Bleeding, also known
as hemorrhaging is blood escaping from
the circulatory system.Bleeding can occur
internally, where blood leaks from blood
vessels inside the body, or externally, either
through a natural opening such as
the mouth, nose, ear, urethra, vagina or anus
, or through a break in the skin
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Blood loss
Hemorrhaging is broken down into four classes by
the American College of Surgeons' advanced
trauma life support(ATLS).
Class I Hemorrhage involves up to 15% of blood
volume. There is typically no change in vital signs
and fluid resuscitation is not usually necessary.
Class II Hemorrhage involves 15-30% of total
blood volume. A patient is often tachycardic with a
narrowing of the difference between
the systolic and diastolic blood pressures. The body
attempts to compensate with peripheral
vasoconstriction. Skin may start to look pale and be
cool to the touch. The patient may exhibit slight
changes in behavior. Volume resuscitation with
crystalloids (Saline solution or Lactated Ringer's
solution) is all that is typically required. Blood
transfusion is not typically required.
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Class III Hemorrhage involves loss of 3040% of circulating blood volume. The
patient's blood pressure drops, the heart
rate increases, peripheral hypoperfusion
(shock), such as capillary refill worsens, and
the mental status worsens. Fluid resuscitation
with crystalloid and blood transfusion are
usually necessary.
Class IV Hemorrhage involves loss of >40%
of circulating blood volume. The limit of the
body's compensation is reached and
aggressive resuscitation is required to prevent
death.
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Types
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Mouth
• Tooth eruption – losing a tooth
• Hematemesis – vomiting fresh blood
• Hemoptysis – coughing up blood from the lungs
Anus
• Melena - upper gastrointestinal bleeding
• Hematochezia – lower gastrointestinal bleeding, or
brisk upper gastrointestinal bleeding
Urinary tract
• Hematuria – blood in the urine from urinary
bleeding
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Upper head
• Intracranial hemorrhage – bleeding in the
skull.
• Cerebral hemorrhage – a type of
intracranial hemorrhage, bleeding within
the brain tissue itself.
• Intracerebral hemorrhage – bleeding in the
brain caused by the rupture of a blood
vessel within the head. See
also hemorrhagic stroke.
• Subarachnoid hemorrhage (SAH) implies
the presence of blood within
the subarachnoid space
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Lungs
• Pulmonary hemorrhage
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Gynecologic
• Vaginal bleeding
• Postpartum hemorrhage
• Breakthrough bleeding
• Ovarian bleeding. :polycystic ovary
syndrome undergoing transvaginal oocyte retrieval.
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Gastrointestinal
• Upper gastrointestinal bleed
• Lower gastrointestinal bleed
• Occult gastrointestinal bleed
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Revealed and concealed hemorrhage
Primary,
reactionary and
secondary hemorrhage
Surgical vs non surgical hemorrhage
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In operation theatre
Hb is poor indicator
Degree of haemorrhage is classified in % of
volume loss
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External vs concealed
Direct external pressure
Wide bore cannula
History of NSAIDS,
history of aneurysm
Fresh bleeding,malaena
Abdominal tenderness
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Cavitary haemorrhage is excluded by rapid
investigation;
abdominal u/s
(FAST) focused abdominal sonar for trauma,
CT scan
Rapidly moved to haemorrhage
control place
 theatre, endoscopy or angiography
suites
 Control must be achived rapidly to
prevent the pt. entering the triad of
coagulopathy- acidosis- hypothermia
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 No
unnecessary investigation or
procedure before bleeding control
 Damage control surgery
Arrest of hemmorrhage
 Control sepsis
 Protect from further injury
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The four central strategies of DCR are:
Anticipate and treat acute traumatic
coagulopathy
Permissive hypotension until haemorrhage
control
Limit crystalloid and colloid infusion to
avoid dilutional coagulopathy
Damage control surgery to control
haemorrhage and preserve physiology.
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Damage control resuscitation strategies
have been shown to
reduce mortality and morbidity in patients
with exsanguinating
trauma and may be applicable in other
forms of acute haemorrhage.
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Blood transfusion is generally the process of
receiving blood or blood products into
one's circulation intravenously. Transfusions
are used for various medical conditions to
replace lost components of the blood. Early
transfusions used whole blood, but modern
medical practice commonly uses only
components of the blood, such as red blood
cells, white blood cells, plasma, clotting factors,
and platelets
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Whole blood
Packed red cell
Fresh frozen plasma(FFP); rich in coagulation
factors removed from whole blood
Cryoprecipitate; rich in factor Vlll and
fibrinogen
platelets concentrate
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Acute blood loss
Anemia during surgery
Symptomatic chronic anemia
Hb >10 g% indication of blood transfusion ??
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Transfusion reaction
Antibodies present in recipient’s serum are
incompatible with donors blood results transfusion
reaction
ABO incompatibility result in severe and potentially
fatal hemolysis and multiple organ failure.
Allergic reaction
Infections
Air embolism
Thrombophlebitis
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coagulopathy
hypocalcemia
hyperkalaemia
hypokalaemia
hypothermia.
<6 Probably will benefit from transfusion
 6–8 Transfusion unlikely to be of benefit in
 the absence of bleeding or impending
 surgery
 >8 No indication for transfusion in the
◦ absence of other risk factors
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First-line therapy, therefore, is intravenous
access and
administration of intravenous fluids.
Access should be through wide-bore
cannula. Long, narrow lines, such as central
venous catheters, have too high a resistance
to allow rapid infusion and are more
appropriate for monitoring than fluid
replacement therapy.
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Debate
more important to understand how and
when to administer it.
In most studies of shock resuscitation there
is no overt difference in response or
outcome between crystalloid (water
soluble)solutions or colloids
more crystalloid than colloid administered in
blinded trials.
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On balance, there is little evidence to
support the administration of colloids,
which are more expensive and have worse
side-effect profiles.
If blood is being lost, the ideal replacement
fluid is blood, although crystalloid therapy
may be required while awaiting blood
products.
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