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Emergency Medicine PreClinEazy

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Summary

This medical teaching session will discuss kidney injury and metabolic acidosis and their connection to homeostasis and how medical professionals can use anti-coagulants, ACE inhibitors, and angiotensin receptor blockers to help manage high blood pressure and help differentiate between the different causes of AKI. Additionally, topics such as electrolytes and sodium/chlorine levels, prostaglandins, and antidiuretic hormones will be discussed to provide insights into patient diagnosis, management, and long-term care.

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Learning objectives

  1. Explain the physiological mechanisms of GFR regulation, with a focus on kidney injury.
  2. Identify the different types of prerenal, intrinsic and postrenal causes of kidney injury.
  3. Describe the pathological markers of kidney injury, including increased creatinine and urea.
  4. Explain how drugs such as ACE inhibitors affect GFR and how they are used to treat kidney injury.
  5. Outline the symptoms of hypocalcemia caused by chronic kidney disease and list the causes of hypercalcemia.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

um, kidney injury on, then. Also, metabolic acidosis, um, and a beegees say, um, first of all, on normal, Jeff are is around 125 millimeters per minute on this could be increased or decreased to maintain the g f r a z a form of homeostasis. Say, um, if the Jeff are had is high. And that would be because the Afrin tortilleria was dilated, allowing lots of blood into the gonorrhea. This and then if the Afrin tortilleria was constricted when that blood was staying a glimmering, less under high pressure and lots of really doubt, um, equally, uh, if the Afrin arterial leading to the gum realist, it's constricted. Then you're gonna end up, um, having a lower BP in the primary less just because less blood is going there and say mystery the effort and arterials dilated, then don't have that back pressure of blood. So you're gonna end up for the love of Jeff are? And ultimately, if you have allergic far, you can remove toxins print blood on, But I could build up and you might end up with today. Okay. Okay. So business and things that might affect Jeff are so prostaglandins on can dilate the Afrin Tarsal area, which would increase year far, um, and obviously and said's, um, affect the, um, the Cox two inhibitor. And then that will mean less prostaglandins it produced. So when you take 10 sets, then you can end up with low prostaglandins. Then you can't dilate your Afrin arterial. Uh, and that's a result you have large fr. And that's one reason that Infects could be hard for having a K I. Okay, then anti. That's released when the atria stretched and it signifies volume. Able AIDS on N. P also dilate different arterial increasing Jeff are more blood leaks out, decreasing a brew blood volume. So the heart's more likely to cope, um, than constriction of the effort Arterial Um, if you have and the attention to then that's going to cause the effort to to constrict, increasing that BP in the laundry lists on forcing blood to leak out. And then, obviously, if you haven't aged inhibitor or an angiotensin receptor blocker, then that's not gonna happen. The effort arterial dilate and then you break get the increase in Jeff are so that's again the reason why it's inhibitors and angiotensin receptor blockers and know helpful and kidney injury. Okay, maybe one to change the BP. So when the blood pressure's high on that Afrin arterial is gonna be stretched on the G f, I would ultimately be too high. Um, and they could be too high pressures in the glomerulonephritis. So to bring that back down, there's actually the muscles within. The arterial will contract in response to the different, uh, tear dilating. And as a result, the Jeff I'll be brought back down day now I want TGV in advance on for the animation on this slide. It's quite over overwhelming, but you can tell last procrastinating by making it okay, So normally you got your electrolytes in your blood on your sodium, and chlorine will be traveling around in the blood. They'll be, and ouch filtrated through the primary less into the cheap on cheap you. And then the Jackson Glomerulus apparatus on contains macular dentist hours. These will detect how much sodium, and it's a cheap you on. If there's lots of sodium, then it was signified that there's a large increase in GFO. So you then produce Brennan um on D. Um, sorry. deal would produce the last remnant on obviously ran in the brain. Abscess during system would increase year far. So if you have less run in, then you can end up decreasing your BP on, um, also in response to a high gear far you're produced a dentist. Mean adenosine constricts the Afrin tall T Rowe, um, with your city decreased. Okay, then if you have two little on say the influence noted, then, um, accidents cells would attack the low sodium I know it release more evident to increase the BP increased side. I'm leaving on from that causes of a k I on this quite difficult topic on Hopefully I'll explain the re. A creatinine ratio is a hard concept to understand. So don't worry too much If you don't get it, the festival Can I ask The chat brought us and pre renal causes of a naked eye. Yeah. So there's some really good answers there. Those people saying hyperperfusion with dehydration. Um uh, death. Um, someone said a breathing test on isis could start finding time. Um, so ultimately, if you don't have the blood going to the, um, going to the kidney, then you're not going to perfused the kidney, and then you end up with a K I. So that's not no kidneys for in itself. But if you have set, this blood test is going to dilate, hypoglycemia is not gonna have the BP. Then re no asterixis. Nice. This is going to restrict movement of blood toward the kidney. Okay, um, that Breanna cause it's on anyone, then you breathe causes off a k. I see. Okay, casing. Really good stuff in the chat. Okay, so I said toxicity. So lots of you speak about No, she's make about drugs. Um, Yep. Say light antibiotics. Um, you can get achy cheaper in a crisis. So if you have prolonged prerenal a k, then if you start the kidneys and blood over a long period of time, you can end up with the crisis of the kidney on from reality is like glomerulonephritis tissues have said on. That was a smooth vessel. Disease, like smoke. Passive past. Yeah. Um, Okay. Now, last one pastry. Know anyone? Think pastry goods. These of freedom causes. Okay. Okay. The last people said stones. That's really good. So ultimately, if you can't, um, Debra of the products of the filter blood. Maybe have care your text own. Um, Then you're gonna get the backflow hand, two views on collecting ducts, and then, um, you're not gonna be able to I'm carry out efficient filtration and the same with enlarged prostates or other obstructions. You're gonna get a blockage, and that's gonna back flow and then damage. Yeah, really good stuff. Okay. Now, um, help differentiate between the different causes off on a K I You can look at the urea crafts mean ratio. Um, there might be easiest here to look at the last column. So because is prerenal or three? No history? No. Okay, so in pre Reno and you're going to end up with a high your ear and a normal craftsman on. Then, in post Reno Reno, you end up with a low creatinine labia on a high or normal craftsman Onda. I'm going to try and explain why I'll go back to the slides, but hopefully the next line you have the help. Okay. Um Okay, so so you have a pre renal cause of an a k. I. So dehydration. You are really dehydrated. Then you end up. Um producing a d H on d. You re absorbed more water on on, but then you end up bringing your ear and crashed me back into the blood. If we get back outside, have 50% of floated. Urea is reabsorbed in the proximal convoluted give you. So if you have a functioning, um, kidney, then you're going to reabsorb that area and then creatinine is not really, um, so it if the kidney is fine, you're going to reabsorb crass urea. But you're not going to be absorbed. Craft me the head when you produce the ADH. Yeah, you're going to bring back your area. Um, I said you're gonna bring back crafts name, but, um, mostly, you know, you're not gonna be a pretty bring back fascinated about, you know, can be bringing back crafts name. Um, And that would be filtered. I said, don't be back. Last name Cathy is gonna be normal, but you are reabsorbing urea. You really high. Okay, um, and then in post renal causes, there's gonna be damage to the kidney. And that means that you're not gonna get absorption pre, uh, urea, because the part on the cheap you that causes reabsorbing off the urea, which is the proximal collecting ducts, and it's damaged. So then you can't absorb any risk area. Yeah, I understand. That's confusing on. I'm happy to answer any questions at the end. That would be fun. The main take home is if you have a higher urea craft mean ratio, then the course is gonna be prerenal. Okay, just other causes of diarrhea. So, um, dehydration, you end up with a higher concentration on If you break down, have more protein in your diet with this. Produce more your area. Um, gee, I pleads, um, it's a really, um they cause of high breo, especially in emergencies settings. Um, on. Then you can also get, um, syndrome of uremia You really it's too high. And you actually got symptoms of that. So hyperkalemic. Um, okay, all right. So often on you got hyperckemia. If you have an a k i onda, that's because your GFI will be low and then you can't feel too much potassium on then and that's going to stay in the blood. Um, and then the same ace inhibitors, like we said before, you're gonna have them that low. Jeff are and then really metabolic acidosis. You get at it in the blood and having acids in the blood in itself and that causing potassium to be art of cells and into the blood. That course is a high potassium. Um, and then you can also get, uh, life threatening written years, Which is why we're worried about high potassium and hyperckemia. Um, and then you can treat that with time, incident and extras infusions like pretend the diabetes case. No hypo. Oh, um, how senior? Okay, they before me one to this slides. Anyone know why you get hypokalemia in kidney injuries or kidney failure? Okay, I brought question maybe. Uh huh. So kidneys play a really important role in metabolizing, um, bit mindy on producing counter trial, which is a whole main, um, that causes more calcium to be absorbed from the bone on from the intestines. So, uh, even if you're getting enough vitamin D in your diet and from sunlight, if your kidneys aren't functioning, then we're not going to be able to you convert the vitamin D into you a useful had a breakdown product like cats, the trial. So you're just gonna end up with locks of 25 hydroxy on cholecalciferol. Oh, in your blood. But not the new store cancer trial. Richard, shoot through absorbing calcium. So ultimately, if you have chronic kidney disease, then you're going to end up, um, with lots of, um 25 hydroxy cut colon has it for Oh, not enough cancer trial. And then ultimately not enough for absorption of know the not absorption. Oh, uh, cause it. And here, distance symptoms of hypocalcemia. Okay, Just by where? On the topic curve. Calcium. Does anyone know? Um, what causes off as I brought in symptoms are hyper calcemia. Yeah, so good to see that. You remember Your revision is going well, so bone stones, groans, moans, weather, new monitor you want to years on, But that that's the one for hyper casino bone pain. Um, right, kidney stones, abdominal pains, that grains. And then he moans, get psychiatric symptoms as well. So a beegees um maybe detox people find them tough. Um, Andi, this is just an easy way. If your brain doesn't the exam on you can't think. Then just look at the pH so worked through it. Systematically. Birth looking, pa. Then look at that part of part of pressure comes outside. Then if we look at the left hand corner, you can see But every respect recalls of acidosis or our closest pH and the conduct side air going in different directions say the top top left corner, the pH is going down on the partial pressure of Come dioxide his boss, We're going down. So I it can't be any pretreat cause on there must be a matter. Politkovskaya Onda Does anyone want look at the bicarb and then decide what matter? But it caused This is okay that I'm asking, um, how would you describe the top? Left A B J? Yeah. Okay, so, um, Megan said it's metabolic acidosis with respiratory compensation. Um, I agree it's metabolic acidosis. Um, with your spirit, your compensation. I haven't put respect your compensation, but I should have done on if you're being productive. You would say it's partial respect recompensation because, um hasn't compensated enough for the pH to go back into normal range. Okay, so we give another one ago. If you look at the top, right, ABG, you can see the pH um, having a cut back, then have a look at the part of pressure comes out sides, and then the bicarb. This one's a little bit harder. So I'll give you a moment to think about and then put What do you think on the answer is into the shop? Yeah. Okay. Okay. You can get some really good dances. It's a, um if you got a normal pH and then say that doesn't really fit. I grew up in the two on be looking at the part of pressure comes outside. That's high Had so you can imagine the patients Probably not breathing very much entertaining comes outside, and then you can look at the on the bicarb. Say, here the bicarb is 38 which is high. Um, okay, so but the bike cards high on the carbon dioxide is also high. Um, then you can see on. But this has to be a respectfully acidosis, Um, or it's a, um, matter. Folic. Our closest. Um, okay. However, you can see the pH is on the lower side of normal on D. Um, also, the oxygen's low. So, you know, they're not breathing very much on correct answer. Respiratory ask days with full metabolic compensation. Yeah, like lots of you said on then just wanted to make a note about, um, compensation in general. So here the bicarb compensated. It takes about 3 to 5 days for the kidneys to produce bicarb to a lot of compensation. Um, so you know that this is gonna be a chronic picture. There's a chronic prosperity acidosis condition like the PD Okay, than the nine duck. So I know this is next plane in lots of different ways that can sometimes be very complicated again. Hopefully can give you some high. You fox feet. Remember, free exams. Um, the head of just throwing loads of words that you on. But we will go over it and explain it. That's really good. Nouman IX on. I've got four and I got metabolic acidosis or non and gap Online cap. That's what the Casodex This is Agneta on magma say in an eye and got metabolic acidosis or Acma. Um, I used to need my name on it. Much piles say methano on you. Bring me a said you have kidney failure. You bring me up, you can get high your area. Um DKA and I'm not gonna bother breathing. It'll that this is just something you can refer back to on this one's much piles and then knowing that metabolic acidosis is used cars. Okay. Okay. No, actually, I can explain this a bit better. So imagine this box is and your blood on in your blood you have sodium and yours have potassium on your Catherine's, and then you're on irons. Um, you have bicarb on chlorothiazide. And then you also have your your organic acids that you're lactate your tonic acids on Botox in decorating put up. So when we calculate Yeah. No, you're great. Um, when you talk to that, you're a nine. Gap you and get your concentration of sodium. And then you subtract your concentration chloride on your concentration of bicarb, and then you don't include the other, and I ins. So you always expect. Um, yeah. Sorry. You would always expect you to have a positive ana wind up on. It's normally less than 12. And that's if you, uh he don't think leap Potassium, if you do include potassium than a B. Um, less than 16. It's a kid normal, and I'm happy. Less than 12. Okay, Right. Just right by this out. Okay, so if you end up with a d e. K for an increased lactate like you do in an eye and gap, metabolic acidosis. Then these and I, and it's going to increase. And then when the nines increase, then they're going to soak up lots of the bicarb, my cup of decrease. And then in that formula, we had sodium minus cried, and you're gonna be able to subtract less bicarb, and then you have a Oh, um, and I got metabolic acidosis because the ana and gaps could be greater than 12. Okay, Okay, then in non benign gap metabolic acidosis, um, you're gonna end up with, um, again a lower, uh, bicarb. But if you just leave by carpeting body without increasing, uh, these other and I and assets that we've been talking about um then instead of getting a a nine gap, you just end up compensating by reabsorbing more chloride ion. So then the chloride to increase when the bicarb decreases. Um and then that would mean that, and I and that stays stable. Okay, so just hopefully explain that more simply then, Acma, you're gonna end up producing lots of Ganic. I ends and they're going to say cup the bike up and then in the Magna, you're not going to be just a You're not going to produce these other assets. So Okay, uh, you're just gonna get knots a bicarb, and then that's compensated by increasing chlorides. And you end up with no overrule change in your honorariums that measured in the animal kingdom. Okay, um, is complex on. That's a really good you keep it is out there with better animations not shown you on that. You don't understand that. Just give us such, um, and go for any rain time. But hopefully, um, that was how Put somebody okay, so on to see questions. Um, Sana, Can we relate the pole? Thank you. Okay, So I've checked in the bones. Question. I think you saw it before, actually, um, yeah. Give these. Okay. I'll give you some time, then we'll go through them. Have been very mean with the last two questions. Just a heads up. Yeah, I think we go up to 92 of the start. They give a few more maintenance. Okay. Okay. I think that uh okay, right. Okay, So the first question most of you went for the correct answer. Um, which is, um, the macula density cells detect low sodium causing Brennan release, which is gonna increase the BP. Right. Um, and then the Afrin arterial is good, but dilate on. You're gonna have a increase in Jeff are. So that's correct. And then there are a couple of red herrings of the end. I'm happy That makes you that one. Okay, this was mean on, but I'm happy that mostly you got the correct answer. I didn't really mention it on in the presentation, but the kidneys, they really put important role in production. Are him a club in on that? Because they produced PPA re stimulates blood cell production. It is a hormone on on. It's going to cause your body on your bones back by married to produce more red blood cells on how that if you're in chronic kidney failure, hand collect stage renal failure, like in this case, you're not gonna be able to be a pa. Um, and that's great. So, um, get anemia. Okay, lots people said hypokalemia, But in fact, you'll get hyper clean. Yeah, um, firstly, because you're not really put a filter potassium out the blood on. But then you're also not commuting. Filled the toxins, you're gonna get metabolic acidosis. And then that draws potassium out of cells as well. So it will get hyper, uh, Tellinya, not ah, hypokalemia. Um, And then sitting with urea, you can end up with a higher you over here. Okay, um, but I didn't give you much time to read that name on it. Um, that all the causes on here on a do too Non. I'm we're close it. Sorry. Um ah. Gt on, cause metabolic acidosis say rule correct. Um, but, um, be question is meant to say initially, um, what is the cause? Um, off and on I and got metabolic acidosis. So all of these cause non online and got metabolic acidosis that metformin because on and I got metabolic acidosis. And that's because that for Member interfere with the crap cycle on it will lead Teo an increase in lactate. Um, on increasing knocked eight. Who's is you'll, um and I got metabolic acidosis. Uh huh. Okay. Like shown by that Teo column thing where you can increase in organic times. I'm sorry. Organic acids in the blood, which produces back up on it increases your nine cats. Who? Okay, um, I'm sorry. I felt quite chaotic. Um, but hopefully you gained some stuff in that presentation. Hands. I will pass on T Sahara. I was that. Thank you, Toby. I love the animations. I was saying I love how you did. The ions is really cool. Um, great. Thanks, guys. And it's going to give you a quick, um, three minute break for break from physiology. If you want to come back up to 28 and then we can get on with, um, shock on by the 18 when there's somebody reach a point when there is enough to need oxygen. Well, basically, most of the time, actually, people that come into E T I just a lot of benefit just a little bit ill if they just even know they had, like, trauma. But the oxygen sounds okay there. Still given, like, a little bit of oxygen in the form of a nasal cannula. We'll go over that in a second of the different types, but, um, critically, I think that oxygen therapy is like indicated, most importantly on, obviously, when somebody sats are not very good on def. acutely ill. Always. Or you suspect that they're going to get worse. Um, So, for example, if somebody is having in my car gene in function a C s. Um, if you guys remember from from case to Okay, so 12, the pneumonic for the management of a C s is Mona and the oh in Mona stands for oxygen therapy. So if somebody has sats off less than or equal to 94% you can consider giving them oxygen. Um, on. That's an example. Um, the one that comes up a lot and exams as well as our skis is COPD patients. So because it's because of the pathophysiology of COPD, COPD patients are very find it very difficult to have high oxygen saturation that you'll ever find that it's no. It's accepted that it's normal for them to not have high saturation. So while it's having 88% 02 SATs in you or me and like normal, but as your normal people would be life threatening and you'd be really concerned if somebody with a long history of COPD has a saturation of like 86 you'd be like, Oh, that's bad. I'm gonna give you a bit of oxygen, but I'm more like insanely concerned, if you know what I mean. So the target oxygen saturations in patients with COPD and obstructive sleep apnea, which is like severe obstructive Risperdal conditions. Dog, it's That's our 80 88 to 92% and that makes sense. So that's I've highlighted that orange cause that kind of comes up a lot on exams on. I would remember that. But that percentage and for what diseases use it in terms of oxygen delivery systems. Um, there's so many good resource is online. So, actually, if you go to the clinical skills folder or Learning Central, they've uploaded a very nice facility like editorial, um, for oxygen delivery systems and they some it up Really? Well, um, which is worth looking at, Um, but anyways, this is kind of ah, very quick summary of what you need to know. The picture of the bottom. There is actually my notes from last year Not right. The handwriting is not great, cause I was revising this like, a few days before Xtampza. But everything like the main things that I learned for the exam, like the f i 02 is that different oxygen masks can provide. It's something I remember rising as well as like the most important indications. So, for example, a nasal cannula is like this. It's a thing that goes around and into somebody's nose, just like the ones you see. You like movies and stuff, and that is like the most basic form of oxygen delivery. I say that because one it can't really provide a very, um, high fraction of inspired oxygen F i 02. I should explain, Right? Fire to is sorry. F i. O. T. Stands for a fraction of inspired oxygen, which is like in the environment right now in a row, have about 21% oxygen. Um, where is when somebody requires oxygen? Obviously, you want them to be breathing something that's higher than 21%. They cannot coordinate that tissues. And so a nasal cannula, um, can give you up to like 30 to 40% which is which is all right, which is good. It does the job in some people, but it's the most basic kind. So in people who are not critically ill, if somebody's had a bit of trauma or something, that a needle cannula can be used. Also, the flow is only about 1 to 60 just a minute. So that's volume per minute. Which is which is Yeah, the next in the ladder off oxygen therapy than have face masks, which is over here, the second one. You kind of It's very basic. Um, it's It's a real breathing mask, which means that it's like when somebody breathes like when somebody breathes in the auction and they breathe out with everything out, like there's no way of not letting the mix of that makes sense. So they kind of, um, that means that because the air breathing is the oxygen given to them, plus the other breathing out it's again not a very high fraction of inspired oxygen that's achieved so you can achieve a higher. I overdo with face mask than you can with nasal cannula. But again, it's not extremely high because so kind of contaminated with and that you breathe out. So this is bigger though nasal cannula but still not amazing for like critically ill patients and can provide higher flow than nasal cannula as well. You don't have a Venturi mosque, which is one here and the way you identify eventually mask is you. Look at this thing. There's like that green cylindrical bit and basically different Venturi masks have different colored nozzles and each nozzle we provide a fixed if I or two. So that's the advantage of Inventory Mosque. And the main thing I would remember is that if somebody requires a fixed f i 02 and you want to make sure that a patient is getting a very specific, um, if I oh, to that eventually Mosque kind of has these filters in these nose abs that will ensure that. So, like if you go to the clinical Skill Center, for example, you'll see that like right Jello green, black, um, mentoring mosques and order them provide, like 40% 50% 60% 70% if I oh, to basically. So based on each patient you choose, we're going to give. Then you have the non rebuilding mask. This is probably like like this is the most important one in critically ill patients because two reasons. One, it says in the name is non rebreathe thing, which means that they breathe in the oxygenated ever given to them when they breathe out All the, uh, they breathe out is no is shoved back out through some holes in the mosque, which make sure that they don't really breathe. The Advair just breathes out as an insures that, um, their breathing in a row that's as pure was possible. Essentially, so you can give you can achieve really high if I oh, two's with a non rebreather mask, which is what you want in people who are critically ill. Um, Andi, this is like high flow. Oxygen is well, you can write 10 to 15 liters of oxygen in these patients. So this is what needs use for, like, patients. And, like sepsis and stuff. You are quite ill. Um, so on exam setting thes in The most important part is that, remember, is that like, um, in situations where you need high flow high oxygen, you consider laundry breather in COPD patients who require a set. If I or two like predictable SATs, you give a momentary mask and people who require oxygen therapy. But I know that a lot. You can give them a nasal cannula or face mask. The older, um, nebulizer masks if somebody comes in with acute asthma attack, and they require some salve you. Tomorrow you can give them nebulized albuterol with the mask on Dad's an example of When you use that, you can use it for other drugs as well, especially flaccid a shin. So if you go two anesthetics and placement, you'll see them using some anesthetic drugs in a nebulized mosque to sedate patients. Great. Um, okay, that auction there before you guys, I thought, Also go belong lump eines really quickly. So these curves a really important to learn because they love to ask about it. They love to ask you how curves change. So I thought I spent some time going over that. So lung compliant essentially is a measure. If you think of your lungs of the balloon, you know when you blow a balloon and the first bit of the balloon is really hard to blow up. But as you keep blowing up a balloon, it gets easier and easier. That's kind of the way a lungs work in, in a way. So, um, it's like, how much effort are you putting to achieve how much change in volume on mathematically, that's like a change in volume over a change in pressure. So if I put a little bit of pressure, is it going to give me a big change in volume? That means it's a very compliant long because I'm putting a little bit of pressure on the lungs. Inflating a lot on that means that on the longest last sick and it's able to spread on is very compliant. And that's a good sign. Usually, um, So in terms of the graph, that's kind of go over how this graph is even drawn. Okay, so forget the line. Just look at the purple. A graph for now, the purple lines. So when we're I inflating the lung, when you add a certain amount of pressure, let's say over here, I'm gonna get a pen, Actually, um, so let's say you add this amount of pressure, okay, over here now, when you got a bit of on a pressure, obviously that's going to make the make the lungs inflate, and you're going to get a certain amount of volume inflated, right? You can see with this graph that obviously, as you add more and more pressure, you're kind of positively feedback ing and therefore you're getting more volume, right? And that's kind of what happens. Yes, as you can see, as you have more pressure, it gets more inflated. You get more volume and notice how the curve gets steeper as you go up. And this is like I said, it's because, like, as you have more pressure, get easier and easier to inflate the lung, and this is what that is. So what happens when the compliance of the lung changes? Speaking in terms of like in In terms of words, if somebody's lung is suddenly less compliant, for example, if they have pulmonary fibrosis or if they're quite old, where they've lost a lot of the elastic tissue in their lungs, that means that it requires a lot more effort and a lot more pressure to inflate the lungs to the same amount. So, in terms of my drawing, um, hold on. How do I delete this stuff? Give me sick. Okay. So in terms of my joy along that lost some of its compliance is gonna be a bit like this. So I'm playing a bit of pressure, and I'm getting a very little change in volume over here, as you can see as before in a normal lung. If I applied that same amount of pressure, I got a higher change in volume. So as you can see when you have along, that's less compliant. The same amount of pressure is giving you a lot, much small amount of volume in the lung, and that means it's not spreading as much and is therefore less compliant. If we go further down, the curve is well, you can see that even when you increase the pressure, a significant amount like over here it's still giving you a much lower volume changed than it would in a normal lung. A normal lung is giving you this much volume. Um, and that's kind of what, along with pulmonary fibrosis, for example, would look like let's talk about a long that is extremely compliant to the fuck, to the point where it's like pathological, right? So, for example, when you have emphysema on, do you have like in COPD patients? For example, Um, what's happening? Org sample even in like pulmonary edema, when there's lots of fluid surrounding the lung, what's gonna happen now is that it's it's almost reading too much. So like for example, if I had a little bit of pressure, it's like spreading. It's expanding so much that you're getting an insane amount of volume. So it's over here, Um, and it's extremely compliant. This is fine to certain extent until the point where it gets inefficient on do the gas exchange is not happening efficiently enough that you that you'd be happy with, um and the problem with losing elastin, Greek oil, for example and emphysema is that, um, you're like, you're like you're, like, expanding because you have all this space. But when you recoil, there's not an efficient exchange in gas because of the lack of elasticity. Yeah, and so it really what? You're losing his efficiency here on. That's what an increased what? That will increase compliance. And the lung looks like So that would be example in, like pulmonary edema or emphysema. Um, okay, have that makes sense or it's quite hard to understand, but I would just remember these curves their exam in which way they shift based on what? The place of what the pathology is. Okay, great. So let's move. Mechanical ventilation. I Actually, I when I like this last year, I feel like I didn't I didn't give it enough attention because I was so stressed about learning example, like learning all the other stuff for the exams. But then I've gone over it again, and I actually think it's really cool and really interesting on when I see it on placement on my mom was like, 80. I can actually apply it on. It's really cool, especially if you if you want placement of the I see you like this, is everywhere, and it's really useful to understand how this works. Um, so what is mechanical ventilation? It's when you're basically helping someone breathe your assisting someone on to breathe on. This happened in more than day by shoving balls to pressure down somebody's throat, and this helps them either helps their breathing over places they're breathing for them entirely. So what kind of situations would you need? Mechanical ventilation, while one is when somebody obviously like just is not oxygenating that issues enough, for example, if they've had a collapsed in their lungs at actresses or if they have, like pneumonia, where they're so whether Parenchyma is just so thinking that oxygenation is just not happening well enough and they're not the norm Bentyl ating well enough, not getting enough oxygen to that issues that you have to get them to breathe. You have to help them to breathe. Um, if somebody has obstructive lung problems for examples of their COPD or acute respiratory distress syndrome, um, then they're not able to breathe out the carbon dioxide getting in the oxygen but not breathing out the carbon dioxide. And this is bad again because HYPOCAPNIA is what drives you to breathe like extreme hypercapnia is toxic and can kill you. And therefore you need to help someone breathe. They can remove the carbon dioxide. The third situation is if somebody, for example, has had a spinal injury, and they kind of their GCS is like five. They can't manually like they just not like unconscious on Ben. Their respiratory like system is just suppressed. Um, that means that they're not going to be able to operate that muscles Onda. If if there's like a foreign body or anything in that lower like saliva, they're going to aspirated because it's going to go down the lungs on, but just very dangerous because they're just, um, like, not able to control their own lungs, and there are mentally a shin, and therefore you have to mechanically ventilated them to completely replace their lungs for them. Basically, because they just can't do themselves because they're really out of it. So those are the three in situations that would be indicated for a mechanical ventilation. So that's good. Over some terms in ventilation. Oh, I swear that animations for these Oh, no. Sorry. Okay, Anyways, F I o dread mentioned earlier is fraction of inspired oxygen. So, like I mentioned normally in the environment is 21% off the area Brief. Where is in people who I want achieve you want want to give them higher than 21% if they're not very well, actually oxygenated on room air p e i 02 is pressure have expired oxygen. This is common, especially when you go like diving and stuff. Um, what I like the It's kind of the the pressure of oxygen in the air out 21 k p a. Um, and you can also control the pressure of oxygen when you give someone oxygen. And that would be, um, different. For example, in a BG you see that oxygen is like 10 to 14 k p a. And that's what the pressure in spite oxygen basically is. Um, p a 02 with the capital A is alveolar a partial pressure and essentially that What that is is a measure off the number of oxygen molecules. And then, uh, the onus on. And the reason this is different from p 02 with a small A is because by the time oxygen gets from your nose to your lungs to alveolus, um, it's kind of contaminated with like, um, like bored water vapor on common dioxide. That it's much along the way and therefore be a 02 is very different from pa I or two and small pea and small A. P or two. Because small P 02 is a more pure form of oxygen that's been absorbed into your arteries. Um, and with that will be higher usually. And finally, as a 02 is like we talked about what your pulse oximeter measures. See a partial pressure your your your person takes saturation off oxygen. So that is, um, what percentage of your hemoglobin is fully saturated with oxygen is what as a you too is like a mansion, Dahlia. Good. Okay. And a few more terms now, Um, respiratory rate is a number of breaths per minutes. Um, so you're probably done this in your respiratory examination? Various keys are looking at somebody's chest expand. How many times in a minute title volume which I will abbreviated TV later in this presentation is the volume of air that you can that you normally breathing I/O each breath, um, with like and this is excluding the reserve you have of the bottom of your lungs. So right now, as I'm speaking, how much volume is going I/O off my lungs lead breath without me trying to hard. That's title volume. Minute ventilation, like the word says is how much air you ventilating in 11 minute. So that's the volume of air. Breathe a minute. Uh, and peep. Can someone tell me what people stands for in the chapped? I want to make this way. We're into active. I'm really sorry. The animation seems to be messed up. Like what is people Stanfel Anyone positive and experience repressor. That's perfect. Exactly. So if you don't really understand what that is, um I'll go over and now peop essentially like the word says. First, that's breaking down, right? Positive, which means a positive pressure, which means you're shoving some air somewhere because you possibly pushing experiment tree, which means it has something to do with the end of a breath end to end experience reasons happening at the end of a breath on pressure. So essentially in somebody with, um, COPD, for example, a lot of the alveoli I have been destroyed because of, you know, the emphysema, right? And as a result, because they have less alveola, I obviously the breathing is less efficient because they have less are really working towards ventilation. So in these patients, what you can do is you can artificially open up the, uh, viola by shoving some pressure in there. The pressure will force the alveolitis open, and this means that your recruiting more alveola to participate in regulation. This is this is called peeps. A peek is the amount of pressure you apply to recruit morale. Viola. So, as you can imagine as you increase people, that is, as you increase your positive end experience, you pressure you're opening up more of your life your recruiting morale Viola to participate in land elation and gas exchange. Um, there are some situations where people can be dangerous where you cannot You shouldn't increase peak. And we'll go over that, Um, actually, but anybody think of something in the chat of where increasing people would be dangerous is a challenging question. I know. Especially if this is the first time your understanding what people is also, if I know people, is difficult to understand at first. But it's really important for exams. And that's why I spent I'm explaining it. But so it doesn't make sense. Please tell me I'm happy to be. Explain it clearly. Fusion tension. Yeah. Tension. Pneumothorax. Perfect. Exactly. Um, know COPD is when you would use it. That is a positive indication with the people. So comes that someone's attention to north or X and absolutely right. So basically, while speak produces well whilst people increases the pressure in your alveoli in opens them Well, you also have to remember is that when you're shoving pressure down someone's throat, you're increasing that intrathoracic pressure, and this can put a lot of this can. This can put a lot off a lot of work load on the on the heart. So what's gonna happen is if your peep is too high, there's the intra thoracic pressure becomes really high, and that starts to compress on the heart. That's going to decrease venous return, which is in turn going to decrease preload and is there for going to decrease cardiac output. So, for example, if somebody has attention pneumothorax, they already have a really high pressure in that in that thoracic cavity on this is going to make it worse. Yes, somebody's a cardiac tamponade drops the right in cardiac tamponade. You already have this pressure on your heart and therefore giving them people if then oxygenated. Giving them a higher peak value would just make this worse and worse and the cardiac output. So that's also an example, or what people dangerous. It's ab. So do people understand? The peak is if you don't let me know when I'm happy to explain it. Okay. Okay, um, in terms of the kind of my cancellation, it can broadly be divided to two types. You have either invasive or noninvasive. When I say invasive, it means you're like putting an endotracheal tube down less throat where it's going to say just below the vocal cords, Um, and this is when people like, really struggled to just ventilate on their own and required to basically replace their breathing for them. And this is like, obviously, like critically ill patients essentially are, for example, in patients who will exit dated so the like. Patients going into like open heart surgery, for example, are really sedated and therefore will require, um to be intubated and get mechanically ventilated. Noninvasive is like CPAP and by pap, which I'll go over. But essentially, you just use a mask on there. Just just a matter of using a mask. And there's nothing really to put down that foot. That's borderline it. Now, when you're thinking of ventilating someone, there's a lot of variables that you can change. There's a lot of things that you can manipulate and play around with that can help, um, ventilate somebody based on what their problem is. So you can either. You can manipulate how much volume off a rowing into their lungs. Um, you convert, you can manipulate the pressure off the air going in. You can manipulate the rate at which this volume goes in and the flow is well, the flow refers to, um the flow refers to how quickly the certain fixed rate of volume goes in. So while rate is like are like I've leaders per minute flow is kind of like like, um, controlling it on a much in a much more volume basis. If you want to say that within the next one minute, I want this person to get, um, a certain amount of a certain amount of oxygen that's more detailed parameter of measuring ventilation. Also, you can control oxygen. So again, if I or two a swell, um, I also many times ventilation can be patient controlled, so sometimes a patient can control how fast they breathe. So, for example, if I went any now and my own and I needed to be back and Clevenger elated, but I was conscious, Um, that means that I can control how fast I breathe. I don't need the machine to do that for me, and therefore I can kind of control it myself. So a lot of times, if patients are capable of it, they are able to control the rate, for example, themselves where sometimes with that sedated or their GCS is quite low off the quite ill, and eventually you can control it for them. So this is kind of an example of what it would look like. So this is a ventilator on the left. Here on bees are the main parameters that you manipulate in really time on a ventilator. The respiratory rate, Um, which is the radio, which they breathe Hominy times every minute. Title volume. Which is the volume of gas going in our lungs in a, um, per minute. Um, And then if I overdo, which is about the amount of oxygen is giving them and people, so do you. How Open How many Advil I do you want to recruit in this patient? Do you need to recruit more of your eye health? Um, breathe in terms of the accident elation would have drawn here is like a very poor drawing off like an endotracheal tree and a trick your tube, Um, which is going down into somebody's vocal cords. Um, and I don't know if you guys know how catheters work, but in a male catheter you have to put it in and then inflate a water balloon which make sure that the catheter sits the blood and doesn't come out. You do a similar thing and a trickle to you where you put it down there, throat. And then you inflate this little balloon here around the vocal chords and that make sure that the tube doesn't come up. This is a drawing of that, Um, and the reason I'm giving you these settings now is because I'm going to give you, like, uh, I'm just going to show you, um, what a graph looks like. So if somebody's been mechanically ventilated, you've probably seen this in one of your lectures is where they they really tragic plane to you. How the graphs look, um, in somebody who's being mechanically ventilated on, you know, it could be really daunting to look up. I'm going to try and break it down and explain it. So, um, that's look at a normal patient. Okay, Somebody who's on these parameters. Somebody who's breathing 16 times a minute. Somebody who is receiving funding mills off airport per minute and somebody's breathing 50% oxygen and is on five Paschal's off people. What is that graph going to look like? And why does it look like that? So I'm gonna get my pen. So let's start with the pressure, okay? Just think of regular ventilation when you when you are going to breathe. What's gonna happen when you take a deep breath? You are, firstly decreasing the intra thoracic pressure. Right? Because when the thorax, when depression, your thorax decreases, that's what draws Aaron. A decrease in pressure will increase, increase the volume of your thorax. And that's what happens every one of us in every breath that we take. If we take this random patient I have here when they're starting to breathe before they start a breath, they're going to decrease the pressure in the thorax. The pressure's going to go down to negative pressure. This is going to trigger an increase in volume off the thorax. So at the same time of the pressure goes down, the volume is suddenly going to shoot up because it's inversely proportional. And then as the volume goes up, the pressure is going to slowly increase as well. Like this. And once the pressure has reached its peak was the pressures reached its peak. The volume has older reached. It's big, which means your lungs up peak inflated as inflated as they can be. And at this point, you're going to start breathing out. And how do you start breathing out? The pressure in your lungs have to drop again to the pressure your lungs is going to drop. And this is going to trigger you to release the volume. So this so the volume in your lungs will go down against this is expiration. That makes sense. But notice how the pressure the pressure graph is not gonna go down back to zero is going to stay here. And can someone tell me what this is again? Someone tell me why the pressure is not going to go back down to zero. Why is the pressure not going? Yes, people, Exactly. So this pressure here is called peek people. We have a people five here. As you can see, this is the pressure that's keeping you out of your eye open at breast. So no matter how hard you breathe, the people is going to ensure that at the end of exploration, there's always going to be some amount of pressure in the annual Leola to make sure that they don't close because in this patient we want to make sure that a certain amount of alveola always open and therefore you always need this amount off positive and exploratory pressure to stay. What's gonna happen with flow when this is happening? So look at this point where the brush is decreased and the volume is now increasing. As you can imagine. If the volume is increasing, the flow is going to also increase. The flow has gone up, and then the flow remains. Study for a bit while your lungs are feeling. And then once the pressure has reached its peak and you start breathing out, the flow is gonna go back down again. And the flow is going to be negative for a bit because all the air is going out and not in. And they're forgetting negative flow. And then eventually it's going to call call back to normal to zero. So it's essentially are one breath looks. She will go over that again. Before you started breath, you are going to decrease the pressure on your thorax. It becomes negative. This is going to trigger. An increase in volume is going to go up. Then your pressure is going to increase because they're inversely proportional because so now your body office, he wants to push the out. Um, and basically, in order to do that, it's going to increase the pressure, which is going to push all the air out, and it's going to go back to pique, and the volume is gonna go back down to zero and your people maintained at five. But we said, and in terms of flow again, what's gonna happen is that at this point, it's going to go up. The flow was going to increase as the volume increases is going to say constant plateau for a bit while your lungs, the feeling and then during expiration your flow is going to become negative. Um, because you're breathing air out and eventually it's gonna come back to normal. Now, there's a very interesting case where somebody is not able to breathe at all on their own, and they require the machine to completely replace their breathing. So, in this case that I just showed you this person is able to decrease the intra thoracic pressure over here such that they can initiate breathing. Can someone tell me, um, an example? If someone tell me what would happen if somebody was incapable of breathing in their own at all? Required the machine to do all the work for them. How this graph look different specifically, the pressure cough in somebody that is sedated and requires a machine to breathe for them. How would this pressure graph look different? Somebody said inspirational left positive pressure. Exactly. So when you're breathing your own like you said. But like I said, the way you start breathing is by decreasing the pressure in your thorax. You're able to do this without thinking, right, and this is what starts breathing when the machine is reading for you. Your machine doesn't really care with the existing pressure, and your thorax is because it's just going to shove, add on your throat and therefore in somebody who is uncompleted replacement, mechanical ventilation, they're not going. They're not gonna have this downstream stuff. They're going to go straight into mechanic event. They're going to go straight into breathing like this and going to come back, so it's not going to go up. It's not gonna go down. This says this bit is no gonna exist. Basically, this doesn't happen and you know, going to get that down world Slope because there is no need for the person to develop an intra thoracic pressure, lower interest, elastic pressure because the machine is doing it for them, If that makes sense. Sorry, there's really complicated. But if that makes sense, um, on the next light, I've just drawn it, and I've kind of showing you how it looks different. So, in a patient initiated breath, obviously the intra thoracic pressure becomes negative. Whereas in a machine initiated breath, the patient is no longer breathing. And therefore there is no depth and pressure. Um, and most commonly, when somebody is a mechanical ventilation, um, you give them a priest that title volume on. That's why the volume remains constant. To meet breath like you set it on the machine like Okay, this person is going to breathe 500 mils with each breath and therefore this represent a fixed, um, title volume. So I have a quick case for you guys are know if with the answers already. Basically, um, can someone tell me based on this blood gas result? What my be wrong with his patient? Like, what is what is this that guy show you? Yeah. Okay. Great. Um respectfully acidosis. Perfect. So join a job is gone through this, but basically, if if you have, you could see here that they're acidotic because the pH is low, you know, they're in some kind of acidosis. The way you know, the respiratory is because that PCO two is high. So because they have access carbonate the hypocapnia, you know that the cause of the respiratory and you can also see that by by cob is normal, Which means that really doesn't really matter. Body problem, because they're bicarb is normal. Which means that kidneys are kind of one normal and two working to compensate for this first perjury acidosis. And in this case, this would be a fully compensated respiratory acidosis, because the bicarbonate is in the normal range. If the bicarbonate wasn't like in the lower range of the bicarb of, like, 20 or 18. But that would be partial compensation. Um, and is that Oh, that makes sense. So I have a case here in the proper boxes of this patient. So this patient who has developed this is Rachel acidosis was on these settings, was had a respiratory rate of 12 was on 400 mils off with the title volumes 100 mils. They were in 40% of oxygen. And that people that five and based on the Risperdal Yeah, pseudocysts. Obviously, we want to help this bus and get better. And how do we know what settings to change? So one, you know that if they breathe faster, they're going to get more air I/O, which is good. And therefore you can increase the Risperdal rate, which we've done to 14 16 second. You know that if you concertos more volume down their throat, that's also good, because that also increases gas exchange so you can increase the title volume 200 mils when it comes to F I. 02 of us is people. Um, in most cases, unless there's a real indication to increase people. Example. In COPD, you don't really bother because of the risks. It possesses the risks it poses to your cardiac output. And so you just would increase the oxygen for asthma as you can first, um, in congestive heart failure, however, um, increasing people is good. Um, I don't have time to explain why that would be good, but if you're interested, you could look it up later. If somebody had congestive heart failure, increasing people's good as it would help squeeze the blood out. Andrea, leave the pressure on the heart. Um, because it degrees the cardiac out. But I can't say that now. Sorry, there's no time. But if you really look that up later yourselves, um, two situations you should know that you can look into of how these grafts change is if you look at how these grafts change in acute respiratory distress syndrome and in COPD will be really useful. Um, I put a link to YouTube video that is excellent in describing mechanical ventilation and how it changes in these two diseases, and I would highly recommend that you give it a go. So usually, like 15 minutes on D explains it. It's so clearly I would definitely recommend watching it later. When you have Time Labs does mechanical ventilation, I'm gonna go into shock. So So how do you define short? The shock is essentially a state where in in three times it's when they're circulating flick failure, which is do with your vasculature, obviously, and this failure off circulation is meaning that your tissues are not getting oxygenated well enough. And this is color was a generalized hypoxia throughout your body. This is bad because if all the tissues in your body are not getting oxygenated and auction is not being delivered, this can cause end organ damage and and organ failure on. That's why shock is so important to recognize and treat quit. So what I mean by that, for example, is if you look at somebody in a normal a normal person right there getting enough oxygen, they have no problems delivering oxygen to the tissues. Um Andi, also, there are cells individually are able to respond aerobically on their own. And therefore, in you and me, for example, if I'm going on a walk right now, obviously when I'm going on this walk, my my oxygen demand is going to increase. However, because my circulation is great, I think because my circulation is fine, that means that I'm able to keep up with this increased demand and also note that my cells are also fine individually and myself, also responding aerobically to generate their own source of oxygen and therefore, in a normal person who was exercising or it rest. They don't really have problems keeping up with increased oxygen demand, however, in somebody who has isn't a shock state, whether it's problems there circulation this problems were delivering oxygen. This is a problem because it's made reached a point where they're not delivering enough oxygen to that. Issues on their cells are respire ing and aerobically and therefore producing lactic acid, which could put them a lactic acidosis and could make all their problems worse and eventually reach a point where so many of that tissue is not getting oxygenated. This concludes organ failure. Like I said, So, really, the problem here is in circulation, and they're different causes for this problem we should go into. These are different stages of shocked that I briefly just went over. So initially, you notice that somebody is just, like, kind of generally poorly perfused they might have. They might be hypotensive. That cap refill is gonna be a bit slow on the heart rate initially is compensating, and it's really fast trying to compensate for this cardiac output, and they may not have peed very much because there's no much fluid circulating around as the shock said gets worse. The hypertension is going to get worse. And like I said, they're going to start responding and aerobically their cells, producing more and more lactate. Pretty normal Actiq acidosis. The lactic acidosis is going to make them breathe fast. As you noticed, they become more and more to keep it on. All this toxins are going to get to their brain. And also because the hypertensive that cerebrum is going to be hypo perfused and this can cause altered mental status. And generally all of this stuff put together as it gets worse, get all these other problems. You get my card, you'll ski Mia, as you know, which can in Fox and be bad. I can put you in disseminated intravascular coagulation because, um, it releases lots of it causes release of off clotting factors and information on ball. So again, because all your organs are not being perfused well enough, you get multiple organ failure. That's kind of what what happens in shock. So the main three determinants of whether somebody is shocked is these three things one how much oxygen is in their blood is dissolved in the plasma right now to how much of it is actually is attached to the hemoglobin. And three, how much blood is flowing right now. So cardiac output, how much better is flowing to oxygenation? How much oxygenation Oxygen is in the blood on three. How much of this auction is actually attached to hemoglobin? This is what forms your shock equation. Then you might have seen earlier. So one how much blood is flowing in the arteries is determined by heart rate. Preload after lowered contractility. How much oxygen is dissolved in the plasma, determined by partial price of oxygen on how soluble this oxygen is in the plaza. That's a constant value to be fair, but partial plate of oxygen is the main variable there on how much of this oxygen is your hemoglobin carrying? How saturated is it? All of these things put together will determine whether somebody is getting adequate oxygen to all of that issues. And if anyone, if any one of these things is going wrong, you can try to compensate by manipulating the other thing. So if somebody, for example, is that oxygen sides are okay on their P, 02 is okay, but you can tell that they're BP is low on the on. The heart rate is high. This is telling you that this bit off the shock equation is not doing very well. And therefore you can maybe, um, compensate by giving them oxygen about giving them vasopressin is to try and improve this better than a shot. Um, so this is kind of what this is kind of a shock equation broken down. If that makes sense, different variables that go into it. So what? The different kinds of shock. So you have four different types of shop mainly, um, this is hypovolemia shop. This is when there's not enough fluid in your in your body to begin with. So if somebody has, like, a four day history of really bad diarrhea, they've lost lots of fluid and if they haven't had anything to replace it, they're going to be really hypovolemia. If somebody has had a major trauma, lost lots of blood, this means they've had a hemorrhage, a bleed which can also lead a big loss of blood. But them in hypothalamic shop, because again, the overall volume off that body has gone down. If somebody has had is having a acute heart problem, For example, we talked about cardiac tamponade earlier, but that has a lot off. Sorry, locally tamponade. Ignore that. Talk about, um, like an arrhythmia of somebody's in ventricular. But back in Cardia, this means authentic defibrillation than the heart is pumping really weirdly on the north, generating adequate Codec off. But they can put them a cardiogenic shock. If somebody has cardiac tamponade, which is like an external heart problem, this is putting a lot of pressure on the heart externally, and 10 is kind of obstructing the filling and obstructing the feeling off the heart. This is called obstructive shop on. If somebody example if they're sepsis is bad enough, often anaphylactic. If the anaphylaxis is that an allergic reaction? This can cause something. It's called distributive shock, because what's going to happen here is that they're gonna be All the inflammatory markers are gonna be quaking and everywhere and going to cause all the vessels to become really key, which means that BP becomes really low because all the fluid is leaking out of the blood into pervert issues. Uh, this go distributive shock. Another type of distributive shock is neurogenic shock, which is a bit different, and we'll go into that in a second. That's the main classifications of shock. Um, something that's important to recognize is how the hemodynamic changes in the different types of shock. Okay, so I'll talk through them. So in somebody who has had, ah hypovolemia shock, which means there's not much fluid in them right now. Obviously, there's no any fluid. And so your preload is going to be less because your because your venous return is less and there's not much fluid to begin with. There's not much fluid getting to your heart, and there's not much fluid. Getting to your left ventricle is your preload is less. In order to compensate for this lack of pre load, your body is going to try and in, you know, sorry, because you're prelaw is less. Your cardiac output is therefore less bright because cardiac output is defined by, um is defined by a stroke volume into heart rate. Um, on. If you're pre load is low, that means your stroke volume is low, and in order to improve your stroke volume, you can increase your peripheral vascular resistance, and so your body is going to ink create a peripheral vascular resistance to try and improve this preload and that's called increasing after load. A lot of terms. I'm really sorry. So what's basically gonna happen is that you're gonna have uncreative of, like, increased sympathetic response that's going to cause peripheral vasoconstriction. And this means that is going to try and increase your BP on this called increased after Lord, Um and this is because your hypovolemia in your BP is low. Your body is also going to try to compensate for this type of a limit shop on this low BP by increasing the contractility of your heart. And this is an attempt to increase your stroke volume and increase your cardiac output to get the BP back up in distributive shock. For example, in sepsis, what's happening in sepsis is that you have this massive release of influx inflammatory markers that is going to like I said, make your vessels very leaky. So your BP is low Onda because the whole point of sepsis is that your body is trying to get your white blood cells everywhere around, and therefore it makes the muscles really leaky. So it's easy for the white blood cells to get around with. The consequence of this is that invasive dilates everything and therefore you're after load becomes low and your preload is low cause not much is getting back to the lung to the heart. So in order to compensate for this, your contractility is going to increase again. Some more can be pumped out by the heart in the temperature. Compensate for this cardiac output That's a Zatz been quite low in cardio cardiogenic shock. For example, if you have, like a a a text in OSIs problem, then really, what's happening is that all the blood is getting stuck in the ventricle, right, because the blood can't leave through the aortic valve because the the valves to nose and therefore all the blood is building up and cooling in the left ventricle. This because it's more blood, you are going to get a higher preload onda. What's gonna happen is because your ventricle is not able to pump out the blood because the aortic valve is that really snows. This causes increased after lose because it's really narrow and your and your heart is struggling to pump for that up. Do you have an increased preload an increase after load Onda. Obviously your heart is struggling to pump at this point and therefore you get a decrease contractility in obstructive shock. If you have cardiac tamponade, for example, what's gonna happen is that it's pressing on your heart and your heart is unable to expand. And because it can't expand, your venous return is decreased. Your venous return is decreased. You have decreased stroke volume and decrease preload. And like I said, because your heart is struggling to expand yeah, heart is struggling to pump out the blood. This is also a form of after load and therefore you have increased after load an obstructive shop. In order to compensate this, your heart is going to try to increase security to maintain cardiac output because in cardiac tamponade, like he's on the S p A. Um, people tend to be hypotensive. You need to maintain stroke. You need to maintain your cardiac output and therefore increase contractility. So this is all those things I just said someday up in another table. But with other human dynamics are amateurs that you can kind of go through your own time. Okay, so how it will really make shop somebody's had a massive bleed or somebody's a lot of diarrhea or somebody had a massive burn, and they've lost lots of fluid from the skin of the GI tract or in the form of blood. The physiological response. This is three main thing that you need to know. One is the bowel receptors and the bandage receptors that acts to not only increase sympathetic drive but also get your rest system involved to increase about pressure because your hyperbole make and you're hypertensive. But you're bein which receptor reflects Basically, acts to put more volume back into the vessels is going to take the volume that everywhere else in your body, like in your tissues in your interstitial spaces, and it's going to try and shove it back into your blood. And that's what the Bane Bridge receptor does in in theory. In summary, um, your threshold want. Like I said, his activation of your sympathetic response, which would cause things like increasing your peripheral vascular resistance that would help the increase of that pressure and also increase your heart rate to increase, um, cardiac output. So patients who presented hyperbole make shock the way you can pick up on. This is when they come in. Obviously, the very poorly puff used to the cap refill is going to be very slow. You'll notice that their skin looks mortals very dry. If you open their mouth, look at the mucous membranes gonna look very dry on. They might be cold and clammy in the extremities. Um, and you will see signs of underlying illness. For example, if they've had diarrhea for a long time, they'll tell you that if they're signs of a massive bleed, for example, if they've been vomiting blood, that's a sign that they've obviously, like, lost a lot of blood. How do you manage this first thing? Obviously, really Put the fluid back in them they've lost would put it back. Whether this is in the form of blood because it had a bleed is up to you to decide. But you need to put the fluid back to give them. Give them, um, blood, uh, give them fluids and then consider giving them basal presses. I'm to help with the low BP is, well, cardio cardiogenic shock. Um, can because, like I said, with the neuropathy's arrhythmias, or even in people with really really bad my card in and functions. What's gonna happen is your heart's not pumping anymore as well as it should, and therefore your body has to reinstate the BP by activating a baroreceptor response and your ass activation to put the BP back where it waas. You can find people a shins with cardiogenic shock by looking for signs off again slow capri filled because that signifies poor profusion. Underlying heart failure for examples of peripheral edema raised JVP um, also like you can be able to hear murmurs or auscultation or they give your history of syncope or palpitations of the value of problems or arrhythmias. The mainstay treatment, the Collagenic Shop first line is usually given them diuretics and then heart failure on giving them enough troops to help the heart to become more contract time. Yeah, basically, I giving IV fluid bolus in college and shock is generally contra indicated, especially then heart failure. And they have peripheral edema because really, these patients have a Dema have lots of fluid in them, is just the fluid is in the wrong place and therefore stuffing them with more fluid is you're not going to help because the flu is not gonna end up in the right place and therefore patient's and heart failure. Cardiogenic shock giving them IV fluid is usually contra indicated and you give them enough tropes. Basic price is indirect. Six. Instead in obstructive shock. Uh, examples of this I've mentioned is Kartik camping out what his impaired feeling of the heart and the heart kind pump because it's like restricted. Um, if somebody is having attention pneumothorax. This means that increased intrathoracic pressure, which is a bit like our company out because obstructs your heart's ability to expand and fill. Uh, if somebody had a massive pulmonary embolism, this means that the pulmonary pressure is going to be high, and therefore your left ventricle is gonna have problems pumping this results. This is increased after load on their focus, cause on obstruction to your heart. First ability to pump clinical features again. You'll see things like raised JVP because the blood is not being pumped out. It's pulling up against low coppery filled because of poor profusion, low BP on underlying maybe cardiac problems that you might see um and um of management. You can give these patients lead resource to reinstate fluid. But really, you're the one. A. Find out what the primary problem is that they have in cardiac tamponade. You want to get them pericardiocentesis and remove that fluid from the mediastinum to relieve the obstruction. If you've had a P e, relieve the obstruction by giving them from realizes removed the embolism from the lungs and hopefully that will solve itself. Sort of have up. Then you have distributed shop, so we have three types. Um, septic shock is severe. Sepsis UTI infection bacteremia spreading to your blood physical features again. Um, this time, no, Um, the problem is not really in pop up poor profusion because actually, what happened is that they're very razor dilated. There is a lot off space as a lot of things flowing. It is just flowing to slowly, as in, like it's just way too leaky. So what's gonna happen is actually have warm skin because they raised the dilated. The Narcan have a port cap refill. Usually you're going to see signs of infections or fever. Raise heart rate performance. Excess six sepsis, six. Look for rays, lactate. Look. A reduced urine output. You notice that they might be Yeah, all the uric, Um, And also look for other signs of infections. Have you had a cough? Chest infection, stiff neck headache, meningitis? Ah, uti, your sepsis. Uh, well, treatment for septic shock. Would you? Based on sepsis six to give him antibiotics, give them fluid, give him oxygen therapy. Um, and consider giving them vasopressin is if they're obs are not stable enough. Um, anaphylaxis. If somebody has known exposure to allergens off this is the first episode off being exposed to allergens. Um, this again is really rapid onset because people react like in minutes to hours on in and of Lexus, uh, looking for a rash, looking for a demon, um, interval access and the main first line treatment kind of lactic shop. It's adrenaline on for progress says purposes. I would memorize the dosage of adrenaline you given under flexes. Go to pass. Met. You have a great table summarizing the dosage of ana of adrenaline. Like it's one in 1000. For example, in adults. Um, front. Yeah. Definitely learned that management of anaphylactic shock, a fan of Lexus and also consider razor process. If that was on stable, for example, low BP, high hot drinks that New York cardiogenic shock is a bit of an odd one is very different from the others, and it's because the etiology is very odd. If somebody's had a spinal cord injury, this basically messes with their sympathetic system and makes them basically like, basically met like destroy the sympathetic system and they become very power sympathetically driven. And this causes bradycardia. So where is all the other kind of shock? So far, we've seen low BP, high heart rate and your a cardiogenic shock. You see low heart rate because your power sympathetic system it's taking over, not your sympathetic system. Uh, that's how kind of how you can tell the difference. Um, and the only difference in management here would be you'd give consider giving them atropine for bradycardia if indicated, it's bad enough and try to, like, fix. The underlying problem is, well, fab. So that's that's my talk. I'm going to put this pulled back up again for you guys do the questions. Um, so if you want to answer the questions again and be great, this's the first one is the same one as in the beginning. Yeah, um, I'm gonna give you more seconds with this one second question. Oh, I didn't put them all. Hold on. Let's go back to the beginning. Cool. Is it the second question on the third question, some disaster. Why, after Lord was increased in cardio cardiogenic shock. Um, it depends on the it's yours, you carriage. Any jokes I gave the example of aortic stenosis, which is really bad. Or like if you have, like, infected undercard itis of like your valves and that's causing problems, for example. In that case, then your heart is not able to pump the blood out because the valve is an obstruction and because you're not able to pump out off load after load is anything that poses a challenge to left ventricle to pump the blood up. So about aortic valve would be an example of that. Um, if somebody has is in the intricate fibrilation for a while, there's older means of the cardiac output is going to be severely compromised because obviously he's like fibrillating, and it's not really back pumping any blood out in any kind of synchrony, which is bad on Bear. Four. Like again, your heart is struggling to pump, and that's increase after load. Um, somebody's asked and distributed shock. Why does your after load not go up in distributed shock, especially in in Septus? Andi in anaphylaxis. Remember that the primary problem there is that there's an insane amount of a zoo dilation, an insane amount of like leaky vessels. That's half that's that's that's been caused by the step by your immune response. That's the primary problem is that your vessels are extremely leaky and therefore, like your body, is in the state off opening up your vessels. And therefore the response is not going to be too close them back up again because your body is trying to save yourself from sepsis by opening up your vessels of that makes sense. Um, it can do both the same time. What's the difference with intubation and mechanical ventilation? Intubation can be done in invasive mechanical ventilation, so mechanical ventilation can be invasive or noninvasive and invasive. You put an endotracheal tube and you intubated someone with the tube, whereas in my cat wires and non invasive, you just give them a mask. So intubation is part off invasive mechanical ventilation of that make sense. Okay, Fab Thanks so much for answering the pole. Guys, I'm going to go over the SPS I really quickly. And if you stick to the end, you can ask me questions. Um and I'm happy to stay back and answer them. So on a Sorry to interrupt. I've also got a question that I was gonna hope to try and answer when you're done. But just think it's You wonder what I'm doing over at Queen over it, but go for your skates. Missed. I can't find Okay. Um fine. First one, here we have a a a man who has value disease on it, obviously in hypothalamic shop because he his BP is low, His SATs a low. He's confused. He's oliguric. He's not cost very much urine. Hey is called peripheries, so you can tell he's in some kind of shock state, right? The valvular disease is meant to push you towards a cardio cardiogenic kind of picture on the fact that he has peripheral edema. Also kind of tells you may have he may have heart failure. Symptoms of management. You're like, Okay, this is cardio cardiogenic shock. How my gonna manage this? Um, because he has heart failure and he has peripheral edema. Ah, fluid Bolus is contra indicated in this case because giving somebody with peripheral edema fluid makes not much sense because all that fluid is going to go and sit in their damages area like it's not going to go to the right place. So that makes sense. So you'd give them, you know, tropes and you give them diuretics and potentially raise oppresses to help cardiogenic shock. Next question we have sand was young, male just suffered some trauma. He is too breathless to reply in sentences. Yes, and stride on examination. A poorly perfect used low BP, low oxygen SATs, first line management. Um, this is mostly testing your A B c D management, which I didn't have time to go over the lecture. Basically, um, anybody who comes in when you first assess them again, you do 80 Management airways, breathing, circulation, disability, everything else. So again, airways, the first thing you do is potentially you consider which in left, because he's not able to speak properly. You want to make sure there's nothing obstructing his airway on day four. You always this airway first, and then once you've and then you go on that all the order after that. That's why Chin Lift was the correct answer on this one. This lady Lisa has chest pain low. He's hypotensive talking Codec sweaty pale has raised JVP and his muffled heart sounds. Anyone tell me I'm try out of symptoms that you can identify this patient. There's a name Becks Triad was what is the diagnosis in this patient? Cardiac tamponade? Colic company are typically textbook presents with hypertension, low BP on raised JVP and muffled heart sounds. And that's the type off obstructive shock to the correct answer. Here was a obstructed Yes, there's much it goes. My SBA is Thanks everyone listening or not gonna answer any question.