Transcribed by Jacqueline Heath Lecture Date: 9/24/14

General Pathology Hemodynamic Circulatory Disorders IV by Dr. Vernillo

[Slide 59] [Edema]

Ok. Edema. Two flavors. Transudate. Exudate. What do we see in heart disease? Is this
inflammatory edema or non-inflammatory edema? Now, there are inflammatory reactions going
on in the heart, I got that. PMNs come in and blah blah blah blah blah blah blah. But Im talking
about the fluid in the lung. Why is the fluid there? Your left heart fails. What is happening?
Why are you getting pulmonary edema? Somebody said it, go ahead. Speak up for the kind of
money youre paying for an education, speak up! Whats that? Increased hydrostatic pressure,
okay. Youre pretty much there youre right. If that left heart fails and it cant pump blood
forward, then all that blood is going to back up and that is a tremendous increase in pressure
within the lung bed because all that blood goes back to the pulmonary vein and into the small
venules and then in the microcirculation these venules anastomose with little capillaries, little
capillaries, and these capillaries make up the wall of the alveolar sac and they get congested
because of that increased hydrostatic pressure from that failing left. And what follows
congestion? Like night that follows day? Edema. So now that edema pours out into the air sacs
and theres nothing to hold that fluid back. Take a sponge if youre curious, put it under a sink
with running tap water, what happens to the holes in the sponge? They fill up quickly with what,
water! This is what happens with your lung in heart failure. So increased hydrostatic pressure is
an important pathogenic mechanism in edema. Alright?
Ok so you get pulmonary edema. That is not inflammatory. Thats due to increased
hydrostatic pressure. Thats a non-inflammatory fluid. That is called a transudate. The
inflammatory one is an exudate. What clinical setting would you see that? Well teach you a lot
about this in next term in systemic path. Infections. Pulmonary infections. Bacterial infections
of the lung. Classically lobar pneumonia, pneumococcal pneumonia, if you get enough infection
in your lung, you have increase in vascular permeability. That is another mechanism for edema.
But that edema is an exudate because it is inflammatory and infectious. So those are the two
major forms of edema. Alright, and it may be generalized, it may be localized, Ta da ba bu bu
buah. [really, he said that.]

[Slide 60] [Normal Capillary Filtration]

Ok now, were not going to go through this in great detail. This is just how capillaries
function. But what this diagram is trying to show, which is really a pictorial representation of
this. That preceded it, this descriptive [went back to the slide before this one]. Is that youre
trying to maintain a balance. So Im in heart failure. No Im not, but say I am. Im in heart
failure, my left hearts not happy.
Oh one more thing, Im going to back track. I dont mean to jump, but its to reinforce a
concept that I mentioned last class. Hypertension causes ventricular hypertrophy, left ventricular
hypertrophy so it stiffens the heart. Increased workload. Myocardial cells make proteoglycans
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
which are mucopolysaccharides. Myocardial cells also synthesize other matrix molecules like
collagen and these bulk up the wall making it thick to withstand the increased pressure from
hypertension. But what does hypertension also do to the arteries, the coronary arteries that feed
that same heart? You had it! Come on, what does it do? Endothelial injury. If its hypertension,
if its smoking, if its excess lipid either from being obese or being a poorly controlled diabetic,
all of those things are forms of injury, and once you have injury, I dont care what form it comes
in, it will initiate the process of atherosclerosis. Hypertension causes mechanical injury. So now
whats happening to the coronary arteries that feed that heart in the setting of uncontrolled
hypertension? Are there plaques there? If there are plaques there, do you have enough blood flow
there? Because what are the plaques do to the internal diameter of the coronary artery? They
decrease, or narrow it, we call that stenosis. So if you have less blood getting in there, you have
less blood getting to that heart. So picture, you talk about being punched in the face twice.
Blood pressure not only thickens the left ventricular wall, thus making it stiff and less compliant,
and diminishing its efficacy as a pump, at the same time, it damages the coronary arteries so
badly that you get less blood because of plaques that build up in those arteries. Youve got a
heart thats stiff and non-compliant, and on top of that, its getting even less blood. Thats what
hypertension does to your heart. And thats pretty wicked. You cant do worse than that.
Remember, the key is control. So if the patient has hypertension and theyre controlling that
hypertension, Glorious! Its when they dont control their disease that its not so glorious.

[Slide 61] Diagram of a capillary bed

So heres a picture showing the capillary bed, the microcirculation. You have swollen
legs from left failure, from congestion in your veins, left leading to right failure. What do you
call that congestion in veins? Its in veins. What do you call that type of congestion? Speaketh.
What do we call that? Is it excess blood in the vein? What is the word for excess in Greek?
Hyper! The word for blood? Emia. Hyperemia. What do we call that in a vein? Passive
hyperemia. You better be on the ball for my questions. And dont come to me and argue with
me aww aww.. youve better make sure you know what youre doing. Because Im gonna tell
you something. Youre gifted people. Im not diminishing your intelligence at all. But you just
have to have a little zest. You have to work at it. Because as brilliant as you are, youre going to
have to work at it. If you think four days before the exam is going to do it for you, its not. Not
in my course its not. Its not to frighten you. Its just that when you get pathology, you have to
do more than memorize your way through, you have to understand interrelationships for things
because your patient is an integrated system. They dont come into this school, check their brain
in the basement, put their liver on the second floor, put their heart on the fourth. They come in
as one whole person! And theyre asking you questions! And guess what!? Youve gotta have
the answers. And if you dont have the answers, youve gotta speak to a physician because thats
their field of expertise. And know what to ask them! Are you getting this? I mean I know youre
getting this.
Ok. So now your legs swell. The lymphatics, what are they going to do? Pick up that
fluid is right! And they go, and they travel, and they enter the vascular system. They enter the
large veins near the heart. For example, they eventually dump into the subclavian vein. Theyre
gettin fluid away. But if theres that much fluid inside your lungs, inside your legs rather, theres
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
that much fluid, are the lymphatics eventually going to efficiently bring it back? No! So your
lymphatics are trying to do the best that they can to bring all that fluid back to the right side of
your heart, but if youve got that much congestion in your leg veins and that much subsequent
edema, you aint gonna be able to bring it back.

[Slide 62] Causes of Local Edema

Local edema? Inflammation, lymphatic obstruction again. Cuz if you obstruct the
lymphatics you cant bring back fluid! Um, burns, immune reactions. Angioedema, what the
devil is that? We see these things on commercials on TV all the time. What is angioedema? If
you take this drug AND.. your lips swell, your face swells, your tongue swells, and you have
difficulty breathing, you better see your physician right away, because youll be dead if you
dont. And when the lips and facial muscles swell, we call that angioedema and we see that in
certain immune reactions, for example, in response to drugs. What type of hypersensitivity
reaction is that? These are the kinds of questions I ask on exams. I will pull from other areas in
your course and dump them into questions, so youll have 2-3 questions on one case. I want to
see if you can make connections, and I know you can, but youre going to have to learn to think
like that. Because patients will come to you with all sorts of interesting diseases and drugs.
Dr what am I gonna do? What are you going to tell them, I dunno, Ill se you Wednesday?
Theyre going to be looking to you for an answer, so youve gotta really be on your game. And I
have friends who are surgeons, medical professions, surgeons, and they sweat or shmitz, little
drops of red blood. They are brilliant people like you are. They may know 90% of what they
need to know. But they lose patients on the 10% they dont know. Thats pretty scary, and when
Im in the clinic, and Ive been around for more than a millennium or so, I sometimes hope that
Im asking the right questions and know all the information I need. Youre never going to have
it 100%, so if you dont study effectively, youre looking at squa.t when you walk into the clinic
for what you can use. So youve really gotta be on top of your game. I cant say that enough.
And if you tell me you dont have enough time, Ive-got-this-to-do, Ive-got-that-to-do and
some of you have families, some of you have the important responsibility of taking care of
children. A number of you, I mean, youre busy people. And some of you have other
responsibilities superimposed. You have to go out and get a part time job to make enough
money to make ends meet, whatever it is, this is the place to learn it, right here. So when you
take notes in that seat, youve paid a lot of do-re-me for that seat. Youre sitting there. Thats the
time for you to take notes, jot it down, and if you dont understand something, and some of you
are asking great questions, the podcast cant do this for you. All it can do is record me. Poor
thing. Thats all it can do. So you have to give yourself time to learn it. And when you start
taking notes, youre studying right then and there. And sometimes youre not going to have
more time than that, youre such busy people. Aigh. For the amount of money youre paying for
an education if your laptop doesnt work or you forgot it, take out a piece of paper and a
crayon if you have to.

Transcribed by Jacqueline Heath Lecture Date: 9/24/14
[Slide 63] Picture of angioedema

Ok. Angioedema. Puffy lips. Fun. If your patient starts looking like that, what are you
gonna do? Uh, you have funny looking lips, Mr. Smith.. What are you gonna do? What are
you gonna do? [student: ER] Yeah! Call an ambulance! Absolutely.

[Slide 64] Common Causes of Generalized Edema

Now, causes of generalized edema. We mentioned congestive heart failure. Again,
congestive heart failure is a term that applies to left heart failure when the lungs become
congested. And obviously, since right failure arises mostly from left, the lungs are still
congested, so we have congestion in the setting of left AND right failure. We call that bi-
ventricular failure. But its congestive failure just the same, whether its left, or whether its left
and right. Why does that lead to edema? Go ahead, say? Increased hydrostatic pressure.
Increased hydrostatic pressure leads to pulmonary edema because the left heart is failing and the
pressures backing up into those little capillaries and the sacs are getting full of fluid. .
Why do the legs swell? Why is there edema there instead of congestive heart failure? Whats
happening there? [student: the blood backs up to the right side of the heart] Nice . the blood
backs up into the right side of the heart. And now the right side cant get that blood back up cuz
its all coming back here. Backward failure. And now when all that blood backs up into the
veins thats passive congestion, and that leads to edema.
Why would renal disease cause you to swell like the Pillsbury dough boy? Whats the
major cause of renal failure in this country? [response] Absolutely, diabetes, hypertension and
sometimes both. Im actually on an ethics committee looking at policies for transplantation
because were seeing more and more people dying from kidney disease. Dying from kidney
disease. Waiting to get kidneys. Very interesting legal and ethical issues involved with policy.
Why would renal disease cause edema? [student: because you cant I cant hear] Well, okay
so what happens in renal disease, is you have glomerular disease and youre losing.. protein!
You start peeing out protein. And if its really bad renal disease, youll start peeing out albumin.
Whats the molecular weight of albumin, biochemistry students, whats the molecular weight of
albumin? [Pretty big.] Pretty big, alright, lets work on that. Pretty big, so is an elephant. Give
me something more specific. 68,000 grams on a mole. So Its a big protein. If youre losing
albumin, you have to have a lot of damage! Thats like a Volkswagon. When youve got that
kind of damage, youre getting albumin in your urine. Albuminuria, so youre losing protein
from your blood. What does protein do in your blood? [responses] Pulls water back into.. my
blood vessels. What do we call that? Osmotic or oncotic pressure. So another important
pathogenic mechanism to edema is loss of oncotic pressure. Loss of proteins, because youre
peeing them out! Why would cirrhosis of the liver cause edema? And I said to one student, Jack
Daniels, grey goose, black label, and this student looked at me and had no idea what I was
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
talking about. And I was absolutely shocked. I said, you dont know what that is? [in a small
voice,] Alcohol. So now, if you damage enough of your liver, and your liver scars, we call that
cirrhosis. Well be talking about that in great detail in the part of the hepatobiliary disease part
of the course next term. Why would you get edema though? Well, right, exactly the liver makes
the albumin. So youre not making albumin, so youre back to the same situation you were in
kidney failure. In kidney failure, youre making albumin but youre peeing it out. In liver
disease, youre not making albumin but in either case, you dont have enough oncotic pressure
and you get edema. What do we call generalized edema? Anasarca. Yeah.

[Slide 65] Picture of Pitting Edema

Yeah. Theres pitting edema. You can actually grade the degree of clinical edema by the
depth of the pit. The deeper the pit, the worse the edema, the worse the heart failure. Yeah, its
a nasty disease.

[Slide 66] Disorders Associated with Edema

Now, disorders associated with edema. Look at this again. Weve gone through this, so
youre experts now. Increased hydrostatic pressure seen in the setting of? Congestive heart
failure, left failure, leading to pulmonary edema, the hallmark of left failure. What is the clinical
characteristics of right heart failure, whether it be from left, or whether it be from cor pulomnale?
What are the clinical characteristics of right failure? [distended jugular?] Distended jugular?
Distended jugular because blood is backing up into veins and the jugular vein is a tributary of
what major vein? The superior vena cava. Right. So youre getting the jugular vein. So if
somebody comes in and theyve got a distended blue vein in their neck, what are you thinking?
[Student: right failure] Right failure. Right failure from left or right failure by itself. So even
before you look at that patient, they sit down, and you know theyve got a heart problem! So it
backs up into the veins. Backs up into the liver. Blood goes down through the inferior vena
cava, inferior vena cava goes through the liver, its got short hepatic veins on it, and it dumps
blood into the sinusoids of the liver. What happens to the liver? [swells] It swells up, what do
we call that? Whats the term for large in pathology? Megaly. Hepatomegaly. Alright, so thats
due to heart failure. We call it a nutmeg liver. N-u-t-m-e-g. Its seen in the setting of heart
failure! Lets see would you get enlargement of your spleen in heart failure? Yes you would.
Why? Splenic vein is exactly right. And the splenic vein is a branch of the portal vein. Yeah,
good. So you have hepatomegaly, splenomegaly, jugular vein distention, edema of your legs,
edema of your feet, the manifestations of right heart failure. Whether it be cor pulmonale, right
failure alone, or right failure from left, which is most common. Very nice. Very very nice.
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
Decreased plasma protein concentration. Why do we have a decrease in oncotic
pressure? We just reviewed that. Renal disease, give me another one. Jack Daniels. Liver
disease. Cirrhosis. And in this country the most common cause of cirrhosis is alcohol. What is
the second most common cause? [student: obesity] Obesity. Hold on. Obesity is a good answer.
Its not the most common cause but I daresay if we continue to see more and more cases of
obesity in this country, it will lead to cirrhosis because obesity leads to a fatty liver. And if the
liver remains fatty, its injury, and eventually that injury is replaced by scar, and there is some
thinking right now that fatty liver from obesity may be an important contributory cause towards
cirrhosis going forward. But someone said it over here. Hepatitis. Absolutely. What are the two
forms of hepatitis that have carrier states, which means you never get rid of the critter? C and B.
Which one has the higher carrier state? C. We dont have a vaccine for C. We have a vaccine
for B, and its very efficacious. But people that dont get the vaccine, people who get B and
dont eliminate it, we call them carriers, and carrier rates for hepatitis B is about 10%. Hepatitis
C is about 85%.
Increased capillary permeability. Where do we see that? Angioedema. Swelling of the
lips. If the capillarys permeability increases in the setting of immune response, youre pouring
out fluid. Thats a mechanism of edema. What kind of hypersensitivity reaction do we call that,
where you see swelling of the lips to a drug? Youve got four flavors. Which one? Did you have
this? [no] why did you tell me that you havent had this? Say Dr. Vernillo, we didnt have this! If
Im listening for an answer, I dont have an answer.. Type I. Thats an allergic reaction. I mean I
dont know every single thing youve learned. I know some things, but I dont know every
single thing. So dont hesitate to say, Dr. Vernillo, we didnt have that. Ill teach it to you
now. Type I. Type 2 is kidney disease. A specific type of kidney disease called Good Pasture.
Type 3 is lupus. Type 4? tuberculosis. And type I diabetes which is an immuo form of diabetes.
So you know, just tell me. Im happy to teach you and learn from you. Thats my privilege.
Lymphatic obstruction can cause edema. Why would you have edema from lymphatic
obstruction? [Cant hear student response.] Its as simple as that. Its exactly right. You cant
bring fluid back up.

[Slide 67] Diagram of Lymphatics

Thats just a diagram to show what weve been discussing about the lymphatics.

[Slide 68] Disorders Associated with Edema - Increased Hydrostatic Pressure

Increased hydrostatic pressure, we see that in inflammation, right? Hyperemia. Active
hyperemia, in arterioles. You have more blood in arterioles. Thats increased hydrostatic
pressure. Or an increased venous pressure. Why would you have increased pressure in veins in
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
the setting of venous thrombosis? If Ive got a thrombus over here, and Ive got blood in by vein
back here, is tha blood moving? So that represents an increase in pressure. Is it a form of
congestion? What follows congestion? Edema, so does that leg swell? So now that poor
shlepper has a swollen leg, and he gets out of bed. And he starts walking. And then suddenly, he
gets acute chest pain. Acute dyspnea, d-y-s-p-n-e-a. It means that you cant breathe well. And he
dies like that, and hes deader than a door nail. What happened to him? If he was in that bed
from surgery, was he out dancing the day before? No! So hes in bed, and whats happening to
the blood in his veins? Stasis. And that formed a thrombus, and then thrombus embolized. And
where did the embolus go? To the pulmonary artery, and block the flow of blood into his lung.
Acute cor pulomnale. Pulmonale, not pulmonale [?] Its not Italian.
Okay. . . Congestive heart failure. Cirrhosis. These are forms of increased venous
pressure, well talk to you about that. The reason cirrhosis increases venous pressure is because
the portal vein in the liver gets strangulated by scar from cirrhosis. So the pressure inside that
vein increases because its being obstructed and strangulated by scar. And when that happens in
the portal vein, all the tributaries of that portal vein dilate in a compensatory response to get that
pressure off that trunk. Vagal [? Or agal?] veins. Esophageal veins. Gastric veins. They all
undergo dilatation. So in alcoholic liver disease, the esophageal veins can dilate from
longstanding cirrhosis and they can rupture. Thats the common cause of death in alcoholics.
They drown on their own blood. Ascites fluid in the peritoneal cavity, called hydroperitoneum.
Well talk more about the mechanisms of ascites next term. And hypervolemia is associated
with renal disease.

[Slide 69] Disorders Associated with Edema Decreased Plasma Protein Concentration

Decreased plasma protein concentration. Nephrotic syndrome, thats kidney disease.
Cirrhosis, you dont make albumin, youre malnourished, you dont get enough protein, what is
that disease called in African children? Kwashiorkor, so they actually get an endemenous [?]
stomach because they dont have enough protein and they lose oncotic pressure. Alright.

[Slide 70] [Disorders Associated with Edema Increased Vascular Permeability]

Increased vascular permeability, inflammation, burns. These cause injury, and then you
have edema. We dont need to stress over adult respiratory distress syndrome at this point.

[Slide 71] - Disorders Associated with Edema - Lymphatic Obstruction

Transcribed by Jacqueline Heath Lecture Date: 9/24/14
Lymphatic obstruction. Cancer. Tumor can actually compress lymphatics. It can also
compress blood vessels. Well talk more about that next term. Anybody know what post-
surgical lymphedema is? Lymph, lymphatic, edema, associated with lymphatics. You see this
commonly when people have breast cancer and they remove the breast and they cut through all
the lymphatics and you no longer have adequate drainage in that area and your arm swells.
Thats called post-surgical lymphedema. Its an absolutely dreadful and tragic disease.
Fibrosis can cause obstruction in lymphatics. It just wraps around lymphatics. When you
have radiation therapy, you get injury to tissue, you get scarring in relationship to injury. You
can actually wind up with lymphatics obstruction because the scar will wrap its way around the
lymphatic channels.
Sir, your name! [James]. James! Sir!
[James] Post surgical lymphedema. How do you get rid of the, since you cant drain the
fluid, how do you get rid of the fluid? [Thats the best I can understand. Its quiet. Sorry.]
[Vernillo] Its a great question and I dont know the answer to that. If you have post-
surgical lymphedema, how do you get rid of the fluid that builds up in that part of your body? I
dont know! I honestly dont know how they drain it. I dont know if they put a shunt in there to
try to drain it, or a tube, but I honestly dont know thats a good question but I dont know the
surgical modality for that.

[Slide 72] Fluid Accumulation in Body Cavities
Skipped
[Slide 73] Circulatory Disorders
Ok. Fluid loss and overload. Were coming to the end of this.

[Slide 74] Fluid loss and Overload

What time do we have here? We should be out of here, Vernillo. So, fluid loss in
overload. Youre being a good audience because for you to sit here and endure this kind of
abuse And by the way, and obviously its too late to say it, but if you have to go to the
bathroom, I dont want to see this Hmm Go! I always tell my students, but well teach this in
hepatobiliary disease, that your eyeballs turn yellow in jaundice. Its known as icterus. I dont
have retrograde backup icterus in your eyeballs because youre not urinating. Go to the
bathroom. Now, fluid loss and overhydration overload.

[Slide 75] Fluid Loss and Overload
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
Now, fluid loss and overhydration, overload. This is fun. Actually, its not so fun
because these are common conditions. And theyre serious ones.

[Slide 75] Dehydration

So you dehydrate. You can dehydrate if you dont have enough fluid intake. You can
dehydrate if you lose too much fluid. Major cause of death in Africa. Cholera. Because they
dont have sanitation. You get a cholera infection, you get a gastroenteritis, an intestinal disease
from that and you lose a heck of a lot of fluid, you get a luminous, watery diarrhea. And if they
dont treat that effect, you lose a lot of fluid volume. Now if you lose a lot of fluid volume,
either because you dont take enough in or you lose too much, what happens to your blood
volume? It decrease, and if your blood volume decreases, what happens to the beating of your
heart? It decreases to the point that it can stop. There is a philosophical truth there, a very
fundamental philosophical and clinical truth. The heart cant pump if it doesnt have enough
blood. So if you lose a lot of fluid, you lose blood volume and your heart stops pumping and we
call that shock. Ill talk about that in a moment.
It happens, and it happens often in Africa and other developing countries where they
dont have adequate sanitation. We take it for granted that we can drink water out of the tap, but
listen to me very carefully. I dont mean to say this against any company that makes this drink
the water out of your tap already! The water out of your tap has fluoride in it. Its filtered. You
dont have to go buy water in a bottle! Its not safer! Drink it outta of your tap already! And it
costs you a couple pennies for a glass of water. And youre buying a bottle with mountains on it,
and it looks you know very, and they get it out of the Fuji islands, they probably get it out of the
Bisake [?] river! Good grief! Okay.

[Slide 76] Overhydratation

Overhydration. This is when you take in too much fluid. And that can happen from
excessive bodily fluids. And that can be deadly! What is iatrogenic mean? Caused by the
clinician. Not good! And you can wind up with cerebral edema from overhydration, you can end
up with congestive heart failure because your heart will then get an overload of fluid which
would represent an increase in blood volume and work load. Now there are two major forms of
workload typically that the heart faces. One is hypertension. The other that were going to be
talking about in a lot more detail is valvular diseas. When your valves dont work properly in
your heart you cant push blood properly from one chamber to the next with any efficiency. And
so these chambers start to get loaded up with blood and that represents an increased workload.
Increased workloads on the heart can result in ventricular hypertrophy and valve disease. It
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
depends on which valve is damaged, but the concept is both hypertension and valvular disease
can cause an increased workload on the heart and cause the heart to fail.

[Slide 77] Circulatory Disorders
Skipped

[Slide 78] - Shock

Shock! Lets make it simple. Shock means you cant perfuse your organs with blood.
Two major reasons. Actually, four important reasons but well concentrate mostly on two and
mention a third.

[Slide 79] - Consequences

Your heart is not pumping. Its decreasing. Youre not profusing your blood. You have
hypotension. These are the consequences of shock. Lets look more generally then at the kinds of
shock there are that cause these things to happen. Because all of these consequences are the
result of shock. There are different types of shock that Ill describe, but the end result is what
you see on this slide, regardless of the cause of the shock.

[Slide 80] - Types of Shock

So, cardiogenic shock. That means your heart is damaged. What will cause that? I cant
pump, Im in shock. What will cause that? Cardiogenic means originating from the heart. What
will cause that? An infarct is perfect. So you wind up with an MI. That will cause you to go into
shock. If you cant pump, its a woodbox and lilies and 6 feet of dirt for you! So again,
cardiogenic shock means your heart cant pump and an MI is a good cause. Theres another
cause. You get a dead heart. Pumpy pump pump pump, and the heart is dead. What do you
think can happen to that dead heart. Lets say it hasnt scarred yet, which will take maybe two
months at least to get a scar on your heart. And by the way, parenthetically, is a scar on your
heart muscle a good deal? No! Because if youve got a scar which is non-fucntional thats sitting
on your heart are you gonna be conducting current? Not too well. So if your patients have
infarctions theyre going to be on anti-arrhythmics so they dont go into arrhythmia. This is just
the body trying to heal itself. But its not a bargain.
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
Okay, so the point is that even before that happens, three days out, when youve got those
PMNs in the diagram that I showed you, those little things that look like flea crap, and theyre
digesting the heart muscle, thats coagulative necrosis. What do you think can happen to that
wall at that time if that muscle is weakened and necrotic? Give me the obvious answer, because
I know you know it! It can rupture! Thatll kill you. And what can happen is that the blood from
that ruptured, dead wall, will get into the pericardial sac! What do you think that blood is going
to do to the beating of your heart if your heart is still bleeding? Stop it! And thats called cardiac
tamponade? Ill show you the next slide. Thats another form of cardiogenic shock. Its an
outcome of infarction.
Hypovolemic shock- you dont get enough fluid or you have a bacterial infection like a
gastroenteritis, an intestinal infection, youre losing fluid.

[Slide 81] - Cardiogenic Shock

So cardiogenic shock causes, somebody said it, an MI. Somebody mentioned cardiac
tamponade. The middle two. The middle two. What would be the relationship between
pulmonary embolus and cardiogenic shock, now that you are all experts on this, and you now
know it. Oh come on. If you dont know the answer, do you really think Im going to shoot you.
She shakes her head yes. Is your name, is it Kim? [Kit]. Its Kim? No, whats your name? [Kit]
Kit! How did I get that close? Does she have a name stamped on her forehead? Does she have a
badge? No. She told me her name in the first class. Kit, Kit with a T. I was calling her Kim.
What would the relationship be between pulmonary embolism and cardiogenic shock? See how I
start to learn names? Everyone is looking at you like this he really means this. What is the
relationship between cardiogenic shock and pulmonary embolism? I know youre getting tired
and your mind can only digest what the seat can endure, and youre sweating and shmitzing?
And I got it. But were almost coming to the end of the hour here. Why? Whats the connection?
[Answer that I cant understand] Perfect! You block the pulmonary artery and the heart cant
pump and we call that? Acute cor pulmonale, and that leads to cardiogenic shock. Your heart
cant pump, youre in shock. Why myocarditis?
I give you these slides, and I take time to explain all this fun stuff to you. The reason I am
is that I want you to have an understanding of interrelationships of things. For you to go over
here and memorize this stuff, and you take the exam, and as soon as you walk out that door, like
those people on some island in Greek mythology who ate the petals of the lotus flower and
forgot everything? You are lotus petal eaters. All the sudden youve forgotten what youve taken
the exam for because youve taken a big enema dump and you havent made connections. Its
fleeting! And when you get to be my age, memory is even more fleeting! So its better if you
actually understand the interrelationships between things. They give you the hooks.
Why would myocarditis lead to cardiogenic shock? It could be viral, it could be bacterial,
I dont care what causes the inflammation. Its inflammation of the myocardium. Go ahead,
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
someone had their hand up over there. Whats your name? [Dan] Go ahead, is that a sports
jacket? [Uh no] What is it? [I dont know] You dont know? [Its a hoodie] So whats that? Its a
hoodie? Okay, so Ill stay away from you, go ahead. [Edema, uh can stretch the heartI cant
hear the rest]. Okay, thats right! As the British would say, its spot on! When you have
inflammation of your heart muscle, youre absolutely right. Youve pick that up, that you have
inflammation, you have edema, you spread the fibers. You cant conduct a rhythm. Not good.
You go into arrhythmia and die.
Weve mentioned cardiac tamponade when your heart can rupture. All of these things
can cause cardiogenic shock. Nice.

[Slide 82] Hypovolemic Shock

Hypovolemic shock. What is endotoxemia? All youve gotta do is listen. When I went
on sabbatical leave, and I told my students I was doing a masters in ethics, which I did, um, and
they said to me, youre going back to school!? and I said, yeah! And Im being taught by
brilliant people and all I have to do is sit there like you are right now, and listen and be taught. I
dont have to go up there and teach it, theyre teaching me! Think of what a privilege it is to sit
there and have me blab in front of you! Im doing the work over here!
Now, what is endotoxemia? [Infection?] From what? [Bacteria?] What kind of bacteria?
[Gram negative?] Nice. And gram negative bacteria can cause an increase in capillary
permeability. And that is a mechanism of edema. Now if its severe and youve got a lot of
edema, where is that fluid going? Into the tissues! Is it staying in your blood stream? Are you
losing blood volume? Yeah! If you lose enough fluid, you lose blood volume. So endotoxemia
can cause hypovolemic shock. You lose blood volume because you lose fluid. Burns, or if
youre in Brooklyn, boins? Burns. Whatever. Why would burns lead to hypovolemic shock?
Why do you have skin on your body? So you can look pretty! It may make you look handsome
and pretty but why!? What does skin do? [Protects] It protects you from fluid loss. So if you
have enough burns, if you have real burns and you lose a lot of fluid. You lose a lot of volume
and cant retain fluids and you go into shock, thats hypovolemic shock.
Trauma, hemorrhage. You get stabbed on Nolstrand Ave in downtown Brooklyn at 3:00
in the morning. You lose blood. You get hit by a yellow cab on first ave. Or a green cab. It
doesnt make a difference what color. You have trauma, you lose blood. Acute injury to the
brain and spinal cord can lead to a form of hypovolemic shock. Its called neurogenic shock.
Were not going to go into any detail on that. And anaphylaxis, which we mentioned. Again, if
you swell up from a drug.
Ok, so increased permeability is a mechanism, burns, you lose a lot of fluid. All of these
things result in losing fluid.

Transcribed by Jacqueline Heath Lecture Date: 9/24/14
[Slide 83] Diagram

Okay. So this mechanism puts together what you and I have been chatting about. Look
whats central to the diagram. Decreased cardiac output. All roads lead to ROME. There are
many different ways to end up at an endpoint. If youre hypovolemic on the left, if you lose
fluid from end I cant speak anymore, endotoxemia, burns, trauma, anaphylaxis, hemorrhage,
diarrhea, which I mentioned, gastroenteritis and cholera. The end result is that youre
eventuating in decreased blood loss. Decreased blood volume, less blood getting into your
venous system on return. Your heart is not pumping. So hypovolemic shock eventuates in
decreased cardiac output and you die! And cardiogenic shock, as you can see from that arrow
there, goes directly to the heart because its an insult on the pump itself. Whether it be MI,
whether it be myocarditis, whether it be temponade.

[Slide 84] Mechanisms of Cell injury in Shock

Mechanisms of Cell injury and shock, this you can read to your hearts content. Um, this
basically just mentions how cells die in the setting of shock. You have anoxia. Thats the
principal point. You dont have enough oxygen, you dont have enough profusion. If your cells
dont have enough oxygen, they get very unhappy and they die! Okay.

[Slide 85] Septic Shock (Endotoxic Shock)

And septic shock is endotoxic shock, which we mentioned. Causes massive increases
permeability, causes massive loss of fluid, and you collapse. We take these things for granted in
this country that we have the resources to deal with these things.
Um, whats another form of septic shock? Actually, another form of hypovolemic shock
thats infectious? Its in the notes.. Emboli, hemorrhagic fever, thats a nasty sucker! I mean,
they dont have the resources in that country. Ive been to Tanzania. Ive done outreach work in
Tanzania, which is east Africa, um, theyre living in huts. Theyre living off of dirt. Its a pity to
see people have to live like that. Its a real pity. You dont realize how luck you have it until
youre living in developing country And part of the problem thats going on with Ebola virus
in West Africa in seeing all the young in Nigeria is that in Liberia they dont have enough
resources there, so when they develop this, they basically go home and die because theres
nothing anyone can do for them. Here, if we get a physician who gets an infection, what do they
do? They whisk them off to Atlanta or Nebraska, they put them in a containment area and take
care of them. We dont have that. So when you have something like a hemorrhagic shock, you
have something like a hemorrhagic infection, you lose a lot of blood, you have hypovolemic
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
shock. Its like trauma, its like hemorrhaging from being cut. Its the same thing; you lose a lot
of blood, you go into hypovolemic shock, and in this case, it happens to be a bacterium and its
dying. This is something called SIRS, MODS, its uh its basically multiple organ dysfunction
syndrome, Im not gonna get all that happy about it. Dr. Phelan puts it in, she likes to put it in,
its multiple organ dysfunction from an inflammatory response. Do not lose hair follicles over
this.

[Slide 87] Vascular Compensatory Mechanisms in Shock

Now, youre hemorrhaging. Youre losing volume. Or your hearts not pumping. What is
your body going to do if you lose fluid volume or your hearts not pumping and its saying, Im
not perfusing my organs, whether Im losing fluid, or whether my pump is not working. What is
a compensatory response going to be when the body senses a threat and its losing a lot of blood?
Increased heart rate, and whats going to happen to my little arterioles? Theyre going to
constrict. Im going to do everything I can to prevent further blood loss. Thats a compensatory
response. So the renin angiotensin system kicks in, you stimulate water resorption, youre trying
to bring in salt to raise your blood pressure so you can pump. The thing you need to understand
about compensatory response is that theyre a response to usually a situation that is pathological
and it can be acute or chronic. But the compensatory response, regardless of the timeframe, are
short-lived. Unless they can correct the underlying problem, the compensatory response will not
save you. Thats not my phone.
So left ventricular hypertrophy is a compensatory response to hypertension, but unless
they can treat the hypertension and give you drugs to make your heart pump more efficiently,
your heart gets more inefficient. You withstand a greater force at the expense of a weaker heart.
Thats what compensatory responses are. They dont win the day, they try to save you from
immediate fatality. But often they dont win.

[Slide 88] Critical Organs Affected by Shock

These are the critical organs affected by shock. Say yay! everybody say yay its the
last slide! [class: yay!] Yay! I dont hear a woo hoo!! Alright, well take that. Now, any form of
shock, whether it by hypovolemic, whether it be cardiac, is going to eventuate in critical organs
going downhill because you dont have enough blood to perfuse those organs. Be it
hypovolemic, cardiac, be it septic, any form of shock we dont perfuse your organs results in
multiple organ failure. And so pick pretty much any one on the list heart, kidneys lungs, its a
devastating disease. So that now brings us to a close on this now this is what I want you to do.
You know this is what I want you to do. Okay. I want you.. we have conferences next week.
Do you have any exams coming up? [Yes] Of course, why I am I asking that? When is your next
Transcribed by Jacqueline Heath Lecture Date: 9/24/14
exam? [Friday] Friday this Next Friday. October [third]. If I remember correctly and I
think Ive got it right, my conferences start the week after that on October 6
th
. Do you have
anything that October 6
th
week? [one] One? One in what? [CR2, dentistry] Okay, but you dont
have a week loaded with exams, and you have an exam coming up on the third, and what is that
one? [cariology] Listen to me. Important. You have one exam on that Friday. Start looking at
the ntoes now. My students. Youre not going to want to hear this. My students that get As and
Bs in this course. Youre going to think theyre crazy. But thats how students do well. They
dont have to have 350 IQs. They take notes. They go home, that night, or the night after that,
and they manage their time. They listen to the tape and they take notes on the tape. The podcast.
And that podcast can be made available to you on the same day, depending on when the
presentation is offered. They go back and they review the notes. Then they haunt me. They
email me. Haunt me! Email me! Im delighted to answer your questions. Its why you put me
here. Dont ask me a couple days before an exam because youre not going to learn it all. But if
you do that, youll start putting it together so that when you come to the conferences, on the 6
th

of October, you look at these notes, youve already got a working understanding of the material
because Im going to call on you. Oh yeah. Im going to call on your in the conference, even if
youre sitting all that in the back of the room. I said this on my last lecture. This is not a harry
potter film. You are not under the cloak of invisibility. I see you. And so I will go back there and
I will call you and I get the most dramatic reactions that are intensely physiologic. Eh eh! And if
you dont come into lecture and you dont listen to those notes, and you dont take notes and
listen, youre coming into that seminar without any understanding of how to answer my
questions. So how much do you think youre going to get out of my conference? You think four
days before an exam is going to work? Let me tell you why now It aint gonna work. Okay, it
may have worked in your first year courses, but it will not work here. Because this discipline is
going to take your important first year courses, which they are well taught indeed, and apply the
principles. You see how I spent time going over all those slides with you? I didnt just read the
list to you, I taught you the connections on that list. I want you to go back and teach yourself
that so when I ask you a question. Youll understand what Im asking you. This, in essence, is
what patient care is. Its not memorizing letters. Your patient comes in, and you know.. what
are we gonna do today? You have to think your way through it, you have to use this, Im not
telling you this memorization isnt going to work. And you come from a generation that you
have computers, you get all this information, you memorize all of it. As I said, youve got to
integrate it. So Im going to try to my best to teach all my students, who sometimes want to
throw pitchforks at me, and some of them still do, they come to me after the boards, and they tell
me its a combination of the teaching we do, and not just me, Dr. Phelan and many of us who
teach this, and the hard work of very intelligent students that make that happen. And they come
back and they say, well those boards questions were simple. Those board questions were
ridiculous. Those board questions were a lot easier than the questions you give us on the exams!
And you know my response to that? Your patients are going to be tougher than your board
exams, and my exams together! Alright? So this is what I prepare you for. So I wish you a good
week going forward, an exam on Friday, which is cariology? Pretty important stuff, and after
that, a good weekend, and as I said again, when you get to the weekend, go out and have a
couple drinks, and again if you dont drink, my apologies to you, Im sorry.
Transcribed by Jacqueline Heath Lecture Date: 9/24/14