 Yeah, thank you. Thank you for the question. I'm so glad that at least I'm able to connect to you. Otherwise, I was thinking I will not be able to take up any questions today. Okay, Shruti, are you there? Right now? Okay, any other question? So, if any other questions are there, then we can go little in sequence so that the concept is also clear and we don't go haphazard. I note down one question. What is irreversible shock? Great. I will discuss it. Any other question is there? We'll wait for two minutes and I will discuss the question. Okay, anyways, I hope that you have seen my video in Circulatory Shock. I prepared, I thought that if you people watch it, then it will be much better. So, coming to irreversible shock, irreversible shock is the last page of shock. See, any kind of shock, the cause may be any. Okay, hypoxia. Hypoxia we will discuss. Though it is shock is one cause of hypoxia. So, what I was talking is that any, whatever is the cause of shock, ultimately, if we do not intervene, it will ultimately progress to irreversible shock. And irreversible shock is that which despite the intervention of the clinician cannot be affected. Okay, so even though it will show some false readings of cardiac output and blood pressure and for some time we may feel that cardiac output and blood pressure have risen, but ultimately it will go on and deteriorate because actually in irreversible shock, what happens? The key factor which is the energy stores have been depleted and once the energy stores of the cells have been depleted. So, basically it is due to tissue hypoxia only whenever hypoxia occurs, oxygen is not available and oxygen cannot be used to generate ATP. Okay, so cells use the stores which are there, which are due to the ATP which is present, creatine phosphate which is there. So, it starts using these phosphate stores very fast and even when we are providing intervention, it takes some time to recreate these stores. So, the rate of utilization of the stores is so much and they have been depleted that with intervention rate of creation of the stores cannot match with the rate of utilization. So, ultimately irreversible shock cannot be fixed and the patient then cannot be saved actually. So, that is irreversible shock, very rare case is okay to maybe, but it cannot be corrected. So, that is irreversible shock and actually there are so many things happening in body that ultimately this hypoxia becomes worse. One very important concept is that there is activation of the coagulation system because the endothelium is damaged because of the hypoxia, the endothelium gets so damaged. Now, this little bit might not be given in all physiology books or maybe give you if any book is given in point wise manner then they will just enumerate books. But try to understand that whenever there is shock then the blood supply of all the organs, yeah blood supply is correct, blood supply of all the organs gets decreased and it causes hypoxia and why it leads to necrosis of tissues because see very important concept is all cells have sodium potassium 80 paste and sodium potassium 80 paste is the one which is important for maintaining the ionic gradients within the cells and if these ionic gradients are not maintained then the cell volume is going to change because water will move. Once that starts that movement of the water starts the cell will swell, it will, the functioning of all other transporters will break down and it will ultimately releasing lot of contents and these contents basically especially the lysosomes which are there lysosomes have proteases. So these may be released and they will again these proteases will start the breakdown of the nearby tissues as well. So that is why hypoxia lead to necrosis of the tissue that cells start dying which is not natural death and there is breakdown of the neighboring tissues also starts. So this is ischemia and ultimately hypoxia which is causing the increase in the coagulation right with increase in coagulation there is consumption of the coagulation factors platelets start getting consumed all the coagulation factors start getting consumed. So there is a disseminated intravascular coagulation DICs start. So some places there is clots are clots are being formed and because at some places clots are being formed lot of clots are being formed there is consumption of these clotting factors other places there will be lot of bleeding. So that is the main concept that how why shock it is so dangerous okay and it is very important that it is to be intervened at early stage that is in the beginning stage that is a non-progressive stage of shock where body is trying to but maybe pseudo try to understand it no be pseudo cardiac output is maintained BP is maintained. So we have to actually correct the cause also in that stage also if we don't correct the cause in first stage itself then the person will land up into progressive stage. So thing is that we have to identify the shock which I have not discussed in the video which I have released but we have to understand what are the features of the shock right. So because the sympathetic system activity is there heart rate is going to increase the person is going to have palpitations right and the because there is so much vasoconstriction the skin will be cold except in case of anaphylactic shock where there is the cause itself is vasodilation that the skin will be warm okay so that we have to understand that tachycardia palpitations hold the skin then there might be sinuses also okay so with the identification we will be able to intervene at an early stage fine any any other questions on shock I think in the video I have very explained it from the physiology point of view in a very basic manner right so that you understand that because what happens in books it is given in like four or five pages it is given and all the mechanisms which we study in BP right they are also given in shock in fully like two pages and all then we start reading that re-reading that and the concept of shock is lost. Basically we are reading the BP regulatory mechanisms what I see in Gaiden Gaiden has very beautifully explained this shock but sometimes students get lost in between anyways any other question Srishti have you understood the question Hind have you understood how hypoxia and ischemia lead to necrosis of tissue basically it is the sodium potassium 80 paste remember rule of thumb sodium potassium 80 paste is present in all the cells and it is present on basolateral so this concept will help you when you are studying the mechanism of the salivary secretion mechanism of any secretion gastric acid secretion anywhere you will see where ionic movement is there always start with the activity of the sodium potassium 80 paste okay so that is just another sidetrack we took Hind have you understood any other questions are there in this there can you respond in the chat box what I will do is that I will edit this live stream and only the question and answer part I will include in the video so that it is easy for later see also think in treatment part anybody who wants to ask any question in treatment which physiology textbook would you recommend to be best as a standard textbook for next exam for next exam preparation the standard textbook is obviously guidance and get on you cannot understand the concepts which are going to to be asked they are not there in any other book which book I think many people have started reading these books on which give points points actually if you see my notes also I have not done points once I have done the concept why is I have retained the concept because when I read that those books I also don't understand anything frankly I have to tell you and you see the questions in neat PG whatever previous year questions are there what happens that they ask the concept they are not much bothered about each and every point right if you understand the concept you will be able to answer the question so obviously guidance and then on you have to understand obviously ganong is difficult so I myself don't recommend students to read ganon I recommend guidance to to be read okay so needs to be read and especially I didn't give you one pick when you are reading guidance because it is huge it looks huge though this concepts are repeated okay so what you can do is just a minute I will move little bit okay so what you can do is first always go through the headings headings and subheadings okay and then see what is there because and I personally say that first reading should be like a novel so you just go through very fast it is very important that you read the chapter very fast in first reading and what will happen you will do some things you will retain but you will get an overview of the stuff and then after that you try to if you are talking to somebody if you discuss then it is great otherwise when we read everything runs in our mind it is a natural process of remembering things then you should go for next reading when you go then you should go with your this thing highlighting marker and all so I recommend first reading should be extremely fast first go through the headings and subheadings then read very fast you will get an overview and then next reading you do with statistics so I know guidance is nowadays students are not referring guidance but there are a lot of videos concept based videos are there and what I see is the students finding very difficult to read books I know times have changed but the questions are coming from Gaitan only and what I see rather is that not only south east south east station edition the graphs are from the original Gaitan actually that I am seeing some graphs are not there in south east station edition okay so okay but at least minimum you should read the south east station edition thank you Shreya for your question I hope I have not increased your anxieties with this answer and maybe I will ask in next time that which books so I will do a poll which books do students read so that we get to know what is the status right any other question on any topic on anything then maybe I will be able to take some questions I don't know Telugu actually I am from Uttar Pradesh and Hindi I have forgotten much of Hindi I generally speak in English only because I have stayed in I have stayed in Maharashtra I have learned some Marathi I have stayed in Kerala I tried to learn Malayalam there but I stayed there for very short time then I went back to Lucknow I went to Gopal and now finally I am in Pondicherry and little bit Tamil I have learned I think I might be right or wrong I don't know don't laugh on me but guys my original language is Hindi in final year also yeah I obviously conscious the same only and to geologic you have to refer every time great Muzapar Nagar UP how how she knows me yes she is means she is watching my videos or there is some another because once what happens somebody contacted me telling that okay um Richa Gupta are you Richa Gupta she said yes I am Richa Gupta then they were talking in Hindi properly they talked and all then finally I understood they are talking about some teacher in UP and she is also in physiology and her name is also Richa Gupta so he is the same Richa Gupta UP I don't know but if she is watching my youtube videos and she likes them thank you then Architej for letting me know and do convey my regards to Dr. Farah also I'm so glad that I'm able to connect to you and okay she was watching my video videos thank you so much Hi Shinji you have any question actually um okay I'm so glad I was talking I'm so glad that I could connect with you people and I will do this very very often now because now I have found out that this five to five thirty time I can devote to you people so before life for me life was like nine to four I'm at work and you won't believe but I sleep by nine o'clock and I wake up at five o'clock but I have some my own activity I exercise and it's like very packed so I was thinking where to include this live session and everybody was telling through this live session but I will definitely do more of these and I'm loving it talking to you people going live like this she used to learn from your videos thank you thank you and she finished physiology yeah there are many md students who actually contacted me and now they are faculty also and sometimes it happens I meet them also personally and then they come oh are you madam same Richa Gupta we used to watch your videos thank you for letting me know agitation so glad thank you so much okay if there are no more questions on shocker then can we say bye bye because I will stick to five to five thirty initially because I really want to do more often this thing hi Farhana has the best wishes for you yeah I'm so glad that way you are watching my videos and hi Farhana as I am really really very glad best wishes best wishes so if there are no more questions on shock can we take leap for tomorrow or next topic and I will share short soon I will post it it will be very soon probably next Monday only I will do this three days I cannot do because my family is visiting me so that's why but definitely definitely I think two times a week I will add this in my schedule so very often I am going to meet you so be ready with a lot of questions and we will discuss a lot of physiology and maybe some personal talk also we will have I loved it okay can we end the stream bye bye thank you so much agitation thank you so much thank you bye bye all thanks for joining I will be glad to clear all your questions on physiology and maybe beyond also see you then bye