Definition & Introduction► Escape of the blood from the vessels either internally or externally.► Hemorrhage must be recognized and managed aggressively to reduce the severity and duration of shock and avoid death or multiple organ failure.► Hemorrhage is treated by arresting the bleeding, not by fluid resuscitation or blood transfusion.► To resuscitate the patients who have ongoing hemorrhage physiological exhaustion (coagulopathy, acidosis and hypothermia) and subsequently death.
Pathophysiology► Hemorrhage hypovolemic shock cellular anaerobic metabolism lactic acidosis decrease function of coagulase protease coagulopathy further hemorrhage.► This hemorrhage is exacerbated by the ischemic endothelial cells activating anticoagulant pathway.► In compensatory state of the shock blood supply to the muscles is reduced, which become unable to generate the heat hypothermia► As coagulation functions poorly at low temp. further hemorrhage.► Further hypoperfusion and worsening acidosis and hypothermia physiological exhaustion “Death”
Effects Of Medical Therapy In Hemorrhagic Shock► Medical therapy has a tendency to worsen this effect.► Intravenous fluid and transfused blood are cold and worsening the hypothermia.► During the surgery body cavity become open that leads to further heat loss.► Crystalloid solution are acidic themselves.► Thus every efforts made rapidly to stop hemorrhage and avoid physiological exhaustion such as 1- Coagulopathy 2- Acidosis 3- Hypothermia
Revealed Hemorrhage► Revealed Hemorrhage is obvious external hemorrhage, result from 1- Exsanguination from open arterial wound 2- From massive haemetemesis 3- From duodenal ulcer
Concealed Hemorrhage► Concealed hemorrhage is contained within the body cavity and must be suspected. Concealed hemorrhage may be 1- Traumatic concealed hemorrhage 2- Non – Traumatic concealed hemorrhage► In trauma hemorrhage may be concealed within the chest, abdominal cavity, pelvis, retroperitonium or in limbus may be associated with concealed vascular injury and log bone fracture.► Non – traumatic concealed hemorrhage include GIT bleeding & rupture aortic aneurysm
Primary Hemorrhage► Hemorrhage occurring immediately as result of an injury or surgery is recognized as “ primary hemorrhage”
Recreationary Hemorrhage► Recreationary hemorrhage is delayed hemorrhage within 24 hours and usually caused by the 1- Dislodgement of clot by the resuscitation 2- Normalization of blood pressure 3- Vasodilatation (cessation of reflex vasospasm) 4- Technical failure such as slippage of ligature
Secondary Hemorrhage► Secondary hemorrhage is caused by the sloughing of the wall of vessels► It usually occurs 7 – 14 days after the injury and precipitated by the factors such as 1- Infection 2- Pressure necrosis (result from drain) 3- Malignancy
Surgical & Non-surgical hemorrhage► Surgical hemorrhage is the result of injury and amenable to surgical control, or from angioembolism► Non – surgical hemorrhage is general ooze from all raw surface due to coagulopathy, it can not be stopped by surgical mean, require correction coagulation abnormalities► Note: Packing can stop non-surgical hemorrhage
Degree & Classification Of Hemorrhage► Degree of hemorrhage classified in to 4 classes 1- Blood volume loss < 15% 2- Blood volume loss between 15 – 30% 3- Blood volume loss between 30 – 40% 4- Blood volume loss > 40%► Estimation of amount of blood that has been lost is difficult and inaccurate and usually underestimation of actual value► Hemoglobin level is a poor indicator of the hemorrhage as it represent conc. Not actual amount► In early stage of the rapid hemorrhage HB conc. Become unchanged, but later HB and haemotcrit will fall.
Basis Of Hemorrhagic Treatment► Treatment of the hemorrhage depend upon degree of the hypovolemic shock according to 1- Vital Signs 2- Preload assessment 3- Base deficit 4- Most important among these is dynamic response to fluid therapy.► In non-responder or transitient responder pts it is necessary to identify and control the site of the bleeding.