Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. May 15, 2019 • Volume 12 • Number 10 cases-anesthesia-analgesia.org 369 Copyright © 2018 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000932 C raniofacial stab injuries also are described as Jael syndrome, which is a biblical reference to Jael killing Sisera. 1,2 Those injuries may cause extensive hemor- rhage and airway obstruction making mask ventilation and endotracheal intubation diffcult or even impossible. 3–7 We present the case of a patient with a maxillofacial stab injury through the left orbit with the knife tip in close proximity to the left internal carotid artery without any apparent vas- cular or neural injuries. The most challenging aspect of the patient’s management was to prevent coughing and any knife and/or head movement during intubation to avoid internal carotid artery injury. Written patient consent was obtained for this publication. CASE REPORT An 18-year-old man was admitted to the emergency room with a knife lodged into the left lower eyelid region. He was conscious and neurologically intact. The airway was not compromised, and minimal bleeding from the left maxil- lary sinus was noted. The patient was sedated with fentanyl (1 μg/kg IV bolus) and midazolam (total IV dose of 5 mg) in the emergency room, underwent initial evaluation and imaging, and subsequently was taken to the interventional neuroradiology suite. Because the knife handle had broken off during the assault, it did not impede access to the patient’s airway (Figure A). Initial plain flms confrmed the trajectory of the knife from the orbit along the skull base (Figure B). Computed tomography demonstrated the course of the blade at its entrance into the left orbit and maxillary sinus, with its tip nearing the skull base. Subsequent arteriography confrmed the tip to be in close proximity of the left inter- nal carotid artery with no injury to other large neck or skull base vessels (Figure C). We noticed no other abnormalities, such as intracranial involvement, skull base, or ocular globe hematoma. Mask ventilation was complicated because of the prox- imity of the retained knife blade and also carried a high risk of internal carotid artery injury in the event the knife moved. We used a rigid cervical collar and taped the head to the table to minimize any movement. To prepare the patient for awake nasal fberoptic intubation, we used intravenous glycopyrrolate (total dose of 0.2 mg) and topical anesthesia of the nasopharynx—5 mL of lidocaine 2% (20 mg/mL) with epinephrine (1:100,000)—applied by nasal atomizer. We subsequently lubricated the right nostril with lido- caine gel and serially dilated it with nasal trumpets of increasing size. Afterward, we inserted the fexible fber- optic bronchoscope loaded with the 7.0 endotracheal tube, passed it through the nasopharynx, and held it superior to the vocal cords to prevent refex cough. At this point, we applied cricoid pressure and administered induction doses of fentanyl (1 μg/kg IV bolus), propofol (2 mg/kg IV bolus), and rocuronium (1 mg/kg IV bolus). As soon as patient was paralyzed, we passed the bronchoscope through the vocal cords and positioned the endotracheal tube above the carina. The patient remained immobile throughout the pro- cedure. General anesthesia was maintained with a mixture of oxygen (2 L/min) and sevofurane (1.8%) combined with a continuous propofol infusion (50 μg/kg/min). Thereafter, the interventional neuroradiology team placed endovascular balloons distal and proximal to the point of the potential blade tip injury to the left internal carotid artery to perform a temporary occlusion if massive bleeding was encountered. The knife was removed through the entrance wound, and superfcial blood vessels were cauterized after that. Immediate postsurgical angiography did not show any signs of development of hematomas. The eyelid laceration was primarily closed, and the patient then was extubated after emergence from anesthesia. He was clinically stable and demonstrated intact face movements with no apparent neurological defcits, visual acuity loss, or ocular motility problems. He was observed in the neuro- intensive care unit overnight and transferred to the ward A patient presented with a stab injury caused by a knife penetrating the orbital foor and maxil- lary sinus along the skull base with the tip situated adjacent to the left internal carotid artery. A fexible fberoptic bronchoscope loaded with an endotracheal tube was initially positioned superior to the vocal cords and advanced into the trachea immediately following induction. The blade was removed after occluding endovascular balloons were positioned distal and proximal to the potential internal carotid artery injury site. Therefore, contralateral nasal fberoptic intuba- tion might be safely performed in patients with unilateral maxillofacial trauma, no intracranial penetration, and minimal bleeding. (A&A Practice. 2019;12:369–71.) From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; †Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois; ‡Department of Anesthesiology, Reanimatology and Intensive Care Medicine, Varaždin General Hospital, Varaždin, Croatia; and §Department of Neurology, Medical College of Wis- consin, Milwaukee, Wisconsin. Accepted for publication October 29, 2018. Funding: None. The authors declare no conficts of interest. Address correspondence to Vicko Gluncic, MD, PhD, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave, Chicago, IL 60657. Address e-mail to vicko.gluncic@gmail.com. Anesthetic Management of Jael Syndrome With Impacted Blade in Close Proximity to the Internal Carotid Artery: A Case Report Vicko Gluncic, MD, PhD,*† Anita Lukić, MD, PhD,‡ Eva Hanko, MD,* and John Lynch, MD§ CASE REPORT E