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Shock, Hemorrhage Shock, Hemorrhage andand
ThrombosisThrombosis
ShockSystemic hypoperfusion due to:
–Reduction in cardiac output–Reduction in effective circulating
blood volume
Hypotension Impaired tissue perfusionCellular hypoxia
Spinal cord injuryVascular tonePooling of blood5. Anaphylactic
-IgE mediated hypersensitivity
* high mortality
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Stages of Shock: Basic Pathology 7/e
Non-Progressive Stage Progressive Stage Irreversible Stage
-compensatory reflexmechanisms activated(baroreceptors/catechol. release)-perfusion maintained
-tissue hypoperfusion & worsened circulatorymetabolic imbalance
-severe cell & tissueinjury with no chance of recovery
Significance of Hemorrhage
NO CLINICAL FINDINGS:
10-20% of bld. vol. lostOR
slow blood loss
HYPOVOLEMICSHOCK:
larger blood lossesOR
more rapid bld. loss
Congestion (Hyperemia)
Increased volume of blood in affected tissue•Mechanism:
arterial and arteriolar dilatation
bld.flow intocapillaries
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Edema
*The abnormal accumulation of fluid in the intercellular tissue spaces or body cavities
-localized-systemic
Edema fluids: nomenclature
-abdomen: ascites-pleural cavities: effusions / hydrothorax-pericardium: effusion-total body: anasarca
Extravascular/Edema Fluids:TerminologyTransudate:
-low protein content-non-inflammatory
-ultrafiltrate of plasma (mostly albumin) -due to osmotic/hydrostatic imbalance-no increase in vasc. permeab.)
-S.G. < 1.012
Exudate:-high protein concentration-inflammatory
-due to altered permeab. of small bld. vessels
-S.G. >1.020
Mechanisms of edema formation
• plasma colloid oncotic pressure• hydrostatic pressure• endothelial permeability• lymphatic blockage
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Thrombosis: the Virchow triad
Thrombosis
Endothelial injury
Abnormal blood flow hypercoagulability
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Types & Fate of Thrombi
•Arterial: coronary, cerebral, aorta + branches •Venous: 90% in deep leg veins
-also peri-uterine, peri-prostatic•Mural: heart
•Propagation•Embolization•Dissolution•Organization and recanalization
Types
FateBrainSpleenkidneys
Arterial thrombi(“left-sided”)Lungs
Venous thrombi(“right-sided)
Right-sided thromboemboli:Classic example is pulmonary emboli
Paradoxical embolus: throughpatent foramen ovale to left side
saddleembolus
RV
Left-sided thromboemboli:Classic examples are mural thrombi inLeft atrium/ventricle or endocarditis
Pulmonary infarct (wedge-shaped region of necroticlung). Seen in only approx.10% of pulmonary emboli becauseof dual lung perfusion from bronchialarteries
brain
spleen
kidneys
Atrial appendagethrombi (often inmitral stenosis +atrial fibrillation)
mitral valveendocarditisMural thrombus
In left ventricle(e.g., after myocardialInfarction & hypokinesis)
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Acute myocardial infarction
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PulmonaryInfarct
Disseminated Intravascular Coagulation (DIC)(Consumption Coagulopathy)
• Widespread thrombosis in microcirculation• Platelets & fibrin in capillaries• Mechanism: Activate intrinsic pathway• Clinical: sepsis—obstetrical catastrophe--
cancer—extensive tissue damage• Hematologic: rapid consumption of fibrinogen,
platelets, prothrombin, V, VIII, X– Generation of d-dimers (“fibrin split products”)
Sepsis & Septic shock: definitions
1. SEPSIS: suspected or proven infection
+ systemic inflammatory responsesyndrome: fever, tachycardia,tachypnea, leukocytosis
2. SEVERESEPSIS: sepsis +
ORGAN DYSFUNCTION:hypotension, hypoxemia, oliguria,metabolic acidosis, thrombocytope-nia, obtundation
3. SEPTIC SHOCK:
severesepsis
+ORGAN DYSFUNCTION,HYPOTENSION, despiteadequate fluid resuscitation
750,000 cases of sepsis / yr. in U.S.
bacteriapneumonia
meningitis
inflam. bowel dis. GU tract(urosepsis)
Sources:
sepsis
Immune cell “cross-talk”
in sepsis
NEJM 2003;348: 138-150
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Toll-like receptors(TLR)
•Family of PPR’s(pattern recognition
receptors)•TLR2: peptidoglycan
Gram+ org’s
•TLR 4: LPS (endotoxin)
Gram- org’sleukocyte
macPMN
TLR’sTNFIL-1
PG’s
upregulateadhesion molecules
iNOS
NO
vasodilation
Role ofinnate immuneresponse insepsis:proinflam. cytokines
•edema• vasc. permeab.
systemic acute-phase response
B
T
Th1 Th2
PROINFLAM. cytokines:TNF, IL-1
ANTI-INFLAM. cytokines:IL-4, IL-10
Role of adaptiveimmune response
in sepsis
anti-inflam.shift in sepsis
Roles ofprocoagulant-anti-coagulantbalance
LPSdamage
tissue factor(thromboplastin)
coagulation
fibrinthrombus
levels of:•Protein C•Protein S•Antithrombin III•Tissue factor-
pathway inhibitorPRO
anti
NEJM 2006; 355: 1699-1713
Organ Dysfunction in Septic Shock
vasodilation
fluid
vascularresistance
hypovolemia
myocardialcontractility
+
NOTNFIL-6
Circulatory shock
renalfailure(“pre-renal”)
PMN
acute lung injury