This presentation is made by Dr Ashok Jaisingani, If any one like this please give your comments.

1. HEMORRHAGE
By Dr. Ashok Jaisingani

2. Definition & Introduction
► Escape of the blood from the vessels either
internally or externally.
► Hemorrhage must be recognized and managed
aggressively to reduce the severity and duration of
shock and avoid death or multiple organ failure.
► Hemorrhage is treated by arresting the bleeding,
not by fluid resuscitation or blood transfusion.
► To resuscitate the patients who have ongoing
hemorrhage  physiological exhaustion
(coagulopathy, acidosis and hypothermia) and
subsequently death.

3. Pathophysiology
► Hemorrhage  hypovolemic shock  cellular anaerobic
metabolism  lactic acidosis  decrease function of
coagulase protease  coagulopathy  further
hemorrhage.
► This hemorrhage is exacerbated by the ischemic
endothelial cells activating anticoagulant pathway.
► In compensatory state of the shock blood supply to the
muscles is reduced, which become unable to generate the
heat  hypothermia
► As coagulation functions poorly at low temp.  further
hemorrhage.
► Further hypoperfusion and worsening acidosis and
hypothermia  physiological exhaustion  “Death”

4. Effects Of Medical Therapy In
Hemorrhagic Shock
► Medical therapy has a tendency to worsen this effect.
► Intravenous fluid and transfused blood are cold and
worsening the hypothermia.
► During the surgery body cavity become open that leads to
further heat loss.
► Crystalloid solution are acidic themselves.
► Thus every efforts made rapidly to stop hemorrhage and
avoid physiological exhaustion such as
1- Coagulopathy
2- Acidosis
3- Hypothermia

5. Revealed Hemorrhage
► Revealed Hemorrhage is obvious external
hemorrhage, result from
1- Exsanguination from open arterial wound
2- From massive haemetemesis
3- From duodenal ulcer

6. Concealed Hemorrhage
► Concealed hemorrhage is contained within the
body cavity and must be suspected. Concealed
hemorrhage may be
1- Traumatic concealed hemorrhage
2- Non – Traumatic concealed hemorrhage
► In trauma hemorrhage may be concealed within
the chest, abdominal cavity, pelvis, retroperitonium
or in limbus may be associated with concealed
vascular injury and log bone fracture.
► Non – traumatic concealed hemorrhage include
GIT bleeding & rupture aortic aneurysm

7. Primary Hemorrhage
► Hemorrhage occurring immediately as result
of an injury or surgery is recognized as “
primary hemorrhage”

8. Recreationary Hemorrhage
► Recreationary hemorrhage is delayed
hemorrhage within 24 hours and usually
caused by the
1- Dislodgement of clot by the resuscitation
2- Normalization of blood pressure
3- Vasodilatation (cessation of reflex
vasospasm)
4- Technical failure such as slippage of
ligature

9. Secondary Hemorrhage
► Secondary hemorrhage is caused by the
sloughing of the wall of vessels
► It usually occurs 7 – 14 days after the injury
and precipitated by the factors such as
1- Infection
2- Pressure necrosis (result from drain)
3- Malignancy

10. Surgical & Non-surgical hemorrhage
► Surgical hemorrhage is the result of injury
and amenable to surgical control, or from
angioembolism
► Non – surgical hemorrhage is general ooze
from all raw surface due to coagulopathy, it
can not be stopped by surgical mean,
require correction coagulation abnormalities
► Note: Packing can stop non-surgical
hemorrhage

11. Degree & Classification Of
Hemorrhage
► Degree of hemorrhage classified in to 4 classes
1- Blood volume loss < 15%
2- Blood volume loss between 15 – 30%
3- Blood volume loss between 30 – 40%
4- Blood volume loss > 40%
► Estimation of amount of blood that has been lost is difficult
and inaccurate and usually underestimation of actual value
► Hemoglobin level is a poor indicator of the hemorrhage as
it represent conc. Not actual amount
► In early stage of the rapid hemorrhage HB conc. Become
unchanged, but later HB and haemotcrit will fall.

12. Basis Of Hemorrhagic Treatment
► Treatment of the hemorrhage depend upon
degree of the hypovolemic shock according to
1- Vital Signs
2- Preload assessment
3- Base deficit
4- Most important among these is dynamic
response to fluid therapy.
► In non-responder or transitient responder pts it is
necessary to identify and control the site of the
bleeding.