Hemorrhage Control in a Facial Gunshot Wound: A Case Report

Abstract

Gunshot wounds (GSWs) to the head or face are among the most complex injuries secondary to a number of vital structures in a relatively small volume of space. Hemorrhage can be difficult to control with traditional techniques, and ongoing hemorrhage can further complicate securing the airway. We present the use of a hemostatic gel in a facial GSW. A 74-year-old male suffered a self-inflicted GSW to the submandibular region with significant hemorrhage in the setting of a suspected overdose of apixaban (Eliquis) and alprazolam (Xanax). Traditional methods were unable to control the bleeding, and a syringe of Traumagel, a hemostatic gel, was then deployed into the complex wound, which achieved hemostasis.

Plain Language Summary

Gunshot wounds to the chin often involve critical structures, making it challenging to control bleeding with standard methods. This case demonstrates how Traumagel, a hemostatic gel, was used after traditional methods failed to control the bleeding. The gel proved effective at controlling bleeding in complex lower facial injuries, demonstrating its utility for emergency service providers.

Introduction

Gunshot wounds (GSWs) to the head or face, although uncommon, account for 10–11% of all firearm injuries.¹ Suicide as a leading cause of death in the United States has been increasing over the past 30 years and in 2019, over half of all suicides were from firearms, killing over 47,000 people.² Facial GSWs with a transoral or submental trajectory have the potential to compromise the patient’s airway and can be devastating due to the number of vital structures in a considerably small volume of space. Further, there may be an unknown extent of bony damage and significant hemorrhage, leading to an inability to control the airway. The complex wound and injury trajectory are difficult to manage with traditional hemostatic methods.

Triage of these patients consists of resuscitative measures following Advanced Trauma Life Support (ATLS) principles, with early attention directed toward securing the airway and maintaining adequate ventilation, which may be particularly challenging in the setting of severe maxillofacial hemorrhage.³ In addition to significant bleeding, the presence of laryngeal injury, displaced teeth, tongue and bone fragments, and soft tissue edema may quickly complicate airway management. Prompt hemorrhage control is therefore a critical component of both prehospital and hospital care. Established hemostatic strategies include direct pressure, gauze packing, tourniquets when anatomically feasible, and commercially available topical hemostatic agents. These include dressing-based products such as kaolin-impregnated gauze, as well as other topical hemostatic agents that use a variety of materials and mechanisms to augment hemorrhage control. While these approaches are effective in many settings, complex craniofacial wounds are often highly irregular and may be difficult to pack adequately, and removal of some dressing-based hemostatic materials at definitive care may disrupt clot integrity and contribute to recurrent bleeding.⁴

Traumagel is a flowable hemostatic device supplied as a prefilled, single-use 30-cc syringe and indicated for the temporary external control of moderate-to-severe bleeding.⁵ It consists of naturally derived polysaccharides and conforms to the wound surface following application, forming a mechanical barrier at the site of bleeding. The polysaccharide polymers may also promote hemostasis through interactions with platelets and other blood components, although these effects are considered secondary to the device’s primary mechanical mechanism of action. Unlike porous dressing-based agents that may become incorporated into the developing clot, the nonporous gel remains distinct from the thrombus, which may facilitate removal with less disruption of the newly formed clot. The gel is intended to complement rather than replace established hemorrhage control methods and may offer particular advantages in irregular wounds where conventional packing or dressing-based agents are difficult to apply effectively.⁶

Herein, we present a case of a facial GSW with significant hemorrhage thought to be complicated by an overdose of apixaban. Ongoing hemorrhage required activation of a massive transfusion protocol and bleeding remained uncontrolled despite repeated attempts with conventional gauze packing, including impregnated gauze. The gauze was removed and Traumagel was deployed into the wound. The gel’s flowable nature conformed to the irregular wound geometry without the need for additional bulky packing material. Further, without an expanding property in the hemostatic gel, it was not thought to present a risk of airway obstruction. In deciding to use the gel, it was determined that the wound cavity was sufficiently large to permit direct visualization, application, and subsequent irrigation and removal of the hemostatic gel. Application of the gel achieved hemostatic control and cessation of ongoing bleeding. This case highlights the potential utility of flowable hemostatic agents in large, anatomically constrained wounds where conventional packing methods are difficult to apply and remove.

Case Presentation

A 74-year-old male presented to the emergency department with a self-inflicted, low-velocity gunshot wound (GSW) to the lower mandible, anterior maxilla, and nasal cavity. Based on scene findings and EMS documentation, there was also concern for intentional overdose with apixaban and alprazolam, although no serum drug concentrations or formal toxicology testing were obtained to confirm the extent of exposure. The injury occurred approximately 2 hours before arrival, and the patient suffered cardiac arrest at the scene upon EMS arrival. He was successfully resuscitated, and his airway was secured with a laryngeal mask airway (LMA) in the field. On arrival to the emergency department (ED), he experienced a second cardiac arrest and again underwent successful resuscitation with several rounds of advanced cardiovascular life support (ACLS), activation of the massive transfusion protocol (MTP; 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets), and administration of 2 g of tranexamic acid (TXA). His airway was secured with an endotracheal tube, and the submental wound was packed with impregnated gauze; however, packing proved difficult because of the wound’s depth, irregular configuration, and ongoing hemorrhage. He was taken emergently for computed tomography (CT), which demonstrated a comminuted fracture involving the left mandibular body and angle with associated maxillary air-fluid levels. No retained foreign bodies were identified, and the cribriform plate remained intact (Figure 1). Following imaging, he required an additional round of MTP because of persistent hemorrhage originating from the inferior alveolar artery within the mandibular canal. The gauze packing was removed, and a 30-cc syringe of Traumagel was applied directly into the wound (Figures 2 and 3), filling the large submandibular defect. Manual pressure was maintained for 3 minutes, resulting in complete hemostasis (Figure 4). This allowed completion of the trauma team’s primary survey, which identified no additional injuries. Within 24 hours, the wound was thoroughly irrigated, and all Traumagel was removed while hemostasis was maintained. No evidence of increased infection or retained material was observed following complete removal. During his hospitalization, the patient underwent definitive mandibular reconstruction by the oral and maxillofacial surgery service, along with placement of a tracheostomy and gastrostomy tube. He was ultimately discharged to a rehabilitation facility.

Figure 1.

Three-dimensional volume-rendered CT reconstruction demonstrates a highly comminuted ballistic injury to the left mandible, with extensive fragmentation and displacement involving the mandibular body and angle.

Figure 2.

Traumagel being deployed into the wound. The syringe is placed deep within the complex wound, adjacent to the area of active bleeding. The 30-cc syringe is then quickly deployed into the GSW.

Figure 3.

The full syringe of Traumagel has been distributed into the wound. As visualized, the gel has filled the irregular nature of the submandibular GSW.

Figure 4.

After Traumagel is applied, pressure is held for three minutes or until hemostasis is achieved. This is typically accomplished manually by placing gauze over the gel applied to the wound.

Discussion

Facial GSWs present a difficult clinical challenge to responding clinicians. For those who survive, there comes extensive damage to the lower face with associated injury to vital structures. In terms of immediate management and resuscitation, ATLS guidelines are for airway management first. However, a modified algorithm of C-ABC is employed in many trauma centers, with the initial “C” representing catastrophic bleeding.⁷ A military corollary is MARCH, a protocol for treating battlefield injuries where M represents massive hemorrhage, followed by airway, respiratory, circulation and hypothermia/head injury. Particularly with a facial/head and neck injury, the rapid control of ongoing bleeding helps to facilitate securing of an airway, by either endotracheal intubation or surgical processes. Further, the need for urgent airway control in facial GSWs is between 20–60%⁸ and often needs to be performed by prehospital clinicians in the field, where ongoing bleeding can complicate an already difficult procedure. Controlling hemorrhage efficiently and rapidly gives the responding personnel the best chance of securing a potentially difficult airway. Other airway management adjuncts, such as bag/valve/mask ventilation, can prove impossible secondary to maintaining an airway seal due to the location and complexity of injury.

Traditional hemorrhage control methods, such as manual compression, gauze packing, and impregnated hemostatic dressings, have significant limitations in managing bleeding from wounds with highly variable locations, sizes, and complexities. Generally, hemostatic gauzes and dressings are challenging to apply in irregular or junctional wounds as they require forceful packing that can be painful and time-consuming.^9–11 With incomplete initial hemostasis, the irregularity of the injury and proximity of other vital structures make additional packing increasingly difficult. Additionally, removal of traditional hemostatic agents at definitive management can lead to clot disruption and rebleeding. Hemostatic gels offer a solution to these limitations. They are rapidly applied and easily conform to complex wounds of varying geometry. In this case, the gel’s composition forms a mechanical barrier that supports clot formation without adhering to tissue, allowing for clean removal with simple saline irrigation. Its application required minimal time, no forceful packing, and only required consistent pressure for 3 minutes.

We report here the use of a gel to manage a complex GSW to the face with ongoing hemorrhage. We achieved hemostasis, which was critical to allowing the patient to stabilize and proceed to definitive treatment. Further, the hemostatic gel proved effective in the presumed setting of an apixaban overdose, which complicates hemostatic control. The complex nature of this facial GSW limited traditional hemostatic methods, such as gauze packing and even impregnated gauze, to achieve hemostasis. A flowable hemostatic agent such as Traumagel may have a role in treating these complicated patients.

Conclusion

Facial gunshot wounds (GSWs) are among the most complex injuries that emergency personnel manage, often presenting with deep and complex wounds accompanied by ongoing hemorrhage. These cases are further complicated by the need for airway control amid ongoing bleeding. Traditional methods of wound packing are often ineffective at controlling bleeding due to the wound’s irregular nature. We present the use of a hemostatic gel in the management of a submandibular GSW. After traditional techniques failed to achieve hemostasis, a 30-cc syringe of Traumagel was deployed, flowing throughout the wound and achieving hemostasis. This case presents an initial use of Traumagel for a facial GSW and suggests a role in treating patients with difficult bleeding scenarios.

This report has several important limitations. The suspected apixaban overdose was based on clinical findings and EMS documentation, without laboratory confirmation of clinically relevant apixaban exposure or anticoagulant effect; therefore, the extent to which anticoagulation contributed to the severity or persistence of hemorrhage cannot be determined. Additionally, as a single case report, we acknowledge that this case cannot establish the comparative efficacy or safety of Traumagel relative to conventional hemostatic approaches or determine the generalizability of its use to other patients or wound patterns. Rather, this case describes the application of a flowable hemostatic agent to manage a complex, irregular facial GSW in which conventional wound packing was technically challenging.

Ethics and Consent Statement

The authors submit that the activities described in the approval application did not meet the regulatory definition of human subject research provided in 45 CFR 46.102; thus, Institutional approval was not required for the case report or for publishing the case details in this report.

Informed Consent

Written informed consent was obtained from the patient for publishing anonymized information, including images in this article.

Author Contributions

Both Thomas R Knobl and Tyler N Carruth made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

TNC is an employee of Cresilon Inc. TNC contributed to the technical accuracy of the product description; however, he was not involved in clinical decision-making or patient care. Clinical author TRK oversaw case interpretation and reporting, reports no conflicts of interest and declares no known competing financial or personal conflicts. No author received any compensation from Cresilon for their contributions to this manuscript.