anatomy of the skeletal system - sums.ac.ir

In the name of God

Physiology: Circulation

Moradian MD, MPH, PhD candidate

Tehran University of Medical Sciences

[email protected]

2015

http://www.tums.ac.ir/

http://books.google.com/books?id=iTlsd7Sk8yoC&printsec=frontcover

http://www.spnu.ac.ir/home.aspx

http://www.sums.ac.ir/

Blood Circulation

Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings

Figure 11.3

http://www.sums.ac.ir/~moradij/wp

Structure of vasculature changes in response to different needs

تئوري‌هبي‌پبيه‌گزدش‌خون

:اعت تافت ياس تا هتاعة تافت خى جزياى1. كچك ػزق تز دفؼي هاد غذا ،O2، CO2 تاثيز

خى گزدػ ػصثي كتزل هظؼي جزياى اي و هجوع تا للة د تزى2.

.هي ؽد كتزل ػصثي پيام تافتي خى جزياى كتزل اس هغتمل ؽزياي فؾار كتزل3.

:اعت د للة تزى كتزل يا هظؼي ا ريذي هخاسى امثاض للة، پوپي لذرت) ؽزياچ

ا (كلي


Vascular system possesses different mechanisms for promoting continuous flow of

blood to the capillaries:

Elastic recoil smooth m. regulation of diameter sphincters

valves

Muscular arteries

‌:نكبت ظزفيتي هماهتي ػزق هذت خى كوتز عزػت :هيزگ سياد همؽغ عؽح تثادل تزاي تيؾتزي

5) دليم در ػثري خى همذار :خى جزياى هيشاى (دليم ليتزدر


VEINS

CAPACITY

VESSELS

HEART

80 mmHg 120 mmHg

SYSTOLE

DIASTOLE

ARTERIES (LOW COMPLIANCE)

CAPILLARIES


محل درصد

گردش سيستميم 84

وريد 64

شريانچه و مىيرگ 13

ريىي 9

قلب 7

توزيع خون در بدن


Even though there are many mechanisms for altering the radius of the vascular

system, pressure still drops as blood moves further away from the heart.



‌(فيزيك‌جزيبن‌خون)اصول‌همودينبميك‌‌

Ohm Law لاى ان اي اي/جزياى لاي Laminar تيغ Turbulent گزدتادي/جزياى هتلاؼن

لاى پآسي لاى لاپلاط

كوپلياظ


P1 P2

P1 > P2

FLOW

FLOW = P

R

P = FLOW x R

R =

mm Hg

L/min

or

ml/sec

mm Hg

ml/sec

Peripheral Resistance Units (PRU)

P

FLOW

Ohm Law قانون اهم


Blood flows down a pressure gradient

The absolute value of the pressure is not important to flow, unlike

the difference in pressure (DP or gradient)

P directly proportional to F


(Poiseuille's equation) اگي -پاسي لاى

Q خى، جزياى هيشاى Pفؾار رگ ؽؼاع r رگ، ؼل L يغكسيت،

ؽؼاع چارم تاى تا خى جزياى هيشاى هغتمين راتؽ آى تا رگ هماهت ػكظ راتؽ

خى 18 پلاعوا) دارد ارتثاغ جزياى هماهت تا يغكسيت (آب تزاتز 3-4

η

P r4

8L Q =


v = Pr2 /8L

Q = vr2

Poiseuille's Law

Pr4

8L Q =

P

R Flow =

R = 8L/r4


Resistance = tendency of the vascular system to oppose flow; Flow =

• Influenced by: length of the tube (L), radius of the tube (r), and viscosity of the

blood () Poiseuille’s Law R = L/r

4

• In a normal human, length of the system is fixed, so blood viscosity and radius of

the blood vessels have the largest effects on resistance

1

R

http://cvphysiology.com/Hemodynamics/H003.htm


All four tubes have the same driving pressure. Which tube has the

greatest flow? The least flow?


Greek alphabet Αα Alpha Νλ Nu

Ββ Beta Ξμ Xi

Γγ Gamma Ον Omicron

Γδ Delta Ππ Pi

Δε Epsilon Ρξ Rho

Εδ Zeta ζο Sigma

Ζε Eta Ση Tau

Θζ Theta Τπ Upsilon

Ηη Iota Φθ Phi

Κθ Kappa Υρ Chi

Λι Lambda Φς Psi

Μκ Mu Χσ Omega

http://en.wikipedia.org/wiki/Greek_alphabet

http://en.wikipedia.org/wiki/Nu_(letter)

http://en.wikipedia.org/wiki/Beta

http://en.wikipedia.org/wiki/Xi_(letter)

http://en.wikipedia.org/wiki/Gamma

http://en.wikipedia.org/wiki/Omicron

http://en.wikipedia.org/wiki/Delta_(letter)

http://en.wikipedia.org/wiki/Pi_(letter)

http://en.wikipedia.org/wiki/Epsilon

http://en.wikipedia.org/wiki/Rho

http://en.wikipedia.org/wiki/Zeta

http://en.wikipedia.org/wiki/Sigma

http://en.wikipedia.org/wiki/Eta

http://en.wikipedia.org/wiki/Tau

http://en.wikipedia.org/wiki/Theta

http://en.wikipedia.org/wiki/Upsilon

http://en.wikipedia.org/wiki/Iota

http://en.wikipedia.org/wiki/Phi

http://en.wikipedia.org/wiki/Kappa

http://en.wikipedia.org/wiki/Chi_(letter)

http://en.wikipedia.org/wiki/Lambda

http://en.wikipedia.org/wiki/Psi_(letter)

http://en.wikipedia.org/wiki/Mu_(letter)

http://en.wikipedia.org/wiki/Omega

غثت :واتكزيت ك خى حجن درصذ ا تعػ اؽغال گيچ

اس يكي ك ؽد هي تز هثز فاكتراي .اعت يغكسيت



‌گزدببدي/لايه‌اي‌جزيبن پيذايؼ احتوال :ريلذس

گزدتادي جزياى يغكعيت، چگالي، V خى، عزػت d رگ لؽز

پاييي احتوال 2000 تالا احتوال 3000

كرتكف صذاي

η


‌:(لاپلاس‌قبنون)‌رگي‌اشببع‌قببليت اي فيثزاي ؽذى كؾيذ تزاي هحيؽي يزي هايچ

.تواذ تالي اتغاع حالت ت رگ ك تؽري رگ ديار در .اعت اؽثاع لاتل ؽزياى اس تيؾتز تز 8 ريذ

لاتليت اؽثاع رگي ; افشايؼ حجن

افشايؼ فؾار × حجن الي


‌(رگي‌پذيزش)‌كمپليبنس افشايؼ جي هيلي ليتز ز اساي ت هي تاذ ك خي همذار .ؽد اثاؽت خى گزدػ اس هؼيي تخؼ در فؾار

لاتليت اؽثاع رگي; كهپلياظ /حجن الي

تاتزايي ، ؽزياى اعت تزاتز 3 ريذا در خى حجن .اعت ؽزياى تزاتز 24 ريذا كهپلياظ

C = V

P

كهپلياظ رگي ; افشايؼ حجن

افشايؼ فؾار


VASCULAR COMPLIANCE

C = V

P P

RE

SS

UR

E (

mm

Hg

)

VOLUME (L)

1 2 3 4

Arteries

Veins

100-

Cv = 24 x Ca

Ca = =2.5 ml/mmHg

Cv = = 60 ml/mmHg

250 ml 100 mmHg

300 ml 5 mmHg


DIFFUSION BETWEEN BLOOD

& INTERSTITIAL FLUID

Plasma Proteins BLOOD

O2 CO2 Glucose

INTERSTITIAL

FLUID

CELL

active transport


نيزوهبي‌استبرلينگ

Kf= 0.01 ml/min/ 100 gr


FLUID BALANCE

40-

30-

20-

10-

0-

PR

ES

SU

RE

(m

mH

g)

Filtration vs. Reabsorption

Outward Forces:

1. Capillary blood pressure

(Pc = 35 to 15 mmHg)

2. Interstitial fluid pressure

(PIF = 0 mmHg)

3. Interstitial fluid colloidal

osmotic pressure

(IF = 3 mmHg) TOTAL = 38 to 18 mmHg

Inward Force:

1. Plasma colloidal osmotic

pressure (C = 28 mmHg)


The lymphatic system is a “scavenger”

system that removes excess fluid, excess

protein molecules, debris, and other matter

from the tissue spaces. Normally, when fluid

enters the terminal lymphatic capillaries, the

lymph vessel walls automatically contract for

a few seconds and pump the fluid into the

blood circulation slight negative pressure

that has been measured for fluid in the

interstitial spaces



“PUMP”

Compression

Smooth muscle contraction

2 - 3 L/day ( 120 ml/hr)

LYMPHATIC CAPILLARY

Special structure of the lymphatic capillaries that permits

passage of substances of high molecular weight into the

lymph.

Anchoring Filaments



Colloid Osmotic Pressure of the Plasma



Filtration Reabsorption

Via lymphatics



Mean Pressures of the Capillary



CAPILLARY FLUID SHIFT

Pout > c Pout < c

Pc Pc

FAVORS FILTRATION FAVORS REABSORPTION

PULMONARY CIRCULATION http://www.sums.ac.ir/~moradij/wp

كتزل جزياى خى

:هظؼي (پيؼ هيزگي اعفكتزاي) آرتزيل :حاد

آدسيي، :رگي كذ گؾاد هاد :هتاتليك يذرصى، پتاعين، يغتاهيي، كزتي، دي اكغيذ

اكغيضى فمذاى (خى فؾار) جزياى تظيوي خد :هيصيك


Metabolism and Blood Flow


كتزل جزياى خى :هظؼي

تافت اعولاريت درج تا رگ تؼذاد :هذت دراس

رگي اذتليال رؽذ :خي رگ رؽذ فاكتراي

(VEGF)، آپيصيي فيثزتلاعتي، رؽذ

رهى ،(تصل الخاع اسهتر) عوپاتيك :ػوهي


Chemical Physiologic role Source Type

NE (a ) Baroreceptor reflex Sympathetic neurons Neural

Endothelin Paracrine Vascular endothelium Local

Serotonin Platelet aggregation, smooth

muscle contraction

Neurons, digestive

tract, platelets

Local, neural

Substance P Pain, increased capillary

permeability

Neurons, digestive

tract

Local, neural

Vasopressin Increase blood pressure during

hemorrhage

Posterior pituitary Hormonal

Angiotensin II Increase blood pressure Plasma hormone Hormonal

Prostacyclin Minimize blood loss from

damaged vessels before

coagulation

endothelium local

Substances causing contraction in vascular

smooth muscle


Chemical Physiologic role Source Type

Nitric oxide Paracrine mediator Endothelium Local

Atrial natriuretic

peptide

Reduce blood pressure Atrial myocardium,

brain

Hormonal

Vasoactive intestinal

peptide

Digestive secretion, relax

smooth muscle

Neurons Neural, hormonal

Histamine Increase blood flow Mast cells Local, systemic

Epinephrine (b2) Enhance local blood flow

to skeletal muscle, heart,

liver

Adrenal medulla Hormonal

Acetylcholine

(muscarinic)

Erection of clitoris, penis Parasympathetic

neurons

neural

Bradykinin Increase blood flow via

nitric oxide

Multiple tissues Local

Adenosine Enhance blood flow to

match metabolism

Hypoxic cells local

Substances that mediate vascular smooth muscle

relaxation

Blood Pressure


What Is Blood Pressure?

Blood pressure is the

force of blood pushing

against the arteries.

Blood is carried to all

parts of your body in

vessels called arteries.

Each time the heart beats

(about 60-70 times a minute

at rest), it pumps out blood

into the arteries.

What Is Blood Pressure?

Your blood pressure is at its

highest when the heart beats,

pumping the blood.

When the heart is at

rest, between beats,

your blood pressure

falls. This is called SYSTOLIC pressure. 120/ 80

This is called DIASTOLIC pressure.

Bottom number

http://www.hsfpe.org/


Arterial Blood Pressure (continued)

Diastolic pressure is more important, because diastolic

period is longer than the systolic period in the cardiac

cycle. است تر مهم دياستىل فشار

Pulse pressure = Systolic BP – Diastolic BP. فشار نبض

Mean arterial pressure = Diastolic BP + 1/3 Pulse press.

In normal adult 120/80 mmHg


ثط فؾار

عيغتل فؾار تيي تزاختلاف هثز ػاهل :(ثط فؾار)دياعتل

اي حجن عمغ - عيغتل فؾار رفتي تالا :ظزت دياعتل فؾار

فؾار افشايؼ هؼاي ت تدى كوتز :كهپلياظ حجن رفتي تالا تا اعت


Effects of gravity on arterial

and venous pressures.

Each cm of distance

produces a 0.77 mmHg

change.



Click to edit Master title style How to Measure Blood

Pressure

Vital Signs in the Ambulatory Setting: An Evidence-Based Approach

Cecelia L. Crawford

RN, MSN


Sphygmomanometer

Automated

BpTRU™ BP Devices

http://www.vsmmedtech.com/

Blood Pressure – An Overview

Equipment for accurate BP

measurement

Functional & calibrated machine

Right-sized cuff

Pen or pencil

Flowsheet, chart, or medical record

Clean hands and fingers!

Patient in a comfortable & relaxed

position

Wait 5 minutes if patient was active

Right Cuff in the Right Place

Cuff width = 20% more than upper arm

diameter

Cuff width = 2/3 of upper arm length

Cuff bladder length encircles 80% of upper arm

Cuff arrow aligned with brachial artery

Inside of the elbow

http://connection.lww.com/products/evans-smith

Blood Pressure Procedure

1. Wash hands & put on gloves, if appropriate

2. Provide privacy

3. Assist patient to a comfortable & relaxed position

4. Back supported, legs uncrossed

Blood Pressure – An Overview CAUSE SYSTOLIC BP CORRECTIVE ACTION

Sit without back support + 6 to 10 Support back (sit in chair)

Full bladder + 15 Empty bladder before BP taken

Tobacco/caffeine use + 6 to 11 Don’t use before clinic appointment

BP taken when arm is:

Parallel to body

Unsupported

Elbow too high

Elbow too low

+ 9 to 13

+ 1 to 7

+ 5

False low

While seated in chair, patient’s arm

must be straight out and supported,

with elbow at heart level

“White coat” reaction + 11 to 28 Have someone else take the BP

Talking or hand gestures + 7 No talking or use of hands during BP

Cuff too narrow/small + 8 to 10

Right-sized cuff properly placed over

bare upper arm Cuff too wide/large False low

Cuff not centered + 4

Cuff over clothing + 5 to 50 (Pickering et al., 2005; Perry & Potter, 2006)

Blood Pressure Procedure 4. Unplug & roll machine near the patient

5. Ensure connecter hose will reach

6. Turn on machine to self-test

7. Select proper arm cuff size

– Small adult cuff

– Medium adult cuff

– Large adult cuff

– Pediatric cuff

http://www.pharmj.com/Hospital/Editorial/200501/meetings/p27ashp.html






Blood Pressure Procedure

8. Expose upper arm completely – Do not put cuff over clothing! – Machine can’t “hear” the pulse with clothing

9. Upper arm properly supported at level 10. Squeeze air from cuff & attach connector hose and Check for kinks 11. Wrap flat cuff snugly around the upper arm 12. Arrow mark on cuff is at inside of elbow

Blood Pressure Procedure 13. Set machine for adult or pediatric BP

14. Press start button

15. No talking or hand gestures by you or the patient

16. Check digital display for BP when cuff is fully deflated

17. Repeat BPs may be taken if 2 minutes apart

18. Remove cuff and replace clothing


http://www.sums.ac.ir/~moradij/wp 3

RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSUREMEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE

2.

• The cuff must be level with heart.

• If arm circumference exceeds 33 cm,a large cuff must be used.

• Place stethoscope diaphragm over

brachia l artery.

2.2.

•• The cuff must be level with heart.The cuff must be level with heart.

•• If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.

•• Place stethoscope diaphragm overPlace stethoscope diaphragm over

brachia l artery.brachia l artery.

1.

• The patient shouldbe relaxed and the

arm must besupported.

• Ensure no tight

clothing constrictsthe arm.

1.1.

•• The patient shouldThe patient shouldbe relaxed and thebe relaxed and the

arm must bearm must besupported.supported.

•• Ensure no tightEnsure no tight

clothing constrictsclothing constrictsthe arm.the arm.

3.

• The column ofmercury must be

vertical .

• Infla te to occlude thepulse. Deflate at 2 to

3 mm/s. Measure

systolic (first sound)and diastolic

(disappearance) tonearest 2 mm Hg.

3.3.

•• The column ofThe column ofmercury must bemercury must be

vertical .vertical .

•• Infla te to occlude theInfla te to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to

3 mm/s. Measure3 mm/s. Measure

systolic (first sound)systolic (first sound)and diastolicand diastolic

(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.

StethoscopeStethoscope

MercuryMercury

machinemachine

MEASURING BLOOD PRESSURE

TURBULENT FLOW

1. Cuff pressure > systolic blood pressure--No sound.

2. The first sound is heard at peak systolic pressure.

3. Sounds are heard while cuff pressure < blood pressure.

4. Sound disappears when cuff pressure < diastolic pressure.


Factors affecting ABP: Sex … M > F …due to hormones/ equal at menopause.

Age … Elderly > children …due to atherosclerosis.

Emotions … due to secretion of adrenaline &

noradrenaline.

Exercise … due to venous return.

Hormones … (e.g. Adrenaline, noradrenaline, thyroid H).

Gravity … Lower limbs > upper limbs.

Race … Orientals > Westerns … ? dietry factors, or

weather.

Sleep … due to venous return.

Pregnancy … due to metabolism. http://www.sums.ac.ir/~moradij/wp

What factors influence blood pressure?

Cardiac Output (Stroke volume×HR)

(عزػت ظزتاى×اي ظزت حجن)د للة تزى

Total Peripheral Resistance

هماهت ػزلي

Co= BP× TPR


Factors determining ABP:

Blood Pressure = Cardiac Output × Peripheral Resistance

(BP) (CO) Flow

(PR) Diameter of arterioles

BP depends on:

1. Cardiac output CO = SV X HR.

2. Peripheral resistance.

3. Blood volume.


Regulation of ABP

Maintaining B.P. is important to ensure a steady blood flow (perfusion) to tissues.

B.P. is regulated neurally through centers in medulla oblongata:

1. Vasomotor Center (V.M.C.), or (pressor area):

Sympathetic fibers.

2. Cardiac Inhibitory Center (C.I.C.), or (depressor area):

Parasympathetic fibers (vagus).


Regulation of ABP

حفظ جزياى خى تزاي تزلزاري جزياى هذام خى ت تافت ا لاسم اعت

جزياى خى اس ؼزيك هزاكشي در تصل الخاع ت ؽكل ػصثي :تظين هي ؽد

كاؼ تزى د هماهت هار عوپاتيك هزكش اسهتر ػزق

گيزذ فؾار كن در جذار دليشا ؽزياى ا ريي


cardiac control centers in medulla oblongata

Regulation of ABP (continued)

1. Cardiacaccelerator center (V.M.C)

2. Cardiacinhibitory center (C.I.C)

Sympathetic n. fibers Parasympathetic n. fibers

Regulatory mechanisms depend on: a. Fast acting reflexes: Concerned by controlling CO (SV, HR), & PR.

b. Long-term mechanism: Concerned mainly by regulating the blood volume.


افشايؼ ظزتاى للة

تزگؾت تيؾتز خى ت دليش

اتغاع ديار دليش

گؾادي رفلكغي آرتزيل ا

هار تزؽح رهى ظذ ادراري

افشايؼ حجن ادرار

خى فؾار كاؼ حجن خى


Blood pressure Controls Mechanisms

Fast Acting (Neural) ( لي)هكايغن عزيغ

Baro receptor feedback تاررعپتر

Chemo receptors ( تفظ-افت سياد فؾار)گيزذ ؽيوايي

CNS Ischemia كوثد اكغيضى دعتگا ػصثي هزكشي


1. Baroreceptors reflex:

Baro receptors are receptors found in carotid

sinus & aortic arch.

Are stimulated by changes in BP.

BP

+ Baroreceptors

= V.M.C ++ C.I.C

= Sympathetic

Vasodilatation & TPR

+ Parasympathetic

Slowing of SA node ( HR) & CO


2. Chemoreceptors reflex: Chemoreceptors are receptors found in carotid & aortic bodies.

Are stimulated by chemical changes in blood mainly hypoxia ( O2), hypercapnia ( CO2), & pH changes.

BP

+ Chemoreceptors ++ V.M.C = C.I.C

+ Sympathetic

Vasoconstriction & TPR

= Parasympathetic

HR

Haemorrhage

Hypoxia

+ Adrenal medulla


Peripheral chemoreceptors

regulating respiration

Aortic bodies* On aorta

Send sensory info to medulla

through X (vagus n)

Carotid bodies+ At fork of common carotid

artery

Send info mainly through IX

(glossopharyngeal n)

*

+


Regulation of Breathing


Short term (Minutes) كتا هذت

Renin-Angitensin

Vessels Relaxation كؾيذ ؽذؽل ؽذى رگ

Fluid Shift هيزگي تغييز هحل هايغ


Renin

Aldosterone

Adrenal cortex

Corticosterone

Angiotensinogen

(Lungs)

renal blood flow &/or Na+

++ Juxtaglomerular apparatus of kidneys (considered volume receptors)

Angiotensin I

Converting enzymes

Angiotensin II (powerful

vasoconstrictor)

Angiotensin III (powerful

vasoconstrictor)

Renin-Angiotensin System:

Aldosterone is the main regulator of Na+ retention. http://www.sums.ac.ir/~moradij/wp


Long term (Hours) دراسهذت

Kidnyes ا ديرس فؾاري كلي

Renin- Angiotensin-Aldostrone


Regulation of Blood Volume:

A long-term regulatory mechanism.

Mainly renal:

1. Renin-Angiotensin System.

2. Anti-diuretic hormone (ADH), or

vasopressin.

3. Low-pressure volume receptors.


HORMONAL REGULATION

Epinephrine & Norepinephrine

From the adrenal medulla

Renin-angiotensin-aldosterone

Renin from the kidney

Angiotensin, a plasma protein

Aldosterone from the adrenal cortex

Vasopressin (Antidiuretic Hormone-ADH)

ADH from the posterior pituitary


3. Other Vasomotor Reflexes:

1. Atrial stretch receptor reflex:

Venous Return ++ atrial stretch receptors

reflex vasodilatation & BP.

2. Thermoreceptors: (in skin/or hypothalamus)

• Exposure to heat vasodilatation.

• Exposure to cold vasoconstriction.

3. Pulmonary receptors:

Lung inflation vasoconstriction.


ػاهل هثز تز تزگؾت خى در عيازگ ا

ا پوپ (جي هيلي ليتز 3 تا 6) عي

ػعلاي پوپ

عوپاتيك امثاض


گزدػ خى كززي

للة چپ عوت ت عيازگي خى رد :تثشيي ؽت

(O2 104 ← 95 فؾار)

دياعتلي خزعاي

عي افشيؼ تا آاعتهس

ػزق گؾادي β تگي α آدرزصيك گيزذ

كزز گؾادي :للة هايچ اس ؾت :آدسييhttp://www.sums.ac.ir/~moradij/wp

Will all the students pass the exam?


If they try their best!


anatomy of the skeletal system - sums.ac.ir

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