Haemorrhage - A Medical Presentation PDF

HAEmorrhage By AHMED ABDELFATTAH  Definition Classification Physiological response to hemorrhage Clinical Picture Treatment FLUID THERAPY Hemorrhage = bleeding means Escape of blood outside the circulatory system. Classifications: I. According to site of bleeding: 1....

HAEmorrhage By AHMED ABDELFATTAH  Definition Classification Physiological response to hemorrhage Clinical Picture Treatment FLUID THERAPY Hemorrhage = bleeding means Escape of blood outside the circulatory system. Classifications: I. According to site of bleeding: 1. External (revealed): Bleeding is visible through the skin as in wounds, From a body orifice as in epistaxis or hematemesis, hematuria. 2. Internal (concealed): More serious and must be suspected, actively investigated and controlled. , examples; Hemoperitoneum Retroperitoneal hemorrhage Hemothorax. II. Type of disrupted vessel: 1. Arterial: The blood is bright red in colour Comes in pulsatile jets. Bleeding is more from the proximal than the distal end. 2. Venous: Blood is dark red in colour Comes as a steady flow. More from the distal than the proximal end. Can be terrifying if a large vein is injured. 3. Capillary: Bleeding occurs as diffuse ooze Bright red blood. Sudden cessation of oozing during a surgical operation means cardiac arrest.  III. According to Timing in relation to the onset of trauma: 1. Primary hemorrhage: Occurs at the time of trauma 2. Reactionary hemorrhage: Occurs within 24 hours after trauma. As the blood pressure rises due to correction of Hypovolemia, or secondary to postoperative pain An insecure ligature is going to slip or a clot is going to dislodge  3. Secondary hemorrhage: Occurs 1 - 2 weeks after trauma and is precipitated by factors such as infection eroding vessel walls, e.g. after hemorrhoidectomy or tonsillectomy. , pressure necrosis (such as from a drain) or malignancy. It can be fatal if a large vessel is involved, e.g. the carotid after sloughing of the skin flaps of a radical neck dissection IV. According to etiology: 1. Traumatic: Accidental Surgical Interventional procedures, e.g. biopsy. 2. Pathological: Atherosclerotic (ruptured aortic aneurysm). Inflammatory (bleeding peptic ulcer). Neoplastic (hematuria in renal cancer).  3. Spontaneous: Bleeding diathesis e.g. hemophilia, can: Increase the amount of traumatic and pathological bleeding Cause bleeding with little or no trauma. It cannot be stopped by surgical means (except packing) but requires correction of the coagulation abnormalities.  Physiological response to heamorrhage (1) Stopping the bleeding by: VC of injured blood vessel with subsequent clotting (2) Maintaining effective circulating volume for critical tissue ( heart & brain) at the expense on less critical (skin, skeletal muscle), and is achieved by:  In summary, a number of integrated mechanisms operate to stop hemorrhage and maintain perfusion for critical organs. These mechanisms allow survival without therapy for losses up to 15% of blood volume.  Greater losses or poor cardiovascular reserve eg.(CAD, severe anemia) lowers patients tolerance to hemorrhage and leads to progressive hypovolemia, shock and death unless appropriate therapy is instituted.  Clinical Picture: I. Symptoms: 1. Weakness and fainting especially when standing. 2. The patient feels cold and thirsty. II. Signs: 1. The patient looks tired, pale. 2. Anxious or drowsy. 3. Tachycardia & then progressive hypotension. 4. Tachypnea 5. Hypothermia coagulopathy. 6. Skin; pale, cold & clammy. 7. Oliguria.  In patient with haemorraghe, it is important to have rough estimate of blood loss from clinical data Blood volume is estimated as 70 ml/kg in adults, and 80 ml/ kg in children. Four classes of haemorrhage are recognized based on clinical changes in haemodynamic parameters and indices of tissue perfusion.  Haemorrhage must be recognized and managed aggressively to reduce the severity and duration of shock and avoid death and/or multiple organ failure. Haemorrhage is treated by arresting the bleeding, and not by fluid resuscitation or blood transfusion.  Although necessary as supportive measures to maintain organ perfusion, attempting to resuscitate patients who have on-going haemorrhage will lead to physiological exhaustion (coagulopathy, acidosis and hypothermia) and subsequently death. Management: I. Stop the hemorrhage: Packing, pressure, Position e.g. limb elevation Pressure on the feeding artery e.g. the brachial artery in distal upper limb bleeding Definitive management ??Cause of bleeding. II. IV line: two short peripheral canulas; III. Blood Sample 1. Blood group 2. Cross matching 3. CBC 4. Hematocrite 5. Coagulation profile IV. Give IV fluids or blood according to the severity of bleeding; V. Oxygen mask VI. Keep the patient warm VII. Insert a Urinary Catheter and check urine output. VIII. General care: Analgesics, bed rest, elevate the legs IX. Monitoring of treatment: 1. Frequency of monitoring: i. every 15 minutes until the patient is resuscitated, ii. then half-hourly for 2 hours iii. then four hourly What to monitor: Pulse & blood pressure Respiratory rate Urine output (0.5-1 ml/kg/hour) Skin & temperature Mental state (level of consciousness) Central Venous Pressure Reference SRB’s Manual of Surgery 3rd ed. Thank You