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Hematoma Complication of Local Anesthesia Cause, Problems and Prevention

February 6, 2013 By Dr. Chetan Leave a Comment

Hematoma is the effusion of the blood into the extravascular spaces, resulting from the

nicking of a blood vessel, either an artery or vein, during the injection of a local anesthetic

in the oral cavity. A hematoma developing subsequent to the nicking of an artery usually

increases rapidly in size until treatment is done to it, because of the significantly greater

blood pressure within the artery. Nicking a vein may or may not result in the formation of a

hematoma. Tissue density surrounding the injured vessel is a determining factor for the

Hematoma formation and its size.

a) Cause of Hematoma How it is formed

b) Problems Due to Hematoma

c) Prevention of Hematoma

d) Management of Hematoma

Discussed below are the cause, problem, prevention and the management techniques of

Hematoma that is caused due to improper LA technique. Hematoma can occur anywhere in

the body, wherever the injection is given and it ruptures the wall of the blood vessel in such

a way that the repair of it does not happen quickly, and the blood is lost continuously into

the tissues where it actually does not belong.

Cause of Hematoma

Hematoma is caused due to the increased pressure of the blood vessels, especially the

maxillary and mandibular posterior arteries, where the puncture after the posterior superior

alveolar nerve block, or the inferior alveolar nerve block leads to the formation, and

comparably the areas of hard palate where the density of the tissue is much higher, the

hematoma rarely develops in those areas. The tissues surrounding these vessels more

readily take significant volumes of blood and enlarge in size. The blood effuses from vessels

until extravascular exceeds intravascular pressure or clotting occurs. The Hematomas that

are formed after the inferior alveolar nerve block are usually only visible intraorally,

whereas the hematomas after the Posterior Superior Alveolar Nerve block are visible

extraorally.

Problems due to Hematoma

Hematoma rarely causes any significant problems, but there is a bruise resulted intraorally

and nothing is usually visible extraorally. Possible complications of hematoma include

Trismus and pain. The swelling and discoloration of the region usually subside within 7 to 14

days. A hematoma causes an inconvenience to the patient and an embarrassment to the

person administering the drug.

Prevention of Hematoma

Hematoma does not always happen, but at the same time it is not a condition that can be

prevented always. Still, there are a few precautions and ways using which one can try to

prevent the Hematomas from being formed after the nerve block administration:

Having the proper knowledge of the normal anatomy involved in the proposed

injection site is very important. Certain techniques have a greater risk of visible

hematoma. The PSA nerve block is the most common, followed by the Inferior Alveolar

Nerve Block and the mental/incisive nerve blocks too are the other common injection

techniques after which the Hematoma is seen.

If at all the patients anatomy is a bit different, you need to modify the injection

technique. For example, the depth of penetration for a Posterior Superior Alveolar

nerve block may be decreased in a patient with smaller facial characteristics.

Use a short needle for the PSA nerve block to decrease the risk of hematoma. Minimize the number of needle penetrations into tissue, as this damages the walls of

the blood vessels more. Try to give a single injection with a proper insertion, rather

than multiple trials.

Never use a needle as a probe in tissues.

Management of the Hematoma as Local Anesthesia Complication Immediate and

Subsequent

February 19, 2013 By Dr. Chetan Leave a Comment

Hematoma is the effusion of the blood from the vessels, due to any injury or puncture

mainly during the administration of the Local Anesthesia. Check the sectionHematomafor

the causes, problems and ways to prevent the Hematoma formation. Below are the ways

how one can manage the Hematoma if it occurs after the Local Anesthesia is administered.

The two ways of management of Hematoma are:

a) Immediate Management of Hematoma due to Local Anesthesia

b) Subsequent Management of Hematoma due to Local Anesthesia

It depends a lot on the timing after the Local Anesthesia, when the Hematoma is formed

and when you detect it. If at all the hematoma formation is detected immediately after the

LA is administered, one can apply finger pressure on particular areas based on the LA given,

but on the later stages there are different precautions and steps to be followed if the

Hematoma doesnt subside immediately.

Immediate Management of Hematoma

Whenever local anesthesia is given, and this is followed by the formation of a swelling of

any size, its advised to apply direct pressure on the site where there is the swelling or

bleeding or the accumulation of blood. For most of the cases, the blood vessel lies inbetween the skin and bone, and when the injection leads to bleeding, the pressure has to be

applied in these areas for more than 2 minutes. This way of management would effectively

stops the bleeding.

Hematoma due to Inferior Alveolar Nerve Block: Whenever hematoma occurs due to the

administration of the Inferior alveolar nerve block, the pressure has to be applied to the

medial aspect of the mandibular ramus. C linical manifestations of the hematoma are

intraoral: possible tissue discoloration and probable tissue swelling on the medial (lingual)

aspect of the mandibular ramus.

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Hematoma due to Anterior Superior alveolar (Infraorbital) nerve block: Pressure has to be

applied to the skin directly over the Infraorbital Foramen. Clinical manifestation is

discoloration of the skin below the lower eye lid. Hematoma is unlikely to arise with Anterior

Superior Alveolar nerve block because the technique described requires application of

pressure to the injection site throughout drug administration and for a period of 2 to 3

minutes after, thus there is no potential injury or cause for Hematoma.

Hematoma due to Incisive (mental) nerve block: Just like the ASA nerve block, here the

pressure is applied directly over the mental foramen, on the skin or mucous membrane

while administering the local anesthesia, and thus the risk of Hematoma formation is largely

reduced. Clinical manifestations are discoloration of skin over the mental foramen orswelling in the mucobuccal fold in the region of the mental foramen.

Hematoma due to Buccal nerve block or any palatal injection: Place pressure at the site of

bleeding, and it would slowly get reduced. In these injections the clinical manifestations of

hematoma are usually visible only within the mouth.

Hematoma due to Posterior superior alveolar nerve block: The Posterior Superior Alveolar

(PSA) nerve block usually produces the largest and most esthetically unappealing

Hematoma. The Infratemporal Fossa, into which bleeding occurs, is a place that can

accommodate a large volume of blood. There is a colorless swelling that appears on the side

of the face, usually a few minutes after the LA administration, and it is only then the

Hematoma is recognized. The size increases over a period of days, both inferiorly and

anteriorly towards the lower front region of the cheek. Due to the location of the blood

vessels that are involved, it becomes difficult to apply pressure on the site where the

bleeding is occurring. It is also relatively difficult to apply pressure directly to the posterior

superior alveolar artery (the primary source of bleeding), the facial artery, and the

pterygoid plexus of veins. They are located posterior, superior, and medial to the maxillary

tuberosity. Bleeding normally ceases when external pressure on the vessels exceeds the

internal pressure or when clotting occurs. Digital pressure can be applied to the soft tissues

in the mucobuccal fold as far distally as can be tolerated by the patient (without eliciting a

gag reflex). Apply pressure in a medial and superior direction. If available, ice should be

applied (extraorally) to increase pressure on the site and help constrict the vessel.

Subsequent Management of Hematoma

Once you have identified Hematoma, and the immediate steps are taken, the patient may

be discharged after the bleeding stops. Note the hematoma on the patients dental chart.Advise the patient about possible soreness and limitation of movement (trismus). If either

of these develops, begin treatment as described for tr ismus. There will likely be

discoloration as a result of extravascular blood elements, which gradually gets resorbed

over 7 to 14 days.

If there is any soreness, advise the patient to have any analgesic such as Aspirin. After the

incident, try to avoid applying heat to that area for at least 6 hours, because heat produces

vasodilation, and this may further increase the size of the Hematoma. Heat may be applied

to the region beginning the next day. It serves as an analgesic, and its vasodilating

properties may increase the rate at which blood elements are resorbed, although its benefits

are debatable.

The patient should apply warm moist towels to the affected area for 20 minutes every hour.

After the recognition of the hematoma formation, initially Ice may be applied, as it would

act as both an analgesic and a vasoconstrictor, and it may aid in minimizing the size of the

hematoma.

Time (tincture of time) is the most important element in managing a hematoma. With or

without treatment, a hematoma will be present for 7 to 14 days. Avoid additional dental

therapy in the region until symptoms and signs resolve.