Sevoflurane mask anesthesia for urgent tracheostomy in an uncooperative trauma patient with a difficult airway

Purpose: Proper care of the trauma patient often includes tracheal intubati on to insure adequate ventilation and oxygenation, protect the airway from aspiration, and facilitate surgery. Airway management can be particularly c omplex when there are facial bone fractures, head injury and cervical spine instability. Clinical Features: A 29-yr-old intoxicated woman suffered a motor vehicle a ccident. Injuries consisted of multiple abrasions to her head, forehead, an d face, right temporal lobe hemorrhage, and complex mandibular fractures wi th displacement. Mouth opening was < 10 mm. Blood pressure was 106/71 mmHg, pulse 109, respirations 18, temperature 37.3 degrees C, SpO(2) 100%. Chest and pelvic radiographs were normal and the there was increased anterior an gulation of C4-C5 on the cervical spine film. Drug screen was positive for cocaine and alcohol. The initial plan was to perform awake tracheostomy wit h local anesthesia, However, the patient was uncooperative despite sedation and infiltration of local anesthesia. Sevoflurane, 1%, inspired in oxygen 100%, was administered via face mask. The concentration of sevoflurane was gradually increased to 4%, and loss of consciousness occurred within one mi nute. The patient breathed spontaneously and required gentle chin lift and jaw thrust. A cuffed tracheostomy tube was surgically inserted without comp lication. Blood gas showed pH 7.40, PCO2 35 mmHg, PO2 396 mmHg, hematocrit 33.6%. Diagnostic peritoneal lavage was negative. Pulmonary aspiration did not occur. Oxygenation and ventilation were maintained throughout the proce dure. Conclusion: Continuous mask Ventilation with sevoflurane is an appropriate technique when confronted with an uncooperative trauma patient with a diffi cult airway.