Name = Bleeding
ICD9 = ICD9|456.20
Bleeding, technically known as hemorrhaging/haemorrhaging (see American and British spelling differences) is the loss of
bloodfrom the circulatory system. [cite web|url=http://www.healthline.com/adamcontent/bleeding|title=Bleeding Health Article|publisher=Healthline|accessdate=2007-06-18] 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.The complete loss of blood is referred to as exsanguination, [cite web|url=http://dictionary.reference.com/browse/exsanguination|title=Dictionary Definitions of Exsanguination|publisher=Reference.com|accessdate=2007-06-18] and desanguinationis a massive blood loss. Loss of 10-15% of total blood volume can be endured without clinical sequelae in a healthy person, and blood donationtypically takes 8-10% of the donor's blood volume. [cite web|url=http://www.blood.co.uk/pages/b36faint.html|title=Blood Donation Information|publisher=UK National Blood Service|accessdate=2007-06-18]
Causes, prevalence, and risk factors
Hemorrhage generally becomes dangerous, or even fatal, when it causes
hypovolemia(low blood volume) or hypotension(low blood pressure). In these scenarios various mechanisms come into play to maintain the body's homeostasis. These include the "retro-stress-relaxation" mechanism of cardiac muscle, the baroreceptorreflex and renal and endocrine responses such as the renin- angiotensin- aldosteronesystem (RAAS).
Certain diseases or medical conditions, such as
haemophiliaand low plateletcount ( thrombocytopenia), may increase the risk of bleeding or may allow otherwise minor bleeds to become health or life threatening. Anticoagulantmedications such as warfarincan mimic the effects of haemophilia, preventing clotting and allowing free blood flow.
Death from hemorrhage can generally occur surprisingly quickly. This is because of '
positive feedback'. An example of this is 'cardiac repression', when poor heart contraction depletes blood flow to the heart, causing even poorer heart contraction. This kind of effect causes death to occur more quickly than expected.
Types of bleeding
Hemorrhaging is broken down into 4 classes by the American College of Surgeons'
Advanced Trauma Life Support(ATLS). [Manning, JE "Fluid and Blood Resuscitation" in Emergency Medicine: A Comprehensive Study Guide. JE Tintinalli Ed. McGraw-Hill: New York 2004. p227]
* 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.
* 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. The patient might start acting differently. Volume resuscitation with crystalloids (Saline solution or
Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required.
* Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's
blood pressuredrops, the heart rate increases, peripheral perfusion, such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusionare usually necessary.
* Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion (shock). Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment of these patients.
Traumatic bleeding is caused by some type of injury. There are different types of
wounds which may cause traumatic bleeding. These include:
* 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- (Also called a blood tumor) - Caused by damage to a blood vessel that in turn causes blood to collect under the skin.
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
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
The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a
medical procedurealso falls into this category.
Due to underlying medical conditions
Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels (
aneurysmor dissection), arteriovenous malformation, ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.
The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation,
haemostasisand related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.
Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body.
Hemostasisinvolves several components. The main components of the hemostatic system include plateletsand the coagulation system. Plateletsare small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to non-steroidal anti-inflammatory drugs(or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.
There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on
coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic Hemophilia Awhile deficiencies of Factor IX cause "Christmas disease"( hemophilia B). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with autoimmunediseases. von Willebrand diseaseis another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.
In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication,
warfarin("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin Kin the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.
Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either
fresh frozen plasmaof specific clotting factors, such as Factor VIIIfor patients with hemophilia.
All people who have been injured should receive a thorough assessment. It should be divided into a primary and secondary survey and performed in a stepwise fashion, following the "ABCs". Notification of EMS or other rescue agencies should be performed in a timely manner and as the situation requires.
The primary survey examines and verifies that the patient's Airway is intact, that s/he is Breathing and that Circulation is working. A similar scheme and mnemonic is used as in CPR. However, during the pulse check of C, attempts should also be made to control bleeding and to assess perfusion, usually by checking
capillary refill. Additionally a persons mental status should be assessed (Disability) or either an AVPUscale or via a formal Glasgow Coma Scale. In all but the most minor cases, the patient should be Exposed by removal of clothing and a secondary survey performed, examining the patient from head to toe for other injuries. The survey should not delay treatment and transport, especially if a non-correctable problem is identified.
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. Peroxide or iodine solutions (such as Betadine) can injure the cells that promote healing and may actually impair proper wound healing and delay closure. [Waston, JR "et al." Adv Skin Wound Care. 2005 Sep;18(7):373-8. PMID: 16160464]
Emergency Bleeding Control
Severe bleeding poses a very real risk of death to the casualty if not treated quickly. Therefore, preventing major bleeding should take priority over other conditions, save failure of the heart or lungs. Most protocols advise the use of direct pressure, rest and elevation of the wound above the heart to control bleeding.
The use of a
tourniquetis not advised in most cases, as it can lead to unnecessary necrosisor even loss of a limb. Tourniquets should rarely be used as it is usually possible to stop bleeding by the application of manual pressure.Fact|date=April 2007
Bleeding from body cavities
The only minor situation is a spontaneous nosebleed, or a nosebleed caused by a slight trauma (such as a child putting his finger in his nose).
Simultaneous externalised bleeding from the ear may indicate brain trauma if there has been a serious head injury. Loss of consciousness, amnesia, or fall from a height increases the likelihood that there has been a severe injury. This type of injury can also be found in motor vehicle accidents associated with death or severe injury to other passengers.
Hemoptysis, or coughing up blood, may be a sign that the person is at risk for serious bleeding. This is especially the case for patients with cancer. Hematemesisis vomiting up blood from the stomach. Often, the source of bleeding is difficult to distinguish and usually requires detailed assessment by an emergency physician.
Internal bleeding occurs entirely within the confines of the body and can be caused by a medical condition (such as
aortic aneurysm) or by trauma. Symptoms of internal bleeding include pale, clammy skin, an increased heart rate and a stupor or confused state.
The most recognisable form of internal bleeding is the
Risk of blood contamination
Because skin is watertight, there is no immediate risk of infection to the aide from contact with blood, provided the exposed area has not been previously wounded or diseased. Before any further activity (especially eating, drinking, touching the eyes, the mouth or the nose), the skin should be thoroughly cleaned in order to avoid cross contamination.
To avoid any risk, the hands can be prevented from contact with a glove (mostly
latexor nitrile rubber), or an improvised method such as a plastic bag or a cloth. This is taught as important part of protecting the rescuer in most first aid protocols.
Following contact with blood, some rescuers may choose to go to the
emergency department, where post-exposure prophylaxiscan be started to prevent blood-borne infection.
As a medical treatment
Before the advent of modern medicine the technique of
bloodletting, or phlebotomy, was used for a number of conditions: causing bleeding intentionally to remove a controlled amount of excess or "bad" blood. Phlebotomy is still used as an extremely effective treatment for Haemochromatosis.
Exsanguination- death by bleeding
Hematemesis- vomiting fresh blood
Hematochezia- rectal blood
Hematuria- blood in the urine from urinary bleeding
Hemoptysis- coughing up blood from the lungs
Intracerebral hemorrhage- bleeding in the brain caused by the rupture of a blood vessel within the head. See also hemorrhagic stroke.
Subarachnoid hemorrhage(SAH) implies the presence of blood within the subarachnoid spacefrom some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or arteriovenous malformation(AVM). The scope of this article is limited to these nontraumatic hemorrhages.
Upper gastrointestinal bleed
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