Massive Bleeding (Hemorrhage)

Copious

discharge of blood from the blood vessels or a rapid and uncontrollable loss or outflow.

is the loss of blood or blood escape

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, nose, ear or anus, or through a break in the skin.

Causes:
Bleeding arises due to either traumatic injury, underlying medical condition, or a combination. Traumatic Injury: >Laceration- Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.

>Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery. >Punctured Wound - Caused by an object that penetrated the skin. >Crushing Injuries- Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself. >Ballistic Trauma- Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Medical Condition - causes of bleeding not directly due to trauma >Intravascular changes - changes of the blood within
vessels (e.g. blood pressure, clotting factors) >Intramural changes- changes arising within the walls of blood vessels (e.g. aneurysms, dissections, AVMs, vasculitides) >Extravascular changes - changes arising outside blood vessels (e.g. H pylori infection, brain abscess, brain tumor)

The patient may have an internal hemorrhage that is invisible or an external hemorrhage that is visible on the outside of the body.

Bleeding into the spleen or liver is internal hemorrhage. Bleeding from a cut on the face is an external hemorrhage.

Classification
Class I Hemorrhage involves up to 15% of blood volume. Class II Hemorrhage involves 15-30% of total blood volume. Class III Hemorrhage involves loss of 30-40% of circulating blood volume. Class IV Hemorrhage involves loss of >40% of circulating blood volume.

Assessment:
The px is assessed for signs of shock: >cool

moist skin >falling blood pressure >increased heart rate >delayed capillary refill >decreasing urine volume

Laboratory &Diagnostics
Radiology and initial treatment X-ray FAST (Focused Assessment with Sonography for Trauma) DPL (Diagnostic Peritoneal Lavage) DPL has 97 % sensitivity for blood in the peritoneal cavity. However, it is not a quantitative assessment indicating the amount of bleeding.

 CT (Computed Tomography) CT scanning with intravenous contrast is considered the gold standard of trauma imaging. Angiography and angioembolisation Angiography in the trauma patient should not be seen only as a diagnostic tool, but as a method to control the bleeding by embolisation, placement of covered stent grafts or insertion of balloon catheters.

Laboratory tests
No laboratory tests are diagnostic of major bleeding. The only crucial blood sample is the one used for assessing the ABO-blood type and cross matching. A full screen should be performed from venous blood drawn within the ED. Frequent arterial blood gas (ABG) tests are useful in providing information on the presence of metabolic acidosis. Since this is the hallmark of shock, the test can be used as an adjunct to determine when the patient is fully resuscitated.

If possible, before you try to stop severe bleeding, wash your hands to avoid infection and put on synthetic gloves. Don't reposition displaced organs. If the wound is abdominal and organs have been displaced, don't try to push them back into place cover the wound with a dressing.

Management
Fluid Replacement is imperative to maintain circulation two large-bore intravenous cannulae are inserted may include isotonic solution, colloid and blood component therapy

O-negative blood for women of child bearing age and in emergent situation. Additional platelets and clotting factors are given.

 Control of external Hemorrhage

rapid physical assessment firm pressure is applied over the bleeding area or the involved artery The injured part is elevated immobilize extremity apply torniquet as a last resort when external hemorrhage cannot be controlled in any other way

 Control of internal Bleeding

Packed red blood cells (O-negative) are administered at a rapid rate Surgery Pharmacologic therapy Arterial blood specimens obtained Px maintained in supine

Ineffective Tissue Perfusion Deficient Fluid Volume Decreased Cardiac Output

Hemostatic resuscitation for massive bleeding: the paradigm of plasma and platelets--a review of the current literature.

QUESTIONS
1. Nurse Fidz is going to administer an IVF to

a patient experiencing hemorrhage. What appropriate IVF should he administer?

a.) Lactated Ringers solution b.)D50W c.) 0.33% NaCl d.)D5IMB

2.

Which of the following is not a management for patients with massive bleeding?

a.) Apply pressure directly to the wound. b.) Have the injured lie down and cover the person. c.) Apply tourniquet proximal to the wound for 30 min. d.) Administer isotonic solution as prescribed.

3. Patient

is rushed to the Hospital because of trajectory gunshot wound. Within the resuscitation area he is indicated for X-ray examination and revealed massive hemothorax. What is the appropriate intervention?

a.) Chest drain insertion b.) Insertion of balloon catheter for angiography c.) Administer coagulants

References Brunner and Suddarths Medical Surgical Nursing volume 2 Nurses Pocket Guide www.ncbi.nlm.nih.gov www.wikipedia.com

Thank You!!