Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um Hey guys, welcome to another week of lectures. Um Today we have Doctor Ally. He's going to be presenting on an aesthetic emergencies. He is a fellow at the Royal National orthopedic Hospital. He's going to become a CCT soon enough. Um So you have a wide range of knowledge available to you. So please do and ask questions at the end are lectures are sponsored by the MDU and our CPD approved. So at the end of each lecture, we'll send out a feedback form. Once you fill out these feedback forms, you will get a certificate of attendance issue to you, right? I'll hand over things to Doctor Ally. Is that all right? Yeah. Thank you, Jerome. Uh So, hello, everyone as Jerome mentioned, my name is no. Um even though it says ST seven as of today, I uh just become an anesthetic consultant and I'm interested mainly in regional anesthesia and human factors. Uh because I just think it's fascinating how much of our work is actually the non technical stuff as opposed to all the clinical stuff. Um I'm also a LS instructor. Um And so that's on Recess Council UK courses like a LS and people's and stuff. Um So how to introduce this session? I guess when I was first asked to talk about an aesthetic emergencies, uh non anaesthetist especially, I kind of struggled because really anesthesia is not specialty you with pathologies, you know, the pathologies in anesthesia are created by us. And the few conditions that are anesthesia specific are so rare and wonderful. Uh You will probably never come across them, we rarely come across them ourselves. Um And so what the plan for today is, I'm gonna try and give you more of a way of thinking as opposed to uh specific guidance on, on what to do. So it's more the how as opposed to the what. Uh and, you know, again, I'm not an expert on all this subject matter, but I'm very happy to try and answer any questions that you have and uh you know, we can all have interesting discussion at the end, hopefully. So, uh yeah. Well, uh yes, that was the aims and objectives. So the first thing I just kind of wanted to know uh just general interest, see who's in the room, uh What specialties people were thinking of uh going into. Um And so I'm not put all the options there on purpose just because I want to get a broad sense of who's in the room. Um And I'm not never really sure if, if we choose a specialty or, or if the check specialty chooses us um or if it's a bit of both. Um But nonetheless, uh hopefully I can convince at least one of you today that anesthesia is the career for you. Um So I'm not sure how these questions work, whether the results are live or whether we will just look at them at the end. Um So we haven't see them here. So, yeah, mainly surgeons, 40% 30% medics. Uh And about a third of people are doing something else. No one wants to do general practice. And that's very interesting because 50% of doctors in the UK will become GPS or general practitioners. Um So, but no one ever says they want to. So, um how it ends up happening, who knows? Um And so we can move on so to introduce the kind of topic of an aesthetic emergencies, I guess, first, it's important to understand what an anesthetist actually does. So really we're peri operative physicians. And so that means we look after patient's before surgeries and the pre operative period where we investigate them and try and optimize them for surgery and try and understand how risky the surgery is that we can make a plan for both the surgery and the post operative period. Obviously, we do the anesthetic during surgery, but postoperatively, it's also pain management. It's looking after them on intensive care or HD you. Um And it's really the job of an anesthetist during an anesthetic or, you know, in surgery is a constant vigilance for what I'm calling variables and you're constantly assessing these variables and trying to understand, you know, why there might be becoming deranged and then trying to make sure that they remain in a uh normal range. Um And by normal range, I mean, a range that is uh satisfactory to maintain life. Um And obviously, in addition to that, we're obliterating consciousness and sometimes movement. Um So now the next thing to say about emergencies very um generically is that most emergencies, no one calls you and says, oh, I've got an endocrine emergency or I've got a, you know, patient with this specific, they've got anaphylaxis, you know, they call you, the nurse will call you or someone will say I've got a patient with a heart rate of this or a BP of that or they're unconscious. And so really the best approach to managing an emergency is not to know all the conditions that can cause an emergency. But I understand all the variables that when deranged enough will need to an emergency. So now that being said, top tips for emergency. Um so first top tip is ABC, ABC ABC. And you know, obviously I'm talking not about the alphabet for airway breathing circulation. Once you're done going through the airway breathing circulation, go back, do it again. If you get lost, then you don't know what to do next. Start ABC again. Just keep making sure that you've thought about everything in those three domains. Um The next thing is always fall back on two basic principles and, and we'll talk about what basic principles are important. Um, now I know there's a kind of quite an international attendance at, at these talks. I don't know what kind of your local or national guidelines that you may or may not have, but there's plenty available on the internet from the Recess Council And you know, not using your brain or your memory in an emergency is a very good idea. Um Relying on something that is not just objective but written on a piece of paper is far more reliable and safe. And so I I very much encourage that there's no shame in asking for the Anaphylaxis algorithm. Uh when you're dealing with the patient you think has anaphylaxis. Um And the last thing really is is human factors. And the main thing that stops people from managing emergency as well is uh stress and we've all felt it not just in an emergency but at different points in life. And we all know that it can make us perform less well and make things harder. And so trying to find a way to remain calm. And this is a simple things like taking a deep breath and counting to three, thinking out loud and trying to get others to help you with your thinking, taking a step back, putting your hands in your pockets and just looking at it from a kind of third person perspective to get a bit more um insight into what might be happening and what you might need to do and we'll talk a little bit about human factor. It's right at the end as well. Um And so what do I mean by variables? So, variables are really the things that we measure in observations or they're, they're kind of a surrogate marker of these variables. But the ones that I'm going to talk about today, there's many variables, but these are the ones that I think are the most important. And that's your cardiac output, which is basically the stuff that comes out of your heart. Um So your, your blood flow, your oxygenation and then those two combined to achieve something called oxygen delivery. So once you've got not just blood pumping around your body, but oxygen being constantly enriched into that blood, you get what's called oxygen delivery to your tissues. And it's a lack of oxygen delivery that leads to hypoxia. Um And shock is essentially not that different a condition, but it's the, the lack of oxygen delivery at the cellular level is what shock is. And there's many types of hypoxia and shock and many causes. But we're going to talk about basic principles instead of going into specifics today. The next very important thing is ventilation and that's different to oxygenation. Often a kind of confused uh concept or p people think they're the same, but ventilation is, is purely about your carbon dioxide in your blood. So, we'll talk a little bit about how that is, uh, physiologically regulated and managed. And then there's a few others that I will touch on. But, but, you know, these four are the main ones that deal with keeping you alive in the short term anyway. And so, uh, now I didn't change this. I don't think you're able to rank with your question. So maybe just pick the organ that you think uh will be damaged the fastest from a lack of oxygen. And let's see what people think. Hopefully we'll all know the answer to this. Uh would have been a bit more complicated if you could rank them. But yeah, everyone's going for brain and, and that is, you know, I think a well known thing, maybe even um non medics may, may know that. But the key thing to understand is the final common pathway to all death is a lack of oxygen delivery to your tissues. It doesn't matter what causes it, but it's a lack of oxygen delivery, whether it's your heart stopping beating, whether it's a big pulmonary embolism, whether it's a big stroke that stops you from breathing or causes you to have a cardiac arrest, it's always lack of oxygen delivery to your tissues. And so that's the kind of key focus of my message today is think about how you your patient may or may not be doing on that metric of oxygen delivery. So cardiac output, what is cardiac output? Well, there's an equation which helps things, I don't know, anesthetics. We love equations and we love graphs and we love numbers were very objective and uh actually cardiac output is your stroke volume, which is the amount it's a volume which is the milliliters of blood that is ejected from your left ventricle in every beat of your heart. So your cardiac output is your stroke volume, times your heart rate. Um hopefully, that concept you will come across. Um and that should help you later on when we're talking about different variables that become deranged or measurements of variables. Anyway, uh remembering that equation will help you. And then the other equation that is related is BP equals cardiac output times. SBR an SVR stands for systemic vascular resistance. And that's basically the kind of tone of your blood vessels, you know. So if your blood vessels in sepsis, they can become very baggy, very relaxed, very dilated. And so you're SVR is very low. And so even though most people with sepsis have a very high cardiac output because they've got a high heart rate, um they're SVR becomes so low that their BP overall is low. Um And then equally, you know, someone with a very low cardiac output will naturally basically constrict if they're bleeding, for example, to compensate for the low cardiac output. Um now this graph over here, it's called the Frank Starling curve. And what that shows basically is is how cardiac output changes as your left ventricular end diastolic pressure, which essentially is just a way of a measure of how much blood is in your left ventricle at the end of diastole. So if your ventricle is nice and full at the end of diastole, you're going to get a big cardiac output and if it's empty, then you'll get a low cardiac output. And there's lots of things that can cause it to be empty. Um like bleeding, like mitral regurgitation or um pulmonary vascular resistance being high on the hypertension. Um But essentially this is the concept of preload, um which is the kind of amount of blood going into your heart from your venous system. Uh and how that affects your cardiac output. Um Okay. So that's cardiac output. Next is oxygenation. Again, another equation, it looks horrible. I was hoping it wasn't gonna come up in this way because my normal power point uh wasn't able to be kind of shown at the time. But your equation that is talking about how you get oxygen from the atmosphere into your body. And so po two you may have come across is the pressure of oxygen in your blood and that is equal to the amount fio two is the fraction of inspired oxygen. And so normally, uh in Aaron in the room on this planet is about 21% of the oxy, 21% of air is oxygen. And so uh you multiply that by the atmospheric pressure, roughly speaking, and you subtract from that the kind of carbon dioxide pressure in your lungs. Um And so you know, the thing to kind of just be aware of there is that what mainly is going to be affecting your po two is your fio two. So however much oxygen you're breathing is gonna directly correlate with how much oxygen is in your blood. But the second thing that is going to affect that, excuse me is your ventilation versus your perfusion matching. And so what that really is is uh the parts of your lungs that are getting blood and they're getting air coming I/O of them are the bits that are going to be doing the job of oxygenation for you. If you've got a part of your lung that is not being perfused. For example, if you've got a pulmonary embolus, blocking the blood flow to a certain lobe of your lung, then you'll have a ventilation perfusion mismatch or VQ mismatch is also another way that people say this. And uh that's another important concept to, to kind of get your head around because that explains why people with chest infections might have hypoxia for people with pulmonary embolisms might have hypoxia. It's all about the ventilation versus perfusion mismatch. So, in the chest infection, you've got perfused areas of lung, blood's going to all the lung. But because of all the kind of muck and mucus and infection in your airways, there's no ventilation to those areas. And the last thing on this slide that I'd like to just quickly draw your attention to is the concept of tidal volume versus your functional residual capacity. Now, your tidal volume is not where your gas exchange has taken place, your functional residual capacity, which is the amount of gas left in your lungs after you've done a normal breath out. That's actually where gas exchange is taking place because you've got roughly 2 to 2.5 liters of air in your lungs at all times. And your tidal volume, which for an average 70 kg human is about 500 mils, that's just replenishing your fr see with fresh oxygen. Um And so when someone loses their FRC, like, for example, if they're lying down flat or they're obese or pregnant, which presses up on your diaphragm, then you lose the area of the lungs or part of it where gas exchange is taking place. So that's FRC. So next, we'll talk about oxygen delivery. So now oxygen delivery, what that really is is um it's oxygen content multiplied by cardiac output. And so uh the oxygen content equation is written there and really, you know, you can ignore it or it's not something you're ever gonna use. But the main thing to be aware of their is that PO two, which we all can see on an arterial blood gas, for example, that is a very small contributor of your oxygen content. Okay. It's, it's a marker of your oxygen content. That's why we look at it on a blood gas. But actually it's, that's PO two is the amount of oxygen that's dissolved in your blood and most of your oxygen is not dissolved in your blood. Most of it is bound to hemoglobin. And so really the two things that, that decide how much oxygen you've got in your blood or your oxygen content is your a tree and your sats because sats is a measure of oxy hemoglobin. It's not measure of anything else. It's just talking about what percentage of oxy hemoglobin does your arterial blood have? Okay. I was going to talk about the oxy hemoglobin association curve but we won't talk about that today. I'm sure you cover that kind of stuff in your course. Um So next is ventilation and so really ventilation is, is just one simple thing which is your minute volume, which is simply your title volume multiplied by your respiratory rate. Um And it's normally, you know, in, in the region of 5 to 10 liters, let's say it's directly correlated with your SEO two which you can see on this graph here, it's not a linear, exactly linear but between the kind of normal ranges of respiration, it's pretty linear. So the faster your breathing or the larger breaths you're taking, the lower your seo two will be and, and vice versa. Okay. So that's why when someone, um, has a lot of opiates on board or when they're got a brain injury and they're not breathing so good, they can become a danger of CO2 going up and then they become acidotic and then they get other problems. And so, um when someone's respiratory rate is low, um, that's a thing to be aware of is that their CO2 will also likely be high um as a result because they're not clearing their CO2. Okay. Now, there is a few other variables, glucose obviously very important because you need it to make uh your A TP um from the Krebs cycle without a kind of uh lactic acidosis or anaerobic respiration. Um electrolytes and temperature are all very important for kind of homeostasis. Um And hemoglobin we've already spoken about as being, you know, the main way that you actually carry and transport oxygen and oxygen is what keeps you alive. So these are all important things to kind of quickly look at in an emergency if you can because they might tell you what's wrong or what you need to do to fix it. Um Okay. And so next slide is gonna be a quick question which, which of these patient's would you feel least confident managing in an emergency? Someone calls you? They're like you got a whatever elderly co morbid a little pediatric fit and well patient or a pregnant patient. Um You know, which one of these would make you feel the most anxiety about being called to. Um I was interested to see this 10, very even split. Unless you've got three responses. One for each. Now, I'm scared of pregnant ladies. That's interesting. Uh a few more there. Okay. So yeah, getting a mix. It's a bit of a trick question to be honest. Um And, and the reason is it really doesn't matter which type of patient you've got what matters is, what is the problem you're being called about. And you know, that will decide how difficult or stressful or urgent that problem is. And so now let's talk about what you, how you might actually be called. Um when someone you know in their scores, you to the ward about a patient. Um And so all the next few slides are going to have this generic format. They're not saying a lot, it's more just talking about the principles and hopefully, you know, if you've got questions, we can talk about those more at the end. Um So it will just be talking about why each emergency is important, what kinds of patient's get it and then we're gonna split the kind of actions you can take um to manage those emergencies into conservative, non invasive and invasive. The reality is often you'll be doing a lot of these things in tandem. So it's not a sequential thing but it just things to be aware of. What can you do that simple? What can you do? That's not invasive. What can you do? That is a bit extreme, but often that's the life saving thing, you know. Um And so, um the first one we'll talk about is our favorite and aesthetics and that's airway obstruction. So, why is it important? Well, it's the and ABC to begin with, which obviously um makes it sound very important. It's right there at the start. But really, it's something that uh if not dealt with. Well, there's very few options in the long run to manage airway obstruction. And uh you know, people can generally go very quickly from having almost no signs and symptoms to being in complete airway obstruction. And so who gets it? You can get it, you know, developing uh in a more insidious way like people that get cancers or infections in their airway, upper airway. Um People like in, in, in some countries, it's a lot more common to get certain types of infections like tracheitis or epical otitis because certain vaccines are not commonly available. Um And so even kids will get it in those cases, are there more common in kids, those those problems, but you can also get it more kind of acutely in an inpatient setting uh in, in patients that are having surgery, for example. Uh and they, you know, snoring for example, is a type of airway obstruction. It's just a partial airway obstruction. And so when people have had opiates or an anesthetic, they tend to get a degree of airway obstruction. Um, and that can continue into the post operative period or it can recur in people with kidney problems because they don't clear the drugs so well. And so a big range of people that can get it. Um, what are the conservative things you can do? Um So really if you, if you think about anatomy here, um there's different things that will contribute to the obstruction, but generally lying down flat will cause venous congestion and that will add to any reason. So whether, whether the reasons from, you know, loose lax muscle tone or whether it's from a tumor or infection, venous congestion will make that problem worse and we probably all experienced it. You know, when we have a bit of a cold and our nose is congested. When you're lying down, it tends to be us. Whereas when you sit up or stand up, it's a lot better. So sitting people up positioning them well, clearing secretions from their mouth carefully because you don't want to make things worse by pushing things down. Um, often helps a lot. The next thing you can do that's quite simple, not very invasive is give them nebulizers. And so it can be saline nebulizers if, if the thing that's blocking is, is secretions or it can be adrenaline nebulizers, which is a very good basic constrictor. Um, and it's pretty safe to give adrenaline via nebulizer as well. Steroids. University helpful for, uh, airway obstruction, um, from, from most causes. And then there's things like Heliox, which is a gas mixture of helium and oxygen. And so that is got kind of a different density to normal air or oxygen and it passes a lot easier through smaller openings. Um, not available all the time everywhere but something to be aware of. But ultimately, the bottom line is, if the airway obstruction is not resolving, you need to take control of that airway. And there's only two ways you can do that. One is by putting a tube in through the mouth that goes down into the trachea and the other is going straight into the neck by a tracheostomy. Um So that's an obstruction, hypoxia. Now again, you know, airway obstruction can cause hypoxia often. Um And the thing to focus on in hypoxia is the SATS, not the PO two really. And so, uh why is it important? We know why it's important. It's because oxygen delivery is, is impaired by hypoxia and people will have a cardiac arrest if their oxygen levels remain low enough, um they will become acidotic progressively. And so the people that get it again, you can get it chronically or acutely. Um chronically, people can have it from conditions like COPD, bronchiectasis cystic fibrosis, um or acutely, you know, it's one of the most common things you're, you're going to see as, as a, as a junior doctor, especially, uh, that's chest infections, um, causing hypoxia or a kind of more blood flow related problem, like a pulmonary embolism. Setting people up encouraging deep breath and coughing. Why do we do that? And that improves the FRC? Okay? And so improving the FRC gives people a bit more space to do gas exchange. Um You can support that a bit further by doing something noninvasive and that's adding in noninvasive ventilation or NIV or BIPAP or CPAP, whatever you wanna call it, whatever you call it in your relative institutions or countries. And that just basically gives more pressure to the airways to keep them open. Um and encourage more gas exchange. Obviously, oxygen is, you know, must and nebulizers often are helpful if someone's got a bit fleas or a lot of secretions. But again, the final ultimate uh solution to hypoxia is intubation and then once you've intubated them, you can do a bronchoscopy to clear out secretions. Um You know, tumor's can also obviously give you hypoxia if they block off a complete airway. Um And so, um in cases where you've kind of completely blocked off your airway intubation isn't gonna help either. Um it's like a big trip, keel mass or something. And in those cases, you do something called ECMO or extracorporeal membrane oxygenation and that's where you basically connect the patient up to a machine that takes their blood out, oxygenates it and pumps it back in. And uh yeah, sorry if I'm being patronizing with this. Um Now over here, I was kind of hoping that basically there is something behind this algorithm, but basically this is the air less algorithm from the recess Council UK. And I really want to talk about cardiac arrests and I just, I don't know if anyone else is covered cardiac arrests, but obviously, it's the kind of classic emergency, the the emergency you're avoiding trying to avoid when someone's having any other emergency. Um And so I'm not going to talk about why it's important, not going to talk about who gets it because anyone can get it for a variety of courses. Um But really, you know, the algorithm is excellent um encourage people to look at it and, and memorize it, um print it out and have it in your organization's. Um basically the key to a cardiac arrest. There's only two things that you really need to do, which is CPR and defibrillation. Everything else is kind of a nice to have. It doesn't really matter early cpr and defibrillation when the rhythm is appropriate is what saves lives, even adrenaline, which is part of every cardiac arrest algorithm has not actually been shown to improve outcomes. Um ECMO again is another thing that can keep a patient alive in these situations. Yes, sorry. Next. Right. Thank you. So, hypertension BP is a bit low. You know, why is it important? Well, looking at our equations, um, you know, BP is a combination of your cardiac output, an SVR and so someone can have a low cardiac output or a low SVR and that gives them a low BP. Um, and without a good BP, you're not going to have good oxygen delivery mostly. Um, who gets it? Well, some people just get it normally. You know, a lot of you probably are young and fit and your BP is probably, you know, under 100. Normally some of you anyway. Um, so fit and well, people can have what is described as hypertension, but it's not actually a problem because as long as it's enough to maintain blood flow and oxygenation to all your vital organs, it's good enough. It's not a problem and so be aware of that. But otherwise it's, it's a common problem that you can get from bleeding. So lack of blood volume, you can get it from sepsis. So your SVR has gone down a lot and your blood, you know, you're, you're pumping out loads of blood very fast, but your, your blood vessels are gone from that big to that big and suddenly the pressure is very low. Um, or it can be in kind of a drug induced way. You know, we've given someone too much of a beta blockers or anesthetic drugs or something. And uh, so many, many causes. But what can we do about it? Well, it's all just a bit of physics really. You know, uh, the reason why people have problems is that generally the blood's not going to their brain. That's why they faint if you lie them down or, or put their legs up. Especially most people can tolerate very low BP in that position. You know, even down to 70 they will tolerate it if they're lying down with their legs up. Um You can use maneuvers like a valsalva manoeuvre, but I would exercise caution with that because you can get a rebound drop in your BP. Um And then obviously increasing your blood volume and stopping anything that could be causing your uh BP to be low. So drugs or, or if someone's bleeding, you know, stop the bleeding. Um But really that, that the proper measures the treat hypertension if these things don't work uh invasive drugs. So iron, a tropes base oppresses and these are things that you can only really do at least in the UK in intensive care um in a monitored environment because they're quite nasty drugs that can have quite extreme side effects. So next one is high pay attention. Um And again, it's not very common emergency, you know, a lot of people have very high BP. Um And it's not a problem in the acute short term. Um I'm looking at the time here and I think I might actually skip over this one. But, you know, basically, uh thinking about the same equations of SVR being too high. Um And often, you know, anxiety or pain can give you a high SVR. So just treating those things will bring BP down. Um But ultimately, most people don't get hypertension in a very acute way unless they've got like a pheochromocytoma or a uh neurological uh cause of it. So, not a very common one. Let's skip over it for now. Uh Next one is bradycardia. So this is a more common one. And again, is it important? Well, it's only really important. So if you look at those equations of, you know, it's right in the kind of hierarchically uh in the top of that where heart rate time is your cardiac output is giving you uh sorry time is your stroke volume is giving you your cardiac output. So if your cardiac output is fine, it doesn't matter what your heart rate is cause you will still generate a good enough BP from it. Fit people have very low heart rates and it's not a problem. If someone's BP is fine, it's very unlikely that the heart rate on its own is a problem. But as people get older, you can get low heart rates for pathological reasons like a v know dysfunction um or electrolyte disturbances. And so generally, in a pathological way, sense of who gets it, it's generally elderly people that are, have some cardiac dysfunction or people that have been given drugs um in an appropriate dose like beta blockers. And so really conservatively, you can wake the patient up, you know, make sure that they're not just asleep and that's why the heart rate slow, but you can't really too much else. Um then you can give them drugs, basically different drugs to bring their heart rate up. And so vagolytic sar the more safe ones, the things like atropine or glycopyrrolate. And again, this algorithm from the resource council covers most of these things. Um they're stronger drugs that you can use just in intensive care like isoprenaline. Um but pacing is the kind of, you know, backup option in, in a very extreme emergency, just be aware, you're delivering a shock, small shock to the patient with each beat. And so generally, you're not gonna give them something uh whilst you're doing the pacing and you're only really resort to pacing if you've got what's called an adverse or life threatening feature. And that's things like they've passed out or they have gone into heart failure, um etcetera, etcetera. So, um next is tachycardia again, very good algorithm. Again, it affects people with cardiac pathologies generally. Um But also people with sepsis often have uh you know, not just a sinus tachycardia, which is not pathology, but pathological tachycardias like atrial fibrillation and flat hair. Um Obviously, the ventricular tachycardias are far more uh pathological or cause more often cause problems and need prompt treatment. Again, there's a great algorithm. They're um but in terms of conservative things you can do corrected sinus massage or about salva manoeuvre. And that just puts a little bit of pressure onto your corrupted bodies um which are responsible for mediating. You're kind of vagal tone and your vagus nerve is what brings your heart rate down. Um Oh Baykal stimulation, uh drugs you can give them are, you know, just fluids will bring some tachycardia is down, electrolytes like magnesium and potassium work. I think just as well as beta blockers when they're not in the correct range. So if your potassium and magnesium is low, that's probably gonna be what fixes an edge or fibrillations more so than a beta blocker, which might just bring the heart rate down for a bit. So I always check the potassium and the magnesium with the tachycardia. But if you've got life threatening features and you need to treat this quickly, you've got to do the DC cardioversion. So a synchronized shock by a defibrillator um to try and get them out of it. Um There are stronger drugs like amiodarone, but again, you tend to give those in a monitored environment, at least in the UK. So it's a quick run through of the kind of things you might be called about on the ward. So, you know, someone saying someone's got a low or high heart rate, BP or whatever it may be. Now, we can talk a little bit more just about anesthesia specific emergencies. Um, and I wasn't sure if there was going to be the ability for people to talk. Um, and this question is any really relevant if you can, but I'm not sure if there is a poll for this but should have just been a yes. No, I mean, I'll be surprised if people have heard of any anesthesia specific emergencies. Um, that alone more than one. But as we don't have the ability, you can comment on the, on the page under, send the message in on what you Yeah. Okay. So if anyone knows of any anesthesia pathologies just type it into the chat peri operative emergencies. Yeah. Yeah. So, so there are different ones. Yeah. Allergic, yeah. Nice Emma allergic reactions. I mean, obviously you can get those in any specialty. But yes, we see it a lot more in anesthetics because we give a lot more drugs to people in a naive way. Um, antibiotics. And so yeah, we do see more anaphylaxis in um yeah, POSTOP urine retention, I guess is a wouldn't, I don't know if I would say it's an emergency but definitely something that we cause we've got an acronym for it which is poor po you are. Um But yeah, I mean, we've got a few that are anesthesia specific. Um, and let's move on to those now. Um So uh we can move past that slide as well. Thanks Jerome. And so, nor Ingo spasm, which is something I've never heard of before. I did anaesthetics. It is what it sounds like. It's a spasm of your laryngitis or inlet or your vocal cords. And it actually only happens to people when they're in a anesthetist state and often it's when they're not anesthetized enough. Um And so what happens is, uh they close off their vocal cords and this is, I think a reaction that, that not just humans but all, um at least mammals might be or land animals have. So that let's say you fall into the water unconscious, uh It stops you from aspirating water into your lungs. And so even if you're half unconscious, your vocal cords will close off and you will not aspirating water, um you'll probably still die because, you know, someone needs to get you out the water, uh save you, but it's a reaction that we see in anesthetics and it causes strider, which is a high pitched upper airway sound. A lot of people say it's inspiratory. You know, it's not, it's, it's just a high pitched upper airway sound. Um And it's one of the scariest sounds for anesthetist. It can be caused by other things. Stridor and I put a list on there for you. Um But really, it's uh something that you can an aesthetic setting only treat by either giving someone Moranis anesthesia. So like more propofol or by paralyzing them so that their vocal cords naturally relax. And I almost killed someone once um because they went into laryngospasm there sat struct to 27 before we managed to break the spasm and start getting some oxygen in. And that was one of the scariest days of my life. Um She had just given birth to a child via Cesarean section under a G A. So she had not yet met her child or seen her husband since the birth of the child. And I was just worrying in my head that I was gonna go out and I'm going to tell this husband a newborn baby that they're, you know, wife and mother is dead. Um It's because of something that ultimately is simple and perhaps if I've been more vigilant, um I may have been able to avoid, that's the laryngospasm. Um watch out for it. Now, this is actually the most terrifying event for anaesthetist and that's I can't intubate and I can't oxygenate this patient. Um which means generally what you've done is you've given someone an anesthetic there now, unconscious and not breathing and you've done that. And uh you also can't fix it basically. And so really the only way you can deal with this is something we call front of neck access and it's extremely, extremely rare. I've not even seen this yet and I hope I never do, but essentially what it entails is grabbing someone by the throat slicing their neck open and shoving a endotracheal tube in just using a scalpel. A number 10 scalpel, a lot of surgeons in the room. So you probably know what that means. I don't really know what it means. I just know I want a number 10 scalpel in an emergency. Um So I've got a picture they're demonstrating how you would basically do is make a little hole, put what we call a buggy or an introducer in and the new railroad, the tube over it. Uh The few instances are paid off. It's an absolute bloodbath and a shit show and survival rates are pretty, pretty poor. Um And you feel pretty shit after it because you basically have killed the patient as the anesthetist because there's nothing wrong with them before you gave them the anesthetic and then they're dead. Um So it's a, it's a horrible uh condition for us and all scared of it. Uh Next slide, uh something called local anesthetic toxicity. This is something you may see, especially my uh colleagues here that are more interested in um uh surgery. Um I'm gonna just answer this question quickly about the last um condition which is what's different. A tracheostomy. So the difference is the tracheostomy is generally performed. First of all, tracheostomy is, you know, performed in quite a controlled setting with an anesthetist that's actually got control of the airway usually, although you can do them awake. But the main difference is that tracheostomy is performed between the second and the third, generally cricoid, um not quite, quite to keel rings. Um Whereas this is performed through the cricothyroid membrane. So it's right up at the top. And mainly we do that because it's, it's the biggest uh space that we can find. It's, you can palpate it quite easily by a landmark technique. Um And so, yes, it's different to a tracheostomy. Um And then generally, once you've done it, you have to get a surgeon, the ent surgeon in to do an actual tracheostomy. So I think a proper tracheostomy from my understanding from my surgical colleagues is done between the second and the third or a bit lower down basically um on your trachea between the 2nd and 3rd tracheal rings. This is done higher up cricothyroid membrane. Um So local anesthetic toxicity is basically when you give someone too much local anesthetic. Um and they get either cardiac dysfunction or neurological dysfunction. Uh it's quite insidious. It's quite rare and uh can basically cause someone to have a cardiac arrest. And the treatment is something called intralipid, which just mops up the local anesthetic, good to be aware of as a surgeon. That's why it's important to aspirated before you inject local anesthetic, not just injecting it blindly. Uh in certain areas are more prone, injecting local anesthetic into certain areas, uh will more likely cause um local anesthetic toxicity and that's generally areas that are more vascular. So like inside your pleura. So if you're doing thoracic surgery and you put a pleural uh local anesthetic in is very vascular, higher chances of local anesthetic toxicity. And that's why they are safe, recommended maximum dose is that if you're doing the injection of local anesthetic, you should be aware of. Um I woke up with that today. Next is something called malignant hypothermia. It's very rare to zone more dominant disease. I've never come across it. Um And essentially, it's quite similar to neuroleptic malignant syndrome, which is uh something caused by antipsychotic drugs. Um and it basically leads to a spasm of all your muscles and it's triggered for some reason by a variety of anesthetic drugs that are completely different categories. You know, that some of them are actually anesthetic drugs. Some of them are muscle relaxants, but they're all drugs that only we use. Um And for some reason they cause this condition but no other drugs from other specialties do. So this was God's way of punishing us for having quite nice large style. Otherwise, treatment is simple, just remove the trigger, give them supportive care. And then Dantrolene um is something that helps your, your kind of muscles to relax by blocking the kind of calcium, uh calcium intake to the cells. And calcium is what really allows cells, muscle cells to contract. Um So yeah, next anaphylaxis again, follow the guidelines. What is the treatment for anaphylaxis. There is only one treatment for anaphylaxis and that is adrenaline. Give adrenaline, give it early. Don't be afraid to give it and give it again if you have to because that is what will save someone's life. Um, there is refract to your anaphylaxis and you, you probably want an anesthetist around when you're dealing with, with anaphylaxis. But, you know, don't remember your, your simple principles of raising people's legs up in the air to give them a bit more preload. Because essentially what's happening anaphylaxis is you're getting a very low SVR if you remember from our equation. So your, your blood vessels are dilating. Your systemic vascular resistance is low and adrenaline not only uh increases your systemic vascular resistance, but it also has some effect on the mast cells that are responsible uh for the kind of mass IgE um mediated release of histamine uh steroids. Yes. No helpful. You know, not in the short term and histamines helpful. Maybe again, not in the short term. So it is really all about adrenaline. Um and then obviously controlling their, their BP and oxygenation until the adrenaline can take effect. Again, a Reese's Cup Council guideline for you if you need it. I put this one in patient fire because I thought it was quite fun. Yeah, sometimes patient's catch on fire. We do laser surgery. Sometimes we get to wear cool goggles or orange or different colored. Actually, depending on the type of laser, but patient's can catch on fire because a lot of things are flammable in, in an operating theater, oxygen is flammable. So hexedine who used to clean patient's is flammable. Um, and so really, you know, if the fire is, is not in the patient's airway, you just need to remove everything that's on the patient that might be on fire and then just soak them with Saline. Um, you can also use a CO2 extinguisher. Um But yeah, just the way it was quite, I've actually seen this one once, um a fire on, on a patient, but it was just on the, on the drapes. And so I don't think anyone got bent. Um Next, this is a good one for, for anyone really, especially surgeons and that's massive blood loss. And so you may or may not have come across the concept of the deadly triad or the lethal triad. Um And that is basically the combination of hypothermia acidosis and coagulopathy. And these three together tend to kind of run in a pack. You know, they're like friends. As soon as blood loss, massive blood loss starts taking place, they all congregate and, and cause further blood loss because, you know, if someone's been injured out of the hospital, they tend to be hypothermic. If you have massive blood loss, what what what's going to happen, you're going to have a low blood volume and so your cardiac output will be low, your oxygen delivery will be poor. If your auction deliveries poor, you're going to start doing anaerobic respiration in your cells because you're not getting oxygen. And so as a result, um you will then start becoming acidotic from lactic acid build up. Um and in acidotic state or your enzymes or your clotting factors don't work very well. And the last thing is coagulopathy. And often we cause this one by giving people a lot of fluid in the short term and diluting their blood out. And so then this worsens a coagulopathy. Um and so really just to be aware of it, you know, someone's bleeding, keep them warm, try and control acidosis, you can compensate for metabolic acidosis by encouraging either hyperventilation or if they're intubated, increase their respiratory rate to reduce their CO2. And that will improve the acidosis somewhat and think about not just giving fluids, giving blood, giving clotting factors, giving fibrinog in or FFP or whatever you have available in your institutions. Um And don't forget, some people have modified this lethal, tried to call it a lethal, I don't know, quad lit or something and that's calcium. So calcium, a lot of people don't realize is actually clotting factor number four. So, you know, you've got your 1234, whatever, up to, you know, 10 clotting factors, clotting factor number four, uh is calcium and it's, it's a cofactor for a lot of other factors to activate them. And so you need to make sure someone's calcium is topped up if you've given them in the region of 1 to 2 liters, one liter of blood um or blood products even uh I would think about starting to give calcium straight away at that point because they're calcium will start becoming depleted very quickly. Um So next question again, this was meant to be a rank but instead just pick the one that you think causes um is the highest of the most likely cause of iatrogenic harm. So by that, I mean, harm caused by uh medical errors or errors of people in the hospital. Um Let's see, we've got some comment in the chat. Okay. So most people know the answers, which is very good. You've all been doing your, your reading and homework and stuff. Um okay, starting to get a bit more in decision. But yes, drug error is the main cause of iatrogenic harm. And what's really interesting. A lot of people don't realize is one in 10 patient's um in patient's in, in developed countries as preventable harm as a result of human error. Um and we have something in the UK that we call never events, which is basically a list of, you know, maybe 10 or 15 different things that should never ever happen in a healthcare setting because their mistakes, these include things like operating on the wrong side of the body or leaving a kind of foreign but foreign object inside a patient, you know, and the reason why these are deemed to be never events is because there's even though any system that includes humans will always be prone to error. Uh That kind of concept is that if you can optimize the way a human is working, you can severely minimize, I wouldn't say that I can, I would be confident saying anything is never going to happen, but you can definitely minimize the potential for an error taking place. And so um let's talk a bit about human factors very quickly. And so yeah, first thing as we just said, receiving healthcare very dangerous. Um One in a million chance these are just, some numbers are found on the internet. One in a million chance of someone being harmed while traveling on a plane. In comparison, there's about one in 300 chance of someone for patient being harmed during healthcare. Patient harm is the 14th leading cause of morbidity and mortality globally. And that's comparable numbers are comparable to things like TB and malaria, which I was quite surprised when I, when I found that that number. Um and really uh the things that cause doctors, nurses to make mistakes is often not a lack of knowledge or a lack of understanding or, or, you know, not knowing how to do the right thing, but it's usually non clinical things. And I've kind of listed these 12 things here. I can't remember what there's a nice way to describe them, like the 12 evil sins off, you know, human factors or something. But essentially it's, it's all the soft skills, communication, teamwork, stress, poor systems, um, you know, lack of awareness norms often, you know, it's like, oh, well, everyone just does that. So I'm just going to do that too, even though I'm not really sure why. Um, and so human factors, ergonomics is something, you know, it's, it's a growing field. It's been taken up by the airline industry or the ones that kind of pioneer it. I'm not sure if a lot of you are aware but flying used to be very dangerous or, or a lot more dangerous. It was a lot more common to have accidents and obviously a plane crashing, it means usually instant death for hundreds of people or, or, you know, at least dozens of people. And so it's quite a significant thing, um, to take place and when they analyzed it, they found something like 40 or 50% off, these crashes were completely avoidable. They were just down to what they started calling human factors. And now human factors has kind of evolved into this multi industry, um, concept that, that people use everywhere from, you know, industrial processes to financial, to healthcare. And, uh, it's more about the way we work as opposed to, um, what we do in work, you know. So it's the, how about the what? And really I'm not going to kind of tell you too much more about human factors, but just to say at this stage, uh at the same stage that you're at in my career, I looked at these things, we had some of this stuff at medical school, like about calm skills and how to manage stress and then how to communicate and had to be in a team and all this stuff. And I didn't take it too seriously cause I just thought this is nonsense. It's common sense, but really, you know, focusing on this stuff is what's going to make you. Thank you for being a good doctor to an excellent doctor. Um and not just a doctor for your patient's, but an excellent doctor for your colleagues. Um And for the wider organization as well. Um And so, uh that's it really um you can do a quick bit about questions. Um I'm not sure how long I'm supposed to have. It's just coming up to seven. Someone did ask a question that I've not answered yet. Um And that is any biochemical profiles predisposing to spontaneous combustion. Um I'm not sure if I fully understand the question. Uh But when you say spontaneous combustion, you mean without, because obviously for a fire, you need three things, you need heat, you need fuel, you need oxygen. So if you mean spontaneous combustion, ie combustion without one of those three things that's just obviously not possible. Um But biochemical profiles of a patient. I don't think there's anything about a patient, but there's kind of surgical factors that can predispose like laser surgery, obviously, um or a very oxygen rich environment. Um So anesthetic factors, you know, someone's having opted flow um or high flow nasal oxygen you may call it um and then you do laser surgery with that. That is a very high risk thing for uh uh fine. Yeah. Okay, perfect. Is there there are questions I don't want to like to ask. Give it a minute. Okay. What I can do is um if you go on to the next slide, your oh my can summarize whilst people think of any questions and then if there isn't any, we can just end there. But basically, I think if you go away, I was hoping you would go away with learning nothing new, just having a different understanding of things. And so um hopefully, you know, you, you, you will feel that understanding basic principles and knowing how to manage them is really the way to approach any emergency. Um and emergencies are very rarely obvious at presentation. So, you know, you're never going to walk up to something and say this is um hyperkalemic ventricular tachycardia. So it's always gonna be they've got a tachycardia. What do I do? Um Don't underestimate human factors and remember that planning and preparation always outweigh Axion and execution. And so focus on that in your clinical life and I would argue non clinical life, you know, just in general. Um, don't worry too much about what actually happens, worry more about how much you thought about it. What is the protocol for a fire in or close to the airways? Um, okay. So, really, um, we don't have a guideline in the way that I've shown you those guidelines. Um, but the main thing that's a problem with any airway, fire or fire that can damage the airway, even if it's not in the airway is that it causes airway swelling and that can be quick and it can be quite extreme. And so you wanna remove anything that could be hot or could have caught fire from the airway. And often that means taken the endotracheal tube out. If they've got one flood, the airway with Saline doesn't matter if it goes down into the lungs, it's just saline and then uh intubate them. Uh again, because they're probably gonna get massive swelling and then they'll get airway obstruction. And when that happens, you won't be able to intubate them. And so you want to have that tube in before that point. And usually that point happens about 12 to 24 hours after the insult. And so that, you know, often people will be okay and then suddenly they'll collapse. But the principle for all fires, patient fires is the same, remove anything that could be on fire flooded with Saline. And then if their airway has been exposed, uh you know, consider intubation when intubating. How long have you got to do it? When do you decide you can't intubate car auction? Eight. Okay. So how long have you got? That's an interesting question. You can actually work this out from a physiological sense. So you're, you're FRC is what we said, that's where all your oxygen lives. Um And if you've given someone 100% oxygen to breathe via a mask, so that their whole FRC is full of oxygen. And let's say it's three liters. Is your fr see. Um, now we know that. Well, I know, but, you know, now, you know that you can, your oxygen consumption per minute is roughly 100 and 50 mils per minute of oxygen. If you've got three liters of pure oxygen in your lungs, it's 100 and 50 mils per minute. That's basically 20 minutes. Now, in, that's, in principle, in practice, your FRC is not going to be that big when you've anesthetized someone because they're muscle tone is lax. They're usually lying down. Um And so in practice, you probably actually got up to about 56 minutes, you know, depending on how obese the patient is. Um, you decide you can't intubate when you've tried to do it and you just, you know, you, you won't find it easy often from, from the first look. Um, because you can't see that the glottic this, um, but you've got a variety of techniques. We've got algorithms that help us. Um But really, it's not about whether you can't intubate because the can't intubate bit is really not important. It's, it's that you can't oxygenate and not being able to oxygenate is a much more simple thing. And that's just even just about bag mask ventilation, you know, so just putting the mask on the face and it's squeezing the bag like itself inflating bag. Um And, and that you decide when you've tried often, it's called a two person technique where you squeeze the mask down onto someone's fit, one person just holds the patient space and the mosque and the second person just squeezes the bag and when to experienced people struggle to do that or can't do that, then, you know, you're in trouble. Um That's when you need to start thinking about getting the front of neck access ready. I have never come across someone that I've not been able to oxygenate without someone else's help um or with sorry, with someone else's help. Um And so it's extremely rare. Um But yeah, there are famous cases of it happening. Um So yeah, it's a, it's very stressful specialty about people say 2% of the time, but 98% of the time, it's very nice. We kind of just sit there and make fun of the surgeons for choosing they're ridiculous lifestyle. Uh and then go home and have a nice, nice rest that usually do a bit of breath warning most anesthetist. So I just watch it on TV. Um So yeah, highly recommend it as a career. Very interesting. Um But if you've got a specific pash in, in life or in medicine, uh I would say go for that cause anaesthetics doesn't often attract someone who's very enthusiastic about anaesthetics where people that enjoy the general kind of psi ins and med medicine side of things. Um and like doing practical stuff with their hands. Um but uh don't want to dedicate their entire life, day and night to a job basically. Um They want something else in life too. Right? Perfect. And that was, that was nice little ending there. Um Yeah. 01 more question. What do they do on the, I see you. What tasks. So it's interesting. I see you didn't, it didn't exist as a specialty until quite recently. Um I don't know if it exists in every, I don't know where people are from in, in this, in this talk, but it didn't exist in this country in the UK until probably about 20 years ago. And even now it's the faculty of Intensive Care Medicine. It's a part of the Royal College of Anesthetists. And that's because an itu patient is just a patient having an anesthetic, having all the variables measured and corrected and that was invented in anesthesia basically. Um And so um what can we do? We can do everything the medics are the ones that can't do everything. There's two things that happen on. I see you. One is you measure and correct all these different deranged variables. And uh you do that to allow the patient to stay alive whilst the primary problem causing that derangement of variables it's corrected often. You know, that thing might be something like a sepsis or uh they've got post operative insult, but they've bled a lot often. The thing that corrects it is time. It's, it's not, you know, the medicines or the, or the clever, you know, uh, anti inflammatory drugs or the antibiotics even it's just time. And so what, what we do our remit is, uh, I think I could be an intensive care consultant in this country if I wanted to. Um, I think in most countries, anesthetists are the main type of doctor that is an intensive ist. But I'd love to hear if, if you guys have a different kind of system in your countries. Um Okay, perfect. I think that's the end of the lecture and the questions again. Thank you so much for, for joining us today and giving this lecture, uh, was quite informative, uh, from the start to the end again. I'm sure all the feedback forms have been sent to you guys already. If not, please do let us know and we can send it on to you. Um uh Thank you so much for joining today. We'll be back next week again with another lecture. Soap.