Hemostasis and methods to control bleeding

it includes steps of controlling bleeding, primary and secondary hemostasis etc...

1. hemostasis Dr. Imran A slam Assistant Professor North Surgical W ard

2. introduction Hemostasis is the process of forming clots in the walls of damaged blood vessels and preventing blood loss while maintaining blood in the fluid state within the vascular system.

3. virchow’s triad Coagulation is combination of Stasis of blood Endothelial injury Hypercoagulability

4. Events in hemostasis Hemostasis means prevention of ‘Blood Loss’. Hemostasis is achieved by several mechanism:- Vascular constriction Formation of platelet plug Formation of blood clot Growth of fibrous tissue into the clot.

5. 1.Vascular constriction The contraction results from:- Local myogenic spasms Local autacoid factors Nervous reflexes Platelets release, T hromboxane-A2 which is responsible for vasoconstriction of smaller vessels. The more severely a vessel is traumatized, the greater the degree of vascular spasm.

6. 2.Formation of platelet plug MECHANISM OF PLATELET PLUG Platelet adhesion Platelet activation Platelet aggregation Formation of temporary hemostatic plug

7. 3.BLOOD COAGULATION IN RUPTURED VESSEL Third mechanism for hemostasis is formation of blood clot Clot begins to develop- severe trauma-15 to 20 sec minor trauma-1 to 2 min

8. Coagulation pathways These mechanisms are set into play by:- Trauma to the vascular wall and the adjacent tissues Contact of the blood with damaged endothelial cells a) Extrinsic pathway for initiating blood clotting b) Intrinsic pathway for initiating blood clotting

9. EXTRINSIC PATHWAY FOR INITIATING BLOOD CLOTTING

10. Intrinsic pathway

11. Formation of fibrin network In response to rupture of the vessel or damage to the blood itself-formation of prothrombin activator Prothrombin activator catalyzes conversion of prothrombin to thrombin Thrombin catalyzes fibrinogen into fibrin fibers.

12. CONVERSION OF PROTHROMBIN TO thrombin and then fibrinogen into fibrin

13. BLOOD CLOT The clot is a meshwork Fibrin fibers also adhere to damaged surfaces of blood vessels. As the clot contracts, the edges are further pulled together, contributing ultimate state of Hemostasis.

14. CONVERSION OF FIBRINOGEN TO FIBRIN-FORMATION OF THE CLOT

15. CLOTTING PROCESS IN A TRAUMATIZED BLOOD VESSEL

16. Methods of haemostasis

17. Methods of haemostasis

18. Mechanical hemostasis

19. Direct pressure First choice to control bleeding Fast and simplest Small Arterial bleeding Venous bleeding 15-20 sec Not recommended in major artery and veins.

20. Fabric pads/gauze/sponge Used with direct pressure It is used in - only pressure is not an option -systemic bleeding due to infection, trauma, massive blood loss, and platelet dysfunction.

21. Suture/staples/ligating clips Suture – used in major arteries and veins Ligation of facial artery, lingual artery, and external carotid artery

22. Types of Ligation Stick Tie: Also called as transfixation . Used for High Blood pressure Proximal part of the vessels Regular Tie Used for Distal part of the vessels Also used for tubectomy .

23. Staples - sterile and disposable titanium staples Ligating clips- quick and easy decrease foreign body reaction various size

24. Use of Hemostats Hemostats (Mosquito and Artery) are designed to catch bleeders. Can be straight or curved.

25. Bone wax Is a mixture of Beeswax (70%) and Vaseline (30%). It is a non-absorbable material , becoming soft and malleable in the hand when warmed Its Hemostatic effect is based on physical rather than biochemical properties. It has been used in bone surgeries

26. Trans Catheter arterial embolization -Restricts tumors blood supply . -Arterial embolization preferentially interrupts tumors blood supply and stalls growth until neovascularization - Used to control bleeding in Hemangiomas

27. Thermal Energy Method

28. Methods: Heat (Cautery) Electro cautery: it is the use of high frequency alternating current for cutting, coagulating, dessication or fulgurating tissue in both open and laparoscopic procedure monopolar electro surgery bipolar electro surgery bipolar electrosurgery vessel sealing technology argon enhanced coagulation technology Ultrasonic device Lasers

29. Monopolar electro cautry Most frequently used Two electodes - active (the pencil) - dispersive Modes - coagulation mode - cutting mode - blend mode Current flows through the patient from electrode (active) to electrode (dispersive)

30. Bipolar electro surgery Current does not flow through the patient’s body Lower voltage Indicated in limited thermal spread Delicate tissue, small anatomical tissue Safe for implanted medical devices such as pacemaker, internal cardioconverter fibrillator etc.

31. Chemical methods

32. Pharmacological agents Topical haemostatic agent Passive active

33. Pharmacological agents Sterile haemocoagulase solution Epinephrine Vitamin k Protamine Desmopressin Lysin analogs Etamsylate

34. Epinephrine Causes direct vasoconstriction Can be applied topically and can be injected with LA Prolong analgesic effect Reduces bleeding during surgery Topical - The drug is applied with the help of gauze pack in concentration of 1:1000 over a oozing It is also injected along with local anesthetics in concentration of 1:80,000 and 1:2,00,000.

35. Vitamin K Plays important role in coagulation process Helps in production of fibrinogen and prothrombin in liver Route- orally and IV(slow) IM and subcutaneous is not recommended because irratic absorption Dose- Males: 120 mcg/day PO Females: 90 mcg/day PO  5-10 mg IV (dilute in 50 mL IV fluid and infuse over 20 min

36. Protamine Reverse heparin anticoagulation activity Adverse effect- anaphylaxis, acute pulmonary vasoconstriction, right ventricular failure Contraindication -diabetic - pt undergone vasectomy -drug allergy -previous protamine exposure Dose -1.0 -to- 1.5 mg protamine sulfate IV for every 100 IU of active heparin

37. Lysine Analogues Tranexamic acid- loading dose 2-7gm Follwed by 20-250 mg hourly Total dose of 3-10gm Oral dose; 500 mg 6-8 hrly Children; 1.25g/5 ml of syrup Inj - 0.5-1g slow i.v infusion TID

38. Topical Haemostatic Agents Passive- collagen based product - oxidised regenerated cellulose - gelatine Active haemostat - thrombin product - pooled human plasma thrombin - recombinant thrombin