The document discusses management of intraoral bleeding during surgery. It covers hemostasis mechanisms, factors influencing surgical bleeding, adverse effects of bleeding, characteristics of ideal hemostatic agents, and various methods of hemostasis including mechanical, thermal, and chemical approaches. Common hemostatic agents discussed include adrenaline, bone wax, thrombin, gelfoam, and fibrin glue. Proper agent selection and application technique are important to control bleeding during oral surgery procedures.
Instruments used in oral and maxillofacial surgeryCing Sian Dal
Instruments used in oral and maxillofacial surgery
Copyright (c) Dr. Ko Ko Maung
Department of Oral & Maxillofacial Surgery
University of Dental Medicine, Yangon
Instruments used in oral and maxillofacial surgeryCing Sian Dal
Instruments used in oral and maxillofacial surgery
Copyright (c) Dr. Ko Ko Maung
Department of Oral & Maxillofacial Surgery
University of Dental Medicine, Yangon
The presentation deals with the various suturing materials available and the different kinds of techniques used. Attempts have been made to simplify the text and support with suitable illustrations. Hope you like it!
Suggestions and feedback will be highly appreciated! :)
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
The presentation deals with the various suturing materials available and the different kinds of techniques used. Attempts have been made to simplify the text and support with suitable illustrations. Hope you like it!
Suggestions and feedback will be highly appreciated! :)
Detailed discussion on diagnosis and management of TMJ ankylosis. Surgical anatomy and applied aspects of TMJ is discussed. Reconstruction of ramus-condyle unit is also discussed. Compications of TMJ surgery are also discussed
The presentation deals with the basics of hemorrhage i.e. classification, etiology. It also covers the mechanism of hemostasis and the various methods to achieve hemostasis.
Hope you like it! Suggestions and feedback will always be well appreciated. :)
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
5. There are 3 mechanisms that work together to stop the flow of blood.
They are :-
•Vasoconstriction
•Platelet plug formation
•Clotting of blood
Hemostasis 5
11. The best management of intraoperative hemorrhage is prevention.
This includes a thorough preoperative patient history, necessary
medical consults, familiarity with managing patients with possible bleeding diathesis,
meticulous intraoperative technique, and appropriate postoperative instructions, care,
and followup.
11
12. During oral surgical procedures, persistent minor oozing of blood is common,
although occasionally a bleeding episode prevents the continuation of the
procedure and requires immediate attention.
The usual sources for this intraoperative complication are incision into an area
of granulomatous tissue, vessels in the periosteum or mucosa, or encountering
nutrient arteries in the alveolar bone.
12
13. The dentist should be familiar with the range of methods, techniques,
materials, and their application during different types of bleeding episodes.
Having a broad knowledge of the management approaches will allow the
clinician to know when to apply a particular approach.
One of the more common methods of intraoperative hemorrhage control
involves the use of a topical hemostatic agent
13
14. • Type of procedure
• Patient position
• Surgical incisions
• Exposed bone
• Large surfaces of exposed
capillaries
• Unseen sources of bleeding
• Tissues that cannot be sutured or
low-pressure suture lines
• Adhesions stripped during surgery
Procedural
factors
• Specific anatomical considerations
• Medications (eg. Anticoagulants)
• Coagulopathies
• Platelet dysfunction or deficiency
• Fibrinolytic activity
• Coagulation factor deficiencies
• Medical conditions
• Nutritional status
Patient
factors
Factors influencing Surgical bleeding
14
15. • Visual obstruction of the surgical field
• Need for blood transfusions
• Reduction in core temperature
• Thrombocytopenia
• Hypovolemic shock
Adverse effects of Surgical bleeding
15
18. Characteristics of an Ideal hemostatic agents
for clinical use:
(1) capability to stop large vessel arterial and venous bleeding within minutes
of application when applied to an actively bleeding wound through a pool
of blood;
(2) no requirement for mixing or pre-application preparation;
(3) simplicity of application
(4) light weight and durable;
(5) long shelf life in extreme environments;
(6) safe to use with no risk of injury to tissues or transmission of infection;
(7) cost-effective
18
19. The techniques for local hemostasis may be
classified as
Mechanical
Thermal
Chemical
19
21. •Application of pressure basically counteracts hydrostatic pressure within the
bleeding vessel until such time that a clot can form and occlude the bleeding
orifice.
• Pressure is usually able to control most of the hemorrhages.
•Pressure should be appied directly over the bleeding site firmly over a guaze
packfor atleast five minutes.
Pressure
21
22. •Use of hemostats (also called a hemostatic clamp, arterial forceps,)
•Haemostat (mosquito,artery) forces are specially designed to catch bleeding
points in the surgical area.these can be straight or curved.
•Curved haemostats are used more frequently,because of their versatility and
ease in tying the ligature around the tip of forceps.
Hemostats
22
23. •Transected blood vessel may need to be tied with the help of a ligature.
•When large artery needs to be ligated,nonabsorbable material like 3-0 black
silk is preferred.
•Smaller vessels can be ligated with 3-0 catgut,or polyglactin.
•Large pulsatile artery ligated with double transfixation.
Sutures and ligation
23
24. Embolization of the vessels
With the help of angiography ,the exact bleeding point can be localized.
Agents which can be used for embolization include steel coils, polyvinyl
alcohol foam , gel foam, silicon spheres, methyl methacrylate.
These particles are placed via a catheter superselectively into the bleeding
vessel .
24
26. Heat achieves haemostasis by denaturation of proteins which results in coagulation
of large areas in the tissue. In cauterization, heat is transmitted from the instrument
by conduction directly to the tissues.
Cautery
26
27. In electrocautery,heating occurs by induction from an alternating current source.it
is an effective and convenient way of controlling hemorrhage.
Electrocautery can be applied directly to bleeding point or after catching the
bleeding point with haemostat.then cautery pont is touched to the haemostat
causing of the vessel through the action of heat.
Electrosurgery
27
28. oThe argon beam coagulator (ABC) delivers
radiofrequency electrical energy to tissue across a jet of
argon gas, providing noncontact, monopolar,
electrothermal hemostasis.
oIn this ,coagulator monopolar current is transmitted to
the tissues through the flow of argon gas which allows
bleeding from vessels that are smaller than 3mm in
diameter to be controlled without use of haemosats or
ligatures.
Argon-beam coagulator
28
29. Lasers usually result in bloodless surgery ,as these effectively coagulate the small
blood vessels during cutting of tissues
Argon laser provides excellent hemostasis and coagulation
Lasers
29
30. Chemical methods
I. Astringent agents and styptics
II. Bone wax
III. Thrombin
IV. Gelfoam
V. Oxycel
VI. Surgicel
VII. Fibrin glue
VIII. Adrenaline
IX. others
30
31. •Adrenaline or epinephrine,applied topicaly induces vasoconstriction and thus
helps in acheiving hemostasis.
• Extensive application or undiluted preparation can cause systemic effects
therefore ,care should be exercised while using adrenaline.
•It can also be injected along with local anesthetic in a concentration of 1:80,000
to 1:2,00,000
Adrenaline
31
32. Chemical agents vary in their hemostatic actions.
Monsel’s solution contains Ferric sulphate and it acts by precipitating proteins.It is
quite effective in arresting capillary bleeding.
Tannic acid also helps in precipitating proteins.
Mann hemostatic is a mixture of tannic acid,alum and chlorbutamol.
Silver nitrate and ferric chloride are used in case of minimal capillary bleeding
Astringent agents and styptics
32
33. Is a mixture of beeswax (70%) and Vaseline (30%).
Used to help mechanically control bleeding from bone surfaces during
surgical procedures.
It is a non-absorbable material,becoming soft and malleable in the hand
when warmed an is most commonly supplied in sterile sticks
Bone wax
33
34. Topical use of thrombin acts by converting fibrinogen into.fibrin clot
Topical thrombin indicated as an aid to hemostasis whenever oozing blood and minor
bleeding from capillaries and small venules is accessible and control of bleeding by
standard surgical techniques (such as suture, ligature or cautery) is ineffective or
impractical.
Thrombin
34
35. •Gelfoam sterile powder is a fine, dry, heat-sterilized light powder prepared by
milling absorbable gelatin sponge.
•It is a water-insoluble,off-white, nonelastic, porous, pliable product
•While its mode of action is not fully understood, its effect appears to be more
physical than the result of altering the blood clotting mechanism.
Gelfoam
35
37. 37
When not used in excessive amounts,Gelfoam is absorbed completely,
with little tissue reaction
When placed in soft tissues, Gelfoam is usually absorbed completely in
from 4 to 6 weeks, without inducing excessive scar tissue.
This absorption is dependent on several factors, including:
•The amount used
•Degree of saturation with blood or other fluids
•Site of use.
38. Usage 38
Gelfoam should be cut to the minimum size
required to attain hemostasis. Gelfoam may be
applied dry or saturated with a physiologic
saline solution.
When applied dry, Gelfoam should be manually
compressed before application to the bleeding
site.
When used with saline, Gelfoam should be
soaked in the solution, then withdrawn,
squeezed between gloved fingers to expel air
bubbles present in the interstices, replaced in
saline, and kept there until needed.
Gelfoam should be applied to the bleeding
surface and held in place with moderate
pressure until hemostasis is attained
It is not necessary to apply suction to
Gelfoam, since Gelfoam will draw up blood
into its interstices by capillary action
39. •Gelfoam should not be used in closure of skin incisions because it
may interfere with healing of the skin edges.
•This is due to mechanical interposition of gelatin and is not secondary
to intrinsic interference with wound healing.
•Gelfoam should not be placed in intravascular compartments, because
of the risk of embolization.
Contra-Indications:
39
40. Flowable Gelatin
Composition(combination of two
independent agents and consists of
bovine-derived gelatin granules coated
in human-derived thrombin that works
in combination to form a stable clot at
the bleeding site)
Animal-derived gelatin mixed with
thrombin (or saline) in a flowable
consistency
Mode of action
Gelatin provides a matrix for
platelet adhesion and
aggregation
Thrombin aids in fibrin clot
formation
Will not work if the area is not
actively bleeding
40
41. Flowable Mechanism of Action
• Applied to the tissue surface at the base of the lesion. Its
granules fill the wound and conform to its shape.
• Granules expand approximately 20% within about 10
min and restrict the flow of blood. Blood that percolates
through the spaces is exposed to high concentrations of
thrombin.
• A clot forms around the matrix provided by the
granules and remains in place at the tissue surface.
41
43. Oxidized regenerated cellulose is also known as Surgicel or Oxycel in its
commercial forms is derived from alpha-cellulose that is actually plant-based.
Oxycel is an absorbable haemostat that has been used to control bleeding safely,
simply and effectively
Oxycel or Surgicel
43
44. Provides a matrix for platelet adhesion, accelerating
the formation of the platelet plug that will form the
foundation of the fibrin clot
Creates an area of low pH causing localized
vasoconstriction
Oxidized Regenerated Cellulose (ORC) absorbs
blood and becomes a gel covering the site of vessel
injury
How Does SURGICEL Work? 44
45. Why is SURGICEL Bactericidal?
This pH lowering effect remains until
the material is fully absorbed (7-14
days)
Under acidic conditions, bacteria
become less active
This causes localized area of low pH
(3.4-3.7)
Contact with moisture triggers the
breakdown of cellulose and the release
of cellulosic acid
45
46. Conforms to wound site, minimal sticking to gloves or instruments
Effective hemostasis for classic 6-8 minutes, Nu-knit 3-5 minutes, fibrillar 3-4
minutes
No immunogenicity potential, bactericidal
Absorption within 7-14 days (depending on amount used, degree of saturation
with blood)
46
47. •Fibrin glue(also called Fibrin sealant) is a formulation used to create a fibrin clot
aiding in hemostasis
•It is made up of fibrinogen(lyophilised pooled human concentrate) and
thrombin(bovine, which is reconstituted with calcium chloride) that are applied to
the tissue sites to glue them together.it may also contain aprotinin,fibronectin and
plasminogen
•Thrombin is an enzyme and converts fibrinogen into fibrin monomers between
10 and 60 seconds giving rise to a three-dimensional gel.
Fibrin Glue
47
48. Fibrin glue is "Fibrin Fibronectin Sealing System (FFSS)"
It is available as two component system: first component contains highly concentrated
fibrinogen, factor XIII, fibronectin, and traces of other plasma proteins. The second
component contains thrombin, calcium chloride, and antifibrinolytic agents such as
aprotinin.
Mixing of two components promotes clotting with the formation and cross-linking of
fibrin.
48
49. When periodontal plastic surgical procedures done
or implants placed in esthetic zone, fibrin sealants
may be variable alternative to closing flaps with
sutures and with histologic benefits
In periodontal plastic surgeries of esthetically
important areas it gives better results than sutures.
49
50. Fibrin Sealants
EVICEL
Uses human thrombin (all
human components)
Low risk of immune reaction
No aprotinin or tansexamanic
acid
Prep time <1 minute
Clear clot
Spray or drip
TISSEEL
Uses bovine thrombin
Higher risk of immune reaction
Contains aprotinin
Prep time 15 minutes
Cloudy white clot
Spray (syringe or pressure
delivery) or drip
50
51. Precautions and limitations
1. Fibrin sealant cannot be used in individuals who are known to be
hypersensitive to bovine protein
. 2. Fibrin sealant cannot be indicated for the treatment of massive and
brisk arterial or venous bleeding
3. To avoid risk of allergic anaphylactic reaction and/or thromboembolic
events, which may be life threatening, fibrin sealant should not be applied
intravascularly or into the tissues.
51
54. Co-Seal and BioGlue most commonly used
Creates a shell over the area applied
Caution not to cover things that will be removed
Synthetic Sealants
BioGlue
Composed of Glutaraldehyde and purified bovine serum albumin (BSA)
Binds covalently to tissue surface proteins (won’t work if place on non-protein
surface)
Supplied with multiple syringe tips as they clot off as soon as there is no active
injection.
54
55. CoSeal
Composed of two synthetic polyethylene glycols (PEGs) in
hydrogen chloride and sodium phosphate
When mixed the PEGS form a hydrogel that adheres to
tissue and covalently bonds to itself
Completely synthetic, no gluteraldehyde
Swells up to 4 times its volume in 24 hrs and additional
swelling may occur as the gel resorbs
55
56. Chitosan-based dressing
Chitosan is a biodegradable,nontoxic,complex
carbohydrate derived from chitin(a naturally occuring
substance from zeolites): when the deacetylation of chitin
is above 70% the generic name” Chitosan” is applied
In the form of an acid salt it has a mucoadhesive activity
It has a positive charge and it attracts RBCs and Platelets
which have negative charge.
The freeze-dried Dressing augments its sealing action
Also offers an antibacterial barrier
56
57. •Hemostatic mechanism is due to activation of thromboplastin formation on
damaged vessel walls and decrease prostacyclin 2 synthesis and facilitates platelet
aggregation. Ethamsylate reduces capillary bleeding in the presence of normal
number of platelets.
•It acts by correcting abnormal platelet adhesion.
•It exerts antihyaluronidase action,improves capillary wall.stability,not stabilize
fibrin(not an antifibrinolytic).
Ethamsylate 57
58. Indications: used in prevention and.treatment of capillary
bleeding in
*menorrhagia
*epistaxis
*hematuria
*after tooth extraction
Efficacy is unsubstantiated
adverse effects like rash are common and blood pressure falls only after IV injection.
Dose: 250-500 mg TDS oral /IV
58
59. Tranexamic acid
Tranexamic acid 4.8% oral rinse is an antifibrinolytic agent
that stabilizes clots and facilitates clot formation by
competitively inhibiting plasminogen, the enzyme responsible
for activating plasmin.
It can also be useful as a prophylactic mouthwash in patients
who are on anticoagulant medications which require oral
surgery. It can be used preoperatively, intraoperatively, or
postoperatively to manage bleeding. It is very popular as a
post-operative hemostatic mouthwash.
59
60. Botroclot
Haemocoagulase :- A proteolytic enzyme from venom of South American
viper,Bothrops atorox, A plasma clotting agent for fibrinogen(a haemostatic)
INDICATIONS:
• Topical capillary bleeding & tissue oozing
• Hastens coagulation through multiple actions
• Promotes cosmetically elegant, scarless wound healing
• Arrests bleeding in cuts and wounds
• Surgical incisions
• Post Hysterectomy
• Plastic Surgeries, Skin Grafting (Donor & Receptor
areas)
• Dental Extractions
60
61. Dosage:
Apply 5 to 10 drops or sufficient quantity to cover the wound
completely.
61
62. Conclusion
Control of bleeding is the most important integral part of any surgical
treatment procedure. Proper prior evaluation of the patient & complete
medical and family history are very much essential to overcome intra
operative & post operative bleeding arising from undetected bleeding
disorders
62
63. References
1. Contemporary Oral and Maxillofacial Surgery – Peterson
2. Textbook of Pathology – Harshmohan.
3. Textbook of Oral Surgery – Vinod Kapoor
4. Review of hemostatic agents used in dentistry. McBee WL, Koerner KR.
63
Dentists perform a variety of surgical procedures frequently requiring the need for a hemostatic agent. Exodontia, tissue biopsies, placement of endosseous implants, and periodontal surgery are just some examples where hemostatic agents may be beneficial.
Hereditary
hemophilia A
hemophilia B
von Willebrand’s disease
Acquired
vitamin K deficiency
Druginduced hemorrhage
massive blood transfusion
BEFORE GOIN TO TOPIC PERSE , HEMOSTATIC AGENTS
LETS HAV A BRIEF IDEA ABOUT HEAMOSTATSIS
Hemostasis is a process which causes bleeding to stop,.
Hemostasis occurs when blood is present outside of the body or blood vessels. It is the instinctive response for the body to stop bleeding and loss of blood. During hemostasis three steps occur in a rapid sequence. Vascular spasm is the first response as the blood vessels constrict to allow less blood to be lost. In the second step, platelet plug formation, platelets stick together to form a temporary seal to cover the break in the vessel wall. The third and last step is called coagulation or blood clotting.
Vasoconstriction is produced by vascular smooth muscle cells, and is the blood vessels first response to injury.
When a blood vessel is damaged, there is an immediate reflex, initiated by local sympathetic pain receptors, which helps promote vasoconstriction.
The damaged vessels will constrict (vasoconstrict) which reduces the amount of blood flow through the area and limits the amount of blood loss.
Platelets play one of the biggest roles in the hemostatic process. When platelets come across the injured endothelium cells, they change shape, release granules and ultimately become ‘sticky’. Platelets express certain receptors, some of which are used for the adhesion of platelets to collagen.
Platelets release cytoplasmic granules such as adenosine diphosphate (ADP), serotonin and thromboxane A2. Adenosine diphosphate (ADP) attracts more platelets to the affected area, serotonin is a vasoconstrictor and thromboxane A2 assists in platelet aggregation, vasoconstriction and degranulation. As more chemicals are released more platelets stick and release their chemicals; creating a platelet plug and continuing the process in a positive feedback loop.
Clots form upon the conversion of fibrinogen to fibrin, and its addition to the platelet plug (secondary hemostasis).
Coagulation or blood clotting uses fibrin threads that act as a glue for the sticky platelets.
As the fibrin mesh begins to form the blood is also transformed from a liquid to a gel like substance through involvement of clotting factors and pro-coagulants.
The coagulation process is useful in closing up and maintaining the platelet plug on larger wounds.
The release of prothrombin also plays an essential part in the coagulation process because it allows for the formation of a thrombus, or clot, to form. This final step forces blood cells and platelets to stay trapped in the wounded area.
Contact activation pathway (intrinsic)[edit]
The contact activation pathway begins with formation of the primary complex on collagen by high-molecular-weight kininogen (HMWK),prekallikrein, and FXII (Hageman factor). Prekallikrein is converted to kallikrein and FXII becomes FXIIa. FXIIa converts FXI into FXIa. Factor XIa activates FIX, which with its co-factor FVIIIa form the tenase complex, which activates FX to FXa
Tissue factor pathway (extrinsic)[edit]
The main role of the tissue factor pathway is to generate a "thrombin burst", a process by which thrombin, the most important constituent of the coagulation cascade in terms of its feedback activation roles, is released very rapidly. FVIIa circulates in a higher amount than any other activated coagulation factor.
Pathway: Common Pathway
The common pathway consists of the cascade of activation events leading from the formation of activated factor X to the formation of active thrombin, the cleavage of fibrinogen by thrombin, and the formation of cleaved fibrin into a stable multimeric, cross-linked complex.
NATURAL INHIBITOR OF COAGULATION CASCADE
PROTEIN S
PROTEIN C
TISSUE FACTOR PATHWAY INHIBITOR
ANTITHROMBIN III
THOMBOMODULIN
Although these are easily listed, application in practice can be challenging. Multiple obstacles may prevent the implementation of the management steps listed. Some of these hurdles include treating patients with an undisclosed or undiagnosed medical condition, improper information retrieval, or difficult surgical conditions. Poor patient compliance with medication or postoperative instructions also are factors to be considered
Identification of the source of the bleeding requires good illumination, adequate retraction, and thorough suctioning. Once identified, the bleeding site should be packed, clamped, cauterized, burnished, debrided, and/or sutured for control. Topical hemostatic agents should be available, and if necessary, applied
Why to Use Hemostatic Agents
Minimize blood loss
Improve visualization
Save operative time
Reduce or avoid transfusion
Manage anticoagulated patient
Avoid conversion of lap procedures
Prevent leakage of non-bloody fluids
Decrease post-op drainage and infection
Decrease hospital length of stay
Product cost
Availability
Storage
Speed to hemostasis
Durability of hemostasis
Source (bovine, porcine, human, plant)
Immunogenicity
Impact on infection/healing
Absorption rate
Swelling
Usually electrosurgical thermocoagulation is done after catching the bleeding point with artery forceps,if the vessel is small.
The large vessels are ligated with sutures
Electrocautery has replaced direct heat application.
When an electrosurgery unit isn’t available,dental burnisher like instrument can be directly heated over a flame and applied directly to the bleeding point in the oral cavity.
It causes tissue destruction producing a burning smell and smoke during application.this cannot control haemorrhage from large vessels,which need to be ligated.
The tip of coagulator held approx. 1cm from the tissue.
A flow of argon gas clears the surgical site of fluids to allow curren to be focusseddirectly on tissue,with reduced carbonization.
There is formation of 1-2mm of Eschar,that covers bleeding surface and remains attached to the tissues with less tendency to rebleed
Laser coagulation: The coagulation (clotting) of tissue using a laser. A coagulation laser produces light in the visible green wavelength that is selectively absorbed by hemoglobin, the pigment in red blood cells, in order to seal off bleeding blood vessels.
This is not used as agent of choice in patients with hypertension or previously existing cardiac disease
The vasocostrictor effect is reversible so there exists need to watch carefully for the recurrence of bleeding when its efect wears off.
This solution can control superficial bleeding
BY TAMPONADE EFFCET IT STOPS BLEEDING
Its hemostatic effect is based on physical rather than biochemical properties.when smeared across the bleeding edge of the bone, blocking the holes and causing immediate bone hemostasis through a tamponade effect.It have no active hemostatic properties (i.e. does not activate the blood clotting cascade)
It has been used in bone surgeries for a long time; not proper for combat/accident casualty care
The wax was sterilized by boiling and kept in stoppered bottles
it is tissue friendly and quite efective .
It is applied to the bleeding tisaues via a pck,gelatin sponge or surgicel.
This is not to be used for the treatment of severe or brisk arterial bleeding.
Do not use in individuals known to have anaphylactic or severe systemic reaction to human blood products.
Hypersensitivity reactions, including anaphylaxis, may occur.
Gelfoam sterile sponge, used dry or saturated with sterile sodium chloride solution
Gelfoam sterile powder, saturated with sterile sodium chloride solution are indicated in surgical procedures as a hemostatic device, when control of capillary, venous, and arteriolar bleeding by pressure, ligature, and other conventional procedures is either ineffective or impractical.
However, in case of brisk arterial bleeding, the pressure of the flow may prevent the sponge from remaining securely anchored, and bleeding is likely to continue.
When not used in excessive amounts,Gelfoam is absorbed completely, with little tissue reaction
When placed in soft tissues, Gelfoam is usually absorbed completely in from 4 to 6 weeks, without inducing excessive scar tissue.
This absorption is dependent on several factors, including:
The amount used
Degreeof saturation with blood or other fluids
Site of use.
Gelfoam should be cut to the minimum size required to attain hemostasis. Gelfoam may be applied dry or saturated with a physiologic saline solution.
When applied dry, Gelfoam should be manually compressed before application to the bleeding site.
When used with saline, Gelfoam should be soaked in the solution, then withdrawn, squeezed between gloved fingers to expel airbubbles present in the interstices, replaced in saline, and kept there until needed.
Gelfoam should be applied to the bleeding surface and held in place with moderate pressure until hemostasis is attained
It is not necessary to apply suction to Gelfoam, since Gelfoam will draw up blood into its interstices by capillary action.
It starts working within minutes, swelling to create a pseudo-clot, which puts pressure on the wound, helping to speed up the normal clotting process and preventing further blood loss.
The pseudo-clot can be removed in a gelatinous state after one or two days, or can be left in situ, where itis fully absorbed after one to two weeks
As it is a plant-based product made from oxydised cellulose there is no risk of contamination with animal or human products when using Oxycel
Contraindication:Patinets who are allergic to cellulose analogues
Absorbable – Oxycel fully dissolves in the body between seven and 14 days, removing the need for further intervention that can increase the potential of re-bleed.
Fibrin-sealing system is effective as a means of fixing tissues after periodontal surgery, as fibrin glue is easier and quicker to use than sutures.
Sutures cause inflammation around themselves, while fibrin glue enhances early wound healing.
The fibrin glue is easier and quicker to use than sutures.
The fibrin sealing system provides better early hemostasis and complete adhesion of the whole surface of the tissues to the underlying layer.
Sutures cause inflammation themselves; fibrin glue enhances early wound healing.
The fibrin sealing system is effective as a means of fixing tissues after periodontal surgery
It should be applied with pressure for 3 minutes and then release ; can be left on the wound for 48 h ; easily removed by saline without disturbing the clot
It can be use even for high flow ,high pressure bleeding: combat operations; hemodialysis;etc
No complications have been reported
Used in prevention and.treatment of capillary bleeding in menorrhagia,after abortion,,epistaxis,malena,hematuria,after tooth extraction
The main role of plasmin in the body is clot degradation or fibrinolysis; hence, tranexamic acid non-competitively inhibits plasmin and stabilizes clot formation.