Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient

doi:10.1016/j.ijom.2007.11.005

International Journal of Oral and Maxillofacial Surgery

Volume 37, Issue 5, May 2008, Pages 405-414

https://doi.org/10.1016/j.ijom.2007.11.005 Get rights and content

Abstract

Hypovolaemic shock is a common cause of morbidity and mortality following trauma, accounting for approximately 30% to 40% of trauma deaths. Life-threatening blood loss from the maxillofacial region is uncommon, but represents one of a number of possible sites which must be rapidly identified and controlled. Bleeding from the face may not be obvious especially in awake, supine patients and it poses an obvious threat to the unprotected airway. Identification requires careful assessment. Control of bleeding in the maxillofacial region requires a number of correctly sequenced techniques. Computerized tomographic imaging is now playing an increasingly important role in identifying blood loss, especially in the chest, abdomen and pelvis. This need may potentially result in the transfer of patients, with unrecognised facial injuries, outside the relative safety of the emergency department. The concepts of the ‘lethal triad’ and ‘biologic first hit’ have resulted in new strategies in managing the profoundly shocked patient, although some of these remain controversial. Debate continues over the optimal blood pressure, fluid administration and role of surgical intervention in the actively bleeding patient. These may have an impact on the timing and extent of any proposed maxillofacial repairs, and are discussed.

Section snippets

Hypovolaemia and facial injuries in the multiply injured patient

Advances in trauma care continue to improve outcomes in patients following injury². Yet, despite even the best efforts, major or multisystem trauma still carries significant morbidity and mortality. One of the commonest causes of mortality in the severely injured patient is hypovolaemic shock, which is often treatable if recognised early. Haemorrhage is responsible for 30%–40% of trauma mortality31, 88 Life-threatening facial haemorrhage is relatively uncommon⁸⁶ in the multiply injured patient,

What is shock?

Shock is defined as “a profound haemodynamic and metabolic disturbance, characterized by failure of the circulatory system to maintain adequate perfusion of the vital organs”²². In trauma this is usually as a result of acute blood loss, although other causes exist (or may co-exist).

Research has now shown that a ‘lethal triad’ of acidosis, hypothermia and coagulopathy combine to produce the so-called ‘biologic first hit’, the magnitude of which is directly related to mortality34, 85 This triad

Initial considerations during evaluation

Patients can rapidly lose significant amounts of circulating blood into their abdomen, pelvis, chest, retroperitoneal space and around fracture sites in the limbs. They can also lose significant amounts externally, through open wounds. Loss of blood sufficient to result in life-threatening shock can potentially occur into just one of these sites following penetrating injuries, or it can occur at multiple sites following high-velocity blunt trauma. In some cases the site of blood loss may be

Where is the patient bleeding?

Once ‘A’ (airway) and ‘B’ (breathing) have been addressed, the next step is ‘C’ – circulation and control of haemorrhage. Priorities at this stage of the primary survey are to stop any obvious and significant blood loss and establish wide-bore intravenous access. The statement “any cold and tachycardic patient should be considered to be in hypovolaemic shock until proven otherwise”² is helpful in the rapid identification of such patients. Although the earliest clinically measurable sign of

Fluid administration, optimal blood pressure and permissive hypotension

The administration of intravenous fluids in hypotensive trauma patients is currently one of the most controversial issues in trauma. The ‘end points of resuscitation’, i.e. those physiological parameters which indicate we can safely transfer the patient, are still not clearly defined in the literature – this is often a clinical decision.

There are two different types of haemorrhagic shock in trauma.

1.
‘Controlled haemorrhagic shock’ (CHS) in which the bleeding source has been identified and

Crystalloids or colloids?

Another common dilemma is which type of fluid should be given during resuscitation? For many years the choice has been between crystalloids and colloids, but more recently there has been interest in the use of hypertonic saline.

Crystalloids are safe, inexpensive and equibrilate rapidly throughout the extracellular compartment, restoring the extracellular fluid deficit associated with blood loss and tissue swelling. In many centres their use has become routine in the initial treatment of injured

Hypertonic saline

More recently, a number of clinical and experimental studies have shown some benefits in using small volumes of hypertonic saline solution (approximately 250 ml) as an initial fluid bolus following acute blood loss. Many of these benefits relate to an anti-inflammatory effect. Hypertonic saline, given early enough, has been shown to reduce inflammation by down-regulating neutrophil activation and reducing gut ischaemia²¹, up-regulating anti-inflammatory cytokines⁵⁷, and reducing capillary leakage

Blood, blood components and pharmacological products

ATLS teaches that blood may be required in patients who remain in shock following the administration of 2 l of crystalloid. The use of blood in resuscitation remains controversial, as it has been shown that transfusion is not always necessary and in some circumstances may be harmful. Blood does have an obvious advantage over other fluids due to its oxygen-carrying capacity, although this is not maximal following initial transfusion. ‘Massive’ transfusions have been shown to be associated with

Damage control⁷¹

Despite these advances in the understanding of fluid resuscitation, almost one third of all trauma deaths are still directly related to blood loss, and the management of the profoundly shocked, multiply injured patient is another controversial topic in the literature. New strategies in the management of these patients can have a major impact on the early management of craniofacial injuries¹¹. It has been shown that just a single episode of hypotension, no matter how brief, can double the

‘The patient's still bleeding’

In the presence of persistent haemorrhage, despite appropriate interventions, it is important to consider coagulation abnormalities, either pre-existing (e.g. haemophilia, chronic liver disease, warfarin therapy) or acquired (e.g. dilutional coagulopathy from blood loss or disseminated intravascular coagulation). Emergency surgical intervention may be required as part of the primary survey: ‘C – circulation with control of haemorrhage’. If so, it is important to remember that the secondary

Supra-selective embolization

This is increasingly being reported as an effective alternative to surgical ligation in life-threatening facial haemorrhage. The use of supra-selective embolization in trauma is still controversial, but has been reported to be very successful with certain obvious advantages over surgery. It is increasingly used in extremity trauma and bleeding secondary to pelvic fractures1, 18, 81, and is now well documented as a successful treatment modality in penetrating injuries¹⁰, blunt injuries and

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Cited by (25)

MOXAIC: A classification of major maxillofacial wounds, concerning 310 cases
2022, Journal of Stomatology, Oral and Maxillofacial Surgery
Although classification for facial fractures have been extensively described in the literature, corresponding systems for major maxillofacial wounds (MMW) are few. We would like to present MOXAIC: a new classification system for MMW.
A retrospective study of 310 patients with MMW who underwent emergency operation between January 2005 and December 2016. MMW was defined as a facial wound longer than 10 cm, which includes damage to the craniofacial bone or other important facial structures such as the carotid arteries, facial nerves, parotid gland, Stensen's duct, or the eye. All the patients were followed at least 36 months.
Based on the shape of the wound, the severity, and the mechanism of injury we were able to classify the MMW into five types: O, X, A, I, C. For each wound type we then looked at the treatment required and the outcome, objectively classified as good, satisfactory, or poor, concerning anatomical correction, aesthetics, and function.
+ Type OCircumferential wound: 81.6% result good.
+ Type X-Oblique wound: only 48.1% good, despite initial multidisciplinary approach.
+ Type A-Transverse facial wound: 78.1% good.
+ Type I-Direct wound: Immediate airway management and hemorrhage control are important. 48.8% good.
+ Type CCut wound: 88.1% good.
The above classification was named MOXAIC which is a mnemonic of 'Maxillofacial' and the five wound types: O, X, A, I, C.
This classification is highly reproducible, easy to use, and allows quick treatment work up and prognosis. However, this classification requires further specialist review and study.
Factors affecting survival following self-inflicted head and neck gunshot wounds: A single-centre retrospective review
2016, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
On presentation, the patient with a SIHNGSW may be hypotensive and active bleeding may be minimal. On administration of fluids, the patient's blood pressure may rise, and bleeding – both obvious and occult – may recommence.16 This is referred to colloquially as the ‘pop the clot’ phenomenon.
Self-inflicted head and neck gunshot wounds are a common modality of suicide in the USA. This study reviewed all self-inflicted head and neck gunshot wound patients with complete records (n = 157) treated at a tertiary centre between 2002 and 2012 inclusive. The associations between mortality and patient/clinical variables were evaluated with the χ² test or Fisher's exact test for statistical difference testing. Outcomes recorded were death (n = 92, 59%), discharge to long-term care/rehabilitation (n = 58, 37%), and discharge home (n = 7, 4%). The majority of patients were male (86.6%) and single/separated/divorced (55.5%). The mortality rate by site, in descending order, was temporal 82%, frontal scalp 69%, submental/intraoral 30%, and neck 25%. Involvement of the central nervous system (n = 127) resulted in a 70% mortality, but a lower mortality was observed among patients with an avulsion injury (P = 0.025). A tracheostomy within 24 h of admission was statistically associated with improved survival (P < 0.001), but confounding factors were found. Multivariate analysis revealed increasing age, temporal entry site, and the severity of central nervous system involvement to be positively associated with an increased mortality.
Maxillofacial trauma in the emergency department: A review
2014, Surgeon
Citation Excerpt :
The authors recommend the use of nasal tampons initially rather than catheters as these can displace fractured facial bones on inflation (see Fig. 5). Once haemostasis is achieved, maxillofacial injuries do not always require immediate formal repair.32 Temporary stabilization may be the most appropriate option, thereby allowing for resuscitation, prioritization of injuries, planning of investigations and procedures.
In 1978 the Advanced Trauma Life Support guidelines were first implemented and are viewed by many as the gold standard of care in the emergency setting.
It may not be immediately obvious where assessment and management of maxillofacial injuries fits within these trauma guidelines. This article aims to provide a concise, contemporary guide for the treatment of maxillofacial trauma in the emergency setting.
An electronic database search was conducted in PubMed and Science Direct on articles from 1970 to the present day. The key search terms were Maxillofacial, Trauma, ATLS, Advanced Trauma Life Support, EMST, Early Management of Severe Trauma, Airway, Eye, Ophthalmic and Management. The findings were compiled into a review article. The article was then reviewed by experts in the fields of Maxillofacial Surgery and Ophthalmology to ensure content and contextual accuracy.
Physicians are becoming increasingly exposed to major maxillofacial injuries. Resuscitative measures can be complex and require prompt decisions especially in gaining a secure airway. A proposed treatment algorithm for maxillofacial trauma patients has been devised by the authors.
It is imperative that sight preserving assessment and interventions are not forgotten in the emergency management of maxillofacial trauma. We propose an algorithm for the management of maxillofacial trauma, and recommend the use of CT as a powerful adjunct to clinical examination in patients with maxillofacial trauma.
Damage control applied to severe maxillofacial trauma
2014, Revue de Stomatologie, de Chirurgie Maxillo-faciale et de Chirurgie Orale
Le damage control se définit par la mise en œuvre en urgence extrême d’un premier temps de réanimation et chirurgical, ne cherchant pas à réparer les lésions, mais à rétablir un fonctionnement physiologique correct. Ces dernières années, le damage control a considérablement amélioré la prise en charge des polytraumatisés, notamment en chirurgie de guerre. En traumatologie maxillofaciale, la détresse respiratoire et le choc hémorragique sont des urgences vitales immédiates. Nous exposons les spécificités d’une prise en charge type damage control chez le traumatisé maxillofacial grave. Des critères cliniques et biologiques ont été définis pour décider d’une prise en charge type damage control, chez les patients présentant des hémorragies faciales massives post-traumatiques. La phase initiale rapide rétablit les fonctions vitales : les voies aériennes sont libérées et sécurisées : intubation orotrachéale, cricothyroïdotomie, puis trachéotomie chirurgicale. L’hémostase des vaisseaux faciaux est réalisée par différents moyens : packing, tamponnement nasal, radio-embolisation, ligature sélective puis carotidienne externe si besoin. La phase de réanimation équilibre les éléments de la triade létale : hypothermie–coagulopathie–acidose métabolique. La deuxième phase intervient à distance, son but est la réparation anatomique lésionnelle. La prise en charge du traumatisé maxillofacial grave correspond à un damage control, avec ses spécificités.
Damage control is defined by the extreme emergency implementation of a first resuscitation and surgical step, during which there is no attempt at repairing lesions but only at restoring adequate physiological function. In recent years, “damage control” has considerably improved the management of polytrauma patients, especially in war surgery. Respiratory distress or hemorrhagic shock requirements are critical maxillofacial emergencies. We present the specificities of “damage control” management for patients with severe maxillofacial trauma. Some clinical and biological criteria have been defined to choose “damage control” strategy, in patients presenting with life-threatening facial hemorrhage after facial trauma. A rapid initial stage restores vital functions. Airways are maintained and secured: oro-tracheal intubation, cricothyroidotomy, surgical tracheotomy. Facial bleeding is controlled with various means: oronasal packing, angiographic embolization, selective ligation then external carotid artery if necessary. The resuscitation step stabilizes the lethal triad: hypothermia, coagulopathy, metabolic acidosis. The second step that comes in later is a surgical repair of facial injuries. “Damage control” can be adequately applied to the management of patients with severe maxillofacial trauma.
Initial Assessment and Intensive Care of the Trauma Patient
2012, Oral and Maxillofacial Trauma
Patterns of maxillofacial injuries caused by terrorist attacks in Iraq: Retrospective study
2011, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Unless they are associated with injuries to other vital structures, maxillofacial injuries rarely cause death. Life-threatening facial hemorrhage has been reported in up to 10% of major facial injuries14. In this study, four victims died from pure maxillofacial injuries, three of them having severe trauma to the mid face.
Over the past 5 years, Iraq has witnessed daily terrorist attacks mainly using improvised explosive devices. The aim of this study was to analyze the patterns of maxillofacial injuries caused by terrorist attacks in a sample of Iraqi casualties. Records from two hospitals, including 551 patients who sustained maxillofacial injuries due to terrorists attacks, were analyzed according to the patients’ age, sex, site of injury, type of injury and cause of injury. Concomitant injuries and mortality were also considered. The most common age group affected was those aged 15–29 years. Most of these injuries were caused by improvised explosive devices (71%). More than one facial zone was injured in 212 patients (38%). Isolated soft tissues injuries were detected in (54%) of victims. Pure maxillofacial injuries comprised 33%. The most common injuries associated with this type of trauma were eye injuries (29%). The mortality rate was 2% from pure maxillofacial injuries. Terrorist attacks cause unique maxillofacial injuries, which should be considered a new entity in the trauma field.

View all citing articles on Scopus

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Invited Review PaperTraumaAdvanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient

Abstract

Section snippets

Hypovolaemia and facial injuries in the multiply injured patient

What is shock?

Initial considerations during evaluation

Where is the patient bleeding?

Fluid administration, optimal blood pressure and permissive hypotension

Crystalloids or colloids?

Hypertonic saline

Blood, blood components and pharmacological products

Damage control71

‘The patient's still bleeding’

Supra-selective embolization

Injury

J Vasc Interv Radiol

Injury

J Emerg Med

Injury

Injury

Injury

Injury

Lancet

Ann Fr Anesth Reanim

J Surg Res

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Curr Surg

Resuscitation

Injury

J Am Coll Surg

Injury

Ann Emerg Med

Injury

Injury

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Arterial embolization is a rapid and effective technique for controlling pelvic fracture hemorrhage

J Trauma

Advanced Trauma Life Support for Doctors ATLS

A review of recombinant factor VII for refractory bleeding in non-haemophilic trauma patients

J Trauma

Randomised controlled trial on the effect of a 20% mannitol solution and a 7,5% saline/6% dextran solution on increased intracranial pressure after brain injury

Crit Care Med

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries

N Engl J Med

Prehospital fluid resuscitation in trauma: the IDF-MC Consensus Panel Summary

J Israeli Mil Med

Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials

J Trauma

Prospective evaluation of the sensitivity of physical examination in chest trauma

J Trauma

Maxillofacial injuries and life-threatening hemorrhage: treatment with transcatheter arterial embolization

J Trauma

The preventative treatment of wound shock

JAMA

Improved outcome with fluid resuscitation in treatment of uncontrolled haemorrhagic shock

J Am Coll Surg

Crystaloids vs colloids in fluid resuscitation: A systematic review

Crit Care Med

Failure of chest X-rays to diagnose pneumothoraces after blunt trauma

Anaesthesia

The role of angiography in the management of haemorrhage from major fractures of the pelvis

J Bone Joint Surg Br

Prehospital hypertonic saline resuscitation of patients with hypotension and severe traumatic brain injury. A randomised controlled trial

JAMA

Enhanced recognition of “lung sliding” with power color Doppler imaging in the diagnosis of pneumothorax

J Trauma

Hypertonic saline resuscitation limits neutrophil activation after trauma-haemorrhagic shock

Shock

Hypotensive resuscitation during active haemorrhage: Impact on inhospital mortality

J Trauma

Factor VIIa for correction of traumatic coagulopathy

J Trauma

Endoscopic transantral sphenopalatine artery ligation for intractable posterior epistaxis

Ann Otol Rhinol Laryngol

Do we really need routine CT scanning in the primary evaluation of blunt chest trauma in patients with ‘normal’ chest radiograph?

J Trauma

“Low-dose” recombinant activated factor VII results in less blood and blood product use in traumatic haemorrhage

J Trauma

Death in the operating room: an analysis of a multi-center experience

J Trauma

Invited Review Paper
Trauma
Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient

Damage control⁷¹