Difficult intubation in traumatic tongue bifurcation

Abstract

Sir, Airway management of the multiple trauma patients presents a series of challenges.[1] Many trauma patients present difficult airways that require a different approach and formulation of a planned series of steps before airway management is initiated. Maxillofacial trauma compromises the patient's airway and therefore it must be protected.[2] Difficult mask ventilation and endotracheal intubation are anticipated in such patients. In addition, the patient is usually regarded as having a “full stomach” and has not been cleared of a cervical spine injury. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. A 28-year-old man was brought to our emergency department 4 h after an alleged history of road-traffic accident. He presented with head injury, traumatic tongue bifurcation [Figure 1], and fractured maxilla and mandible. GCS at presentation was E2V3M5. He was unconscious and irritable with heart rate of 120/ min, blood pressure 96/60 mmHg, and respiratory rate 30/ min. Oxygen saturation was 90–93% on face mask with O2 flow 6 L/min. Traumatic tongue bifurcation causing airway obstruction by folding of tongue backward and blood trickling into the oropharynx caused him considerable distress.Figure 1: Two cut portions of tongueEmergency endotracheal intubation was planned before the patient was shifted for emergency computerized tomography scan and surgery. After adequate preoxygenation with a mask held close to the face, we performed direct laryngoscopy, which showed a traumatically bifurcated tongue with the two halves moving in opposite directions and blood in the oropharynx. It was not possible to visualize laryngeal inlet. We therefore planned a different approach for intubation in view of trauma to oropharynx. We gave Propofol 80 mg intravenous and applied two stay sutures from the tip of two portions of injured tongue and pulled them anteriorly in close approximation. After that, laryngoscopy was performed and suctioning of oropharynx was done. We were able to visualized laryngeal inlet and intubate the trachea with 7.5 mm ID cuffed nasal endotracheal tube with the help of cricoid pressure. Manual in line stabilization of spine (MILS) was applied in both the attempts of laryngoscopy. The correct placement of the endotracheal tube was confirmed by chest auscultation. The entire process took 60 seconds. The patient subsequently underwent emergency craniotomy for evacuation of contusion/hematoma, tongue repair [Figure 2], and plating of maxilla and mandible under general anesthesia.Figure 2: After repairThere are various approaches described in literature for managing airway in facial trauma chiefly laryngeal mask airway,[3] Glidescope, fiberoptic intubation, submental/retrograde intubation, and tracheostomy. However, these approaches are well suited in cases of elective surgeries requiring fixation of fracture segments. The problem in our case was emergency management of facial trauma with traumatic bifurcation of tongue obstructing laryngeal view on laryngoscopy. We were not comfortable in administering muscle relaxant as we were not sure to be able to intubate the trachea. Propofol, which has the property of jaw relaxation, decrease pharyngeal reflex and abduction of vocal cords seemed as a better alternative as a better alternative.[4] On reviewing the literature, we found that applying sutures over lacerated portions of tongue and pulling forward are an acceptable means of aiding laryngoscopy and intubation. After completion of surgery patient was shifted on ventilator support because of compromised airway and impaired consciousness level. The trachea was successfully extubated next morning. After extubation patient was conscious but drowsy and maintained O2 saturation 97–99% on face mask with O2 flow 6 L/min. We wish to bring to the notice of readers that at times a little innovation and quick thinking may help in managing such types of cases which may present to us.