Wednesday, February 18, 2009

Massive Hemorrhage in Facial Fracture Patients – an Article Review

There is little in the literature regarding management of “significant hemorrhage from fractures of the midface.”   The authors of this article (full reference below) did a retrospective study to try to look at this complication and its management.
Hemorrhage from facial fractures can threaten life by causing hypovolemic shock or by contributing to airway obstruction.  They found no established definition of massive hemorrhage from facial fractures, so devised the following:
Fracture of the midface or skull base plus hemorrhage into pharynx
* Causing tachycardia (pulse rate >100) and hypotension (systolic pressure <100) with no other cause identified, or
* Necessitating acute transfusion with two or more units of packed red cells, or
* Where blood loss from that source was measured as greater than 500 ml.
Using the above definition, the authors went through the discharge data system (Australian health care system) to identify all those patients  (January 1, 1984, to December 31, 2003) who had been discharged with diagnosis codes for malar bone, maxillary, or skull base fractures (mandible fractures were not included in the population).  This list was then cross-referenced to include a diagnosis code of epistaxis or a procedure code such as  arrest of hemorrhage, nasal packing, or blood transfusion.   The medical records of these patients were then examined to see if they met the above definition of massive hemorrhage from facial fracture.
In addition to the retrospective study, the details of any new cases of massive hemorrhage in facial fractures were documented over an additional 1-year period. The incidence of cases was calculated for both the 20-year period and the subsequent 1-year period. The clinical presentation, management, and outcome data of cases were analyzed as a whole, with those of the retrospective cases being combined with those of the recent cases.

Incidence and Mortality
The retrospective study included 4501 patients with codes for maxillary, malar, or skull base fractures.  They found only 50 patients with codes for both facial fractures and at least one of the codes indicating bleeding.  Only 15 of these met the definition of massive hemorrhage from facial fractures.  That gives an incidence of 0.33% facial fracture patients with massive hemorrhage over the twenty year period.
During the one year period, 226 patients with midface or skull base fractures were treated.  Four of these had massive bleeding or an incidence  of 1.77 percent.
In the combined data set, seven of the 19 patients died during the hospital admission in which they had the facial fractures.  The patients who died had multiple injuries so it is difficult to attribute the cause of death to one pathology alone.

Clinical Presentation
Most patients were male with a median age of 48 years (range, 18 to 83 years).  Most common cause of injury was motor vehicle accident.  Most patients had other injuries besides the facial fracture, including significant head injuries.
Most patients had significant hypovolemia on presentation.
Descriptions of facial fracture patterns
Five patients were described as having skull base fractures or Le Fort III fractures, with an additional three patients reported as having fractures of individual bones of the skull base (sphenoids or ethmoids). Four of these eight patients died. Of the 10 patients identified with a Le Fort fracture, five died.

The authors discuss the following at important aspects of management:
1.  Recognition of Facial Fracture Hemorrhage as Significant
2.  Arrest of Hemorrhage Method
In three patients, arrest of hemorrhage was attempted with nasal/oral/pharyngeal packing alone. All three patients died. As all three had multiple injuries, the contribution of the facial fracture hemorrhage to death was difficult to quantify.
Ten patients had insertion of balloon catheters of some sort--Foley catheters or Brighton epistaxis catheters--and no vessel ligation. Four of these patients died; again, each of the deaths occurred in the context of polytrauma.
Five patients had ligation of a vessel, either the external carotid, maxillary, or anterior ethmoidal, with or without other measures. None of these patients died. No patients had radiological embolization of vessels to the face.
3.  Airway Management
4.  Blood Transfusion
All patients were given a transfusion of packed red cells. The median number of units given was 9 and the mean number was 10.

Their Procedure for Arrest of Massive Facial Fracture Hemorrhage
    • Use a head light
    • Insert bite block to keep mouth open
    • Place a 2/0 silk suture through the tongue to aid retraction
    • Check the balloons on 2 X 30 ml Foley catheters
    • Insert Foley catheter slowly into one nostril observing the pharynx for its emergence
    • Use Yankaur sucker and Magill forceps to check Foley catheter is in the pharynx
    • Repeat procedure on other side
    • Put catheters on light bleeding stops secure position of catheters at nares with umbilical cord clamp
    • Remove bite block (they can cause fracture distraction and increased bleeding if left in place)
    • If bleeding does not stop – increase tension on catheters and then secure with cord clamp
    • Place foam rubber under each umbilical cord clamp to reduce pressure on skin
    • Inject soft palate and periosteum around posterior maxilla with lidocaine and adrenaline (1 in 80,000) and pack oral cavity with gauze if bleeding from hard palate

Their Conclusions:
Massive hemorrhage from facial fractures is an under-recognized and inconsistently managed phenomenon. Although low in incidence, its timely recognition and better management may reduce the high mortality rate in this group of patients.

Article is worth reading.

Massive Hemorrhage in Facial Fracture Patients: Definition, Incidence, and Management; Plastic and Reconstructive Surgery:Volume 123(2)February 2009pp 680-690; Dean, Nicola R. Ph.D., F.R.A.C.S.(Plas.); Ledgard, James P. M.B.B.S.; Katsaros, James M.B.B.S., F.R.A.C.S.(Plas.)


rlbates said...

Jabulani, Thank you for you comment. I thought I "approved" it, but it never came through. Here it is and I thank you for it.

"Despite my not being a medico, I am constantly fascinated by your blogs like this. It makes for very interesting reading and lifts the tedium of the day. Thank you."

Anonymous said...

greetings from indonesia, i'm razzaqy, a GP practicing at the ER. this is somewhat useful for me, since i have just got 2 cases with skull base fracture to be likely a primary cause of hypovolemic shock in these 3 days at my hospital.