OBJECTIVES:-

At the end of presentation , Participants will be able to,

 Gain knowledge about haemorrhage

 Define haemorrhage

 Describe various factors that causes haemorrhage

 Differentiate between different types of haemorrhage

 Elaborate classification

 Mechanism of clotting

 Learn about WHO grading of haemorrhage

 Discuss causes & and symptoms of haemorrhage

 Manage haemorrhage in emergency

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 INTRODUCTION

Haemorrhage is the loss of blood escaping from the circulatory system. Bleeding can
occur internally, where blood leaks from blood vessels inside the body, or externally,
either through a natural opening such as mouth, nose, ear, urethra, vagina, anus, or any
break in the skin. Uncontrolled bleeding can rapidly lead to shock and death. Bleeding,
technically known as Haemorrhage. The complete loss of blood is referred to as
Esanguination, and massive blood loss from the circulatory system is called as
Desanguination.

DEFINITION:-

The term haemorrhage refers to a large amount of bleeding in a short time.

( Thygerson,Gulli & krohmer 2006;pp.23)

An escape of blood from a ruptured blood vessel.

( Weller & Wells 1990; pp:217)

Haemorrhage is the last of blood from a vessel.

( Malcolm R. Colmer 1986; pp: 98)

In general,

Haemorrhage or bleeding is termed as a loss of blood from the circulatory system.

Bleeding can occur internally, where blood leaks from the blood vessels inside the body
or externally through various natural openings.

CLASSIFICATION OF HAEMORRHAGE

1. Depending on the SOURCE OF BLEEDING:

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a) External haemorrhage:- When bleeding is revealed and seen outside, it is called
external haemorrhage. for example, epistaxis.
b) Internal haemorrhage:- bleeding is concealed and not seen outside, for
example, intracranial hematoma.

2. Depending on the NATURE OF BLEEDING VEESEL:

a) Arterial haemorrhage :- the blood is bright red and sports with the heartbeat. it
is recognised as bright red blood, supprouting as a jet which rises and falls in
time with the pulse. In a protracted bleeding, advent quantities of intravenous

fluids other than blood are given, it can become watery in nature. blood loss is
more rapid from the vein of the corresponding size.

b) Capillary haemorrhage:- the blood oozes over the surface and is darkish red in
colour. oozing over several hours can result in considerable blood loss.

c) Venous haemorrhage :-the bloody stock in colour. There is a no supporting and

the rate of loss is much less severe than arterial blood.

3. Depending upon TIME OF HAEMORRHAGE :

a) Primary haemorrhage :-occurs at the time of trauma or surgery.

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b) Refractory haemorrhage :-occurs within 24 hours of trauma or operation.
c) Secondary haemorrhage :-occurs after 7 to 14 days of trauma or operation.

4. Depending upon VOLUME OF BLOOD LOSS:

a) Mild haemorrhage:- blood loss is less than 500 mL

b) Moderate haemorrhage:- blood loss is 500- 1000mL
c) Severe haemorrhage :-blood loss is more than 1 litre.

5. Depending upon SPEED OF BLOOD LOSS:

a) Acute haemorrhage:- massive bleeding in short span of time.

b) Chronic haemorrhage:- slow bleeding small in quantity for long time.

6. Depending upon PERCENTAGE OF BLOOD LOSS:

a) Class 1 haemorrhage:
 Involves up to 15% of blood loss
 There is typically no change in vital signs
 Fluid resuscitation is not usually necessary.

b) Class 2 haemorrhage:-
 Involves loss of 15 to 30% of total blood volume
 Tachycardia without giving off difference between the sister leak and
diastolic pressure.
 The body attempts to compensate with peripheral vasoconstriction skin
may start to look pale and be cool to touch volume resuscitation with

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 crystalloid( saline solution or lactated ringer solution is all that is typically
required blood transfusion is not typically required

c) Class 3 haemorrhage:-
 Involves loss of 30 to 40% of circulating blood volume
 the patient’s blood pressure drops
 heart rate increases
 peripheral perfusion such as capillary refill versions and the mental status
versions
 fluid resuscitation with crystalloid blood transfusion usually necessary

d) Class 4 haemorrhage:-
 Involves loss of more than 40% of circulatory blood volume

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  The limit of body’s compensation is reached and aggressiveness
excitation is required to prevent death.

ETIOLOGY:-

 TRAUMATIC:-

I. Abrasions:- also called grace this is caused by transverse action of a foreign object
against the skin and usually does not penetrate below the epidermis
II. Excoriation:- commonly with abbreviation this is caused by mechanical destruction
of skin although it usually has an underlying medical cause
III. Hematoma:- also called Bloody tumor this is caused by damage to a blood vessel
that in turn causes blood to collect under the skin
IV. Lacerations:- irregular wound caused by blunt impact to a soft tissue overlying a
hard tissue or earring such as in childbirth in some instances this can also be used to
describe an incision
V. Incision:- a cut into a body tissue or organ such as buy a scalpel made during surgery
VI. Puncture wound:- this is caused by an object that penetrated the skin and underlying
layers such as a nail needle or knife
VII. Contusion:- also known as a Bruce this is a blunt trauma damaging a tissue under the
surface of the skin
VIII. Crushing injuries:- these are caused by a great or extreme amount of force applied
over a long period of time the extent of a crushing injury may not immediately
present itself
IX. Gunshot wounds:- these are caused by projectile weapons this may include two
external wounds entry and exit and contagious wound between the two.

 MEDICAL CONDITIONS:-

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 Medical bleeding denotes hemorrhage as a result of an underlying medical condition blood
can escape from the blood vessels as a result of three basic pattern of injury:-

i. Intravascular changes:- stages of blood within vessels for example increase in blood
pressure decrease in clotting factors
ii. Intramural changes:- changes arising within the walls of blood vessels for example
aneurysms dissections
iii. Extravascular changes:- changes arising outside the blood vessels for example h pylori
infection brain abscess brain tumor.

 COAGULATION SYSTEM:-

Certain medical conditions can also make patients susceptible to bleeding these are the
conditions that affect the medical hemostatic function of the body him used asses involves
several components the main components of the hemostatic system include platelets and the
coagulation system platelets are small blood components that form a plug in the blood vessel
wall that stops bleeding platelets also produces a variety of substances that stimulate the
production of blood clot.

i. NSAID'S:- one of the most common cause of increased bleeding risk is exposure to to
nonsteroidal anti-inflammatory drugs the prototype for these drugs is aspirin which
inhibits the production of thromboxanes the that inhibits the the activation of platelets and
thereby increase the risk of bleeding
ii. Deficiencies of coagulation:- deficiencies of coagulation factors are associated with
clinical bleeding for instance A deficiency of factor VIII causes classic haemophilia a
while deficiency of factor 9 causes Christmas disease that is haemophilia b antibodies to
factor VIII can also in activate sector 7 and precipitate bleeding that is very difficult to
control
iii. Warfarin related:- warfarin act as inhibiting agent for Production of Vitamin K in the
gut vitamin K is required for the production of the clotting factors 2nd 7th 9th and 10th in the
liver one of the most common causes of War and related bleeding is taking antibiotics the
gut bacteria makes vitamin K and are killed by antibiotics this decrease vitamin K levels
and therefore the production of these clotting factors

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ORIGIN OF HAEMORRHAGE:

 Mouth:-
 Hematemesis:- vomiting fresh blood
 Hemoptysis:- coughing up blood from the lungs
 Hematochezia:- rectal blood
 Hematuria:- blood in the urine from urinary bleeding
 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 blood
vessel within the head
 Subarachnoid hemorrhage:- implies the presence of blood within the
subarachnoid space from some pathologies the common medical use of term s a h
refers to the nontraumatic types of hemorrhage usually from the rupture of Berry
aneurysm or arteriovenous malformation
 Lungs:- pulmonary hemorrhage
 Gynecologic:- vaginal bleeding postpartum hemorrhage and ovarian bleeding.

Clinical manifestations:-

 Pain
 Hypoxia
 Cynosis
 delayed capillary refill
 increased heart rate
 difference between systolic and diastolic
 stupor
 thirsty
 decreased urine output
 disability
 bruising
 skin colour changes cold and clammy skin

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  rising pulse rate
 falling blood pressure
 confused mental state

Diagnostic studies:-

 History collection
 Physical Examination

WHO BLEEDING SCALE

COAGULATION SCREENING TEST

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COMPLICATIONS:-

 Hypovolemic shock
 Infection
 Thrombocytopenia
 Shock/ coma
 Death

TREATMENT:-

The natural arrest of hemorrhage or normal mechanism of hemostasis this is a complex

process which changes blood from a fluid to a solid state intact blood vessels are Central
to moderating bodies tendency to clot the endothelial cells of that intact vessels prevented
from thrombus formation by secreting tissue this plasminogen Activator TPA add bio in
activating from bin add adenosine diphosphate injury to vessels overwhelmed these
protective mechanism and hemostasis and ensues.

Haemostasis is maintained in the body via three mechanisms:-

 VASCULAR SPASM:- damaged blood vessels constrict

 PLATELET PLUG FORMATION:- platelets and higher to the damaged and

epithelium to form platelet plug (primary haemostasis) and then degranulate.

 BLOOD COAGULATION:- clots form upon the conversion of fibrinogen to

fibrin at its addition to the platelet plug (secondary haemostasis.)

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Haemostasis proceeds in Two Phases:-

o Primary
o Secondary

PRIMARY HAEMOSTASIS :-
Primary hemostasis is characterized by vascular construction platelet adhesion
and formation of soft aggregation of great plug, It begins immediately after
endothelial disruption injury causes temporary local contraction of vascular
smooth muscle basic instruction slows blood flows enhancing platelet adhesion
and activation
 Adhesion occurs when circulating Von willebrand factor attaches to the sab
endothelium next glycoproteins on the platelet surface at highest to the sticky Von
willebrand factor platelets collect across the injured surface these platelets are
then activated by contact with the collagen kolaj and activated platelets form
pseudopodes which stretch out to cover the injured surface and Bridge exposed
fibres the collagen activated platelet members expose receptors which bind
circulating fibrinogen to their services fibrinogen has many platelet binding sites
and aggregation of platelet and fibrinogen build-up to form a soft plug platelet
aggregation occurs about 20 seconds after injury.
 Primary haemostasis is short lived the immediate post injury vascular
constriction abates quickly if the floor is allowed to increase the soft plug
could be sheared from friction.

SECONDARY HAEMOSTASIS:-

 Secondary haemostasis is responsible for stabilizing the soft clot and

maintaining vasoconstriction. Vasoconstriction is maintained by platelet
secretion of serotonin, prostaglandin and thromboxane the soft plug is solid
defined through a complex interaction between platelet membrane enzymes
and coagulation factors.

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   Coagulation factors are produced by the liver and circulate in an
inactive form until the coagulation cascade is initiated the cascade occurs in
steps the completion of each step activates another equation factor in the chain
reaction which leads to the conversion of fibrinogen to fibrin the injured
surface possibly creating an emboli.

FIRST AID TREATMENT:-

 Check the victims ABCs.

 If the victim has ABC complications treat those first CAB always take priority.
call an ambulance.
 Treat for shock.
 Assist the victim into the most comfortable position.
 Monitor CAB and vitals until the ambulance arrives.

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MANAGEMENT IN EMERGENCY :-

 Immediate measures
 bleeding from body cavities
 measure for internal bleeding
 measures for Oxygen and Cardiac function
 fluid replacement

IMMEDIATE MEASURES:-

 But the patient clothing away and carry out a rapid physical examination
 apply form pressure over the bleeding area
 apply form pressure dressing over the bleeding area
 elevate the injured part to stop in a capillary bleeding above the heart level
immobilize the injured part that may be extremity to control blood loss.

BLEEDING FROM BODY CAVITIES (EXTERNAL BLEEDING)

External Haemorrhage means loss of blood from the circulatory system which can be
seen easily or identified.

Treatment

In all first aid situations the primary. Priority is to protect yourself. So put on protective
gloves before approaching the victim. The external bleeding is treated using three key
techniques, which allow the bodies natural repair. Process to start. these can be
remembered using the acronym mini red, which stands For

 Rest

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  Elevation
 Direct pressure
 Dressing

Rest

In all the cases of haemorrhage, resting the client in one place is very important. Because
frequent movement will increase the bleeding or haemorrhage.

Elevation

In case of larger bleeds, it may be necessary to elevate the wound above the level of heart.
This decreases the blood flow to the affected area, slowing the blood flow, assisting the
clothing. Elevation only works on the peripheries of the body limbs and head and is not
appropriate for body wounds. You should also ask the victim to hold his wounded part of
body as high as possible.

Direct pressure

The most important part of these three is direct pressure. This is simply placing pressure
on the wound in order to stop the flow of blood. This is the best done using a dressing,

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such a sterile gauze pad. If the blood starts to come through the dressing you are using,
Additional dressings to the top, do a maximum of three. Where an articulate area of body
is wounded such as the arms or hands, it is important to consider the position of the area
in keeping pressure on the wound.

Dressing

Once the bleeding is slowed or stopped, or in some cases, to assist the slowing of the
blood flow, you should consider dressing the wound properly. Two dresser wound, use us
trial low adherent pad, which will not stick to the wound, but will absorb the blood
coming from it. Once this is in place, rap a creep are comforting bandage around firmly.
It should be tight enough to apply some direct pressure. but should not be so tight as to
cut blood flow of below the bandage. a simple cheque for the bandage being too tight on
a limb wound is capillary refill cheque.

For example, hold the hand or foot above the level of heart and formally pinched the
nail, if it takes more than two seconds for the pink colour to turn under the nail, then the
bandage is likely to be too tight.

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If the blood starts to come through the dressing you have applied, add another on top,
do a maximum of three, if these are all saturated. Remove the top two, leaving the closest
dressing too wound in place. This ensures that any blood clots that have formed are not
disturbs, otherwise, the wound would be opened new.

Other measures :-

 Application of tourniquet:-this is rarely required except for control of

our torrential haemorrhage from the Limb. A temporary tourniquet may
have to be divised in sudden emergency. it should be 3 to 4 inches wide it
can be a handkerchief, scarf or a tie. The great danger of tourniquet is that
if it is left on for more than 30 minutes then gangrene of the limb may
occur. The time of application and removal of tourniquet should be
recorded. The Limb on which a tourniquet is applied should be kept
elevated afterwards to control edema which may result from venous
congestion.
 Surgical ligation:- it is necessary if the bleeding is persistent.
 Coagulation :-. It can be used to coagulate the blood from small blood
vessels.
 Pack:- it will be temporary controlsevere haemorrhage. This method is
used in operation Theatre to control temporary or sudden haemorrhage.

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 The Theatre nurse should always have a pack readily available for this
emergency.
 Styptics :-these are also used to control bleeding and they act as
astringents. Astringents should be such as snake venom or adrenaline may
be used locally in certain cases. thrombin and gel, foam can be used in
some cases such as in low pressure bleeding from veins and capillaries.

Internal bleeding

Internal bleeding is the bleeding which occurs inside the body. Sometimes the blood will
leak from the inside the body, causing pain and shock, even though you cannot see the
blood loss.

Aetiology

 Falls
 motorcycle accidents
 Injuries from explosion
 Car accidents
 Gunshot wounds
 Stab wounds etc

Recognition

A person may be bleeding internally if one of these things happen

o Rhinorrhea due to head trauma.

o Otoria occurs from severe head trauma.
o Melina.
o Haematuria.
o Bright red blood, a blood like coffee grounds is in the vomit.
o Blood comes from the women birth canal after an injury or during pregnancy.
o Bruising over the abdominal or chest area.
o Pain over vital organs.
o fractured femur

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But remember, a person may be bleeding inside the body, even though you cannot see
the bleeding. If you see the signs of shock and no apparent injuries, always suspect
internal bleeding. Check the skin colour changes, in case of internal bleeding the skin
may become pale and cold and cyanosis maybe present.

Measures for internal haemorrhage

 Suspect internal bleeding in patient with hypovolemic shock with no external

signs of bleeding, rising pulse rate, falling blood pressure, thirst, cold and clammy
skin, moist skin.
 Give whole blood or plasma expanders at the rate of blood loss
 Prepare the patient immediately for surgical interventions to identify and control
sources of bleeding
 Apply pneumatic anti shock garment one available to control internal bleeding
and to facilitate blood flow to vital areas. primary use it for hypovolemic shock
secondary to bleeding into lower parts of body.
 Monitor the patients hemodynamic response. Octane blood gas determination,
establish venous return, monitoring as an index of amount of replacement fluid to
the patient.
 Maintain patient in supine position till hemodynamic or circulatory parameter
begin to improve.

Control of internal haemorrhage first aid in case of emergency:-

The following methods can be used to control bleeding

 The organ is emptied:- of blood clots if possible that is in case of severe

bleeding from bladder, or catheter is passed and bladder is emptied.
 The vessels are encouraged to contract:- a lot of Saline or sodium
bicarbonate to which a few drops of adrenaline and solution have been added,
is of great value in washing the organ. This can be repeated every two hourly.
The use of ergometrine after the birth of placenta is an example of
stimulating the vessels of contract. Pitocin intravenous may be effective in
control of bleeding from is esophageal varies.
 Packing:- it can be done with gauze soaked in adrenaline is effective.
 Surgical ligature:- surgical ligation can be done in case of ruptured spleen.

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  Internal pressure- this may be applied by the balloon of tri luminal to been
bleeding esophageal varies or by the balloon of foley's catheter in the
prostatectomy cavity.

First day treatment in case of internal bleeding:-

 Lay the casualty down with the head the law raises legs by use of pillow.
 Keep him calm and relaxed, reassure him.
 Do not allow him to move.
 Keep up the body heat with a thin blankets or coat.
 Do not give anything to eat or drink aspiration may occur.
 Do not apply ice bags or hot water bottles to chest or abdomen.
 Take him to the hospital as early as possible.
 Transport gently.

fluid replacement

 Insert intravenous cannula to provide means of blood replacement.

 We draw blood sample for analysis, typing, add for cross matching.
 Give fluid replacement, including balanced electrolyte solution and blood, depending
upon the chemical estimation of blood loss to correct intra vascular deficit and interstitial
fluid space deficit.
 Fresh whole blood is infused. Blood infusion is done in case of massive haemorrhage.
 Additional platelets and coagulation factors are given in large amount of blood since his
placement blood is deficit in gloating factors.
 Warm the blood commercial warmer or a basin of warm water. massive blood
replacement has a cooling effectiveness causing cardiac arrest.

Rate of infusion depends upon the severity of blood loss and chemical evidence of hypoxia.

Restoration of blood volume:-

Blood volume can be restored by blood transfusion-

Indications for blood transfusion-

i. To counteract the effect of severe haemorrhage and replace blood loss.

ii. To prevent shocking operations where blood loss is considerable such as rectal
resection , hysterectomy and arterial surgery.

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 iii. In severe burns to make up for blood lost by burning but only after plasma and
electrolyte have been replaced.
iv. To correct severe anaemia from cancer aphasia and similar conditions from slow
continuous haemorrhage. in a blood transfusion as in all intravenous injections, that
you being another portion of the delivery operators must be free from air.

Transfusion under increased pressure

In some circumstances usually of large rapid blood loss maybe necessitate blood transfusion
more quickly than possible by the simple gravity drip method.

Following methods can be used

 Pressure cuff this is an inflatable cover placed around the bag of blood, when it is
inflated it exerts external pressure on the bag of blood, does increasing the flow of
blood into the patient.
 Pressure pump administration Some transfusion gives set permits either gravity or
pressure pump administration of blood.

Precautions during blood transfusion

 Patient and transfusion operator should be kept under constant supervision.

 Blood must be transfused according to the rate prescribed by the doctor.
approximately 25 drops per minute. In the casual rate of blood transfusion which
means the Baggies transfer you’d in four hours.
 Suffers from cardiac pulmonary diseases or severe anaemia must be transfused at the
slow rate sometimes at 12 drops per minute.
 Half an hourly pulse rate and temperature should be recorded.
 If blood transfusion is for shock, blood pressure and pulse rate should be recorded
after each unit of blood.
 All the patients should be watched for symptoms of transfusion reaction after first few
ml of blood from each unit of blood, such allergies reaction, pyrexia, air embolism,
overloading, thrombophlebitis is etc.

Measures for oxygenation and cardiac function

 Add administer humidified oxygen

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 Watch for cardiac arrest. Patients who have haemorrhage are the candidates for cardiac
arrest caused by hypovolemic shock with the secondary anoxemia.
 Assess with ECG monitor for dysrhythmias.

Post operative management

 In case of shock, patient shall be placed in a shock position that is laying flat on back
with legs elevated at a 20 degree angle while knees are kept straight.
 a sedated or analgesic is administered as prescribed. The moon should be inspected for
any bleeding and us trail dressing should be placed.
 In case of haemorrhage, elevate the infected part above the heart level. and start the
transfusion of blood and products and determine the cause of haemorrhage as the initial
therapeutic measure.

Special measures

Anti shock garments

These are of two types

 Non pneumatic anti shock garments.

 Pneumatic anti shock garments.

Non pneumatic anti shock garments

NASG is a low technology first aid device used to treat hypovolemic shock.

How it works

When in shock the brain, heart and lungs are deprived of oxygen because blood accumulates
in the lower abdomen and legs. The NASG reverses shock by returning blood to the heart,
lungs and brain. This restores the persons consciousness, pulse and blood pressure.
Additionally, this decreases bleeding from the parts of the body compressed under it.

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Pneumatic anti shock garments

Pneumatic anti show government is an inflatable garment used to combat shock, stabilise
fractures, promote hamsters and increase peripheral vascular resistance. It is also called
MAST SUIT ( military anti shock trouser.)

Military anti shock trousers are medical devices used to treat severe blood loss, they are
also indicated for stabilisation of unstable pelvic fracture.

Characteristics

 Lightweight reusable

 Lower body counter pressure

 Decrease bleeding

 Reverse shock

 Contributes to decreased morbidity and mortality

Uses

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 Stabilises the patient while evaluating, transporting, all preparing for definite if surgical
treatment.
 Can be safely and comfortably used up to 48 hours.
 Me arrest bleeding and avoid surgical intervention.
 May decrease need 4 or number of blood transfusions.
 During delays, such as waiting for interventional radiology.

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