Massive Bleeding

Massive Bleeding (Hemorrhage)

Copious discharge of blood from the blood vessels or a rapid and uncontrollable loss or outflow.

is the loss of blood or blood escape from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, mouth, nose, ear or anus, or through a break in the skin.

Causes: Bleeding arises due to either traumatic injury,

underlying medical condition, or a combination.

Traumatic Injury:>Laceration- Irregular wound caused by blunt

impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.

>Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery.

>Punctured Wound - Caused by an object that penetrated the skin.

>Crushing Injuries- Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself.

>Ballistic Trauma- Caused by a projectile weapon, this may include two external wounds (entry and exit) and a contiguous wound between the two

Medical Condition- causes of bleeding not directly due to trauma

>Intravascular changes - changes of the blood within vessels (e.g. ↑ blood pressure, ↓ clotting factors)

>Intramural changes- changes arising within the walls of blood vessels (e.g. aneurysms, dissections, AVMs, vasculitides)

>Extravascular changes - changes arising outside blood vessels (e.g. H pylori infection, brain abscess, brain tumor)

The patient may have an internal hemorrhage that is invisible or an external hemorrhage that is visible on the outside of the body.

• Bleeding into the spleen or liver is internal hemorrhage.• Bleeding from a cut on the face

is an external hemorrhage.

Classification• Class I Hemorrhage involves up to 15% of blood

volume.• Class II Hemorrhage involves 15-30% of total

blood volume.• Class III Hemorrhage involves loss of 30-40% of

circulating blood volume. • Class IV Hemorrhage involves loss of >40% of

circulating blood volume.

Assessment:The px is assessed for signs of shock:

>cool moist skin>falling blood pressure>increased heart rate>delayed capillary refill>decreasing urine volume

Laboratory &Diagnostics

• Radiology and initial treatment• X-ray • FAST (Focused Assessment with Sonography

for Trauma)• DPL (Diagnostic Peritoneal Lavage) DPL has 97 % sensitivity for blood in the

peritoneal cavity. However, it is not a quantitative assessment indicating the amount of bleeding.

• CT (Computed Tomography) CT scanning with intravenous contrast is

considered “the gold standard” of trauma imaging.

• Angiography and angioembolisation Angiography in the trauma patient should not

be seen only as a diagnostic tool, but as a method to control the bleeding by embolisation, placement of covered stent grafts or insertion of balloon catheters.

Laboratory tests No laboratory tests are diagnostic of major

bleeding. The only crucial blood sample is the one used for

assessing the ABO-blood type and cross matching. A full screen should be performed from venous

blood drawn within the ED. Frequent arterial blood gas (ABG) tests are useful in providing information on the presence of metabolic acidosis. Since this is the hallmark of shock, the test can be used as an adjunct to determine when the patient is fully resuscitated.

If possible, before you try to stop severe bleeding, wash your hands to avoid infection and put on synthetic gloves. Don't reposition displaced organs. If the wound is abdominal and organs have been displaced, don't try to push them back into place — cover the wound with a dressing.

Management

• Fluid Replacement is imperative to maintain circulation

two large-bore intravenous cannulae are inserted

may include isotonic solution, colloid and blood component therapy

O-negative blood for women of child bearing age and in emergent situation.

Additional platelets and clotting factors are given.

• Control of external Hemorrhagerapid physical assessment firm pressure is applied over the

bleeding area or the involved arteryThe injured part is elevatedimmobilize extremityapply torniquet as a last resort when

external hemorrhage cannot be controlled in any other way

• Control of internal BleedingPacked red blood cells (O-negative) are

administered at a rapid rateSurgeryPharmacologic therapyArterial blood specimens obtainedPx maintained in supine

Nursing Diagnosis

Ineffective Tissue PerfusionDeficient Fluid VolumeDecreased Cardiac Output

Current TrendsHemostatic resuscitation for massive bleeding: the paradigm of plasma and

platelets--a review of the current literature.

QUESTIONS

1. Nurse Fidz is going to administer an IVF to a patient experiencing hemorrhage. What appropriate IVF should he administer?

a.) Lactated Ringer’s solutionb.)D50Wc.) 0.33% NaCld.)D5IMB

2. Which of the following is not a management for patients with massive bleeding?

a.) Apply pressure directly to the wound.b.) Have the injured lie down and cover the

person.c.) Apply tourniquet proximal to the wound for 30

min.d.) Administer isotonic solution as prescribed.

3. Patient is rushed to the Hospital because of trajectory gunshot wound. Within the resuscitation area he is indicated for X-ray examination and revealed massive hemothorax. What is the appropriate intervention?

a.) Chest drain insertionb.) Insertion of balloon catheter for

angiographyc.) Administer coagulants

ReferencesBrunner and Suddarth’s

Medical Surgical Nursing volume 2

Nurse’s Pocket Guidewww.ncbi.nlm.nih.govwww.wikipedia.com

Thank You!!