HEMORRHAGE AND

HEMOSTASIS
HEMORRHAGE AND BLEEDING
 The escape of blood from the vessels

 According to the vessel involved in bleeding

 Capillary hemorrhage
 Arterial hemorrhage
 Venous hemorrhage
 According to the ammount
 Small < 500 ml
 Medium 500 – 1500
 Large > 1500 ml
 Internal
 External
 Internal exteriorized
 HEMORRHAGIC LESIONS

 Petechial lesion
 Ecchymosis
 Hematoma
 Internal bleeding
 External bleeding
 PETECHIAL LESIONS,
PURPURIC LESIONS SMALLER
THAN 3 MM.
PLANTAR MIDFOOT
ECCHYMOSIS
TMT JOINT TRAUMA LESIONS
 BLACK EYE,
PERIORBITAL ECCHYMOSIS,
EXTRAVASATION OF RBC INTO
THE SURROUNDING TISSUE,
PATCHES GREATER THAN 3MM
HAMSTRING BRUISING
ANKLE SPRAIN
CHRONIC VENOUS ULCER
 EXTERNAL BLEEDING
 Epistaxis
 Hemoptysis
 Hematemesis
 Melena
 Hematochezia
 Hematuria
 POSTTRAUMA HEMORRHAGE

 HEAD INJURY

 NECK INJURY
 HEAD INJURY
 INTRACRANIAL BLEEDING
 EXTRADURAL BLEEDING
 SUBDURAL BLEEDING
 INTRACEREBRAL BLEEDING
 SKULL FRACTURES
 SCALP ECCHYMOSIS
 PERIORBITAL HEMATOMA
 SUBCONJUNCTIVAL HEMORRHAGE
 MASTOID BRUISING
 PHARYNGEAL BRUISING
EXTRADURAL HEMATOMA
 SUBDURAL HEMATOMA
1/3 OF PTS. HAVE A LUCID PERIOD,
MAJORITY ARE DROWSY,
UNILATERAL HEADACHE,
BRAIN DAMAGE MORE SEVERE,
PROGNOSIS WORSE - EDH
INTRACRANIAL HEMATOMA
INTRACRANIAL HEMATOMA
 GCS
 Less than or equal to 8 at 6 h.- 50% die
 Severe head injury 3 – 8

 Moderat head injury 8-13

 Mild head injury 14-15

False- hypothermia, intoxication, sedation
Impossible to evaluate- dysphasic, intubated pts.
and with facial or spinal cord injury
 NECK INJURY

 BLUNT NECK INJURY

 NECK WOUNDS
 Mr. Ty Royd

 26 y.o. man from Shawinigan minding his

own business when he is stabbed with a
paring knife in the anterior neck, lateral to his
thyroid gland. He is bleeding some but
appears stable.
What do you do?

A) Careful intubation
B) Go directly to the OR
C) Take a fiber optic look for airway injury
D) CT neck
E) Angiography with possible embolisation
F) Cross your fingers and pull the knife
 CHEST INJURY

 HEMOTHORAX

 HEMOPERICARDIUM

 CARDIAC INJURY
 ABDOMINAL INJURY

 BLUNT ABDOMINAL TRAUMA

 PENETRATING ABDOMINAL WOUNDS

 G-I BLEEDING
 UPPER G-I BLEEDING

 LOWER G-I BLEEDING

ARTERIAL BLEEDING
GASTRIC LYMPHOMA
BLEEDING DU
BLEEDING D.U.
BLEEDING COLON CANCER
BLEEDING HEMORRHOIDS
 PHYSICAL EXAMINATION
HEMORRHAGIC PATIENT

 Mental state
 Color, temperature, moisture of the skin
 BP and PR
 RR
 Complete exam. to head to toes
 HEMORRHAGIC SHOCK

 Shock= an acute change in c-v function of

sufficient magnitude to compromise tissue
perfusion

 Hemorrhagic shock = hypovolemic shock,

produced by a sudden loss of blood
 30% of blood volume is lost
 HEMORRHAGIC SHOCK

 BP< 90 mm.Hg.
 Tachycardia with weak, thready pulse,
 Polypnea
 Cold, clammy, pale skin
 Urinary output< 30 ml/h or none
 SHOCK INDEX
 SHOCK INDEX = PR/SBP
 NORMAL= 70/140= 0,5

 1= POTENTIAL SHOCK, 20% LOSS

 1,5 = OVERT SHOCK, 30% LOSS
 2= SEVERE SHOCK, 50% BLOOD LOSS
 2,5= LETHAL BLEEDING, >50% LOSS
 ACUTE ANEMIA

 10-20% OF BLOOD VOLUME LOSS

 TACHYCARDIA
 WEAK PULSE
 POSTURAL HYPOTENSION
 Cause of bleeding

 Cirrhosis- rupture of esophageal varices

 Nasopharyngeal lesion- swallowed blood
 Peptic ulcer- NG aspiration
 Colorectal tumor- PR exam.
 LAB.TESTS
 Blood group
 RBC
 Hb, Ht
 Platelets
 Prothrombine time
 OTHER CAUSES OF BLEEDING

 PLATELET DISORDERS

 DISORDERS OF BLOOD COAGULATION

 PLATELET DISORDERS
 THROMBOCYTOPENIA
 REDUCED PRODUCTION
 ABNORMAL DISTRIBUTION
 INCREASED DESTRUCTION

 ABNORMAL PLATELET DESTRUCTION

 UREMIA
 DRUGS
 COAGULOPATHY
 CONGENITAL DISORDERS
 HEMOPHILIA A
 HEMOPHILIA B
 ACQUIRED DISORDERS
 D.I.C.
 VIT. K. DEFICIENCY
 LIVER DISEASE
 ANTICOAGULANTS
 LAB TESTS
 PLATELET COUNT
 BLEEDING TIME
 CLOTTING FACTORS
 PT
 PTT
 TT
 FIBRIN SPIT PRODUCTS
 PRINCIPLES OF HEMOSTASIS
 Clipping and ligation
 Diathermy
 Monopolar
 Bipolar
 Cutting
 Tourniquet
 Pressure
 SURGICAL HEMOSTASIS
ELECTRO-COAGULATION AND
SUTURING
TRANSFUSION OF BLOOD
& BLOOD PRODUCTS
 FRESH BLOOD COMPONENTS
 WHOLE BLOOD
 RED BLOOD CELL IN ADDITIVE
SOLUTION
 PLATELETS
 FRESH FROZEN PLASMA (FFP)
 CRYOPRECIPITATE
 PLASMA FRACTION
 HUMAN ALBUMIN
 PROTHROMBIN COMPLEX
CONCENTRATES
 IMMUNOGLOBULIN PREPARATION
(90% Ig G)
 RED CELL SEROLOGY
 ABO ANTIGENS
 RHESUS ANTIGENS (Rh)
 OTHER RED CELL ANTIGENS
 Kell antigens
 Duffy antigens
 Kidd antigens
 PRETRANFUSION TESTING
 TYPE AND SCREEN
 CROSS- MATCHING
 EMERGENCY REQUIREMENTS FOR
BLOOD
 ORDERING BLOOD IN AN
EMERGENCY
 Immediately take samples for cross-matching
 Inform the blood bank of the emergency,the volume of
blood required,and where blood is to be delivered
 One individual should take responsibility for all
communications with the blood bank, and should
ensure that it is clear who will be responsible for the
blood delivery
 In cases of exsanguinations use emergency group O
Rh(D)-negative blood.
 Do not ask for cross-matched blood in an emergency
 BLOOD ADMINISTRATION
 Before administrating blood 2 staff members (one of
whom must be a doctor or trained staff nurse) must
check
 the patient’s full identity
 the blood pack, compatibility label and report form
 the blood pack for signs of haemolysis or leakage from the
pack.
 Any discrepancies means that the blood must not be
transfused and that the laboratory must be informed
 TRANSFUSION ERRORS
 Almost all deaths from transfusion reaction are due to
ABO incompatibility
 Errors in patient identification at the time of blood
sampling or administration are the major cause
 When taking the initial blood sample
 check the patient’s identity verbally and on the wrist
identification band
 label the sample fully before leaving the bedside
 make sure that the blood request form is clearly and
accurately completed.
 ADVERSE EFFECTS OF
TRANSFUSION
 ACUTE HAEMOLYTIC REACTIONS
 DELAYED HAEMOLYTIC REACTIONS
 FEBRILE NON-HAEMOLYTIC REACTION
 ALLOIMMUNIZATION
 ALLERGIC REACTIONS
 CARDIAC FAILURE
 GRAFT-VERSUS-HOST REACTION
 TRANSFUSION- ASSOCIATED LUNG INJURY
 IMMUNE MODULATION
 TRANSFUSION-TRANSMITTED INFECTIONS
 BACTERIAL INFECTIONS
 AUTOLOGOUS TRANSFUSION
 PREOPERATIVE DONATION
 ISOVOLAEMIC HAEMODILUTION
 CELL SALVAGE
 TRANSFUSION REQUIREMENTS IN
SPECIAL SURGICAL SETTINGS
 MASSIVE TRANSFUSION
 THROMBOCYTOPENIA
 COAGULATION FACTOR DEFICIENCY
 HYPOCALACAEMIA
 HYPERKALEMIA & HYPOKALAMIA
 HYPOTHERMIA
 ADULT RESPIARATORY DISTRESS
SYNDROME (ARDS)
 MASSIVE BLOOD TRANSFUSION
 This is defined as the transfusion of the equivalent of the
circulating blood volume within a 24hour period (in practice 10-
20 units in an adult)
 Common identifications for massive blood transfusion are major
trauma, gastrointestinal bleeding and obstetrics complications.
 Major problems associated with massive blood transfusion
include
 underlying coagulopathy

 thrombocytopenia

 lack of coagulation factor 5 & 8

 hyperkalaemia

 hypothermia
 METHODS TO REDUCE THE NEED
FOR BLOOD TRANSFUSION
 ACUTE VOLUME REPLACEMENT
 HYDROXYETHYL STARCH (HES)
 DEXTRAN 70
 DEXTRAN40
 UREA-BRIDGED GELATIN (HAEMACCEL
 MECHANISM FOR REDUCED
BLOOD USE IN SURGERY
 PREOPERATIVE
 * Surgery elective – Correct the Haemoglobin level.
 Stop drugs that interfere Haemostasis
 INTRAOPERATIVE
 Posture

 Use of Vasoconstrictors

 Use of tourniquets

 Use of anti-fibrinolytic drugs eg Aprotinin

 Using Fibrin Sealant

 POST OPERATIVELY
 Blood can be salvaged from drains into collection devices that permit
reinfusion
 Decision to transfuse post operatively should depend

* Age of the patient

* Ability to tolerate lower levels of anaemia
* Rate & amount of continuing blood loss