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Peter

What Is Self Control? My Experience And More

I went to the Restaurant today! I was hungry, plus I had been feeling drive-less recently.

Ordered a plate of food to take home, because I was too down to even cook. Then I noticed the Alcohol 🤩 in their fridge. 

Honestly felt like I needed some to help my mood, atleast temporarily. I did ask the price, got the money and was ready to pay. 

It was gonna boost me, alcohol really would make me feel different, I am pretty sure of a short but worth the while benefit with alcohol, any day anytime.

You won’t believe it, but I did chicken out of getting it ☺️.
I call that self control, don’t know what you call it, unmanly? Weak? Asocial? Poverty? Erm? Whatever?

I was able to give up:
1) Some pleasure I thought I needed more than anything else at that moment
2) Some pleasure with an obvious short term benefit
3) Some pleasure that demands spending and continuous spending to maintain.
4) An energy drink (literally)

I was able to control myself. We all need self control to achieve at different focuses. I mean, I could make a list, but let’s refrain as you keep in mind that you need that self control EVERYDAY, EVERYTIME.

Edit: 
It's been three years since that piece was written. I ll like to share with you that I have learnt more about self control. I hope what I learnt amazes you.

I have learned that the best self-control to give isn't the resistance of food, liquor or sex. It's isn't denial of your feelings or the status quo, but the acceptance of it, then finding a way to live through it becomes profitable. It's not the denial of thoughts or obvious feelings, it's is the control of thoughts and feelings (accept what it is and how you feel about certain situations, yet be wise enough to control the reactions of such feelings.

The best of self-control is the resistance of the self. Your self. Your very own heart (Ego itself)

The best of self control is achieved when you:
1) Completely accept your past with happiness (the good and bad of it)

2) Accepting today that you are in control of very little (and so you are practicing detaching yourself emotionally without neglect of duty to those around you or your environment because up till this point, we have ignorantly messed our destinies with our hands)

3) And attempting to create the future with best unbiased knowledge and analysis you can muster (because what you do for the future is what the future would do for you)

You ll find that many "good" people (myself inclusive, that's if I am even considered a good person) find it hard to break that paragraph even. 
We regret/cherish the past - it's gone.
Many are control freaks and believe that they must succeed at everything they lay their hands on and create the future with as much biased knowledge they can manifest.

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Peter

Shock

General Concept of Shock
- Underperfusion of tissues
- Medical Emergency
- May become irreversible

General Signs and Symptoms of Shock (HARLOT)
- Hypotension symptoms and signs  (BP decrease)
- Altered Mental Status (CNS)
- Renal failure (Low urine output)
- Lactic acidosis (Secondary to Hypoxia to tissues)
- Oxygen level of the Vein (Mixed Venous Oxygen) is decreased in all Types of Shock except in Septic shock.
- Tachycardia/Tachypnea

Types of Shock
-      Cardiogenic Shock
-      Hypovolemic
* Distributive types of Shock
-      CNS shock 
-      Septic shock 

How Shock affects the system (CSV)
- CO
- SVR
- Volume status

Approach to Shock (BIJI'S TV)
Bleeding Hx (Hypovolemic shock)
Infection site & Fever (Septic shock)
JVD (Cardiogenic)
Ischemia Heart Disease Hx (Cardiogenic)
Spinal cord/Neuro deficits (Neurogenic shock)

Trauma site (Hypovolemic shock)
Vomiting & Diarrhea (Hypovolemic shock)

Ask for BIJI'S TV in Shock

General Mgt for Shock
1. Airway
2. Breathing
3. Circulation
4. Treat Specific type
5. Generous IV fluids (Except Cardiogenic or Neurogenic - Judicious)

Pressures in the heart chambers
* If we can remember the pressure of Right and Left Ventricles, we can remember the rest
1. Right ventricle = 25/5 mmHg (i.e Pressure of Pulm trunk - 25/pressure of right atrium - 5)
2. Left Ventricle = 130/10mmHg (i.e Pressure of Aortic trunk/Pressure of left atrium)

Pressure in Ventricles =  Pressure of the Next vessel or Chamber/Pressure of the previous vessel or chamber

The Atriums
Right Atrium = >2mmHg - < 5 mmHg (Right5)
Left Atrium = > 5 mmHg – < 12 mmHg (Notice left atrium is double right Atrium – 2 x 5 = 10mmHg)

Cardiogenic shock
- CO isn't sufficient to maintain tissue perfusion
- SBP < 90 (Cardio9enic shock)
- Urine output < 20 mL/hr (Class 2 shock)
- Adequate Left Ventricular filling pressure (Decreased in Hypovolemic shock)
- Vasopressors used in treatment of cardiogenic shock are those produced in the Brain (Dopamine > Norepinephrine)

Causes of Cardiogenic shock
- Basically any Disease of the heart, or structures around the heart can lead to a cardiogenic shock
1. Post-MI (Ischemia to Cardiomyocytes = Poor Contractility)
2. Cardiac Tamponade (esp. in rapidly developing)
3. Tension pneumothorax (Pressure transmitted to the heart muscle)
4. Arrhythmias
5. Massive Pulmonary Embolism (leads to RVF)
6. Myocardial diseases (Cardiomyopathies, Myocardities)
7. Mechanical abnormalities (Valves, VSDs)

Features of Cardiogenic shock
1. Specific
- JVD (Increased PCWP)
- Pulmonary congestion (Pressure transmitted to the pulmonary vessels from the heart)

2. Non-Specific (HARLOT)
- Hypotension (Beta/Sympathetic activation = Sweating = Cold clammy skin)
- Altered Mental status
- Renal failure (< 20mL/hr)
- Lactic acidosis
- Oxygen from Mixed Venous Oxygen is Low (Decreased in all shocks except Septic shock)
- Tachycardia/Tachypnea

Diagnosis of Cardiogenic Shock
1. ECG
- Identifies Myocardial Infarction (MI)
- Identifies Arrhythmias

2. Echocardiogram
- Identifies Mechanical origin of Shock (Valvular, VSD)
- Estimates Ejection Fraction (EF)
- Identifies Pericardial Effusion and Cardiac Tamponade

3. Hemodynamic monitoring (Swan-Ganz catheter)
- PCWP (Keep at < 18 mmHg)
- CO (keep at >4L/min)
- Cardiac index (Keep at >2.2)
- SVR

4. Decreased Mixed Venous Oxygen levels
- Low CO = Tissue extract more oxygen from blood

Treatment for Cardiogenic Shock
Non-Specific
1. ABCs
Airway (Make sure to check/guard the airway)
Breathing (Make sure patient is breathing)
Circulation (Maintain circulation, May give IV fluids)

Specifics (VIVIDS)
1. VasoPressors (Help Increase Systemic Arterial BP)
2. Inotropes (Increase Contraction of heart = Increase CO)
3. Vasodilators (not part of initial treatment, Use with Inotropes, improves blood delivery)
4. Intra-Aortic Balloon Pump (IABP) (< Afterload, < Cardiac O2 demand, > CO)
- Does the job of Inotropes (>CO), Afterload reducing agents (< Afterload) plus B-blocker (< Cardiac O2 demand)
5. Diuretics (If pt is vol. overload on venous side, don't give IV fluid)
6. Specific treatment for Underlying cause 
 
Specific Management for some underlying causes of Cardiogenic Shock

* Acute MI (BAN PROS)
Beta blockers, Anticoagulants, Nitrates, Pain control (Morphine), Revascularization, Oxygen, Statins (Take home)
- Standard Tx and
- Revascularization (PCI, CABG)

* Tamponade
- If severe = Pericardiocentesis/Surgery

* Valvular abnormalities
- Surgery 

* Arrhythmias
- Anti-arrhythmics
- Removal of cause (Drugs or Medical condition)

Some Modalities used to treat Cardiogenic Shock
1. Vasopressors
- Dopamine > Norepinephrine (Means Dopamine more commonly used) 
- Dopamine + Dobutamine (Synergic to Increase Cardiac Output)

2. Afterload-reducing agents (Vasodilators)
- Not initial tx (may worsen hypotension)
- Often used later with Vasopressors (Dopamine)
1. Nitroglycerin
2. Nitroprusside

3. Intra-Aortic Balloon Pump (IABP)
- Gives Mechanical support to failing heart
- Works opposite to Pumping sequence of the heart
- Positioned distal to Subclavian artery in descending Aorta
- Enhances Myocardial Oxygenation and Cardiac Output

* How IABP works opposite of the normal heart sequence of Pumping
i. Pumps during diastole (Inflates at onset of diastole)
- Increases Diastolic pressure
- Increases Coronary Perfusion (because it pumps during diastole the heart rests in systole) 

ii. Relaxes during Systole (Deflates before systole)
* Decreases Afterload 

* Indications for IABP (Severe compromise of Cardiac output, Vessels or Ischemic complications)
i. Refractory Angina
ii. Mechanical complications of MI
iii. Cardiogenic shock
iv. Decreased CO states
v. Bridge to Surgery in severe AS

* Remember Intra-Aortic Balloon Pump with IABP, it mimics
i. Inotropes (Increase in Cardiac Output)
ii. Afterload reducers (Decreases Afterload)
iii. Beta blockers (Reduces Oxygen demand)
 

Hypovolemic Shock
- Decreased Circulatory blood volume
- Importance: Rate of Loss > Volume lost 
i. Slower loss = Effective compensation (When > 20% of volume is lost, compensation begins to fail)
ii. Worse prognosis with Acute loss
- Poor compensation in Co-morbidities (Cardiac diseases, Infections)
- Central Venous Pressure is decreased (Normal/Increased in cardiogenic shock)
- Tachypnea (Hyperventilation) is common is Hypovolemic shock
i. Respiratory compensation for Metabolic acidosis (lactic acidosis from tissue underperfusion)
- Just like in Cardiogenic shock, Sympathetics are activated (Cold and Clammy skin)
i. Cold skin (Due sympathetic activation and superficial vessel constriction, shunting blood to internal organs) 
ii. Clammy skin (Due to sweating from sympathetic activation)

Causes of Hypovolemic shock
i. Hemorrhagic (Any cause of bleeding)
ii. Non-Hemorrhagic (Any cause of dehydration, 3rd spacing in Bowel obstruction)

Classes of Hypovolemic Shock
- Four Classes
- Based on HARLOT
i. Hypovolemia
- Volume lost
- Decreased BP
- Pulse
- Pulse pressure
- Capillary refill
ii. Altered Mental Status
iii. Renal failure 
iv. Lactic acidosis (Tachypnea)
v. Mixed Venous Oxygen Saturation (Tachypnea)
vi. Tachycardia
 
The Classes of Hypovolemic shock
i. Class I (1)
- > 10% of Volume lost
- Adequate compensation (Nothing else affected)

ii. Class II (2)
- > 20% of vol lost
- Compensation is failing
- Every system is mildly affected (Pulse > 100)
- Urine output ( > 20mL/hr)

iii. Class III (3)
- > 30% of blood volume lost
- Every system is Moderately affected (Pulse > 120)
- Urine output < 20 mL/hr

iv. Class IV (4)
- > 40% of volume lost
- Every system is severely affected (Pulse >140)

Diagnosing Hypovolemic shock
- Check with HARLOT 
1. Hypotension signs (Vitals)
2. Altered Mentation (Anxious, Confused, Coma)
3. Renal failure ( 20-30mL/hr)
4. Lactic acidosis (Metabolic acidosis = Tachypnea)
5. Mixed Venous Oxygen Saturation (approx 75-80%)
4. Tachycardia

- IF dx is still unclear
* Central Venous Line, Swan-Ganz catheter may help (Signs of Hypovolemia and Sympathetic activation)
i. Decreased Pulmonary Capillary Wedge Pressure (PCWP) 
ii. Decreased Central Venous Pressure (CVP)
iii. Decreased CO > SVR {due to Sympathetic/Beta activation)

Treatment of Hypovolemic Shock (ABCs)
1. Airway and Breathing 
(If Severe/Circulatory collapse = Intubation & Mech. ventilatn)
2. Circulation
* If Non-Hemorrhagic
- Crystalloid solution + Electrolyte replacement

* If Hemorrhagic shock
- Apply Pressure to site

* If Shock is more than Class 2/3 = Give IV fluids (Bolus - Continuous - Check/monitor patient)

* If Shock is in Class 3/4, may require Whole Blood (PRBCs, FFP, Platelets in 1:1:1) 

Indicators of Effectiveness of treatment in Hypovolemic shock
1. Urine output monitor
2. Swan-Ganz catheter/Central Venous Line

 
Septic shock
- Hypotension induced by Sepsis
- May persist despite adequate fluids
- Hypoperfusion = Multiple Organ System Failure = Death
- Worsening progression Systemic Inflammatory Response Syndrome (SIRS) - Sepsis - Shock - Multi-Organ dysf (MOD)
- Most common cause of death in ICU
- Common causes (Invasive infection in any organ- can be from any focus)
i. Pneumonia (Lungs)
ii. Pyelonephritis (Kidneys
iii. Meningitis (CNS membrane)
iv. Abscess (Any focus)
v. Cholangitis (Bile duct)
vi. Cellulitis (Skin)
vii. Peritonitis (Peritonium)

Signs and Symptoms of Septic Shock
Specific
i. Flushing/Warm extremities (Unlike Cold and Clammy skin Hypovolemic/Cardiac shock)
- Due to Peripheral vasodilation from immune reaction to toxins
ii. Cardiac Output = Normal or Slight increase
- Due to Sympathetic activation = > Co, Inc Tachycardia.
- Also due to decreased Systemic Vascular Resistance (SVR) - less force heart pumps against
iii. Reduced EF (EF = SV/EDV)
- Increased End Diastolic Volume vs Systolic Volume i.e ((Volume that enters ventricle vs Volume that leaves the ventricle)
iv. Increased Mixed Venous Oxygen saturation
-      Due  
1.    Hyperdynamic circulation
2.    Improper circulation of Cardiac output (from systemic vasodilation)
3.    Inability of tissue to adequately extract oxygen (Due to SIRS)
iv. Systemic Inflammatory Response syndrome (SIRS)
v. Fever or Hypothermia (If Young, Elderly, Very ill, Immunocomp.)

Non-Specific signs

vi. Signs of Shock HARLOT

Diagnosis of Septic Shock
* A Clinical Diagnosis
* Look for Site/Source of Infection
* Blood culture (Ironically, Gram +ve organisms are more common than Gram -ve causes)

Complications 
- Severe Compromise of HARLOT
- Commons are
i. Renal Acute Tubular Necrosis (ATN)
- Due to underperfusion of kidneys (Often ist organ affected)
- KIdneys overwork to conserve fluid despite little blood supply
- ATN finally ensues from Ischemia to the tubules

ii. Lactic acidosis leads to Disseminated Intravascular Coagulation (DIC)
- Occurs in very ill cases (Dysfnc of platelets in acidic environ)

iii. Severe Hypotension leads to Multi-Organ Dysfunction Syndrome (MODS)
- Multi Organ failure due to underperfusion