Sie sind auf Seite 1von 6

University of Colorado Denver School of Medicine Disease and Defense Course IDTP5004A Instructor: Francisco G.

. La Rosa, MD, Associate Professor e!ruary "0th# $0"0

HEMODYNAMIC DISORDERS, THROMBOEMBOLIC DISEASE, AND SHOCK


%eco&&ended %eadin': Cha(ter 4 ) *+e&odyna&ic Disorders*# in ,u&ar# Robbins and Cotran: Pathologic Basis of Disease, 8 th ed. -. Saunders Co/ This is also availa!le free online at: htt(:00111/&dconsult/co&0das0!oo20!ody034$45444)$000"$4300/ht&l Learning Objectives: "/ $/ 7/ 4/ 5/ 5/ 9/ 4/ Discuss the three (atho'enetic &echanis&s of transudate for&ation/ Descri!e clinico) (atholo'ic e6a&(les/ Define and co&(are0contrast active vs/ (assive hy(ere&ia/ 8ist so&e ter&s used to descri!e different ty(es of he&orrha'e/ Descri!e the features# (ossi!le outco&es# (redis(osin' factors and co&(lications of thro&!osis/ Define and descri!e disse&inated intravascular coa'ulation/ Define thro&!o)e&!olus and co&(are venous and arterial thro&!oe&!oli/ Descri!e a&niotic fluid# air0'as and fat e&!oli and their clinical)(atholo'ic syndro&es/ Define infarction# cite its features and co&(are0contrast arterial vs/ venous infarcts/ Discuss arterial infarction 1ith re'ard to total vs/ (artial o!struction/ Discuss reversi!ility# healin' and &odifyin' factors/ Define and descri!e the four ty(es of shoc2# the 2ey &eta!olic chan'es# the three sta'es and four i&(ortant tar'et or'ans and lesions/ EDEMA and E!!"SION

3/ I "/

E#e$a 'enerally refers to fluid accu&ulation in interstitial tissue: effusion to fluid accu&ulation in a !ody cavity/ -hen due to (urely he&odyna&ic chan'es the fluid is a transudate ;unli2e the e6udate 1hich accu&ulates as the result of infla&&ation</ %evie1 the differences !et1een transudate and e6udate ;see =Acute > Chronic Infla&&ation? handout</ $/ Anasarca ) syste&ic ede&a and effusions due to he&odyna&ic cause;s</ Transudate/ 7/ Ascites ) 'enerally refers to fluid accu&ulation in the (eritoneal cavity: clinically &ay refer to a transudate ty(e of fluid ;he&odyna&ic<# !ut also used in situations 1hich are due to infla&&ation ;e6udate</ A/ Patho'enesis of trans%#ate:

"/

Increase# intravasc%&ar '(#r)static *ress%re/ Increased intravascular (ressure in ca(illaries and venules =(ushes? 1ater# electrolytes and a s&all a&ount of lo1 M- (rotein &olecules out of the vessels and into ad@acent interstitial tissue and0or !ody cavities/

Atiolo'y S(ecific 'ravity ;'0&8< Total (rotein ;'0d8< luid0seru& (rotein ratio luid0seru& 8D+ ratio luid0seru& 'lucose ratio Cells ;leu2ocytes<

TRANS"DATE Increased hydrostatic (ressure B"/0"5 B7/0 B0/5 B0/5 C"/0 Do

E+"DATE Iinfla&&ation C"/0"5 C7/0 C0/5 C0/5 B"/0 Ees

E a!"le: Increased (ressure in the left ventricle of the heart ;left)sided heart failure< is trans&itted !ac21ards to the left atriu&# (ul&onary veins and then to the (ul&onary venules and ca(illaries/ The result is the for&ation of transudate in the se(tal and then in the alveolar s(aces/ This is called (ul&onary ede&a/ Pul&onary ede&a fluid is often =cou'hed u(/? It a((ears frothy and is often !lood)tin'ed/ The latter is due to the lea2a'e of %.Cs/ Pul&onary ede&a &ay !e acute ;e&er'ency< or chronic/ It results in dys(nea and tachy(nea/ It &ay also result in hy(o6e&ia and hy(erca(nia/ If acute and severe it can cause acute res(iratory failure/ Can you (redict the conseFuences of ri'ht)sided heart failureG $/ %educed intravascular oncotic (ressure/ Most often this is due to hy(oal!u&ine&ia/ E a!"les: 8iver disease ;e/'/ cirrhosis< results in a &ar2ed reduction in al!u&in synthesis/ %enal disease ;e/'/ ne(hrotic syndro&e< results in a &ar2ed loss of al!u&in/ 7/ Increased (ressure in ly&(hatic vessels E a!"le: %adical &astecto&y in 1hich the e6cision of a6illary ly&(h nodes !loc2s the nor&al draina'e of ly&(h and results in the accu&ulation of fluid in the (atientHs ar&/ II "/ HY,EREMIA Active/ Dilatation of arteries0arterioles results in increased !lood flo1 ;(erfusion< of a tissue or or'an/ The tissue a((ears red/ This 1as the &echanis& for the =redness? of acute infla&&ation/ ,assive/ I&(aired venous draina'e results in stasis and the accu&ulation of deo6y'enated !lood/ The tissue has a !luish tin'e due to the accu&ulation of deo6y'enated he&o'lo!in/

$/

Aither of these &ay !e acute or chronic/ The ter& =c)ngesti)n? is so&e ti&es used to descri!e a hy(ere&ic or'an or tissue/

Disease > Defense .loc2 =+e&odyna&ic Disorders# Thro&!oe&!olic Disease and Shoc2?

Pa'e $

A6a&(le: Passive hy(ere&ia resultin' in acute or chronic (assive con'estion of the liver or s(leen/ The or'ans are enlar'ed and the liver &ay !e tender/ Can you 'ive e6a&(les of so&e causes of acute and chronic (assive con'estion of the liver and0or s(leenG III HEMORRHA-E The nor&al and disease as(ects of coa'ulation are discussed in the coa'ulation lectures/ These are the &ost i&(ortant lesions related to coa'ulation disorders: "/ $/ 7/ ,etec'iae ) (inhead siIe: ,%r*%ra ) u( to " c&/: Ecc'($)ses ) lar'er He$at)$a ) a &ass co&(osed of !lood infiltratin' soft tissue/ He$)t')ra. / 'e$)*ericar#i%$ / 'e$)*erit)ne%$ ) !lood 1ithin the res(ective !ody cavity/

I0 THROMB"S ;The (rocess is called thro&!osis< eatures: "/ Intravascular $/ Mass of coa'ulated !lood co&(osed of (latelets# fi!rin and entra((ed cells and other (las&a (roteins/ Aarly ) lines of Jahn are (resent ) alternatin' layers of (latelets and fi!rin/ 7/ Adherent to the lu&inal surface of the vessel/ Distin'uish fro&: "/ #n $itro clot $/ Post&orte& clot ) does not adhere to the vessel 1all/ Thin2 of an auto(sy situation in 1hich it is i&(ortant to distin'uish a (ost)&orte& clot fro& a thro&!us/ 7/ Clottin' of a he&ato&a or he&orrha'ic e6udate/ Kutco&e: "/ L(sis/ The role of fi!rinolytic a'ents in the !lood/ $/ ,r)*agati)n/ Anlar'e&ent and e6tension of the thro&!us/ 7/ Organi1ati)n/ i!rosis of the thro&!us/ More on this (rocess 1hen 1e discuss re(air/ 4/ Recana&i1ati)n/ Durin' or'aniIation ne1 channels &ay for& 1ithin the thro&!us: these &ay allo1 rene1ed !lood flo1 throu'h the o!structed vessel/ Predis(osin' factors: "/ Stasis of !lood flo1 ;varicose veins# (rolon'ed !ed rest< $/ Don)la&inar !lood flo1 7/ Increased !lood viscosity ;dehydration</ 4/ Da&a'e to the endotheliu&0vascular 1all e/'/ atherosclerosis# vascular trau&a/ 5/ +y(ercoa'ula!le state/ Co&(lications: "/ %educed !lood flo1 to a tissue0or'an resultin' in ische&ic in@ury or infarction/ $/ ra'&ents of thro&!us !rea2 off and result in thro&!oe&!oliIation/ Disse$inate# intravasc%&ar c)ag%&ati)n 2DIC3 DIC occurs as a co&(lication of &any disease states# &ost nota!ly Lra&)ne'ative se(sis ) endoto6in effect/ Also o!stetric co&(lications# &etastatic cancer# e6tensive trau&a ) all associated 1ith e6tensive tissue necrosis/ Clottin' factors !eco&e activated inside the !lood vessels due to endoto6ins released !y the !acteria and a disse&inated consu&(tion of clottin' factors is (roduced: as a conseFuence# the (atient starts !leedin' throu'h &ucosae# s2in and !lood internal vessels/ The (resence of fi!rin s(lit (roducts in the !lood is dia'nostic of DIC/

Disease > Defense .loc2 =+e&odyna&ic Disorders# Thro&!oe&!olic Disease and Shoc2?

Pa'e 7

0 EMBOLISM or EMBOL"S ;the (rocess is called e&!oliIation< A (article0&ass 1hich is carried in the !lood strea& as far as its siIe 1ill allo1/ It !eco&es lod'ed at that (oint and o!structs the vessel/ T'r)$b)e$b)&%s is the &ost co&&on ty(e/ Thro&!oe&!oli arise fro& thro&!i and ran'e in siIe fro& &icrosco(ic to those 1hich are lar'e enou'h to occlude &a@or arteries/ Thro&!oe&!oli &ay occur in either arteries or veins/ 8i2e thro&!i they &ay under'o lysis# (ro(a'ation# or'aniIation and0or re)canaliIation and can result in ische&ic in@ury and infarction/ The &ost co&&on ty(e of ven)%s t'r)$b)e$b)&%s arises fro& a thro&!us in the dee( le' veins/ These are &ostly (roduced in (atients 1ith varicose veins and0or (rolon'ed !ed rest ;i/e/: (ost)sur'ery</ ra'&ents of the thro&!i travel to the lun' 1here they occlude the (ul&onary artery and &ay result in infarction in the lun'/ Actually# &ost (ul&onary thro&!oe&!oli do not result in infarction/ Devertheless# since (ul&onary e&!oli are co&&on# (ul&onary infarction is a relatively co&&on clinical (ro!le&/ In 'eneral the ter& =e&!olus? ;e/'/ (ul&onary e&!olus< is synony&ous 1ith =thro&!oe&!olus/? Syste&ic arteria& t'r)$b)e$b)&i usually arise fro& &ural thro&!i in the heart either as a conseFuence of valvular disease or after a &yocardial infarction/ %u(tured thro&!i travel via the syste&ic arterial syste& to such or'ans as the !rain# 2idneys# s(leen and e6tre&ities/ They usually result in infarction;s< in those sites/ A$ni)tic 4&%i# e$b)&i ) a$ni)tic 4&%i# in4%si)n s(n#r)$e "/ Kccur durin' la!or or i&&ediately (ost(artu&/ $/ %are !ut freFuently fatal/ They are a &a@or cause of &aternal &ortality/ 7/ Clinically ) sudden res(iratory insufficiency and cyanosis ) follo1ed !y shoc2# seiIures# co&a/ 4/ Tear in (lacental &e&!ranes and ru(ture of uterine veins results in an =infusion? of a&niotic fluid and (articulate &atter into the &aternal venous circulation/ The (atho'enesis involves &ore than @ust the &echanical0o!structive effects of e&!oli ) rather# it a((ears that the che&ical (ro(erties of the a&niotic fluid affect endothelial cells# e/'/ of the lun's/ Air/-as e$b)&i "/ May occur durin' delivery0a!ortion# chest 1all0lun' trau&a: Air in@ected intravenously is li2ely to !e a!sor!ed 1hile air in@ected intra)arterially is &ore li2ely to act as an e&!olus and result in infarction/ $/ May occur as the result of a ra(id chan'e in at&os(heric (ressure# e/'/ in divers/ -hile divin'# increased a&!ient (ressure allo1s increased 'as to dissolve in the !lood/ -ith too ra(id deco&(ression co&in' to the surface# 'as co&es out of solution and for&s !u!!les in the !lood ) es(ecially nitro'en/ These !u!!les act as e&!oli/ This ty(e of situation is 2no1n as deco&(ression sic2ness# =the !ends? or Caiss)n #isease/ !at e$b)&i ) 4at e$b)&is$ s(n#r)$e "/ Scattered fat e&!oli are co&&only found at auto(sy follo1in' severe !one fractures/ $/ A s&all (ercenta'e of such cases &anifest fat e&!olis& syndro&e/ This is characteriIed !y the onset# " ) 7 days after the trau&a# of acute res(iratory insufficiency# often acco&(anied !y neurolo'ical si'ns 1hich &ay (ro'ress to co&a/ Cutaneous (etechiae are co&&on/ Death

Disease > Defense .loc2 =+e&odyna&ic Disorders# Thro&!oe&!olic Disease and Shoc2?

Pa'e 4

occurs in a!out "0M of cases/ At auto(sy 'lo!ules of fat are found in the s&all vessels of the lun's# !rain and other or'ans/ 7/ As in a&niotic infusion syndro&e# fat e&!oli syndro&e is thou'ht to !e due to &ore than @ust the &echanical effects of the e&!oli and che&ical in@ury a((ears to (lay a role/ Kther ty(es of e&!oli: "/ Atherosclerotic (laFue ) es(ecially fro& the aorta to the 2idneys/ $/ Tu&or ) in cancer (atients/ 7/ .one &arro1 ) es(ecially after trau&a# e/'/ resuscitative effort 1ith fracture of the sternu&/ Its findin' is considered a ter&inal event not necessarily res(onsi!le for death/ 4/ Tro(ho!lastic cells in the lun's of (re'nant 1o&en/ Considered to !e a non)(atholo'ic event/ 0I IN!ARCT ;the (rocess is called infarction< "/ An area of ische&ic necrosis 1hich ty(ically results fro& o!struction of the corres(ondin' artery !y a thro&!us or an e&!olus/ Ty(ically 1ed'e)sha(ed and (ale ;=1hite infarct?< ) unless there is so&e associated he&orrha'e ; e/'/ in the lun'</ $/ Infarction is an irreversi!le (rocess and healin' occurs !y fi!rosis/ 7/ Does total arterial o!struction al1ays result in infarctionG Do ) if there is a dual or c)&&atera& b&))# s%**&(/ 4/ Can infarction occur in the a!sence of total arterial o!structionG Ees ) all that is needed for infarction to occur is for the o6y'en su((ly to !e insufficient to sustain the life of the affected tissue/ This &ay occur# for e6a&(le# as the result of (artial o!struction ische&ic in@ury e6acer!ated !y hy(o6e&ia and0or !y increased needs for o6y'en !y the tissue/ -e 1ill say &ore a!out this 1hen 1e discuss &yocardial infarction durin' s&all 'rou( sessions/ 5/ Infarcts due to syste&ic venous o!struction are &uch less co&&on than arterial/ K!struction of a vein allo1s !lood to enter the tissue ) !ut not e6it: this leads to severe (assive con'estion# he&orrha'e and infarction/ Nenous infarcts are ty(ically he&orrha'ic ;=red infarct?</ 5/ actors 1hich &odify the develo(&ent of an infarct include the ty(e of vascular su((ly# the rate of develo(&ent of the o!struction# the vulnera!ility of the tissue to hy(o6ia# and the o6y'en concentration of the arterial !lood su((ly/ 0I SHOCK is the syste&ic hy(o(erfusion of cells and tissue/ It is characteriIed !y &ar2ed hy(otension ;tachycardia< 1ith increased (ulse rate/ Aero!ic cellular &eta!olis& s1itches to anaero!ic 1ith increased lactate (roduction ;lactic acidosis</ our ty(es "/ Cardio'enic ) reduced cardiac out(ut# e/'/ as the result of a lar'e &yocardial infarct/ $/ +e&orrha'ic0hy(ovole&ic ) reduced !lood volu&e# e/'/ !urns 1ith &assive fluid loss/ 7/ Se(tic ) &ost often Lra&)ne'ative !actere&ia/ Andoto6ins are &ediated !y tu&or necrosis factor ;TD <# interleu2in)" ;I8)"< and other che&ical &ediators/ This results in a freFuently irreversi!le situation of syste&ic vasodilatation# endothelial da&a'e and direct in@ury to cells/ It is the usual cause of syste&ic infla&&atory res(onse syndro&e ;SI%S< and the &ost co&&on cause of ICU death/ 4/ Deuro'enic# e/'/ anaesthesia 1ith severe 1ides(read (eri(heral vasodilatation/ Nery unco&&on/ Sta'es "/ Don(ro'ressive ) refle6 co&(ensatory &echanis&s result in the (erfusion of vital or'ans/

Disease > Defense .loc2 =+e&odyna&ic Disorders# Thro&!oe&!olic Disease and Shoc2?

Pa'e 5

$/ Pro'ressive ) hy(o(erfusion of tissues 1ith increasin' circulatory and &eta!olic i&!alances/ 7/ Irreversi!le ) des(ite te&(orary interventional correction of he&odyna&ic defects# cellular and tissue in@ury are so severe as to (reclude survival/ Ma@or sites of in@ury "/ .rain ) hy(o6ic ence(halo(athy $/ 8un's ) =shoc2 lun'? ) adult res(iratory distress syndro&e ;A%DS< 7/ ,idneys ) acute tu!ular necrosis 4/ L/I/ ) he&orrha'ic necrosis of the &ucosa

TERMINOLO-Y: A&niotic fluid e&!olis& and infusion syndro&e Anasarca Ascites Caisson disease Con'estion Collateral !lood su((ly Dia(edesis Disse&inated intravascular coa'ulation ;DIC< A&!olis& ;e&!olus< Acchy&osis at e&!olis& and syndro&e +y(ere&ia +e&ato&a Infarction ;infarct< 8ines of Jahn Kr'aniIation Petechiae Pur(ura %ecanaliIation Shoc2 Thro&!osis ;thro&!us< Thro&!oe&!olus Transudate Tu&or Decrosis actor ;TD <

Disclai&ers: "/ The (ri&ary 'oal of this cha(ter is to study the learnin' o!@ectives outlined at the !e'innin' of this handout/ The &aterial to study is (rovided in the lectures# the handouts and the reco&&ended te6t!oo2s/ All these sources (rovide the content over 1hich you 1ill !e tested/ The lectures are intended to (rovide !road infor&ation of the &aterial found in the te6t!oo2s and handouts# and to 'ive the students the o((ortunity to as2 Fuestions on su!@ects not clear in the te6ts/ The handouts do not see2 to follo1 u( the seFuence of the lectures# and &ost i&(ortantly# they are not a surro'ate of the !oo2s/ $/ The te6t (resented in this handout has !een edited !y Dr/ 8a %osa fro& &aterial found in your !oo2s# fro& (u!lished articles and other educational 1or2s/ This handout is solely for educational (ur(ose and not intended for co&&ercial or (ecuniary !enefit ;see USA Co(yri'ht 8a1# Section ""0# =8i&itations on e6clusive ri'hts: A6e&(tion of certain (erfor&ances and dis(lays?</ %e(roduction and use of this handout can !e done only for educational use/ ODo1nloadP the USA Co(yri'ht 8a1 version# Kcto!er $003/

Disease > Defense .loc2 =+e&odyna&ic Disorders# Thro&!oe&!olic Disease and Shoc2?

Pa'e 5

Das könnte Ihnen auch gefallen