Page 66 - JSOM Fall 2018

nasal and oral packing and pressure dressings. Hypovolemic injury. 21,22 Finally, battlefield providers should be aware of the
shock is an important cause of death after trauma. According dynamic nature of CMF trauma and continuously reevaluate
to studies from civilian and military research groups, hemor­ wounded warriors for sources of bleeding that may become
rhage is responsible for up to 40% of deaths after traumatic more apparent with resuscitation and normotension.
injury. 11,12 Importantly, more than half of these deaths are
thought to occur before patients reach the hospital, which Ocular Trauma
highlights the importance of early and aggressive control Combat­sustained trauma to the CMF region may result in
of posttraumatic bleeding on the battlefield. Substantial, ocular injury. 23,24 Patients with combat­sustained CMF trauma
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life­threatening CMF bleeding is relatively uncommon in have a higher incidence of ocular injury. These injuries in­
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patients with multiple injuries but has been reported to be clude open globe, orbital fractures, intraocular foreign bod­
as high as 11% and, therefore, requires prompt intervention ies, corneal injury, orbital compartment syndrome, and optic
when present. Substantial CMF bleeding is most likely to nerve injuries. 24,25 Forward providers should be aware of these
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occur after extensive mid­ or panfacial injuries such as those injuries and make the assessment of when these patients
encountered on the battlefield. 15 should be evacuated to a higher echelon of care to be treated
by a specialist. At a minimum, forward providers should be
Manual pressure is of utmost importance on the field to tem­ able to obtain visual acuity, extraocular motility, pupil exam­
porize visible hemorrhage. Actively bleeding wounds, most ination, and visual fields. Although recognizing ocular injury
notably in the scalp, and other major facial lacerations should is more difficult on an unconscious patient, doing so is critical
be closed promptly, preferably using strong, nonabsorbable for TCCC providers. Patients with anomalies on any of these
suture in a continuous and full­thickness fashion to minimize examinations should be promptly evacuated, when possible,
the risk of any persistent deep wound bleeding. Substantial to a higher level of care. If globe rupture is suspected, the ex­
blood loss can occur from large scalp lacerations. Stapling amination should be discontinued and the globe protected by
wounds closed temporarily will help reestablish hemostasis, as a Fox eye shield or a cup secured to the face. The presence
well. Compression wraps can help temporize bleeding wounds of hemorrhagic chemosis, loss of vision, uveal prolapse, and
and stabilize fractures. Caution should be taken when apply­ intraocular hemorrhage may indicate a globe rupture. It is im­
ing pressure wraps to patients with suspected ocular injuries, portant to not place any pressure on the globe if a rupture is
because this can potentially exacerbate a ruptured globe. suspected. Foreign bodies protruding from the orbit should
be left in place until evacuated to a higher echelon of care.
Battlefield providers should be particularly vigilant about pos­ Intraocular foreign body should be suspected in a patient who
terior scalp lacerations, which might not be easily detected sustained a blast injury and has abnormal findings on ocular
when patients are in the supine position. Significant epistaxis examination.
is usually controlled successfully with pressure packing. In
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cases of persistent bleeding of nasal origin or from deep cer­ Orbital compartment syndrome can have devastating visual
vical wounds, balloon tamponade using a an inflated Foley consequences if unrecognized and not treated promptly. CMF
catheter balloon has been reported. Care should be taken, trauma can result in retrobulbar hemorrhage or intrusion of
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however, to prevent injury to surrounding deep cervical struc­ bone into the orbit, which, in turn, can cause increase in in­
tures and significant displacement of unstable facial skeletal traorbital pressure. This increased pressure may limit perfu­
segments, both of which can exacerbate bleeding. Therefore, sion of the globe and the optic nerve, resulting in irreversible
it is important to proceed with manual stabilization of facial ischemic injury. Symptoms of orbital compartment syndrome
fractures before nasal packing or other maneuvers that may include vision loss, eye pain, proptosis, ophthalmoplegia, and
displace facial skeletal segments. On occasion, the reduction an afferent pupillary defect. The diagnosis is clinical. Lateral
itself can help tamponade hemorrhage. If substantial hemor­ canthotomy and inferior cantholysis should be performed
rhage persists, exploration and ligation of the external carotid promptly by the forward provider when these signs are present
artery through a cervical approach and the ethmoidal artery and orbital compartment syndrome is suspected. This simple
through an orbital approach have been described. However, intervention can save a patient’s eyesight.
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these approaches have been associated with poor success rates
due to extensive collateralization between the internal and ex­ Management of Concurrent Injuries
ternal carotid arteries. 19 Forward teams treating patients who sustain combat­related
CMF trauma should be vigilant about frequently encountered
It is critical to highlight and discuss the challenges and con­ concurrent injuries and familiar with their initial management
siderations that should be kept in mind when managing CMF on the field. Cervical spine injury is notoriously common in
trauma in the acute setting. Although CMF hemorrhage can patients sustaining CMF trauma and has been reported to be
be substantial, it is unlikely to be the sole cause of hypovo­ as high as 6%. The main goal of early, appropriate cervical
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lemic shock, and battlefield trauma teams must adhere to spine management is to prevent spinal cord injuries and their
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established trauma protocols such as advanced trauma life potential devastating consequences. Challenges in assessment
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support and TCCC, and maintain a heightened level of clin­ of the cervical spine include patient confusion, altered mental
ical vigilance for other injuries that could be responsible for status, or unresponsiveness following CMF injury, which may
hypovolemic or other forms of shock. Furthermore, CMF prevent forward providers from obtaining an objective eval­
hemorrhage management is closely related to airway stabili­ uation. The intimate relationship between definitive airway
zation and management, because significant bleeding reach­ establishment in patients who require it and prevention of cer­
ing the airway can compromise ventilation and oxygenation. vical spine injury is another important consideration that chal­
CMF fracture maneuvering should also be performed with lenges combat trauma teams in the austere environment. Other
cervical spine inline stabilization in mind, given that patients traumatic injuries that may compromise patient hemodynamic
with CMF trauma are at risk for concomitant cervical spine stability, blood pressure, and spinal cord perfusion also must

64 | JSOM Volume 18, Edition 3 / Fall 2018