Haemorrhage

For MBBS Students

1. Dr. Md. Majedul Islam FCPS(Surgery) Asst Professor of JIMCH Haemorrhage

2. Haemorrhage : 1. may be defined as an escape of blood outside its containing vessel , or 2. extravasation of blood from its containing vessels.

3. Classification/Types According to Type of blood vessels: Arterial Venous Capillary B. A/C to onset/timing: Primary Reactionary Secondary

4. According to Nature/Visibility: Revealed haemorrhage and Concealed haemorrhage D. A/C to type of intervention : Surgical Hge Non- surgical Hge. E. A/C to the Duration: Acute Hge. Chronic Hge.

5. A . Arterial Hge: 1. Bright red 2. mitted as spurting jet 3. Can lead to severe blood loss 4. Often hard to control B. Venous Hge : Darker red Steady and copious flow Color becomes further darker with oxygen desaturation Usually easy to control

6. C. Capillary Hge : Bright red Rapid and oozing Blood loss becomes serious if continues for hours Generally minor & easy to control

7. Onset/Timing Primary Hge : haemorrhage occurring immediately due to an injury (or surgery). Cause: injury to vessels May be arterial, venous or capillary. More common in surgery on malignancies

8. B. Reactionary haemorrhage : Bleeding within 24 hours ( usually 4-6 hrs ) of surgery. Cause : Slipping of ligature, Dislodgement of clot or Cessation of reflex vasospasm Example of Reactionary Hge: Thyroidectomy Tonsillectomy Prostatectomy Haemorrhoidectomy

9. C. Secondary Hge: Hge occurs after 7-14 days of surgery. Cause: sloughing of vessel due to infection, pressure necrosis, Malignancy, Presence of foreign body. Common after hemorrhoids surgery, GI surgery & amputations.

10. According to Nature/Visibility: External Haemorrhage or Revealed Hge : Example : soft tissue injuries Bleeding from the limb vessels, wound, Nose( epistaxis ) Hemoptysis Hematemesis Malena .

11. Internal Haemorrhage or Concealed : Internal or invisible bleed – Causes: 1. Blunt or Penetrating trauma 2. May remain concealed as in ruptured spleen or liver. Concealed hemorrhage may become revealed as in haemetemesis or melaena in peptic ulcer bleed

12. Example of internal Hge: Haemocranium (Blood in side the cranium by trauma) i.e : EDH, SDH, ICH Haemothorax (Blood in the thoracic cavity by blunt trauma) Hemoperitoneum (blood in side the peritoneal cavity) , liver, spleen or mesenteric injury or rupture ectopic pregnancy. Retroperitoneal Hge: Injury to kidney, rupture aortic aneurysm. Fracture long bone: Blood collect inside the limb( femur fracture).

13. Revision Questions of Professional Examination: Lets check it Out

14. Clinical Feature of Hge Depends upon 2 factor: Amount of Blood loss. Speed of Blood Loss. Acute Blood Loss(internal bleeding/Concealed Hge) Increasing Pallor Increasing Pulse Increasing restlessness Deep respiration Sign of Shock

15. Sign of Shock Cold clammy skin Tachycardia Hypotension Reduced Urine output Collapse peripheral vein Altered consciousness level Feature of Chronic Blood Loss : Anemia

16. Monitoring of Hge(Acute): 1. Pulse Rate: 10% Blood Loss, No problem – Just Tachycardia 50% Blood Loss - Pulse Absent. Measure every 15/30 min Interval When Pt is Stable – Monitor 4 hourly. 2. Blood Pressure. Blood pressure is usually well maintained and only falls after 30–40 per cent of circulating volume has been lost. 3. Urine Output. Normal Urine output 1ml/kg/hr or 1ml/min Half than normal is Ok But less than 30 ml/hr – Oliguria If blood loss > 50% - Anuria develop.

17. Control Of Hge Control bleeding using these techniques: A. Non Surgical Technique Direct pressure (“pressure dressing”) and Packing Elevation Pressure points(Brachial artery,Femoral artery) Tourniquets Application Adrenaline soaked gauze/pad Warm mop/Hot mop. B. Surgical : Catch the bleeding point by artery forceps. Ligation of bleeding vessels Electro-cauterization. Reapir (liver injry , kidney injury, great vessels). Excision ( soid organ where repair not possible i.e – spleen, kidney)

18. C. Endoscopic technique: Sclerotherapy Cauterization Ligation D. Modern technique: Transarterial chemo- embolisation / Angioembolisation . Others: Gel foam/Gelatin sponge. Spongiostant . Muscle Bone wax.

19. How you will restore blood volume: Blood Transfusion Hemaccel (artificial Plasma solution) I/V fluid(Hartman/Ringer’s Lactate)