HSC Section 3 - Trauma, Critical Care and Sleep Medicine

The Journal of TRAUMA Injury, Infection, and Critical Care

found to be associated with low Glasgow Coma Scale, pres- ence of shock, high injury severity scores, and need for emergent laparotomy. In our series, TAE was used for oro- nasal bleeding in 20 patients with blunt trauma and 12 with penetrating wounds. Vessels most frequently embolized were the internal maxillary artery (65%) and the facial artery (13%). TAE was successful in controlling oronasal bleeding in 28 (87.5%) patients. TAE offers several advantages over operative ap- proaches to arterial ligation. 6 Operative exploration of these complex wounds with tissue swelling, soft tissue defects, and comminuted fractures may be extremely difficult. Angiogra- phy with microcatheters allows distal access to the precise location of bleeding sites for super selective embolization. Multiple, often bilateral, bleeding points can be identified and controlled by TAE, which can be performed relatively quickly and requires only local anesthesia. Finally, angiog- raphy performed for TAE may also be used to identify bleed- ing from ethmoid arteries or ophthalmic artery branches for which risks of embolization are higher. In these rare circum- stances, arteriographic identification may aid in surgical plan-

ning to directly ligate these branches of the internal carotid artery. Complications of TAE such as blindness, facial nerve palsy, other cranial nerve deficits, tongue necrosis, and em- bolic ischemia have been rarely reported. 2,6,14 No complica- tions of TAE were observed in our multicenter study. Based on the experience of the nine participating insti- tutions and review of the current literature, we propose algo- rithms for the management of severe oronasal hemorrhage caused by blunt and penetrating trauma (Figs. 1 and 2). Resuscitation must begin with effective airway management and aggressive treatment of shock. For wounds with signifi- cant soft tissue disruption such as close range gunshot and shotgun wounds, patients may be optimally treated in the OR for airway establishment and control of hemorrhage by man- ual pressure, debridement, and direct ligation of bleeding vessels. Patients with more limited penetrating wounds and blunt trauma can be initially managed by anterior or posterior packing. If effective at completely controlling hemorrhage, then these patients can undergo delayed maxillofacial repair after associated injuries have been treated. If hemorrhage is not controlled by packing, a brief trial of temporary facial fracture reduction may be attempted. Failure to achieve he- mostasis following these techniques mandates urgent TAE for control of hemorrhage. Angiography occasionally assists in the identification of bleeding from ethmoid arteries or branches of the ophthalmic arteries which may require a direct surgical approach for ligation. Once oronasal bleeding is controlled, associated injuries are treated before delayed maxillofacial repair. The implementation of an algorithmic approach to these rare but life-threatening injuries may result in improved outcomes. Further prospective evalua- tion is warranted. REFERENCES 1. Tung TC, Tseng WS, Chen CT, Lai JP, Chen YR. Acute life- threatening injuries in facial fracture patients: a review of 1,025 patients. J Trauma. 2000;49:420–424. 2. Bynoe RP, Kerwin AJ, Parker HH III, et al. Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization. J Trauma. 2003;55:74–79. 3. Ardekian L, Samet N, Shoshani Y, Taicher S. Life-threatening bleeding following maxillofacial trauma. J Craniomaxillofac Surg. 1993;21:336–338. 4. Shimoyama T, Kaneko T, Horie N. Initial management of massive oral bleeding after midfacial fracture. J Trauma. 2003;54:332–336. 5. Fratianne RB, Cocanour CS. Exsanguinating craniofacial trauma. Advances Trauma Crit Care. 1992;7:159–173. 6. Komiyama M, Nishikawa M, Kan M, Shigemoto T, Kaji A. Endovascular treatment of intractable oronasal bleeding associated with severe craniofacial injury. J Trauma. 1998; 44:330 –334. 7. Sakamoto T, Yagi K, Hiraide A, et al. Transcatheter embolization in the treatment of massive bleeding due to maxillofacial injury. J Trauma. 1988;28:840–843. 8. Liao C, Hsu Y, Chen C, Tseng YY. Transarterial embolization for intractable oronasal hemorrhage associated with craniofacial trauma: evaluation of prognostic factors. J Trauma. 2007;63:827– 830.

Fig. 2. Algorithm for management of blunt maxillofacial injuries with severe oronasal bleeding.

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