Best lecture you have given that I have seen and FINALLY explains why the hospital in ft worthless texas couldn't get my BP to go up despite giving me medication to increase BP and increasing IV fluids but was not successful and they never checked lactic acid level nor aldosterone either and they never resolved the 77 / 49 hypotension and it's because they are not true professionals
I just ran across an article that a young man in Houston became septic due to a flea bite. They gave him Vasopressors but now he's lost both arms (up to the forearm) and feet. Could this be because they constricted those blood vessels to the point tissue died?
I'm not in the medical profession but I could follow this clear teaching. I'll hope that if I or loved ones face this situation that the med staff have taken MedCram's courses!
I've fellowed this concept during my entire residency since 2018 , but we've never put a name on it , it good to label it though , it is a trap indeed , thank you
This is why we used the Swan Ganz catheter in the 1980's and 1990's and even into the 2012 era .. we were able to determine the cardiac output and systemic vascular resistance and pulmonary capillary wedge pressure and O2 delivery almost continuously and choose the best pressors and inotropes and know when to use (or not use) volume challenges and how much to use .. I saw a rapid decline in the quality of critical care and understanding of physiology when we stopped using them .. also a lot of vasopressor trapping .. we could get data even when we were not at the bedside .. critical care is declining rapidly in this country
If your EF is 10% and you are septic with a tanking BP I don’t think anything is going to change your outcome. We just don’t accept death anymore. 90 years old, sacral decubes the size of a football, septic, renal failure, encephalopathy and family members wanting everything possible for aunt Becky. But thanks for reminding me of swan gantz.
@@buckbenelli8 We may not accept death anymore but there are important things about how we handle it. For instance, when my dad died, the doctor who was coming to give his condition said "He's very sick. Everybody dies. Let nature take it's course." No empathy, no caring, just let him die and move on. I'm a very peaceful person at heart but I've never been so offended in my life. I know doctors need to develop a thick skin to stay sane but this was ridiculous. Then he goes off duty and another dr comes on. Finally a few hours later my dad's heart stops. The new dr comes in and explains he doesn't feel ethical with trying to start his heart etc. We agreed and let him go. Then the nurses, with little more caring than the first doctor said "You will want to take any jewelry etc that is his before you go." and a less than sympathetic "Sorry for your loss" from one nurse. The nurses then started congratulating the dr on how he talked to us etc. So we don't have to get into all the professionalism aspects of being uncaring, talking in front of family etc. We may not accept death anymore, but we can surely do what we can for the living.
Another complex issue explained brilliantly for the non-medical people. Would you consider doing some shorts on first aid especially...choking, cpr for heart attacks, dressing wounds, heat fatigue, drowning? I want to learn and give you the views instead of another channel. Thanks doc 🙏
Please about danger of overheating temperature’s effects especially on children and how to avoid risks of dehydration….Thank you for your brilliant teaching…I wish med cram teaching would be part of medical curriculum in all provinces of Canada.
My sister died in 2006 from sepsis induced stroke. I found this very interesting and it makes me wonder even more what they actually did or did not do when she died.
That was a terrific explanation of a very complex biological system process Doc! Yet another video that I have to forward to my cousin who is an M.D. Keep up the great work that you do! 👍👍
It is possible for patients with sepsis to need three vasopressors so it can happen and it’s perfectly appropriate. But this case is something that rarely may occur so you have to look out for because it’s potentially a trap that you can get into.
Jeez, hard to hear this one. This happened to my uncle's in December. They were trying to treat the low BP and just kept dumping in bicarb... Kidneys failed first then the heart
When norephrine dose hits the 1mcg/kg/min, I usually start to combine it with dobutamine. Then increasing NE and dobu as needed until it both maxed out. If they both are already on maximum dose, we need to reconsider whether the definite treatments (antibiotics etc) are working or not, or are there any other underlying disease beside septic. Too much vasoconstrictor can lead to new acute myocardial injury -> death
I’m 49 years old. Started watching this channel when COVID started. Now I’m so interested in learning about the complex human organism. Makes me want to become a nurse. Thanks so much for sharing your wealth of knowledge with us.
"When CON-VID started". You are now being enlightened ... In March 2020 ...David Bullard ... president of the FRB stated ..."This has nothing to do with any virus ... it's a planned economic shutdown beginning the first quarter of this year". ...aka...The greatest theft of wealth in the history of the world. All for ZION BANKING CONTROL.
Just wondering why a b1 and b2 stimulant wouldn't be used in the first place? Would it overstress the heart if it was nomal EF? Another clearly explained video 👍
This makes me wonder how they treated me when I was in cardiogenic shock 3.5 years ago. I'm not saying they did anything wrong, just that I have amnesia subsequent to cardiac arrest and it's all a black hole to me and the medical records I have access to don't mention details like this.
I hate to be negative, but when there's a mistake that might lead to a lawsuit a hospital's lawyer may insist on muzzling what gets written. I saw that in a situation where a young woman was on bicarb to counter acidosis after heart surgery. The IV in her right arm leaked into her tissue, doing serious damage, including an arm that was a sickening slate grey. When she was transferred from the post-op ICU to my unit, I read the medical records to understand what had happened. There was nothing, absolutely nothing there. Reading along, all seemed to be going well post-op. Then, from one note to the next it was clear something had gone wrong but with no explanation of what or why. What I did know was passed along orally. There was zero chance there wouldn't be at least the threat of a lawsuit. The girl and her mother were furious, and the girl's dad was a lawyer in the state attorney general's office.
@@Inkling777 I'm wondering if it's a different type of record. The stuff in the online portals are reports test results, but never mention meds given. Surprisingly, one of my reports did mention a possible previous medical error as a potential cause. The new doctors wrote that a previous stent in which a fresh clot spontaneously formed in a cardiac artery was "remarkably under-expanded", meaning either the previous angioplasty was performed improperly or the stent chosen was too narrow for the lumen of that artery. The note from the cardiologist who did the previous procedure mentioned choosing this one because using this stent to save money. But the clot formed several years after the procedure and past my state's statute of limitations for medical errors (which is based on the date of the error, not the date of discovery of the error). So, the good news is the new docs put in a larger stent after removing the clot. The bad news it that means the narrower one probably broke to accommodate it. So now I'm like Tony Stark, with broken bits of metal around my heart.
Hi Dr. Seheult. I have been a follower of your channel and a MedCram subscriber for several years. You have incredibly well constructed content and concise clinically relevant videos. However, sphygmomanometer is pronounced “sfig-MO-man-ometer”, not “sfig -ma- nometer. “. Just a little errata and thanks for your outstanding content!
If these informational videos are geared toward health professionals, then great! However, the average "Joe" who possesses a great deal of comprehension capabilities and common sense would more than likely have to face a condescending "professional" when questioned about the care that they or a loved one is receiving. It's unfortunate, but it happens! Lord knows that some dr's and RNs get offended when their plan of treatment gets questioned by the lowly Joe! And...as a side note.....the healthcare system in this country gets a big fat "F." So, I for one appreciate the MedCram lectures because an informed person is less likely to fall through the cracks.....though the relentless battle for good quality healthcare is stressful, costly, and tiring.....which just adds to the issue that brings you into the system in the first place.
I completely agree. I think it’s always a good idea to have a well informed patient If for no other reason that they understand what it is that’s going on. It’s also very important that healthcare providers listen to their patients they can be a wealth of good information.
Interesting! The feedback about lack of oxygen that causing even more lack of oxygen. As an engineer I never imagined organism have feedback path that is such opposite to maintaining life
Aside from dobutamine - thoughts on milrinone? The hf cardiologist where i work go to this after a right heart cath shows low ci/ co. And likewise with your excellent drawing - keeping track of mentation ( brain blood flow ) and urine output ( kidney blood flow ) and blood creatinine.
We also stared not auscultation for extra heart sounds - like the new onset of an S3 - and early intervention - ED does get lactate levels - but what of the “art” of medicine - not just the reactive “protocols” -
What is midodrine, and is this a vasopressor? I have a spinal cord injury and very low blood pressure, midodrine is sued to help increase my blood pressure. I take 5mg daily. Is there a better method to increase blood pressure for spinal cord injury? Thank you
Well as the prospective patient...I will tell the team to get an ultrasound and figure my ejection fraction before giving me vasopressors....if I am conscious....but ...I seriously doubt they will listen.
how about when the patient has a component of ACS as well as the sepsis? will the increased heart function (& subsequent heart demand) tip itself over to a more serious cardiac event?
Might dopamine be used to get out if the trap, it has beta 1 activity and peripheral vasodilation effects, stimulating cardiac contractility and preserving critical organ perfusion?
Here’s a review that looked at this back in 2015 and did a nice job of showing how often this is happening unfortunately. www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.115.015431?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
@@Medcram THE LINK IS TO A REVIEW FROM EIGHT YEARS AGO. That is irrelevant to what's happening ever since the "vaccines" were introduced. We understand any newer studies would not support the "safe & effective" lie.
Earlier this week, A-List Hollywood actor “Jamie Foxx [was] rushed to the hospital after suffering a stroke,” according to the headline of a TMZ story. Coincidentally, the Screen Actors’ Guild required actors to be jabbed before working on Hollywood sets during the pandemic.
This content is inappropriate for TH-cam. This is medical knowledge meant for medical personnel, not lay people. Don’t turn to TH-cam for medical advice. Contact your primary care physician and specialists for help in understanding your body and your health. I Further want to criticize the statement in huge red letters on the start page of your video, which says ‘the most dangerous trap in the ICU.’ That’s scary! It scares people into watching the video. And it also helps to engenders distrust of medical personnel. This is seriously counterproductive. You should be ashamed of yourself! And yes, I am a healthcare professional.
Dragisa Gudelj 25, the brother of Serbia midfielder Nemanja Gudelj who plays for Sevilla, suffered a cardiac arrest during the 11th minute of the first half. Nothing to see here, just another really young athlete collapsing with cardiac arrest on the field.
Onpattro is a RNA in nanoparticle medication FDA approved in 2018 and is infused intravenously at orders of magnitude higher doses every three weeks indefinitely. They’ve were doing it for 3 years before the vaccine. You are only saying something now? No one had issues with Onpattro then (for good reason) why now?
Thank you so much! God bless you! 🙏❤️💯. God bless everyone who reads this and love you all: make sure you know Jesus Christ as your Lord and Saviour everyone! He is coming soon! Accept and believe in Jesus Christ! John 3:16, Revelation 20:15, 1 Corrinthians 15 1-4, Romans 10 9 and 10, Ephesians 2 8-9
Dr. you are so awesome! I am a retiree living in Brittany France and while there may be some good doctors here, I find them lacking in being thorough, and adding natural therapies. I have learned so much from your videos and am more secure getting all the details from you as I prepare for my later years. I even now follow your protocol for sunlight and infrared and it DOES make a difference. A million thanks for helping us Americans abroad.
@@Medcram That is amazing! I have been there. My other half Thomas and I just renovated a large villa once part of an old manoir in Plestin-les-Greves , northwest Brittany, and we have 2 guest rooms. I will send your office the details in case you ever want to visit our region., a way of giving back to you and your family.
I really appreciate you brought out this topic. I've been an ICU nurse for more than a decade and I work in 3 different facility. However, few of which if I count who think the way you analyze the situation. Thank you as always.
Have you ever used cuffs that pump synchronously with the heart to raise blood pressure when the heart is not up to the task in this sort of situation?
This cannot happen in an icu !! This what I feel: The basic formula for Hemodynamics is MAP= CO x SVR. That means you need to consider preload, contractility and afterload. When one starts anyone on vasopressors it’s most often because map of at least 65 or SBP of 90 isn’t maintained with fluid boluses. So the pt in your example appeared to be in cardiac failure or possibly a pulmonary embolism.( both will have low ef) also the patient was fluid overloaded. Thought you mentioned the use of echo no word on RA/ RV dilatation. Obviously if the pt has SBP
There are patient who have sepsis with heart failure, require vasopressors first but then require inotropes on top of vasopressors. EGDT allows for this but many have abandoned the practice of checking SCvO2 who that protocol. Realize that this can happen.
@@Medcram inotropes on top of vasopressors, yes we can use when vasopressors are at very low high dose. cannot use when vasopressors are high,dual or triple vasopressor. How do you taper a pressor with an inotrope? That too dobutamine which is only b1 and whose use is usually by what is called dobutamine trial and for good reason. You mentioned patient was in norad and Epi and or vasopressin? Sepsis is a hyper dynamic state, lots more happening there with myocardial dysfunction.
Roger... nice one though there are quite a lot of ways to differentiate cardiogenic and septic shock and the management varies very differently. its not a trap. its a misdiagnosis. you have made great lectures but this one will result in non critical care persons not using the right management when its really needed. just read up the comments for this video. i know this is not what you had in mind.
Thank you, Dr. Seheult, for explaining this difficult situation. I have encountered this as an ICU RN many times during my career (80's-90''s). This was back before US or Echo was widely available. But there was another indicator of EF that we used then and it required no equipment, only the human hand. It was finding and assessing the PMI (Point of Maximal Impulse) when the patient was in the Left-lying position. It can be technique-dependent but it takes only a minute or so (of course allowing that the patient can be turned). A "good" PMI presents with a smaller diameter and firmer pulse against the hand. This, in my experience, correlates with an EF of over 50%. No, there are no papers. It's just what I found when I had patients who had Swan-Ganz catheters post-op and I would correlate with their PMIs. So how would it fit into standard practice? It probably would not, but, in the middle of the night, with no docs around, no imaging techs, you have to gather as much information as you can about the cardiovascular system of your patient. If I felt a strong PMI, I would consider other factors besides cariogenic, for example, is there evidence of multi-system failure, are coags off, etc.. If I found a diffuse, weak PMI, and in the presence of other worrying signs, I'd definitely start waking people up, techs, docs, etc. because I'm gonna need some help.
Echocardiograms take about 20 to 30 minutes to gather the information and then another 10 to 15 minutes to be read by a cardiologist. So it can’t be done all the time.
Hello Doctor, I've experienced at least 3 episodes of sleep paralysis in the recent days, It was a very frightening experience. After that I'm very afraid and anxious to sleep alone, can you explain why this is happening and how can I overcome this condition please help me 🥺🥺
Sleep paralysis can be a symptom of sleep deprivation, or it might be a symptom of narcolepsy. I would definitely talk to a physician and perhaps get a sleep study if that is indicated.
There is a virus that can cause this effect. Also a feeling of falling... And a very hard difficulty of breathing can occur which sometimes causes the person to have a heart attack. I hope that you are feeling better as this was two weeks ago that posted this. People have been known to expose people to this virus in order to facilitate creating a manipulation for whatever purposes or intentions they have... I don’t know where it came from or the natural environment or anything. But it’s been used for intelligence operations and psychological warfare operations.
I am not a medical professional. However lactic acid in the blood can be very helpful with infectious vectors in the blood. Understanding how to facilitate the pattern using breathe control can save a life.
Yes, it is a potential temporary fix for acidosis. However, there’s some evidence that it may actually make intracellular acidosis worse so it is controversial.
So for a patient in cardiogenic shock with presumably low ejaction fraction, we start with noradrenaline plus dobutamine infusion? (as a medical management, apart from finding the cause of his shock).
Milrinone is a phosphodiesterase type 3 inhibitor, which allows intracellular cAMP to persist and cause protein kinase A to phosphorylate L-type Ca2+ channels, increasing their open duration, in cardiac myocytes during phase 2 of depolarization, giving it an inotropic action. But the tradeoff is that milrinone can be arrhythmogenic.
You said you have come into this situation several times over the years, who would have been caring for them previous to your arrival? Is there a bare minimum needed to be an ICU doctor?
@@Medcram good point though this reminds me of another question I've had about respiratory physiology. Under normal physiological conditions the large majority of oxygen is carried by hemoglobin no, but there is some solubility of oxygen in water, and unlike hemoglobin, it's not really saturable, and in fact it's nearly linearly proportional to the partial pressure of oxygen in contact with the the solvent as per Henry's law. I've assumed that this is why you see astounding World Records On who submerge themselves in water in excess of 15 minutes after spending a half hour or so breathing pure oxygen. In a supersaturated oxygen environment how much of the oxygen carried by the blood is just in solution as opposed to being transported by the hemoglobin. Can you double or more than maximum amount of oxygen being transported by the blood, about to be on what's being transported by the hemoglobin?
Here’s a review that looked at this back in 2015 and did a nice job of showing how often this is happening unfortunately. www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.115.015431?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Study doc cites gives extremely low number as compared to today. This doc has a blind spot of vaccine, and will never talk about the elephant in the room today. He is approved by TH-cam and wants to stay the way - political correct.
Join us at medcram.com for these and other courses.
Best lecture you have given that I have seen and FINALLY explains why the hospital in ft worthless texas couldn't get my BP to go up despite giving me medication to increase BP and increasing IV fluids but was not successful and they never checked lactic acid level nor aldosterone either and they never resolved the 77 / 49 hypotension and it's because they are not true professionals
Very nice review doctor. does medical students get alot out of your videos ?
medcrap
I just ran across an article that a young man in Houston became septic due to a flea bite. They gave him Vasopressors but now he's lost both arms (up to the forearm) and feet. Could this be because they constricted those blood vessels to the point tissue died?
I'm not in the medical profession but I could follow this clear teaching. I'll hope that if I or loved ones face this situation that the med staff have taken MedCram's courses!
They can also just pay attention in school, during on the job training, ask their mentor, and read their textbooks.
In your dreams ...
I've fellowed this concept during my entire residency since 2018 , but we've never put a name on it , it good to label it though , it is a trap indeed , thank you
This is why we used the Swan Ganz catheter in the 1980's and 1990's and even into the 2012 era .. we were able to determine the cardiac output and systemic vascular resistance and pulmonary capillary wedge pressure and O2 delivery almost continuously and choose the best pressors and inotropes and know when to use (or not use) volume challenges and how much to use .. I saw a rapid decline in the quality of critical care and understanding of physiology when we stopped using them .. also a lot of vasopressor trapping .. we could get data even when we were not at the bedside .. critical care is declining rapidly in this country
I remember shooting those cardiac outputs and evaluating the hemodynamic calculations😉
If your EF is 10% and you are septic with a tanking BP I don’t think anything is going to change your outcome. We just don’t accept death anymore. 90 years old, sacral decubes the size of a football, septic, renal failure, encephalopathy and family members wanting everything possible for aunt Becky. But thanks for reminding me of swan gantz.
I think it's universal, swan ganz is underutilized everywhere nowadays
We started using them again after 15 years … had to relearn lol
@@buckbenelli8 We may not accept death anymore but there are important things about how we handle it. For instance, when my dad died, the doctor who was coming to give his condition said "He's very sick. Everybody dies. Let nature take it's course." No empathy, no caring, just let him die and move on. I'm a very peaceful person at heart but I've never been so offended in my life. I know doctors need to develop a thick skin to stay sane but this was ridiculous. Then he goes off duty and another dr comes on. Finally a few hours later my dad's heart stops. The new dr comes in and explains he doesn't feel ethical with trying to start his heart etc. We agreed and let him go. Then the nurses, with little more caring than the first doctor said "You will want to take any jewelry etc that is his before you go." and a less than sympathetic "Sorry for your loss" from one nurse. The nurses then started congratulating the dr on how he talked to us etc. So we don't have to get into all the professionalism aspects of being uncaring, talking in front of family etc. We may not accept death anymore, but we can surely do what we can for the living.
Another complex issue explained brilliantly for the non-medical people.
Would you consider doing some shorts on first aid especially...choking, cpr for heart attacks, dressing wounds, heat fatigue, drowning? I want to learn and give you the views instead of another channel. Thanks doc 🙏
That’s a very good idea.
Please about danger of overheating temperature’s effects especially on children and how to avoid
risks of dehydration….Thank you for your brilliant teaching…I wish med cram teaching would be
part of medical curriculum in all provinces of Canada.
My sister died in 2006 from sepsis induced stroke. I found this very interesting and it makes me wonder even more what they actually did or did not do when she died.
That was a terrific explanation of a very complex biological system process Doc! Yet another video that I have to forward to my cousin who is an M.D. Keep up the great work that you do! 👍👍
Explained beautifully.
I'm kind of shocked that doctors in the ICU need to be told this! Don't they already know it?!!
It is possible for patients with sepsis to need three vasopressors so it can happen and it’s perfectly appropriate. But this case is something that rarely may occur so you have to look out for because it’s potentially a trap that you can get into.
I found that interesting and easily understood, thank you.
Thank you Dr. Secheult, your information saves lives. Very much appreciated that you take the time to explain here, your schedule must be crazy.
Yes. It is! Lol
This is very interesting. I learned something new. Thank you.
جزاك الله خيراً
Really valuable information clearly explained. Thanks!
Wow! I'm not in medicine, but I am a caregiver. This information is very good to know. Thanks!
Jeez, hard to hear this one. This happened to my uncle's in December. They were trying to treat the low BP and just kept dumping in bicarb... Kidneys failed first then the heart
So sorry to hear that. Sometimes, even when we recognize these issues and treated appropriately the patient still does not make it through.
Have you ever done a video on the affects of taking DHEA? I would be really interested in what you have to say about it!
When norephrine dose hits the 1mcg/kg/min, I usually start to combine it with dobutamine. Then increasing NE and dobu as needed until it both maxed out. If they both are already on maximum dose, we need to reconsider whether the definite treatments (antibiotics etc) are working or not, or are there any other underlying disease beside septic. Too much vasoconstrictor can lead to new acute myocardial injury -> death
That's very good info, dobutamine is so under utilized in these patients. Especially with those who have known poor ef.
excellent explanation doc! thanks!.
You are welcome!
I’m 49 years old. Started watching this channel when COVID started. Now I’m so interested in learning about the complex human organism. Makes me want to become a nurse. Thanks so much for sharing your wealth of knowledge with us.
"When CON-VID started". You are now being enlightened ... In March 2020 ...David Bullard ... president of the FRB stated ..."This has nothing to do with any virus ... it's a planned economic shutdown beginning the first quarter of this year". ...aka...The greatest theft of wealth in the history of the world. All for ZION BANKING CONTROL.
Great class!!!
Doc, could you make a video on magnesium and its connection to stress and the vicious circle of stress and anxiety and magnesum deficiency?
Just wondering why a b1 and b2 stimulant wouldn't be used in the first place? Would it overstress the heart if it was nomal EF? Another clearly explained video 👍
The main reason why we wouldn’t use it is because B2 stimulation would cause more vasodilation and exacerbate the sepsis
If this is taught about and you pay attention in school, this is not a trap.
Can an active cancer that is producing lactic acid weaken the heart's pumping function? Thanks.
This makes me wonder how they treated me when I was in cardiogenic shock 3.5 years ago. I'm not saying they did anything wrong, just that I have amnesia subsequent to cardiac arrest and it's all a black hole to me and the medical records I have access to don't mention details like this.
I hate to be negative, but when there's a mistake that might lead to a lawsuit a hospital's lawyer may insist on muzzling what gets written. I saw that in a situation where a young woman was on bicarb to counter acidosis after heart surgery. The IV in her right arm leaked into her tissue, doing serious damage, including an arm that was a sickening slate grey. When she was transferred from the post-op ICU to my unit, I read the medical records to understand what had happened. There was nothing, absolutely nothing there. Reading along, all seemed to be going well post-op. Then, from one note to the next it was clear something had gone wrong but with no explanation of what or why. What I did know was passed along orally. There was zero chance there wouldn't be at least the threat of a lawsuit. The girl and her mother were furious, and the girl's dad was a lawyer in the state attorney general's office.
@@Inkling777 I'm wondering if it's a different type of record. The stuff in the online portals are reports test results, but never mention meds given.
Surprisingly, one of my reports did mention a possible previous medical error as a potential cause. The new doctors wrote that a previous stent in which a fresh clot spontaneously formed in a cardiac artery was "remarkably under-expanded", meaning either the previous angioplasty was performed improperly or the stent chosen was too narrow for the lumen of that artery. The note from the cardiologist who did the previous procedure mentioned choosing this one because using this stent to save money. But the clot formed several years after the procedure and past my state's statute of limitations for medical errors (which is based on the date of the error, not the date of discovery of the error). So, the good news is the new docs put in a larger stent after removing the clot. The bad news it that means the narrower one probably broke to accommodate it. So now I'm like Tony Stark, with broken bits of metal around my heart.
Hi Dr. Seheult. I have been a follower of your channel and a MedCram subscriber for several years. You have incredibly well constructed content and concise clinically relevant videos. However, sphygmomanometer is pronounced “sfig-MO-man-ometer”, not “sfig -ma- nometer. “. Just a little errata and thanks for your outstanding content!
If these informational videos are geared toward health professionals, then great! However, the average "Joe" who possesses a great deal of comprehension capabilities and common sense would more than likely have to face a condescending "professional" when questioned about the care that they or a loved one is receiving. It's unfortunate, but it happens! Lord knows that some dr's and RNs get offended when their plan of treatment gets questioned by the lowly Joe! And...as a side note.....the healthcare system in this country gets a big fat "F." So, I for one appreciate the MedCram lectures because an informed person is less likely to fall through the cracks.....though the relentless battle for good quality healthcare is stressful, costly, and tiring.....which just adds to the issue that brings you into the system in the first place.
I completely agree. I think it’s always a good idea to have a well informed patient If for no other reason that they understand what it is that’s going on. It’s also very important that healthcare providers listen to their patients they can be a wealth of good information.
Interesting! The feedback about lack of oxygen that causing even more lack of oxygen. As an engineer I never imagined organism have feedback path that is such opposite to maintaining life
If it causes low cardiac output then yes.
Thanks!
Thank you so much
Aside from dobutamine - thoughts on milrinone? The hf cardiologist where i work go to this after a right heart cath shows low ci/ co.
And likewise with your excellent drawing - keeping track of mentation ( brain blood flow ) and urine output ( kidney blood flow ) and blood creatinine.
Yes, milrinone is also an acceptable medication. That one particular reduces pulmonary pressure more than dobutamine does so it has its uses certainly
We also stared not auscultation for extra heart sounds - like the new onset of an S3 - and early intervention - ED does get lactate levels - but what of the “art” of medicine - not just the reactive “protocols” -
Let’s assume no ultrasound available for some reason, would just starting dobutamine be an option
what about m ethylene blue ?????
works well for a short time. disables endothelial NO. good for refractory vasodilation. Big allergy potential.
Agree
What is midodrine, and is this a vasopressor? I have a spinal cord injury and very low blood pressure, midodrine is sued to help increase my blood pressure. I take 5mg daily. Is there a better method to increase blood pressure for spinal cord injury? Thank you
That is a well known vasopressors that can be taken orally.
Well as the prospective patient...I will tell the team to get an ultrasound and figure my ejection fraction before giving me vasopressors....if I am conscious....but ...I seriously doubt they will listen.
how about when the patient has a component of ACS as well as the sepsis? will the increased heart function (& subsequent heart demand) tip itself over to a more serious cardiac event?
Yes that can happen
How does one with a low EF get off of the dobutamine? Is the low EF reversible?
Either EF improves or implantable device or your body adjusts but you are limited
@@Medcram thanks
as a plumber i can understand this so clearly. lol
Might dopamine be used to get out if the trap, it has beta 1 activity and peripheral vasodilation effects, stimulating cardiac contractility and preserving critical organ perfusion?
Much has been said about its renal perfusion effects that really haven’t panned out. Unfortunately it also causes more arrhythmias than the others.
"It's a trap!", Ackbar, Admiral
I think a lot of people are maxed out on vasopressors may also be suffering from relative adrenal insufficiency.
That’s a good point. In most of my patients I add hydrocortisone 50 mg IVQ6.
Lesley Swick van Ness, a popular former news anchor in Illinois, died suddenly Monday. She was just 42 years old.
Utah State Wide Receiver Josh Davis Suffers Sudden Cardiac Arrest During Practice. Just another 20 somethin having a normal cardiac arrest, not
Here’s a review that looked at this back in 2015 and did a nice job of showing how often this is happening unfortunately.
www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.115.015431?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
@@Medcram THE LINK IS TO A REVIEW FROM EIGHT YEARS AGO. That is irrelevant to what's happening ever since the "vaccines" were introduced. We understand any newer studies would not support the "safe & effective" lie.
@@Medcram lolz. The more you copy and paste this, It actually turns the light bulb on. Keep it up 🤣🤣😂
Earlier this week, A-List Hollywood actor “Jamie Foxx [was] rushed to the hospital after suffering a stroke,” according to the headline of a TMZ story.
Coincidentally, the Screen Actors’ Guild required actors to be jabbed before working on Hollywood sets during the pandemic.
After listening to this for three minutes I've realized how stupid I am.
Good info. So if beta agonists get you out of the vasopressor trap, can beta blockers get you into it?
If in acute heart failure? Yes.
Dopamine came out in the 1970's; the others are older. I guess you can't improve on the originals.
This content is inappropriate for TH-cam. This is medical knowledge meant for medical personnel, not lay people. Don’t turn to TH-cam for medical advice. Contact your primary care physician and specialists for help in understanding your body and your health. I Further want to criticize the statement in huge red letters on the start page of your video, which says ‘the most dangerous trap in the ICU.’ That’s scary! It scares people into watching the video. And it also helps to engenders distrust of medical personnel. This is seriously counterproductive. You should be ashamed of yourself! And yes, I am a healthcare professional.
Dragisa Gudelj 25, the brother of Serbia midfielder Nemanja Gudelj who plays for Sevilla, suffered a cardiac arrest during the 11th minute of the first half. Nothing to see here, just another really young athlete collapsing with cardiac arrest on the field.
Onpattro is a RNA in nanoparticle medication FDA approved in 2018 and is infused intravenously at orders of magnitude higher doses every three weeks indefinitely. They’ve were doing it for 3 years before the vaccine. You are only saying something now? No one had issues with Onpattro then (for good reason) why now?
Thank you Prof for the enlightening lecture👍👍👍
Thank you so much! God bless you! 🙏❤️💯. God bless everyone who reads this and love you all: make sure you know Jesus Christ as your Lord and Saviour everyone! He is coming soon! Accept and believe in Jesus Christ! John 3:16, Revelation 20:15, 1 Corrinthians 15 1-4, Romans 10 9 and 10, Ephesians 2 8-9
Amen!
@@suhwateezea.214 God bless you!!! 🙏❤️
Dr. you are so awesome! I am a retiree living in Brittany France and while there may be some good doctors here, I find them lacking in being thorough, and adding natural therapies. I have learned so much from your videos and am more secure getting all the details from you as I prepare for my later years. I even now follow your protocol for sunlight and infrared and it DOES make a difference. A million thanks for helping us Americans abroad.
My ancestors were from Nantes! They built the cathedrals in that area! curate.nd.edu/show/5712m61647x
That area is so nice! I’ve been several times.
@@Medcram That is amazing! I have been there. My other half Thomas and I just renovated a large villa once part of an old manoir in Plestin-les-Greves , northwest Brittany, and we have 2 guest rooms. I will send your office the details in case you ever want to visit our region., a way of giving back to you and your family.
I really appreciate you brought out this topic. I've been an ICU nurse for more than a decade and I work in 3 different facility. However, few of which if I count who think the way you analyze the situation. Thank you as always.
Have you ever used cuffs that pump synchronously with the heart to raise blood pressure when the heart is not up to the task in this sort of situation?
This cannot happen in an icu !!
This what I feel:
The basic formula for Hemodynamics is MAP= CO x SVR. That means you need to consider preload, contractility and afterload.
When one starts anyone on vasopressors it’s most often because map of at least 65 or SBP of 90 isn’t maintained with fluid boluses.
So the pt in your example appeared to be in cardiac failure or possibly a pulmonary embolism.( both will have low ef) also the patient was fluid overloaded. Thought you mentioned the use of echo no word on RA/ RV dilatation.
Obviously if the pt has SBP
There are patient who have sepsis with heart failure, require vasopressors first but then require inotropes on top of vasopressors. EGDT allows for this but many have abandoned the practice of checking SCvO2 who that protocol. Realize that this can happen.
@@Medcram inotropes on top of vasopressors, yes we can use when vasopressors are at very low high dose. cannot use when vasopressors are high,dual or triple vasopressor. How do you taper a pressor with an inotrope? That too dobutamine which is only b1 and whose use is usually by what is called dobutamine trial and for good reason.
You mentioned patient was in norad and Epi and or vasopressin?
Sepsis is a hyper dynamic state, lots more happening there with myocardial dysfunction.
Why wouldn’t lactic acid be measured to determine if the course of medicine caused it to increase?
Is there a way to evaluate lactic acid in cases like this to educate decisions?
Man, this is really interesting in this lecture
Wow! You really simplified the vasopressors! Thank you!
Roger... nice one though there are quite a lot of ways to differentiate cardiogenic and septic shock and the management varies very differently. its not a trap. its a misdiagnosis. you have made great lectures but this one will result in non critical care persons not using the right management when its really needed. just read up the comments for this video. i know this is not what you had in mind.
thank you so much , best
Thank you, Dr. Seheult, for explaining this difficult situation. I have encountered this as an ICU RN many times during my career (80's-90''s). This was back before US or Echo was widely available. But there was another indicator of EF that we used then and it required no equipment, only the human hand. It was finding and assessing the PMI (Point of Maximal Impulse) when the patient was in the Left-lying position. It can be technique-dependent but it takes only a minute or so (of course allowing that the patient can be turned). A "good" PMI presents with a smaller diameter and firmer pulse against the hand. This, in my experience, correlates with an EF of over 50%. No, there are no papers. It's just what I found when I had patients who had Swan-Ganz catheters post-op and I would correlate with their PMIs. So how would it fit into standard practice? It probably would not, but, in the middle of the night, with no docs around, no imaging techs, you have to gather as much information as you can about the cardiovascular system of your patient. If I felt a strong PMI, I would consider other factors besides cariogenic, for example, is there evidence of multi-system failure, are coags off, etc.. If I found a diffuse, weak PMI, and in the presence of other worrying signs, I'd definitely start waking people up, techs, docs, etc. because I'm gonna need some help.
Amazing the diagnostic skills we used to have before all this technology. Thank you.
I feel so fortunate to have stumbled on your videos! Now i am cramming in a good way... thanks!
The mouse dot is hard to follow.
Shouldn't there then be an echocardiogram machine at every ICU bed to routinely monitor heart function?
Echocardiograms take about 20 to 30 minutes to gather the information and then another 10 to 15 minutes to be read by a cardiologist. So it can’t be done all the time.
Dude, they don't even have water tanks on the PAP machine. It's like sticking a leaf blower to somebody's face and expecting them to be tolerate it
Hello Doctor, I've experienced at least 3 episodes of sleep paralysis in the recent days, It was a very frightening experience. After that I'm very afraid and anxious to sleep alone, can you explain why this is happening and how can I overcome this condition please help me 🥺🥺
Sleep paralysis can be a symptom of sleep deprivation, or it might be a symptom of narcolepsy. I would definitely talk to a physician and perhaps get a sleep study if that is indicated.
Have you been measured for sleep apnea?
There is a virus that can cause this effect.
Also a feeling of falling...
And a very hard difficulty of breathing can occur which sometimes causes the person to have a heart attack.
I hope that you are feeling better as this was two weeks ago that posted this.
People have been known to expose people to this virus in order to facilitate creating a manipulation for whatever purposes or intentions they have...
I don’t know where it came from or the natural environment or anything.
But it’s been used for intelligence operations and psychological warfare operations.
Fluids. Optimize that Starling curve.
I am not a medical professional.
However lactic acid in the blood can be very helpful with infectious vectors in the blood.
Understanding how to facilitate the pattern using breathe control can save a life.
Studying your data points as my stepdad has premature heart failure and I want to be darn sure they don't give him improper treatment.
Excellent video!
It's definitely not uncommon for some of these patients to receive bicarb or even a bicarb drip.
Yes, it is a potential temporary fix for acidosis. However, there’s some evidence that it may actually make intracellular acidosis worse so it is controversial.
So for a patient in cardiogenic shock with presumably low ejaction fraction, we start with noradrenaline plus dobutamine infusion? (as a medical management, apart from finding the cause of his shock).
Well, if it’s cardiogenic shock, you pretty much found the cause of the shock. If it’s pure, cardiogenic shock, then dobutamine should work just fine.
If the HR is >120s Would you use milrinone instead of dobutamine??
Yes, a very good choice. Especially if the pulmonary artery pressure were elevated.
I wonder if milrinone or isoproterenol could be used. Milrinone is B1 selective and isoprotererenol is pure B1 and B2 selective?
Milrinone is a PD3 inhibitor (Inotropic) not B1.
Milrinone is a phosphodiesterase type 3 inhibitor, which allows intracellular cAMP to persist and cause protein kinase A to phosphorylate L-type Ca2+ channels, increasing their open duration, in cardiac myocytes during phase 2 of depolarization, giving it an inotropic action. But the tradeoff is that milrinone can be arrhythmogenic.
Is there any certification available to show proficiency in sepsis recovery?
Not really. It’s just part of being board-certified in critical care medicine.
You said you have come into this situation several times over the years, who would have been caring for them previous to your arrival? Is there a bare minimum needed to be an ICU doctor?
Would supplemental oxygen help lower the lactic acid and help the energetics of the heart?
It might but if the hemoglobin is already saturated adding more will not be incrementally beneficial as much as increasing cardiac output.
@@Medcram good point though this reminds me of another question I've had about respiratory physiology. Under normal physiological conditions the large majority of oxygen is carried by hemoglobin no, but there is some solubility of oxygen in water, and unlike hemoglobin, it's not really saturable, and in fact it's nearly linearly proportional to the partial pressure of oxygen in contact with the the solvent as per Henry's law. I've assumed that this is why you see astounding World Records On who submerge themselves in water in excess of 15 minutes after spending a half hour or so breathing pure oxygen. In a supersaturated oxygen environment how much of the oxygen carried by the blood is just in solution as opposed to being transported by the hemoglobin. Can you double or more than maximum amount of oxygen being transported by the blood, about to be on what's being transported by the hemoglobin?
@@michalchikaccording to google, only about 2% is carried in the blood/plasma.
@@SusanKay- hyperbaric oxygen shouldn't be necessary 100% pure oxygen was sufficient for a world record breath-holding to be set at over 24 minutes.
The Script Guitarist Mark Sheehan Dead at 46. Wonder if he died of sleep apnea, vasopressor toxicity or CAP? Baffling
Footballer Zé Carlos Suffers a Shock During a Game, Collapses Twice (VIDEO). No biggie just another young athlete collapsing TWICE
Here’s a review that looked at this back in 2015 and did a nice job of showing how often this is happening unfortunately.
www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.115.015431?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Study doc cites gives extremely low number as compared to today. This doc has a blind spot of vaccine, and will never talk about the elephant in the room today. He is approved by TH-cam and wants to stay the way - political correct.