This document discusses hemorrhage and shock in oral surgery. It defines hemorrhage as bleeding from damaged blood vessels and describes different types including arterial, venous, capillary and bony bleeding. It also discusses classifications based on timing, duration and location. The document then covers hemostasis techniques including mechanical, thermal and chemical methods. It describes hereditary coagulopathies like hemophilia A and B. Finally, it defines and discusses different types of shock including hypovolemic, cardiogenic, septic, neurogenic and anaphylactic shock along with their signs, symptoms and treatments.

1. Hemorrhage & Shock
Its Management In
Oral Surgery
Instructor – Dr.Jesus George 1

2. Hemorrhage
 Bleeding
 Escape of blood from a blood vessel due to
damage or injury in vasculature
2

3. Types
 A-depending upon the nature of the
vessel
 Arterial hemorrhage
 Bright red color
 Pulsation of the artery can be seen
 Venous hemorrhage
 Dark red color,
 Non-pulsating with steady flow(constant
flow)
 Difficult to control because vein gets
retracted
3

4. Cont.
 Capillary hemorrhage
 Red colour
 Slowly oozes out
 It becomes significant if there is
bleeding tendencies
 Bony bleeding
 From nutrient vessels in bone
 Usually follows removal of lower 3rd
molar
4

5. Cont.
 B. Depending upon timing of
hemorrhage
 Primary hemorrhage -occurs at the time
of surgery
 Reactionary or intermediate
hemorrhage -occurs after 24 hrs of
surgery(causes-hypertension in
postoperative period, sneezing,coughing)
 Secondary hemorrhage -occurs after
48-72 hrs after surgery (infection)
5

6. Cont.
 C-depending upon the duration of
hemorrhage
 Acute hemorrhage -occurs suddenly
(esophageal variceal bleeding due to
portal hypertension)
 Chronic hemorrhage-(hemorrhoids or
piles or chronic duodenal ulcer
6

7. Cont.
 D-depending upon the nature of
bleeding
 External hemorrhage - epistaxis
 Internal hemorrhage - splenic rupture
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8. Laboratory tests for screening
 Bleeding time (aspirin therapy)
 Platelet count (liver disease, c/c leukemia)
 Prothrombin time (heparin therapy, liver
disease)
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9. Hemostasis
 Control or arrest of bleeding
9

10. Local hemostatic measures
 Mechanical methods
 Thermal methods
 Chemical methods
10

11. Mechanical methods
 Pressure
 Use of hemostats
 Sutures & ligation
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12. Thermal methods
 Cautery
 Electrosurgery
 Cryosurgery
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13. Chemical methods
 Astringents (ferric sulfate in ethyl cellulose)
 Styptics (epsilon amino caproic acid local &
systemic)
 Bone wax (bees wax(7)+olive
oil(2)+phenol(1),helps in platelet aggregation)
 Gelfoam (compressed sponge made up of porcine
skin & have physical action)
 Adrenaline
 Surgicel (knitted fabric, interaction with platelets)
 Fibrin glue (thrombin+fibrinogen+factor8)
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14. Prevention of hemorrhage during &
after extraction
 Primary hemorrhage – tender handling
of soft tissues & bone.
 Reactionary hemorrhage – semi supine
or sitting posture, diazepam 5 mg at
bedtime or antihypertensive drugs after
consultation with the physician
 Secondary hemorrhage - antibiotics
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15. Control of hemorrhage from major
arteries
 Greater palatine artery
 Pressure pack
 A round bolus of gauze is made of
adequate size , so that it does not cause
gagging
 It is kept in place by tie over sutures for
24 to 48 hours
 Pressure pack can be safely removed
after 48 hours
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16. Cont.
 Lingual artery
 Local clamping of the artery & application
of electrocautery usually controls bleeding
 Superficial temporal artery
 Electrocautery
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17. Hereditary coagulopathies
 Hemophilia -a
 Hemophilia -b
17

18. Hemophilia -a
 Caused by deficiency of factor 8
 Sex-linked recessive inherited disorder
 Seen in males
 Hemophilia-a is graded as mild ,
moderate ,& severe
 Mild - factor 8 level ranges from 6 to 30
percent
 Moderate - factor 8 level ranges from 1
to 5 percent
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19. Cont.
 Severe - factor 8 level ranges from nil to
1 percent
 Clinical features - prolonged bleeding
tendencies even after a mild trauma
 Patients are higher risk for bleeding after
oral surgical procedures
19

20. Hemophilia b
 It is caused by deficiency of factor 9
 It is congenital disorder& transmitted as
sex--linked recessive trait
 Clinical manifestations of this disease
are similar to hemophilia a
20

21. Shock
 Shock is a pathophysiologic condition
clinically recognized as a state of
inadequate perfusion due to
inadequate blood flow,there is
inadequate delivery of nutrients to the
tissues & inadequate removal of
cellular waste products from tissue cells,
results in disruption of vital organ
functions.
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22. Clinical features
 Mild - <20% blood loss
 Cold, calmy,moist skin
 ↓ in BP
 Rapid pulse
 Collapsed neck veins
 Concentrated urine
22

23. Cont.
 Moderate - >20-40%
 Feeling of thirsty
 Hypotension
 Rapid pulse
 Oliguria or anuria
 Severe - >40 %
 Agitated & confused patient
 Hypotension
 Rapid pulse
 Rapid respiration
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24. Classification
 Hypovolemic shock
 Cardiogenic shock
 Septic shock
 Neurogenic shock
 Anaphylactic shock
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25. Hypovolemic shock
 Decrease in the circulating or effective
intravascular volume
 Most common type of shock in
maxillofacial trauma
 Hypovolemic shock is classified into
 1.Haemorrhagic shock
 2.Non- hemorrhagic shock
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26. Cont.
 Hemorrhagic shock is due to loss of
blood from the body causing decreased
venous return & thus decreasing the
cardiac output
26

27. Cont.
 Non-hemorrhagic shock-there is
massive fluid shift from intravascular
compartment to extra vascular
compartment causing decreased blood
volume &thus decreasing tissue perfusion.
 can result from burns, crush injuries,
pancreatitis, peritonitis & pleural effusion,
water loss due to severe diarrhea, vomiting,
hyperglycemia & nephritis
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28. Cont.
 Treatment
 Control bleeding
 Legs raised & body supine is preferred
posture as this increases venous return &
cardiac index
 Fluid replacement; normal saline or ringer
lactate
28

29. Cardiogenic shock
 Inadequate cardiac output , impaired
oxygen delivery & reduced tissue
perfusion, caused by loss of effective
contractile function of myocardium
 Treatment
 Dopamine is the vasopressor of choice. It
is diluted in normal saline or 5%dextrose
drip
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30. Septic shock
 Produced by microorganisms or toxins
 May be produced by bacteria ,virus &
fungi
 Inflammatory response causing
vasodilatation & hypovolemia
 Clinically: fever, tachycardia&
respiratory alkalosis
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31. Cont.
 Treatment
 Early & effective volume replacement
 Restoration of tissue perfusion
 Control of infection with antibiotic therapy
 I.V betamethasone or dexamethasone
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32. Neurogenic shock
 Vasovagal syncope or emotional fainting
 Blockage of sympathetic nervous system
→dialatation of blood vessels →hypovolemia
→shock
 Predisposing factors – fear, anxiety, painPredisposing factors – fear, anxiety, pain
- fatigue- fatigue
- fasting- fasting
- hot & humid weather- hot & humid weather
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33. Cont.
 Signs & symptoms(Clinical feature):Signs & symptoms(Clinical feature):
 Pale, cold & moist skinPale, cold & moist skin
 Slow pulse initially followed by rapid pulseSlow pulse initially followed by rapid pulse
 DizzinessDizziness
 WeaknessWeakness
 Nausea & sweatingNausea & sweating
 Loss of consciousnessLoss of consciousness
 Dilated pupilDilated pupil
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34. Cont.
 Prevention
 Reassurance
 Achieve confidence of the patient
 Anxiolytic medication prior to surgery
(diazepam 5 mg 1 tablet night before the
surgery & one 1/2hr before surgery)
 patient should not come with empty stomach
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35. Cont.
 ManagementManagement
 Monitoring pulseMonitoring pulse
 Lowering head to improve cerebellar circulationLowering head to improve cerebellar circulation
 Loosening of tight cloths at neckLoosening of tight cloths at neck
 Smelling of salt of aromatic ammoniaSmelling of salt of aromatic ammonia
 Flashing the face with cold waterFlashing the face with cold water
 Glucose drinksGlucose drinks
 Inj.dexamethasoneInj.dexamethasone
 Reassurance of patientReassurance of patient
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36. Anaphylactic shock
 Caused by anaphylaxis of penicillin&
streptomycin
 Treatment
 Oxygen
 Airway
 Injection adrenaline
 Cardiopulmonary resuscitation
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