HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Maxillofacial Injuries With Severe Hemorrhage

alone in two patients, and combined with temporary fracture reduction in seven patients. One patient died from uncon- trolled hemorrhage. Shimoyama et al. 4 were able to control massive oral bleeding in all five patients managed by nasal packing and temporary fracture reduction. These authors stated that arterial ligation or embolization techniques should only rarely be necessary. The efficacy of packing techniques alone or with temporary fracture reduction has been ques- tioned by other investigators. 6,8,9 Failure of packing in pa- tients with severe maxillofacial trauma may be caused by combined nasal and oral bleeding with large defects allowing communication between the nasal and oral cavities. 6,9 In patients with comminuted facial fractures, there may be in- sufficient solid bony walls for packing to buttress against. 6,9 Packing is also ineffective for bleeding from ethmoid arteries and distal branches of the internal maxillary artery, such as the sphenopalatine and descending palatine arteries. 8,9,11 Sakamoto et al. 7 reported that oronasal packing alone achieved hemostasis in only 4 (29%) of 14 patients with massive bleeding from maxillofacial injuries. This parallels our experience with anterior or posterior or both packing. Although these techniques slowed the rate of hemorrhage in 44% of patients, packing controlled hemorrhage in only 29% and failed to control hemorrhage at all in 27%. These packing techniques may, therefore, be a useful adjunct to slow hem- orrhage while other, more effective procedures to completely control hemorrhage are performed. Emergency operations for control of hemorrhage consist of several approaches. For patients with active bleeding from large soft tissue defects such as those caused by close range gunshot and shotgun wounds, direct transfer to the OR may facilitate airway establishment and control of hemorrhage by manual compression, direct arterial ligation, debridement, and temporary closure of lacerations. In our series, 57% of patients with penetrating wounds were taken directly to the OR for these indications. Twelve (20%) patients with blunt trauma were treated by emergency operation for control of bleeding from lacerations; three required ligation of the su- perficial temporal artery. Blind ligation of the external carotid arteries was not employed in any patient in our series. Al- though historically recommended by some authors as a “last ditch” effort to control intractable bleeding from facial fractures, 3,12 it is rarely effective because of rich collateral blood flow. 5,6,9 Therapeutic percutaneous embolization of the maxillary arteries for intractable epistaxis was first reported by Sokoloff et al. 13 in 1974. With the advent of microcatheter techniques, even more selective arterial embolization has resulted in control of intractable epistaxis in 96% of patients, with a neurologic complication rate of 6% (no significant sequelae). 14 In 1983, Murakami et al. reported the use of TAE to control maxillary artery bleeding in a patient with craniofacial trauma who later died of exsanguination from other sources of facial hemorrhage. 10 In 1988, Sakamoto et al. 7 reported successful transcatheter embolization of the external carotid artery or its

branches in four patients with massive bleeding because of maxillofacial injury. Komiyama et al. 6 were able to control intractable oronasal bleeding from craniofacial injuries in all nine patients managed with TAE. In seven of nine cases, they were able to visualize extravasation from multiple arteries. Bleeding was bilateral in six patients and involved the sphe- nopalatine arteries in seven patients. No patients sustained neurologic complications during or after the procedure. By- noe et al. 2 performed TAE of 6 internal maxillary arteries and 10 external carotid arteries in 11 patients with life-threatening hemorrhage from maxillofacial injuries. Complications of the procedures included two groin hematomas, partial necrosis of the tongue in one patient, and one facial nerve palsy. Re- cently, Liao et al. 8 reported their results with TAE in 34 patients with intractable oronasal hemorrhage associated with craniofacial trauma. Active bleeding was most frequently (47%) found to be from the internal maxillary artery. TAE was successful in hemorrhage control for 27 (79%) patients. In their series, TAE improved patient survival; mortality was

Fig. 1. Algorithm for management of penetrating maxillofacial in- juries with severe oronasal bleeding.

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