What happens when there is major blood loss? Symptoms of acute and slow blood loss
Bleeding- blood coming out of blood vessels in external environment, in the cavity and tissue.
Distinguishes between internal and external bleeding. At outdoor bleeding, blood is poured into the external environment, when internal – in the cavity (pleural, abdominal, cranial cavity), in tissues and organs.
Based on the origin of bleeding, they are divided into traumatic caused by mechanical damage vascular wall, and non-traumatic, Related pathological changes vascular wall.
Bleeding can be primary or secondary. Primary bleeding occurs at the time of injury , secondary– after a certain period of time after injury or stopping bleeding. Early secondary bleeding often appears on the 2-5th day after injury due to the expulsion of a blood clot from a vessel or a breakthrough of the hematoma. Late secondary bleeding is caused by purulent melting of a blood clot or necrosis of the vascular wall (they are observed 10-15 days after injury).
Depending on the type of damaged blood vessel, bleeding is divided into arterial, venous, arterial-venous and capillary. Bleeding from parenchymal organs is called parenchymal.
Arterial hemorrhage is bleeding from damaged arteries, the gushing blood is bright red in color and is ejected in a strong pulsating stream. Blood flows out of the central end (segment) of the vessel. Arterial bleeding is the most dangerous, usually very intense and the blood loss is large. If large arteries, the aorta, are damaged, blood loss incompatible with life may occur within a few minutes, and the patient dies.
Venous bleeding occurs when veins are damaged. The blood is dark red (dark cherry) in color and flows out slowly, continuously (i.e. in a uniform stream). Blood is released from the peripheral segment of the damaged vessel. Venous bleeding is less intense than arterial bleeding and is therefore rarely of a threatening nature. When the veins of the neck and chest are injured, due to negative pressure in these veins, air can enter them (an air bubble - embolus), causing blockage of the lumen of a blood vessel - an air embolism, which can cause lightning death,
Capillary bleeding - occurs when the smallest blood vessels - capillaries - are damaged. Such bleeding is observed with shallow skin cuts and abrasions; Capillary blood has a scarlet color and oozes evenly from the entire surface of the damaged tissue.
Parenchymatous bleeding – observed in case of damage to parenchymal organs (liver, kidneys, spleen, lungs). Essentially, it is like mixed bleeding from arteries, veins and capillaries. Blood flows profusely and continuously from the entire wound surface of the organ. Since the vessels are enclosed in organ tissue and do not collapse, spontaneous stopping of bleeding almost never occurs.
Blood loss, anemia, signs. Bleeding always leads to blood loss, i.e. loss of some blood. The blood mass of an adult is 1/13 of body weight; those. about 5l. 40-50% of the total amount of blood circulates in the bloodstream, the rest is located in blood depots (liver, skin, spleen). The volume of circulating blood (BCV) depends on the body weight and age of a person, it is approximately determined by the formula: BCC = body weight x 50.
A significant change in BCC is dangerous for human life. An adult without special consequences tolerates a loss of 300-400 ml to 500 ml of blood. For a child, such a loss can be fatal, but for one year old child A loss of just 200 ml of blood is fatal. Exhausted, hungry, tired, and elderly people do not tolerate blood loss well. Women tolerate blood loss more easily than men.
Loss of 50% of blood (2-2.5 liters) in an adult is fatal. The loss of 25% of blood (1-1.5 l) leads to a sharp circulatory disorder and severe oxygen starvation, i.e. development of a severe clinical picture acute anemia. The loss of 1 liter of blood already becomes dangerous, although the body, when stopping bleeding, can compensate for this loss (due to vasoconstriction, blood leaving the depot, and fluid entering the bloodstream from the interstitial spaces).
With the loss of 1-1.5 liters of blood, a bleeding complication develops - acute anemia. Developing at the same time clinical picture manifested by a sharp disturbance of blood circulation (phenomena of collapse and anemia of the brain). Acute anemia can develop with less blood loss, but it occurs very quickly, both externally and internal bleeding.
Symptoms of anemia: the patient complains of increasing weakness, dizziness, tinnitus, ringing in the head, darkening and flashing “spots” in the eyes, thirst, nausea, vomiting, drowsiness. The skin and visible mucous membranes become pale, cyanosis of the lips and tip of the nose appears, cold sticky sweat, dry skin, and facial features become sharpened. The patient is inhibited (sometimes excited), breathing is rapid, pulse is rapid, weak filling (thread-like), arterial pressure low. Subsequently, loss of consciousness occurs due to anemia of the brain, the pulse disappears, convulsions appear and death may occur.
The average amount of blood in the body of an adult is 6-8% of the total mass, or 65-80 ml of blood per 1 kg of body weight, and in the body of a child - 8-9%. That is average volume blood in an adult male is 5000-6000 ml. A decrease in the total blood volume is called hypovolemia, an increase in blood volume compared to the norm is hypervolemia
Acute blood loss develops when a large vessel is damaged, when a very rapid drop in blood pressure occurs to almost zero. This condition is observed with a complete transverse rupture of the aorta, superior or inferior veins, or pulmonary trunk. The volume of blood loss is insignificant (250–300 ml), but due to a sharp, almost instantaneous drop in blood pressure, anoxia of the brain and myocardium develops, which leads to death. The morphological picture consists of signs acute death, a small amount of blood in the body cavities, damage to a large vessel and a specific sign - Minakov's spots. At acute blood loss no bleeding of internal organs is observed. With massive blood loss, there is a relatively slow flow of blood from damaged vessels. In this case, the body loses about 50–60% of the available blood. Over several tens of minutes, a gradual drop in blood pressure occurs. The morphological picture is quite specific. “Marbled” skin, pale, limited, islandy cadaveric spots that appear in more late dates than with other types of acute death. Internal organs are pale, dull, dry. A large amount of spilled blood in the form of clots (up to 1500–2500 ml) is found in the body cavities or at the scene of the incident. During internal bleeding, sufficiently large volumes of blood are needed to saturate the soft tissue around the injury.
The clinical picture of blood loss does not always correspond to the amount of blood lost. With slow bleeding, the clinical picture may be blurry, and some symptoms may be completely absent. The severity of the condition is determined primarily on the basis of the clinical picture. With very large blood loss, and especially with rapid bleeding, compensatory mechanisms may be insufficient or will not have time to turn on. In this case, hemodynamics progressively worsen as a result of a vicious circle. Blood loss reduces oxygen transport, which leads to a decrease in oxygen consumption by tissues and the accumulation of oxygen debt, resulting in oxygen starvation The central nervous system is weakened contractile function myocardium, IOC decreases, which, in turn, further impairs oxygen transport. If this vicious circle is not broken, then increasing violations lead to death. Sensitivity to blood loss is increased by overwork, hypothermia or overheating, time of year (in the hot season, blood loss is less tolerated), trauma, shock, ionizing radiation, and concomitant diseases. Gender and age matter: women are more tolerant of blood loss than men; Newborns, infants and the elderly are very sensitive to blood loss.
Blood loss is a deficiency of circulating blood volume. There are only two types of blood loss - hidden and massive. Hidden blood loss is a deficiency of red blood cells and hemoglobin; the plasma deficiency is compensated by the body as a result of the phenomenon of hemodilution. Massive blood loss is a deficiency in circulating blood volume, leading to dysfunction of cardio-vascular system. The terms “hidden and massive blood loss” are not clinical (related to the patient), these are academic (physiology and pathophysiology of blood circulation) study terms. Clinical terms: (diagnosis) posthemorrhagic Iron-deficiency anemia corresponds to hidden blood loss, and the diagnosis hemorrhagic shock - massive blood loss. As a result of chronic hidden blood loss, you can lose up to 70% of red blood cells and hemoglobin and save your life. As a result of acute massive blood loss, you can die, losing only 10% (0.5 l) of your blood volume. 20% (1l) often leads to death. 30% (1.5 l) of blood volume is an absolutely fatal blood loss if it is not compensated. Massive blood loss is any blood loss exceeding 5% of the blood volume. The volume of blood that is taken from the donor is the boundary between hidden and massive blood loss, that is, between that to which the body does not respond and that which can cause collapse and shock.
- Minor blood loss (less than 0.5 l) 0.5-10% of bcc. Such blood loss is tolerated healthy body without consequences or manifestation of any clinical symptoms. There is no hypovolemia, blood pressure is not reduced, pulse is within normal limits, slight fatigue, skin is warm and moist, has a normal shade, consciousness is clear.
- Average (0.5-1.0 l) 11-20% bcc. Easy degree hypovolemia, blood pressure decreased by 10%, moderate tachycardia, pale skin, cold extremities, pulse slightly increased, breathing increased without rhythm disturbance, nausea, dizziness, dry mouth, possible fainting, twitching of individual muscles, severe weakness, adynamia, slow reaction on others.
- Large (1.0-2.0 l) 21-40% bcc. Moderate severity of hypovolemia, blood pressure reduced to 100-90 mm Hg. Art., pronounced tachycardia up to 120 beats/min, breathing is very rapid (tachypnea ) with rhythm disturbances, sharp progressive pallor of the skin and visible mucous membranes, lips and nasolabial triangle are cyanotic, pointed nose, cold sticky sweat, acrocyanosis, oliguria, darkened consciousness, painful thirst, nausea and vomiting, apathy, indifference, pathological drowsiness, yawning (a sign of oxygen starvation), pulse - frequent, small filling, weakened vision, flickering spots and darkening in the eyes, clouding of the cornea, hand tremors.
- Massive (2.0-3.5 l) 41-70% bcc. Severe degree of hypovolemia, blood pressure reduced to 60 mm Hg, sharp tachycardia up to 140-160 beats/min, thread-like pulse up to 150 beats/min, on peripheral vessels cannot be palpated, can be detected on the main arteries much longer, the patient’s absolute indifference to the environment, delirium, consciousness is absent or confused, sharp deathly pallor, sometimes a bluish-gray tint of the skin, “ goose pimples», cold sweat, anuria, Cheyne-Stokes type breathing, convulsions may be observed, the face is haggard, its features are pointed, sunken dull eyes, an indifferent look.
- Fatal (more than 3.5 l) more than 70% of the bcc. Such blood loss is fatal for a person. Terminal state (preagonia or agony), coma, blood pressure below 60 mm Hg. Art., may not be detected at all, bradycardia from 2 to 10 beats/min, agonal breathing, superficial, barely noticeable, dry, cold skin, characteristic “marbling” of the skin, disappearance of pulse, convulsions, involuntary release of urine and feces, dilated pupils , then agony and death develop.
Question 4: basic requirements when performing blood transfusions
The main task in treatment hemorrhagic shock is to eliminate hypovolemia and improve microcirculation. From the first stages of treatment, it is necessary to establish a jet transfusion of fluids (saline solution, 5% glucose solution) to prevent reflex cardiac arrest - empty heart syndrome.
Immediate stopping of bleeding is possible only when the source of bleeding is accessible without anesthesia and everything that accompanies a more or less extensive operation. In most cases, patients with hemorrhagic shock have to be prepared for surgery by infusing various plasma-substituting solutions and even blood transfusions into a vein, and continue this treatment during and after surgery and stop the bleeding.
Infusion therapy aimed at eliminating hypovolemia is carried out under the control of central venous pressure, blood pressure, cardiac output, total peripheral vascular resistance and hourly diuresis. For replacement therapy When treating blood loss, combinations of plasma substitutes and canned blood products are used, based on the volume of blood loss.
To correct hypovolemia, blood substitutes with hemodynamic action are widely used: dextran preparations (reopolyglucin
Polyglucin), gelatin solutions (gelatinol), hydroxyethyl starch (refortan
Acute blood loss leads to bleeding of the body due to a decrease in the volume of circulating blood. This primarily affects the activity of the heart and brain.
As a result of acute blood loss, the patient experiences dizziness, weakness, tinnitus, drowsiness, thirst, darkening of the eyes, anxiety and a feeling of fear, facial features become sharpened, fainting and loss of consciousness may develop.
Loss of blood pressure is closely associated with a decrease in circulating blood volume; the body reacts to this by turning on defense mechanisms, which were mentioned above.
Therefore, following a drop in blood pressure, the following appear:
- severe pallor of the skin and mucous membranes (this is a spasm of peripheral vessels);
- tachycardia (compensatory reaction of the heart);
- shortness of breath (the respiratory system struggles with a lack of oxygen).
All these symptoms indicate blood loss, but to judge its magnitude, hemodynamic readings (pulse and blood pressure data) are not enough; clinical blood data (number of red blood cells, hemoglobin and hematocrit values) are required.
BCC- this is the volume of formed elements of blood and plasma.
The number of red blood cells during acute blood loss is compensated by the release of previously non-circulating red blood cells located in the depot into the bloodstream.
But blood dilution occurs even faster due to an increase in the amount of plasma (hemodilution).
A simple formula for determining BCC:
BCC = body weight in kg multiplied by 50 ml.
BCC can be more accurately determined taking into account the gender, body weight and constitution of a person, since muscles are one of the largest blood depots in the human body.
The BCC value is also affected by active image life. If a healthy person is placed on bed rest for 2 weeks, his blood volume decreases by 10%. Long-term ill people lose up to 40% of their blood volume.
Hematocrit- is the ratio of the volume of blood cells to its total volume.
On the first day after blood loss, it is impossible to estimate its value by hematocrit, since the patient proportionally loses both plasma and red blood cells.
And one day after hemodilution, the hematocrit indicator is very informative.
Algover Shock Index- This is the ratio of pulse to systolic blood pressure. Normally it is 0.5. At 1.0 comes dangerous condition. At 1.5 - a clear shock.
Hemorrhagic shock is characterized by pulse and blood pressure indicators depending on the degree of shock.
Speaking about blood loss and loss of bcc, you need to know that the body is not indifferent to what kind of blood it loses: arterial or venous. 75% of the blood in the body is in the veins (low pressure system); 20% - in the arteries (system high pressure); 5% - in capillaries.
Blood loss of 300 ml from the artery significantly reduces the volume of arterial blood in the bloodstream, and hemodynamic parameters also change. And 300 ml of venous blood loss will not cause a big change in indicators. Donor body loss 400 ml venous blood compensates independently.
Children and old people tolerate blood loss especially poorly; a woman’s body copes with blood loss more easily.
V. Dmitrieva, A. Koshelev, A. Teplova
"Signs of acute blood loss" and other articles from the section
Bleeding is defined as the penetration of blood beyond the vascular bed, which occurs either when the walls of blood vessels are damaged or when their permeability is impaired. A number of conditions are accompanied by bleeding, which is physiological if the blood loss does not exceed certain values. These are menstrual bleeding and blood loss in postpartum period. The causes of pathological bleeding are very diverse. Changes in vascular permeability are observed in diseases and pathological conditions such as sepsis, scurvy, final stages chronic renal failure, hemorrhagic vasculitis. In addition to mechanical causes of vascular destruction due to trauma, the integrity of blood vessels can be impaired due to hemodynamic factors and changes in the mechanical properties of the vascular wall itself: hypertension against the background of systemic atherosclerosis, rupture of an aneurysm. Destruction of the vessel wall can occur as a result of a pathological destructive process: tissue necrosis, tumor disintegration, purulent melting, specific inflammatory processes(tuberculosis, etc.).
There are several classifications of bleeding.
By the appearance of a bleeding vessel.
1. Arterial.
2. Venous.
3. Arteriovenous.
4. Capillary.
5. Parenchymatous.
According to the clinical picture.
1. External (blood from the vessel enters the external environment).
2. Internal (blood leaking from the vessel is located in the tissues (with hemorrhages, hematomas), hollow organs or body cavities).
3. Hidden (without a clear clinical picture).
For internal bleeding there is an additional classification.
1. Bleeding into tissue:
1) hemorrhages in the tissue (blood flows into the tissue in such a way that they cannot be separated morphologically. The so-called impregnation occurs);
2) subcutaneous (bruising);
3) submucosal;
4) subarachnoid;
5) subserous.
2. Hematomas (massive bleeding into the tissue). They can be removed using a puncture.
According to the morphological picture.
1. Interstitial (blood spreads through the interstitial spaces).
2. Interstitial (bleeding occurs with tissue destruction and cavity formation).
According to clinical manifestations.
1. Pulsating hematomas (in the case of communication between the hematoma cavity and the arterial trunk).
2. Non-pulsating hematomas.
Intracavitary bleeding is also noted.
1. Bleeding into natural body cavities:
1) abdominal (hemoperitoneum);
2) the cavity of the heart sac (hemopericardium);
3) pleural cavity(hemothorax);
4) joint cavity (hemarthrosis).
2. Blood leakage into hollow organs: gastrointestinal tract (GIT), urinary tract and etc.
According to the rate of bleeding.
1. Acute (from large vessels, a large amount of blood is lost within minutes).
2. Acute (within an hour).
3. Subacute (within 24 hours).
4. Chronic (over weeks, months, years).
By time of occurrence.
1. Primary.
2. Secondary.
Pathological classification.
1. Bleeding resulting from mechanical destruction walls of blood vessels, as well as in case of thermal lesions.
2. Arrosive bleeding resulting from the destruction of the vessel wall by a pathological process (tumor disintegration, bedsores, purulent melting, etc.).
3. Diapedetic bleeding (if the permeability of blood vessels is impaired).
2. Acute blood loss clinic
Blood performs a number of important functions in the body, which mainly boil down to maintaining homeostasis. Thanks to transport function blood in the body, a constant exchange of gases, plastic and energy materials becomes possible, hormonal regulation etc. The buffer function of blood is to maintain acid-base balance, electrolyte and osmotic balances. Immune function also aimed at maintaining homeostasis. Finally, the delicate balance between the coagulation and anticoagulation systems of the blood maintains its fluid state.
Bleeding Clinic consists of local (caused by the leakage of blood into the external environment or into tissues and organs) and general signs of blood loss.
Symptoms of acute blood loss is a unifying clinical sign for all types of bleeding. The severity of these symptoms and the body's response to blood loss depend on many factors (see below). The amount of blood loss considered fatal is when a person loses half of all circulating blood. But this is not an absolute statement. The second important factor that determines the body's response to blood loss is its rate, that is, the speed at which a person loses blood. When bleeding from a large truncus arteriosus death can occur with smaller amounts of blood loss. This is due to the fact that the body’s compensatory reactions do not have time to operate at the proper level, for example, with chronic blood loss in volume. The general clinical manifestations of acute blood loss are the same for all bleeding. There are complaints of dizziness, weakness, thirst, spots flashing before the eyes, and drowsiness. The skin is pale, and if the bleeding rate is high, cold sweat may occur. Not uncommon orthostatic collapse, development of fainting conditions. An objective examination reveals tachycardia, decreased blood pressure, and low-fill pulse. With the development of hemorrhagic shock, a decrease in diuresis occurs. In red blood tests, there is a decrease in hemoglobin, hematocrit and red blood cell count. But changes in these indicators are observed only with the development of hemodilution and in the first hours after blood loss are not very informative. Expressiveness clinical manifestations blood loss depends on the rate of bleeding.
There are several severity of acute blood loss.
1. With a deficit of circulating blood volume (CBV) of 5-10%. The general condition is relatively satisfactory, there is an increase in pulse rate, but it is sufficiently full. Blood pressure (BP) is normal. When examining blood, hemoglobin is more than 80 g/l. On capillaroscopy, the state of microcirculation is satisfactory: on a pink background there is rapid blood flow, at least 3-4 loops.
2. With a deficit of bcc up to 15%. The general condition is moderate. Tachycardia up to 110 per minute is noted. Systolic blood pressure decreases to 80 mm Hg. Art. Red blood tests show a decrease in hemoglobin from 80 to 60 g/l. Capillaroscopy reveals rapid blood flow, but against a pale background.
3. With a deficit of bcc up to 30%. General serious condition patient. The pulse is thread-like, with a frequency of 120 per minute. Blood pressure drops to 60 mm Hg. Art. Capillaroscopy shows a pale background, slow blood flow, 1-2 loops.
4. If the BCC deficit is more than 30%. The patient is in a very serious, often agonal state. Pulse and blood pressure on peripheral arteries none.
3. Clinical picture of various types of bleeding
It is possible to clearly determine from which vessel the blood is flowing only when external bleeding. As a rule, with external bleeding, diagnosis is not difficult. When arteries are damaged, blood flows into the external environment in a strong pulsating stream. The blood is scarlet. This is a very dangerous condition, since arterial bleeding quickly leads to critical anemia of the patient.
Venous bleeding, as a rule, is characterized by a constant flow of dark blood. But sometimes (when large venous trunks are injured) there may be diagnostic errors, since transmission pulsation of the blood is possible. Venous bleeding is dangerous possible development air embolism(with low central venous pressure (CVP)). At capillary bleeding There is a constant flow of blood from the entire surface of the damaged tissue (like dew). Particularly severe are capillary bleedings that occur when parenchymal organs are injured (kidneys, liver, spleen, lungs). This is due to the structural features capillary network in these organs. Bleeding in this case is very difficult to stop, and during surgery on these organs this becomes a serious problem.
For various types internal bleeding the clinic is different and not as obvious as with external ones.
Methods for determining the volume of blood loss
There is a method for approximate determination of the volume of blood loss by clinical signs(see chapter “Clinic of acute blood loss”).
Liebov's method is used for surgical interventions. The amount of blood lost by patients during the intervention is defined as 57% of the weight of all gauze pads and balls used.
Method for determining blood loss by specific gravity of blood (according to Van Slyke). The specific gravity of blood is determined using a set of test tubes containing a solution copper sulfate in various dilutions. The blood to be tested is sequentially dripped into solutions. The specific gravity of the dilution in which the drop does not sink and lingers for some time is considered equal to the specific gravity of blood. The volume of blood loss is determined by the formula:
Vcr = 37 x (1.065 – x),
where Vcr is the volume of blood loss,
x is a certain specific gravity of blood, as well as according to Borovsky’s formula, taking into account the hematocrit value and blood viscosity.
This formula is slightly different for men and women.
ДЦКм = 1000 x V + 60 x Ht – 6700;
ДЦКж = 1000 x V + 60 x Ht – 6060,
where DCm is the deficiency of circulating blood for men,
DCBzh – deficiency of circulating blood for women,
V – blood viscosity,
Ht – hematocrit.
The only drawback of this formula can be considered a certain inaccuracy of the values determined with its help in early period after blood loss, when compensatory blood dilution (hemodilution) has not yet occurred. As a result, the volume of blood loss is underestimated.
4. The body's reaction to bleeding
The adult human body contains approximately 70-80 ml/kg of blood, and not all of it is in constant circulation. 20% of the blood is in the depot (liver, spleen). The circulating volume consists of blood that is not in the vessels of the depositing organs, and the main part of it is contained in the veins. The arterial system constantly contains 15% of the body’s total blood, 7-9% is distributed in the capillaries, and the rest is deposited in the venous system.
Since blood performs homeostatic functions in the body, everything physiological mechanisms aimed at preventing violations of its functioning.
The human body is quite resistant to blood loss. There are both systemic and local mechanisms for spontaneous stopping of bleeding. TO local mechanisms include reactions of a damaged vessel, which are caused both by its mechanical properties (due to the elastic properties of the vascular wall, its contraction occurs and the lumen of the vessel closes with intima screwing in) and vasomotor reactions (reflex spasm of the vessel in response to damage). TO general mechanisms include coagulation and vascular-platelet mechanisms of hemostasis. When a vessel is damaged, the processes of platelet aggregation and the formation of fibrin clots are triggered. Due to these mechanisms, a blood clot is formed, which closes the lumen of the vessel and prevents further bleeding.
All mechanisms are aimed at maintaining central hemodynamics. To this end, the body tries to maintain the volume of circulating blood by activating the following mechanisms: blood is released from the storage organs, blood flow slows down, and blood pressure decreases. In parallel, blood flow is maintained predominantly along main vessels(with priority blood supply to vital organs - heart and brain). When the mechanism of centralization of blood supply is turned on, microcirculation is seriously affected, and disturbances in blood flow along the microcirculatory bed begin long before clinically detectable signs of disturbances in macrocirculation (it should be borne in mind that blood pressure can be normal with a loss of up to 20% of bcc). Violation capillary blood flow leads to disruption of the blood supply to the organ parenchyma, the development of hypoxia and degenerative processes in it. An adequate indicator of the state of microcirculation is the following: clinical indicator, like the flow-hour of urine.
General reaction according to Gulyaev, bleeding occurs in four phases. This is protective (until the bleeding stops), compensatory (centralization of blood flow), reparative (hemodilution due to movement tissue fluid and lymph into the bloodstream) and regenerative (restoration of the normal hematocrit value due to the regeneration of formed elements) phases.
5. Stop bleeding
Temporary stopping methods.
1. Finger pressure (mainly for arterial bleeding). A method to immediately stop bleeding. Allows you to gain time. Unfortunately, stopping bleeding with this method is extremely short-lived. Places of digital pressure of arteries:
1) carotid artery. The inner edge of the sternocleidomastoid muscle is at the level of the upper edge of the thyroid cartilage. The artery is pressed against the carotid tubercle on the transverse process of the VI cervical vertebra;
2) subclavian artery. It does not lend itself well to finger pressure, so it is possible to limit blood flow through it by moving the arm back as far as possible at the shoulder joint;
3) axillary artery. Snuggling in armpit to the humerus. The approximate place of pressure is along the front border of hair growth;
4) brachial artery. Presses against the humerus. Approximate pressing location – inner surface shoulder;
5) femoral artery. Pressed against pubic bone. The approximate place of compression is the border between the middle and inner thirds of the inguinal ligament.
2. Maximum flexion of the limb in the joint with a roller (arterial) using:
1) pressure bandage (for venous, capillary bleeding);
2) tourniquet. It is applied proximal to the wound site for arterial bleeding, distal for venous bleeding. Using a tourniquet for arterial bleeding, it can be applied for a maximum of 1.5 hours. If after this time the need for its use remains, it is dissolved for 15-20 minutes and then applied again, but to a different place;
3) clamping on a vessel in the wound (for arterial or venous bleeding);
4) temporary endoprosthetics (in case of arterial bleeding in the absence of the possibility of an adequate final stop in the near future). Effective only with mandatory heparinization of the patient;
5) exposure to cold (with capillary bleeding).
Final stopping methods.
1. Ligation of a vessel in the wound.
2. Ligation of the vessel throughout.
3. Vascular suture.
4. Vascular transplantation.
5. Vessel embolization.
6. Vessel replacement (previous methods are used for damage to large vessels that remain to stop bleeding mainly from small arterial trunks).
7. Laser coagulation.
8. Diathermocoagulation.
In the presence of massive bleeding that occurs with serious disturbances in the hemostatic system (DIC syndrome, consumption coagulopathy, etc.), the listed methods of stopping bleeding may not be enough; sometimes additional therapeutic measures are required to correct them.
Biochemical methods effects on the hemostatic system.
1. Methods affecting the body as a whole:
1) transfusion of blood components;
2) platelet mass, fibrinogen intravenously;
3) cryoprecipitate intravenously;
4) aminocaproic acid parenterally and enterally (as one of the methods of hemostasis for gastric bleeding, especially erosive gastritis).
2. Methods local impact. They are used for operations that involve damage to the tissue of parenchymal organs and are accompanied by capillary bleeding that is difficult to stop:
1) wound tamponade with muscle or omentum;
2) hemostatic sponge;
3) fibrin film.
– a fast-flowing process of irreversible blood loss in a very short period of time. It begins as a consequence of injuries (closed or open type) and a violation of the integrity of blood vessels in certain types of diseases (ulcerative condition of the gastrointestinal tract, myocardial infarction, hemophilia). Poses a threat to the life of the body.
Types of disease
This problem is classified according to the following degrees of severity:
- mild – loss is 10–20% of the bcc (does not exceed 1 liter);
- average – 20–30% (up to 1.5 l);
- heavy – up to 40% (no more than 2 l);
- massive hemorrhage – more than 40% (more than 2 l);
- supermassive or fatal - more than 50%. In the vast majority of cases, it leads to irreversible consequences of homeostasis.
If there is a deficit of circulating blood volume (CBV) of forty percent and no treatment is provided qualified assistance very often leads to death.
Acute blood loss of III, IV or V degrees is often the source of hemorrhagic shock.
Causes
The main root causes of this disease include injuries to arterial and venous vessels, wounds, fractures, ruptures of internal organs, as well as diseases - stomach and duodenal ulcers, varicose veins of the esophagus, Mallory-Weiss syndrome, and pulmonary infarction.
Symptoms
The symptoms of external hemorrhage are visible to the naked eye. Its internal loss is much more difficult to determine. Signs of this type of disorder include unexpected weakness, rapid pulse, thirst, dizziness, pale complexion, hemoptysis, vomiting, abdominal tension, and fainting. Especially complex cases caused by shortness of breath, cold sweating, and possible fainting.
At the slightest manifestation of symptoms, you should immediately make an appointment with a doctor.
Diagnostics
When examining this disease, radiography, MRI, ultrasound, and laparoscopy are used.
For precise setting diagnosis, consultations with a doctor are prescribed - a vascular, abdominal or thoracic surgeon, as well as other doctors.
Treatment
Treatment methods largely depend on the patient’s well-being. If the blood deficiency is up to one liter, the body copes on its own, provided that the bleeding is stopped in time (produced by available means - application of a tourniquet, pressure bandage or clamp). If it exceeds 1 liter, then doctors individually prescribe blood transfusions and the introduction of plasma substitutes (saline, glucose, polyglucin). The second degree requires transfusion of plasma substitutes in a volume exceeding the total loss by two to three times and an additional infusion of five hundred to one thousand milliliters. The third – 3–4 times. If this is a case of heavy blood loss, then there is a need for transfusion of two or three volumes of blood and several plasma substitutes. To restore the damaged organ and neutralize bleeding, surgery takes place. Under any circumstances, there is a need for systematic monitoring: measuring temperature and blood pressure, monitoring respiratory rate and urinary secretions. The rehabilitation period directly depends on the root cause of the disease.
Prevention
To avoid such problems, it is necessary to observe safety precautions at home and in professional activities. Watch your diet. Promptly treat diseases that can cause such disorders. Play sports and drive healthy image life.
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 varies 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 C deficiency, 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
Based on this feature, 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.
Bleeding into abdominal cavity called haemoperitoneum, in the chest - haemothorax, in the pericardial cavity - haemopericardium, in 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 common symptoms determine local ones, make diagnostic punctures (punctures), and use additional research methods.
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 everything has changed vascular wall in this area and at any time, recurrent bleeding is possible.
With the flow
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 the outcome of bleeding: 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 obvious internal bleeding, when blood in one form or another enters the external environment not immediately, but through 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 use 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's 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.
Hemorrhage is the irreversible loss of blood by a person as a result of injury or illness. Death from loss of blood is the most common cause of death.
Causes of blood loss
There are usually two causes of blood loss: traumatic and non-traumatic.
As the name suggests, the first group includes bleeding resulting from rupture of blood vessels from injuries caused by external forces. Especially dangerous bleeding arise when open fractures and in case of damage central vessels. In such cases, blood loss occurs rapidly and often the person does not even have time to get help.
Non-traumatic bleeding occurs due to a malfunction in the hemostatic system, which ensures the preservation of blood in a liquid state on the one hand and the prevention and blocking of bleeding on the other. In addition, they can occur in pathological conditions of the heart and blood vessels, liver, gastrointestinal tract, oncological diseases and hypertension. The danger of this type of bleeding is that it is difficult to diagnose and difficult to treat.
General signs of blood loss
Bleeding can be external and internal. External ones are easily determined, because It is difficult not to notice such bleeding, especially heavy bleeding. Arterial bleeding is more dangerous, when bright blood spurts out of the wound, it is difficult to stop and a dangerous condition can arise very quickly. At venous bleeding the blood is dark and flows out of the wound calmly, it is easier to stop; with severe wounds it can stop on its own.
There are also capillary bleedings, when blood oozes through damaged skin. If capillary bleeding is external, then, as a rule, it does not lead to a large loss of blood, but with the same internal bleeding, the blood loss can be significant. There are cases when all three types of bleeding are combined and this is very bad for the victim.
Internal bleeding can occur in hollow organs: intestines, stomach, trachea, uterus, bladder, as well as in internal cavities: skull, abdominal cavity, pericardium, chest. The danger of this bleeding is that it may not be noticed for a long time and precious time may be lost.
Signs of blood loss include
Blood loss leads to decreased nutrition of organs, primarily the brain. Because of this, the patient feels dizzy, weak, darkened in the eyes, tinnitus, anxiety and a feeling of fear, his facial features become sharpened, fainting and loss of consciousness may occur.
With further blood loss, blood pressure decreases, a spasm of blood vessels occurs, so the skin and mucous membranes turn pale. Due to the compensatory reaction of the heart, tachycardia occurs. From lack of oxygen in respiratory system shortness of breath occurs.
Signs of blood loss depend on the amount of blood lost. It is better to measure it not in milliliters, but as a percentage of the bcc - the volume of circulating blood, because People's body weights are different and the same amount of lost blood will be tolerated differently by them. An adult has about 7% of blood in the body, and young children have about twice as much. The bcc, which takes part in blood circulation processes, is about 80%, the rest of the blood is in reserve in the depositing organs.
What is acute blood loss
Acute blood loss is the body's response to a decrease in blood volume. How faster body loses blood and the greater the volume of blood loss, the more severe the victim’s condition and the worse the prognosis for recovery. Age and general state health influence the possibility of recovery; a younger person without chronic diseases will cope with blood loss, even significant, faster. And temperature environment has its effect; at a lower temperature, blood loss is more easily tolerated than in the heat.
Classification of blood loss
In total, there are 4 degrees of blood loss, each of which has its own symptoms:
- Blood loss mild degree . In this case, the loss of BCC is 10-20% (from 500 to 1000 ml) and this is quite easily tolerated by patients. The skin and mucous membranes hardly change color, they simply become paler, the pulse may increase to 100 beats per minute, and the pressure may also decrease slightly.
- Moderate blood loss. In this case, the loss of bcc is 20-40% (up to 2000 ml.) and a picture of 2nd degree shock appears: the skin, lips, subungual beds are pale, the palms and feet are cold, the body is covered with large drops of cold sweat, the amount of urine decreases. The pulse increases to 120 beats. per minute, the pressure decreases to 75-85 mmHg.
- Severe blood loss. The loss of bcc is 40-60% (up to 3000 ml), grade 3 shock develops: the skin becomes sharply pale with a grayish tint, the lips and subungual beds are bluish, drops of cold sticky sweat are on the body, consciousness is almost lost, urine is not excreted. The pulse increases to 140 beats. per minute, the pressure drops to 70 mmHg. and below.
- Extremely severe blood loss occurs when the loss of bcc is more than 60%. In this case, a terminal state occurs - the transition from life to death due to irreversible changes in brain tissue and impairment acid-base balance in organism. Skin is cold and damp, sharply pale color, subungual beds and lips are gray, there is no consciousness. There is no pulse in the extremities, it is determined only in the sleepy and femoral artery, blood pressure is not determined.
Diagnosis of acute blood loss
In addition to diagnosing the signs listed above, which everyone can see, in medical institutions Additional examinations are carried out to more accurately determine the degree of blood loss. For example, according to the “shock index” - the ratio of pulse rate to pressure indicator. In addition, blood is taken for analysis to determine the amount of red blood cells, hemoglobin level, acid-base balance. Carry out and x-ray examination, MRI, ultrasound and a number of others.
Internal bleeding is diagnosed if there is additional signs: hemoptysis with lung damage, vomiting “coffee grounds” with bleeding in the gastrointestinal tract, tension in the anterior abdominal wall with bleeding into the abdominal cavity.
The body reacts to blood loss by releasing blood from the depot in the liver and spleen; in the lungs, arteriovenous shunts open - direct connections between veins and arteries. All this helps the victim ensure the flow of blood to vital important bodies within 2-3 hours. The task of relatives or eyewitnesses of the injury is to provide timely and correct first aid and call an ambulance.
Principles of treatment of blood loss
In acute blood loss, the main thing is to stop the bleeding. For external bleeding, apply a tight tourniquet above the wound and record the time. Depending on the type of wound, you can also apply a pressure bandage or at least apply a tampon and secure it. The easiest temporary solution is to press the damaged area with your finger.
Therapy for blood loss consists of replenishing the amount of lost blood through transfusion. For blood loss up to 500 ml. this is not required, the body is able to cope with the task of replenishing the lost blood volume. In case of more extensive blood loss, not only blood is transfused, but also plasma substitutes, saline and other solutions.
In addition to replenishing blood loss, it is important to restore urination within 12 hours after injury, because may arise irreversible changes in the kidneys. For this purpose, special infusion therapy is performed.
When internal organs are damaged, surgery is most often performed.
