Section 3 - Hemodynamic Disorders, Thromboembolism, & Shock

Why is too much bleeding bad? Too much clotting?

Bleeding = lose blood pressure

Clotting = blockage doesn't allow things to reach designation

What is the flow of blood within organs and tissues of the body?

Hemodynamic

What is the process involved with the appropriate resolution of bleeding, causing bleeding to stop?

Hemostasis

What is the formation of a blood clot within a vessel?

Thrombosis

What is the term used to describe the process of blood transitioning from a fluid to semi-solid/gel-like state, and the physical changes of blood at the site of thrombosis?

Coagulation

What is the final product of thrombosis and is commonly referred to as a "blood clot"?

Thrombus

Obesity, immobility, family history, chronic inflammation conditions, pregnancy, smoking, advanced cancer, trauma, surgery, old age, dehydration, & diabetes can increase the risk of what pathology?

Blood clots

What is an unattached mass that is moving/traveling through the bloodstream that can reach narrowing's and block blood flow to distal areas?

Embolus

What is the term that is used to describe a vascular blockage by a piece of material that has broken loose form a thrombus (clot) and results in blood obstruction?

Thromboembolism

Where does Thromboembolism occur more frequently in?

Venous circulation

What is a localized collection of blood within the body?

Hematoma

What term is used to describe profuse amounts of blood loss from a ruptured blood vessel?

Hemorrhage

Adequate blood supply is critical to provide/remove what to the cell?

Provide nutrients and remove metabolic waste

What are the 3 most common examples of hemodynamic disorders causing mobility and mortality in the US?

1) Myocardial infarction (heart attack)

2) Cerebral infarction (stroke)

3) Pulmonary embolism (PE)

Hyperemia and Congestion both refer to times where there is a ________ in the amount of blood within a tissue.

INCREASE

What is the active process involving arteriole vasodilation to increase tissue blood flow? Is this pathological?

Hyperemia

Not necessarily pathological

What are three instances in which Hyperemia occurs?

1) Acute inflammation

2) Exercise (regulate body temp or engorge skin & muscles)

3) Non Exercise (engorge GI tract after eating to assist digestion)

What is the passive process involved in increasing blood volume due to impaired venous outflow? Is this pathologic?

Congestion

Pathological!

What are two examples of Congestion?

Congestive Heart Failure (can cause congestion in lungs and rest of body)

Deep Vein Thrombosis (blood clot formation usually distal to site of DVT, ex: lower extremity)

Is Erythema (redness) the result of Congestion or Hyperemia? What about Cyanosis?

E: Hyperemia

C: Congestion

(C w/ C)

What two mechanisms occur during Congestive Heart Failure?

1) Heart can't keep up

2) Too much blood returning back which causes accumulation

What are some examples of chronic tissue congestion?

1) Chronic Pulmonary Congestion

2) Congestive Hepatopathy

What type of chronic tissue congestion occurs as a result of Congestive Heart Failure, causing blood congestion within the lungs?

Chronic Pulmonary Congestion

What is the accumulation of fluid/edema localized within the lungs and plural cavity and is seen in pulmonary congestion?

Hydrothorax

What are 3 key features of chronic pulmonary congestion?

1) A fibrotic alveolar septa

2) frank hemorrhage (bleeding happening RIGHT NOW)

3) Macrophages & hemosiderin = "Heart failure cells"

What type of chronic tissue congestion inhibits/obstructs venous blood from draining from the liver?

Congestive Hepatopathy

What are three key features of congestive hepatopathy?

1) fibrosis

2) hemorrhage

3) necrosis (nutmeg liver) **

(LOOK FOR IMAGE ON EXAM of nutmeg liver)

What is the accumulation of excess interstitial fluid? What does this indicate?

Edema

indicates Pathology

What % of the body is water? What fraction of this water is intracellular fluid?**

60%

2/3

What is extracellular fluid?

Interstitial fluid & fluid in vessels

What is the fluid that surrounds cells but is outside of circulation?

Interstitial fluid

What is the accumulation of body-wide subcutaneous edema?

Anasarca

When edema is localized to the peritoneal cavity, what is it called?

Ascites

When edema is localized to the lower extremities/ankles due to gravity, what is this called?

Dependent edema

(Remember, occurs in ankles or sacrum area)

What type of edema occurs due to increased intracranial pressure from abnormal BBB (tumor/trauma/infection) or from a cell membrane injury (toxins/hypoxia)?

Cerebral edema

What two categories of pathologies do we see Ascites with?

1) Cirrhosis

2) Cancer, blood clots, etc

(NOTE: Due to Occlusion of hepatic veins)

What are the two opposing forces of fluid balance? Which is the push and which is the pull?

*(KNOW THIS FOR EXAM ITS IMPORTANT)*

1) Hydrostatic Pressure = Push

- aka BLOOD PRESSURE;

-- if too great, cause edema

2) Colloid Osmotic Pressure (oncotic) = Pull

-- plasma proteins important for maintaining this (albumin)

-- directly opposes hydrostatic pressure

What type of edema is "protein-poor"? What type is protein-rich?

Poor: Transudate

Rich: Exudate

What type of edema is inflammatory? Which type is non-inflammatory? **

Inflammatory: Exudate

Non-inflammatory: Transudate

What type of edema is non-pitting? Which one is pitting? **

Non Pitting: Exudate accumulation

Pitting: Transudate accumulation

What type of edema leaves a depression in swollen tissue once external pressure is removed? Which does not? **

Depression: Pitting Edema

No Depression: Non-Pitting Edema

Which type of edema is protein rich, invovled with osmosis, and inflammatory?

Non-Pitting Edema

(My Ex shows no PITY; Exudate has NO PITting edema)

What type of edema is protein poor, increased hydrostatic pressure, and noninflammatory? **

Pitting-Edema

What three things can cause inflammation to increase vessel permeability?

1) Infection

2) Injury

3) Allergies

How is Colloid Osmotic pressure maintained?

Plasma protein (ex: albumin most common)

If hydrostatic pressure is too great, what happens to the fluid travel? How about Oncotic Pressure?

Will cause fluid to leave vasculature

Will cause fluid to enter the vasculature

NOTE: Increased hydrostatic and decreased oncotic (osmotic) leads to edema

What is the liquid portion of the blood containing proteins such as albumin?

Plasma

Edema can be caused by what 5 things?

1) Inflammation

2) Too much hydrostatic pressure

3) Too little oncotic pressure

4) Vessel obstruction

5) Retention of sodium or H2O

What is an obstruction in venous drainage resulting in increased hydrostatic pressure that is localized? Generalized?

Localized = DVT (deep vein thrombosis)

Generalized = Congestive Heart Failure

What is the most common cause of increased hydrostatic pressure?

Obstructions in venous drainage

Reduced Colloid Osmotic Pressure causes hypoalbuminemia. What is Hypoalbuminemia?

Low albumin levels in blood

What are the two reasons there are too few plasma proteins in reduced Oncotic Pressure?

1) Reduced production (hepatitis/cirrhosis, liver failure, malnutrition)

2) Increased loss (nephrotic syndrome)

What is a common reason why plasma proteins may be lost to the external environment via urination? What is this damage to?

Nephrotic syndrome

-- Damage to glomeruli of the kidney

What are 4 major syndromes involved in the mechanism of edema?

1) Heart failure

2) Kidney (Renal) Failure

3) Hepatic Liver Faiulre

4) Nephrotic Syndrome

How does Heart Failure lead to Edema? (3)

1) Retention of Na and H2O

2) Increases blood volume

3) Increase capillary hydrostatic pressure

How does Nephrotic Syndrome lead to Edema? (2)

1) Decrease in plasma albumin

2) Decrease osmotic pressure

How does Liver failure lead to edema? (2)

1) Retention of Na and H2O

2) Increase blood volume

What part of kidney damage is the decrease in glomerular filtration rate and decrease in Na excretion?

Proteinuria

Impaired/Obstruction of lymph drainage can lead to what?

Lymphedema (Edema)

What three things results in obstructed lymphatic flow?

1) Fibrosis following chronic inflammatory conditions

2) Local tissue distortion from trauma/surgery or inactivity

3) Lymphatic obstruction from neoplasm/tumor

What can lead to the inflammation/fibrosis of lymphatic obstruction?

Due to infection, surgery, ionizing radiation, filariasis

What is a result of lymphatic filariasis infection that tends to infect and obstruct the inguinal lymphatic vessels and causes lymphatic fibrosis?

Elephantiasis

What is a common cause of localized lymphatic obstruction due to neoplastic invasion?

Breast tumors (malignant or benign)

When breast tumors obstruct lymphatic flow, it commonly can cause what three things to occur?

1) Inverted nipple

2) Peau d'orange change to skin (dimpling)

3) lymphedema of entire upper extremity drained by lymph nodes

Sodium and water retention can lead to osmosis (water follows salt), which leads to _____ blood volume and therefore _____ pressure

Increase blood volume

Increase pressure (hydrostatic)

Sodium retention is an example of what kind of pressure?

Hydrostatic pressure

What four things can lead to sodium and water retention?

1) Very high salt diet

2) Hypoperfusion to kidneys

3) Acute renal failure

4) Poststreptococcal glomerulonephritis

What is it called when blood moves from inside the blood vessel into the external tissue through extravasation?

Hemorrhage

T/F: Hemorrhages occur both internally and externally

TRUE

What occurs when a hemorrhage (bleeding) results in an accumulation of blood within a tissue?

Hematoma (aka Bruise)

What 3 things is the severity of a hemorrage based off of?

1) Rate of loss

2) volume of loss

3) site of loss

What is Hypovolemic shock? **

Loss of >20% of the persons total blood volume (1 L or more)

Which type of Hemorrhage is more likely to deplete iron stores? Is this an internal or external hemorrhage?

Iron-deficiency anemia (IDA)

-- External!

What are the very small areas of hemorrhage that are approximately 1-2 mm on the skin, mucosa, or serosal surfaces?

Petechiae

What are 3 common causes of Petechiae?

Decresed

- Platelets

- Vitamin C (vessel fragility)

- Vitamin K

What are the slightly larger hemorrhages that are approximately 3-5 mm in diameter?

Purpura

What are 3 common causes of Purpura?

1) Mechanical trauma

2) Vasculitis

3) Vessel Fragility

What type of AIDS cancer can purpura lead to?

Kaposi Sarcoma

What are larger areas of hemorrhage (>1 cm) that are commonly called a bruise?

Contusion/Ecchymoses

What is the difference between the contusion & Ecchymoses?

Contusions result from trauma

Ecchymoses result from trivial traumas which would not be expected to cause pronounced bruising

-- commonly result of patients with bleeding tendencies

Contusions/Ecchymoses transitions from reddish-blue to a blue-green and then a yellow-brown due to breakdown of what?

Hemoglobin to bilirubin to hemosiderin

In normal hemostasis, what usually inhibits thrombosis (clotting) until injury exposes a "tissue factor", keeping clotting form not occurring until injury?

Endothelium

What "tissue factor" within underlying smooth muscle does endothelium release when injured to initiate a cascade of clotting?

Thrombin

What are the two processes working together to form a clot?

1) Platelets (form primary plug)

2) Coagulation Cascade (from endothelial initiation --> release fibrin)

What type of hemostasis occurs when platelets aggregate on the vessel wall following endothelial damage?

Primary Hemostasis

Endothelial damage results in the release of _________ which binds to exposed collage?

von Willenbrand factor (vWF)

Platelets are activated when they encounter what? What do they do once activated?

vWF bound to collagen

Formation of initial "primary hemostatic plug"

What type of hemostasis involves the fomration of a fibrin-rich clot?

Secondary Hemostasis

Injury to the vascular endothelia will expose ______ which activates a series of reactions that end in the formation of a thrombin?

Tissue Factor

Thrombin cleaving fibrinogen into an insoluble protein (fibrin) will allow for what? Why is this important?

formation of fibrin-rich mesh serving as a clot lasting longer than the "plug" in primary hemostasis

-- prevents further hemorrhage at site of injury and provide time to perform repair process

What is the complex series of enzymatic reactions that assist in the formation of fibrin-rich clot via the formation of thrombin?

Coagulation cascade

What are the three primary abnormalities that cause intravascular thrombosis? (aka Virchow's Triad) **

1) Endothelial injury

2) Abnormal Blood flow

3) Hypercoagulability

Why is Virchow's Triad important? **

thrombosis lies at center of many lethal or disabling pathologies such as myocardial infarction, cerebral infarction, or pulmonary emboli

What is the primary cause of thrombosis within the inside of the heart or arterial system?

Endothelial injury

What process is when injury to endothelial cells causes normal anti-thrombotic endothelia to become pro-thrombotic?

Endothelial activation

What are 5 factors that can cause endothelial injury?

1) Formation of atherosclerotic plaques (inside heart post MI)

2) Inflammation

3) abnormal blood flow (Vasculities)

4) Hypercholesterolemia (Hypertension/High cholesterol)

5) Toxic exposure (smoking)

Where is abnormal blood flow commonly limited to?

Areas of blood turbulence or areas of slow blood flow (stasis)

aneurysm, varicosity, arrhythmia, immobility, and heart valve stenosis are stimuli that produce what?

Abnormal blood flow

Abnormal blood flow promotes what?

Endothelial activation

What conditions have excessively viscous blood that results in stasis and makes blood excessively prone to clotting?

Polycythemia

Sickle Cell disease