Bleeding

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Bleeding definition for the Cardiovascular Trials

Background, TIMI, GUSTO, CURE, ACUITY HORIZONS, CURRENT OASIS, STEEPLE, PLATO, GRACE, ISAR-REACT3, ESSENCE, the Bleeding Academic Research Consortium (BARC) The incidence of bleeding complications varies from 1% to 10% during treatment of acute coronary syndromes (ACS) and PCI (Percutaneous coronary intervention). This is in part due to use of combination of multiple drugs like aspirin, heparin, warfarin, platelet P2Y12 inhibitors, glycoprotein IIb/IIIa inhibitors, direct thrombin inhibitor and also the invasive procedures (percutaneous coronary intervention, Coronary artery bypass graft) during this period. Also, the bleeding complications have been found to be associated with increase in incidence of short and long term adverse outcomes like death, non-fatal MI (myocardial infarction), stroke and stent thrombosis. The exact mechanism underlying this is not clearly defined but may be due to the cessation of evidence based therapies (like antiplatelet, Beta blockers, statin), effect ofblood transfusion, co morbidities and anemia that are seen more in patients with bleeding complications. Therefore, bleeding presents as an important safety endpoint in many of the cardiovascular trials. However, there is a lack of uniformity in the definitions of bleeding that could be used in the cardiovascular trials that in turn make it difficult to conduct and compare the results of different trials. Several bleeding definitions have been used in different clinical trials – TIMI, GUSTO, CURE, ACUITY HORIZONS, CURRENT OASIS, STEEPLE, PLATO, GRACE, ISAR-REACT3, ESSENCE, Amlani. et.al. .To decrease the heterogeneity and to adopt standardized bleeding end-point definitions for patients receiving antithrombotic therapy, the Bleeding Academic Research Consortium (BARC) was convened comprising representatives from different fields of medicine. These standardized definitions will help researchers determine the relative safety of different antithrombotic therapies. These definitions are recommended for both clinical trials and registries.

First aid

Minor bleeding

Minor bleeding is bleeding that falls under a Class I hemorrhage and the bleeding is easily stopped with pressure.

The largest danger in a minor wound is infection. Bleeding can be stopped with direct pressure and elevation, and the wound should be washed well with soap and water. A dressing, typically made of gauze, should be applied. Peroxide or iodine solutions (such as Betadine) can injure the cells that promote healing and may actually impair proper wound healing and delay closure.

Emergency Bleeding Control

Main article: Emergency bleeding control

Severe bleeding poses a very real risk of death to the casualty if not treated quickly. Therefore, preventing major bleeding should take priority over other conditions, save failure of the heart or lungs. Most protocols advise the use of direct pressure, rest and elevation of the wound above the heart to control bleeding.

The use of a tourniquet is not advised in most cases, as it can lead to unnecessary necrosis or even loss of a limb. Tourniquets should rarely be used as it is usually possible to stop bleeding by the application of manual pressure.

Bleeding from body cavities

The only minor situation is a spontaneous nosebleed, or a nosebleed caused by a slight trauma (such as a child putting his finger in his nose).

Simultaneous externalised bleeding from the ear may indicate brain trauma if there has been a serious head injury. Loss of consciousness, amnesia, or fall from a height increases the likelihood that there has been a severe injury. This type of injury can also be found in motor vehicle accidents associated with death or severe injury to other passengers.

Hemoptysis, or coughing up blood, may be a sign that the person is at risk for serious bleeding. This is especially the case for patients with cancer. Hematemesis is vomiting up blood from the stomach. Often, the source of bleeding is difficult to distinguish and usually requires detailed assessment by an emergency physician.

Internal bleeding

Main article: Internal bleeding

Internal bleeding occurs entirely within the confines of the body and can be caused by a medical condition (such as aortic aneurysm) or by trauma. Symptoms of internal bleeding include pale, clammy skin, an increased heart rate and a stupor or confused state.

The most recognizable form of internal bleeding is the contusion or bruise.

Risk of blood contamination

Because skin is watertight, there is no immediate risk of infection to the aide from contact with blood, provided the exposed area has not been previously wounded or diseased. Before any further activity (especially eating, drinking, touching the eyes, the mouth or the nose), the skin should be thoroughly cleaned in order to avoid cross contamination.

To avoid any risk, the hands can be prevented from contact with a glove (mostly latex or nitrile rubber), or an improvised method such as a plastic bag or a cloth. This is taught as important part of protecting the rescuer in most first aid protocols.

Following contact with blood, some rescuers may choose to go to the emergency department, where post-exposure prophylaxis can be started to prevent blood-borne infection.

As a medical treatment

Before the advent of modern medicine the technique of bloodletting, or phlebotomy, was used for a number of conditions: causing bleeding intentionally to remove a controlled amount of excess or "bad" blood. Phlebotomy is still used as an extremely effective treatment for Haemochromatosis.

See also

• Aneurysm
• Coagulation
• Upper gastrointestinal bleed
• Vaginal bleeding
• Intracerebral hemorrhage - bleeding in the brain caused by the rupture of a blood vessel within the head. See also hemorrhagic stroke.
• Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or arteriovenous malformation(AVM). The scope of this article is limited to these nontraumatic hemorrhages.
• Intracranial hemorrhage
• Cerebral hemorrhage
• Postpartum hemorrhage
• Hematuria - blood in the urine from urinary bleeding
• Hemoptysis - coughing up blood from the lungs
• Hematemesis - vomiting fresh blood
• Hematochezia - rectal blood
• Exsanguination - death by bleeding

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