External bleeding will present with profuse bleeding or the eminent escape of blood from the circulatory system through the body’s natural orifices. The following presentations are seen in external or eminent hemorrhage:

• Hemoptysis (coughing out of fresh blood)
• Hematemesis (vomiting out of blood)
• Hematochezia (exit of fresh blood through the anus)
• Melena (passing out of darkened, dried blood with the stools)
• Hematuria (passage of blood from the urine)
• Vaginal bleeding 
• Pelvic bleeding (bleeding from any organs of the pelvis like the ovaries) [5]
• Ecchymosis (bleeding within the skin layers)
• Wounds (bleeding from any disrupted layer of skin or mucous membrane)

Internal bleeding has a diverse variety of presentation based on the location of the bleeding. The following system wise signs and symptoms are associated with internal hemorrhage:

• Intracranial hemorrhage: Change in sensorium, vomiting, headache, and hypertension
• Subarachnoid hemorrhage: Neck rigidity, loss of consciousness, and cardiac arrhythmia
• Pulmonary hemorrhage: Dyspnea, hemoptysis and shock
• Intrauterine hemorrhage: Pelvic distention, flaccid uterus, and signs of shock [6].
• Gastrointestinal hemorrhage: Abdominal distention, hematochezia, melena and hypotension.
• Femoral hemorrhage: Ecchymosis and unexplained shock

A complete and meticulous physical examination of the skin can easily reveal the sites and location of any external hemorrhage. Careful chest and abdominal examination can give away some signs of internal hemorrhage within the cavity. A complete neurological examination and mental state examination can reveal signs of intracranial hemorrhages. The following confirmatory tests and diagnostic modalities are used to diagnose internal hemorrhage among suspected patients:

• Blood tests: A serial hemoglobin and hematocrit level is an accurate means of determining the presence of active bleeding. Platelet count will be a good indicator of primary thrombocytopenia disorders [7]. Prothrombin time and partial thromboplastin time determines the integrity of the clotting mechanisms of the body. 
• Immune assays: These immune link assays can determine the presence of certain hemorrhagic viruses like Dengue and Ebola virus that causes hemorrhagic fever.
• Imaging studies: Gastrointestinal series [8], ultrasound, CT-scan, and MRI can elucidate intracranial, intrathoracic and intraabdominal hemorrhages. 
• Spinal tap: Intrathecal bleeding or subarachnoid hemorrhage are confirmed with a bloody spinal tap.
• Urinalysis: This test can detect the actual volume of blood cells that escapes from the urinary system.
• Occult blood: This stool exam test can show occult bleeding through concentration methods and microscopy to diagnose slow gastrointestinal hemorrhages.

A number of hemorrhages seen in superficial wounds and physiologic hemorrhage in menstruation resolve spontaneously without intervention. Although some wounds may profusely bleed until direct pressure or a proximal tourniquet is applied to stop the bleeding. Visible bleeders in incised and hacking wounds can be ligated while vital vessels can be microsurgically anastomosed for hemostasis. Internal hemorrhages within a sturdy cavity like the skull can spontaneously halt, although brain tissue damage is already eminent in most cases. Serious internal hemorrhages within the pericardial, thoracic, abdominal, and femoral cavity can only be controlled by open surgery. Recombinant clotting factors can alleviate hemorrhagic conditions brought about by clotting factor deficiencies [9]. The physiologic instability brought about by the considerable volume of blood loss from hemorrhage can be resuscitated with crystalloid fluids and blood transfusion [10].

The outlook of patients with hemorrhage greatly depends on the volume of blood lost and the promptness of the resuscitative efforts to stabilize the bleeding. The hemorrhage classes described in the ATLS varies directly to morbidity and mortality rating. The internal hemorrhage’s morbidity and mortality ratings is relative to the volume of the potential space that the lost blood can fill in during bleeding. In general, internal hemorrhage carries a poorer prognosis than external hemorrhage.

Hemorrhage may be brought about by the following medical factors:

• Wounds
• Hemorrhagic stroke
• Yellow fever
• Primary thrombocytopenia [2]
• Ebola virus infection
• Clotting and bleeding disorders [3]
• Dengue hemorrhagic fever
• Vitamin K deficiency

The epidemiology of hemorrhage varies on the specific types of pathology and the location of the pathology in the body. For example internal bleeding within the brain may be conveniently divided to traumatic brain injury and hemorrhagic strokes which have their own inferential prevalence and incidence rating. Hemorrhage occurs in all ages and in all known cultures of the world with no sexual predilection. Only females develop intrauterine bleeding and post-partum bleeding that may seriously complicate if left untreated. In the same way, only females within the reproductive age of 15 to 45 years old experience physiologic hemorrhage or bleeding during menstruation. Almost 100,000 deaths every year are caused by postpartum hemorrhages accounting for 25% of all maternal deaths worldwide [4].

Hemorrhage results when the natural hemostatic capabilities like the clotting mechanism of the body is undermined and results to continuous bleeding externally or internally. Internal hemorrhage results when there is a break in the blood vessels as caused by external trauma, vasopressure (hemorrhagic stroke), baropressure (pulmonary edema), increased vascular fragility (hemorrhagic infections) or spontaneous bleeding. Blunt abdominal trauma can cause the liver and spleen tissues to exude blood continuously and cause hypovolemic shock. Uncontrolled hypertension may rupture weakened cerebral and coronary vessels causing internal bleeding.

Abrupt changes in altitude may facilitate the edematous changes in the lungs and cause bleeding in the process. Infections like Dengue hemorrhagic fever and Ebola virus infection can render the internal vessel fragile due to an immune mediated inflammatory reactions of the vessels causing hemorrhagic bleed within the body cavities. External bleeding like those found in wounds are often times easier to control because it is immediately visible and results in the immediate intervention for hemostasis.

Accidental wounds may be prevented by a prudently putting away knives and sharp objects away from children’s reach. Tetanus prophylaxis should always be updated to prevent fatal complications from simple hemorrhage in superficial wounds. Internal hemorrhage caused by blunt chest and abdominal injury can actively be prevented by securing one’s seatbelts during driving. Protective gears should always be in place during high risk sports like skating, skate boarding and roller blading to prevent accidental bleeding. Infants are routinely injected with phytomenadione (vitamin K) to prevent internal bleeding from a variety of causes. Patients in frank sepsis should be aggressively treated to prevent the occurrence of disseminated intravascular coagulation (DIC) that perpetually causes uncontrolled internal hemorrhage that could be fatal.

Hemorrhage is clinically defined as bleeding or excessive bleeding brought about by bleeding disorders, ruptured vessels, infections, clotting disorders, and vitamin K deficiency. Hemorrhage may be roughly defined as the progressive escape of blood from the circulatory system. Hemorrhage or bleeding may occur internally where the blood and plasma persistently leaks within the body, or externally where blood exudes from the natural orifices of the body including the mouth, ears, nose, urethra, anus, vagina or any break in the integrity of the skin including the mucous membrane. The massive loss of blood may lead to hypovolemic shock while the complete loss of the blood that causes death is referred to as exsanguination. According to the American College of Surgeons’ (ACS) advanced trauma life support (ATLS) manual, there are four classes of hemorrhage according to volume of blood loss [1].

• Class 1 hemorrhage refers to blood loss of not more than 15% of the total blood volume with no physiological changes noted and no need for any intervention.
• Class 2 hemorrhage happens between 15% to 30% blood loss with consequent minor physiologic compensation that may require fluid resuscitation with crystalloids.
• Class 3 hemorrhage when there is a 30% to 40% blood loss with some signs of shock requiring both crystalloids and whole blood transfusion for stabilization.
• Class 4 hemorrhage is defined as blood loss of more than 40% of total blood volume that exceeds the body’s capacity to compensate and requires aggressive resuscitation to prevent death.

Definition

Hemorrhage is clinically defined as an abnormal blood flow brought about by trauma, bleeding disorders, ruptured vessels, infections, clotting disorders, and vitamin K deficiency.

Cause

Hemorrhage can be caused by wounds, bleeding disorders, trauma, hemorrhagic stroke, and hemorrhagic infections.

Symptoms

External hemorrhages are seen as an escape of the blood elements from circulatory systems through the skin or any other body orifices like the mouth, nose, anus, urethra, and vagina. Internal hemorrhage will present with various symptomatology based on the location of the hemorrhage.

Diagnosis

A meticulous physical examination of the skin for wounds and natural body orifices will easily reveal external hemorrhages. Blood tests, imaging studies, spinal tap, stool exam and urinalysis may be required to diagnose internal hemorrhages.

Treatment and follow-up

Some hemorrhages does not require any treatment while a number may only need direct pressure and tourniquet. Intrathoracic, pericardial, intraabdominal, femoral hemorrhages requires open surgery for vessel ligation. Crystalloid fluids and whole blood are given to stabilize physiological disturbances in the circulatory system.

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