Bleeding, technically known as hemorrhaging/haemorrhaging (see American and British spelling differences) is the loss of blood from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, mouth or anus, or through a break in the skin. The complete loss of blood is referred to as exsanguination, and desanguination is a massive blood loss. Loss of 10-15% of total blood volume can be endured without clinical sequelae in a healthy person, and blood donation typically takes 8-10% of the donor's blood volume.
Hemorrhage generally becomes dangerous, or even fatal, when it causes hypovolemia (low blood volume) or hypotension (low blood pressure). In these scenarios various mechanisms come into play to maintain the body's homeostasis. These include the "retro-stress-relaxation" mechanism of cardiac muscle, the baroreceptor reflex and renal and endocrine responses such as the renin - angiotensin - aldosterone system (RAAS).
Certain diseases or medical conditions, such as haemophilia and low platelet count (thrombocytopenia), may increase the risk of bleeding or may allow otherwise minor bleeds to become health or life threatening. Anticoagulant medications such as warfarin can mimic the effects of haemophilia, preventing clotting and allowing free blood flow.
Death from hemorrhage can generally occur surprisingly quickly. This is because of 'positive feedback'. An example of this is 'cardiac repression', when poor heart contraction depletes blood flow to the heart, causing even poorer heart contraction. This kind of effect causes death to occur more quickly than expected.
Hemorrhaging is broken down into 4 classes by the American College of Surgeons' Advanced Trauma Life Support (ATLS).
Individuals in excellent physical and cardiovascular shape 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 (shock). 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.
Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:
The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category.
Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels (aneurysm or dissection), arteriovenous malformation, ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.
The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation, haemostasis and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.
Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. Hemostasis involves several components. The main components of the hemostatic system include platelets and the coagulation system.
Platelets are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.
There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic Hemophilia A while deficiencies of Factor IX cause "Christmas disease"(hemophilia B). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with autoimmune diseases. von Willebrand disease is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.
In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, warfarin ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.
Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either fresh frozen plasma of specific clotting factors, such as Factor VIII for patients with hemophilia.
The primary survey examines and verifies that the patient's Airway is intact, that s/he is Breathing and that Circulation is working. A similar scheme and mnemonic is used as in CPR. However, during the pulse check of C, attempts should also be made to control bleeding and to assess perfusion, usually by checking capillary refill. Additionally a persons mental status should be assessed (Disability) or either an AVPU scale or via a formal Glasgow Coma Scale. In all but the most minor cases, the patient should be Exposed by removal of clothing and a secondary survey performed, examining the patient from head to toe for other injuries. The survey should not delay treatment and transport, especially if a non-correctable problem is identified.
Minor bleeding is bleeding that falls under a Class I hemorrhage and the bleeding is easily stopped with pressure.
The largest danger in a minor wound is infection. Bleeding can be stopped with direct pressure and elevation, and the wound should be washed well with soap and water. A dressing, typically made of gauze, should be applied. Peroxide or iodine solutions (such as Betadine) can injure the cells that promote healing and may actually impair proper wound healing and delay closure.
Severe bleeding poses a very real risk of death to the casualty if not treated quickly. Therefore, preventing major bleeding should take priority over other conditions, save failure of the heart or lungs. Most protocols advise the use of direct pressure, rest and elevation of the wound above the heart to control bleeding.
The use of a tourniquet is not advised in most cases, as it can lead to unnecessary necrosis or even loss of a limb. Tourniquets should rarely be used as it is usually possible to stop bleeding by the application of manual pressure.
The only minor situation is a spontaneous nosebleed, or a nosebleed caused by a slight trauma (such as a child putting his finger in his nose).
Simultaneous externalised bleeding from the ear may indicate brain trauma if there has been a serious head injury. Loss of consciousness, amnesia, or fall from a height increases the likelihood that there has been a severe injury. This type of injury can also be found in motor vehicle accidents associated with death or severe injury to other passengers.
Hemoptysis, or coughing up blood, may be a sign that the person is at risk for serious bleeding. This is especially the case for patients with cancer. Hematemesis is vomiting up blood from the stomach. Often, the source of bleeding is difficult to distinguish and usually requires detailed assessment by an emergency physician.
Internal bleeding occurs entirely within the confines of the body and can be caused by a medical condition (such as aortic aneurysm) or by trauma. Symptoms of internal bleeding include pale, clammy skin, an increased heart rate and a stupor or confused state.
The most recognisable form of internal bleeding is the contusion or bruise.
Because skin is watertight, there is no immediate risk of infection to the aide from contact with blood, provided the exposed area has not been previously wounded or diseased. Before any further activity (especially eating, drinking, touching the eyes, the mouth or the nose), the skin should be thoroughly cleaned in order to avoid cross contamination.
To avoid any risk, the hands can be prevented from contact with a glove (mostly latex or nitrile rubber), or an improvised method such as a plastic bag or a cloth. This is taught as important part of protecting the rescuer in most first aid protocols.