WHAT TO DO IN THE EVENT OF A HEMORRHAGE
- INTRODUCTION
Frequent emergency at the dental office.
Bloody acts are part of the common practice of
Dentist: Frequent emergencies at the dental office+++
Real emergency requiring rapid treatment.
Goals:
1/Detect patients at risk.
2/Dealing with hemorrhage that occurs during surgery
3/ Provide emergency care to a patient with a hemorrhage.
- THE INTERROGATION
Medical history:
- Processing in progress:
- Anti-vitamin K anticoagulants.
- aspirin
- NSAID (non-steroidal anti-inflammatory drug)
- High blood pressure
- Liver damage: viral hepatitis.
- Patients undergoing chemotherapy.
- Did the patient follow all the recommendations given by the dentist following the dental extraction (do not spit, refrain from eating or drinking hot drinks)?
- ADDITIONAL EXAMINATIONS
- Radiological assessment
- Dental or retro-alveolar panoramic.
- This radiographic assessment should make it possible to detect a fracture of the dental socket, a fractured apex left in the socket or an uncuretted lesion.
- Biological assessment
- Hemostasis assessment: NFS-TS-TP-INR-TCA
- ETIOLOGIES
- GENERAL DIRECT CAUSES
- hematological disorders: anemia, thrombopathies, hemophilia, etc.
- arteriovenous malformations
- Vit K deficit.
- vascular anomalies
- GENERAL INDIRECT CAUSES :
- Medication intake :
- Nonsteroidal anti-inflammatory drugs,
- acetylsalicylic acid-based drugs (aspirin).
- anticoagulants (heparin, antivit K).
- general diseases :
- Liver diseases (cirrhosis, hepatitis, etc.)
- Ethylism,
- LOCAL CAUSES:
- Intervention in the presence of inflammation
- Iatrogenic causes:
- alveolar fracture
- presence of apex granuloma not cured
- presence of angioma etc…
- Post-surgical causes due to disruption of the clot: abuse of mouthwash.
- TREATMENT
- PREVENTIVE :
Before any bloody act, question them on:
- family and personal background.
- Previous interventions.
- The existence of spontaneous and repeated cutaneous, mucous or digestive bleeding which are signs of capillary fragility.
- Perform a thorough clinical examination.
- general curative:
- A missing factor contribution:
vitamin K intake if deficient.
- Removal of the triggering factor: stopping Aspégic
- LOCAL CURATIVE TREATMENT
After removing the cause of the hemorrhage, the practitioner has a whole local therapeutic arsenal at his disposal:
- Local hemostatics thrombase, surgicel
- Resorbable collagen (pangen…)
- GRF glues
- Gutters (stens, Kerr paste, resin, etc.)
- Antifibrinolytics (Exacyl®, Capramol®, Hémocaprol®)
- Surgical means (stitches).
Ensure hemostasis by:
- cleaning the wound using a sterile compress to be able to carry out a rapid clinical examination to determine the origin and nature of the hemorrhage.
- If necessary, repeat local anesthesia with a vasoconstrictor (if there is no medical contraindication).
- Clean the alveolus thoroughly
- extract the residual apex.
- If there is an apical lesion, curettage it.
- Establish internal hemostasis Pack the alveolus with a hemostatic agent: Surgicel® or Thrombase 500 powder.
- Apply compression that will be maintained for 20 minutes to promote clot formation.
- This compression will be done using a small packet of rolled compresses placed at the level of the alveolus
- if necessary change the compresses in order to check the quality of local hemostasis and the stopping of the bleeding.
- Post-operative advice: avoid eating too hot food and overusing mouthwash.
SYNCOPE DISCOMFORT
- Faintness
- INTRODUCTION
- Discomfort is a term widely used by both patients and healthcare professionals, and is used to describe many different situations.
- Discomfort is an extremely common reason for consultation in general medicine as well as in emergency medicine, where it represents nearly 10% of admissions.
- The term discomfort covers a wide variety of clinical situations.
- Questioning, simple clinical and paraclinical data allow diagnostic orientation in 70 to 80% of patients
- DEFINITION
- The consensus conference of the French-speaking emergency medical society describes the malaise as
” an acute, regressive episode, characterized by a disturbance of consciousness or vigilance (brief loss of consciousness or lipothymia), with or without hypotonia which may be responsible for a fall. The return to the previous state is spontaneous, rapid or progressive. “
- Fainting is a transient malaise characterized by an anxious feeling of impending fainting with pallor, sweating, ringing in the ears and blurred vision. This malaise is often preceded by nausea and rarely results in total loss of consciousness. It should be considered a minor equivalent of syncope.
- PHYSIOPATHOLOGY
Resulting from a disturbance of cerebral metabolism, due to a deficit in one of its two fundamental substrates: oxygen or glucose.
This energy deficit is due to four mechanisms:
- Interruption of cerebral circulation.
- Decreased cardiac output.
- Drop in blood pressure.
- Decrease in the blood content of energy substrates.
- VAGAL DISCOMFORT:
- Vagal discomfort, the most common form in
dental office, usually occurs in conditions of stress, overheated atmosphere, associated with acute pain.
This phenomenon is frequently found in young adults.
- Prodromes are characteristic and begin with muscle weakness, associated with visual and hearing disturbances, pallor and cold sweats with possible dizziness.
- Persistence of the discomfort can lead to generalized hypotonia and in some cases a short-term loss of consciousness.
- CAT
- The appearance of prodromes should immediately suggest vagal discomfort.
- In addition to the need to stop ongoing treatment , it is appropriate, if necessary, to prevent the patient from falling, to keep him lying down, legs raised, in the supine position while waiting for the symptoms to disappear.
If the discomfort persists or recurs, seek medical advice from the emergency services.
- Monitor breathing and circulation.
- Reassure the patient
- Dab face with cool water.
- THE SPASMOPHILIA CRISIS:
- The spasmophilia crisis is a poorly understood syndrome, linked to a state of neuromuscular hyperexcitability .
- The attacks are manifested by episodes of tetany, hyperventilation, paresthesias of the extremities and face.
- The spasmophilia crisis is most often attributed to a state of anxiety or anguish (manifested by hyperventilation), encountered more frequently in women.
- Hyperventilation leads to hypocapnia which can be controlled by having the patient breathe CO2-enriched air, for example by breathing into a paper bag.
- The spasmophilia crisis can also be the expression of a defect in the regulation of calcium/potassium ions.
- ORTHOSTATIC HYPOTENSION:
- It is a clinical syndrome characterized by a feeling of dizziness, narrowing and obscuring of the visual field, giving way of the legs, occurring when moving from a lying to a standing position.
- These manifestations are accompanied by a drop in systolic pressure of at least 20 mm of mercury and 10 mm of mercury in diastolic pressure.
- Orthostatic hypotension:
- The transition from prolonged decubitus to the orthostatic position is accompanied by a redistribution of blood volume to the lower limbs of between 0.5 and 1L, thus creating cerebral ischemia.
- This phenomenon is counterbalanced by parasympathetic neuro-hormonal and cardiovascular regulation with vasoconstriction of the vessels of the lower limbs and an increase in heart rate.
- The lack of postural adaptation therefore leads to vagal-type discomfort without prior manifestation, and directly linked to the change of position.
- These manifestations are preferentially found in patients undergoing hypotensive treatment.
- Be vigilant with these patients and plan a gentle and gradual recovery, or even have the patient wait in a sitting position for a few minutes between the supine position and the orthostatic position.
- In all cases, vital functions will be monitored, and oral re-sugaring with fast and slow sugars is required as soon as consciousness is regained.
- In the absence of remission, emergency services should be called immediately, particularly in diabetic patients whose condition is progressing towards coma.
- hypoglycemic with convulsions, cardiorespiratory collapse and risk of obstruction by aspiration.
- In addition, a prolonged coma causes cerebral edema with permanent neurological sequelae.
- Syncope
- Syncope characterized by a sudden total loss of consciousness resulting in a fall.
- Its duration is short and recovery is complete in a few minutes without post-critical symptoms (blunt syncope).
- Syncope is a malaise of cardiac etiology occurring preferentially in the elderly, presenting a cardiovascular history such as arrhythmia, paroxysmal rhythm or conduction disorders, etc.
- The absence of prodromes makes it a sudden malaise that is difficult to predict.
- However, the patient’s clinical picture will raise concerns about signs such as dyspnea, palpitations, chest pain , in the elderly.
- The recovery of consciousness is as sudden and spontaneous as the loss of consciousness and is accompanied by amnesia of the malaise.
- Syncope can be life-threatening , especially if it is prolonged or its frequency increases.
- It will therefore be necessary during the malaise to rule out the possibility of cardiorespiratory arrest, and upon regaining consciousness to keep the patient lying down while monitoring vital parameters (heart and respiratory rates, blood pressure and blood sugar).
- Medical advice is necessary and cardiological care will be strongly recommended.
WHAT TO DO IN THE EVENT OF A HEMORRHAGE
Early cavities in children need to be treated promptly.
Dental veneers cover imperfections such as stains or cracks.
Misaligned teeth can cause difficulty chewing.
Dental implants provide a stable solution to replace missing teeth.
Antiseptic mouthwashes reduce bacteria that cause bad breath.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush preserves enamel and gums.