Hemorrhage or bleeding refers to is blood escaping from the circulatory system. A hemorrhage may be external and visible on the outside of the body or internal, where there is no sign of bleeding outside the body. Bleeding from a cut on the face is an external hemorrhage. Bleeding into the spleen or liver are examples of internal hemorrhage.
Classification of hemorrhage as per blood loss
Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardia as body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch.
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.
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.
The World Health Organization Scale for measure the severity of bleeding.
|Grade 0||no bleeding|
|Grade 1||petechial bleeding;|
|Grade 2||mild but clinically significant blood loss|
|Grade 3||gross blood loss, requires transfusion (severe);|
|Grade 4||debilitating blood loss, retinal or cerebral associated with fatality|
Common Sites of Hemorrhage
- Tooth eruption _ losing a tooth
- Hematemesis – vomiting fresh blood
- Hemoptysis – coughing up blood from the lungs
- Hematochezia – rectal blood
- Melena – loss of blood through faeces
- Urinary tract
- Hematuria – blood in the urine from urinary bleeding
- Upper head
- Cerebral hemorrhage – a type of intracranial hemorrhage, bleeding within the brain tissue itself.
- Intracerebral hemorrhage – bleeding in the brain
- Subarachnoid hemorrhage implies the presence of blood within the subarachnoid space
- Arteriovenous malformation
- Intracranial hemorrhage – bleeding in the skull.
- Pulmonary hemorrhage
- Vaginal bleeding
- Postpartum hemorrhage
- Breakthrough bleeding
- Ovarian bleeding
Causes of Hemorrhage
Bleeding arises due to either traumatic injury, underlying medical condition, or a combination.
Trauma can lead to different types of wounds and associated bleeding may occur.
Bleeding from a medical procedure also falls into this category.
Disorders of coagulation and hemostasis may lad to atraumatic bleeds. Hemophilia is one such example.
Some drugs can also affect these mechanisms.
NSAID, warfarin, and heparin are few examples.
Different Types of Hemorrhages
Arterial haemorrhage is recognised as bright red blood, spurting as a jet which rises and falls in time with the pulse. In protracted bleeding, and when quantities of intravenous fluids other than blood are given, it can become watery in appearance.
Venous hemorrhage is a darker red, a steady and copious flow. Blood loss is particularly rapid when large veins are opened.
It must be noted that pulmonary artery haemorrhage is dark red (venous blood) whereas bleeding from the pulmonary veins is bright red (oxygenated).
Capillary haemorrhage is a bright red, often rapid, ooze.
Hemorrhage During or after Surgery
IT occurs at the time of injury or operation.
Reactionary haemorrhage may follow primary haemorrhage within 24 hours (usually 4—6 hours) and is mainly due to rolling (‘slipping’) of a ligature, dislodgement of a clot or cessation of reflex vasospasm.
Secondary hemorrhage occurs after 7—14 days, and is due to infection and sloughing . Pressure of a drainage tube, a fragment of bone, a ligature in an infected area or cancer.
Signs of Hemorrhage
Visible blood is the most obvious sign in external hemorrhage, but to notice internal hemorrhage the symptom of the effect caused are noted.
For example a stroke following brain hemorrhage.
Treatment of Hemorrhage
For external bleeding, further loss is minimized by pressure and packing, position and rest, operative procedures as needed like ligation, repair and excision. Fluid replacement and blood transfusion are carried as per needs.
Elevation of limbs employs gravity to reduce bleeding. Elevation also causes helpful vasoconstriction.
Internal bleeding require different management protocols depending on the site and its effects.