Massive Hemorrhage in Facial Fracture Patients

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PEDIATRIC/CRANIOFACIAL Massive Hemorrhage in Facial Fracture Patients: Definition, Incidence, and Management Nicola R. Dean, Ph.D., F.R.A.C.S.(Plas.) James P. Ledgard, M.B.B.S. James Katsaros, M.B.B.S., F.R.A.C.S.(Plas.) Adelaide, Australia

Background: Significant hemorrhage from fractures of the midface is a recognized phenomenon, but because it is an uncommon occurrence, there is little in the literature to guide management of these patients. Methods: The authors performed a retrospective study of life-threatening hemorrhage in facial fracture patients attending the Royal Adelaide Hospital over 20 years and report four recent cases. Results: The incidence of massive hemorrhage was found to be 0.33 percent of patients with fracture of the midface or skull base over the 20 years before 2004 and 1.7 percent in the subsequent year. Of the 19 patients identified from case notes and recent experience, seven died. In terms of management of hemorrhage, three patients had packing alone, 10 had balloon catheters inserted, and five had ligation of a vessel. Most patients had multiple other injuries, including six patients with head injuries. The mean number of units of packed red cells transfused was 9.5 (median, 7.5). In five of the cases identified, there was a delay in recognizing that facial fractures were the major source of hemorrhage. Conclusions: Massive hemorrhage from facial fractures is an underrecognized 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. (Plast. Reconstr. Surg. 123: 680, 2009.)

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emorrhage from facial fractures can threaten life by causing hypovolemic shock or by contributing to airway obstruction. Few studies have described the incidence of this phenomenon.1– 4 It is not mentioned in the Advanced Trauma Life Support handbook,5 and hence specific management of severe bleeding from facial fractures is not routinely taught. This study was initiated after the death of a patient from massive hemorrhage from facial fractures. Its aim was to determine the incidence of this condition and analyze its management and outcomes. The Royal Adelaide Hospital treats approximately 60,000 inpatients and 200,000 outpatients per year and treats between 100 and 150 patients with skull or facial fractures per year. This article reports the

results of a 20-year retrospective study and outlines the four cases that occurred in the following year.

From the Flinders Medical Center, Flinders University; and Royal Adelaide Hospital. Received for publication April 15, 2008; accepted August 4, 2008. Presented at the Royal Australasian College of Surgeons Annual Trainees Conference, in Wellington, New Zealand, 2005, and awarded best clinical paper prize. Copyright ©2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31819565da

Disclosure: None of the authors has any commercial association with any products described in this article and has no financial conflicts of interest. This research was not formally funded. It was initiated by the corresponding author while she was a trainee and all authors have performed the research either in spare time or during time employed at the Royal Adelaide Hospital (a public sector hospital).

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PATIENTS AND METHODS To accurately measure the incidence of a condition, that condition must first be well defined. As there is no established definition of massive hemorrhage from facial fracture, we devised a definition as follows: 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

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