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  • HemodynamicsHEMORRHAGE

    Dr.CSBR.Prasad, M.D.

  • HEMORRHAGEHemorrhage - extravasation of blood due to rupture of BVCapillary bleeding:

    Chronic congestion Hemorrhagic diatheses Rupture of a large artery or vein - due to: Vascular injury

    Trauma Atherosclerosis Inflammatory Neoplastic erosion of the vessel wall

    *Hemorrhage generally indicates extravasation of blood due to vessel rupture. As described previously, capillary bleeding can occur under conditions of chronic congestion, and an increased tendency to hemorrhage from usually insignificant injury is seen in a wide variety of clinical disorders collectively called hemorrhagic diatheses ( Chapter 13 ). However, rupture of a large artery or vein is almost always due to vascular injury, including trauma, atherosclerosis, or inflammatory or neoplastic erosion of the vessel wall.

  • Manifestations depends on size, extent, and location of bleeding. Hematoma (accumulation of blood within tissue )Petechiae (1 - 2 mm hemorrhages into skin, mucous membranes, or serosal surfaces )Purpura (3 mm) Ecchymoses (>1 - 2 cm) subcutaneous hematomas Large accumulations of blood in one or another of the body cavities - hemothorax, hemopericardium, hemoperitoneum, or hemarthrosis

    *Hemorrhage may be manifested in a variety of patterns, depending on the size, extent, and location of bleeding. Hemorrhage may be external or may be enclosed within a tissue; accumulation of blood within tissue is referred to as a hematoma. Hematomas may be relatively insignificant (a bruise) or may be sufficiently large as to be fatal (e.g., a massive retroperitoneal hematoma resulting from rupture of a dissecting aortic aneurysm; Chapter 11 ). Minute 1- to 2-mm hemorrhages into skin, mucous membranes, or serosal surfaces are denoted as petechiae ( Fig. 4-5A ) and are typically associated with locally increased intravascular pressure, low platelet counts (thrombocytopenia), defective platelet function (as in uremia), or clotting factor deficits. Slightly larger (3 mm) hemorrhages are called purpura. These may be associated with many of the same disorders that cause petechiae and may also occur secondary to trauma, vascular inflammation (vasculitis), or increased vascular fragility (e.g., in amyloidosis). Larger (>1 to 2 cm) subcutaneous hematomas (i.e., bruises) are called ecchymoses and are characteristically seen after trauma but may be exacerbated by any of the aforementioned conditions. The erythrocytes in these local hemorrhages are degraded and phagocytosed by macrophages; the hemoglobin (red-blue color) is then enzymatically converted into bilirubin (blue-green color) and eventually into hemosiderin (gold-brown color), accounting for the characteristic color changes in a hematoma. Large accumulations of blood in one or another of the body cavities are called hemothorax, hemopericardium, hemoperitoneum, or hemarthrosis (in joints). Patients with extensive hemorrhage occasionally develop jaundice from the massive breakdown of red cells and systemic release of bilirubin.

  • A - Punctate petechial hemorrhages of the colonic mucosaB - Intracerebral hemorrhageConsequences of thrombocytopenia

    *Figure 4-5 A, Punctate petechial hemorrhages of the colonic mucosa, seen here as a consequence of thrombocytopenia. B, Fatal intracerebral bleed. Even relatively inconsequential volumes of hemorrhage in a critical location, or into a closed space (such as the cranium), can have fatal outcomes.

  • Petechial hemorrhages (pinpoint hemorrhages) seen on the epicardium of the heart

    *Here are petechial hemorrhages seen on the epicardium of the heart. Petechiae (pinpoint hemorrhages) represent bleeding from small vessels and are classically found when a coagulopathy is due to a low platelet count. They can also appear following sudden hypoxia.

  • Hemopericardium Cardiac tamponade

    *This is hemopericardium as demonstrated by the dark blood in the pericardial sac opened at autopsy. Massive blunt force trauma to the chest (often from the steering wheel) causes a rupture of the myocardium and/or coronary arteries with bleeding into the pericardial cavity. The extensive collection of blood in this closed space leads to cardiac tamponade.

  • Aortic tear with hemorrhages

    *Sometimes a sudden deceleration injury in a vehicular accident produces a tear in the aorta. This usually happens just distal to the great vessels. If one's parachute fails to open, the tear is usually at the root of the aorta. The tear leads to sudden loss of blood and shock.

  • Lacerated Liver [Peritoneal hemorrhages]

    *Massive abdominal blunt force injury often leads to liver injury, since it is the largest internal organ. Note the multiple lacerations over the capsule. Damage to abdominal organs with lacerations, crush injuries, and rupture can lead to bleeding into the peritoneal cavity known as hemoperitoneum. A peritoneal lavage can detect such bleeding.

  • Ecchymoses

    *The blotchy areas of hemorrhage in the skin are called ecchymoses (singular ecchymosis), or also as areas of purpura. Ecchymoses are larger than petechiae. They can appear with coagulation disorders.

  • Hematoma

    *A localized collection of blood outside the vascular system within tissues is known as a hematoma. Here is a small hematoma under the toenail following trauma, which has a bluish appearance from the deoxygenated blood within it.

  • Adrenal hemorrhage

  • Raccoon eyes

  • Hematoma

  • Hematoma

  • Purpura - HSP

  • Subconjunctival hemorrhage

  • Subdural hematoma

  • Subdural hematoma

  • Subgaleal hemorrhage

  • Subgaleal hemorrhage

  • Clinical significance of hemorrhage Depends on the volume and rate of bleeding & blood loss: Rapid loss of up to 20% of the blood volume

    or slow losses of even >20%

    Losses >20% may result in hemorrhagic (hypovolemic) shock

    The site of hemorrhage is also important:

    Trivial bleeding in the subcutaneous tissues innocuous Trivial bleeding in the brain may cause death

    External loss Vs Internal loss:

    Chronic or recurrent external blood loss Loss of iron and IDA Hemorrhage into body cavities or tissues No iron deficiencyNo adverse effects

    *Rapid loss of up to 20% of the blood volume or slow losses of even larger amounts may have little impact in healthy adults; greater losses, however, may result in hemorrhagic (hypovolemic) shock (discussed later). The site of hemorrhage is also important; bleeding that would be trivial in the subcutaneous tissues may cause death if located in the brain ( Fig. 4-5B ) because the skull is unyielding and bleeding there can result in increased intracranial pressure and herniation ( Chapter 28 ). Finally, loss of iron and subsequent iron-deficiency anemia become a consideration in chronic or recurrent external blood loss (e.g., peptic ulcer or menstrual bleeding). In contrast, when red cells are retained, as in hemorrhage into body cavities or tissues, the iron can be reused for hemoglobin synthesis.

  • E N Dgoto Hemostasis & Thrombosis

    *Hemorrhage generally indicates extravasation of blood due to vessel rupture. As described previously, capillary bleeding can occur under conditions of chronic congestion, and an increased tendency to hemorrhage from usually insignificant injury is seen in a wide variety of clinical disorders collectively called hemorrhagic diatheses ( Chapter 13 ). However, rupture of a large artery or vein is almost always due to vascular injury, including trauma, atherosclerosis, or inflammatory or neoplastic erosion of the vessel wall. *Hemorrhage may be manifested in a variety of patterns, depending on the size, extent, and location of bleeding. Hemorrhage may be external or may be enclosed within a tissue; accumulation of blood within tissue is referred to as a hematoma. Hematomas may be relatively insignificant (a bruise) or may be sufficiently large as to be fatal (e.g., a massive retroperitoneal hematoma resulting from rupture of a dissecting aortic aneurysm; Chapter 11 ). Minute 1- to 2-mm hemorrhages into skin, mucous membranes, or serosal surfaces are denoted as petechiae ( Fig. 4-5A ) and are typically associated with locally increased intravascular pressure, low platelet counts (thrombocytopenia), defective platelet function (as in uremia), or clotting factor deficits. Slightly larger (3 mm) hemorrhages are called purpura. These may be associated with many of the same disorders that cause petechiae and may also occur secondary to trauma, vascular inflammation (vasculitis), or increased vascular fragility (e.g., in amyloidosis). Larger (>1 to 2 cm) subcutaneous hematomas (i.e., bruises) are called ecchymoses and are characteristically seen after trauma but may be exacerbated by any of the aforementioned conditions. The erythrocytes in these local hemorrhages are degraded and phagocytosed by macrophages; the hemoglobin (red-blue color) is then enzymatically converted into bilirubin (blue-green color) and eventually into hemosiderin (gold-brown color), accounting for the characteristic color changes in a hematoma. Large accumulations of blood in one or another of the body cavities are called hemothorax, hemopericardium, hemoperitoneum, or hemarthrosis (in joints). Patients with extensive hemorrhage occasionally develop jaundice from the massive breakdown of red cells and systemic release of bilirubin.

    *Figure 4-5 A, Punctate petechial hemorrhages of the colonic mucosa, seen here as a consequence of thrombocytopenia. B, Fatal intracerebral bleed. Even relatively inconsequential volumes

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