haemorrrhage

1. HAEMORRHAGE

2. • Haemorrhage ( haem – blood, rhegmynia– to burstforth )
• Haemorrhage meansthe escapeor extravasation of bloodfrom ruptured blood vessel

3. Typesof haemorrhage
1.Accordingto time of onsetof bleeding-
• Primary–occursat the time of injury
• Reactionaryorintermediate- occurswithin 24 hrsofinjury,
Dueto dislodgementof clot/ ligatureslippingdueto
increasedbloodpressure,restlessness,coughingor vomiting
• Secondary– occursafter 24 hrsto severaldaysafter surgery
but usuallytake placeafter 7 -14 daysafter injury,dueto
infection& sloughingof vessel; Predisposingfactoris
foreignbody

4. 2. Dependingontypeof vessel
involved
• Arterial - pulsatile(spurts), brisk& brightredin color
• Venous–darkredcolor,,flowssteadily,bloodlossiscopious& difficult to
stop,maybecomedarkerif the patient isinstateof anoxia.
• Capillary-Bleedingpoint isnot discernable
• Not severe
• Caneasilybecontrolledbydigitalpressure
• Color-intermediateshadebetweenarterial & venous.

6. 3. Accordingto siteof haemorrhage
• External/revealed haemorrhage –is seen externally

7. • Internal/concealedhaemorrhage-not seenexternally
• Ex-pepticulcer, fractureof majorbones,ruptureof liver& spleen
• Concealedinternalhaemorrhageisrevealedinthe formof
haematemesis( bloodinvomiting), malena(bloodinstools),
hematuria( bloodinurine)

8. 4. Accordingto amountofbloodloss

9. ClassI–
• 15%OR750mlof bloodloss
• equivalentof donatingoneunitblood
• Minimaltachycardia
• NomeasurablechangesinB.P.,pulsepressureor
respiration
• Noreplacementrequired
• Bloodvolumeisrestoredin24 hrs

10. • ClassII–
• 15- 30 %bloodloss( 750 -1500ml)
• Symptoms-Tachycardia,Tachypnea& decreasedpulse pressuredue
to increased diastolic pressure caused by increased circulating
catecholamines
• Urinaryoutput mildlyaffected ( usually20-30 ml/hr)
• Somemayrequireblood tranfusion
• Butstabilizedinitially bycrystalloids
• Ex-traumato liver ,spleen, longbone#, major surgery

11. • ClassIII-
• 30 -40 %of bloodloss(1500-2000 ml)
• Clinicalsignsof inadequate perfusion,marked
tachycardia,tachypnea,changesinmental status&
measurablefall insystolicpressure,diaphoresis- increased
sweating,decreaseurinary output
• Thisisleastamountof bloodlossthat consistently causes
dropinsystolicbloodpressure
• Patientalwaysrequires transfusion
• E.g.Ruptureof liver,spleen, multiple #, burns

12. • ClassIV–
• >40% bloodloss( approx.2000 ml) isimmediately life
threatening
• Symptoms-markedtachycardia, significantlydecreasedB.P., Narrow
pulsepressure,urinary output negligible& mental status markedly
depressed,coldpale skin
• Theyrequirerapidtransfusion& immediatesurgical intervention
• If >50%- LOC, losspulse, andB.P.
• Thereisconsistentfall insystolicB.P.Onlywhenmorethan 30%of blood
volumeislost

13. 6. Dependingontime & treatment
pattern ofhaemorrhage
• Acute
• chronic

14. MEASURINGBLOODLOSS
• Bloodclot – sizeof clenchedfist =500 ml

15. ESTIMATIONOFBLOODLOSS

16. SWAB WEIGHING
• weighingof swab( 1 gm=1ml) & addingto volume of bloodinsuction
• Bloodlossestablishedbythismethod ismuchlessthan actual bloodloss, plasma& water
• In moderate surgeries– multiply by1 ½
• In longersurgeries– multiply by2

18. MANAGEMENTOFHAEMORRHAGE

20. MANAGEMENTOFHAEMORRHAGE
• 1. stopbloodlossby–
• - pressure& packing
• - position& rest
• - haemostasisby–local& systemicmethods
• - operativeprocedures( ligation, repair&excision)
• 2. restorebloodvolume

21. STOPPINGBLOODLOSS
• Pressure& packing– with adressing/pack , whichis
boundtightly or with , finger pressure( for 5 min )

22. • In operation theatre usedfor
• A.Temporarycontrolof haemorrhage
• B.Foramputation
• C.Bloodlessfield for orthopedic& softtissue injury

23. POSITION& REST
• ELEVATIONOFLIMBS–
causesvasoconstriction&
employsgravityto
decreased bleeding
• Esmarchbandagesapplied
temporarily to limbsreduce
the vascularcompartment
• Restlessnessdecreasesby
injection Morphine ( 10-15
mgIM/SC, 2-10 mgIV )

24. HAEMOSTATIC MEASURES
• Duringanysurgicalprocedure complete
hemostasismustbeachievedbefore closureof
wound .
• Direct control of bleeding at site of injury isbest
method
• Surgicalbleeding mostof timesiscausedby
ineffective local hemostasis

25. Haemostatic agentscanbe -
• - local
• - systemic

26. Localhemostatic measures-
• Mechanical
• Thermal
• chemical

27. MECHANICAL
• Pressure–
• Counteractshydrostatic forceof bloodwithin vesseluntil clot canform & occludethe
orifice
• Able to controlmostof the haemorrhages
• Pressureshouldbe applied directly over bleedingsite with a guazepackfor atleast 5
minutes
• Shouldnot lift packafter every minute to check
• Posttraumatic bleeding/ pharyngeal bleedingcanbecontrolledbynasalpacking( anterior
/ posterior)
• In fracture mandible, bleedingfrom secondaryinferior dental artery usuallystops
spontaneouslywith pressurepacks
• Severemaxillofacialbleedingcanbecontrolledbytemporary or definitive reduction&
fixation

28. USEOFHEMOSTATS-
• Curved/ straight,
crushingof small vessels
, stopsbleeding
• After catchingthe
bleedingpoint ,
electrosurgicalthermo
coagulationisdone, if
vesselis small

29. SUTURES & LIGATION
• Whenlargepulsatile artery needs
ligation , non–absorbablemateriallike
3-0 blacksilkispreferred
• Smallvesselscanbeligatedwith 3-0
catgut/g polygalactin
• Thepresenceof non– absorbable
material in aninfectedwoundcanlead
to extrusion/ sinustract formation
• Largearterieswith pulsations( ECA)
shouldhavedoubletransfixation suture
passedthroughvesselwall to prevent
slippage

30. HALFLIFEOFSUTUREMATERIAL
• ‘ Timerequired for the tensile strengthof material
to reducehalf of its original value ’
• Dissolutiontime istime elapsesbefore the thread
iscompletely dissolved
• Ex-Half Lifeof vicryl is7-14 days
• Tensilestrengthremained after 14 daysisonly 20-
30 %

31. EMBOLIZATIONOFVESSELS
• With the help of angiography,
exactbleedingpoint canbe
localized
• Agentsusedare – steelcoils,
polyvinyl alcoholfoam, gelfoam
, siliconspheres, methyl
methacrylate
• Theyare placedvia catheter
superselectivelyinto bleeding
vesselusuallyvia femoral artery

32. THERMAL
• CRYOSURGERY–
• Extremecoolinghasbeen usedfor hemostasis
• Temperaturerangesfrom -20 degreecelciusto -180 degree
celcius
• Atthistemperature tissues, capillaries,smallarterioles &
venulesundergocryogenic necrosis
• Causedbydehydration & denaturation of lipid molecules
• Especiallyusedfor superficial hemangiomas

33. ARGON BEAM COAGULATOR
• Representsnew form of
electrocautery & ismore
effective than standard
cautery
• In thiscoagulatornonpolar
current istransmitted to
tissuesthroughthe flow of
argongas

34. • Thisallowsbleedingfrom vesselswith diameter <3 mm, to becontrolled
without useof hemostats/ ligatures
• Tipisheld approximately 1 cmfrom tissue,flow of argongasclears
surgicalsite of fluidsto allow current to be focuseddirectly ontissuewith
decreased carbonization
• Thereisformation of 1-2 mmof escher( scarproducedbythermal burn or
corrosive/ gangrene) that coversthe bleedingsurface& remains
attached to tissueswith tendencyto rebleed
• Possibilityof gasembolismbut canbe eliminated bynot placing
handpiecetip in direct contactwith tissues

35. LASERS

36. CAUTERY
• Heat activated hemostasisby
denaturation of proteinswhich
resultsin coagulationof large
area of tissues
• In cauterizationheat is
transmitted oninstrumentsby
conductiondirectly into tissues
• Whenelectrocauteryunit isnot
available , dental burnisherlike
instrument heated& applied
directly onbleeding point
• ELECTROCAUTERY– Heat occurs
byinductionfrom alternating
current

37. CHEMICAL METHODS
• LOCALAGENTS–
• 1. astringents& styptics–
• Monsel’ssolution– containsferric
subsulphate& it actson
precipitating proteins
• Effective in arrestingcapillary
bleeding & postextractionbleeding
in medullary bone
• Silvernitrate istoxic, carcinogenic
& ferric chloride canbe usedin
minimal capillary bleeding

38. TANNICACID
• (i) Also precipitates
proteins and causes
clot formation
• (ii) more helpfulas
homeremedy
• (iii) Patient askedto
bite onfolded tea bag
in caseof post
extraction bleeding

39. BONEWAX( Beeswax +salicylicacid)
• Bleedingoccuringfrombony
canalisdifficult to occludeasit
isconfinedwithin canal
• Smallquantity of bonewaxcan
be applied
• It actsbymechanicalocclusion,
but largequantitiescancause
foreignbodygranuloma
formation & infection
• Thisshouldbeused judiciously

40. • Topicallyactsbyconvertingfibrinogen – fibrin clot
• Kindto tissues& very effective
• Appliedvia apackor gelatin sponge

41. GELFOAM
•
•
•
•
•
•
•
Made from gelatin & isspongelike
Hasnointrinsic hemostaticaction
Main hemostatic activity is related to large
surface area , which comes in contact with
blood& further swellsonabsorbing blood
Exertspressure& actsasscaffoldfor fibrin
network
Absorbedby phagocytosis
Shouldbe moistenedin salineor thrombin
solution prior to application
It will harbour microbeswhichin turn will
cause alveolar osteitis & delayin repair

42. OXYCEL
• Oxidizedcellulose& anapplication releases
celluloseacid– markedaffinity for Hb– artificial
clot
• Shouldbeapplieddry asacidformedduring
wetting process, it activates thrombin orother
hemostaticagent
• Acidproducedalsoinhibitsepithelization ,thusit is
not usedover epithelial surfaces

43. SURGICEL
• Glucosepolymer based,sterile knitted fabric prepared by
controlled oxidation or regenerated cellulose
• Localaction isbybindingof Hbto oxycelluloseallowing dressing
to expandinto gelatinousmass,whichactsasscaffoldfor clot
formation & stabilization
• Canbe applied dry or soakedinthrombin
• Removedbyliquefaction & phagocytosisoverthe period of one
weekto one month
• Doesnot inhibit epithelization & canbeusedonepithelial
surfaces

44. • Ref– British Dental Journal ( BDJ)
• volume215, page104 (10August2013)
• Author – D.Mc Donnell

45. TOOTHETTE
• Asmallpieceof Surgicel( haemostatic cellulose) wrapped arounda
Toothette (a pink spongeona stickusedto provide moistureto patients
who are unable to swallow)
• Thehaemostatic matrix canbedelivered directly to a bleedingsocketasit
clingswell to the sponge
• Thespongeitself canthen beeasilybitten downonbythe patient and
mouldsto the socket,in contrastto the uncomfortable bulkinessof gauze.
• Anaddition Toothette isthat it canbe safelyplacedin the woundby the
patient or clinicianwith advantage of reabsorption

46. FIBRINGLUE
•
•
•
•
•
•
Biologicaladhesive containingthrombin
fibrinogen& factorXIII & aprotinum
Thrombinconvertsfibrinogeninto
unstablefibrinclot
FactorXIII stabiliesclot
Aprotinum - preventsdegeneration
Duringwoundhealing, fibroblastsmove
throughfibrin meshworkformingmore
permanent framework composedof
collagenfibres
Noriskof viral infectionsbecauseof
pasteurizationof plasmacomponents&
haslittle /no antigenicpotential

47. ADRENALINE
• Applied topically causesvasoconstriction
• Extensiveapplicationor undiluted prep shouldbe
carefully used– systemic action
• Applied in guage( 1:1000) overoozingsite , canalso
beinjected with LA(1:80,000 to 1:2,00,000)
• Shouldnot beusedin hypertensives
• Vasoconstrictoreffect isreversible– watch for
recurrence

48. FERACCYLUM
• Localhemostatic & antisepticagent
• Hemostaticeffect – Basedonthe formation of synthetic complex
consistingof it’s adductwith plasmaprotein principally albumin
( this complex get brokendownoverperiod of time )
Contraindications-concomitantuse of ferrocrylum with epsilonamino
caproicacidinterferes with the formation of feracrylum albumin clot
Specialprecaution – not for parenteral use& shouldbe usedwithout dilution
Indication – adjunct to conventional hemostatic procedurein varied surgical
procedures, dental extractions & oral surgeries
Dose-undiluted solution to beapplied directly or pouredoverbleeding
surface

49. RUSSELVIPERVENUM

51. • Principle- adhesiondueto charge.
• Axiostat madewith100%chitosanhas
beendesignedto bepositivelycharged
andbloodcellscarrya net negative
charge.
• Whenbloodcomesin contactwith
Axiostat, oppositelychargedcomponents
are attracted andform bonds.
• Thisresultsin a strongadhesivesealthat
actsasa mechanical barrier preventing
bloodfrom leakingout.

52. • .
• Themilitary variant is extensively used by the DefenseForcesworldwide.
Thisbattlefield proven technology is used to manage gunshotwoundsand
blastinjuries. It comesin camouflaged,ruggedmetal pouchpacking for
easycarrying and withstand extreme temperature.

53. Axiostat isa sterile, non-absorbablehaemostaticdressingintended to controlbleedingwithin
minutesof applicationbyproviding anactive mechanical barrier to the woundsite.

54. SYSTEMIC AGENTS
• WHOLE BLOOD–
- Freshwhole blood– containsall factors
- Necessaryto type & crossmatchbloodbeforetransfusion
- Must be checkedfor HCV, HIV,HbsAg
- Banked blood
- Poorsourceof platelets
- FactorII /VII/ IX/ XIare(+)
- Oneunit of platelet conc.Has more viable platelets than oneunit of fresh
whole bloodbut isaninadequate source of factor VIII

55. PLATELET RICH PLASMA
•
•
•
•
•
•
Advisableto increaseplatelet level of
rangeof 50,000 – 1,00,000 /ul to
provideprotection
Canbe collectedfrom donatedwhole
blood& directly from patients via
plasmapheresis
Platelet conc.Arevariable for 3 days
whenstoredat roomtemperature
Variability decreaseson refrigeration
Must beinfusedquicklyvia short I/V
transfusionsetwith nofilter
Oneunit PRPraisescountby7,000 -
10,000 /ul

56. FRESH FROZEN PLASMA
• 1 unit ( 150 ml ) usuallycollectedfrom onedonor
• Containsall coagulationfactorsincluding200 ufactor VIII ,200 ufactor IX& 400 mg fibrinoge
• Storedat -30 degC, infusedwithin 2 hoursafterdefrosting

57. CRYOAPRECIPITATE
• 15 ml vial contains– 100 u
factor VIII
• 250 mgfibrinogen & factor
XIII & vonwillebrandfactor
• Storedat -30 degree celcius
• Eachbag is from one donor
& isnot treated for inactive
viruses
• Thususeisassociatedwith
riskof viral transfer

58. TRASYLOL
•
•
•
Polypeptide obtained from
bovine parotid gland, it acts
primarily asplasmin
inhibitor , alsoinhibits
trypsin , chymotrypsin,
kallikrein & plasminogen
activation to some degree
Suppliedas– 1000 & 500
kallikrein inhibitoryunits
/ml
Givenas– singletransfusion
in doseof 5000-10,000 KIU
IV

59. ADRENOCHROME
MONOSEMICARBOZONE&ETHAMSYLATE
•
•
•
•
Adrenochrome monosemicarbozon1
mg/ml Inj. Isgiven, 2 ml /6 hours
before surgicalprocedure( Decreases
capillaryfragility )
Indication – epistaxis, renal
hemorrhage,secondary hemorrhage
Ethamsylatereducescapillary
bleedingin presenceof normal
numberof platelets
Actsbycorrectingabnormalplatelet
adhesion

60. Vitamin K
• K1 – phylokinones
• K2 – monoquinones
• K3- menadione
• Acetomenaphthrone

61. Vitamin K
• Fat– solublerequiredin synthesisof factor 8, 9,10
,Prothrombin
• Action– vit. K– Epoxide– reduction– activevit. K
• Onlyuseof vit kisprophylaxis& treatment of bleedingdue
to deficiencyof clotting factors
• Dietary requirement – 5-10 mg/ day
• Deficiencyoccursdueto - deficient diet , prolonged
antimicrobial therapy , obstructivejaundice, malabsorption
syndrome, liver diseases( cirrhosis,viral hepatitis –
respondspoorly to vit. K)

62. • Toreverseeffectsof overdoseof oral anticoagulant –
• PHYTONADIONE– Preparationof choice –
• Mild – justomit few dosesof anticoagulant
• Moderate – 10 mgIM followed by5 mgonce /twice
• Severe– 10 mgIM followedby5 mg4hourly

63. Ethamsylate
•
•
•
Inhibits prostacyclin
synthetaseenzyme
resultingin prevention of
PGinducedvasodilatation
& antiplatelet aggregation
Indication – epistaxis,
hemoptysis,
postoperatively
Dose– 250 – 500 mg TDS
oral / IV

64. Protamine sulphate
•
•
•
Stronglybasic, low
molecularweight protein
Indication – antidote for
heparin in uncontrolled
bleeding
Dose– 1 mgfor every
100 Uof heparinIV (
seldomneeded as
heparin disappearsitself
in few hours)

65. TRANEXAMIC ACID
•
•
•
Producesantifibrinolytic
effect byblockinglysine
binding site onplasminogen
& prevent bindingto fibrin
Indication – overdoseof
fibrinolytic , tooth
extraction in hemophillia ,
recurrent epitaxis
Dose– 1- 1.5 gm, 2-4 times
daily orally ( 15 – 25 mg/kg
) , 0.5 – 1 gmslowIV 3
times daily ( 10-15 mg/kg)

66. EPSILONAMINO –CAPROICACID
• Analogof aminoacidlysine, it combineswith lysinebindingsite of plasminogenwhich
cannotbindto fibrin & lyseit
• It isspecificantidote of fibrinolyticagents
• Dose– 5 mg/oral /IV followed by1 gm/hour till bleedingstops( maximum30 gmsin 24
hrs)

67. SURGICALMANAGEMENT

68. • Acuteretrobulbar hemorrhage – associatedwith zygomatic
complexfractures
• Midface fracturesfracuresor ocular trauma
• Most commonlyit occurspost– operatively followingreduction
of zygomaticfracture , orbital floor or oroantral surgery
• Clinicalfeatures – proptosis, opthalmoplegia , decreasedvisual
acuity, tenseglobewith dilating pupil & pale opticdisc
• Treatment –
• Decompression– medical / surgical

69. SURGICAL DECOMPRESSION
• EitherdecreasedLA/ GA
• If followingorbital surgeryexistingincisioncanbe used
• Otherwiselateral brow incisionisused
• Otherwiselateral orbital rim & peri-orbitalincised
- Deepenedto lateral orbital rim & peri- orbitalincised
- Peri-orbital elevated proceedingposteriorly, if subperiostealhematomais
present
- It isevacuatedwith suction
- If nosubperiostealhematomathen periorbital isincised& intra – coronalspace
openedbyblunt dissection-anyhematomaisevacuated– softcorrugateddrain
placed& incisionclosedduringinterrupted sutures

70. POST– OPERATIVECARE
• Recoveryof visionisdramatic , drain removed
when drainage ceased
• Medical measurescanbecontinued with oral
acetazolamide500 mgODor BD& oral
prednisolone 60 mg/day
• If proptosispersistsor intraocular pressure
remainshigh

71. MAXILLOFACIALHEMORRHAGE
• Bleedingfrom facial lacerationsusuallyceasespontaneouslyor
canbe controlled by pressure
• Transectionof branchesof ECAwill require clamping& ligation
• It isusuallyaccessiblethroughwoundin a clean laceration
• But, in gunshotwoundcontrol maybe difficult
• Similarly in comminuted fracturesof midface , control of primary
hemorrhage from nose& mouth maysometimesbe impossible
bylocal measures
• Secondaryhemorrhage isalsodifficult to deal with simple
methods

72. ARRESTOFHAEMORRHAGE-
1. PRESSURE– usinggauzeswabs, digital pressureor
occlusal pressureby patients
2. Clamping& ligation – vesselthat isaccessiblewithin
a wound
3. Staysutures– temporary suturesacrossthe wound
which2-0 /3-0 blacksilk
4. Arterial ligation – when localmeasuresalone fail to
control bleeding, ligation of branchesECAmaybe
necessaryunderideal surgicalconditionsin theatres

73. Controlof Haemorrhage from major
arteries

74. GREATERPALATINE ARTERY
• Runsanteriorly from the greater
palatine foramen in the submucosa
of the hardpalate
• Incisionoverthe palate shouldbe
made parallel
• Bleedingiscopious& application of
clampis difficult
• Haemorrhagecanbecontrolled by
a pressurepackwhichiskept in a
placebytie oversuturesfor 24 to
48 hrs

76. SUBLINGUALARTERY
• Canoccuraccidentallybyslippingof sharpinstrument , duringimplant placement
• May lead to largesublingualhematomawhich, if not controlled,cancompromiseairway& maybelifethreatening
• Isasmallartery & localclamping& electrocauteryusuallycontrolsthebleeding
• Mostlyisabranchof lingual artery , but maybeabranchof submentalartery (10%)
• Sosometimesligationof lingual artery maynot stopbleeding& facialartery needsto beligated

77. LINGUALARTERY
• Secondanterior branchof ECA
• Arisesjustbelow the facial artery or from a commonlinguofacial trunk

78. •
•
•
•
•
•
•
• Submandibularcurvillinear incisionistakenfrom the gonial
angleto mentalregion, extendinginferolaterallyoverlying
hyoid bone
Theskin, platysma& deepfasciaare incised& lowerpole
of the submandibularglandisexposed
TheglandislIfted upwards& tendon of digastricmuscle
exposed
Mylohyoid & hyoglossusare areidentified
Hypoglossalisfoundat the posteriorborder of mylohyoid
muscle
Fibresof hyoglossuswithin the lingualtriangleare
seperatedbluntly& the gapbetweenthese fibres,lingual
artery isidentified& ligated
Ligationcanalsodoneat it’s originfrom ECA
EvenbyligatingECAbleedingcanstill continue becauseof
anastomosis

79. FACIALARTERY
•
•
•
•
•
Isthird anterior branchof ECA
Ligatedat the point whereit crosseslowerborder
of mandible anterior to massetermuscle,
accompaniedbyfacial veinwhichliesposteriorto
it
Marginal mandibularbranchof facial nerve crosses
superficiallyover facialvessels
Toprevent damage to this nerve submandibular
incision is given one to two cmbelow the lower
border of mandible.
Theskinsubcutaneoustissue, platysma & deep
fasciaare cut& retractedupwards& the artery lies
anterior to masseter muscle
• It isisolated, tied &cut

80. MAXILLARYARTERY
•
•
•
Terminalbranchof ECA&
situated deep sodirect
ligation isdifficult
Trans– antral approachis
used, it isat riskduringTMJ
surgery,asit liesmedial to
condylar neck
Direct pressurewith packing
, cancontrol the bleeding in
majority of casesor ligation
of ECAhasto be done

81. REF– ‘JAMAOTORHINOLOGY,HEAD& NECKSURGERIES
‘ ANATOMICALVARIABILITYOFTHEMAXILLARYARTERYFINDINGSFROM100
ASIANCADAVERICDISSECTIONS;AUGUST16, 2010 ’

82. External carotid artery
•
•
•
•
•
•
Extensiveanastomosisof all branchesof
ECAoccursacrossthe midline, the
unilateral ligation doesnot stop
hemorrhage completelyandwill not give
bloodlessfield
ECACanbeligatedat two placesfirst in
the carotidtriangle
Arrestsbleedingfrom all the branches
exceptsuperiorthyroid artery
Secondlyretromandibularfossa, bleeding
exclusivelyfrom maxillary artery
Indications– Haemorrhage from
maxillofacialregionnot controlledby
localmeasures
Anesthesia– generalanesthesia

83. SUPERFICIALTEMPORARYARTERY
• Bleedingbestcontrolledbydirectidentification of point & electro coagulation
• Pulsationcanbefelt justanterior to preauricular region
• It isusuallyencounterduringsurgeryof the temporomandibular joint throughthe preauricular incision

84. LADDERTECHNIQUE
• Advisedby– Dr.Barry Eppley
• IndianaUniversity
• Article publishedon– 5 th sept2018
• 1) Enlargedbranchesof the superficialtemporal artery are usuallymultiple andrarely a single branch.
• 2) Asinglebranchsuperficialtemporal artery enlargementstill requiresmulti-level ligationtreatment.
• 3) Eachligation point involves asmall5mmskinincisionwith adoubleligationsusingpermanent suture.

85. NASAL HAEMORRHAGE
•
•
•
Usuallyceasesspontaneously
following maxillofacial injury but ,
somecasesrequire active
measures
Often anterior nasalpackswill
sufficebut , hemorrhagefrom post
nasalspacewill require a post
nasal pack
Wecanuse– guazepacksbright on
balloon , foley catheters

86. Procedure
1
•
•
•
•
. UsingEpistats–
Insert epistat into eachnostril ,aiming
for a fingertip inserted into mouth to
backof soft palate , soposteriorcuffis
restingin nasopharynx
Inflate posterior cuff with upto 10 ml of
saline ;withdraw epistat until resistance
felt at nasopharyngealwall
Inflate anterior cuffwith 30 mlsaline
Suctioncathterscanbeinserted through
the central lumento aid in cleaning
debrisfrom nasopharynx

88. ABSENCEOFHEMOSTATS

89. • Insert 12- 14 guagefoley catheterwith 20 ml balloonsinto the nose,aimingagain
for the fingertip
• Inflate balloonwhencatheteruntil the balloonoccludesagainstchoana
• Pullbackoncatheter until ballonoccludesagainst choana
• Tiecatheterstogetherafter passingbehindheadopposite& releaseperiodically
to prevent ischemicnecrosis
• Insert bismuth, iodoform ,paraffin paste5 cmribbonguazepacksinto nosein
front of balloons& foley’s catheter
• In patients with baseof skullfracture– riskof enteringcranialcavity – foleys or
epistat shouldbedirected caudally
• Massivebleedingcontrolledbycompressionof maxillaagainstcranialbasewith
splints
• Lastresort- Ligationof ipsilateral ECAor its branch

90. BLOOD DONATION
• Theaverageadult hasabout 10 unitsof bloodin hisbody.Roughly1 unit isgivenduringa
donation.
• Ahealthy donormaydonate red bloodcellsevery 56 days,or doublered cellsevery 112
days.
• Ahealthy donormaydonate platelets asfew as7 daysapart, but a maximumof 24times

91. Blood Transfusion
• Introduction-
• FirstdescribedbyRichardlower ( 1666) in animals& in man( 1667 ) usingcalf’s
blood
• Firstsuccessfulmanto mantransfusionwasreported byJBlundell,in 1818 , an
obstetrician
• Landsteiner in 1930 first observed agglutination of human red cells byserum
belonging to other individuals & described the ABOgroups according to two
types of agglutinogens
• Thefourth groupABwasdescribedbyphysicianDecastelliin 1902
• WhenRequired– one540 ml bloodraisesHb1 gm%. If Hb<6gm%, blood
transfusionisdesirable
• If major operationsto be performed Hbmustbe>10 gm%

93. BOMBAYBLOODGROUP

94. INDICATIONS
• Commonestisacutebloodlosswith reductionin circulatoryvolumeof 30 %or
more
• Duringmajor operationswheregoodamountof bloodlossis inevitable
• Deepburns( Dueto considerable hemolysis& Destructionof RBC’s)
• Anemicpatient ( preoperative bloodtransfusionor postoperatively )
• In certain coagulationdisorderslike hemophillia,thrombocytopenicpurpura,
christmasdisease
• Severemalnutrition & hypoproteinemia – before anysurgery
• In caseof erythroblastosisfetalis
• Chemotherapyof malignantdiseases
• sepsis

95. CONTRAINDICATIONS
• Advancedbilateral kidneydisease
• Severecoronaryartery diseaseor myocardial
damage
• Congestivecardiac failure
• Polycythemiavera

96. Merits
• Restoreblood volume
• Increaseoxygencarrying capacity
• Coagulopathyof bloodisincreased

97. Demerits
• Techniqueisnot easy
• Cannotbegivenimmediately without grouping&
crossmatching
• Storageisdifficult , cannotbeusedafter 3 weeks
• Storedat 4 degreeCwith 3.8 %NaCitrate in a
ratio of 9:1
• Transfusionassociated reactions

98. RATEOFBLOODTRANSUSION
Begungenerallyat 2 to 3 ml per minute & increasedasfollows
1. For elective transfusion into normal circulatory system infus
8-10 ml per minute with 60-80 minutes per transfusion ( 40-
50 drops/min)
2. In embarrassedcardiovascularsystemespeciallyin elderly 4
5 ml per minute ( 30 min/transfusion)
3. In acutehypovolumia infuseat maximumobtainable rate
until systolicbloodpressureis100 mmof Hg(200 drops
/min)

99. Complicationsof blood transfusion
• Theseare –
• TransfusionReactions
• Transmissionof disease

100. TRANSFUSION REACTIONS
• 1. Incompatibility / acutehemolytic reaction
• Thereare three causesof incompatibility–
• Unmatchedblood, destruction of donor’sRBCbyspecific
antibodies in recipient blood– chieflyantiA, antiB, antiD of
rhesussystem
• Transfusionof already hemolysedbloodbyheating overfreezing
or shaking
• Transfusionof bloodafter expiry date

101. EXPIRY DATE
• RBC& WHOLEBLOOD- 21days
• HeparinizedBlood– 48 Hrs
• Platelet Concentrate– 72 hrs
• freshfrozenplasmaandcryoprecipitateis12 months
• frozenbloodcellsis3 yearsfrom the date of
donation, storedat -65°Cor colder.After
reconstitution, expiration date iswithin 24 hours,
storedat temperatures between 1° and6°C.

102. Clinicalfeatures -
• Charectersticfeature ispain in loin
• Firstrigor& fever
• Headache,nausea ,vomiting
• Tinglingsensationin the extremities
• Feelingof tightnessin chestand dyspnoea
• Shock& lossofconsciousness
• Urine output diminished& haemoglobinuria in 2 to 3hours
• Appearanceof jaundiceisdefinite signappearswithin 24 to 36 hours
• Ultimately renal failure dueto blockageof renal tubuleswith hematin pigment

103. Treatment
• Transfusionstoppedimmediately
• Freshsampleof blood& urine of patient sendto lab for checkingalongwith rejected
bottle
• Highdoseof steroidsto stopAg-Ab reaction
• Alsoantihistaminicsin early stages
• IV fluidsstarted. Haematin pigmentstend to precipitate in acidmedium, soalkalization
donewith 10 ml of isotonicsolutionof sodiumlactate & simultaneously10 ml of sodium
bicarbonateinjected I.V.
• Oxygento overcome effectsof intrapulmonary shunting
• Frusamide80 to 120 mg iv to provokediuresis
• Antihistamine& hydrocortisonemaybe given
• Haemodialysiswith artificial kidneymaybeusedin extreme cases
• Adrenaline1:10000 slowIV injected maintain cardiacoutput ,anaphylaxis

104. MASSIVEBLOODTRANSFUSION
• Transfusing10 unitsof bloodin a24-hour period
• Amassivebloodtransfusionmaybeneeded in caseswhere
someoneisin shockdueto rapidblood loss.
• Traumaticinjuries andcomplicationsfrom surgerycanlead to
massiveblood loss.
• Possiblecomplicationsof amassivebloodtransfusion include:
- Hyperkalemia
- Congestiveheart failure
- Thrombophlebitis
- Air embolism
- TransfusionHemosiderosis