1. Maxillofacial Trauma Haemorrhage Control Dr Ben Rahmel Maxillofacial Registrar

4. Maxillofacial Haemorrhage ATLS Principles Acute concerns: –Airway care –Control of profuse bleeding –Vision threatening injuries –C-spine

5. 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.

6. Airway In the acute setting use an oral tube Allows access for oral and nasal packing Subsequent tracheostomy or submental intubation

7. Airway

9. 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

10. 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.

11. 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

12. Manual Reduction

13. 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

14. 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

15. Rapid Rhino

16. Key Issues

17. 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

18. 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

19. Ongoing Bleeding

20. 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).

21. 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

22. Embolisation

24. 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

25. Maxillofacial Haemorrhage