Hemorrhage or bleeding refers to 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 can occur in almost any area of the body.
Internal bleeding occurs when there is a damaged vessel or organ.
External bleeding is generally through a break in the skin. It can also occur when internal bleeding exits through a natural orifice such as mouth, nose, anus, vagina.
Hemorrhage in stomach cancer visualized by endoscope, Image from Wikipedia, in public domain
Types of Hemorrhage
It is done by World Health Organization Scale
Grade 0
No bleeding
Grade 1
Petechial bleeding
Grade 2
Mild but clinically significant
Grade 4
Sever bleeding requiring transfusion
Grade 5
Severe associated with fatality
Depending on Bleeding vessels
Arterial
Arterial hemorrhage is recognized 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
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 hemorrhage is dark red (venous blood) whereas bleeding from the pulmonary veins is bright red (oxygenated).
Capillary
Capillary hemorrhage is a bright red, often rapid, ooze.
Bleeding after Surgery
Primary hemorrhage
It occurs at the time of injury or operation.
Reactionary hemorrhage
Reactionary hemorrhage may follow primary hemorrhage 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
Secondary hemorrhage occurs after 7—14 days, and is due to infection and sloughing. The pressure of a drainage tube, a fragment of bone, a ligature in an infected area or cancer.
Depending on their Presentation
- Hematemesis – vomiting fresh blood
- Hemoptysis – coughing up blood from the lungs
- Hematochezia – Loss of fresh blood through the rectum
- Melena – loss of blood through feces
- Hematuria – Blood in the urine from urinary bleeding
Causes of Hemorrhage
The hemorrhage occurs due to either trauma, a medical condition or combination. Some drugs may affect the coagulation pathway and cause bleeding.
Traumatic bleeding
Trauma is an important cause of hemorrhage and can lead to bleeding anywhere in the body.
Common types of traumatic are
- Abrasions or grazes
- Hematoma or bruises
- Lacerations
- Puncture wounds or animal bites
- Crushing injuries
- Gunshot injuries
- Fractures
Medical Conditions
There is a large number of medical conditions that may lead to bleeding including the following.
- Hemophilia
- Leukemia
- Liver disease
- Menstrual bleeding
- Coagulation Disorders
- Thrombocytopenia, low blood platelet count
- von Willebrand disease
- Vitamin K deficiency
- Bowel obstruction
- Congestive heart failure (CHF)
- Tumors
- Acute bronchitis
- Endometriosis
- Aneurysm
Drugs
Some drugs like NSAID, warfarin, and heparin can also affect these mechanisms.
Management of Hemorrhage
Visible blood is the most obvious sign in external hemorrhage. Internal bleeding, on the other hand, may go unnoticed unless it is substantial or affect a vital area causing symptoms.
Internal bleeding may be completely asymptomatic or cause symptoms depending on the region. Pulmonary bleeding may present as hemoptysis or hemothorax.
GI bleeding may cause hematemesis, melena or bleeding per rectum.
Bleeding in urine may be a sign of urinary infection.
Bleeding in the brain may present with a neural deficit.
Minor bleeding wounds require wound cleaning and dressings.
In case of substantial bleed, the further loss is minimized by pressure and packing, position, and rest.
The definite treatment of external bleeding depends on the site and size of the wound but may include operative procedures as needed like ligation, repair, and excision. Fluid replacement and blood transfusion are carried as per needs.
The elevation of limbs employs gravity to reduce bleeding. Elevation also causes helpful vasoconstriction.
Internal bleeding requires different management protocols depending on the site and its effects.