Cogbill Thomas H, Cothren Clay C, Ahearn Meghan K, Cullinane Daniel C, Kaups Krista L, Scalea Thomas M, Maggio Lindsay, Brasel Karen J, Harrison Paul B, Patel Nirav Y, Moore Ernest E, Jurkovich Gregory J, Ross Steven E
Department of Surgery, Gundersen Lutheran Medical Center, LaCrosse, Wisconsin, USA.
J Trauma. 2008 Nov;65(5):994-9. doi: 10.1097/TA.0b013e318184ce12.
Airway establishment and hemorrhage control may be difficult to achieve in patients with massive oronasal bleeding from maxillofacial injuries. This study was formulated to develop effective algorithms for managing these challenging injuries.
Trauma registries from nine trauma centers were queried over a 7-year period for injuries with abbreviated injury scale face >/= 3 and transfusion of >/=3 units of blood within 24 hours. Patients in whom no significant bleeding was attributed to maxillofacial trauma were excluded. Patient demographics, injury severity measures, airway management, hemostatic procedures, and outcome were analyzed.
Ninety patients were identified. Median injury severity scores for 60 blunt trauma patients was 34 versus 17 for 30 patients with penetrating wounds (p < 0.05). Initial airway management was by endotracheal intubation in 72 (80%) patients. Emergent cricothyrotomy and tracheostomy were necessary in 7 (8%) and 5 (6%) patients, respectively. Seventeen (57%) patients with penetrating wounds were taken directly to the operating room for airway control and initial efforts at hemostasis versus 12 (20%) patients with blunt trauma (p < 0.05). Anterior or posterior or both packing alone controlled bleeding in only 29% of patients in whom it was used. Transarterial embolization (TAE) was used in 12 (40%) patients with penetrating injuries and 20 (33%) patients with blunt trauma. TAE was successful for definitive control of hemorrhage in 87.5% of patients. Overall mortality rate was 24.4%, with 6 (7%) deaths directly attributable to maxillofacial injuries.
Initial airway control was achieved by endotracheal intubation in most patients. Patients with penetrating wounds were more frequently taken directly to the operating room for airway management and initial efforts at hemostasis. Patients with blunt trauma were much more likely to have associated injuries which affected treatment priorities. TAE was highly successful in controlling hemorrhage.
颌面部损伤导致大量口鼻出血的患者可能难以建立气道并控制出血。本研究旨在制定有效的算法来处理这些具有挑战性的损伤。
查询了9个创伤中心7年期间的创伤登记资料，筛选出简明损伤定级（AIS）面部评分≥3且在24小时内输注≥3单位血液的损伤患者。排除无明显出血归因于颌面部创伤的患者。分析患者的人口统计学资料、损伤严重程度指标、气道管理、止血程序及结局。
共识别出90例患者。60例钝性创伤患者的损伤严重程度评分中位数为34，而30例穿透伤患者为17（p<0.05）。72例（80%）患者初始气道管理采用气管插管。分别有7例（8%）和5例（6%）患者需要紧急环甲膜切开术和气管切开术。17例（57%）穿透伤患者直接被送往手术室进行气道控制和初步止血，而钝性创伤患者为12例（20%）（p<0.05）。单独采用前鼻孔或后鼻孔填塞或两者同时填塞仅能控制29%使用该方法患者的出血。12例（40%）穿透伤患者和20例（33%）钝性创伤患者采用了经动脉栓塞术（TAE）。TAE在87.5%的患者中成功实现了出血的确定性控制。总体死亡率为24.4%，6例（7%）死亡直接归因于颌面部损伤。
大多数患者通过气管插管实现了初始气道控制。穿透伤患者更常直接被送往手术室进行气道管理和初步止血。钝性创伤患者更有可能伴有影响治疗优先级的相关损伤。TAE在控制出血方面非常成功。
