Bleeding – izlity blood to the external environment, natural cavities of a body, bodies and fabrics. Can arise at violation of integrity of a vessel or increase in permeability of a vascular wall; to develop owing to injuries or diseases; to be arterial, venous, capillary, parenchymatous or mixed. The clinical importance of bleeding depends on size and the speed of blood loss. Symptoms – weakness, dizziness, pallor, tachycardia, decrease HELL, faints. Detection of external bleeding does not represent difficulties as the source is visible with the naked eye. For diagnosis of internal bleeding depending on localization various tool techniques can be used: puncture, laparoscopy, X-ray contrast research, endoscopy etc. Treatment, as a rule, quick.
Bleeding – a pathological state at which blood from vessels streams to the external environment or in internals, fabrics and natural cavities of a body. Is a state at which emergency medical service is necessary. Loss of considerable volume of blood, especially within a short period of time, poses a direct threat of life of the patient and can become the reason of a lethal outcome. Depending on the reason of their emergence traumatologists, abdominal surgeons, chest surgeons, neurosurgeons, urologists, hematologists and some other experts can be engaged in treatment of bleedings.
Taking into account the place to which blood streams allocate the following types of bleedings:
- External bleeding – to the external environment. There is a visible source in a type of a wound, an open change or the smashed soft fabrics.
- Internal bleeding – in one of natural cavities of a body which is reported with the external environment: bladder, lung, stomach, intestines.
- The latent bleeding – in fabrics or the cavities of a body which are not reported with the external environment: in mezhfastsialny space, brain ventricles, a joint cavity, belly, pericardiac or pleural cavities.
As a rule, in clinical practice the latent bleedings call internal, however taking into account features of pathogenesis, symptoms too, diagnostics and treatments they are allocated in separate subgroup.
Depending on type of the damaged vessel, distinguish the following types of bleedings:
- Arterial bleeding. Arises at damage of a wall of an artery. Differs in the high speed of blood loss, poses hazard to life. Blood bright red, streams the intense pulsing stream.
- Venous bleeding. Develops at damage of a wall of a vein. Speed of blood loss is lower, than at injury of an artery of similar diameter. Blood dark, with a cherry shade, flows an equal stream, the pulsation usually is absent. At damage of large venous trunks pulsing in beat of breath can be observed.
- Capillary bleeding. Arises at damage of capillaries. Blood is emitted with the separate drops reminding dew or condensate (a symptom of "bloody dew").
- Parenchymatous bleeding. Develops at damage of parenchymatous bodies (a spleen, a liver, kidneys, lungs, a pancreas), cavernous tissue and spongy substance of a bone. Because of features of a structure of these bodies and fabrics the damaged vessels are not squeezed by surrounding fabric and not reduced that causes considerable difficulties at a bleeding stop.
- The mixed bleeding. Arises at simultaneous injury of veins and arteries. Wound of the parenchymatous bodies having the developed arterial and venous network becomes the reason, as a rule.
Depending on weight bleeding can be:
- Lung (loss no more than 500 ml of blood or 10-15% of OTsK).
- Average (loss of 500-1000 ml or 16-20% of OTsK).
- Heavy (loss of 1-1,5 l or 21-30% of OTsK).
- Massive (loss more than 1,5 l or more than 30% of OTsK).
- Deadly (loss of 2,5-3 l or 50-60% of OTsK).
- Absolutely deadly (loss of 3-3,5 l or more than 60% of OTsK).
Taking into account an origin allocate traumatic bleedings which develop as a result of a trauma of not changed bodies and fabrics and pathological bleedings which arise owing to pathological process in any body or are a consequence of the increased permeability of a vascular wall.
Depending on emergence time experts in the field of traumatology distinguish primary, early secondary and late secondary bleedings. Primary bleedings develop directly after a trauma, early secondary – in time or after operation (for example, as a result of sliding of a ligature from a vessel wall), late secondary – in several days or weeks. Suppuration with the subsequent fusion of a wall of a vessel is the cause of late secondary bleedings.
Dizziness, weakness, short wind, strong thirst, pallor of skin and mucous membranes, pressure decrease, increase of pulse are among the general symptoms of bleeding (tachycardia), preunconscious states and faints. Expressiveness and speed of development of the listed symptoms is defined by blood expiration speed. Sharp blood loss is transferred heavier chronic as in the latter case the organism manages "to adapt" to the happening changes partially.
Local changes depend on features of a trauma or pathological process and a type of bleeding. At external bleedings there is a violation of integrity of integuments. At bleeding from a stomach there is a melena (a tar-like black liquid chair) and vomiting the changed dark blood. At esophageal bleeding bloody vomiting, but blood brighter, red, but not dark is also possible. Bleeding from intestines is followed meleny, but characteristic dark vomiting at the same time is absent. At injury of a lung the bright red, light foaming blood otkharkivatsya. The gematuriya is characteristic of bleeding from a kidney lokhanka or a bladder.
The latent bleedings – the most dangerous and the most difficult in respect of diagnostics, them it is possible to reveal only on indirect signs. At the same time the blood accumulating in cavities squeezes internals, breaking their work that in certain cases can become the reason of development of dangerous complications and the death of the patient. is followed by breath difficulty, short wind and weakening of a perkutorny sound in the lower departments of a thorax (when solderings in a pleural cavity obtusion in the top or average departments is possible). At a haemo pericardium because of a sdavleniye of a myocardium warm activity is broken, cardiac arrest is possible. Bleeding in an abdominal cavity is shown by an abdominal distension and obtusion of a perkutorny sound in its sloping departments. At bleeding in a cavity of a skull there are neurologic frustration.
The expiration of blood out of borders of the vascular course exerts the expressed negative impact on all organism. Because of bleeding OTsK decreases. As a result warm activity worsens, bodies and fabrics receive less oxygen. At long or extensive blood loss anemia develops. Loss of considerable volume of OTsK during the short period of time becomes the reason of traumatic and gipovolemichesky shock. The shock lung develops, the volume of a kidney filtration decreases, there is an oliguriya or an anury. In a liver the necrosis centers are formed, parenchymatous jaundice is possible.
Bleedings at wounds
The cut, chipped and cut, hurt, fragmentary and chipped wounds are followed izlitiy blood to the external environment. The volume of first aid depends on a type of bleeding. At arterial bleeding on an extremity impose a plait from an elastic rubber tape, previously having enclosed under it the fabric strip put in several layers. It is necessary to consider that imposing of a plait on a shin or a forearm is inefficient as vessels in these segments are located so that it is difficult "to peredavit" them outside. Therefore at the wounds of the top extremity which are followed by arterial bleeding, the plait is imposed on a shoulder, and at wounds of the lower extremity – on a hip.
The area of a wound is closed a sterile bandage, the victim is given anesthetic and urgently brought to medical institution. If transportation takes considerable time, it is necessary to weaken periodically a plait, pressing down the injured artery places of wound are higher. For adults the maximum time of imposing of a plait makes 1 hour, for children – it is no more than 20 minutes. At the wounds which are followed by venous bleeding the pressing bandage is applied. At capillary bleeding of rather usual sterile bandage.
Diagnosis at external bleedings is simple. The key moment of diagnostics is detection of internal injuries and important anatomic educations. If the bottom of a wound is inaccessible for direct survey, and localization does not allow to exclude violation of integrity of muscles, joints, natural cavities and internals, the patient is directed to additional inspection and appoint consultations of the corresponding experts: heart surgeon, thoracic surgeon, abdominal surgeon, urologist etc. If necessary the thorax X-ray analysis, an arthroscopy, a laparoscopy, ultrasonography, MRT and other researches can be carried out.
Patients with an internal injury turn into maintaining experts of the corresponding profile. Patients with damage of capillaries, veins and small arteries are directed to traumatologists. With violation of integrity of large arterial trunks vascular surgeons are engaged in treatment of wounds. At receipt do to all patients with arterial and venous bleeding blood test for blood loss assessment. Treatment consists in carrying out PHO. Operation is carried out under local anesthesia or the general anesthesia. At damage of large arterial trunks on a wall of a vessel impose seams or use transplants. The volume of surgeries at violation of integrity of internals depends on character and weight of a trauma.
Bleeding at changes
All changes are followed by bleeding from the damaged bone fragments. At open changes blood streams outside and in surrounding fabrics, at closed extra articulate – only in surrounding fabrics, at closed intra articulate – in a joint cavity. The volume of blood loss depends on localization and a type of a change. At a fracture of a finger only several milliliters of blood are lost, at a shin fracture – 500-700 ml, at basin changes – from 800 ml to 3 l. At damage of a vessel by a sharp otlomk of a bone massive blood loss is possible also in cases when integrity of rather small bone is broken (for example, humeral). Loss of considerable volume of OTsK at changes is one of the reasons of development of traumatic shock.
First aid consists in anesthesia and an immobilization the tire. At open changes apply a sterile bandage a wound. The patient is brought to emergency station or traumatologic office. For specification of the diagnosis appoint a X-ray analysis of the damaged segment. At open changes carry out PHO, for the rest tactics of treatment depends on a look and localization of damage. At the intra articulate changes which are followed gemartrozy carry out a joint puncture. At traumatic shock hold the relevant antishock activities.
Bleeding at other injuries
ChMT can be complicated by the latent bleeding and formation of a hematoma in a skull cavity. At the same time the fracture of bones of a skull is observed not always, and patients during the first hours after a trauma can well feel that complicates diagnostics. At the closed fractures of edges the injury of a pleura which is followed by internal bleeding and formation of a gemotoraks sometimes is observed. At a stupid injury of an abdominal cavity bleeding from the injured liver, a spleen or hollow bodies (a stomach, intestines) is possible. Bleedings from parenchymatous bodies are especially dangerous in view of massiveness of blood loss. Bystry development of shock is characteristic of such injuries, without the immediate qualified help usually there comes the lethal outcome.
At injuries of lumbar area the bruise or a rupture of a kidney is possible. In the first case blood loss insignificant, the certificate of bleeding is emergence of blood in urine, in the second – the picture of quickly accruing blood loss which is followed by pain in lumbar area is observed. At bruises of the lower part of a stomach there can be a rupture of an urethra and bladder.
First aid at all internal bleedings of the traumatic nature consists in anesthesia, ensuring rest and immediate delivery of the patient in specialized medical institution. The patient is stacked in horizontal position with the raised legs. To area of estimated bleeding put cold (a bubble or a hot-water bottle with ice or cold water). At suspicion of esophageal or gastric bleeding to the patient do not allow to eat and drink.
At a pre-hospital stage whenever possible hold antishock events, carry out completion of OTsK. At receipt in medical establishment continue infusional therapy. The list of diagnostic actions depends on the nature of a trauma. At ChMT appoint consultation of the neurosurgeon, a X-ray analysis of a skull and EhoEG, at a gemotoraksa – a thorax X-ray analysis, at a stupid injury of a stomach – consultation of the surgeon and a diagnostic laparoscopy etc.
Treatment in most cases quick – opening of the corresponding cavity with the subsequent bandaging of a vessel, an ushivaniye, removal of all damaged body or its part. At insignificant bleedings the waiting tactics which is combined with holding conservative actions can be applied. At a gemotoraksa treatment, as a rule, conservative – pleural punctures or drainage of a pleural cavity. In all cases control over a condition of the patient is exercised, if necessary compensation of blood loss is carried out.
Not traumatic bleedings
Not traumatic bleedings from full bodies of a gastrointestinal tract, mainly from top are rather widespread (a gullet, a stomach), is more rare – the lower departments of digestive tract. Mallori-Veyss's syndrome, erosive gastritis, stomach ulcer, a malignant tumor, polyps and a varicosity of a gullet at cirrhosis can become the reason of esophageal and gastric bleeding. Bleeding from the lower departments of a digestive tract can be observed at diverticulums of a thick and small intestine, polyps, malignant tumors, a disease Krone, nonspecific ulcer colitis, thrombosis or an embolism of mezenterialny vessels, and also ruptures of aneurisms of mezenterialny arteries.
The diagnosis is established on the basis of local (characteristic dark vomiting, a melena) and the general symptoms of internal bleeding. For specification of a source appoint special inspections: FGDS, kolonoskopiya etc. Treatment includes completion of OTsK and elimination of a source of blood loss. At Mallori-Veyss's syndrome apply antatsida, cold, aminocaproic acid and stimulators of folding; in hard cases make a gastrotomiya and stitch ruptures of a mucous membrane. At stomach ulcer tactics is defined by the speed of blood loss and data of FGDS. In mild cases use endoscopic techniques (an obkalyvaniye, electrothermic coagulation), in heavy carry out a stomach resection. At a varicosity of a gullet carry out conservative treatment: enter Blackmore's probe, appoint medicamentous therapy. At the proceeding bleeding carry out the emergency laparotomy with a proshivaniye of subkardialny department of a stomach.
Bleeding from lungs and bronchial tubes can develop at malignant tumors, severe forms of pulmonary tuberculosis, mitralny heart diseases, aorta aneurism, foreign matters of bronchial tubes, lung gangrene, a lung heart attack, adenoma of bronchial tubes and bronkhoektaza. The diagnosis is established on the basis of characteristic signs and these additional researches: X-ray analysis of a thorax, KT of a thorax, bronkhoskopiya and angiography of bronchial arteries. Depending on the reason an izlitiya of blood both conservative, and expeditious treatment is possible. In some cases carry out an endoscopic tamponada of a bronchial tube.