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

• Inflammation

  Abstract BACKGROUND Systemic inflammation plays a critical role in the pathophysiological process of intracranial hemorrhage (ICH). [ncbi.nlm.nih.gov]

  The urgent bronchoscopy showed plentiful blood remnants on tracheobronchial tree and signs of chronic inflammation without active bleeding. [journalpulmonology.org]

  Causes of hemorrhage per diapedesis include: hypoxia or anoxia abnormal coagulation of blood toxic injury inflammation of vessel wall nutritional deficiency Hemorrhage per diapedesis is often classified according to the size of the hemorrhagic spot: We're [vet.uga.edu]

• Chills

  You may have PPH if you have heavy bleeding from the vagina that doesn’t slow or stop, blurred vision, chills, or if you feel weak or feel faint. You’re more likely to have PPH if you’ve had it in the past. [marchofdimes.org]

  For infection consider asking: “Have you had any fever, chills, shakes, night sweats, malaise, fatigue, or decreased appetite?” [cancertherapyadvisor.com]

• Tachypnea

  Beginning 2 weeks after onset, he developed paroxysmal hyperthermia, tachycardia, tachypnea, hypertension, and generalized dystonic movements. [ncbi.nlm.nih.gov]

  Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness.[3] A patient may lose more than 30% of their blood volume [en.wikipedia.org]

  Vital signs are reviewed for fever, tachycardia, tachypnea, and low oxygen saturation. [merckmanuals.com]

• Hematemesis

  Here, we present a case of a 6-year-old Asian boy with hematemesis and elevated alanine aminotransferase (ALT) (80 U/L) and aspartate aminotransferase (AST) (69 U/L) levels on day 2 of oseltamivir administration. [ncbi.nlm.nih.gov]

  The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices. [merckmanuals.com]

  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 [symptoma.com]

  […] can be considered a fortuitous symptom for the early diagnosis of a small tumor in the lung.(1) The clinical history will help to determine the amount of blood loss and will facilitate the differential diagnosis among hemoptysis, pseudohemoptysis and hematemesis [scielo.br]

  Often the result of strain, including sneezing, coughing, vomiting or other kind of strain Nose Epistaxis - nosebleed Mouth Tooth eruption – losing a tooth Hematemesis – vomiting fresh blood Hemoptysis – coughing up blood from the lungs Lungs Pulmonary [en.wikipedia.org]

• Melena

  Gastrointestinal hemorrhage: Abdominal distention, hematochezia, melena and hypotension. [symptoma.com]

  Location Descriptive Term Biliary tract Hemobilia Fallopian tubes Hemosalpinx Lower GI tract Hematochezia; melena Upper GI tract Hematemesis Joints Hemarthosis Lungs/Bronchi (coughed up) Hemoptysis Nasal passages Epistaxis Skin Ecchymosis Urinary tract [medical-dictionary.thefreedictionary.com]

  Gynecologic Vaginal bleeding Postpartum hemorrhage Breakthrough bleeding Ovarian bleeding - this is a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome undergoing transvaginal oocyte retrieval.[7] Anus Melena [en.wikipedia.org]

  Review of systems should specifically query about bleeding from sites other than those volunteered (eg, patients complaining of easy bruising should be questioned about frequent nosebleeds, gum bleeding while tooth brushing, melena, hemoptysis, blood [msdmanuals.com]

• Blood in Stool

  Blood tests, imaging studies, spinal tap, stool exam and urinalysis may be required to diagnose internal hemorrhages. [symptoma.com]

  […] in stool or urine). [msdmanuals.com]

• Hematochezia

  Gastrointestinal hemorrhage: Abdominal distention, hematochezia, melena and hypotension. [symptoma.com]

  Location Descriptive Term Biliary tract Hemobilia Fallopian tubes Hemosalpinx Lower GI tract Hematochezia; melena Upper GI tract Hematemesis Joints Hemarthosis Lungs/Bronchi (coughed up) Hemoptysis Nasal passages Epistaxis Skin Ecchymosis Urinary tract [medical-dictionary.thefreedictionary.com]

  […] hemorrhage Breakthrough bleeding Ovarian bleeding - this is a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome undergoing transvaginal oocyte retrieval.[7] Anus Melena - upper gastrointestinal bleeding Hematochezia [en.wikipedia.org]

• Hypotension

  A 51-year-old woman presented to the emergency room with sudden-onset severe abdominal pain, as well as hypotension and low level of hemoglobin. [ncbi.nlm.nih.gov]

  When the hypotension is very severe (e.g., mean arterial pressures The combined effects of arterial hypotension and sympathetic activation lead to activation of humoral compensatory mechanisms. [cvphysiology.com]

  Recommend laparotomy in hypotensive pts w/ SFP and strong consideration of angio prior to laparotomy in hypotensive pts w/ UFP. [east.org]

  Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness.[3] A patient may lose more than 30% of their blood volume [en.wikipedia.org]

  Introduction Defined as the loss of > 1000mL of blood loss within the first 24 hours after delivery regardless of the route of delivery physiologic stress can cause hypotension and increased cortisol demand (problematic in primary adrenal insufficiency [medbullets.com]

• Tachycardia

  CASE REPORT A 68-year-old man who underwent a right nephrectomy for RCC 8 years ago was referred to the Emergency Department (ED) complaining of upper-chest pain radiating to the left shoulder, tachycardia, and increased dysphonia. [ncbi.nlm.nih.gov]

  Vital signs and general appearance can indicate hypovolemia (tachycardia, hypotension, pallor, diaphoresis) or infection (fever, tachycardia, hypotension with sepsis). [msdmanuals.com]

  Over time, internal bleeding can cause low blood pressure (hypotension), increased heart rate (tachycardia), increased breathing rate (tachypnea), confusion, drowsiness, and loss of consciousness.[3] A patient may lose more than 30% of their blood volume [en.wikipedia.org]

• Flushing

  Preoperative clinical parameters, surgeon status, number of catheters and catheter-days, subgaleal tunneling distance, frequency of urokinase flush, and prophylactic antibiotics were compared between the infective and noninfective groups. [ncbi.nlm.nih.gov]

  If it is normal and thrombin time is prolonged, provides presumptive evidence that a plasma sample contains heparin (eg, residual heparin after extracorporeal bypass or in a sample drawn from an IV line kept open with heparin flushes) because reptilase [msdmanuals.com]

  […] removed carefully after every centrifuge and the volume of the final RBCs solution was approximately 1 mL. 18 F labeling of NHS ester 1 and 2 In a typical radiosynthesis, an aliquot of cyclotron-proton bombarded, pure [ 18 O]-water was received and flushed [doi.org]

• Hemianopsia

  In 1 patient with a focal hematoma and minute hemorrhages, a permanent neurologic deficit was present at discharge (hemiparesis, facial droop, hemianopsia). [ajnr.org]

• Epistaxis

  English Bleeding drug-related events, ranging from petechiae and epistaxis to severe gastrointestinal haemorrhage and CNS bleeding, were reported in patients taking SPRYCEL (see section 4.4). [mymemory.translated.net]

  Epistaxis[edit] Epistaxis, or nosebleed, is a special case, where almost all first aid providers train the use of pressure points. [en.wikipedia.org]

  In children and adults, presentation is usually bruising, epistaxis and mouth bleeding. [clinicaladvisor.com]

  The bandage should be loosened at 12-min to 15-min intervals to prevent arterial obstruction. lung hemorrhage Hemorrhage from the lung, with bright red and frothy blood, frequently coughed up. nasal hemorrhage Epistaxis. petechial hemorrhage Hemorrhage [medical-dictionary.thefreedictionary.com]

• Irritability

  Nosebleeds may develop in people who have colds or chronic hay fever symptoms (postnasal drip, sneezing, or a runny, stuffy, or itchy nose) because nasal tissues become inflamed and irritated. [northshore.org]

  The draining blood can irritate brain tissue, causing swelling, or cerebral edema. As blood accumulates and compresses the surrounding brain tissue, it can form a mass, known as a hematoma. [uabmedicine.org]

  Symptoms can include: Sudden, severe headache Dizziness or fainting Trouble with vision, speech, or movement Confusion, extreme irritability, or sudden personality change, or coma Fever Stiff neck Seizures or convulsions Nausea and vomiting How is intracranial [fairview.org]

  […] múltiple A02 Escalofríos A03 Fiebre A04 Astenia/cansancio/debilidad A05 Sensación de enfermedad A06 Desmayo/síncope A07 Coma A08 Inflamación A09 Problemas de sudoración A10 Sangrado/hemorragia NE A11 Dolor torácico NE A13 Miedo al tratamiento A16 Lactante irritable [iqb.es]

  When blood from trauma irritates brain tissues, it causes swelling. This is known as cerebral edema. The pooled blood collects into a mass called a hematoma. [webmd.com]

• Meningism

  Other diagnostic possibilities include: pseudo-subarachnoid hemorrhage bacterial meningitis tuberculous meningitis granulomatous meningitis neurosarcoidosis [radiopaedia.org]

  BACKGROUND: Traumatic pseudoaneurysm of the middle meningeal artery (PMMA) is rare. Its rupture is associated with high mortality, so an early diagnosis is recommended for this risky condition. [ncbi.nlm.nih.gov]

  Meninges The brain is covered from inside out by the pia mater, the arachnoid mater, the dura mater and the skull roof (fig. 5). Figure 5. Normal anatomy of the cerebral meninges. [startradiology.com]

  Fractures of the temporal bone can disrupt the middle meningeal artery, leading to high-pressure bleeding within the cranial vault. Herniation can occur within hours if the hematoma is not evacuated, so early recognition is key. [cdemcurriculum.com]

• Communicating Hydrocephalus

  Another cause of increased volume of the ventricular system is hydrocephalus. Hydrocephalus can be subdivided into communicating and non-communicating hydrocephalus. [startradiology.com]

• Uterine Hemorrhage

  The three types of pathologic uterine hemorrhage are essential uterine hemorrhage (metropathia haemorrhagica), which occurs with pelvic, uterine, or cervical diseases; intrapartum hemorrhage, which occurs during labor; and postpartum hemorrhage, which [medical-dictionary.thefreedictionary.com]

  Trauma (approximately 20%): Lacerations of uterus, cervix or vagina Uterine rupture At cesarean delivery, hemorrhage from the uterine incision is generally caused by an excessively lateral extension of the incision. [medical4free.com]

  Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med. 1995 Mar. 40(3):189-93. [Medline]. AbdRabbo SA. [emedicine.medscape.com]

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.

• Polyps

  A general ENT usually cannot see if you have a polyp with the traditional scope. That is because the equipment available to most general ENTs is not sophisticated enough to get a close view of the vocal folds and their vibration. [voicedoctorla.com]

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.

1. Manning JE. Fluid and Blood Resuscitation in Emergency Medicine: A Comprehensive Study Guide. JE Tintinalli Ed. McGraw-Hill: New York 2004. p227.
2. Webert KE, Cook RJ, Sigouin CS, et al. The risk of bleeding in thrombocytopenic patients with acute myeloid leukemia. haematologica 2006;91:1530-1537.
3. Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med. Nov 4 2010; 363(19):1791-800.
4. Abouzahr C. Antepartum and postpartum haemorrhage. In: Murray CJ, Lopez AD, eds. Health Dimensions of Sex and Reproduction. Boston, Mass: Harvard University Press; 1998:172-4.
5. Liberty G, Hyman JH, Eldar-Geva T, Latinsky B, Gal M, Margalioth EJ. Ovarian hemorrhage after transvaginal ultrasonographically guided oocyte aspiration: a potentially catastrophic and not so rare complication among lean patients with polycystic ovary syndrome. Fertil. Steril. 93 (3): 874–879.
6. Baskett TF. Complications of the third stage of labour. In: Essential Management of Obstetrical Emergencies. 3rd ed. Bristol, England: Clinical Press; 1999:196-201.
7. Xiong X, Buekens P, Alexander S, Demianczuk N, Wollast E. Anemia during pregnancy and birth outcome: a meta-analysis. Am J Perinatol. 2000; 17(3):137-46.
8. Ryan MJ, Key SM, Dumbleton SA, MD, et al. Nonlocalized Lower Gastrointestinal Bleeding: Provocative Bleeding Studies with Intraarterial tPA, Heparin, and Tolazoline. J Vasc Interv Radiol. 2001; 12:1273-77.
9. Aledort LM. Off-label use of recombinant activated factor VII--safe or not safe? N Engl J Med. Nov 4 2010; 363(19):1853-4.
10. Stoneham MD. An evaluation of methods of increasing the flow rate of i.v. fluid administration. Br J Anaesth. Sep 1995; 75(3):361-5.