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Hemodynamic Disorders: By: Dr. SL Rasonable
Hemodynamic Disorders: By: Dr. SL Rasonable
Hemodynamic Disorders: By: Dr. SL Rasonable
• Hydrostatic Pressure
• Push water out
Causes:
• Lymphatic Obstruction
• Lymphedema
• Chronic Inflammation with Fibrosis
• Filariasis
• Mastectomy (Breast Removal)
Edema & Effusion
• Subcutaneous Edema • Pulmonary Edema
High hydrostatic pressure Lungs 2 to 3x the normal
Distribution is by gravity: weight
Frothy, blood tinged fluid
dependent Edema Left Ventricular Failure
Cardiac or Renal disease ARDS
• Periorbital
Edema Bacterial Infection
Edema of the eyelids • BrainEdema
Severe Renal Disease Localized or generalized
Narrowed sulci, distended gyri
Herniation leads to death
Hyperemia &
Congestion
Hyperemia & Congestion
• Both from increased Blood Volumes
• Hyperemia
Active process
Arteriolar dilatation leads to increased blood flow
Erythema: Increased Oxygenated Blood at the tissues
• Congestion
Passive process
Reduced blood flow from the tissues
Cardiac Failure – Systemic
Venous Obstruction – Localized
Hyperemia & Congestion
LUNGS
Acute Pulmonary Congestion
Engorged aveolar capillaries
Alveolar septal edema
Focal intraalveolar hemorrhage
Chronic Pulmonary Congestion
Thickened, fibrotic septa
Hemosiderin – laden macrophages
(heart failure cells)
Hyperemia & Congestion
LIVER
• Acute Hepatic Congestion
Distended central vein and
sinusoids
• Chronic Passive Congestion
Gross: Nutmeg Liver
Microscopic: centrilobular
hemorrhage, hemosiderin-laden
macrophages and hepatocyte
necrosis
Hemostasis,
Hemorrhagic Disorders
and Thrombosis
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Hemostasis
process by which blood clots form at sites of vascular
injury
• Hemorrhagic Disorders
excessive bleeding
• Thrombotic Disorders
blood clots (often referred to as thrombi) form within intact
blood vessels or within the chambers of the heart
Hemostasis, Hemorrhagic Disorders and Thrombosis
ARTERIOLAR
VASOCONSTRICTION
• Markedly reduces blood
flow
• Reflex neurogenic
mechanisms
• Augmented by Endothelin
• Transient effect
Hemostasis, Hemorrhagic Disorders and Thrombosis
PRIMARY HEMOSTASIS
• Primary Hemostatic Plug/
Platelet Plug Formation
• von Willebrand Factor
(vWF) & collagen
• Platelet Adherence
• Platelet Activation
• Granule Release
• Recruitment
• Platelet Aggregation
Hemostasis, Hemorrhagic Disorders and Thrombosis
PLATELETS
• Alpha Granules:
• P-selectin, Fibrinogen,
Factor V, vWF, PF-4,
PDGF, TGF-B
• Dense Granules:
• ADP, ATP, iCa,
serotonin, epinephrine
Hemostasis, Hemorrhagic Disorders and Thrombosis
SECONDARY
HEMOSTASIS
Fibrin deposition
Hemostasis, Hemorrhagic Disorders and Thrombosis
SECONDARY HEMOSTASIS
Hemostasis, Hemorrhagic Disorders and Thrombosis
FIBRINOLYSIS
• Plasmin
• Breaks down fibrin and
interferes with
polymerization
Hemostasis, Hemorrhagic Disorders and Thrombosis
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Platelet inhibitory effects
• Anticoagulant effects
• Thrombomodulin bind thrombin
• endothelial protein C receptor bind protein C
• vitamin K–dependent protease that requires a cofactor, protein S.
• Activated protein C/protein S complex is a potent inhibitor of
coagulation factors Va and VIIIa
• Heparin-like molecules
• Activate antithrombin
• Inhibit thrombin and IXa, Xa, XIa, XIIa
• Tissue Factor Pathway Inhibitor
• Inhibit VIIa
• Fibrinolytic Effects
THROMBOSIS
Hemostasis, Hemorrhagic Disorders and Thrombosis
ENDOTHELIAL INJURY
• Endothelial activation or
dysfunction
• Procoagulant changes
• Antifibrinolytic effects
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Promote endothelial
activation, enhancing
ANORMAL BLOOD procoagulant activity and
leukocyte adhesion
FLOW • Disrupt laminar flow and
• Turbulence – arterial bring platelets into contact with
and cardiac thrombosis the endothelium
• Stasis – venous thrombi • Prevent washout and dilution
of activated clotting factors by
fresh flowing blood and the
inflow of clotting factor
inhibitors
Hemostasis, Hemorrhagic Disorders and Thrombosis
ANORMAL BLOOD FLOW
• Aneurysms – Aortic and arterial dilatations result
in local stasis
• Acute Myocardial Infarction – Cardiac mural
thrombi
• Rheumatic Mitral Valve Stenosis – Atrial dilation
and fibrillation
• Hyperviscosity – (Polycythemia vera), small
vessel stasis
• Sickle Cell Anemia – deformed RBCs impede
blood flow to small vesselsc
Hemostasis, Hemorrhagic Disorders and Thrombosis
HYPERCOAGULABILITY
Inherited
• Factor V Leiden mutation
Acquired
• Hyperestrogenic state
• Cancer
• Smoking
• Heparin Induced Thrombophilia
• Anti-Phospholipid Antibody Syndrome (APAS)
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Morphology:
• Lines of Zahn
gross and microscopic laminations
Pale platelet and fibrin deposits alternating with darker red cell-rich
layers
• Mural Thrombi
Heart chambers and Aortic lumen
Arrythmias, DCM, MI, myocarditis
• Arterial Thrombi
Occlussive
Coronary, cerebral and femoral arteries
Friable network of platelets, fibrin, red cells and WBCs
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Morphology:
• Venous Thrombi
Phlebothrombosis
Invariably occlusive forming a long luminal cast
Enmeshed red cells – red, or stasis thrombi
Firm, focally attached to the vessel wall and has lines of Zahn
Lower extremity vein
• Post Mortem Clots
Gelatinous, dark red dependent portion
Yellow (chicken fat) upper and red lower
Not attached to the vessel wall
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Morphology:
• Vegetations
Thrombi in the heart valves
Fungi or bacteria
Infective endocarditis
Non bacterial thrombotic endocarditis
Sterile vegetations in persons with Hypercoagulable states
Libman-Sacks endocarditis
Sterile Verrucous
Systemic Lupus Erythematosus
Hemostasis, Hemorrhagic Disorders and Thrombosis
FATE OF THE THROMBUS
• Propagation
Accumulate additional platelets and fibrin
• Embolization
Thrombi dislodge and travel to other sites
• Dissolution
Result of Fibrinolysis
• Organization and Recanalization
Fibrous Lump after vessel wall changes
Hemostasis, Hemorrhagic Disorders and Thrombosis
• Fat
globules from bone marrow at
pulmonary vessels after LONG Fat Embolism Syndrome
BONE FRACTURE Pulmonary insufficiency
Neurologic Symptoms
• Trauma or Burns Anemia-thrombocytopenia
• 90% Dyspnea
in severe skeletal injuries
Tachycardia
• <10% have any clinical findings Coma after 1 to 3 days onset
of symptoms
Air Embolism
• Gas bubbles form frothy masses
Obstruct vessel flow
Distal Ischemic Injury
Bends: gas bubbles in muscles
• Surgical Complication or Chest Wall and joints
Injury Chokes: edema, hemorrhages,
• Air >100cc atelectasis or emphysema in
lungs
• Decompression Sickness
Sudden decreases in atmospheric
Caisson Disease
Chronic Form of
pressure
Scuba and deep sea divers Decompression Sickness
Amniotic Fluid Embolism
Symptoms
• Fifth most common cause of maternal • Sudden Severe
mortality Dyspnea
• Ominous complication of labor and • Cyanosis
immediate postpartum period • Shock
• Tear in the placental membrane or uterine • Neurologic
vein rupture impairment
• Findings: fetal skin, lanugo hair, fat from • Pulmonary Edema
vernix caseosa, muci • DIC
Infarction
An infarct is an area of ischemic necrosis caused by occlusion of either
the arterial supply or the venous drainage
Red Infarct
• Venous occlusions (testicular
torsion)
• Loose, spongy tissues
• Tissueswith dual circulations (lung,
small intestine)
• Tissuespreviously congested by
sluggish venous outflow
• Reestablished flow to a site of
arterial occlusion
White Infarct
• Arterialocclusions in solid
organs with end-arterial
circulation and tissue density
that limit blood seepage
Heart, Spleen and Kidney
Infarction
• Wedge-shaped
Apex-occluded vessel • Ischemic Coagulative Necrosis
Base-Organ periphery – dominant histologic
Serosal surface can have characteristic
fibrinous exudate • Septic Infarctions
• Infected cardiac valve
• Fresh infarcts are poorly
vegetations embolize or
defined but delineates microbes seed necrotic tissue
better over a few days • Converted into an abscess
Infarction
Factors
• Vascular Supply Anatomy
• Rateof Occlusion
Slow rate – less likely to cause infarction
• TissueVulnerability to Hypoxia
Neurons – 3 to 4 min
Myocardial cells – 20 to 30 min
Fibroblasts – hours
• Hypoxemia
Shock
Shock
•astate in which diminished cardiac output or
reduced effective circulating blood volume
impairs tissue perfusion and leads to cellular
hypoxia
Shock
Cardiogenic Shock
• Low cardiac output due to Myocardial pump
failure
• Intrinsic damage (MI)
• Extrinsic compression (Cardiac Tamponade)
• Ventricular arrythmias
• Outflow Obstruction (PE)
Hypovolemic Shock