Hemorrhage & Shock Its Management In Oral Surgery Instructor – Dr.Jesus George 1

Hemorrhage Bleeding Escape of blood from a blood vessel due to

damage or injury in vasculature

2

Types A-depending upon the nature of the

vessel Arterial hemorrhage

Bright red color Pulsation of the artery can be seen

Venous hemorrhage Dark red color, Non-pulsating with steady flow(constant

flow) Difficult to control because vein gets

retracted 3

Cont.Capillary hemorrhage

Red colour Slowly oozes out It becomes significant if there is

bleeding tendencies Bony bleeding

From nutrient vessels in bone Usually follows removal of lower 3rd molar

4

Cont. B. Depending upon timing of

hemorrhage Primary hemorrhage -occurs at the time

of surgery Reactionary or intermediate

hemorrhage -occurs after 24 hrs of surgery(causes-hypertension in postoperative period, sneezing,coughing)

Secondary hemorrhage -occurs after 48-72 hrs after surgery (infection)

5

Cont. C-depending upon the duration of

hemorrhage Acute hemorrhage -occurs suddenly

(esophageal variceal bleeding due to portal hypertension)

Chronic hemorrhage-(hemorrhoids or piles or chronic duodenal ulcer

6

Cont. D-depending upon the nature of

bleeding External hemorrhage - epistaxis Internal hemorrhage - splenic rupture

7

Laboratory tests for screening Bleeding time (aspirin therapy) Platelet count (liver disease, c/c leukemia) Prothrombin time (heparin therapy, liver

disease)

8

Hemostasis Control or arrest of bleeding

9

Local hemostatic measures Mechanical methods Thermal methods Chemical methods

10

Mechanical methods Pressure Use of hemostats Sutures & ligation

11

Thermal methods Cautery Electrosurgery Cryosurgery

12

Chemical methods Astringents (ferric sulfate in ethyl cellulose) Styptics (epsilon amino caproic acid local &

systemic) Bone wax (bees wax(7)+olive

oil(2)+phenol(1),helps in platelet aggregation) Gelfoam (compressed sponge made up of porcine

skin & have physical action) Adrenaline Surgicel (knitted fabric, interaction with platelets) Fibrin glue (thrombin+fibrinogen+factor8)

13

Prevention of hemorrhage during & after extraction Primary hemorrhage – tender handling

of soft tissues & bone. Reactionary hemorrhage – semi supine

or sitting posture, diazepam 5 mg at bedtime or antihypertensive drugs after consultation with the physician

Secondary hemorrhage - antibiotics

14

Control of hemorrhage from major arteries Greater palatine artery Pressure pack A round bolus of gauze is made of

adequate size , so that it does not cause gagging

It is kept in place by tie over sutures for 24 to 48 hours

Pressure pack can be safely removed after 48 hours

15

Cont. Lingual artery Local clamping of the artery & application

of electrocautery usually controls bleeding Superficial temporal artery Electrocautery

16

Hereditary coagulopathies Hemophilia -a Hemophilia -b

17

Hemophilia -a Caused by deficiency of factor 8 Sex-linked recessive inherited disorder Seen in males Hemophilia-a is graded as mild ,

moderate ,& severe Mild - factor 8 level ranges from 6 to 30

percent Moderate - factor 8 level ranges from 1

to 5 percent

18

Cont. Severe - factor 8 level ranges from nil to

1 percent Clinical features - prolonged bleeding

tendencies even after a mild trauma Patients are higher risk for bleeding after

oral surgical procedures

19

Hemophilia b It is caused by deficiency of factor 9 It is congenital disorder& transmitted as

sex--linked recessive trait Clinical manifestations of this disease

are similar to hemophilia a

20

Shock Shock is a pathophysiologic condition

clinically recognized as a state of inadequate perfusion due to inadequate blood flow,there is inadequate delivery of nutrients to the tissues & inadequate removal of cellular waste products from tissue cells, results in disruption of vital organ functions.

21

Clinical features Mild - <20% blood loss

Cold, calmy,moist skin ↓ in BP Rapid pulse Collapsed neck veins Concentrated urine

22

Cont. Moderate - >20-40%

Feeling of thirsty Hypotension Rapid pulse Oliguria or anuria

Severe - >40 % Agitated & confused patient Hypotension Rapid pulse Rapid respiration

23

Classification Hypovolemic shock Cardiogenic shock Septic shock Neurogenic shock Anaphylactic shock

24

Hypovolemic shock Decrease in the circulating or effective

intravascular volume Most common type of shock in

maxillofacial trauma Hypovolemic shock is classified into 1.Haemorrhagic shock 2.Non- hemorrhagic shock

25

Cont. Hemorrhagic shock is due to loss of

blood from the body causing decreased venous return & thus decreasing the cardiac output

26

Cont. Non-hemorrhagic shock-there is

massive fluid shift from intravascular compartment to extra vascular compartment causing decreased blood volume &thus decreasing tissue perfusion. can result from burns, crush injuries,

pancreatitis, peritonitis & pleural effusion, water loss due to severe diarrhea, vomiting, hyperglycemia & nephritis

27

Cont. Treatment Control bleeding Legs raised & body supine is preferred

posture as this increases venous return & cardiac index

Fluid replacement; normal saline or ringer lactate

28

Cardiogenic shock Inadequate cardiac output , impaired

oxygen delivery & reduced tissue perfusion, caused by loss of effective contractile function of myocardium

Treatment Dopamine is the vasopressor of choice. It

is diluted in normal saline or 5%dextrose drip

29

Septic shock Produced by microorganisms or toxins May be produced by bacteria ,virus &

fungi Inflammatory response causing

vasodilatation & hypovolemia Clinically: fever, tachycardia&

respiratory alkalosis

30

Cont. Treatment Early & effective volume replacement Restoration of tissue perfusion Control of infection with antibiotic therapy I.V betamethasone or dexamethasone

31

Neurogenic shock Vasovagal syncope or emotional fainting Blockage of sympathetic nervous system

→dialatation of blood vessels →hypovolemia →shock

Predisposing factors – fear, anxiety, painPredisposing factors – fear, anxiety, pain

- fatigue - fatigue

- fasting- fasting

- hot & humid weather- hot & humid weather

32

Cont. Signs & symptoms(Clinical feature): Signs & symptoms(Clinical feature):

Pale, cold & moist skinPale, cold & moist skin Slow pulse initially followed by rapid pulseSlow pulse initially followed by rapid pulse DizzinessDizziness WeaknessWeakness Nausea & sweatingNausea & sweating Loss of consciousnessLoss of consciousness Dilated pupilDilated pupil

33

Cont. Prevention

Reassurance Achieve confidence of the patient Anxiolytic medication prior to surgery

(diazepam 5 mg 1 tablet night before the surgery & one 1/2hr before surgery)

patient should not come with empty stomach

34

Cont. Management Management

Monitoring pulseMonitoring pulse Lowering head to improve cerebellar Lowering head to improve cerebellar

circulationcirculation Loosening of tight cloths at neckLoosening of tight cloths at neck Smelling of salt of aromatic ammoniaSmelling of salt of aromatic ammonia Flashing the face with cold waterFlashing the face with cold water Glucose drinksGlucose drinks Inj.dexamethasoneInj.dexamethasone Reassurance of patient Reassurance of patient

35

Anaphylactic shock Caused by anaphylaxis of penicillin&

streptomycin Treatment Oxygen Airway Injection adrenaline Cardiopulmonary resuscitation

36