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A Critical Review of the Literature and an Evidence Based Approach for
Life Threatening Hemorrhage in Maxillofacial Surgery

Shachika Khanna, BDS, DMD, Alexander Bee Dagum, M.D., F.R.C.S. (C), F.A.C.S..
Stony Brook University Medical Center, Stony Brook, NY, USA.

Background: Life threatening facial hemorrhage in Maxillofacial Surgery (MFS) has an incidence of 1 to 11 % in the trauma patient and 38 %t (1972) to 1 % (2005) in elective surgery. The treatment of acute hemorrhage to prevent hypovolemic shock or airway obstruction forms the basis of emergency care and necessitates the need for further analysis given the multitude of options proposed for treatment. A systematic review of the literature was undertaken in order to formulate an evidence base approach to the treatment of life threatening hemorrhage in MFS.
Materials and Methods: A comprehensive search of journal articles was performed using PubMed and Ovid databases. Keywords and phrases used were “life threatening facial hemorrhage”, “life threatening facial bleeding”, “external carotid artery ligation” and “external carotid artery embolization”. Our search yielded 1,441 articles. In an attempt to focus on hemorrhage exclusively from traumatic and operative events, articles which cited hematological disorders as the underlying cause of bleeding were excluded from the study. There were 40 articles which met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence there was one Level II, 21 Level III, 12 Level IV and 6 Level V papers.
Result: Seven Level III evidence based studies noted a high association between mid-face injuries, particularly Lefort III fractures and massive oro-nasal hemorrhage. One Level II study, 8 Level III studies and 3 Level IV studies concluded that the internal maxillary artery was most frequently associated with intractable post-traumatic hemorrhage. One Level II, 16 Level III, 3 Level IV and 3 Level V articles cited anterior and posterior nasal packing and conservative measures as the first attempt to manage traumatic hemorrhage. Subsequently, 8 Level III studies re-enforced the importance of temporary reduction of facial fractures as an effective means to control massive hemorrhage early in the algorithm. 7 Level III studies, 4 Level IV and 2 Level V studies documented the importance of ligation of arteries as one of the absolute measures to manage facial hemorrhage while one Level II, 14 Level III, 2 Level IV and 3 Level V studies alluded to embolization as the most reliable technique for control of the hemorrhage. In orthognathic surgery, the internal maxillary artery was most frequently the source of massive hemorrhage according to 2 Level III, 4 Level IV and 1 Level V studies. 2 Level III, 5 Level IV and 1 Level V study proposed packing as the first attempt to tamponade the hemorrhage. TwoLevel IV and one Level V study cited pseudoaneurysm as a potentially life threatening vascular complication following elective surgery.
Management of facial hemorrhage should be performed in a sequential and consistent manner to optimize outcome. An evidence based algorithm for post-traumatic and elective life threatening hemorrhage in MFS based on this critical review of the literature will be presented and discussed.

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