Hemorrhage is a process of lose of
blood either through a wound or because
of any medical condition. Children are
very prone to injuries as they are in the
stage of attaining their motor
developments. A complex system of
clotting, anti-clotting mechanics exists to
ensure clot formation only in the presence
of blood vessel injury and to limit clotting
process. Dysfunction of these system
leads to bleeding.
Hemorrhage is the loss of blood or
blood escape from the circulatory
system. Bleeding can occur
internally, where blood leaks
from blood vessels inside the
body, or externally, either through a
natural opening such as the
mouth, nose, ear,
vagina or anus, or through a break in
Hemorrhage is classified into four
classes by the American College of
Surgeons' Advanced Trauma Life
• Class i
• Class ii
• Class iii
• Class iv
CLASS I HEMORRHAGE
It involves up to 15% of blood
volume. There is typically no
change in vital signs and fluid
resuscitation is not usually
CLASS II HEMORRHAGE
• It involves 15-30% of total blood volume.
• A patient is often tachycardia (rapid
heart beat) with a narrowing of the
difference between the systolic and
diastolic blood pressures.
• The body attempts to compensate
with peripheral vasoconstriction.
• Skin may start to look pale and be cool
to the touch.
• Child may exhibit slight changes
• Volume resuscitation with
(Saline solution or Lactated
Ringer's solution) is all that is
• Blood transfusion is not typically
CLASS III HEMORRHAGE
• It involves loss of 30-40% of
circulating blood volume.
• The patient's blood
pressure drops, the heart
rate increases, peripheral hypo
perfusion (shock), such as capillary
• The mental status worsens.
• Fluid resuscitation with crystalloid
and blood transfusion are usually
CLASS IV HEMORRHAGE
• It involves loss of >40% of
circulating blood volume.
• The limit of the body's
compensation is reached and
aggressive resuscitation is
required to prevent death.
Bleeding arises due to either traumatic
injury, underlying medical condition, or
a combination of injury and medical
• Traumatic Injury
• Medical condition
It is caused by some type of injury.
There are different types
of wounds which may cause traumatic
bleeding. These include:
• Puncture Wound
• Crushing Injuries
• Ballistic Trauma
• Abrasion - Also called a graze, this is
caused by transverse action of a foreign
object against the skin, and usually does
not penetrate below the epidermis
• Excoriation - In common with
Abrasion, this is caused by mechanical
destruction of the skin, although it
usually has an underlying medical cause
• Hematoma - Caused by damage to a
blood vessel that in turn causes blood to
collect under the skin.
• Laceration - Irregular wound caused by
blunt impact to soft tissue overlying hard
tissue or tearing such as in childbirth. In
some instances, this can also be used to
describe an incision.
• Incision - A cut into a body tissue or
organ, such as by a scalpel, made during
• Puncture Wound - Caused by an object
that penetrated the skin and underlying
layers, such as a nail, needle or knife
• Contusion - Also known as a bruise, this
is a blunt trauma damaging tissue under
the surface of the skin
• Crushing Injuries - Caused by a great or
extreme amount of force applied over a
period of time. The extent of a crushing
injury may not immediately present
• Ballistic Trauma - Caused by a projectile
weapon such as a firearm. This include
two external wounds (entry and exit) & a
contiguous wound between the two
'Medical bleeding' denotes hemorrhage as
a result of an underlying medical condition
(i.e. causes of bleeding that are not directly
due to trauma). Blood can escape
from blood vessels as a result of 3 basic
patterns of injury:
• Intravascular changes
• Intramural changes
• Extra vascular changes
• Intravascular changes - changes of the
blood within vessels (e.g. ↑ blood
pressure, ↓ clotting factors)
• Intramural changes - changes arising
within the walls of blood vessels
(e.g. aneurysms, dissections, AVMs, vascul
• Extra vascular changes - changes arising
outside blood vessels
(e.g. H pylori infection, brain
abscess, brain tumour)
There are certain medications which
causes increased bleeding risk.
exposure to non steroidal anti
inflammatory drugs, inhibit the
activation of platelets and increase
risk of bleeding. The effect of aspirin is
irreversible, so it will be present until
the replacement of platelets.
2. WARFARIN ( Coumadin)
it acts by inhibiting the
production of vitamin K in the gut.
It is required for the production of
the clotting factors ii, vii, ix and x in
liver. Therefore it affects
production of clotting factors.
• deficiency of Factor VIII causes
classic Haemophilia A
• deficiencies of Factor IX cause
"Christmas disease"(haemophilia B).
• deficiency of or abnormal function
of the "von Willebrand"
factor, which is involved in platelet
activation named von willebrand
the factors which will have a major effect on the
way a wound is managed are :
• The type of wound
(incision, laceration, puncture etc.)
• area of the body affected
• presence of any foreign objects in wound.
The key principles of wound management are:
• Direct pressure
• Pressure points
• Keeping the wound above the level of the
heart will decrease the pressure at the
point of injury.
• It will reduce the bleeding.
• This mainly applies to limbs and the head,
as it is impractical (in some cases
damaging) to attempt to move the torso
around to achieve this.
• Most emergency management protocols
do not use elevation on limbs which are
broken, as this may exacerbate the injury.
• Placing pressure on the wound will constrict the
blood vessels manually
• Ideally a barrier, such as gauze should be used
between the pressure supplier and the wound,to
help reduce chances of infection and help the
wound to seal.
• Direct pressure can be used with some foreign
objects protruding from a wound, and to achieve
this, padding is applied from either side of the
object to push in and seal the wound - objects
are never removed.
• put firm pressure on the wound with a
• Continue to hold pressure for ten
minutes or until the bleeding stops.
• If the bleeding doesn't stop or if the
wound seems very deep or
penetrating, especially if the edges of
the wound do not come together by
themselves or the wound is more than
1/2 inch long, you should seek medical
attention right away
For minor wounds that quickly stop
• you can next gently wash the wound with
warm, soapy water.
• Cover the wound with an antibiotic cream
or ointment and apply a sterile dressing.
• You should wash the wound daily and
reapply the antibiotic cream and dressing
until healing is complete.
• If the wound show signs of
infection, becoming red, tender or
draining pus, you should get medical
• Sometimes using icepacks will help
• Fill a freezer bag with ice.
• Bind the wound with tight bandage
• Apply ice pack with direct pressure for
In situations where direct pressure and
elevation are either not possible or proving
ineffective, it is advised to use pressure points
to constrict the major artery which feeds the
point of the bleed.
• This is performed at a place where a pulse can
be found, such as in the femoral artery.
• it is used only when other methods have not
• It is a last resort because areas of the body that
are not bleeding will also have their blood flow
• Each arm or leg has a major artery
• Apply direct pressure to the wound and
elevation of the injured area
• Use four fingers to feel for a pulse.
• Once the pulse has been located, apply
firm pressure with the heel of the hand or
use four fingers along the path of the
artery to compress the artery against the
Eg : When the bleeding is from the
leg, the pressure point is over the femoral
• If there are no suspected injuries to the
head, neck, or spine and the child can be
moved, place her on her back.
• When the bleeding is coming from the
arm, the pressure point is over the
brachial artery. This can be found at the
middle of the inner aspect of the arm, just
underneath the biceps muscle on the top
of the arm.
Epistaxis or a nosebleed is a special
case, where almost all first aid
providers train the use of pressure
points. The appropriate point here
is on the soft fleshy part of
the nose, which should constrict
the capillaries sufficiently to stop
bleeding, although obviously, this will
not stop bleeding which originates in
the nasopharynx or the tear ducts
• Make the child to sit or stand
• Make him to lean forward
• put firm pressure on nose by
squeezing the lower half of his nose.
• Keep firm pressure for ten full
minutes and then release your hold
and see if it is still bleeding.
• If the bleeding hasn't stopped, apply
pressure for another ten minutes.
• Get medical help if doesn't stop.
Another method of achieving
constriction of the supplying artery is
via the use of a tourniquet - a tightly
tied band which goes around a limb to
restrict blood flow. Tourniquets are
routinely used in order to
bring veins to the surface
for cannulation, although their use in
emergency medicine is more limited.
• The treatment of internal bleeding is
beyond simple first aid, and should
be life threatening.
• The definitive treatment for internal
bleeding might be surgical
treatment, or doctor may suggest
vitamin K or plasma / blood
• Treatment should be for underlying
In pediatric trauma, we don’t just
have an injured child, we have an
injured family. Psychological support
is very essential in emergency
management. Reassure child, calm
him and also support family.