HAEMORRHAGE. METHODS OF BLEEDING CONTROL
Hemorrhage (haemorrhagia) is among the most frequently issues of traumas and totally different human illnesses — a direct reason behind loss of life of almost 40% of sufferers. Efficient strategies of wrestle with bleeding permit to enhance the results of therapy, lower the mortality and to extend the protection of surgical operations.
Hemorrhage is the blood outpouring from broken blood vessels. There are totally different classifications of bleedings relying upon the precept which makes up their foundation. Physiological (menstruation) and pathological (traumas, tumours, and inflammatory processes) bleedings are distinguished.
Pathological bleedings might be brought on by injury to the vessel’s wall in trauma (h. per rhexin), as a consequence of pathological course of (h. per diabrosim), which destroys the wall of a vessel (tumor, inflammatory course of, ulcer), or as a consequence of imbalance of permeability of the vascular wall throughout infectious processes, scurvy, sepsis (h. per diapedesin).
In line with the anatomic precept relying upon the sort of a broken vessel the arterial, venous, capillary, parenchymatous bleedings are distinguished. Probably the most harmful is arterial bleeding, which leads to speedy anemia and loss of life of the affected person in case of inefficient therapy. The colour of the blood, pace of discharge, pulsating blood stream have significance for differential analysis of the desired sorts of bleedings. For instance, the basic arterial bleeding manifests itself in vibrant crimson blood, excessive pace of discharge and pulsating blood stream. The venous bleeding, in distinction, is characterised by darkish blood, even and sluggish blood movement. However the indicators can have a relative worth, as a number of venous bleedings (from the principle veins) might be accompanied by pulsating blood-stream of vibrant crimson shade (for instance, from the jugular vein).
Probably the most informative attribute for differentiating the sorts of bleedings are the outcomes of making use of a tourniquet. A proximal utility of the tourniquet in relation to the wound stops arterial bleeding.
Capillary bleeding is small; the blood flows from the entire floor of the wound, stopping, as a rule, independently.
A particular sort of capillary bleeding is parenchymatous one (in injury of the liver, spleen, and so forth.), thus the entire wounded floor bleeds, and the blood doesn’t cease independently, as a result of the bleeding vessels are mounted within the stroma and don’t collapse. Parenchymatous steadily ends in acute anemia.
Relying upon the place blood is flowing, exterior and inner bleedings are distinguished. With inner bleeding the blood pours into totally different cavities and tissues: belly (hemoperitoneum), chest (hemothorax), cardiac sac (hemopericardium), joint cavity (hemarthrosis), into comfortable tissue (hematoma).
Revealing blood within the secretion and excretion of an organism permits to seek out the place of bleeding and to take efficient measures in stopping the inner bleeding. Relying upon the revealing of blood in secretion and excretion the next sorts of inner bleeding are distinguished:
— nasal bleed (epistaxis);
— haemoptysis, bleeding from the respiratory tract (haemoptoe);
— bloody defecation (melena), brought on by bleeding from totally different components of the gastrointestinal tract;
— bleeding from the urinary tracts (haematuria);
— bleeding from the genitals (metrorrhagia);
— intestinal bleeding (enterorrhagia);
— abdomen bleeding (gastrorrhagia).
Hemorrhages when the discharges blood shouldn’t be discovered and solely secondary attributes of bleeding are registered (anemia, knowledge from laboratory analyses) are referred to as latent.
By the point of incidence the next are distinguished: main bleedings (that occurred instantly after the injury to the vessel) and secondary ones (some time after the bleeding stopped).
Secondary bleedings are divided into early (first 2 days after injury) and late (from the third day to a number of months). Secondary haemorrhages might be brought on by inadequate stopping of bleedings throughout surgical processing or operative intervention (badly mounted knot, slipping of the ligature), modifications within the chemical compound of the blood (avitaminosis, lower in blood coagulation capacity, haemophilia) addition of septic processes (putrefactive an infection of the wound with the next melting of blood clots), tumour processes (tumor decay).
The scientific image of bleedings consists of native attributes and normal signs. The key attribute is the revealing of blood. Throughout inner bleedings native attributes depend on the compressed organ, focus of the blood (weakening in broken websites throughout intraabdominal bleedings, signs of tamponade of the center throughout accumulation of blood within the pericardium — weak spot, arrhythmia, growth of cardiac dullness, and so forth.).
The final attributes are characterised by the event of the acute anemia scientific image as collapse and anemia of the mind: paleness of the pores and skin and mucous, dryness of the pores and skin, thirstiness, sharp options of the face, pulse fall (frequent, small filling and strain), lower in blood strain, blackness within the eyes, anxiousness, drowsiness, lack of consciousness, weak spot, involuntary urination and defecation.
Laboratory strategies of analysis assist the physician estimate the severity of blood loss and its risk to life.
Evaluation of quantity of erythrocytes, haemoglobin, hematocrit have particular worth for estimation of the severity of bleeding and blood loss, which has taken place. The quantity of erythrocytes and haemoglobin is a relative indicator as a result of they’re made with out bearing in mind the quantity of blood. Inside first 3 h the quantity of haemoglobin and erythrocytes nearly don’t differ from the traditional degree. Hydremic response (saturation of the blood with tissue fluid as a substitute of misplaced erythrocytes) is discovered solely in just a few hours and lasts for 10–11 days. The extra huge the blood loss the extra intensive the hydraemia response. Regardless of of the bleeding arrest, the parameters (erythrocytes, haemoglobin) proceed to scale back and anemia will increase. In a light diploma of blood loss (globular quantity (GV) — 10–20%) the contents of erythrocytes is on the typical 4.4·1012/l, with average blood loss (deficiency of GV — from 20 as much as 30%) — 3.5·1012/l, in extreme diploma (deficiency of GV is 30% and larger) — 2.6·1012/l.
Quantity of haemoglobin throughout blood loss change as the next:
— gentle diploma — 108–158 g/l;
— center — from 108 as much as 141 g/l;
— extreme — from 25 as much as 108 g/l.
In sensible work, the hematocrit quantity is broadly used for the definition of the extent of blood loss. Regular — 45–50%. The gentle diploma of blood loss is accompanied by a lower in hematocrit as much as 30%, average — as much as 25%, extreme — decrease than 25%. The hematocrit additionally depends upon the phrases of analysis after the acute blood loss. Throughout first 2–3 h the hematocrit degree doesn’t differ from regular, however with growth of hydraemia reactions and haemodilution of blood the hematocrit quantity progressively reduces.
In emergency surgical procedure, the Phillips—Barashkov’s take a look at is broadly unfold for the estimation of blood loss diploma. It consists in definition of relative density of blood and plasma with the appliance of an answer of copper sulfate (relative density is from 1.034 as much as 1.075). A drop of blood is sunk from the peak of 1 cm into an answer (relative density is 1.050). If the density of blood is decrease than the density of the answer, the drop will rise to the floor without delay, and whether it is larger, it is going to sink. The density is decided till the drop of blood stays hanging within the liquid for 3–4 s.
If the relative density of blood is 1.057–1.054, based on Barashkov the blood loss makes up 500 ml, if the relative density is 1.053–1.050 — from 600 as much as 1,000 ml, if 1.049–1.044 — 1,100– 1,500 ml, if 1.043 and decrease — greater than 1,500 ml.
For high quality analysis of blood loss the principal worth is the blood quantity (BV), plasma quantity (PV), GV.
The premise of the strategies figuring out BV and its elements consists of the precept of dissolution of a sure indicator, the focus, which is decided some time after the introduction into plasma or blood. Radioisotope strategies are utilized to outline BV with the assistance of carbon isotopes (51С2 and 52С2), iodine isotopes (131І and 132І), dyes (Evans’ blue — shade T-1824) or dextrin (polyglukine). The parameters of BV and its elements are calculated by the physique weight of the affected person and the typical hematologic parameters obtained from wholesome folks.
The next levels of blood loss are distinguished:
— I gentle (blood loss as much as 500 ml);
— ІІ center (from 600 as much as 1,000 ml);
— ІІІ extreme (from 1,100 as much as 1,500 ml);
— ІV deadly (over 50% of the quantity of blood).
The dedication of the blood loss diploma has an enormous worth within the prognosis of bleeding and therapy. For penalties of bleeding the scale and pace of blood loss, the overall situation of an organism, the age of the affected person and the situation of the cardiovascular system are essential. Throughout bleeding a fancy mechanism of adaptation to blood loss develops in an organism, which consists of: angiospasm, acceleration of cardiac exercise and respiration, improve in BV because of the consumption of blood and tissue fluid into the blood channel from the depot. The situation of coagulation blood system has nice significance for the bleeding final result. With disturbances of coagulation (for instance, haemophilia) even a small bleeding can result in acute anemia and loss of life of the affected person.
Issues and penalties of bleeding might be totally different. Sudden lack of blood causes the acute anemia image with the event of haemorrhagic shock of various levels of severity. Arterial and central venous strain with the event of anemia of the mind tissue decreases first. In huge blood loss the situation of the affected person sharply worsens: sharp options of the face, dense chilly sweat, paleness and cyanosis of the pores and skin, chilly extremities, lower in physique temperature, drowsiness, indifference, dilated pupils. Involuntary defecation might be noticed. Throughout progressing — unconsciousness. Loss of life can come due to slightly small bleedings if the very important capabilities of organs (hemorrhages within the mind, within the pericardium cavity with the event of cardiac tamponade) improve. Air embolism can happen in injury of huge essential veins, specifically on the neck.
Hemorrhage results in quite a lot of extreme issues. When hematoma of the comfortable tissue collides with the opening of a giant vascular tube, a pulsating hematoma can develop. Additional, with the formation of connective tissue capsules, synthetic traumatic aneurysm (arterial, arteriovenous) takes place, which could be very harmful due to the late issues growth (ruptures, thromboses, embolism, and ischemia of tissue).
Hematomas are nutrient medium for the event of microorganisms, which get instantly with a wound or hematogenously. Thus, abscesses happen. Blood clots which irritate the encircling tissue function the rationale for native irritation with the proliferation of tissue and the formation of scars of various density. That’s the reason haemorrhages in serous cavities (pleural, pericardium, belly) can result in the event of adhesive course of, which adversely impact the organ’s capabilities (adhesive pericarditis, pleuritis, adhesive intestinal obstruction). haemorrhages within the joints steadily disrupt their mobility, due to salts deposit and the event of exostosis.
Strategies of Bleeding Arrest
Medical follow and first support for bleedings relies upon upon the localization, quantity and character of bleeding, severity of somatic situation of the affected person. Momentary and full methods of bleeding arrest are distinguished. Strategies of momentary bleeding arrest are utilized principally throughout the pre-admission interval, throughout transportation of the affected person.
Strategies of momentary bleeding arrest are the next: bandage utility, lifted place of the extremities, maximal bending of the extremities within the joint and compression of the vessels at this website, handbook urgent of the vessel on an extent, utility of a tourniquet and a clip on the vessel which is bleeding within the wound. Any of the strategies has sure indications. Bandage is used primarily with harm of fantastic and common diameter vessels; it doesn’t cease the bleeding in giant arteries harm. The raised place of the extremities is utilized for injuried capillaries and fantastic veins, steadily in a mix with a bandage.
The maximal joint bending of extremities is utilized in wounds of the popliteal, humeral, femoral arteries. Handbook urgent alongside the artery is utilized in emergency with harm of huge arteries (carotid, humeral, and so forth.) as technique of momentary stoppage of haemorrhage earlier than making use of a tourniquet or whereas taking it off.
It’s unimaginable to arrest bleeding for a very long time with this technique, as a result of the hand placing on the strain will get drained.
Making use of a tourniquet is the essential technique of temporal bleeding stoppage. Whereas making use of a tourniquet, it’s essential to observe the next guidelines:
A tourniquet is utilized principally in case of arterial bleeding.
A tourniquet is utilized on the extremities with one bone (shoul-
der, hip), as a result of being utilized on the forearm or shin it’s much less efficient (the vessel passes by the interosseous membrane and solely the veins shall be compressed).
A lining must be underneath the tourniquet (in order that to not injurethe pores and skin).
It’s mandatory to use a tourniquet on the higher and middlethird of the hip or shoulder, in order that there isn’t any compression of the nerves (ulnar, ischiadicus).
A tourniquet is utilized for two h, throughout the winter interval theextremities are to be warmed in order that frostbite doesn’t happen.
It’s essential to let the tourniquet up just a few instances throughout 2 h,combining this technique of bleeding arrest with handbook urgent the vessels; in the summertime — for 1–1.5 h, within the winter — for 1 h, then each 15 min.
If the tourniquet is utilized accurately, the pores and skin is pale, pulsation of the arteries underneath the positioning of the utilized tourniquet is absent.
A very good technique of haemorrhage stoppage is making use of a haemostatic clip on the vessel which bleeds within the wound. Accordingly transport immobilization is important.
Full arrest of bleeding is carried out in a hospital. 4 teams of strategies of haemostasis are distinguished:
1) mechanical;
2) thermal;
3) chemical;
4) organic.
Tying a vessel in wounds on an extent, imposing a vascular suture, making use of a bandage and tamponade, utility of vascular prosthetic gadget (shunts) belong to mechanical strategies of haemostasis.
Ligation is essentially the most widespread technique to cease bleedings; it’s utilized in wound of fantastic and center caliber vessels, apart from essential vessels. Ambruas Pare′ utilized ligation for the primary time. Imposing a vascular suture or making use of prosthetic units (shunts) is a perfect technique to cease bleedings. An important benefit within the growth of the strategies of vascular sutures belongs to Alexis Karrel. Totally different sorts of sutures and prosthetic units are utilized. Corpses’ vessels, specifically ready, autograft (of the affected person’s vein), artificial prosthetic units (nylon, dacron, and so forth.) can be utilized as prosthetic units.
Whether it is unimaginable to make use of any of the talked about strategies, capillary and parenchimatous bleeding might be stopped by tamponade of the injuries with gauze tampons. This technique is compelled, with the air pollution of the wound it will probably help within the growth of the wound an infection. Tamponade of the wound is carried out throughout 48 h. The compelled imply is leaving within the wound the clip utilized on the vessel whether it is unimaginable to impose a ligature. This implies shouldn’t be dependable as a result of the bleeding can begin once more after the removing of the clip.
Thermal strategies of bleeding arrest consist in utility of excessive and low temperatures. With a view to cease parenchymatous haemorrhages they use sizzling options of 0.85% sodium chloride. Electrocauter, ultrasonocauter, surgical laser are used for cauterization of vessels which bleed. As the way in which of haemostasis with the assistance of low temperatures regional cooling (blister with ice, units of native hypothermia), in addition to cryodestruction (with the assistance of various cryogenic units) are utilized.
Chemical strategies of haemostasis embody the appliance of vasoconstrictive units and the preparations which promote the blood coagulation skills (adrenaline, preparations of ergot, calcium chloride, ε-aminocapronic acid, and so forth.).
Technique of bleeding arrest are divided into exterior and inner. Amongst exterior means adrenalin is utilized. At native utility it causes narrowing and coagulation of vessels. Adrenaline is used at native anaesthesia (in dental follow). The shortcoming of the strategy is that after the termination of adrenaline motion within the postoperative interval the vessels can dilate and bleeding renews.
Hydrogen peroxide is utilized with mucosa haemorrhages (the nostril, gindiva, tongue, after tooth extraction).
Inner technique of arrest of bleeding are divided into 2 subgroups: medication which offer narrowing of vessels (adrenalin, adroxon) and medicines which improve blood coagulation (calcium chloride, ε-amynocapronic acid, sodium ethamsylate).
Organic strategies of haemostasis might be divided into the next teams:
Tamponade of bleeding wounds with animal tissue wealthy in thromboplastin (omentum, fatty tissue, muscle, fascia, and so forth.). This method is utilized primarily with parenchymatous capillary bleeding.
Native utility of blood preparations (thrombin, haemostatic sponge, fibrinous movie, organic antiseptic tampon, and so forth.).
Haemotransfusion and utility of blood preparations whichmake higher its capacity to coagulate (plasma, thrombocyte mass, fibrinogen, prothrombin advanced, antihemophylic globulin А). The indication for haemotransfusion is the diploma of blood loss. With the gentle diploma (as much as 500 ml) haemotransfusion is indicated, blood loss is compensated for with blood substitutes and infusion brokers.
With average blood loss it’s essential to compensate as much as 50% of the misplaced blood by transfusion, the remainder is compensated with blood substitutes. With extreme blood loss (1,500 ml and extra), it must be compensated as quickly as doable with contemporary blood and utilization of direct transfusion.
The administration of nutritional vitamins (C, Okay as vicasol) assists in theimprovement of blood coagulation and stopping haemorrhages.
The appliance of blood serum of human and animals, whichis injected intramuscularly, offers a haemostatic impact, will increase a capability of blood to coagulate.