What the Anesthesiologist Should Know before the Operative Procedure

Facial fractures are the major type of maxillofacial trauma. They also result in airway compromise, vision loss and hemorrhage, which can be life-threatening. The causes of facial fractures vary, with the most common being motor vehicle accidents, sport related injuries, assaults and gunshots. Following high velocity trauma, most patients have other major injuries besides facial fractures; there is a 20 percent incidence of life-threatening injuries associated with facial fractures. Knowing the mechanism of injury is important in anticipating what other injuries may also occur with facial fractures.

Management of the airway and prevention of secondary complications are major concerns in taking care of patients with facial fractures. Airway management must be the absolute priority in patients with facial fractures because a compromised airway can lead to airway obstruction, hypoxia and death. Managing the airway in patients with facial fractures can be very challenging to anesthesiologists. These patients often present with altered mental status, full stomachs and can be vomiting. Patients may also have laryngeal, laryngotracheal injuries, hematomas and associated cervical spine injuries. Many facial fractures can be accompanied by other significant injuries outside the facial region. The most common type of injuries were limb injury, brain, chest, spine and abdominal injuries. Life-threatening complications may also occur following what appears initially to be trivial injuries to the head and neck region. Therefore, clinical assessment needs to be both systemic and repeated, in order to establish the priorities in the patient’s care. Priorities for treating facial fractures are preservation of life followed by restoration of anatomical structure and function.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Repair of facial fractures can be urgent or emergent which depends on the injuries and associated injuries. Airway compromise, ocular injuries or massive bleeding require emergent care. Priorities for treating facial fractures are preservation of life followed by restoration of form and function. Many facial fractures are associated with multiple trauma, such as brain injury, cervical spine injury and major abdominal injuries, severe limb injuries, massive blood loss which many cause significant morbidity. The repair of facial fractures has to be coordinated with the timing of treatment of life-threatening injuries. Contraindications to proceeding with primary repair include hemodynamic instability, unstable spinal injury, associated with neurological impairment, evolving ocular injury or elevation of intracranial pressure that require management before facial fracture repair. Advantages of early reduction and fixation include easier manipulation and reduction of fractures, completion of facial fracture before the onset of serious complications such as sepsis, acute respiratory distress syndrome. Early repair of facial fracture in the presence of a dural tear may lower the incidence of cerebral fluid leaking and subsequent development of infection.

Emergent- Facial fractures are rarely required emergency surgery, but severe hemorrhage and compromise of the airway with facial fractures require emergent surgical intervention to control massive facial hemorrhage and insure adequate ventilation and gas exchange. The airway management for anesthesiologists is challenging. In these cases, facial fractures may be associated with cervical spine injury, laryngeal, laryngeal tracheal injury, brain injury and hemodynamic instability duo to other major injuries.

Urgent- Heavily contaminated wounds and some open facial fractures without compromised airway, massive hemorrhage and major associated injuries may be considered urgent, surgery within a few hours.

Elective- Closed and stable simple facial fracture without airway compromise, such as zygomatic, mandibular fractures and clean lacerations maybe elective, surgery can wait over 24 hours to two weeks. The airway management can still be a challenge for anesthesiologists.

2. Preoperative evaluation

The history and nature of the injury is important in anticipating what other injuries may present. Knowledge of the mechanism of injury is a vital component in the assessment of the injured patients, which can provide important information to the possibility of associated and sometimes occult injuries. It is approximately 15 percent of all injuries, particularly spinal and orthopedic injuries, may be missed following initial assessment. The Advanced Trauma Life Support (ATLS) system of trauma care (ABCDE) has been generally accepted as the gold standard in the initial management of multiple trauma patients.

Airway maintenance with cervical spine protection: Patients with facial fractures must be classified as having difficult airway. Airway management is always a challenge to anesthesiologists in patients with facial fractures. Not only does the trauma directly involve the airway, but there also associated injuries and conditions such as cervical spine fracture, full stomach, hypoxemia, alcohol or drug intoxication. There is often some degree of comprised airway due to the presence of loose teeth, blood and displaced fragments of the fractures. It is critical to preoperatively assess every patient by completing a full history and physical examination. A thorough history can provide clues in detecting a possible difficult airway and possible concomitant injuries, especially cervical spine injuries. The incidence of cervical spine injuries is approximately 2%. Airway examination provides crucial information for airway management. Careful review of imaging studies, such as radiographs and CT scans, will provide useful information regarding problems with the airway, facial fractures and associated injuries. If the patient arrives in the operating room already intubated, the endotracheal tube must be secured and position of the endotracheal tube must be verified.

Ventilation: If patient is conscious and alert, with a spontaneous breathing rate about 20 breath per minutes and no signs of airway obstruction, the patients airway is considered adequate. Supplemental oxygen with a face mask should be maintained. The oropharynx should be carefully suctioned. The patient may present with stridor, dyspnea, dysphagia, or cyanosis, and then a differential diagnosis of airway obstruction due to bleeding, hematoma or foreign bodies, or aspiration should be considered. Mechanical ventilation may be compromised by pulmonary contusion, pneumothorax or hemothoraces. Repeat physical examination with chest auscultation, blood gases, chest radiographs and/or CT scans should be done.

Hemostasis and Hemodynamics: Patients with facial fractures may have other major injuries, such as massive hemorrhage, chest injuries, cardiac contusion, pericardial tamponade and major vascular injuries. If patients present with hemodynamic instability without a known etiology, abdominal ultrasound, CT scan and echocardiographic studies should be done.

Neurological status: Patients sustaining facial fractures are at high risk of accompanying injuries, including spinal and brain injuries. Careful neurological evaluation is important to diagnose concomitant cervical spine injuries and brain injuries. Altered mental status, amnesia, loss of consciousness, evidence of increased ICP, seizures, focal deficits, abnormal GCS score, vomiting and pupillary asymmetry are predictors of intracranial hemorrhage. Preoperative CT scan is warranted for patients with these findings. All facial fracture patients should be considered for cervical spine precaution until cleared with imaging and by history and physical exam.

Exposure and environment: Patients with facial fractures and multiple injuries are at risk for hypothermia and possible inhalation injuries if the patients were in fires.

Medically unstable conditions that warrant further evaluation include altered mental status, hemodynamic instability especially with unknown etiology, worsening neurologic deficits and respiratory failure.
Delaying surgery may be indicated if patient has stable and secured airway and facial fracture related hemorrhage is controlled.

3. What are the implications of co-existing disease on perioperative care?

Perioperative evaluation- Preoperative airway evaluation must be detailed and thorough. Particular attention should be focused on the mouth opening, neck mobility, mask fit and the existence of any maxillofacial deformity and intraoral debris

Perioperative risk reduction strategies- Patients may not be able to take medications orally. Those that are essential, like beta blockers in patients with known CAD, can be converted to intravenous medications.

b. Cardiovascular system

Acute/unstable conditions: Hypotension may be a result of severe hemorrhage caused by facial fractures. The incidence of massive bleeding of facial fractures is from 1.2% to 11%. Hypotension may be caused by concomitant injuries outside the facial region. Cardiac tamponade is life threatening. The presence of neck vein distention, hypotension and muffled heart sound, pulsus paradoxus and mechanism of injury may make cardiac tamponade a possible diagnosis. Pericardiocentesis provides temporary relief. Myocardial contusion is diagnosed by EKG changes, which are consistent with ischemia and elevation of cardiac enzymes. Patient with cardiac contusion may be at high risk for heart block and ventricular fibrillation. Patient with a wide mediastinum on their chest radiograph should be considered as having a possible aortic dissection. Echocardiograms should be considered in patients with hypotension.

Baseline coronary artery disease or cardiac dysfunction – Goals of management: The majority of patients with facial fractures are young males. However, elderly patients may present with facial fractures and they should be considered as having coronary artery disease. The goal of management of patients with CAD is to prevent cardiac ischemia and to maintain important chronic medications, including beta blockers, and statins. Aspirin, beta blockers and anti-hypertensives should be held until hemodynamic stability is established

c. Pulmonary

Pneumothorax, hemothorax and pulmonary contusion may be seen in high velocity trauma. Multiple rib fractures may compromise the function of the thorax and patients may have a flail chest. Hypoxia is often severe in patients who have sustained pulmonary contusions. Pneumothoraces and hemothoraces should be treated with placement of chest tubes. A persistent air leak from chest tube may indicate a bronchial injury. Chest radiographs and CT Scans should therefore be considered for patients with facial fractures who have any signs of respiratory distress.

d. Renal-GI:

e. Neurologic:

Acute issues: Brain injuries are caused by high velocity trauma and occur most frequently in patients with severe midfacial fractures, complex facial fractures and zygomatic orbital fractures. Severe intracranial hemorrhage is diagnosed by CT Scan in 3% of facial fracture patients who have Glasgow Coma Scale of 15 even without other neurological abnormalities. Cervical spine injuries should be suspected in every patient with facial fractures. The incidence of spine injury is about 2% in these patients. Head CT scan is indicated for nearly all patients with facial fractures

f. Endocrine:

For patients with diabetes, blood sugar should be closely monitored and controlled.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

4. What are the patient's medications and how should they be managed in the perioperative period?

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

This may include medications specific to diseases associated with surgery- *** The majority of patients with facial fractures are young healthy males. However, elderly patients with comorbidities, including CAD, or COPD, may present with facial fractures after they fall or when the elderly are trauma victims. The elderly trauma victims should be questioned as to what medications they take and essential medications should be continued.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Medications for hypertension, arrhythmias and CAD should be continued in stable patients.
Pulmonary: Inhaler should be continued if patient tolerates.
Renal: Diuretic should be held in trauma victims until it is clear the patient is hemodynamically stable.
Neurologic: anti seizure medication should be continued.
Anti-platelet: Anti-platelet medications should be stopped 5-7 days prior to elective surgery after discussion with patient’s cardiologist. Platelets should be transfused for patients taking anti-platelet against who require emergency surgery. Aspirin should be stopped after consultation with the patient’s cardiologist and /or neurologist. Agents that promote bleeding, such as aspirin and anti-platelet drugs may need to be held if the patient is bleeding
Psychiatric: anti depression and anxiety medication should be continued if tolerated by patient.

j. How To modify care for patients with known allergies –

For patient with known allergies, those agents should be avoid.

k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented – avoid all trigger agents such as succinylcholine and inhalational agents:

Proposed general anesthetic plan:
Ensure MH cart available:

[- MH protocol]
Family history or risk factors for MH:
Local anesthetics/ muscle relaxants:

5. What laboratory tests should be obtained and has everything been reviewed?

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Facial fractures can make it difficult to deliver adequate tidal volume during musk ventilation. Patients present with facial fractures must be classified as having potential difficult airway until the airway was secured. A general statement about the various options should be covered here. Specifics regarding the appropriateness (for the general option) and the benefits/drawbacks/issues (eg. antiplatelet agents for regional) should be included in each section. In the regional section, include any adjuvants like common sedation or general. A discussion of patient positioning and any special concerns with regard to positioning injury should be included.

a. Regional anesthesia

Regional anesthesia is primarily used for awake fibroptic intubation or tracheostomy in patients with facial fractures which may compromised airway, such as Le Fort II to III facial fractures, sedation and general anesthesia may further compromise airway in such high risk patients. Regional anesthesia may be used as anesthetic for surgeries, such as closed reduction for nasal fractures.

Peripheral Nerve Block

Preparation of patient for awake fibroptic intubation includes psychological preparation, explaining the steps in securing the airway, and premedication. Medications, such as sedatives, which may cause loss of consciousness or interference with airway reflexes should be avoided. Glycopyrrolate is a good choice for premedication, as it decreases upper airway secretions without crossing the blood-brain barrier.

Topicalization and nerve blocks from the oral or nasal cavity to the trachea. Topicalization of the oral or nasal mucosa is performed by spraying lidocaine or benzocaine. The nerves to be blocked include the glossopharyngeal, the superior laryngeal nerve and the recurrent nerves. The lingual and pharyngeal branches of the glossopharyngeal nerve provide sensation to the posterior third of the tongue and oropharynx.

The glossopharyngeal nerves are blocked by bilateral injection of 2 ml of 2% lidocaine into the base of the palatoglossal arch (the anterior tonsillar pillar) with 25-gauge needle.

The internal branch of the superior laryngeal nerve and the recurrent nerve innervate the mucosa of epiglottis and aryepiglottic fold. Bilateral superior laryngeal nerve blocks and transtracheal blocks will anesthetize the mucosa below the epiglottis. The superior laryngeal nerve block is performed by locating the hyoid bone, 3 ml of 2% lidocaine is infiltrated i cm below each greater cornu.

A transtracheal block is performed by identifying the cricothyroid membrane and penetrating the membrane with 25-gauge needle at end of inspiration. After confirming of intratracheal by aspiration of air, 2 ml of 2% lidocaine is injected in to the trachea at end of expiration.

Nasal procedures can be done under local anesthesia with or without sedation. The anterior ethmoidal nerve and sphenopalatine nerves provide sensory innervation to the nasal septum and lateral walls. These nerves can be blocked by packing the nose with gauze soaked with local anesthetic. Application of epinephrine-containing local anesthetic or cocaine (4% or 10% ) will provide vasoconstriction and may decrease intraoperative bleeding. Intranasal cocaine (maximum dose is 3 mg/kg) is rapidly absorbed and reaches peak level in 30 minutes. Intranasal cocaine may cause hypertension, ventricular ectropies and tachycardia.

Benefits: Peripheral nerve blocks and topicalization provide anesthesia or analgesia with or without sedation, keeping patient awake and avoiding airway compromise in patients with complicated facial fractures or in patients with complicated medical issues.

Drawbacks: The peripheral nerve blocks and topicalization may block cough reflex and the swallowing reflex and so may increase risks of aspiration. The nerve blocks may be difficult to perform due to anatomical distortion caused by the facial fractures.
Issues: Peripheral nerve blocks requires the cooperation of patients.

b. General Anesthesia

Benefits: General anesthesia with a secure airway is often preferred for facial fracture surgery. Airway obstruction in patients with facial fractures is a life-threatening complication in maxillofacial trauma. Airway management must be the absolute priority in any patient with a severe facial fracture. In emergency cases, the airway must be secured before any diagnostic procedures. In patient with complicated facial fractures, such as Le Fort II to III, or when patients have concomitant injuries, such as brain injury requiring prolonged ventilator support, tracheostomy under local anesthesia is done. In intubated patients, tracheostomy can be done after all diagnostic procedures, including endoscopy, are completed.
Drawbacks: General anesthesia requires secured airway which is often a major challenge to anesthesiologists in patients with facial fractures.
Other issues:
Airway concerns: Facial fractures are often associated with full stomachs, hypoxemia, intoxication., concomitant injuries, such as cervical fractures, brain injuries. In cooperative patients, with complex facial fractures, successful awake oral or nasal fibroptic intubation has been done. Alternative airway management for patients with difficult airways includes (1) tracheostomy under local anesthesia, (2) cricothyrotomy, (3) awake blind intubation, (4) retrograde intubation, and (5) submental and submandibular intubation.

c. Monitored Anesthesia Care

Benefits: Monitored anesthesia care is applied to minor facial fracture repairs, such as close reduction of nasal fractures. monitored anesthesia care might be applied with local anesthesia for tracheostomy in patient with complicated facial fractures.
Drawbacks: The airway is not protected. There is risk of aspiration and airway obstruction.
Other Issues: Monitored anesthesia care requires patient’s cooperation. General anesthesia with endotracheal intubation is always a backup plan.

6. What is the author's preferred method of anesthesia technique and why?

General anesthesia with secured airway is preferred for most facial fracture surgeries.There is often some degree of comprised airway due to the presence of blood, loose teeth and displaced fragments of the fractures. Facial fractures may also directly involve the airway. Full stomachs, alcohol and drug intoxication, and associated injuries, such as brain injury, cervical spine injury and abdominal injuries, increase the risks of aspiration. The management of the airway depends upon the type of facial fractures, the planned surgical procedures and the associated injuries. Nasal or oral endotracheal intubation is the most frequent choice for airway management. Nasal intubation should be avoid in patient with Le Fort II or III fractures. Tracheostomy is the choice for patients with complex facial fractures and concomitant injuries which require prolonged mechanical ventilation support. If the patient is cooperative, an awake direct or fiberoptic intubation with topicalization is preferred. If the patient is uncooperative, an inhalation induction can be done, maintaining spontaneous breathing with sevoflurane. Equipment and personnel for performing an emergency tracheostomy should be immediately available. Video laryngoscopes, such as C-Max and Glide scope, are useful tools for managing difficult airways. Maintenance of anesthesia depends upon facial fractures, concomitant injuries and surgical procedures. Nitrous oxide should be avoided, if any chance of the presence of a pneumothorax. Total intravenous anesthesia (TIVA) is an option, if neurological monitoring, such as SSEP, is used during surgery.

What prophylactic antibiotics should be administered?

Prophylactic antibiotics should be administered one hour before surgical incision. (1) Cefazolin 1 to 2 g iv. (2) Clindamycin 600 to 900 mg iv (3) Ampicillin.Sulbactam 1,5 g iv (4) Cefazolin i g and metronidazole 500 mg iv. In patient with complex facial fracture and possible cerebrospinal fluid leakage, broad spectrum antibiotic, such as Vancomycin 1 gm Gentamicin 80 mg and Cefatriaxone 1 g iv, should be administered one hour prior surgical incision.

What do I need to know about the surgical technique to optimize my anesthetic care?

Many facial fractures can be accompanied by other major injuries out side facial region, such as brain injury, cervical spine injury and major abdominal injuries. A compromised airway can lead to airway obstruction and hypoxia. Management of airway in patient with facial fractures can be very challenging to anesthesiologists. Priorities for treating facial fractures are preservation of life followed by restoration of form and function. Discussion with the surgical team regarding the airway management and the priorities of surgical procedures are very important. To optimize anesthetic care, I need to know (1) The type and severity of facial fractures and associated injuries. (2) The route of airway management, naso or oral tracheal intubation. (3) Tracheostomy prior anesthesia induction or after endotracheal intubation. (4) Intermaxillary fixation ( maxillomandibular wiring ) after surgery. (5) Special monitoring, such as nerve monitoring, ICP monitoring, may be required during surgery.

What can I do intraoperatively to assist the surgeon and optimize patient care?

Controlled hypotension may be considered to control blood loss during the repair of facial fractures in patients with stable hemodynamics and without concomitant injuries or baseline cardiovascular diseases.

What are the most common intraoperative complications and how can they be avoided/treated?

Airway obstruction is the most common intraoperative complication. The proximity of the airway is in the surgical field, anesthesiologist is far from the airway. These increase the possibility of airway complication, which may be caused by kinking of endotracheal tube, disconnection, or perforation of the tube by a surgical instrument. Careful fixation of endotracheal tube prior surgery and choice of the proper endotracheal tube and monitoring of ETCO2 and airway pressure may decrease and prevent airway complication. Pneumothoraces may present with facial fractures, it would be wise to avoid nitrous oxide in patients who have sustained multiple traumatic injuries.

Complications

Cardiac: Severe hemorrhage in facial fracture is rare. The reported incidence of massive hemorrhage from 1.2 to 11 %. Concomitant injuries, such as head, abdominal and orthopedic injuries, make the contribution of facial hemorrhage difficult to assess. In patients with orbital fractures, severe cardiac arrhythmia, such as bradycardia, ventricular ectopy and cardiac arrest, may be caused by traction on extraocular muscles or pressure on the eyeball(oculocardiac reflex). if the patient with facial fractures presents with arrhythmias and hypotension, concomitant cardiac injury should be considered.

Pulmonary: Airway obstruction may be caused by laryngeal edema, hematoma, vocal cords or nerve injuries. Hypoxia may be caused by aspiration of blood, foreign bodies, fracture fragments and gastric content, and pulmonary contusion, pneumothorax, hemothorax and acute lung injury.

Neurologic: Facial nerve injuries, optic nerve injuries and cerebrospinal fluid leakage may be result of facial fractures.

a. Neurologic:

b. If the patient is intubated, are there any special criteria for extubation?

At the end of surgery, the oropharyngeal pack ( throat pack ) must be removed and the larynx must be suctioned. In patient with complex facial fractures and prolonged surgery, the risk of postoperative airway edema is increased, patient should be kept intubated. if patient with cervical spine injury or multiple trauma, tracheostomy should be performed in the operating room. Extubation should be attempted only if the patient is stable. Patient must be hemodynamically stable, fully awake, following commands, no sign or symptom of airway obstruction before extubation.

c. Postoperative management

What analgesic modalities can I implement?

Intravenous opioids are the usual therapy for postoperative pain management for patients who have undergone repair of facial fractures, which can be patient controlled analgesia if the patient is cooperative and awake.

What level bed acuity is appropriate?

Patients with complex facial fractures with or without concomitant injuries should stay in ICU for postoperative monitoring. Patients with uncomplicated facial fractures should be admitted to monitored unit for airway observation. Patients may develop airway obstruction after extubation.

What are common postoperative complications, and ways to prevent and treat them?

Postoperative airway obstruction may be caused by secretions, blood clots, laryngeal edema, nerve injuries and hematomas. Patient should be carefully evaluated before extubation. Patient’s upper body should be elevated. Steroids, such as dexamethasone 10 to 16 mg iv may be administered before extubation. Humidified oxygen and recemic epinephrine nebulization may be administered for laryngeal edema. Equipment for endotracheal reintubation, including fibroptic bronchoscope, should be available at the bedside. For patients with intermaxillar fixation, wire cutter should be available at patients bedside for emergency airway management.

What's the Evidence?

Reehal, P. “Facial Injury in Sport”. Curr. Sports Med. Rep.,. vol. 9. 2010. pp. 27-34.

Rerry, M. “Advanced Trauma Life Support (ATLS) and Facial Trauma: can one size fit all”. Int. J. Oral Maxillofac. Surg. vol. 37. 2008. pp. 209-214.

Dean, RN, Ledgard, PJ, Katsaros, J. “Massive Hemorrhage in Facial Fracture Patients: Defination, Incidence, and management”. Plast. Reconstr. Surg. vol. 123. 2009. pp. 680-690.

Kuttenberger, JJ, Hardt, N, Schlegel, C. “Diagnosis and Initial Management of Laryngotracheal Injuries Associated with Facial Fractures”. J Cranio-Maxillofac. Surg. vol. 32. 2004. pp. 80-84.

Kloss, F, Laimer, K, Hohlrieder, M, Ulmer, H, Hackl, W, Benzer, A, Schmutzhard, E, Gassner, R. “Traumatic Intracranial Hemorrhage in Conscious Patients with facial Fracturrs- A review of 1959 cases”. J Cranio-Maxillofac Surg. vol. 36. 2008. pp. 372-377.

Fraioli, ER, Branstetter, FB, Deleyiannis, WB F. “Facial Fractures: Beyond Le Fort”. Otolaryngol Clin N Am. vol. 41. 2008. pp. 51-76.

Huang, JJ, Wu, J, Brandt, K. “Airway Management of a Patient with Facial Trauma”. J Clin Anesth. vol. 14. 2002. pp. 302-304.

Orfanos, GJ, Quereshy. “Causes of the Difficult Airway”. Atlas Oral Maxillofacial Surg N Am. vol. 18. 2010. pp. 1-9.

Mohan, R, Iyer, R, Thaller, S. “Airway Management in Patients with Facial Trauma”. J Craniofac Surg. vol. 20. 2009. pp. 21-23.

Anwer, HMF, Zeitoun, LM, Shehata, EAA. “Submanibidular appoach for tracheal intubation in patients with panfacial fractures”. Br J Anaesth. vol. 98. 2007. pp. 835-840.

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