Internal bleeding

Internal bleeding (also called internal hemorrhage) is a loss of blood from a blood vessel that collects inside the body. Internal bleeding is usually not visible from the outside.[1] It is a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into the chest, abdomen, retroperitoneal space, pelvis, and thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly.[2] Internal bleeding is a medical emergency and should be treated immediately by medical professionals.[2]

Internal bleeding
Other namesInternal hemorrhage
Internal bleeding in the brain

Signs and symptoms

At first, there may be no symptoms of internal bleeding. If an organ is damaged and it bleeds, it can be painful. Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness.[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 or hypovolemic shock, which is a type of shock that occurs when there is not enough blood to reach organs in the body.[5]

Early symptoms include anxiety, increased breathing rate, weak peripheral pulses, and cold skin on the arms and legs. If internal bleeding is not treated, the heart and breathing rate will continue to increase while blood pressure and mental status decrease. Eventually, internal bleeding can result in death by blood loss (exsanguination).[4] The median time from the onset of hemorrhagic shock to death by exsanguination is 2 hours.[4]

Causes

Trauma

The most common cause of death in trauma is bleeding.[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 and blunt trauma.[2]

Non-traumatic

A number of pathological conditions and diseases can lead to internal bleeding. These include:

Other
This stomach with Linitis plastica (Brinton's disease) can cause internal bleeding

Internal bleeding could be caused by medical error as a result of complications after surgical operations or medical treatment. Some medication effects may also lead to internal bleeding, such as the use of anticoagulant drugs or antiplatelet drugs in the treatment of coronary artery disease.[10]

Diagnosis

Vital signs

Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, and mental status.[11] Advanced trauma life support (ATLS) by the American College of Surgeons separates hemorrhagic shock into four categories.[3][4][12]

Classification of Hemorrhagic Shock[3][4][12]
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
  • Slightly anxious
Class II hemorrhage 15 - 30% 100 - 120 Normal or minimally decreased systolic 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
  • Altered mental status (anxious, confused)
  • Decreased urine output
Class IV hemorrhage > 40% > 140 Systolic blood pressure < 90 mmHg Narrowed (< 25 mmHg) >35
  • Significantly altered mental status (confused, lethargic)
  • Cool, clammy skin with delayed capillary refill
  • Significantly decreased or absent urine output

Assessing circulation occurs after assessing the patient's airway and breathing (ABC (medicine)).[5] If internal bleeding is suspected, a patient's circulatory system is assessed through palpation of pulses and doppler ultrasonography.[2]

Physical examination

It is important to examine the person for visible signs that may suggest internal bleeding:[2]

It is also important to look for the source of the internal bleeding.[2] If internal bleeding is suspected after trauma, a FAST exam may be performed to look for bleeding in the abdomen.[2][3]

Imaging

If the patient has stable vital signs, they may undergo diagnostic imaging such as a CT 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]

By location

Internal bleeding can occur anywhere in the body. Some symptoms of internal bleeding depend on the location of the bleed. Some examples of types of internal bleeding include:

Treatment

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]

Fluid replacement

If a patient has low blood pressure (hypotension), intravenous fluids can be used until they can receive a blood transfusion. In order to replace blood loss quickly and with large amounts of IV fluids or blood, patients may need a central venous catheter.[3] 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 a massive transfusion protocol.[3] The massive transfusion protocol replaces red blood cells, plasma, and platelets in varying ratios based on the cause of the bleeding (traumatic vs. non-traumatic).[4]

Stopping the bleeding

It is crucial to stop the internal bleeding immediately (achieve hemostasis) 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, ruptured abdominal aortic aneurysm) is correlated with an increased death rate.[4]

Unlike with external bleeding, most internal bleeding cannot be controlled by applying pressure to the site of injury.[3] Internal bleeding in the thorax and abdominal cavity (including both the intraperitoneal and retroperitoneal space) cannot be controlled with direct pressure (compression). A patient with acute internal bleeding in the thorax 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 with acute internal bleeding in the abdomen or pelvis after trauma may require use of a REBOA 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 a bone fracture in the arms or legs may be partially controlled with direct pressure using a tourniquet.[3] After tourniquet placement, the patient may need immediate surgery to find the bleeding blood vessel.[4]

Internal bleeding where the torso meets the extremities ("junctional sites" such as the axilla or groin) cannot be controlled with a tourniquet. For bleeding at junctional sites, a dressing with a blood clotting agent (hemostatic dressing) should be applied.[4]

A campaign is to improve the care of the bleeding known as Stop The Bleed campaign is also taking place.[13]

References
  1. Auerback, Paul. Field Guide to Wilderness Medicine (PDF) (12 ed.). pp. 129–131. Retrieved 13 March 2019.
  2. Fritz, Davis (2011). "Vascular Emergencies". Current Diagnosis & Treatment: Emergency Medicine (7e ed.). New York: McGraw-Hill. ISBN 978-0071701075.
  3. Colwell, Christopher. "Initial management of moderate to severe hemorrhage in the adult trauma patient". UpToDate. Retrieved 5 March 2019.
  4. Cannon, Jeremy (January 25, 2018). "Hemorrhagic Shock". The New England Journal of Medicine. 378 (4): 370–379. doi:10.1056/NEJMra1705649. PMID 29365303.
  5. International Trauma Life Support for Emergency Care Providers. Pearson Education Limited. 2018. pp. 172–173. ISBN 978-1292-17084-8.
  6. Teixeira, Pedro G. R.; Inaba, Kenji; Hadjizacharia, Pantelis; Brown, Carlos; Salim, Ali; Rhee, Peter; Browder, Timothy; Noguchi, Thomas T.; Demetriades, Demetrios (December 2007). "Preventable or Potentially Preventable Mortality at a Mature Trauma Center". The Journal of Trauma: Injury, Infection, and Critical Care. 63 (6): 1338–46, discussion 1346–7. doi:10.1097/TA.0b013e31815078ae. PMID 18212658.
  7. Duncan, Nicholas S.; Moran, Chris (2010). "(i) Initial resuscitation of the trauma victim". Orthopaedics and Trauma. 24: 1–8. doi:10.1016/j.mporth.2009.12.003.
  8. Lee, Edward W.; Laberge, Jeanne M. (2004). "Differential Diagnosis of Gastrointestinal Bleeding". Techniques in Vascular and Interventional Radiology. 7 (3): 112–122. doi:10.1053/j.tvir.2004.12.001.
  9. Bray, M. (2009). "Hemorrhagic Fever Viruses". Encyclopedia of Microbiology. pp. 339–353. doi:10.1016/B978-012373944-5.00303-5. ISBN 9780123739445.
  10. Pospíšil, Jan; Hromádka, Milan; Bernat, Ivo; Rokyta, Richard (2013). "STEMI - the importance of balance between antithrombotic treatment and bleeding risk". Cor et Vasa. 55 (2): e135–e146. doi:10.1016/j.crvasa.2013.02.004.
  11. Current Diagnosis & Treatment: Emergency Medicine. McGraw-Hill. 2011-05-23. ISBN 978-0071701075.
  12. ATLS- Advanced Trauma Life Support - Student Course Manual (10th ed.). American College of Surgeons. 2018. pp. 43–52. ISBN 978-78-0-9968267.
  13. Pons, MD, Peter. "Stop the Bleed - SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury".
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