# Internal bleeding

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Leakage of blood within the body

This article is about the medical condition. For the death metal band, see [Internal Bleeding](/source/Internal_Bleeding).

Medical condition

Internal bleeding Other names Internal hemorrhage Internal bleeding in the brain Specialty Vascular surgery, hematology, emergency medicine Complications Hemorrhagic shock, exsanguination

**Internal bleeding** (also called **internal haemorrhage**) is a loss of blood from a [blood vessel](/source/Blood_vessel) that collects inside the body, and is not usually visible from the outside.[1] It can be a serious [medical emergency](/source/Medical_emergency) but the extent of severity depends on bleeding rate and location of the bleeding (e.g. head, torso, extremities). Severe internal bleeding into the [chest](/source/Chest), [abdomen](/source/Abdomen), [pelvis](/source/Pelvis), or [thighs](/source/Thigh) can cause [hemorrhagic shock](/source/Hemorrhagic_shock) or [death](/source/Death) if proper medical treatment is not received quickly.[2] Internal bleeding is a medical emergency and should be treated immediately by medical professionals.[2]

## Signs and symptoms

Signs and symptoms of internal bleeding may vary based on location, presence of injury or trauma, and severity of bleeding. Common symptoms of blood loss may include:

- Lightheadedness

- Fatigue

- Urinating less than usual

- Confusion

- Fast heart rate

- Pale and/or cold skin

- Thirst

- Generalized weakness

Visible signs of internal bleeding include:

- Blood in the urine

- Dark black stools

- Bright red stools

- Bloody noses

- Bruising

- Throwing up blood

Of note, it is possible to have internal bleeding without any of the above symptoms, and pain may or may not be present.[3]

A patient may lose more than 30% of their blood volume before there are changes in their vital signs or level of consciousness.[4] This is called hemorrhagic or [hypovolemic shock](/source/Hypovolemic_shock), which is a type of [shock](/source/Shock_(circulatory)) that occurs when there is not enough blood to reach organs in the body.[5]

## Causes

Internal bleeding can be caused by a broad number of things and can be broken up into three large categories:

- Trauma, or direct injury to blood vessels within the body cavity

- Genetic and acquired conditions, along with various medications, that result in an increased bleeding risk

- Other

### Traumatic

The most common cause of death in trauma is [bleeding](/source/Bleeding).[6] Death from trauma accounts for 1.5 million of the 1.9 million deaths per year due to bleeding.[4]

There are two types of trauma: [penetrating trauma](/source/Penetrating_trauma) and [blunt trauma](/source/Blunt_trauma).[2]

- **Penetrating trauma** is the most common cause of vascular injury and can result in internal bleeding. It can occur after a [ballistic](/source/Ballistic_trauma) injury or [stab wound](/source/Stab_wound). If [penetrating trauma](/source/Penetrating_trauma) occurs in blood vessels close to the heart, it can quickly lead to hemorrhagic or [hypovolemic shock](/source/Hypovolemic_shock), [exsanguination](/source/Exsanguination), and [death](/source/Death).[2]

- **Blunt trauma** is another cause of vascular injury that can result in internal bleeding. It can occur after a high speed [deceleration](/source/Acceleration) in an [automobile accident](/source/Automobile_accident).[2][7]

### Non-traumatic

A number of pathological conditions and diseases can lead to internal bleeding. These include:

- Blood vessel rupture as a result of high [blood pressure](/source/Blood_pressure), [aneurysms](/source/Aneurysms), [peptic ulcers](/source/Peptic_ulcers), or [ectopic pregnancy](/source/Ectopic_pregnancy).[8]

- Other diseases linked to internal bleeding include [cancer](/source/Cancer), [hematologic disease](/source/Hematologic_disease), [Vitamin K](/source/Vitamin_K) deficiency, and rare [viral hemorrhagic fevers](/source/Viral_hemorrhagic_fevers), such as the [Ebola](/source/Ebola), [Dengue](/source/Dengue_fever) or [Marburg](/source/Marburg_virus_disease) viruses.[9]

### Other

This stomach with [Linitis plastica](/source/Linitis_plastica) (Brinton's disease) can cause internal bleeding

Internal bleeding could be a result of complications following surgery or other medical procedures. Some medications may also increase a person's risk for bleeding, such as [anticoagulant](/source/Anticoagulant) drugs or [antiplatelet drugs](/source/Antiplatelet_drugs) in the treatment of [coronary artery disease](/source/Coronary_artery_disease).[10]

## Diagnosis

### Vital signs

Blood loss can be estimated based on heart rate, blood pressure, respiratory rate, and mental status.[11] Blood is circulated throughout the body and all major organ systems through a closed loop system. When there is damage to the blood vessel or the blood is thinner than the physiologic consistency, blood can exit the vessel which disrupts this close-looped system. The [autonomic nervous system (ANS)](/source/Autonomic_nervous_system) responds in two large ways as an attempt to compensate for the opening in the system. These two actions are easily monitored by checking the heart rate and blood pressure. Blood pressure will initially decrease due to the loss of blood. This is where the ANS comes in and attempts to compensate by contracting the muscles that surround these vessels. As a result, a person who is bleeding internally may initially have a normal blood pressure. When the blood pressure falls below the normal range, this is called [hypotension](/source/Hypotension). The heart will start to pump faster causing the heart rate to increase, as an attempt to get blood delivered to vital organ systems faster. When the heart beats faster than the healthy and normal range, this is called [tachycardia](/source/Tachycardia). If the bleeding is not controlled or stopped, a patient will experience tachycardia and hypotension, which altogether is a state of shock, called [hemorrhagic shock](/source/Hemorrhagic_shock).

[Advanced trauma life support](/source/Advanced_trauma_life_support) (ATLS) by the American College of Surgeons separates hemorrhagic shock into four categories.[12][4][13]

Classification of Hemorrhagic Shock[12][4][13] Estimated blood loss Heart rate (per minute) Blood pressure Pulse pressure (mmHg) Respiratory rate (per minute) Other Class I hemorrhage < 15% Normal or minimally elevated Normal Normal Normal Slightly anxious Class II hemorrhage 15 - 30% 100 - 120 Normal or minimally decreased systolic blood pressure Narrowed 20 - 30 Mildly anxious Cool, clammy skin with delayed capillary refill Class III hemorrhage 30 - 40% 120 - 140 Systolic blood pressure < 90 mmHg or change in blood pressure > 20-30% from presentation Narrowed 30 - 40 Altered mental status (anxious, confused) Decreased urine output Class IV hemorrhage > 40% > 140 Systolic blood pressure < 90 mmHg Narrowed (< 25 mmHg) >35 Significantly altered mental status (confused, lethargic) Cool, clammy skin with delayed capillary refill Significantly decreased or absent urine output

Assessing circulation occurs after assessing the patient's airway and breathing ([ABC (medicine)](/source/ABC_(medicine))).[5] If internal bleeding is suspected, a patient's [circulatory system](/source/Circulatory_system) is assessed through [palpation](/source/Palpation) of [pulses](/source/Pulse) and [doppler ultrasonography](/source/Doppler_ultrasonography).[2]

### Physical examination

It is important to examine the person for visible signs that may suggest the presence of internal bleeding and/or the source of the bleed.[2] Some of these signs may include:

- [a wound](/source/Wound)

- bruising [\[ecchymosis](/source/Ecchymosis)]

- blood collection [[hematoma](/source/Hematoma)]

- abnormal skin sensation [[paresthesia](/source/Paresthesia)]

- signs of [compartment syndrome](/source/Compartment_syndrome)

### Imaging

If internal bleeding is suspected a [FAST exam](/source/FAST_exam) may be performed to look for bleeding in the abdomen.[2][12]

If the patient has stable [vital signs](/source/Vital_signs), they may undergo diagnostic imaging such as a [CT scan](/source/CT_scan).[4] If the patient has unstable vital signs, they may not undergo diagnostic imaging and instead may receive immediate medical or surgical treatment.[4]

## Treatment

Management of internal bleeding depends on the cause and severity of the bleed. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.[2]

### Fluid replacement

If a patient has low blood pressure ([hypotension](/source/Hypotension)), intravenous fluids can be used until they can receive a [blood transfusion](/source/Blood_transfusion). In order to replace blood loss quickly and with large amounts of IV fluids or blood, patients may need a [central venous catheter](/source/Central_venous_catheter).[12] Patients with severe bleeding need to receive large quantities of replacement blood via a blood transfusion. As soon as the clinician recognizes that the patient may have a severe, continuing hemorrhage requiring more than 4 units in 1 hour or 10 units in 6 hours, they should initiate a [massive transfusion protocol](/source/Massive_transfusion_protocol).[12] The massive transfusion protocol replaces [red blood cells](/source/Red_blood_cell), [plasma](/source/Blood_plasma), and [platelets](/source/Platelet) in varying ratios based on the cause of the bleeding (traumatic vs. non-traumatic).[4]

### Stopping the bleeding

It is crucial to stop the internal bleeding immediately (achieve [hemostasis](/source/Hemostasis)) after identifying its cause.[4] The longer it takes to achieve hemostasis in people with traumatic causes (e.g. [pelvic fracture](/source/Pelvic_fracture)) and non-traumatic causes (e.g. [gastrointestinal bleeding](/source/Gastrointestinal_bleeding), ruptured [abdominal aortic aneurysm](/source/Abdominal_aortic_aneurysm)), the higher the death rate is.[4]

Unlike with external bleeding, most internal bleeding cannot be controlled by applying pressure to the site of injury.[12] Internal bleeding in the [thorax](/source/Thorax) and [abdominal cavity](/source/Abdominal_cavity) (including both the [intraperitoneal](/source/Intraperitoneal) and [retroperitoneal space](/source/Retroperitoneal_space)) cannot be controlled with direct pressure (compression). A patient with acute internal bleeding in the [thorax](/source/Thorax) after trauma should be diagnosed, resuscitated, and stabilized in the Emergency Department in less than 10 minutes before undergoing surgery to reduce the risk of death from internal bleeding.[4] A patient with [acute](/source/Acute_(medicine)) internal bleeding in the [abdomen](/source/Abdomen) or [pelvis](/source/Pelvis) after trauma may require use of a [REBOA](/source/REBOA) device to slow the bleeding.[4] The REBOA has also been used for non-traumatic causes of internal bleeding, including bleeding during childbirth and gastrointestinal bleeding.[4]

Internal bleeding from a [bone fracture](/source/Bone_fracture) in the arms or legs may be partially controlled with direct pressure using a [tourniquet](/source/Tourniquet).[12] After tourniquet placement, the patient may need immediate [surgery](/source/Surgery) to find the bleeding [blood vessel](/source/Blood_vessel).[4]

Internal bleeding where the torso meets the extremities ("junctional sites" such as the [axilla](/source/Axilla) or [groin](/source/Groin)) cannot be controlled with a tourniquet; however there is an FDA approved device known as an Abdominal Aortic and Junctional Tourniquet (AAJT) designed for proximal aortic control, although very few studies examining its use have been published.[14][15][16][17][18][19] For bleeding at junctional sites, a dressing with a blood clotting agent ([hemostatic dressing](/source/Hemostatic_dressing)) should be applied.[4]

A campaign to improve the care of bleeding known as the *Stop The Bleed* campaign is also taking place.[20]

## References

1. **[^](#cite_ref-1)** Auerback, Paul. [*Field Guide to Wilderness Medicine*](https://www.clinicalkey.com/service/content/pdf/watermarked/3-s2.0-B9780323597555000125.pdf?locale=en_US) (PDF) (12 ed.). pp. 129–131. Retrieved 13 March 2019.

1. ^ [***a***](#cite_ref-:1_2-0) [***b***](#cite_ref-:1_2-1) [***c***](#cite_ref-:1_2-2) [***d***](#cite_ref-:1_2-3) [***e***](#cite_ref-:1_2-4) [***f***](#cite_ref-:1_2-5) [***g***](#cite_ref-:1_2-6) [***h***](#cite_ref-:1_2-7) [***i***](#cite_ref-:1_2-8) Fritz, Davis (2011). ["Vascular Emergencies"](https://accessmedicine.mhmedical.com/content.aspx?sectionid=40357256&bookid=385). *Current Diagnosis & Treatment: Emergency Medicine* (7e ed.). New York: McGraw-Hill. [ISBN](/source/ISBN_(identifier)) [978-0071701075](https://en.wikipedia.org/wiki/Special:BookSources/978-0071701075).

1. **[^](#cite_ref-3)** ["DynaMed"](https://www.dynamed.com/approach-to/bleeding-disorders-approach-to-the-patient#GUID-3E705886-D638-4802-8787-DAC11314E72B). *www.dynamed.com*. Retrieved 2023-10-08.

1. ^ [***a***](#cite_ref-:3_4-0) [***b***](#cite_ref-:3_4-1) [***c***](#cite_ref-:3_4-2) [***d***](#cite_ref-:3_4-3) [***e***](#cite_ref-:3_4-4) [***f***](#cite_ref-:3_4-5) [***g***](#cite_ref-:3_4-6) [***h***](#cite_ref-:3_4-7) [***i***](#cite_ref-:3_4-8) [***j***](#cite_ref-:3_4-9) [***k***](#cite_ref-:3_4-10) [***l***](#cite_ref-:3_4-11) [***m***](#cite_ref-:3_4-12) [***n***](#cite_ref-:3_4-13) Cannon, Jeremy (January 25, 2018). "Hemorrhagic Shock". *The New England Journal of Medicine*. **378** (4): 370–379. [doi](/source/Doi_(identifier)):[10.1056/NEJMra1705649](https://doi.org/10.1056%2FNEJMra1705649). [PMID](/source/PMID_(identifier)) [29365303](https://pubmed.ncbi.nlm.nih.gov/29365303). [S2CID](/source/S2CID_(identifier)) [205117992](https://api.semanticscholar.org/CorpusID:205117992).

1. ^ [***a***](#cite_ref-:2_5-0) [***b***](#cite_ref-:2_5-1) *International Trauma Life Support for Emergency Care Providers*. Pearson Education Limited. 2018. pp. 172–173. [ISBN](/source/ISBN_(identifier)) [978-1292-17084-8](https://en.wikipedia.org/wiki/Special:BookSources/978-1292-17084-8).

1. **[^](#cite_ref-6)** Teixeira, Pedro G. R.; Inaba, Kenji; Hadjizacharia, Pantelis; Brown, Carlos; Salim, Ali; Rhee, Peter; Browder, Timothy; Noguchi, Thomas T.; Demetriades, Demetrios (December 2007). "Preventable or Potentially Preventable Mortality at a Mature Trauma Center". *The Journal of Trauma: Injury, Infection, and Critical Care*. **63** (6): 1338–46, discussion 1346–7. [doi](/source/Doi_(identifier)):[10.1097/TA.0b013e31815078ae](https://doi.org/10.1097%2FTA.0b013e31815078ae). [PMID](/source/PMID_(identifier)) [18212658](https://pubmed.ncbi.nlm.nih.gov/18212658).

1. **[^](#cite_ref-7)** Duncan, Nicholas S.; Moran, Chris (2010). "(i) Initial resuscitation of the trauma victim". *Orthopaedics and Trauma*. **24**: 1–8. [doi](/source/Doi_(identifier)):[10.1016/j.mporth.2009.12.003](https://doi.org/10.1016%2Fj.mporth.2009.12.003).

1. **[^](#cite_ref-sciencedirect.com_8-0)** Lee, Edward W.; [Laberge, Jeanne M.](/source/Jeanne_LaBerge) (2004). "Differential Diagnosis of Gastrointestinal Bleeding". *Techniques in Vascular and Interventional Radiology*. **7** (3): 112–122. [doi](/source/Doi_(identifier)):[10.1053/j.tvir.2004.12.001](https://doi.org/10.1053%2Fj.tvir.2004.12.001). [PMID](/source/PMID_(identifier)) [16015555](https://pubmed.ncbi.nlm.nih.gov/16015555).

1. **[^](#cite_ref-9)** Bray, M. (2009). "Hemorrhagic Fever Viruses". *Encyclopedia of Microbiology*. pp. 339–353. [doi](/source/Doi_(identifier)):[10.1016/B978-012373944-5.00303-5](https://doi.org/10.1016%2FB978-012373944-5.00303-5). [ISBN](/source/ISBN_(identifier)) [9780123739445](https://en.wikipedia.org/wiki/Special:BookSources/9780123739445).

1. **[^](#cite_ref-10)** Pospíšil, Jan; Hromádka, Milan; Bernat, Ivo; Rokyta, Richard (2013). ["STEMI - the importance of balance between antithrombotic treatment and bleeding risk"](https://doi.org/10.1016%2Fj.crvasa.2013.02.004). *Cor et Vasa*. **55** (2): e135–e146. [doi](/source/Doi_(identifier)):[10.1016/j.crvasa.2013.02.004](https://doi.org/10.1016%2Fj.crvasa.2013.02.004).

1. **[^](#cite_ref-11)** *Current Diagnosis & Treatment: Emergency Medicine*. McGraw-Hill. 2011-05-23. [ISBN](/source/ISBN_(identifier)) [978-0071701075](https://en.wikipedia.org/wiki/Special:BookSources/978-0071701075).

1. ^ [***a***](#cite_ref-Uptodate_12-0) [***b***](#cite_ref-Uptodate_12-1) [***c***](#cite_ref-Uptodate_12-2) [***d***](#cite_ref-Uptodate_12-3) [***e***](#cite_ref-Uptodate_12-4) [***f***](#cite_ref-Uptodate_12-5) [***g***](#cite_ref-Uptodate_12-6) Colwell, Christopher. ["Initial management of moderate to severe hemorrhage in the adult trauma patient"](https://www.uptodate.com/contents/initial-management-of-moderate-to-severe-hemorrhage-in-the-adult-trauma-patient?search=hemorrhagic%20shock&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H2303255334). *UpToDate*. Retrieved 5 March 2019.

1. ^ [***a***](#cite_ref-:4_13-0) [***b***](#cite_ref-:4_13-1) *ATLS- Advanced Trauma Life Support - Student Course Manual* (10th ed.). American College of Surgeons. 2018. pp. 43–52. [ISBN](/source/ISBN_(identifier)) [978-78-0-9968267](https://en.wikipedia.org/wiki/Special:BookSources/978-78-0-9968267).

1. **[^](#cite_ref-14)** Croushorn J. Abdominal Aortic and Junctional Tourniquet controls hemorrhage from a gunshot wound of the left groin.JSpecOperMed.2014;14(2):6–8.

1. **[^](#cite_ref-15)** Croushorn J, Thomas G, McCord SR. Abdominal aortic tourniquet controlsjunctional hemorrhage from a gunshot wound of the axilla.J Spec Oper Med.2013;13(3):1–4.

1. **[^](#cite_ref-16)** Rall JM, Ross JD, Clemens MS, Cox JM, Buckley TA, Morrison JJ. Hemo-dynamic effects of the Abdominal Aortic and Junctional Tourniquet in ahemorrhagic swine model.JSurgRes. 2017;212:159–166.

1. **[^](#cite_ref-17)** Kheirabadi BS, Terrazas IB, Miranda N, Voelker AN, Grimm R, Kragh JF Jr, Dubick MA. Physiological Consequences of Abdominal Aortic and Junc-tional Tourniquet (AAJT) application to control hemorrhage in a swinemodel.Shock (Augusta, Ga). 2016;46(3 Suppl 1):160–166.

1. **[^](#cite_ref-18)** Taylor DM, Coleman M, Parker PJ. The evaluation of an abdominal aortictourniquet for the control of pelvic and lower limb hemorrhage.Mil Med.2013;178(11):1196–1201.

1. **[^](#cite_ref-19)** Brannstrom A., Rocksen D., Hartman J., et al Abdominal aortic and junctional tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage. J. Trauma Acute Care Surg.. 2018;85(4):717-724. [doi](/source/Doi_(identifier)):[10.1097/TA.0000000000002013](https://doi.org/10.1097%2FTA.0000000000002013)

1. **[^](#cite_ref-20)** Pons, MD, Peter. ["Stop the Bleed - SAVE A LIFE: What Everyone Should Know to Stop Bleeding After an Injury"](https://web.archive.org/web/20160928155845/http://www.bleedingcontrol.org/~/media/bleedingcontrol/files/stop%20the%20bleed%20booklet.ashx). Archived from [the original](https://www.bleedingcontrol.org/~/media/bleedingcontrol/files/stop%20the%20bleed%20booklet.ashx) on September 28, 2016.

## External links

The Wikibook *[First Aid](https://en.wikibooks.org/wiki/First_Aid)* has a page on the topic of: ***[Internal Bleeding](https://en.wikibooks.org/wiki/First_Aid/Internal_Bleeding)***

v t e Trauma Principles Polytrauma Major trauma Traumatology Triage Resuscitation Trauma triad of death Assessment Clinical prediction rules Abbreviated Injury Scale Injury Severity Score NACA score Revised Trauma Score Investigations Diagnostic peritoneal lavage Focused assessment with sonography for trauma Management Principles Advanced trauma life support Damage control surgery Early appropriate care Trauma center Trauma surgery Trauma team Procedures Resuscitative thoracotomy Pathophysiology Injury MSK Bone fracture Degloving Joint dislocation Soft tissue injury Respiratory Diaphragmatic rupture Flail chest Hemothorax Pneumothorax Pulmonary contusion Cardio Cardiac tamponade Internal bleeding Thoracic aorta injury GI Blunt kidney trauma Splenic injury Neuro Intracranial hemorrhage Penetrating head injury Traumatic brain injury Mechanism Blast injury Blunt trauma Burn Crush injury Electrocution Gunshot wound Penetrating trauma Stab wound Region Abdominal trauma Chest injury Facial trauma Head injury Spinal cord injury Demographic Geriatric trauma Pediatric trauma Complications Acute respiratory distress syndrome Chronic traumatic encephalopathy Compartment syndrome Contracture Volkmann's contracture Crush syndrome Rhabdomyolysis Embolism air fat Post-traumatic stress disorder Subcutaneous emphysema Wound healing

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Adapted from the Wikipedia article [Internal bleeding](https://en.wikipedia.org/wiki/Internal_bleeding) by Wikipedia contributors ([contributor history](https://en.wikipedia.org/wiki/Internal_bleeding?action=history)). Available under [Creative Commons Attribution-ShareAlike 4.0 International](https://creativecommons.org/licenses/by-sa/4.0/). Changes may have been made.