pathophys Flashcards
- General
etiology, pathogenesis, cellular mechanism, clinical, diagnostics, treatment, prognosis
- Health and disease
Health vs disease
noxas: physical, chemical, biological, psycho
reaction to noxa:
1. reaction - babinski sign
2. process
3. state
spreading: blood, lymph, neuro
- health and disease
stages:
1. incubation
2. prodromal - first nonspecific symptoms
3. manifestation - specific symptoms
4. outcome - healing/chronic/death
time course: acute/chronic - 6weeks
classification:
- recurrence, new, etc.
- health and disease
Pathogenesis = mechanism of origin, development and course of disease
- genes
1 single gene:
- cystic fibrosis (AR): CFTR, cl-
- sickle cell (AR): hemoglobin B
- achondroplasia (AD): dwarfism
1 chromosome:
- patau, edward, downs
- klinefelter (47XXY), turner (45XO)
multifactorial: hypertension, alzheimers
- inflammation
macroscopic:
- 5 cardinal signs: redness, swelling, heat, pain, function
microscopic:
- alteration
- excudation
- proliferation - specific/nonspecific granulation tissue (fibroblasts –> fibrotization)
mediators: histamines, cytokines, prostaglandins, leukotrienes
course:
- acute: healing with/without defect
- chronic
factors affecting inflammation: circulation, DM, drugs, nutrition
systemic aspects:
- fever, leukocytosis, CRP, fatigue, loss of appetitte
- hypersensitivity, autoimmunity, immunodeficiency
hypersensitivity:
- immediate - allergies –> IgE + basophils
- cytotoxic - autoimmune hemolytic anemia
–> antibody + antigen - immune complex - Arthus reaction
–> antibody + antigen - delayed - MS –> T-cells activated
- autoimmune - myasthenia gravis –> cell signaling
autoimmune:
1. local (organ-specific) - DM1, hashimoto, Crohn´s
2. systemic - scleroderma
immunodeficiency:
1. primary - genetic (B/T-cell deficiency)
2. secondary - acquired
- response to noxas
factors: hypoxia, chemicals, microorganisms,
mechanisms: metabolism, protein synthesis, plasma membrane
general body response:
- CNS + Endocrine system
stress:
- stages:
1. alarm stage: SNS + pituitary gland
2. fight/flight: hypothalamus-hypophysis-adrenal cortex
3. exhaustion: death
stressors: somatic + psychological
effects of catecholamines:
- SNS effects
- cortisol effects
stress-related diseases: hypertension, asthma, ulcers, eczema, DM, fatigue
- fluid + electrolytes
extracellular - 40%, Na+
intracellular - 20%, K+
Na/K ATPase
regulation:
thirst - osmolarity
ADH - kidneys
Na+ balance - RAAS
hypovolemia - RAAS/ADH
hypervolemia - edema
hypernatremia - 145mmol/L
hyponatremia - 135
hyperkalemia - 5.5mmol/L –> heart failure
hypokalemia - 3.5mmol/L
- fluid + electrolytes
- acid base
buffers:
bicarbonate
phosphate
hemoglobin
protein
- buffering
- respiration
- kidney
metabolic acidosis:
kussmaul breathing, hyperkalemia, vomiting
metabolic alkalosis:
tetany, hypokalemia, arrythmia
respiratory acidosis:
hypoventilation
respiratory alkalosis:
hyperventilation
- thermoregulation
low temp: thyroid hormones, SNS, shivering
high temp: sweating, SNS
fever - infection
hypothermia: under 35
frostbite - gangrene
hyperthermia: over 38,5
heat cramps/collapse
burns - blisters
large burns - distributive shock
- thermoregulation
- carbohydrate metabolism
primary:
glycogenosis
Von-Gierke - liver, glucose-6-phosphatase
Pompe - muscular
secondary:
DM
fructose - fructokinase + aldolase B
disaccharide deficiency
- diabetes mellitus
acute:
ketoacidosis -
hypoglycemia - 3,9mmol/L
coma
chronic: microangiopathy: nephropathy, retinopathy, neuropathy
macroangiopathy: peripheral vascular disease, diabetic foot (gangrene)
- pain
somatogenic
psychogenic
nociceptive
acute pain
chronic pain - 6 months
pain threshold
pain tolerance
pain - age: resistance with age
nociceptors
spino-thalamic
- obesity
tests: BMI, skin thickness
primary/secondary
hypertrophic/hyperplastic
risk: MI, DM, hypertension, hyperlipidemia
exogenous/endogenous factors:
childhood obesity
- anemia
men: 13,5 g/L
women: 12 g/L
symptoms:
microcytic, normocytic, macrocytic
RBC loss:
autoimmune hemolytic: immunoglobulins
hereditary spherocytosis:
sickle-cell disease:
glucose-6-phosphate dehydrogenase:
- anemia - hemoglobinopathies
- esophageal disorders
achalasia - no peristalsis, closed
diffuse esophageal spasm - hot/cold drinks
esophagitis - GERD/medication/allergies, ulcers/Barrets –> adenocarcinoma
tumors:
leiomyoma - benign
male 50 years
squamous cell carcinoma - 90%, middle esophagus
adenocarcinoma - distal esophagus, Barrets,
- gastritis
antacids
acute:
edema
chronic:
autoimmune - no HCl –> no B12
helicobacter pylori
adenocarcinoma:
intestinal - helicobacter pylori
diffuse - worse prognosis
males 70 years
dysplasia
chronic gastritis
- peptic ulcer disease
stomach - eating pain
duodenum - fasting pain
Helicobacter pylori
NSAIDs
Zollinger-Ellison - gastrinoma
stress, smoking, alcohol
hemorrhage
perforation
- malabsorption
digestion:
pancreas enzymes + cholestasis + lactase
absorption:
celiac - gluten attack
fat - steatorrhea
proteins/carbs - diarrhea
iron/B9/B12 - microcytic anemia
anemia, osteoporosis, neurological
- ileus
mechanical: adhesions, hernias, volvulus, IBD, intussusception
non-mechanical: paralysis, inflammation, hypothyroidism, electrolytes
pressure –> ischemia
- diverticular + inflammatory colon
diverticular disease:
true/false
sigmoid colon
hematochezia vs melena
diverticulitis
fiber
crohn´s:
all layers, not continual
ulcerative colitis:
inner layer, continual
- jaundice
prehepatic: hemolysis, malaria/transfusion, dark feces + normal urine
hepatic: Crigler-Najjar, pale feces + dark urine
posthepatic: pale feces, dark urine,
neonatal: low activity of conjugation, kernicterus,
- hepatitis + cirrhosis
hepatitis:
acute/chronic - 6 months
A - acute, benign, fecal-oral
B - chronic, vaccine, blood, cancer
C - chronic, no vaccine!, blood, cancer
D - need B,
E - fecal-oral, pregnancy
cirrhosis:
fibrotization
central veins + sinusoids
- portal hypertension
cirrhosis
esophagus - esophageal varices
rectum - hemorrhoids
round ligament - caput medusa
12mmHg
splenomegaly
ascites
–> hepatic encephalopathy
prehepatic - obstruction
intrahepatic - cirrhosis
posthepatic - Budd-Chiari
- cholecystitis + cholelithiasis
cholecystitis:
acute:
gallstone
bacteria –> peritonitis
chronic:
fibrotization –> porcelain gallbladder
cholelithiasis:
4F
cholesterol stones
bilirubin stones
- pancreatitis
acute:
gallstones, alcohol, trauma
- interstitial - only edema
- hemorrhagic - sepsis
lipase + amylase
ultrasound
atlanta classification
chronic:
gallstones, alcohol
no pancreatic juice –> maldigestion + DM
- mitral stenosis
mitral valve: LA –> LV
cause:
- rheumatic fever –> commissural fissure
what happens:
- concentric hypertrophy
- atrial fibrillation
- thrombus –> brain
symptoms:
- diastolic murmur
treatment:
- valve repair
- surgical replacement
- mitral regurgitation
mitral valve: 2 leaflets, LV –> LA
cause:
- chordae tendinae
- papillary muscles
what happens:
- eccentric hypertrophy
symptoms:
- systolic murmur
treatment:
- valve repair
- surgical replacement
- aortic stenosis
aortic valve: 3 leaflets, LV –> system
cause:
- chronic rheumatic fever
what happens:
- concentric hypertrophy
symptoms:
- systolic murmur
- microangiopathic hemolytic anemia
treatment: surgical replacement
- aortic regurgitation
aortic valve: 3 leaflets, system –> LV
cause:
- 50% aortic root dilation
- dissection, aneurysm
- infective endocarditis
- chronic rheumatic fever
what happens:
- eccentric hypertrophy
symptoms:
- diastolic murmur
treatment: surgical replacement
- tricuspid disease + pulmonary valve disease
valve: 3 leaflets
tricuspid regurgitation:
- eccentric hypertrophy
- distended jugular veins
- peripheral edema
- hepatosplenomegaly
tricuspid stenosis:
- rheumatic fever –> fibrotization
- arrythmia risk (pacemaker cells stretched)
pulmonary stenosis:
- concentric hypertrophy
- microangiopathic hemolytic anemia
pulmonary regurgitation:
- eccentric hypertrophy
- infective endocarditis
- rheumatic heart disease
- circulatory shock
hypovolemic:
- non-hemorrhagic
- hemorrhagic
cardiogenic:
- cardiac tamponade
- endocarditis
obstructive shock:
- tamponade
- pulmonary embolism
- pneumothorax
distributive shock:
- septic shock: mast cells –> histamine
- anaphylactic shock: mast cells –> histamine
- neurogenic: spinal cord
- vasogenic: medicine
stages:
1. non-progressive
2. progressive
heart, kidneys, GIT, brain, lungs, liver:
- necrosis
- circulatory shock
- circulatory shock
- ischemic heart disease
causes:
- atherosclerosis
- vasculitis = kawasaki
- heart hypertrophy
risk factors:
- genetics
- LDL
- hypertension
- smoking
- DM
presentation:
- stable angina
- prinzmetal angina: smoking/alcohol
acute coronary syndrome:
- unstable angina
- STEMI
- NSTEMI
symptoms:
1. first 24 hours: coagulative necrosis, arrythimas, tachycardia, fibrillation, cardiogenic shock
- 1-3 days: neutrophils + fibrinous pericarditis
- 3-14 days: macrophages + granulation tissue
- 2 weeks: fibrotic tissue + angiogenesis
- ischemic heart disease
- ischemic heart disease
- acute/subacute/chronic MI
right coronary: posterior + basal
left anterior descending: anterior + apical
left circumflex: lateral
mechanical dysfunction:
- contraction
- myocardial rupture
- pericarditis
- aneurysm
- congestive heart failure
blood –> lungs
systolic heart failure:
- high volume, low stroke = below 40%
diastolic heart failure:
left-sided heart failure:
- stiffer myocardium
- lungs auscultation + dyspnea
right-sided heart failure:
- cor pulmonale
- blood –> system
- jugular distention, edema, hepatosplenomegaly, ascites
- dysrrythmias - normal/abnormal automaticity
normal automaticity:
1. sinus bradycardia - 60bpm
2. sinus tachycardia - 100bpm
3. sinus arythmias - breathing
abnormal automaticity:
1. ectopic beats - premature beats + extra beats
2. atrial fibrillation - ectopic foci –> chaos
3. ventricular tachycardia -
4. ventricular fibrillation - cardiac arrest
5. wandering pacemaker - multifocal atrial tachycardia, irregular rhytm
6. sick sinus syndrome - delayed or no PQRST
- dysrrhytmias - conduction
paroxysmal supraventricular tachycardia - 150-200bpm
AV node reentral tachycardia: 120-250bpm, narrow QRS
Wolf-Parkinson-White: extra conduction pathways, ventricles pre-excitation
SA block:
- degree 1: no clinical manifestation
- degree 2: no PQRST + 2x PP loss
- degree 3: sudden loss of P then QRST
AV block: length of PQ
- no or decreased conduction
- degree 1 and 2: Mobitz type 1/2
- degree 3: full block
- dysrrythmias - escape beats
escape beat = ectopic foci
premature beat = premature
atrial/AV/ventricular escape beat:
- atrial: P wave different, QRS narrow, 60bpm
- AV: no P wave, QRS narrow, 40-60bpm
- ventricular: no P wave, QRS wide, 25-40bpm
premature atrial/AV/ventricular beat:
- atrial: earlier abnormal P wave
- AV: no P, normal QRS
- ventricular: QRS wide, purkinje fibers
ventricular tachycardia:
ventricular flutter: 250-350bpm, between tachycardia and fibrillation
ventricular fibrillation: cardiac arrest
- atrial flutter + fibrillation
atrial flutter:
- 1 ectopic focus
- sawtooth
- sometimes through AV node –> QRS
- normal ventricles
atrial fibrillation:
- 2 ectopic foci
- irregular rhythm
- sometimes through AV node –> QRS
- irregular, normal QRS
- inherited heart disease - shunts
right to left shunt:
persistent truncus arteriosus
transposition of great vessels
tetralogy of fallot - ventricle septum
total anomalous pulmonary venous return
tricuspid atresia
left to right shunt:
ventricular septum defect
atrial septum defect
patent ductus arteriosus
coarctation of aorta
- silent ischemic heart disease -
type 1,2,3
first 24 hours:
1-3days: fibrinous pericarditis
3-14days: macrophages, granulation tissue
2weeks: fibrotic tissue, angiogenesis
dysfunction:
contraction, rupture, pericarditis, aneurysm
- circulation
hyperemia: red, temperature, cyanosis,
arterial - dilation
peristaltic -
venous - obturation
hemorrhage:
hypovolemia - class 1-4: 15%, 30%, 40%
thrombosis:
coagulative-thrombolytic factors
Virschow´s triad: blood flow + vessel + blood composition
thrombi:
red, white, mixed (bead, layered), hyaline (hyaline + thrombocytes)
ATH:
tunica intima
smoking, hyperlipidemia, obesity, lifestyle
- thromboembolism
deep venous thrombosis:
endothelium, vasoconstriction, collagen + tissue factors, platelet plug, fibrin mesh, pulmonary embolism, Homan´s sign positive, virchow´s triad
postthrombotic syndrome:
chronic pain, swelling, redness, ulcers
- systemic hypertension
acute:
180/120, pheochromocytoma, hypertensive crisis
chronic:
140/90
primary: obesity + stress + age,
secondary: kidneys, cushing syndrome, pregnancy
complications: heart, brain, eye, kidney
- systemic hypertension
- systemic hypotension
acute
chronic
circulatory collapse:
SNS + adrenal gland + emotions + stress
shock:
hypovolemic:
non-hemorrhagic + hemorrhagic
cardiogenic:
MI + cardiac tamponade
distributive = vasodilation:
septic shock
anaphylactic shock
neurogenic shock
syncope: loss of consciousness
- symptoms of respiratory disease
cough:
3 weeks -
3months/2years: chronic bronchitis
sputum:
100ml
hemoptysis:
chest pain - pleural inflammation
digital clubbing - heart failure (bronchiectasis)
cyanosis - central/peripheral
hypo/hypercapnia: 45mmHg
- obstructive disorders
test:
FEV1 and FVC1
COPD:
chronic bronchitis - mucus
emphysema - elasticity
asthma - inflammation
bronchiectasis - dilated bronchi
- restrictive disorders
= decreased total lung capacity
pneumoconiosis
sarcoidosis - granuloma, giant cells with fibroblasts
hypersensitivity pneumonitis
extrapulmonary: obesity, myasthenia gravis
idiopathic pulmonary fibrosis:
- ventilation disorders
obstructive:
COPD, asthma, bronchiectasis
restrictive:
pneumoconiosis, sarcoidosis
- lung circulation disturbances
pulmonary hypertension: 25mmHg
pulmonary embolus:
dead space in lung perfusion
–> respiratory alkalosis
pulmonary edema:
cardiogenic - left heart failure
non-cardiogenic - bacteria, trauma, low proteins
- regulation of breathing
control system:
medulla oblongata, aortic bodies, carotid sinus
CNS disorders - trauma, ALS
neuromuscular - myasthenia gravis
respiratory system - COPD, asthma
sleep apnea
cheyne-stokes respiration:
deeper –> gradual stop –> apnea
Biot´s respiration:
quick + shallow –> pons trauma + opioids
sleep apnea - obstructive/central
- ventilation disturbances
ventilation/perfusion ratio = V/Q
apex/base?
alveolar dead space + pulmonary shunt + V/Q mismatch
low V/Q - chronic bronchitis, asthma, acute pulmonary edema
high V/Q - embolism, emphysema
- respiratory failure
acute:
obstruction, lung injury, stroke
hypoxemic, hypercapnic, respiratory acidosis
sweat, anxiety, heart pump, arrythmia
chronic:
COPD, cystic fibrosis, neuromuscular, obesity, pneumonia
acute respiratory distress syndrome:
sepsis, aspiration, trauma –> inflammation
toxic agents + ROS + hyaline membrane
- tests - obstructive
spirometry - FEV1, FVC
plethysmography
classifications:
residual volume - up
FRC - up
FEV1 - down
FVC - down
chronic bronchitis + emphysema + asthma + bronchiectasis
- tests - restrictive
spirometry - FEV1, FVC
plethysmography
total lung capacity - down
FVC - up
FEV - up
- chronic bronchitis + emphysema
chronic bronchitis: blue bloaters
mucus
emphysema: pink puffers
elasticity
centro-acinar - smoking
pan-acinar - alpha1anti-trypsin
- asthma
inflammation + hypersensitivity
broncho-constriction –> narrowing - smooth muscle
eosinophils damage walls
sputum - crystals + spirals
ventolin
- respiratory - defense mechanisms
physical:
- cilia, mucus, reflex (cough, sneezing)
chemical:
- surfactant, anti-microbial proteins
immunological - WBC:
- innate: macrophages, neutrophils, NK-cells
- adaptive: T-cells + B-cells
alveolar macrophages
- anoxia
anoxia/hypoxia
generalized/tissue hypoxia -
hypoxic hypoxia - COPD + high-altitude
anemic hypoxia - anemia + blood
stagnant hypoxia - shock + heart-failure
histotoxic hypoxia - cyanide poison
metabolic hypoxia - sepsis
brain-damage: 3 min
necrosis
- Oxidants + disturbances + consequences
respiratory burst - NADPH
reperfusion injury - ischemia
consequences - chronic diseases
defense mechanisms - glutathione + superoxide dismutase
- Glomerular disorders
symptoms: oliguria, edema, hypertension
nephrotic syndrome: edema, proteinuria, lipiduria, albuminuria, hyperlipidemia
nephritic syndrome: oliguria, proteinuria, hematuria, hypertension
acute GN: nephritic syndrome, streptococcus, children, renal failure, IgG, IgM
rapidly progressing GN: nephritic syndrome
IgA nephropathy:
minimal changes: nephrotic syndrome
membranous GN: nephrotic syndrome
focal segmental: nephrotic syndrome
membranoproliferative GN: nephrotic syndrome + nephritic syndrome
- tubular disorders
tubulointerstitial nephritis:
acute
chronic
acute tubular necrosis:
- nephrotic syndrome
proteinuria
hypoalbuminemia
hyperlipidemia
- glomerulonephritis - acute/chronic
acute
chronic: hyalinosclerosis
- urinary tract obstruction
kidney stones:
- magnesium, citrate
- types: calcium oxalate, calcium phosphate, uric acid, struvite, cysteine
- symptoms:
hydronephrosis:
complications - serum creatitine + electrolyte imbalance + compression atrophy
- pyelonephritis - acute/chronic
acute:
- ascending infection + blood infection
- wbc casts in urine
chronic:
- scarring + fibrosis
- renal edema - hydronephrosis
hydronephrosis
- acute renal insufficiency
symptoms: oliguria, uremia, high creatinine
prerenal: decreased blood flow, RAAS activated, hypovolemic state
intrarenal: acute tubular necrosis, nephrotoxins
postrenal: kidney stones, prostatic hyperplasia
consequences: hyperacidemia, hyperkalemia, hyperphosphatemia, hyperlipidemia, hyperuremia
- chronic renal insufficiency
causes: hypertension, DM, inherited diseases
Hypertension: –> ischemia + glomerulosclerosis
DM: –> glomerulosclerosis
- efferent arterioles stiff and narrow
symptoms: hyperuremia, hyperkalemia, hypocalcemia
- renal stones
- chronic renal failure by DM
- uremic syndrome
acute renal insufficiency
- cerebral ischemia + hemorrhage
transient ischemic attack
atherosclerosis: middle cerebral + internal carotid
penumbra
cytotoxic edema
ROS
first 4-6h: brain edema (inflammation reaction)
symptoms: facial dropping, speech, weak arms/legs
- extrapyramidal syndromes
involuntary movement, muscle rigidity
parkinson: dopamine-neurons in substantia nigra (basal ganglia), progressive, adult-onset
- symptoms: shaking, muscle rigidity
tremor: too much neural acitivity
tics:
huntington: basal ganglia, death
- symptoms: movement, cognition, emotion
bradykinesia: slow movement
dyskinesia: abnormal movement
- myasthenia gravis
type 2 hypersensitivity
antibodies against ACH receptors on skeletal muscles
= muscle atrophy
young women + old men
symptoms: drooping eyelids, facial paralysis, respiratory paralysis,
- intracranial pressure
cranial cavity:
- 0-15mmHg pressure, respiration/coughing/sneezing, 80% brain tissue
causes: tumor, trauma, hemorrhage, edema
syptoms: eyes, seizure, motor function, vital signs
treatment: medication, ventricular drainage, elevation of head, hyperventilation (CO2 –> vasoconstriction)
- spinal shock + spinal injuries
vulnerable: cervico-thoracic + thoraco-lumbar
hemorrhage + edema –> hypoxia + necrosis
neurogenic shock: above T6
–> hypotension/bradycardia
cervical cord injury: above C4
–> respiration problems
T2-T12: full upper body control
L1-L5: some leg control
S1-S5: some foot control,
bowel/bladder problems
- cerebellum
posterior cranial fossa
superior cerebellar peduncle –> brainstem
middle cerebellar peduncle –> midbrain
inferior cerebellar peduncle –> medulla oblongata
nystagmus
cerebellar ataxia - no coordination
cerebellar tremor
- thalamus + hypothalamus
process sensory stimuli –> body reaction
2 thalamic structures –> cerebral cortex + cerebellum + subcortical areas
thalamus:
sensory processing
thalamic pain syndrome
movement disorders
hypothalamus:
ANS, behaviour, emotions
regulate pituitary gland release hormones
neuroendocrine regulation
autonomic function
sleep
appetite, energy
- brain stem
medulla oblongata - cardiac, respiratory, vomiting
pons - respiratory, trigeminal CN + facial CN
midbrain - eyes reflex, ears reflex, muscle rigidity, tremor
ischemic stroke
hemorrhagic stroke
traumatic brain injury
tumors
inflammation + infection - meningitis, encephalitis, MS
degenerative - Parkinson
- brain/spinal-cord tumors
astrocytoma: glial cells, adults
ependymoma: ependymal cells, children
medulloblastoma: cerebellum, children, metastasis
extradural: bone, malignant, metastasis
intradural: benign, extramedullary/intramedullary
- menopause
climax - transitional phase
menopause - 1 year since last menstruation, no follicles responding to FSH/LH
perimenopause:
- some years before
- without ovulation
- less estrogen/progesterone
- higher FSH + less estrogen –> hot flashes + night sweats
- less estrogen = cardiovascular disease + osteoporosis
- mood swings
- male reproductive
hypogonadism - testosterone
primary:
- klinefelter
- cryptorchidism
secondary:
- pituitary disorders
- obesity
fetal life, puberty, adulthood
- joints
osteoarthritis:
- synovial joints
- inflammation + pain
- risk: age, overweight
rheumatoid arthritis:
- chronic inflammation
- T-cells + cytokines –> scar tissue in synovial membrane –> bone/joints destroyed
gout:
- uric acid in joints, big toe
- symptoms: pain, swelling
- dermatology
acne vulgaris: sebaceous glands
eczema: hypersensitivity, atopic/allergic/seborrheic
psoriasis: thick scalp, sunlight/steroid cream
benign lesions: squamous cell papilloma, seborrheic keratosis
pre-malignant: xeroderma pigmentosum, solar keratosis, intraepidermal carcinoma
malignant: basal cell carcinoma, squamous cell carcinoma, malignant melanoma
- SIRS
sepsis:
- response to infection
- septic shock
- can damage organ systems
treatment: antibiotics + fluids
SIRS criteria (min. 2 of these):
- temp lower than 36, above 38
- HR over 90
- RR over 20
- WBC lower than 4, above 12g/L
- glucose above 7,7mmol/L
severe sepsis:
- between sepsis and septic shock with 1 criteria of hypoperfusion
criteria of hypoperfusion:
- consciousness
- hypoxemia less than 10kPa
- lactate above 2,5mmol/L
- oliguria less than 30ml/h
septic shock mortality - 40%
sepsis –> less blood flow + blood clot
SOFA score: 6 organ failure scores
- respiratory + neurological + cardiovascular + coagulation + hepatic + renal
