I

ntr
oduct
ion
Thet
erm haemor
rhagemeansescapeofbl
oodf
rom t
hebl
oodv
essel
s.
Haemor
rhageorbl
eedi
ngobv
iousl
yimpl
i
esr
upt
ureofabl
oodv
essel
.Rupt
ureofal
arge
ar
ter
yorv
eini
sal
mostal
way
scausedbysomef
orm ofi
njur
y,suchast
rauma,
at
her
oscl
erosi
s,ori
nfl
ammat
oryorneopl
ast
icer
osi
onoft
hev
essel
wal
l
.Ani
ncr
eased
t
endencyofhaemor
rhagei
sencount
eredi
nawi
dev
ari
etyofcl
i
nical
disor
der
sknown
col
l
ect
ivel
yast
hehaemor
rhagi
cdi
atheses.

Ty
pesofhaemor
rhage
Ar
ter
ialhaemor
rhagepr
esent
sasbr
ightr
edbl
ood,
spur
ti
ngasaj
ett
hatr
ises
andf
all
sint
imewi
tht
hepul
se.I
npr
otr
act
edbl
eedi
ng,
andwheni
ntr
avenousf
lui
ds
ot
hert
hanbl
oodar
egi
ven,
itmaybecomewat
eryi
nappear
ance.
Venoushaemor
rhagei
sadar
kerr
ed,
steadyandcopi
ousf
low.Thecol
our
dar
kensst
il
lfur
therf
rom excessi
veoxy
gendesat
urat
ionwhenbl
oodl
ossi
ssev
ere,
ori
n
r
espi
rat
orydepr
essi
onorobst
ruct
ion.Bl
oodl
ossi
spar
ti
cul
arl
yrapi
dwhenl
argev
eins
ar
einj
ured.Venousbl
eedi
ngcanbeunderi
ncr
easedpr
essur
e,asi
nasphy
xia,
orf
rom
r
upt
uredv
ari
cosev
eins.Rapi
dbl
oodl
ossmayal
sooccuri
npor
tal
hyper
tensi
onwi
th
oesophageal
var
ices.
Capi
ll
aryhaemor
rhagei
sar
api
d,br
ightr
edooze.Al
thoughl
esssev
ere,
thebl
ood
l
osscanbecomeser
iousi
fcont
inuedf
ormanyhour
s,asi
nhaemophi
l
ia.
Pr
imar
yhaemor
rhageoccur
satt
het
imeofi
njur
yoroper
ati
on.
React
ionar
yhaemor
rhagemayf
oll
owpr
imar
yhaemor
rhagewi
thi
n24hour
s
(
usual
l
y4-
6hour
s)andi
smai
nlyduet
osl
i
ppi
ngofal
i
gat
ure,
disl
odgementofacl
ot,
or
cessat
ionofr
efl
exv
asospasm.Thepr
eci
pit
ati
ngci
rcumst
ancesar
e(a)ar
isei
nbl
ood
pr
essur
eandt
her
efi
l
li
ngofv
enoussy
stem onr
ecov
eryf
rom shockand(
b)
r
est
lessnessandact
swhi
chr
aisev
enouspr
essur
e(coughi
ngandv
omi
ti
ngaf
ter
t
hyr
oidect
omymaycauser
eact
ionar
yhaemor
rhagewi
thi
naf
ewhour
s)
Secondar
yhaemor
rhageoccur
saf
ter7-
14day
s,andi
sduet
oinf
ect
ionand
sl
oughi
ngofpar
toft
hewal
lofanar
ter
y.Pr
edi
sposi
ngf
act
orsar
epr
essur
eofa
dr
ainaget
ube,
afr
agmentofbone,
ali
gat
urei
nani
nfect
edar
ea,
orcancer
.Iti
sal
soa
compl
i
cat
ionofar
ter
ial
sur
ger
yandamput
ati
ons.I
tisher
aldedby‘
war
ning’
haemor
rhages,
whi
char
ebr
ightr
edst
ainsont
hedr
essi
ng,
fol
l
owedbyasuddensev
ere
haemor
rhage,
whi
chmaybef
atal
.
Ext
ernalhaemor
rhagei
scl
i
nical
l
yvi
sibl
e(r
eveal
ed)haemor
rhage.
I
nter
nalhaemor
rhagei
sinv
isi
ble(
conceal
ed)haemor
rhage.Thebl
eedi
ngmaybe
conceal
edi
nrupt
uredspl
eenorl
i
ver
,fr
act
uredf
emur
,rupt
uredect
opi
cgest
ati
on,
ori
n
cer
ebr
alhaemor
rhage.Theconceal
edhaemor
rhagemaybecomer
eveal
edasi
n
haemat
emesi
sormal
aenaf
rom abl
eedi
ngpept
icul
cer
,asi
nhaemat
uri
afr
om a
r
upt
uredki
dney
,orv
iat
hev
agi
nai
nacci
dent
alut
eri
nehaemor
rhageofpr
egnancy
.
Whent
hebl
oodi
str
appedwi
thi
nthet
issuesoft
hebody
,theaccumul
ati
oni
s
r
efer
r oasahaemat
edt oma.Whent
hebl
oodaccumul
atesi
noneoft
hebodycav
iti
es,
it
i
sref
err oashaemot
edt hor
ax,
haemoper
icar
dium,
haemoper
it
oneum orhaemar
thr
osi
s.
Mi
nut
ehaemor
rhagesi
ntot
heski
n,mucousmembr
anesorser
osal
sur
facesar
eknown
aspet
echi
ae.Sl
i
ght
lyl
argerhaemor
rhagesar
edesi ed pur
gnat pur
a.Al
arger
subcut
aneoushaemat
oma(
over
1to2cm i
ndi
amet
er)i edanecchy
scal
l mosi
s.
Chr
oni
chaemor
rhageoccur
sincasesofhaemor
rhoi
ds,
fibr
oids,
car
cinomasand
pept
icul
cer
.Ther
eisnodi
minut
ionofbl
oodv
olumeast
her
eist
imef
orpl
asma
r
epl
acement
,butr
edcel
lrepl
acementl
agsbehi
ndr
esul
ti
ngi
nast
ateofanaemi
c
hy
poxi
a(mi
crocy
tichy
pochr
omi
c),
requi
ri
ngani
ncr
easedcar
diacout
put
.These
pat
ient
sdev
elophi
ghout
putcar
diacf
ail
ure;
theymustnotbet
ransf
usedwi
thwhol
e
bl
ood,
butr
equi
repackedcel
l
sinst
ead.

Nor
malhaemost
asi
s

Haemost
asi
sisacompl
expr
ocesst
hatpr
event
sort
ermi
nat
esbl
oodl
ossf
rom

i
ntr
avascul
arspace,
prov
idesaf
ibr
innet
wor
kfort
issuer
epai
r,andul
ti
mat
ely
,remov
es

t
hef
ibr
inwheni
tisnol
ongerneeded.Fourmaj
orphy
siol
ogi
cev
ent
spar
ti
cipat
e,bot
hin
sequenceandi
nter
dependent
ly,
int
hehemost
ati
cpr
ocess.

1.Vascul
arconst
ri
cti
on

Adher
enceofendot
hel
i
alcel
l
stoadj
acentendot
hel
i
alcel
l
smaybesuf
fi
cientt
o

causecessat
ionofbl
oodl
ossf
rom t
hei
ntr
avascul
arspace.Vasoconst
ri
cti
oni
sthe

i
nit
ial
vascul
arr
esponset
oinj
uryev
enatt
hecapi
l
lar
ylev
el.Thi
soccur
spr
iort
opl
atel
et

adhesi
on.Thev
ascul
arr
esponsef
act
oral
soi
ncl
udest
hecont
ri
but
ionofpr
essur
e

pr
ovi
dedbyt
hesur
roundi
ngt
issues.

2.Pl
atel
etf
unct
ion

Pl
atel
etsar
e2μm di
amet
erf
ragment
sofmegakar
yocy
tesnumber
ing200,
000t
o

400, mm3i
000/ nci
rcul
ati
ngbl
ood.Theydonotnor
mal
l
yadher
etoeachot
her
.Inj
uryt
o

t
hei
nti
maexposessubendot
hel
i
alcol
l
agent
owhi
chpl
atel
etsadher
ewi
thi
n16seconds

oft
het
raumat
icev
ent
.Theyt
henexpandanddev
eloppseudopodal
processesandal
so

i
nit
iat
ear
eleaser
eact
iont
hatr
ecr
uit
sot
herpl
atel
etsf
rom t
hesur
roundi
ngbl
ood.Thus

al
oosepl
atel
etaggr
egat
efor
ms,
seal
i
ngt
hedi
srupt
edbl
oodv
essel
.

3.Coagul
ati
on

Thi
sist
hepr
ocessbywhi
chpr
othr
ombi
nisconv
ert
edi
ntot
hepr
oteol
yti
c

enzy
met
hrombi
n,whi
ch,
int
urn,
cleav
est
hef
ibr
inogenmol
ecul
etof
ormi
nsol
ubl
efi
bri
n

i
nor
dert
ost
abi
l
iseandaddt
othepl
atel
etpl
ug.Coagul
ati
onconsi
stsofaser
iesof

zy
mogensact
ivat
ionst
agesi
nwhi
chci
rcul
ati
ngpr
o-enzy
mesar
econv
ert
edi
n

sequencet
oact
ivepr
oteases.Thecl
ott
ingsy
stem f
oll
owst
wopat
hway
s-t
hei
ntr
insi
c

pat
hwayt
hati
nvol
vescomponent
snor
mal
l
ypr
esenti
nthebl
ood,
andext
ri
nsi
cpat
hway
t
hati
sini
ti
atedbyt
issuel
i
popr
otei
n.

4. Fi
bri
nol
ysi
s

Thi
sisanat
ural
processdi
rect
edatmai
ntai
ningt
hepat
encyofbl
oodv
essel
sby

l
ysi
soff
ibr
indeposi
ts.Thi
sisdependentupont
heenzy
me,
plasmi
n,whi
chi
sder
ived

f
rom apr
ecur
sorpl
asmapr
otei
ncal
l
edpl
asmi
nogens.
 Hemor
rhagi
cdi
sor
der
s
Thesei
ncl
udet
hosecondi
ti
onsi
nwhi
cht
her
eisabnor
mal
haemor
rhageduet
o
absenceordef
ect
sofpl
atel
etsorcl
ott
ingf
act
orsandsomespeci
fi
cpat
hol
ogi
c
condi
ti
ons.Theyhaemor
rhagi
cdi
sor
der
smaybebasi
cal
l
ydi
vi
dedi
nto(
a)congeni
tal
and(
b)acqui
redhemost
ati
cdef
ect
s.

Congeni
talhaemost
ati
cdef
ect
s
1.Pl
atel
etdef
ici
enci
esi
ncl
udi
ngv
onWi
l
lebr
and’
sdi
sease,
Ber
nar
d-Soul
i
ersy
ndr
ome,
Gl
anzmann’
sthr
ombast
heni
aandcongeni
tal
pri
mar
yrel
easedef
ect
s.
2.Congeni
tal
def
ect
sofcoagul
ati
onf
act
ors
a)Fact
orVI
IIdef
ici
ency(
classi
cal
haemophi
l
ia)
b)Fact
orI
Xdef
ici
ency(
Chr
ist
masdi
sease)
c)v
onWi
l
lebr
and’
sdi
sease
d)Fact
orXI(
PTA)def
ici
ency(
Rosent
hal
’
ssy
ndr
ome)
e)Fact
orV(
Proaccel
eri
n)def
ici
ency(
Par
ahaemophi
l
ia)
f
) Fact
orVI
I(Pr
oconv
ert
in)def
ici
ency
g)Fact
orX(
Stuar
t-
Prower
)def
ici
ency
h)I
nher
it
edhy
popr
othr
ombi
nemi
a(Fact
orI
Idef
ici
ency
)
i
)Inher
it
edf
ibr
inogenabnor
mal
i
ties
j
) Congeni
tal
Fact
orXI
IIdef
ici
ency

Acqui
redhemost
ati
cdef
ect
s
1.Pl
atel
etabnor
mal
i
tiesi
ncl
udi
ngi
diopat
hict
hrombocy
topeni
cpur
pur
a(I
TP)
,
t
hrombot
ict
hrombocy
topeni
cpur
pur
a,sy
stemi
clupuser
ythemet
osus(
SLE)
2.Acqui
redhy
pof
ibr
inogenemi
a
a)Def
ibr
inat
ionsy
ndr
ome/consumpt
ivecoagul
opat
hy/DI
C
b)Fi
bri
nol
ysi
s
3.My
elopr
oli
fer
ati
vedi
seases
a)Pol
ycy
themi
aver
a
b)My
eloi
dmet
apl
asi
a
4.Ant
icoagul
antt
her
apy
 Test
sofhemost
asi
sandbl
oodcoagul
ati
on
Themosti
mpor
tantassessmentofhemost
asi
sisacar
eful
hist
oryandphy
sical
exami
nat
ion.Cer
tai
nlabor
ator
ytest
sar
ehel
pful
inassessi
ngapat
ientasasur
gical
risk
f
orhaemor
rhage.

Pl
atel
etcount

Thi
sisacr
it
ical
scr
eeni
ngt
estsi
ncet
hrombocy
topeni
aist
hemost
commonabnor
mal
i
tyofhemost
asi
sint
hesur
gical
pat
ient
.Thenor
mal
plat
eletcounti
s
300+50x103/
mm3.Butt
hev
alueof60,
000t
o70, mm3ar
000/ eusual
l
ysuf
fi
cientt
o
pr
ovi
deadequat
ehemost
asi
sfol
l
owi
ngt
raumaorsur
gical
procedur
esi
fot
her
hemost
ati
cfact
orsar
enor
mal
.

Bl
eedi
ngt
ime

Thi
sassessesbot
hthei
nter
act
ionbet
weenpl
atel
etsandadamagedbl
ood
v
essel
andt
hef
ormat
ionofapl
atel
etpl
ug.Bl
eedi
ngt
imemaybeabnor
mal
in
t
hrombocy
topeni
a,qual
i
tat
ivepl
atel
etdef
ect
s,v
onWi
l
lebr
and’
sdi
seaseandal
soi
n
somepat
ient
swi
thf
act
orVdef
ici
encyorhy
pof
ibr
inogenemi
a.Thenor
mal
val
uesv
ary
dependi
ngont
het
echni
queempl
oyed.TheDuke’
sbl
eedi
ngt
imeshoul
dnotexceed3½
mi
nut
es.TheI
vymet
hodhasanupperl
i
mitof5mi
nut
es.

Pr
othr
ombi
nti
me

Thi
stestmeasur
est
hespeedoft
heev
ent
sint
heext
ri
nsi
cpat
hwayofbl
ood
coagul
ati
on.At
issuesour
ceofpr
ocoagul
anti
saddedwi
thcal
cium t
oanal
i
quotof
ci
tr
atedpl
asmaandt
hecl
ott
ingt
imedet
ermi
ned.Thel
abor
ator
yshoul
dest
abl
i
sh
nor
mal
dil
uti
oncur
vesandnor
mal
val
uesdai
l
y.ThePTwi
l
lbepr
olongedi
nthe
pr
esenceofev
enmi
nut
eamount
sofhepar
in.Thet
estdet
ect
sdef
ici
enci
esoff
act
orI
I,
V,
VII
,Xandf
ibr
inogen.Theone-
stagePTi
sthepr
efer
redmet
hodofassessi
ng
ant
icoagul
ati
onwi
thcoumar
inandi
ndanedi
onedr
ugs.
Par
ti
alt
hrombopl
ast
int
ime

Thi
sisascr
eeni
ngt
estf
ort
hei
ntr
insi
ccl
ott
ingpat
hway
.Iti
ssensi
ti
vet
othe
l
evel
soff
act
orsVI
II
,I
X,XIandXI
I,
aswel
last
hef
act
orsnor
mal
l
ydet
ect
edbyt
heone-
st
agePT.Ther
angeofnor
mal
fort
hist
estv
ari
eswi
tht
hepr
oductused.ThePTT,
when
usedi
nconj
unct
ionwi
thone-
stagePT,
canhel
ptopl
aceacl
ott
ingdef
ecti
nthef
ir
stor
secondst
ageoft
hecl
ott
ingpr
ocess.

Thr
ombi
nti
me

Thi
stestdet
ect
squal
i
tat
iveabnor
mal
i
tiesi
nfi
bri
nogen,
cir
cul
ati
ng
ant
icoagul
ant
sandi
nhi
bit
orsoff
ibr
inpol
ymer
isat
ion.Thecl
ott
ingt
imeoft
hei
s
measur
edf
oll
owi
ngt
headdi
ti
onofast
andar
damountoft
hrombi
ntoaf
ixedv
olumeof
pl
asma.Cont
rol
sofnor
mal
plasmamustber
uni
npar
all
el.Fai
l
ureoft
hecl
ott
ofor
m,i
s
consi
stentwi
thsev
eredi
minut
ionoff
ibr
inogen.

Test
soff
ibr
inol
ysi
s

Fi
bri
ndegr
adat
ionpr
oduct
scanbemeasur
edbyi
mmunol
ogi
cmet
hods.The
pl
asmapr
otami
nepar
acoagul
ati
ont
estspeci
fi
cal
l
ydet
ermi
nesf
ibr
inmonomer
s,t
he
ear
lypr
esenceofwhi
chi
sasi
gnofabnor
mal
ear
lyf
ibr
inol
ysi
s.The
t
hromboel
ast
ogr
am i
sagr
aphi
crepr
esent
ati
onofcl
ott
ingobt
ainedbyempl
oyi
nga
speci
ali
nst
rument
.
 Feat
uresandmeasur
ementofacut
ebl
oodl
oss
Thesi
gni
fi
canceofhaemor
rhagedependsont
hev
olumeofbl
oodl
oss,
ther
ate
ofl
oss,
andt
hesi
teofhaemor
rhage.Suddenl
ossesofupt
o20%oft
hebl
oodv
olume
orsl
owl
ossesofev
engr
eat
eramount
smayhav
eli
tt
lecl
i
nical
signi
fi
cance.Lar
geror
mor
eacut
elossesmayi
nducehaemor
rhagi
c(hy
pov
olemi
c)shock.Thesi
teof
haemor
rhagei
sal
soi
mpor
tant–ahaemor
rhaget
hatwoul
dbet
ri
vi
ali
nthe
subcut
aneoust
issuesmaycausedeat
hwhenl
ocat
edi
nthebr
ainst
em.
Besi
desv
isi
blebl
oodl
oss,
thesi
gnsofcont
inui
ngacut
ebl
oodl
ossi
ncl
ude
i
ncr
easi
ngpal
l
or,
incr
easi
ngpul
ser
ate,
rest
lessnessandi
npr
otr
act
edbl
eedi
ng,
deep
i
nspi
rat
ionswi
thi
ndr
awi
ngoft
heal
anasae.Thesear
eaccompani
edbyacol
dand
cl
ammyski
n,empt
yvei
nsandl
aterby t
hir
st,
tinni
tusandbl
i
ndness,
ast
hesubj
ect
goesdeeperi
ntoshock.

Pul
ser
ate,
bloodpr
essur
eandpul
sepr
essur
e

I
tisessent
ial
tocont
inual
l
ymoni
torabl
eedi
ngpat
ient
.Gener
all
y,l
ossofbl
ood
f
rom t
hev
ascul
arcompar
tmenti
sassoci
atedwi
tht
achy
car
dia.Af
all
ofpr
essur
eint
he
v
essel
sresul
tsi
nexci
tat
ionoft
hesy
mpat
het
icsy
stem andi
nhi
bit
ionof
par
asy
mpat
het
icsy
stem,
causi
ngani
ncr
easei
nhear
trat
e.Butt
hedegr
eeofl
ossof
i
ntr
avascul
arv
olumeandt
heamountofr
educt
ionofv
enousr
etur
ninf
luencest
his
ef
fect
.Inf
act
,insl
owhaemor
rhagei
not
her
wiseheal
thyi
ndi
vi
dual
s,bl
oodl
ossl
ess
t
han1000ml
wil
lnotpr
oducesi
gni
fi
cantchangei
npul
ser
ate.Lat
er,
aft
ert
hegener
al
condi
ti
onoft
hepat
ienti
sst
abi
l
ised,
changesi
npul
ser
atemaybeofuset
oassess
r
esponset
ovol
umet
her
apy
.
Ar
ter
ial
bloodpr
essur
eisnor
mal
l
ymai
ntai
nedbyt
hecar
diacout
putand
per
ipher
alr
esi
stance.Thus,
whent
hecar
diacout
puti
sreducedbecauseofl
ossof
i
ntr
avascul
arv
olume,
thebl
oodpr
essur
emayr
emai
nnor
mal
asl
ongast
het
otal
per
ipher
alr
esi
stancecanbei
ncr
easedt
ocompensat
efort
her
educt
ioni
nbl
oodv
olume.
Butast
hequant
it
yofbl
oodl
ossi
ncr
eases,
reduct
ioni
ncar
diacout
putbecomesso
gr
eatt
hatt
headapt
ivehomeost
ati
cmechani
smscannol
ongercompensat
efort
he
r
educedv
olume.Thent
her
eisapr
ogr
essi
vehy
pot
ensi
on.
Thepul
sepr
essur
e(sy
stol
i
cmi
nusdi
ast
oli
c)i
sameasur
eoft
hest
rokev
olume
oft
hel
efthear
t.I
fthepul
ser
atei
snoti
ncr
eased,
andt
hepul
sepr
essur
eisl
ow,
it
i
ndi
cat
est
hatt
hecar
diacout
puti
sreduced.Thepul
sepr
essur
eisagoodi
ndi
cat
orof
assessmentoff
lui
dlossf
rom t
hev
ascul
arcompar
tment
.

Ur
ineout
put

Ur
ineout
putshoul
dber
ecor
dedi
nthemanagementofal
lpat
ient
ssuf
fer
ingf
rom
haemor
rhageandshock.I
tisani
ndi
cat
orofr
enal
bloodf
low,
whi
chi
sdet
ermi
nedby
t
hecar
diacout
put
.Theki
dneyi
squi
tesensi
ti
vet
othepat
hophy
siol
ogi
cal
ter
ati
onsof
f
lui
dloss.Thechangesi
nrenal
funct
ioni
nducedbyhy
pov
olemi
amayv
aryf
rom si
mpl
e
ol
i
gur
iawi
thaconcent
rat
edandaci
dur
inet
ohi
ghout
putr
enal
fai
l
urewi
thaur
ineof
l
owspeci
fi
cgr
avi
tyandhi
ghpH,
orf
rankanur
icr
enal
fai
l
ure.

Measur
ingbl
oodl
oss

1. Bl
oodcl
ott
hesi
zeofacl
enchedf
isti
sroughl
yequal
to500ml
2. Swel
l
ingi
ncl
osedf
ract
ures–Moder
ateswel
l
ingi
ncl
osedf
ract
uresoft
ibi
a
equal
s500-
1500ml
bloodl
oss.Moder
ateswel
l
ingi
naf
ract
uredshaf
toff
emurequal
s
500-
2000ml
bloodl
oss(
RuscoeCl
ark)
3. Swabwei
ghi
ng–I
noper
ati
ont
heat
res,
thebl
oodl
osscanbemeasur
edby
wei
ghi
ngt
heswabsbef
oreandaf
teruseandaddi
ngt
het
otal
soobt
ained(
1g=1ml
)to
t
hev
olumeofbl
oodcol
l
ect
edi
nthesuct
ionordr
ainagebot
tl
es.Howev
er,
inext
ensi
ve
woundsandoper
ati
ons,
thebl
oodl
ossest
imat
edi
nthi
swayi
smuchl
esst
hant
he
t
otal
amountofbl
ood,
plasmaandwat
erl
ostf
rom t
hev
ascul
arsy
stem becauseof
l
ossoff
lui
dint
othet
issues,
byev
apor
ati
onofsweatf
rom ski
n,l
ossofwat
erv
iat
he
l
ungsandf
rom t
hewoundi
tsel
f,account
ingf
oratl
eastanaddi
ti
onal
20%.
Haemogl
obi
nlev
elandPCV

Thel
evel
ofhaemogl
obi
nisest
imat
edi
ng/
dl(
g/100ml
),nor
mal
val
uesbei
ng12-
16g/
dl.I
nhaemor
rhage,
ther
eisnoi
mmedi
atechange,
butwi
thi
naf
ewhour
s,t
hel
evel
i
slower
edbyhaemodi
l
uti
oncausedbyt
hemov
ementoff
lui
dint
othev
ascul
ar
compar
tmenti
nor
dert
orest
oret
hebl
oodv
olume.Thedegr
eeofdi
l
uti
oncanbe
gaugedbyt
hehaemat
ocr
itr
eadi
ng(
PCV)
.Thenor
mal
rangeofhaemat
ocr
itv
aluef
or
v
enousbl
oodi
s40-
56%i
nmen,
35-
48%i
nwomenand32-
44%i
nchi
l
dren.Somehour
s
af
tert
hest
artofhaemor
rhage,
thePCVwi
l
lbel
ower
edbyhaemodi
l
uti
on.

Cl
assi
fi
cat
ionofhemor
rhagi
cshock by
Amer
icanCol
legeofsur
geonscommi
tt
eeont
rauma1984

Cl
assI Acut
ebl
oodl
oss-
15%oft
otal
bloodv
olume.Pul
se&r
espi
rat
ion
i
ncr
eased.BPnotsi
gni
fi
cant
lyaf
fect
ed.
Cl
assI
I Acut
ebl
oodl
ossof20–25%oft
otal
bloodv
olume.I
ncr
easedpul
se&
r
espi
rat
ion.Decr
easedBP.Nodecr
easei
nur
ineout
put
.
Cl
assI
II Bl
oodl
ossof30–40%oft
otal
bloodv
olume.I
ncr
easedpul
se&
r
espi
rat
ion.Decr
easedBP&Ur
ineout
put
.
Cl
assI
V 40–50%l
ossoft
otal
bloodv
olume.Lackofv
ital
signs.Decr
easedur
ine
out
put
.Obt
undedment
alst
atus.