Circulatory disorders and Shock

Hemostasis: arrest bleeding, either by the physiological

properties of vasoconstriction and coagulation or by surgical
means.
Any disturbance in circulatory system cause the following
lesions:

1. Edema
2. Hyperemia and Congestion
3. Hemorrhage
4. Thrombosis
5. Embolism
6. Ischemia / Infarction
1- Edema
Definition of edema:
- Edema is an abnormal collection of fluid in the interstitial
space that may be localized or generalized
- An abnormal increase in interstitial fluid within tissues is
called edema.
- Fluid collections in the different body cavities:
hydrothorax, hydropericardium, and hydroperitoneum
(the last is more commonly called ascites).

- Anasarca is a severe and generalized edema with

widespread subcutaneous tissue swelling.
Causes of Edema
• 1. Increased hydrostatic pressure (Increase Blood pressure)
• Impaired venous return
• Congestive heart failure
• Venous obstruction or compression
• Thrombosis
• External pressure

• 2. Decreased osmotic (oncotic) pressure

• loss or reduced albumin synthesis
• Nephrotic syndrome
• protein-losing gastroenteropathy
• Malnutrition
3. lymphatic obstruction
• lymphedema
• Elephantiasis (Filariasis – Wuchereria)
• Neoplastic – breast carcinoma
• Post-surgical (LN resection)

4.Increase capillary permeability

• Acute and chronic inflammation

5- RAAS

.
Types of Edema
1- Generalized edema
can be documented by weight gain and often is associated with
increased capillary hydrostatic pressure as seen in:
• Congestive heart failure (CHF)
• Renal failure with increased sodium and water load
• After expansion of the intravascular volume from IV fluids
• Conditions of sodium retention.

2- Localized edema
• Edema in the whole body (Anasarca)
• In the peritoneal cavity (Ascites-Hydro peritoneum)
• In the pleural space (Pleural effusion -Hydrothorax)
• In the heart (Pericardial effusion- Hydro pericardium)
• In the lower extremities (Peripheral edema)
 Transudate Exudate

Protein
Low High
contents
Cells
Low High
contents
▪ Inflammation
▪ High hydrostatic pressure
Cause ▪ Lymphatic
▪ Low osmotic pressure
obstruction

Specific
< 1.012 > 1.020
gravity
Edema Summary
• Edema results from the movement of fluid from the
vasculature into the interstitial spaces; the fluid may be
protein poor (transudate) or protein rich (exudate).
• Edema may be caused by:
• Increased hydrostatic pressure (e.g., heart failure)
• Increased vascular permeability (e.g., inflammation)
• Decreased colloid osmotic pressure resulting from reduced
plasma albumin
• Decreased synthesis (e.g., liver disease, protein
malnutrition)
• Increased loss (e.g., nephrotic syndrome)
• Lymphatic obstruction (e.g., inflammation or neoplasia)
• Sodium retention (e.g., renal failure)
2. Hyperemia and Congestion
Hyperemia and congestion are an increase in blood volume in particular
tissue
•Hyperemia – active (arteriolar dilation)
• Hyperemia is always localized. If it occurred all over the body,
there wouldn't be enough blood in the major vessels and shock
would ensue
•Red color

•Congestion – passive (impaired venous return)

•Systemic and local
•Blue color (cyanosis), edema
•Accumulation of deoxygenated Hb
 Hyperemia Congestion
- Hyperemia is defined as excess - The big difference is that
blood (especially in the capillaries) congestion is due to obstruction
in a part of the body. (active). of venous return (passive
process)
- Associated with the body’s - Congestion is often
response to an insult accompanied by edema

Gross appearance: Gross appearance:

− bright red − dark blue-red tinge
− warmer than usual − swollen
− swollen − cooler than normal
− pulse may be felt readily − if chronic, the tissue may
have a brown color
3. Hemorrhage and shock
Hemorrhage: Escape of blood from the cardiovascular system
(extravasation).

•Types of hemorrhage
• External Hemorrhage (Bleeding).
• Internal (in the tissue) any accumulation is called a hematoma.
• Hematomas may be insignificant or so massive that death
ensues.

•Causes of hemorrhage:
• Trauma subcutaneous or intramuscular hemorrhage.
• Septicemia, viremia or toxic conditions.
• Thrombocytopenia (decreased numbers of platelets)
Effect and significance of hemorrhage:
According to amount and rate of blood loss
o If rapid blood loss occurs (1/4 to 1/3 of the total blood volume over a
period of less than a few hours), hypovolemic shock and perhaps death
will occur.
o Total blood volume lost > 20% (Hypovolemia) → hemorrhagic
shock
o If slower blood loss occurs (1/2 total blood volume over weeks or
months), no serious consequences may occur because the body
compensates.

According to site of hemorrhage

o severity of consequences exceeds what is normally seen
with amount of blood loss, for instance, intracranial
hemorrhage or hemopericardium.
o severity of consequences is generally proportional to the
amount of blood loss.
 Shock:
o Shock is a critical condition brought on by the
sudden drop in blood flow through the body
oSystemic hypoperfusion due to reduction of cardiac
output / effective blood volume circulation.
•Hypotension → cellular hypoxia.

Clinical features of shock

- Hypotension - Tachycardia
- Tachypnea -Cool cyanotic skin
- Dizziness and fainting
Origins of shock:
1.Cardiogenic: failure of myocardial pump myocardial
infarction, arrhythmias pulmonary embolism
2.Hypovolemic: inadequate blood/plasma volume
hemorrhage fluid loss (vomiting, diarrhoea, burns,
trauma)
3.Septic: vasodilation+endothelial injury Gram+,
Gram- bacteria
4.Neurogenic: loss of vascular tone spinal cord injury
5.Anaphylactic: IgE–mediated hypersensitivity
 4. Thrombosis
Thrombosis:
Formation, development or presence of intravascular
clotting in a living person.

Thrombus: intravascular clot

Site of Thrombi
1. Arterial -Coronary, cerebral, femoral
2. Lower extremities(90%)-superficial /deep veins of
legs
3. Ovarian, periuterine, portal hepatic vein in sites of
stasis
4. Cardiac (usual mural)
5. Heart Valves (vegetation)
 5. Embolism
Embolus (Emboli: Pleural ) are solid, fluid or gaseous material
carried by the blood stream from the site of their origin or
entry into the circulation to a site distant from its site of origin

Thromboembolus: A thrombus formed in one location

that detaches from the vessel wall and travels to a distant
site. (99% of all emboli arise from a thrombus).

Thromboembolism: Obstruction of a blood vessel with

thrombotic material carried by the blood stream from the site
of origin to plug another vessel.
 Classification\ types of emboli
•Thromboemboli –commonest: arterial, venous
•Air (gas )
•Fat
•Bone marrow, bone fracture.
•Tumor
•Cholesterol
•Foreign body (Parasites)
•Amniotic fluid
6.Ischemia and Infarction
Ischemia
•Greek ischein“to restrain” + haima“blood”
•Ischemia occurs when the blood supply to a tissue is
inadequate to meet the tissue’s metabolic demands.

•Ischemia has 3 principal biochemical components:

–Hypoxia (including anoxia)
–Insufficiency of metabolic substrates
–Accumulation of metabolic waste

•Therefore, ischemia is a greater insult to the cells and tissues

than hypoxia alone.
Ischemia is reversible
Ischemia may cause infarction
Infarction
- Area of ischemic necrosis caused by occlusion of
either the arterial supply or the venous drainage in a
particular tissue.

- Notes: 50% of all human deaths result from

myocardial or cerebral infarction due to
cardiovascular disease.
- Infarction is irreversible
- 48 hours most become paler
- Kidney infarcts are usually white (ischemic, pale)
- Pulmonary infarcts are usually red
 Myocardial Ischemia
- The Ischemia is the medical
condition where the blood supply
gets reduced to the heart muscle,
and it leads to the issues like angina
pectoris (severe pain in the chest
spreading to the shoulders).
Myocardial Infarction (MI)
- The myocardial infarction is the
worst type of ischemia, where the
death of heart muscle takes place
due to the continuous inadequate
supply of blood to the heart
muscles.

- Caused due to the reduced blood - Caused by the blockage of blood

flow to the heart muscle. flow to the heart muscle.

- Myocardial ischemia is a mild - Myocardial infarction is the

nature heart’s condition. chronic type of heart trouble which
can even lead to the death of the
patient in minutes.
Types of infarction:
1- Pale (white) infarct: Lacks blood, also called
anemic infarction. Occurs with arterial occlusions in
solid organs (heart, kidney).

2- Red infarct: Filled with blood. Seen with venous

occlusions in lung, liver, brain, small intestine.

3- Septic infarct: When the necrotic tissue of an

infarct is seeded by pyogenicbacteria the tissue
becomes a good growth medium for these pathogenic
organisms.