- Radiologic results are crucial to discern anatomic distortion and airway integrity.
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- Limited mouth opening and accumulated blood, secretions, and foreign bodies can all obscure visualization and compromise DL, VAL, and FSI.
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- Perform awake intubation if patient is cooperative, stable, and able to clear airway; this will maintain both spontaneous ventilation and O2 saturation.
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- If awake, intubation fails, airway compromise occurs or the patient is agitated, an awake tracheostomy may be the best approach.
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- BVM ventilation may be difficult and result in displacement of facial fractures or even airway compromise.
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- Blind intubation (oral and nasal) is discouraged: It may dislodge foreign bodies (teeth, bony fragments, blood clot) into the airway or create a false passage. Blind nasal attempts in the setting of midface fracture may lead to violation of the cranial vault.
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- Nasal intubation is not contraindicated in a patient with lateral or posterior skull base fractures; FSI could be safely performed even if the fracture occurred in the central anterior skull base. Risk versus benefit discussion for choosing nasal route for intubation should be documented in a patient's record.
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- If initial oral intubation interferes with the surgical approach, it can be converted later to submental or nasal intubation.
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