Brit. J. Anaesth.
(1966), 38, 250
METHODS OF ASSESSMENT OF BLOOD LOSS IN THE SHOCKED AND
INJURED PATIENT
BY
J. W. L. DAVIES
MJ?.C. Industrial Injuries and Bums Research Unit, Accident Hospital,
Birmingham 15, England
The volume of blood lost by injured patients has
been the subject of many studies since the direct
measurements of plasma volume in battle casual-
ties by Keith (1919). Less precise indices of blood
loss have been described in terms of the amount
of tissue damage (Grant and Reeve, 1951) and the
degree of swelling of closed injuries of the ex-
tremities (Clarke, Topley and Flear, 1955). The
standard methods of measuring blood volume
depend on estimating the dilution of carefully
measured amounts of either dyes or radioactive
labels. These methods are much more accurate
than those described by Grant and Reeve, but
are also more laborious. The recently introduced
semi-automatic instruments for measuring blood
volume using radioactive methods (Williams and
Fine, 1961; Hobbs, 1965) now give rapid estima-
tions which are reliable and probably as accurate
as careful estimations by the earlier radioactive
methods.
The advantages and disadvantages of these
methods of assessing blood loss are summarized
in table I.
ASSESSMENT FROM THE AMOUNT OF TISSUE
DAMAGE
Grant and Reeve (1951) devised this method
during their study of battle casualties in the 1939-
45 War. The unit of volume is taken as the
patient's hand—the closed fist for deep wounds
and the open hand for surface wounds. The fol-
lowing four categories of severity help the initial
assessment of blood lost.
(1) Small wounds (less than 1 hand of tissue
damage) show a blood loss of rarely
more than 20 per cent of blood volume.
(2) Moderate wounds (between 1 and 3 hands
of tissue damage), a blood loss of be-
tween 20 and 40 per cent of blood
volume.
(3) Large wounds (between 3 and 5 hands of
tissue damage), a blood loss of about 40
per cent of blood volume.
(4) Very large wounds (more than 5 hands of (
tissue damage), a blood loss of 50 per
cent or more of blood volume.
Although this assessment can be made with speed
and ease its usefulness is limited in injuries such
as closed fractures and stab wounds. The open
hand also aids the assessment of the extent of
tissue damage due to burning, since the area it
covers is about 1 per cent of the body surface.
MEASUREMENT OF LIMB VOLUME
(a) Comparison of normal and injured limbs by
fluid displacement. In normal individuals the
volume of one limb does not usually differ in
volume by more than about 5 per cent from that of
its fellow, and below knee volumes do not differ by
more than 50 to 75 ml. In closed fractures of the
lower limb, therefore, volume differences of more
than 100 ml are probably due to swelling (Clarke,
Topley and Flear, 1955).
(b) Comparison of circumferential measurements
of normal and injured limbs (CotterilL 1951). The
circumferential measurements are made with a
tape measure at 2 cm intervals and the sum of the
volume of the 2 cm high cylinders calculated. A
10-20 per cent error is introduced by assuming
that limbs have a circular cross-section. In prac-
tice increased limb volume due to swelling may
be measured to within ±250 ml for a swollen
thigh or ± 150 ml for the lower part of the leg
(Clarke, Topley and Flear, 1955). Within 12 hours
of acute injury the volume of blood contained in
the tissues around a closed fracture agrees well
with the measured decrease in blood volume
(Clarke, Topley and Flear, 1955).

The advantages and disadvantages of various methods of measuring blood loss.
Method
Estimate of volume of tissue damage.
Measurement of limb volume.
(a) Fluid displacement.
(b) Circumferential measurement.
Measurement of plasma volume.
(1) T-1824.
(2) Protein labelled with radioactive
iodine (125I or 13I I).
Measurement of red cell volume.
(1) Using " P .
(2) Using <"Cr.
Simultaneous estimates of red cell and
plasma volume.
Semi-automatic instruments.
(a) Volemetron.
(b) Hemolitrc.
(c) Blood Volume Computer.
TABLE I
Disadvantages Advantages
Relatively inaccurate, particularly in arterial injuries. A rapid and simple estimate
suitable for massive soft tissue
injuries.
Confined to Only used if single limb injured since uninjured Rapid measurement of the size
closed injuries. limb acts as control. of swelling and its rate of
f increase.
Inaccurate when Error of method = 10-20 per cent. No venepunctures or injection
injuries cause Assumption made that all of swelling consists of radioactive materials.
shortening. of blood.
Error of method often more than 10 per cent mainly due to presence Freedom from hazards of radio-
of lipaemia or free haemoglobin. activity.
Measuring equipment relatively
Multiple blood samples required. Estimation time = 1^-2 hours. cheap and found in most hos-
Repeated estimations inconvenient. Estimations inaccurate in patients pitals.
with burns.
Radioactive materials. Multiple blood samples required. No errors due to lipaemia or
Estimation time=l hour. free haemoglobin.
Calculation of RBCV from BV or PV is dependent on haematocrit. Either BV or PV measured.
Radioactive counting equipment expensive. Error less than 10 per cent.
Estimations inaccurate in patients with burns. Repeat estimations easy.
Estimation time=2i—3 hours.
Label impermanent.
Multiple blood samples re- Radioactive materials. Red cell volume measured with
quired. Calculation of BV from RBCV an error of less than 5 per cent
Estimation time 1-li hours. is dependent on haematocrit. in patients with burns and other
Label almost permanent. Radioactive counting equipment injuries.
Multiple blood samples required expensive.
only from severely injured
patients.
Radioactive materials. Estimation time c. 2 hours. No extra blood samples re-
quired. Estimate not dependent
on haematocrit. Most accurate
estimation of blood volume.
Radioactive materials. Estimate of RBCV is dependent on haematocrit Blood volume estimate within
and equipment very expensive. Doses of radioactivity for instruments 20 min, using a 15-minute
(a) and (b) fairly expensive and of short shelf life (3 weeks). mixing time. RBCV and PV
obtained 10 min later. Repeat
estimations easy. 13S
Long shelf
life (6 months) of I albumin
for instrument (c).
252
MEASUREMENT OF PLASMA VOLUME
(a) Dye method. For a plasma volume estimation
an accurately known volume (or weight) of a
saline solution of T-1824 (c. 10 mg dye) is injec-
ted intravenously. Blood samples are taken from a
remote vein 10, 20 and 30 minutes after the injec-
tion, the plasma separated and the concentration
of dye in the plasma compared in a spectrophoto-
meter with plasma standards containing known
amounts of dye. In this measurement of plasma
dye concentration a substantial error may arise
from the presence of either free haemoglobin or
lipaemia. Careful handling of blood samples can
reduce haemolysis to neglible proportions and
lipaemia is slight in persons who have been
starved for about 12 hours. However, in emer-
gency work blood samples taken soon after injury
are often lipaemic, and this makes measurements
of dye concentration inaccurate. The dye extrac-
tion processes remove lipaemia but are laborious
and unsuitable for emergency work. Full details
of the T-1824 plasma volume method have been
described by Gregersen (1944).
(b) Radioactive methods. Plasma volume esti-
mations made with radioactively-labelled proteins
do not suffer from these disadvantages, but the
administration of radioactivity may sometimes be
undesirable (e.g. in pregnancy). The technique of
making a plasma volume estimation with either
115
I or 131I labelled human albumin is essentially
similar to that using T-1824. Since, however,
plasma or whole blood may be assayed for radio-
activity either the plasma or the blood volume
respectively is determined. The red cell volume
can be calculated from the plasma or blood
volume using the venous haematocrit corrected
for trapped plasma (Chaplin and Mollison, 1952)
and the average body/venous haematocrit ratio
(see below).
Neither T-1824 nor radioactive iodine labelled
albumin gives accurate plasma volume estimations
in patients with burns (Davies, 1960).
MEASUREMENT OF RED CELL VOLUME
Prior to 1950 radioactive phosphorus ("P) was
the label of choice for a red cell volume estima-
tion. Although an estimation took approximately
3 hours—mainly because of the time required to
BRITISH JOURNAL OF ANAESTHESIA
prepare the labelled red cells—the result of a care-
ful estimation had an error of less than ± 5 per
cent (Reeve and Veall, 1949). The modification
introduced by Mollison et al. (1958), resulting in
a more rapid and efficient labelling of red cells,
reduced the time required for an estimation of
equal accuracy to about 2 hours. The introduc-
tion of radioactive chromium (51Cr) by Sterling
and Gray (1950) further reduced the time re-
quired for an estimation to less than 2 hours. It
simplified the process of preparing the labelled
red cells and also made possible the study of red
cell survival since the 51Cr label within the red
cell is relatively permanent (Mollison and Veall,
1955).
Red cells are labelled with "Cr by incubation
with radioactive sodium chromate solution at room
temperature. The labelled cells are washed twice
with isotonic saline before intravenous injection of
an accurately known volume (or weight) of the cell
suspension. A blood sample is taken after a mixing
time of 15 minutes unless disturbances of the
circulatory system suggest an abnormal mixing
time, when three or more blood samples should
be taken at 10-minute intervals. The red cell
volume is calculated from the observed dilution
of radioactivity using the venous haematocrit
corrected for trapped plasma. The whole blood
volume is calculated from the red cell volume and
the body haematocrit (i.e. venous haematocrit X
0.90).
The use of the haematocrit in the calculation of
blood volume from plasma or red cell volume may
introduce an error due to the difference between
the venous (or arterial) haematocrit and the body
haematocrit. Because the haematocrit of blood in
very small capillaries is much lower than that in
large vessels, the body haematocrit is only about
90 per cent of the venous haematocrit. Whilst the
body/venous haematocrit ratio averages 0.90, its
range in a variety of clinical conditions lies be-
tween 0.70 and 1.00 Because of this possible varia-
tion the most accurate estimate of blood volume
is the sum of the red cell and plasma volume
separately and simultaneously measured. Im-
mediately sequential estimations of red cell and
plasma volume can be used, but the known and
sometimes rapid fluctuations in plasma volume
make this method potentially less accurate than
simultaneous estimations.
BLOOD LOSS IN THE SHOCKED AND INJURED PATIENT
SIMULTANEOUS MEASUREMENTS OF RED CELL AND
PLASMA VOLUME
Most simultaneous estimations have so far been
made with T-1824 and « P or 51Cr labelled red
cells. The accuracy is, however, limited by that
of the plasma volume estimate. Recently more
accurate and reliable estimates of blood volume
have been obtained using liSl labelled albumin
and 51Cr labelled red cells. Although these two
isotopes are injected simultaneously, their radia-
tion characteristics are sufficiently different that
51
Cr may be accurately assayed in the mixture.
Separation of plasma from whole blood allows
assay of the 135I alone.
For further details of these red cell and plasma
volume methods using radioactive labels, see
Davies and Topley (1959), Davies (1960, 1966).
SEMI-AUTOMATIC INSTRUMENTS FOR MEASURING
BLOOD VOLUME
The recently developed semi-automatic instru-
ments for blood volume measurement (e.g.,
Volemetron, Hemolitre and Blood Volume Com-
puter) have simplified these estimations by
eliminating most of the manipulations required
in the standard methods.
The net amount of radioactivity (usually 13l I
labelled albumin) injected into the patient is
determined by assay of the contents of a dispos-
able plastic syringe before and after intravenous
injection. The dilution of the injected radioactivity
is measured after a 15-minute mixing time by
assay of a blood sample taken from a vein remote
from that into which the radioactivity was in-
jected. The dilution volume is calculated by the
instrument and presented on a dial or register
directly reading in litres of blood volume.
A blood volume estimate is available about 5
minutes after taking the 15-minute blood sample
and a red cell volume estimate 10 minutes later
using the haematocrit measured in a high-speed
centrifuge. Red cells labelled with 51Cr may also
be used to measure blood volume in some of these
instruments. The advantages of a rapid estimation
are, however, lost when the labelled red cells are
prepared by the standard method. Substitution of
l
" I labelled albumin for 1S1I labelled albumin as
the injected dose of radioactivity has further im-
proved the convenience of blood volume estima-
tions. The long radioactive half-life of 125Iodine
253
(58 days) ensures a shelf life of about six
months for doses of 1ISI labelled albumin (cf.
three weeks for 131I labelled albumin). The instru-
ment specifically designed to use 115I (the Blood
Volume Computer) costs about half that of other
iastruments and has only one-tenth of the weight
(Hobbs, 1965).
Whilst these instruments have improved the
convenience and rapidity with which a blood
volume estimation can be made, the calculated
red cell or plasma volume is less accurate because
of use of the haematocrit. Until a semi-automatic
instrument becomes available which will separ-
ately assay a mixture of isotopes and thus give
estimates of both red cell and plasma volume,
standard methods must be used if the most
accurate estimation of blood volume is required.
DISCUSSION
In the shocked and injured patient disturbances
of the circulation may cause a prolonged mining
time. In these circumstances serial blood samples
should be taken at intervals of about 10 minutes
until mixing appears complete. Blood samples
taken immediately after complete mixing will give
the most accurate estimations of red cell or plasma
volume. In seriously injured patients with oligae-
mia, vasoconstriction may, however, make venous
sampling difficult at a time when multiple blood
samples are desirable.
Although a carefully performed red cell or
plasma volume estimation may have an error of
not more than 5 per cent, a considerably greater
error may be introduced when the result is com-
pared with the patient's expected normal red cell
or plasma volume to give an estimate of blood loss.
Whilst the most accurate estimate of these normal
values is derived from lean body mass (Mul-
downey, 1957) its estimation from total body
water is time-consuming and unlikely to be
reliable after serious injury. In emergency work
only height and weight can usually be measured.
From these two measurements the most accurate
prediction of normal values is given by the follow-
ing regression equations (Nadler et al., 1962):
blood volume (adult males)
=0.3669H 3 +0.03219R7+0.6041;
blood volume (adult females)
=0.3561H 3 +0.03308VF+0.1833;
where H=height in metres and W=weight in
kilograms.
254
The normal male red cell volume is 44 per
cent of the male blood volume and the normal
female red cell volume 40 per cent of the female
blood volume.
If the nature of the injury prevents accurate
measurement of weight the normal values may be
predicted from height alone with an error of up to
15 per cent. This error is reduced to about
5 per cent when the patient's weight is near the
ideal for height.
The amount and timing of blood loss in both
Service and civilian injuries (Prentice et al., 1954;
Clarke et al., 1961) has been calculated from serial
blood volume estimations usually made soon after
injury, before and after reparative surgery and
during the ensuing weeks. Similar studies have
been made in patients with burns (Topley and
Jackson, 1957; Davies, 1964). Although the esti-
mations made soon after injury may be less
accurate than those made postoperatively when
the circulation is more stable, the trend of the
results suggests that the initial estimation usefully
indicates the amount of early blood loss. Blood
lost during surgical procedures may also be
directly measured by weighing soaked swabs, etc.,
and aspirate, or more accurately by estimation of
the haemoglobin or electrolyte content of as-
pirate and the fluid in which all bloodstained items
have been washed (Coller, Crook and lob, 1944;
Gardiner and Dudley, 1962).
A retrospective estimate of blood loss is ob-
tained from haemoglobin or haematocrit values
estimated during the second week after injury.
By this time the presence of anaemia suggests that
the early blood loss was inadequately replaced by
blood transfusion (Topley and Clarke, 1956).
By comparison of measured losses with the ex-
tent and severity of injury, these serial blood
volume estimations have provided information
for use as a guide to the management of future
patients. With increasing clinical experience of
the amount and timing of blood loss, however, the
most valuable role of blood volume estimations is
probably as a check on the adequacy of blood
volume replacement rather than as a measure of
the need prior to replacement.
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