HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of J Trauma. 2008; 65(5):994-999.

The Journal of TRAUMA Injury, Infection, and Critical Care

Management of Maxillofacial Injuries With Severe Oronasal Hemorrhage: A Multicenter Perspective Thomas H. Cogbill, MD, Clay C. Cothren, MD, Meghan K. Ahearn, BS, Daniel C. Cullinane, MD, Krista L. Kaups, MD, Thomas M. Scalea, MD, Lindsay Maggio, BS, Karen J. Brasel, MD, Paul B. Harrison, MD, Nirav Y. Patel, MD, Ernest E. Moore, MD, Gregory J. Jurkovich, MD, and Steven E. Ross, MD

Background: Airway establishment and hemorrhage control may be difficult to achieve in patients with massive oronasal bleeding from maxillofacial injuries. This study was formulated to develop effective algorithms for managing these challenging injuries. Methods: Trauma registries from nine trauma centers were queried over a 7-year period for injuries with abbreviated injury scale face > 3 and transfusion of > 3 units of blood within 24 hours. Patients in whom no significant bleeding was attributed to max- illofacial trauma were excluded. Patient demographics, injury severity measures, airway management, hemostatic proce- dures, and outcome were analyzed. Results: Ninety patients were identi- fied. Median injury severity scores for 60

87.5% of patients. Overall mortality rate was 24.4%, with 6 (7%) deaths directly attributable to maxillofacial injuries. Conclusions: Initial airway control was achieved by endotracheal intubation in most patients. Patients with penetrating wounds were more frequently taken di- rectly to the operating room for airway management and initial efforts at hemo- stasis. Patients with blunt trauma were much more likely to have associated inju- ries which affected treatment priorities. TAE was highly successful in controlling hemorrhage. Key Words: Maxillofacial trauma, Oronasal hemorrhage, Epistaxis, Facial fractures, Angioembolization.

blunt trauma patients was 34 versus 17 for 30 patients with penetrating wounds ( p < 0.05). Initial airway management was by endotracheal intubation in 72 (80%) pa- tients. Emergent cricothyrotomy and tra- cheostomy were necessary in 7 (8%) and 5 (6%) patients, respectively. Seventeen (57%) patients with penetrating wounds were taken directly to the operating room for airway control and initial efforts at hemostasis versus 12 (20%) patients with blunt trauma ( p < 0.05). Anterior or pos- terior or both packing alone controlled bleeding in only 29% of patients in whom it was used. Transarterial embolization (TAE) was used in 12 (40%) patients with penetrating injuries and 20 (33%) patients with blunt trauma. TAE was successful for definitive control of hemorrhage in

J Trauma. 2008;65:994 –999.

M ost maxillofacial injuries are not life threatening and are superseded in priority by associated injuries. De- finitive management of facial injuries is often de- layed for days while other more pressing injuries are treated. However, a relatively small number of maxillofacial injuries pose a formidable challenge during resuscitation due to dif- ficult airway management and massive hemorrhage. In a

series of 1,025 facial fracture patients, Tung et al. 1 described 17 (1.7%) patients who developed airway compromise re- quiring an emergency procedure to establish an airway and 10 (0.9%) patients in whom shock was caused by life-threatening hemorrhage from facial fractures. In another series of 912 patients with facial fractures, Bynoe et al. 2 reported the over- all incidence of life-threatening hemorrhage to be 1.2%; 5.5% in the subset of patients with Lefort II and III fractures. Ardekian et al. 3 reported severe bleeding in 4.5% of 222 patients with mid-face fractures. Shimoyama et al. 4 identified massive bleeding in 0.96% of 521 patients after mid-facial fractures. Options for airway management in this small, but chal- lenging group of patients include endotracheal intubation (ET), cricothyrotomy, and tracheostomy. Procedures avail- able to control life-threatening hemorrhage after maxillofa- cial trauma include anterior nasal packing, posterior nasal packing or balloon tamponade, emergent intermaxillary fix- ation (IMF), transarterial embolization (TAE), and operative control of bleeding by direct arterial ligation or “blind” liga- tion of the external carotid arteries. Several authors have proposed algorithms for the management of massive bleeding after maxillofacial trauma, but to date no consensus has been reached. 2–8 There remain proponents of packing and IMF as

Submitted for publication March 5, 2008. Accepted for publication June 26, 2008. Copyright © 2008 by Lippincott Williams & Wilkins

From the Department of Surgery (T.H.C., N.Y.P.), Gundersen Lutheran Medical Center, LaCrosse, Wisconsin; Denver Health Medical Center (C.C.C., E.E.M.), Denver, Colorado; Harborview Medical Center (M.K.A., G.J.J.), Seattle, Washington; Mayo Clinic (D.C.C.), Rochester, Minnesota; Community Regional Medical Center (K.L.K.), Fresno, California; R. Ad- ams Cowley Shock Trauma Center (T.M.S.), Baltimore, Maryland; Cooper University Hospital (L.M., S.E.R.), Camden, New Jersey; Froedert Memorial Lutheran Medical Center (K.J.B.), Milwaukee, Wisconsin; and Wesley Med- ical Center (P.B.H.), Wichita, Kansas. Presented at the 38th Annual Meeting of the Western Trauma Association, February 24–March 1, 2008, Squaw Creek, Olympic Valley, California. Address for reprints: Thomas H. Cogbill, MD, Department of Surgery, Gundersen Lutheran Medical Center, 1836 South Avenue, La Crosse, WI 54601; email: THCogbil@gundluth.org. DOI: 10.1097/TA.0b013e318184ce12

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