Exyernal Hemorrage

1. External Hemorrhage
DR BEDEER ELSHERBINY
PHARM D, MS CLINICAL PHARMACY,BCPS

2. MECHANISM OF INJURY
Penetrating trauma in combination with an increase in high-energy road traffic
accidents may account for the increased incidence of major thoracic vascular injury .
In one large review, 5760 cardiovascular injuries were sustained in 4459 patients,
mainly in young males, who represented 90 percent of all of penetrating injuries.
Truncal (including neck) vascular injuries predominated at 66 %, with the lower
extremity region representing only 19 % of all vascular injuries.
The mechanism of injury varied and included
high-velocity weapons (70 to 80 percent),
stab wounds (10 to 15 percent) and
blunt trauma (5 to 10 percent).

3. CLASSIFICATION OF HEMORRHAGE
Class 1
Mild
Class 2
Moderate
Class 3
Severe
Class 4
Severe
Blood loss up to 15% 15 to 30% 30 to 40% more than 40%
Heart rate minimally elevated
or normal,
tachycardia
(HR 100 to 120 bpm)
Heart rate (≥120
bpm)
Marked tachycardia
(HR >120 bpm).
Blood pressure No change Minimum change in
systolic blood
pressure
significant drop in
blood pressure
significant
depression in blood
pressure
Pulse No change decreased markedly elevated Pulse pressure is
narrowed (≤25
mmHg)
Respiratory rate No change tachypnea markedly elevated markedly elevated

4. Initial assessment focus on
1
• Recognize and reverse life-threatening injuries
(eg, tension pneumothorax, cardiac tamponade) immediately
2
• Preventing or limiting ongoing blood loss
3
• Restoring intravascular volume if necessary
4
• Maintaining adequate oxygen delivery to vital organs

6. Direct pressure is the primary and preferred means for controlling external hemorrhage.
A tourniquet may be required to control bleeding from a severe extremity injury.
 Vascular access is obtained as rapidly as possible. Two short, large-bore (16-gauge or larger) intravenous (IV) lines
placed in the antecubital region are ideal but not always possible. Intraosseous devices can be placed rapidly and
offer an effective alternative when there is difficulty placing an IV catheter
Placement of a central venous catheter (size 8 French) can be performed when adequate peripheral access cannot
be obtained and allows measurement of central venous pressure. Some experts advocate use of distal saphenous
vein cut downs due to ease of access and consistency of anatomy
Traumatic shock occurs most often from hemorrhage, commonly from an intra-abdominal injury due to blunt
trauma. Ultrasound is an integral part of the initial evaluation of the trauma patient. During the initial resuscitation,
the extended Focused Assessment with Sonography for Trauma (eFAST) exam is performed to assess first for
pericardial blood and then for intraperitoneal bleeding and pneumothorax
Ultrasound has largely replaced diagnostic peritoneal lavage (DPL) in the initial assessment of the trauma patient,
although DPL may retain a role in specific circumstances.

7.  Direct pressure is the preferred means for controlling external hemorrhage
 clamping bleeding vessels under direct visualization is acceptable.
 blind clamping should not be performed
 Scalp lacerations can bleed profusely can be managed by
 inject lidocaine with epinephrine directly into the wound,
 by placing clips (eg, Raney clips)
 or by closing the wound with stitches using heavy suture
 Use of a tourniquet to stop hemorrhage in cases of amputation or
severe extremity injury when other measures have not successfully
controlled bleeding.
Tourniquets should be released periodically (eg, every 45 minutes) when
possible to avoid prolonged ischemia and possible tissue loss

8.  Unstable pelvic fractures and associated vascular injuries
can cause hemorrhagic shock.
 Stabilization of the pelvis by applying a circumferential
pelvic
binder or tying a sheet firmly around the pelvis can reduce
bleeding.
 Such interventions are most important with "open-book"
pelvic fractures (in which the symphysis pubis is disrupted
[≥2.5 cm], the pelvis opened, and the retroperitoneal
space enlarged)
 In addition to immediate orthopedic consultation,
interventional radiology and vascular surgery may be
needed to help control hemorrhage.
This anterior-posterior (AP) radiograph of the pelvis
reveals significant diastasis at the symphysis pubis of
this trauma patient. Such fractures can cause
significant hemorrhage. Emergent treatment consists
of closing the fracture and stabilizing the pelvis by
applying a pelvic binder or tying a sheet tightly around
the lower pelvis.

9.  Methods for identifying no compressible bleeding include
 focused abdominal sonography for trauma (FAST) for the abdomen.
 chest radiograph for the chest.
 computed tomography (CT) for the retroperitoneal space.
 Hemodynamically stable patients can undergo CT for further assessment.
 Unstable patients should be stabilized either by resuscitation in the operating room
or, in some situations, with resuscitative endovascular balloon occlusion of the aorta
(REBOA) prior to going to the CT

10. 1 2
Controlcompressible andextremity bleeding Minimizetheuse ofintravenous (IV)fluids in
theresuscitation of traumapatients
Give IV fluids only for the resuscitation of
hypotensive patients (eg, MAP <65), and
then only until blood is available
4 5 6
Transfuse bloodproducts assoonas the
need is recognized.
Blood products(ie, red bloodcells, plasma
[clottingfactors],andplatelets) should be
giveninequivalent amounts
Usethromboelastography,or comparable
rapid point-of-careassessment of
coagulation,
to guidetraumaresuscitation whenever
possible.
2
Rapidlymobilizeallneeded resources
(eg, surgery, anesthesia, bloodbank, transfer to
trauma center).
3
in a 1:1:1 ratio. Whole blood can
be used if available

11. Commonly used
IV solutions

13. DRUG TREATMENTS FOR HEMORRHAGE
Haemostatic agents
Ant fibrinolytic agents
Recombinant factor VIIa
Red blood cell substitutes

14. Haemostatic agents
In some circumstances, external hemorrhage
cannot be controlled using direct pressure and
standard dressings.
Hemostatic products that control bleeding,
including
 Chitosan dressing,
 Kaolin-impregnated sponge
 fibrin sealant dressing
Ant fibrinolytic agents
safe and effective at reducing bleeding
I. Aminocaproic acid
II. Tranexamic acid
reduce mortality from bleeding
III. Aprotinin
Recombinant factor VIIa
off-label use
Red blood cell substitutes
Research continues into oxygen-carrying resuscitation fluids
that can serve as alternatives to packed red blood cells.
The ideal replacement fluid would
 Transport oxygen effectively,
 Expand intravascular volume,
 Exhibit few or no side effects,
 Demonstrate great durability.
 Potential substitutes (eg, hemoglobin-based oxygen
carriers, perfluorocarbons).

15. References
Initial management of moderate to severe hemorrhage in the adult trauma patient
https://www-uptodate-com.eu1.proxy.openathens.net/contents/initial-management-of-
moderate-to-severe-hemorrhage-in-the-adult-trauma-
patient?source=history_widget#H3772339605
Author:Christopher Colwell, MDSection Editor:Maria E Moreira, MDDeputy Editor:Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2020. | This topic last updated: Apr 21, 2020.