Jaw facial multiple fractures combined with cranial bottom fractures line under-path trachea intubation 1 case

Jaw trauma patients generally need general anesthesia during surgery, the breath tube intubation will affect the operation of surgery, therefore, more use of nasal trachea intubationFor patients with concranial fractures, cerebrospinal fluid (nasal) leakage, nasal fractures, etcwith contrait altific evidence, tracheotomy usually needs to be cut, but tracheotomy has high risk, the shortcomings of comorbiditiesIn October 2018, our hospital used a lower-cut tracheal intubation for 1 case of multiple facial fractures in the jaw, so that patients could avoid trachea incision and successfully operate, as reported below1Clinical datamale, 29 years old, 176 cm tall, weighing 74 kgDue to the car accident caused multiple skull and facial fractures into the hospitalAdmission examination: electrocardiogram, chest tablets are generally normalHead CT shows: jaw fracture, double upper jaw fracture, double cheekbone fracture, cheekbone fracture, nasal bone multiple fractures, nasal fracture, cranial fracture, intracranial gas, right tibia epidural hemorrhagelaboratory examination: blood routine, urine routine, liver and kidney function and clotting II are not abnormalDeny a history of diabetes, heart disease, etcIt is proposed to have a fracture dissocial fracture in the lower jaw bone under general anaesthetic, a fractured double upper jaw bone, a fractured double-sided palate bone, and a fractured nasal bone to open the internal fixationVisit the patient before surgery and explain the anaesthetic method and related operation to the patientDue to the operation of the upper and lower jaw bone reset need to bite the right, can not carry out the breath tube intubation, but the patient has a skull fracture, nasal fracture, nasal fracture, for the nasal intubation taboo certificate, therefore, the need for trachea incision, but the patient firmly does not accept trachea incisionSo the patient is introduced to the method and process of undercut trachea intubation, the patient accepts and signs the consent form of anesthesia the preparation and modification of the pre-anaesthetic trachea catheter: because the connection tube at the back of the trachea is thick erased and has a flank, it can cause greater trauma when the jaw is worn out, so the connecting tube at the back of the trachea duct needs to be removed before the jaw is worn This patient needs to strengthen the trachea catheter with a wire, as the connection tube and catheter binding of this type of trachea catheter are not stronge enough to be removed and the trachea duct s/ improvement: the connecting tube of the strengthened trachea duct is destroyed (Figure 1A) and replaced with the connecting tube of the removable ordinary trachea duct (Figure 1B) Disinfect the backup after the trachea duct modification is complete The patient fasted 8h before surgery After entering the operating room, blood pressure, electrocardiogram, pulse oxygen saturation are regularly monitored In-room blood pressure is 125/75mmHg, heart rate 65 times/min, SpO2 100% Open the upper extremities venous pathway, under Lidoca local immersion anesthesia, the right artery punctured tube pressure measurement After the airway evaluation of trachea intubation difficulties to give rapid sequential anesthesia induction: tell the patient to take a deep breath, mask to absorb pure oxygen 5min after the vein to give shufentani 20 sg, propofol 150 mg, poku brominated ammonium 50mg, no positive pressure ventilation, 90s after the visual laryngology guide by the mouth to transform the modified No 7 steel wire reinforced trachea tube insertion Figure 1 The modification of the reinforced trachea catheter After confirming that the position of the trachea duct is appropriate, the trachea duct is simply fixed and the anaesthetic machine is mechanically ventilated Intraoperative intravenous continuous pump propofol 6 mg kg-1 h-1 and rifenite 0.01 to 0.1 sg.kg-1-h-1 maintenance of general anesthesia, intermittently given to the ammonium rocobromino The dose of rifentini is adjusted according to the patient's blood pressure Take a flat seat as required by the maxillofacial surgery, with a slight shoulder rest iodine volt disinfection area, spread sterile single, in the left jaw front to do a about 1 cm incision, paste the inner side of the jaw to the bottom of the mouth for blunt separation, cut open the tongue side of the bottom mucous membrane (cut parallel to the lower tongue wrinkle wall), the formation of the under-mouth channel, suspend the anaesthetic machine, remove the trachea trachea The connecting tube of the catheter, in turn, uses the hemorrhage clamp to the inflatable tube of the trachea tube sleeve and the far end of the trachea duct from the bottom of the mouth to the underarm incision out of the mouth, and then re-attached the connecting tube, the anaesthetic machine control breathing (during the operation of the anaesthetic machine to stop ventilation time of about 30s), the trachea duct with stitches fixed (Figure 2) Figure 2 After the tone tube intubation (A) the underarm tube (B) In the process of making the jaw passage, avoid the important structure of the front and outer side of the mouth, such as the jaw gland catheter, the lower tongue gland, etc The whole intubation process went smoothly, the operation lasted 5h, completed the jaw fracture, double upper jaw fracture, double cheekbone fracture, nasal bone fracture cut-off reset internal fixation Intraoperative infusion 1500 ml, bleeding 50 ml, urine volume 450 ml The vital signs were stable, the blood pressure was maintained at 110 to 130/60 to 70mmHg, the heart rate was 55 to 75 times/min, and SpO2 remained 100% during the process of changing the trachea catheter ization pathway Arterial blood gas analysis: pH7.40, PO2 175mmHg, PCO2 40mmHg, BE-1mmol/L After the operation to suspend the anaesthetic machine, first remove the pipe far end of the trachea catheter, the trachea catheter far end and the trachea catheter cap sac inflatable tube from the bottom of the jaw back to the mouth, reattached the connecting tube after the anaesthetic machine mechanical ventilation, stitching the inner and outer jaw incision (Figure 3) After Figure 3 stitches the wound inside and outside the jaw, the trachea duct again pulls the out of the mouth
After the patient is awake and muscle strength is restored, remove the trachea duct through the mouth After the patient's sobriety follow-up patient recovered well, no complications, after the operation 10d successfully discharged from the hospital 2 Discussion jaw facial fracture surgery, through the mouth intubation of the jaw fracture reset, bite relationship to determine the inconvenience, the conventional take through the nasal trachea intubation of the whole hemp But if the fracture is affected by sieve sinuses, sieve plate caused by brain injury, cranial fracture, cerebrospinal fluid ear (nasal) leakage, nasal fracture with nasal compartment, sieve bone injury, nasal mucosa tear, hematoma, etc., all make the nasal trachea intubation caused difficulties, and nasal intubation can cause such patients nasal mucosis necrosis, aggravation or induced sinusitis, nasal hemorrhagic, nasal hemorrinis and other complications If the fracture of the skull is accompanied by a torn meninges, there is a risk of intracranial infection and gas intubation through the nasal trachea intubation, which often requires tracheotomy However, tracheotomy trauma is larger and complications are more, even if the micro-invasive transdermal dilated tracheotomy, there are bleeding, infection, injury and throat nerves, convection gas, airway stenosis, gas chest and scar left behind after the extraction of the tube affect the aesthetics and other complications, not accepted by some patients undercut path trachea intubation method introduced by Altemir 1986, the operation of the simple, less traumatic, avoid the nasal intubation and tracheotomy complications, avoid aggravation of brain injury, surgery can be not interfered with by the trachea tube to the fracture dislocation and bite relationship recovery, so as to improve the treatment effect of fracture This law is applicable to complex facial fractures, need to reset intra-reset fixation, inconvenience through the mouth or nasal intubation and refusal of tracheotomy, although the jaw fracture due to pain, chewing disorder and reflexostic spasms, fracture sciatica or jaw joint injury and other reasons to restrict the opening, but after intravenous induction, jaw fracture patients can increase the opening degree, most can be quickly induced to complete the tube tube patients in the assessment of no difficulty intubation, we use rapid sequential induction, because the patient's skull fracture, intracranial gas build-up, in order to prevent positive pressure mask ventilation so that the secretions and gases into the pharynx cavity into the cranial caused by retrograde infection, and even cause intracranial air pressure injury Compared with traditional tracheotomy, there are no important blood vessels and nerve walking in this area, loose tissue, this operation is simple, the amount of bleeding is small due to the small incision (about 1 cm) under the epidermis, so that the incision and trachea catheter diameter is similar, so that the catheter and the incision skin and muscles form friction fixed, coupled with suture fixation, the chance of catheter shift and accidental shedding during the procedure is very small The results of Schutz et al have shown that the complications of the undercut trachea intubation are lower than those of trachea, which can replace trachea incision to some extent Although the underarm intubation is slightly more than tracheotomy, it is a invasive operation that may cause bleeding, oral skin fistula, hypothal gland catheters and damage to the tongue nerve Hemp through the lower tube may cause obvious scarring under the jaw, under-mouth infection, nerve damage, mucus cysts and other complications taboo evidence is mainly: patient rejection, blood clotting abnormalities and jaw deformities The operation of establishing the lower path should pay attention to the following points: (1) underarm incision should avoid the nerve branch jaw edge branch; (2) intra-mouth incision should be done accurately at the end of the mouth mucous membrane and the transition between the tooth groove mucosa (i.e., between the lower endotherium and the tooth groove bone), cut the mucous membrane after the blunt separation mainly, to avoid injury and lower the utage of the tongue, and (3) from the underarm to the bottom of the mouth of the viscosis and should be given to the full bleeding and pressure after the removal of the hemorrhy , in addition, in order to prevent the trachea catheter from being crushed and twisted, it is necessary to apply a wire to strengthen the trachea duct, in order to better prevent the trachea catheter displacement, if necessary, can be stitched at the skin incision We combined intracranial gas from a multiple maxill facial fracture with a combination of intracranial gas, and at the same time refused trachea incision patients to use the undercut path trachea intubation, successfully completed jaw surgery and fracture reset intra-fixation This method is simple to operate, avoidthe inherent complications brought about by tracheotomy and airway management difficulties, to bring convenience to the operation of surgery, and is conducive to the rapid recovery of patients, worthy of clinical promotion and continuous improvement