What are the symptoms of severe bleeding?

Symptoms of Severe Bleeding

Severe bleeding is characterized by increased pulse rate (>100-140 beats per minute), decreased blood pressure, decreased pulse pressure, increased respiratory rate (>30-40 breaths per minute), decreased urine output, and altered mental status including anxiety, confusion, or lethargy. 1

Vital Sign Changes

• Pulse rate: Increases progressively with blood loss severity - >100 beats per minute in moderate bleeding, >120 in more severe cases, and >140 in critical hemorrhage 1
• Blood pressure: Initially maintained but eventually decreases as bleeding becomes more severe 1
• Pulse pressure: Becomes narrower (decreased) as bleeding progresses 1
• Respiratory rate: Increases from 20-30 breaths per minute in moderate bleeding to >40 in severe cases 1

Mental Status Changes

• Mild to moderate bleeding: Slight to mild anxiety 1
• Severe bleeding: Anxiety, confusion, disorientation 1
• Critical bleeding: Lethargy, decreased consciousness, stupor or coma (especially with intracranial hemorrhage) 1

Other Clinical Manifestations

• Urine output: Decreases from 20-30 ml/hour in moderate bleeding to 5-15 ml/hour in severe cases, becoming negligible in critical hemorrhage 1
• Skin appearance: Cool, clammy skin with decreased capillary refill due to vasoconstriction 1
• Shortness of breath: Develops with significant blood loss 1
• Orthostatic changes: Drop in blood pressure (≥20 mmHg systolic or ≥10 mmHg diastolic) upon standing 1

Specific Signs Based on Bleeding Location

• Intracranial hemorrhage: Unusually intense headache, vomiting, reduced consciousness, vision changes, numbness, weakness, aphasia, ataxia, vertigo, seizures 1
• Gastrointestinal bleeding: Visible blood in vomit or stool, black tarry stools (melena), or bright red blood per rectum (hematochezia) 1
• External bleeding: Visible blood loss from wounds, continuous bleeding despite direct pressure 2

Severity Classification

According to the American College of Surgeons Advanced Trauma Life Support classification, hemorrhage severity can be categorized based on blood loss volume 1:

• Class I: <750 ml blood loss (mild symptoms)
• Class II: 750-1,500 ml blood loss (moderate symptoms)
• Class III: 1,500-2,000 ml blood loss (severe symptoms)
• Class IV: >2,000 ml blood loss (critical symptoms)

Warning Signs of Life-Threatening Bleeding

• Hemodynamic instability: Systolic blood pressure <90 mmHg, decrease in systolic blood pressure >40 mmHg, or mean arterial pressure <65 mmHg 1
• Signs of shock: Tachycardia, hypotension, decreased consciousness, and poor peripheral perfusion occurring together 1
• Bleeding from critical sites: Thoracic, airway, pericardial, intra-abdominal, retroperitoneal, intra-articular, or intracranial locations 1
• Ongoing visible blood loss: Continued external bleeding despite initial pressure or treatment measures 1

Clinical Pitfalls

• Blood pressure may initially be maintained despite significant blood loss, particularly in younger patients, making it an unreliable early indicator of severe bleeding 1
• Medications such as beta-blockers may mask tachycardia, a key early sign of blood loss 1
• Elderly patients or those with chronic hypertension may show signs of shock at higher blood pressure readings than typically expected 1
• Orthostatic vital sign changes may be absent in patients who cannot stand or sit up due to injuries 1