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British Journal of Oral and Maxillofacial Surgery 59 (2021) 700–704

Haemorrhage control beyond Advanced Trauma Life

Support (ATLS) protocol in life threatening maxillofacial
trauma – experience from a level I trauma centre
P.M.U.D. Dar a , P. Gupta a , R.P. Kaul a , A. Kumar b , S. Gamangatti b , S. Kumar a , A. Gupta a ,
M. Singhal c , S. Sagar a,∗
a Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi
110029, India
b Department of Radio Diagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi 110029, India
c Department of Plastic and Reconstructive Surgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New

Delhi 110029, India

Accepted 3 September 2020
Available online 11 September 2020

Abstract

Maxillofacial injuries are usually not life-threatening and do not get priority over other associated injuries. However, some maxillofacial
injuries with active oral or nasal bleeding need immediate management due to threatened airway and blood loss. In the case of major active
vascular bleeding, measures such as local pressure, anterior nasal packing, posterior nasal packing, and balloon tamponade are ineffective. In
these cases, angiography and transcatheter arterial embolisation (TAE) are used to treat life-threatening haemorrhage caused by maxillofacial
trauma. We analysed the medical records of 39 patients with severe maxillofacial trauma and life-threatening haemorrhage that was a result
of intractable oral or nasal bleeding. These patients were considered for TAE from January 2010 to December 2019. A total of 1668 patients
was admitted, out of which 39 (2.3%) had severe maxillofacial injuries with life-threatening oral or nasal bleeding and underwent TAE. Out
of a total of 39 patients, 38 were male and one female. Ages ranged from 16 to 65 years. Road traffic injury was the most common cause of
injury (79.5%), Lefort I and II were the most common facial fractures, and traumatic brain injury was the most common associated injury.
Embolisation and bleeding control were done successfully in all 39 patients with no procedure-related complications. A total of 17 deaths
during the study period were due to severe traumatic brain injuries or haemorrhagic shock.
© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Haemorrhage; Facial Fracture; Embolisation

Introduction agement of maxillofacial injuries is always deferred for days

Most maxillofacial injuries are not life-threatening and do not
get priority over other associated injuries.1,2 Definitive man-
∗ Corresponding author at: Jai Prakash Narayan Apex Trauma Centre, All
India Institute of Medical Sciences, Room No. 229, New Delhi 110029,
India.
E-mail address: sagar.sushma@gmail.com (S. Sagar).
because of other more serious injuries. However, there is a
relatively smaller number of maxillofacial injuries with active
oral or nasal bleeding that need immediate management due
to threatened airway and blood loss. Primary bleeding is con-
trolled by the application of pressure, anterior nasal packing,
posterior nasal packing, balloon tamponade, and correction
of coagulopathy. However, these measures are ineffective
in cases of major active vascular bleeding. The surgical

https://doi.org/10.1016/j.bjoms.2020.09.012
0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 P.M.U.D. Dar et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 700–704
approach is also difficult and time-consuming. Ligation of
the external carotid artery (ECA) helps to control bleeding
but is associated with high mortality and is also nonselective.
Recently angiography and transcatheter arterial embolisation
(TAE) have been used to treat life-threatening haemorrhage
from maxillofacial trauma.3,4 This is not a new technique and
was proposed by Brooks and others in 1930.5 This technique
was first used as an elective procedure to reduce blood sup-
ply to tumours and arteriovenous malformations and later as
an alternative to surgical ligation in cases of severe uncon-
trolled epistaxis.6 In this retrospective study, we assessed the
effectiveness of TAE in the treatment of severe maxillofacial
injuries with life-threatening haemorrhage.
Material and methods
We analysed the prospectively-maintained retrospective data
from the medical records of patients with severe maxillo-
facial trauma and life-threatening haemorrhage caused by
intractable oral or nasal bleeding. Patients who reported to our
emergency department (ED) and underwent angioembolisa-
tion from January 2010 to December 2019 were evaluated
in the study. Clinical records of these patients were analysed
for demographics; vital signs at presentation; haemodynamic
status, Glasgow coma scale (GCS); associated injuries; the
interval between the time of injury and procedure; and effec-
tiveness of TAE in treatment of life-threatening haemorrhage
from maxillofacial injuries. All patients were first managed
with conventional means such as manual pressure, tight
Fig. 1. a. Lateral angiogram showing contrast blush from branch of internal maxillary artery. b. Post embolisation angiogram showing gelfoam embolisation
of internal axillary artery and absence of haemorrhage.
701
anterior and posterior nasal packing, closure with sutures,
and ligation of the bleeding vessels to control any obvious
haemorrhage. When bleeding was not controlled by these
conventional means, alternative measures such as neck explo-
ration and ligation of the ECA or TAE were considered.
Patients were also evaluated for other possible sites of
haemorrhage (intra-abdominal, intrathoracic, or extremity
injuries) by physical examination, focused assessment by
ultrasonography in trauma (FAST) and computed tomogra-
phy (CT). If haemorrhage was noted from other sources, it
was managed accordingly.
Transcatheter arterial embolisation (TAE)
Patients considered for TAE were put in a supine position
on an angiography suite table, the catheterisation site was
cleaned with antiseptics, local anaesthetic was infiltrated,
and a small (3-4 mm) stab incision was made over the
catheter puncture. A right transfemoral approach was used
for angiography. A 4-French or 5-French (VERT slip-cath
beacon tip catheter; Cook) diagnostic catheter was inserted,
diagnostic angiogram of common carotid arteries (CCA),
internal carotid arteries (ICA), and external carotid arter-
ies (ECA) were obtained to localise the bleeding vessel
and guide angioembolisation (Fig. 1a). If the bleeding was
from the single nostril or if it was predominantly from one
side, ipsilateral arteries were tackled first. Selective angio-
graphic studies of ECA were done to look for the source
of bleeding and to rule out potentially dangerous collat-
erals. Super selective cannulation of ECA branches was
702 P.M.U.D. Dar et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 700–704
Table 1
Showing type of facial fractures data are no. (%).
Serial No. Fracture type Unilateral
1 Le-fort – I 13 (33.33)
2 Le-fort – II 11 (28.21)
3 Le-fort – III 03 (7.69)
4 Nasal bone 05 (12.8)
Table 2
Showing arteries with active bleeding on Digital Subtraction Angiography
data are no. (%).
Serial No. Injured vessel and angioembolisation
1 Internal maxillary artery
2 Facial artery
3 External carotid artery
4 Lingual artery
done using hydrophilic microcatheters (Progreat® 2.7 French
microcatheters, Terumo Interventional systems) in selective
cases with active bleeding in distal branches or with tortuous
anatomy of the parent vessel.
Fibred coils and gel foam pledgets (Gelfoam® , Pfizer)
were used as embolisation agents (Fig. 1b). The cases in
which angiographic study did not reveal active leakage of
contrast materials, the internal maxillary arteries (IMA) of
both sides were empirically embolised using gel foam parti-
cles with the tip of catheter placed distally to the meningeal
and deep temporal branches. Gel foam was the most com-
monly used, but coils were used preferably in cases of active
contrast extravasation.
Results
From January 2010 to December 2019 a total of 20108
patients were admitted under trauma surgery and the crit-
ical care department. Of these, 1668 (8.3%) patients were
identified as having maxillofacial injuries. Out of these 1668
patients, 39 (2.3%) had severe maxillofacial injuries with life
threatening oral or nasal bleeding, underwent TAE, and were
included in this study. Out of these 39 patients, 38 were male
and one female, with mean (range) ages of 31.8 (16-55) years.
The mechanisms of these injuries are shown in Fig. 2.
Road traffic injury (RTI) was the most common mech-
anism of injury (79.5%). The different types of fractures
sustained are shown in Table 1. A total of 87.2% patients
exhibited documented Le Fort fractures. Traumatic brain
injury (intracranial, extradural, subdural, or subarachnoid
haemorrhage) was the most common associated injury
(58.9%). Other associated injuries included chest injury
(5%), abdominal injury (5%), pelvic fracture (2.5%), and
upper and lower extremity fractures (10.2%).
Table 2 shows the sites of bleeding and embolisation of the
particular arteries done in all patients. Fig. 2 shows that the
sources of intractable maxillofacial bleeding were identified
and controlled in all 39 patients. The internal maxillary artery
was the most common vessel embolised (74.4%). There
were no procedure-related complications. Seventeen patients
Bilateral (43.5%) died during the study period. All these deaths that
08 (20.51) occurred were due to associated severe traumatic brain injury
14 (35.90) (n = 8) and haemorrhagic shock (n = 9). Patients with haem-
11 (28.21) orrhagic shock died due to irreversible organ damage despite
bleeding control from maxillofacial injuries. Out of the 17
patients who died, 14 had a road traffic injury (RTI), two had
falls from height and one had FAI. All patients were young
(around 29 years). None of the patients who survived (56.5%)
developed systemic or neurological complications post TAE.
Patients
29 (74.4)
4 (10.2)
4 (10.2)
Discussion
2 (5.1)
The worldwide incidence of maxillofacial injuries is as high
as 10% in various studies.6 These are not life-threatening
but can pose a serious compromise to airway and circula-
tion on certain occasions. Without emergent interventions,
such patients may easily develop various fatal complica-
tions. In such cases, securing the airway is the first priority,
which is done by suctioning the blood, secretions, debris,
foreign bodies, or dislodged teeth and dentures. The airway
is secured using a Guedel airway or endotracheal intuba-
tion if needed. Severe anatomical deformity due to trauma or
excessive blood obscuring the airway may warrant a cricothy-
roidotomy in the ED. These patients are also at significantly
higher risk of sustaining traumatic brain injury or cervical
spine injury.7
A total of 58% cases in our study had associated severe
traumatic brain injuries. With ongoing resuscitative mea-
sures, the cause of shock needs to be ascertained in the
ED. The initial management must be focussed on how to
stop bleeding. In severe maxillofacial fractures, there can be
nasal or oral bleeds, however, other regions such as the tho-
rax, abdomen, pelvis, and long bones need to be addressed
and evaluated for haemorrhage. Incidence of life-threatening
maxillofacial haemorrhage in our study was noted to be 2.3
%, which is consistent with the available literature.2
In maxillofacial injuries, profuse bleeding may occur as
a result of injury to the major branches of the external
carotid artery (ECA) and the respective sub-branches. In most
patients, the internal maxillary artery (IMA) on either side,
or both sides, is the most common cause of life-threatening
maxillofacial bleeding. During initial stabilisation, it is pru-
dent to do anterior and posterior nasal packing and watch for
haemostasis. Other manoeuvres include balloon tamponade,
triple lumen balloon catheter, and temporary reduction of
fractures (Supplemental Figs. 3 A-C, online only). By these
methods, we would be able to control the bleeding in most
patients. The cause of failure is likely due to either combined
nasal and oral bleeding with large defects, or a bleed from
the ethmoidal arteries and distal branches of IMA (internal
maxillary artery).8 These cases would mandate an interven-
tional procedure, which could be either surgical or minimally
invasive.
 P.M.U.D. Dar et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 700–704
Fig. 2. Mechanism of injury.
Surgical options include ligation of the ECA or its
branches, but this is not feasible and effective due to the
rich collateral supply and altered anatomy caused by trauma.
As an exception, the bleeding from ethmoidal branches of
the ophthalmic artery would warrant a surgical intervention
and not embolisation, to avoid neurological complica-
tions. Angioembolisation is a well-established technique
for surgically-inaccessible haemorrhage, including refrac-
tory epistaxis.6 In our series, we performed 39 TAE in patients
with maxillofacial injuries. leading to life threatening haem-
orrhage, which was not controlled by other ED procedures.
Agents commonly used were gel foam particles and coils. The
usual access was from the femoral artery and DSA was done
first. Though contrast extravasation from the culprit vessel
was the site of embolisation, the procedure was however com-
pleted empirically for terminal branches of the IMA many
times. Initial shock, associated injuries, haemodynamic sta-
bility, and neurological status determine the post-procedural
prognosis. In our series, patients showed good technical and
clinical success, but there were 17 deaths. All of them had
either severe traumatic brain injuries or haemorrhagic shock.
Patients who survived underwent staged reconstruction pro-
cedures for various maxillofacial fractures and are doing
well. Patients may develop intervention-related complica-
tions such as cerebrovascular accidents (CVA), blindness,
regional necrosis (lips or tongue), facial nerve palsy, or
trismus.9 However, none of the patients in our series devel-
oped these complications.
Conclusion
Exsanguinating oral or nasal bleeding that is intractable to
routine packing and other measures is a relatively uncommon
scenario in maxillofacial injuries. Most common causes of
703
mortality in maxillofacial trauma are associated with severe
traumatic brain injuries or haemorrhagic shock. Selective
angioembolisation of maxillofacial vessels has strengthened
the armamentarium of trauma centres worldwide. This pro-
cedure is quick and safe in experienced hands, given the
haemodynamic stability of the patient. The implementation
of an algorithmic approach in these uncommon cases results
in improved outcome. The expertise and early involvement
of an interventional radiologist can reduce mortality even in
resource-limited trauma facilities.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
Institutional Review Board and the Research Committee
approval was obtained. Patients’ consent for publication was
not required.
Data are available upon reasonable request
Data can be obtained from the corresponding author upon
request.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at doi:https://doi.org/10.1016/
j.bjoms.2020.09.012.
704 P.M.U.D. Dar et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 700–704
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