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Circulation Part 4
How is cardiac output measured in humans?

One common method is called the Fick Procedure.

Take a measure of oxygen absorption by the lungs by respiratory oxygen meter, which measures
the difference in oxygen of air inhaled then exhale. You can get this reading in amount of
oxygen in ml/min. Suppose the result of a patient test was 200 ml/min of oxygen absorbed.
Now you can run a catheter into the right atria and draw some blood and measure its oxygen
content. Suppose it measures 160 ml/L. Now take a blood sample from any artery. Assume
that reading is 200 ml/L. From these data, you can calculate cardiac output (CO).

From the above data, you know that the lung capillaries absorbed 40 milliliters of oxygen for
each liter of blood that passes through the lungs. You know that the lung capillaries
absorb 200 ml/min, therefore 200/40 = 5 liters/min of blood passes through the lungs,
which is cardiac output.

Oxygen absorbed per minute by the lungs (ml/min)

Cardiac Output =
Arterioven ous Oxygen difference (ml/liter of blood)
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Circulation Part 4
Valsalva Maneuver

When a person forcefully expires against a closed glottis, changes occur in intrathoracic pressure that dramatically affect
venous return, cardiac output, arterial pressure, and heart rate. This forced expiratory effort is called a Valsalva
maneuver.

Initially during a Valsalva, intrathoracic (intrapleural) pressure becomes very positive due to compression of the thoracic
organs by the contracting rib cage. This increased external pressure on the heart and thoracic blood vessels compresses
the vessels and cardiac chambers by decreasing the transmural pressure across their walls. Venous compression, and the
accompanying large increase in right atrial pressure, impedes venous return into the thorax. This reduced venous return,
and along with compression of the cardiac chambers, reduces cardiac filling and preload despite a large increase in
intrachamber pressures. Reduced filling and preload leads to a fall in cardiac output by the Frank-Starling mechanism.
At the same time, compression of the thoracic aorta transiently increases aortic pressure (phase I); however, aortic
pressure begins to fall (phase II) after a few seconds because cardiac output falls. Changes in heart rate are reciprocal to
the changes in aortic pressure due to the operation of the baroreceptor reflex. During phase I, heart rate decreases
because aortic pressure is elevated; during phase II, heart rate increases as the aortic pressure falls.

When the person starts to breathe normally again, aortic pressure briefly decreases as the external compression
on the aorta is removed, and heart rate briefly increases reflexively (phase III). This is followed by an increase in
aortic pressure (and reflex decrease in heart rate) as the cardiac output suddenly increases in response to a rapid
increase in cardiac filling (phase IV). Aortic pressure also rises above normal because of a baroreceptor, sympathetic-
mediated increase in systemic vascular resistance that occurred during the Valsava.

Similar changes occur whenever a person conducts a force expiration against either a closed glottis or high pulmonary
outflow resistance, or when the thoracic and abdominal muscles are strongly contracted. This can occur when a person
strains while having a bowel movement. Similar changes can also occur when a person lifts a heavy weight while
holding their breath.

Major concept: Heart rate is inverse to aortic pressure because of autonomic reflex.

From: http://www.cvphysiology.com/Hemodynamics/H014.htm
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Circulation Part 4
Dive Reflex

The mammalian diving reflex is a reflex in mammals which optimizes respiration to allow
staying underwater for extended periods of time. It is exhibited strongly in aquatic mammals
(seals, otters, dolphins, etc.), but exists in a weaker version in other mammals, including
humans. Diving birds, such as penguins, have a similar diving reflex. Every animal's diving
reflex is triggered specifically by cold water contacting the face – water that is warmer than
21 °C (70 °F) does not cause the reflex, and neither does submersion of body parts other than
the face. Also, the reflex is always exhibited more dramatically, and thus can grant longer
survival, in young individuals.

Upon initiation of the reflex, three changes happen to the body, in this order:

Bradycardia is the first response to submersion. Immediately upon facial contact with cold water,
the human heart rate slows down ten to twenty-five percent. Seals experience changes that
are even more dramatic, going from about 125 beats per minute to as low as 10 on an
extended dive. Slowing the heart rate lessens the need for bloodstream oxygen, leaving more
to be used by other organs.

Next, peripheral vasoconstriction sets in. When under high pressure induced by deep diving,
capillaries in the extremities start closing off, stopping blood circulation to those areas. Note
that vasoconstriction usually applies to arterioles, but in this case is completely an effect of
the capillaries. Toes and fingers close off first, then hands and feet, and ultimately arms and
legs stop allowing blood circulation, leaving more blood for use by the heart and brain.
Human musculature accounts for only 12% of the body's total oxygen storage, and the body's
muscles tend to suffer cramping during this phase. Aquatic mammals have as much as 25 to
30% of their oxygen storage in muscle, and thus they can keep working long after capillary
blood supply is stopped.

Finally is the blood shift that occurs only during very deep dives. When this happens, organ and
circulatory walls allow plasma/water to pass freely throughout the thoracic cavity, so its
pressure stays constant and the organs aren't crushed. In this stage, the lungs' alveoli fill up
with blood plasma, which is reabsorbed when the animal leaves the pressurized environment.
Thus, both a conscious and an unconscious person can survive longer without oxygen under
cold water than in a comparable situation on dry land. Children tend to survive longer than
adults when deprived of oxygen underwater. The exact mechanism for this effect has been
debated and may be a result of brain cooling similar to the protective effects seen in patients
treated with deep hypothermia.
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Circulation Part 4
When the face is submerged, receptors that are sensitive to cold within the nasal cavity and other
areas of the face supplied by cranial nerve V (trigeminal) relay the information to the brain
and then innervate cranial nerve X, which is part of the autonomic nervous system. This
causes bradycardia and peripheral vasoconstriction. Blood is removed from the limbs and all
organs but the heart and the brain, creating a heart-brain circuit and allowing the mammal to
conserve oxygen.

In humans, the mammalian diving reflex is not induced when limbs are introduced to cold water.
Mild bradycardia is caused by subjects holding their breath without submerging the face
within water. When breathing with face submerged this causes a diving reflex which
increases proportionally to decreasing water temperature. Activating the diving reflex with
cold water can be used to treat supraventricular tachycardia (SVT). However the greatest
bradycardia effect is induced when the subject is holding breath with face submerged.

In general, Supraventricular tachycardia (SVT) is not life threatening, but episodes can be
treated or prevented.

Because of the mild dive reflex in humans, cold water on the face or back of neck is sometime
applied with patients having SVT as a way to slow the heart rate down.

Another approach is to using the Valsalva maneuver. It works by increasing intra-thoracic

pressure and affecting baro-receptors (pressure sensors) within the arch of the aorta. It is
carried out by asking the patient to hold their breath and try to exhale forcibly as if straining
during a bowel movement, or by getting them to hold their nose and blow out against it.

There are many other vagal maneuvers including a Carotid sinus massage, carried out by firmly
pressing the bulb at the top of one of the carotid arteries in the neck, is effective but is often
not recommended due to risks of stroke in those with plaque in the carotid arteries.

Most of the above came from Wikipedia.

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Circulation Part 4
For the final exam, you will be tested on Heart Valves and Heart Sounds: Valvular and
Congenital Heart Defects (Chapter 23, Guyton). You will also be tested on Circulatory
Shock and Its Treatment. (Chapter 24, Guyton).