Internal Haemorrhage Management (Surgical Emergency)

Clinical assessment

Diagnosis is primarily clinical based on mechanism of injury (if trauma), signs of hemodynamic instability (shock), and signs localized to the suspected body cavity (abdominal distension/tenderness, pelvic pain, chest signs). Unexplained shock, especially after trauma, should raise high suspicion for internal hemorrhage.

Investigations

• Focused Assessment with Sonography for Trauma (FAST) exam: Bedside ultrasound to rapidly detect free fluid (blood) in pericardium, pleural spaces, and peritoneal cavity (Morison's pouch, splenorenal recess, pelvis). Highly valuable in trauma.
• Diagnostic Peritoneal Lavage (DPL): Older technique, invasive, used if ultrasound unavailable/equivocal to detect intra-abdominal blood (rarely used now if FAST available).
• Laboratory: Hemoglobin/Hematocrit (may be normal initially, lags behind acute loss), Blood group and Cross-match (URGENT), Coagulation studies (INR, PTT, Fibrinogen), Pregnancy test (females of childbearing age).
• Imaging (if patient stable enough, often bypassed for immediate surgery if unstable): Chest X-ray (hemothorax), Pelvic X-ray (fractures), CT Scan (Abdomen/Pelvis/Chest) - can identify source of bleeding if patient is stable enough for transport/scan.
• Culdocentesis (for suspected ruptured ectopic - less common now with ultrasound).

Diagnostic criteria

Clinical signs of shock +/- evidence of bleeding into a body cavity (e.g., positive FAST scan, abdominal distension) in appropriate clinical context (trauma, suspected ectopic etc.). Often a diagnosis made concurrently with resuscitation and leading directly to surgery.

Non-pharmacological management

• Immediate Resuscitation (Simultaneously with diagnosis/preparation for surgery):
• - ABCDE approach.
• - Airway: Secure airway (intubation often needed).
• - Breathing: High-flow oxygen, assist ventilation.
• - Circulation: Establish large-bore IV access (x2). Rapid infusion of warmed crystalloids (NS/RL) initially, followed quickly by blood products.
• - Blood Transfusion: URGENT. Activate massive transfusion protocol if available. Give O-negative blood initially if cross-matched blood not ready. Transfuse PRBCs, FFP, and platelets in balanced ratio (e.g., 1:1:1) for massive hemorrhage.
• - Control External Bleeding.
• Surgical Intervention (Definitive Treatment):
• - IMMEDIATE Laparotomy (or Thoracotomy/other procedure based on location) is life-saving to identify and control the source of bleeding.
• - DO NOT DELAY surgery attempting full stabilization - hemodynamic stability may only be achieved after surgical control.
• - Damage control surgery principles may apply in severe polytrauma/massive hemorrhage (initial control of bleeding/contamination, temporary closure, ICU resuscitation, planned re-operation).

Pharmacological treatment

• IV Fluids: Warmed isotonic crystalloids (NS/RL).
• Blood Products: PRBCs, FFP, Platelets, Cryoprecipitate (as part of massive transfusion protocol or guided by labs/clinical picture).
• Tranexamic Acid (TXA): Consider early administration (within 3 hours of injury) in trauma patients with significant hemorrhage (e.g., 1g IV over 10 min, followed by 1g IV over 8 hours).
• Vasopressors: Generally avoided as primary treatment for hemorrhagic shock (treat volume loss first), but may be temporary bridge in profound shock refractory to fluids/blood while awaiting surgical control.
• Reversal agents: If bleeding related to anticoagulants (e.g., Vitamin K/PCC/FFP for warfarin).
• Anesthesia: Rapid sequence induction using hemodynamically stable agents (e.g., ketamine, etomidate). Minimize cardiac depressant drugs.

Monitoring

Continuous monitoring of vital signs (HR, BP, SpO2, RR), ECG. Monitor response to fluid/blood resuscitation (vital signs, urine output - Foley catheter essential, mental status, lactate clearance). Monitor hemoglobin, coagulation parameters frequently during massive transfusion. Monitor temperature (prevent hypothermia).