BLEEDING INSIDE

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The severely injured patient arriving to the hospital with continuous bleeding or deep haemorrhagic shock generally has a poor chance of survival unless early control of bleeding, proper resuscitation and blood transfusion are achieved. This is particularly true for patients who present with uncontrolled bleeding due to multiple penetrating injuries or patients with multiple injuries and unstable pelvic fractures with ongoing bleeding from fracture sites and retroperitoneal vessels.

The common denominator in these patients is the exhaustion of physiological reserves with resulting profound acidosis, hypothermia and coagulopathy, also known as the 'bloody vicious cycle'. In , Stone and colleagues described the techniques of abbreviated laparotomy, packing to control haemorrhage and of deferred definitive surgical repair until coagulation has been established [ ].

Since then, a number of authors have described the beneficial results of this concept, now called 'damage control' [ 50 , 54 , , , , - ]. Damage control surgery of the abdomen consists of three components: the first component is an abbreviated resuscitative laparotomy for control of bleeding, the restitution of blood flow where necessary and the control of contamination. This should be achieved as rapidly as possible without spending unnecessary time on traditional organ repairs that can be deferred to a later phase. The abdomen is packed and temporary abdominal closure is performed.

The second component is intensive care treatment, focused on core re-warming, correction of the acid-base imbalance and coagulopathy as well as optimising the ventilation and the haemodynamic status. The third component is the definitive surgical repair that is performed only when target parameters have been achieved [ - ]. Although the concept of 'damage control' intuitively makes sense, no RCTs exist to support it. Retrospective studies support the concept showing reduced morbidity and mortality rates in selective populations [ 50 , , , ].

The same 'damage control' principles have been applied to orthopaedic injuries in severely injured patients [ , - ]. Scalea was the first to coin the term 'damage control orthopaedics' [ ]. Relevant fractures are primarily stabilised with external fixators rather than primary definitive osteosynthesis [ , ].

What are the symptoms of internal bleeding?

The less traumatic and shorter duration of the surgical procedure aims to reduce the secondary trauma load. Definitive osteosynthesis surgery can be performed after 4 to 14 days when the patient has recovered sufficiently. Retrospective clinical studies and prospective cohort studies seem to support the concept of damage control [ , - ].

The only available randomised study shows an advantage for this strategy in 'borderline' patients [ ]. We recommend the use of topical haemostatic agents in combination with other surgical measures or with packing for venous or moderate arterial bleeding associated with parenchymal injuries Grade 1B. A wide range of local haemostatic agents are currently available for use as adjuncts to traditional surgical techniques to obtain haemorrhage control.

These topical agents can be particularly useful when access to the bleeding area is difficult. Local haemostatic agents include collagen, gelatin or cellulose-based products, fibrin and synthetic glues or adhesives that can be used for both external and internal bleeding while polysaccharide-based and inorganic haemostatics are still mainly used and approved for external bleeding.

The use of topical haemostatic agents should consider several factors such as the type of surgical procedure, cost, severity of bleeding, coagulation status and each agent's specific characteristics. Some of these agents should be avoided when autotransfusion is used and several other contraindications need to be considered [ , ].


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The capacity of each agent to control bleeding was initially studied in animals but increasing experience from humans is now available [ - ]. The different types of local haemostatics are briefly presented according to their basis and haemostatic capacity:. They are often combined with a procoagulant substance such as thrombin to enhance the haemostatic effect. A positive haemostatic effect has been shown in several human studies [ - ].

Swelling of the gelatin in contact with blood reduces the blood flow and, in combination with a thrombin-based component, enhances haemostasis. A similar or superior haemostatic effect has been observed compared with collagen-based agents [ - ]. The mechanism of action is complex and depends on the purity or combination with other substances such as cellulose or fibrin. A number of different products are currently available and have been shown to be efficient for external use.

An observational study showed that haemorrhage control was achieved using an N-acetylglucosamine-based bandage applied to 10 patients with severe hepatic and abdominal injuries, acidosis and clinical coagulopathy [ ]. We recommend a target systolic blood pressure of 80 to mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury Grade 1C.

In order to maintain tissue oxygenation, traditional treatment of trauma patients uses early and aggressive fluid administration to restore blood volume. This approach may, however, increase the hydrostatic pressure on the wound, cause a dislodgement of blood clots, a dilution of coagulation factors and undesirable cooling of the patient. The concept of low-volume fluid resuscitation, so-called 'permissive hypotension', avoids the adverse effects of early aggressive resuscitation while maintaining a level of tissue perfusion that, although lower than normal, is adequate for short periods [ ].

A controlled hypotensive fluid resuscitation should aim to achieve a mean arterial pressure of 65 mmHg or more [ ]. Its general effectiveness remains to be confirmed in RCTs; however, studies have demonstrated increased survival when a low volume fluid resuscitation concept was used in penetrating trauma [ , ]. In contrast, no significant difference in survival was found in patients with blunt trauma [ ]. One study concluded that mortality was higher after on-site resuscitation compared with in-hospital resuscitation [ ].

It seems that greater increases in blood pressure are tolerated without exacerbating haemorrhage when they are achieved gradually and with a significant delay following the initial injury [ ]. All the same, a recent Cochrane systematic review concluded that there is no evidence from RCTs for or against early or larger volume intravenous fluids to treat uncontrolled haemorrhage [ ]. However, a recent retrospective analysis demonstrated that aggressive resuscitation techniques, often initiated in the prehospital setting, appear to increase the likelihood that patients with severe extremity injuries develop secondary abdominal compartment syndrome ACS [ ].

In this study, early, large-volume crystalloid administration was the greatest predictor of secondary ACS. Moreover, a retrospective analysis of the German Trauma Registry database including 17, multiply injured patients showed that the incidence of coagulopathy increased with increasing volume of intravenous fluids administered pre-clinically. The low-volume approach is contraindicated in TBI and spinal injuries, because an adequate perfusion pressure is crucial to ensure tissue oxygenation of the injured central nervous system.

In addition, the concept of permissive hypotension should be carefully considered in the elderly patient and may be contraindicated if the patient suffers from chronic arterial hypertension.

Brain Hemorrhages

A recent analysis from an ongoing multi-centre prospective cohort study suggests that the early use of vasopressors for haemodynamic support after haemorrhagic shock in comparison to aggressive volume resuscitation may be deleterious and should be used cautiously [ ]. However, this study has several limitations: the study is a secondary analysis of a prospective cohort study, and was not designed to answer the specific hypothesis tested. Thus, it is not possible to separate vasopressor from the early management of trauma patients.

In addition, although the use of a vasopressor helps to rapidly restore arterial pressure, it should not be viewed as a substitute for fluid resuscitation and the target blood pressure must be respected. We recommend that crystalloids be applied initially to treat the bleeding trauma patient Grade 1B. We suggest that hypertonic solutions also be considered during initial treatment Grade 2B.

We suggest that the addition of colloids be considered within the prescribed limits for each solution in haemodynamically unstable patients Grade 2C.

What Is A Hyphema?

It is still unclear what type of fluid should be employed in the initial treatment of the bleeding trauma patient. Although several meta-analyses have shown an increased risk of death in patients treated with colloids compared with patients treated with crystalloids [ - ] and three of these studies showed that the effect was particularly significant in a trauma subgroup [ , , ], a more recent meta-analysis showed no difference in mortality between colloids and crystalloids [ ].

If colloids are used, modern hydroxyethyl starch or gelatin solutions should be used because the risk:benefit ratio of dextran is disadvantageous. Problems in evaluating and comparing the use of different resuscitation fluids include the heterogeneity of populations and therapy strategies, limited quality of analysed studies, mortality not always being the primary outcome, and different, often short, observation periods.

It is therefore difficult to reach a definitive conclusion as to the advantage of one type of resuscitation fluid over the other.


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Promising results have been obtained with hypertonic solutions. Recently, a double-blind, RCT in patients with blunt traumatic injuries analysed the effect of the treatment with ml of 7. The intent-to-treat analysis demonstrated no significant difference in organ failure and in acute respiratory disress syndrome ARDS -free survival. One study showed that the use of hypertonic saline was associated with lower intracranial pressure than with normal saline in brain-injured patients [ ] and a meta-analysis comparing hypertonic saline dextran with normal saline for resuscitation in hypotension from penetrating torso injuries showed improved survival in the hypertonic saline dextran group when surgery was required [ ].

However, Cooper and colleagues found almost no difference in neurological function six months after TBI in patients who had received pre-hospital hypertonic saline resuscitation compared with conventional fluid [ ]. In conclusion, the evidence suggests that hypertonic saline solutions are safe, and will improve haemodynamics during hypovolaemic resuscitation.

The evidence for increased survival with use of hypertonic saline solutions is inconclusive.

Internal Bleeding Signs, Symptoms, Causes & Treatment

It is possible that certain subgroups might benefit from hypertonic saline solutions, but further research is required [ ]. We recommend early application of measures to reduce heat loss and warm the hypothermic patient in order to achieve and maintain normothermia Grade 1C. In a retrospective study with patients, hypothermia was an ominous clinical sign, accompanied by high mortality and blood loss [ ]. The profound clinical effects of hypothermia ultimately lead to higher morbidity and mortality, and hypothermic patients require more blood products [ ].

Hypothermia is associated with an increased risk of severe bleeding, and hypothermia in trauma patients represents an independent risk factor for bleeding and death [ ]. Steps to prevent hypothermia and the risk of hypothermia-induced coagulopathy include removing wet clothing, covering the patient to avoid additional heat loss, increasing the ambient temperature, forced air warming, warm fluid therapy and, in extreme cases, extracorporeal re-warming devices [ , ]. Animal and human studies of controlled hypothermia in haemorrhage have shown some positive results compared with normothermia [ , ].

Contradictory results have been observed in meta-analyses that examine mortality and neurological outcomes associated with mild hypothermia in patients with TBI, possibly due to the different exclusion and inclusion criteria for the studies used for the analysis [ - ]. The speed of induction and duration of hypothermia, which may be very important factors that influence the benefit associated with this treatment. It has been shown that five days of long-term cooling is more efficacious than two days of short-term cooling when mild hypothermia is used to control refractory intracranial hypertension in adults with severe TBI [ ].

Obviously, the time span of hypothermia is crucial, because a recent prospective RCT in children with severe TBI showed that hypothermic therapy initiated within 8 hours after injury and continued for 24 hours did not improve the neurological outcome and may increase mortality [ ].

Furthermore, the mode of inducing cerebral hypothermia induction may influence its effectiveness. Mean intracranial pressure 24, 48 or 72 hours after injury was significantly lower in the selective brain cooling group than in the control group [ ]. Prolonged hypothermia may be considered in patients with isolated head trauma after haemorrhage has been arrested. Patients most likely to benefit from hypothermia are those with a GCS at admission between 4 and 7 [ ].

Possible side effects are hypotension, hypovolaemia, electrolyte disorders, insulin resistance and reduced insulin secretion and increased risk of infection [ ].

Risk of Internal Bleeding Heightened with Anticoagulant Therapy

Further studies are warranted to investigate the postulated benefit of hypothermia in TBI taking these important factors into account. Erythrocytes contribute to haemostasis by influencing the biochemical and functional responsiveness of activated platelets via the rheological effect on platelet margination and by supporting thrombin generation [ ]; however, the optimal Hct or Hb concentration required to sustain haemostasis in massively bleeding patients is unclear.

Further investigations into the role of the Hb concentration on haemostasis in massively transfused patients are therefore warranted. The effects of the Hct on blood coagulation have not been fully elucidated [ ]. An acute reduction of the Hct results in an increase in the bleeding time [ , ] with restoration upon re-transfusion [ ].