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Haemorrhage

1. Hemorrhage Bleeding, technically known as hemorrhage. It is the loss of blood from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, mouth or anus, or through a break in the skin.

2. The term "hemorrhagic" comes from the Greek "haima," blood + rhegnumai," a free and forceful escape of blood. The complete loss of blood is referred to as exsanguinations and desanguination is a massive blood loss. Loss of 10-15% of total blood volume can be endured without clinical sequelae in a healthy person, and blood donation typically takes 8-10% of the donor's blood volume. Hemorrhage Contd.

3. Clotting mechanism coagulation is a complex process by which blood forms clots. vessel wall is covered by a platelet and fibrin containing clot to stop bleeding and begin repair of the damaged vessel. Disorders of coagulation can lead to an increased risk of bleeding (hemorrhage) and/or clotting (thrombosis

4. Coagulation involves both a cellular (platelet ) and a protein(coagulation factor) component. Coagulation begins almost instantly after an injury to the blood vessel has damaged the endothelium (lining of the vessel). Primary hemostasis :Platelets immediately form a plug at the site of injury. Secondary hemostasis :occurs simultaneously: proteins in the blood plasma, called coagulation factors or clotting factors, respond in a complex cascade to form fibrin strands which strengthen the platelet plug. Clotting mechanism Contd.

5. Classification Hemorrhaging is broken down into 4 classes by the American College of Surgeons' Advanced Trauma Life Support (ATLS). Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.

6. Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch.. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer solution) is all that is typically required. Blood transfusion is not typically required.

7. Class III Hemorrhage Involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral perfusion, such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.

8. Class IV Hemorrhage Involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached Aggressive resuscitation is required to prevent death.

9. Causes Traumatic Traumatic bleeding is caused by some type of injury. There are different types of wound which may cause traumatic bleeding. Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause Hematoma - - Caused by damage to a blood vessel that in turn causes blood to collect under the skin.

10. causes Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin Crushing Injuries - Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself. Ballistic Trauma - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

11. Causes Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision. Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery. Puncture Wound - Caused by an object that penetrated the skin and underlying layers, such as a nail, needle or knife

12. Medical conditions increasing bleeding risk Anatomical deformities Aneurism :localised blood filled dilation of a blood vessel Arterio venous malformation : connection between arteries and veins Other conditions :infection, ulcers, cancer,

13. Condition that can affect normal hemostasis Thrombocytopenia : a decrease in number of platelet. Thrombasthenia: A decreased function of platelets Hemophilia: x linked recessive disorder in factor VIII is deficient Christmas disease: deficiency of factor IX Von Willebrand disease: deficiency of Von Willebrand factor which help in platelet activation

14. Drugs NSAIDs: inhibit platelet activation eg:aspirine Warfarin : inhibit vitamin K which is needed for the production of factors II, VII, IX,and X

15. management Minor bleeding Minor bleeding is bleeding that falls under a Class I hemorrhage and the bleeding is easily stopped with pressure. The largest danger in a minor wound is infection Bleeding can be stopped with direct pressure and elevation, and the wound should be washed well with soap and water. A dressing, typically made of gauze, should be applied. or iodine solutions (such as Betadine ) can also be used

16. Pressure points In situations where direct pressure and elevation are either not possible or proving ineffective, the use of pressure to constrict the major artery which feeds the point of the bleed is advocated . This is usually performed at a place where a pulse can be found. There are risks involved in performing pressure point constriction, including necrosis of the area below the constriction.

17. Pressure points Application of pressure in carotid artery may cause damage to brain Pressure on the carotid artery can also can cause vagal tone induced bradycardia. Other dangers in use of a constricting method include rhabdomyolysis, which is a build up of toxins below the pressure point.

18. Tourniquet Another method of achieving constriction of the supplying artery is via the use of a tourniquet- a tightly tied band which goes around a limb to restrict blood flow. Their use in emergency medicine is more limited, and is restricted in most countries. An emergency tourniquet should in any case never be applied to the forearm or lower leg since the arteries in these locations run between bones and can not be compressed

19. Tourniquet Improvised tourniquets, however, usually fail to achieve force enough to compress the arteries of the limb and thus do not only fail to stop arterial bleeding but actually increase bleeding due to the impaired venous blood flow.

20. Pressure Dressing A sterile dressing applied with pressure to a hemorrhaging wound enhances clot formation, compresses open blood vessels, and protects the injury from further invasion by infectious organisms. Sometimes more harm is done to the patient by secondary infection than the trauma itself

21. Antihemorrhagics Vitamin K/ Inj . Phytomenadione / Menadione : 5-10 mg/day orally for deficiency Fibrinogen: 0.5g infused in acute fibrinogenic state Inj. Tranexa 1000mg IV stat fb 500mg IV / oral TDS Factor IX: It is a synthetic protein prescribed for control and prevention of hemorrhagic episodes in patients with hemophilia B.

22. Avatrombopag tablets are prescribed for treating abnormally low platelet counts or a condition of thrombocytopenia in adult patients with severe liver dysfunction who are planning to undergo a medical or dental procedure . Antihemorrhagics

23. Antifibrinolytics amino acids (Aminocaproic acid, Tranexamic acid, Aminomethylbenzoic acid) Local hemostatics Absorbable gelatin sponge · Oxidized cellulose · Tetragalacturonic acid hydroxymethylester · Adrenalone · Thrombin · Collagen · Calcium alginate · Epinephrine Other systemic hemostatics Etamsylate · Carbazochrome · Batroxobin · Romiplostim Antihemorrhagics

24. Care plan Fluid volume deficit r/t acute blood lose Monitor vital signs Monitor hemodynamic values Administer replacement fluids or blood as odered Place patient on supine position with leg elevated Monitor hemogram and hematocrit

25. Impaired gas exchange r/t decreased oxygen carrying capacity Monitor oxygen saturation with oxymetry and ABG Use supplemental O2 as ordered Monitor breath sounds and pulmonary symptoms Position patients head end up if at all posibile Care plan

26. Decreased cardiac out put r/t hemorrhage Maintain work load by maintaining bed rest Assess vital signs assess hemodynamic parameters Evaluate hourly for amount and specific gravity Verify acid base balance by ABG Administer IV fluids and blood products as prescribed

27. Impaired skin integrity r/t truma Assess wound healing skin and tissue integrity Change dressing as order Provide adequate nutrition Administer antibiotics as ordered Change the position frequently

28. High risk for infection r\t trauma Assess vital signs temperature, wound condition Monitor WBC Obtain culture as ordered Change dressing as ordered Assess for any oozing or bleeding

29. Anxiety r\t trauma and bleeding Provide environment that encourage open discussion of emotional issues Mobilize patient support system and involve these resources as appropriate resources as appropriate Identify possible hospital resources for patient and family support

30. Sawicka-Powierza J , Ołtarzewska AM , Chlabicz S . Department of Family Medicine and Community Nursing, Medical University of Białystok , Poland. [email protected] AIM; to evaluate patients' knowledge about the safety of acenocumarol treatment, the therapeutic range of International Normalized Ratio (INR) and its interactions with other medications and food. METHODS: 140 patients on long-term acenocumarol treatment were included in the study. They were interviewed using a questionnaire . The questions concerned their understanding of the reasons for the treatment, knowledge of target INR ratio, frequency of INR examination, factors influencing INR values e.g. drugs, food, alcohol and the like. RESULTS: 115 (82.1%) patients declared knowledge of target INR ratio, but only 88 (62.9%) answered correctly. Percentages of correct answers for the questions evaluating knowledge about acenocumarol treatment did not exceed 50%. CONCLUSIONS: Level of patients' knowledge about the safety of OAC treatment was very low. Insufficient knowledge was observed particularly in patients with lower education levels and those over 60 years of age. RESULTS: 115 (82.1%) patients declared knowledge of target INR ratio, but only 88 (62.9%) answered correctly. Percentages of correct answers for the questions evaluating knowledge about acenocumarol treatment did not exceed 50%. METHODS: 140 patients on long-term acenocumarol treatment were included in the study. They were interviewed using a questionnaire . The questions concerned their understanding of the reasons for the treatment, knowledge of target INR ratio, frequency of INR examination, factors influencing INR values e.g. drugs, food and alcohol

31. Summary Definition Causes Types Management

32. References : Smeltzer S.C ,Bare B.G Medical surgical nursing 10 th edition Tripati K.D Essentials of medical pharmacology 1 st edition