Internal bleeding is a condition in which blood is poured either into the natural cavity of the body (stomach, bladder, uterus, lungs, joint cavity, etc.), or into the space artificially formed by the spilled blood (retroperitoneal, intermuscular). Symptoms of internal bleeding depend on its localization and the degree of blood loss, usually include dizziness, weakness, drowsiness, loss of consciousness. Pathology is diagnosed on the basis of external examination data, results of radiography, CT, MRI and endoscopic examinations. Treatment – infusion therapy, surgical elimination of the source of bleeding.
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Internal bleeding is a loss of blood in which blood does not flow outwards, but into one of the cavities of the human body. The cause may be an injury or a chronic disease. The massive nature of blood loss, the late treatment of patients for help and diagnostic difficulties in detecting this pathology increase the severity of the problem and turn internal bleeding into a serious threat to patients’ lives. The treatment is carried out by specialists in the field of clinical traumatology, abdominal and thoracic surgery, neurosurgery, vascular surgery.
The cause of internal bleeding can be both trauma and some chronic diseases. Massive, life–threatening post-traumatic bleeding into the abdominal cavity can develop as a result of blunt abdominal trauma with damage to the spleen and liver, less often – the pancreas, intestines or mesentery (with a blow, a fall from a height, a car accident, etc.). Bleeding into the pleural cavity usually occurs with multiple rib fractures with damage to intercostal vessels and the pleura. In isolated cases, it is caused by fractures of 1-2 ribs.
Bleeding into the cranial cavity is one of the dangerous complications of traumatic brain injury. Since the skull, unlike other natural cavities, has a rigidly fixed volume, even a small amount of spilled blood causes compression of brain structures and poses a threat to the patient’s life. It should be borne in mind that intracranial bleeding can develop not only immediately after the injury, but also after several hours or even days, sometimes against the background of complete well–being.
Bleeding into the joint cavity can be caused by both an intra-articular fracture and a bruise. There is no immediate danger to life, however, in the absence of treatment, it can lead to serious complications.
A significant proportion of the total number of internal bleeding is bleeding into the cavity of an organ that develops due to chronic diseases of the gastrointestinal tract: malignant tumors, peptic ulcer of the stomach and intestines, erosive gastritis, varicose veins of the esophagus with cirrhosis of the liver, etc. In surgical practice, Mallory-Weiss syndrome is also often found – cracks in the esophagus due to alcohol abuse or a single copious meal.
Another fairly common cause of internal bleeding is gynecological diseases: ovarian ruptures, ectopic pregnancy, etc. In gynecological practice, there are internal bleeding after abortions. There may also be internal bleeding during presentation or premature placental abruption, postpartum bleeding with delayed placental outlet, ruptures of the uterus and birth canal.
There are several classifications of internal bleeding:
- Taking into account the cause of occurrence: mechanical (due to damage to blood vessels during injuries) and erosive (due to damage to the vascular wall during necrosis, germination and decay of the tumor or destructive process). In addition, diapedetic bleeding is isolated, which occurs due to increased permeability of the wall of small vessels (for example, with scurvy or sepsis).
- Taking into account the volume of blood loss: light (up to 500 ml or 10-15% of the volume of circulating blood), medium (500-1000 ml or 16-20% of CBV), severe (1000-1500 ml or 21-30% of CBV), massive (more than 1500 ml or more than 30% of CBV, fatal (more than 2500-3000 ml or more than 50-60% CBV), absolutely fatal (more than 3000-3500 ml or more than 60% of CBV).
- Taking into account the nature of the damaged vessel: arterial, venous, capillary and mixed (for example, from an artery and vein or from a vein and capillaries). If blood flows from the capillaries of any parenchymal organ (liver, spleen, etc.), such bleeding is called parenchymal.
- Taking into account the localization: gastrointestinal (into the cavity of the esophagus, stomach or intestines), into the pleural cavity (hemothorax), into the pericardial sac (hemopericardium), into the joint cavity, etc.
- Taking into account the place of accumulation of spilled blood: cavities (in the pleural, abdominal, etc. cavities) and interstitial (in the thickness of tissues with their impregnation).
- Taking into account the presence or absence of obvious signs of bleeding: obvious, in which the blood, even after some time and in a modified form, “comes out” through natural openings (for example, staining the stool black), and hidden, in which it remains in the body cavity.
- Taking into account the time of occurrence: primary, arising immediately after traumatic damage to the vascular wall, and secondary, developing some time after the injury. In turn, secondary bleeding is divided into early (develop on 1-5 days due to slipping of the ligature or ejection of the thrombus) and late (usually occur on 10-15 days due to purulent melting of the thrombus, necrosis of the vessel wall, etc.).
Common early signs of this pathology are general weakness, drowsiness, pallor of the skin and mucous membranes, dizziness, cold sweat, thirst, darkening of the eyes. Fainting is possible. The intensity of blood loss can be judged by changes in pulse and blood pressure, as well as by other clinical signs. With low blood loss, there is a slight increase in pulse rate (up to 80 beats / min) and a slight decrease in blood pressure, in some cases clinical symptoms may be absent.
Moderate internal bleeding is indicated by a drop in systolic pressure to 90-80 mmHg and an increase in pulse rate (tachycardia) to 90-100 beats/min. The skin is pale, there is a cooling of the extremities and a slight increase in breathing. Possible dry mouth, fainting, dizziness, nausea, adynamia, pronounced weakness, slow reaction.
In severe cases, there is a decrease in systolic pressure to 80 mmHg and below, an increase in pulse rate to 110 and above beats / min. There is a strong increase in frequency and violation of the rhythm of breathing, sticky cold sweat, yawning, pathological drowsiness, tremor of the hands, darkening of the eyes, indifference, apathy, nausea and vomiting, a decrease in the amount of urine excreted, excruciating thirst, darkening of consciousness, sharp pallor of the skin and mucous membranes, cyanotic extremities, lips and nasolabial triangle.
With massive internal bleeding, the pressure decreases to 60 mm Hg, the pulse rate increases to 140-160 beats / min. It is characterized by periodic breathing (Cheyne-Stokes), absence or confusion of consciousness, delirium, sharp pallor, sometimes with a bluish-gray tinge, cold sweat. The look is indifferent, the eyes are sunken, the facial features are pointed.
With fatal blood loss, a coma develops. Systolic pressure drops to 60 mm Hg or is not determined. Agonal breathing, sharp bradycardia with a heart rate of 2-10 beats / min., convulsions, dilation of the pupils, involuntary excretion of feces and urine. The skin is cold, dry, “marble”. In the future, agony and death ensue.
Nausea and vomiting of dark blood (“coffee grounds”) indicate the flow of blood into the stomach or esophagus. Tar-like stools can be observed with internal bleeding in the upper digestive tract or small intestine. The release of unchanged scarlet blood from the anus indicates hemorrhoids or bleeding from the lower parts of the large intestine. If blood enters the abdominal cavity, there is a dulling of sound in shallow places during percussion and symptoms of irritation of the peritoneum during palpation.
With pulmonary bleeding, there is a cough with bright foamy blood, with accumulation of blood in the pleural cavity – pronounced shortness of breath, difficulty breathing, lack of air. The outflow of blood from the female genital organs indicates bleeding into the uterine cavity, less often – the vagina. With bleeding in the kidneys or urinary tract, hematuria is observed.
At the same time, a number of symptoms may not manifest themselves or be poorly expressed, especially with a small or moderate severity of internal bleeding. This significantly complicates the diagnosis and sometimes becomes the reason that patients turn to doctors already at late stages, with a significant deterioration due to significant blood loss.
If internal bleeding is suspected, it is necessary to carry out a number of diagnostic measures to confirm the diagnosis and clarify the cause of blood loss. A detailed examination is performed, including pulse and blood pressure measurement, chest auscultation, palpation and percussion of the abdominal cavity. To confirm the diagnosis and assess the severity of blood loss, laboratory tests of hematocrit, hemoglobin level and the number of red blood cells are carried out.
The choice of special research methods is carried out taking into account the alleged cause of internal bleeding: for diseases of the gastrointestinal tract, finger examination of the rectum, gastric probing, esophagogastroduodenoscopy, colonoscopy and rectoromanoscopy can be performed, for lung diseases – bronchoscopy, for bladder lesions – cystoscopy. In addition, X-ray, ultrasound and radiological techniques are used.
Diagnosis of latent internal bleeding, in which blood enters closed cavities (abdominal, thoracic, cranial cavity, pericardium, etc.), is also made taking into account the alleged source of blood loss. The disappearance of the lower contour of the lung on the X-ray and darkening in the lower parts with a clear horizontal border indicates a hemothorax. In doubtful cases, an X-ray is performed. If bleeding into the abdominal cavity is suspected, laparoscopy is performed, if intracranial hematoma is suspected, skull x-ray and echoencephalography are performed.
It is necessary to ensure the delivery of the patient to the department of specialized care as quickly as possible. The patient needs to be provided with peace. If a hemothorax or pulmonary hemorrhage is suspected, the patient is given a semi-sitting position, with blood loss in other areas, they are laid on a flat surface. Cold should be placed on the area of the alleged source of bleeding (for example, an ice pack). It is strictly forbidden to warm the affected area, put enemas, give laxatives or inject drugs into the body that stimulate cardiac activity.
Patients are admitted to the hospital. The choice of the department is carried out taking into account the source of internal bleeding. Traumatic hemothorax is treated by traumatologists, non-traumatic hemothorax and pulmonary hemorrhages are treated by thoracic surgeons, intracranial hematomas are treated by neurosurgeons, uterine bleeding is treated by gynecologists. In case of blunt abdominal trauma and gastrointestinal bleeding, hospitalization is carried out in the department of general surgery.
The main tasks in this case are urgent stopping of internal bleeding, compensation of blood loss and improvement of microcirculation. From the very beginning of treatment, for the prevention of empty heart syndrome (reflex cardiac arrest due to a decrease in the volume of CBV), restoration of the volume of circulating fluid and prevention of hypovolemic shock, a jet transfusion of 5% glucose solution, saline solution, blood, plasma and blood substitutes is performed.
Sometimes internal bleeding is stopped by tamponade or cauterization of the bleeding area. However, in most cases, urgent surgical intervention under anesthesia is required. If there are signs of hemorrhagic shock or the threat of its occurrence at all stages (preparation for surgery, surgical intervention, the period after surgery), transfusion measures are performed.
With pulmonary bleeding, bronchial tamponade is performed. With medium and small hemothorax, pleural puncture is performed, with large hemothorax – thoracotomy with suturing of a lung wound or ligation of a vessel, with loss of blood into the abdominal cavity – emergency laparotomy with suturing of a wound of the liver, spleen or other damaged organ, with intracranial hematoma – trepanation of the skull.
In case of gastric ulcer, gastric resection is performed, in case of duodenal ulcer, the vessel is stitched in combination with vagotomy. With Mallory-Weiss syndrome (bleeding from an esophageal crack), endoscopic bleeding arrest is performed in combination with cold, the appointment of antacids, aminocaproic acid and blood clotting stimulants. If conservative treatment is ineffective, surgery (stitching cracks) is indicated.
Internal bleeding due to ectopic pregnancy is an indication for emergency surgery. With dysfunctional uterine bleeding, tamponade of the uterine cavity is performed, with massive bleeding due to abortion, birth trauma and after childbirth, surgical intervention is performed.
Infusion therapy is carried out under the control of blood pressure, cardiac output, central venous pressure and hourly diuresis. The volume of infusion is determined taking into account the severity of blood loss. Hemodynamic blood substitutes are used: dextran, rheopolyglucin, solutions of salts and sugars, as well as blood preparations (albumin, freshly frozen plasma, erythrocyte mass).
If blood pressure cannot be normalized, despite the infusion therapy, after stopping the bleeding, dopamine, norepinephrine or adrenaline are injected. For the treatment of hemorrhagic shock, pentoxifylline, dipyridamole, heparin and steroid drugs are used. After eliminating the threat to life, the acid-base balance is corrected.