Podcast 110 – Exsanguinating Hemorrhage from Mid-Face Fractures

crush-head

Just got back from Toronto, where I learned about Chubby Bunny.

Chubby_Bunny_(gluttony)-by Derby

Chubby Bunny by Derby

But what we are actually going to talk about today is the management of Severe Hemorrhage from Mid-Face Blunt Trauma

Algorithm

Ann Plast Surg 2012;69:474

mid-face-algo

Take the Airway

Suction-as-you-go ETT Set-up

Partner Suction a la Strayer

These airways are all Cricon 3

Anterior Packing

I use Rapid-Rhino 5.5 cm but you go with whatever you are comfortable with. Soak it in STERILE WATER, not saline despite what i blathered in the audio (Thanks Brent!)

Posterior Packing

We use foleys in preference to commercial devices for standard epistaxis. This series explains why: (Injury. 2003 Dec;34(12):901-7. Complications with use of the Epistat in the arrest of midfacial haemorrhage.)

Use 12 – 14F (or whatever you got)

Witness passage into the posterior pharynx from both foleys with laryngoscope

Inflate a smaller volume first (6-8 mL) and then apply traction until it wedges, this allows the balloon to wedge in the posterior choana

Inflate to 20 ml

Apply traction

I use the system at the end of this video on Blakemore Passage

Reapply the anterior packs bilaterally

Temporary Fracture Fixation

trans-palat-fix

Image from Injury  Volume 34, Issue 12, December 2003, Pages 901–907 Holmes et al. From that article, “When there is a mid-palatal split, however, this haemostatic technique will possibly fail and additional measures will be required to achieve haemostasis. The split palate should be stabilised with a transpalatal circumdental wire , before placing packing.”

Angiography

IR of the internal maxillary is usually what is needed

May also be branches of ethmoidal in skull base fx

TXA for Epistaxis

EM Lit of Note’s Review

McKesson Oral Prop?

EMJ 2010; 27 :156 e 158. doi:10.1136/emj.2008.070219

Anyone know about this? Comment in the show notes.

Additional References

  • Case Discussion (Ann Plast Surg 2–1;46:159)
  • Case Series on IR (J Trauma 2003;55:74)
  • Another Case Series on Management (J Trauma 2008;65:994)
  •  A Decade’s experience with balloon tamponade fro traumatic hemorrhage (The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 70(2), February 2011, pp 330-333)
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Comments

  1. Pretty sure the Rapid Rhino should only be wet in water, not saline, or else the haemostatic agent is partially deactivated.

    • Brent, That is real time peer review–love it! Thanks, just made the correction above.

      • Scott, while you’ve never covered it, we’ve had success in using hemostatic gauze in the prehospital setting for oral bleeds if we can see the site of bleeding within the oral cavity. Z-Medica,(no conflicts..just a great product)make a 4×4 with hemostatic agents. Using those and long hemostat, or magills makes it easy to get bleeding to stop in the posterior oropharynx…

  2. Ram Reddy says:

    Don’t say we never taught you anything Scott!!

    chubby bunny!!!!!! wash it down with some milky bag.

    Ram

  3. Hi Scott

    I hope you forgive a question that might be stupid, but why even bother with a regular tube? Why not just do the surgical airway right of the bat. I imagine in consequent surgeries and or interventions the endotracheal tube will only be disturbing in the field anyway.

    • b/c the surgical airway you offer, the cric, should only be in place for a day. Emergent trachs don’t usually work out as nicely. So if you get an ETT, then the surgeons will do a trach as the 1st part of their operation in the OR with good lighting and no emergency.

  4. Rob McDonald. says:

    Glad you have amended the rapid rhino in the show notes. It will still work but without the same haemostatic effect. Love the show.

  5. David Cowan says:

    Scott,

    Maybe it has been mentioned before, but what is your take on doing a wire retrograde cric on a patient that is bleeding from the midface like this? It seems like one of your partners could be attempting this while you are trying to intubate. If you get the tube, they can stop and you haven’t done anything too invasive with the retrograde attempt. If you don’t get the tube, you should be seeing their wire any second to pass your tube over.

  6. Peter Fritz says:

    Hey Scott,
    Glad I listened to this post recently. While coordinating retrievals the other day I got called about a 85yo guy that hit the steering wheel with his face without a seatbelt. By the time the paramedics got to him many hours later, as he was on an isolated farm, he had BP 70, HR170 and a GCS 3 from the facial bleeding alone! GCS and haemodynamics improved after 2 L crystalloids but he was still hosing out when they rang me. I suggested the 2 foleys as you described and the bleeding subsided enough for them to be able to intubate safely and stabilise his haemodynamics for the chopper ride to Melbourne.
    Thanks for the post.
    Cheers

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