Blood in the abdominal cavity. Bleeding in the abdominal cavity symptoms Bleeding in the abdominal cavity

Internal hidden bleeding, i.e. bleeding into closed body cavities, occurs mainly as a result of damage to internal organs (liver, lung, etc.), and blood is not released outside.

There are specific symptoms of internal bleeding, knowledge of which can help in the timely diagnosis of this complex problem.

Such bleeding can be suspected only by changes in the general condition of the victim and by symptoms of fluid accumulation in a particular cavity.

Bleeding into the abdominal cavity is manifested by pallor, weak rapid pulse, thirst, drowsiness, darkening of the eyes, fainting. When bleeding into the chest cavity, these symptoms are combined with shortness of breath.

When bleeding into the cranial cavity, signs of compression of the brain come to the fore - headache, impaired consciousness, breathing difficulties, paralysis, etc.

In modern surgery, special attention is paid to internal bleeding. This is due to the fact that internal bleeding is much more difficult to diagnose compared to open bleeding. This means that the medical assistance provided may be delayed. Internal bleeding is characterized by the outpouring of blood into the natural cavities of the body or artificially created spaces.

Depending on the amount of blood shed, there are three degrees of bleeding: moderate, moderate and severe.

The main causes include: rib fractures with rupture of intercostal vessels and damage to lung tissue, malignant neoplasms of internal organs, closed injuries to the liver, spleen, intestines, complications of diseases of such organs as the esophagus (with varicose veins), stomach and duodenum, liver, female sexual

Main signs of internal bleeding:

Sticky cold sweat
Pallor
Shallow breathing
Pulse is frequent and weak

Signs and symptoms that are not so pronounced and may only become apparent after some time:

Blue skin discoloration (hematoma formation in the area of injury)
Soft tissues that are tender, swollen, or hard to the touch
The victim feels nervous or restless
Rapid, weak pulse, rapid breathing, nausea or vomiting, decreased level of consciousness
Pale skin that feels cool or damp to the touch
Feeling of unquenchable thirst
Bleeding from natural orifices of the body (nose, mouth, etc.)

First aid for internal bleeding:

Provide complete rest
Place the victim in a semi-sitting position
Apply ice or cold water to the suspected bleeding site
Urgently transport the victim to a surgical hospital

Frequency of internal bleeding

Bleeding most often occurs when the gastrointestinal tract is affected. Therefore, it is worth getting acquainted with emergency treatment methods for gastrointestinal bleeding. In total, there are about 20 diseases, the most significant and common among which are: acute erosive gastritis and stomach cancer, varicose veins of the esophagus, cirrhotic liver disease. In the case of stomach cancer, the danger is a disintegrating tumor. The only sign that allows the patient to suspect something is wrong is the darkening of the stool, which occurs due to the coagulated blood contained in it. If vomiting occurs, the vomited masses, again due to coagulated blood, have the color of coffee grounds.

Symptoms of internal bleeding depend on its location and the degree of blood loss. In some cases, it is necessary to distinguish bleeding from the esophagus or stomach from bleeding from a damaged lung. In case of lung pathology, foamy, unchanged scarlet blood is released.

Diseases of the female reproductive system can also cause internal bleeding. The most common cause is tubal abortion. When a fallopian tube ruptures, blood accumulates in the abdominal cavity, creating a feeling of tension and some pressure in the pelvis, especially on the rectum. By the way, bleeding from the anus is also quite common. Subsequently, irritation of the peritoneum occurs with blood, which leads to the development of a state of shock, loss of consciousness, and fainting. The pulse in this case becomes frequent and thread-like. Upon examination, abdominal bloating, stool and gas retention are revealed. The patient becomes pale and covered in cold sweat.

Symptoms of hemothorax (blood in the chest)

How to identify and recognize internal bleeding in the chest? If blood accumulates in the pleural cavity, the so-called hemothorax develops. The pleural cavity is a small space that separates the lungs from the chest. The reasons leading to the development of hemothorax include the following: falls from a height, injuries with damage to the ribs and intercostal vessels, knife wounds, lung cancer, lung abscesses (that is, the formation of abscesses in the lung tissue).

When blood accumulates in the pleural cavity, there is difficulty breathing when inhaling and when coughing, sharp pain in the chest, a disturbance in the general condition - dizziness, weakness, fainting, pale skin, increased heart rate and breathing, sweating. Percussion of the patient's chest reveals a shortening of the percussion sound over the affected half, weakening or complete absence of breathing. On an x-ray, it is possible to determine signs of mediastinal displacement towards the healthy lung.

Hemarthrosis (blood in the joint cavity)

A common joint lesion is the development of hemarthrosis, which means the accumulation of blood in the joint cavity. A similar condition occurs as a result of injury, less often with hemophilia, scurvy. The anemic symptom is expressed insignificantly, in contrast to the local symptoms. The clinic distinguishes three degrees. With grade 1 hemarthrosis, mild pain is noted, the contours of the joint are slightly smoothed, and the range of motion is not changed. In general, the volume of blood in the joint is up to 15 ml. Grade 2 is characterized by severe pain, which intensifies with exercise, and smoothness of the joint is noted. There is an increase in the circumference of the affected joint by 1.5 - 3 cm compared to a healthy one. In the case of hemarthrosis of the knee joint, voting of the patella is observed. The blood content in the cavity is up to 100 ml. At grade 3, the pain syndrome is acute, the outlines of the joint are completely changed. The joint's circumference increases to 5 cm, and mobility is severely limited. Blood volume is more than 100 ml.

General symptoms

Thus, there are signs of bleeding that occur in any case, regardless of the source of the bleeding. Early signs include: pale skin and visible mucous membranes, cold sweat, general weakness, dizziness, darkening of the eyes, if the lungs are affected - cough with streaks of blood, if the digestive system is involved in the process - bloody vomiting or bloody diarrhea, symptoms of peritoneal irritation , which occurs when internal organs (spleen, liver, kidney) rupture. With moderate bleeding, a number of symptoms may be either mild or not appear at all

In other words, bleeding leads to the development of anemia. In addition to the above symptoms, anemia is manifested by increased heart rate and hypotension, that is, a decrease in blood pressure. The changed parameters directly depend on the degree of blood loss: with moderate - pulse no more than 75 beats per minute, systolic pressure drops to 100 mm Hg. Art.; with average - the pulse rises to 100 beats per minute, blood pressure decreases to 90-80 mm Hg. Art.; in severe cases, the pulse rises to 120-140 beats per minute, systolic blood pressure drops below 80 mm Hg. Art.

Diagnostics

In case of combined trauma, laparocentesis is performed; it is a simple, fast, affordable and gentle method for diagnosing injuries to the abdominal organs and internal bleeding. An ultrasound of the abdominal organs is also sometimes performed.

An important point in confirming the diagnosis is laboratory blood tests. The analysis reveals a decrease in the number of red blood cells, the amount of hemoglobin and a drop in hematocrit.

If such symptoms and diagnostic data are detected, it is necessary to immediately identify the cause of the underlying disease and begin treatment. It should be remembered that the earlier the cause of internal bleeding is identified, the more effective and rapid the recovery process will be.

Internal bleeding is one of the most dangerous types of bleeding, requiring immediate hospitalization.

Save on social networks:

Probably everyone has come across such a concept as “bleeding”. It would seem that recognizing him would not be difficult for anyone. But everything is always clear only with external bleeding, but if internal bleeding occurs, the symptoms of which may be hidden, everything can be much more complicated. After all, no one will immediately understand in which tissues and organs it occurred. And further treatment of the affected tissue depends on this.

Bleeding - what is it?

Bleeding refers to any situation where blood escapes from the blood vessels. There are external and internal bleeding. External are those in which blood flows into the external environment through natural openings or wounds, for example, uterine or from the final sections of the intestine. Internal bleeding occurs when the blood does not come out, but remains inside the body, forming hematomas in the organs - accumulations of blood. An example is when blood flows into the pleura, abdominal cavity, joints, and cardiac lining.

In addition to dividing into external and internal, as well as hidden or obvious, they are divided according to which vessel is damaged:

capillary;
venous;
arterial;
parenchymal;
mixed.

Capillary bleeding is characterized by saturation. Blood is released rather slowly in the form of droplets that resemble dew. Capillaries are the smallest human vessels. This bleeding can be stopped by tightly bandaging the wound. If there are no problems with the coagulation system, then medical attention is not needed in this case.

During venous bleeding, dark, streaming blood is released from the wound surface. Serious blood loss is possible. The victim must be taken to a medical facility, and tight bandaging is used as first aid.

When bleeding from an artery, the blood pulsates and flows. It is scarlet in color and quickly flows out of the wound. It is necessary to apply a tourniquet above the damaged area. Apply a tight bandage to the wound. The tourniquet can be kept for no more than an hour.

Parenchymal bleeding can occur with injuries to the cancellous bone, cavernous tissue and parenchymal organs. Such bleeding is very life-threatening; the victim must be taken to the hospital as quickly as possible. You cannot stop this type of bleeding on your own; it can be profuse.

With mixed bleeding, blood can flow from various vessels, and also be combined with parenchymal ones. Most often, such blood loss occurs due to injuries to organs in which the vascular network is well developed.

Types of internal bleeding

Internal bleeding, the symptoms of which are very insidious, pose a great danger to human health and even life. The severity of the victim’s condition with this pathology directly depends on how large the vessel is damaged, that is, on its diameter. The larger the affected vessel, the more dangerous the bleeding, and the greater the blood loss may be.

There are the following types of internal bleeding:

into the abdominal cavity, when internal organs rupture - spleen, liver - abdominal bleeding;
from the pelvic organs: uterus, ovaries, fallopian tubes;

All these pathologies have their own signs and characteristics that allow the doctor to suspect something is wrong inside the body.

Causes of internal bleeding

Internal bleeding, the symptoms of which can be erased, never occurs as the main pathology. They are caused either by an underlying disease, or injury, or a number of different circumstances. Internal bleeding can occur due to the following reasons:

abdominal injuries, both open and closed, which can damage internal organs, such as the small intestine, spleen, liver;
a ruptured ovary can lead to internal bleeding;
ruptured pelvic or ovarian cyst;
traumatic injuries of the lower back;
intestinal and stomach ulcers;
varicose veins of the stomach or esophagus;
aortic dissection (with an aneurysm);
malignant tumors of the abdominal and retroperitoneal space of the stomach, intestines in the stage of decay;
esophageal damage.

Intestinal bleeding

Intestinal bleeding can occur with various diseases of the intestine (both large and small). Most often it is caused by a duodenal ulcer. Bleeding can also be caused by tumor rupture and simple trauma. The patient may feel dizzy, spots flashing before the eyes, and sticky cold sweat. If bleeding is in the upper intestines, you may vomit coffee grounds and have black or dark cherry-colored stools. Intestinal bleeding most often requires urgent surgical intervention. In any case, stopping internal bleeding and treating its consequences are carried out in a hospital under the supervision of medical personnel.

Symptoms of bleeding of internal organs

If a person suddenly turns pale, clammy sweat appears, blood pressure drops sharply, pulse increases, internal bleeding can be suspected. The symptoms of this pathology will leave no doubt if you are careful. Drowsiness and indifference to the outside world may also occur literally five minutes after the person has been sociable and active.

Bleeding in the stomach

Internal bleeding of the stomach is one of the most dangerous conditions. A person feels general symptoms characteristic of internal bleeding. In addition, he most often vomits coffee grounds and black feces. This bleeding can be caused by a stomach ulcer, a malignant tumor that has disintegrated, or an abdominal injury.

What to do if bleeding of internal organs occurs?

If a person experiences a deterioration in health, indicating that he has internal bleeding, the symptoms of which are basically similar to each other, you should immediately call an ambulance. Before paramedics arrive or if the patient has to be transported independently, you must first of all place him on his back. Apply cold to the suspected area of bleeding. You should not try to stop internal bleeding on your own; treatment should only be carried out by a doctor.

Methods for stopping internal bleeding in the abdominal cavity

At the first symptoms of internal bleeding, you should immediately consult a doctor. You should not console yourself with the illusion that it will stop, because such a condition is life-threatening. After taking a medical history, specialists collect a small amount of stool and vomit to send for analysis. This test is done to check for the presence of blood in them.

After diagnosing the disease, doctors provide assistance with internal bleeding - diagnostic procedures, for example, endoscopy, x-rays, rectomanosigmoidoscopy, colonoscopy and some others. All these measures are carried out in order to determine where exactly the source of bleeding is located. In some cases, a therapeutic and diagnostic injection of a sclerosing agent is used, and electrocoagulation can be used. Laser radiation is also an effective method.

But the most effective is the radical method - surgery. This procedure is especially often used when the bleeding is acute and there is no time for unnecessary actions. But after surgery there is no guarantee that it will not open again. Therefore, the patient is observed in the hospital for some time.

All therapeutic measures are aimed at achieving several goals during bleeding.

The use of drugs that reduce the activity of gastric secretion.
The bleeding is stopped as quickly as possible.
Additionally, blood is injected if the loss is large.
There is a fight against DIC syndrome.
It is also important to bring a person out of a state of shock; the fight against collapse is carried out.

Who is susceptible to such bleeding?

There is a certain risk group - people who are more likely to experience internal bleeding. We have already discussed the symptoms of this condition. These are patients who have pathologies such as:

nonspecific ulcerative colitis;
oncological diseases of the abdominal organs;
erosive gastritis;
intussusception;
any gastroenterological hypertrophic diseases;
polyposis;
stomach ulcer;
some benign tumors of the gastrointestinal tract.

But these diseases are not necessarily accompanied by bleeding. You should not give in to panic; you must remember that the bleeding in these cases can almost always be stopped. The main thing is to take the necessary measures to stop it and not delay in seeing a doctor. Having diseases that are at risk, you need to remember all medical prescriptions. For example, about strict adherence to a diet, the correct eating regimen, and the necessary organization of a healthy lifestyle. It is important to monitor your health and contact specialists in a timely manner.

- leakage of blood into the peritoneal cavity or retroperitoneal space due to a violation of the integrity of the blood vessels located here, parenchymal or hollow organs. When bleeding into the abdominal cavity, weakness, pallor, cold sweat, rapid pulse, drop in blood pressure, abdominal pain, fainting or shock develop. The main role in the diagnosis of bleeding in the abdominal cavity is played by examination of the patient, dynamics of hemoglobin and hematocrit levels, laparocentesis and laparoscopy. Treatment of bleeding into the abdominal cavity is surgical - laparotomy with revision of internal organs; Antishock, hemostatic and transfusion therapy are carried out in parallel.

General information

Bleeding into the abdominal cavity (intra-abdominal bleeding, hemoperitoneum) in gastroenterology can be a symptom of a disease or damage to internal organs and tissues. The danger of bleeding into the abdominal cavity, like any internal bleeding, is its hidden nature, which can pose a threat to the patient’s life. As a result of bleeding into the abdominal cavity, hemoperitoneum occurs - accumulation of blood in the peritoneal cavity and retroperitoneal space. Bleeding into the abdominal cavity is complicated by the development of hypovolemic and neurogenic shock. Hypovolemic shock is associated with a rapid decrease in circulating blood volume (by 25% or more) and hemodynamic disturbances, neurogenic (traumatic) shock is associated with excessive pain impulses.

Causes of bleeding into the abdominal cavity

Bleeding into the abdominal cavity is based on traumatic and non-traumatic causes. Bleeding into the abdominal cavity can be caused by mechanical trauma to the chest and abdominal trauma: closed - due to impact, compression; open - with a gunshot or stab wound, as well as injuries associated with abdominal operations. In this case, a traumatic rupture of the parenchymal or hollow organs of the gastrointestinal tract, genitourinary system, as well as blood vessels located in the folds of the peritoneum, the thickness of the mesentery and the greater omentum occurs. Bleeding into the abdominal cavity in the postoperative period is usually associated with the slipping (cutting) of a ligature applied to the vessels of the mesentery or organ stumps.

Bleeding into the abdominal cavity of non-traumatic origin develops spontaneously with the complicated course of certain diseases and pathological processes of internal organs. Bleeding can be observed with tumors of the abdominal organs; conditions leading to decreased blood clotting; ectopic pregnancy; rupture of an aneurysm of the abdominal aorta, rupture of the spleen due to malaria, rupture of a cyst and ovarian apoplexy. Bleeding into the retroperitoneal space is much less common.

Symptoms of bleeding into the abdominal cavity

The clinical picture of bleeding into the abdominal cavity is determined by the severity of blood loss - its intensity, duration and volume.

Signs of intra-abdominal bleeding include pallor of the skin and mucous membranes, general weakness, dizziness, cold sweat, a sharp drop in blood pressure, severe tachycardia (pulse rate - 120-140 beats per minute), local or diffuse abdominal pain, aggravated by movement. A patient with bleeding into the abdominal cavity tries to take a sitting position to relieve abdominal pain (the “stand up” symptom).

When the diaphragmatic peritoneum is irritated by accumulated blood, pain can radiate to the chest, shoulder blade and shoulder; When bleeding into the retroperitoneal space, back pain is noted. In case of profuse bleeding into the abdominal cavity, the pain becomes intense and loss of consciousness is possible; with acute massive blood loss, collapse develops.

Diagnosis of bleeding into the abdominal cavity

A patient with suspected bleeding into the abdominal cavity is subject to urgent examination in a hospital. The abdominal area is examined to identify characteristic signs of injury (open wounds, abrasions, bruises).

Superficial palpation reveals softness and slight soreness of the anterior abdominal wall, its limited participation in breathing, and mild symptoms of peritoneal irritation. Deep palpation is carried out carefully, as it causes severe pain in the area of the damaged organ or the entire abdominal wall. Percussion of the abdomen in the presence of bleeding into the abdominal cavity is very painful; due to the accumulation of blood, dullness of sound is noted in sloping areas. Auscultation of the abdomen reveals a decrease in bowel sounds. When a hollow organ ruptures, local manifestations of bleeding into the abdominal cavity may be masked by signs of incipient peritonitis.

Digital rectal and vaginal examinations reveal bulging and severe pain in the anterior wall of the rectum and posterior vaginal fornix. If a disturbed tubal pregnancy is suspected, puncture of the abdominal cavity through the wall of the posterior vaginal fornix is of great diagnostic importance. Laboratory blood tests for bleeding into the abdominal cavity show an increasing decrease in hemoglobin levels, red blood cell counts, and hematocrit.

In case of internal bleeding, plain radiography helps determine the presence of free fluid (blood) in the abdominal cavity. Ultrasound of the pelvic organs and ultrasound of the abdominal cavity reveals the source of bleeding in the internal organs and the accumulation of anechoic fluid. The main methods for diagnosing bleeding in the abdominal cavity are endoscopic examinations -

In case of acute blood loss and a sharp drop in blood pressure, anti-shock and anti-hemorrhagic infusion therapy is carried out: transfusion of blood substitutes (or reinfusion of recently leaked blood into the abdominal cavity), administration of analeptic drugs. This helps to increase and replenish blood volume, improve the rheological properties of blood and microcirculation.

If the fact of bleeding in the abdominal cavity is established, emergency surgical intervention (laparotomy) is indicated, including inspection of the abdominal organs to detect the source of bleeding and stop it, eliminating existing damage.

The prognosis for bleeding into the abdominal cavity is quite serious, depending on the cause and intensity of the bleeding, as well as the speed and scope of surgical care.

With internal bleeding, blood accumulates in organs and body cavities. It cannot be determined visually!

First aid for internal bleeding:

If there is internal bleeding into the pelvic cavity or abdomen, you can help by pressing the abdominal aorta against the spine with your fist. It is advisable to place a handkerchief or several layers of gauze between the skin and the hand.

In case of gastrointestinal bleeding, the patient is given pieces of ice to swallow.

Do not heat the injured area, give laxatives, give enemas or give medications that stimulate heart activity!

Causes

Internal bleeding is the flow of blood into the body cavity or human organs and into the interstitial spaces. The cause of this condition may be associated with injury or chronic pathologies.

The following diseases and conditions can lead to internal bleeding:

injuries with damage to internal organs (liver, lungs, spleen);
peptic ulcer of the duodenum and stomach;
rupture of an internal cyst;
closed fractures;
dissecting aortic aneurysm;
gynecological diseases (ovarian apoplexy, ectopic pregnancy);
varicose veins of the esophagus and stomach;
decaying malignant tumors.

These conditions can be triggered by accidents, strong blows, falls from a height, active physical activity, alcohol abuse, and large meals.

Symptoms

With internal bleeding, the following symptoms develop that require first aid. Clinically, the condition is accompanied by objective (external manifestations) and subjective (feelings of the victim) symptoms. The first of these includes:

pointed facial features;
pallor of the skin and mucous membranes;
low blood pressure;
hand tremors;
tachycardia (pulse more than 100 beats per minute);
cold sweat, perspiration;
dyspnea;
muscle tension;
cold extremities;
fainting.

Subjective signs:

dizziness;
drowsiness, weakness;
darkening of the eyes;
yawn;
nausea;
noise in the head;
dry mouth;
tinnitus;
nausea, vomiting;
confused consciousness.

With hemorrhage in the abdominal cavity, pain occurs during palpation (palpation) and heaviness in the abdomen, the “Vanka-Vstanka” symptom is the development of pain in the left or right shoulder, neck in a supine position, sitting, the pain disappears, but dizziness appears.

Gastrointestinal bleeding is characterized by the absence of abdominal pain, melena (black stool), and brown vomit (coffee grounds).

When the abdominal aorta ruptures or the kidneys and adrenal glands are injured, blood accumulates in the retroperitoneal space, pain occurs in the lower back, and when tapping on this area it becomes unbearable. Red blood cells may also appear in the urine.

When blood leaks into the muscles, bruises and hematomas occur in the area of injury. In this case, the main help is cold.

If the bleeding is caused by gynecological diseases, then the general symptoms include hyperthermia, pain, heaviness, a feeling of fullness in the lower abdomen, pressure on the anus, a feeling of swelling of the mucous tissues inside.

Injury to a vessel in the lungs is usually accompanied by a cough, along with which foamy blood or blood streaks come out.

When cerebral bleeding occurs, the tissues of the organ are compressed, resulting in unbearable headaches, vomiting, impaired speech and motor activity, and convulsions.

The severity of the condition can be judged by pulse and blood pressure readings. Systolic pressure is below 80 mmHg. Art. and pulse above 110 beats per minute. indicates a serious condition and the need for assistance and urgent hospitalization. With blood loss of more than 2-3.5 liters, coma develops, followed by agony and death.

Diagnostics

Diagnosing internal bleeding can be quite difficult; for this, first of all, an examination is performed, measuring blood pressure and pulse, tapping and palpating the abdominal cavity, and listening to the chest. To assess the severity of blood loss and the amount of assistance needed, laboratory tests of hemoglobin and hematocrit (red blood cell volume) levels are performed.

Diagnostic methods depend on the cause of internal hemorrhage:

For gastrointestinal pathology: esophagogastroduodenoscopy, digital examination of the rectum, colonoscopy, gastric intubation and sigmoidoscopy;
If the lungs are affected, bronchoscopy;
For bladder disease - cystoscopy.

Ultrasound, radiological and x-ray techniques are also widely used. If bleeding into the abdominal cavity is suspected, laparoscopy is performed, and for intracranial hematoma, echoencephalography and skull radiography are performed.

Specialized medical care

The victims receive full assistance and are treated in a hospital. The department of which depends on the type of bleeding, the therapy is carried out by doctors of different profiles: gynecologists, thoracic surgeons, neurosurgeons, traumatologists, etc.

The main goals of medical care:

urgent stop of internal hemorrhage;
restoration of microcirculation;
replacement of lost blood;
prevention of empty heart syndrome by replenishing blood volume;
prevention of hypovolemic shock.

In all cases, infusion therapy is performed (the volume depends on internal blood loss): transfusion of polyglucin, saline solution, stabizol, gelatinol, glucose, blood and its preparations (albumin, fresh frozen plasma, red blood cells), plasma substitutes. At the same time, blood pressure, central venous pressure and diuresis are monitored.

If blood pressure does not rise due to infusions, norepinephrine, dopamine and adrenaline come to the rescue. For hemorrhagic shock, heparin, trental, steroid hormones and chimes are prescribed.

In some cases, internal hemorrhage is stopped by cauterization or tamponade of the bleeding area. But more often, emergency surgery under anesthesia is necessary. If the development of hemorrhagic shock is suspected, transfusion measures must be carried out.

In case of gastric bleeding, resection is indicated; in case of duodenal ulcer, vagotomy and suturing of the vessel are indicated. The outpouring of blood from the fissure of the esophagus is stopped endoscopically in combination with cold, taking antacids and hemostatic drugs. If the assistance provided does not bring results, the cracks are sutured.

In case of internal bleeding from the lungs, it is necessary to pack the bronchus. Accumulated blood from the pleural cavity is removed by puncture; in severe cases, a thoracotomy with suturing of the site of lung injury or ligation of the vessel is necessary. Emergency laparotomy is performed in all cases of ruptures of abdominal organs, and craniotomy is necessary for intracranial hematoma.

For internal gynecological hemorrhages, vaginal tamponade or surgery is performed, sometimes with removal of the ovary, fallopian tube or uterus.

External and internal bleeding of varying severity are observed in almost any injury. An ordinary bruise is a subcutaneous accumulation of blood from damaged vessels. In patients with bleeding disorders (hemophilia), even small wounds bleed profusely. Superficial wounds of the face and head, palmar surface of the hands, soles, where the network of blood vessels is well defined, a small layer of fatty tissue and a relatively large amount of connective tissue, are characterized by heavy bleeding.

Yu.P. Butylin, V.Yu. Butylin, D.Yu. Butylin; anesthesiology-resuscitation service of the medical and health-improving association of the Cabinet of Ministers of Ukraine; Department of Anesthesiology, Reanimatology and Disaster Medicine of the National Medical University. A.A. Bogomolets; Department of Resuscitation and Intensive Care of the Institute of Cardiovascular Surgery named after. N.M. Amosova AMS of Ukraine

The intensity of hemorrhage is influenced by the caliber of the vessel, the level of blood pressure, the presence or absence of clothing and shoes. The greatest danger to life is caused by external and internal damage to large arterial and venous trunks, accompanied by large blood loss.

Internal bleeding

Pulmonary hemorrhage is the release of pure blood in portions from 5-10 to 50 ml or more.

Causes. Destructive lung diseases: tuberculosis (66%), suppurative diseases (8.8%), bronchiectasis (5.9%), pneumosclerosis (2.7%), cancer (2.1%). Bleeding may be a consequence of pneumonia, pulmonary infarction, air cysts, severe forms of candidiasis and some extrapulmonary diseases (mitral valve stenosis, aortic aneurysm, hypocoagulation) with hypertension or stagnation in the pulmonary circulation (left ventricular failure, aortic valve defects), Goodpasture syndrome (necrotic alveolitis of unknown etiology), Rendu-Osler disease (hereditary hemorrhagic telangiectasia). A complex of various factors is involved in the pathogenesis of pulmonary hemorrhage. The main role is played by specific and nonspecific changes in the vascular wall in contact with the affected areas of the lung. The main sources of bleeding are bronchial arteries, which are eroded or ruptured during inflammatory processes. The vessels, as a rule, become deformed, dilate aneurysmically, their walls lose elasticity and often ulcerate.

In most patients with inflammatory diseases of the lungs, vascularization of the submucosal layer and bronchial mucosa is pronounced, and when eroded, heavy bleeding also occurs. This is facilitated by the activation of local fibrinolysis and impaired hemocoagulation as a result of prolonged intoxication and massive chemotherapy, especially in pulmonary tuberculosis in the 4-6th month of treatment. Only moderate or large blood loss (500 ml or more) leads to obstructive breathing disorders, acute hypovolemia and the development of emergency conditions. Pulmonary blood loss of more than 240-600 ml over 24-48 hours is considered massive. In severe cases of profuse bleeding, sudden death is possible, the cause of which is the development of asphyxia due to widespread airway obstruction and concomitant bronchospasm. The amount of blood loss in this case plays a secondary role. Only massive sudden pulmonary hemorrhage due to a rupture of an aortic aneurysm into the respiratory tract, lung cancer and erosion of a large vessel can lead to rapid asphyxia. Lightning pulmonary hemorrhage is not accompanied by a cough.

The most common complication of pulmonary hemorrhage is aspiration pneumonia.

Therapeutic measures must be strictly differentiated depending on the etiology of the underlying disease (Fig. 1).

Abdominal bleeding

There are bleedings from the digestive tract, intra-abdominal, retroperitoneal.

To the reasons in which bleeding from the digestive tract occurs includes the following.

Diseases of the esophagus (malignant and benign tumors, diverticula, ulcerative esophagitis, paraesophageal hernia, foreign bodies, specific and nonspecific diseases).
Diseases of the stomach and duodenum (ulcers, malignant and benign neoplasms, diverticula, erosive gastritis, duodenitis, Mallory-Weiss syndrome, tuberculosis, syphilis).
Diseases of nearby organs (hiatal hernia, pancreatic cyst, calculous pancreatitis, abdominal tumors growing into the stomach and duodenum).
Diseases of the liver, spleen and portal vein (cirrhosis, tumors, cholelithiasis, liver injury, thrombosis of the portal vein and its branches).
Diseases of the heart and blood vessels (atherosclerosis, hypertension, periarteritis nodosa).
General diseases accompanied by ulcerations of the stomach and duodenum (burns, infectious diseases, postoperative acute ulcers, acute ulcers arising from diseases of the nervous and cardiovascular systems, from drug, hormonal therapy and poisoning).
Hemorrhagic diathesis and diseases of the blood system (hemophilia, leukemia, Werlhof's disease, lymphogranulomatosis).

The most common cause (60-75% of cases) of gastrointestinal bleeding is destructive changes in the walls of the stomach or intestines. In percentage terms, they are distributed as follows: ulcers of the dilated veins of the esophagus - 15, stomach ulcers - 10, duodenal ulcers - 40, erosive gastritis - 10, stomach cancer - 15, ulcerative colitis - 4, hemorrhoids - 1, other causes - 5 .

The mechanism of bleeding is due to general (blood clotting disorders and hormonal reactions) and local (erosion of the mucous membrane and submucosal layer of the stomach and intestines with subsequent erosion of the vessel) factors.

Ulcerative bleeding can be arterial, venous and capillary, but rarely occurs simultaneously from two or three vessels. General disorders include slowing down the third phase of hemostasis under the influence of hydrochloric acid (peptic factor). Particularly dangerous is an increase in the concentration of trypsin in the blood, which activates the conversion of profibrinolysin into fibrinolysin and thus triggers the reaction of local fibrinolysis, local hypophyrinogenemia, lysis of a blood clot in the vessel and resumption of bleeding. The most typical location of bleeding sources is shown in Figure 2.

A description of the clinical picture and principles of therapeutic management of a patient with abdominal bleeding is presented in Figure 3.

Stomach bleeding

Often, gastric bleeding is the first and only symptom of the disease.

Causes: gastric ulcer, benign (polyp, leiomyoma, neurinoma, lipoma) and malignant neoplasms (cancer, sarcoma), erosive (hemorrhagic) gastritis, Mallory-Weiss syndrome, chronic hepatitis, cirrhosis of the liver, gastric syphilis, tuberculosis, medication (salicylates, anticoagulants, glucocorticoids). In the acute period of myocardial infarction, bleeding from acute erosions and ulcers of the mucous membrane of the digestive tract is observed.

In patients in critical condition (sepsis, shock), stress ulcers quite often develop; in their pathogenesis, the main role is played by ischemia of the mucous membrane, disruption of the gastric mucous barrier and an increase in the concentration of hydrochloric acid in the gastric contents, destroying the surface epithelium. Massive bleeding occurs in 4-15% of patients with stress ulcers, often from small superficial defects of the mucous membrane.

Clinic heterogeneous, depends on the volume and duration of blood loss. Almost always, before the development of full-blown symptoms, bloody vomiting and black stools, increasing lethargy, weakness, increased fatigue, and decreased ability to work are noted. Typical signs of acutely developing anemia are as follows: dizziness, noise in the head, ringing in the ears, flashing “spots” before the eyes, pale skin and mucous membranes, shortness of breath, cold sticky sweat, drop in blood pressure, tachycardia. These symptoms occur immediately after the start of bleeding, appear the faster the more intense it is, and characterize the latent period. The duration of bleeding depends on the degree and rate of blood loss. Bloody vomiting and tarry stools (melena) are the most reliable, but not always the first signs of gastric bleeding. Melena can appear either a few hours or one or two days after bleeding begins.

Vomiting can be scarlet blood, clots, sometimes the vomit has the color of coffee grounds, it depends on the location of the ulcer and the severity of the bleeding. Scarlet blood is usually observed with bleeding from the veins of the esophagus or a stomach ulcer, vomit the color of coffee grounds - with perforation of a duodenal ulcer. A characteristic symptom of ulcer bleeding is the disappearance or reduction of abdominal pain, the so-called. "silent" period.

The diagnosis is finally established after the patient is brought out of shock. X-ray and endoscopy make it possible to make an accurate diagnosis in 90% of patients. During gastroscopy, local hemostasis is possible.

Treatment. In case of severe blood loss, hemostatic and replacement therapy is necessary. Acute blood loss (volume up to 1-1.5 l) is compensated with plasma substitutes (colloids, crystalloids, dextran, reogluman, rheosorbilact, gekodez), which are administered intravenously in a stream or drip from 400 to 1200 ml. The rate of administration is determined by the general condition of the patient, the level of blood pressure, heart rate, and Ht value. Moderate hemodilution (Ht 25-30%) is a favorable factor. With blood loss from 1.5 to 3 liters, the ratio of plasma replacement solutions and canned blood for transfusion therapy should be 1:1, with losses of more than 3 liters - 1:2. The amount of plasma replacement drugs should always be about a third of the blood volume (maximum 1.5 l), with the obligatory consideration of the Ht indicator.

Emergency surgery is indicated.

Bloody stool

The location of the source of bleeding can be judged by the consistency and color of the stool.

Liquid, dark cherry-colored stool is typical of massive bleeding from the colon; tar-like – for acute profuse from the small intestine; black shaped (melena) – from the stomach and duodenum. If bleeding occurs from the cecum, ascending and transverse colons, then the color of the stool is dark burgundy or reddish-brown, from the descending colon and sigmoid colon it is bright red or cherry-raspberry. The closer the vessel defect is to the anus, the less the color of the blood changes. When bleeding from the rectum, an admixture of blood is found on the surface of normally colored stool. If it is abundant, then pure blood without feces is often released. When internal hemorrhoids bleed, the blood accumulates in the ampulla of the rectum and is then thrown out when the urge to defecate occurs. Scarlet color indicates the presence of hemorrhoids or rectal fissure. When bleeding is combined with diarrhea, the stool is bright red. To exclude the presence of a bleeding tumor or other source of bleeding, it is necessary in all cases to perform a digital examination of the rectum and colonoscopy.

Intra-abdominal bleeding

Causes: trauma, ectopic pregnancy, surgery. Penetrating and non-penetrating wounds, compression, crushing, falling from a great height, or a strong blow to the abdomen can lead to rupture of internal organs with subsequent bleeding into the abdominal cavity. Typical damage locations are shown in Figure 4.

Clinic determined by the amount of blood loss and the consequences of damage to hollow organs. If the intestines and bladder are not damaged, then at first the blood does not irritate the peritoneum, so the abdomen is soft; later, clear symptoms of peritonitis are revealed. Diagnosis of blunt abdominal trauma is especially difficult. The consequence may be severe bleeding from ruptures of the liver, spleen, mesentery or kidney.

Treatment: emergency surgery is indicated.

Ectopic pregnancy

Causes: implantation and development of the fertilized egg outside the uterus, most often (99% of cases) in the fallopian tube, which is destroyed by chorionic villi. As a result, the fertilized egg either peels off from the wall and is expelled into the abdominal cavity (tubal abortion), or the fallopian tube ruptures. The type of termination of an ectopic pregnancy determines the characteristics of the clinical picture.

Clinic. A common symptom for both types of bleeding is pain in the lower abdomen with a relatively short delay in menstruation (1-3 weeks). Pain is often accompanied by nausea, vomiting, increased heart rate, decreased blood pressure and other signs of increasing bleeding. Against this background, symptoms characteristic of a ruptured fallopian tube or tubal abortion appear. Pipe rupture is characterized by an acute onset and rapid progression of symptoms. Usually, against the background of general good condition, sharp pain appears in the lower abdomen, radiating to the external genitalia and rectum. Pain in the rectal area is often misinterpreted by the patient as an urge to defecate. With heavy bleeding, it can radiate to the neck and shoulder blade. Soon symptoms of bleeding and acute abdomen appear: vomiting, dizziness, fainting, tachycardia, decreased blood pressure, severe weakness. Palpation of the abdomen reveals tension in the abdominal wall muscles, especially in the lower parts, and a positive Shchetkin-Blumberg sign. With massive bleeding into the abdominal cavity, dullness of percussion sound in the lateral parts of the abdomen is detected. When carefully moving the patient from side to side, the boundaries of dullness move. There may not be any bloody discharge from the genitals.

A careful vaginal examination (rough examination increases bleeding!) reveals slight cyanosis of the mucous membranes of the vagina and cervix. When the pregnancy is up to 7 weeks, the size of the uterus corresponds to it. If the period is longer, there is a slight lag in the size of the uterus from the expected period (one of the characteristic signs of an ectopic pregnancy). Sometimes a tumor-like formation is palpated in the area of the uterine appendages without clear boundaries (peritubal hematoma). The posterior part of the vaginal vault is sharply painful on palpation, the pain intensifies with the displacement of the uterus towards the pubis.

Tubal abortion begins with periodic or constant pain in the lower abdomen and sacrum, radiating downwards. Each new flow of blood into the abdominal cavity is accompanied by increased pain and semi-fainting. On the 2-3rd day, characteristic dark bloody discharge is released from the genital tract, and sometimes parts of the falling membrane come off. The discharge is persistent and does not stop, despite the use of uterine contractions and even diagnostic curettage (a characteristic sign!). In the intervals between attacks of pain, the patient's condition is satisfactory. Hematomas form near the fallopian tube or in the rectal-uterine space, which can be detected during vaginal examination. Symptoms of internal bleeding and peritoneal irritation are less pronounced and may even be absent.

The diagnosis of impaired ectopic pregnancy is based on medical history, clinical findings and additional research methods. There is a history of delayed menstruation by 2-3 weeks, less often - more. In some patients, with a very early termination of pregnancy, there may not be a delay, and spotting associated with the disintegration and release of the falling membrane is mistakenly mistaken for the beginning of normal menstruation.

All types of ectopic pregnancy are characterized by pain on palpation of the posterior part of the vaginal vault and the presence of a tumor-like formation in the area of the uterine appendages. Puncture of the posterior vaginal vault is of great diagnostic importance. In case of severe bleeding due to a rupture of the fallopian tube or a rapidly flowing tubal abortion, when the picture of internal bleeding is beyond doubt, there is no need for this manipulation. Obtaining dark blood with small clots during puncture confirms the diagnosis. Bright blood, rather, indicates an injury to a blood vessel. During a tubal abortion, the blood clots and is therefore not detected during puncture. This does not exclude the presence of an ectopic pregnancy.

Treatment. If the diagnosis of an impaired tubal pregnancy is established or suspected, urgent hospitalization is indicated. Before transportation, the patient should not be given painkillers, so as not to change the clinical picture of the disease, and cold should not be applied to the lower abdomen. In the hospital, an emergency operation is performed, the deficit of blood volume is compensated, and symptomatic therapy is prescribed.

Retroperitoneal bleeding

Retroperitoneal bleeding is usually a consequence of severe trauma or complications of puncture biopsy, angiography, therapy with anticoagulants and fibrinolytic agents (Fig. 5).

Dissecting aortic aneurysm

Causes. Most patients with aortic dissection (mostly men) have hypertension, atherosclerosis, or syphilis. Based on location, acute aortic dissections are divided into three types. In type I, the dissection begins in the area of the ascending aorta and continues distally; in type II, the rupture is limited to the ascending aorta; in type III, the rupture begins distal to the origin of the large vessels of the aortic arch.

Clinic: sudden severe pain inside the chest radiating to the back, epigastric region and lower extremities. When the thoracic part of the aorta is affected, the pain is localized behind the sternum, in the back or epigastrium, when the abdominal part of the aorta is affected - in the abdomen and lumbar region. Pain rarely radiates to the upper extremities and usually spreads along the spine (along the course of the dissection), gradually reaching the lower abdomen and pelvis. The symptoms of dissecting aneurysm of the thoracic aorta are similar to those of myocardial infarction, and those of the abdominal part are similar to renal colic. In acute aortic dissection, pulsation in the peripheral arteries may be disrupted or disappear. As a result of retrograde dissection, acute regurgitation of the aortic valve is possible. In almost 50% of cases, neurological symptoms are detected. Loss of consciousness often occurs. Most patients develop collapse; a sharp drop in blood pressure is not always observed. The diagnosis is confirmed by symptoms associated with the spread of aortic dissection to the area of origin of the great vessel or several vessels (pulse asymmetry in the upper and lower extremities, hemiparesis, paraplegia or stroke, pain in the lumbar region, hematuria, scrotal edema).

X-rays, computed tomography, nuclear magnetic resonance of the chest and abdominal cavity can provide reliable information about the location of the aneurysm. Changes in the ECG indicate left ventricular hypertrophy and are caused by hypertension. There is also a decrease in the content of red blood cells and hemoglobin in the blood.

Treatment: the first is pain relief, the second is surgical intervention, the third is correction of blood loss.

Chapter from the book “Intensive care of emergency conditions. Pathophysiology, clinical picture, treatment. Atlas" is published with the permission of the authors and Novy Druk LLC.