What is the best practice for emergency management of bleeding mid face fractures?

Emergency Management of Bleeding Midface Fractures

Immediate nasal packing combined with temporary fracture reduction is the first-line intervention for controlling life-threatening hemorrhage from midface fractures, with early surgical intervention or angiographic embolization reserved for cases where packing fails. 1, 2, 3

Immediate Assessment and Initial Control

Rapid Clinical Evaluation

• Assess the extent of hemorrhage using the American College of Surgeons Advanced Trauma Life Support (ATLS) grading system to classify blood loss severity 4
• Recognize that massive bleeding from midface fractures, while uncommon (0.33-1.7% incidence), carries high mortality if not promptly controlled 5
• Critical pitfall: Delays in recognizing that facial fractures are the major source of hemorrhage occurred in 26% of cases in one series, contributing to mortality 5

Airway and Breathing Management

• Secure the airway as the absolute first priority before addressing bleeding 6
• Avoid hyperventilation and excessive positive end-expiratory pressure in severely hypovolemic patients, as this decreases cardiac output 4, 7
• Administer high-flow oxygen to maintain tissue oxygenation 7

Primary Hemorrhage Control

First-Line Intervention: Nasal Packing with Fracture Reduction

• Apply immediate nasal packing as the primary intervention - this successfully controlled bleeding in 90% of patients in one series 2
• Combine nasal packing with temporary fracture reduction in 70% of cases to optimize bleeding control 2
• Ensure adequate packing technique, as inadequate initial packing is a common cause of treatment failure 1
• Recognize that bleeding typically originates from the nasal cavity and associated structures (sinuses, skull base, nasopharynx), even when blood presents in the oral cavity 3

Resuscitation During Hemorrhage Control

• Establish large-bore intravenous access immediately 7
• Target systolic blood pressure of 80-100 mmHg until bleeding is controlled (permissive hypotension) in patients without brain injury 4, 7
• Important caveat: This permissive hypotension strategy does NOT apply to patients with concomitant head injury, who comprised 32% of massive facial hemorrhage cases in one series 5
• Initiate crystalloid resuscitation, adding colloids within prescribed limits 4, 7
• Anticipate significant transfusion requirements - mean of 9.5 units packed red cells in massive midface hemorrhage 5

Escalation for Refractory Bleeding

Timing of Intervention

• Minimize time between injury and definitive intervention - delays in surgical control increase mortality 4
• If initial nasal packing fails to control hemorrhage, proceed immediately to advanced interventions 1

Surgical Intervention

• Early operative intervention successfully controlled bleeding in approximately 50% of cases requiring escalation beyond packing 1
• Direct surgical bleeding control with packing and local hemostatic procedures should be attempted before vessel ligation 4
• Consider damage control surgery principles in patients with deep hemorrhagic shock, ongoing bleeding, and coagulopathy 4, 7

Angiographic Embolization

• Angiography with embolization can be used alone or as an adjunct to surgery with good results 1
• This modality is particularly valuable when surgical exploration fails to identify or control the bleeding source 1
• Consider early angiographic embolization for patients with ongoing hemodynamic instability despite adequate initial interventions 4

Diagnostic Workup During Stabilization

Laboratory Monitoring

• Obtain baseline complete blood count, prothrombin time, activated partial thromboplastin time, and fibrinogen 7
• Do NOT rely on single hematocrit measurements as an isolated marker for bleeding 4, 7
• Monitor serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 4, 7

Imaging Considerations

• Perform focused abdominal sonography for trauma (FAST) to exclude concomitant torso bleeding in polytrauma patients 4, 7
• Hemodynamically stable patients with high-energy mechanisms should undergo CT to identify associated injuries 4, 7
• Remember: Most patients with massive midface hemorrhage have multiple other injuries requiring evaluation 5

Coagulopathy Management

Antifibrinolytic Therapy

• Consider tranexamic acid (10-15 mg/kg bolus followed by 1-5 mg/kg/h infusion) in bleeding trauma patients 4, 7
• This is particularly relevant given the coagulopathy risk in patients with systolic blood pressure below 70 mmHg 4

Temperature Control

• Actively warm the patient and all transfused fluids to prevent hypothermia, which exacerbates coagulopathy 7

Critical Pitfalls to Avoid

• Delayed recognition: Facial fractures may be overlooked as the major hemorrhage source in polytrauma patients 5
• Inadequate initial packing: Failure to achieve proper nasal packing technique leads to unnecessary escalation 1
• Excessive delay before escalation: When packing fails, proceed rapidly to surgery or angiography rather than repeated inadequate packing attempts 1
• Inappropriate ventilation: Hyperventilation worsens outcomes in hypovolemic patients 4, 7
• Ignoring permissive hypotension contraindications: Patients with head injuries (32% of cases) require different blood pressure targets 5