HEMORRHAGE

priyakrishnan

DEFINITION
y Haemorrhage is copious escape of blood

from a blood vessel. Haemorrhage comes from the Greek word HAIMA = blood and RHEGNUMAI = to break forth- a free and forceful escape of blood .

PATHOPHYSIOLOGY

CLASSIFICATION OF HAEMORRHAGE
1 .GENERAL yPRIMARY yIN TERMEDIARY/REACTIONARY ySECONDARY

2. ACCORDING TO THE TYPE OF BLOODVESSELS

3 . ACCORDING TO LOCATION
EVIDENT OR EXTERNAL -Visible Bleeding on the surface. INTERNAL (CONCEALED) Bleeding that cannot be seen. Internal Bleeding. 4

BASED ON THE DURATION OF HAEMORRHAGE

ACUTE HAEMORRHAGE

4 BASED ON THE DURATION OF HAEMORRHAGE

 ACUTE HAEMORRHAGE  CHRONIC HAEMORRHAGE

WHO CLASSIFICATION OF BLEEDING

y Grade 0 y Grade 1 y Grade 2 y Grade 3

No bleeding Petechial Bleeding Mild Blood loss Gross Blood Loss, Debilitating blood loss,

Requires blood transmission

y Grade 4

Retinal or Cerebral associated with fatality

COMMON SOURCE OF SEVERE HEMORRHAGE

y EXTERNAL BLEEDING y NOSE( Epistaxis) y OESOPHAGUS AND STOMACH

GASTROINTESTINAL BLEEDING
Etiology include Trauma any where along the GI tract. Erosion or ulcers. Inflammation such as oesophagitis, gastritis , IBD Anal disorders such as haemorrhoids. Irritation of mucous membrane due to certain drugs such as alcohol and aspirin containing compounds

Signs and symptoms .

y Massive bleeding:- Acute bright red hematemesis or

large amount of malena which clots in the stool. y Sub acute bleeding
Intermittent melena or coffee ground emesis. Hypotension. Weakness, dizziness.

y Chronic bleeding

Intermittent appearance of blood. Increased weakness, paleness or shortenesss of breath. Occult blood.

y PEPTIC ULCER DISEASE y Peptic ulcer disease is the break in the continuity of

oesophageal, gastric, duodenal mucosa. An ulcer may occur in any part of the GI tract that comes into contact with gastric juices. y COLON AND RECTUM y Usually red blood in stools, sometimes melena from digestion of blood pigment y Haemorrhoidal dieases are the main cause of bleeding. Bleeding is bright red seen in the toilet or upon wiping

GENITO URINARY SYSTEM

y Renal trauma

Traffic accidents and falls in which the client lands on the abdomen , flank or back are the most common cause of injury, usually from blunt trauma. Clinical manifestation y Hematuria(gross or microscopic)is a cardinal manifestation and is found in about 80% of cases. y Bruises over the clients flank and lower back secondary to retro peritoneal haemorrhage known as GREY TURNERS SIGN.

y Renal tract

Haemorrhage may occur from neoplasm , cystitis, nephritis, kidney stone. y Uterus and vagina Excessive menustruation , neoplasm abortion y Post partum Haemorrhage :- Any amount of bleedidng from or into the genital tract following birth of the baby upto the end of the peurperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and fall in B P .

INTERNAL INTRA PERITONIAL y Intra-Abdominal Injuries, are the main cause of bleeding. The injuries are either penetrating or blunt-trauma. Intra thoracic (hemothorax) y Chest Trauma:May be penetrating injuries or blunt injuries results from falls or blows to the chest. Major danger associated with chest injuries are internal bleeding and punctured organs.

Intracranial y a) Subdural haemorrhage : It results from tear of a vein. Longer period is required for the hematoma to form and cause pressure on the brain. y b) Subarachnoid Haemorrhage :-occur as a result of trauma or hypertension. y c). Intracerebral haemorrhage:-Most common in patients with hypertension and cerebral atherosclerosis, degenerative changes due to these disease usually cause rupture of the vessel.Also seen in disease conditions like brain tumour, use of medications like oral anti-coagulations. y d) Epidural Haemorrhage:- It is a neurological emergency. It follows skull fracture with a tear of the middle artery or other meningeal artery.

y Post Operative Complication of major surgeries y Lung surgery y Assess chest drainage tube Measure and document the

amount of drainage coming from the pleural space in the collection chamber.
y
y 500 to 1000 ml of drainage occur within first 24hours after surgery. y 100 to 300 ml of drainage may accumulate during first two hours

after this, the drainage should be lessen. y Excessive drainage or a sudden large increase may require further surgery.

y Heart

Bleeding can occur as a complication of open heart surgery. Haemorrhage may be due to inadequate hemostasis, disruption of suture lines. y HEMATOLOGICAL DISORDERS Disorders of blood vessels and the blood clotting mechanisms are the main cause of bleeding. y Haemophilia :- Is known to be due to an absence of certain clotting factors and is in curable.Closed hemorrhage :- that is hemorrhage under the skin or into an internal organ may occur.A large haematoma results ,and in case of a joint the haemarthrosis leads to stiffening and deformity. y Thrompocytopenia In this condition there is a shortage of platelets due to excessive destruction. y Platelet count is less than 20,000 mm3.

y COMPLICATION OF ANTICOAGULANT AND y

y y

y y y

THROMBOLYTIC THERAPY. Anti coagulant therapy is the administration of medications to disrupt the bloods natural clotting mechanism ,for preventing formation of a thrombus in post operative patients. THROMPOLYTIC THERAPY. It is the administration of thrombolytic agents to dissolve any formed thrombus and can inhibit the bodys hemostatic function.Thrombolytic agents are available for parenteral use only. Commonly used thrombolytics include Strepto kinase Urokinase Tissue plasminogen activator.

y EFFECTS OF HAEMORRHAGE y Acute Renal shut down y Liver cell dysfunction y Cardiac depression y Hypoxic effect y GIT mucosal ischaemia y Sepsis y Interstitial edema, ARDS y Hypovolemic shock

y COMPLICATION OF HAEMORRHAGE y Shock y Death

DIAGNOSTIC MEASURES Laboratory Studies

y CBC y Prothrombin time and/or activated partial thromboplastin time y Urine output rate can help guide adequacy of perfusion. y ABGs (Levels reflect acid-base and perfusion status.)

y Typed and cross matched packed red blood cells should be

ordered immediately based on clinical suspicion of hemorrhagic shock. Fresh frozen plasma and platelets also may be required to correct or prevent coagulopathies that develop in severe hemorrhagic shock

Imaging Studies y Standard radiography y Computed tomography y Ultrasonography y Directed angiography Other Tests y An ECG can be useful for detecting dysrhythmias and cardiac sequelae of shock.

GENERAL MANAGEMENT FIRST AID MANAGEMENT

y External Bleeding

y Management y - DRABC y - lay casualty down y - apply direct pressure to the site of bleeding y - raise and rest the injured part when possible y - loosen tight clothing y - give nothing by mouth y - seek medical aid urgently.
Direct pressure y Apply direct pressure to the wound with your fingers or hand.

2 . Uncontrolled Bleeding
y Using a constrictive bandage

3. Internal Bleeding y - lay the casualty down y - raise the legs or bend the knees y - loosen tight clothing y - seek medical aid urgently y - give nothing by mouth

y y y y y y y y y y y y y y y y

MEDICAL MANAGEMENT Restoration of blood loss Blood transfusion,albumin 4.5%, SAG-M blood, saline, haemacel, dextran, plasma infusion may be used. (I unit of blood should raise 1 gm % hemoglobin ) Oxygen support , intubation, ventilator and critical care should be given Foot end of the patient should be elevated. Apply pressure and packing Wound exploration and proceeding ie, ligation of the small vessel, suturing the wound part vessel suturing, excision of the tissues. Absolute rest ,analgesics morphine 10-20 mg IM/IV to relieve pain,sedation. Laporatomy for liver or spleen or mesentery or bowel injuries, suturing . splenectomy Topical applications for local ooze :-oxycel, gauze soacked with adrenaline,bone wax for oozing from bone and other local agents (collagen,thrombin) In venous haemorrhage ,elevation, ligation of veins ,or in case of large vein suturing of venous wall, pressure bandaging, packing will be helpful. Tourniquet are often used in operation theatre for control of heamorrhage in limbs. But it is not advisable as a first aid measure. Total parenteral nutrition ,central venous pressure monitoring,electrolyte management are all equally important. Steroid injection ,antibiotics ,ventilator support are often required.

y LOCAL HEMOSTATIC AGENTS y Gelatin sponge y Oxidised cellulose y Collagen sponge y Microfibrillar collagen y Topical thrombin y Bonewax y Gelatin matrices y Topical cryoprecipitate

NURSING MANAGEMENT OF PATIENTS WITH HAEMORRHAGE.

y Cardiac output decreased related to inadequate

circulatory blood volume. y Breathing pattern, ineffective related to decreased pulmonary blood flow and Hypoxia. Gas exchange impaired related to hypoxia secondary to altered blood flow.
y Tissue perfusion inflective related to decreased

circulating blood volume. y Fluid volume deficit related to blood loss.