Haemorrhage By Dr Aseel Mahmood General surgeon Member

Haemorrhage By Dr Aseel Mahmood General surgeon Member of Royal college of surgeons (England) MRCS FICMS

Types of haemorrhages

v According to the source of bleeding: § Arterial bleeding : Is recognized as bright red blood spurting as a jet which rises and falls in time with the pulse. In protracted bleeding and when quantities of intravenous fluids other than blood are given it can become watery in appearance. § Venous bleeding : Is a dark- red steady and copious flow. The color darkens still further from excessive oxygen desaturation when blood loss is severe or in respiratory depression and obstruction. Blood loss is particularly rapid when large veins are opened as a common femoral or jugular veins. § Capillary haemorrhage: Is bright red often rapid ooze. If continuing for many hours blood loss can become serious as in haemophillia.

v According to the time of injury: üPrimary haemorrhage : Occurs at time of injury or operation üReactionary haemorrhage : bleeding within 24 hours (usually 4 -6 hours) and is mainly due to (slipping) of a ligature, dislodgement of clot or cessation of reflex vasoconstriction. The precipitating factors are a rise of blood pressure and refilling of the venous system, recovery from shock, restlessness, coughing and vomiting which raise the venous pressure. üSecondary haemorrhage : Occurs after 7 -14 days and is due to infection and sloughing of part of the wall of an artery, predisposing factors are pressure of the drainage tube, a fragment of bone, a ligature in infected area or cancer.

v According to visibility • External haemorrhage : Is visible bleeding usually from opened wound called revealed haemorrhage. • Internal haemorrhage : Called concealed haemorrhage as in ruptured spleen or liver, fracture femur, ruptured ectopic pregnancy or in cerebral haemorrhage. Concealed hg can become revealed hg as in haematemesis or malaena from bleeding peptic ulcer or as in haematuria from ruptured kidney or via the vagina in accidental uterine hg of pregnancy.

v According to wether it is surgical or non-surgical hg § Surgical haemorrhage is due to a direct injury and is amenable to surgical control (or other techniques such as angioembolisa- tion). § Non-surgical haemorrhage is the general ooze from all raw surfaces due to coagulopathy and cannot be stopped by surgical means (except packing

Assessment & Measurement of acute blood loss : Assessment and management of blood loss must be related to preexisting circulating blood volume which can be derived from the patient's weight as in : infant 80 -85 mlkg adult is 65 -75 mlkg

The measurement of blood loss is done by : 1 - Blood clot : The size of clenched fist if roughly equal to 500 ml. 2 - Swelling in closed fracture : Moderate swelling in closed fractureof the tibia equals 500 -1500 mlkg blood loss. Moderate swelling infractured shaft of the femur equals 5002000 mlkg. 3 - Swab weighing : In operating theater, blood loss can be measuredby weighing the swabs after use and subtracting the dry weight. The resulting total obtained as 1 g=1 ml is added to the volume of blood collected in suction or drainage bottles.

4 - Haemoglobin level : Normal value being 12 -16 gdl there is no immediate change in Hb level but after several hours the level falls by influx of interstitial fluid in to vascular compartment to restore the blood volume.

The most important assessment is clinical (specially if concealed) How?

Clinically: • Restless , anxious , confused , comatose (end stage) • Pale except? • Cold clammy extremities • Dry mouth and conjunctiva • Hypotension and tachycardia except? • Tachypnooea • Delayed capillary refilling • Decrease UOP

Management: ABC • Identify haemorrhage : External hg may be obvious, but the diagnosis of concealed hg may be more difficult. Any shock should be assumed to be hypovolaemic until proved otherwise, and similarly, hypovolaemia should be assumed to be due to haemorrhage until this has been excluded. Immediate resuscitative manoeuvre eg direct pressure should be placed over the site of external hg. • Airway and Breathing should be assessed and controlled as necessary. • Large-bore intravenous access (2 cannula ) should be instituted and blood drawn for cross-matching. Emergency blood should be requested if the degree of shock and ongoing hg warrants this.

Minimize further blood loss by : • 1 - Pressure and packing : The first aid treatment of hg from a wound is a pressure dressing made from any thing handy which is soft and clean. The dressing or pack should be bound on tightly. The other type of pressure is digital pressure as for episaxis. • 2 - Position and rest : Elevation of limbs as in rupture of varicose veins employs gravity to reduce bleeding. Elevation also causes vasoconstriction. A bed elevator is often used to raise the foot of the bed thus increasing venous return to the heart and maintain cardiac out put. Gravity is also used in certain operations as in thyroidectomy when the patient is tilted feet down ward called reverse trendelenburg position, or as in stripping of varicose vein when a head down tilt is used called trendelenburg position. • 3 - Operative procedures techniques : Artery forceps (haemostat) and clips.

Thank you