# hyperperfusion



## onecrazykid108 (Jun 26, 2010)

What treatments would you do for someone with a fever? just cool off their skin?


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## usafmedic45 (Jun 26, 2010)

First things first: If you're looking for medical advice, this is not the place to go.  Following any advice here without consulting a physician is a bad idea and you do so at your own risk.  

OK, now that the disclaimer is out of the way, as an EMS provider you are not going to do much for someone with a fever unless they are showing signs of neurologic problems due to it (seizures, coma, etc).  Even then, the best treatment in those cases is  transport and general supportive care.   Only in extreme cases (heat stroke, drug induced hyperthermia, etc) would aggressive cooling such as ice packs, dousing the patient in cold water, etc in the field be indicated.  If the patient is dehydrated, starting an IV and using judicious amounts of IV fluids to _begin to correct _it is indicated.

The only thing worse than a high fever is letting the temperature rebound after bringing it down initially.  Follow your local protocols, but like I said, the best bet for your average fever patient is keep them in a cool ambulance, remove as much clothing as you can (stripping them naked is not necessary in most cases) and transporting the patient to the hospital.


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## CAOX3 (Jun 26, 2010)

Bring them to the hospital.  The origin of the fever needs to be addressed.  

We used to give tylenol, not any more and we are not allowed external cooling.

And why is this titled hyperperfusion?  Like in Cerebral hyperperfusion syndrome?


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## usafmedic45 (Jun 26, 2010)

> we are not allowed external cooling



Not even in heat stroke and other circumstances where you need to bring the temperature down ASAP?


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## CAOX3 (Jun 26, 2010)

usafmedic45 said:


> Not even in heat stroke and other circumstances where you need to bring the temperature down ASAP?



Sorry, I meant in fever of uknown origin. 

In heat emergencies and such we can.


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## usafmedic45 (Jun 26, 2010)

CAOX3 said:


> Sorry, I meant in fever of uknown origin.
> 
> In heat emergencies and such we can.


Ah...ok.  That makes more sense.


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## onecrazykid108 (Jun 26, 2010)

When someone is in hypoperfusion (shock) their skin gets cool thats why you keep them warm with blankets.  I named it hyperperfusion because if somoene is getting too much perfusion they get warm and turn red ect.

and i'm not seeking medical advice just curious.


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## usafmedic45 (Jun 27, 2010)

> I named it hyperperfusion because if somoene is getting too much perfusion they get warm and turn red ect



That ("too much perfusion") is not an accurate description of what is going on in fever though.  It's a poor choice for the title of this thread.  Perhaps going back and brushing up on your physiology and pathophysiology is in order?


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## Smash (Jun 27, 2010)

onecrazykid108 said:


> When someone is in hypoperfusion (shock) their skin gets cool thats why you keep them warm with blankets.  I named it hyperperfusion because if somoene is getting too much perfusion they get warm and turn red ect.
> 
> and i'm not seeking medical advice just curious.



Someone can be in shock and have warm, flushed skin, good systolic blood pressure and bounding pulses.


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## MrBrown (Jun 27, 2010)

Smash said:


> Someone can be in shock and have warm, flushed skin, good systolic blood pressure and bounding pulses.



It is how most of my patients feel when I turn up


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## LondonMedic (Jun 27, 2010)

Smash said:


> Someone can be in shock and have warm, flushed skin, *good systolic blood pressure *and bounding pulses.


Remind me please? :blush:


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## Smash (Jun 27, 2010)

LondonMedic said:


> Remind me please? :blush:



Sorry, should have said adequate rather than good. Hyperdynamic shock states like warm septic shock where inadequate perfusion occurs at a tissue level despite elevated cardiac index; due to massively increased metabolic demand it is essentially a supply/demand mismatch. Systolic bp often appears 'normal' but a fall in diastolic (widened pulse pressure) indicates loss of vascular tone. This is normally compensated for by a rise in heart rate, but this is limited in some patients with poor sympathetic tone like the elderly. 

But you knew that!


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## MrBrown (Jun 27, 2010)

Smash said:


> Sorry, should have said adequate rather than good. Hyperdynamic shock states like warm septic shock where inadequate perfusion occurs at a tissue level despite elevated cardiac index; due to massively increased metabolic demand it is essentially a supply/demand mismatch. Systolic bp often appears 'normal' but a fall in diastolic (widened pulse pressure) indicates loss of vascular tone. This is normally compensated for by a rise in heart rate, but this is limited in some patients with poor sympathetic tone like the elderly.
> 
> But you knew that!



I can honestly said I had never heard of "hyperdynamic shock" so at the mo I am doing some lookey-loo'ing online.

This is very interesting, sounds like this fellow needs fluids, ceftriaxone, inotropes, IV acetamyophen and some sort of pro-coagulation support; maybe a unit or two of FFP.

Brown is over his head here ... LM, be a dear, ring up Red Base for me, tell them its a go


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## LondonMedic (Jun 27, 2010)

Smash said:


> Sorry, should have said adequate rather than good. Hyperdynamic shock states like warm septic shock where inadequate perfusion occurs at a tissue level despite elevated cardiac index; due to massively increased metabolic demand it is essentially a supply/demand mismatch. Systolic bp often appears 'normal' but a fall in diastolic (widened pulse pressure) indicates loss of vascular tone. This is normally compensated for by a rise in heart rate, but this is limited in some patients with poor sympathetic tone like the elderly.
> 
> But you knew that!


That's sepsis, as per Surviving Sepsis, it's not actually shock until there's refractory hypotension.


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## Smash (Jun 27, 2010)

LondonMedic said:


> That's sepsis, as per Surviving Sepsis, it's not actually shock until there's refractory hypotension.



So a state of global inadequate tissue perfusion is not shock unless hypotension is present?


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## LondonMedic (Jun 27, 2010)

Smash said:


> So a state of global inadequate tissue perfusion is not shock unless hypotension is present?


Apparently so.

http://www.ccmtutorials.com/infection/sepsis/page3.htm
http://www.survivingsepsis.org/

The 'warm' and 'cold' definitions are out.


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## Smash (Jun 27, 2010)

Well I guess that show how out of date I am! 

So how do we refer to someone in whom there is high cardiac output but inadequate organ perfusion?


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## LondonMedic (Jun 27, 2010)

Smash said:


> Well I guess that show how out of date I am!
> 
> So how do we refer to someone in whom there is high cardiac output but inadequate organ perfusion?


Well, _as per the guidance_, they have Sepsis (or SIRS).

Anyway, how would you measure and diagnose organ underperfusion? Lactate? StO2? UOP? I would argue, strongly, that anyone who is underperfused enough to have diagnosable end organ dysfunction is going to be hypotensive, certainly by MAP. And if they're not, they soon will be.


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## MrBrown (Jun 27, 2010)

LondonMedic said:


> Well, _as per the guidance_, they have Sepsis (or SIRS).
> 
> Anyway, how would you measure and diagnose organ underperfusion? Lactate? StO2? UOP? I would argue, strongly, that anyone who is underperfused enough to have diagnosable end organ dysfunction is going to be hypotensive, certainly by MAP. And if they're not, they soon will be.



I agree but bloody hell I don't know, what am I, a doctor?


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## lightsandsirens5 (Jun 27, 2010)

MrBrown said:


> It is how most of my patients feel when I turn up


 
Brown, that orange jumpsuit would send even a perfectly healthy person into shock.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

So someone with good cardiac output but low organ perfusion has sepsis? I's confoosed.:unsure: It would seem that there would be more causes than that. Isn't saying that a person with said problem has sepsis like saying the because an animal is covered in black fur that it is a dog? 

I'm just a lowly ambulance riding Int. here, but this seems strange.


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## Smash (Jun 27, 2010)

LondonMedic said:


> Well, _as per the guidance_, they have Sepsis (or SIRS).



Oh I see, it's a change in terminology.  Duly noted.



> Anyway, how would you measure and diagnose organ underperfusion? Lactate? StO2? UOP? I would argue, strongly, that anyone who is underperfused enough to have diagnosable end organ dysfunction is going to be hypotensive, certainly by MAP. And if they're not, they soon will be.



I never argued that _I_ would be diagnosing organ hypo-perfusion, but you underline my point to the OP well.  Warm skin or a 'normal' systolic BP alone does not a well perfused patient make.


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## Smash (Jun 27, 2010)

lightsandsirens5 said:


> Brown, that orange jumpsuit would send even a perfectly healthy person into shock.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> 
> So someone with good cardiac output but low organ perfusion has sepsis? I's confoosed.:unsure: It would seem that there would be more causes than that. Isn't saying that a person with said problem has sepsis like saying the because an animal is covered in black fur that it is a dog?
> ...



There are indeed other conditions that would cause such a problem: I used sepsis as one example, thereby ensuring I exhibited my ignorance to the fullest!

Sepsis is a clinical syndrome (SIRS in the setting of a known or strongly suspected pathogen, but I may not be up to date on that neither) not a specific disease.


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## Smash (Jun 27, 2010)

MrBrown said:


> I agree but bloody hell I don't know, what am I, a doctor?



*Brown, MBBS* <-- Um... yes?  I thought MBBS was what you antipodeans got after your name when you hung up your shingle?


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## usafmedic45 (Jun 27, 2010)

> Lactate? StO2? UOP?



Yes, maybe and yes (assuming you mean urinary output).  The big three cheap and easy ways to do it are level of consciousness (cerebral perfusion), extremity perfusion and urinary output (renal perfusion).


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## LondonMedic (Jun 28, 2010)

usafmedic45 said:


> Yes, maybe and yes (assuming you mean urinary output).  The big three cheap and easy ways to do it are level of consciousness (cerebral perfusion), extremity perfusion and urinary output (renal perfusion).


Yep, but they're all hard to measure with any sort of confidence, especially out of hospital.


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## usafmedic45 (Jun 28, 2010)

Eh....only if you're concerned with interrater reliability and that's not really a major concern unless you're doing research.


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## irish_handgrenade (Jun 28, 2010)

MrBrown said:


> It is how most of my patients feel when I turn up



prolly the accent... just a thought.:unsure:


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## MrBrown (Jun 28, 2010)

irish_handgrenade said:


> prolly the accent... just a thought.:unsure:



Yeah or our meds with funny names like adrenaline and GTN ... or that blokes in orange jumpsuits swanning out of a red and yellow helicopter are just a bit too much?

Mind you the only person who told me I talk funny was a lady in Dallas!


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## Smash (Jun 28, 2010)

MrBrown said:


> Yeah or our meds with funny names like adrenaline and GTN ... or that blokes in orange jumpsuits swanning out of a red and yellow helicopter are just a bit too much?
> 
> Mind you the only person who told me I talk funny was a lady in Dallas!



That wasn't a lady.


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## MrBrown (Jun 28, 2010)

Smash said:


> That wasn't a lady.



Well you do have to wonder, a full secondary survey at that time was not appropriate so I'm just not sure.

I mean I tried but you know maybe it got lost in translation I mean I did not think it was too hard to understand; all I said was "Oi mate look here, are you blind as I am or are you just a bit stupid yeah, what the bloody hell does that say, see right there in huge big green letters it says 'DOCTOR' right, do you see that?"


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