The document discusses hemodynamic disorders, focusing on edema and hemorrhage. Edema is characterized by the accumulation of interstitial fluid, influenced by hydrostatic and osmotic pressures, with various pathophysiological causes and clinical implications. Hemorrhage involves the extravasation of blood and can have varying significance based on location and volume, affecting clinical outcomes based on underlying conditions.

2. HEMODYNAMIC
DISORDERS

3. CONTENTS
Edema
Pathophysiological causes of edema
Morphology and clinical correlation
of edema
Hemorrhage
Manifestations and clinical
significance of hemorrhage

4. EDEMA
Edema is an accumulation of
interstitial fluid within tissues.
Extravascular fluid can also collect in
body cavities such as the pleural
cavity (hydrothorax), the pericardial
cavity (hydropericardium), or the
peritoneal cavity (hydroperitoneum,
or ascites).

5. Anasarca is severe, generalized
edema marked by profound swelling
of subcutaneous tissues and
accumulation of fluid in body cavities.
Fluid movement abetween the
vascular and interstitial spaces is
governed mainly by two opposing
forces—the vascular hydrostatic
pressure and the colloid osmotic
pressure produced by plasma

6. Normally, the outflow of fluid
produced by hydrostatic pressure at
the arteriolar end of the
microcirculation is neatly balanced by
inflow due to the slightly elevated
osmotic pressure at the venular end;
hence there is only a small net
outflow of fluid into the interstitial
space, which is drained by lymphatic
vessels.

7. Either increased hydrostatic pressure
or diminished colloid osmotic
pressure causes increased movement
of water into the interstitium.
The edema fluid that accumulates
owing to increased hydrostatic
pressure or reduced intravascular
colloid typically is a protein-poor
transudate; it has a specific gravity
less than 1.012.

8. By contrast, because of increased
vascular permeability, inflammatory
edema fluid is a protein-rich exudate
with a specific gravity usually greater
than 1.020.

9. PATHOPHYSIOLOGICAL
CAUSES OF EDEMA
Increased Hydrostatic Pressure
Impaired Venous Return
Congestive heart failure
Constrictive pericarditis
Ascites (liver cirrhosis)
Venous obstruction or compression
Thrombosis
External pressure (e.g., mass)
Lower extremity inactivity with prolonged dependency
Arteriolar Dilation
Heat
Neurohumoral dysregulation

10. Reduced Plasma Osmotic Pressure (Hypoproteinemia)
Protein-losing glomerulopathies (nephrotic syndrome)
Liver cirrhosis (ascites)
Malnutrition
Protein-losing gastroenteropathy
Lymphatic Obstruction
Inflammatory
Neoplastic
Postsurgical
Postirradiation

11. Sodium Retention
Excessive salt intake with renal insufficiency
Increased tubular reabsorption of sodium
Renal hypoperfusion
Increased renin-angiotensin-aldosterone secretion
Inflammation
Acute inflammation
Chronic inflammation
Angiogenesis

12. MORPHOLOGY
Edema is easily recognized on gross
inspection; microscopic examination
shows clearing and separation of the
extracellular matrix elements.
Subcutaneous edema can be diffuse
but usually accumulates preferentially
in parts of the body positioned the
greatest distance below the heart
where hydrostatic pressures are
highest.

13. Thus, edema typically is most
pronounced in the legs with standing,
a relationship termed dependent
edema.
Finger pressure over edematous
subcutaneous tissue displaces the
interstitial fluid, leaving a finger-
shaped depression; this appearance is
called pitting edema.

14. Edema due to renal dysfunction or
nephrotic syndrome often manifests
first in loose connective tissues (e.g.,
the eyelids, causing periorbital
edema).
With pulmonary edema, the lungs
often are two to three times their
normal waeight, and sectioning
reveals frothy, sometimes blood-
tinged fluid consisting of a mixture of

15. Brain edema can be localized (e.g.,
due to abscess or tumor) or
generalized, depending on the nature
and extent of the pathologic process
or injury.

16. CLINICAL CORRELATION
Subcutaneous edema, signals
potential underlying cardiac or renal
disease; however, when significant, it
also can impair wound healing or the
clearance of infections.
Pulmonary edema, frequently is seen
in the setting of left ventricular failure
but also may occur in renal failure,
acute respiratory distress syndrome,
and inflammatory and infectious

17. Brain edema is life-threatening; if the
swelling is severe, the brain can
herniate (extrude) through the
foramen magnum. With increased
intracranial pressure, the brain stem
vascular supply can be compressed.
Either condition can cause death by
injuring the medullary centers

18. HEMORRHAGE
Hemorrhage, defined as the
extravasation of blood from vessels,
occurs in a variety of settings.
The risk of hemorrhage (often after a
seemingly insignificant injury) is
increased in a wide variety of clinical
disorders collectively called
hemorrhagic diatheses.

19. Trauma, atherosclerosis, or
inflammatory or neoplastic erosion of
a vessel wall also may lead to
hemorrhage, which may be extensive
if the affected vessel is a large vein or
artery.

20. MANIFESTATIONS OF
HEMORRHAGE
Hemorrhage may be external or
accumulate within a tissue as a
hematoma, which ranges in
significance from trivial (e.g., a
bruise) to fatal.
Large bleeds into body cavities are
given various names according to
location—hemothorax,
hemopericardium, hemoperitoneum,
or hemarthrosis (in joints).

21. PETECHIAE
Petechiae are minute (1 to 2 mm in
diameter) hemorrhages into skin,
mucous membranes, or serosal
surfaces, ; causes include low platelet
counts (thrombocytopenia), defective
platelet function.

22. PURPURA AND ECCHYMOSES
Purpura are slightly larger (3 to 5
mm) hemorrhages, causes include
trauma, vascular inflammation
(vasculitis), and increased vascular
fragility.
Ecchymoses are larger (1 to 2 cm)
subcutaneous hematomas
(colloquially called bruises).

23. CLINICAL SIGNIFICANCE OF
HEMORRHAGE
Depends on the volume of blood lost
and the rate of bleeding.
The site of hemorrhage also is
important.
Chronic or recurrent external blood
loss (e.g., due to peptic ulcer)
frequently culminates in iron
deficiency anemia