The compromised airway 262
Tracheostomy tube problems 264
Massive bleeding from the face and mouth 268
Massive bleeding from the neck 270
Retrobulbar haemorrhage 272
• This is possibly the most important section in thisbook.
• It is written on the assumption that you have ATLS training (or
• Contrary to ATLS teaching, however, in some circumstances, usually
in head and neck cancer cases, a tracheostomy is an option in an
emergency situation but it is carried out by an experienced head and
• You should be prepared to undertake a cricothyroidotomy from day
one of an OMFSjob.
• Read the section on cricothyroidotomy (see E pp. 240–1) and get into
the habit when you are in theatre of examining the patient’s neck and
asking yourself:‘Where is the cricothyroid membrane?’
• In OMFS you will encounter compromised airways in the following
— Unexpected bleeding and swelling
— Tracheostomy complications (see E pp. 264–6).
The trauma patient
• ATLS rulesapply.
• Trauma patients most commonly have airway problems because the
fractured facial bones are posteriorly displaced, or there is bleeding into
the pharynx, or there is a laryngeal injury.
• If possible, sit the patient up, lean them forwards, and suck out
• Be prepared to physically pull fractured bones and the tongue forward
to clear the obstructed airway.
• If you cannot do this because of the need for C- spine immobilization
and clearance, you could log roll patient 180° on a stretcher so that they
are facing the oor as a temporary measure until senior help arrives.
• If that is not an option, rapid sequence intubation is required and the
trauma team leader should request this while you do what you can to help
with suction and manipulation of fragments as previously described.
The postoperative patient
• This is more likely in orthognathic, FOM, and oncology surgery.
• Consider if removal of sutures and/ or evacuation of a clot mighthelp.
• ‘Sit them up, give oxygen, suck out mouth and nose’ should be the
advice that you give over the phone whilst you are making your way
briskly to theward.
• Postoperative patients may be dicult intubations so the need for
cricothyroidotomy is more likely.
• Get anaesthetic helpearly.
The abscess patient
• In these cases, airway obstruction can be very sudden and is usually
due to laryngeal oedema. The key to avoiding disasters is to spot the
warning red ags and act quickly.
• You must never be left alone with these patients— gethelp.
• Patients die rst from airway obstruction, so the priority is to secure the
airway, not an immediate incision and drainage.
Refusal to lieback
Shortness of breath, tachypnoea, and falling O
saturation are very
, get IVaccess
call for senior OMFShelp.
• Management will depend to some extent on the anaesthetist’s
• If the anaesthetist is suitably trained, they may wish to do an
awake breoptic nasoendotracheal intubation, usually with needle
• If the anaesthetist is not trained in awake breoptic intubation and
there is insucient time to wait for someone who is, you must do
something immediately. This probably means a cricothyroidotomy.
If the anaesthetist attempts normal intubation, ensure that either
the cricothyroid membrane is marked with permanent ink or, even
better, you have inserted a needle cricothyroidotomy— this will buy
you some time if the airway is lost and acts as a guide for surgical
• You may not have time to wait until you get to theatre to dothis.
• Use IV antibiotics, uids, and dexamethasone by all means, but do not
allow this to delay the securing of a denitive airway.
• Don’t get bogged down with denitions like ‘Ludwig’s angina’. What
matters to your patient right now is securing their airway.
The cancer patient
Patients with advanced tumours around the glottis and tongue base can pre-
sent with acute loss of airway and require emergency cricothyroidotomy
or tracheostomy. They may also have sudden bleeding (due to metastatic
disease around the great vessels) which can cause rapid neck swelling and
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261 Chapter10EmergenciesThe compromised airway 262Tracheostomy tube problems 264Massive bleeding from the face and mouth 268Massive bleeding from the neck 270Retrobulbar haemorrhage 272 262CHAPTER10 EmergenciesThe compromisedairwayGeneralpoints• This is possibly the most important section in thisbook.• It is written on the assumption that you have ATLS training (or equivalent).• Contrary to ATLS teaching, however, in some circumstances, usually in head and neck cancer cases, a tracheostomy is an option in an emergency situation but it is carried out by an experienced head and neck surgeon.• You should be prepared to undertake a cricothyroidotomy from day one of an OMFSjob.• Read the section on cricothyroidotomy (see E pp. 240–1) and get into the habit when you are in theatre of examining the patient’s neck and asking yourself:‘Where is the cricothyroid membrane?’• In OMFS you will encounter compromised airways in the following situations:• Trauma• Abscesses• Tumour obstruction• Postoperatively:— Unexpected bleeding and swelling— Tracheostomy complications (see E pp. 264–6).The trauma patient• ATLS rulesapply.• Trauma patients most commonly have airway problems because the fractured facial bones are posteriorly displaced, or there is bleeding into the pharynx, or there is a laryngeal injury.• If possible, sit the patient up, lean them forwards, and suck out themouth.• Be prepared to physically pull fractured bones and the tongue forward to clear the obstructed airway.• If you cannot do this because of the need for C- spine immobilization and clearance, you could log roll patient 180° on a stretcher so that they are facing the oor as a temporary measure until senior help arrives.• If that is not an option, rapid sequence intubation is required and the trauma team leader should request this while you do what you can to help with suction and manipulation of fragments as previously described.The postoperative patient• This is more likely in orthognathic, FOM, and oncology surgery.• Consider if removal of sutures and/ or evacuation of a clot mighthelp.• ‘Sit them up, give oxygen, suck out mouth and nose’ should be the advice that you give over the phone whilst you are making your way briskly to theward.• Postoperative patients may be dicult intubations so the need for cricothyroidotomy is more likely.• Get anaesthetic helpearly. THE COMPROMISEDAIRWAY263 The abscess patient• In these cases, airway obstruction can be very sudden and is usually due to laryngeal oedema. The key to avoiding disasters is to spot the warning red ags and act quickly.• You must never be left alone with these patients— gethelp.• Patients die rst from airway obstruction, so the priority is to secure the airway, not an immediate incision and drainage.• Dangersigns:• ‘Hot potato’voice• Refusal to lieback• Drooling ofsaliva• Tachycardia• Distressed• Shortness of breath, tachypnoea, and falling O2 saturation are very latesigns.• Youmust:• get anaesthetistnow• give O2, get IVaccess• call for senior OMFShelp.• Management will depend to some extent on the anaesthetist’s experience.• If the anaesthetist is suitably trained, they may wish to do an awake breoptic nasoendotracheal intubation, usually with needle cricothyroidotomy insitu.• If the anaesthetist is not trained in awake breoptic intubation and there is insucient time to wait for someone who is, you must do something immediately. This probably means a cricothyroidotomy. If the anaesthetist attempts normal intubation, ensure that either the cricothyroid membrane is marked with permanent ink or, even better, you have inserted a needle cricothyroidotomy— this will buy you some time if the airway is lost and acts as a guide for surgical cricothyroidotomy.• You may not have time to wait until you get to theatre to dothis.• Use IV antibiotics, uids, and dexamethasone by all means, but do not allow this to delay the securing of a denitive airway.• Don’t get bogged down with denitions like ‘Ludwig’s angina’. What matters to your patient right now is securing their airway.The cancer patientPatients with advanced tumours around the glottis and tongue base can pre-sent with acute loss of airway and require emergency cricothyroidotomy or tracheostomy. They may also have sudden bleeding (due to metastatic disease around the great vessels) which can cause rapid neck swelling and airway obstruction. 264CHAPTER10 EmergenciesTracheostomy tube problemsGeneralpoints• You need to be familiar with tracheostomy tubes and how they work (Fig. 10.1 and Fig.10.2).• The website http:// www.tracheostomy.org.uk is an excellent site for anyone who has anything to do with tracheostomies, and we advise you to look at this sitenow.• It is important to appreciate that although tracheostomy tubes are designed to help with ventilation they can also be a source of obstruction.• The most common problems you will have with tracheostomy tubes are blockage, displacement, and bleeding aroundthem.Blocked tracheostomytubes• If a patient is completely dependent on the tracheostomy tube for ventilation, then a blockage is immediately life- threatening. You must remove the inner tube if there is one, suction the outer tube, let the cu down, and give high- ow oxygen. While doing this ask someone else (e.g. the ward nurse) to call the crash team or at the very least to fast bleep the on- call anaesthetist.• If that still doesn’t help, then you need to either remove the tube completely or if you have time and the ability, change it over a boogie.• If you don’t know how to change a tracheostomy tube and you do not have time to wait for someone else to arrive, take the tube out and see what happens. This often solves the problem but if not you must get an airway by some other means as quickly as possible. This may mean using a bag– valve– mask, laryngeal mask, or intubation or even cricothyroidotomy. Unless you are experienced do not go exploring the neck with tracheal dilators in hope of nding the tracheal stoma. It is unlikely that you will nd it and you are wasting precioustime.Fig.10.1 Diagrams of tracheostomy tubes:(a) cued fenestrated tube; (b)non- cued non- fenestrated tube; (c)paediatric tube. Reproduced from Corbridge R, Steventon N.‘Oxford Handbook of ENT and Head and Neck Surgery’, p.241 (Oxford:2010). With permission from Oxford UniversityPress. TRACHEOSTOMY TUBE PROBLEMS265 • If the patient is ‘breathing around’ a blocked tracheostomy tube, they may be struggling to breathe but you have a bit more time to remove the inner tube, and to clean and suction. Let the cu down and give oxygen as outlined above. Call for senior help quickly if there is no rapid improvement with these measures, e.g. the diagnosis could be wrong and there may a be need to have a look down the tube with a nasendoscope.Fig.10.2 Diagram of tracheostomy tube position (note fenestration). Reproduced from Corbridge R, Steventon N.‘Oxford Handbook of ENT and Head and Neck Surgery’, p.241 (Oxford:2010). With permission from Oxford UniversityPress. 266CHAPTER10 EmergenciesDisplacedtubes• If the tube is displaced within the rst few days of placement the tract will rapidly close and re- insertion of the tube will be near impossible except under controlled conditions.• Therefore, if you cannot see the tracheal stoma clearly (unless a Bjork ap has been used, this is unlikely) do not waste time trying to do the impossible, but get an airway by any other means. Use bag– valve– mask for the time being until the anaesthetist arrives. They will then consider intubation. You will still be of use because the anaesthetist will want to know what surgery has been done etc. We advocate the use of silk stay sutures placed at the time of tracheostomy to facilitate tube re- insertion. These simple sutures help to bring the tracheostomy stoma towards the skin and can greatly facilitate this manoeuvre.• If bag– valve– mask ventilation is not successful, the anaesthetist has not arrived yet, and you are not trained to intubate, proceed immediately to cricothyroidotomy. Likewise, if intubation is unsuccessful.• When you are ventilating a patient with bag– valve– mask you may need to occlude the neck wound to obtain better ventilation, but don’t think that if the air comes out it will be easy to get tube backin!Bleeding aroundtracheostomytubes• Massive bleeding around the tube warrants the usual resuscitation steps and immediate return to theatre. Don’t forget to inate the cu to protect the airway. Place two large- bore cannulae, cross- match 4 units, and tell your senior that the patient is on their way to theatre.• Management of lesser bleeding may be more open to interpretation and discussion, so you should do the basics (get lines in, inate cu, cross- match, etc.) but call your senior before you arrange to return to theatre.• Recent guidelines suggest that if the bleeding occurs >72 hours after placement of the tracheostomy tube, the patient should return to theatre for endoscopic examination of the trachea to exclude an innominate artery stula.• An innominate artery stula can present with a smallish herald bleed followed by catastrophic and usually fatal bleeding. It is fortunately quite rare. • The other more common source of bleeding around tracheostomy tubes which have been in for a few days is the granulation tissue which forms around the tube and which bleeds easily. It is usually treated by packing some ribbon gauze around the tube and correcting any coagulopathies if appropriate. TRACHEOSTOMY TUBE PROBLEMS267 268CHAPTER10 EmergenciesMassive bleeding fromthe face andmouthGeneralpointsThe most common causes you will encounterare:• facial fractures• nosebleed not associated with facial fractures• facial and oral lacerations.Bleeding fromfacial fractures• If safe to do so, sit the patient up and allow them to lean forward.• Get a good light source and suction out mouth and anteriornose.• Try to nd the source of bleeding.• Bleeding from midface (see also E p. 90 and p. 230):• Pass a Foley catheter along the nasal oor so that the balloon is just beyond the posterior nasal aperture and inate balloon, bothsides.• Pull the inated balloons against the posterior nasal aperture and then pack the nasal cavity with nasal tampons, bothsides.• Use a disposable drain clamp to secure the Foley catheters and maintain pressure.• Now try to impact the maxilla vertically by placing a bite block between theteeth.• Bleeding from the mandible:• Try to reduce the fragments and compress across the fractures.• This may need LA and bridle wires (see also E pp. 220–2 and p.233).• Beware of bleeding into the FOM which can posteriorly displace the tongue and obstruct the airway perhaps several hours later on the ward in the middle of night, so look for and manage it sooner rather thanlater.• Bleeding from pan- facial fractures:• If both jaws are fractured it can be more dicult to control bleeding as the mandible will not compress the maxilla.• Place Foley catheters and pack the nose as before, reduce mandible fractures, and bridle wire if possible, but you may need to get the patient intubated and go to theatre immediately.• Intubation is usually via an oral endotracheal tube, but in theatre the team may need to consider tracheostomy or submental intubation to allow xation of the mandible.Bleeding fromfacial laceration• Usually from facial, supercial temporal, or supraorbital arteries.• Stay calm and apply pressure with a carefully placed fresh gauzeswab.• Check observations and past medical history.• Resuscitate and if past medical history dictates, manage accordingly. For example, is the patient anticoagulated?• Clean the area with sterile saline ± suction and apply pressure directly to the bleeding point. Examine thewound.• Is there a facial nerve injury? Check this before you give anyLA. MASSIVE BLEEDING FROMTHE FACE ANDMOUTH269 • Once you have done this, give LA around the wound. Sometimes this measure alone is enough to stop the bleeding because of the vasoconstriction properties of adrenaline in the LA cartridge.• Only clip and tie the artery if you can see it clearly. You need to tie both ends of the vessel.• Bipolar diathermy must be used with similar caution. Do not diathermy the facialnerve!• If you are not happy to do this, clean the wound and apply pressure whilst you are waiting for senior help to arrive.• The key to success is applying pressure directly to the bleeding point and not in a vague area through ve already blood- soaked gauzeswabs!Nosebleed not associated withfacial fractures• Epistaxis is often idiopathic and spontaneous, but exacerbating medical problems include:• anticoagulation/ coagulopathy• hypertension• hereditary haemorrhagic telangiectasia.• Sit patient forward and pinch nostrils.• Meanwhile resuscitate; two large- bore cannulae, G&S, coagulation screen, FBC including platelet count, and monitor response to resuscitation.• If this doesn’t work, you will need to pass nasal tampons down both sides of the nose (see E p. 230).• If this doesn’t work, take the tampons out, pass Foley catheters (see E p. 230), and then put new tamponsin.• Do not attempt nasal cautery unless you are trained todoso.• If the bleeding persists despite the Foley catheters and tampons, get 4 units cross- matched urgently and increase uid resuscitation. Chase the coagulation screen and obtain senior advice. Consider interventional radiology or endoscopic surgery (usually fromENT).• The most common error in epistaxis is failure to appreciate the severity of blood loss and a failure to resuscitate the patient adequately. 270CHAPTER10 EmergenciesMassive bleeding fromtheneckGeneralpoints• In this section we will not discuss the subtleties of all penetrating neck injuries (see E pp. 98–100), but only those with major bleeding.• Usually one of two scenarios:• Penetrating injury, usually stabbing• Carotid blow- out.Penetrating neck injuries• ATLS all the way. Patients with neck stabbings can die from A, B, C, or even D if the spinal cord is hit, so don’t go straighttoC.• Of specialnote.• Make sure you have the trauma team with you and work together as ateam.• Get a denitive airway and be aware of risk of lung injury at the Bstage.• At C, apply pressure to the bleeding site if possible. Get two large- bore cannulae in and request a cross- match. Resuscitate and monitor— ideally this should be being done by a member of the team as the airway is being secured.• Your senior should be called.• Resuscitate and if possible stabilize the patient, but what saves life is stopping the bleeding which means getting to theatre immediately.• Don’t delay this by sending patient to exsanguinate in a CT scanner!• It can be helpful at stressful times such as massive neck bleeds to have some classications to hand for reminders, so here’sone.• The neck can be divided into threezones.• Zone Iis base of neck— special risk of great vessel, lung, oesopha-gus, trachea, and brachial plexus injuries.• Zone II is mid- neck— injuries to carotid, jugular, pharynx, larynx, and spinal cord, but less likely to be missed as easy to inspect.• Zone III is between angle of mandible and skull base— parotid glands, pharynx, spinal cord, and cranial nerves at risk. Dicult to inspect and access surgically.• Do not be fooled by the neck bleed which stops and the patient becomes haemodynamically stable. It must be explored.Carotid blow- out• This is a horrendous situation to be in for everyone, so you will have to rise to the challenge. However, reading this section and your previous experience of ATLS should prepare you in somepart.• Carotid blow- out usually aects postoperative patients after resection with neck dissections, especially post- radiotherapy salvage surgery for recurrent disease.• More likely if there has been some breakdown of the neckwound.• May be preceded by a herald bleed. That is a lesson best learned in this section rather than at a morbidity and mortality (M&M) meeting. MASSIVE BLEEDING FROMTHENECK271 • If you make a diagnosis at herald bleed stage, interventional radiology may be helpful.• Otherwise:• First, be aware of the patient’s resuscitation status!• Apply a lot of pressure to the bleedingpoint.• Get seniorhelp.• Get to theatre.• Resuscitate as best you can whilst on the way to theatre.• The only chance of survival (710%) is prompt arrest of bleeding.• Ischaemic stroke is a recognized complication of surgery, but the alternative to surgery isdeath.• In some scenarios the patient should not be actively managed, and may have specically requested not to be resuscitated or returned to theatre. This is the usually the case in patients who have incurable cancer and are aware of the risk of death from carotid blow- out.• There will be a carotid blow- out protocol to hand. Everything will be well documented and managed by head and neck nurses and the palliative care team. This situation calls for calmness and peace, as best as can be achieved for the patient and their relatives. Read the protocol and discuss with the palliative care team about it if you ever have any patients in this category on your ward. Most protocols include the use of diamorphine and midazolam. Letting someone go can be one of the hardest things for a doctor to do, but you will be better for it. It is always traumatic for everyone because of the horrendous nature of the event, and don’t feel bad if you are struggling to cope emotionally after such a case— there is always help at hand via the occupational health department. 272CHAPTER10 EmergenciesRetrobulbar haemorrhageGeneralpoints• Bleeding behind the eye can follow trauma to the periorbital region or after surgery such as orbital oor repair, reduction of fractured zygoma, or obviously ophthalmic surgery. The incidence is 0.3% of these fractures or following surgery forthem.• The pathophysiology is complicated, but for simplicity think of it as a type of compartment syndrome where bleeding occurs in the orbit causing a rise in intraorbital pressure which leads to blindness by ischaemic injury to the anterior opticnerve.• Primary treatment is increase the volume of orbit and to a lesser extent try to reduce the pressures in the orbit medically.• Prompt decompression <90 minutes from the onset of symptoms will save sight. Delay, usually due to failure to recognize RBH (by not looking for it), leads to blindness.How torecognizeRBHIn a trauma or postoperative patient, reducing visual acuity plus any one of the following must be considered to beRBH:• Pain.• Proptosis.• Ophthalmoplegia.• Loss of direct light reex (with preservation of consensual reex for distinction candidates).• Tense hardeye.ManagementofRBHSee Fig.10.3.• The diagnosis is clinical. Imaging should not delay treatment.• Treatment is surgical ± medical.• Call your senior, but you may be expected to perform the decompression. Time is of the essence.• If you are taking a phone call about a patient in an ED at another hospital, you should advise them to get someone to do a decompression (senior ED doctor or ophthalmologist), or to start the medical management in the meantime and prepare to transfer the patient to you if no one is available to manage the surgical decompression.• If your senior will be there soon, he or she may advise you to start the medical management and prepare equipment for decompression. RETROBULBAR HAEMORRHAGE273 Fig.10.3 Algorithm of the management options for a retrobulbar haemorrhage. IV, intravenous; LA/ GA, local/ general anaesthesia. Reproduced from Journal of Oral and Maxillofacial Surgery, 65:2, Winterton etal., Review of management options for a retrobulbar hemorrhage. Copyright (2007), with permission from Elsevier. 274CHAPTER10 EmergenciesSurgical decompressionofRBH• If you are with the patient, perform a lateral canthotomy and inferior cantholysis immediately. There is no need to go to theatre.• Inject LA around the lateral canthus.• Take an artery clip and crush the lateral canthus between the jaws all the way from the junction of the upper and lower lids down to the orbitalrim.• Cut the crushed tissue with scissors. This will allow the lower eyelid to swingout.• Now locate the inferior canthus with the tips of the scissors and cutit.• When you release the tense inferior canthus, the orbital septum and the proptosed globe will pop forwards.• Keep cutting the canthus until this has happened. Don’t be afraid. There is no tissue there that you are cutting which cannot be repaired at a later date, but loss of vision is permanent!• Now monitor. If visual acuity is returning over a few minutes— great.• If not, you either need more surgery or it may be that medical management in combination with surgery is required, and your senior will have to decide whether more decompression is possible or whether to start somedrugs.• Following this immediate management, the patient needs to be prepared for denitive surgery in theatre under GA. This may include evacuation of a clot if postoperative or further decompression if post- trauma.Medical managementofRBH• Acetazolamide is a carbonic anhydrase inhibitor and shrinks the vitreous but has a delayed eect. Give 500mgIV.• Mannitol is an osmotic diuretic and has an immediate eect. Give 20 mL of 20% mannitol IV quickly.• Hydrocortisone 100 mg IV may also be of benet.• Mega- doses of corticosteroids are unproven in RBH and are probably dangerous.Final pointonRBHWhen you are called to see a patient with pan- facial fractures who is already intubated, you should consider the possibility that they have RBH and the clock started ticking from the time of the injury.