maxillofacial trauma haemorrhage control dr ben rahmel maxillofacial registrar

Maxillofacial Trauma

Haemorrhage Control

Dr Ben RahmelMaxillofacial 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

Airway

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


• 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.


• 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

Manual Reduction


• 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


• 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

Rapid Rhino

Key Issues

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

Ongoing Bleeding

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. dilutional coagulopathy 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

Embolisation

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