Just got back from Toronto, where I learned about Chubby Bunny.
But what we are actually going to talk about today is the management of Severe Hemorrhage from Mid-Face Blunt Trauma
Algorithm
Take the Airway
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
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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Scott Weingart
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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…
Love it Ryan-thanks
Don’t say we never taught you anything Scott!!
chubby bunny!!!!!! wash it down with some milky bag.
Ram
Can’t type, too many marshmallows in my mouth : )
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.
Thanks for clearing that:-)
Glad you have amended the rapid rhino in the show notes. It will still work but without the same haemostatic effect. Love the show.
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.
I was just wondering the same thing myself.
crash retrograde always seems like such a clever idea when speaking theoretically, but it doesn;t have a great track record in real life scenarios. Not saying it couldn’t work, just that it usually doesn’t and then you’ve burned a bunch of time.
much better move imho is to just do the cric, temporize with packing and then intubate from above with bougie or bronch and remove the cric while you are still in the ED
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
Thanks so much for sharing that case Peter!!
I have heard of soaking a rapid rhino in epinephrine to provide some vasoconstriction. Do you have any thoughts on this practice?
we soak in TXA