Int. J. Oral Maxillofac. Surg.

2008; 37: 309–320

doi:10.1016/j.ijom.2007.11.002, available online at http://www.sciencedirect.com

Invited Review Paper

Trauma

Advanced Trauma Life Support M. Perry1, C. Morris2

1
Regional and Maxillofacial Trauma Units,
Belfast, UK; 2Derbyshire Royal Infirmary,
Derby, UK

(ATLS) and facial trauma: can

one size fit all?
Part 2: ATLS, maxillofacial
injuries and airway
management dilemmas
M. PerryC. Morris: Advanced Trauma Life Support (ATLS) and facial trauma: can
one size fit all?. Int. J. Oral Maxillofac. Surg. 2008; 37: 309–320. # 2007
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. Maxillofacial trauma poses an obvious threat to the patient’s airway, which
may not be immediately evident. In the multiply injured patient, the co-existence of
actual or potential injuries elsewhere may complicate airway management, notably
in the presence of full spinal immobilization. Following high-velocity trauma,
injuries to the cervical spine must be assumed to be present. They also need to be
ruled out in an appropriate and timely manner, as patients may wish to sit up.
Assessment and management of the airway in maxillofacial trauma can be difficult,
requiring a senior anaesthetist or other individual appropriately trained in
emergency airway care. A number of management options may exist to protect the
airway, each with advantages and drawbacks. Agitation and vomiting can occur
unexpectedly and need to be managed safely with due consideration to the spine.
Oral and maxillofacial surgeons need to be aware of these dilemmas and their early
Keywords: ATLS; Priorities; Airway; Vomiting;
warning signs, and be skilled in emergency surgical airway procedures, especially if
Spine; Transfer; Assessment; Emergency; Cra-
involved as part of the trauma team. Prolonged immobilization is associated with niofacial; Trauma.
significant morbidity and mortality. A number of protocols currently exist for
‘clearing’ the spine. Imaging now plays a greater role, especially in the obtunded, Accepted for publication 6 November 2007
unconscious or intubated patient, and this is discussed. Available online 18 January 2008

0901-5027/040309 + 12 $30.00/0 # 2007 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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310 Perry, Morris
Maxillofacial trauma poses an obvious
threat to the patient’s airway. In many
cases, this is best managed by allowing
the patient to position themselves upright,
thereby maintaining their own airway.
Following high-velocity trauma, the co-
existence of craniofacial injuries with
actual or potential injuries elsewhere
may preclude this approach. This is parti-
cularly the case in the presence of spinal or
pelvic fractures, which may be put at risk
of displacement if loaded axially through
the weight of an upright torso. Following
‘significant’ craniofacial trauma, or high
velocity trauma, injuries to the spine
(notably cervical) must be assumed to
be present until excluded1,65 Current opi-
nion is to transfer and maintain these
patients in the supine position, thereby
providing some degree of spinal protec-
tion. The clinical dilemma arising from
this strategy is how best to manage the
airway. Not all patients need to remain
supine indefinitely, but which ones can we
allow to sit up safely in the early stages of
their assessment?
Airway management in maxillofacial
trauma needs a senior anaesthetist or other
individual appropriately trained in emer-
gency airway care. For a number of rea-
sons all patients, but especially those with
maxillofacial injuries, may vomit unex-
pectedly. Unfortunately this can occur at
any time during their management, includ-
ing when available assistance is limited. In
such unexpected scenarios what can the
single-handed clinician do to simulta-
neously protect both the airway and any
spinal injuries? Simple measures will be
discussed, but in the event of inability to
maintain or secure the airway, maxillofa-
cial or other trained surgeons must be
prepared to provide appropriate access
surgically.
Part 1 of this series of review articles
discussed the importance of understand-
ing how the mechanism of injury can
help identify possible hidden injuries107.
Following ‘significant’ craniofacial
trauma, or high-velocity trauma, cervical
spine protection is necessary in the early
stages of assessment, and this involves
the use of a well fitting hard collar.
Unfortunately such collars can restrict
access to the oropharynx, face and ante-
rior neck, which on occasion may be
urgently required. Definitive repair of
maxillofacial trauma may also require
the head to be turned in order to gain
access to some of the injuries. In such
instances, when can the neck be ‘cleared’
on clinical grounds and, if not (notably in
unconscious patients), can it be cleared
by any other means?
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Initial considerations pressure and compromise the airway
directly20,69,108. Agitation can have many
In all patients, irrespective of whether
causes, notably alcohol, substance abuse
facial injuries are present or not, the first
and brain injury, but of immediate concern
priority is always to assess the airway,
is agitation secondary to hypoxia and pain,
while simultaneously protecting the (cer-
as these can often be readily addressed. If
vical) spine. This initially involves seek-
the patient fails to settle promptly despite
ing a verbal response to questions like
adequate oxygenation, correction of
‘what happened?’ or ‘how do you feel?’.
severe hypovolaemia and appropriate pain
Although an appropriate verbal response
relief, and essential investigations cannot
is encouraging, when facial injuries are
be undertaken, formal anaesthesia with
evident this should always be followed by
intubation and ventilation must be
direct inspection of the mouth and phar-
urgently considered. This is usually safer
ynx. Oral and facial bleeding can often go
than sedating the patient without provid-
unrecognised unless carefully looked for,
ing definitive airway control.
and foreign bodies must be carefully
removed. Correctly fitting rigid collars
restrict mouth opening and make assess- Airway obstruction in the supine
ment of the oropharynx difficult, but in all patient – ‘if you leave the patient
cases if the potential for airway compro- facing towards heaven, it won’t be
mise exists, these should be loosened long before they get there’
enough to enable thorough examination. (paraphrased, original source
During this time manual in-line immobi- unknown)
lization of the neck must be correctly
ATLS states that ‘‘Cervical spine injury
performed.
requires continuous immobilization of the
Immediate and delayed airway com-
entire patient with a semirigid cervical
promise in facial trauma may arise as a
collar, backboard, tape and straps before
result of varying combinations of tissue
and during transfer to a definitive-care
displacement, oedema and bleeding3,73.
facility’’1, and it can immediately be seen
Foreign bodies, vomit and traumatic brain
how the presence of facial injuries can
injury are also common causes. In awake,
potentially result in complications.
supine patients facial bleeding may not be
Although conscious and supine patients
obvious if the blood is swallowed, but if it
may be able to maintain their airway, this
continues uncontrolled it places the
does not mean it is secure and it is con-
patient at risk of vomiting later (possibly
stantly at risk. Alcohol, bleeding and brain
when they are under less supervision).
injury are commonly seen in many
With fractures of the mandible swallow-
patients, especially in the UK, and these
ing may be painful and not as effective in
increase the risks of unexpected loss of
keeping the airway clear100. Retrophar-
protective reflexes and obstruction. Alco-
yngeal haematoma, secondary to high
hol intoxication, commonly associated
cervical spine injuries, has also been
with facial trauma in many countries, is
reported to result in delayed airway
well known to result in both loss of con-
obstruction78, emphasising the need for
sciousness and vomiting.
regular and thorough reassessment of the
Significant soft-tissue swelling also
airway in all patients. Its presence should
occurs commonly in ‘panfacial’ injuries
also alert the clinician to the possibilities
and this may prompt the need for early
of a cervical spine fracture and develop-
intubation with a view to tracheostomy
ment of progressive respiratory failure.
later. Occasionally, airway-threatening
Urgent anaesthetic assessment is
swelling can occur in the absence of
required.
any fractures, and has been reported in
Currently accepted immobilisation of
patients taking anticoagulants or those
the cervical spine requires either manual
with clotting abnormalities25. Traumatic
in-line techniques, or a hard collar, blocks
swelling is made worse by the elevated
and straps, although these components
venous pressures and reduced lymphatic
lack a sound scientific basis60. In agitated
drainage which occur in the supine posi-
patients, attempts to restrain or immobi-
tion122. Fractures of the hyoid bone72
lize the head simply creates a fulcrum, and
(seen on the lateral cervical spine film)
increased leverage on the neck as the torso
should also be regarded as a ‘marker’ of
moves. In these circumstances, patients
significant injury to the adjacent soft tis-
may only tolerate a hard collar. Caution
sues (rather like fractures of the first and
is still required, as even this has the poten-
second ribs) indicating a risk of obstruc-
tial to displace low cervical injuries in a
tion. Swelling can take several hours to
combative patient44,67. Collars have
develop, highlighting the ATLS principle
also been shown to increase intracranial
of re-evaluation.

In all immobilized and supine patients
with facial injuries, two critical manage-
ment decisions are therefore necessary:
1. does the airway need securing? (i.e.
anaesthesia and intubation), and
2. if so, how urgently?
These require careful risk/benefit ana-
lysis on an individual patient basis. Not all
facial injuries are an immediate airway
threat, yet airway compromise can occur
unexpectedly in both ‘major’ and ‘minor’
injuries. Considerations include the fol-
lowing.
1. Early intubation protects the airway
relatively quickly, and in combative
patients enables rapid progression with
the remainder of the primary survey.
Life-saving interventions, such as pla-
cement of a chest drain, can also pro-
ceed much more quickly. Anecdotally,
facial haemorrhage can be more readily
identified in the non-swallowing
patient, as blood overspills from the
mouth. On the negative side, securing
the airway early is often performed in
less than ideal circumstances, and in
patients with ‘uncleared’ cervical
spines. The resultant loss of contact
with the patient at such an early stage
in their assessment also makes it harder
to asses them clinically for other inju-
ries. Neurological deterioration (cen-
tral and peripheral), spinal tenderness
(following log rolling), evolving
abdominal tenderness and compart-
ment syndromes can no longer be eval-
uated on clinical grounds. Anaesthesia
may result in significant haemody-
namic instability during induction
and maintenance, complicating the
clinical picture and potentially
adversely affecting the cerebral perfu-
sion pressure. From a maxillofacial and
ophthalmic perspective, visual impair-
ment, visual deterioration or increasing
retrobulbar pain may not be recog-
nised. Very often this approach com-
mits the patient to additional imaging,
notably computed tomographic (CT)
scanning of the head, spine and torso,
depending on the clinical picture.
2. Conversely, helping the patient main-
tain their airway enables regular
repeated clinical examination else-
where for evolving injuries, but the
airway is constantly at risk and will
be much harder to secure if the patient
suddenly vomits. Following high-
energy injuries, and in the presence
of multiple facial fractures, progressive
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Advanced Trauma Life Support (ATLS) and facial trauma
swelling can make intubation at a later
stage more difficult.
A senior experienced anaesthetist, or
other clinician trained in advanced emer-
gency airway management, should there-
fore be present during the assessment of
these potentially problematic patients. A
‘difficult intubation trolley’ should also be
readily available in the emergency depart-
ment24.
Vomiting in supine patients
Unexpected vomiting is a particularly
difficult problem in all immobilized
patients, which poses an obvious,
immediate threat to the unprotected air-
way. Its management is even more diffi-
cult in the presence of a possible cervical
spine injury. In all supine patients vomit-
ing can occur at any time and with very
little warning, often well after the primary
survey has been completed and the trauma
team has dispersed. Alcohol intoxication,
drugs (including opioids administered for
pain relief), anxiety and a full stomach are
all common precipitants. Swallowed
blood, which may be unrecognised and
concealed despite large volumes, is also a
potent stimulus. Facial injuries do not
need to be extensive for this to occur,
and bleeding from isolated nasal or unre-
duced mandibular fractures may, in com-
bination with other factors, be sufficient
to trigger vomiting. Unexpected vomiting
can also occur in the presence of brain
injury, vestibular dysfunction and when
patients are transferred.
Early warning signs may include
repeated requests or attempts by the
patient to sit up. This may initially be
misinterpreted as ‘difficult’ behaviour sec-
ondary to alcohol, brain injury or drugs.
With mandibular fractures, swallowing
may be painful and not as effective in
keeping the airway clear100. A critical
management decision is therefore required
in deciding which patients are at a high
risk of pulmonary aspiration from vomit-
ing and require intubation to protect the
airway. Not all patients vomit, and the
difficulty therefore lays in deciding which
patients should have their airway secured
as a precaution, just in case they vomit.
This decision is even more critical if inter-
hospital transfer or imaging (notably CT)
outside the relative safety of the resuscita-
tion room is necessary.
Vomiting in the multiply injured patient
is poorly dealt with in the literature and
ATLS course. It is often stated that this is
best managed by log rolling the patient
and using high-flow suction through a soft
311
wide-bore suction catheter. Which side
(right or left) the patient is rolled onto
must be clearly stated beforehand and may
vary according to the injuries sustained.
This is a coordinated process requiring at
least 4 individuals trained in the technique,
and is therefore one which cannot be read-
ily performed when vomiting occurs unex-
pectedly. Log rolling must not be carried
out single handedly, as if attempted will
put the spine at risk. So what should the
lone clinician do? This depends on the
circumstances in which vomiting occurs.
1. If vomiting occurs on arrival, where the
patient is still securely immobilized
and strapped to the spine board, tilting
the board head down approximately 6–
12 inches and clearing the airway using
high-flow suction is probably the safest
approach. This is a procedure that any
single-handed clinician can do safely
rather than struggle to roll the patient or
waiting for help to arrive. Although
tilting the spine board laterally is some-
times suggested, this can be difficult,
especially with heavy patients, and
may still put the spine at risk from
lateral shift, if the straps are not fully
secure. In the head-down position
vomitus preferentially flows into the
oropharynx from the oesophagus redu-
cing the risk of soiling the laryngeal
inlet and airway. Although this will
raise intracranial pressure, which is
undesirable in the presence of a brain
injury, this does not seem to be clini-
cally significant and represents a com-
promise93 The head-down position,
rather than lateral rotation, is also a
better position to take over the airway
for manual ventilation and rapid intu-
bation if necessary.
2. When warnings signs are recognised
and time allows, log rolling may be
possible. Repeated episodes of vomit-
ing will require repeated log rolling,
additional patient movement, and a
final turn back to the supine position
to enable intubation. With the patient in
the lateral position the collar would
almost certainly need to be loosened
in order to allow the mouth to open and
clear the airway. ‘In-line stabilisation’
then becomes almost meaningless. Log
rolling also interrupts and slows down
ongoing assessment and management.
3. Occasionally patients may forcibly
attempt to sit up to protect their airway,
cough or vomit. This is a difficult
scenario but should not be resisted
simply because they may have a poten-
tial spinal injury. If the mechanism of
312 Perry, Morris
injury suggests that the patient’s inju-
ries are confined above the collar
bones, the patient may be gently sat
up and a hard collar applied. The head
can also be manually supported if
necessary.
4. With all conscious patients, i.e. those
with a Glasgow Coma Scale (GCS) 12
or more, who actively ask to sit up,
allowing them to do so under close
observation is a reasonable approach.
This is based on the following princi-
ples and generalisations.
a. Talking indicates a level of vocal
cord function and the patient’s abil-
ity to protect their airway if upright.
In this position the need for intuba-
tion is reduced.
b. In order to sit up, the awake patient
will have sufficient muscle tone to
maintain spinal stability.
c. This conscious level is compatible
with pain appreciation and the abil-
ity to protect their spine.
d. The desire to sit up is often driven
by impending airway compromise,
or vomiting – the patient often
knows best.
e. Spinal immobilisation is only
appropriate for co-operative or
unconscious patients. Patients who
are agitated and actively resisting
lying supine are almost always best
left to adopt their position of choice.
Forcible restraint against active
movement increases the forces
applied to a (possibly unstable)
spine.
In our experience, vomiting is best man-
aged by lowering the head of the trolley
while clearing the airway with suction.
This is a procedure that any single-handed
clinician can do safely. Although poten-
tially messy and distressing to the patient,
it is effective in clearing the airway and
maintains spinal immobilisation. Patients
who are supine and in head-blocks should
always have an experienced nurse escort
and suction with them at all times, parti-
cularly when they are taken out of the
resuscitation room (for imaging etc.).
They should also be observed at all times,
until the cervical spine is ‘cleared’ and the
blocks removed. The rigid spinal board
should also be regarded as an extrication
aid for pre-hospital transfer, and patients
should be removed from it during or very
shortly after the primary survey.
‘Can I sit up?’
This is another difficult dilemma in the
multiply injured patient who also has
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facial injuries – what should we do with
the patient who repeatedly tries to sit up
but who may have significant injuries else-
where? Repeated requests or attempts to
sit up may indicate a desire to vomit or
unrecognised partial airway obstruction
from swelling, loss of tongue support or
bleeding. Patients may try to sit forwards
and drool, thereby allowing blood and
secretions to drain from the mouth. In
the presence of multiple injuries this posi-
tion is at variance to ATLS teaching:
‘‘. . .proper immobilisation is achieved
with the patient in the neutral position ie
supine without rotating or bending the
spinal column’’1. In the presence of torso
injuries the upright position will axially
load the entire spine and pelvis, even if the
head is supported.
Perhaps the largest clinical dilemma,
demanding the greatest level of clinical
judgement is the patient with fluctuating
levels of consciousness and cooperation
with a GCS of around 12. A common
scenario is the intoxicated aggressive
and combative male, following a fight or
assault, who typically has a full stomach.
There is often mild brain injury and
obvious facial trauma which cannot be
accurately assessed. This patient will not
accept ATLS recommendations for cervi-
cal spine control and will usually sit up or
walk about with little response to reason.
In these circumstances an unstable cervi-
cal spine injury is relatively rare53 and if
there are no signs of high-energy impact
elsewhere (skin injury or bony deformity)
thoracolumbar spine injury is also unli-
kely; sitting the patient up may be the least
hazardous option in the short term.
In all potentially multiply injured
patients with facial injuries another criti-
cal management decision is required:
1. do we mange the patient in a supine
position, which protects the spine, but
puts the airway at risk and may require
urgent intubation, or
2. can we sit them up, which initially
avoids intubation and allows us to
assess them clinically, but which may
then aggravate any torso or spinal inju-
ries?
Careful assessment and judgement is
therefore required in those patients with
an apparent isolated significant facial
injury, and this is based on the mechanism
of injury and concern for other injuries. If
allowed to sit up, the head still needs to be
supported to minimize axial loads and, if
possible, a hard collar should be applied to
support the neck. When multisystem
injury is clearly evident, attempts by the
patient to sit up are even more proble-
matic, and if the patient is combative,
despite adequate oxygenation, correction
of severe hypovolaemia and appropriate
pain relief, early intubation and ventilation
may be necessary to secure the airway.
These two positional extremes (supine
versus upright) are mutually exclusive and
any solution is a compromise following
assessment of the relative risks of keeping
the patient supine with potential airway
obstruction against the risks of axial load-
ing of a potential spine or pelvic injury.
Patients with co-existing thoracolumbar
and facial injuries are therefore a particu-
larly difficult group to manage63. These
spinal fractures may occur in up to 10% of
multiple injuries, but they can be unrec-
ognised in up to a quarter of these during
initial assessment because of:15,108,110,120
1) low GCS and/or intoxication,
2) anaesthesia,
3) painful distracting injuries,
4) prescribed analgesia (intravenous opi-
ates).
This reinforces the concept of the
mechanism of injury, which supports
screening for the following injuries.
1. High-velocity impacts (e.g. motor-
vehicle collision as a pedestrian, ejec-
tion from vehicle, airbag deployment,
fatalities or severe injuries to other
vehicle occupants).
2. Falls from a height (typically greater
than the height of the individual or >6
feet).
3. In patients with pelvic fractures or
lower limb long-bone fractures.
Due to its central location in the body
and surrounding supporting structures,
ligamentous injury of the thoracolumbar
spine does not appear to occur without an
associated fracture and therefore screen-
ing can be done with plain radiographs or
CT. If chest or abdominal helical multi-
plane CT is indicated the images obtained
can be reconstructed to examine the thor-
acolumbar spine63.
One category of patients not to under-
estimate are domestic falls. While not as
dramatic sounding as a high-speed motor-
vehicle accident, spinal injuries can occur
in up to 15% of patients following domes-
tic falls or accidents on stairs.
Patients with thoracolumbar spine inju-
ries are not only at risk of airway and
spinal cord damage, but these fractures
may be associated with life-threatening
retroperitoneal or mediastinal injuries,

all of which may be impossible to pick up
in drowsy, intoxicated, analgesed or intu-
bated patients. The retroperitoneal space is
not often thought of as a cavity, yet
patients can potentially lose most of their
circulating volume into it. Unfortunately
assessment of the retroperitoneum is dif-
ficult in the resuscitation room and CT is
often required.
Management of the airway: initial
considerations
Management of the airway in the presence
of significant facial injuries should involve
an experienced clinician with advanced
airway skills. In the UK this is usually
an anaesthetist, but internationally this
may be an emergency physician surgeon
or other individual. A number of guide-
lines in the management of the ‘difficult
airway’ and its intubation are now avail-
able, not all of which detail the airway in
trauma2,26,61,62,103. In all trauma patients,
high-flow oxygen should be given in con-
junction with pulse oximetry monitoring.
Rigid collars must be applied carefully to
avoid displacing any mandibular fractures
and precipitating airway compromise28,77
In the immobilized supine patient, high-
volume suction (using a wide-bore soft
plastic sucker) should always be available
to clear the mouth, nose and pharynx of
blood and secretions. If the patient is
awake care is required not to induce
vomiting. Any loss of the protective gag
reflex during suctioning indicates a deeply
unconscious patient, and this should
prompt urgent consideration of endotra-
cheal intubation.
The jaw thrust and chin lift are com-
monly used airway maintenance techni-
ques, but may be difficult to carry out in
the presence of severely comminuted
mandibular fractures. Both have been
shown to produce movement of the cervi-
cal spine33 and may be performed with
counter support of the head to prevent this.
Disimpaction of displaced middle third
fractures should also be carried out with
counter support and due regard for the
cervical spine. With all procedures it is
important not to excessively manipulate
the neck. The ‘sniffing the morning air’
position, namely atlanto-axial extension
and cervical flexion, is used to aid visua-
lisation during laryngoscopy in the unin-
jured spine. It does not help in maintaining
the airway per se, and is contraindicated in
suspected cervical spine injury.
In the actively bleeding face, some
manoeuvres, such as reduction of dis-
placed fractures, may help reduce bleed-
ing and partially restore the airway. Care
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Advanced Trauma Life Support (ATLS) and facial trauma
must be taken not to excessively manip-
ulate the fractures as this is not only
painful, but results in further blood loss
and can tear mucosa. Other procedures,
such as nasal packs and temporary binding
of mandibular fractures, may complicate
airway management and be difficult to
perform in uncooperative patients.
Management of the airway:
maintenance techniques
Oropharyngeal (Guedel) airways are often
poorly tolerated and can precipitate vomit-
ing and laryngospasm. If not placed cor-
rectly they can push the tongue
backwards, resulting in obstruction. Naso-
pharyngeal airways are better tolerated but
are often associated with epistaxis. Con-
cerns have been raised about their use in
midface injuries or suspected anterior
skull-base fractures (as with naso-gastric
and naso-tracheal tubes), following
reports of intracranial positioning1,17. In
reality the risks are low7 and in experi-
enced hands these devices can be safely
passed. Although intracranial intubation4
is a theoretical complication of nasotra-
cheal intubation in anterior skull-base
fractures, we could find no references to
support this belief, and there is no clear
association with meningitis when com-
pared to oral intubation. Nevertheless,
excessive manipulation during airway pla-
cement may, in theory, extend any dural
tears.
If the airway is patent but there is no
spontaneous ventilation then manual ven-
tilation will be needed. Here a tight-fitting
‘anaesthetic’ mask is needed and exces-
sive pressure, to maintain an airtight seal,
may displace mobile fractures, potentially
making intubation more urgent. Aggres-
sive ‘bagging’ may also force inspired
gases through any fractures communicat-
ing with the airway (including anterior
skull base). Obese men with beards are
particularly difficult to manage. They can
be difficult to mask ventilate and a gener-
ous smearing of lubricant jelly over the
beard is often required to get an effective
seal. Mask ventilation should be a two-
person technique, i.e. one person holding
the mask and maintaining a seal and an
assistant squeezing the bag.
Before 1990, the choice of airway
device was essentially limited to the face-
mask or an endotracheal tube. Since then,
a number of supraglottic airway devices
have become available. The laryngeal
mask airway (LMA) was introduced in
the UK in the late 1980s and has achieved
widespread use in elective anaesthetic
practice. In some circumstances this
313
may be considered; for example, in a deeply
unconscious patient where all other main-
tenance techniques have failed to restore a
patent airway. Although the LMA is cuffed
to help maintain its position, the airway is
not formally protected and aspiration with
soiling of the airway can occur105. When
mask ventilation and tracheal intubation are
unexpectedly difficult, LMAs facilitate res-
cue ventilation, although they should only
be regarded as an oropharyngeal airway,
not a tracheal tube. Improperly inserted
LMAs can induce vomiting and result in
movement of the neck, although this is rare
when performed by properly trained staff.
The use of LMAs in trauma is still con-
troversial.
None of the above adjuncts provide a
secure airway, and a definitive airway (i.e.
a cuffed tube in the trachea) must be
considered if there is any doubt about
the patient’s ability to protect their own
airway immediately, or in the near future.
Intubation in facial trauma is a challenging
technique and difficulties may result in
aspiration, hypoxaemia, hypercarbia and
hypertension, all of which may signifi-
cantly worsen any co-existing brain
injury. Sedation is required, resulting in
loss of contact with the patient and a
greater reliance on imaging to fully iden-
tify their injuries. There is also a risk of
secondary pneumonia, hypotension and
reduced cerebral perfusion pressure
requiring vasoactive drugs.
Management of the airway: definitive
techniques
Urgent definitive airways include oro-tra-
cheal intubation, naso-tracheal intubation
and surgical cricothyroidotomy. All are
relatively safe in experienced hands58 so
long as the technique is one with which the
clinician is most confident86. All have
been shown to be safe even in the presence
of an unstable cervical spine injury.
Recently revised guidelines from the
Association of Anaesthetists of Great Brit-
ain and Ireland59 now provide clear
recommendations as to which patients
need to be intubated following brain inju-
ries and which require transfer59. These
guidelines are broadly similar to other
international publications1,66. Some of
these indications are directly related to
facial trauma. Intubation and ventilation
are recommended when any of the follow-
ing are associated.
1) Bilateral mandibular fractures. This is
an interesting recommendation when
one considers the frequency with
314 Perry, Morris
which bilateral fractures are seen.
Strict adherence to this guideline alone
may result in a number of unnecessary
anaesthetics.
2) Copious bleeding into the mouth.
3) Loss of protective laryngeal reflexes.
4) A GCS <8 or >2 point fall.
5) Seizures.
6) Deteriorating blood gases.
To these we would suggest adding:
7) when gross swelling is anticipated, and
8) in ‘significant’ facial injuries where a
long inter-hospital transfer is required.
‘Significant’ requires clinical judge-
ment on a case-by-case basis.
In the majority of cases oro-tracheal
intubation is the preferred technique of
choice. When this is urgently required
and the neck has not yet been ‘cleared’,
manual in-line cervical immobilisation
throughout the procedure becomes essen-
tial. Cadaveric and clinical studies have
shown that, despite best efforts at in-line
immobilisation, movement of the cervical
spine still occurs during intubation82,87.
Fortunately, clinical studies have repeat-
edly shown that laryngoscopy with cervi-
cal in-line stabilisation is safe –
laryngoscopy and myelopathy have never
been directly associated92 The choice of
instrumentation may also be important in
this respect38, and reports suggest that less
cervical manipulation occurs when the
McCoy laryngoscope blade and bougie
are used37,75,81. Interestingly, in some pan-
facial injuries intubation is easier than
anticipated, as the mobile facial bones
can be gently displaced by the laryngo-
scope blade providing an adequate view of
the vocal cords. Difficult visualisation of
the cords more often occurs when there is
ongoing bleeding and swelling of the pos-
terior oropharynx. Despite this observa-
tion, a ‘difficult intubation trolley’ should
again be available24 and the potential for
an urgent surgical airway recognised.
In the absence of midface or craniofa-
cial fractures, blind naso-tracheal intuba-
tion and fibre-optically assisted oro- and
naso-tracheal intubation have been sug-
gested as alternatives. Along with surgical
airways, these techniques have all been
shown to result in minimal manipulation
of the cervical spine39. In most units in the
UK, blind nasal intubation is regarded
critically and rarely carried out in a trauma
setting. Contrary to popular
belief6,7,41,43,49,71,108,116 nasal intubation
has been shown to be safe in the presence
of skull-base fractures4 with no reports of
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intracranial passage, but it is technically
more demanding, increases the rate of
bleeding and sinusitis beyond 72 h and
requires a patent nasal airway113. Awake
fibre-optic intubation, although useful in
spinal injuries, is not without risks91, par-
ticularly in an emergency setting where
visualisation is usually limited by the pre-
sence of blood and oedema, and the airway
being partially obstructed89. Retrograde
intubation is a technique which has also
been shown to minimize cervical spine
manipulation, but experience in the
trauma setting is limited. Difficulty in
passing the guidewire cephalad and
impaction of the endotracheal tube on
the anterior commissure of the larynx
are common difficulties limiting its use-
fulness8,68,119,123.
Management of the airway: surgical
techniques
Surgical airways are required when it is
not possible to secure the airway by any
other means within a safe period of time.
Time is of the essence and failure to
adequately oxygenate the patient rapidly
results in cerebral hypoxia in 3 min and
death within 5 min. In these circum-
stances, emergency options include cri-
cothyroidotomy (needle or surgical),
tracheotomy (needle or surgical) and tra-
cheostomy (surgical or percutaneous). The
cricothyroid membrane is now the pre-
ferred site for emergency surgical access
as it is usually relatively superficial, less
vascular and in most cases readily identi-
fiable, even if it is not possible to extend
the neck. This surgical approach avoids
the thyroid gland and associated vessels
and has a lower rate of complications125.
Needle cricothyroidotomy is advocated
by ATLS1 but (as with nasotracheal intu-
bation) routine use has remained contro-
versial. It is said to ‘buy time’ when
conventional techniques fail to adequately
ventilate, allowing a limited degree of
oxygenation, while preparing for a surgi-
cal cricothyroidotomy. ATLS recom-
mends that oxygen is delivered at a rate
of 15 l/min via a Y-connector or 3-way
tap, with 1 s inspiration and 4 s expiration.
This delivers only 250 ml of gas into the
trachea during each inspiration, some of
which will pass up into the upper airway
rather than into the lungs. Carbon dioxide
removal is also inadequate as expired
gases pass out through the patient’s non-
ventilating airway. Complications during
cannula placement can occur and failure to
achieve adequate oxygen delivery is com-
mon, unless a large-bore cannula and
pressurized injector system (4 atmo-
spheres) are used88,95. With these high-
pressure systems gaseous distension of the
soft tissues of the neck can occur if the
catheter tip is not in the trachea, making
any subsequent attempts at tracheal access
more difficult. Barotrauma is also com-
mon and if concerns exist about this, gas
flow must be reduced to 2 l/min to avoid
progressive hyperinflation. This results in
even less oxygenation. Both complica-
tions can be fatal.
Surgical cricothyroidotomy is now
advocated by both the American College
of Surgeons (ACS) Committee on Trauma
and the British Trauma Society (BTS) as
an appropriate choice of emergency air-
way control when endotracheal intubation
is not possible114. Several techniques have
been described12,21,27,34. The main advan-
tage of surgical cricothyroidotomy over
needle cricothyroidotomy is that a larger
airway (such as a 4.0-mm minitrach or
paediatric uncuffed endotracheal tube) can
be introduced, facilitating positive pres-
sure ventilation and reliable expiration
with removal of carbon dioxide. This is
especially important in the head injury
patient. If a large enough tube is possible,
the need to convert a surgical cricothyr-
oidotomy to a tracheostomy at a later date
has also been questioned125. Tube size is
sometimes restricted due to the limited
dimensions of the cricothyroid membrane;
too large a tube may lead to flexion defor-
mity of the larynx. As an alternative,
commercial cannula-over-needle-style
kits, which enable bag and mask ventila-
tion via 15/22-mm connections, are now
available. Tracheostomy is now generally
regarded as inappropriate in the emer-
gency setting, as it is time consuming,
technically more difficult to perform and
requires a previously secured airway dur-
ing the procedure83. Percuatneous tra-
cheostomy using dilating forceps has
also been described as an emergency air-
way ‘salvage’ procedure, but should only
be performed by experienced practitioners
familiar with the technique90.
Principles of airway management for
the ‘occasional’ practitioner (i.e.
most of us)
Keep it simple – if intubation is not a skill
you commonly perform it is best not to
attempt it. Although all trauma patients
must have a patent, protected airway and
be adequately ventilating 100% oxygen,
this may not mean they all need to be
intubated. Call early for expert airway
assistance. In the meantime, stepwise pro-
gression through the following scheme
may help the non-specialist in a hospital

setting to manage the airway appropri-
ately.
1. Give high-flow oxygen (15 l/min via a
non-rebreathing bag).
2. Consider a jaw thrust with counter
support of the head. Do not use a head
tilt or chin lift as these are more likely
to extend the upper cervical spine.
3. Consider an oropharyngeal airway if
the patient is deeply unconscious and
obstructing (i.e. GCS <8 and no
response to a strong jaw thrust. Avoid
nasopharyngeal airways.
4. If the airway is patent and there is no
spontaneous ventilation then manually
ventilate with a self-inflating bag and
mask (size 4 for a woman, 5 for a man).
Get someone else to squeeze the bag.
Call for urgent anaesthetic assistance.
5. If GCS <8, there is no response to a
jaw thrust and you cannot manually
ventilate with a face mask, insert a
small LMA – size 3 for a woman
and size 4 for a man. If it leaks add
more air into the cuff, up to a maximum
of 30 ml.
6. If you are sufficiently experienced,
consider oro-tracheal intubation.
Remember not to extend the head. If
you are not sufficiently experienced
continue to maintain the airway and
ventilate the patient.
7. If you cannot intubate and cannot ven-
tilate the patient, suction the mouth
with a large-bore Yankauer and per-
form a surgical cricothyroidotomy –
the patient will rapidly die otherwise.
Alcohol and drug ingestion
In the acute trauma setting it is best to
assume patients have a full stomach and
are at risk of aspiration. Alcohol and blood
in the stomach delay gastric emptying and
together with opiates (administered for
pain relief) can precipitate vomiting. If
this seems likely consider the administra-
tion of an intravenous histamine type 2
receptor antagonist (e.g. ranitidine) and a
pro-kinetic drug (such as metoclopramide)
while awaiting intubation. Although often
practiced, passing an (oro)gastric tube to
decompress the stomach in an awake
patient is fraught with problems and will
often provoke vomiting.
If the patient’s blood alcohol levels are
high, they are unlikely to fall in the next
12–24 h and the following ‘hangover’ will
almost certainly be associated with vomit-
ing. If the patient’s consciousness level is
of concern, intubation is likely. In these
circumstances a CT scan of the brain is
indicated64,66. Urine or plasma screening
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Advanced Trauma Life Support (ATLS) and facial trauma
for drug ingestion should be guided by the
available history, but paracetamol levels
should always be checked since treatment
of overdose is available but is time depen-
dent. Coma following overdose of para-
cetamol/opioid analgesic preparations can
be antagonized with naloxone and benzo-
diazepines with flumazenil – this may
make management easier as the patient
becomes more conscious. Such antago-
nists only have a short duration of action
and seizures may occur.
Managing the cervical spine: initial
considerations
In adults, cervical spine injury following
blunt polytrauma has been reported to
occur in approximately 5–10% of
patients14,112. In maxillofacial trauma,
cervical spine injuries have been reported
to occur in up to 6%10,19,51,52,118,124,
although this figure has been chal-
lenged53,102. The incidence of a significant
and unstable cervical injury following
assault is reported as being much lower106.
Although the association between facial
fractures and cervical spine injury would
seem intuitive, a number of workers have
questioned whether this is indeed the case,
and that instead it is the association of
traumatic brain injury which increases the
risk of spinal injury9,94. Several patterns of
cervical spine injury have been reported
following facial trauma84 but this is of
little practical use in the resuscitation
room. Missed spinal injuries109 are asso-
ciated with high rates of neurological
complications, and for any mechanism
of injury capable of causing cervical
spinal injury the safest policy is to assume
an injury is present until it can be cleared
according to accepted protocols1. Unfor-
tunately, immediate clearance is rarely
possible23. Although immobilisation of
the cervical spine does not preclude sur-
gery, intubation is more difficult and the
repair of complex craniofacial injuries
may be technically more challenging
when you cannot turn the head.
Injury to the spinal cord itself can also
potentially affect how we manage facial
injuries, although this is a controversial
area. Aside from not moving the neck,
there is now some evidence to suggest
that a limited amount of neurological
recovery may be possible under optimal
conditions. It has been suggested that in
partial cord lesions there is a peripheral
ischaemic zone which has the potential to
recover. This is very sensitive to even
momentary periods of hypotension, either
through a drop in blood pressure or move-
ment at the fracture site. At the lower
315
cervical level this could effectively mean
the difference between paraplegia and
quadriplegia. For this reason, some spinal
surgeons are now advocating keeping
patients absolutely flat for 2 weeks, with
complete immobilisation of the neck
and the avoidance of any procedures,
including general anaesthesia, which
may result in significant blood loss or
hypotension. This clearly has an impact
on the management and timing of any facial
injuries.
ATLS teaches that ‘trauma occurring
above the clavicle should raise a high
index of suspicion for a potential cervical
spine injury’ and strict application of this
principle means all patients with maxillo-
facial or craniofacial trauma must be
included in this group. Considerable var-
iation now exists in the process of exclud-
ing spinal injury, and the confident
exclusion of cervical spine injuries in
some patients can be very difficult22,40.
This is particularly so in agitated, unco-
operative, poorly responsive or unrespon-
sive patients. A number of reviews and
guidelines outlining initial management
and assessment of spinal injuries have
now been published101. The clinical
exclusion of cervical spine injury is almost
impossible following significant facial
trauma and/or in the presence of multiple
injuries. In such cases, distracting injuries,
brain injury or a questionable spinal exam-
ination will prevent clearance on clinical
grounds.
‘Clearing’ the cervical spine
Clearance of the entire spine, especially
the neck, should be undertaken as soon as
is practically possible. This is due to the
problems of prolonged spinal immobilisa-
tion97,98. Unfortunately there has been a
lack of consensus on the optimal way to do
this within the UK48,70,99 and internation-
ally46. Ideally, the neck should be cleared
prior to the repair of any facial injuries,
although this may not be possible70,99.
Rigid spinal boards were originally devel-
oped as extrication aids for pre-hospital
care. Because of the risks associated,
every effort should be made to get the
multiply injured patient off the spine
board as soon as possible, usually at the
end of the primary survey1,80. The cervical
spine still needs to be protected (manual
stabilisation or collar, lateral restraints and
tape) until the neck has been ‘cleared’.
This can cause problems in the presence of
craniofacial injuries requiring immediate
intervention in the resuscitation room.
Although collars can be removed and
in-line manual immobilisation performed,
316 Perry, Morris
gaining access to the posterior oropharynx
can be very difficult without causing some
neck movement, as shown in cadaveric
studies. Hard collars should always fit
properly, and this is particularly important
in the presence of mandibular fractures,
where poorly fitting collars have been
reported to precipitate airway problems.
Rigid collars have also been reported as
significantly raising the intracranial pres-
sure secondary to a tourniquet effect,
although the clinical significance of this
is yet to be established20,54,69,79,108.
Clearance of the cervical spine on clin-
ical grounds is now generally accepted as
possible31,35,55,56 so long as all of the fol-
lowing criteria are met5,13,29,30,32,36,42,50,121.
1. Fully awake, i.e. GCS 14 or 15.
2. No alcohol or intoxicants (in the
patient).
3. No (painful) distracting injuries.
4. No pain or tenderness of the spine on
deep palpation.
5. Active movement without pain or neu-
rological change.
Sequencing is important. Before the
collar can be removed and the neck exam-
ined, the patient must be free of neck and
distracting pain, and a peripheral neuro-
logical examination should be negative.
The collar is opened and then removed,
maintaining manual in-line immobilisa-
tion, and the entire neck examined for
tenderness (especially posteriorly). If this
is negative the patient is then asked to
gently move the head to one side, while it
is supported, then the other. If this is
negative the patient is then asked to lift
their head off the bed. If at any point the
patient develops either significant pain in
the cervical spine or neurological symp-
toms, the neck is not ‘cleared’ and immo-
bilisation is reapplied.
In the majority of patients clearance is
reasonably straight forward, and provided
all criteria are met it is now felt that there
is no need to image the cervical spine, and
immobilisation can be safely removed on
clinical grounds alone64,121 Clinical jud-
gement is required in some areas; for
example, what do we define as a ‘distract-
ing’ injury? Stubbed toes and broken vital
teeth with pupal exposure are arguably
very painful injuries, but are these distract-
ing enough to prevent clearance? Are
facial injuries distracting enough to pre-
vent clearance? This is not clear in the
literature, although recent studies have
suggested injuries to the lower torso
may not be distracting enough to prevent
good clinical examination.
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Clearance of the cervical spine in the
presence of multiple injuries and/or brain
injury is much more complicated and dif-
ficult16. Most patients cannot be cleared
following clinical examination and the
likelihood of a spinal injury is higher. In
these cases imaging is required, and the
options include plain radiography, CT,
magnetic resonance imaging (MRI) and
dynamic fluoroscopy45.
In considering plain radiographs the 3
standard ATLS views (lateral, anteropos-
terior and open-mouth odontoid peg)
should now be regarded as inadequate76,
identifying only around 90% of cervical
spine injuries121. In the presence of brain
injury and an abnormal brain CT scan the
false negative rate of plain radiographs at
the craniocervical junction is approxi-
mately 10%11,18,74,85.
As yet there is no universally accepted
protocol for cervical spine clearance when
clinical examination is not possible. There
are now a number of guidelines and
review articles illustrating the varied
approaches currently available1,65,97,98.
Most available evidence suggests that
helical CT of the entire cervical spine
(from the craniocervical junction down
to and including the T3 disk space) is
sufficiently sensitive and specific to allow
clearance of the cervical spine in the
poorly responsive or unresponsive patient.
The false-negative rate is typically less
than 0.5%45,57,98,104,115,117. A recent sur-
vey in the UK suggested approximately
75% of hospitals receiving trauma now
have access to such scanners96. If helical
CT is not available then plain radiographs
(the ATLS three-view ‘trauma series’)
supplemented with high-resolution CT
(i.e. 1.52 mm pitch and collimation) of
the craniocervical junction (occiput to
C2), plus any inadequately visualized or
suspicious areas, also has a low false-
negative rate of below 1%98. There are
now a large number of guidelines recom-
mending the routine use of a brain CT scan
for any obtunded trauma patient who
requires intubation, regardless of the
levels of alcohol or other toxins1,64,66. In
such cases the cervical spine should also
be routinely scanned, ideally in a helical
scan, from occiput to the level of the third
thoracic disk space. Scanning of any facial
injuries should also be considered at this
time, in view of the speed of most scan-
ners.
Concerns still exist that isolated liga-
mentous injury may be missed with plain
films and CT and that the patient’s cervical
spine cannot be cleared with these mod-
alities. In these circumstances manage-
ment options include the following.
1) Await the patient’s recovery and repeat
the clinical assessment. This is not a
validated technique (although it is a
very common approach) and exposes
patients to the risk of prolonged spinal
immobilisation80,98.
2) Perform an MRI scan. This is very
sensitive in detecting soft-tissue and
ligamentous injury. Some studies
based on MRI findings have suggested
up to 25% of occult ligamentous inju-
ries may be missed by radiographs and/
or CT. Unfortunately, the specificity of
MRI is less certain and the significance
of many of these injuries is not known.
MRI is now the recommended imaging
modality of choice for suspected spinal
cord injury (e.g. in the presence of
abnormal neurology, such as clonus
or hyperreflexia) and this should be
considered as an emergency proce-
dure63.
3) Perform dynamic fluoroscopy. This is a
specialist technique involving dynamic
manipulation of the unconscious
patient’s cervical spine during contin-
uous fluoroscopic screening to detect
instability. A previous small meta-ana-
lysis suggested occult ligamentous
injury rates of approximately 2%,
although more recent analysis suggests
dynamic testing offered very little
beyond combined radiographs and
CT in detecting significantly unstable
injuries98
The process of spinal clearance there-
fore involves a balance of risks and ben-
efits. On the one hand are the risks of
missing a possible ligamentous injury in
an unstable neck14. The false-negative rate
in detecting significantly unstable cervical
spine injuries using helical CT is approxi-
mately 0.5% and there is little evidence
that any of the previously described tech-
niques can improve on this. Conversely,
the risks of prolonged spinal immobilisa-
tion carry associated morbidity and mor-
tality. Rigid cervical collars (e.g. Laerdal
Stif-Nek) were originally designed for
extrication and patient transfer, and just
a few hours application can result in pres-
sure sores. Some semi-rigid collars (e.g.
Aspen) have been reported to reduce this
risk while providing similar levels of
immobilisation.
If the patient has been formerly anaes-
thetized and neuromuscular blocking
agents have been administered, then lat-
eral restraints and tape only are adequate
and the collar can be safely removed – the
patient is not going to actively move. A
clear label should be visible (e.g. on the
patient’s forehead) to remind staff that the

collar must be re-applied for any log rolls.
Spinal boards can result in pressure sores
and ulceration47 after as little as 20 min in
the presence of spinal cord injuries. Ulti-
mately, this decision must be taken on an
individual patient basis with the accep-
tance that whichever strategy is followed
it is not without risk.
Steroids in trauma
The use of steroids in trauma is a con-
troversial and difficult topic. Glucocorti-
coids are often used to reduce airway
oedema, although evidence for this benefit
is largely limited to children post extuba-
tion60 and one should be cognizant of
other effects. The recent CRASH (Corti-
costeroid Randomisation After Severe
Head injury) study identified an excess
mortality in the presence of head injury
if high-dose methylprednisolone is admi-
nistered111 and this practice should now be
actively avoided. This may have implica-
tions in the management of some vision-
threatening injuries. Similarly, the routine
administration of high doses of steroids for
early spinal cord injury is controversial
and, despite having been advocated by
ATLS, has been challenged on the
grounds of lack of efficacy and significant
complications65; the impact on head inju-
ries should be recognised.
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