Bundeswehrkrankenhaus Ulm Abteilung HNO Kopf-Halschirurgie

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Archibald Cannon
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1 Kai Johannes Lorenz and Klaus Effinger Department of Otorhinolaryngology, Head and Neck Surgery Department of Radiology and interventional Radiology German Armed Forces Hospital

Incidence of hemorrhage under battle conditions Since the last 30 years the incidence of head and neck injuries in battlefield is increasing: 39% of all soldiers injured during Operation Iraqi

The head and neck areas has an excellent blood supply The prognosis of wounded soldiers is determined by the degree of bloodloss-induced hypovolaemia and by the respiratory situation, uncontrolled

2 Incidence of hemorrhage under battle conditions Since the last 30 years the incidence of head and neck injuries in battlefield is increasing: 39% of all soldiers injured during Operation Iraqi Freedom II had wounds in this aera. The head and neck areas has an excellent blood supply The prognosis of wounded soldiers is determined by the degree of bloodloss-induced hypovolaemia and by the respiratory situation, uncontrolled haemorrhage accounts for the majority of deaths in combat. quick and adequate action is necessary Rustemeyer J, Kranz V, Bremerich A (2007) Injuries in combat from with particular reference to those to the head and neck : a review. Br J Oral Maxillofac Surg 45 : Wade AL, Dye JL, Mohrle CR, Galarneau MR (2007) Head face,and neck injuries during Operation Iraqi Freedom II : results from the US Navy Marine Corps Combat Trauma Registry. J Trauma 63 : Mabry RL, Holcomb JB, Baker AM: United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield. J Trauma. 49: (2003).

airway management is performed by means of either tracheal intubation with a cuffed tube to prevent aspiration or an

4 Incidence of hemorrhage under battle conditions Beside airway management, haemorrhage control is one of the measures that ultimately determine whether a patient with severe head and neck injuries can be transferred to secondary care or not. airway management is performed by means of either tracheal intubation with a cuffed tube to prevent aspiration or an emergency cricothyrotomy, haemorrhage control is much more difficult owing to the complex anatomical conditions in the head and neck area.

5 Haemorrhage treatment nose and midface Trauma induced bleeding from the nasal and midfacial area is mostly a combined venous and arterial hemorrhage risk of inducing additional injuries (orbit and brain)

6 Haemorrhage treatment nose and midface Pneumatic tamponade with hematostatic CMC cover Epitaxis catheder with double cuff Nasopharynx (posterior bleeding) and nasal cavity For use on operations, and especially for treatment by non-medical personnel, the use of epistaxis catheters has proved to be useful

7 Haemorrhage treatment nose and midface Use of a bladder catherder for control of a posterior epitaxis Remember! Any nose tamponade has to be secured to prevent aspiration!

8 Haemorrhage treatment nose and midface YES NEVER Correct orientation for the introduction of internal nose dressing is a virtual line between the tipof the nose and the tragus cartilage of the ear

$skull fractures no uncontrolled compression to prevent a dislocation of the different parts$

9 Haemorrhage treatment head and face light compression bandage because of the underlying bone, this area is well-suited for compression and pressure dressings In case of unstable skull fractures no uncontrolled compression to prevent a dislocation of the different parts of the calvaria and an aggravation of cerebral symptoms. under no circumstances compress the airway

10 Haemorrhage in the oral and pharyngeal area Bleeding from the oral and pharyngeal area, as caused by injuries of the mandible, the floor of the mouth and the tongue, is associated with an extremely high risk of blood aspiration and obstruction of the airways. Treatment of haemorrhage without blocking the airways is difficult immediate airway management by means of surgical access (cricothyrotomy) is required insert thin layers of gauze into the oral-pharyngeal area. number of gauze layers need to be documented one end of each layer should be left outside the mouth in order to prevent later aspiration of the inserted material.

11 Haemorrhage in the neck area MONSON Haemorrhage in the neck area may be caused by injuries to skin vessels or subcutaneous veins as well as massive bleeding from the carotid sheath. 33% 33% 23% multiple 11% Fox CJ et al. J Vasc Surg 2006; 44: 86 Battle induced neck injuries are mostly located in the region II or III. Haemorrhage for the region II is much easier to handle the injuries in the regions I or III.

12 Haemorrhage in the neck area Initial haemorrhage control in neck injuries is limited to digital compression of the relevant vessels or light compression bandage In case of arterial haemorrhage, particularly in the area of the carotid artery avoid a complete closure in order to prevent hypoperfusion and subsequent brain ischemia.

13 Haemorrhage in the neck area Use of bladder catheders for small penetrations with arterial bleeding Especially Zone III and Zone I

14 Haemorrhage treatment face and neck Arista Use of haemostyptics four different groups: Microporous Polysaccharide Hemospheres Quickclot Poly-N-acetylglucosamine Zeolites Celox Human fibrin wound dressing

15 advantages Absolutely no preparation time No special storage conditions Potentially improves patient comfort Easy to use (non medical personnel)

16 Haemorrhage treatment face and neck

18 Haemorrhage in the midface and nasal area Haemorrhage in the area of the nose, the paranasal sinuses and the nasopharynx is also treated primarily by means of tamponades Final haemorrhage control can be performed as part of the treatment of the mid-facial bone injuries after transfer to Role 3 or Role 4 or repatriation. If a transfer is not possible and bleeding can not be controlled even after several days of applying tamponade, an experienced head and neck surgeon should treat the source of haemorrhage.

Haemorrhage in the midface and nasal area Local

nasopharyngeal area can be treated by means of

artery (maxillary artery) can be performed using

19 Haemorrhage in the midface and nasal area Local arterial haemorrhage in the nasal and nasopharyngeal area can be treated by means of monopolar or bipolar coagulation. If the source of haemorrhage can not be identified, ligation (clipping) of the bleeding artery (maxillary artery) can be performed using an osteoplastic approach to the maxillary sinus or, for the ethmoidal arteries, a medial canthotomy.

20 Haemorrhage in the oral cavity and pharynx injuries of the mouth or pharynx: haemorrhage control performed through compression or under visually control electrosurgical coagulation. extensive injuries of the mouth and pharynx: haemostatic agents combined with tamponade extensive haemorrhage and haemorrhage that can not be localised: ligation of the supplying arteries following the external carotic artery via a cervical access

is controlled by suture, ligation or careful coagulation with due consideration of the surrounding structures, particularly nerves.

21 Haemorrhage in the neck area Heavily bleeding neck injuries are treated in the trauma room or in the OR (general anaesthesia, including haemodilution and/or transfusion of blood products) Careful exploration of the soft tissue of the neck Venous haemorrhage is controlled by suture, ligation or careful coagulation with due consideration of the surrounding structures, particularly nerves. take into account the situation of the upper respiratory tract and oesophageal area: any penetrating injuries there must be treated accordingly.

22 Haemorrhage in the neck area arterial haemorrhage: smaller end arteries can be treated by ligation. external carotid artery: ligation at the junction above the bifurcation or at each of its branches ligation of the common or internal carotid arteries only in exceptional situations. If possible, a temporary stent should be inserted into the vessel. a piece of a infusion tube can be inserted and blood flow can be maintained until treatment at a Role 3 unit or until after repatriation

23 Summary Survival odds of military personnel wounded in combat substantially depend on the extent of blood loss until initial treatment is given. Uncontrolled haemorrhage is responsible for a large proportion of fatalities in combat situations. Successful haemorrhage control, particularly in the head and neck area, until definite surgical intervention is possible, requires profound anatomical knowledge and a certain degree of surgical skills. In addition the use of haemostatic agents can improve haemorrhage control and minimise the frequency of secondary haemorrhage

24 Thank you for your attendance!

Dr. Sami Zaqout Faculty of Medicine IUG

Dr. Sami Zaqout Faculty of Medicine IUG The Nose External Nose Nasal Cavity External Nose Blood and Nerve Supplies of the External Nose Blood Supply of the External Nose The skin of the external nose Branches of the ophthalmic and the maxillary