OTHER TRAUMATIC INJURIES

Head and Neck Surgery (also see Chapter 65 )

With the exception of emergency exploration of penetrating trauma to zone II of the neck (from the clavicles up to the angle of the mandible), most surgical repair of head and neck trauma will occur in the subacute phase after complete resuscitation and secondary diagnostic studies. Anesthetic management of these patients is not substantially different from similar elective procedures, although coexisting injuries may influence patient positioning and ventilator settings. Surgery on the mandible and maxilla will be facilitated by nasotracheal intubation, although the anesthesiologist should not jeopardize a secure airway by attempting to switch from an oral to a nasal tube in a patient in whom visualization of the larynx might be difficult because of traumatic swelling or body habitus. It is safer in these cases for the surgeon to either work around an oral tube secured behind the second molar (to allow dental occlusion) or place a tracheostomy if the need for intubation and mechanical ventilation is likely to be protracted. Securing the endotracheal tube to the molar with a fine-gauge wire will help stabilize it through the operation. Surgery on the zygoma and the nasal, orbital, and ethmoid bones will be possible with an oral endotracheal tube. All these surgeries will lead to significant soft tissue swelling in the immediate postoperative period, often necessitating several days of continued intubation and sedation until sufficient venous drainage has occurred to allow safe extubation.