Course - M.

Sc Nursing I Year
Subject- Advanced Nursing Practice
Unit / Topic - V / Bio- psycho social pathology
Title - Haemorrhage
Prepared by - Dr.M.Kavimani Adhavan, Ph.D.(N).,Principal
Ms.Girija.K M.Sc (N)
Assistant professor
 OBJECTIVES
At the end of the presentation learners will be able to:

• review of anatomy and physiology of blood

• define haemorrhage

• understand the causes or risk to develop haemorrhage

• Classify the haemorrhage

• describe the pathophysiology of haemorrhage

 OBJECTIVES
At the end of the presentation learners will be able to:

• enumerate the clinical features of haemorrhage

• evaluate the diagnostic findings of haemorrhage

• explain the management of haemorrhage

• elaborate the prevention of haemorrhage

• enlist the complication of haemorrhage

 INTRODUCTION
• Blood is the vital fluid present in the body, carries oxygen and nutrients to
the tissues.

• Loss of blood due to any reason beyond a certain point is potentially life
threatening and may lead to exsanguination.

• The word haemorrhage is synonymous with bleeding.

• Escape of blood from ruptured blood vessels (or) large flow of blood from
a damaged blood vessel.
 Overview of blood

• Blood is composed of plasma and three types of cells: RBC, WBC and
platelets.

• Plasma: the straw- coloured or pale yellow liquid component of blood in

which blood cells are suspended.

• Haemoglobin: the iron-containing substance in red blood cells that binds

transports oxygen from the alveoli of the lungs to the tissues of the body. It
consists of protein (globulin) and haem (a porphyrin ring with an atom of
iron at its center.
 Overview of blood
• Red blood cells’ primary function is to transport oxygen between the lungs
and tissues of the body.

• White blood cells, the cells of the immune system, provide defence against
pathogens.

• Platelets are involved in clot formation during wound healing.

• Blood is an extracellular matrix tissue in which various blood cells are

suspended in the plasma matrix.

• Blood volume is a regulated variable that is proportional to blood pressure

and a component of homeostasis.
 Overview of blood
• Blood is vital for normal metabolic function due to the transfer of oxygen,
carbon dioxide, and glucose to and from the body’s tissues. It also
transports a number of other cells and molecules throughout the body

• Injury can cause blood loss. A healthy adult can lose almost 20% of blood
volume (1 L) before the first symptom (restlessness) begins, and 40% of
volume (2 L) before hypovolemic shock sets in.
 DEFINITION

Bleeding is also known as a haemorrhage or simply blood

loss, is blood escaping from the circulatory system from
damaged blood vessels. It can occur internally or externally
either through a natural opening such as the mouth, nose, ear,
urethra, vagina or anus, or through a wound in the skin.
 causes
• Bleeding arising due to either external or internal wounds inflicted by an object /
person on a victim.

• Chronic or long-term high blood pressure

• Blood-thinning medications

• Genetic clotting conditions

• Corticosteroids

• Antibiotics

• Antidepressants
 causes

• Uncontrolled blood sugar levels

• Long-term dehydration

• Smoking

• Excessive or chronic alcohol use

• Use of illegal drugs

• Stimulant medications, such as diet pills

 causes

• Anti clotting medication

• Stroke

• Liver, kidney or spleen conditions

• Cancer

• Deep vein thrombosis

 Classification

• Depending on nature of the vessel involved

• Depending on the timing of haemorrhage

• Depending on the duration of haemorrhage

• Depending on the nature of bleeding

• Depending upon type of intervention

 I. Depending on nature of the vessel involved

A) SOURCE- ARTERIAL
• Bright red
• Emitted as spurting jet
• Can lead to severe blood loss
• Often hard to control
 I. Depending on nature of the vessel involved

B) SOURCE - VENOUS
• Darker red
• Steady and copious flow
• Colour becomes further darker
with oxygen desaturation
• Usually easy to control
 I. Depending on nature of the vessel involved

C) SOURCE- CAPILLARY
• Bright red
• Rapid on oozing
• Blood loss become serious if continues for
hours
• Generally minor & easy to control
 II. Depending on the timing of haemorrhage
B) SECONDARY
A) PRIMARY
• Occurs at the time of surgery • Occurs after 7-14 days if surgery
• Cause is injury to vessels • Cause is sloughing of vessel due
• May be arterial, venous or to infection, pressure necrosis or
capillary malignancy.
• More common in surgery on • 1st a warning stain followed by a
malignancies sudden severe bleed
• Common after haemorrhoids
surgery, GI surgery & amputations.
 II. Depending on the timing of haemorrhage

C) REACTIONARY

• Bleeding within 24 hours (usually 4-6 hours) of surgery

• Cause is slipping of ligature, dislodgement of clot or cessation of reflex
vasospasm
• Bleed starts when there is a rise in the arterial or venous pressure.
 III. Depending on the duration of haemorrhage
B) CHRONIC
A) ACUTE
• Occurs suddenly (e.g.) • Rapid blood loss can include
oesophageal variceal bleeding surgery, childbirth, trauma, or a
due to portal HT. ruptured blood vessel. It can result
from a stomach ulcer, cancer, or
tumour. 
 IV. Depending on the nature of bleeding

B) EXTERNAL / REVEALED
A) INTERNAL /CONCEALED
• Invisible, concealed haemorrhage • External / visible bleed – soft
• It may be concealed as in tissue injuries
ruptured spleen or liver, fractured • Bleeding from the limb vessels,
femur & cerebral haemorrhage. wound , nose etc.
 V. Depending on type of intervention
B) NON SURGICAL
A) SURGICAL
It result of injury and amenable to General ooze from all raw surface
surgical control or from due to coagulopathy, it can not be
angioembolism. stopped by surgical means require
correction coagulation abnormalities.
 Degree of haemorrhage

Degree of haemorrhage is classified into 4 classes:

1. Blood loss <15%

2. Blood loss between 15-30%

3. Blood loss between 30-40%

4. Blood loss>40%
 pathophysiology

Bleeding Hypovolemia Hypo perfusion

Cellular anaerobic metabolism + lactic acidosis

Decrease coagulation proteases coagulopathy

( increased ischaemic cells – anticoagulation pathway)

Decreased tissue perfusion + BS – gut & decreased muscle

(early in compensatory process) Cont..
 Cont…
Under perfused muscle – unable to generate heat

Hypothermia

HGE Hypo perfusion Acidosis

Death
 Clinical features
• Pallor

• Rapid feeble pulse

• Thirst

• Giddiness

• Cold & clammy skin due to vasoconstriction

• Fall in blood pressure

Cont..
 Clinical features
• Cyanosis

• Restlessness

• Nausea

• Tachycardia

• Tachypnoea

• Dry face , dry mouth and goose skin appearance (due to contraction of
arrector pilorum)

• oliguria
Dangers of haemorrhage

Massive loss of blood

Shock

Death
 Diagnostic evaluation
Methods of determining acute blood loss
• Normal blood volume is estimated as 70ml/kg- children & adults

80ml/kg- neonates

• Estimation – difficult & inaccurate

• Hb% and PCV estimation

• Measurement of CVP

• Continuous tissue oxygen tension measurement.

 Diagnostic evaluation
Measurement of blood loss
• Blood clot: the size of a clenched fist is roughly equal to 500ml.

• Swelling in closed fractures:

Moderate swelling in closed fracture of the tibia equals 500-1500 ml

blood loss.

Moderate swelling in a fractured shaft of femur equals 500 -2000 ml

blood loss.

• OT- blood in suction apparatus measured & swabs soaked in blood –

 Management
Concepts :
• Clinically identify HE/ Hypovolemia and shock

• Resuscitation – O2 / blood & fluids

• Identify site of HE- USG, Endoscopy, CT scan, DPL, Blood tools etc.

• Control of HE- surgery, endoscopic control, therapeutic embolization

• Definitive treatment if any

Cont..
 Management
Concepts :
• Sepsis control

• Prevention of coagulopathy

• Critical care management

• End point resuscitation , fluids & electrolyte management

• Prevention of organ failure

 Management
Local management:

Restore blood volume

First aid treatment by packing, pressure, position and tourniquets.

Optimize oxygen delivery

Monitoring

pulse, BP, temperature, conscious level, cardiac venous pressure.

Cont..
 Management
General management:
• Injection of Morphine (10-15mg) as soon as possible

• Hospitalization after temporary arrest of the bleeding

• Antibiotics

• Vitamins

• Corrective measures for bleeding diathesis

• IV fluid & if required blood transfusion should be started immediately.

Cont..
 Management
Intraoperative management:
• Regional block anaesthesia must be avoided

• Another way to prevent excessive bleeding is the meticulous handling of

soft tissues.

Postoperative management:

• Application of pressure for 10 min with moistened gauze on the flap

• Rinsing is prohibited

• Ant fibrinolytic mouthwash the day after periodontal treatment Cont..

 Management

Postoperative management:

• Antibiotics, penicillin, erythromycin, tetracycline, metronidazole, ampicillin,

amoxicillin + clavulanic acid.
 Prevention & control
Bleeding from bone:

• Burnishing the bone in the area of the bleed with molt, elevator or curette.

• If it is ineffective bone wax can be compressed in that area.

Soft tissue bleeding :

• Applying pressure using moist gauze for 2-5 min.

• If ineffective vessel ligation use reabsorbable suture

• Beside this various topical haemostatic agents can be used.

Cont..
 Protocol for control bleeding
Apply direct pressure with gloved hand & apply sterile dressing

No Bleeding stopped? Yes

Elevate extremity:
above victim’s heart continue
direct pressure

No Bleeding stopped?

Locate pressure point, apply

pressure
No
Bleeding stopped?
Cont..
 Protocol for control bleeding

No Bleeding stopped?

Bleeding from extremity? Yes

No Apply tourniquet Treat for shock:

(last resort) • Care for wound
• Seek definitive care

Definitive therapy
Cont..
 Complication

• Organ failure

• Seizures

• Coma

• Death
 Conclusion

Control of bleeding is the most important integral part of any surgical

procedure.

“PREVENTION IS BETTER THAN CURE”