1. HEMORRHAGE & SHOCKHEMORRHAGE & SHOCK
Dr.V.RAMKUMAR
CONSULTANT DENTAL&FACIOMAXILLARY SURGEON
REGNO: 4118 TAMILNADU- INDIA( ASIA)

2. Hemmorhage is defined as excessiveHemmorhage is defined as excessive
escape of blood outside the blood vessel.escape of blood outside the blood vessel.
Based on vessel bleedingBased on vessel bleeding
 Artery veinArtery vein

3. Other typeOther type
PrimaryPrimary
ReactionaryReactionary
secondarysecondary

4. Primary haemorrhagePrimary haemorrhage
It refers to the escape of blood at the timeIt refers to the escape of blood at the time
of injuryof injury
Reactionary haemorrhageReactionary haemorrhage
It occurs with in first 24 hrsIt occurs with in first 24 hrs
It is due to displacement of blood clotIt is due to displacement of blood clot

5. Secondary haemorrhageSecondary haemorrhage
It occurs after 7 to 10 days after injuryIt occurs after 7 to 10 days after injury
It is due to sepsisIt is due to sepsis
acid pusacid pus
Digestion of vessel wallDigestion of vessel wall

6. Clinical signs and symptomsClinical signs and symptoms
DizzinessDizziness
BleedingBleeding
Rapid heart rate and respiratory rateRapid heart rate and respiratory rate

7. INTERNAL BLEEDING- Bleeding with inINTERNAL BLEEDING- Bleeding with in
body cavitybody cavity
EXTERNAL BLEEDING-Blood escapingEXTERNAL BLEEDING-Blood escaping
through wound in skinthrough wound in skin
SPONTANEOUS BLEEDING- patient onSPONTANEOUS BLEEDING- patient on
oral hypoglceamic agents, heriditaryoral hypoglceamic agents, heriditary
coagulopathy.coagulopathy.

8. Steps in haemostasisSteps in haemostasis
vasoconstrictionvasoconstriction
platelet plug &primary haemostasisplatelet plug &primary haemostasis
activation of clotting mechanismactivation of clotting mechanism
secondary haemostasissecondary haemostasis
fibrous organisationfibrous organisation

9. Primary haemostasisPrimary haemostasis
It is a process of platelet plug formationIt is a process of platelet plug formation
It occurs with in seconds of injuryIt occurs with in seconds of injury
important in stopping of blood from vesselimportant in stopping of blood from vessel
Release of granules and plateletRelease of granules and platelet
aggregationaggregation

10. Secondary hemostasisSecondary hemostasis
 It occurs via clotting process.It occurs via clotting process.
Reaction 1. intrinsic phaseReaction 1. intrinsic phase
factors 7, 9, 11, 12,along with calcium &factors 7, 9, 11, 12,along with calcium &
plasma protein(PTT)plasma protein(PTT)
Reaction 2. release of tissue thromboplastinReaction 2. release of tissue thromboplastin
(PT)(PT)
Reaction 10. activation of factor 10.Reaction 10. activation of factor 10.

11. Reaction 4. conversion of prothrombin toReaction 4. conversion of prothrombin to
thrombin(factor 5)thrombin(factor 5)
Fibrinogen – fibrin (thrombin)Fibrinogen – fibrin (thrombin)

12. List of Coagulation factors:List of Coagulation factors:
II
IIII
IIIIII
IVIV
VV
VIIVII
VIIIVIII
IXIX
XX
XIXI
XIIXII
XIIIXIII
FibrinogenFibrinogen
ProthrombinProthrombin
Tissue thromboplastinTissue thromboplastin
CalciumCalcium
Accelerator Globulin (AcG), ProaccelerinAccelerator Globulin (AcG), Proaccelerin
Serum Prothrombin conversion accelerator (SPGA)Serum Prothrombin conversion accelerator (SPGA)
Antihemophilic globulin (AHG)Antihemophilic globulin (AHG)
Plasma thromboplastin component (PTC; Christmas factor)Plasma thromboplastin component (PTC; Christmas factor)
Sturat-Power factorSturat-Power factor
Plasma thromboplastin antecedent (PTA)Plasma thromboplastin antecedent (PTA)
Hageman factorHageman factor
Fibrin stabilizing factor (FSF)Fibrin stabilizing factor (FSF)

14. Lab testLab test
 Bleeding time.Bleeding time.
 Clotting time.Clotting time.
 Platelet time.Platelet time.
 Prothrombin time.Prothrombin time.
 Partial thromboplastin time.Partial thromboplastin time.

15. Local haemostatic measureLocal haemostatic measure
Mechanical methodsMechanical methods
PressurePressure
HemostatHemostat
Sutures & ligationSutures & ligation
EmbolizationEmbolization

16. Thermal agentsThermal agents
CauteryCautery
ElectrosurgeryElectrosurgery
CryosurgeryCryosurgery
laserlaser

17. Chemical methodsChemical methods
 Local agentsLocal agents
 Astringent agent and stypticAstringent agent and styptic
 Bone waxBone wax
 ThrombinThrombin
 Gel foamGel foam
 Oxy celOxy cel
 SurgicelSurgicel
 Fibrin glueFibrin glue
 adrenalineadrenaline

18. Systemic agentsSystemic agents
 Whole bloodWhole blood
 Platelet rich plasmaPlatelet rich plasma
 Fresh frozen plasmaFresh frozen plasma
 CryoprecipitateCryoprecipitate
 Etamsylate(1mg)Etamsylate(1mg)

19. Ligation of major vesselsLigation of major vessels
External carotid and its branchesExternal carotid and its branches
Ligation of greater palatine vesselLigation of greater palatine vessel

20. shockshock
 It is a pathophyisiological conditionIt is a pathophyisiological condition
,clinically recogonized as a state of in,clinically recogonized as a state of in
adequate perfusion.adequate perfusion.

21. classificationclassification
Hypovolemic shockHypovolemic shock
Cardiogenic shockCardiogenic shock
Septic shockSeptic shock
Neurogenic shockNeurogenic shock

22. Clinical manifestationClinical manifestation
Mild <20% - postural hypotension,Mild <20% - postural hypotension,
collapsed neck vein.collapsed neck vein.
moderate>20-40% oliguria ,anuria.moderate>20-40% oliguria ,anuria.
severe>40% agitation. confusion ,rapidsevere>40% agitation. confusion ,rapid
deep respiration.deep respiration.

23. Basic monitoringBasic monitoring
Pulse oximeterPulse oximeter
BPBP
Heart rateHeart rate
Central venous pressureCentral venous pressure

24. Basic haemodynamic mechanismBasic haemodynamic mechanism
 Reduced circulating blood volumeReduced circulating blood volume
 Decreased venous return to heartDecreased venous return to heart
 Decreased cardiac out putDecreased cardiac out put
 Reduced blood flow through tissuesReduced blood flow through tissues
 Tissue hypoxiaTissue hypoxia
 AcidosisAcidosis

25. HYPOVOLEMIC SHOCKHYPOVOLEMIC SHOCK
 in circulating blood volumein circulating blood volume
 Hypovolemic shockHypovolemic shock
 Haemorrhagic Non haemorrhagicHaemorrhagic Non haemorrhagic
Example (fluid loss vomiting burns)Example (fluid loss vomiting burns)

26. Inadequate cardiac outputInadequate cardiac output
Impaired OImpaired O22 delivery and reduced tissue perfusiondelivery and reduced tissue perfusion
Causes-Causes-
 Loss of effective contractile function of myocardiumLoss of effective contractile function of myocardium
 Reducing adequate forward outputReducing adequate forward output
Cardiogenic shockCardiogenic shock

27. Clinical feature –Clinical feature –
 Increase pulmonary artery wedge pressureIncrease pulmonary artery wedge pressure
 Decrease cardiac our putDecrease cardiac our put
 Increase peripheral vascular resistanceIncrease peripheral vascular resistance
 Less mean arterial presser (<60 mmHg)Less mean arterial presser (<60 mmHg)
Management –Management –
 Identifying the causeIdentifying the cause
 Dopamine (vasopressor), norepinephrine andDopamine (vasopressor), norepinephrine and
doputaminedoputamine

28. Neurogenic shockNeurogenic shock
 In neurogenic shock vascular capacity increasesIn neurogenic shock vascular capacity increases
so much that even the normal amount of bloodso much that even the normal amount of blood
becomes incapable of adequately filling thebecomes incapable of adequately filling the
circulatory system.circulatory system.

29. Early Signs and symptoms –Early Signs and symptoms –
Pale skinPale skin
PerspirationPerspiration
NauseaNausea
TachycardiaTachycardia
Feeling of warmth in neck or faceFeeling of warmth in neck or face

30. Late symptoms –Late symptoms –
 Coldness in hands and feetColdness in hands and feet
 HypotensionHypotension
 BradycardiaBradycardia
 DizzinessDizziness
 Visual disturbanceVisual disturbance
 Pupillary dilationPupillary dilation
 Hyperpnoea andHyperpnoea and
 loss of consciousnessloss of consciousness

31. Septic shockSeptic shock
Due to cell membrane endothelial injuryDue to cell membrane endothelial injury
Peripheral vasodilatationPeripheral vasodilatation
Example Ecoli, klebsiellaExample Ecoli, klebsiella

32. ANAPHYLACTIC SHOCKANAPHYLACTIC SHOCK
Histamine release.Histamine release.
Increased capillary permeability.Increased capillary permeability.
Smooth muscle contraction.Smooth muscle contraction.

33. Management –Management –
 Early and effective volume replacementEarly and effective volume replacement
 Restoration of tissue perfusionRestoration of tissue perfusion
 Adequate OAdequate O22 supply to cellssupply to cells
 AntibioticsAntibiotics

34. DIVISION OF OMFS