HAEMORRHAGIA Bleeding
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1 HAEMORRHAGIA Bleeding
2 Cassification Size Location pathomechanism
3 Hematoma: external or may be enclosed within a tissue petechial rash (spot) : 1-2 mm hemorrhages into skin, mucous membranes, or serosal surfaces increased intravascular pressure thrombocytopenia defective platelet function (as in uremia), clotting factor deficits Purpura: 3 mm same disorders that cause petechiae secondary to trauma, vascular inflammation (vasculitis), increased vascular fragility (amyloidosis)
4 PETECHIAL BLEEDING
5 Ecchymosis: >1 to 2 cm after trauma Suffusion: superfitial between tissue layers Parenchymal bleeding/apoplexia Brain adrenals Meningococcus sepsis / Waterhouse- Friderichsen syndrome
6 Ecchymosis
7 Pathomechanism Haemorrhagia per rhexim vessel injury Vasculitis Fragility ATS aneurysm Haemorrhagia per errosionem (erosion) Erosive gastritis Ulcer Tumor Haemorrhagia per diapedesim Permeability Platelet
8 Location Hemothorax Hemopericardium Hemascos/hemoperitoneum Hemarthros Metrorrhagia/Menorrhagia Intracranial bleeding Epidural Subdural Subarachnoid Intracerebral/parenchymal
9
10 Epidural hematoma Temporal bone fracture Middle meningeal artery laceration Lucidum intervallum (interval) patients can be lucid for several hours between the moment of trauma and the development of neurologic signs epidural hematoma may expand rapidly and is a neurosurgical emergency requires prompt drainage
11 HAEMATOMA EPIDURALE
12 Subdural hematoma acute subdural hematoma Clot of blood between the dura mater and the outer arachnoid layer of the leptomeninges due to stretching and tearing of veins on the brain s surface / Bridging veins shakes the brain SDHs greater than 1 cm at the thickest point generally require rapid surgical treatment
13 SUBDURAL
14
15 Chronic subdural hematoma No identifiable history of head trauma. Risks include Long-term heavy alcohol use Long-term use of aspirin, anti-inflammatory drugs such as ibuprofen, or blood thinning (anticoagulant) medication such as warfarin Diseases associated with reduced blood clotting Head injury Old age
16 Chronic subdural hematoma Symptoms Decreased memory Difficulty speaking or swallowing Difficulty walking Sleepiness Headache Weakness or numbness of arms, legs, face
17 Subarachnoid hematoma Definition: extravasation of blood into the subarachnoid space between the pial and arachnoid membranes Symptoms Sudden onset of severe headache (the classic feature) Accompanying nausea or vomiting Symptoms of meningeal irritation Photophobia and visual changes Focal neurologic deficits Sudden loss of consciousness at the ictus
18 Subarachnoid hematoma Traumatic / head trauma nontraumatic (or spontaneous) hemorrhage ruptured cerebral aneurysm arteriovenous malformation (AVM).
19 circle of Willis Subarachnoid hematoma
20 SUBARACHNOID
21 Saccular aneurysms
22
23 Parenchymal Hypertensive intraparenchymal hemorrhage Basal gangia putamen (50% to 60% of cases) thalamus, pons, cerebellar hemispheres Charcot Bouchard microaneurysms Hyaline arteriooscerosis hemangioma AV malformation
24 Lobar hemorrhages: (cerebral hemispheres) hemorrhagic diathesis, DIC neoplasms, drug abuse, infectious and noninfectious vasculitis, cerebral amyloid angiopathy
25 Apoplexia cerebri
26 APOPLEXIA
27 MALFORMATION
28 Pathomechanism of bleeding A. thrombocytopenia B. thrombocytopathy C. coagulopathy D. vasculopathy
29 A. Thrombocytopenia: < /mm 3 Normal count /mm 3 < /mm 3 spontaneus bleeding /mm 3 post traumatic bleeding platelet production -bone marrow insuf. - drugs -infection (HIV /CD4) platelet survival - ITP - DIC - giant hemangioma (Kasabach-Merritt sy) - TTP (thrombotic thrombocytopenic purpura) -HUS sequestration -hypersplenism
30 B. Thrombocytopathia: 1. Congenital: - defects of adhesion - defects of aggregation - defects of release a. Bernard-Soulier (GpIb-vWf) b. Glanzmann thrombasthenia (GpIIb-IIIa. fibrinogen) 2. Acquired - aspirin (cyclooxygenase inhibitor) -uremia - HIV (CD4, GpIIb-III)
31 C. Coagulopathy 1. Hereditery v Willebrand disease - bleeding time - platlet count norm. - Spontaneous bleeding - autosomal dominanat Hemophilia A(f.VIII) Hemophilia B (f.ix) - X- linked - bleeding time norm. - coag. time - Hemarthros-ankylosis 2. Acquired - hepatic (K vitamin) f.ii-vii-ix-x, protein C, - DIC
32 D. Vasculopathy 1. Acquired -Infection / Vasculitis Waterhouse Fridericksen sy septicemia -Drug reaction/ hypersnsitivity (IC) -Amyloid -steroid /Cushing sy -Henoch-Schönlein (IC) 2. Hereditery -Rendu-Osler Weber (HHT/herediter hemorrhagic teleangiectasis) -Ehlers-Danlos sy
33 PLATELET HEMOSTASIS ENDOTHEL COAGULATION
34
35
36 Platelets promote hemostasis by the following interconnected mechanisms adhering to sites of vascular injury or artificial surfaces releasing compounds from their granules aggregating together to form a hemostatic platelet plug providing a procoagulant surface for activated coagulation protein complexes on their phospholipid membranes
37 ENDOTHEL
38 Antithrombotic Prothrombotic Platelet aggregation inhibition PGI2 NO ADPase Thrombin binding and inhibition Heparin like molecules Protein C/S activation Alpha 2-macroglobulin Fibrinolysis Tissue plasminogen activator ( t-pa) Platelet aggregation stimulation Von Willebrand S factor PAF Procoagulant factors Tissue factor Binding factors IXa, Xa Factor V Inhibition of fibrinolysis t-pa inhibitor
39 COAGULATION
40
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