Presentation Transcript

1. Hemorrhage(Draft)

2. http://www.docstoc.com/docs/106382628/Hematocrit-plasma-and-serum http://www.docstoc.com/docs/106382628/Hematocrit-plasma-and-serum
3. http://www.pxbiovision.com/science/science/science/preanalyticalPhase_files/stacks_image_34.png http://www.pxbiovision.com/science/science/science/preanalyticalPhase_files/stacks_image_34.png http://www.cdha.nshealth.ca/system/files/hemolysis.jpg
4. http://upload.wikimedia.org/wikipedia/commons/4/42/Classical_blood_coagulation_pathway.png http://upload.wikimedia.org/wikipedia/commons/4/42/Classical_blood_coagulation_pathway.png
5. Extrinsic http://www.varnerlab.org/storage/post-images/Fig_1_Network-Coagulation.png?__SQUARESPACE_CACHEVERSION=1255571758345
6. Intrinsic
7. Prothrombin Time Blood Test-PT This test is done to evaluate the blood for its ability to clot. It is often done before surgery to evaluate how likely the patient is to have a bleeding or clotting problem during or after surgery. Normal PT Values: 10-12 seconds (this can vary slightly from lab to lab) Common causes of a prolonged PT include vitamin K deficiency, hormones drugs including hormone replacements and oral contraceptives, disseminated intravascular coagulation (a serious clotting problem that requires immediate intervention), liver disease, and the use of the anti-coagulant drug warfarin. Additionally, the PT result can be altered by a diet high in vitamin K, liver, green tea, dark green vegetables and soybeans. http://www.intechopen.com/source/html/42171/media/image3_w.jpg http://surgery.about.com/od/beforesurgery/qt/PTPTTINRtests.htm
8. Partial Thromboplastin Time Blood Test-PTT This test is performed primarily to determine if heparin (blood thinning) therapy is effective. It can also be used to detect the presence of a clotting disorder. It does not show the effects of drugs called “low molecular weight heparin” or most commonly by the brand name Lovenox. Normal PTT Values: 30 to 45 seconds (this can value slightly from lab to lab) Extended PTT times can be a result of anticoagulation therapy, liver problems, lupus and other diseases that result in poor clotting. http://www.intechopen.com/source/html/42171/media/image3_w.jpg http://surgery.about.com/od/beforesurgery/qt/PTPTTINRtests.htm
9. International Normalized Ratio Blood Test-INR Normal INR Values: 1 to 2 The INR is used to make sure the results from a PT test is the same at one lab as it is at another lab. In the 1980’s the World Health Organization determined that patients may be at risk because the results of a PT test would vary from one lab to another, based upon the way the test was done. The “normal” range for one lab would be different than a “normal” value from another lab, creating problems for patients who were being treated in several locations. In order to standardize the results between labs, the INR was created. The INR result should be the same, regardless of the location where the tests are performed. INR=(PT patient/PT normal)ISIPT patient = patient's measure PT (seconds) PT normal = laboratory's geometric mean value for normal patients (seconds) ISI = International Sensitivity Index http://easycalculation.com/medical/inr.php http://surgery.about.com/od/beforesurgery/qt/PTPTTINRtests.htm
10. Figure 3 Action of LMWHs on the traditional coagulation cascades, showing coagulation factors PKK and HMWK Davenport, A. (2011) What are the anticoagulation options for intermittent hemodialysis? Nat. Rev. Nephrol. doi:10.1038/nrneph.2011.88
11. http://www.mayomedicallaboratories.com/images/articles/hottopics/2008/2008-10-pvariables/slide7.jpg http://www.mayomedicallaboratories.com/images/articles/hottopics/2008/2008-10-pvariables/slide7.jpg http://www.lienchiny.com.tw/UserFiles/pd/P2010120800096_S.jpg
12. D-dimer is the degradation product of crosslinked (by factor XIII) fibrin. It reflects ongoing activation of the hemostatic system. http://emedicine.medscape.com/article/2085111-overview http://ahdc.vet.cornell.edu/sects/coag/test/D-dimer.gif
13. http://lifeinthefastlane.com/wp-content/uploads/2010/05/D-dimer-flowchart.jpg http://lifeinthefastlane.com/wp-content/uploads/2010/05/D-dimer-flowchart.jpg
14. Hemorrhage Extravasation of blood into the extravascular space. Capillary bleeding can occur under conditions of chronic congestion. Rupture of a large artery or vein results in severe hemorrhage and is almost always due to vascular injury, including trauma, atherosclerosis, or inflammatory or neoplastic erosion of the vessel wall.
15. Capillary Bleeding http://www.glowm.com/resources/glowm/graphics/figures/v2/1080/15.jpg http://www.sciencephoto.com/image/303985/350wm/P2120043-Ruptured_capillary,_SEM-SPL.jpg
16. http://www.drugs.com/health-guide/images/205035.jpg http://radiographics.rsna.org/content/27/2/497/F28.large.jpg http://www.intechopen.com/source/html/19550/media/image9.jpeg
17. http://www.intechopen.com/books/diagnosis-screening-and-treatment-of-abdominal-thoracoabdominal-and-thoracic-aortic-aneurysms/the-pathohistology-of-abdominal-aortic-aneurysm http://www.intechopen.com/books/diagnosis-screening-and-treatment-of-abdominal-thoracoabdominal-and-thoracic-aortic-aneurysms/the-pathohistology-of-abdominal-aortic-aneurysm
18. http://www.intechopen.com/source/html/16902/media/image4.jpeg http://www.intechopen.com/source/html/16902/media/image4.jpeg
19. Hemorrhage Extravasation of blood due to ruptured vessels From hemo = blood, rrhagia = to burst forth Hemorrhage may be external or internal Hemorrhage may be obvious (gross) or hidden (occult) This is whole blood with RBCs, not just edemic transudates or exudates
20. Hematomas Hemorrhage may be external or contained within a tissue. Any accumulation is called a hematoma. Hematomas may be relatively insignificant or so massive that death ensues. http://media.zenfs.com/en_us/News/YahooSports/1304308620.jpg http://ars.els-cdn.com/content/image/1-s2.0-S1878764912000241-gr1.jpg
21. The Ocular Pathology of Terson's Syndrome  http://www.sciencedirect.com/science/article/pii/S0161642009013852
22. Hematoma--subdural
23. http://www.daviddarling.info/images/spleen_cross-section.jpg Subcapsular Hematoma http://www.vetmed.vt.edu/education/curriculum/vm8304/lab_companion/histo-path/vm8054/labs/Lab13/Images/LYMPL28.JPG
24. Minute 1- to 2-mm hemorrhages into skin, mucous membranes, or serosal surfaces are called petechiae These are most commonly associated with locally increased intravascular pressure, low platelet counts (thrombocytopenia), or defective platelet function (as in uremia).
25. Petechiae from Strangulation
26. Figure 3Kinetics of inflammatory bleeding in thrombocytopenic mice during reverse passive Arthus reaction. (A) Photographs of progressing rpA in the dorsal skinfold chamber. In the absence of platelets, petechial bleeding was clearly visible after 2 hours and increased with time. In nondepleted animals there were virtually no petechial spots. Window diameter was 12 mm. (B) Microscopic view of the progressing rpA in a thrombocytopenic mouse. Petechial bleeding was detected at 20 minutes, with further growth of the spot at 40 minutes. Bar = 200 μm. (C) Petechial spots visible to the eye (∼ 100 μm) were counted during rpA in thrombocytopenic and control animals. The difference in incidence of petechiae became statistically significant within 1 hour (P < .01; n = 4). At t = 4 hours, the petechiae became confluent, impairing quantification. Error bars represent SEM. http://bloodjournal.hematologylibrary.org/content/111/10/4958/F3.expansion
27. Slightly larger (≥3 mm) hemorrhages are called purpura. These may be associated with many of the same disorders that cause petechiae or can be secondary to trauma, vascular inflammation (vasculitis), or increased vascular fragility (e.g., in amyloidosis). http://www.healthandphysicaleducationteacher.com/wp-content/uploads/2011/05/Purpura-2-300x223.jpg http://openi.nlm.nih.gov/detailedresult.php?img=3175359_cde0003-0022-f02&req=4 http://25.media.tumblr.com/tumblr_li2muuU9eb1qg1up7o1_500.jpg Figure 2: Microscopic examination of palpable purpura. Severe pandermalleucocytoclasticvasculitis without granulation (HE, original magnification ×40; inset: ×400). http://www.pediatrics.wisc.edu/education/derm/tutb/48m.jpg
28. The below is still in draft form
29. Larger (>1 to 2 cm) subcutaneous hematomas (i.e., bruises) are called ecchymoses. The red cells in these lesions are degraded and phagocytized 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 bruise.
30. Echymoses or contusions
31. Depending on the location, a large accumulation of blood in a body cavity is denoted as a hemothorax, hemopericardium, hemoperitoneum, or hemarthrosis (in joints). Patients with extensive bleeding can develop jaundice from the massive breakdown of red cells and hemoglobin.
32. Indications of internal hemorrhage Deep Anemia—fewer circulating RBCs Increased indirect bilirubin (unconjugated, albumin-bound) Surface Hemorrhage under the skin or mucous membranes looks red (oxygenated Hb) or purple (deoxygenated Hb)
33. Distribution of hemorrhage(s) Multifocal indicates problem affecting vessels or platelets thrombocytopenia or thrombocytopathy reduced number or function of platelets preventing coagulation inherited coagulation defects—hemorrhagic diathesis anticoagulants inhibit production of vitamin K-dependent coagulation proteins end stage hepatic disease. With approximately 80% loss of functional hepatic tissue, production of coagulation factors can become inadequate. disseminated intravascular coagulation (DIC) coagulation out of control vasculitis immune mediated--precipitation of Ag-Ab complexes, which are chemotactic for neutrophils, resulting in vascular damage infections of endothelium Focal distribution single or a few focal hemorrhages are typical of trauma regional neoplasm, thrombosis, or microbial invasion problems with protein clotting factors
34. Hemopericardium This is hemopericardium as demonstrated by the dark blood in the pericardial sac opened at autopsy. Penetrating trauma or 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. A pericardiocentesis, with needle inserted into the pericardial cavity, can be a diagnostic procedure.
35. Gastrointestinal hemorrhage When rate is slow, blood is digested or lost in feces In upper GI, blood turns black and tarry as it is digested and is called melena Melena is symptomatic of peptic ulcers, ruptured esophageal varices, cancers In lower GI, blood remains red and is excreted with feces Fecal occult blood test; now fecal immunochemical test FOBT used dye adsorbed on paper to detect Fenton reaction catalyzed by heme iron FIT uses Ab against globin portion of hemoglobin
36. Hemorrhage into cavities Pleural hemorrhage—hemothorax Build-up of pressure prevents lung expansion Prevents gas exchange May lead to lung collapse Instigates coughing or hiccups, which exacerbates bleeding Pericardial hemorrhage—hemopericardium Build-up of external pressure inhibits filling Cardiac tamponade = compression Intracranial hemorrhage Always bad because of the rigid cranium CSF pressure increases rapidly if bleeding rate is greater than rate of fluid resorption
37. Hemodynamics Maintenance of blood volume Maintenance of blood pressure Mainenance of clot-free flow plasmin Development of clot in response to vascular damage—hemostasis thrombin-fibrin
38. Clotting v. thrombosis THROMBUS: Blood that has solidified within the vascular lumens or cardiac chambers CLOT: Blood that has solidified anywhere else THROMBOEMBOLISM: Portion of thrombus that travels through the vasculature to form a plug elsewhere EMBOLISM: vascular plug, not always from a thrombus
39. Consequences of acute hemorrhage Loss of blood beyond a certain volume will cause systemic hypotension rapid compensation by the baroreceptor response leads to peripheral vasoconstriction fluids shift from the interstitial into the IV compartment slower response from the renin-angiotensin-aldosterone system results in vasoconstriction and retention of sodium and water by the kidney antidiuretic hormone (ADH) also kicks in, acts on nephron to promote water resorption Loss of blood beyond the body's ability to compensate will cause systemic hypotension, reduced cardiac filling, reduced tissue perfusion, loss of erythrocytes and their Hb, hypoxemia, and a further cascade of events called shock
40. Blood loss Class I: up to 15% of blood volume typically no change in vital signs routine blood donation amounts to ~10% Class I: 15-30% of total blood volume tachycardia (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures compensatory peripheral vasoconstriction; cool, pale skin; altered mental status, dizzy or confused fluid resuscitation with saline or Lactated Ringer's solution Class III: 30-40% of circulating blood volume blood pressure drops, heart rate increases, peripheral perfusion worsens, mental status worsens fluid resuscitation and/or blood transfusion Class IV: >40% of circulating blood volume hypovolemic shock--limit of the body's compensation is reached aggressive resuscitation is required to prevent death
41. Hypovolemic, cardiogenic shock Causes Blood loss Dehydration Reduced cardiac output Deranged peripheral vasomotor control Consequenses Inadequate perfusion Hypoxia, lactic acidosis Recovery dependent on duration and severity
42. Stages of Shock Early Stage Compensatory mechanisms maintain perfusion of vital organs Include increased heart rate and increased peripheral resistance Progressive Stage Compensatory systems no longer adequate with tissue hypoperfusion Onset of circulatory and metabolic imbalance, especially metabolic acidosis from lactic acidemia Irreversible Stage Organ damage and metabolic disturbances Survival not possible
43. Clinical consequences Hypotension Weak, rapid pulse (tachycardia) Shallow rapid breathing (tachypnea) Cool, damp, cyanotic skin Tissue injuries are due to hypoxia