Thromboembolism
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Thromboembolism and autopsy
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Thromboembolism
- 1. THROMBOEMBOLISM Dr Priyal Jain P G in Forensic Medicine UCMS Delhi
- 2. Embolism It is a detached intravascular solid/ liquid or gaseous mass that is carried by the blood to a site distant from it`s point of origin.
- 6. Aggregation
- 7. Risk Factors Acquire Strong ◦ Surgery ◦ Trauma ◦ Central venous catheters ◦ Metastasized cancers Moderate ◦ APLS ◦ Peurperium ◦ Prolonged bed rest ◦ Non metastasized cancers
- 8. Risk Factors Mild ◦ Pregnancy ◦ OCP ◦ HRT ◦ Obesity ◦ Long haul air travel ◦ Age
- 9. Risk Factors Inherited ◦ Anti-thrombin deficiency ◦ Protein C deficiency ◦ Protein S deficiency ◦ Factor V leiden ◦ Prothrombin 20210A ◦ Non O blood group ◦ Dysfibrinogenimia
- 10. Risk Factors Mixed / Unknown ◦ High Levels of factor viii ◦ High Levels of factor ix ◦ High Levels of factor xi ◦ High Levels of fibrinogen ◦ High Levels of TAFI ◦ Low Levels of TFPI
- 11. Clinical Features Lung ◦ Dyspnea. ◦ Tachypnea. ◦ Hemoptysis. ◦ Tachycardia. ◦ Hypoxemia. ◦ Sudden death.
- 12. Clinical Features Heart ◦ Myocardial infarction Brain Cerebral Infarction Kidney Renal Infarction
- 15. Bowden cable
- 16. Ageing of Trombus Hemolysis of RBCs and amorphous mass formation----------------------- 24-48 hrs PTAH Staining Purplish fibrin strands ------ 1 day Meshwork of strand and sheets-- 4 days Deeply purple strand--------- 2 wks
- 17. Ageing of Thrombus Endothelial proliferation bud – 2nd day Covering by endothelium starts 24 hrs Covering by endothelium finish 24-72 hr Anchoring thrombus 4th day
- 18. Ageing of Thrombus Fibroblast starts 1 wk Fibroblast Maximum 4 wk Elastic fibers >4 wk Maximum density 2 month Capillary formation Begins 2nd day Contains RBCs 2nd wk Canalization 3 month Full lumen restoration 6-12 months
- 19. Fat Embolism Risk factors ◦ # of long bones/ # pelvic bones/ multiple # ◦ Burns ◦ Barotrauma ◦ Soft tissue injury ◦ Surgery (mastectomy) ◦ Sepsis ◦ Steroid ◦ DM ◦ Alcoholic fatty liver, acute pancreatitis
- 20. Micro-emboli of fat ↓ ↓ Free fatty acid occlusion of circulation ↓ ↓ plt, rbc aggregation ↑ ↓ Injury to endothelium → ↑ ↓ ↓ Vascular occlusion
- 21. Susceptible organs Lung Brain Myocardium Kidney
- 22. Clinical feature Pulmonary insufficiency ◦ Sudden Tachypnea, Dyspnea, tachycardia, Neurological symptoms ◦ Irritability, Restlessness Anaemia Thrombocytopenia
- 23. P M APPEARANCE Frozen Section + staining sudan black Skin --- petechial hemorrhages Brain – white matter of cerebrum, cerebellum, brain stem Heart – interfiber capillaries Kidney – glomerulli Eye - retina and optic nerve
- 24. Mason scale Oil Red O Frozen Section of lung 0: no emboli seen 1: emboli found after some searching 2: emboli easily seen 3: emboli present in large amount 4: emboli present in potentially fatal No.
- 25. Air embolism Risk Factors ◦ Venous air embolism aspiration of air in neck vein refilling of therapeutic pneumothorax tearing of visceral pleura ◦ Arterial air embolism lung laceration baro-trauma bends criminal abortion mercy killing
- 26. Post mortem procedure Cranial cavity ↓ Thorax ↓ Abdomen ↓ Pericardial sac
- 27. Methods Window in sternum Open heart with clamping of vessels Submerge opening or syringing Aspirometer withTween 80 Pyrogallol test ◦ 2% , 4 ml , 2drops NaOH , yellow , brown (+)
- 28. Amniotic Fluid Embolism Risk Factors Multiparity Abruption Intrauterine Fetal Death Tumultuous labour Oxytocin or Prostaglandin hyper stimulation Caesarean section Manual removal of the placenta
- 29. Pathophysiology Probably an anaphylactoid-type reaction to the intravascular ingress of amniotic fluid This causes widespread vasoconstriction including pulmonary and cardiac vessels There is ↓myocardial contractility and acute left heart failure If the mother survives the initial cardio respiratory failure then DIC and haemorrhage is inevitable Survivors may suffer stroke due to cerebral infarction
- 30. Clinical Feature Acute fetal distress followed quickly by maternal collapse with hypotension, dyspnoea and cyanosis. Sudden loss of consciousness or seizure. Often proceeds or occurs immediately after delivery. Maternal collapse during Caesarean section. Followed by profuse post partum haemorrhage.
- 31. P M Findings Classical findings are presence of squamous cells shed from fetal skin, lanugo hair, fat from vernix caseosa and mucin derived from the respiratory/ GI tract.