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{{short description|Loss of blood escaping from the circulatory system}}{{redirect2|Hemorrhage|Haemorrhage|the song by
{{for multi|the
{{Infobox medical condition (new)
| image = Bleeding finger.jpg
| caption = A bleeding wound in the finger
| synonyms = Hemorrhaging, haemorrhaging, blood loss
| field = [[Emergency medicine]], [[hematology]]
| symptoms =
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| deaths =
}}
'''Bleeding''',
}}</ref> Bleeding can occur [[Internal bleeding|internally]], or externally either through a natural opening such as the [[Mouth (human)|mouth]], [[human nose|nose]], [[ear]], [[urethra]], [[vagina]] or [[anus]], or through a puncture in the [[human skin|skin]].
[[Hypovolemia]] is a massive decrease in blood volume, and death by excessive loss of blood is referred to as [[exsanguination]].<ref>{{cite web|url=http://dictionary.reference.com/browse/exsanguination|title=Dictionary Definitions of Exsanguination|publisher=Reference.com|access-date=2007-06-18|archive-url=https://web.archive.org/web/20070711062056/http://dictionary.reference.com/browse/exsanguination|archive-date=2007-07-11|url-status=live}}</ref> Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious [[sequela|medical difficulties]] (by comparison, [[blood donation]] typically takes 8–10% of the donor's blood volume).<ref>{{cite web|url=http://www.blood.co.uk/pages/b36faint.html|title=Blood Donation Information|publisher=UK National Blood Service|access-date=2007-06-18 |archive-url = https://web.archive.org/web/20070928035216/http://www.blood.co.uk/pages/b36faint.html <!-- Bot retrieved archive --> |archive-date = 2007-09-28}}</ref> The stopping or controlling of bleeding is called [[hemostasis]] and is an important part of both [[first aid]] and [[surgery]].
==Classification==▼
[[File:Eye hemorrhage.jpg|thumbnail|A [[subconjunctival hemorrhage]] is a common and relatively minor post-[[LASIK]] complication.]]▼
[[Image:Pulmonary haemorrhage - high mag.jpg|thumb|right|[[Micrograph]] showing abundant [[hemosiderin]]-laden [[alveolar macrophage]]s (dark brown), as seen in a [[pulmonary hemorrhage]]. [[H&E stain]].]]▼
===Blood loss===▼
Hemorrhaging is broken down into four classes by the American College of Surgeons' [[advanced trauma life support]] (ATLS).<ref name="EM2004">{{cite book|veditors = Tintinalli JE, Kelen GD, Stapczynski JS|vauthors = Manning JE|title=Emergency Medicine: A Comprehensive Study Guide, Sixth edition|chapter=Fluid and Blood Resuscitation|date=2003-11-04|publisher=McGraw Hill Professional|isbn=978-0-07-150091-3|page=227}}</ref>▼
* '''Class I Hemorrhage''' involves up to 15% of blood volume. There is typically no change in vital signs and [[fluid resuscitation]] is not usually necessary.▼
* '''Class II Hemorrhage''' involves 15-30% of total blood volume. A patient is often [[Tachycardia|tachycardic]] (rapid heart beat) with a reduction in the difference between the [[Systole (medicine)|systolic]] and [[diastolic]] blood pressures. The body attempts to compensate with [[Vasoconstriction|peripheral vasoconstriction]]. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids ([[Saline (medicine)|Saline solution]] or [[Lactated Ringer's solution]]) is all that is typically required. [[Blood transfusion]] is not usually required.▼
* '''Class III Hemorrhage''' involves loss of 30-40% of circulating blood volume. The patient's [[blood pressure]] drops, the [[heart rate]] increases, peripheral hypoperfusion ([[shock (circulatory)|shock]]) with diminished [[capillary refill]] occurs, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.▼
* '''Class IV Hemorrhage''' involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.▼
This system is basically the same as used in the staging of [[hypovolemia|hypovolemic shock]].▼
Individuals in excellent physical and [[Circulatory system|cardiovascular]] shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment.▼
===Massive hemorrhage===▼
Although there is no universally accepted definition of massive hemorrhage, the following can be used to identify the condition: "(i) blood loss exceeding circulating blood volume within a 24-hour period, (ii) blood loss of 50% of circulating blood volume within a 3-hour period, (iii) blood loss exceeding 150 ml/min, or (iv) blood loss that necessitates plasma and platelet transfusion."<ref name="pmid21490815">{{cite journal | vauthors = Irita K | title = Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events | journal = Korean J Anesthesiol | volume = 60 | issue = 3 | pages = 151–60 | date = March 2011 | pmid = 21490815 | pmc = 3071477 | doi = 10.4097/kjae.2011.60.3.151 }}</ref>▼
===World Health Organization===▼
The [[World Health Organization]] made a standardized grading scale to measure the severity of bleeding.<ref name="pmid17043016">{{cite journal | vauthors = Webert K, Cook RJ, Sigouin CS, Rebulla P, Heddle NM | title = The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia | journal = Haematologica | volume = 91 | issue = 11 | pages = 1530–37 | date = November 2006 | pmid = 17043016 }}</ref>▼
{| class ="wikitable"▼
|-▼
| Grade 0▼
| no bleeding;▼
|-▼
| Grade 1▼
| [[petechial]] bleeding;▼
|-▼
| Grade 2▼
| mild blood loss (clinically significant);▼
|-▼
| Grade 3▼
| gross blood loss, requires transfusion (severe);▼
|-▼
| Grade 4▼
| debilitating blood loss, retinal or cerebral associated with fatality▼
|}▼
==Types==
* Upper head
** [[Intracranial hemorrhage]] – bleeding in the skull.
** [[Intracerebral hemorrhage|Cerebral hemorrhage]] – a type of intracranial hemorrhage, bleeding within the brain tissue itself.
** [[Intracerebral hemorrhage]] – bleeding in the brain caused by the rupture of a blood vessel within the head. See also [[hemorrhagic stroke]].
** [[Subarachnoid hemorrhage]] (SAH) implies the presence of blood within the [[subarachnoid space]] from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or [[arteriovenous malformation]] (AVM).<ref name="Roth 2011 pp. 2423–2423">{{cite book | last=Roth | first=Elliot J. | title=Encyclopedia of Clinical Neuropsychology | chapter=Subarachnoid Hemorrhage (Aneurysmal subarachnoid hemorrhage) | publisher=Springer New York | publication-place=New York, NY | year=2011 | doi=10.1007/978-0-387-79948-3_2201 | pages=2423|quote=A subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space that exists between the arachnoid and pia membranes that surround the brain.}}</ref> The scope of this article is limited to these nontraumatic hemorrhages.
* Eyes
** [[Subconjunctival hemorrhage]] – bloody eye arising from a broken blood vessel in the [[sclera]] (whites of the eyes). Often the result of strain, including sneezing, coughing, vomiting or other kind of strain
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*** [[Postpartum hemorrhage]]
*** [[Breakthrough bleeding]]
** Ovarian bleeding – This is a potentially catastrophic and not so rare complication among lean patients with [[polycystic ovary syndrome]] undergoing [[transvaginal oocyte retrieval]].<ref name="Liberty">{{cite journal |vauthors=Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ |title=Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome |journal=Fertil. Steril. |volume= 93|issue= 3|pages= 874–879|date=December 2008 |pmid=19064264 |doi=10.1016/j.fertnstert.2008.10.028 |doi-access=free }}</ref>
* Anus
** [[Melena]] – upper gastrointestinal bleeding
** [[Hematochezia]] – lower gastrointestinal bleeding, or brisk upper gastrointestinal bleeding
* Vascular
** Ruptured [[
** Aortic transection
** Iatrogenic injury
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=== Traumatic injury ===
Traumatic bleeding is caused by some type of injury. There are different types of [[wound]]s which may cause traumatic bleeding. These include:{{cn|date=June 2022}}
* [[Abrasion (medical)|Abrasion]] – Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the [[Epidermis (skin)|epidermis]].
* [[Excoriation]] – In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause.
* [[Hematoma]] – Caused by damage to a blood vessel that in turn causes blood to collect
* [[Laceration]] – Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
* [[Surgical incision|Incision]] – A cut into a body tissue or organ, such as by a [[scalpel]], made during surgery.
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* [[Ballistic trauma|Ballistic Trauma]] – Caused by a projectile weapon such as a firearm. This may include two external wounds (entry and exit) and a contiguous wound between the two.
The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, or ears may signal internal bleeding, but cannot be relied upon. Bleeding from a [[medical procedure]] also falls into this category.{{cn|date=June 2022}}
=== Medical condition ===
"Medical bleeding" denotes hemorrhage as a result of an underlying medical condition (i.e. causes of bleeding that are not directly due to trauma). Blood can escape from [[blood vessel]]s as a result of 3 basic patterns of injury:{{cn|date=June 2022}}
* [[blood|Intravascular changes]] – changes of the blood within vessels (e.g. ↑ [[blood pressure]], ↓ [[clotting factors]])
* [[blood vessel|Intramural changes]] – changes arising within the walls of blood vessels (e.g. [[aneurysms]], [[aortic dissection|dissections]], [[arteriovenous malformation|AVMs]], [[vasculitides]])
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Some medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal hemostatic (bleeding-control) functions of the body. Such conditions either are, or cause, [[bleeding diathesis|bleeding diatheses]]. [[Hemostasis]] involves several components. The main components of the hemostatic system include [[platelets]] and the [[blood coagulation|coagulation]] system.
[[Platelets]] are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to [[nonsteroidal anti-inflammatory drugs]] (NSAIDs). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs (for example Ibuprofen) inhibit the activation of [[platelets]], and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.{{cn|date=June 2022}}
There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on [[coagulation]]. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic [[hemophilia A]] while deficiencies of Factor IX cause "Christmas disease"([[hemophilia B]]). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with [[autoimmune]] diseases. Another common bleeding disorder is [[Von Willebrand disease]]. It is caused by a deficiency or abnormal function of the "Von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.
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=== Infection ===
Infectious diseases such as [[Ebola]], [[Marburg virus disease]] and [[yellow fever]] can cause bleeding.{{cn|date=June 2022}}
== Diagnosis/Imaging ==
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[[Dioxaborolane]] chemistry enables radioactive [[fluoride]] ([[Fluorine-18|<sup>18</sup>F]]) labeling of [[red blood cell]]s, which allows for [[positron emission tomography]] (PET) imaging of intracerebral hemorrhages.<ref>{{Cite journal|last1=Wang|first1=Ye|last2=An|first2=Fei-Fei|last3=Chan|first3=Mark|last4=Friedman|first4=Beth|last5=Rodriguez|first5=Erik A|last6=Tsien|first6=Roger Y|last7=Aras|first7=Omer|last8=Ting|first8=Richard|date=2017-01-05|title=18F-positron-emitting/fluorescent labeled erythrocytes allow imaging of internal hemorrhage in a murine intracranial hemorrhage model|journal=Journal of Cerebral Blood Flow & Metabolism|volume=37|issue=3|pages=776–786|language=en|doi=10.1177/0271678x16682510|pmid=28054494|pmc=5363488}}</ref>
▲===Classification===
▲[[File:Eye hemorrhage.jpg|thumbnail|A [[subconjunctival hemorrhage]] is a common and relatively minor post-[[LASIK]] complication.]]
▲[[Image:Pulmonary haemorrhage - high mag.jpg|thumb|right|[[Micrograph]] showing abundant [[hemosiderin]]-laden [[alveolar macrophage]]s (dark brown), as seen in a [[pulmonary hemorrhage]]. [[H&E stain]].]]
▲====Blood loss====
▲Hemorrhaging is broken down into four classes by the American College of Surgeons' [[advanced trauma life support]] (ATLS).<ref name="EM2004">{{cite book|veditors = Tintinalli JE, Kelen GD, Stapczynski JS|vauthors = Manning JE|title=Emergency Medicine: A Comprehensive Study Guide, Sixth edition|chapter=Fluid and Blood Resuscitation|date=2003-11-04|publisher=McGraw Hill Professional|isbn=978-0-07-150091-3|page=227}}</ref>
▲* '''Class I Hemorrhage''' involves up to 15% of blood volume. There is typically no change in vital signs and [[fluid resuscitation]] is not usually necessary.
▲* '''Class II Hemorrhage''' involves 15-30% of total blood volume. A patient is often [[Tachycardia|tachycardic]] (rapid heart beat) with a reduction in the difference between the [[Systole (medicine)|systolic]] and [[diastolic]] blood pressures. The body attempts to compensate with [[Vasoconstriction|peripheral vasoconstriction]]. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids ([[Saline (medicine)|Saline solution]] or [[Lactated Ringer's solution]]) is all that is typically required. [[Blood transfusion]] is not usually required.
▲* '''Class III Hemorrhage''' involves loss of 30-40% of circulating blood volume. The patient's [[blood pressure]] drops, the [[heart rate]] increases, peripheral hypoperfusion ([[shock (circulatory)|shock]]) with diminished [[capillary refill]] occurs, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.
▲* '''Class IV Hemorrhage''' involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.
▲This system is basically the same as used in the staging of [[hypovolemia|hypovolemic shock]].
▲Individuals in excellent physical and [[Circulatory system|cardiovascular]] shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment.{{cn|date=November 2021}}
▲====Massive hemorrhage====
▲Although there is no universally accepted definition of massive hemorrhage, the following can be used to identify the condition: "(i) blood loss exceeding circulating blood volume within a 24-hour period, (ii) blood loss of 50% of circulating blood volume within a 3-hour period, (iii) blood loss exceeding 150 ml/min, or (iv) blood loss that necessitates plasma and platelet transfusion."<ref name="pmid21490815">{{cite journal | vauthors = Irita K | title = Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events | journal = Korean J Anesthesiol | volume = 60 | issue = 3 | pages = 151–60 | date = March 2011 | pmid = 21490815 | pmc = 3071477 | doi = 10.4097/kjae.2011.60.3.151 }}</ref>
▲====World Health Organization====
▲The [[World Health Organization]] made a standardized grading scale to measure the severity of bleeding.<ref name="pmid17043016">{{cite journal | vauthors = Webert K, Cook RJ, Sigouin CS, Rebulla P, Heddle NM | title = The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia | journal = Haematologica | volume = 91 | issue = 11 | pages = 1530–37 | date = November 2006 | pmid = 17043016 }}</ref>
▲{| class ="wikitable"
▲|-
▲| Grade 0
▲| no bleeding;
▲|-
▲| Grade 1
▲| [[petechial]] bleeding;
▲|-
▲| Grade 2
▲| mild blood loss (clinically significant);
▲|-
▲| Grade 3
▲| gross blood loss, requires transfusion (severe);
▲|-
▲| Grade 4
▲| debilitating blood loss, retinal or cerebral associated with fatality
▲|}
==Management==
{{Main|Emergency_bleeding_control#Wound_management}}
{{
Acute bleeding from an injury to the skin is often treated by the application of direct pressure.<ref>{{cite web |title=Severe bleeding: First aid |url=https://www.mayoclinic.org/first-aid/first-aid-severe-bleeding/basics/art-20056661 |website=Mayo Clinic |access-date=15 June 2020 |language=en}}</ref> For severely injured patients, [[tourniquet]]s are helpful in preventing complications of [[shock (circulatory)|shock]].<ref>{{cite journal |last1=Scerbo |first1=MH |last2=Holcomb |first2=JB |last3=Taub |first3=E |last4=Gates |first4=K |last5=Love |first5=JD |last6=Wade |first6=CE |last7=Cotton |first7=BA |title=The Trauma Center Is Too Late: Major Limb Trauma Without a Pre-hospital Tourniquet Has Increased Death From Hemorrhagic Shock |journal=J Trauma Acute Care Surg |date=December 2017 |volume=83 |issue=6 |pages=1165–1172 |doi=10.1097/TA.0000000000001666 |pmid=29190257|s2cid=19121937 }}</ref> [[Anticoagulant]] medications may need to be discontinued and possibly reversed in patients with clinically significant bleeding.<ref>{{cite web |last1=Hanigan |first1=Sarah |last2=Barnes |first2=Geoffrey D |title=Managing Anticoagulant-related Bleeding in Patients with Venous Thromboembolism |url=https://www.acc.org/latest-in-cardiology/articles/2019/10/07/14/29/managing-anticoagulant-related-bleeding-in-patients-with-venous-thromboembolism |website=American College of Cardiology |access-date=15 June 2020}}</ref> Patients that have lost excessive amounts of blood may require a [[blood transfusion]].<ref>{{cite journal |last1=Nunez |first1=TC |last2=Cotton |first2=BA |title=Transfusion Therapy in Hemorrhagic Shock |journal=Curr Opin Crit Care |date=December 2009 |volume=15 |issue=6 |pages=536–41 |doi=10.1097/MCC.0b013e328331575b |pmid=19730099 |pmc=3139329}}</ref>
The use of [[Cyanoacrylate|cyanoacrylate glue]] to prevent bleeding and seal battle wounds was designed and first used in the [[Vietnam War]].<ref>{{cite news |last1=Harris |first1=Elizabeth A. |date=28 March 2011 |title=Harry Coover, Super Glue's Inventor, Dies at 94 |language=en |newspaper=The New York Times |url=https://www.nytimes.com/2011/03/28/business/28coover.html |access-date=2018-06-30}}</ref> Skin glue, a medical version of "super glue", is sometimes used instead of using traditional stitches used for small wounds that need to be closed at the skin level.<ref>{{Cite web |date=2018-06-26 |title=How do I care for a wound treated with skin glue? |url=https://www.nhs.uk/common-health-questions/accidents-first-aid-and-treatments/how-do-i-care-for-a-wound-treated-with-skin-glue/ |access-date=2022-12-10 |website=nhs.uk |language=en}}</ref>
==Etymology==
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== See also ==
* [[Aneurysm]]
* [[
* [[Anemia]]
* [[Coagulation]]
* [[Contusion]]
* [[Exsanguination]]
* [[Hematophagy
* [[Hemophilia]]
* [[Hematoma]]
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