Abstract
The objective of this retrospective study was to identify predictors of angiographic hemostasis among patients with life-threatening traumatic oronasal bleeding (ONB) and determine the threshold for timely referral or intervention. The diagnosis of traumatic, life-threatening ONB was made if the patient suffered from craniofacial trauma presenting at triage with unstable hemodynamics or required a definitive airway due to ONB, without other major bleeding identified. There were 4404 craniofacial trauma patients between January 2015 and December 2019, of which 72 (1.6%) fulfilled the diagnosis of traumatic life-threatening ONB. Of these patients, 39 (54.2%) received trans-arterial embolization (TAE), 11 (15.3%) were treated with other methods, and 22 (30.5%) were excluded. Motor vehicle accidents were the most common cause of life-threatening ONB (52%), and the internal maxillary artery was the most commonly identified hemorrhaging artery requiring embolization (84%). Shock index (SI) was significantly higher in the angiographic hemostasis group (p < 0.001). The AUC-ROC was 0.87 (95% CI, 0.88–1.00) for SI to predict angiographic hemostasis. Early recognition and timely intervention are crucial in post-traumatic, life-threatening ONB management. Patients initially presenting with SI > 0.95 were more likely to receive TAE, with the TAE group having statistically higher SI than the non-TAE group whilst receiving significantly more packed red blood cells. Hence, for patients presenting with life-threatening traumatic ONB and a SI > 0.95, TAE should be considered if preliminary attempts at hemostasis have failed.
Highlights
Life-threatening oronasal bleeding (ONB) after craniofacial trauma is infrequent with an approximate incidence rate of 1%, but mortality rates can be as high as 85.9% if hemostasis is not achieved [1,2,3,4,5]
And adequate intervention is critical in reducing hemorrhage-related mortality, while delayed recognition and subsequent management may lead to unfavorable outcomes and dire consequences [1,3,8,9,10]
Recognition and well-timed intervention are crucial in the management of posttraumatic life-threatening ONB
Summary
Life-threatening oronasal bleeding (ONB) after craniofacial trauma is infrequent with an approximate incidence rate of 1%, but mortality rates can be as high as 85.9% if hemostasis is not achieved [1,2,3,4,5]. High rates of mortality in traumatic, life-threatening ONB remain a challenge for clinical physicians [1,3,6,7]. For patients presenting with traumatic ONB, clinical management follows Advanced Trauma. Life Support (ATLS) protocols along with airway protection, vital sign stabilization, bleeder identification, and hemostasis. The current consensus is to perform conservative treatment first (consisting of fluid resuscitation, blood transfusion, and anterior and posterior nasal packing) followed by trans-arterial embolization (TAE). The association of TAE with several major complications such as cerebrovascular accident, nephrotoxicity, facial nerve palsy, monocular blindness, and soft tissue necrosis have been previously reported
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