hemorrhage

1. Hemorrhage
ContentsContents
IntroductionIntroduction
• Hemorrhage – escape of blood from the blood vessel.
• Synonymous – bleeding
• Loss of blood- Life threatening
IntroductionIntroduction
• Haematoma :Haematoma : swelling due to extravasation of blood into tissue.
• Ecchymoses:Ecchymoses: skin & mucous membranes
• Purpura :Purpura : 1 cm haemorrages into skin & mucous membranes.
• Petechiae :Petechiae : minute pin head
Causes Of HemorrhageCauses Of Hemorrhage
•• TraumaTrauma
oo Penetrating wound to blood vesselPenetrating wound to blood vessel
oo LabourLabour
•• SpontaneousSpontaneous
oo Ruptured aneurysmRuptured aneurysm
oo Bleeding disordersBleeding disorders
oo Acute leukamiasAcute leukamias
•• InflammatoryInflammatory
oo Chronic peptic ulcerChronic peptic ulcer
oo Thyroid ulcersThyroid ulcers
oo polyarteritis nodosapolyarteritis nodosa
•• Neoplastic invasionNeoplastic invasion
oo Vascular Invasion of carcinoma of tongueVascular Invasion of carcinoma of tongue
•• Vascular diseaseVascular disease
oo AtherosclerosisAtherosclerosis
•• Elevated pressureElevated pressure
oo varicose veins systemic hypertensionvaricose veins systemic hypertension

2. ClassificationClassification
1.1. TYPE OF BLOOD VESSEL:TYPE OF BLOOD VESSEL:
•• ArterialArterial
•• VenousVenous
•• CapillaryCapillary
2.2. TIMING OF HEMORRHAGE:TIMING OF HEMORRHAGE:
o Reactionary
o Primary
o Secondary
3.3. DURATION OF HEMORRHAGE:DURATION OF HEMORRHAGE:
o Acute : sudden – oesophageal variceal bleeding due to portal hypertension
o Chronic –haemorrhoids, chronic duodenal ulcer
4.4. 4. NATURE OF BLEEDING :4. NATURE OF BLEEDING :
• Revealed
• concealed

3. StagesStages
MILDMILD
• Blood loss < 500ml
• Peripheral venoconstriction
MODERATEMODERATE
• Blood loss 500ml -1000ml
• Release of adrenalin , nor adrenalin
• Increased ADH
• c/f : extremities, pulse, BP, oliguria.
SEVERESEVERE
• Blood loss > 1000 ml
• Worsening of signs & symptoms of 2nd stage
• c/f : pulse , hypotension, oliguria
• Oedema
• Kinins
• Brain stem hypoxia.
• Myocardial contractility increases.
• Kidney , skeletal muscles
HemostasisHemostasis
• Four important steps
o Bleeding Starts
o Vessals Constrict
o Platelet Plug
o Fibrin Obt
PRIMARY HEMOSTASISPRIMARY HEMOSTASIS
• Platelet plug formation
• Within seconds
• Primary hemostatic plug–
SECONDARY HEMOSTASISSECONDARY HEMOSTASIS
• Activation of clotting process – fibrin
• Strengthening of primary plug
FACTOR NAME
I Fibrinogen
II Protrombin
III Thromboplastin
IV Calcium

4. V Labile / pro-accelerin
VI Not designated
VII Proconvertin / co- thromboplastin
VIII Anti hemophilic factor / von willebrand factor
IX Plasma thrombolastin component / Christmas factor
X Stuart – Prower factor
XI Plasma thromboplastin antecedent
XII Hageman factor
XIII Fibrin – stabilizing factor
Fitzgerald
F
High – molecular – weight kininogen
Fletcher F Pre – kallikrein
Clotting cascadeClotting cascade
Inhibitors of coagulationInhibitors of coagulation
• Thrombin formation is sluggish – absence of platelet aggregation.

5. • Circulatory anticaogulants antithrombin , heparin, protein C & S
• Fibrinolytic mechanism
• PG I2
• Tissue factor pathway inhibitor
• Thrombomodulin
Clinical EvaluationClinical Evaluation
• History
• Physical examination
• Laboratory test
Laboratory testsLaboratory tests
•• Bleeding time: platelet function, B.T >10min – increased risk. Prolonged:Bleeding time: platelet function, B.T >10min – increased risk. Prolonged:
thrombocytopenia, von willebrand’s disease, platelet dysfunction .Methods: Ivy,Dukethrombocytopenia, von willebrand’s disease, platelet dysfunction .Methods: Ivy,Duke
•• Clotting time: measures all stages of coagulation in the intrinsic system. Prolonged :Clotting time: measures all stages of coagulation in the intrinsic system. Prolonged :
moderately severe hemophilia, afibrinogenemia, severe fibrinolytic states, presence ofmoderately severe hemophilia, afibrinogenemia, severe fibrinolytic states, presence of
heparin. Monitor heparin therapy. Method : Lee & White method, Wright’s capillary tubeheparin. Monitor heparin therapy. Method : Lee & White method, Wright’s capillary tube
method.method.
•• Platelet count: 1,50,000 to 4,50,000/µl.Platelet count: 1,50,000 to 4,50,000/µl.
o 50,000- 1,00,000/µl : severe trauma, surgery
o < 5o,ooo/ µl : easy bruising –petechiae, ecchymoses.
o <20,000/ µl : spontaneous bleeding – internal bleeding.
o Minor oral surgeries: 80,000- 1,00,000/ µl.
•• Protrombin time:Protrombin time:
o extrinsic pathway- V, VII, X….
o Common pathway- I, II, V. ….
o Prolonged: anticoagulant therapy, vit K def.,
o def. of factor- V, VII, X, prothrombin, fibrinogen.
o Normal PT: 12- 14 sec.
o dental procedures: PT < 11/2 of control value.
•• Partial thromboplastin time (PTT)Partial thromboplastin time (PTT)
o Intrinsic pathway: VIII, IX, X, XI, XII
o Common Pathway: I, II, V
o Prolonged in hemophiliacs.
o Normal PTT 35- 45 sec
Local hemostatic measuresLocal hemostatic measures
•• MECHANICAL METHODS:MECHANICAL METHODS:
o Pressure
o Use of hemostats
o Sutures & ligation
o Embolization of the vessels
•• THERMAL AGENTSTHERMAL AGENTS

6. o Electrosurgery
o Cryosurgery
o Argon- beam coagulator
o Lasers (BDJ 2007 vol: 202)
•• CHEMICAL AGENTSCHEMICAL AGENTS
o Astringent agents & styptics
 Monsel’s solution – ferric sulphate
 Tannic acid
 Mann hemostatic
 Silver nitrate &
 Ferric chloride
o Bone wax
o Thrombin
o Gelfoam
o Oxygel
o Fibrin glue
o Adrenalin – vasoconstriction
 1: 1000 – oozing site
 1: 80,000 – 1: 2,00,000 - LA
Absorbable hemostatic agents ( Carranza 10th ed pg: 890 )Absorbable hemostatic agents ( Carranza 10th ed pg: 890 )
Generic (brand)Generic (brand) DirectionsDirections Adverse effectsAdverse effects PrecautionsPrecautions
Absorbable gelatinAbsorbable gelatin
spongesponge
(Gelfoam)(Gelfoam)
Cut & applied toCut & applied to
bleedingbleeding
surfacessurfaces
Nidus for infection orNidus for infection or
abscessabscess
Overpacked- interfere withOverpacked- interfere with
healinghealing
Oxidized celluloseOxidized cellulose
(Oxygel)(Oxygel)
Effective whenEffective when
applied toapplied to
wound drywound dry
thanthan
moistenedmoistened
Foreign body reactionForeign body reaction Friable- difficult to place, bone –Friable- difficult to place, bone –
impairs boneimpairs bone
regeneration, surfaceregeneration, surface
dressing- inhibitsdressing- inhibits
eithelializationeithelialization
Oxidized regeneratedOxidized regenerated
cellulosecellulose
(Surgicel(Surgicel
absorbableabsorbable
hemostat)hemostat)
Cut & appliedCut & applied Encapsulation, cystEncapsulation, cyst
formation, foreignformation, foreign
body reactionbody reaction
Deep wounds – interfere withDeep wounds – interfere with
wound healing, bonewound healing, bone
formationformation
Microfibrillar collagenMicrofibrillar collagen
hemostathemostat
(Collacote,(Collacote,
Collatape,Collatape,
Collaplug)Collaplug)
Cut, shaped, appliedCut, shaped, applied Abscess formation,Abscess formation,
hematoma, woundhematoma, wound
dehisence. Allergy/dehisence. Allergy/
foreign body reactionforeign body reaction
Interferes wound healing, inInterferes wound healing, in
socket – increased painsocket – increased pain

7. ThrombinThrombin
(Thrombostat)(Thrombostat)
Applied topicallyApplied topically Allergic reaction – sensitivityAllergic reaction – sensitivity
to bovine materialsto bovine materials
Do not inject into tissues orDo not inject into tissues or
vasculature – causesvasculature – causes
severe clotting - fatalsevere clotting - fatal
Systemic agentsSystemic agents
•• WHOLE BLOODWHOLE BLOOD
o excessive blood loss, hypovolaemic shock.
o specific blood components- unavailable
o Screening, Type & cross matching- mandatory
o Rarely used
•• ADRENOCHROME MONOSEMICARBAZON :ADRENOCHROME MONOSEMICARBAZON :
o 2 ml / 6 hourly before surgical procedure. Doubtful efficacy
•• ETHAMSYLATE:ETHAMSYLATE:
o reduces capillary bleeding when platelets are adequate.
Systemic agentsSystemic agents
(( JCDA 2007 vol 73)JCDA 2007 vol 73)
• PLATELETS (1 unit: 50ml, count is raised by 6,000 …)
• Indications
o platelet count
o < 10,000 in non bleeding
o < 50,000 pre surgical level
o < 50,000 actively bleeding individuals
o Non destructive thrombocytopenia
• FRESH FROZEN PLASMA (1 unit- 150-250ml. )
• Indicatons
o Undiagnosed bleeding disorder with active bleeding
o Severe liver disease
o Transfusing > 10 units of blood
o Immune globulin deficiency
• EPSILON AMINOCAPROIC ACID
o Antifibrinolytic, 250mg/ml- oral…
o systemic: 75mg/kg- 6 hr.

8. o Adjunct to support clot formation
• CRYOPRECIPITATE (1 unit: 10-15 ml)
• Indications
o Hemophilia A
o von Willebrand’s disease
o Fibrinogen deficiency
• TRANEXAMIC ACID
o Antifibrinolytic, 4.8% mouth rinse.
o Systemic: 25mg/kg- 8hr.
o Adjunct to support clot formation
• FACTOR IX CONCENTRATE (I unit – 1- 1.5%. Contains II, VII, IX, X)
• Indications
o Hemophilia B – active bleeding, pre surgery
o Prothrombin complex conc. Used for hemophilia A
• FACTOR VIII CONCENTRATE (1 unit: 2% increase. Heat treated- vWB factor)
• Indications
o Hemophilia A – active bleeding, presurgery
o Von willebrand’s disease
• DESMOPRESSIN (0.3 microg/kg iv or sc)
• Indications
o Von willebrand’s disease – active bleeding & pre surgery
o Liver disease
o Bleeding oesophageal varices