ANATOMY AND PHYSIOLOGY (OXY-VENTI)

Deep Venous System

The venous system refers to the network of veins that work to deliver deoxygenated blood back
to your heart. Deep Veins, a classification of superficial veins, are found in muscles or along
bones. The tunica intima (innermost layer)  of a deep vein usually has a one-way valve to prevent
blood from flowing backward. Nearby muscles also compress the deep vein to keep blood
moving forward. Deep veins are almost always beside an artery with the same name (e.g. the
femoral vein is beside the femoral artery). Collectively, they carry the vast majority of the blood.
Occlusion of a deep vein can be life-threatening and is most often caused by thrombosis.
Occlusion of a deep vein by thrombosis is called deep vein thrombosis.

Virchow’s Triad
Virchow’s triad represents three qualities in physiology that can result in thrombosis, which can
lead to pathologies such as pulmonary embolism and deep venous thrombosis. These include:
1. Endothelial Damage - Damage to the endothelial wall of a vessel alters the dynamics of
blood flow.When an insult to the wall occurs, flow disruption or “turbulence” occurs.
Turbulent flow within a vessel occurs when the rate of blood flow becomes too rapid, or
blood flow passes over an affected surface; this creates disordered flow and eddy
currents, increasing the friction of flow within a vessel.
2. Venous Stasis - lead to platelet contact with the endothelial lining such as with the use of
a tourniquet, hypotension, or with knee flexion during surgery. It occurs with impaired
mobility, which will cause the venous circulation to slow down and the clotting factors in
the blood to clump together, ultimately leading to DVT.
3. Hypercoagulability - Hypercoagulability, can be affected by tissue debridement, collagen,
fibrinogen, and tissue thromboplastin.

Thrombus/ Thrombosis
An aggregation of platelets, erythrocytes, and even WBCs typically trapped within a mass of
fibrin strands. It can form within an intact or only slightly damaged blood vessel. In a large
vessel, a thrombus will adhere to the vessel wall and decrease the flow of blood, and is referred
to as a mural thrombus. In a small vessel, it may actually totally block the flow of blood and is
termed an occlusive thrombus. Thrombi are most commonly caused by vessel damage to the
endothelial lining, which activates the clotting mechanism.

Embolism
When a portion of a thrombus breaks free from the vessel wall and enters the circulation, it is
referred to as an embolus. An embolus that is carried through the bloodstream can be large
enough to block a vessel critical to a major organ. When it becomes trapped, an embolus is
called an embolism. In the heart, brain, or lungs, an embolism may accordingly cause a heart
attack, a stroke, or a pulmonary embolism

Coagulation Cascade
Coagulation, the formation of a blood clot and is sometimes characterized as a cascade, because
one event prompts the next as in a multi-level waterfall. The result is the production of a
gelatinous but robust clot made up of a mesh of fibrin—an insoluble filamentous protein derived
from fibrinogen, in which platelets and blood cells are trapped. Blood clotting involves three
steps. First, vascular spasm constricts the flow of blood. Next, a platelet plug forms to
temporarily seal small openings in the vessel. Coagulation then enables the repair of the vessel
wall once the leakage of blood has stopped. The synthesis of fibrin in blood clots involves either
an intrinsic pathway or an extrinsic pathway, both of which lead to a common pathway.

Pulmonary Circulation
In the pulmonary loop, deoxygenated blood exits the right ventricle of the heart and passes
through the pulmonary trunk. The pulmonary trunk splits into the right and left pulmonary
arteries. These arteries transport the deoxygenated blood to arterioles and capillary beds in the
lungs. There, carbon dioxide is released and oxygen is absorbed. Oxygenated blood then passes
from the capillary beds through venules into the pulmonary veins. The pulmonary veins transport
it to the left atrium of the heart. The pulmonary arteries are the only arteries that carry
deoxygenated blood, and the pulmonary veins are the only veins that carry oxygenated blood.

Heart
The heart sends deoxygenated blood to the lungs, where the blood loads up with oxygen and
unloads carbon dioxide, a waste product of metabolism. Made up of four chambers: two upper
chambers known as the left atrium and right atrium and two lower chambers called the left and
right ventricles. It is also made up of four valves: the tricuspid, pulmonary, mitral and aortic
valves.

Inferior vena cava

The inferior vena cava is ultimately responsible for the transport of almost all venous blood
(deoxygenated) from the abdomen and lower extremities back to the right side of the heart for
oxygenation.

Right Atrium
The right atrium receives deoxygenated blood from the superior and inferior vena cava, and from
the coronary veins. It pumps this blood through the right atrioventricular orifice (guarded by the
tricuspid valve) into the right ventricle

Right Ventricle
The right ventricle (RV) is the most anterior of the four heart chambers. It receives deoxygenated
blood from the right atrium (RA) and pumps it into the pulmonary circulation. During diastole,
blood enters the right ventricle through the atrioventricular orifice through an open tricuspid
valve (TV).

Lungs 
The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right and
left bronchi; on the inferior surface, the lungs are bordered by the diaphragm. The diaphragm is
the flat, dome-shaped muscle located at the base of the lungs and thoracic cavity. The lungs are
enclosed by the pleurae, which are attached to the mediastinum. The right lung is shorter and
wider than the left lung, and the left lung occupies a smaller volume than the right. The cardiac
notch is an indentation on the surface of the left lung, and it allows space for the heart. The apex
of the lung is the superior region, whereas the base is the opposite region near the diaphragm.
The costal surface of the lung borders the ribs. The mediastinal surface faces the midline.
Each lung is composed of smaller units called lobes. Fissures separate these lobes from each
other. The right lung consists of three lobes: the superior, middle, and inferior lobes. The left
lung consists of two lobes: the superior and inferior lobes. A bronchopulmonary segment is a
division of a lobe, and each lobe contains multiple bronchopulmonary segments. Each segment
receives air from its own tertiary bronchus and is supplied with blood by its own artery. Some
diseases of the lungs typically affect one or more bronchopulmonary segments, and in some
cases, the diseased segments can be surgically removed with little influence on neighboring
segments. A pulmonary lobule is a subdivision formed as the bronchi branch into bronchioles.
Each lobule receives its own large bronchiole that has multiple branches. An interlobular septum
is a wall, composed of connective tissue, which separates lobules from one another.

Pulmonary Artery
A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood
from the right side of the heart to the lungs. The largest pulmonary artery is the main pulmonary
artery or pulmonary trunk from the heart, and the smallest ones are the arterioles, which lead to
the capillaries that surround the pulmonary alveoli.

Concept of Pain
Pain is a subjective experience with two complementary aspects: one is a localized sensation in a
particular body part; the other is an unpleasant quality of varying severity commonly associated
with behaviors directed at relieving or terminating the experience.

Pain can be classified as physiologic, which refers to the body’s protective mechanism to avoid
tissue injury, or pathologic, which arises from tissue injury and inflammation or damage to a
portion of the nervous system. Pathologic pain can be further divided into categories such as
nociceptive (peripheral tissue injury), neuropathic (damage to peripheral nerves or spinal cord),
visceral (stimulation of pain receptors in the thoracic or abdominal viscera), and somatic (injury
to tissues other than viscera, such as bones, joints, muscles and skin). It can also be defined
temporally as acute (arising from a sudden stimulus such as surgery or trauma) or chronic
(persisting beyond the time normally associated with tissue injury).

Types of pain
Acute pain means the pain is short in duration (relatively speaking), lasting from minutes
to about three months (sometimes up to six months). Acute pain also tends to be related to a soft-
tissue injury or a temporary illness, so it typically subsides after the injury heals or the illness
subsides. Acute pain from an injury may evolve into chronic pain if the injury doesn’t heal
correctly or if the pain signals malfunction.
Chronic pain is longer in duration. It can be constant or intermittent. For example,
headaches can be considered chronic pain when they continue over many months or years – even
if the pain isn’t always present. Chronic pain is often due to a health condition, like arthritis,
fibromyalgia, or a spine condition.
Neuropathic pain is due to damage to the nerves or other parts of the nervous system. It
is often described as shooting, stabbing, or burning pain, or it feels like pins and needles. It can
also affect sensitivity to touch and can make someone have difficulty feeling hot or cold
sensations. Neuropathic pain is a common type of chronic pain. It may be intermittent (meaning
it comes and goes), and it can be so severe that it makes performing everyday tasks difficult.
Because the pain can interfere with normal movement, it can also lead to mobility issues.  
Nociceptive pain is a type of pain caused by damage to body tissue. People often
describe it as being a sharp, achy, or throbbing pain. It’s often caused by an external injury. For
example, if you hit your elbow, stub your toe, twist your ankle, or fall and scrape up your knee,
you may feel nociceptive pain. This type of pain is often experienced in the joints, muscles, skin,
tendons, and bones. It can be both acute and chronic.
Radicular pain is a very specific type of pain that can occur when the spinal nerve gets
compressed or inflamed. It radiates from the back and hip into the leg(s) by way of the spine and
spinal nerve root. People who have radicular pain may experience tingling, numbness, and
muscle weakness. Pain that radiates from the back and into the leg is called radiculopathy. It’s
commonly known as sciatica because the pain is due to the sciatic nerve being affected. This
type of pain is often steady, and people can feel it deep in the leg. Walking, sitting, and some
other activities can make sciatica worse. It is one of the most common forms of radicular pain.

Nociception refers to the processing of a noxious stimulus resulting in the perception of pain by
the brain. The components of nociception include transduction, transmission, modulation and
perception. 

Transduction refers to the processes by which tissue-damaging stimuli activate nerve

endings. It is the conversion of a noxious stimulus (mechanical, chemical or thermal) into
electrical energy by a peripheral nociceptor (free afferent nerve ending). This is the first step in
the pain process, and can be inhibited by NSAID’s, opioids and local anesthetics. 
Transmission refers to the relay functions by which the message is carried from the site
of tissue injury to the brain regions underlying perception. It describes the propagation through
the peripheral nervous system via first-order neurons. Nerve fibers involved include A-delta
(fast) fibers responsible for the initial sharp pain, C (slow) fibers that cause the secondary dull,
throbbing pain, and A-beta (tactile) fibers , which have a lower threshold of stimulation.
Transmission can be reduced by local anesthetics and alpha-2 agonists. 
Modulation is a recently discovered neural process that acts specifically to reduce
activity in the transmission system. It occurs when first-order neurons synapse with second-order
neurons in the dorsal horn cells of the spinal cord. Excitatory neuropeptides (including, but not
limited to, glutamate, aspartate and substance P) can facilitate and amplify the pain signals in
ascending projection neurons. At the same time, endogenous (opioid, serotonergic and
noradrenergic) descending analgesic systems serve to dampen the nociceptive response.
Modulation can be influenced by local anesthetics, alpha-2 agonists, opioids, NSAIDs, tricyclic
antidepressants (TCA’s) and NMDA receptor antagonists. 
Perception is the subjective awareness produced by sensory signals; it involves the
integration of many sensory messages into a coherent and meaningful whole. Perception is a
complex function of several processes, including attention, expectation, and interpretation.is the
cerebral cortical response to nociceptive signals that are projected by third-order neurons to the
brain. It can be inhibited by general anesthetics, opioids and alpha-2 agonists.