Hemorrhage

Objectives
 Define hemorrhage and its types
 Understand the importance of hemorrhage control in
maxillofacial procedures
 Classify hemorrhage by timing, source, and severity
 Recognize causes of maxillofacial hemorrhage
 Discuss management approaches and Understand
complications
 Apply knowledge through real-life clinical scenarios
 Outline
 Introduction
 Relevant Anatomy
 Classification of Hemorrhage
 Etiology of Maxillofacial Hemorrhage
 Clinical Features
 Diagnosis and Assessment
 Management of Hemorrhage
 Complications of Hemorrhage
 Prevention Strategies
 Case Scenarios
 References
 Introduction
 Hemorrhage, defined as the escape of blood from the circulatory
system, is a significant medical concern that can arise from
various causes, including trauma, surgical procedures, and
underlying medical conditions.
 Recognizing the signs and symptoms of hemorrhage is vital for
timely intervention. A clear understanding of the causes, types,
and management strategies for hemorrhage in the maxillofacial
area is vital for ensuring patient safety and optimal surgical
outcomes.
 Definition...
Hemorrhage is the loss of blood from the circulatory system due to
the rupture or injury of blood vessels. This can occur internally,
where blood leaks into body cavities or tissues, or externally,
where blood escapes through a natural opening or a break in the
skin. The severity and impact of hemorrhage depend on the
volume of blood lost, the rate of bleeding, and the affected vessel
type—arterial, venous, or capillary.
Classification of
Hemorrhage
Based on source
1. Arterial Hemorrhage
This type of hemorrhage occurs when an artery is damaged. It is
typically characterized by bright red, pulsatile blood flow that may
spurt with each heartbeat.
Common causes include trauma, lacerations, or ruptured
aneurysms.
 Clinical Significance: Arterial hemorrhage can lead to rapid blood
loss and is often life-threatening if not controlled quickly.
2. Venous Hemorrhage
Venous hemorrhage occurs when a vein is damaged. The
blood is usually darker red and flows steadily rather than
spurting.
It can result from trauma, surgical complications, or
conditions like varicose veins.
 Clinical Significance: While venous bleeding can be serious,
it typically does not lead to as rapid a loss of blood volume
as arterial bleeding.
3. Capillary Hemorrhage
This type involves the smallest blood vessels (capillaries) and
is characterized by oozing of blood from small cuts or abrasions.
The blood is usually dark red and seeps out slowly.
Common causes include minor injuries, abrasions, or
conditions that affect blood clotting.
 Clinical Significance: Capillary hemorrhage is generally less
severe and often self-limiting, but extensive capillary bleeding
can still lead to significant blood loss in certain situations.
 Based on timing
1. Acute Hemorrhage
Occurs suddenly and typically within minutes to hours after an
injury or event.
Examples:- Traumatic brain injury leading to acute subdural or
epidural hematoma.
• Acute gastrointestinal bleeding due to trauma or ulceration
• Post-operative bleeding that occurs shortly after surgery.
2. Subacute Hemorrhage
Occurs within a few days (usually 3 to 7 days)
after the initial event. The term "subacute"
often refers to the evolving nature of the
hemorrhage as it starts to organize or resolve.
Examples:-Subacute subdural hematoma,
where blood accumulates and may begin to clot
and organize.
• Hemorrhagic transformation of an ischemic
stroke that occurs a few days after the initial
event.
3. Chronic Hemorrhage
Refers to bleeding that occurs over a longer period, typically
weeks to months. This can be due to ongoing bleeding from a
source that is not immediately life-threatening.
Examples:- Chronic subdural hematoma, which may develop
gradually over weeks or months, often in elderly
patients.
• Chronic gastrointestinal bleeding from conditions
like peptic ulcers or malignancies, leading to iron
deficiency anemia over time.
4. Recurrent Hemorrhage
Refers to episodes of bleeding that occur repeatedly over time,
often from the same source.
Examples:-Recurrent nosebleeds (epistaxis) due to underlying
conditions like hypertension or vascular malformations.
• Recurrent gastrointestinal
bleeding in patients with chronic
ulcers or varices.
Based on clinical severity
 It is classified into four classes (Class I–IV)
according to the estimated percentage of total
blood volume lost. This classification helps guide
clinical decision-making, especially in emergency
and trauma settings
 Class 1 Hemorrhage

Blood loss Clinical Signs Management

Up to 15% of HR: <100 beats per Generally, no

total blood minute. specific
volume BP: Normal intervention is
(approximately RR: Slightly elevated needed;
750 mL in a 70 (14-20 breaths per monitoring may
kg adult) minute). suffice.
Patient may be
asymptomatic or
mildly anxious.
 Class 2 Hemorrhage

Blood loss Clinical Signs Management

15-30% of total HR: 100-120 beats Fluid

blood volume per minute resuscitation
(approximately BP: Normal or slightly with crystalloids
750-1500 mL) decreased may be initiated;
RR: Elevated (20-30 close monitoring
breaths per minute). is required.
Patient may exhibit
mild confusion or
anxiety.
 Class 3 Hemorrhage

Blood loss Clinical Signs Management

30-40% of total HR: 120-140 beats Aggressive fluid

blood volume per minute resuscitation is
(approximately BP: Hypotensive required, often with
1500-2000 mL) (systolic BP <90 crystalloids and
mmHg) RR: Elevated possibly blood
(>30 breaths per products.
minute). Consideration for
Patient may be surgical intervention
lethargic or
 Class 4 Hemorrhage

Blood loss Clinical Signs Management

>40% of total HR: >140 beats per Immediate

blood volume minute resuscitation with
(more than 2000 BP: Markedly large volumes of
mL) hypotensive fluids and blood
RR: Very high (>35 products is critical.
breaths per minute) Surgical intervention
Patient may be is often urgently
lethargic or required to control
unresponsive. the source of
Importance of hemorrhage control in maxillo
facial surgery
1. Minimizing Blood Loss
2. Improving Visibility
3. Reducing Complications
4. Facilitating Surgical Techniques
5. Enhancing Patient Safety
6. Postoperative Recovery
7. Psychological Impact
8. Legal and Ethical Considerations
 Relevance in trauma, surgery and
dental procedures
 Hemorrhage control is a critical aspect of trauma management,
surgical procedures, and dental interventions.
1. Trauma
In traumatic injuries, rapid hemorrhage control is essential to prevent shock
and death. The "Golden Hour" emphasizes the importance of timely
intervention. Methods such as direct pressure, tourniquets, and hemostatic
dressings are often employed to control bleeding in emergency settings.
Trauma patients require thorough assessment to identify sources of bleeding.
Cont...
2. Surgery
In elective and emergency surgeries, controlling hemorrhage is vital
for maintaining a clear surgical field and preventing excessive blood
loss. Surgeons use various techniques, including clamping,
cauterization, ligation of vessels, and the application of hemostatic
agents (e.g., gelatin sponges, thrombin).Minimizing blood loss during
surgery leads to quicker recovery times, reduced need for
transfusions, and improved overall patient outcomes.
 Cont...
3. Dental Procedures
Dental surgeries, such as extractions or
implant placements, can involve significant
vascular structures. Effective hemorrhage
control is crucial for patient [Link]
may use local anesthetics with vasoconst
rictors, suturing techniques, and hemostatic
agents to control bleeding during
procedures.
Anatomy Relevant to Hemorrhage in the
Maxillofacial Region

 Vascular supply of the face and oral cavity

The vascular supply of the face

and oral cavity is primarily
provided by branches of the
external carotid artery, along
with contributions from other
vessels.
1. External Carotid Artery:-The external carotid artery branches into
several key arteries that supply the face and oral cavity:
• Facial Artery:
Pathway: Arises from the external carotid artery and travels across the
mandible to the face.
Branches: • Inferior Labial Artery: Supplies the lower lip.
• Superior Labial Artery: Supplies the upper lip.
• Lateral Nasal Artery: Supplies the side of the nose.
• Angular Artery: Supplies the medial canthus of the eye.
• Maxillary Artery:
Pathway: A terminal branch of the external carotid artery that supplies deep
structures of the face.
Branches: • Inferior Alveolar Artery: Supplies the mandibular teeth and
branches into the mental artery (supplying the chin) and incisive artery
(supplying anterior teeth).
• Buccal Artery: Supplies the buccal mucosa.
• Infraorbital Artery: Supplies the maxillary teeth, maxilla, and skin
of the face below the orbit.
• Sphenopalatine Artery: Supplies the nasal cavity and contributes
to the palatine arteries.
• Superficial Temporal Artery:
Pathway: A terminal branch of the external carotid artery that supplies the
lateral aspect of the head.
Branches: • Frontal Branch: Supplies the forehead.
• Parietal Branch: Supplies the scalp.
• Transverse Facial Artery:
• A branch of the superficial temporal artery that supplies the
parotid gland and nearby facial structures.
2. Internal Carotid Artery
While not a primary supplier of the face, branches of the internal carotid artery
contribute to facial vascularization indirectly through anastomoses:
• Ophthalmic Artery:-Supplies structures in the orbit and has branches that
contribute to facial areas, such as the dorsal nasal artery.
3. Oral Cavity Supply
The oral cavity receives its blood supply mainly from branches of the maxillary
artery:
• Lingual Artery: Supplies the tongue and floor of the mouth.
• Sublingual Artery: A branch of the lingual artery that supplies the sublingual
gland and floor of the mouth.
• Palatine Arteries (Greater and Lesser): Supply the hard palate and soft palate,
respectively.
 Venous drainage and venous plexus of Face and oral cavity
1. Venous Drainage of the Face
• Facial Vein:-The primary vein draining the superficial structures of the face. It
begins at the angular vein (formed by the union of the supratrochlear and
supraorbital veins) and runs downwards along the side of the nose, passing
through the face and draining into the internal jugular vein.
- It has several tributaries, including:
• Inferior Labial Vein: Drains the lower lip.
• Superior Labial Vein: Drains the upper lip.
• Lateral Nasal Vein: Drains parts of the nose.
• Angular Vein: Connects with the ophthalmic veins and can communicate
with the cavernous sinus.
• Retromandibular Vein:-Formed by the union of the superficial temporal vein and
maxillary vein.
It has anterior and posterior divisions
 Anterior Division: Joins with the facial vein and drains into the internal jugular
vein.
 Posterior Division: Joins with the posterior auricular vein to form the external
jugular vein.
• Superficial Temporal Vein:-Drains blood from the scalp and superficial structures
of the temporal region, merging with the maxillary vein to form the retromandibular
vein.
• Maxillary Vein:- Drains blood from deep facial structures, including the pterygoid
plexus, and joins with the superficial temporal vein to form the retromandibular
vein.
2. Venous Plexus of the Face
• Pterygoid Venous Plexus:- A network of small veins located in the
infratemporal fossa.
• Drains blood from deep facial structures, including the nasal
cavity, paranasal sinuses, teeth, muscles of mastication, and more.
• The plexus communicates with
• The facial vein (via emissary veins).
• The maxillary vein (which drains into the retromandibular
vein).
• The cavernous sinus (which is clinically significant due to its
potential role in spreading infections).
3. Venous Drainage of the Oral Cavity
• Lingual Vein:-Drains blood from the tongue and floor of the
mouth.
• It typically drains into the internal jugular vein.
• Sublingual Veins:-Drain blood from the sublingual gland and
floor of the mouth, often draining into the lingual vein or
directly into the internal jugular vein.
• Inferior Alveolar Vein:- Drains blood from the mandibular
teeth and alveolar region, emptying into the pterygoid plexus.
• Buccal Veins:-Drain blood from the buccal mucosa and may
drain into the pterygoid plexus or facial vein.
 Dangerous zone of Face
The "danger zone" of the face refers to areas where infections can spread
more easily due to the unique venous drainage patterns, particularly involving
the pterygoid venous plexus and retromandibular vein.
1. Pterygoid Venous Plexus
• Location: The pterygoid venous plexus is located in the infratemporal fossa,
surrounding the lateral pterygoid muscle.
• Connections: • Facial Vein • Maxillary Vein • Cavernous Sinus
Infections originating in the teeth, gums, or skin of the face can travel through
the facial vein and enter the pterygoid plexus. This can lead to serious
complications such as cavernous sinus thrombosis, which is an infection of the
cavernous sinus that can cause severe neurological symptoms.
2. Retromandibular Vein
• Location: The retromandibular vein is formed by
the union of the superficial temporal vein and
maxillary vein within the parotid gland.
• Similar to the pterygoid plexus, the
retromandibular vein can also serve as a conduit
for infections from the face or oral cavity to spread
to deeper structures. Infections can travel from
dental abscesses or facial infections through the
anterior division to the internal jugular vein and
then into systemic circulation, leading to serious
complications.
Etiology of maxilofacial hemorrhage
1. Traumatic Causes
 Road Traffic Accidents: High-impact collisions can result in significant
facial injuries, leading to lacerations and fractures that may damage
blood vessels.
 Assaults: Physical violence can cause blunt or penetrating injuries to
the face, resulting in hemorrhage.
 Sports Injuries: Contact sports can lead to facial trauma, including
fractures and soft tissue injuries.
 Falls: Accidental falls can result in maxillofacial injuries, especially in
elderly patients.
2. Surgical Procedures 3. Pathological Conditions
 Extractions  Tumors
 Orthognathic Surgery  Infections
 Cleft Lip and Palate Repair  Dental Conditions
 Biopsies and Tumor Resection

4. Systemic Causes
 Bleeding Disorders
 Anticoagulant Therapy
 Liver Disease
 Platelet Disorders
  When assessing a patient with maxillofacial hemorrhage, it is
essential to recognize both local and systemic clinical features.
Local Signs
1. Bleeding from the Mouth:
• May present as bright red blood or darker,
older blood depending on the source.
• Can be associated with trauma, dental
extractions, or oral lesions.
2. Nasal Bleeding (Epistaxis):
• Blood may drain from one or both nostrils.
• Often occurs due to trauma, nasal fractures, or underlying conditions
affecting the nasal vasculature.
3. Wound Site Bleeding:
• Visible bleeding from lacerations or surgical sites in the face or neck.
• May be accompanied by swelling, bruising, or signs of
infection if present.
4. Swelling and Ecchymosis:
• Localized swelling and discoloration around the injury site
can indicate underlying bleeding and tissue damage.
5. Difficulty Breathing or Swallowing:
• Severe hemorrhage can lead to airway compromise,
necessitating immediate intervention.
Systemic Signs
1. Pallor:
• Skin may appear pale due to blood loss and reduced perfusion.
• Conjunctival pallor may also be observed.
2. Tachycardia:
• Increased heart rate as a compensatory mechanism in response to blood loss.
• May indicate hypovolemia or shock.
3. Hypotension:
• Low blood pressure can signify significant blood loss and reduced circulating
volume.
• Monitoring blood pressure is critical in assessing the severity of hemorrhage.
4. Shock:
• Signs of shock may include confusion, weakness, cold and clammy skin, rapid
breathing, and decreased urine output.
• Hypovolemic shock is a critical condition requiring immediate medical attention.
 Vital Sign Monitoring and Early Warning
Signs
 Regular Monitoring:
• Vital signs should be monitored frequently (every 15 minutes initially) to detect changes in
the patient’s condition.
• Key parameters include heart rate, blood pressure, respiratory rate, and oxygen saturation.
 Early Warning Signs:
• Increased heart rate (>100 bpm) or significant drop in blood pressure (systolic BP <90
mmHg).
• Altered mental status (confusion, lethargy).
• Rapid respiratory rate (>20 breaths/min).
• Decreased urine output (less than 30 mL/hour).
 Diagnosis and assessment
 When diagnosing and assessing a patient with maxillofacial
hemorrhage, a systematic approach is essential.
1. History Taking 3. Imaging
• Trauma History • X-ray
• Medications • CT Scan
• Medical History • Angiography (if necessary)
2. Physical Examination 4. Laboratory Tests
• General Assessment • Complete Blood Count (CBC)
• Local Examination • Coagulation Studies
• Neurological Examination • Bleeding Time and Clotting Time
 Management of Hemorrhage
 Hemorrhage, or excessive bleeding, can occur due to various
reasons, including trauma, surgical complications, or underlying
medical conditions. Effective management is crucial to prevent
shock and other life-threatening complications. The
management of hemorrhage can be categorized into immediate
emergency care, surgical management, and medical
management.
 A. Immediate Emergency Care

1. ABC (Airway, Breathing, Circulation):

AIRWAY
ABC Analysis

 Ensure the
patient's airway
is clear.
BREATHING
 Assess the
adequacy of
breathing.
CIRCULATION
 Check for signs
of shock
 2. Hemorrhage Control:

• Direct Pressure: Apply direct pressure to the

site of bleeding using a sterile dressing or clean
cloth. Maintain pressure for at least 5-10
minutes before reassessing.

• Gauze Packing: For severe bleeding from

wounds that cannot be controlled by direct
pressure, pack the wound with sterile gauze.
This can help to apply pressure internally
and promote clot formation.
 • Hemostatic Agents: Use hemostatic
dressings or agents (e.g., QuikClot, Celox) that
promote clotting in traumatic hemorrhages.
These agents are especially useful in pre-
hospital settings or when surgical intervention
is delayed.

B. Surgical Management
1. Ligation of Bleeding Vessels:
• In cases where a specific bleeding vessel
can be identified, surgical ligation (tying
off) is performed to stop the hemorrhage.
2. Electrocautery: This technique involves
using electrical current to coagulate tissue and
seal off bleeding vessels during surgery. It is
often used in laparoscopic and open surgeries.
3. Suturing of Bleeding Tissues: Suturing can be
employed to directly close lacerations or incisions
that are bleeding. This method is effective for
smaller vessels and superficial wounds.
4. Vessel Embolization: In cases of severe
hemorrhage, particularly in the pelvic or abdominal
regions, interventional radiology may be used to
embolize (block) specific blood vessels supplying the
area of bleeding.
C. Medical Management
1. Tranexamic Acid: is an anti-fibrinolytic medication that helps prevent the
breakdown of blood clots. It is particularly effective in traumatic hemorrhages and
can reduce mortality when administered early (within 3 hours of injury) (CRASH-2
trial).
2. Vitamin K: If bleeding is due to anticoagulant overuse (e.g., warfarin),
administering Vitamin K can help restore normal coagulation factors and control
bleeding.
3. Blood Transfusion: In cases of significant blood loss
(typically defined as a loss of 30% or more of total blood
volume), blood transfusions may be necessary to restore
circulating blood volume and improve oxygen-carrying
capacity.
4. IV Fluids and Resuscitation: Administer IV fluids
(crystalloids such as normal saline or lactated Ringer's
solution) to maintain blood pressure and circulation
during resuscitation efforts. The goal is to achieve
hemostatic resuscitation, avoiding fluid overload while
ensuring adequate perfusion.
 Complications of
Hemorrhage
1. Hypovolemic Shock
Severe blood loss → ↓ blood volume
Signs: tachycardia, hypotension, cold skin,
confusion
Can lead to organ failure if untreated
2. Hematoma Formation
Blood pools in soft tissues
Swelling, discoloration, delayed healing
May need drainage if large
3. Airway Obstruction
Blood accumulation in mouth/oropharynx
Causes: hematoma, tongue displacement,
inhaled blood
Emergency: may need suction, intubation, or
tracheostomy

4. Infection / Abscess
Blood acts as medium for bacterial growth
Fever, swelling, discharge
May require antibiotics + surgical drainage
5. Delayed Healing / Wound Dehiscence
Bleeding disrupts tissue repair, can lead to open wounds, infection risk
6. Reoperation Needed
Re-bleeding or incomplete hemostasis
Requires surgical re-entry and vessel ligation
7. Life-Threatening Outcomes
Hemorrhagic shock → cardiovascular collapse
Rare but fatal if unmanaged
8. Systemic Complications
Coagulopathy, acidosis, hypothermia
 Prevention Strategies of Hemorrhage

1. Preoperative Assessment
Review medical & bleeding history
Check anticoagulant use
Lab tests: PT, aPTT, INR, platelet
count
2. Surgical Planning 4. Local Hemostasis
Know vascular anatomy Apply direct pressure
Use gentle tissue handling Use cautery, sutures, hemostatic
Plan incision & exposure agents
carefully Common agents: Gelfoam, Surgicel,
3. Surgical Technique bone wax
Sharp dissection over blunt 5. Medical Management
tearing Stop anticoagulants early if safe
Maintain clear field with Use Vitamin K or Tranexamic Acid
suction (TXA)
Identify & avoid key vessels Desmopressin for clotting disorders
6. Multidisciplinary Team 8. Postoperative Monitoring
Hematologist: bleeding Check for bleeding/swelling
disorders
Anesthesiologist: monitor Monitor vitals, drainage, Hb levels
vitals & fluids
Act quickly if bleeding reoccurs
Internal medicine: manage
systemic diseases 9. Emergency Preparedness
7. Patient Instructions Keep suction, IV, oxygen ready
Avoid spitting, rinsing, straws
post-op Stock blood products, hemostatic
Use cold compress first 24 hrs tools
Teach signs of bleeding to Know when to refer for vascular
report support
 Cases & Examples of Hemorrhage

 Clinical case examples are crucial to understand how

hemorrhage can occur in maxillofacial settings and how it is
managed in real-time.
Case 1: Severe Bleeding After Mandibular Fracture (Road
Traffic Accident)
Patient: 28-year-old male, no prior medical history
Incident: Motorcycle accident, hit face-first on the
pavement
Findings:
 Deep laceration on the chin
 Comminuted mandibular fracture
 Active arterial bleeding from the floor of the mouth
 Oxygen saturation dropped due to blood aspiration
Management:
 Immediate suctioning and airway secured via orotracheal intubation
 Bleeding identified from the **facial artery** branch
 Ligation of bleeding vessel
 Fracture stabilized with titanium plates
 Blood transfusion given (2 units)
Outcome:
 Successful recovery
 Wound healed well, no long-term complications

 Key note: Airway protection and early bleeding control saved the
patient’s life.
Case 2: Postoperative Hemorrhage After Third
Molar Extraction
Patient: 19-year-old female, previously healthy
Procedure: Surgical removal of impacted lower third molar
Day 1 Post-Op: Continuous oozing, slight swelling
Day 2 Post-Op: Sudden re-bleeding at night, blood clot expelled
Findings:
 Poorly formed clot ("dry socket" risk)
 Bleeding due to injury to **lingual artery branch**
Management:
 Re-cleaning of the socket
 Placement of hemostatic dressing (oxidized cellulose)
 Pressure applied for 30 minutes
 Patient advised on strict post-op care (no rinsing/spitting)
Outcome:
 Bleeding stopped, follow-up clean
 Full recovery in 10 days

 Key note: Post-op instructions and bleeding control techniques are

critical in dental surgery.
Case 3: Intraoperative Hemorrhage During Orthognathic
Surgery

Patient: 35-year-old male undergoing Le Fort I osteotomy for Class III

malocclusion
During Surgery:
• Profuse bleeding noted after maxillary down-fracture
• Bleeding from descending palatine artery
Management:
 Immediate packing and suction
 Artery clamped and cauterized
 Surgery continued after hemostasis
Outcome:
 Extended surgery duration
 No major complications post-op

 Key note: Knowledge of vascular anatomy prevents

complications and ensures rapid management.
Case 4: Delayed Hemorrhage in Warfarin Patient After
Implant Placement

Patient: 66-year-old male on long-term warfarin (atrial fibrillation)

Procedure: Dental implant placement in maxillary premolar region
Pre-op INR: 2.5 (therapeutic range but high risk)
Bleeding: Delayed bleeding 12 hours post-op, patient found soaked in
blood
Management:
 Local pressure applied immediately
 INR reassessed: elevated to 3.1
 Vitamin K administered, implant site reopened and cauterized
 Referral to hematologist for anticoagulant adjustment
Outcome:
 Bleeding controlled, but implant failed due to exposure
 Re-attempted after INR control and healed site

 Key note: High-risk patients must be carefully planned and

monitored; multidisciplinary coordination is key.
Conclusion
 Reference
1. Roberts I, et al. "The CRASH-2 trial: tranexamic acid for traumatic
hemorrhage." *Lancet*, 2010.
2. Shakur H, et al. "Mortality outcomes with antifibrinolytic use in trauma
patients." *JAMA Surgery*, 2010.
3. McGowan J, et al. "Management of traumatic hemorrhagic shock." *Journal of
Trauma and Acute Care Surgery*, 2015.
4. Schreiber MA, et al. "Trauma resuscitation: an evidence-based approach."
*Current Opinion in Critical Care*, 2008.
5. American College of Surgeons Committee on Trauma. "Advanced Trauma Life
Support (ATLS) Student Course Manual," 10th Edition.
 Group Members
1. Hermela Terefe...............................................................1368/13
2. Lulwa Mohammed..........................................................1374/13
3. Meron Afework...............................................................1361/13
4. Sara Abdella.....................................................................1375/13
5. Yedideya Zebene..............................................................1366/13
Thank You!

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