Department of General Surgery Medical Academy named after S.I. Georgievskiy, The Federal State Autonomous Educational Establishment of Higher Education “Crimean Federal University named after V.I. Vernadsky” Ministry of Education and Science of the Russian Federation

For the 3rd year students

The text of the lectures and the minimum amount of knowledge necessary for a understanding of the subject material. Topic: Bleeding

Authors: prof.Mikhailychenko V.Yu, Starykh A.A.

2015

Bleeding Bleeding, technically known as hemorrhaging or hæmorrhaging (see American and British spelling differences), is blood escaping from the circulatory system. Etiology : trauma and some diseases (tuberculosis, cancer, peptic ulcer). What is blood? Functions of blood. Blood is basically a type of a connective tissue which is found in the human body in fluid state. It is made up of plasma which is a highly viscous liquid and 3 different types of blood cells that are floating around in it. Almost 92% of the plasma is water while the rest consists of enzymes, hormones, antibodies, nutrients, gases, salts, proteins and metabolites of various kinds. Besides plasma, the cellular constituents of blood are red and white blood cells and . What are the functions of blood? What about the functions for each blood component? Functions of Blood Blood performs many important functions within the body including:  Supply of oxygen to tissues (bound to hemoglobin, which is carried in red cells)  Supply of nutrients such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins (e.g., blood lipids))  Removal of waste such as carbon dioxide, urea, and lactic acid  Immunological functions, including circulation of white blood cells, and detection of foreign material by antibodies  , the response to a broken blood vessel, the conversion of blood from a liquid to a semi-solid gel to stop bleeding.  Messenger functions, including the transport of hormones and the signaling of tissue damage  Regulation of body pH  Regulation of core body temperature  Hydraulic functions Blood Components and Their Functions 1. Plasma About 55% of blood is blood plasma, a fluid that is the blood's liquid medium, which by itself is straw-yellow in color. The blood plasma volume totals of 2.7–3.0 liters (2.8–3.2 quarts) in an average human. It is essentially an aqueous solution containing 92% water, 8% blood plasma proteins, and trace amounts of other materials. Plasma circulates dissolved nutrients, such as glucose, amino acids, and fatty acids (dissolved in the blood or bound to plasma proteins), and removes waste products, such as carbon dioxide, urea, and lactic acid. Other important components include:  Serum albumin  Blood-clotting factors (to facilitate coagulation)  Immunoglobulins (antibodies)  lipoprotein particles  Various other proteins  Various electrolytes (mainly sodium and chloride)

The term serum refers to plasma from which the clotting proteins have been removed. Most of the proteins remaining are albumin and immunoglobulins. Plasma is the most abundant component of blood. It has a number of functions which includes carrying glucose which is the most important nutrient required by each cell for generating energy. The other nutrients that are also carried by plasma include vitamins, cholesterol, amino acids, triglycerides and fatty acids. All of these nutrients are carried by plasma to and from each and every cell present in the body. Plasma is also responsible for the transportation of Cortisol and thyroxin hormones, which attach themselves to the plasma proteins and are then taken to all parts of the body. Homeostasis and management of the functioning of cells is also among the duties performed by plasma with the help of the inorganic ions that it contains in large quantities. Healing of wounds and stopping spillage of blood through clotting is another function of plasma which is made possible due to the presence of clotting agents in it. Plasma even plays a part in helping the body fight against the germs and infections thanks to the antibodies named gammaglobulins that are present in it. 2. White Blood Cells The infections that threaten to damage the body are handled by the white blood cells found in blood. White blood cells contain bacterial agents trying to penetrate into the body. These cells which are also known by the name of leukocytes are formed in the stem cells of the bone morrow and start circulating in the body by means of blood as well as the lymph fluid. The whole immune system of a human body is dependent on these white blood cells to identify the pathogens, cells with cancerous material in them and matters which is foreign to the body. In addition to identifying them, leukocytes are also tasked with the duty of destroying and cleaning the body of these enemy cells. 3. Red Blood Cells 4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: Red blood cells contain the blood's hemoglobin and distribute oxygen. Mature red blood cells lack a nucleus and organelles in mammals. The red blood cells (together with endothelial vessel cells and other cells) are also marked by glycoproteins that define the different blood types. The proportion of blood occupied by red blood cells is referred to as the hematocrit, and is normally about 45%. The combined surface area of all red blood cells of the human body would be roughly 2,000 times as great as the body's exterior surface. The main job assigned to the red blood cells present in the blood is to make sure that the oxygen is delivered to all the cells of the body when the pumping of the blood has been carried out by the heart. The red blood cells have a very quick speed at which they travel through both the veins and arteries. The veins have a relatively smaller wall around them as compared to the arteries since the pressure of the blood is not too intense when it passes through them in comparison to the arteries. 4. Platelets 200,000–500,000 thrombocytes:Also called platelets, they take part in blood clotting (coagulation). from the coagulation cascade creates a mesh over the plug. The platelets are the lightest and the smallest components of blood. Due to their small size they usually travel near the walls of the vessels carrying blood. The wall of the blood vessels which is made up of special cells named endothelium stop the platelets from sticking to them. However, in the case of an injury, this layer of endothelium cells gets damaged and the blood starts flowing out from the blood vessels. When this happens the platelets react immediately and get attracted by the tough fiber which surrounds the walls of the blood vessels. The platelets then stick to the fibers and begin changing their shape thereby making a type of seal which stops the blood from flowing out of the body.

Classification of bleeding I) Bleeding may occur: 1. Inside the body when blood leaks from blood vessels or organs  Intratissue  Internal Bleeding into pleural cavity, cranial cavity, abdominal cavity. 2. Outside the body when blood flows through a natural opening (such as the vagina, mouth, or rectum) 3. Outside the body when blood moves through a break in the skin. II ) Three Main Types of Bleeding

In preparing yourself to identify and treat different types of bleeding, you must first have a good understanding of the three distinct types of bleeding that a person can experience. 1. Capillary Bleeding Capillaries are the smallest blood vessels in your body; they are about as thin as the hairs on your head. When a minor scrape or cut opens some capillaries, the bleeding is almost always very slow and small in quantity. Your body's natural clotting mechanism is able to stop most cases of capillary bleeding within seconds to minutes. 2. Venous Bleeding Deep cuts have the potential to cut open veins. A cut vein typically results in a steady but relatively slow flow of dark red blood. The best way to stop most cases of venous bleeding is to put direct pressure on the wound. 3. Arterial Bleeding This is the least common and most dangerous type of bleeding. It involves bright red blood that comes out in large volume, and in spurts that correspond with each beat of your heart. In most cases of arterial bleeding, direct and extremely firm pressure on the wound is the best way of stopping it. If direct pressure is not applied, a severe arterial wound can cause you to bleed to death within a few minutes. 4. Parenchymal hemorrhage Intraparenchymal hemorrhage is bleeding into the tissue of the internal organs. III) occult bleeding- escape of blood in such small quantity that it can be detected only by chemical tests or by microscopic or spectroscopic examination. Occult gastrointestinal bleeding commonly manifests as iron deficiency anemia or fecal occult blood. Iron deficiency anemia results from chronic occult gastrointestinal bleeding. Evaluation of asymptomatic patients who have iron deficiency anemia or fecal occult blood usually should begin with investigation of the colon. Colonoscopy is preferred, but flexible sigmoidoscopy plus air contrast barium enema, or computed tomographic colonography may be acceptable in certain circumstances. If evaluation of the colon does not reveal a bleeding site, evaluation of the upper gastrointestinal tract is mandatory in patients who have iron deficiency anemia, and this should be considered in those who have fecal occult blood. In patients who have gastrointestinal symptoms, evaluation of the portion of the gastrointestinal tract from which the symptoms is derived should be pursued initially. The role of small intestinal investigation is controversial, and this probably should be reserved for patients who have iron deficiency anemia and persistent gastrointestinal symptoms or those who fail to respond to appropriate therapy. Celiac sprue should be considered as a potential cause of iron deficiency anemia in all patients. The treatment and prognosis of patients who have iron deficiency anemia or fecal occult blood depends on the gastrointestinal tract abnormality(ies) identified. Those without identifiable bleeding sites generally respond to conservative management and have a favorable prognosis. On the other hand, the outlook is poorer for patients with refractory occult blood loss or those who have vascular ectasias. Both groups of patients are clinically challenging and require a focused and experienced team approach to diagnosis and therapy.

IV ) 1. Primary hemorrhage-that which soon follows an injury.(no more 3 days) 2. Secondary hemorrhage-that which follows an injury after a considerable lapse of time. (more then 4-5 days) V ) 1. Acute (bleeding speed 25 ml/min) 2. Chronic bleeding ( bleeding for a long time)

❶ 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. ❷ 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. ❸ 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. ❹ 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. VII) The World Health Organization made a standardized grading scale to measure the severity of bleeding. Grade 0 no bleeding Grade 1 petechial bleeding; Grade 2 mild blood loss (clinically significant) Grade 3 gross blood loss, requires transfusion (severe); Grade 4 debilitating blood loss, retinal or cerebral associated with fatality

VIII) Petechial hemorrhages A petechia , plural petechiae is a small (1 - 2 mm) red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels). Petechiae" refers to one of the three descriptive types of bleeding into the skin based solely on size, the other two being purpura and ecchymosis. Petechiae are by definition less than 3 mm. The most common cause of petechiae is through physical trauma such as a hard bout of coughing, vomiting or crying, which can result in facial petechiae, especially around the eyes. Petechiae in this instance are harmless and usually disappear within a few days. Petechiae may be a sign of thrombocytopenia (low platelet counts) when platelet function is inhibited (e.g., as a side effect of medications or during certain infections), or in clotting factor deficiencies.[1] They may also occur when excessive pressure is applied to tissue (e.g., when a tourniquet is applied to an extremity or with excessive coughing or vomiting). If unsure, petechiae should always be quickly investigated. They can be interpreted as vasculitis, an inflammation of the blood vessels, which requires immediate treatment to prevent permanent damage. Some malignancies can also cause petechiae to appear. Petechiae should be investigated by a doctor to rule out the more dangerous conditions. Dermatologists can be the most helpful specialists in these conditions because they can more easily identify if the condition is petechiae or some similar looking but less worrisome rash. The significance of petechiae in children depends on the clinical context in which they arise. Petechiae in children can occur with viral infections. In this instance, they do not necessarily signify a serious illness. However, they are a hallmark signal of some potentially serious illnesses, such as meningococcemia, leukemia, and certain causes of thrombocytopenia, of which meningococcemia can cause death within 48 hours of infection. Therefore, their presence should not be ignored. Petechiae (in the face) may also be present in cases of self asphyxiation. Categories of causes  Infections: Bartonella infection or cat scratch disease, Bolivian hemorrhagic fever, Boutonneuse fever, Cerebral malaria, Congenital syphilis, Crimean–Congo hemorrhagic fever, Cytomegalovirus, Dengue fever, Ebola, Endocarditis, Influenza A virus subtype H1N1, Hantavirus, Infectious mononucleosis, Marburg virus, Neisseria meningitides, Rocky Mountain spotted fever, Scarlet fever, Typhus  Non-infectious conditions: Hypocalcemia, Idiopathic thrombocytopenic purpura, Leukemia, Celiac Disease, Aplastic anaemia, Scurvy, Lupus, Childhood protein- energy malnutrition such as Kwashiorkor or Marasmus, Erythroblastosis fetalis, Henoch-Schönlein purpura, Kawasaki disease, Schamberg's disease, Ehlers– Danlos syndrome, Sjogren's Syndrome  Trauma and Asphyxiation (discussed below)

Symptoms of bleeding  Blood coming from an open wound  Bruising Shock, which may cause any of the following symptoms:  Confusion or decreasing alertness  Clammy skin  Dizziness or light-headedness after an injury  Low blood pressure  Paleness (pallor)  Rapid pulse, increased heart rate  Shortness of breath  Weakness Symptoms of internal bleeding may also include:  Abdominal pain and swelling  Chest pain  External bleeding through a natural opening  Blood in the stool (appears black, maroon, or bright red)  Blood in the urine (appears red, pink, or tea-colored)  Blood in the vomit (looks bright red, or brown like coffee-grounds)  Vaginal bleeding (heavier than usual or after menopause)  Skin color changes that occur several days after an injury (skin may black, blue, purple, yellowish green)

Diagnosis of bleeding. 1. Clinical symptoms 2. Special methods of diagnosis /puncture, endoscopy, angiography, ultrasound, CT scan, MRI/ 3. Laboratory studies / number of erythrocytes 4-5h10 / 12 / l hemoglobin N-125-160 g / l, hematocrit N -44-47%

Assessment of severity

parameter The bleeding severity index

PS in min

arterial pressure N N ↓ ↓↓↓ N

N or ↓ ↓↓ ↓↓↓ Ps pressure ↑

Respirat. movements

Urine output per 0 hour Central nervous excitation excitation inhibition Precoma system

blood volume , ml

Considerations Get emergency medical help for severe bleeding. This is very important if you think there is internal bleeding. Internal bleeding can very quickly become life threatening. Immediate medical care is needed. Serious injuries don't cause heavy bleeding. Sometimes, relatively minor injuries can bleed a lot. An example is a scalp wound. You may bleed a lot if you take blood-thinning medication or have a bleeding disorder such as hemophilia. Bleeding in such people requires immediate medical attention. The most important step for external bleeding is to apply direct pressure. This will stop most external bleeding.

Always wash your hands before (if possible) and after giving first aid to someone who is bleeding. This helps prevent infection. Try to use latex gloves when treating someone who is bleeding. Latex gloves should be in every first aid kit. People allergic to latex can use a nonlatex glove. You can catch viral hepatitis if you touch infected blood. HIV can be spread if infected blood gets into an open wound, even a small one. Although puncture wounds usually don't bleed very much, they carry a high risk of infection. Seek medical care to prevent tetanus or other infection. Abdominal and chest wounds can be very serious because of the possibility of severe internal bleeding. They may not look very serious, but can result in shock. Seek immediate medical care for any abdominal or chest wound. If organs are showing through the wound, do not try to push them back into place. Cover the injury with a moistened cloth or bandage. Apply only very gentle pressure to stop the bleeding. Blood loss can cause blood to collect under the skin, turning it black and blue (bruised). Apply a cool compress to the area as soon as possible to reduce swelling. Wrap the ice in a towel and place the towel over the injury. Do not place ice directly on the skin.

First Aid First aid is appropriate for external bleeding. If bleeding is severe, or if you think there is internal bleeding or the person is in shock, get emergency help. Calm and reassure the person. The sight of blood can be very frightening. If the wound affects just the top layers of skin (superficial), wash it with soap and warm water and pat dry. Bleeding from superficial wounds or scrapes is often described as "oozing," because it is slow. Lay the person down. This reduces the chances of fainting by increasing blood flow to the brain. When possible, raise up the part of the body that is bleeding. Remove any loose debris or dirt that you can see from a wound. Do NOT remove an object such as a knife, stick, or arrow that is stuck in the body. Doing so may cause more damage and bleeding. Place pads and bandages around the object and tape the object in place. Put pressure directly on an outer wound with a sterile bandage, clean cloth, or even a piece of clothing. If nothing else is available, use your hand. Direct pressure is best for external bleeding, except for an eye injury. Maintain pressure until the bleeding stops. When it has stopped, tightly wrap the wound dressing with adhesive tape or a piece of clean clothing. Place a cold pack over the dressing. Do not peek to see if the bleeding has stopped. If bleeding continues and seeps through the material being held on the wound, do not remove it. Simply place another cloth over the first one. Be sure to seek medical attention. If the bleeding is severe, get medical help and take steps to prevent shock. Keep the injured body part completely still. Lay the person flat, raise the feet about 12 inches, and cover the person with a coat or blanket. DO NOT move the person if there has been a head, neck, back, or leg injury, as doing so may make the injury worse. Get medical help as soon as possible.

IMMEDIATE TREATMENT FOR A BLEEDING WOUND 1. ELEVATION If a patient’s limb is bleeding, raise it. This will usually control venous bleeding. If his wound is in the upper part of his body, sitting him up may help, but be careful that he does not faint.

2. DIRECT PRESSURE Press a large dressing firmly over his wound and wait five minutes. This is usually much more effective than a haemostat. Don’t do anything more until you have waited for at least five minutes, unless a torrent of blood pours from the dressing. If bleeding stops, be thankful and don’t meddle with the dressing.

3. PRESSURE POINTS These are much less effective than direct pressure. Press: (1) the patient’s carotid artery against the transverse process of his 6th cervical vertebra. (2) His temporal artery against his skull just in front of his ear. (3) His subclavian artery against his first rib. (4) His brachial artery against the middle of his humerus. (5) His femoral artery over his mid– inguinal point.

4. HAEMOSTATS If bleeding continues after after five minutes, a large vessel may have been injured, probably an artery, more likely from a tear rather than complete transection. When an artery is completely divided, bleeding usually stops. Secure the bleeding vessel with a haemostat. This is hardly ever necessary.

CAUTION! (1) Get proximal control by pressing on a pressure point first. (2) The vessel must be clearly visible. Don’t jab the haemostat blindly into a pool of blood. Be sensible about where you apply a haemostat. Some vessels accompany important nerves. For example, don’t crush a patient’s ulnar nerve in trying to clamp his ulnar artery. When the haemostat is in place, incorporate it in the dressings. Don’t remove it and try to tie the vessel until he is in the theatre. PACKING a Use this to control deep inaccessible bleeding when the above methods fail. Pack the wound with broad strips of folded gauze. If necessary, hold it in place with deep sutures taking a bite of the uninjured tissue well wide of the edges of the wound.

IMMEDIATE TREATMENT FOR A BLEEDING WOUND. A, the methods you see here will usually control arterial and venous bleeding from a wound like this one. B, raise the patient’s bleeding limb and press on the wound. C, and D, apply a pressure dressing. A roll of bandage kept firmly in place is a convenient way of doing this. Kindly contributed by Peter Safar TEMPORARY SUTURES In some situations, such as the face, temporary haemostatic sutures may be useful. Don’t let them strangle the tissues. FIRST AID TOURNIQUETS The few first aid indications for a tourniquet are: (1) When other methods of controlling bleeding have failed, bleeding threatens the patient’s life, and the risk of losing his limb can be accepted. (2) A rapidly increasing arterial haematoma in a closed injury. (3) Some cases of snake bite. CAUTION! (1) A tourniquet is too often applied by first aid workers in a way which impedes the venous return, and so increases bleeding instead of stopping it. (2) Record the time at which it was applied. (3) It must be supervised and released every 15 minutes. If a patient arrives with an effective tourniquet that has been in place more than two hours (rare), he is in serious danger of the crush syndrome. The sudden release into his circulation of toxic metabolites, especially myoglobin from his injured muscles, may cause renal failure and kill him. So, if an effective tourniquet has been in place for many hours, and his limb is ischaemic, amputate it at or above the level of the tourniquet.

How to stop bleeding in a hospital? 1. physical methods to stop bleeding  local hypothermia (use ice pack when patients have nosebleed, to slow blood flow)  Cryosurgery (cryotherapy) is the use of extreme cold in surgery to destroy abnormal or diseased tissue. The term comes from the Greek words cryo (κρύο) ("icy cold") and surgery (cheirourgiki – χειρουργική) meaning "hand work" or "handiwork". Cryosurgery has been historically used to treat a number of diseases and disorders, especially a variety of benign and malignant skin conditions.  surgical diathermy

❶ diathermy the use of high-frequency electromagnetic currents as a form of physical therapy and in surgical procedures. The term diathermy is derived from the Greek words dia and therma, and literally means “heating through.” adj., adj diather´mal, diather´mic. Surgically, the extreme heat that can be produced by diathermy may be used to destroy neoplasms, warts, and infected tissues, and to cauterize blood vessels to prevent excessive bleeding. ❷ laser Laser surgery is surgery using a laser (instead of a scalpel) to cut tissue. Examples include the use of a laser scalpel in otherwise conventional surgery, and soft tissue laser surgery, in which the laser beam vaporizes soft tissue with high water content. Laser resurfacing is a technique in which molecular bonds of a material are dissolved by a laser. Laser surgery is commonly used on the eye. Techniques used include LASIK, which is used to correct near and far-sightedness in vision, and photorefractive keratectomy, a procedure which permanently reshapes the cornea using an excimer laser to remove a small amount of tissue.Types of surgical lasers include carbon dioxide, argon, Nd:YAG, and KTP. ❸ Argon plasma coagulation or APC is a medical endoscopic procedure used primarily to control bleeding from certain lesions in the gastrointestinal tract, and also sometimes to debulk tumours in the case of patients for whom surgery is not recommended. It is administered during esophagogastroduodenoscopy or colonoscopy. APC involves the use of a jet of ionized argon gas (plasma) that is directed through a probe passed through the endoscope. The probe is placed at some distance from the bleeding lesion, and argon gas is emitted then ionized by a high voltage discharge (approx 6kV). High-frequency electrical current is then conducted through the jet of gas, resulting in coagulation of the bleeding lesion on the other end of the jet. As no physical contact is made with the lesion, the procedure is safe if the bowel has been cleaned of colonic gases, and can be used to treat bleeding in parts of the gastrointestinal tract with thin walls, such as the cecum. The depth of coagulation is usually only a few millimetres. APC is used to treat the following conditions:  angiodysplasiae, anywhere in the GI tract  gastric antral vascular ectasia, or watermelon stomach  colonic polyps, after polypectomy  radiation proctitis  esophageal cancer

2. Special methods to stop bleeding  Ligation of the blood vessels Ligation of the blood vessels (Ligation) encircled around the vessel and tighten the thread (ligation) is used as a means of final stop bleeding or prevent it, at least to change the direction of blood flow in the area of the vascular bed (eg, from the superficial veins to the deep.) For ligation of blood vessels usually use silk: the ligation of large vessels — silk № 4-7, small — № 1-2 . For dressing of small muscular vessels, and medium-sized vessels in the infected wound using catgut (for one room thick silk). Ligation of the blood vessels in the wound or produce for the vessel (above current levels). Ligation vessel in the wound — the most reliable way to the final stop bleeding (see). The ends of the vessel captured clips (Kocher, Pean, or others), slightly tighten and anatomical forceps removed from the tissues. In the 2-10 mm from the end of the vessel (the farther, the larger vessel) surrounded filament (20- 35 cm length of the thread — the longer, the deeper is the vessel) and the ends of its marine unit delay. Tightening the first cross node, remove the clamp and tighten the second cross, making sure that the first did not faint. At the end of a very large vessels (femoral, axillary and larger) often impose two ligatures at a short distance from one another. Ends of the threads are cut off the further away from the site, the thicker the thread (with ligation of blood vessels silk — 2-4 mm, catgut — 4-8 mm). Small vessels and muscle tissue are ligated, not distinguished from the surrounding tissue. On remote vessels (especially in the vessels of the brain) is used instead of clipping ligation of vessels . Sometimes a wide gaping wound visible major damage to the vessel, which is easy to capture the clip. In this case the delivery of the wounded to the doctor will take a 2-2.5 hours (time to secure the waist harness), apply a ligature can and experienced paramedic. Thread to tighten tight, but so that it does not cut through the vessel wall. Evacuating wounded by circling around the limb of provisional (not tightened) harness. Ligation of the blood vessels throughout the produce through a specially made the cut. Exposing the vascular bundle, to be dressing otseparovyvayut vessel and surround the ligature (usually performed with a needle thread Deschamps). Thread vdet to the eye so that its short end lying on the outer (curved) side of the needle and had a length of about 10 cm (too long end difficult to pull out of the eye, a short may slip). To layer two ligatures equalize the length of both ends of the thread and running them under vessel, slit near the eye. Then, extending the threads, tighten the ligature. Surgical wound is usually sewn up tight. By ligation of the great arteries (femoral, popliteal, and especially the shoulder) were forced to resort, failing vascular suture (see) as it threatens gangrenous limb. Before non-urgent operations on the vessels necessary training collaterals, which can ensure the circulation in the case of imminent ligation of blood vessels. Training produced by pressure artery (finger or with a special device — a compressor) at the root of limbs — in the groin, in the axillary fossa — until no pulse on the foot, wrist. Sessions pressing repeat 8-10 times a day, first for 10 min., Then made up to 20-25 minutes. Check the effectiveness of training in various ways — capillaroscopy, capillary pressure measurements, angiography. The simplest method — a test for fatigue, if off the main artery does not cause rapid fatigue and cessation of movement of the foot (flexion — extension) or hand (squeezing — unclamping), and the patient can continue to about 2 minutes. Therefore collaterals developed enough. Usually the gym collateral circulation takes about 3-4 weeks. If you need urgent main artery ligation (mainly in field conditions) and lack of time for training collaterals simultaneously make (if necessary) and the corresponding vein ligation. This difficulty occurs when blood outflow partly compensates for its lack of flow creates a so-called reduced circulation. Another method — a blood transfusion in the peripheral end ligated artery, causing the expansion of collateral vasculature. Circulatory failure caused by persistent spasm of collaterals can prevent gangrene, making the lumbar or cervical-thoracic novocaine blockade or sympathectomy  Sengstaken–Blakemore tube A Sengstaken–Blakemore tube is a medical device inserted through the nose or mouth and used occasionally in the management of upper gastrointestinal hemorrhage due to esophageal varices (distended and fragile veins in the esophageal wall, usually a result of cirrhosis). The use of the tube was originally described in 1950, although similar approaches to bleeding varices were described by Westphal in 1930. With the advent of modern endoscopic techniques which can rapidly and definitively control variceal bleeding, Sengstaken–Blakemore tubes are rarely used at present. The device consists of a flexible plastic tube containing several internal channels and two inflatable balloons. Apart from the balloons, the tube has an opening at the bottom (gastric tip) of the device. More modern models also have an opening near the upper esophagus; such devices are properly termed Minnesota tubes. It is passed down into the oesophagus and the gastric balloon is inflated inside the stomach. A traction of 1 kg is applied to the tube so that the gastric balloon will compress on the gastroesophageal junction to reduce the blood flow to esophageal varices. If the use of traction alone cannot stop the bleeding, the esophageal balloon is also inflated to help stop the bleeding. The esophageal balloon should not remain inflated for more than six hours, to avoid necrosis. The gastric lumen is for aspirating stomach contents. Generally it is used only in emergencies where bleeding from presumed varices is impossible to control by administration of medication. It may be difficult to position, particularly in an unwell patient, and may inadvertently be inserted in the trachea, hence endotracheal intubation before the procedure is strongly advised to secure the airway. The tube is often kept in the refrigerator in the hospital's emergency department, intensive care unit and gastroenterology ward. It is a temporary measure: ulceration and rupture of the esophagus and stomach are recognized complications

Sengstaken–Blakemore tube

 operations : splenectomy (rupture of the spleen), lobectomy (pulmonary hemorrhage etc.  Endovascular embolization embolization is a nonsurgical, minimally invasive procedure performed by interventional radiologists and interventional neuroradiologists. It involves the selective occlusion of blood vessels by purposely introducing emboli, in other words deliberately blocking a blood vessel. Embolization is used to treat a wide variety of conditions affecting different organs of the human body. The treatment is used to occlude: Recurrent hemoptysis, Arteriovenous malformations (AVMs), Cerebral aneurysm, Gastrointestinal bleeding, Epistaxis, Varicocele, Primary post- partum hemorrhage, Surgical hemorrhage, uterine fibroids, Growths.

The treatment is used to slow or stop blood supply thus reducing the size of the tumour:  Kidney lesions  Liver lesions, typically hepatocellular carcinoma (HCC). Treated either by particle infarction or transcatheter arterial chemoembolization (TACE).  Uterine fibroids  Malignant Hypertension

3. chemical methods Topical Hemostatic Agents: An antihemorrhagic agent is a substance that promotes hemostasis (stops bleeding). It may also be known as a hemostatic agent. A styptic (also spelled stiptic) is a specific type of antihemorrhagic agent that works by contracting tissue to seal injured blood vessels. Styptic pencils contain astringents. Antihemorrhagic agents used in medicine have various mechanisms of action:  Systemic drugs work by inhibiting fibrinolysis or promoting coagulation.  Locally-acting hemostatic agents work by causing vasoconstriction or promoting platelet aggregation.

Locally-acting hemostatic agents 1. Hydrogen peroxide 2. Epinephrine 3. Inhibitors of fibrinolysis (aminocaproic acid) 4. Gelatin Commonly used gelatin products include Gelfoam and Gelfilm , Surgifoam. 5. is an antihemorrhagic, or hemostatic, agent that will cease blood flow by causing the aggregation and adhesion of platelets in the blood to form a platelet plug, ceasing blood flow from an open wound. It is hoped that this drug can be used in the future for preventing excessive blood flow during surgical operations and the treatment of hemorrhoids, but research on its effectiveness and the severity of possible side effects remains to be fairly inconclusive. Hemostatic agents resorptive action (accelerate of thrombosis)  Inhibitors of fibrinolysis (aminocaproic acid)  calcium chloride  Etamsylate Ethamsylate is a haemostatic agent; also promotes angioprotective and proaggregant action. It stimulates thrombopoiesis and their release from bone marrow. Haemostatic action is due to activation of thromboplastin formation on damaged sites of small blood vessels and decrease of PgI2 (Prostacyclin I2) synthesis; it also facilitates platelet aggregation and adhesion, that at last induce decrease and stop of hemorrhage.  Vitamin K is a group of structurally similar, fat-soluble vitamins the human body needs for complete synthesis of certain proteins that are required for blood coagulation, and also certain proteins that the body uses to manipulate binding of calcium in bone and other tissues. The vitamin K-related modification of the proteins allows them to bind calcium ions, which they cannot do otherwise. Without vitamin K, blood coagulation is seriously impaired, and uncontrolled bleeding occurs. Low levels of vitamin K also weaken bones and promote calcification of arteries and other soft tissues. 4. Biological methods 1. , 2. Blood transfusion is generally the process of receiving blood products into one's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood, such as red blood cells, white blood cells, plasma, clotting factors, and platelets. 3. Plasma transfusion 4. Transfusion of platelets