HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Maxillofacial Injuries With Severe Hemorrhage

extremely effective in hemorrhage control. 3,4 Others promul- gate TAE as a more definitive method of achieving hemostasis. 2,6–9 Each of these studies suffers from relatively small numbers of patients with life-threatening hemorrhage, and few studies have investigated both blunt and penetrating trauma. The collective experience of nine contemporary trauma centers with access to each of the above treatment modalities was reviewed to determine the success, failure, and complication rates of these procedures, and to propose more rational algorithms for management of maxillofacial trauma with severe oronasal hemorrhage. MATERIALS AND METHODS This multicenter review involved nine Western Trauma Association participating institutions: Gundersen Lutheran Medical Center, La Crosse, WI; Denver Health Medical Cen- ter, Denver, CO; Harborview Medical Center, Seattle, WA; Mayo Clinic, Rochester, MN; Community Regional Medical Center, Fresno, CA; R. Adams Cowley Shock Trauma Cen- ter, Baltimore, MD; Cooper University Hospital, Camden, NJ; Froedert Memorial Lutheran Medical Center, Milwaukee, WI; and Wesley Medical Center, Wichita, KS. Trauma registries at all institutions were queried for patients treated from January 1, 1999 through December 31, 2005 for blunt and penetrating injuries with abbreviated in- jury scale face 3 and transfusion of 3 units of packed red blood cells within 24 hours of admission. Patients in whom there was no significant bleeding from the maxillofacial in- juries were excluded from analysis. Also excluded were pa- tients with overwhelming associated injuries managed with comfort care measures only. Patient demographics, injury severity measures, physiologic parameters, methods of airway management, hemostatic maneuvers, and outcome were ana- lyzed. Comparisons of continuous variables were made using Student’s t test or Wilcoxons rank sum test, and comparisons of discontinuous variables were made using 2 analysis or Fisher’s exact test when appropriate. Level of confidence was defined as p 0.05. RESULTS Ninety-four patients were identified from the trauma registries at the nine participating institutions. Four patients with massive-associated brain injuries managed with comfort care measures alone were excluded from the analysis. The remaining 90 patients comprised the study group. There were 67 (74%) men and 23 (26%) women. Ages ranged from 15 years to 89 years (median, 36 years). There were 60 (67%) blunt mechanisms of injury and 30 (33%) penetrating wounds (Table 1). Injury severity scores ranged from 13 to 50 (median, 34) in patients with blunt trauma versus 9 to 75 (median, 17) after penetrating wounds ( p 0.001) (Table 2). Associated injuries after blunt trauma in- volved the head in 53 (88%), spine in 14 (23%), chest in 35 (58%), abdomen in 16 (27%), pelvis in 8 (13%), and extrem- ities in 26 (43%). Penetrating wounds were isolated to the

Table 1 Mechanisms of Injury for 90 Patients With Severe Hemorrhage Associated With Maxillofacial Trauma Blunt 60 (67%) Motor vehicle crash 31 Auto or pedestrian 8 Agricultural accident 4 Fall 3 Explosion 3 Motorcycle crash 2 Industrial accident 2 Miscellaneous 7 Penetrating 30 (33%) Gunshot wound 22 Shotgun wound 6 Axe wound 1 Miscellaneous 1

Table 2 Comparison of Patients With Maxillofacial Trauma From Blunt Versus Penetrating Injury Mechanisms

Blunt (n 60)

Penetrating (n 30) 35 (15–65) 8 (0–26) 17 (9–75) 5 (3–48) 17 (57%) 12 (40%) 6 (20%)

Age (yr)

38.5 (15–89)

NS NS

Lowest BD

6 (0–30)

p

ISS

34 (13–50) 8 (3–36) 12 (20%)

0.05

PRBC (units) 24 h

NS

p

Directly to OR

0.05

Angioembolization 20 (33%)

NS NS

Mortality

19 (26.7%)

Data expressed as median (range). BD, base deficit; ISS, injury severity score; NS, not significant; PRBC, packed red blood cells; OR, operating room.

face and head in 26 (87%) patients. Shock (systolic blood pressure 90 mm Hg) occurred in 30 (50%) blunt trauma victims and 16 (53%) patients with penetrating wounds. The median lowest recorded base deficit was 6 after blunt trauma versus 8 in penetrating trauma patients ( p 0.97). Units of packed red blood cells transfused within 24 hours of admis- sion ranged from 3 to 36 (median, 8 units) after blunt trauma and 3 to 48 (median, 5 units) after penetrating wounds ( p 0.38). Factor rVIIa was administered to only two patients, each after blunt trauma. Airway Management Most (93%) patients required early, definitive airway management. Initial airway control was by ET in 72 (80%) patients. Emergent cricothyrotomy and tracheostomy were necessary in 7 (8%) and 5 (6%) patients, respectively. The initial airway (ET or cricothrotomy) was converted to a tra- cheostomy in the operating room (OR) within 24 hours of injury in 32 patients. Therefore, 37 (41%) patients ultimately required tracheostomy.

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