IV. Table of contents of teaching

Bleeding (haemorrhagia) — expiration of blood from blood vessels at the damage or violation of permeability of their wall.

Classification of bleeding:

I. Depending on the reason of origin: a) mechanical damages, break of vessels (haemorrhagia per rhexin); b) arrosional bleeding (haemorrhagia per diabrosin); c) diapedesis bleeding (haemorrhagia per diapedesin); d) violation of chemical composition of blood, change of rolling up the anticoagulative systems of blood.

II. Taking into account the type of bleeding vessel: a) arterial, b) arteriovenous, c) vein, d) capillary, e) parenchymatous.

ІІІ. In relation to an external environment and clinical displays: a) outward, b) internal, c) hidden.

IV. At times origins: a) primary, b) second.

At the outward bleeding a blood is poured out on external environment.

The internal bleeding can take place both in a cavity, and in fabric. Hemorrhage in fabric are the result of impregnation of the last by a blood with formation of the slight swelling. Massive hemorrhage can be accompanied by stratification of fabric with formation of artificial cavity by the filled blood – haematomas. An appearing haematoma can resolve or round her appears capsule, and a haematoma grows into a cyst.

Special seat is taken by bleeding in serous cavities — pleura, abdominal. Such bleeding differ by massiveness because of that are rarely stopped spontaneously. It is conditioned to those, that the blood poured out in serous cavities loses a capacity for coagulation, and the walls of these cavities do not create the mechanical obstacle for a poured out from vessels blood; in pleura cavities, in addition, from negative pressure a suctorial effect is created.

Bleeding without clinical signs behave to hidden. How an example is it is possible to lead bleeding not clinically showing up from gastric ulcers and duodenum. Such bleeding can be exposed only by a laboratory method – by research of excrement on the hidden blood.

The primary bleeding arise up directly after the damage of vessel, second — through some interval of time after the stop of the primary bleeding.

Factors determining blood loss volumei and end of bleeding

Reason of death at blood loss — loss of functional properties of blood (transfer of oxygen, carbon dioxide, nutritives, products of exchange, detoxication function and other) and violation of circulation of blood (sharp vascular insufficiency – hemorrhagic shock). The end of bleeding is determined alongside factors, but have the deciding value the volume and speed of blood loss: rapid blood loss near ⅓ of circulatory blood volume is dangerous for the life, sharp blood loss making the about half circulatory blood volume is absolutely mortal.

Speed and volume of blood loss rely on a character and type of the damaged vessel. Most rapid blood loss is marked at the damage of arteries.

In the end of blood loss the important value has the common state of organism. Healthy people easier carry blood loss. Unfavorable terms arise up at traumatic shock, preceding anaemia, exhaustion, starvation, traumatic protracted operations and etc.

The end of blood loss relies on rapid adaptation of organism to blood loss. So, other things being equal easier carry blood loss and quick adapt oneself to her the women and donors, as a loss of blood at menstruations or permanent donor create favourable terms for compensation of different systems, above all things cardiovascular, to blood loss.

Supercooling, as well as overheating, negatively tells on adaptability of organism to blood loss.

Heavily children carry blood loss and aged. At children it is conditioned by the anatomical and physiological features of organism; for new-born the loss of even a few milliliters of blood is dangerous. At aged because of age changes in a heart, vessels (atherosclerosis) the adaptation to blood loss considerably below, than at youths.

A danger for the life is determined by the role of organ which a hemorrhage happened in. So, an insignificant hemorrhage in the matter of cerebrum can be extremely dangerous because of defeat vitally of important centers.

The danger of blood loss is related to development of hemorragic shock, weight of which is conditioned by intensity, duration of bleeding and volume of the lost blood. Rapid loss 30% of circulatory blood volume conduces to sharp anaemia, hypoxia of cerebrum and can end by death of patient. At the insignificant, but protracted bleeding hemodynamics changes small, and a patient can live even at the decline of level of haemoglobin to 20 g/l.

Sharp blood loss because of the circulatory blood volume decline can result in hemorragic shock, development of which it is possible at blood loss equal 20-30% circulatory blood volume. In the basis of shock disorders lie of central and peripheral hemodynamics because of hypovolume. At heavy massive blood loss as a result of disorder of hemodynamics, paresis of capillaries, decentralization of bloodstream, and shock, come can pass to the irreversible stage.

Acidosis develops at the increase of blood loss, there are sharp violations in the system of microcirculation, there is aggregation of red corpuscles in capillaries.

Important to define the size of blood loss, that, along with the stop of bleeding, is had by the deciding value for the choice of medical tactic.

Table of contents of red corpuscles, haemoglobin (Nb), hematokrit (Ht) it is necessary to determine at once at the receipt sick and repeat in future. These indexes in the first clock at the heavy bleeding do not reflect the size of blood loss objectively, because autohemodilution comes later (maximally she is expressed through 1,5-2 days). Are the most valuable indexes Ht and relative closeness of blood, which reflect correlation between the uniform elements of blood and plasma. At a relative closeness 1,057-1,054, Hb 65-62 g/l, Ht 40-44 blood loss makes to 500 ml, at a relative closeness 1,049-1,044, Hb 53-38 g/l, Ht 30-23 – more 1000ml.

Reliable determination of size of blood loss it is very important in clinical practice. From its size the anaesthetic depends during the operation, transfusional tactic and conduct of postoperative period. In clinical practice more frequent than all the visual method of determination of size of krovopoteri is used; however even at the most experimental specialists an error makes to 30 %. The degree of the circulatory blood volume (CBV) deficit reflects the Algover shock index (the relation of frequency of cardiac abbreviations to the size of systole is arterial pressure). In a norm the Algover index less than 1, at an index more than 1,5 the CBV deficit makes more than 40%, that makes the direct threat of life of patient. However, the Algover index is uninforming at patients with a vasohypertonic syndrome.

One of methods of determination of size of blood loss is the hematokrit method Moore, the size of blood loss is determined on a formula:

BL = CBV_D (HT_D – HT_A)/HT_D

where BL – size of blood loss; CBV_D – due circulatory blood volume; HT_D – due size of hematocrit (men – 45, women – 42); HT_A – actual size of hematocrit, definite after the stop of bleeding and stabilization of hemodinamics.

In this formula in place of hematokrit it is possible to use maintenance of haemoglobin. However it follows to mean that the concentration methods of determination of size of blood loss, based on the index of hematocrit and maintenance of haemoglobin, can be recommended for computations only at slow blood loss, because their truth values become the real only on achievement of the complete breeding of blood, which takes place in an organism during 2-3 days.

Determination of the circulatory blood volume deficit and his components is the most informing method of establishment of size of blood loss: volume of circulatory plasma, volume of uniform elements – globular volume. A research method is based on introduction to the vascular river-bed of definite quantity of indicators. The method of the circulatory blood volume determination by Evans dark blue is enough exact (the paint T-1824). On concentration of divorced in a blood indicator the volume of circulatory plasma is determined; taking into account hematocrit, by tables calculate circulatory blood volume and globular volume. The due indexes circulatory blood volume and his components find on tables which mass of body and floor of patient are indicated in. On a difference between due and actual indexes the circulatory blood volume deficit is determined, globular volume, volume of circulatory plasma, i.e. size of blood loss. However most objective presently it follows to count the radionuclide method of the circulatory blood volume research, the error of which hesitates within the limits of 3-5 %.

Four Degrees of weight of blood loss select depending on the volume of the blood and level of the circulatory blood volume decline poured out:

І – easy degree: loss of a 500-700 ml blood (the circulatory blood volume decline on 10-12 %);

ІІ – middle degree: loss of a 1000-1500 ml blood (the circulatory blood volume decline on 15-20 %);

ІІІ – heavy degree: loss of a 1500-2000 ml blood (the circulatory blood volume reduction on 20-30 %);

The ІV degree — massive blood loss: loss more than 2000 ml blood (the circulatory blood volume decline more than on 30%).

The clinical signs looked after at blood loss, allow to define its degree.

The in good time begun medical treatment can warn development of hemorragic shock, that is why beginning him follows maximally quickly. In the case of heavy blood loss still to determination of blood type and tests on compatibility of blood of patient and donor proceed to introduction of blood substitute liquids, application of which is based on that loss of plasma and, consequently, reduction by an circulatory blood volume survive by organism much heavier, than loss of red corpuscles. Albumen, protein, polyglukin well hold out in a bloody river-bed; in the case of necessity it is possible to use crystalloid solutions, but it should be remembered that they quickly abandon a vascular river-bed. Low-molecular dekstran (reopolyglukin) fill in the volume of intravascular liquid, microcirculation and rheologic properties of blood is improved. Blood transfusion is needed at the decline of level of haemoglobin below 80 g/l and index of hematocrit less 30. At heavy sharp blood loss begin medical treatment with stream inflowing of blood in 1, 2 or 3 veins and only after getting up systolic arterial pressure is higher 80 mm of mercury column an item is passed to tiny inflowing. For the removal of anaemia use infusion of red corpuscles mass; to enter appropriate after infusion of blood substitute, because it improves capillary bloodstream and diminishes depositing of uniform elements of blood.