The Department of Orthopedic,Traumatology &

Extreme medicine

KOGILAVANEE SUBRAMANIAM
(vanee)

GROUP 4
BLEEDING
Definition of Bleeding:
Bleeding refers to the loss of blood. Bleeding
can happen inside the body (internally) or
outside the body (externally). It may occur:
Inside the body when blood leaks from blood
vessels or organs
Outside the body when blood flows through a
natural opening (such as the vagina, mouth,
or rectum)
Outside the body when blood moves through
a break in the skin
Classification
By blood loss
Class I Hemorrhage involves up to 15% of blood
volume. There is typically no change in vital signs
and fluid resuscitation is not usually necessary.
Class II Hemorrhage involves 15-30% of total
blood volume. A patient is often tachycardic (rapid
heart beat) with a narrowing of the difference
between the systolic and diastolic blood pressures.
The body attempts to compensate with peripheral
vasoconstriction. Skin may start to look pale and
be cool to the touch. The patient may exhibit
slight changes in behavior. Volume resuscitation
with crystalloids (Saline solution or Lactated
Ringer's solution) is all that is typically required.
Blood transfusion is not typically required.
Class III Hemorrhage involves loss of 30-40%
of circulating blood volume. The patient's blood
pressure drops, the heart rate increases,
peripheral hypoperfusion (shock), such as
capillary refill worsens, and the mental status
worsens. Fluid resuscitation with crystalloid
and blood transfusion are usually necessary.
Class IV Hemorrhage involves loss of >40%
of circulating blood volume. The limit of the
body's compensation is reached and aggressive
resuscitation is required to prevent death
This system is basically the same as used in the
staging of hypovolemic shock
World Health Organization
The World Health Organization made a
standardized grading scale to measure the
severity of bleeding
Grade 0 - no bleeding
Grade 1 - petechial bleeding;
Grade 2 - mild blood loss (clinically significant);
Grade 3 - gross blood loss, requires transfusion
(severe);
Grade 4 - debilitating blood loss, retinal or
cerebral associated with fatality
By origin
 Mouth
Hematemesis - vomiting fresh blood
Hemoptysis - coughing up blood from the lungs
 Hematochezia - rectal blood
 Hematuria - blood in the urine from urinary bleeding
 Upper head
Intracranial hemorrhage - bleeding in the skull.
Cerebral hemorrhage - a type of intracranial hemorrhage, bleeding
within the brain tissue itself.
intracerebral hemorrhage - bleeding in the brain caused by the
rupture of a blood vessel within the head. See also hemorrhagic
stroke.
Subarachnoid hemorrhage (SAH) implies the presence of blood
within the subarachnoid space from some pathologic process. The
common medical use of the term SAH refers to the nontraumatic
types of hemorrhages, usually from rupture of a berry aneurysm
or arteriovenous malformation(AVM). The scope of this article is
limited to these nontraumatic hemorrhages.
Lung
Pulmonary hemorrhage
Gynecologic
o Vaginal bleeding
o Postpartum hemorrhage
o Breakthrough bleeding
o First trimester bleeding
o Antepartum hemorrhage
o Ovarian bleeding. This is a potentially
catastrophic and not so rare complication
among lean patients with polycystic ovary
syndrome undergoing transvaginal oocyte
retrieval.
Upper gastrointestinal bleed
Causes:
Bleeding can be caused by injuries or can
occur spontaneously.
Spontaneous bleeding is most commonly
caused by problems with the joints or the
gastrointestinal or urogenital tracts.
 Traumatic Injury
Traumatic bleeding is caused by some type of injury.
There are different types of wounds which may cause
traumatic bleeding. These include:
Abrasion - Also called a graze, this is caused by
transverse action of a foreign object against the skin,
and usually does not penetrate below the epidermis
Excoriation - In common with Abrasion, this is
caused by mechanical destruction of the skin,
although it usually has an underlying medical cause
Hematoma - Caused by damage to a blood vessel
that in turn causes blood to collect under the skin.
Laceration - Irregular wound caused by blunt
impact to soft tissue overlying hard tissue or tearing
such as in childbirth. In some instances, this can also
be used to describe an incision.
Incision - A cut into a body tissue or organ, such
as by a scalpel, made during surgery.
Puncture Wound - Caused by an object that
penetrated the skin and underlying layers, such
as a nail, needle or knife
Contusion - Also known as a bruise, this is a
blunt trauma damaging tissue under the surface
of the skin
Crushing Injuries - Caused by a great or
extreme amount of force applied over a period of
time. The extent of a crushing injury may not
immediately present itself.
Ballistic Trauma - Caused by a projectile
weapon, this may include two external wounds
(entry and exit) and a contiguous wound between
the two
 Medical Condition
'Medical bleeding' denotes hemorrhage as a result of
an
underlying medical condition (i.e. causes of bleeding
that
are not directly due to trauma). Blood can escape from
blood vessels as a result of 3 basic patterns of injury:
Intravascular changes - changes of the blood within
vessels (e.g. ↑ blood pressure, ↓ clotting factors)
Intramural changes - changes arising within the
walls of blood vessels (e.g. aneurysms, dissections,
AVMs, vasculitides)
Extravascular changes - changes arising outside
blood vessels (e.g. H pylori infection, brain abscess,
brain tumor)
 Symptoms:
Blood coming from an open wound
Bruising
Shock, which may cause any of the following
symptoms:
Confusion or decreasing alertness
Clammy skin
Dizziness or light-headedness after an injury
Low blood pressure
Paleness (pallor)
Rapid pulse, increased heart rate
Shortness of breath
Weakness
Symptoms of internal bleeding
may also include
Abdominal pain
Abdominal swelling
Chest pain
External bleeding through a natural opening
Blood in the stool (appears black, maroon, or bright
red)
Blood in the urine (appears red, pink, or tea-colored)
Blood in the vomit (looks bright red, or brown like
coffee-grounds)
Vaginal bleeding (heavier than usual or after
menopause)
Diagnostic Test
Physical examination
 Examine for petechial body rash (pinhead size red rash) which is
common in any disorder that might cause thrombocytopenia
(reduced platelets), platelet dysfunction or vasculitis
 Examine for bruises which may suggest Hemophilia, Christmas
disease, platelet disorders or disseminated intravascular
coagulation
 Examine for bleeding gums - if bleeding gums is present with skin
bruises suggests platelet disorders or disseminated intravascular
coagulation.
 Look for gum hypertrophy (enlargement) which occurs in
monocytic Leukemia, pregnancy, scurvy, gingivitis and in patients
taking phenytoin
 Examine for evidence of malignancy e.g. enlarged lymph nodes
 Examine for enlarged spleen which may suggest Hodgkin's
disease,leukemia, lupus erythematosus, thrombocytopenic
purpura or aplastic anemia
 Examine for swollen painful joints typical of Hemophilia or
Rheumatoid arthritis
 Urine analysis - searching for blood.
Blood tests
• Full blood count
• Platelet count - reduced in Idiopathic thrombocytopenic
purpura, leukemia,aplastic anemia, lupus erythematosus,
certain drugs.
• Coagulation profile including INR, PT, APTT
• Skin bleeding time
• Fibrinogen assay and estimation of fibrin degradation
products if suspect Disseminated intravascular
Coagulation
• More sophisticated bleeding disorder tests depending on
suspicion e.g. Hemophilia screening, von Willebrand's
disease, platelet function studies, platelet antibodies
• Antinuclear antibodies may help to diagnose lupus
erythematosus
• Rheumatoid factor may help to0 diagnose Rheumatoid
arthritis
• Plasma ascorbic acid level if suspect scurvy
Other tests
•Bone marrow examination - may be required
to exclude secondary causes of
thrombocytopenia (reduced platelets) e.g.
leukemia, aplastic anemia.
•Radiology investigations
•Spleen, liver and bone scans
•CT scan of pelvis and abdomen depending on
suspicion
Treatment
First Aid:
First aid is appropriate for external bleeding. If bleeding is
severe, or if shock or internal bleeding is suspected, get
emergency help immediately.
 Calm and reassure the person. The sight of blood can be
very frightening.
 If the wound is superficial, wash it with soap and warm
water and pat dry. Superficial wounds or scrapes are
injuries that affect the top layers of skin and bleeding from
such wounds is often described as "oozing," because it is
slow.
 Lay the person down. This reduces the chances of fainting
by increasing blood flow to the brain. When possible, raise
up the part of the body that is bleeding.
 Remove any obvious loose debris or dirt from a wound. If an
object such as a knife, stick, or arrow becomes stuck in the
body, DO NOT remove it. Doing so may cause more damage
and may increase bleeding. Place pads and bandages
around the object and tape the object in place.
 Put pressure directly on an outer wound with a sterile
bandage, clean cloth, or even a piece of clothing. If
nothing else is available, use your hand. Direct
pressure is best for outside bleeding, except for an eye
injury.
 Maintain pressure until the bleeding stops. When it has
stopped, tightly wrap the wound dressing with adhesive
tape or a piece of clean clothing. Place a cold pack over
the dressing. Do not peek to see if the bleeding has
stopped.
 If bleeding continues and seeps through the material
being held on the wound, do not remove it. Simply
place another cloth over the first one. Be sure to seek
medical attention.
 If the bleeding is severe, get medical help and take
steps to prevent shock. Keep the injured body part
completely still. Lay the person flat, raise the feet about
12 inches, and cover the person with a coat or blanket.
However, DO NOT move the person if there has been a
head, neck, back, or leg injury, as doing so may make
the injury worse. Get medical help as soon as possible.
 Do Not:
 DO NOT apply a tourniquet to control bleeding, except as a
last resort. Doing so may cause more harm than good. A
tourniquet should be used only in a life-threatening
situation and should be applied by an experienced person
 If continuous pressure hasn't stopped the bleeding and
bleeding is extremely severe, a tourniquet may be used
until medical help arrives or bleeding is controllable.
 It should be applied to the limb between the bleeding site
and the heart and tightened so bleeding can be controlled
by applying direct pressure over the wound.
 To make a tourniquet, use bandages 2 to 4 inches wide and
wrap them around the limb several times. Tie a half or
square knot, leaving loose ends long enough to tie another
knot. A stick or a stiff rod should be placed between the two
knots. Twist the stick until the bandage is tight enough to
stop the bleeding and then secure it in place.
 Check the tourniquet every 10 to 15 minutes. If the
bleeding becomes controllable, (manageable by applying
direct pressure), release the tourniquet.
DO NOT peek at a wound to see if the bleeding is
stopping. The less a wound is disturbed, the more
likely it is that you'll be able to control the bleeding
DO NOT probe a wound or pull out any embedded
object from a wound. This will usually cause more
bleeding and harm
DO NOT remove a dressing if it becomes soaked
with blood. Instead, add a new one on top
DO NOT try to clean a large wound. This can cause
heavier bleeding
DO NOT try to clean a wound after you get the
bleeding under control. Get medical help
 Call immediately for emergency
medical assistance if:
Bleeding can't be controlled, or is associated with a
serious injury
The wound might need stitches, or if gravel or dirt
cannot be removed easily with gentle cleaning
You think there may be internal bleeding or shock
Signs of infection develop, including increased pain,
redness, swelling, yellow or brown fluid, swollen
lymph nodes, fever, or red streaks spreading from the
site toward the heart
The injury involves an animal or human bite
The patient has not had a tetanus shot in the last 5-10
years
Stopping bleeding with direct
pressure:
Stopping bleeding with a
tourniquet:
Stopping bleeding with pressure
and ice:
 Medical Treatment
Initial treatment of internal bleeding will
include stabilizing the patient, meaning that
the ABCs of resuscitation take priority for the
care provider.
A: Airway. Patients with altered or
decreased mental status may not be awake
enough to breathe on their own.

B: Breathing. Even if the airway is open, the

lungs may not adequately be functioning and
may need assistive care to allow oxygen to be
transferred from the lung to the bloodstream.
C: Circulation. The body requires blood to circulate
to all its cells to provide oxygen and nutrients and to
remove waste products. Treatment is aimed to
maintain blood pressure and circulation. Often
intravenous fluids only are required. Sometimes
blood transfusion is needed. A few patients will
require immediate transfusions with universal donor
blood (type "O negative" blood).
Specific treatment for internal bleeding depends
upon the source of the bleeding. The common goal
for treatment is to find the source of bleeding and
stop it. At the same time, treatment will be directed
to repair or stabilize any damage that the bleeding
caused.
Once the acute situation has resolved, treatment will
try to correct the underlying cause of bleeding to
prevent future episodes.
 Surgery
Surgery is reserved for those patients with
internal bleeding where the bleeding cannot
be controlled by less aggressive treatment or
where the bleeding is causing damage
because of its location.
When orthopedic surgeons repair fractures, it
has an added benefit of decreasing the
amount of bleeding from the fracture site and
minimizing future blood loss.