This topic is under the General Principles of Surgery. It is very important for MBBS - Students. New method of resuscitation called the Damaged Control Resuscitation is carried out in controlling the hemorrhage.

1. Prof.U.Murali.
HAEM ORRHAGE

2. LEARNING OBJECTIVES
 Define hge & Types of haemorrhage.
 Outline the pathophysiology of Hge.
 Classify Hge based on the blood loss.
 Mention the C/F of haemorrhage.
 Ways of Measuring blood loss.
 Effects of Hge & Signs of significant Hge.
 Describe the management of Hge.

3. DEFINITION
 Hemorrhage means escape of
blood outside its containing vessel.
[OR]
 Extravasation of blood from its
containing vessel.

4. TYPES / CLASSIFICATION
 1. Depending on source of the vessel involved
 2. Depending on the timing of hemorrhage
 3. Depending on the duration of hemorrhage
 4. Depending on the type / nature of bleeding
 5. Depending upon mode of intervention

5. 1A - SOURCE - ARTERIAL
 Bright red
 Emitted as
spurting jet
 Can lead to
severe blood loss
 Often hard to
control

6. 1B - SOURCE – VENOUS
 Dark red
 Steady and slow
flow
 Color becomes
further darker
 Usually easy to
control

7. 1C - SOURCE – CAPILLARY
 Bright red
 Rapid and oozing
 Blood loss
becomes serious if
continues for
hours
 Generally minor
& easy to control

8. 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

9. 2B - TIMING - REACTIONARY
 Bleeding within 24 hours ( usually 4 - 6
hours ) of surgery.

10. 2C - TIMING – SECONDARY
 Occurs after 7 - 14 days of surgery.
 1st a warning stain followed by a sudden
severe bleed.

11. 3 – DURATION
 Acute Hemorrhage: occurs suddenly after
trauma (or) surgery. Eg: Cuts / Lacerations,
Gunshot wound, Crushing injury.
 Chronic Hemorrhage: It is chronic
repeated bleeding for a long period like in
hemorrhoids, bleeding peptic ulcer,
carcinoma caecum, etc..
 Acute on Chronic Hemorrhage: It is
more dangerous as the bleeding occurs in
individuals who are already hypoxic, which
may get worsened faster.

12. 4A – NATURE / TYPE
External Hemorrhage (or) Revealed
External (or) visible bleed – soft tissue
injuries.
Bleeding from the limb vessels, wound,
nose etc.

13. 4B – NATURE / TYPE
 Internal Hemorrhage (or) Concealed
 Internal (or) invisible bleed – Blunt (or)
Penetrating trauma.
 May remain concealed as in ruptured spleen,
liver, ruptured ectopic pregnancy.
 Concealed hemorrhage may become revealed
as in hematemesis (or) melena in PUD.

14. 5 – TYPE OF INTERVENTION
Surgical Hemorrhage: is the result
of injury and amenable to surgical
control, (or) from angio-embolization.
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.

17. PATHOPHYSIOLOGY
Bleeding → Hypovolaemia → Hypoperfusion
Cellular anaerobic metabolism + Lactic acidosis
↓ coag.proteases → coagulopathy & Hge
{ ↑ Ischemic cells - anticoagulation pathway }
↓ tissue perfusion + BS – gut & muscle ↓
[ early in compensatory process ]

18. - CONTD
Under perfused muscle – unable to generate heat
Hypothermia
(Coag. Fn. Poor ↓ temp)
Hge Hypoperfusion Acidosis
DEATH

20. PATHOPHYSIOLOGY
 In trauma and surgery, the combination of tissue trauma
and hypovolemic shock leads to the development of an
endogenous coagulopathy called acute traumatic
coagulopathy (ATC).
 Up to 25% of all trauma patients develop ATC within
minutes of injury and it is associated with a fourfold
increase in mortality. ATC is characterized by systemic
hyperfibrinolysis, low fibrinogen levels and platelet
dysfunction.
 ATC evolves into a more complex, multifactorial ‘trauma
induced coagulopathy’ [TIC] owing to further
derangements induced by resuscitation (Figure - last slide).
 Fluid and red blood cell transfusions lead to dilution of
coagulation factors, which worsens the preexisting
coagulopathy.

21. CLINICAL FEATURES
 Pallor, thirsty, cyanosis
 Tachycardia, tachypnea
 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…

22. MEASUREMENT OF BLOOD LOSS
 Normal blood volume ( 5 l ) is estimated as
1. 70 ml/kg – children & adults
2. 80ml/kg – neonates.
 Estimation – is difficult &
inaccurate.
 Hb % and PCV estimation.
 OT - Blood in suction apparatus
– measured & swabs soaked in
blood – weighed.

25. TREATMENT – CONCEPTS
I. Airway, Breathing, Circulation [ABC] –
 O2 - To be started
 Correction of Hypotension
Fluid therapy
Whole Blood / PRC / FFP NS / RL
II. Damage Control Resuscitation [DCR] – 4 principles
 Rapid hemorrhage control
 Permissive hypotension
 Avoiding dilutional coagulopathy
 Treating existing coagulation deficits.
IMMEDIATE RESUSCITATION

27. TREATMENT – CONCEPTS
IDENTIFY & CONTROL OF HEMORRHAGE
I. Stop the blood loss –
 Pressure | Packing | Position & Rest
II. External Hemorrhage – Obvious…
 Wound exploration & proceeding
 Ligation / Suturing – wound / vessel
 Topical applications for local ooze
III. Internal Hemorrhage
 Intercostal tube placement
 Laparotomy
 Intrabdominal pack
 Endoscopic / Angiographic control..

28. TREATMENT – CONCEPTS
OTHER MEASURES
 Ventilator and Critical care [ICU].
 Keeping patient warm.
 Correction and prevention of further coagulopathy (TIC) -
Tranexamic acid | Fibrinogen & Prothrombin complex
concentrate (PCC) transfusion. Cryoprecipitate are also
beneficial.
 Catheterization, Foot end elevation and monitoring.
 Antibiotics are often required. Analgesics - to relieve pain.
 Total parenteral nutrition (TPN), Central venous pressure
(CVP) monitoring, Electrolyte management are all equally
important.
 Sedation if required. Adequate rest….

30. MANAGEMENT - CONCEPTS
 Identify – Hge / Hypovolaemia & Shock – clinically.
 Resuscitation – O2 / Blood & Fluids.
 Identify site of Hge - U/S, endoscopy, CT scan, DPL,
Blood tools etc.
 Control of Hge – Surgery, endoscopic control,
therapeutic embolization.
 Definitive treatment if any.
 Sepsis & Pain control.
 Prevention of coagulopathy.
 Critical care management – ICU.
 End-point resuscitation - fluids & electrolyte
management, prevention of organ failure.

31. TO SUMMARIZE
 Types of hemorrhage.
 Pathophysiology of hemorrhage.
 C/F of hemorrhage.
 Effects of hemorrhage.
 Classification according to blood loss.
 Various treatment aspects of hemorrhage.
 Methods of measuring blood loss.

32. REFERENCES

33. QUESTION TIME
 Classify hemorrhage.
 List 4 precipitating factors of Reactionary hemorrhage.
 What is meant by class – II Hemorrhage loss?
 Mention the ways of measuring blood loss.
 Explain the pathophysiology of hemorrhage.
 Identify the 4 key principles of D C R.
 Enumerate 4 clinical features of hemorrhage.
 Outline the management concepts of hemorrhage.

34. ONE OF THE FOLLOWING IS NOT TRUE
REGARDING THE CAUSES OF SECONDARY
HEMORRHAGE –
 a) Infection.
 b) Sloughing of the wall of the vessel.
 c) Slipping of the ligature.
 d) Pressure necrosis.

35. ONE OF THE FOLLOWING IS NOT TRUE
REGARDING THE CAUSES OF SECONDARY
HEMORRHAGE –
 a) Infection.
 b) Sloughing of the wall of the vessel.
 c) Slipping of the ligature.
 d) Pressure necrosis.

36. A FEMALE WITH SUSPECTED CHILD ABUSE WAS
BROUGHT TO THE CASUALTY WITH SEVERE
BLEEDING FROM PERINEUM. WHAT SHOULD BE THE
FIRST LINE OF MANAGEMENT? –
 a) Internal iliac artery ligation.
 b) Whole blood transfusion.
 c) Airway maintenance.
 d) Inform police before starting the
treatment.

37. A FEMALE WITH SUSPECTED CHILD ABUSE WAS
BROUGHT TO THE CASUALTY WITH SEVERE
BLEEDING FROM PERINEUM. WHAT SHOULD BE THE
FIRST LINE OF MANAGEMENT? –
 a) Internal iliac artery ligation.
 b) Whole blood transfusion.
 c) Airway maintenance.
 d) Inform police before starting the
treatment.

38. WHERE IS THE SECOND STEP OF DAMAGE
CONTROL RESUSCITATION CARRIED OUT? –
 a) In emergency.
 b) In ICU.
 c) In OT.
 d) Prehospital resuscitation.

39. WHERE IS THE SECOND STEP OF DAMAGE
CONTROL RESUSCITATION CARRIED OUT? –
 a) In emergency.
 b) In ICU.
 c) In OT.
 d) Prehospital resuscitation.

40. THREE HOURS AFTER THYROIDECTOMY, A PATIENT
BEGINS TO BLEED FROM THE OPERATED SITE. THIS
FORM OF BLEEDING IS CALLED –
 a) Primary hemorrhage.
 b) Reactionary hemorrhage.
 c) Secondary hemorrhage.
 d) Tertiary hemorrhage.

41. THREE HOURS AFTER THYROIDECTOMY, A PATIENT
BEGINS TO BLEED FROM THE OPERATED SITE. THIS
FORM OF BLEEDING IS CALLED –
 a) Primary hemorrhage.
 b) Reactionary hemorrhage.
 c) Secondary hemorrhage.
 d) Tertiary hemorrhage.

42. ONE OF THE FOLLOWING IS NOT THE LETHAL
TRIAD COMPONENT OF HEMORRHAGE –
 a) Hypoxia.
 b) Hypothermia.
 c) Metabolic acidosis.
 d) Progressive coagulopathy.

43. ONE OF THE FOLLOWING IS NOT THE LETHAL
TRIAD COMPONENT OF HEMORRHAGE –
 a) Hypoxia.
 b) Hypothermia.
 c) Metabolic acidosis.
 d) Progressive coagulopathy.

44. THANK YOU
“When there is blood loss, replace with blood”

45. Apply direct pressure:
• with gloved hand,
• sterile dressing(s).
Bleeding stopped? Yes
No
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