Symptoms

Orthostatic dizziness, weakness, fatigue, shortness of breath, and palpitations are common symptoms of hemorrhage. Signs of hemorrhage include tachycardia, hypotension, pallor, and cold moist skin.

Treatment

Pressure should be applied directly to any obviously bleeding body part, and the part should be elevated. Cautery may be used to stop bleeding from visible vessels. Ligation of blood vessels, surgical removal of hemorrhaging organs, or the instillation of sclerosants is often effective in managing internal hemorrhage. Procoagulants (such as vitamin K, fresh frozen plasma, cryoprecipitate, desmopressin) may be administered to patients with primary or drug-induced bleeding disorders. Transfusions of red blood cells may be given if bleeding compromises heart or lung function or threatens to do so because of its pace or volume.

For trauma patients with massive bleeding, the experienced nurse or emergency care provider may apply pneumatic splints or antishock garments during patient transportation to the hospital. These devices may prevent hemorrhagic shock.

CAUTION!

First Aid

Almost all arterial bleeding can be controlled with direct pressure to the wound. If it cannot be controlled with applied pressure, the responsible artery may need to be surgically ligated. See: arterial bleeding for table; pressure point

First Aid

The wound should be compressed with the thumbs placed transversely across the neck, both above and below the wound, and the fingers directed around the back of the neck to aid in compression. Urgent surgical consultation is required.

Etiology

It usually results from rupture of aneurysm, extremely high blood pressure, brain trauma, or brain tumors.

Symptoms

Most people with intracerebral bleeding experience headache. This type of hemorrhage may cause symptoms of stroke (such as unconsciousness, apnea, vomiting, hemiplegia) and death. There may be speech disturbance, incontinence of the bladder and rectum, or other findings, depending on the area of brain damage.

Treatment

Supportive therapy is needed to maintain airway and oxygenation. Neurosurgical consultation should be promptly obtained. Hydration and fluid and electrolyte balance should be maintained. Rehabilitation may include physical therapy, speech therapy, and counseling.

Patient care

Patients with ICH should be treated emergently with infusions of recombinant factor VIIa in an intensive care unit, where minute-to-minute monitoring of intracranial pressures, blood glucose levels, neurological status, and hemodynamics can be carried out. Patients should initially be kept at bedrest with the head of the bed elevated. Fever should be suppressed and seizures prevented with the administration of anticonvulsant drugs. As the patient stabilizes, rehabilitation supervised by occupational therapists, physical therapists, and speech therapists should be initiated.

Treatment

If the bleeding is at the knee or below, a pad should be applied with pressure. If the bleeding is behind the knee, a pad should be applied at the site and the leg bandaged firmly. The bandage should be loosened at 12-min to 15-min intervals to prevent arterial obstruction.

Patient care

Many instances of PPH can be prevented with the administration of oxytocin, misoprostol, or other uterotonic medications. The woman's prenatal, labor, and delivery records are reviewed. The presence of risk factors is noted, and the woman's pulse, blood pressure, fundal and bladder status, and vaginal discharge are assessed every 15 min. If the fundus is boggy, it is massaged to stimulate uterine contractions, and then the status of the woman's bladder is assessed. If the bladder is distended, the patient is encouraged to void and then postvoiding fundal status is assessed; if the fundus remains firm after massage, the fundus and vaginal flow are reassessed in 5 min. See: fundal massage

If bleeding does not respond to the above measures or if the fundus remains firm and the patient exhibits bright red vaginal discharge, retained placental fragments or cervical or vaginal laceration should be suspected; the practitioner who delivered the baby should be notified. Continued massage at this point is contraindicated; the physician or nurse midwife may order uterotonic agents to stimulate uterine contractions. Vital signs should be closely monitored. Common findings in hemorrhage include an increase in pulse rate, often associated with a drop in blood pressure. Pharmacological agents such as methylergonovine or prostaglandin F2 analogs may be administered intramuscularly or intravenously. If blood loss has been extensive, intravenous infusions or blood transfusion may be needed to combat hypovolemic shock. If the patient exhibits signs of a clotting defect, prompt life-saving treatment is imperative. See: disseminated intravascular coagulation

The patient is prepared for and the primary caregiver is assisted with examination of the uterine cavity, removal of any placental fragments, or repair of any lacerations. To reduce the patient's anxiety, all procedures are explained, support and comfort are provided, and the mother is assured that her newborn is receiving good care.

Etiology

Subconjunctival hemorrhage can result from blunt trauma to the eye or from increased intracranial or intraocular pressure.

Symptoms

Patients have visible bleeding between the sclera and the conjunctiva.

Treatment

A subconjunctival hemorrhage normally resolves within 1 to 7 days.

Treatment

A pad or gauze should be inserted into the wound and pressure applied. Failure of the bleeding to stop requires surgical consultation.

Etiology

Common causes are trauma; congenital abnormalities; pathologic processes (such as tumors; infections, esp. of the alimentary, respiratory, and genitourinary tracts); and generalized vascular disorders such as purpuras and coagulation defects. Hemorrhage may also result from premature separation of the placenta, particularly with extravasation into the uterine musculature, and from retained products of conception after abortion or delivery. See: abruptio placentae; Couvelaire uterus

Treatment

An umbrella pack will apply pressure to the uterine arterial supply. When ultrasonography reveals that retained placental fragments are the source of hemorrhage, they are usually removed by suction or surgical curettage. If the uterus is flaccid, it can usually be stimulated to contract by administering intravenous oxytocin. The patient may need transfusion and, in some cases, surgery to prevent fatal hemorrhage.

Patient care

The patient should be reassured while direct pressure to the wound is applied and the affected body part is elevated. If bleeding does not stop after 15 min of direct pressure, evaluation by a health care provider is advisable. Vital signs should be monitored whenever bleeding does not stop with direct pressure, and IV fluids should be initiated as necessary to prevent hypovolemic shock.