1	Chapter 8, Part 2 Disease—Causes and Pathophysiology
2	Part 2 Topics Disease Risk Hypoperfusion Shock Multiple Organ Dysfunction Syndrome
3
4	Many factors combine to cause disease. (1 of 3) Genetics Environment Lifestyle Age Gender
5	Many factors combine to cause disease. (2 of 3) Inherited traits are determined by molecules of deoxyribonucleic acid (DNA). Each somatic cell contains 46 chromosomes. Sex cells contain 23 chromosomes.
6	Many factors combine to cause disease. (3 of 3) An offspring receives 23 chromosomes from the mother and 23 chromosomes from the father. One or more chromosomes may be abnormal and may cause a congenital disease or a propensity toward acquiring a disease later in life.
7	"Most disease processes are multifactorial..." Most disease processes are multifactorial in origin.
8	Disease Effects on Individuals Host Agent Environment
9	Disease Effects on Populations Incidence Prevalence Mortality
10	Family History and Associated Risk Factors
11	Immunologic Disorders A number of immunologic disorders are more prevalent among those with a family history of the disorder.
12	Cancer Some types of cancer tend to cluster in families and seem to have a combination of genetic and environmental causes. Breast cancer Colorectal cancer
13	Endocrine Disorders The most common endocrine disorder is diabetes mellitus. Leading cause of: Blindness Heart disease Kidney failure Premature death Both Type I and Type II diabetes can be family related.
14	Hematological Disorders There are many causes of hereditary hematological disorders such as gene alteration and histocompatibility (tissue interaction) dysfunctions. Hemophilia Hemochromatosis
15	Cardiovascular Disorders The cardiovascular system can be greatly affected by genetic disorders. Elongation of the QT interval Mitral valve prolapse Coronary artery disease Hypertension Cardiomyopathy
16	Renal Disorders Caused by a variety of factors, primarily hypertension. EMS is increasingly being called upon to deal with complications of dialysis including: Problems with vascular access devices Localized infection and sepsis Electrolyte imbalances
17	Rheumatic Disorders Gout is a disorder both genetic and environmental characterized by the deposit of crystals in the joints, most commonly the great toe. The crystals form as a result of abnormally high levels of uric acid in the blood.
18	Gastrointestinal Disorders Lactose intolerance Crohn’s disease Peptic ulcers Cholecystitis Obesity
19	Neuromuscular Disorders Diseases of the nervous and muscular systems include: Huntington’s disease Multiple sclerosis Alzheimer’s disease
20	Psychiatric Disorders Genetic and biological causes of these disorders are being studied and increasingly understood. Schizophrenia Manic-depressive illness (bipolar disorder)
21	Hypoperfusion
22	"Hypoperfusion (shock" Hypoperfusion (shock) is inadequate perfusion of body tissues.
23
24	Components of the Circulatory System (1 of 2) The pump (heart) The fluid (blood) The container (blood vessels)
25	Components of the Circulatory System (2 of 2)
26	The Pump The heart is the pump of the cardiovascular system. Receives blood from the venous system, pumps it to the lungs for oxygenation, and then pumps it to the peripheral tissues.
27	Stroke Volume (1 of 2) The amount of blood ejected by the heart in one contraction.
28	Stroke Volume (2 of 2) Factors affecting stroke volume: Preload Amount of blood delivered to the heart during diastole Cardiac contractile force The strength of contraction of the heart Afterload The resistance against which the ventricle must contract
29
30	Contractile Force Is affected by circulating hormones called catecholamines. Epinephrine Norepinephrine
31	Cardiac Output Cardiac output is the amount of blood pumped by the heart in one minute. Stroke volume x Heart rate = Cardiac output
32	Blood Pressure Peripheral vascular resistance is the pressure against which the heart must pump.
33	The Fluid Blood is thicker and more adhesive than water. Consists of plasma and the formed elements. Red cells, white cells, platelets Transports oxygen, carbon dioxide, nutrients, hormones, metabolic waste products, and heat. An adequate amount is needed for perfusion, and volume must be adequate to fill the container.
34	The Container (1 of 2) Blood vessels serve as the container of the cardiovascular system. Under control of the autonomic nervous system they can adjust their size and selectively reroute blood through microcirculation. Microcirculation is comprised of the small vessels: arterioles, capillaries,and venules.
35	The Container (2 of 2) Capillaries have a sphincter between the arteriole and capillary called the pre-capillary sphincter. The pre-capillary sphincter responds to local tissue demands such as acidosis and hypoxia, and opens as more blood is needed.
36	Blood Flow Regulation Peripheral vascular resistance Pressure within the system
37	Post-Capillary Sphincter At the end of the capillary between the capillary and venule is the post-capillary sphincter. The post-capillary sphincter opens when blood needs to be emptied into the venous system.
38	The Fick Principle (1 of 2) The movement and utilization of oxygen in the body is dependent upon the following conditions: Adequate concentration of inspired oxygen. Appropriate movement of oxygen across the alveolar/capillary membrane into the arterial bloodstream.
39	The Fick Principle (2 of 2) Adequate number of red blood cells to carry the oxygen. Proper tissue perfusion. Efficient off-loading of oxygen at the tissue level.
40	The Pathophysiology of Hypoperfusion
41	Causes of Hypoperfusion (1 of 3) Inadequate pump Inadequate preload Inadequate cardiac contractile strength Excessive afterload
42	Causes of Hypoperfusion (2 of 3) Inadequate fluid Hypovolemia
43	Causes of Hypoperfusion (3 of 3) Inadequate container Dilated container without change in fluid volume (inadequate systemic vascular resistance) Leak in the container
44	Shock at the Cellular Level Shock causes vary; however, the ultimate outcome is impairment of cellular metabolism.
45	Impaired Use of Oxygen When cells don’t receive enough oxygen or cannot use it effectively, they change from aerobic to anaerobic metabolism.
46	Glucose Breakdown (1 of 2) Stage one, glycolysis, is anaerobic (does not require oxygen). It yields pyruvic acid, with toxic by-products such as lactic acid, and very little energy.
47	Glucose Breakdown (2 of 2) Stage two is aerobic (requires oxygen). In a process called the Krebs or citric acid cycle, pyruvic acid is degraded into carbon dioxide and water, which produces a much higher yield of energy.
48	Compensation and Decompensation Usually the body is able to compensate for any changes. However when the various compensatory mechanisms fail, shock develops and may progress.
49	Compensation Mechanisms The catecholamines epinephrine and norepinephrine may be secreted. The renin-angiotensin system aids in maintaining blood pressure. Another endocrine response by the pituitary gland results in the secretion of anti-diuretic hormone (ADH).
50	Shock Variations (1 of 3) Compensated shock is the early stage of shock during which the body’s compensatory mechanisms are able to maintain normal perfusion.
51	Shock Variations (2 of 3) Decompensated shock is an advanced stage of shock that occurs when the body’s compensatory mechanisms no longer maintain normal perfusion.
52	Shock Variations (3 of 3) Irreversible shock is shock that has progressed so far that the body and medical intervention cannot correct it.
53	Types of Shock Cardiogenic Hypovolemic Neurogenic Anaphylactic Septic
54	Cardiogenic Shock The heart loses its ability to supply all body parts with blood. Usually the result of left ventricular failure secondary to acute myocardial infarction or CHF. Many patients will have normal blood pressures.
55	Cardiogenic Shock Evaluation The major difference between cardiogenic shock and other types of shock is the presence of pulmonary edema causing: Difficulty breathing. As fluid levels rise, wheezes or crackles (rales) may be heard. There may be a productive cough with white or pink-tinged foamy sputum. Cyanosis, altered mentation, and oliguria.
56	Cardiogenic Shock Treatment (1 of 2) Assure an open airway. Administer oxygen. Assist ventilations as necessary. Keep the patient warm.
57	Cardiogenic Shock Treatment (2 of 2) Elevate the patient’s head and shoulders. Establish IV access with minimal fluid administration. Monitor the heart rate. Dopamine or dobutamine may be administered.
58	Hypovolemic Shock Shock due to loss of intravascular fluid Internal or external hemorrhage Trauma Long bones or open fractures Dehydration Plasma loss from burns Excessive sweating Diabetic ketoacidosis with resultant osmotic diuresis
59	Hypovolemic Shock Evaluation (1 of 2) Altered level of consciousness. Pale, cool, clammy skin. Blood pressure may be normal, then fall.
60	Hypovolemic Shock Evaluation (2 of 2) Pulse may be normal then become rapid, finally slowing and disappearing. Urination decreases. Cardiac dysrhythmias may occur.
61	Hypovolemic Shock Treatment Airway control. Control severe bleeding. Keep the patient warm. Administer a bolus of crystalloid solution for fluid replacement. Non-trauma or no blood loss: Bolus crystalloid or colloid solutions Trauma or blood loss: “Permissive hypotension.” – SBP of 70-85 mmHg PASG if part of local protocol.
62	Neurogenic Shock Results from injury to brain or spinal cord causing an interruption of nerve impulses to the arteries. The arteries dilate causing relative hypovolemia. Sympathetic impulses to the adrenal glands are lost, preventing the release of catecholamines with their compensatory effects.
63	Neurogenic Shock Evaluation Warm, dry, red skin Low blood pressure Slow pulse
64	Neurogenic Shock Treatment Airway control. Maintain body temperature. Immobilization of patient. Consider other possible causes of shock. IV access and medications that increase peripheral vascular resistance.
65	Anaphylactic Shock A severe immune response to a foreign substance. Signs and symptoms most often occur within a minute, but can take up to an hour. The most rapid reactions are in response to injected substances: Penicillin injections Bees, wasps, hornets
66	Anaphylactic Shock Evaluation (1 of 2) Because immune responses can affect different body systems, signs and symptoms vary widely: Skin: Flushing, itching, hives, swelling, cyanosis Respiratory system: Breathing difficulty, sneezing, coughing, wheezing, stridor, laryngeal edema, laryngospasm
67	Anaphylactic Shock Evaluation (2 of 2) Cardiovascular system: Vasodilation, increased heart rate, decreased blood pressure Gastrointestinal system: Nausea, vomiting, abdominal cramping, diarrhea Nervous system: Altered mental status, dizziness, headache, seizures, tearing
68	Anaphylactic Shock Treatment Airway protection; may include endotracheal intubation. Establish an IV of crystalloid solution. Pharmacological intervention: Epinephrine, antihistamines, corticosteroids, vasopressors, inhaled beta agonists.
69	Septic Shock An infection that enters the bloodstream and is carried throughout the body. The toxins released overcome the compensatory mechanisms. Can cause the dysfunction of an organ system or result in multiple organ dysfunction syndrome.
70	Septic Shock Evaluation The signs and symptoms are progressive. Increased to low blood pressure High fever, no fever, or hypothermic Skin flushed, pale, or cyanotic Difficulty breathing and altered lung sounds Altered mental status
71	Septic Shock Treatment Airway control. IV of crystalloid solution. Dopamine to support blood pressure. Monitor heart rhythm.
72	Multiple Organ Dysfunction Syndrome MODS is the progressive impairment of two or more organ systems from an uncontrolled inflammatory response to a severe illness or injury.
73
74	Primary MODS Organ damage results directly from a specific cause such as ischemia or inadequate tissue perfusion from shock, trauma, or major surgery. Stress and inflammatory responses may be mild and undetectable. During this response, neutrophils, macrophages, and mast cells are thought to be “primed” by cytokines.
75	Secondary MODS The next time there is an injury, ischemia, or infection the “primed” cells are activated, producing an exaggerated inflammatory response. The inflammatory response enters a self-perpetuating cycle causing damage and vasodilation. An exaggerated neuroendocrine response is triggered causing further damage.
76	MODS 24 Hours after Resuscitation Low grade fever Tachycardia Dyspnea Altered mental status General hypermetabolic, hyperdynamic state
77	MODS within 24 to 72 Hours Pulmonary failure begins.
78	MODS within 7 to 10 Days Hepatic failure begins. Intestinal failure begins. Renal failure begins.
79	MODS within 14 to 21 Days Renal and hepatic failure intensify. Gastrointestinal collapse. Immune system collapse.
80	MODS after 21 Days Hematological failure begins. Myocardial failure begins. Altered mental status resulting from encephalopathy. Death.
81	Part 2 Summary Disease Risk Hypoperfusion Shock Multiple Organ Dysfunction Syndrome