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Thromboembolic Disease

Thromboembolic Disease

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Published by jslum

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Published by: jslum on Jul 05, 2011
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11/04/2012

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romoemoc seaseDefinition
Thrombosis  Clotting of blood at inappropriate sitesEmbolism  Migration of clotsInfarct  Obstruction of blood flow to tissue (lead to cell death)
Normal Haemostasis
Vascular injury
Brief period of vasospasm
Exposure of subendothelial collagen
Platelet adhesion, activation
Platelet aggregation (1° haemostasis)
Release of TF (tissue factor)
Activation of coagulation sequences
Formation of fibrin
Permanent haemostatic plug (2° haemostasis)
Coagulation Cascade3 Important Factors
Vascular wall lining
y
 
Endothelium
y
 
S
ub-endothelium connective tissuePlatelets  haemostatic plugCoagulation system  activated in cascade fibrin formation
E
ffectsAnti-Thrombotic Pro-Thrombotic
Anti-platelet effectsAnti-coagulation properties
y
 
H
eparin like molecules
y
 
Thrombodulin activation of protein C,
S
 
y
 
2 macroglobulinFibrinolysis(tissue plasminogen activator)Platelet adhesion, aggregation
y
 
VW factor
y
 
Platelet activating factorsProcoagulant factors
y
 
Tissue factor
y
 
Binding sites for factor IX, X, VInhibition of fibrinolysis(t-PA inhibitor)
 
 
ThrombosisDefinition
Pathological process, denotes formation of clotted massof bloodWithin non-interrupted vascular systemInappropriate activation of normal haemostatic process
Thrombogenesis (Virchows Triad)
E
ndothelial injury
Especially thrombi of heart, arteriesCauses
y
 
Myocardial infarction
y
 
Myocarditis
y
 
Atherosclerosis
y
 
Inflammatory valve diseases
y
 
Prosthetic heart valves
H
aemodynamic stress in
y
 
H
ypertension
y
 
Radiation
y
 
Chemicals
y
 
Bacterial toxins
y
 
H
ypercholesterolaemia
y
 
Immune reaction
Alteration in Blood Flow
Turbulence
y
 
Arterial, cardiac thrombi
y
 
Eg. Over ulcerated A
S
plaques, aneurysms, MI, healed rheumatic M
S
 
S
tasis
y
 
Venous thrombi
y
 
Eg. Varicose veins, hyperviscosity syndrome (polycythemia)
 Alteration in Blood (Hypercoagulability)Primary Secondary
Antithrombin III deficiencyProtein C,
S
deficiencyFibrinolysis defectsProlonged bed rest, immobilizationMyocardial infarctionTissue damageCardiac failureDisseminated carcinomaDICProsthetic heart valves
Morphology
H
eart/ aorta
y
 
L
ines of Zahn
y
 
Alternating pale layers of platelet, fibrinseparated by darker layers of red cellsVeins
y
 
N
o line of Zahn
y
 
Resemblecoagulated blood Mural thrombiVegetations
ThrombiArterial Venous
Coronary, cerebral, femoral DVT veins of lower limbs
S
uperimposed on A
S
lesions
S
tasis (major cause)Pale, gray white, friable
L
ine of Zahn +Firmly attached to vascular wallRed blue, ill-defined pale gray fibrinstrandsAttached to underlying wallContraction of lumen  restoration of blood flowPropagation in both directionsCan propagate both ways
VegetationsBacterial/ Infective
E
ndocarditisNon-Bacterial Thrombotic
E
ndocarditis
Blood borneinfectionof heart valvesThrombi laden with microorganismsUninfectedvalvesOld patient with terminal CaChronic illnessDue to
y
 
H
ypercoagubility
y
 
S
ubendocardial injury
Difference  Thrombus, ClotThrombus Clot
L
iving animals Dead animalsFlowingstream
S
tatic blood streamPlatelet initiation
N
o platelet scaffoldingDry, friable, granular Moist, shiny, gelatinous
S
hape not confined to vessel
S
hape confined to vessel
L
ine of Zahn +Red, current jelly appWithdrawal difficult Withdrawal easy
Fate of Thrombus
Propagation obstruction of major vessels, ischemiaEmbolizationDissolution removed by fibrinolysisOrganization, fibrosis  incorporated into wallRecanalization, establishment of blood flowCentral softening, septic mass
 
 
E
mbolismDefinition
Detached intravascular liquid, solid, gaseous massCarried by blood to a site (distant from its point of origin)
Types
Pulmonary embolism
S
ystemic embolismAmniotic fluid embolismGaseous embolismFat embolismTumour embolismTherapeutic embolismMisc.
Pulmonary
E
mbolism
DVTof legs (90%)Carried along progressively larger channels
Right heart
Pulmonary vasculature
DVT common in
Prolongedimmobilization PostoperativestateObesityProlonged use of OCP 
H
eart disease
N
eoplasia
S
ystemicdisease (collagen anomalies)Primaryhypercoagulablestate
E
ffects
Fatal massive PE (results insaddle embolusat pulmonary bifurcation)Right heart failure (Cor pulmonale)Multiple emboli pulmonary hypertension, right heart failure
S
mall multiple PE in medium sized arteries (pulmonary haemorrhage)Emboli in small end-arterioles (infarction)Form delicate bridgingfibrous websEmbolus pass through interarterial/ interventricular septal defect
y
 
S
ystemic circulation, obstruct middle sized arteries
y
 
Paradoxical embolism
Pulmonary Thromboembolus
L
arge vein in leg
IVC
Main pulmonary arteriesThrombi embolize most often from large veinsin legs, pelvis (thrombi form with stasis)
Saddle Pulmonary Thrombo
E
mbolus
(TE)
 Infective
E
mboli
Result from infective thrombi(eg. Valvular vegetation in bacterial endocarditis)Infective agent weaken vessel wall  mycotic aneurysm
Vegetation on Heart ValvesSystemic
E
mbolism
Embolism through arterial circulationThrombi of heart (especially left ventricle  MI, R
H
D) (80-85%)Detached arthroma in large arteriesEffects  infarct, gangrene
S
eptic emboli  suppurative foci
Amniotic Fluid
E
mbolism
S
udden respiratory difficultyCyanosisCV shockTonic-clonic convulsionComa
If survive
Pulmonary edemaARD
S
 
Ex
cessive uterine bleeding
Due to DIC (disseminated intravascular coagulation)
Causes
Tear in placental membrane/ rupture of uterus, cervical vessels(infusion of amniotic fluid into maternal circulation)Epithelium squame, lanugo hair, vernix caseosa, mucin, bile, meconium inpulmonary microcirculation at PM
Air, Gaseous
E
mbolismAir
E
mbolismGaseous
E
mbolism(Decompression sickness)Causes
Cervical operationBlood transfusion, IV infusionRupture of venous sinuses in laborTubal insufflations
S
tab wound chestTreatment of pneumothorax
H
aemodialysis
Consequences
ARDConvulsionComa
 
Exposed to sudden change in ATMPressure released
Bubble of gas come outForm gas masses in vessels/ tissue
Pathophysiology
Respiration under  pressure
Gas dissolved in blood, tissue fluid
Rapid decompression
Release of O2,
N
2
O2 dissolves,
N
2 forms bubbles
Occlusion of vessels
Fat
E
mbolism
Fracture of long boneMultiple fracture of ribs in extensive cardiac massage
S
ickle cell anaemia  infarct BMRupture fatty liverInterosseous phlebography
Tumour
E
mbolism
Tumour invasion of local blood vesselChronic DIC  vessel obstruction, haemorrhage
Therapeutic
E
mbolism
Gel foamMuscle
S
ilicon
Miscellaneous
E
mbolism
FB  bullets, talc, silk, polythene tube, fiberParasites  schistosoma  PV liverRed cell aggregatesMicroemboli  athroma, platelets, fibrin, Ca, silicon, fat

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