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Hemorrhages and Hemostasis
Hemorrhage is blood flow from vessels in to tissues, cavities of body or outside of the body.
Reason of hemorrhage can by : trauma ( injury) of the vessels, pathological process outside of the vessels as a tumors overgrowth, ulcerative process of stomach, duodenum or bleeding from intact vessels ( coagulation disorders by sepsis or other infectious - toxic processes ).
A hemorrhage is one of most dangerous factors in an injury. The extend of the danger depends on the character of the wound(incised, contused etc.) and number of the factors: size of the wounds, type of injured vessels(artery, vein).
If the blood flows to the exterior from the wound, it is an external hemorrhage; if the blood flows into the tissues or cavities as a thoracic, abdominal, joints, it's known as an internal hemorrhage. If bleeding occurs into cavities witch communicate with the environment(stomach, intestins, urinary organs), it may be discharged to the exterior and the hemorrhage becomes visible(external).
Hemorrhage which occurs immediately after trauma(injury) is primary. Hemorrhage witch occurs few days after trauma is secondary. The reasons of this bleeding are : dislocation of the thrombus which was obstructed injured vessel; septic resolution of thrombus, displacement of the ligature , damage to vascular walls by foreign bodies ( shell splinters, bone fragments), destruction of the vessels walls by a purulent process. Because such hemorrhages are possible, the patient mast by watched as long as wound heals, especially during first weeks or during several infections process.
Hemorrhages are divided according type of vessels in to: arterial, venous, capillary, parenchymatous hemorrhages.
Arterial hemorrhages are the most rapid and dangerous. In injures to aorta and others major arteries the patient may die before he is administered any aid. Arterial hemorrhage can by recognized by color of blood and type of bleeding. Blood is injected in spurt(as a pulsation stream) and it's color is bright-red(blood is rich of oxygen). Compression of artery arrest the bleeding.
Venous hemorrhages can by determined by the dark red color of the blood (poor of oxygen and rich of carbon dioxide), blood flows by a continuous stream. In such cases lowering the bleeding part of the body and compression of the vessels between the heart and site of bleeding intensifies the hemorrhage. In injures of the major veins, especially on the neck, air may gain entrance into them and produced so called airs embolism with rapidly leads to death owing to obstruction of cardiac or cerebral vein.
Capillary hemorrhage occurs in injuries to the minutest vessels(capillaries); in this injures no separate bleeding vessels can be seen, the blood oozes out of the entire surface of the injury. The color of the blood is between arterial and venous. A capillary hemorrhage usually stops spontaneously, due to clotting of the blood. Bat this type of bleeding is dangerous mainly in cases of impaired blood coagulation(hemophilia, diseases of the liver).
Parenchymatous hemorrhages occurs in injury to the internal organs which are rich in blood vessels ( spleen, kidney, lungs, liver); these hemorrhages are usually arrest with difficulty because the injures involve arteries, veins, capillaries.
And now some words bout other terminology.
Petechia - blood bruise in the skin.
Ecchymosis - blood bruise in the mucous.
Sugillation, suffusion - blood bruise in the submucous areas.
Haematoma - limited concentration of the blood in the tissues.
Epistaxis - bleeding from the nose.
Gastrorrhagia - bleeding from the stomach.
Haemoptoe - blood expectoration during coughing.
Haematemesis - vomiting with a blood.
Haematuria - urination with a blood, erithrocytes in the urine.
Blood accumulation in the pericardial cavity - haemopericardium.
Blood accumulation in the pleural cavity - haemothorax.
Blood accumulation in the abdominal cavity - haemoperitoneum.
If is bleeding from upper part of small intestins or stomach excrements are black so called - melena.
Acute anemia caused by massive hemorrhages.
The danger of a hemorrhage to the life of patient depends primarily on the amount of blood lost. The loss of 200-400 ml of blood(not rapid) not change for worse general condition of adults. A blood loss of 1000- 1200 ml is dangerous. The rate of bleeding, age, the patients general condition, sex are importance as regards the results of hemorrhage. Women tolerate hemorrhage more easily than men do. In injures to the major arteries or veins, the patient may lost 500 - 800 ml of blood in short time and die before administrating any aid. A loss of 250-300 l of blood is fatal for one-year-old child.
Every injury causes bigger or smaller lose of blood. There are approximate quantities of blood, what can be lost during the following injures:
1. Fractures of bones :
upper arm - 600 - 650 ml
forearm - 300 - 600 ml
pelvic bones - 1200 - 2500 ml
femur - 1000 - 1800 ml
shin bones - 800 - 1000 ml
2. Injures to the :
thorax organs - 500 - 1800 ml
abdominal parenchymatous organs 1700 ml.
Every bloody operation is connected with blood lose too :
appendectomy - 15 - 40ml
operation of hernia - 50 - 500ml
cholecystectomy - 150 - 500ml
resection of stomach 190 - 600ml
splenectomy - 100 - 800ml
pulmonectomy - 300 - 1800ml
The clinical signs of hemorrhages:
The patient want to drink, complains of weakness, of things going dark before his eyes, dizziness, begins to yawn?, sometimes faints. Examination of the patient reveals pallor, especially on the extremities and ears, sometimes cyanosis, the skin can be cool, clammy with pale. Other sins can by tachycardia, tachypnea, decreasing of blood pressure. Routine laboratory tests as follows : decreasing amount of Hb, Ht, erythrocytes and in some cases increasing amount of leucocytes.
The patient's sings and symptoms depend on size of blood volume deficit.
In general, uncomplicated losses up to 15% of circulated blood volume result in a mild resting tachycardia about 100 beats/min, normal blood pressure, pulse pressure, respiratory rate, skin color and temperature.
With losses between 15% to 30% of blood volume, the tachycardia increases to greater than 100 beats/min, systolic blood pressure is normal, pulse pressure is decreased, the respiratory rate is slightly increased, the nail beds can be pale. The patient may by anxious.
With losses of 30% to 40% ( 1500-2000ml in 70kg male) the tachycardia is increased to greater than 120 beats/min, systolic blood pressure, pulse pressure are decreased. The skin is cool, clammy, pale, mottled coloration.
Hemorrhage - hypovolemic shock
Shock occurs when in result of blood losses blood flow is unable to ensure normal tissues oxygenation, nutrition and elimination of products of metabolism. In the initial stage of shock organism compensates blood losses by centralization of blood circulation, providing better blood supply to heart, brain, kidney, liver, decreased perfusion of skin, subcutaneous tissues, muscles, intestines. If the bleeding continues, function of heart, brain, kidney, liver becomes impaired and patient may die. The cause of death is hypovolemia.
Organism's adaptation mechanisms in case of bleeding
1. Constriction of the injured vessel and inversion of its intima inside.
2. Formation of clot in the injury place.
3. Tachycardia, tachypnoe to provide better oxygenation and metabolism of tissues.
4. Autohemodilution - compensation of hypovolemy by blood dilution with extracellular liquids.
5. Activation of blood coagulation system.
Stopping of the bleeding
The external blleeding will be stopped temporary during during the first medical assistence. If the bleeding is capillary ar venous, compressig dressing shoulf be used to stop it, keeping to all rules of aassipsis and antisepsis. In most cases the bleeding stops finally.
venous and capillary bleeding can be stopped by eleveting the extremity - elevation.
If the bleeding is from major's arterias or vens, following methods to stop it should be used:
short time stopping and final stopping of the bleeding.
Stopping of bleeding for a short time
1. Compression of the artery with the digids (fist).
Artery must be compressed between the heart and the wound.
Artery can be pressed to the bone in certain points.
Abdominal aorta is pressed by fist in middle or inferior part of abdomen.
Temporal aorta is pressed by fits to temporal bone in front of the helix ear.
Arteria carotis should be pressed to the processus transversus of VI cervical vertebra along the crus medialis of m. strnocleidomastoideus.
Arteria subcliavia should be pressed to the I cost over the clavicula between the cruss of m. strnocleidomastoideus.
Arteria mandibularis should be pressed by the thumb to the angulus mandibulae.
Arteria axilaris should be pressed to the capitulum of os humeri ( hand must by shifed foward).
Arteria axilaris should be pressed behid ligamentum inquinalis to the ramus ossis pubicus.
Arteria poplitea should be compressed in the regio poplitea. The thumb must be put in the front of knee joint, and withthe other fingers arteria should be pressed in the regio poplitea.
Compresing of the artery should be continjed until better method for stopping the bleeding can be appied.
2. Maximal flexion of the extremity anf fixation.
3. Tightening of the member with a spesial rubber waist-band-tourniqet.
This method was offered by F.Esmarch in 1873. Acording it all soft tissuses are compressed and the blood-vessel pressed to the bone. Tourniquet is applied on between the heart and the wound.
The rules of applying of the tourniquet:
lining must by done, skin crouching must by avoided, tourniquet must have it's passport, patient with the turniquet should by accompanied by the medical personnel, when the tourniquet is turned on, the extremity must be elevated, the tourniqet must by kept on no longer than one and half an hour. If there is need to keep it longer, after one and half an hour it must by taken of for 1-2 minutes. At this time the artery should be compressed proximally in one of described points. After this the tourniquet should be turned on in the different place. Tourniquet damages soft tissuses, nervs, vessels, thrombosis, necrosis of tissuses can develope. If there is psibillity, pneumatic tourniquets should by used.
If there is no special tourniquet belt , waist-band can be used.
First medical assitence when the bleeding accurs from the different organs.
Meidical assistence, when the bleeding is from the nose:
pacinent is placed in the half-sitting pasitio, cold thermophor is applied on the nose and the nape, warm thermophor is applied on the feet, tampon is inserted into the nasal hole. If the bleeding goes after these measures, posterior tamponade of the nose must by provide on by specialist of the otorhinolaringology.
Meidical assistence, when the bleeding is from the lungs: frightened patient must bu quietened, patient must be placed in the half-sitting pasition or the appropriate pasitino for postural drainage must be find, give the patient to dring water with salt ( 1 spot of salt on a glass of water), patient must to speak less, further treatment of patient must be carried on in the thoracical or ftysiatric department.
Meidical assistence, when the bleeding is from the upper part of digestiv tract: give the patient quietness - make him lie down, thermophore with ice is putted on the region of ventricle, food, drink is not given, patient must by administered to the surgical deparment. These patient are very serious. If there is need, oxygen inhalation can be given.
Meidical assistence, when internal bleeding is suspected: absolut quietness must be given, thermophor with ice is applied on the abdomen, no food, no drink, oxigen inhalation. Patient must by administered to the surgical deparment as soon as posible. These patient are very serious.
Final stopping of the bleeding.
Mechanical : compresional bandage or tampon, ligation or suture over the vessels, torsio of the vessels, angiotripsia, suture or transplantation of blood vessel.
Physical: cold ( causes vasoconnstriction), high temperature ( causes coagulation of proteins and accelerates hemocoagulation) , diathermy, laser( coagulates proteins and vessels.
Biological : blood transfusion or blood components such as plasma, trombocitic mass, fibrinogen; infusion of blood preparations ( preprotrombin complex, antihemophilic globulin); tamponade with autotissuses( omentum, mucle, fascia), local aplication of blood preparations( thrombin ,hemostatic sponge, fibrin plate, biological antiseptic tampon).
Chemical:
vasoconstrictors( Sol. adrenalini 0.1%); preparations, increasing coagulation (Calcium chloride, gelatin, protamini sulphatum, vicasolum, dicinone); inhibitors of fibrinolysis ( ac.e-aminocapronicum, contrical, trasilol).