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DISORDERS
Overview
Edema (increased fluid in the ECF) Hyperemia (INCREASED flow) Congestion (INCREASED backup) Hemorrhage (extravasation) Hemostasis (opposite of thrombosis) Thrombosis (clotting blood) Embolism (downstream travel of a clot) Infarction (death of tissues w/o blood) Shock (circulatory failure/collapse)
EDEMA
ONLY 4 POSSIBILITIES!!!
Increased Hydrostatic Pressure Reduced Oncotic Pressure Lymphatic Obstruction Sodium/Water Retention
Na+ RETENTION
Excessive salt intake with renal insufficiency Increased tubular reabsorption of sodium
INFLAMMATION
Acute inflammation Chronic inflammation Angiogenesis
CHF EDEMA
INCREASED VENOUS PRESSURE DUE TO FAILURE
DECREASED RENAL PERFUSION, triggering of RENINANGIOTENSION-ALDOSTERONE complex, resulting ultimately in SODIUM RETENTION
HEPATIC ASCITES
PORTAL HYPERTENSION HYPOALBUMINEMIA
ASCITES
RENAL EDEMA
SODIUM RETENTION
SUBCUTANEOUS (PITTING) DEPENDENT ANASARCA LEFT vs RIGHT HEART PERIORBITAL PULMONARY CEREBRAL (closed cavity, no expansion)
HERNIATION of cerebellar tonsils HERNIATION of hippocampal uncus over tentorium HERNIATION, subfalcine
EDEMA
Pitting Edema
Transudate vs Exudate
Transudate
results from disturbance of Starling forces specific gravity < 1.012 protein content < 3 g/dl, LDH LOW
Exudate
results from damage to the capillary wall specific gravity > 1.012 protein content > 3 g/dl, LDH HIGH
HYPEREMIA/(CONGESTION)
HYPEREMIA
Active Process
CONGESTION
Passive Process Acute or Chronic
CONGESTION
LUNG
ACUTE CHRONIC
LIVER
ACUTE CHRONIC
CEREBRAL
Kerley B
Air Bronchogram
ACUTE, CHRONIC
EVOLUTION of HEMORRHAGE
ACUTE CHRONIC PURPLE GREEN BROWN HGB BILIRUBIN HEMOSIDERIN
HEMOSTASIS
OPPOSITE of THROMBOSIS
PRESERVE LIQUIDITY OF BLOOD PLUG sites of vascular injury
THREE COMPONENTS
VASCULAR WALL, i.e., endoth/ECM PLATELETS COAGULATION CASCADE
PLAYERS
ENDOTHELIUM PLATELETS COAGULATION CASCADE
ENDOTHELIUM
NORMALLY
ANTIPLATELET PROPERTIES ANTICOAGULANT PROPERTIES FIBRINOLYTIC PROPERTIES
IN INJURY
PRO-COAGULANT PROPERTIES
ENDOTHELIUM
ANTI-Platelet PROPERTIES
Protection from the subendothelial ECM Degrades ADP (inhib. Aggregation)
ANTI-Coagulant PROPERTIES
Membrane HEPARIN-like molecules Makes THROMBOMODULIN Protein-C TISSUE FACTOR PATHWAY INHIBITOR
ENDOTHELIUM
PROTHROMBOTIC PROPERTIES
Makes vWF, which binds PlatsColl Makes TISSUE FACTOR (with plats) Makes Plasminogen inhibitors
ENDOTHELIUM
ACTIVATED by INFECTIOUS AGENTS ACTIVATED by HEMODYNAMICS ACTIVATED by PLASMA ACTIVATED by ANYTHING which disrupts it
PLATELETS
ALPHA GRANULES
Fibrinogen Fibronectin Factor-V, Factor-VIII Platelet factor 4, TGF-beta
NORMAL platelet on LEFT, DEGRANULATING ALPHA GRANULE ON RIGHT AT OPEN WHITE ARROW
PLATELET PHASES
ADHESION SECRETION (i.e., release or activation or degranulation) AGGREGATION
PLATELET ADHESION
Primarily to the subendothelial ECM
Regulated by vWF, which bridges platelet surface receptors to ECM collagen
PLATELET SECRETION
BOTH granules, and
Binding of agonists to platelet surface receptors AND intracellular protein PHOSPHORYLATION
PLATELET AGGREGATION
ADP TxA2 (Thromboxane A2) THROMBIN from coagulation cascade also FIBRIN further strengthens and hardens and contracts the platelet plug
PLATELET EVENTS
ADHERENCE to ECM SECRETION of ADP and TxA2 EXPOSE phospholipid complexes Express TISSUE FACTOR PRIMARYSECONDARY PLUG STRENGTHENED by FIBRIN
COAGULATION CASCADE
INTRINSIC(contact)/EXTRINSIC(TissFac) ProenzymesEnzymes Prothrombin(II)Thrombin(IIa) Fibrinogen(I)Fibrin(Ia) Cofactors
Ca++ Phospholipid (from platelet membranes) Vit-K dep. factors: II, VII, IX, X, Prot. S, C, Z
COAGULATION TESTS
(a)PTT INTRINSIC (HEP Rx) PT (INR) EXTRINSIC (COUM Rx) BLEEDING TIME (PLATS) (2-9min) Platelet count (150,000-400,000/mm3) Fibrinogen Factor assays
THROMBOSIS Pathogenesis
Endothelial Injury Alterations in Flow Hypercoagulability Morphology Fate Clinical Correlations Venous Arterial (Mural)
Virchows TRIANGLE
ENDOTHELIAL INJURY
THROMBOSIS
HYPERCOAGULATION
ENDOTHELIAL INJURY
Jekyll/Hyde disruption
any perturbation in the dynamic balance of the pro- and antithrombotic effects of endothelium, not only physical damage
ENDOTHELIUM
ANTI-Platelet PROPERTIES
Protection from the subendothelial ECM Degrades ADP (inhib. Aggregation)
ANTI-Coagulant PROPERTIES
Membrane HEPARIN-like molecules Makes THROMBOMODULIN Protein-C TISSUE FACTOR PATHWAY INHIBITOR
ENDOTHELIUM
PROTHROMBOTIC PROPERTIES
Makes vWF, which binds PlatsColl Makes TISSUE FACTOR (with plats) Makes Plasminogen inhibitors
1 HYPERCOAGULABILITY
(INHERITED) COMMONEST: Factor V and Prothrombin defects
Common: Mutation in prothrombin gene,
Mutation in methylenetetrahydrofolate gene
2 HYPERCOAGULABILITY
(ACQUIRED)
Prolonged bed rest or immobilization Myocardial infarction Atrial fibrillation Tissue damage (surgery, fracture, burns) Cancer (TROUSSEAU syndrome, i.e., migratory thrombophlebitis) Prosthetic cardiac valves Disseminated intravascular coagulation Heparin-induced thrombocytopenia Antiphospholipid antibody syndrome (lupus anticoagulant syndrome) Cardiomyopathy Nephrotic syndrome Hyperestrogenic states (pregnancy) Oral contraceptive use Sickle cell anemia Smoking, Obesity
MORPHOLOGY
ADHERENCE TO VESSEL WALL
HEART (MURAL) ARTERY (OCCLUSIVE/INFARCT) VEIN
FATE of THROMBI
PROPAGATION (Downstream) EMBOLIZATION DISSOLUTION ORGANIZATION RECANALIZATION
D.V.T.
INACTIVITY!!!
Trauma
Surgery
Burns Injury to vessels, Procoagulant substances from tissues Reduced t-PA activity
ACUTE MYOCARDIAL INFARCTION = OLD ATHEROSCLEROSIS + FRESH THROMBOSIS ARTERIAL THROMBI also may send fragments DOWNSTREAM, but these fragments may contain flecks of calcified or cholesterol PLAQUE also LODGING is PROPORTIONAL to the % of cardiac output the organ receives, i.e., brain, kidneys, spleen, legs, or the diameter of the downstream vessel
ARTERIAL/CARDIAC THROMBI
CHOLESTEROL clefts are components of atherosclerotic arterial plaques, NOT venous thrombi!!!
ATHEROEMBOLI
SHOCK
NOT a primary disease CONSUMPTIVE coagulopathy, e.g., reduced platelets, fibrinogen, F-VIII and other consumable clotting factors, brain, heart, lungs, kidneys, MICROSCOPIC ONLY
Pulmonary
Aneurysms)
EMBOLISM
PULMONARY EMBOLISM
USUALLY SILENT, USUALLY SILENT CHEST PAIN, LOW PO2, S.O.B. Sudden OCCLUSION of >60% of pulmonary vasculature, presents a HIGH risk for sudden death, i.e., acute cor pulmonale, ACUTE right heart failure SADDLE embolism often/usually fatal PRE vs. POST mortem blood clot:
PRE: Friable, adherent, lines of ZAHN
SYSTEMIC EMBOLI
PARADOXICAL EMBOLI 80% cardiac/20% aortic Embolization lodging site is proportional to the degree of flow (cardiac output) that area or organ gets, i.e., brain (15%), kidneys (~25%), legs, splanchnic (~25%), liver (~25%)
OTHER EMBOLI
FAT (long bone fxs, also
bones with marrow)
INFARCTION
Defined as an area of necrosis* secondary to decreased blood flow HEMORRHAGIC vs. ANEMIC RED vs. WHITE
END ARTERIES vs. DUAL ARTERY SUPPLY
ACUTEORGANIZATIONFIBROSIS
INFARCTION FACTORS
NATURE of VASCULAR SUPPLY
Single end arteries such as kidney, spleen? Dual blood supply such as lung, liver?
RATE of DEVELOPMENT
SLOW (BETTER) FAST (WORSE)
VULNERABILITY to HYPOXIA
MYOCYTE vs. FIBROBLAST
HEART
SHOCK
Pathogenesis
Cardiac Septic Hypovolemic
SHOCK
Definition: CARDIOVASCULAR COLLAPSE
GENERAL RESULTS
INADEQUATE TISSUE PERFUSION CELLULAR HYPOXIA If UN-corrected, a FATAL outcome
TYPES of SHOCK
CARDIOGENIC: (Acute, Chronic Heart
Failure)
HYPOVOLEMIC: (Hemorrhage or
Leakage)
CARDIOGENIC shock
MI VENTRICULAR RUPTURE ARRHYTHMIA CARDIAC TAMPONADE PULMONARY EMBOLISM (acute RIGHT heart failure or cor pulmonale)
HYPOVOLEMIC shock
HEMORRHAGE, Vasc. compartmentH2O VOMITING, Vasc. compartmentH2O DIARRHEA, Vasc. compartmentH2O BURNS, Vasc. compartmentH2O
SEPTIC shock
OVERWHELMING INFECTION ENDOTOXINS, i.e., LPS (Usually Gm-) Gm+ FUNGAL SUPERANTIGENS, (Superantigens are polyclonal
T-lymphocyte activators that induce systemic inflammatory cytokine cascades similar to those occurring downstream in septic shock, toxic shock superantigens by staph are the prime example.)
* Think of this as a TOTAL BODY inflammatory response, or early total body infarct!
ENDOTOXINS
Usually Gm Degraded bacterial cell wall products
Poly-Saccharides
Attach to a cell surface antigen known as CD-14
ENDOTOXINS
MYOCARDIAL CONTRACTILITY
DIFFUSE ENDOTHELIAL ACTIVATION LEUKOCYTE ADHESION ALVEOLAR DAMAGE (ARDS) DIC VITAL ORGAN FAILURE CNS
NON-PROGRESSIVE
(compensatory mechanisms)
PROGRESSIVE
(acidosis, early organ failure)
IRREVERSIBLE
NON-PROGRESSIVE
COMPENSATORY MECHANISMS
CATECHOLAMINES
VITAL ORGANS PERFUSED
PROGRESSIVE
HYPOPERFUSION EARLY VITAL ORGAN FAILURE OLIGURIA
ACIDOSIS
PATHOLOGY
MULTIPLE ORGAN FAILURE SUBENDOCARDIAL HEMORRHAGE (why?) ACUTE TUBULAR NECROSIS (why?) DAD (Diffuse Alveolar Damage, lung) (why?) GI MUCOSAL HEMORRHAGES (why?) LIVER NECROSIS (why?) DIC (why?)
ARDS/DAD
MYOCARDIAL NECROSIS
ATN
DIC