Internal Bleeding

Bleeding in general is an alarming sign to the body. Comprehensive analysis is taken into consideration in evaluating the appropriate cause of the bleeding. This enables a prophylaxis approach and also categorizes the type of bleeding into internal or external. Internal bleeding is associated with many pre-existing conditions. In many cases internal bleeding may occur because of a trauma caused in a particular region affecting a vital organ of the body.

Clinical signs and evaluations of internal bleeding

External bleeding has causes such as wounds, laceration or an injury. Internal bleeding is difficult to identify. It is necessary to identify the exact location and damage of the blood vessel be it an artery or a vein. The body's only responses to such damages are clot formation through platelet aggregation and also thrombus. This immediate response of the body is to prevent hemorrhage and hypoxia in the organ systems.

Many clinical parameters are evaluated in the emergency room to understand and identify the exact cause of the bleeding inside the body. In case of internal bleeding, patients are immobilized to avoid further damage. Underlying fractures and bone disruptions are evaluated in case of internal fractures. Body orifices should be administered with dressings to prevent blood loss and infection. Vital parameters such as oxygen saturation, blood pressure, and pupil analysis are done to evaluate hypoxia and heart rate in case of trauma. Neurological, cardiovascular, respiratory and musculoskeletal systems are examined for blood vessel damage and associated prominent complaints of pain.

After thorough examination of the patient and recording the history, radiological investigations are required to detect vital organ damage. Surgical interventions are required in case of fracture, brain hemorrhage and other adverse organ damage. In patients who are on anticoagulants and blood thinning medications, internal bleeding is imminent in case of trauma.

In case of internal bleeding associated organ damage, the predominant reason is the damage of blood vessels in the organ due to compression. Most common examples are abdominal injuries caused during sports such as football and wrestling. Head injuries are more common in sports associated with more physical contact such as martial arts and boxing. Other important reasons are shift in internal organs in case of trauma. Internal bleeding is directly associated with long term alcohol consumption as it affects the blood vessels of the hepatic portal system. The complications associated with internal bleeding are severe as they may lead to death of the patient. This happens when transfusion doesn't happen on time.

Blood thinners

Doctors prescribe medicines for varied reasons, to cure an ailment, to prevent or stop an infection, to ease symptoms, to reduce risks etc. But if there is one particular group of medicines where there is a need for rigorous monitoring regime when taken, it is blood thinners. Not without a reason. Though approved by the FDA, if not handled properly, prolonged use of blood thinners can be unsafe.

Need for Blood thinners

Blood thinners reduce the ability of the blood to clot. Blood thinners belong to a class of drugs called anticoagulants. Immediately after an injury, a scrape or a cut, the blood coagulates and seals the wound, forming a scab to protect from infection. The blood clots formed will be naturally dissolved in the body after the injury is healed. Here blood clotting is a saver and is essential for the body.

The mechanism is regarded as dangerous when blood clots form in the blood stream without an obvious injury and if the blood clot fails to dissolve naturally after the injury heals. The situation poses great risks as it can block circulation; the blood clot can travel to the arteries or veins in the brain, heart, kidneys, lungs and limbs. This in turn can lead to life-threatening conditions such as heart attack, stroke, damage body's organs and in extreme cases result in loss of life.

An updated (February 2014) American Academy of Neurology (AAN) guideline recommends people with an irregular heartbeat to take blood thinners to reduce the risk of stroke. As per doctor's prescription, every year around 2 million people take blood thinner medications every day. It is strongly recommended that blood thinner be taken only under medical supervision.

New vs. old blood thinners

Warfarin was introduced sixty years ago. It is regarded as the oldest anticoagulant blood thinner medication. For decades, Warfarin was the only blood thinner available to lower risks of stroke. There are new additions. A recent study has showed that new blood thinners might be more effective than older medications.

• Dabigatran (Generic name) approved by FDA in October 2010
  
• Rivaroxaban (Generic name) approved by FDA in October 2011
  
• Apixaban (Generic name) approved by FDA in December 2012.
  

Detailed studies comparing Warfarin with the new addition state the following:

• New drugs are similar or even better than warfarin in preventing stroke.
  
  
• As the optimal dose of Warfarin varies from patient to patient, blood levels of patients on Warfarin need to be checked periodically.
  
  
• New blood thinner medications are regarded as more convenient because the patients taking them do not need to have blood levels checked.
  
  
• A study on effectiveness reflected that new blood thinners were approximately 20% more effective in reducing the risk of stroke and 10 % more effective in reducing the risk of death when compared to warfarin.
  
  
• New blood thinners, in addition to being more convenient, are potentially more effective than and similar in safety to warfarin.
  
  
• New blood thinners are more expensive than Warfarin.
  
  
• Long-term safety and side effects of new blood thinners is not yet available.
  
  
• With Warfarin, it is easier to reverse the blood thinning effect if a patient is bleeding or needs urgent surgery.

Types of blood thinners

It is chemical formulations that contribute to preventing clotting in various ways. Broadly blood thinner medications are classified into anticoagulant and anti platelet blood thinners.

Anticoagulant blood thinners

Anticoagulant blood thinner medications help decrease the tendency of blood clot formation. There are two ways to decrease the formation of blood clots in the body. Anticoagulants can interfere with platelets or block the body's production of clotting substances. Anticoagulant blood thinners are prescribed for people who have had a condition caused by a blood clot or are at risk of developing one.

Anticoagulant blood thinners are usually given by mouth. In some cases anticoagulants are given intravenously or by injecting them just under the skin (subcutaneously).

Warfarin: Warfarin is the generic drug. In the US, Warfarin is sold under the brand names Coumadin and Jantoven. Doctors prescribe Warfarin for two reasons, to prevent the formation of harmful blood clots or treat an existing blood clot. Some conditions for which Warfarin is prescribed include:

• Atrial fibrillation
  
• Stroke
  
• After a heart attack
  
• Clotting disorder
  
• Heart valve disease or heart valve replacement
  
• Treatment or prevention of Deep Venous Thrombosis (blood clots in the veins) and/or pulmonary embolism (blood clots in the lungs).

Patients prescribed Warfarin ought to know how Warfarin works. Knowing helps limit the intake of vitamin K rich foods like dark green vegetables such as broccoli, spinach, turnip greens, green peas etc. At any time, the blood needs certain proteins to clot. These proteins are made in the liver. To enable the liver in the process, Vitamin K is required.

When Warfarin is administered, it reduces the liver's ability to use Vitamin K. Warfarin and Vitamin K work against each other. Thus, the formation of blood clot becomes harder. The interaction between Warfarin and Vitamin K explains the need to partake a diet that is constant in Vitamin K while on Warfarin. The dosage of Warfarin may vary from person to person. A blood test may be recommended to determine the dosage. This blood test, Prothrombin Time or International Normalized Ratio is required to monitor the body's response to Warfarin. Based on test results, Warfarin dose will be determined.

Side effects of Warfarin

Warfarin or Heparin, a common side effect of any anticoagulant medication is the risk of excessive bleeding. As these medicines prolong or lengthen or makes blood clot formation harder, it increases the time for formation of blood clots. If the time taken is too long, there is a possibility of excessive bleeding. There are other symptoms to look out for which are more common with Warfarin. Patients on Warfarin should immediately seek medical attention for any these common Warfarin side effects.

• passing blood in your urine or feces (stools)
  
• passing black feces
  
• severe bruising
  
• prolonged nosebleeds for more than 10 minutes
  
• bleeding gums
  
• blood while throwing up (vomiting)
  
• coughing up blood
  
• unusual headaches
  
• sudden severe back pain
  
• difficulty breathing or chest pain

Women who take Warfarin should contact health care provider if they experience heavy or increased bleeding during menstruation or any other bleeding from the vagina.

Irrespective of the gender, some patients may experience rashes, diarrhea, nausea, hair loss while on Warfarin. These are not common side effects but are termed as additional side effects of Warfarin.

Doctors do advice patients to seek help if the patient is involved in a major accident, experiences a significant blow to the head and finds it difficult to stop bleeding, if any. As Warfarin can interact with many other medicines, so do inform the doctor about all the medications being taken.

Warfarin during pregnancy: Warfarin should be avoided during pregnancy and women with certain health conditions like high blood pressure, ulcer in the digestive tract should not take Warfarin as it can lead to severe health complications.

Long terms risks of using Warfarin: Extensive research on prolonged use of Warfarin suggests that the risk increases with age. The patient is at risk of serious or even fatal bleeding including internal bleeding. In particular the risks are:

• Bleeding strokes, or brain strokes (hemorrhage strokes)
  
• Calcium build-up in the arteries and narrowing of the aortic valve that goes from the heart and carries oxygen to the body (aortic valve stenosis)

Heparin: Heparin is the generic name. In US, Heparin is available under the brand names Lipohepin, liquaemin and Panheparin. Heparin decreases the clotting ability of the blood and also prevents existing clots from getting larger. Thereby, the normal body systems dissolve the clots that are already formed. Heparin is usually administered as an injection. Heparin can be injected subcutaneously or as an intravenous infusion. The advantage of IV is that it can be turned off quickly for safety reasons. Heparin is prescribed for conditions such as:

• Deep venous thrombosis
  
• Arterial embolism
  
• Pulmonary embolism
  
• Prevention of blood clot during heart surgery, dialysis or blood transfusions
  
• Peripheral artery obstruction by a foreign substance or a blood clot
  
• Treatment to prevent peripheral artery thrombo-embolism.

It helps to know how heparin works. Heparin ensures that an anti-clotting protein which is present in the body works better, thus decreasing the clotting ability of the blood.

Available in different strengths, the doctor must prescribe the strength depending on the purpose for which it is prescribed. During the course of treatment, the doctor may increase or decrease the dosage.

Side effects of heparin

A unique possible side effect of Heparin is that several weeks after stopping the injection, bleeding episodes may occur. If the patient notices bruising or unusual bleeding such as a nosebleed, blood in the urine or stools, black or tarry stools or any other bleeding that doesn't cease, contact your healthcare provider.

Besides the common side effects of anticoagulant medications, Heparin's other side effects are visible at that point where the solution is injected.

• Swelling
  
• Pain
  
• Irritation
  
• Bruising

Herparin during pregnancy: FDA category for Heparin is C meaning there isn't established information that proves whether Heparin affects the fetus. It is best for pregnant women as well as breast-feeding mothers to use Heparin only if the medicine is prescribed by the doctor.

Long term risks of using Heparin

Prolonged use of Heparin particularly in the elderly may cause osteoporosis, a condition in which the bones become weak and may break easily.

Antiplatelet blood thinners

Antiplatelet blood thinner medications work to prevent the platelets (small cells in the blood) from clumping together to form a blood clot. This happens by inhibiting the production of thromboxane, a chemical that signals other platelets to come together. By inhibiting the production of thromboxane, platelets cease to come together to form the blood clot.

Thromboxane's role is helpful for a normal healthy individual who has suffered a wound. It acts as a self-sealing material. But, in the case of a stroke survivor, thromboxane's ability to bind and form a blood clot is potentially life-threatening. Hence, the need to use an antiplatelet blood thinner which are usually available in the form of tablets only.

Doctors prescribe antiplatelet Aspirin to patients who have had a stroke or TIA (transient ischemic attack) so as to reduce the risk of having another stroke. This is possible with Aspirin as it interferes with the blood's clotting action. The dosage varies from patient to patient and is largely guided by the patient's health condition.

Though Aspirin is available OTC (over the counter), doctors recommend low doses of Aspirin for patients with the following medical history.

• Patients who have had prior heart attacks
  
• Patients who have had prior strokes
  
• Patients with exertional and unstable angina
  
• Patients with TIAs (transient ischemic attack called mini-stroke)
  
• Patients at risk of atherosclerosis.

Aspirin is prescribed to patients who are considered to be at risk of having heart attack or stroke. Anyone with high cholesterol, high blood pressure, diabetic and smoke aggressively are regarded to be at risk of having heart attack or stroke.

Side effect of Aspirin

Most common side effect of taking low doses of Aspirin (100 mg dose) is heartburn and stomach upset. Seldom has there been a very serious side effect related to taking Aspirin as a blood thinner medication. However it is best to be aware of possible serious side effects such as bruising/bleeding, difficulty hearing, ringing in the ears, and change in urine amount, persistent or severe nausea /vomiting, unexplained tiredness, dizziness, dark urine, yellowing of eyes or skin.

Aspirin during pregnancy

The FDA has not assigned formally a pregnancy category. Aspirin is not recommended for use during pregnancy and while breast-feeding as it excretes into breast milk in small amounts.

Other antiplatelet blood thinners

Besides Aspirin, other antiplatelet medicines that are prescribed to prevent the platelets from sticking together include the following. Doctors prescribe a specific antiplatelet blood thinner taking into account the specific health condition and relative effectiveness of the blood thinner medicine. New drugs are continually added to the list with FDA approval.

• Aspirin plus clopidogrel (brand name Plavix) is prescribed for patients who are diagnosed with coronary syndrome such as unstable angina or have had a heart attack, if stent is implanted or if the patient has had a stroke or mini stroke.
  
  
• Aspirin plus extended dipyridamole (brand name Aggrenox) is prescribed for patients who have had a stroke or mini stroke (TIA).
  
  
• Clopidogrel (brand name Plavix) is recommended by doctors if Aspirin is not suitable for a patient who has been diagnosed with acute coronary syndrome or had a stent implanted.

Long term risks of using Aspirin

Daily use of aspirin can have serious side effects including internal bleeding. Prolonged use of aspirin at higher doses (> 500 mg) can cause stomach ulcers, and can also prolonged bleeding.

CAT scan

Computed Axial Tomography (CAT scan) is a process of using computers to generate three dimensional images from a flat two dimensional X rays pictures through the 'slice' technique. Aided by computer, cross-sectional views are generated and if needed three dimensional images of the internal organs and structures of the body. In CAT scan the body is seen in 'slices' from the skin to the central part of the body. When all the levels (slices) are added together, a three dimensional picture of an organ is obtained. Together the cross sections give a very accurate picture of where the tumor is and how big or small it is. They also show how close the major body organs are to the area that needs to be treated or operated upon. A CAT scan can be used to define both the normal and abnormal structures the body. It also helps as an accurate guide in placement of instruments and treatments for undergoing procedures.

• The head is examined for trauma injuries, such as blood clots or skull fractures.
  
• Spine is studied for any infections and to check the anatomy of intervertebral discs and spinal cord.
  
• Density of the bone in evaluating osteoporosis is also accurately measured by CAT scan.
  
• CAT scans are used in the chest to identify tumors, cysts or infections.
  
• CAT scans of the abdomen are helpful in defining body organ anatomy, including visualizing liver, gall bladder, pancreas, spleen, aorta, kidneys, uterus and ovaries. Also CAT scans help to verify the presence or absence of tumors, infection, abnormal anatomy or changes in the body from trauma.
  
• CAT scans help to guide the radiologist in performing certain procedures such as biopsyand suspected cancers, removal of internal fluids for various tests.

Many of the procedures in CAT scan are minimally invasive. CAT scan is very low risk procedure. The amount of radiation in CAT scan is very minimal. Unlike MRI, CT scans can be done even if the patient has a pace maker or an internal cardioverter defibrillator devices implanted into the chest to help regulate the heart beat. CAT scan may pose a potential risk to the fetus during the first trimester of pregnancy. Sometimes in contrast studies using iodine-based, there may be itching, a rash, hives or a feeling of warmth throughout the body. But these reactions tend to go away quickly. Very rarely does a more serious reaction occur during intravenous contrast studies. This anaphylactic reaction results in severe hives and/or difficulty in breathing.

Benefits of CAT Scan

• Diagnose muscle and bone disorders such as bone tumors and fractures
  
• Pinpoint the location of tumor, infection and blood clot
  
• Guide certain procedures in surgery
  
• Detect and monitor diseases such as cancer or heart disease
  
• Detect internal injuries and internal bleeding.