Hemorrhage: Types and Classifications

Hemorrhage

• Hemorrhage is the escape of blood outside the circulatory system.
• Classification by bleeding site:
  • External: Bleeding visible through the skin (wounds) or body orifices (epistaxis, hematemesis, hematuria).
  • Internal (concealed): More serious, requires investigation and control. Examples include hemoperitoneum, retroperitoneal hemorrhage, and hemothorax.
• Classification by type of disrupted vessel:
  • Arterial: Bright red blood in pulsatile jets, bleeding more from the proximal end.
  • Venous: Dark red blood in a steady flow, bleeding more from the distal end, can be alarming if a large vein is injured.
  • Capillary: Diffuse oozing, bright red blood. Sudden cessation of oozing can indicate cardiac arrest.
• Classification by timing in relation to trauma:
  • Primary: Occurs at the time of trauma.
  • Reactionary: Occurs within 24 hours after trauma, often due to blood pressure changes after treatment or postoperative pain.
  • Secondary: Occurs 1-2 weeks after trauma, precipitated by factors like infection or necrosis of vessel walls, or malignancy.
• Classification by etiology:
  • Traumatic: Accidental or surgical, includes interventional procedures like biopsies.
  • Pathological: Atherosclerotic (e.g., ruptured aortic aneurysm), inflammatory (e.g., bleeding peptic ulcer), or neoplastic (e.g., hematuria in renal cancer).
  • Spontaneous: Bleeding diathesis like hemophilia, increasing traumatic and pathological bleeding; cannot be controlled by surgical means (except packing), requires correcting coagulation abnormalities.
• Physiological response to hemorrhage:
  • Stopping bleeding: Vasoconstriction and subsequent clotting of injured blood vessels.
  • Maintaining circulating volume: Prioritizing vital organs (heart, brain) over less critical regions (skin, skeletal muscle).
• Summary: Integrated mechanisms stop hemorrhage and maintain critical organ perfusion. They permit survival without treatment for losses up to 15% of blood volume.
• Clinical picture:
  • Symptoms: Weakness, fainting (especially when standing), feeling cold and thirsty.
  • Signs: Tiredness, pale skin, anxiety/drowsiness, tachycardia progressing to hypotension, tachypnea, hypothermia, coagulopathy, pale, cold, clammy skin, oliguria.
• Management:
  • Arresting bleeding: packing, pressure, limb elevation, pressure on feeding vessel (e.g., brachial artery).
  • Definitive treatment: Identifying the cause of bleeding.
  • IV line: Two short peripheral cannulas.
  • Blood sample: Blood group, cross-matching, CBC, hematocrit, coagulation profile.
  • IV fluids or blood: Based on severity of bleeding.
  • Other: Oxygen mask, keep the patient warm, urinary catheter, analgesics, bed rest, elevate legs.
• Monitoring:
  • Frequent monitoring: every 15 minutes initially, then hourly or semi-hourly for 2 hours and later four hourly, until stabilized.
  • Monitor: Pulse, blood pressure, respiratory rate, urine output, skin, temperature, mental status, and central venous pressure.
• Reference: SRB's Manual of Surgery 3rd ed.