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CANADIAN JOURNAL OF ANESTHESIA
mL showed pH 7.40, PCO 35 mmHg, PO 396
mmHg, hematocrit 33.6%. Diagnostic peritoneal lavage
was insufficient mouth opening for placement of a
Combitube or laryngeal mask airway.
2
2
was negative.
It is recognized that this patient was at increased risk
for gastric regurgitation and pulmonary aspiration with
deep sedation and general anesthesia by face mask.
Despite this increased risk, rapid sequence intubation
together with cricoid pressure was not considered
because of the inability to open the mouth. The priori-
ties in this patient were to establish a definitive airway
by providing optimal conditions for tracheostomy while
at the same time preventing hypoxemia. Had regurgita-
tion occurred prior to insertion of the cuffed tra-
cheostomy tube, the plan was to place the patient in a
head-down position to permit vomitus to run out of the
mouth. Oropharyngeal and tracheobronchial suction-
ing, including bronchoscopy to remove food particles,
would also be necessary. Thorough tracheobronchial
suctioning would have awaited placement of the tra-
cheostomy tube. Pharmacologic agents to stimulate
gastric emptying (e.g., metoclopramide) were not used,
although these agents may be helpful in some patients.
Nasotracheal intubation via a flexible fibreoptic
bronchoscope was considered but not done because of
the possibility of basilar skull fracture with disruption
of the cribriform plate of the ethmoid bone. In these
instances, the tracheal tube may traverse the fractured
cribiform plate and disrupt the brain substance. Blind
nasal intubation was not considered because of the
above factors and because this technique may result in
loss of the airway due to epistaxis or hematoma.5
Experience with inhalational induction in adults has
previously been limited by the relatively slow uptake
of halothane and the relatively high noxious nature of
the other gases desflurane, isoflurane, and enflurane
which produced complications such as excessive secre-
tions, coughing, and laryngospasm during induction.
In contrast, sevoflurane has a low blood:gas solubility
and is associated with smooth induction of anesthesia
with minimal or no airway irritation or cough, rapid
control of anesthetic depth, and preservation of spon-
Subsequent work-up revealed that the right
mandibular condyle had been driven up and through
the glenoid fossa and was in an intracranial position
(
Figure 1). There was a large right temporal lobe
hemorrhage (Figure 2). Other injuries were a dis-
placed left subcondylar mandibular ramus fracture and
a right comminuted parasymphseal mandible fracture.
Three days later, surgery was performed to remove the
condyle from the intracranial fossa, reconstruct the
right glenoid fossa with bone graft and temporal mus-
cle flap, and repair the symphysis and left subcondylar
fractures. She was discharged to a rehabilitation facili-
ty on the 18th postoperative day with independent
mobility and activities of daily living, but mild cogni-
tive dysfunction.
Discussion
Numerous techniques are available for tracheal intu-
1,2
bation in the injured patient. Because of the inabili-
ty to open the mouth and the severity of the facial
fractures, a decision was made to secure the airway
using awake tracheostomy with local anesthesia.
Although this technique has the advantage of preserv-
ing spontaneous ventilation while at the same time
maintaining protective airway reflexes, tracheostomy
may not be well tolerated in uncooperative patients
such as the one presented in this report. Trauma
patients are often uncooperative during airway
maneuvres because of drug intoxication (e.g., alcohol,
cocaine), head injury, hypoventilation, hypoxia, and
3
other factors. Refusal to cooperate during intubation
may result in excessive patient movement, airway trau-
ma, elevated intracranial pressure, and possible cervi-
cal spine injury. Because of the fluctuating level of
consciousness, we were reluctant to administer opioid
agents. It is possible that the agitation was due to
painful injuries, and that the use of midazolam and
propofol may have contributed to worsening of the
confusion of an already obtunded patient with a
closed head injury.
7
taneous ventilation. Despite the possible adverse
effects of volatile anesthetic agents on cerebral
autoregulatory capacity, cerebral blood flow, and
8–10
The use of deep sedation or general anesthesia has
been shown to decrease upper airway tone and cause
airway occlusion during spontaneous ventilation.
intracranial pressure,
sevoflurane has been shown
to provide significant neuronal protection in the pres-
4
1 1
ence of hypoxia and ischemia. Moreover, doses as
Thus, it is not surprising that the patient required a
jaw thrust and chin lift maneuver to prevent airway
obstruction as the concentration of sevoflurane was
increased. Head extension was not done because of
suspected cervical spine injury. Transtracheal jet venti-
lation was the backup plan to oxygenate the patient
and ventilate the lungs in an emergency since there
high as 1.5 MAC sevoflurane do not impair static rate
of cerebral autoregulation provided that normocapnia
1
2
is maintained, as occurred in this report. For these
reasons, sevoflurane was chosen instead of the other
volatile agents. Nitrous oxide was not used because it
reduces the inspired oxygen concentration and may
enlarge air- containing spaces (e.g., pneumothorax,
Sell
