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General objective: At the end of our 30-minute discussion, the learners will be able to comprehend knowledge about bleeding.

Moreover, the learners will be able to understand the significance of proper management of bleeding in application for their upcoming profession.

Specific Objectives:
After the 30-minute lecture discussion about the subject matter, the learners will be able to: define what bleeding means; figure out some causes of such; recognize the classes of hemorrhage; enumerate the types of bleeding; differentiate the characteristics of the three (3) types of external bleeding according to what kind of blood vessel is damaged; recognize the signs of internal bleeding; know the operative techniques in bleeding-control; and be familiarized on what to do when bleeding occurs.

Specific Objectives:
the lecturers will be able to: explain what the subject matter is about; define what bleeding is; distinguish the difference of the two types of bleeding; make clear the different classes of hemorrhage; present the different characteristics of the types of external bleeding; impart the knowledge about the treatment and management when bleeding occurs; present the operative techniques in controlling bleeding; and encourage participation by asking some questions during the lecture proper.

Massive Bleeding/Hemorrhage

Janine T. Lozarita Ellamieh Joy D. Rosa

What is hemorrhage?
Hemorrhage is the medical term for bleeding (lost of blood from the body) Refers to the amount of bleeding (500cc) in a short time.

Causes of hemorrhage:
Trauma blunt or penetrating injury, iatrogenic trauma, surgical procedures. Underlying pathology peptic ulcers, aneurysms, AV malformations, malignancy, uremia, etc. Coagulation disorders e.g hemophilia Drugs NSAIDS, warfarin, etc

Classes of hemorrhage:
Class I up to 15% blood loss - usually, no change in BP, pulse pressure or respiratory rate - minimal tachycardia may be there - CRT > 3 seconds volume loss 10% Class II blood loss 15-30% - tachycardia, tachypnea, decreased pulse pressure, cold clammy skin, delayed capillary refill, slight anxiety

Class III loss of 30-40% -marked tachycardia and tachypnea, decreased systolic BP, oliguria, altered mental status like confusion or agitation -most will require blood transfusion
Class IV loss of > 40% blood volume -marked tachycardia, decreased BP (diastolic may be unrecordable), markedly decreased or no urinary output, depressed mental status ( or loss of consciousness) cold and pale skin. - immediately life threatening.

Two types of bleeding:

Internal Hemorrhage External hemorrhage

External Bleeding:
Refers to blood coming from an open wound. Can be classified into three types according to blood vessel that is damaged: - an artery, vein or capillary

External Bleeding:
Bleeding which is visible Also called revealed hemorrhage Easy to assess the blood loss and to control the hemorrhage E.g hemorrhage due to cut wounds, ruptured varicose veins, hematemesis

Arterial bleeding:
Blood spurts (up to several feet) from the wound). Is the most serious type of bleeding because a large amount of blood can be lost in a very short period of time.

Venous bleeding:
Blood from a vein flows steadily or gushes. Is easier to control than arterial bleeding

However, bleeding from deep veins can be as massive and as hard to control as arterial bleeding.

Capillary bleeding:
The most common type of bleeding Quite often, this type of bleeding will clot and stop by itself.

come in contact with blood with your bare hands protect yourself with medical exam gloves, extra gauze pad, or clean cloths, or have the victim apply the direct pressure. If you use your bare hands, do so only as a last resort. After the bleeding has stop and the wound has been cared for, vigorously wash your hands with soap and water.

use direct pressure on eye injury, a wound with an embedded object, or a skull fracture.

remove a blood-soaked dressing. Apply another dressing on top and continue to apply direct pressure over the wound. apply pressure bandage so tightly that it cuts off circulation. Check the radial pulse if the bandage is on an arm; for a leg, check the posterior tibial pulse. use a tourniquet. They are rarely needed and can damage nerves and blood vessels.

Treatment for hemorrhage:

Urgent treatment required Resuscitation Minimize further blood loss - direct pressure - packing with rolls of wide gauze - elevate affected area - drugs: vasopressin

Internal Bleeding:
Occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. The amount of bleeding depends upon the amount of damage to an organ and the blood vessels that supply it, as well as the body's ability to repair breaks in the walls of the blood vessels. It can be difficult to detect and can be life threatening. Repair mechanisms of the body: 1. Blood clotting 2. Spasm of the blood vessels

Internal Bleeding:
- Invisible bleeding - Concealed bleeding E.g ruptured spleen or liver, cerebral hemorrhage May become revealed e.g. hematemesis or melena in case of peptic ulcer bleed, hematuria from injured kidney, etc.

Causes of Internal Bleeding Due to Trauma

Blunt trauma Penetrating trauma Sources of internal bleeding due to trauma intracranial hemorrhage Hemothorax hemopericardium and cardiac tamponade Tears in the large blood vessels near the center of the body (aorta, superior and inferior vena cava, and their major branches).

Recognizing an Internal Bleeding

The signs of internal bleeding may be seen in either injured or suddenly ill victims:
Bright red blood from the mouth or rectum or blood in the urine Nonmenstrual vaginal bleeding Vomited blood; maybe bright red, dark red, or look like coffee grounds Black, foul smelling, tarry stools Pain, tenderness, bruising or swelling Broken ribs, bruises over the lower chest, or a rigid abdomen

Symptoms of Internal Bleeding

Due to trauma:
Abdominal pain and/or swelling Light-headedness, dizziness, or fainting Ecchymosis Swelling, tightness, and pain Headache and loss of consciousness

Diagnostic Exams and Tests

Complete blood count (CBC) or hemogram INR (international normalized ratio) and PTT (partial thromboplastin time) Computerized tomography (CT scan) Ultrasound Endoscopy, colonoscopy, and anoscopy

Operative Techniques:
Hemostats artery forceps, clips, ligature Electrocautery Topical haemostatic agents: gelatin sponge (oxygel), crushed patch of muscle, adrenaline soaked gauze Restoration of intravascular volume - isotonics - plasma expanders - blood and blood products Identify the primary cause of bleeding and treat it.

Thank You!