This document discusses haemorrhage or bleeding from blood vessels. It defines haemorrhage and describes the pathophysiology where bleeding leads to hypovolaemic shock and complications like acidosis. It then classifies haemorrhage based on anatomical source, timing, visibility, duration and amount of blood loss. Clinical features and investigations for haemorrhage are provided. Management of haemorrhage focuses on arresting bleeding through pressure, packing and procedures before restoring blood volume.

1. HAEMORRHAGE
DR MD SWHERAJUL ISLAM
FCPS(SURGERY), FACS(USA)
ASSISTANT PROFESSOR(SURGERY)
SHEIKH SAYERA KHATUN MEDICAL COLLEGE

2. HAEMORRHAGE
Haem means Blood
Rhegmynia means to burst
forth(rush out)

3. HAEMORRHAGE
Extravasation of blood from close
cardiovascular system
(Don’t use the term escape of
Blood)

4. Pathophysiology
Haemorrhage leads to a state of
hypovolaemic shock.

5. Pathophysiology
Bleeding
↓↓ ↓↓ ↓
Hypovolaemia
↓↓ ↓↓ ↓
Low cardiac output
↓↓ ↓↓ ↓
Tachycardia and shunting of blood from splanchnic
vessels by venoconstriction to maintain perfusion of
vital organs like brain, heart, lungs, kidneys

6. Pathophysiology
↓↓ ↓↓ ↓
Hypoxia
↓↓ ↓↓ ↓
Activation of cardiac depressants
↓↓ ↓↓ ↓
Anaerobic metabolism and altered cell membrane
function causing influx of more sodium and calcium
inside the cell and potassium comes out of the cell

7. Pathophysiology
↓↓ ↓↓ ↓
Hyponatraemic, hyperkalaemic, hypocalcaemic
metabolic acidosis
↓↓ ↓↓ ↓
Lysosomes of cell get lysed releasing powerful
enzymes which is lethal to cell itself
↓↓ ↓↓ ↓
SICK CELL SYNDROME

8. Pathophysiology
Platelets and coagulants are activated leading to formation of
small clots DIC and further bleeding.
↓↓ ↓↓ ↓
Progressive haemodilution leading to total circulatory failure
Initially there is compensatory hypovolaemic shock and later
there is decompensatory hypovolaemic shock which will lead to
MODS and death.
DIC, acidosis and hypothermia are the major factors in
worsening the situation in haemorrhage

9. Physiological exhaustion
( The triad of death)
Hypothermia
Coagulopathy Acidosis

10. Classification
According to
1. Anatomical source
2. Timing
3. According to Visibility
4. Duration
5. According to amount of blood loss
6. Cause
7. Amount of blood loss (Degree)

11. According to Anatomical
source
Arterial
Venous
Capillary

13. According to Timing
 Primary haemorrhage
-- occurring
immediately as a result
of an injury (or
surgery)
 Reactionary haemorrhage is
delayed haemorrhage (within 24
hours) caused by
Dislodgement of clot by
resuscitation
Normalization of blood pressure
Vasodilatation
Slippage of a ligature

14. According to Timing
Secondary haemorrhage
usually occurs 7–14
days after injury
caused by sloughing
of the wall of a vessel
precipitated by
 infection,
 pressure necrosis
(such as from a drain)
or
 malignancy.

15. According to Visibility
*Revealed haemorrhage
obvious external
haemorrhage, such as
exsanguination from an
open arterial wound
*Concealed haemorrhage
contained within the body
cavity
In trauma within the chest,
abdomen, pelvis or
retroperitoneum or in the
limbs, with contained
vascular injury or associated
with long-bone fractures
non-traumatic concealed
haemorrhage include occult
gastrointestinal bleeding or
ruptured aortic aneurysm.

16. Revealed Haemorrhage


17. Concealed Haemorrhage


18. Initially concealed but later
revealed
Any bleeding from
natural orifices
Haemoptysis
Haematemesis
Epistaxis
Haematuria
Haematocazia
Melaena
P/V bleeding
Bleeding through Ear

19. According to Duration
 Acute haemorrhage
(exsanguinous haemorrhage: The most extreme
form of hemorrhage, with an initial blood loss of >
40% and ongoing bleeding which, if not surgically
controlled, will lead to death)
 chronic haemorrhage
 Acute on chronic haemorrhage

20. According to amount of blood
loss
Mild-----< 500 ml blood loss
Moderate…..500-1000 ml blood loss
Severe……>1000 ml blood loss.

21. According to Cause
Surgical haemorrhage
Non-surgical haemorrhage

22. According to Cause
 Surgical haemorrhage is the result of a direct injury
and is amenable to surgical control (or other
techniques such as angioembolization)
 Non-surgical haemorrhage is the general ooze from
all raw surfaces due to coagulopathy; it cannot be
stopped by surgical means (except packing) but
requires correction of the coagulation abnormalities

23. According to Amount of blood loss
(Degree)
Degree of haemorrhage is classified in to four classes
Class1: Blood volume lost as percentage of < 15%
Class 2 :Blood volume lost as percentage of 15–30%
Class 3 :Blood volume lost as percentage of 30–40%
Class 4: Blood volume lost as percentage of > 40%

26. Clinical Features of
Haemorrhage
• Pallor, thirsty
• Cyanosis
• Tachycardia
• Tachypnoea
• Air hunger.
• Cold clammy skin due to vasoconstriction
• Dry face, dry mouth and goose skin appearance (due to
contraction of arrector pilorum)

27. Clinical Features of
Haemorrhage
•Goose Bump

28. Clinical Features of
Haemorrhage
• Rapid thready pulse
• Oliguria
• Features related to specific causes
• Hypotension

29. Signs of significant blood loss
 Pulse > 100/minute
 Systolic BP< 100 mmHg
 Diastolic BP drop on sitting or standing > 10
mmHg
 Pallor/ sweating
 Shock index (ratio of pulse rate to blood pressure)
> 1

30. Measurement of Blood Loss
 Clot size of a clenched fist is 500 ml
 Blood loss in a closed tibial fracture is 500-1500
ml; in a fracture femur is 500-2000 ml
 Weighing the swab before and after use is an
important method of on-table assessment of
blood loss

31. Measurement of Blood Loss
 Hb% and PCV estimation.
 Blood volume estimation using radioiodine
technique or micro hematocrit method.
 Measurement of CVP or PCWP
 Investigations specific for cause: U/S abdomen,
Doppler and often angiogram in vascular injury,
chest X-ray in haemothorax, CT scan in major
injuries, CT scan head in head injuries

32. Rains Factor
Total amount or of Blood loss =
 Total difference in swab weight × 1.5
Or
 Total difference in swab weight × 2 (For larger
wounds and larger operations)

33. Effects of haemorrhage
 Acute renal shut down
 Liver cell dysfunction
 Cardiac depression
 • Hypoxic effect
 • Metabolic acidosis
 • GIT mucosal ischaemia
 • Sepsis
 • Interstitial oedema, AV shunting in lung- ARDS
 • Hypovolaemic shock- MODS

36. Management
Identify haemorrhage
Immediate resuscitative manoeuvres
 Identify the site of haemorrhage
Haemorrhage control
Arrest of bleeding
Restoration of blood volume

37. Arrest of bleeding
5P”s
Pressure
Packing
Positioning
Procedure
Pray…..

38. Arrest of bleeding
1. Pressure and Packing
2. Position and Rest
3. Operative procedure
-Ligation
-Diathermy coagulation
-Suturing
-Pressure by ‘peanut’ of gauze
-Topical application for oozing biological gauze or
sponge (Oxycel or gelatin sponge), gauze soaked
in adrenalin
-Patches of vein or Dacron mesh
-Excision of whole or part of viscus

39. Haemostasis
Haemostasis is the human body's
response to blood vessel injury and
bleeding
 It involves a coordinated effort
between platelets and numerous blood
clotting proteins (or factors), resulting
in the formation of a blood clot and
subsequent stopping of the bleeding.

42. Local haemostatic agents:
• Gelatin sponge (Gel foam)
• Oxidised cellulose (Surgicel)
• Collagen sponge (Helistat)
• Cyano acrylic Glue(vietnum war)
• Microfibrillar collagen (Avitene)
• Topical thrombin
• Bone wax (derived from bees wax + almond oil)
• Gelatin matrices (Floseal)
• Topical cryoprecipitate