Bleeding syndrome. Bleeding syndrome Complaints characteristic of bleeding syndrome
With external bleeding, the diagnosis is very simple. It is almost always possible to identify its nature (arterial, venous, capillary) and adequately, based on the amount of leaked blood, determine the volume of blood loss.
It is somewhat more difficult to diagnose internal obvious bleeding, when blood in one form or another enters the external environment not immediately, but after a certain time. Pulmonary hemorrhage involves coughing up blood or foaming blood coming from the mouth and nose. With esophageal and gastric bleeding, vomiting of blood or “coffee grounds” type occurs. Bleeding from the stomach, biliary tract and duodenum usually manifests itself as tarry stools. Raspberry, cherry or scarlet blood may appear in the stool from various sources of bleeding in the colon or rectum. Bleeding from the kidneys is manifested by scarlet colored urine - haematuria. It should be noted that with obvious internal bleeding, bleeding does not become obvious immediately, but somewhat later, which makes it necessary to use general symptoms and the use of special diagnostic methods.
The most difficult diagnosis is hidden internal bleeding. Local symptoms for them can be divided into 2 groups:
Detection of bleeding,
· change in the function of damaged organs.
Signs of bleeding can be detected in different ways depending on the location of the source of bleeding. When bleeding into the pleural cavity (haemothorax), there is a dullness of the percussion sound over the corresponding surface of the chest, weakening of breathing, displacement of the mediastinum, as well as symptoms of respiratory failure. When bleeding into the abdominal cavity - bloating, weakened peristalsis, dullness of percussion sound in sloping areas of the abdomen, and sometimes symptoms of peritoneal irritation. Bleeding into the joint cavity is manifested by an increase in the joint in volume, severe pain, and dysfunction. Hemorrhages and hematomas usually manifest as swelling and severe pain.
In some cases, changes in organ function resulting from bleeding, and not the blood loss itself, are the cause of deterioration and even death of patients. This applies, for example, to bleeding into the pericardial cavity. The so-called pericardial tamponade develops, which leads to a sharp decrease in cardiac output and cardiac arrest, although the amount of blood loss is small. Bleeding in the brain, subdural and intracerebral hematomas are extremely difficult for the body. Blood loss here is insignificant and all symptoms are associated with neurological disorders. Thus, hemorrhage in the middle cerebral artery usually leads to contralateral hemiparesis, speech impairment, signs of damage to the cranial nerves on the affected side, etc.
For the diagnosis of bleeding, especially internal, special diagnostic methods are of great value.
General symptoms of bleeding.
Classic signs of bleeding:
· Pale, moist skin.
· Tachycardia.
· Decrease in blood pressure (BP).
The severity of symptoms depends on the amount of blood loss. Upon closer examination, the clinical picture of bleeding can be presented as follows.
Bleeding divided into external and internal.
External bleeding characterized by the flow (outflow) of blood outward - through a wound of the skin or mucous membrane. External hidden (“invisible”) bleeding is called bleeding into the lumen of a hollow organ (stomach, intestines, bladder, trachea) communicating with the external environment.
Internal bleeding characterized by the flow (outflow) of blood into closed cavities (abdominal, pleural cavity, pericardial cavity, skull), they usually occur hidden and therefore their diagnosis is very difficult.
This section does not bleeding is considered caused by traumatic injuries. The subject of discussion is bleeding that occurs as complications of various diseases and pathological conditions of the body.
A doctor in his practice may encounter any type of bleeding: the most common in the clinic are hemoptysis and pulmonary bleeding, gastric, intestinal, nasal, uterine bleeding, hematuria.
Acute Blood Loss Clinic consists primarily of:
- symptomatology of acutely developed anemia;
- signs of acute vascular insufficiency;
- manifestations from the bleeding organ (system);
- hematological syndrome.
Minor bleeding usually have little effect on the general condition of the patient, go unnoticed or are manifested by transient moderate general weakness and dizziness, increased heart rate and a slight drop in blood pressure. Significant blood loss (300-350 ml or more) significantly affects the condition of the victim; in the future, if the bleeding continues, the patient’s life may be threatened. Sometimes the bleeding is so strong and profuse that it leads to death within a short time.
Acutely developed anemia as a result of bleeding, it is characterized by the patient’s anxiety, complaints of severe weakness, thirst, tinnitus, darkening of the eyes, dizziness, nausea and vomiting, yawning. Upon examination, attention is drawn to the pallor of the skin and mucous membranes; the patient's face is haggard with pointed features and sunken eyes; Loss of consciousness and convulsions may occur.
Acute bleeding clinic, in addition to signs of anemia and varying degrees of vascular insufficiency, in some cases it is accompanied by manifestations from the bleeding organ (system) - for example, shortness of breath, cough, often paroxysmal with hemoptysis and pulmonary hemorrhage; nausea and bloody vomiting due to gastric bleeding; discharge of blood from the genital tract during uterine bleeding; change in the size (shape) of the abdominal cavity due to bleeding into the abdominal cavity, etc.
Internal bleeding can lead to compression of nearby organs and disruption of their function. Thus, hemorrhage in the pericardial cavity can lead to compression of the heart (tamponade), and in the cranial cavity - to compression of the brain, hemorrhage can cause acute respiratory and heart failure, etc.
Hematological syndrome of acute blood loss characterized by a progressive decrease in hemoglobin, the number of red blood cells, and hematocrit. However, we must remember that the fall in hemoglobin content and the number of red blood cells in the blood can continue even after bleeding has stopped due to compensatory hydremia.
Patients with bleeding can be roughly divided into two groups:
Group I bleeding- obvious (“visible”) bleeding, where the diagnosis is not difficult (bloody vomiting, pulmonary hemorrhage, etc.) - this requires hospitalization and clarification of the location of bleeding, determination of the severity of bleeding, anemia.
If bleeding continues, repeated bleeding with an established localization of the lesion may raise the question of surgical intervention. The provision of emergency surgical or medical care in each individual case is decided individually, based on specific situations. For example, with thrombocytopenic purpura in cases of sharp exacerbation with profuse bleeding, when all drug methods are ineffective, there is a need for splenectomy. Or another example: if nosebleeds are caused by damage to the nasal mucosa or injury, then emergency care will involve the use of a surgical procedure (the competence of an ENT doctor); if nosebleeds occur due to hypertension, intensify antihypertensive therapy.
II group of bleeding- patients with suspected bleeding. The diagnosis of hidden internal bleeding is assumed on the basis of vascular insufficiency syndrome and signs of anemia, and is clarified (confirmed) by diagnostic studies - endoscopic, puncture methods, etc.; consultations with specialists: surgeon, gynecologist, urologist, etc.
In these cases, a feature of the doctor’s work is that specialists need to be invited “to take over”, and not take the patient to specialists.
Question about the amount of blood loss, the intensity of bleeding must also be decided on the basis of anamnesis, the general clinical picture, the severity of collapse, the level of hemoglobin and the number of red blood cells in the peripheral blood, and the hematocrit index.
Bleeding and blood loss syndrome Principles of diagnosis and treatment. Organization of the nursing process. Causes of bleeding, classification. Methods of temporary and final stop of bleeding. Features of transportation of victims. Prepared by Students 302 SD Birulina Alena and Borodenok Daria
Human life, the normal functioning of all organs, depend on the efficiency of blood circulation. Indicators of the adequacy of blood circulation are the patient’s good health, normal coloring of the skin and mucous membranes, normal pulse rate (60-80 beats per minute), good filling, normal arterial and venous pressure, etc. One of the main reasons leading to circulatory disorders is is a decrease in circulating blood volume (CBV). A necessary condition for the adequacy of blood circulation is a sufficient volume of blood volume. A significant change in blood volume, which is most often observed during blood loss, is dangerous for human life.
Bleeding is the outpouring of blood from the bloodstream into the external environment or body cavity. Blood loss is the loss of part of the body's blood due to bleeding. In the human bloodstream, depending on body weight and age, an average of 2.5 to 5 liters circulates. Approximately BCC is determined by the formula: BCC = body weight * 50. Approximately 60% of the blood circulates through the vessels, and the remaining 40% is located in the blood depot (spleen, bone marrow, etc.)
Classification of bleeding 1. By Arterial bleeding is characterized by a pulsating stream of scarlet blood; Venous bleeding - slow flow of dark or dark cherry blood; types: Capillary - slight bleeding from the entire surface of the wound, stops on its own; Parenchymal - a type of capillary bleeding from parenchymal organs, but does not stop on its own; Mixed.
2. Due to: Post-traumatic – as a result of injury or wound, including the operating room; Erosive - due to corrosion of the vessel walls by a pathological process (gastric ulcer, purulent melting, tumor disintegration, etc.) Diapedetic - bleeding without damaging the integrity of the vessel walls - in case of blood diseases (hemophilia) and vitamin deficiencies (scurvy).
3. According to communication with the external environment: External - blood flows into the external environment. Internal – flowing blood has no communication with the external environment. Hidden – flowing blood has an indirect communication with the external environment.
Internal bleeding, in turn, can be: In tissue: ü Hemorrhages - diffuse saturation of tissue with blood ü Hematoma - accumulation of blood in tissue with the formation of a cavity. In the body cavity: v In the abdominal cavity - hemoperitonium - in case of damage to parenchymal organs; v In the joint cavity - hemartosis. v Into the pleural cavity - hemothorax - with rib fractures or knife wounds. v Into the cavity of the heart sac - hemopericardium - accumulation of a significant amount of blood in the pericardial cavity, which causes compression of the heart.
Hidden bleeding includes: Gastrointestinal bleeding (peptic ulcer, varicose veins of the esophagus, erosive gastritis) - manifested by vomit the color of “coffee grounds” or tarry stools; Pulmonary hemorrhage is manifested by hemoptysis; Bleeding from the urinary tract and hematuria.
4. By time of occurrence: Primary - immediately after injury or spontaneous damage to the walls of blood vessels; Early secondary - in the first hours after a vessel injury, due to the rejection of a blood clot, with high blood pressure, slipping or cutting of ligatures from the vessels; Late secondary - several days, weeks after damage to the vessel, due to purulent melting of the walls of blood vessels and tissues.
Clinical manifestations of bleeding: Local symptoms: ü With external bleeding, blood flows into the external environment; ü When bleeding into the abdominal cavity, symptoms of peritoneal irritation and dull pain in different places of the abdomen develop; ü When bleeding into the pleural cavity, there is compression of the lung, shortness of breath, dullness of percussion sound, weakening of breathing during auscultation; ü With gastrointestinal bleeding - nausea, vomiting “coffee grounds”, stools the color of “milena”. General symptoms: ü Pale skin, cold sweat, weakness, dizziness, fainting, dry mouth, flashing spots before the eyes, decreased blood pressure, tachycardia.
DEGREES OF SEVERITY: I degree mild - compensated shock loss of blood volume 10 -15%, heart rate 80 -90 per min, p. Blood pressure 100 mm Hg. II degree: moderate severity – subcompensated shock loss of bcc 20 -30%; Heart rate 120140/min; With. Blood pressure 80 -90 mm Hg. Art. III degree: severe - decompensated reversible shock - loss of blood volume 40 -45%; Heart rate more than 140/min; With. Blood pressure 60 -70 mm Hg. Art. ; severe pallor of the skin and mucous membranes, cyanosis of the lips, shortness of breath. IV degree: extremely severe decompensated shock – loss of blood volume >45%, pulse cannot be palpated or thread-like, p. HELL
Additional diagnostic methods General blood test; Fibroduadenoscopy (if bleeding of the stomach, esophagus, type 12 intestine is suspected); Digital examination of the rectum; Sigmoidoscopy and fibrocolonoscopy - if bleeding from the colon is suspected; Ultrasound – for fluid accumulation in the abdominal cavity; Puncture of the posterior vaginal fornix in women - blood during ectopic pregnancy, rupture of an ovarian cyst; Puncture of the pleural cavity - for hemothorax; Laparocentesis - laparoscopy for suspected intraperitoneal bleeding.
Complications 1. Hemorrhagic shock; 2. Necrosis of organs deprived of blood circulation; 3. Compression of vital organs by blood; 4. Infection with hematomas; 5. Chronic anemia - anemia, with prolonged small blood losses (stomach ulcer, uterine bleeding).
Methods to stop bleeding: Temporary: ü Applying a tight pressure bandage; ü Elevated position of the limb; ü Maximum flexion of the limb at the joint; ü Finger pressing of the vessel to the bone; ü Application of an Esmarch tourniquet; ü Tight wound tamponade; ü Application of hemostatic clamps; ü Temporary bypass of large vessels with different tubes to preserve blood supply at the time of transportation to a medical facility. Final: Mechanical: Ligation of a vessel in the wound; Ligation of the vessel throughout; Prolonged wound tamponade; Vascular suture. Physical - effects of temperature. ü Chemical: Ca. Cl; adrenalin; aminocaproic acid. ü Biological: § Hemostatic sponge; § Fibrin film; § Muscle tamponade; § Blood transfusion, plasma, platelet mass, Vit. S and K, Vikasol. ü § § ü
Features of blood loss in children: A loss of 500 ml can be fatal. Signs: Pale face, bluish lips, clammy and cool skin. If the child is conscious, he constantly wants to drink. The pulse is frequent and weak. Chills may begin. If the child can speak, then he complains that he sees things around him unclearly, is scared, worried, the child may yawn and gasp for air. With large blood loss, he loses consciousness.
Features of transportation: 1. 2. 3. The patient is delivered as soon as possible to a medical institution; Create absolute peace; Victims in a state of acute blood loss are transported in a lying position, with a jet intravenous infusion of blood substitutes, the foot end of the stretcher is raised up; If internal bleeding is suspected, cold should be applied to the area of suspected bleeding; As prescribed by the doctor, administer hemostatic drugs - Ca. Cl, vitamin K and C, Vikasol. During transportation, it is necessary to monitor the condition of the victim: appearance, consciousness, control of heart rate and blood pressure.
Bleeding and blood loss. Mechanisms of bleeding. Local and general symptoms of bleeding. Diagnostics. Assessing the severity of blood loss. The body's response to blood loss.
Bleeding is the flow (outflow) of blood from the lumen of a blood vessel due to its damage or disruption of the permeability of its wall. In this case, 3 concepts are distinguished - actual bleeding, hemorrhage and hematoma.
Bleeding is said to occur when blood actively flows from a vessel (vessels) into the external environment, a hollow organ, or body cavities.
In cases where blood, leaving the lumen of the vessel, impregnates and imbibes the surrounding tissues, we speak of hemorrhage; its volume is usually small, and the rate of blood flow decreases.
In cases where spilled blood causes tissue separation, pushes organs apart, and as a result an artificial cavity filled with blood is formed, we speak of a hematoma. The subsequent development of a hematoma can lead to three outcomes: resorption, suppuration and organization.
If the hematoma communicates with the lumen of the damaged artery, they speak of a pulsating hematoma. Clinically, this is manifested by the detection of hematoma pulsation during palpation and the presence of systolic murmur during auscultation.
Classification of bleeding.
Anatomical classification
All bleeding differs according to the type of damaged vessel and is divided into arterial, venous, capillary and parenchymal. Arterial bleeding. Blood flows out quickly, under pressure, often in a pulsating stream. The blood is bright scarlet. The rate of blood loss is quite high. The volume of blood loss is determined by the caliber of the vessel and the nature of the injury (lateral, complete, etc.). Venous bleeding. Constant flow of cherry-colored blood. The rate of blood loss is less than with arterial bleeding, but with a large diameter of the damaged vein it can be very significant. Only when the damaged vein is located next to a large artery can a pulsating jet be observed due to transmission pulsation. When bleeding from the veins of the neck, you need to remember the danger of air embolism. Capillary bleeding. Mixed bleeding is caused by damage to capillaries, small arteries and veins. In this case, as a rule, the entire wound surface bleeds, which, after drying, becomes covered with blood again. Usually less massive than with damage to larger vessels. Parenchymal bleeding. It is observed when parenchymal organs are damaged: liver, spleen, kidneys, lungs. In essence, it is capillary bleeding, but is usually more dangerous, which is associated with the anatomical and physiological characteristics of parenchymal organs.
According to the mechanism of occurrence
Depending on the reason that led to the release of blood from the vascular bed, three types of bleeding are distinguished: Haemorrhagia per rhexin - bleeding due to mechanical damage (rupture) of the vessel wall. Most common. Haemorrhagia per diabrosin - bleeding due to arrosion (destruction, ulceration, necrosis) of the vascular wall due to some pathological process. Such bleeding occurs during an inflammatory process, tumor decay, enzymatic peritonitis, etc. Haemorrhagia per diapedesin - bleeding when the permeability of the vascular wall is impaired at the microscopic level. An increase in the permeability of the vascular wall is observed in diseases such as vitamin deficiency C, Henoch-Schönlein disease (hemorrhagic vasculitis), uremia, scarlet fever, sepsis and others. The state of the blood coagulation system plays a certain role in the development of bleeding. Disruption of the thrombus formation process in itself does not lead to bleeding and is not its cause, but it significantly aggravates the situation. Damage to a small vein, for example, usually does not lead to visible bleeding, since the system of spontaneous hemostasis is triggered, but if the state of the coagulation system is impaired, then any, even the most minor injury can lead to fatal bleeding. The most well-known blood clotting disorder is hemophilia.
In relation to the external environment
According to this criterion, all bleeding is divided into two main types: external and internal.
In cases where blood from a wound flows out into the external environment, we speak of external bleeding. Such bleeding is obvious and can be quickly diagnosed. Bleeding through drainage from a postoperative wound is also called external bleeding.
Internal bleeding is called bleeding in which blood flows into the lumen of hollow organs, into tissues or into the internal cavities of the body. Internal bleeding is divided into obvious and hidden.
Internal obvious bleeding is called those bleedings when blood, even in an altered form, appears outside after a certain period of time and the diagnosis can therefore be made without a complex examination and identification of special symptoms. Such bleeding includes bleeding into the lumen of the gastrointestinal tract.
Internal obvious bleeding also includes bleeding from the biliary system - haemobilia, from the kidneys and urinary tract - haematuria.
With hidden internal bleeding, blood flows into various cavities and is therefore not visible to the eye. Depending on the location of the bleeding, such situations have special names.
The flow of blood into the abdominal cavity is called haemoperitoneum, into the chest cavity - haemothorax, into the pericardial cavity - haemopericardium, into the joint cavity - haemartrosis.
A feature of bleeding into serous cavities is that plasma fibrin is deposited on the serous surface. Therefore, the spilled blood becomes defibrinated and usually does not clot.
Diagnosis of hidden bleeding is most difficult. In addition to general symptoms, local ones are determined, diagnostic punctures are made, and additional research methods are used.
By time of occurrence
According to the time of occurrence of bleeding, there are primary and secondary.
The occurrence of primary bleeding is associated with direct damage to the vessel during injury. It appears immediately or in the first hours after damage.
Secondary bleeding can be early (usually from several hours to 4-5 days after injury) and late (more than 4-5 days after injury).
There are two main reasons for the development of early secondary bleeding:
Slipping of the ligature applied during the initial operation from the vessel.
Flushing of a blood clot from a vessel due to an increase in systemic pressure and acceleration of blood flow or due to a decrease in the spastic contraction of the vessel that usually occurs during acute blood loss.
Late secondary or arrosive bleeding is associated with destruction of the vascular wall as a result of the development of an infectious process in the wound. Such cases are among the most difficult, since the entire vascular wall in this area is changed and recurrent bleeding is possible at any time.
Downstream
All bleeding can be acute or chronic. In acute bleeding, the outflow of blood is observed in a short period of time, and in chronic bleeding it occurs gradually, in small portions. Sometimes, for many days, there is a slight, sometimes periodic, bleeding. Chronic bleeding can occur with stomach and duodenal ulcers, malignant tumors, hemorrhoids, uterine fibroids, etc.
According to the severity of blood loss
Assessing the severity of blood loss is extremely important, since it determines the nature of circulatory disorders in the patient’s body and, ultimately, the danger of bleeding for the patient’s life.
Death during bleeding occurs due to circulatory disorders (acute cardiovascular failure), and also, much less frequently, due to the loss of the functional properties of blood (transfer of oxygen, carbon dioxide, nutrients and metabolic products). Two factors are of decisive importance in the development of bleeding outcome: the volume and rate of blood loss. A sudden loss of about 40% of circulating blood volume (CBV) is considered incompatible with life. At the same time, there are situations when, against the background of chronic or periodic bleeding, patients lose a much larger volume of blood, red blood counts are sharply reduced, and the patient gets up, walks, and sometimes even works. The general condition of the patient is also of certain importance - the background against which bleeding develops: the presence of shock (traumatic), initial anemia, exhaustion, failure of the cardiovascular system, as well as gender and age.
There are different classifications of the severity of blood loss.
It is most convenient to distinguish 4 degrees of severity of blood loss: mild, moderate, severe and massive.
Mild degree - loss of up to 10-12% of bcc (500-700 ml).
Average degree - loss of up to 15-20% of bcc (1000-1400 ml).
Severe degree - loss of 20-30% of bcc (1500-2000 ml).
Massive blood loss - loss of more than 30% of the blood volume (more than 2000 ml).
Determining the severity of blood loss is extremely important for deciding on treatment tactics, and also determines the nature of transfusion therapy.
Local symptoms of bleeding.
With external bleeding, the diagnosis is very simple. It is almost always possible to identify its nature (arterial, venous, capillary) and adequately, based on the amount of leaked blood, determine the volume of blood loss.
It is somewhat more difficult to diagnose internal obvious bleeding, when blood in one form or another enters the external environment not immediately, but after a certain time. Pulmonary hemorrhage involves coughing up blood or foaming blood coming from the mouth and nose. With esophageal and gastric bleeding, vomiting of blood or “coffee grounds” type occurs. Bleeding from the stomach, biliary tract and duodenum usually manifests itself as tarry stools. Raspberry, cherry or scarlet blood may appear in the stool from various sources of bleeding in the colon or rectum. Bleeding from the kidneys is manifested by scarlet colored urine - haematuria. It should be noted that with obvious internal bleeding, bleeding does not become obvious immediately, but somewhat later, which makes it necessary to use general symptoms and the use of special diagnostic methods.
The most difficult diagnosis is hidden internal bleeding. Local symptoms for them can be divided into 2 groups:
detection of bleeding,
change in the function of damaged organs.
Signs of bleeding can be detected in different ways depending on the location of the source of bleeding. When bleeding into the pleural cavity (haemothorax), there is a dullness of the percussion sound over the corresponding surface of the chest, weakening of breathing, displacement of the mediastinum, as well as symptoms of respiratory failure. When bleeding into the abdominal cavity - bloating, weakened peristalsis, dullness of percussion sound in sloping areas of the abdomen, and sometimes symptoms of peritoneal irritation. Bleeding into the joint cavity is manifested by an increase in the joint in volume, severe pain, and dysfunction. Hemorrhages and hematomas usually manifest as swelling and severe pain.
In some cases, changes in organ function resulting from bleeding, and not the blood loss itself, are the cause of deterioration and even death of patients. This applies, for example, to bleeding into the pericardial cavity. The so-called pericardial tamponade develops, which leads to a sharp decrease in cardiac output and cardiac arrest, although the amount of blood loss is small. Bleeding in the brain, subdural and intracerebral hematomas are extremely difficult for the body. Blood loss here is insignificant and all symptoms are associated with neurological disorders. Thus, hemorrhage in the middle cerebral artery usually leads to contralateral hemiparesis, speech impairment, signs of damage to the cranial nerves on the affected side, etc.
For the diagnosis of bleeding, especially internal, special diagnostic methods are of great value.
General symptoms of bleeding.
Classic signs of bleeding:
Pale moist skin.
Tachycardia.
Reduced blood pressure (BP).
The severity of symptoms depends on the amount of blood loss. Upon closer examination, the clinical picture of bleeding can be presented as follows.
weakness,
dizziness, especially when raising the head,
“darkness in the eyes”, “spots” before the eyes,
feeling of lack of air,
anxiety,
Upon objective examination:
decreased diuresis.
pale skin, cold sweat, acrocyanosis,
physical inactivity,
lethargy and other disturbances of consciousness,
tachycardia, thready pulse,
decrease in blood pressure,
Clinical symptoms with varying degrees of blood loss.
Mild – no clinical symptoms.
Moderate - minimal tachycardia, decreased blood pressure, signs of peripheral vasoconstriction (pale, cold extremities).
Severe - tachycardia up to 120 bpm, blood pressure below 100 mm Hg, anxiety, cold sweat, pallor, cyanosis, shortness of breath, oliguria.
Massive - tachycardia more than 120 bpm, blood pressure - 60 mm Hg. Art. and below, often not determined, stupor, severe pallor, anuria.
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Hemorrhagic syndrome is a symptom complex based on bleeding (internal and external; venous, arterial, capillary) and bleeding (hemorrhagic diathesis).
Leading symptoms:
Fainting (sometimes the first sign of bleeding);
Bleeding;
Bleeding.
Etiology. The causes of bleeding are violations of the integrity of the vascular wall as a result of injury; various diseases manifested by the formation of ulcers; lack of blood clotting factors.
Diagnosis of hidden bleeding
(according to M.G. Veylo, G. Shubin, 1971)
Table 55
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Clinical picture. Bleeding can be arterial, venous and capillary; external, internal and hidden.
Symptoms of arterial bleeding:
The color of blood is scarlet;
It flows out quickly in a pulsating stream;
Often complicated by shock (acute blood loss).
Symptoms of venous bleeding:
The color of the blood is dark red;
Flows out in a uniform stream;
Complicated by acute blood loss and embolism.
With capillary bleeding, blood is released slowly, in the form of a “sponge.”
Symptoms of internal bleeding (into the cavity): weakness, dizziness, thirst, shortness of breath, pallor of the skin and visible mucous membranes, tachycardia, arterial hypotension, possible loss of consciousness.
Hidden bleeding - weakness, dizziness gradually appears, and anemia develops. Bleeding from natural orifices goes unnoticed for a long time.
There are 3 degrees of bleeding severity.
Symptoms of 1st degree: weakness, tachycardia (100 beats/min), pale skin, but the skin is warm. BPS not Level 2 symptoms: severe weakness, P > 100 beats/min, BPS - 80-100 mm Hg, moist skin.
Symptoms of the 3rd degree: hemorrhagic shock, severe weakness, pale, cold skin, P - thread-like, blood pressure - 80 mm Hg, anuria.
dmi. CBC, BAC, “prothrombin index”, blood coagulation factors, bleeding duration, blood pressure measurement, X-ray examinations of organs, ultrasound of internal organs.
FAM, fecal occult blood test.
According to indications: sternal puncture, biopsy.
Differential diagnosis
The causes of bleeding or hemorrhage must be investigated.
Hemorrhagic diathesis Other causes of bleeding
1. Thrombocytopenic 1. Nasal (rhinitis, arterial hypertension)
purpura 2. From the gums (periodontal disease)
2. Hemorrhagic vasculitis 3. Menorrhagia (erosions, polyps)
3. Hemophilia 4. Uterine (tumors, childbirth)
4. DIC syndrome 5. Hematuria (urolithiasis, tumors, polyps)
6. Gastrointestinal (ulcerative lesions, inflammation, tumors)
7. Hemoptysis (PE, tuberculosis, lung cancer)
Emergency care (basic principles)
Stop bleeding (using a pressure bandage, inserting a tampon soaked in a 3% hydrogen peroxide solution into the wound, applying an ice pack, a tourniquet - depending on the type of bleeding).
In case of internal bleeding, administer hemostatic agents: etamsylate (dicinone) 12.5% solution 2 ml intravenously,
5% solution of aminocaproic acid 100 ml intravenously by stream or drip, blood substitutes intravenously by drip during long-term transportation.
Administer adroxon 0.025% solution 1-2 ml intramuscularly for capillary bleeding.
Paramedic tactics
Hospitalization is indicated for arterial, venous bleeding and depending on the cause and degree of bleeding. More details can be found in the sections describing each of the bleedings. Nosebleed
Causes: hypertension, nasal trauma, ARVI, infectious diseases, blood diseases, nasal tumors. Symptoms:
Bleeding from the nose;
Coughing up blood clots when throwing the head back;
Vomiting dark blood and clots;
Paleness of the skin;
Difficulty or shutdown of nasal breathing on one or both sides;
When you blow your nose, there is an admixture of fresh blood.
Urgent Care
Place the patient in a sitting position without throwing his head back.
Ask the patient to blow the contents from both sides of the nose.
Place 5-6 drops of naphthisin, sanorin or galazolin into both halves of the nose.
After instillation, add another 10-15 drops of a 3% hydrogen peroxide solution.
Place cold on the bridge of your nose (ice pack, wet cold towel).
Invite the patient to breathe: inhale through the nose, exhale through the mouth.
If bleeding continues, insert a cotton ball or small swab into the nose and press the wing of the nose against the nasal septum on one or both sides for 4~8 minutes.
Invite the patient to cough up the contents of the mouth to ensure that bleeding has stopped or continued.
If the bleeding has stopped, release the pressure on the tampon and, without removing it, apply a sling-shaped bandage.
If bleeding continues, ask the patient to blow his nose again.
Anesthetize the nasal cavity with a 10% lidocaine solution from a can and perform anterior nasal tamponade (see protocol). Apply a sling bandage.
Observe for 5-8 minutes.
Note. If blood pressure is high, lower it.
Paramedic tactics
If bleeding through the tampon continues, transport the patient to the clinic emergency room.
In case of heavy bleeding, administer intravenous hemostatic agents (see above) and transport the patient to the ENT department of the hospital.
Transportation - on a stretcher in a semi-sitting position.
BLEEDING FROM DILATED VEINS OF THE ESOPHAGUS
The cause is cirrhosis of the liver.
Symptoms:
Bleeding from the mouth.
Jaundice.
Telangiectasia on the skin.
Enlarged spleen (liver).
Dilated vessels on the anterior wall of the chest and
Urgent Care
Etamsylate (dicinone) 12.5% solution 2 ml IV, IM. Aminocaproic acid 5% solution 100 ml i.v.
Paramedic tactics
Calling a special resuscitation team (stopping bleeding with a special probe with an inflatable balloon). Transport to the intensive care unit.
GASTROINTESTINAL BLEEDING
Causes: gastric ulcer, nonspecific ulcerative colitis, corrosive hemorrhagic gastritis, gastrointestinal tumors, hemorrhagic diathesis.
Symptoms of stomach bleeding:
Vomit the color of coffee grounds.
Weakness, dizziness.
Paleness of the skin.
Symptoms of bleeding from the large intestine:
Unchanged blood in the stool.
No vomiting.
General weakness.
Symptoms of acute blood loss:
Symptoms of hemorrhagic shock (see corresponding syndrome).
Fainting states.
Examination, tactics, medications for gastrointestinal bleeding.
Collection of medical history and complaints.
General therapeutic visual examination.
General therapeutic palpation.
General therapeutic percussion.
General therapeutic auscultation.
Pulse study.
Respiration rate measurement.
Prescription of drug therapy for diseases of the esophagus, stomach, and duodenum.
Catheterization of the cubital and other peripheral veins. Palpation for pathology of the sigmoid and rectum.
Table 56
Medicines
Urgent Care
The patient's position is supine.
If there is a lot of blood loss, raise his legs. Prohibit the intake of food and medications for gastric bleeding, except for 5% aminocaproic acid orally, 1 tbsp. spoon again.
Cold on the stomach.
Etamsylate 12.5% 2-4 ml IV or IM.
ATTENTION!
1. The administration of calcium chloride is undesirable, as it causes vasodilation (increased bleeding).
2. Vikasol - will not have a hemostatic effect, since there is no vit. K-deficiency.
General hemostatic agents
Aminocaproic acid 5% - 100 ml i.v.
Etamsylate (dicinone) 12.*5% - 2-4 ml IV or IM.
Adroxon 0.025% 1-2 ml IM (used for capillary and parenchymal bleeding).
To combat hypovolemia - plasma replacement solutions: dextrose 400 ml, hydroxyethyl starch 400 ml.
Paramedic tactics
Mandatory hospitalization in the surgical department accompanied. Transportation lying on a stretcher,
in case of large blood loss - with the head bowed. During transportation, continue taking aminocaproic acid in tablespoons.
Hospitalization is carried out depending on the underlying disease in the intensive care, trauma or surgical departments.
BLEEDING FROM THE EXTERNAL AUDITORY CANAL
Causes: injuries to the auditory canal, tympanic septum or medial wall of the tympanic cavity, skull injuries (fracture of the base of the skull), injuries to the mandibular joint (impact to the lower jaw), otitis media of influenza etiology.
The leading symptom is bloody discharge from the external auditory canal.
Symptoms of otitis media:
Ear pain; .
Hearing loss;
Dizziness;
Balance disorder.
Symptoms of a fracture of the base of the skull:
Sudden hearing loss;
Vestibular disorders (dizziness, nausea, vomiting);
Facial nerve paresis.
Urgent Care
Tamponade of the ear canal with a dry sterile gauze pad or cotton ball.
For pain, nausea, vomiting - 0.1% atropine sulfate solution 1 ml subcutaneously.
Aseptic bandage on the ear.
Paramedic tactics
Transport the patient to the ENT department of the hospital.
For head injuries, go to the surgical (neurosurgical) department in a lying position on a stretcher.
BLEEDING AFTER TOOTH EXTRACTION
This is profuse bleeding that does not stop on its own from an extraction wound.
Reasons: rupture and crushing of the gums at the time of extraction; vascular paralysis after the use of adrenaline; bleeding disorders.
Symptoms:
Obvious bleeding from the tooth socket;
Blood staining of saliva.
Bleeding may last a day or more and is complicated by anemia.
Urgent Care
Remove the blood clot from the socket using tweezers. Rinse your mouth with a 3% hydrogen peroxide solution.
Perform tamponade of the hole with gauze or iodoform turunda or a hemostatic sponge.
Place a gauze pad on the tampon and ask the patient to squeeze it by closing his teeth.
Observation - after 1 hour, if bleeding continues, change the tampon in the hole.
Paramedic tactics
After assistance is provided, the patient is left at home with a recommendation to continue treatment at the dental clinic.
Hospitalization is indicated for hemophilic influenzae or heavy bleeding that is not amenable to treatment measures.
OBSTETRIC-GYNECOLOGICAL
BLEEDING
Bleeding in the first half of pregnancy
Causes: spontaneous abortion, ectopic pregnancy.
Symptoms:
Bloody discharge from the genital tract.
Heaviness in the lower abdomen.
Cramping pain.
Profuse bleeding due to incomplete abortion.
Increase in temperature due to infection.
Urgent Care
In case of threatened abortion
Magnesium sulfate 25% 10-15 ml IM (reduces muscle tone) in the later stages - 20-30 weeks.
In the early stages - no-spa 2% 2 ml IM or papaverine hydrochloride 2% 2 ml IM.
During abortion in progress
Calcium chloride 10% - 10 ml i.v.
Ascorbic acid 5% 2-3 ml with 20 ml 40% glucose. Dicynone 12.5% solution 2 ml i.v.
ATTENTION! The use of cutting agents is not indicated (they may cause increased bleeding).
Paramedic tactics
All patients with spontaneous abortion are urgently hospitalized in a specialized hospital. Transportation is carried out on foot or on a stretcher, depending on the degree of bleeding.
Bleeding during pregnancy
The reason is placenta previa.
Symptoms:
Bloody discharge at the end of pregnancy or at the beginning of labor.
No pain.
Blood pressure is reduced.
Urgent Care
For heavy bleeding: isotonic sodium chloride solution 300-400 ml IV in a bolus.
Urgent hospitalization to the pregnancy pathology department.
Bleeding during childbirth (in the third period - atonic bleeding)
Survey, tactics.
General thermometry.
Visual examination in gynecology.
Palpation in gynecology.
Respiration rate measurement.
Pulse study.
Heart rate measurement.
Blood pressure measurement in peripheral arteries.
Studying the level of total hemoglobin in the blood using an analyzer.
Intramuscular administration of drugs.
Intravenous administration of drugs.
Transporting a patient by emergency medical services.
Table 57
Medicines
Bleeding during the afterbirth period
The reason is violations during separation of the placenta. Symptoms If you press with the edge of your palm above the womb, the umbilical cord is retracted, which means that the placenta has not separated.
Blood loss of more than 400 ml requires emergency care!
Urgent Care
Bladder catheterization.
When separating the placenta, check its integrity. Do not try to release the afterbirth when there are no signs of its release.
Oxygen therapy (and during transportation).
Bleeding in the early postpartum period (from the moment of birth of the placenta within 24 hours)
Causes: hypotension or atony of the uterus, damage to the soft birth canal (rupture of the cervix, vaginal walls), the presence of placental remains in the uterine cavity, blood clotting disorders.
Clinical picture. Bleeding begins after the placenta is delivered or some time after. Blood loss can be up to 1 liter or more.
Symptoms:
Paleness of the skin and mucous membranes;
Tachycardia;
Decreased blood pressure;
Dizziness;
General weakness.
Note. The blood is collected in a tray and determined
quantity.
Physiological blood loss is 200-250 ml, acceptable - 0.5% of body weight, pathological - more than 0.5% of body weight.
Examination, tactics and medications for dysfunctional uterine bleeding complicated by hemorrhagic shock.
Collection of medical history and complaints in gynecology.
Respiration rate measurement.
Pulse study.
Heart rate measurement.
Blood pressure measurement in peripheral arteries.
Prescription of drug therapy for diseases of the female genital organs.
Intravenous administration of drugs.
Transporting a patient by emergency medical services.
Table 58
Medicines
Urgent Care
Lower the head end of the bed (stretcher).
Place an ice pack on your lower abdomen.
Perform external massage of the uterus.
For uterine hypotension, administer 5-10 units of oxytocin in a 5% solution of 500 ml of glucose intravenously.
Paramedic tactics
Having warned the maternity hospital staff about the bleeding, urgently hospitalize the patient in the nearest obstetric hospital. During transportation - infusion therapy with blood substitutes and pressing the abdominal aorta with a fist.
Uterine (gynecological) bleeding
Causes: pathological processes in the uterus in women of different age groups, trauma.
The leading symptom is bleeding from the genital tract, which usually does not coincide with the period of menstruation.
Symptoms:
Signs of trauma to the uterus and vagina.
Finding out other reasons.
Presence of bleeding.
Acute posthemorrhagic anemia.
Decreased blood pressure.
Weak pulse.
Tachycardia
Urgent Care
Enter:
Drugs that contract the uterus:
Pituitrin 5 units 1 ml IM;
Ergotal 0.05% 1 ml IM;
Hemostatic agents:
Etamsylate 12.5% 2~4 ml IV;
Aminocaproic acid 5% 100 ml intravenously;
Coldness in the lower abdomen.
In case of cervical bleeding - tight vaginal tamponade with a gauze swab soaked in a furatsilin solution (see the paramedic's protocol).
ATTENTION!
If uterine fibroids are suspected, do not administer contractile agents.
Paramedic tactics
If there is slight bleeding and satisfactory general condition, and there is no suspicion of ectopic pregnancy, it is recommended to visit a gynecologist.
In case of heavy bleeding, transport to the gynecological department of the hospital.
RENAL BLEEDING
Causes: damage to the kidney or bladder. Symptoms
Macrohematuria for a long time;
Dysuria; .
Pain in the lumbar region;
Radiation of pain to the groin;
There may be renal colic;
