Massive Hemorrhage in Facial Fracture Patients

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.)

H

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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Volume 123, Number 2 • Massive Hemorrhage in Facial Fracture • 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.

The Australian health care system has a unified discharge coding system containing codes for both diagnoses and procedures.6 The discharge coding data system was used to identify all those patients who, over a 20-year period (January 1, 1984, to December 31, 2003), had been discharged with diagnosis codes for malar bone, maxillary, or skull base fractures (mandible fractures were not included in the population). This patient list was then cross-referenced with the names of those discharged with a diagnosis code of epistaxis or procedure codes of arrest of hemorrhage, nasal packing, or blood transfusion. The resultant list of patients was then used as the base population for study. The medical records of these patients were examined for criteria for massive hemorrhage from facial fracture as defined above. If the criteria were met, the patient was designated as a “case” and the medical records were further examined for the following details: presentation, including age and sex, mechanism of injury, fracture pattern, concurrent injuries, and blood pressure and pulse; and management, including airway management, arrest of hemorrhage, and volume of blood products given. Any apparent delay in management of the facial fracture hemorrhage and the outcome of the patients were also noted. Data were recorded and analyzed and an incidence of massive hemorrhage from facial fractures was calculated. A further 50 sets of case notes were randomly selected from the population of facial fracture patients to assess the rate of false negatives (patients recorded as a noncase when they were in fact a case). In addition, the hospital “miscode” rate was also examined as a potential source of error.

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. The results were tabulated for comparison of case features (Table 1). Individual data for incidence and mortality, clinical presentation, and management of hemorrhage are presented in the Results.

CASE REPORTS Case 1 Case 1 involved a 62-year-old male driver in a head-on motor vehicle accident who had significant facial trauma and was trapped in his vehicle for more than 1 hour by intrusion of metalwork into the driver’s compartment. He was intubated because of massive facial bleeding. No past medical history was available, but he was noted to have a median sternotomy scar.

He had had one cardiac arrest before referral to the plastic surgery team and had another cardiac arrest on the way to the operating room to stop the facial fracture hemorrhage. He received 15 units of packed red cells but died on the operating table from continuing hemorrhage and cardiovascular decompensation, despite attempts at balloon tamponade of his fractures. It was later found that he had been taking anticoagulants following coronary artery bypass surgery. His death was reported to the coroner but no postmortem examination was performed. No facial radiographs or computed tomography scans were performed due to his hemodynamic instability. The operating surgeon had noted that on clinical examination he had a Le Fort I–type fracture and a sagittal split of his hard palate.

Case 2 Case 2 was that of a 25-year-old male driver who had collided with a concrete post. His car turned over and he was trapped upside down in his vehicle. He sustained complex Le Fort facial fractures plus a sagittal split of his hard palate, as well as bilateral condyle fracture dislocations and a parasymphyseal mandible fracture (Fig. 1). He was intubated in the resuscitation room and immediately transferred to the operating room. Foley catheters were inserted and the balloons were inflated in the pharynx. Moderate traction was placed on the catheters and then maintained by means of an umbilical cord clamp (Fig. 2). The oral cavity and remainder of the pharynx were then packed with gauze. These procedures arrested the hemorrhage and the patient went on to have the remainder of his trauma survey. He required transfusion with 9 units of packed red cells. His nonfacial injuries were a small subdural hematoma and fractured ribs. He proceeded to have a tracheostomy and plate fixation of his panfacial fractures without further complication and made a good recovery, returning to full employment (Fig. 3).

Case 3 Case 3 was that of a 78-year-old male driver involved in a head-on collision who was trapped in his car by intruding metalwork and bleeding from his face. He also had major lower limb injuries. He had continuing hypotension after splinting of his lower limbs, and a fast scan of his abdomen was negative.

Nasopharyngeal balloon catheters had been inserted but he continued to bleed from his face and had a clinically obvious Le Fort I fracture. He was taken to the operating room for ligation of his external carotid hemorrhage (Fig. 4). Ligation of the external carotid on the left side only reduced his facial bleeding, but he was then found to have an avulsed internal mammary artery that was bleeding into his thoracic cavity. This was embolized radiologically and he became hemodynamically stable. He received 45 units of packed red blood cells in total and had a long course of treatment in intensive care. Fixation of his Le Fort fracture was straightforward. He was eventually discharged from the hospital to a rehabilitation center and then home, where he returned to good function.

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Plastic and Reconstructive Surgery • February 2009 Table 1. Summary of Cases Management of Bleeding

Case

Mechanism (categorized)

Airway Management

Description

Categorized

1

64-yr-old man in head-on collision trapped in car by face; taking anticoagulants; cardiac arrest before arrival; died on operating table attempting to arrest facial hemorrhage

Automobile accident

Emergency intubation

Nasal packing and balloon catheters

Balloon catheters but no vessel ligation ⫹/⫺ packing

2

25-yr-old man in motor vehicle accident; trapped in vehicle upside down; airway full of blood; two unsuccessful attempts at intubation at scene

Automobile accident

Emergency intubation

Balloon catheter and nasal packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

3

78-yr-old man in motor vehicle accident; during arrest of hemorrhage from facial fractures still unstable; had avulsed internal mammary artery; blood in thorax

Automobile accident

Emergency intubation

Nasal packing and balloon catheters then external carotid ligation

Ligation of vessel ⫹/⫺ other measures

4

37-yr-old man on motorbike vs. car

Motorcycle accident

Emergency intubation

Balloon catheter and packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

5

69-yr-old pedestrian hit by car; facial fractures and skull base fractures, tibial fracture, hemopneumothorax, subdural; underwent negative laparotomy after drop in BP 54-yr-old male front-seat passenger in car that collided with rear end of truck

Pedestrian struck by automobile

Emergency intubation

Packing of anterior and posterior nasal space then oropharynx packed

Packing only

Automobile accident

Emergency intubation

Foley catheters plus gauze packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

6

Description

7

21-yr-old female pedestrian hit by car; profuse bleeding from nose and mouth requiringd intubation and 7-unit transfusion

Automobile accident

Emergency intubation

Foley catheters and nasal packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

8

28-yr-old man cycling home from pub hit by car; agitated, with significant bleeding from nose; transferred from rural town shocked (systolic BP of 70); 1100 ml of blood aspirated from NG tube

Bicycle accident

Emergency intubation

Brighton tubes and nasal packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

9

19-yr-old in motor vehicle accident with Le Fort I plus II plus open fracture of mandible and head injury; arrived at 0030 hr from peripheral hospital; Hb dropped from 100 to 60 g/liter by 0330 hr from continuous bleed from mouth; by 0430 Hb had dropped to 42 g/liter; nose and mouth packed; facial wounds sutured; external carotid explored but not ligated; at 1000 hr left external carotid ligated

Automobile accident

Emergency intubation

Nasal packing and ligation of external carotid

Ligation of vessel ⫹/⫺ other measures

10

18-yr-old in motor vehicle accident; driver not wearing seatbelt; car vs. tree; panfacial fractures

Automobile accident

Emergency tracheostomy

Foley catheters and nasal packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

11

24-yr-old man on motorbike in head-on collision with car; found in middle of road in large pool of blood

Motorcycle accident

Emergency intubation

Throat and nasal packing; taken to OR for tracheostomy and insertion of balloon catheters and packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

12

83-yr-old man fell down 3 steps

Fall

No acute intubation

Nasal packing with paraffin gauze

Packing only

13

48-yr-old woman shot in face

Gunshot wound

Emergency intubation

Taken to OR for packing and ligation of maxillary artery

Ligation of vessel ⫹/⫺ other measures

14

62-yr-old man fell from a bicycle while riding downhill

Bicycle accident

Emergency intubation

Nasal packing and Foley catheters

Balloon catheters but no vessel ligation ⫹/⫺ packing

15

26-yr-old male assault victim attended emergency with epistaxis; had nasal packing and Foley catheters, then anterior ethmoidal artery ligation

Assault

No acute intubation

Foley catheters and nasal packing, then anterior ethmoidal artery ligation

Ligation of vessel ⫹/⫺ other measures

16

63-yr-old backseat passenger in motor vehicle accident

Automobile accident

Emergency intubation

Not documented

Not known

17

78-yr-old pedestrian hit by car; “blood in airway” at scene and hemodynamic state deteriorated; underwent negative laparotomy; died

Pedestrian struck by automobile

Emergency intubation

Nasal packing

Packing only

18

75-yr-old man clubbed around face in home invasion and shot in groin/abdomen

Assault

No acute intubation

Foley catheters and nasal packing

Balloon catheters but no vessel ligation ⫹/⫺ packing

19

41-yr-old male assault victim

Assault

No acute intubation

Foley catheter and nasal packing with kaltostat, then anterior ethmoidal artery ligation

Ligation of vessel ⫹/⫺ other measures

BP, blood pressure; Hb, hemoglobin; NG, nasogastric; OR, operating room; MI, myocardial infarction; PMH, past medial history; COAD, chronic obstructive airways disease.

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Volume 123, Number 2 • Massive Hemorrhage in Facial Fracture Table 1. (Continued)

Fracture Pattern (description) Le Fort I plus sagittal split in palate

Nonfacial Injuries # Humerus and dislocated hip

Pulse Units of Rate on Systolic BP Packed Red Arrival on Arrival Lowest Hb Cells Negative (bpm) (mmHg) (g/liter) Transfused Laparotomy

Outcome

Delay in Hemorrhage Recognition No delay

Comments

70

90

99

15

No

Died

Panfacial fractures Cerebral contusion including Le Fort II and palatal split and bilateral condylar fractures

130

80

80

7

No

Discharged No delay

Recovered well

Le Fort I

Bilateral # femurs and # tibia plus thoracic injury

101

85

65

45

Yes

Discharged No delay

Recovered well

Le Fort II

Spleen injury (did not require acute surgery)

135

123

82

10

No

Discharged No delay

Recovered well

“Facial fractures” and skull base

Flail chest, # C2, # occiput, # tibia

180

50

72

7

Yes

Died

Delay

Le Fort II plus skull base

Severe brain injury

92

111

91

9

No

Died

No delay

Sphenoid and mandible

# Pelvis and tibia

130

60

96

10

No

Discharged No delay

Did not attend follow-up

Skull base fracture (sphenoid/petrous temporal bone/ occipital bone)

Extradural hemorrhage, # rib, buttock laceration

120

70

120

8

No

Discharged No delay

Lived through initial injury but died from drug overdose after discharge

Le Fort I plus II plus mandit

# Radius

154

142

42

12

No

Discharged Delay

Long interval between arrival and recognition of significant facial hemorrhage

Le Fort II plus split palate plus mandible

# Sternum

92

75

87

12

No

Discharged No delay

Le Fort III plus I plus mandible plus split palate

None

88

130

79

8

No

Discharged No delay

Left zygoma/maxilla/ orbit/ fractured sphenoid

# Pelvis and ribs

80

110

73

1

No

Died

Complex maxillary/ orbital fracture

None

70

80

75

4

No

Discharged No delay

Midface fractures and parietal fracture

Subdural and sub arachnoid hemorrhage

96

77

88

10

No

Died

Ethmoid plate, nasal bones, and zygoma

None

80

130

83

3

No

Discharged Delay

12 hours between presentation and anterior ethmoidal artery ligation; patient tachy 120

Le Fort II

# Pelvis and tibia

115

170

88

3

No

Discharged No delay

Initial details unclear; from rural hospital

Skull base fracture

Intracranial hemorrhage, # tibia

120

80

110

7

Yes

Died

Delay

Jehovah’s Witness

Le Fort II

Shotgun wound to groin/abdomen developed ischemic lower limbs

103

140

116

10

No

Died

No delay

Right zygoma fracture with orbital floor

None

95

120

70

9

No

Discharged Delay

Difficult to know what role facial fracture bleeding had in demise; mostly ischemic legs caused death Transferred from rural hospital 2 days after fracture with tachycardia pallor and melaena

No delay

No delay

Taking anticoagulants for previous coronary artery bypass surgery

Was found to be brain dead; organs donated

Had an MI during admission and PMH of COAD; died of respiratory problems; brisk arterial bleeding occurred several hours after admission

Died of brain injury

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Fig. 1. Case 2. Computed tomography scan showing complex fracture pattern.

Fig. 3. Case 2. Appearance after recovery from facial fractures.

Fig. 4. Case 3. Intraoperative view of procedure for arrest of hemorrhage.

Fig. 2. Case 2. Intraoperative views taken after insertion of Foley catheters.

Case 4 Case 4 was that of a 37-year-old male motorcyclist who had a head-on collision with a car. He was wearing a “skull cap” helmet with no face protection features. He was bleeding continuously from the mouth and nose and was intubated in the

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resuscitation room because of the threat to his airway (Fig. 5).

He had insertion of nasopharyngeal balloon catheters and gauze packing of the remainder of the pharynx and oral cavity.

This stopped the hemorrhaging and his condition stabilized (Fig. 6). He received 10 units of packed red cells in total. His nonfacial injuries included a transverse process fracture of his cervical spine, a splenic tear, a fractured right patella, a skull base fracture, and a soft-tissue injury to his right thumb.

The treatment of his facial fractures followed a tracheostomy and there were no significant complications. He was discharged home.

RESULTS Incidence and Mortality In the retrospective study, of the population of 4501 patients with codes for maxillary, malar, or

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Fig. 5. Case 4. Patient before insertion of Foley catheters.

bleeding. On review of the medical records, 15 of these patients met the constructed definition of massive hemorrhage from facial fractures. An additional four cases occurred during the study period, yielding a total of 19 cases. The hospital miscode rate (i.e., the proportion of patient episodes that were given an incorrect code) was found to be nonsignificant (1.2 percent) at the annual audit of the hospital coders.7 Of the 50 randomly selected case notes, there were no cases that met the criteria for massive hemorrhage from facial fractures (i.e., no false negatives). The incidence of massive hemorrhage in malar, maxillary, or skull base fractures in the 20-year period was 0.33 percent. The incidence in the 1-year period during the study was 1.77 percent (four patients of 226 with midface or skull base fractures).

In the combined data set, seven of the 19 patients died during the hospital admission in which they had the facial fractures. In many cases, cause of death was difficult to attribute to one pathology alone since those who died all had multiple injuries.

Clinical Presentation In most cases, the patients were male; the median age was 48 years (range, 18 to 83 years) (Table 1). The causes of injury varied, with the most common being motor vehicle accident. Most patients had other injuries besides the facial fracture, including significant head injuries. Crude data for hemodynamic status–-systolic blood pressure (mean, 101 mmHg) and pulse (mean, 108 bpm)–indicated that most patients had significant hypovolemia on presentation. Descriptions of facial fracture patterns in the case notes and radiology reports were heterogeneous and in some cases not easily classified. 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.

Fig. 6. Case 4. Patient after tongue retraction suture and Foley catheter insertion.

skull base fractures, 18 had a code for epistaxis, 29 had a code for transfusion, and 16 had a code for nasal packing or control of epistaxis. In total there were 50 patients with codes for both facial fractures and at least one of the codes indicating

Management Recognition of Facial Fracture Hemorrhage as Significant In five cases there appeared to be a definite delay in recognition of the magnitude of the facial fracture hemorrhage. For example, one patient was referred nonurgently from another hospital while tachycardic, hypotensive, and with melaena.

Three negative laparotomies were performed in

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Plastic and Reconstructive Surgery • February 2009 attempts to identify an abdominal source of bleeding. In two of the cases where there was an identifiable delay, the patient died. In other cases there may also have been some element of delay in diagnosis, but unless it was clearly identified from the medical records, a descriptor of “delay” was not used.

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.

Airway Management Four patients had no intubation of their airway, and of these, two subsequently died. Fourteen patients had emergency intubation either at the scene of the accident or in the emergency room, and one patient had an emergency tracheostomy.

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. The mean was skewed by one case in which 45 units of packed red cells were given. One transfusion was commenced in a Jehovah’s Witness before the discovery of the patient’s religious beliefs and was ceased immediately when this information emerged.

DISCUSSION Incidence This study showed that the incidence of massive hemorrhage in facial fractures is low but that the phenomenon carries a high risk of death. This is in agreement with the findings of others. Gwyn et al. pointed out in 1970 that many patients with facial fractures were multitrauma patients and that the incidence of hypovolemic shock was small but significant (1.4 percent in their series of patients).2 Cannell et al. described 34 patients with maxillofacial injuries in a cohort of emergency helicopter transfer patients, with “severe hemorrhage” occurring in seven patients, six of whom died.4 As with our group of patients, many had

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concomitant head injuries, making the contribution of the facial hemorrhage difficult to assess. In their review of life-threatening complications in maxillofacial trauma, Ardekian et al. showed a variability in the reported incidence of massive hemorrhage from 0 percent to 11 percent of facial trauma.8 Bynoe et al.1 examined 912 cases of facial injuries and found the incidence of life-threatening hemorrhage to be 1.2 percent. Buchanan and Holtmann3 highlighted the danger of epistaxis in facial fracture patients and reported an incidence of 11 percent of 312 midface fracture patients as having “significant epistaxis.” There was, however, no definition of what was considered significant epistaxis. The true incidence of massive facial fracture hemorrhage in different centers is not clear because there is no agreed upon definition of the phenomenon at present. To make meaningful comparisons among experiences, both the numerator and the denominator must have agreed definitions (i.e., what is massive facial fracture hemorrhage and which facial fractures should be included in study populations). We propose that a classification of facial fracture hemorrhage (Fig. 7) be adopted and the term “massive facial fracture hemorrhage” be used to mean hemorrhage of a defined type as described in the Patients and Methods section of this article and in Figure 7.

Creating such a classification would improve awareness of the need to look for and treat facial fracture hemorrhage within the framework of the Advanced Trauma Life Support survey, would aid further research in this field, and would allow better communication between referring physicians about such patients.

The increased number of cases of massive facial fracture hemorrhage in the 12 months following the retrospective study may represent a real increase in incidence. Improved paramedical and retrieval services could be factors contributing to this pattern. The veracity of this trend needs to be verified by further study.

Delay in Appropriate Treatment This study highlights the fact that hemorrhage from facial fractures is sometimes underestimated as a cause of hypovolemia and consequently not arrested early. This can have potentially fatal consequences for patients. Perry et al.9 commented in their review of facial injuries that unrecognized bleeding was common and that this was often because a significant amount of blood can be swallowed by the patient. Tung et al.10 also reported delayed recognition of severity of facial fracture

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Fig. 7. Classification of facial fracture hemorrhage.

hemorrhage and attributed two of the five deaths in their cohort to this delay in diagnosis. They found that 19 of 64 patients with facial fractures had hemorrhagic shock. As in our study, they reported one patient whose nasopharyngeal bleeding was treated with nasal packing alone; the patient proceeded to negative laparotomy before the magnitude of the bleeding from the face was recognized.

Delay in diagnosis may be due in part to the rarity of facial fractures being the main source of bleeding in multitrauma patients. Perry et al. commented, “When hypovolemic shock is present, facial injuries are unlikely to be the sole cause.”9 While it is true that in any large group of multitrauma patients only a few will have hypovolemic shock due to facial fracture bleeding, we would suggest that this does not mean that it should be assumed that the hypovolemic shock is due to some other injury. We have shown that this assumption leads to delayed treatment of the facial fracture hemorrhage, with significant consequences.

Method of Arrest of Hemorrhage Although there were few patients in this study who were treated with nasal packing alone, none survived. In Tung et al.’s series,10 a patient treated initially with nasal packing alone also died, and it seems reasonable to conclude that nasal packing alone is an inadequate treatment for patients with massive hemorrhage from facial fractures. The case studies described showed that balloon catheters can be effective for arresting hemorrhage, either alone or in combination with other maneuvers. Cannell’s group also adopted the use of bal-

loon catheters (epistats) and sometimes used these in conjunction with looped wire reduction of the fractures and mouth props.4 Perry et al. also advocated the use of mouth props and wires to hold fractures in reduction.9 We did not use intermaxillary fixation or plate-and-screw fixation of fractures acutely. It was contemplated in case 1, but the degree of hemorrhage precluded the visualization necessary for accurate fracture reduction and placement of small screws and plates.

Although we understand there may be a place for intermaxillary fixation in holding the reduction of some maxillary fractures, it is important to consider that in most of our cases the site of the fracture (and bleeding) was between the maxilla and the skull base or upper face and that securing the maxilla to the mandible cannot compress this site. In addition, the logistics of intermaxillary fixation can be difficult; placement of full wire intermaxillary fixation is time-consuming and dependent on good dentition. Quicker “four-screw” intermaxillary fixation is likely to be insufficient when both the mandible and maxilla are fractured.

Lynham et al. briefly describe the management of bleeding in the facial fracture patient, mentioning reduction and wire fixation and nasal packing and balloon catheters as well as vessel ligation.11 Yang et al. advocate an algorithm for early embolization, although their recommendation is based on a single case.12 None of these studies had enough patients for a statistical comparison of methods. Bynoe et al. have, however, shown some evidence that embolization of facial vessels by radiological methods is at least as effective as vessel ligation.1 The avail-

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Plastic and Reconstructive Surgery • February 2009 ability of these techniques will vary among hospitals, but it would seem, from the evidence in this study and in other literature, that what is important is the early recognition of the magnitude of the hemorrhage and the early arrest of hemorrhage by some means. Our group would advocate early orogastric intubation with a large-bore tube.

This allows aspiration of swallowed blood and hence more accurate assessment of blood loss, and does not incur the risks of nasogastric intubation.

We would agree with Perry et al. that facial hemorrhage should be treated at the “C� stage of the Advanced Trauma Life Support survey9 and treatment should not wait for secondary surveys and so on, by which time the patient may be irreversibly hypovolemic.

As massive hemorrhage from facial fractures is an unusual occurrence in the experience of individual treating doctors, we would agree with Yang et al.12 that a guiding algorithm or protocol would be helpful. We have developed guidance for arrest of bleeding in facial fracture hemorrhage and a broader protocol for emergency management of patients with facial fracture hemorrhage (Figs. 8 through 10). It should be noted that our protocol advocates embolization in cases of persistent bleeding. This is because although there were no cases of embolization in our series, we were convinced that it was the occlusion of the bleeding vessels that was the important factor in success,

Fig. 8. Procedure for arrest of facial fracture hemorrhage.

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Fig. 9. Position of catheters (note that the endotracheal tube is also likely to be present).

rather than the mechanism by which the occlusion was achieved; in addition, the literature indicates that radiological embolization is just as effective as surgical ligation and has less morbidity.1 There was a high rate of tracheal intubation in this group of patients, and early airway protection was obviously an important element of their care.

Two patients in this group who were not intubated died, although it was difficult to assess whether loss of airway control was a contributing factor to death. Ardekian et al. pointed out the variation in

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Fig. 10. Protocol for emergency management of facial fracture hemorrhage.

percentage of tracheostomies carried out (between 0.9 percent and 12.3 percent) and themselves discussed the problem of the heterogeneity of the facial fracture populations studied. They came to the conclusion that earlier diagnosis and treatment would improve the prognosis of those with life-threatening complications of maxillofacial trauma.8

The common thread through all the literature on hemorrhage in facial fractures is that it is rare but life-threatening and that its life-threatening nature is often not perceived by the doctors looking after these patients. This failure of recognition leads to failure to arrest the hemorrhage in a timely manner. We believe that the key to improving the prognosis of this group of patients is to

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Plastic and Reconstructive Surgery • February 2009 promote awareness of this phenomenon and promote a safe and straightforward primary management protocol. Classification of hemorrhage in facial fractures should be used in all patients with a midface or skull base fracture. Recording a class of hemorrhage in each of these patients will ensure the treating primary doctor will properly assess this aspect of the facial injuries. Protocols for assessment and treatment of this condition should be included and taught in Advanced Trauma Life Support courses. We propose a classification of facial fracture hemorrhage and a definition of massive facial fracture hemorrhage as described in the Patients and Methods section of this article.

We recommend that these be adopted for the purposes of further research and interhospital auditing and communication, as well as for optimizing the management of individual patients.

Nicola R. Dean, Ph.D., F.R.C.S.(Eng.), F.R.A.C.S.(Plas.)

Department of Surgery Flinders Medical Center Bedford Park Adelaide SA 5042, Australia nicoladean@iprimus.com.au

ACKNOWLEDGMENTS

The authors acknowledge the contribution of the patients who gave their consent for photographs to be used in this article. They also acknowledge the contributions of Lesley Ward, Department of Medical Records, Royal Adelaide Hospital, and the photographers of the Department of Clinical Photography, Royal Adelaide Hospital.

REFERENCES 1. Bynoe RP, Kerwin AJ, Parker HH, et al. Maxillofacial injuries and life-threatening hemorrhage: Treatment with transcatheter arterial embolization. J Trauma Injury Infection Crit Care 2003;55:74–79.

2. Gwyn PP, Carraway JH, Horton CE, et al. Facial fractures: Associated injuries and complications. Plast Reconstr Surg.

1971;47:225–230.

3. Buchanan RT, Holtmann B. Severe epistaxis in facial fractures. Plast Reconstr Surg. 1983;71:768–770.

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Plastic Surgery Educational Foundation Mission Statement The mission of the Plastic Surgery Educational Foundation® is to develop and support the domestic and international education, research, and public service activities of plastic surgeons.

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