Management of bleeding

In short management of bleeding

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

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

4. Fig: Different types of bleeding

5. 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.

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

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

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

9. 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 3 rd & 4 th degree blood lose.

10. 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 .

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

12. Pressure points to control of bleeding: Temporal artery: For bleeding from scalp Facial artery: For bleeding from face Carotid artery: For bleeding from neck Subclavian artery: For bleedig from chest wall and armpit Brachial artery : For bleedig from upper limB Femoral artery: For bleeding from lower limb

13. CONT…..

14. Trendelenburg position

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

24. 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