Maxillofacial Trauma Haemorrhage Control Dr Ben Rahmel Maxillofacial Registrar
Maxillofacial Haemorrhage • ATLS Principles • Acute concerns: • Airway care • Control of profuse bleeding • Vision threatening injuries • C-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.
Airway • In the acute setting use an oral tube • Allows access for oral and nasal packing • Subsequent tracheostomy or submental intubation
Sitting up • This 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 Haemorrhage • Bleeding following facial trauma may be either revealed or concealed • In major midface and panfacial injuries blood loss can quickly become significant • In these patients, blood loss is usually from multiple sites along the fracture planes and from associated soft tissues, rather than from a named vessel • This makes control of bleeding difficult.
Maxillofacial Haemorrhage • Direct pressure, clips and sutures may all be used to control obvious external bleeding • When displaced midface fractures are present, manual reduction not only improves the airway, but is frequently effective in controlling blood loss from the fracture sites
Maxillofacial Haemorrhage • Once reduced oral packing (or a mouth prop) can be used to support the reduction • Multiple throat packs or vaginal packs can be used to pack the oral cavity
Maxillofacial Haemorrhage • Epistaxis, 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 cases • Urinary catheters can be passed and wedged into the post-nasal space for posterior bleeding
Key Issues • The nasal passage goes straight back not up • Judgement 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 Issues • With unstable midfacial fractures - inflation of the balloons may displace the fractures thereby increasing blood loss. • Temporary stabilisation of the reduced fractures prior to inflation • Pack the oral cavity prior to packing the nasal cavity • Often mandibular fractures require surgical stabilisation
Coagulopathies • In the presence of persistent haemorrhage, despite appropriate interventions, remember to consider coagulation abnormalities • Pre-existing (haemophilia, chronic liver disease, Warfarin therapy), • Acquired (e.g. dilutionalcoagulopathy from blood loss, or DIC).
Embolisation • Effective alternative to surgical ligation in life-threatening facial haemorrhage • Catheter-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
Surgical Intervention • If bleeding continues despite reduction of facial fractures and packing • Ligation of the external carotid, and ethmoidal, arteries, via the neck and orbit, respectively should be considered • Extensive collateral supply exists so ligation may not work or may be necessary on both sides