Maxillofacial Trauma
Haemorrhage Control
Dr Ben Rahmel
Maxillofacial Registrar
Maxillofacial Haemorrhage
• ATLS Principles
• Acute concerns:
– Airway care
– Control of profuse bleeding
– Vision threatening injuries
– C-spine
Airway
• The potential for obstruction is present in almost
all patients with significant facial injuries, due to
pooling of blood and secretions in the pharynx,
especially when supine.
• In most conscious patients this is simply
swallowed – but will collect in the stomach.
• However, with midface fractures, particularly
fractures of the mandible, swallowing may be
painful and less effective in clearing the airway.
Airway
• In the acute setting use an oral tube
• Allows access for oral and nasal packing
• Subsequent tracheostomy or submental
intubation
Airway
Airway
Sitting up
• This may indicate a
desire to vomit, or
unrecognised partial
airway obstruction from
swelling, loss of tongue
support, or bleeding.
• Patients may try to sit
forwards and drool,
thereby allowing blood
and secretions to drain
Maxillofacial Haemorrhage
• Bleeding following facial trauma may be
either revealed or concealed
• In major midface and panfacial injuries
blood loss can quickly become significant
• In these patients, blood loss is usually
from multiple sites along the fracture
planes and from associated soft tissues,
rather than from a named vessel
• This makes control of bleeding difficult.
Maxillofacial Haemorrhage
• Direct pressure, clips and sutures may all
be used to control obvious external
bleeding
• When displaced midface fractures are
present, manual reduction not only
improves the airway, but is frequently
effective in controlling blood loss from the
fracture sites
Manual Reduction
Maxillofacial Haemorrhage
• Once reduced oral packing (or a mouth
prop) can be used to support the reduction
• Multiple throat packs or vaginal packs can
be used to pack the oral cavity
Maxillofacial Haemorrhage
• Epistaxis, either in isolation or associated
with midface fractures may be controlled
using a variety of nasal balloons, or packs.
• Rapid rhino packs provide effective
haemostasis in most cases
• Urinary catheters can be passed and
wedged into the post-nasal space for
posterior bleeding
Rapid Rhino
Key Issues
Key Issues
• The nasal passage goes straight back not
up
• Judgement is required with pan facial
injuries due to the risk of cranial intubation.
• In patients with profuse haemorrhage a
risk/benefit analysis is needed
Key Issues
• With unstable midfacial fractures - inflation
of the balloons may displace the fractures
thereby increasing blood loss.
• Temporary stabilisation of the reduced
fractures prior to inflation
– Pack the oral cavity prior to packing the nasal
cavity
– Often mandibular fractures require surgical
stabilisation
Ongoing Bleeding
Coagulopathies
• In the presence of persistent
haemorrhage, despite appropriate
interventions, remember to consider
coagulation abnormalities
– Pre-existing (haemophilia, chronic liver
disease, Warfarin therapy),
– Acquired (e.g. dilutional coagulopathy from
blood loss, or DIC).
Embolisation
• Effective alternative to surgical ligation in
life-threatening facial haemorrhage
• Catheter-guided angiography followed by
embolisation involving: balloons, stents,
coils, or chemicals.
• Supra-selective embolisation can be
performed without the need for a general
anaesthetic and, in experienced hands, is
relatively quick
Embolisation
Embolisation
Surgical Intervention
• If bleeding continues despite reduction of
facial fractures and packing
• Ligation of the external carotid, and
ethmoidal, arteries, via the neck and orbit,
respectively should be considered
• Extensive collateral supply exists so
ligation may not work or may be necessary
on both sides
Maxillofacial Haemorrhage
Maxillofacial Haemorrhage
Maxillofacial Haemorrhage
Maxillofacial Haemorrhage