Internal bleeding – a state at which blood streams or in a natural cavity of an organism (a stomach, a bladder, a uterus, lungs, a joint cavity and so forth), or in the space which is artificially formed by the streamed blood (zabryushinny, intermuscular etc.). Can develop as a result of a trauma or a chronic disease. Symptoms of internal bleeding depend on its localization and degree of blood loss. More often they have the general character: dizziness, weakness, drowsiness, consciousness loss, etc. Due to the lack of characteristic signs internal bleedings are much more difficultly diagnosed. In considerable number of cases pose a direct threat for the patient's life.
Internal bleeding – loss of blood at which blood expires not outside, and in one of cavities of a human body. The trauma or a chronic disease can become the reason. Massive character of blood loss, the late request of patients for the help and diagnostic difficulties at detection of this pathology increase gravity of a problem and turn internal bleedings into serious threat for life of patients.
There are several classifications of internal bleedings:
Taking into account the cause: mechanical (owing to damage of vessels at injuries) and arrozivny (owing to damage of a vascular wall at a necrosis, germination and disintegration of a tumor or destructive process). Besides, allocate the diapedezny bleedings arising because of increase in permeability of a wall of small vessels (for example, at a scurvy or sepsis).
Taking into account blood loss volume: a lung (to 500 ml or 10-15% of volume of the circulating blood), an average (500-1000 ml or 16-20% of OTsK), heavy (1000-1500 ml or 21-30% of OTsK), massive (more than 1500 ml or more than 30% of OTsK), deadly (more than 2500-3000 ml or more than 50-60% of OTsK), absolutely deadly (more than 3000-3500 ml or more than 60% of OTsK).
Taking into account character of the damaged vessel: arterial, venous, capillary and mixed (for example, from an artery and a vein or from a vein and capillaries). If blood streams from capillaries of any parenchymatous body (a liver, a spleen etc.), such bleeding is called parenchymatous.
Taking into account the place of a congestion of the streamed blood: band (in pleural, belly, etc. cavities) and interstitial (in thickness of fabrics with their treatment).
Taking into account existence or lack of strong indications of bleeding: obvious, at which blood even if through any time and in the changed look, "leaves" through natural openings (for example, painting a chair in black color), and hidden at which it remains in a body cavity.
Taking into account emergence time: primary, arising right after traumatic damage of a vascular wall, and secondary, developing after a while after a trauma. In turn secondary bleedings are subdivided on early (develop for 1-5 days because of sliding of a ligature or pushing out of blood clot) and late (usually arise for 10-15 day because of purulent fusion of blood clot, a vessel wall necrosis, etc.).
The reason of internal bleeding can become both a trauma, and some chronic diseases. Massive, life-threatening post-traumatic bleeding can develop in an abdominal cavity as a result of a stupid injury of a stomach with injury of a spleen and liver, is more rare – a pancreas, intestines or a bryzheyka (at blow, falling from height, a car accident etc.). Bleeding in a pleural cavity usually arises at multiple fractures of edges with damage of intercostal vessels and pleurae. In isolated cases fractures of 1-2 edges become its reason.
Bleeding in a cavity of a skull is one of dangerous complications of a craniocereberal trauma. As the skull, unlike other natural cavities, has rigidly fixed volume, even a small amount of the streamed blood causes a sdavleniye of brain structures and poses a threat for the patient's life. It is necessary to consider that intra cranial bleeding can develop not only right after a trauma, but also several hours later or even days, sometimes – against the background of full wellbeing.
Bleeding in a cavity of a joint can be caused by both an intra articulate change, and a bruise. Does not pose direct hazard to life, however in the absence of treatment can cause serious complications.
The considerable share from total of internal bleedings is made by the bleedings in a cavity of any body developing owing to chronic diseases of digestive tract: malignant tumors, stomach ulcer of a stomach and intestines, erosive gastritis, a gullet varicosity at cirrhosis etc. In surgical practice Mellori-Weiss's syndrome – gullet cracks owing to abuse of alcohol or single plentiful meal also quite often meets.
Gynecologic diseases are one more rather common cause of internal bleedings: ruptures of ovaries, extra-uterine pregnancy and so forth. In gynecologic practice internal bleedings after abortions meet. Also internal bleedings when prelying are possible or a premature otsloyka of a placenta, postnatal bleedings at a placenta exit delay, ruptures of a uterus and patrimonial ways.
The general early symptoms of internal bleeding are the general weakness, drowsiness, pallor of skin and mucous membranes, dizziness, cold sweat, thirst, darkening in eyes. Faints are possible. About intensity of blood loss it is possible to judge as by change of pulse and arterial pressure, and by other clinical signs.
At small blood loss insignificant increase of pulse is observed (to 80 beats/min) and insignificant decrease HELL, in some cases clinical symptoms can be absent.
Falling of systolic pressure to 90-80 mm Hg and increase of pulse (tachycardia) to 90-100 beats/min testifies to internal bleeding of average weight. Skin is pale, the cold snap of extremities and insignificant increase of breath is noted. Dryness in a mouth, faints, dizziness, nausea, an adinamiya, the expressed weakness, reaction delay is possible.
In hard cases decrease in systolic pressure to 80 mm Hg and below, increase of pulse to 110 and higher than a beats/min is observed. Strong increase and violation of a rhythm of breath, sticky cold sweat, yawning, pathological drowsiness, a tremor of hands, darkening in eyes, indifference, apathy, nausea and vomiting, reduction of amount of the emitted urine, painful thirst, a black-out, sharp pallor of skin and mucous, a tsianotichnost of extremities, lips and a nasolabial triangle is noted.
At massive internal bleedings pressure decreases to 60 mm of mercury., increase of pulse to 140-160 beats/min is noted. It is characteristic periodic breath (Cheyna-Stokes), absence or confusion of consciousness, nonsense, sharp pallor, sometimes – with a livid shade, cold sweat. The look is indifferent, the eyes which sank down the features pointed.
At deadly blood loss the coma develops. Systolic pressure goes down to 60 mm of mercury. or is not defined. Breath is agonalny, sharp bradycardia with ChSS of 2-10 beats/min., spasms, expansion of pupils, involuntary allocation calla and urine. Skin is cold, dry, "marble". Further there comes the agony and death.
Nausea and vomiting dark blood ("a coffee thick") demonstrate the expiration of blood in a cavity of a stomach or a gullet. The tar-like chair can be observed at internal bleeding in the top departments of a digestive tract or a small intestine. Release of not changed scarlet blood from back pass testifies to hemorrhoids or bleeding from the lower departments of a large intestine. If blood comes to an abdominal cavity, obtusion of a sound in flat places at percussion comes to light and symptoms of irritation of a peritoneum at a palpation.
At pulmonary bleeding there is cough with bright foamy blood, at a blood congestion in a pleural cavity – the expressed short wind, breath difficulty, shortage of air. The expiration of blood from female genitals testifies to bleeding in a uterus cavity, is more rare – vaginas. At bleeding in kidneys or urinary tract the gematuriya is observed.
At the same time, a number of symptoms can not be shown or be poorly expressed, especially – at small or moderate expressiveness of internal bleeding. It significantly complicates diagnostics and sometimes becomes the reason that patients see doctors already at late stages, at considerable deterioration in a state owing to considerable blood loss.
At emergence of suspicion of internal bleeding it is necessary to hold a number of diagnostic events for confirmation of the diagnosis and specification of the reason of blood loss. The detailed survey including measurement of pulse and arterial pressure, a thorax auskultation, a palpation and percussion of an abdominal cavity is carried out. For confirmation of the diagnosis and assessment of weight of blood loss laboratory researches of a gematokrit, level of hemoglobin and quantity of erythrocytes are conducted.
The choice of special methods of a research is carried out taking into account an alleged cause of internal bleeding: at diseases of digestive tract the manual research of a rectum, sounding of a stomach, an ezofagogastroduodenoskopiya, a kolonoskopiya and a rektoromanoskopiya can be carried out, at pulmonary diseases – a bronkhoskopiya, at damage of a bladder - a tsistoskopiya. Besides, radiological, ultrasonic and radiological techniques are used.
Diagnosis of the latent internal bleedings at which blood comes to the closed cavities (belly, chest, a skull cavity, a pericardium etc.) is also made taking into account an estimated source of blood loss. Disappearance of the lower contour of a lung on the roentgenogram and blackout in the lower departments with clear horizontal boundary testifies to a gemotoraksa. In doubtful cases the roentgenoscopy is carried out. At suspicion of bleeding the laparoscopy is carried out to an abdominal cavity, at suspicion of an intra cranial hematoma – a X-ray analysis of a skull and an ekhoentsefalografiya.
It is necessary to provide as fast as possible delivery of the patient in office of the specialized help. The patient needs to provide rest. At suspicion on or pulmonary bleeding the patient is given a semi-sitting position, at blood loss in other areas stack on a plain surface. On area of an estimated source of bleeding it is necessary to put cold (for example, a bubble with ice). It is strictly forbidden to heat sick area, to give enemas, give laxatives or to inject the drugs stimulating warm activity in an organism!
Specialized medical assistance
Patients are hospitalized in a hospital. The choice of office is carried out taking into account a source of internal bleeding. Treatment of a traumatic gemotoraks is performed by traumatologists, not traumatic gemotoraks and pulmonary bleedings – thoracic surgeons, intra cranial hematomas – neurosurgeons, uterine bleedings – gynecologists. At a stupid injury of a stomach and gastrointestinal bleedings hospitalization in office of the general surgery is performed.
The main tasks in this case – an urgent stop of internal bleeding, compensation of blood loss and improvement of microcirculation. From the very beginning of treatment for prevention of a syndrome of empty heart (reflex cardiac arrest owing to reduction of volume of OTsK), restoration of volume of the circulating liquid and prevention of gipovolemichesky shock jet transfusion of 5% of solution of glucose, physiological solution, blood, plazmo-and blood substitutes is made.
Sometimes the stop of internal bleeding is made by a tamponada or cauterization of the bleeding site. However urgent surgical intervention under anesthetic in most cases is required. At signs of hemorrhagic shock or threat of its emergence at all stages (preparation for operation, surgery, the period after operation) transfusion actions are made.
At pulmonary bleeding the tamponada of a bronchial tube is made. At an average and small gemotoraks the pleural puncture is carried out, at a big gemotoraks – a torakotomiya with an ushivaniye of a wound of a lung or bandaging of a vessel, at loss of blood in an abdominal cavity – the emergency laparotomy with an ushivaniye of a wound of a liver, spleen or other damaged body, at an intra cranial hematoma – cranial trepanation.
At stomach ulcer the stomach resection is made, at a duodenum ulcer – a vessel proshivaniye in combination with a vagotomiya. At Mellori-Weiss's syndrome (bleeding from a gullet crack) the endoscopic stop of bleeding in combination with cold, purpose of antatsid, aminocaproic acid and stimulators of fibrillation is carried out. If conservative treatment is inefficient, operation (a proshivaniye of cracks) is shown.
Internal bleeding owing to extra-uterine pregnancy is the indication for the emergency surgical intervention. At dysfunctional uterine bleedings make a uterus cavity tamponada, at massive bleedings owing to abortion, a patrimonial trauma and after the delivery carry out surgery.
Infusional therapy is performed under control HELL, warm emission, the central venous pressure and an hourly diuresis. The volume of infusion is defined with expressiveness of blood loss. Blood substitutes of haemo dynamic action are applied: dextran, , solutions of salts and sugars, and also blood medicines (albumine, freshly frozen plasma, eritrotsitarny weight).
If HELL does not manage to be normalized, despite the carried-out infusional therapy, after a stop of bleeding enter a dopamine, noradrenaline or adrenaline. Apply to treatment of hemorrhagic shock , , heparin and steroid medicines. After elimination of threat for life carry out correction of acid-base balance.