Ministry of Higher Education and Scientific Research

Erbil Polytechnic University

Stage:2
Dep: Physiotherapy Department
Subject: Pathophysiology

Bleeding

Supervised by: Suhaira Abdullah

Prepared by: Group of Students

1-Asma Ibrahim

2-Ahmad Nizar

3-Shukriya Eirfan

4-Muhammad Nahro

2020-2021
Preface

First of all, we would like to express our gratitude to Allah enabling us to complete
Our Report.

In order to gain more knowledge in the field of “Pathophysiology”. We are required to

make a report on ‘’Bleeding’’. The basic objective behind doing this report is to get
knowledge of Bleeding and Types of it.

In this report we have included a brief about introduction of ‘Bleeding, Bleeding

disorders, Types of Bleeding, and Classifications of Bleeding.

Doing this report helped us to enhance our knowledge about Bleeding and Different
Types& classes of Bleeding.

We doing undergo many experiences related with our topic. Through this report we come
to know about importance of team work and role of devotion towards the work.
Contents

Headings Page Number

Preface

Introduction 1-2

Bleeding 3

Classes of Bleeding 3-4

Internal and External Bleeding 4-9

Brain Bleeds 9-10

Conclusion 11-12

References 13
Introduction
The body possesses innate mechanisms to control bleeding in the setting of an injury. An
understanding of these basic physiologic processes is critical to aid in the identification and diagnosis
of bleeding disorders. The hemostatic system is responsible for maintaining blood in a fluid state,
free of the aggregation of platelets and thrombus formation with the help of *There are two types of
prostacyclin, antithrombin III and nitric oxide within the endothelial cells. These problems:
-Your blood may not form
naturally occurring substances found in the blood assist in the prevention of clots
clots normally, known as
by causing conversion of plasminogen to plasmin to promote a bleeding disorder. This
happens when your body
fibrinolysis. Damage or injury to the endothelium will initiate a cascade of events
does not make enough
in an attempt to control bleeding. Disruption of the endothelium will first cause platelets or clotting factors,
or they don't work the way
local vasoconstriction to occur, limiting blood flow to the area. Primary
they should.
hemostasis initiates by platelets with the release of von Willebrand factor (vWF),
-Your blood may make too
a large plasma glycoprotein made and stored in endothelial cells and many clots, or the clots may
megakaryocytes. Platelets and vWF will combine to form a plug at the site of not dissolve properly

injury. Circulating vWF continues to bind with collagen and Factor VIII as well
as other endothelial substances, allowing the platelet plug to adhere to the area of
injury.[1] Through activation of the clotting cascade (see image) and secondary hemostasis, this initial
platelet plug will get reinforced to a sturdy fibrin clot. The clotting cascade operates through a dual
process system in which the various clotting factors become activated with the result being the
formation of a fibrin strand or clot at the site of tissue injury. A deficiency of any of the essential
clotting factors will result in difficulty forming a fibrin clot, and excessive bleeding can occur.

Bleeding disorders fall into two main categories: inherited and acquired. Inherited bleeding disorders
have a genetic predisposition and involve a deficiency of coagulation factors. Acquired bleeding
disorders can be caused by conditions that an individual may develop at any point during their
lifetime. These can be broader in range and dependent on comorbid conditions. The focus of this
discussion will be on congenital coagulopathies; acquired bleeding disorders will be considered to be
outside the scope of the information presented here.
Bleeding disorders may present in correlation with their severity, and some may be undetected until a
major trauma or surgery occur. Patients with a severe form of hemophilia In hemophilia, categorized
as less than 1% of normal plasma levels, will often present with 20 to 30 episodes of epistaxis a year,
excessive bleeding after minor traumas or into muscles and joints (hemarthrosis). Diagnosis usually

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occurs within the first two years of life and can be immediately evident after circumcision. Newborns
can also present with intracranial hemorrhages, cephalohematoma or umbilical cord bleeding
immediately following delivery. Those with a more moderate form of the disease (6 to 30% of normal
levels) may only bleed excessively after surgery or a major trauma.
Von Willebrand factor (vWF) is a glycoprotein produced in endothelial cells and megakaryocytes that
is responsible for facilitating platelet binding after injury of the endothelial surface occurs. Von
Willebrand disease is a common congenital bleeding disorder in which there is a deficiency or
dysfunction of vWF. Factor VIII levels can be affected as well. The disease presents similarly to that
of a platelet abnormality and can exhibit variable clinical symptomatology from mild mucocutaneous
bleeding of the nose or gingiva or menorrhagia to hemarthrosis in more severe cases. The disease
categorized into three types. Type I is the most common, representing 60 to 80% of cases. Type 1
von Willebrand disease is a heterozygous deficiency in which there may be only 20% to 40% of
normal levels of vWF in addition to a reduction in Factor VIII levels. Patients with Type I von
Willebrand disease can present with mild clinical symptoms like a propensity for easy bruising,
mucosal bleeding or menorrhagia. Medications which inhibit prostaglandin and thromboxane synthesis
may significantly exacerbate symptoms and can often aid in initial diagnosis. Type II von Willebrand
disease is less common, representing approximately 17% of the reported cases, and is characterized by
a qualitatively abnormal vWF which can also be associated with thrombocytopenia and decreased
Factor VIII. There are four distinct subtypes within the Type 2 category. Type 2A lacks a normal
vWF multimer because of abnormal proteolysis or reduced secretion of the factor. Type 2B is a
mutation which causes the vWF to be hyperactive and have an increased binding affinity to platelets
causing the creation of complexes which are quickly cleared from the circulation, ultimately resulting
in thrombocytopenia. Type 2M possesses a decreased platelet binding ability to vWF with depleted
factor levels, and Type 2N exhibits a decrease in binding of vWF to Factor VIII. Type III is the rarest
and the most severe form of the disease representing approximately 3% of the cases, where there are
markedly diminished levels of vWF and FVIII.

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Bleeding
Bleeding, also known as a hemorrhage, hemorrhage, or simply blood loss,
is blood escaping from the circulatory system from damaged blood vessels.

A bleeding wound in the

finger

Classes of Bleeding
Recognizing the degree of blood loss via vital sign and mental status abnormalities is important.
The American College of Surgeons Advanced Trauma Life Support (ATLS) hemorrhagic shock
classification links the amount of blood loss to expected physiologic responses in a healthy 70 kg
patient. As total circulating blood volume accounts for approximately 7% of total body weight, this
equals approximately five liters in the average 70 kg male patient.

• Class 1: Volume loss up to 15% of total blood volume, approximately 750 mL. Heart rate is
minimally elevated or normal. Typically, there is no change in blood pressure, pulse pressure,
or respiratory rate.

• Class 2: Volume loss from 15% to 30% of total blood volume, from 750 mL to 1500 mL.
Heart rate and respiratory rate become elevated (100 BPM to 120 BPM, 20 RR to 24 RR).
Pulse pressure begins to narrow, but systolic blood pressure may be unchanged to slightly
decreased.

• Class 3: Volume loss from 30% to 40% of total blood volume, from 1500 mL to 2000 mL. A
significant drop in blood pressure and changes in mental status occur. Heart rate and
respiratory rate are significantly elevated (more than 120 BPM). Urine output declines.
Capillary refill is delayed.

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 • Class 4: Volume loss over 40% of total blood volume. Hypotension with narrow
pulse pressure (less than 25 mmHg). Tachycardia becomes more pronounced (more than 120
BPM), and mental status becomes increasingly altered. Urine output is minimal or absent.
Capillary refill is delayed.

Again, the above is outlined for a healthy 70 kg individual. Clinical factors must be taken into account
when assessing patients. For example, elderly patients taking beta blockers can alter the patient’s
physiologic response to decreased blood volume by inhibiting mechanism to increase heart rate. As
another, patients with baseline hypertension may be functionally hypotensive with a systolic blood
pressure of 110 mmHg.

Internal and External Bleeding

External Bleeding
External bleeding is when blood is leaving the body through some type of wound. Any incident in
which you physically saw blood would be an external bleed. Our circulatory system is
*bleeding can be
made up of our heart pumping blood through arteries to deliver oxygenated blood to external, or outside the
body, like when you get
tiny capillaries that distribute the blood to all of our tissues. Our veins collect the blood
a cut or wound. It can
from the capillaries and return the un-oxygenated blood back to our heart. also be internal, or
inside the body, like
The blood vessels that make up our circulatory system come in all shapes and sizes. when you have an
injury to an
Arteries and veins range from large to small depending on the area of the body. By
internal organ.
looking at the picture of our circulatory system, you can understand why some injuries
may bleed more heavily than others.

External Bleeding Types

There are three types of external bleeding that are categorized by which blood vessel is damaged.
These include capillary, venous, and arterial bleeding.

1. Capillary Bleeding

John is playing catch with his buddy in the street. As John runs to catch the ball,
he twists his ankle and falls to the ground. He stops his fall with his hands and
feels the sting of pain immediately. He looks at his palms. He has scraped them

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all up on the pavement of the road. They are filled with dirt and small rocks. Blood is slowly oozing
from the wounds.

John experienced capillary bleeding. The abrasions he obtained to his palms were not deep injuries and
only damaged the tiny capillaries in his palms. Capillary bleeding is the most common type of
bleeding. It's a minor injury in which the blood vessels are able to clot and stop the bleeding by
themselves.

2. Venous Bleeding

Suzie was preparing dinner for her family. She was cutting up vegetables for a
salad when suddenly she sliced into the top of her thumb. Immediately blood
was steadily flowing from her thumb, and the shock from seeing red blood was
alarming. Suzie acted quickly and grabbed a paper towel to apply pressure to her
thumb.

Venous bleeding occurs when a vein is damaged. In this type of bleeding, the blood flows steadily. If
it's a large vein, the bleeding may actually be gushing. When a vein is cut, most veins will collapse,
which helps to slow the bleeding. If it's a deep vein such as an iliac vein, the bleed can be just as
difficult to control as an arterial bleed. But in most venous bleeding, applying pressure and allowing the
body to clot will stop the bleeding.

3. Arterial Bleeding

Phillip was building a deck for his backyard. He had a new wood saw that he
was trying out. While he was cutting a piece of wood, something went wrong.
Before he knew it, he realized he had cut his arm right above the wrist. Blood
was shooting out in spurts and in large amounts. He felt panicked, but he acted
promptly by hollering for help. His wife rushed out to apply a towel firmly to the wound while calling
911.

Arterial bleeding is the most serious type of bleeding. Since arteries are carrying oxygenated blood
that is being pumped from the heart, the blood will spurt out in the rhythm of the heart beating. Due to
the pressure from the heart continuing to pump the blood, large amounts of blood can quickly be lost.
It's unlikely that an arterial bleed will clot. It's essential to apply firm pressure to slow down the
bleeding.

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Most Common Causes of External Bleeding
The most common cause of external bleeding is some type of trauma to the body. It can be either a
minor or a major trauma. For example:

Four-year-old Hannah was running on the sidewalk when she tripped and caught herself with her
hands. She obtained abrasions to her palms that were bleeding a small amount. Hannah experienced
capillary bleeding.

Twenty-year-old Jimmy was out shooting his new gun with his buddies. The gun jammed and while he
was trying to fix it, he shot himself in the foot. Due to the extent of damage the bullet caused; Jimmy
experienced arterial bleeding.

Sarah and her family were driving to a movie one Saturday evening. As she was turning, a car ran a red
light and slammed into the side of her vehicle. The impact crushed the car in and broke her left arm,
causing the bone to stick out of her skin. Her daughter in the passenger seat hit her head on the window
and had bleeding from the injury. This type of injury could be arterial or venous bleeding depending on
which blood vessels were damaged.

Wesley was fixing dinner and slicing meat for a stew. The knife was dull so he found himself using
more pressure and he accidentally cut his finger. Wesley experienced venous bleeding.

All of these examples resulted in external bleeding. The most common cause of external bleeding is
some type of trauma that causes an open wound and cuts blood vessels, resulting in bleeding.

Other Causes of External Bleeding

There are some less likely causes of external bleeding as well. Certain medical conditions will increase
the likelihood of having external bleeding. They don't cause the bleeding itself, but place you at higher
risk of bleeding, even with only minor injuries. Hemophilia is a bleeding disorder that affects your
body's ability to clot to stop bleeding. If you have a bleed, it will take much longer to stop the bleeding.

Leukemia is a cancer that affects your blood cells. Platelets are a blood cell that is important in
helping your body to clot when there is a bleed. With leukemia, you have a low number of platelets.

6
So, if you have some type of injury that bleeds, it will be difficult to stop the bleeding. Something as
simple as brushing your teeth, may result in excessive bleeding.

Any other medical condition that causes low platelet levels or affects the clotting process will have the
same effect. This includes thrombocytopenia, vitamin K deficiency, or liver disease, as well as
others.

Internal Bleeding
Internal bleeding refers to a situation where the person's blood escapes the blood vessels (veins and
arteries) but remains within the body. In short, it's blood loss inside the body.

That isn't to say that the blood that is accumulating somewhere within the body will never make it out
of the body, since it can in some situations. But the blood loss definitely begins with the blood escaping
the vasculature and pooling somewhere inside first.

Internal bleeding is more properly called internal hemorrhage. This is because 'hemo-' refers to
blood and '-rrhage' refers to the excessive flow of something.

Causes of Internal Bleeding

What could possibly cause this to happen? There are numerous possibilities. Here's just a few of them:

Jack was recently in a serious car accident that damaged his internal blood vessels. Major
physical trauma is thus one potential cause of internal bleeding.

Amy has cancer and some types of cancer can invade or spread to blood vessels and cause internal
bleeding.

Jill has been taking large doses of nonsteroidal anti-inflammatory drugs for her joint pain. The
problem? This can damage the digestive tract and cause bleeding into the digestive system. So,
some medications may predispose to internal bleeding. Another good example of this is a blood-
thinning medication, such as warfarin.

Cody has numerous cardiovascular problems, such as long-standing high blood pressure. His heart
and blood vessels disorders have weakened his blood vessels, and made it more likely that they will
dilate and potentially burst.

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Serious damage to the liver, leading to liver failure or cirrhosis, can also predispose to internal
bleeding. One reason for this is the fact that the liver is responsible for the manufacture of many
clotting factors that help your blood clot. Things that can lead to serious liver problems like this include
viral infections and alcohol abuse.

Signs and Symptoms

The signs and symptoms of internal bleeding will vary depending on the cause, location, severity, and
duration of blood loss. Here are some examples:

Let's say someone has a case of hemorrhagic stroke. This is a kind of stroke where a blood vessel in the
brain ruptures and bleeds out into the brain. This can cause everything from an extremely bad
headache to confusion to loss of consciousness.

Or consider the following scenario. Someone takes medications called NSAIDs, which can lead to
ulceration of the digestive tract. An ulcer is like a sore. Bleeding ulcers will cause blood to escape the
lining of the digestive tract. This could lead to serious pain, blood in the vomit or stool, and even
anemia.

What if someone just had major surgery? For numerous different reasons, surgery poses a risk of
internal bleeding even after the procedure has been completed. One possible cause is that the surgeon
simply missed 'closing up' a blood vessel that was severed during a procedure. Over a relatively short
period, this can lead to confusion, paleness, and a fast heart rate as signs of shock set it.

How about cancer? Cancer in the urinary tract can cause blood in a person's urine, another sign of
possible internal hemorrhage. Trauma to the skin can result in bruising, technically a kind of internal
bleeding as well.

The signs and symptoms you just learned about were not case-specific. They sometimes overlap
between various causes. For instance, a person with significant digestive bleeding may not only have
blood in their vomit or stood but also paleness, a fast heart rate, and even loss of consciousness.

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Treatment
The treatments for internal bleeding will have some general considerations applicable to all causes and
then many specific ones which address the specific causes of the internal bleeding itself.

In some minor cases of internal bleeding, there may not be any need for treatment. The doctor may
simply observe the patient for any worsening signs or symptoms and address them if they arise. In
severe cases of bleeding, a person may need to be given intravenous fluids and even blood transfusions
to correct for abnormalities such as dangerous drops in blood pressure as a result of all that blood loss.

Specific causes of the bleeding will also need to be addressed. A medication may need to be stopped or
switched. Perhaps the person needs emergency surgery to stop the bleeding and repair any damage that
might have occurred. This is all decided on a case by case basis.

Brain Bleeds
Jean has just left the hospital from visiting her nephew, who had been admitted the week before with a
brain bleed. Fortunately, he was able to have surgery and is recovering well. Jean isn't familiar with
bleeding on the brain and goes home to look up some information on it. During her search, she
discovers that bleeding can occur at various places within the head and is named according to the
location of the bleed.

Jean learns that bleeding anywhere in the skull is called

intracranial intracranial
an intracranial hemorrhage. Bleeding within the brain tissue is hemorrhag hemorrhag
e e
referred to as intracerebral hemorrhage. If bleeding occurs between
the brain tissue and the membrane covering of the brain, it is called intracranial
hemorrhag
a subarachnoid hemorrhage. e

Intracerebral
hemorrhage

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A Specific Type of Stroke Can Cause Bleeding in the Brain
Jean seems to recall a friend of the family who had a stroke and was hospitalized for bleeding in the
brain. When Jean looked into information related to strokes, she discovered that about 13% of all
strokes that occur are called hemorrhagic strokes. This is the type of stroke that causes bleeding in the
brain. When one has bleeding from a stroke, the symptoms are frequently the same as the symptoms of
an ischemic stroke, or a stroke that does not involve any bleeding in the brain. Commonly seen
symptoms are weakness on one side of the body, speech difficulty, numbness, or facial drooping.

Symptoms of Sudden Bleeding

Jean remembers when her nephew was first admitted to the hospital with his brain bleed. He was
rushed to the emergency room, complaining of the worst headache he has ever had in his life. Jane
reads that a major symptom of sudden bleeding is a severe headache. The pressure from the bleed can
build quickly and also lead to nausea and vomiting. Jean is thankful they were able to get her nephew
to the emergency room in time. She thinks about how she heard the doctors talking about a blown
pupil, which is when one's pupil becomes dilated (wide), and doesn't constrict (narrow) with exposure
to light. As Jean continues her reading, she realizes that a blown pupil is a very severe sign of brain
bleeding. It indicates the pressure within the head has built so much that it is affecting the eyes.

Others Symptoms of Brain Bleeding

Additional symptoms that can occur with brain bleeding are sleepiness, inability to concentrate, or
losing consciousness altogether. Seizures can be another symptoms of brain bleeding. This usually
occurs when blood touches brain tissue itself and irritates the cells.

Symptoms of Gradual, Slow Bleeding

Jean's nephew experienced a sudden bleed. However, Jean is learning that people can have slow,
gradual bleeding in the brain as well. Sometimes this happens if someone has a closed head injury,
such as a fall. The bleeding is so gradual that one often doesn't show signs of it until two or three
weeks after the injury. People who experience slow brain bleeds usually have dizziness, behavior
changes, confusion, or headaches. It is as important for these people to report to the emergency room
quickly as it is for people who experience sudden bleeds.

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Conclusion
Damage or injury to the endothelium will initiate a cascade of events in an attempt to control
bleeding. Disruption of the endothelium will first cause local vasoconstriction to occur, limiting blood
flow to the area. Primary hemostasis initiates by platelets with the release of von Willebrand factor
(vWF), a large plasma glycoprotein made and stored in endothelial cells and megakaryocytes.

Bleeding, also known as a hemorrhage, hemorrhage, or simply blood loss, is blood escaping from
the circulatory system from damaged blood vessels. Class 1: Volume loss up to 15% of total blood
volume, approximately 750 mL. Heart rate is minimally elevated or normal. Typically, there is no
change in blood pressure, pulse pressure, or respiratory rate. Class 2: Volume loss from 15% to 30% of
total blood volume, from 750 mL to 1500 mL. Heart rate and respiratory rate become elevated
(100 BPM to 120 BPM, 20 RR to 24 RR). Pulse pressure begins to narrow, but systolic blood pressure
may be unchanged to slightly decreased. Class 3: Volume loss from 30% to 40% of total blood volume,
from 1500 mL to 2000 mL. A significant drop in blood pressure and changes in mental status
occur. Heart rate and respiratory rate are significantly elevated (more than 120 BPM). Urine output
declines. Capillary refill is delayed. Class 4: Volume loss over 40% of total blood volume. Hypotension
with narrow pulse pressure (less than 25 mmHg). Tachycardia becomes more pronounced (more than
120 BPM), and mental status becomes increasingly altered. Urine output is minimal or absent.
Capillary refill is delayed.

External bleeding is any type of bleeding that's leaving the body through an open wound.
Our circulatory system is made up of our heart pumping blood through our arteries to systems of
tiny capillaries to deliver oxygen to all of our tissues. Our veins then pick up the blood from the
capillaries and return it to the heart. There are three different types of external bleeding that are based
on which of these blood vessels are affected. Capillary bleeding is the most common type of external
bleeding and the most minor injury. This occurs when capillaries are damaged and bleeding occurs.
This type of bleeding is minor, and the blood vessel is able to clot and stop the bleeding by itself.
Venous bleeding occurs when a vein is damaged. In this type of bleeding, the blood loss flows at a
steady pace. When a vein is cut, it will usually collapse, which aids in slowing the bleeding. Some
veins are larger than others. If a large vein is cut, the bleed can be very difficult to stop. Arterial
bleeding occurs when an artery is cut. This is the most serious type of external bleeding. Since the heart
is pumping blood through the arteries, the blood will rhythmically spurt in large amounts from the

11
wound. This type of injury is unlikely to clot due to the pumping pressure. It's absolutely vital to apply
firm pressure to this type of wound and to get medical help. internal bleeding or internal hemorrhage,
refers to bleeding inside of the body. The signs and symptoms of the internal bleeding may vary
depending upon the exact cause of the bleeding, and they include: Headache, Pain in the abdomen,
confusion, Loss of consciousness, Paleness, A fast heart rate, Blood in the vomit, stool, or urine. The
exact treatment is decided on a case by cases basis. Medication may need to be stopped or switched.
Surgery to stop the bleeding may be necessary. Intravenous fluids or blood transfusions might need to
be performed.

external bleeding is blood leaving the body through an open wound. There are three types of external
bleeding based on which blood vessel is affected. Capillary bleeding is the most common and is
considered a minor injury. Venous bleeding has steady bleeding; if a deep vein is damaged it can be
more difficult to control the bleeding. Arterial bleeding is the most serious type of bleeding as it results
in large amounts of blood loss. The most common cause of external bleeding is from some type of
trauma that damages the blood vessels. This includes cuts, abrasions, gunshot wounds, crushing
wounds, and puncture wounds, as well as many other causes. Less common causes of external bleeding
include different medical conditions. These medical conditions don't necessarily cause the bleeding, but
if an injury occurs, the bleed will be more significant and more difficult to stop. Such conditions
include hemophilia, which is a bleeding disorder that affects the body's ability to clot. Leukemia is a
cancer of the blood cells that results in low levels of platelets. Without enough platelets, it is difficult
for the body to clot to stop bleeding. Any disorder that affects the clotting process can have this same
effect.

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References

✓ https://europepmc.org/article/med/31082094
✓ https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bleeding
✓ https://study.com/academy/lesson/external-bleeding-definition-types.html
✓ https://helptown.ch/en/pediatric-emergencies/internal-and-external-bleeding/
✓ https://www.healthline.com/health/bleeding#:~:text=External%20bleeding%20happens%20w
hen%20blood,mouth
✓ https://web.archive.org/web/20110210143239/http://www.healthline.com/adamcontent/ble
eding
✓ https://www.healthline.com/health/bleeding#complications
✓ https://study.com/academy/lesson/what-are-the-most-common-causes-of-external-
bleeding.html
✓ https://study.com/academy/lesson/internal-brain-bleeding-signs-symptoms.html
✓ https://www.ncbi.nlm.nih.gov/books/NBK470382/#:~:text=Class%201%3A%20Volume%20loss
%20up,750%20mL%20to%201500%20mL.
✓ https://study.com/academy/lesson/internal-bleeding-definition-causes.html
✓ https://www.britannica.com/science/hemorrhage

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