Internal Bleeding (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Charles Patrick Davis, MD, PhD
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
IN THIS ARTICLE
Internal Bleeding Causes
Internal bleeding may occur in three instances:
Most people appreciate that injuries occur when great force is applied to the body. Falling from a height or being involved in a car accident may cause compression or deceleration forces that can damage the organs in the body without necessarily lacerating or cutting the skin. External bleeding is easy to recognize. Internal bleeding may be more difficult to appreciate.
Damaged Blood Vessels
Damage to the blood vessels occurs due to trauma. The amount of internal bleeding that occurs depends upon the severity of the force applied, the blood vessel that is injured, and the condition of the patient prior to injury. For example, a person taking warfarin (Coumadin), a medication that inhibits blood from clotting, will likely have more bleeding from the same amount of force due to trauma than a person whose clotting factors are working normally.
Blood vessel walls may be weakened because of chronic high blood pressure, which can cause them to dilate and form aneurysms that are at higher risk of bleeding because of weak vessel walls. However some aneurysms may also be congenital (present from birth). Regardless, the aneurysms are at risk for leaking or rupturing, and depending upon their location, may have devastating consequences. For example, an aneurysm of a cerebral artery (those that supply blood to the brain) may bleed and cause a hemorrhagic stroke; while a patient may bleed to death due to an aortic aneurysm that ruptures, causing severe internal bleeding into the abdominal cavity.
Orthopedic injuries almost always cause internal bleeding. Bone marrow is where blood cell production takes place and it has a generous blood supply for this to occur. When a bone breaks, significant bleeding may be expected. Long bones like the humerus (upper arm bone), femur (thigh bone), and pelvic bones can cause the body to lose 10% or more of its blood supply.
Compression injuries occur when an external force is applied to the body and an organ is compressed between two hard surfaces. For example, if a football player is tackled, the force of the tackle may compress the spleen between the ribs and the backbone enough to make it rupture and bleed. Or imagine a weight falling on a foot compressing the tissues and the bones of the foot between the weight and the ground; there is potential for bleeding because blood vessels have ruptured.
Deceleration injuries occur when the moving body is stopped very quickly. When traveling in a vehicle; an individual is moving with the speed of the car. If the car hits a wall, the speed becomes zero very quickly. A classic deceleration injury can occur when a rapidly moving human body strikes a stationary object (chest hits a steering wheel when the vehicle hits a tree), causing the moving aorta to hit the chest wall and rupture causing fatal internal bleeding. Different parts of the body will stop at different times and the difference in the deceleration may cause organs to shift and the blood vessels that are attached to tear. If a person hits their head in a fall, the brain may fall for a fraction of a second longer than the skull that initially hits the ground. This can cause the arteries that run on the surface of the brain to tear and bleed forming epidural or subdural hematomas.
Some individuals have inherited bleeding disorders that cause spontaneous bleeding. Minimal trauma or even no apparent injury can cause internal bleeding. The most common bleeding disorder is Von Willebrand's disease affecting 1% to 2% of the population, and hemophilia affecting almost 20,000 people in the USA.
Clotting factors are manufactured in the liver and any damage to the liver will increase bleeding risk. While viral infections may cause hepatitis leading to liver failure, alcohol abuse is the most common reason for the liver to fail. Aside from the lack of clotting factors in the blood, liver failure or cirrhosis can also cause blood to flow abnormally in the liver or portal system, which leads to the formation of swollen veins in the esophagus and other parts of the body. Called varices, these veins have the tendency to aggressively bleed.
Medications are often prescribed to "thin" the blood to prevent blood clots from forming or for treating blood clots that have already occurred. Common reasons for prescribing medications such as warfarin (Coumadin) and heparin (medications that inhibit clotting factor function) include atrial fibrillation, deep venous thrombosis, and pulmonary embolism. Clopidogrel (Plavix), dipyridamole (Persantine), and prasugrel (Effient) are medications that inhibit platelet function and are often used to prevent heart attack, stroke, and peripheral vascular disease.
Aspirin is an over-the-counter (OTC) medication that is commonly recommended to prevent heart attack and stroke. It works by inhibiting platelets that help blood to clot and can be a risk factor for internal bleeding.
Alcohol, smoking, aspirin, ibuprofen and other nonsteroidal antiinflammatory medications can cause irritation of the lining of the esophagus, stomach, and intestine thus predisposing individuals to internal bleeding.
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