End organ damage

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End organ damage is severe impairment of major body organs due to high blood pressure or states of low blood pressure or low blood volume. [1] This can present as a heart attack or heart failure, pulmonary edema, neurologic deficits including a stroke, or acute kidney failure. [2]

Contents

Pathophysiology

End organ damage typically occurs in either states of very high blood pressure or states of shock where there is very low blood pressure or low circulating blood volume. [1]

Hypertensive

When blood pressures are critically high (>180/120 mm Hg) or the rate of rise in blood pressure is rapid, a large volume of blood circulating in a small space creates turbulence and can damage the inner lining of blood vessels. The body’s repair systems are activated by damage and circulating blood components, like platelets, work on repair. The deposition of platelets can clutter the vessel space and impair the body’s natural ability to produce nitrous oxide, which would dilate blood vessels and help lower blood pressure. When high pressure is pushing on the walls of narrowed blood vessels, fluid leaves the inside of blood vessels and moves to the space just outside. This impairs necessary blood flow and cuts off circulating oxygen, which can lead to tissue death and permanent damage to the brain, heart, arteries, and kidneys. This may occur as a result of chronic or poorly controlled hypertension, illicit drug use, or as a complication of pregnancy. [3] Recent studies have shown that activation of the immune system may also be closely involved with the development of end organ damage in hypertensive states. [4]

Shock

Shock is when the body does not have adequate circulation to provide oxygen to body tissues. Hypovolemic shock occurs due to low circulating volume of fluids in the blood vessels. Distributive shock, which can occur due to anaphylaxis or sepsis, results in widespread dilation of blood vessels in the body resulting in lower blood pressure. In cases of extremely low circulating volume or inability to maintain an adequate blood pressure, body tissues do not receive enough oxygen and nutrients. [5] When tissues lack oxygen and adequate circulation, organs can fail. [6]

Clinical presentation

Hypertensive

Important definitions

Presentation

Source: [3]

Shock

Important definitions

  • Systemic Inflammatory Response Syndrome (SIRS) meets any two criteria: [7]
    • Body temperature >38 or <36 degrees Celsius
    • Heart rate >90 beats per minute
    • Respiratory rate >20 breaths per minute or partial pressure CO2 <32 mm Hg
    • White blood cell count >12000 or <4000 per microliter or >10% immature forms or bands
  • qSOFA score helps predict organ dysfunction outside of the intensive care unit by assessing 3 components: [7]
    • Systolic blood pressure <100 mm Hg
    • Maximum respiratory rate >21 breaths per minute
    • Lowest Glasgow coma score <15

Presentation

Source: [8]

  • Altered mental status - person may not be oriented to person, place, or time
  • Delayed capillary refill - skin may be pale or mottled, limbs may be cool
  • Little or no urine output - poor urine output
  • Absent bowel sounds

Evaluation and work-up

Physical examination

Labs

Imaging

Management

Hypertensive

When there is concern for the presence or development of end organ damage, blood pressure should be lowered emergently with intravenous antihypertensive medications. Patients should be admitted to the hospital to be closely monitored for complications of end organ damage, notably strokes. Blood pressure should be lowered a maximum of 10% over the first hour and 25% over the first two hours as rapid lowering of blood pressure can lead to decreased blood flow in the brain and cause the development of an ischemic stroke. Once blood pressure is stabilized, patients can be changed from intravenous medications to oral. [3]

For patients with long-standing hypertension, patient education on the importance of consistently taking prescribed medications and keeping blood pressure well-controlled is critical. [2] Additionally, future treatments may focus not only on blood pressure control but also the reduction of local inflammation that can lead to end organ damage. [4]

In pregnant patients where there is concern for pre-eclampsia, patients should be given magnesium sulfate and admitted. Urine output, breathing, and reflexes should be monitored closely with concern for the development of worsening kidney function and magnesium toxicity. Systolic blood pressure should be treated with antihypertensive medications only if it is higher than 160 mm Hg. [2]

Shock

When a patient is in shock, the development of end organ damage is typically due to circulating blood volume or blood pressure that is not high enough to maintain oxygen and nutrient supply to vital organs. Initial treatment is focused on stabilizing the patient. Fluids are given to increase circulating blood volume. Vasopressors, medications that constrict blood vessels, can also be given in order to maintain a higher blood pressure and help vital organs receive enough oxygen and nutrients. High-dose steroids, like hydrocortisone, may also help maintain blood pressures in patients. Close monitoring in the critical care unit is often necessary to measure blood pressures. [7]

The next step in treating end organ damage due to septic shock is to identify the source of the infection and treat it. Broad-spectrum antibiotics can be started that will treat many potential bacteria before cultures grow the specific bacteria that is causing the infection. Once cultures identify the culprit of the infection, the antibiotic therapy can be changed so that it is only covering what needs to be treated. Treatment of the source of infection should resolve low blood pressures that compromise vital organ function. Complications, including acute respiratory distress syndrome, acute kidney injury, and electrolyte abnormalities, can be treated proactively and managed on an individual basis. [7]

Related Research Articles

<span class="mw-page-title-main">Edema</span> Accumulation of excess fluid in body tissue

Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area may feel heavy, and joint stiffness. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Hypertension</span> Long-term high blood pressure in the arteries

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

<span class="mw-page-title-main">Shock (circulatory)</span> Medical condition of insufficient blood flow

Shock is the state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms of shock may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest, as complications worsen.

<span class="mw-page-title-main">Sepsis</span> Life-threatening organ dysfunction triggered by infection

Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs.

<span class="mw-page-title-main">Fluid replacement</span>

Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.

<span class="mw-page-title-main">Septic shock</span> Dangerously low blood pressure due to damage from an organ infection

Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defines septic shock as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by requiring a vasopressor to maintain a mean arterial pressure of 65 mm Hg or greater and having serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%.

<span class="mw-page-title-main">Hypotension</span> Abnormally low blood pressure

Hypotension, also known as low blood pressure, is a cardiovascular condition characterized by abnormally reduced blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood and is indicated by two numbers, the systolic blood pressure and the diastolic blood pressure, which are the maximum and minimum blood pressures within the cardiac cycle, respectively. A systolic blood pressure of less than 90 millimeters of mercury (mmHg) or diastolic of less than 60 mmHg is generally considered to be hypotension. Different numbers apply to children. However, in practice, blood pressure is considered too low only if noticeable symptoms are present.

<span class="mw-page-title-main">Hypovolemia</span> Low blood volume

Hypovolemia, also known as volume depletion or volume contraction, is a state of abnormally low extracellular fluid in the body. This may be due to either a loss of both salt and water or a decrease in blood volume. Hypovolemia refers to the loss of extracellular fluid and should not be confused with dehydration.

Antihypertensives are a class of drugs that are used to treat hypertension. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke, heart failure, kidney failure and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and can reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used medications are thiazide diuretics, calcium channel blockers, ACE inhibitors, angiotensin II receptor antagonists (ARBs), and beta blockers.

<span class="mw-page-title-main">Hypovolemic shock</span> Medical condition

Hypovolemic shock is a form of shock caused by severe hypovolemia. It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a medical emergency; if left untreated, the insufficient blood flow can cause damage to organs, leading to multiple organ failure.

A complication in medicine, or medical complication, is an unfavorable result of a disease, health condition, or treatment. Complications may adversely affect the prognosis, or outcome, of a disease. Complications generally involve a worsening in the severity of the disease or the development of new signs, symptoms, or pathological changes that may become widespread throughout the body and affect other organ systems. Thus, complications may lead to the development of new diseases resulting from previously existing diseases. Complications may also arise as a result of various treatments.

<span class="mw-page-title-main">Hypertensive kidney disease</span> Medical condition

Hypertensive kidney disease is a medical condition referring to damage to the kidney due to chronic high blood pressure. It manifests as hypertensive nephrosclerosis. It should be distinguished from renovascular hypertension, which is a form of secondary hypertension, and thus has opposite direction of causation.

<span class="mw-page-title-main">Nephritic syndrome</span> Medical condition

Nephritic syndrome is a syndrome comprising signs of nephritis, which is kidney disease involving inflammation. It often occurs in the glomerulus, where it is called glomerulonephritis. Glomerulonephritis is characterized by inflammation and thinning of the glomerular basement membrane and the occurrence of small pores in the podocytes of the glomerulus. These pores become large enough to permit both proteins and red blood cells to pass into the urine. By contrast, nephrotic syndrome is characterized by proteinuria and a constellation of other symptoms that specifically do not include hematuria. Nephritic syndrome, like nephrotic syndrome, may involve low level of albumin in the blood due to the protein albumin moving from the blood to the urine.

<span class="mw-page-title-main">Hypertensive emergency</span> Very high blood pressure and signs of organ damage

A hypertensive emergency is very high blood pressure with potentially life-threatening symptoms and signs of acute damage to one or more organ systems. It is different from a hypertensive urgency by this additional evidence for impending irreversible hypertension-mediated organ damage (HMOD). Blood pressure is often above 200/120 mmHg, however there are no universally accepted cutoff values.

<span class="mw-page-title-main">Acute decompensated heart failure</span> Medical condition

Acute decompensated heart failure (ADHF) is a sudden worsening of the signs and symptoms of heart failure, which typically includes difficulty breathing (dyspnea), leg or feet swelling, and fatigue. ADHF is a common and potentially serious cause of acute respiratory distress. The condition is caused by severe congestion of multiple organs by fluid that is inadequately circulated by the failing heart. An attack of decompensation can be caused by underlying medical illness, such as myocardial infarction, an abnormal heart rhythm, infection, or thyroid disease.

<span class="mw-page-title-main">Pathophysiology of hypertension</span>

Pathophysiology is a study which explains the function of the body as it relates to diseases and conditions. The pathophysiology of hypertension is an area which attempts to explain mechanistically the causes of hypertension, which is a chronic disease characterized by elevation of blood pressure. Hypertension can be classified by cause as either essential or secondary. About 90–95% of hypertension is essential hypertension. Some authorities define essential hypertension as that which has no known explanation, while others define its cause as being due to overconsumption of sodium and underconsumption of potassium. Secondary hypertension indicates that the hypertension is a result of a specific underlying condition with a well-known mechanism, such as chronic kidney disease, narrowing of the aorta or kidney arteries, or endocrine disorders such as excess aldosterone, cortisol, or catecholamines. Persistent hypertension is a major risk factor for hypertensive heart disease, coronary artery disease, stroke, aortic aneurysm, peripheral artery disease, and chronic kidney disease.

<span class="mw-page-title-main">Complications of hypertension</span>

Complications of hypertension are clinical outcomes that result from persistent elevation of blood pressure. Hypertension is a risk factor for all clinical manifestations of atherosclerosis since it is a risk factor for atherosclerosis itself. It is an independent predisposing factor for heart failure, coronary artery disease, stroke, kidney disease, and peripheral arterial disease. It is the most important risk factor for cardiovascular morbidity and mortality, in industrialized countries.

Hypertensive disease of pregnancy, also known as maternal hypertensive disorder, is a group of high blood pressure disorders that include preeclampsia, preeclampsia superimposed on chronic hypertension, gestational hypertension, and chronic hypertension.

<span class="mw-page-title-main">Labile hypertension</span> Medical condition

Labile hypertension occurs when there are unexpected changes in blood pressure. The term can be used to describe when people have blood pressure measurements that abruptly fluctuates from being abnormally high, approximately 140/90mm Hg or over and returns to its normal range.

<span class="mw-page-title-main">Hypertension and the brain</span>

Hypertension is a condition characterized by an elevated blood pressure in which the long term consequences include cardiovascular disease, kidney disease, adrenal gland tumors, vision impairment, memory loss, metabolic syndrome, stroke and dementia. It affects nearly 1 in 2 Americans and remains as a contributing cause of death in the United States. There are many genetic and environmental factors involved with the development of hypertension including genetics, diet, and stress.

References

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  7. 1 2 3 4 Chakraborty RK, Burns B (May 2023). "Systemic Inflammatory Response Syndrome.". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   31613449.
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