Now, let’s go on here to just a little bit,
make sure that were clear. And we are able to
identify everything that’s according here.
Now, what I wish to point out to you is – well, pressures.
You see LV, Left ventricular pressure.
You see RV, right ventricular pressure.
What are we gonna do? What kind of maneuver
are we going to then perform?
And which we are going to see differences in pressure
based on the pathology of pericardial effusion.
This is called pulsus paradoxus is where we are.
Now, before we move on though you must understand
the normal physiology, so that this makes further sense too.
Otherwise, you’re going to completely,
completely answer incorrectly.
You don’t want that.
So what’s happening? Upon inspiration, quickly walk me through
this. What happens to the man of blood returning to the heart?
Increase or decrease?
Remember, inspiration die from contracts moves
downwards the thoracic portion decrease
and becomes a vacuum. And there is more blood
coming into the right side of the heart.
Remember, well upon inspiration, what then happens to S2?
Upon inspiration, S2 gets further apart doesn’t it?
A2 P2, what’s that called physiologic split.
Is that clear? So far so good.
Where is the more blood right now? You tell me,
there is more blood where, on the right side.
And how you can confirm that’s physiologic splitting of S2?
In addition, can you tell – let me ask you a question.
Upon inspiration, what may happen to your heart rate?
Any idea? And this, you will probably have to memorize.
Upon inspiration your heart rate increases. So they might
be a slight tachy. Alright a slight tachy, upon inspiration.
So there is a things that we’ve talk about, and
you’ve known about. But just continue with this.
Upon inspiration there is mode on the right side.
and so therefore – I want you to think about that,
Interventricular septum, the wall, it thus
separating the right side from the left side.
Where is the more blood with inspiration?
Where, where, where?
Right side. Good.
What is going to do to the wall? What wall?
Intraventricular septum for example.
Its going to push it to the left side, right?
Its gonna push it to the left side. Why?
Because there is more blood in your heart. Why?
Because of inspiration. Why?
Diaphragm move downward. Its pulling
more blood in to the heart.
Are you with me? Good.
So where is there less blood? Transiently upon
inspiration. Where is there a less blood?
Less blood on the left side, because there is less space.
That’s one reason as to why is there less blood on the
left side. What quick me here? Where else may happen?
You just put more blood into the right side upon inspiration,
I’m going to bring in physio here, we have too.
Now, with inspiration, I need you to work with
me and along with that compared to exercise.
An exercise, how much more blood is
coming through the right side?
Obviously more. Aren’t you increasing cardiac --
Close your eyes, you got this. Don’t memorize it.
You know, when you exercise obviously your
gonna increase cardiac output, correct?
The only way you can do that is to then a veno constrict.
So far inspiration exercise more blood in the heart. Good.
Next. Right ventricle output. Increases
because of more blood. Right?
So now, you are increasing cardiac
output from the right ventricle,
Where are you going? Where are you going?
Don’t go to the bathroom yet. Stay here.
You are gonna inject into the pulmonary
artery from the right ventricle, clear?
So there is more blood in the pulmonary artery.
How do you think that the pulmonary capillaries
are going to respond with more blood?
Dilate or is it going to constrict?
Remember this in physio an important, important point has
to be and you can automatically apply this to exercise as well.
When there is more blood that has been kick out from the
right ventricle, obviously, the pulmonary capillaries
are going to dilate, has to think about
exercise, don’t you need more oxygen?
It makes no sense for you to constrict your
pulmonary capillaries. That doesn’t happen.
So, so far, inspiration exercise, more blood in the heart, increase
cardiac output form the right ventricle pulmonary artery.
We have vasodilation. So far so good? Okay.
So when we have pulmonary capillaries,
which are vasodilated now, its inspiration,
the point is, it doesn’t want to move forward because
its pulling the blood in the pulmonary capillaries.
In addition, with inspiration, you are
also moving the septum to the left side.
The combination of increase pulling pulmonary capillary
and moving the wall to the left side therefore causes
decrease with inspiration, decrease
amounts of blood in your left side.
How can you confirm that? How can you confirm that?
Your systolic blood pressure with inspiration normally
may drop; drop 10 millimeters mercury by definition
that is the limit, that is the full capacity at this point.
It should not drop great than 10 – I said drop,
you should not drop great than 10 millimeters mercury.
But it will drop them because there is
less amount of blood in the left side.
And you are measuring your blood pressure
cuff in the brachial, right?
So therefore, your blood pressure would drop now.
What happens here with effusions?
So now you’ve understood? Now you’ve understood the physiology. Let’s put in our effusion.
So now your effusion with pericardial cavity.
That means that you have your heart which is more restricted
And therefore, upon inspiration, you are gonna
go through the same physiology.
But now at this point, upon inspiration,
you see that, you see that arrow on top?
The arrow on top is then dropping the systolic blood pressure,
upon inspiration greater than 10 milliliters mercury.
We have a problem, this is called Pulsus Paradoxus.
Are they just gonna come out in a stem of a question?
or attending and just tell you, that’s pulsus paradoxus.
No, because that is actually not the most act
who have name isn’t it? Its not at all a paradox.
It’s just an exaggeration of the normal, is that clear?
Now, if it isn’t, I would like for you to go back and review
the basic concepts that I just lay down the foundation form.
So that at any time you encountered the concept of
pulsus paradoxus, you’re absolutely clear.
In pericardial effusion because of the restriction of
the heart, upon inspiration, you will have a greater than
10 millimeters mercury drop of systolic blood pressure.
And that is not normal. And that is what that arrow indicating.
Lets move on please.