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HAEMORRHAGE

BY
Dr

HAYDER M. ABDULNABI
DM, CABS

29/02/1429

TYPES OF BLEEDING
DEPNDING ON THE SOURSE
OF BLEEDING
1- ARTERIAL BRIGHT RED AND
COMES IN JETS WITH THE PULSE
OF THE PATIENT
2- VENOUS DARK RED BLOOD ,
STEADY AND COPIOUS
3- CAPILLARY BRIGHT RED RAPID
OOZE ( ABRASIONS )
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DEPENDING ON THE TIME OF


OCCURANCE
1- PRIMARY BLEEDING OCCURS AT THE
TIME OF INJURY OR OPERATION
2- REACTIONARY BLEEDING USUALLY
OCCURS IN 4-6 HOURS OR WITH IN THE
24 HOURS THAT FOLLOW THE PRIMARY
BLEEDING, DUE TO EITHER SLIPPING
OF LIGATURE , DISLOGEMENT OF A
CLOT OR CESSATION OF THE REFLEX
VASOSPASM.
THE PRESIPITATING FACTOR ARE
A- THE INCREASE IN THE BLOOD
PRESSURE AFTER RECOVERY FROM
SHOCK OR ANASTHESIA
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B- RESTLESSNESS OF THE PATIENT


C- COUGHING AND VOMITING THAT
INCREASE THE VENOUS PRESSURE
3- SECONDARY BLEEDING OCCUR
WITHIN 7-14 DAYS AFTER THE
PRIMARY TRAUMA OR OPERATION AND
THE CAUSE IS ALWAYS INFECTION
WHICH LEADS TO SLOUGHIN OF AN
ARTERY IN AN AREA BY PRESSURE OF
A DRAIN TUBE OR A BONE FRAGMENT
OR BY SLIPPING OF A LIGATURE IN AN
INFECTED AREA OR MALIGNANT
TISSUE
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DEPENDING ON THE VISIBILITY


A- EXTERNAL ( REVEALED ) BLEEDING
B- INTERNAL ( CONCAELED )
BLEEDING LIKE INTRA-ABDOMINAL
OR INTRACRANIAL BLEEDING
THE INTERNAL BLEEDING MAY
BECOME EXTENAL AS IN
HEMATEMESIS DUE TO A BLEEDING
PEPTC ULCER OR HEMATURIA AFTER
RENAL INJURY OR AN INTRUTERINE
BLEEDING TURNS INTO BLEEDING
PER VAGINA
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HOW TO MEASURE ACUTE


BLOOD LOSS ?
A NORMAL BLOOD VOLUME IS 80-85 ML / KG IN INFANTS
AND ABOUT 65-75 ML / KG IN ADULTS
1- BLOOD CLOT SIZE A CLENCHED FIST SIZE CLOT
ROUGHLY EQUALS 500 ML
2 - SITE OF A CLOSED # SWELLING -- A MODERATE
SWELLING IN A # TIBIA EQUALS TO 500- 1500 ML OF
BLOOD, WHILE A MODERATE SWELLING IN A # FEMUR
EQUALS TO 500-2000 ML OF BLOOD LOSS
3- SWAB WEIGHING BY SUBSTRACTING THE WEIGHT
OF SOACKED SWABS FROM THEIR WEIGHT WHEN
THEY WERE DRY AND THE BLOOD LOSS IS 1 ML FOR
EVERY 1 GM DIFFERENCE
4- HEMOGLOBIN LEVEL ESTIMATION THERE IS NO
IMMEDIATE DECREASE IN Hg LEVEL AFTER BLEEDING
BUT AFTER 8 HOURS IT WILL DROP BECAUSE OF THE
INFLUX OF THE INTERSITIAL FLUID INTO THE
VASCULAR COMPARTEMENT ( DILUTION )
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TREATMENT
1- PRESSURE ON THE SITE OF BLEEDING
BY PACKING OR DIGITS OR BALOONS
INFLATED AT THE SITE OF BLEEDING
( ESOPHAGEAL VARICES)
2- REST AND POSITION BY ELEVATION
OF THE INJURED LIMB TO DECREASE
BLOOD RETURN TO THE HEART
3- OPERATIVE PROCEDURES BY USING
HEMOSTATS, CLIPS, DIATHERMY,
LIGATURES, GELATIN SPONGES, AND
ADRENALIN SOACKED GAUZE ( 1: 1000 )
4- BLOOD TRANSFUTION
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INDICATION OF BLOOD
TRANSFUSION
1- ANEMIA-- RECENT STUDY SHOWED
THAT A TRANSFUSION THRESHOLD OF
70G/L WAS AS SAFE AND POSSIBLY
SUPERIOR TO ONE OF 100G/L IN
CRITICAL CARE PATIENTS. A MINIMUM
PREOPERATIVE HAEMOGLOBIN OF
100G/L IS NO LONGER REGARDED AS
ESSENTIAL, AS MANY PATIENTS WITH A
LOWER HAEMOGLOBIN TOLERATE
SURGERY AND SEEM TO RECOVER JUST
AS WELL.
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2- BLOOD LOSS IF GREATER THAN


30PER CENT OF ESTIMATED BLOOD
VOLUME,
PATIENTS WITH MASSIVE BLOOD
LOSS, DEFINED AS THOSE REQUIRING
TRANSFUSION OF A VOLUME OF
BLOOD GREATER THAN THEIR BLOOD
VOLUME WITHIN 24H
DEPLETION OF COAGULATION
FACTORS IS UNUSUAL, BECAUSE
STORED BLOOD CONTAINS ADEQUATE
AMOUNTS OF ALL EXCEPT FOR
FACTORS V AND VIII, WHICH FALL
DURING STORAGE.
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3- REPLACEMENT OF BLOOD COMPONENTS


RED & WHITE BLOOD CELLS, COAGULATION
FACTORS, PLASMA

PROCEDURE FOR BLOOD


TRANSFUSION
1- PRETRANSFUSION COMPATIBILITY
TESTING -- A. BLOOD GROUPING ,THE ABO
AND RHD GROUPS OF THE PATIENT ARE
DETERMINED.
B Donor blood of the same ABO and RhD
group as the patient is selected.
D. Cross-matching-- The full cross-match
involves testing the patient's plasma
against a sample of the red cells from the
donor unit in a direct agglutination test.
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2- BLOOD ORDERING A. ELECTIVE


SURGERY-- SUFFICIENT TIME
SHOULD BE ALLOWED FOR THE
LABORATORY TO CARRY OUT
PRETRANSFUSION TESTING.
B.
EMERGENCIES-- THERE MAY BE
INSUFFICIENT TIME FOR FULL
PRETRANSFUSION TESTING.
USE 2 UNITS OF O RHD-NEGATIVE
BLOOD ('EMERGENCY STOCK') ,
TO ALLOW ADDITIONAL TIME FOR
THE LABORATORY TO GROUP THE
PATIENT.
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Blood, blood components, and blood - 3


products-- Blood collected from donors is
:processed into
A- Blood components, such as red cell
and platelet concentrates, fresh frozen
plasma and cryoprecipitate, which are
prepared from a single donation of blood
by simple separation methods such as
centrifugation, and transfused without
further processing.
B- Blood products, such as coagulation
factor concentrates and albumin and
immunoglobulin solutions, which are
prepared by complex processes using the
plasma from many donors as the starting
material.
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Strategies for avoiding or


reducing the use of blood
tranfusion

By discontinuing antiplatelet and anticoagulant


drugs, if possible, several days before
surgery.
Anaemia, if present, should be investigated
and treated appropriately in advance of
elective surgery.
Intraoperative measures include the use of
meticulous surgical and anaesthetic
techniques, a cautious use of anticoagulants
during surgery, and the use of drugs to
enhance haemostasis AND THE USE OF
AUTOLOGOUS TRANSFUSION.
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Autologous transfusion
THERE ARE THREE TYPES OF AUTOLOGOUS
TRANSFUSION:
PREDEPOSIT. THE PATIENT DONATES 25 UNITS OF- 1
BLOOD AT APPROXIMATELY WEEKLY INTERVALS
.BEFORE ELECTIVE SURGERY
PREOPERATIVE HAEMODILUTION. ONE OR TWO- 2
UNITS OF BLOOD ARE REMOVED FROM THE PATIENT
IMMEDIATELY BEFORE SURGERY AND
.RETRANSFUSED TO REPLACE OPERATIVE LOSSES
BLOOD SALVAGE. BLOOD LOST DURING OR AFTER- 3
SURGERY MAY BE COLLECTED AND RETRANSFUSED.
SEVERAL TECHNIQUES OF VARYING LEVELS OF
SOPHISTICATION ARE AVAILABLE. OPERATIVE SITE
MUST BE FREE OF BACTERIA, BOWEL CONTENTS,
.AND TUMOUR CELLS
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Complications of blood
transfusion
1-- Immediate haemolytic transfusion
reactions
This is the most serious complication of blood
transfusion and is usually due to ABO
incompatibility. There is complement activation
by the antigen-antibody reaction, usually due to
IgM antibodies, leading to rigors, lumbar pain,
dyspnoea, hypotension, haemoglobinuria, and
renal failure. At the first suspicion of any serious
transfusion reaction, the transfusion should
always be stopped and the donor units returned
to the blood transfusion laboratory with a new
blood sample from the patient to exclude a
.haemolytic transfusion reaction
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DELAYED HAEMOLYTIC TRANSFUSION-- 2


REACTIONS
THESE MAY OCCUR IN PATIENTS
ALLOIMMUNIZED BY PREVIOUS
TRANSFUSIONS OR PREGNANCIES. THE
ANTIBODY TITRE IS TOO LOW TO BE
DETECTED BY PRETRANSFUSION
COMPATIBILITY TESTING, BUT A
SECONDARY IMMUNE RESPONSE
OCCURS AFTER TRANSFUSION,
RESULTING IN DESTRUCTION OF THE
TRANSFUSED CELLS, USUALLY BY IGG
ANTIBODIES. THE PATIENT MAY
DEVELOP ANAEMIA AND JAUNDICE
ABOUT A WEEK AFTER THE
TRANSFUSION, ALTHOUGH MANY ARE
.CLINICALLY SILENT
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NON-HAEMOLYTIC (FEBRILE)-- 3
TRANSFUSION REACTIONS
FEBRILE REACTIONS ARE A COMMON
COMPLICATION OF BLOOD
TRANSFUSION IN PATIENTS WHO HAVE
PREVIOUSLY BEEN TRANSFUSED OR
PREGNANT. THE USUAL CAUSE IS THE
PRESENCE OF LEUCOCYTE ANTIBODIES
IN THE RECIPIENT ACTING AGAINST
TRANSFUSED LEUCOCYTES, LEADING TO
RELEASE OF PYROGENS. TYPICAL SIGNS
ARE FLUSHING AND TACHYCARDIA,
FEVER (>38C), CHILLS, AND RIGORS.
PARACETAMOL MAY BE USED TO
. REDUCE THE FEVER
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Urticaria And Anaphylaxis--4


Urticarial Reactions Are Often Attributed To
Plasma Protein Incompatibility But, In Most
Cases, They Are Unexplained. They Are
Common But Rarely Severe; Stopping Or
Slowing The Transfusion, And Intravenous
Chlorpheniramine 10Mg (Adult Dose), Are
.Usually Sufficient Treatment
Anaphylactic Reactions Occasionally Occur;
Severe Reactions Are Seen In Patients
Lacking IgA Who Produce Anti-IgA That
Reacts With IgA In The Transfused Blood.
The Transfusion Should Be Stopped And
Adrenaline 0.5Mg Intramuscular And
Chlorpheniramine 10Mg Intravenous
Should Be Given Immediately;
. Endotracheal Intubation May Be Required
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5 TRANSMISSION OF INFECTION
HEPATITIS, HUMAN IMMUNODEFICIENCY VIRUS
OTHER VIRUSES: CYTOMEGALOVIRUS, EPSTEIN
BARR VIRUS, HUMAN T-CELL
LEUKAEMIA/LYMPHOMA VIRUS TYPE 1 (HTLV-1)
PARASITES: MALARIA, TRYPANOSOMIASIS,
TOXOPLASMOSIS SYPHILIS AND TRANSFUSION
OF BLOOD CONTAMINATED WITH BACTERIA
CIRCULATORY FAILURE DUE TO VOLUME-- 6
OVERLOAD.7-- IRON OVERLOAD DUE TO
MULTIPLE TRANSFUSIONS. 8-- MASSIVE
TRANSFUSION OF STORED BLOOD MAY CAUSE
BLEEDING AND ELECTROLYTE CHANGES. 9-THROMBOPHLEBITIS 10-- AIR EMBOLISM

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