drugs were potent respiratory infections

if you loved the lastone, and i know you did, you'll really love this one too. i don't hold back anything. i'm always talkingabout receptors. i'm always talking aboutmechanisms of action. again, to explain why,to help you remember why, some of these things. vasopressors and inotropes,these are some things that you have access to.

i want give you why is onedrug preferred over another. not because somebodytold you so, but to tell you,physiologically speaking, why. granted, it's probably goingto match your protocol. so what. and now you know why. and if you ever had todeviate from protocol, granted you'd getwhipped and yelled at, maybe you would atleast hypothesize

why you would need to deviate. or maybe i need to call for medcontrol and ask for something. objective-- compared andcontrast some of these things. obviously, volume status inyour critically ill patients. kind of talk aboutwhat physiologically is going on when someoneis actually in shock. there's a coupledifferent shocks. they're hypotensive. that's what you know.

why are they hypotensive? there's different reasons tobe hypotensive and in shock. list some of these bloodpressure or cardiac output things. talk about lactic acid andsome of the other things that we would be lookingfor in the hospital. and i'm giving it toyou and you're like, but we don't do any of this. i know.

what happens if you pick apatient up and transfer him to another hospital? then you may have someof this at your disposal. i'm not saying you'redoing anything with it, but it's there. i want you to knowwhy is it there. what else can youpossibly be doing, right? just taking an intense personfrom one place to another, right?

if i'm wrong, i canjust shut up now. and don't tell me i'm wrongbecause you want me to shut up. i'm wiley. also describe the catecholaminevasopressors and inotopres. what makes themsomewhat different. and what are someclinical endpoints you need to look forwhen these are running. pretty much what that isall saying, what is shock? i'm shocked.

no i'm not. because if i wasshocked it would be a life-threateningcondition that occurs when the body is notgetting enough blood flow. so, there's manythings that can cause not getting enough blood flow. can lead to, obviouslyif left unchecked can lead to yourorgans not doing well. because they're notgetting enough blood flow.

as blood is going to beshunted, and blood is always shunted to your brain. you can live without kidneys,your body knows this. your brain, not so much. so everything always tendsto shunt to the brain. brain, heart, but you know, youdon't do well without liver, all these other things. shock requiresimmediate medical help. types of shock.

hypovolemic. that's a big word. what does that mean? yeah. low volume-- hypovolemic. low volume. they either lost blood,paid for college by plasma, i don't know. they lost blood.

cardiogenic shock. it generates from the heart. the heart is the problem. so you're not gettingenough blood flow because the pump's broken. if your sump pump is broken,your basement is flooded. kind of same thing with this. we'll talk about it. distributive shockand obstructive shock.

obstructive shock couldbe a massive clot. or, if we have a massiveclot in our lung area, we like to call it a pe. you don't tend to livelong with a massive pe. so these things areobviously of major-- so what will affectblood pressure? this is not rocket science. i am not telling you anythingthat is not painfully obvious. if your pump is notworking, as we talked about,

your sump pump is notworking, you've got a backup. your blood flow is not goingif your heart is not working. you've get an mi, somearrhythmia, acute heart failure, some valvular disease. heart's not working well. hypovolemia. hemorrhage. intractable diarrhea. you always forget about that.

you think there's no waythey'd poop themselves-- you can lose a lotof volume in stool. funny, it's funny, wealways talked about poop from when we were little. we'll still laugh alittle bit about it. not so funny when you poopout four liters or more. you can lose a lot ofwater, and a lot of salt. heat stroke, same thing. lay out in the sun, do alot of work in the sun,

technically couldbe going into shock. we kind of forgetabout those things. like yes, ok, we know aboutthem, we pick these people up. it can be verydangerous as well. decreased cardiacoutput and vasodilation. this happens in sepsis, orsometimes is drugs induced. anaphylactic shockis the same thing. and neurotrauma. if you actually wind up shockingor damaging your spinal cord,

you will becomehypotensive enough because the nervessupplying the vessels stop and those vessels open up,and they become hypotensive. and for a shortperiod of time, you need to give them apressor to get those back. they'll bounce back eventually. but if you don'trecognize it, the person can actually die on you. now you go from a neck injuryyou can go into a shock,

because the vasculaturewill open up. because they're notgetting that neurotone. everything that leadssomeone to death is always a vicious cycle. to get this viciouscycle, whatever it is, you're not supplyingenough blood. so you have inadequateblood flow to the organs, your tissues become hypoxic. we're a dual-fuel system, soif you don't get enough oxygen,

what's it going to do? you're going to switchto anaerobic metabolism. anaerobic metabolismmakes lactic acid. in a short period of time, whenyou're running really hard, that's ok. you can stop and you startbreathing and it's good. but when you can't, and youkeep building up lactic acid, it becomes a problem. then you get ametabolic acidosis,

which causes cardiacdepression, which then causes inadequate bloodflow to the tissue. which then causes more,and more, and more, and you can spiralyourself right out. so you've got tobreak this somehow, in any of these places,stop that cycle. so how can we break this cycle? where is the system broken? try to figure out, hey,they are low blood pressure.

where's the system broken? where can i intervene? trying to figure out whereis it initiating from is of great help. it's very hard to do,especially in the field. but it's something thatwe're all trying to do. do i need a vasopressor? maybe. maybe not.

what happens if iadd a vasopressor and it's really the heart? am i helping the heart out? i'm adding stress to the heart. oh, well, the heartwas actually sick. we'll talk aboutthat in a little bit. how much of avasopressor is too much? when i start making theheart sick and sicker. let's say the heartwasn't the sick part,

but i can make the heartsick with my vasopressors. sorry, this is moreof a joke, if anybody knows the movie, sure thing. unfortunately it's fromthe '80s, and i'm old. anyway. who made liquid soap and why? we're going talkabout monitoring. and we'll go quicklythrough the monitoring. this is a lecture i give tomany people, so i apologize.

some of this monitoring stuffmay not always apply to you. but it will apply ifyou pick patients up from one icu to another. so we'll talk about andanswer five of the six. i don't know who madeliquid soap and why. they probably madea lot of money. hemodynamic and oxygentransfer monitoring. blood pressure isthe gold standard. mean arterial pressure iswhat we're really looking for,

is more of a mean than systolic. you want to knowwhat that average is. that's what your mean gives you. what is the heart rate? if i can figureout cardiac output. to get cardiac output, ineed an invasive line placed. i can't get cardiac outputin the emergency department either. so i'm in the same boat you are.

i can't get that. i can just kind of go by myother signs and symptoms. well, i don't think theirheart's working too good. you look at how they'reoxygenating, stuff like that. cardiac index is actuallyyour cardiac output. and i'll talk about all these. over body service area, strokevolume is how much squeeze, how much volume is being ejectedwhen their heart is beating. central venous pressure.

that is how much pressureis in your venous system. when we look atyour blood pressure, that's how much pressureis in your arteries. as your blood goes from yourarteries to the capillaries, the capillaries arelarge, very spacious. you lose a lot of pressure. when we talk aboutlike 120 over 80 is what we look forin a blood pressure. on the venous side,we're looking like 10.

that's how muchpressure you lose as it goes intoyour venous side. and 10 is actuallya great number. you're topped off. you're looking good. you've got enoughvolume onboard. you can also look atsystemic vascular resistance. if i take your bloodpressure right now, let's say it's a gardenhose, and you're doing fine.

and the spigot is turned on andi'm able to knock that knob off so i can't turn it up anymore. you've got great pressurewith the garden hose. i'm able to takeoff the garden hose and now i put on the fire hose. it was a great stream before. how is that streaming out now? and that's whatyour svr gives you. systemic vascular resistance.

you didn't lose any volume. the vasculature just went ughh. this is what you see in sepsis. the heart's fine,the pump's working. the volume didn't go anywhere. i just put on some fire hoses. pulmonary, thisa wedge pressure. a very, very specialcatheter gets this one. we almost neversee this anymore.

but it is of great value. pulmonary artery pressurewould get on an echo. when you're looking atoxygen purposes, when you look at someone'spulse ox, you're looking at theirarterial oxygenation saturation, your sao2. that's what you'relooking at in a pulse ox. you like to see that 100%. somewhere in the 90sis fine by me too.

but you're looking at 80s-- ifthey have copd it may be ok. i'm not necessarily happy. you get a mixed venous, thatbecomes a lot more complicated. some of these otheroxygenation stuff. you can actually get to apoint where you can find out how much oxygen you aredelivering to the end cells. which actually gets to thatwhole vicious cycle thing, when we're talkingabout we didn't deliver enough oxygen, which causes itto switch to a different fuel

system. lab values. cbc tells you how muchblood somebody has. electrolytes can kindof point to how well the heart's working. metabolic panel, bloodgas, lactate level as well. your mean arterial pressureis very good for us to know. and your mean arterial pressuretechnically can be calculated. i know machines give it toyou, but it can be calculated.

your heart is activelybeating a third of the time. so you take your systolicblood pressure times one third. and guess what? it's not beating2/3 of the time. voodoo math there dude. i know it's hard. but if it's a third of the timeit's beating, 2/3 of the time it's not. so you get a diastolicpressure, when it's not beating,

times 2/3's. that will give you yourmean arterial pressure. that's how you calculate it. why is the meanarterial pressure more so when you'reevaluating this? it's because the arterialpressure is an endpoint. you want to get that averagepressure up high enough that you're delivering enoughoxygen to all the end cells. so if you're looking atit systolically speaking,

let's say you've got 120 over 2. my mean pressure stinks. not really deliveringenough oxygen. and if you're in bypass surgery,they'll put you on a pump. let's say they put you on pump,your pressure is 50 over 50. it's a constant pump. it's not like a heart beating. so it's really focusingon what we're looking for. we need restorationof adequate perfusion,

is really whatyou're looking for . coronaries, also your brain. map's less than 50, you'renot getting enough delivery. svr is your systemvascular resistance. you're going to seethis more in sepsis. don't worry aboutcalculating for central cvp. we talked about it already. skip that. what will affect your cvp?

blood volume. what else? also if you're in some sortof right heart failure. will this make sense to you? if my pump is broken, will isee the backup before the pump or after the pump? before the pump. so if my right heart is failingme, say i had my rca occluded and i blew out theright side of my heart

and my right heartis failing me now, where will i see the backup? in the body, the vasculature. so this should make some sense,if my central venous pressure, which normally is low, isstarting to get pretty high, there's a chance that yourright heart is failing. eventually right heart failurewill lead to all heart failure. the left side as well. heart rate we know.

cardiac output issimply calculated if you know stroke volume. you know how muchvolume is being ejected, you take that timesyour heart rate. that gives you cardiac output. that is an ok determinanton how your heart is doing, but it's not the best. the best determinantis cardiac index. why?

cardiac index is basedon body surface area. [inaudible] exactly. it's geared towardshow much mileage that heart has to beat against. you take a very, very smallperson with that same output, it doesn't have to travelover all that mileage. you take someone verytall, very large, that's a lot ofvasculature mileage

you need to pump against. same thing as with hoses. if i link as manyhoses as i can, will that pressure beas good as if i only had a really short hose? no. the really short hose is reallyfiring out from the source. so intuitively itshould make some sense. so when i'm looking at-- grantedthese numbers you can't get

in the field, i can't getin the emergency department. but if i've gotsomeone in an icu the probably havethis hooked up. they probably have animmediate monitor, a catheter, that's giving themcardiac index. it's giving themcardiac output as well. but what you really wantto look at it not output. you want to look at index. we don't get these anymore.

wedge pressure is veryimportant as well. it tells you howmuch backup you get. and what it is doing,i will tell you. you get it from aswan-ganz catheter, not that you need to know that. swan-ganz catheter,what they would do is they would put thecatheter in the right atria, put it in the rightventricle, blow up a balloon and have it float intothe pulmonary artery.

pretty dangerous. yes it is. that's why we don't doit too much anymore. because if you blow outany of those things, you're probablyhurting your heart as in permanently hurtingyour heart and not living. but what that willtell you is how much pressure is in your lungs. if the left side, which isthe biggest side of my heart,

is failing me, where'smy backup going to be? in the lungs. i'm going to have a lot oflung backup or pressure. this swan-ganz catheter wouldtell me that kind of pressure. it will also tell you how muchvolume the person has on board. your cvp is lessinvasive, and it will tell you thevolume as well. but we used to use the swan-ganzcatheter with this wedge pressure to find out how goodthe left heart was working

and see how much volumesomebody had on board. oxygen delivery. we will blow past this. lactic acid wealready talked about. if you've got someonewho is hypotensive, and it could be shock,what would you look for? well, primary labs youdon't necessary worry about. what do you worry aboutfor a patient history? what do you want to know?

what meds they're on? have they been eating? have they been pooping a lot? has the poop been diarrhea? has it been blood? these are things thathelp you and help us when the he gets there. you guys tell us thisstuff all the time when you're dropping people off.

he pooped a lot ofblood, because i have to hose out the rig ican tell you that right now. you're telling us this. so he could be hypovolemic. could be septic. they're feverish, they're hot. you've got to know ifsomeone has got somewhat of an infection. they were in the hospitaland had some kind of surgery.

and now that side isoozing with some pus. it doesn't takerocket science to go, there could be an infectionthere causing the hypotension. so some of these thingsare just painfully obvious as a possible source. things to think about. cardiogenic is harder to see,unless they have a known chf. cardiogenic shock and chf arefairly similar, fairly close. cardiogenic shock tends tobe, you weren't expecting it.

somehow the heart took ashot, took an unexpected turn. chf tends to gradually come on. they didn't take enough lasix. they're already ontreatments more than likely. obstructive causes. trauma, that's obvious. gi bleed tends to be obvious. intractable diarrheatends to be obvious. delivery or miscarriage,all these things

are going to be obvious. you will know these uponpicking the person up. get them some fluids on board. cardiogenic causes. mi, that's obvious. like boy, i did an ekgand it's tombstones. if the pharmacist can recognizeit's an mi, you guys can too. trust me. an arrhythmia, youcan recognize that.

acute heart failure,taught to recognize. if it's an unknownheart failure, it is tough to recognize. so then you're looking atsome of those other things and weeding out. well, they're notbleeding to death. it's a guy. he didn't have a miscarriage. you go through allthe other things.

valvular disease. you listen to theheart and it seems like one is really loudor regurging really well. if you can hear itwithout the stethoscope, that's probably the problem. if you hear the swish,swish of the heart without the stethoscope,that's a six out of six murmur if you'relooking at the grading. that's where itdoesn't take much.

that means their valveis pretty much shot. sepsis. bacterial, fungal, or viraltends to be the cause. things you need to look for. very quick facts--and again an aside. brought you through all thatterrible stuff that you rarely look at to get you to some ofthe stuff that you do look at. your best vasopressorin the world within normal limits-- fluids.

if blood pressure is low,the best thing you can do is give them some fluids. as long as they don't have chf. even if you give someone500, even with chf, that ain't gonna domuch of anything. they'd have to be sobrittle of a chf person that you-- to put theminto full failure, they'd be living in thehospital on iv drugs. trust mt.

so you're not going tohurt anybody with 500. maybe not even a liter. whatever your protocols are. your best pressor in thewhole world is always fluids. always. catecholamine receptoris less responsive when the patient is acidotic. that's a physiological fact. so let's say you have tostart somebody on a pressor

and you know they're acidotic. it may not work real well. let's say someone is coding. let's say you come upon somebodywho has already been coding and somebody is doing cpr. and you give them some epi. and it doesn'tnecessarily work right. they're probably acidotic. even though somebody is doingcpr, and it's great cpr,

it's not as good as theheart is ever going to be. they're gradually gettingmore and more acidotic. you give somebodya milligram of epi, the body will respond atless than a milligram. i can't tell you howmuch less, but it's less than what itwould normally be. so maybe the next epi may work. i'm just letting you knowsome of these things. if something goesdown in front of you.

like they were fineand all of a sudden they go down in front ofyou, that epi may work. because they're notmaybe as acidotic. so some of thesephysiological facts may help you toknow maybe i need to work this a little longer. maybe i need to keepdoing the things i'm doing to get tothat same endpoint. may need ludicrous amounts ofcatecholamine vasopressors.

when i'm talking to some of mypharmacy students and i'm like, ok, let's say i want to startsomebody on an epi drip. they'll want tostart them at two. normally i would like two. but if they'rereally acidotic, no. i don't want to startthem at two mics a minute. i want to start them atfour, eight, something. or titrate it quickly,knowing that their body is not going to see the same amount.

so it helps you to know,i need to move faster with these drips, then slower. because the personis probably acidotic. so some of these arejust tricks of the trade. just things to knowphysiologically. once you know that, you canget somebody better, faster. what you have learnedabout heart failure really will apply in thiscardiogenic shock stuff. it just applies.

what i ask myself when i'vegot somebody who's hypotensive, my first questionis, is the heart ok? is it a pump issue? that's always my first question. because the otherstuff is obvious. you're seeing blood fall out ofsomebody, yeah that's obvious. i know it's hypovolemic shock. i don't even have toask is it a pump issue? because that's something that'sgoing to kill them right away.

is it an arrhythmia, isit somewhat like that? is the heart ok? heart seems like it's ok. all right. then i'm looking hey,is the piping ok? is my vasculature ok? and is it a supply issue? supply issue is always the lastfor me because it's obvious. they've had a miscarriage,they've had something.

it's so obvious, it seems. not always. the gi bleed that bled outwell before you got there and he cleaned himself up. he bled out so much that hedoesn't have much more to give. we start giving himfluids, all of a sudden he starts going again. oh! that's why he's hypotensive.

i thought it was something else. it wasn't obvious. have i seen that? yes. it wasn't obvious until youget the fluids back in him. let's talk about some ofthese drugs that you can use. yay. dobutamine. you don't have access toit immediately on a rig,

i'm assuming. but you can pick somebodyup who's on dobutamine. dobutamine affectscatecholamine receptors, so obviously it isaffected by acidosis. all it does is helpthe heart squeeze. dobutamine justaffects the beta. going through all this. all it will do is have theheart beat faster and stronger. that's all it does.

that's great. right? downside is canproduce hypotension. whoops. you know i don'twant hypotension. right. so you normally are notgoing to dobutamine itself. rare case would chf. what happens is you'vegot stretch receptors

on the aortic arch. once they feel that pressurethat activates them, they relax their vasculature. if you've got chf, they'realready stretched out. you can give a chfpatient dobutamine. they won't respond like that. they're already stretched out. you see chf patients gettingdobutamine boluses, maybe even at home.

it can happen. dopamine. dopamine's effectis three stage. it depends on your rate. going back to dobutamine. you can still usedobutamine as long as you take into accounttheir hypotension. so if you put onanother vasopressor that's going to blockthat hypotension.

put on norepi, put on dopamine. when do you wantincreased contractility? when do you want theheart to beat better. when in those shocks doyou want it to beat better? which granted, you mightnot necessarily 100% know. but we may finallyfigure it out. i've actually done this. i don't have thesemonitors to find out if they're in cardiogenic shock.

but i"m watching their pulseox get better when i give them a slight bolus of epi. hey, the pulse ox will getbetter, then it falls off. the pulse ox will getbetter, then it falls off. because i'm helping theheart beat a little better, then it falls off. i'm like, i thinkit's cardiogenic. should give some dobutamine. doesn't work all the time,but when you can see it.

dopamine has an effectthat's based on your rate. do you guys haveaccess to dopamine? you know the variousrates that it's at will give you different effects. so at low dose weused to call it renal. we don't do this anymore. it in theory would helpthe kidneys be supplied. it doesn't. in practice it doesn't work.

so anybody that says they'redoing renal dose dopamine, they're wrong. intermediate rates, 2 to10, it stimulates the beta. which just means heart. so you get increasedcontractility, cardiac output, your heart's beating better. and you also get betterperfusion all around in your heart. so between 2 and10, you're really

looking at kickingthe heart better. you don't reallyget that hypotension like you do with the dobutamine. that's why dopamine isa little bit better when you're looking atjust cardiogenic. you can go anywherebetween 2 and 10 and get that almostsame response you get from dobutamine. almost the same response.

not fully. at high rates, nowyou're clamping. any time you see alpha, thatis vasculature clamp down, or causinghypertension, or trying to increase someone'sblood pressure. so you get lessof that beta, you get more vasculature squeeze. so you get less heart kick,more vascular squeeze. let's say i don't havecardiogenic shock,

let's say i've justgot septic shock. so the vasculature is big. instead of garden hose,i've got the fire hose. higher dose dopamine. don't start at two. don't start at ten. if you know it'snot cardiogenic. if it's sepsis, start at ten. very high rates,then you're really

actually decreasingrenal blood flow. that's all you're doing. epinephrine. we all know epi, epi boluses. anybody know how we came up witha milligram for code purposes? how we cam up with a milligram? anybody? it's the dose that theywould use to restart a heart, on average, when they didopen heart surgeries back

in '60s, '70s, whenever it was. so kind of like a dose onaverage that would help kick start a heartthat they had stopped. so that's how we cameup with a milligram. is it really sciencethat it's a milligram? it might even be weight-based. who knows. we haven't reallyfound their science. because it's tough to do adrug study on people dying.

it's tough to getthe volunteers, know where the volunteers are. and you definitely can'tget college students to sign up fornear-death experiences. they find that bad. any time you see alpha,think of vasculature squeeze. any time you see beta,think of heart squeeze. this squeezes both. alpha, so you getvasculature squeeze,

and you get the heart to kick. epi is great for gettingthe heart to kick good, and also to get thevasculature to squeeze. downside is, if you'vegot a sick heart, yay, i got that to squeeze better. wait, i'm workingagainst this resistance. you can actually makea sick heart sicker. because yes, you gotit to beat harder against a lot more pressure.

it's like taking yourwater pump that's not quite good in yourcar and flooring it. it always works better. your pump is probablypumping faster. until it dies, becauseit's probably going to. because it wasalready weak to start. you mechanics outthere, i'm trying to give you a visualization. so epi is good when you lookat getting the heart to work.

but think about theeffects afterwards. you will make asick heart sicker. so as long as they don'thave a cardiogenic issue, epi is not poor. cardiogenic issue, you'regoing to make it worse. you'll notice it. they look better, thenthey tail off quick. start thinking maybethe heart is sick. maybe i need mydopamine at 2 to 10.

norepi is epi-like. its alpha and beta givesyou that vascular squeeze. uses that beta, but alittle less tachycardia. so a little lesssqueeze on the heart. but same thing you getwith epi, you pretty much get with norepi. you don't have thataccess to you in the rig, but you'retransporting patients. sepsis protocols, norepiis the drug of choice.

phenylephrine is another drugyou don't have on the rig, but you may be transporting. all it does is affectthe alpha essentially. it doesn't do anythingat all to the heart. so you just getvasculature squeeze. you can increasesomeone's blood pressure. it doesn't do anythingto the heart at all. if they don't havea sick heart, fine. they've got a sick heart, youmade it sicker really fast.

because it doesn't doanything for the heart at all. you just stressed the heart out. follow? everyone's with me? boring as heck, right? staying awake? wish i had my amphetaminesto spread now. vasopressin. you have vasopressinavailable for you, right?

vasopressin does not affect thecatecholamine receptor at all when it's working. so is it affectedby acidosis at all? the answer is no, ifyou wish to look ahead. remember i said yourcatecholamine receptor is less responsive when you're acidotic. your vasopressin is not. so say you come acrosssomebody who has been down, someone's doing cpr.

you don't know howlong they've been down. v-fib, v-tach, whatever. you shock them, certainly. they're still in it. your assumption, because youdon't know how long they've been down, could bethat they're acidotic. your protocol saysreach for epi. maybe reach for vasopressin. because it will work thesame potency no matter what.

downside is, ifit's a sick heart, you've caused a lot ofvasculature resistance, a lot of stress on that heart. and you haven't helpedthe heart at all. that's the give and take. works no matter what. acidotic, nonacidotic,doesn't matter. but if there was aheart issue-- you don't know if there'sa heart issue.

obviously you thinkit's a heart issue because the heart'snot working well. but you don't haveto worry about, hey, they're not gettingthe full thing. so trying to give you some hintswhen you're out in the field doing what you're doing. there's all that alpha, betastuff that i talked about. you kind of link the drugsto where they are affecting. that's for your ownbenefit when you go home.

a loose diagram ofwhat the drug's alpha was affecting the beta inthat visual graphics look. so you're going to link itup to where is it working. because you're going toclamp down on any of these. you're clampingdown on something. you're even clamping downon gut and stuff like that. until you clamp downso hard, so long-- we have some patients in theicu, we start to worry about, are we starving thegut of blood supply

because we've beenclamping down so long. it can cause moredamage with this stuff. yes, their body is alive. but eventually we're going tokill off something possibly if we overstretch stuff. cardiogenic shock treatment. we need to increase theircardiac output, aka index. possibly increase ordecrease there resistance. if they've got asick heart, i've

got to worry about howmuch resistance they have. goal is, i want thecardiac index about 2.2. granted you don't havethat index marker. i don't have thatindex marker, either. but you can see that they'redelivering oxygen better. you can just see that. and a cvp of 10 and awedge pressure of 15. same thing like chf. cardiogenic shock is like chf.

luckily there was somebodyback in the-- well i don't know when this was. forrester's hemodynamicclassification, kind of did with chf. they don't necessarily teachchf much like this anymore. but if you know what theircardiac index is and you know what theirwedge pressure is, and you take thispoint right here and you put it onwhere they are.

and you want them lessthan 15 and above 2.2, follow the arrows. a cave man can do this. it's not rocket science. it's look at a graph. some people don'tlook at the graph and they wind upguessing and spit-balling and stuff like this. there's science outthere, and why not use it?

so if you've got somebodywho is not beating well. it's almost like heart failure. heart failurewould be over here. fluid loaded and heartnot working well. get their heart to work better. you can use dopamine,whatever, to get the heart working better. and you give them diuretics. you get them over here.

what about in the field? you've got someonewho has bad chf? where do you start? you start nitro? nitro moves you this way too. where you want to be. that's why you start nitro. you're decreasing thatresistance on that heart and having the heartwork a little bit better.

supplying blood to the kidneysso they can actually pee. that's why you're doing nitro. i can show you a graphwhy you're doing nitro. do the nitro to havethe heart beat better. before you do, if anybodyhas a diuretic that they're able to give, do not give thediuretic until the nitro's been on for like 10minutes or so, please. have the heart beat betterand supply the kidneys before you actuallygive a diuretic.

or else the diuretic is notactually getting to the kidneys like you want it to. have the kidney supply be betterbefore you give the diuretic. there are some units outthere that have diuretics. start the nitro, let thatrun for a little bit, then do a diuretic. ideally. there are ways that wecan actually dose stuff once we know someof these numbers.

that's why i'm tellingyou some of these things. any questions oncardiogenic shock stuff? realize if you stress theheart with the resistance, you're going to makethe heart sicker. but you need them also tohave a good blood pressure. i don't have a goodanswer for you. you give them a lot offluids, that's not necessarily your friend either. start with dopamine.

start with some otherstuff like that. dobutamine soundsgood, but you've got to cover for thatreflex hypotension. septic shock. there's other guidelinesout there as well. don't have to eventhink about this stuff. make sure theyhave enough volume. i'm really over-explaining this. i'm making it where a doctorwill punch me in the face

that it's too simplified. but it is mostly true. if i take a dirty, disgustingnail and scratch your hand, it gets inflamed right? what? and your white blood cellsneed to come out and fight it, so it gets inflamed to limit,to try to enclose that exposure, and to get thewhite cells there. now let's say i put dirtyand disgusting stuff

in your vessels. what does that do? same thing. they expand out. that's really what's goingon with septic shock. heart's fine, the volume's fine. vasculature justgot really huge. ok. well how can you fix that?

best fix in the whole world--fluids, fluids, fluids, fluids, and fluids. until their cvp-- granted youdon't have that monitored. i don't necessarilyhave that monitored until the doc puts it in. until their cvpis about like 10. is somewhere between 8 and 10. but it's going to be a while. it would be a coupleliters in before they

may come close to that. unless of coursethey've got chf. you've got somebodywho's history is like, they hadan infection, they have hypotension, you can geta couple liters in probably, to get their fluid up. because the gardenhose that was good, now they've got the fire hose. the reason why?

the bacteria is in there. your body is doingwhat it should do. it just happens to be, oh yes,we also need blood pressure. oh darn. that vicious cyclething we need to. break make sense, what'sgoing on with septic shock? cvp less than eight, yougive a lot of fluids. we look for meanarterial pressure of 65. anything less than 50, you'renot supplying enough blood.

65 is really your best bet. if their heart rateis greater than 100, which most of the time itis, if you've got somebody with low blood pressureand their heart rate is not greater than 100,they might have a drug onboard causingthat, like a beta blocker. more than likely it is. so you would add norepi. norepi is your drugof choice for sepsis.

so if you're picking upsomebody who is septic and they're not on norepi, andthey're somewhat tachycardic, i'd be suspicious whythey're still on norepi. not that you need toask for something else. hopefully you're justtransporting from one place to another. we realize that person isnot on probably the best pressor they should be on. there might be a reasonthey're on that one.

but i'm just letting youknow it's not ideal for you. if the heart rateis less than 100, it could be because betablocker, something else, or just because. you could give them dopamine. and you're really looking forthe mean arterial pressure, like i said. when you get toa point where you get their blood pressurestabilized, and they're still--

you get a mixed venous,this gets very complicated. i'm telling you too much. now we're really to the pointwhere we're fine tuning. where the person isgoing to live, but boy, we could make themso much better. you can possibly add just alittle bit of the dobutamine to have the heart beat betterto actually get a better supply. it's like a recipe. you follow the recipe,the person's better.

sometimes people don'tfollow the recipe and then you have topick them up and maybe take them somewhere else. or whatever. just trying to let youknow what is normally the case that should occur. if you pick up somebodywho's in septic shock, there are things you shouldbe seeing unless there's some other comorbidity,some other reason why.

what do i want you totake away from this? you can give epi. you can give dopamine,all those things. realize the difference onthe dosing of the dopamine will cause different effects. a little more cardiac andthen a lot more vasculature. you can stress out the heart. clamping on the vasculatureis not helping the heart. epi does help theheart, but only

for a short period of time. you can actually overpower that. back in the day, sometimespeople would do high dose epi. the reason why itfell out of favor, and it really wasn'tin favor to begin with, is yes you can getsomebody back because you overpower that acidosis. you could see thereason why they wanted to use high dose epi.

the person's been acidotic. i want to give them moreepi to equal a milligram. they don't know howmuch more to give them, but they give them more. but it causes somuch resistance, you're going to causesomeone's heart to fail. so that's why youreally shouldn't do it. as long as youunderstand [inaudible] of why some people do it.

any other questions at all? that's stuff you already knew? trying to explain the why. granted yes, your med persontold you, because i said so. and maybe explained it. i'm trying to reallygive you the science why. so if you have togo off reservation, or are asked tocall, maybe you have an idea what you can ask for.

that's it. i don't have anything else. i've bored you enough.