Damage to blood vessels
Observations in disease
On the wards
Toilet floor, seat, bowl
Observations in trauma
Onto the floor and four more
E is for exposure
Narrowed pulse pressure
Any injured patient who is cool and has tachycardia is considered to be in shock until proved otherwise
Reduced systolic BP
Agitation, anxiety, confusion, dizzy, faint
Fast, weak and thready
Cold and clammy
Peripheral arterial and venous constriction
Reduced capillary refill
Sites of haemorrhage
Nose / Ears
Treatment of haemorrhage
A, B, C, D, E.
Fix the leak, and replace fluid loss.
Management, degree and speed.
Management in primary
Use of pressure;
Temperature effects, local or systemic.
When body temperature is low, the blood will flow.
Post op, post trauma, over early transfusion,
Wound cleaning and antibiotics
Restore fluid volumes
Oral rehydration solutions
For every big bleed 3 for 1 you will need.
1-2 litres rapidly
Child, 20 ml / Kg
> 1500 mls, blood
Check end organ perfusion and oxygenation
Level of consciousness
Types of responder
Minimal or none
Classification of acute haemorrhage (for a 70Kg man, blood is 7% of body weight, so 5 l in total)
Class 1 Class 2 Class 3 Class 4
Blood loss (mls) Up to 750 750-1500 1500-2000 >2000
Blood loss % Up to 15% 15-30% 30-40% >40%
Pulse rate <100 100-120 120-140 >140
Blood pressure Normal Normal Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30 mls 20-30 5-15 Negligible
Mental state Slightly anxious More anxious Anxious confused Confused, lethargic
Fluid replacement Crystalloid Crystalloid Crystalloid + blood Crystalloid + blood
Physiological compensations after haemorrhage
Blood pressure = cardiac output x SVR
CO = HR x SV
Tachycardia maintains CO
Vasoconstriction reduces blood supply to skin, muscles, gut to maintain blood supply to kidneys, heart, brain
Venoconstriction increases preload
Baroreceptors, medulla oblongata, adrenalin vasoconstriction, arterial and venous
Fluid compartments and third spacing.
Haemorrhage is associated with profound vasoconstriction of arterioles, i.e. the precapillary resistance vessels.
This increases the pressure drop along the arterioles.
This means that capillary pressures are correspondingly lower.
This will result in a reduction in tissue fluid formation and an increase in its reabsorption.
Fluid will therefore enter the vascular compartments increasing intravascular volume.
Fluid will also be replaced by drinking.
In haemorrhage whole blood is lost.
Therefore in the initial stages haemoglobin content, haematocrite, red cell count will be unchanged.
Therefore can not be uses as indicators for the degree of haemorrhage.
As tissue fluid enters the circulation over the next 2 - 3 hours the remaining RBCs will be diluted.
Therefore haemoglobin content, haematocrite, red cell count will all fall.
Some red cells will be replaced in the short term from
reserves held in the spleen.
Lost blood cells will be replaced during the next few weeks due to increased bone marrow activity.
Feed your patients after a bleed.
Haemorrhage in children
Fear and stress
More subtle signs
Progressive weakening of peripheral pulses
Narrowed pulse pressure to less than 20
Skin mottling instead of clammy
Dulled response to pain
Drop in BP
Reduced urine output
Childs blood volume 80ml / Kg
Bolus 20 ml /Kg
3 for 1 rule applies
Possibly up to 60ml / Kg
Haemorrhage in the elderly
Decreased ability for sympathetic response
Reduced ability to increase heart rate
Atheroma increaser organ sensitivity to reduced perfusion
Reduced diffusion capacity of the lungs compounds cellular hypoxia
Kidneys can not preserve volume very well
Mortality and morbidity rates increase with age
Prompt aggressive resuscitation and good monitoring
Disorders of blood clotting