Heatstroke

 Caused by overexposure to sun and extremely high

temperatures

 Occurs when the brain fails to control its own

"thermostat".

 It’s a life-threatening condition which the victim may

become unconscious within minutes.

Heatstroke
 Definition

- core temperature > 41° C OR

- core temp > 40.5 ° C with anhidrosis (absence
or severe deficiency of sweating)

- altered mental status or both

Heatstroke
 Exertional: typically seen in healthy young adults who
overexert themselves in high ambient temperatures or in a
hot environment to which they are not acclimatized.

 Patients sweat normally.

- non-exertional (classic): usually affects elderly and
debilitated patients with chronic underlying disease. Result
of impaired thermoregulation combined with high
ambient temperatures. Often due to impaired sweating
Heatstroke
 Clinical findings

o 3 cardinal signs are:

 CNS dysfunction

 hyperpyrexia (core temperature >40° C)

 hot dry skin. Pink or ashen depending on circulatory

state. However may be clammy and sweat
Heatstroke
 CNS findings:

 Direct thermal toxicity causes cell death, cerebral oedema

and local haemorrhage
- irritability or irrational behaviour may precede the
development of either form of heatstroke
- confusion, aggressive behaviour, delirium, convulsions
and pupillary abnormalities may progress rapidly to coma
Heatstroke
 CVS findings

- tachycardia
- hypotension or normotension with wide pulse
pressure
- myocardial pump failure.
Heatstroke
 RS findings

- extreme tachypnoea with RR up to 60/min

- pulmonary oedema
- direct thermal injury to pulmonary vascular
endothelium may lead to Acute respiratory distress
syndrome (ARDS)
Heatstroke
 Symptoms
 Headache, nausea, dizziness
 Red, dry, very hot skin (sweating has ceased)
 Pulse-strong & rapid
 Small pupils
 Very high fever
 May become extremely disoriented
 Unconsciousness and possible convulsions
Heatstroke
 If exposure to heat continues, the body temperature rises and heatstroke may
develop
 Cessation of sweating

 Body temperature of 40.5 degree C or higher

 Rapid and shallow breathing

 Rapid heartbeat

 Elevated or lowered blood pressure

 Confusion and disorientation

 Seizure

 Fainting, which may be the first sign in older adults

Heatstroke
 Left untreated, heat stroke may progress to coma.

 Death may result due to kidney failure, acute heart

failure, or direct heat induced damage to the brain.

First Aid- Heatstroke
 HEATSROKE IS LIFE THREATENING!
 Remove victim to cooler location, out of the sun
 Loosen or remove clothing and immerse victim in very cool
water if possible
 If immersion isn't possible, cool victim with water, or wrap
in wet sheets and fan for quick evaporation
 Use cold compresses-especially to the head & neck area,
also to armpits and groin
First Aid- Heatstroke
 Seek medical attention immediately--continue first aid to
lower temp. until medical help takes over

 Do NOT give any medication to lower fever--it will not be

effective and may cause further harm

 Do NOT use an alcohol rub

 It is not advisable to give the victim anything by mouth

(even water) until the condition has been stabilized.
Heatstroke- Therapy
 Treatment of heat stroke is usually carried out in a
critical care unit.

 The body temperature is lowered by sponging the

body with tepid water or loosely wrapping the person
in a wet sheet and placing him or her near a fan.

 Intravenous fluids are given.

14
Preventing heat-related illness

 Dress for the heat — Wear lightweight, light-coloured

clothing. Light colours will reflect away some of the
sun’s energy. It is also a good idea to wear hats or to
use an umbrella.
 Drink water — Carry water or juice with you and drink
continuously even if you do not feel thirsty. Avoid
alcohol and caffeine, which dehydrate the body.
 Avoid foods that are high in protein, which increase
metabolic heat.
 Stay indoors when possible.
 Take regular breaks when engaged in physical activity
on warm days.
 Take time out to find a cool place.
Cold-related Injuries

– Hypothermia

– Frostbite
Factors Increasing Risk of Cold
Injuries • Nicotine (Smoking)

• Previous cold-related injury • Age

• Improper clothing and

• Predisposing health equipment
conditions • Under-activity

• Over-activity
• Fatigue, poor physical
• Cold conditions:
condition
– Temperature
• Poor nutrition – Wind
– Wetness
• Dehydration
• Length of exposure

• Medication
Preventing Cold-related Injuries
• Wear appropriate clothing.

• Avoid wetness or excessive sweating.

• Stay dry. Change into dry clothes and shoes if they

become wet.

• Keep active. Avoid sitting or standing still for prolonged periods.

• Take frequent breaks in warm, shielded areas.

• Work in pairs to keep an eye on each other.

• Consume warm, high calorie food often.

• Drink plenty of warm non-caffeinated, non-alcoholic

liquids.

• Don’t smoke.
Hypotermia- Medical Emergency
 Hypothermia ("low heat”) is a potentially serious and fatal
health condition resulting from the body’s failure to
maintain its normal core temperature of 37°C.

 When exposed to cold conditions, your body begins to lose

heat faster than it can be produced.

 Prolonged exposure to cold eventually uses up your body’s

stored energy and your core body temperature drops to
35°C or below. The result is hypothermia.
Hypotermia
It can occur at warmer temperatures as high as 18.3°C, or more, if a
person becomes chilled from prolonged exposures to wetness (rain, snow,
submersion in cold water, or sweat) and accompanying winds.

Generally, in cold dry environments, hypothermia occurs over a period

of hours.

In cold water, core temperature can drop to dangerous levels in a matter
of minutes.

Most cases of hypothermia occur in air temperatures from -1.1°C to 4.4

°C.
Immersion Hypothermia
 Water transfers heat away from the human body 25
times faster than air, so even moderate water
temperatures can be dangerous in a relatively short
time.
Stages of Hypothermia
Approximate Core Body Temperature
Mild hypothermia 36.6°C– 35°C
Moderate hypothermia 35°C – 32.2°C
Severe hypothermia <32.2°C
Mild Hypothermia
• Shivering, mild to severe

• Sensation of cold, then pain in extremities

• Pale, waxy, cold skin

• Numbness of hands

• Able to walk and talk

• Irritability (mental)
Moderate Hypothermia
• Sluggish; labored movements

• Loss of fine motor coordination in hands

• Confused, may appear alert

• Irrational behavior – “paradoxical undressing” (person starts to undress,

unaware s/he is cold)

• Apathetic/flattened affect –
"I don't care” attitude"

• Difficulty speaking

• Sluggish thinking

• Signs of depression
Severe Hypothermia
• Shivering stops

• Exposed skin blue or puffy

• Muscle coordination very poor, muscle rigidity

• Stupor

• Can’t walk

• Decreased pulse and respiration rate

• Irregular heart rhythm

• appearance of awareness

• Semi-conscious

• Amnesia, memory lapses

Possible Death from Hypothermia
Core body temperature below 28.3°C – 25.5°C

• Erratic, shallow breathing

• May not be able to feel pulse
• Pupils dilated and fixed
• Cold, blue skin
• Unresponsive to any stimuli
• Pulmonary edema, cardiac and respiratory failure
• Death possible below 25.5°C
• Brain activity seriously slowed
• Unconscious, appears comatose or dead

“No one is dead until warm and dead”

Treatment of Hypothermia
Mild Hypothermia

• Remove wet clothes from victim and replace with dry clothes and/or
wrap in warm blankets; cover the head.

• Move to a warm environment.

• Do not exercise to warm up.

• Do not re-warm person in a warm bath or by massaging or rubbing.

• Drink a warm (not hot) sugary drink.

Avoid drinks with caffeine (coffee, tea,
or hot chocolate) or alcohol.

• Transport victim to an emergency medical facility for evaluation.

• Handle the victim gently and minimize his or her exertion.

Treatment of Hypothermia
Moderate Hypothermia

• Call for emergency help.

• Follow the procedures as mild hypothermia

In addition:
• Cover all extremities completely, place very warm objects,
such as hot packs or water bottles on the victim's head,
neck, chest and groin. Arms and legs should be warmed
last.

• Handle the victim gently. Rough handling can cause

heartbeat irregularities and death.
Treatment of Hypothermia
Severe Hypothermia
• Call for emergency help.
• Give CPR if necessary.
• Follow the procedures for treating mild hypothermia.
• Do not apply external heat (hot water bath, heat lamp,
electric blanket, electric heater, etc.) to re-warm.
• Transport the victim to an emergency medical facility as
soon as possible.
• Handle the victim very gently. Transport to hospital for
treatment as soon as possible
Frostbite
 In cold conditions, your body reduces heat loss and increases heat
production in order to maintain an internal (core) body temperature
of 37°C.

 Over time, your body will decrease blood flow to your extremities and
outer skin and shift it to the body core to keep the internal organs
warm.

 However, this allows exposed skin and the extremities to cool rapidly
and increases the risk of cold-related injuries, such as frostbite.
Frostbite
Body Core
 Heart
 Brain
Normal  Lungs
core body • Liver
temperature: • Kidneys
37°C

Extremities
• Legs, feet
• Arms, hands
Frostbite
 Frostbite occurs when the deep layers of the skin and other body
tissues freeze (tissue temperature <-2.2°C- -1.1°C). Ice crystals form,
destroying tissues and causing permanent damage. In severe cases,
amputation of the frostbitten area may be required.

• toes/feet
• fingers/ hand
• ears
• nose
• cheeks
• chin
Frostbite
 Frostbite can be classified into two main divisions:

Superficial (mild)

Deep (severe)
Superficial Frostbite
• Includes all layers of the skin

• Initially redness in light skin, grayish in dark skin

• Burning, tingling, itching, or cold sensations in the affected

areas, followed by numbness

• Skin turns white, waxy; some resistance when pressed (feels

firm or “wooden” but underlying tissue is soft); cold to the
touch

• May have blistering

Deep Frostbite
• Involves skin, muscle, tendons, nerves, blood vessels; may
include bone

• White or yellowish waxy skin that turns purplish blue as it thaws

• Underlying tissue hard, no resistance when pressed, may appear

blackened and dead

• Blood-filled blisters and swelling may develop

• May develop blood clots

Treatment of Frostbite
• Move the person to a warm dry area. Don’t leave the person alone.

• Remove any wet or tight clothing that may cut off blood flow to the affected
area.

• Treat for hypothermia if victim is also experiencing hypothermia. Do not rub

the affected area, because rubbing causes damage to the skin and tissue.

• Gently place the affected area in a warm water bath and monitor the water
temperature to slowly warm the tissue.

• Don’t pour warm water directly on the affected area because it will warm the
tissue too fast causing tissue damage. Warming takes about 25-40 minutes.
Treatment of Frostbite
 After the affected area has been warmed, it may
become puffy and blister. The affected area may have a
burning feeling or numbness. When normal feeling,
movement, and skin color have returned, the affected
area should be dried and wrapped to keep it warm.
 Seek medical attention as soon as possible.
 If there is a chance the affected area may get cold
again, do not warm the skin. If the skin is warmed
and then becomes cold again, it will cause severe
tissue damage.
Bites
 Animal Bites

- Dogs are responsible for about 80% of all animal

bites
Rabies
*Virus found in warm blooded
animals
*Spreads though saliva (biting or
licking)
Rabies: Indications
Attacks unprovoked

*Acts strangely (was friendly, now aggressive, was

wild, now acts docile)

*High risk species

Animal Bites: What to Do
*Family pet: confine and observe for 10
days
*Stray dog or cat: will be killed and head
submitted for testing
*Dead animal: entire body sent for
testing
Animal Bites: What to Do
*High risk species bite:
*Start treatment for rabies immediately
*Clean wound with soap and water
*Rinse with water under pressure
*Control bleeding
Human Bites: What to do
*Lots of bacteria in human
mouth
*Chance of infection is
great
*Clean wound with soap &
water
*Rinse with water under
pressure for 5 –10 minutes
*Control bleeding
*Cover with dressing
Snake Bites
Snake Bites: Pit Vipers
Severe burning pain at bite site

2 small puncture wounds

Swelling (within 5 minutes)

Discoloration and blood- filled blisters

sweating, weakness
Snake Bites: Pit Vipers
Get away from snake!
*Keep victim quiet
*Avoid walking, moving if possible
*Gently wash with soap and water

Keep track of venom spread

Snake Bites: Pit Vipers
DO NOT:

*Apply ice (frostbite)

*“Cut & Suck” (not effective)

Snake Bites: Nonpoisonous
*Gently wash with soap and water

*Care for bite as you would a minor wound

Insect Stings
*Anaphylactic shock:

*Severe life threatening

allergic reaction
Insect Stings
*Bees leave their stinger behind.

*Remove by scraping with hard object such as credit

card.
Insect Stings
*Wash sting with soap and
water
*Apply ice pack
*A paste of baking soda
and water can ease pain
*Analgesic for pain
*Observe for severe allergic
reaction (30 minutes)
Mosquito Bites
*Carry many diseases:
 Malaria
 Yellow fever
 Encephalitis
Mosquito Bites: What to Do
Clean site with soap &
water
Ice pack
Use Calamine lotion
Antihistamine prn
Choking Emergencies
 Choking is a total or partial obstruction of airway
 Common cause of respiratory arrest
 Immediate care is needed
Choking Risks
 Over 4,600 people die from choking each year
 Adults over age 65 are twice as likely to die as younger
people from choking
 Trying to swallow large pieces of food that haven’t
been chewed sufficiently
 Eating too quickly
 Eating while engaged in other activities
 Alcohol or drugs often involved
 Dentures increase risk
 History of stroke
Mild Choking
 Victim is coughing forcefully

 Victim is getting some air

 May be making wheezing or high-pitched sounds with

breath

 Do not interrupt coughing or attempts to expel object

Severe Choking
 Victim getting little air or none
 Victim may look frantic and be clutching at throat
(universal sign of choking)
 Victim may have pale or bluish coloring around mouth
and nail beds
 Victim may be coughing weakly and silently or not at
all
 Victim cannot speak
 The universal sign for choking is hands clutched to
the throat.
 If the person doesn't give the signal, look for these
indications:
• Inability to talk
• Difficulty breathing or noisy breathing
• Squeaky sounds when trying to breathe
• Cough, which may either be weak or forceful
• Skin, lips and nails turning blue or dusky
• Skin that is flushed, then turns pale or bluish in color
• Loss of consciousness
Choking Care
(Responsive Adult or Child)
 Responsive choking victim who is coughing:
 Encourage coughing to clear object

 Responsive choking victim who cannot speak or cough

forcefully:
 Give abdominal thrusts

• If choking victim becomes unresponsive, immediately call help

• Begin CPR with chest compressions
 If the person is able to cough forcefully, the person

should keep coughing.

 If the person is choking and can't talk, cry or laugh

forcefully, the American Red Cross recommends a

"five-and-five" approach to delivering first aid:

• Give 5 back blows. Stand to the side and just
behind a choking adult. Place one arm across the
person's chest for support. Bend the person over at
the waist so that the upper body is parallel with the
ground. Deliver five separate back blows between
the person's shoulder blades with the heel of your
hand.
• Give 5 abdominal thrusts. Perform five abdominal
thrusts (also known as the Heimlich maneuver).
• Alternate between 5 blows and 5 thrusts until the
blockage is dislodged.
 The American Heart Association doesn't teach the back blow
technique, only the abdominal thrust procedures. It's OK not to use
back blows if you haven't learned the technique. Both approaches
are acceptable.
 To perform abdominal thrusts (Heimlich maneuver) on someone
else:
• Stand behind the person. Place one foot slightly in front of the
other for balance. Wrap your arms around the waist. Tip the person
forward slightly. If a child is choking, kneel down behind the child.
• Make a fist with one hand. Position it slightly above the person's
navel.
• Grasp the fist with the other hand. Press hard into the abdomen
with a quick, upward thrust — as if trying to lift the person up.
• Perform between six and 10 abdominal thrusts until the blockage
is dislodged.
Abdominal Thrusts (chest thrust)
• 5 Back blows
• 5 Chest thrusts

For a child, kneel down behind.

Responsive to Unresponsive
 If complete airway obstruction not cleared, victim will
become unresponsive in minutes
 Quickly and carefully lower victim to floor on back
 Begin CPR with 30 chest compressions
 Check for object in mouth each time you open it to give
rescue breaths
Unresponsive Victim
 Check for normal
breathing
 If victim not breathing
normally, start CPR with 30
chest compressions
 If first breath doesn’t go in
after opening airway – try
again to open airway and
give breath
 If second breath doesn’t go
in – give care for choking
Choking Infants
 If infant is crying or coughing – watch for object to
come out
 If infant cannot cry or cough
 Have someone call help
 Give alternating back blows (slaps) and chest thrusts
 If infant becomes unresponsive – give CPR starting
with chest compressions
 Check for object in mouth each time before giving a
rescue breath
SHOCK
• Inadequate oxygen delivery to meet metabolic demands

• Results in global tissue hypoperfusion and metabolic

acidosis

• Shock can occur with a normal blood pressure and

hypotension can occur without shock

Shock
• Inadequate systemic oxygen delivery activates
autonomic responses to maintain systemic
oxygen delivery
• Sympathetic nervous system
• NE, epinephrine, dopamine, and cortisol release
• Causes vasoconstriction, increase in HR, and increase of cardiac
contractility (cardiac output)

• Renin-angiotensin axis
• Water and sodium conservation and vasoconstriction
• Increase in blood volume and blood pressure
 Shock
• Cellular responses to decreased systemic oxygen delivery
• ATP depletion → ion pump dysfunction
• Cellular edema
• Hydrolysis of cellular membranes and cellular death
• Goal is to maintain cerebral and cardiac perfusion
• Vasoconstriction of splanchnic, musculoskeletal, and renal
blood flow
• Leads to systemic metabolic lactic acidosis that overcomes the
body’s compensatory mechanisms
Multiorgan Dysfunction
Syndrome (MODS)
• Progression of physiologic effects as shock ensues
• Cardiac depression

• Respiratory distress

• Renal failure

• DIC

• Result is end organ failure

 Approach to the Patient in Shock
• ABCs
• Cardiorespiratory monitor
• Pulse oximetry
• Supplemental oxygen
• IV access
• ABG, labs
• Foley catheter
• Vital signs including rectal temperature
 Approach to the Patient in Shock
• Physical examination

• Vital Signs

• CNS – mental status

• Skin – color, temp, rashes

• CV – JVD, heart sounds

• Resp – lung sounds, RR, oxygen sat, ABG

• GI – abd pain, rigidity, guarding, rebound

• Renal – urine output

Shock

• If you palpate a pulse,

60

you know SBP is at

70

least this number 80

90
 Goals of Treatment
• ABCDE
• Airway
• control work of Breathing
• optimize Circulation
• assure adequate oxygen Delivery
• achieve End points of resuscitation
Therapy- Circulation
• Isotonic crystalloids
• Titrated to:
• CVP 8-12 mm Hg
• Urine output 0.5 ml/kg/hr (30 ml/hr)
• Improving heart rate
• May require 4-6 L of fluids
• No outcome benefit from colloids
 Maintaining Oxygen Delivery
• Decrease oxygen demands
• Provide analgesia and anxiolytics to relax muscles
and avoid shivering
• Maintain arterial oxygen saturation/content
• Give supplemental oxygen
• Maintain Hemoglobin > 10 g/dL
• Serial lactate levels or central venous oxygen
saturations to assess tissue oxygen extraction
Types of Shock
• Hypovolemic

• Septic

• Cardiogenic

• Anaphylactic

• Neurogenic

• Obstructive
Hypovolemic Shock
• Non-hemorrhagic
• Vomiting
• Diarrhea
• Bowel obstruction, pancreatitis
• Burns
• Neglect, environmental (dehydration)
• Hemorrhagic
• GI bleed
• Trauma
• Massive hemoptysis
• AAA rupture
• Ectopic pregnancy, post-partum bleeding
Hypovolemic Shock
• ABCs
• Establish 2 large bore IVs or a central line
• Crystalloids
• Normal Saline or Lactate Ringers
• Up to 3 liters
• PRBCs
• O negative or cross matched
• Control any bleeding
• Arrange definitive treatment
Sepsis
• Two or more of SIRS criteria
• Temp > 38 or < 36 C
• HR > 90
• RR > 20
• WBC > 12,000 or < 4,000

• Plus the presumed existence of infection

• Blood pressure can be normal!
Septic Shock
• Sepsis (remember definition?)
• Plus refractory hypotension
• After bolus of 20-40 mL/Kg patient still has one of the
following:
• SBP < 90 mm Hg
• MAP < 65 mm Hg
• Decrease of 40 mm Hg from baseline
Sepsis
Septic Shock
• Clinical signs:
• Hyperthermia or hypothermia
• Tachycardia
• Wide pulse pressure
• Low blood pressure (SBP<90)
• Mental status changes
• Beware of compensated shock!
• Blood pressure may be “normal”
Treatment of Septic Shock
• 2 large bore IVs

• NS IVF bolus- 1-2 L wide open (if no contraindications)

• Supplemental oxygen

• Empiric antibiotics, based on suspected source, as

soon as possible
Cardiogenic Shock
• Defined as: • Signs:
• SBP < 90 mmHg • Cool, mottled skin
• CI < 2.2 L/m/m2 • Tachypnea
• PCWP > 18 mmHg • Hypotension
• Altered mental status
• Narrowed pulse pressure
• Rales, murmur
Treatment of Cardiogenic Shock
• AMI
• Aspirin, beta blocker, morphine, heparin

• If no pulmonary edema, IV fluid challenge

• If pulmonary edema

• Dopamine – will ↑ HR and thus cardiac work

• Dobutamine – May drop blood pressure

• Combination therapy may be more effective

• PCI or thrombolytics
Anaphylactic Shock
• Anaphylaxis – a severe systemic
hypersensitivity reaction characterized by
multisystem involvement
• IgE mediated
• Anaphylactoid reaction – clinically
indistinguishable from anaphylaxis, do not
require a sensitizing exposure
• Not IgE mediated
Anaphylactic Shock
• First- Pruritus, flushing, urticaria appear

•Next- Throat fullness, anxiety, chest tightness,

shortness of breath and lightheadedness

•Finally- Altered mental status, respiratory distress

and circulatory collapse
Anaphylactic Shock
• Risk factors for fatal anaphylaxis
• Poorly controlled asthma
• Previous anaphylaxis
• Reoccurrence rates
• 40-60% for insect stings
• 20-40% for radiocontrast agents
• 10-20% for penicillin
• Most common causes
• Antibiotics
• Insects
• Food
Anaphylactic Shock
• Mild, localized urticaria can progress to full anaphylaxis
• Symptoms usually begin within 60 minutes of exposure
• Faster the onset of symptoms = more severe reaction
• Biphasic phenomenon occurs in up to 20% of patients
• Symptoms return 3-4 hours after initial reaction has cleared
• A “lump in my throat” and “hoarseness” heralds life-
threatening laryngeal edema
Anaphylactic Shock- Diagnosis
• Clinical diagnosis
• Defined by airway compromise, hypotension, or
involvement of cutaneous, respiratory, or GI
systems
• Look for exposure to drug, food, or insect
• Labs have no role
Anaphylactic Shock- Treatment
• ABC’s
• Angioedema and respiratory compromise require
immediate intubation
• IV, cardiac monitor, pulse oximetry
• IVFs, oxygen
• Epinephrine
• Second line
• Corticosteriods
• H1 and H2 blockers
Neurogenic Shock
Neurogenic Shock
• Loss of sympathetic tone results in warm and dry skin

• Shock usually lasts from 1 to 3 weeks

• Any injury above T1 can disrupt the entire sympathetic

system
• Higher injuries = worse paralysis
Neurogenic Shock- Treatment
• A,B,Cs
• Remember c-spine precautions
• Fluid resuscitation
• Keep MAP at 85-90 mm Hg for first 7 days
• Thought to minimize secondary cord injury
• If crystalloid is insufficient use vasopressors
• Search for other causes of hypotension
• For bradycardia
• Atropine
• Pacemaker
Obstructive Shock
• Tension pneumothorax
• Air trapped in pleural space with 1 way valve,
air/pressure builds up

• Mediastinum shifted impeding venous return

• Chest pain, SOB, decreased breath sounds

• No tests needed!

• Rx: Needle decompression, chest tube

Obstructive Shock
• Cardiac tamponade
• Blood in pericardial sac prevents venous return to and
contraction of heart
• Related to trauma, pericarditis, MI
• Beck’s triad: hypotension, muffled heart sounds, JVD
• Diagnosis: large heart CXR, echo
• Rx: Pericardiocentesis
Obstructive Shock
• Pulmonary embolism
• Virscow triad: hypercoaguable, venous injury, venostasis

• Signs: Tachypnea, tachycardia, hypoxia

• Rx: Heparin, consider thrombolytics

Obstructive Shock
• Aortic stenosis
• Resistance to systolic ejection causes decreased cardiac
function
• Chest pain with syncope
• Systolic ejection murmur
• Diagnosed with echo
• Vasodilators (NTG) will drop pressure!
• Rx: Valve surgery