The concept of bleeding. Course of lectures on resuscitation and intensive care 10 bleeding classification signs of complications

In case of violation of the permeability of the vessel wall or its damage, bleeding begins. In this case, blood can flow from the vessel or into the body, or out through wounds on the skin or natural openings: nose, mouth, vagina, anus. The classification of bleeding is quite complicated and is divided depending on the time and causes of its occurrence, the type of damaged vessel, the rate of development, the volume of blood lost, and the severity.

The reasons

There are two main causes of bleeding: as a result of trauma and due to internal pathological processes, that is, they are traumatic and atraumatic (or pathological).

traumatic

They arise as a result of exposure to traumatic factors that exceed the characteristics of the strength of the vessels. This results in mechanical damage. vascular wall. This is the most common cause bleeding.

Atraumatic

May begin without any provoking factor. Occur in the following cases:

• with pathological processes occurring in the body: ulceration, necrosis, destruction of the vascular wall, for example, with the collapse of a tumor, inflammation, peritonitis and others;
• with increased permeability of the vessel wall at the microscopic level, which can happen with diseases such as hemorrhagic vasculitis, vitamin C deficiency, scarlet fever, uremia, sepsis and others.

The process of bleeding to a large extent depends on the state of the coagulation system. By themselves, violations in her work cannot be the cause of bleeding, but significantly worsen the situation. If a small vessel is damaged, with a normally working hemostasis system, significant blood loss does not occur and the blood stops quickly. If, for example, the process of thrombus formation is disturbed in the body, then even a minor injury can result in death from blood loss. An example of a disease in which the process of hemostasis is impaired is hemophilia.

Classifications

In medical practice, several classifications of bleeding are accepted according to different features.

Anatomical

Bleeding in this case is divided according to the type of damaged vessel:

1. Capillary. Occur when small veins, arteries, capillaries are damaged. Usually not massive, as a rule, the entire damaged surface bleeds (in the form of a mesh).
2. Venous. Characterized by a continuous stream of dark blood. The speed depends on the diameter of the vein: the larger it is, the faster it flows out. Bleeding from the neck veins is the most dangerous, since there is a possibility of developing an air embolism.
3. Arterial. The speed is often high, the amount of blood lost depends on the diameter of the vessel and the type of damage. Scarlet blood flows out under pressure, usually in a pulsating stream.
4. Parenchymal. Occur when damaged organs such as the liver, lungs, kidneys, spleen, which are called parenchymal. These bleedings are capillary, but due to anatomical features these organs they pose a danger.
5. Mixed . In this case, all types of vessels bleed simultaneously.

By time of occurrence

According to this classification, there are two types: primary and secondary bleeding:

• Primary - begin immediately after damage to the vessel.
• Secondary - occur some time after the injury. They are further divided into two types: early (within three days from the moment of injury, after the thrombus is pushed out of the damaged vessel) and late (three days after the injury, usually due to the development of purulent inflammatory processes).

In relation to the external environment

According to this classification, bleeding is divided into several types:

• External - blood flows from an ulcer or wound located on the surface of the body, so they are easily diagnosed.
• Internal - occur in organs, their cavities, tissues. They are divided into strip (blood pours into the articular, pleural, abdominal, pericardial cavities) and interstitial (blood pours into the thickness of the tissues and forms hematomas). Accumulations of blood that has poured into a cavity or tissue are called hemorrhages in medicine. There are several types: petechiae, ecchymosis, bruising, hematoma, vibices.
• Hidden - do not have pronounced signs, according to some classifications they are internal.

By type of flow

There are two types:

• Acute - blood flows out in a short time.
• Chronic - characterized by the duration of bleeding, while there is a gradual release of blood in small portions. The duration of bleeding is typical for diseases such as hemorrhoids, stomach ulcers, malignant tumor, uterine fibroids and others.

By severity

There are several classifications on this basis. Most often, four degrees of severity are distinguished:

• Mild - blood loss is from 10 to 12%, or from 500 to 700 ml.
• Average - from 16 to 20%, or up to 1400 ml.
• Severe - from 20 to 30%, or from 1500 to 2000 ml.
• Massive - blood loss over 30%, or more than 2000 ml.

This classification of bleeding is very important. An assessment of the severity helps to determine the nature of circulatory disorders and the danger of blood loss for a person. Knowing the severity is necessary in order to correctly prescribe treatment and choose the tactics of blood transfusion.

Severe bleeding can be fatal, and usually death in this case is due to acute cardiovascular failure. Sometimes the cause of death can be the loss of blood functions (transfer of gases, nutrients, metabolic products).

The outcome of bleeding is determined by the rate and volume of blood loss. A loss of more than 40% is considered incompatible with life. In chronic processes, a person can lose no less blood and have low level erythrocytes, but at the same time live and work. When assessing severity, consider:

• general state the patient (initial anemia, the presence of shock, cardiovascular insufficiency, exhaustion of the body);
• his gender;
• age.

In case of bleeding, the wound must be treated with an antiseptic and a pressure bandage applied; an unwound bandage can be used as a tampon

Help with bleeding

Violation of the integrity of tissues and blood vessels is a frequent phenomenon, so each person should know what to do with bleeding. Properly rendered first aid can save a person's life.

capillary

This slight bleeding usually stops on its own quickly. In some cases, a bandage is required. Before bandaging, the wound must be treated with an antiseptic solution.

Venous

This bleeding is characterized by the fact that dark blood flows in a jet. If possible, the victim is placed in such a way that the damaged area is above the level of the heart.

For moderate bleeding, packing and applying a tight bandage will suffice. A rolled bandage can be used as a tampon.

With severe bleeding, a tourniquet is required below the injury site. If the blood stops, then the help is provided correctly.

With arterial bleeding, an immediate stop of blood is required, which is usually done by pressing the damaged vessel against the nearest bone so that its lumen is completely closed

Arterial

It is distinguished by scarlet blood, beating with a fountain. If medium-sized vessels are damaged, then tight bandaging may be sufficient. If a large artery is damaged, a tourniquet will be required, after which the patient must be taken to the hospital for treatment as soon as possible. Before doing this, you need to do the following:

1. Lay the victim down so that the wound is above the heart.
2. To stop the bleeding before applying the tourniquet, press the damaged artery with your finger.
3. Now you need to apply a tourniquet above the wound. It can be replaced with any suitable item at hand: a belt, a towel, a rope, etc.
4. The tourniquet can not be kept for more than one and a half hours. Therefore, if a person could not be delivered to a medical facility during this time, you need to press the artery with your finger, remove the tourniquet for five minutes, and then apply it again, but a little higher than last time.

The tourniquet cannot be applied for more than an hour and a half, so you must always attach a note in which you indicate the time of its application

internal

It is difficult to recognize such bleeding on your own, but if there is a suspicion of it, then the following must be done:

1. The victim should take a semi-sitting or lying position, while a pillow should be placed under the legs.
2. If bleeding in the stomach is expected, a person should not drink or eat, you can only rinse your mouth with cool water.
3. Cold should be applied to the site of suspected bleeding. It can be, for example, a bottle of water, under which you need to put a piece of cloth.

Methods for stopping blood

Stopping the blood is spontaneous and artificial. The second, in turn, is divided into temporary and final. Before the victim is taken to a medical facility for treatment, the following methods of temporary stop are used:

1. The simplest and affordable way- this is tamponade and dressing. It is effective in bleeding from veins, capillaries and small arteries. With the help of a swab and a pressure bandage, the lumen of the vessel is reduced, which leads to the formation of a blood clot.
2. Pressing the vessel with a finger necessary when an immediate stop of blood from an artery is needed. The vessel is pressed against the nearby bones above the wound, in case of damage to the cervical arteries - below the wound. To perform this technique, you need to make an effort so that the lumen of the artery is completely closed. The carotid artery is pressed against the tubercle of the transverse process of the sixth cervical vertebra, the subclavian artery - against the first rib at a point above the clavicle, the femur - against the pubic bone, the humerus - against humerus(its inner surface), axillary - to the head of the humerus in the armpit.
3. The most reliable way is to apply a tourniquet. Due to its simplicity and availability, it is widely used. Despite some shortcomings, it fully justifies itself in providing first aid for injured limbs. If it is applied correctly, the bleeding will immediately stop. When working with a tourniquet, certain rules must be observed in order to avoid the negative consequences of squeezing the limb. It must be remembered that it must be applied only to the lining and for no more than 1.5 hours, and in winter no more than an hour. It should be clearly visible, so a piece of bandage is tied to it. Be sure to attach a note in which to write the time of application of the tourniquet.
4. Another well-known and enough effective method – limb flexion. It is necessary to bend all the way in the joint (knee, elbow, hip), which is located above the wound, and then fix it with bandaging.

For the final stop of the blood, the patient is taken to the hospital, where he will be treated further. The final methods are:

• suturing;
• tamponade when it is impossible to suture the vessel;
• embolization - the introduction of an air bubble into the vessel and its fixation at the site of damage;
• local administration of hemocoagulants (substances for blood clotting of artificial or natural origin).

Conclusion

Bleeding can be life-threatening, so you need to learn to distinguish between their types and be able to properly provide first aid, on which a person’s life may depend. Even a temporary stop of blood, before the patient is taken to the hospital for treatment, can be decisive.

Blood loss is a widespread and evolutionarily oldest damage to the human body that occurs in response to the loss of blood from the vessels and is characterized by the development of a number of compensatory and pathological reactions.

Classification of blood loss

The state of the body that occurs after bleeding depends on the development of these adaptive and pathological reactions, the ratio of which is determined by the volume of lost blood. The increased interest in the problem of blood loss is due to the fact that almost all surgical specialists meet with it quite often. In addition, mortality rates for blood loss remain high to date. Blood loss of more than 30% of circulating blood volume (CBV) in less than 2 hours is considered massive and life-threatening. The severity of blood loss is determined by its type, the speed of development, the volume of lost blood, the degree of hypovolemia and the possible development of shock, which is most convincingly presented in the classification of P. G. Bryusov (1998), (Table 1).

Classification of blood loss

1. Traumatic, wound, operating)

2. pathological (diseases, pathological processes)

3. artificial (exfusion, therapeutic bloodletting)

By the speed of development

1. acute (> 7% BCC per hour)

2. subacute (5-7% BCC per hour)

3. chronic (‹ 5% BCC per hour)

By volume

1. Small (0.5 - 10% bcc or 0.5 l)

2. Medium (11 - 20% BCC or 0.5 - 1 l)

3. Large (21 - 40% BCC or 1-2 liters)

4. Massive (41 - 70% BCC or 2-3.5 liters)

5. Fatal (> 70% BCC or more than 3.5 L)

According to the degree of hypovolemia and the possibility of developing shock:

1. Mild (deficit of BCC 10–20%, deficiency of GO less than 30%, no shock)

2. Moderate (deficiency of BCC 21–30%, deficiency of GO 30–45%, shock develops with prolonged hypovolemia)

3. Severe (deficit of BCC 31–40%, deficiency of GO 46–60%, shock is inevitable)

4. Extremely severe (deficit of BCC over 40%, deficiency of GO over 60%, shock, terminal state).

Abroad, the most widely used classification of blood loss, proposed by the American College of Surgeons in 1982, according to which there are 4 classes of bleeding (Table 2).

Table 2.

Acute blood loss leads to the release of catecholamines by the adrenal glands, which cause spasm of peripheral vessels and, accordingly, a decrease in the volume of the vascular bed, which partially compensates for the resulting deficiency of BCC. Redistribution of organ blood flow (centralization of blood circulation) allows you to temporarily maintain blood flow in vital organs and ensure life support in critical conditions. However, later this compensatory mechanism can cause the development of severe complications of acute blood loss. A critical condition, called shock, inevitably develops with a loss of 30% of BCC, and the so-called "death threshold" is determined not by the amount of bleeding, but by the number of red blood cells remaining in circulation. For erythrocytes, this reserve is 30% of the globular volume (GO), for plasma only 70%.

In other words, the body can survive the loss of 2/3 of the circulating red blood cells, but will not tolerate the loss of 1/3 of the plasma volume. This is due to the peculiarities of compensatory mechanisms that develop in response to blood loss and are clinically manifested by hypovolemic shock. Shock is understood as a syndrome based on inadequate capillary perfusion with reduced oxygenation and impaired oxygen consumption by organs and tissues. It (shock) is based on peripheral circulatory-metabolic syndrome.

Shock is a consequence of a significant decrease in BCC (i.e., the ratio of BCC to the capacity of the vascular bed) and a deterioration in the pumping function of the heart, which can manifest itself with hypovolemia of any origin (sepsis, trauma, burns, etc.).

A specific cause of hypovolemic shock due to loss of whole blood can be:

1. gastrointestinal bleeding;

2. intrathoracic bleeding;

3. intra-abdominal bleeding;

4. uterine bleeding;

5. bleeding into the retroperitoneal space;

6. ruptured aortic aneurysms;

7. injury, etc.

Pathogenesis

The loss of BCC disrupts the performance of the heart muscle, which is determined by:

1. Cardiac minute volume (MOS): MOV = SV x HR, (SV - stroke volume of the heart, HR - heart rate);

2. filling pressure of the cavities of the heart (preload);

3. the function of the heart valves;

4. total peripheral vascular resistance (OPVR) - afterload.

With insufficient contractility of the heart muscle, part of the blood remains in the cavities of the heart after each contraction, and this leads to an increase in preload. Part of the blood stagnates in the heart, which is called heart failure. In acute blood loss leading to the development of BCC deficiency, the filling pressure in the heart cavities initially decreases, as a result of which the SV, MOS and BP decrease. Since the level of blood pressure is largely determined by the minute volume of the heart (MOV) and total peripheral vascular resistance (OPVR), to maintain it at the proper level with a decrease in BCC, compensatory mechanisms are activated to increase heart rate and OPSS. Compensatory changes that occur in response to acute blood loss, include neuroendocrine changes, metabolic disorders, changes in the cardiovascular and respiratory systems. Activation of all links of coagulation causes the possibility of the development of disseminated intravascular coagulation ( DIC syndrome). In the order of physiological protection, the body responds to its most frequent damage by hemodilution, which improves blood fluidity and reduces its viscosity, mobilization of erythrocytes from the depot, a sharp decrease in the need for both BCC and oxygen delivery, an increase in respiratory rate, cardiac output, return and utilization of oxygen. in tissues.

Neuroendocrine shifts are realized by activation of the sympathoadrenal system in the form of an increased release of catecholamines (adrenaline, norepinephrine) by the adrenal medulla. Catecholamines interact with a- and b-adrenergic receptors. Stimulation of adrenergic receptors in peripheral vessels causes vasoconstriction. Stimulation of p1 - adrenoreceptors localized in the myocardium, has a positive ionotropic and chronotropic effects, stimulation of p2-adrenergic receptors located in blood vessels causes slight dilatation of arterioles and constriction of veins. The release of catecholamines during shock leads not only to a decrease in the capacity of the vascular bed, but also to the redistribution of intravascular fluid from peripheral to central vessels, which contributes to the maintenance of blood pressure. The hypothalamus-pituitary-adrenal system is activated, adrenocorticotopic and antidiuretic hormones, cortisol, aldosterone are released into the blood, resulting in an increase in the osmotic pressure of the blood plasma, leading to an increase in the reabsorption of sodium and water, a decrease in diuresis and an increase in the volume of intravascular fluid. There are metabolic disorders. Developed blood flow disorders and hypoxemia lead to the accumulation of lactic and pyruvic acids. With a lack or absence of oxygen, pyruvic acid is reduced to lactic acid (anaerobic glycolysis), the accumulation of which leads to metabolic acidosis. Amino acids and free fatty acid also accumulate in tissues and exacerbate acidosis. The lack of oxygen and acidosis disrupt the permeability of cell membranes, as a result of which potassium leaves the cell, and sodium and water enter the cells, causing them to swell.

Changes in the cardiovascular and respiratory systems in shock are very significant. The release of catecholamines in the early stages of shock increases TPVR, myocardial contractility and heart rate - the goal of centralization of blood circulation. However, the resulting tachycardia very soon reduces the time of diastolic filling of the ventricles and, consequently, the coronary blood flow. Myocardial cells begin to suffer from acidosis. In the event of a prolonged shock, respiratory compensation mechanisms become untenable. Hypoxia and acidosis lead to increased excitability of cardiomyocytes, arrhythmias. Humoral shifts are manifested by the release of mediators other than catecholamines (histamine, serotonin, prostaglandins, nitric oxide, tumor necrotizing factor, interleukins, leukotrienes), which cause vasodilation and an increase in the permeability of the vascular wall, followed by the release of the liquid part of the blood into the interstitial space and a decrease in perfusion pressure. . This exacerbates the shortage of O2 in the tissues of the body, caused by a decrease in its delivery due to microthrombosis and an acute loss of O2 carriers - erythrocytes.

AT microvasculature changes that have a phase character develop:

1. 1 phase - ischemic anoxia or contraction of pre- and post-capillary sphincters;

2. 2nd phase - capillary stasis or expansion of precapillary venules;

3. Phase 3 - paralysis of peripheral vessels or expansion of pre- and post-capillary sphincters ...

Crisis processes in the capillary reduce the delivery of oxygen to the tissues. The balance between the delivery of oxygen and the need for it is maintained as long as the necessary tissue oxygen extraction is provided. When delaying the start of the intensive care oxygen delivery to cardiomyocytes is disrupted, myocardial acidosis increases, which is clinically manifested by hypotension, tachycardia, shortness of breath. A decrease in tissue perfusion develops into global ischemia with subsequent reperfusion tissue damage due to increased production of cytokines by macrophages, activation of lipid peroxidation, release of oxides by neutrophils, and further microcirculation disorders. Subsequent microthrombosis forms a violation of the specific functions of organs and there is a risk of developing multiple organ failure. Ischemia changes the permeability of the intestinal mucosa, which is especially sensitive to ischemic-reperfusion mediator effects, which causes the dislocation of bacteria and cytokines into the circulation system and the occurrence of such systemic processes as sepsis, respiratory distress syndrome, multiple organ failure. Their appearance corresponds to a certain time interval or stage of shock, which can be initial, reversible (reversible shock stage) and irreversible. To a large extent, the irreversibility of shock is determined by the number of microthrombi formed in the capillaron and the temporary factor of the microcirculation crisis. As for the dislocation of bacteria and toxins due to intestinal ischemia and impaired permeability of its wall, this situation is not so unambiguous today and requires additional research. Nevertheless, shock can be defined as a condition in which the oxygen consumption of the tissues is inadequate to their needs for the functioning of aerobic metabolism.

clinical picture.

With the development of hemorrhagic shock, 3 stages are distinguished.

1. Compensated reversible shock. The volume of blood loss does not exceed 25% (700-1300 ml). Moderate tachycardia, blood pressure is either unchanged or slightly reduced. Saphenous veins become empty, CVP decreases. There are signs of peripheral vasoconstriction: cold extremities. The amount of urine excreted is reduced by half (at a rate of 1–1.2 ml / min). Decompensated reversible shock. The volume of blood loss is 25–45% (1300–1800 ml). The pulse rate reaches 120-140 per minute. Systolic blood pressure falls below 100 mm Hg, the value of pulse pressure decreases. Severe shortness of breath occurs, partly compensating for metabolic acidosis by respiratory alkalosis, but can also be a sign of a shock lung. Increased cold extremities, acrocyanosis. Cold sweat appears. The rate of urine output is below 20 ml/h.

2. Irreversible hemorrhagic shock. Its occurrence depends on the duration of circulatory decompensation (usually with arterial hypotension over 12 hours). The volume of blood loss exceeds 50% (2000-2500 ml). The pulse exceeds 140 per minute, systolic blood pressure falls below 60 mm Hg. or not defined. Consciousness is absent. oligoanuria develops.

Diagnostics

Diagnosis is based on the assessment of clinical and laboratory signs. In conditions of acute blood loss, it is extremely important to determine its volume, for which it is necessary to use one of the existing methods, which are divided into three groups: clinical, empirical and laboratory. Clinical methods make it possible to estimate the amount of blood loss based on clinical symptoms and hemodynamic parameters. The level of blood pressure and pulse rate before the start of replacement therapy largely reflect the magnitude of the BCC deficit. The ratio of pulse rate to systolic blood pressure allows you to calculate the Algover shock index. Its value, depending on the deficit of the BCC, is presented in Table 3.

Table 3. Assessment based on the Algover shock index

Capillary filling test, or symptom " white spot» allows you to evaluate capillary perfusion. It is carried out by pressing on the fingernail, forehead skin or earlobe. Normally, the color is restored after 2 s, with a positive test - after 3 or more seconds. Central venous pressure (CVP) is an indicator of the filling pressure of the right ventricle, reflects its pumping function. Normal CVP ranges from 6 to 12 cm of water column. A decrease in CVP indicates hypovolemia. With a deficiency of BCC in 1 liter, the CVP decreases by 7 cm of water. Art. The dependence of the CVP value on the BCC deficit is presented in Table 4.

Table 4 Assessment of circulating blood volume deficit based on central venous pressure

Hourly diuresis reflects the level of tissue perfusion or the degree of filling of the vascular bed. Normally, 0.5-1 ml / kg of urine is excreted per hour. A decrease in diuresis less than 0.5 ml/kg/h indicates insufficient blood supply to the kidneys due to a deficiency of BCC.

Empirical methods for assessing the volume of blood loss are most often used in trauma and polytrauma. They use the average statistical values ​​of blood loss, established for a particular type of damage. In the same way, it is possible to roughly estimate the blood loss during various surgical interventions.

Average blood loss (l)

1. Hemothorax - 1.5–2.0

2. Fracture of one rib - 0.2–0.3

3. Abdominal injury - up to 2.0

4. Fracture of the pelvic bones (retroperitoneal hematoma) - 2.0–4.0

5. Hip fracture - 1.0–1.5

6. Shoulder/shin fracture - 0.5–1.0

7. Fracture of the bones of the forearm - 0.2–0.5

8. Fracture of the spine - 0.5–1.5

9. Scalped wound the size of a palm - 0.5

Operational blood loss

1. Laparotomy - 0.5–1.0

2. Thoracotomy - 0.7–1.0

3. Amputation of the lower leg - 0.7–1.0

4. Osteosynthesis of large bones - 0.5–1.0

5. Resection of the stomach - 0.4–0.8

6. Gastrectomy - 0.8–1.4

7. Resection of the colon - 0.8–1.5

8. C-section – 0,5–0,6

Laboratory methods include the determination of hematocrit (Ht), hemoglobin concentration (Hb), relative density (p) or blood viscosity.

They are divided into:

1. calculation (use of mathematical formulas);

2. hardware (electrophysiological impedance methods);

3. indicator (the use of dyes, thermodilution, dextrans, radioisotopes).

Among the calculation methods, the Moore formula is most widely used:

KVP \u003d BCCd x Htd-Htf / Htd

Where KVP is blood loss (ml);

BCCd - the proper volume of circulating blood (ml).

Normally, in women, BCCd averages 60 ml / kg, in men - 70 ml / kg, in pregnant women - 75 ml / kg;

№d - proper hematocrit (for women - 42%, for men - 45%);

Nf is the patient's actual hematocrit. In this formula, instead of hematocrit, you can use the hemoglobin indicator, taking 150 g / l as its proper level.

You can also use the value of blood density, but this technique is applicable only for small blood loss.

One of the first hardware methods for determining BCC was a method based on measuring the basic resistance of the body using a reopletismograph (it was used in the countries of the "post-Soviet space").

Modern indicator methods provide for the establishment of BCC by changing the concentration of the substances used and are conventionally divided into several groups:

1. determination of the plasma volume, and then the total blood volume through Ht;

2. determination of the volume of erythrocytes and, according to it, the entire volume of blood through Ht;

3. simultaneous determination of the volume of erythrocytes and blood plasma.

Evans dye (T-1824), dextrans (polyglucin), human albumin labeled with iodine (131I) or chromium chloride (51CrCl3) are used as an indicator. But, unfortunately, all methods for determining blood loss give a high error (sometimes up to a liter), and therefore can only serve as a guideline for treatment. However, the definition of VO2 should be considered the simplest. diagnostic criterion detection of shock.

The strategic principle of transfusion therapy for acute blood loss is the restoration of organ blood flow (perfusion) by achieving the required BCC. Maintaining the level of coagulation factors in quantities sufficient for hemostasis, on the one hand, and to resist excessive disseminated coagulation, on the other. Replenishment of the number of circulating red blood cells (oxygen carriers) to a level that provides the minimum sufficient oxygen consumption in tissues. However, most experts consider hypovolemia to be the most acute problem of blood loss, and, accordingly, the replenishment of BCC, which is a critical factor for maintaining stable hemodynamics, is in the first place in the treatment regimens. The pathogenetic role of a decrease in BCC in the development of severe homeostasis disorders predetermines the importance of timely and adequate correction of volemic disorders on treatment outcomes in patients with acute massive blood loss. The ultimate goal of all efforts by the resuscitator is to maintain adequate tissue oxygen consumption to maintain metabolism.

General principles treatment of acute blood loss are as follows:

1. Stop bleeding, fight pain.

2. Ensuring adequate gas exchange.

3. Replenishment of the BCC deficit.

4. Treatment of organ dysfunction and prevention of multiple organ failure:

Treatment of heart failure;

Prevention of renal failure;

Correction of metabolic acidosis;

Stabilization of metabolic processes in the cell;

Treatment and prevention of DIC.

5. Early prevention of infection.

Stop bleeding and control pain.

With any bleeding, it is important to eliminate its source as soon as possible. With external bleeding - pressing the vessel, pressure bandage, tourniquet, ligature or clamp on the bleeding vessel. With internal bleeding - urgent surgical intervention, carried out in parallel with therapeutic measures to remove the patient from shock.

Table No. 5 presents data on the nature of the infusion therapy for acute blood loss.

1. Infusion starts with crystalloids, then colloids. Hemotransfusion - with a decrease in Hb less than 70 g / l, Ht less than 25%.

2. Infusion rate for massive blood loss up to 500 ml/min!!! (catheterization of the second central vein, infusion of solutions under pressure).

3. Correction of volemia (stabilization of hemodynamic parameters).

4. Normalization of globular volume (Hb, Ht).

5. Correction of violations of water-salt metabolism

The fight against pain, protection from mental stress is carried out by intravenous (in / in) administration of analgesics: 1-2 ml of a 1% solution of morphine hydrochloride, 1-2 ml of a 1-2% solution of promedol, and sodium hydroxybutyrate (20-40 mg /kg of body weight), sibazon (5–10 mg), it is possible to use subnarcotic doses of calypsol and sedation with propofol. Dose narcotic analgesics should be reduced by 50% due to possible respiratory depression, nausea and vomiting that occurs when intravenous administration these drugs. In addition, it should be remembered that their introduction is possible only after the exclusion of damage to internal organs. Ensuring adequate gas exchange is aimed at both the utilization of oxygen by tissues and the removal of carbon dioxide. All patients are shown prophylactic administration of oxygen through a nasal catheter at a rate of at least 4 l/min.

When respiratory failure The main goals of treatment are:

1. ensuring patency respiratory tract;

2. prevention of aspiration of stomach contents;

3. release of the respiratory tract from sputum;

4. lung ventilation;

5. restoration of tissue oxygenation.

Developed hypoxemia may be due to:

1. hypoventilation (usually in combination with hypercapnia);

2. discrepancy between ventilation of the lungs and their perfusion (disappears when breathing pure oxygen);

3. Intrapulmonary blood bypass (protected by pure oxygen breathing) caused by adult respiratory distress syndrome (PaO2 ‹ 60–70 mm Hg FiO2 > 50%, bilateral pulmonary infiltrates, normal ventricular filling pressure), pulmonary edema, severe pneumonia ;

4. violation of the diffusion of gases through the alveolo-capillary membrane (disappears when breathing pure oxygen).

Lung ventilation after tracheal intubation is carried out in specially selected modes that create conditions for optimal gas exchange and do not disturb central hemodynamics.

Replenishment of the BCC deficit

First of all, with acute blood loss, the patient should create an improved Trendelburg position to increase venous return. Infusion is carried out simultaneously in 2-3 peripheral or 1-2 central veins. The rate of replenishment of blood loss is determined by the value of blood pressure. As a rule, at first, the infusion is carried out by stream or fast drip (up to 250-300 ml / min). After stabilization of blood pressure at a safe level, the infusion is carried out by drip. Infusion therapy begins with the introduction of crystalloids. And in the last decade there has been a return to the consideration of the possibility of using hypertonic solutions of NaCI.

Hypertonic solutions of sodium chloride (2.5-7.5%), due to the high osmotic gradient, provide rapid mobilization of fluid from the interstitium into the bloodstream. However, the short duration of their action (1–2 hours) and relatively small volumes of administration (no more than 4 ml/kg of body weight) determine their predominant use in prehospital stage treatment of acute blood loss. Colloidal solutions of antishock action are divided into natural (albumin, plasma) and artificial (dextrans, hydroxyethyl starches). Albumin and protein fraction plasma effectively increase the volume of intravascular fluid, tk. have high oncotic pressure. However, they easily penetrate the walls of the pulmonary capillaries and the basement membranes of the glomeruli of the kidneys into the extracellular space, which can lead to edema of the interstitial tissue of the lungs (adult respiratory distress syndrome) or kidneys (acute kidney failure). The volume of diffusion of dextrans is limited, because they cause damage to the epithelium of the renal tubules ("dextran kidney"), adversely affect the blood coagulation system and immunocomponent cells. Therefore, today "drugs of the first choice" are solutions of hydroxyethyl starch. Hydroxyethyl starch is a natural polysaccharide derived from amylopectin starch and consisting of high molecular weight polarized glucose residues. The feedstock for the production of HES is starch from potato and tapioca tubers, grains of various varieties of corn, wheat, and rice.

HES from potato and corn, along with linear amylase chains, contains a fraction of branched amylopectin. Hydroxylation of starch prevents its rapid enzymatic cleavage, increases the ability to retain water and increase colloid osmotic pressure. In transfusion therapy, 3%, 6% and 10% HES solutions are used. The introduction of HES solutions causes isovolemic (up to 100% with a 6% solution) or even initially hypervolemic (up to 145% of the injected volume of a 10% solution of the drug) volume-replacing effect, which lasts at least 4 hours.

In addition, HES solutions have the following properties that are not available in other colloidal plasma-substituting preparations:

1. prevent the development of increased capillary permeability syndrome by closing the pores in their walls;

2. modulate the action of circulating adhesive molecules or inflammatory mediators, which, circulating in the blood during critical conditions, increase secondary tissue damage by binding to neutrophils or endotheliocytes;

3. do not affect the expression of surface blood antigens, i.e. do not violate immune reactions;

4. do not cause activation of the complement system (consists of 9 serum proteins C1 - C9) associated with generalized inflammatory processes that disrupt the functions of many internal organs.

It should be noted that in last years there have been separate randomized trials of a high level of evidence (A, B) indicating the ability of starches to cause kidney dysfunction and preferring albumin and even gelatin preparations.

At the same time, since the end of the 70s of the XX century, perfluorocarbon compounds (PFOS) began to be actively studied, which form the basis of a new generation of plasma expanders with the function of O2 transfer, one of which is perftoran. The use of the latter in acute blood loss makes it possible to influence the reserves of three levels of O2 exchange, and the simultaneous use of oxygen therapy makes it possible to increase the reserves of ventilation.

Table 6. The share of perftoran use depending on the level of blood replacement

Clinically, the degree of hypovolemia reduction reflects the following signs:

1. increased blood pressure;

2. decrease in heart rate;

3. warming and pinking skin; - increase in pulse pressure; - diuresis over 0.5 ml/kg/h.

Thus, summing up the above, we emphasize that the indications for blood transfusion are: - blood loss of more than 20% of the due BCC, - anemia, in which the hemoglobin content is less than 75 g / l, and the hematocrit number is less than 0.25.

Treatment of organ dysfunction and prevention of multiple organ failure

One of the most important tasks is the treatment of heart failure. If the victim was healthy before the accident, then in order to normalize cardiac activity, he usually quickly and effectively replenishes the BCC deficiency. If the victim has a history of chronic diseases heart or blood vessels, then hypovolemia and hypoxia aggravate the course of the underlying disease, therefore, special treatment is carried out. First of all, it is necessary to achieve an increase in preload, which is achieved by increasing the BCC, and then to increase myocardial contractility. Most often, vasoactive and inotropic agents are not prescribed, but if hypotension becomes persistent, not amenable to infusion therapy, then these drugs can be used. Moreover, their application is possible only after the full compensation of the BCC. Of the vasoactive agents, the first-line drug for maintaining the activity of the heart and kidneys is dopamine, 400 mg of which is diluted in 250 ml of isotonic solution.

The infusion rate is chosen depending on the desired effect:

1. 2–5 µg/kg/min (“renal” dose) dilates mesenteric and renal vessels without increasing heart rate or blood pressure;

2. 5-10 mcg/kg/min gives a pronounced ionotropic effect, mild vasodilation due to stimulation of β2-adrenergic receptors or moderate tachycardia;

3. 10–20 mcg/kg/min leads to a further increase in the ionotropic effect, severe tachycardia.

More than 20 mcg / kg / min - a sharp tachycardia with a threat of tachyarrhythmias, narrowing of the veins and arteries due to stimulation of a1_ adrenoreceptors and deterioration in tissue perfusion. Due to arterial hypotension and shock, as a rule, acute renal failure (ARF) develops. In order to prevent the development of the oliguric form of acute renal failure, it is necessary to control hourly diuresis (normal in adults is 0.51 ml / kg / h, in children - more than 1 ml / kg / h).

Measurement of the concentration of sodium and creatine in urine and plasma (with acute renal failure, plasma creatine exceeds 150 μmol / l, glomerular filtration rate is below 30 ml / min).

Infusion of dopamine in the "renal" dose. Currently, there are no randomized multicenter trials in the literature demonstrating the effectiveness of the use of "renal doses" of sympathomimetics.

Stimulation of diuresis against the background of the restoration of BCC (CVD more than 30–40 cm of water column) and satisfactory cardiac output (furosemide, IV at the initial dose of 40 mg with an increase if necessary by 5–6 times).

Normalization of hemodynamics and compensation of circulating blood volume (BCV) should be carried out under the control of DZLK (pulmonary capillary wedge pressure), CO (cardiac output) and OPSS. In shock, the first two indicators progressively decrease and the last increases. Methods for determining these criteria and their norms are well described in the literature, but, unfortunately, they are routinely used in clinics abroad and rarely in our country.

Shock is usually accompanied by severe metabolic acidosis. Under its influence, myocardial contractility decreases, cardiac output decreases, which contributes to a further decrease in blood pressure. The reactions of the heart and peripheral vessels to endo- and exogenous catecholamines are reduced. O2 inhalation, mechanical ventilation, infusion therapy restore physiological compensatory mechanisms and in most cases eliminate acidosis. Sodium bicarbonate is administered in severe metabolic acidosis (pH of venous blood below 7.25), having calculated it according to the generally accepted formula, after determining the indicators of acid-base balance.

A bolus may be given immediately at 44–88 mEq (50–100 mL 7.5% HCO3), with the remainder over the next 4–36 hours. It should be remembered that excessive administration of sodium bicarbonate creates prerequisites for the development of metabolic alkalosis, hypokalemia, and arrhythmias. maybe sharp increase plasma osmolarity, up to the development of hyperosmolar coma. In shock, accompanied by a critical deterioration in hemodynamics, stabilization of metabolic processes in the cell is necessary. Treatment and prevention of DIC, as well as early prevention of infections, is carried out, guided by generally accepted schemes.

Justified, from our point of view, is the pathophysiological approach to solving the problem of indications for blood transfusions, based on the assessment of oxygen transport and consumption. Oxygen transport is a derivative of cardiac output and blood oxygen capacity. Oxygen consumption depends on the delivery and ability of the tissue to take oxygen from the blood.

When replenishing hypovolemia with colloid and crystalloid solutions, the number of erythrocytes is reduced and the oxygen capacity of the blood is reduced. By activating the sympathetic nervous system cardiac output rises compensatory (sometimes exceeding normal values ​​by 1.5–2 times), microcirculation “opens up” and hemoglobin affinity for oxygen decreases, tissues take relatively more oxygen from the blood (oxygen extraction coefficient increases). This allows you to maintain normal oxygen consumption with a low oxygen capacity of the blood.

In healthy people, normovolemic hemodilution with a hemoglobin level of 30 g/l and a hematocrit of 17%, although accompanied by a decrease in oxygen transport, does not decrease oxygen consumption by tissues, the blood lactate level does not increase, which confirms the sufficiency of oxygen supply to the body and the maintenance of metabolic processes at sufficient level. In acute isovolemic anemia up to hemoglobin (50 g / l), in patients at rest, tissue hypoxia is not observed before surgery. Oxygen consumption does not decrease, and even slightly increases, the level of blood lactate does not increase. In normovolemia, oxygen consumption does not suffer at a delivery level of 330 ml/min/m2, at lower delivery there is a dependence of consumption on oxygen delivery, which corresponds to approximately a hemoglobin level of 45 g/l with normal cardiac output.

Increasing the oxygen capacity of blood by transfusing canned blood and its components has its negative sides. Firstly, an increase in hematocrit leads to an increase in blood viscosity and a deterioration in microcirculation, which creates an additional load on the myocardium. Secondly, a low content of 2,3-DPG in erythrocytes of donor blood is accompanied by an increase in the affinity of oxygen for hemoglobin, a shift in the dissociation curve of oxyhemoglobin to the left, and, as a result, a deterioration in tissue oxygenation. Thirdly, transfused blood always contains microclots, which can "clog" the capillaries of the lungs and dramatically increase the pulmonary shunt, impairing blood oxygenation. In addition, transfused erythrocytes begin to fully participate in oxygen transport only 12-24 hours after blood transfusion.

Our analysis of the literature showed that the choice of means for the correction of blood loss and posthemorrhagic anemia is not a settled issue. This is mainly due to the lack of informative criteria for assessing the optimality of certain methods of compensating transport and oxygen consumption. The current trend towards a decrease in blood transfusions is due, first of all, to the possibility of complications associated with blood transfusions, limitation of donation, refusal of patients from blood transfusions for any reason. At the same time, the number of critical conditions associated with blood loss various genesis, increases. This fact dictates the need for further development of methods and means of substitution therapy.

An integral indicator that allows an objective assessment of the adequacy of tissue oxygenation is the saturation of hemoglobin with oxygen in mixed venous blood (SvO2). A decrease in this indicator to less than 60% over a short period of time leads to the appearance of metabolic signs of tissue oxygen debt (lactic acidosis, etc.). Therefore, an increase in the content of lactate in the blood can be a biochemical marker of the degree of activation of anaerobic metabolism and characterize the effectiveness of the therapy.

What is blood loss is best known in surgery and obstetrics, since they most often encounter a similar problem, which is complicated by the fact that there was no single tactic in the treatment of these conditions. Every patient needs individual selection optimal combinations of therapeutic agents, because blood transfusion therapy is based on the transfusion of donor blood components that are compatible with the patient's blood. Sometimes it can be very difficult to restore homeostasis, since the body reacts to acute blood loss with a violation of the rheological properties of blood, hypoxia and coagulopathy. These disorders can lead to uncontrolled reactions that threaten to end in death.

Hemorrhage acute and chronic

The amount of blood in an adult is approximately 7% of its weight, in newborns and infants this figure is twice as high (14-15%). It also increases quite significantly (on average by 30-35%) during pregnancy. Approximately 80-82% takes part in blood circulation and is called volume of circulating blood(OTsK), and 18-20% is in reserve in the depositing authorities. The volume of circulating blood is noticeably higher in people with developed muscles and not burdened with excess weight. In full, oddly enough, this indicator decreases, so the dependence of BCC on weight can be considered conditional. BCC also decreases with age (after 60 years) by 1-2% per year, during menstruation in women and, of course, during childbirth, but these changes are considered physiological and, in general, do not affect the general condition of a person. Another question is if the volume of circulating blood decreases as a result of pathological processes:

• Acute blood loss caused by traumatic impact and damage to a vessel of large diameter (or several with a smaller lumen);
• Acute gastrointestinal bleeding associated with human diseases of ulcerative etiology and being their complication;
• Blood loss during operations (even planned ones), resulting from a surgeon's mistake;
• Bleeding during childbirth, resulting in massive blood loss, is one of the most severe complications in obstetrics, leading to maternal death;
• Gynecological bleeding (uterine rupture, ectopic pregnancy, etc.).

Blood loss from the body can be divided into two types: sharp and chronic, and chronic is better tolerated by patients and does not carry such a danger to human life.

Chronic (hidden) blood loss is usually caused by persistent but minor bleeding(tumors, hemorrhoids), in which compensatory mechanisms that protect the body have time to turn on, which does not occur with acute blood loss. With hidden regular blood loss, as a rule, the BCC does not suffer, but the amount blood cells and hemoglobin levels drop markedly. This is due to the fact that replenishing the volume of blood is not so difficult, it is enough to drink a certain amount of liquid, but the body does not have time to produce new formed elements and synthesize hemoglobin.

Physiology and not so

The loss of blood associated with menstruation is a physiological process for a woman, it does not have a negative effect on the body and does not affect her health, if it does not exceed permissible values. The average blood loss during menstruation ranges from 50-80 ml, but can reach up to 100-110 ml, which is also considered the norm. If a woman loses more blood than this, then one should think about it, because a monthly blood loss of approximately 150 ml is considered abundant and in one way or another will lead to and in general can be a sign of many gynecological diseases.

Childbirth is a natural process and physiological blood loss will definitely take place, where values ​​of about 400 ml are considered acceptable. However, everything happens in obstetrics, and it should be said that obstetric bleeding is quite complex and can become uncontrollable very quickly.

At this stage, all the classic signs of hemorrhagic shock are clearly and clearly manifested:

• Cold extremities;
• Paleness of the skin;
• acrocyanosis;
• Dyspnea;
• Muffled heart sounds (insufficient diastolic filling of the heart chambers and deterioration of the contractile function of the myocardium);
• Development of acute renal failure;
• Acidosis.

Distinguishing decompensated hemorrhagic shock from irreversible is difficult because they are very similar. Irreversibility is a matter of time, and if decompensation, despite treatment, continues for more than half a day, then the prognosis is very unfavorable. Progressive organ failure, when the function of the main organs (liver, heart, kidneys, lungs) suffers, leads to the irreversibility of shock.

What is infusion therapy?

Infusion therapy does not mean replacing lost blood with donor blood. The slogan “a drop for a drop”, which provides for a complete replacement, and sometimes even with a vengeance, has long gone into oblivion. - a serious operation involving the transplantation of foreign tissue, which the patient's body may not accept. Transfusion reactions and complications are even more difficult to deal with than acute blood loss, so whole blood is not transfused. In modern transfusiology, the issue of infusion therapy is solved differently: blood components are transfused, mainly fresh frozen plasma, and its preparations (albumin). The rest of the treatment is supplemented by the addition of colloidal plasma substitutes and crystalloids.

The task of infusion therapy in acute blood loss:

1. Restoration of the normal volume of circulating blood;
2. Replenishment of the number of red blood cells, as they carry oxygen;
3. Maintaining the level of clotting factors, since the hemostasis system has already responded to acute blood loss.

It makes no sense for us to dwell on what the tactics of a doctor should be, since for this you need to have certain knowledge and qualifications. However, in conclusion, I would also like to note that infusion therapy provides for various ways of its implementation. Puncture catheterization requires special care for the patient, so you need to be very attentive to the slightest complaints of the patient, since complications can also occur here.

Acute bleeding. What to do?

As a rule, first aid in case of bleeding caused by injuries is provided by people who are nearby at that moment. Sometimes they are just passers-by. And sometimes a person has to do it himself if trouble has caught him far from home: on a fishing or hunting trip, for example. The very first thing to do - try with the available improvised means or by finger pressing the vessel. However, when using a tourniquet, it should be remembered that it should not be applied for more than 2 hours, so a note is placed under it indicating the time of application.

In addition to stopping bleeding, first aid also consists in carrying out transport immobilization if fractures occur, and making sure that the patient falls into the hands of professionals as soon as possible, that is, it is necessary to call a medical team and wait for her arrival.

Provide emergency assistance medical workers, and it consists of:

• Stop the bleeding;
• Assess the degree of hemorrhagic shock, if any;
• Compensate the volume of circulating blood by infusion of blood substitutes and colloidal solutions;
• Carry out resuscitation in case of cardiac and respiratory arrest;
• Transport the patient to the hospital.

The faster the patient gets to the hospital, the more chances he has for life, although even in stationary conditions treating acute blood loss is difficult, as it never leaves time for reflection, but requires quick and clear action. And, unfortunately, he never warns of his arrival.

Video: acute massive blood loss - lecture by A.I. Vorobyov

Bleeding always poses a serious threat to the life of the victim. This is due to the fact that a sufficient volume of circulating blood (CBV) is necessary condition circulation. In turn, the adequacy of blood circulation is a necessary condition for maintaining the vital activity of the human body, since its violation leads to the loss of all those diverse and complex functions that blood performs.

Depending on the person's body weight and age, a certain amount of blood circulates in the human bloodstream (on average, from 2.5 to 5 liters). One of the main tasks of surgery is to stop bleeding.

Bleeding is the outflow of blood from blood vessels in violation of their integrity or permeability.

Hemorrhage is the outflow of blood from damaged vessels into tissues or body cavities.

Bleeding of any origin requires the adoption of emergency measures to stop it.

shock bleeding vessel ligation

Classification of bleeding

I. Due to the occurrence:

• 1. Traumatic - occur when a blood vessel is mechanically damaged as a result of an injury.
• 2. Pathological - arise as a result of any disease (non-traumatic).
• a) arrosine bleeding - occurs as a result of corroding the vascular wall of any pathological process.

For example: ulcer, suppuration, tumor decay.

b) neurotrophic bleeding - develop as a result of a malnutrition of the vascular wall or a violation of metabolic processes in it.

For example: bedsores, measles, rubella, scarlet fever, scurvy - vitamin C deficiency and others.

c) hypocoagulation bleeding - due to a violation of blood coagulation processes.

For example: hemophilia, Werlhof's disease, cirrhosis of the liver, DIC - syndrome, overdose of anticoagulants.

II. According to the type of bleeding vessel:

• 1. Arterial bleeding - the outflow of blood from a damaged artery - is characterized by a massive ejection of bright red blood in the form of a fountain, it flows out quickly, in a pulsating stream. The color of blood is bright red due to oxygen saturation. If large arteries or the aorta are damaged, most of the circulating blood can flow out within a few minutes, and blood loss incompatible with life will occur.
• 2. Venous bleeding - the outflow of blood from a damaged vein - is characterized by a slow flow of blood of a dark cherry color. It is characterized by a continuous flow of blood from a damaged vessel due to low pressure in the veins and is not life-threatening for the victim. The exception is the large veins of the thoracic and abdominal cavity. Injuries to the large veins of the neck and chest are dangerous due to the possibility of air embolism.
• 3. Capillary bleeding - outflow of blood from the smallest blood vessels - capillaries. Such bleeding is observed with shallow cuts and abrasions of the skin, muscles, mucous membranes, bones. This bleeding usually stops on its own. Its duration increases significantly with reduced blood clotting.
• 4. Parenchymal - outflow of blood in case of damage to the parenchymal organs - the liver, spleen, kidneys and lung. These bleedings are similar to capillary ones, but more dangerous than them, since the vessels of these organs do not collapse due to anatomical structure stroma of the organ, there is profuse bleeding, which requires emergency care.
• 5. Mixed bleeding - this bleeding combines the signs of two or more of the above.

III. In connection with the external environment.

• 1. External bleeding - blood is poured directly into the external environment, onto the surface of the human body through a defect in its skin.
• 2. Internal bleeding - the most diverse in nature and complex in diagnostic and tactical terms. Blood is poured into the lumen of hollow organs, into tissues or into the internal cavities of the body. They are dangerous by compression of vital organs. Internal bleeding is divided into:
  • a) obvious internal bleeding - blood is poured into the internal cavities and then goes out into the external environment. For example: bleeding into the lumen of the gastrointestinal tract, pulmonary, uterine, urological bleeding.
  • b) latent internal bleeding - blood is poured into closed cavities that do not have communication with the external environment. Bleeding in some cavities received special names:
    • - in the pleural cavity - hemothorax (hemothoraks);
    • - in the abdominal cavity - hemoperitoneum (hemoperitoneum);
    • - in the pericardial cavity - hemopericardium (hemopericardium);
    • - in the joint cavity - hemarthrosis (hemarthrosis).

A feature of bleeding into the serous cavities is that fibrin is deposited on the serous cover, so the outflowing blood becomes defibrinated and usually does not clot.

Latent bleeding is characterized by the absence of obvious signs of bleeding. They can be interstitial, intestinal, intraosseous, or hemorrhages can impregnate tissues (hemorrhagic infiltration occurs), or form accumulations of outflowing blood in the form of a hematoma. They can be identified special methods research.

The blood accumulated between the tissues forms artificial cavities, which are called hematomas - intermuscular hematomas, retroperitoneal hematomas, mediastinal hematomas. Very often in clinical practice there are subcutaneous hematomas - bruises that do not entail any serious consequences.

IV. By the time of occurrence:

• 1. Primary bleeding - begins immediately after exposure to a traumatic factor.
• 2. Secondary bleeding - occur after a certain period of time after the primary bleeding stops and are divided into:
  • a) secondary early bleeding - occur from several hours to 4-5 days after the primary bleeding stops, as a result of the ligature slipping from the vessel or washing out of the thrombus due to increased blood pressure.
  • b) late secondary bleeding - develop in a purulent wound as a result of erosion (arrosion) of a thrombus or vascular wall by pus after more than five days.

V. By duration:

• 1. Acute bleeding - the outflow of blood is observed for a short period of time.
• 2. Chronic bleeding - prolonged, persistent bleeding, usually in small portions.

VI. By clinical manifestation and localization:

• - hemoptysis - hemopneic;
• - bloody vomiting - hematemesis;
• - uterine bleeding- metrorrhagia;
• - bleeding into the urinary cavitary system - hematuria;
• - bleeding into the abdominal cavity - hemoperitoneum;
• - bleeding into the lumen of the gastrointestinal tract - tarry stools - melena;
• - epistaxis - epistaxis.

VII. According to the severity of blood loss:

• 1. I degree - mild - blood loss is 500 - 700 ml. blood (BCC is reduced by 10-12%);
• 2. II degree - medium - blood loss is 1000-1500 ml. blood (BCC is reduced by 15-20%);
• 3. III degree - severe - blood loss is 1500-2000 ml. blood (BCC is reduced by 20-30%);
• 4. IV degree - blood loss is more than 2000 ml. blood (BCC is reduced by more than 30%).
• 3. Clinical manifestations of bleeding

The manifestation of symptoms and their severity depend on the intensity of bleeding, the magnitude and speed of blood loss.

Subjective symptoms appear with significant blood loss, but they can also occur with a relatively small blood loss that occurred quickly, at the same time.

Victims complain of: increasing general weakness, dizziness, tinnitus, darkening in the eyes and flickering of "flies" before the eyes, headache and pain in the heart area, dry mouth, thirst, suffocation, nausea.

Such complaints of the victim are the result of a violation of the blood circulation of the brain and internal organs.

Objective symptoms can be detected when examining the victim: drowsiness and lethargy, sometimes there is some agitation, pallor of the skin and mucous membranes, frequent pulse of weak filling, rapid breathing (shortness of breath), in severe cases, Chain-Stokes breathing, decrease in arterial and venous pressure, loss consciousness. Local symptoms are different. With external bleeding, local symptoms are bright and easily identified. With internal bleeding, they are less pronounced and sometimes difficult to determine.

There are three degrees of blood loss:

Mild blood loss - heart rate - 90-100 beats per minute, arterial pressure- 110/70 mm. rt. Art., hemoglobin and hematocrit remain unchanged, BCC is reduced by 20%.

The average degree of blood loss - pulse up to 120 - 130 beats per minute, blood pressure 90/60 mm. rt. Art., Ht-0.23.

Severe degree of blood loss - there is a sharp pallor of the mucous membranes and skin, cyanosis of the lips, severe shortness of breath, very weak pulse, heart rate - 140-160 beats per minute, hemoglobin level decreases to 60 g / l or more, hemotacrit rate up to 20%, BCC is reduced by 30-40%.

The body can independently compensate for the loss of blood no more than 25% of the BCC due to protective reactions, but on condition that the bleeding is stopped.

To assess the severity of the victim's condition and the amount of blood loss, the Altgover shock index is used - the ratio of the pulse to the systolic pressure (PS / BP). Normally, it is equal to - 0.5.

For example:

I degree - PS / BP \u003d 100/100 \u003d 1 \u003d 1l. (deficit of BCC 20%).

II degree - PS/BP=120/80=1.5=1.5l. (deficit of BCC 30%).

III degree - PS/BP=140/70=2=2l. (deficit of BCC 40%).

In addition to the severity of blood loss, clinical manifestations depends on:

• - gender (women tolerate blood loss more easily than men);
• - age (the clinic is less pronounced in middle-aged people than in children and the elderly);
• - from the initial state of the victim (the condition worsens with initial anemia, debilitating diseases, starvation, traumatic long-term operations).
• 4. Possible Complications bleeding

by the most frequent complications bleeding are:

• 1. Acute anemia, which develops with a loss of blood from 1 to 1.5 liters.
• 2. Hemorrhagic shock, in which there are severe violations microcirculation, respiration and multiple organ failure develops. Hemorrhagic shock requires emergency resuscitation and intensive care.
• 3. Compression of organs and tissues with outflowing blood - compression of the brain, cardiac tamponade.
• 4. Air embolism, which can endanger the life of the victim.
• 5. Coagulopathic complications - a violation in the blood coagulation system.

The outcome of bleeding is more favorable, the sooner it is stopped.

5. The concept of hemostasis. Ways to temporarily and permanently stop bleeding

Stop bleeding - hemostasis.

To stop bleeding, temporary (preliminary) and final methods are used.

I. Ways to temporarily stop bleeding.

Temporary stop of bleeding is carried out in order to provide emergency care to the victim at the pre-hospital stage and is carried out within the time period necessary to take measures for the final stop of bleeding.

It is carried out with bleeding from arteries and large veins. With bleeding from small arteries, veins and capillaries, measures to temporarily stop bleeding can lead to a final one.

Temporary stop of external bleeding is possible in the following ways:

• 1. Giving the damaged part of the body an elevated position;
• 2. Pressing the bleeding vessel in the wound with a finger;
• 3. Pressing the damaged artery above the site of bleeding (throughout);
• 4. Pressing the bleeding vessel in the wound with a pressure bandage;
• 5. Clamping of the artery by fixing the limb in the position of maximum flexion or overextension of it in the joint;
• 6. Clamping of the artery by applying a tourniquet;
• 7. Applying a hemostatic clamp in the wound;
• 8. Tight tamponade of the wound or cavity with a dressing.

II. Methods for the final stop of bleeding.

The final stop of bleeding is carried out by a doctor in a hospital. Almost all victims with injuries are subject to surgical treatment. With external bleeding, primary surgical treatment of the wound is more often performed.

With internal and hidden external bleeding, more complex operations: thoracotomy - opening of the pleural cavity, laparotomy - opening of the abdominal cavity.

Methods for the final stop of bleeding:

With external bleeding, mainly mechanical methods of stopping are used, with internal bleeding - if surgery is not performed - physical, chemical, biological and combined.

Mechanical methods:

• 1. Ligation of the vessel in the wound. To do this, a hemostatic clamp is applied to the bleeding vessel, after which the vessel is tied up.
• 2. Vessel ligation throughout (Gunter's method) is used when it is impossible to detect the ends of the vessel in the wound, as well as in secondary bleeding, when the arrosive vessel is in the inflammatory infiltrate. For this purpose, an incision is made above the injury site, based on topographic anatomical data, the artery is detected and ligated.
• 3. Twisting the vessel, previously captured with a hemostatic forceps, then suturing and ligating along with the surrounding tissues.
• 4. Clipping of bleeding vessels with metal clips. It is used in cases where the bleeding vessel is difficult or impossible to tie. This method is widely used in laparo- and thoracoscopic operations, neurosurgery.
• 5. Artificial vascular embolization. It is used for pulmonary, gastrointestinal bleeding and bleeding of cerebral vessels.
• 6. Vascular suture can be performed manually and mechanically.
• 7. Vessel sealing. This method of hemostasis is used for bleeding from the vessels of the cancellous bone. Sealing of vessels is performed with a sterile paste, which is rubbed into the bleeding surface of the cancellous bone. The paste consists of 5 parts of paraffin, 5 parts of wax and 1 part of Vaseline.

Physical methods:

• 1. Application of hot saline. In case of diffuse bleeding from a bone wound, a parenchymal organ, wipes moistened with hot (75°C) isotonic sodium chloride solution are applied.
• 2. Local application cold. Under the influence of cold, a spasm of small blood vessels occurs, blood flow to the wound decreases, which contributes to vascular thrombosis and stop bleeding. Ice packs are applied to the postoperative wound, subcutaneous hematomas, the abdomen with gastrointestinal bleeding and give the patient pieces of ice for swallowing.
• 3. Diathermocoagulation. It is used to stop bleeding from damaged vessels of subcutaneous adipose tissue, muscles, small vessels, parenchymal organs.
• 4. Laser photocoagulation. Focused in the form of a beam of quantum electron waves, laser radiation dissects tissues and simultaneously coagulates small vessels of parenchymal organs.
• 5. Cryosurgery. It is used in operations with extensive blood circulation. The method consists in local freezing of tissues and promotes hemostasis.

Chemical methods:

The method is based on the use of vasoconstrictor and blood clotting agents.

• - Vasoconstrictor drugs- adrenaline, dopanin, pituitrin.
• - Means that increase blood coagulation include: calcium chloride 10% -10 ml., Epsilon - aminocaproic acid, calcium gluconate, hydrogen peroxide 3%.
• - Means that reduce the permeability of the vascular wall: rutin, ascorbic acid, ascorutin, dicynone, etamsylate.

Biological methods:

• 1. Tomponade of a bleeding wound with the patient's own tissues.
• 2. Intravenous use of hemostatic agents of biological origin.

Used: transfusion of whole blood, plasma, platelet mass, fibrinogen, antihemophilic plasma, the use of fibrinolysis inhibitors (kontrykal, vikasol).

Article content: classList.toggle()">expand

All people experience bleeding throughout their lives. Hemorrhage is a condition in which blood leaks from a damaged vessel. The most common is capillary bleeding, which the body usually copes with on its own. Venous and arterial bleeding is life-threatening and requires medical attention. But the most insidious are considered internal bleeding, which is difficult to detect.

It is important to be able to distinguish between types of bleeding and know their main characteristics in order to provide first aid in a timely manner and save a person's life. After all, incorrect diagnosis or violation of the rules for stopping bleeding can cost the victim his life.

What types of bleeding are there, what are the main signs of external and internal hemorrhages, what are the actions when providing the first medical care(PMP) - you will learn about this and much more later in the article.

Classification of bleeding

Hemorrhages are divided into different types, this is necessary to save time and make it easier to determine the treatment plan. After all, thanks to prompt diagnostics, you will not only save a life, but also minimize blood loss.

General classification of types of bleeding:

• Depending on the site of bleeding:
  • External - a type of bleeding that is in contact with the external environment;
  • Internal - blood is poured into one of the body cavities;
• Depending on the damaged vessel:
  • - damaged capillaries;
  • - the integrity of the veins is broken;
  • - blood flows out of the arteries;
  • Mixed - different vessels are damaged;

• Depending on the body cavity into which the blood flows:
  • Bleeding into the free abdominal cavity;
  • The blood bleeds into internal organs;
  • Hemorrhage in the cavity of the stomach or intestines;
• Depending on the amount of blood loss:
  • I degree - the victim lost about 5% of the blood;
  • II degree - loss of up to 15% of the fluid;
  • III degree - the volume of blood loss is up to 30%;
  • VI degree - wounds lost from 30% of blood or more.

The most dangerous for life are III and VI degree of blood loss. Next, we consider in detail the characteristics of various and at the same time the most common and dangerous species bleeding.

capillary

The most common is capillary hemorrhage. This is external bleeding, which is considered not life-threatening, unless the area of ​​injury is too large or the patient has reduced blood clotting. In other cases, the blood ceases to flow out of the vessels on its own, since a blood clot forms in its lumen, which clogs it.

Capillary bleeding occurs due to any traumatic injury, during which the integrity of the skin is violated.

As a result of an injury, blood of a bright scarlet color evenly flows out of damaged capillaries (the smallest blood vessels). The liquid flows out slowly and evenly, there is no pulsation, since the pressure in the vessels is minimal. The amount of blood loss is also insignificant.

First aid for capillary bleeding is to disinfect the wound and apply a tight bandage.

In addition, a cold compress can be applied to the damaged area. Usually, with capillary bleeding, hospitalization is not needed.

Venous

Venous hemorrhage is characterized by a violation of the integrity of the veins that are under the skin or between the muscles. As a result of a superficial or deep wound, blood flows out of the vessels.

Symptoms of venous hemorrhage:

• Blood of a maroon hue flows from the vessels, a barely perceptible pulsation may be present;
• The hemorrhage is quite strong and is manifested by a constant flow of blood from the damaged vessel;
• When you press on the area under the wound, bleeding decreases.

Venous bleeding is life threatening, because in the absence of timely medical care, the victim may die from heavy blood loss. The body in rare cases can cope with such a hemorrhage, and therefore it is not recommended to hesitate to stop it.

If the superficial veins are damaged, the hemorrhage is less intense, and if the integrity of the deep vessels is violated, profuse blood loss (abundant bleeding) is observed.

With venous bleeding, the victim can die not only from massive blood loss, but also from an air embolism. After damage to a large vein, air bubbles clog its lumen at the time of inspiration. When the air reaches the heart, it cuts off the flow of blood to important organs, as a result, a person can die.

Arterial

Arteries are large blood vessels that lie deep in soft tissues. They transport blood to all important organs. If the integrity of the vessel is violated, blood begins to flow out of its lumen.

Similar articles

Arterial bleeding is rare. Most often, the injury occurs as a result of a knife, gunshot or mine-explosive wound. This dangerous damage threatens a person's life, because blood loss is quite large.

If you do not help the victim with arterial bleeding within 3 minutes after the injury, then he will die from exsanguination.

It is easiest to identify arterial hemorrhage, for this, pay attention to the following signs:

• The blood is bright red;
• Blood does not flow, but pulsates from the wound;
• The bleeding is very profuse;
• The blood does not stop even after pressing under the wound or above it;
• The wound is localized at the site of the proposed passage of the artery.

Intense arterial hemorrhage quickly provokes profuse blood loss and shock. If the vessel ruptures completely, then the victim can die from exsanguination of the body in just 1 minute. That is why arterial bleeding requires surgery. first aid. A tourniquet is most often used to stop the bleeding.

What are the main signs of external bleeding, you now know, then we will consider what to do if the hemorrhage occurs inside the body.

internal

This type of hemorrhage is the most insidious, since, unlike external bleeding, it does not have obvious symptoms. They appear when a person has already lost a lot of blood.

Internal hemorrhage is a condition characterized by bleeding into one of the cavities of the body due to damage to blood vessels.

Check for bleeding early stage possible by the following signs:

• The victim feels weak, he is drawn to sleep;
• There is discomfort or pain in the abdomen;
• Without a reason, blood pressure drops;
• The pulse quickens;
• The skin turns pale;
• There is pain when the victim tries to get up, which disappears when he assumes a semi-sitting position.

Types of internal bleeding occur as a result of penetrating wounds of the abdomen, lower back, broken ribs, stab-knife or gunshot injuries. As a result, the internal organs are injured, because of which the integrity of their vessels is violated and bleeding begins. As a result, blood accumulates in the abdominal cavity, chest, impregnates wounded organs or subcutaneous adipose tissue(hematoma).

The intensity of internal bleeding is different, that is, they can develop quickly or increase over several days after the injury. The severity of such hemorrhages depends on the size of the injury of a particular organ.

In most cases, the spleen is damaged, a little less often - the liver. A single-stage organ rupture provokes instantaneous and rapid bleeding, and a two-stage one provokes a hematoma inside the organ, which ruptures over time, and the victim's condition deteriorates sharply.

Gastrointestinal

This type of hemorrhage is most often a complication of diseases of the digestive tract (for example, stomach and duodenal ulcers). Blood accumulates in the cavity of the stomach or intestines and does not come into contact with air.

It is important to detect symptoms of gastrointestinal hemorrhage in time in order to transport the victim to a medical facility.

Symptoms of gastrointestinal hemorrhage:

• The patient feels weak, dizzy;
• The pulse quickens, and the pressure decreases;
• The skin turns pale;
• There are attacks of vomiting with an admixture of blood;
• Liquid bloody stools or thick black stools.

The main reasons for this complication are ulcers, oncological diseases, various necrotic processes on the inner lining of the gastrointestinal tract, etc. Patients who know their diagnosis should be prepared for such situations in order to go to the hospital on time.

First aid for different types of hemorrhages

It is important to be able to conduct a differentiated diagnosis in order to determine the type of bleeding in time and provide competent first aid.

General rules that should be followed for any bleeding:

• If symptoms of bleeding occur, the wounded person is laid on his back;
• The person providing assistance should observe that the victim is conscious, periodically check his pulse and pressure;

• Treat the wound with an antiseptic solution (hydrogen peroxide) and stop the bleeding with a pressure bandage;
• A cold compress should be applied to the damaged area;
• Then the victim is transported to a medical facility.

The above actions will not harm a person with any type of bleeding.

Detailed tactics of actions for different types of bleeding are presented in the table:

The above measures will help stop the hemorrhage and save the victim.

Harness rules

This method of stopping blood is used for severe venous or arterial hemorrhages.

To properly apply a tourniquet, follow these steps:

It is important to be able to distinguish between different types of bleeding in order to competently provide first aid to the victim.

It is important to strictly follow the rules of first aid, so as not to worsen the condition of the wounded. By remembering even the basic rules, you can save a person's life.