Hematoma

Question 1

Clotting Cascade

Answer 1

Intrinsic pathway: XII, XI, IX, VIII

Extrinsic pathway: VII

Common pathway: X, V, II, fibrin, XIII

Question 2

Lab tests

Answer 2

Full blood count/platelet count
> Normally 150-450,000, above 50k then can do minor procedures

Prothrombin time
> extrinsic pathway

Activated partial thromboplastin time
> intrinsic pathway
> haemophiliacs (lack IX, X)
> heparin therapy
> 25-35s +/- 7s

Thrombin time

Bleeding time
> 7-9 mins
> doesnt measure bleeding risk, so mainly academic

INR
> ratio of PT of patient to average PT, 0.8-1.2 normal, >1.2 anticoagulative, warfarin should be 3-4
> extrinsic pathway

Question 3

Types of haemorrhage

Answer 3

Primary: intraop

Reactionary: within 24h
> intraoperative hypotension
> ligature slips

Secondary: 4-7 days
> infection
> trauma
> have to remove clot and clean

Question 4

Haemorrhagic shock signs and symptoms

Answer 4

Tachycardia
Dizziness
Agitation
Increased RR
Decreased urine output

Question 5

Types of blood transfusions

Answer 5

RBC
Platelets
Fresh frozen plasma

Question 6

Intraoperative control of bleeding

Answer 6

Be familiar w surgical anatomy
Clean incisions
Consider primary closure
Avoid vascular structures
Electrocautery

Question 7

Preoperative control of bleeding

Answer 7

Injection technique
Vasoconstrictors
Getting patient history
> past exp of prolonged bleeding (surgeries, injuries, menstruation)
> duration and type of bleeding
> systemic disorders
> drugs
> family history

Question 8

Primary control of bleeding

Answer 8

Make clean incisions

Smoothen sharp spicules which may injure tissues when suturing

Inspect soft tissues, base of socket and bone for bleeding

Inspect lingual tissues (may have fractured lingual plate and bleeding from bone)

Remove granulation tissue

Insert gelfoam/surgicel

Suture (figure of 8)

Apply pressure

Consider impressions and splints

Question 9

Angina haemorrhagica bullosa

Answer 9

Spontaneous hemorrhagic blister on soft palate, buccal mucosa or tongue

Can be due to trauma from food or beverages

Generally associated with fragile BV, diabetes or hypertension

Can randomly burst, if v big j drain

Question 10

Hematoma

Answer 10

Abnormal collection of blood outside BV

Can be caused by extrusion of endo materials

Question 11

Gelfoam (Spongiostan)

Answer 11

Porcine gelatin sponge

Mechanical matrix, acting as a scaffold for hastening clot formation and providing structural support

Apply into socket, dont apply pressure bc friable, place holding sutures (figure of 8)

Question 12

Oxidized cellulose (surgicel)

Answer 12

Denatures blood proteins

Mechanically activates clotting cascade

Causes local vasoconstriction

Acidic, bacteriostatic but also nerve irritant so dont pack on exposed nerve or get numbness

Absorbs in 4-8 weeks so dont need to remove

Question 13

Tranexamic acid

Answer 13

4.8% 10ml qid for 2 days

Antifibrinolytic, can be given systemically

Binds to lysine receptors on plasmin, inactivating plasminogen and blood clot breakdown

Significantly reduces post-op bleeding when applied after clot formation

Question 14

Adjuncts

Answer 14

Laser

Electrocautery (cutting/coagulation)
> Bipolar
> Monopolar

Fibrin glue

Chemical cautery

Splints

Topical thrombin (converts fibrinogen to fibrin to encourage clotting)

Question 15

Surgical re-exploration

Answer 15

Mainly for other discplines where you can get extensive internal bleeding

Open up, destroy existing clot, ligate/coagulate bleeding points and then repack

Question 16

Emergency cases?

Answer 16

Prothrombin complex concentrates

Fresh frozen plasma

Fibrinogen concentrate

Question 17

Follow-up for bleeding complaints

Answer 17

1) Reassure patient, re-emphasize post-op instructions

2) Come back to clinic if needed to:
> pressure pack
> LA (vasoconstrictor)
> identify bleeding source
> suture
> local measures like surgicel, gelfoam, tranexamic acid etc

3) If still bleeding refer
> lab tests
> hematology consult
> follow up

Question 18

Drain indications

Answer 18

Prophylactic
> remove excess blood/serum
> remove pus, blood, serous exudates, chyle or bile

Therapeutic
> drain pus, blood, serous exudates
> drain air from pleural cavity
> drain ascites

Question 19

Types of drains

Answer 19

Vacuum

Non vacuum
> e.g. penrose drain, using a soft, flat ribbon-like latex tube, with a gauze tied around the external end to absorb fluid drained