HAEMORRHAGE
BY
Dr
HAYDER M. ABDULNABI
DM, CABS
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TYPES OF BLEEDING
DEPNDING ON THE SOURSE OF
BLEEDING
1- ARTERIAL– BRIGHT RED AND COMES IN JETS
WITH THE PULSE OF THE PATIENT
2- VENOUS – DARK RED BLOOD , STEADY AND
COPIOUS
3- CAPILLARY– BRIGHT RED RAPID OOZE (
ABRASIONS )
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DEPENDING ON THE TIME OF
OCCURANCE
1- PRIMARY BLEEDING – OCCURS AT THE TIME OF
INJURY OR OPERATION
2- REACTIONARY BLEEDING – USUALLY OCCURS IN
4-6 HOURS OR WITH IN THE 24 HOURS THAT
FOLLOW THE PRIMARY BLEEDING, DUE TO
EITHER SLIPPING OF LIGATURE , DISLOGEMENT
OF A CLOT OR CESSATION OF THE REFLEX
VASOSPASM.
THE PRESIPITATING FACTOR ARE
A- THE INCREASE IN THE BLOOD PRESSURE AFTER
RECOVERY FROM SHOCK OR ANASTHESIA
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B- RESTLESSNESS OF THE PATIENT
C- COUGHING AND VOMITING THAT INCREASE
THE VENOUS PRESSURE
3- SECONDARY BLEEDING – OCCUR WITHIN 714 DAYS AFTER THE PRIMARY TRAUMA OR
OPERATION AND THE CAUSE IS ALWAYS
INFECTION WHICH LEADS TO SLOUGHIN OF
AN ARTERY IN AN AREA BY PRESSURE OF A
DRAIN TUBE OR A BONE FRAGMENT OR BY
SLIPPING OF A LIGATURE IN AN INFECTED
AREA OR MALIGNANT TISSUE
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DEPENDING ON THE VISIBILITY
A- EXTERNAL ( REVEALED ) BLEEDING
B- INTERNAL ( CONCAELED ) BLEEDING LIKE
INTRA-ABDOMINAL OR INTRACRANIAL
BLEEDING
THE INTERNAL BLEEDING MAY BECOME
EXTENAL AS IN HEMATEMESIS DUE TO A
BLEEDING PEPTC ULCER OR HEMATURIA
AFTER RENAL INJURY OR AN INTRUTERINE
BLEEDING TURNS INTO BLEEDING PER
VAGINA
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HOW TO MEASURE ACUTE BLOOD
LOSS ?
A NORMAL BLOOD VOLUME IS 80-85 ML / KG IN INFANTS AND
ABOUT 65-75 ML / KG IN ADULTS
1- BLOOD CLOT SIZE – A CLENCHED FIST SIZE CLOT ROUGHLY EQUALS
500 ML
2 - SITE OF A CLOSED # SWELLING -- A MODERATE SWELLING IN A #
TIBIA EQUALS TO 500- 1500 ML OF BLOOD, WHILE A MODERATE
SWELLING IN A # FEMUR EQUALS TO 500-2000 ML OF BLOOD LOSS
3- SWAB WEIGHING – BY SUBSTRACTING THE WEIGHT OF SOACKED
SWABS FROM THEIR WEIGHT WHEN THEY WERE DRY AND THE
BLOOD LOSS IS 1 ML FOR EVERY 1 GM DIFFERENCE
4- HEMOGLOBIN LEVEL ESTIMATION – THERE IS NO IMMEDIATE
DECREASE IN Hg LEVEL AFTER BLEEDING BUT AFTER 8 HOURS IT
WILL DROP BECAUSE OF THE INFLUX OF THE INTERSITIAL FLUID
INTO THE VASCULAR COMPARTEMENT ( DILUTION )
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TREATMENT
1- PRESSURE ON THE SITE OF BLEEDING –BY
PACKING OR DIGITS OR BALOONS INFLATED AT
THE SITE OF BLEEDING ( ESOPHAGEAL VARICES)
2- REST AND POSITION – BY ELEVATION OF THE
INJURED LIMB TO DECREASE BLOOD RETURN TO
THE HEART
3- OPERATIVE PROCEDURES – BY USING
HEMOSTATS, CLIPS, DIATHERMY, LIGATURES,
GELATIN SPONGES, AND ADRENALIN SOACKED
GAUZE ( 1: 1000 )
4- BLOOD TRANSFUTION
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INDICATION OF BLOOD TRANSFUSION
1- ANEMIA-- RECENT STUDY SHOWED THAT A
TRANSFUSION THRESHOLD OF 70 G/L WAS
AS SAFE AND POSSIBLY SUPERIOR TO ONE OF
100 G/L IN CRITICAL CARE PATIENTS. A
MINIMUM PREOPERATIVE HAEMOGLOBIN
OF 100 G/L IS NO LONGER REGARDED AS
ESSENTIAL, AS MANY PATIENTS WITH A
LOWER HAEMOGLOBIN TOLERATE SURGERY
AND SEEM TO RECOVER JUST AS WELL.
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2- BLOOD LOSS – IF GREATER THAN 30 PER
CENT OF ESTIMATED BLOOD VOLUME,
PATIENTS WITH MASSIVE BLOOD LOSS,
DEFINED AS THOSE REQUIRING
TRANSFUSION OF A VOLUME OF BLOOD
GREATER THAN THEIR BLOOD VOLUME
WITHIN 24 H
DEPLETION OF COAGULATION FACTORS IS
UNUSUAL, BECAUSE STORED BLOOD
CONTAINS ADEQUATE AMOUNTS OF ALL
EXCEPT FOR FACTORS V AND VIII, WHICH
FALL DURING STORAGE.
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3- REPLACEMENT OF BLOOD COMPONENTS –
RED & WHITE BLOOD CELLS, COAGULATION FACTORS,
PLASMA
PROCEDURE FOR BLOOD TRANSFUSION
1- PRETRANSFUSION COMPATIBILITY TESTING -- A.
BLOOD GROUPING ,THE ABO AND RHD GROUPS OF
THE PATIENT ARE DETERMINED.
B Donor blood of the same ABO and RhD group as the
patient is selected.
D. Cross-matching-- The full cross-match involves
testing the patient's plasma against a sample of the
red cells from the donor unit in a direct
agglutination test.
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2- BLOOD ORDERING – A. ELECTIVE
SURGERY-- SUFFICIENT TIME SHOULD
BE ALLOWED FOR THE LABORATORY TO
CARRY OUT PRETRANSFUSION TESTING.
B. EMERGENCIES-THERE MAY BE INSUFFICIENT TIME FOR
FULL PRETRANSFUSION TESTING.—USE
2 UNITS OF O RHD-NEGATIVE BLOOD
('EMERGENCY STOCK') , TO ALLOW
ADDITIONAL TIME FOR THE
LABORATORY TO GROUP THE PATIENT.
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3- Blood, blood components, and blood products-Blood collected from donors is processed into:
A- Blood components, such as red cell and
platelet concentrates, fresh frozen plasma and
cryoprecipitate, which are prepared from a
single donation of blood by simple separation
methods such as centrifugation, and transfused
without further processing.
B- Blood products, such as coagulation factor
concentrates and albumin and immunoglobulin
solutions, which are prepared by complex
processes using the plasma from many donors
as the starting material.
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Strategies for avoiding or reducing the
use of blood tranfusion
By discontinuing antiplatelet and anticoagulant drugs, if
possible, several days before surgery.
Anaemia, if present, should be investigated and treated
appropriately in advance of elective surgery.
Intraoperative measures include the use of meticulous surgical
and anaesthetic techniques, a cautious use of anticoagulants
during surgery, and the use of drugs to enhance haemostasis
AND THE USE OF AUTOLOGOUS TRANSFUSION.
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Autologous transfusion
THERE ARE THREE TYPES OF AUTOLOGOUS
TRANSFUSION:
1- PREDEPOSIT. THE PATIENT DONATES 2–5 UNITS OF BLOOD
AT APPROXIMATELY WEEKLY INTERVALS BEFORE ELECTIVE
SURGERY.
2- PREOPERATIVE HAEMODILUTION. ONE OR TWO UNITS OF
BLOOD ARE REMOVED FROM THE PATIENT IMMEDIATELY
BEFORE SURGERY AND RETRANSFUSED TO REPLACE
OPERATIVE LOSSES.
3- BLOOD SALVAGE. BLOOD LOST DURING OR AFTER SURGERY
MAY BE COLLECTED AND RETRANSFUSED. SEVERAL
TECHNIQUES OF VARYING LEVELS OF SOPHISTICATION ARE
AVAILABLE. OPERATIVE SITE MUST BE FREE OF BACTERIA,
BOWEL CONTENTS, AND TUMOUR CELLS.
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Complications of blood transfusion
1-- Immediate haemolytic transfusion reactions
This is the most serious complication of blood
transfusion and is usually due to ABO incompatibility.
There is complement activation by the antigenantibody reaction, usually due to IgM antibodies,
leading to rigors, lumbar pain, dyspnoea, hypotension,
haemoglobinuria, and renal failure. At the first
suspicion of any serious transfusion reaction, the
transfusion should always be stopped and the donor
units returned to the blood transfusion laboratory with
a new blood sample from the patient to exclude a
haemolytic transfusion reaction.
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2-- DELAYED HAEMOLYTIC TRANSFUSION
REACTIONS
THESE MAY OCCUR IN PATIENTS ALLOIMMUNIZED
BY PREVIOUS TRANSFUSIONS OR PREGNANCIES.
THE ANTIBODY TITRE IS TOO LOW TO BE
DETECTED BY PRETRANSFUSION COMPATIBILITY
TESTING, BUT A SECONDARY IMMUNE
RESPONSE OCCURS AFTER TRANSFUSION,
RESULTING IN DESTRUCTION OF THE
TRANSFUSED CELLS, USUALLY BY IGG
ANTIBODIES. THE PATIENT MAY DEVELOP
ANAEMIA AND JAUNDICE ABOUT A WEEK AFTER
THE TRANSFUSION, ALTHOUGH MANY ARE
CLINICALLY SILENT.
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3-- NON-HAEMOLYTIC (FEBRILE) TRANSFUSION
REACTIONS
FEBRILE REACTIONS ARE A COMMON
COMPLICATION OF BLOOD TRANSFUSION IN
PATIENTS WHO HAVE PREVIOUSLY BEEN
TRANSFUSED OR PREGNANT. THE USUAL CAUSE
IS THE PRESENCE OF LEUCOCYTE ANTIBODIES IN
THE RECIPIENT ACTING AGAINST TRANSFUSED
LEUCOCYTES, LEADING TO RELEASE OF
PYROGENS. TYPICAL SIGNS ARE FLUSHING AND
TACHYCARDIA, FEVER (>38°C), CHILLS, AND
RIGORS. PARACETAMOL MAY BE USED TO
REDUCE THE FEVER.
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4--Urticaria And Anaphylaxis
Urticarial Reactions Are Often Attributed To Plasma
Protein Incompatibility But, In Most Cases, They
Are Unexplained. They Are Common But Rarely
Severe; Stopping Or Slowing The Transfusion, And
Intravenous Chlorpheniramine 10 Mg (Adult
Dose), Are Usually Sufficient Treatment.
Anaphylactic Reactions Occasionally Occur; Severe
Reactions Are Seen In Patients Lacking IgA Who
Produce Anti-IgA That Reacts With IgA In The
Transfused Blood. The Transfusion Should Be
Stopped And Adrenaline 0.5 Mg Intramuscular
And Chlorpheniramine 10 Mg Intravenous Should
Be Given Immediately; Endotracheal Intubation
May Be Required.
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5– TRANSMISSION OF INFECTION
HEPATITIS, HUMAN IMMUNODEFICIENCY VIRUS
OTHER VIRUSES: CYTOMEGALOVIRUS, EPSTEIN–
BARR VIRUS, HUMAN T-CELL
LEUKAEMIA/LYMPHOMA VIRUS TYPE 1 (HTLV-1)
PARASITES: MALARIA, TRYPANOSOMIASIS,
TOXOPLASMOSIS SYPHILIS AND TRANSFUSION OF
BLOOD CONTAMINATED WITH BACTERIA
6-- CIRCULATORY FAILURE DUE TO VOLUME
OVERLOAD.7-- IRON OVERLOAD DUE TO MULTIPLE
TRANSFUSIONS. 8-- MASSIVE TRANSFUSION OF
STORED BLOOD MAY CAUSE BLEEDING AND
ELECTROLYTE CHANGES. 9-- THROMBOPHLEBITIS
10-- AIR EMBOLISM
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