Bleeding

From Ganfyd

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 generally occurs due to a problem with the clotting system e.g., Haemophilia or more commonly due to physical damage to a blood vessel, the most common cause of which is probably trauma.

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.

A normal haemoglobin level does not mean a patient has not recently had a large bleed, it won't fall until dilution has occurred

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:
  • Subarachnoid haemorrhage
  • Subdural haemorrhage
  • Extradural haemorrhage
  • Epidural or Spinal haematoma
• Haemothorax
• Bleeding into the pericardium, e.g. from aortic dissection, causing cardiac tamponade.
• Post-thyroidectomy haematoma

Sites

(non-exhaustive list)

Nasopharynx

• Epistaxis

Respiratory

• From tumours, causing haemoptysis
• Haemothorax

Cardiac

• Aortic dissection
• Ventricular aneurysms
• Penetrating trauma

Gastrointestinal bleeding

• Upper gastrointestinal bleeding
• Pancreatitis
• Lower gastrointestinal bleeding
  • Meckel's diverticulum
  • Haemorrhoids

Gynaecology

• Menorrhagia
• Endometriosis
• Post-coital bleeding

Vascular Abnormalities

• Aneurysms
  • Berry aneurysm leading to SAH
  • Ruptured abdominal aortic aneurysm
  • Other aneurysms of large vessels, e.g. iliac, femoral, popliteal
• Arterio-venous malformations.
• Hereditary haemorrhagic telangectasia

Management

The patient usually presents with bleeding and shock. The basic treatment is

1. ABC of resuscitation
2. Stop the bleeding - usually by direct pressure to the bleeding point if possible
3. Replace lost volume and blood products - Blood transfusion
4. Replace clotting factors if these are depleted.

Bleeding and anaesthesia

See:

• Blood transfusion and the anaesthetist: management of massive haemorrhage from the Association of Anaesthetists of Great Britain and Ireland

European guideline

Spahn, D. R. et al. Management of bleeding following major trauma: a European guideline. Critical Care, published online February 13, 2007.