Haemorrhage

Damage to blood vessels

Arterial - pulsating, bright red blood

Venous - steady stream of dark red blood

Capillary - oozing from a wound surface

Forms of haemorrhage

Primary - occurs at time of injury

Reactionary - within 24 hours of injury, reaction to increasing BP

Secondary - 7 - 10 days after injury, due to infection.

Site of haemorrhage

External - always examine the whole body surface

Internal - into a body space or potential space

Revealed - internal haemorrhage may become revealed

Haematemesis

Haemoptysis

Haematuria.

Haemothorax

Abdominal

Intracranial

Intraoccular

Risk associated with internal haemorrhage depends on place and volume

Place

May exert pressure on vital structures

Thyroid

Pressure on the trachea due to haematoma from vascular thyroid gland, causes dyspnoea and stridor

Intracranial

Compression of the brain, risk of conning

Intrahepatic

Damage to liver cells inside intact capsule

Pressure on a nerve

May cause reversible or irreversible loss of function

Pericardial - tamponarde may embarrass the normal function of the heart

Normal adult blood volume is 5 litres - acute loss of 2 litres may cause death

Effects of haemorrhage

Acute haemorrhage;

Transitory drop in BP producing fainting or giddiness, prolonged drop in BP leads to shock

Chronic haemorrhage:

Insidious symptoms such as tiredness, faintness, blackouts and dizziness

Clinical features

Increase in pulse - fast, weak and thready

Blood pressure progressively drops

Pallor pale, white, cyanosis

Skin cold and clammy

Peripheral arterial and venous constriction

Reduced capillary refill

Tachypnoea if severe

Organ hypoperfusion

Gut -

Brain - agitation, anxiety, confusion, dizzy, faint, loss of consciousness

Kidneys -

Myocardium -

Intracranial bleeds BP goes up not down.

Treatment of haemorrhage

Fix the leak, and replace fluid loss.

Management depends on the degree and speed with which blood loss has occurred

Restore fluid volumes

Oral fluids

Oral rehydration solutions

Nasogastric fluids

PR infusions

IVIs

Intravenous fluids

Crystalline

Colloid

Blood

Primary haemorrhage

Direct pressure

Direct pressure above site or round site if foreign body in wound

Indirect pressure

Lie patient flat

Elevate limb

Keep cool, do not warm up

Cover wound with sterile or clean dressing after haemostasis

Clip and ligate bleeding sites within a wound

Internal

Pre and post op care, often as an emergency

Replacement of lost blood

Keep patient still to prevent removing blood clots

General management

Observations for onset of shock

Intravenous fluids for hypovolaemia

Plasma replacement/expanders/colloids, (titrate with BP and CVP if available)

Whole blood or packed cells with colloids

Monitor cardiac, renal, cerebral and respiratory function

Reactionary haemorrhage

May be necessary to return patient to theatre

Secondary

Normal treatment of haemorrhage with special attention to wound care combined with antibiotic therapy

Pathophysiology

Haemorrhage is associated with profound vasoconstriction of arterioles, i.e. the precapillary resistance vessels

This increases the pressure drop along the arterioles

This means that capillary pressures are correspondingly lower

This will result in a reduction in tissue fluid formation and an increase in its reabsorption

Fluid will therefore enter the vascular compartments increasing intravascular volume

In haemorrhage whole blood is lost

Therefore in the initial stages haemoglobin content, haematocrite, red cell count will be unchanged

Therefore can not be uses as indicators for the degree of haemorrhage

As tissue fluid enters the circulation over the next 2 - 3 hours the remaining RBCs will be diluted

Therefore haemoglobin content, haematocrite, red cell count will all fall

Some red cells will be replaced in the short term from reserves held in the spleen

Lost blood cells will be replaced during the next few weeks due to increased bone marrow activity