Cardiovascular 1 Flashcards
1
Q
Most common cause of premature death in the world
A
CVD
2
Q
Patients frequently have more than one
A
CVD
3
Q
Many different types of CVD disease
(6)
A
- Hypertension (HTN)
- Atherosclerosis
- Angina Pectoris
- Congestive Heart Failure
- Arrhythmias
- Bacterial Endocarditis
4
Q
Types of CVDs
(8)
A
- Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
- Hypertension (HTN)
- Coronary Artery Disease (CAD)
- Angina Pectoris
- Bacterial Endocarditis
- Congestive Heart Failure (CHF)
- Arrhythmia
- Valvular disease
5
Q
- Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
A
- coronary artery disease leads to infarction
6
Q
- Bacterial Endocarditis
A
- infection, inflammation and scarring
7
Q
- Congestive Heart Failure (CHF)
(2)
A
- dilated ventricles with weak muscles
- thickened myocardium
8
Q
- Arrhythmia
A
–uncoordinated electrical signals
Bradycardia v. Tachycardia
9
Q
- Valvular disease
(2)
A
- stenotic and not capable of full closure for blood circulation
- leads to CHF
10
Q
CVD Risk factors
conditions (5)
A
high BP
high cholesterol
diabetes
rheumatic fever
>1 CVD
11
Q
CVD Risk factors
behavioral
(6)
A
unhealthy diet
physical inactivity
obesity
too much alcohol
tobacco use
stress
12
Q
CVD Risk factors
family history
(3)
A
genetics
becoming older
ethnicity
13
Q
high BP (2)
A
- Stiffens vessels which reduces blood flow
- also a risk for stroke, kidney disease and dementia
14
Q
high cholesterol (1)
A
LDLs
15
Q
diabetes
A
- Unstable glucose levels affect healthy myocardium function; angiopathy
16
Q
Rheumatic fever
A
–valvular disease
17
Q
unhealthy diet
A
- Carbs, fats, caffeine, Na+
18
Q
physical inactivity
A
poor circulation
19
Q
obesity
A
- Excess weight stresses heart function, HTN, CAD
20
Q
too much alcohol
A
- increases BP, arrythmias
21
Q
tobacco use
A
- increases HR, BP, CAD, etc.
22
Q
Predisposing etiologies
(4)
A
- Congenital
- Hypertension (positive CVD feedback
cycle) - Ischemia (positive CVD feedback cycle)
- Inflammation
23
Q
Contributary anatomic abnormalities
(5)
A
- Hypertrophy
- Dilation
- Valves
- Regurgitation
- Stenosis
24
Q
Physiologic changes
(3)
A
- Arrhythmias
- Heart failure
- Ischemia
25
Staging of Cardiovascular Disease (CVD)
class 1
Physical Activity:
Symptoms:
physical activity: no limitation
no dyspnea, fatigue or palpitations with physical activity
26
Staging of Cardiovascular Disease (CVD)
class 2
Physical Activity:
Symptoms:
physical activity: slight limitation
fatigue, dyspnea, palpitations present with physical activity
27
Staging of Cardiovascular Disease (CVD)
class 3
Physical Activity:
Symptoms:
physical activity: marked limitation
less than normal physical activity results in symptoms. comfortable at rest
28
Staging of Cardiovascular Disease (CVD)
class 4
Physical Activity:
Symptoms:
physical activity: severely limited. exacerbates symptoms
symptoms present at rest
29
Signs and Symptoms of Cardiovascular Disease
Signs
(6)
* Elevated BP
* Irregular or abnormal heart rate
* Abnormal respiratory rate
* Shortness of breath upon exertion
* Prolonged bleeding/easy bruising
* Surgical scars
30
Signs and Symptoms of Cardiovascular Disease
Symptoms
* Patient is uncomfortable in supine position
31
* The less the symptoms and the better the control of risk factors
THEN
* the --- a patient manages the stress
AND
* the --- likely the patient will have a life threatening incident during a dental procedure
better
less
32
* The greater the symptoms and the poorer the control of risk factors
THEN
* the --- a patient manages the stress
AND
the --- likely the patient will have a life threateningincident during a dental procedure
worse
more
33
Low Level Intervention
(6)
* Health/medical evaluation
* Exams
* Prophy
* Radiographs
* Optical oral scans
* Alginate impressions
34
Moderate Intervention
(4)
* SRP (scaling and root planning)
* Simple restorative procedures; 1-2 teeth
* Simple extractions; 1-2 teeth
* Restorative impressions needing retractions
and longer setting times
35
High Risk Intervention
(6)
* Complex restorative procedures on >2 teeth
* Multiple extractions
* Surgical extractions
* Implant placement
* Full arch impressions
* Dental care under general anesthesia
36
Primary Hypertension
(2)
* Multifactorial, gene-environment
* 90-95% of cases
37
Secondary hypertension
(4)
* Renal disease and renin-producing
tumors
* Endocrine
* Cardiovascular
* Neurologic
38
* Endocrine
(5)
➢Adrenal
➢Exogenous hormones
➢Pregnancy
➢Pheochromocytoma
➢Thyroid
39
* Neurologic
(4)
➢Psychogenic
➢Sleep apnea
➢Intracranial vascular pressure
➢Exogenous
40
Complications
(7)
* Myocardial infarction
* Stroke
* Coronary artery disease
* Peripheral artery disease
* Heart failure
* Retinopathy
* End-stage renal disease
41
Blood Pressure
Determined by
indirect measurement in the upper extremities with a BP
cuff and stethoscope
42
Determined by indirect measurement in the upper extremities with a BP
cuff and stethoscope
➢ Cuff should encompass ---% of the circumference of the arm.
➢ Center of cuff over
➢ Cuff too small →
➢ Cuff too large →
80
brachial artery
falsely elevated values*
falsely low values*
43
‘White Coat HTN’ elevate BP by
30 mm Hg*
44
Pregnant pts w/ ≥ 10 mm Hg increase in systolic BP from baseline
➢ Risk of
eclampsia →immediate referral
45
Blood Pressure
Arm position matters
➢ Horizontal at heart level (mid-sternum)
46
Arm below heart level
Over-Estimates systolic and diastolic pressures
Similar to Cuff too small →falsely elevated values
47
Arm above heart level
under-estimates systolic and diastolic pressures
Similar to Cuff too large →falsely low values
48
Hypertension
Goals depend on patient
age and comorbidities
Generally, goals are between <130 - 149/80-90 mm Hg
49
Blood Pressure
NO dental care at UMKSC SOD if BP
≥ 180/110 mmHg
➢ 180/120 is classified as a Hypertensive Urgency by the AHA based on
2017 guidelines
➢ Urgent referral →see doctor ASAP
➢ If patient is symptomatic →Emergency Room
50
Medical Management
* Lifestyle modifications
(3)
➢ Diet (increase fruit intake, decrease sodium, increased potassium)
➢ Physical exercise/weight loss
➢ Tobacco cessation and alcohol intake reduction
51
Oral Manifestations
None due to hypertension itself
* Side-effects of pharmacotherapy:
(7)
➢ Dry mouth (anti-adrenergics and diuretics)
➢ Burning mouth (ACEi)
➢ Taste changes (antiadrenergics, ACEi)
➢ Angioedema (ACEi, ARB)
➢ Gingival hyperplasia (calcium-channel blockers, what are the other 2?)
➢ Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
➢ Lupus-like lesions (hydralazine)
52
Questions to Ask Your Patient with Hypertension
Physical Activity
* Do you feel shortness of breath at rest?
* Are you physically active?
➢ What kind of physical activities do you engage in?
➢ Do you feel shortness of breath after exercise?
➢ Does it limit the intensity of your physical activity
53
questions
Hypertension History
* How long have you had high blood pressure?
* Who manages your blood pressure, primary care or a cardiologist?
* How long have you been on this current antihypertensive regimen?
* Have there been any recent changes to your blood pressure medication? Why?
54
questions
Hypertension Monitoring
(3)
* What is your usual BP level at the doctor’s office?
* Do you check your BP at home?
* What are your usual readings, how high does it get?
55
Dental Considerations for the Hypertensive Patient
Serious potential complications of severe uncontrolled HTN:
(4)
* Stroke
* Angina
* Arrhythmia
* Myocardial infarction
56
(3) may increase the patient’s BP and lead to complications
Stress, anxiety, fear
57
Patients taking nonselective beta-blockers
➢Use of vasoconstrictor can cause an acute rise in BP
58
Patients may be sensitive to sudden position changes causing
orthostatic hypotension
59
Dental Considerations for the Hypertensive Patient
Pre-operative considerations
* Reduce Stress and Anxiety
➢ May need oral and/or inhalation sedation
60
Intra-operative considerations
(3)
* Profound anesthesia!!!! (MOST IMPORTANT)
* Limit epi to 2 carpules if taking a selective beta-blocker, (2 carp rule)*
* Don’t use epinephrine-gingival retraction cord
61
Post-operative considerations
(4)
* Avoid macrolide antibiotics with calcium channel blocker (↑ CCB levels)
* Avoid long-term use of NSAIDs (>2 weeks)
* Stage 2, monitor BP during treatment, if 180/110 stop tx!
* Raise patient slowly after treatment b/c of hypotension
62
MEDICAL CONSULT LETTER –GENERAL GUIDELINES
(2)
Make explicit to physician when writing a medical consult (categorize procedure risks not dental details)
Ask very specific questions to the physician in relation to the current disease status of the patient
63
time of procedure -
risk category
64
Hypertension Medical Consult Questions*
(4)
* What is the patient’sBP goal (range)
* What have been patient’sin-office BP readings?
* Does the patient have any end-organ damage?
* Current medications prescribed to manage
Hypertension
65
Cardiac measures**
(4)
* Stress reduction protocol
* Nitrous oxide
* Profound anesthesia
* Cardiac epi dose = max 0.04mg
66
* Cardiac epi dose = max 0.04mg
✓Articaine for
✓2% lidocaine 1:100,00 epi for
✓3% mepivacaine without epi for
maxillary blocks and maxillary or mandibular infiltrations
IANB
anesthesia
67
Atherosclerosis
* Inflammatory disorder with accumulation of
lipid plaque within the arterial walls
➢ Thickened intima (decreased arterial lumen)
➢ Decreased oxygen
➢ Decreased blood flow to the myocardium
68
Atherosclerosis
* Leads to
(5)
➢ Stenosis
➢ Angina (stable ischemic disease)
➢ MI
➢ Ischemic stroke (acute ischemic disease)
➢ Peripheral arterial disease
69
Atherosclerosis –Risk Factors
➢Depression
➢Family history of CVD
➢Insulin resistance
➢Diabetes mellitus
➢Male sex
➢Age
➢Smoking
➢Lack of exercise
➢Obesity
➢Stress
➢Depression
➢Family history of CVD
➢Hyperlipidemia
(↑LDL)
➢Hypertension
➢Insulin resistance
➢Diabetes mellitus
70
Atherosclerotic plaques can lead to:
(2)
- ischemia
- thrombosis, (vascular blockage) if they
rupture
71
Atherosclerosis of the Circulatory System (Heart)
* Associated symptoms
(2)
➢ Chest pain
➢ Angina
72
Atherosclerosis of the Circulatory System (Heart)
* Complications
(5)
➢ Unstable angina
➢ Myocardial infarction (necrosis)
➢ Thrombosis
➢ Embolism
➢ Aneurysm
73
Angina Pectoris
* Chest pain resultant from
ischemic changes
➢Mid-chest pain described as
o“aching, heavy squeezing pressure or tightness”
74
Angina Pectoris
* Pain may radiate (3)
* Pain lasts
* --- used to resolve angina
➢Shoulder, arms, jaw
5-15 minutes
➢ If unstable angina, may be longer
Vasodilation
75
Angina Pectoris
May be stable or unstable
* Stable
(4)
➢Imbalanced cardiac perfusion
➢Stable symptoms, reproducible, predictable, consistent
➢Chest pain precipitated by physical activity/exertion
➢Resolves with cessation of activity
76
* Unstable
(4)
➢Disruption of atherosclerotic plaque
➢Possible partial thrombosis, embolism or vasospasm
➢Symptoms increasing
➢Chest pain at rest or with less intense physical activity/exertion
77
Myocardial Infarction
* Definition
➢Lose normal (2)
➢--- ventricle MI more common
Irreversible coagulative necrosis of the myocardium
conduction and contraction
Left
78
Myocardial Infarction
* Symptoms similar to angina, plus
➢--- features
➢Severe --- pain with (3)
Radiating
substernal
shortness of breath, profuse sweating, and loss of consciousness
79
Myocardial Infarction
Pain does not resolve with --- and is more prolonged
vasodilators
80
Medical Management
Treatment/reduction of modifiable risk factors and associated disease
Hypertension
(2)
➢Beta-blockers
➢Calcium channel blockers
81
Angina
(1)
➢Nitrates (nitroglycerin) –stable angina
82
Stroke
(1)
➢Antiplatelet agents (aspirin, clopidogrel) –stroke prevention
83
Revascularization (interventional)
(2)
➢ Percutaneous transluminal coronary angioplasty with stenting (PCI;
stent)
➢ Coronary artery bypass grafting (CABG)
84
Hyperlipidemia
(5)
➢Fibrates
oGemfibrozil
➢Niacin
oNiaspan
➢Omega-3 fatty acids
oLovaza
➢HMG-CoA reductase inhibitor
oStatins
➢Cholesterol absorption
inhibitor
oEzetimibe
➢Bile acid sequestrants
oCholestyramine
oColestipol
85
FOR ALL ISCHEMIC DISEASE
(3)
1. Severity of the disease
2. Stability and cardiopulmonary reserve of the patient
(i.e., the ability to tolerate dental care)
3. Type and magnitude of the dental procedure
86
Ischemic Heart Disease
Same questions as HTN + :
(6)
* Do you have chest pain?
* Do you get chest pain after exercise or at rest?
* How often? When was the last time?
* Has there been any change in frequency or intensity of your chest
pain?
* Do you take anything to make it stop?
* Have you ever had cardiac surgery?
* Which procedure(s)
- How long ago was it?
* Have you ever had a MI?
- How long ago?
87
* Make sure you and/or patient have --- on day of visit to use
where applicable.
* Be aware of signs and symptoms of MI and be prepared for an
emergency
* No elective treatment in patient with unstable angina or recent
history of MI (major risk)
nitroglycerin
88
Do you bruise easily?
(3)
* Are you taking aspirin or clopidogrel (antiplatelet meds)?
* When you cut yourself how long does it take to stop bleeding?
* Have you ever been hospitalized for bleeding?
89
* Increased bleeding expected, have local measures ready
* In general, no need to stop
* If extensive surgery, may consider
antiplatelet therapy
drug holiday with physician
consultation
90
Recent Myocardial Infarction <1
month
(3)
* Urgent dental care only
➢ACUTE dental pain or infection
* Consultation with physician
* Consider referral to specialized center
91
Past Myocardial Infarction
>1 month
* Consider severity of cardiac status and
comorbidities
* --- can measure the
degree of heart failure
➢Measures amount (%) of
* Consider appropriate management
protocols
Ejection Fraction
blood that
leaves the left ventricle after
contraction.
92
Past Myocardial Infarction
>1 month
* Consider severity of
* Consider appropriate management
protocols
cardiac status and
comorbidities
* Ejection Fraction can measure the
degree of heart failure
➢Measures amount (%) of blood that
leaves the left ventricle after
contraction.
93
* Ejection Fraction (EF) %: 55% to 70%
* Pumping Ability of the Heart:
* Level of Heart Failure/Effect on Pumping:
Normal
Heart function may be normal or you may have heart failure with preserved EF (HF-pEF).
94
* Ejection Fraction (EF) %: 40% to 54%
* Pumping Ability of the Heart:
* Level of Heart Failure/Effect on Pumping:
Slightly below normal
Less blood is available so less blood is ejected from the ventricles. There is a lower-than-normal amount of oxygen-rich blood available to the rest of the body. You may not have symptoms.
95
* Ejection Fraction (EF) %: 35% to 39%
* Pumping Ability of the Heart:
* Level of Heart Failure/Effect on Pumping:
* Pumping Ability of the Heart: Moderately below normal
* Level of Heart Failure/Effect on Pumping: Mild heart failure with reduced EF (HF-rEF).
96
* Ejection Fraction (EF) %: Less than 35%
* Pumping Ability of the Heart:
* Level of Heart Failure/Effect on Pumping:
* Pumping Ability of the Heart: Severely below normal
* Level of Heart Failure/Effect on Pumping: Moderate-to-severe HF-rEF. Severe HF-rEF increases the risk of life-threatening heartbeats and cardiac dyssynchrony/desynchronization (right and left ventricles do not pump in unison).
97
Stress Reduction in Stable Angina or Past Myocardial Infarction
* Ideal
(3)
➢No ischemic symptoms
➢Intermediate risk
➢No other risk factors
98
Stress Reduction in Stable Angina or Past Myocardial Infarction
Procedural Precautions
➢Short appointments in the --
➢Pre-treatment --
➢Availability of --
➢-- sedation
➢-- –oxygen sedation
➢Profound --
➢Limit amount of --
➢Avoid --
➢Effective post-operative -- control
morning
vital signs
nitroglycerin
Oral
Nitrous oxide
local anesthesia
vasoconstrictor
epinephrine-impregnated retraction cord
pain
99
Pre op sedation: (2)
short acting benzodiazepine (triazolam 0.125-0.25 mg)
1 hr before appointment and possibly the night before the day of the appointment
100
Ischemic Heart Disease
Drug interactions and oral manifestations
Same as HTN + :
(3)
* HLD
* Limit epinephrine as discussed earlier
* Bleeding as discussed earlier –limit NSAIDs.
101
* HLD
* Statins –avoid CYP inhibitors (fluconazole, clarithromycin
* ↑ statin levels
102
SA node
(3)
* Primary pacemaker
* Regulates atrial function
* Produces P wave (atrial
depolarization)
103
AV node
(2)
* Regulates atrial impulses entering
ventricles
* Slows conduction rate of SA
generated impulses
104
QRS complex
* Simultaneous depolarization of the
ventricles
105
T wave
* Repolarization of the ventricles
106
Arrhythmia
Disruption of the electrical impulse generation or conduction in the heart that
leads to abnormal cardiac function
107
Arrhythmia
* Formation of
* Increased
*(2) impulse formation
* Delayed ---
* --- of the heart after refractory period
abnormal impulse
impulse formation
Enhanced or abnormal
depolarization
Re-excitation
108
Arrhythmia
The disruption may be due to an area of:
(4)
* Infarction
* Ischemia
* Electrolyte imbalance
* Medication
109
The most common cause of sudden cardiac death is
ventricular fibrillation*
110
Causes of arrhythmias
(6)
* Cardiovascular disorders
* Pulmonary disorder
* Autonomic disorder
Arrhythmia
* Hyperthyroidism
* Drugs
* Electrolyte imbalance
* Anxiety and anger
111
* Cardiovascular disorders
(5)
* Myocardial infarction
* Mitral stenosis
* Valvular disease
* Ischemic heart disease
* Congestive heart failure
112
* Pulmonary disorder
(2)
➢Pneumonia
➢Obstructive lung disease
113
* Drugs
(6)
➢ Epinephrine
➢ Alcohol
➢ Digitalis
➢ Morphine
➢ Beta-blockers
➢ Tricyclic antidepressants, and
others
114
Bradycardia
Tachycardia
* <60 beats/min
* >100 beats/min
115
Arrhythmia
Symptoms
(6)
* Palpitations, fatigue
* Dizziness, syncope, angina
* Congestive heart failure
* Shortness of breath
* Orthopnea
* Peripheral edema
116
Atrial Fibrillation
(4)
* Most common arrhythmia
* Rapid uncontrolled atrial activity
* Irregularly irregular rhythm
* Risk of arterial clot formation
➢ Embolism and stroke
117
Heart Block
* Impulse is partially or completely blocked
➢Prolonged or no conduction
118
* First-degree
➢ Longer conduction time
119
* Second-degree
➢ Mobitz I
➢ Mobitz II*
oMore prolonged and no P wave
oRepetitive or occasional sudden blocks w/o previous prolonged
conduction time
120
* Third-degree
(2)
➢ No impulses –COMPLETE BLOCK *
➢ Indication for pacemaker
121
Ventricular Arrhythmias
(4)
* Premature ventricular complexes (PVCs)
* Common
* Abnormal QRS complex + pause
* Increased risk of death if patients have underlying CVD (heart failure,
MI, valvular heart disease
122
Ventricular tachycardia
(3)
* If more than 3 consecutive PVC at 100 beats/min
* If lasts for more that 30 seconds, requires termination
* Torsades de pointes –potentially life-threatening
123
Ventricular flutter and fibrillation
(3)
* Lethal
* Consequence of ischemic heart disease
* Cardiac contraction is not sequential, chaotic
124
Pharmacotherapy
* Antiarrhythmics
125
Pharmacotherapy
* Oral anticoagulants
➢ Clopidogrel (Plavix)
(2)
oInhibits platelet agglutination
oplatelet count not affected
126
Pharmacotherapy
* Oral anticoagulants
➢ ASA (Aspirin 81mg - low dose)
(2)
oInhibits platelet agglutination
oplatelet count not affected
127
Drugs that cause gingival hyperplasia (3)
Ca channel blockers (20% of pt affected)
-nifedipine
-verapamil
Immunosuppressants (30% of pt affected)
-cyclosporin
-tacrolimus
Anticonvusants (50% of pt affected)
-phenytoin
128
Pharmacotherapy
* Oral anticoagulants
➢ Warfarin (Coumadin)
(3)
oVitamin K antagonist
oINR monitoring
oHighly variable
129
Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct thrombin inhibitor
(2)
oDabigatran (Pradaxa)
oReversal agent available
130
Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct Factor Xa inhibitors
(4)
oRivaroxaban (Xarelto)
oApixaban (Eliquis)
oEdoxaban (Savaysa)
oReversal agents not available
131
NEVER STOP ANTICOAGULATION FOR DENTAL TREATMENT UNLESS
RISK OF THROMBOSIS --- RISK OF MASSIVE BLEED
CONSULT PHYSICIAN IF EXTENSIVE SURGERY NECESSARY
CONSIDER REFERRAL TO SPECIALIZED CENTER
EXTENSIVE SURGERY
>
132
Non-pharmacologic
(4)
* Pacemakers
* Implanted Cardioverter-Defibrillator (ICD)
* Surgery
* Electrocardioversion and defibrillation
133
* Implanted Cardioverter-Defibrillator (ICD)
(1)
➢ Sets pace and shocks
134
* Surgery
(3)
➢ Tissue resection
➢ Cardiac ablation
➢ Surgery to address underlying cause such as stenosis
135
Dental Treatment Considerations
* What type of arrhythmia?
questions
(5)
➢ When diagnosed? How frequent?
➢ How treated?
➢ Do you have a pacemaker or
defibrillator?
➢ Have you ever required emergency
intervention for arrhythmia?
➢ Is your arrhythmia stable now?
136
Dental Treatment Considerations
(3)
* What type of arrhythmia?
Assess comorbidities (CVD, pulmonary)
* ROS: palpitations, chest pain, dizziness,
shortness of breath, syncope
137
If severity, nature, treatment of C.A. is unclear obtain
Med Consult
138
High Risk Arrhythmia
* -- elective dental care
* Dental treatment should be limited to -- care only
- Treatment of (3)
* If necessary treatment, obtain a --
* Management may include an (4)
* Cautious use of --- (contraindicated if taking --)
* Prophylactic --
Defer
urgent
ACUTE pain, bleeding, or infection, only
medical consult
IV line, pulse oximeter, BP and oxygen, electrocardiogram monitoring
epinephrine, digoxin
nitroglycerin
139
****Limit Local Anesthetics.
2 Carp or < Rule (Lido 1:100 epinephrine)
140
Intermediate and Low Risk Arrhythmia
Elective care can be provided with following management protocols:
(4)
*Stress/Anxiety reduction:
*Assess pretreatment vital signs, have nitroglycerin available, limit
epinephrine (LA and gingival cord)
*Profound local anesthesia and pain control
*Devices
141
*Stress/Anxiety reduction:
➢Oral sedative &/or inhalation sedative
142
Devices
(3)
➢Electrosurgery units contraindicated in patient with pacemakers and ICDs
➢Ultrasonic scalers –low risk interference
➢Battery operated curing lights –low risk interference
143
Dental Treatment Considerations
* Do you take a blood thinner?
(5)
➢ How often do you have your INR measured?
➢ What was your last reading? What has been your range? (Ideal: < 3)
➢ When is your next reading?
➢ Does it take a long for you to stop bleeding after a cut?
➢ Have you ever been hospitalized due to bleeding?
144
Local measures for hemostasis/
*Gelatin sponges (Gelfoam)
*Oxidized cellulose
*Chitosan hemostatic products
*Sutures
*Gauze with applied pressure
*Topical tranexamic acid
*Topical aminocaproic acid (Amicar)
*Topical thrombin
*Electrocautery* - not with pacemakers
