A hemorrhage of major proportions represents a double threat to the homeostasis of the person.

First, acute severe blood loss can decrease the blood volume to a point of cardiovascular collapse, irreversible shock, and death. In this situation, the loss of circulating red cells is of far less importance than the sudden depletion of the blood volume. Second, when blood loss is more gradual, the circulating red cell mass may be so depleted as to impair oxygen delivery to vital organs. The response to these threats involves a number of physiologic mechanisms, including adjustments in cardiovascular dynamics, blood volume, red cell production, and oxygen transport by erythrocytes. The clinical manifestations of acute blood volume loss reflect adjustments in cardiac output and vascular tone that help prevent circulatory collapse and maintain oxygen supply to vital organs. As outlined in a normal person can rapidly lose up to 20 percent of the blood volume without signs or symptoms of anemia or cardiovascular collapse. If the hemorrhage exceeds 20 percent, signs of cardiovascular distress appear. At first, this is limited to tachycardia with exercise and postural hypotension. When the blood loss exceeds 30 to 40 percent of the blood volume, there is a fall in cardiac output and the gradual onset of shock: The patient becomes immobile and exhibits air hunger; a rapid, thready pulse; and cold, clammy skin. Unless further hemorrhage is prevented and effective therapy is begun, organ damage and death ensue. A very rapid blood loss that exceeds 50 percent of the patients blood volume carries a high mortality rate unless immediate volume replacement therapy is initiated. With acute hemorrhage, the hemoglobin or hematocrit will not reflect the quantity of blood lost. Once hemorrhage has ceased, the recovery of the red cell mass to normal is usually accomplished gradually without inconvenience to the patient. Serious attempts at increasing iron supply by combination therapy should therefore be reserved for those situations where a rapid maximum response is essential, as in preparation of a patient for surgery or in the treatment of prolonged, continuous hemorrhage. Blood transfusion should be reserved for those instances where normal response mechanisms and iron supplementation are insufficient to sustain an adequate red cell mass or the acuteness of the situation demands an immediate response