Hemorrhage And Its Management

Define hemorrhage, its types, causes, investigations, and measures to control hemorrhage.

Answer. Hemorrhage is defined as the escape of blood from the cardiovascular system to the surface of the body or into the body tissues or cavities.

Hemorrhage Causes

Trauma
Infections
Local irritants
Congenital malformations
Surgical (intraoperative/postoperative)
Hemorrhage due to abnormalities in clotting factors:

Hemorrhage Clotting factor deficiencies

Hereditary: Hemophilia A, Haemophilia B,
Thrombocytopenia.
Anticoagulant, antiplatelet, or fibrinolytic therapy:
Warfarin, coumarin, heparin, enoxaparin, aspirin,clopidogrel etc.
Liver disease.

Dysfunction of clotting—multiple myeloma:

Hemorrhage due to abnormalities in platelets

Hemorrhage Deficiencies:

Idiopathic thrombocytopaenia purpura
Secondary thrombocytopaenia purpura
Leukemia.

Thrombocytosis

Dysfunction: Thrombocytopenia.

Hemorrhage due to systemic disease

Viral infection
Scurvy
Allergy.

Investigations

Patients with the above-mentioned causes may be advised to be subjected to an investigation before any oral surgical procedure.

Hemorrhage Investigations are:

Clotting time
Bleeding time
Prothrombin time and International normalized ratio
Activated partial thromboplastin time
Factors assay.

Hemorrhage Investigations For Measuring Blood Loss

Hb% and PCV estimation
Blood volume estimation using the radioiodine technique or microhematocrit method
Measurement of CVP or PCWP
Investigations specific for cause, i.e. ultrasonography of abdomen, Doppler and often angiogram in vascular injury, Chest X-ray in hemothorax, CT scan in major injuries, CT scan head in head injuries.

Hemorrhage Measures to Control Hemorrhage

Hemorrhage Mechanical Methods

Pressure: Firm pressure is applied over the bleeding site for 5 minutes.
Hemostat: It is applied at bleeding points and leads to direct occlusion of the bleeding vessel
Sutures and ligation: For severed blood vessels ligature is done. For large pulsating arteries, suturing is done.

Hemorrhage Chemical Methods

Adrenaline: It leads to vasoconstriction of bleeding capillaries
Thrombin: Converts fibrinogen into fibrous clot
Surgicel: Acts by forming acid products from partial dissolution which coagulate plasma protein
Surgical fibrillar: It is modified surgical and is used on irregular surfaces and inaccessible areas
Oxycel: Platelet plugs in its meshwork and forms the clot
Gelatine sponge Or Gelfoam/surgical
Microfirillar collagen (Avitene)
Fibrous glue
Styptics and astringents: They precipitate protein and arrest bleeding
Alginic acid
Natural collagen sponge: It activates coagulation factors
XI and XIII and help in clotting
Fibrin sponge: It stimulates coagulation forming normal clots and also acts as a temporary plug over small injured blood vessels
Bone wax: It is used in cases of bleeding from bone or chipped edges of bone. It is softened with fingers and applied to the bleeding site
Ostene: a new water-soluble bone hemostatic agent.

Hemorrhage Thermal Agents

Electrocautery/surgical diathermy: Small capillaries and bleeding vessels are coagulated by diathermy.
Monopolar diathermy
Bipolar diathermy
Cryosurgery
Lasers: Coagulate small blood vessels.