HAEMORRHAGE

ETIOLOGY:-

y TRAUMA
y SURGERY Intra- Operative/
Post- Operative

SPONT ANEOUS BLEEDING:-

y LOCAL CAUSES:- y Infections and Inflammations

y Tuberculosis for example pulmonary tuberculosis
y Peptic ulcer, Reflux Esophagitis, Ulcerative colitis

y TUMORS y BENIGN- for example Nasopharyngeal ka

Fibroma papilloma of urinary bladder
y MALIGNANT for example carcinoma of tongue,
larynx, kidneys

y MECHANICAL y VARICOSE VEINS

DISORDERS y HEMORRHOIDS,
y ARTERIOVENOUS MALFORMATIONS
y ARTERIAL ANEURYSMS

y GENERAL CAUSES y Defect of blood vessels for example VASCULAR

PURPURA, TELANGIECTASIA, VASCULITIS
y Disorders of platelets for example
REDUCE NUMBER OF PLATELETS,
PLATELET DYSFUNCTION
y Deficiency of coagulation factors for example
HAEMOPHILIA, CHRISTMAS DISEASE,
hypervitaminosis K, anticoagulant drugs.

OBVIOUSLYTRAUMA IS THE MOST IMPORTANT CAUSES OF

HAEMORRHAGE
CLASSIFICATION:- (SPD PI)

I. BASED ON THE SOURCE OF BLEEDING:

A. ARTERIAL ~ Is BRIGHT RED IN COLOUR, SPURTING LIKE JET ALONG WITH

PULSE OF THE PATIENT.
~ SIGNIFICANT BLOOD LOSS in a SHORT SPAN OF TIME.

B. VENOUS ~ Is DARK RED, STEADY AND CONTINUOUS FLOW.

Blood loss may be SEVERE AND RAPID when bleeding is from
FEMORAL VEIN, JUGULAR VEIN, OTHER MAJOR VEINS,
VARICOSE VEIN.
~ Pulmonary arterial blood is dark red in colour and pulmonary venous blood is
bright red in colour.

C. CAPILLARY: ~ Here BLEEDING IS RAPID AND BRIGHT RED.

~ It is often severe due to CONTINUOUS OOZE like sweating from
MULTIPLE SPOTS.

II. BASED ON THE TIME OF ONSET OF BLEEDING IN RELATION TO ANY OPERATIVE

PROCEDURE:

CAUSES:-
A.PRIMARY: Occurs AT THE TIME OF INJURY OR ~ TRAUMA
OPERATION.

lB. REACTIONARY: It occurs WITHIN 24 HOURS AFTER ~ SLIPPING OF LIGATURE

SURGERY OR AFTER ~ DISLODGEMENT OF CLOT
INJURY.(COMMONL YIN 4-6 ~ RISING BLOOD PRESSURE
HOURS). ~ MOST COMMONLY ARISES
FROM SMALL BLOOD
VESSELS
C. SECONDARY: It occurs in 7-14 DAYS AFTER ~ TUBERCULOUS
SURGERY. PULMONARY CAVITY
BLEEDING
~ PEPTIC ULCER BLEEDING
~ HEMORRHOIDECTOMY
~ Bleeding following
ARTERIAL SURGERY AND
AMPUTATION
~ EROSION OF VESSEL by
CANCER OR ITS
MET AST ASIS, for example,
from carotid artery in
carcinoma tongue
 III. BASED ON THE TYPE OF HAEMORRHAGE:

A. REVEALED IT IS VISIBLE EXTERNAL HAEMORRHAGE

HAEMORRHAGE

B. CONCEALED INTERNAL HAEMORRHAGE.

HAEMORRHAGE Y LIVER INJURY
Y SPLEEN INJURY
Y FRACTURE FEMUR
Y CEREBRAL HAEMORRHAGE
Y HAEMOTHORAX

C. INITIALLY Y HAEMATEMESIS (Vomiting of Blood)

CONCEALED BUT Y MELAENA (Dark Tarry stool with or without visible blood.)
LATER REVEALED Y HAEMATURIA (Blood in Urine, may range from very obvious to
Microscopic)
IV. BASED ON THE DURATION OF HAEMORRHAGE:

A. ACUTE HAEMORRHAGE It is SUDDEN, SEVERE HAEMORRHAGE after TRAUMA,

SURGERY.

B. CHRONIC It is CHRONIC REPEATED BLEEDING for a long period

HAEMORRHAGE: like in HEMORRHOIDS, BLEEDING PEPTIC ULCER,
CARCINOMA CAECUM etc.

They present with CHRONIC ANAEMIA with

HYPERDYNAMIC CARDIAC FAILURE.
They are in a state of CHRONIC HYPOXIA. It is corrected by
PACKED CELL TRANSFUSION not by WHOLE BLOOD
ITSELF.

Cause has to be treated accordingly.

C. ACUTE ON CHRONIC IT IS MORE DANGEROUS

HAEMORRAGE: as the bleeding occurs in individuals who are
ALREADY HYPOXIC, which may get worsened faster.

V. BASED ON THE POSSIBLE INTERVENTION:

A. SURGICAL Can be corrected by SURGICAL INTERVENTION.

HAEMORRHAGE

B. NON-SURGICAL is diffuse ooze due to COAGULATION ABNORMALITIES

HAEMORRHAGE and Ole.
 PATHOPHYSIOLOGY of HAEMMORRHAGE:-

BLEEDING
!
HYPOVOLAEMIA
!
LOW CARDIAC OUTPUT
!
TACHYCARDIA and SHIFTING of BLOOD from SPLANCHNIC VESSELS by VENOCONSTRICTION
Splanchnic- relating
so as to maintain PERFUSION OF VITAL ORGANS LIKE BRAIN, HEART, LUNGS, KIDNEYS.
to Viscera or Internal
!
HYPOXIA Organs, esp. those in
! the abdomen.
ACTIV ATION OF CARDIAC DEPRESSANTS
!
ANAEROBIC METABOLISM and ALTERED CELL MEMBRANE FUNCTION CAUSING INFLUX OF
MORE SODIUM AND CALCIUM INSIDE THE CELL AND POTASSIUM COMES OUT OF THE CELL Sick cell syndrome is a
! medical condition which
HYPONATRAEMIC, HYPERKALAEMIC, HYPOCALCAEMIC METABOLIC ACIDOSIS.
results in the reduced
!
LYSOSOMES OF CEUGET LYSED RELEASING POWERFUL ENZYMES functioning of the
WHICH IS LETHAL TO CELL ITSELF Cellular Na-K pump,
! which is responsible for
SICK CELL SYNDROME maintaining
PLATELETS AND COAGULANTS ARE ACTIVATED LEADING TO FORMATION OF SMALL CLOTS
Homeostasis.
DIC AND FURTHER BLEEDING.
!
PROGRESSIVE HAEMODILUTION LEADING TO TOTAL CIRCUIATORYFAILURE.

~ Initially there is COMPENSATORY HYPOVOLAEMIC SHOCK and later there is

DECOMPENSATORY HYPOVOLAEMIC SHOCK which will lead to MODS and DEATH.

~ DIC, ACIDOSIS and HYPOTHERMIA are the major factors in worsening the situation in
haemorrhage.

CLASSIFICAnON OF HAEMMORHAGIC SHOCK

I. Up to 15% « 750 ml) NORMAL

II. Blood loss 15-30% PALOR, THIRSTY,

(750-1500ml) TACHYCARDIA

III. Blood loss 30-40% HYPOTENSION,

(1500-2000ml). TACHYCARDIA,
OLIGURIA,
CONFUSION

IV. Blood loss> 40% RAPID PULSE, LOW

(> 2000 ml). BP,ANURIA,
UNCONSCIOUSNESS,
MODS
CLINICAL FEATURES OF HAEMORRHAGE:-

~ VISIBLE EXTERNAL BLEEDING

INTERNAL BLEEDING IS DIAGNOSED BY:-
~ PALLOR, THIRSTY.
~ CYANOSIS.
~ TACHYCARDIA.
~ TACHYPNOEA.
~ AIR HUNGER.
~ COLD CLAMMY SKIN DUE TO VASOCONSTRICnON.
~ DRY FACE, DRY MOUTH AND GOOSE SKIN APPEARANCE.
~ RAPID THREADY PULSE.
~ OLIGURIA.O
~ HYPOTENSION.
~ AT SITE OF BLEEDING THERE MIGHT BE :-
SWELLING DUE TO HAEMATOMA,
ACCUMULA nON OF BLEEDING HAS OCCURRED IN A CLOSED CAVITY, LIKE
HAEMOTHORAX, HAEMOPERITONIUM.

HAEMOTHORAX- COLLECTION OF BLOOD IN THE PLEURAL SPACE

HAEMOPERITONIUM - COLLECTION OF BLOOD IN THE PERITONIAL CAVITY

SIGNS OF SIGNIFICANT BLOOD LOSS:-

~ PULSE> 100/MINUTE
~ SYSTOLIC BP< 100 mm Hg

MEASUREMENT I ESTIMATION OF BLOOD LOSS:-

~ CLOT SIZE of a CLENCHED FIST is 500 ml.

~ Blood loss in a CLOSED TIBIAL FRACTURE is 500-1500 ml; in a FRACTURE FEMUR is 500-
2000 ml.
~ WEIGHING THE SWAB before and after use is an important method of on-table assessment of
blood loss.
~ HEMOGLOBIN and PCV ESTIMATION.
~ BLOOD VOLUME ESTIMATION- this involves use of RADIOIODINE TECHNIQUE or
MICROHEMATOCRIT METHOD.

EFFECTS OF HAEMORRHAGE:-

~ ACUTE RENAL SHUT DOWN

~ LIVER CELL DYSFUNCTION
~ CARDIAC DEPRESSION
~ HYPOXIC EFFECT
~ METABOLIC ACIDOSIS
~ GIT MUCOSAL ISCHAEMIA
~ SEPSIS
~ HYPOVOLAEMIC SHOCK- MODS
TREATMENT:-

The Further Blood Loss includes 2 MAl OR COMPONENTS:-

1. CONTROL OF BLEEDING 2. RESTORATION OF BLOOD

VOLUME
BLOOD LOSS is sto:Q:Qed by:- ~ Restoration of blood loss:
PRESSURE, By:-
PACKING, BLOOD TRANSFUSION,
USE OF LOCAL HEMOSTATIC AGENTS ALBUMIN 4.5%,
- GELATIN SPONGE, SAG-M blood,
- OXIDIZED CELLULOSE, SALINE,
- COLLAGEN SPONGE, HAEMACCEL (GELATIN),
-THROMBIN, DEXTRAN, PLASMA INFUSIONS.
- LIGATION OF BLOOD VESSEL

3.0THERS:-

Note: One unit of blood should raise 1 gm% of Hemoglobin.

~ CATHETERIZATION, FOOT END ELEVATION, MONITORING.

~ OXYGEN SUPPORTjINTUBATIONjVENTILATOR and CRITICAL CARE.

~ WOUND EXPLORATION and PROCEEDING, i.e. LIGATION of the SMALL VESSEL,

SUTURING the WOUND PART, VESSEL SUTURING (ANASTOMOSIS), EXCISION of the
TISSUES.

~ ABSOLUTE REST, ANALGESICS, MORPHINE 10-20 mg IMjIV TO RELIEVE PAIN,

SEDATION.

~ TUBE THORACOSTOMY for HAEMOTHORAX.

~ LAPAROTOMY for LIVER OR SPLEEN OR MESENTERY OR BOWEL INJURIES,

SUTURING, SPLENECTOMY.

~ TOPICAL APPLICATIONS FOR LOCAL OOZE -

OXYCEL,
GAUZE SOAKED WITH ADRENALINE,
BONE WAX FOR OOZING FROM BON and
OTHER LOCAL HAEMOSTATIC AGENTS (COLLAGEN, THROMBIN).

~ In VENOUS HAEMORRHAGE, ELEVATION, LIGATION OF VEIN OR IN CASE OF LARGE

VEIN SUTURING OF VENOUS WALL, PRESSURE BANDAGING, PACKING will be helpful.

~ TOURNIQUET is often used in OPERATION THEATRE for CONTROL OF HAEMORRHAGE

in limbs. But it is not advisable as a first aid measure.

~ TPN, CVP MONITORING, ELECTROLYTE MANAGEMENT are all equally important.

~ STEROID INJECTION, ANTIBIOTICS, VENTILATOR SUPPORT ARE often required.