Chapter 2: Cardiovascular System

Section 2d: Management of Bleeding

Causes

Bleeding can be of two types, either external i.e. there has been a skin wound for whatever reason, blood escapes from it and is visible to the attendant and internal bleeding by an indirect injury for example blast injury to the lung or blunt trauma to the abdomen or a fall from a height can result in damage to the internal organs and skeleton. This will result in bleeding which is not visible but nevertheless highly significant as evident by shock (pulse more than 100, systolic BP less than 100, capillary return more than 2 seconds).

Internal bleeding may be the result of medical conditions such as an ulcer or a tumour of the bowel, which can bleed internally, or injury to internal organs. Eventually the blood will leak out either upwards by being vomited or coughed up by the patient or downwards by being passed in the motions.

Prevention

Clearly if one takes care in a hazardous environment this should minimise the risk of injuries.

Signs

External bleeding - obvious.

Internal bleeding - the damaged area will be a source of pain and the affected organ will have limited function e.g. a limb which is broken and bleeding will be sore, swollen and the subject will be unable to use it. In the case of internal bleeding in a cavity the local signs are very likely to be

1. Skull - confusion then coma note that shock unlikely unless the wound is open.
2. Chest - impaired breathing and local pain.
3. Abdomen - degree of pain is variable and the abdomen may be very tender to light touch.

The other signs of bleeding are (where the volume lost has been sufficient to derange the circulation and produce shock). The subject -

1. becomes anxious
2. becomes breathless
3. has a rapid thready pulse which is difficult to feel
4. feels pale and clammy
5. blood pressure being reduced (normal 120/80)
6. capillary return is lengthened

Management under normal/hyperbaric conditions is the same -

1. Control external bleeding by direct pressure followed by securing an appropriate bandage. In the case of a limb one must take care that if the pressure required to control the bleeding is sufficient to cut off the circulation to the distal (part of the limb away from the body) then the dressing must be released from time to time to allow some blood to go down the limb to ensure it's survival.
2. In the case of internal bleeding little can be done to control it but every measure should be made to treat the shock. Ideally two intravenous lines should be set up with large bore cannulae and appropriate amounts of fluid given to maintain vital signs near normality. The useful way of assessing adequate resuscitation is that the subject is able to produce normal amounts of urine. This is sometimes best assessed by passing a catheter into the bladder to measure urine output. Normal urinary output is 75-150ml/hour for a 70kg subject.