▴ 그림 196. 외출혈
a-동맥에서 나는 외출혈, b-정맥에서 나는 외출혈
c-모세혈관에서 나는 외출혈, d-동맥, e-정맥
Copyright ⓒ 2012 John Sangwon Lee, MD, FAAP
3. 모세혈관에서 나는 외출혈과 내출혈
● 피부가 얇게 벗겨지거나 손상되거나 또는 신체 내 어떤 손상이 생길 때 모세혈관이나 림프관 등에서 피와 조직액과 림프액 등이 체외 또는 그 주의 체내로 조금씩 스며 나올 수 있다.
● 선행 건강 문제가 있지 않는 한 대개의 경우 모세혈관에서 나는 피는 자연적으로 지혈되는 것이 보통이다.
■ 출혈의 진단
● 외출혈이 있을 때 증상·징후와 병력을 참작하여 육안으로 확인하고 검진해 외출혈이 있다고 바로 진단할 수 있다.
● 외출혈과 내출혈이 동시 있을 때도 병력, 검진 등으로 진단할 수 있으나 내출혈을 진단하는 데는 출혈의 정도와 출혈하는 신체의 부위에 따라 초음파 검사, X-선 검사, CT 사진 검사 등 여러 가지 검사로 진단 할 때도 있다.
● 원인을 확실히 알 수 없는 내출혈이나 외출혈이 생기면, 출혈의 원인을 정확히 파악해 치료를 효과적으로 한다.
● 또 그 출혈의 원인에 따라 치료를 달리한다.
● 출혈로 생긴 증상 징후에 따라 치료한다.
● 비정상적으로 피가 나면 CBC 피검사, 프로트롬빈 시간(Prothrombin time/PT), 부분적 트롬보플라스틴 시간(Partial thromboplastin time/PTT), 출혈 시간(Bleeding time) 검사 등 혈액검사로 출혈의 원인을 더 확실히 알아보고 원인에 따라 치료한다.
● 출혈이 있을 때 의사들은 다음 표 23에 있는 여러 가지 임상검사를 분별 있게 한다.
Emergency Treatment for External and Internal Bleeding
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● Internal bleeding (internal hemorrhage) is bleeding from one part of the body into another part of the body, while external bleeding (external hemorrhage) is bleeding from inside the body to the outside.
● Bleeding can occur as internal bleeding only, external bleeding only, or both simultaneously.
● The causes of internal and external bleeding are various.
● Thrombocytopenia, sepsis, hemophilia, or trauma can cause internal bleeding only, external bleeding only, or both simultaneously.
● Abrasions, lacerations, stab wounds, fractures, or gunshot wounds can cause external and/or internal bleeding simultaneously.
● This section mainly discusses external bleeding.
● (See also Anemia due to acute bleeding).
■ Symptoms and Signs of External and Internal Bleeding
● The symptoms and signs vary depending on the cause and severity of the external and internal bleeding.
● If about 15% of the total blood volume is suddenly lost due to bleeding, shock can occur.
● If about 30% of the total blood volume is lost in a short time, severe shock can occur.
● If a large amount of blood is lost in a short time due to bleeding, all body tissues cannot receive a sufficient supply of blood. Therefore, all cells in the body can experience oxygen deficiency.
● If the blood volume decreases rapidly, blood pressure can drop below normal, and the heart rate can become faster than normal and weaker.
● If the heart beats abnormally fast for a prolonged period, it can weaken the heart and lead to cardiopulmonary failure.
● Losing a significant amount of blood quickly due to bleeding can lead to shock within minutes and even death.
● Severe external bleeding caused by traffic accidents or gunshot wounds is usually accompanied by internal bleeding.
● In cases of severe external bleeding, apply pressure to the bleeding wound with your hand to stop the bleeding (see Figures 204-210) or use other methods of emergency hemostasis.
● When a person goes into shock due to significant blood loss from external or internal bleeding, provide immediate first aid on the spot without delay and seek help from paramedics, a doctor, or a hospital emergency room.
● Depending on the situation, elevate the lower body 15-30 degrees higher than the upper body to allow more blood to flow to vital organs such as the brain, heart, lungs, liver, and kidneys.
● Transport the patient as quickly as possible to a large hospital emergency room where blood transfusions and other appropriate follow-up emergency treatments can be provided, preferably using an ambulance.
● Detailed emergency treatment methods for external bleeding are described below.
▴ Figure 194. Veins on the back of the hand
Copyright ⓒ 2012 John Sangwon Lee, MD, FAAP
■ Types of Bleeding
1. External and Internal Bleeding from Arteries
▴ Figure 195. Arteries (red) and Veins (blue)
Depending on the size of the blood vessel, blood from an artery is generally bright red and gushes out, while blood from a vein is dark red and oozes out slowly, and blood from capillaries oozes out in small amounts. Copyright ⓒ 2012 John Sangwon Lee, MD, FAAP
● Blood from an artery is bright red, and bleeding usually occurs in spurts, with more or less blood being expelled depending on the contraction and relaxation cycle of the heart.
● External or internal bleeding from a large artery severed by a cut or stab wound will not stop naturally, and if the bleeding is not stopped immediately, a large amount of blood can be lost in a short time, potentially leading to a life-threatening situation.
● Severe bleeding can also occur when a large vein is severed, and the bleeding may not stop naturally. However, when a small vein is severed, the ends of the severed vein can naturally contract, effectively sealing the ends of the severed vein. Blood clots can form at the ends of the severed vein, naturally stopping the bleeding.
● When a large amount of blood is lost in a short time due to external or internal bleeding, the person can quickly go into shock and die.
2. External and Internal Bleeding from Veins
● The color of external and internal bleeding from small veins is dark blue, and the blood usually flows out continuously in small amounts, not in spurts with each heartbeat.
● However, when a large vein is severed, a large amount of blood can be lost, almost similar to external or internal bleeding from an artery.
● Generally, external or internal bleeding from a vein is much easier to stop than external or internal bleeding from an artery.
● If a large vein near the heart or a large vein far from the heart is severed, air or blood clots can enter the severed vein. Air or blood clots that enter the heart, such as through venous blood, can enter the pulmonary artery blood vessels. Sometimes, the pulmonary artery blood vessels can become blocked by air or blood clots, preventing blood from flowing normally from the heart to the lungs. This can lead to various symptoms and signs.
● An embolism caused by air is called an air embolism, and an embolism caused by a blood clot is called a thromboembolism.
▴ Figure 196. External bleeding
a-External bleeding from an artery, b-External bleeding from a vein
c-External bleeding from capillaries, d-Artery, e-Vein
Copyright ⓒ 2012 John Sangwon Lee, MD, FAAP
3. External and internal bleeding from capillaries
● When the skin is thinly peeled or damaged, or when there is any internal injury, blood, tissue fluid, and lymph fluid may seep out of capillaries or lymphatic vessels to the outside of the body or into the surrounding tissues.
● In most cases, unless there is a pre-existing health problem, bleeding from capillaries usually stops naturally.
■ Diagnosis of bleeding
● When there is external bleeding, the diagnosis can be made immediately by considering the symptoms and signs, medical history, and visual examination.
● When both external and internal bleeding are present, the diagnosis can be made through medical history and examination, but diagnosing internal bleeding may require various tests such as ultrasound, X-ray, and CT scans, depending on the extent and location of the bleeding.
● If the cause of internal or external bleeding is unclear, identifying the cause is crucial for effective treatment.
● Treatment also varies depending on the cause of the bleeding.
● Treatment is based on the symptoms and signs caused by the bleeding.
● If there is abnormal bleeding, blood tests such as CBC (Complete Blood Count), Prothrombin time (PT), Partial thromboplastin time (PTT), and Bleeding time tests are performed to more accurately determine the cause of the bleeding, and treatment is given according to the cause.
● When bleeding occurs, doctors judiciously perform various clinical tests as shown in Table 23.
표 23. 출혈하는 환아의 출혈 스크린 검사