HAEMORRHAGE

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HAEMORRHAGE

• BY
• Dr
• HAYDER M. ABDULNABI
• DM, CABS

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TYPES OF BLEEDING

• DEPNDING ON THE SOURSE OF BLEEDING
• 1- ARTERIAL BRIGHT RED AND COMES IN JETS WITH
  THE PULSE OF THE PATIENT
• 2- VENOUS DARK RED BLOOD , STEADY AND COPIOUS
• 3- CAPILLARY BRIGHT RED RAPID OOZE ( ABRASIONS )

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• DEPENDING ON THE TIME OF OCCURANCE
• 1- PRIMARY BLEEDING OCCURS AT THE TIME OF
  INJURY OR OPERATION
• 2- REACTIONARY BLEEDING USUALLY OCCURS IN 4-6
  HOURS OR WITH IN THE 24 HOURS THAT FOLLOW THE
  PRIMARY BLEEDING, DUE TO EITHER SLIPPING OF
  LIGATURE , DISLOGEMENT OF A CLOT OR CESSATION OF
  THE REFLEX VASOSPASM.
• THE PRESIPITATING FACTOR ARE
• A- THE INCREASE IN THE BLOOD PRESSURE AFTER
  RECOVERY FROM SHOCK OR ANASTHESIA

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• B- RESTLESSNESS OF THE PATIENT
• C- COUGHING AND VOMITING THAT INCREASE THE VENOUS
  PRESSURE
• 3- SECONDARY BLEEDING OCCUR WITHIN 7-14 DAYS
  AFTER THE PRIMARY TRAUMA OR OPERATION AND THE
  CAUSE IS ALWAYS INFECTION WHICH LEADS TO
  SLOUGHIN OF AN ARTERY IN AN AREA BY PRESSURE OF A
  DRAIN TUBE OR A BONE FRAGMENT OR BY SLIPPING OF A
  LIGATURE IN AN INFECTED AREA OR MALIGNANT TISSUE

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• DEPENDING ON THE VISIBILITY
• A- EXTERNAL ( REVEALED ) BLEEDING
• B- INTERNAL ( CONCAELED ) BLEEDING LIKE
  INTRA-ABDOMINAL OR INTRACRANIAL BLEEDING
• THE INTERNAL BLEEDING MAY BECOME EXTENAL AS
  IN HEMATEMESIS DUE TO A BLEEDING PEPTC ULCER OR
  HEMATURIA AFTER RENAL INJURY OR AN INTRUTERINE
  BLEEDING TURNS INTO BLEEDING PER VAGINA

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HOW TO MEASURE ACUTE BLOOD LOSS ?

• A NORMAL BLOOD VOLUME IS 80-85 ML / KG IN INFANTS
  AND ABOUT 65-75 ML / KG IN ADULTS
• 1- BLOOD CLOT SIZE A CLENCHED FIST SIZE CLOT
  ROUGHLY EQUALS 500 ML
• 2 - SITE OF A CLOSED SWELLING -- A MODERATE
  SWELLING IN A TIBIA EQUALS TO 500- 1500 ML OF
  BLOOD, WHILE A MODERATE SWELLING IN A FEMUR
  EQUALS TO 500-2000 ML OF BLOOD LOSS
• 3- SWAB WEIGHING BY SUBSTRACTING THE WEIGHT OF
  SOACKED SWABS FROM THEIR WEIGHT WHEN THEY WERE
  DRY AND THE BLOOD LOSS IS 1 ML FOR EVERY 1 GM
  DIFFERENCE
• 4- HEMOGLOBIN LEVEL ESTIMATION THERE IS NO
  IMMEDIATE DECREASE IN Hg LEVEL AFTER BLEEDING BUT
  AFTER 8 HOURS IT WILL DROP BECAUSE OF THE INFLUX
  OF THE INTERSITIAL FLUID INTO THE VASCULAR
  COMPARTEMENT ( DILUTION )

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TREATMENT

• 1- PRESSURE ON THE SITE OF BLEEDING BY PACKING
  OR DIGITS OR BALOONS INFLATED AT THE SITE OF
  BLEEDING ( ESOPHAGEAL VARICES)
• 2- REST AND POSITION BY ELEVATION OF THE
  INJURED LIMB TO DECREASE BLOOD RETURN TO THE
  HEART
• 3- OPERATIVE PROCEDURES BY USING HEMOSTATS,
  CLIPS, DIATHERMY, LIGATURES, GELATIN SPONGES, AND
  ADRENALIN SOACKED GAUZE ( 1 1000 )
• 4- BLOOD TRANSFUTION

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INDICATION OF BLOOD TRANSFUSION

• 1- ANEMIA-- recent study showed that a
  transfusion threshold of 70 g/l was as safe and
  possibly superior to one of 100 g/l in critical
  care patients. A minimum preoperative haemoglobin
  of 100 g/l is no longer regarded as essential, as
  many patients with a lower haemoglobin tolerate
  surgery and seem to recover just as well.

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• 2- blood loss IF greater than 30 per cent of
  estimated blood volume,
• Patients with massive blood loss, defined as
  those requiring transfusion of a volume of blood
  greater than their blood volume within 24 h
• Depletion of coagulation factors is unusual,
  because stored blood contains adequate amounts of
  all except for factors V and VIII, which fall
  during storage.

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• 3- REPLACEMENT OF BLOOD COMPONENTS
• RED WHITE BLOOD CELLS, COAGULATION FACTORS,
  PLASMA
• Procedure for blood transfusion
• 1- Pretransfusion compatibility testing -- A.
  Blood grouping ,The ABO and RhD groups of the
  patient are determined.
• b Donor blood of the same ABO and RhD group as
  the patient is selected.
• D. Cross-matching-- The full cross-match
  involves testing the patient's plasma against a
  sample of the red cells from the donor unit in a
  direct agglutination test.

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• 2- Blood ordering A. Elective surgery--
  Sufficient time should be allowed for the
  laboratory to carry out pretransfusion testing.
• B.
  EmergeNCIES-- There may be insufficient time for
  full pretransfusion testing.use 2 units of O
  RhD-negative blood ('emergency stock') , to allow
  additional time for the laboratory to group the
  patient.

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• 3- Blood, blood components, and blood products--
  Blood collected from donors is processed into
• A- Blood components, such as red cell and
  platelet concentrates, fresh frozen plasma and
  cryoprecipitate, which are prepared from a single
  donation of blood by simple separation methods
  such as centrifugation, and transfused without
  further processing.
• B- Blood products, such as coagulation
  factor concentrates and albumin and
  immunoglobulin solutions, which are prepared by
  complex processes using the plasma from many
  donors as the starting material.

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Strategies for avoiding or reducing the use of
blood tranfusion

• By discontinuing antiplatelet and anticoagulant
  drugs, if possible, several days before surgery.
• Anaemia, if present, should be investigated and
  treated appropriately in advance of elective
  surgery.
• Intraoperative measures include the use of
  meticulous surgical and anaesthetic techniques, a
  cautious use of anticoagulants during surgery,
  and the use of drugs to enhance haemostasis AND
  THE USE OF AUTOLOGOUS TRANSFUSION.

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• Autologous transfusion
• There are three types of autologous transfusion
• 1- Predeposit. The patient donates 25 units of
  blood at approximately weekly intervals before
  elective surgery.
• 2- Preoperative haemodilution. One or two units
  of blood are removed from the patient immediately
  before surgery and retransfused to replace
  operative losses.
• 3- Blood salvage. Blood lost during or after
  surgery may be collected and retransfused.
  Several techniques of varying levels of
  sophistication are available. operative site must
  be free of bacteria, bowel contents, and tumour
  cells.

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Complications of blood transfusion

• 1-- Immediate haemolytic transfusion reactions
• This is the most serious complication of
  blood transfusion and is usually due to ABO
  incompatibility. There is complement activation
  by the antigen-antibody reaction, usually due to
  IgM antibodies, leading to rigors, lumbar pain,
  dyspnoea, hypotension, haemoglobinuria, and renal
  failure. At the first suspicion of any serious
  transfusion reaction, the transfusion should
  always be stopped and the donor units returned to
  the blood transfusion laboratory with a new blood
  sample from the patient to exclude a haemolytic
  transfusion reaction.

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• 2-- Delayed haemolytic transfusion reactions
• These may occur in patients alloimmunized by
  previous transfusions or pregnancies. The
  antibody titre is too low to be detected by
  pretransfusion compatibility testing, but a
  secondary immune response occurs after
  transfusion, resulting in destruction of the
  transfused cells, usually by IGg antibodies. The
  patient may develop anaemia and jaundice about a
  week after the transfusion, although many are
  clinically silent.

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• 3-- Non-haemolytic (febrile) transfusion
  reactions
• Febrile reactions are a common complication of
  blood transfusion in patients who have previously
  been transfused or pregnant. The usual cause is
  the presence of leucocyte antibodies in the
  recipient acting against transfused leucocytes,
  leading to release of pyrogens. Typical signs are
  flushing and tachycardia, fever (gt38C), chills,
  and rigors. Paracetamol may be used to reduce the
  fever.

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• 4--Urticaria And Anaphylaxis
• Urticarial Reactions Are Often Attributed To
  Plasma Protein Incompatibility But, In Most
  Cases, They Are Unexplained. They Are Common But
  Rarely Severe Stopping Or Slowing The
  Transfusion, And Intravenous Chlorpheniramine
  10 Mg (Adult Dose), Are Usually Sufficient
  Treatment.
• Anaphylactic Reactions Occasionally Occur Severe
  Reactions Are Seen In Patients Lacking IgA Who
  Produce Anti-IgA That Reacts With IgA In The
  Transfused Blood. The Transfusion Should Be
  Stopped And Adrenaline 0.5 Mg Intramuscular And
  Chlorpheniramine 10 Mg Intravenous Should Be
  Given Immediately Endotracheal Intubation May Be
  Required.

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• 5 Transmission Of Infection
• Hepatitis, Human Immunodeficiency Virus Other
  Viruses Cytomegalovirus, Epsteinbarr Virus,
  Human T-cell Leukaemia/Lymphoma Virus Type 1
  (HTLV-1) Parasites Malaria, Trypanosomiasis,
  Toxoplasmosis Syphilis AND Transfusion Of Blood
  Contaminated With Bacteria
• 6-- Circulatory Failure Due To Volume
  Overload.7-- Iron Overload Due TO Multiple
  Transfusions. 8-- Massive Transfusion Of Stored
  Blood May Cause Bleeding And Electrolyte Changes.
  9-- Thrombophlebitis 10-- Air Embolism