Presentation on theme: "Diagnosis and Management of Hemorrhage in Oral Surgery"— Presentation transcript:
1Diagnosis and Management of Hemorrhage in Oral Surgery Division of Oral and Maxillofacial SurgeryCollege of DentistryKing Saud University
2What is meant by Hemorrhage ? Prolonged or uncontrolled bleeding is often referred to as hemorrhage.The amount of blood lost as a result of hemorrhage can range from minimal to significant quantities.
3Hemorrhage in SurgeryHemorrhage can occur to a greater or lesser degree during all surgical procedures and it’s management depends upon whether the patient is hematologically normal or suffers from some disturbance in the normal clotting mechanism.
5Hemorrhage in Oral Surgery The overwhelming majority of patients who undergo oral surgical procedures are those who have normal haemostatic mechanism.Therefore, significant or major hemorrhages are not that common in oral surgery except in patients who have a bleeding / clotting disorder or those who are on anticoagulants.
6Hemorrhage in Oral Surgery However, uncontrolled and persistent bleeding can occur in some healthy patients after dental extraction.Therefore, it is still important to achieve proper hemostasis in all patients during oral surgical procedures, so as to prevent excessive post-operative blood loss.
7Normal Mechanism of Hemostasis Hemostasis is a complicated process.It involves a number of events
13HEMOSTASIS DEPENDENT UPON: Vessel Wall Integrity Adequate Numbers of PlateletsProper Functioning PlateletsAdequate Levels of Clotting FactorsProper Function of Fibrinolytic Pathway
14Hemorrhage in Oral Surgery Hemorrhage following Oral Surgical procedures can occur due to local or systemic causes.In healthy patients the postoperative bleeding is mainly due to local causes.
15Local causes of hemorrhage in oral surgery Local causes of hemorrhage originate in either soft tissue or bone.
16Local causes of hemorrhage in oral surgery –Soft tissue bleeding Soft tissue bleeding is either arterial, venous, or capillary in nature.
17Local causes - Soft tissue bleeding in oral surgery Arterial bleeding is bright red and spurting in nature.Arteries in the soft tissues at risk during oral surgical procedures are the lies posterior portion of hard palate) greater palatine artery and the buccal artery (lies lateral to the retromolar pad)
18Local causes - Soft tissue bleeding in oral surgery Venous blood is dark red in color and flows steadily and heavily especially if the vein is large.Capillary bleeding is bright red in color and is more of a minimal ooze.
19Local causes – Osseous (Bony) bleeding in oral surgery Troublesome bone bleeding originates either from nutrient canals in the alveolar region, central vessels, such as the inferior alveolar artery, or from central vascular lesions (Hemangioma or Vascular malformation)
20Systemic causes of hemorrhage in oral surgery Some patients with heriditary conditions such as hemophilia, Von Willebrand’s disease are susceptible for hemorrhage following oral surgical procedures.Patients with thrombocytopenia (decreased platelet count) , Leukemia e.t.c., are also at risk of prolonged bleeding after surgery.Patients with uncontrolled hypertension.
21Systemic causes of hemorrhage in oral surgery Patients with H/O prosthetic heart valve replacement, Stroke (Cerebrovascular accident) e.t.c., take oral anticoagulants like Aspirin or Warfarin to prevent the occurrence of a thromboembolic episode.These patients are also at risk of prolonged severe bleeding during and after an oral surgical procedure.
22Types of Hemorrhage - Primary Hemorrhage This occurs during the surgery, as a result of injury like cutting or laceration of the artery or bleeding from bone.This also occurs when surgery is done in an infected area with a lot of granulation tissue.It can also occur after a very short period of time immediately after surgery.This type of bleeding is really normal and can be controlled easily.
23Types of Hemorrhage - Intermediate / Reactionary Hemorrhage This type of bleeding occurs within a few hours after surgery.This type of bleeding occurs as a result of failure of coagulation to occur (as in patients with systemic bleeding problems or those on anticoagulants)Patients who have unknowingly disturbed / dislodged the clot are also prone for this type of bleeding.
24Types of Hemorrhage - Secondary Hemorrhage This occurs after 7 to 10 days after surgery. This is mainly due to partial division of blood vessel in combination with infection of the wound (Like patient’s who undergo radical neck dissection e.t.c.,).This type of bleeding is not very frequently encountered after oral surgery procedures.
25Management of Primary Hemorrhage in Normal patients The management of bleeding during surgery (Primary bleeding) can be achieved by the following means,Securing / ligation of blood vessels with silk sutures.Use of pressure swab to achieve hemostasis.Use of electrocautery to achieve hemostasis.Use of hemostatic agents like bone wax, surgicel,e.t.c.,Hypotensive anaesthesia (G.A) and use of vasoconstrictors in L.A.
26Local Measures ( Synthetic Materials) There are several materials that are commercially available that are used locally for achieving adequate hemostasis.
36Management of Intermediate Hemorrhage in Normal patients The management of bleeding that occurs immediately after surgery (Reactionary bleeding) involves proper examination of the surgical wound to identify the site of bleeding (i.e ) from bone or soft tissue.If bleeding is from bone then the hemostatic agents like bone wax or gelfoam is usually used.If bleeding is from soft tissues then, ligation / cauterization of blood vessels along with the use of hemostatic agents like surgicel and suturing of the wound is carried out.
37Management of Secondary Hemorrhage in Normal patients The management of this type of bleeding that occurs a few days after surgery involves the removal of any debris from the wound surface that promotes the infection of the wound.Identify the source of bleeding and treat as would be done in a patient with secondary bleeding.Surgical stents can be placed over extraction sockets for stabilization of clot and prevention of wound contamination.
38Management of Hemorrhage in patients with bleeding disorders / and those on anticoagulant therapy The usual protocol involved in the treatment of this group of patients consists of pre-operative blood investigations and preoperative correction of the underlying deficiency (Replacement of Clotting factors / platelets) if any in these patients.Subsequently, after this appropriate local measures are used to decrease the chances of post-operative bleeding.
39LABORATORY EVALUATION PLATELET COUNTBLEEDING TIME (BT)PROTHROMBIN TIME (PT)PARTIAL THROMBOPLASTIN TIME (PTT)THROMBIN TIME (TT)
40PLATELET COUNT NORMAL 100,000 - 400,000 CELLS/MM3 < 100, Thrombocytopenia50, ,000 Mild Thrombocytopenia< 50, Severe Thrombocytopenia
41PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTION BLEEDING TIMEPROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTIONNORMAL VALUE2-8 MINUTES
42PROTHROMBIN TIME Measures Effectiveness of the Extrinsic Pathway NORMAL VALUE10-15 SECS
43PARTIAL THROMBOPLASTIN TIME Measures Effectiveness of the IntrinsicPathwayNORMAL VALUE25-40 SECS
44THROMBIN TIME Time for Thrombin To Convert Fibrinogen Fibrin A Measure of Fibrinolytic PathwayNORMAL VALUE9-13 SECS
45Management of Hemorrhage in patients with uncontrolled hypertension. This group of patients need appropriate medical consultation for initiation of medical treatment to decrease their Blood Pressure.Thus once their B.P is controlled, then the bleeding decreases and with local measures the hemorrhage is controlled.