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Module 6 - Oral Surgery > Bleeding - Oral Surgery Complications > Flashcards

Bleeding - Oral Surgery Complications Flashcards

1
Q

4 abnormalities that can increase bleeding risk?

A
  1. Vascular abnormalities.
  2. Platelet deficit - number.
  3. Platelet deficit - quality/ function.
  4. Clotting mechanism.
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2
Q

How can you differentiate between bleeding due to a platelet problem vs due to clotting factor problem?

A
  • Platelet issue would show PERSISTENT HEMORRHAGE FROM THE TIME OF INJURY/TRAUMA.
  • Clotting factor issue would show HEMOSTASIS and later BLEEDING.
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3
Q

How does bleeding due to PLATELET abnormalities usually present?

A
  • SMALL (usually)
  • Petichiae up to ecchymosis
  • Usually SUPERFICIAL bleeds.
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4
Q

How does bleeding due to CLOTTING abnormalities usually present?

A
  • Likely to be DEEP ex. into JOINTS.
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5
Q

What are the general values of platelets (normal and reduced) associated with different bleeding presentations?

A
  • Normal: 150-450
  • 50: PETECHIAL
  • 20 to 50: PETECHIAL + ECCHYMOSIS.
  • Less than 20: Melaena, haematamesis, haematuria
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6
Q

What is melaena?

A

blood in stool

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7
Q

what is hematemesis?

A

bloody vomit

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8
Q

what is haematuria?

A

blood in urine

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9
Q

4 HEREDITARY causes of increased bleeding risk?

A
  • Hemophilia VIII and IX.
  • Factor XIII
  • vW disease
  • Ehler danols
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10
Q

What does vW affect? What is its effect?

A

Affects vW factor and thus PLATELET ADHESION - causes INCREASED BLEEDING.

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11
Q

What is Ehler Danlos?

A
  • Connective tissue disorder characterized by mutations in type 5 collagen which affects the INTEGRITY OF BLOOD VESSELS.
  • Results in INCREASED BLEEDING RISK.
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12
Q

How is the liver involved in the stopping bleeding?

A
  • Hepatocytes are involved in the SYNTHESIS OF COAGULATION FACTORS.
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13
Q

How can severe liver disease increase bleeding risk? (3)

A
  • Deficiency in serum coagulation factors.
  • Abnormal structure and function of fibrinogen.
  • Impaired clearance of activated clotting factors and thus INCREASED FIBRONOLYSIS.
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14
Q

How can alcoholism increase bleeding risk (2)?

A
  • Can cause LIVER CIRRHOSIS which can affect COAGULATION FACTORS.
  • ALCOHOL-INDUCED THROMBOCYTOPENIA (deficit in PLATELETS).
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15
Q

How large is a petichiae?

A

Small 1mm hemmorhage.

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16
Q

Where does ecchymosis usually present (3).

A
  • Skin, epithelium of the nose, uterus.
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17
Q

4 types of ACQUIRED increased bleeding risk?

A
  • Medications
  • Liver disease.
  • Alcoholism.
  • Hematological malignancy (lymphoma, leukaemia).
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18
Q

10 conditions than in MH would raise suspicions for you if the patient is anticoagulae=ted/ antiplatelets.

A
  1. DVT.
  2. PE.
  3. IHD.
  4. Cardiac syndromes.
  5. AF.
  6. MI
  7. CVA (cerebro-vascular accident/ ischaemic stroke).
  8. TIA
  9. Surgical patients at risks of thromboembolism.
  10. Pregnancy.
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19
Q

What are the 4 types of anticoagulants?

A
  1. Coumarins.
  2. Parenteral heparin.
  3. LMW heparin.
  4. Non Vit K (NOACs)
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20
Q

what type of anticoagulant is warfarin

A

Coumarin

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21
Q

What is the mode of action of apixaban, edoxaban and rivaroxaban?

A

Direct and reversible inhibitors of factor 10A.

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22
Q

2 occasions LMW is useful?

A
  • Pregnancy.
  • Long periods of stasis in a hospital bed (ex. operating theater).
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23
Q

5 types of parentral anticoagulants?

A
  • Heparin sodium.
  • LMW heparin.
  • Dalteparin sodium.
  • Enoxiparin.
  • Tinzaparin.
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24
Q

Hemodyalisis and heparin?

A
  • Patients that undergo hemodyalisis may be heparinized the day of their dialysis.
  • Can see them THE FOLLOWING DAY once the heparin effects have worn off.
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25
Q

What can long term use of heparin cause?

A

Can result in PLATELET DISORDERS.

26
Q

5 antiplatelet drugs?

A
  • Clopidogrel.
  • Aspirin/ NSAIDs.
  • Prasugrel
  • Ticagrelor.
  • Dipyridamole
27
Q

What is the mode of action of aspirin?

A
  • Irreversible inhibitor of cyclo-oxygenase.
  • Ultimately affects arachidonic acid pathway.
28
Q

4 NOACs?

A
  • Rivaroxaban.
  • Apixaban.
  • Edoxaban.
  • Dagibatran.
29
Q

What is the mode of action of dagibatran?

A
  • Direct thrombin (factor 2a) inhibitor.
30
Q

What are coumarins (what is their mode of action)?

A
  • Vitamin K antagonists.
  • Affect the coagulaiton factors reliant on the Vitamin K carboxylase enzyme.
31
Q

Wha does the Vitamin K carboxylase enzyme do?

A
  • Adds a carboxyl group to these factors necessary for function.
32
Q

What clotting factors do coumarins affect?

A

Clotting factors 2,7,9 and 10.

33
Q

3 coumarins?

A
  • Warfarin sodium.
  • Acenocoumarol.
  • Phenindione.
34
Q
A
  • INR of less than 4.
35
Q

What do we do if INR is above 4?

A

Cannot proceed (blood less able to clot).

36
Q

What do we do if INR is way below the therapeutic index?

A

Contact the prescriber - patient at risk of a thromboembolic event.

37
Q

When does primary bleeding occur?

A

Intra operative from the soft/hard tissues.

38
Q

What could prolonged primary bleeding indicate?

A

Platelet deficit.

39
Q

What are the primary hemostatic mechanisms after vascular injury?

A
  1. Vasoconstriction.
  2. Platelet adhesion.
  3. Platelet activation.
  4. Platelet aggregation.
  5. PRIMARY PLATELET PLUG.
40
Q

Secondary hemostatic mechanisms?

A

Clotting cascade.

41
Q

When is reactionary bleeding?

A
  • Sometime after the primary platelet plus.
  • Around 2-3 hours Post Op.
42
Q

What is reactionary bleeding potentially associated with?

A
  • LA wears off
  • ALTHOUGH vasoconstrictor has a very short hald life (10 minutes).
  • Likely FAILURE OF THE SECONDARY HEMOSTATIC MEASURES.
43
Q

When does secondary bleeding occur? Why?

A
  • up to 14 days post op.
  • Due to INFLAMMATORY PROCESSES LINKED WITH LOCALIZED INFECTION.
44
Q

Why does secondary bleeding occur?

A

Due to infection.

45
Q

What do you suspect if reactionary bleeding is prolonged?

A

Platelet deficiency.

46
Q

How do you stop primary bleeding in soft tissue (3)?

A
  • Pressure.
  • Suture.
  • BIPP pack.
47
Q

What is considered normal bleeding?

A

Stops 2-5 minutes post extraction.
- Stops with biting pressure or firm digital pressure.

48
Q

How does crushing stop bleeding?

A

For BONY bleeds in cancellous bone, CRUSH any bleeding vessels by placing direct pressure.

49
Q

What bleeds is electrocautery suitable for? What does it do?

A
  • Not suitable for BONY bleeds but suitable for SOFT TISSUE BLEEDS.
  • Uses electric current rhough the site which BURNS it.
50
Q

8 methods to help hemostasis?

A
  1. Pressure (immediate general).
  2. Suture (pressure - immediate local).
  3. Bone wax (bony bleed).
  4. Crush (bony bleed).
  5. Electrocautery (soft tissue).
  6. Sodium Nitrate (soft tissue).
  7. Hemostatic agents.
  8. Antifibrinolytics (Tranexamic acid).
51
Q

6 hemostatic agents?

A
  • Gelatin
  • Collagen
  • Cellulose based.
  • Adhesive (used extraorally).
  • Topical thrombin.
  • Antifibrinolytics (tranexamic acid).
52
Q

What is tranexamic acid used for?

A

In patients with vW disease or other fibronolytic disorders.

53
Q

What can we give to patients on warfarin to stop bleeding?

A
  • Vitamin K.
  • However there will be a rapid reversal and the patient will be very not anticoagulated. DO NOT DO ROUTINELY- ONLY AT TIMES OF NEED.
54
Q

What is considered severe ongoing haemorrhage following XLA (5)?

A
  • Mouth filling up with fresh blood.
  • Biting pressure not useful.
  • Having difficulty suctioning the blood.
  • Cannot see.
  • Patient anxious and spitting out blood.
55
Q

4 bleeding instances to refer?

A
  • Severe ongoing haemorrhage.
  • Reached extent of capabilities (ex. suturing, pressure etc and bleeding still moderate).
  • Decreased BP (100/60).
  • Increased HR > 100bmp as both could indicate FLUID LOSS.
56
Q

2 characteristics of severe fluid loss?

A
  • Increased HR > 100bpm.
  • Decreased BP: 100/60.
57
Q

What causes a hematoma?

A
  • Persistent arteriolar bleed once everything is closed up and there is no opportunity for the bleed to escape.
58
Q

What is the treatment for a hematoma if caught early (2)?

A
  • Empty using a WIDE SYRINGE.
  • Open the surgical wound and allow blood to drainn.
59
Q

What is the treatment for a hematoma if caught later (has formed gel-like mass)?

A

Incision and surgical removal.

60
Q

What are 2 concerns with hematomas?

A
  • Risk of bleeding.
  • Source of severe infection.
  • Bleeding into anatomic spaces (ex. FOM)
61
Q

When do hematomas occur in dentistry (2)?

A
  • Extraction of mandibular third molars.
  • Surgical extraction of maxillary third molars.

Module 6 - Oral Surgery (11 decks)

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