| Internal bleeding | |
|---|---|
| Other names | Internal hemorrhage |
 | |
| Internal bleeding in the brain | |
| Specialty | Vascular surgery,hematology,emergency medicine |
| Complications | Hemorrhagic shock,exsanguination |
Internal bleeding (also calledinternal haemorrhage) is a loss of blood from ablood vessel that collects inside the body, and is not usually visible from the outside.[1] It can be a seriousmedical emergency but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into thechest,abdomen,pelvis, orthighs can causehemorrhagic shock ordeath if proper medical treatment is not received quickly.[2] Internal bleeding is a medical emergency and should be treated immediately by medical professionals.[2]
Signs and symptoms of internal bleeding may vary based on location, presence of injury or trauma, and severity of bleeding. Common symptoms of blood loss may include:
Visible signs of internal bleeding include:
Of note, it is possible to have internal bleeding without any of the above symptoms, and pain may or may not be present.[3]
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 orhypovolemic shock, which is a type ofshock that occurs when there is not enough blood to reach organs in the body.[5]
Internal bleeding can be caused by a broad number of things and can be broken up into three large categories:
The most common cause of death in trauma isbleeding.[6] 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 andblunt trauma.[2]
A number of pathological conditions and diseases can lead to internal bleeding. These include:
Internal bleeding could be a result of complications following surgery or other medical procedures. Some medications may also increase a person's risk for bleeding, such asanticoagulant drugs orantiplatelet drugs in the treatment ofcoronary artery disease.[10]
Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, and mental status.[11] Blood is circulated throughout the body and all major organ systems through a closed loop system. When there is damage to the blood vessel or the blood is thinner than the physiologic consistency, blood can exit the vessel which disrupts this close-looped system. Theautonomic nervous system (ANS) responds in two large ways as an attempt to compensate for the opening in the system. These two actions are easily monitored by checking the heart rate and blood pressure. Blood pressure will initially decrease due to the loss of blood. This is where the ANS comes in and attempts to compensate by contracting the muscles that surround these vessels. As a result, a person who is bleeding internally may initially have a normal blood pressure. When the blood pressure falls below the normal range, this is calledhypotension. The heart will start to pump faster causing the heart rate to increase, as an attempt to get blood delivered to vital organ systems faster. When the heart beats faster than the healthy and normal range, this is calledtachycardia. If the bleeding is not controlled or stopped, a patient will experience tachycardia and hypotension, which altogether is a state of shock, calledhemorrhagic shock.
Advanced trauma life support (ATLS) by the American College of Surgeons separates hemorrhagic shock into four categories.[12][4][13]
| 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 |
|
| Class II hemorrhage | 15 - 30% | 100 - 120 | Normal or minimally decreasedsystolic 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 |
|
| Class IV hemorrhage | > 40% | > 140 | Systolic blood pressure < 90 mmHg | Narrowed (< 25 mmHg) | >35 |
|
Assessing circulation occurs after assessing the patient's airway and breathing (ABC (medicine)).[5] If internal bleeding is suspected, a patient'scirculatory system is assessed throughpalpation ofpulses anddoppler ultrasonography.[2]
It is important to examine the person for visible signs that may suggest the presence of internal bleeding and/or the source of the bleed.[2] Some of these signs may include:
If internal bleeding is suspected aFAST exam may be performed to look for bleeding in the abdomen.[2][12]
If the patient has stablevital signs, they may undergo diagnostic imaging such as aCT 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]
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]
If a patient has low blood pressure (hypotension), intravenous fluids can be used until they can receive ablood transfusion. In order to replace blood loss quickly and with large amounts of IV fluids or blood, patients may need acentral venous catheter.[12] 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 amassive transfusion protocol.[12] The massive transfusion protocol replacesred blood cells,plasma, andplatelets in varying ratios based on the cause of the bleeding (traumatic vs. non-traumatic).[4]
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It is crucial to stop the internal bleeding immediately (achievehemostasis) after identifying its cause.[4] The longer it takes to achieve hemostasis in people with traumatic causes (e.g.pelvic fracture) and non-traumatic causes (e.g.gastrointestinal bleeding, rupturedabdominal aortic aneurysm), the higher the death rate is.[4]
Unlike with external bleeding, most internal bleeding cannot be controlled by applying pressure to the site of injury.[12] Internal bleeding in thethorax andabdominal cavity (including both theintraperitoneal andretroperitoneal space) cannot be controlled with direct pressure (compression). A patient with acute internal bleeding in thethorax 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 withacute internal bleeding in theabdomen orpelvis after trauma may require use of aREBOA 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 abone fracture in the arms or legs may be partially controlled with direct pressure using atourniquet.[12] After tourniquet placement, the patient may need immediatesurgery to find the bleedingblood vessel.[4]
Internal bleeding where the torso meets the extremities ("junctional sites" such as theaxilla orgroin) cannot be controlled with a tourniquet; however there is an FDA approved device known as an Abdominal Aortic and Junctional Tourniquet (AAJT) designed for proximal aortic control, although very few studies examining its use have been published.[14][15][16][17][18][19] For bleeding at junctional sites, a dressing with a blood clotting agent (hemostatic dressing) should be applied.[4]
A campaign to improve the care of bleeding known as theStop The Bleed campaign is also taking place.[20]
