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14 hemorrhage & shock

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14 hemorrhage & shock

  1. 1. Hemorrhage & Shock Its Management In Oral Surgery Instructor – Dr.Jesus George 1
  2. 2. Hemorrhage  Bleeding  Escape of blood from a blood vessel due to damage or injury in vasculature 2
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. Cont.  D-depending upon the nature of bleeding  External hemorrhage - epistaxis  Internal hemorrhage - splenic rupture 7
  8. 8. Laboratory tests for screening  Bleeding time (aspirin therapy)  Platelet count (liver disease, c/c leukemia)  Prothrombin time (heparin therapy, liver disease) 8
  9. 9. Hemostasis  Control or arrest of bleeding 9
  10. 10. Local hemostatic measures  Mechanical methods  Thermal methods  Chemical methods 10
  11. 11. Mechanical methods  Pressure  Use of hemostats  Sutures & ligation 11
  12. 12. Thermal methods  Cautery  Electrosurgery  Cryosurgery 12
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Cont.  Lingual artery  Local clamping of the artery & application of electrocautery usually controls bleeding  Superficial temporal artery  Electrocautery 16
  17. 17. Hereditary coagulopathies  Hemophilia -a  Hemophilia -b 17
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. Clinical features  Mild - <20% blood loss  Cold, calmy,moist skin  ↓ in BP  Rapid pulse  Collapsed neck veins  Concentrated urine 22
  23. 23. Cont.  Moderate - >20-40%  Feeling of thirsty  Hypotension  Rapid pulse  Oliguria or anuria  Severe - >40 %  Agitated & confused patient  Hypotension  Rapid pulse  Rapid respiration 23
  24. 24. Classification  Hypovolemic shock  Cardiogenic shock  Septic shock  Neurogenic shock  Anaphylactic shock 24
  25. 25. 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
  26. 26. Cont.  Hemorrhagic shock is due to loss of blood from the body causing decreased venous return & thus decreasing the cardiac output 26
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Cont.  Treatment  Early & effective volume replacement  Restoration of tissue perfusion  Control of infection with antibiotic therapy  I.V betamethasone or dexamethasone 31
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. Cont.  ManagementManagement  Monitoring pulseMonitoring pulse  Lowering head to improve cerebellar circulationLowering head to improve cerebellar circulation  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 patientReassurance of patient 35
  36. 36. Anaphylactic shock  Caused by anaphylaxis of penicillin& streptomycin  Treatment  Oxygen  Airway  Injection adrenaline  Cardiopulmonary resuscitation 36

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