Hematoma Complication of Local Anesthesia Cause, Problems and Prevention February 6, 2013 By Dr.

r. 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:

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 section Hematoma for 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 in between 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. Clinical manifestations of the hematoma are intraoral: possible tissue discoloration and probable tissue swelling on the medial (lingual) aspect of the mandibular ramus.

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

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 or swelling 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 trismus. 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.