Bleeding: symptoms, stopping bleeding

Bleeding is the leakage of blood from a vessel into the external environment, tissues or any body cavity. The presence of blood in a certain cavity has its own name. Thus, the accumulation of blood in the chest cavity is called hemothorax, in the abdominal cavity - hemoperitoneum, in the pericardium - hemopericardium, in a joint - hemarthrosis, etc. The most common cause of bleeding is trauma.

Hemorrhage is a diffuse saturation of any tissue with blood (for example, subcutaneous tissue, brain tissue).

A hematoma is a collection of blood confined to tissue.

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Symptoms bleeding

Symptoms of bleeding depend on which organ is damaged, the caliber of the injured vessel, and where the blood flows. All signs of bleeding are divided into general and local symptoms.

The general symptoms of external and internal bleeding are the same. They are weakness, dizziness with frequent fainting, thirst, pale skin and (especially) mucous membranes (white lips), frequent small pulse, progressively falling and unstable blood pressure, a sharp decrease in the number of red blood cells and hemoglobin content.

Local symptoms of external bleeding have already been listed; the main ones are bleeding from a wound. Local symptoms of internal bleeding are extremely varied, their occurrence depends on the cavity into which the blood flows.

• Thus, in case of bleeding into the cranial cavity, the main clinical picture consists of symptoms of compression of the brain.
• When bleeding occurs into the pleural cavity, signs of hemothorax occur with a whole range of physical signs (shortness of breath, shortening of percussion sound, weakening of breathing and vocal fremitus, limitation of respiratory excursions) and data from auxiliary research methods (chest X-ray, puncture of the pleural cavity).
• When blood accumulates in the abdominal cavity, symptoms of peritonitis (pain, nausea, vomiting, tension of the muscles of the anterior abdominal wall, symptoms of peritoneal irritation) and dullness in the sloping parts of the abdomen occur. The presence of free fluid in the abdominal cavity is confirmed by ultrasound, puncture or laparocentesis.
• Due to the small volume of the cavity, bleeding into the joint is not massive, so acute anemia, which threatens the patient’s life, never occurs, as with other intracavitary bleeding.
• The clinical picture of an intra-tissue hematoma depends on its size, location, caliber of the damaged vessel, and the presence of communication between it and the hematoma. Local manifestations include significant swelling, increased limb volume, bursting tissue compaction, and pain syndrome.

A progressively growing hematoma can lead to gangrene of the limb. If this does not happen, the limb is somewhat reduced in volume, but a deterioration in the trophism of the distal part of the limb is clearly observed. During the examination, pulsation is found above the hematoma, and a systolic murmur is also heard there, which indicates the formation of a false aneurysm.

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Forms

There is no single international classification of bleeding. A "working" classification has been adopted, reflecting the most important aspects of this complex problem that are necessary for practical activities. The classification was proposed for clinical practice by Academician B.V. Petrovsky. It includes several main positions.

• According to the anatomical and physiological principle, bleeding is divided into arterial, venous, capillary and parenchymatous; they have features in the clinical picture and methods of stopping.
• With arterial bleeding, the blood is scarlet in color, flows out in a pulsating stream, does not stop on its own, which quickly leads to severe acute anemia.
• In venous bleeding, the blood is dark in color and flows out more slowly the smaller the caliber of the vessel.
• Parenchymatous and capillary bleedings are outwardly the same, their difference from the previous ones is the absence of a visible source of bleeding, duration and complexity of hemostasis.
• Based on clinical manifestations, bleeding is divided into external and internal (cavity, hidden).
• With external bleeding, blood flows out into the external environment.
• With internal bleeding, blood gets into a body cavity or a hollow organ. Hidden bleeding from injuries is almost never the case. It is often caused by stomach and intestinal ulcers.
• Depending on the time of occurrence of bleeding, primary, secondary early and secondary late bleeding are distinguished.
• Primary ones begin immediately after the injury.
• Secondary early ones occur in the first hours and days after the injury as a result of the thrombus being pushed out of the injured vessel. The causes of these bleedings are violation of the principles of immobilization, early activation of the patient, and increased blood pressure.
• Secondary late bleeding may develop at any time after the wound has become suppurated. The reason for their development is the purulent melting of a thrombus or vessel wall by an inflammatory process.

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Arterial bleeding

Occurs when an artery is injured: scarlet, bright red blood that spurts out of the wound in a stream, like a fountain. The intensity of blood loss depends on the size of the damaged vessel and the nature of the injury. Severe bleeding occurs with lateral and penetrating wounds of arterial vessels. With transverse ruptures of vessels, spontaneous stopping of bleeding is often observed due to contraction of the vessel walls, inversion of the torn intima into its lumen, followed by the formation of a thrombus. Arterial bleeding is life-threatening, since a large amount of blood is lost in a short period of time.

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Venous bleeding

In venous bleeding, the pouring out non-oxygenated blood is dark in color, does not pulsate, slowly flows into the wound, and the peripheral end of the vessel bleeds more. Injury to large veins located close to the heart is dangerous not only because of profuse bleeding, but also because of air embolism: air entering the lumen of a blood vessel during breathing with impaired circulation in the pulmonary circulation, often leading to the death of the patient. Venous bleeding from medium and small vessels is less life-threatening than arterial bleeding. Slow blood flow from venous vessels, vascular walls that easily collapse when compressed contribute to the formation of a thrombus.

Due to the peculiarities of the vascular system (the arteries and veins of the same name are located close to each other), isolated damage to arteries and veins is rare, so most bleeding is of the mixed (arterial-venous) type. Such bleeding occurs when an artery and vein are injured simultaneously and is characterized by a combination of the signs described above.

Capillary bleeding

Occurs when mucous membranes and muscles are damaged. With capillary bleeding, the entire wound surface bleeds, blood "oozes" from damaged capillaries, bleeding stops when a simple or slightly pressing bandage is applied.

Injuries to the liver, kidneys, and spleen are accompanied by parenchymatous bleeding. The vessels of the parenchymatous organs are tightly fused with the connective tissue stroma of the organ, which prevents their spasm; spontaneous stopping of bleeding is difficult.

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External bleeding

This is the outpouring of blood onto the surface of the body from wounds, ulcers (usually from varicose veins), and rarely from skin tumors.

By the type of the bleeding vessel, they are divided into: arterial (blood is scarlet, spurts, and if a large vessel is injured, it pulsates); venous (blood is dark, flows in a sluggish stream, but can be intense if large veins are injured); capillary (sweating in the form of individual drops that merge with each other; with extensive damage to the skin, they can cause massive blood loss). In terms of time, most bleeding is primary. Secondary bleeding rarely develops, mainly erosive from ulcers.

Diagnostics of external bleeding does not cause difficulties. Tactics: at the scene of the incident, reconciliation of methods of temporary stopping of bleeding, transportation to a surgical hospital for final stopping of bleeding and correction of blood loss.

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Intratissue bleeding

They develop due to trauma (bruises, fractures), diseases accompanied by increased vascular permeability, or blood clotting disorders (hemophilia, aureka syndrome in liver failure and hypovitaminosis K); vascular ruptures and aneurysm dissections. They can form superficially with localization in the skin, subcutaneous tissue and intermuscular spaces; and intraorgan (mainly in parenchymatous organs) due to trauma (bruises) and aneurysm ruptures. They are divided into 2 types.

1. In cases of uniform tissue saturation with erythrocytes (imbibition), the process is called hemorrhage. Superficial hemorrhages do not cause diagnostic difficulties, since they are visible to the eye as a bruise, which resolves on its own with gradual fading: the first 2 days it has a purple-violet hue; up to the 5-6th day - blue; up to the 9-10th day - green; up to the 14th day - yellow.
2. A free accumulation of liquid blood - in the subcutaneous tissue, intermuscular spaces, in loose tissues, for example, in the retroperitoneal space; tissues of parenchymatous organs - is called a hematoma.

Superficial hematomas with accumulation of blood in the subcutaneous tissue and intermuscular spaces are formed: by trauma (bruises, fractures, etc.) or; rarely, by ruptures of vascular aneurysms. Clinically, they are accompanied by an increase in the volume of the segment, often protruding above the bruise. Palpation reveals an elastic, soft, moderately painful formation, most often with a fluctuation symptom (a feeling of fluid rolling under the hand). In case of aneurysm rupture, pulsation of the hematoma is additionally determined, sometimes visible to the eye, systolic murmur is heard during auscultation. The diagnosis, as a rule, does not cause difficulties, but in case of doubt, it can be confirmed by angiography.

Hematomas may become purulent, giving a typical picture of an abscess.

Tactics: bruises; treated on an outpatient basis by surgeons or traumatologists; in case of hematomas, hospitalization is advisable.

Intracavitary bleeding

Intracavitary bleeding is understood as bleeding into serous cavities. Bleeding: into the cranial cavity is defined as intracranial hematoma; into the pleural cavity - hemothorax; into the pericardial cavity - hemopericardium; into the peritoneal cavity - hemoperitoneum; into the joint cavity - hemarthrosis. Bleeding into the cavity is not only a syndrome complicating the course of the underlying pathological process, more often trauma, but also the main obvious manifestation of injury or rupture of the parenchymatous organ.

Intracranial hematomas are formed mainly by craniocerebral trauma, less often by rupture of vascular aneurysms (more often in boys aged 12-14 years during physical exertion). They are accompanied by a fairly pronounced clinical picture, but require differential diagnosis with severe brain contusions and intracerebral hematomas, although they are often combined with meningitis.

Hemothorax may develop with a closed chest injury with damage to the lung or intercostal artery, penetrating chest wounds and thoracoabdominal injuries, ruptures of vascularized lung bullae in bullous emphysema. In these cases, hemothorax is also a manifestation of damage. In its pure form (only blood accumulation), hemothorax occurs only with isolated damage to the intercostal vessels. In all cases of lung damage, a sign of a violation of its tightness is the formation of hemopneumothorax, when, along with the accumulation of blood, the lung collapses and air accumulates in the pleural cavity. Clinically, it is accompanied by a picture of anemic, hypoxic, hypovolemic and pleural syndromes. To confirm the diagnosis, it is necessary to perform an X-ray of the lungs, a puncture of the pleural cavity, and, if indicated and possible, a thoracoscopy. Differential diagnostics are carried out with pleurisy, chylothorax, hemopleurisy, mainly based on puncture data and laboratory examination of the puncture.

Hemopericardium develops with closed and penetrating chest injuries, when the effect of the transmitting agent falls on the anterior sections of the chest. The pericardium contains only 700 ml of blood, blood loss does not cause the development of acute anemia syndrome, but hemopericardium is dangerous due to cardiac tamponade.

The clinical picture is characteristic and is accompanied by rapid development of heart failure: depression of consciousness; progressive (literally by the minute) decrease in blood pressure; increase in tachycardia with a marked decrease in filling, subsequently - with a transition to filiform, until complete disappearance. At the same time, general cyanosis, acrocyanosis, cyanosis of the lips and tongue rapidly increase. In terms of differential diagnosis, it is necessary to remember that such progressive development of cardiovascular failure does not occur with any cardiac pathology, even with myocardial infarction - either cardiac arrest occurs immediately, or there is a slow progression. Percussion, which is difficult to carry out in extreme situations, reveals an expansion of the borders of the heart and the cardiovascular bundle. Auscultation: against the background of sharply weakened heart tones in the first minutes, you can hear a splashing noise; subsequently, extremely muffled tones are noted, and more often the symptom of "flutter". It is necessary to differentiate from pericarditis. In all cases, the complex must begin with a pericardial puncture, ECG, and after unloading the pericardium, conduct an X-ray and other studies;

Hemoperitoneum develops with closed and penetrating abdominal trauma, perforation of hollow organs, ovarian apoplexy and ectopic pregnancy with rupture of the fallopian tubes. Considering that the peritoneal cavity contains up to 10 liters of fluid, hemoperitoneum is accompanied by the development of acute anemia syndrome.

In case of damage to the stomach, liver, intestines, the contents of which are a powerful irritant to the peritoneum, the clinical picture of peritonitis immediately develops. In case of "pure" hemoperitoneum, the picture is smoothed out, since the blood does not cause strong irritation of the peritoneum. The patient is bothered by moderate abdominal pain, decreasing in a sitting position (the "Tumbler-toss" symptom), since the blood flows from the solar plexus to the small pelvis and the irritation is removed; weakness and dizziness - due to; blood loss; bloating - due to the lack of peristalsis. On examination: the patient is pale, often with an ashy tint of the skin of the face; lethargic and indifferent - due to the development of hemorrhagic shock; on palpation - the abdomen is soft, moderately painful, symptoms of peritoneal irritation are not expressed; percussion, only with large volumes of hemoperitoneum - dullness in the flanks, in other cases - tympanitis, due to intestinal distension.

Hemarthrosis is bleeding into the joint cavity, which develops mainly with injuries. Knee joints, which bear the maximum physical load and have increased vascularization, are most often affected. Other joints rarely cause hemarthrosis and do not have such a bright clinical picture.

Intraorgan hemorrhages are blood effusions into the cavities of hollow organs. They are second in frequency after external hemorrhages. All of them are dangerous not only because of the amount of blood loss, but also because of the dysfunction of internal organs. They are difficult to diagnose, provide first aid, and choose a method for treating the underlying pathology that caused the bleeding.

Pulmonary hemorrhage

The causes of pulmonary hemorrhage are varied: atrophic bronchitis, tuberculosis, abscesses and gangrene of the lungs, bronchial polyps, malformations, lung tumors, infarction pneumonia, etc. This type of hemorrhage is classified as the most dangerous, not because of blood loss, but because it causes the development of acute respiratory failure, since it causes either hemoaspiration (inhalation of blood into the alveoli with their blockage), or atelectasis of the lung, when it is completely filled with blood.

Blood is released during coughing: foamy, scarlet in color (in case of alveolar tumors and infarction pneumonia - pink).

The patient may swallow this blood, developing reflex vomiting in the form of "coffee grounds". Sputum must be collected in measuring jars. The amount is used to judge the intensity of bleeding, and the sputum is also sent for laboratory testing. When up to 200 ml of blood is released per day, the process is called hemoptysis; when up to 500 ml of blood is released per day, it is defined as intense bleeding; with a larger amount - as profuse bleeding.

The diagnosis is confirmed not only by the clinical picture: hemoptysis, acute respiratory failure syndrome, cacophony during auscultation of the lungs. But also radiologically, hemoaspiration is manifested by multiple small darkenings in the lungs in the form of a "money blizzard", atelectasis - homogeneous darkening of the lung - the whole or lower lobes, with a shift of the mediastinum: to the side of the darkening (with darkenings due to effusion in the pleural cavity, the mediastinum shifts to the opposite side); with infarction pneumonia - triangular darkening of the lung with the apex to the root. Bronchoscopy with a tube endoscope is absolutely indicated.

Such a patient should be hospitalized: if there is an indication of a tuberculosis process - in the surgical department of the anti-tuberculosis dispensary; in the absence of tuberculosis - in the thoracic surgery department; in case of tumors of the lungs and bronchi - in oncology dispensaries or the thoracic department.

Gastrointestinal bleeding

They develop with ulcers of the stomach and duodenum, colitis, tumors, cracks in the mucous membrane (Mallory-Weiss syndrome), atrophic and erosive gastritis (especially after drinking surrogate drinks).

For diagnosis and determination of the intensity of this type of bleeding, 2 main symptoms are important: vomiting and changes in stool. In case of weak bleeding: vomiting in the form of "coffee grounds", formed stool, black; color. In case of severe bleeding: vomiting in the form of blood clots; liquid stool, black (melena). In case of profuse bleeding: vomiting of uncoagulated blood; stool or no stool, or mucus in the form of "raspberry jelly" is released. Even if there is a suspicion, an emergency FGDS is indicated. X-ray of the stomach is not performed in the acute period.

Esophageal bleeding occurs from varicose veins of the esophagus in portal hypertension caused by liver failure in cirrhosis, hepatitis, liver tumors. The clinical picture of the bleeding itself resembles gastrointestinal bleeding. But the patient's appearance is typical of liver failure: the skin is sallow, often icteric, the face is puffy, there is a capillary network on the cheekbones, the nose is bluish, dilated and tortuous veins are visible on the chest and torso; the abdomen may be enlarged in volume due to ascites; the liver is often sharply enlarged, dense, painful on palpation, but may also be atrophic. In all cases, these patients have right-sided ventricular failure with hypertension of the pulmonary circulation: shortness of breath, pressure instability, arrhythmia - up to the development of pulmonary edema. Emergency FGDS is indicated for diagnosis and differential diagnosis.

Intestinal bleeding - from the rectum and colon can be caused most often by hemorrhoids and anal fissures; less often - polyps and tumors of the rectum and colon; even less often - nonspecific ulcerative colitis (NUC). Bleeding from the upper colon is accompanied by liquid bloody stool in the form of blood clots or melena. Bleeding from the rectum is associated with hard stool, and bleeding from tumors or polyps begins before stool, and bleeding from hemorrhoids and anal fissures occurs after stool. They are venous, not abundant, and easily stop on their own.

For differential diagnostics, an external examination of the anal ring, digital examination of the rectum, examination of the rectum using a rectal mirror, rectoscopy, and colonoscopy are performed. The complex use of these research methods allows for an accurate topical diagnosis. X-ray methods. U research (irrigoscopy) is used only if cancer is suspected. In case of bleeding from the colon and sigmoid colon, colonoscopy has the greatest diagnostic effect, since it is possible not only to carefully examine the mucous membrane, but also to coagulate the bleeding vessel - to perform electroresection of the bleeding polyp.

Postoperative bleeding

As a rule, they are secondary early. Bleeding from postoperative wounds occurs when a thrombus is pushed out of the wound vessels. The measures begin with applying an ice pack to the wound. If bleeding continues, the edges of the wound are spread and hemostasis is performed: by ligating the vessel, suturing the vessel with tissues, diathermocoagulation.

To control the possibility of intra-abdominal bleeding, tubular drains are inserted into the abdominal and pleural cavities after surgery, which are connected to vacuum aspirators of various types: directly connected to the drains ("pears") or through Bobrov jars. Normally, up to 100 ml of blood is released through the drains in the first 2 days. When bleeding occurs, a profuse flow of blood begins through the drains. This can be due to two reasons.

Afibrinogenic bleeding

They develop with large expenditures of blood fibrinogen, which occurs during long, more than two hours, operations on the abdominal and thoracic organs, massive blood loss with the development of DIC syndrome. A distinctive feature of these hemorrhages are: early onset after surgery (almost immediately, although the surgeon is confident in the hemostasis); it is slow and does not respond to hemostatic therapy. Confirmed by testing the blood fibrinogen content. Blood fibrinogen can be restored, and, consequently, bleeding can be stopped by transfusing donor fibrinogen (but it is in very short supply). This can be done by reinfusing one's own blood pouring into the cavities. It is collected in a sterile Bobrov jar without a preservative, filtered and reinfused. Blood fibrinogen is restored on its own in 2-3 days.

Obvious early secondary bleeding develops when the ligature slips off the vessel due to a defect in its application. A distinctive feature is the sudden and massive flow of blood through the drains with a sharp deterioration in the patient's condition. To stop such bleeding, despite the serious condition of the patient, an emergency repeat operation is performed (relaparotomy or rethoracotomy).

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Treatment bleeding

A distinction is made between spontaneous and artificial stopping of bleeding. Spontaneous stopping occurs when small-caliber vessels are damaged due to their spasm and thrombosis. Trauma to larger-caliber vessels requires the use of therapeutic measures; in these cases, stopping bleeding is divided into temporary and final.

Temporary stopping of bleeding does not always justify its name, since often the measures taken for it in case of injury of medium-sized vessels, especially venous ones, provide a final stop. Measures for temporary stopping of bleeding include an elevated position of the limb, a pressure bandage, maximum flexion of the joint, finger pressure on the vessel, application of a tourniquet, application of a clamp to the vessel and leaving it in the wound.

The most common procedure in physical therapy to stop bleeding is the application of cold.

This action involves applying a compress to the affected area - a bag containing ice, so that the blood vessels in the skin narrow, as well as in the internal organs in this area. As a result, the following processes occur:

1. The skin's blood vessels reflexively narrow, resulting in a decrease in its temperature, the skin becoming pale, heat transfer decreasing, and blood being redistributed to the internal organs.
2. The blood vessels in the skin reflexively expand: the skin becomes pinkish-red and warm to the touch.
3. The capillaries and venules expand, the arterioles narrow; the blood flow rate decreases; the skin becomes crimson and cold. After that, the vessels narrow, then there is a regional decrease in bleeding, the metabolism slows down, and oxygen consumption decreases.

The objectives of the cold procedure:

• Reduce inflammation.
• Reduce (limit) traumatic swelling.
• Stop (or slow down) the bleeding.
• Anesthetize the affected area.

The pressure bandage is applied as follows. The injured limb is raised. A sterile cotton-gauze roll is applied to the wound and it is tightly bandaged. The elevated position of the limb is maintained. The combination of these two techniques allows for successful venous bleeding to be stopped.

If blood vessels are damaged in the elbow or popliteal fossa, bleeding can be temporarily stopped by maximal flexion of the joint, fixing this position with a soft tissue bandage.

If the main arteries are damaged, bleeding can be stopped briefly by pressing the vessel against the underlying bones with your fingers. This type of bleeding control (due to the rapid onset of fatigue in the hands of the person providing assistance) can only last for a few minutes, so a tourniquet should be applied as soon as possible.

The rules for applying a tourniquet are as follows. The injured limb is raised and wrapped above the wound in a towel, onto which the tourniquet is applied. The latter can be standard (Esmarch's rubber tourniquet) or improvised (a piece of thin rubber hose, belt, rope, etc.). If the tourniquet is rubber, it must be stretched strongly before application. When the tourniquet is applied correctly, the pulse in the distal part of the limb disappears. Considering that the duration of the tourniquet on the limb is no more than 2 hours, it is necessary to note the time of its application, write it down on paper and attach it to the tourniquet. The patient must be transported to a medical facility accompanied by a health worker. The final stop of bleeding can be achieved in various ways: mechanical, thermal, chemical and biological.

Mechanical methods of final stopping of bleeding include tamponade, ligation of the vessel in the wound or along its length, vascular suture. Hemostasis with a gauze tampon is used for capillary and parenchymatous bleeding, when it is impossible to use other methods. After thrombosis of the vessels (after 48 hours), it is advisable to remove the tampon to avoid infection. Ligation of the vessel in the wound must be performed under visual control. The bleeding vessel is grasped with a hemostatic clamp, ligated at the base with one knot, the clamp is removed and a second knot is tied. Sometimes the source of bleeding is hidden by a powerful muscle mass, for example, in the gluteal region, searching for it is fraught with additional significant trauma. In such cases, the vessel is ligated along its length (internal iliac artery). Similar interventions are performed for late secondary bleeding from a purulent wound. A vascular suture is applied when sewing the ends of a cut vessel or when its crushed section is replaced with a transplant or endoprosthesis. Hand sutures are used with silk threads or they are performed using special devices that fasten the ends of the torn vessel with tantalum clips.

Thermal methods include exposure of bleeding vessels to low and high temperatures. Most often, to prevent the formation of intermuscular hematomas and hemarthroses, skin exposure to cold is used in the form of ice packs, irrigation with ethyl chloride, cold compresses, etc. Capillary and parenchymatous bleeding is well stopped by compresses with a hot 0.9% sodium chloride solution. Electrocoagulation using diathermy provides good hemostasis for bleeding from small and medium-sized vessels.

Chemical methods of stopping bleeding include the use of vasoconstrictors and blood clotting agents, used both locally and intravenously. The most common are lotions and wound irrigations with hydrogen peroxide solutions, 0.1% epinephrine solution, calcium and sodium chlorides. 10% calcium chloride solution, 5% ascorbic acid solution, 4% aminocaproic acid solution, etc. are administered intravenously.

Biological methods of stopping are used mainly for capillary and parenchymatous bleeding. The cause of such bleeding is surgical interventions associated with the separation of extensive adhesive conglomerates and damage to parenchymatous organs (liver, kidneys). All methods of biological stopping of bleeding can be divided into the following groups:

• tamponade of a bleeding wound with autologous tissues rich in thrombokinase (omentum, muscle, adipose tissue, fascia); tamponade is performed with a free piece of omentum, muscle, or a pedicle transplant with suturing to the edges of the wounds;
• transfusion of small doses (100-200 ml) of red blood cell mass, plasma;
• introduction of menadione sodium bisulfite and 5% ascorbic acid solution;
• local application of blood derivatives (fibrin film, hemostatic sponge, etc.): they are introduced into the wound and left there after it is sutured.

In acute anemia, there is a need to determine the volume of blood loss. It can be approximately determined in the following ways.

Based on the clinical picture.

• There are no hemodynamic disturbances - the amount of blood loss is up to 10% of the circulating blood volume.
• Pale skin, weakness, heart rate up to 100 per minute, blood pressure decreased to 100 mm Hg - blood loss up to 20% of the circulating blood volume.
• Severe pallor of the skin, cold sweat, adynamia, heart rate up to 120 per minute, blood pressure less than 100 mm Hg, oliguria - blood loss up to 30% of the circulating blood volume.
• Impaired consciousness, heart rate up to 140 beats per minute, blood pressure less than critical, anuria - blood loss more than 30% of the circulating blood volume.
• In case of fractures of the tibia, the volume of blood loss is usually 0.5-1 l, thigh - 0.5-2.5 l, pelvis - 0.8-3 l.

The amount of blood loss can only be reliably determined using laboratory tests (using tables or nomograms that take into account blood pressure, BCC, hematocrit, specific gravity of blood, etc.)

Acute blood loss should be immediately compensated, and if the hemoglobin level is 100 g/l and hematocrit is 30%, a transfusion of blood products is indicated.