8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 1/106
Hemodynamic Disorders
Thrombosis
& Shock
1
Dr. Riad ShraimAl-Quds University
Faculty o !edicine
"atholo#y De$artment
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 2/106
%irculatory disorders
• 'dema
• Hy$eremia and %on#estion
• Hemorrha#e• Thrombosis
• 'mbolism
• (narction
• Shock2
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 3/106
• Total body )aterTotal bod
y )ater
– *aries rom +,-, o body )ei#ht*aries rom +,-, o body )ei#ht
– /oun#0 healthy men 1 ,2-32 /oun#0 healthy men 1 ,2-32
– /oun#0 healthy )omen 1 +,-,2 /oun#0 healthy )omen 1 +,-,2
– decreases )ith a#edecreases )ith a#e
3
Distribution o 4ody 5aterDistribution o 4ody 5ater
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 4/106
• (ntracellular com$artment(ntracellular co
m$artment
– 2/3 of body water (+2 body )ei#ht+2 body )ei#ht)
• '6tracellular com$artment'6tracellular com
$artment
– 1/3 of body water (72 body )ei#ht72 body )ei#ht)
• "lasma"lasma (water = 4% - 5% body weight)
• (nterstitial luid(nterstitial luid (water = 15% body weight)
4
Distribution o 4ody 5aterDistribution o 4ody 5ater
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 5/106
'dema 8ormal luid balance
32 o body )ei#ht is )ater
79: ;3< o this luid is intracellular
=9: ;::< is e6tracellular0 mostly asinterstitial luid
> , o total body luid is in thevascular com$artment
Fluid in 2 ?# man@5
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 6/106
•(n a healthy 2 k# male(n a healt
hy 2 k# male
• Total body water is ~ +7 +7 ~ !% "#
• This is contained in t)o maBor com$artmentsThis is contained in t)o maBor com$artments
1$ the itra&ell'lar fl'id (7C 7C ~ 4!% "#)
2$ the etra&ell'lar fl'id (=+ =+ ~ 2!% "#)
– the iterstitial fl'id (=2., =2., ~ 15% "#)
– *las+a (:., :., ~ 5% "#) , rterial , .eo's
Distribution o 4ody 5aterDistribution o 4ody 5ater
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 7/106
8ormal luid balance The bala&e betwee vascular hydrostatic $ressure ad
$lasma colloid osmotic $ressure is the driig for&e that
+aitais +oe+et of fl'ids betwee as&'lar ad
iterstitial s*a&es
0or+ally the eit of fl'id ito the iterstiti'+ at the
arteriolar end is al+ost bala&ed by iflow of fl'id fro+ the
iterstiti'+ ba& ito the as&'lar bed at the venular end
s+all a+o't of fl'id stays i the iterstiti'+ be&a'se of
little higher hydrostati& *ress're to *'sh fl'ids o't
This little a+o't of fl'id is draied ba& by lym$hatics
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 8/106
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 9/106
8ormal luid balance
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 10/106
1!
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 11/106
'dema'dema
'dema is increased luid in the interstitial
tissue s$aces
olle&tio of fl'id i body &aities is a+ed
a&&ordig to *la&e6 hydrothora6-hydrothora6- *le'ral eff'sio
hydro$ericardium-hydro$ericardium- *eri&ardial eff'sio
hydro$eritonium-hydro$eritonium- as&ites
Anasarca is seere ad geerali7ed ede+a
with *rofo'd s'b&'taeo's tiss'e swellig11
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 12/106
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 13/106
"atho$hysiolo#ic %ate#ories o 'dema
(ncreased hydrostatic $ressure(ncreased hydrostatic $ressure
(m$aired venous return
1- ogestie heart fail're
2- ostri&tie *eri&arditis
3- s&ites (lier &irrhosis)
4- .eo's obstr'&tio or &o+*ressio6
a- Thro+bosisa- Thro+bosisb- 8teral *ress're (t'+or)b- 8teral *ress're (t'+or)
&- 9a&tiity of lower li+b&- 9a&tiity of lower li+b
13
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 14/106
Reduced plasma osmotic pressure:Reduced plasma osmotic pressure:
1- Protein losing glomerulopathies (nephrotic
syndrome)
2- Liver cirrhosis
3- Malnutrition4- Protein losing gastroenteropathy
Lymphatic obstruction:Lymphatic obstruction:
1-Infammatory2- Neoplastic
3- Post-surgical
4- Post-irradiation 14
"atho$hysiolo#ic %ate#ories o 'dema"atho$hysiolo#ic %ate#ories o 'dema
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 15/106
ym$hedemaym$hedema inin
the arm aterthe arm aterlet mastectomylet mastectomy
ym$hatic obstructionym$hatic obstruction
15
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 16/106
'le$hantiasis'le$hantiasis a case o ilariasis a case o ilariasis
ym$hatic obstruction
1
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 17/106
$eau dEoran#e ;oran#e $eel< a$$earance$eau dEoran#e ;oran#e $eel< a$$earance
1
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 18/106
Sodium retentionSodium retention
1- 8&essie 0a itae with real is'ffi&ie&y
2- 9&reased t'b'lar absor*tio of 0a
a- Renal hy$o$erusionRenal hy$o$erusion
b- (ncreased renin-an#iotensin-(ncreased renin-an#iotensin-
aldosterone secretionaldosterone secretion
(nlammation(nlammation &'te ifla++atio
1
"atho$hysiolo#ic %ate#ories o 'dema"atho$hysiolo#ic %ate#ories o 'dema
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 19/106
Subcutaneous edema
• :ae differet distrib'tios de*edig o the &a'se
• 9t &a be diff'se or it +ay be +ore *ro+iet i theregios with the highest hydrostati& *ress'res (the
ede+a distrib'tio is ifl'e&ed by graity ad is
ter+ed de$endent).
• 'dema o the de$endent $arts o the body'dema o the de$endent $arts o the body (e$g$
the legs whe stadig) is a $rominent eature ois a $rominent eature o
cardiac ailure0 $articularly o the ri#ht ventriclecardiac ailure0 $articularly o the ri#ht ventricle.
• ;iger *ress're oer sigifi&atly ede+ato's
s'b&'taeo's tiss'e dis*la&es the iterstitial fl'id
ad leaes a in#er-sha$ed de$ressiona in#er-sha$ed de$ression so-&alled
$ittin# edema$ittin# edema. 1
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 20/106
$ittin#
edema
2!
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 21/106
21
'dema d'e to renal dysunction or ne$hrotic syndrome
is +ore seere tha &ardia& ede+a and aects all $arts o
the body eually. 9t +ay be iitially +aifested i tiss'es with
a loose &oe&tie tiss'e +atri e$g$ eyelids &a'sig
$eriorbital edema$eriorbital edema
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 22/106
PulmonaryPulmonary
edemaedemaresults in
difuse
opacicatio
n o the lung
22
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 23/106
The s'rfa&e of the brai with cerebral edema de+ostrates
a flatteed s'rfa&e$ The s'l&i are arrowed$
23
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 24/106
The t)o ty$es o edema luid
'6cudate6
9fla++atory ede+a has a high *rotei
&otet ad is asso&iated with a
ifla++atory rea&tio$
Transudate6
0oifla++atory ede+a has a low *rotei
&otet is &a'sed by alteratios i
he+odya+i& for&es a&ross the &a*illary wall
(he+odya+i& ede+a)$24
H i d % ti
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 25/106
Hy$eremia and %on#estionHy$eremia
9t<s a active *ro&ess that res'lts fro+ i&reased blood flow
be&a'se of arteriolar dilationarteriolar dilation$
Tiss'es that hae hy*ere+ia +eas that they have morehave more
o6y#enated bloodo6y#enated blood ad will a$$ear more reda$$ear more red
%on#estion
9t<s a $assive *ro&ess it +ay res'lt fro+ im$aired venousim$aired venous
returnreturn fro+ the tiss'e ioled
Tiss'es will have deo6y#enated blood
The tiss'e has a blue-red &olor (cyanosiscyanosis)
a'ses +ay be lo&al or syste+i&6 &ardia& or he*ati&25
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 26/106
Hy$eremia versus con#estion
9 both &ases there is a increasedincreased
volume and $ressurevolume and $ressure of blood i a
gie tiss'e with asso&iated ca$illaryca$illary
dilationdilation ad a *otetial for luidluid
e6travasatione6travasation
9 hy$eremia i&reased iflow leads
to egorge+et with oygeated
blood res'ltig i erythemaerythema$
9 con#estion di+iished o'tflow
leads to a &a*illary bed swolle with
deoygeated eo's blood ad
res'ltig i cyanosiscyanosis$
2
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 27/106
(n chronic $assive con#estion0 there )ill be
=- Stasis of *oorly oygeated blood
7- hroi& hy$o6ia d'e to i+*aired &ir&'latio
:- De#eneration & Death of the *are&hy+al &ells i that tiss'e
+- ersistet &ogestio of the &a*illaries will &a'se their
r'*t're res'ltig i oci o hemorrha#e
,- >ed &ells frag+ets ad e&roti& tiss'e will be *hago&ytosed
res'ltig i a##re#ates o hemosiderin macro$ha#es
2
%on#estion
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 28/106
Hemorrha#eHemorrha#e
Hemorrha#eHemorrha#e si+*ly +eas bleedin#bleedin#
4leedin#4leedin# +ay o&&'r d'e to clottin# disordersclottin# disorders or
fro+ traumatrauma
%a$illary bleedin# &a o&&'r be&a'se of
con#estioncon#estion traumatrauma or inlammationinlammation
4leedin#4leedin# +ay be e6ternal or internal (withi the
tiss'es)
olle&tio of blood withi a tiss'e is &alled
hematomahematoma$ ar#e hematomas can be atalar #e hematomas can be atal2
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 29/106
2
hematoma
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 30/106
8ail bed - Hematoma
3!
H h
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 31/106
?igifi&a&e of bleedig de$ends on the amount
ad the $lace where bleedig o&&'rs$
?+all a+o'ts of bleedig i the &raial &aity +ay
be fatal whereas 1$5 liters of blood i the sto+a&h
+ay *ass 'oti&ed by the *atiet$
Ra$id bleedin#Ra$id bleedin# of '* to 72 of total body blood
+ay be &o+*esated for by the body ad does ot
&a'se serio's &lii&al +aifestatios
Slo) bleedin#Slo) bleedin# +ay res'lt i iron deiciency
anemia *arti&'larly i elderly *eo*le 31
Hemorrha#e
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 32/106
Hemorrha#eHemorrha#e
?+all he+orrhages of =-7 mm ito the si or
+'&o's +e+braes are &alled $etechiae$etechiae
"etechiae are caused because o"etechiae are caused because o
=- increased intravascular $ressure
7- lo) $latelet count
:- deective $latelet unction
+- clottin# actor deiciency
32
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 33/106
"etechial he+orrhages of the &oloi& +'&osa as a
&ose@'e&e of thrombocyto$eniathrombocyto$enia$ 33
Hemorrha#e
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 34/106
PurpurasPurpuras: larger hemorrhages: 3-53-5
mmmm
auses:auses:
1- increased intravascular pressure
2- lo! platelet count
3- deective platelet unction
4- clotting actor deciency
!" vasculitis
#" increased vascular ragility
$" trauma 34
Hemorrha#e
H h
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 35/106
• 'cchymosis6 are s'b&'taeo's he+ato+a
They are =-7 cm=-7 cm i area
The erythrocytes i these he+orrhages are
$ha#ocytosed ad degraded$
Their hemo#lobin ;red-blue in color<hemo#lobin ;red-blue in color< will be
&oerted to bilirubinbilirubin whi&h is blue #reenblue #reen i &olor
8et'ally bilir'bi will be &oerted to
hemosiderinhemosiderin a #olden-bro)n#olden-bro)n &olored +aterial35
Hemorrha#e
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 36/106
bruise or 'cchymosis'cchymosis is a id of iA'ry 's'ally &a'sed
by bl't i+*a&t i whi&h the &a*illaries are da+aged
allowig blood to see* ito the s'rro'dig tiss'e$
3
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 37/106
ar#er accumulations o blood
=- hemothora66 blood i the *le'ral &aity
7- hemo$ericardium6 blood i the *eri&ardial &aity
:- hemoarthrosis6 blood i the Aoit
+- hemo$eritoneum6 blood i the *eritoeal &aity
3
Hemorrha#e
( ti
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 38/106
(narction• (narction is a areas of ischemic necrosis that is
&a'sed by o&&l'sio of either the arterial s'**ly or the
venous draiage i a *arti&'lar tiss'e$
• '6am$les
• Byo&ardial ifar&tio
• erebral ifar&tio
• 'l+oary ifar&tio
• "owel ifar&tio
• 8tre+ities e&rosis (gagree)
3
5h t l l i l d t
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 39/106
5hat vascular lesions lead to
inarction@
Thrombosis
'mbolism
8teral &o+*ressio
Twistig of *edi&le
rterial s*as+
:e+orrhage fro+ a tra'+a3
GG
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 40/106
Uncommon causes o inarction
• *asos$asm o vessels6 &oroaries i
ri7+etal agia
• %om$ression fro+ o'tside by t'+ors or ede+a
• T)istin# of the essels as i torsio of testis or
itestial it'ss's&e*tio or ol'l's
• 'ntra$ment of essels as i strag'lated heria
• Traumatic r'*t're of the blood s'**ly
4!
9testialtorsio of testis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 41/106
41
9testial
it'ss's&e*tio
Stran#ulated hernia
torsio of testis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 42/106
42
T ( t
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 43/106
Ty$es o (narcts
• 5hite inarcts ;anemic<5hite inarcts ;anemic< o&&'rs i arterial
occlusions or i solid or#ans (s'&h as heart
s*lee ad idey)
•Sha$e o inarctsSha$e o inarcts – 9far&ts are geerally )ed#e sha$ed$ The a*e
of the wedge is at the site of the o&&l'ded
essel ad the base *oits towards the*eri*hery of the orga
– 9f the base of the ifar&ts is a sero's s'rfa&e
there will be ibrinous e6udate o that s'rfa&e43
The inarcts are $ale
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 44/106
44
The inarcts are $ale
and )ed#e-sha$ed0
relectin# the
distribution o the
blood su$$ly
T ( t
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 45/106
Ty$es o (narctsRed inarcts are hemorrha#ic inarcts and occur
• 9 loose tiss'es lie l'g that *er+its &olle&tio ofblood
• 9 tiss'es with dual blood su$$ly6 lie i the l'gs
ad itestie
• 9 venous occlusion (e$g$ oaria torsios)
• 9 tiss'es that are already &ogested fro+ i+*aired
venous flow (e$g$ lier con#estion)
• 9 re$erusion of tiss'es after arterial o&&l'sio that
has &a'sed e&rosis 45
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 46/106
'6am$les o (narction
4
)hite inarct in s$leen
Hemorrha#ic0 rou#hly )ed#e-
sha$ed $ulmonary inarct
"U!8AR/ (8FAR%T"U!8AR/ (8FAR%T
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 47/106
"U!8AR/ (8FAR%T"U!8AR/ (8FAR%T
• 8B"CD9ET9C0 TC
?BDD F9?TD
.8??8D? 90 DG0H
BI G?8
(S%H'!(%(S%H'!(%
8'%RS(S8'%RS(S C;
T9??G8 C>
(8FAR%T(8FAR%T4
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 48/106
Factors that aect develo$ment o inarctFactors that aect develo$ment o inarct
=.=. 8ature o the vascular su$$ly8ature o the vascular su$$ly
That<s why orgas with d'al blood s'**ly do ot
deelo* ifar&tios if there is obstr'&tio to s+all
blood essels
The l'g has *'l+oary ad bro&hial blood
s'**ly
G**er etre+ities with radial ad 'lar blood
s'**ly
#hereas orgas s'&h as s*lee idey ad the
eye has ed-arterial blood s'**ly 4
Factors that aect develo$ment o inarctFactors that aect develo$ment o inarct
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 49/106
Factors that aect develo$ment o inarctFactors that aect develo$ment o inarct
7. Rate o develo$ment o occlusionRate o develo$ment o occlusion
?lowly deelo*ig o&&l'sio +ay gie ti+e for
alteratie *athway
:. Susce$tibility o involved tissue to hy$o6iaSusce$tibility o involved tissue to hy$o6ia
8eurons8eurons 'dergo irreersible da+age if they are
de*ried of their blood s'**ly for oly 3-4 +i'tes
!yocardial cells die after 2!-3! +i'tes
+. 6y#en content o the blood6y#en content o the blood
%yanotic *atiets or anemics are +ore liely to deelo*
ifar&tio as &o+*ared to or+al *eo*le
4
Hemostasis & Thrombosis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 50/106
Hemostasis & Thrombosis
8ormal Hemostasis8ormal Hemostasis the *ro&ess by whi&hthe *ro&ess by whi&h
the blood is +aitaied i a &lot-free fl'id statethe blood is +aitaied i a &lot-free fl'id state
ad *rod'&es a lo&al he+ostati& *l'g at sitesad *rod'&es a lo&al he+ostati& *l'g at sites
of as&'lar iA'ryof as&'lar iA'ry
ThrombosisThrombosis ia**ro*riate a&tiatio of the
he+ostati& *ro&ess i 'iA'red as&'lat're or
for+atio of thrombus i the settig of
relatiely +ii+al as&'lar iA'ry5!
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 51/106
Hemostasis
*asoconstriction
"latelet activation
"latelet a##re#ation
%oa#ulation cascade
Stable clot ormation
%lot dissolution
51
"rimary hemostasis"rimary hemostasis
Secondary hemostasisSecondary hemostasis
;$rimary hemostatic $lu#<;$rimary hemostatic $lu#<
;secondary hemostatic $lu#<;secondary hemostatic $lu#<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 52/106
Seuence o hemostasis
(- *asoconstriction• 9++ediately after iA'ry there is a iitial
vasoconstriction$
• This is sti+'lated by the release of endothelin
fro+ the edothelial &ells$
• TheThe endothelinendothelin is a i+*ortat aso&ostri&tor is a i+*ortat aso&ostri&tor
52
Seuence o hemostasisSeuence o hemostasis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 53/106
Seuence o hemostasisSeuence o hemostasis
((- "rimary hemostasis
Activation & adherence of platelets: latelets
adhere to e*osed etra&ell'lar +atri (8B) ia
o #illebrad fa&tor (v5F) ad are a&tiated$
&tiated *latelets 'dergo a sha*e &hage ad
gra'le releaseJ released F ad thro+boae 2
(TK2) lead to f'rther platelet aggregation to for+
the $rimary hemostatic $lu#the $rimary hemostatic $lu#$53
Seuence o hemostasis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 54/106
Seuence o hemostasis(((- Secondary hemostasis
Do&al a&tiatio of the &oag'latio &as&ade (iolig tissue
actor ad *latelet *hos*holi*ids) res'lts i fibri
*oly+eri7atio reifor&ig the *latelets ito a defiitie
secondary hemostatic $lu#secondar y hemostatic $lu#$
The tissue factorThe tissue factor ;;cellular li$o$rotein< has the followinghas the following
characteristics:characteristics:
is a $ro-coa#ulant actor is a $ro-coa#ulant actor
synthesied by endotheliumsynthesied by endothelium
is released at the site o inBuryis released at the site o inBury
54
Seuence o hemostasis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 55/106
Seuence o hemostasis(*- Antithrombotic counter re#ulation
ti&oag'latio +e&hais+ is triggered after thefor+atio of *er+aet &lot by *oly+eri7atio of
fibri ad aggregatio of *latelets
o'ter-reg'latory +e&hais+s s'&h as releaseof Tissue plasminogen activator (t-"A0 a
fibriolyti& *rod'&t) ad thrombomodulin
(iterferig with the &oag'latio &as&ade) are
a&tiated to *reet f'rther e*asio of the &lot
ad li+it the he+ostati& *ro&ess to the site of iA'ry$
55
Hemostasis & Thrombosis
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 56/106
• 4oth hemostasis and thrombosis are
de$endent on
=. The vascular )all ;'ndothelium<The vascular )all ;'ndothelium<
7.7. "latelets"latelets
:.:. The coa#ulation cascadeThe coa#ulation cascade
5
Hemostasis & Thrombosis
%om$onents
= 'ndothelium=. 'ndothelium
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 57/106
=. 'ndothelium=. 'ndotheliumThe endothelial cells normally $osses
ati*latelet ati&oag'latio ad fibriolyti& *ro*erties
( the endothelial cells are inBured or activated0
they deelo* *ro-&oag'lat f'&tios
These activators i&rease *ro&oag'lat a&tiity ad
de&rease ati&oag'lat a&tiity
'6am$les o endothelial cells activators
=- %ytokines (-= and T8F=- %ytokines (-= and T8F
7- "lasma mediators7- "lasma mediators
:- (nectious a#ents:- (nectious a#ents 5
'ndothelial cells synthesie
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 58/106
'ndothelin aso&ostri&tor
Tissue actor 6 a&tiate the &oag'latio &as&ade the etrisi& *athway
"I(7 L 86 asodilators ad ihibit *latelet aggregatio
Adenosine di$hos$hatase degrades F ad ihibits *latelet
aggregatio
He$arin like molecules6 allow atithro+bi to ia&tiate thro+bi
fa&tor Ka ad other &aog'latio fa&tors
Thrombomodulin6 &oert thro+bi fro+ *ro&oag'lat to ati&oag'lat
t-"A6 *ro+otes fibriolysis of the fibri &lot
v5F that hel*s bid *latelets to &ollage 5
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 59/106
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 60/106
"#
" #
!
"rothrombotic $ro$erties o endothelium"rothrombotic $ro$erties o endothelium
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 61/106
(ntact endothelial cells serve $rimarily to inhibit $latelet
adherence & blood clottin#. Ho)ever0 inBury or activation
o endothelial cells results in a $rocoa#ulant $henoty$e
that contributes to localied clot ormation
latelets adhere to the e*osed s'b-edothelial &ollage$ This
is fa&ilitated by v5F se&reted by edothelial &ells
8dothelial &ells secrete tissue actor whi&h a&tiates the
etrisi& &lottig *athway
8dotheli'+ secretes $lasmino#en activator inhibitors
whi&h de*ress fibriolysis
1
"rothrombotic $ro$erties o endothelium"rothrombotic $ro$erties o endothelium
7 "latelets
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 62/106
• t iA'ry site *latelets &o+e i &ota&t with
8B ad they 'dergo three general
reactions6
=- Adhesion and sha$e chan#e
7- Secretion
:- A##re#ation
2
7. "latelets
"latelets
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 63/106
"latelet adhesion"latelet adhesion
Adhesion of *latelets )ith colla#en i the 8B at
the ti+e of iA'ry is fa&ilitated by v5F$
#; a&t as a bridge betwee *latelet s'rfa&e
re&e*tors ad e*osed &ollage
Heeti& defi&ie&ies of #; (o #illebrad
disease) or its re&e*tors res'lt i serio's bleedig
disorders$
3
"latelets
"latelets
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 64/106
"latelet a##re#ation"latelet a##re#ation
The aso&ostri&tor thro+boae 2 (TK2 se&reted by
*latelets) is a *otet sti+'l's for *latelet aggregatio$ This is
the *ri+ary he+ostati& *l'g ad is reersible
Thrombin for+ed i the &oag'latio &as&ade bids to
*latelet s'rfa&e ad with AD" ad TJA7 &a'ses f'rther
*latelet aggregatio followed by *latelet &otra&tio ad
be&o+ig irreersible (se&odary he+ostati& *l'g)
Thro+bi &oert ribrino#en to ibrin that adds to
&e+etig of the *latelet *l'g4
"latelets
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 65/106
"latelet a##re#ation"latelet a##re#ation
The clinical use o as$irin
;a cycloo6y#enase inhibitor< in
$atients at risk or coronary
thrombosis is related to its ability to
inhibit the synthesis o TJA7$
5
: %oa#ulation %ascade: %oa#ulation %ascade
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 66/106
:. %oa#ulation %ascade:. %oa#ulation %ascade
(tKs com$osed o t)o $ath)ays
1$ The intrinsic $ath)ayintrinsic $ath)ay iitiated by the a&tiatio of
:age+a fa&tor
2$ The e6trinsic $ath)aye6trinsic $ath)ay whi&h is a&tiated by the tiss'e
fa&tor
9t<s a series of rea&tios i whi&h ia&tie *roe7y+es
are &oerted ito a&tie e7y+es This res'lts i the for+atio of thrombin that
&oerts the sol'ble fibrioge ito isol'ble ibrin
%oa#ulation cascade%
oa#ulation cascade
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 67/106
#
0ote the &o++o li
betwee the itrisi& ad
etrisi& *athways at the
leel of fa&tor 9K a&tiatio
;a&tors i red boes
re*reset ia&tie
+ole&'les
&tiated fa&tors are
idi&ated with lo)er-casea ad gree bo$
:B#M6 high-+ole&'lar-
weight iioge$
%oa#ulation %ascade
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 68/106
%oa#ulation %ascade
Intrinsic PathwayIntrinsic Pathway (12, 11, 9, 8)
Extrinsic PathwayExtrinsic PathwayTissueTissue factor, (7)
Fibrinogen Fibrin
CommonCommon
PathwayPathway
(5,2)
(Factor 1)
Prothrombin
Thrombin
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 69/106
%oa#ulation %ascade%oa#ulation %ascade
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 70/106
• lottig is reg'lated i a way to be &ofied to the site
of iA'ry by t)ot)o natural anticoa#ulantsnatural anticoa#ulants6
=.=. Antithrombins ;e.#.0 antithrombin (((<Antithrombins ;e.#.0 antithrombin (((<
9t ihibits the a&tiity of thro+bi fa&tor 9Ka Ka K9a L K99a
tithro+bi is a&tiated by bidig to he*ari lie
+ole&'les o edothelial &ells
7.7. "rotein % and S"rotein % and S
They are two vitamin ? de$endent *roteis
They ia&tiate &ofa&tors .a ad .999a
!
%oa#ulation %ascade%oa#ulation %ascade
Fibrinolytic %ascadeFibrinolytic %ascade
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 71/106
Fibrinolytic %ascadeFibrinolytic %ascade
• "esides id'&ig &oag'latio a&tiatio of the &lottig
&as&ade also sets ito +otio a fibrinolytic cascade that
will li+it the si7e of the fial &lot by a&tiatio of plasmin$
• "lasmin is obtaied fro+ the *re&'rsor *las+ioge
either by K99a or by *las+ioge a&tiators (+aily t-)
• "lasmin breas dow fibri *rod'&ig fibri s*lit *rod'&ts
(also &alled fibri degradatio *rod'&ts)• ;ibriolysis is blo&ed by Plasminogen activator inhibitors
1
*ircho) triad in thrombosis are
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 72/106
=. 'ndothelial inBury
7. 4lood hy$ercoa#ulability
:. Stasis or turbulence o blood lo)
Thrombosis
2
=. The endothelial cell inBury=. The endothelial cell inBury
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 73/106
=. The endothelial cell inBury=. The endothelial cell inBury
• Doss of edotheli'+ leads to e*os're of 8B adhere&e
of *latelets release of tiss'e fa&tor lo&al de*letio of H92
ad t-
• arti&'larly i+*ortat i thro+b's for+atio i the heart ad
arterial &ir&'latio
• Fysf'&tioal edotheli'+ +ay elaborate greater a+o'ts
of *ro&oag'lat fa&tors (e$g$ adhesio +ole&'les to bid
*latelets tiss'e fa&tor) ad s+aller a+o'ts of
ati&oag'lat effe&tors (e$g$ thro+bo+od'li H92 t-)$
3
The endothelial cell inBuryThe endothelial cell inBury
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 74/106
%auses o endothelial cell inBury
hysi&al disr'*tio
:y*ertesio
T'rb'let flow oer s&arred ales
"a&terial edotois
>adiatio
:y*er&holesterole+ia Toi& s'bsta&es (e$g$ &igarette s+oe)
4
The endothelial cell inBuryThe endothelial cell inBury
7 Alteration in normal blood lo)7 Alteration in normal blood lo)
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 75/106
7. Alteration in normal blood lo)7. Alteration in normal blood lo)
;low of *latelets i the blood is la+iar
Turbulence or stasis )ill result in
1) brig *latelets ito &ota&t with the edotheli'+
2) *reet dil'tio of a&tiated &lottig fa&tors by fresh-flowig blood
3) *ro+ote edothelial &ell a&tiatio *redis*osig to
lo&al thro+bosis ad le'o&yte adhesio
4) delay the iflow of &lottig fa&tor ihibitors ad *er+it
the b'ild-'* of thro+bi
5
: Hy$ercoa#ulability: Hy$ercoa#ulability
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 76/106
:. Hy$ercoa#ulability:. Hy$ercoa#ulability
• %onditions associated )ith an increased risk%onditions associated )ith an increased risk
o thrombosiso thrombosis
"rimary ;Ienetic< causes
=- Factor * mutations
7- "rothrombin mutations
:- Antithrombin ((( deiciency
+- "rotein % and S deiciency
Hy$ercoa#ulabilityHy$ercoa#ulability
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 77/106
• Secondary ;Acuired< causes
'6am$les
1$ rologed bed rest or i++obili7atio
2$ Byo&ardial ifar&tio3$ Tiss'e da+age (s'rgery fra&t're b'rs)
4$ a&er
5$ rostheti& &ardia& ales
$ Fisse+iated itraas&'lar &oag'latio
$ D'*'s ati&oag'lat
Hy$ercoa#ulabilityHy$ercoa#ulability
$hrombosis: %&RP'&L&%&RP'&L&
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 78/106
$hrombosis: %&RP'&L& %&RP'&L&
• Thro+bi +ay deelo* aywhere i the &ardioas&'lar
syste+
• Thro+bi are of ariable si7e ad sha*e
• area of atta&h+et to the 'derlyig essel or heart wallfre@'etly fir+est at the *oit of origi is &hara&teristi& of all
thro+bi$
• Thrombi are si#niicant becauseThrombi are si#niicant because
1) they &a'se obstruction of arteries ad eis
2) they are *ossible so'r&es of emboli
Thrombosis in heart chambers & aorta
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 79/106
&
• !ural thrombi!ural thrombi are those thro+bi that for+ o the
walls of the heart chambers and aorta
• %auses%auses arrhyth+ias dilated &ardio+yo*athy B9
+yo&arditis &atheter tra'+a
ines o Lahnines o Lahn
*rod'&ed d'e to alteratig
*ale layers of *latelets ad
fibri with dar layers of
>" i thro+bi for+ed i
the heart or aorta
%oronary artery0 ri#ht0 )ith thrombus fillig ad
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 80/106
&o+*letely o&&l'dig the l'+e$ Thro+bi i &oroary
arteries are almost al)ays d'e to edothelial da+age
res'ltig rom atherosclerosis$
!
%ross section o a coronary artery. The intima0 to )hich a
th b i tt h d i k dl thi k d b
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 81/106
thrombus is attached0 is markedly thickened by
atherosclerosis. The thrombus nearly ills the lumen0 but
in one area0 it has retracted rom the vessel )all.
1
*enous thrombosis ;$hlebothrombosis<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 82/106
• hara&teristi&ally o&&'r i sites of stasis
• +ay ot be well atta&hed ad are *roe to
e+boli
• They &otai +ore >"s therefore ow
as red0 or stasis0 thrombi
• !% of &ases iole the eis of loweretre+ities
2
*enous thrombosis ;$hlebothrombosis<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 83/106
• ?'*erfi&ial eo's
thro+bi 's'ally o&&'r
i the sa*heo's
syste+ *arti&'larly i
ari&osities
• Su$ericial thrombi
+ay &a'se swellig
ad *ai b't seldo+
e+boli7e3
Dee$ thrombi i
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 84/106
4
the large eis
*arti&'larly those
aboe the ee
Aoit i the
*o*liteal fe+oral
L ilia& eis are
+ore serio's as
they +ay
e+boli7e
;5here @<
Dee$ *ein Thrombosis ;D*T<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 85/106
5
dee* eo's thro+boses are asy+*to+ati& i 5!% of
&ases$ da&ed age bed rest ad i++obili7atio
i&rease the ris of dee* ei thro+bosis
Fate o ThrombusFate o Thrombus
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 86/106
=.=. "ro$a#ation"ro$a#ation thro+bi +ay a&&'+'late +ore
fibri L *latelets &a'sig obstr'&tio7.7. 'mboliation'mboliation thro+bi +ay deta&hed ad be
tras*orted to other sites i the as&'lat're
:.:. DissolutionDissolution thro+bi +ay be re+oed byfibriolyti& a&tiity
+.+. r#aniation and Recanaliationr#aniation and Recanaliation Thro+bi +ay
id'&e ifla++atio ad fibrosis ( organization ) ad +ay be&o+e recanalized (re-establish
as&'lar flow) or they +ay be i&or*orated ito a
thi&eed as&'lar wall$ (i old thro+bi)
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 87/106
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 88/106
*ein )ith or#aniin# and recanaliin# thrombus
;illig this essel is a red thro+b's atta&hed to the essel wall$ 9
oe area it has retra&ted for+ig a &res&et-sha*ed l'+e
'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 89/106
'mbolism
• bor+al solid +ass &arried i blood$
• Ty*es$ – Thromboembolism - atheros&lerosis
– Fat - ;ra&t'res
– Ias – Naisso disease<
– iuid – +ioti& fl'id
• C't&o+e of 8+bolis+ – ollateral &ir&'latio
– 9far&tio
– :e+orrhage
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 90/106
'mbolism'mbolism
'mbolus'mbolus
'mbolus'mbolus
!
'mbolism'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 91/106
embolusembolus is a deta&hed itraas&'lar solid liuid
or #aseous mass that is &arried by the blood to a site
distat fro+ its *oit of origi
GG of all e+boli re*reset *art of thro+b's he&e
the &o++oly 'sed ter+ thromboembolismthromboembolism
Rare orms o emboli include
dro*lets of fat b'bbles of air or itroge
atheros&leroti& (cholesterol emboli), t'+or frag+ets
bits of boe +arrow or foreig bodies s'&h as b'llets$1
"ulmonary Thromboembolism"ulmonary Thromboembolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 92/106
9t is &o++o i hos*itali7ed *atiets
Crigiates +aily i dee* eis of the lower
etre+ities
8+boli trael to the right side of the heart to the
*'l+oary arteries
Bay be so large to blo& the +ai *'l+oary
artery at the site of bif'r&atio &alled saddlesaddleembolusembolus
Bay be s+all to *ass ito s+aller bra&hes
2
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 93/106
Fate o $ulmonary embolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 94/106
?'dde death right etri&'lar fail're or
&ardioas&'lar &olla*se o&&'r whe !% or +ore ofthe *'l+oary &ir&'latio is obstr'&ted with e+boli$
!-!% are clinically silent be&a'se they are
s+all 'dergo dissol'tio or re&aali7atio
8+boli& obstr'&tio of +edi'+-si7ed arteries +ay
res'lt i $ulmonary hemorrha#e
B'lti*le e+boli oer ti+e +ay &a'se $ulmonary
hy$ertension with right etri&'lar fail're
4
Systemic Thromboembolism >efers to e+boli tra elig ithi the arterial &ir& latio
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 95/106
>efers to e+boli traelig withi the arterial &ir&'latio
!% arise fro+ itra-&ardia& +'ral thro+bi asso&iated with
let ventricular wall ifar&ts (2/3)with dilated let atria (1/3)
The rest ori#inates rom6
• Atherosclerosis i aorta or fro+ aorti& ae'rys+s
• "arado6ical embolism rarely e+boli +ay trael fro+eo's to arterial &ir&'latio ia a &o++'i&atio
betwee arterial L eo's &ir&'latio
!aBor sites or lod#in# o systemic emboli!aBor sites or lod#in# o systemic emboli
the lower etre+ities (5%) ad the brai (1!%)
arterial e+boli &a'se inarction of tiss'es i the distrib'tio
of the obstr'&ted essel$ 5
Fat 'mbolismFat 'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 96/106
'tiolo#y +aily after fra&t'res of log boes or
rarely i the settig of soft tiss'e tra'+a ad b'rs
Fat embolism syndromeFat embolism syndrome ;atal i abo't 1!% of &ases
>es*iratory6 ta&hy*ea dys*ea
0e'rologi&al6 irritability restlessess ad &o+a
Thro+bo&yto*eia with &hara&teristi& *ete&hiae
9t geerally deelo*s 1 to 3 days after iA'ry
The *athogeesis ioles both +e&hai&al obstr'&tio
ad toi& iA'ry to edotheli'+ by ;;
The fat e+bol's eters the &ir&'latio fro+ +arrowFat 'mbolismFat 'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 97/106
The fat e+bol's eters the &ir&'latio fro+ +arrow
after r'*t're of boe as&'lar si'soids or fro+
adi*ose tiss'e thro'gh r'*t're of tiss'e e'les
4one marro) embolus in the $ulmonary circulation0 the
cleared vacuoles re$resent marro) at
Air 'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 98/106
ir +ay eter the &ir&'latio d'rig s'rgi&al
obstetri& *ro&ed'res or as a &ose@'e&e of &hest
wall iA'ry
Heerally O 1!! +D of air is re@'ired to *rod'&e a
&lii&al effe&t
+ay &a'se fo&al is&he+ia i the brai ad heart
+ay &a'se ede+a he+orrhages ad fo&alatele&tasis or e+*hyse+a leadig to res*iratory
distress i the l'gs
Amniotic Fluid 'mbolismAmniotic Fluid 'mbolism
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 99/106
• The 'derlyig &a'se is the leaage of a+ioti&
fl'id (ad its &otets) ito the +ateral &ir&'latioia a tear i the *la&etal +e+braes ad r'*t're
of 'terie eis$
• The *rese&e of the followigs i the *'l+oary
&ir&'latio will &ofir+ the diagosis6
– ?@'a+o's &ells fro+ fetal si
– hair
– +'&i deried fro+ fetal res*iratory or H9 tra&ts
Shock ;cardiovascular colla$se<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 100/106
• ?yste+i& hy*o*erf'sio d'e to a red'&tio either
i &ardia& o't*'t or i the effe&tie &ir&'latigblood ol'+e
• Ty$es o shockTy$es o shock
=. %ardio#enic shock
• '+* fail're
7. Hemorrha#ic ;hy$ovolemic< shock
• Fe&rease i blood ol'+e
:. Se$tic shock
• ;ail're of +i&ro&ir&'latio to retai *ress're leadig
to wide s*read *eri*heral asodilatatio1!!
(- %ardio#enic shock
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 101/106
• ;ail're of +yo&ardial *'+* owig to itrisi& +yo&ardial
da+age etrisi& *ress're or obstr'&tio to o'tflow
%auses%auses
1$ +yo&ardial ifar&tio
2$ &ardia& ta+*oade
3$ o'tflow obstr'&tio i *'l+oary e+bolis+4$ etri&'lar arrhryth+ia
Si#ns and sym$toms
• Ta&hy&ardia
• :y*otesio
• Ta&hy*ea
• >estlessess agitatio
• allor L sweatig 1!1
((. Hy$ovolemic shock
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 102/106
>es'lts fro+ loss of blood or *las+a ol'+e
%auses%auses
1$ :e+orrhage
2$ ;l'id loss fro+ seere o+itig diarrhea
b'rs or tra'+a
?igs ad sy+*to+s of hy*oole+i& sho&
are the sa+e as i &ardiogei& sho&
1!2
(((. Se$tic Shock
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 103/106
• >es'lts fro+ s*read of a iitially lo&ali7ed ife&tio (e$g$
abs&ess *eritoitis *e'+oia) ito the bloodstrea+$
• C&&'rs whe a oerwhel+ig ife&tio leads to low blood
*ress're ad ital orgas +ay ot f'&tio *ro*erly
• :as 25% to 5!% +ortality rate
• Ce of the +ost &o++o &a'ses of death i itesie &are
'its
• %aused by systemic microbial inection%aused by systemic microbial inection
– Bost &o++oly (~ !%) #ram-ne#ative ife&tios
(endotoxic shock)
– &a also o&&'r with gra+-*ositie ad f'gal ife&tios$1!3
"atho#enesis o Se$tic Shock
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 104/106
• 8dotois are ba&terial wall li*o*olysa&&harides (D?s)
• D? a&tiate +oo'&lear &ell with *rod'&tio of &he+i&al
+ediators
• The &olle&tie effe&t of these +ediators res'lt i6
– ;eer a&'te-*hase rea&tio e'tro*hilia – .asodilatio6 hy*otesio
– #ides*read edothelial &ell iA'ry
– &tiatio of the &oag'latio syste+ – B'ltiorga syste+ fail're
1!4
Shock ;less common ty$es<
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 105/106
8euro#enic shock8euro#enic shock
• he+odya+i& sho& d'e to loss o vascular tone ad*eri*heral *oolig of blood res'ltig i asodialtio
• %auses6 s*ial &ord iA'ry or tra'+a
Ana$hylactic shockAna$hylactic shock
• iitiated by a geerali7ed i++'oglob'li 8-+ediatedhy*ersesitiity res*ose
• asso&iated with systemic vasodilatation ad i&reasedas&'lar *er+eability
• &a'ses a s'dde i&rease i the &a*a&ity of the as&'larbed whi&h &aot be filled ade@'ately by the or+al&ir&'latig blood ol'+e$ Th's tiss'e hy*o*erf'sioad &ell'lar aoia res'lt$
1!5
Sta#es o Shock
8/10/2019 Hemodynamic Disorders Thrombosis
http://slidepdf.com/reader/full/hemodynamic-disorders-thrombosis 106/106
• (nitial non$ro#ressive sta#e(nitial non$ro#ressive sta#e the &a'satie fa&tors of
sho& are &otaied ad *erf'sio of ital orgas is
+aitaied (ade@'ate &o+*esatory +e&hais+)
• "ro#ressive sta#e"ro#ressive sta#e tiss'e hy$o$erusion &oti'es
res'ltig i tiss'e hy$o6ia ad +etaboli& dist'rba&es
(e$g$ aaerobi& gly&olysis *rod'&ed la&ti& a&idosis)$
o+*esatory +e&hais+ is o loger ade@'ate
• (rreversible sta#e(rreversible sta#e the *atiet has +'lti*le orga
fail're ad death be&o+es ieitable
Top Related