Immediate Management of Suspected Internal Bleeding and Missed Facial Fractures in the ER
Patients with suspected internal bleeding and missed facial fractures require immediate intervention focused on hemorrhage control and airway management. 1, 2
Initial Assessment and Stabilization
- Immediately assess for hemorrhagic shock using ATLS classification (based on vital signs, mental status, and urine output) to determine severity of blood loss 1
- Secure the airway first, as facial fractures can compromise airway patency through bleeding, edema, or anatomical distortion 3
- Control external bleeding with direct pressure, nasal packing, or temporary fracture reduction if significant facial hemorrhage is present 4, 5
- Perform rapid assessment for signs of intracranial hemorrhage, including seizures and vomiting/nausea, which are the strongest predictors of intracranial bleeding in facial fracture patients 6
Diagnostic Approach
- For suspected torso trauma with possible internal bleeding, immediately perform ultrasonography (FAST) or CT imaging to detect free fluid 1, 2
- Hemodynamically stable patients should undergo comprehensive CT imaging to identify the source and extent of bleeding 1, 2
- Include contrast-enhanced CT with delayed urographic phase if urinary tract injury is suspected (indicated by gross hematuria and lower abdominal bruising) 7
- Remember that a negative FAST examination does not exclude retroperitoneal bleeding or specific organ injuries 7
Management Algorithm Based on Hemodynamic Status
For Hemodynamically Unstable Patients:
- Urgent intervention is required rather than additional imaging 2, 8
- Patients with significant free intra-abdominal fluid and hemodynamic instability should undergo immediate surgical intervention 1, 8
- Apply damage control surgery principles with rapid control of hemorrhage as the primary goal 8
- For pelvic fractures with ongoing bleeding, implement concurrent pelvic stabilization (external fixation or pelvic binder) 8
For Hemodynamically Stable Patients:
- Perform comprehensive CT imaging to identify all injuries 1, 2
- Consider angiography and potential embolization for persistent bleeding, particularly with pelvic fractures 2, 5
- Evaluate for intracranial hemorrhage, especially if risk factors like seizures, vomiting/nausea, or cranial vault fractures are present 6
Critical Considerations
- Be aware that facial fractures are often associated with other injuries, including head trauma, thoracic, abdominal, and genitourinary injuries 1
- High-energy mechanisms (like motor vehicle crashes) producing facial fractures have a higher likelihood of causing severe internal bleeding 1, 9
- Mortality increases approximately 1% every 3 minutes of delay in controlling significant internal hemorrhage 8
- The incidence of massive hemorrhage from facial fractures is relatively low (0.33-1.7%), but carries a high mortality rate when it occurs 9
- In patients with facial fractures, even those without obvious symptoms, approximately 1.2% may have intracranial hemorrhage requiring intervention 6
Common Pitfalls to Avoid
- Failing to recognize facial fractures as a potential source of significant hemorrhage, which can lead to delayed intervention 9
- Relying solely on FAST examination to exclude significant bleeding, as it has limited sensitivity for specific injuries 7
- Neglecting to assess for intracranial hemorrhage in facial fracture patients, even when classic symptoms are absent 6
- Delaying intervention in hemodynamically unstable patients with free intra-abdominal fluid 1, 8