Management of severe haemorrhage from midface trauma

 

Exsanguinating haemorrhage from midface trauma is a rare but potentially catastrophic event. The following is an approach to pack and splint the midface as a bridge to definitive treatment.

 

1. Intubate the patient

 

• Anticipate a difficult airway. In severe midface trauma there will often be increased space for intubation due to the movement of maxillary and mandibular fractures but the view will almost certainly be obscured by blood.

 

• Large bore suction eg: DuCanto (if available) is recommended utilising a technique where the intubator leads with suction to decontaminate the airway – aka SALAD (Suction Assisted Laryngoscopy and Airway Decontamination). You can read more about SALAD in this EMCRIT article and watch this video

 

• If large bore suction is not available, having 2 standard yankauer suction devices available is recommended.

 

• Consider induction with the patient in a semi upright position if feasible.

 

• Severe midface trauma may result in a surgically inevitable airway – it is recommended that the team is prepared to perform emergency front of neck access (cricothyroidotomy) in case of a “can’t intubate can’t oxygenate” situation

 

2. Place 2x nasal tamponade devices (one into each nostril) – ideally Rapid Rhino, Epistat or similar.

 

• Tape the strings/pilot balloons of the device against the face to avoid migration posteriorly.

 

• Do not blow up the balloons yet – if they nasal space is expanded without bracing the maxilla against the mandible (in step 3), further bleeding can occur.

 

• Note – there is a risk of penetrating the intracranial space if a base of skull fracture is present. Be sure to insert the devices horizontally along the floor of the nasal cavity.

 

3. Place bite blocks on either side of the endotracheal tube at the level of the molars.

 

• The aim is to brace the hard palate against the lower jaw.

 

• most Emergency Departments do not have bite blocks. If your hospital performs ORL or maxillofacial surgery they will likely have them available. If not, bite blocks can be fashioned by cutting a 7.5cm crepe bandage in half and wedging each piece between the rear molars to brace the mouth open.

 

• Note – if the mandible has not been cleared of fracture, bite blocks may not be the best option, as placing them causes mandible fracture diastasis, and may exacerbate haemorrhage / re-initiate haemorrhage from mandible vasculature.

 

 

4. Place a hard cervical spine collar to brace the mandible up

 

5. Now blow up the nasal tamponade devices.

 

 

As mentioned above – this is a temporising measure. These patient will need urgent ORL or maxillofacial review and either angiography or operative management.

 

Author: Emma Batistich

Published date: 19/12/22

Review date: 19/12/24