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HAEMORRHAGE
&
BLOOD TRANSFUSION
By;
Col Abrar Hussain Zaidi
SEQUENCE
INTRODUCTION
importance
physiology/homeostasis
integrity of circulatory system
TYPES/CAUSES
CONTROLE METHODS
BLOOD TRANSFUSION
INTRODUCTION
INTRODUCTION
Definitions
Haemorrhage--bleeding
Escape of blood from a blood-vessel
Exsanguination- total loss of blood
Desanguination- major loss of blood
[Encyclopedia Britannica]
INTRODUCTION
Subject’s importance
Haemorrhage is one of the basic problems
and considerations in surgery
From-trivial trauma or major abdominal organ
injuries-to- congenital and acquired
coagulation disorders
A wide spectrum of problems involves
haemorrhage
Transfusion of blood is the main remedy
INTRODUCTION
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Clinical
Situation
Trauma /accidents
General operatiove interventions
Gynaecological procedures
Congenital coagulation disorders
Acquired coagulation disorders
Dic
Anticoagulants
Fulminent sepsis
Mof
• Common surgical conditions pres w bleed
Intracranial haemorrhages/cva
Upper git bleed/haemetemesis and melena
Bleeding haeorrhoids
Chronic wounds
Anal fissures
Aneurysms
INTRODUCTION
Physiology
• BODY’S SYSTEM OF HOMEOSTSIS
• INTEGRITY OF EVERY SYSTEM
ANATOMICAL
FUNCTIONAL
INTRODUCTION
Claude Bernard’s concepts
French physiologist Claude Bernard (18131878), the founder of experimental
physiology and experimental pharmacology.
Bernard believed that the body has
mechanisms by which it seeks to maintain a
stable internal environment despite changes
in the external environment- Homeostasis
[ 1851]
INTRODUCTION
What Prevents Haemorrhage
NATURAL BARRIERS AGAINST HAEMORRHAGE
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Integrity of vascular wall
Coagulation system
INTRODUCTION
Body’s response to
haemorrhage/injury
Attempts to repair the loss & restore
normality
There are several interrelated stages
Local response / Gen response
Aims at:
•
wall repair
•
Restoration of volume loss
INTRODUCTION
Body’s response to
haemorrhage/injury
Virchow 1856 famous triad:
• 1. Stasis
• 2. Endothelial damage
• 3. Hypercoaguable states
local
• Vasoconstriction
• Platelet aggregation and plug formation
• Coagulation leading to Fibrin formation –Intrinsic &
Extrinsic Paths
General
• Compartmental Volume movement
PATHOLOGICAL BASIS OF
HAEMORRHAGE
BLEEDING CAN RESULT DUE TO:
LOSS OF INTEGRITY OF WALL
TRAUMA/OERATIONS
COAGULATION DEFECTS
CONGENITAL - H.PH
AQUIRED
-DIC
ETIOLOGY OF HAEMORRHAGE
CAUSES OF HAEMORRHAGE
•
INJURY /TRAUMA [+ operations]-It commonly results in
tearing or cutting of a blood-vessel-integrity of
wall breached - Trivial OR Major
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DISEASES
that alter coagulation
Congenital –platelet defects
Coagulation factor defects
Acquired
scurvy
Sepsis
DIC
TYPES OF HAEMORRHAGE
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AMOUNT OF LOSS --MINOR/MAJOR
ACUTE/CHRONIC
ARTERIAL/VENOUS/CAPILLARY/MIXED
LOCALIZED/DIFFUSE
EXTERNAL/ INTERNAL
OVERT/OCCULT
TYPES OF HAEMORRHAGE
Bleeding from an artery is of a bright red colour, and
escapes from the end of the vessel nearest the heart
in jets synchronous with the heart's beat
Bleeding from a vein is of a darker colour; the flow is
steady, the bleeding is from the distal end of the
vessel .
Capillary bleeding is a general oozing from a raw
surface .
TYPES OF HAEMORRHAGE
SPECIFIC TYPES
• Bruise or ecchymosis .
Extravasation of blood /pouring out of blood
into the areolar tissues, which become boggy
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Haematemesis and melena
Haemoptysis .
Haematuria
Epistaxis
TYPES OF HAEMORRHAGE
CLASSIFICATION OF SURGICAL HAEMORRHAGE
Haemorrhage has been classified as—
1-Primary, occurring at the time of the injury
2-Reactionary, or within twenty-four hours of the
accident, during the stage of reaction
3-Secondary, occurring at a later period and
caused by faulty application of a ligature or
septic condition of the wound . In severe
haemorrhage, as from the division of a large
artery, the patient may collapse and death
ensue from syncope .
Hemorrhage -four classes
American
College of Surgeons' Advanced Trauma Life Support (ATLS)
• Class I Hemorrhage involves up to 15% of blood volume.
There is typically no change in vital signs and fluid
resuscitation is not usually necessary.
• Class II Hemorrhage involves 15-30% of total blood
volume. A patient is often tachycardic (rapid heart beat)
with a narrowing of the difference between the systolic
and diastolic blood pressures. The body attempts to
compensate with peripheral vasoconstriction. Skin may
start to look pale and be cool to the touch. The patient
may exhibit slight changes in behavior. Volume
resuscitation with crystalloids (Saline solution or Lactated
Ringer's solution) is all that is typically required. Blood
transfusion is not typically required.
Hemorrhage -four classes
American
College of Surgeons' Advanced Trauma Life Support (ATLS
• Class III Hemorrhage
involves loss of 30-40% of circulating blood
volume.
blood pressure drops, the heart rate
increases, peripheral perfusion (shock), such as
capillary refill worsens, and the mental status
worsens. Fluid resuscitation with crystalloid and
blood transfusion are usually necessary.
• Class IV Hemorrhage involves loss of >40% of
circulating blood volume. The limit of the body's
compensation is reached and aggressive
resuscitation is required to prevent death.
NB
Fit Individuals may have more effective compensatory
mechanisms before experiencing cardiovascular collapse.
These patients may look deceptively stable, with minimal
derangements in vital signs, while having poor peripheral
perfusion.
Elderly patients or those with chronic medical conditions
may have less tolerance to blood loss, less ability to
•
compensate, and may take medications such as
betablockers that can potentially blunt the cardiovascular
response. Care must be taken in the assessment of these
patients.
EFFECTS OF HAEMORRHAGE
Depend upon following:
• Acute loss vs Chronic loss
• The amount of loss
• The compensatory mechanisms
• General state of health
EFFECTS OF HAEMORRHAGE
Depends upon the amount of blood loss
Stages of Hypovolemia
Stage 1
• Up to 15% blood volume loss (750mls)
• Compensated by constriction of vascular bed
• Blood pressure maintained
• Normal respiratory rate
• Pallor of the skin
• Slight anxiety
EFFECTS OF HAEMORRHAGE
Stage 2
• 15-30% blood volume loss (750 - 1500mls)
• Cardiac output cannot be maintained by arterial
constriction
• Tachycardia >100bpm
• Increased respiratory rate
• Blood pressure maintained
• Increased diastolic pressure
• Narrow pulse pressure
• Sweating from sympathetic stimulation
• Mildly anxious/Restless
EFFECTS OF HAEMORRHAGE
Stage 3
• 30-40% blood volume loss (1500 - 2000mls)
• Systolic BP falls to 100mmHg or less
• Classic signs of hypovolemic shock
• Marked tachycardia >120 bpm
• Marked tachypnoea >30 bpm
• Decreased systolic pressure
• Alteration in mental status (Anxiety, Agitation)
• Sweating with cool, pale skin
EFFECTS OF HAEMORRHAGE
Stage 4-----Shock
• Loss greater than 40% (>2000mls)
• Extreme tachycardia with weak pulse
• Pronounced tachypnoea
• Significantly decreased systolic blood
pressure of 70 mmHg or less
• Decreased level of consciousness
• Skin is sweaty, cool, and extremely pale
(moribund)
MANAGEMENT OF HAEMORRHAGE
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Prevention
Precautions during surgery
Operative method of control of
haemorrhage
Blood Transfusion
SURGICAL HAEMOSTASIS
NATURAL OR ARTIFICIAL
Natural CONTROLE/arrest of haemorrhage arises
from ;
(1) the coagulation of the blood itself,
(2) the diminution of the heart's action as in
fainting,
(3) changes taking place in the cut vessel
causing its retraction and contraction .
SURGICAL HAEMOSTASIS
EXTERNAL HAEMORRHAGE /WOUNDS
The surgical procedure for the treatment of an
open wound is(1) arrest of haemorrhage;
(2) cleansing of the wound and removal of any
foreign bodies;
(3) careful apposition of its edges and surfaces—
sutures of aseptic silk or catgut, the surfaces by
carefully applied pressure;
(4) free drainage, if necessary, to prevent
accumulation either of blood or serous effusion;
(S) avoidance of sepsis;
(6) perfect rest of the part .
SURGICAL HAEMOSTASIS
Surgical treatment of haemorrhage
minor means of arresting bleeding are:
cold, which is most valuable in general oozing and
local extravasations;
very hot water, 130° to 16o F., a powerful
haemostatic; position, such as elevation of the limb,
valuable in bleeding from the extremities;
styptics or astringents, applied locally, as
perchloride of iron, tannic acid and others, the most
valuable being suprarenal extract .
SURGICAL HAEMOSTASIS
Surgical treatment of haemorrhage
DIRECT PRESSURE
In small blood-vessels pressure will be
sufficient to arrest. haemorrhage permanently .
LIGATURE
In large vessels with a reef-knot
main artery of the limb exposed by dissection
at the most accessible point .
SURGICAL HAEMOSTASIS
Surgical treatment of haemorrhage
• Diathermy
• Sutures
• Harmonic devices
TRANSFUSION MANAGEMENT
• Early recognition of significant blood loss
• it is commoner to see patients who have been undertransfused than over-transfused. I
• t is essential to pay attention to and act on
recordings of pulse rate and blood pressure.
• In a fit patient without cardiac disease, persistent
tachycardia − even if blood pressure is maintained −
is likely to indicate continuing blood loss.
SURGICAL HAEMOSTASIS
INTERNAL HAEMORRHAGE /WOUNDS
Causes
• Penetrating wounds
chest,abdomen,neck,limbs
• Upper GI haemorrhage
BleedingUlcers
• Lower GI haemorrhage
Diverticulosis
Haemorrhoids
Carcinomas
SURGICAL HAEMOSTASIS
INTERNAL HAEMORRHAGE /WOUNDS
Principles of management
Teat the primary cause
Avoid irrevercible shock
Flid electrolytes
Blood and blood produvts
• Types of bleeding
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• A subconjunctival hemorrhage is a common and
relatively minor post-LASIK complication.
•
• The endoscopic image of linitis plastica, a type of
stomach cancer leading to a leather bottle-like
appearance with blood coming out of it.
RESPONSE IN INJURY
Vasoconstriction is mediated through intrinsic mechanisms and
various vasoactive agents (thromboxane A2 and serotonin)
released during platelet aggregation.
COAGULATION SYSTEM
• Virchow in 1856 described the famous triad:
• 1. Stasis
• 2. Endothelial damage
• 3. Hypercoaguable states
• The coagulation system is based on the coagulation
cascade. The end points of this cascade include the
formation of thrombin and fibrin.
• Throughout this system there can be defects in the
multiple enzymes or extrinsic factors contributing to its
dysfunction.
Fibrinolysis
There is a delicate balance between formation and lysis of
Transfusion management
• All patients require large-bore intravenous cannulas.
Central venous pressure monitoring is valuable in
major haemorrhage or if there is cardio-respiratory
disease.
• Haemoglobin concentration − interpretation
• The haemoglobin can underestimate the extent of
blood loss in cases of acute haemorrhage before
haemodilution has occurred, or can overestimate it
if the patient is already anaemic from chronic blood
loss.
• Table 3.2. Coagulation cascade
Intrinsic
• Contact Tissue factor + VIIa
• XIa + VIII
Common Pathway
• Xa + V
• IIa
• Clot
• Gastrointestinal haemorrhage: haematemesis and melaena
• Haematemesis: vomiting fresh red blood.
• Coffee-ground vomiting: vomiting of altered black blood.
• Melaena: the passage of black tarry stools.
• Bleeding may be from oesophageal varices or from other
sites (non-variceal bleeding).
• Acute upper gastrointestinal (GI) bleeding affects 50 to
150 per 100,000 of the population each year and
accounts for a substantial proportion of all blood used in
UK hospitals. In the UK in 1995, mortality was reported to
be 11% in patients admitted to hospital because of
bleeding and 33% in those who developed gastrointestinal
bleeding while hospitalised for other reasons. In the west
of Scotland in 1997, the corresponding figures were 8.2%
and 43%. Most deaths are in elderly patients with