What is Hemorrhage?

• Definition: Hemorrhage means losing blood from a damaged blood vessel.

• Location:

  • Internal: Bleeding happens inside the body tissues or cavities (blood is ‘trapped’).

  • External: Bleeding flows outside the body, either from a visible wound or a body opening (like nose, mouth, vagina).

• Severity: Can range from minor (like a small bruise) to major and life-threatening.

• Key Point: Most significant hemorrhages are medical emergencies.

Types of Hemorrhages

Since blood vessels are everywhere, hemorrhage can happen in many places. Examples include:

• Hemothorax: Blood collects in the space between the lungs and the chest wall (pleural space). Can press on the lungs, causing breathing problems or chest pain.

• Intracranial Hemorrhage (Brain Bleed): Uncontrolled bleeding inside the brain tissue or in the layers covering the brain.

  • If in the brain tissue itself: Called a hemorrhagic stroke. Severe, can worsen rapidly. Different from ischemic stroke (blocked blood flow).

  • Types also include Subarachnoid hemorrhage (bleeding between brain and outer covering) and Epidural/Subdural hematomas (bleeding between skull/coverings).

• Postpartum Hemorrhage (PPH): Heavy vaginal bleeding after childbirth. A serious, potentially fatal condition. Can happen right after delivery or up to 12 weeks later.

• Subarachnoid Hemorrhage (SAH): Bleeding into the area beneath the arachnoid membrane (one of the protective layers around the brain and spinal cord). This is an emergency.

• Subconjunctival Hemorrhage: Bleeding in the white part of the eye. The blood is contained under the conjunctiva membrane. Usually not serious.

• Bruises (Contusions): Bleeding under the skin (usually minor internal hemorrhage).

• Hematoma: A collection or pooling of blood in the tissues, often causing a lump.

Symptoms and Causes

Symptoms of Hemorrhaging:

Symptoms vary greatly depending on where the bleeding is and how much blood is lost.

• Class I Hemorrhage (Up to 15% blood volume loss): Typically no noticeable symptoms.

• Class II Hemorrhage (15% to 30% blood volume loss): Early signs may include:

  • Feeling dizzy or lightheaded (due to dropping blood pressure).

  • Feeling tired and weak.

  • Nausea and vomiting.

  • Shortness of breath or faster breathing.

  • Increased heart rate (tachycardia).

  • Action: Seek immediate medical help (Call emergency services).

• Severe Hemorrhage (Over 30% blood volume loss): Can lead to severe symptoms and dangerous complications:

  • Confusion.

  • Seizures.

  • Loss of consciousness.

  • Hypovolemic shock (circulatory collapse due to low blood volume).

Specific Symptoms of Internal Hemorrhage by Location:

• Head: Sudden severe headache (often described as “worst headache of my life”), changes in vision, confusion, weakness on one side of the body.

• Chest: Difficulty breathing, chest pain, coughing up blood.

• Abdomen: Abdominal swelling or feeling full/distended, bruising on the abdomen, vomiting blood, blood in urine or stool.

• Bones, Joints, Muscles: Bruising, swelling, pain. Important: Bleeding into a confined space (like within muscles or compartments) can cause increased pressure on nerves and vessels (Compartment Syndrome) – this is a medical emergency requiring urgent attention to prevent permanent damage.

How to Know if You’re Hemorrhaging:

• It can be difficult to judge blood loss, especially internally or from expected sources (like postpartum bleeding).

• Be aware of your body and the symptoms of excessive blood loss (dizziness, fatigue, breathing changes).

• Crucial: Always seek medical help if you are concerned about the amount or source of bleeding.

Causes of Hemorrhages:

Hemorrhage results from damage to one or more blood vessels. Severity depends on the location and size of the damaged vessel.

Many factors and conditions can cause bleeding or increase risk:

• Conditions affecting blood clotting (e.g., hemophilia, von Willebrand disease, antiphospholipid syndrome).

• Use of certain medications that thin the blood (e.g., warfarin, aspirin, clopidogrel, apixaban).

• Diseases affecting blood vessels (vascular diseases), such as aneurysms (weak, bulging artery walls) or hereditary hemorrhagic telangiectasia.

• Injuries and trauma (e.g., cuts, fractures, brain injury, gunshot/knife wounds).

• Damage to internal organs (e.g., stomach ulcer bleeding).

• Complications from medical procedures like surgery.

• Certain infections, particularly viral hemorrhagic fevers (e.g., Ebola, dengue), which damage blood vessels.

• Alcohol use disorder (risk factor for some types like SAH).

• Cancer.

Diagnosis

• Healthcare providers diagnose hemorrhage by assessing symptoms (what the patient feels, e.g., dizziness) and signs (what is observed, e.g., fast heart rate, low blood pressure).

• The next steps are to find the source/location and the underlying cause. External bleeding is usually obvious, but internal bleeding can be hidden.

• Diagnosis involves:

  • Physical examination.

  • Review of symptoms and medical history.

  • May require imaging tests (like CT scans, MRI, ultrasound) to visualize internal bleeding.

  • Laboratory tests (like blood counts, clotting factors).

Management and Treatment

Treatment is based on:

• Location (internal vs. external).

• Severity of blood loss.

• The underlying reason for the bleeding.

• The patient’s overall health and other injuries/conditions.

• Severe or unexplained bleeding requires hospital treatment.

• Healthcare team will find and treat the cause. This may involve:

  • Surgery to repair damaged vessels or stop bleeding.

  • Vitamin K injections (if bleeding is linked to certain medications like warfarin).

  • Administering IV fluids to replace volume.

  • Blood transfusions to replace lost red blood cells, plasma, or platelets.

First Aid for Severe External Hemorrhage:

If you encounter severe external bleeding:

1. Call Emergency Services (911 or local equivalent) immediately.

2. Position: Lay the person down. If a limb is bleeding severely, elevate it above the heart if possible (unless fracture is suspected).

3. Apply Pressure:

   • Cover the wound with clean cloth or sterile gauze (if available).

   • Apply direct, firm pressure to the wound with your hands. If the person can, have them do it.

   • Do not remove any object embedded in the wound; apply pressure around the object.

4. Bandage: If possible, secure the dressing with a bandage or clean cloth, maintaining pressure.

5. Tourniquet: Use a tourniquet only as a last resort for severe, uncontrollable bleeding from a limb when direct pressure is not working. Requires proper training.

Prognosis (Outlook)

• The outlook after a hemorrhage depends on:

  • The specific type and location of bleeding.

  • How severe the blood loss is.

  • How quickly treatment is received.

  • The patient’s age and overall health status.

• Key Factor: Prompt medical treatment significantly improves the chance of a good outcome.

Potential Complications

Complications primarily occur because major blood loss reduces blood flow and oxygen delivery to organs. This can cause tissue and cell damage.

• General Severe Complications:

  • Organ failure.

  • Seizures.

  • Coma.

  • Death (Hemorrhage is a major cause of preventable death, especially from trauma).

• Specific Complications by Type:

  • Brain hemorrhage can lead to permanent brain damage and long-term neurological problems.

  • Severe postpartum hemorrhage can cause damage to the pituitary gland (Sheehan syndrome).

• Other Complications (including hospitalization-related):

  • Rebleeding (bleeding happens again).

  • Complications from being in the hospital, such as deep vein thrombosis (DVT – blood clots in deep veins) or infection.