Maxillofacial TraumaHaemorrhage Control

Dr Ben RahmelMaxillofacial Registrar

Maxillofacial HaemorrhageATLS PrinciplesAcute concerns:Airway careControl of profuse bleedingVision threatening injuriesC-spine

Airway The potential for obstruction is present in almost all patients with significant facial injuries, due to pooling of blood and secretions in the pharynx, especially when supine.In most conscious patients this is simply swallowed but will collect in the stomach. However, with midface fractures, particularly fractures of the mandible, swallowing may be painful and less effective in clearing the airway.

AirwayIn the acute setting use an oral tube Allows access for oral and nasal packingSubsequent tracheostomy or submental intubation

Airway

Airway

Sitting upThis may indicate a desire to vomit, or unrecognised partial airway obstruction from swelling, loss of tongue support, or bleeding. Patients may try to sit forwards and drool, thereby allowing blood and secretions to drain

Maxillofacial HaemorrhageBleeding following facial trauma may be either revealed or concealedIn major midface and panfacial injuries blood loss can quickly become significantIn these patients, blood loss is usually from multiple sites along the fracture planes and from associated soft tissues, rather than from a named vesselThis makes control of bleeding difficult.

Maxillofacial HaemorrhageDirect pressure, clips and sutures may all be used to control obvious external bleedingWhen displaced midface fractures are present, manual reduction not only improves the airway, but is frequently effective in controlling blood loss from the fracture sites

Manual Reduction

Maxillofacial HaemorrhageOnce reduced oral packing (or a mouth prop) can be used to support the reductionMultiple throat packs or vaginal packs can be used to pack the oral cavity

Maxillofacial HaemorrhageEpistaxis, either in isolation or associated with midface fractures may be controlled using a variety of nasal balloons, or packs. Rapid rhino packs provide effective haemostasis in most casesUrinary catheters can be passed and wedged into the post-nasal space for posterior bleeding

Rapid Rhino

Key Issues

Key IssuesThe nasal passage goes straight back not upJudgement is required with pan facial injuries due to the risk of cranial intubation. In patients with profuse haemorrhage a risk/benefit analysis is needed

Key IssuesWith unstable midfacial fractures - inflation of the balloons may displace the fractures thereby increasing blood loss. Temporary stabilisation of the reduced fractures prior to inflationPack the oral cavity prior to packing the nasal cavityOften mandibular fractures require surgical stabilisation

Ongoing Bleeding

CoagulopathiesIn the presence of persistent haemorrhage, despite appropriate interventions, remember to consider coagulation abnormalitiesPre-existing (haemophilia, chronic liver disease, Warfarin therapy),Acquired (e.g. dilutional coagulopathy from blood loss, or DIC).

EmbolisationEffective alternative to surgical ligation in life-threatening facial haemorrhageCatheter-guided angiography followed by embolisation involving: balloons, stents, coils, or chemicals.Supra-selective embolisation can be performed without the need for a general anaesthetic and, in experienced hands, is relatively quick

Embolisation

Embolisation

Surgical InterventionIf bleeding continues despite reduction of facial fractures and packingLigation of the external carotid, and ethmoidal, arteries, via the neck and orbit, respectively should be consideredExtensive collateral supply exists so ligation may not work or may be necessary on both sides

Maxillofacial Haemorrhage

Maxillofacial Haemorrhage

Maxillofacial Haemorrhage

Maxillofacial Haemorrhage