Internal Bleeding

What to do now

1. Call 911 or your local emergency number.
2. Lay the person flat and keep them warm. Raise their legs if there is no injury to the legs, hips or spine.
3. Do not give food or drink, in case surgery is needed.
4. If they are unconscious but breathing, place them on their side unless spinal injury is suspected.
5. For visible bleeding at the same time, press firmly on the wound.
6. Watch breathing and be ready to start CPR.

Signs and symptoms by location

Internal bleeding causes two kinds of symptoms: those of blood loss in general, and those of blood collecting in a particular place.

General signs of blood loss

• dizziness or lightheadedness, especially on standing
• fainting
• pale, cold, clammy skin
• fast heart rate and fast breathing
• thirst
• weakness and confusion
• low urine output

These signal hemorrhagic shock when severe.

By location

Causes

Injuries

• vehicle crashes, falls, sports collisions and assaults
• blunt trauma that ruptures the spleen or liver
• fractures, especially of the pelvis and thigh bone
• penetrating wounds

Without injury

• Gastrointestinal bleeding: peptic ulcers, esophageal varices, diverticular bleeding, tumors and inflammatory bowel disease
• Ruptured blood vessels: abdominal aortic aneurysm, brain aneurysm
• Pregnancy-related: ectopic pregnancy, placental abruption, bleeding after birth
• Ruptured ovarian cyst
• Blood thinners: warfarin and newer anticoagulants raise the risk of bleeding anywhere, including the brain (anticoagulant-associated bleeding)
• Bleeding disorders: hemophilia, von Willebrand disease, low platelets, liver disease
• Medicines: NSAIDs and aspirin increase gut bleeding risk
• Tumors that bleed
• Spontaneous rupture of the spleen in infections such as mononucleosis

Internal bleeding after a fall or accident

Bleeding can be delayed or slow. Symptoms may not appear for hours or, with head injuries, days to weeks (a slowly expanding subdural hematoma). Older adults and anyone on blood thinners should be assessed after a fall, even if they feel well. Watch for increasing pain, swelling, dizziness, headache or confusion over the following days.

Diagnosis

• Vital signs and examination: pulse, blood pressure, skin color, belly tenderness
• Blood tests: hemoglobin (may be normal early), clotting tests, blood type and cross-match
• Bedside ultrasound (FAST scan) in trauma, to detect blood in the belly or around the heart
• CT scan: the main test for locating bleeding in the head, chest and abdomen
• Endoscopy and colonoscopy: to find and treat gut bleeding
• Angiography: to locate and block bleeding vessels

Treatment

• Resuscitation: IV fluids, blood transfusion (red cells, plasma and platelets) and oxygen
• Reversing blood thinners: with specific antidotes when available
• Stopping the source: - endoscopic treatment for ulcers and varices - embolization by interventional radiology, blocking the bleeding vessel through a catheter - surgery, for example to repair the spleen, liver, aorta or remove an ectopic pregnancy - drainage of blood around the lungs or brain
• Tranexamic acid: a medicine that reduces clot breakdown, used early in significant trauma
• Observation: small, stable bleeds may be monitored in the hospital

Complications

• hemorrhagic shock and organ failure
• brain damage from bleeding in or around the brain
• compartment syndrome in limbs
• anemia
• death if not treated promptly

Frequently asked questions

What are the first signs of internal bleeding?

Early signs include pain or swelling at the site, dizziness, weakness, pale or clammy skin and a fast heartbeat. Depending on the location, there may be black or bloody stools, vomiting blood, blood in urine, coughing blood, or headache and confusion.

Can internal bleeding stop on its own?

Small internal bleeds sometimes stop on their own, such as minor bruising in muscles. Significant internal bleeding often continues and can be life-threatening. Anyone with signs of internal bleeding needs medical assessment to find and control the source.

How long after a fall can internal bleeding occur?

Bleeding usually begins at the time of injury, but symptoms may develop over hours. Bleeding around the brain in older adults or people on blood thinners can appear days to weeks later. Seek care for increasing pain, headache, confusion or dizziness after a fall.

What does internal bleeding in the stomach look like?

Bleeding in the stomach may cause vomiting of red blood or dark material that looks like coffee grounds, and black, sticky, tar-like stools. Dizziness, weakness and fainting may follow. This needs emergency care.

How do doctors find internal bleeding?

Doctors use examination, blood tests, a bedside ultrasound (FAST scan) after trauma, and CT scans to locate bleeding. Endoscopy or colonoscopy finds bleeding in the gut, and angiography can show the exact bleeding vessel.