Internal bleeding (hemorrhage within body cavities or tissues) is life-threatening because blood loss and pressure drop impair oxygen delivery to organs. Some minor bleeds may self-resolve, but major internal hemorrhage requires urgent medical care.
Blood consists of red blood cells (erythrocytes), which convey oxygen throughout the body, white blood cells (leucocytes), which fight introduced infection, platelets which assist in the clotting process, and plasma, the fluid portion of blood.
Blood is moved around the body under pressure by the heart and blood vessels. But without adequate blood volume and pressure, the human body soon collapses. Bleeding, or hemorrhage, poses a serious threat by causing both the volume and the pressure of the blood to decrease through blood loss.
Causes
- Peptic ulcers
- GI (gastrointestinal) tumors
- Endometriosis in women
- Ruptured cysts
- Post-surgical bleeding
- Bleeding on the brain, for example, a hemorrhage stroke
- Fractured bones
- A ruptured ectopic pregnancy
- Aortic aneurysms
Signs & Symptoms
- Abdominal, chest, or flank pain and tenderness
- Bruising, swelling, or rigidity of the trunk
- Coughing, vomiting, or passing blood in stool/urine
- Signs of shock: rapid weak pulse, pale cool clammy skin, dizziness, altered consciousness
Visible internal bleeding
Visible internal bleeding can vary in appearance depending on the site of the bleeding. Look out for the following:
- Lungs – frothy, bright red blood coughed up by the casualty
- Stomach – a dark matter which looks like coffee grounds coughed up by the casualty or red blood in the vomit
- Intestine/Bowel – dark, loose, foul-smelling stools
- Urinary Tract – dark or red-colored urine
- Ears – bright, sticky blood or blood mixed with clear fluid
- Bruising – the tissues look dark due to the blood under the skin. This is usually caused by blows from blunt instruments or by crushing.
Concealed internal bleeding
In the case of concealed internal bleeding, the first aider is heavily reliant on a patient’s history, signs, and symptoms. Judgment and experience play a part, but it may come down to your ‘gut feeling.’
If you’re unsure, assume the worst and treat for internal bleeding. The detection of internal bleeding relies upon good observations and an appreciation of the physical forces that have affected the casualty.
The symptoms of internal bleeding can look similar to those of a patient suffering from shock.
Here are some signs to look out for:
- Skin appearance: Does the patient have cool, clammy, or unusually pale skin?
- Level of consciousness: Check a patient’s eyes, voice, and motor skills to assess their level of consciousness. See our guide on AVPU and GCS.
- Pulse rate: Check for a weak or rapid pulse. Anything over 100 beats per minute indicates concern.
- Respiratory rate: Check for rapid or shallow breathing.
Internal bleeding in the brain
Check for the following symptoms:
- Changes in vision
- Changes in speech
- Loss of strength, coordination, and motor skills
- Severe headache
- Confusion
- Extreme tiredness
- Nausea and vomiting
- Bleeding from the nose and/or ears
Internal bleeding in the chest
Check for the following symptoms:
- Chest pain
- Trouble breathing or shortness of breath
- Rapid shallow breathing
- Rapid heart rate
- Coughing up blood
Internal bleeding in the abdomen
This excludes the signs of gastrointestinal (GI) bleeding (find more information on this below.) For all other bleeding on the abdomen, look out for:
- Pain anywhere in the abdomen region, including the stomach, flank, and pelvis.
- Blood in the urine
- Extreme episodes of vomiting
- Bruising around the abdomen, particularly down the sides and the navel area.
Gastrointestinal bleeding
Gastrointestinal bleeding (GI) bleeding differs somewhat from other types of internal bleeding.
GI bleeding is not normally associated with trauma. Instead, common causes include:
- GI Infections, such as gastroenteritis and colitis.
- Stomach ulcers and other irritations to the lining of the stomach.
- Inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease.
- Diverticular disease: a relatively common condition where small pouches push out through the walls of the intestines.
- Excessive alcohol consumption that can lead to ruptured blood vessels in the stomach and the esophagus.
- Hemorrhoids that become irritated or inflamed.
- Anal fissures and anal abscesses.
- A rare condition called ischemic colitis.
- Bowel, colon, or rectal cancer.
When to Call Emergency Services
- Any suspicion of internal bleeding after trauma (e.g., falls, motor-vehicle crash)
- Visible blood from mouth, nose, ears, or rectum
- Sudden severe pain, increasing distension of the abdomen
- Signs of shock or collapse (fainting, rapid breathing)3
First Aid Steps
- Call 911 (or local emergency number) immediately; do not delay.
- Ensure scene safety and don PPE (gloves, eye protection) if available.
- Position the person lying flat; if no spinal injury suspected, elevate legs about 30 cm to promote blood flow to vital organs.2
- Loosen tight clothing and cover with a blanket to prevent hypothermia; do not give food or fluids by mouth.
- Monitor airway, breathing, and circulation every few minutes; be prepared to begin CPR if the person becomes unresponsive.3
- If external wounds accompany the bleed, apply firm direct pressure and secure a sterile dressing—without compressing the abdomen or chest.
- Stay with the person, offer reassurance, and relay observations (vital signs, level of consciousness) to arriving EMS personnel.
Do’s and Don’ts
| Do | Don’t |
|---|---|
| Call emergency services without delay | Attempt to locate or remove internal bleeding |
| Keep the person lying flat and legs elevated | Give anything by mouth (food, drink, medication) |
| Monitor vital signs and mental status | Massages, heat packs, or abdominal manipulation |
| Apply external pressure to visible wounds | Leave the person unattended |
| Stay calm and provide reassurance | Delay summoning professional medical help |
REFERENCES
- Jaime Jordan, Internal Bleeding ,Revised Jul 2024, https://www.msdmanuals.com/home/injuries-and-poisoning/first-aid/internal-bleeding
- American Red Cross , Bleeding, Life-Threatening Internal, https://www.redcross.org/take-a-class/resources/learn-first-aid/bleeding-life-threatening-internal
- Mike Figuero, First Aid for Bleeding, July 17, 2020, https://www.aedcpr.com/articles/first-aid-for-bleeding/
- Internal Bleeding, First Aid Management, https://www.firstaidanywhere.com/internal-bleeding-first-aid.html
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