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Volume 1, Chapter 12 Pathophysiology

How Cells Respond to Change and Injury

Pathology & Pathophysiology ____________________________________: the study of diseases and its causes ____________________________________: the study of how diseases alter normal physiology

Cellular AdaptationCells, tissues, organs, and organ systems can adapt to both

____________________________________ and injurious conditions.Adaptation to external stressors results in ____________________________________ of structure

and function.Examples: Growth of the uterus during pregnancy, dilation of the left ventricle after an MI.

Types of Cellular Adaptations (1 of 2) ____________________________________—decreased size resulting from a decreased workload.Hypertrophy—an ____________________________________ in cell size resulting from an increased

workload.

Types of Cellular Adaptations (2 of 2)Hyperplasia—An ____________________________________ in the number of cells resulting from

an increased workload.Metaplasia—____________________________________ of one type of cell by another type of cell

that is not normal for that tissue.Dysplasia—A change in cell ____________________________________, shape, or appearance

caused by an external stressor.

Forms of Cellular Injury ____________________________________ Chemicals Infectious Agents Inflammatory reactions Physical agents ____________________________________ factors Genetic factors

Signs and Symptoms of Cellular ChangeFatigue and malaiseAltered ____________________________________Fever ____________________________________ heart rate associated with feverPain

Cell Death (1 of 2)____________________________________ (“Falling Apart”): Injured cell releases enzymes that engulf and destroy the cell.

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Injured cell releases enzymes that engulf and destroy the cell.Cells ____________________________________.Eliminating damaged and dead cells allows tissues to repair and possibly regenerate.

Cell Death (2 of 2)____________________________________ (“Cell Death”):A pathological process in which cells swell and rupture. Death of the cellGangrenous ____________________________________: Cell death over a wide area

Gangrene

Fluids and Fluid Imbalances

____________________________________ is the most abundant substance in the human body.

Edema (1 of 4)Accumulation of water in the ____________________________________ space due to disruption in

the forces and mechanisms that normally keep net filtration at zero.

Edema (2 of 4)Excess fluid in the interstitial space. May result from: A decrease in plasma oncotic force resulting from a decrease in plasma proteins Increased hydrostatic ____________________________________ Increased capillary permeability resulting from mechanisms of inflammation and

____________________________________ response Lymphatic channel obstruction, which can result from infection or surgical removal

Edema (3 of 4)Can be ____________________________________ or within a certain organ system.

– For example: Sprained ankle vs. pedal edema.

Edema (4 of 4)Water in interstitial spaces is not available for ____________________________________ processes.Edema, therefore, can cause a relative condition of ____________________________________.

Intravenous Therapy

Intravenous Therapy Intravenous (IV) therapy is the introduction of fluids and other substances into the

____________________________________ side of the circulatory system. Used to replace ____________________________________ lost through hemorrhage, for electrolyte

or fluid replacement, and for introduction of medications directly into the vascular system.

Fluid ReplacementHypovolemic shock:1st choice: Whole blood2nd choice: packed ____________________________________3rd choice: plasma or plasma substitute4th choice: ____________ or NS

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4 choice: ____________ or NS

Fluid ReplacementShock due to plasma loss (Burns):1st choice: ____________________________________ 2nd choice: plasma substitute3rd choice: LR or ____________

Fluid ReplacementDehydration:1st choice: ____________ or ____________

Fluid Selection LR or NS is the preferred IV fluid for traumatic injuries and for

____________________________________ replacement

Administration Set SelectionA-Set (10 or 15gtt) is the preferred administration set for

____________________________________ and emergencies requiring fluid replacement– AKA “Regular Set” or “Macrodrip”

____________________________________ (60gtt) is the preferred administration set when fluid overload is a concern– AKA “Microdrip”– Piggy back drips, CHF, Renal Failure, Pediatrics

Preferred IV Sites In cardiac arrest patients, never go below the ____________________________________ space. EJ

is an optionTry to avoid:

– Joints (except for A/C)– Near pulse points– ____________________________________ extremities

Watch for “____________________________________” IV locations– Use a splint if needed

IV Catheter Sizes (1 of 2)The larger the number, the ____________________________________ the sizeEMS ranges from 22ga to 14ga IV cathetersButterflies range from 21ga to 27ga

– Used predominately in ____________________________________– Flush tubing

Large bore is considered 16 to 14ga– 18ga is considered medium bore to smaller large bore

IV Catheter Sizes (2 of 2)For the most part, no IV smaller than a ___________ga should be started on an adult; 18ga

for traumatic patients where fluid replacement may be neededThe larger and ____________________________________ the catheter, the easier it is to administer

fluids and drugs

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The larger and ____________________________________ the catheter, the easier it is to administer fluids and drugs

IV Fluid Rates: TKOTKO (To Keep Open): used to allow access to administer fluids or drugs if neededAKA ____________________________________ (Keep Vein Open)Used on patients where ____________________________________ is not requiredUsed on trauma patients and all other patients where there is no need for immediate fluids

IV Fluid Rates: Other RatesWide Open (WO): used to infuse high volume of fluids

– Used for the treatment of shock and for fluid ____________________________________Volume Over Time

– Specific ____________________________________ over a certain time frameMedicated IV Rates

– A specific dosage over a certain time frameParkland Burn Formula

– Used to replace fluids in burn patients

Blood Transfusion

Blood and Blood Components (1 of 2) ____________________________________: the liquid portion of the blood

– Consists of 92% waterErythrocytes (red blood cells): transports oxygen; 99 percent of blood cells. ____________________________________: iron-based compound that binds with oxygen

Blood and Blood Components (2 of 2) ____________________________________ (white blood cells): responsible for immunity and

fighting infection. ____________________________________ (platelets): major role in blood clotting.

Blood TypesBlood is typed by the presence or absence of antigens ABO SystemBlood type A carries only ___________ antigensBlood type B carries only B antigensBlood type ___________ carries both A and B antigens

– universal ____________________________________Blood type O carries neither A nor B antigens

– universal ____________________________________

The Rh SystemDocuments the Rh antigen __________AKA the Rh FactorDocumented as ____________________________________ (present) or

____________________________________ (not present)Rh incompatibility can cause harmful immune responseNegative Rh factor blood can be given to patients whose Rh factor is negative or positive

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Negative Rh factor blood can be given to patients whose Rh factor is negative or positive

Fluid Replacement• The most desirable fluid for blood loss replacement is whole

____________________________________ ____________________________________ can be separated from formed elements by centrifuge

leaving packed red blood cells– Can be used to only replace RBCs and not blood volume

Table 12-9 Resuscitation Fluids (Page 269)Resuscitation Fluid Used

Transfusion ____________________________________ occur when there is a discrepancy between the blood type of the patient and the type of the blood being transfused.

Signs and Symptoms of Transfusion Reactions ____________________________________ChillsHivesHypotensionPalpitations ____________________________________

Flushing of the skinHeadache Loss of ____________________________________Nausea ____________________________________Shortness of breath

Treatment of Transfusion Reactions (1 of 2) IMMEDIATELY ____________________________________ the transfusion. Save the substance being transfused. ____________________________________ IV infusion.

Treatment of Transfusion Reactions (2 of 2)Assess the patient’s ____________________________________ status.Administer ____________________________________.Contact medical direction.Be prepared to administer mannitol, diphenhydramine, or furosemide.

Intravenous Fluids

Hemoglobin-Based Oxygen-Carrying Solutions (HBOCs)Commonly referred to as “blood ____________________________________”

– Compatible with all blood types– Do not require blood ____________________________________, testing, or cross-matching

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– Do not require blood ____________________________________, testing, or cross-matchingGaining in popularity, but now not common in EMS

ColloidsColloids ____________________________________ in intravascular spaces for an extended period

of time and have oncotic force (will pull fluids into circulatory system).– Plasma protein fraction (Plasmanate)– Salt-poor albumin– ____________________________________– Hetastarch (Hespan)

CrystalloidsContains no large ____________________________________Crystalloid solutions are the primary compounds used in prehospital care.

– Isotonic solutions– ____________________________________ solutions– Hypotonic solutions

Common EMS FluidsLactated Ringers: ____________________________________ Crystalloid SolutionNormal Saline: Isotonic Crystalloid SolutionD5W: ____________________________________ Crystalloid Solution

Acid-Base Derangements

Respiratory AcidosisCaused by abnormal retention of ____________________________________ from impaired ventilation due to problems occurring in the lungs or respiratory center of the brain.

Increased CO2 = ____________________________________ pHRespirations= CO2 + H2O H2CO3 H+ + HCO3

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Treatment is to improve or assist ventilations

Respiratory AlkalosisCaused by ____________________________________ respiration and excessive elimination of CO2.

The CO2 level is decreased and the pH is increased.Decreased CO2 = ____________________________________ pHRespirations=CO2 + H2O H2CO3 H+ + HCO3

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Treatment, if required, is to increase CO2 level

Metabolic AcidosisResults from the production of metabolic acids such as lactic acid due to

____________________________________ metabolism These acids consume bicarbonate ions. Can be the result of dehydration, ____________________________________, or medication usage.pH is decreased, CO2 is ____________________________________ H+ + HCO3

- H2CO3 H2O + CO2

Metabolic AcidosisTreatment is to treat ____________________________________ cause, and:

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Treatment is to treat ____________________________________ cause, and: ____________________________________ to eliminate excess CO2 and subsequently Hydrogen ionCould require Sodium Bicarbonate

Compensation for metabolic acidosis begins with an increase in ____________________________________.

Metabolic Alkalosis It is usually caused by administration of ____________________________________, loss of chloride

ions associated with prolonged vomiting, and overzealous administration of sodium bicarbonate.

The pH is increased and the ____________________________________ level is normal.H+ + HCO3

- H2CO3 H2O + CO2

Treatment is to correct underlying problem

Acid Base ImbalancesNormally, ____________________________________ a respiratory and metabolic component are

present in an acid-base imbalance.Actual determination requires arterial blood gas studies (ABGs)ABGs include pH, PaCO2, ____________________________________, bicarbonate concentration,

and O2 sats

Determining Acid/Base Imbalances1) Look at pH

– Low = ____________________________________– High = alkalosis

2) Look at CO2– Normal = ____________________________________– High or low = Respiratory

Most are a combination– Ex: Respiratory acidosis with slight metabolic acidosis

Acid Base Example 1 Lab values:

– pH is 7.30– PaCO2 is 38– Pa02 is 90

Is this acidosis, normal, or alkalosis? ____________________________________ Is CO2 high, low, or normal? ____________________________________What is the acid/base imbalance? ____________________________________ ____________________________________

Acid Base Example 2 Lab values:

– pH is 7.58

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– pH is 7.58– PaCO2 is 44– Pa02 is 90

Is this acidosis, normal, or alkalosis? ____________________________________ Is CO2 high, low, or normal? ____________________________________What is the acid/base imbalance? ____________________________________ ____________________________________

Acid Base Example 3 Lab values:

– pH is 7.64– PaCO2 is 34– Pa02 is 88

Is this acidosis, normal, or alkalosis? ____________________________________ Is CO2 high, low, or normal?Slightly ____________________________________What is the acid/base imbalance?Metabolic ____________________________________ with slight Respiratory

____________________________________

Acid Base Example 4 Lab values:

– pH is 7.20– PaCO2 is 49– Pa02 is 88

Is this acidosis, normal, or alkalosis? ____________________________________ Is CO2 high, low, or normal?Slightly ____________________________________What is the acid/base imbalance? ____________________________________ ____________________________________

Hypoperfusion

Hypoperfusion (shock) is inadequate ____________________________________ of body tissues.

Shock occurs first at the ____________________________________ level and progresses to the tissues, organs, organ systems, and ultimately the entire organism.

The Pathophysiology of Hypoperfusion

Causes of Hypoperfusion (1 of 2)Inadequate pump

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Inadequate ____________________________________. Inadequate cardiac contractile strength. Inadequate heart ____________________________________.Excessive afterload.

Causes of Hypoperfusion (2 of 2)Inadequate fluid ____________________________________.Inadequate container ____________________________________ container without change in fluid volume (inadequate

systemic vascular resistance). ____________________________________ in the container.

MetabolismAll cells must have metabolism

– Oxygen and nutrients in; CO2 and ____________________________________ out ____________________________________ Metabolism: requires oxygen, hormones (glucose)

– Normal metabolism ____________________________________ Metabolism: occurs when oxygen and/or glucose is not

available– Produces lactic acid as waste product

Shock at the Cellular Level (1 of 2)Regardless of the cause, the ultimate outcome of shock is impairment of cellular

metabolismShock is caused by:

– Impaired use of ____________________________________ and/or– Impaired use of ____________________________________

Shock at the Cellular Level (2 of 2)Metabolism changes from aerobic to anaerobic metabolism producing buildups of

____________________________________ and other waste productsCell membranes rupture and cellular ____________________________________ soon follows

Figure 12-86 The Pathogenesis of Shock in the Human (Page 305)

Stages of Shock ____________________________________: body is able to compensate ____________________________________ (Progressive): body no longer able to compensate and

deterioration begins ____________________________________: damage is too extensive to be reversed

Compensation MechanismsThe ____________________________________ epinephrine and norepinephrine may be secreted

by the sympathetic nervous system.Blood vessels ____________________________________ to maintain blood pressure.Another endocrine response by the

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Another endocrine response by thepituitary gland results in the secretion of anti-diuretic hormone (ADH).

Types of Shock ____________________________________Hypovolemic ____________________________________Anaphylactic ____________________________________

Cardiogenic ShockThe heart loses its ability to supply all body parts with blood.Usually the result of ____________________________________ ventricular failure secondary to

acute myocardial infarction or CHF.Many patients will have ____________________________________ blood pressures.

Evaluation of Cardiogenic ShockThe major difference between cardiogenic shock and other types of shock is the presence of

pulmonary ____________________________________ causing:Difficulty breathing.As fluid levels rise, wheezes, ____________________________________, or rales may be heard.There may be a productive ____________________________________ with white or pink-tinged

foamy sputum.Cyanosis.

Treatment of Cardiogenic Shock (1 of 2)Assure an open airway.Administer ____________________________________Assist ____________________________________ as necessaryKeep the patient warm

Treatment of Cardiogenic Shock (2 of 2)Establish IV access with ____________________________________ fluid administration; especially

with pulmonary edemaMonitor the ECG at Paramedic level ____________________________________, Norepiphrine, or Dobutamine may be administered to

support BP if needed at Paramedic level.

Hypovolemic ShockShock due to loss of ____________________________________ fluid. Internal or external hemorrhage.Trauma. Long bones or open fractures. ____________________________________.Plasma loss from burns.Excessive ____________________________________.Diabetic ketoacidosis with resultant osmotic diuresis.

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Diabetic ketoacidosis with resultant osmotic diuresis.

Evaluation of Hypovolemic ShockAltered level of ____________________________________.Pale, cool, ____________________________________ skin.Blood pressure may be normal, then fall.Pulse may be ____________________________________ then become rapid, finally slowing and

disappearing.Urination decreases.Cardiac dysrhythmias may occur.

Treatment of Hypovolemic ShockAirway control.Control severe ____________________________________.Keep the patient ____________________________________.Administer a bolus of ____________________________________ crystalloid solution for fluid

replacement (NS or LR).

Neurogenic ShockResults from injury to brain or spinal cord causing an interruption of

____________________________________ impulses to the arteries.The arteries ____________________________________ causing relative

hypovolemia.Sympathetic impulses to the adrenal

glands are lost, ____________________________________ the release of catecholamines with their compensatory effects.

Evaluation of Neurogenic ShockWarm, dry, red skin ____________________________________ injury site

– Due to vasodilation and the inability to release catecholamines ____________________________________ blood pressureNormal to slow ____________________________________.

– Due to lack of catecholamine releasePossible priapism in males

Treatment of Neurogenic ShockAirway control. ____________________________________Maintain body temperature. ____________________________________ of patient.Consider other possible causes of shock. IV fluids to fill ____________________________________ spaceMedications that increase peripheral vascular resistance such as Dopamine or

Norepinephrine (Paramedic level).

Anaphylactic ShockAn exaggerated severe response to a foreign substance

(____________________________________)

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(____________________________________) Signs and symptoms most often occur within a minute, but can take up to an hour

– The more rapid the onset, the more ____________________________________ the reactionThe most rapid reactions are in response to ____________________________________ substances

Evaluation of Anaphylactic Shock (1 of 2)Because immune responses can affect different body systems, signs and symptoms vary

widely:Skin:

-Flushing, itching, ____________________________________, swelling, cyanosis.Respiratory system:

-Breathing difficulty, sneezing, coughing, ____________________________________, stridor, laryngeal edema, laryngospasm.

Evaluation of Anaphylactic Shock (2 of 2)Cardiovascular system:

-____________________________________, increased heart rate, decreased blood pressure. Gastrointestinal system:

-____________________________________, vomiting, abdominal cramping, diarrhea. Nervous system:

-Altered mental status, dizziness, headache, seizures, tearing.

Treatment of Anaphylactic Shock ____________________________________ protection, may include endotracheal intubation.Establish an IV of isotonic ____________________________________ solution (NS or LR).Pharmacological intervention:

-Epinephrine, antihistamines, corticosteroids, vasopressors, inhaled beta agonists.

Septic ShockAn infection that enters the bloodstream and is carried throughout the body.The toxins released overcome the ____________________________________ mechanisms.Can cause the dysfunction of an organ system or result in multiple organ dysfunction

syndrome.

Evaluation of Septic ShockThe signs and symptoms are progressive. Increased to ____________________________________ blood pressure.High ____________________________________, no fever, or hypothermic.Skin flushed, ____________________________________, or cyanotic.Difficulty breathing and altered lung sounds.Altered mental status.

Treatment of Septic ShockAirway controlOxygen IV of crystalloid solution to ____________________________________ perfusion

– May require ____________________________________ boluses

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Administer ____________________________________ as allowedDopamine to support blood pressure at Paramedic level .

Multiple Organ Dysfunction SyndromeMODS is the progressive impairment of ____________________________________ or more organ

systems from an uncontrolled inflammatory response to a severe illness or injury.Many patients who were resuscitated from shock died a few

____________________________________ later. ____________________________________ shock is the most common cause of MODSMODS is the major cause of death following sepsis, trauma, and burn injuries

MODS 24 Hours After Resuscitation Low grade fever.Tachycardia. ____________________________________.Altered mental statusGeneral hypermetabolic state

MODS Within 24 to 72 Hours ____________________________________ failure begins resulting in hypoxia

MODS Within 7 to 10 Days ____________________________________ failure begins. Intestinal failure begins. ____________________________________ failure begins.

MODS Within 14 to 21 DaysRenal and hepatic failure ____________________________________.Gastrointestinal collapse. ____________________________________ system collapse.

MODS After 21 Days ____________________________________ (blood system) failure begins. ____________________________________ failure beginsAltered mental status resulting from encephalopathy (brain infection)Death

The Body’s 3 Lines of DefenseAnatomic barriers: External defense that consists of:

– ____________________________________ – Mucus membranes that line the respiratory, GI, and GU tracts

____________________________________ response: Non-specific attack any invader to isolate, destroy and eliminate it

____________________________________ response: develops more slowly with specialized response

Role of the Immune System in Stress

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Complex interaction among nervous, ____________________________________, and immune systems

Relationship is not fully understood but a variety of immune-related disorders are associated with ____________________________________

The suppression of the immune system function that is caused by stress-related products of the sympathetic nervous and endocrine system has been linked to a number of immune-mediated diseases

Table 12-21 Stress- and Immune-Related Diseases and Conditions (Page 347) (1 of 2)

Table 12-21 Stress- and Immune-Related Diseases and Conditions (Page 347) (2 of 2)

Stress, Coping, and Illness Interrelationships ____________________________________ stress: caused by events that directly affect body ____________________________________ stress: unpleasant emotions caused by life eventsThose who cope positively with stress have reduced chance of becoming ill; those who

don't have greater chance of becoming ill

ConclusionThe cell is the basic unit of lifePerfusion of tissues necessary to provide essential nutrients to cells and to remove wastes. Inadequate perfusion is hypoperfusion or shock and can be lethalStress can also contribute to disea

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