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.
Incidence and Mortality
Clinical PresentationMost 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.
ManagementThe 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.
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
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.
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