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BLEEDING (HEMORRHAGE)

Blood is meant to be circulated by the heart through blood vessels to supply the body’s organs with oxygen and nutrients (circulatory system). These blood vessels include arteries, veins, and capillaries. When the integrity of the blood vessel wall is damaged, there is a clotting mechanism in place to repair the damage and minimize the amount of blood that leaves the injured blood vessel.

Bleeding, also known as hemorrhage, is blood escaping from the circulatory system. It is caused either by traumatic injury, underlying medical condition, or a combination.

Bleeding may occur inside the body (internal bleeding) or outside the body (external bleeding).

Internal bleeding may occur when blood leaks from blood vessels or organs. External bleeding may occur when blood flows through a natural opening (such as the vagina, mouth, or rectum); or when blood moves through a break in the skin.

Symptoms include blood coming from an open wound and bruising. Bleeding can also cause shock, which may include any of the following symptoms:

  • Confusion or decreasing alertness
  • Clammy skin
  • Dizziness or light-headedness after an injury
  • Low blood pressure
  • Paleness (pallor)
  • Rapid pulse
  • Increased heart rate
  • Shortness of breath
  • Weakness

Symptoms of internal bleeding may include:

  • Abdominal pain and swelling
  • Chest pain
  • Skin color changes that occur several days after an injury (skin color may be black, blue, purple, yellowish green)

Blood coming from a natural opening in the body may also be a sign of internal bleeding. These symptoms include:

  • Blood in the stool (appears black, maroon, or bright red)
  • Blood in the urine (appears red, pink, or tea-colored)
  • Blood in the vomit (looks bright red, or brown like coffee-grounds)
  • Vaginal bleeding (heavier than usual or after menopause)

DIAGNOSIS

External bleeding is usually easy to recognize. A laceration of the skin bleeds, a person may cough or vomit blood, or a woman develops vaginal bleeding.

The diagnosis for internal bleeding begins with the health care practitioner taking a history and performing a physical examination on the patient. The situation and the source of the bleeding will focus the testing strategy on the part of the body that may be involved with the bleeding. Sometimes the direction of diagnosis is self evident; a motor vehicle crash victim who complains of abdominal pain will have attention directed to the abdomen. Sometimes it is less evident. A confused patient may have issues with bleeding in the brain, or may be so anemic (decreased red blood cell count) from blood loss elsewhere, that the brain is not getting enough oxygen and nutrients to function properly.

Blood tests may include:

  1. A complete blood count (CBC) or hemogram to assess for anemia and an abnormal platelet count.
  2. INR (international normalized ratio) and PTT (partial thromboplastin time) are blood clotting studies that may be measured to screen for abnormal coagulation.
  3. Depending upon the situation, the hospital blood banking system may be alerted to begin the process of crossmatching blood products for potential transfusion.

Diagnostic imaging tests such as X-rays, Doppler ultrasound, and CT scan may be used depending upon the suspected underlying medical problem associated with the internal bleeding.

Computerized tomography (CT scan) is the primary tool used in emergency situations to access for bleeding or swelling in the brain. In a small fraction of patients who have bleeding from a ruptured cerebral aneurysm (a blood vessel that leaks in the brain), the CT will initially be normal and a lumbar puncture may be performed to help make the diagnosis.

CT scan is also one of the tests that can be performed to access for bleeding within the abdomen and chest. It is especially helpful in trauma to look for bleeding from the solid organs of the abdomen like the liver, spleen, and kidney. It is ideal for evaluating the retroperitoneal space for bleeding and can also evaluate fractures of the pelvis and spine.

In cases of potential bleeding from a major blood vessel, CT angiography may be considered to look for a specific blood vessel that is bleeding.

Ultrasound may be used to look for sources of bleeding, most often where there is an obstetric or gynecologic source of bleeding.

Endoscopy, colonoscopy, and anoscopy are used to look for sources of bleeding in the gastrointestinal tract. Using a flexible scope with an attached camera, a gastroenterologist may look into the stomach and intestine, rectum, and colon to find the source of bleeding. Using the same instrument, cautery (electricity used to coagulate or cauterize a blood vessel) may stop the bleeding if the source is found.

 

TREATMENT

First aid is appropriate for external bleeding. If bleeding is severe, or if you think there is internal bleeding, or the person is in shock, get emergency help.

  • Calm and reassure the person. The sight of blood can be very frightening.
  • If the wound affects just the top layers of skin (superficial), wash it with soap and warm water and pat dry. Bleeding from superficial wounds or scrapes is often described as “oozing,” because it is slow.
  • Lay the person down. This reduces the chances of fainting by increasing blood flow to the brain. When possible, raise up the part of the body that is bleeding.
  • Remove any loose debris or dirt that you can see from a wound.
  • Do NOT remove an object such as a knife, stick, or arrow that is stuck in the body. Doing so may cause more damage and bleeding. Place pads and bandages around the object and tape the object in place.
  • Put pressure directly on an outer wound with a sterile bandage, clean cloth, or even a piece of clothing. If nothing else is available, use your hand. Direct pressure is best for external bleeding, except for an eye injury.
  • Maintain pressure until the bleeding stops. When it has stopped, tightly wrap the wound dressing with adhesive tape or a piece of clean clothing. Place a cold pack over the dressing. Do not peek to see if the bleeding has stopped.
  • If bleeding continues and seeps through the material being held on the wound, do not remove it. Simply place another cloth over the first one. Be sure to seek medical attention.
  • If the bleeding is severe, get medical help and take steps to prevent shock. Keep the injured body part completely still. Lay the person flat, raise the feet about 12 inches (30 centimeters), and cover the person with a coat or blanket. DO NOT move the person if there has been a head, neck, back, or leg injury, as doing so may make the injury worse. Get medical help as soon as possible.

Initial treatment of internal bleeding will include stabilizing the patient, meaning that the ABCs of resuscitation take priority for the care provider.

A: Airway. Patients with altered or decreased mental status may not be awake enough to breathe on their own.

B: Breathing. Even if the airway is open, the lungs may not adequately be functioning and the patient may need help with their breathing so oxygen can be transferred from the lungs to the bloodstream.

C: Circulation. The body requires blood to circulate to all its cells to provide oxygen and nutrients and to remove waste products. Treatment is aimed to maintain blood pressure and circulation. Often intravenous fluids only are required. Sometimes blood transfusion is needed. A few patients will require immediate transfusions with universal donor blood (type “O negative” blood).

Specific treatment for internal bleeding depends upon the source of the bleeding. The common goal for treatment is to find the source of bleeding and stop it. At the same time, treatment will be directed to repair or stabilize any damage that the bleeding caused.

Once the acute situation has resolved, treatment will be aimed at correcting the underlying cause of the bleeding and to prevention of future episodes.

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