Haemorrhage

In the human body, our blood vessels form a vital network, transporting life-sustaining blood to every cell and organ. When this delicate system is compromised, and blood escapes from its usual confines, we experience what medically is known as a haemorrhage. This isn't just about a simple cut; haemorrhage encompasses any form of bleeding, from the faint bruise under the skin to massive internal bleeding that can threaten life itself. It's a critical concept in medicine, demanding swift recognition and often immediate intervention. 

This detailed guide will talk about haemorrhage, shedding light on its various forms, underlying causes, and the vital steps taken to control it.

Haemorrhage, pronounced 'hem-or-idge', is the medical term for the escape of blood from a ruptured blood vessel. Essentially, it means bleeding. This bleeding can be external, where blood exits the body through a wound or orifice (like a nosebleed), or internal, where blood collects inside the body cavities or tissues. The severity of a haemorrhage depends on several factors: the amount of blood lost, the rate at which it is lost, and the location of the bleeding. Even a relatively small amount of blood loss in a critical area, such as the brain, can have devastating consequences, while a larger loss from a less critical area might be tolerated better, provided it's controlled quickly.

Blood loss from haemorrhage can lead to a state of shock, known as hypovolaemic shock, if the volume of circulating blood becomes too low to deliver sufficient oxygen to the body's tissues and organs. This highlights why prompt recognition and management of haemorrhage are absolutely critical in medical emergencies.

Haemorrhage can be classified in various ways, primarily by its location, cause, and the type of blood vessel involved. Understanding these distinctions is crucial for accurate diagnosis and effective treatment of bleeding.

1. By Location

External Haemorrhage: Blood exits the body through a break in the skin or from a natural opening.

• Epistaxis (Nosebleed): Common and usually benign.
• Haematemesis: Vomiting blood (from the upper gastrointestinal tract).
• Melaena: Black, tarry stools due to digested blood (from the upper gastrointestinal tract).
• Haematochezia: Bright red blood in stool (from the lower gastrointestinal tract).
• Haematuria: Blood in the urine.
• Haemoptysis: Coughing up blood (from the respiratory tract).
• Otorrhagia: Bleeding from the ear.
• Vaginal Bleeding: Outside of menstruation (e.g., postpartum haemorrhage).

Internal Haemorrhage: Blood collects within body cavities or tissues and does not exit the body. This can be more dangerous as it's not always visible.

• Intracranial Haemorrhage: Bleeding inside the skull, which can compress the brain.
• Intra-abdominal Haemorrhage: Bleeding into the abdominal cavity (e.g., ruptured spleen, ectopic pregnancy).
• Retroperitoneal Haemorrhage: Bleeding behind the abdominal lining.
• Haemothorax: Bleeding into the chest cavity around the lungs.
• Haemarthrosis: Bleeding into a joint space (common in haemophilia).
• Haematoma: A collection of clotted blood outside blood vessels, under the skin (e.g., a severe bruise) or in tissues.

2. By Type of Blood Vessel

Arterial Haemorrhage: Blood from an artery; typically bright red, spurts or pulses with each heartbeat, and is difficult to control. This is the most serious type due to rapid blood loss.

Venous Haemorrhage: Blood from a vein; usually darker red, flows steadily and continuously, and is generally easier to control than arterial bleeding.

Capillary Haemorrhage: Blood from capillaries; typically a slow, oozing flow, bright red, and usually stops on its own. This is seen in minor cuts and abrasions.
 

3. By Severity (based on estimated blood loss for adults):

Class 1: Up to 15% blood volume lost (minimal symptoms).

Class 2: 15-30% blood volume lost (tachycardia, mild drop in blood pressure).

Class 3: 30-40% blood volume lost (significant tachycardia, hypotension, altered mental status).

Class 4: Over 40% blood volume lost (severe shock, immediate life threat).

Haemorrhage can result from a wide range of factors, broadly categorised into trauma, medical conditions, and therapeutic interventions.

1. Trauma

• Blunt Trauma: Injuries from impacts, falls, or collisions (e.g., car accidents, sports injuries) can cause internal bleeding from damaged organs (spleen, liver, kidneys) or blood vessels, even if there's no visible external wound.
• Penetrating Trauma: Injuries from sharp objects (knives, glass, shrapnel) or projectiles (bullets) directly cut or tear blood vessels.
• Fractures: Bone fractures, especially of large bones like the femur or pelvis, can cause significant blood loss into surrounding tissues.
   

2. Medical Conditions

• Blood Clotting Disorders:
  • Haemophilia: Genetic deficiency in specific clotting factors.
  • Von Willebrand Disease: Deficiency or defect in von Willebrand factor, affecting platelet adhesion.
  • Thrombocytopenia: Low platelet count, impairing clot formation.
  • Liver Disease: Impaired production of clotting factors by the liver.
  • Vitamin K Deficiency: Vitamin K is essential for producing several clotting factors.
  • Disseminated Intravascular Coagulation (DIC): A severe, systemic condition leading to widespread clotting and bleeding due to rapid consumption of clotting factors.
• Blood Vessel Abnormalities:
  • Aneurysms: Weakened, bulging areas in artery walls that can rupture (e.g., aortic aneurysm, cerebral aneurysm leading to subarachnoid haemorrhage).
  • Arteriovenous Malformations (AVMs): Abnormal tangles of blood vessels that can rupture.
  • Varices: Enlarged, twisted veins that can rupture (e.g., oesophageal varices in liver disease).
• Ulcers and Erosions:
  • Peptic Ulcers: Open sores in the lining of the stomach or duodenum, often caused by H. pylori infection or NSAID use, can erode into blood vessels.
  • Gastritis/Oesophagitis: Inflammation of the stomach or oesophagus can lead to bleeding.
• Cancers: Tumours can erode into blood vessels, causing bleeding (e.g., colon cancer causing rectal bleeding, lung cancer causing haemoptysis).
• Infections: Severe infections (sepsis) can sometimes lead to DIC. Certain infections can also cause inflammation or damage to blood vessels.
• High Blood Pressure (Hypertension): Chronically high blood pressure can weaken blood vessels, increasing the risk of rupture, especially in the brain (intracerebral haemorrhage).
• Pregnancy and Childbirth:
  • Postpartum Haemorrhage (PPH): Excessive bleeding after childbirth, often due to uterine atony (uterus fails to contract), retained placental tissue, or tears.
  • Ectopic Pregnancy: Rupture of a pregnancy outside the uterus.
  • Placental Abruption/Placenta Praevia: Complications during pregnancy involving the placenta.

3. Therapeutic Interventions/Medications

• Anticoagulants (Blood Thinners): Medications like warfarin, heparin, rivaroxaban, dabigatran, apixaban, and edoxaban are designed to prevent blood clots but increase the risk of bleeding.
• Antiplatelet Drugs: Aspirin, clopidogrel, ticagrelor, etc., prevent platelets from clumping, increasing bleeding risk.
• Surgery: All surgeries carry a risk of bleeding, though this is usually controlled by the surgical team.
• Biopsies and Medical Procedures: Invasive diagnostic or therapeutic procedures can inadvertently damage blood vessels.

The symptoms of haemorrhage depend on the location, amount, and rate of blood loss. They can range from obvious external bleeding to subtle signs of internal bleeding or shock.

Visible External Bleeding:

• Obvious blood loss: From a wound, nose, mouth, rectum, vagina, or urine.
• Petechiae: Tiny red or purple pinpoint spots under the skin.
• Purpura: Larger purple or brown spots on the skin.
• Ecchymosis (Bruising): Discolouration of the skin due to blood pooling underneath.
   

Signs of Internal Bleeding or Significant Blood Loss (Hypovolaemic Shock):

• Weakness and Fatigue: Due to reduced oxygen-carrying capacity (anaemia) from blood loss.
• Dizziness or Lightheadedness: Especially when standing up.
• Fainting (Syncope).
• Rapid Heart Rate (Tachycardia): The heart tries to compensate for reduced blood volume by pumping faster.
• Low Blood Pressure (Hypotension): As blood volume decreases.
• Pale, Clammy Skin: Reduced blood flow to the skin.
• Shortness of Breath (Dyspnoea): Due to less oxygen reaching tissues.
• Altered Mental Status: Confusion, disorientation, restlessness, or loss of consciousness due to reduced blood flow to the brain.
• Cold Extremities: Hands and feet feel cold due to poor circulation.
• Decreased Urine Output: Kidneys try to conserve fluid.
• Abdominal Pain or Swelling: If bleeding occurs in the abdominal cavity.
• Severe Headache with Neurological Changes: If bleeding occurs in the brain (e.g., sudden severe headache, weakness on one side of the body, vision changes).
• Vomiting Blood (Haematemesis) or Passing Black, Tarry Stools (Melaena): Indicates bleeding in the upper digestive tract.
• Passing Bright Red Blood from the Rectum (Haematochezia): Indicates bleeding in the lower digestive tract.

Diagnosing haemorrhage involves quickly identifying the source and severity of bleeding, especially in emergency situations.

Clinical Assessment:

• Medical History: Inquiring about recent trauma, medical conditions (e.g., ulcers, liver disease, clotting disorders), medications (especially blood thinners), and any symptoms of bleeding.
• Physical Examination: Assessing vital signs (heart rate, blood pressure, respiratory rate), checking for external bleeding, bruising, petechiae, tenderness, and signs of shock (pallor, clammy skin, altered mental status). Neurological examination for suspected brain bleeds.

Laboratory Tests:

• Full Blood Count (FBC): Measures haemoglobin and haematocrit (to assess blood loss), platelet count (to check for thrombocytopenia).
• Coagulation Profile: Prothrombin Time (PT), Activated Partial Thromboplastin Time (aPTT), and International Normalised Ratio (INR) to assess clotting factor function, especially important for patients on blood thinners.
• Blood Type and Crossmatch: Crucial for preparing blood transfusions.
• Liver and Kidney Function Tests: To check for underlying organ dysfunction that might contribute to bleeding.
• Fibrinogen and D-dimer: To assess for conditions like DIC.

Imaging Studies:

• Ultrasound: Useful for detecting internal bleeding in the abdomen (e.g., FAST exam in trauma), or for gynaecological causes (e.g., ectopic pregnancy).
• CT Scan: The gold standard for detecting internal bleeding in the head (intracranial haemorrhage), chest, abdomen, and pelvis. Can identify the exact location and extent of bleeding.
• MRI: Provides more detailed images of soft tissues and can be used for brain haemorrhages, especially subacute bleeds.
• Angiography (CT or Conventional): Involves injecting dye into blood vessels to visualise them and identify the exact source of bleeding, often used when embolisation is planned.

Endoscopy/Colonoscopy: If gastrointestinal bleeding is suspected, an upper endoscopy (to examine the oesophagus, stomach, and duodenum) or colonoscopy (to examine the large bowel) can directly visualise the bleeding source and allow for immediate intervention.

Diagnostic Peritoneal Lavage (DPL): An older technique used in trauma to detect blood in the abdominal cavity, largely replaced by FAST ultrasound.

The treatment of haemorrhage is highly dependent on its location, severity, and underlying cause. The primary goals are to stop the bleeding, replace lost blood volume, and treat any underlying conditions.

1. Immediate Life Support and Haemorrhage Control:

• Direct Pressure: For external bleeding, applying firm, direct pressure to the wound is the first and most crucial step.
• Elevation: Elevating the injured limb above the heart can help reduce blood flow.
• Tourniquet: In severe, life-threatening limb bleeding that cannot be controlled by direct pressure, a tourniquet may be applied as a last resort.
• Fluid Resuscitation: Intravenous (IV) fluids (Brands: Haemaccel) are given to replenish lost fluid volume, electrolytes, and maintain blood pressure.
• Blood Transfusion: If significant blood loss has occurred, transfusions of red blood cells, plasma, and platelets may be necessary to restore oxygen-carrying capacity and clotting ability.
• Tranexamic Acid (TXA): An antifibrinolytic drug (Brands: Trenaxa, Pause) that helps stabilise blood clots, often used in trauma, postpartum haemorrhage, and certain types of medical bleeding.
• Reversal of Anticoagulation: If the patient is on blood thinners, specific reversal agents (e.g., Vitamin K, fresh frozen plasma, prothrombin complex concentrate) may be administered.

2. Identifying and Addressing the Source:

• Surgical Intervention: For major internal bleeding (e.g., ruptured spleen, ectopic pregnancy, major trauma, large vessel injury), surgery is often required to repair damaged vessels or remove bleeding organs.
• Endoscopic Procedures: For gastrointestinal bleeding, an endoscopy can be used to visualise the bleeding source and apply techniques like clips, banding, thermal coagulation, or injection therapy to stop the bleed.
• Interventional Radiology (Angiography with Embolisation): For certain types of internal bleeding (e.g., some GI bleeds, arterial bleeds in the limbs, post-traumatic bleeding), radiologists can insert a catheter into an artery, locate the bleeding vessel, and block it using coils or other embolic agents.
• Neurological Intervention: For intracranial haemorrhage, treatment depends on the type and location. This might involve surgery (e.g., craniotomy to remove haematoma or clip an aneurysm) or less invasive monitoring and medication.
• Uterine Massage and Medications (for Postpartum Haemorrhage): For PPH, uterine massage and medications (e.g., oxytocin, ergometrine, misoprostol) are used to contract the uterus and stop bleeding.

3. Treating Underlying Causes:

• Clotting Factor Replacement: For individuals with haemophilia or other specific clotting factor deficiencies, direct replacement of the missing factor is given.
• Platelet Transfusion: For severe thrombocytopenia, platelet transfusions may be given to boost counts temporarily.
• Management of Liver Disease: Treating underlying liver disease can improve clotting factor production.
• Blood Pressure Control: For haemorrhages linked to hypertension, controlling blood pressure is vital.

• Anticoagulant or antiplatelet medication use: Blood thinners increase bleeding risk.
• Underlying clotting disorders: Such as haemophilia or von Willebrand disease.
• Severe trauma: Accidents, falls, injuries.
• High blood pressure: Weakens blood vessels, especially in the brain.
• Liver disease: Impairs production of clotting factors.
• Certain types of cancer: Can erode blood vessels.
• Recent surgery or medical procedures: Inherent risk of bleeding.
• Advanced age: Fragile blood vessels, more co-morbidities.
• Alcohol abuse: Can impair clotting and damage the liver.
• Pregnancy and childbirth complications: Such as postpartum haemorrhage.

• Hypovolaemic shock: Life-threatening drop in blood pressure due to massive blood loss.
• Organ damage: Due to lack of oxygen from reduced blood flow (e.g., kidney failure, brain injury).
• Anaemia: From chronic or acute blood loss, leading to fatigue and weakness.
• Neurological deficits: From intracranial haemorrhage (e.g., stroke, paralysis, cognitive impairment).
• Compartment syndrome: Swelling and pressure in muscle compartments, common in limb trauma.
• Infection: Risk if haematoma becomes infected.
• Death: In severe, uncontrolled haemorrhage.

Living with a chronic bleeding tendency or recovering from a major haemorrhage requires careful attention to your health.

• Understand Your Specific Condition: Learn as much as you can about your type of bleeding disorder or the cause of your haemorrhage. Knowing your triggers and how to manage them is crucial.
• Adhere to Your Treatment Plan: Consistently take prescribed medications, attend all follow-up appointments, and follow your doctor's advice regarding lifestyle modifications.
• Be Vigilant for Bleeding Signs: Regularly check for new bruising, petechiae, or any unexplained blood. Be particularly aware of symptoms of internal bleeding (e.g., severe headache, abdominal pain).
• Carry Medical Identification: Wear a medical alert bracelet or carry a card detailing your condition and current medications. This is vital in an emergency when you might not be able to communicate.
• Communicate with Your Healthcare Team: Maintain open communication with your doctors, nurses, and pharmacists. Report any new symptoms, concerns, or side effects promptly.

Misconception: All bleeding is visible and external.

Reality: Many of the most dangerous haemorrhages are internal, meaning blood collects inside the body and doesn't appear externally. Symptoms of internal bleeding can be subtle, such as weakness, dizziness, or abdominal pain, making them harder to detect.

Misconception: A small amount of blood loss is never serious. 

Reality: The severity of haemorrhage isn't just about the volume of blood lost, but also its location. A small amount of bleeding in a critical area like the brain or around the heart can be life-threatening due to pressure on vital organs, even if the total blood loss is minimal.

Misconception: Only severe injuries cause haemorrhage. 

Reality: While severe trauma is a major cause, haemorrhage can occur from seemingly minor incidents or even spontaneously due to underlying medical conditions (like bleeding disorders, high blood pressure, or stomach ulcers) or as a side effect of common medications (like blood thinners).

You should see a doctor immediately or seek emergency medical attention if you experience:

• Any significant or uncontrolled bleeding: Especially if it's arterial (spurting blood).
• Signs of shock: Dizziness, fainting, rapid heart rate, low blood pressure, pale/clammy skin, confusion.
• Symptoms suggestive of internal bleeding: Severe, unexplained abdominal pain, vomiting blood, black or tarry stools, bright red blood in stools, severe headache with neurological changes (weakness, vision changes).
• Bleeding that doesn't stop with direct pressure.
• Bleeding after an injury, even if minor, if you are on blood thinners.

• What is the likely cause of my bleeding/haemorrhage?
• What is the most appropriate treatment for my condition?
• Are there any medications I should avoid or be careful with?
• What are the signs of serious bleeding I should watch out for?
• What is my risk of future bleeding episodes?
• Are there any lifestyle changes I should make to reduce my risk?
• Should I carry a medical alert card or wear a medical bracelet?

• Stay Calm and Provide First Aid: In an acute bleeding emergency, your calm demeanor is crucial. Apply direct pressure to external wounds, elevate the injured area if possible, and call for emergency medical services (e.g., 999 in the UK).
• Be Aware of Their Medical History: If they have a known bleeding disorder or are on blood thinners, understand their specific condition and emergency plan. Know where their emergency medications are (if any).
• Monitor for Symptoms of Internal Bleeding: After an injury or if they have an underlying condition, be vigilant for subtle signs of internal bleeding such as increasing pain, swelling, unexplained fatigue, pallor, dizziness, or changes in consciousness.

Haemorrhage, the uncontrolled escape of blood from vessels, is a critical medical event that demands swift recognition and intervention. Far more than just a visible cut, it encompasses a spectrum of bleeding episodes, from minor bruises to life-threatening internal leaks in vital organs. Understanding the diverse types, myriad causes – be it trauma, underlying medical conditions, or medication side effects – and the often subtle symptoms is paramount. While the prospect of severe bleeding can be daunting, advancements in diagnosis and treatment, coupled with effective preventative strategies, offer significant hope. By empowering ourselves with knowledge, adhering to medical guidance, and fostering supportive environments, we can navigate the complexities of haemorrhage, mitigating its risks and safeguarding health.