HAEMORRHAGE. BY Dr HAYDER M. ABDULNABI DM, CABS. TYPES OF BLEEDING. DEPNDING ON THE SOURSE OF BLEEDING 1 - ARTERIAL – BRIGHT RED AND COMES IN JETS WITH THE PULSE OF THE PATIENT 2 - VENOUS – DARK RED BLOOD , STEADY AND COPIOUS 3 - CAPILLARY – BRIGHT RED RAPID OOZE ( ABRASIONS ).
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HAYDER M. ABDULNABI
DEPNDING ON THE SOURSE OF BLEEDING
1- ARTERIAL– BRIGHT RED AND COMES IN JETS WITH THE PULSE OF THE PATIENT
2- VENOUS – DARK RED BLOOD , STEADY AND COPIOUS
3- CAPILLARY– BRIGHT RED RAPID OOZE ( ABRASIONS )
1- PRIMARY BLEEDING – OCCURS AT THE TIME OF INJURY OR OPERATION
2- REACTIONARY BLEEDING – USUALLY OCCURS IN 4-6 HOURS OR WITH IN THE 24 HOURS THAT FOLLOW THE PRIMARY BLEEDING, DUE TO EITHER SLIPPING OF LIGATURE , DISLOGEMENT OF A CLOT OR CESSATION OF THE REFLEX VASOSPASM.
THE PRESIPITATING FACTOR ARE
A- THE INCREASE IN THE BLOOD PRESSURE AFTER RECOVERY FROM SHOCK OR ANASTHESIA
C- COUGHING AND VOMITING THAT INCREASE THE VENOUS PRESSURE
3- SECONDARY BLEEDING – OCCUR WITHIN 7-14 DAYS AFTER THE PRIMARY TRAUMA OR OPERATION AND THE CAUSE IS ALWAYS INFECTION WHICH LEADS TO SLOUGHIN OF AN ARTERY IN AN AREA BY PRESSURE OF A DRAIN TUBE OR A BONE FRAGMENT OR BY SLIPPING OF A LIGATURE IN AN INFECTED AREA OR MALIGNANT TISSUE
A- EXTERNAL ( REVEALED ) BLEEDING
B- INTERNAL ( CONCAELED ) BLEEDING LIKE INTRA-ABDOMINAL OR INTRACRANIAL BLEEDING
THE INTERNAL BLEEDING MAY BECOME EXTENAL AS IN HEMATEMESIS DUE TO A BLEEDING PEPTC ULCER OR HEMATURIA AFTER RENAL INJURY OR AN INTRUTERINE BLEEDING TURNS INTO BLEEDING PER VAGINA
A NORMAL BLOOD VOLUME IS 80-85 ML / KG IN INFANTS AND ABOUT 65-75 ML / KG IN ADULTS
1- BLOOD CLOT SIZE – A CLENCHED FIST SIZE CLOT ROUGHLY EQUALS 500 ML
2 - SITE OF A CLOSED # SWELLING -- A MODERATE SWELLING IN A # TIBIA EQUALS TO 500- 1500 ML OF BLOOD, WHILE A MODERATE SWELLING IN A # FEMUR EQUALS TO 500-2000 ML OF BLOOD LOSS
3- SWAB WEIGHING – BY SUBSTRACTING THE WEIGHT OF SOACKED SWABS FROM THEIR WEIGHT WHEN THEY WERE DRY AND THE BLOOD LOSS IS 1 ML FOR EVERY 1 GM DIFFERENCE
4- HEMOGLOBIN LEVEL ESTIMATION – THERE IS NO IMMEDIATE DECREASE IN Hg LEVEL AFTER BLEEDING BUT AFTER 8 HOURS IT WILL DROP BECAUSE OF THE INFLUX OF THE INTERSITIAL FLUID INTO THE VASCULAR COMPARTEMENT ( DILUTION )
1- PRESSURE ON THE SITE OF BLEEDING –BY PACKING OR DIGITS OR BALOONS INFLATED AT THE SITE OF BLEEDING ( ESOPHAGEAL VARICES)
2- REST AND POSITION – BY ELEVATION OF THE INJURED LIMB TO DECREASE BLOOD RETURN TO THE HEART
3- OPERATIVE PROCEDURES – BY USING HEMOSTATS, CLIPS, DIATHERMY, LIGATURES, GELATIN SPONGES, AND ADRENALIN SOACKED GAUZE ( 1: 1000 )
4- BLOOD TRANSFUTION
1- ANEMIA-- recent study showed that a transfusion threshold of 70 g/l was as safe and possibly superior to one of 100 g/l in critical care patients. A minimum preoperative haemoglobin of 100 g/l is no longer regarded as essential, as many patients with a lower haemoglobin tolerate surgery and seem to recover just as well.
2- blood loss – IF greater than 30 per cent of estimated blood volume,
Patients with massive blood loss, defined as those requiring transfusion of a volume of blood greater than their blood volume within 24 h
Depletion of coagulation factors is unusual, because stored blood contains adequate amounts of all except for factors V and VIII, which fall during storage.
RED & WHITE BLOOD CELLS, COAGULATION FACTORS, PLASMA
Procedure for blood transfusion
1- Pretransfusion compatibility testing -- A. Blood grouping ,The ABO and RhD groups of the patient are determined.
bDonor blood of the same ABO and RhD group as the patient is selected.
D. Cross-matching-- The full cross-match involves testing the patient's plasma against a sample of the red cells from the donor unit in a direct agglutination test.
2- Blood ordering – A. Elective surgery-- Sufficient time should be allowed for the laboratory to carry out pretransfusion testing.
B. EmergeNCIES-- There may be insufficient time for full pretransfusion testing.—use 2 units of O RhD-negative blood ('emergency stock') , to allow additional time for the laboratory to group the patient.
3- Blood, blood components, and blood products-- Blood collected from donors is processed into:
A- Blood components, such as red cell and platelet concentrates, fresh frozen plasma and cryoprecipitate, which are prepared from a single donation of blood by simple separation methods such as centrifugation, and transfused without further processing.
B- Blood products, such as coagulation factor concentrates and albumin and immunoglobulin solutions, which are prepared by complex processes using the plasma from many donors as the starting material.
By discontinuing antiplatelet and anticoagulant drugs, if possible, several days before surgery.
Anaemia, if present, should be investigated and treated appropriately in advance of elective surgery.
Intraoperative measures include the use of meticulous surgical and anaesthetic techniques, a cautious use of anticoagulants during surgery, and the use of drugs to enhance haemostasis AND THE USE OF AUTOLOGOUS TRANSFUSION.
There are three types of autologous transfusion:
1- Predeposit. The patient donates 2–5 units of blood at approximately weekly intervals before elective surgery.
2- Preoperative haemodilution. One or two units of blood are removed from the patient immediately before surgery and retransfused to replace operative losses.
3- Blood salvage. Blood lost during or after surgery may be collected and retransfused. Several techniques of varying levels of sophistication are available. operative site must be free of bacteria, bowel contents, and tumour cells.
1-- Immediate haemolytic transfusion reactions
This is the most serious complication of blood transfusion and is usually due to ABO incompatibility. There is complement activation by the antigen-antibody reaction, usually due to IgM antibodies, leading to rigors, lumbar pain, dyspnoea, hypotension, haemoglobinuria, and renal failure. At the first suspicion of any serious transfusion reaction, the transfusion should always be stopped and the donor units returned to the blood transfusion laboratory with a new blood sample from the patient to exclude a haemolytic transfusion reaction.
These may occur in patients alloimmunized by previous transfusions or pregnancies. The antibody titre is too low to be detected by pretransfusion compatibility testing, but a secondary immune response occurs after transfusion, resulting in destruction of the transfused cells, usually by IGg antibodies. The patient may develop anaemia and jaundice about a week after the transfusion, although many are clinically silent.
Febrile reactions are a common complication of blood transfusion in patients who have previously been transfused or pregnant. The usual cause is the presence of leucocyte antibodies in the recipient acting against transfused leucocytes, leading to release of pyrogens. Typical signs are flushing and tachycardia, fever (>38°C), chills, and rigors. Paracetamol may be used to reduce the fever.
Urticarial Reactions Are Often Attributed To Plasma Protein Incompatibility But, In Most Cases, They Are Unexplained. They Are Common But Rarely Severe; Stopping Or Slowing The Transfusion, And Intravenous Chlorpheniramine 10 Mg (Adult Dose), Are Usually Sufficient Treatment.
Anaphylactic Reactions Occasionally Occur; Severe Reactions Are Seen In Patients Lacking IgA Who Produce Anti-IgA That Reacts With IgA In The Transfused Blood. The Transfusion Should Be Stopped And Adrenaline 0.5 Mg Intramuscular And Chlorpheniramine 10 Mg Intravenous Should Be Given Immediately; Endotracheal Intubation May Be Required.
Hepatitis, Human Immunodeficiency Virus Other Viruses: Cytomegalovirus, Epstein–barr Virus, Human T-cell Leukaemia/Lymphoma Virus Type 1 (HTLV-1) Parasites: Malaria, Trypanosomiasis, Toxoplasmosis Syphilis AND Transfusion Of Blood Contaminated With Bacteria
6-- Circulatory Failure Due To Volume Overload.7-- Iron Overload Due TO Multiple Transfusions. 8-- Massive Transfusion Of Stored Blood May Cause Bleeding And Electrolyte Changes. 9-- Thrombophlebitis10-- Air Embolism