Hemorrhage

Hemorrhage
• Leakage of blood due to ruptured vessels
 From hemo = blood, rrhagia = to burst forth
• Hemorrhage may be external or internal
• Hemorrhage may be obvious (gross) or
hidden (occult)
• This is whole blood with RBCs, not just
transudates or exudates
 The World Health Organization made a
standardized grading scale to measure the
severity of bleeding

• Grade 0 no bleeding
• Grade 1 petechial bleeding;
• Grade 2 mild blood loss (clinically
significant);
• Grade 3 gross blood loss, requires
transfusion (severe);
• Grade 4 debilitating blood loss, retinal or
cerebral associated with fatality
 TYPES OF HAEMORRHAGE

• Primary haemorrhage
 Primary haemorrhage occurs at the time of
injury or operation.
• Reactionary haemorrhage
 Reactionary haemorrhage may follow primary
haemorrhage within 24 hours (usually 4—6
hours) and is mainly due to rolling (‘slipping’)
of a ligature, dislodgement of a clot or
cessation of reflex vasospasm.
• Secondary haemorrhage
 Secondary haemorrhage
occurs after 7—14 days, and
is due to infection and
sloughing of part of the wall
of an artery
 Precipitating factors
• Pressure of a drainge tube
• Fragement of bone
• Ligature in infected area
• carcinoma
• It may also be classified as
 External hemorrhage
• Also known as revealed hemorrhage. Visible.
 Internal hemorrhage
• Also known as concealed hemorrhage.
• E.g. ruptured spleen or liver, fractured femur,
cerberal hemorrhage etc.
• It may become revealed hemorrhage as in
hematemesis or melena from bleeding peptic ulcer
or in hematuria from ruptured kidney.
 How much blood loss?
• Class I: up to 15% of blood volume
 typically no change in vital signs
 routine blood donation amounts to ~10%
• Class II: 15-30% of total blood volume
 tachycardia (rapid heart beat) with a narrowing of the difference
between the systolic and diastolic blood pressures
 compensatory peripheral vasoconstriction; cool, pale skin;
altered mental status, dizzy or confused
 fluid resuscitation with saline or Lactated Ringer's solution
• Class III: 30-40% of circulating blood volume
 blood pressure drops, heart rate increases, peripheral perfusion
worsens, mental status worsens
 fluid resuscitation and/or blood transfusion
• Class IV: >40% of circulating blood volume
 hypovolemic shock--limit of the body's compensation is reached
 aggressive resuscitation is required to prevent death
 Indications of internal hemorrhage

• Deep
 Anemia—fewer circulating RBCs
 Increased indirect bilirubin (unconjugated,
albumin-bound)
• Surface
 Hemorrhage under the skin or mucous
membranes looks red (oxygenated Hb) or
purple (deoxygenated Hb)
Enclosed bleeding by size and shape
• Petechiae are flat, tiny, 1- to 2-mm, multifocal
 locally increased intravascular pressure, coagulation (platelet)
defects, the trauma of sudden hypoxia (strangulation)
 from Italian, petecchie = flea bites (puh-teek-ee-uh)
 petechia (s.); petechiae (pl.); petechial (adj)
• Purpura are flat, small, ≥1 mm, multifocal
 Term used to describe platelet-related bleeding disorders that
result in bruised skin and/or mucous membranes
 from Latin, purple
• Ecchymoses, contusions (bruises) are smooth and
noticeably large, >1 cm, focal
 trauma, vascular inflammation
 chymose = juicy
• Hematoma are emergent, lumpy, hardened, focal
 Clotted blood collected near the skin surface or internally at
serosal surfaces or aneurysms
 Distribution of hemorrhage(s)
Multifocal indicates problem affecting vessels or platelets
 thrombocytopenia or thrombocytopathy
• reduced number or function of platelets preventing coagulation
 inherited coagulation defects—hemorrhagic diathesis
 anticoagulants inhibit production of vitamin K-dependent coagulation
proteins
 end stage hepatic disease.
• With approximately 80% loss of functional hepatic tissue, production of
coagulation factors can become inadequate.
 disseminated intravascular coagulation (DIC)
• coagulation out of control
 vasculitis
• immune mediated--precipitation of Ag-Ab complexes, which are chemotactic
for neutrophils, resulting in vascular damage
• infections of endothelium
Focal distribution
 single or a few focal hemorrhages are typical of trauma
 regional neoplasm, thrombosis, or microbial invasion
 problems with protein clotting factors
Petechiae from strangulation
Petechiae
Petechiae
Petechiae or purpurae
Senile or actinic purpura
Echymoses or contusions
Hematoma--subdural
Hematoma
Subcapsular hematoma
Hemopericardium
This is hemopericardium as demonstrated
by the dark blood in the pericardial sac
opened at autopsy. Penetrating trauma or
massive blunt force trauma to the chest
(often from the steering wheel) causes a
rupture of the myocardium and/or coronary
arteries with bleeding into the pericardial
cavity. The extensive collection of blood in
this closed space leads to cardiac
tamponade. A pericardiocentesis, with
needle inserted into the pericardial cavity,
can be a diagnostic procedure.
 Gastrointestinal hemorrhage
• When rate is slow, blood is digested or lost
in feces
 In upper GI, blood turns black and tarry as it is
digested and is called melena
• Melena is symptomatic of peptic ulcers, ruptured
esophageal varices, cancers
 In lower GI, blood remains red and is excreted
with feces
• Fecal occult blood test; now fecal immunochemical
test
– FOBT used dye adsorbed on paper to detect Fenton
reaction catalyzed by heme iron
– FIT uses Ab against globin portion of hemoglobin
 Hemorrhage into cavities
• Pleural hemorrhage—hemothorax
 Build-up of pressure prevents lung expansion
• Prevents gas exchange
• May lead to lung collapse

• Pericardial hemorrhage—hemopericardium
 Build-up of external pressure inhibits filling
 Cardiac tamponade = compression
• Intracranial hemorrhage
 Always bad because of the rigid cranium
 CSF pressure increases rapidly if bleeding rate is
greater than rate of fluid resorption
 Hemodynamics
• Maintenance of blood volume
• Maintenance of blood pressure
• Mainenance of clot-free flow
 plasmin
• Development of clot in response to
vascular damage—hemostasis
 thrombin-fibrin
Consequences of acute hemorrhage
• Loss of blood beyond a certain volume will cause
systemic hypotension
 rapid compensation by the baroreceptor response leads to
peripheral vasoconstriction
 fluids shift from the interstitial into the IV compartment
 slower response from the renin-angiotensin-aldosterone system
results in vasoconstriction and retention of sodium and water by
the kidney
 antidiuretic hormone (ADH) also kicks in, acts on nephron to
promote water resorption
• Loss of blood beyond the body's ability to compensate
will cause systemic hypotension, reduced cardiac filling,
reduced tissue perfusion, loss of erythrocytes and their
Hb, hypoxemia, and a further cascade of events called
shock
 Clinical consequences
• Hypotension
• Weak, rapid pulse (tachycardia)
• Shallow rapid breathing (tachypnea)
• Cool, damp, cyanotic skin
• Tissue injuries are due to hypoxia
 Measurement of acute blood loss

• Assessment and management of blood

loss must be related to the pre-existing
circulating blood volume, which can be
derived from the patient’s weight:
• • infant 80—85 ml/kg;
• • adult 65—75 ml/kg
• Measuring blood loss
• • Blood clot the size of a clenched fist
is roughly equal to 500 ml.
• • Swelling in closed fractures.
Moderate swelling in closed fracture of the
tibia equals 500—1500 ml blood loss.
Moderate swelling in a fractured shaft of
femur equals 500—2000 ml blood loss.
• Swab weighing.
 In the operating theatre, blood loss can be
measured by weighing the swabs after use
and subtracting the dry weight. The resulting
total obtained (1 g = 1 ml) is added to the
volume of blood collected in the suction or
drainage bottles
• Haemoglobin level
 This is estimated in g/100 ml (g/dl), normal
values being 12—16 g/100 ml (12—16 g/dl).
There is no immediate change in
haemorrhage, but after some hours the level
falls by influx of interstitial fluid info the
vascular compartment in order to restore the
blood volume
 Treatment of haemorrhage

• Minimise further blood loss by pressure

and packing, position and rest, operative
procedures (ligation, repair and excision)
and then fluid resuscitation as described
below.
• Restore blood volume by blood
transfusion, albumin 4.6 percent, SAG-
mannitol (SAG-M) blood, saline, gelatin,
dextran and plasma infusions