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FLUID AND HEMODYNAMIC DERANGEMENTS - PART II

FLUID AND HEMODYNAMIC DERANGEMENTS - PART II. SOCORRO CRUZ – YANEZ MD, FPSP. THROMBOSIS. Definition : Formation of a solid clotted mass ( thrombus ) derived from blood elements ( vessel , platelets , CF) intravascularly in a living person.

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FLUID AND HEMODYNAMIC DERANGEMENTS - PART II

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  1. FLUID ANDHEMODYNAMIC DERANGEMENTS- PART II SOCORRO CRUZ – YANEZ MD, FPSP

  2. THROMBOSIS Definition : Formation of a solid clotted mass ( thrombus ) derived from blood elements ( vessel , platelets , CF) intravascularly in a living person. A.K.A antemortem clot

  3. ENDOTHELIAL ATTACHMENT LINESOF ZAHN THROMBUS

  4. POSTMORTEM CLOT • Formed extravascularly • Postmortem ( clotting after death ) • Involves only clotting factors • “ currant jelly “ or “ chicken fat “ clot

  5. Rubbery, gelatinous • Forms perfect cast • on vessel wall • No attachment to • endothelium POST- MORTEM CLOTS

  6. POST MORTEM CLOT

  7. NORMAL HEMOSTASIS Functions : 1. Maintenance of blood in a fluid, clot free state 2. Ability to produce hemostatic plug at site of vascular injury

  8. FACTORS OF NORMAL HEMOSTASIS • Blood vessel/ endothelium • Platelets • Coagulation system

  9. SEQUENCE OF EVENTS IN HEMOSTASIS • Vasoconstriction • Primary hemostatic plug • Secondary hemostatic plug • Thrombosis and anti-thrombotic events

  10. NORMAL HEMOSTASIS :A. VASOCONSTRICTION • Stimulated by vascular injury • Mediated by : a . sympathetic NS b. Endothelin secretion

  11. BLOOD VESSEL WALL CONTRIBUTION 1. Elaboration of prothrombotic factors / substances : a. vWF- platelet binding co-factor b. extrinsic tissue factor- activates extrinsic clotting pathway c. Plasminogen activators inhibitors – inhibits fibrinolysis • Insulation of platelets from subendothelial collagen

  12. BLD VESSEL CONTRIBUTION Cont… • Elaboration of humoral factors ( endothelin)  vasoconstriction 4. Role of subendothelial collagen

  13. BLOOD VESSEL WALL CONTRIBUTION (Cont..) • Elaboration of anti-thrombotic substance a. Plt aggregator inhibitors: prostacyclin , ADPase , NO b. Anti-thrombin inhibitors : thrombomodulin, heparin like molecule c. Fibrinolytic : t-PA

  14. PLATELET ROLE IN HEMOSTASIS: • Formation of Io hemostatic plug A. Platelet adhesion - attachment to site of injury and exposed collagen - needs vWF to bridge platelet and collagen

  15. PLATELET ROLE (cont..) • Platelet secretion and release Alpha granules Dense bodies - fibrinogen - ADP - fibronectin - Ca - PDGF - histamine - PF4 - serotonin

  16. PLATELET ROLE (cont..) • Platelet aggregation ( platelet to platelet interaction ) - formation of temporary ( primary ) hemostatic plug - stimulated by ADP, TXA2 thrombin

  17. PLATELET ROLE (cont..) 4. Platelet contraction • viscous metamorphosis • formation of secondary hemostatic plug • mediated by octomyosin

  18. ROLE OF COAGULATION SYSTEM IN HEMOSTASIS • conversion of thrombin to fibrinogen and formation of fibrin  thrombus • may be stimulated by extrinsic and intrinsic pathway

  19. ANTI-CLOTTING MECHANISM • Depletion of clotting factors • Clearance of CF by liver • Fibrinolysis : plasmin and plasminogen • Proteases • Anti-thrombin

  20. THROMBOSIS : PREDISPOSING FACTORS • INJURY TO ENDOTHELIUM • ALTERATION IN NORMAL BLOOD FLOW • ALTERATION IN THE BLOOD ( hypercoagulable state )

  21. Endothelial Injury : • Acute Myocardial Infarction • Atherosclerosis • Cigarette smoking • Vasculitis • Hypertension • Hypercholesterolemia

  22. Alterations in blood flow • Stasis • Aneurysm • Valvular stenosis / regurgitation • Vascular obstructions

  23. Hypercoagulability • Immobilization • Malignancy • APAS • DIC • Nephrotic syndrome • Oral contraceptive use

  24. THROMBUS : Morphology • Endothelial wall attachments • Gross and microscopic laminations ( LINES OF ZAHN ) • Compositions : laminated platelets, fibrin, RBC and WBC

  25. ENDOTHELIAL ATTACHMENT THROMBUS

  26. ENDOTHELIAL ATTACHMENT W/ RBC , PLT , FIBRIN

  27. THROMBUS : LINES OF ZAHN

  28. 2 1 LINES OF ZAHN

  29. THROMBUS : COMPONENTS OF LAYERS 1 – Pale areas( fibrin/platelets ) 2- Red areas ( RBC,WBC , fibrin )

  30. THROMBUS : COMPONENTS OF LAYERS 1 – Pale areas( fibrin/platelets ) 2- Red areas ( RBC,WBC , fibrin )

  31. THROMBUS : Morphology TYPES OF THROMBI : • Mural thrombus • Vegetations • Arterial / occlusive / white or conglutination thrombi • Venous/phlebothrombosi/ red or coagulative thrombi

  32. MURAL THROMBUS

  33. MURAL THROMBUS

  34. MURAL THROMBUS

  35. MURAL THROMBUS

  36. ENDOCARDIALTHROMBOTIC VEGETATION

  37. THROMBUS VALVE

  38. ARTERIAL / OCCLUSIVE THROMBUS

  39. ARTERIAL THROMBUS

  40. ARTERIAL THROMBUS , RECENT , OCCLUSIVE

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