Lec. 7 Hemorrhage and wound healing PDF

At the end of this Lecture, you will:  know the meaning of haemorrhage, types and management of each types. Learn the basic information on Wounds: Definition, types & International classification of wound. Simplified information on the phases of normal wound healing versus abnormal wound heal...

At the end of this Lecture, you will:  know the meaning of haemorrhage, types and management of each types. Learn the basic information on Wounds: Definition, types & International classification of wound. Simplified information on the phases of normal wound healing versus abnormal wound healing. Know how to identify the state of wound by shape.  Hemorrhage ‫ حالة يهرب فيها الدم من‬:‫ ما معنى النزيف أو النزيف؟ ج‬1 ‫س‬ ‫ يحدث عادة أثناء الكسر في جدار جدار ا;وعية‬.‫الدورة الدموية‬.‫الدموية‬ Q.1 What is the meaning of Haemorrhage or bleeding? A: A state in which the blood escapes from the circulatory system. It usually occurs during breakage in the wall of a vascular wall. Q2 : How can we classify bleeding? A: Many different classifications available. According to its visibility Revealed Hemorrhage: Blood or dischages associated with changed colour blood is clearly visible to us when it comes out of human body through: Skin. Body openings: Oral cavity, nose, ear, anus,genitourinary system. Concealed Hemorrhage: Blood can not be seen directly, but we suspect its presensce inside closed body cavities Cranial, thoracic, abdominal, pelvic, inside body organs or inside the limbs or joint. According to type of vessel injured: Arterial bleeding : usually bright red, spurting pulsatile jet. Sometimes seen watery in cases of giving large amounts of I.V. fluids other than blood. Venous bleeding: darker red, non pulsatile and usually copious in amount. Capillary bleeding: red oozing blood. According to time of bleeding after trauma or surgery: Primary bleeding : it is the bleeding that usually occurs directly following trauma or surgery. Reactionary bleeding: bleeding that occurs later on, usually with in the 1st 24 hours after surgery or trauma. Causes: A. Clot (slipping= dislodgement) from its site. It can occur after the patient return to normal blood pressure. B. Surgical technical error: Silpping of surgical ligature of a blood vessel. C. Accidental sloughing of the clot over skin by accidental external trauma or during changing of dressing. Secondary bleeding: bleeding which occurs after the 1st 24 hours( usually from 7-14 days following ‫نبوب‬%‫ انسكاب جدار الوعاء الدموي عن طريق العدوى أو نخر الضغط عن طريق تصريف ا‬:‫السبب‬ surgery or trauma..‫أو تطور الورم الخبيث إلى جدار تلك الوعاء الدموي‬ Cause: vessel wall sloughing by infection, pressure necrosis by tube drain or progression of malignancy to the wall of that blood vessel. According to etiology: Surgical bleeding ( or traumatic): occurs at the site of direct injury, planned surgery or abnormality of vessel wall. This type is usually amenable to surgical control of bleeding. Non surgical (Medical) bleeding : occurs due to coagulation disorder, needs medical correction of coagulopathy after pressure on bleeding site.e.g: in haemophilia. ‫ ويحتاج إلى‬، ‫يحدث بسبب اضطراب التخثر‬ ‫تصحيح طبي ?عت=ل التخثر بعد الضغط‬ ‫ في‬:‫ثال‬G‫ على سبيل ا‬.‫على موقع النزيف‬.‫الهيموفيليا‬  ‫نسان الطبيعي؟‬-‫ما مقدار الدم الذي يمتلكه جسم ا‬ Q.3: Howmuch blood does normal human body have? A: Normal human body adult has about 5 Liter 80 cc/Kg in neonates and young children, 70 cc/Kg for adult. Q.4 : Why we should stop bleeding? A: Blood contains cells, water, minerals & proteins vital for normal clotting. Continuous blood loss will affect the level of all these contents, most importantly blood volume and proteins. Loss of large amount of blood can lead to decreased tissue perfusion ( hypovolemic shock), which makes the human body entering a worse vicious cycle of : acidosis, coagulopathy & hypothermia. End result of all these is the loss of physiological homeostasis, vital organ failure and finally death.  ‫فقود أثناء النزيف؟‬0‫ كيف نعرف مقدار الدم ا‬، ‫كطبيب‬ Q.5 : As a doctor, How do we know howmuch blood was lost during bleeding?.‫عادة صعبة وتحتاج إلى خبرة‬ ‫مقاييس التقدير التقريبي لكمية‬ A: usually difficult and needs experience. :‫الدم ا@فقودة هي‬ Measures of Rough estimation for the amount of lost blood are the following :.‫ سم مكعب‬500 ‫شدودة حوالي‬1‫تجلط الدم داخل قبضتك ا‬ Blood clot inside your clenched fist is about 500 cc..‫ سم مكعب‬2000-500 ‫تورم معتدل في الفخذ بسبب تشخيص كسر عظم الفخذ حوالي‬.‫ سم مكعب‬500 ‫تورم معتدل في الفخذ بسبب تشخيص كسر الظنبوب حوالي‬ Moderate swelling of thigh due to diagnosed fracture femur about 500-2000 cc. Moderate swelling of thigh due to diagnosed fracture tibia about 500 cc..‫متص‬$‫صاصة على مقاييس تساعدك على قياس حجم الدم ا‬$‫ يحتوي جهاز ا‬، ‫داخل غرفة العمليات‬ Inside the operation room, sucker device has scales that help you measure the volume of blood suckered. ‫ جرام من‬1.‫بللة بالدم وطرح وزن الشاش الجاف لفقدان وزن الدم‬9‫يمكن ترجيح عبوات الشاش ا‬.‫ سم مكعب من الدم‬1 ‫الدم يساوي تقريبًا‬ The packs of gauzes which are soaked with blood can be weighted and substract the weight of dry gauze to get the weight of blood lost. 1 gram blood roughly equals to 1 cc blood. Q.6 : You are in the emergency room. A case of trauma came to you with heavy bleeding. What are the steps that you should follow in sequence to manage this patient? A: 1st of all, this is a top emergency & you need teamwork.  Call for the nursing staff for help.  If visible bleeding, press on bleeding site to decrease bleeding.  Ensure intact airway, breathing, 2 widebore I.V canula and take blood sample for investigation for Blood group, Rh and cross matching. You can prepare blood according to the senior doctor request.  Give i.V. fluid Judiously with continuous checking of the vital signs.  Keep the patient in warm environment. ‫ سائل بحكمة مع التحقق ا'ستمر من‬.IV ‫إعطاء‬ ‫ حافظ على ا'ريض في بيئة‬.‫مات الحيوية‬E‫الع‬  Seek for other injury sites..‫خرى‬I‫صابات ا‬K‫ البحث عن مواقع ا‬.‫دافئة‬  Haemorrhage control inside the Emergency room :.‫باشر بإصبعك )أصابعك( أو عبوات نظيفة‬5‫ ثم قم بالضغط ا‬، ‫حاول تحديد موقع النزيف الدقيق‬ Try to Identify the exact bleeding site, then do direct pressure by your gloved finger(s) or clean packs..‫ؤقت عن النزيف‬,‫شبك الجراحي للتوقف ا‬,‫ فيمكنك استخدام ا‬، ‫ مرئيًا بوضوح‬Bleeder ‫إذا كان‬ If bleeder is clearly visible, you can use surgical clamp for temporary cessation of bleeding..‫عكوس‬8‫ ا‬Trendelenburg ‫ريض في وضع‬8‫ ضع ا‬، ‫ في حالة النزيف من الرقبة‬:‫وقع النزيف‬8 ‫قم بتغيير وضع الجسم وفقًا‬ Change the body position according to bleeding site: If bleeding from neck, put patient on Reversed Trendelenburg`s position..‫ ارفع الطرف‬،‫في حالة النزيف من الطرف‬ If bleeding from limb, elevate the limb. Q.7 : How to stop bleeding at operation room? ‫نظار‬%‫نصمام الوعائي أو التحكم با‬7‫الخياطة الجراحية أو تقنية ا‬ A: Surgical suturing, Angioembolisation technique or endoscopic control ‫ماذا يجب أن نفعل بعد التوقف الناجح للنزيف؟‬ Q.8 :What we should do following successful cessation of bleeding ? A: Resuscitation, correction of coagulopathy & continuous close follow up of : Vital signs, urine output and operation site.  Wound Healing ‫ على سبيل‬.‫مة أنسجة الجسم‬1‫ الجرح هو كسر في س‬:‫ما هو ا?عنى السريري للجرح؟ ج‬.‫ إلخ‬، ، ‫ القلب‬، ‫ العظام‬، ‫ الغشاء ا?خاطي‬، ‫ الجلد‬:‫ا?ثال‬ Q.9 : What is clinical meaning wound ? A: Wound is a breakage in the integrity of a body tissue. e.g: skin, mucosa, bone, heart,,,etc.  ‫هل كل الجروح جروح مفتوحة؟‬ Q.10 : Do all wounds are open wounds? A: Absolutely no. Wounds could be closed wound with intact skin. Mechanism & the quantity of force from external trauma decide the shape of wound. Penetrating wounds:  Puncture wounds..‫ ثقب الجروح‬:‫ اختراق الجروح‬  Surgical wounds and incisions. ‫ الحروق‬.‫الجروح والجروح الجراحية‬ ‫الحرارية أو الكيميائية أو الكهربائية‬  Thermal, chemical or electric burns, and radiation. ‫ جروح‬.‫ لدغات ولسعات‬.‫شعاع‬B‫وا‬  Bites and stings. ‫ أو مقذوفات أخرى‬، ‫طلقات نارية‬ ‫عالية السرعة يمكن أن تخترق‬  Gunshot wounds, or other high velocity projectiles that can.‫نفجار‬Q‫الجسم مثل إصابة ا‬ penetrate the body like blast injury. Blunt force trauma.  Abrasions..‫صدمة القوة الحادة‬  Lacerations..‫ تمزقات‬.‫سحجات‬  Skin tears..‫تمزق الجلد‬ See Pages 48,49,50 and Box 3.1, 3.2 & 3.3 In your textbook. ( Bailey & Love) for further reading regarding classification of wounds. Q.11 : How can we differentiate between acute wound and chronic one? A: Acute wound is the wound that last less than 3 weeks. When the wound does not heal within the first 3 weeks, usually called chronic wound. Q.12 : How does the wound normally heal? A: The wound heals by passing through 3 phases: Following hemostasis, Phase.1 = Inflammatory phase ( Day1-Day2). Phase.2 = Proliferatory phase.( Day3-week3). Phase.3 = Maturation ( Remodelling) phase.(Week3- months to years). Q13 : What are the factors that can lead to abnormal acute wound healing? A: Many factors. Some factors relates to the wound itself. Others relate to the human body. Q. 14 : Do all open wound types heal or to be closed directly following injury? A: Not all wounds should be closed at time of injury. Some wounds need to postpone its closure. On this base, acute wound healing or closure are ‫تحتاجوقتإلى‬ ‫ق جميع الجروح‬.‫ يجب إغ‬3 ‫ بعض الجروح‬.‫ا?صابة‬ ، ‫ في هذه القاعدة‬.‫قها‬.‫تأجيل إغ‬ classified into 3. ‫يتم تصنيف التئام الجروح الحادة‬.3 ‫ق إلى‬.‫أو ا?غ‬  ‫هل جميع أنواع الجروح الجراحية نظيفة أو معقمة؟‬ Q.15 : Do all the types of surgical wound are clean or sterile wound? A: No. Surgical wounds are classified into 4 classes regarding their contamination with microorganisms. ‫ فئات تتعلق بتلوثها بالكائنات‬4 ‫تصنف الجروح الجراحية إلى‬.‫الحية الدقيقة‬