Bleeding disorder

Question 1

List three acquired hemorrhagic disorders.

Answer 1

Disseminated intravascular coagulation (DIC) and liver disease

Vitamin K deficiency
Drug induced (anti-platelet, anti- coagulant)

pdf 150 for more info

Question 2

List three methods to control epistaxis

Answer 2

Manual haemostasis

Nasal packing

Nasal cauterisation

Question 3

How does manual haemostasis control epistaxis?

Answer 3

Squeeze nostrils together for 5-10 min, without frequent peeking

Head in neutral/lowered position (NOT hyperextended ∵ risk of aspiration)

± gauze moistened with adrenaline (1 : 10000) / phenylephrine (for vasoconstriction)

Question 4

How does nasal packing control epistaxis?

Answer 4

Anterior: Vaseline® (petroleum jelly gauze filled with Abio ointment), Merocel® (expandable)

Posterior: rolled gauzes, inflatable balloon devices

All packing should be removed in 3-4 days

Question 5

How does nasal cauterisation control epistaxis?

Answer 5

Chemical: silver nitrate

Electrocauterisation: requires LA, use rigid endoscopy, reserved for severe/pos bleeding

Question 6

List two causes of bleeding tendency resulting in epistaxis

Answer 6

Haemophilia A (F8), B (F9), von Willebrand disease

Question 7

What are the causes of hemorrhagic disorders?

Answer 7

Genetics (haemophilia, vWD), liver disease (liver failure), medications (anticoagulants, antiplatelets)

Question 8

What are the salient points of a history-taking for a patient with previous post-operative bleeding history?

Answer 8

Time:
How long have you had the bleeding problem? How long have you been on anticoagulants?

Describe:
your bleeding problem

Past:
Have you had problems with previous dental appointments?

Cause:
What is the cause of your bleeding problem/ why are you on anticoagulants?

Lab:
What are your most recent laboratory results relative to your anticoagulation/ bleeding problem status?

Question 9

What are the types of anticoagulants?

Answer 9

Aspirin, warfarin, heparin

Question 10

List the laboratory blood tests for a patient with previous post-operative bleeding history.

Answer 10

Activated partial thromboplastin time (aPTT) (intrinsic)

Prothrombin time (PT) (extrinsic)

INR (normal = 1; therapeutic = 2-3; OK for extraction if under 3.5)

Bleeding time (BT) (Simplate)

Platelet count

Thrombin time (TT)

Question 11

What is the dental management before the appointment? (on warfarin)

Answer 11

Consult patient’s physician

Question 12

List 4 conditions that may need to consider for post-operative bleeding after extraction (2)

Answer 12

Haemophili A
Haemophilia B
von Willebrand disease
Liver cirrhosis

Question 13

List two causes of bleeding tendency resulting in epistaxis

Answer 13

Thrombocytopenia

Drug induced such as aspirin

Question 14

Patient got mitral valve replacement in the past and is on anticoagulant. He is scheduled for extraction.
a. What anticoagulant is he taking? (3)

Answer 14

Wafarin, heparin

Question 15

Patient got mitral valve replacement in the past and is on anticoagulant. He is scheduled for extraction.
b. What blood test would you perform? (2)

Answer 15

INR, aPTT, PT, platelet count

Question 16

Patient got mitral valve replacement in the past and is on anticoagulant. He is scheduled for extraction.
c. What are the dental complications of his condition? (2.5)

Answer 16

Infection, bleeding

Question 17

Patient got mitral valve replacement in the past and is on anticoagulant. He is scheduled for extraction.
d. What is the dental management before the appointment? (2.5)

Answer 17

FROM: BCSH: British committee of standard hematology
Check INR prior 72 hours (<4safe, > 4 send to hospital)

Heparin: significant first pass effect, only iv, latest heparin in capsule can be taken orally

Antibiotic Prophylaxis

Question 18

Given: the patient has history of atrial fibrillation (2010, 2)
a. Give 2 medications that the patient should take to prevent stroke?

Answer 18

Aspirin, warfarin

Question 19

Given: the patient has history of atrial fibrillation (2010, 2)
b. Give the laboratory test that test anti-coagulation status.

Answer 19

INR

Question 20

Given: the patient has history of atrial fibrillation (2010, 2)
c. What are the complications in major oral surgery?

Answer 20

Pacemaker
Bleeding
Fresh frozen plasma transfusion
Give vit K
Thromboembolism
Infection control
Antibiotic Prophy for major surgery: cellulitis, more than 4hours, foreign body like implant, immunocommpromsed like chemotherapy, DM, kidney dialysis, organ transplant (also need prophy in MOS) *in hospital*