Bleeding

Bleeding . It is advisable to distinguish bleeding external, available diagnostics during examination, and a variety of internal bleeding - from the gastrointestinal tract, pulmonary, into the abdominal cavity, into soft tissues (intermuscular spaces, retroperitoneal tissue, etc.). In all types of blood loss, the main threat to the life of the patient is not the loss of the mass of the carrier of oxygen - hemoglobin, but hypovolemia - loss of the mass of the circulating blood as a whole, but primarily of its plasma, which leads to "centralization" of blood circulation, desolation of small vessels of the parenchymal organs, , Microthrombin arterioles and venules. In turn, developing due to a drop in blood pressure and stasis in small vessels, disseminated intravascular coagulation (ICE) leads to a further increase in microthrombin. Especially often it occurs at the age after 50 years, when depletion of the fibrinolysis system (opposing DIC-syndrome) develops rather quickly, and microthrombogenesis acquires the features of a vicious circle.

Do not assume that the standard symptoms of bleeding in the gastrointestinal tract - vomiting coffee grounds, melena - always helps the doctor in his diagnostic search. Often, and the one and the other signs are either absent or are found many hours after the bleeding.

The most important symptoms of bleeding, which develops sharply: sudden dryness in the mouth, pallor, anxiety of the patient, desolation of peripheral veins is a symptom of "empty vessels". Usually observed tachycardia with bleeding into the gastrointestinal tract or into the abdominal cavity may be absent due to irritation of the vagus nerve (vagal reflex).

In itself, the detection of the symptom of "empty vessels" against a background of dry mouth and paleness is a sufficient basis for immediate intravenous injection of 1 liter of freshly frozen plasma with jet or rapid drops (about 100 per 1 minute). The need for transfusion of erythrocyte mass in acute blood loss can not be objectified by indicators of blood analysis, since both hemoglobin and erythrocyte content within the next hours after acute blood loss can remain practically within the norm at any degree of actual anemization. Therefore, the indicator determining the need for transfusion of erythrocyte mass, its quantity, is the paleness of the conjunctiva, mucous membranes, dyspnea (participation of the wings of the nose in the inspiration act), persistence after the transfusion of the plasma, anxiety or congestion (more common in old people). Usually it is necessary to transfuse plasma much more than erythrocytes. Except for cases of massive blood loss, transfusion therapy should be started not with erythrocytes, but with freshly frozen plasma.

With small blood loss, not accompanied by circulatory disorders (dyspnea, tachycardia, falling blood pressure), transfusion therapy is either not needed at all, or it can be limited to transfusion of saline or colloidal solutions, plasma substitutes. Transfusion of whole blood in all cases of bleeding is contraindicated (except when the doctor does not have blood components - freshly frozen plasma and erythrocyte mass), since erythrocyte agglomerates in whole blood and largely inactivated factors of the fibrinolysis system lead to deepening of the DIC syndrome at Acute blood loss, which in turn provokes the resumption of stopped bleeding.

It should be borne in mind that in elderly people, bleeding from acute gastric ulcers is often determined by the DIC syndrome that has arisen in connection with some other diseases (myocardial infarction, cerebrovascular accident, collapse in severe infection, etc.) . With repeated bleeding, even if there are no signs of circulatory disorders, it is advisable to transfuse fresh frozen plasma with rapid drops in the amount of 500-1000 ml with a haemostatic purpose.