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Clinical Procedures & Support Services

Internal Haemorrhage (Surgical Context)

Management principles for severe internal bleeding into a body cavity or space, often requiring urgent surgical intervention to control the source and resuscitation.

Also known as: Internal Bleeding

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Referral and warning signs

When to refer

IMMEDIATE EMERGENCY REFERRAL/TRANSFER to a hospital (RR/H) capable of managing massive haemorrhage, providing blood products, and performing emergency surgery (laparotomy/thoracotomy). Do not delay transfer attempting full stabilization if bleeding is ongoing.**

Red flags

  • Signs of persistent or worsening shock despite initial fluid resuscitation.
  • Known or highly suspected source of major internal bleeding (e.g., ruptured spleen/liver/aorta/ectopic).
  • Massive haemothorax or haemoperitoneum.
  • Penetrating trauma to torso.
  • Unstable pelvic fracture.

Signs and symptoms

  • Signs of Hypovolemic Shock: Tachycardia, Hypotension, Pallor, Cool extremities, Sweating, Altered mental status, Oliguria.
  • Symptoms related to location:
  • - Intra-abdominal: Abdominal pain, distension, guarding, rebound tenderness (if peritoneal irritation).
  • - Intrathoracic (Haemothorax): Dyspnoea, reduced breath sounds, dullness to percussion.
  • - Pelvic: Pelvic pain, instability (fracture).
  • - Retroperitoneal: Back/flank pain, bruising.
  • - Intracranial: Neurological deficits, headache, decreased consciousness.
  • Source may be traumatic (blunt/penetrating) or non-traumatic (ruptured aneurysm, ectopic pregnancy, GI bleed into cavity, tumour erosion).

Risk factors

  • Trauma.
  • Anticoagulant use.
  • Bleeding disorders.
  • Aneurysms.
  • Ectopic pregnancy.
  • Liver/spleen pathology.
  • Post-operative bleeding.

Diagnosis

Clinical assessment

Diagnosis based on clinical signs of shock PLUS evidence or high suspicion of bleeding into a non-compressible space (abdomen, chest, pelvis, retroperitoneum). Identify potential source based on mechanism/history.

Investigations

  • Clinical assessment (ABCDE, vital signs).
  • FAST Scan (Focused Assessment with Sonography for Trauma): Rapid bedside ultrasound to detect free fluid (blood) in pericardium, peritoneum, pleura.
  • Chest X-ray (haemothorax).
  • Pelvic X-ray (fracture).
  • CT Scan (with contrast): More definitive localization of bleeding source in stable patients.
  • Diagnostic Peritoneal Lavage (DPL): Older technique if ultrasound unavailable/equivocal in trauma.
  • Blood tests: FBC (Hb may be normal initially), Group & Cross-match URGENTLY.
  • hCG test (females of reproductive age).

Diagnostic criteria

Clinical signs of haemorrhagic shock with evidence/suspicion of bleeding into a major body cavity.

Management

Non-pharmacological management

  • Simultaneous Resuscitation and Source Control.
  • ABCDE Approach: Secure airway, high-flow oxygen, establish large-bore IV access (x2).
  • Control External Bleeding (if any).
  • Keep Patient Warm.
  • Rapid Transport to Operating Theatre if ongoing haemodynamic instability or identified source requiring surgery.

Pharmacological treatment

  • Fluid Resuscitation: IV Crystalloids (NS/RL) initially, but transition rapidly to blood products.
  • Blood Transfusion: URGENT. Activate Massive Transfusion Protocol if available. Transfuse Packed Red Cells (PRBCs) / Whole Blood (O-negative initially if needed, then group-specific/crossmatched). Aim for balanced resuscitation with FFP and Platelets (e.g., 1:1:1 ratio of PRBC:FFP:Platelets in massive haemorrhage).
  • Tranexamic Acid (TXA): Give early in trauma patients with significant bleeding (e.g., 1g IV over 10 min, then 1g over 8h).
  • Reverse anticoagulation if applicable.
  • Vasopressors (use cautiously, after adequate volume resuscitation).

Surgical Management

  • Damage Control Surgery / Definitive Haemostasis:
  • - Laparotomy / Thoracotomy / Pelvic Packing: To identify and directly control the source of bleeding (ligation, repair, packing, resection e.g., splenectomy).
  • - Focus on stopping major haemorrhage quickly, controlling contamination, temporary closure, then transfer to ICU for further resuscitation before definitive repair ('damage control' principle in severe trauma).

Monitoring

Continuous monitoring of vital signs, urine output, mental status. Monitor Hb, coagulation profile, lactate, acid-base status.

Complications

  • Hypovolemic shock.
  • Cardiac arrest.
  • Organ failure (due to hypoperfusion).
  • Coagulopathy / DIC.
  • Abdominal compartment syndrome.
  • Infection.
  • Death.

Prevention

  • Trauma prevention.
  • Management of conditions predisposing to bleeding (aneurysms, ectopic).
  • Careful anticoagulation management.

Patient education

  • (Usually provided later to patient/family):
  • Explanation of the life-threatening bleeding event.
  • Surgical procedure performed.
  • Need for intensive care / ongoing monitoring.
  • Potential complications and recovery process.

Uganda-specific notes

Trauma (RTA, assault) is a major cause. Ruptured ectopic pregnancy and complications of PPH are also key causes. Access to rapid blood transfusion (including FFP/platelets) and emergency surgery is critical but limited. FAST scan availability is increasing. Damage control principles important.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 24, Section 24.1.2

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.1.2 (Shock Management)

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