martes, 8 de octubre de 2013

Vía aérea en trauma facial/Airway in facial trauma

Perspectivas actuales en el manejo intraoperatorio de la vía aérea en trauma maxilofacial

Current perspectives in intra operative airway management in maxillofacial trauma.
Vidya B, Cariappa KM, Kamath AT.
Department of Oral and Maxillofacial Surgery, D J College of Dental Sciences and Research, Modinagar, Ghaziabad, UP India.
J Maxillofac Oral Surg. 2012 Jun;11(2):138-43. doi: 10.1007/s12663-011-0316-8. Epub 2011 Dec 23.
OBJECTIVE: Maxillofacial trauma presents a complex problem due to the disruption of normal anatomy. In such cases, we anticipate a difficult oral intubation that may hinder intraoperative IMF. Nasal and skull base fractures do not advocate use of nasotracheal intubation. Hence, other anesthetic techniques should be considered in management of maxillofacial trauma patients with occlusal derangement and nasal deformity. This study evaluates the indications and outcomes of anesthetic management by retromolar, nasal, submental intubation and tracheostomy. METHODOLOGY: Of the 49 maxillofacial trauma cases reviewed, that required intraoperative IMF, 32 underwent nasal intubation, 9 patients had tracheostomy, 5 patients utilized submental approach and 3 underwent retromolar intubation. RESULTS: Among patients who underwent nasal intubation, eight cases needed fiberoptic assistance. In retromolar approach, though no complication was encountered, constant monitoring was mandatory to avoid risk of tube displacement. Consequently, submental intubation required a surgical procedure which could result in a cosmetically acceptable scar. Though invasive, tracheostomy has its benefits for long term ventilation. CONCLUSION: Intubation of any form performed in a maxillofacial trauma patient is complex and requires both sound judgement and considerable experience. KEYWORDS: Intermaxillary fixation, Maxillofacial trauma, Nasal intubation, Retromolar technique, Submental intubation, Tracheostomy

Cuestiones en el manejo de vía aérea crítica (Que anestesia; cual vía aérea operatoria?)
Issues of critical airway management (Which anesthesia; which surgical airway?).
Bonanno FG.
Trauma Directorate, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.
J Emerg Trauma Shock. 2012 Oct;5(4):279-84. doi: 10.4103/0974-2700.102353.
Which anesthesia for patients with critical airway? Safe and effective analgesia and anesthesia in critical airway is a skilled task especially after severe maxillofacial injury combined with head injury and hemorrhagic shock. If on one side sedation is wanted, on the other hand it may worsen theairway and hemodynamic situation to a point where hypoventilation and decrease of blood pressure, common side-effect of many opioids, may prejudice the patient's level of consciousness and hemodynamic compensation, compounding an already critical situation. What to do when endotracheal intubation fails and blood is trickling down the airways in an unconscious patient or when a conscious patient has to sit up to breathe? Which surgical airway in critical airway? Comparative studies among the various methods of emergency surgical airway would be unethical; furthermore, operator's training and experience is relevant for indications and performance.
KEYWORDS:Ketamine, maxillofacial trauma, neck trauma, remifentanyl, tracheostomy

Intubación submentoniana en pacientes con fracturas panfaciales: Un estudio prospectivo
Submental intubation in patients with panfacial fractures: A prospective study.
Shetty PM, Yadav SK, Upadya M.
Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore, Karnataka, India.
Indian J Anaesth. 2011 May;55(3):299-304. doi: 10.4103/0019-5049.82685.
Submental intubation is an interesting alternative to tracheostomy, especially when short-term postoperative control of airway is desirable with the presence of undisturbed access to oral as well as nasal airways and a good dental occlusion. Submental intubation with midline incision has been used in 10 cases from October 2008 to March 2010 in the Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Mangalore. All patients had fractures of the jaws disturbing the dental occlusion associated with fracture of the base of the skull, or/and a displaced nasal bone fracture. After standard orotracheal intubation, a passage was created by blunt dissection with a haemostat clamp through the floor of the mouth in the submental area. The proximal end of the orotracheal tube was pulled through the submental incision. Surgery was completed without interference from the endotracheal tube. At the end of surgery, the tube was pulled back to the usual oral route. There were no perioperative complications related to the submental intubation procedure. Average duration of the procedure was less than 6 minutes. Submental intubation is a simple technique associated with low rates of morbidity. It is an attractive alternative to tracheotomy in the surgical management of selected cases of panfacial trauma.
Airway management, panfacial fractures, submental intubation

Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor

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