00:01
Now with dynamic auscultation,
things that you want to pay attention to.
00:06
Altering heart sounds by changing
circulatory hemodynamics.
00:10
We will be spending
time with this.
00:11
You have heard hard grip.
00:12
You have heard of watch this,
I am going to disappear for one second.
00:15
What did I do?
Rapid squat, right.
00:17
So these are some of the changes
or these are some
of the maneuvers
that we will be conducting
or you will be asked about
and depending on the maneuver how
is that going to affect or influence
the heart valves and heart
sounds, is that clear?
Now this can be
separate, but clinical,
we are going to use some
of these depending on
what you are trying to
confirm for diagnosis.
00:40
And once you understand
the physiologic alteration,
then you've got your diagnosis.
00:44
Let us continue.
00:45
Before we even get there though,
let us make sure that we understand
the difference between
preload and afterload please.
00:51
Now, how do you increase
your venous return?
Well, we'll talk about
this manouveres coming up.
00:55
But if you were to
increase your venous return
to where? To right atrium,
to right ventricle,
what have you done to preload?
You have increased your preload.
What does preload mean to you?
Preload means that it is the amount of
fluid or volume within the heart, okay.
01:10
So if you increase the
venous return for example,
if you are to
constrict the veins.
01:14
If you constrict the veins,
are you picturing this?
Not the arteries but the veins.
01:19
The veins are a
major pooling area.
01:21
If you constrict the veins, you are
increasing venous return to the right side.
01:24
What are you doing
to the preload?
You are increasing it.
It is that simple.
01:28
Preload is the volume of
blood in the ventricle.
01:30
What if you decrease
the venous return?
Well, if you decrease
the venous return,
volume of blood into right
atrium, right ventricle
such as standing up.
01:38
If you go from supine
position to standing up,
then where is my blood?
In the dependent areas.
It is down in the lower extremity.
01:46
What happens to venous return?
It decreased, didn't it?
So you have decreased preload.
01:51
Now, what is definition of afterload
that you want to know here?
Because this is important.
01:55
Afterload is when you
have increased resistances
that the left
ventricle was facing.
02:02
The left ventricle,
when it faces increased resistance.
02:08
Give me some examples.
02:10
Aortic stenosis,
coarctation of aorta
and tell me about the arterials.
02:15
Take your time.
02:17
What state are the arterials in,
in which it would then provide increased
resistance to the left ventricle?
Did you listen to my question?
What state is my arterials in
providing increased resistance
to your left ventricle?
Constriction.
02:36
Arterials are the most
important component
or contributor to
resistance as you know,
especially TPR,
total peripheral resistance.
02:45
If you can split your arterial,
what happens with TPR?
Increase your TPR.
02:49
What then happens to afterload?
You increase the afterload.
02:52
Are you seeing this?
So afterload is that simple.
02:56
It is the resistance that the
left ventricle is facing period.
02:59
And I just gave you
bunch of differentials.
03:01
What are they again?
Aortic stenosis, coarctation of aorta
and arteriolar vasoconstriction.
03:07
Continue.
03:08
Now let us talk about
those actual maneuvers
and we will go through
the pathophysio.
03:12
Deep inspiration,
okay,
so what does that mean to you?
Let's all take a deep breath.
03:19
You're with me? Good.
03:20
But then just happened the diaphragm
contracted, which way did it go?
Downwards.
03:26
What happened to
abdominal pressure?
Increased upon deep inspiration.
03:30
What happened to the
thoracic pressure?
It decreased.
03:33
It literally became a vacuum.
03:36
It is going to suck up
like a straw.
03:39
It is going to suck up
the blood into the heart.
03:42
What is my topic?
Increased venous return upon
deep inspiration, is that clear?
When you have deep inspiration,
increased venous return to the right side,
what then may happen to the intensity
of the murmurs on the right side?
It would obviously increase.
03:58
Clear?
Next. Supine position
versus standing up.
04:01
If you are supine,
which I hope that you
are not in right now
because if you were, there is every
possibility that you are falling asleep.
04:09
Supine position
would be lying flat.
04:11
You're lying flat.
04:13
So, therefore, you are making
it easier or more difficult
for blood to return
to the heart?
You are making it easier, right.
04:19
And that is our topic increased
venous return, supine position.
04:22
What if you went from
supine to erect position?
The blood then drops where?
Down to the legs.
04:27
So decreased in venous
return, it is that simple.
04:30
Passive leg elevation.
04:32
You pay attention to
the same thing here.
04:34
So you are going to raise your legs
and when you do so then what happens?
You are going to then return the
blood to the right side, clear?
Increased venous return.
04:41
Rapid squatting,
now this is important.
04:43
There are two major issues that you want
to pay attention with squatting, please.
04:47
Here you are going to do this quickly.
04:50
Okay, let's just think of
me just rapidly squatting.
04:52
When I did so,
then it increased the venous return.
04:55
Here comes more blood.
04:57
Okay, that's one example here that you
may want to think about clinically.
05:02
Now, what about if
this was a child.
05:05
What do children like to do?
They like to play.
05:07
They like to go run.
"Hey mummy, can I go play?"
"Of course you can." Right?
So the child wants to play.
05:13
Then all of a sudden
the child is playing
and cannot breathe or having
a hard time breathing,
and the child really
instinctively is going to do what?
Squats.
05:24
Now, what is the diagnosis in this patient
in which after playing for little bit,
the child instinctively
knows to squat?
It is called the Tet spell.
05:33
So what is happening there?
What I am going to do for you here
is make sure that we delineate
the two different type
of squatting maneuvers
and depending as to what
you are trying to confirm
is going to give you
different types of diagnosis.
05:48
If it is rapid squatting, yes, it does
bring about increased venous return
but tell me about the patient,
the child who just squatted,
when the child is
feeling a little cyanotic
with a little hypoxemia,
it is the fact that there
might have been what?
There might have been pulmonic
stenosis, number 1.
06:05
Number 2, there might have been
right ventricular hypertrophy.
06:07
Number 3, there was what?
Ventricular septal defect.
06:10
Number 4,
there was overriding aorta.
06:12
What am I referring to?
Obviously tetralogy of Fallot.
Tetra, four.
06:18
And what kind of shunt is this?
It is a congenital
cyanotic heart disease,
a right to left shunt,
right from the beginning.
06:25
Because the right ventricular
hypertrophy is then shifting.
06:27
What kind of blood is in the
right ventricle? Tell me.
06:30
Good, deoxygenated.
06:31
And that right ventricular hypertrophy
is pushing the blood through the
VSD into left side.
What kind of shunt?
Right to left shunt.
So what do we have? Cyanosis.
06:41
Who is feeling it? The child is.
06:43
So what is the child
doing instinctively?
Squatting. To do what?
Not to increase venous return.
06:49
So why is the child squatting?
To increase TPR.
06:53
How do you do that?
You increase TPR by
constricting arterials.
06:57
I just got then telling you what
happens when you increase TPR?
You increase afterload.
07:02
When you increase afterload,
who is facing
increased resistance?
The left ventricle.
07:08
And so therefore what
happens to the shunt?
It gets reversed,
instead of right to left shunt
that type of squatting
with tetralogy of Fallot
will then turn into a
left to right shunt.
07:17
Now, is this the only time we will see it?
Not at all.
07:20
Talked about this in embryology.
07:21
We will talk about this further as we
are getting to congenital heart disease.
07:24
Why am I bringing this up?
Because you must be very clear
about the issues of squatting.
07:30
Let's continue. Now,
let us talk about valsalva.
What are you doing?
Don't ask.
But if you must, so be it.
07:38
Looks like I'm constipated.
07:39
What am I doing?
I have closed my
epiglottis phase II,
and that's you pay attention to.
07:46
So when you are expiring
against a closed epiglottis,
what happens to thoracic pressure?
You've increased it.
07:51
Good. Good.
07:53
You have increased
your thoracic pressure.
07:54
Initially in phase I, what did you
do to your pulmonary capillaries?
You close your
pulmonary capillaries.
08:00
Would you tell me as to what is
distal to the pulmonary capillaries?
I believe it is the left atrium.
Correct.
08:05
And by
quickly closing pulmonary capillaries,
you increase venous return to left side,
but that is not the point.
08:11
The point here is
during phase II.
08:13
If you continue to squeeze
your pulmonary capillaries,
there isn't any
more blood in there.
08:18
Look, there is no
more blood in there.
08:21
So what will happen to venous return?
It decreases.
08:23
Are you with me?
If you continue to squeeze
and because of that increased
expiration against a closed epiglottis,
then at some point you are
going to decrease venous return
and that you must
pay attention to
because that becomes important to
us as we get into valvular diseases
and at that point I will
repeat this very point.
08:44
Well, let us go from supine
position to standing up.
08:50
So you stand or sitting up
quickly, then what then happens?
The blood then rushes
down into your legs.
08:55
What happens to venous
return ladies and gentleman?
It is going to decrease.
08:59
There is your blood
down in the feet.
09:01
It is not in your heart.
09:02
Now,
you take me one step further.
09:04
What did you learn in
physiology already?
You've heard about
baroreceptor reflex.
09:08
Baroreceptor reflex, where are they
located in, these baroreceptors?
They are located in your
sinuses, aren't they?
Which one is more sensitive?
The carotid aortic sinus.
09:16
The carotid,
the carotid sinus because
that is not accustomed
to large amounts of
blood like the aorta is.
09:23
The aorta is accustomed
to large amounts of blood.
09:26
It is not as sensitive.
09:27
The carotid has
glossopharyngeal.
09:29
The blood has then gone where?
Down into legs.
09:32
Then what happens stretch?
Decreased stretch.
09:35
When you have decreased stretch,
what happens to pharynx?
Decreased pharynx.
09:39
My blood is then
rushed down into legs.
09:41
What kind of outflow do you want from
the autonomic nervous system please?
Good. Sympathetic.
09:47
It is exactly what is happening.
It is called the baroreceptor reflex.
09:50
You're going to be asked about
this, guaranteed you will,
in many places.
09:55
Alright, now let us take
a look at these other
maneuvers that then will help
you diagnose your patient.
10:02
I want you to take your hand and
I want you to clench your fist
and I want you to
come at me right now.
10:07
Because "Dr.
Raj, you're driving me crazy.
10:09
You are frustrating me.
10:10
You are giving me all this information.
I just want to hit you."
Okay, so you clench your fist.
You with me?
So is that your sympathetic system?
Of course, it is.
10:18
So when you do a hand grip, a sympathetic
nervous system because you are angry.
10:22
Calm down, it's okay.
10:23
If you have a stress probably
good time to grab, right.
10:26
So here you are,
you are squeezing it.
10:27
And what have you done to your arterials?
You have constricted it.
10:30
What have you done to your TPR?
You have increased it.
10:33
Once again,
when you increase your
TPR, what have you done?
Are you affecting
your afterload?
Yes, you are.
10:39
Then what have you done to your after load?
You have increased it.
10:41
Why is it important?
You shall see
and I will keep coming back to this
point where you have understood,
you have understood,
by increasing that afterload,
then where is my blood?
In the left ventricle.
10:54
It is having a hard time getting
out of the left ventricle
and you shall see and you will
understand why an aortic stenosis.
11:01
When you do a handgrip,
what happens intensely as a murmur?
Decrease.
11:07
Don't worry,
we will talk about it again.
11:09
What about exercise?
Well exercise, once again,
you've talk about this in physiology,
what is it going to
do to your arterials?
It was my question.
11:17
What is it going to
do to your arterials?
Vasodilate, it has to.
11:21
Why in the world would you want
to increase your TPR and exercise?
That makes no sense.
11:25
You want to make sure that
you have vasodilations
so that you properly
oxygenate your tissues. Clear?
In the meantime, what is happening
to your veins in exercise?
Venoconstriction.
11:35
The combination of the two.
11:36
Well, what do you know
about cardiac output?
You might go from 5 liters.
11:41
You might have increased by
100 percent to 10 liters.
11:44
That is amazing in exercise.
11:46
In this case here,
increased flow across your valves.