Internal bleeding (also called internal hemorrhage) is a loss of blood from a

blood vessel The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away ...

that collects inside the body. Internal bleeding is usually not visible from the outside. It is a serious

medical emergency A medical emergency is an acute injury or illness that poses an immediate risk to a person's life or long-term health, sometimes referred to as a situation risking "life or limb". These emergencies may require assistance from another, qualified p ...

but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into the chest,

abdomen The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...

retroperitoneal space The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...

pelvis The pelvis (plural pelves or pelvises) is the lower part of the trunk, between the abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also called bony pelvis, or pelvic skeleton). The ...

, and thighs can cause

hemorrhagic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a ...

death Death is the irreversible cessation of all biological functions that sustain an organism. For organisms with a brain, death can also be defined as the irreversible cessation of functioning of the whole brain, including brainstem, and brain ...

if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

Signs and symptoms

At first, there may be no symptoms of internal bleeding. If an organ is damaged and it bleeds, it can be painful. Over time, internal bleeding can cause low

blood pressure Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...

(

hypotension Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the dias ...

), increased heart rate (

tachycardia Tachycardia, also called tachyarrhythmia, is a heart rate that exceeds the normal resting rate. In general, a resting heart rate over 100 beats per minute is accepted as tachycardia in adults. Heart rates above the resting rate may be normal (su ...

), increased breathing rate (

tachypnea Tachypnea, also spelt tachypnoea, is a respiratory rate greater than normal, resulting in abnormally rapid and shallow breathing. In adult humans at rest, any respiratory rate of 1220 per minute is considered clinically normal, with tachypnea be ...

), confusion, drowsiness, and loss of consciousness. A patient may lose more than 30% of their blood volume before there are changes in their vital signs or level of consciousness. This is called hemorrhagic or

hypovolemic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a ...

, which is a type of

shock Shock may refer to: Common uses Collective noun *Shock, a historic commercial term for a group of 60, see English numerals#Special names * Stook, or shock of grain, stacked sheaves Healthcare * Shock (circulatory), circulatory medical emerge ...

that occurs when there is not enough blood to reach organs in the body. Early symptoms include anxiety, increased breathing rate, weak peripheral pulses, and cold skin on the arms and legs. If internal bleeding is not treated, the heart and breathing rate will continue to increase while blood pressure and mental status decrease. Eventually, internal bleeding can result in death by blood loss ( exsanguination). The median time from the onset of hemorrhagic shock to death by exsanguination is 2 hours.

Causes

Trauma

The most common cause of death in trauma is bleeding. Death from trauma accounts for 1.5 million of the 1.9 million deaths per year due to bleeding. There are two types of trauma:

penetrating trauma Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or ''non-penetrating'' trauma may have some deep dama ...

and

blunt trauma Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...

. *

Penetrating trauma Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or ''non-penetrating'' trauma may have some deep dama ...

is the most common cause of vascular injury and can result in internal bleeding. It can occur after a

ballistic Ballistics may refer to: Science * Ballistics, the science that deals with the motion, behavior, and effects of projectiles ** Forensic ballistics, the science of analyzing firearm usage in crimes ** Internal ballistics, the study of the proce ...

injury or stab wound. If

occurs in blood vessels close to the heart, it can quickly lead to hemorrhagic or

, exsanguination, and

. *

Blunt trauma Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...

is another cause of vascular injury that can result in internal bleeding. It can occur after a high speed deceleration in an automobile accident.

Non-traumatic

A number of pathological conditions and diseases can lead to internal bleeding. These include: * Blood vessel rupture as a result of high

, aneurysms,

esophageal varices Esophageal varices are extremely dilated sub-mucosal veins in the lower third of the esophagus. They are most often a consequence of portal hypertension, commonly due to cirrhosis. People with esophageal varices have a strong tendency to develop ...

, peptic ulcers, or

ectopic pregnancy Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. ...

. * Other diseases linked to internal bleeding include

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

, hematologic disease,

Vitamin K Vitamin K refers to structurally similar, fat-soluble vitamers found in foods and marketed as dietary supplements. The human body requires vitamin K for post-synthesis modification of certain proteins that are required for blood coagulation ...

deficiency, and rare

viral hemorrhagic fevers Viral hemorrhagic fevers (VHFs) are a diverse group of animal and human illnesses in which fever and hemorrhage are caused by a viral infection. VHFs may be caused by five distinct families of RNA viruses: the families ''Filoviridae'', ''Flavi ...

, such as the

Ebola Ebola, also known as Ebola virus disease (EVD) and Ebola hemorrhagic fever (EHF), is a viral hemorrhagic fever in humans and other primates, caused by ebolaviruses. Symptoms typically start anywhere between two days and three weeks after becom ...

, Dengue or

Marburg Marburg ( or ) is a university town in the German federal state (''Bundesland'') of Hesse, capital of the Marburg-Biedenkopf district (''Landkreis''). The town area spreads along the valley of the river Lahn and has a population of approximate ...

viruses.

Other

Internal bleeding could be caused by medical error as a result of complications after surgical operations or medical treatment. Some medication effects may also lead to internal bleeding, such as the use of

anticoagulant Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where the ...

drugs or antiplatelet drugs in the treatment of

coronary artery disease Coronary artery disease (CAD), also called coronary heart disease (CHD), ischemic heart disease (IHD), myocardial ischemia, or simply heart disease, involves the reduction of blood flow to the heart muscle due to build-up of atherosclerotic pla ...

Diagnosis

Vital signs

Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, and mental status. Advanced trauma life support (ATLS) by the American College of Surgeons separates hemorrhagic shock into four categories. Assessing circulation occurs after assessing the patient's airway and breathing (

ABC (medicine) ABC and its variations are initialism mnemonics for essential steps used by both medical professionals and lay persons (such as first aiders) when dealing with a patient. In its original form it stands for ''Airway'', ''Breathing,'' and '' Circul ...

). If internal bleeding is suspected, a patient's

circulatory system The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...

is assessed through palpation of pulses and

doppler ultrasonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of ...

Physical examination

It is important to examine the person for visible signs that may suggest internal bleeding: * a wound * bruising cchymosis/nowiki> * blood collection nowiki/>hematoma">hematoma.html" ;"title="nowiki/>hematoma">nowiki/>hematoma* abnormal skin sensation [paresthesia] * signs of compartment syndrome It is also important to look for the source of the internal bleeding. If internal bleeding is suspected after trauma, a FAST exam may be performed to look for bleeding in the abdomen.

Imaging

If the patient has stable

vital signs Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a ...

, they may undergo diagnostic imaging such as a

CT scan A computed tomography scan (CT scan; formerly called computed axial tomography scan or CAT scan) is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers ...

. If the patient has unstable vital signs, they may not undergo diagnostic imaging and instead may receive immediate medical or surgical treatment.

By location

Internal bleeding can occur anywhere in the body. Some symptoms of internal bleeding depend on the location of the bleed. Some examples of types of internal bleeding include: *Head:

Intracranial hemorrhage Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds ( intraventricular bleeds and intraparenchymal bleeds), subarachnoid bleeds, epidural bleeds, and subdural bleeds. ...

cerebral hemorrhage Intracerebral hemorrhage (ICH), also known as cerebral bleed, intraparenchymal bleed, and hemorrhagic stroke, or haemorrhagic stroke, is a sudden bleeding into the tissues of the brain, into its ventricles, or into both. It is one kind of bleed ...

subarachnoid hemorrhage Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consci ...

, subdural hematoma, epidural hematoma *Torso: cardiac tamponade,

pulmonary hemorrhage Pulmonary hemorrhage (or pulmonary haemorrhage) is an acute bleeding from the lung, from the upper respiratory tract and the trachea, and the pulmonary alveoli. When evident clinically, the condition is usually massive.hemothorax,

aortic aneurysm An aortic aneurysm is an enlargement (dilatation) of the aorta to greater than 1.5 times normal size. They usually cause no symptoms except when ruptured. Occasionally, there may be abdominal, back, or leg pain. The prevalence of abdominal aortic ...

, gastrointestinal bleeding (

upper gastrointestinal bleeding Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. D ...

lower gastrointestinal bleeding Lower gastrointestinal bleeding, commonly abbreviated LGIB, is any form of gastrointestinal bleeding in the lower gastrointestinal tract. LGIB is a common reason for seeking medical attention at a hospital's emergency department. LGIB accounts for ...

blunt kidney trauma The kidney is injured in approximately 10 percent of all significant blunt abdominal trauma. Of those, 13 percent are sports-related when the kidney, followed by testicle, is most frequently involved. However, the most frequent cause by far is t ...

splenic injury A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision. Signs and symptoms In minor injuries with little bleeding, there may be abdomin ...

retroperitoneal bleeding Retroperitoneal bleeding is an accumulation of blood in the retroperitoneal space. Signs and symptoms may include abdominal or upper leg pain, hematuria, and shock. It can be caused by major trauma or by non-traumatic mechanisms. Signs and sympto ...

, postpartum bleeding,

*Extremities:

bone fracture A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...

, hemarthrosis

Treatment

Management of internal bleeding depends on the cause and severity of the bleed. ''Internal bleeding is a medical emergency and should be treated immediately by medical professionals''.

Fluid replacement

If a patient has low blood pressure (

), intravenous fluids can be used until they can receive a

blood transfusion Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mo ...

. In order to replace blood loss quickly and with large amounts of IV fluids or blood, patients may need a

central venous catheter A central venous catheter (CVC), also known as a central line(c-line), central venous line, or central venous access catheter, is a catheter placed into a large vein. It is a form of venous access. Placement of larger catheters in more central ...

. Patients with severe bleeding need to receive large quantities of replacement blood via a

. As soon as the clinician recognizes that the patient may have a severe, continuing hemorrhage requiring more than 4 units in 1 hour or 10 units in 6 hours, they should initiate a

massive transfusion protocol Blood transfusion is the process of transferring blood products into a person's circulation intravenously. Transfusions are used for various medical conditions to replace lost components of the blood. Early transfusions used whole blood, but mod ...

. The massive transfusion protocol replaces

red blood cell Red blood cells (RBCs), also referred to as red cells, red blood corpuscles (in humans or other animals not having nucleus in red blood cells), haematids, erythroid cells or erythrocytes (from Greek ''erythros'' for "red" and ''kytos'' for "holl ...

plasma Plasma or plasm may refer to: Science * Plasma (physics), one of the four fundamental states of matter * Plasma (mineral), a green translucent silica mineral * Quark–gluon plasma, a state of matter in quantum chromodynamics Biology * Blood pla ...

, and platelets in varying ratios based on the cause of the bleeding (traumatic vs. non-traumatic).

Stopping the bleeding

It is crucial to stop the internal bleeding immediately (achieve

hemostasis In biology, hemostasis or haemostasis is a process to prevent and stop bleeding, meaning to keep blood within a damaged blood vessel (the opposite of hemostasis is hemorrhage). It is the first stage of wound healing. This involves coagulation, whi ...

) after identifying its cause. The longer it takes to achieve

in people with traumatic causes (e.g.

pelvic fracture A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones (ischium, pubis, ilium), or tailbone. Symptoms include pain, particularly with movement. Complications may include internal ble ...

) and non-traumatic causes (e.g. gastrointestinal bleeding, ruptured abdominal aortic aneurysm), the higher the death rate is. Unlike with external bleeding, most internal bleeding cannot be controlled by applying pressure to the site of injury. Internal bleeding in the

thorax The thorax or chest is a part of the anatomy of humans, mammals, and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main divisions of the cre ...

and

abdominal cavity The abdominal cavity is a large body cavity in humans and many other animals that contains many organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the th ...

(including both the intraperitoneal and

) cannot be controlled with direct pressure (compression). A patient with acute internal bleeding in the

after trauma should be diagnosed, resuscitated, and stabilized in the Emergency Department in less than 10 minutes before undergoing surgery to reduce the risk of death from internal bleeding. A patient with

acute Acute may refer to: Science and technology * Acute angle ** Acute triangle ** Acute, a leaf shape in the glossary of leaf morphology * Acute (medicine), a disease that it is of short duration and of recent onset. ** Acute toxicity, the adverse eff ...

internal bleeding in the

after trauma may require use of a

REBOA Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure performed during resuscitation of critically injured trauma patients. Originally developed as a less invasive alternative to emergency thoracotomy ...

device to slow the bleeding. The

has also been used for non-traumatic causes of internal bleeding, including bleeding during childbirth and gastrointestinal bleeding. Internal bleeding from a

in the arms or legs may be partially controlled with direct pressure using a

tourniquet A tourniquet is a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood. It may be used in emergencies, in surgery, or in post-operative rehabilitation. A simple tourniquet can be made from a stick and ...

. After

placement, the patient may need immediate

surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

to find the bleeding

. Internal bleeding where the torso meets the extremities ("junctional sites" such as the axilla or groin) cannot be controlled with a tourniquet; however there is an FDA approved device known as an Abdominal Aortic and Junctional Tourniquet (AAJT) designed for proximal aortic control, although very few studies examining its use have been published. For bleeding at junctional sites, a dressing with a blood clotting agent (

hemostatic dressing An antihemorrhagic (antihæmorrhagic) agent is a substance that promotes hemostasis (stops bleeding). It may also be known as a hemostatic (also spelled haemostatic) agent. Antihemorrhagic agents used in medicine have various mechanisms of action: ...

) should be applied. A campaign is to improve the care of the bleeding known as ''Stop The Bleed'' campaign is also taking place.

References

External links

{{Trauma , state=autocollapse Bleeding Injuries Medical emergencies