HEMORRHAGE AND ITS MANAGEMENT

Presented By: SILAO, Sr. Nerlyn L.

 WHAT IS HEMORRHAGE?

• Denotes the escape of blood from a blood vessel.

• Any damage to the vasculature leads to the outflow of blood.

• 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

1. Depending on the SOURCE OF BLEEDING:

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.

2. Depending on the NATURE OF BLEEDING VESSEL:

i) Arterial Hemorrhage: Bright red in color. Blood emitted as a jet with each heartbeat.

ii) Venous Hemorrhage: Dark red in color. Blood flow is steady.

iii) Capillary Hemorrhage: Bright red in color. Generalized ooze of blood instead of blood flow.

3. Depending upon TIME OF HEMORRHAGE:

i) Primary Hemorrhage: Occurs at the time of trauma or surgery.

ii) Reactionary Hemorrhage: Occurs within 24 hours of trauma or operation.

iii) Secondary Hemorrhage: Occurs after 7 – 14 days of trauma or operation.

4. Depending upon VOLUME OF BLOOD LOSS:

i) Mild Hemorrhage: Blood loss ≤ 500 mL.

ii) Moderate Hemorrhage: Blood loss 500 – 1000 mL.

iii) Severe Hemorrhage: Blood loss ≥ 1 L.

5. Depending upon SPEED OF BLOOD LOSS:

i) Acute Hemorrhage: Massive bleeding in short span of time.

ii) Chronic Hemorrhage: Slow bleeding small in quantity for long time.
6. Depending upon PERCENTAGE OF BLOOD LOSS:

i) Class I: Up to 15%.

ii) Class II: Between 15 – 30%.

iii) Class III: Between 30 – 40%.

iv) Class IV: More than 40%.

ETIOLOGY

• Trauma.

• Infections.

• Congenital malformations.

• Surgical (intraoperative/postoperative).

• Due to systemic diseases (viral infection, scurvy, allergy).

• Abnormalities in clotting factor (hemophilia A, multiple myeloma).

• Abnormalities in platelets (leukemia, ITP, thrombocytosis, thrombocytopenia). 6

 HEMOSTASIS

• Mechanism of cessation of extravasation of blood.

• Four important steps:

 Injured blood vessel undergoes constriction due to spasm.

 Activation of platelets and formation of platelet plug.

This leads to primary hemostasis.

 Activation of clotting mechanism and formation of clot leading to completion of secondary

hemostasis.

 Fibrous organization of clot or retraction of clot.

 Mechanism of Hemostasis

 PRIMARY HEMOSTASIS

• Process of platelet plug formation at the site of injury.

• 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.

• Completed in several minutes and is important in bleeding from larger vessels.

• Some substances promote clotting (called procoagulants) and some prevent clotting (called
anticoagulants).

• There is a complex interaction of various factors of coagulation in the formation of a clot.

 Coagulation Mechanism

 Coagulation mechanism can be broken down into series of 4 reactions:

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

Reaction 3: • Factor X is activated by proteases generated in the previous two reactions.

Reaction 4: • Prothrombin is converted into thrombin in presence of factor V, calcium and

phospholipids. • Main role of thrombin is conversion of fibrinogen into fibrin. • It also activates factor V,
VIII and XIII and helps in platelet aggregation and secretion.

 CLINICAL EVALUATION

• Evaluation of patient with co – ordinated history and physical examination provides valuable clues.

• History should include following questions:

1. Is there any personal or family history of bleeding tendency?

2. Has the patient undergone surgery or extractions previously?

3. Any history of hematuria, GIT hemorrhage, epistaxis?

4. What medication is the patient taking or has taken recently?

• Note for any splenomegaly, hepatomegaly.

• Hepatic insufficiency should be assessed.

• Assessment of skin and mucosal surfaces.

 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

3. Prothrombin Time (PT): • Normal PT is usually 12 – 14 seconds. • Prolonged in patients on warfarin

anticoagulant therapy, vitamin K deficiency or deficiency of factor V, VII, X, prothrombin or fibrinogen.

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.

 METHODS OF ACHIEVING HEMOSTASIS MECHANICAL METHODS

• Pressure.

• Hemostat.

• Sutures and Ligation.

CHEMICAL METHODS

Local Agents:

• Adrenaline.

• Thrombin.

• Surgicel.

• Oxycel.

• Surgicel Fibrillar.

• Gelatine Sponge.

• Microfibrillar Collagen.

• Fibrous Glue.

• Styptics and Astringents.

• Alginic Acid.

• Natural Collagen Sponge.

• Bone Wax.

• Ostene.

Systemic Agents:

• Whole Blood.

• Platelet Rich Plasma.

• Fresh Frozen Plasma.

• Cryoprecipitate.

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:

1. ADRENALINE • Topical application of adrenaline brings about vasoconstriction of bleeding capillaries.

• Available in ampoule, which is applied with the help of gauze. • Concentration of 1 in 1000 is used for
hemostasis over the oozing site.

2. THROMBIN • Helps in converting fibrinogen into fibrous clot.

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.

THERMAL AGENTS Heat achieves hemostasis by denaturation of proteins.

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:

• Permits any degree of hemorrhage control.

• Provides clear and improved view.

• Increases efficiency.

• Reduces chair side time.

• Gives pressure – less cutting.

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