This document discusses physiology directed CPR and haemodynamically directed CPR. It notes that cardiac arrest is not a diagnosis and various underlying pathologies must be considered. During closed chest compressions, a proportion of cardiac output is generated through cardiac and thoracic pumping. Studies show that targeting specific blood pressure and coronary perfusion pressure goals during CPR improves survival outcomes compared to standard AHA guidelines. Monitoring diastolic blood pressure and central venous pressure can help guide interventions like fluid administration or vasopressor use to meet haemodynamic targets and optimize circulation during CPR.
The CVP in patient with hypovolemic shock
case :
Mostafa 22years old
Agitated and compleaning of abdominal pain
Airway is patent
Respiratory rate 32 per min.
BP 90/60 mmHg.
Pulse 130 bpm.
Temp 36C.
Abdominal distension.
Cold skin
Nsogastric tube rvealed green liqued
Urinary cathetar revealed dark urine
Hemoglobin is 7.
FAST is postive.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
3. Cardiac Arrest is NOT a diagnosis
It’s the final pathway for all pathologies leading to death
Important to consider underlying pathologies - ?reversible causes
Presumed cardiac
Structural – CAD, cardiomyopathies, WPW, genetic
Electrical – long QT, Brugada
Informed suspicion
Electrolyte, toxic, metabolic, hypo/hyperthermia
Mechanical interference – PE, tamponade
Aortic dissection
Respiratory arrest
4. Physiology of circulation during closed chest
compressions
CCC and recoil of chest generate a proportion of cardiac output by two means –
Cardiac pump model
Thoracic pump model
Cardiac output
Severely depressed during CPR (10-33% prearrest values in exp. animals)
Majority directed to organs above the diaphragm
brain blood flow 50-90%
Cardiac blood flow 20-50%
Lower extremeties and abdominal visera <5%
Flow to brain and heart improved by vasopressors
5. Assessing circulation adequacy during CPR
Coronary Perfusion
Occurs primarily during diastolic phase
Myocardial blood flow is optimum during CCC when aortic diastolic pressure >40mmHg
Vascular pressures below critical levels associated with poor outcomes
Exhaled CO2
Excellent non-invasive indicator of effective resus
After intubation CO2 levels are primarily dependant on blood flow
During CPR if blood flow starts to increase, more alveoli are perfused and etCO2 levels rise
Spontaneous circulation etCO2 value < 40mmHg
etCO2 corresponds with coronary perfusion pressure, cardiac output and survival
7. Studies
Patient-centric blood pressure-targeted cardiopulmonary resuscitation improves
survival from cardiac arrest.
Sutton et al. Am J Respir Crit Care Med. 2014 Dec 1;190(11):1255-62
20 female 3-month-old swine
After 7 minutes of asphyxia (ETT clamped), VF was induced
randomly received 10 minutes period of CPR before defibrillation
blood pressure-targeted care consisting of titration of compression depth to a systolic blood pressure of
100 mm Hg and vasopressors to a coronary perfusion pressure greater than 20 mm Hg (BP care)
American Heart Association Guideline care consisting of depth of 51 mm with standard advanced cardiac
life support epinephrine dosing (Guideline care).
The 24-hour survival was higher in the BP care group (8 of 10) compared with Guideline care (0
of 10); P = 0.001.
Coronary perfusion pressure was higher in the BP care group (+8.5 mm Hg; vs 3.9-13.0 mm Hg;
P < 0.01)
Blood pressure-targeted CPR improves 24-hour survival compared with optimal
American Heart Association care in a porcine model of asphyxia-associated VF cardiac
arrest.
8. Studies
A quantitative comparison of physiologic indicators of cardiopulmonary
resuscitation quality: Diastolic blood pressure versus end-tidal carbon dioxide
R.W. Morgan et al. Resuscitation 104 (2016) 6–11
Two models of cardiac arrest (primary ventricular fibrillation [VF] and asphyxia-associated
VF)
3-month old swine received either standard AHA guideline-based CPR or patient-centric,
BP-guided CPR.
Mean values of DBP and ETCO2 in the final 2 min before the first defibrillation attempt
were compared
60 animals, 37 (61.7%) survived to 45 min.
DBP was higher in survivors than in non-survivors (40.6 ± 1.8 mmHg vs. 25.9 ± 2.4 mmHg; p
< 0.001)
ETCO2 was not different (30.0 ± 1.5 mmHg vs. 32.5 ± 1.8 mmHg; p = 0.30
In both primary and asphyxia-associated VF porcine models of cardiac arrest, DBP
discriminates survivors from non-survivors better than ETCO2. Failure to attain a
DBP >34 mmHg during CPR is highly predictive of non-survival.
9. ABP and CVP
Supine CVP similar to pressures in femoral artery
In supine patient arterial BP ≡ CVP
Femoral artery cannulation
Continuous pressure monitoring
Access to ABGs
Direct feedback from the intraarterial pressure waveform
Improved CCC technique
10. Assess HD goals
CVP <10mmHG
Rapid fluid bolus
thinking is that CVP <10 = volume down, so giving volume improves venous return
Interpediance threshold device / pulmonary vasodilator
Study by fire department – gave 2L crystalloid to arrest pt = florid pulm oedema
CVP >20mmHG
Consider echo to evaluate possible cause
PE -> tPA
PTx/effusion -> drain it
Sepsis -> inotropes
11. Assess HD goals
Diastolic BP <35-40mmHg
Consider more frequent adrenaline or adrenaline infusion
Consider vasopressin
Systolic BP <100mmHg
Optimise hand position - by improving impulse -> get better sBP on ejection
Use echo to check
Change depth and rate
increased depth leads to increased ejection and higher sBP
Increased rate to 130, but may inversely decrease depth
12. “next cycle”
Assess vent and O2 (if HD goals met)
ABGs
If pH <7.2, paO2 < 70 - > increase vent rate 50% (8 -> 16/18)
Does VBG represent venous pooling
Focusing on oxygenation
Current trail doing ABG and VBG – ABG better thus far
NIRS – near infrared spectroscopy (pulse Ox)
If >50% and paO2 >200 -> decrease FiO2 50%
Editor's Notes
In a recent emcrit podcast Scott had discussion with Dr Sutton (a paediatric intensivist and researcher), about physiology directed CPR.
So today we will refresh ourselves with the physiology of CPR and then look at the suggestions made in the podcast and whether we can incorporate them into our CPR efforts.
Current algorithm is “one fits all” and is very much resuscitator orientated.
Current training focuses on a uniformed approach to resus care that doesn’t incorporate an individualised response to resus efforts. It assumes all cardiac arrest victims can be treated with a uniform chest compression depth and standardised interval administration of vasopressor drugs.
This design is important for easy of training especially for all the out of hospital arrests, but can skilled in-hospital teams be trained to tailor resus. efforts to the individual patients physiology.
We already tailor some aspects of the resus in so much as to seek and treat any reversible causes. The loved T’s and H’s.
Most common cause is coronary atherosclerosis
*Cardiomyopaties – dilated, hyperthrophic*
*Genetic- valve, congenital, ion-channel abnormality*
*Resp – asthma, drowning*
While T’s and H’s are important the main focus today is on what’s actually happening during CPR. What is the physiology of the circulation.
We need to consider the cardiac and thoracic pumps – can someone tell me…
Cardiac – direct compression b/w sternum and vertebral bodies squeezes blood out of heart. Fresh blood in during recoil.
Thoracic – thoracic pressure changes themselves responsible for blood flow being generated during CCC.
*flow to rest of body below diaphragm unchanged or decreased*
For successful resus you need a myocardial blood flow of 15-30ml/min/100g body mass. To achieve this, CCC need to generate adequate cardiac output and CPP.
Myocardial blood flow is optimum during CCC when aortic diastolic pressure >40mmHg and myocardial perfusion pressures >20-25mmHg.
Below this outcomes are poor.
*CPP = aortic end diastolic pressure – right atrial diastolic pressure*
Decreased pulm blood flow during CPR causes lack of perfusion of many alveoli. Therefore alveolar content – no CO2. Therefore mixed alveolar etCO2 will be low and correlate poorly with arterial CO2. However during CPR if……
If CPR successful, CO2 values correlate with success of CPR
Busy slide form Emcrit podcast as discussed with Dr Robert Sutton.
In USA approx. 200000 patients each year have an in hospital arrest with professional CPR. Most occurring in ICU perhaps due to the successful implementation of early warning signs and MET teams.
So can we tailor CPR to the patient
The CPR algorithm needs to be straight forward for teams to follow, but as emergency/icu physicians, can we direct CPR to individual patients and hopefully positively affect outcomes.
1. CVP in femoral vessels???
- looking at pressure difference in supine patient – really not that different.
- And what are we really looking for in resus?? We are looking for trends and responses
So not 100% perfect in groin but enough to give us a trend and implement change.
2. Arterial vs vein – there is no colour or pressure difference in CPR between artery and vein, but in age of ultrasound this is unlikely to be issue. We have ‘real time’
-
No real data to support these guidelines yet.
CVP <10 Rapid fluid bolus - thinking is that CVP <10 = volume down, so giving volume improves venous return
ITD –pulmonary vasodilator again improves venous return.
FD study – not enough to just give fluids.
CVP >20 – what could be causing raised pressures that can essentially be reversed -> echo box
CVP 10-20 – no change to algorithm
Targeting BP better than just standard care for everyone.
Better to use coronary perfusion pressures if you could, but difficult to get. dBP is there -> ‘look up at the monitor’ …… needs study
Bolus adrenaline q1min > infusion anyway (1mcg/kg/min) just basal amount in background. No survival benefit shown
Vaspressin – already had some β on board from adrenaline so try vasopressin instead of noradrenaline.
Increase rate may inversely decrease depth. Need to check with echo and be ready to have more hands for CCC, or mechanical compression device.
If HD goals met then assume some pulm blood flow.
Increasing rr will have HD consequence (why HD goals need to be met) but heart not happy in acidic environment – wont beat
If hurts HD’s can back off. But if you can blow off some CO2 then can possibly improve patients chances.
Pulse ox and waveform – picks up pulsitility – don’t know what average BP is when it starts to pick up. Is rate its getting picked up under our CPR rate ??? Is it first sign there's a rhythm there.