This document provides an overview of the management of bleeding. It defines hemorrhage and classifies it according to source, time of onset, visibility, and mode of onset. Reactionary hemorrhage occurs within 24 hours and secondary hemorrhage occurs 7-14 days later, often due to infection. Management involves controlling external bleeding through pressure, packing, and positioning as well as controlling internal bleeding through fluid resuscitation, operative techniques, and addressing any precipitating factors in reactionary or secondary hemorrhage. The effects of significant blood loss include shock, organ dysfunction, and metabolic derangements.

1. WELCOME TO CME PROGRAM
TOPIC
MANAGEMENT OF BLEEDING
PRESENTER
DR. MD. SHAHADAD HOSSAIN
DEPARTMENT OF SURGERY

2. Definition
Haemorrhage or bleeding: Is defined as extravasation of
blood from the blood vessel to the exterior

4. Classification of haemorrhage:
According to source of blood :
1) Arterial
2) venous
3) Capillary

5. Fig: Different types of bleeding

6. CONT….
According to time of onset:
1) Primary hemorrhage: Occurs at the time of
trauma or operation.
2) Reactionary hemorrhage: Occurs within 24
hours of primary haemorrhage( usually 4-6
hours) e.g. after tonsillectomy, after
thyroidectomy
3) Secondary haemorrhage: Occurs after 7- 14
days of primary haemorrhage due to infection.

7. CONT…
• According to visibility:
1) External/ revealed/ visible:
Skin cut
Haematemesis
Haemoptysis
Epistaxis
Melaena.
2) Internal/ concealed/ invisible:
Ruptured spleen or liver.
Fractured femur.

8. CONT…..
• According to mode of onset:
1)Acute:
Injury
Bleeding during operation
2)Chronic:
Hookworm infestation
Bleeding peptic ulcer
Haemorrhoids
Menorrhagia
Carcinoma

9. Degrees of haemorrhage
1st 2nd 3rd 4th
Blood volume lost as
percentage of total
<15% 15-30% 30-40% >40%

10. CLINICAL FEATURES
Symptoms of bleeding :
Fainting attack
Shallow breathing with gasps
Profuse sweating
Thirst
Blurred vision
Unconsciousness
Signs :
Cold and clammy skin
Weak and rapid pulse
Low blood pressure
Anaemia
Signs of shock may be found incase
of 3rd & 4th degree blood lose.

11. Management of bleeding
Control of external bleeding:
a)Pressure of packing:
1) pressure dressing made from anything, which is soft and
clean.
2) Direct pressure.
3) Packing by means of rolls of wide gauze.
4) Tourniquets.
5) Clothes pack for epitaxis.

12. CONT…
• b) Indirect pressure on pressure points.
c) Position and rest:
1) Elevation of limbs
2) Trendelenburg position (feet tilted downwards).

13. Pressure points to control of bleeding:
1) Temporal artery: For bleeding from scalp
2) Facial artery: For bleeding from face
3) Carotid artery: For bleeding from neck
4) Subclavian artery: For bleedig from chest wall and armpit
5) Brachial artery : For bleedig from upper limB
6) Femoral artery: For bleeding from lower limb

14. CONT…..

15. TRENDELENBURG POSITION

16. Control of internal bleeding:
1) Maintenance of ABC
2) Proper positioning: left lateral position
3) Restoration of blood volume to prevent shock by:
-blood transfusion
-intravenous fluid:Hartman’s solution, 5% DNS
-infusion of plasma or dextran

17. CONT….
4) Operative techniques:
-Pressure by artery forceps or clips
-Topical application of gelatin sponge or adrenaline
-Coagulation with diathermy
-Ligation of bleeding vessel with catgut or silk
-Suturing of vessels
-Splenectomy

18. Reactionary haemorrhage:
Bleeding occurs within 24 hours of primary haemorrhage.
Causes:
-slipping of ligature
-dislodgement of clot
-cessation of reflex vasospasm
Precipitating factors:
-rise in arterial blood pressure
-restlessness,coughing ,vomiting which raises venous pressure

19. Management of reactionary haemorrhage:
Diagnosis:
1)Careful examination of site of operation: excessive swelling may be
present
2)Careful examination of drain tube :excessive collection of blood
3)Severe anaemia
4)Tachycardia
5)BP: increased
6)RR: may be increased
7)Urine output: reduced
8)Estimation of Hb%, hematocrit, ESR

20. Treatment of reactionary heamorrhage
1)Removal of dressing
2)Open the layers of wound to relieve the tension
3)Patient is taken to be OT
4)Evacuation of haematoma
5)Secure the bleeding points
6)Endotracheal intubation may be needed to relieve airway
obstruction in case of thyroidectomy

21. Secondary haemorrhage:
Bleeding occurs after 7-14 days of primary haemorrhage
Can be occurred in any type of surgery where there is infection.
Common after haemorrhoidectomy, GI surgery, amputations.
Causes:
1)Infection
2)Trauma
3)Sloughing of the wall of a vessel

22. Management of secondary haemorrhage:
Diagnosis:
1)Bright red stains on dressing , followed by sudden severe
haemorrhage
2)Patient becomes anaemic
3)Tachycardia
4)Hypotension
5)Temperature: raised
6)Urine output: reduced
7)Patient may be toxic and restless

23. Treatment of secondary heamorrhage
1) Control of infection by appropriate antibiotics.
2) Restoration of blood volume by blood transfusion
3) Prevention of further blood loss by:
-pressure and pack
-complete bed rest and proper positioning

24. CONT…
-operative techniques:
clamping and ligation
coagulation by diathermy
sclerosing agent
sponge stain

25. Effects of haemorrhage
1) Acute renal shut down
2) Hypovolaemic shock
3) Liver cell dysfunction
4) Cardiac depression
5) Hypoxic effect
6) Metabolic acidosis
7) GIT mucosal ischaemia
8) Sepsis
9) Interstitial oedema
10) ARDS