Bleeding is generally a bad thing with a few exceptions where doctors remove blood to treat several diseases such as polycythaemia, haemochromatosis, in the emergency treatment of pulmonary oedema and to relieve venous congestion in plastic surgery grafts.
Bleeding is usually apparent and blood hard to miss. However, in the ill patient who is tachycardic and hypotensive then blood loss must be actively looked for. This includes a full examination and checking of orifices - mouth, ears, rectal examination and looking for blood-stained undergarments.
More difficult is the patient who bleeds internally. It is quite easy to lose a litre or 2 of blood into the pelvis following trauma or retroperitoneally in haemorrhagic pancreatitis or a ruptured aneurysm. Have a low threshold for scanning and urgent senior advice.
Chronic loss of small amounts of blood, commonly in the gut, may not be apparent until anaemia of an iron-deficient type appears. This generally requires investigation to an appropriate extent. Faecal occult blood screening as an early detection for colon cancer is one of the screening programmes likely to be introduced in prosperous countries.
In certain forms of haemorrhage, the volume of blood loss is less of an issue compared to the site and pressure effect of the bleeding. Examples include:
- Central nervous system:
- Bleeding into the pericardium, e.g. from aortic dissection, causing cardiac tamponade.
- Post-thyroidectomy haematoma
- Aortic dissection
- Ventricular aneurysms
- Penetrating trauma
- Upper gastrointestinal bleeding
- Lower gastrointestinal bleeding
- Arterio-venous malformations.
- Hereditary haemorrhagic telangectasia
The patient usually presents with bleeding and shock. The basic treatment is
- ABC of resuscitation
- Stop the bleeding - usually by direct pressure to the bleeding point if possible
- Replace lost volume and blood products - Blood transfusion
- Replace clotting factors if these are depleted.
Bleeding and anaesthesia
- Blood transfusion and the anaesthetist: management of massive haemorrhage from the Association of Anaesthetists of Great Britain and Ireland
Spahn, D. R. et al. Management of bleeding following major trauma: a European guideline. Critical Care, published online February 13, 2007.