Advanced Airway Management in Oral and Maxillofacial Trauma

Note: the following case is based on numerous scenarios of similar presentation, not one specific case. Citations inline offer context for additional training and education.

Introduction

Maxillofacial trauma represents one of the most challenging airway emergencies encountered in prehospital medicine. Unlike straightforward upper airway obstruction, facial trauma creates a complex anatomical puzzle: disrupted anatomy, hemorrhage, soft-tissue swelling, and the risk of aspiration. This piece will not dive into the classification of fractures under the widely known Le Fort classification, but for those interested, additional information is available here.

Emergency medicine, whether in the field or the hospital, begins with the “A” of airway in the airway, breathing, and circulation assessment model known elegantly as the ABCs. All medical professionals learn this mnemonic, and it grounds us in a consistent, repeatable, and necessary assessment workflow that is responsible worldwide for the reduction of death and disability.

Case presentation

A 42-year-old male with a history of major depression is discovered by family members following a failed suicide attempt with a firearm. Law enforcement and BLS arrived on scene approximately seven minutes after the injury, initially securing the scene and weapon and assuring no other threats to rescuers.

Our patient presents conscious and mildly combative, in severe distress, confused, with moderate altered mental status. At this point it is unclear whether the patient has consumed alcohol or drugs. Respiratory rate is 32 breaths/min; a non-rebreather has been placed by EMTs and is mostly achieving “blow-by” efficacy; respirations are labored and gurgling, with periodic episodes of apnea; SpO₂ is 84% on room air and declining; there is massive facial hemorrhage from the right lateral face and oral cavity with blood draining into the lungs, gunpowder burns to soft tissue, and a partially obstructed zygoma.

The quick-thinking BLS team placed the patient in a semi-prone position to allow hemorrhage to drain from the oral cavity and pharynx — an initial step that, along with suction, was likely the most impactful and life-saving intervention of the episode.

Ballistic inquiry determines that a 12-gauge shotgun slug was discharged. The entry wound is inferior to the left mandible, and the exit wound is through the right cheek just below the zygoma. The patient’s airway is compromised by lack of structure, bleeding, and edema. GCS is 12, with vital signs as follows: HR 118, BP 136/89, RR 32, SpO₂ 84%.

Already the team should be thinking about securing the airway and the likelihood of medication-facilitated intubation (RSI). But this decision cannot be made lightly, since a sedated and paralyzed patient such as this has a high likelihood of complication or failure. Surgical or alternative airway methods may be necessary.

Assessment

Airway: extremely compromised oral and nasal pharynx, with potential damage to the trachea and posterior structures. The airway is further compromised by hemorrhage, edema, and the likelihood of teeth, bone, and related shrapnel obstructing airflow. The patient is tachypneic due to obstruction and appears air-starved. Circulatory status shows a rapid, thready pulse, and an ECG has not yet been obtained.

Risk considerations

In this patient, the combination of penetrating facial trauma, massive hemorrhage, progressive soft-tissue edema, and declining oxygenation created a rapidly deteriorating situation. This airway must be secured. Gunshot wounds to the face involve massive vascular injury. This patient’s bleeding was not just oral — it was actively draining into the pharynx and trachea. Attempting oral intubation without first clearing and controlling hemorrhage would result in rapid airway loss, aspiration, and death.

Unlike blunt trauma, where the underlying skeleton is largely intact, penetrating injury destroys bone and soft tissue. The wound at the right mandibular angle meant: (1) structural loss preventing normal jaw mechanics, (2) massive swelling obscuring anatomical landmarks, and (3) devascularized tissue increasing infection and inflammation risk — significant current and future airway risk.

Emergency medical treatment

At the initial presentation the paramedic must ask: can this airway be secured with an ET tube, or will it require an alternative approach or surgical cricothyrotomy? Further, given that the reconstructive and surgical future is significant, any ET tube placed may remain in place longer than usual.

A paramedic in charge faced with this scenario is likely to take several core initial decisions. First is transport and transport time, as this patient clearly requires advanced imaging and several interventional surgical teams — trauma surgery, ENT, plastics, and more. The patient must go to a Level 1 trauma center, which makes ground-versus-rotor an early decision. If the patient needs to be flown, an air-care request must be set in motion and a landing zone established. Ordinarily this can be decided en route, based on familiarity with location and geography, with the resource placed on standby pending launch.

On-scene immediate steps include suction, IV access, and a second paramedic to prepare medications for planned RSI — etomidate or ketamine for induction, and paralytics such as succinylcholine or rocuronium (sux or roc). Choices are largely regional-protocol dependent. This means having someone setting up the ET role and suction (including deep sterile suction options), and preparing the portable transport ventilator (PTV) and monitoring equipment.

Today, a tremendous adjunct to airway management in the field and in hospital is video laryngoscopy via GlideScope or a similar device — a tool that enables easier visualization of the vocal cords and coordinated use of a bougie to introduce an endotracheal tube.

The team provided aggressive suction to remove blood, clots, and debris from the obstructed airway. After IV access, the decision to proceed with induction and paralysis was made, and the video scope was used to position a bougie and pass a 7.0 ET tube. The tube was secured and the patient placed on a ventilator. Placement was confirmed visually, by equal bilateral chest rise, and by waveform capnography with an associated measurement of 38 mmHg. Despite placement and airway security, continuous suction remained necessary throughout the episode of care.

Pearls of wisdom

Penetrating facial trauma is an extreme airway emergency. It is important to do what is possible and not intervene where intervention is unnecessary. There is no shame in maintaining suction and BLS airway management if that is the best treatment for the patient. In this case, suctioning and positioning were likely the interventions that produced the best outcome. The use of sedation is important: despite the presenting trauma, this patient has strong suicidal ideation, and such patients can be uncooperative and combative — a liability during airway management and a risk to the team. Sedation here was both necessary and appropriate. Early notification to the trauma center and identification of rotor-transport options remain critical decision points.

Technical note: submental intubation

Submental (transmental) intubation is a rescue technique that has gained attention in the literature. In this approach, an ET tube is passed through the floor of the mouth and out under the chin (the submental area). This technique, borrowed from complex surgical models, remains plausible. It carries risk to the sublingual artery, floor of mouth, and lingual nerves — though in a case such as this, each of those structures has likely already been materially compromised. More information on the technique is available here.