|Year : 2019 | Volume
| Issue : 2 | Page : 96-99
Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report
Tanmay Tiwari, Anshu Singh, Jyoti Rawat, Jyothi Chaudhary
Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||28-Aug-2019|
Dr. Tanmay Tiwari
Department of Anesthesiology and Critical Care, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Irrational driving among youth is a matter of serious concern in the present world. India leads the way having one of the highest numbers of road traffic accidents (RTAs) globally. Penetrating injury of the face following RTA can be catastrophic due to the close vicinity of vital structures and major blood vessels. Management of airway is of foremost importance for the successful resuscitation of the trauma patient as per the Advanced Trauma Life Support guidelines. We report a case of successful nasal intubation and subsequent anaesthetic management following sedation with ketamine and dexmedetomidine of a young male with penetrating injury of the floor of mouth and base of tongue by an iron rod. Such a combination of ketamine and dexmedetomidine can be an attractive option for airway management in acute trauma settings.
Keywords: Airway management, dexmedetomidine, ketamine, mandibular injury, trauma
|How to cite this article:|
Tiwari T, Singh A, Rawat J, Chaudhary J. Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report. Airway 2019;2:96-9
|How to cite this URL:|
Tiwari T, Singh A, Rawat J, Chaudhary J. Difficult airway caused by retained iron rod penetrating through floor of mouth and base of tongue following road traffic accident: A case report. Airway [serial online] 2019 [cited 2019 Nov 11];2:96-9. Available from: http://www.arwy.org/text.asp?2019/2/2/96/265617
| Introduction|| |
Penetrating injuries of face and neck carry high risk of morbidity and mortality. Their incidence following road traffic accident (RTA) is globally on the rise. India has the dubious distinction of having the highest fatality following RTA, with fatalities following road accident increasing more than nine times from 14,500 in 1970 to 137,400 in 2013. Management of the airway and early surgical exploration under antimicrobial coverage is required for reducing the associated morbidity and infection. Airway management can be challenging at times and requires proper planning and execution according to the individual patient's clinical condition and hospital set-up.
| Case Report|| |
A previously healthy young male aged 25 years and weighing 55 kg was brought to the emergency department of our hospital following RTA. While executing stunts on his motorbike, he fell onto an iron rod on the road divider, which penetrated the floor of mouth and passed through the base of tongue. On arrival in the emergency department, he was apprehensive and in obvious distress due to the iron rod in situ. Physical examination revealed a laceration over the left eyebrow with an iron rod passing from the floor of the mouth and piercing the base of the tongue with secretions and no visibly active oral bleeding [Figure 1], [Figure 2], [Figure 3]. Glasgow Coma Scale was 15/15, and there was no episode of vomiting or loss of consciousness. He had no history of medication use, drug allergy or substance abuse. The need for immediate definitive airway management and surgical exploration was apparent.
|Figure 1: Anterior view of the patient showing the iron rod coming out through the mouth|
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|Figure 2: Lateral view of the patient showing the iron rod projecting from the mouth|
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|Figure 3: Inferior view of the patient showing the lower end of the iron rod|
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On preoperative assessment, his vitals indicated a blood pressure in supine position of 142/78 mm Hg, pulse rate of 118 beats/min and oxygen saturation of 94% on room air. On auscultation, bilateral vesicular breath sounds were documented, and no visible thoracic injury was present. Physical examination, including assessment of the thorax, abdomen and pelvis, was essentially normal. The patient had partaken a solid meal 1 h prior to the accident. Patient management was started with rapid assessment of airway, breathing and circulation along the Advanced Trauma Life Support guidelines laid down by the American College of Surgeons. After obtaining written informed consent, the patient was taken to the operating room for surgical exploration and debridement under general anaesthesia.
The patient was nursed in the lateral position, with oxygen being administered by a nasal cannula at 3 l/min. Multiparameter monitors including electrocardiogram, noninvasive blood pressure and pulse oximetry were attached. Two intravenous access lines of 20 G each were established in both the forearms. A difficult airway cart was prepared and checked. It was noted that the flexible fibreoptic bronchoscope (FOB) was not available. The patient was explained about the procedure, and no premedication was given. Once the patient was comfortable in the operating room environment, two drops of a vasoconstrictor (xylometazoline 0.1%) were instilled in each of the nostrils.
In view of the anticipated difficult airway, one attempt at awake nasal intubation was planned (with a back-up plan of tracheostomy). The penetrating iron rod exiting through the mouth precluded the possibility of a proper mask fit for preoxygenation. An endotracheal tube (ETT) of size 7.0 mm ID was lubricated and passed through the left nostril into the nasopharynx to provide continuous oxygenation through the breathing circuit during the procedure. Injection dexmedetomidine at 1 μg/kg and ketamine at 1 mg/kg were given as slow boluses over 5 min to provide adequate sedation to proceed with nasal intubation under mild sedation. As both the ends of the iron rod were clearly visible, an attempt was made to partially dislodge the iron rod by gently withdrawing it in a rotatory manner from the mandibular side until the tongue became free. This provided space for laryngoscopy after the bolus dose of ketamine and dexmedetomidine had been administered. Laryngoscopy was performed with manual in-line stabilisation of the cervical spine, and the glottis was visualised (Cormack and Lehane Grade II). The ETT was gently passed through the glottic opening into the trachea using the Magill forceps. The cuff was inflated, and the ETT was securely fixed. [Figure 4] General anaesthesia was induced using injection ketamine 25 mg and injection atracurium 25 mg, and a throat pack was placed. Anaesthesia was maintained using oxygen, air and desflurane. At the end of the surgery, residual neuromuscular blockade was antagonised using neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg intravenously. The postoperative course was uneventful, and the patient was discharged after 5 days in hospital.
|Figure 4: Endotracheal tube fixed following successful nasotracheal intubation|
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| Discussion|| |
Penetrating injuries of the neck and face are a threat to life because of their close proximity to vital structures and their propensity to rapidly progress to complete airway obstruction, secondary to evolving oedema and associated bleeding and secretions. Thus, airway management remains the first priority of resuscitation. The incidence of traumatic airway injury is 0.4% and 4.5%, respectively, for blunt and penetrating trauma. Spontaneous breathing should be maintained to avoid collapse of the traumatised airway, and muscle relaxants should be avoided till a definitive airway has been established. The use of rapid sequence intubation is controversial in penetrating neck injury because the associated oedema and airway distortion can make both mask ventilation and intubation difficult.
In view of anticipated difficult mask ventilation, awake nasotracheal intubation was planned in our patient using a combination of dexmedetomidine (1 μg/kg) and ketamine (1 mg/kg). We used the combination because of the antagonistic haemodynamic effects of both the drugs, which is recommended for procedural sedation. The nasal route was preferred because of the iron rod that was protruding into the posterior part of the oral cavity. In addition, a partially introduced ETT into the nasopharynx served as a conduit for oxygenation throughout the process of intubation. Because of non-availability of the FOB and also to avoid the risk of blind nasotracheal intubation, we improvised using available resources and created room for laryngoscopy and intubation by gently rotating the iron rod towards the floor of the mouth, taking care not to completely remove it from the base of the tongue. Once the upper edge of the iron rod was displaced enough to provide space within the oral cavity, we performed direct laryngoscopy with manual in-line stabilisation of the cervical spine and guided the ETT into the glottis with the help of Magill forceps.
Herein, we have reported the successful airway management of a patient with a penetrating injury of floor of the mouth by an iron rod that also passed through the base of the tongue. The key to successful management is thorough preparation and improvisation with patient-centric individualised approach.
Declaration of patient consent
The authors certify that the patient has given consent for his images and other clinical information to be published. The patient was explained that his name would not be revealed and due efforts would be made to conceal his identity, though anonymity cannot not be guaranteed.
The authors wish to acknowledge the timely interventions of the Surgical, Trauma and Emergency Medicine Staff of King George's Medical University, Lucknow, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh SK. Road traffic accidents in India: Issues and challenges. Transp Res Procedia 2017;25:4712-23.
ATLS Subcommittee, American College of Surgeons' Committee on Trauma, International ATLS working group. Advanced trauma life support (ATLS®): The ninth edition. J Trauma Acute Care Surg 2013;74:1363-6.
Kummer C, Netto FS, Rizoli S, Yee D. A review of traumatic airway injuries: Potential implications for airway assessment and management. Injury 2007;38:27-33.
Abernathy JH 3rd
, Reeves ST. Airway catastrophes. Curr Opin Anaesthesiol 2010;23:41-6.
Mandavia DP, Qualls S, Rokos I. Emergency airway management in penetrating neck injury. Ann Emerg Med 2000;35:221-5.
Tobias JD. Dexmedetomidine and ketamine: An effective alternative for procedural sedation? Pediatr Crit Care Med 2012;13:423-7.
Baumgartner FJ, Ayres B, Theuer C. Danger of false intubation after traumatic tracheal transection. Ann Thorac Surg 1997;63:227-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]