HAEMORRHAGE. METHODS OF BLEEDING CONTROL

Hemorrhage (haemorrhagia) is one of the most often complications of traumas and different human diseases — a direct cause of death of nearly 40% of patients. Effective methods of struggle with bleeding allow to improve the result of treatment, decrease the mortality and to increase the safety of surgical operations.

Hemorrhage is the blood outpouring from damaged blood vessels. There are different classifications of bleedings depending upon the principle which makes up their basis. Physiological (menstruation) and pathological (traumas, tumours, and inflammatory processes) bleedings are distinguished.

Pathological bleedings can be caused by damage to the vessel’s wall in trauma (h. per rhexin), due to pathological process (h. per diabrosim), which destroys the wall of a vessel (tumor, inflammatory process, ulcer), or due to imbalance of permeability of the vascular wall during infectious processes, scurvy, sepsis (h. per diapedesin).

According to the anatomic principle depending upon the kind of a damaged vessel the arterial, venous, capillary, parenchymatous bleedings are distinguished. The most dangerous is arterial bleeding, which results in rapid anemia and death of the patient in case of inefficient treatment. The color of the blood, speed of discharge, pulsating blood stream have importance for differential diagnosis of the specified kinds of bleedings. For example, the classic arterial bleeding manifests itself in bright red blood, high speed of discharge and pulsating blood stream. The venous bleeding, in contrast, is characterized by dark blood, even and slow blood flow. But the signs can have a relative value, as multiple venous bleedings (from the main veins) can be accompanied by pulsating blood-stream of bright red color (for example, from the jugular vein).

The most informative attribute for differentiating the kinds of bleedings are the results of applying a tourniquet. A proximal application of the tourniquet in relation to the wound stops arterial bleeding.

Capillary bleeding is small; the blood flows from the whole surface of the wound, stopping, as a rule, independently.

A special kind of capillary bleeding is parenchymatous one (in damage of the liver, spleen, etc.), thus the whole wounded surface bleeds, and the blood does not stop independently, because the bleeding vessels are fixed in the stroma and do not collapse. Parenchymatous frequently results in acute anemia.

Depending upon where blood is flowing, external and internal bleedings are distinguished. With internal bleeding the blood pours into different cavities and tissues: abdominal (hemoperitoneum), chest (hemothorax), cardiac sac (hemopericardium), joint cavity (hemarthrosis), into soft tissue (hematoma).

Revealing blood in the secretion and excretion of an organism allows to find the place of bleeding and to take effective measures in stopping the internal bleeding. Depending upon the revealing of blood in secretion and excretion the following kinds of internal bleeding are distinguished:

— nasal bleed (epistaxis);

— haemoptysis, bleeding from the respiratory tract (haemoptoe);

— bloody defecation (melena), caused by bleeding from different parts of the gastrointestinal tract;

— bleeding from the urinary tracts (haematuria);

— bleeding from the genitals (metrorrhagia);

— intestinal bleeding (enterorrhagia);

— stomach bleeding (gastrorrhagia).

Hemorrhages when the discharges blood is not found and only secondary attributes of bleeding are registered (anemia, data from laboratory analyses) are called latent.

By the time of occurrence the following are distinguished: primary bleedings (that occurred directly after the damage to the vessel) and secondary ones (a while after the bleeding stopped).

Secondary bleedings are divided into early (first 2 days after damage) and late (from the 3rd day to several months). Secondary haemorrhages can be caused by insufficient stopping of bleedings during surgical processing or operative intervention (badly fastened knot, slipping of the ligature), changes in the chemical compound of the blood (avitaminosis, decrease in blood coagulation ability, haemophilia) addition of septic processes (putrefactive infection of the wound with the following melting of blood clots), tumour processes (tumor decay).

The clinical picture of bleedings consists of local attributes and general symptoms. The major attribute is the revealing of blood. During internal bleedings local attributes depend upon the compressed organ, concentration of the blood (weakening in damaged sites during intraabdominal bleedings, symptoms of tamponade of the heart during accumulation of blood in the pericardium — weakness, arrhythmia, expansion of cardiac dullness, etc.).

The general attributes are characterized by the development of the acute anemia clinical picture as collapse and anemia of the brain: paleness of the skin and mucous, dryness of the skin, thirstiness, sharp features of the face, pulse fall (frequent, small filling and pressure), decrease in blood pressure, blackness in the eyes, anxiety, drowsiness, loss of consciousness, weakness, involuntary urination and defecation.

Laboratory methods of diagnosis help the doctor estimate the severity of blood loss and its threat to life.

Analysis of amount of erythrocytes, haemoglobin, hematocrit have special value for estimation of the severity of bleeding and blood loss, which has taken place. The amount of erythrocytes and haemoglobin is a relative indicator because they are made without taking into account the amount of blood. Within first 3 h the amount of haemoglobin and erythrocytes almost do not differ from the normal level. Hydremic reaction (saturation of the blood with tissue fluid instead of lost erythrocytes) is found only in a few hours and lasts for 10–11 days. The more massive the blood loss the more intensive the hydraemia reaction. Despite of the bleeding arrest, the parameters (erythrocytes, haemoglobin) continue to reduce and anemia increases. In a mild degree of blood loss (globular volume (GV) — 10–20%) the contents of erythrocytes is on the average 4.4·1012/l, with moderate blood loss (deficiency of GV — from 20 up to 30%) — 3.5·1012/l, in severe degree (deficiency of GV is 30% and greater) — 2.6·1012/l.

Amount of haemoglobin during blood loss change as the following:

— mild degree — 108–158 g/l;

— middle — from 108 up to 141 g/l;

— severe — from 25 up to 108 g/l.

In practical work, the hematocrit number is widely used for the definition of the extent of blood loss. Normal — 45–50%. The mild degree of blood loss is accompanied by a decrease in hematocrit up to 30%, moderate — up to 25%, severe — lower than 25%. The hematocrit also depends on the terms of research after the acute blood loss. During first 2–3 h the hematocrit level does not differ from normal, but with development of hydraemia reactions and haemodilution of blood the hematocrit number gradually reduces.

In emergency surgery, the Phillips—Barashkov’s test is widely spread for the estimation of blood loss degree. It consists in definition of relative density of blood and plasma with the application of a solution of copper sulfate (relative density is from 1.034 up to 1.075). A drop of blood is sunk from the height of 1 cm into a solution (relative density is 1.050). If the density of blood is lower than the density of the solution, the drop will rise to the surface at once, and if it is greater, it will sink. The density is determined until the drop of blood remains hanging in the liquid for 3–4 s.

If the relative density of blood is 1.057–1.054, according to Barashkov the blood loss makes up 500 ml, if the relative density is 1.053–1.050 — from 600 up to 1,000 ml, if 1.049–1.044 — 1,100– 1,500 ml, if 1.043 and lower — more than 1,500 ml.

For quality evaluation of blood loss the principal value is the blood volume (BV), plasma volume (PV), GV.

The basis of the methods determining BV and its components consists of the principle of dissolution of a certain indicator, the concentration, which is determined a while after the introduction into plasma or blood. Radioisotope techniques are applied to define BV with the help of carbon isotopes (51С₂ and 52С₂), iodine isotopes (131І and 132І), dyes (Evans’ blue — color T-1824) or dextrin (polyglukine). The parameters of BV and its components are calculated by the body weight of the patient and the average hematologic parameters received from healthy people.

The following degrees of blood loss are distinguished:

— I mild (blood loss up to 500 ml);

— ІІ middle (from 600 up to 1,000 ml);

— ІІІ severe (from 1,100 up to 1,500 ml);

— ІV fatal (over 50% of the amount of blood).

The determination of the blood loss degree has a big value in the prognosis of bleeding and treatment. For consequences of bleeding the size and speed of blood loss, the general condition of an organism, the age of the patient and the condition of the cardiovascular system are important. During bleeding a complex mechanism of adaptation to blood loss develops in an organism, which consists of: angiospasm, acceleration of cardiac activity and respiration, increase in BV due to the intake of blood and tissue fluid into the blood channel from the depot. The condition of coagulation blood system has great importance for the bleeding outcome. With disturbances of coagulation (for example, haemophilia) even a small bleeding can lead to acute anemia and death of the patient.

Complications and consequences of bleeding can be different. Sudden loss of blood causes the acute anemia picture with the development of haemorrhagic shock of different degrees of severity. Arterial and central venous pressure with the development of anemia of the brain tissue decreases first. In massive blood loss the condition of the patient sharply worsens: sharp features of the face, dense cold sweat, paleness and cyanosis of the skin, cold extremities, decrease in body temperature, drowsiness, indifference, dilated pupils. Involuntary defecation can be observed. During progressing — unconsciousness. Death can come because of rather small bleedings if the vital functions of organs (hemorrhages in the brain, in the pericardium cavity with the development of cardiac tamponade) increase. Air embolism can occur in damage of large main veins, in particular on the neck.

Hemorrhage leads to a number of severe complications. When hematoma of the soft tissue collides with the opening of a large vascular tube, a pulsating hematoma can develop. Further, with the formation of connective tissue capsules, artificial traumatic aneurysm (arterial, arteriovenous) takes place, which is very dangerous because of the late complications development (ruptures, thromboses, embolism, and ischemia of tissue).

Hematomas are nutrient medium for the development of microorganisms, which get directly with a wound or hematogenously. Thus, abscesses occur. Blood clots which irritate the surrounding tissue serve as the reason for local inflammation with the proliferation of tissue and the formation of scars of different density. That is why haemorrhages in serous cavities (pleural, pericardium, abdominal) can lead to the development of adhesive process, which adversely effect the organ’s functions (adhesive pericarditis, pleuritis, adhesive intestinal obstruction). haemorrhages in the joints frequently disrupt their mobility, because of salts deposit and the development of exostosis.

Methods of Bleeding Arrest

Medical practice and first aid for bleedings depends upon the localization, volume and character of bleeding, severity of somatic condition of the patient. Temporary and complete ways of bleeding arrest are distinguished. Methods of temporary bleeding arrest are applied basically during the pre-admission period, during transportation of the patient.

Methods of temporary bleeding arrest are the following: bandage application, lifted position of the extremities, maximal bending of the extremities in the joint and compression of the vessels at this site, manual pressing of the vessel on an extent, application of a tourniquet and a clip on the vessel which is bleeding in the wound. Any of the methods has certain indications. Bandage is used mainly with injury of fine and average diameter vessels; it does not stop the bleeding in large arteries injury. The raised position of the extremities is applied for injuried capillaries and fine veins, frequently in a combination with a bandage.

The maximal joint bending of extremities is used in wounds of the popliteal, humeral, femoral arteries. Manual pressing along the artery is applied in emergency with injury of large arteries (carotid, humeral, etc.) as means of temporary stoppage of haemorrhage before applying a tourniquet or while taking it off.

It is impossible to arrest bleeding for a long time with this method, because the hand putting on the pressure gets tired.

Applying a tourniquet is the basic method of temporal bleeding stoppage. While applying a tourniquet, it is necessary to follow the following rules:

A tourniquet is applied mostly in case of arterial bleeding.

A tourniquet is applied on the extremities with one bone (shoul-

der, hip), because being applied on the forearm or shin it is less effective (the vessel passes through the interosseous membrane and only the veins will be compressed).

A lining should be under the tourniquet (so that not to injurethe skin).

It is necessary to apply a tourniquet on the upper and middlethird of the hip or shoulder, so that there is no compression of the nerves (ulnar, ischiadicus).

A tourniquet is applied for 2 h, during the winter period theextremities are to be warmed so that frostbite does not occur.

It is necessary to let the tourniquet up a few times during 2 h,combining this method of bleeding arrest with manual pressing the vessels; in the summer — for 1–1.5 h, in the winter — for 1 h, then every 15 min.

If the tourniquet is applied correctly, the skin is pale, pulsation of the arteries under the site of the applied tourniquet is absent.

A good method of haemorrhage stoppage is applying a haemostatic clip on the vessel which bleeds in the wound. Accordingly transport immobilization is necessary.

Complete arrest of bleeding is carried out in a hospital. 4 groups of methods of haemostasis are distinguished:

1) mechanical;

2) thermal;

3) chemical;

4) biological.

Tying a vessel in wounds on an extent, imposing a vascular suture, applying a bandage and tamponade, application of vascular prosthetic device (shunts) belong to mechanical methods of haemostasis.

Ligation is the most widespread method to stop bleedings; it is applied in wound of fine and middle caliber vessels, except for main vessels. Ambruas Pare′ applied ligation for the first time. Imposing a vascular suture or applying prosthetic devices (shunts) is an ideal method to stop bleedings. A great merit in the development of the techniques of vascular sutures belongs to Alexis Karrel. Different kinds of sutures and prosthetic devices are applied. Corpses’ vessels, specially prepared, autograft (of the patient’s vein), synthetic prosthetic devices (nylon, dacron, etc.) can be used as prosthetic devices.

If it is impossible to use any of the mentioned methods, capillary and parenchimatous bleeding can be stopped by tamponade of the wounds with gauze tampons. This method is compelled, with the pollution of the wound it can assist in the development of the wound infection. Tamponade of the wound is carried out during 48 h. The compelled mean is leaving in the wound the clip applied on the vessel if it is impossible to impose a ligature. This means is not reliable because the bleeding can start again after the removal of the clip.

Thermal methods of bleeding arrest consist in application of high and low temperatures. In order to stop parenchymatous haemorrhages they use hot solutions of 0.85% sodium chloride. Electrocauter, ultrasonocauter, surgical laser are used for cauterization of vessels which bleed. As the way of haemostasis with the help of low temperatures regional cooling (blister with ice, devices of local hypothermia), as well as cryodestruction (with the help of different cryogenic devices) are applied.

Chemical methods of haemostasis include the application of vasoconstrictive devices and the preparations which promote the blood coagulation abilities (adrenaline, preparations of ergot, calcium chloride, ε-aminocapronic acid, etc.).

Means of bleeding arrest are divided into external and internal. Among external means adrenalin is applied. At local application it causes narrowing and coagulation of vessels. Adrenaline is used at local anaesthesia (in dental practice). The shortcoming of the method is that after the termination of adrenaline action in the postoperative period the vessels can dilate and bleeding renews.

Hydrogen peroxide is applied with mucosa haemorrhages (the nose, gindiva, tongue, after tooth extraction).

Internal means of arrest of bleeding are divided into 2 subgroups: drugs which provide narrowing of vessels (adrenalin, adroxon) and drugs which increase blood coagulation (calcium chloride, ε-amynocapronic acid, sodium ethamsylate).

Biological methods of haemostasis can be divided into the following groups:

Tamponade of bleeding wounds with animal tissue rich in thromboplastin (omentum, fatty tissue, muscle, fascia, etc.). This technique is applied mainly with parenchymatous capillary bleeding.

Local application of blood preparations (thrombin, haemostatic sponge, fibrinous film, biological antiseptic tampon, etc.).

Haemotransfusion and application of blood preparations whichmake better its ability to coagulate (plasma, thrombocyte mass, fibrinogen, prothrombin complex, antihemophylic globulin А). The indication for haemotransfusion is the degree of blood loss. With the mild degree (up to 500 ml) haemotransfusion is indicated, blood loss is compensated for with blood substitutes and infusion agents.

With moderate blood loss it is necessary to compensate up to 50% of the lost blood by transfusion, the rest is compensated with blood substitutes. With severe blood loss (1,500 ml and more), it should be compensated as soon as possible with fresh blood and usage of direct transfusion.

The administration of vitamins (C, K as vicasol) assists in theimprovement of blood coagulation and stopping haemorrhages.

The application of blood serum of human and animals, whichis injected intramuscularly, gives a haemostatic effect, increases an ability of blood to coagulate.