.

Facial fractures and submental tracheal intubation

Submental tracheal intubation is a simple, quick and effective alternative to oral and nasal tracheal intubation or tracheostomy in the surgical management of selected patients with craniomaxillofacial injuries. It has a low morbidity and it does not impede the surgical field, allowing for temporary maxillo-mandibular fixation (jaw wiring) intra-operatively, and nasal assessment, manipulation and bone grafting, either simultaneously or as an independent procedure. We report 12 cases utilizing this technique in this retrospective study, this includes 11 patients with mid-facial fractures and associated base of skull fractures, and one patient who underwent an elective Le Fort III advancement. The techniques and indications for submental tracheal intubation are described.