FLUID AND HEMODYNAMIC DERANGEMENTS - PART II

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Presentation transcript:

FLUID AND HEMODYNAMIC DERANGEMENTS - PART II SOCORRO CRUZ – YANEZ MD, FPSP

THROMBOSIS Definition : Formation of a solid clotted mass ( thrombus ) derived from blood elements ( vessel , platelets , CF) intravascularly in a living person. A.K.A antemortem clot

ENDOTHELIAL ATTACHMENT LINES OF ZAHN THROMBUS

POSTMORTEM CLOT Formed extravascularly Postmortem ( clotting after death ) Involves only clotting factors “ currant jelly “ or “ chicken fat “ clot

POST- MORTEM CLOTS Forms perfect cast on vessel wall No attachment to Rubbery, gelatinous Forms perfect cast on vessel wall No attachment to endothelium POST- MORTEM CLOTS

POST MORTEM CLOT

NORMAL HEMOSTASIS Functions : 1. Maintenance of blood in a fluid, clot free state 2. Ability to produce hemostatic plug at site of vascular injury

FACTORS OF NORMAL HEMOSTASIS Blood vessel/ endothelium Platelets Coagulation system

SEQUENCE OF EVENTS IN HEMOSTASIS Vasoconstriction Primary hemostatic plug Secondary hemostatic plug Thrombosis and anti-thrombotic events

NORMAL HEMOSTASIS : A. VASOCONSTRICTION Stimulated by vascular injury Mediated by : a . sympathetic NS b. Endothelin secretion

                                                                                                           

BLOOD VESSEL WALL CONTRIBUTION 1. Elaboration of prothrombotic factors / substances : a. vWF- platelet binding co-factor b. extrinsic tissue factor- activates extrinsic clotting pathway c. Plasminogen activators inhibitors – inhibits fibrinolysis Insulation of platelets from subendothelial collagen

BLD VESSEL CONTRIBUTION Cont… Elaboration of humoral factors ( endothelin)  vasoconstriction 4. Role of subendothelial collagen

BLOOD VESSEL WALL CONTRIBUTION (Cont..) Elaboration of anti-thrombotic substance a. Plt aggregator inhibitors: prostacyclin , ADPase , NO b. Anti-thrombin inhibitors : thrombomodulin, heparin like molecule c. Fibrinolytic : t-PA

PLATELET ROLE IN HEMOSTASIS: Formation of Io hemostatic plug A. Platelet adhesion - attachment to site of injury and exposed collagen - needs vWF to bridge platelet and collagen

PLATELET ROLE (cont..) Platelet secretion and release Alpha granules Dense bodies - fibrinogen - ADP - fibronectin - Ca - PDGF - histamine - PF4 - serotonin

PLATELET ROLE (cont..) Platelet aggregation ( platelet to platelet interaction ) - formation of temporary ( primary ) hemostatic plug - stimulated by ADP, TXA2 thrombin

PLATELET ROLE (cont..) 4. Platelet contraction formation of secondary viscous metamorphosis formation of secondary hemostatic plug mediated by octomyosin

                                                                                                           

ROLE OF COAGULATION SYSTEM IN HEMOSTASIS conversion of thrombin to fibrinogen and formation of fibrin  thrombus may be stimulated by extrinsic and intrinsic pathway

                                                                                                                                                                 

ANTI-CLOTTING MECHANISM Depletion of clotting factors Clearance of CF by liver Fibrinolysis : plasmin and plasminogen Proteases Anti-thrombin

                                                                                                           

                                                                                                                                                                                                                             

THROMBOSIS : PREDISPOSING FACTORS INJURY TO ENDOTHELIUM ALTERATION IN NORMAL BLOOD FLOW ALTERATION IN THE BLOOD ( hypercoagulable state )

Endothelial Injury : Acute Myocardial Infarction Atherosclerosis Cigarette smoking Vasculitis Hypertension Hypercholesterolemia

Alterations in blood flow Stasis Aneurysm Valvular stenosis / regurgitation Vascular obstructions

Hypercoagulability Immobilization Malignancy APAS DIC Nephrotic syndrome Oral contraceptive use

THROMBUS : Morphology Endothelial wall attachments Gross and microscopic laminations ( LINES OF ZAHN ) Compositions : laminated platelets, fibrin, RBC and WBC

ENDOTHELIAL ATTACHMENT THROMBUS

ENDOTHELIAL ATTACHMENT W/ RBC , PLT , FIBRIN

THROMBUS : LINES OF ZAHN

2 1 LINES OF ZAHN

THROMBUS : COMPONENTS OF LAYERS 1 – Pale areas( fibrin/platelets ) 2- Red areas ( RBC,WBC , fibrin )

THROMBUS : COMPONENTS OF LAYERS 1 – Pale areas( fibrin/platelets ) 2- Red areas ( RBC,WBC , fibrin )

THROMBUS : Morphology TYPES OF THROMBI : Mural thrombus Vegetations Arterial / occlusive / white or conglutination thrombi Venous/phlebothrombosi/ red or coagulative thrombi

                                                                                                             MURAL THROMBUS

MURAL THROMBUS

MURAL THROMBUS

MURAL THROMBUS

ENDOCARDIAL THROMBOTIC VEGETATION

THROMBUS VALVE

ARTERIAL / OCCLUSIVE THROMBUS

ARTERIAL THROMBUS

ARTERIAL THROMBUS , RECENT , OCCLUSIVE

THROMBOSIS WITH ORGANIZATION

THROMBUS RENAL ARTERY

Thrombi Morphology: Venous Venous thrombi Usually occlusive Red (because they form in stasis syndrome and have more associated enmeshed RBCs) Long - forming a cast of vein with markings on them from venous valves Red blood cells alternating with peripheral areas of fibrin

Venous Thrombi: Clinical Lab test: D- dimer test

ARTERIAL VENOUS THROMBI THROMBI Occur at site of stasis Forward propagation Occlusion and fragmentation Red , stasis thrombi More RBC content Occur site injury/ turbulence Retrograde growth Prone to occlusion Gray white thrombi More PLT and fibrin, less RBC

THROMBUS : CLINICAL SIGNIFICANCE 1. Obstruction of blood flow ischemia and infarction 2. Source of thrombo-emboli

CAROTID ARTERY ANGIOGRAM- ARTERIAL OCCLUSION

GANGRENE SECONDARY TO ARTERIAL OBSTRUCTION

THROMBO-EMBOLISM

THROMBUS : OUTCOME 1. Propagation 2. Lysis and resolution 3. Embolization 4. Organization

                                                                                                                                                                                                                        

THROMBO-EMBOLISM RIGHT VENTRICLE AND PULM ART

RECANALIZED THROMBUS ORGANIZED THROMBUS

RECALANIZED & ORGANIZED PTE

RECANALIZED THROMBUS

RECANALIZATION OF THROMBUS

Dissiminated Intravascular Coagulopathy ( DIC ) Definition : An acute, subacute or chronic thrombotic disorder occurring 2o to cx of variety of clinical dis, presenting with thrombotic ischemia , consumption coagulopathy and shock.

DIC : Disseminated intravascular coagulopathy AKA. Defibrination syndrome Microcirculatory thromb Consumption coagulopathy Clinical assoc : sepsis burns snake bites shock abruption placenta AFE retained dead fetus carcinomatosis

DIC : MORPHOLOGY Multiple microthrombi in diff organs ( brain, heart, lungs , kidneys, adrenals ) Assoc ischemic / hypoxic injury to tissues Multiple hemorrhages

MICROTHROMBOSIS DIC

MICROTHROMBOSIS