Overview: A haemorrhage denotes
bleeding from damaged blood vessels. It may be external and
readily apparent, or internal and concealed. The impact ranges
from minor, self-limited bruising to rapidly fatal blood loss. This guide
summarises types, pathophysiology, clinical presentation, diagnostic
approaches, acute management, definitive treatments, complications, risk stratification
and prognosis. The aim is to present clear, actionable clinical information for
clinicians, students and informed patients.
Table of contents
- What is a haemorrhage?
- Classification by location and mechanism
- Internal versus external haemorrhage — clinical implications
- Common anatomical sites and clinical presentations
- Causes and pathophysiological mechanisms
- Clinical features and red flags
- Diagnostic approach and investigations
- Acute management — first response and stabilisation
- Definitive treatment modalities
- Complications and risk factors
- Prognosis and follow-up considerations
- Prevention and patient education
- Frequently asked questions (FAQs)
- References (titles only — no links)
1. What is a haemorrhage?
A haemorrhage is
the escape of blood from the vascular compartment due to disruption of vessel
integrity. It may occur in the external environment (through a wound or
orifice) or within body cavities and organs (internal haemorrhage). Clinically,
haemorrhage is significant when it results in hemodynamic instability, impaired
tissue perfusion, or organ dysfunction.
Key point: Hemodynamic impact, not
just visible blood loss, determines clinical urgency. Even occult
internal bleeding can be life-threatening.
2. Classification by location
and mechanism
Haemorrhages
are most usefully categorised by location, anatomical
compartment, and mechanism.
By compartment:
- External haemorrhage —
blood exits the body (e.g., lacerations, epistaxis).
- Internal haemorrhage —
blood accumulates within tissues or body cavities (e.g., intracranial,
intra-abdominal, intrathoracic).
By vessel type/mechanism:
- Arterial bleeding —
high-pressure, pulsatile blood loss; rapid volume depletion.
- Venous bleeding —
lower pressure, may be profuse if large veins affected.
- Capillary/venule bleeding —
oozing, often slower.
- Bleeding into tissue —
contusions and haematomas.
Special categories:
- Postpartum haemorrhage (PPH) —
obstetric emergency after delivery.
- Subarachnoid haemorrhage (SAH) —
bleeding into the subarachnoid space, frequently due to aneurysm rupture.
- Intracerebral haemorrhage —
bleeding within the brain parenchyma.
- Haemothorax —
blood in the pleural space.
- Gastrointestinal haemorrhage —
upper or lower GI bleeding.
Key point: Identifying the
compartment and source guides immediate management.
3. Internal versus external
haemorrhage — clinical implications
External haemorrhage is
usually visible and amenable to immediate first-aid measures (direct pressure,
elevation, haemostatic dressings). Internal haemorrhage can be
deceptive — the external appearance may be minimal or absent, while the
internal blood loss can be large.
Clinical implications:
- External bleeding allows visual assessment but may still cause
massive blood loss.
- Internal bleeding requires high clinical vigilance and often
imaging; signs are frequently non-specific (e.g., hypotension, confusion,
abdominal pain, back pain, dyspnoea).
Key point: Always consider
internal bleeding when unexplained haemodynamic compromise occurs after trauma,
surgery, or spontaneously in patients on anticoagulants.
4. Common anatomical sites and
clinical presentations
Head and brain
- Intracerebral haemorrhage (ICH): focal
neurological deficit, reduced level of consciousness, headache, vomiting,
hypertension history.
- Subarachnoid haemorrhage (SAH): sudden
severe "thunderclap" headache, neck stiffness, photophobia,
meningism, possible loss of consciousness.
Thorax
- Haemothorax: pleuritic
chest pain, respiratory distress, reduced breath sounds, dullness to
percussion; may progress to tension physiology.
- Pulmonary hemorrhage: haemoptysis,
hypoxia.
Abdomen and retroperitoneum
- Intra-abdominal bleeding (e.g., splenic rupture): abdominal pain, distension, peritonism, referred shoulder
pain (Kehr’s sign), hypotension.
- Retroperitoneal haemorrhage: flank/back
pain, sometimes minimal abdominal signs; common with anticoagulation.
Gastrointestinal tract
- Upper GI bleeding (oesophagus, stomach, duodenum): haematemesis, melena.
- Lower GI bleeding (colon, rectum, small bowel): bright red blood per rectum, haematochezia.
Genital/obstetric
- Postpartum haemorrhage (PPH): heavy
vaginal bleeding after delivery; uterine atony is the most common cause.
Limbs and soft tissues
- Haematoma and compartment syndrome: swelling, pain, tense compartments, neurovascular compromise.
Eyes
- Subconjunctival haemorrhage: visible
red patch on sclera; usually benign and self-limited.
Key point: Presentation varies
with location; correlate symptoms with likely compartments and risk factors
(trauma, anticoagulation, aneurysm, obstetric history).
5. Causes and pathophysiological
mechanisms
Trauma
- Blunt or penetrating injury disrupts vessels.
- Iatrogenic causes: surgical bleeding, invasive procedures, vascular
access complications.
Vascular lesions
- Aneurysm rupture (e.g., intracranial saccular aneurysm — SAH).
- Arteriovenous malformations (AVMs).
- Atherosclerotic vessel disruption.
Coagulopathy and haemostatic defects
- Congenital (e.g., haemophilia, von Willebrand disease).
- Acquired: liver disease, disseminated intravascular coagulation
(DIC), thrombocytopenia.
- Anticoagulant and antiplatelet medications (warfarin, direct oral
anticoagulants, aspirin, clopidogrel).
Medical conditions
- Hypertension (risk factor for intracerebral haemorrhage).
- Malignancy invading vessels.
- Vascular inflammation (vasculitis).
Infective causes
- Viral haemorrhagic fevers (rare in many settings but significant in
endemic regions).
- Sepsis-associated coagulopathy.
Obstetric causes
- Uterine atony, retained placenta, genital tract lacerations,
uterine rupture.
Key point: Treatment requires
addressing both the bleeding source and predisposing haemostatic abnormalities.
6. Clinical features and red
flags
Local signs
- External bleeding, expanding haematoma, visible wound.
Systemic signs of significant blood loss
- Tachycardia, hypotension, pallor, cold clammy skin, oliguria,
altered mental status (from hypoperfusion).
Red flags indicating life-threatening haemorrhage
- Systolic blood pressure <90 mmHg or signs of shock.
- Rapidly expanding neck or facial haematoma risking airway
compromise.
- Neurological deterioration (suggesting intracranial haemorrhage).
- Massive haemoptysis or haematemesis.
- Postpartum bleeding >500 mL (vaginal delivery) or >1000 mL
(caesarean) with ongoing blood loss.
Key point: Rapid assessment and
triage using ABC principles (Airway, Breathing, Circulation) are essential.
7. Diagnostic approach and
investigations
Immediate bedside evaluation
- Airway assessment (risk
of airway compromise, particularly with facial/neck bleeding).
- Breathing and oxygenation —
respiratory rate, oxygen saturation, signs of haemothorax or pulmonary
haemorrhage.
- Circulatory status —
heart rate, blood pressure, capillary refill, peripheral perfusion.
- Focused history —
onset, mechanism (trauma, recent procedures), medications
(anticoagulants), obstetric status.
- Focused physical examination —
wound inspection, abdominal palpation, neurological exam.
Essential investigations
- Blood tests: full
blood count (haemoglobin, platelets), coagulation screen (INR, aPTT),
blood type and crossmatch, electrolytes, lactate, liver function tests.
- Point-of-care ultrasound (FAST/extended-FAST): rapid assessment for intraperitoneal or pericardial fluid in
trauma.
- Chest X-ray: suspected
haemothorax, pulmonary pathology.
- CT imaging: CT
brain for suspected intracranial haemorrhage; CT angiography for vascular
sources; CT abdomen/pelvis for intra-abdominal bleeding.
- Endoscopy: upper
GI endoscopy for suspected upper gastrointestinal bleeding.
- Angiography: diagnostic
with potential for therapeutic embolisation (interventional radiology).
Key point: Imaging choice is
guided by clinical stability — unstable patients require immediate
resuscitation; imaging is deferred until the patient is stabilised or if it
will change immediate management.
8. Acute management — first
response and stabilisation
Pre-hospital and immediate measures
- Call for emergency help and
transfer to an appropriate acute facility.
- Control external bleeding: apply
firm direct pressure with gauze or dressings; do not remove impaled
objects—stabilise them.
- Tourniquet use: apply
a tourniquet for severe limb bleeding when direct pressure fails — record
application time.
- Airway protection: prepare
for airway management if compromised.
- High-flow oxygen and
continuous monitoring.
- IV access: two
large-bore peripheral cannulae (or central venous access if necessary).
- Fluid resuscitation: balanced
crystalloids; avoid excessive crystalloid that may dilute clotting
factors.
- Blood transfusion: follow
massive transfusion protocols if required (balanced ratio of red cells,
plasma, platelets).
- Reverse anticoagulation: when
indicated (e.g., vitamin K and prothrombin complex concentrate for
warfarin; specific reversal agents for DOACs where appropriate).
- Analgesia and sedation as
required, with caution to avoid masking neurological changes.
Resuscitation principles
- Follow Advanced Trauma Life Support (ATLS) or equivalent protocols.
- Permissive hypotension may
be considered in uncontrolled haemorrhage until haemorrhage control is
achieved (except in traumatic brain injury where adequate cerebral
perfusion is required).
- Massive transfusion protocols (MTP): activate early for anticipated large blood loss.
Key point: Early haemorrhage
control and correction of coagulopathy save lives; anticipate the need for
blood and reversal agents.
9. Definitive treatment
modalities
Local haemostatic measures
- Suturing, vessel ligation, topical haemostatic agents.
- Haemostatic dressings and packing for cavities (e.g., nasal
packing, pelvic packing).
Endovascular therapy
- Angiographic embolisation: effective
for pelvic fractures, solid organ injuries (liver, kidney, spleen), and
some GI bleeds.
- Minimally invasive and organ-sparing in many cases.
Surgical intervention
- Laparotomy/thoracotomy/craniotomy for
uncontrolled internal bleeding or presence of injuries requiring operative
repair.
- Indications include peritonitis, expanding haematoma with
compartment syndrome, refractory haemodynamic instability.
Neurosurgical measures
- Decompressive craniectomy, evacuation of intracerebral haematoma for selected patients.
- Management of subarachnoid haemorrhage: securing ruptured aneurysms by endovascular coiling or
surgical clipping.
Obstetric care
- Uterotonic agents (oxytocin,
ergometrine where appropriate) for uterine atony.
- Surgical interventions: uterine
balloon tamponade, uterine artery embolisation, uterine compression
sutures, hysterectomy as a life-saving measure.
Pharmacological
- Antifibrinolytics: tranexamic
acid (TXA) has established benefit in trauma and postpartum haemorrhage
when given early.
- Replacement therapy: blood
components, cryoprecipitate, factor concentrates as indicated.
- Reversal agents: vitamin
K, prothrombin complex concentrates, idarucizumab for dabigatran,
andexanet alfa for factor Xa inhibitors (where available and indicated).
Key point: Choice of definitive
therapy depends on site, cause, haemodynamic status, and available expertise
and resources.
10. Complications and risk
factors
Immediate complications
- Hypovolaemic shock and multi-organ failure.
- Rebleeding after initial control.
- Airway compromise (particularly cervicofacial haematomas).
Early and late complications
- Infection in haematomas or surgical sites.
- Ischaemic injury following
prolonged hypotension.
- Neurological deficits after
intracranial haemorrhage.
- Compartment syndrome with
soft-tissue bleeding.
- Thromboembolic events in
immobilised patients.
- Chronic anaemia and
need for prolonged transfusion or iron therapy.
Risk factors for poor outcome
- Advanced age, comorbid cardiovascular disease, uncontrolled
hypertension, anticoagulant therapy, delayed presentation, massive blood
loss, and multi-system trauma.
Key point: Risk mitigation
includes early control, correction of coagulopathy, appropriate prophylaxis for
venous thromboembolism when safe, and vigilant monitoring.
11. Prognosis and follow-up
considerations
Prognosis
varies widely. Mortality and morbidity depend on:
- Anatomical site (intracranial
and major thoracic haemorrhages carry higher risk).
- Volume and rate of blood loss.
- Time to definitive control.
- Patient comorbidities and baseline functional status.
Follow-up care includes:
- Monitoring haemoglobin, renal function, and coagulation parameters.
- Rehabilitation for neurological or functional deficits.
- Review and adjustment of anticoagulation therapy balancing
thrombosis versus bleeding risk.
- Investigation for underlying causes (e.g., aneurysm screening in
non-traumatic SAH, coagulation workup).
Key point: Early multidisciplinary
involvement (surgery, interventional radiology, haematology, critical care,
rehabilitation) optimises outcomes.
12. Prevention and patient
education
Primary prevention
- Control cardiovascular risk factors (e.g., blood pressure
management to reduce risk of intracerebral haemorrhage).
- Safe prescribing and regular review of anticoagulant/antiplatelet
therapy; educate patients on bleeding risks and signs.
Secondary prevention
- Address reversible causes (e.g., aneurysm repair, correcting
coagulopathy).
- Vaccination and safe practices where infectious haemorrhagic
diseases are a concern.
Patient education
- Recognise red flags: sudden severe headache, unexplained dizziness
or weakness, tachycardia, persistent bleeding, syncope.
- For patients on anticoagulants: carry information about medication
and reversal agents; seek prompt evaluation for any significant bleed.
Key point: Informed patients and
cautious management of bleeding risks reduce harm.
13. Frequently asked questions
(FAQs)
Q: Why can a haemorrhage be fatal?
A: Severe haemorrhage leads to loss of circulating volume causing hypovolaemic
shock, inadequate tissue perfusion, multi-organ failure and death if not
rapidly corrected.
Q: How can internal bleeding be detected early?
A: Early detection relies on clinical suspicion: unexplained hypotension,
tachycardia, falling haemoglobin, abdominal distension or neurological changes
should prompt urgent imaging and investigation.
Q: How do you control external haemorrhage at the scene?
A: Apply firm direct pressure, maintain pressure until bleeding stops, use a
tourniquet for uncontrollable limb bleeding if trained to do so, and seek
emergency care.
Q: Can people on anticoagulants survive internal bleeding?
A: Many can if recognised early and managed promptly; reversal of
anticoagulation, targeted interventions and supportive care are often
effective.
Q: When should tranexamic acid be given?
A: TXA is indicated early in trauma with significant bleeding and in postpartum
haemorrhage within recommended time windows as part of established protocols.
14. References
- “Management of Major Haemorrhage: A Practical Guide”
- “Trauma Resuscitation and Haemorrhage Control”
- “Clinical Guidelines for the Management of Intracranial
Haemorrhage”
- “Postpartum Haemorrhage: Emergency Management and Protocols”
- “Tranexamic Acid in Trauma and Obstetric Haemorrhage: Evidence and
Guidelines”
- “Surgical and Endovascular Techniques for Haemorrhage Control”
- “Haemostatic Disorders and Anticoagulation Reversal: Clinical
Practice”
Closing summary
Haemorrhage is a heterogeneous clinical problem that ranges from trivial to life-threatening.
Rapid recognition, targeted resuscitation, correction of haemostatic
abnormalities and definitive control of the bleeding source are the pillars of
effective management. A multidisciplinary approach and close attention to risk
factors and prevention strategies improve patient outcomes. If there is any
concern about active or suspected bleeding, immediate medical evaluation is
essential.
Disclaimer: This article provides general clinical information about haemorrhage for educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. If you suspect a severe bleed or haemorrhage, seek immediate emergency medical attention. Always follow the guidance of qualified healthcare professionals for personal medical care.
