BLEEDING CONTROL

SEQUENCE

IMPORTANCE Physiology/homeostasis Integrity of circulatory systemTYPES/CAUSESCONTROL METHODSBLOOD TRANSFUSION

Subject’s importance

Hemorrhage 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 hemorrhage.

Transfusion of blood is the main remedy

Clinical Situation-Bleeding

Trauma /accidents General operative interventions Gynecological procedures Common surgical conditions that presents with bleeding- Intracranial hemorrhages/CVA Upper GIT bleed/ hematemesis and melena Bleeding hemorrhoids Chronic wounds Aneurysms Coagulation disorders

Congenital- Hemophil ia, vWF deficiency Acquired

DIC Anticoagulants Fulminant sepsis

What Prevents Hemorrhage

NATURAL BARRIERS AGAINST HAEMORRHAGE

Integrity of vascular wall Coagulation system

Body’s response to hemorrhage/injury

Attempts to repair the loss & restore normality

There are several interrelated stages

Local response / Generalized response

Aims at: Wall repair Restoration of volume loss Correction of coagulation abnormalit ies

Signs of the bleeding

Local

Hematoma, suffusion, ecchymosis

Compression in the pleural cavity, in pericardium, in the skull

Functional disturbancies – e.g. hyperperistalsis

General Pale skin, Cyanosis, Decreased BP, Tachycardia, Difficulty in breathing,

sweating, decreased body

temperature, unconsciousness, cardiac standstill

Signs of shock

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Body’s response to hemorrhage/injury

Local Vasoconstriction Platelet aggregation and plug formation Coagulation leading to Fibrin formation –Intrinsic

& Extrinsic Pathways

General Cardiac stimulation Compartmental Volume movement

TYPES OF HAEMORRHAGE

AMOUNT OF LOSS -MINOR/MAJOR

ACUTE/CHRONIC

ARTERIAL/VENOUS/CAPILLARY/MIXED

LOCALIZED/DIFFUSE

EXTERNAL/ INTERNAL

OVERT/OCCULT

TYPES OF HAEMORRHAGE

ARTERIAL BLEEDING is of a bright red colour, and escapes from the end of the vessel in jets, synchronous with the heart's beat

VENOUS BLEEDING 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 .

Hemorrhage and ShockWhat happens when you start to

bleed? – it depends on how much blood you lose

Normal Adult Blood Volume is about 5 Litres

Severity of Hemorrhage

The Direction Of Hemorrage

External

Internal In a luminar organ (hematuria, hemoptysis, melena)

In body cavities (intracranial, hemothorax, hemoperitoneum, hemopericardium, hemarthros)

Among the tissues (hematoma, suffusion)

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Internal Hemorrhage

INTERNAL HAEMORRHAGE /WOUNDS

Causes Penetrating wounds –o chest, abdomen, neck, limbs Upper GI haemorrhage-o Bleeding Ulcers Lower GI haemorrhage

o Diverticulosiso Haemorrhoidso Carcinomas

External Hemorrhage

BleedingPREOPERATIVE HEMORRHAGE

Prehospital care! – maintenance of the airways, ventillation and circulation

bandages, direct pressure, torniquets

INTRAOPERATIVE HEMORRHAGEanatomical and/or diffuse

depending on the surgeon, the surgery, position,

the size of the vessel, pressure in the vessel

(ANESTHESIA)

POSTOPERATIVE BLEEDINGineffective local hemostasis, undetected hemostatic defect, consumptive coagulopathy or fibrinolysis

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CLASSIFICATION OF SURGICAL HAEMORRHAGE

Primary Hemorrhage occurring at the time of the injury or surgery

Reactionary Hemorrhage within twenty-four hours of the accident/surgery, due to

slippage of ligature, hypertension post op

Secondary Hemorrhage occurring at a later period (48-72hrs) and caused by

septic condition of the wound (infection).

EFFECTS OF HAEMORRHAGE

Depend upon following: Acute loss vs Chronic loss The amount of loss The compensatory mechanisms General state of health

SURGICAL HEMOSTASIS

Aim – to prevent the flow of blood from the incised or transected vessels

Mechanical methods

Thermal methods

Chemical and biological methods

Radiological/Interventional methods

Adequate blood/blood products transfusion

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SURGICAL HAEMOSTASIS

Natural CONTROL/arrest of hemorrhage arises from-

(1) changes taking place in the cut vessel causing its retraction and contraction

(2) the coagulation mechanism of the blood

(3) temporary-platelet plug Permanent-fibrin clot.

SURGICAL HEMOSTASISMECHANICAL METHODS

Digital pressure – direct pressure,

e.g. Pringle maneuver

Tourniquet

Ligation

Suturing

Preventive hemostasis

Clips

Bone wax

other

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SURGICAL TREATMENT OF HAEMORRHAGE

First Aid Management DIRECT PRESSURE In small blood-vessels

pressure will be sufficient to arrest, hemorrhage permanently

LIMB ELEVATION TOURNIQUET

APPLICATION

CLIPS FOR CONTROLLING BLEEDING

LIGATURE In large vessels with a reef-knot main artery of the limb exposed

by dissection at the most accessible point .

SUTURING & LIGATURE

THERMAL METHODS Low temperature

Hypothermia – eg. stomach bleeding

Cryosurgery

Dehydratation and denaturation of fatty tissue

Decreases the cell metabolism

Vasoconstriction

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THERMAL METHODS High temperature

Electrosurgery – electrocauterization

Monopolar diathermy

Bipolar diathermy

Harmonic devices

Laser surgery

coagulation and vaporization

for fine tissues

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Diathermy

Thermal methods High temperature

Electrocoagulation

Electrofulguration (A)

Electrodessication

Electrosection

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Hemostasis with chemical and biological methodsVASOCONSTRICTION COAGULATION HYGROSCOPIC EFFECT

Absorbable collagen

Absorbable gelatin

Microfibrillar collagen

Oxidized cellulose

Oxytocin

Epinephrine

Thrombin

QuikClot

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Hemostasis with chemical and biological methods

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HemCon

Bleeding Control by Interventional Radiology

Interventional Radiology

Post trauma-intra abdominal bleeding

Gastro intestinal bleeding control- Upper

Lower

Uterine atony causing Postpartum hemorrhage

Embolisation particles

Post trauma

Vascular and solid organ trauma. Celiac angiogram showing 3 foci of extravasation in spleen, 2 in the upper pole (arrow) and 1 in the lateral aspect of the mid spleen

Post—super-selective embolization splenic angiogram demonstrating microcoils in good position and no evidence of further extravasation

Gastrointestinal Bleeding