HSC Section 3 - Trauma, Critical Care and Sleep Medicine

The Journal of TRAUMA Injury, Infection, and Critical Care

Anterior or Posterior Packing and IMF Anterior or posterior or both packing was used as an initial attempt to achieve hemostasis in 50 (56%) patients; 37 after blunt trauma and 13 after penetrating wounds. This technique was successful in controlling hemorrhage in only 29% of patients in whom it was used but slowed the rate of bleeding in an additional 44%. IMF was used as an initial attempt at achieving hemostasis in only 13 (14%) patients, but was successful in controlling hemorrhage in 9 (69%). Emergency Operation for Hemorrhage Twenty-nine (32%) patients were taken directly to the OR for control of hemorrhage. There were 17 (57%) patients with penetrating wounds taken directly to the OR versus 12 (20%) patients with blunt trauma ( p 0.05). Most of these patients underwent debridement, control of unnamed vessels, and preliminary closure of lacerations. In four patients with penetrating wounds, named arteries were ligated (three facial arteries and one ascending pharyngeal artery). In three pa- tients with blunt injuries, named arteries were ligated (three superficial temporal arteries). No patients underwent “blind” ligation of external carotid arteries and no patients required specific ligation of internal maxillary or ethmoid arteries. Transarterial Embolization TAE was used to control hemorrhage in 32 (36%) patients; 20 (33%) after blunt trauma and 12 (40%) after penetrating wounds. Embolizations were performed by de- ployment of microcoils with or without the addition of ab- sorbable gelatin. Fifty-one arteries were embolized. Arteries embolized were the internal maxillary—33 (65%), facial—7 (13%), internal carotid—3 (6%), external carotid—2 (4%), lingual—2 (4%), sphenopalatine—1 (2%), ascending pharyngeal—1 (2%), and unnamed arteries—2 (4%) (Table 3). Bilateral TAE was performed in 10 patients after blunt trauma and 1 with a penetrating injury. TAE was successful for definitive control of hemorrhage in 11 (91%) patients with penetrating wounds and 17 (85%) patients with blunt trauma. A second (redo) embolization procedure was not performed in any patient. Of the four patients in whom TAE failed, three later died of exsanguination. One survived after two trips to the OR with direct ligation of facial arteries and veins. There were no procedure-related complications. Table 3 Fifty-one Vessels Treated by Transarterial Embolization Internal maxillary artery 33 Facial artery 7 Internal carotid artery 3 External carotid artery 2 Lingual artery 2 Sphenopalatine artery 1 Ascending pharyngeal artery 1 Unnamed artery 2

Mortality Twenty-two (24.4%) patients died; 16 (26.7%) after blunt trauma and 6 (20%) after penetrating wounds. The cause of death was severe-associated brain injury in 14, exsanguination in 5, pulmonary embolus in 1, multiple sys- tem organ failure in 1, and concurrent lye ingestion in 1. Death was directly attributable to the maxillofacial injury in 6 (7%) patients, 5 because of exsanguination and 1 from multiple system organ failure. DISCUSSION Initial treatment priorities for patients with maxillofacial injuries and severe associated oronasal bleeding are no dif- ferent than for any multiply injured trauma patient—airway, ventilation, and management of shock, including hemorrhage control. However, establishment of a secure airway may be very challenging because of soft tissue disruption, swelling, unstable facial fractures, and ongoing hemorrhage. The use of nasotracheal intubation has been discouraged in this clinical setting. ET with in-line stabilization is clearly the procedure of choice, if anatomically possible. If tissue disruption, swell- ing, or massive hemorrhage preclude successful ET, then a surgical airway by cricothyrotomy or emergency tracheos- tomy is required. Tung et al. 1 found that only 17 (1.7%) of 1,025 patients with facial fractures developed airway com- promise requiring an emergency procedure. In our series of 90 patients with severe oronasal bleeding from maxillofacial trauma, ET was possible in 80% whereas emergency crico- thyrotomy and tracheostomy were required in 8% and 5%, respectively. An additional 32 patients with initial ET or cricothyrotomy were converted to tracheostomy in the OR within 24 hours to assist with definitive repair of the maxil- lofacial injuries. The primary focus of our study was the contemporary management of oronasal hemorrhage associated with maxil- lofacial injuries. The key sources of arterial bleeding associ- ated with mid-facial trauma are the internal maxillary, facial, and superficial temporal branches of the external carotid arteries and the ethmoid and ophthalmic branches of the internal carotid arteries. 5,10 Options for management include anterior nasal packing, posterior nasal packing or balloon tamponade, emergent IMF, TAE, and operative control of bleeding by direct arterial ligation or “blind” ligation of the external carotid arteries. Tight anterior nasal and posterior oronasal packing is often used as the initial attempt to stem oronasal hemorrhage in patients with mild to moderate rates of bleeding. These techniques are highly effective with mild to moderate epi- staxis. Even in patients with massive oronasal bleeding after mid-facial fractures, these techniques alone or in concert with temporary fracture reduction have been demonstrated to suc- cessfully control hemorrhage. 3,4 Ardekian et al. 3 treated 10 patients with life-threatening hemorrhage from mid-face fac- tures. Bleeding was definitively controlled by nasal packing

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