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

2. 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

3. ENDOTHELIAL
ATTACHMENT
LINES OF
ZAHN
THROMBUS

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

6. 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

7. POST MORTEM CLOT

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

9. FACTORS OF NORMAL HEMOSTASIS
Blood vessel/ endothelium
Platelets
Coagulation system

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

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

13. 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

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

15. 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

16. 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

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

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

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

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

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

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

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

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

33. Hypercoagulability Immobilization Malignancy APAS DIC
Nephrotic syndrome
Oral contraceptive use

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

35. ENDOTHELIAL ATTACHMENT
THROMBUS

36. ENDOTHELIAL ATTACHMENT W/ RBC , PLT , FIBRIN

37. THROMBUS : LINES OF ZAHN

38. 2 1
LINES OF ZAHN

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

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

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

42.                                                                                                             
MURAL THROMBUS

43. MURAL THROMBUS

44. MURAL THROMBUS

45. MURAL THROMBUS

46. ENDOCARDIAL THROMBOTIC VEGETATION

47. THROMBUS
VALVE

48. ARTERIAL / OCCLUSIVE THROMBUS

49. ARTERIAL THROMBUS

50. ARTERIAL THROMBUS , RECENT , OCCLUSIVE

51. THROMBOSIS WITH ORGANIZATION

52. THROMBUS RENAL ARTERY

53. 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

54. Venous Thrombi: Clinical
Lab test:
D- dimer test

56. 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

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

58. CAROTID ARTERY ANGIOGRAM- ARTERIAL OCCLUSION

59. GANGRENE SECONDARY TO ARTERIAL OBSTRUCTION

60. THROMBO-EMBOLISM

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

63. THROMBO-EMBOLISM RIGHT VENTRICLE AND PULM ART

64. RECANALIZED THROMBUS
ORGANIZED THROMBUS

65. RECALANIZED & ORGANIZED PTE

66. RECANALIZED THROMBUS

67. RECANALIZATION
OF THROMBUS

68. 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.

69. 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

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

71. MICROTHROMBOSIS
DIC

72. MICROTHROMBOSIS