Haemorrhage

Question 1

What are the 3 categories of haemorrhage?

Answer 1

Primary bleeding - bleeding that occurs within the intraoperative period
Reactive bleeding - occurs within 24 hours of the operation
Secondary bleeding - occurs 7-10 days post-operatively

Question 2

Why does haemorrhage occur and how is it managed?

Answer 2

Primary bleeding should be resulved during the operation
Reactive bleeding occurs due to a ligature that slips or a missed vessel due to intraoperative hypotension and vasoconstriction, meaning only once the BP normalises will bleeding occur
Secondary haemorrhage is due to erosion of a vessel from a spreading infection - most often seen when a heavily contaminated wound is closed priamrily

Question 3

What are the clinical features of haemorrhage?

Answer 3

Shock:
Tachypnoea
Tachycardia
Dizziness
Agitation
Visible bleeding
Decreased decreased urine output

Hypotension is often a late sign

Question 4

How should a patient with suspected haemorrhage be examined?

Answer 4

Exposure to look for bleeding, systemic palpation of the surgical area looking for swelling, discolouration, disproportionate tenderness or any peritonism
Review the observations and grade any degree of shock

Question 5

How is haemorrhage managed if there is suspected post-op bleeding?

Answer 5

A-E assessment
IV access 18G cannula - ideally larger
Rapid fluid resuscitation

Read operation notes clarifying type of surgery and location of wounds, drains or important areas

Direct pressure to bleeding site if visible

Senior review

Urgent blood transfusion if moderate to severe post-operative haemorrhage - if severe bleeding this soul due in the for of packed RBCs, platelets, FFP,

Re-opration may be necessary

Question 6

What can post-thyroidectomy or parathyroidectomy bleeding lead to?

Answer 6

Airway obstruction because the pretracheal fascia of the neck will only distend so far and if filled with blood, will cause tracheal compression and asphyxiation.

Removal of skin clips, deep sutures and suction of haematoma is required.

Question 7

What artery is vulnerable to injury from laparoscopic ports?

Answer 7

Inferior epigastric artery from the external iliac artery
Runs up the abdominal wall below the rectum muscle vertically in the mid-clavicular line

Due to gas insufflation this may not be noticed at time of surgery

Especially in laparoscopic surgery or surgery with a Pfannestiel incision

Question 8

Where will bleeding from the external iliac artery go?

Answer 8

Into the retroperitoneum