BLEEDING AFTER EXTRACTION

Transcription

1 Course: DENTOALVEOLAR SURGERY 1 BLEEDING AFTER EXTRACTION Assoc. Prof. Peter STANKO, MD, PhD oral and maxillofacial surgeon Comenius University in Bratislava, Faculty of Medicine Dpt. Stomatology & Maxillofacial Surgery, St Elisabeth s Hospital Head: Prof. Vladimír Javorka, MD, CSc.

2 PRIMARY HAEMOSTASIS A. VESSELSs - Vasoconstriction - Release of tissue lipoproteins + phospholipids B. TROMOCYTES - Adhesion on moistenable surface - Release of Tr phospholipids - Agregation (white thrombus).

3 CASCADE of PLASMATIC COAGULATION FACTORS Inner activator External activator XII. tissue lipoprot. XI. Ca ² + IX VII. VIII. / Ca ² +, Tr phospholipid X X.a V. / Ca ² + Prothrombin Thrombin Fibrinogen FIBRIN (physiological fibrinolyis = plasmin).

4 CRITERIA for DIVISION of postextractional bleeding 1. INTENSITY (moderate "alveolar oozing to severe profuse, pulsating) 2. T I M E (immediate, delayed) 3. ETHIOLOGY (local causes, general causes).

5 TIME of the haemorrhage after extraction a./ IMMEDIATE b./ DELAYED - early after 48 hours (reactional / by coagulopathies) - late after 7 days (secondary).

6 A./ LOCAL REASONS of the hemorrhage -inpropriate activity of patient (hard food, excessive oral rinsing, suctioning, tongue) - remained root, granuloma, foreign body (feeling, bone) - laceration of gingiva / surrounding mucosa - injury of inf. alveolar a. (mandible) - antral mucosa (maxilla, OA comm.) - minor / major fractures (alveolar bone, jaw) - hemangioma (bone location).

7 FIRST AID by hemorrhage from the hemangioma replant the extracted tooth (like a stopper) let the patient bite on a swab make pressure on the carotid artery monitor the vital signs (blood pressure, pulse documentation) call help.

8 B./ GENERAL REASONS of the hemorrhage Hypertension - Common cold or other infections - Menstruation - Diabetes mellitus (microangiopathy) - Hypovitaminosis (vitamin C, K) - Disorders of the haemostasis.

9 B./ GENERAL REASONS of the hemorrhage - 2 DISORDER of the HAEMOSTASIS 1. primary haemostasis (vasculopathies = disorders of wall of vessel trombocytopeny resp. trombocytopathies) 2. secondary haemostasis (coagulopathies = decreased / pathological formation of the coagulation ff./ 3. fibrinolysis (increased fibrinolysis rare, phenomenon DIC = disseminated hypofibrinogenaemia/. intravascular coagulation, consumpsion

10 B./ GENERAL REASONS of the hemorrhage - 3 COAGULOPATHIES - Acquired (Hepathopathies = ff. dependent on vitamne K - II, VII, IX, X. Arteficial hypocoagulation by medicaments after IM or TED, hemodialysis, contraceptives etc.) - Congenital (hemophilia A, B, C, parahemophilia, immunocoagulopathies) PLATELETE DISORDERS - Acquired trombocytopeny under 60, aspirin (antiagregant therapy) - Congenital trombocytopathies.

11 Parameters of haemostasis Tr - trombocyty (10.9 / l ) - time of bleeding (Duke) normal 2 5 min - time of coagulation (Lee-White) normal 4 10 min PT - protrombin time (Quick) normal sek, % INR - International Normalized Ratio normal 0,0 1,2 aptt - activated Partial Thromboplastin Time normal = sec TT - trombin time normal = sec

12 Matrace suture

13 RISK LEVELS of the parameters of haemostasis Number of trombocytes Tr < 50 x10.9/ml Protrombin time (Quick) > 70% safe < 50% milde risk < 35% high risk (regarding surgery) I N R within (ideal level by cumarins).

14 Absorbable haemostatic materials - Gelatin sponge (Gelaspon) - Fibrin foam (Spongostan) - Oxycelulosis (Traumacel powder, root shaped pins) - Fibrin glue (Beriplast, fibrinogen + trombin) - Bone wax

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19 GENERAL THERAPY by bleeding A. Haemostatics 1. Vitamin K (Kanavit) acutly 1-3 ampuls i.m., prevent. 3x15-20 drops orally 4 days before surgery 2. Etamsylatum (Dicynone) parenterally 3. Inhibítors of fibrinolysis (Pamba, Styptogen, Cumbrix) B. Substitutional therapy 1. Substitution of the missing factor (haematologist) 2.Transfusion of full blood / erytromass (at least 2 doses) 3.plasma and others.

20 EVALUATION of bleeding after extraction - From simple to more complicated causes 1. Firstly thorough anamnesis, local clinical + x-ray examination 2. Then haematology etc.

21 MANAGEMENT of postextracion haemorrhage - It is better prevent than treat disorders 1.General prevention (interdisciplinary approach) 2. Local preventive measurments (suture, cooling, recommendations etc.)

22 Thank you for attention Doc. Stanko P.CSc. CSc., Klinika stomatológie a maxilofacialnej chirurgie LFUK a OÚSAO Foto a grafika J.Mikloš LFUK 2008