In-Patient Dental Anesthesia Major oral and fasciomaxillary surgery Classifications:  Major Orthognathic Surgery (late teenage& adults)  Tumor surgery (elderly)  Palate Surgery (infants&children)

In-Patient Dental Anesthesia Problems:  Major problem: Airway Management  Extensive, long operations  Significant blood loss  Poor nutritional status  Micro-vascular surgery

In-Patient Dental Anesthesia Airway Management IMPORTANT POINTS  NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED  RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION  FULL RANGE EF DIFICULT INTUBATION EQUIPMENT MUST BE AVAILABLE

In-Patient Dental Anesthesia Airway Management Choice of the technique depends on several factors:  Patient safety  Experience of the anesthetist  Known difficult airway  Requirements: nasal or oral  Post operative jaw wiring

Emergency Maxillofacial Surgery Maxillofacial Trauma

Types of Injury  Fasciomaxillary Injury Accompanied injury  Neck Injury  Cervical Spine Injury  Head Injury  Closed Head Injury & Cervical Spine Injury

Fasciomaxillary Injury  One third of causalities  Maxilla is the most common(24%)  Followed by the mandible (18%)  Most maxillary fractures are compound comminuted Types Le Forte I: Transverse Fracture Le Forte II Pyramidal Fracture Le Forte III: Craniofacial Fracture

Neck Injury  10% are accompanied by carotid artery injuries  Presented with either severe hematoma or expanding neck hematoma  Symptoms Dysphagia Constant cough Hemoptysis Inspiratory stridor Hoarseness of voice Subcutaneous Emphysema  Types Open Trauma Closed Trauma

Cervical Spine, Spinal Cord Injury  Should always be considered  Involvement of C7 (or oedema of near by cervical spines)  Significant Hemodynamic Instability  Significant Respiratory Distress

Head Injury  17.5% with facial fractures (10% severe)  Early recognition  Loss of consciousness  Glascow Coma Scale  Secondary brain insult

Pre- Anesthetic Assessment Problems  Airway Obstruction (early tracheostomy is not universal)  Difficult Intubations  Unstable Cervical Spine  AcuteAirway Problems: Aspired teeth Oral bleeding Trismus Epistaxis Nasal CSF leakage

Pre- Anesthetic Assessment Problems  Blood loss in excess of patient blood volume  Full Stomach ( blood, debris, delayed emptying)  Large Air leaks, Risk of subcutaneous emphysema, pneumothorax

Pre- Anesthetic Assessment Problems  CSF leaks with constant risk of meningitis  Increased ICP with secondary brain insult  Presence of co-existing disease (ASA)  Existing drug or alcohol intoxication

Anesthetic management I) Specific Management  Facial Trauma  Facial Trauma with Closed Head Injury  Facial Trauma with Spinal Cord Injury  Facial Trauma and Neck Injury II) General III) Airway

Anesthetic management Specific Management : Facial Trauma All facial traumas must be Suspected for IC and Spinal injuries Airway  Hold tongue, head down, turned one side  Nasopharyngeal airway (I&CI)  Throat pack  Scissors or wire cutter

Anesthetic management Specific Management: Facial Trauma with closed head injury Reduction of ICP is the Main Goal  Not a situation for blind nasal  Head elevation 20 o –30 o  Control body temperature  Prophylactic phenytoin  Avoid hypervolemia and hypotonic fluids  Avoid hypoglycemia and hyperglycemia

Anesthetic management Specific Management: Facial Trauma with spinal cord injury  Not a situation for blind nasal  ET intubation (technique)  Respiratory dysfunction (up to 3 weeks)  Spinal shock

Anesthetic management Specific Management: Facial Trauma with neck Injury Airway Secure then control hemorrhage Airway  ETT through the wound  Awake orotracheal intubation  Avoid MR in uncertain airway Respiration ( Risk of pneumothorax)  Avoid IPPV  Avoid nitrous oxide  Avoid sedation Hypovolemia

Anesthetic management General Management  IV lines, Urinary catheters, stomach tubes  Monitors  Measure to reduce ICP  Fluid therapy and replacement therapy  FIO 2 should be at maximum  Premedication  Anticholinergics  Avoid premedication  Heavy premedication

Anesthetic management General Management Important Points  Airway must be a priority (secondary brain insult)  Excitement is a sign of hypoxia rather than pain  Accidental extubation is a well recognized hazards

Anesthetic management General Management Important Points  Decreasing level of consciousness is a reliable sign of head injury  Major surgery may be delayed until the patient’s neurological conditions has established  Important to differentiate between blood and CSF  Consider all patient full stomach

Anesthetic management Airway  CHRACTERISTICS  TECHNIQUE (algorism)  Awake vs. anesthetized  Nasotracheal vs. Orotracheal  Blind vs. Visual  Direct vs. Fiberoptic  Antegrade vs. Retrograde  Tracheostomy, Cricothyrotomy  Transtracheal Jet Ventilation

Anesthetic management Airway : CHRACTERISTICS  Dynamic not static  All hypoxic  All full stomach  Unique optimum position for the airway (semi prone, sitting up, leaning forward)

Anesthetic management Airway : Technique Is there a possibility of concurrent basal skull fracture? Nasotracheal intubation is absolute contraindication

Anesthetic management Airway : Technique Is there a possibility of injury of cervical spine?  Manual in line axial traction  Bullard laryngoscope (It matches anatomy not to align the airway to match the blade)

Open the Airway E ndotracheal Intubation “Aligning Axes of the Airway”

Open the Airway E ndotracheal Intubation “ Laryngoscopes ”

Anesthetic management Airway : Technique Is the patient is unable to open his mouth? Why?  Reflex spasm (I.e.Trismus) ( Anesthesia may relief the spasm)  Mechanical dysfunction (i.e.TMJ) (Blind nasal intubation or Fiberoptic intubation)  Bimandibular fracture at the level of second or first molar

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