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DR. MURALI. U. M.S ; M.B.A.
PROF. OF SURGERY
D.Y.PATIL MEDICAL COLLEGE
MAURITIUS.
HAEMORRHAGE
DEFINITION
 Haemorrhage means escape of blood
outside its containing vessel.
CLASSIFICATION
 Depending on nature of the vessel involved
 Depending on the timing of haemorrhage
 Depending on the duration of Haemorrhage
 Depending on the nature of bleeding
 Depending upon type of Intervention
1A - SOURCE - ARTERIAL
 Bright red
 Emitted as spurting
jet
 Can lead to severe
blood loss
 Often hard to control
1B - SOURCE – VENOUS
 Darker red
 Steady and copious
flow
 Color becomes further
darker with oxygen
desaturation
 Usually easy to
control
1C- SOURCE – CAPILLARY
 Bright red
 Rapid and oozing
 Blood loss becomes
serious if continues
for hours
 Generally minor &
easy to control
2A - TIMING - PRIMARY
 Occurs at the time of surgery
 Cause is injury to vessels
 May be arterial, venous or capillary
 More common in surgery on malignancies
2B - TIMING - REACTIONARY
 Bleeding within 24 hours ( usually 4-6 hrs ) of
surgery
 Cause is slipping of ligature, dislodgement of clot
or cessation of reflex vasospasm
 Bleed starts when there is a rise in the arterial
or venous pressure.
2C - TIMING – SECONDARY
 Occurs after 7-14 days of surgery
 Cause is sloughing of vessel due to infection,
pressure necrosis or malignancy.
 1st a warning stain followed by a sudden severe
bleed
 Common after hemorrhoids surgery, GI surgery
& amputations.
3 – DURATION
 Acute Haemorrhage: occurs suddenly. eg.
Oesophageal variceal bleeding due to portal HT.
 Chronic Haemorrhage.
4A – NATURE / TYPE
 External Haemorrhage or Revealed :
 External or visible bleed – soft tissue injuries
 Bleeding from the limb vessels, wound,nose etc.
4B – NATURE / TYPE
 Internal Haemorrhage or Concealed :
 Internal or invisible bleed – Blunt or Penetrating
trauma
 May remain concealed as in ruptured spleen or
liver
 Concealed hemorrhage may become revealed as
in haemetemesis or melaena in peptic ulcer bleed
5 – TYPE OF INTERVENTION
 Surgical Haemorrhage: is the result of injury
and amenable to surgical control, or from
angioembolism.
 Non-Surgical Haemorrhage: is general ooze
from all raw surface due to coagulopathy, it can
not be stopped by surgical mean, require
correction coagulation abnormalities.
PATHOPHYSIOLOGY
Bleeding → Hypovolaemia → Hypoperfusion
Cellular anaerobic metabolism + Lactic acidosis
↓ coag.proteases → coagulopathy & Hge
{ ↑ Ischaemic cells - anticoagulation pathway }
↓ tissue perfusion + BS – gut & muscle ↓
[ early in compensatory process ]
- CONTD
Underperfused muscle – unable to generate heat
Hypothermia
Coag. Fn. Poor ↓ temp.
Hge Hypoperfusion Acidosis
DEATH
CLINICAL FEATURES
 Pallor, thirsty, cyanosis
 Tachycardia, tachypnoea
 Cold clammy skin due to vasoconstriction
 Dry face, dry mouth and goose skin
appearance (due to contraction of arrector
pilorum).
 Rapid thready pulse, hypotension
 Oliguria
 Features related to specific causes
DEGREE OF
HAEMORRHAGE
 Degree of hemorrhage is classified into 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%
MEASUREMENT OF BLOOD
LOSS
 Normal blood volume ( 5 l ) is estimated as
70 ml/kg – children & adults and 80ml/kg –
neonates.
 Estimation – difficult & inaccurate
 OT - Blood in suction apparatus – measured &
swabs soaked in blood – weighed.
 Hb% and PCV estimation.
MANAGEMENT - CONCEPTS
 Identify – Hge / Hypovolaemia & Shock – clincally
 Resuscitation – O2 / Blood & Fluids
 Identify site of Hge - U/S, endoscopy, CT scan, DPL,
Blood tools etc.
 Control of Hge – Surgery, endoscopic control,
therapeutic embolisation.
 Definitive treatment if any
 Sepsis control
 Prevention of coagulopathy
 Critical care management
 End-point resuscitation, fluids & electrolyte
management, prevention of organ failure
“When there is blood loss,
replace with blood”
Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? YesNo
Elevate extremity:
• above victim’s heart,
continue direct pressure
Locate pressure point,
apply pressure:
• maintain direct pressure
over wound
Treat for shock:
• care for wound,
• seek definitive care
Bleeding stopped?
Bleeding stopped?
No
Bleeding from
extremity?
No
Apply tourniquet
(last resort)
Yes
No
Definitive therapy
Haemorrhage

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Haemorrhage

  • 1. DR. MURALI. U. M.S ; M.B.A. PROF. OF SURGERY D.Y.PATIL MEDICAL COLLEGE MAURITIUS. HAEMORRHAGE
  • 2. DEFINITION  Haemorrhage means escape of blood outside its containing vessel.
  • 3. CLASSIFICATION  Depending on nature of the vessel involved  Depending on the timing of haemorrhage  Depending on the duration of Haemorrhage  Depending on the nature of bleeding  Depending upon type of Intervention
  • 4. 1A - SOURCE - ARTERIAL  Bright red  Emitted as spurting jet  Can lead to severe blood loss  Often hard to control
  • 5. 1B - SOURCE – VENOUS  Darker red  Steady and copious flow  Color becomes further darker with oxygen desaturation  Usually easy to control
  • 6. 1C- SOURCE – CAPILLARY  Bright red  Rapid and oozing  Blood loss becomes serious if continues for hours  Generally minor & easy to control
  • 7. 2A - TIMING - PRIMARY  Occurs at the time of surgery  Cause is injury to vessels  May be arterial, venous or capillary  More common in surgery on malignancies
  • 8. 2B - TIMING - REACTIONARY  Bleeding within 24 hours ( usually 4-6 hrs ) of surgery  Cause is slipping of ligature, dislodgement of clot or cessation of reflex vasospasm  Bleed starts when there is a rise in the arterial or venous pressure.
  • 9. 2C - TIMING – SECONDARY  Occurs after 7-14 days of surgery  Cause is sloughing of vessel due to infection, pressure necrosis or malignancy.  1st a warning stain followed by a sudden severe bleed  Common after hemorrhoids surgery, GI surgery & amputations.
  • 10. 3 – DURATION  Acute Haemorrhage: occurs suddenly. eg. Oesophageal variceal bleeding due to portal HT.  Chronic Haemorrhage.
  • 11. 4A – NATURE / TYPE  External Haemorrhage or Revealed :  External or visible bleed – soft tissue injuries  Bleeding from the limb vessels, wound,nose etc.
  • 12. 4B – NATURE / TYPE  Internal Haemorrhage or Concealed :  Internal or invisible bleed – Blunt or Penetrating trauma  May remain concealed as in ruptured spleen or liver  Concealed hemorrhage may become revealed as in haemetemesis or melaena in peptic ulcer bleed
  • 13. 5 – TYPE OF INTERVENTION  Surgical Haemorrhage: is the result of injury and amenable to surgical control, or from angioembolism.  Non-Surgical Haemorrhage: is general ooze from all raw surface due to coagulopathy, it can not be stopped by surgical mean, require correction coagulation abnormalities.
  • 14.
  • 15. PATHOPHYSIOLOGY Bleeding → Hypovolaemia → Hypoperfusion Cellular anaerobic metabolism + Lactic acidosis ↓ coag.proteases → coagulopathy & Hge { ↑ Ischaemic cells - anticoagulation pathway } ↓ tissue perfusion + BS – gut & muscle ↓ [ early in compensatory process ]
  • 16. - CONTD Underperfused muscle – unable to generate heat Hypothermia Coag. Fn. Poor ↓ temp. Hge Hypoperfusion Acidosis DEATH
  • 17. CLINICAL FEATURES  Pallor, thirsty, cyanosis  Tachycardia, tachypnoea  Cold clammy skin due to vasoconstriction  Dry face, dry mouth and goose skin appearance (due to contraction of arrector pilorum).  Rapid thready pulse, hypotension  Oliguria  Features related to specific causes
  • 18. DEGREE OF HAEMORRHAGE  Degree of hemorrhage is classified into 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%
  • 19. MEASUREMENT OF BLOOD LOSS  Normal blood volume ( 5 l ) is estimated as 70 ml/kg – children & adults and 80ml/kg – neonates.  Estimation – difficult & inaccurate  OT - Blood in suction apparatus – measured & swabs soaked in blood – weighed.  Hb% and PCV estimation.
  • 20. MANAGEMENT - CONCEPTS  Identify – Hge / Hypovolaemia & Shock – clincally  Resuscitation – O2 / Blood & Fluids  Identify site of Hge - U/S, endoscopy, CT scan, DPL, Blood tools etc.  Control of Hge – Surgery, endoscopic control, therapeutic embolisation.  Definitive treatment if any  Sepsis control  Prevention of coagulopathy  Critical care management  End-point resuscitation, fluids & electrolyte management, prevention of organ failure
  • 21. “When there is blood loss, replace with blood”
  • 22. Apply direct pressure: • with gloved hand, • sterile dressing(s). Bleeding stopped? YesNo Elevate extremity: • above victim’s heart, continue direct pressure Locate pressure point, apply pressure: • maintain direct pressure over wound Treat for shock: • care for wound, • seek definitive care Bleeding stopped? Bleeding stopped? No Bleeding from extremity? No Apply tourniquet (last resort) Yes No Definitive therapy