Bleeding

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Causes, prevalence, and risk factors

Hemorrhage generally becomes dangerous, or even fatal, when it causes hypovolemia (low blood volume) or hypotension (low blood pressure). In these scenarios various mechanisms come into play to maintain the body's homeostasis. These include the "retro-stress-relaxation" mechanism of cardiac muscle, the baroreceptor reflex and renal and endocrine responses such as the renin - angiotensin - aldosterone system (RAAS).

Certain diseases or medical conditions, such as haemophilia and low platelet count (thrombocytopenia) may increase the risk of bleeding or may allow otherwise minor bleeds to become health or life threatening. Anticoagulant medications, such as warfarin can mimic the effects of haemophilia, preventing clotting, and allowing free blood flow.

Death from hemorrhage can generally occur surprisingly quickly. This is because of 'positive feedback'. An example of this is 'cardiac repression', when poor heart contraction depletes blood flow to the heart, causing even poorer heart contraction. This kind of effect causes death to occur more quickly than expected.

Types of bleeding

A subconjunctival hemorrhage is a common and relatively minor post-LASIK complication.

Hemorrhage is broken down into 4 classes by the American College of Surgeons' Advanced Trauma Life Support (ATLS).^[1]

Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient might start acting differently. Volume resuscitation with crystaloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required.
Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral perfusion, such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystaloid and blood transfusion are usually necessary.
Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.

Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital sounds, while having poor peripheral perfusion (shock). Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate and take medications, such as betablockers, which may blunt the cardiovascular response. Care must be taken in the assessment of these patients.

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Bleeding definition for the Cardiovascular Trials

Overview

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^[2].

Causes

Traumatic

Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:

Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis
Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
Hematoma - (also called a blood tumor) - caused by damage to a blood vessel that in turn causes blood to collect under the skin.
Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery.
Puncture Wound - Caused by an object penetrated the skin and underlying layers, such as a nail, needle or knife
Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
Crushing Injuries - caused by a great or extreme amount of force applied over a long period of time. The extent of a crushing injury may not immediately present itself.
Gunshot wounds - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category.

Due to underlying medical conditions

Medical bleeding is that associated with an increased risk of bleeding due to an underlying medical condition. It will increase the risk of bleeding related to underlying anatomic deformities, such as weaknesses in blood vessels (aneurysm or dissection), arteriovenous malformation, ulcerations. Similarly, other conditions that disrupt the integrity of the body such as tissue death, cancer, or infection may lead to bleeding.

The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation, haemostasis and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.

Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. Hemostasis involves several components. The main components of the hemostatic system include platelets and the coagulation system.

Platelets are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic Hemophilia A while deficiencies of Factor IX cause "Christmas disease"(hemophilia B). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with autoimmune diseases. von Willebrand disease is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.

In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, warfarin ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.

Deficiencies of platelet function may require platelet transfusion while deficiciencies of clotting factors may require transfusion of either fresh frozen plasma of specific clotting factors, such as Factor VIII for patients with hemophilia.

First aid

All people who have been injured should receive a thorough assessment. It should be divided into a primary and secondary survey and performed in a stepwise fashion, following the "ABCs". Notification of EMS or other rescue agencies should be performed in a timely manner and as the situation requires.

The primary survey examines and verifies that the patient's Airway is intact, that s/he is Breathing and that Circulation is working. A similar scheme and mnemonic is used as in CPR. However, during the pulse check of C, attempts should also be made to control bleeding and to assess perfusion, usually by checking capillary refill. Additionally a persons mental status should be assessed (Disability) or either an AVPU scale or via a formal Glasgow Coma Scale. In all but the most minor cases, the patient should be Exposed by removal of clothing and a secondary survey performed, examining the patient from head to toe for other injuries. The survey should not delay treatment and transport, especially if a non-correctable problem is identified.

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.^[3]

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

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.

References

↑ Manning, JE "Fluid and Blood Resuscitation" in Emergency Medicine: A Comprehensive Study Guide. JE Tintinalli Ed. McGraw-Hill: New York 2004. p227
↑ Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J; et al. (2011). "Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium". Circulation. 123 (23): 2736–47. doi:10.1161/CIRCULATIONAHA.110.009449. PMID 21670242.
↑ Waston, JR et al. Adv Skin Wound Care. 2005 Sep;18(7):373-8. PMID: 16160464