Haemorrhage M Kamil Department of Surgery - PowerPoint Presentation

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Haemorrhage

M Kamil

Department of Surgery

2018-2019

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Haemorrhage →

hypovolaemic shock

Tissue trauma + hypovolaemic shock → Acute Traumatic Coagulopathy (ATC)ATC → Trauma-Induced Coagulopathy (TIC) This is multifactorial:1. Ongoing bleeding with fluid and red blood cell resuscitation → dilution of coagulation factors which worsens the Coagulopathy2. Hypoperfusion → hypothermia → Coagulopathy and further haemorrhage

Haemorrhage

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3. Hypoperfusion

→

Under perfused muscle → Acidosis + Hypothermia → poor coagulation functions →further haemorrhage → hypoperfusion and worsening Acidosis and Hypothermia. 4. Cold Intravenous blood and fluids → Hypothermia. 5. Surgery → opened body cavity → further Hypothermia 6. Surgery → further bleeding → resuscitation with acidic crystalloid fluids (e.g. normal saline has a pH of 6.7) →

Acidosis

Haemorrhage

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Coagulopathy

+

Acidosis (pH < 7.2) + Hypothermia (< 35o C)

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Grossly:Revealed haemorrhage

Concealed haemorrhage

Classification:

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Revealed haemorrhage

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Concealed Haemorrhage

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Concealed Haemorrhage

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According to time frame (time of occurrence)

Primary

haemorrhage occurring immediately due to an injury (or surgery)Reactionary delayed haemorrhage (within 24 hours) and is usually due to dislodgement of clot by resuscitation, normalisation of blood pressure and vasodilatation. Reactionary haemorrhage may also be due to technical failure, such as slippage of a ligatureSecondarydue to sloughing of the wall of a vessel. It usually occurs 7–14 days after injury and is precipitated by factors such as infection, pressure necrosis (such as from a drain) or malignancyClassification:

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Surgical Haemorrhagedue to a direct injury and is

amenable to

surgical control (or other techniques such as angioembolisation)Non-surgical Haemorrhagethe general ooze from all raw surfaces due to coagulopathy and cannot be stopped by surgical means (except packing). Treatment requires correction of the coagulation abnormalitiesClassification:

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Blood volume normally is around 5 liters

Adults and children = 70ml/kg; Neonates = 80ml/kg

Estimation of the amount of blood that has been lost is difficult, inaccurate and usually underestimates the actual valueIn the theater; blood collected in suckers is counted. Swabs socked in blood is weighedBlood collected in drains can be countedBUT concealed haemorrhage is difficult to estimateHaemoglobin level is a poor indicatorVital signs; CVP; pH; Base Deficit and Dynamic Response to Fluid Therapy Estimation of the amount of blood lost

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Management

Immediate resuscitative measures:

Direct pressure should be placed over the site of external haemorrhageAirway and breathing should be assessed and controlled as necessary Large-bore intravenous cannulablood drawn for typing and cross-matching. Emergency blood should be requested if the degree of shock and ongoing haemorrhage warrants this

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Identification of the site of concealed haemorrhage

:

Aim: to define the next step in haemorrhage control (operation, angioembolisation, endoscopic control)Clues:History: (previous episodes, known aneurysm, non-steroidal therapy for gastrointestinal (GI) bleeding) Clinical examination: (nature of blood – fresh, melaena; abdominal tenderness, etc.). For shocked trauma patients, the external signs of injury may suggest internal haemorrhage, but haemorrhage into a body cavity (thorax, abdomen) must be excluded with rapid investigations (chest and pelvis x-ray, abdominal ultrasound or diagnostic peritoneal aspiration).Management

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Control of haemorrhage:

Must be rapid to prevent triad of

Coagulopathy – Acidosis – HypothermiaUn-necessary actions and investigations is omittedProlonged volume resuscitation with crystalloid is not beneficialBlood components to correct coagulopathy is desirableResorting to “Damage Control Surgery” (DCS), part of strategy of “Damage Control Resuscitation” (DCR)Once haemorrhage and sepsis controlled; aggressive resuscitation; rewarming and correction of coagulopathy should followManagement

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What is meant by Damage Control Resuscitation?

A recent strategy with FOUR main components:

First: anticipate and treat Acute Traumatic Coagulopathy (ATC) to prevent trauma-induced Coagulopathy (TIC)Second: Permissive Hypotension therapy until haemorrhage controlledThird: limitation of Crystalloid and Colloid infusion to avoid Dilutional coagulopathyFourth: Damage Control Surgery (DCS) which entails:Arresting haemorrhageControl of sepsisProtection from further injuryNothing else Management

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Haemorrhage control- direct pressure

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Haemorrhage control- direct pressure

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Haemorrhage control- surgical clamps

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Haemorrhage control- surgical clamps

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Haemorrhage control- packing

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Haemorrhage control- packing

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Haemorrhage control- balloon inflation

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Haemorrhage control-

balloon inflation

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Haemorrhage control- haemostatics

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Haemorrhage control- bone wax

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Haemorrhage control- electrocautery

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Haemorrhage control- photocoagulation

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Bleeding control: Ligature and clips

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That is the end

Thanks for listening