Lec. 10 Hemodynamics Disorders

Textbook of
Pathology
Hemodynamics Disorders:
Haemorrhage & Shock
Haemorrhage
• Haemorrhage is the escape of blood from a
blood vessel.
• The bleeding may occur externally (outside of
the body), or internally into the serous cavities
(e.g. haemothorax), or into a hollow viscus
(e.g. stomach).
• Extravasation of blood into the tissues with
resultant swelling is known as haematoma.
• Large extravasations of blood into the skin and
mucous membranes are called ecchymoses.
• Purpuras are small areas of haemorrhages
(upto 1 cm) into the skin and mucous
membrane.
• Petechiae are minute pinhead-sized
haemorrhages.
Etiology
• Trauma to the vessel wall e.g. penetrating
wound in the heart or great vessels.
• Spontaneous haemorrhage e.g. rupture of an
aneurysm, septicaemia.
• Inflammatory lesions of the vessel wall e.g.
bleeding from chronic peptic ulcer, blood
vessels traversing a tuberculous cavity in the
lung.
• Neoplastic invasion e.g. haemorrhage
following vascular invasion in carcinoma of the
tongue.
• Elevated pressure within the vessels e.g.
cerebral and retinal haemorrhage in systemic
hypertension, severe haemorrhage from
varicose veins due to high pressure in the
veins of legs or oesophagus.
Effects
• The effects of blood loss depend upon 3 main
factors:
– The amount of blood loss;
– The speed of blood loss; and
– The site of haemorrhage.
• The loss up to 20% of blood volume suddenly
or slowly generally has little clinical effects
because of compensatory mechanisms.
• A sudden loss of 33% of blood volume may
cause death, while loss of up to 50% of blood
volume over a period of 24 hours may not be
necessarily fatal.
• However, chronic blood loss generally
produces iron deficiency anaemia, whereas
acute haemorrhage may lead to serious
immediate consequences such as
hypovolaemic shock.
Shock
Introduction
• The term “shock” may refer to a psychologic
or a physiologic type of shock.
• Psychologic shock; is caused by a traumatic
event and is also known as acute stress
disorder.
• This type of shock causes a strong emotional
response and may cause physical responses as
well.
• The focus of this lecture is on the multiple
causes of physiologic shock.
Shock
• It is a life-threatening clinical syndrome of
cardiovascular collapse characterised by:
– An acute reduction of effective circulating
blood volume (hypotension); and
– An inadequate perfusion of cells and tissues
(hypoperfusion).
• If uncompensated, these mechanisms may
lead to impaired cellular metabolism and
death.
Classification and Etiology
• Hypovolaemic shock; is the most common
type of shock and is caused by insufficient
circulating volume. The most common cause
of hypovolemic shock is hemorrhage.
• Cardiogenic shock; is caused by the failure of
the heart to pump effectively, without actual
reduction of blood volume (normovolaemia)
results in cardiogenic shock.
• Distributive shock; is low blood pressure due
to a dilation of blood vessels within the body,
this can be caused by;
– Systemic infection (septic shock),
– A severe allergic reaction (anaphylactic
shock), or
– Spinal cord injury (neurogenic shock).
Pathogenesis
• In general, all forms of shock involve following
3 derangements:
– Reduced effective circulating blood volume.
– Reduced supply of oxygen to the cells and
tissues with resultant anoxia.
– Inflammatory mediators and toxins released
from shock induced cellular injury.
Clinical Features
• The classical features of decompensated shock
are characterised by depression of 4 vital
processes:
– Very low blood pressure (hypotension);
– Subnormal temperature (hypothermia);
– Weak and fast pulse (tachycardia); and
– Shallow and fast respiration (tachypnea).
• In addition, the patients in shock have;
– Pale face,
– Sunken eyes,
– Weakness,
– Cold and clammy skin.
Complications
• Life-threatening complications are due to
hypoxic cell injury resulting in immuno-
inflammatory responses and activation of
various cascades (clotting, complement).
• These include the following:
– Acute respiratory distress syndrome (ARDS);
– Disseminated intravascular coagulation;
– Acute renal failure (ARF); or
– Multiple organ dysfunction syndrome.
• With progression of the condition,
the patient may develop stupor,
coma and death.

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