ROGER JONES ET AL. 2005. OXFORD TEXTBOOK OF PRIMARY MEDICAL CARE.

OXFORD UNIVERSITY PRESS

Principles of Pathophysiology and Emergency Medical Care

Oleh Jeffrey W. Myers,Marianne Neighbors,Ruth Tannehill-Jones

http://www.medicinenet.com/internal_bleeding/article.htm

What is internal bleeding?

While the general public understands that internal bleeding means bleeding that can't be seen on the outside of the body, medical personnel tend to use terms that describe precisely where inside the body the bleeding is found. The internal bleeding may occur within tissues, organs, or in cavities of the body including the head, chest, and abdomen. Examples of other potential sites of bleeding include the eye, lining tissues of the heart, muscles, and joints. Bleeding outside the body is quite easy to recognize. If the skin is damaged by a laceration, puncture, or abrasion, blood can be witnessed as it streams out of the body. The scalp, with its rich blood supply, is notorious for demonstrating massive blood loss. Internal bleeding can be much more difficult to identify. It may not be evident for many hours after it begins, and symptoms occur when there is significant blood loss or if a blood clot is large enough to compress an organ and prevent it from functioning properly. Internal bleeding occurs when damage to an artery or vein allows blood to escape the circulatory system and collect inside the body. The amount of bleeding depends upon the amount of damage to an organ and the blood vessels that supply it, as well as the body's ability to repair breaks in the walls of the blood vessels. The repair mechanisms available include both the blood clotting system and the ability of blood vessels to go into spasm to decrease blood flow to an injured area. Patients who take anti-clotting medication such as warfarin (Coumadin),clopidogrel (Plavix), heparin, or aspirin are more prone to bleeding than people who do not take these medications. These individuals may experience significant bleeding even with relatively minor injury or illness, and the risk of bleeding needs to be balanced against the benefits of taking the medication. Some people have genetic or inborn errors of the blood clotting system. Minor injuries may cause major bleeding in these cases. Hemophilia and von Willebrand disease are two examples

What causes internal bleeding?

Bleeding most often occurs due to injury, and depending upon the circumstances, the amount of force required to cause bleeding can be quite variable. Blunt trauma Most people understand that falling from a height or being involved in a car accident can inflict great force and trauma upon the body. If blunt force is involved, the outside of the body may not necessarily be damaged, but enough compression may occur to internal organs to cause injury and bleeding.

Imagine a football player being speared by a helmet to the abdomen. The spleen or liver may be compressed by the force and cause bleeding inside the organ. If the hit is hard enough, the capsule or lining of the organ can be torn, and the bleeding can spill into the peritoneum (the space in the abdominal cavity that contains abdominal organs such as the intestines, liver, and spleen). If the injury occurs in the area of the back or flank, where the kidney is located, retroperitoneal bleeding (retro=behind; behind the abdominal cavity) may occur. The same mechanism causes bleeding due to crush injuries. For example, when a weight falls on a foot, the weight doesn't give, nor does the ground. The force needs to be absorbed by either the bone or the muscles of the foot. This can cause the bone to break and/or the muscle fibers to tear and bleed.

Other structures are compressible and may cause internal bleeding. For example, the eye can be compressed in the orbit when it is hit by a fist or a ball. The globe deforms and springs back to its original shape. Intraorbital hemorrhage may occur.

Deceleration trauma Deceleration may cause organs in the body to be shifted inside the body. This may shear blood vessels away from the organ and cause bleeding to occur. This is often the mechanism for intracranial bleeding such as epiduralor subdural hematomas. Force applied to the head causes an acceleration/deceleration injury to the brain, causing the brain to "bounce around" inside the skull. This can tear some of the small veins on the surface of the brain and cause bleeding. Since the brain is encased in the skull, which is a solid structure, even a small amount of blood can increase pressure inside the skull and decrease brain function. Fractures Bleeding may occur with broken bones. Bones contain the bone marrow in which blood production occurs. They have rich blood supplies, and significant amounts of blood can be lost with fractures. The break of a long bone such as the femur (thigh bone) can result in the loss of one unit (350500cc) of blood. Flat bones such as the pelvis require much more force to cause a fracture, and many blood vessels that surround the structure can be torn by the trauma and cause massive bleeding. Pregnancy Bleeding in pregnancy is never normal, though not uncommon in the first trimester, and is a sign of a potential miscarriage. Early on, the concern is a potential ectopic or tubal pregnancy, in which the placenta and the fetus implant in the Fallopian tube or another location outside of the uterine cavity. As the placenta grows, it erodes through the tube or other involved organs and may cause fatal bleeding. Bleeding after 20 weeks of pregnancy may be due to placenta previa or placental abruption, and urgent medical care should be accessed. Placenta previa describes the situation in which the placenta attaches to the uterusclose to the opening of the cervix and may cause painless vaginal bleeding. Abruption occurs when the placenta partially separates from the uterine wall and causes significant pain with or without bleeding from the vagina. Spontaneous bleeding Internal bleeding may occur spontaneously, especially in those people who take anticoagulation medications or who have inherited bleeding disorders. Routine bumps that occur in daily life may cause significant bleeding issues. Medication Internal bleeding may be caused as a side effect of medications (most often from nonsteroidal antiinflammatory drugs such as ibuprofen and aspirin) and alcohol. These substances can cause inflammation and bleeding of theesophagus, stomach, and duodenum, the first part of the small intestine as it leaves the stomach. Alcohol abuse Long-term alcohol abuse can also cause liver damage, which can cause bleeding problems through a variety of mechanisms.

What are the signs and symptoms of internal bleeding?

The symptoms of internal bleeding depend upon where the bleeding is located, how much bleeding has occurred, and what structures and functions in the body are affected. Blood outside the circulatory system (the heart and blood vessels) is very irritating to tissues, causing inflammation and pain. Examples of some internal bleeding situations are listed below. Intracranial bleeding from trauma or from a leaking aneurysm often causes pain but may also present with altered mental function. Neurological exam results range from a near-normal exam

to confusion tocoma. Symptoms of stroke, includingweakness, slurred speech, and loss of vision, may also be associated with intracerebral bleeding. The signs and symptoms depend upon where and how much blood there is in the brain. If the bleeding continues, symptoms become progressive and easier to recognize. Intra-abdominal bleeding may be hidden and present only with pain, but if there is enough blood loss, the patient may complain of weakness,lightheadedness, shortness of breath, and other symptoms of shock anddecreased blood pressure. Once again, the symptoms depend upon where in the abdomen the bleeding occurs.

If there is gastrointestinal bleeding, the patient may vomit bright red blood, or if it has been in the stomach for a period of time, the vomit may look like coffee grounds. Bowel movements may be bloody or they may be black and tarry, again depending upon the location of the bleeding in the gastrointestinal tract. If the internal bleeding causes blood to spill into the peritoneum, there can be a significant amount of pain with any movement, and the abdomen can become tense and feel rigid to touch. Sometimes intra-abdominal blood will track toward the skin and can be appreciated on physical examination. Cullen's sign is the term used to refer to the appearance of bruising surrounding the umbilicus. Grey-Turner sign is bruising in the flanks.

Blood seen in the urine may be due to internal bleeding at any site within the urinary tract, from the kidney to the bladder. Often bladder infectionsare associated with blood in the urine but other causes need to be considered based upon the particular symptoms as well as the patient's age and medical history, especially males who may have had prostate surgery. Men and women who have had radiation therapy may develop inflammation of the bladder wall which can cause a significant amount of bleeding. Bleeding may occur deep within muscles after injury, and rarely,compartment syndrome may occur. Should so much bleeding occur that the pressure build-up within the muscle is greater than the patient's blood pressure, blood cannot get to the muscle cells, and they begin to die. Symptoms include intense pain, difficulty moving the joints below the injury, and loss of sensation. Most commonly this is seen in the shin and forearm and may or may not be associated with a broken bone. Bleeding may also occur into joints, causing significant pain and loss ofrange of motion. This most frequently is seen in patients who are on anti-coagulation medications. An injury may or may not be needed to cause the bleeding.

How is internal bleeding diagnosed?

The diagnosis of internal bleeding begins with a thorough history taken by the health care practitioner. This is followed by a physical examination, concentrating on the area of the body where the internal bleeding may have occurred. For example, if there is concern about bleeding in the brain, the physical examination will focus on the neurologic system, or if it is intra-abdominal bleeding, the exam will be directed toward the abdomen. Blood tests may be performed to check for alow red blood cell count, or anemia. However, if the bleeding occurs rapidly, the initial hemoglobin reading or red blood cell count may be normal. The suspicion of internal bleeding will often require an imaging test to look for the bleeding source.

If there is concern that there is gastrointestinal bleeding, agastroenterologist may use fiber optic scopes to look into the esophagus and stomach (endoscopy) or into the colon (colonoscopy) to identify the source. If found, the physician may be able to stop the bleeding using electricity to cauterize or burn the blood vessel that is bleeding.

Computerized tomography (CT) is the most common test to look for bleeding in the brain. It is also able to identify brain swelling and fractures of the skull. Ultrasound may be used to look for blood in the abdomen. While it has its place in the management of trauma, ultrasound is especially useful in evaluating obstetric and gynecologic problems such as bleeding from an ovarian cyst or an ectopic or tubal pregnancy. Computerized tomography is an effective tool in looking for intra-abdominal and retroperitoneal bleeding. It can evaluate the potential injury site, the severity of organ damage, and whether the bleeding is contained within an organ (such as the liver, kidney or spleen) or whether the bleeding has spilled into the peritoneum. It is also a helpful test in assessing pelvic fractures. If the source of bleeding is thought to be due to a damaged artery,angiography may be used to evaluate the arterial blood flow.

In some situations in which the patient is critically ill from internal bleeding, the decision may be made to undergo emergency surgery to find and repair the bleeding site. This may occur in trauma victims with abdominal or chest injuries who have unstable vital signs (decreased level of consciousness,low blood pressure, and other signs of shock) and are at risk for bleeding to death if they were to wait for diagnostic tests.
A person may be bleeding internally if one of these things happens:

Blood comes out of the nose or mouth (occurs from severe head trauma) Blood or clear fluid comes out of the ear (occurs from severe head trauma) Blood is in the stool Blood is in the urine Bright red blood, or blood like 'coffee-grounds', is in the vomit Blood comes from a woman's vagina (birth canal) after an injury or during pregnancy Bruising over the abdominal or chest area Pain over vital organs Fractured femur

But remember, a person may be bleeding inside the body, even though you cannot see the bleeding. If you see the signs of shock and no apparent injuries, always suspect internal bleeding. Check the skin color changes. In cases of internal bleeding the skin may become pale and cold, and cyanosis may be present.

How is internal bleeding treated?

The initial treatment plan of any patient with internal bleeding begins with assessing the patient's stability and making certain the ABCs are well maintained. This includes making certain the patient's: Airway is open, that the patient is Breathing, and that there is adequate Circulation, meaning good pulse and blood pressure. The definitive treatment of internal bleeding depends upon where the bleeding is occuring, the individual situation, and the stability of the patient. The basic goals include identifying and stopping the source of bleeding and repairing any damage that the bleeding may have caused.

What are the complications of internal bleeding?

Depending upon where it occurs, if not recognized, internal bleeding may cause organ failure, shock, and death. For example:

If there is uncontrolled bleeding in the chest or abdomen, the body may lose enough circulating red blood cells to compromise oxygen delivery to cells in the body. This situation is called shock. If the bleeding is not stopped and if fluid resuscitation and perhaps blood transfusion are not provided, the patient may die. Internal bleeding in the brain may cause minimal damage, but if there is enough to cause increased pressure or if the bleeding increases, enough brain tissue may be damaged to cause stroke-like symptoms, coma, and death.

Internal Bleeding At A Glance

Internal bleeding may occur in many areas of the body and may cause significant local pain. If enough bleeding occurs, signs of shock may be apparent. Bleeding is a recognized complication of anti-coagulation medications such as aspirin, clopidogrel (Plavix), warfarin (Warfarin), and heparin. The benefits of these medications need to be balanced against the risk of bleeding. Bleeding is never normal in pregnancy. If internal bleeding is suspected, it is important to seek medical care.

External Bleeding
Bleeding is a common reason for the application of first aid measures and can be internal or external. The principle difference is whether the blood leaves the body - external bleeding can be seen, whereas in internal bleeding, no blood can be seen. There are many causes of external bleeding, which fall in to seven main categories, which are:

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 Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth Incision - A clean 'surgical' wound, caused by a sharp object, such as a knife 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 Gunshot wounds - Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Recognition
Recognizing external bleeding is usually easy, as the presence of blood should alert you to it. It should however be remembered that blood may be underneath or behind a victim. It may be difficult to find the source of bleeding, especially with large wounds or (even quite small) wounds with large amounts of bleeding. If there is more than 5 cups of bleeding, then the situation is life-threatening.

Treatment
As with all first aid situations, the priority is to protect yourself, so put on protective gloves before approaching the victim. All external bleeding is treated using three key techniques, which allow the body's natural repair process to start. These can be remembered using the acronym mnemonic 'RED': Rest Elevation Direct pressure Rest In all cases, the less movement the wound undergoes, the easier the healing process will be, so rest is advised. Rest will also reduce the pulse rate, thus the severity of the bleeding, especially in the case of arterial bleeding. Elevation Direct pressure is usually enough to stop most minor bleeds, but for larger bleeds, it may be necessary to elevate the wound above the level of the heart (whilst maintaining direct pressure the whole time). This decreases the blood flow to the affected area, slowing the blood flow, and assisting clotting. Elevation only works on the peripheries of the body (limbs and head) and is not appropriate for body wounds. You should ask the victim to hold their wound as high as possible. You should assist them to do this if necessary, and use furniture or surrounding items to help support them in this position. If it is the legs affected, you should lie them on their back (supine), and raise their legs. Direct Pressure The most important of these three is direct pressure. This is simply placing pressure on the wound in order to stem the flow of blood. This is best done using a dressing, such as a sterile gauze pad (although in an emergency, any material is suitable). If the blood starts to come through the dressing you are using, add additional dressings to the top, to a maximum of three. If you reach three dressings, you should remove all but the one in contact with the wound itself (as this may cause it to reopen) and continue to add pads on top. Repeat this again when you reach three dressings. The reason for not simply adding more dressings is that it becomes harder to apply the direct pressure which is clearly needed if this much blood is produced. Where an articulate area of the body is wounded (such as the arms or hands), it is important to consider the position of the area in keeping pressure on the wound. For example, if a hand is cut 'across' from the thumb to halfway across the palm, the wound can be closed with direct pressure by simply clasping the victim's hand shut. However, if the hand was wounded from between the two middle fingers down to the wrist, closing the hand would have the effect of opening the wound, and so the victim should have their hand kept flat.

In most cases, during the initial treatment of the bleed, you will apply pressure by hand in order to stem the flow of blood. In some cases, a dressing may help you do this as it can keep pressure consistently on the wound. If you stop the flow by hand, you should then consider dressing the wound properly, as below.

Dressing
Once the bleeding is slowed or stopped, or in some cases, to assist the slowing of the blood flow you should consider dressing the wound properly. To dress a wound, use a sterile low-adherent pad, which will not stick to the wound, but will absorb the blood coming from it. Once this is in place, wrap a crepe or conforming bandage around firmly. It should be tight enough to apply some direct pressure, but should not be so tight as to cut blood flow off below the bandage. A simple check for the bandage being too tight on a limb wound is a capillary refill check; to do this, hold the hand or foot (dependent on what limb is injured) above the level of the heart and firmly pinch the nail. If it takes more than 2 seconds for the pink color to return under the nail, then the bandage is likely to be too tight. If the blood starts to come through the dressing you have applied, add another on top, to a maximum of three. If these are all saturated, remove the top two, leaving the closest dressing to the wound in place. This ensures that any blood clots that have formed are not disturbed; otherwise, the wound would be opened anew.

Special cases
Nosebleeds (epistaxis) If a person has nosebleed, have them pinch the soft part of the nose firmly between thumb and forefinger, just below the end of the bone. If necessary, do this yourself, but it is preferable to have them do it themselves if they are able to do it effectively. The victim should lean their head slightly forward and breathe through their mouth. You can also leave the head in a neutral position, but never tilt the head back. Tilting the head forward ensures that blood isn't ingested (as it can cause vomiting) or inhaled (choking hazard). If you are unsuccessful at stopping the bleeding after 10 minutes of direct pressure, you should assess the blood flow. If the blood flow is minor, you could consider using an ice pack on the bridge of the nose to help stem the flow. If the nose continues to bleed with a fast flow, you should seek medical assistance, probably from the ambulance. Embedded Objects If there is something embedded in the wound, do not remove it. Instead, apply pressure around the object using sterile gauze as described above. Rolled bandages are perfect for this. Be careful not to disturb the object, as moving it may exacerbate the bleeding. This doesn't apply to superficial splinters and such. A useful rule of thumb: if it's causing bleeding, don't remove it. If it isn't, feel free. Stab, puncture or gunshot wounds to the body These wounds are life threatening, and after assessing the ABCs of the victim, you should immediately summon an ambulance. As always, you should check that you are not in danger when approaching these victims (from someone with a knife or gun, for instance). As with all embedded objects, ensure you do not remove the item from the body. If possible, you should sit the victim up (as blood in the body will go to the lowest point, allowing the heart and lungs to work as efficiently as possible). You should also lean them to the injured side, keeping the healthy side free from incursion by blood.

Assess the victim for open chest wounds or abdominal injuries, and treat accordingly. Amputations If a body part has been amputated, immediately summon ambulance assistance, and treat the wound for bleeding first as above. Cover the amputated part with a moist dressing and place it in a clean plastic bag, and place this bag into a bag of ice and water, sending it with the victim to the hospital (it should be labeled with their name, and where it belongs). You should avoid putting the part in direct contact with ice, as this can cause irreparable damage, meaning that surgeons are unable to reattach it. If the body part is partially amputated, do not detach, but treat as a wound.