hemorrhage and blood transfusion

Hemorrhage and Blood Hemorrhage and Blood TransfusionTransfusion

Dr.Muddather A.MohammedDr.Muddather A.MohammedFJMC (A&E)FJMC (A&E)

HS(A&E)HS(A&E)

ObjectivesObjectivesAt the end of this lecture the student

should be able to: Define hemorrhage , triad of death Know the classification of hemorrhage

according to different criteria. Understand the principles of

management of blood loss. Know the basic principles of blood

groups Know how to use blood and blood

products Understand the risks of blood transfusion

HemorrhageHemorrhage

It is the escape of blood It is the escape of blood outside circulatory systemoutside circulatory system

CLASSIFICATIONSCLASSIFICATIONS

ORIGINORIGIN1)1) Arterial:Arterial:

The blood is bright red in color.The blood is bright red in color. The blood comes in pulsatile jets (spurting).The blood comes in pulsatile jets (spurting). The bleeding more from the proximal than the distal The bleeding more from the proximal than the distal

end.end.

2)2) Venous:Venous: The blood is dark red in color.The blood is dark red in color. The blood comes as a steady flow.The blood comes as a steady flow. It is more from the distal than the proximal end.It is more from the distal than the proximal end.

EXCEPTIONS --- PULMONARY----COLOREXCEPTIONS --- PULMONARY----COLOR

3)3) Capillary:Capillary: Bleeding occurs as diffuse ooze of bright red bloodBleeding occurs as diffuse ooze of bright red blood..

Site:Site:

ExternalExternal:: Bleeding is visible (revealed).Bleeding is visible (revealed).

InternalInternal:: Bleeding is invisible(concealed)Bleeding is invisible(concealed)Could occur in body cavity e.g. Could occur in body cavity e.g.

peritoneal ,pleural,peritoneal ,pleural,or it may occur into a tissue e.g. fracture or it may occur into a tissue e.g. fracture

hematoma (Interstitial hemorrhage) hematoma (Interstitial hemorrhage)

NOTE:NOTE:A concealed hemorrhage may become A concealed hemorrhage may become

revealed as in case of bleeding peptic revealed as in case of bleeding peptic ulcer------ hematemesis or melaena.ulcer------ hematemesis or melaena.

Timing in relation to the onset of Timing in relation to the onset of trauma:trauma:

PrimaryPrimary hemorrhage occurs at the time of trauma (injury hemorrhage occurs at the time of trauma (injury

or operation).or operation).

ReactionaryReactionary Hemorrhage occurs within 24 hours after trauma Hemorrhage occurs within 24 hours after trauma

usually (4-6 hours) .due tousually (4-6 hours) .due to slipping of ligature, dislodgment of a clot or slipping of ligature, dislodgment of a clot or

cessation of vasospasm.cessation of vasospasm.

Precipitating factors arePrecipitating factors are1- rise in arterial blood pressure.1- rise in arterial blood pressure.2-restlessness , cough and vomiting --- rise in 2-restlessness , cough and vomiting --- rise in

venous pressurevenous pressure

Secondary Secondary Hemorrhage occurs one to two weeks after trauma Hemorrhage occurs one to two weeks after trauma

due to infection and sloughing of part of the wall due to infection and sloughing of part of the wall of an artery .of an artery .

Predisposing factors:Predisposing factors: drainage tube , fragment of bone or ligature in drainage tube , fragment of bone or ligature in

infected area or cancer.infected area or cancer.

More common in anorectal wounds More common in anorectal wounds e.g.hemorrhoidectomye.g.hemorrhoidectomy

4.4. Etiology.Etiology. Traumatic: (surgical)Traumatic: (surgical)

AccidentalAccidental Surgical operationsSurgical operations Interventional procedures.Interventional procedures.

Pathological: (nonsurgical)Pathological: (nonsurgical) Atherosclerotic (ruptured aortic aneurysm).Atherosclerotic (ruptured aortic aneurysm). Inflammatory (bleeding peptic ulcer).Inflammatory (bleeding peptic ulcer). Neoplastic (hematuria in renal cancer).Neoplastic (hematuria in renal cancer). Bleeding diathesis Bleeding diathesis can increase the amount of can increase the amount of

traumatic and pathological bleeding,even can cause traumatic and pathological bleeding,even can cause bleeding with little or no trauma (spontaneous bleeding with little or no trauma (spontaneous hemorrhage). hemorrhage). Note anticoagulantsNote anticoagulants and antiplatletsand antiplatlets

Circulating blood volume Circulating blood volume The adult human has approximately The adult human has approximately

5 litres of blood 5 litres of blood (70 ml/ kg) children and adults(70 ml/ kg) children and adults ( 80 ml/ kg neonates).( 80 ml/ kg neonates).

Clinical EvaluationClinical Evaluation

Measuring blood Measuring blood loss(cont.)loss(cont.)

Blood clotBlood clot of clenched fist size= 500ml of clenched fist size= 500ml Swelling of closed fractureSwelling of closed fracture e.g. e.g. Tibia= 500-1000mlTibia= 500-1000ml Shaft of femur=500-2000mlShaft of femur=500-2000ml Swab weighingSwab weighing 1g=1ml after 1g=1ml after

subtracting the dry weight. Note subtracting the dry weight. Note evaporation and other fluid loss in evaporation and other fluid loss in operation.operation.

Suction and drainage bottlesSuction and drainage bottles


Central venous pressure Central venous pressure measurementmeasurement


Hemoglobin and packed cell volume Hemoglobin and packed cell volume levellevel::

Normal Hb ---12-16gm/100mlNormal Hb ---12-16gm/100ml Normal pcv--- Hb x3 roughlyNormal pcv--- Hb x3 roughly

Poorly correlate with amount of blood Poorly correlate with amount of blood loss in the immediate post hemorrhage loss in the immediate post hemorrhage periodperiod

TREATMENT OF TREATMENT OF HEMORRAHGEHEMORRAHGE

TO STOP OR TO STOP OR MINIMIZE MINIMIZE FURTHER BLOOD FURTHER BLOOD LOSSLOSS

VOLUME VOLUME REPLACEMENT REPLACEMENT

Minimizing further blood Minimizing further blood lossloss

Pressure and packing .Pressure and packing . Position and rest.Position and rest. Intra –operative methods Intra –operative methods

VOLUME VOLUME REPLACEMENTREPLACEMENT

Intravenous fluidsIntravenous fluids

Blood transfusionBlood transfusion

BLOOD TRANSFUSIONBLOOD TRANSFUSION

Blood groupingBlood grouping Blood group antigens (sugars or proteins Blood group antigens (sugars or proteins

on red cell membranes)on red cell membranes) ABO system ABO system Group A have anti-B in their plasmaGroup A have anti-B in their plasma Group B have anti-AGroup B have anti-A Group O have anti-A and anti-BGroup O have anti-A and anti-B Group AB have neither Group AB have neither Anti-A and B are naturally occurring IgM Anti-A and B are naturally occurring IgM

antibodiesantibodies

Frequency of ABO Blood Frequency of ABO Blood GroupsGroups

Group O 46%Group O 46% Group A 42%Group A 42% Group B 9%Group B 9% Group AB 3%Group AB 3%

The Rh Blood Group The Rh Blood Group SystemSystem

Described by Landsteiner in 1940Described by Landsteiner in 1940 Antibodies produced as a result of Antibodies produced as a result of

pregnancy or transfusionpregnancy or transfusion Immune antibodies - IgGImmune antibodies - IgG Can cause haemolytic disease of the Can cause haemolytic disease of the

newborn and transfusion reactionsnewborn and transfusion reactions First antigen discovered given the First antigen discovered given the

notation Dnotation D

Other Blood Group Other Blood Group SystemsSystems

Although ABO and Rh are the Although ABO and Rh are the most important most important

Other systems are important if Other systems are important if patient has the antibodiespatient has the antibodies

Important systems are Kell, Important systems are Kell, Duffy, Kidd and MNSDuffy, Kidd and MNS

Antibodies can cause severe Antibodies can cause severe transfusion reactionstransfusion reactions

2

Up to 5 days

2

Procedure of blood Procedure of blood transfusiontransfusion

Donor selection.Donor selection. Collecting blood from the donor.Collecting blood from the donor. Blood unit testing.Blood unit testing. Blood storage.Blood storage. storage in blood bank.storage in blood bank. temp 4±2 temp 4±2 OOC. C. Special bag containing 75ml anticoagulat Special bag containing 75ml anticoagulat

solution --citrate phosphate dextrose (CPD) solution --citrate phosphate dextrose (CPD) or citrate phosphate dextrose +adenin.or citrate phosphate dextrose +adenin.

Note the temporary reduction in Note the temporary reduction in OO22release.release.

Crossmatching/ Crossmatching/ Compatibility TestingCompatibility Testing

Patients plasma tested against Patients plasma tested against donor red cellsdonor red cells

Full procedure take one hour.Full procedure take one hour. ?? Emergency . Emergency . Some blood banks are moving to Some blood banks are moving to

computer crossmatching (electronic computer crossmatching (electronic crossmatch)crossmatch)

Giving bloodGiving blood Selection and preparation of the site .Selection and preparation of the site . Cannula insertion.Cannula insertion. Check donor blood and patient I.D. Check donor blood and patient I.D. Detailed written instructions.Detailed written instructions. Note--- blood warming.Note--- blood warming.

AUTO TRANSFUSIONAUTO TRANSFUSION

Allergic reactions Hem olytic reactions Others e.g*sensitizationto leucocytes and platelets*im m uno-sensitization

IM M ULOGICAL REACTIONS

S IMPLE PYREXIAL REACTION Infection Transm ission

Congestive heart failure H yperka lem ia ------ a nd Air em bolism

NON-IM M ULOGICAL REACTIONS

COM PLICATIONS OF BLOOD TRAN SFUSION

Complications Of Blood TransfusionComplications Of Blood Transfusion


Simple pyrexial reaction, most common Simple pyrexial reaction, most common The patient develops chills, fever, headache, The patient develops chills, fever, headache,

nausea and vomiting due to Some pyrogens nausea and vomiting due to Some pyrogens in the transfusion apparatus .in the transfusion apparatus .

Treatment : stop transfusion (Temporarily) Treatment : stop transfusion (Temporarily) and give antipyretics.and give antipyretics.


Congestive Cardiac failure,Congestive Cardiac failure,

This is liable to occur in elderly persons especially if a This is liable to occur in elderly persons especially if a large volume of blood is administered too rapidly.large volume of blood is administered too rapidly.

It is recommended to transfuse packed red cells rather It is recommended to transfuse packed red cells rather than whole blood to correct anemia in elderly persons.than whole blood to correct anemia in elderly persons.


Allergic reactions.Allergic reactions. Range form mild itching and urticaria to a severe Range form mild itching and urticaria to a severe

reaction with laryngeal edema and reaction with laryngeal edema and collapse(anaphylaxis) .collapse(anaphylaxis) .

Etiology: due to the recipient's response to allergens in Etiology: due to the recipient's response to allergens in the donor's blood.the donor's blood.

Blood transfusion should be stopped CHECK AND SEND Blood transfusion should be stopped CHECK AND SEND FOR RECHECKFOR RECHECK

Treat shock if present ( adrenalin + crystalloids)Treat shock if present ( adrenalin + crystalloids) Antihistamin and corticosteroids Antihistamin and corticosteroids

Hemolytic reactionsHemolytic reactions..

Etiology: due to:Etiology: due to: The presence of antibodies in the recipient's blood The presence of antibodies in the recipient's blood

against one or more of the antigens of the donor's against one or more of the antigens of the donor's cellscells

Should be avoided by correct blood grouping Should be avoided by correct blood grouping ABO ,Rh and cross matching.ABO ,Rh and cross matching.

Nearly always due to human error.Nearly always due to human error.

Complications Of Blood Transfusion

Clinical Picture of acute Clinical Picture of acute Hemolytic ReactionHemolytic Reaction

Hemolytic reactions present after the transfusion Hemolytic reactions present after the transfusion of less than 50 ml by fever, chills, flushing, of less than 50 ml by fever, chills, flushing, constricting pain in the chest, dyspnea and pain in constricting pain in the chest, dyspnea and pain in the flanks.the flanks.

Examination reveals tachycardia and hypotension.Examination reveals tachycardia and hypotension. In anaesthetized patients the only manifestations In anaesthetized patients the only manifestations

of hemolytic reactions are sudden tachycardia, of hemolytic reactions are sudden tachycardia, hypotension and bleeding tendency.hypotension and bleeding tendency.

A major hemolytic reactions will lead to A major hemolytic reactions will lead to hemoglobinuria, jaundice and acute renal failure hemoglobinuria, jaundice and acute renal failure due to acute tubular necrosis. due to acute tubular necrosis.

Management of acute hemolytic reaction :Management of acute hemolytic reaction : Stop the infusion immediately Check patient and unit Stop the infusion immediately Check patient and unit

ID .ID . Send the donor's blood and a sample of the patient's Send the donor's blood and a sample of the patient's

blood for repeat typing and cross matching in blood for repeat typing and cross matching in addition to Hb and bilirubin + patient urine shoul be addition to Hb and bilirubin + patient urine shoul be send for lab. send for lab.

Correct the shock by infusion of crystalloid solution.Correct the shock by infusion of crystalloid solution. Insert a Foley's catheter and check that there is an Insert a Foley's catheter and check that there is an

adequate urine output. An loop or osmotic diuretic as adequate urine output. An loop or osmotic diuretic as mannitol is given .mannitol is given .

Keep an alkaline urine to protect against acute renal Keep an alkaline urine to protect against acute renal failure. IV infusion of sodium bicarbonate is failure. IV infusion of sodium bicarbonate is indicated.indicated.

Transmission of infectionTransmission of infection.. Viral hepatitis (B or C). This is now the most feared Viral hepatitis (B or C). This is now the most feared

complication. The virus can be transmitted by whole complication. The virus can be transmitted by whole blood or blood products. It is now obligatory to test the blood or blood products. It is now obligatory to test the donor for hepatitis viruses.donor for hepatitis viruses.

AIDS: HIV infection can be transmitted by blood or by AIDS: HIV infection can be transmitted by blood or by its products.its products.

Syphilis: This is now rare, Spirochetes cannot survive Syphilis: This is now rare, Spirochetes cannot survive at the blood bank temperature for more than 4 days.at the blood bank temperature for more than 4 days.

Malaria: The disease is transmitted only by red cells, Malaria: The disease is transmitted only by red cells, not by blood components.not by blood components.

Septicemia: Bacteria can survive, but they cannot Septicemia: Bacteria can survive, but they cannot multiply significantly in refrigerated blood, However, if multiply significantly in refrigerated blood, However, if the blood is allowed to warm, bacteria can grow and the blood is allowed to warm, bacteria can grow and Gram-negative endotoxins can cause septicemic shock.Gram-negative endotoxins can cause septicemic shock.

Massive blood transfusionMassive blood transfusion

Defined as the transfusion of Defined as the transfusion of blood that is greater in blood that is greater in volume than a patient's volume than a patient's normal blood volume in less normal blood volume in less than 24 hours .than 24 hours .

hemorrhage and blood transfusion

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