2. Embolism
Embolism
Can be solid ((thrombus), Liquid (Amniotic fluid) or Gas
Can be solid thrombus), Liquid (Amniotic fluid) or Gas
(Air, Nitrogen) carried by blood flow from the site of
(Air, Nitrogen) carried by blood flow from the site of
origin
origin
Most commonly detached thrombus = also called
Most commonly detached thrombus = also called
thrombo – embolism
thrombo – embolism
Rarely Fat, Air/ Nitrogen, Cholesterol emboli, Tumor
Rarely Fat, Air/ Nitrogen, Cholesterol emboli, Tumor
emboli, Foreign bodies
emboli, Foreign bodies
Consequence vascular obstruction Infarction
Consequence vascular obstruction Infarction
Types systemic (arterial), Pulmonary
Types systemic (arterial), Pulmonary
Dr. Krishna Tadepalli, MD, www.mletips.com
3. Emboli - Types
Systemic
Pulmonary
Systemic
Pulmonary
Arterial ((exception
Arterial exception
Paradoxical ))
Paradoxical
Arise in heart
Arise in heart
Cause infarctions
Cause infarctions
lower extremities –
lower extremities –
75%, Brain (15%),
75%, Brain (15%),
Kidney, spleen)
Kidney, spleen)
• Venous
• Venous
• DVT
• DVT
• Emboli cause
• Emboli cause
Pulmonary embolism
Pulmonary embolism
((silent in 50% of pts.).
silent in 50% of pts.).
If 60% of pulmonary
If 60% of pulmonary
circulation is blocked
circulation is blocked
sudden death due to
sudden death due to
acute cor -pulmonale
acute cor -pulmonale
(Rt. Heart Failure)
(Rt. Heart Failure)
Dr. Krishna Tadepalli, MD, www.mletips.com
6. Fat embolism
Fat embolism
Causes Most common (90%) with fractures of long
Causes Most common (90%) with fractures of long
bones, less commonly following soft tissue trauma, Burns
bones, less commonly following soft tissue trauma, Burns
When ?? 3-5 days after the injury
When 3-5 days after the injury
Clinical Heart =Tachycardia
Clinical Heart =Tachycardia
Lungs Tachypnea,
Lungs Tachypnea,
Blood Petechiae, Anemia
Blood Petechiae, Anemia
Mechanism Mechanical ((obstruction)
Mechanism Mechanical obstruction)
Biochemical Neutral fats cause platelet & RBC aggregation
Biochemical Neutral fats cause platelet & RBC aggregation
and destruction
and destruction
Free fatty acids endothelial injury
Free fatty acids endothelial injury
Diagnosis Frozen sections stained with fat stains ((oil
Diagnosis Frozen sections stained with fat stains oil
red –O, Sudan IV)
red –O, Sudan IV)
Hematological findings (anemia, Petechiae on
Hematological findings (anemia, Petechiae on
nondependent parts) are very useful
nondependent parts) are very useful
Dr. Krishna Tadepalli, MD, www.mletips.com
11. Infarction
Infarction
Definition = ischemic necrosis of tissue due to occlusion
Definition = ischemic necrosis of tissue due to occlusion
of arterial ((in most of cases) or venous ((in gonads)
of arterial in most of cases) or venous in gonads)
circulation
circulation
Most common cause of Death in USA
Most common cause of Death in USA
Most commonly in 99% of cases = arterial occlusion
Most commonly in 99% of cases = arterial occlusion
by thrombo-embolism
by thrombo-embolism
Rarely venous drainage problem ((in Testis, Ovary)
Rarely venous drainage problem in Testis, Ovary)
Very rarely vasospasm
Very rarely vasospasm
Morphological Types Red & White
Morphological Types Red & White
Wedge shaped with base at the periphery of organ
Wedge shaped with base at the periphery of organ
Final outcome Coagulative necrosis ((Liquefactive in
Final outcome Coagulative necrosis Liquefactive in
Brain)
Brain)
Septic infarction = in pts. With infective Endocarditis
Septic infarction = in pts. With infective Endocarditis
Dr. Krishna Tadepalli, MD, www.mletips.com
12. Infarctions- Types
Red (Hemorrhagic)
White (Anemic)
Red (Hemorrhagic)
White (Anemic)
Venous occlusion
Venous occlusion
In loose tissues
In loose tissues
(lung)
(lung)
Organs with dual
Organs with dual
blood supply (Lungs,
blood supply (Lungs,
Liver)
Liver)
Previously congested
Previously congested
organs
organs
((nutmeg liver)
nutmeg liver)
Re- perfused tissues
Re- perfused tissues
• Arterial occlusion
• Arterial occlusion
• Solid organs
• Solid organs
• End arterial supply
• End arterial supply
((Kidney, Spleen,
Kidney, Spleen,
Retina, Heart)
Retina, Heart)
Dr. Krishna Tadepalli, MD, www.mletips.com
15. Final outcome of Infarction in heart
Final outcome of Infarction in heart
How old is it ( after the onset of MI)?
Dr. Krishna Tadepalli, MD, www.mletips.com
16. Hemodynamic Disorders, Thromboembolic
Hemodynamic Disorders, Thromboembolic
Disease, and Shock
Disease, and Shock
OBJECTIVES
OBJECTIVES
Edema
Edema
Hyperemia and Congestion
Hyperemia and Congestion
Hemorrhage
Hemorrhage
Hemostasis and Thrombosis
Hemostasis and Thrombosis
Embolism
Embolism
Infarction
Infarction
Shock
Shock
Dr. Krishna Tadepalli, MD, www.mletips.com
17. Shock = Cardiovascular collapse
Shock = Cardiovascular collapse
• Final common pathway of many disorders
• Final common pathway of many disorders
((Hemorrhage, Trauma, Burns, MI, PE, Sepsis)
Hemorrhage, Trauma, Burns, MI, PE, Sepsis)
• Main Event Systemic Hypo perfusion ((due to
• Main Event Systemic Hypo perfusion due to
↓cardiac output or effective circulatory volume)
↓cardiac output or effective circulatory volume)
•• Types
Types
– Cardiogenic = MI, Ventricular rupture, PE, etc.,
– Cardiogenic = MI, Ventricular rupture, PE, etc.,
– Hypovolemic = Hemorrhage, Fluid loss
– Hypovolemic = Hemorrhage, Fluid loss
– Septic = most important
– Septic = most important
– Others = Neurogenic, Anaphylactic ((Type 1 HSR)
– Others = Neurogenic, Anaphylactic Type 1 HSR)
Dr. Krishna Tadepalli, MD, www.mletips.com
18. Septic Shock = by Gram +ve bacteria
Septic Shock = by Gram +ve bacteria
• MCC of mortality in ICU (in USA)
• MCC of mortality in ICU (in USA)
• Incidence is ↑ ((due to high risk pts., ↑ # of invasive
• Incidence is ↑ due to high risk pts., ↑ # of invasive
procedures & immuno-compromised pts.)
procedures & immuno-compromised pts.)
•• Endotoxic shock MC sub type of septic shock ((70%
Endotoxic shock MC sub type of septic shock 70%
of cases),
of cases),
•• Cause LPS
Cause LPS
•• Super antigens bacterial proteins cause polyclonal
Super antigens bacterial proteins cause polyclonal
activation of T – Lymphocytes
activation of T – Lymphocytes
––
––
Example ––TSS toxin-1 by Staph. Aureus
Example TSS toxin-1 by Staph. Aureus
Cause multi organ failure
Cause multi organ failure
Dr. Krishna Tadepalli, MD, www.mletips.com
19. Septic shock Endotoxic shock
Septic shock Endotoxic shock
•• Causes= LPS (Endotoxin = Lipid core and
Causes= LPS (Endotoxin = Lipid core and
PolySaccharide coat)
PolySaccharide coat)
•• Effects
Effects
– Low LPS levels Activate Macrophages Local
– Low LPS levels Activate Macrophages Local
inflammation healing
inflammation healing
– Moderate LPS levels ↑cytokines systemic
– Moderate LPS levels ↑cytokines systemic
effects
effects
– Higher LPS levels Septic shock syndrome
– Higher LPS levels Septic shock syndrome
•• Mechanism LPS binds with Circulating Protein
Mechanism LPS binds with Circulating Protein
later the complex binds with CD 14 All of them
later the complex binds with CD 14 All of them
finally bind with TLR-4
finally bind with TLR-4
– The interaction on endothelium ↓anticoagulant
– The interaction on endothelium ↓anticoagulant
properties
properties
– The interaction on Macrophages ↑ cytokines
– The interaction on Macrophages ↑ cytokines
(TNF, IL-1)
(TNF, IL-1)
Dr. Krishna Tadepalli, MD, www.mletips.com