Classification of bleeding by volume. Course of lectures on resuscitation and intensive care

The wounded may die from blood loss

with normal hemoglobin and five

millions of red blood cells.

Doliotti, 1940

Acute blood loss is a complex of compensatory-adaptive reactions of the body that develop in response to a primary decrease in the volume of circulating blood and are manifested by characteristic clinical signs. Among the reasons for the development of terminal conditions, acute blood loss is one of the first places in trauma, internal bleeding, surgical interventions, etc.

CLASSIFICATION OF BLOOD LOSS

The classification of blood loss is based on the nature of different types of bleeding, the degree of severity and resistance of the body.

Types of bleeding differ in the localization of its source and the time of occurrence.

According to localization, the following types of bleeding are distinguished.

Arterial bleeding is the most dangerous, especially in case of damage to the main vessels. With such bleeding, if help is not provided immediately (a tourniquet, pressure on the vessel, etc.), even relatively small amounts of blood loss (500-800 ml) can lead to circulatory decompensation and death. The blood is usually scarlet (with severe hypoventilation it has the color of venous blood), flows out in a pulsating stream (with hypotension, the terminal state does not pulsate).

Venous bleeding is usually profuse but may stop spontaneously. In such cases, blood flows out in a continuous stream, quickly filling the wound, which requires active surgical hemostasis. The relatively slow rate of blood loss also determines the longer stability of hemodynamics - failure of compensation occurs more often with a loss of 30-50% of the BCC.

Parenchymal (capillary) bleeding is essentially venous and poses a threat in case of extensive damage to the parenchyma of the lungs, liver, kidneys, spleen and pancreas or severe hemostasis disorders. Particularly dangerous are internal bleeding from parenchymal organs.

External bleeding is easily diagnosed. They accompany surgical operations, injuries with damage to the outer integument of the body and limbs (penetrating wounds of the chest and abdomen can be combined with damage to internal organs).

Internal bleeding is the most difficult group of bleeding in diagnostic and tactical terms. Moreover, intracavitary bleeding (pleural and abdominal cavities, joints) are distinguished by defibrination and non-coagulability of the outflowing blood, and interstitial bleeding (hematoma, hemorrhagic infiltration) - the impossibility of determining the volume of blood loss and often the absence of signs.

Mixed bleeding is a type of internal bleeding. In such cases, bleeding into a hollow organ (often into the organs of the gastrointestinal tract) first manifests itself as internal and, in the absence of a clinic of hypovolemia or a corresponding syndrome of organ disease, causes diagnostic errors, then, when melena, hematuria, etc. appear, it becomes external obvious .Depending on the location of the source, there are also bleeding pulmonary, esophageal, gastric, intestinal, renal, uterine, etc.

According to the time of occurrence of bleeding, there are primary and secondary.

Primary bleeding occurs immediately after damage to the vessel.

Secondary bleeding can be early and late.

Early bleeding occurs in the first hours or days after injury (especially often on the 3rd-5th day). Their cause is the mechanical separation of a thrombus as a result of an increase in blood pressure or the elimination of vascular spasm.

Secondary late bleeding occurs, as a rule, with suppuration of wounds and is dangerous in that it can cause the development of circulatory decompensation even with insignificant blood loss. Secondary bleeding also includes bleeding associated with blood clotting disorders. The most common cause is the development of generalized intravascular coagulation or improper anticoagulant therapy.

The degree of resistance to blood loss depends on its volume, the speed with which the blood leaves the vascular bed, and the compensatory capabilities of the organism ("initial background").

Depending on the amount of blood loss, there are light (15-25% BCC), medium (25-35%), severe (35-50%) and massive (more than 50% BCC) blood loss.

The rate of blood loss determines certain clinical signs of ce.

With a slow loss of even very large volumes of blood, significantly exceeding the BCC (hemoptysis, melena, hematuria, hemobilia, etc.), the clinical picture may not manifest itself, hemodynamic disorders develop gradually and rarely reach a critical level, pronounced and persistent hydremia is sometimes noted, accompanied by a decrease in hematocrit, hemoglobin content and the number of red blood cells; acute hypoxia, as a rule, is not accompanied, i.e. the patient is in a state of stable compensation, which is based on compensatory hemodilution. Only a sudden acceleration of bleeding or the occurrence of a purulent-septic complication leads to rapid decompensation.

In case of blood loss at a rate significantly exceeding the capabilities of the hydremic reaction (up to 20-50 ml / min and more), compensation can be provided only by the hemodynamic mechanism, which is manifested by the corresponding clinical symptom complex. In this case, circulatory decompensation develops due to a sharp decrease in the effective volume of circulating blood and, to a lesser extent, depends on the total volume of blood loss.

So, with bleeding at a rate of up to 100-300 ml / min (for example, with a wound to the heart, rupture of an aortic aneurysm, simultaneous polytrauma), death can occur from cardiac arrest in the very first minutes ("empty" heart).

According to the rate of blood loss, several characteristic types can be distinguished.

Lightning-fast (usually massive) blood loss occurs when the heart and great vessels are damaged during surgery, with injuries and certain diseases (rupture of an aneurysm, etc.). Clinically, they are manifested by a sharp drop in blood pressure, a mild arrhythmic pulse, pallor with a grayish tint, retraction of the eyeballs (they become soft on palpation), loss of consciousness, and cardiac arrest. The whole clinic develops within a few minutes and in out-of-hospital conditions, as a rule, ends in death. In a medical institution, an attempt to save the patient consists in the immediate surgical stop of bleeding against the background of resuscitation.

Acute blood loss accompanies damage to large arteries or veins in the same situations as fulminant ones.

In particular, with bleeding from the carotid, iliac, femoral arteries or from the vena cava, jugular, portal veins, severe blood loss is characteristic. Its clinical signs are not as critical as with lightning. However, in acute blood loss, hypotension and impaired consciousness develop quickly, within 10-15 minutes, which requires stopping the bleeding by any method available in this case.

Moderate blood loss occurs with damage to vessels of a relatively smaller caliber (limbs, mesentery, parenchymal organs). The severity of clinical manifestations in this case depends equally on the speed (moderate) and on the volume of blood loss.

Ordinary surgical blood loss, the magnitude of which depends on the duration of the operation and does not exceed 5-7% of the BCC per hour on average, is subacute. The same group should include blood loss associated with increased bleeding of the surgical wound due to the development of consumption coagulopathy (stages 2-3 of the DIC syndrome).

Chronic oozing blood loss (erosive gastritis, hemobilia, hemorrhoids, granulating burn wounds, etc.) are the least dangerous, because they are rarely accompanied by circulatory disorders. However, they exhaust patients both in connection with the pathology that causes them, and because of the development of chronic anemia, which is difficult to correct with antianemic drugs and fractional blood transfusions.

It is very difficult to determine the volumetric rate of blood loss. Even knowing the duration of bleeding and the total volume of blood flowing out, one can only calculate the average volumetric velocity, while bleeding is almost never uniform during the entire period of injury or surgery. Nevertheless, such a calculation, if possible, should always be done, since this allows you to clarify the correctness of the replacement therapy being carried out.

A very important factor determining the compensatory capabilities of the body in acute blood loss is the initial state of the body. Prolonged fasting, including in connection with the pathology of the digestive system; physical fatigue; psychological exhaustion; hyperthermia; endogenous (purulent-septic complications) or exogenous (poisoning) intoxication; dehydration; previous (even small) blood loss; anemia; early postoperative period; postresuscitation illness; burns; deep anesthesia; prolonged use of hormonal and vasoactive drugs; extensive sympathetic blockade during epidural anesthesia is far from a complete list of conditions that increase the body's sensitivity to blood loss and weaken its natural physiological compensation mechanisms.

Thus, only a comprehensive assessment makes it possible to obtain a more or less satisfactory determination of the severity of blood loss. According to A. I. Gorbashko (1982), the most stable indicator of the degree of blood loss is the deficit of globular blood volume (GO), which, of course, requires measurement of BCC and its components.

IMPACT OF BLOOD LOSS ON THE ORGANISM

The macrocirculation system (central hemodynamics) in acute blood loss changes quite characteristically.

Sympathoadrenal stimulation that accompanies acute hypovolemia is aimed at maintaining the necessary level of blood circulation in the vital organs, which are the brain and heart. As a result of this stimulation, adrenaline and other mediators of the sympathetic nervous system enter the general circulation, their vasoconstrictive action is mediated in areas rich in alpha-adrenergic receptors. At the same time, the hemodynamic reaction manifests itself already in the first minutes of blood loss by a reduction in the capacitive part of the venous system (mainly the portal circulation system), which in an initially healthy person provides compensation for up to 10-15% of the BCC deficiency with virtually no changes in cardiac output and blood pressure. Moreover, a slight increase in the level of catecholamines (by 2-3 times), entering the bloodstream at this initial stage, contributes to the necessary increase in cardiac output (MCV) due to both moderate tachycardia (up to 90-100 bpm) and regional dilatation of the arterial vessels of the brain, heart and lungs, which somewhat reduces the total value of peripheral vascular resistance (OPC). As a result, a hyperkinetic type of blood circulation develops, which determines the good compensatory capabilities of the body and the likelihood of a positive prognosis.

If bleeding occurs in a patient with initial but compensated hypovolemia, and also if the volume of blood loss exceeds 15-20% of the BCC, the venomotor mechanism of compensation is insufficient, blood flow to the heart decreases, which leads to more pronounced sympathoadrenal stimulation and the implementation of mechanisms aimed at delaying fluids in the body and a more significant decrease in the capacity of the vascular bed. Fluid retention is provided by a decrease in natriuresis and an increase in the processes of reabsorption under the influence of aldosterone and antidiuretic hormone, released simultaneously with catecholamines. The capacity of the vascular bed decreases due to regional redistribution of blood flow under the influence of catecholamines, the concentration of which increases by 1-2 orders of magnitude and reaches the level necessary to influence the resistance vessels. As a result, "centralization" of blood circulation occurs. At the same time, local regulation of blood flow, which ensures regional functioning and metabolism, is replaced by a general one, aimed at maintaining the necessary level of metabolism in organs that determine the preservation of life. Vascularly active substances, acting on the myogenic elements of the peripheral vessels, increase the resistance to blood flow at the level of arterioles and precapillary sphincters, which is accompanied by an increase in the peripheral blood pressure and, all other things being equal, an increase in the residual volume of the heart. Even with a reduced intensity of blood flow, this mechanism contributes to the normalization of cardiac activity (preservation of tonogenic dilatation) and maintaining the required level of blood pressure. An increase in resistance at the entrance to the capillaries causes a decrease in hydrostatic transcapillary pressure and the emergence of another compensatory mechanism - a hydremic reaction, i.e., an excess flow of fluid from the interstitial space into the capillary network. Hydremic compensation for blood loss is quite long (up to 48-72 hours). During this time, up to 2 liters or more of fluid can enter the vascular bed. However, the volumetric rate of hydremia is low (in the first 2 hours - up to 90-120 ml / h; decreases to 40-60 ml / h at 3 - 6 hours and then sets on average at the level of 30-40 ml / h) and does not can provide the necessary correction of BCC in case of rapid blood loss.

The positive effects of centralization of blood circulation can be completely offset in the future by developing microcirculation deficiency and functional insufficiency of "peripheral" but vital organs (kidneys, liver, lungs) due to total shunting of blood flow. In the stage of centralized circulation, the stroke volume begins to decrease, the minute output is maintained at a normal or even somewhat elevated level only due to tachycardia, the total heart rate increases sharply, but the type of hemodynamics becomes eukinetic and thus creates the illusion of relative well-being, supported by the stability of systolic blood pressure. Meanwhile, mean arterial and diastolic pressure rises and reflects the degree of increase in vascular tone. Thus, the centralization of blood circulation, being, of course, an expedient compensatory reaction of the circulatory system, becomes pathological when the process is generalized and contributes to the emergence of irreversibility. In other words, compensation in the macrocirculation system is achieved by decompensation in the microcirculation system.

With an increase in blood loss to 30-50% of the BCC, a long period of centralization of blood circulation, or with an initially weakened background, decompensation develops - hemorrhagic shock. This process can be divided into two stages: reversible and irreversible. They differ only in some indicators of central hemodynamics and, of course, in the outcome.

At the stage of reversible shock, arterial hypotension arises and increases, the lower limit of which (for systolic pressure) should be considered 60-70 mm Hg. Art. At the same time, an early initial sign of decompensation, ahead of blood pressure indicators, is a decrease in CVP. In general, a reversible shock is characterized by a decrease in all indicators of central hemodynamics, with the exception of a minute ejection, which remains at a normal or subnormal level due to critical tachycardia (140-160/min). This is what distinguishes a reversible shock from an irreversible one. In the initial stage of shock, the OPS is still increased, and then quickly falls.

Irreversible shock is a continuation of the reversible and the result of uncorrectable decompensation of the central and peripheral circulation, the development of multiple organ failure, and deep energy depletion of the body. It is characterized by unresponsiveness and a steady decline in all hemodynamic parameters (Fig. 1).

Microcirculation disorders in acute blood loss are secondary and occur if centralization of blood circulation develops. Prolonged sympathoadrenal stimulation leads to a predominant vasoconstrictor response of precapillary sphincters and shunting of blood flow through arteriovenous anastomoses. This sharply reduces the intensity of the flow of blood and oxygen into the capillaries and immediately affects the nature of metabolic processes -

Blood - its formed elements and proteins are lost during acute blood loss in proportion to the magnitude of the latter. However, in normal clinical practice, it is very difficult to determine this deficit, because in the first 24 hours, when the process of natural (hydremia) or artificial (infusion therapy) blood thinning is still small, the concentration indicators practically do not change. The level of blood hemoglobin and hematocrit, the number of erythrocytes and the content of total protein begin to decrease only with a rapid loss of 40-50% of BCC or more. At the same time, there is a clear dynamics of such changes in the posthemorrhagic period (Fig. 4): the maximum decrease on days 2–4, followed by recovery to the initial level on days 10–28.

METHODS FOR DETERMINING BLOOD LOSS

There are many methods for determining blood loss, but this fact itself speaks of their imperfection. Indeed, sufficiently accurate methods are complex and therefore not widely used, while accessible and simple ones have a number of serious drawbacks or give a large percentage of error.

All methods can be divided into two groups:

Direct or indirect determination of "external" blood loss, i.e. the volume of blood lost during trauma, external bleeding, surgery, in the postoperative period,

Determination of "internal" blood loss, based on the assessment of individual compensatory mechanisms, BCC deficiency or the general resistance of the body to hypovolemia.

External blood loss can be determined by the following methods.

A visual assessment of the amount of blood loss by the degree of blood staining of the surgical material, underwear, the rate of blood flow into the wound is based on the experience of the surgeon and knowledge of the main average values ​​of blood loss during operations most often performed with his participation. However, even for experienced surgeons in the case of atypical operations, the error with this method of determination can be very large (2-3 or more times compared to the actual value). Another, more common cause of the error is hypo- or hyperchromia of the blood. In the first case, due to the lower intensity of blood staining of the surgical material and the wound (especially when hemoglobin is less than 60 g/l), the actual blood loss is always greater than the expected one and, if not underestimated, is dangerous in anemic patients. In the second case, the amount of blood loss is overestimated, which may lead to an unjustified appointment of a blood transfusion.

Weighing the patient before and after surgery on a special table-scale allows you to take into account not only the volume of blood loss, but also the loss of fluid during evaporation from the surface of the body, wounds, and breathing. However, it is difficult to take into account “net” blood loss, as well as the overall fluid balance, if the operation is long and if multicomponent infusion therapy is performed, solutions are used for irrigation and washing of the wound and cavities.

Weighing surgical material and underwear is one of the simplest methods. It does not require special equipment (it is enough to have dial scales), it can be used in any operating room, it makes it possible to determine blood loss step by step with the help of even junior medical personnel.

All varieties of the weight (gravimetric) method give an error in the range of 3-15%, which is quite acceptable for practical purposes. The main disadvantages of the method are the difficulty of accurately accounting for the mass of solutions used during the operation (for washing wounds, anesthesia, etc.), as well as the complete impossibility of determining the volume of tissue fluid or fluids flowing from cavities (peritoneal, pleural) and cystic formations. In addition, with the same total mass of blood, the loss of its liquid part and formed elements in different patients is different. Finally, blood on non-standard surgical linen (sheets, gowns, etc.) dries out rather quickly and is taken into account, as a rule, only by an approximate visual assessment.

Since the blood contains a colored substance - hemoglobin, its determination is possible using colorimetry. The fundamental basis of the colorimetric method is the determination of the total amount of hemoglobin lost by the patient with blood. The method for determining blood loss is quite simple.

A basin with tap water (5 or 10 liters, depending on the expected volume of blood loss; for children, the volume can be 1-2 liters) is placed at the operating table, where all the material moistened with blood is dumped during the operation. When stirred, the erythrocytes quickly (within 20-30 s) are hemolyzed, and the solution acquires the properties of a true one, which makes it possible to take a sample from it at any time to determine the concentration of hemoglobin. The latter can be performed both directly in the operating room using a hemometer, and in the laboratory using one or another express method. Knowing the concentration of hemoglobig in the input and blood of the patient, calculations are made.

Since the calculation by the formula requires a certain amount of time, a table is used, with the help of which the amount of blood loss is determined from known values ​​within a few seconds. The average error of the method is ± 3-8%.

This technique greatly simplifies and makes the use of devices with microprocessor devices more modern and reliable. One of the simplest foreign devices is a block of a washing device (where bloody material is placed with a certain amount of water) with a photocolorimeter that automatically calculates and indicates the amount of blood loss.

Compared to weighing methods, the colorimetric method is less dependent on unaccounted for volumes of liquids. Indeed, with a volume of water in the pelvis equal to 5 liters, an unaccounted volume of even 1 liter will give an error not exceeding 20%, which is ± 200 ml for a blood loss of 1000 ml and does not significantly change the treatment tactics. In addition, the method makes it possible to obtain the total amount of blood loss for each moment of the study. In general, this variant of the colorimetric method is preferable to weighing methods, especially for medical institutions with a limited number of employees working simultaneously in the operating room.

Determining the amount of blood loss by collecting blood into a measuring vessel directly or using an aspiration system is sometimes performed during blood reinfusion in case of injuries, ectopic pregnancy; in thoracic, vascular surgery, spine and brain surgery. The basis of the error and inconvenience of this technique is the need for strict accounting of the fluids used during the operation, as well as increased evaporation of water during continuous continuous operation of the aspirator. Perhaps, the expansion of indications for reinfusion of autologous blood, including blood collected during surgical interventions, will allow technical improvement of this method.

The determination of blood loss during minor operations by counting the number of red blood cells in the blood lost by the patient is carried out according to the following method. Before the operation, the number of erythrocytes in 1 mm 3 of the patient's blood is determined. During the operation, all material with blood is dumped into one basin containing 1 liter of physiological sodium chloride solution. After the operation, the contents of the pelvis are thoroughly mixed and the number of erythrocytes in 1 mm 3 of the solution is determined.

The determination of blood loss by measuring changes in the electrical conductivity of a dielectric solution (distilled water) when one or another amount of blood enters it is based on the constancy of its electrolyte composition. Scheme of a device that automatically determines the amount of blood loss. Since distilled water does not conduct electricity, when the electrical circuit is closed in its original position, the galvanometer needle (graded in ml of blood loss) will remain in the zero position. The entry of surgical material moistened with blood (electrolyte) into the tank will create conditions for the passage of current, and the arrow will deviate by an amount corresponding to the volume of blood loss. A significant drawback of the method is its vulnerability in the event of an electrolyte imbalance, which is quite realistic in conditions of massive blood loss and centralization of blood circulation. This reality also arises during infusion therapy of blood loss, which is unthinkable without the use of electrolyte solutions. Despite the fact that the author provided appropriate corrections for electrolytes introduced from outside, the device was not put into mass production.

Tables of average blood loss give the doctor the opportunity to tentatively predetermine the amount of probable blood loss during typical operations that occur without complications. With atypical or complicated operations, this technique is unacceptable due to the large percentage of errors. At the same time, the indicators presented in the tables of not only average losses, but also the possible (observed) maximum limits of their fluctuations allow the novice surgeon to tune in to a more realistic attitude towards blood loss during "standard" operations.

Among the indirect methods, one should not forget the approximate assessment of the amount of blood loss by determining the size of the wound by placing the hand on it ("rule of the palm"). The area occupied by one brush corresponds to a volume of about 500 ml (10% BCC), 2-3-20%, 3-5-40%, over 5-50% and more. Such an assessment allows both at the scene of the incident, at the pre-hospital stage, and upon admission of the victim to the hospital, to determine the program for first aid and subsequent therapy.

CLINIC AND DIAGNOSIS OF BLOOD LOSS

Bleeding in surgical practice is a common occurrence, and if the blood is poured out, the diagnosis and treatment tactics are not difficult. In connection with the ability to quickly stop bleeding, the risk of developing hemorrhagic shock occurs only if the heart and large vessels are damaged. With closed injuries, internal bleeding, the symptoms of blood loss are not immediately determined; the doctor's attention is focused on the formulation and formulation of the diagnosis, the fact of blood loss as the main link in pathogenesis is relegated to the background and becomes apparent only when "sudden" signs of hypovolemia appear (severe weakness, dizziness, ringing in the ears, flies before the eyes, unmotivated fainting, difficulty breathing , pallor, sweating, cold distal extremities). However, it must be taken into account that such symptoms are a consequence of a pronounced compensation for blood loss, the volume of which by this time can reach 30-50% of the BCC, because less blood loss in an initially healthy person is not clinically manifested.

In fact, the symptom complex "acute blood loss" is a clinical reflection of circulatory hypoxia (or "hypovolemic hypocirculation", according to G. N. Tsibulyak, 1976), which develops with a significant deficiency of BCC or primary weakness of adaptive and compensatory mechanisms.

Since acute blood loss is a distinctly staged process, a consistent assessment of clinical signs is appropriate.

In the initial, adaptive (adaptive) stage, clinical manifestations are scarce - only a slight increase in heart rate and respiration are detected, cardiac output increases slightly, OPS decreases without going beyond the normal range, i.e., in aggregate, a hyperkinetic type of blood circulation develops from the side of central hemodynamics . Most often, such changes are not fixed or are explained by stress, i.e., in fact, at this stage the person is still healthy, and if the BCC deficiency does not increase, all deviations spontaneously normalize, physiological balance sets in. Such dynamics is typical for blood loss not exceeding 5-15% of the BCC. With greater blood loss or insufficiency of physiological adaptation (patients with concomitant pathology of blood circulation and respiration, elderly patients, children under 3 years old, etc.), homeostatic function disorders occur, “switching on” more powerful compensation mechanisms, in particular, “centralization” of blood circulation. Therefore, clinical manifestations at this stage characterize not the amount of blood loss, but the severity of compensation.

Signs of centralization of blood circulation are quite characteristic. Systolic blood pressure (SD) is within the normal range or slightly increased (by 10-30 mm Hg); diastolic (DD) and mean (SDD) are increased, and the degree of this increase correlates with the degree of vasoconstriction. Stroke volume (SV) is naturally reduced. At the same time, MSV is maintained at the level of the previous stage, which is provided by increasing tachycardia. Peripheral venous pressure is increased, and the central one remains within the normal range. Peripheral circulation is disturbed. As a result, the skin and visible mucous membranes turn pale (a sign primarily of vascular spasm, and not anemia), the “white spot” symptom becomes positive (after pressing on the skin in the rear of the hand, the bleeding spot disappears slowly, longer than 10 s), the skin temperature decreases - it cold to the touch, dry. The difference between the temperature in the axillary region and the rectal region increases to 2-3 ° C. Capillaroscopically, the initial elements of intravascular aggregation and an increase in the number of "plasma" capillaries that do not contain erythrocytes are detected. Red blood values ​​do not go beyond normal fluctuations. Tendencies to hypercoagulation, moderate hypoalbuminsmia, and compensated metabolic acidosis are noted. Diuresis decreases to 20-30 ml/h (0.3-0.5 ml per minute). Despite the BCC deficiency, superficial veins can be successfully punctured. Consciousness is preserved, but the patient has anxiety, anxiety, sometimes excitement, increased breathing; moderate thirst.

With prolonged centralization (more than 6-8 hours), urination stops, short-term fainting may occur, especially when standing up (orthostatic instability of blood pressure).

Compensatory-adaptive mechanisms are biologically determined by non-life-threatening volumes of blood loss. Therefore, with an acute BCC deficiency of more than 30-50%, they turn out to be insolvent, which is accompanied by an unreasonably long and, as a result, pathological centralization or decompensation of blood circulation. Decompensation with blood loss is commonly referred to as hemorrhagic shock.

Diagnosis of hemorrhagic shock in the presence of an established fact of bleeding is not particularly difficult. The main clinical manifestation of this condition is arterial hypotension. The rate of fall in blood pressure depends on the rate of blood loss and the degree of stability of the circulatory system.

In the stage of "reversible" shock, there is a decrease in DM and DD. MSV is at the lower limit of normal and tends to further decrease. Tachycardia increases to limit values ​​(140-160/min). Venous pressure (both CVP and PVD) steadily decreases and can reach 0. DD, DDD and OPS evenly fall, which is a reflection of the initial signs of vascular collapse. Orthostatic instability of blood pressure increases - patients become very sensitive to changes in body position. Hypokinetic blood circulation develops and increases. In the skin and other peripheral vascular zones, along with spasmodic and "empty" vessels, there are more and more dilated capillaries with signs of total cell aggregation and cessation of blood flow, which is clinically accompanied by the appearance of "marbling" of the skin, first on the limbs, and then on body. Body temperature decreases even more (temperature gradient - more than 3 ° C); acrocyanosis appears against the background of pallor. Heart sounds are muffled; systolic murmur is often heard. ECG shows signs of diffuse changes and myocardial ischemia. Shortness of breath becomes constant, the respiratory rate reaches 40-50 per 1 min; the appearance of periodic breathing of the Kussmaul type (breathing of the “driven beast”) is possible. The symptoms of a "shock" lung are determined. Oliguria is replaced by anuria. Intestinal peristalsis, as a rule, is absent (drop in the electrokinetic potential of pacemaker membranes). With lightning-fast blood loss, blood concentrations do not change or decrease slightly; with a longer, and especially in combination with infusion therapy, they decrease, but rarely reach critical numbers (1/3 of the norm). In connection with violations of liver functions, toxins and “middle molecules” accumulate in the blood, hypoproteinemia and protein imbalance increase. Metabolic acidosis becomes uncompensated, combined with respiratory acidosis. The symptoms of DIC syndrome increase and are determined laboratory and clinically.

"Irreversible" shock differs from "reversible" only in the depth of disturbances, the duration of decompensation (more than 12 hours) and the progression of multiple organ failure. Indicators of central hemodynamics are not determined. Consciousness is absent. Generalized tonic-clonic convulsions, hypoxic cardiac arrest are possible.

A much more difficult problem in terms of diagnostics is blood loss without signs of external bleeding (for example, with a closed injury of the chest and abdomen, ectopic pregnancy, duodenal ulcer, etc.). V. D. Bratus (1989) writes quite emotionally about this:

“... Whenever, after a short time after a sudden profuse bloody vomiting, a patient is delivered to the emergency room of the surgical department, whose pale face is covered with cold sticky sweat, shiny eyes with dilated pupils look attentively and imploringly at the doctor, the latter, first of all, and painful questions relentlessly arise: what is the nature of the resulting profuse bleeding? What was the immediate cause of its occurrence? Does the bleeding still continue, and if it has stopped, what is the real threat of its resumption?...”

Indeed, the appearance of the classic triad of hypovolemia (arterial hypotension, frequent and small pulse, cold wet skin) already indicates hemorrhagic shock, when quick and vigorous action is needed.

To determine the source of internal bleeding, endoscopic and radiological (scanning, tomography) diagnostic methods are currently widely used, which make it possible to make a topical diagnosis with a high degree of certainty. In the clinical aspect, in addition to general signs of hypovolemia, centralization of blood circulation and shock, one should be aware of the symptoms most characteristic of each type of internal bleeding (esophageal, gastric, pulmonary, uterine, etc.).

GENERAL PRINCIPLES OF THERAPY FOR ACUTE BLOOD LOSS

The therapy of acute blood loss is built according to the stage of its compensation, and the algorithm of the treatment program consists of the following components:

Establishing the diagnosis of "acute blood loss" and the nature of bleeding;

Determining the stage of compensation for blood loss;

Final hemostasis and elimination of BCC deficiency;

Stabilization of central hemodynamics;

Diagnosis and correction of the consequences of hypovolemia;

Monitoring the effectiveness of therapy.

The diagnosis should be established as soon as possible, but therapeutic measures should be started even if bleeding is suspected, because the time factor in these situations is extremely important. It is especially important to identify ongoing internal bleeding with all available diagnostic methods.

The stage of development or compensation of blood loss determines the entire tactics of treatment. If it starts at the first, subclinical, stage, the effect is usually positive, it is possible to avoid the development of hypercompensation and major complications. In the early stage of circulatory centralization, when the process has not yet reached its culminating generalization, the main efforts should be aimed at reducing or eliminating centralization. At the same time, in its late stage after the onset of multiple organ failure, artificial decentralization is not only ineffective, but also dangerous, since uncontrolled collapse can develop. At this stage, rheological hemocorrectors are used, hemodilution is appropriate, correction of organ disorders, DIC syndrome is necessary. Stages of hemorrhagic shock require multicomponent substitution therapy using modern methods of intensive care and resuscitation.

Hemostasis is a prerequisite for the effectiveness of infusion therapy for blood loss. Immediate stopping of bleeding by any method suitable for a particular case (application of a tourniquet, tamponade, pressure bandage, clamping of the vessel throughout, application of a hemostatic clamp) is carried out at the prehospital stage, and the final hemostasis is performed in the dressing room or operating room of the hospital.

The elimination of BCC deficiency is the basis of the infusion program for the treatment of acute blood loss. The doctor, who is given such a task, needs to decide what, how and how much to transfuse.

When choosing a drug, it should be borne in mind that at present, even with massive acute blood loss, the first infusion agent is not blood, but blood substitutes that can quickly and steadfastly eliminate hypovolemia. This is dictated by the fact that hypoxia, even with lethal blood loss, develops as a result of circulatory rather than hemic insufficiency. In addition, whole donated blood (even fresh) has such a "set" of shortcomings that the transfusion of large amounts of it causes serious, purely fatal complications. The choice of blood substitutes and their combination with blood is determined by the stage of compensation for blood loss.

With compensated blood loss without manifestations of centralization of blood circulation (i.e., with blood loss up to 15-20% of the BCC), infusions of colloidal blood substitutes (polyglucin, blood plasma) are indicated in combination with crystalloids (Ringer's solution, lactasol, quartasol) in a ratio of 1: 2 .

In the stage of centralization of blood circulation, blood substitutes are used that have a rheological effect (rheopolyglucin with albumin, lactasol in various combinations). With concomitant DIC syndrome, as well as for its prevention, early use of fresh frozen plasma (up to 500-800 ml / day) is recommended. Whole blood is not transfused. Erythrocyte mass is indicated when the level of hemoglobin in the blood drops to 70-80 g / l (the total volume of erythrocyte-containing solutions is up to 1/3 of the volume of blood loss).

Hemorrhagic shock strongly dictates the need for active infusion therapy, and the appointment of colloid and crystalloid solutions in a 1:1 ratio is also in the first place. The most effective colloids are rheopolyglukin, albumin. Due to the relatively lower anti-shock activity, plasma can only be an addition to infusion after stabilization of hemodynamics at a safe level. You should not get carried away with infusions of large volumes of blood substitutes in order to quickly “normalize” blood pressure. If intravenous administration of 800-1000 ml of any blood substitute at a rate of 50-100 ml / min does not lead to a change (increase) in blood pressure, then there is a pronounced pathological deposition and a further increase in the volumetric infusion rate is inappropriate. In this case, without stopping the infusion of blood substitutes, vasopressors (dopamine up to 5 μg / kgmin, etc.) or glucocorticoids (hydrocortisone up to 1.5-2 g / day, etc.) are used. As in the previous stages, repeated infusions of fresh frozen plasma (up to 400-600 ml 2-4 times a day) are pathogenetically justified.

Hemorrhagic shock usually develops with massive blood loss, when a deficiency of erythrocytes leads to a deterioration in the gas transport function of the blood and there is a need for appropriate correction. The method of choice is the transfusion of erythrocyte mass or washed erythrocytes, but only after stabilization of hemodynamics and, preferably, peripheral circulation. Otherwise, the red blood cells will not be able to perform their primary function of carrying oxygen and the infusion will be useless at best.

Of the complex blood substitutes, rheogluman is very effective. Its use is advisable in the stage of centralization of blood circulation and in the initial period of hemorrhagic shock.

It is not advisable to use glucose solutions to replenish the BCC in case of blood loss. The latter quickly moves to the intracellular sector, without significantly increasing the BCC. At the same time, cellular overhydration, which develops as a result of the introduction of large amounts of glucose, plays a negative role.

Correction of BCC deficiency is carried out mainly by intravenous infusions. This method is technically simple. Infusions by this method are made into the largest, capacitive, reservoir and, therefore, have a direct effect on venous return, especially if several veins are used simultaneously, including the central veins. Puncture and catheterization of one of the central veins is a necessary condition for effective (and controlled) therapy of acute blood loss.

Compensation for moderate blood loss (including the operating room) can be provided by infusion into one vein if the lumen of the needle or catheter is about 2 mm. This diameter allows, if necessary, to inject into the vein a crystalloid solution at a rate of more than 100 ml/min, a colloid - up to 30-40 ml/min, which is sufficient for the primary correction of sudden massive bleeding.

BLOOD TRANSFUSION

Blood, you need to know, is a very special juice.

Goethe, Faust

Since time immemorial, blood has attracted the attention of the observant person. Life was identified with it, and the development of medicine and the victorious march of hemotherapy in the second half of the 20th century. only reinforced this view. Indeed, blood, being a mobile internal environment of the body and at the same time distinguished by a relative constancy of composition, performs the most important diverse functions that ensure the normal functioning of the body.

BLOOD TRANSFUSION METHODS

The main and most widely used method is indirect blood transfusion into peripheral or central veins. For transfusion, canned whole blood, red blood cells or washed red blood cells are used, depending on the infusion program. This program is compiled by a doctor based on an assessment of the nature and dynamics of the pathological process (the severity of anemia, the state of peripheral and central hemodynamics, the amount of BCC deficiency, etc.) and the main properties of the infusion drug.

Intravenous infusion makes it possible to achieve different transfusion rates (drip, jet) and is not inferior to other methods (intra-arterial, intraosseous) in efficiency, especially in cases where central veins are used or transfusion is performed simultaneously into several veins.

Blood transfusion should be carried out using disposable plastic systems. However, if these are not available, "reusable" systems manufactured directly in the hospital can be used.

The method of intra-arterial transfusion is currently practically not used, since it is technically more complicated than intravenous, and can cause serious complications associated with damage and thrombosis of arterial trunks. At the same time, with a shallow drop in vascular tone, a positive effect can be achieved with the help of vasopressors, and in the case of total circulatory decompensation, intra-arterial injection is ineffective or gives only a short-term effect.

The intraosseous method of blood transfusion is not a competitor for intravenous, but can be used when there is no access to veins, in children, with burns, etc.

Direct blood transfusion is a method of directly transfusing blood from a donor to a recipient without stabilizing or preserving it. So only whole blood can be transfused intravenously. This method does not provide for the use of filters during transfusion, which significantly increases the risk of small thrombi entering the recipient's bloodstream, which inevitably form in the transfusion system, and this is fraught with the development of thromboembolism of small branches of the pulmonary artery.

Currently, direct blood transfusion is considered as a forced therapeutic measure. It is carried out only in an extreme situation - with the development of sudden massive blood loss, in the absence of large amounts of red blood cells, fresh frozen plasma, cryoprecipitate in the doctor's arsenal. Instead of a direct blood transfusion, you can resort to a transfusion of freshly prepared "warm" blood.

The method of exchange blood transfusion (blood replacement operation - 03K) can be used if it is necessary to carry out emergency detoxification (in case of exogenous poisoning with hemolytic poisons, methemoglobin formation, hemotransfusion shock, in severe forms of hemolytic disease of the newborn, etc.) and there is no possibility apply modern, more effective and less dangerous methods (hemo- or lymphosorption, plasmapheresis, hemodialysis, peritoneal dialysis, forced diuresis, etc.).

By exchange transfusion is meant the "complete" or partial removal of blood from the bloodstream with its replacement with the same or a slightly larger amount of donor blood. For a "complete" exchange transfusion in an adult, 10-15 liters of whole donor blood is required, that is, 2-3 times more in volume than BCC. The purpose of such a transfusion is to remove toxic substances circulating in the blood. For partial replacement, 2-6 liters of blood are used.

For exchange transfusion, blood with a shelf life of no more than 5 days can be used, but freshly prepared is preferable. Moreover, it is necessary to carefully observe all the rules for preventing incompatibility.

Exchange transfusions of blood are carried out in two ways - continuous and intermittent. In the first case, bloodletting and blood transfusion are performed simultaneously, making sure that the amount of infused blood matches the amount of output. In the second case, one vein is used, alternating bloodletting with transfusion.

The operation of exchange blood transfusion begins with bloodletting (50-100 ml), after which donor blood is infused with a slight excess. The number of phlebotomies and the volume of exfused blood depend on the condition of the patient and on the level of blood pressure. If the maximum blood pressure is not lower than 100 mm Hg. Art., bloodletting up to 300-400 ml is acceptable. At lower blood pressure (not lower than 90 mm Hg), the volume of a single bloodletting should not exceed 150-200 ml. The average rate of transfusion should ensure the correspondence between the volumes of withdrawn and injected blood (50-75 ml/min). A higher rate of it can cause the phenomena of citrate shock. In the case of the use of polyglucin, the initial volume of bloodletting can be increased by 2-3 times.

Bloodletting is performed from a large vein through a needle or catheter, or by exposure and puncture of the radial artery. Blood is poured into any vein by venipuncture or venesection.

Autohemotransfusion is one of the promising methods of infusion therapy, which consists in transfusing the patient's own blood. This eliminates the risk of complications associated with group and Rh incompatibility of donor blood, the transfer of infectious and viral diseases (syphilis, hepatitis, AIDS, etc.), alloimmunization, with the development of homologous blood syndrome. In addition, the cellular elements of one's own blood take root faster and better, are functionally more complete than donor ones. It should also be emphasized that microaggregates formed when using any methods of blood preservation in freshly preserved autologous blood are not so pronounced and, most importantly, can be destroyed in the bloodstream if blood is taken and returned to the patient immediately or within the first six hours.

Autohemotransfusion is indicated for patients with a rare blood group, if it is impossible to find a donor, during surgical interventions in patients with impaired liver and kidney functions, if a large blood loss is predicted, which significantly increases the risk of transfusion complications during transfusion of donor blood and erythrocytes. Recently, autohemotransfusion has become more widely carried out even with relatively small volume of blood loss operations in order to reduce the thrombogenic risk as a result of hemodilution that occurs after blood exfusion.

Autohemotransfusion is contraindicated in severe inflammatory processes, sepsis, severe liver and kidney damage, as well as pancytopenia. It is absolutely contraindicated in pediatric practice.

The technique of autohemotransfusion does not differ from that of blood sampling from donors and is relatively simple. However, this method is rarely used in clinical practice. This is explained, firstly, by the fact that preliminary blood sampling from the patient and its stabilization must be carried out under strictly aseptic conditions (in the blood transfusion unit, operating room, in a clean dressing room) by personnel not involved in servicing surgical patients, which is not always possible. (Ideally, autotransfusion should be performed by a special team or in a hospital blood transfusion unit.) Secondly, a constraint in relation to the use of autotransfusion is that only a small volume of blood (250-400 ml) can be exfused at a time and the patient can be operated on after this. not earlier than in 5-7 days. (and if you need to prepare 1000 ml of blood or more, then the time is delayed for several weeks).

In practical medicine, more preference is given to the method of so-called intraoperative hemodilution. It consists in a single-stage blood sampling from a patient in the operating room immediately before surgery. Moreover, the patient is taken to the operating room in advance, and after introducing him into anesthesia from another peripheral (less often central) vein, necessarily under the "cover" of infusion of blood substitutes (lactasol, Ringer's solution), blood is taken (up to 800-1200 ml) into standard vials with preservative or heparin (1000 units per 500 ml of blood), replacing it with one and a half or two times the volume of Ringer's solution with reopoliglyukin or 10% albumin solution in a ratio of 3-4:1. Return of autologous blood begins from the moment of final surgical hemostasis. The rate of infusion is dictated by hemodynamic parameters. All blood should be returned to the patient during the first postoperative day. A correctly applied technique causes moderate hemodilution, which favorably affects the peripheral circulation; reduction of the absolute loss of cellular elements and blood proteins; as a rule, the normalization of hemostasis; significantly better than with the transfusion of the same volumes of donor blood, the course of the postoperative period; eliminates the need for any serological and compatibility tests, as well as additional infusions of canned donor blood.

For intraoperative hemodilution, a doctor and a nurse who own this technique are specially allocated (if the staff is not trained, it is better to use donor blood!). This technique requires sterile blood collection systems, vials of hemopreservative, heparin, accessories for peripheral vein puncture or venesection.

The method of preliminary sampling of autoplasma (plasmapheresis) with its subsequent freezing and use during surgery also deserves special attention, which makes it possible to compensate for a deficiency of up to 20-25% of the BCC without the use of donor blood.

A variety of autohemotransfusion is reinfusion, or reverse blood transfusion. If certain conditions are required when using the preliminary blood sampling method, then reinfusion can be performed for most surgical interventions, both urgent and elective. Reinfusion has gained particular value at the present time, when it has become clear what dangers the patient is exposed to when transfusing donor blood and what it costs the state in material terms. The results of numerous studies have shown that the blood pouring into the serous cavity or wound (if not bacterially contaminated) is almost identical to the blood circulating in the body. She is always "at hand" with the surgeon. Its volume is approximately equal to the amount of blood loss. The transfusion of such blood is safe and economical, and it eliminates the complications associated with the transfusion of massive doses of canned donor blood.

In urgent surgical situations, blood should be reinfused from the pleural cavity (with closed and penetrating wounds of the chest with damage to the heart, lungs, arterial and venous vessels), from the abdominal cavity (with splenic ruptures, liver injuries, damage to blood vessels and diaphragm, ectopic pregnancy); with combined thoracoabdominal wounds without damage to hollow organs (primarily the intestines); during urgent operations on the vessels of the extremities.

In elective surgery, it is necessary to reconsider the attitude to the problem of irretrievable blood loss as a fatal inevitability - in many surgical operations accompanied by large blood loss, it is possible not to drain the surgical field with tampons, but to aspirate blood from the wound and reinfuse it if the latter is not contaminated with pus or intestinal contents. This is especially true of operations on the organs of the chest, on the spine, osteoplastic operations in an orthopedic clinic.

In the postoperative period, it is possible to reinfuse the blood released on the first day through the drains (subsequently, for such a reinfusion, the discharge from the drainage must be centrifuged, and the erythrocytes must be washed from the exudate).

There are 2 main methods of reinfusion, which differ in the way blood is taken.

The simplest and least traumatic for blood cells is the method, which consists in scooping it out of the pleura or peritoneum cavity using a previously prepared and sterilized scoop, glass, glass jar. The collected blood is filtered by gravity through 8 layers of sterile gauze into a Bobrov jar or into 250 and 500 ml vials containing, respectively, 50 and 100 ml of one of the standard hemopreservatives or 500 and 1000 IU of heparin. This blood is reinfused to the patient directly during the operation or in the immediate postoperative period. To exclude possible hemolysis, it is recommended that, starting blood sampling and filtration, centrifugation of the sample taken into the test tube is recommended. Pink plasma above the erythrocyte layer indicates the presence of hemolysis. Such blood cannot be reinfused.

The second method is more convenient for blood sampling in the depth of the wound and directly from the surgical field. It is carried out with the help of aspiration systems. However, this method is used much less frequently than the first, because the blood from the surgical field, regardless of the volume lost, is not currently used, with rare exceptions. Meanwhile, this blood is similar to the blood that collects in the cavities, but its cellular elements are somewhat more traumatized during sampling.

Reinfusion of autologous blood can be performed without any samples and serological studies, with a given volumetric rate. With massive reinfusions, one should take into account the increased fibrinolytic activity of autologous blood, which can be dangerous in the hypocoagulable stage of the DIC syndrome.

Reinfusion of blood is contraindicated if the period of its stay in the cavity exceeds 24 hours or hemolysis of erythrocytes is detected or blood has poured into the cavity containing pus or intestinal contents. At the same time, it is known that reinfusion increases the body's resistance to infection and the danger is not the bacteria themselves, but the blood altered as a result of microbial contamination. This is confirmed by reports of good outcomes in reinfusions of blood infected with intestinal contents in life-threatening blood loss. Therefore, without in any way ignoring contraindications, it should be remembered that they can become relative if reinfusion is the only possible measure of help in life-threatening blood loss.

In the postoperative period, reinfusion is usually indicated in surgery of the chest cavity, when bleeding through the drains can be quite significant and usually requires hemocorrection, and transfusion of donor blood is undesirable. The peculiarity of reinfusion in such cases is as follows. Blood, accumulating in the pleural cavity, is defibrinated and does not coagulate, that is, it does not require stabilization. In the first 3-6 hours after surgery, the drainage blood contains a small amount of pleural exudate. It can be infused immediately as it accumulates. In the next 6-18 hours, the drainage extravasate retains the properties of blood serum and has an admixture of formed elements. Reinfusion of the latter is possible only after their washing in a physiological solution of sodium chloride.

COMPLICATIONS AND REACTIONS DURING BLOOD TRANSFUSION

Complications in blood transfusion may arise due to errors and technical errors, may be due to the properties of the transfused blood, as well as the immunological incompatibility of the blood of the donor and recipient.

Errors can occur due to careless documentation, failure to follow instructions, incorrect assessment of the agglutination reaction.

When determining blood groups of the ABO system, deviations from the rules are a violation of the order of arrangement of standard sera or erythrocytes in racks and their application to the plate, the wrong ratio of the amount of serum and erythrocytes, non-compliance with the time required for the reaction (5 min), failure to conduct a control reaction with the serum of the group ABo(IV), contamination or use of wet pipettes, plates, sticks, use of poor quality standards, such as expired serum (not active enough) or contaminated or partially dried serum, which can cause a non-specific agglutination reaction, etc. These deviations and the errors associated with them can lead to an incorrect assessment of the result of the reaction as a whole and in each individual drop, which may be as follows.

1. The person who determines the blood type believes that agglutination has not occurred, while it actually is or should appear. This happens:

a) when agglutination begins late or is weakly expressed, which may be due to the low activity of standard sera or the weak agglutination of the blood erythrocytes of the subject (in the presence of these two reasons, agglutination may not appear at all at the same time, for example, low-active serum of the Bα (111) group does not give agglutination with erythrocytes group Aβ (II), if the agglutination of the latter is low; in order to avoid this error, it is necessary to observe the course of the reaction for at least 5 minutes and especially carefully for those drops in which agglutination has not yet occurred; in addition, only active sera should be used, the agglutinating ability of which checked and complies with the requirements of the instructions);

b) with an excess of blood, if too large a drop of it is taken (to avoid this error, it is necessary to observe the ratio of the volumes of the tested blood and standard serum or standard erythrocytes and tested serum approximately 1:10);

c) at a high temperature (above 25 °C) of the ambient air, for example in hot weather (to avoid this error, the reaction should be carried out on a chilled plate).

2. The person who determines the blood type believes that agglutination has occurred, while in fact it is absent. This error may occur if:

a) the erythrocytes of the tested blood are folded into "money columns", which can be mistaken for agglutinates with the naked eye (to avoid this error, it is necessary to add isotonic sodium chloride solution to them and subsequently shake the plate, which, as a rule, destroys the "money columns") ;

b) the tested erythrocytes show the phenomenon of auto- or pan-agglutination (in order to avoid this error, it is impossible to determine blood groups at temperatures below 15 ° C and it is necessary to use standard sera of the ABo (V) group;

c) low-quality serum is used, giving non-specific agglutination (to avoid this error, it is necessary to tightly cork open ampoules with serum with cotton wool or adhesive tape, however, in this case, you can not use cloudy serum or with signs of drying);

d) the mixture of erythrocytes and serum is not shaken (in this case, erythrocytes, settling to the bottom, form separate clusters that can simulate agglutination; in order to avoid this error, it is necessary to periodically shake the plate on which the determination is carried out);

e) observation is carried out for too long - more than 5 minutes (in this case, the mixture of erythrocytes and serum begins to dry out and granularity appears on its periphery, which simulates agglutination; in order to avoid this error, the observation time should not exceed 5 minutes).

However, even with a correct assessment of the reaction in each individual drop, an erroneous conclusion can be made about the blood group, if the order of the standards in a stand or on a plate is confused.

In all cases of indistinct or questionable results, it is necessary to re-determine the blood group using standard sera from other series, as well as by the cross method.

Errors in determining the Rh factor can be caused by:

a) the use of anti-Rhesus serum without taking into account the blood group (to avoid this mistake, Rh-affiliation should always be determined only after determining the blood group of the A BO system);

b) the wrong ratio of serum and erythrocyte volumes (the basic rule should be observed: erythrocytes should always be several times less than serum);

c) a change in the temperature regime (in laboratory studies by the method of conglutination or agglutination in a salt medium, the temperature should be within the limits of 46-48 ° C and 37 ° C, respectively);

d) adding a drop of isotonic sodium chloride solution (causes dilution and a decrease in serum activity);

e) early (up to 10 minutes) or late (drying) evaluation of the result.

Technical errors are rare these days. However, they can lead to serious, sometimes fatal complications.

An air embolism can occur if the blood transfusion system is not properly filled, and especially when using the blood pumping method. This formidable complication develops as a result of air entering through the bloodstream into the right heart and then into the lungs. It is manifested by sudden shortness of breath, anxiety, rapidly increasing cyanosis of the face and acrocyanosis, tachycardia and cardiac arrhythmia, a sharp decrease in blood pressure (due to acute hypoxic coronary artery bypass grafting). Sometimes a characteristic "purr" can be heard above the heart. Massive air embolism leads to lightning death.

In order to prevent air embolism during the transfusion of blood and its components, it is strictly forbidden to use any injection equipment, and it should be transfused only with disposable plastic systems. Even if an air embolism is suspected, it is necessary to immediately begin cardiopulmonary resuscitation (indirect heart massage, mechanical ventilation using the “mouth-to-mouth” method), in no case removing the needle (or catheter) from the vein, so that infusion and drug therapy (naturally, the blood transfusion system should be replaced and an infusion of rheopolyglucin or lactasol should be started). The choice of further measures depends on the effect of primary resuscitation.

Pulmonary embolism (PE) is also a very serious complication. Its main cause may be the ingress of an embolus (blood clot) into various vessels of the small circle (the trunk of the pulmonary artery, its main or small branches) and their acute occlusion. Large emboli, if there is a filter dropper in the transfusion system, cannot enter the patient's venous system. Their source can be either thrombophlebitis, stagnation of blood in the veins of the lower extremities, etc. of the patient himself, or blood clots that form directly in the puncture needle (or catheter). Therefore, most often there is embolization and thrombosis of small branches of the pulmonary artery and the clinical picture does not develop as rapidly as it happens with embolism of the main trunk or main branches: anxiety, shortness of breath, chest pain, tachycardia, moderate arterial hypertension appear; body temperature usually rises, hemoptysis is possible; X-ray may reveal infarction-pneumonia or interstitial pulmonary edema. Any form of PE, including small branches, is always accompanied by acute respiratory failure, manifested by increased respiration, hypoxemia and hypercapnia.

In case of violation of the permeability of the vessel wall or its damage, bleeding begins. In this case, blood can flow from the vessel or into the body, or out through wounds on the skin or natural openings: nose, mouth, vagina, anus. The classification of bleeding is quite complicated and is divided depending on the time and causes of its occurrence, the type of damaged vessel, the rate of development, the volume of blood lost, and the severity.

Causes

There are two main causes of bleeding: as a result of trauma and due to internal pathological processes, that is, they are traumatic and atraumatic (or pathological).

traumatic

They arise as a result of exposure to traumatic factors that exceed the characteristics of the strength of the vessels. In this case, mechanical damage to the vascular wall occurs. This is the most common cause of bleeding.

Atraumatic

May begin without any provoking factor. Occur in the following cases:

• with pathological processes occurring in the body: ulceration, necrosis, destruction of the vascular wall, for example, with the collapse of a tumor, inflammation, peritonitis and others;
• with increased permeability of the vessel wall at the microscopic level, which can happen with diseases such as hemorrhagic vasculitis, vitamin C deficiency, scarlet fever, uremia, sepsis and others.

The process of bleeding to a large extent depends on the state of the coagulation system. By themselves, violations in her work cannot be the cause of bleeding, but significantly worsen the situation. If a small vessel is damaged, with a normally working hemostasis system, significant blood loss does not occur and the blood stops quickly. If, for example, the process of thrombus formation is disturbed in the body, then even a minor injury can result in death from blood loss. An example of a disease in which the process of hemostasis is impaired is hemophilia.

Classifications

In medical practice, several classifications of bleeding are accepted according to various criteria.

Anatomical

Bleeding in this case is divided according to the type of damaged vessel:

1. Capillary. Occur when small veins, arteries, capillaries are damaged. Usually not massive, as a rule, the entire damaged surface bleeds (in the form of a mesh).
2. Venous. Characterized by a continuous stream of dark blood. The speed depends on the diameter of the vein: the larger it is, the faster it flows out. Bleeding from the neck veins is the most dangerous, since there is a possibility of developing an air embolism.
3. Arterial. The speed is often high, the amount of blood lost depends on the diameter of the vessel and the type of damage. Scarlet blood flows out under pressure, usually in a pulsating stream.
4. Parenchymal. Occur when damaged organs such as the liver, lungs, kidneys, spleen, which are called parenchymal. These bleedings are capillary, but due to the anatomical features of these organs, they are dangerous.
5. Mixed . In this case, all types of vessels bleed simultaneously.

By time of occurrence

According to this classification, there are two types: primary and secondary bleeding:

• Primary - begin immediately after damage to the vessel.
• Secondary - occur some time after the injury. They are further divided into two types: early (within three days from the moment of injury, after the thrombus is pushed out of the damaged vessel) and late (three days after the injury, usually due to the development of purulent inflammatory processes).

In relation to the external environment

According to this classification, bleeding is divided into several types:

• External - blood flows from an ulcer or wound located on the surface of the body, so they are easily diagnosed.
• Internal - occur in organs, their cavities, tissues. They are divided into strip (blood pours into the articular, pleural, abdominal, pericardial cavities) and interstitial (blood pours into the thickness of the tissues and forms hematomas). Accumulations of blood that has poured into a cavity or tissue are called hemorrhages in medicine. There are several types: petechiae, ecchymosis, bruising, hematoma, vibices.
• Hidden - do not have pronounced signs, according to some classifications they are internal.

By type of flow

There are two types:

• Acute - blood flows out in a short time.
• Chronic - characterized by the duration of bleeding, while there is a gradual release of blood in small portions. The duration of bleeding is typical for diseases such as hemorrhoids, stomach ulcers, malignant tumors, uterine fibroids and others.

By severity

There are several classifications on this basis. Most often, four degrees of severity are distinguished:

• Mild - blood loss is from 10 to 12%, or from 500 to 700 ml.
• Average - from 16 to 20%, or up to 1400 ml.
• Severe - from 20 to 30%, or from 1500 to 2000 ml.
• Massive - blood loss over 30%, or more than 2000 ml.

This classification of bleeding is very important. An assessment of the severity helps to determine the nature of circulatory disorders and the danger of blood loss for a person. Knowing the severity is necessary in order to correctly prescribe treatment and choose the tactics of blood transfusion.

Severe bleeding can be fatal, and usually death in this case is due to acute cardiovascular failure. Sometimes the cause of death can be the loss of blood functions (transfer of gases, nutrients, metabolic products).

The outcome of bleeding is determined by the rate and volume of blood loss. A loss of more than 40% is considered incompatible with life. In chronic processes, a person can lose no less blood and have a low level of red blood cells, but at the same time live and work. When assessing severity, consider:

• the general condition of the patient (initial anemia, the presence of shock, cardiovascular insufficiency, exhaustion of the body);
• his gender;
• age.

In case of bleeding, the wound must be treated with an antiseptic and a pressure bandage applied; an unwound bandage can be used as a tampon

Help with bleeding

Violation of the integrity of tissues and blood vessels is a frequent phenomenon, so each person should know what to do with bleeding. Properly rendered first aid can save a person's life.

capillary

This slight bleeding usually stops on its own quickly. In some cases, a bandage is required. Before bandaging, the wound must be treated with an antiseptic solution.

Venous

This bleeding is characterized by the fact that dark blood flows in a jet. If possible, the victim is placed in such a way that the damaged area is above the level of the heart.

For moderate bleeding, packing and applying a tight bandage will suffice. A rolled bandage can be used as a tampon.

With severe bleeding, a tourniquet is required below the injury site. If the blood stops, then the help is provided correctly.

With arterial bleeding, an immediate stop of blood is required, which is usually done by pressing the damaged vessel against the nearest bone so that its lumen is completely closed

Arterial

It is distinguished by scarlet blood, beating with a fountain. If medium-sized vessels are damaged, then tight bandaging may be sufficient. If a large artery is damaged, a tourniquet will be required, after which the patient should be taken to the hospital for treatment as soon as possible. Before doing this, you need to do the following:

1. Lay the victim down so that the wound is above the heart.
2. To stop the bleeding before applying the tourniquet, press the damaged artery with your finger.
3. Now you need to apply a tourniquet above the wound. It can be replaced with any suitable item at hand: a belt, a towel, a rope, etc.
4. The tourniquet can not be kept for more than one and a half hours. Therefore, if a person could not be delivered to a medical facility during this time, you need to press the artery with your finger, remove the tourniquet for five minutes, and then apply it again, but a little higher than last time.

The tourniquet cannot be applied for more than an hour and a half, so you must always attach a note in which you indicate the time of its application

Internal

It is difficult to recognize such bleeding on your own, but if there is a suspicion of it, then the following must be done:

1. The victim should take a semi-sitting or lying position, while a pillow should be placed under the legs.
2. If bleeding in the stomach is expected, a person should not drink or eat, you can only rinse your mouth with cool water.
3. Cold should be applied to the site of suspected bleeding. It can be, for example, a bottle of water, under which you need to put a piece of cloth.

Methods for stopping blood

Stopping the blood is spontaneous and artificial. The second, in turn, is divided into temporary and final. Before the victim is taken to a medical facility for treatment, the following methods of temporary stop are used:

1. The easiest and most affordable way is tamponade and dressing. It is effective in bleeding from veins, capillaries and small arteries. With the help of a swab and a pressure bandage, the lumen of the vessel is reduced, which leads to the formation of a blood clot.
2. Pressing the vessel with a finger necessary when an immediate stop of blood from an artery is needed. The vessel is pressed against the nearby bones above the wound, in case of damage to the cervical arteries - below the wound. To perform this technique, you need to make an effort so that the lumen of the artery is completely closed. The carotid artery is pressed against the tubercle of the transverse process of the sixth cervical vertebra, the subclavian artery - against the first rib at a point above the clavicle, the femur - against the pubic bone, the humerus - against the humerus (its inner surface), the axillary - against the head of the humerus in the armpit.
3. The most reliable way is to apply a tourniquet. Due to its simplicity and availability, it is widely used. Despite some shortcomings, it fully justifies itself in providing first aid for injured limbs. If it is applied correctly, the bleeding will immediately stop. When working with a tourniquet, certain rules must be observed in order to avoid the negative consequences of squeezing the limb. It must be remembered that it must be applied only to the lining and for no more than 1.5 hours, and in winter no more than an hour. It should be clearly visible, so a piece of bandage is tied to it. Be sure to attach a note in which to write the time of application of the tourniquet.
4. Another well-known and fairly effective method is limb flexion. It is necessary to bend all the way in the joint (knee, elbow, hip), which is located above the wound, and then fix it with bandaging.

For the final stop of the blood, the patient is taken to the hospital, where he will be treated further. The final methods are:

• suturing;
• tamponade when it is impossible to suture the vessel;
• embolization - the introduction of an air bubble into the vessel and its fixation at the site of damage;
• local administration of hemocoagulants (substances for blood clotting of artificial or natural origin).

Conclusion

Bleeding can be life-threatening, so you need to learn to distinguish between their types and be able to properly provide first aid, on which a person’s life may depend. Even a temporary stop of blood, before the patient is taken to the hospital for treatment, can be decisive.

Table of contents of the subject "Acute Blood Loss. Classification of Bleeding. Classification of Bleeding. Injuries and Wounds of Body Parts. Head Injury. Head Bruise. Brain Bruise (UGM). Traumatic Brain Injury (TBI, TBI).":


3. Classification of bleeding according to the time of occurrence. primary bleeding. Secondary bleeding. Early and late secondary bleeding. Classification of bleeding according to the rate of development. Lightning blood loss. Acute bleeding. Chronic blood loss.
4. Clinic of bleeding. General principles of treatment of external acute blood loss. Immediate temporary stop of external bleeding. Temporary stop of bleeding. Quick stop bleeding. Stop bleeding from wounds of the neck and head.
5. Stop bleeding from wounds of the upper extremities. Clamping of blood vessels. Stop bleeding of the lower extremities. Harness. The imposition of a tourniquet. Harness rules.
6. Injuries and injuries of body parts. Head injury. Head injury. Traumatic brain injury (TBI, TBI).
7. Diagnosis of traumatic brain injury (TBI, TBI). Signs of a head injury. General issues in the diagnosis of TBI. Cerebral symptoms.
8. Classification of traumatic brain injury (TBI, TBI). Classification of head injuries. Closed craniocerebral injury (TBI). Concussion of the brain (CCM).
9. Brain contusion (UGM). Minor brain injury. Brain contusion of moderate severity.
10. Brain contusion of severe severity. Brain compression. intracranial hematoma. Compression of the brain by a hematoma. Lucid interval.

Acute blood loss is a syndrome that occurs in response to a primary decrease in BCC. Classification of bleeding is carried out according to the source, clinical manifestations, time of occurrence, depending on the location of the source of bleeding, on the volume of BCC deficiency and the rate of blood loss.

I. By source:
1. Arterial bleeding.
2. Venous bleeding.
3. Parenchymal (and capillary) bleeding.
4. Mixed bleeding.

II. According to clinical manifestations:
1. External bleeding.
2. Internal bleeding.
3. Hidden bleeding.

III. By time of occurrence:
1. Primary bleeding.
2. Secondary bleeding: early secondary, late secondary.

IV. Depending on the localization of the source of bleeding: pulmonary, esophageal, gastric, intestinal, renal, etc.

V. Depending of the volume of deficit of the BCC in percent: light (15-25%), medium (25-35%), heavy (35-50%), massive (more than 50%).

VI. According to the rate of blood loss:
1. Lightning (more often massive).
2. Acute blood loss.
3. Chronic blood loss.

Blood loss - a pathological process that occurs as a result of bleeding and is characterized by a complex set of pathological disorders and compensatory reactions to a decrease in circulating blood volume and hypoxia due to a decrease in the respiratory function of the blood.

Etiological factors of blood loss:

Violation of the integrity of blood vessels (wound, damage by a pathological process).

Increased vascular wall permeability (ARP).

Reduced blood clotting (hemorrhagic syndrome).

In the pathogenesis of blood loss, 3 stages are distinguished: initial, compensatory, terminal.

Initial. BCC decreases - simple hypovolemia, cardiac output decreases, blood pressure falls, circulatory type hypoxia develops.

Compensatory. A complex of protective and adaptive reactions is activated, aimed at restoring the BCC, normalizing hemodynamics, and providing oxygen to the body.

terminal stage blood loss can occur with insufficient adaptive reactions associated with severe diseases, under the influence of adverse exogenous and endogenous factors, extensive trauma, acute massive blood loss exceeding 50-60% of the BCC and the absence of therapeutic measures.

In the compensatory stage, the following phases are distinguished: vascular-reflex, hydremic, protein, bone marrow.

Vascular reflex phase lasts 8–12 hours from the onset of blood loss and is characterized by spasm of peripheral vessels due to the release of catecholamines by the adrenal glands, which leads to a decrease in the volume of the vascular bed (“centralization” of blood circulation) and helps to maintain blood flow in vital organs. Due to the activation of the renin-angiotensin-aldosterone system, the processes of sodium and water reabsorption in the proximal tubules of the kidneys are activated, which is accompanied by a decrease in diuresis and water retention in the body. During this period, as a result of an equivalent loss of blood plasma and formed elements, a compensatory flow of deposited blood into the vascular bed, the content of erythrocytes and hemoglobin per unit volume of blood and the hematocrit value remain close to the original ("hidden" anemia). Early signs of acute blood loss are leukopenia and thrombocytopenia. In some cases, an increase in the total number of leukocytes is possible.

Hydramic phase develops on the 1st or 2nd day after blood loss. It is manifested by the mobilization of tissue fluid and its entry into the bloodstream, which leads to the restoration of plasma volume. "Dilution" of blood is accompanied by a progressive decrease in the number of erythrocytes and hemoglobin per unit volume of blood. Anemia is normochromic, normocytic in nature.

Bone marrow phase develops on the 4-5th day after blood loss. It is determined by an increase in the processes of erythropoiesis in the bone marrow as a result of hyperproduction by the cells of the juxtaglomerular apparatus of the kidneys, in response to hypoxia, erythropoietin, which stimulates the activity of the committed (unipotent) precursor cell of erythropoiesis - CFU-E. The criterion for sufficient regenerative capacity of the bone marrow (regenerative anemia) is an increase in the blood content of young forms of erythrocytes (reticulocytes, polychromatophiles), which is accompanied by a change in the size of erythrocytes (macrocytosis) and the shape of cells (poikilocytosis). Perhaps the appearance of erythrocytes with basophilic granularity, sometimes single normoblasts in the blood. Due to increased hematopoietic function of the bone marrow, moderate leukocytosis develops (up to 12×10 9 /l) with a shift to the left to metamyelocytes (less often to myelocytes), the number of platelets increases (up to 500×10 9 /l and more).

Protein compensation is realized due to the activation of proteosynthesis in the liver and is detected within a few hours after bleeding. Subsequently, signs of increased protein synthesis are recorded within 1.5-3 weeks.

Types of blood loss:

By type of damaged vessel or chamber of the heart:

arterial, venous, mixed.

By the volume of blood lost (from BCC):

mild (up to 20-25%), moderate (25-35%), severe (more than 35-40%).

According to the time of onset of bleeding after an injury to the heart or vessel:

Primary - bleeding begins immediately after the injury.

Secondary - bleeding delayed in time from the moment of injury.

Place of bleeding:

External - hemorrhage into the external environment.

Internal - hemorrhage in the body cavity or in the organs.

The outcome of bleeding is also determined by the state of the body's reactivity - the perfection of adaptation systems, gender, age, concomitant diseases, etc. Children, especially newborns and infants, endure blood loss much harder than adults.

A sudden loss of 50% of the BCC is fatal. Slow (over several days) blood loss of the same volume of blood is less life-threatening, since it is compensated by adaptation mechanisms. Acute blood loss of up to 25–50% of the BCC is considered life-threatening due to the possibility of developing hemorrhagic shock. In this case, bleeding from the arteries is especially dangerous.

Recovery of erythrocyte mass occurs within 1–2 months, depending on the volume of blood loss. In this case, the reserve fund of iron in the body is consumed, which can cause iron deficiency. Anemia in this case acquires a hypochromic, microcytic character.

The main dysfunctions of organs and systems in acute blood loss are shown in Fig. 1

Figure 1. - The main violations of the functions of organs and systems in acute blood loss (according to V.N. Shabalin, N.I. Kochetygov)

Continued bleeding leads to the depletion of the body's adaptive systems involved in the fight against hypovolemia - develops hemorrhagic shock. Protective reflexes of the macrocirculation system in this case are no longer sufficient to ensure adequate cardiac output, as a result of which systolic pressure quickly drops to critical numbers (50-40 mm Hg). The blood supply to the organs and systems of the body is disturbed, oxygen starvation develops and death occurs due to paralysis of the respiratory center and cardiac arrest.

The main link in the pathogenesis of the irreversible stage of hemorrhagic shock is the decompensation of blood circulation in the microvasculature. Violation of the microcirculation system occurs already in the early stages of the development of hypovolemia. Prolonged spasm of capacitive and arterial vessels, aggravated by a progressive decrease in blood pressure with incessant bleeding, sooner or later leads to a complete stop of microcirculation. Stasis sets in, erythrocyte aggregates form in spasmodic capillaries. The decrease and slowdown of blood flow occurring in the dynamics of blood loss are accompanied by an increase in the concentration of fibrinogen and globulins in blood plasma, which increases its viscosity and promotes erythrocyte aggregation. As a result, the level of toxic metabolic products rapidly increases, which becomes anaerobic. Metabolic acidosis is compensated to a certain extent by respiratory alkalosis, which develops as a result of reflex hyperventilation. Gross violations of vascular microcirculation and the entry of under-oxidized metabolic products into the blood can lead to irreversible changes in the liver and kidneys, as well as adversely affect the functioning of the heart muscle even during the period of compensated hypovolemia.

Measures for blood loss

Treatment for blood loss is based on etiotropic, pathogenetic and symptomatic principles.

anemia

Anemia(literally - anemia, or general anemia) is a clinical and hematological syndrome characterized by a decrease in hemoglobin and / or the number of red blood cells per unit volume of blood. Normally, the content of erythrocytes in peripheral blood in men averages 4.0-5.0×10 12 /l, in women - 3.7-4.7×10 12 /l; the hemoglobin level is 130-160 g/l and 120-140 g/l, respectively.

Etiology: acute and chronic bleeding, infections, inflammation, intoxication (with salts of heavy metals), helminthic invasions, malignant neoplasms, beriberi, diseases of the endocrine system, kidneys, liver, stomach, pancreas. Anemia often develops in leukemia, especially in their acute forms, with radiation sickness. In addition, pathological heredity and disorders of the body's immunological reactivity play a role.

General symptoms: pallor of the skin and mucous membranes, shortness of breath, palpitations, as well as complaints of dizziness, headaches, tinnitus, discomfort in the heart, severe general weakness and fatigue. In mild cases of anemia, general symptoms may be absent, since compensatory mechanisms (increased erythropoiesis, activation of the functions of the cardiovascular and respiratory systems) provide the physiological need for oxygen in tissues.

Classification. The existing classifications of anemias are based on their pathogenetic features, taking into account the peculiarities of etiology, data on the content of hemoglobin and erythrocytes in the blood, erythrocyte morphology, type of erythropoiesis and the ability of the bone marrow to regenerate.

Table 1. Anemia classification

Criteria	Types of anemia
I. For a reason	Primary Secondary
II. By pathogenesis	Posthemorrhagic Hemolytic Diserythropoietic
III. By type of hematopoiesis	Erythroblastic Megaloblastic
IV. By the ability of the bone marrow to regenerate (by the number of reticulocytes)	Regenerative 0.2-1% reticulocytes Regenerative (aplastic) 0% reticulocytes Hyporegenerative< 0,2 % ретикулоцитов Hyperregenerative > 1% reticulocytes
V. By color index	normochromic 0.85-1.05 hyperchromic >1.05 hypochromic< 0,85
VI. The size of red blood cells	Normocytic 7.2 - 8.3 microns Microcytic:< 7,2 мкм Macrocytic: > 8.3 - 12 microns Megalocytic: > 12-15 microns
VII. According to the severity of development	chronic

Bleeding(haemorragia: synonym for hemorrhage) - intravital outflow of blood from a blood vessel in case of damage or violation of the permeability of its wall.

Classification of bleeding

Depending on the sign underlying the classification, the following types of bleeding are distinguished:

I. Due to the occurrence:

1). Mechanical bleeding(h. per rhexin) - bleeding caused by a violation of the integrity of blood vessels in trauma, including combat damage or surgery.

2). Arrosive bleeding(h. per diabrosin) - bleeding that occurs when the integrity of the vessel wall is violated due to the germination of the tumor and its decay, when the vessel is destroyed by continued ulceration during necrosis, a destructive process.

3). Diapedetic bleeding(h. per diapedesin) - bleeding that occurs without violating the integrity of the vascular wall, due to an increase in the permeability of small vessels due to molecular and physico-chemical changes in their wall, in a number of diseases (sepsis, scarlet fever, scurvy, hemorrhagic vasculitis, phosphorus poisoning and etc.).

The possibility of bleeding is determined by the state of the blood coagulation system. In this connection, they distinguish:

- fibrinolytic bleeding(h. fibrinolytica) - due to a violation of blood clotting due to an increase in its fibrinolytic activity;

- cholemic bleeding(h. cholaemica) - due to a decrease in blood clotting in cholemia.

II. By type of bleeding vessel (anatomical classification):

1). arterial bleeding(h. arterialis)- Bleeding from a damaged artery.

2). Venous bleeding(h. venosa)- bleeding from an injured vein.

3). Capillary bleeding(h.capillaris) - bleeding from capillaries, in which blood oozes evenly over the entire surface of damaged tissues.

4). Parenchymal bleeding(h. parenchymatosa) - capillary bleeding from the parenchyma of any internal organ.

5). Mixed bleeding(h. mixta) - bleeding occurring simultaneously from arteries, veins and capillaries.

III. In relation to the external environment and taking into account clinical manifestations:

1). External bleeding(h. extema) - bleeding from a wound or ulcer directly to the surface of the body.

2). Internal bleeding(h.intema) - bleeding into tissues, organs or body cavities.

3). Hidden bleeding(h. occuta) - bleeding that does not have pronounced clinical manifestations.

In turn, internal bleeding can be divided into:

a) Internal bleeding(h. Cavalis) - bleeding into the abdominal, pleural or pericardial cavity, as well as into the joint cavity.

b) Interstitial bleeding(h. interstitialis) - bleeding into the thickness of the tissues with their diffuse imbibition, stratification and hematoma formation.

The accumulation of blood from a vessel in the tissues or cavities of the body is called hemorrhage(haemorrhagia).

ecchymosis(ecchymosis) - extensive hemorrhage into the skin or mucous membrane.

Petechia(petechia, syn. point hemorrhage) - a spot on the skin or mucous membrane with a diameter of 1-2 mm, caused by capillary bleeding.

Vibices(vibices, syn. purple linear spots) - hemorrhagic spots in the form of stripes.

Bruise(suffusio, bruise) - hemorrhage into the thickness of the skin or mucous membrane.

Hematoma(haematoma, synonymous with bloody tumor) - a limited accumulation of blood in tissues with the formation of a cavity in them containing liquid or clotted blood.