Management of severe haemorrhage from midface trauma

Exsanguinating haemorrhage from midface trauma is a rare but potentially catastrophic event.

Early adoption of simple measures to reduce bleeding is essential – accept permissive hypotension (if no spinal or head injury concerns), position the patient head up if possible, ensure early administration of TXA, broad infiltration of adrenaline containing local anaesthesia and direct pressure.

It is essential to ensure that oral haemorrhage is under control before sending a patient for CT as patients that are tolerating bleeding while sitting up can rapidly lose their airway due to pooling and clotting of blood in the oropharynx if lain flat for scanning.

 

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.
  • have the cricothryroid membrane marked on the patient’s neck with front of neck access equipment at the bedside in case of a can’t intubate, can’t ventilate situation

 

• 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.
  • Oral bleeding can become dangerous once the patient is supine. Blood can quickly clot in the pharynx and cause asphyxiation. Often patients will prefer to be lying laterally if conscious (and spinal precautions permit) and given a suction to use themselves.

 

 

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

 

• Prior to inserting, cophenylcaine spray up each nostril can be useful. Also the merocel or rapid rhinos can be impregnated with 1:1000 adrenaline to aid in vasoconstriction after insertion.

 

• Tie the strings together loosely across the nasal columella. Alternatively 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.

 

• Dedicated posterior nasal packing may occasionally be required. Foley catheters fed through the nose can be inflated once visualised in the oropharynx and then withdrawn to obturate the posterior nasal space. The anterior nasal spaces can then be further packed with Merocel/rapid rhino

 

• 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.

 

• Inject broad infiltration of 2% lignocaine with adrenaline throughout the oral mucosa in the buccal tissues early, to reduce mucosal bleeding. Any tongue lacerations can also be helped in this way.

 

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.

 

• Le fort I fractures tend to cause the maxilla to slip backwards and downwards, due to way they propagate. Dental malocclusion/mucosal bruising and obviously any gross mobility would all be indicators of this. Try to avoid mobilising the fractured maxilla too much, as this will exacerbate bleeding.

 

 

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.

 

First published: Dec 2022 (Author: Emma Batistich)
Updated January 2025 (James Olsen) 
Approved by: Northern Region Trauma Network, Health New Zealand | Te Whatu Ora – Northern Region, NRHL, St John
Review due: 2 years