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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 5-9

Epidemiology and management of life-threatening hemorrhage secondary to maxillofacial injuries: Analysis of 14 cases in a Nigerian tertiary care center


Department of Dental Surgery, Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Web Publication8-Dec-2016

Correspondence Address:
Otasowie D Osunde
Department of Dental Surgery, Maxillofacial Unit, University of Calabar Teaching Hospital, Calabar
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1597-1112.195447

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  Abstract 

Background: Life-threatening hemorrhage from the maxillofacial region is a rare occurrence. In this study, the management of maxillofacial patients with life-threatening acute blood loss in a Nigerian tertiary health care facility is presented.
Materials and Methods: Data on the management of all consecutive patients who presented to the Accident and Emergency department of our institution with life-threatening hemorrhage arising from trauma to the oral and maxillofacial region were prospectively collected over a 4-year period. The information obtained included demographics, etiology, vital signs at presentation, interval between injury and presentation, nature and mechanism of injury, sources of bleeding, treatment done, postoperative follow-ups, and outcome. The data were analyzed using the Statistical Package for Social Sciences (SPSS version 13, SPSS Inc, Chicago, Illinois, USA). Statistical significance was set at a P < 0.05.
Results: Fourteen patients (males = 12; female = 2) with age ranging from 17 to 65 years, mean 29.8 ± 12.82 years were managed within the study period. Majority of the victims were students (n = 7; 50%), and assault (n = 6; 42.9%) and road traffic accidents (n = 5; 38.5%) were the dominant modes of injury. The source of intraoral bleeding was from fractured mandible (n = 2) and lacerated tongue. The time interval between injury and time of presentation at treatment center ranged from 50 min to 1380 min (about 23 h), with a mean time interval of 275.1 ± 446.02 min. Ligation of the bleeder vessels combined with suturing of lacerations (n = 10; 71.4%) was the most common methods of arrest of hemorrhage in affected patients. Three of the patients required transfusion of whole blood plus intravenous infusion of crystalloids. The other eleven cases received only crystalloids.
Conclusion: Early presentation achieved by prompt referral to a health facility with the requisite workforce and facility will bring about good treatment outcome and avoid preventable deaths.

Keywords: Hemorrhage, life-threatening, maxillofacial injuries


How to cite this article:
Osunde OD, Bassey GO. Epidemiology and management of life-threatening hemorrhage secondary to maxillofacial injuries: Analysis of 14 cases in a Nigerian tertiary care center. Afr J Trauma 2016;5:5-9

How to cite this URL:
Osunde OD, Bassey GO. Epidemiology and management of life-threatening hemorrhage secondary to maxillofacial injuries: Analysis of 14 cases in a Nigerian tertiary care center. Afr J Trauma [serial online] 2016 [cited 2017 Oct 22];5:5-9. Available from: http://www.afrjtrauma.com/text.asp?2016/5/1/5/195447


  Introduction Top


Life-threatening facial hemorrhage is defined as hemorrhage associated with facial trauma or recent elective maxillofacial surgery resulting in hypovolemic shock, tachycardia (heart rate [HR] >100 bpm), hypotension (systolic blood pressure [SBP] ≤90 mmHg; diastolic blood pressure ≤60 mmHg), and a drop in hematocrit to 24% or hemoglobin to 8 g/dL from normal values of 38%-51% and 12-17 g/dl for both parameters, respectively.[1] These features will necessitate acute resuscitation in accordance with the current guidelines for Advanced Trauma Life support. Although the oral and maxillofacial region is well vascularized, injuries to this region, especially those arising from trauma rarely, result in life-threatening hemorrhage. In multiple injured maxillofacial patients who present with signs and symptoms of hypovolemic shock, it is often advised to look for bleeding elsewhere, especially for the presence of orthopedic injuries, damage to abdominal viscera, or other sources of occult blood loss.[2] This is because blood loss from the maxillofacial region alone may not be sufficiently high enough to tilt the patient toward hypovolemic shock.[2] In rare instances, life-threatening hemorrhage secondary to maxillofacial injuries has been reported.[3],[4] An approximate incidence of 1% has been documented for uncontrollable orofacial bleeding from a review of published reports.[4],[5],[6] In contrast, one report observed a prevalence of hemorrhagic shock as high as 24% following maxillofacial injury.[7]

There is a paucity of information on life-threatening hemorrhage arising from maxillofacial injuries from this part of the world, as supported by a review of literature from Nigeria. In the present paper, we present the management of 14 patients who presented to the Accident and Emergency Unit of University of Calabar Teaching Hospital with life-threatening hemorrhage secondary to injuries to the maxillofacial region.


  Materials and Methods Top


Data on the management of all consecutive maxillofacial trauma patients who presented to the Accident and Emergency Department of the University of Calabar Teaching Hospital from January 2012 to December 2015 were prospectively collected. The study was conducted in accordance with the Good Clinical Practice and the Declaration of Helsinki in 1975, as revised in 2000, and the protocol was approved by the Ethics Committee of our institution. The information obtained included demographics, etiology, vital signs at presentation, interval between injury and presentation, nature and mechanism of injury, sources of bleeding, treatment done, postoperative follow-ups, and outcome. For the purpose of this study, the criteria outlined by Khanna and Dagum[1] were used in determining life-threatening hemorrhage: Acute blood loss resulting in hypovolemic shock. Based on the American College of Surgeons' classification, this is either Class I (750-1500 mL) or Class II (1500-2000 mL) of blood loss.[8] The other criteria were tachycardia (HR >100 bpm), hypotension (SBP ≤ 90 mmHg), and a drop in hematocrit to 24% or hemoglobin to 8 g/dL. Patients who were brought dead on arrival at the Accident and Emergency Department of our institution were excluded from the study.

The collected data were analyzed using the Statistical Package for Social Sciences (SPSS version 13). Categorical variables were presented as frequencies and percentages while continuous variables as range, mean, and standard deviation. Statistical significance was set at a P < 0.05.


  Results Top


During the 4 years period of study, a total of 289 maxillofacial trauma patients were seen out of which 14 presented with life-threatening hemorrhage giving a percentage of 4.8%. All the patients except two were males (male: female ratio, 6:1) with age ranging from 17 to 65 years, mean 29.8 ± 12.8 years. The demographic characteristics, etiology, anatomical site involved, and the number of bleeding points at presentation and the time interval between injury and presentation at treatment center are shown in [Table 1]. Majority of the victims were students (n = 7; 53.8%), and assault (n = 6; 42.9%) closely followed by road traffic accidents (RTAs) (n = 5; 35.7%) were the dominant modes of injury. Extraoral soft-tissue injuries involving the neck, scalp, cheek, and forehead were mostly observed [Table 1]. The source of intraoral bleeding was from fractured mandible (n = 2; 14.3%) and lacerated tongue. The facial artery or its tributaries were the most common bleeders encountered (n = 7; 50%). Other vessels were branches from the superficial temporal artery (n = 5; 35.7%) and the lingual vessels (n = 2; 14.3%). The time interval between injury and time of presentation at treatment center ranged from 50 min to 1380 min (about 23 h), with a mean time interval of 275.1 ± 446.02 min [Table 1]. The Glasgow Coma Score (GCS) on presentation ranged from 14 to 15.
Table 1: Demographic and clinical characteristics of patients (n=14)


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Ligation of the bleeder vessels (facial artery or its tributaries, transverse facial artery, and lingual) combined with suturing of lacerations (n = 10; 71.4%) was the most common method of arrest of hemorrhage in affected patients. This was distantly followed by application of pressure packs and suturing of the lacerated soft tissues (n = 5; 35.7%). Two of the cases required temporary reduction and immobilization plus application of bone wax on the exposed surfaces of the fractured segments of the mandible [Table 2]. Three of the patients required transfusion of whole blood (about 1-2 pints) plus intravenous infusion of crystalloids (normal saline). The other 11 cases received only crystalloids. On the whole, about 93% of the patients had 1500 mL of normal saline or less, while the remaining 7% had over 1500 mL of normal saline. Other details of fluid and blood requirements are as shown in [Table 2].
Table 2: Modality of control of bleeding, infusion, and blood requirements


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All the patients were placed on oral hematinics in the form of fersolate (tablet 400 mg 12 hourly), Vitamin C (tablet 200 mg 8 hourly), and B-multivitamin complex (2 tablets 8 hourly) for up to 2 weeks postsurgery. The basal blood pressure readings, pulse rate as well as haematocrit values and heamoglobin concentration improved steadily after treatment as seen in the postoperative review periods [Table 3]. Of the 14 patients, 13 (92.9%) were successfully managed and discharged from the hospital while 1 (7.1%) mortality was recorded.
Table 3: Mean blood pressure readings, plus hematocrit and hemoglobin concentration at different time in patients (n=14)


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  Discussion Top


Maxillofacial injury is commonly seen in the practice of emergency medicine. Major maxillofacial injury itself can be life threatening. Apart from the danger of potential airway compromise, severe hemorrhage from branches of carotid artery causing hemorrhagic shock can occur. Significant bleeding tending toward hypovolemic shock is adjudged to be generally low, in the range of 0.37%-1.2%.[4],[9] The relatively high value of 4.8% obtained in the present study may be due to the small sample size.

The causative factors for the bleeding encountered in the present review are similar to known causes of maxillofacial trauma. Although RTA has been the dominant etiologic factor for maxillofacial injury in this environment, as supported by previous Nigerian studies,[10],[11],[12] assault surprisingly ranked higher than RTA in this series. Several reasons could be adduced for this. First, the enforcement of legislation on the use of seat belts among commuters coupled with the ban of the use of motorcycles from the Calabar metropolis may have accounted for the low RTA-related injury. Another reason for this observation may be explained in terms of the location of the study center. The University of Calabar Teaching Hospital is located in a metropolitan city within the oil-rich Niger delta area of Nigeria, known for lots of restiveness and high criminal tendencies among the several unemployed youths. In addition, the hospital is located very close to a tertiary institution which has been notorious for cultism in the past. It is likely that some of the observed cases of assaults may have been due to cult-related activities even though the victims may not readily disclose this information for fear of prosecution by law enforcement agencies. Furthermore, many of the youths and the men in the locality indulge a lot in drinking of alcohol and taking of other mood-enhancing agents or drugs. Thus, little argument results in unnecessary provocation or altercations, and various degrees of injuries are inflicted in the process. The age and gender distribution of the affected patients support this assertion.

Soft-tissue injuries were the dominant injuries type and this stems from the fact that assault was the leading cause of maxillofacial trauma in the present study, with knives and cutlasses being the main weapons of assault. This supports the observations made in previous Nigerian studies,[11],[13] including a recent one from Uyo, in Southern Nigeria.[14] Although gunshot-related maxillofacial injuries are now a common occurrence, especially from Northern Nigeria due to the current wave of terrorist attacks, it is not infrequently reported from the southern part of the country.[13],[15] Majority of gunshot injuries recorded in the southern part of Nigeria are as a result of armed robber-related activities.[15],[16]

Blood loss from the maxillofacial region may be related to the injury mechanism, being worse in gunshot injuries and assault-related injuries arising from the use of knives or cutlasses. In isolated maxillofacial injury secondary to RTA, blood loss is minimal or moderate except there are other concomitant injuries such as splenic rupture or orthopedic injuries. The main vessels involved in maxillofacial injuries, especially when soft-tissue injuries coexist with fractures of the facial skeleton, are ethmoidal artery, ophthalmic, vidian branch of internal carotid, and maxillary artery.[4],[17] In most cases, bleeding can be easily controlled, but rarely severe epistasis that ranges from 2% to 4% of all facial trauma arises from the maxillary artery, creating difficulty in hemorrhage control.[4] In the present study, the most common source of bleeding was the facial artery or its branches and the superficial temporal artery. Bleeding from the ethmoidal artery or other branches of the maxillary artery was not observed in the present study. This finding may be due to the absence of complex midfacial fractures such as Le Fort and naso-orbito-ethmoidal fractures in this study.

Management of actively bleeding patients entails controlling the source of hemorrhage and volume replacement in cases of prolonged bleeding that may have resulted in hypovolemia. Different modalities of controlling hemorrhage are well documented and these ranged from application of pressure pack, hemostatic agents, vasoconstrictor, as well as direct ligation of blood vessels and suturing of soft-tissue laceration.[18],[19] In the present study, combinations of different hemorrhage controlling modalities were employed. In two instances, where continuous bleeding per oral was encountered with mandibular fracture, reduction and fixation of the fractured segment using 0.5 mm soft stainless steel wire were adopted in conjunction with use of bone wax smeared on the exposed fractured segments to control the bleeding. This modality of controlling blood loss from facial skeletal fractures is well documented and has been utilized in previous reports.[20],[21]

Crystalloid (0.9% normal saline) was mainly used for volume replacement in majority of cases in this study. In addition, oral hematinics (iron and vitamins) were prescribed to the patients after successfully controlling all bleeding points. With this regimen, mean basal hematocrit and hemoglobin concentrations showed remarkable improvement within a 1 month of commencement of treatment. Our finding is supported by the results of a previous study.[22] Other method that has been shown to rapidly increase the rate of erythropoiesis in blood loss anemia is the use of recombinant erythropoietin.[23] None of our patients in the present study benefitted from this agent owing to cost and lack of easy availability in our environment.

The rate of blood transfusion in acute blood loss arising from maxillofacial injuries is poorly documented. One study reported 16.7% as prevalence of blood transfusion in maxillofacial trauma.[24] The 23.1% prevalence obtained in this study was slightly higher than that mentioned above because of differences in the methods of study. While the former study administered tranexamic acid, which is known to reduce blood loss and hence transfusion requirement, the drug was not used in this series.

The outcome of management of patients with acute blood loss arising from maxillofacial injuries depends on the injury mechanism, site of injury, number of bleeding points and the sources, and most importantly, the time of first consultation at the Accident and Emergency Department. In this study, majority of the injured patients presented within the first 2 h postinjury, with an overall GCS in the range of 14-15. Thus, none of the patients was catheterized as they were fully conscious and well ambulated. All patients rapidly attained GCS of 15, except one of the cases who deteriorated further and died within 1 h of presentation. The patient presented with bilateral epistaxis, as well as bleeding from the posterior nasal opening, with blood tracking down the oropharynx. In addition, he was suspected of having other yet to be identified occult sources of blood loss. The patient presented about 23 h after the accident and died while he was being resuscitated and stabilized for further evaluation by other specialized surgical units.


  Conclusion Top


In the absence of any concomitant injury as well as blood clotting disorders, patients with blood loss from the maxillofacial region can be successfully managed using the routine treatment modalities of controlling blood loss. Early presentation achieved by prompt referral to a health facility with the requisite workforce and facility will bring about good treatment outcome and avoid preventable deaths.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Khanna S, Dagum AB. A critical review of the literature and an evidence-based approach for life-threatening hemorrhage in maxillofacial surgery. Ann Plast Surg 2012;69:474-8.  Back to cited text no. 1
    
2.
Dean NR, Ledgard JP, Katsaros J. Massive hemorrhage in facial fracture patients: Definition, incidence, and management. Plast Reconstr Surg 2009;123:680-90.  Back to cited text no. 2
    
3.
Cogbill TH, Cothren CC, Ahearn MK, Cullinane DC, Kaups KL, Scalea TM, et al. Management of maxillofacial injuries with severe oronasal hemorrhage: A multicenter perspective. J Trauma Inj Infect Crit Care 2008;65:994-9.  Back to cited text no. 3
    
4.
Ardekian L, Samet N, Shoshani Y, Taicher S. Life-threatening bleeding following maxillofacial trauma. J Craniomaxillofac Surg 1993;21:336-8.  Back to cited text no. 4
    
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Gamanagatti S, Prasad TV, Kumar A, Singhal M, Sagar S. Angioembolisation in maxillofacial trauma: An initial experience in a tertiary care center. J Maxillofac Oral Surg 2016;15:59-66.  Back to cited text no. 5
    
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7.
Sakamoto T, Yagi K, Hiraide A, Takasu A, Kinoshita Y, Iwai A, et al. Transcatheter embolization in the treatment of massive bleeding due to maxillofacial injury. J Trauma 1988;28:840-3.  Back to cited text no. 7
    
8.
American College of Surgeons. Advanced Trauma Life Support Course Manual. Chicago, Illinois: American College of Surgeons; 1997. p. 103-12.  Back to cited text no. 8
    
9.
Harris T, Rice S, Watts B, Davies G. The emergency control of traumatic maxillofacial haemorrhage. Eur J Emerg Med 2010;17:230-3.  Back to cited text no. 9
    
10.
Obuekwe ON, Ojo MA, Akpata O, Etetafia M. Maxillofacial trauma due to road accidents in Benin City, Nigeria: A prospective study. Ann Afr Med 2003;2:58-63.  Back to cited text no. 10
    
11.
Osunde OD, Amole IO, Ver-or N, Akhiwu BI, Adebola RA, Iyogun CA, et al. Pediatric maxillofacial injuries at a Nigerian teaching hospital: A three-year review. Niger J Clin Pract 2013;16:149-54.  Back to cited text no. 11
    
12.
Adebayo ET, Ajike OS, Adekeye EO. Analysis of the pattern of maxillofacial fractures in Kaduna, Nigeria. Br J Oral Maxillofac Surg 2003;41:396-400.  Back to cited text no. 12
    
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Obimakinde OS, Okoje VN, Fasola AO. Pattern of assault-induced oral and maxillofacial injuries in Ado-Ekiti, Nigeria. Niger J Surg 2012;18:88-91.  Back to cited text no. 13
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14.
Nwashindi A, Dim EM, Osunde OD, Nwashindi NM, Uduma FU. An analysis of cutlass injuries to the face from assault in Southern Nigeria. Niger J Exp Clin Biosci 2014;2:115-9.  Back to cited text no. 14
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Onuminya JE, Ohwowhiagbese E. Pattern of civilian gunshot injuries in Irrua, Nigeria. S Afr J Surg 2005;43:170-2.  Back to cited text no. 15
    
16.
Bassey GO, Anyanechi CE, Chukwuneke FN. Civilian gunshot injuries to the oro-facial region in Calabar, South-South Nigeria, 2002-2006. Niger J Med 2008;17:257-60.  Back to cited text no. 16
    
17.
Buchanan RT, Holtmann B. Severe epistaxis in facial fractures. Plast Reconstr Surg 1983;71:768-71.  Back to cited text no. 17
    
18.
Heetveld MJ, Harris I, Schlaphoff G, Sugrue M. Guidelines for the Management if Haemodynamically Unstable Pelvic Fracture Patients. ANZ J Surg 2004;74:520-29.  Back to cited text no. 18
    
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20.
Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: Advanced trauma life support. Emerg Med J 2006;23:796-7.  Back to cited text no. 20
    
21.
Brennan J. Experience of first deployed otolaryngology team in Operation Iraqi Freedom: The changing face of combat injuries. Otolaryngol Head Neck Surg 2006;134:100-5.  Back to cited text no. 21
    
22.
McDermott PJ. Jehovah′s witness: A management dilemma in severe maxillofacial trauma. Br J Oral Maxillofac Surg 1992;30:331-4.  Back to cited text no. 22
    
23.
Spahn DR. Anemia and patient blood management in hip and knee surgery: A systematic review of the literature. Anesthesiology 2010;113:482-95.  Back to cited text no. 23
    
24.
Dakir A, Ramalingam B, Ebenezer V, Dhanavelu P. Efficacy of tranexamic acid in reducing blood loss during maxillofacial trauma surgery - A pilot study. J Clin Diagn Res 2014;8:ZC06-8.  Back to cited text no. 24
    



 
 
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