Hemorrhage

Question 1

What are the 2 types of bleeding?

Answer 1

external (revealed)
- hematemesis, epistaxis, hematuria
internal (concealed)
- hemoperitoneum, retroperitoneal hemorrhage, hemothorax

Question 2

What should be suspected in a trauma patient with a systolic blood pressure of less than 90?

Answer 2

bleeding until proven otherwise

Question 3

Pulsatile jets occur in?

Answer 3

arterial bleeding

Question 4

How to know which disrupted vessel is affected?

Answer 4

ARTERIAL VEIN CAPILLARY

• bright red - dark red - bright red
• pulsatile jets - steady flow - diffuse oozing
• bleeding proximal - more from distal - sudden cessation of bleeding during
  - terrifying if large vein is injured surgery means cardiac arrest

Question 5

When does reactionary hemorrhage occur?

Answer 5

• within 24 hours after trauma
• when pressure rises due to correct of hypovolemia or secondary to post-op pain
• insecure slipped ligation or dislodged clot

Question 6

when does secondary hemorrhage occur?

Answer 6

1 -2 weeks after trauma

precipitated by factors like infection eroding blood vessels
Pressure necrosis
Malignancy

Question 7

What are the etiologies for bleeding?

Answer 7

traumatic 
- accidental 
- surgical
- interventional procedures 
pathological
- atherosclerotic 
- inflammatory 
- neoplastic  
spontaneous
- bleeding diathesis (hemophilia)

Question 8

What are the physiological responses to hemorrhage?

Answer 8

• stopping the bleeding

- maintaining effective circulating volume

Question 9

What are the factors affecting the physiological response?

Answer 9

neural

endocrine

Question 10

What neural factors effect the physiological response to bleeding?

Answer 10

Sympathetic discharge causing:

• constriction of veins to restore functional blood volume
• constriction of arterioles to raise peripheral resistance
• increase rate and strength of cardiac contraction
• transcapillary refill improves overall circulatory volume

Question 11

Sympathetic discharge increases in proportion to what?

Answer 11

A drop is

• arterial pressure
• venous return & atrial filling pressure

Question 12

What are the endocrine factors affecting the physiological response to bleeding?

Answer 12

• catecholamines from adrenal medulla
• ACTH, cortisol, & growth hormone
• renin-angiotensin aldosterone system
• vasopressin (ADH)

Augment vasoconstriction & contribute to transcapillary refill

Question 13

The factors affecting the physiological response to hemorrhage can withstand how much of the loss of blood?

Answer 13

15% (less than 750ml)

Question 14

What lowers the patients physiological tolerance to hemorrhage?

Answer 14

Greater losses

Poor cardiovascular reserve (severe anemia)

Question 15

What are the symptoms that a hemorrhagic patient presents with?

Answer 15

• Weakness & fainting (esp when standing)

- Cold & thirsty (put a thin blanket)

Question 16

What are the signs of hemorrhage?

Answer 16

• tired & pale patient
• anxious or drowsy
• tachycardia & then progressive hypotension
• tachypnea
• hypothermia coagulopathy
• cold & clammy
• Oliguria (normal 1mL/kg/hr)

Question 17

What’s the cause of tachycardia in a hemorrhagic patient?

Answer 17

Hypotension

Pain

Question 18

What is the normal blood volume?

Answer 18

70mL/kg in ADULTS

80mL/kg in CHILDREN

Question 19

What are the signs of a patient presenting with stage I bleeding?

Answer 19

• <15% (750-999mL) loss of blood
• heart rate is normal
• blood pressure is normal
• breathing is normal
• capillary refill in normal
• bowel sounds are present
• urinary output is >30ml/hr
• metal state is normal or slightly anxious

Question 20

What are the signs of Stage II bleeding?

Answer 20

• 15 - <30% (1000-1499mL)
• tachycardia >100bpm
• orthostatic changes in BP (increase in vasoconstriction intensifies in non-critical organs)
• RR mildly increases
• > 2 seconds capillary refill: clammy skin
• hypoactive bowel sounds
• 20 - 30ml/hr
• mildly anxious or agitated

Question 21

What are the signs of Stage III bleeding?

Answer 21

• 30% - <40% (1,500 - 1999)
• tachycardia >120bpm
• markedly decreased BP (<90mmHg SBP)
• moderate tachypnea
• > 3 seconds capillary refill, pale skin
• paralytic ileus
• <20 ml/hr urinary output
• confused, agitated

Question 22

What are the signs of stage IV bleeding?

Answer 22

• > 40% (2000 - or more)
• tachycardia >140bpm
• profoundly decreased <80mmHg SBP
• marked tachypnea, respiratory collapse
• > 3 seconds, cold mottled skin
• paralytic ileus, mucosal necrosis
• anuria
• obtunded

Question 23

What is the first line of treatment in hemorrhage?

Answer 23

Arresting the bleeding

Question 24

What are the method used to stop the hemorrhage?

Answer 24

1- packing, pressure
2- position (limb elevation)
3- pressure on feeding artery
4- treat the cause

Question 25

What are the steps of management of hemorrhage?

Answer 25

``` 1- stop bleeding 2- IV line 3- blood sample 4- give IV fluids or blood 5- oxygen mask 6- keep patient warm 7- insert urinary catheter 8- general care 9- monitor treatment ```

Question 26

When should the IV line be inserted?

Answer 26

2 short peripheral canulas inserted ASAP after stopping hemorrhage to avoid venous collapse

Question 27

How frequently should a hemorrhagic patient be monitored?

Answer 27

- every 15 minutes until patient is resuscitated - half - hourly for 2 hours - four hourly

Question 28

What are the most important things to be monitored?

Answer 28

- pulse & pressure - RR - urine output (0.5-1mL/kg/hr) - skin & temperature - mental state - central venous pressure

Question 29

What are the indications of fluid therapy?

Answer 29

- rapid restoration of fluid & electrolytes in dehydration due to vomiting, diarrhea, shock (due to hemorrhage, sepsis, or burn) - total parenternal nutrition - anaphylaxis, cardiac arrest, hypoxia - post gastrointestinal surgeries - for maintenance or replacement of loss

Question 30

What are the problems that could occur in fluid therapy?

Answer 30

- needs hospitalization - fluid overload - thrombophlebitis - pyrogenic reaction - discomfort

Question 31

How much sodium is present in one liter of normal isotonic saline?

Answer 31

154 mEq

Question 32

What is Ringer’s lactate?

Answer 32

``` Most physiological fluid Crystalloid containing: 130 mEq of sodium 4 mEq/It of potassium 109 mEq/It of chloride 28 mEq/It of lactate (bicarbonate) 3 mEq of calcium ```