Abstract
Purpose: Proper care of the trauma patient often includes tracheal intubation to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. Airway management can be particularly complex when there are facial bone fractures, head injury and cervical spine instability.
Clinical Features: A 29-yr-old intoxicated woman suffered a motor vehicle accident. Injuries consisted of multiple abraisons to her head, forehead, and face, right temporal lobe hemorrhage, and complex mandibular fractures with displacement. Mouth opening was<10 mm. Blood pressure was 106/71 mmHg, pulse 109, respirations 18, temperature 37.3°C, SpO2 100%. Chest and pelvic radiographs were normal and the there was increased anterior angulation of C4–C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy with local anesthesia. However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one minute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without complication. Blood gas showed pH 7.40, PCO2 35 mmHg, PO2 396 mmHg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the procedure.
Conclusion: Continuous mask ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a difficult airway.
Résumé
Objectif: Le traitement d’un traumatisem comprend souvent l’intubation endotrachéale qui assure la ventilation et l’oxygénation adéquates, protège les voies aériennes contre l’aspiration et facilite l’opération. La prise en charge des voies aériennes peut être particulièrement complexe en cas de fractures des os du visage, de lésion à la tête et d’instabilité de la colonne cervicale.
Éléments cliniques: Une femme de 29 ans, intoxiquée, victime d’un accident d’automobile, présentait de multiples écorchures à la tête, au front et au visage, une hémorragie au lobe temporal droit et des fractures complexes avec déplacement de la mandibule. L’ouverture de la bouche était < 10 mm, la pression sanguine de 106/71 mmHg, le pouls de 109, la respiration de 18, la température de 37,3 °C, la SpO2 de 100 %. Les radiographies pulmonaire et pelvienne étaient normales et le cliché de la colonne cervicale montrait une angulation antérieure accrue de C4–C5. Le dépistage des drogues a révélé la présence de cocaïne et d’alcool. On a d’abord planifié une trachéotomie vigile sous anesthésie locale, mais la patiente collaborant peu, on a administré, au masque, du sévoflurane à 1 % dans 100 % d’oxygène. La concentration de sévoflurane a graduellement monté à 4 % et la perte de conscience a eu lieu en moins d’une minute. La patiente a respiré spontanément et il a fallu légèrement soulever le menton et avancer la mandibule. Un tube de trachéotomie à ballonnet a été inséré chirurgicalement sans complication. L’analyse des gaz du sang a indiqué un pH de 7,40, une PCO2 de 35 mmHg, une PO2 de 396 mmHg et un hématocrite de 33,6 %. Le lavage diagnostique péritonéal a été négatif. ll n’y a pas eu d’aspiration pulmonaire. L’oxygénation et la ventilation ont été maintenues tout au long de l’intervention.
Conclusion: La ventilation continue au masque avec du sévoflurane est appropriée chez un patient non coopératif victime d’un traumatisme et dont les voies aériennes sont peu accessibles.
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Smith, c.E., Fallon, W.F. Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway. ja]Can J Anaesth 47, 242–245 (2000). https://doi.org/10.1007/BF03018920
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DOI: https://doi.org/10.1007/BF03018920