This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (August 2007)

Bleeding
Classification and external resources
A bleeding human finger
ICD-10	R58
MeSH	D006470

Bleeding, technically known as hemorrhaging or haemorrhaging (see American and British spelling differences), is the loss of blood or blood escape from the circulatory system.^[1] Bleeding can occur internally, where blood leaks from blood vessels inside the body, or externally, either through a natural opening such as the vagina, mouth, nose, ear or anus, or through a break in the skin. Desanguination is a massive blood loss, and the complete loss of blood is referred to as exsanguination.^[2] Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties, and blood donation typically takes 8–10% of the donor's blood volume.^[3]

Classification[link]

A subconjunctival hemorrhage is a common and relatively minor post-LASIK complication.

The endoscopic image of linitis plastica, a type of stomach cancer leading to a leather bottle-like appearance with blood coming out of it.

Micrograph showing abundant hemosiderin-laden alveolar macrophages (dark brown), as seen in a pulmonary hemorrhage. H&E stain.

Blood loss[link]

Hemorrhaging is broken down into four classes by the American College of Surgeons' Advanced Trauma Life Support (ATLS).^[4]

• Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary.
• Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient may exhibit slight changes in behavior. Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required.
• Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral hypoperfusion (shock), such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary.
• Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death.

This system is basically the same as used in the staging of hypovolemic shock.

Individuals in excellent physical and cardiovascular shape may have more effective compensatory mechanisms before experiencing cardiovascular collapse. These patients may look deceptively stable, with minimal derangements in vital signs, while having poor peripheral perfusion. Elderly patients or those with chronic medical conditions may have less tolerance to blood loss, less ability to compensate, and may take medications such as betablockers that can potentially blunt the cardiovascular response. Care must be taken in the assessment of these patients.

World Health Organization[link]

The World Health Organization made a standardized grading scale to measure the severity of bleeding.^[5]

Origin[link]

• Mouth
  • Hematemesis - vomiting fresh blood
  • Hemoptysis - coughing up blood from the lungs
• Hematochezia - rectal blood
• Hematuria - blood in the urine from urinary bleeding
• Upper head
  • Intracranial hemorrhage - bleeding in the skull.
  • Cerebral hemorrhage - a type of intracranial hemorrhage, bleeding within the brain tissue itself.
  • Intracerebral hemorrhage - bleeding in the brain caused by the rupture of a blood vessel within the head. See also hemorrhagic stroke.
  • Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process. The common medical use of the term SAH refers to the nontraumatic types of hemorrhages, usually from rupture of a berry aneurysm or arteriovenous malformation(AVM). The scope of this article is limited to these nontraumatic hemorrhages.
• Lung
  • Pulmonary hemorrhage
• 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.^[6]
• Upper gastrointestinal bleed

Causes[link]

Bleeding arises due to either traumatic injury, underlying medical condition, or a combination.

Traumatic Injury[link]

Traumatic bleeding is caused by some type of injury. There are different types of wounds which may cause traumatic bleeding. These include:

• Abrasion - Also called a graze, this is caused by transverse action of a foreign object against the skin, and usually does not penetrate below the epidermis
• Excoriation - In common with Abrasion, this is caused by mechanical destruction of the skin, although it usually has an underlying medical cause
• Hematoma - Caused by damage to a blood vessel that in turn causes blood to collect under the skin.
• Laceration - Irregular wound caused by blunt impact to soft tissue overlying hard tissue or tearing such as in childbirth. In some instances, this can also be used to describe an incision.
• Incision - A cut into a body tissue or organ, such as by a scalpel, made during surgery.
• Puncture Wound - Caused by an object that penetrated the skin and underlying layers, such as a nail, needle or knife
• Contusion - Also known as a bruise, this is a blunt trauma damaging tissue under the surface of the skin
• Crushing Injuries - Caused by a great or extreme amount of force applied over a period of time. The extent of a crushing injury may not immediately present itself.
• Ballistic Trauma - Caused by a projectile weapon such as a firearm. This may include two external wounds (entry and exit) and a contiguous wound between the two

The pattern of injury, evaluation and treatment will vary with the mechanism of the injury. Blunt trauma causes injury via a shock effect; delivering energy over an area. Wounds are often not straight and unbroken skin may hide significant injury. Penetrating trauma follows the course of the injurious device. As the energy is applied in a more focused fashion, it requires less energy to cause significant injury. Any body organ, including bone and brain, can be injured and bleed. Bleeding may not be readily apparent; internal organs such as the liver, kidney and spleen may bleed into the abdominal cavity. The only apparent signs may come with blood loss. Bleeding from a bodily orifice, such as the rectum, nose, ears may signal internal bleeding, but cannot be relied upon. Bleeding from a medical procedure also falls into this category.

Medical condition[link]

'Medical bleeding' denotes hemorrhage as a result of an underlying medical condition (i.e. causes of bleeding that are not directly due to trauma). Blood can escape from blood vessels as a result of 3 basic patterns of injury:

• Intravascular changes - changes of the blood within vessels (e.g. ↑ blood pressure, ↓ clotting factors)
• Intramural changes - changes arising within the walls of blood vessels (e.g. aneurysms, dissections, AVMs, vasculitides)
• Extravascular changes - changes arising outside blood vessels (e.g. H pylori infection, brain abscess, brain tumor)

The underlying scientific basis for blood clotting and hemostasis is discussed in detail in the articles, Coagulation, hemostasis and related articles. The discussion here is limited to the common practical aspects of blood clot formation which manifest as bleeding.

Certain medical conditions can also make patients susceptible to bleeding. These are conditions that affect the normal "hemostatic" functions of the body. Hemostasis involves several components. The main components of the hemostatic system include platelets and the coagulation system.

Platelets are small blood components that form a plug in the blood vessel wall that stops bleeding. Platelets also produce a variety of substances that stimulate the production of a blood clot. One of the most common causes of increased bleeding risk is exposure to non-steroidal anti-inflammatory drugs (or "NSAIDs"). The prototype for these drugs is aspirin, which inhibits the production of thromboxane. NSAIDs inhibit the activation of platelets, and thereby increase the risk of bleeding. The effect of aspirin is irreversible; therefore, the inhibitory effect of aspirin is present until the platelets have been replaced (about ten days). Other NSAIDs, such as "ibuprofen" (Motrin) and related drugs, are reversible and therefore, the effect on platelets is not as long-lived.

There are several named coagulation factors that interact in a complex way to form blood clots, as discussed in the article on coagulation. Deficiencies of coagulation factors are associated with clinical bleeding. For instance, deficiency of Factor VIII causes classic Hemophilia A while deficiencies of Factor IX cause "Christmas disease"(hemophilia B). Antibodies to Factor VIII can also inactivate the Factor VII and precipitate bleeding that is very difficult to control. This is a rare condition that is most likely to occur in older patients and in those with autoimmune diseases. von Willebrand disease is another common bleeding disorder. It is caused by a deficiency of or abnormal function of the "von Willebrand" factor, which is involved in platelet activation. Deficiencies in other factors, such as factor XIII or factor VII are occasionally seen, but may not be associated with severe bleeding and are not as commonly diagnosed.

In addition to NSAID-related bleeding, another common cause of bleeding is that related to the medication, warfarin ("Coumadin" and others). This medication needs to be closely monitored as the bleeding risk can be markedly increased by interactions with other medications. Warfarin acts by inhibiting the production of Vitamin K in the gut. Vitamin K is required for the production of the clotting factors, II, VII, IX, and X in the liver. One of the most common causes of warfarin-related bleeding is taking antibiotics. The gut bacteria make vitamin K and are killed by antibiotics. This decreases vitamin K levels and therefore the production of these clotting factors.

Deficiencies of platelet function may require platelet transfusion while deficiencies of clotting factors may require transfusion of either fresh frozen plasma or specific clotting factors, such as Factor VIII for patients with hemophilia.

See also[link]

• Anaesthesia Trauma and Critical Care
• Aneurysm
• Autohemorrhaging
• Coagulation
• Exsanguination - death by bleeding
• Hemophage
• Hemophilia

Footnotes[link]

Jagjit Singh
Jagjit Singh performing at Jaidev Hall, Bhubaneswar, on 7 September 2011
Background information
Birth name	Jagmohan Singh
Born	(1941-02-08)8 February 1941 Sri Ganganagar, Bikaner State, India
Died	10 October 2011(2011-10-10) (aged 70) Mumbai, Maharashtra, India
Genres	Ghazal, Classical, Devotional, Folk
Occupations	Composer, Singer, Music Director, Activist, Entrepreneur
Instruments	Vocals, Harmonium, Tanpura, Piano
Years active	1965–2011
Labels	EMI, HMV, Saregama, Universal Music, Sony BMG Music Entertainment, Polydor, TIPS, Venus, T-Series, Magna Sound, Big Music, Times Music

Jagjit Singh, born Jagmohan Singh); (8 February 1941 – 10 October 2011) was a prominent Indian Ghazal singer, songwriter and musician. Known as "the Ghazal King", he gained acclaim together with his wife, another renowned Indian Ghazal singer Chitra Singh in the 1970s and 1980s. Their combination album comprising music from the films, Arth and Saath Saath is the HMV's largest selling combination album of all time.^{[citation needed]} Sajda (An Offering, 1991), Jagjit Singh's magnum opus double album with Lata Mangeshkar holds the same record in non-film category.^{[citation needed]} He had sung in numerous languages. He was awarded the Padma Bhushan by the government of India in 2003.

Singh is credited for the revival and popularity of ghazal, an Indian classical art form, by choosing poetry that was relevant to the masses and composing them in a way that laid more emphasis on the meaning of words and melody evoked by them. In terms of Indian Classical music, his style of composing and Gayaki (singing) is considered as Bol-pradhan, one that lays emphasis on words. He highlighted this in his music for films such as Prem Geet (1981), Arth and Saath Saath (1982), and TV serials Mirza Ghalib (1988) and Kahkashan (1991). Jagjit Singh is considered to be the most successful ghazal singer and composer of all time in terms of both critical acclaim and commercial success. With a career spanning over five decades and a repertoire comprising over 80 albums,^[1] the range and breadth of his work has been regarded as genre-defining. He is the only composer and singer to have composed and recorded songs written by Prime Minister - Atal Behari Vajpayee - also a critically acclaimed poet - in two albums, Nayi Disha (1999) and Samvedna (2002).

Singh's 1987 album, Beyond Time, was the first digitally recorded release in India.^{[citation needed]} He was regarded as one of India's most influential artistes. Together with sitar legend Ravi Shankar and other leading figures of Indian classical music and literature, Singh voiced his concerns over politicisation of arts and culture in India and lack of support experienced by the practitioners of India's traditional art forms, particularly folk artists and musicians. He also lent active support to several philanthropic endeavors such as the library at St. Mary's School, Mumbai, Bombay Hospital, CRY, Save the Children and ALMA.

Early life and career[link]

Jagjit Singh was born on 8 February 1941 in Sri Ganganagar, Rajasthan, India. His birth name was Jagmohan but this was changed to Jagjit after his parents sought the advice of a member of the Sikh Namdhari sect.^[2] His parents were themselves Sikhs, called Amar Singh and Bachan Kaur, and had several other children, with sources variously reporting the number between six and eleven.^[3][4]

Educated initially at Khalsa High School and Sri Ganganagar Government College, Singh obtained an arts degree from DAV College at Jalandhar and then a post-graduate degree in history from Kurukshetra University in Haryana. Throughout this time, and as a consequence of a natural talent that was spotted by his father, Singh learned music both in Sikh temples and from musicians such as Pandit Chaganlal Sharma and Ustad Jamaal Khan, both of whom were trained in classical Indian music. He performed on radio and on stage, as well as composing some material, although he subsequently claimed that his father, who was a government employee, had hoped that he would become an engineer.^[5] On another occasion his memory was that his father aspired for him to become a bureaucrat, and that his siblings also were encouraged musically.^[3]

In March 1965, and without the knowledge of his family,^[5] Singh moved to Mumbai, where there were many opportunities for music artists because of the Bollywood film industry. He obtained work initially as a singer of advertising jingles and later progressed to playback singing.^[2] In the same year he persuaded the record company HMV to produce an EP, and he also altered his Sikh image by abandoning his turban, shaving and cutting his hair.^[5] His first film role was in Dharati Na Chhoru, a Gujarati production by Suresh Amin.^{[citation needed]}

Fame[link]

Singh was still struggling to make a living in 1967 when he met the Bengali-born Chitra Dutta.^[5] She was also a jingle singer, and was unhappily married with a daughter. She subsequently divorced and then married Singh in December 1969.^[3] Following the birth of their son, Vivek, the couple performed as a singing duo but it was not until the 1976^{[clarification needed]} release of an album entitled The Unforgettables that they found significant, and surprising, success. In the interval, the primary difficulty for them had been that the ghazal music genre was dominated by Muslim artists,^[5] and especially those from Pakistan.^[6]

The Unforgettables, which was the couple's first LP,^[3] was an unconventional recording and it turned them into stars. The song Baat Niklegi from the album achieved great popularity for Singh and his wife.^[4] The Independent described it in 2011 as "ground-breaking ... it became a transformative, before-and-after milestone in the history of Indian popular and ghazal music. It remains that." Using modern arrangements, it consists of ten tracks that include two on which they sang as a duo and the remainder equally split between Jagjit and Chitra singing the lead. The Independent further noted that "This format of solo and duet performances from the first commercially successful husband-and-wife team in Indian popular music proved astonishingly successful."^[2] Jagjit explained that "I was determined to polish up the genre and make it more acceptable to modern tastes, so chose simple poems and set them to simple tunes. I also introduced western instrumentation to make them livelier." Thereafter, the couple worked both on solo and joint musical projects and performed concerts worldwide. There was also success from involvement with the film industry and they amassed a considerable wealth,^[5] while Jagjit became known as "the Ghazal king".^[6]

Jagjit Singh's work in film^[7] encompassed playback singing for productions such as Arth, Saath Saath and Premgeet. He also composed all of the songs for the latter, as well as for the TV serial Mirza Ghalib that was based on the life of the eponymous poet, Mirza Ghalib.^{[citation needed]}

Among their subsequent duo recordings of the 1970s were Shiv Kumar Batalvi – Birha da Sultan (1978), Live in Concert at Wembley (1979) and Come Alive (1979). Of those released in the 1980s, Ecstasies (1984) has been described as "one of their finest".^[2] The joint projects ceased in 1990 when their eighteen year-old son, Vivek, was killed in a road accident. Chitra felt unable to sing following these events. Monica, Chitra's daughter from her first marriage, committed suicide in 2009.^[2][5]

Although Jagjit continued to work and to have success after Chitra withdrew from public life he, too, was affected by the death of Vivek. The Guardian notes that he "suffered from deep depression and his anguish was often evident in his live performances." Aside from occupying himself with solo projects, which he performed in several languages,^[6] he also collaborated with Lata Mangeshkar on an album entitled Sajda, an Urdu word meaning "prostration".^[2][5]

On 10 May 2007, in the presence of numerous political and diplomatic luminaries at an event held in the Central Hall of the Parliament of India, Jagjit Singh rendered Bahadur Shah Zafar's famous ghazal Lagta nahin hai dil mera to commemorate the 150th anniversary of the Indian Rebellion of 1857.^[4][8]

Death[link]

Singh toured the UK in 2011 and was due to perform with Ghulam Ali in Mumbai^[5] but suffered a cerebral hemorrhage on 23 September 2011. He was in a coma for over two weeks and died on 10 October 2011 at Lilavati Hospital, in Mumbai. He was cremated the following day at Chandanwadi Crematorium in Mumbai.^[9][10]

A number of tributes have been paid to Singh after his death,^{[11][12][13][14][15]} and some tried to encash his popularity which was criticised by his wife.^[16]

Awards[link]

• In 2003, Singh was awarded the Padma Bhushan, India's third highest civilian award, by the Government of India^[5]
• In 1998, Jagjit Singh was awarded Sahitya Academy Award, a literary honor in India. He was awarded this literary honor for popularizing the work of Mirza Ghalib.
• Sangeet Natak Academy Award
• Sahitya Kala Academy Award by Rajasthan Government in 1998
• Ghalib Academy by Delhi Government in 2005
• Dayavati Modi Award
• Lata Mangeshkar Samman in 1998 by Madhya Pradesh Government
• D. Litt. by Kurukshetra University, Haryana in 2003
• Teacher's Lifetime Achievement Award in 2006

Film scores[link]

Discography[link]

References[link]

External links[link]

• Jagjit Singh on BBC
• 'Ghazal King' Jagjit Singh dies, BBC
• Jagjit Singh at Internet Movie Database

Wikimedia Commons has media related to: Jagjit Singh