You are on page 1of 11

ROGER JONES ET AL. 2005. OXFORD TEXTBOOK OF PRIMARY MEDICAL CARE.

OXFORD UNIVERSITY PRESS

Myers.Marianne Neighbors.Principles of Pathophysiology and Emergency Medical Care Oleh Jeffrey W.Ruth Tannehill-Jones .

.

heparin. behind the abdominal cavity) may occur.medicinenet. and depending upon the circumstances. the weight doesn't give. and the risk of bleeding needs to be balanced against the benefits of taking the medication. where the kidney is located.com/internal_bleeding/article. Hemophilia and von Willebrand disease are two examples What causes internal bleeding? Bleeding most often occurs due to injury. when a weight falls on a foot. Examples of other potential sites of bleeding include the eye. If the skin is damaged by a laceration. If blunt force is involved. For example. retroperitoneal bleeding (retro=behind. and the bleeding can spill into the peritoneum (the space in the abdominal cavity that contains abdominal organs such as the intestines. and abdomen. muscles. the capsule or lining of the organ can be torn. chest. This can cause the bone to break and/or the muscle fibers to tear and bleed. These individuals may experience significant bleeding even with relatively minor injury or illness. puncture.htm What is internal bleeding? While the general public understands that internal bleeding means bleeding that can't be seen on the outside of the body. The force needs to be absorbed by either the bone or the muscles of the foot. Internal bleeding occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. or abrasion.  Imagine a football player being speared by a helmet to the abdomen. The scalp. If the hit is hard enough. or in cavities of the body including the head.clopidogrel (Plavix). The spleen or liver may be compressed by the force and cause bleeding inside the organ. and joints.   . The repair mechanisms available include both the blood clotting system and the ability of blood vessels to go into spasm to decrease blood flow to an injured area. blood can be witnessed as it streams out of the body. and symptoms occur when there is significant blood loss or if a blood clot is large enough to compress an organ and prevent it from functioning properly. liver. as well as the body's ability to repair breaks in the walls of the blood vessels. If the injury occurs in the area of the back or flank. the outside of the body may not necessarily be damaged. organs. The same mechanism causes bleeding due to crush injuries. the amount of force required to cause bleeding can be quite variable. lining tissues of the heart. The internal bleeding may occur within tissues. Minor injuries may cause major bleeding in these cases. The amount of bleeding depends upon the amount of damage to an organ and the blood vessels that supply it. medical personnel tend to use terms that describe precisely where inside the body the bleeding is found. with its rich blood supply. is notorious for demonstrating massive blood loss. or aspirin are more prone to bleeding than people who do not take these medications. Bleeding outside the body is quite easy to recognize. Some people have genetic or inborn errors of the blood clotting system.http://www. It may not be evident for many hours after it begins. nor does the ground. but enough compression may occur to internal organs to cause injury and bleeding. Patients who take anti-clotting medication such as warfarin (Coumadin). Internal bleeding can be much more difficult to identify. Blunt trauma Most people understand that falling from a height or being involved in a car accident can inflict great force and trauma upon the body. and spleen).

Early on. causing the brain to "bounce around" inside the skull. Other structures are compressible and may cause internal bleeding. For example. Since the brain is encased in the skull. causing inflammation and pain. how much bleeding has occurred. in which the placenta and the fetus implant in the Fallopian tube or another location outside of the uterine cavity. the concern is a potential ectopic or tubal pregnancy. The break of a long bone such as the femur (thigh bone) can result in the loss of one unit (350500cc) of blood. Deceleration trauma Deceleration may cause organs in the body to be shifted inside the body. What are the signs and symptoms of internal bleeding? The symptoms of internal bleeding depend upon where the bleeding is located. especially in those people who take anticoagulation medications or who have inherited bleeding disorders. Intracranial bleeding from trauma or from a leaking aneurysm often causes pain but may also present with altered mental function. Examples of some internal bleeding situations are listed below. As the placenta grows. Routine bumps that occur in daily life may cause significant bleeding issues. They have rich blood supplies. These substances can cause inflammation and bleeding of theesophagus. Flat bones such as the pelvis require much more force to cause a fracture. even a small amount of blood can increase pressure inside the skull and decrease brain function. and urgent medical care should be accessed. Force applied to the head causes an acceleration/deceleration injury to the brain. stomach. Spontaneous bleeding Internal bleeding may occur spontaneously. Bones contain the bone marrow in which blood production occurs. and is a sign of a potential miscarriage. Blood outside the circulatory system (the heart and blood vessels) is very irritating to tissues. Alcohol abuse Long-term alcohol abuse can also cause liver damage. and duodenum. which can cause bleeding problems through a variety of mechanisms. Neurological exam results range from a near-normal exam . it erodes through the tube or other involved organs and may cause fatal bleeding. and what structures and functions in the body are affected. Bleeding after 20 weeks of pregnancy may be due to placenta previa or placental abruption. Abruption occurs when the placenta partially separates from the uterine wall and causes significant pain with or without bleeding from the vagina. Fractures Bleeding may occur with broken bones. Pregnancy Bleeding in pregnancy is never normal. the first part of the small intestine as it leaves the stomach. and significant amounts of blood can be lost with fractures. Medication Internal bleeding may be caused as a side effect of medications (most often from nonsteroidal antiinflammatory drugs such as ibuprofen and aspirin) and alcohol. This can tear some of the small veins on the surface of the brain and cause bleeding. This is often the mechanism for intracranial bleeding such as epiduralor subdural hematomas. This may shear blood vessels away from the organ and cause bleeding to occur. Placenta previa describes the situation in which the placenta attaches to the uterusclose to the opening of the cervix and may cause painless vaginal bleeding. Intraorbital hemorrhage may occur. which is a solid structure. though not uncommon in the first trimester. the eye can be compressed in the orbit when it is hit by a fist or a ball. The globe deforms and springs back to its original shape. and many blood vessels that surround the structure can be torn by the trauma and cause massive bleeding.

Bowel movements may be bloody or they may be black and tarry. and rarely. and they begin to die. Symptoms of stroke. the patient may vomit bright red blood. or if it is intra-abdominal bleeding. if the bleeding occurs rapidly. there can be a significant amount of pain with any movement. and the abdomen can become tense and feel rigid to touch. slurred speech. and loss of vision. If found.   Blood seen in the urine may be due to internal bleeding at any site within the urinary tract. the initial hemoglobin reading or red blood cell count may be normal. may also be associated with intracerebral bleeding. The suspicion of internal bleeding will often require an imaging test to look for the bleeding source. Intra-abdominal bleeding may be hidden and present only with pain. again depending upon the location of the bleeding in the gastrointestinal tract. and other symptoms of shock anddecreased blood pressure.lightheadedness. and loss of sensation. Most commonly this is seen in the shin and forearm and may or may not be associated with a broken bone. the physical examination will focus on the neurologic system. Symptoms include intense pain. or if it has been in the stomach for a period of time. This is followed by a physical examination. Often bladder infectionsare associated with blood in the urine but other causes need to be considered based upon the particular symptoms as well as the patient's age and medical history. How is internal bleeding diagnosed? The diagnosis of internal bleeding begins with a thorough history taken by the health care practitioner. Grey-Turner sign is bruising in the flanks. includingweakness. If the internal bleeding causes blood to spill into the peritoneum. concentrating on the area of the body where the internal bleeding may have occurred. Sometimes intra-abdominal blood will track toward the skin and can be appreciated on physical examination. agastroenterologist may use fiber optic scopes to look into the esophagus and stomach (endoscopy) or into the colon (colonoscopy) to identify the source. especially males who may have had prostate surgery. shortness of breath.  If there is concern that there is gastrointestinal bleeding. Bleeding may occur deep within muscles after injury. If the bleeding continues. However. Men and women who have had radiation therapy may develop inflammation of the bladder wall which can cause a significant amount of bleeding. difficulty moving the joints below the injury.  If there is gastrointestinal bleeding. Blood tests may be performed to check for alow red blood cell count. from the kidney to the bladder. . Cullen's sign is the term used to refer to the appearance of bruising surrounding the umbilicus. the physician may be able to stop the bleeding using electricity to cauterize or burn the blood vessel that is bleeding. the patient may complain of weakness. causing significant pain and loss ofrange of motion. if there is concern about bleeding in the brain. The signs and symptoms depend upon where and how much blood there is in the brain. This most frequently is seen in patients who are on anti-coagulation medications. Once again. but if there is enough blood loss. An injury may or may not be needed to cause the bleeding. or anemia.compartment syndrome may occur. For example. the exam will be directed toward the abdomen. the vomit may look like coffee grounds. the symptoms depend upon where in the abdomen the bleeding occurs.to confusion tocoma. Bleeding may also occur into joints. symptoms become progressive and easier to recognize. Should so much bleeding occur that the pressure build-up within the muscle is greater than the patient's blood pressure. blood cannot get to the muscle cells.

and  that there is adequate Circulation. even though you cannot see the bleeding. Ultrasound may be used to look for blood in the abdomen. ultrasound is especially useful in evaluating obstetric and gynecologic problems such as bleeding from an ovarian cyst or an ectopic or tubal pregnancy. While it has its place in the management of trauma. This may occur in trauma victims with abdominal or chest injuries who have unstable vital signs (decreased level of consciousness. The basic goals include identifying and stopping the source of bleeding and repairing any damage that the bleeding may have caused. It can evaluate the potential injury site. Computerized tomography is an effective tool in looking for intra-abdominal and retroperitoneal bleeding. the individual situation.  that the patient is Breathing. A person may be bleeding internally if one of these things happens:          Blood comes out of the nose or mouth (occurs from severe head trauma) Blood or clear fluid comes out of the ear (occurs from severe head trauma) Blood is in the stool Blood is in the urine Bright red blood.  Computerized tomography (CT) is the most common test to look for bleeding in the brain. It is also a helpful test in assessing pelvic fractures. the severity of organ damage. This includes making certain the patient's: Airway is open. and whether the bleeding is contained within an organ (such as the liver. In cases of internal bleeding the skin may become pale and cold. How is internal bleeding treated? The initial treatment plan of any patient with internal bleeding begins with assessing the patient's stability and making certain the ABCs are well maintained. If you see the signs of shock and no apparent injuries.low blood pressure. Check the skin color changes. and cyanosis may be present. always suspect internal bleeding. kidney or spleen) or whether the bleeding has spilled into the peritoneum. or blood like 'coffee-grounds'.angiography may be used to evaluate the arterial blood flow.  . It is also able to identify brain swelling and fractures of the skull. The definitive treatment of internal bleeding depends upon where the bleeding is occuring. is in the vomit Blood comes from a woman's vagina (birth canal) after an injury or during pregnancy Bruising over the abdominal or chest area Pain over vital organs Fractured femur But remember. If the source of bleeding is thought to be due to a damaged artery. and the stability of the patient. meaning good pulse and blood pressure. a person may be bleeding inside the body. and other signs of shock) and are at risk for bleeding to death if they were to wait for diagnostic tests. the decision may be made to undergo emergency surgery to find and repair the bleeding site.   In some situations in which the patient is critically ill from internal bleeding.

whereas in internal bleeding. shock. which fall in to seven main categories. this is caused by mechanical destruction of the skin. For example:  If there is uncontrolled bleeding in the chest or abdomen. this may include two external wounds (entry and exit) and a contiguous wound between the two . The principle difference is whether the blood leaves the body . needle or knife Contusion .   External Bleeding Bleeding is a common reason for the application of first aid measures and can be internal or external. and usually does not penetrate below the epidermis Excoriation . and death. but if there is enough to cause increased pressure or if the bleeding increases. such as a knife Puncture Wound . enough brain tissue may be damaged to cause stroke-like symptoms. no blood can be seen. such as a nail. which are:        Abrasion . internal bleeding may cause organ failure. coma. if not recognized. this is caused by transverse action of a foreign object against the skin.Caused by an object penetrated the skin and underlying layers. warfarin (Warfarin).  Internal Bleeding At A Glance   Internal bleeding may occur in many areas of the body and may cause significant local pain. If the bleeding is not stopped and if fluid resuscitation and perhaps blood transfusion are not provided. although it usually has an underlying medical cause Laceration . the patient may die. Bleeding is a recognized complication of anti-coagulation medications such as aspirin.Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth Incision .Also called a graze. the body may lose enough circulating red blood cells to compromise oxygen delivery to cells in the body. signs of shock may be apparent. and death.A clean 'surgical' wound. clopidogrel (Plavix). If internal bleeding is suspected. If enough bleeding occurs.Caused by a projectile weapon.Also known as a bruise.What are the complications of internal bleeding? Depending upon where it occurs. this is a blunt trauma damaging tissue under the surface of the skin Gunshot wounds . and heparin. This situation is called shock. caused by a sharp object. Internal bleeding in the brain may cause minimal damage.external bleeding can be seen.In common with Abrasion. The benefits of these medications need to be balanced against the risk of bleeding. Bleeding is never normal in pregnancy. it is important to seek medical care. There are many causes of external bleeding.

Repeat this again when you reach three dressings. you should lie them on their back (supine). Treatment As with all first aid situations. any material is suitable). This is best done using a dressing. add additional dressings to the top. and use furniture or surrounding items to help support them in this position. You should assist them to do this if necessary. then the situation is life-threatening. Elevation Direct pressure is usually enough to stop most minor bleeds. so put on protective gloves before approaching the victim. closing the hand would have the effect of opening the wound. and assisting clotting. It may be difficult to find the source of bleeding. You should ask the victim to hold their wound as high as possible. slowing the blood flow. but for larger bleeds. . if a hand is cut 'across' from the thumb to halfway across the palm. such as a sterile gauze pad (although in an emergency. it may be necessary to elevate the wound above the level of the heart (whilst maintaining direct pressure the whole time).Recognition Recognizing external bleeding is usually easy. you should remove all but the one in contact with the wound itself (as this may cause it to reopen) and continue to add pads on top. It should however be remembered that blood may be underneath or behind a victim. the less movement the wound undergoes. However. especially in the case of arterial bleeding. Where an articulate area of the body is wounded (such as the arms or hands). If you reach three dressings. If it is the legs affected. For example. This is simply placing pressure on the wound in order to stem the flow of blood. it is important to consider the position of the area in keeping pressure on the wound. If there is more than 5 cups of bleeding. All external bleeding is treated using three key techniques. so rest is advised. thus the severity of the bleeding. as the presence of blood should alert you to it. Direct Pressure The most important of these three is direct pressure. especially with large wounds or (even quite small) wounds with large amounts of bleeding. This decreases the blood flow to the affected area. the wound can be closed with direct pressure by simply clasping the victim's hand shut. The reason for not simply adding more dressings is that it becomes harder to apply the direct pressure which is clearly needed if this much blood is produced. and so the victim should have their hand kept flat. If the blood starts to come through the dressing you are using. the easier the healing process will be. if the hand was wounded from between the two middle fingers down to the wrist. Rest will also reduce the pulse rate. the priority is to protect yourself. to a maximum of three. which allow the body's natural repair process to start. and raise their legs. Elevation only works on the peripheries of the body (limbs and head) and is not appropriate for body wounds. These can be remembered using the acronym mnemonic 'RED': Rest – Elevation – Direct pressure Rest In all cases.

as below. but should not be so tight as to cut blood flow off below the bandage. If possible. Dressing Once the bleeding is slowed or stopped. to a maximum of three. If the blood flow is minor. Once this is in place. you should seek medical assistance. Special cases Nosebleeds (epistaxis) If a person has nosebleed. don't remove it. To dress a wound. You should also lean them to the injured side. add another on top. Rolled bandages are perfect for this. If these are all saturated. do this yourself. Embedded Objects If there is something embedded in the wound. If the nose continues to bleed with a fast flow. If it takes more than 2 seconds for the pink color to return under the nail. feel free. If the blood starts to come through the dressing you have applied. remove the top two. which will not stick to the wound. In some cases. you should sit the victim up (as blood in the body will go to the lowest point. Tilting the head forward ensures that blood isn't ingested (as it can cause vomiting) or inhaled (choking hazard). If it isn't. you could consider using an ice pack on the bridge of the nose to help stem the flow. the wound would be opened anew. and after assessing the ABCs of the victim. You can also leave the head in a neutral position. puncture or gunshot wounds to the body These wounds are life threatening. . to assist the slowing of the blood flow you should consider dressing the wound properly. As always. keeping the healthy side free from incursion by blood. for instance). but it is preferable to have them do it themselves if they are able to do it effectively. If you stop the flow by hand. you will apply pressure by hand in order to stem the flow of blood. If you are unsuccessful at stopping the bleeding after 10 minutes of direct pressure. probably from the ambulance. hold the hand or foot (dependent on what limb is injured) above the level of the heart and firmly pinch the nail. you should then consider dressing the wound properly. Stab. you should immediately summon an ambulance. just below the end of the bone. then the bandage is likely to be too tight. but will absorb the blood coming from it. A useful rule of thumb: if it's causing bleeding. allowing the heart and lungs to work as efficiently as possible).In most cases. leaving the closest dressing to the wound in place. a dressing may help you do this as it can keep pressure consistently on the wound. use a sterile low-adherent pad. A simple check for the bandage being too tight on a limb wound is a capillary refill check. It should be tight enough to apply some direct pressure. Instead. This ensures that any blood clots that have formed are not disturbed. Be careful not to disturb the object. The victim should lean their head slightly forward and breathe through their mouth. to do this. but never tilt the head back. during the initial treatment of the bleed. as moving it may exacerbate the bleeding. As with all embedded objects. or in some cases. do not remove it. have them pinch the soft part of the nose firmly between thumb and forefinger. ensure you do not remove the item from the body. If necessary. you should check that you are not in danger when approaching these victims (from someone with a knife or gun. wrap a crepe or conforming bandage around firmly. apply pressure around the object using sterile gauze as described above. you should assess the blood flow. otherwise. This doesn't apply to superficial splinters and such.

but treat as a wound. do not detach. and place this bag into a bag of ice and water.Assess the victim for open chest wounds or abdominal injuries. meaning that surgeons are unable to reattach it. immediately summon ambulance assistance. . as this can cause irreparable damage. and treat accordingly. and treat the wound for bleeding first as above. sending it with the victim to the hospital (it should be labeled with their name. Cover the amputated part with a moist dressing and place it in a clean plastic bag. Amputations If a body part has been amputated. If the body part is partially amputated. You should avoid putting the part in direct contact with ice. and where it belongs).