BLEEDING (haemorrhagia; grech, haima blood + rhein a leak) — the expiration of blood from blood vessels at disturbance of an integrity or permeability of their wall.
By origin To. divide on traumatic, caused by a bruise of a vascular wall (including at surgery), and not traumatic, connected from it patol, changes (increase in permeability of a vascular wall, a new growth, inflammatory process, defeat by ionizing radiation etc.).
On origins — on To. from a gap (haemorrhagia per rhexin), from corrosion (haemorrhagia per diabrosin, arrosive To.), from infiltration (haemorrhagia per diapedesin). By the form the bleeding vessel To. divide on arterial, arteriovenous (mixed), venous, capillary; capillary To. from parenchymatous body call parenchymatous. In the place of outpouring of blood distinguish To. outside at which blood streams directly on a body surface through defect of an integument; internal — with outpouring of blood in the closed perigastrium or in a gleam of hollow body, at the same time allocate hidden To., determined only by special methods of a research; interstitial (intersticial) at which blood accumulates in interfabric intervals, forming hematoma (see), or impregnates fabrics; in the latter case not plentiful To. call hemorrhage (see). Some types internal To. have special names: haemoptoe — pneumorrhagia (see), haematemesis — a hematemesis (see. Hematemesis ), metrorrhagia — uterine bleedings (see) etc. All variety To. at damages of blood vessels B. V. Petrovsky combined in uniform classification: by the form To. — arterial, venous, arteriovenous (mixed); towards. — outside, interstitial, Intra bone; on terms. To. — primary, secondary (early, later, recurrent or repeated).
Traumatic outside To. on time and a proximate cause of emergence it is accepted to divide on primary and secondary which can be repeated. Primary To. accompanies each wound as one of its three cardinal signs (pain, a gaping, bleeding). Primary To. are a consequence of a rupture of a vessel (haemorrhagia per rhexin). According to H. H. Petrova, secondary To. arise in the further course of a wound and happen a double origin: from the vessels damaged at the time of wound; from the vessels which were not injured at an injury, but underwent destruction during the further course of a wound. In the latter case To. though anamnesticly it is also connected with an injury, but often comes from corrosion (haemorrhagia per diabrosin) and consequently, it has to be treated as not traumatic. Depending on features To. exerts a certain impact on an organism of the patient. In one cases To. does not create in itself threat for life of the patient, but has important diagnostic value as a symptom of this or that disease (damage). In other cases strong or long To. threatens life of the victim, at the same time it is necessary to apply immediately rational to lay down. actions. According to A. V. Gulyaev, V. A. Negovsky, I. R. Petrov, etc., danger To. consists in development of hemorrhagic shock, in a pathogeny to-rogo the leading role belongs not to loss of erythrocytes, and a degrowth of the circulating blood and, therefore, hemodynamic disturbances. Insignificant, but very long (months, years) To. is reflected in a hemodynamics a little, and the patient in these cases can exist even if the hemoglobin content decreased to 2 g of %.
Bystry loss of 40% of hemoglobin of its initial contents with simultaneous falling of the ABP to 70 mm of mercury. threatens with death from acute anemia of a brain. Therefore, weight blood losses (see) is defined, in addition to intensity To. (amount of the blood following for a unit of time), as well its duration; the last depends on a greatest or smaller opportunity for a spontaneous stop To. Disturbance of an integrity of a vessel and blood, izlity from it, lead to emergence of a number of interoceptive impulses both from the damaged vascular wall, and from vascular pressoreceptors far from the place of damage. Composite vasomotor reaction is resulted by redistribution of the circulating blood with reduction of speed of a blood-groove in an affected vessel. Strengthening of ability to a thrombogenesis and a bystry blood coagulation conducts to obturation of defect of a vascular wall (see. Hemostasis ). Thrombosing of a vessel is caused by disturbance of an integrity of a vascular wall with the subsequent aggregation of thrombocytes (see. Thrombosis ). Finally under favorable conditions there comes the spontaneous stop To., as occurs at the majority To. of capillaries, medium-sized veins or small arteries. Obturation blood clot of the injured large artery since the high speed of a blood-groove interferes with formation of blood clot in defect of a vascular wall is less probable, and the clots which were in time to be formed are easily pushed out. Danger To. from parenchymatous abdominal organs — in their hidden character and duration. Are less dangerous parenchymatous To. from tissue of a lung which usually stop spontaneously, without leading to deadly blood loss. To. from arteries are most dangerous. So, To. not only from an aorta, and even from a femoral or axillary artery can lead to deadly blood loss in several minutes (in animal experiments — in 1,5 — 3 min.), especially at children and old men. The most dangerous To., a cut can lead to sudden death, is To. from a cardial cavity at its wound (see. Heart, damages ). Women transfer To. it is better, than men. Venous To. constitute big danger if the large vein bleeds if To. has strip character, at last, if the vein is squeezed below the place of damage (on a blood flow). In other cases venous To. more often perhaps dangerous complication — air stops spontaneously, however at the same time embolism (see). Any To. can threaten life in cases of disturbance of ability to a spontaneous stop at hemophilias (see), thrombocytopenia (see), and also at acute radial illness (see). The raised bleeding in the eclipse period of a radial illness is explained by disturbance of vasomotor reaction on an injury; the damaged vessels are not reduced, their gleam gapes. In the period of a heat of a disease vessels become fragile, there comes thrombocytopenia, in blood anticoagulants collect that leads to falloff of coagulability of blood and to increase in time of K. Vtorichnoye K. during this period loses ability to a spontaneous stop, and styptic actions are often ineffective.
The blood which streamed in fabric and a cavity is a good medium for development of microorganisms (unlike the blood which is in a gleam of a vessel, edge possesses bactericidal action). Thus, any hematoma, any accumulation of blood at internal To. is the contributing factor for development of an infection — suppuration, a cut, in turn, considerably worsens a condition of the patient and consequently, and the forecast. A good medium for development of an infection arises also at outside capillary To., since in this case there are entrance gate for an infection and optimal conditions for emergence inf. complications. If after a stop internal To. the infection will not develop, blood collapses and a large number of commissures is formed. In cases when the streamed blood is limited to the capsule, the hematoma which is reported with a gleam of a vessel is formed. If it is an artery, then the pulsing hematoma is formed in the beginning, and false can develop later aneurism (see).
Diagnosis aims not only establishment of existence and the place To., but also definition of its origin and features. At outside To. investigate a condition of the large blood vessels able to be its source. Also color of the streaming blood matters: scarlet — at arterial, dark cherry — at venous To. Spouting, a pulse jet specify on arterial To., but are observed not always. At To. blood can follow from large veins of an upper half of a body a discontinuous stream, but synchronously to breath, but not pulse. At capillary To. blood flows evenly from all surface of a wound. At internal To. diagnosis is more difficult. If To. occurs in a gleam of hollow bodies, blood is soon emitted outside through natural foramens of a body. However it is not always easy to distinguish the nature even such explicit internal To. Release of blood through a mouth can be connected with To. from easy and upper respiratory tracts, from a throat, a gullet, a stomach, a duodenum; a hamaturia — with To. from a kidney, a bladder, an ureter; a bloody chair — with To. from any department went. - kish. path. The state and color of the emitted blood is of great importance for the diagnosis: foamy scarlet blood — at pulmonary To., vomiting «a coffee thick» — at gastric and duodenal To.; a tar-like chair — at To. from upper parts went. - kish. path. However not always these signs allow to define localization of a source To., in this connection it is necessary to resort to difficult diagnostic testings: radiological, endoscopic, the selection angiography, etc.
To. in the closed perigastrium because blood is not emitted outside, it can be distinguished only on the changes caused by blood loss and on symptoms of accumulation of liquid in this or that cavity. To. in an abdominal cavity the hl is shown. obr. a picture of an acute anemia — pallor, low frequent pulse, thirst, drowsiness, blackout, a faint; the last can come also at the very beginning of intraperitoneal To. (see. Hemoperitoneum ), napr, at an extrauterine pregnancy as a result of vasomotor reaction on begun K. Mestno sometimes it is possible to find unsharply expressed symptoms of irritation of a peritoneum — an insignificant muscle tension of an abdominal wall, Shchetkin's symptom — Blyumberg, etc. (see. Peritonitis ); intestinal noise disappear; obtusion in sloping parts of a stomach appears only in cases of a massive hemoperitoneum; at women protrusion of a back vault of the vagina can be revealed. In cases of a simultaneous effluence in an abdominal cavity of intestinal contents, bile, etc. local symptoms To. mask the rough phenomena of peritonitis; existence of shock can complicate assessment of the general symptoms of an acute anemia. Therefore scoping of the circulating blood and a hematocrit, calculation of erythrocytes and definition of a hemoglobin content is important; considerable and bystry falling of these indicators speaks about intraperitoneal To. From white blood the neutrophylic leukocytosis — result of leukocytic reaction to the blood which streamed in an abdominal cavity is observed. At To. in a chest cavity (see. Hemothorax ) the symptoms caused by an acute anemia are combined with signs of accumulation of Blood in a pleural cavity that it is possible to find by means of percussion, auscultation, roentgenoscopy and a trial puncture. At To. in a joint (see. Hemarthrosis ), in a cavity of a pericardium (see. Hemopericardium ), skulls, to the spinal canal blood loss is usually insignificant and clinically is not shown. On the first place signs of dysfunction of appropriate authority, a part of the body caused by preferential mechanical effect of the blood which accumulated in a cavity — disturbance of movements in a joint, the phenomena of a cardiac tamponade, all-brain focal nevrol, symptoms, spinal frustration act. Depending on localization the arising disturbances can directly threaten life of the patient (a cardiac tamponade, an intracranial hematoma).
For diagnosis of internal bleedings by M. B. Bagdasarov and Yu. G. Shaposhnikov the tracer technique is offered. Its essence is that the radionuclide entered intravenously together with the streaming blood collects in fabrics, in a cavity or in a gleam of hollow body. Increase in radioactivity on the site of damage is found in the way radiometry (see). For diagnosis internal To. colloid solution 198Au which is normal absorbed by reticuloendothelial cells of a liver can be used and practically in 15 — 20 min. disappears from a blood channel. Detection of the radio indicator in any sites, except a liver, testifies about proceeding To. at the time of the research. For the purpose of dynamic observation for judgment about proceeding To. or the stop can use it such radionuclide which it is long (several hours and even days) circulates in a vascular bed and, collecting at proceeding To. in fabrics, increases the radioactivity of this area. The radio isotope research allows to reveal To. from a gullet, the cardia and output department of a stomach, a duodenum, a small and large intestine, appendages of a uterus. The method is used also at the combined and combined damages, at the closed injury of a skull, breast, stomach, extremities. The radiometry is made by the portable SRP-68-1 radiometer or scanners.
At recognition To. estimate also its weight. At outside To. it is estimated, based on character To. (arterial, venous etc.), caliber of the bleeding vessels, speed an izlitiya of blood. Weight internal To. it is necessary to determine by expressiveness of symptoms of the arisen blood loss and by the speed of their increase. V. I. Struchkov, E. V. Lutsevich (1971) distinguish four degrees To. The I degree — the general condition of the patient is satisfactory, pulse is speeded a little up, sufficient filling, the ABP normal, the hemoglobin content is higher than 8 g of %, deficit of the volume of the circulating blood (VCB) no more than 5%; at kapillyaroskopiya (see) — a pink background, 3 — 4 rows of capillary loops with a bystry homogeneous blood-groove clearly are visible. The II degree — the moderately severe state, pulse frequent, is lowered by the ABP to 80 mm of mercury., the hemoglobin content — to 8 g of %, deficit of OTsK reaches 15%; at a kapillyaroskopiya — a pale background, number of capillary loops it is reduced twice, a blood stream bystry, but not homogeneous. The III degree — serious condition, pulse threadlike, the ABP — to 60 mm of mercury., hemoglobin — to 5 g of %, deficit of OTsK — 30%; at a kapillyaroskopiya only 1 — 2 loops are visible, their venous and arterial parts are difficult distinguishable. The IV degree — a state borders with agonal, pulse and ABP are not defined, hemoglobin less than 5 g of %, deficit of OTsK exceed 30%; at a kapillyaroskopiya — a background gray, loops of capillaries are not visible. Definition of weight To. very important at the operative measures connected with essential blood loss (see. Surgery ).
Treatment at To. it is carried out by means of physical (mechanical, thermal), the biological and medicamentous funds allocated for a stop To. — temporary (preliminary) or constant (final). The first prevents dangerous blood losses) and allows to win time for transportation of the patient, specification of the diagnosis and preparation for radical actions. Medicamentous and biological styptic means of a systemic effect (see. Styptic means ) are effective when topographical and anatomic features To. do not exclude a possibility of its spontaneous stop. The main means of fight with To. ways of local action and first of all mechanical serve a little inclined to a spontaneous stop. With their help either recovery of a continuity of affected vessels, or closing of their ends tightly, or, at last, only the termination of access of blood to the damaged piece of a vessel can be carried out. The first two ways use for a final stop To., and the third — both for final, and for a temporary stop To. In the latter case switching off of a vessel is temporary and is carried out mainly in the anemic ways whereas constant switching off requires a bloody operative measure.
The temporary stop of bleeding is reached by imposing of a styptic plait, turning, a tourniquet (see. Plait styptic ), pressure upon the bleeding vessel in the place of disturbance of its integrity or throughout a vessel places of damage are higher (on a blood flow). On site damages the vessel can be squeezed by the compressing bandage, a load, fingers imposed on a wound or entered into it, at last, by a hard tamponade. For a prelum of a vessel on an extent manual pressing of arteries, fixing of an extremity serve in a certain «haemo static» situation and special tools — compressors. The most well-tried remedy of a temporary stop To. the applying a tourniquet, however range of application of the last, as well as banners in general is, it is limited to hl. obr. extremities. An applying a tourniquet across Momburgu for a prelum of a ventral aorta not safely. To an applying a tourniquet on a neck at To. from a carotid artery (with a level or through an axillary hollow of the healthy party) resort seldom as well as to an applying a tourniquet on the head. The compressing bandage is most effective at To. from soft tissues, a thin coat lying on bones (covers of a skull, area of knee and elbow joints). Pressure a load, usually in combination with cooling (a bubble with ice), is used by hl. obr. at interstitial To. from small vessels (hemorrhages). Imposing of a load (a bag with sand) on an operational wound is quite often applied to prevention of postoperative hematomas. Pressure fingers on a wound (through the applied bandage) can serve as initial reception of first aid which allows to win time for preparation for an applying a tourniquet or a compressing bandage. Pressing of a vessel the fingers entered into a wound is not recommended as reception most and mutual assistance though applied by the surgeon it saved life the wounded more than once. The riparian forest the tamponade of a wound is also not among actions most and mutual assistance; the medic shall carry out it. The gauze tampon which hardly filled a wound is fixed then a compressing bandage. At some types To. the tamponade of the bleeding wound can be means not only a temporary, but also final stop To. The imposing of rare seams on skin over a hard tampon practicing sometimes for a temporary stop To. in field conditions, it is not safe since if in the next few hours seams are not removed and the tamponade is replaced with more perfect way of a hemostasis, then the hardest wound complications can develop. The riparian forest the tamponade is contraindicated at wounds of a popliteal space since in these cases it usually leads to gangrene of an extremity.
Manual pressing of an artery on an extent is carried out on the site where it is located superficially and near a bone, to a cut can be pressed (fig.). Correctly executed manual pressing provides switching off of an artery rather full, but short-term since even very strong person cannot continue it more than 15 — 20 min. This reception is important by preparation for an applying a tourniquet and especially at its change, but can be useful also to reduction of blood loss at extremity operation, especially at amputation, to-ruyu for some reason or other it is impossible to execute, using a plait. Well manual pressing of humeral and femoral arteries works well, it is worse — the general sleepy. It is even more difficult to squeeze a subclavial artery, to-ruyu it is necessary to press to the I edge, in depth behind a clavicle. Therefore at To. from subclavial and axillary arteries it is more favorable to use fixing of the hand which is most got back and pressed to a back. The haemo static effect of this reception is explained by the coming prelum and. subclavia between a clavicle and the I edge. Fixing to the full the bent elbow at To. from a forearm or a brush and a knee at To. from a shin or foot also gives haemo static effect; at injuries of a femoral artery high, unavailable to an applying a tourniquet fixing of a hip to a stomach at the maximum bending in knee and coxofemoral joints is effective. Various compressors and pilots are used generally to a temporary stop To., most often from carotid arteries.
During short switching off from blood circulation the bleeding vessel quite often is thrombosed. Then a preliminary stop To. it can be final. So, at To. from medium-sized vessels the compressing bandage gives lasting haemo static effect sometimes, cover action, unlike a banner or manual pressing, long time can proceed. After removal of the plait imposed at To. from a large artery, can seem that there came the final stop To. But this impression is wrong: the blood clots formed for a short time switching off still are very fragile, and To., as a rule, renews in the next few hours.
A final stop of bleeding
the Most important means of a final stop To. serve vascular seam (see) and bandaging in a wound of both ends of the bleeding vessel. Other types bandagings of blood vessels (see) with success can be applied not in all cases. At To. from some vessels which bandaging is difficult or impossible it is replaced cliping of vessels (see). A reliable way of a final stop To. — removal of the bleeding body (e.g., the broken-off spleen) or its parts (e.g., parts of a stomach together with the bleeding ulcer). In some cases the listed ways of a final stop To. are inapplicable. Then use special receptions and methods. If the large bleeding vessel is taken by a clip, but it is not possible to bring under it a ligature, the clip can be left to a demeure (fr. on a residence, i.e. for long time) before its falling away, a cut occurs in 8 — 12 days when the vessel is reliably thrombosed. This reception in field conditions can be used also for a temporary stop To., at the subsequent stage to make bandaging of a vessel. It is important to provide a full immovability of the tool in a wound; its rings need to be fixed carefully bandage together with a bandage. In case of impossibility to isolate a vessel in the changed fabrics or at big fragility of a vascular wall the ligature of en masse (fr. all weight) taking a vessel together with surrounding fabrics is applied. At To. from the numerous vessels located in very brittle fabric (e.g., in a parenchyma of a liver) or, on the contrary, in dense, tenacious fabrics (covers of a skull), use a styptic seam, in loops to-rogo fabrics together with the vessels passing in them are taken (see. Seams surgical ).
At parenchymatous To., plentiful To. from small vessels of a contaminated wound the tamponade can be applied by a usual gauze, to-ruyu to 8 — to the 10th day gradually take from a wound, or the resolving material, a fibrinny sponge (see. Fibrinnaya sponge, film ), blood cotton wool, biol, an antiseptic tampon (see. Styptic means ). The sponge from starch which also have haemo static properties is abroad used as the resolving tampon. Rather well also the nitrogauze resolves. In need of quality of the resolving material for a tamponade the catgut (in the form of locks, balls) or a fibrinny film can be used. The absorbable fibrinny gelatin sponge and blood cotton wool, in addition to mechanical action, render and biol, effect, promoting a bystry thrombogenesis. At
To. from a svezhepovrezhdenny parenchyma with success the covering of the bleeding surface can be applied by synthetic resin adhesive. A good way of a stop To. from a wound of a liver — a tamponade muscular tissue or an epiploon (a free rag or a rag on a leg). Such biol, a tampon in combination with suture on a wound of a liver, at the same time fixing and the rag, also renders at the same time mechanical and biol, action. To. from a wound of a lung usually stop suture.
Thermal ways of a stop To. are based on ability of proteins to be curtailed at high temperature. They matter hl. obr. for fight with To. during surgeries. At diffusion To. from a bone wound applying of the napkins or balls moistened hot (50 — 60 °) can be used by isotonic solution of sodium chloride. In the main thermal way of a stop To. is diathermocoagulation (see), edges is essential in cases when the alloying of small vessels is difficult or it is impossible (vessels of a brain and its covers, vessels of a bladder). Diathermocoagulation can use widely and for a stop To. from hypodermic cellulose and muscles at any operative measure. More and more broad use for a stop To. find laser (see) and methods cryosurgeries (see). Hemostatics of a systemic effect are widely used at not traumatic internal To. (a pneumorrhagia, uterine To. etc.), at traumatic To. have hl. obr. auxiliary value as addition to local means of a hemostasis. The role them is especially big at bleeding caused by this or that patol. state. From styptic means of a systemic effect the most effectively direct hemotransfusion, transfusion in small doses (100 — 150 ml) of fresh isogenic stored blood, plasma (see. Hemotransfusion ), transfusion trombotsitny weight (see).
From styptic means of local action have special value biological (a fibrinny sponge, biol, an antiseptic tampon, etc.). The Fibrinny sponge is applied as per se as a resorptional tampon, and on usual gauze tampons for what it is crushed in powder. Some of topical biol, means apply only on gauze tampons — thrombin, autogemostol, similar to the haemo table applied before, but made not from animal, and from donor blood. Medicamentous styptic drugs of local action, vasoconstrictive apply restrictedly in some special areas (an ear, a throat, Nov), and coagulating — hl. obr. in life, at a microtrauma (a shaving pencil, etc.).
In the second half of 20 century for a stop of pulmonary, went. - kish., brain To. methods of artificial embolization of vessels by means of lysing (muscular homogenate, gelatinous sponges, etc.) and not lysing are developed and implemented in a wedge, practice (polystyrenes, silicone, etc.) means. At heavy To., followed by hemorrhagic shock, treatment shall be complex using physical, biological, medicamentous means.
The stop of brain bleeding
the Hemostasis in surgery of a brain is of great importance since even small To. considerably complicates operation, and the insufficient hemostasis gives in the postoperative period a terrible complication — an intracranial postoperative hematoma, leads edges to heavy complications. Methods of a stop To. from vessels of a meninx and substance of a brain differ from all-surgical methods of a hemostasis. It is connected with the fact that vessels of a firm meninx pass in more thickly covers, and vessels of a brain are located on a surface, in cracks, marrow, a cut has a soft consistence. Large brain arteries are on the basis of a brain; approach to such arteries is complicated by narrowness of a surgery field, the limited sizes of a trepanation opening and small opportunities to displace a brain. To devices which use for drainage of a surgery field at To. from vessels of a brain and its covers, the sucking-away device (aspirator) allowing to keep a surgery field pure even at considerable To belongs. Universal remedy of a stop To. monopolar or bipolar coagulation is (see. Diathermocoagulation ). At To. from large arteries or veins for a hemostasis use silver clip-on earrings, to-rymi clamp the bleeding vessel (see. Cliping of vessels ). At diffusion To. from a wound of a brain apply the wadded strips or small gauze tampons moistened with hydrogen peroxide. Very good, and sometimes irreplaceable means of a hemostasis in the depth of a wound of a brain or from a firm meninx at a separation of veins or small damage of a sine of a firm meninx is the absorbable gelatin sponge. In certain cases it is necessary to use styptic clips and bandaging of vessels.
In surgery of a brain methods of the prevention are closely connected with a problem of a hemostasis To. and the methods promoting a hemostasis. Preliminary electrothermic coagulation or cliping of brain vessels concerns to the first. After these manipulations the section of a cerebral cortex and his arteries passes without blood. To the methods promoting a stop brain To., the managed arterial hypotonia belongs (see. Hypotonia artificial ) — decrease in the ABP to 70 — 50 mm of mercury. At hypotonia decreases To., what considerably facilitates coagulation or cliping of the bleeding vessel. At To. from a small vessel the bleeding place is covered with a wadded strip, through to-ruyu aspirate blood. At the continuing aspiration the wadded strip is displaced until the damaged vessel seems. At the same time blood is absorbed by cotton wool and is removed an aspirator, the surgery field remains pure. Well visible bleeding vessel is coagulated or cliped. At To. from a large artery, a vein or defect of aneurism the aspirator shall be brought to the place To. so that the stream of blood got directly to an aspirator. This reception leaves a surgery field pure and allows to coagulate or clip a vessel precisely. At coagulation of the bleeding vessel the last is taken branches of coagulative tweezers on which current of an electrocoagulator moves. During the cliping of a vessel the clip by means of the special holder brought to a vessel is squeezed before full closing of a gleam of an artery. After that a klipsoderzhatel unclench and the clip remains on a vessel. At To. in the depth of a wound use the special klipsoderzhatel bent at right angle with the extended branches. At use of an absorbable gelatin sponge its small piece in the form of a plate is put and gently pressed tweezers or a tampon to the bleeding place. In 2 — 3 min. the sponge sticks to fabrics and reliably stops To. At a stop To. from vessels of a firm meninx it is better to use imposing of clips since at coagulation the firm meninx shrivels.
Postoperative bleedings meet more often at patients with the lowered coagulability of blood. Practically it is necessary to meet bleeding because of long jaundice, at diseases of bilious ways, an echinococcus of a liver, acute fibrinolysis (see). Arising diffusion capillary To. leads usually only to formation of a hematoma (at the sewn-up wound) or to long blotting of a bandage at the trained wound. To. becomes dangerous if the bleeding surface is very big that perhaps after operation for an echinococcus of a liver in the open way. Walls of a cavity persistently and plentifully bleed and to stop it To. can be difficult. The most reliable way — a tamponade a gauze with powder of an absorbable gelatin sponge or with thrombin. It is at the same time necessary to apply hemostatics of a systemic effect. Life-threatening gastric To. after stomach operations meet seldom; the single hematemesis in the first days after operation does not serve as the proof dangerous gastric To. Repeated vomiting, even the low-changed blood, usually also stops under the influence of conservative actions (see. Gastrointestinal bleeding ). Only in exceptional cases at persistently proceeding vomiting the question of need of relaparotomy, pointing of an anastomosis and bandaging of the bleeding vessel can rise fresh blood with the phenomena of the accruing acute anemia.
Polostnye K. after abdominal organs operations are among the hardest complications. They can arise owing to sliding or eruption of the ligature imposed on a vessel of a mesentery, a leg of a cyst, etc. The most part of these To. it is observed after appendectomies. However, cases of this sort make the 100-th shares percent that total number of appendectomies. Besides, there is an opinion that in some cases similar To. remains not distinguished and stops spontaneously, but leads in view of infection of the streamed blood to development of purulent processes in an abdominal cavity which are registered in quality inf. complications of appendectomy. Postoperative To. in an abdominal cavity it is shown almost only by a picture of an acute anemia since symptoms from a stomach are often imperceptible against the background of the changes inherent to the postoperative period. The accruing anemization, especially falling of a hematocrit, number of erythrocytes and a hemoglobin content forms a basis of the diagnosis. At To. after appendectomy of the phenomenon of an acute anemia accrue gradually, during one and even two days. At To. from larger vessel the picture develops much quicker. Treatment consists in relaparotomy and to K. Posleoperatsionnoye K. stop in a chest cavity can arise from a wound of a chest wall, pleural commissures, a parenchyma of a lung or from large vessels owing to sliding of a ligature, and also acute fibrinolysis (see). At To., not followed by the expressed hemodynamic disturbances, ordinary haemo static events, including the means increasing coagulability of blood are held (epsilonaminokapronovy to - that, Haemophobinum, etc.). At massive To. the retorakotomiya for a hemostasis with simultaneous completion of blood loss is shown.
After operations on large vessels To. most often can arise owing to discrepancy of the vascular seam applied to recovery of a continuity of a vessel or at its prosthetics, anastamosing, shunting; less perhaps To. as a result of sliding of a ligature from the tied-up vessel. If at operation technical errors are not allowed, then as the main reason for insolvency of seams and ligatures serves the infection of an operational wound which extended to a vascular wall. The persons who underwent operations on large vessels demand especially attentive observation and full readiness of personnel for an immediate temporary stop possible To., what is most feasible on extremities using the plait which is hung up in advance on a bed or the hip which is led round around, a shoulder (a provisional plait).
Bleedings at gunshot wounds
In a varying degree To. it is observed at any wound; as a complication of wounds are considered only To., menacing to considerable blood loss (see). Such To., by data A. A. Vasilyeva, during the Great Patriotic War occurred at 25% of wounded. In the majority they are connected with injury of arteries, is more rare than parenchymatous bodies, is even more rare than veins. At stages of medical evacuation hl were observed. obr. To. from vessels of extremities since at wounds of larger vessels first aid is ineffective, and To. often leads to death in the battlefield. The vast majority To. comes from the vessels damaged at the time of wound; only apprx. 15% of all To. falls to the share of the vessels which are originally not damaged, but victims in the subsequent course of a wound (damage by the displaced fragment of a bone, decubitus from a foreign body, from the drainage which is imprudently brought to a vascular bundle, an arrosion as a result of purulent fusion). To. from a wound without visible disturbance of a vascular wall due to its excessive permeability (haemorrhagia per diapedesin) are possible at a traumatosepsis and especially at an acute radial illness. As shows experience of the Great Patriotic War, it is very frequent To., regarded as arrosive, it appeared To. from a vessel, wound to-rogo was not timely distinguished. To. from the vessels damaged at the time of wound can arise in different terms and to be primary and secondary. Secondary To. are subdivided on early and late. Early secondary To. arise preferential during from 2 to 4 days from the moment of wound in connection with disturbance of obturation of a vessel by pushing out from it fresh blood clot under the influence of concussions during the transportation of the wounded or owing to increase in blood pressure in connection with fever, escaping of shock or with the made transfusion. Late secondary To. begin most often during from 10 to 15 days from the moment of wound as a result of purulent fusion of blood clots, sequestration of the ends of the damaged vessel, a necrosis and rejection of fabrics, obturirovavshy the wound channel. According to S. A. Rusanov, a nek-swarm number K. it was connected with a rupture of traumatic aneurisms and arose in 25 — 30 days after wound later. Late secondary To. often emergence of harbingers precedes: the bloody coloring wound separated small clots in separated wounds, sudden fervescence; quite often before To. there are new and already being available symptoms of wound of an artery, napr amplify, pulse on the periphery during the strengthening of the being available noise disappears or there are noise at the disturbance of pulse found before. Emergence of these alarming signs forces to expect in the next few hours To. from a wounded vessel. Shortly before the beginning secondary To., having an arrosive origin, there can also be some of these phenomena (temperature increase, a bloody discharge). Important feature late secondary To. their ability to bystry, but extremely unreliable spontaneous stop is. Suddenly begun plentiful To. can stop immediately (so-called alarm To.) by itself or under the influence of temporary switching off of a vessel so at removal of the imposed plait it is not found. This circumstance can mislead the surgeon therefore it is necessary to remember what in similar cases arises repeated To., often repeated.
Recognition To. at wounded it is inseparably linked with diagnosis of damages of large blood vessels. These damages at an attentive research of pulse on the periphery of an extremity and auscultation of area of the wound channel are asymptomatic less than in 10% of cases. In other cases it is possible to establish or lack of pulse on the periphery of an extremity (at cross wounds of arteries), or noise (at side wounds). Check of these symptoms during the rendering the qualified surgical help is obligatory at everyone wounded in an extremity, especially in the presence of essential To. from a wound. In doubtful cases primary surgical treatment of a wound shall include audit of the corresponding large vessels. It is necessary to remember that wound of a vessel and To. from it are possible at any localization of wound openings, and therefore the arrangement of the last far from a projection of a vascular bundle does not exclude a possibility of wound of a vessel. Check of a condition of vessels (pulse on peripheries, noise) gives the chance not only to estimate correctly available To., but also to provide it where it did not begin yet.
A stop To. at wounded it is carried out by the described general rules. At the advanced stages of medical evacuation (including a stage of rendering the first medical assistance) ways of a temporary stop are used To., and since a stage, on Krom give the qualified surgical help, the final stop of bleeding is carried out. Early operation on the damaged vessels is of particular importance at the combined radiation defeats. In these cases the lowered resilience of an infection and oppression of reparative processes extremely increase probability late To. from a wounded vessel. Having arisen in the heat of a radial illness, it To. will demand the operation extremely undesirable and a dangerous radial illness in this period of a current. Therefore all operations on the damaged vessels at the combined radiation defeats shall be executed as soon as possible — not later 3 — the 4th day from the moment of defeat. Fight with capillary To. from the granulating wound, inevitable at an acute beam syndrome, the hl is carried out. obr. by means of the means normalizing coagulability of blood and permeability of a vascular wall (ascorbic to - that, phthiocol, hemotransfusion fractional doses). Locally on a wound the fibrinny sponge, thrombin, autogemostol etc. shall be applied. Prevention To. at the combined radiation defeats comes down to most care with the granulating wound (see. the Combined defeats ). Recognition and treatment band To. at wounded — see. Hemopericardium , Hemoperitoneum , Hemothorax .
the Outcome To. is defined by timeliness of its final stop and immediate completion of blood loss. At observance of these conditions the forecast favorable. However at traumatic To. emergence of the dangerous complications threatening with a recurrence To is possible.
Prevention is most feasible concerning postoperative (a careful hemostasis) and secondary To. at wounds. In the latter case it comes down to early recognition of damage of a large vessel and timely (prior to the beginning of secondary To.) operations on it. Both to, and after operation by the patient strict rest (an immobilization of an extremity) and vigilant observation, especially if wounds open or purulent shall be provided.
Bibliography: Akhutin M. N. Field surgery, M., 1942, bibliogr.; Bagdasarov M. B. and Shaposhnikov Yu. G. A new radio isotope way of detection of bleedings, in book: Aktualn. vopr. gastroenterol., under the editorship of A.S. Loginov, page 131, M. 1975; Vishnevsky A. A. and Schreiber M. I. Field surgery, M., 1975; Herzen of II. A. O bleedings, M. — L., 1940; Golovin of G. V. and P about d at r with to and I am R. A. O methods of determination of size of blood loss, Vestn, hir., t. 112, No. 6, page 133, 1974, bibliogr.; Lytkin M. I. and To l of ohms and ets V. P. Acute injury of the main blood vessels, L., 1 973, bibliogr.; The multivolume guide to surgery, under the editorship of B. V. Petrovsky, t. 1, M., 1962, t. 10, 1964; Petrovsky B. V. Surgical treatment of wounds of vessels, M., 1949, bibliogr.
S. A. Rusanov, Yu. V. Struchkov; M. B. Bagdasarov, Yu. G. Shaposhnikov (is glad), E. I. Zlotnik (neyrokhir.).