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Bonagua, Joachim Anne Clare G. DMD2E

Anesthesiology Lec March 7, 2014

Local anesthetics are frequently administered in dentistry and thus can be

expected to be a major source of drug-related complications in the dental office.

Additionally, the dentist will more often be confronted with the treatment of risk

patients; thus, the incidence of side effects can be expected to rise. 

Complications of Local Anesthesia

Anesthetic toxicity (overdose)

While rare in adults, young children are more likely to experience toxic reactions

because of their lower weight. Most adverse drug reactions occur within 5-10minutes of injection. Overdose of local anesthetics are caused by high blood

levels of anesthetic as a result of an inadvertent intravascular injection or

repeated injections. Local anesthetic overdose results in excitation followed by

depression of the central nervous system and to a lesser extent of the

cardiovascular system.

Early subjective symptoms of the central nervous system include dizziness,

anxiety and confusion and may be followed by diplopia, tinnitus, drowsiness and

circumoral numbness or tingling. Objective signs include muscle twitching,

tremors, talkativeness, slowed speech and shivering followed by overt seizureactivity. Unconsciousness and respiratory arrest may occur.

The initial cardiovascular system response to local anesthetic toxicity is an

increase in heart rate and blood pressure. As blood plasma levels of the

anesthetic increase, vasodilatation occurs followed by depression of the

myocardium with subsequent fall in blood pressure. Bradycardia and cardiac

arrest may follow.

Local anesthetic toxicity is preventable by following proper injection technique,

i.e., aspiration during slow injection. Clinicians should be knowledgeable of

maximum dosages based on weight. If lidocaine topical anesthetic is used it

should factored into the total administered dose as it can infiltrate into the

vascular system. After injection the patient should be observed for any possible

toxic response as early recognition and intervention are the keys to a successful

outcome.

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While generally safe, local anesthetic agents can be toxic if used in excessive

doses or administered improperly. Even when administered properly, patients

may still experience unintended reactions to local anesthetics.

Excessive doses may be unintentionally administered in several ways.

Repetitive (small) doses of local anesthetic to achieve an adequate level of

anesthesia may lead to eventual administration of toxic doses.

Injection of anesthesia in a confined space may result in excessive fluid

pressure that may damage nerves.

Doses intended for epidural or intra-support-tissue administration may be

accidentally delivered as intravascular injection, resulting in accelerated

systematic absorption.

The toxic effects of local anesthetics can be classified by localized and systemiceffects.

Toxicity:

Localized

A cause of local toxicity is allergic reaction to para-aminobenzoic acid (PABA).

These reactions range from urticaria to anaphylaxis. 

PABA is a metabolic product of the degradation of  Ester class of local

anesthetics, such as procaine (Novocaine), benzocaine, and, to a lesser degree,amide class anesthetics such as lidocaine, and prilocaine. It is also a metabolic

by-product of pramod methylparaben, a preservative in multi-dose vials of

lidocaine. When allergic response to injected anesthetics does occur, it is most

likely due to the ester class local anesthetics. The amide class of local

anesthetics is far less likely to produce allergic reaction. Use of topical

anesthetics for relief of eye pain can result in severe corneal damage.

Systemic

Systemic toxicity of local anesthetics can be described by the direct effects onthe immune system, blood (hematologic), central nervous system, 

and cardiovascular system. 

Immune system

As noted previously, allergic reaction to metabolic break-down of anesthetic

agents and preservatives (PABA) can cause anaphylaxis. 

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Hematologic

Methemoglobinemia is a process where iron in hemoglobin is altered, reducing

its oxygen-carrying capability, which produces cyanosisand symptoms

of  hypoxia. Benzocaine, lidocaine, and prilocaine all produce this effect,

especially benzocaine.

Central Nervous System

Systemic toxic reactions to locally administered anesthetics are progressive as

the level of the anesthetic agent in the blood rises. Initial symptoms suggest

some form of central nervous system excitation such as a ringing in the ears

(tinnitus), a metallic taste in the mouth, or tingling or numbness of the mouth.

Advanced symptoms include motor twitching in the periphery followed by grand

mal seizures, coma, and eventually respiratory arrest.

Cardiovascular

Cardiovascular effects are primarily those of direct myocardial depression

and bradycardia, which may lead to cardiovascular collapse. At extremely high

levels, cardiac arrhythmia or hypotension and cardiovascular collapse occur.

Management

Intravenous lipid emulsions may be useful for cardiotoxicity; however, the

evidence at this point is still limited.

This treatment is termed lipid rescue. This method of toxicity treatment was

invented by Dr. Guy Weinberg in 1998, and had not been widely used until after

the first published successful rescue in 2006. Since then more than a dozen

case reports have been published. Recently, lipid therapy held the cover of the

May 2008 issue of Anesthesia & Analgesia, where the bulk of the issue had to

do with this life saving technique.

Though most reports to date have used Intralipid, a commonly available

intravenous lipid emulsion, other emulsions, such as Liposynand Medialipid havealso been shown to be effective.

There is ample supporting animal evidence and human case reports of

successful use in this way. In the UK, efforts have been made to publicise this

use more widely and lipid rescue has now been officially promoted as a

treatment by the Association of Anaesthetists of Great Britain and Ireland.

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There is now one published case report of successful treatment of

refractory cardiac arrestin bupropion and lamotrigine overdose using lipid

emulsion.

Although lipid rescue mechanism of action is not completely understood it may

be that the added lipid in the blood stream acts as a sink, allowing for theremoval of lipophilic toxins from affected tissues. This theory is compatible with

two studies on lipid rescue for clomipramine toxicity in rabbits and with a clinical

report on the use of lipid rescue in veterinary medicine to treat a puppy with

moxidectin toxicosis.

Allergic reactions

Allergic reactions are sensitivities to substances called allergens that come intocontact with the skin, nose, eyes, respiratory tract, and gastrointestinal tract.

They can be breathed into the lungs, swallowed, or injected.

Although allergic reactions to injectable amide local anesthetics are rare,

patients may exhibit a reaction to the bisulfite preservative added to anesthetics

containing epinephrine. Patients with a sulfa allergy should not receive

articaine. Patients may also exhibit allergic reactions to benzocaine topical

anesthetics. Allergies can manifest in a variety of ways including urticaria,

dermatitis, angioedema, fever, photosensitivity and anaphylaxis.

Considerations

Allergic reactions are common. The immune response that causes an allergic

reaction is similar to the response that causes hay fever. Most reactions happen

soon after contact with an allergen.

Many allergic reactions are mild, while others can be severe and life-threatening.

They can be confined to a small area of the body, or they may affect the entire

body. The most severe form is called anaphylaxis or anaphylactic shock. Allergic

reactions occur more often in people who have a family history of  allergies. 

Although first-time exposure may only produce a mild reaction, repeated

exposures may lead to more serious reactions. Once a person has had an

exposure or an allergic reaction (is sensitized), even a very limited exposure to

a very small amount of allergen can trigger a severe reaction.

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Most severe allergic reactions occur within seconds or minutes after exposure to

the allergen. However, some reactions can occur after several hours,

particularly if the allergen causes a reaction after it has been eaten. In very rare

cases, reactions develop after 24 hours.

Anaphylaxis is a sudden and severe allergic reaction that occurs within minutes

of exposure. Immediate medical attention is needed for this condition. Without

treatment, anaphylaxis can get worse very quickly and lead to death within 15

minutes.

DO NOT

  Do NOT assume that any allergy shots the person has already received

will provide complete protection.

  Do NOT place a pillow under the person's head if he or she is having

trouble breathing. This can block the airways.

  Do NOT give the person anything by mouth if the person is having trouble

breathing.

Paresthesia

Paresthesia is a sensation of tingling, tickling, prickling, pricking, or burning of aperson's skin with no apparent long-term physical effect. The manifestation of a

paresthesia may be transient or chronic.

The most familiar kind of paresthesia is the sensation known as "pins and

needles" or of a limb "falling asleep". A less well-known but still fairly common

paresthesia is formication. 

Paresthesia or "persistent anesthesia" is a transient or potentially permanent

condition of extended numbness after administration of local anesthesia and the

injected anesthetic has terminated.

Potential causes include trauma induced to the nerve sheath during

administration of the injection, hemorrhage about the sheath, type of anesthetic

used, or administration of anesthetic potentially contaminated with alcohol or

sterilizing solutions.

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Paresthesia is the persistence of anesthetic symptoms beyond the expected

duration. It can be caused by trauma to the nerve by the needle during

injection. It can also be caused by hemorrhage in and around the

nerve. Reports of paresthesia are more common with articaine and prilocaine

and thus nerve block should be avoided in children with these local

anesthetics. The tongue and lips are the most common areas affected. Most

cases resolve in 8 weeks without treatment.

TREATMENT

Medications offered can include the immunosuppressant prednisone, 

intravenous gamma globulin (IVIG), anticonvulsants such

asgabapentin or Gabitril and antiviral medication, among others, according to

the underlying cause.

In addition to treatment of the underlying disorder, palliative care can include

the use of topical numbing creams, such as lidocaine or prilocaine. Care must

be taken to apply only the necessary amount, as excess can contribute to the

condition. Otherwise, these products offer extremely effective, but short-lasting,

relief from the condition.

Paresthesia caused by shingles is treated with appropriate antiviral medication.

Postoperative soft tissue injury

Accidental biting or chewing of the lip, tongue or cheek is a problem seen in

very young pediatric mentally or physically disabled patients. Soft tissue

anesthesia lasts longer than pulpal anesthesia and may be present for up 4

hours after local anesthesia administration. The most common area of trauma

is the lower lip and to a lesser extent the tongue, followed by the upper lip.

Infection

Infection, especially a needle track infection, which manifests itself pretty late,

can occur. To prevent infection it is recommend that needles not be reused in apatient's mouth. Fresh needles should always be used, and the area to be

penetrated should be cleaned prior to insertion of the needle.

Complications from Nerve Block

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Facial nerve paralysis may occur temporarily with a nerve block. Again, reassure

the patient that the condition will disappear as the anesthetic agent is

metabolized.

Complications resulting from a maxillary nerve block are rare, but may include:

-  regional sixth nerve block, results in temporary teplopia for the patient

-  hematoma (rare)

-  retrobulbar block (rare)

-  optic nerve block, which can result in temporary blindness (rare)

Important complications of local anaesthesia

  Pain

  Bleeding and haematoma formation

  Nerve injury due to direct injury

  Infection  Ischaemic necrosis

Several preventive measures can be followed:

  Select a local anesthetic with a duration of action that is appropriate for thelength of the planned procedure.

  Advise the patient and accompanying adult about the possibility of injury if thepatient bites, sucks or chews on the lips, tongue and cheek. They shoulddelay eating and avoid hot drinks until the effects of the anesthesia are totally

dissipated.

  Reinforce the warning with patient stickers and by placing a cotton roll in themucobuccal fold if anesthesia symptoms persist.

  The management of soft tissue trauma involves reassuring the patient andparent (it's okay if the tissue turns white), allowing up to a week for the injuryto heal, and lubricating the area with petroleum jelly or antibiotic ointment toprevent drying, cracking and pain.

COMPLICATIONS ATTRIBUTED TO NEEDLE INSERTION

SYNCOPE

Fainting, "blacking out," or syncope is the temporary loss of consciousness

followed by the return to full wakefulness. This loss of consciousness may be

accompanied by loss of muscle tone that can result in falling or slumping over.

To better understand why fainting can occur; it is helpful to explain why

somebody is awake.

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The brain has multiple parts, including two hemispheres, the cerebellum, and

the brain stem. The brain requires blood flow to provide oxygen

andglucose (sugar) to its cells to sustain life. For the body to be awake, an area

known as the reticular activating system located in the brain stem needs to be

turned on, and at least one brain hemisphere needs to be functioning. For

fainting or syncope to occur, either the reticular activating system needs to lose

its blood supply, or both hemispheres of the brain need to be deprived of blood,

oxygen, or glucose. If blood sugar levels are normal blood flow must be briefly

disrupted to the whole brain or to the reticular activating system.

Fainting is not caused by head trauma, since loss of consciousness after ahead

injury is considered a concussion. However, fainting can cause injury if the

person falls and hurts themselves, or if the faint occurs while participating in an

activity like driving a car.

Fainting is differentiated from seizure, during which patients may also lose

consciousness.

CAUSES

Decreased blood flow to the brain can occur because 1) the heart fails to pump

the blood; 2) the blood vessels don't have enough tone to maintain blood

pressure to deliver the blood to the brain; 3) there is not enough blood or fluidwithin the blood vessels; or 4) a combination of reasons one, two, or three

above.

SIGNS AND SYMPTOMS

With fainting (syncope), the patient is unaware that they have passed out and

fallen to the ground. It is only afterward that they understand what has

happened.

There may be symptoms or signs before the syncopal episode, which may

include:

  The person may feel lightheaded, nauseated, sweaty, or weak. There may

be a feeling of  dizziness or vertigo(with the room spinning), vision may

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fade or blur, and there may be muffled hearing and tingling sensations in

the body.

  With pre-syncope or a near-faint, the same symptoms will occur, but the

person doesn't quite lose consciousness.

During the episode, when the person is unconscious, there may a few twitches

of the body which may be confused with seizure activity.

The person may have some confusion after wakening but it should resolve

within a few seconds.

After a syncopal episode, there should be a quick return to normal mental

function, though there may be other signs and symptoms depending upon the

underlying cause of the faint. For example, if the individual is in the midst of a

heart attack, he or she may complain of  chest pain or pressure.

DIAGNOSIS

As with most medical conditions, the history is the key in finding out why a

patient faints. Since most episodes of syncope do not occur while the patient is

wearing a heart monitor in front of a medical provider, it is the description of

how the patient felt and what bystanders or family members witnessed that will

give clues to the diagnosis.

Physical examination will try to look for signs that will give direction to the

potential diagnosis. Heart monitoring may be done to look for heart rhythm

disturbances. Blood pressure may be checked both lying and standing to

uncover orthostatic hypotension. Examination of the heart, lung, and neurologic

system may uncover a potential cause if these are abnormal.

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Initial diagnostic tests may include an electrocardiogram (EKG) and screening

blood tests like a complete blood count(CBC), electrolytes, glucose, and kidney

function tests. Thyroid blood tests may be performed.

Heart rhythm disturbances may be transient and not always evident at time of

the examination. On occasion, a heart monitor (Holter monitor) can be worn as

an outpatient for 24 or 48 hours or for up to 30 days (event monitor). Abnormal

heart rhythms and rates may be uncovered as the potential cause of syncope.

A tilt-table test can be used to uncover orthostatic hypotension and is usually

done on an outpatient basis. The patient is placed at an angle on a table for 30-

45 minutes (every institution has its own protocol) and blood pressure andpulse rate are measured with the patient in different positions.

Depending upon the suspicions of the health care provider, imaging may be

done of the brain using computerized tomography (CT scan) or magnetic

resonance imaging (MRI).

Often these tests are normal and a presumptive diagnosis is made of a non life-threatening event.

However, the medical care provider may decide, in consultation with the patient, whether further

testing is required and whether testing should occur in the hospital or as an outpatient. It may be

reasonable in some cases to take a watchful waiting approach and not proceed with any further

evaluation.

Can fainting (syncope) be prevented?

Depending upon the cause, there may be opportunity to prevent fainting spells.

For example:

  Patients who have had a vasovagal episode may be aware of the warning

signs and be able to sit or lie down before passing out and avert the

fainting episode.

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  For older patients with orthostatic hypotension, waiting for a second after

changing positions may be all that is needed to allow the body's reflexes to

react.

  Medications may be adjusted if they are thought to be the potential cause

of fainting or syncope.

  Adequate fluid intake may be enough to prevent dehydration as the cause

for syncope.

  There is an increased awareness of syncope and sudden death in younger

athletes due to hypertrophic cardiomyopathy. A variety of screening tests

are available to assess potential risk for sudden death, but no consensus

yet as to who and when to screen athletes has emerged.

MUSCLE TRISMUS

Trismus, or lockjaw, refers to reduced opening of the jaws caused by spasm of

the muscles of mastication, or may generally refer to all causes of limited

mouth opening. It is a common problem with a variety of causes, and may

interfere with eating, speech, oral hygiene, and could alter facial appearance.

There is an increased risk of aspiration. Temporary trismus is much morecommon than permanent trismus, and may be distressing and painful, and limit

or prevent medical examination or treatments requiring access to the oral cavity.

Classically, the definition of trismus is an inability to open the mouth due to

muscular spasm, but more generally it refers to limited mouth opening of any

cause. Another definition of trismus is simply a limitation of movement.

Historically and commonly, the term lock jaw  was sometimes used as a

synonym for both trismus and tetanus. Normal mouth opening ranges from 35

to 45 mm. Males usually have slightly greater mouth opening than females. (40-

60mm)=(avg-35mm). The Normal Lateral movement is (8-12mm). Some have

distinguished mild trismus as 20-30 mm interincisal opening, moderate as 10-

20 mm and severe as less than 10 mm.

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Differential diagnosis

Traditionally causes of trismus are divided into intra-articular (factors within

the temporomandibular joint [TMJ]) and extra-articular .

Intra-Articular Causes 

-  Ankylosis

  True Bony Ankylosis: can result from trauma to chin, infections and from

prolonged immobilization following condylar fracture

  Treatment- several surgical procedures are used to treat bony ankylosis,

E.g.: Gap arthroplasty using interpositional materials between the cut

segments.

  Fibrous Ankylosis: usually results due to trauma and infection

  Treatment- trismus appliances in conjunction with physical therapy.

-   Arthiritis Synovitis

-  Meniscus Pathology

Extra-Articular Causes

 Infection

  Odontogenic- Pulpal

  Periodontal

  Pericoronal

  Non-Odontogenic- Peritonsillar abscess

  Tetanus

  Meningitis

  Brain abscess

  Parotid abscess

  The hallmark of a masticatory space infection is trismus. Or infection inanterior compartment of lateral pharyngeal space results in trismus. If these

infections are unchecked, can spread to various facial spaces of the head &

neck and lead to serious complications such as cervical cellulitis/

mediastinitis.

  Treatment: Elimination of etiologic agent along with antibiotic coverage

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  Trismus or lock jaw due to masseter muscle spasm, can be a primary

presenting symptom in tetanus, Caused by clostridium tetani, where

tetanospasmin (toxin) is responsible for muscle spasms.

  Prevention: primary immunization (DPT)

Dental Treatment

  Dental trismus is characterized by a difficulty in opening the jaw. It is a

temporary condition with a duration usually not longer than two weeks.

Dental trismus results from some sort of insult to the muscles of mastication,

such as opening the jaw for a period of time or having a needle pass through

a muscle. Typical dental anesthesia to the lower jaw often involves the

needle passing into or through a muscle. In these cases it is usually the

medial pterygoid or the buccinator muscles.

  Oral surgery procedures, as in the extraction of lower molar teeth, may

cause trismus as a result either of inflammation to the muscles of

mastication or direct trauma to the TMJ.

  Barbing of needles at the time of injection followed by tissue damage on

withdrawal of the barbed needle causes post-injection persistent paresthesia,

trismus and paresis.  Treatment: in acute phase:

  Heat therapy

  Analgesics

  A soft diet

  Muscle relaxants (if necessary)

  Note: When acute phase is over the patient should be advised to

initiate physiotherapy for opening and closing mouth.

Trauma

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Fractures, particularly those of the mandible and Fractures of zygomatic arch

and zygomatic arch complex, Accidental incorporation of foreign bodies due to

external traumatic injury Treatment: fracture reduction, removal of foreign

bodies with antibiotic coverage.

TMJ Disorders

  Extra-capsular disorders – Myofascial Pain Dysfunction Syndrome

  Intra-capsular problems – Disc Displacement, Arthritis, Fibrosis, .. etc.

  Acute closed locked conditions – displaced meniscus

Tumors and Oral care

Rarely, trismus is a symptom of nasopharyngeal or infratemporal tumors/

fibrosis of temporalis tendon, when patient has limited mouth opening, always

premalignant conditions like oral submucous fibrosis (OSMF) should also be

considered in differential diagnosis.

Drug Therapy

Succinyl choline, phenothiazines and tricyclic antidepressants causes trismus as

a secondary effect. Trismus can be seen as an extra-pyramidal side-effect of

metaclopromide, phenothiazines and other medications.

Radiotherapy and Chemotherapy

  Complications of Radiotherapy:

  Osteoradionecrosis may result in pain, trismus, suppuration and

occasionally a foul smelling wound.

  When muscles of mastication are within the field of radiation, it leads to

fibrosis and result in decreased mouth opening.

  Complications of Chemotherapy:

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  Oral mucosal cells have high growth rate and are susceptible to the toxic

effects of chemotherapy, which lead to stomatitis.

Congenital / Developmental Causes

  Hypertrophy of coronoid process causes interference of coronoid against the

anteromedial margin of the zygomatic arch.

  Treatment: Roronoidectomy

  Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot

and mouth abnormalities and trismus.

Miscellaneous disorders

  Hysteric patients: Through the mechanisms of conversion, the emotional

conflict are converted into a physical symptom. E.g.: trismus

  Scleroderma: A condition marked by edema and induration of the skin

involving facial region can cause trismus

Common causes

  Pericoronitis (inflammation of soft tissue around impacted third molar) is the

most common cause of trismus.

  Inflammation of  muscles of mastication. It is a frequent sequel to surgical

removal of mandibular third molars (lower wisdom teeth). The condition is

usually resolved on its own in 10–14 days, during which time eating and oral

hygiene are compromised. The application of heat (e.g. heat bag extraorally,

and warm salt water intraorally) may help, reducing the severity and

duration of the condition.

  Peritonsillar abscess, a complication of  tonsillitis which usually presents withsore throat,dysphagia, fever, and change in voice.

  Temporomandibular joint dysfunction (TMD).

  Trismus is often mistaken as a common temporary side effect of

many stimulants of the sympathetic nervous system. Users

of  amphetamines as well as many other pharmacological agents commonly

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report bruxism as a side-effect; however, it is sometimes mis-referred to as

trismus. Users' jaws do not lock, but rather the muscles become tight and

the jaw clenched. It is still perfectly possible to open the mouth.[9] 

  Submucous fibrosis. 

OTHER CAUSES

  Acute osteomyelitis

  Ankylosis of the TMJ (fibrous or bony)

  Condylar fracture or other trauma.

  Gaucher disease which is caused by deficiency of the

enzyme glucocerebrosidase. 

  Giant cell arteritis

  Infection

  Local anesthesia (dental injections into the infratemporal fossa)

  Needle prick to the medial pterygoid muscle

  Oral submucous fibrosis.

  Radiation therapy to the head and neck.

  Tetanus, also called lockjaw  for this reason

  Malignant hyperthermia

  Malaria severa

  Secondary to neuroleptic drug use

  Malignant otitis externa

  Mumps

  Peritonsillar abscess

  Retropharyngeal or parapharyngeal abscess

  Seizure

TREATMENT

Treatment requires treating the underlying condition with dental

treatments, physical therapy, and passive range of motion devices. Additionally,

control of symptoms with pain medications (NSAIDs), muscle relaxants, and

warm compresses may be used. Splints have been used.

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Hyperesthesia

Hyperesthesia is an increased sensitivity to the stimuli. It could be elevated

sensation of touch, hearing, smell or vision for instance. Increased touch

sensitivity is called tactile sensitivity or tactile defensiveness while auditory

sensitivity is the name given to increased sound sensation.

Causes

Excessive consumption of caffeine can temporarily induce this condition in

humans, due to excessive stimulaton of the spinal cord, as well as the cortex

and medulla in the central nervous system. However, this is far from the only

cause, and usually wears off after 3-5 hours.

In some cases, an outside stimulus is not involved and it is triggered by

overstimulation of the area of the brain involved in sensation, in which case the

hyperesthesia should resolve within a few hours. Whenever hyperesthesia

occurs, it is advised that the patient may lie in a cool, quiet, dark place to

resolve the condition. In some, aerobic breathing exercises and physiotherapy is

beneficial.

Chronicity

But when hyperesthesia manifests as chronic, a neurologist is consulted who

may prescribe medications such as analgesics to dull sensation, anti-seizure

medications, and also anti-anxiety drugs.

Tactile hyperesthesia

Tactile sensitivity could occur in ADHD, fragile X syndrome and autism.

According to a large study conducted at Hebrew University, 69 percent of boys

with ADHD also had tactile hyperesthesia. It may be present as a symptom in

neurologic disorders such as herpes family viral infections, peripheral

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neuropathy and radiculopathies. When the respective neurologic disorder is

treated, hyperesthesia is simultaneously treated. Tactile sensitivity in children is

treated by therapy under the guidance of a trained occupational therapist. In

the process the child is guided through structured but fun-filled activities thatchallenge the child’s sensation, according to the Sensory Processing Disorder

Foundation.

Treatment

Treatment is based on underlying cause of the symptom. If the symptom is

treated, hyperesthesia in other words could also be treated. For example,

hyperesthesia, which occurs in vitamin B12 deficiency, is treated by prescribing

vitamin B12 supplements.

Hematoma

  A hematoma is a collection of blood outside of a blood vessel.

  Symptoms of hematomas depend upon their location and whether

adjacent structures are affected by the inflammation and swelling

associated with the bleeding.

  Treatment of a hematoma depends upon which organ or body tissue is

affected.

  Superficial hematomas of the skin and soft tissue, such as muscle, may be

treated with rest, ice, compression, and elevation (RICE). Heat may also

be considered.

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What is a hematoma?

By definition, a hematoma is a collection of blood outside of a blood vessel. It

occurs because the wall of a blood vessel wall, artery, vein or capillary, has

been damaged and blood has leaked into tissues where it does not belong. The

hematoma may be tiny, with just a dot of blood or it can be large and cause

significant swelling.

The blood vessels in the body are under constant repair. Minor injuries occur

routinely and the body is usually able to repair the damaged vessel wall by

activating the blood clotting cascade and forming fibrin patches. Sometimes the

repair fails if the damage is extensive and the large defect allows for continued

bleeding. As well, if there is great pressure within the blood vessel, for example

a major artery, the blood will continue to leak through the damaged wall and

the hematoma will expand.

Blood that escapes from within a blood vessel is very irritating to the

surrounding tissue and may cause symptoms of inflammation including pain,

swelling, and redness. Symptoms of a hematoma depend upon their location,

their size, and whether they cause associated swelling or edema.

What are the types of hematomas?

Hematomas are often described based upon their location.

The most dangerous hematomas are those that occur inside the skull. Because

the skull is an enclosed box, anything that takes up space increases pressure

within that box and potentially impairs the ability of the brain to function.

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Epidural hematomas 

These occur because of trauma, often to the temple, where the middle

meningeal artery is located. Bleeding accumulates in the epidural space, outsidethe “dura” which is the lining of the brain. Because of the way the dura is

attached to the skull, small hematomas can cause significant pressure and brain

injury.

Subdural hematomas 

These may also occur because of trauma but the injury is usually to the veins in

the brain. This causes a slower leak of blood, which enters the “subdural” space

below the dura. The space below the dura has much more room for blood to

accumulate before brain function suffers. As people age, they lose some brain

tissue and the subdural space is relatively larger. Bleeding into the subdural

space may be very slow, gradually stop, and not cause acute symptoms. These

 “chronic” subdural hematomas are often found incidentally on computerized

tomography (CT) scans as part of a patient evaluation for confusion or because

another traumatic incident occurred. However, subdural hematomas may belarge, cause associated brain swelling, and may be lethal.

Intracerebral hematomas 

These occur within the brain tissue itself. Intracerebral (intra= within +

cerebrum=brain) hematomas may be due to bleeding from uncontrolled high

blood pressure, an aneurysm leak or rupture, trauma,tumor, or stroke. 

Scalp hematomas 

These occur on the outside of the skull and often can be felt as a bump on the

head. Because the injury is to the skin and muscle layers outside of the skull,

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Pelvic bone fractures 

These can also bleed significantly since it takes a large amount of force to break

these bones and nearby veins and arteries can also be damaged. It is verydifficult to compress the area to decrease the amount of bleeding. Pelvic

hematomas are hidden and the amount of blood loss may be difficult to assess.

Intramuscular hematomas 

It can be very painful due to the amount of swelling and inflammation. Some

muscles are surrounded by tough bands of tissues. If enough bleeding occurs,

the pressure within these compartments can increase to the point that a

 “compartment syndrome”  can occur. In this situation, the blood supply of the

muscle is compromised and the muscle and other structures such as nerves can

be permanently damaged. This is most commonly seen in the lower leg and

forearm. Compartment syndrome may also be seen as a complication of

fractures. This is a true surgical emergency and medical care should be

accessed immediately if compartment syndrome is suspected. For the health

care professional, one clue to think of the diagnosis is finding a patient whosepain is out of proportion to the physical findings.

Subungual hematomas 

These are the result of crush injuries to the fingers or toes. Bleeding occurs

under the fingernail or toenail and since it is trapped, pressure builds causing

pain. Trephination, or drilling a hole through the nail to remove the blood clot,

relieves the pressure and resolves the injury. Over time, the nail repairs itself.

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Bruises and contusions of the skin (ecchymosis) are terms that describe

subcutaneous hematomas. These occur due to trauma or injuries to the

superficial blood vessels under the skin. Individuals who take anticoagulant

medication are more prone to subcutaneous hematomas.

Intra-abdominal hematomas and hemorrhage may be due to a variety of

injuries or illnesses. Regardless of how the blood gets into the abdomen, the

clinical finding is peritonitis (irritation of the lining of the abdomen). Hematomas

may occur in solid organs such as the liver, spleen, or kidney. They may occur

within the walls of the bowel, including the small intestine (duodenum, jejunum,

and ileum) or the large intestine (colon). Hematomas may also form within the

lining of the abdomen called the peritoneum or behind the peritoneum in the

retroperitoneal space (retro=behind).

Passing clots or hematomas 

It is a common complaint when women menstruate. Blood can accumulate in

the vagina as part of the normal menses and instead of flowing out immediately,

it may form small blood clots. Passing blood clots after delivering a baby is alsorelatively common. However, vaginal bleeding and passing blood clots or

hematomas while pregnant is not normal and should be a sign to seek

immediate medical attention.

Hematomas may occur anywhere in the body. Regardless of how a hematoma is

described or where it is located, it remains a collection of clotted blood outside

of a blood vessel.

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REFERENCES:

http://www.dentalcare.com/en-US/dental-education/continuing-

education/ce325/ce325.aspx?ModuleName=coursecontent&PartID=9&SectionID

=-1

http://www.patient.co.uk/doctor/important-complications-of-anaesthesia

http://ccnmtl.columbia.edu/projects/aegd/mod01_atla_comp.html