HEMORRHAGE HEMORRHAGE

By Dr. Ashok Jaisingani By Dr. Ashok Jaisingani

Definition & Introduction Definition & Introduction

► Escape of the blood from the vessels either Escape of the blood from the vessels either internally or externally.internally or externally.

► Hemorrhage must be recognized and Hemorrhage must be recognized and managed aggressively to reduce the severity managed aggressively to reduce the severity and duration of shock and avoid death or and duration of shock and avoid death or multiple organ failure.multiple organ failure.

► Hemorrhage is treated by arresting the Hemorrhage is treated by arresting the bleeding, not by fluid resuscitation or blood bleeding, not by fluid resuscitation or blood transfusion.transfusion.

► To resuscitate the patients who have ongoing To resuscitate the patients who have ongoing hemorrhage hemorrhage physiological exhaustion physiological exhaustion (coagulopathy, acidosis and hypothermia) and (coagulopathy, acidosis and hypothermia) and subsequently death. subsequently death.

Pathophysiology Pathophysiology

► Hemorrhage Hemorrhage hypovolemic shock hypovolemic shock cellular cellular anaerobic metabolism anaerobic metabolism lactic acidosis lactic acidosis decrease decrease function of coagulase protease function of coagulase protease coagulopathy coagulopathy further hemorrhage. further hemorrhage.

► This hemorrhage is exacerbated by the ischemic This hemorrhage is exacerbated by the ischemic endothelial cells activating anticoagulant pathway. endothelial cells activating anticoagulant pathway.

► In compensatory state of the shock blood supply to In compensatory state of the shock blood supply to the muscles is reduced, which become unable to the muscles is reduced, which become unable to generate the heat generate the heat hypothermia hypothermia

► As coagulation functions poorly at low temp. As coagulation functions poorly at low temp. further hemorrhage. further hemorrhage.

► Further hypoperfusion and worsening acidosis and Further hypoperfusion and worsening acidosis and hypothermia hypothermia physiological exhaustion physiological exhaustion “Death” “Death”

Effects Of Medical Therapy In Effects Of Medical Therapy In Hemorrhagic Shock Hemorrhagic Shock

► Medical therapy has a tendency to worsen this Medical therapy has a tendency to worsen this effect. effect.

► Intravenous fluid and transfused blood are cold and Intravenous fluid and transfused blood are cold and worsening the hypothermia. worsening the hypothermia.

► During the surgery body cavity become open that During the surgery body cavity become open that leads to further heat loss. leads to further heat loss.

► Crystalloid solution are acidic themselves.Crystalloid solution are acidic themselves.► Thus every efforts made rapidly to stop hemorrhage Thus every efforts made rapidly to stop hemorrhage

and avoid physiological exhaustion such as and avoid physiological exhaustion such as 1- Coagulopathy 1- Coagulopathy 2- Acidosis 2- Acidosis 3- Hypothermia 3- Hypothermia

Revealed Hemorrhage Revealed Hemorrhage

►Revealed Hemorrhage is obvious Revealed Hemorrhage is obvious external hemorrhage, result fromexternal hemorrhage, result from1- Exsanguination from open arterial 1- Exsanguination from open arterial woundwound2- From massive haemetemesis 2- From massive haemetemesis 3- From duodenal ulcer 3- From duodenal ulcer

Concealed Hemorrhage Concealed Hemorrhage

► Concealed hemorrhage is contained within Concealed hemorrhage is contained within the body cavity and must be suspected. the body cavity and must be suspected. Concealed hemorrhage may be Concealed hemorrhage may be 1- Traumatic concealed hemorrhage 1- Traumatic concealed hemorrhage 2- Non – Traumatic concealed hemorrhage 2- Non – Traumatic concealed hemorrhage

► In trauma hemorrhage may be concealed In trauma hemorrhage may be concealed within the chest, abdominal cavity, pelvis, within the chest, abdominal cavity, pelvis, retroperitonium or in limbus may be retroperitonium or in limbus may be associated with concealed vascular injury and associated with concealed vascular injury and log bone fracture.log bone fracture.

► Non – traumatic concealed hemorrhage Non – traumatic concealed hemorrhage include GIT bleeding & rupture aortic include GIT bleeding & rupture aortic aneurysm aneurysm

Primary Hemorrhage Primary Hemorrhage

►Hemorrhage occurring immediately as Hemorrhage occurring immediately as result of an injury or surgery is result of an injury or surgery is recognized as “ primary hemorrhage” recognized as “ primary hemorrhage”

Recreationary Hemorrhage Recreationary Hemorrhage

►Recreationary hemorrhage is delayed Recreationary hemorrhage is delayed hemorrhage within 24 hours and usually hemorrhage within 24 hours and usually caused by the caused by the 1- Dislodgement of clot by the 1- Dislodgement of clot by the resuscitation resuscitation 2- Normalization of blood pressure 2- Normalization of blood pressure 3- Vasodilatation (cessation of reflex 3- Vasodilatation (cessation of reflex vasospasm)vasospasm)4- Technical failure such as slippage of 4- Technical failure such as slippage of ligature ligature

Secondary Hemorrhage Secondary Hemorrhage

►Secondary hemorrhage is caused by Secondary hemorrhage is caused by the sloughing of the wall of vessels the sloughing of the wall of vessels

► It usually occurs 7 – 14 days after the It usually occurs 7 – 14 days after the injury and precipitated by the factors injury and precipitated by the factors such as such as 1- Infection 1- Infection 2- Pressure necrosis (result from drain) 2- Pressure necrosis (result from drain)

3- Malignancy 3- Malignancy

Surgical & Non-surgical Surgical & Non-surgical hemorrhage hemorrhage

►Surgical hemorrhage is the result of Surgical hemorrhage is the result of injury and amenable to surgical control, injury and amenable to surgical control, or from angioembolism or from angioembolism

►Non – surgical hemorrhage is general Non – surgical hemorrhage is general ooze from all raw surface due to ooze from all raw surface due to coagulopathy, it can not be stopped by coagulopathy, it can not be stopped by surgical mean, require correction surgical mean, require correction coagulation abnormalitiescoagulation abnormalities

►Note: Packing can stop non-surgical Note: Packing can stop non-surgical hemorrhage hemorrhage

Degree & Classification Of Degree & Classification Of Hemorrhage Hemorrhage

► Degree of hemorrhage classified in to 4 classes Degree of hemorrhage classified in to 4 classes 1- Blood volume loss < 15% 1- Blood volume loss < 15% 2- Blood volume loss between 15 – 30% 2- Blood volume loss between 15 – 30% 3- Blood volume loss between 30 – 40% 3- Blood volume loss between 30 – 40% 4- Blood volume loss > 40% 4- Blood volume loss > 40%

► Estimation of amount of blood that has been lost is Estimation of amount of blood that has been lost is difficult and inaccurate and usually underestimation difficult and inaccurate and usually underestimation of actual value of actual value

► Hemoglobin level is a poor indicator of the Hemoglobin level is a poor indicator of the hemorrhage as it represent conc. Not actual amounthemorrhage as it represent conc. Not actual amount

► In early stage of the rapid hemorrhage HB conc. In early stage of the rapid hemorrhage HB conc. Become unchanged, but later HB and haemotcrit will Become unchanged, but later HB and haemotcrit will fall. fall.

Basis Of Hemorrhagic Basis Of Hemorrhagic Treatment Treatment

► Treatment of the hemorrhage depend upon Treatment of the hemorrhage depend upon degree of the hypovolemic shock according todegree of the hypovolemic shock according to1- Vital Signs 1- Vital Signs 2- Preload assessment 2- Preload assessment 3- Base deficit 3- Base deficit 4- Most important among these is dynamic 4- Most important among these is dynamic response to fluid therapy.response to fluid therapy.

► In non-responder or transitient responder pts In non-responder or transitient responder pts it is necessary to identify and control the site it is necessary to identify and control the site of the bleeding. of the bleeding.