Hemorrhage (Bled to death)

Bleeding, also known as hemorrhaging or haemorrhaging, is blood escaping from the circulatory system. Bleeding arises due to either traumatic injury, underlying medical condition, or a combination.

Bleeding can occur internally, where blood leaks from blood vessels inside the body, or externally, either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a break in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination.

Hemorrhaging is broken down into four classes by the American College of Surgeons' advanced trauma life support (ATLS).

• Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
• Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required.
• Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral hypoperfusion (shock), such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.
• Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death. This system is basically the same as used in the staging of hypovolemic shock.

Causes

Traumatic Injury

• There are different types of wounds which may cause traumatic bleeding. These include:
  • Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis
  • Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
  • Hematoma - Caused by damage to a blood vessel that in turn causes blood to collect under the skin.
  • Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
  • Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery.
  • Puncture Wound - Caused by an object that penetrated the skin and underlying layers, such as a nail, needle or knife
  • Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
  • Crushing Injuries - Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself.
  • Ballistic Trauma - Caused by a projectile weapon such as a firearm. This may include two external wounds (entry and exit) and a contiguous wound between the two. Medical condition
• The causes of bleeding that are not directly due to trauma. Blood can escape from blood vessels as a result of 3 basic patterns of injury:
  • Intravascular changes - changes of the blood within vessels (e.g. ↑ blood pressure, ↓ clotting factors)
  • Intramural changes - changes arising within the walls of blood vessels (e.g. aneurysms, dissections, AVMs, vasculitides)
  • Extravascular changes - changes arising outside blood vessels (e.g. H pylori infection, brain abscess, brain tumor)
• Medical conditions that can cause bleeding:
  • hemophilia, inherited bleeding disorder with a lack or low levels of certain clotting factor proteins
  • leukemia, a cancer of the blood cells, most frequently of the WBCs (white blood cells)
  • liver disease
  • menorrhagia, heavy or prolonged menstrual bleeding
  • thrombocytopenia, low blood platelet count
  • von Willebrand disease, a deficiency of von Willebrand factor that helps blood clot
  • vitamin K deficiency
  • brain trauma
  • bowel obstruction
  • congestive heart failure (CHF)
  • lung cancer
  • acute bronchitis
  • severe hypothermia
• Some Medications can increase the chances of excessive bleeding, such as:
  • Blood-thinning medications (anticoagulation meds)
  • antibiotics, when used on a long-term basis
  • radiation therapy
  • Aspirin

Types of Hemorrhage: (There are numerous types & sites)

• Postoperative hemorrhage - after surgery
• Postpartum hemorrhage - from childbirth
• Arterial hemorrhage - from an artery
• Venous hemorrhage - from a vein
• Capillary hemorrhage - from a capillary
• Primary hemorrhage - if bleeding immediately follows an injury
• Reactionary hemorrhage - delayed bleeding after injury
• Secondary hemorrhage - delayed bleeding from sepsis
• Hematuria - blood in the urine from urinary bleeding
• Hemoptysis - coughing up blood from the lungs
• Hematemesis - bleeding in the stomach

Statistics:

• Each year more than half a million people bleed to death following traffic accidents, combat wounds, and other severe trauma. Soon a lot of those fatalities might be avoidable. Discover Magazine - Stanching the Flow of Deaths by Blood Loss
  • After a traumatic injury, hemorrhage is responsible for over 35% of pre-hospital deaths and over 40% of deaths within the first 24 hours, second only to the rates of death due to severe central nervous system injury. National Trauma Institute - Hemorrhage
• Traumatic and non-traumatic causes of hemorrhage carry significant mortality and morbidity. JEMS - Stop the Bleeding
  • Approximately 5 million people die every year around the world from accidental and non-accidental trauma, making trauma the leading cause of death in people under the age of 45.
  • Exsanguination accounts for approximately one-third of these deaths and the majority, which are due to exsanguination, occur within the first 48 hours.
  • Massive hemorrhage is second only to neurologic injuries as a cause of death due to trauma.
  • Hemorrhage carries with it not only the threat of immediate death due to blood loss, but also increased mortality due to multi-organ failure and sepsis.
  • Massive blood loss often starts a cascade of shock, inflammation and coagulopathy that can worsen blood loss and foil attempts at resuscitation.
  • Despite advances in transfusion medicine and medical care, massive blood loss is still a major cause of mortality—whether you’re in a third-world country or even a first-world one.
  • Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. BioMed Central - Critical Care - The acute management of trauma hemorrhage: a systematic review of randomized controlled trials
• The direct pregnancy-related maternal mortality rate in the United States is approximately 7-10 women per 100,000 live births. Medscape - Postpartum Hemorrhage
  • The most recent Practice Bulletin from the American College of Obstetricians and Gynecologists places the estimate at 140,000 maternal deaths per year.
  • Obstetric haemorrhage is the world’s leading cause of maternal mortality, responsible for an estimated 127 000 deaths annually. Postpartum haemorrhage (PPH) is the most common type of obstetric haemorrhage and accounts for the majority of the 14 million cases that occur each year. World Health Organization - Making Pregnancy Safer, Reducing the Global Burden: Postpartum Haemorrhage
• An estimated 6 million people in the United States have an unruptured brain aneurysm, or 1 in 50 people. Brain Aneurysm Foundation - Brain Aneurysm Statistics
  • The annual rate of rupture is approximately 8 – 10 per 100,000 people or about 30,000 people in the United States suffer a brain aneurysm rupture.
  • Intracerebral hemorrhage represents approximately 10% to 15% (10-30/100,000 population) of all strokes.  About 2 million of the 15 million strokes worldwide are intracerebral hemorrhages.  Minneapolis Clinic of Neurology - Intracerebral Hemorrhage (Hemorrhagic Stroke)
  • Men are more likely to suffer an intracerebral hemorrhage than women.
  • In a recent review, 34% of patients died from their intracerebral bleed 3 months after the event.  Another study documented death rates after an intercerebral bleed of 31% at 7 days, 59% at one year, 82% at 10 years and more than 90% at 16 years. 
  • About 30% to 60% of people with an intracerebral hemorrhage die. In those who survive long enough to reach an emergency room, bleeding usually has stopped by the time they are seen by a doctor. Many people with ruptured aneurysms or subarachnoid hemorrhages also do not survive long enough to reach a hospital. Of those who do, about 50% die within the first month of treatment. However, in people with subarachnoid hemorrhages resulting from arteriovenous malformations, the risk of death is only about 15%. Drugs.com - Hemorrhagic Stroke
• Incidence rate statistics in the USA: Right Diagnosis - Statistics about Hemorrhage
  • Estimated 2.24 postoperative hemorrhages or hematomas with surgical drainage or evacuation occurred per 1,000 surgical discharges in the US 2000
• The study showed that uncontrolled blood loss was the leading cause of death in 90 percent of the potentially survivable battlefield cases and in 80 percent of those who died in a military treatment facility. Military Times - Study: 25% of war deaths medically preventable
  • But the study also notes that 90 percent of the deaths occurred before the injured reached a medical facility: of the 4,090 troops who suffered mortal wounds on the battlefield, 1,391 died instantly and 2,699 succumbed before arriving at a treatment center.
• Upper GI bleeding has been estimated to account for up to 20 000 deaths annually in the United States (international records are not available). World of Journal of Gastroenterology - Trends on gastrointestinal bleeding and mortality: Where are we standing?
  • The overall incidence of acute upper GI haemorrhage has been estimated to be 50 to 100 per 100 000 persons per year.
  • Regarding bleeding from the lower GI tract, it appears that haemorrhage from rectum and anus and the incidences of diagnosis of occult blood in stool are increasing
  • Oesophageal varices form less than 10% of the all causes of GI haemorrhages. However, patients with variceal haemorrhage have a mortality rate of at least 30% during their initial hospitalization, with a one year mortality rate approaches 60%. Patients who have bled once from oesophageal varices have a 70% chance of rebreeding, and approximately one third of further bleeding episodes are fatal.

History of Hemorrhage Control

• Getting medical personnel to recognize the seriousness and significance of hemorrhage has been a problem throughout the history of trauma care. Oddly, from the ancient world until the early 20th century, “bloodletting” was actually prescribed to treat a multitude of ailments including hemorrhage. It was common practice prior to surgery, and prior to amputation, for doctors to first “bleed” a patient the approximate amount of blood contained in the limb in an effort to decrease inflammation and infection.
• Bloodletting was considered an effective treatment to “cause hemorrhages to cease” until the late 1800s, and Sir William Osler still advocated bloodletting in the Principles and Practice of Medicine in 1923. Interestingly, this was at the same time that transfusion medicine and blood-banking was becoming safe and an accepted practice.
  • George Washington is a famous example of how death was hastened by bloodletting. After becoming ill, Washington called for a physician to bleed him. He underwent the procedure three times, having approximately 3.7 L of blood removed in 10 hours. He died shortly thereafter. Although therapeutic phlebotomy is still in use to treat hemochromatosis, it thankfully is no longer part of trauma care.

Famous People who died from hemorrhaging:

1. Ranker - Famous People Who Died of Cerebral Hemorrhage (184 people listed)
2. Ranker - Famous People Who Died of Brain Hemorrhage (11 people listed)
3. Ranker - Famous People Who Died of Hemorrhage (19 people listed)

For Further Reading:

• Wikipedia - Bleeding
• Health Line - What Causes Hemorrhage? 36 possible conditions
• Right Diagnosis - Types of Hemorrhage
• JEMS - Stop the Bleeding
• World of Journal of Gastroenterology - Trends on gastrointestinal bleeding and mortality: Where are we standing?
• Wikipedia - Maternal death

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