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hemorrhage (bleeding)

Bleeding from the rupture of a blood vessel. Etiology: 1) frequency, severity & type of bleeding are clues to etiology. 2) hemostatic plug disorder a) cutaneous bleeding - petechiae - purpura - ecchymosis b) mucous membrane bleeding - epistaxis - oropharyngeal bleeding - menorrhagia 3) coagulation disorder a) deep hematomas b) hemarthrosis c) delayed bleeding after surgery or trauma Epidemiology: - of persons mean age 54 years, 3976 had major bleeding during 1,281,896 person years follow-up - 73% of major bleeding events were GI - 274 fatal bleeding events - 153 due to intracerebral hemorrhage - case fatalities from GI bleed 3.4-4.6% [4] Pathology: - breakdown in the control of bleeding through interplay of vasoconstriction, platelet aggregation, & coagulation Laboratory: 1) complete blood count (CBC) 2) prothrombin time (PT) & aPTT 3) additional testing as indicated a) bleeding time b) von Willebrand factor (vWF) c) specific assays for coagulation factor VIII or factor IX d) dilute whole blood clot lysis e) euglobulin clot lysis time f) dilute thrombin time g) serum fibrinogen h) qualitative factor XIII assay Complications: - extracranial hemorrhage is associated with - 15% increase in ADL disability - 15% increase in iADL disability - 8% increase in nursing home stays - 4% increase in mortality [6] Management: 1) pressure over bleeding vessels 2) monitor: blood pressure, heart rate 3) correct underlying bleeding diathesis - 4-factor prothrombin complex concentrates for life-threatening bleeding due to warfarin [1] 4) correct hypovolemia a) normal saline or lactated Ringers b) blood transfusion if indicated 5) UrgentQR applied directory to wound may be of value 6) tranexamic acid may be of benefit for severe hemorrhage [2] - effectiveness of tranexamic acid decreases 10% for every 15-minute delay & is negligible at 3 hours [3] Notes: - model predicts risks for major hemorrhage [5]

Related

control of hemorrhage petechiae

Specific

bleeding gums; gingival bleeding ecchymosis exsanguination hematuria hemoptysis immune or idiopathic thrombocytopenic purpura (ITP) internal hemorrhage mucosal bleeding ocular hemorrhage (hemophthalmos) otorrhagia penile fracture purpura; retiform purpura

General

circulatory system disease sign/symptom

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 19. American College of Physicians, Philadelphia 1998, 2022
  2. The NNT: Tranexamic Acid for Severe Trauma. http://www.thennt.com/nnt/tranexamic-acid-for-severe-trauma/ - CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomised, placebo-controlled trial. Lancet 2010 Jun 15; [e-pub ahead of print]. PMID: 20554319 http://dx.doi.org/10.1016/S0140-6736(10)60835-5 - Levy JH. Antifibrinolytic therapy: New data and new concepts. Lancet 2010 Jun 15; [e-pub ahead of print]. PMID: 20554318 http://dx.doi.org/10.1016/S0140-6736(10)60939-7
  3. Gayet-Ageron A, Prieto-Merino D et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: A meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2017 Nov 7; [e-pub]. PMID: 29126600 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32455-8/fulltext - Dries DJ. Tranexamic acid: Is it about time? Lancet 2017 Nov 7 PMID: 29126598 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32806-4/fulltext
  4. Selak V, Kerr A, Poppe K et al Annual Risk of Major Bleeding Among Persons Without Cardiovascular Disease Not Receiving Antiplatelet Therapy. JAMA. 2018;319(24):2507-2520. PMID: 29946729 https://jamanetwork.com/journals/jama/fullarticle/2685989
  5. Selak V, Jackson R, Poppe K et al. Predicting bleeding risk to guide aspirin use for the primary prevention of cardiovascular disease: A cohort study. Ann Intern Med 2019 Feb 26; PMID: 30802900 https://annals.org/aim/article-abstract/2726667/predicting-bleeding-risk-guide-aspirin-use-primary-prevention-cardiovascular-disease
  6. Parks AL et al. Long-term functional outcomes and mortality after hospitalization for extracranial hemorrhage. J Hosp Med 2022 Apr; 17:235. PMID: 35535921 https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12799