Secondary delayed hemorrhage:Secondary delayed hemorrhage: if it occurs after 24 hours of injury.

HemostasisHemostasis

Delayed hemorrhage:Delayed hemorrhage: is often the result is often the result of ineffective treatment of primary of ineffective treatment of primary hemorrhage such as (slipped ligatures, hemorrhage such as (slipped ligatures, necrosis, suppuration of ligated or necrosis, suppuration of ligated or cauterized vessels).cauterized vessels).Intermediate delayed hemorrhage:Intermediate delayed hemorrhage: it occurs within 24 hours of injury.

Disadvantage of Disadvantage of hemorrhage:hemorrhage:1.1. Bleeding obscures the surgical field there Bleeding obscures the surgical field there

by reducing operative efficiency.by reducing operative efficiency.

2.2. Blood on the field and surgeon materials Blood on the field and surgeon materials provides an ideal medium for bacterial provides an ideal medium for bacterial growth and increases the surgical wound growth and increases the surgical wound infection.infection.

3.3. Postoperative hemorrhage prevents proper Postoperative hemorrhage prevents proper coaptation of wound edges, this leads to coaptation of wound edges, this leads to delays healing and infection.delays healing and infection.

4.4. Severe hemorrhage may result shock, Severe hemorrhage may result shock, hypoxemia, and death of the patient.hypoxemia, and death of the patient.

Hemorrhage can be prevented during Hemorrhage can be prevented during operations on the limbs, penis and operations on the limbs, penis and tail by following methods:tail by following methods:

1- The use of a tourniquet:1- The use of a tourniquet: is a band, piece is a band, piece of rubber gas tubing from 15-20 inches long or of rubber gas tubing from 15-20 inches long or cord wound tightly round the limb or cord wound tightly round the limb or appendage above the seat of operation for appendage above the seat of operation for arterial bleeding and below it for venous arterial bleeding and below it for venous bleeding.bleeding.

The tourniquet also compresses the nerves, The tourniquet also compresses the nerves, producing a numbing effect and acting to a producing a numbing effect and acting to a certain extent as a local anesthetic.certain extent as a local anesthetic.Note:Note: tourniquets should not be applied for a tourniquets should not be applied for a period of more than 20 minutes.period of more than 20 minutes.

2- The use of Esmarch’s Bandage:2- The use of Esmarch’s Bandage: is an is an elastic bandage applied from the distal part of elastic bandage applied from the distal part of the extremity to a point above the seat of the extremity to a point above the seat of operation. A tourniquet is then applied here operation. A tourniquet is then applied here and the bandage removed.and the bandage removed.

3- Digital compression:3- Digital compression: pressure pressure maintained on the chief vessel of supply by maintained on the chief vessel of supply by fingers of an assistant or by a blunt object.fingers of an assistant or by a blunt object.4- The hypodermic injection of 4- The hypodermic injection of Adrenalin:Adrenalin: this is useful for the prevention this is useful for the prevention of capillary hemorrhage. Applied on a of capillary hemorrhage. Applied on a mucous surface it has a blanching effect, and mucous surface it has a blanching effect, and is useful for operations on the conjunctiva.is useful for operations on the conjunctiva.

Bloodless operation methods:Bloodless operation methods:A) The thermo-cautery:A) The thermo-cautery: this acts best this acts best when used at a dull red heat, to coats of the when used at a dull red heat, to coats of the vessel retracting and contracting, vessel retracting and contracting, diminishing its lumen, and an eschar diminishing its lumen, and an eschar forming on its orifice and acting as a plug. forming on its orifice and acting as a plug. The auto-cautery such as the Electrical The auto-cautery such as the Electrical cautery.cautery.

B) Crushing:B) Crushing: the loop of chain is gradually tightened the loop of chain is gradually tightened on the enclosed tissues, which are severed by digress on the enclosed tissues, which are severed by digress without any hemorrhage. The middle and inner coats without any hemorrhage. The middle and inner coats of the vessels first give may and retract and contract, of the vessels first give may and retract and contract, while the outer coat is drawn out so that its inner while the outer coat is drawn out so that its inner surface are pressed into contact, forming a sort of cap surface are pressed into contact, forming a sort of cap over the mouth of the vessel.over the mouth of the vessel.

C) Blunt dissection:C) Blunt dissection: it is performed by it is performed by rupturing the tissues by the pressure of a blunt rupturing the tissues by the pressure of a blunt instrument, and is sometimes employed for the instrument, and is sometimes employed for the isolation of large vessels and for the separation isolation of large vessels and for the separation of tumors without opening arteries or veins.of tumors without opening arteries or veins.

D) Ligation:D) Ligation: the elastic or other ligature is or other ligature is sometimes employed for the removal of sometimes employed for the removal of organ. When the incision is made, blood organ. When the incision is made, blood escapes and more or less conceals the field escapes and more or less conceals the field of operation.of operation.

E) Tearing:E) Tearing: tearing of the tissue is often tearing of the tissue is often employed in the removal of tumors employed in the removal of tumors loosely attached and situated in the loosely attached and situated in the vicinity of important vessels and nerves.vicinity of important vessels and nerves.

Arrest of hemorrhage during and Arrest of hemorrhage during and after operation:after operation:1- Digital Compression:1- Digital Compression: already described already described in the prevention of hemorrhage, may by in the prevention of hemorrhage, may by adopted temporarily until the operation is adopted temporarily until the operation is completed, when some other means is completed, when some other means is adopted as a permanent hemostatic.adopted as a permanent hemostatic.2- The Thermo-Cautery:2- The Thermo-Cautery: this is an this is an effective instrument for arresting effective instrument for arresting hemorrhage by the production of an eschar hemorrhage by the production of an eschar which closes the mouths of the bleeding which closes the mouths of the bleeding vessels until a coagulum forms therein, such vessels until a coagulum forms therein, such as used a dull red heat.as used a dull red heat.

3- Ligation:3- Ligation: ligation of bleeding vessels ligation of bleeding vessels with silk or catgut, preferably the former, is with silk or catgut, preferably the former, is surest method of arresting hemorrhage. The surest method of arresting hemorrhage. The bleeding end is seized longitudinally with an bleeding end is seized longitudinally with an artery forceps and drawn slightly out of the artery forceps and drawn slightly out of the tissue, and is then ligatured by making one tissue, and is then ligatured by making one knot with the thread round the forceps.knot with the thread round the forceps.

4- Torsion:4- Torsion: is sufficient to arrest hemorrhage is sufficient to arrest hemorrhage from small vessels. The bleeding end of the from small vessels. The bleeding end of the vessel is secured with the artery forceps vessel is secured with the artery forceps drawn out slightly and twisted on its long axis drawn out slightly and twisted on its long axis several times until a twisted end is left which several times until a twisted end is left which will not untwist when released.will not untwist when released.

Note:Note: compression with the forceps for a compression with the forceps for a few minutes is sufficient to stop bleeding for few minutes is sufficient to stop bleeding for small vessels.small vessels.

5- Forcipressure:5- Forcipressure: it consists in applying an it consists in applying an artery forceps to the end of the vessel end artery forceps to the end of the vessel end leaving it in position until it is convenient to leaving it in position until it is convenient to apply a ligature, or for a period of long time apply a ligature, or for a period of long time until a stable thrombus is formed.until a stable thrombus is formed.

Gave three examples for Gave three examples for each following depending on each following depending on etiological types wounds?etiological types wounds?

1- Open wound1- Open wound 2- Closed 2- Closed

woundwound