Lateral Canthotomy

Lateral Canthotomy &
cantholysis
PHEMC 1st Oct 2014
Will Sargent & Prakash Patel
ED Consultant/ Maxillofacial Surgery Registrar
Royal Darwin Hospital
Indications
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Orbital compartment syndrome:
- Acute facial trauma with retrobulbar haemorrhage
Recent retrobulbar anaesthesia
Eyelid surgery
Infection
Intra- ocular emphysema
• Compromises opthalmic artery
•  optic nerve and central retinal artery are compressed =
ischaemia
• - visual loss within 90 minutes
• *** OCULAR EMERGENCY ***
Indications
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Pain
Acute decrease in visual acuity/ visual loss
Proptosis
Diplopia
Dilated pupil
Increased intra-ocular pressure (>40 mm Hg, Normal 10- 21mm
Hg)
• Afferent pupillary defect
• Decreased ability to differentiate red shades
• Chemosis
• Ecchymosis around eye
• *bold = absolute indications for canthotomy
Contraindication
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Globe rupture
- hyphema
- peaked/ tear drop shaped pupil
- irregular pupil
Exposed uveal tissue (red- brown)
Restriction in range of movement that is
greatest in direction of rupture
Don’t wait for a CT!!!
Ocular emergency requiring immediate management
Periorbital soft tissues
Lateral canthal ligament
Complications
• Irreversible vision loss can occur if retina ischemia
time is greater than 90-120 minutes.
• Iatrogenic globe injury by forceps or scissor tips
• Ptosis due to damage to the levator aponeurosis,
• Injury to the lacrimal gland and lacrimal artery,
which also lie superiorly.
• Bleeding
• Infection.
• Ectropion
Mandibular Blocks
- An extra- oral approach
PHEMC 1st Oct 2014
Prakash Patel
Maxillofacial Surgery Registrar
Royal Darwin Hospital
ED Indications
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Trauma (e.g. fractured mandible)
Facial pain/ odontogenic pain
Infection
Inability to open mouth
Tongue lacerations
Anatomy- V3
Anatomy- Maxillary Artery
Anatomy
Landmarks:
1) Zygomatic
arch
2) Condyle of
mandible
Target zone:
Just superior to
sigmoid notch
Technique
Technique
• Palpate bony landmarks
• Prepare local anesthetic and equipment (30mm blue
23 gauge needle)
• Prep skin with alcohol swab/ chlorhexidine
• Inject perpendicular to skin ~ 1 thumb width below
zygomatic arch & anterior to mandibular condyle
• Aim to touch bone at superior aspect of sigmoid notch
• Pass needle just superior to sigmoid notch,
• Inject the needle all the way to its hub
• Aspirate
• Inject 5-10 ml of local anesthetic (usually 0.25%
marcaine w. adrenaline for 6-8 hrs of anaesthesia)
Nasopharyngeal packing workshop – Oct conference ED
Key Points:
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Small no. of pts present with severe facial haemorrhage – can exsanguinate if not controlled
High likelihood of associated internal head / neck trauma
Need to Take the airway first before packing
Try Anterior packing first – reassess – then posterior packing if not controlled
Involve Max Fac early - ? emergency OT or angiography
Injuries: - Mostly blunt injuries
1) Facial injuries associated with other serious inj (Taumatic brain inj, C-spine #, Airway
obstruction, Pulmonary contusion, Aspiration )
2) Types of facial injuries
a. Mid Facial # (la fort I - III)
b. Mandibular#
c. TMJ disruption
d. Zygomatic, nasal, orbital #
e. Soft tissue injury and oedema
f. Haemorrhage
g. Associated – Base of skull #, Traumatic Brain inj, C-spine #, carotid inj
La Fort # - like crumple zones – Nasal cavity, para-nasal sinuses, orbits act as a series of
compartments and progressively collapse and absorb energy to protect brain and cord.
I
II
III
1) I – (horizontal ) involves maxilla at the level of the nasal fossa, horizontal plane at the level of
nose – palate-facial separation
2) II – (triangular) involves maxilla, nasal bones, and medial aspects of orbits – freely mobile
pyramidal shaped portion of maxilla
3) III – (transverse)# line runs parallel with the base of skull – upper nasal bridge, most of orbit
and zygomatic arches (ethmoid bone and cribiform plate BOS #) – cranio-facial dissociation
Signs: Gross edema of soft tissue over the middle third of the face, bilateral circumorbital
ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity,
diplopia, enophthalmos, cracked pot sound – mobile midface for II and III
Management:
1) Resuscitate – ABCDE principals
2) Assess and take the Airway – always assume it’s difficult
a. Surgical (cricothryriodotmy / tracheostomy req) – prep
i. ENT / Anaesthetics – prep neck for surg
ii. CMAC with 2 suckers, or mec asp on ETT
3) Stop / Arrest the bleeding
a. Anterior packing (Rapid rhino)
b. Posterior packing (foleys / or Nasal tampon)
c. Gentle forward traction
d. Angiography (internal Maxillary artery, ethmoids)
e. ? TXA
f. Wire reduction of palatal # - Max Fac
4) Involve Max Fac early – Re Emergent surgical intervention
5) Secondary considerations (Wash wounds, ADT, Antibiotics)
6) Imaging – CTA - ? Intracranial inj, ? base of skull #, ? spinal inj, ? carotid / vertebral arteries
Packing process - What you need:
Nerves of steel!!
1) Intubated (mouth or neck), sedated pt with secure airway!! (can’t do this without first
dealing with the A)
2) Laryngoscope - ? easier with CMAC
3) Suction available
4) 2 X Foley catheters 12-14 Fr ?? (bigger is easier)
5) Lube for your foleys
6) 20Mls syringe with N saline
7) 2 X large gynae tampons (compressed to matchbox size)
8) 1.0/2.0 silk suture material
9) 2 x rapid rhinos for anterior nasal packing
10) Ability to provide gentle traction on the catheters after insertion
Method –
1) Intubate and sedate pt with the help of Anaesthetic or ENT colleagues – call Max Fac
2) Lube your Two x Fr 14 foleys, and tie your large gynae tampon with 2.0 silk in the middle
3) Under direct vision (with laryngoscope) – pass both foleys into each nare along the floor on
the nose – watch passage into oro-pharynx
4) Retrieve through the mouth with magils forceps
5) Tie tampon to the end of the foleys (through the eyes) with the 2.0 silk (match box size)
6) Guide the tampon into the posterior oro-pharnx with you index finger (someone needs to
support your airway to prevent dislodgment)
7) Gentle traction on the foleys from the nose to pull the nasal tampon into place and digital
pressure through the mouth
8) ? inflate the foleys balloons with 6-10mls N saline
9) Insert 2 rapid rhinos into the medial anterior naso-pharynx for ant packing in normal way
(soak in water – then insert along floor of nose, inflate with air)
10) Apply Gentle traction (counter traction by tying to additional Ext tampon as a bolster)
11) Re-assess mouth for continued bleeding
12) High Fives all round – can leave for 48-72hrs (? Antibiotic cover)
Consider other haemostatic parameters – Clotting factors, Keep warm, PH, Calcium
Complications:
1) Pressure necrosis from packs
2) Dislodgement of airway if intubated orally
3) FB placed in Mouth and nose – label well and document
Airway issues:
Take the airway!! – multiple approaches
Why airway compromise / difficult airway:
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Posterio-inferior displacement of maxilla – block nasopharynx
# teeth, bone fragments, vomitus, blood, FB – airway obstruction
Haemorrhage
Soft tissue swelling and oedema
Aspiration risk
C-spine immobilisation
Poorly defined anatomy / deformity / debris
Difficult BMV and mask seal
If Pt is breathing – Allow the pt to breath spontaneously until optimal conditions are available
(ENT/Anaos)
Options:
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RSI with direct laryngoscopy or video-laryngoscopy
Cricothyrotomy / awake tracheostomy
Awake fiberoptic intubation
Awake laryngoscopy
Supraglottic airways – LMA or ILMA
Dirrect Laryngoscopy techniques
Suction as you go ETT setup – ETT attached to Mec aspirator and suction
Partner suction with CMAC – 4 people required (team effort – co-ordinated visualisation of
the glottis)
1 person doing video laryngoscope – CMAC
1 person (left of intubator) – welding a yanker and looking at screen
1 person (right of intubator) - welding a yanker and looking at screen
4th person setting up for a surgical airway – (getting kit ready and prepping neck
Periarrest – RSI - Dirrect laryngoscopy with CMAC, LMA backup with Surgical airway if CICO
Stable – Resus or OT – with Anaos – awake fibreoptic – with ENT surgical back up
Useful references –
1) Lifeinthefastlane – Airway issues in facial trauma / facial trauma
2) EMcrit pod cast 110 – exsanguinating haemorrhage from mid-face fractures
3) Handbook of trauma care – Liverpool hospital trauma manual