I. Introduction
A. Natural Disease
B. Sudden Death Unexpected Death
C. No Physician
II. No Physician
A. Poverty
B. Christian Scientists
1. Pretty darn old
2. Healthy lifestyle
3. Cancer
C. Fear
1. Breast tumor
2. Rodent ulcer
III. Sudden Death
Death within ~12 hours of symptoms
Went to bed, woke up dead.
C. Hypertensive and atherosclerotic cardiovascular disease
1. 50% Sudden and unexpected
2. 85% ACVD
3. DM makes it worse
4. Tamponade, ruptured infarct 100%
5. AMI, 90%
6. 1-2-3 vessels > 75% stenosis 70%
7. Angina
a. Stable
b. Unstable
c. Prinzmetal’s
8. Claudication
9. Silent killer
a. labile
b. Not show up in Dr.’s Office
c. If physical signs present, it existed.
d. Weasel words
D. Systematic examination of the heart
1. Heart weight 0.05% TBW in kg
a. 350 g M, 300 g F; +/- 40 gm M 30 gm F
b. 2 SD 410, 360
c. Over 500 g sudden death at any time
i. Big hearts don’t beat right
d. Over 750 g cor bovinum
e. IHSS
i. hypertrophic cardiomyopathy
ii. Death in 40’s
iii. Genetic
iv. Wavy fibers
2. Coronary arteries
a. Anomalous origin, course, tunneling
b. Cystic medial necrosis
c. CA dissection women, peripartum
3. Chambers
a. Scarring
b. Thinning
c. Fatty replacement
4. Valves
a. Floppy valves–Marfan’s other collagen vascular diseases
b. Artificial valves
i. Anticoagulation
ii. Mechanical breakage
5. Conduction system
a. Pain in the arse
b. SA node anteriolateral junction of the SVC/RA artery
c. Funny right ventricle
i. Dysplasia of the fibers
ii. Fatty infiltration
d Long QT–molecular studies
i. Mayo Clinic
ii. Takes for bloody ever
6. Commotio Cordis
Vasculature
a Aorta
i. atherosclerosis
ii. CMN
Marfan’s
b. Atherosclerotic aneurysms
i. Smoking
ii. Infrarenal distribution
iii. >5 cm operate
iv. 90% mortality emergent disease
v. 1% elective procedure
vi Gore-tex grafts
c. What other things do you have to graft?
I. Aorta bi-fem, fem distal, fem-popleteal, amputation (fem-chop)
Carotid atherosclerosis
Plaque disruption
E. Pulmonary Emboli Truly instantaneous
1. 90% come from popleteal veins
a. Saddle emboli
2. Hypercoagualable state
a. Balance between clotting and anticoagulants
i. Factor V Leiden
ii. Activated protein C resistance
iii. Lupus anticoagulant (anti cardiolipin antibodies)
iv. OCP
v. Smoking
vi. Obesity
vii. Immobilization
3. History, best predictor is previous PE
a. Hemoptysis, dyspnea, anxiety
b. V/Q mismatch
c. >60% of one lung fatal
d. Little ones resolve
F. CNS
1. Berry Aneurysms
a. Circle of Willis middle and anterior
b. Congenital
c. 1 in 20 adults have one
d. Worst headache of life
2. AVM
a. Blood vessels with arteries going directly to veins
b. Spontaneously bleed
c. Embolize
3. Strokes
a. 60% atherosclerotic
b. 20% embolic
c. Brain exquisitely sensitive to anoxia/ischemia
i. Neurons, astrocytes, oligodendroglia, microglia, vascular endothelium
ii. Sommer’s sector in the Hippocampus, Purkinje cells of cerebellum, watershed
iii. Hemorrhagic vs. ischemic reperfusion injury
iv Calpains, Ca++ channel blockers
v. Lenticulostriate branches of middle cerebral artery a) Anatomic reason Little arteries off big
Total head
4. Epilepsy–SUDEP–SUdden DEath in EPelepsy
a. Poorly controlled males
b. Epileptics drown
c. Driving and epilepsy
i. Some states required report
ii. Kinds of seizures
F. Infectious Diseases
1. Not usually sudden or unexpected
a. These things take time
b. Setting of immunosuppression
i. Lots of immunosuppressed people running around out there
ii. Clostridium perfringens and rectal
2. Nisseria meningiditdis
a. Respiratory route
b. Dorms and barracks
c. Young adults
d. People freak out news media etc.
3. Legonella pneumophilia
a. Water organism
b. Chevy plant
4. Lemierre’s syndrome
a. Supperative jugular thrombophelbitis
b. Fusobacterium necrophorum
c. Toxic shock
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