What are the Causes of Bleeding?
Bleeding is the release of blood from the blood vessels into a body cavity or space. Blood that comes out of the skin and other tissues can be called external bleeding. Bleeding that occurs inside the body is called internal bleeding and includes bleeding into such spaces as:
Blood may also build up under pressure and cause swelling (such as a hematoma). External or internal bleeding may occur after an injury to those areas, but not always.
A number of diseases and conditions can cause abnormal or excessive bleeding including type 2 diabetes, liver disease, hemophilia, heart attack, disseminated intravascular coagulation (DIC), and anticoagulant use among others. The most common causes include bruising due to minor trauma, menstruation, nosebleeds, and bleeding disorders.
What are the types of bleeding?
There are three main types of bleeding:
1. Non-arterial & arterial both- Referred as either active or passive
2. Venous – Arterial
3. Capillary – Venous All blood begins as venous blood since it is oxygen-poor and rich in waste products.
It travels to the heart through a network of veins that leads from the various parts of the body into larger superior vena cava veins at the top end around where your heart is.
It then enters your heart chambers via the pulmonary vein which brings deoxygenated blood from our body back to our hearts and enter the right atrium (the upper chamber) to mix with the oxygenated blood from the lungs, and then enters the right ventricle, which pumps it out via pulmonary artery to reach your lungs. So this is how our blood moves from all around our body through veins into the heart and finally to the lungs for the next round of oxygenation.
Your heart chambers on both sides consist of two chambers; the left atrium where deoxygenated venous blood first enters, and the left ventricle, where it is pumped out (this time fully oxygenated) on its way back to the whole body through aorta arteries (arteries carry blood away from the heart), which has many branches that fill up every organ in your body. This is why you can live even with only one functioning heart ventricle.
So this is how your blood moves from your heart chambers into your arteries and back to the heart again. Now, after the oxygenated blood has been sent out of our bodies through the aorta, it follows major arteries up away from our hearts in every direction you can think of—to supply organs and muscles with oxygenated fresh blood.
There are smaller arteries branching off these large ones called arterioles that go to even tinier capillaries which transfer our life-giving oxygen to each cell of the body itself before the veins bring back the deoxygenated or waste-laden blood from around our cells, right where they are supposed to be, ready for them to pick up more wastes and take them back again to the heart chambers.
signs and symptoms of hemorrhage:
vomiting blood, stool that looks like tar or is a very dark colored
decreased alertness decreased responsiveness to stimulation. Difficulty waking up from sleep.
GCS score less than 5 in a child with a traumatic brain injury- need dopamine infusion and rapid sequence intubation for airway protection. If your patient is hypotensive after volume resuscitation considers giving vasopressors such as noradrenaline or norepinephrine if they are not already on one.
Do not give adrenaline (epinephrine) because there is no benefit and it may actually worsen the cardiovascular situation. Consider early and aggressive fluid resuscitation until you have thoracic and abdominal imaging performed to exclude significant intraperitoneal hemorrhage.
If there is obvious external bleeding, apply direct pressure to try and stop the bleeding ASAP. This can be done by putting your hand on the wound or applying a clean cloth over the wound and pressing it down firmly.
Pressure should not be released until emergency services arrive (at which point you might want to transfer care of the patient if possible). If this cannot be applied directly due to an open fracture, squeeze surrounding tissues as hard as you can to reduce blood flow.
For internal injuries that cause pain when compressed- consider using nonsteroidal anti-inflammatory drugs e.g ibuprofen (200mg 3 times daily) for 24 hours before the presentation (in patients > 16 years old), after 8 hours do a repeat CT scan without contrast to see if there has been any progression of bleeding.
For pain relief consider morphine as a continuous infusion (4mg/hour). Be aware that giving too much morphine can cause respiratory depression and seizures, so titrate the dose accordingly.
For all patients with major head injury presenting within 12 hours of the injury occurring you should give dexamethasone 8mg intravenously. This is because it reduces mortality and morbidity and intracranial pressure (ICP) by decreasing cerebral edema postinjury.
The drug takes about 30 minutes before it starts to take effect, so its use requires early monitoring for adverse effects such as fluid overload or hypokalemia (low potassium). Also, be aware that high doses (>1g) should not be given because it can cause adrenal suppression and cortisol deficiency.
You should also give prophylactic antibiotics as soon as possible to all patients with acute intracerebral hemorrhage or traumatic brain injury because of the risk of sepsis from contamination by mouth flora.
For a fully grown adult who presents about 12 hours after stroke onset you want high-dose aspirin (300mg) and clopidogrel if they have a stent in place, prasugrel instead if they have been on ticagrelor before the presentation, or ticlopidine if they haven’t been on either drug before.
In all cases, you want to give prophylactic anticonvulsant therapy for at least the first week. Valproic acid at a loading dose of 20mg/kg is recommended for all people with supratentorial cerebral hemorrhage and those who have had a seizure at any time after their stroke (independently of their GCS score). For those who do not fit these criteria, you still want to give valproic acid as it is also an anticonvulsant and neuroprotectant.
cervical bleeding causes:
Vomiting is a common symptom and can be caused by:
Haematemesis (vomiting blood) and melaena (black tarry stool from digested blood via the gut) are concerning for upper GI bleeding.
When this occurs, you should give tranexamic acid 1g as an intravenous bolus, then continue to give it at a dose of 1g 3 times per day until they stop bleeding or get definitive treatment.
It reduces mortality in people with major trauma by about 30%. There is no need to monitor the INR because there is no antidote to reverse its effects should problems arise. You should also avoid giving antiplatelet drugs because there is a potential risk that clots could dislodge and cause further bleeding.
The main thing to watch out for is neurological problems (e.g. cranial nerve palsies), which could indicate that the bleeding is coming from within or around the brain itself rather than outside of it in the neck.
Awareness of the signs of spinal cord compression (neurological findings in a specific order- Brown-Sequard syndrome, central cord syndrome, anterior cord syndrome) as well as other causes such as epidural hematoma can be helpful too whenever there appears to be a change in neurological function. This is because these conditions will typically result from head injuries due to trauma e.g falls, motor vehicle accidents, etc.)
In patients with acute headaches and papilledema, you should immediately give dexamethasone because it reduces the risk of vision loss.
Patients with symptoms of meningitis (especially fever and nuchal rigidity) should be given antibiotics; either benzylpenicillin or ceftriaxone.
For all adult patients with symptoms referable to the neck (e.g. odynophagia, earache/otalgia, dysphagia), consider an immediate ENT referral for endoscopy to rule out oesophageal cancer.
This usually presents as itching that is worse in well-lit areas e.g bathrooms, bedrooms, etc., accompanied by excoriations due to vigorous scratching- sometimes so much so that they form scabs. It is a neuro-dermatological condition that occurs in older people and tends to affect the third most commonly out of all dermatomes, i.e. the C8 dermatome on the lateral part of the hand or forearm.
In order to correctly diagnose it, you need to apply a strong light source when the patient has pruritus in order to increase its visibility because when viewed under normal lighting conditions it can be virtually imperceptible due to its thinness and pinpoint size (similar in appearance to freckles).
The reason behind this condition is unknown but it may be caused by calcitonin gene-related peptide (CGRP) release by peripheral sensory neurons in response to exogenous factors such as alcohol intake, drugs (e.g. beta-blockers), stress, etc. or from endogenous factors such as sweating with exertion and at night-time in bed due to pyrexia which results from a low body temperature threshold for itch sensation.