Oral Surgery Flashcards
(110 cards)
1
Q
Indications for 8 XLA
A
Un-restorable caries
Non-Txable pulpal/periapical pathology
Cellulitis, abscess, osteomyelitis
Resorption of adjacent/tooth
Tooth follicle disease: cyst (dentinogerous), tumour
Tooth in line of jaw surgery: #, orthognathic
Pericoronitis
2
Q
What is pericoronitis?
A
Soft tissue inflammation related to crown of PE tooth
Most common reason for 8 XLA
Incidence: 70% PE 8s
3
Q
Discuss acute pericoronitis
A
Symptoms
- pain + swelling localised to operculum
- radiation of pain
- severe: trismus, facial swelling
- spread of infection to tissue spaces (rare)
Exam
- EO swelling, lymphadenopathy
- trismus
- tender operculum
Management
- analgesic
- chlorhexidine
- operculum debridment (LA)
- opposing tooth: XLA, smooth cusps
- affected tooth: XLA
4
Q
Discuss chronic pericoronitis
A
As acute +
- pus exuding from beneath operculum
- x-ray: widening of pericoronal space, sclerosing osteitis
- traumatised operculum from OE U8
Management: AB
- temp: 38.5C
- feel unwell
- dysphagia
- recent 8 pain
5
Q
What are not indications for 8 XLA?
A
Asymptomatic
L. ant. crowding
6
Q
Local factors affecting 8 XLA
A
Opening: trismus reason Bone quality/density - bisphosphonates - radiotherapy - hypercementosis Tooth - angulation - crown size - crown:root - root morphology - caries Anatomy - ID canal - maxillary sinus - cystic change Adjacent teeth - restorations - PD - caries
7
Q
Additional risks associated w/ U8 and L8 XLA
A
L8
- temporary/permanent altered sensation lip/chin/tongue
- 0.2% permanent tongue
- 0.5% permanent lip/chin
U8
- OAC
- # maxillary tuberosity
8
Q
Dx criteria for MRONJ
A
Previous/current Tx w/ anti-resorptive/angiogenic drug
Exposed bone or bone probed through IO/EO fistula in maxillofacial region persisted >8/52
No Hx radiotherapy jaws
No obvious metastatic disease jaws
9
Q
Reasons for pt to be taking anti-resorptive/angiogenic
A
Osteoporosis Hypercalcaemia Bone - Paget’s - osteogenesis imperfecta - fibrous dysplasia Cancer - w/ bone metastases: breast, prostate, lung, kidney, thyroid, bowel - w/o bone metastases - Multiple myeloma - other: giant cell lesions, fibrous dysplasia
10
Q
What are bisphosohonates?
A
Anti-resorptives
Pyrophosphate analogues share C-P-C chemical core
Inhibit bone resorption: osteoclastic apoptosis
High affinity for bone; esp. high turnover areas
Less effect when new bone laid over
Long t1/2: 10y
Oral tablets: 1-10% intestinal absorption
IV: >70% reach bone
11
Q
Examples of bisphosphonates
A
Alendeonate
Clodronate
Risedronate
12
Q
What is denosumab?
A
Anti-resorptive RANKL inhibitor: interfere osteoclast function Doesn’t bind to bone Effect diminished 6/12 post-Tx SC injection
13
Q
Examples of denosumab
A
Prolia: red. skeletal event osteoporotic pt; take 6/12
XGEVA: red. skeletal event pt w/ bone metastases from solid tumours; 4/52
- higher conc., more freq.
14
Q
What are anti-angiogenesis drugs?
A
Medications inhibit formation new blood vessels
Target multiple kinases involved in angiogenesis
15
Q
Discuss examples of anti-angiogenetic
A
Bevacizumab: Ca Tx
- monoclonal Ab: sits of cell surface
- blocks VEGF ligand
Sunitinib: GI stromal, renal cell carcinoma, pancreatic neuroendocrine
- tyrosine kinase inhibitor
- blocks angiogenesis
- blocks cell proliferation
16
Q
MRONJ pathophysiology
A
Unknown
Inhibition osteoclast differentiation + function -> apoptosis
- red. bone turnover + remodelling
Inflammation + infection: local, systemic
Angiogenesis inhibition
Others
- soft tissue healing
- innate/acquired immune dysfunction
17
Q
MRONJ risk factors for bisphosphonates
A
Route: oral (0.02%), IV (2-16%) Duration: oral (4y+), 3 IV infusions Dose Potency Tx: OS > trauma > spontaneous L > U; post. > ant. Immunosuppressed: azathioprine, methotrexate, steroids Immunocompromised: DM, HIV Chemotherapy, anti-angiogenesis
18
Q
MRONJ risk in cancer pt
A
Higher risk
Not exposed anti-resorptive/angiogenic: 0-1.9/10000
Exposed bisphosphonates/denosumab: 50-100x inc. risk
Exposed bevacizumab: 20/10000
- inc. w/ concurrent bisphosphonates
19
Q
MRONJ risk for osteoporosis pt
A
Low risk <1/1000 develop ONJ Oral/IV: similar risk - less potent cf cancer Tx 100x smaller cf cancer Tx Duration: >4y inc. risk
20
Q
Management strategies for pt before starting anti-resorptive/angiogenic
A
Pre-dental assessment
- XLA all poor prognosis/unrestorable
- allow mucosal healing before starting drugs
— esp for IV BP + denosumab
Encourage good OH
Smoking cessation
21
Q
Management strategies for pt on anti-resorptive/angiogenic
A
Regular dental appt Maintain OH Non-OS Tx done in practice - restorations - endo - prosthesis - NSPT
22
Q
Prevention of MRONJ
A
XLA 1 sextant/T
CHX m/w
Flapless surgery
1ry closure w/ split thickness flap (no exposed bone)
23
Q
Evidence for AB when Tx anti-resorptive/angiogenic pt
A
Low risk: no evidence
High risk
- pre: amoxicillin 500mg stat
- post: amoxicillin 500mg TDS, CHX, review
24
Q
Evidence for drug holidays
A
Low evidence Probably no harm due to long t1/2 Oncologists can discontinue drug for Ca pt if ONJ develops; - cancer status - ONJ extent + severity
25
Management goals for MRONJ
Prioritise + support continued oncological Tx
Persevere QoL
Control pain + 2ry infection
Prevent extension + development new necrosis
26
Local and systemic factors affecting socket healing
Local
- inflammation
- foreign bodies
- bony fragments
- tooth tissue
- radiation exposure -> endarteritis
Systemic
- medications
- smoking
- DM
- malignancy
- diet/nutrition
- vascular disease
27
Aetiology of alveolar osteitis
Dry socket
Organised blood clot in XLA socket lost
- never forms: bone disease affecting blood supply
- prematurely lost: smoking, rinsing
- disintegrated: proteolytic bacteria
Bacteria colonise + proliferate
- escape host defence in socket
Further colonisation -> encourage clot lysis
Localised inflammation of alveolar bone
- prevents spread of infection beyond socket
28
Risk factors for dry socket
```
Traumatic XLA
Md > Mx; post. > ant.
F, OCP
Smoker: -ve pressure remove clot
PD, poor OH
Bony disease affecting blood supply
- Paget’s, osteopetrosis, CRT of H+N, cemento-osseous dysplasia
Previous dry socket
Excessive vasoconstrictor (LA)
```
29
Clinical presentation of dry socket and Ix
Clinical
- pain; few days post-XLA
- no blood clot; grey slough, bone/debris
- gingival inflammation
- halitosis, bad taste
Ix
- completely clinical Dx
- X-ray for bony fragment if >2/52
30
Management of alveolar osteitis
```
Reassurance
Irrigation
- saline
- CHX; no evidence
Dressing; Alvogyl
Smoking cessation
Analgesia: ibuprofen, paracetamol
Review
Repeat (if req.)
If no resolution = wrong Dx
```
31
Osteomyelitis aetiology
Inflammation of bone usually due to infection
Source
- haematogenous: rare, poss. children
- direct: XLA, surgery, #, PA lesion (usually)
Usually bacterial: Strep., Staph., Prevotella, Porphyromonas
Forms in confined spaces of Md: medullary cavity (bone marrow space)
Eventual necrosis -> liquefaction + pus formation
- sub-periosteal reactive bone formation try to prevent spread
32
Clinical presentation of osteomyelitis
Pain: pus formation in confined space
- throbbing, entire Md
- poorly localised cf dry socket
```
Swelling: oedematous, collection (localised pus), bone
Exposed necrotic bone +/- suppuration
- 1/+ IO/EO sinuses
Paraesthesia: CNV3; lip + chin numbness
- if ID canal affected
```
Lymphadenopathy
Pyrexia, malaise
Trismus
33
Ix and Mx of osteomyelitis
Ix
- pus sample; AB sensitivity
- X-ray: plain, CBCT, CT
- bloods: leukocytosis
Mx
- empirical AB therapy
— clindamycin (good bony penetration)
- removal + debridement (if severely contaminated)
- long term AB; Outpatient Parenteral AB Therapy
34
What is osteoradionecrosis?
Non-healing region of bone in irradiated area
- persisted >3/12
- in absence of recurrent malignancy
35
Staging of ORN
Notani
1: confined to alveolar bone
2: limited to alveolar bone +/- mandible above level of mandibular canal
3: extended to mandible below level of mandibular canal w/ skin fistula or pathological #
36
Prevention of ORN
Full dental assessment + prophylactic XLA
Diet change, F advice
Relieve dentures to avoid mucosal trauma
Regular recall
Good communication w/ hospital
37
Local + systemic risk factors for osteomyelitis
Local
- Md > Mx
- red. vascularity/vitality
- medications: bisphosphonates
- irradiation: CRT
- bony disease: Paget’s, osteopetrosis
Systemic: immunodeficient;
- DM
- leukaemia
- agranulocytosis
- medications: corticosteroids, CRT
- malnutrition: osteomalacia, Ricket’s
- age
38
Discuss acute osteomyelitis
Acute exudative inflammation reaction within bone
- dense neutrophilic infiltrate within bone marrow
Compression + thrombosis of periosteal vessels -> ischaemic necrosis
Reactive bone formation; min. cf chronic
39
Discuss chronic osteomyelitis
More common
Clinical: dif. pain nature + duration
- low level dull ache
- always present
cf acute
- localised sclerotic bone
- CRT more likely implicated
Mx
- corticotomy: holes made in bone, allow periosteum vascularity to permeate
- AB beads
40
Complications of osteomyelitis
Septicaemia: enter bloodstream
Acute bacterial arthritis: inflammation of joint space
Pathological #: extensive bone weakened
41
Clinical + radiographic findings of ORN
```
Clinical: similar to COM
- sterile: asymptomatic
- infection -> intractable OM
— spreads rapidly
— painful necrosis
— sloughing of orofacial soft tissues
- healing slower/none
- no periosteal reaction; bone acellular
```
Radiographic: similar to OM
- ill defined
- mottled
- mixed radiodensity
- bony sequestra
- haphazard trabecula
42
Aetiology of ORN
Irradiation affects bone vascularity
- vessel intima proliferation -> thickening -> occlusion (endertaritis obliterans)
- thrombosis
= loss of vitality (aseptic necrosis)
43
Mx of ORN
Conservative: AB, analgesic, OH
Hyperbaric O2 therapy: inc. O2 supply
Surgery: resection + reconstruction
Medications: pentoxifylline, tocopherol
- anti-radiation fibrosis, antioxidant
- scavenge free radicals -> prevent oxidation
Severe cases surgical reconstruction only option
44
Aetiology of facial #s
```
Road traffic accidents
Assault: drugs, alcohol
Falls: epilepsy, MS
Sports
Firearms
Dentistry
Pathology
```
45
Types of #
Simple (closed): no communication w/ external structure
Compound (open): communication w/ skin/mucosa/PDL
Comminuted: multiple fragments
Complicated: involves important structure (artery)
Green stick: partial, children
Pathological: due to disease
46
Early Mx of all #s
ABC
```
Control bleeding
Other serious injuries: head, cervical spine, abdomen, thorax
Other #s
CSF leak
Ocular damage
Red. + immobilise if compromising airway
Lacerations
Antimicrobial + tetanus prophylaxis
```
47
Sites of Md #
```
Dentoalveolar 3%
Condyle: intra/extracapsular 36%
Coronoid 2%
Ramus 3%
Angle 20%
Body 21%
Para/symphysis 14%
```
48
Clinical signs of Md #
```
Occlusal derangement: open bite
Step deformity
Para/anaesthesia
Mobility across #
Pain, tenderness
Swelling: haematoma (sublingual), oedema
IO bleeding
Loose teeth
Dysphagia
Limited movement/trismus
Otorrhoea: blood, CSF
```
49
Tx of Md #s
Reduction: bring #s closer together
- compound/open: surgical exposure
- simple/closed: fast (manipulation), slow (elastic traction)
Fixation: relocate
- indirect: inter-Mx #; Leonard buttons/eyelets/archbar/IMF screws
- direct: screw/plate/wire/pin
Immobilisation: prevent movement
Rehabilitation
- soft diet
- jaw exercises
- elastics
- occlusal adjustment
50
Complications of Md #
Malunion
Delayed union
Non-union
Infection: osteomyelitis, screw/plate
Malocclusion
Nerve injury
TMJ ankylosis
51
Types of mid. 1/3 #
```
Alveolar
Central
Zygomatic complex
Orbital
Nasal
```
52
General features of mid. 1/3 #s
```
Airway obstruction
Ecchymoses: circumorbital, subconjunctival
Gross facial oedema
Bleeding, CSF leak
Mx mobility
Occlusal disturbance
```
53
Tx for mid. 1/3 #s
Reduction
- correct craniofacial relationship
- correct occlusal relationship
Fixation: in/direct
- external: craniomaxillary, craniomandibular (old)
- internal: plates, wires, wires to Mx splint/antral pack
54
Types of central mid. 1/3 #s
Le Fort 1/2/3
55
Discuss Le Fort 1 #
Anatomy
- low level, sub-zygomatic
- detachment of alveolar process w/ palate from Mx complex
- sup. floor of nose + antrum
Clinical: Mx move independently
- local injury evidence: bruising, oedema (B sulcus)
- gagging on post. teeth, ant. OB
- altered sound on percussion
56
Discuss Le Fort 2 #
Anatomy
- pyramidal
- sub-zygomatic
- through lat. + ant. walls Mx sinus and through infraorbital margin
- join across bridge nose
Clinical: nose move independently
- rapid facial swelling: bruising, oedema
- bilateral, circumorbital + subconjunctival ecchymoses
- epistaxis
- infraorbital anaesthesia
- interference w/ ocular movement
57
Discuss Le Fort 3 #
Anatomy
- high level
- supra-zygomatic
- through lat. walls orbits + orbital floor
- detachment of zygomatic bones @ frontozygomatic suture across zygomatic arch
Clinical: orbits move
- as Le Fort 2
- subconjunctival ecchymoses (outer quadrant cf inner LF2)
58
Clinical features of zygomatic complex #s
```
Ecchymoses: circumorbital, subconjunctival
Cheek oedema
Zygoma tenderness + flattening
Limited ocular movement
Diplopia
Strabismus
Limited lat. excursion to injury
Limited opening/closing
Epistaxis
Para/anaesthesia (gum, cheek)
Infraorbital rim notch
Dimple over zygomatic arch
```
59
Tx indications + modalities for zygomatic complex #s
Indications
- aesthetics
- limited Md/ocular movement
Modality
- reduction
- IO elevation: upper B sulcus incision
- Gillies Lift: EO elevation, temporal incisor
- Poswillo Hook
60
Clinical features of orbital blow out
```
No step defect: orbital rim intact
- Thin orbital floor + med. wall #
Contents herniate into antrum
Enophthalmos
Diplopia
Limited movement
```
61
Tx for orbital blowout #
```
Restore orbital vol.
Remove herniated tissue from antrum
Graft defect in floor/med. wall
- Ti
- bone
```
62
Effect of benign lesions
Excessive accumulation of cells leads to
- pressure atrophy: adjacent parenchyma
- fibrous capsule: more resistant connective tissue
- obstruction
63
General features of benign lesions
```
Encapsulated; esp. if in solid organ
Shape: round (moulded by surrounding tissues)
Size: small cf malignant
Slow growing
Bleeding + ulceration rare
Can prod. hormones (endocrine tissue)
```
64
Indications for removal of benign lesions
```
Pain
Red. function
Aesthetics
Continual growth
Pressure on adjacent structures
Weakening of structures
Infection
```
65
Surgical management methods
```
Excision
Curettage
Enucleation
Marsupialisation
Lithotripsy
Laser
Diathermy
Cryotherapy
```
66
Discuss excision + curettage
Excision
- cut lesion out
- suitable for small lesions; won’t leave large defect
- direct important
— long axis parallel skin creases/wrinkles
— along muscle will cause scaring
Curettage: scrape out
67
Discuss enucleation
Removal of whole lesion/cyst w/ lining/capsule
Suitable for large lesions
Incise mucosa over lesion + dissect lesion out
Success is dependent on
- complete removal of lining
- uneventful healing
- no 2ry infection blood clot
68
Dis/advantages of enucleation
Adv
- cavity closed to mouth
- little aftercare req.
- complete lining available for histology
Disadv
- recurrence; if incomplete lining removal
- blood clot may be infected
- haemorrhage
- vital teeth apices/structures may be damaged
- large cyst may weaken jaw
- can’t visualise cavity (1ry closure)
69
Discuss marsupialisation
Decompress cyst be creating largest poss. surgical window consistent w/ anatomy
- relieve intro-cystic pressure -> regresses in size until eliminated
Incomplete lining removal + make continuous w/ mouth/antrum
Hole must be large enough to prevent closure + cyst recreation
- pack
- wait for granulation tissue
- 6/12
70
Dis/advantages of marsupialisation
Adv
- less bone removal (avoid pathological # Md)
- cavity visible
- save associated tooth (dentigerous cyst)
- avoid damage adjacent structures
Disadv
- pt needs to keep clean
- whole lining not available for histology
- epithelial lining may be friable + difficult to suture
- several appts; repack cavity as shrinks + repairs
- orifice may closure -> cyst reform
- bony infill may not occur
71
Discuss LASER for soft tissue uses
CO2 laser
Method
- beam hits
- temp rise -> proteins denature + thrombosis
- cellular H2O boils -> ruptures cells -> tissue vaporised
- once desiccated, temp rise more + adjacent tissues heat (carbonisation)
Uses
- cutting: vaporisation
- coagulation: protein denaturation -> cell death + haemostasis
- har tissue surgery
72
Dis/advantages of laser surgery
Adv
- dry working field
- red. blood loss
- red. post-op oedema, pain, fibrosis
- fibre-optic delivery; reach places not poss. w/ surgery
Disadv
- cost
- complexity
- no specimen for pathology
73
Uses of diathermy
Coagulation (bipolar)
Fulguration: destruction of small growth/area
Cutting (monopolar)
74
Disadvantages of diathermy
Burns
Explosions
Electrocution
Pacemakers
75
Discuss cryotherapy
Tissue denaturation by cold medium
Direct application of NO2 or through cryoprobes (-196C)
Use: fluid filled lesions
76
Discuss freeze-thaw cycles of cryotherapy
Causes formation of ice-ball
Intracellular ice formation inc. cell volume + disruption occurs on thawing
Repeated cycles -> red. lesion mass
77
What is effectiveness of cryotherapy dependant on?
Absolute temp change
Rate of change
No. cycles
T of temp decrease
78
Dis/advantages of cryotherapy
Adv
- no cutting
- tissue intact + no bleeding
- done w/o LA
Disadv
- cost
- no pathology specimen
- large amount post-op swelling + ulceration
- depigmentation (lip)
79
Function of maxillary sinus
Moisten + warm inhaled air
Lighten skull
Resonance
Immunological (URT)
80
What is oro-antral communication?
Communication b/w mouth + maxillary sinus
81
Predisposing factors for OAC
```
XLA UMs
Tooth-antrum relationship/proximity
Submerged teeth
Large antrum
Hypercementosis
Bone loss (perio)
Excessive force
Surgery near sinus (cyst removal)
```
82
Dx of OAC
```
Hollow sound when aspirator in socket (gentle)
Bubbling bleeding
Air entry into mouth when holding nose
Antral lining/bone on roots
X-ray: defect in floor
```
83
OAC Tx
Prevention better
Tx before sinus becomes infected
Small: horizontal mattress suture
Large: buccal advancement flap
Acrylic plate/obturator
Antral regime
84
Post-op instructions following OAC Tx
No smoking or nose blowing
Don’t drink through straw
Sneeze with mouth open
Antral regime
- AB prescription
- inhalations: Karvol
- nose drops: ephedrine
85
Discuss oro-antral fistula
OAC that has epithelialised
- at least 48-72h later
Clinical
- regurgitation of food/fluids into nose
- epistaxis
- chronic sinusitis
- antral mucosa prolapse into mouth
- X-ray: fluid in sinus
Tx
- AB pre-surgery; clean antrum
- excise fistula tract; 2 epithelialised edges won’t heal
- buccal advancement flap +/- buccal fat pad
86
Predisposing factors for # tuberosity
```
Lone standing UMs
Hypercementosis
Bulbous/splayed roots
Large antrum
Excessive force
```
87
Dx + Tx # tuberosity
Dx: feel tooth + bone moving together
```
Tx
- small
— raise buccal flap
— dissect # bone + tooth out under direct vision
— close: prevent OAC
— post-op instructions
- large
— leave, allow to heal 8/52
— surgical XLA
— AB
```
88
Aetiology of acute sinusitis
```
Influenza
Cold leading to 2ry bacterial infection
Measles
Whooping cough
Penetrating injury
Dental related
```
89
Predisposing factors for acute sinusitis
Poor/dec. drainage
Virulent infection
Deviated septum
Debilitated pt
90
Clinical findings of acute sinusitis
```
Constant nagging pain mid-face
Pyrexia
Tenderness (esp. when moving head)
Mucopurulent discharge
Facial swelling, cheek oedema
Teeth TTP but vital
Lack of transillumination
X-ray: opacity
```
91
Tx of acute sinusitis
Medical
- bed rest
- AB
- decongestants
- inhalations
- analgesic
Surgical
- antral washouts; remove fluid if unresponsive to medical
- intranasal antrostomy (enlarge ostium)
92
Complications of acute sinusitis
Spread to other sinuses
Laryngitis
Otitis media
Chronicity
93
Discuss chronic sinusitis
Aetiology: same + inadequate Tx acute
Clinical
- mucopurulent discharge
- thickened antral mucosa
- nasal obstruction
- X-ray: opacity
- no transillumination
Tx
- medical: same
- surgical
— antral washout
— intranasal antrostomy (create drainage point)
— Caldwell-Luc (remove irreversibly damaged mucosa)
— Functional Endoscopic Sinus Surgery (enlarge nasal passage)
Complications: same
94
Steps involved in normal haemostasis
Vessel vasoconstriction
1ry haemostasis: platelet aggregation -> platelet plug
2ry haemostasis: blood coagulation -> fibrin clot
Fibrin degradation by plasmin to dissolve clot
95
Discuss normal mechanism of vessel vasoconstriction
Local factor-mediated neurogenic vasoconstriction
Small vessels + capillaries closed by pure platelet plug w/o blood clots
Larger wounds req. clot
96
What pathological conditions predispose to clot formation?
```
Atheroma
Vessel fragility (long term steroids)
Abnormal vessel
Vascular lesions
Altered haemodynamics
```
97
Discuss 1ry haemostasis mechanism
Exposed collagen (damaged endothelium) binds + activates platelets
Platelet factors released from granules; ADP, Thromboxane A2
More platelets attracted
Platelet plug formed
98
Causes of thrombocytopenia
```
Production failure
- general marrow failure
— marrow aplasia
— megaloblastic anaemia
— leukaemia, myeloma
— myelofibrosis
- megakaryocyte depression
- drugs; alcohol, chemotherapy
- viruses
- chemicals
- congenital
```
```
Survival Failure
- autoimmune
— idiopathic thrombocytopenia purpura
— SLE
- HIV
- malaria
- chronic lymphocytic leukaemia
- non-autoimmune
— disseminated intra-vascular coagulation
— drugs; aspirin, cytotoxics, valproate
```
99
Causes of disturbed platelet function
Drugs: aspirin, NSAIDs, clopidogrel
Von Willibrand’s disease: defective/red. vWF
Defective granule prod./function; uraemia, haematological malignancy
100
Briefly outline coagulating cascade
Intrinsic pathway: activated by damage within blood vessel
- contact activation pathway
- contact w/ exposed collagen
Extrinsic pathway: activated by damage outside blood vessel
Both activate CFX -> common pathway + clot formation
- fibrinogen -> cross-linked fibrin (stable clot)
101
Congenital clotting disorders
```
Haemophilia A (CF8C deficient)
Haemophilia B (CF9 deficient)
Von Willibrand’s disorder (vWF deficient/abnormal)
```
102
Acquired clotting disorders
```
Anticoagulant: warfarin, heparin, NOACs
VitK deficiency/malabsorption: CF2/7/9/10
Liver disease
Disseminated intravascular coagulation
Large vol. blood transfusions
```
103
Systemic methods of achieving haemostasis
CF8/9
- fresh frozen plasma
- purified factors
- cryoprecipitate
Desmopressin
- synthetic analogue vasopressin
- stim. release: CF8, vWF, tPA
Tranexamic acid
- synthetic derivative lysine
- anti-fibrinolytic
Platelets
VitK
104
Most common local haemostatic agents
```
Packs
Suture
Oxidised cellulose (Surgicel, Oxycel)
Adrenaline
Tranexamic acid m/w
```
105
Discuss Mx of thrombocytopenia + haemophilia pt
Thrombocytopenia
- bleeding when platelets <50x10^9
- transfusion pre-XLA (consult haematologist)
- additional: pack + suture
Haemophilia
- Tx in hospital in conjunction w/ haematologist
- req.
— factor replacement
— desmopressin
— systemic tranexamic acid
- caution w/ ID blocks, infiltration where poss.
- additional: pack + suture
- adverse: immune response to factor, infectious disease spread
106
Mx of warfarin pt
Never stop warfarin
Check INR <72h pre-Tx
- >4.0 postpone
Tx at start of day
```
Atraumatic as poss.
Additional
- pack + suture
- 5% tranexamic m/w QDS
Carefully check haemostasis
Care if prescribing
```
107
Drug interactions w/ warfarin
```
Metronidazole
Fluconazole + azole antifungals
NSAIDs
Alcohol
Barbiturates
```
108
Mx of NOAC pt
Apixaban + dabigatran: BDS
- miss morning dose
- take normal evening dose
Rivaroxaban + edoxaban: ODS
- morning: delay, 4h post-haemostasis
- evening: take as normal
Additional: pack + suture
109
Mx of anti-platelet pt
Aspirin: don’t stop
Others: don’t stop
Simple precautions
- pack
- suture
- tranexamic acid
Avoid NSAIDs
110
Define 1ry, reactionary + 2ry bleeding
1ry
- immediate, occurs during procedure
- soft tissue, inflammation, damage to blood vessel, bony bleed, granuloma
Reactionary
- few hrs later (up to 24h)
- loss of clot, bleeding disorder/anti-platelet/coagulation medications, adrenaline wearing off
2ry
- few days later
- infection, bleeding disorder/anti-coagulation medication
