1

EC. Bleeding

The average adult blood volume represents 7% of body weight (or 70 ml/kg of body weight).
Estimated blood volume (EBV) for a 70 kg person is approximately 5 l. Blood volume varies
with age and physiologic state. When indexed to body weight, older individuals have a smaller
blood volume. Children have EBVs of 8–9% of body weight, with infants having an EBV as
high as 9–10% of their total body weight.

Estimating blood loss is complicated by several factors, including urinary losses and the
development of tissue edema. Massive hemorrhage may be defined as loss of total EBV within a
24-hour period, or loss of half of the EBV in a 3-hour period.

Bleeding is the name commonly used to describe blood loss. It can refer to blood loss inside the
body (internal bleeding) or blood loss outside of the body (external bleeding).

Bleeding may occur:

 Inside the body when blood leaks from blood vessels or organs
 Outside the body when blood flows through a natural opening (such as the vagina,
mouth, or rectum)
 Outside the body when blood moves through a break in the skin

What Are the Common Causes of Bleeding?

Bleeding is a very common symptom that can be caused by a variety of incidents or conditions.
Possible causes include:

Traumatic Bleeding

Traumatic bleeding is caused by an injury. Injuries can vary in severity, but most will cause
bleeding to some degree. Common types of traumatic injury include:

 abrasions or grazes that do not penetrate below the skin

 hematoma or bruises
 lacerations or incisions
 puncture wounds from items such as a needle or knife
 crushing injuries
 gunshot wounds (caused by a weapon such as a gun)

Medical Conditions

There are also a number of medical conditions that can cause bleeding. This is generally rarer
than traumatic bleeding but can still happen to varying degrees. Conditions that can cause
bleeding include:

 haemophilia
 leukemia
 liver disease
 menorrhagia
 thrombocytopenia
 Von Willebrand’s disease
 2
 vitamin K deficiency
 brain trauma
 bowel obstruction
 congestive heart failure
 lung cancer
 acute bronchitis

Medicines

Some medicines can increase your chances of bleeding or even cause bleeding. Typically, you
will be warned about this and advised what to do when you are first prescribed the medication.

Medications that may be responsible for bleeding include:

 blood-thinning medications
 antibiotics, when used on a long-term basis
 radiation therapy

Pathology and pathophysiology of bleeding

Anatomy and function of blood vessels under normal conditions.

Anatomical localisation of pathological process can predispose certain vessels to

bleeding (i.e. in haemorrhagic stroke the site of bleeding is frequently to internal capsule). Also
anatomy of vessel can be responsible, mainly if the vessel wall is pathologically changed
(atherosclerosis, vasculitis, collagenoses). Abnormal anatomy of vessel wall can predispose to
bleeding in patients with vascular purpuras, but it is often difficult to prove the vessel damage on
clinical grounds.

Mechanism of blood clotting

Three factors are needed for normal haemostasis: vessel wall, platelets and plasma
proteins (coagulation factors). Primary haemostasis occurs in seconds, as platelet plug is formed.
There are four steps of primary haemostasis: platelet activation, adhesion, degranulation and
aggregation. Arachidonic acid plays an important role, as it is converted by cyclooxygenase
either to thromboxan A2 (which occurs in platelets and promotes their activation) or to
prostacyclin PGI1 (this occurs in endothelial cells and have an opposite effect). Secondary
haemostasis last minutes. During secondary haemostasis, coagulation factors of internal and
external cascade are activated and fibrin is formed from fibrinogen. It is important to notice that
internal and external coagulation cascade are interconnected - factor VIIa activates not only X,
but also IX to IX a, making the internal pathway of physiological importance.

Determine whether it’s an artery or vein.

If the blood is oozing, it’s a vein. The blood is probably also a darker color because it doesn’t
have as much oxygen. The bleeding usually stops after about five minutes of pressure. If you
can’t apply direct pressure, apply pressure just distal (toward fingers or toes) to the wound.
Remember, it’s draining back to the heart.
 3
If the blood is spurting, it’s an artery. Arteries contract and expand to aid in pumping the flow.
They may need more pressure to stop the bleeding. If pressure does stop it, hold the wound for
up to fifteen minutes if you can. Then pack it with clean cloth and apply a bandage. The bleeding
should be under control before closing the wound with suture or tape.

Capillary bleeding: is usually slow and oozing due to their small size and low pressure.
Although there may be a significant amount of bleeding, the majority of capillary bleeding is
considered to be minor and is easy to control in most cases. Capillary bleeding is usually the
result of an abrasion also known as a scrape. The color of capillary bleeding can be bright red or
darker red depending on the amount of oxygen it is carrying.

Symptoms
 Blood coming from an open wound
 Bruising
 Shock, which may cause any of the following symptoms:
o Confusion or decreasing alertness
o Clammy skin
o Dizziness or light-headedness after an injury
o Low blood pressure
o Paleness (pallor)
o Rapid pulse, increased heart rate
o Shortness of breath
o Weakness

Symptoms of internal bleeding may also include:

 Abdominal pain and swelling

 Chest pain
 External bleeding through a natural opening
o Blood in the stool (appears black, maroon, or bright red)
o Blood in the urine (appears red, pink, or tea-colored)
o Blood in the vomit (looks bright red, or brown like coffee-grounds)
o Vaginal bleeding (heavier than usual or after menopause)
 Skin color changes that occur several days after an injury (skin may black, blue, purple,
yellowish green)

Clinical manifestation of bleeding

1. Epistaxis. Usually is caused by vascular malformation, hypertension, drugs, tumour or

trauma in nasopharyngeal localisation. Therapy is usually local - nose tamponade, rarely the
operation is needed.

2. Eye bleeding. It is not usually life-threatening, but can lead to damage of vision, if
localised in certain areas (i.e. retinal or vitreous bleeding), while in other cases is not significant,
just frightening (subconjunctival bleeding).

3. Ear bleeding. Can be a sign of tumour or inflammation, but often comes in fractures of
skull basis and can be associated with intracerebral bleeding. X-ray and in appropriate cases also
CT scan has to be made.
 4
4. Bleeding after dental extraction - if severe, can lead to discovery of previously silent
coagulation defect. Local and non-specific antifibrinolytic treatment (e-aminocaproic acid) is
usually appropriate.

5. Other bleeding in ORL localisation can lead to airway obstruction and/or risk of
suffocation.

6. Haemoptysis, haemoptoe - comes in coagulation abnormalities, pneumonia, lung

cancer, tuberculosis, mycosis, mitral valve stenosis, cardiac decompensation or aspiration of
foreign body. Diagnostic procedures and treatment should generally be conservative (chest X-
ray, CT, bronchoscopy, bronchial arteriography). Bronchoscopic evacuation of blood can be
helpful. In most cases, the pulmonary bleeding is not life-threatening and stops spontaneously. In
rare situations when gross bleeding occurs, either surgical treatment or artificial embolisation of
bleeding bronchial artery is needed).

7. Gastrointestinal bleeding is caused by drugs (usually aspirin-containing or NSAIDs),

peptic ulcer or oesophageal varices. It manifests as haematemesis, melaena or enterorrhagia.
Endoscopical diagnosis is a method of choice in most cases and should be performed as soon as
possible, because endoscopical therapy (sclerotization of varices, adrenaline injection in peptic
ulcer bleeding, laser photocoagulation) can often be instituted. Angiography is helpful only
during active bleeding (not after it cessation). In liver disease, haemocoagulation abnormalities
are often present, which can be corrected by fresh frozen plasma. In gross or refractory bleeding,
surgical treatment after volume repletion is necessary. Mortality of gastrointestinal bleeding still
approaches 10%.

8. Haematuria (microscopical or macroscopical) usually is not life-threatening nor does it

lead to iron-deficiency anaemia, because usually it does not escape early detection. However, it
can be a presenting symptom of serious disorder (trauma, urolithiasis, tumour, infection,
glomerulonefritis) and the cause of bleeding can be sought. Both visualisation (urography,
ultrasound CT, endoscopy) and function methods should be employed according to the clinical
situation. In some cases, endoscopical or ultrasound methods can be utilised also for treatment of
urolithiasis or bladder papilloma.

9. Metrorrhagia can be life-threatening. Usually the cause of bleeding is gynaecological

(myomatosis, cancer, hormonal dysbalance), but it can be a presenting sign of rare hereditary
(factor V deficiency, dysfibrinogenaemia) or acquired (idiopathic thrombocytopenic purpura,
disseminated intravascular coagulation) bleeding disorder.

10. Intraperitoneal bleeding is either traumatic or becomes as a part of splenic or hepatic

disorders (sepsis, infectious mononucleosis, myelofibrosis, malaria, liver haemangioma). If
shock together with lower abdominal symptoms occur, gynaecological cause should be sought
(ectopic pregnancy). Treatment is surgical - splenectomy, suture or partial liver resection,
salpingectomy.

11.Skin and mucosal membrane haemorrhage usually points out to bleeding disorder.
Teleangiectasia can be hereditary (Rendu-Osler-Weber disease) or acquired (liver disease,
pregnancy, flebectasia). Purpura senilis, Cushing disease or renal failure can lead to skin
haemorrhages caused by collagen depletion of vessel walls. They can be presenting sign of
acquired platelet disorder (ITP), leukaemia, anticoagulation overdose or disseminated
intravascular coagulation. Cutaneous purpura fits into a picture of a number of infectious
disorders (meningococcaemia, sepsis, leptospirosis, Rocky mountain fever), autoimmune
diseases (vasculitis) or skin disorders.
 5
12. Contagious diseases - bleeding due to hepatorenal function disturbing in leptospirosis,
hepatitis of different types,meningitis
13. Internal diseases - autoimmune diseases,liver,complication of analgetic and
anticoagulant treatment
14. Bleeding into joint a musculosceletal system in are trauma origins and is specially
important in bleeding disorders. Repeated hemartros in hemofilia causes infectious
complications and ankylosis with movement troubles.
15.Bleeding into peritoneal and reproteritoneal cavity. Blunt abdominal trauma causes
rupture of spleen, liver or kidneyas. Clinical picture is peritoenal signs and shock,high leucocyte
count is present and patient should be carefully observed for urgent laparotomy. In various
bleeding disorders and infectious mononucleosis rupture of these organs can be seen after minor
or innocent trauma (spleen palpation) or spontaneously. Also bening or malignant tumors
present in abdominal cavity can bleed spontaneously (liver adenoma, liver metastatic tumour
nodule).
16.Bleeding of female reproductive organs - intraperitoneal or vissible through vagina is
caused by ectopic pregnancy and ovarial cysts. Signs of peritoneal iritation is seen. Careful
personal history is necesssary and endoscopic investigation necessary. Laparotomy is
frequently required.
17.Bleeding in tumors of various origins is caused by local destruction of tumour vesssels or
surrounding tissue, coagulation defects in primary site or in metastatic site.
18. Elderly people bleed from various reasons due to occult malignant tumors,
peptic ulcers due to often prescribed analgesics for arthrosis and ischemic heart disease.Also
atherosclerotic vessel malformation in often seen in colonic teleangiectasia, eye and
nasopharyngeal reagion.
19. Bleeing in childern appers in trauma and hematologic disease, epistaxis often present.
20. Head (Cranial) bleeding is often underdiagnosed due to nonspecific signs
dificulty in obtaining of valid personal history. Without careful investigation and follow-up with
adequate treatment has high mortality. CT scan is very helpful.These bleedings occurs in
various anatomical localities : epidural, subdural, intrameningeal and intraparenchymatous with
different clicinal manifestation. The cause of bleeding is traumatic very often silent in alkoholic
patients covered by intoxication symptoms.
The cerebrovascular bleeding occurs due to atherosclerotic disease,hypertension and bleeding
disorders. Neurological signs with changes of pupila and eye fundus is helpful, limbs movement
assesment and regular follow up od the state of conciousness is also important.
21. Bleeding disorders. Low level of platelets is caused by decreasing of production,
increasing destruction due to immunogeni or non-immunogenic causes,sequestration of platelet
in spleen is caused by portal hypertension, myeloproliferative and lymfoproliferative disorders.
Often induced by drugs as neoplastic chemotherapy, thiazid diuretics,etanol and heparin
treatment. Drug withdrawal is mostly helpful. Idiopathic tromcocytopenic purpura (ITP) is cured
by steroid, plasmafersis,splenectomy and platelet transfusion.
Vessel wall increased permeability is a cause of trombotic trombocytopenic purpura
Schoenlein Henoch (TTP)and is manifested mostly after various streptococcal disease.
Protein coagulation defect is inborn and geneticaly trasnmitted in hemofilia, aquired defect
is seen in various liver diseases,disseminated intravsacular coagulation and deficit of vitamin K
in small bowel disease or during coumarine anticoagulant treatment.
22. Disorders of blood coagulation

Systemic responses to acute blood loss

The first response to blood loss is an attempt to form a clot at the local site of hemorrhage. As
hemorrhage progresses, catecholamines, antidiuretic hormone, and atrial natriuretic receptors
respond to the perceived loss of volume by vasoconstriction of arterioles and muscular arteries
 6
and by increasing the heart rate. The aim of these compensatory mechanisms is to increase
cardiac output and maintain perfusion pressure. Urine output drops somewhat and thirst is
stimulated to maintain circulating blood volume.

Anxiety may be related to the release of catecholamines and to mild decreases in cerebral blood
flow. A person who is bleeding briskly also may develop tachypnea and hypotension. As
hypovolemia worsens and tissue hypoxia ensues, increases in ventilation compensate for the
metabolic acidosis produced by increased carbon dioxide production. Compensatory
mechanisms are eventually overwhelmed by volume losses, and blood flow to the renal and
splanchnic vasculature decreases and systolic blood pressure declines. The loss of coronary
perfusion pressure adversely affects myocardial contractility; cerebral blood flow decreases,
resulting in the loss of consciousness, coma, and eventually death.

Table 1
Classification of hemorrhage

Class

Parameter I II III IV
Blood loss (ml) <750 750–1500 1500–2000 >2000
Blood loss (%) <15% 15–30% 30–40% >40%
Pulse rate (beats/min) <100 >100 >120 >140
Blood pressure Normal Decreased Decreased Decreased
Respiratory rate (breaths/min) 14–20 20–30 30–40 >35
Urine output (ml/hour) >30 20–30 5–15 Negligible
CNS symptoms Normal Anxious Confused Lethargic

Treatment
The main goals of resuscitation are to stop the source of hemorrhage and to restore circulating
blood volume. Actively bleeding patients should have their intravascular fluid replaced because
tissue oxygenation will not be compromised, even at low hemoglobin concentrations, as long as
circulating volume is maintained. Hemoglobin concentration in an actively bleeding individual
has dubious diagnostic value because it takes time for the various intravascular compartments to
equilibrate. Rather, therapy should be guided by the rate of bleeding and changes in
hemodynamic parameters, such as blood pressure, heart rate, cardiac output, central venous
pressure, pulmonary artery wedge pressure, and mixed venous saturation.

First Aid
First aid is appropriate for external bleeding. If bleeding is severe, or if you think there is internal
bleeding or the person is in shock, get emergency help.

1. Calm and reassure the person. The sight of blood can be very frightening.
2. If the wound affects just the top layers of skin (superficial), wash it with soap and warm
water and pat dry. Bleeding from superficial wounds or scrapes is often described as
"oozing," because it is slow.
 7
3. Lay the person down. This reduces the chances of fainting by increasing blood flow to
the brain. When possible, raise up the part of the body that is bleeding.
4. Remove any loose debris or dirt that you can see from a wound.
5. Do NOT remove an object such as a knife, stick, or arrow that is stuck in the body. Doing
so may cause more damage and bleeding. Place pads and bandages around the object and
tape the object in place.
6. Put pressure directly on an outer wound with a sterile bandage, clean cloth, or even a
piece of clothing. If nothing else is available, use your hand. Direct pressure is best for
external bleeding, except for an eye injury.
7. Maintain pressure until the bleeding stops. When it has stopped, tightly wrap the wound
dressing with adhesive tape or a piece of clean clothing. Place a cold pack over the
dressing. Do not peek to see if the bleeding has stopped.
8. If bleeding continues and seeps through the material being held on the wound, do not
remove it. Simply place another cloth over the first one. Be sure to seek medical
attention.
9. If the bleeding is severe, get medical help and take steps to prevent shock. Keep the
injured body part completely still. Lay the person flat, raise the feet about 12 inches, and
cover the person with a coat or blanket. DO NOT move the person if there has been a
head, neck, back, or leg injury, as doing so may make the injury worse. Get medical help
as soon as possible.

DO NOT
 DO NOT apply a tourniquet to control bleeding, except as a last resort. Doing so may
cause more harm than good. A tourniquet should be used only in a life-threatening
situation and should be applied by an experienced person
 If continuous pressure hasn't stopped the bleeding and bleeding is extremely severe, a
tourniquet may be used until medical help arrives or bleeding is controllable.
o It should be applied to the limb between the bleeding site and the heart and
tightened so bleeding can be controlled by applying direct pressure over the
wound.
o To make a tourniquet, use bandages 2 to 4 inches wide and wrap them around the
limb several times. Tie a half or square knot, leaving loose ends long enough to
tie another knot. A stick or a stiff rod should be placed between the two knots.
Twist the stick until the bandage is tight enough to stop the bleeding and then
secure it in place.
o Check the tourniquet every 10 to 15 minutes. If the bleeding becomes
controllable, (manageable by applying direct pressure), release the tourniquet.
 DO NOT peek at a wound to see if the bleeding is stopping. The less a wound is
disturbed, the more likely it is that you'll be able to control the bleeding
 DO NOT probe a wound or pull out any embedded object from a wound. This will
usually cause more bleeding and harm
 DO NOT remove a dressing if it becomes soaked with blood. Instead, add a new one on
top
 DO NOT try to clean a large wound. This can cause heavier bleeding
 DO NOT try to clean a wound after you get the bleeding under control. Get medical help

Restoration of the intravascular fluid volume

Since the time of World War II, the accepted therapeutic dogma has been to restore blood
volume rapidly and achieve normal physiologic parameters. Generations of physicians have been
 8
trained to reverse blood loss within the 'golden hour' in order to preserve organ function and
prevent death.

The awareness of 'third space losses' into the interstitium and tissues resulted in the 'three-to-one'
rule for resuscitation: that is, 3 ml of crystalloid (Ringers lactate or normal saline) for every 1 ml
of blood loss replaced.

Four issues should be considered when treating active blood loss: type of fluid to give, how
much, how fast, and what the therapeutic end-points are. The ideal fluid for resuscitation has not
been established.

Colloidal solutions, such as albumin and hetastarch (6% hydroxyethyl starch in 0.9% NaCl), can
be administered to increase circulatory volume rapidly.

Blood substitutes

Blood substitutes have been tried in many forms

When to transfuse

The use of blood and blood products is necessary when the estimated blood loss from
hemorrhage exceeds 30% of the blood volume (class III hemorrhage). Determining this point has
been extremely difficult during an acute hemorrhage because of hemodilution produced by fluid
resuscitation. As mentioned previously, whereas formulas have been proposed to estimate blood
losses, the use of blood as a resuscitative fluid is empirical.

Presently, a hypotensive patient who fails to respond to 2 l crystalloid in the face of probable
hemorrhage should be treated with blood and blood products.

Haemostatic
An antihemorrhagic agent is a substance that promotes haemostasis (stops bleeding) It may
also be known as a hemostatic (also spelled haemostatic) agent.

A styptic (also spelled stiptic) is a specific type of antihemorrhagic agent that works by
contracting tissues to seal injured blood vessels. Styptic pencils contain astringents.

Antihemorrhagic agents used in medicine have various mechanisms of action:

 Systemic drugs work by inhibiting fibrinolysis or promoting coagulation.

 Locally-acting hemostatic agents work by causing vasoconstriction or promoting platelet
aggregation

Systemic
There are several classes of antihemorrhagic drugs used in medicine. These include
antifibrinolytics, blood coagulation factors, fibrinogen, and vitamin K

Local
 9
Topical hemostatic agents have been gaining popularity for use in emergency bleeding control,
especially in military medicine. They are available in two forms—as a granular powder poured
on wounds, or embedded in a dressing.

About tranexamic acid

Type of medicine Antifibrinolytic
Used for To prevent or treat heavy bleeding
Also called Cyklokapron®
Available as Tablets and injection

Tranexamic acid is given to stop or reduce heavy bleeding. When you bleed, your body forms
clots to stop the bleeding. In some people these break down causing too much bleeding.
Tranexamic acid works by stopping the clots from breaking down and so reduces the unwanted
bleeding.

It is used to control bleeding in a number of different conditions. It reduces unwanted or heavy

bleeding following some surgery (such as surgery on the prostate, bladder, or cervix),
nosebleeds, heavy periods (menorrhagia), bleeding inside the eye, tooth extraction in people who
bleed more easily than normal, and in a condition called hereditary angio-oedema.