General Principles of Pathophysiology Energy Metabolism PerfusionShock PerfusionShock.

General Principles of General Principles of PathophysiologyPathophysiologyGeneral Principles of General Principles of PathophysiologyPathophysiology

Energy MetabolismEnergy Metabolism

PerfusionPerfusion

ShockShock

Energy MetabolismEnergy Metabolism

PerfusionPerfusion

ShockShock

TopicsTopicsTopicsTopics

Define shock in terms of cellular Define shock in terms of cellular functionfunction

Review the requirements for adequate Review the requirements for adequate cellular perfusion (Fick principle)cellular perfusion (Fick principle)

Review the mechanisms for starling’s Review the mechanisms for starling’s lawlawPreload vs. afterloadPreload vs. afterloadMuscle contractionMuscle contraction

Define shock in terms of cellular Define shock in terms of cellular functionfunction

Review the requirements for adequate Review the requirements for adequate cellular perfusion (Fick principle)cellular perfusion (Fick principle)

Review the mechanisms for starling’s Review the mechanisms for starling’s lawlawPreload vs. afterloadPreload vs. afterloadMuscle contractionMuscle contraction

Topics ContinuedTopics ContinuedTopics ContinuedTopics Continued

Discuss the mechanisms for oxygen Discuss the mechanisms for oxygen transporttransportoxyhemoglobin dissociation curveoxyhemoglobin dissociation curve

Define the stages of shockDefine the stages of shock Describe different causes of shockDescribe different causes of shock Define multiple organ dysfunction Define multiple organ dysfunction

syndromesyndrome

Discuss the mechanisms for oxygen Discuss the mechanisms for oxygen transporttransportoxyhemoglobin dissociation curveoxyhemoglobin dissociation curve

Define the stages of shockDefine the stages of shock Describe different causes of shockDescribe different causes of shock Define multiple organ dysfunction Define multiple organ dysfunction

syndromesyndrome

Shock DefinedShock DefinedShock DefinedShock Defined

Inadequate tissue perfusionInadequate tissue perfusion Anaerobic metabolismAnaerobic metabolism

Inadequate tissue perfusionInadequate tissue perfusion Anaerobic metabolismAnaerobic metabolism

Final Common Pathway!Final Common Pathway!Final Common Pathway!Final Common Pathway!

Aerobic MetabolismAerobic MetabolismAerobic MetabolismAerobic Metabolism

6 O2

GLUCOSE

METABOLISM

6 CO2

6 H2O

36 ATP

HEAT (417 kcal)

Anaerobic MetabolismAnaerobic MetabolismAnaerobic MetabolismAnaerobic Metabolism

GLUCOSE METABOLISM

2 LACTIC ACID

2 ATP

HEAT (32 kcal)

Anaerobic? So What?Anaerobic? So What?Anaerobic? So What?Anaerobic? So What?

InadequateInadequateCellularCellular

OxygenationOxygenation

InadequateInadequateCellularCellular

OxygenationOxygenation

AnaerobicAnaerobicMetabolismMetabolism

AnaerobicAnaerobicMetabolismMetabolism

MetabolicMetabolicFailureFailure

MetabolicMetabolicFailureFailure

MetabolicMetabolicAcidosisAcidosis

MetabolicMetabolicAcidosisAcidosis

InadequateInadequateEnergyEnergy

ProductionProduction

InadequateInadequateEnergyEnergy

ProductionProduction

Lactic AcidLactic AcidProductionProduction

Lactic AcidLactic AcidProductionProduction

Cell Death!Cell Death!Cell Death!Cell Death!

Homeostasis is maintenance of Homeostasis is maintenance of balancebalanceHomeostasis is maintenance of Homeostasis is maintenance of balancebalance

Requires proper functioning systemsRequires proper functioning systemsCardiovascularCardiovascularRespiratoryRespiratoryRenalRenal

Requires proper functioning systemsRequires proper functioning systemsCardiovascularCardiovascularRespiratoryRespiratoryRenalRenal

Physiology of PerfusionPhysiology of PerfusionPhysiology of PerfusionPhysiology of Perfusion

Dependant on 3 components of Dependant on 3 components of circulatory systemcirculatory systemPumpPumpFluidFluidContainerContainer

Dependant on 3 components of Dependant on 3 components of circulatory systemcirculatory systemPumpPumpFluidFluidContainerContainer

Factors Affecting The PumpFactors Affecting The PumpFactors Affecting The PumpFactors Affecting The Pump

PreloadPreload Contractile forceContractile force

Frank-starling mechanismFrank-starling mechanism AfterloadAfterload

PreloadPreload Contractile forceContractile force

Frank-starling mechanismFrank-starling mechanism AfterloadAfterload

Muscle AnatomyMuscle AnatomyMuscle AnatomyMuscle Anatomy

Contraction: Sliding FilamentsContraction: Sliding FilamentsContraction: Sliding FilamentsContraction: Sliding Filaments

image from: http://www.accessexcellence.com/AB/GG/muscle_Contract.html

What Is Blood Pressure?What Is Blood Pressure?What Is Blood Pressure?What Is Blood Pressure?

BP = Cardiac Output BP = Cardiac Output X Systemic Vascular ResistanceX Systemic Vascular Resistance

BP = Cardiac Output BP = Cardiac Output X Systemic Vascular ResistanceX Systemic Vascular Resistance

CO = Stroke VolumeCO = Stroke VolumeX Heart RateX Heart Rate

CO = Stroke VolumeCO = Stroke VolumeX Heart RateX Heart Rate

What Affects Blood Pressure?What Affects Blood Pressure?What Affects Blood Pressure?What Affects Blood Pressure?

ANS balanceANS balance ContractilityContractility

PreloadPreloadStarling’s lawStarling’s law

AfterloadAfterload

ANS balanceANS balance ContractilityContractility

PreloadPreloadStarling’s lawStarling’s law

AfterloadAfterload

Autonomic Nervous System Autonomic Nervous System Review…Review…Autonomic Nervous System Autonomic Nervous System Review…Review…

Quiz Time! Yeah!Quiz Time! Yeah!Quiz Time! Yeah!Quiz Time! Yeah!

JeopardyJeopardyJeopardyJeopardy

Controls vegetative functions,exits the Controls vegetative functions,exits the CNS at high in the neck and low in the CNS at high in the neck and low in the back.back.

Controls vegetative functions,exits the Controls vegetative functions,exits the CNS at high in the neck and low in the CNS at high in the neck and low in the back.back.

What is the What is the parasympathetic nervous system?parasympathetic nervous system?

What is the What is the parasympathetic nervous system?parasympathetic nervous system?


The chief neurotransmitter of the The chief neurotransmitter of the sympathetic nervous system.sympathetic nervous system.

The chief neurotransmitter of the The chief neurotransmitter of the sympathetic nervous system.sympathetic nervous system.

What is What is Norepinephrine?Norepinephrine?

What is What is Norepinephrine?Norepinephrine?


The ‘cutesy’ name for the The ‘cutesy’ name for the parasympathetic nervous system.parasympathetic nervous system.

The ‘cutesy’ name for the The ‘cutesy’ name for the parasympathetic nervous system.parasympathetic nervous system.

What is What is ‘‘Feed or Breed’?Feed or Breed’?

What is What is ‘‘Feed or Breed’?Feed or Breed’?


Two types of parasympathetic receptors.Two types of parasympathetic receptors.Two types of parasympathetic receptors.Two types of parasympathetic receptors.

What is nicotinic (NMJ)What is nicotinic (NMJ)and muscarinic (organs)?and muscarinic (organs)?What is nicotinic (NMJ)What is nicotinic (NMJ)and muscarinic (organs)?and muscarinic (organs)?


Two types classes of sympathetic Two types classes of sympathetic receptors.receptors.

Two types classes of sympathetic Two types classes of sympathetic receptors.receptors.

What is What is alpha and beta?alpha and beta?

What is What is alpha and beta?alpha and beta?


The ‘cutesy name’ for the sympathetic The ‘cutesy name’ for the sympathetic nervous system.nervous system.

The ‘cutesy name’ for the sympathetic The ‘cutesy name’ for the sympathetic nervous system.nervous system.

What is What is ‘‘fight or flight’?fight or flight’?

What is What is ‘‘fight or flight’?fight or flight’?


Stimulation of this receptor causes an Stimulation of this receptor causes an increase in peripheral vasoconstriction.increase in peripheral vasoconstriction.

Stimulation of this receptor causes an Stimulation of this receptor causes an increase in peripheral vasoconstriction.increase in peripheral vasoconstriction.

What is alpha 1?What is alpha 1?What is alpha 1?What is alpha 1?


Stimulation of this receptor causes an Stimulation of this receptor causes an increase in myocardial contractility.increase in myocardial contractility.

Stimulation of this receptor causes an Stimulation of this receptor causes an increase in myocardial contractility.increase in myocardial contractility.

What is beta 1?What is beta 1?What is beta 1?What is beta 1?


Stimulation of this receptor causes an Stimulation of this receptor causes an increase in bronchodilation.increase in bronchodilation.

Stimulation of this receptor causes an Stimulation of this receptor causes an increase in bronchodilation.increase in bronchodilation.

What is beta 2?What is beta 2?What is beta 2?What is beta 2?


Stimulation of this receptor causes a Stimulation of this receptor causes a decrease in the sympathetic activation.decrease in the sympathetic activation.

Stimulation of this receptor causes a Stimulation of this receptor causes a decrease in the sympathetic activation.decrease in the sympathetic activation.

What is alpha 2?What is alpha 2?What is alpha 2?What is alpha 2?


Two types of parasympathetic receptors.Two types of parasympathetic receptors.Two types of parasympathetic receptors.Two types of parasympathetic receptors.

What is nicotinic (NMJ)What is nicotinic (NMJ)and muscarinic (organs).and muscarinic (organs).What is nicotinic (NMJ)What is nicotinic (NMJ)and muscarinic (organs).and muscarinic (organs).

Changes in Afterload and PreloadChanges in Afterload and PreloadChanges in Afterload and PreloadChanges in Afterload and Preload

Peripheral Peripheral vasoconstriction…vasoconstriction…

Peripheral Peripheral vasoconstriction…vasoconstriction…

peripheral vascular peripheral vascular resistance…resistance…


afterload…afterload… afterload…afterload…

blood pressure.blood pressure. blood pressure.blood pressure.


Peripheral Peripheral vasodilation…vasodilation…

Peripheral Peripheral vasodilation…vasodilation…



afterload…afterload… afterload…afterload…

blood pressure.blood pressure. blood pressure.blood pressure.


fluid volume…fluid volume… fluid volume…fluid volume…

preload…preload… preload…preload…

contractility contractility (Starling’s Law)…(Starling’s Law)…

contractility contractility (Starling’s Law)…(Starling’s Law)…

cardiac output.cardiac output. cardiac output.cardiac output. blood pressure.blood pressure. blood pressure.blood pressure.

FluidFluidFluidFluid

Must have adequate Must have adequate amounts of amounts of hemoglobinhemoglobin

Must have adequate Must have adequate intravascular volumeintravascular volume

Must have adequate Must have adequate amounts of amounts of hemoglobinhemoglobin

Must have adequate Must have adequate intravascular volumeintravascular volume

Maintenance of Fluid VolumeMaintenance of Fluid VolumeMaintenance of Fluid VolumeMaintenance of Fluid Volume

Renin-Angiotensin-Aldosterone system.Renin-Angiotensin-Aldosterone system.Works through kidneys to regulate balance Works through kidneys to regulate balance

of Naof Na++ and water. and water.

Renin-Angiotensin-Aldosterone system.Renin-Angiotensin-Aldosterone system.Works through kidneys to regulate balance Works through kidneys to regulate balance

of Naof Na++ and water. and water.

Renin-Angiotensin-AldosteroneRenin-Angiotensin-AldosteroneRenin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone

PlasmaPlasmavolumevolume

PlasmaPlasmavolumevolume

[Na+][Na+] [Na+][Na+]

KidneyKidney(juxtaglomerular(juxtaglomerular

apparatus)apparatus)

KidneyKidney(juxtaglomerular(juxtaglomerular

apparatus)apparatus)Detected by

Releases

ReninReninReninRenin

AngiotensinogenAngiotensin I…Angiotensin I…Angiotensin I…Angiotensin I…

Converts

&/Or

Via ACE(AngiotensinConvertingEnzyme)

Angiotensin II…Angiotensin II…Angiotensin II…Angiotensin II…

Renin-Angiotensin-AldosteroneRenin-Angiotensin-AldosteroneRenin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone

Angiotensin II…Angiotensin II…Angiotensin II…Angiotensin II…

vasoconstrictionvasoconstriction vasoconstrictionvasoconstriction PVRPVR PVRPVR

BP!BP! BP!BP!

thirstthirst thirstthirst

FluidFluidvolumevolume

FluidFluidvolumevolume

ADHADH(anti-diuretic(anti-diuretic

hormone)hormone)

ADHADH(anti-diuretic(anti-diuretic

hormone)hormone)

AdrenalAdrenalcortexcortex

AdrenalAdrenalcortexcortex

Releases

AldosteroneAldosteroneAldosteroneAldosteroneNa+Na+

reabsorptionreabsorption

Na+Na+reabsorptionreabsorption

HemostasisHemostasisHemostasisHemostasis

The stoppage of bleeding.The stoppage of bleeding. Three methodsThree methods

Vascular constrictionVascular constrictionPlatelet plug formationPlatelet plug formationCoagulationCoagulation

The stoppage of bleeding.The stoppage of bleeding. Three methodsThree methods

Vascular constrictionVascular constrictionPlatelet plug formationPlatelet plug formationCoagulationCoagulation

CoagulationCoagulationCoagulationCoagulation

Formation of blood clotsFormation of blood clots Prothrombin activatorProthrombin activator Prothrombin Prothrombin thrombin thrombin Fibrinogen Fibrinogen fibrin fibrin Clot retractionClot retraction

Formation of blood clotsFormation of blood clots Prothrombin activatorProthrombin activator Prothrombin Prothrombin thrombin thrombin Fibrinogen Fibrinogen fibrin fibrin Clot retractionClot retraction

FibrinolysisFibrinolysisFibrinolysisFibrinolysis

PlasminogenPlasminogen Tissue plasminogen activator (tPA)Tissue plasminogen activator (tPA) PlasminPlasmin

PlasminogenPlasminogen Tissue plasminogen activator (tPA)Tissue plasminogen activator (tPA) PlasminPlasmin

Disseminated Intravascular Disseminated Intravascular CoagulationCoagulationDisseminated Intravascular Disseminated Intravascular CoagulationCoagulation

““A systemic thrombohemorrhagic disorder A systemic thrombohemorrhagic disorder … with evidence of:… with evidence of:

1)1) Procoagulant activationProcoagulant activation

2)2) Fibrinolytic activationFibrinolytic activation

3)3) Inhibitor consumptionInhibitor consumption

4)4) End-organ failure”End-organ failure”

““A systemic thrombohemorrhagic disorder A systemic thrombohemorrhagic disorder … with evidence of:… with evidence of:

1)1) Procoagulant activationProcoagulant activation

2)2) Fibrinolytic activationFibrinolytic activation

3)3) Inhibitor consumptionInhibitor consumption

4)4) End-organ failure”End-organ failure”

Bick, R.L. Seminars in Thrombosis and Hemostasis 1996

Pathophysiology of DICPathophysiology of DICPathophysiology of DICPathophysiology of DIC

Uncontrolled acceleration of clotting Uncontrolled acceleration of clotting cascadecascade

Small vessel occlusionSmall vessel occlusion Organ necrosisOrgan necrosis Depletion of clotting factorsDepletion of clotting factors Activation of fibrinolysisActivation of fibrinolysis Ultimately severe systematic Ultimately severe systematic

hemorrhagehemorrhage

Uncontrolled acceleration of clotting Uncontrolled acceleration of clotting cascadecascade

Small vessel occlusionSmall vessel occlusion Organ necrosisOrgan necrosis Depletion of clotting factorsDepletion of clotting factors Activation of fibrinolysisActivation of fibrinolysis Ultimately severe systematic Ultimately severe systematic

hemorrhagehemorrhage

ContainerContainerContainerContainer

Vasculature is continuous, closed and Vasculature is continuous, closed and pressurized systempressurized system

Microcirculation responds to local tissue Microcirculation responds to local tissue needsneeds

Blood flow dependent on PVRBlood flow dependent on PVR

Vasculature is continuous, closed and Vasculature is continuous, closed and pressurized systempressurized system

Microcirculation responds to local tissue Microcirculation responds to local tissue needsneeds

Blood flow dependent on PVRBlood flow dependent on PVR

Fick PrincipleFick PrincipleFick PrincipleFick Principle

Effective movement and utilization of OEffective movement and utilization of O2 2

dependent on:dependent on:Adequate fioAdequate fio22

Appropriate OAppropriate O22 diffusion into bloodstream diffusion into bloodstream

Adequate number of RBCsAdequate number of RBCsProper tissue perfusionProper tissue perfusionEfficient hemoglobin ‘loading’Efficient hemoglobin ‘loading’

Effective movement and utilization of OEffective movement and utilization of O2 2

dependent on:dependent on:Adequate fioAdequate fio22

Appropriate OAppropriate O22 diffusion into bloodstream diffusion into bloodstream

Adequate number of RBCsAdequate number of RBCsProper tissue perfusionProper tissue perfusionEfficient hemoglobin ‘loading’Efficient hemoglobin ‘loading’

Fick PrincipleFick PrincipleFick PrincipleFick Principle

Perfusion = Arterial OPerfusion = Arterial O22 Content - Content -

Venous OVenous O22 Content Content Affected by:Affected by:

Hemoglobin levelsHemoglobin levelscirculation of RBCscirculation of RBCsdistance between alveoli and capillariesdistance between alveoli and capillariespH and temperaturepH and temperature

Perfusion = Arterial OPerfusion = Arterial O22 Content - Content -

Venous OVenous O22 Content Content Affected by:Affected by:

Hemoglobin levelsHemoglobin levelscirculation of RBCscirculation of RBCsdistance between alveoli and capillariesdistance between alveoli and capillariespH and temperaturepH and temperature

Onloading Oxygen in LungsOnloading Oxygen in LungsOnloading Oxygen in LungsOnloading Oxygen in Lungs

Pressure

Saturation

oxyhemeglobin

deoxyhemeglobin

pH 7.4

pH 7.45

pH shifts curve to pH shifts curve to leftleft ‘ ‘onloading’ in lungsonloading’ in lungs

pH shifts curve to pH shifts curve to leftleft ‘ ‘onloading’ in lungsonloading’ in lungs

Remember:Remember:COCO22 [H [H++]]


Offloading Oxygen in TissuesOffloading Oxygen in TissuesOffloading Oxygen in TissuesOffloading Oxygen in Tissues

Pressure

Saturation

oxyhemeglobin

deoxyhemeglobin

pH 7.4

pH 7.35

pH shifts curve to pH shifts curve to rightright ‘ ‘offloading’ to tissuesoffloading’ to tissues

pH shifts curve to pH shifts curve to rightright ‘ ‘offloading’ to tissuesoffloading’ to tissues



Causes of Inadequate PerfusionCauses of Inadequate PerfusionCauses of Inadequate PerfusionCauses of Inadequate Perfusion

Inadequate pumpInadequate pump Inadequate preloadInadequate preload Poor contractilityPoor contractility Excessive afterloadExcessive afterload Inadequate heart rateInadequate heart rate

Inadequate fluid volumeInadequate fluid volume HypovolemiaHypovolemia

Inadequate containerInadequate container Excessive dilationExcessive dilation Inadequate systematic vascular resistanceInadequate systematic vascular resistance

Inadequate pumpInadequate pump Inadequate preloadInadequate preload Poor contractilityPoor contractility Excessive afterloadExcessive afterload Inadequate heart rateInadequate heart rate

Inadequate fluid volumeInadequate fluid volume HypovolemiaHypovolemia

Inadequate containerInadequate container Excessive dilationExcessive dilation Inadequate systematic vascular resistanceInadequate systematic vascular resistance

Responses to ShockResponses to ShockResponses to ShockResponses to Shock

Normal compensation includes:Normal compensation includes:Progressive vasoconstrictionProgressive vasoconstrictionIncreased blood flow to major organsIncreased blood flow to major organsIncreased cardiac outputIncreased cardiac outputIncreased respiratory rate and volumeIncreased respiratory rate and volumeDecreased urine outputDecreased urine output

Normal compensation includes:Normal compensation includes:Progressive vasoconstrictionProgressive vasoconstrictionIncreased blood flow to major organsIncreased blood flow to major organsIncreased cardiac outputIncreased cardiac outputIncreased respiratory rate and volumeIncreased respiratory rate and volumeDecreased urine outputDecreased urine output

Cellular Response to ShockCellular Response to ShockCellular Response to ShockCellular Response to Shock

TissueTissueperfusionperfusion


NaNa++ Pump PumpFunctionFunction

NaNa++ Pump PumpFunctionFunction

ATPATPsynthesissynthesis

ATPATPsynthesissynthesis

AnaerobicAnaerobicmetabolismmetabolism

AnaerobicAnaerobicmetabolismmetabolism

Cellular edemaCellular edema Vascular volumeVascular volume

Cellular edemaCellular edema Vascular volumeVascular volume

Impaired cellularImpaired cellularmetabolismmetabolism

Impaired cellularImpaired cellularmetabolismmetabolism

OO22

useuse

OO22

useuse

Intracellular NaIntracellular Na++

& water& water

Intracellular NaIntracellular Na++

& water& water

Impaired Impaired glucose glucose

usageusage

Impaired Impaired glucose glucose

usageusage

Stimulation of Stimulation of clotting cascade & clotting cascade &

inflammatoryinflammatoryresponseresponse

Stimulation of Stimulation of clotting cascade & clotting cascade &

inflammatoryinflammatoryresponseresponse

Stages of ShockStages of ShockStages of ShockStages of Shock

CompensatedCompensated UncompensatedUncompensated IrreversibleIrreversible

CompensatedCompensated UncompensatedUncompensated IrreversibleIrreversible

Compensated ShockCompensated ShockCompensated ShockCompensated Shock

Defense mechanisms are successful in Defense mechanisms are successful in maintaining perfusionmaintaining perfusion

PresentationPresentationTachycardiaTachycardiaDecreased skin perfusionDecreased skin perfusionAltered mental statusAltered mental status

Defense mechanisms are successful in Defense mechanisms are successful in maintaining perfusionmaintaining perfusion

PresentationPresentationTachycardiaTachycardiaDecreased skin perfusionDecreased skin perfusionAltered mental statusAltered mental status

Uncompenstated ShockUncompenstated ShockUncompenstated ShockUncompenstated Shock

Defense mechanisms begin to failDefense mechanisms begin to fail PresentationPresentation

HypotensionHypotensionProlonged Cap refillProlonged Cap refillMarked increase in heart rateMarked increase in heart rateRapid, thready pulseRapid, thready pulseAgitation, restlessness, confusionAgitation, restlessness, confusion

Defense mechanisms begin to failDefense mechanisms begin to fail PresentationPresentation

HypotensionHypotensionProlonged Cap refillProlonged Cap refillMarked increase in heart rateMarked increase in heart rateRapid, thready pulseRapid, thready pulseAgitation, restlessness, confusionAgitation, restlessness, confusion

Irreversible ShockIrreversible ShockIrreversible ShockIrreversible Shock

Complete failure of compensatory Complete failure of compensatory mechanismsmechanisms

Death even in presence of resuscitationDeath even in presence of resuscitation

Complete failure of compensatory Complete failure of compensatory mechanismsmechanisms

Death even in presence of resuscitationDeath even in presence of resuscitation

Types of ShockTypes of ShockTypes of ShockTypes of Shock

HypovolemicHypovolemic CardiogenicCardiogenic NeurogenicNeurogenic AnaphylacticAnaphylactic SepticSeptic

HypovolemicHypovolemic CardiogenicCardiogenic NeurogenicNeurogenic AnaphylacticAnaphylactic SepticSeptic

Hypovolemic ShockHypovolemic ShockHypovolemic ShockHypovolemic Shock

““Fluid failure”Fluid failure” Decreased intravascular volumeDecreased intravascular volume Causes?Causes? ““Third spacing”Third spacing”

““Fluid failure”Fluid failure” Decreased intravascular volumeDecreased intravascular volume Causes?Causes? ““Third spacing”Third spacing”

Cardiogenic ShockCardiogenic ShockCardiogenic ShockCardiogenic Shock

COCO COCOR.A.S.R.A.S.ActivationActivation

R.A.S.R.A.S.ActivationActivation

DyspneaDyspnea DyspneaDyspnea

OO22

supplysupply

OO22

supplysupply

Volume/Volume/PreloadPreload

Volume/Volume/PreloadPreload

SVRSVR SVRSVR

PeripheralPeripheral& pulmonary& pulmonary

edemaedema

PeripheralPeripheral& pulmonary& pulmonary

edemaedemaImpairedImpaired

myocardial functionmyocardial function

ImpairedImpairedmyocardial functionmyocardial function

MyocardialMyocardialOO22 demand demand

MyocardialMyocardialOO22 demand demand

CatecholamineCatecholamineReleaseRelease

CatecholamineCatecholamineReleaseRelease

Neurogenic ShockNeurogenic ShockNeurogenic ShockNeurogenic Shock

Sympathetic ToneSympathetic ToneOrOr

Parasympathetic ToneParasympathetic Tone

Sympathetic ToneSympathetic ToneOrOr

Parasympathetic ToneParasympathetic Tone

Vascular ToneVascular ToneVascular ToneVascular Tone

Massive VasodilationMassive VasodilationMassive VasodilationMassive Vasodilation

SVR & PreloadSVR & Preload SVR & PreloadSVR & Preload Cardiac OutputCardiac Output Cardiac OutputCardiac Output



Anaphylactic ShockAnaphylactic ShockAnaphylactic ShockAnaphylactic Shock

““Container failure”Container failure” Massive & systemic allergic reactionMassive & systemic allergic reaction Large release of histamineLarge release of histamine Increases membrane permeability & Increases membrane permeability &

vasodilationvasodilation

““Container failure”Container failure” Massive & systemic allergic reactionMassive & systemic allergic reaction Large release of histamineLarge release of histamine Increases membrane permeability & Increases membrane permeability &

vasodilationvasodilation

Septic ShockSeptic ShockSeptic ShockSeptic Shock

““Container failure”Container failure” Systemic infectionSystemic infection

““Container failure”Container failure” Systemic infectionSystemic infection

Multiple Organ Dysfunction Multiple Organ Dysfunction SystemSystemMultiple Organ Dysfunction Multiple Organ Dysfunction SystemSystem

Progressive dysfunction of two or more Progressive dysfunction of two or more organ systemsorgan systems

Caused by uncontrolled inflammatory Caused by uncontrolled inflammatory response to injury or illnessresponse to injury or illnessTypically sepsisTypically sepsis

Progressive dysfunction of two or more Progressive dysfunction of two or more organ systemsorgan systems

Caused by uncontrolled inflammatory Caused by uncontrolled inflammatory response to injury or illnessresponse to injury or illnessTypically sepsisTypically sepsis

ReferencesReferencesReferencesReferences

New York Presbyterian hospital hypertension center:New York Presbyterian hospital hypertension center: Http://pc101186.Med.Cornell.Http://pc101186.Med.Cornell.eduedu//htchomehtchome//htbkhtbk//HtbkindexHtbkindex..

htmhtm Biographics Gallery: Biographics Gallery: http://www.http://www.accessexcellenceaccessexcellence

.com/AB/GG/#Anchor-Building-11481.com/AB/GG/#Anchor-Building-11481 RAS (Renin-Angiotensin-Aldosterone System):RAS (Renin-Angiotensin-Aldosterone System):

http://www.science.mcmaster.ca/Biology/4S03/RAS.HTMhttp://www.science.mcmaster.ca/Biology/4S03/RAS.HTM A graduate student’s hypertension page:A graduate student’s hypertension page:

http://www.teaching-biomed.man.ac.uk/student_projects/2http://www.teaching-biomed.man.ac.uk/student_projects/2000/mnpm6ven/default.htm000/mnpm6ven/default.htm

New York Presbyterian hospital hypertension center:New York Presbyterian hospital hypertension center: Http://pc101186.Med.Cornell.Http://pc101186.Med.Cornell.eduedu//htchomehtchome//htbkhtbk//HtbkindexHtbkindex..

htmhtm Biographics Gallery: Biographics Gallery: http://www.http://www.accessexcellenceaccessexcellence

.com/AB/GG/#Anchor-Building-11481.com/AB/GG/#Anchor-Building-11481 RAS (Renin-Angiotensin-Aldosterone System):RAS (Renin-Angiotensin-Aldosterone System):

http://www.science.mcmaster.ca/Biology/4S03/RAS.HTMhttp://www.science.mcmaster.ca/Biology/4S03/RAS.HTM A graduate student’s hypertension page:A graduate student’s hypertension page:

http://www.teaching-biomed.man.ac.uk/student_projects/2http://www.teaching-biomed.man.ac.uk/student_projects/2000/mnpm6ven/default.htm000/mnpm6ven/default.htm

General Principles of Pathophysiology Energy Metabolism PerfusionShock PerfusionShock.

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