Hemorrhage and its Management

The presentation deals with the basics of hemorrhage i.e. classification, etiology. It also covers the mechanism of hemostasis and the various methods to achieve hemostasis.
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1. HEMORRHAGE AND ITS MANAGEMENT Presented By : Akshat Sachdeva BDS Final Year Manav Rachna Dental College 1

2. WHAT IS HEMORRHAGE? Denotes the escape of blood from a blood vessel. Any damage to the vasculature leads to the outflow of blood. Blood carries oxygen and nutrients to the tissues and is vital for body functions. Loss of blood due to any reason beyond a certain point is potentially life threatening and may lead to exsanguination (blood loss to a degree sufficient to cause death). 2

3. CLASSIFICATION OF HEMORRHAGE Depending on the SOURCE OF BLEEDING : External Hemorrhage : When bleeding is revealed and seen outside, e.g. epistaxis. Internal Hemorrhage : Bleeding is concealed and not seen outside, e.g. intracranial hematoma. 2. Depending on the NATURE OF BLEEDING VESSEL : Arterial Hemorrhage : Bright red in color. Blood emitted as a jet with each heartbeat. Venous Hemorrhage : Dark red in color. Blood flow is steady. Capillary Hemorrhage : Bright red in color. Generalized ooze of blood instead of blood flow. 3

4. 3. Depending upon TIME OF HEMORRHAGE : Primary Hemorrhage : Occurs at the time of trauma or surgery. Reactionary Hemorrhage : Occurs within 24 hours of trauma or operation. Secondary Hemorrhage : Occurs after 7 – 14 days of trauma or operation. 4. Depending upon VOLUME OF BLOOD LOSS : Mild Hemorrhage : Blood loss ≤ 500 mL. Moderate Hemorrhage : Blood loss 500 – 1000 mL. Severe Hemorrhage : Blood loss ≥ 1 L. 4

5. 5 5. Depending upon SPEED OF BLOOD LOSS : Acute Hemorrhage : Massive bleeding in short span of time. Chronic Hemorrhage : Slow bleeding small in quantity for long time . 6. Depending upon PERCENTAGE OF BLOOD LOSS : Class I : U p to 15%. Class II : Between 15 – 30%. Class III : Between 30 – 40%. Class IV : More than 40%.

6. ETIOLOGY Trauma. Infections. Congenital malformations. Surgical (intraoperative/postoperative). Due to systemic diseases (viral infection, scurvy, allergy). Abnormalities in clotting factor (hemophilia A, multiple myeloma). Abnormalities in platelets (leukemia, ITP, thrombocytosis, thrombocytopenia). 6

7. HEMOSTASIS Mechanism of cessation of extravasation of blood. Four important steps: Injured blood vessel undergoes constriction due to spasm. Activation of platelets and formation of platelet plug. This leads to primary hemostasis . Activation of clotting mechanism and formation of clot leading to completion of secondary hemostasis . Fibrous organization of clot or retraction of clot. 7

8. Mechanism of Hemostasis 8

9. PRIMARY HEMOSTASIS Process of platelet plug formation at the site of injury. Occurs within seconds of injury and is important for stoppage of blood from small arterioles, venules and capillaries. There is platelet adhesion, release of granules and platelet aggregation resulting in formation of primary hemostatic plug. 9

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11. SECONDARY HEMOSTASIS Activation of clotting process in plasma that results in formation of fibrin which strengthens the primary hemostatic plug. Completed in several minutes and is important in bleeding from larger vessels. Some substances promote clotting (called procoagulants) and some prevent clotting (called anticoagulants). There is a complex interaction of various factors of coagulation in the formation of a clot. 11

12. 12 Coagulation Mechanis m

13. Coagulation mechanism can be broken down into series of 4 reactions : Reaction 1 : Intrinsic or contact phase of coagulation. Factors VIII, IX, XI, XII along with calcium and plasma proteins take part. Partial thromboplastin time screens this. Reaction 2 : Extrinsic pathway for initiation of coagulation. Release of tissue thromboplastin from injured tissues. Protease complex formed between factor VII, calcium and tissue thromboplastin , which activates factor X. Prothrombin time screens this. 13

14. Reaction 3: Factor X is activated by proteases generated in the previous two reactions. Reaction 4: Prothrombin is converted into thrombin in presence of factor V, calcium and phospholipids. Main role of thrombin is conversion of fibrinogen into fibrin. It also activates factor V, VIII and XIII and helps in platelet aggregation and secretion. 14

15. CLINICAL EVALUATION Evaluation of patient with co – ordinated history and physical examination provides valuable clues. History should include following questions: Is there any personal or family history of bleeding tendency? Has the patient undergone surgery or extractions previously? Any history of hematuria, GIT hemorrhage, epistaxis? What medication is the patient taking or has taken recently? Note for any splenomegaly, hepatomegaly. Hepatic insufficiency should be assessed. Assessment of skin and mucosal surfaces. 15

16. LABORATORY TESTS Bleeding Time (BT): Patients with BT more than 10 minutes have increased risk of bleeding. Various methods for measuring BT, e.g. Ivy, Duke and template. BT is prolonged in thrombocytopenia, Von – Willebrand’s disease and platelet dysfunction. 2. Platelet count : Normal count: 1.5 – 4.5 lakhs per cumm of blood. When count becomes 50,000 – 1 lakh per cumm , there is mild prolongation of BT. Patients with count less than 50,000 per cumm have easy bruising. Minor oral surgical procedures can be done if count is above 80,000 – 1 lakh per cumm . 16

17. 3. Prothrombin Time (PT): Normal PT is usually 12 – 14 seconds. Prolonged in patients on warfarin anticoagulant therapy, vitamin K deficiency or deficiency of factor V, VII, X, prothrombin or fibrinogen. 4. Partial T hromboplastin Time (PTT): Prolonged in hemophiliacs. Normal PTT is less than 45 seconds. PTT is relatively insensitive to changes in intrinsic coagulation system. Small changes in PTT may be of great significance. 17

18. METHODS OF ACHIEVING HEMOSTASIS MECHANICAL METHODS Pressure. Hemostat. Sutures and Ligation. CHEMICAL METHODS Local Agents: Adrenaline. Thrombin. Surgicel . Oxycel . Surgicel Fibrillar . Gelatine Sponge. 18

19. Microfibrillar Collagen. Fibrous Glue. Styptics and Astringents. Alginic Acid. Natural Collagen Sponge. Bone Wax. Ostene . Systemic Agents: Whole Blood. Platelet Rich Plasma. Fresh Frozen Plasma. Cryoprecipitate. THERMAL AGENTS Cautery. Electrocautery . Cryosurgery. Lasers. 19

20. MECHANICAL METHODS PRESSURE Immediate measure for capillary or venous bleeding. Firm pressure should be applied over the bleeding site using either fingers or gauze for at least 5 minutes . This would control most hemorrhages by counteracting the hydrostatic pressure of the bleeding vessel. 2. HAEMOSTAT Application of haemostat at the bleeding point helps in direct occlusion of the bleeding vessel 20

21. 3. SUTURES AND LIGATION Severed blood vessels may be tied with ligatures. A ligature replaces the hemostat as a permanent method of effective hemostasis . For large pulsatile artery, a trans – fixation suture to prevent slipping is indicated. Non – resorbable sutures such as silk and polyethylene are used as they evoke less tissue reaction. 21

22. CHEMICAL METHODS Local Agents: 1. ADRENALINE Topical application of adrenaline brings about vasoconstriction of bleeding capillaries. A vailable in ampoule, which is applied with the help of gauze. Concentration of 1 in 1000 is used for hemostasis over the oozing site. 2. THROMBIN H elps in converting fibrinogen into fibrous clot. 22

23. 3. SURGICEL Oxidized cellulose polymer obtained by dissolving pure alpha- cellulose in an alkaline solution. A cts by forming acid products from partial dissolution that coagulates the plasma proteins to form a black or brown sticky gelatinous clot. A pplied surgicel resorbs from the site in 4 to 8 weeks. Disadvantage is that the surgicel clot is not formed by normal physiological mechanism. 23

24. 4. SURGICEL FIBRILLAR: M odified surgicel or oxidised regenerated cellulose in layers that can be adapted to irregular surfaces and inaccessible areas. Complete resorption occurs in 2 weeks. 5. GELATINE SPONGE OR GELFOAM OR SURGIFOAM: Formed from purified pork skin gelatin. C ompletely absorbable material. H as the capacity to absorb 45 times its weight in blood. R esorbs completely in 4 to 6 weeks. 24

25. 4. OXYCEL O xidized cellulose polymer product. This absorbable hemostatic material is manufactured by controlled oxidation of cellulose using nitrous dioxide. C ellulosic acid present in it has affinity for hemoglobin which leads to the formation of artificial clot. S hould be applied on the dry surface as the acid formed during the wetting process inactivates the thrombin. The platelets plug into its meshwork like surface & helps in clot formation. 25

26. 6 . MICROFIBRILLAR COLLAGEN (AVITENE) Collagen derived from bovine skin cause contact activation in addition to direct platelet aggregation. A bsorption time is 3 months. 7 . FIBRIN GLUE B iological adhesive which contains thrombin, fibrinogen, factor XIII, aprotinin . Thrombin converts fibrinogen to unstable fibrin clot, factor XIII stabilizes the clot and aprotinin prevents its degradation. 26

27. 8 . STYPTICS & ASTRINGENTS Precipitates protein & arrests bleeding. Commonly used styptics & astringents are Monsel’s solution containing ferric subsulfate & tannic acid. Thrombin & gelatin sponge are now widely used. 9 . ALGINIC ACID P laced over the bleeding sites, a protective film is formed over the bleeding site, this film compresses the capillaries & stabilizes the blood clot. 10. NATURAL COLLAGEN SPONGE W hite sponge material, fully absorbable. It stimulates the platelet aggregation thereby enhancing hemostasis. A ctivates coagulation factors XI & XIII. Preferred in patients who are susceptible for hemorrhage after dental surgical procedures. 27

28. 11. FIBRIN SPONGE O btained from bovine material. C hemically treated to avoid allergic reactions. A pplied on the bleeding site especially in post extraction socket. F ully absorbed by the tissues within 4-6 weeks. 12. OSTENE (a new water soluble bone hemostatic agent) N ew bone hemostatic agent, made of water-soluble alkylene oxide copolymers. S howed no incidence of adverse response in the cortical defect site, medullary cavity or the surrounding tissue. 28

29. 13. BONE WAX Sterilized, non – absorbable mix of waxes. Consists of seven parts by weight of wax (white bees wax, paraffin wax & an isopropyl ester of palmitic acid), two parts of olive oil and one part of phenol. I ndicated in cases of bleeding from the bone or from chipped edges of bone. B one wax is softened with the fingers to desired consistency & then applied over the bleeding site. Its hemostatic mechanism is through mechanical obstruction of the osseous cavity containing the bleeding vessels. 29

30. 30 Systemic Agents: Whole Blood : Fresh whole blood refers to blood that is administered within 24 hours of its donation. Whole blood transfusion indicated when there is excessive blood loss. Contains all factors for coagulation. Must be checked for HIV, hepatitis B, C viruses. 2. Platelet Rich Plasma : Platelets can be collected from donated whole blood. Platelet concentrates are viable for 3 days when stored at room temperature. Must be infused quickly via short i.v. tranfusion set. One unit raises platelet count by approx 7,000 to 10,000 cells per cu mm.

31. 31 3. Fresh Frozen Plasma: Unit of fresh frozen plasma is collected from one donor and contains all coagulation factors. Stored at -30°C, should be infused within 2 hours once defrosted. 4. C ryoprecipitate: Stored at -30°C. Each bag is derived from single donor and is not treated to inactivate viruses. Associated with a substantial risk of viral transmission.

32. THERMAL AGENTS Heat achieves hemostasis by denaturation of proteins. Cautery: Heat is transmitted from instrument by conduction directly to the tissues. E lectro – cautery has replaced direct heat application. Dental burnisher like instrument can be directly heated over flame and applied directly to the bleeding point. 32

33. Electrocautery : Most widely used. Electrocautery can be applied directly to bleeding point . Cautery point is touched to the hemostat, causing sealing of vessel through action of heat . Causes tissue destruction producing burning smell and smoke during application . Effective and convenient way of controlling hemorrhage. 33

34. 34 Advantages of electrocautery : Permits any degree of hemorrhage control. Provides clear and improved view. Increases efficiency. Reduces chair side time. Gives pressure – less cutting.

35. Cryosurgery : Extreme cooling has been used for hemostasis. Temperature ranging from -20°C to -180°C are used. Tissues, capillaries, small arterioles and venules undergo cryogenic necrosis. Caused by dehydration and denaturation of lipid molecules. Specially used to treat superficial hemangiomas . Lasers : Lasers usually result in bloodless surgery. Effectively coagulate the small blood vessels during cutting of tissues. 35

36. REFERENCES Textbook of Oral and Maxillofacial Surgery by Neelima Anil Malik (3 rd edition). Textbook of Oral and Maxillofacial Surgery by S.M. Balaji (2 nd edition). Textbook of Surgery for Dental Students by Sanjay Marwah (1 st edition ). Essentials of Pathology for Dental Students by Harsh Mohan (4 th edition). 36

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