Journal of the International Clinical Dental Research Organization

REVIEW ARTICLE
Year
: 2022  |  Volume : 14  |  Issue : 1  |  Page : 13--16

Management of hemorrhage in maxillofacial injuries using foley's catheter – A review of literature


Merlyn Elizabeth Monsy, Sumir Gandhi, Inderjot Singh, Tarun Koshy Isaac, Angel Subramanium, Rik Mukherjee 
 Department of Oral and Maxillofacial Surgery, Christian Dental College, Ludhiana, Punjab, India

Correspondence Address:
Dr. Merlyn Elizabeth Monsy
A-601, Alpine, Mohan Altezza, Near Aggarwal College, Ghandare, Kalyan, Thane - 421 301, Maharashtra
India

Abstract

As globalization and digitalization takes place in today's time, wars also advance both in technology along with the arms being used. In today's date, wars are not confined to swords and cannons as it was in traditional warfare, rather the weapons used today are more inclined to injure and wound the population than to kill, thus making the treatment a challenge for the surgeons and clinicians present on the battle ground with the limited resources available.This review was conducted to understand the use of Foley's catheter, which is readily available at all trauma centers for the immediate management of bleeding in penetrating injuries of head and neck region. Methodology: An in-depth search was conducted on Google Scholar and PubMed data bases in an organized order to summarize the final results. Since Foley's catheter is a readily available tool and requires minimal skills for placement, it can be used to as temporary balloon tamponade to control bleeding and hemorrhage on the battle field as an emergency protocol. However, there is a need to develop definite international guidelines and further literature should be worked upon the same for the better understanding of this technique.



How to cite this article:
Monsy ME, Gandhi S, Singh I, Isaac TK, Subramanium A, Mukherjee R. Management of hemorrhage in maxillofacial injuries using foley's catheter – A review of literature.J Int Clin Dent Res Organ 2022;14:13-16


How to cite this URL:
Monsy ME, Gandhi S, Singh I, Isaac TK, Subramanium A, Mukherjee R. Management of hemorrhage in maxillofacial injuries using foley's catheter – A review of literature. J Int Clin Dent Res Organ [serial online] 2022 [cited 2022 Aug 7 ];14:13-16
Available from: https://www.jicdro.org/text.asp?2022/14/1/13/349747


Full Text



 Introduction



Among all the trauma cases, it has been found that penetrating neck injuries constitute about 5%–10% across the globe and most commonly are due to stab wounds from intense aggressive assault, self-harm, gunshot injuries, and road traffic accidents.[1] Military trauma has turned more lethal with the popularity of low-intensity conflicts and the introduction of more life-threatening weapons when compared to the traditional war methods. The increase in craniomaxillofacial injuries can be attributed to deficient maxillofacial protective gear, thus making it more susceptible to injuries.[2] Since the head-and-neck region is highly vascular with important neurological and aerodigestive structures, it becomes an essential anatomical region for the clinician to understand and become accustomed to while managing on the war field.[3] Bleeding from these penetrating neck injuries along with a breach in platysma muscle can lead to aspiration and further airway obstruction.[3],[4] The patient should be immediately taken for an operative exploration and bypass surgery in case of hemodynamic instability or “hard sign” of injury to vital structures, as mentioned by the trauma centers.[3] The recent advancement in managing such injuries is early and aggressive open reduction, followed by intermaxillary fixation along with reconstructive techniques, soft-tissue debridement, and closure of the wound as compared to the traditional three-phase approach consisting of initial debridement and suturing, succeeded by conservative closed reduction using splints and ligatures, after which delayed repair and reconstruction of residual bone deformities is performed such that the soft tissue is completely healed.[2] This becomes even more challenging with the absence of international guidelines and lack of literature on the imaging modalities to be used, assessment criteria and best possible treatment for these grievous injuries.[3] Facial hemorrhages in patients with maxillofacial fractures can be predicted using clinical symptoms such as nausea or vomiting and seizures.[4] Firoozmand and Velmahos described the technique of gaining temporary control over these injuries using Foley's catheters in emergency operative situations.[4] This review was conducted to understand the method of balloon tamponade using Foley's catheter which is readily available at all battlefields, thereby managing the life-threatening injuries by controlling bleeding by modern techniques.

 Methodology



A thorough literature search was conducted on PubMed and Google Scholar. The keywords used were hemorrhage, balloon tamponade and and maxillofacial injuries on Google Scholar, and; ([[balloon tamponade] and hemorrhage] and maxillofacial surgeries) in PubMed [Figure 1].{Figure 1}

The literature review consists of case reports, case series, retrospective studies, and retrospective cohort studies written in the English language only.

 Discussion



Foley's catheter as a lifesaving tool

The military advices that in case of penetrating neck injuries or maxillofacial trauma, Foley's catheter balloon could be used to provide tamponade.[5] During the 1980s Iraq–Iran war, Shuker pioneered this technique and applied it in the management of cases with extensive uncontrolled bleeding.[6] Foley's catheter tamponade proved to be the best possible solution in small penetrating injuries from bullets or small shell fragments when compared to immediate digital pressure or visible clamping and ligation to control the bleeding. This uncontrolled bleeding is also the immediate factor causing airway obstruction or “drowning” lungs. According to Shuker, the most lethal of maxillofacial war injuries are vascular missile injuries causing death from exsanguination or cerebral ischemia. The characteristic feature, however, is mass casualties during combat or terrorist strikes and sporadic civilian gunshot injuries which have become more common in urban areas resulting in life-threatening airway obstructions.[7] As Jose et al. stated, establishing airway and controlling hemorrhage are the two most critical aspects of penetrating injuries from gunshot or grenade blasts during counterinsurgency operations.[8] Thus, with the help of Foley's catheter balloon tamponade, these aspects are not just overcome but have also proved to be effective in mass casualties.

Anatomical considerations

Jose et al. reported high mortality associated with penetrating injuries of the maxillofacial region due to the bleeding vessels. In addition, it becomes difficult to manage wounds that are deep to the investing layer of deep fascia. Furthermore, the presence of bony structures and fragile anatomic structures such as the brain and eyes makes it almost impossible to control bleeding by external pressure.[8] Shuker mentioned about the critical zone extending from the angle of the mandible to the base of skull containing the cervical portion of the internal carotid artery, external carotid artery, and its other branches, in the particular maxillary, facial, lingual, ascending pharyngeal, middle meningeal arteries and jugular veins along with the prevertebral plexus.[6] The main obstacle associated with large lacerations of the jugular venous system was air embolism leading to hypotension and respiratory distress.[7]

Technique of application

All the authors had similar techniques with slight variations in the time of removal. Foley's catheter number 18–20 was slowly inserted into the laceration and the balloon was inflated with 10 ml saline which is generally sufficient to arrest bleeding, thus establishing appropriate pressure on the adjacent tissues without affecting microcirculation. To maintain the catheter in place, sutures are placed along the margin firmly. Approximate time for positioning of Foley's catheter was estimated to be <1 min. The balloon can be inflated up to 30 ml without failure of the balloon in case of severe bleeding.[8] According to Shuker, a catheter is placed for 72 h without any complication, for 7–10 days in case of deep soft-tissue injuries, and for 15–20 days if involving the maxillary sinus.[6],[7]

Benefits of Foley's catheter balloon tamponade

Authors reported the use of Foley's catheter aiding in achieving hemodynamic stabilization, thereby granting extra time to conduct computed tomography angiography to exclude the chances of major vessel injury. Due to the ease of application, it involves minimal or no training for emergency situations. It can be used to prevent tissue collapse and the formation of hematoma until definitive treatment can be made available. Furthermore, if used along with hemostatic gauze, it increases the effectiveness resulting in the control of hemorrhage. The outcome of Foley's catheter tamponade is the control of both distal and proximal hemorrhage. It is a very reliable technique facilitating the prevention of air embolism from internal jugular vein injuries, hence making it adequate for emergency use without causing any collateral damage.[8],[6]

Challenges associated with the technique

Vigorous catheter balloon dilatation to control hemorrhage might lead to pushing the fractured bone fragments into the orbit or intracranially, increasing morbidity. Furthermore, the catheter should not be used with saline but rather should be air filled in injuries within the vicinity of airway, thereby preventing spillage of saline in case of balloon rupture into the airway.[8] Overinflation should also be avoided to inhibit tissue necrosis. To avoid such situations, the balloon should be placed in a varied position. In addition, one must also take care of the communication being created with the naso-orbito-ethmoidal region while inserting the catheter.[7]

Constraints

The authors recommended to consider surgical exploration once the patient is stabilized. Open exploration or angiography and selective embolization of the involved vessel should be carried out in cases of grave injuries where bleeding cannot be managed by balloon tamponade alone.[8]

 Conclusion



The modern era of terrorism and advances in war systems has led to an increase in the potential to create catastrophic disasters, leading to the involvement of citizens in grievous injuries and thereby not only confining such hazardous wounds to the army or soldiers. This situation has led to a new challenge for the health-care workers and paramedics present in these zones. There is an immediate need to save lives rather than ideal treatment at the time of mass destruction. Therefore, the surgeons made use of Foley's catheter to encounter one of the biggest challenges of uncontrolled bleeding using the temporary balloon tamponade technique. Since this technique has proven to be efficient, less time consuming, and requires minimal skill, it should be brought to everyday routine practice. The maxillofacial region could prove to be the best anatomically complex area in understanding this technique because of the contralateral vasculature present, thus one can work without the fear of tissue necrosis due to loss of vascularity. There is a need for standardization, and therefore, international guidelines should be made for the same. To date, there have not been many discussions about this technique in literature and therefore put forth an interesting and impulsive technique for researchers to work upon and thus aid in adding knowledge to this subject area.

Acknowledgment

The completion of this review would not have been possible without the help of all the authors involved. The group would like to especially thank our families for their constant support. We are also grateful to Christian Dental College for leading us so far. Above all the great Almighty for all the knowledge and wisdom along with countless love.

All authors gave their final approval and agree to be accountable for all aspects of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2Jeyaraj P, Chakranarayan A. Treatment strategies in the management of maxillofacial ballistic injuries in low-intensity conflict scenarios. J Maxillofac Oral Surg 2018;17:466-81.
3Nowicki JL, Stew B, Ooi E. Penetrating neck injuries: A guide to evaluation and management. Ann R Coll Surg Engl 2018;100:6-11.
4Vriens MR, Leenen LP. Damage control of maxillofacial haemorrhage. Inj Extra 2008;39:225-7.
5Dixon J. Improved mortality from penetrating neck and maxillofacial trauma using Foley catheter balloon tamponade in combat. J Emerg Med 2014;46:321.
6Shuker S. The management of hemorrhage from severe missile injuries using Foley catheter balloon tamponade. J Oral Maxillofac Surg 1989;47:646-8.
7Shuker ST. The immediate lifesaving management of maxillofacial, life-threatening haemorrhages due to IED and/or shrapnel injuries: “When hazard is in hesitation, not in the action”. J Craniomaxillofac Surg 2012;40:534-40.
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