Hemorrhage & Shock Its Management In Oral Surgery Instructor – Dr.Jesus George 1
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
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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
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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)
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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
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Cont. D-depending upon the nature of
bleeding External hemorrhage - epistaxis Internal hemorrhage - splenic rupture
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Laboratory tests for screening Bleeding time (aspirin therapy) Platelet count (liver disease, c/c leukemia) Prothrombin time (heparin therapy, liver
disease)
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Hemostasis Control or arrest of bleeding
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Local hemostatic measures Mechanical methods Thermal methods Chemical methods
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Mechanical methods Pressure Use of hemostats Sutures & ligation
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Thermal methods Cautery Electrosurgery Cryosurgery
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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)
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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
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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
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Cont. Lingual artery Local clamping of the artery & application
of electrocautery usually controls bleeding Superficial temporal artery Electrocautery
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Hereditary coagulopathies Hemophilia -a Hemophilia -b
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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
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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
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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
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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.
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Clinical features Mild - <20% blood loss
Cold, calmy,moist skin ↓ in BP Rapid pulse Collapsed neck veins Concentrated urine
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Cont. Moderate - >20-40%
Feeling of thirsty Hypotension Rapid pulse Oliguria or anuria
Severe - >40 % Agitated & confused patient Hypotension Rapid pulse Rapid respiration
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Classification Hypovolemic shock Cardiogenic shock Septic shock Neurogenic shock Anaphylactic shock
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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
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Cont. Hemorrhagic shock is due to loss of
blood from the body causing decreased venous return & thus decreasing the cardiac output
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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
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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
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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
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Septic shock Produced by microorganisms or toxins May be produced by bacteria ,virus &
fungi Inflammatory response causing
vasodilatation & hypovolemia Clinically: fever, tachycardia&
respiratory alkalosis
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Cont. Treatment Early & effective volume replacement Restoration of tissue perfusion Control of infection with antibiotic therapy I.V betamethasone or dexamethasone
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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
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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
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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
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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
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Anaphylactic shock Caused by anaphylaxis of penicillin&
streptomycin Treatment Oxygen Airway Injection adrenaline Cardiopulmonary resuscitation
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