The golden hour pre-load Contractility Afterload MAP = CO x SVR

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The golden hour pre-load Contractility Afterload MAP = CO x SVR

Lopera, Natalia, General Assignment Reporter has reference to this Academic Journal, PHwiki organized this Journal CIRCULATORY FAILURE `Shock` David Walker Critical Care Consultant University College London Hospitals Or `what to do with the blood pressure , when you don’t know what to do with the blood pressure`! Confused elderly lady, limited story, limited PMH, no true diagnosis, BP 80/45 (And the smart ass medical registrar has done everything) Do you: Covertly set off your bleep in addition to leave the ward Fake illness in addition to go home Pop to the WC in addition to weep Do your best – even when you know your best might not be enough DO NOT CRY IN FRONT OF THE PATIENT Ask yourself – is this blood pressure adequate Shock: (Significant tissue oxygen debt (impaired organ oxygenation or utilisation) frequently a case of too little, too late!

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Clinical situation There are two situations in which you might be alerted to a ‘poor circulation’: 1. Low blood pressure is recorded 2. Effects of low flow or perfusion Brain Kidney Acidosis The golden hour Don`t wait until the morning Principals Pump (heart) Resistance (vessels) Flow (CO)

It’s the same old story in AAU: Confused elderly lady, limited story, limited PMH, no true diagnosis, BP 80/45 Mean arterial BP (MAP) = systolic + (diastolic x 2) 3 BP 120/80: MAP 93 mmHg = 120 + (80 x 2) 3 MAP >65 is a good starting point (but may need to be higher) PRESSURE FLOW RESISTANCE Sympathetic response

PRESSURE (Surrogate) FLOW (of interest) RESISTANCE (who knows!) CO = MAP/SVR (this equations has 2 unknowns!) (Significant tissue oxygen debt (impaired organ oxygenation or utilisation) Blood pressure – It does matter! Management Confused elderly lady, limited story, limited PMH, no true diagnosis, BP 80/45 Step one – Make the diagnosis Back to the history (its often all there) Careful examination What tests corroborate diagnosis

1. Cardiac output (low flow shock) 2. Vascular resistance (low resistance) CO SVR SVR CO LOW BP OR SIGNS OF LOW PERFUSION HR increase cold sweaty clammy tachypnoea

Causes: 1. Hypovolaemic 2. Cardiogenic 3. Pulmonary embolus 4. Tension pneumothorax 5. Cardiac tamponade Inappropriately dilated Febrile usually Large volume pulse & Signs of low organ perfusion Septic shock Anaphylaxis

What can & should we measure pH in addition to lactate End organ perfusion Scv O2 MAP CVP SVO2>70% Extraction of Oxygen Airway Breathing Circulation

pre-load The greater the stretch the greater the as long as ce of contraction PAWP / CVP BLOOD VOLUME Filling – What is the concept

Lopera, Natalia La Estrella de Tucson General Assignment Reporter www.phwiki.com

What is a fluid challenge Lactate pH Scv O2 BP/Pulse CVP Brain Heart Kidney Resp Reassess Pulmonary oedema = excess lung water Does not always equal excess vascular water Patient could be volume deplete in addition to have pulmonary oedema CAREFULLY, but remember RAP is a poor correlate of cardiac output But measure it in addition to watch as long as changes Careful not to over interpret

Oesophageal Doppler – measures flow a better concept Contractility Afterload Only when the circulating volume optimised – consider:- Squeeze – (afterload) (vasopressor) Pump – (contractility) (inotrope) CO = MAP/SVR MAP = CO x SVR Drugs Adrenaline Nor-adrenaline

QUESTIONS Happy doctors

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