GENERAL SURGERY

ASSIST. PROF. Dr. LUTFI GHULAM AWAZLI

Consultant General Surgery and Cosmetic Laser Surgery

University of Baghdad
College of Dentistry
20123 - 2024
  BLEEDING / HAEMORRHAGE :

 Definition:
Bleeding is escaping of blood from the damaged blood vessels into the
surrounding tissue.
Bleeding can be externally (outside the body) or internally (inside the body).
Examples of Bleeding:

(Stomach bleeding) (Nasal bleeding) (Skin bleeding)

 Classification of bleeding
according to:

1) 6)
Causes of
bleeding The amount of blood
volume loss/ or degree
of bleeding

2) 5)
The type of
Mode of treatment
blood vessel that
is damaged 3) 4)
Time of bleeding Visibility of bleeding
 1) Classification of bleeding according to Causes of bleeding:
A variety of conditions can cause bleeding. These include:
1 - Traumatic bleeding: Many types of trauma can cause wound bleeding,
Examples :
 Open wounds ( Abrasion, Laceration, Incision, Avulsion, Puncture,
Penetrating and Gunshot).
 Closed wounds ( Crushing injuries and Hematoma ).
2 - Non-Traumatic bleeding: Includes:
A - Medical diseases: Some medical diseases can cause bleeding (Nasal
bleeding, Intracerebral bleeding, GIT bleeding).
Examples of medical diseases include:
 Hemophilia, Leukemia, Thrombocytopenia, Liver disease, Hypertension,
Bleeding duodenal ulcer, Esophageal varices, Hemorrhoids,
B - Drugs induced bleeding: Some drugs ( Medications ) that may be
responsible for bleeding, Examples :
 Blood-thinning medications (Heparin, Enoxaparin, Warfarin).
 Non Steroidal Anti-Inflammatory Drugs (Aspirin, Profen, Voltaren,
Ponstan).
2) Classification of bleeding according to the Type of Blood Vessel
that is damaged:
A. Capillary Bleeding: B. Venous Bleeding:
 Superficial lesions cut the capillaries.  Deep tuc snoisel the veins .
 The bleeding is always bright red,  The bleeding is dark red steady,
very slow and small in quantity relatively slow flow.

C. Arterial Bleeding:
 Deep tuc snoisel the arteries .
 The bleeding is bright red, fast, large volume ni dna spurts,
pulsating correspond with each beat of the heart .
 This is the most dangerous type of bleeding.
severe arterial bleeding can cause deathsetunim wef a nihtiw
3) Classification of bleeding according to Time of bleeding:

A - Primary bleeding is bleeding occurring immediately as a result of

an injury (or surgery).

B - Reactionary bleeding is delayed bleeding (within 24 hours) after

injury or surgery and is usually caused by dislodgement of clot, or
slipping of ligature. This bleeding occurs as a result of resuscitation,
normalization of blood pressure and vasodilatation.

C - Secondary bleeding is caused by sloughing of the wall of a vessel. It

usually occurs ( days ) after injury and is precipitated by factors such
as infection, pressure necrosis (such as from a drain).
 4) Classification of bleeding according to Visibility:
 External / Revealed bleeding:
Blood loss outside the body.
Example:
 In trauma, Bleeding from an
open wound / Skin.
 In non-trauma, Bleeding from
the nose . Or any severe bleeding
in the GIT or Urinary system, It
is internal at the start but later on
it becomes external.
 Internal / Concealed bleeding:
Blood loss inside the body.
Example:
 In trauma, bleeding within the
chest, abdomen, or bone fracture.
 In non-trauma, Intracerebral
bleeding, or intraocular bleeding.
5) Classification of bleeding according to Mode of treatment:

A. Surgical bleeding :
 It is the bleeding that can be stopped by surgical means.
 Examples:
Traumatic wound bleeding, Hemorrhoids, Ruptured aortic aneurysm.

B. Non-surgical bleeding :
 It is the bleeding that cannot be stopped by surgical means. It requires
correction of the coagulation abnormalities.
 Examples:
Hemophilia, Thrombocytopenia, Drug induced bleeding.
6) Classification of bleeding according to the Amount of blood
volume loss / Degree of bleeding :
 The degree of bleeding can be classified into classes 1– 4 based on the
estimated blood loss by the American College of Surgeons, Advanced Trauma
Life Support (ATLS).
 The adult human has approximately 5 liters of blood ( 70 ml/ kg for adult,
80 ml/ kg for children and 90 ml/kg for a neonates).
 Class I bleeding
 Characteristics features :
 Amount of blood loss: Minimal Blood Loss:
. Blood Volume Loss < 15%
i.e. Adult blood loss < 750 ml

 Vital signs : There is no change in vital signs.

 Cardiovascular : Heart rate normal

Blood Pressure normal
 Respiratory : Respiratory Rate normal
 Neurologic: Slightly anxious
 Skin: Warm and pink
 Renal: Normal urine output

 Treatment: Stop bleeding

Fluid resuscitation is not usually necessary.
 Class II bleeding
 Characteristics features :
 Amount of blood loss: Mild Blood Loss:
. Blood Volume Loss 15% - 30 %
i.e. Adult blood loss 750 ml – 1500 ml
 Vital signs :
 Cardiovascular: Mild increase in heart rate ( Mild Tachycardia)
Mild Hypotension
 Respiratory : Mild increase in Respiratory Rate (Mild Tachypnea)
 Neurologic: More anxious and Confused
 Skin: Cool extremities
 Renal: Decrease in urine output (Oliguria)

 Treatment: Stop bleeding

Fluid resuscitation (Crystalloids: Normal saline or .
. Lactated Ringer's solution) is all that is required.
. Blood transfusion is not usually required.
 Class III bleeding
 Characteristics features :
 Amount of blood loss: Moderate Blood Loss
. Blood Volume Loss 30 % - 40%
i.e. Adult blood loss 1500 ml -2000 ml
 Vital signs :
 Cardiovascular: Moderate increase in HR (Moderate Tachycardia)
Thready peripheral pulses
Moderate Hypotension
Metabolic Acidosis
 Respiratory : Moderate increase in RR (Moderate Tachypnea)
 Neurologic: Irritable, Lethargic
 Skin: Cool extremities, Pallor
 Renal: Oliguria with Blood Urea Nitrogen (BUN) increased
 Treatment: Stop bleeding
. Fluid resuscitation (crystalloid: NS and Ringers) .
. + Blood transfusion are usually necessary.
 Class IV bleeding
 Characteristics features :
 Amount of blood loss: Severe Blood Loss
. Blood Volume Loss : > 40%
Adult blood loss > 2000 ml
 Vital signs :
 Cardiovascular: Severe increase in HR (Severe Tachycardia)
Thready central pulses
Severe Hypotension and shock
Severe Metabolic Acidosis and Coagulopathy
 Respiratory : Severe increase in RR (Severe Tachypnea + Dyspnea)
 Neurologic: Lethargic, Coma
 Skin: Cold extremities (Hypothermia), Pallor, Cyanosis
 Renal: Anuria (No urine output)
 Treatment: Aggressive resuscitation is required to prevent death.
ABCDEF management:
. (Fluid + Blood + Plasma and Platelet transfusion).
  Pathophysiology and Complication of bleeding :
 Continuous bleeding leads to hypovolemia and hypotension and this cause a state of
Hypovolemic shock with inadequate tissue perfusion (Hypoperfusion = Ischemia).
 Ischemic tissue is unable to generate heat (Metabolism ) and so Hypothermia results.
 Ischemic tissue also leads to cellular hypoxia that result in anaerobic metabolism and
Lactic acidosis.
 Hypothermia and Lactic acidosis lead to Coagulopathy which result in defect in
homeostasis' (defect in blood clot ) and thus further bleeding and shock, which can lead to
multiple organ failure, brain damage and death.

Figure: Triad of Death

Three factors hypothermia,
Diagram showing the Pathophysiology and Coagulopathy, Acidosis result in
Complication of continuous bleeding. death.
THE END