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ISCHEMIA ACUT A

ISCHEMIA ACUT A. Definitie : obstructia brutala a unui ax arterial “Marea drama arteriala”. Etiologie: 1. Embolia 70% 2. Tromboza 19% 3. Traumatism in momentul de fata o adevarata endemie(traumatisme rutiere). Etiologie. Cauze : embolia

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ISCHEMIA ACUT A

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  1. ISCHEMIA ACUTA

  2. Definitie: obstructia brutala a unui ax arterial “Marea drama arteriala” • Etiologie: 1. Embolia 70% 2. Tromboza 19% 3. Traumatism in momentul de fata o adevarata endemie(traumatisme rutiere)

  3. Etiologie • Cauze: embolia - intrinseci tromboza corpi straini - extrinseci traumatisme compresiuni hipoperfuzii blocarea intoarcerii venoase anevrism aorta

  4. Cauze de embolie • Arteriale: ateroembolism anevrisme • Venoase: tromboflebite (phlegmatia coreulea) embolie pulmonara( cr. presiunea) • Corpi straini • Fragmentetumorale • Embolia gazoasa operatii pe cord, boala de cheson • Embolia grasoasa traumatisme

  5. Cauze de tromboza • Degenerative - ateroscleroza - anevrisme - hematom disecant - ateroscleroza mediei( boala Monckeberg) - medionecroza chistica idiopatica( boala Erdheim)

  6. Cauze de tromboza • Inflamatorii - B. Buerger - arterita granulomatoasa - periartrita nodoasa, lupus - arterite nespecifice

  7. Cauze de tromboza • Traumatisme - directe - indirecte - cateterizari, injectii - chirurgie vasculara - sindrom de loja • Grefe arteriale • Afectiuni hematologice • Alte afectiuni - boli infectioase

  8. Localizare

  9. Fiziopatologie • Obstructie brusca ischemie scade pres de perf tisulara spasm reflex • Tromboza secundara extensie proximal si distal in cele vechi peste 12-24 ore tromboza venoasa • Dezechilibru intre aport-necesar de O2

  10. Fiziopatologie • Microcirculator - staza capilara si edem celular datorat intrarii Na+-iesire K+ tromboza in microcirculatie - edemul comprima capilarele accentueaza staza si aparitia sludge - irevers. leziuni - obstr. capilara cu leucocite

  11. 1. Tulburari metabolice glicoliza anaeroba duce la: - acumulare de metaboliti: acid lactic, piruvic, amine vasodilatatoare -acidoza metabolica/hipopotasemie distructii celulare(membrana) elibereaza K+,P- - distructii musculare elibereaza • mioglobina precipita necroza tubulara IRA( mioglobinurie) • creatinina 2. Sindrom de compartiment Atentie la dezobstructiile tardive

  12. Anatomie Patologica • Exista diferenta de toleranta la ischemie - 4-6 ore nervii periferici(degenerescenta mielinica) placa neuromotorie - 6-8 ore celulele musculare - aprox 12 ore structuri vasculare - peste 12 ore pielea si tes. Subcutanat - peste 24 ore tesut osos

  13. Tablou Clinic • Cei 6 P (G. H. Pratt) - pain atroce “ colica arteriala a lui Fiolle” - pulselessness - pallor - paresthesia - paralysis - prostation

  14. Tablou Clinic • Semne obiective 1. Absenta puls FFI puls capilar 2.Paloare 3. Hipotermie 4. Semne de prognostic intunecat - cianoza - marmoratie - rigiditate musculara - anestezie cutanata - tulburari trofice flictene gangrena

  15. Paraclinic • Neinvaziv - doppler periferic/cardiac • Invaziv - angiografie

  16. Esential pt. diagnostic • Absenta pulsului • Durere • Anamneza

  17. Embolie - bolnav tinar - afectiune cardiaca - absenta lez arteriale - arteriografie imag cupuliforma abs lez aterosclerotice abs colateralelor Tromboza - bolnav mai in virsta - mai putin zgomotos - fara afectiune cardiaca - boala arteriala preexist - arteriografie imaginea obstructiei prezenta colateralelor artera patologica Diagnostic diferential

  18. Evolutie dramatica rapida spre deces

  19. Tratament I. Prim ajutor - diagnostic - heparina cu doza de incarcare de 100-200u/kg 1000U/h; 5000U la 4-6 ore control de anticoagulare 1,5-1,8 val de control - calmarea durerii - vasodilatator papaverina - transport

  20. Tratament • Medicamentos tonicardiace • Chirurgical - embolectomie directa indirecta - trombendarterectomie - by pass • - amputatii Nechiurgical - doze mari de heparina - trombolitic -radiologie interventionala

  21. Doze mari de heparina 20000 u bolus 2000-4000 u/ora I.v • Tromboliza- streptokinaza, urokinaza, activator recombinat al plasminogenului strepto 250000 in 30 min. I.v. in 20-50 ml glucoza 5%; 100000 u/h 24-72 ore uro 4400 u/kg/h 12-24 ore rt-PA 100 mg in 2 ore ATENTIE se poate face si local

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