Tag Archives: Weird trauma

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WTF? Submental Intubation? (Best Of)

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By request, I’m republishing this interesting post.

Here’s one of the weirder procedures I’ve seen in some time. Imagine that you need a definitive airway, but you can’t use the face for some reason (mouth or nose). The usual choice would be a tracheostomy, right? But what if you only need it for a few days? Typically, once placed, trachs must be kept for several weeks before decannulation is safe.

Enter submental intubation. This technique involves passing an endotracheal tube through the anterior floor of the mouth, and then down the airway. This leaves the facial bones, mandible, and skull base untouched.

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The technique is straightforward. After initially intubating the patient  orotracheally, a 1.5cm incision is created just off the midline in the submental area. Using a hemostat, all layers are penetrated, entering the oropharynx just lateral to the tongue. A 1.5cm incision is then made parallel to the gum line of the lower teeth. The connector at the proximal end of the endotracheal tube is removed, and a hemostat is placed through the chin incision again. The proximal end of the ET tube is grasped from within the pharynx and pulled out through the skin, leaving the distal (balloon) end in the trachea. The connector is reinserted, and the tube is then hooked up to the anesthesia circuit again. The tube is secured using a stitch under the chin. After a final position check, the surgical procedure can commence.

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There are a number of variations on this technique, so you may encounter slightly different descriptions. The tube can be pulled at the end of the procedure, or left for a few days to ensure safe extubation, if needed.

A small series of 10 patients undergoing this technique was reviewed, and there were no short or long term problems. Scarring under the chin was acceptable, and was probably less noticeable than a trach scar.

Bottom line: This is a unique and creative method for intubating patients with very short-term airway needs while their facial fractures are being fixed. Brilliant idea!

Reference: Submental intubation in patients with panfacial fractures: a prospective study. Indian J Anaesth 55(3):299-304, 2011.

Photo source: internet

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Explain This! The Answer

This patient was running from an assailant at top speed and fell, tumbling for several feet. Medics found him in this position and pondered how to secure him for transport. eventually they just used straps and belts to hold him on a backboard.

The injury is an interesting one. He has a femur fracture, but there is a twist (literally). If he was a contortionist and had found a way to bend his knee toward his head, his toes would point to his face. If you look at the thigh, twisted muscle bellies can be seen.

The diagnosis is a mid-shaft femur fracture with a 180 degree rotation of the distal portion.

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Weird Trauma: Pruning Shears to the Head and Neck

This case made the national news yesterday, and I wanted to make a few comments on the ideal management of this type of injury.

An 86 year old Arizona man was trimming plants in his back yard and fell on his pruning shears. One of the handle grips pushed into his orbit and through his pharynx into his neck. How do you think through something like this?

First, always check vital signs. If the patient is hypotensive, they must go to the operating room. Even if vital signs are stable, ongoing bleeding necessitates an operation before anything else.

If vital signs are stable, then a road map showing vial structures is essential. The patient should be taken to CT so the exact position of the object can be determined. Any involved structures (carotid artery, esophagus) can be identified and a proper plan can be developed. 

Then and only then can a stable patient be taken to the OR. Appropriate incisions should be placed so that key portions of the foreign object can be viewed as they are removed. In this case, incisions were made under his lip and into the maxillary sinus wall to monitor the removal process. The carotid artery had been cleared by CT. Once removed, any remaining bleeding can be addressed. 

A final point: any problem like this that has the potential to involve the airway requires that a skilled anesthesiologist be present with appropriate airway management equipment, and the surgeon needs to have all equipment ready to place a tracheostomy on short notice.

This patient did well after removal and was treated with about 3 weeks of antibiotics for his sinus injuries. His inferior orbital wall was rebuilt, and overall he did well postoperatively. He is seriously reconsidering doing any gardening again.