Haemorrhage? Escape of blood from ruptured blood vessels into surrounding tissues.

1. HAEMORRHAGE AND
MANAGEMENT

2. PRESENTED BY- ABHIJIT
SARKAR
3RD YEAR BDS
HALDIA INSTITUTE OF DENTAL
SCIENCES & RESEARCH

3. DEFINITION
Escape of blood from blood vessels into surrounding tissue. When a vessel is
injured, haemorrhage continues as long as the vessel remains open and the
pressure in it exceeds the pressure outside of it. Normally, coagulation closes the
vessel and stops the bleeding. Uncontrolled haemorrhage can result from
anticoagulant therapy, haemophilia, or severe blood-vessel damage, leading to
excessive blood loss and shock.

4. CLASSIFICATION
 Depending on the nature of vessel involved:
(i) Arterial Haemorrhage: Bright red in colour, jets out. Pulsation of the
artery can be seen. It can be easily controlled as it is visible.
(ii) Venous Haemorrhage: Dark red in colour. It never jets out but oozes out.
Difficult to control because vein gets retracted, non pulsatile.
(iii) Capillary Haemorrhage: Red colour, never jets out, slowly oozes out. It
becomes significant if there are bleeding tendencies.

6. Fig: Arterial Haemorrhage

7.  Depending upon the timing of haemorrhage:
(i) Primary Haemorrhage: Occurs at the time of trauma or surgery.
(ii) Reactionary Haemorrhage: Occurs after 6-12 hours of surgery.
Hypertension in post operative period, violent sneezing, coughing or
retching, are the usual causes.
e.g. Superior thyroid artery can bleed post operatively if ligature
slips. Hence, it is better to ligate it twice.
(iii) Secondary Haemorrhage: Occurs after 5-7 days of surgery. Its
due to infection which eats away the suture material, causing
sloughing of vessel wall.
e.g. bleeding after 5-7 days of surgery for haemorrhoids.

8. Fig: Haemorrhage occurring at the time of Surgery

9.  Depending on the nature of bleeding:
(i) External Haemorrhage: When bleeding is revealed and
seen outside.
e.g. epistaxis.
(ii) Internal Haemorrhage: Bleeding is concealed and not
seen outside.
e.g. splenic rupture following injury, ruptured ectopic gestation,
liver laceration following injury.

10. Fig: Epitaxis

11. Fig: Internal Haemorrhage

12. Fig: Internal haemorrhage

13.  Depending upon duration of haemorrhage
(i) Acute Haemorrhage: Occurs suddenly.
e.g. Oesophageal variceal bleeding due to portal hypertension.
(ii) Chronic Haemorrhage: Occurs over a period of time.
e.g. Haemorrhoids/piles or chronic duodenal ulcer, tuberculous ulcer
of the ileum, diverticular disease of the ileum diverticular disease
of the colon.

14. Fig: Oesophageal variceal bleeding

15. Fig: Chronic Duodenal Ulcer

16. HAEMORRHAGIC SHOCK
Haemorrhagic shock is a condition of reduced tissue
perfusion, resulting in the inadequate delivery of oxygen and
nutrients that are necessary for cellular function. Whenever
cellular oxygen demand outweighs supply, both the cell and
the organism are in a state of shock.

18. ETIOLOGY
 Trauma.
 Infections.
 Congenital malformations.
 Surgical (intraoperative/postoperative).
 Due to systemic diseases (viral infection, scurvy, allergy).
 Abnormalities in clotting factor (hemophilia A, multiple myeloma).
 Abnormalities in platelets (leukemia, ITP, thrombocytosis, thrombocytopenia)

19. CLINICAL FEATURES
 Pallor
 Cyanosis
 Tachycardia
 Tachypnea
 Cold clammy skin due to vasoconstriction.
 Dry face, dry mouth and goose skin appearance
 Rapid thready pulse
 Oliguria
 Features related to specific causes
 Hypotension

20. SIGNS OF SIGNIFICANT BLOOD LOSS
 Pulse > 100/minute
 Systolic BP < 100mm Hg
 Diastolic BP drop on sitting or standing > 10mm Hg
 Pallor/ sweating
 Shock index > 1

21. EFFECTS OF HAEMORRHAGE
 Acute renal shut down
 Liver cell dysfunction
 Hypoxic effect
 Metabolic acidosis
 GIT mucosal ischaemia
 Sepsis
 Interstitial edema, A-V shunting in lungs- ARDS
 Hypovolemic shock MODS

22. PATHOPHYSIOLOGY
Bleeding
Hypovolemia
Low cardiac output
Tachycardia and shunting of blood from splanchnic vessels by venoconstriction so as to maintain
perfusion of vital organs lke brain, heart, lungs and kidneys.
Hypoxia
Activation of cardiac depressants
Anabolic metabolism and altered cell membrane function causing influx of more sodium and
calcium inside the cell and potassium comes out of cell

23. Hyponatremic, hyperkalemic, hypocalcemic metabolic acidosis
Lysosomes of cell lysed releasing powerful enzymes which is lethal to cell itself
SICKLE CELL SYNDROME
Platelets and coagulants are utilized leading to DIC and further bleeding
Progressive hemodilution leading to total circulatory failure
Initially there is compensatory hypovolaemic shock and later there is decompensatory
hypovolaemic shock which will lead to MODS and death.
Acidosis and hypothermia are major factors in worsening the situation in haemorrhage.

24. HAEMOSTASIS
 It is a process which causes bleeding to stop, meaning to keep blood within a
damaged blood vessel. Opposite of haemorrhage is haemostasis.
 Four important steps:
Injured blood vessel undergoes constriction due to spasm.
Activation of platelets and formation of platelet plug. This leads to primary
haemostasis.
Activation of clotting mechanism and formation of clot leading to completion
of secondary hemostasis.
Fibrous organization of clot or retraction of clot.

25. Fig: Steps of Haemostasis

26. MEASUREMENT OF BLOOD LOSS
 Clot size of a clenched fist is 500 ml.
 Blood loss in a closed tibial fracture is 500-1500 ml in a fracture femur is 500-
2000 ml.
 Weighing the swab before and after use is an important method of on table
assessment of blood loss.
 Hb% and PCV estimation.
 Blood volume estimation.
 Measurement of CVP or PCWP.
 Investigation specific for cause: Ultrasound abdomen, Doppler study in
vascular injury and often angiogram, chest X-ray in hemothorax, CT scan in
major injuries, CT head in head injuries.

27. Fig: Hb Estimation

28. Fig: PCV Estimation

29. Fig: Abdominal Ultrasound

30. Fig: Chest X-Ray of Haemothorax

31. Fig: CT scan of head injury

32. MANAGEMENT

33. GENERAL MEASURES
 Hospitalization
 Care of all critically ill patients starts with A, B and C
A- Airway
B- Breathing
C- Circulation
 Oxygen should be administered by facemask for all patients who are in shock
but are conscious and are able to maintain their airway.
 If unconscious endotracheal intubation and ventilation with oxygen may be
necessary.

34. SPECIFIC MEASURES
 Pressure and packing
To control bleeding from nose, scalp: packing using roller gauze with or without adrenaline
to control bleeding from nose.
Bleeding from vein: middle thyroid vein during thyroidectomy, lumber veins during lumbar
sympathectomy can be controlled using pressure pack for a few minutes.
Sengstaken tube used to control bleeding from oesophageal varices: internal tamponade
 Position and rest
Elevation of the leg controls bleeding from varicose veins
Elevation of the head end reduces venous bleeding in thyroidectomy- Anti Trendelberg Position
Sedation to relieve anxiety- Morphine in titrated doses of 1-2 mg intravenously.

35. Fig: Roller Gauze

36. Fig: Sengstaken Tube

37. Fig: Anti-Trendelberg Position

38.  Tourniquets
Indications:
(a) Reduction of fractures
(b) Repair of tendons
(c) Repair of nerves
(d) When a bloodless field is desired during the surgery
Contraindications:
Patient with peripheral vascular disease.
Types:
(a) Pneumatic cuffs with pressure gauge
(b) Rubber bandage
Precautions:
(a) Too loose a tourniquet does not serve the purpose.
(b) Too tight: Arterial thrombosis can occur which may result in gangrene.
(c) Too long(duration of application): Gangrene of the limb. Hence, when a
tourniquet is applied, the time of inflation should be noted down and
at the end of 45 minutes to an hour, deflated at least for 10 minutes and
reinflated only if necessary.
Complications:
(a) Ischaemia and gangrene
(b) Tourniquet nerve palsy

39. Fig: Pneumatic cuffs with pressure gauge

40. Fig: Torniquet

41.  Sugical methods to control haemorrhage:
Application of artery forceps (Spencer Well’s forceps) to control
bleeding from veins, arteries and capillaries.
Application of ligatures for bleeding vessels
Cauterisation (diathermy)
Application of bone wax (Horsley’s wax which is bee’s wax in almond oil)
to control bleeding from cut edges of bones.
Silver clips are used to control bleeding from cerebral vessels (Cushing
clip)
Surgical procedure: Splenectomy for splenic rupture, hysterectomy
for uncontrollable postpartum haemorrhage, laparotomy for control of
bleeding from ruptured ectopic pregnancy.

42. Fig: Spencer Well’s forceps

43. Fig: Electrocauterisation

44. Fig: Silver clips to control bleeding from cerebral vessels

45. REFERENCES
 Manipal’s Manual of Surgery (2nd edition) by K. Rajgopal Shenoy
 SRB’s Manual of Surgery (5th edition) by Sriram Bhat M
 https://www.britannica.com/science/hemorrhage
 https://emedicine.medscape.com/article/432650-overview

46. THANK YOU