Classification and etiology
According to the time of manifestation, secondary hemorrhages are divided into two groups:
- Early (up to 3 days). Associated with technical errors or hemodynamic shifts. Causes: slipping of loosely tied ligatures, hemorrhagic anemia, as well as dislodgement of blood clots from vessels due to a spike in blood pressure (especially if the surgery was performed under conditions of shock or controlled hypotension).
- Late (from 3 days to several weeks).
Globally, the causes of development are divided into general and local:
- Hemostatic disorders: sepsis, cholemia, hemophilia.
- Iatrogenic and mechanical factors: dislodgement of a blood clot during careless dressing changes, removal of tampons or drains.
- Purulent-inflammatory processes (main cause): the development of necrosis leads to the purulent breakdown of protective blood clots. Additionally, the vessel wall can be destroyed by pressure sores (from the pressure of drains, metal fragments, or bone shards) or undergo primary necrosis.
Clinical presentation
The severity of the patient's condition depends on the caliber of the damaged vessel, the nature of the wound, and the volume of blood loss. The clinical picture consists of general and local manifestations.
External hemorrhages:
- The main sign is soaking of the dressing (bright red blood in arterial injury, dark blood in venous trauma).
- If the wound is sutured tightly, a hematoma forms. The patient feels pain and a sensation of fullness in the surgical area, and swelling is visually apparent.
Internal hemorrhages: Signs of systemic blood loss come to the first plane: skin pallor, increasing weakness, tachycardia (rapid pulse of weak volume), hypotension. Laboratory tests show a drop in hemoglobin and hematocrit. Local symptoms depend on the localization. When blood accumulates in cavities, hemothorax, hemoperitoneum, or hemopericardium develops. When bleeding into the gastrointestinal tract occurs, "coffee ground" emesis, bloody vomiting, melena (tarry stool), or stool mixed with fresh blood appears.
Emergency care and treatment algorithm
The arrest of secondary hemorrhage is based on the same principles as primary hemorrhage, but follows a strict sequence:
- Temporary arrest (emergency stage): performed by nursing staff before the surgeon arrives. Digital pressure, pressure dressing, tourniquet application, or tight packing is used.
- Surgical tactics: removal of sutures and thorough wound revision.
- Definitive arrest: vessel ligation, suture placement, suturing of parenchymal organs (liver, ovary). For capillary bleeding, a hemostatic sponge or gauze pack is used.
Important treatment nuances:
- If temporary arrest is possible, definitive surgical hemostasis is performed only after the patient is resuscitated from hemorrhagic shock (infusion of blood substitutes).
- In internal (cavitary) hemorrhages, when temporary arrest is not feasible, emergency surgery is indicated (relaparotomy, rethoracotomy). Surgical intervention and anti-shock therapy proceed strictly simultaneously.
- Blood reinfusion of blood shed into serous cavities is possible if no more than 24 hours have passed since the onset of bleeding and the blood is not contaminated with GI contents.
- In case of coagulation disorders, drug support is actively used: aminocaproic acid, fibrinogen, antihemophilic factor, plasma cryoprecipitate, platelet concentrate.
Specifics of managing a purulent wound
Ligation of a bleeding vessel directly within a purulent wound is completely unreliable. Due to the progressive purulent-necrotic process, ligatures will inevitably cut through, and the hemorrhage will recur.
Method of choice: ligation of the vessel in continuity, i.e., outside the site of injury, within visually healthy tissues. This avoids the breakdown of sutures and creates an additional reserve of collateral circulation.
Prevention
To minimize risks, the surgical team must follow a number of rules:
- Ideal hemostasis: wound closure is performed only with an absolutely "dry" surgical field. At the slightest doubt, additional electroscoagulation or ligation is used.
- Quality primary surgical debridement (PSD): complete removal of foreign bodies (bullets, pellets, loose bone fragments).
- Competent drainage: tubes are installed taking into account the topography of major vessels to avoid causing pressure sores on the wall.
- Combating infection: strict asepsis and timely antibiotic therapy to prevent purulent breakdown.
- Coagulation control: all patients undergo baseline parameter checks before surgery (clotting time, platelets, prothrombin). In case of jaundice, blood diseases, or a poor medical history, a comprehensive coagulogram is prescribed.
Briefly: answers to topical questions
What is arrosive secondary hemorrhage and what is its pathogenesis?
Arrosive hemorrhage (haemorrhagia per diabrosin) is a type of bleeding resulting from the destruction of the entire thickness of the vessel wall by a pathological process. Pathogenesis involves necrosis and breakdown of the vessel wall under the influence of various damaging factors. Main causes of arrosive hemorrhage:
- Purulent-inflammatory processes — development of necrosis in the wound and purulent tissue breakdown.
- Malignant tumors — destruction of the wall by a growing neoplasm.
- Necrosis — for example, caseous necrosis in the wall of a tuberculous cavity or fibrinoid necrosis.
- Exposure to chemical agents — the action of gastric juice in an ulcer.
- Invasion by chorionic villi — damage to the vessels of the fallopian tube in ectopic pregnancy.
The Rule of Three C's for a purulent wound: Vessel (Сосуд), Medium (Среда), Neighborhood (Соседство). In a purulent Medium, a Vessel cannot be ligated — look for a healthy Neighborhood (ligation in continuity).
Class and exam questions
Why are secondary hemorrhages tolerated worse by patients than primary ones?
It arises against the background of compensatory reserves already depleted after the initial injury or surgery, so the clinical severity of the condition often exceeds the actual volume of lost blood.
Is it possible to place a ligature on a vessel directly in an infected wound?
No, this will lead to recurrence. Under the influence of the purulent process, the ligature will cut through, and the vessel will continue to necrose. Ligation "in continuity" within healthy tissues is necessary.
When is reinfusion of shed blood permitted?
Blood can be collected, filtered, and reinfused if it has accumulated in serous cavities, has not contacted GI contents, and less than a day has passed since the bleeding.
What else to study on this topic
- Technique of major vessel ligation in continuity
- Indications for prescribing blood products (cryoprecipitate, fibrinogen)
- Rules for drain placement and vascular topographic anatomy
- Management tactics for patients with baseline hemostatic disorders
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