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HAEMORRHAGE AND ARREST OF

HAEMORRHAGE

Prof Moe Moe Tin


Professor &Head
Department of Surgery
UM2
MB.BS, M Med Sc Surgery,FRCSEd,Dr. Med Sc Surgery,
Dip in Med Ed, Fellowship in Colorectal Surgery

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What is haemorrhage ?
• The escape of blood from the vessels of living
tissue

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Types of Haemorrhage
DEPENDS ON ORIGIN
1. Arterial haemorrhage
2. Venous haemorrhage
3. Capillary haemorrhage

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1. Arterial haemorrhage
• bright red
• spurting jet
• which rises and falls in time with the pulse

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2. Venous haemorrhage
• coming from vein
• dark red
• flows steadily without spurts

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3. Capillary haemorrhage
• bright red
• quite a rapid ooze
• if continue for several hours , blood loss
become serious

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DEPENDS ON TIMING

1. Primary haemorrhage
2. Reactionary haemorrhage
3. Secondary haemorrhage

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1. Primary haemorrhage
• which takes place at the time of injury or
operation

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2. Reactionary haemorrhage
• occurs within 24 hours
due to
- slipping of a ligature
- dislodgement of a clot
- may occur due to arterial spasm at the time of
injury but later the spasm passed off with
resulting haemorrhage

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• rise in BP
• refilling of venous system on recovery from
shock
• Coughing, vomiting ,straining , restlessness

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3. Secondary haemorrhage
• one or two weeks after injury or operation
• due to
- infection and sloughing of part of the wall of an
artery
- pressure of drainage tube
- the presence of a fragment of bone
- ligature in an infected area and cancer

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DEPENDS ON VISIBILITY

1. Internal haemorrhage or concealed


haemorrhage
2. external haemorrhage or revealed
haemorrhage

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Internal or concealed haemorrhage
• invisible
• eg. rupture of spleen , ruptured ectopic
pregnancy , fracture femur

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External or revealed haemorrhage
• visible
• eg . femoral artery cut off

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Initially concealed but later revealed

• Eg . Haematuria, haematemesis and melaena

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DEPEND ON CHRONICITY

Acute – sudden , severe after trauma or surgery


Chronic
– long period , such as haemorrhoids , bleeding
Peptic ulcer
- present with chronic anaemia with
hyperdynamic cardiac failure
- in a state of chronic hypoxia

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• Acute on chronic haemorrhage
• more dangerous as the bleeding occurs in
individuals who are already hypoxic which
may get worsened faster

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DEPEND ON POSSIBLE INTERVENTION

1. surgical haemorrhage
2. non surgical haemorrhage

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Surgical haemorrhage
• Due to direct injury
• Corrected by surgical intervention

Non surgical haemorrhage


• General ooze from raw surfaces
• due to coagulopathy and DIC
• cannot be stopped by surgical means
• requires correction of coagulation
abnormalities
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• PATHOPHYSIOLOGY OF HAEMORRHAGE
BLEEDING

hypovolaemia

low cardiac output

Tachycardia and shunting of blood from splanchnic vessels by


vasoconstriction
So , maintain perfusion of vital organs like brain , heart , lungs ,
kidneys

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hypoxia

activation of cardiac depressants

Anaerobic metabolism and altered cell membrane function


causing influx of more sodium and calcium inside the cell and
potassium comes out of the cells

Hyponatraemic . Hyperkalaemic , hypocalcaemic metabolic


acidosis

Lysosomes of cell get lysed releasing powerful


enzymes which is lethal to cell itself

SICK CELL SYNDROME


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Platelets amd coagulants are activated leading to
formation of small clots DIC and further bleeding
• Progressive haemodilution and leading to total
circulatory failure Initially compensatory
hypovolaemic shock and

• Later decompensatory hypovolaemic shock


• Lead to MODS and death
• Major factors worsening the haemorrhage - DIC ,
acidosis and hypothermia

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• Initially compensatory hypovolaemic shock
and
• Later decompensatory hypovolaemic shock
• Lead to MODS and death
• Major factors worsening the haemorrhage -
DIC , acidosis and hypothermia

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CLINICAL FEATURES PF HAEMORRHAGE

• Paller , thirsty , cynosis


• Tachycardia , tachypnoea
• Air hunger
• Cold clummy skin due to vasoconstriction
• Dry face , dry mouth and goose skin appearance
due to contraction of arrector pilorum
• Rapid thready pulse , hypotension
• Oliguria
• Features related to specific causes

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Signs of significant blood loss

• PR >100/minute
• SBP <100 mmhg
• Diastolic BP drop on sitting or standing >10
mmHg
• Pallor / sweating
• Shock index ( ie ratio of PR to BP )> 1 (cardiac
index )

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Circulation blood volume
• Infants – 80-85ml/ kg
• Adults – 65-75ml/kg

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Estimation of the amount of blood loss
• Blood clot – size of closed fist is about 500 ml
• Swelling in closed fracture
– 500- 1500 ml in tibia fracuture
_ 2 litres in fracture femur
• Swab weighing – 1gm = 1ml but multiply by 1.5 or 2 in
mastectomy, gastrectomy or APR
• Measurement of haemoglobin level , haematocrit, CVP
, PCWP ,cardiac output and urine output
• Blood volume estimation using radioiodine technique
or microhaematocrit method

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EFFECTS OF HAEMORRHAGE

• Acute renal shut down


• Liver cell dysfunction
• Cardiac depression
• Hypoxic effects
• Metabolic acidosis
• GIT mucosa ischaemia
• Sepsis
• Interstitial oedema , AV shunting in lung – ARDS
• Hyvolaemic shock – MODS

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HAEMORRHAGE CLASSIFICATION
ATLS 9TH EDITION

I II III IV
Blood loss ml Up to 750 750-1500 1500-2000 >2000
Blood loss % Upto 15 15-30 30-40 >40
PR <100 100-120 120-140 >140
BP N N Decreased Decreased
Pulse pressure N/ increased Decreased Decreased Decreased
RR 14-20 20-30 30-40 >40
Urine output( >30 20-30 5-15 Negligible
ml/hr)
Mental status Slightly anxious Mildly anxious Anxious , Confused and
confused lethargic
Initial fluid Crystalloid Crystalloid Crystalloid and Crystalloid and
replacement blood blood

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TREATMENT
• Restoration of blood loss – blood , albumin
4.5% , SAG-M blood , saline , haemaccel (
gelatin ) , dextran, plasma infusion
• 1 unit of blood = I gm of Hb
• Catheterization
• Foot end raise
• Monitoring
• Oxygen support
• Pressure , packing , bandaging , tourniquet
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• Wound exploration and proceeding ie ligation of
small vessels , excision of tissue
• Absolute rest
• Analgesic , sedation
• Intercostal drain for haemothorax
• Laparotomy
• Topical application for local ooze – oxycel , gauze
soaked with adrenaline
• TPN, CVP monitoring , electrolyte management
• Steroid injection , antibiotic , ventilator support

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Arrest of bleeding or hemostasis
• Pressure and packing
• - eg gauze pack, balloon tamponade
• Position and rest
• - elevation of the limbs
• Tourniquet
• - used in OT for control of haemorrhage in
limbs

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Operation techniques
• artery forceps and clips , ligated with sutures ,
coagulate with diathermy, laser , ultrasonic
energy , microwave energy
• part or whole of a bleeding viscus excised –
eg splenectomy or hepatectomy
• Endoscopic control
• Therapeutic embolization

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Local haemostatic agents
• Gelatin sponge ( gel foam)
• oxidised cellulose ( Surgicel )
• Gauze soaked with adrenaline
• bone wax for oozing from bone
• Collagen sponge
• Microfibrillar collagen powder
• Topical thrombin
• Topical cryoprecipitate , topical EACA ( Epsilon
amino caproic acid )

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Gelatin sponge

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Oxidized cellulose

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Bone wax

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Thank you

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