MANAGEMENT OF HEMORRHAGE IN ORAL SURGERY

INTRODUCTION / DEFINITION


Hemorrhage denotes the escape of blood from blood vessels. The volume of blood loss ranges from minimal to significant. It is synonymous with bleeding. Any injury to blood vessels leads to bleeding, and some hemorrhage can be life-threatening. The severity depends on the patient's hematologic status and the nature of the clotting mechanism.

MECHANISM OF HEMOSTASIS


Hemostasis involves three main phases:

  1. Vascular phase: Vasoconstriction occurs immediately after vessel damage.
  2. Platelet phase: Platelets adhere to the damaged surface, forming a temporary plug.
  3. Coagulation phase: Involves intrinsic and extrinsic pathways, converting fibrinogen to fibrin to complete the clot.

Clotting Mechanism Pathway:

  • Intrinsic: XII → XI → IX → VIII → X
  • Extrinsic: Tissue Thromboplastin → VII → X
  • Common: X → V → II (Prothrombin) → Thrombin → I (Fibrinogen) → Fibrin → XIII → Stable Clot

Factors Affecting Hemostasis

  • Vascular integrity
  • Platelet count and function
  • Clotting factor levels
  • Fibrinogen pathway functionality

TYPES OF HEMORRHAGES

  • Arterial: Pulsatile, bright red, brisk flow
  • Venous: Dark red, steady flow, copious due to facial vein anatomy
  • Capillary: Oozing, bluish red, controlled with pressure

Classification by Timing

  • Primary: Immediate, short duration post-surgery
  • Reactionary: Few hours post-op; caused by disturbed clot or systemic conditions
  • Secondary: 4–10 days later due to infection or incomplete vessel ligation

Internal vs. External Bleeding

  • Internal: Confined to body cavities
  • External: Apparent on skin
  • Can be spontaneous, bony, or soft tissue-related

MANAGEMENT OF HEMORRHAGE

i) History Taking

  • Demographics
  • Family and dental history
  • Previous surgery and bleeding episodes

ii) Clinical Examination

Check for:

  • Adenopathy
  • Splenomegaly
  • Hepatomegaly
  • Jaundice
  • Skin/mucosal petechiae
  • Ecchymosis
  • Gynecomastia, testicular atrophy

iii) Laboratory Tests

  • Bleeding Time: < 10 mins
  • Platelet Count: 150,000–450,000/mm³
  • PT (Prothrombin Time): 12–14 seconds
  • PTT (Partial Thromboplastin Time): Evaluates intrinsic pathway

Common Causes of Prolonged Bleeding:

  • Warfarin use
  • Vitamin K deficiency
  • Deficiencies in Factors V, VII, X, Prothrombin, or Fibrinogen
  • Liver disease

LOCAL HEMOSTATIC MEASURES

Mechanical Methods

  • Pressure with gauze
  • Hemostats (e.g. mosquito forceps)
  • Suturing or ligation
  • Embolization using agents like steel coils, PVA foam, etc.

Thermal Methods

  • Cautery
  • Electrosurgery
  • Cryosurgery: for superficial hemangiomas
  • Argon Beam Coagulator: ≤ 3mm bleeding
  • Laser coagulation

Chemical Methods (Local)

  • Astringents: Monsel’s solution, tannic acid, silver nitrate
  • Bone wax
  • Topical thrombin
  • Gel foam
  • Oxycel (oxidized cellulose)
  • Surgicel (glucose polymer fabric)
  • Fibrin glue
  • Adrenaline (vasoconstrictor)
  • Other agents: Avitene, Etik collagen, 5% tranexamic acid

SYSTEMIC HEMOSTATIC AGENTS

  • Whole blood: For significant hemorrhage and hypovolemic shock
  • Platelet Rich Plasma (PRP): Viable for 3 days
  • Fresh Frozen Plasma (FFP): Contains Factor V, VIII, fibrinogen
  • Cryoprecipitate: Factor VIII, fibrinogen, von Willebrand factor
  • Adenochrome & Ethamsylate: Pre-op use for platelet function
  • Hypotensive Anesthesia: Reduces bleeding during surgery
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