Bleeding: symptoms, stop bleeding

Bleeding is the flow of blood from the vessel into the external environment, tissue or some cavity of the body. The presence of blood in a particular cavity has its name. So, the accumulation of blood in the chest cavity is called hemothorax, in the abdominal cavity - by hemoperitoneum, in the pericardium - by hemopericardium, in the joint - by hemarthrosis, etc. The most common cause of bleeding is trauma.

Hemorrhage - diffuse impregnation with blood of any tissue (eg, subcutaneous tissue, brain tissue).

Hematoma - a collection of blood, limited to tissues.

[1], [2], [3]

Symptoms of the bleeding

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

Common symptoms of external and internal bleeding are the same. This weakness, dizziness with frequent fainting, thirst, pallor of the 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 with external bleeding have already been listed; the main ones are bleeding from the wound. Local symptoms with internal bleeding are extremely diverse, their occurrence depends on the cavity into which blood flows.

• So, when bleeding into the cavity of the skull, the main clinical picture is the symptoms of compression of the brain.
• When bleeding into the pleural cavity, there are signs of hemothorax with the whole complex of physical signs (shortness of breath, shortening of percussion sound, weakening of breathing and voice tremor, restriction of respiratory excursions) and data of auxiliary research methods (chest x-ray, pleural cavity puncture).
• With the accumulation of blood in the abdominal cavity symptoms of peritonitis (pain, nausea, vomiting, muscle tension of the anterior abdominal wall, symptoms of irritation of the peritoneum) and dullness in the steep belly places. 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 there is never acute anemia, which threatens the patient's life, as with other intracavitary hemorrhages.
• The clinical picture of the interstitial hematoma depends on its size, localization, the caliber of the damaged vessel and the presence of a communication between it and the hematoma. Local manifestations - a significant swelling, an increase in the size of the limb, bursting thickening of the tissues, pain syndrome.

Progressively increasing hematoma can lead to gangrene of the extremity. If this does not happen, the limb somewhat decreases in volume, but the deterioration of trophic distal end of the limb is clearly observed. In the study, pulsation is found over the hematoma, and systolic murmur is heard there, which indicates the formation of a false aneurysm.

[4], [5], [6], [7], [8], [9]

Forms

There is no uniform international classification of bleeding. A "working" classification has been adopted reflecting the most important moments of this complex problem that are necessary for practical activity. Classification proposed in clinical practice by Academician B.V. Petrovsky. It includes several basic positions.

• According to the anatomical and physiological principle of bleeding are divided into arterial, venous, capillary and parenchymal, they have peculiarities in the clinical picture and methods of stopping.
• With arterial bleeding blood scarlet color, flowing pulsating jet, does not stop on its own, which quickly leads to severe acute anemia.
• With venous bleeding, the blood of a dark color flows more slowly, the smaller the caliber of the vessel.
• Parenchymal and capillary hemorrhages externally proceed in the same way, their difference from previous ones is the absence of a visible source of bleeding, the duration and complexity of hemostasis.
• According to clinical manifestations, bleeding is divided into external and internal (cavity, latent).
• With external bleeding, blood flows into the external environment.
• With internal bleeding, the blood enters any cavity of the body or a hollow organ. There is almost no hidden bleeding in injuries. Its cause is often the ulcer of the stomach and intestines.
• By the time of occurrence of bleeding, primary, secondary early and secondary late bleedings are isolated.
• Primary starts immediately after the injury.
• Secondary early appear in the first hours and days after the injury as a result of pushing a thrombus from a wounded vessel. The causes of these bleedings are violation of the principles of immobilization, early activation of the patient, increased blood pressure.
• Secondary late bleeding can develop at any time after the suppuration of the wound. The reason for their development is a purulent melting of the thrombus or vessel wall inflammatory process.

[10], [11], [12]

Arterial bleeding

Arises when the artery is injured: scarlet, bright red color of blood, which is ejected from the wound by a stream, in the form of a fountain. The intensity of blood loss depends on the size of the damaged vessel and the nature of the wound. Severe bleeding occurs with lateral and through wounds of arterial vessels. With transverse rupture of the vessels, self-stopping of bleeding is often observed due to shrinking of the vessel walls, screwing the ruptured intima into the lumen of the vessel, followed by the formation of a thrombus. Arterial bleeding is dangerous for life, since a large amount of blood is lost in a short period of time.

[13], [14], [15], [16], [17], [18]

Venous bleeding

With venous bleeding, the flowing neo-oxygenation blood has a dark color, does not pulsate, slowly expands into the wound, the peripheral end of the vessel bleeds more. The wounding of large veins close to the heart is dangerous not only with abundant bleeding, but also with air embolism: air entering the lumen of the blood vessel during breathing with circulatory disturbances in the small circulation, often leading to the patient's death. Venous bleeding from medium and small vessels is less dangerous to life than arterial bleeding. Slow flow of blood from the venous vessels, easily falling off during compression, the vascular walls promote the formation of a thrombus.

In connection with the peculiarities of the vascular system (arteries and veins of the same name are located side by side), isolated damage to the arteries and veins is rare, so most bleeding refers to a mixed (arterial-venous) type. Such bleeding occurs with the simultaneous injury of the artery and vein, characterized by a combination of the characteristics described above.

Capillary bleeding

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

The injuries of the liver, kidneys, and spleen are accompanied by parenchymal hemorrhage. Vessels of parenchymal organs are closely welded to the connective tissue stroma of the organ, which prevents their spasm; spontaneous stop of bleeding is difficult.

[19]

External bleeding

This is the outflow of blood to the body surface from wounds, ulcers (more often from varicose veins), rarely from skin tumors.

By the type of the bleeding vessel they are divided into: arterial (blood of scarlet color, beats by jet, when a large vessel is pulsed); venous (blood of a dark color, goes on a flaccid stream, but can be intense if large veins are damaged); capillary, (sweating in the form of separate drops that merge with each other, with extensive damage to the skin can give massive blood loss). By time, most of the bleeding refers to the primary. Secondary bleeding is rare, mostly arthrosis of ulcers.

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

[20], [21], [22], [23]

Intra-interventional bleeding

Develop with trauma (bruises, fractures), diseases accompanied by increased permeability of blood vessels, or disorders of blood clotting (hemophilia, aureka syndrome in hepatic insufficiency and hypovitaminosis K); ruptures of blood vessels and bundles of aneurysms. Can be formed superficially with localization in the skin, subcutaneous tissue and intermuscular spaces; and intraorganically (mainly in the parenchymal organs) with injuries (bruises) and ruptures of aneurysms. They are divided into 2 types.

1. In cases of uniform impregnation of tissues with erythrocytes (imbibition), the process is called a hemorrhage. Surface hemorrhages do not cause diagnostic difficulties, since they are visible to the eye in the form of a bruise ("bruise"), which dissolves itself with gradual fading: the first 2 days it has a purple-violet hue; up to the 5th-6th day - blue; till 9-10th day - green color; before the 14th day - yellow.
2. Free accumulation of liquid blood - in the subcutaneous tissue, intermuscular spaces, in loose tissues, for example, in the retroperitoneal space; tissues of parenchymal organs - is called a hematoma.

Surface hematomas with blood accumulation in the subcutaneous tissue and intermuscular spaces are formed: with injuries (bruises, fractures, etc.) or; rarely, with ruptures of vascular aneurysms. Clinically accompanied by an increase in the volume of the segment, often contoured over the bruise. At palpation, an elastic soft, moderately painful formation is revealed, most often with a symptom of fluctuations (sensation of rolling the fluid at hand). When the aneurysm ruptures, the pulsation of the hematoma, sometimes visible to the eye, is additionally determined, and systolic murmurs are heard during auscultation. The diagnosis, as a rule, does not cause difficulties, but in case of doubt it can be confirmed by angiography.

Hematomas can get nagged, giving a typical picture of an abscess.

Tactics: bruising; treat out-patient surgeons or traumatologists; with hematomas, hospitalization is desirable.

Intrauterine bleeding

Under intracavitary hemorrhages are understood as serous cavities. Bleeding: the cranial cavity is defined as the intracranial hematoma; in the pleural cavity - hemothorax; in the pericardial cavity - hemopericardium; in the peritoneal cavity - hemoperitoneum; in the cavity of the joint - hemarthrosis. Bleeding in the cavity is not only a syndrome that complicates the course of the main pathological process, more often trauma, but also the main manifestation of the wound or rupture of the parenchymal organ.

Intracranial hematomas are formed mainly with craniocerebral trauma, less often - with rupture of vascular aneurysms (usually in boys 12-14 years old during exercise). They are accompanied by a rather pronounced clinical picture, but differential diagnostics with severe brain contusions and intracerebral hematomas are required, although they are often combined with meningitis.

Haemothorax can be formed with closed chest trauma with damage to the lung or intercostal artery, penetrating wounds of the chest and thoracoabdominal injuries, ruptures of vascularized lungs with bullous emphysema. In these cases, hemothorax is also a manifestation of damage. In its pure form (only accumulation of blood), hemothorax occurs only with isolated damage to the intercostal vessels. In all cases of damage to the lung, a sign of a breach of its tightness is the formation of hemopneumothorax, when along with the accumulation of blood, lung collapse and congestion take place in the pleural air cavity. Clinically accompanied by a picture of anemic, hypoxic, hypovolemic and pleural syndromes. To confirm the diagnosis, it is necessary to perform lung radiography, puncture of the pleural cavity, according to indications and, if possible, thoracoscopy. Differential diagnosis is carried out with pleurites, chylothorax, hemoplethritis, mainly according to the puncture and laboratory examination of the punctate.

Hemopericardium develops with closed and penetrating lesions of the chest, when the action of the translating agent occurs in the anterior thoracic region. Pericardium contains only 700 ml. Blood, blood loss does not cause the development of acute anemia syndrome, but hemopericardium is dangerous by cardiac tamponade.

The clinic is typical, accompanied by rapid development of heart failure: depression of consciousness; progressive (literally by the minute) decrease in blood pressure; the growth of tachycardia with a pronounced decrease in filling, in the subsequent - with the transition into the filiform, until complete disappearance. At the same time, a common cyanosis, acrocyanosis, cyanosis of the lips and tongue grow rapidly. In the differential diagnostic plan, it must be remembered that such a progressive development of cardiovascular insufficiency does not occur with any cardiac pathology, even with myocardial infarction - either cardiac arrests immediately, or a slow progression occurs. With percussion, but it is difficult to conduct in extreme situations, the expansion of the boundaries of the heart and cardiovascular fascicle is revealed. Auscultatory: against the background of sharply weakened heart tones in the first minutes you can hear the sound of splashing; in the subsequent extremely dull tones are noted, and more often the symptom of "flutter". It is necessary to differentiate with pericarditis. In all cases, the complex should start with puncture of the pericardium, ECG, and after discharge of the pericardium, conduct radiography and other studies;

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

With damage to the stomach, liver, intestines, the contents of which is a powerful irritant of the peritoneum, the clinical picture of peritonitis immediately develops. With "pure" hemoperitoneum the picture is smoothed, since the blood does not cause a strong irritation of the peritoneum. The patient is concerned about mild abdominal pain, decreasing in the sitting position (a symptom of "vanka-vstanka"), as blood flows from the solar plexus into the small pelvis and the irritation is removed; weakness and dizziness - because of; blood loss; bloating - due to lack of peristalsis. On examination: the patient is pale, often with an earthy tinge of facial skin; listless and indifferent - due to the development of hemorrhagic shock; with palpation - abdomen, mild, moderately painful, symptoms of irritation of the peritoneum not pronounced; percussion, only with large volumes of hemoperitoneum - dullness in the flanks, in other cases - tympanitis, due to swelling of the intestine.

Hemarthrosis - bleeding into the joint cavity, develops mainly with injuries. Most often affected knee joints, carrying the maximum physical load, and having increased vascularity. Other joints give hemarthrosis rarely and do not have such a vivid clinic.

Intra-organ hemorrhages - effusions of blood in the cavity of hollow organs. By frequency, they stand in second place - after external bleeding. All of them are dangerous not only in terms of blood loss, but also in violation of the function of internal organs. They are difficult to diagnose, provide first aid, choose a method of treating the underlying pathology that caused bleeding.

Pulmonary haemorrhage

The causes of pulmonary hemorrhage are various: atrophic bronchitis, tuberculosis, abscesses and gangrene of the lungs, bronchial polyps, malformations, lung tumors, infarct-pneumonia, etc. This type of bleeding is classified as the most dangerous, not because of blood loss, but because of that , which causes the development of acute respiratory failure, since it forms - or hemoaspiration (inhalation of blood in the alveoli with their obstruction), or atelectasis of the lung, when it is completely filled with blood.

Blood is secreted when coughing: frothy, scarlet (for alveolar tumors and infarct-pneumonia - pink).

The patient can swallow this blood with the development of reflex vomiting in the form of "coffee grounds". Sputum must be collected into measuring jars. The amount is judged on the intensity of bleeding, in addition, sputum is sent to a laboratory study. With the allocation of blood to 200 ml per day, the process is called hemoptysis; when blood is isolated up to 500 ml per day is defined as intensive bleeding; with a larger number - as profuse bleeding. .

The diagnosis is confirmed not only by the clinic: hemoptysis, acute respiratory failure syndrome, cacophony with auscultation of the lungs. But also radiographically hemoaspiration is manifested by a multitude of small blackouts in the lungs in the form of a "monetary blizzard," atelectasis by a homogenous dimming of the lung-all or lower lobes, with a shift in the mediastinum: toward the blackout (when the eclipses diminish due to effusion into the pleural cavity, the mediastinum shifts in the opposite direction ); with infarct-pneumonia - triangular darkening of the lung with a vertex to the root. The bronchoscopy with a tube endoscope is absolutely indicated.

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

Gastrointestinal bleeding

Develop for ulcers of the stomach and duodenum, colitis, tumors, mucosal fissures (Mallory-Weiss syndrome), atrophic and erosive gastritis (especially after consuming surrogate drinks).

To diagnose and determine the intensity of this type of bleeding, two main symptoms are important: vomiting and stool change. With mild bleeding: vomiting in the form of "coffee grounds", a chair decorated, black; colors. With severe bleeding: vomiting in the form of blood clots; the chair is liquid, black (melena). With profuse bleeding: vomiting unbroken blood; stool or not, or mucus in the form of "crimson jelly" is allocated. Even with suspicion an emergency FGS is shown. X-ray in the acute period is not carried out.

Esophageal bleeding occurs from varicose veins of the esophagus with portal hypertension caused by hepatic insufficiency in cirrhosis, hepatitis, liver tumors. The clinic of the bleeding itself resembles the gastrointestinal. But the appearance of the patient is typical for liver failure: skin integument of earthy shade, often jaundiced, puffy face, capillary setochka on cheekbones, blue nose, chest and trunk enlarged and enlarged veins; The abdomen can be enlarged in volume due to ascites; the liver is palpated more often, dense, painful, but can be atrophy. In these patients, in all cases, right-sided ventricular failure occurs with hypertension of the small circulatory system: dyspnea, instability of pressure, arrhythmia - until the development of pulmonary edema. Diagnostic and differential diagnosis shows an emergency FGS.

Intestinal bleeding - from the rectum and large intestine can often give hemorrhoids and rectal fissures; less often - polyps and tumors of the rectum and colon; even more rarely - nonspecific ulcerative colitis (NJC). Bleeding from the upper parts of the colon is accompanied by a liquid bloody stool in the form of blood clots or melena. Bleeding from the rectum is associated with a hard stool, with bleeding from tumors or polyps beginning before the stool, and bleeding from the hemorrhoids and cracks in the rectum occurs after the stool. They are venous, uninvigorated, easily stop on their own.

For differential diagnosis, an external examination of the anal ring is performed, a finger examination of the rectum, rectal examination with the rectal mirror, sigmoidoscopy, colonoscopy. Complex application of these research methods allows you to put an accurate topical diagnosis. X-ray methods. The study (irrigoscopy) is used only if there is a suspicion of cancer. When bleeding from the thick and sigmoid colon, colonoscopy has the greatest diagnostic effect, in which it is possible not only to carefully examine the mucous membrane, but also to coagulate the bleeding vessel, to perform an electroresection of the bleeding polyp.

Postoperative hemorrhage

As a rule, they are secondary early ones. Bleeding from postoperative wounds occurs when the thrombus is ejected from the vessels of the wound. Measures begin with a superimposition on the wound of a bladder with ice. With continuing hemorrhage, the edges of the wound are diluted and haemostasis is carried out: by dressing the vessel, sewing the vessel with tissues, diathermocoagulation.

To control the possibility of developing in-band bleedings into the abdominal and pleural cavities, tubular drains are introduced after the operation, which are connected to vacuum aspirators of various types: directly connected to drains ("pears") or through Bobrov's cans. In the norm of drainage in the first 2 days, up to 100 ml of blood is released. When there is bleeding through the drainage, a copious flow of blood begins. It can be due to two reasons.

Afibrinogenic bleeding

Develop at a high expenditure of fibrinogen, which happens with prolonged, more than two hours, surgery on the organs of the abdominal and thoracic cavity, massive blood loss with the development of DIC syndrome. A distinctive feature of these bleedings are: early timing of the onset of the operation (almost immediately, although the surgeon is confident in the hemostasis performed); it is slow and does not lend itself to haemostatic therapy. Confirmed by the study of blood fibrinogen content. To restore fibrinogen of blood, and, consequently, to stop bleeding, it is possible to transfuse donor fibrinogen (but it is very scarce). This can be done by reinfusion with your own blood, poured into the cavity. It is collected in a sterile can of Bobrov without preservative, filtered and reinfused. Fibrinogen of blood is restored independently for 2-3 days.

Explicit early secondary bleeding develops when the ligature from the vessel slips off with a defect in its superposition. A distinctive feature is the sudden and massive flow of blood through drains with a sharp deterioration in the patient's condition. To stop such bleeding, despite the severe condition of the patient, an emergency repeated operation (relaparotomy or a retoracotomy) is performed.

[24], [25], [26], [27], [28]

Treatment of the bleeding

There are spontaneous and artificial stopping of bleeding. Spontaneous stopping occurs when the vessels of small caliber are damaged due to their spasm and thrombosis. Injury of vessels of a larger caliber requires the use of medical measures, in these cases, the stopping of bleeding is divided into temporary and final.

Temporary stopping of bleeding does not always justify its name, because often taken for it measures for injuring the vessels of medium caliber, especially the venous, give a final stop. Temporary stopping of bleeding includes elevated limb position, pressing bandage, maximal flexion of the joint, finger pressure of the vessel, application of the tourniquet, application of the clamp to the vessel and leaving it in the wound.

The most common procedure in physiotherapy for stopping bleeding is the use of cold.

This action involves the imposition on the affected area of the compress - the package, in which the ice is located, so that the blood vessels that are in the skin, narrowed, as well as in the internal organs that are available in this area. As a result, the following processes occur:

1. Vessels of the skin reflexively contract, resulting in lowering its temperature, it pales, decreases heat transfer and blood is redistributed to internal organs.
2. Vessels in the skin cover reflexively expand: the skin becomes pinkish-red and warm when palpating.
3. Expansion of capillaries and venules, arterioles - narrow; the speed of blood flow decreases; the skin becomes crimson-red and cold. After that, the vessels narrow, then there is a regional decrease in bleeding, metabolism slows down, oxygen consumption decreases.

Objectives of the cold procedure:

• Reduce the inflammatory process.
• Reduce (limit) traumatic edema.
• Stop (or slow) the bleeding.
• Anesthetize the affected area.

The pressure bandage is imposed as follows. The damaged limb is raised. On the wound, a sterile cotton-gauze roll is applied and bandaged tightly. The elevated position of the limb is retained. The combination of these two techniques allows successfully stop the venous bleeding.

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

If the main arteries are damaged, bleeding can be temporarily stopped by finger pressing the vessel to the underlying bones. Such a stoppage of bleeding (due to the rapid occurrence of fatigue of the arms of the caregiver) can be continued for only a few minutes, so it is necessary to apply a tourniquet as soon as possible.

The rules for applying the harness are as follows. The wounded limb is raised and above the wound is wrapped with a towel, onto which a tourniquet is applied. The latter can be standard (rubber band Esmarch) or improvised (a piece of thin rubber hose, belt, rope, etc.). If the tourniquet is rubbery, it is necessary to stretch it before applying it. With properly applied tourniquet, the disappearance of the pulse on the distal limb is noted. Given that the duration of the harness on the limb is no more than 2 hours, it is necessary to detect the time of its superposition, to write down on paper and attach it to the harness. The patient must be transported to a medical institution accompanied by a medical worker. The final stop of bleeding can be performed in various ways: mechanical, thermal, chemical and biological.

To mechanical methods of final stop bleeding should be attributed tamponade, dressing the vessel in the wound or throughout, the vascular suture. Hemostasis with gauze tampon is used for capillary and parenchymal hemorrhages, when there is no possibility of using other methods. After vascular thrombosis (after 48 hours), it is advisable to remove the tampon to prevent infection. The dressing of the vessel in the wound is carried out necessarily under the control of vision. Bleeding vessel is seized with a hemostatic clamp, bandaged at the base with one knot, the clamp is removed and the second knot is tied. Sometimes the source of bleeding is hidden by a powerful muscle mass, for example, in the gluteal region, the search for it is fraught with additional significant trauma. In such cases, the vessel is ligated throughout (internal iliac artery). Similar interventions are performed with late secondary bleeding from a purulent wound. The vascular wool is superimposed when the ends of the intersected vessel are stitched, or when the patch is replaced by a graft or an endoprosthesis. Apply a manual stitch with silk threads or perform it with the help of special apparatuses that hold the ends of the torn vessel with tantalum clips.

Thermal methods include the impact on the bleeding vessels of low and high temperatures. Most often to prevent the formation of intermuscular hematomas, hemarthrosis use the skin effect of cold in the form of ice packs, chloroethyl irrigation, cold lotions, etc. Well stop capillary and parenchymal bleeding lotions with a hot 0.9% solution of sodium chloride. Good hemostasis with bleeding from small and medium-sized vessels gives electrocoagulation with the help of diathermy.

Chemical methods of stopping bleeding include the use of vasoconstrictive and blood clotting drugs used both topically and intravenously. The most commonly used lotions and irrigation of the wound with solutions of hydrogen peroxide, 0.1% solution of epinephrine, calcium and sodium chlorides. Intravenous 10% solution of calcium chloride, 5% solution of ascorbic acid, 4% solution of aminocaproic acid, etc. Are administered.

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

• tamponade of the bleeding wound with autotkins, rich thrombokinase (omentum, muscle, fatty tissue, fascia); perform a tamponade with a free piece of an omentum, a muscle, or a transplant on a pedicle with filing to the edges of wounds;
• transfusion of small doses (100-200 ml) of erythrocyte mass, plasma;
• introduction of menadione sodium bisulfite and 5% solution of ascorbic acid;
• 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 amount of blood loss. Approximately it can be determined by the following methods.

According to the clinical picture.

• There are no hemodynamic disturbances - the magnitude of blood loss to 10% of the BCC (the volume of circulating blood).
• Pale skin, weakness, the number of heartbeats to 100 per minute, blood pressure is reduced to 100 mm Hg. - Blood loss value up to 20% BCC.
• The sharp pallor of the skin, cold sweat, adynamia, the number of heartbeats to 120 per minute, blood pressure less than 100 mm Hg, oliguria - the amount of blood loss to 30% BCC.
• Disturbance of consciousness, the number of heartbeats to 140 per minute, blood pressure less than critical, anuria - the amount of blood loss more than 30% BCC.
• With fractures of the shin, the volume of blood loss is usually 0.5-1 l, the thigh - 0.5-2.5 l, the pelvis - 0.8-3 l.

It is possible to determine the blood loss value only by means of laboratory tests (according to tables or nomograms, in which the value of blood pressure, bcc, hematocrit, specific gravity of blood, etc.)

Acute bleeding immediately should be compensated, and with hemoglobin levels of 100 g / l and a hematocrit of 30%, transfusion of blood products is indicated.