Bleeding into the internal organs of the cavity and tissue. Bleeding. Rectal fissures

A) ANATOMICAL CLASSIFICATION

Based on the type of bleeding vessel, bleeding is divided into arterial, venous, arteriovenous, capillary and parenchymal.

Arterial bleeding. Bleeding from a damaged artery. Blood flows out quickly, under pressure, often in a pulsating stream, sometimes gushing out. The blood is bright scarlet. The rate of blood loss is quite high. The volume of blood loss is determined by the diameter of the vessel and the nature of the injury (lateral, complete, etc.).

With profuse (heavy) arterial bleeding, the wound is in the projection of a large artery; the gushing blood is bright red (scarlet), beating in a strong pulsating stream. Due to high blood pressure, bleeding usually does not stop on its own. Damage to the main artery is dangerous, both due to rapidly progressing blood loss and ischemia of the tissues to which it must supply blood. The rate of blood loss is high, which often does not allow the development of compensatory mechanisms and can quickly lead to death.

Venous bleeding. Bleeding from a damaged vein. Uniform flow of dark cherry-colored blood. The rate of blood loss is less than with arterial bleeding, but with a large diameter of the damaged vein it can be very significant. Only when the damaged vein is located next to a large artery can a pulsating jet be observed due to transmission pulsation. When bleeding from the veins of the neck, you need to remember the danger of air embolism. If large veins of the upper half of the body are damaged, blood may flow out in an intermittent stream, synchronous with breathing (due to the suction action of the chest), and not with the pulse.

There are significant clinical differences in bleeding when the deep (large, main) and superficial (subcutaneous) veins are damaged. Bleeding due to damage to the main veins is no less, and sometimes even more dangerous, than arterial bleeding, since it quickly leads to a drop in pressure at the mouth of the vena cava, which is accompanied by a decrease in the strength of heart contractions. Such bleeding can lead to air embolism, which especially often develops with damage to the veins of the neck or intraoperative damage to the vena cava. Veins, unlike arteries, have an underdeveloped muscular layer, and the rate of blood loss is almost not reduced due to vessel spasm.

Bleeding from damaged saphenous veins is usually less dangerous, since the rate of blood loss is much lower and there is virtually no risk of air embolism.

Capillary bleeding. Bleeding from capillaries, in which blood oozes evenly from the entire surface of damaged tissue. This bleeding is caused by damage to capillaries and other microvessels. In this case, as a rule, the entire wound surface bleeds, which, after drying, becomes covered with blood again. Such bleeding is observed when any vascularized tissue is damaged (only a few tissues do not have their own vessels: cartilage, cornea, dura mater). Capillary bleeding usually stops on its own.

Capillary bleeding is of clinical significance when there is a large area of ​​the wound surface, disorders of the blood coagulation system and damage to well-supplied tissues.

Arteriovenous bleeding. In the presence of simultaneous arterial and venous bleeding. Particularly common is combined damage to an artery and vein located nearby, as part of one neurovascular bundle. The clinical picture consists of a combination of symptoms of various types of bleeding, and, at the first aid stage, it is not always possible to reliably determine the source and nature of the bleeding.

Parenchymal bleeding. Bleeding from the parenchyma of any internal organ. It is observed when parenchymal organs are damaged: liver, spleen, kidneys, lungs, pancreas. Such bleeding usually does not stop on its own. Since the listed organs mainly consist of parenchyma, they are called parenchymatous. Bleeding when damaged is called parenchymal .

B) ACCORDING TO THE MECHANISM OF APPEARANCE

Depending on the reason that led to the release of blood from the vascular bed, two types of bleeding are distinguished:

Physiological bleeding among women.

Pathological bleeding- other.

According to their origin, pathological bleeding is divided into

- traumatic caused by mechanical damage to the vascular wall (including during surgery), and

- non-traumatic associated with pathological changes in the vascular system (with neoplasms, inflammation, increased permeability of the vascular wall, damage by ionizing radiation, etc.).

Causes of bleeding may be different:

mechanical damage to the vessel wall : injury to a vessel with an open injury or rupture of a vessel with a closed injury;

destruction (destruction) of the vessel wall during a pathological process : ulceration of atherosclerotic plaque, destructive process in tissues (focus of purulent inflammation, stomach ulcer, disintegrating tumor);

increased permeability of the vascular wall (for intoxication of the body, sepsis, vitamin deficiency C), leading to blood leaking through the walls of blood vessels.

Blood clotting disorder ( with hemophilia, thrombocytopenia, disseminated intravascular coagulation, overdose of anticoagulants, cholemia) in itself is not the cause of bleeding. But, it prevents the bleeding from stopping and contributes to the development of prolonged bleeding and massive blood loss.

Read more about the causes of bleeding

Traumatic bleeding - bleeding caused by a violation of the integrity of blood vessels due to injury (wound, rupture of the vessel wall or heart), includingsurgical bleeding (during surgery).

These lesions (injuries) may be open, in which blood flows out through the wound channel, or closed. For example, with closed fractures, blood vessels may be ruptured by bone fragments. Also, traumatic ruptures of internal organs, muscles and other anatomical formations lead to the development of internal bleeding in closed injuries.

Closed vascular injuries pose a great danger, since difficulties in recognizing them often lead to diagnostic errors and untimely provision of assistance. In this case, hemorrhages in the body cavity, as well as retroperitoneal and intermuscular hematomas can be very significant in terms of blood loss, leading to severe acute hypovolemia and hemorrhagic shock.

Non-traumatic bleeding – these are bleedings caused by pathological changes in the walls of blood vessels or the heart.

According to the mechanism of occurrence, they distinguish

- bleeding from rupture(haemorrhagia per rhexin),

- bleeding from corrosion(haemorrhagia per diabrosin - arrosive bleeding,

- bleeding from leakage(haemorrhagia per diapedesin) with increased permeability of the vascular wall.

Rupture of a pathologically altered wall of a vessel or heart.

With an aneurysm of a vessel or heart, hemorrhoids, varicose veins, myocardial infarction, sclerotic changes in the arteries, tubal ectopic pregnancy, etc. Rupture of the wall of a vessel or heart is promoted by an increase in blood pressure.

In this regard, we can separately highlight vicarious hemorrhage– bleeding from small vessels of the mucous membrane of the nasal walls, caused by excess blood pressure, for example during a hypertensive crisis. Or bleeding from secondary hemorrhoids caused by increased pressure in the portal vein (portal hypertension), most often with cirrhosis of the liver.

Corrosion (arrosion) of the vessel wall .

- bleeding through a defect in the vascular wall formed as a result of a pathological process (purulent-necrotic, tumor, etc.).

Arrosive (arrosive) bleeding arises

When the vascular wall is corroded (destructed) (when the vascular wall grows with a malignant tumor and disintegrates - destruction of the tumor;

With necrosis, including ulcerative process;

With caseous necrosis in the wall of the tuberculous cavity;

In case of destructive inflammation, including purulent inflammation, when melting of the vessel wall at the source of inflammation may occur;

With enzymatic melting of the vascular wall with pancreatic juice containing proteases, lipases, amylases in pancreatic necrosis, etc.).

Increased permeability of microvascular walls.

Diapedetic hemorrhage ( due to increased permeability of vessel walls) occurs as a result of blood leakage from microvessels (arterioles, capillaries and venules). An increase in the permeability of the vascular wall is observed in hemorrhagic diathesis, including systemic vasculitis, vitamin deficiency (especially vitamin deficiency C), uremia, sepsis, scarlet fever, other infectious and infectious-allergic diseases, as well as benzene and phosphorus poisoning.

The state of the blood coagulation system plays a certain role in the development of bleeding. Violation of the thrombus formation process in itself does not lead to bleeding and is not its cause, but it significantly aggravates the situation. Damage to a small vein, for example, usually does not lead to visible bleeding, since the system of spontaneous hemostasis is triggered, but if the state of the coagulation system is impaired, then any, even the most minor injury can lead to fatal bleeding. The most well-known diseases affecting the blood clotting process are hemophilia and Werlhof's disease. Disseminated intravascular coagulation syndrome and cholemia also lead to decreased blood clotting. Often there are decreases in blood coagulation of medicinal origin, which occur when using indirect anticoagulants that disrupt the synthesis of blood coagulation factors VII, IX, X in the liver; direct anticoagulants (for example, heparin); thrombolytic drugs (for example, streptase, streptokinase, urokinase, streptolyase, etc.), as well as non-steroidal anti-inflammatory drugs (for example, acetylsalicylic acid, butadione, etc.), which disrupt platelet function.

BleedingAndness- tendency to prolonged, low-intensity bleeding; observed when there is a violation of the blood coagulation mechanism and (or) an increase in the permeability of the vascular wall.

Hemorrhagic diathesis is a condition characterized by increased bleeding, a tendency to prolonged bleeding, which is observed with blood clotting disorders and (or) increased permeability of the vascular wall.

The Greek word diathesis means a tendency or predisposition to something, such as certain diseases or inappropriate reactions to ordinary stimuli.

C) IN RELATION TO THE EXTERNAL ENVIRONMENT

All bleeding is divided into three main types: external, internal and mixed. There are also various combinations of these types of bleeding in one patient.

I. External bleeding occurs from a wound (or from a trophic skin ulcer) directly into the external environment, outward, onto the surface of the body.

IIMixed bleeding e - this is bleeding into the lumen of a hollow organ that communicates with the external environment through the natural openings of the body. In mixed bleeding, blood first accumulates in cavities that communicate (normally) with the external environment, and then, through the natural openings of the body, is released out, unchanged or altered. A typical example is bleeding into the lumen of the gastrointestinal tract: with gastric bleeding, blood first accumulates in the stomach and is then released in the form of bloody vomiting; vomiting of “coffee grounds” is possible (hemoglobin under the influence of hydrochloric acid turns into black hydrochloric acid hematin) and ( or) bloody stools, often black (melena). In addition to bleeding into the lumen of the gastrointestinal tract, bleeding into the lumen of the tracheobronchial tree and into the urinary tract - hematuria - can be considered mixed.

1. Esophageal, gastric, intestinal bleeding (into the lumen of the esophagus, gastrointestinal tract);

2. Pulmonary hemorrhage (into the respiratory tract);

3. Bleeding in the urinary tract (hematuria); urethral bleeding (into the lumen of the urethra, which is manifested by urethrorrhagia - the release of blood from the urethra outside the act of urination); hemospermia (presence of blood in seminal fluid).

4. Uterine bleeding (metrorrhagia).

5. Nosebleeds (epistaxis).

6. Bleeding into the bile ducts (hemobilia).

Gastrointestinal, pulmonary bleeding, bleeding in the urinary tract, etc. occur obvious And hidden.

Overt bleeding manifests itself with obvious clinical signs.

Hidden (occult) bleeding determined only by special research methods.

Obvious bleeding- these are bleedings in which blood, even in a changed form, appears outside after a certain period of time, which is visible to the naked eye. For example, bloody vomiting of unchanged blood or coffee grounds; bloody stools that are red, dark, or even black (melena); hematuria in the form of bloody urine; hemoptysis or discharge of scarlet foamy blood during coughing.

Hidden bleeding - These are such small bleedings in which the naked eye (macroscopically) cannot see the blood coming out from the natural orifices of the body, since there is only a small amount of blood in the test material (feces, urine) (occult blood). It is detected only by special laboratory tests (for hidden gastrointestinal bleeding and microhematuria) and (or) instrumental (endoscopic) research methods.

III. Internal bleeding occurs inside the body:

In body cavities that do not normally communicate with the external environment,

In tissues, organs.

Internal bleeding may cause bleeding in body cavities that do not (normally) communicate with the external environment: cranial cavity, joint cavity (hemarthrosis), pleural cavity (hemothorax), abdominal cavity (hemoperitoneum), into the pericardial cavity (hemopericardium), and blood can also pour out from the vessels in the tissue, in the form of a hematoma(formed as a result of tissue separation, with the formation of a cavity filled with liquid or coagulated blood), or ashemorrhages with tissue soaking in blood (the appearance of petechiae, ecchymoses). With interstitial bleeding (hemorrhage), blood flowing from the vessels can saturate the tissues surrounding the damaged vessel. Hemorrhages into the integument of the body (skin, mucous membranes), with their soaking in blood (which leads to the formation of petechiae and ecchymoses), are also a type of internal bleeding. There are petechiae - pinpoint hemorrhages; ecchymosis (bruising, bruising) - hemorrhages into these tissues larger than petechiae. Petechiae- pinpoint, small spotty hemorrhages in the skin, as well as in the mucous or serous membranes, the size of which, on average, is from the head of a pin to the size of a pea. Ecchymoses(ancient Greek ἐκχύμωσις - “outpouring” from ἐκ- “from-” and χέω- “pour”) - more extensive hemorrhages into the skin or mucous membrane, the diameter of which usually exceeds 2 cm. Ecchymosis is also called a bruise (in everyday life), hemorrhage (in medicine) - a section of surface tissue (skin, mucous membrane) soaked in blood flowing from a damaged vessel (damaged vessels).

Hematomas usually form in denser tissues (brain tissue, liver) or are delimited by fascia (on the limbs). More loose tissues (fatty tissue, muscles), more often, are simply saturated with blood.

As the pressure in the hematoma cavity increases, the bleeding stops, but in the future the tissue delimiting the hematoma may rupture, and the bleeding recurs. This mechanism of early secondary bleeding is characteristic of subcapsular ruptures of the parenchyma of the liver and spleen (two-stage ruptures of the organ with the development of intra-abdominal bleeding).

Small hematomas may resolve over time.

Larger hematomas are usually organized, i.e. are replaced by fibrous connective tissue and turn into a scar.

If a large hematoma exists long enough, the surrounding tissue turns into a scar, and the hematoma becomes surrounded by a fibrous connective tissue capsule. This is how a pseudocyst is formed. In addition, hematomas can fester, turning into phlegmon, and, if there is a strong capsule, into abscesses.

Read more about internal bleeding.

1. Intracavitary (cavitary) bleeding , when blood flows into any large serous cavity of the body that does not normally communicate with the external environment:

A) hemorrhage with accumulation of blood in the abdominal cavity– hemoperitoneum (in case of injury or rupture of blood vessels, abdominal organs or abdominal wall);

b) hemorrhage with accumulation of blood in the pleural cavity– hemothorax;

V) hemorrhage with accumulation of blood in the pericardial cavity– hemopericardium.

G) hemorrhage with accumulation of blood in the joint cavity - hemarthrosis.

Open cavitary (intra-abdominal, intrapleural) bleeding observed when hemoperitoneum, hemothorax with bleeding from the cavity to the outside, through a penetrating wound or through drains. At the same time, the intensity of blood flow outward often does not correspond to the intensity of internal bleeding.

2. Interstitial bleeding (hemorrhage) - This is the flow of blood into the thickness of the tissue.

Interstitial (interstitial) are bleeding in which blood or saturates fabrics or accumulates in the interstitial spaces, forming a hematoma.

A) INintratissue hemorrhage with tissue penetration (hemorrhagic infiltration, hemorrhagic tissue imbibition):

Small pinpoint (petechial) hemorrhages caused by capillary hemorrhage into the thickness of the skin, mucous membrane and serous membranes - hemorrhagic petechiae;

Multiple spontaneous hemorrhages in the skin, mucous membranes of a purplish color (red color with a purple tint) - thrombocytopenic purpura;

- spotted planar hemorrhage into the thickness of the skin or mucous membrane - bruise(bruise, suffusio, ecchymosis);

Hemorrhage into the brain substance in the form of a focus of hemorrhagic softening - intracerebral hemorrhage;

Hemorrhage into the subarachnoid space of the brain or spinal cord - subarachnoid hemorrhage;

Outcome of hemorrhage may be different:

Blood resorption

Formation of a cyst at the site of hemorrhage,

Encapsulation and germination by connective tissue,

Infection and suppuration.

b) Hemat O ma (haematoma; hemato- + -oma; blood tumor) - occurs during interstitial bleeding with tissue dissection and the formation of a cavity containing liquid or coagulated blood accumulated in it.

Types of hematomas according to their localization (by location):

subcutaneous hematoma,

intermuscular hematoma,

subperiosteal hematoma,

retroperitoneal (in the retroperitoneal tissue) hematoma,

perirenal (in the perinephric tissue) hematoma,

extrapleural hematoma (between the soft tissues of the chest wall and the parietal pleura),

paraurethral hematoma (in paraurethral tissue),

mediastinal hematoma (mediastinal hematoma),

intrawound hematoma (with intrawound bleeding, a hematoma in the wound canal formed as a result of hemorrhage into the cavity of a gunshot or stab wound, without significant external bleeding from the wound),

subcapsular (subcapsular) hematoma of any parenchymal organ (spleen, kidney, liver),

intracranial hematoma (with hemorrhage into the cranial cavity),

suprathecal (epidural) hematoma (with hemorrhage between the dura mater and the bones of the skull or spine),

intrathecal (subdural) hematoma (with hemorrhage under the dura mater),

intracerebral (intracerebral) hematoma (with hemorrhage into the substance of the brain),

intraventricular hematoma (with hemorrhage into a ventricle of the brain),

hematocele (hemorrhage with accumulation of blood between the membranes of the testicle, in the tissues of the scrotum).

Blood poured into tissues and cavities provided a good breeding ground for microorganisms. Thus, any hematoma, any accumulation of blood due to internal bleeding. are predisposing factors for the development of suppuration.

Outcomes of hematomas:

Suppuration of a hematoma (formation of an abscess) during infection

Resorption of hematoma;

Organization of a hematoma (germination of the hematoma by connective tissue) with the formation of a scar;

Encapsulation of a hematoma with the formation of a pseudocyst;

Pulsatinghematoma is a hematoma formed as a result of interstitial arterial bleeding and maintaining communication with the lumen of the damaged artery.

Expanding hematoma– this is a pulsating hematoma associated with a damaged large main artery, rapidly increasing in volume and compressing surrounding tissues; in the event of compression of the collateral vessels passing through them, ischemic gangrene of the limb may occur. A false arterial aneurysm (post-traumatic or arrosive) can form from a pulsating hematoma.

Aneurysm(from the Greek aneuryno - expand) is a local (local) expansion of the lumen of a blood vessel or heart cavity due to a pathological change in their walls (usually atherosclerotic) or developmental anomalies.

True aneurysm - This is an aneurysm, the walls of which have layers inherent to this blood vessel.

Congenital aneurysm– an aneurysm resulting from an abnormal development of the vascular wall:

Arterial aneurysm,

Venous aneurysm,

Arteriovenous aneurysm, characterized by the presence of a communication between the artery and the accompanying vein.

Dissecting aneurysm(usually the aorta) is an aneurysm (of the aorta) in the form of an intrawall canal formed as a result of a tear in the inner lining of the vessel and dissection of the vessel wall with blood entering through the tear.

False aneurysm is a pathological cavity communicating with the lumen of the vessel. It is formed by the formation of a connective tissue capsule around a pulsating hematoma formed as a result of injury to the vascular wall (post-traumatic aneurysm); less often when the vessel wall is destroyed by a pathological (inflammatory or tumor) process that has spread to the vessel wall (arrosive aneurysm).

IVVarious combinations of the main types of bleeding in one patient. For example: with a chest injury, a combination of intrapleural bleeding (hemothorax) and bleeding into the respiratory tract (pulmonary hemorrhage) is possible, and if there is a chest injury, external bleeding from damaged vessels of the chest wall wound is also possible. The intensity of each of these bleedings may vary.

D) BY TIME OF APPEARANCE

According to the time of occurrence of bleeding, there are primary and secondary.

Primary bleeding caused by damage to the vessel at the time of injury. It appears immediately after damage to the vessel and continues after the damage.

Secondary bleeding They can be early (usually from several hours to 4-5 days after damage) and late (more than 4-5 days after damage).

Early secondary bleeding develop in the first hours or days after injury due to the expulsion of a blood clot from a vessel or the slipping of a ligature from a vessel (with an increase in blood pressure), as well as due to the end of a vessel spasm. Early secondary bleeding may be caused by damage to blood vessels from a bone fragment or detachment of a blood clot, due to poor transport immobilization, careless repositioning of the victim, etc. It is very important to remember the possibility of secondary early bleeding during anti-shock therapy, when the resulting increase in blood pressure can contribute to the expulsion of the blood clot by current blood.

Late secondary (or arrosive) bleeding develop several days after the injury due to the melting of the blood clot by a purulent process, arrosion (destruction) of the vessel wall in the focus of purulent inflammation. Often, late secondary bleeding is a consequence of destruction of the vessel wall as a result of prolonged pressure from a bone fragment or foreign body (bedsore), purulent melting of a blood clot, erosion of the vessel wall, or rupture of an aneurysm.

D) WITH THE CURRENT

All bleeding can be acute or chronic.

Acute bleeding the most dangerous, bleeding is observed in a short period of time. A rapid loss of 30% of the circulating blood volume (CBV) leads to acute anemia, cerebral hypoxia and can result in the death of the patient.

Chronic bleeding. With chronic bleeding, blood loss occurs slowly and gradually, in small portions, and therefore the body has time to adapt to a slight decrease in blood volume. Sometimes for many days there is a slight, sometimes periodic, bleeding. Chronic bleeding can be observed with stomach and duodenal ulcers, malignant tumors, hemorrhoids, uterine fibroids, etc.

According to the frequency of bleeding there are:

■ one-time;

repeated;

multiple.

External and internal bleeding are the same. These are weakness, dizziness with frequent fainting, thirst, pallor of the skin and (especially) mucous membranes (white lips), frequent small pulse, progressively falling and unstable blood pressure, a sharp decrease in the number of red blood cells and hemoglobin content.

Local symptoms of external bleeding have already been listed; the main ones are bleeding from the wound. Local symptoms of internal bleeding are extremely varied; their occurrence depends on the cavity into which the blood flows.

• Thus, with bleeding into the cranial cavity, the main clinical picture consists of symptoms of brain compression.
• When bleeding into the pleural cavity, signs of hemothorax occur with the whole complex of physical signs (shortness of breath, shortening of the percussion sound, weakening of breathing and vocal tremor, limited respiratory excursions) and data from auxiliary research methods (chest x-ray, puncture of the pleural cavity).
• When blood accumulates in the abdominal cavity, symptoms of peritonitis occur (pain, nausea, vomiting, muscle tension in the anterior abdominal wall, symptoms of peritoneal irritation) and dullness in the sloping areas of the abdomen. The presence of free fluid in the abdominal cavity is confirmed by ultrasound, puncture or laparocentesis.
• Due to the small volume of the cavity, bleeding into the joint is not massive, so acute anemia never occurs, threatening the patient’s life, as with other intracavitary bleeding.
• The clinical picture of an interstitial hematoma depends on its size, location, caliber of the damaged vessel and the presence of communication between it and the hematoma. Local manifestations are significant swelling, an increase in the volume of the limb, bursting tissue compaction, and pain.

A progressively growing hematoma can lead to gangrene of the limb. If this does not happen, the limb decreases somewhat in volume, but a deterioration in the trophism of the distal limb is clearly observed. During the examination, pulsation is found above the hematoma, and a systolic murmur is heard there, which indicates the formation of a false aneurysm.

Forms

There is no uniform international classification of bleeding. A “working” classification has been adopted, reflecting the most important aspects of this complex problem necessary for practical activities. The classification was proposed for clinical practice by academician B.V. Petrovsky. It includes several main positions.

• According to the anatomical and physiological principle, bleeding is divided into arterial, venous, capillary and parenchymal; they have features in the clinical picture and methods of stopping.
• With arterial bleeding, the blood is scarlet, flows out in a pulsating stream, and does not stop on its own, which quickly leads to severe acute anemia.
• With venous bleeding, the blood is dark in color and flows out more slowly the smaller the caliber of the vessel.
• Parenchymal and capillary bleeding outwardly proceed the same way; their difference from the previous ones is the absence of a visible source of bleeding, the duration and complexity of hemostasis.
• Based on clinical manifestations, bleeding is divided into external and internal (cavitary, hidden).
• With external bleeding, blood flows into the external environment.
• In internal bleeding, blood enters a body cavity or hollow organ. There is practically no hidden bleeding in injuries. It is often caused by stomach and intestinal ulcers.
• Based on the time of occurrence of bleeding, primary, secondary early and secondary late bleeding are distinguished.
• Primary ones begin immediately after injury.
• Secondary early ones occur in the first hours and days after injury as a result of the expulsion of a blood clot from a wounded vessel. The causes of these bleedings are violation of the principles of immobilization, early activation of the patient, and increased blood pressure.
• Secondary late bleeding can develop at any time after the wound has suppurated. The reason for their development is purulent melting of a blood clot or vessel wall by an inflammatory process.

Arterial bleeding

Occurs when an artery is injured: scarlet, bright red color of blood, which is ejected from the wound in a stream, in the form of a fountain. The intensity of blood loss depends on the size of the damaged vessel and the nature of the injury. Severe bleeding occurs with lateral and through wounds of arterial vessels. With transverse ruptures of blood vessels, spontaneous stopping of bleeding is often observed due to contraction of the vessel walls, screwing of the torn intima into its lumen, followed by the formation of a blood clot. Arterial bleeding is life-threatening because a large amount of blood is lost in a short period of time.

Venous bleeding

With venous bleeding, the outflowing non-oxygenated blood is dark in color, does not pulsate, flows slowly into the wound, and the peripheral end of the vessel bleeds more heavily. Injury to large veins close to the heart is dangerous not only due to heavy bleeding, but also due to air embolism: air entering the lumen of a blood vessel during breathing with impaired circulation in the pulmonary circulation, often leading to the death of the patient. Venous bleeding from medium and small vessels is less life-threatening than arterial bleeding. The slow flow of blood from the venous vessels and the vascular walls easily collapsing during compression contribute to the formation of a blood clot.

Due to the peculiarities of the vascular system (arteries and veins of the same name are located nearby), isolated damage to arteries and veins is rare, so most bleeding is of the mixed (arterial-venous) type. Such bleeding occurs when an artery and vein are simultaneously injured and is characterized by a combination of the symptoms described above.

Capillary bleeding

Occurs when mucous membranes and muscles are damaged. With capillary bleeding, the entire wound surface bleeds, blood “oozes” from damaged capillaries, the bleeding stops when a simple or slightly pressure bandage is applied.

Injuries to the liver, kidneys, and spleen are accompanied by parenchymal bleeding. The vessels of parenchymal organs are closely fused with the connective tissue stroma of the organ, which prevents their spasm; spontaneous stopping of bleeding is difficult.

External bleeding

This is an outpouring of blood onto the surface of the body from wounds, ulcers (usually from varicose veins), and rarely from skin tumors.

Based on the type of bleeding vessel, they are divided into: arterial (the blood is scarlet, flows in a stream, and when a large vessel is injured, it pulsates); venous (blood is dark in color, flows in a sluggish stream, but can be intense if large veins are damaged); capillary (sweating in the form of separate drops that merge with each other; with extensive damage to the skin, it can cause massive blood loss). In terms of time, most of the bleeding is primary. Secondary bleeding develops rarely, mainly arrosive from ulcers.

Diagnosis of external bleeding does not cause difficulties. Tactics: at the scene of the incident, reconciliation of methods for temporarily stopping bleeding, transportation to a surgical hospital for final stopping of bleeding and correction of blood loss.

Interstitial bleeding

Develop due to trauma (bruises, fractures), diseases accompanied by increased vascular permeability, or blood clotting disorders (hemophilia, Aureka syndrome with liver failure and hypovitaminosis K); ruptures of blood vessels and dissections of aneurysms. They can form superficially with localization in the skin, subcutaneous tissue and intermuscular spaces; and intraorganly (mainly in parenchymal organs) for injuries (bruises) and ruptures of aneurysms. They are divided into 2 types.

1. In cases of uniform saturation of tissues with red blood cells (imbibition), the process is called hemorrhage. Superficial hemorrhages do not cause diagnostic difficulties, since they are visible to the eye in the form of a bruise (“bruise”), which resolves on its own with gradual fading: for the first 2 days it has a purple-purple tint; until the 5-6th day - blue; until the 9-10th day - green; until the 14th day - yellow.
2. Free accumulation of liquid blood - in the subcutaneous tissue, intermuscular spaces, in loose tissues, for example, in the retroperitoneal space; tissues of parenchymal organs - called hematoma.

Superficial hematomas with accumulation of blood in the subcutaneous tissue and intermuscular spaces are formed: due to injuries (bruises, fractures, etc.) or; rarely, with ruptures of vascular aneurysms. Clinically they are accompanied by an increase in the volume of the segment, often protruding contourally above the bruise. Palpation reveals an elastic, soft, moderately painful formation, most often with a symptom of fluctuation (a feeling of liquid rolling under the hand). When an aneurysm ruptures, the pulsation of the hematoma is additionally determined, sometimes visible to the eye, and a systolic murmur is heard on auscultation. The diagnosis, as a rule, does not cause difficulties, but if in doubt, it can be confirmed by angiography.

Hematomas can fester, giving a typical picture of an abscess.

Tactics: bruises; treated on an outpatient basis by surgeons or traumatologists; for hematomas, hospitalization is advisable.

Intracavitary bleeding

Intracavitary refers to bleeding into the serous cavities. Bleeding: into the cranial cavity is defined as an intracranial hematoma; into the pleural cavity - hemothorax; into the pericardial cavity - hemopericardium; into the peritoneal cavity - hemoperitoneum; into the joint cavity - hemarthrosis. Bleeding in the cavity is not only a syndrome that complicates the course of the main pathological process, often injury, but also the main obvious manifestation of injury or rupture of a parenchymal organ.

Intracranial hematomas are formed mainly due to traumatic brain injury, less often - when a vascular aneurysm ruptures (more often in boys aged 12-14 years during physical activity). They are accompanied by a rather pronounced clinical picture, but differential diagnosis is required with severe brain contusions and intracerebral hematomas, although they are often combined with meningitis.

Hemothorax can form with a closed chest injury with damage to the lung or intercostal artery, penetrating chest wounds and thoracoabdominal injuries, ruptures of vascularized lung bullae with bullous emphysema. In these cases, hemothorax is also a manifestation of damage. In its pure form (only blood accumulation), hemothorax occurs only with isolated damage to the intercostal vessels. In all cases of lung damage, a sign of a violation of its tightness is the formation of hemopneumothorax, when, along with the accumulation of blood, collapse of the lung and accumulation of air in the pleural cavity occur. Clinically accompanied by a picture of anemic, hypoxic, hypovolemic and pleural syndromes. To confirm the diagnosis, it is necessary to perform an X-ray of the lungs, puncture of the pleural cavity, and, if indicated, and if possible, thoracoscopy. Differential diagnosis is carried out with pleurisy, chylothorax, hemopleurisy, mainly according to puncture data and laboratory examination of punctate.

Hemopericardium develops with closed and penetrating chest injuries, when the action of the transmitting agent occurs in the anterior parts of the chest. The pericardium holds only 700 ml. blood, blood loss does not cause the development of acute anemia syndrome, but hemopericardium is dangerous due to cardiac tamponade.

The clinical picture is characteristic, accompanied by the rapid development of heart failure: depression of consciousness; progressive (literally minute by minute) decrease in blood pressure; an increase in tachycardia with a pronounced decrease in filling, subsequently with a transition to threadlike, until complete disappearance. At the same time, general cyanosis, acrocyanosis, cyanosis of the lips and tongue quickly increase. In the differential diagnostic plan, it is necessary to remember that such a progressive development of cardiovascular failure does not occur with any cardiac pathology, even with myocardial infarction - either cardiac arrest occurs immediately, or there is a slow progression. With percussion, but it is difficult to carry out in extreme situations, an expansion of the boundaries of the heart and cardiovascular bundle is revealed. Auscultation: against the background of sharply weakened heart sounds, in the first minutes you can hear the sound of splashing; Subsequently, extremely muffled tones are noted, and more often the symptom of “fluttering”. It is necessary to differentiate with pericarditis. In all cases, the complex must begin with a puncture of the pericardium, an ECG, and after unloading the pericardium, radiography and other studies must be performed;

Hemoperitoneum develops with closed and penetrating abdominal trauma, perforation of hollow organs, ovarian apoplexy and ectopic pregnancy due to rupture of the fallopian tubes. Considering that the peritoneal cavity holds up to 10 liters of fluid, hemoperitoneum is accompanied by the development of acute anemia syndrome.

If the stomach, liver, or intestines are damaged, the contents of which are a powerful irritant to the peritoneum, the clinical picture of peritonitis immediately develops. With “pure” hemoperitoneum, the picture is smoothed out, since the blood does not cause severe irritation of the peritoneum. The patient is bothered by moderate pain in the abdomen, which decreases in a sitting position (the “stand-up” symptom), as blood flows from the solar plexus into the small pelvis and the irritation is relieved; weakness and dizziness - due to; blood loss; bloating - due to lack of peristalsis. On examination: the patient is pale, often with an earthy complexion to the face; lethargic and indifferent - due to the development of hemorrhagic shock; on palpation - the abdomen is soft, moderately painful, symptoms of peritoneal irritation are not pronounced; percussion, only with large volumes of hemoperitoneum - dullness in the flanks, in other cases - tympanitis, due to intestinal bloating.

Hemarthrosis is bleeding into the joint cavity, which develops mainly due to injuries. The knee joints that bear the maximum physical load and have increased vascularity are more often affected. Other joints rarely develop hemarthrosis and do not have such a clear clinical picture.

Intraorgan hemorrhages are effusions of blood in the cavities of hollow organs. In terms of frequency, they are in second place - after external bleeding. All of them are dangerous not only in terms of blood loss, but also in terms of dysfunction of internal organs. They are difficult to diagnose, provide first aid, and choose a method of treating the underlying pathology that caused the bleeding.

Pulmonary hemorrhage

The causes of pulmonary hemorrhage are varied: atrophic bronchitis, tuberculosis, abscesses and gangrene of the lungs, bronchial polyps, malformations, lung tumors, infarction-pneumonia, etc. This type of bleeding belongs to the most dangerous categories, not because of blood loss, but because , which causes the development of acute respiratory failure, since it causes either hemoaspiration (inhalation of blood into the alveoli with their blockage), or atelectasis of the lung, when it is completely filled with blood.

Blood is released when coughing: foamy, scarlet in color (for alveolar tumors and infarction pneumonia - pink).

The patient may swallow this blood and develop reflexive vomiting in the form of “coffee grounds.” Sputum should be collected in measuring jars. The intensity of bleeding is judged by the quantity; in addition, the sputum is sent for laboratory testing. When blood is released up to 200 ml per day, the process is called hemoptysis; when bleeding up to 500 ml per day is defined as intense bleeding; with a larger amount - as profuse bleeding. .

The diagnosis is confirmed not only by the clinic: hemoptysis, acute respiratory failure syndrome, cacophony during auscultation of the lungs. But also radiographically, hemoaspiration is manifested by many small darkenings in the lungs in the form of a “money blizzard”, atelectasis is a homogeneous darkening of the lung - the entire or lower lobes, with a displacement of the mediastinum: darkening to the side (with darkening due to effusion into the pleural cavity, the mediastinum shifts to the opposite side ); with infarction-pneumonia - triangular darkening of the lung with the apex towards the root. Bronchoscopy with a tube endoscope is absolutely indicated.

Such a patient should be hospitalized: if there is an indication of a tuberculosis process - to the surgical department of an anti-tuberculosis dispensary; in the absence of tuberculosis - to the thoracic surgery departments; for tumors of the lungs and bronchi - go to the oncology dispensary to the thoracic department.

Gastrointestinal bleeding

They develop with stomach and duodenal ulcers, colitis, tumors, mucosal fissures (Mallory-Weiss syndrome), atrophic and erosive gastritis (especially after consuming surrogate drinks).

To diagnose and determine the intensity of this type of bleeding, 2 main symptoms are important: vomiting and changes in stool. For mild bleeding: vomiting in the form of “coffee grounds”, formed, black stools; colors. In case of severe bleeding: vomiting in the form of blood clots; loose, black stools (melena). In case of profuse bleeding: vomiting of uncoagulated blood; or no stool, or mucus in the form of “raspberry jelly” is released. Even if there is suspicion, emergency FGS is indicated. X-ray of the stomach is not performed in the acute period.

Esophageal bleeding occurs from varicose veins of the esophagus with portal hypertension caused by liver failure in cirrhosis, hepatitis, and liver tumors. The clinical picture of the bleeding itself resembles gastrointestinal bleeding. But the patient’s appearance is characteristic of liver failure: the skin is sallow in color, often jaundiced, the face is puffy, there is a capillary network on the cheekbones, the nose is gray, dilated and tortuous veins are visible on the chest and torso; the abdomen may be enlarged due to ascites; On palpation, the liver is often sharply enlarged, dense, painful, but there may also be atrophy. In all cases, these patients have right-sided ventricular failure with hypertension of the pulmonary circulation: shortness of breath, pressure instability, arrhythmias - up to the development of pulmonary edema. Emergency FGS is indicated for diagnosis and differential diagnosis.

Intestinal bleeding - from the rectum and colon can most often result in hemorrhoids and rectal fissures; less often - polyps and tumors of the rectum and colon; even less common is nonspecific ulcerative colitis (UC). Bleeding from the upper parts of the colon is accompanied by loose, bloody stools in the form of blood clots or melena. Rectal bleeding is associated with hard stools, with bleeding from tumors or polyps beginning before stool, and bleeding from hemorrhoids and rectal fissures occurring after stool. They are venous, not abundant, and easily stop on their own.

For differential diagnosis, an external examination of the anal ring, a digital examination of the rectum, examination of the rectum using a rectal speculum, sigmoidoscopy, and colonoscopy are performed. The integrated use of these research methods makes it possible to make an accurate topical diagnosis. X-ray methods. Investigations (irrigoscopy) are used only if cancer is suspected. When bleeding from the large and sigmoid intestines, colonoscopy has the greatest diagnostic effect, during which it is possible not only to carefully examine the mucous membrane, but also to coagulate the bleeding vessel - to perform electrical resection of the bleeding polyp.

Postoperative bleeding

As a rule, they are secondary early. Bleeding from postoperative wounds occurs when a blood clot is pushed out of the wound vessels. The procedure begins with applying an ice pack to the wound. If bleeding continues, the edges of the wound are separated and hemostasis is carried out: by ligating the vessel, suturing the vessel with tissue, or diathermocoagulation.

To control the possibility of the development of intrastriatal bleeding, tubular drainages are introduced into the abdominal and pleural cavities after surgery, which are connected to various types of vacuum aspirators: directly connected to drainages (“pears”) or through Bobrov’s cups. Normally, up to 100 ml of blood is released through drainages in the first 2 days. When bleeding occurs, a large flow of blood begins through the drains. It may be due to two reasons.

Afibrinogenic bleeding

They develop with high consumption of blood fibrinogen, which happens during long-term, more than two hours, operations on the abdominal and thoracic organs, massive blood loss with the development of disseminated intravascular coagulation syndrome. A distinctive feature of these bleedings are: early periods of occurrence after surgery (almost immediately, although the surgeon is confident in the hemostasis performed); it is slow and does not respond to hemostatic therapy. Confirmed by testing blood fibrinogen levels. Blood fibrinogen can be restored, and, consequently, bleeding can be stopped, by transfusion of donor fibrinogen (but it is very scarce). This can be done by reinfusion with your own blood pouring into the cavities. It is collected in a sterile Bobrov jar without preservative, filtered and reinfused. Fibrinogen in the blood is restored on its own in 2-3 days.

Obvious early secondary bleeding develops when the ligature slips off the vessel due to a defect in its application. A distinctive feature is the sudden and massive flow of blood through the drains with a sharp deterioration in the patient’s condition. To stop such bleeding, despite the serious condition of the patient, an emergency reoperation (relaparotomy or rethoracotomy) is performed.

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Treatment of bleeding

A distinction is made between spontaneous and artificial stopping of bleeding. Spontaneous arrest occurs when small-caliber vessels are damaged due to their spasm and thrombosis. Trauma to larger vessels requires the use of therapeutic measures; in these cases, stopping bleeding is divided into temporary and final.

Temporary stopping of bleeding does not always live up to its name, since measures taken for it when wounding medium-sized vessels, especially venous ones, often lead to a final stop. Measures to temporarily stop bleeding include an elevated position of the limb, a pressure bandage, maximum flexion of the joint, digital pressure on the vessel, application of a tourniquet, application of a clamp to the vessel and leaving it in the wound.

The most common procedure in physical therapy to stop bleeding is application of cold.

This action involves applying a compress - a bag containing ice - to the affected area so that the blood vessels in the skin narrow, as well as in the internal organs in the area. As a result, the following processes occur:

1. The vessels of the skin reflexively constrict, as a result of which its temperature decreases, it turns pale, heat transfer decreases and blood is redistributed to the internal organs.
2. The blood vessels in the skin dilate reflexively: the skin becomes pinkish-red and warm to the touch.
3. Expansion of capillaries and venules, arterioles - narrow; the speed of blood flow decreases; the skin becomes purplish-red and cold. After this, the vessels narrow, then a regional decrease in bleeding occurs, metabolism slows down, and oxygen consumption decreases.

Goals of the cold procedure:

• Reduce the inflammatory process.
• Reduce (limit) traumatic swelling.
• Stop (or slow down) bleeding.
• Anesthetize the affected area.

A pressure bandage is applied as follows. The injured limb is raised. A sterile cotton-gauze roll is applied to the wound and bandaged tightly. The elevated position of the limb is maintained. The combination of these two techniques can successfully stop venous bleeding.

If the blood vessels in the elbow or popliteal fossa are damaged, bleeding can be temporarily stopped by maximally bending the joint, securing this position with a soft tissue bandage.

If the main arteries are damaged, bleeding can be stopped briefly by pressing the vessel with fingers to the underlying bones. This stop of bleeding (due to the rapid onset of fatigue in the hands of the person providing assistance) can only last for a few minutes, so you need to apply a tourniquet as soon as possible.

The rules for applying a tourniquet are as follows. The wounded limb is raised and wrapped in a towel above the wound, onto which a tourniquet is applied. The latter can be standard (Esmarch rubber band) or improvised (a piece of thin rubber hose, belt, rope, etc.). If the tourniquet is rubber, it must be stretched strongly before application. With a correctly applied tourniquet, the disappearance of the pulse in the distal limb is noted. Considering that the duration of the tourniquet on the limb is no more than 2 hours, it is necessary to note the time of its application, write it down on paper and attach it to the tourniquet. The patient must be transported to a medical facility accompanied by a medical professional. The final stop of bleeding can be accomplished in various ways: mechanical, thermal, chemical and biological.

Mechanical methods of finally stopping bleeding include tamponade, ligation of a vessel in the wound or along it, and vascular suture. Hemostasis with a gauze swab is used for capillary and parenchymal bleeding, when it is not possible to use other methods. After thrombosis of blood vessels (after 48 hours), it is advisable to remove the tampon to avoid the development of infection. Ligation of a vessel in a wound must be performed under visual control. The bleeding vessel is grabbed with a hemostatic clamp, tied at the base with one knot, the clamp is removed and a second knot is tied. Sometimes the source of bleeding is hidden by a powerful muscle mass, for example, in the gluteal region; searching for it is fraught with additional significant injury. In such cases, the vessel is ligated along its length (internal iliac artery). Similar interventions are performed for late secondary bleeding from a purulent wound. A vascular suture is applied when suturing the ends of a transected vessel or when its crushed area is replaced with a graft or endoprosthesis. A hand stitch is used with silk threads or it is performed using special devices that fasten the ends of the torn vessel with tantalum clips.

Thermal methods include the effect of low and high temperatures on bleeding vessels. Most often, to prevent the formation of intermuscular hematomas and hemarthrosis, cutaneous exposure to cold in the form of ice packs, irrigation with chlorethyl, cold lotions, etc. is used. Capillary and parenchymal bleeding are effectively stopped by applying a lotion with a hot 0.9% sodium chloride solution. Good hemostasis for bleeding from small and medium-sized vessels is provided by electrocoagulation using diathermy.

Chemical methods of stopping bleeding include the use of vasoconstrictors and blood clotting agents, used both locally and intravenously. The most commonly used are lotions and wound irrigation with solutions of hydrogen peroxide, 0.1% solution of epinephrine, calcium and sodium chlorides. A 10% solution of calcium chloride, a 5% solution of ascorbic acid, a 4% solution of aminocaproic acid, etc. is administered intravenously.

Biological methods of stopping are used mainly for capillary and parenchymal bleeding. The cause of such bleeding is surgical interventions associated with the separation of extensive adhesive conglomerates and damage to parenchymal organs (liver, kidneys). All methods of biological control of bleeding can be divided into the following groups:

• tamponade of a bleeding wound with autologous tissues rich in thrombokinase (omentum, muscle, fatty tissue, fascia); tamponade is performed with a free piece of omentum, muscle, or a pedunculated graft sutured to the edges of the wounds;
• transfusion of small doses (100-200 ml) of red blood cells, plasma;
• introduction of menadione sodium bisulfite and 5% ascorbic acid solution;
• local application of blood derivatives (fibrin film, hemostatic sponge, etc.): they are injected into the wound and left there after it is sutured.

In acute anemia, there is a need to determine the volume of blood loss. Roughly, it can be determined in the following ways.

According to the clinical picture.

• There are no hemodynamic disturbances - the amount of blood loss is up to 10% of the bcc (circulating blood volume).
• Pale skin, weakness, heart rate up to 100 per minute, blood pressure reduced to 100 mm Hg. - the amount of blood loss is up to 20% of the bcc.
• Severe pallor of the skin, cold sweat, adynamia, heart rate up to 120 per minute, blood pressure less than 100 mm Hg, oliguria - blood loss up to 30% of the bcc.
• Disorder of consciousness, heart rate up to 140 per minute, blood pressure less than critical, anuria - the amount of blood loss is more than 30% of the bcc.
• For fractures of the tibia, the volume of blood loss is usually 0.5-1 l, hip - 0.5-2.5 l, pelvis - 0.8-3 l.

It is possible to reliably determine the amount of blood loss only with the help of laboratory tests (using tables or nomograms that take into account the value of blood pressure, blood volume, hematocrit, specific gravity of blood, etc.)

Acute blood loss should be compensated immediately, and if the hemoglobin level is 100 g/l and the hematocrit is 30%, blood transfusion is indicated.

- This is the outpouring of blood into the external environment, natural body cavities, organs and tissues. The clinical significance of the pathology depends on the magnitude and rate of blood loss. Symptoms: weakness, dizziness, pallor, tachycardia, decreased blood pressure, fainting. Detection of external bleeding is not difficult, since the source is visible to the naked eye. To diagnose internal bleeding, depending on the location, various instrumental techniques can be used: puncture, laparoscopy, X-ray contrast study, endoscopy, etc. Treatment is usually surgical.

ICD-10

R58 Bleeding not elsewhere classified

General information

Bleeding is a pathological condition in which blood flows from vessels into the external environment or into internal organs, tissues and natural cavities of the body. Is a condition that requires emergency medical attention. The loss of a significant volume of blood, especially within a short time, poses an immediate threat to the patient's life and can cause death. Treatment of bleeding, depending on the cause of its occurrence, can be carried out by orthopedic traumatologists, abdominal surgeons, thoracic surgeons, neurosurgeons, urologists, hematologists and some other specialists.

Classification

Taking into account the place into which the blood flows, the following types of bleeding are distinguished:

• External bleeding - into the external environment. There is a visible source in the form of a wound, open fracture or crushed soft tissue.
• Internal bleeding - into one of the natural cavities of the body that communicates with the external environment: bladder, lung, stomach, intestines.
• Hidden bleeding– in tissues or body cavities that do not communicate with the external environment: in the interfascial space, ventricles of the brain, joint cavity, abdominal, pericardial or pleural cavities.

As a rule, in clinical practice, hidden bleeding is also called internal, however, taking into account the characteristics of pathogenesis, symptoms, diagnosis and treatment, they are separated into a separate subgroup.

Depending on the type of damaged vessel, the following types of bleeding are distinguished:

• Arterial bleeding. Occurs when the artery wall is damaged. It has a high rate of blood loss and is life-threatening. The blood is bright scarlet and flows out in a tense, pulsating stream.
• Venous bleeding. Develops when the vein wall is damaged. The rate of blood loss is lower than when an artery of similar diameter is damaged. The blood is dark, with a cherry tint, flows in an even stream, and there is usually no pulsation. If large venous trunks are damaged, pulsation in the rhythm of breathing may be observed.
• Capillary bleeding. Occurs when capillaries are damaged. Blood is released in separate drops resembling dew or condensation (symptom of “blood dew”).
• Parenchymal bleeding. Develops when parenchymal organs (spleen, liver, kidneys, lungs, pancreas), cavernous tissue and cancellous bone are damaged. Due to the structural features of these organs and tissues, damaged vessels are not compressed by the surrounding tissue and do not contract, which causes significant difficulties in stopping bleeding.
• Mixed bleeding. Occurs when veins and arteries are simultaneously damaged. The cause, as a rule, is injury to parenchymal organs that have a developed arterial-venous network.

Depending on the severity, bleeding can be:

• Lungs (loss of no more than 500 ml of blood or 10-15% of blood volume).
• Average (loss of 500-1000 ml or 16-20% of bcc).
• Severe (loss of 1-1.5 liters or 21-30% of bcc).
• Massive (loss of more than 1.5 liters or more than 30% of the bcc).
• Fatal (loss of 2.5-3 liters or 50-60% of blood volume).
• Absolutely fatal (loss of 3-3.5 liters or more than 60% of the blood volume).

Taking into account the origin, traumatic bleeding is distinguished, which develops as a result of injury to unchanged organs and tissues, and pathological bleeding, which occurs as a result of a pathological process in any organ or is a consequence of increased permeability of the vascular wall.

Depending on the time of occurrence, specialists in the field of traumatology and orthopedics distinguish between primary, early secondary and late secondary bleeding. Primary bleeding develops immediately after injury, early secondary bleeding occurs during or after surgery (for example, as a result of a ligature slipping from the wall of a vessel), and late secondary bleeding occurs after several days or weeks. The cause of late secondary bleeding is suppuration followed by melting of the vessel wall.

Symptoms of bleeding

Common signs of pathology include dizziness, weakness, shortness of breath, extreme thirst, pale skin and mucous membranes, decreased blood pressure, increased heart rate (tachycardia), pre-syncope and fainting. The severity and rate of development of these symptoms is determined by the rate of bleeding. Acute blood loss is more difficult to tolerate than chronic blood loss, since in the latter case the body has time to partially “adapt” to the changes taking place.

Local changes depend on the characteristics of the injury or pathological process and the type of bleeding. With external bleeding, there is a violation of the integrity of the skin. When bleeding from the stomach occurs, melena (tarry black loose stools) and vomiting of altered dark blood occurs. With esophageal bleeding, bloody vomiting is also possible, but the blood is brighter, red, rather than dark. Bleeding from the intestines is accompanied by melena, but the characteristic dark vomiting is absent. If the lung is damaged, bright scarlet, light foaming blood is coughed up. Bleeding from the renal pelvis or bladder is characterized by hematuria.

Hidden bleeding is the most dangerous and most difficult to diagnose; they can only be identified by indirect signs. At the same time, the blood accumulating in the cavities compresses the internal organs, disrupting their functioning, which in some cases can cause the development of dangerous complications and death of the patient. Hemothorax is accompanied by difficulty breathing, shortness of breath and weakening of percussion sound in the lower parts of the chest (with adhesions in the pleural cavity, dullness in the upper or middle parts is possible). With hemopericardium, due to compression of the myocardium, cardiac activity is disrupted, and cardiac arrest is possible. Bleeding into the abdominal cavity is manifested by bloating of the abdomen and dullness of percussion sound in its sloping sections. When bleeding into the cranial cavity, neurological disorders occur.

The flow of blood beyond the vascular bed has a pronounced negative effect on the entire body. Due to bleeding, the blood volume decreases. As a result, cardiac activity deteriorates, organs and tissues receive less oxygen. With prolonged or extensive blood loss, anemia develops. The loss of a significant volume of bcc over a short period of time causes traumatic and hypovolemic shock. Shock lung develops, the volume of renal filtration decreases, and oliguria or anuria occurs. Foci of necrosis form in the liver, and parenchymal jaundice is possible.

Types of bleeding

Bleeding from wounds

First aid consists of anesthesia and immobilization with a splint. For open fractures, apply a sterile bandage to the wound. The patient is taken to the emergency room or trauma department. To clarify the diagnosis, radiography of the damaged segment is prescribed. For open fractures, PSO is performed; otherwise, treatment tactics depend on the type and location of the injury. For intra-articular fractures accompanied by hemarthrosis, a joint puncture is performed. In case of traumatic shock, appropriate anti-shock measures are taken.

Bleeding from other injuries

TBI can be complicated by hidden bleeding and hematoma formation in the cranial cavity. At the same time, a fracture of the skull bones is not always observed, and patients in the first hours after the injury may feel satisfactory, which complicates the diagnosis. With closed rib fractures, damage to the pleura is sometimes observed, accompanied by internal bleeding and the formation of hemothorax. With blunt trauma to the abdominal cavity, bleeding from the damaged liver, spleen or hollow organs (stomach, intestines) is possible. Bleeding from parenchymal organs is especially dangerous due to the massive blood loss. Such injuries are characterized by the rapid development of shock; without immediate qualified assistance, death usually occurs.

In case of injuries to the lumbar region, a bruise or rupture of the kidney is possible. In the first case, the blood loss is insignificant; bleeding is evidenced by the appearance of blood in the urine; in the second case, there is a picture of rapidly increasing blood loss, accompanied by pain in the lumbar region. With bruises in the lower abdomen, rupture of the urethra and bladder may occur.

First aid for all internal bleeding of a traumatic nature consists of pain relief, ensuring rest and immediate delivery of the patient to a specialized medical facility. institution. The patient is placed in a horizontal position with legs elevated. Apply cold (a bubble or heating pad with ice or cold water) to the area of ​​suspected bleeding. If esophageal or gastric bleeding is suspected, the patient is not allowed to eat or drink.

At the prehospital stage, if possible, anti-shock measures are carried out and blood volume is replenished. Upon admission to medical school. the institution continues infusion therapy. The list of diagnostic measures depends on the nature of the injury. In case of TBI, a consultation with a neurosurgeon, skull X-ray and EchoEG are prescribed, in case of hemothorax - chest X-ray, in case of

Virginity... The cause of so many worries and troubles was this small fold of the mucous membrane, even for modern girls, devoid of prejudices...

Bleeding after the first sex and pain in different girls can be strong, weak or practically absent. The amount and nature of blood lost during defloration is associated with the individual characteristics of the structure of the hymen. Since at the age of 20-22 years a restructuring of the connective tissue base of the hymen occurs with a subsequent decrease in the number of elastic fibers, defloration after a girl reaches 22-25 years of age is always more painful, accompanied by greater hemorrhages and takes longer to heal. Thus, from this point of view, the most favorable age for defloration is 16-19 years.

Thus, a rupture of an ordinary, thin hymen is accompanied by slight bleeding for several hours and moderate discomfort. The tensile hymen can expand to the diameter of the penis, tightly covering it and remain intact. Loss of virginity with a thick (fleshy) or rigid hymen is usually accompanied by heavy bleeding (up to heavy bleeding over the next 3-7 days) and severe pain. Hemorrhages in this case are also observed immediately and continue over a longer period of time.

To learn more,
the influence of one or another hymen on the defloration process:

HOW LONG DOES BLOOD BLEED AFTER THE FIRST TIME?

Below is a description of the condition in case of violation of the average hymen, which does not have any anatomical and physiological features. This description cannot be transferred to a specific person. To do this, you need to undergo an examination by a specialist.

In the first two days, the hemorrhage has a rich dark red, red-violet, red-blue color, and is often located along the entire circumference of the hymen or is localized only near the ruptures. The hymen acquires traumatic swelling either all over or only at the edges of the tears. Also these days, small blood clots and traces of blood at the entrance to the vagina can be seen at the edges of the ruptures. Subsequently, on the 3-5th day, a whitish-yellowish fibrinous coating is observed at the edges of the tears. Hemorrhages in the hymen quickly fade and the edges of the tears usually heal within 1.5-2.0 weeks.

The thinner the hymen, the faster the hemorrhages disappear. By the end of the 3rd week after defloration, only traces of the former hemorrhage can occasionally be seen in the form of alternating sections of the hymen of a heterogeneous reddish tonality. The thin hymen scars and heals after defloration in just 5-7 days. Thick and fleshy ones take longer to heal - by the end of the third and even fourth week.

Any physical impact in this area during the healing period (gynecological examination with a speculum, sexual intercourse, etc.) leads to repeated injury to the hymen, bleeding of varying severity, pain, as well as inflammation of the vulva. The addition of a purulent infection increases the healing time.

DEFLORATION WITHOUT BLOOD

The man himself most often does not feel the moment of rupture of the hymen, so some of them, not seeing blood, begin to ask various questions in their thoughts or out loud. The real situation is that not all girls have a hymen. But if it does exist, then it will not necessarily rupture during the first sexual intercourse, or it is not necessary to immediately expect the appearance of blood. In some cases, the hymen may be absent from birth or lost due to careless masturbation, as well as active participation in certain sports. In this case, when deflowering, there is no blood or pain.

IS THERE A LOT OF BLOOD AT YOUR FIRST SEX?

Doctors recommend abstaining from alcohol abuse before losing virginity for the simple reason that it dilates blood vessels. As a result, there may be much more blood. If the following symptoms are present: the pain is severe and does not go away, the bleeding after defloration immediately became intense or does not stop for a day, purulent discharge from the vagina appears, discomfort when urinating, the temperature rises - you must immediately consult a gynecologist!

WHERE YOU CAN GO
WITH THESE QUESTIONS IN MOSCOW?

The only radical and guaranteed way to avoid possible bleeding during the first intimate relationship is to perform a small operation to cut the hymen. In our clinic, this is carried out under sterile conditions, absolutely painless and psychologically comfortable. If you don’t want to experiment with first sex or are afraid of possible troubles, this option is the best way out!

How to check why there is bleeding or avoid these problems during your first sex?

• Make an appointment with a specialist,
• At the reception, discuss the situation,
• Find out what you can do and how.

Bleeding (haemorrhagia) - leakage of blood from blood vessels due to damage or disruption of the permeability of their walls.

Loss of blood poses an immediate threat to the life of the victim, and his fate depends on immediate measures to stop the bleeding.

Classification of bleeding

I. Depending on the cause of occurrence:

a) mechanical damage, rupture of blood vessels (haemorrhagia per rhexin);

b) arrosive bleeding (haemorrhagia per diabrosin);

c) diapedetic bleeding (haemorrhagia per diapedesin);

d) disturbance of the chemical composition of the blood, changes in the coagulation and anticoagulation systems of the blood.

II. Taking into account the type of bleeding vessel:

a) arterial;

b) arteriovenous;

c) venous;

d) capillary;

e) parenchymal.

III. In relation to the external environment and clinical manifestations:

a) external;

b) internal;

c) hidden.

IV. By time of occurrence:

a) primary;

b) secondary.

Mechanical damage blood vessels can occur with open and closed injuries (ruptures, wounds), burns, frostbite.

Arrosive bleeding occur when the integrity of the vascular wall is violated due to tumor germination and its disintegration, when the vessel is destroyed by spreading ulceration in the case of necrosis, destructive inflammation, etc.

Diapedetic bleeding arise as a result of increased permeability of small vessels (capillaries, venules, arterioles), observed in a number of diseases: vitamin deficiency C, hemorrhagic vasculitis (Henoch-Schönlein disease), uremia, sepsis, scarlet fever, smallpox, phosphorus poisoning, etc. This condition of the vessels is due to molecular, physicochemical changes in their wall.

The possibility of bleeding is determined by the condition blood coagulation system. If blood clotting is impaired, massive blood loss is possible if even small vessels are damaged.

Diseases accompanied by disorders of the blood coagulation system include hemophilia and Werlhof's disease. At hemophilia(hereditary disease) the plasma contains defective specific coagulation factors: factor VIII (hemophilia A) or factor IX (hemophilia B). The disease is manifested by increased bleeding. The slightest injury can lead to massive bleeding that is difficult to stop. At Werlhof's disease(thrombocytopenic purpura) the content of platelets in the blood is reduced.

Severe changes in the blood coagulation system are observed when disseminated intravascular coagulation syndrome(DIC syndrome). The formation of multiple clots and thrombi in the vessels leads to the depletion of blood clotting factors, which causes a violation of its coagulation, hypocoagulation and bleeding: tissue bleeding during surgery, gastrointestinal, uterine bleeding, hemorrhages in the skin, subcutaneous tissue at the injection site, at the site of palpation . The causes of DIC can be shock, sepsis, massive traumatic injuries, multiple fractures, traumatic toxicosis (crush syndrome), massive blood transfusions, massive bleeding, etc.

Disturbances in the blood coagulation system and, as a result, bleeding can be caused by the action of certain medicinal substances. The use of indirect anticoagulants (ethyl biscoumacetate, acenocoumarol, phenindione, etc.), which disrupt the synthesis of blood clotting factors VII, IX, X in the liver, as well as sodium heparin, which has a direct effect on the process of thrombus formation, fibrinolytic drugs (streptokinase, streptodecase etc.), leads to disturbances in the blood coagulation system. Drugs such as phenylbutazone and acetylsalicylic acid can increase bleeding by impairing platelet function.

Bleeding due to blood clotting disorders includes cholemic bleeding. It has long been noted that in patients with jaundice

blood clotting is impaired and both spontaneous bleeding can occur (hemorrhages in the muscles, skin, internal organs, nosebleeds) and increased tissue bleeding during surgery and in the postoperative period. The cause of changes in the blood coagulation system is a decrease in the synthesis of coagulation factors V, VII, IX, X, XIII in the liver due to impaired absorption of vitamin K.

To increase blood clotting, transfusions of plasma, cryoprecipitate, and administration of vitamin K are used.

The nature of the bleeding is determined by the type of damaged vessel.

For arterial bleeding scarlet blood beats in a pulsating stream. The larger the vessel, the stronger the stream and the greater the volume of blood lost per unit of time.

For venous bleeding the flow of blood is constant, only when the damaged vein is located next to a large artery is transmission pulsation possible, as a result of which the blood stream will be intermittent. If large veins in the chest area are damaged, a heart impulse is transmitted to the blood stream or the suction effect of the chest is influenced (when inhaling, the bleeding slows down, when exhaling, it intensifies). Only with high venous pressure, for example, with rupture of varicose veins of the esophagus, does a jet flow of blood occur. If large veins of the neck or subclavian vein are damaged, severe complications and even death may develop due to air embolism. This occurs due to the negative pressure in these veins that occurs during inhalation and the possible entry of air through the damaged vessel wall. Venous blood is dark in color.

Capillary bleeding mixed, there is an outflow of arterial and venous blood. In this case, the entire wound surface bleeds; after removing the spilled blood, the surface becomes covered with blood again.

Parenchymal bleeding are observed when parenchymal organs are damaged: liver, spleen, kidneys, lungs, etc. They are essentially capillary, but they can be more massive, difficult to stop and more dangerous due to the anatomical features of the structure of the vessels of these organs.

For external bleeding blood is poured into the external environment.

Internal bleeding can occur both in the cavity and in the tissue. Hemorrhages in tissue occur by impregnation of the latter with blood with the formation of swelling. The size of the hemorrhage may

be different, which depends on the caliber of the damaged vessel, the duration of bleeding, and the state of the blood coagulation system. The blood poured into the tissue imbibes (impregnates) the intertissue gaps, coagulates and gradually resolves. Massive hemorrhages may be accompanied by tissue dissection with the formation of an artificial cavity filled with blood - hematomas. The resulting hematoma can resolve, or a connective tissue capsule forms around it, and the hematoma turns into a cyst. When microorganisms penetrate the hematoma, the latter suppurates. Unresolved hematomas can grow with connective tissue and become calcified.

Bleeding occupies a special place into the serous cavities- pleural, abdominal. Such bleeding is massive due to the fact that it rarely stops spontaneously. This is due to the fact that blood poured into the serous cavities loses its ability to coagulate, and the walls of these cavities do not create a mechanical obstacle to the blood pouring out of the vessels. In addition, a suction effect is created in the pleural cavities due to negative pressure. Blood clotting is impaired due to the loss of fibrin from the blood, which is deposited on the serous surface, and the process of thrombus formation is disrupted.

TO hidden include bleeding without clinical signs. As an example, clinically silent bleeding from stomach and duodenal ulcers can be cited. Such bleeding can only be detected by a laboratory method - testing stool for occult blood. Undiagnosed, long-term hidden bleeding can lead to the development of anemia.

Primarybleeding occurs immediately after damage to the vessel, secondary- after some period of time after the primary bleeding has stopped.

Factors determining the volume of blood loss and the outcome of bleeding

The cause of death due to blood loss is loss of functional properties of blood (transfer of oxygen, carbon dioxide, nutrients, metabolic products, detoxification function, etc.) and impaired blood circulation (acute vascular insufficiency - hemorrhagic shock). The outcome of bleeding is determined by a number of factors, but the decisive ones are volume and rate of blood loss: rapid blood loss of about a third of the blood volume is life-threatening, acute bleeding is absolutely fatal

loss, amounting to about half of the bcc. Under other unfavorable circumstances, the patient's death may occur with a loss of less than a third of the blood volume.

The rate and volume of blood loss depend on the nature and type of the damaged vessel. The most rapid blood loss occurs when arteries are damaged, especially large ones. When arteries are injured, marginal damage to the vessel is more dangerous than its complete transverse rupture, since in the latter case the damaged vessel contracts, the inner lining is screwed inward, the possibility of thrombus formation is greater and the likelihood of spontaneous stopping of bleeding is higher. With marginal damage, the artery does not contract - it gapes, and bleeding can continue for a long time. Naturally, in the latter case, the volume of blood loss may be higher. Arterial bleeding is more dangerous than venous, capillary or parenchymal bleeding. The volume of blood loss is also affected by disturbances in the blood coagulation and anticoagulation systems.

In the outcome of blood loss, it is important general condition of the body. Healthy people tolerate blood loss more easily. Unfavorable conditions arise with traumatic shock, previous (initial) anemia, debilitating diseases, fasting, traumatic long-term operations, cardiac failure, and disorders in the blood coagulation system.

The outcome of blood loss depends on the body's rapid adaptation to blood loss. Thus, all other things being equal, blood loss is more easily tolerated and women and donors adapt to it more quickly, since blood loss during menstruation or constant donation creates favorable conditions for compensation of various systems, primarily the cardiovascular system, for blood loss.

The body's reaction to blood loss depends on the environmental conditions in which the victim is located. Hypothermia, like overheating, negatively affects the body's adaptability to blood loss.

Factors such as age and gender of the victims, also play a role in the outcome of blood loss. As already indicated, women tolerate blood loss more easily than men. Children and the elderly have a hard time coping with blood loss. In children, this is due to the anatomical and physiological characteristics of the body. Thus, the loss of even a few milliliters of blood is dangerous for a newborn. In the elderly, due to age-related changes in the heart and blood vessels (atherosclerosis), the adaptation of the cardiovascular system to blood loss is significantly lower than in the young.

Localization of bleeding

Even with minor bleeding, there can be a danger to the life of the victim, which is determined by the role of the organ into which the hemorrhage occurred. Thus, a minor hemorrhage into the brain can be extremely dangerous due to damage to vital centers. Hemorrhages in the subdural, epidural, subarachnoid spaces of the skull, even small in volume, can lead to compression of the brain and disruption of its functions, although the volume of blood loss does not affect the state of blood circulation. Hemorrhages into the heart sac, which in themselves, given the small amount of blood loss, are not dangerous, can lead to the death of the victim due to compression and cardiac arrest due to tamponade.

ACUTE BLOOD LOSS

The danger of blood loss is associated with the development of hemorrhagic shock, the severity of which is determined by the intensity, duration of bleeding and the volume of blood lost. A rapid loss of 30% of the blood volume leads to acute anemia, cerebral hypoxia and can result in the death of the patient. With minor but prolonged bleeding, hemodynamics change little, and the patient can live even if the hemoglobin level decreases to 20 g/l. A decrease in blood volume will lead to a decrease in venous pressure and cardiac output. In response to this, the adrenal glands release catecholamines, which leads to vasospasm, resulting in a decrease in vascular capacity and thereby maintaining hemodynamics at a safe level.

Acute blood loss due to a decrease in blood volume can lead to hemorrhagic shock, the development of which is possible with blood loss equal to 20-30% of blood volume. Shock is based on disorders of central and peripheral hemodynamics due to hypovolemia. In case of severe massive blood loss as a result of hemodynamic disorder, capillary paresis occurs, blood flow decentralization occurs, and shock can progress to an irreversible stage. If arterial hypotension continues for more than 12 hours, complex therapy is ineffective and multiple organ failure occurs.

With increasing blood loss, acidosis develops, sudden disturbances occur in the microcirculatory system, and aggregation of red blood cells occurs in the capillaries. Oliguria (decreased amount of urine) initially has a reflex character; in the stage of decompensation it

turns into anuria, which develops as a result of impaired renal blood flow.

Signs of blood loss: pale and moist skin, haggard face, rapid and small pulse, increased breathing, in severe cases, Cheyne-Stokes breathing, decreased central venous pressure and blood pressure. Subjective symptoms: dizziness, dry mouth, thirst, nausea, darkening of the eyes, increasing weakness. However, if bleeding is slow, the clinical manifestations may not correspond to the amount of blood lost.

It is important to determine the amount of blood loss, which, along with stopping bleeding, is crucial for choosing treatment tactics.

The content of red blood cells, hemoglobin (Hb), hematocrit (Ht) must be determined immediately upon admission of the patient and the study must be repeated in the future. These indicators in the first hours of severe bleeding do not objectively reflect the amount of blood loss, since autohemodilution occurs later (it is maximally expressed after 1.5-2 days). The most valuable indicators are Ht and relative blood density, which reflect the relationship between the formed elements of blood and plasma. With a relative density of 1.057-1.054, Hb 65-62 g/l, Ht 40-44, blood loss is up to 500 ml, with a relative density of 1.049-1.044, Hb 53-38 g/l, Ht 30-23 - more than 1000 ml.

A decrease in central venous pressure over time indicates insufficient blood flow to the heart due to a decrease in blood volume. CVP is measured in the superior or inferior vena cava using a catheter inserted into the ulnar or greater saphenous vein of the thigh. The most informative method for determining the amount of blood loss is to determine the deficiency of bcc and its components: the volume of circulating plasma, the volume of formed elements - globular volume. The research technique is based on the introduction of a certain amount of indicators (Evans blue dye, radioisotopes, etc.) into the vascular bed. The volume of circulating plasma is determined by the concentration of the indicator diluted in the blood; Taking into account the hematocrit, the bcc and globular volume are calculated using tables. The proper indicators of blood volume and its components are found from tables that indicate the body weight and gender of the patients. Based on the difference between the expected and actual indicators, the deficit of bcc, globular volume, volume of circulating plasma, that is, the amount of blood loss, is determined.

It should be borne in mind that the amount of blood loss must be judged primarily by clinical signs, as well as by the totality of laboratory data.

Depending on the volume of blood shed and the level of decrease in BCC, they are divided into four degrees of severity of blood loss:

I - mild degree: loss of 500-700 ml of blood (decrease in blood volume by 10-15%);

II - moderate degree: loss of 1000-1500 ml of blood (decrease in blood volume

by 15-20%);

III - severe degree: loss of 1500-2000 ml of blood (decrease in blood volume

by 20-30%);

IV degree - massive blood loss: loss of more than 2000 ml of blood (decrease in blood volume by more than 30%).

Clinical signs observed during blood loss help determine its degree. With grade I blood loss, there are no pronounced clinical signs. With stage II blood loss, the pulse is up to 100 per minute, blood pressure drops to 90 mm Hg, the skin is pale, the limbs are cold to the touch. In case of severe blood loss (III degree), the patient’s restless behavior, cyanosis, pallor of the skin and visible mucous membranes, increased breathing, and “cold” sweat are noted. The pulse reaches 120 per minute, blood pressure is reduced to 70 mm Hg. The amount of urine discharge is reduced - oliguria. With massive blood loss (IV degree), the patient is inhibited, in a state of stupor, severe pallor of the skin, acrocyanosis, and anuria (cessation of urination) are noted. The pulse in the peripheral vessels is weak, thread-like or not detected at all, with a frequency of up to 130-140 per minute or more, blood pressure is reduced to 30 mm Hg. and below.

Timely start treatment can prevent the development of hemorrhagic shock, so it should be started as quickly as possible. In case of severe blood loss, they immediately begin to administer blood replacement fluids, the use of which is based on the fact that the loss of plasma and, consequently, a decrease in blood volume is tolerated by the body much more difficultly than the loss of red blood cells. Albumin, protein, dextran [cf. they say weight 50,000-70,000] are well retained in the bloodstream. If necessary, crystalloid solutions can be used, but remember that they quickly leave the vascular bed. Low molecular weight dextrans (dextran [average molecular weight 30,000-40,000]) replenish the volume of intravascular fluid, improve microcirculation and rheological properties of blood. Transfusion of blood products is necessary when the hemoglobin level decreases below 80 g/l and the hematocrit is less than 30. In case of severe acute blood loss, treatment begins with a jet infusion into one, two or three veins and only after the SBP rises above 80 mm Hg. switch to drip infusion.

To eliminate anemia, infusions of red blood cells are used; it is more advisable to administer it after the infusion of blood substitutes, as this improves capillary blood flow and reduces the deposition of blood cells.

Replenishment of blood loss

With a deficiency of bcc up to 15%, the volume of the infusion medium is 800-1000 ml (crystalloids 80% + colloids 20%) - 100% in relation to the deficiency.

With blood loss of 15-25% of the bcc, the volume of transfusion is 150% of the deficit - 1500-2300 ml, the ratio of crystalloids, colloids and plasma is 4:4:2.

With blood loss of 25-35% of the bcc, the volume of replenishment is 180-220% - 2700-4000 ml (crystalloids 30% + colloids 20%, plasma 30%, erythrocyte mass 20%).

With a deficiency of bcc of more than 35%, the volume of transfusion is 220% - 4000-6000 ml (crystalloids 20% + colloids 30%, plasma 25%, erythrocyte mass - 25%).

Blood transfusions are indicated for blood loss exceeding 35-40% of the blood volume, when both anemia and hypoproteinemia occur. Acidosis is corrected by administration of sodium bicarbonate, trometamol (see. Blood transfusion). The use of drugs that increase vascular tone (vasoconstrictors) is contraindicated until blood volume is completely restored, as they aggravate hypoxia. On the contrary, glucocorticoids improve myocardial function and reduce peripheral vasospasm. Oxygen therapy and hyperbaric oxygenation, used after bleeding has stopped, are indicated.

EXTERNAL AND INTERNAL BLEEDING

External bleeding

The main sign of a wound is external bleeding. The color of the blood can be different: scarlet - with arterial bleeding, dark cherry - with venous bleeding. Bleeding not only from the aorta, but also from the femoral or axillary artery can lead to death within a few minutes after injury. Damage to large veins can also quickly cause death. If large veins of the neck and chest are damaged, a dangerous complication such as an air embolism may occur. This complication develops as a result

air entering through a wound in a vein (into the right side of the heart, and then into the pulmonary artery) and blockage of its large or small branches.

Internal bleeding

In the event of traumatic injury or the development of a pathological process in the area of ​​the vessel, internal bleeding occurs. Recognizing such bleeding is more difficult than external bleeding. The clinical picture consists of general symptoms caused by blood loss and local signs depending on the location of the source of bleeding. In case of acutely developed anemia (for example, a disturbed ectopic pregnancy or rupture of the splenic capsule in the presence of a subcapsular hematoma), pallor of the skin and visible mucous membranes, darkening in the eyes, dizziness, thirst, drowsiness are observed, and fainting may occur. The pulse is frequent - 120-140 per minute, blood pressure is low. With slow bleeding, signs of blood loss develop gradually.

Bleeding into the lumen of hollow organs

If bleeding occurs into the lumen of hollow organs and blood flows out through natural openings, the source of such bleeding is difficult to determine. Thus, the release of blood through the mouth can be caused by bleeding from the lungs, trachea, pharynx, esophagus, stomach, duodenum. Therefore, the color and condition of the gushing blood matter: frothy scarlet blood is a sign of pulmonary hemorrhage, vomiting “coffee grounds” is a sign of gastric or duodenal hemorrhage. Black, tarry stools (melena) are a sign of bleeding from the upper gastrointestinal tract; discharge of scarlet blood from the rectum is a sign of bleeding from the sigmoid or rectum. Hematuria is a sign of bleeding from the kidney or urinary tract.

Taking into account the expected localization of bleeding, special research methods are chosen to identify its source: gastric probing and digital examination of the rectum, endoscopic methods, for example, bronchoscopy - for lung diseases, esophagogastroduodeno-, sigmoidoscopy and colonoscopy - for gastrointestinal bleeding, cystoscopy - for damage to the urinary system, etc. Ultrasound, X-ray and radioisotope research methods are of great importance, especially for determining hidden bleeding that occurs with minor

or uncharacteristic manifestations. The essence of the radioisotope method is that a radionuclide (usually a colloidal solution of gold) is injected intravenously, and together with the flowing blood it accumulates in the tissues, cavity or lumen of internal organs. An increase in radioactivity at the damaged site is detected by radiometry.

Bleeding into closed cavities

Diagnosis of bleeding into closed body cavities is more difficult: the cranial cavity, the spinal canal, the thoracic and abdominal cavities, the pericardium, and the joint cavity. These bleedings are characterized by certain signs of fluid accumulation in the cavity and general symptoms of blood loss.

Hemoperitoneum

Collection of blood in the abdominal cavity - hemoperitoneum (haemoperitoneum)- associated with injury and closed trauma to the abdomen, damage to parenchymal organs (liver, spleen), mesenteric vessels, disruption of ectopic pregnancy, rupture of the ovary, cutting or slipping of a ligature applied to the vessels of the mesentery or omentum, etc.

Against the background of blood loss, local signs are determined. The abdomen participates in breathing to a limited extent, is painful, soft, sometimes slight muscle protection is detected, and symptoms of peritoneal irritation are mild. In sloping areas of the abdomen, dullness of percussion sound is detected (with the accumulation of about 1000 ml of blood), percussion is painful, in women one can observe protrusion of the posterior vaginal fornix, which is determined during vaginal examination. Patients with suspected hemoperitoneum need strict monitoring, determining the dynamics of hemoglobin and hematocrit levels; a rapid drop in these indicators confirms the presence of bleeding. It should be remembered that with simultaneous rupture of a hollow organ, local signs of bleeding will be masked by the symptoms of developing peritonitis.

To clarify the diagnosis, puncture of the abdominal cavity using a “groping” catheter, laparoscopy, and puncture of the posterior vaginal vault are of great importance. If the diagnosis is established, an emergency operation is indicated - laparotomy with revision of the abdominal organs and stopping the bleeding.

Hemothorax

Accumulation of blood in the pleural cavity - hemothorax (haemothorax)- caused by bleeding due to trauma to the chest and lungs, including the operating room, as a complication of a number of diseases of the lungs and pleura (tuberculosis, tumors, etc.). Significant bleeding is observed when the intercostal and internal mammary arteries are damaged. There are small, medium and large (total) hemothorax. With a small hemothorax, blood usually fills only the sinuses of the pleural cavity; with a medium hemothorax, it reaches the angle of the scapula; with a total hemothorax, it occupies the entire pleural cavity. Blood in the pleural cavity, except in cases of severe and massive bleeding, does not clot, since the blood flowing from the lung contains anticoagulant substances.

The clinical picture of hemothorax depends on the intensity of bleeding, compression and displacement of the lungs and mediastinum. In severe cases, the patient's anxiety, chest pain, shortness of breath, pallor and cyanosis of the skin, cough, sometimes with blood, increased heart rate and decreased blood pressure are noted. Percussion reveals a dull sound, vocal tremors and breathing are weakened. The degree of anemia depends on the amount of blood loss. Due to aseptic inflammation of the pleura (hemopleuritis), serous fluid also enters the pleural cavity. When hemothorax becomes infected from a damaged bronchus or lung, a serious complication develops - purulent pleurisy. The diagnosis of hemothorax is confirmed by X-ray examination and pleural puncture. Treatment of small and medium hemothorax is carried out by pleural puncture; if a large hemothorax develops, an emergency thoracotomy with ligation of the vessel or suturing of a lung wound is indicated.

Hemopericardium

Most common cause of hemopericardium (haemopericardium)- accumulation of blood in the pericardial sac - bleeding during injury and closed injuries of the heart and pericardium, less often - with rupture of a cardiac aneurysm, myocardial abscesses, sepsis, etc. Accumulation of 400-500 ml of blood in the pericardium threatens the life of the patient. The patient's anxiety, pain in the heart area, a frightened facial expression, shortness of breath, tachycardia, and a rapid, weak pulse are noted. Blood pressure is low. The displacement or disappearance of the cardiac impulse, expansion of the boundaries of cardiac dullness, and dullness of heart sounds are detected. When the amount of blood in the pericardium increases, a dangerous complication occurs - cardiac tamponade.

If hemopericardium is suspected, a diagnostic puncture is performed. With slow development of hemopericardium and a small accumulation of blood, conservative treatment (rest, cold, pericardial puncture) is possible; in severe cases, emergency surgery is performed and the causes of bleeding are eliminated.

Accumulation of blood in the cranial cavity

Accumulation of blood in the cranial cavity (haemocranion), observed more often due to injury, leads to the appearance of general cerebral and focal neurological symptoms.

Hemarthrosis

Hemarthrosis (haemarthrosis)- accumulation of blood in the joint cavity due to bleeding resulting from closed or open joint injuries (fractures, dislocations, etc.), hemophilia, scurvy and a number of other diseases. If there is significant bleeding, the functions of the joint are limited, its contours are smoothed, fluctuation is determined, and if the knee joint is damaged, the patella balls out. To clarify the diagnosis and exclude bone damage, an X-ray examination is performed.

Joint puncture is both a diagnostic and therapeutic procedure.

Interstitial bleeding

Interstitial bleeding causes formation hematomas, sometimes of considerable size. For example, when a femur is fractured, the amount of blood released may exceed 500 ml. The most dangerous are hematomas that form when large major vessels rupture and crush. In cases where the hematoma communicates with the lumen of the artery, a so-called pulsating hematoma develops, and later, when a capsule is formed, a false aneurysm is formed. Along with the general symptoms of acute anemia, a pulsating hematoma is characterized by two main signs: pulsation over the swelling synchronous with heart contractions and a blowing systolic murmur during auscultation. If the main artery is damaged, the limb is in a state of ischemia, pale, cold to the touch, there are sensory disturbances, the pulse in the distal parts of the artery is not detected. In such cases, emergency surgery is indicated to restore blood supply to the limb.

Interstitial bleeding can lead to tissue impregnation (imbibition) with blood. This type of internal bleeding is called hemorrhage. Hemorrhage can occur in muscles, fatty tissue, brain, heart, kidney, etc.

Hemorrhages are not significant in volume, but can lead to serious consequences (for example, hemorrhage into the brain).

INFLUENCE OF BLOOD LOSS ON THE BODY. PROTECTIVE COMPENSATORY REACTIONS

Developed posthemorrhagic hypovolemia leads to circulatory disorders in the body. As a result, protective and compensatory processes are activated, aimed at restoring the correspondence between the bcc and the capacity of the vascular bed, thereby the body, through adaptive reactions, ensures the maintenance of blood circulation. These reactions involve three main mechanisms.

1. Reducing the volume of the vascular bed due to increased tone of the veins (venospasm) and peripheral arterioles (arteriolospasm).

2. Compensation for the lost part of the bcc due to autohemodilution due to the movement of intercellular fluid into the bloodstream and the release of blood from the depot.

3. Compensatory reaction of life support organs (heart, lungs, brain).

Veno- and arteriolospasm is based on the reflex reaction of baro- and chemoreceptors of blood vessels, stimulation of the sympathetic-adrenal system. An increase in venous tone compensates for the loss of blood volume up to 10-15%. The vessels of the skin, kidneys, liver, and abdominal cavity undergo vasoconstriction, while the vessels of the brain, heart, and lungs remain unchanged, which ensures the maintenance of blood circulation in these vital organs (centralization of blood circulation).

The movement of tissue fluid into the vascular bed occurs quickly. Thus, within a few hours it is possible to transfer liquid in a volume of up to 10-15% of the bcc, and in 1.5-2 days up to 5-7 liters of liquid can move. The influx of tissue fluid does not allow to fully restore lost blood, since it does not contain formed elements and has a low protein content. Hemodilution occurs (dilution, thinning of the blood).

Developed tachycardia, caused by the influence of the sympatheticoadrenal system, allows you to maintain cardiac output

tsa is at a normal level. Hyperventilation ensures adequate gas exchange, which is very important in conditions of hypoxia caused by a low level of hemoglobin in the blood and poor circulation.

Activation due to hypovolemia of the secretion of antidiuretic hormone of the pituitary gland and aldosterone causes an increase in reabsorption in the kidneys and retention of sodium and chlorine ions in the body. Developed oliguria reduces the removal of fluid from the body, thereby maintaining the level of volume.

Such a compensatory reaction cannot last for a long time; the developed state of vascular resistance leads to a failure of compensation. Hypoxia of the liver, kidneys, and subcutaneous tissue causes serious metabolic disorders.

The progression of disorders in the body is due to sludge (sticking together) of red blood cells in the capillaries due to their spasm and slowing of blood flow, as well as increasing tissue hypoxia. In metabolism, anaerobic processes prevail over aerobic ones, and tissue acidosis increases. Such disorders of tissue metabolism and microcirculation lead to multiple organ failure: glomerular filtration decreases or stops in the kidneys and oliguria or anuria develops, necrotic processes occur in the liver, the contractility of the heart decreases due to myocardial damage, interstitial edema develops in the lungs with impaired gas exchange through the pulmonary - capillary membrane (“shock lung”).

Thus, even with stopped bleeding, blood loss leads to serious changes in all vital systems of the body, which makes it necessary to use a wide variety of means and methods of treatment, the main one of which is replenishment of blood loss, and the earlier it is performed, the better for the patient.

STOP BLEEDING

Bleeding from small arteries and veins, as well as from capillaries, in most cases stops spontaneously. Rarely does bleeding from large vessels stop spontaneously.

One of the body's important defense systems is the blood coagulation system. Spontaneous hemostasis in some cases, it allows the body to cope with bleeding on its own.

Hemostasis- a complex biochemical and biophysical process in which a blood vessel and surrounding tissues, thrombus,

bocytes and plasma factors of the blood coagulation and anticoagulation systems.

Contraction of the smooth muscle cells of the vessel leads to vasoconstriction; in the area of ​​vascular damage, the damaged endothelium creates a surface, a place for the formation of a blood clot. Changes in hemodynamics and slowing of blood flow make the process of thrombus formation possible, and thromboplastin of the damaged vessel and surrounding tissues (tissue thromboplastin) takes part in the process of blood clotting. A change in the electrical potential of the damaged vessel, exposure of collagen, accumulation of active biochemical substances (glycoproteins, von Willebrand factor, calcium ions, thrombospandin, etc.) ensure adhesion (sticking) of platelets to the exposed collagen of the vessel wall. Adherent platelets create conditions for platelet aggregation - a complex biochemical process involving epinephrine, ADP, thrombin with the formation of arachidonic acid, prostaglandins, thromboxane and other substances. Aggregated platelets, together with thrombin and fibrin, form a platelet clot - a surface for subsequent thrombus formation with the participation of the blood coagulation system.

In the 1st phase, coagulation occurs with the participation of plasma factors (VIII, IX, XI, XII Hageman factor) and blood platelets - blood thromboplastin is formed. The latter, together with tissue thromboplastin in the presence of Ca 2 + ions, converts prothrombin into thrombin (2nd phase of coagulation), and thrombin, in the presence of factor XIII, converts fibrinogen into fibrin polymer (3rd phase). The process of clot formation ends with its retraction with the formation of a thrombus. This ensures hemostasis and reliably stops bleeding from small vessels. The entire process of thrombosis occurs very quickly - within 3-5 minutes, and processes such as platelet adhesion, the transition of prothrombin to thrombin, and fibrin formation take several seconds.

Continued bleeding if the body cannot cope with it on its own is an indication for temporarily stopping the bleeding.

Methods for temporarily stopping bleeding

Application of a tourniquet

The most reliable method is the application of a tourniquet, but it is used mainly in the extremities.

Rice. 28.Application of a tourniquet: a - preparation for application of a tourniquet; b - beginning of overlay; c - fixation of the first round; d - final view after applying a tourniquet.

The hemostatic tourniquet is a rubber band 1.5 m long, ending with a metal chain on one side and a hook on the other. If arterial bleeding is established, a tourniquet is applied proximal to the site of injury.

The intended area of ​​application of the tourniquet is wrapped in soft material (towel, sheet, etc.), i.e. create a soft pad. The tourniquet is stretched, applied closer to the chain or hook and made into a tourniquet for 2-3 rounds, subsequent turns are applied, stretching the tourniquet. The hook is then attached to the chain (Fig. 28). Be sure to indicate the time of application of the tourniquet, since compression of the artery for more than 2 hours on the lower limb and 1.5 hours on the upper limb is fraught with the development of necrosis of the limb. Control of the correct application of the tourniquet is the cessation of bleeding, the disappearance of pulsation of peripherally located arteries and lung

Rice. 29.Application of a military tourniquet.

“waxy” pallor of the skin of the limb. If transporting a wounded person takes more than 1.5-2 hours, the tourniquet should be periodically removed for a short time (10-15 minutes) until arterial blood flow is restored. In this case, the damaged vessel is pressed with a tamper in the wound or finger pressure is applied to the artery. Then the tourniquet is applied again, slightly higher or lower than the place where it was located.

Subsequently, if necessary, the procedure for removing the tourniquet is repeated: in winter - after 30 minutes, in summer - after 50-60 minutes.

To stop bleeding, a special army tourniquet or an improvised twist can be used (Fig. 29).

Applying a tourniquet to the neck (in case of bleeding from the carotid artery) with a bar or through the armpit on the healthy side is rarely resorted to. You can use a Kramer splint applied to the healthy half of the neck, which serves as a frame (Fig. 30). A tourniquet is pulled over it, which presses the gauze roller and compresses the vessels on one side. If there is no splint, you can use the opposite hand as a frame - it is placed on the head and bandaged. Applying a tourniquet to compress the abdominal aorta is dangerous because injury to internal organs may occur.

Rice. thirty.Applying a tourniquet to the neck.

Application of a tourniquet for bleeding from the femoral and axillary arteries is shown in Fig. 31.

After applying a tourniquet, the limb is immobilized with a transport splint; in the cold season, the limb is wrapped to prevent frostbite. Then, after the administration of analgesics, the victim with a tourniquet is quickly transported to the clinic in a lying position.

Severe and prolonged compression of tissue with a tourniquet can lead to paresis and paralysis of the limb due to both traumatic damage to the nerve trunks and ischemic neuritis that develops as a result of oxygen starvation. The lack of oxygen in the tissues located distal to the applied tourniquet creates favorable conditions for the development of gas anaerobic infection, i.e. for the growth of bacteria,

multiplying without oxygen. Considering the risk of developing severe complications, it is better to temporarily stop bleeding by applying a pneumatic cuff to the proximal part of the limb. In this case, the pressure in the cuff should slightly exceed blood pressure.

Finger pressure on the artery

Finger pressing the artery for a long time, when performed correctly, leads to the cessation of bleeding, but it is short-lived, since it is difficult to continue pressing the vessel for more than 15-20 minutes. The artery is pressed in those areas where the arteries are located superficially and near the bone: carotid artery - transverse process of C IV, subclavian - 1st rib, humerus - area of ​​the inner surface of the humerus, femoral artery - pubic bone (Fig. 32, 33) . Pressing the brachial and femoral arteries works well, but worse - the carotid artery.

Rice. 32.Places where arteries are pressed to temporarily stop bleeding.

Rice. 33.Finger pressure of the carotid (a), facial (b), temporal (c), subclavian (d), brachial (e), axillary (f), femoral (g) arteries to temporarily stop bleeding.

It is even more difficult to compress the subclavian artery due to its location (behind the collarbone). Therefore, when bleeding from the subclavian and axillary arteries, it is better to fix the arm by moving it back as far as possible. In this case, compression of the subclavian artery occurs between the collarbone and the first rib. Finger pressure on the artery is especially important in preparation for applying a tourniquet or changing it, as well as as a technique for amputating a limb.

Flexion of a limb at a joint

Flexion of the limb at the joint is effective provided that the arm bent to failure is fixed in the elbow joint in case of bleeding from the artery.

Rice. 34.Temporary stop of bleeding from arteries by maximum flexion: a - from the femoral artery; b - from the popliteal; c - from the shoulder and elbow.

in the forearm or hand, and in the legs - in the knee joint with bleeding from the vessels of the leg or foot. In case of high injuries of the femoral artery that are inaccessible to applying a tourniquet, the thigh should be fixed to the abdomen with maximum flexion of the limb at the knee and hip joints (Fig. 34).

Wound tamponade and application of a pressure bandage

Wound tamponade and the application of a pressure bandage with immobilization in an elevated position of the limb are a good method of temporarily stopping bleeding from veins and small arteries, from soft tissues covering the bones of the skull, elbow and knee joints. For a tight tamponade, a gauze swab is inserted into the wound, filling it tightly, and then fixed with a pressure bandage. Tight tamponade is contraindicated for wounds in the popliteal fossa, since in these cases gangrene of the limb often develops. Pressure with a weight (sand bag) or in combination with cooling (ice pack) is used for interstitial bleeding, and is also often used as a method of preventing postoperative hematomas.

Pressing the vessel in the wound with your fingers

Pressing the vessel in the wound with fingers is carried out in emergency situations, sometimes during surgery. For this purpose, the doctor quickly puts on a sterile glove or treats the hand with alcohol, iodine and presses or squeezes the vessel in the wound, stopping the bleeding.

Applying a hemostatic clamp

In case of bleeding from damaged deep-lying vessels of the proximal parts of the limb, abdominal cavity, chest, when the above methods of temporarily stopping bleeding cannot be applied, apply a hemostatic clamp to the bleeding vessel in the wound. To avoid injury to nearby formations (nerves), you must first try to stop the bleeding by pressing the vessel with your fingers, and then apply a clamp directly to the bleeding vessel, having previously dried the wound from the blood.

Temporary vessel bypass

Temporary vessel bypass is a method of restoring blood circulation when large arterial vessels are damaged. A dense elastic tube is inserted into both ends of the damaged artery and the ends of the vessel are fixed to the tube with ligatures. This temporary shunt restores arterial circulation. The shunt can function from several hours to several days until it is possible to finally stop the bleeding.

Methods for definitively stopping bleeding

Methods for finally stopping bleeding are divided into four groups: 1) mechanical, 2) physical, 3) chemical and biological, 4) combined.

Mechanical methods Ligation of a vessel in a wound

Ligation of a vessel in a wound is the most reliable way to stop bleeding. To carry it out, the central and peripheral ends of the bleeding vessel are isolated, grabbed with hemostatic clamps and bandaged (Fig. 35).

Ligation of the vessel throughout

Ligation of the vessel along its length is used if it is impossible to detect the ends of the bleeding vessel in the wound (for example, when the external and internal carotid arteries are injured), as well as in case of secondary bleeding.

Rice. 35.Methods for finally stopping bleeding from a vessel: a - applying a ligature; b - electrocoagulation; c - ligation and intersection of the vessel at a distance; d - ligation of the vessel along its length; d - puncture of the vessel.

flows, when the arrozed vessel is located in the thickness of the inflammatory infiltrate. In such cases, focusing on topographic-anatomical data, the vessel is found, exposed and bandaged outside the wound. However, this method does not guarantee the cessation of bleeding from the peripheral end of the damaged artery and collaterals.

If it is impossible to isolate the ends of the vessel, the vessel is ligated along with the surrounding soft tissues. If a vessel is captured by a clamp, but it is not possible to bandage it, you have to leave the clamp in the wound for a long time - up to 8-12 days, until reliable thrombosis of the vessel occurs.

Twisting the vessel

Damaged small-caliber vessels can be grabbed with a hemostatic clamp and the vessel can be twisted using rotational movements.

Wound tamponade

Sometimes, in the presence of small wounds and damage to small-caliber vessels, wound tamponade can be performed. Tampons are used dry or moistened with an antiseptic solution. Typical examples of stopping bleeding are anterior and posterior nasal tamponade for nosebleeds, and uterine tamponade for uterine bleeding.

Clipping

For bleeding from vessels that are difficult or impossible to bandage, clipping is used - clamping the vessels with silver metal clips. After the final stop, the internal

In case of ripple bleeding, part of an organ is removed (for example, resection of the stomach with a bleeding ulcer) or the entire organ (splenectomy for rupture of the spleen). Sometimes special stitches are placed, for example, on the edge of a damaged liver.

Artificial vascular embolization

Currently, artificial vascular embolization methods have been developed and implemented to stop pulmonary, gastrointestinal bleeding and bleeding from bronchial arteries and cerebral vessels. Under X-ray control, a catheter is inserted into the bleeding vessel, and emboli are placed along it, closing the lumen of the vessel, thereby stopping the bleeding. Balls made of synthetic polymeric materials (silicone, polystyrene) and gelatin are used as emboli. At the site of embolization, a thrombus subsequently forms.

Vascular suture

The main indication for applying a vascular suture is the need to restore the patency of the main arteries. The vascular suture must be highly sealed and meet the following requirements: it must not disrupt the blood flow (no narrowing or turbulence), and there must be as little suture material as possible in the lumen of the vessel. There are manual and mechanical seams (Fig. 36).

Rice. 36.Vascular sutures. a - single nodal (according to Carrel): b - single U-shaped; c - continuous wrapping; g - continuous U-shaped; d - mechanical.

The vascular suture is applied manually using atraumatic needles. The ideal is to connect the vessel end to end. A circular vascular suture can be applied using tantalum staples and Donetsk rings. The mechanical suture is quite perfect and does not narrow the lumen of the vessel.

A lateral vascular suture is applied when there is a tangential wound to a vessel. After application, the suture is strengthened with fascia or muscle.

Patches made from biological material

If there is a large defect in the wall resulting from injury or surgery (for example, after removal of a tumor), patches made of biological material (fascia, vein walls, muscles) are used. More often, an autovenous vein is chosen (the great saphenous vein of the thigh or the superficial vein of the forearm).

Transplants

Auto- and allografts of arteries or veins are used as grafts in vascular surgery; prostheses made of synthetic materials are widely used. Reconstruction is performed by applying end-to-end anastomoses or suturing a graft.

Physical methods

Thermal methods of stopping bleeding are based on the ability of high temperatures to coagulate proteins and the ability of low temperatures to cause vasospasm. These methods are of great importance to combat bleeding during surgery. In case of diffuse bleeding from a bone wound, wipes soaked in a hot isotonic sodium chloride solution are applied to it. Applying an ice pack for subcutaneous hematomas and swallowing pieces of ice for gastric bleeding are widely used in surgery.

Diathermocoagulation

Diathermocoagulation, based on the use of high-frequency alternating current, is the main thermal method of stopping bleeding. It is widely used for bleeding from damaged vessels of subcutaneous fatty tissue and muscle, and from small vessels of the brain. The main condition for the use of diathermocoagulation is the dryness of the wound, and when it is carried out, the tissue should not be charred, as this in itself can cause bleeding.

Laser

Laser (electron radiation focused in the form of a beam) is used to stop bleeding in patients with gastric bleeding (ulcers), in people with increased bleeding (hemophilia), and during oncological operations.

Cryosurgery

Cryosurgery - surgical methods of treatment with local application of cold during operations on richly vascularized organs (brain, liver, kidneys), especially when removing tumors. Local tissue freezing can be performed without any damage to healthy cells surrounding the area of ​​cryonecrosis.

Chemical and biological methods

Hemostatic agents are divided into resorptive and local agents. The resorptive effect develops when the substance enters the blood, while the local effect develops when it comes into direct contact with bleeding tissues.

Substances with general resorptive action

Hemostatic substances with a general resorptive effect are widely used for internal bleeding. The most effective is direct transfusion of blood products, plasma, platelets, fibrinogen, prothrombin complex, antihemophilic globulin, cryoprecipitate, etc. These drugs are effective for bleeding associated with congenital or secondary deficiency of individual blood coagulation factors in a number of diseases (pernicious anemia, leukemia, hemophilia and etc.).

Fibrinogen is obtained from donor plasma. Used for hypo-, afibrinogenemia, profuse bleeding of other nature, for replacement purposes.

Currently widely used fibrinolysis inhibitors, having the ability to reduce the fibrinolytic activity of the blood. Bleeding associated with an increase in the latter is observed during operations on the lungs, heart, prostate gland, cirrhosis of the liver, septic conditions, and transfusion of large doses of blood. Both biological antifibrinolytic drugs (for example, aprotinin) and synthetic ones (aminocaproic acid, aminomethylbenzoic acid) are used.

Etamzilat- drugs that accelerate the formation of thromboplastin, they normalize the permeability of the vascular wall and improve microcirculation. Rutoside and ascorbic acid are used as agents that normalize the permeability of the vascular wall.

Menadione sodium bisulfite - a synthetic water-soluble analogue of vitamin K. It is used as a therapeutic agent for bleeding associated with a decrease in prothrombin levels in the blood. Indicated for acute hepatitis and obstructive jaundice, parenchymal and capillary bleeding after wounds and surgical interventions, gastrointestinal bleeding, peptic ulcer, hemorrhoidal and prolonged nosebleeds.

The process of converting prothrombin into thrombin requires a very small amount of calcium ions, which are usually already present in the blood. Therefore, the use of calcium preparations as a hemostatic agent is advisable only in the case of transfusion of massive doses of citrated blood, because when calcium interacts with citrate, the latter loses its anticoagulating properties.

Substances of local action

Local hemostatic agents are widely used. In case of parenchymal bleeding from a liver wound, a kind of biological tampon is used - muscle tissue or omentum in the form of a free flap or a pedicle flap. Of particular importance in surgery is the use of fibrin film, biological antiseptic tampon, hemostatic collagen sponge. Hemostatic and gelatin sponges, biological antiseptic tampon are used to stop capillary and parenchymal bleeding from bones, muscles, parenchymal organs, and for tamponade of the dural sinuses.

Thrombin is a drug obtained from donor blood plasma that promotes the transition of fibrinogen to fibrin. The drug is effective for capillary and parenchymal bleeding of various origins. Before use, it is dissolved in an isotonic sodium chloride solution. Sterile gauze pads or a hemostatic sponge are impregnated with the drug solution and applied to the bleeding surface. The use of thrombin is contraindicated for bleeding from large vessels, since the development of widespread thrombosis with a fatal outcome is possible.

Combined methods

To enhance the effect of hemostasis, various methods of stopping bleeding are sometimes combined. The most common are wrapping muscle tissue or smearing a vascular suture with glue, simultaneous use of various types of sutures, biological tampons, etc. for parenchymal bleeding.

For the treatment of patients with disseminated intravascular coagulation syndrome, it is important to eliminate the cause that caused it, restore bcc, take measures to eliminate renal failure, as well as normalize hemostasis - administration of sodium heparin and (stream) native or fresh frozen plasma, platelet mass; If necessary, use mechanical ventilation.

To stop bleeding caused by the action of drugs, native or fresh frozen plasma is used, in case of an overdose of indirect anticoagulants - menadione sodium bisulfite (vitamin K), in case of an overdose of sodium heparin - protamine sulfate, to inactivate fibrinolytic drugs - aminocaproic acid, aprotinin.

To stop bleeding in patients with hemophilia, cryoprecipitate, antihemophilic plasma, native plasma, native donor plasma, freshly citrated blood, and direct blood transfusions are used.

SECONDARY BLEEDINGS

Secondary bleeding may be early(in the first 3 days) and late- after a long period of time after injury (from 3 to several days, weeks). The division into early and late is determined by the causes of secondary bleeding (as a rule, they differ in the time of manifestation). The cause of early secondary bleeding is a violation of the rules for the final stop of bleeding: insufficient control of hemostasis during surgery or surgical treatment of a wound, loosely tied ligatures on the vessels. Bleeding can be caused by increased blood pressure after surgery (if the patient or wounded person is operated on with low blood pressure), shock, hemorrhagic anemia, controlled arterial hypotension, when blood clots can be pushed out of large or small vessels, or ligatures may slip.

The cause of both early and late secondary bleeding can be disturbances in the blood coagulation or anticoagulation system (hemophilia, sepsis, cholemia, etc.), careless change of blood

bandages, tampons, drainages, which may cause a blood clot to break off and cause bleeding.

The main causes of secondary bleeding are purulent-inflammatory complications in the wound, the development of necrosis, which can lead to the melting of blood clots. Late bleeding can also be caused by bedsores of blood vessels due to pressure on them from bone or metal fragments or drainage. The resulting necrosis of the vessel wall can lead to its rupture and bleeding.

Secondary bleeding, like primary bleeding, can be arterial, venous, capillary, parenchymal, as well as external and internal.

The severity of the patient’s condition is determined by the volume of blood loss and depends on the caliber and nature of the damage to the vessel. Secondary bleeding has a more severe impact on the body than primary bleeding, as it occurs against the background of a condition after previous blood loss (due to primary bleeding or surgery). Therefore, with secondary bleeding, the severity of the patient’s condition does not correspond to the amount of blood loss.

The clinical picture of secondary bleeding consists of general and local symptoms, as with primary bleeding. In case of external bleeding, the first thing to observe is the soaking of the bandage: bright red blood for arterial bleeding, dark blood for venous bleeding. Bleeding into a wound closed with sutures leads to the formation of a hematoma, which is accompanied by pain, a feeling of fullness in the wound, and swelling.

Internal secondary bleeding is characterized primarily by general signs of blood loss: increasing weakness, pallor of the skin, increased frequency and decreased filling of the pulse, decreased blood pressure. According to laboratory studies, there is a decrease in hemoglobin concentration and hematocrit. Local symptoms are determined by the location of the hemorrhage: hemoperitoneum, hemothorax, hemopericardium. Bleeding into the gastrointestinal tract may result in bloody or coffee-ground vomiting, bloody stools, and melena.

Stopping secondary bleeding

The principles of stopping secondary bleeding are the same as for primary bleeding. If secondary bleeding is detected, immediate measures are taken to temporarily stop it using the same methods.

methods and remedies as for primary bleeding - application of a tourniquet, finger pressure of the vessel, pressure bandage, tamponing. In case of massive bleeding from the wound, it is temporarily stopped using one of the methods, and then the sutures are removed and a thorough inspection of the wound is carried out. A clamp is applied to the bleeding vessel and then ligated. In case of capillary bleeding in the wound, it is tightly packed with a gauze swab or a hemostatic sponge.

Ligation of a bleeding vessel in a purulent wound is unreliable due to the likelihood of recurrent bleeding due to the progression of the purulent-necrotic process. In such situations use ligation of the vessel along within healthy tissues. To do this, from the additional reserve, the vessel is exposed proximally, outside the site of its damage, and a ligature is applied. When finally stopping secondary bleeding, the general condition of the patient should be taken into account and should be done after the patient has been recovered from hemorrhagic shock. For this purpose, blood transfusions and blood substitutes with anti-shock action are performed.

In case of established secondary bleeding in the abdominal, pleural cavities, or gastrointestinal tract, when temporary stopping is impossible due to the anatomical features of the location of the bleeding vessel, despite the severity of the patient’s condition, the presence of shock, emergency surgery is indicated - relaparotomy, rethoracotomy. Surgical intervention to stop bleeding and anti-shock measures are carried out simultaneously.

During the operation, the source of bleeding is determined and its final stop is carried out - ligation, suturing, ligation of the vessel along with surrounding tissues, suturing the bleeding parenchyma of the organ - liver, ovary, etc. Blood poured into the serous cavities, if it is not contaminated with the contents of the gastrointestinal tract and no more than 24 hours have passed since the bleeding, collect, filter and infuse into the patient (blood reinfusion). After the bleeding has completely stopped, blood loss replacement and anti-shock therapy are continued.

Mechanical methods are combined with chemical and biological means of stopping bleeding. If the cause of bleeding was a violation of the activity of the blood coagulation or anticoagulation system, special factors are used to increase the blood coagulation system or decrease the activity of the anticoagulation system: plasma cryoprecipitate, antihemophilic factor, fibrinogen, platelet mass, aminocaproic acid, etc.

Preventionsecondary bleeding are the following main points.

1. Careful final stop of primary bleeding in case of vascular damage and during any surgical intervention. Before suturing the wound, the surgical area must be carefully examined (checking hemostasis). If there is no confidence that the bleeding will completely stop, additional techniques are performed - ligation, electrocoagulation of the vessel, and the use of a hemostatic sponge. Only with complete hemostasis is the operation completed by suturing the wound.

2. Careful initial surgical treatment of wounds, removal of foreign bodies - loose bone fragments, metal foreign bodies (shell fragments, bullets, shot, etc.).

3. Prevention of purulent complications from the wound: scrupulous adherence to the rules of asepsis and antisepsis during surgery, antibacterial therapy.

4. Drainage of wounds and cavities, taking into account the topography of blood vessels, in order to prevent the formation of bedsores on their walls and arrosion.

5. Study before each planned operation of the state of the patient’s blood coagulation and anticoagulation system: coagulation time, bleeding time, prothrombin level, platelet count. When these indicators change, as well as in patients with an unfavorable history of increased bleeding or suffering from blood diseases, jaundice, a detailed coagulogram is necessary. In case of disturbances in the state of the blood coagulation system, targeted preoperative preparation is carried out to normalize or improve its condition. Monitoring of the state of hemocoagulation in these patients, who are at risk of secondary bleeding, is carried out systematically in the postoperative period.