Hemorrhage

Consequences of a hemorrhage

A bleeding is known as important when it can soak paper or fabric a handkerchief in a few seconds. The risk is a short-term death: blood is used to transport the Dioxygène necessary to the operation of the bodies like the heart and the brain for example.

According to the quantity of lost blood and the localization of the bleeding, a hemorrhage involves:

a loss of red globules being able to involve a Anémie (reduction in the concentration in Hémoglobine in the Sang, visualized on the Numération Formulates Blood. This weakens goes, according to its degree, to involve a reduction in the oxygenation of fabrics.
a fall of the blood Pressure being able to go until the Collapse with reduction in the perfusion of vital bodies.
If the bleeding is not exteriorized (nonvisible), this one can constitute a pocket under pressure and compress adjacent fabrics or bodies, sometimes vital ( hemorrhage will intra cerebral in the Cerveau for example)

In the event of traumatic hemorrhage of origin (wound), one should not forget the risk infectious . In the case of the small hemorrhages stopping spontaneously, it is necessary to carry out a cleaning or a disinfection of the wound, to see the article Bobologie. In the case of an important hemorrhage, this aspect is secondary in front of the heavy bleeding and is dealt with by the medical team; it can include/understand a antibiothérapie.

Various types of hemorrhage

One distinguishes:

the external hemorrhages : blood runs out by a wound, an effraction of the skin, in general of traumatic origin; a hemorrhage can be hidden by clothing;
the exteriorized hemorrhages : the “escape of blood” is inside the body, but blood runs out by the natural openings:

épistaxis : nosebleed;
Otorragie : bleeding of ear;
Hématémèse : vomiting of blood;
Rectorragie : red blood by the anus, different from the méléna
Méléna (also spelled mœlena ): blood digested in the saddles, appears by a diarrhea noirâtre, nauseous;
Hématurie : blood in the Urine S;
Hémoptysie : presence of blood in the expectorations (lungs);
Métrorragie S: abnormal bleeding originating in the Uterus, exteriorized by the Vagina at the woman (to be distinguished from the Menstruation S or “rules”, phenomenon cyclic and natural of bleeding at the woman in age to procreate). The métrorragies are bleedings apart from the rules whereas the Ménorragie S are particularly prolonged rules or abundant.

internal bleedings : blood runs out inside the body; it can then form a Hématome when blood accumulates in a fabric or a body (muscle, for example). Blood also can épancher in an internal cavity without externalization: Hémopéritoine in the belly, Hémothorax in the lungs or the pleural cavity, Hémopéricarde around the heart. A Ecchymose (or “blue”) is a diffuse infiltration of blood in subcutaneous, secondary fabric with a tiny Traumatisme (but also sometimes revealing of a disease of the vessels).

Leading causes

Traumatic

The wounds with a cutting object, perforating or by weapon cause an external hemorrhage in general.

The hemorrhages can also be caused by a blow, a shock, a fall, or can result from the wrenching of a body by brutal Décélération at the time of a Road accident; they are in general internal bleedings or exteriorized.

Nontraumatic

cardiovascular Causes: arterial Hypertension, rupture of Aneurism, Tumor or broken vascular malformation, aortic Dissection,
digestive Causes: Ulcer digging having reached a large vessel (in particular after the catch of aspirine or anti-inflammatory drugs not stéroïdiens), Disease of Crohn, Hémorroïde S, hemorrhagic colic, Hernia hiatale,
gynaecological Causes: Endométriose, Contraception by Coil, Fibrome S, abundant menorrhagia
Turbid of coagulation primary (i.e. of birth): hemophilia has or B, Maladie of Willebrand, deficit in factor XIII, hypofibrinogenemy, thrombopathy.
Turbid of coagulation secondary (i.e. acquired during the life): hepatic insufficiency, deficit in Vitamin K, coagulopathy of consumption, circulating anticoagulant (within the framework of the Lupus in particular).
tumoral Causes: Cancer of Colon, cancer of the Bladder (hématurie), cancer of the Uterus, cancer of the cervix, cancer of the Stomach (hématémèse), cancer of the Lung (hemoptysy), etc
iatrogenic Causes: Catch of Anticoagulant S (without monitoring of INR), Aspirine, anti-inflammatory drugs not stéroïdiens,
various Causes: .

Treatment of the hemorrhages

A hemorrhage can be tiny and not to need any medical assumption of responsibility. On the contrary, when the bleeding is abundant (if it can soak fabric or paper a handkerchief in a few seconds), the heavy bleeding is in itself dangerous: blood brings the Oxygène to the Organe S, if there is no more blood to feed the bodies (Ischémie), those die, involving the death. If an abundant hemorrhage is not stopped, it will induce a cardiovascular collapse, which irremediably will evolve to the death of the person in the absence of effective cure.

Action to be taken before the arrival of the medical helps

Not very abundant bleedings

A tiny hemorrhage can be characterized by the stop of the bleeding, either spontaneous, or after a short compression, at a patient going well. If it is of traumatic origin, its treatment concerns the Bobologie: cleaning and disinfection (to think of the prevention of the Tetanus at a not vaccinated person). If it is spontaneous, it requires in all the cases a fast but nonurgent medical opinion ; a Rectorragie, for example, is generally consequence of Hémorroïde S without gravity, but can reveal a more serious disease sometimes.

An average “hemorrhage” is a not very abundant bleeding which does not yield, or with difficulty with compression, but the general tolerance remains good: compression is effective, the victim feels well but the bleeding begins again as soon as it is slackened. The victim must then move, if possible, for an urgent doctor visit all while maintaining compression (possibly relayed by a plug maintained in place by a broad bond, or a Compression bandage).

It should be noted that an even benign hemorrhage, can result in a faintness, with sometimes a loss of consciousness, at certain sensitive people. Pulse is in this case slow (contrary to what occurs at the time of a Collapsus), witness of a Malaise vagal, in rule benign.

Abundant bleedings

A serious hemorrhage comprises signs of bad tolerance being able to make fear a cardiovascular collapse: feeling of faintness, sweats, paleness… A call to SAMU is then essential.

In the case of an abundant external hemorrhage, the principle of the treatment rests on:

the protection, to neutralize the cause of the traumatism in particular (for example to move away from the dangerous object);
to support on the part which bleeds to stop the bleeding, or if that is not possible and in the case of a member, to compress the artery upstream (Point compression, Garrot); to maintain the remote support direct or compression to the relay by the helps;
to lengthen and reassure the victim;
to alert medicalized helps (“112” in the European Union, “15” in France); if the witness is alone and must should prevent the helps, it must relay its support by a plug relay (Compression bandage) or a garrot (attention, a garrot too tightened or left too a long time can involve the loss of the member for lack of blood).

In all the cases, to leave the victim to jeun.

See Stop of a hemorrhage.

Hospital extra medical assumption of responsibility

The first goal is to stop the bleeding; the techniques are similar to the techniques of first aid (Compression bandage to be preferred with the garrot, this last having to be made only in the event of failure of direct compression). The second goal is to ensure an oxygenation of the bodies. If the state of the patient is satisfactory (the hemorrhage is stopped, the heavy bleeding is weak, one does not note a sign of aggravation), the assumption of responsibility does not require any particular medicalisation.

If one notes a cardiovascular Collapsus, the first measurement is to set up a Oxygénothérapie.

Then, it is necessary to maintain a blood Pressure stable until the arrival of the hospital. The objective is to reach a minimal blood pressure allowing a transport without danger. For that, an initially venous way (perfusion) is posed, preferably on a large vein. A liquid of filling, container of the ions and macromolecules (preventing the direct passage of the water of the aqueous solution towards fabrics by maintaining a osmotic Pressure correct) is perfusé in a more or less fast way, according to the blood pressure.

Ideally, the doctor benefits from the venous way to take some tubes of blood for analysis: Hémogramme and seeks Blood group particularly for possible a transfusion.

It can be also made use of Vasopresseur S and shock-proof pants; this makes it possible to reduce the time before transport, and thus before the hospital assumption of responsibility. This factor time is critical for the situations requiring of the surgery in urgency (concept of Heure of gold), in particular in the cases of internal bleeding or Polytraumatisme S; in this case, the re-establishment of a blood pressure “correct” is sometimes illusory, and time lost on the spot reduced the chances of survival. It is thus necessary to find a compromise between blood pressure to avoid the death during transport, and time of medicalisation to preserve chances of survival.

Medical care

The therapeutic attitude varies according to the part of the body which bleeds, as well as the abundance of the bleeding:

If the bleeding were abundant with signs of bad tolerance, will have to be discussed a blood Transfusion after control the Blood group and agreement the victim, if it can be collected.

It is very important never not to forget to check the vaccine statute against the Tétanos in the event of wound related to a traumatism!

In all the cases, apart from this emergency assumption of responsibility, the hemorrhages caused by a subjacent disease must receive a specific treatment (after the control of the hemorrhage).

the principles of a surgical treatment of a hemorrhage are:

To ensure the hémostase , i.e. to stop the bleeding by suturing the responsible vessel.
To clean abundantly with the physiological salt solution if it is about a wound
Assurer, if need be, the decompression of adjacent fabrics: evacuation of the hématomes , poses drains .

Particular cases:

not very deep cutaneous Wound: cleaning of the wound to the physiological salt solution then ablation of possible foreign bodies, ablation of fabrics necrotic (dead fabrics), disinfection of the wound and finally joining of the wound.
severe cutaneous Wound: the attitude is the same one, with joining of the touched major plans: Muscle S, Aponévrose S, tendon S, etc an surgical operation is then often necessary.
Wound of the face: Idem, by taking care to practice a Joining without tension to obtain a scar as esthetic as possible.
Hémoptysie: injection of serum pro-coagulant during a bronchial Fibroscopie, or radiological embolisation (injection under radiological control in the artery responsible for particles which will stop the artery mechanically) in the event of failure. Surgical binding of the responsible artery as a last resort.
Rupture of Aneurism cerebral: Neurosurgical treatment with research of aneurism, insulation of its collet, and poses of a clip. Treatment of possible other aneurisms (they are sometimes multiple).
Epistaxis: méchage former (introduction of a fabric soaked with a hemostatic liquid by the nostril), méchage posterior (introduction of this same fabric, but this time in the back gorges in addition to the nostril) in the event of épistaxis very abundant, surgical arterial binding as a last resort.
Hemorrhage of the delivery: uterine revision (manual evacuation of the remainders of Placenta remained in the uterus), joining of vagino-cervical wounds, embolisation of the uterine artery, hysterectomy (ablation of the uterus) as a last resort in the event of unverifiable cataclysmic hemorrhage.
Rupture of varixes œsophagiennes: digestive fibroscopy for visualization, then poses rubber bands, or injection of serum coagulant. Regulation in the second time of a drug bétabloquant for the prevention of the repetitions, and seeks of a Cirrhose.

Drugs against the bleedings

A certain number of molecules were used in the event of hemorrhage in order to limit the importance of it. They are primarily anti-fibrinolytic agents. The principal representatives are the Aprotinine, the caproic Acide amino- and the tranexamic Acide. They are of a utility shown with a less requirement in blood transfusion. They are often used in surgery to this end. The aprotinine causes sometimes a serious Impaired renal function.

The recombining factor VII activated (produced by genetic engineering) stimulates coagulation and also seems promising in the control of the serious bleedings

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