Chapter 16 Vascular Physiology Flashcards
What surround veins and drain interstitial fluid?
lymphatic ducts
What drain into thoracic duct?
lower extremities and left thorax
What drain into right lymphatic duct?
head, neck, right thorax
What is the presentation of SVC Superior Venous Cava Syndrome?
swollen head and neck
unilateral ankle swelling?
DVT until ruled otherwise
bilateral ankle swelling?
right-sided heart failure
What lab value goes up with clots in body?
D-dimer
What radiographic test done for DVT?
Doppler ultrasound
What is Virchow’s triad?
cause of clotting: hypercoagulability, stasis, endothelial injury
Tx for DVT?
heparin
1 Cause venous clots?
stasis
1 cause arterial clots?
endothelial injury
Tx arterial clots
aspirin
Homan’s sign
calf pain upon dorsiflexion
How do veins constrict before arteries?
vessel constriction via norepinephrine (main neurotransmitter of ANS); NE has more affinity for alpha 1 receptors; veins have more alpha 1 receptors
When body loses volume, which is first to constrict, veins or arteries?
veins! always first before arteries
Poor perfusion of skin signs
- poor capillary refill
- cool extremities
- mottled appearance (lentigo reticularis)
Which vessels have greatest surface area and greatest diffusion?
capillaries
Explain Fick’s equation
In capillaries there is hydrostatic pressure pushing out of vessel and oncotic pressure pulling water and proteins into the capillary while the interstitium surrounding the capillary has hydrostatic pressure pushing fluids into capillaries and oncotic pressure pulling fluids out of the capillaries. There is usually a balance, but if the balance is interrupted (i.e. low albumin in the blood), the oncotic pressure inside will be less than the oncotic pressure in intersitium and proteins and fluid will be pulled more into the interstitium ; that is edema.
Which second messengers work in the veins?
veins, alpha 1 receptors, 2nd messenger IP3/DAG, causing constriction
Which second messengers work in the arteries?
beta 2, cAMP, causing dilation
plasma proteins usually don’t leak out of vessels, why not?
heparan sulfate provides a negative charge in the BM that repel negatively charged plasma proteins
What is transudate?
transudate is effusion that is mostly water; due to CHF, renal failure or hypothyroidism
What is exudate?
exudate is effusion that is mostly protein ( greater than 0.5 protein or LDH greater than 0.6 ) caused by purulent, granulomatous, caseous infections; always pathological
The epithelium of aorta is lined by which cells?
stratified squamous
What is the blood supply of the aorta?
vaso vasorum
Monckeberg’s Arteriosclerosis cause
As we get older, vaso vasorum undergoes atherosclerosis, calcifies and dies. The aorta does not have much blood supply and cannot maintain its stratified squamous epithelium. Calcifcations can be seen in the walls of the aorta (not the lumen); physiological response to aging. Loss of epithelial layers will expose underlying smooth muscle to RBC and cause aneurysms and dissections.
causes of aneurysms early in life
syphilis, takayasu, collagen dis., basement membrane dis.
aortic aneurysm Type A
ascending aorta dissection usually from collagen dis. like Marfan’s
aortic aneurysm Type B
descending usually caused by HTN ; usually no surgery, can be controlled with BB, lower BP
Which organs have resistance in series (have to filtrate)
Liver, Kidney, spleen, lung, placenta
If you take out one of the organs that have parallel (with heart), what will happen to blood pressure?
BP will go up (that’s why have to control BP after eclampsia when the placenta is removed)
when does the heart receive blood from coronary arteries?
in diastole
What happens to coronary artery flow if the heart rate is high?
time in diastole is very short and not enough blood can get to the heart; could result in MI
What is the difference between oxygen in artery and its vein
A-V O2 difference
Which organ always has lowest A-V O2 difference?
kidney
Which one has the greatest A-V O2 difference after eating?
GI system
Which organ has the greatest A-V O2 difference after exercise?
skeletal muscle
What does it mean if AV O2 difference increases?
less O2 on venous side, tissue more metabolically active or there was less blood flow into the tissue, forcing it to extract more
What does it mean if AVO2 difference decreases?
more O2 on venous side, tissue less metabolically active; or more blood flow into the tissue
What does it mean if AVO2 difference very low?
blood never reached tissue (shunting)
normal AVO2 difference?
25-40%
example of iatrogenic AV shunt?
guide-wire pokes through vein to artery; dialysis fistula; Blalock-Taussig shunt (descending aorta to pulmonary artery)
example of congenital AVM shunt?
PDA; AVM; Osler-Weber-Rendu (multiple AVMs); Von-Hippel-Lindau multiple AVM in abdomen and brain
example of traumatic AV Shunt
stab wound
If you cut a vessels radius in half, what happens to resistance?
It goes up r to the 4 times
If you increase length of vessel, what happens to flow?
decreases
What does our body regulate first, resistance or pressure?
resistance
If you want to increase flow in the brain, what should you do?
increase PCO2, decrease PO2
If you want to increase flow in the lungs, what shouldyou do?
increase pO2
If you want to increase flow in the kidneys, what shouldyou do?
increase PGE2, increase dopamine, increase ANP (secubitril)
What does adenosine do?
opens up coronary arteries
What happens to your brain vessels in high altitudes?
pO2 decreases, cerebral vessels dilate, ICP rises
mechanism of migraines
vasoconstriction causes localized hypoxia; aura then rapid severe vasodilation causing increased contractility of hear, nausea and vomiting due to ICP increase; increased flow to eyes causing photosensitivity; increased flow to ears causing noise sensitivity
tx migraine
O2, sleep, sumatriptan (acute); propranolol (preventive)
definition of chronic migraine
more than 14 days in one month
What does it mean if CN X is inhibitory?
Increased firing of vagus nerve will lower HR.
lowering firing of vagus nerve will increase HR
Which autonomic center in brain controls NE and maintaining HR and BP when we stand?
nucleus tractus solitarius
What is it called when an elderly persons HR doesn’t go up when he stands?
Sick Sinus Syndrome
What can you give before nitrates to prevent excessive increase in HR after giving nitrates?
beta blocker
What is the normal physiologic response to hypovolemia?
increase HR
definition of orthostatic hypotension
systolic drops by more than 20; diastolic drops by more than 10; HR increases by more than 10
after 20 minutes of decreased blood flow, which part of body takes over in regulation of blood pressure?
JG apparatus releases renin–angiotensinogen–AT1, AT2, aldosterone
actions of AT2
- constricts efferent arteriole more than afferent arteriole; creates backup pressure in glomerulus and increases GFR
- Increases TPR (vasoconstricts arterioles)
- Stimulates ALDO (reabsorbs Na, Excretes K, Excretes H
- stimulates ADH (reabsorbs water along with urea in collecting duct);
- stimulates thirst center in brain
MCC of autonomic dysfunction in adults
diabetes
MCC of autonomic dysfunction in newborns
Riley-Day syndrome
MCC of autonomic dysfunction in Parkinson pt.
Shy-Drager Syndrome
MCC of autonomic dysfunction in elderly
Sick Sinus Syndrome (calcified carotid sinus)
low volume state with high Na
- diabetes insipidus
- elderly neglect (dehydration)
low volume state with low Na
- diarrhea 2. DKA 3. RTA type 2
Which two drugs cause nephrogenic DI?
- lithium 2.demeclocycline
most common cause of hyponatremia?
low volume state
most common cause of hypokalemia?
low volume state
most common cause of hypochloremia
low volume state
st common cause of high TPR?
low volume state
st common cause of metabolic alkalosis?
low volume state, can cause kidney stones
MOA AceI
dilate efferent blood vessels, lower GFR, raise serum creatinine slightly; increase bradykinin; decrease afterload and preload of heart; decreases proteinuria in diabetic nephropathy
Which ACEi doesn’t cause angioedema?
candesartan (because she is sweet!)
If you have sulfur allergy can you take ACEi or ARB?
ARB because many ACEi contain sulfur.
What is vasculitis?
cell mediated inflammation due to low energy state and low volume state; can see schistocytes, petechiae , purpura and ecchymoses
MC nephropathy in children?
Berger’s (IgA nephropathy); 2 weeks after URI
MC vasculitis in children?
HSP ; 2 weeks after gastroenteritis; only vasculitis with normal platelet count
Alport’s
X linked recessive, cataracts, hearing loss; type IV collagen; late onset renal failure
thromboangitis obliterans
Buerger’s: necrotic fingertips in smokers, necrotizing vasculitis
MCC of DIC
sepsis
sign of DIC
fibrin split products; high d-dimers;
tx of DIC
cryoprecipitate
MCC of renal failure in children?
HUS
MCC of HUS
E. Coli infection (raw hamburgers; petting zoo)
thrombotic thrombocytopenic purpura
VWF esterase deficiency (ADAM TS13)
tx of TTP
plasmapheresis
syphilitic aortitis
attacks vaso vasorum; wrinkled tree-bark appearance
Granulomatous attack on aortic arch with weak pulses in Asian female
Takayasu
mucocutaneous lymph node disease in children: inflammed mucosal surface (strawberry tongue), red rash involving palms and soles; diffuse cervical lymph nodes; high fever more than 3 days
Kawasaki’s
Kawasaki’s is the only vasculitis with high platelet count; what is the tx
aspirin daily for 2 years; flu shot yearly while on aspirin
8 diseases that have rashes involving palms and soles (True RoCK SStarSS)
Toxic Shock Syndrome
Rocky Mountain Spotted Fever
Coxsackie A
Kawasaki
Scarlet Fever
Staph Scalded Skin Syndrome
Syphilis
Streptobacilli’s moniiformis
tx for temporal arteritis
high dose steroids right away!
TX for Ankylosing Spondylitis
- NSAIDS
- TNF drugs (once you see deposition in joints)
Name 3 HLA B27 diseases
Ankylosing Spondylitis; Psoriatic Arthritis; Reiter’s Syndrome
What is Reiter’s Syndrome?
post infectious reactive arthritis: conjuctivitis, urethritis, arthritis
TX for Reiter’s
treat infection; NSAIDs for arthritis
If psoriatic pt. has HTN which medicine should you NOT give?
Beta Blockers because decrease perfusion to skin will worsen psoriasis
Which vitamin should you give psoriatic pts because they have high cell turnover?
B9
What is PAN polyarthritis nodosa?
medium-sized artery vasculitis (blood in stool, blood in urine); does not involve lungs; assoc. with HEP B
What vasculitis involves sinus, lungs, and kidneys?
Granulomatitis with polyangitis
What vasculitis involves anti-glomerular basement membrane; lungs and kidneys involved
Goodpasture’s
What category of renal dysfunction is Goodpastures?
RPGN (crescent formation)
What does Goodpastures look like on EM?
linear immunofluorescence
Sudden severe asthma in young adult; P-ANCA +; eosinophils
Churg Strauss also called (EGPA Eosinophilic granulomatosis with polyangitis)
3 Pulmonary Infiltrates with Eosinophilia (PIE Syndromes)
- Churg-Strauss Syndrome
- Aspergillosis
- Loeffler’s Syndrom (due to parasites)
(Necator Americanus, Ascaris lumbricoides, Strongyloidiasis; schistosomiasis; Ancylostoma duodenale
CREST syndrome
Calcinosis
Raynaud’s
Esophageal dysmotility and scarring
Sclerodactyly
Telangectasias
antibody associated with CREST
anti-centromere antibody
antibody associated with scleroderma
anti-smooth muscle antibody; anti SCL70
most severe form of scleroderma
Progressive Systemic Sclerosis
What antibody is involved in Progressive Systemic Sclerosis?
anti-topoisomerase antibody
What disease is caused by anti RNP (ribonucleoprotein) antibodies?
Mixed Connective Tissue Disease (combination of several collagen vascular diseases such as CREST, Scleroderma, RA, etc.
What is rheumatoid factor?
antibody against Fc portion of IgG
What test for RA is most sensitive?
Anti-CCP (citrullinated plasma protein)
What is the only arthritis that affects the joint lining (synovium, pannus)?
RA
TX of RA
- Methotrexate
- within 90 days add TNF inhibitor (etanercept, imatinib)
- follow this treatment at least 2 years+
What is Felty’s Syndrome?
RA with leukopenia and splenomegaly
What is Behcet’s Syndrome?
RA with GI and GU ulcers and uveitis
What is Sjorgen’s Syndrome?
RA with xerostomia, xerophthalmia (dry mouth and dry eyes)
What antibodies are positive in Sjorgen’s?
Anti-Ro, Anti- La, SSA &SSB antibodies
Which marker will show a more severe disease in Juvenile Idiopathic Arthritis?
RF +
complication of JIA and prevention?
blindness; see ophthalmologist yearly
PSGN, Serum Sickness, SBE, SLE, membranoproliferative glomerular nephritis, and cryoglobinemia are what kind of collagen vascular diseases?
with low complement
When does PSGN occur?
2 weeks after ASO + pharyngitis
What does PSGN look like on renal EM?
sub-epithelial humps
What may cause Serum sickness?
vaccinations, MC MMR vaccination
Roth spots, Osler nodes, Janeway lesions
Sub bacterial endocarditis (SBE)
SBE caused by which bacteria?
strept viridans
anti-dsDAN, anti-Smith, anti-cardiolipin
SLE markers
MCC death SLE
renal failure
TX for lupus nephritis
mycophenolate
4 bad associations of cardiolipin antibody?
- stimulates intrinsic clotting system
- blocks vWF, causing vWF like disease
- multiple spontaneous abortions
- false + VDRL
tram trak appearance (split basement membrane) in kidney; type 1 normal complement, C3 nephritic factor; type 2 low complement, dense deposit disease
MPGN (membranoproliferative glomerular nephritis type 1, 2
cold agglutins (IgM)
cryoglobinemia
5 MC causes of cryoglobinemia
I AM HE
Influenza
Adenovirus
Mycoplasma
Hepititis B,C
EBV
warm antibody, bacterial, chronic inflammation
IgG
