HAEMORRHAGE

-- DR PRASHANT PATIL
 Haemorrhage
 Bleeding, technically known as hemorrhage is the loss of
blood or blood escape from the circulatory system.
 Haemorrhage can occur internally, where blood leaks from
blood vessel inside the body or externally, either through a
natural opening such as the nose, ear, mouth, anus , urethra
and vagina or through a break in the skin .
 The complete loss of blood is referred to as exsanguination.
 It needs to be recognised & managed aggressively by arresting
bleeding ( as to decrease duration & severity of shock and to avoid death ) .

 Though transfusion of blood / crystalloids is important for organ

perfusion but with on - going bleeding it can lead to
physiological exhaustion ( coagulopathy, acidosis & hypothermia )
 Haemorrhage - pathophysiology
haemorrhage

Hypovolaemic shock

< Gut perfusion Decrease tissue perfusion

Endothelial cell
< muscle perfusion Cellular anaerobic ischemia
metabolism

Inability to generate
Lactic acidosis Activation of
heat
anticoagulant
pathway

hypothermia < function of

coagulase protease

Heat loss due to Poor functioning of

opening of cavities coagulation
coagulopathy

surgery haemorrhage
 Haemorrhage - classification
 Types of haemorrhage

Type of vessel Duration visibility nature ATLS

arterial Primary External Acute class 1

venous Reactionary Internal Chronic Class 2
capillary secondary Class 3
Class 4
Haemorrhage - classification
 World Health Organization

 The W.H.O. 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
 Haemorrhage - classification
 Features Class I ClassII Class III ClassIV

Bld Vol loss < 15% 15-30% 30- 40% > 40%
Clinical feature no change tachycardia hypotension severe shock
Skin pallor
 Features of haemorrhage

 Arterial : Bright red in colour

blood emits as the spurting jet ( rise /fall in time with pulse )
Can become lighter if large amt of i.v. fluids given .
 Venous : darker in colour. ( except pulmonary vein )
copious flow not in jets.
colour darkens if excessive O2 desaturation
- severe blood loss /respiratory obst or depression
Loss can be rapid - if large veins open e.g. femoral / jugular / IVC
Can be under high pressure – asphyxia / ruptured varicose veins
- ruptured oesophag. varices
 Capillary : Bright red in colour
Oozing type ( if occurs for long time can be serious – haemophilia
 Features of haemorrhage (cont)
 Depending on duration :
Features PRIMARY REACTIONARY SECONDARY

Duration At the time of within 24 hrs within 7-14 days

- surgery ( usually 4 – 6 hrs )
Cause direct injury clot dislodgment infection
- resuscitation

- normalization of BP
- vasodilatation
- > venous ‘ P ‘
coughing
restlessness

caesation of reflex part of vessel wall

vasospasm sloughing
Slippage of ligature vessel involved
due to CA
Sp features Venous haemorrhage Warning Haemorr
may be fatal - hage occur
Features of haemorrhage (cont)
On visibility :
 Revealed : obvious external bleed .
Occurs due to – open arterial / venous blood ( exsanguination +/-)

-- massive haematemesis  DU
 Concealed : Occurs within body
Traumatic - chest/ Abd/Pelvic/ Retroperitonium
- IC bleed
- In limbs ( vascular injury / fracture )
Non Traumatic – Occult GI bleed
- Ruptured aortic aneurysm
- IC bleed
Concealed haemorrhage can become revealed e.g. haematemesis , malena
( bleeding DU )/ haematuria ( renal injury ) / Bleeding PV ( accidental Uterine haemorrhage)
Management of Haemorrhage
 Assessment and management of bld loss must be related to pre-existing
circulatory bld volume ; which is derived from patient’s weight
Neonate - 80-85 ml/kg
Adult & children – 65-75 ml/kg
 But accurate estimation of actual bld loss is difficult & in most of the cases
it is inaccurate as well as under estimated .

 Methods to estimate blood loss .

 Blood clot size : Clot size of clenched fist = 500 cc.
 Swelling in closed fractures : mod swelling in tibia fracture
500 – 1500 ml

: mod swelling in femur fracture

500 – 2000 ml
 Methods to estimate blood loss ( cont )
Swab weighing : Amt of bld loss = wt of swab after use – Dry wt ( 1gm = 1 ml )
+
Volume of blood in suction / drainage bottle
 Prevent loss due to evaporation by prompt transfer of swabs into
polythene bags ( extensive wound / operations )
 Multiply swab wt by 1.5- 2 for extensive surgeries to account for
loss of blood, plasma , water by evaporation / sweating/ via lungs
or into tissue – e.g. rad mastectomy/ gastrectomy etc

Haemoglobin level : It is poor indicator of degree of haemorrhage as it represents a

concentration & not the absolute value
normal level ( 12- 16 g/dl )
no immediate change in value but after some hours it decreases
( interstitial fluid influx ) & also haematocrit levels fall
Measurement of CVP:
 Management of haemorrhage
 Treatment should therefore be based upon degree of Hypovolaemic shock
according to vital signs, preload assessment , base deficit & dynamic
response to fluid therapy . Patients who do not respond / transient
responders indicate on going blood loss ; which should be recognised and
controlled.

 Management thus consists of

 Identification of haemorrhage
 Immediate resuscitative measures
 Identification of site of haemorrhage
 Haemorrhage control
 Management of haemorrhage ( cont)
 Identify haemorrhage : external haemorrhage is easy to identify
concealed is difficult to identify .
Hence any shock to be assumed Hypovolaemic &
should be assumed due to haemorrhage until
excluded .

Immediate resuscitative measures :

Pressure and packing :
First Aid : Pressure dressing made from anything which is soft , clean & handy.
Apply this dressing/ pack tightly .
Other methods include are – digital pressure / clothe pegs / double
balloon ( variceal bleed )
Packing : roll of wide gauze used ( if several packs used , tie ends
together for complete removal later ) . Careful watching
required while packing removal even if bleed appears to stop
If it restarts , urgent surgical intervention required .
 Management of haemorrhage ( cont)
Position & Rest : Limb elevation ( acts by gravity/ causes vasoconstriction)
Bed elevator ( increases venous return to heart )
Trendelenberg / reverse trendelenburg position during surgery

Identify the site of haemorrhage :

once diagnosed ; site of haemorrhage must be identified rapidly so as to control it by
means like surgery , angio- embolism / endoscopy .
History & examination provides clue
previous episodes
known Aneurysms
Use of NSAID ( for GI bleed )
Nature of blood ( fresh / malena / haematochesia )
Abdominal tenderness +/-
Diagnosis of cavitatory blood is important : rapid bed side investigations are
important ( X- Ray /USG/ Diagnostic peritoneal tap ) CT scan done for stable pts
Methodical & definitive work up required for pts not actively bleeding .
Management of haemorrhage ( cont)
 Haemorrhage control : points to remember

 Shift the patient ( bleeding & in shock ) to place of haemorrhage control

i.e. operating room / angiography / endoscopy room .
These pts require full surgical & anesthetic support , monitoring and equipments
for care .
Rapid control of haemorrhage is required ( to prevent pts entering into the triad
of coagulopathy – acidosis – hypothermia & becoming physiologically exhausted
Avoid unnecessary investigations / procedures before control ( prolong attempts
to volume resuscitate the pts before surgery )
Correct coagulopathy with blood component therapy .
Surgery should be minimum to control bleed & sepsis.
Definitive procedures to be done once pts is physiologically capable to sustain it
i.e. Damage control Surgery
 Haemorrhage control :
 Operative techniques :
 mechanical means : Use of haemostats & clips ( acts by pressure )
 ligate the vessel / cauterised it
 Use of sily clips ( for cerebral vessels )
 Suturing techniques ( under running / transfixion )
 suturing the vessel tear
 Pressure by packing - gauze rolls/ peanuts
 Topical applications : Oxycel / Gelatin sponge ( provides network for fibrin &
 platelet deposition )
 Gauze soaked in adrenaline ( 1: 1000 )
 Application of Stypven ( Russell viper venom )
 Patch of – Vein / Dacron mesh / lightly hammered muscle patch ( thrombokinase )
 Excision: Splenectomy / haepatectomy / nephrctomy etc.
Management of haemorrhage ( cont)
 Damage control surgery :
 Damage control surgery (DCS) is a concept of abbreviated laparotomy,
designed to prioritize short-term physiological recovery over anatomical
reconstruction in the seriously injured and compromised patient.
 Over the last 10 yr, a new addition to the damage control paradigm has
emerged, referred to as damage control resuscitation (DCR). This
focuses on initial hypotensive resuscitation and early use of blood
products to prevent the lethal triad of acidosis, coagulopathy, and
hypothermia.
 The use of DCR and DCS have been associated with improved outcomes
for the severely injured and wider adoption of these principles where
appropriate may allow this trend of improved survival to continue. In
particular, DCR may allow borderline patients, who would previously have
required DCS, to undergo early definitive surgery as their physiological
derangement is corrected earlier.
 Management of haemorrhage ( cont.)

 DCS was originally described by Rotondo and colleagues in 1993 as a three-

phase technique. This was later modified by Johnson and Schwab to include a
fourth, pre-theatre phase:
• Part zero (DC 0) emphasizes injury pattern recognition for potential damage
control beneficiaries and manifests in truncated scene times for the
emergency services and abbreviated emergency department DCR by the
trauma team. Rapid-sequence induction (RSI) of anaesthesia and intubation,
early rewarming, and expedient transport to the operating theatre are the key
elements.
• Part one (DC I) occurs once the patient has arrived in theatre and consists of
immediate exploratory laparotomy with rapid control of bleeding and
contamination, abdominal packing, and temporary wound closure.
• Part two (DC II) is the intensive care unit (ICU) resuscitative phase where
physiological and biochemical stabilization is achieved and a thorough tertiary
examination is performed to identify all injuries.
• Part three (DC III) occurs once physiology has normalized and consists of re-
exploration in theatre to perform definitive repair of all injuries. This may
require several separate visits to theatre if multiple systems are injured and
require operative treatment.
Thank You