Top tips for managing the bleeding patient in primary care

ntroductionIn previous oral surgery-related top tips, we have discussed measures to manage oral surgery complications in primary care. 1 This short paper builds on from these tips and outlines specific strategies to manage the patient who has prolonged or abnormal bleeding following soft tissue surgery or exodontia, and provides management advice to anticipate, avoid and manage prolonged or excessive postoperative bleeding. HaemostasisThere are three steps in the normal haemostatic process: 1. Vascular constriction 2. Platelet aggregation 3. Activation of the coagulation cascade to form a fibrin clot. Types of postoperative bleedingThere are three types of postoperative bleeding: 1.Primary bleeding occurs perioperatively due to the surgical intervention/trauma (and may be excessive or prolonged due to complicating local factors or systemic factors) 2. Reactionary bleeding occurs 2-3 hours after surgery as the constrictor effects on the blood vessels of the adrenaline from the local anaesthetic diminish.This may also result from the patient not adhering to the postoperative instructions for wound care leading to disruption of the blood clot/coagulum 3. Secondary bleeding occurs 7-10 days after surgery due to infection at the surgical site which becomes inflamed and hyperaemic. Risk factors for postoperative bleedingRisk factors for haemorrhage can be considered in relation to timing of surgery. 2 1. Preoperative risk factors -eg medical complications, anticoagulant or antiplatelet medication, hypertension 2. Perioperative risk factors -eg traumatic extraction, soft tissue laceration, large vessel disruption, oral antral communication, local vascular abnormalities or pathological lesions 3. Postoperative risk factors -eg local infection or local pathology, retained root or mobile bone fragment, physical trauma to socket disrupting the clot or failure to follow post operative instructions for wound care.