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Maxillofacial Trauma

Maxillofacial Trauma

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Maxillofacial Trauma

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  1. Maxillofacial Trauma Haemorrhage Control Dr Ben Rahmel Maxillofacial Registrar

  2. Maxillofacial Haemorrhage • ATLS Principles • Acute concerns: • Airway care • Control of profuse bleeding • Vision threatening injuries • C-spine

  3. 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.

  4. Airway • In the acute setting use an oral tube • Allows access for oral and nasal packing • Subsequent tracheostomy or submental intubation

  5. Airway

  6. Airway

  7. 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

  8. 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.

  9. 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

  10. Manual Reduction

  11. 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

  12. 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

  13. Rapid Rhino

  14. Key Issues

  15. 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

  16. 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

  17. Ongoing Bleeding

  18. 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).

  19. 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

  20. Embolisation

  21. Embolisation

  22. 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

  23. Maxillofacial Haemorrhage

  24. Maxillofacial Haemorrhage

  25. Maxillofacial Haemorrhage

  26. Maxillofacial Haemorrhage