Just got back from Toronto, where I learned about Chubby Bunny.

Chubby Bunny by Derby

But what we are actually going to talk about today is the management of Severe Hemorrhage from Mid-Face Blunt Trauma

Algorithm

Ann Plast Surg 2012;69:474

Take the Airway

Suction-as-you-go ETT Set-up

Partner Suction a la Strayer

These airways are all Cricon 3

Anterior Packing

I use Rapid-Rhino 5.5 cm but you go with whatever you are comfortable with. Soak it in STERILE WATER, not saline despite what i blathered in the audio (Thanks Brent!)

Posterior Packing

We use foleys in preference to commercial devices for standard epistaxis. This series explains why: (Injury. 2003 Dec;34(12):901-7. Complications with use of the Epistat in the arrest of midfacial haemorrhage.)

Use 12 - 14F (or whatever you got)

Witness passage into the posterior pharynx from both foleys with laryngoscope

Inflate a smaller volume first (6-8 mL) and then apply traction until it wedges, this allows the balloon to wedge in the posterior choana

Inflate to 20 ml

Apply traction

I use the system at the end of this video on Blakemore Passage

Reapply the anterior packs bilaterally

Temporary Fracture Fixation

Image from Injury  Volume 34, Issue 12, December 2003, Pages 901–907 Holmes et al. From that article, "When there is a mid-palatal split, however, this haemostatic technique will possibly fail and additional measures will be required to achieve haemostasis. The split palate should be stabilised with a transpalatal circumdental wire , before placing packing."

Angiography

IR of the internal maxillary is usually what is needed

May also be branches of ethmoidal in skull base fx

TXA for Epistaxis

EM Lit of Note's Review

McKesson Oral Prop?

EMJ 2010; 27 :156 e 158. doi:10.1136/emj.2008.070219

Anyone know about this? Comment in the show notes.

Additional References

* Case Discussion (Ann Plast Surg 2--1;46:159)

* Case Series on IR (J Trauma 2003;55:74)

* Another Case Series on Management (J Trauma 2008;65:994)

*  A Decade's experience with balloon tamponade fro traumatic hemorrhage (The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 70(2), February 2011, pp 330-333)