hemodynamic disorders. thromboembolic disease shock
TRANSCRIPT
![Page 1: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/1.jpg)
Hemodynamic Disorders
![Page 2: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/2.jpg)
•Hemodynamic Disorders
•Thromboembolic Disease
•Shock
![Page 3: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/3.jpg)
Overview
• Edema (increased fluid in the ECF)• Hyperemia (INCREASED flow)• Congestion (INCREASED backup)• Hemorrhage (extravasation)• Hemostasis (keeping blood as a fluid)• Thrombosis (clotting blood)• Embolism (downstream travel of a clot)• Infarction (death of tissues w/o blood)• Shock (circulatory failure/collapse)
![Page 4: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/4.jpg)
WATER• 60% of body• 2/3 of body water is INTRA-cellular• The rest is INTERSTITIAL• Only 5% is INTRA-vascular
EDEMA is SHIFT to the INTERSTITIAL SPACE• HYDRO-
– -THORAX, -PERICARDIUM, -PERITONUM,(ASCITES)– ( EFFUSIONS),
• ANASARCA(total body edema)
![Page 5: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/5.jpg)
Fluid HomeostasisStarling’s Law
Homeostasis is maintained by the opposing effects of:
• Vascular Hydrostatic Pressure – and
• Plasma Colloid Osmotic Pressure
![Page 6: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/6.jpg)
![Page 7: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/7.jpg)
EDEMA
Increased hydrostatic pressure: – Impaired venous return – Congestive heart failure (poor right ventricular function) – Constrictive pericarditis – Ascites (peritoneal dropsy; e.g. from liver cirrhosis) – Venous obstruction or compression (thrombosis, external pressure, dependency of lower limbs)
Arteriolar dilation (heat; neurohumoral dysregulation)
Reduced plasma osmotic pressure (hypoproteinemia) – Nephrotic syndrome (protein-losing glomerulopathies) – Liver cirrhosis (ascites) – Malnutrition – Protein-losing gastroenteropathy
Increased fluid in the interstitial tissue spaces or body
cavities.
![Page 8: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/8.jpg)
Lymphatic obstruction
– Interstitial fluids are removed via lymphatic drainage, to thoracic duct
and left subclavian vein
– Inflammation, neoplasm, surgery, irradiation
Sodium retention (water follows sodium)
– Excess salt intake with renal insufficiency
– Increased tubular reabsorption of sodium (renal hypertension;renal hypoperfusion--
increased renin-angiotensin-aldosterone secretion) Inflammation (acute, chronic, angiogenesis)
![Page 9: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/9.jpg)
CHF EDEMA
• INCREASED VENOUS PRESSURE DUE TO FAILURE
• DECREASED RENAL PERFUSION, triggering of RENIN-ANGIOTENSION-ALDOSTERONE complex, resulting ultimately in SODIUM RETENTION
![Page 10: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/10.jpg)
HEPATIC ASCITES• PORTAL HYPERTENSION• HYPOALBUMINEMIA
![Page 11: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/11.jpg)
RENAL EDEMA• SODIUM RETENTION
• PROTEIN LOSING GLOMERULOPATHIES (NEPHROTIC SYNDROME)
![Page 12: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/12.jpg)
Transudate vs Exudate• Transudate
– results from disturbance of Starling forces– specific gravity < 1.012– protein content < 3 g/dl,
• Exudate– results from damage to the capillary wall– specific gravity > 1.012– protein content > 3 g/dl,
![Page 13: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/13.jpg)
GENERALIZED EDEMA• HEART• LIVER• KIDNEY
Dependent Edema is a prominent feature of Congestive
Heart Failure; in legs if standing or sacrum in sleeping
patient
Periorbital edema is often the initial manifestation of
Nephrotic Syndrome, while late cases will lead to
generalized edema.
![Page 14: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/14.jpg)
Pulmonary Edema
• is most frequently seen in Congestive Heart
Failure
– May also be present in renal failure, adult
respiratory distress syndrome (ARDS), pulmonary
infections and hypersensitivity reactions
![Page 15: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/15.jpg)
Pulmonary Edema
• The Lungs are typically 2-3 times normal weight
• Cross sectioning causes an outpouring of frothy, sometimes blood-tinged fluid
• It may interfere with pulmonary
function
![Page 16: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/16.jpg)
Pulmonary edema
![Page 17: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/17.jpg)
Brain Edema• Trauma, Abscess, Neoplasm, Infection (Encephalitis due
to say… West Nile Virus), etc
The surface of the brain with cerebral edema demonstrates widened gyri with a flattened surface. The sulci are narrowed
![Page 18: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/18.jpg)
Brain Edema
Clinical Correlation The big problem is: There is no place for the fluid to go!
• Herniation into the
foramen magnum will kill
![Page 19: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/19.jpg)
SHOCK• Definition: CARDIOVASCULAR COLLAPSE• Common pathophysiologic features:
– INADEQUATE CARDIAC OUTPUT and/or– INADEQUATE BLOOD VOLUME
• Pathogenesis–Cardiac–Septic–Hypovolemic
![Page 20: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/20.jpg)
GENERAL RESULTS• INADEQUATE TISSUE PERFUSION• CELLULAR HYPOXIA• UN-corrected, a FATAL outcome TYPES of SHOCK• CARDIOGENIC: (Acute, Chronic Heart Failure)
• HYPOVOLEMIC: (Hemorrhage or Leakage)
• SEPTIC: (“ENDOTOXIC” shock, #1 killer in ICU)
• NEUROGENIC: (loss of vascular tone)• ANAPHYLACTIC: (IgE mediated systemic vasodilation and increased
vascular permeability)
![Page 21: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/21.jpg)
CARDIOGENIC shock• MI• VENTRICULAR RUPTURE• ARRHYTHMIA• CARDIAC TAMPONADE• PULMONARY EMBOLISM (acute RIGHT heart
failure or “cor pulmonale”)
![Page 22: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/22.jpg)
HYPOVOLEMIC shock
• HEMORRHAGE, Vasc. compartmentH2O• VOMITING, Vasc. compartmentH2O• DIARRHEA, Vasc. compartmentH2O• BURNS, Vasc. compartmentH2O
![Page 23: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/23.jpg)
SEPTIC shock• OVERWHELMING INFECTION• “ENDOTOXINS”, i.e., LPS (Usually Gm-)• Degraded bacterial cell wall products• Also called “LPS”, because they are Lipo-Poly-Saccharides• Attach to a cell surface antigen known as CD-14
• 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” antigents by staph are the prime example.)
![Page 24: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/24.jpg)
Effects of LipopolysaccharideLPS = lipopolysaccharide
TNF = tumor necrosis factor
IL = interleukin
NO = nitric oxide
PAF = platelet-activating factor
![Page 25: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/25.jpg)
SEPTIC shock events(linear sequence)
• SYSTEMIC VASODILATION (hypotension)
• ↓ MYOCARDIAL CONTRACTILITY• DIFFUSE ENDOTHELIAL ACTIVATION• LEUKOCYTE ADHESION• ALVEOLAR DAMAGE (ARDS)• DIC• VITAL ORGAN FAILURE CNS
![Page 26: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/26.jpg)
NON-PROGRESSIVE• COMPENSATORY MECHANISMS• CATECHOLAMINES• VITAL ORGANS PERFUSED
PROGRESSIVE• HYPOPERFUSION• EARLY “VITAL” ORGAN FAILURE• OLIGURIA
• ACIDOSIS IRREVERSIBLE• HEMODYNAMIC CORRECTIONS of no use
CLINICAL STAGES of shock
![Page 27: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/27.jpg)
Morphologic Features of Shock• Brain: ischemic encephalopathy• lung :DAD (Diffuse Alveolar Damage,)• Heart: subendocardial hemorrhages and
necrosis• Kidneys: acute tubular necrosis or diffuse
cortical necrosis• Gastrointestinal tract: patchy hemorrhages and
necrosis• Liver: fatty change or central hemorrhagic
necrosis• DIC• MULTIPLE ORGAN FAILURE
![Page 28: Hemodynamic Disorders. Thromboembolic Disease Shock](https://reader033.vdocuments.us/reader033/viewer/2022061521/56649c7f5503460f94936330/html5/thumbnails/28.jpg)
CLINICAL PROGRESSIONof SYMPTOMS(linear sequence)• Hypotension • Tachycardia • Tachypnea • Warm skin Cool skin Cyanosis• Renal insufficiency• Obtundance• Death