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Medical Author:

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.

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Medical Editor:

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.

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The symptoms of internal bleeding depend upon the circumstances. Sometimes it is the location of the bleeding and not the amount that makes the difference. Sometimes it is the amount of blood that is lost and sometimes it is a combination of the two.

• Shock may occur if there is enough blood lost to decrease the amount of blood within the circulatory system. The signs and symptoms of shock may include rapid heartbeat, low blood pressure, cool and sweaty skin, and decrease mental function or confusion.
• Most healthy people can lose 10% to 15% of their blood supply and show minimal signs of shock. This blood loss is the equivalent of donating a pint of blood. Symptoms become more severe as more blood is lost.
• Children, the elderly, and those taking certain medications may not exhibit classic signs and symptoms and medical care providers may need to maintain a higher level of suspicion when looking for internal bleeding.
• Orthostatic hypotension (becoming dizzy when attempting to stand) can occur in patients with internal bleeding.
• Bleeding usually causes pain and the area of the body affected is usually the site of the person's complaint. Blood that leaks outside of a blood vessel is very irritating and causes an inflammatory response.
• Blood in the peritoneum causes intense pain that is sometimes difficult to localize especially if blood is spilling everywhere.
• Blood that irritates the diaphragm (the muscle that separates the chest from the abdomen) may cause pain in the chest or pain that radiates to the shoulder.
• Blood may eventually track towards the surface of the skin and can be seen as bruising. Bruising of the flank (Grey-Turner's sign) or around the umbilicus (Cullen's sign) indicate intra-abdominal bleeding.

The complaint of pain is just one element of the history that is taken by the health care practitioner in trying to determine the source of internal bleeding.

Some organs do not tolerate even minimal amounts of bleeding and will have show symptoms of decreased function. Examples of include:

• Bleeding in the brain is usually associated with decreased mental function which may include vomiting, lethargy, coma, seizure, or coma and unconsciousness. There may be the signs of stroke including slurred speech, loss of vision, and weakness of one side of the body.
• Signs and symptoms of bleeding in the eye are decreased or hazy vision, floating objects in the vision, or blindness.
• Some bony joints have little room and bleeding can cause immediate and significant pain. Individuals with hemophilia may complain of chronic pain that is hard to manage or not relieved by ordinary medical intervention (intractable pain) because of bleeding into a joint. This is also true for individuals taking warfarin or heparin, that can bleed spontaneously.

Sings of internal bleeding may take time appear, for example:

• Bleeding from the kidney or bladder may not be recognized until the patient needs to urinate and then the blood is apparent.
• Black tarry stools may indicate bleeding in the stomach or small intestine. (Please note that while a black bowel movement should be concerning, it may also be seen in patients taking iron supplements, Pepto Bismol, or other medications and dietary products).
• Bleeding from an orthopedic injury, usually of the forearm or shin, may cause gradual increase of the pressure within the muscle compartments causing blood supply to the affected area to be compromised. This can lead to intense pain, tingling, numbness, and decreased motion. Compartment syndrome is relatively unusual and does not necessarily occur only with a fracture, since significant contusions can also cause increased pressure formation.
• Blood from a body orifice (mouth, nose, ears, anus, vagina, or urethra) may be a symptom of internal bleeding.

Unfortunately, most of the symptoms of internal bleeding can occur with other medical problems and frequently it takes a doctor to order medical tests to determine the cause of the symptoms listed above.

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