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I did. So welcome back to the preclinical lecture series. This is not excuse about crossing over from clinical school and letting our clinical topics in trying to apply it. A pre clinical module. Such a home fab meant to keppra. Today we got Alice. They're teaching is a little bit about critical care. And the I see you talking about what kinds of things go one in the I see you and so off the support of strategies that we have in the treatments that we have and hopefully how it relates to some of the one a one b and also made the part two topics that you you encounter. Okay, um, Alice off to you, Alice. I think you're still a mute. Hey, Sorry. I was just gonna say, if anybody that has any questions as we go along, little free to put it in the chat on being kind of on on the steps. I can I'm gonna maybe try and get you guys interactive, especially since there's not too many of you on. We can see kind of where we go from there because there's no point of being a lecture. If it's a super by a supervision sized group. So, yeah. Um, so we're gonna be talking today about about like he's just said that Cardiac critical. Yeah, Patient on D. Kind of how that relates to your physiology type top. It's I'm gonna vaginal that in the context of the stools case, Classical case. What? So Ames for today? Start with our example case and kind of talk to the basics of that. And then I hope to touch on some path of his a bit about monitoring and then kind of fun, like electrical slash mechanical support we can do for these kind of patients, right? So here's a patient, um, 60 year old male who presents to the emergency department with Central crushing chest pain. I don't know if anybody wants to put in a chat and be brave and say what central question just made it almost always is. Please do. It would really help. Um, I amazing. Okay, so that's exactly what I was getting out. The idea of this is that it's a really obvious one. So, yeah, this person, um, gets investigated in the emergency department gets troponin, which is a blood test that basically test foreign enzyme that leaks out of the heart. When the heart is damaged on, they get an easy to on the C G says This doesn't has myocardial infarctions on at Mile a specialist settle in layman's terms of heart attack on specifically, it's a stemi, which just basically means that on the CJ a little bit called the ST Segment is elevated. So that's for the S T E is in stemi generally and ST segment elevation. Um, I is worse than a normal ST a settlement ST segment elevation, Um, I, but not completely. But generally we can think of that. I that all right, so any day he's given generic medical management by the doctors there in the emergency department, so they give him morphine. You give him oxygen. I put, if required, because it's not necessarily what we give everybody. So let's say this gentleman didn't have a low oxygen. We wouldn't have to give him that on nitrates, which is basically just a, um, kind of to relieve the symptoms and also just to dilate. The blood vessels in the heart problem flow get through on aspirin, which is also kind of in the painkiller aspect but also in the salt round, Um, helping to prevent the clot. Um, all right, so understand that a few more people have arrived, but then why you haven't missed that for just introducing our man who's coming with Central crushing chest pain and been diagnosed with an myocardial infarction. So heart attack. So they've managed it in the emergency department like this because he's got a stomach. Um, which almost always means the underlying pathology is that one of the coronary arteries has become fully occluded. So by a court or whatever. Is that secluded? This quote me on story, the priority number one is to reopen or revascularize the blocked vessel. So, um, he goes straight path with that stent he's in. Adam works. Um, he gets run through the tunnel on the specialist, so, um, emergency transferred vehicle, They have to pack worth little PCI. So he's he I I'm just gonna do a little set aside. And what about the eyes? Um, so from allies, this kind of was the original kind of clot busting, quote unquote treatment for heart attacks like this up until about 2005. But now it is. It's kind of been superseded by PCI, which doesn't actually mean much or PCI means is that you're doing something to the corn realities through percutaneously means that just means through the skin. So, basically, means is just not open heart surgery. Um, but in the taste PCI almost exclusively means, um that we put something in, we put a wire in through the family brain in the leg such groin or the radial artery, and the rest on we go into the chest on D. Blow up a balloon to try and unblock the artery. Um, plus or minus putting a stent in tow prevent the artery occluding in the future. So this guy gets this. He has PCI Onda. It's successful. Or you can really say when you say something is successful for these people is that when you look on the angiogram, which is something you can see on the left, it appears that the artery or three open So you can see here. I've got a comparative diagram, But here you see, this is an example. I'm not necessarily saying this guy have this, but let's say that was an occlusion at this level. On picture, you can see where the vessels not letting anymore the contrast down it. So when we're doing an angiogram, you can see that there's an occlusion at this level, and then when they open it back up, um, Publix, we see that the procedures been quite a quite successful. So he's then transferred to see to you, which is the critical care for specifically for cardiac patients following the procedure so they can monitor him and they're aching back up and everything's fine. Then, like a day later that so it's a day later. You're a genius doctor on there on the water on the critical care unit on the nurse's beep. You. I hope you guys like my Google image of a sleep. Um, you know, sleep you to say from the 60 year old male. Brian seems a bit confused. Maybe he's a little bit short breath or, you know, do you mind coming into checking him out and you go, Yeah, cool. Okay, I'll come in on. Do you see these things? So you see he's got cold. You go to feel it's hands. He's got really cold hands, cold feet. He's got very pale, mottled skin. It's almost even maybe a little bit blue. You don't Really? Sure. Um you try and feel his pulse is that was resting on the speed, and they're really, really faint. Um, it's a regular pole, so it's not irregular. Um, implying he doesn't have a, um, for example, and major arrhythmia. His heart rate is 1 20 which I'll ask you. What do you think that means? His BP is 100 over 70 again. You can put in the tax. You think you know what that means? Um, over the last hour, he's got a catheter in so you could measure his urine output. Exactly. Because it's going into a little bag at the edge of the bed on go over the last hour. They think that maybe about 40 mL have gone. It's the bag again. If you want. Put the chat with the evening, that's a lot or not very much or normal. He's there on a M s at the top. There just means ultimate ulcerative. So he thinks of it confused. You're not really sure if this is normal cause you haven't really met in that much before, but he doesn't know where he is, and he's only 60 and far as your way. He doesn't have any mental problems going on, so you seem quite confused. And then, as the nurses said, he's a bit short breath. His respiratory rate is 20 which I'll give you the free is a little bit high when you listen with your status stable on his arms, you don't You could hear sort of crackles along the sound of it wet. So does anybody want to come in on any of these things? Someone said hypertension? Yeah, exactly. So I mean normal would be looking at kind of 1 20/1 20/80. I mean, in a gentleman of this age with heart problems, we've probably been looking up higher than that, actually. So 100 over 70 is quite low and yes, and it has come to the conclusion that he might be in shock. So does anybody wanna say with making the heart rate is high? Normal? Yeah. So it's high. Yeah, definitely. So over 100 is probably what we call tachycardia, but the honest if your heart rate's normally 50 and you've got one of 19, and that's actually a two. Um, so he's got high heart rate, which is his of the moment way of compensating for a low BP. So the fact that he's got a low BP and the high heart rate suggest is trying is very best, and he still can't keep it up. So suggest things are going quite south on Yes, someone said low urine output. So why might someone with a low BP have a low urine output? Yeah. So someone said, Yeah, someone said, holding on to fluid. Yeah, exactly. So if you remember your whole grass renting under tension a little stone system which I don't really remember too well but is very useful. Um, basically, if you have a low BP, you Yeah, like someone said, hold on to fluid to problem state. So you get last year far. It's kind of a double whammy off your kidneys work by being refused, so if you're not confusing in them enough, they will not work. But also, your body intentionally shuts down letting go of fluid. Because once do you hold it later in as North says on your keys for in the chat a noxious for why this person might have shock, which someone has really identified on one option. That upset is, maybe he's losing blood. So why I put here is on the next one is a summary of what you guys have said. So, yeah, this guy's got clinical signs of hypo perfusion, which basically just means it got low BP. Not enough blood is getting everywhere. And that explains his confusion because he's not refusing his brain explains his low urine output because it's not confusing his kidneys. It explains the fact that he's cold and muscle because he's not refusing it extremities because it's trying to keep everything in the center. And then that would be shocked. So the top box when somebody said shock that top box is shock. Um, what science did we see? The signs of pulmonary edema. Does anybody remember from the previous slide? Yeah, so the fact that he's got crack was on his lungs and his short of breath. You can be sure to breath just because you're not confusing very well, and therefore you're low on oxygen. So his respirations actually high on that because he's trying to compensate. So what? The crackles absolutely is the sign of a wet, long so basically pulmonary edema. So this guy just doesn't just have shop. So shot being he's not refusing the whole of his systemic circulation, right? He also has fluid or blood backing up in the lungs. So what kind of shot? Well, what kind of problem? Where would you expect a problem to be if it was causing you to not confuse your body off properly but causing your lungs to be incredibly wet? Yeah, so someone's put cardiogenic, and they're completely right. So this gentleman has a problem. So it's almost like imagining if you had if the whole circuit is one John almost tube. He's got enough liquid in here, so it's not losing it. Quit you just not pushing the liquid for words from his heart. So it's basically it's pumped failure. So nothing out. Nothing on the forward side of the heart is getting enough that it's all backing up behind the heart in the lungs. So someone's just said on cardiogenic shock, which is perfect. All right, so a cardiogenic shock. So basically, cardiogenic shock as a definition is a low cardiac output state that leads down the organ. Hyperperfusion um, in this case, it's occurred Second, Rita. So this is one example of the things that can make her second you to extensive left. Ventricular infarctions of this gentleman has had an enormous amount of his left ventricle was embarked it and therefore he has got cardiogenic shock. However, it can occur because you rupture your ventricle. You can occur because of right ventricular function. It can occur because you have a traumatic injury to the heart. So let's say you get hunted in the chest for really, really hard, but we're not punched. Maybe more like hit a steering wheel. Um, I'm breathe your home. We'll get that as well. So anything that causes pump failure, um, it's characterized by both systolic and diastolic dysfunction. So it means the heart isn't working in any part of it. Cycle on do. The study that I've looked at below and kind of copied in the references is the autopsy studies have shown that you need at least 40% of your left ventricle to be affected in order for this to happen. Why so going on to the pathology off it? So if you interrupt the blood flow in an epicardial coronary artery. So I mean, I imagine you guys know what that means, but just to remind you so an epicardial one is just a vessel that's supplying the outside of the heart muscle rub on the inside. Um, so the zone that supplied by that vessel lose its ability to contract basically on it just sits there really, really flattered on if you look on like an echocardiogram. So if you do not sound probe on somebody's chest, to have a section of the heart is just not doing anything. So everything else will be contacting on got sections Just totally felt not doing anything on that basic unions that their pump function is totally terrible, especially if there's more than 40%. So if enough of it undergoes that, you depress the pump function and you get systemic hypertension because you just can't can't push blood out of the heart. So I This is, I think, first year home as far as I remember it. But these are the kind of too important equations all of the other ones go by the by unless your cardiologist. But these ones are really, really important that everybody to remember so cardiac output equals heart rate, times, straight volume. So how much you pump out times have us to do that. Something equals how much you get out basically on. Then, using that cardiac output, we can work out by multiplying by systemic vascular resistance. What someone's matters, which is essentially their average BP. All right, so remember those because they're gonna come back to that later. What? So I mean, in terms of the myocardial pathology coming on from there, um, it's sort of a vicious cycle. So if you imagine this gentleman has had a clot which is blocked some of this heart and killed off a load of it, it's if trying to fix itself so it needs more oxygen than the average tissue would need anyway. So it's got an increased oxygen demand because it's injured on because it's trying so incredibly hard. However, because it's not pumping hard enough, it's decreasing its own profusion. So if you remember in and actually the coronary arteries come off the aorta. So if the heart is a pumping as efficiently as it could, it's not gonna bump to itself is efficiently as it could. So it's a vicious cycle where you get less cardiac output because your heart is damaged, you get less commonly profusion. You already have increased my cardio oxygen demand on. Therefore, your heart gets even more damaged, and then it pumps even less well on. It goes on a circle like that. So it's a vicious cycle that that causes cardiogenic shock. So this is why this gentleman will have presented sort of a day in when things are going really wrong. All right, so getting back to our patients so I'm not going to go over the how you go laugh alternatives and how you diagnose it is not really on fine touch on today. But let's say you go over to see him and you rule out all the alternative. So, for example, what somebody said earlier that he's eating loads, and that's the reason that in short on you diagnose it. So you probably diagnosed it using any CD and unlikely an echo, which is what I said. Putting the ultrasound probe on the chest probably want to chest X ray as well. But that's probably not immediately going to come back. All right, so what can we do for this patient. So when we think about how we're gonna manage things, I quite like a lot of people use this method to think about what your AIDS for how you kind of help them. So usually symptom control comes in a special star of the star. So if they're in pain, you treat that if the example, um you know they're beating massively. You stopped that, but kind of going on from that. The main things we want to be doing with this guy is maintaining your BP on D by proxy can also almost kind of put two into one. So one A and one B as maintain cardiac output because that will maintain the BP. Um, you can't just maintain the BP. So, for example, you could just increase systemic vascular resistance up hugely because you still need It's hard to be pumping. All right, so then also number three would be you need some respiratory support him because he's having trouble breathing, and then ultimately we really want to be reversing, whatever the underlying causes. So if I said how can you maintain BP and how come they tell you cardiac output Does anybody have any ideas? Looking at this? Anything we could do, Like just about anything in the shop? Yeah. So we can increase the contractors? Yep. And we do that. We will joke about it. Yep. Some of the fluids. That is one option in shock. We'll talk about whether that's appropriate here in a sec. Increased preload. Yeah, definitely So increased venous return. So if he's pulling, wrote about in his legs or something like that, we'll get that back in. Yeah, somebody's put, but they want to, um, diaries him. So you some frusemide? Yes, sir. I mean, all of these things can be, um, something you talk. It basically is what I'm trying to get up, eh? So he's already doing this himself in the heart rate one. He's already increased his heart rate. That's how he's trying to up it's cardiac output on then, as we see it in the bottom equation here. Ultimately, the main thing that we care about is this Mac this BP, cause that's what refuses the organs or it's no use having an enormous cardiac output. It your systemic vascular resistance is in the floor and all your blood pools in your feet. Um, so you need Mac. You need map to be higher after perfused organs. Generally, it said that you need it to be about 50 or 60 for them to do anything good, But you can leave them at 40 for a bit, and they won't die. But anyway, you want a 60 to be. I would feel it. Really? Um, all right, so he's already up his own heart rate, but he's an older gentleman. If most of the even the shop of the under age 25 if you guys lost the road blood or thought punched in the chest and went into cardio cardiogenic shock, you could probably increase your heart rate quite high for quite a long time. Uh, because fitness is a real thing. Um, this gentleness 60. So actually, he'll probably crash quite soon. He'll tire basically, and that heart rate will go down. And that's what we're quite scared. Also, we want to improve the other things before his own compensation. Kind of gives up that make sense. So maybe on somebody said fluids, So does somebody want to say why? Why not or what might be the benefit of fluids. What might be the downside of fluids? Does any guesses in the chat? Yep. So somebody said more after load? Yeah. So from our graph before, we did say we want to reduce after load if we can. So Fluid. Yeah, my increase after load, but it does increase BP. So what about if I give you for free? That in almost every type of shock? But no, All we do get fluids. So what about this type of short? Do you think this is one of the ones where we do one of those where we don't Do you have story? I hope you don't mind me speaking rather than twice fine with giving fluids. Do you have to be careful? Because, uh, he's already got pulmonary d s. If you give him too much fluids, just going to make that worse. Yeah, so yeah, you're completely right. This is the one case of shot where we do not get foods. Um, because he's not dry. He's wet on, so he's got enough fluid in him. It's just all in the wrong place. So you're exactly right. We'll make the pulmonary edema horrendously worse. You could give a little bit of the bedside before you diagnosed him with cardio cardiogenic shock. But soon as you've worked out cardiogenic shock and that that's pulmonary edema, you stop because you're completely right. Wet lungs. I mean, he will die from his cardiogenic shock, but giving him fluid won't help that on. They will pop. I mean, it might, but only a tiny bit on not really worth the expense of feeling his lungs up with fluid, because that's incredibly difficult to reverse. Um, pulmonary edema is really something we want to avoid. So the fact that he's already got to that point, it means it's quite severe. So, yeah, we don't live basically for this gentleman, but most cases of shots, you're completely right. Um, whoever said fluids we do want for it. It was much, though, is that I was like, Oh, no, no, no. Uh, Okay, well, let's wait least relax. Um, all right, So yeah. So, pharmacology. I don't know if anybody here is the second year, but there's a lot of drugs that you need to know because the people who write the course the motor know weight is a motor. Yeah, Motor are all cardiologists. So they love this kind of stuff. So, yeah, let's talk about pharmacology. So on the jokes and very suppresses anybody want on a trip to do? Yep. Increased quite contractors. He did they do anything else? Okay, so the heart's country, So, yeah, you're completely right. The heart is contracting, so it basically stronger or increased contractility means the, uh, the heart's contracting harder. Um, some of them increases vascular resistance, but only like one or two. Um are the other thing I'm getting at is that most of them increased heart rate as well, So no, only they increase the four to the heart contraction. They also increased, um, increase the rate at which it contracts. So that's what I know. Jokes do. So anybody? Vasopressin. Is that what the vasopressin do? Laura's already kind of set it in her second common. I'll give you Yes. So all of the mattering PCP. So if you remember the equation that got that BP is, um, cardiac output times, systemic vascular resistance. So I'll give you a clue that either trips increase the cardiac output on days oppresses, increase more the systemic vascular resistance side. So yeah, they both that to increase? Maybe so. Yeah, exactly. There's a constriction. So the first thing you using these people is, you know, traits. So you want to get that heart pumping because that's the main issue here. So, for example, in other types of shock, so in sepsis, for example, is a good example of the other way around. The equation be p equals cardiac output times systemic vascular resistance in sex is the main issue is the systemic vascular resistance bit that is incredibly low in sepsis because they go all red and hot and vasodilator did on blood just pulls everywhere, and they become dis like it's sort of mushy balls of stuff where the they've lost their BP mainly because they can't control his heart is that likes. But it's just pumping into a normal spread of capillaries because they're so vasodilator. So in sex is that's a good example of a kind of one where systemic vascular resistance is way up. This one is a good example of one where cardiac output is the issue. So, um, so we start with that is the logic that I used to remember this. So I'm a jokes as somebody's already said, increased contractility. So they increased cardiac output of increase your beach. It bp when we talked about on the tracks here. We're kind of talking about the specific group of the positive. Ana, try oats. Um, so there's a specific group that increased the force, so it is obviously negative. Ana jokes like calcium channel blockers. Um, that we use in hypertension. So, like the drugs end in P on, do they decrease it? So they're calcium dependent. Um, which basically, just because you need calcium too, do that contraction. So if there's not enough calcium, you have to be looking if if these drugs are we're looking, you know, Is that because this best person has no caffeine? Um, so examples just seeing me? Um, no, all of them. But they can be. So most of them are, for example, like calcium channel agonists, all that kind of thing. Not all of them are. So the examples we have in the bottom are, um, digoxin to beauty. Mean on Miller? No, no, the main ones. I mean, did you to me is probably the most off the s one. But one should know about milrinone the PT three, um, drug. So, I mean, that will kind of a mix, and I'll just beach two receptor agonists, but yeah, So that examples of those. So then we move on to, um, basically aces. So if, for example, the first girl doesn't work, so you do some minor trips they use? I don't know. Um, what the k three doctors love, which is dobutamine. So if you have a visit, the K three ward, I don't know if you guys have lectures from Doctor Krieg. Um, but he is a big fan of the beauty and analysts German accent makes it incredibly memorable is the routine so that I won't always sticks in my head, but they love that drug. Um, so then if they don't work, then you go on the basic places. So you're like, Okay, well, I can't increase cardiocap anymore. Why don't I increase the systemic vascular resistance? So, like, somebody said, they induce basic construction, so they increased the systemic resistance. So I think when I was a second year, I think I had a bit of a feeling that that didn't make any sense, because, I mean, maybe you guys have quickly go around this. But in my head, that seemed to not quite make any sense. Because if you're constricting, surely that means that the organs get less. Blood was always kind of how I thought of it, but I think the idea is kind of that it's not localized or the way I think that now, in the way I understand now is that it's not localized constriction. So if you, you know, constricted just to the kidney than usual it would be terrible and you wouldn't refuse to give me. But you constrict everywhere. And so, actually, overall, it just brings up the BP and helps you to refuse. So they work by tucked in the smooth muscle in arterials on basically, yeah, just decreasing vessel diameter to increased basket of assistance. So examples of them are nor jenaline. I mean, they've changed to starting to call it the Americanized norepinephrine. Now, um, so vasopressin is a good example. Adrenaline presence, just a th Basically it's just a drug form of a th also don't mean so I know someone earlier kind of suggested that might be things that had both. So dopamine is on the vasopressin is slide on. Also, the I'll attract side. So don't mean is the absolute favor of cardiac I to you because it does both. So you don't really have to worry about it. Most trust are very scared of using it. Um, yeah. Needs very, very close monitoring and very type titration to be safe, half with, however so used to using it, and they'll send people to the wart on it. So it really varies, but yeah, don't mean it's the cardiac I to you favorite, because it does. All right. So, I mean, we've kind of already gone over this, That so free just to remind which one here is, Which one of those drugs we just walked about would increase the CEO here in the equation with map. The Imitrex of base. This is the increases, the cardiac output, More traits. So, by elimination, what increases this stomach? Vascular resistance? More inactivation. Yeah. Amazing. There's a press is perfect. All right. So, um, let me just go into the next one right on. Then Someone else said through his mind. So diabetics possibly minus So if this doesn't did not have common redina, we would not use diuretics if we didn't know they were wet. However, if you've got that BP back up over 90. So this guy actually wasn't under 90 ever. But he was heading on. He was quite ill. So it wants their systolic. BP's back over 90. You conducive. I wrecked licks. So the common choices What somebody has just said frusemide, which is a loop directed, um on you have to really closely monitor the patients. So I mean, the main way to monitor them is by urine output. So we already have a cap, had a catheter in the sky, but we didn't. We want to put caster in. Um, it's impossible to measure urine up if you don't put catheters in people. All skis. I'm going to say, How much do you think you read in the mood and also this guy's tool to be going to do anyway? But catheterizing someone's pretty much the only way to measure that you're not so we don't. Everyone, basically. So what's the next thing? Um, mechanical support? So we just talked about Bamaca logical support, So if that doesn't work, we can move on to mechanical support. I think it's also worth saying that sometimes in the emergency department. So if this guy had never been in hospital before, I came in with the symptoms. So let's say it had a heart attack at home. I'm going to cardiogenic shock. Then sometimes they do mechanical support. Um, they put it in in the emergency department as a kind of bridge to going to surgeries. They don't bother putting the month on a collectible support. They just use mechanical support as a bridge to get into the theater. So let's talk about mechanical support. So the kind of main ones we're gonna Well, I'm not going to talk about then trick, you know, assist devices. Basically, that's sort of like a type of bypass, Mr. Martin machine. What I'm little Pataday is intra-aortic blue pants, mainly because I think that probably the coolest thing ever on behalf The reason I think I to you is the best place so into aortic blue pants are kind of like a the pull your a theme tubes. They can see it here, running out there water on. Do you usually insult them by like a femoral artery on you? Head up. You can see it heading up here in this image English because it's attracted at and, uh, subtracted MRI. I think, um, it's It's a day or two like this on Do It inflates and it deflates in time of the heart beat. So it's like two centimeters below subclavian. Vein artery is the aim for it. Eso inflates and deflate in time of the heart rate. So can anybody give me a guess as to whether they think it inflates in style, silly or deflates in the last year, your inflection system, the old deflates in systole? Which do you think would be more helpful? Sometimes people consider this counter in Georgia as a hint somebody for inflates and I sleep to allow cardiac usually people in there. And guess is in not saying that's wrong were saying It's fine. Nobody wants to go against the first answer. All right, this kick onto the next one, so it deflates intensely. All right, hon, inflates and I asleep. So basically, when it deflates in in systole, So if they're if you imagine it like the heart contracting, it deflates. Um, so it's basically like it decreases after load by sucking basically. So if you deflate the blue. You create a vacuum effect on the aorta, which sort of indirectly increases forward flow. Um, so it makes it easier. So that occasion that we had ideal Or if you think about starlings law, where after load, you want to decrease that as much as possible to help love go forward. Um sorry. Yeah. After load to help Good blood go forward. Basically, by deflating this balloon, you create a sort of suction down the aorta which helps blood head forward your intestinal e on. Then during diastole, you inflate it so as the aortic valve shuts. So if you remember your kind of coronary anatomy where the coronary arteries come off just above the aortic valve, when the heart relaxes in the valve shot or when the brother, when the ventricle relaxes and the valve shut, then blood heads back down. The coronary artery is how it normally happens. So if you inflate this ballooned urine, relax, Asian dream diastolic. So a section of the cycle you push blood back down the coronary arteries and increase that wretch. Good. So So basically it has sort of two actions which helped with the issues that we've got from this college a shop. So no, only does it decrease Mike, probably lots in demand, so it helps the heart with its job. But it means the heart is working less hard, so that decreases Theo to demand. It also increases the perfusion were getting and the supply to it. So that's kind of a double whammy on the heart, not needy. It's not so much the heart not needing as much oxygen and then also getting more profusion on oxygen because of the inflation, which is shoving that blood back down the cornea arteries, your PSA, then get in directly increasing cardiac output by sort of that suction effects that reduces after load. So it's kind of amazing, although patients find it incredibly irritating because for every single bit of their heart the machine goes on. They find it really unbelievably irritating, and I can't sleep. But other than that, it's a really good machine. So talk to me about complications. What do you think could be a complication off shoving a giant balloon in somebody's a also or a problem that my arise take apart from my God? Yeah, that would be awful. It could fall So if you inflated too big. So you have to guess. You have to put in the right size of balloon. And you also have to guesstimated the diameter of the aorta. So, yeah, you could just do it too big, even in the first place. And just stretch, they order or dissect the aorta. You're completely right. Usually they tend to inflate it to not completely the edges in order to try and avoid that. So that's one thing. So once they got that sorted out, then what the other issues that could arise. To be honest, with almost all complications, you can just guess them because almost all procedures you do have basically the same ones. Yep, infection, community, always infection. Somebody sent me a direct message saying, Infection, you always get infection and infection in a A water is a terrible thing to get because, as you know, blood from the aorta goes everywhere except kind of the lungs, but ultimately lend up like that. So, yeah, in fact, in there will spread very rapidly and they will be septic, so that's not good. Actual. So what about thinking about having a foreign body inside your vessel What will that do to, for example, your blood course Coagulation and clotting. Yeah, so you can get clots around it. You can get clots getting thrown off by it. You get clots in your legs so they have to take pulses from the legs every hour every half hour. So someone has to come and make sure that the legs haven't gone blue or white or massively swollen because it could just throw off huge clots. They have to be anticoagulated, and they probably would be anyway. But there's a probably post cardiac surgery, but yeah, you're completely like crossing. Not good. Anything else? Anybody know anything that happens? But, for example, mechanical heart valves. Because this is kind of a similar thing. Can they trigger the immune system? Yeah, So, I mean, that's kind of what I'm getting at. So there's two things that can happen with those blood. If you put something foreign in it, it well, so obviously they get infected. Um, they can create, like, a huge amount crafting or a massive thrombus around there, Or throw floated tiny Thomas or, like you say, so taken. They can humanize their blood. So what they do is either three mechanical compression. So if you have, for example, on mechanical heart valve, it actually hits bread blood cells on breaks thumb. This does exactly the same thing, so you can just mechanically destroy your red blood cells. But you can also like you, say Trickett information, which then also causes exactly the same thing so they can end up kind of anemic taken another jaundiced because you've just humanize a load that large. Generally, it's okay, So generally it seemed to be, If you need to use it, use it. But, yeah, there are just some complications to think about it. Think it's useful to talk about um, right? So we've done the first two. Let's talk respiratory support very briefly. It's not the main point of this. Still remain be the first thing is your weight's position them up right? So this person's got pulmonary edema, so they're going to feel a lot worse if you lie down. It's the kind of brief life Thank you about it. Um, so your position them upright. If he had a low oxygen, you give him oxygen. If that didn't work, so if you didn't work by just putting a mask on him. You can give, um, high flow nasal oxygen, which basically just is a better way of giving them it, um, on down. You can also use, um so and I keep e is noninvasive, positive pressure, ventilation. So that's a mask that sort of forces air in. So it's not invasive. It's not a tube down the throat, but it is positive pressure. So the reason that's helpful is because a if they're not getting enough oxygen from the mean so from option two or three, that helps him get extraction. But also it helps with the pulmonary edema. Because if you think about the fact that there's fluid pooling in the lungs, the positive pressure can help with that, um, kind of in a sort of a round about very summarized way by forcing it back in that, um, that's not a total what it is, but it's a nice way of thinking about it on then. The final option is invasive ventilation, which has quite a lot of complications in these people. That can be kind of what's required if if, for example, he's just not got the energy to be breathing for himself. All right, so we've done the rest of it. So then ultimately you want to reverse the cause. So, I mean, how do your vesicles, What even is the force here? Any ideas? We've already talked about one of them because he had the first one when he first came in the first option for reversing course. So it can be kind of useful to think of it like this. So, yes, occlusion comes on gradually or suddenly. So I mean, you guys know about the path is of coronary artery occlusion, so yeah. So statins is kind of a secondary prevention one. You're completely right. So with this guy, it's so bad that we're talking about right now what we do for him. You're completely ride the statins or something. We definitely want to start him on a student. He left the hospital long as he was still alive. Um, which, actually, honestly, um is I mean, he probably will be still alive, but it's not like I'm percent certain at this point. Cardiogenic shock is really, really serious. The fact that he's imparted enough heart get cardiogenic felt is, um worrying, to say the least, So basically our options are what we've already talked about. So you see, I say, Let's say we went back in. We did another angiogram, and it just looked by. Actually, we really didn't open up the artery well enough. Let's do another one. And then does anybody know about a surgical option? Another option, for example, dealing with M I or blocked? Yeah, some of that cabbage. Yeah, so come it. So we another option for this gentleman would basically be. The way I like to think of it is if you think of the coronary artery as a road that's got, like a pothole or a car accident on it, something that's stopping traffic. And that's the issue. That's the clock or occlusion or whatever is. That's what the issue isn't. It stopping blood flow If you want to get cars to their destination, which is ultimately getting blood and oxygen to the bottom of the heart, or further down where the blockage is, you either need to clear the blockage, so you need the need to fill in the hole or get rid of the car accident, or you need to bypass it with like, for example, diversion signs on the road. So if he if he if PCI the one on the right doing a stand on deflated balloon is kind of like the feeling in the whole option. So you might be able to do it well enough. Um, but it might be better in some circumstances to just put it over to the sign up with which is to do the cabbage. So what you would do is you just still a bit of veins from in the legs? Usually, but sometimes in the arm Onda, um, sometimes a memory artery on do you just so it around it. So you just create a diversion. So there's kind of two options are like two people for getting around a blockage in anything, really, but roads on coronary arteries of the way that I think that So they're the two options. We're reversing this for this guy. Um, he's already kind of had this one. So ultimately, you kind of be thinking that making really need to try the left hand one. But, you know, maybe there's an option for doing this one again, or it didn't work the first time properly. All the stents collapsed. You know, we don't know. We want to be re imaging him. And then the final option. Anybody want to put a guess on what? This picture is? A picture off? Yes. And sometimes, um, yeah, I think it's pretty obvious picture. So, yeah. I mean, this guy probably would just found be young enough to be a candida people. They work their cancer for transplant. Maybe if he was in, like, good. There's a very, very stringent less, basically. But if you're in good health generally and you just, for example, lost a whole section of your heart and it looks like it's not be salvageable. So let's say when we angiogram this by actually, it looked like all of his arteries were really all of his coronary arteries were completely patient. The heart was just dead on one side, not the left ventricle didn't protect stool, for example. Then that's when you start thinking actually doing each transplant, these people, and that is kind of the most extreme of physiology, which is just replace it completely, Um, and it's incredibly interesting. You still go read about it in your own time because it's not good today. Yeah, if anybody's got any questions. I'm actually gonna stop screen sharing so that I can kind of see you see the chat I hate That was helping. Wonderful. Thank you, Alice. I was very awesome. And they gave some interest in, uh, doing. I see for some of us in the future, if you don't tell, I'm a big fan of I see.