5. WATER
• 60% of body
• 2/3 of body water is INTRA-cellular
• The rest is INTERSTITIAL
• Only 5% is INTRA-vascular
• EDEMA is SHIFT to the INTERSTITIAL
SPACE
• HYDRO-
– -THORAX, -PERICARDIUM, -PERICARDIUM
• EFFUSIONS, ASCITES, ANASARCA
18. Transudate vs Exudate
• Transudate
– results from disturbance of Starling forces
– specific gravity < 1.012
– protein content < 3 g/dl
• Exudate
– results from damage to the capillary wall
– specific gravity > 1.012
– protein content > 3 g/dl
50. NORMAL platelet on LEFT, “DEGRANULATING” ALPHA
GRANULE ON RIGHT AT OPEN WHITE ARROW
51.
52. PLATELET PHASES
• ADHESION
• SECRETION (i.e.,
“release” or “activation”
or “degranulation”)
• AGGREGATION
53. PLATELET ADHESION
• Primarily to the
subendothelial ECM
• Regulated by vWF, which
bridges platelet surface
receptors to ECM collagen
54. PLATELET SECRETION
• BOTH granules, α and δ
• Binding of agonists to
platelet surface receptors
AND intracellular protein
PHOSPHORYLATION
55. PLATELET AGGREGATION
• ADP
• TxA2 (Thromboxane A2)
• THROMBIN from coagulation
cascade also
• FIBRIN further strengthens
and hardens and contracts the
platelet plug
56. PLATELET EVENTS
• ADHERENCE to ECM
• SECRETION of ADP and TxA2
• EXPOSE phospholipid
complexes
• Express TISSUE FACTOR
• PRIMARYSECONDARY PLUG
• STRENGTHENED by FIBRIN
62. ENDOTHELIAL “INJURY”
• Jekyll/Hyde disruption
–any perturbation in the dynamic
balance of the pro- and
antithrombotic effects of
endothelium, not only physical
“damage”
65. ABNORMAL FLOW
•NON-LAMINAR FLOW
• TURBULENCE
• EDDIES
• STASIS
• “DISRUPTED” ENDOTHELIUM
ALL of these factors may bring
platelets into contact with
endothelium and/or ECF
66. 1˚ HYPERCOAGULABILITY
(INHERITED)
• COMMONEST: Factor V and
Prothrombin defects
• Common: Mutation in prothrombin gene,
Mutation in methyltetrahydrofolate gene
• Rare: Antithrombin III deficiency, Protein C
deficiency, Protein S deficiency
• Very rare: Fibrinolysis defects
74. D.V.T. • D. (CALF, THIGH, PELVIC) V.T.
• CHF a huge factor
• INACTIVITY!!!
• Trauma
• Surgery
• Burns
• Injury to vessels,
• Procoagulant substances from tissues
• Reduced t-PA activity
75. ARTERIAL/CARDIAC THROMBI
• ACUTE MYOCARDIAL INFARCTION =
OLD ATHEROSCLEROSIS + FRESH
THROMBOSIS
• ARTERIAL THROMBI also may send
fragments DOWNSTREAM, but these
fragments may contain flecks of
PLAQUE also
• LODGING is PROPORTIONAL to the %
of cardiac output the organ receives,
i.e., brain, kidneys, spleen, legs, or the
diameter of the downstream vessel
77. Disseminated Intravascular Coagulation
D.I.C.
• OBSTETRIC COMPLICATIONS
• ADVANCED MALIGNANCY
NOT a primary disease
CONSUMPTIVE coagulopathy, e.g.,
reduced platelets, fibrinogen, F-VIII and
other consumable clotting factors,
brain, heart, lungs, kidneys,
MICROSCOPIC ONLY
78.
79. EMBOLISM
•Pulmonary
• Systemic (Mural Thrombi and
Aneurysms)
• Fat
• Air
• Amniotic Fluid
80. PULMONARY EMBOLISM
• USUALLY SILENT
• CHEST PAIN, LOW PO2, S.O.B.
• Sudden OCCLUSION of >60% of
pulmonary vasculature, presents a HIGH
risk for sudden death, i.e., acute cor
pulmonale, ACUTE right heart failure
• “SADDLE” embolism often/usually fatal
• PRE vs. POST mortem blood clot:
– PRE: Friable, adherent, lines of ZAHN
– POST: Current jelly or chicken fat
81.
82.
83. SYSTEMIC EMBOLI
• “PARADOXICAL” EMBOLI
• 80% cardiac/20% aortic
• Embolization lodging site is
proportional to the degree of flow
(cardiac output) that area or organ
gets, i.e., brain, kidneys, legs
84. OTHER EMBOLI
•FAT (long bone fx’s )
•AIR (SCUBA bends)
•AMNIOTIC FLUID,
very prolonged or difficult
delivery, high mortality
85.
86.
87. INFARCTION
• Defined as an area of necrosis*
secondary to decreased blood
flow
• HEMORRHAGIC vs. ANEMIC
• RED vs. WHITE
–END ARTERIES vs. NO END ARTERIES
• ACUTEORGANIZATIONFIBROSIS
88. INFARCTION FACTORS
• NATURE of VASCULAR SUPPLY
• RATE of DEVELOPMENT
–SLOW (BETTER)
–FAST (WORSE)
• VULNERABILITY to HYPOXIA
–MYOCYTE vs. FIBROBLAST
• CHF vs. NO CHF
98. SEPTIC shock
• OVERWHELMING INFECTION
• “ENDOTOXINS”, i.e., LPS (Usually Gm-)
• Gm+
• FUNGAL
• “SUPERANTIGENS”, (Superantigens are polyclonal
T-lymphocyte activators that induce systemic inflammatory
cytokine cascades similar to those occurring downstream
in septic shock, “toxic shock” antigents by staph are the
prime example.)
99. SEPTIC shock events*
(overwhelming infection)
• Peripheral vasodilation
• Pooling
• Endothelial Activation
• DIC
* Think of this as a TOTAL BODY
inflammatory response
100. ENDOTOXINS
• Usually Gm-
• Degraded bacterial cell wall products
• Also called “LPS”, because they are Lipo-
Poly-Saccharides
• Attach to a cell surface antigen known as
CD-14