Hemorrhage Classification Quiz

Hemorrhage

• Hemorrhage is the escape of blood outside the circulatory system.
• Hemorrhage classification is based on different criteria:

Classification by site of bleeding

• External: Bleeding visible through the skin (e.g., wounds) or from body orifices (e.g., epistaxis, hematemesis, hematuria).
• Internal (concealed): More serious, hidden bleeding, requiring active investigation and control (e.g., hemoperitoneum, retroperitoneal hemorrhage, hemothorax).

Classification by type of disrupted vessel

• Arterial: Bright red blood, pulsatile jets, bleeding primarily from the proximal end.
• Venous: Dark red blood, steady flow, bleeding primarily from the distal end, can be dangerous if large veins are injured.
• Capillary: Bleeding as diffuse ooze, bright red blood. Sudden cessation of oozing during surgery may signify cardiac arrest.

Classification by timing in relation to trauma

• Primary: Bleeding occurring at the time of trauma.
• Reactionary: Bleeding occurring within 24 hours after trauma, sometimes due to blood pressure correction post-procedure or postoperative pain.
• Secondary: Bleeding occurring 1-2 weeks after trauma, often due to factors like infection, necrosis, or malignancy, especially around surgical sites.

Classification according to etiology

• Traumatic: Accidental or surgical, including interventional procedures, such as biopsies.
• Pathological: Atherosclerotic (e.g., ruptured aortic aneurysm), inflammatory (e.g., bleeding peptic ulcer), or neoplastic (e.g., hematuria in kidney cancer).
• Spontaneous: Bleeding diathesis (e.g., hemophilia), increased bleeding with little or no trauma, typically treated via correction of coagulation abnormalities.

Physiological Response to Hemorrhage

• Stopping the bleeding: Vasoconstriction of injured blood vessels and subsequent clotting.
• Maintaining effective circulating volume: Prioritizing blood flow to critical organs (heart and brain) at the cost of less critical tissues (skin and skeletal muscle) , which is achieved using various systems

Clinical Picture

• Symptoms: Weakness, fainting (especially standing), feeling cold and thirsty.
• Signs: Pale, tired appearance, anxious or drowsy, tachycardia (fast heart rate), progressive hypotension (low blood pressure), tachypnea (rapid breathing), hypothermia, pale, cold, and clammy skin, and oliguria (reduced urine output).

Management

• Stop the bleeding: Packing, pressure, elevation (e.g., elevating the limb), direct pressure on the blood vessel source. Definitive treatment should also consider the underlying cause of bleeding.
• IV line: Multiple short peripheral cannulas.
• Blood sample: Blood type, cross-matching, complete blood count (CBC), hematocrit, coagulation profile.
• IV fluids/Blood: Administered based on the severity of hemorrhage.
• Other measures: Oxygen mask, maintaining patient warmth, urinary catheter insertion for urine output monitoring, analgesics, bed rest, and elevating the legs (for edema).

Monitoring of Treatment

• Frequent monitoring (every 15 minutes initially, then hourly or half hourly until stable, then every 4 hours) for pulse, blood pressure, respiratory rate, urine output, skin temperature, level of consciousness, and central venous pressure (to assess blood return to heart).

Summary

• Hemorrhage must be aggressively diagnosed and treated to prevent shock, multi-organ failure, and potential death. Treating the bleeding is more effective than just fluid or blood transfusions for most patients.
• Supportive measures to keep organs perfused, such as resuscitaton, can be harmful if severe or uncontrolled hemorrhage continues as it leads to physiological exhaustion/failure.
• Blood volume estimation (around 70 ml/kg in adults, 80 ml/kg in children) and classification is essential for appropriate management.