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Hemorrhages and Hemostasis
Hemorrhage is
blood flow from vessels in to tissues,
cavities of body or outside of the body.
Reason of hemorrhage can by : trauma ( injury) of the
vessels, pathological process outside of the vessels as a
tumors overgrowth, ulcerative process of stomach, duodenum
or bleeding from intact vessels ( coagulation disorders by
sepsis or other infectious - toxic processes ).
A hemorrhage is one of most dangerous factors in an
injury. The extend of the danger depends on the character
of the wound(incised, contused etc.) and number of the
factors:
size
of
the
wounds,
type
of
injured
vessels(artery, vein).
If the blood flows to the exterior from the wound, it
is an external hemorrhage; if the blood flows into the
tissues or cavities as a thoracic, abdominal, joints, it's
known as an internal hemorrhage.
If bleeding occurs into
cavities witch communicate with the environment(stomach,
intestins, urinary organs), it may be discharged to the
exterior and the hemorrhage becomes visible(external).
Hemorrhage
which
occurs
immediately
after
trauma(injury) is primary. Hemorrhage witch occurs
days
after
bleeding
trauma
are
obstructed
:
is
secondary.
dislocation
of
The
the
reasons
thrombus
of
which
few
this
was
injured vessel; septic resolution of thrombus,
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displacement of the ligature , damage to vascular walls by
foreign
bodies
(
shell
splinters,
bone
fragments),
destruction of the vessels walls by a purulent process.
Because such hemorrhages are possible, the patient mast by
watched as long as wound heals, especially during first
weeks or during several infections process.
Hemorrhages are divided
to:
arterial,
venous,
according type of vessels in
capillary,
parenchymatous
hemorrhages.
Arterial hemorrhages are the most rapid and dangerous.
In injures to aorta and others major arteries the patient
may
die
before
he
is
administered
any
aid.
Arterial
hemorrhage can by recognized by color of blood and type of
bleeding.
stream)
Blood
and
it's
is
injected
color
is
in
spurt(as
a
bright-red(blood
pulsation
is
rich
of
oxygen). Compression of artery arrest the bleeding.
Venous hemorrhages can by determined by the dark red
color of the blood (poor of oxygen and rich of carbon
dioxide),
cases
blood
lowering
flows
the
by
a
continuous
bleeding
part
stream.
of
the
In
such
body
and
compression of the vessels between the heart and site of
bleeding
intensifies
the
hemorrhage.
In
injures
major veins, especially on the neck, air may
of
the
gain entrance
into them and produced so called airs embolism with rapidly
leads to death owing to obstruction of cardiac or cerebral
vein.
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Capillary
hemorrhage
occurs
in
injuries
to
the
minutest vessels(capillaries); in this injures no separate
bleeding vessels can be seen, the blood oozes out of the
entire surface of the injury. The color of the blood is
between arterial and venous. A capillary hemorrhage usually
stops spontaneously, due to clotting of the blood. Bat this
type of bleeding is dangerous mainly in cases of impaired
blood coagulation(hemophilia, diseases of the liver).
Parenchymatous
hemorrhages
occurs
in
injury to the
internal organs which are rich in blood vessels ( spleen,
kidney, lungs, liver); these hemorrhages are usually arrest
with
difficulty
because
the
injures
involve
arteries,
veins, capillaries.
And now some words bout other terminology.
Petechia - blood bruise in the skin.
Ecchymosis - blood bruise in the
mucous.
Sugillation, suffusion - blood bruise in the submucous
areas.
Haematoma -
limited concentration of the blood in the
tissues.
Epistaxis - bleeding from the nose.
Gastrorrhagia - bleeding from the stomach.
Haemoptoe - blood expectoration during coughing.
Haematemesis - vomiting with a blood.
Haematuria - urination with a blood, erithrocytes in
the urine.
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Blood accumulation in the pericardial cavity - haemopericardium.
Blood accumulation in the pleural cavity
- haemo-
thorax.
Blood accumulation in the abdominal cavity - haemoperitoneum.
If is bleeding from upper part of small intestins or
stomach excrements are black so called - melena.
Acute anemia caused by massive hemorrhages.
The danger of a hemorrhage to the life of patient
depends primarily on the amount of blood lost.
The loss of
200-400 ml of blood(not rapid) not change for worse general
condition
of adults. A blood loss of 1000- 1200 ml is
dangerous. The rate of bleeding, age, the patients general
condition, sex are
importance as regards the results of
hemorrhage. Women tolerate hemorrhage more easily than men
do. In injures to the
major arteries or veins, the patient
may lost 500 - 800 ml of blood in short time and die before
administrating any aid.
A loss of 250-300 l of blood is
fatal for one-year-old child.
Every injury causes bigger or smaller lose of blood.
There are approximate quantities of blood, what can be lost
during the following injures:
1. Fractures of bones :
upper arm - 600 - 650 ml
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forearm - 300 - 600 ml
pelvic bones - 1200 - 2500 ml
femur - 1000 - 1800 ml
shin bones - 800 - 1000 ml
2. Injures to the :
thorax organs
- 500 - 1800 ml
abdominal parenchymatous organs 1700 ml.
Every
bloody operation is connected with blood lose
too :
appendectomy - 15 - 40ml
operation of hernia - 50 - 500ml
cholecystectomy - 150 - 500ml
resection of stomach 190 - 600ml
splenectomy - 100 - 800ml
pulmonectomy - 300 - 1800ml
The clinical signs of hemorrhages:
The patient want to drink, complains of weakness, of
things going dark before his eyes, dizziness, begins to
yawn?, sometimes faints. Examination of the patient reveals
pallor, especially on the extremities and ears, sometimes
cyanosis, the skin can be cool, clammy with pale. Other
sins can by tachycardia, tachypnea, decreasing of blood
pressure.
Routine laboratory tests as follows : decreasing
amount of Hb, Ht, erythrocytes and in some cases increasing
amount of leucocytes.
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The patient's sings and symptoms depend on size of
blood volume deficit.
In
general,
circulated
blood
tachycardia
about
pulse
pressure,
uncomplicated
volume
100
losses
result
beats/min,
respiratory
in
up
a
to
mild
15%
of
resting
normal blood pressure,
rate,
skin
color
and
temperature.
With losses between 15% to 30% of blood volume, the
tachycardia
systolic
increases
blood
to
pressure
greater
is
than
normal,
100
pulse
beats/min,
pressure
is
decreased, the respiratory rate is slightly increased, the
nail beds can be pale. The patient may by anxious.
With losses of 30% to 40% ( 1500-2000ml in 70kg male)
the tachycardia is increased to greater than 120 beats/min,
systolic blood pressure, pulse pressure are decreased. The
skin is cool, clammy, pale, mottled coloration.
Hemorrhage - hypovolemic shock
Shock occurs when in result of blood losses blood flow
is unable to ensure normal tissues oxygenation, nutrition
and elimination of products of metabolism. In the initial
stage
of
shock
organism
compensates
blood
losses
by
centralization of blood circulation, providing better blood
supply to heart, brain, kidney, liver, decreased perfusion
of skin, subcutaneous tissues, muscles, intestines. If the
bleeding continues, function of heart, brain, kidney, liver
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becomes impaired and patient may die. The cause of death is
hypovolemia.
Organism's adaptation mechanisms in case of bleeding
1. Constriction of the injured vessel and inversion of
its intima inside.
2. Formation of clot in the injury place.
3.
Tachycardia,
tachypnoe
to
provide
better
oxygenation and metabolism of tissues.
4. Autohemodilution - compensation of hypovolemy by
blood dilution with extracellular liquids.
5. Activation of blood coagulation system.
Stopping of the bleeding
The
during
external
during
blleeding
the
first
will
medical
be
stopped
assistence.
temporary
If
the
bleeding is capillary ar venous, compressig dressing shoulf
be used to stop it, keeping to all rules of aassipsis and
antisepsis. In most cases the bleeding stops finally.
venous
and
capillary
bleeding
can
be
stopped
by
eleveting the extremity - elevation.
If the bleeding is from major's arterias or vens,
following methods to stop it should be used:
short
bleeding.
time
stopping
and
final
stopping
of
the
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Stopping of bleeding for a short time
1. Compression of the artery with the digids (fist).
Artery must be compressed between the heart and the
wound.
Artery can be pressed to the bone in certain points.
Abdominal
aorta
is
pressed by fist in middle or
inferior part of abdomen.
Temporal aorta is pressed by fits to temporal bone in
front of the helix ear.
Arteria carotis should be pressed to the processus
transversus of VI cervical vertebra along the crus medialis
of m. strnocleidomastoideus.
Arteria subcliavia should be pressed to the I cost
over
the
clavicula
between
the
cruss
of
m.
strnocleidomastoideus.
Arteria mandibularis should be pressed by the thumb to
the angulus mandibulae.
Arteria axilaris should be pressed to the capitulum of
os humeri ( hand must by shifed foward).
Arteria axilaris should be pressed behid ligamentum
inquinalis to the ramus ossis pubicus.
Arteria poplitea should be compressed in the regio
poplitea. The thumb must be put in the front of knee joint,
and withthe other fingers arteria should be pressed in the
regio poplitea.
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Compresing of the artery should be continjed until
better method for stopping the bleeding can be appied.
2. Maximal flexion of the extremity anf fixation.
3. Tightening of the member with a spesial rubber
waist-band-tourniqet.
This method was offered by F.Esmarch in 1873. Acording
it all soft tissuses are compressed and the blood-vessel
pressed to the bone. Tourniquet is applied on between the
heart and the wound.
The rules of applying of the tourniquet:
lining must by done, skin crouching must by avoided,
tourniquet
must
have
it's
passport,
patient
with
the
turniquet should by accompanied by the medical personnel,
when the tourniquet is turned on, the extremity must be
elevated, the tourniqet must by kept on no longer than one
and half an hour. If there is need to keep it longer, after
one and half an hour it must by taken of for 1-2 minutes.
At this time the artery should be compressed proximally in
one of described points. After this the tourniquet should
be turned on in the different place. Tourniquet damages
soft tissuses, nervs, vessels,
thrombosis, necrosis of
tissuses can develope. If there is psibillity, pneumatic
tourniquets should by used.
If there is no special tourniquet belt , waist-band
can be used.
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First medical assitence when the bleeding accurs from
the different organs.
Meidical assistence, when the bleeding is from the
nose:
pacinent
is
thermophor
is
placed
in
applied
the
on
half-sitting
the
nose
and
pasitio,
the
nape,
cold
warm
thermophor is applied on the feet, tampon is inserted into
the nasal hole. If the bleeding goes after these measures,
posterior
tamponade
of
the
nose must by provide on by
specialist of the otorhinolaringology.
Meidical assistence, when the bleeding is from the
lungs: frightened patient must bu quietened, patient must
be placed in the half-sitting pasition or the appropriate
pasitino
for
postural
drainage
must
be
find,
give
the
patient to dring water with salt ( 1 spot of salt on a
glass
of
water),
patient
must
to
speak
less,
further
treatment of patient must be carried on in the thoracical
or ftysiatric department.
Meidical assistence, when the bleeding is from the
upper part of digestiv tract: give the patient quietness make him lie down, thermophore with ice is putted on the
region of ventricle, food, drink is not given, patient must
by administered to the surgical deparment. These patient
are very serious. If there is need, oxygen inhalation can
be given.
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Meidical
assistence,
when
internal
bleeding
is
suspected: absolut quietness must be given, thermophor with
ice is applied on the abdomen, no food, no drink, oxigen
inhalation. Patient must by administered to the surgical
deparment
as
soon
as
posible.
These
patient
are
very
serious.
Final stopping of the bleeding.
Mechanical : compresional bandage or tampon, ligation
or
suture
over
the
vessels,
torsio
of
the
vessels,
angiotripsia, suture or transplantation of blood vessel.
Physical:
temperature
cold
(
(
causes
causes
vasoconnstriction),
coagulation
of
high
proteins
and
accelerates hemocoagulation) , diathermy, laser( coagulates
proteins and vessels.
Biological
:
blood
transfusion
or blood components
such as plasma, trombocitic mass, fibrinogen;
infusion of
blood preparations ( preprotrombin complex, antihemophilic
globulin);
tamponade
with
autotissuses(
omentum,
mucle,
fascia), local aplication of blood preparations( thrombin
,hemostatic
sponge,
fibrin
plate,
biological
antiseptic
tampon).
Chemical:
vasoconstrictors( Sol. adrenalini 0.1%); preparations,
increasing
coagulation
(Calcium
chloride,
gelatin,
protamini sulphatum, vicasolum, dicinone); inhibitors of
fibrinolysis ( ac.e-aminocapronicum, contrical, trasilol).
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