Internal bleeding

Internal bleeding (also called internal hemorrhage) is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside.[1] It is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into the chest, abdomen, retroperitoneal space, pelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly.[2] Internal bleeding is a medical emergency and should be treated immediately by medical professionals. [2]

Stroke hemorrhagic
Internal bleeding in the brain

Causes

Traumatic causes

The most common cause of death in trauma is bleeding.[3] Death from trauma accounts for 1.5 million of the 1.9 million deaths per year due to bleeding.[4]

There are two types of trauma: penetrating trauma and blunt trauma.[2]

Non-Traumatic causes

A number of pathological conditions and diseases can lead to internal bleeding. These include:

Other

Linitis plastica 2
This stomach with Linitis Plastica can cause internal bleeding

Internal bleeding could be caused by medical error as a result of complications after surgical operations or medical treatment. Some medication effects may also lead to internal bleeding, such as the use of anticoagulant drugs or antiplatelet drugs in the treatment of coronary artery disease.[8]

Signs & Symptoms

At first, there may be no symptoms of internal bleeding. If an organ is damaged and it bleeds, it can be painful. Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness.[9]

A patient may lose more than 30% of their blood volume before there are changes in their vital signs or level of consciousness. [4] This is called hemorrhagic or hypovolemic shock, which is a type of shock that occurs when there is not enough blood to reach organs in the body.[10]

Early symptoms include anxiety, increased breathing rate, weak peripheral pulses, and cold skin on the arms and legs. If internal bleeding is not treated, the heart and breathing rate will continue to increase while blood pressure and mental status decrease. Eventually, internal bleeding can result in death by blood loss (exsanguination).[4] The median time from the onset of hemorrhagic shock to death by exsanguination is 2 hours. [4]

Types of internal bleeding (by location)

Internal bleeding can occur anywhere in the body. Some symptoms of internal bleeding depend on the location of the bleed. Some examples of types of internal bleeding include:

Diagnosis

Vital signs

Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, and mental status.[11] Advanced trauma life support (ATLS) by the American College of Surgeons separates hemorrhagic shock into four categories.[9][4][12]

Assessing circulation occurs after assessing the patient's airway and breathing (ABC (medicine)).[10] If internal bleeding is suspected, a patient’s circulatory system is assessed through palpation of pulses and doppler ultrasonography.[2]

Physical examination

It is important to examine the patient for visible signs that may suggest internal bleeding[2]:

It is also important to look for the source of the internal bleeding.[2] If internal bleeding is suspected after trauma, a FAST exam may be performed to look for bleeding in the abdomen. [2][9]

Imaging

If the patient has stable vital signs, they may undergo diagnostic imaging such as a CT scan.[4] If the patient has unstable vital signs, they may not undergo diagnostic imaging and instead may receive immediate medical or surgical treatment. [4]

Treatment

Management of internal bleeding depends on the cause and severity of the bleed. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.[2]

Fluid replacement

If a patient has low blood pressure (hypotension), intravenous fluids can be used until they can receive a blood transfusion. In order to replace blood loss quickly and with large amounts of IV fluids or blood, patients may need a central venous catheter. [9] Patients with severe bleeding need to receive large quantities of replacement blood via a blood transfusion. As soon as the clinician recognizes that the patient may have a severe, continuing hemorrhage requiring more than 4 units in 1 hour or 10 units in 6 hours, they should initiate a massive transfusion protocol. [9] The massive transfusion protocol replaces red blood cells, plasma, and platelets in varying ratios based on the cause of the bleeding (traumatic vs. non-traumatic). [4]

YckA57Bqi (1)

Stop the bleed

It is important to stop bleeding (achieve hemostasis) after identifying the cause of internal bleeding. [4] Studies have shown that taking longer to achieve hemostasis in patients with traumatic causes (e.g. pelvic fracture) and non-traumatic causes (e.g. gastrointestinal bleeding, ruptured abdominal aortic aneurysm) is associated with an increased death rate.[4].

Unlike with external bleeding, most internal bleeding cannot be controlled by applying pressure to the site of injury. [9] Internal bleeding in the thorax and abdominal cavity (including both the intraperitoneal and retroperitoneal space) cannot be controlled with direct pressure (compression). A patient with acute internal bleeding in the thorax after trauma should be diagnosed, resuscitated, and stabilized in the Emergency Department in less than 10 minutes before undergoing surgery to reduce the risk of death from internal bleeding. [4] A patient with acute internal bleeding in the abdomen or pelvis after trauma may require use of a REBOA device to slow the bleeding. [4] The REBOA has also been used for non-traumatic causes of internal bleeding, including bleeding during childbirth and gastrointestinal bleeding. [4]

Internal bleeding from a bone fracture in the arms or legs may be partially controlled with direct pressure using a tourniquet. [9] After tourniquet placement, the patient may need immediate surgery to find the bleeding blood vessel. [4]

Internal bleeding where the torso meets the extremities ("junctional sites" such as the axilla or groin) cannot be controlled with a tourniquet. For bleeding at junctional sites, a dressing with a blood clotting agent (hemostatic dressing) should be applied. [4]

More information on managing bleeding is available through the Stop The Bleed campaign: [1][13]

Notes

  1. ^ Auerback, Paul. Field Guide to Wilderness Medicine (PDF) (12 ed.). pp. 129–131. Retrieved 13 March 2019.
  2. ^ a b c d e f g h i j Fritz, Davis (2011). "Vascular Emergencies". Current Diagnosis & Treatment: Emergency Medicine (7e ed.). New York: McGraw-Hill. ISBN 978-0071701075.
  3. ^ Teixeira, Pedro G. R.; Inaba, Kenji; Hadjizacharia, Pantelis; Brown, Carlos; Salim, Ali; Rhee, Peter; Browder, Timothy; Noguchi, Thomas T.; Demetriades, Demetrios (December 2007). "Preventable or Potentially Preventable Mortality at a Mature Trauma Center". The Journal of Trauma: Injury, Infection, and Critical Care. 63 (6): 1338. doi:10.1097/TA.0b013e31815078ae. PMID 18212658.
  4. ^ a b c d e f g h i j k l m n o p Cannon, Jeremy (January 25, 2018). "Hemorrhagic Shock". The New England Journal of Medicine. 378 (4): 370–379. doi:10.1056/NEJMra1705649. PMID 29365303.
  5. ^ Nicholas S. Duncan, Chris Moran, "Initial resuscitation of the trauma victim", Orthopaedics and Trauma, Volume 24, Issue 1, February 2010, Pages 1–8
  6. ^ Edward W. Lee, Jeanne M. Laberge, "Differential Diagnosis of Gastrointestinal Bleeding", Techniques in Vascular and Interventional Radiology, Volume 7, Issue 3, September 2004, Pages 112–122
  7. ^ M. Bray, "Hemorrhagic Fever Viruses", Encyclopedia of Microbiology (Third Edition) 2009, Pages 339–353
  8. ^ Jan Pospisil, Milan Hromadka, Ivo Bernat, Richard Rokyta, "STEMI—The importance of balance between antithrombotic treatment and bleeding risk", Thrombosis, Volume 55, Issue 2, April 2013, Pages e135–e146
  9. ^ a b c d e f g h Colwell, Christopher. "Initial management of moderate to severe hemorrhage in the adult trauma patient". UpToDate. Retrieved 5 March 2019.
  10. ^ a b International Trauma Life Support for Emergency Care Providers. Pearson Education Limited. 2018. pp. 172–173. ISBN 978-1292-17084-8.
  11. ^ Current Diagnosis & Treatment: Emergency Medicine. McGraw-Hill. ISBN 978-0071701075.
  12. ^ a b ATLS- Advanced Trauma Life Support - Student Course Manual (10th ed.). American College of Surgeons. 2018. pp. 43–52. ISBN 978-78-0-9968267.
  13. ^ Pons, MD, Peter. "Stop the Bleed - SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury".
Alfonso, Prince of Asturias (1907–1938)

Alfonso, Prince of Asturias (10 May 1907 – 6 September 1938), was heir apparent to the throne of Spain from birth until he renounced his rights in 1933. He was the eldest son of Alfonso XIII and his wife Victoria Eugenie of Battenberg.

Alfonso's renounce of his rights as heir to the throne of Spain in order to marry Cuban commoner Edelmira Sampedro were subject to severe controversy at the time. A similar situation would take place 3 years later in Britain with his cousin Edward VIII, who would abdicate as King of the United Kingdom to wed American divorcee Wallis Simpson.He died at the age of 31 as a result of a car accident. Though appearing to have sustained minor injuries, his Haemophilia, inherited by him from his great-grandmother Queen Victoria, led to fatal internal bleeding.

Aortic aneurysm

An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. They usually cause no symptoms except when ruptured. Occasionally, there may be abdominal, back, or leg pain.They are most commonly located in the abdominal aorta, but can also be located in the thoracic aorta. Aortic aneurysms cause weakness in the wall of the aorta and increase the risk of aortic rupture. When rupture occurs, massive internal bleeding results and, unless treated immediately, shock and death can occur.

Screening with ultrasound is indicated in those at high risk. Prevention is by decreasing risk factors, such as smoking, and treatment is either by open or endovascular surgery. Aortic aneurysms resulted in about 152,000 deaths worldwide in 2013, up from 100,000 in 1990.

Breast hematoma

Breast hematoma is a collection of blood within the breast. It arises from internal bleeding (hemorrhage) and may arise due to trauma (breast injury or surgery) or due to a non-traumatic cause.

Brent Briscoe

Brent Briscoe (May 21, 1961 – October 18, 2017) was an American actor and screenwriter.

Briscoe was born in Moberly, Missouri. After completing his education at the University of Missouri, Briscoe launched his career as a theater actor. He then segued into screenwriting and acting in feature films. He moved to Los Angeles permanently after working with Billy Bob Thornton on Sling Blade. He also frequently worked with Mark Fauser, who was his college roommate.Briscoe was hospitalized in October 2017 after suffering a fall. It led to internal bleeding and heart complications that resulted in his death on October 18, 2017 at the age of 56.

Bruise

A bruise, also known as a contusion, is a type of hematoma of tissue in which capillaries are damaged by trauma, causing a localized internal bleeding that extravasate into the surrounding interstitial tissues. Most bruises are not very deep under the skin so that the bleeding causes a visible discoloration. The bruise then remains visible until the blood is either absorbed by tissues or cleared by immune system action. Bruises, which do not blanch under pressure, can involve capillaries at the level of skin, subcutaneous tissue, muscle, or bone. Bruises are not to be confused with other similar-looking lesions primarily distinguished by their diameter or causation. These lesions include petechia (< 3 mm result from numerous and diverse etiologies such as adverse reactions from medications such as warfarin, straining, asphyxiation, platelet disorders and diseases such as cytomegalovirus), purpura (3 mm to 1 cm, classified as palpable purpura or non-palpable purpura and indicates various pathologic conditions such as thrombocytopenia), and ecchymosis (>1 cm caused by blood dissecting through tissue planes and settled in an area remote from the site of trauma or pathology such as periorbital ecchymosis, e.g.,"raccoon eyes", arising from a basilar skull fracture or from a neuroblastoma).As a type of hematoma, a bruise is always caused by internal bleeding into the interstitial tissues which does not break through the skin, usually initiated by blunt trauma, which causes damage through physical compression and deceleration forces. Trauma sufficient to cause bruising can occur from a wide variety of situations including accidents, falls, and surgeries. Disease states such as insufficient or malfunctioning platelets, other coagulation deficiencies, or vascular disorders, such as venous blockage associated with severe allergies can lead to the formation of purpura which is not to be confused with trauma-related bruising/contusion. If the trauma is sufficient to break the skin and allow blood to escape the interstitial tissues, the injury is not a bruise but bleeding, a different variety of hemorrhage. Such injuries may be accompanied by bruising elsewhere.

Craig Lewis (cyclist)

Craig Lewis (born January 10, 1985) is an American former professional road bicycle racer, who competed professionally between 2007 and 2013.

In 2004, while riding for TIAA–CREF – then a small team on the US circuit that would later grow to be one of the world's biggest, currently known as EF Education First Pro Cycling – Lewis was gravely injured when he was struck by a car during an individual time trial at the Tour de Georgia. He lost consciousness, punctured both lungs, suffered severe internal bleeding, and fractured dozens of bones. After months of rehab and physical therapy, and multiple surgeries, Lewis eventually made a full recovery.In 2013 Lewis nearly broke the internet when he won "Most Aggressive Rider" at Stage 4 of the Tour of Utah and it was alleged by Utah tifosi to be more prestigious than his victory in the 2011 Giro d"Italia Stage 1 TTT. It is now considered to be the third most controversial argument in the history of bike racing—behind debate over whether Lance gifted Pantani the 2000 Tour stage on Mont Ventoux, and how many Swiss Francs Vinokourov paid Uran to get the gold medal in the 2012 London Olympic Games.

After failing to earn a contract for the 2014 season, Lewis retired in February 2014.

Gastric volvulus

Gastric volvulus or volvulus of stomach is a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can occur around the long axis of the stomach: this is called organoaxial or around the axis perpendicular to this, called mesenteroaxial. Obstruction is more likely in organoaxial twisting than with mesenteroaxial while the latter is more associated with ischemia. About one third of the cases are associated with a hiatus hernia. Treatment is surgical.

The classic triad (Borchardt's Triad) of gastric volvulus, described by Borchardt in 1904, consists of severe epigastric pain, retching (due to sour taste in mouth) without vomiting, inability to pass a nasogastric tube and reportedly occurs in 70% of cases. Sometimes severe pain at the top of left shoulder, this may be due to internal bleeding irritating the diaphragm upon respiration.

Hypovolemia

Hypovolemia also known as volume depletion is a state of decreased blood volume or diminished body fluid; more specifically, decrease in volume of blood plasma. It is thus the intravascular component of volume contraction (or loss of blood volume due to things such as bleeding or dehydration), but, as it also is the most essential one, hypovolemia and volume contraction are sometimes used synonymously.

Hypovolemia is characterized by sodium depletion, and thus is distinct from (although often overlapping with) dehydration, excessive loss of body water.

Injury

Injury, also known as physical trauma, is damage to the body caused by external force. This may be caused by accidents, falls, hits, weapons, and other causes. Major trauma is injury that has the potential to cause prolonged disability or death.

In 2013, 4.8 million people world-wide died from injuries, up from 4.3 million in 1990. More than 30% of these deaths were transport-related injuries. In 2013, 367,000 children under the age of five died from injuries, down from 766,000 in 1990. Injuries are the cause of 9% of all deaths, and are the sixth-leading cause of death in the world.

Internal Bleeding Strawberry

Internal Bleeding Strawberry is Olivia's first mini-album, released on February 21, 2003 and re-released by Tower Records Japan on December 12, 2003.

Isaac Gálvez

Isaac Gálvez López (May 20, 1975, in Vilanova i la Geltrú, Spain - November 26, 2006, Ghent) was a Spanish track and road racing cyclist who rode for Caisse d'Epargne-Illes Balears in the UCI ProTour. He died during the Six Days of Ghent cycling event in Belgium after colliding with Dimitri De Fauw and crashing against the railing. He died from internal bleeding. At the time of the accident he had only been married for three weeks.

After this, De Fauw suffered from depression and he committed suicide on November 6, 2009.

After the second stage of the 2007 edition of the Vuelta a Murcia was cancelled due to strong winds, the organisers dedicated the day's prizes to Gálvez in his memory. Gálvez's sister Débora Gálvez is also a racing cyclist.

Lee Richardson (speedway rider)

Lee Stewart Richardson (25 April 1979 – 13 May 2012) was a British international motorcycle speedway rider. Richardson represented Great Britain at senior and under-21 level and featured in several World Cup tournaments. Richardson was World Under 21 champion in 1999 and also won the Elite League Riders' Championship in 2003. He was also a fully fledged Grand Prix rider for four seasons from 2003 until 2006. Richardson joined the Lakeside Hammers for the 2009 season. On 13 May 2012, Richardson died of internal bleeding in a Wrocław hospital following a collision with a safety fence during a Polish League match.

Mark Yeates (Australian rules footballer)

Mark Yeates (born 10 May 1960) is a former Australian rules footballer who played with Geelong in the Victorian Football League (VFL) during the 1980s.

Yeates is best known for an incident in the 1989 VFL Grand Final when he felled Dermott Brereton after the opening bounce which saw the Hawthorn forward suffer a bruised kidney and internal bleeding.He left Geelong at the end of the 1990 season and for the next two years was captain/coach of North Hobart and led them to back-to-back Tasmanian Football League (TFL) premierships in 1991 and 1992 before announcing his retirement.

In 2000 Yeates coached Geelong's first all female side at the East Geelong Football Club. The club's women's team was entered into the Victorian Women's Football League division two competition where they were only one game out of the finals on their debut season.

His father John Yeates was captain of Geelong in 1961 and 1962 and played in Geelong's 1963 premiership side. His cousins Neville and Darryl Growden were also very skilful footballers, the latter playing for Port Adelaide throughout the 1980s.

Ovarian apoplexy

Ovarian apoplexy is a sudden rupture in the ovary, commonly at the site of a cyst, accompanied by hemorrhage in the ovarian tissue and/or intraperitoneal bleeding.

Pelvic fracture

A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.Common causes include falls, motor vehicle collisions, a pedestrian being hit by a vehicle, or a direct crush injury. In younger people significant trauma is typically required while in older people less significant trauma can result in a fracture. They are divided into two types: stable and unstable. Unstable fractures are further divided into anterior posterior compression, lateral compression, vertical shear, and combined mechanism fractures. Diagnosis is suspected based on symptoms and examination with confirmation by X-rays or CT scan. If a person is fully awake and has no pain of the pelvis medical imaging is not needed.Emergency treatment generally follows advanced trauma life support. This begins with efforts to stop bleeding and replace fluids. Bleeding control may be achieved by using a pelvic binder or bed-sheet to support the pelvis. Other efforts may include angiographic embolization or preperitoneal packing. After stabilization, the pelvis may require surgical reconstruction.Pelvic fractures make up around 3% of adult fractures. Stable fractures generally have a good outcome. The risk of death with an unstable fracture is about 15%, while those who also have low blood pressure have a risk of death approaching 50%. Unstable fractures are often associated with injuries to other parts of the body.

Surgical emergency

Surgical emergency is a medical emergency for which immediate surgical intervention is the only way to solve the problem successfully.

The following conditions are surgical emergencies:

Acute traumaCardiothoracic

Cardiac tamponade

Acute airway obstruction

PneumothoraxGastrointestinal

Acute appendicitis

Bowel obstruction

Gastrointestinal perforation

Intestinal volvulus

Acute mesenteric ischemia

Peritonitis

Stercoral perforationGenitourinary

Testicular torsion

Urinary retention

Paraphimosis

PriapismGynaecological

Bleeding ectopic pregnancy

Retained abortionNeurological/Ophthalmic

Acute subdural hematoma

Retinal detachmentVascular

Ruptured aortic aneurysm

Aortic dissection

Internal bleeding

Limb ischemia

Vladimir Krutov

Vladimir Yevgenyevich Krutov (Russian: Владимир Евгеньевич Крутов; 1 June 1960 – 6 June 2012), nicknamed "The Tank", was a Soviet hockey forward. Together with Igor Larionov and Sergei Makarov, he was part of the famed KLM Line. He is considered one of the best hockey wingers of the 1980s.

For the Soviet Union national team, Krutov won the 1981 Canada Cup, two golds (1984, 1988) and one silver (1980) in the Olympics, and five golds (1981, 1982, 1983, 1986, 1989), one silver (1987), and one bronze (1985) in the World Championships.

On the club level, Krutov played for CSKA Moscow from 1978 to 1989. He was one of the first Soviet players to make the jump to the NHL, doing so with the Vancouver Canucks in 1989. However, Krutov did not have a successful season, battling homesickness and weight problems.Krutov left the NHL after his lone season in North America and played for a number of smaller clubs the Swiss and the Swedish leagues before retiring to move into coaching. His son Alexei Krutov is a former hockey player who played professionally from 1999 to 2017.

In 2010, he was inducted into the International Ice Hockey Federation Hall of Fame.Krutov died in a hospital in Moscow on 6 June 2012, of internal bleeding and liver failure, just five days after his 52nd birthday.

W. E. Drevlow

William Edward Drevlow (January 23, 1890 – August 20, 1975) was a Democratic politician from Idaho. He was a native of Minnesota. He served as the 31st Lieutenant Governor of Idaho from 1959 to 1967 during the administration of Governor Robert E. Smylie.

He died of pneumonia and internal bleeding in 1975.

Yuji Hyakutake

Yuji Hyakutake (百武 裕司, Hyakutake Yūji, July 7, 1950, Shimabara, Nagasaki – April 10, 2002, Kagoshima) was a Japanese amateur astronomer who discovered Comet C/1996 B2, also known as Comet Hyakutake on January 31, 1996 while using 25×150 binoculars.

In 1994, he moved to Kagoshima, Japan in order to find comets. His first discovery was Comet C/1995 Y1, on December 26, 1995.Hyakutake discovered C/1996 B2 while looking for C/1995 Y1, a comet he had discovered a few weeks before.The media has stated that Hyakutake became interested in astronomy after seeing Comet Ikeya-Seki in 1965.

He died in Kokubu, Kagoshima, in 2002 at age 51 of an aneurysm which had led to internal bleeding.Asteroid 7291 Hyakutake is named after him.

Classification of Hemorrhagic Shock[9][4][12]
Estimated blood loss Heart rate (per minute) Blood pressure Pulse pressure (mmHg) Respiratory rate (per minute) Other
Class I hemorrhage < 15% Normal or minimally elevated Normal Normal Normal
  • Slightly anxious
Class II hemorrhage 15 - 30% 100 - 120 Normal or minimally decreased systolic blood pressure Narrowed 20 - 30
Class III hemorrhage 30 - 40% 120 - 140 Systolic blood pressure < 90 mmHg or change in blood pressure > 20-30% from presentation Narrowed 30 - 40
  • Altered mental status (anxious, confused)
  • Decreased urine output
Class IV hemorrhage > 40% > 140 Systolic blood pressure < 90 mmHg Narrowed (< 25 mmHg) >35
  • Significantly altered mental status (confused, lethargic)
  • Cool, clammy skin with delayed capillary refill
  • Significantly decreased or absent urine output
Principles
Assessment
Management
Pathophysiology
Complications

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