医学教学课件：局部血液循环障碍

局部血液循环障碍HemodynamicDisordersNANJINGMEDICALUNIVERSITY第四章局部血液循环障碍的表现血量异常

血液性状和内容物的异常

血管壁通透性和完整性改变充血淤血充血和淤血充血Hyperemia病因：静脉血流出受阻心衰局部静脉堵塞或受压病变：

紫绀cyanosisinadequatetissueperfusionandpersistenthypoxia

elevatedintravascularpressures

淤血

Congestion

急性肺淤血急性肺淤血（Prussionbluestain）急性肺淤血慢性肺淤血慢性肺淤血，肺褐色硬化症状：呼吸困难、紫绀、咳痰体征：湿啰音检查：痰涂片治疗：给氧、治疗心衰肺淤血的临床病理联系肝淤血槟榔肝槟榔肝槟榔肝肝淤血肝淤血centrilobularhepaticnecrosiswithhemorrhagecentrilobularhepaticnecrosiswithhemorrhage淤血性肝硬化

肝淤血的临床病理联系症状：肝功能障碍体征：肝大、触痛检查：转氨酶升高治疗：治疗心衰、慢支血栓形成Thrombosis在活体的心血管内，血液发生凝固或血液中某些有形成分析出、凝集形成固体质块的过程。Thepathologiccounterpartof

凝血

hemostasisis血栓形成

thrombosis,theformationofbloodclot(血栓

thrombus)withinintactvessel.hemostasis血管壁thevascularwall血小板platelets凝血因子thecoagulationcascadeBoth凝血hemostasisand血栓形成thrombosis

involvethreeelements：血管内皮

endothelium正常时，内皮抗凝anticoagulant损伤或激活时，内皮促凝procoagulant血小板聚集凝血因子纤溶系统TNFIL-1endotoxin血小板plateletsTxA2(PLt)PGI2(EC)凝血途径Thecoagulationcascade纤溶系统ThefibrinolyticsystemVirchow’striadinthrombosis血管内皮损伤血流状态改变血液高凝状态血栓心肌梗死灶

动脉粥样斑块破裂

血管（瓣膜）炎

高血压

血液涡流状态

放射性损伤高胱氨酸尿症高胆固醇血症吸烟细菌产物内皮损伤ECinjury举例Endothelialdysfunctionpro>antiEndothelialdamageThrombioverulceratedplaquesinatheroscleroticaortathrombiinthecardiacchambersafterMI血流状态改变abnormalbloodflowBothpromoteECactivationandenhancedprocoagulantactivity…使内皮促凝StasisallowsplateletsandleukocytestocontactwiththeEC…致Plt和WBC触壁Stasisslowsthewashoutofactivatedclottingfactorsandimpedestheinflowofclottingfactorinhibitors…局部凝血因子浓度升高涡流turbulance停滞stasis风湿性心脏病（二狭

左房扩张+房颤）长期卧床或久坐HyperviscositySicklecellanemia粥样斑块动脉瘤心肌梗死血流状态改变举例涡流turbulance停滞stasis高凝血状态HypercoagulabilityItislooselydefinedasanyalterationofthecoagulationpathwaysthatpredisposesaffectedpersonstothrombosis先天性

primary(genetic)FactorVmutationProthrombinmutation获得性

secondary(acquired)妊娠，口服避孕药，老年，扩散的肿瘤，创伤，手术，DIC血栓的形态

Morphology起点走向层状结构

linesofZahn

心腔内血栓动脉血栓静脉血栓混合血栓/层状血栓血小板小梁红细胞白细胞血栓形成的过程延续性血栓血栓的形态类型混合血栓mixedthrombus白色血栓palethrombus红色血栓redthrombus透明血栓hyalinethrombus白色血栓血小板血栓疣状赘生物透明血栓/微循环纤维素血栓透明血栓/微循环纤维素血栓termsThrombioccurringinheartchambersorintheaorticlumenaredesignatedmuralthrombi

附壁血栓

Thrombionheartvalvesarecalledvegetations赘生物赘生物发生细菌或真菌感染引起

infectiveendocarditis感染性心内膜炎附壁血栓感染性赘生物死后凝血血栓的结局fatePropagationEmbolizationDissolution

Organizationandrecanalization

1234hours血栓对机体的影响

阻塞血管引起栓塞心瓣膜病出血（DIC）动脉静脉心瓣膜DICisthesuddenorinsidiousonsetofwidespreadthrombosiswithinthemicrocirculation,apotentialcomplicationofnumerousconditionsassociatedwithwidespreadactivationofthrombin.冠脉内血栓冠脉内血栓冠脉造影脑血栓静脉血栓90%发生于下肢表浅静脉血栓疼痛，水肿，溃疡（淤血）深静脉血栓（DVT）

疼痛，水肿膝关节以上DVTpronetoembolize心衰久卧久坐创伤手术烧伤妊娠Trousseausyndrome>50yDeepVenousThrombosis，DVT下肢静脉血栓肺动脉中栓子DVT致肺骑跨性栓塞慢性风湿性心瓣膜病感染性心内膜炎栓塞EmbolismAnembolus（栓子）isadetachedintravascularsolid,liquidorgaseousmassthatiscarriedbybloodtoasitedistantfromitsorigin血栓栓塞Thrombo-embolism脂滴氧/氮气泡胆固醇（粥样斑块碎片）肿瘤栓子羊水骨髓栓子运行的途径

体循环血栓栓塞Systemicembolism肺动脉栓塞Pulmonaryembolism交叉性栓塞逆行性栓塞肺动脉血栓栓塞

Incidence(美国)：

2to4per1000住院病人，死亡率2%(5万)95%ofcases，栓子来源于膝关节及以上DVT栓塞部位不同后果不同amajorpulmonaryartery…medium-sizedarteries…smallend-arteriolarpulmonarybranches…generalstateofthecirculationsizeoftheembolicmass后果骑跨性血栓栓塞saddleembolus肺梗死肺梗死临床表现

clinicalfeatures60-80%…clinicalsilent

(栓子溶解，支气管动脉维持血供)5%...猝死，急性右心衰，心源性休克

(大栓子或多发小栓子致>60%肺循环受阻)10-15%...肺梗死

(呼吸困难，咯血，胸痛)<3%...慢性肺动脉高压，肺心病，肺动脉硬化

(栓塞反复发作)体循环血栓栓塞

80%来源于心腔内附壁血栓2/3左室心梗继发血栓25%左房扩大其他来源：AS斑块继发血栓,动脉瘤内血栓,瓣膜赘生物,交叉性血栓10-15%

Unknown

栓塞部位

下肢(75％)脑(10％)肠，肾，脾

体循环血栓栓塞

梗死?1.2.3.dependson:脂肪栓塞

Fatembolism

病因：软组织挤压伤，长骨骨折<10%的病人出现临床症状少数发生脂肪栓塞综合征fatembolismsyndrome，死亡率10%皮肤瘀斑血小板减少

Neurologicsymptoms易激惹烦躁谵妄昏迷

Pulmonaryinsufficiency呼吸急促呼吸困难心跳加速脂肪栓塞脂肪栓塞脂肪栓塞脂肪栓塞OilredOstainhypoxia空气栓塞

airembolism气体融合后阻塞血流引起缺血进入动脉

进入静脉death心肺

呼出足够多心脏搭桥术头部手术(坐式)产科手术胸壁损伤氮气栓塞

/减压病

Decompressionsickness发病人群：深海作业者，Scubadivers发生机制：临床表现：骨骼肌中和关节气泡集聚疼痛肺循环中气泡集聚水肿，出血，局部肺不张或肺气肿，呼吸衰竭骨坏死(慢性，沉箱病cassiondisease)治疗方法：气体栓塞气体栓塞羊水栓塞

Amnioticfluidembolism罕见的，严重的产科并发症起病：suddenseveredyspnea,cyanosis,andhypotensiveshock,followedbyseizuresandcoma肺水肿，DIC发生机制病理变化：羊水栓子，透明血栓，DAD1/40000死亡率80%羊水栓塞羊水栓塞肿瘤栓塞细菌栓塞梗死InfarctionAninfarct(梗死灶)isanareaofischemicnecrosiscausedbyocclusionofthevascularsupplytotheaffectedtissue.theprocessbywhichsuchlesionsformtermedinfarction.肺梗死脑梗死心肌梗死肠梗死gangrene梗死的病因动脉血栓或动脉栓塞其他原因的动脉受阻(lesscommon)：动脉痉挛，粥样斑块内出血动脉受压(肿瘤/疝/twisting/夹层动脉瘤)Infarctscausedbyvenousthrombosisthususuallyoccuronlyinorganswithasingleefferentvein(e.g.,testisorovary)血管堵塞是否引起组织坏死取决于？ThepresenceorabsenceofanalternativebloodsupplyRateofocclusionTissuevulnerabilitytoischemiaHypoxemia

侧枝循环肠/四肢双重血供肝/肺终末