Haemorrhage

 

Damage to blood vessels

Arterial

Venous

Capillary

 

Forms

Primary

Reactionary

Secondary

Pathological

 

Site

External

Internal

Revealed

 

Observations in disease

Haemoptysis

Haematuria

Haematemesis

Melaena

Per rectum

Intracranial

Subarachnoid haemorrhage

Contusion

Gums

Purpura

Petechial

Haematoma

Post partum

Per vagina

Joint pain

Pulmonary oedema

 

Chronic haemorrhage

Anaemia

Insidious symptoms

Tiredness

Faintness, dizziness

Reticulocytes

 

On the wards

Wound drains

Dressings

Urine bags

Bed rails

Disconnected cannula

Toilet floor, seat, bowl

Bedding

 

Observations in trauma

Onto the floor and four more

Gain history

E is for exposure

Shock

Death

Tachycardia

Skin vasoconstriction

Tachypnoea

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

Pallor

Cold and clammy

Peripheral arterial and venous constriction

Reduced capillary refill

Oliguira, anuria

Cardiac dysrhythmias

 

Sites of haemorrhage

Haemothorax

Peritoneal

Retroperitoneal

Pelvic

Fractures

Intracranial

Pericardial

Nose / Ears

 

Treatment of haemorrhage

A, B, C, D, E.

Give oxygen

Fix the leak, and replace fluid loss.

Management, degree and speed.

 

Management in primary

Use of pressure;

Direct

Ring

Elevation

Indirect

Ligation

Tourniquets

Temperature effects, local or systemic.

When body temperature is low, the blood will flow.

Patient position.

 

 

Reactionary haemorrhage,

Post op, post trauma, over early transfusion,

 

Secondary haemorrhage,

Wound cleaning and antibiotics

 

Restore fluid volumes

Oral fluids

Oral rehydration solutions

Nasogastric fluids

PR infusions

IVIs

Intraossious

 

Intravenous fluids

For every big bleed 3 for 1 you will need.

Warmed

Crystalloid

Colloid

1-2 litres rapidly

Child, 20 ml / Kg

> 1500 mls, blood

Cross matched

Type specific

Type O

Autotransfusion

 

Check end organ perfusion and oxygenation

Urine output

Level of consciousness

Peripheral perfusion

ECG

Respiratory rate

 

Types of responder

Rapid

Transient

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

Pulse pressure         Normal/ increased   Decreased                 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

 

 

 

Transcapillary refill

 

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

Tachycardia

Fear and stress

 

More subtle signs

Progressive weakening of peripheral pulses

Narrowed pulse pressure to less than 20

Cool extremities

Skin mottling instead of clammy

Dulled response to pain

 

Late signs

Drop in BP

Bradycardia

Reduced urine output

 

Management

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

Comorbidities

Mortality and morbidity rates increase with age

Prompt aggressive resuscitation and good monitoring

 

 

Disorders of blood clotting

Hypothermia

Haemophilia

Christmas disease

Thrombocytopenia, aspirin

Heparin

Warfarin

Viper venom