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WHAT IS HEMORRHAGE?
• 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).
CLASSIFICATION OF HEMORRHAGE
i) External Hemorrhage: When bleeding is revealed and seen outside, e.g. epistaxis.
ii) Internal Hemorrhage: Bleeding is concealed and not seen outside, e.g. intracranial hematoma.
i) Arterial Hemorrhage: Bright red in color. Blood emitted as a jet with each heartbeat.
iii) Capillary Hemorrhage: Bright red in color. Generalized ooze of blood instead of blood flow.
ii) Chronic Hemorrhage: Slow bleeding small in quantity for long time.
6. Depending upon PERCENTAGE OF BLOOD LOSS:
i) Class I: Up to 15%.
ETIOLOGY
• Trauma.
• Infections.
• Congenital malformations.
• Surgical (intraoperative/postoperative).
HEMOSTASIS
Mechanism of Hemostasis
PRIMARY HEMOSTASIS
• 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.
SECONDARY HEMOSTASIS
• Activation of clotting process in plasma that results in formation of fibrin which strengthens the
primary hemostatic plug.
• Some substances promote clotting (called procoagulants) and some prevent clotting (called
anticoagulants).
Coagulation Mechanism
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
CLINICAL EVALUATION
• Evaluation of patient with co – ordinated history and physical examination provides valuable clues.
LABORATORY TESTS
1. 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
4. Partial Thromboplastin 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.
• Pressure.
• Hemostat.
CHEMICAL METHODS
Local Agents:
• Adrenaline.
• Thrombin.
• Surgicel.
• Oxycel.
• Surgicel Fibrillar.
• Gelatine Sponge.
• Microfibrillar Collagen.
• Fibrous Glue.
• Alginic Acid.
• Bone Wax.
• Ostene.
Systemic Agents:
• Whole Blood.
THERMAL AGENTS
• Cautery.
• Electrocautery.
• Cryosurgery.
• Lasers.
MECHANICAL METHODS
1. 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
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.
CHEMICAL METHODS
Local Agents:
3. SURGICEL • Oxidized cellulose polymer obtained by dissolving pure alpha- cellulose in an alkaline
solution. • Acts by forming acid products from partial dissolution that coagulates the plasma proteins to
form a black or brown sticky gelatinous clot. • Applied surgicel resorbs from the site in 4 to 8 weeks. •
Disadvantage is that the surgicel clot is not formed by normal physiological mechanism. 23
4. SURGICEL FIBRILLAR: • Modified 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. •
Completely absorbable material. • Has the capacity to absorb 45 times its weight in blood. • Resorbs
completely in 4 to 6 weeks.
6. OXYCEL • Oxidized cellulose polymer product. • This absorbable hemostatic material is manufactured
by controlled oxidation of cellulose using nitrous dioxide. • Cellulosic acid present in it has affinity for
hemoglobin which leads to the formation of artificial clot. • Should 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.
7. MICROFIBRILLAR COLLAGEN (AVITENE) • Collagen derived from bovine skin cause contact activation
in addition to direct platelet aggregation. • Absorption time is 3 months.
8. FIBRIN GLUE • Biological 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
9. 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.
10. ALGINIC ACID • Placed over the bleeding sites, a protective film is formed over the bleeding site, this
film compresses the capillaries & stabilizes the blood clot.
11. NATURAL COLLAGEN SPONGE • White sponge material, fully absorbable. It stimulates the platelet
aggregation thereby enhancing hemostasis. • Activates coagulation factors XI & XIII. • Preferred in
patients who are susceptible for hemorrhage after dental surgical procedures. 27
12. FIBRIN SPONGE • Obtained from bovine material. • Chemically treated to avoid allergic reactions. •
Applied on the bleeding site especially in post extraction socket. • Fully absorbed by the tissues within 4-
6 weeks.
13. OSTENE (a new water soluble bone hemostatic agent) • New bone hemostatic agent, made of water-
soluble alkylene oxide copolymers. • Showed no incidence of adverse response in the cortical defect
site, medullary cavity or the surrounding tissue. 28
14. 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. • Indicated in cases of bleeding from the bone or from chipped edges of bone. • Bone 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.
Systemic Agents:
1. 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.
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. Cryoprecipitate: • 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.
1. Cautery: • Heat is transmitted from instrument by conduction directly to the tissues. • Electro –
cautery has replaced direct heat application. • Dental burnisher like instrument can be directly heated
over flame and applied directly to the bleeding point.
2. 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.
Advantages of electrocautery:
• Increases efficiency.
3. 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.
4. Lasers: • Lasers usually result in bloodless surgery. • Effectively coagulate the small blood vessels
during cutting of tissues.
MCM
EXPOSURE
Submitted by:
SILAO, Sr. Nerlyn L.
BSN - IV
Submitted to:
Mrs. Rosa M. Reyes
MCM Clinical Instructor