Maxillofacial Injury - management of exsanguinating haemorrhage from deforming midface trauma

Introduction

• exsanguinating haemorrhage from midface trauma is a rare but potentially catastrophic event 

Temporary splinting of severe midface injury

• the following is an approach to pack and splint the midface to control exsanguinating haemorrhage as a bridge to definitive treatment 

Indication

• ongoing uncontrollable life-threatening haemorrhage following significant deforming facial fractures 

Potential complications

• failure to secure airway  

• malpositioning of nasal tamponade devices 

• potential worsening of any associated lower face fractures

Equipment

• intubation equipment 

• nasal tamponade device x 2 

• bite block x 2 

  • bite blocks can be fashioned by cutting a 7.5cm crepe bandage in half 

• cervical spine collar (hard collar) 

Procedure

1. Intubate the patient

• Obtain URGENT ENT and Anaesthetic support 

  • maxillo-facial injury will usually be a predictor for a difficult intubation  

  • intubation will be difficult due to bleeding within the oropharynx 

• Suction Assisted Laryngoscopy and Airway Denomination (SALAD)  

  • a technique where the intubator leads with large bore suction to decontaminate the airway (see demonstration video) 

  • if large bore suction is not available utilise TWO standard yankauer suction devices 

• consider intubating the patient sitting upright 

• be prepared to perform a surgical airway PRIOR to commencing intubation 

2. Insert Rapid Rhino nasal tampanade device (or equivalent)

• insert one Rapid Rhino (see demonstration video) into each nostril 

  • pre-soak Rapid Rhino in sterile water for at least 30 seconds 

  • insert Rapid Rhino into the patient’s nostril parallel to the septal floor, or following along superior aspect of the hard palate, until the blue indicator is just past the nares (inside opening of nostril) 
    

    
    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

     

  • tape the strings/pilot balloons of the device against the face to avoid migration posteriorly 

  • do not inflate the balloons at this stage – if they nasal space is expanded without bracing the maxilla against the mandible further bleeding can occur 

3. Place bite locks 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 

• if a bite block is not readily available one 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. 

4. Place a hard cervical spine collar to brace the mandible up

5. Inflate the Rapid Rhinos

• using a 20mL syringe slowly inflate the Rapid Rino device with AIR only 

  • monitor the pilot cuff for direct tactile feedback 

  • stop inflation when the pilot cuff becomes rounded and feels firm when squeezed
    

    

Post procedure care

• patient will need urgent ORL or maxillofacial review and either angiography or operative management