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Saying a yes on the chat, I'll be very happy. Beautiful. That's great. Thank you. Thank you very much. I've got the chart open by my side. So whenever you have questions, don't worry. Um if I do miss them, I do apologize because I'm just sharing my screen. Ok? So we're going to get a start. But just before I start, I'd really appreciate if you guys can be aware that the feedback form is actually up on the chart at the minute. So at the end, I will post it again. So please please complete the feedback form. You guys will get a certificate and also it really helps us improve. Um We'll make a start so that we don't finish too late just in case er I'm Natasha. I am currently in my S3 0 in one of the hospitals in the northeast of England. Um My colleague and I Harry, you will see him shortly during the series. Um We've decided to create this A&E presentation series and we're going to name it A&E Survival Guide and I'm going to be talking to you about chest pain. Ok. So can everybody see the slides moving? So what are we actually going to be learning from today's presentation is one how to take a focus history and examine your patients that are complaining of chest pain in an A&E setting, recognizing common ecg rhythms again in an A&E setting and aware of your management and your trust protocols for chest pain. And most importantly, familiarizing yourself with chest pain differentials. I think um I would like to hope there are a lot of junior doctors on the uh chat today or final your medical students, irrespective of what level you are, you are basically going to see a lot of chest pain through your life. And when you do, it's really important to know how to manage them and initiate treatment for them, especially on an acute setting. And this is more focused to an A&E setting which can still be applied as to when you're back house into one of the medical wards because it is just the first few things that you actually need to do when you see someone with chest pain. So focusing first on the fact that you are in an A&E setting and I will try to paint a very descriptive picture of how it's like when you are an A&E junior doctor. So you are working in your doctor's office, you've got a waiting room filled with patients and I mean, it is filled, there are 100 of them sometimes and what comes up on your screen. I I live in a great hospital where everything's electronic is. We've got a patient that has chest pain. What do we know? He is a 74 year old male, he's complaining of chest pain. And his name is Homer Simpson. Great name. What information do you get from an, a spa setting? And that is basically a nurse triages them and gives you a small snippet of information. So what you have in your notes is that this chest pain has been getting worse. He's needing a new GTN spray, but he is asymptomatic and that is why he is waiting in the waiting room right now. So, can I ask you guys? We've all learned this and it's been drilled inside of us when we are taking a history for chest pain. There is an acronym that we all use to take a history and you know it because I know, you know it so you can pop it down in the chat immediately and we will go through it. Yes. Exactly. Yes. 100% Socrates. We've all heard it before. And the best part about Socrates is it is fast, it's quick and it's efficient and it gets all the information that you need. And it's actually how you manage to come up with a differential. Best part about it is you can use Socrates for any type of pain. It doesn't necessarily have to be chest pain. You'll realize you can use it for Abdo pain. You can use it for leg pain or whatever you wanna call it. So, it is a left-sided chest pain. He started having it about two months ago, describes it as pressure. He's getting a bit annoyed at you because he's like, well, it just feels like pressure on my chest. Obviously, it's pain. It goes down to his left arm and with it, he's got a bit of dyspnea. He's a bit nauseous. He's a bit of diaphoresis. So he's a bit sweaty. He's a bit of a larger gentleman as well. So he's telling you that it depends how much I woke up or how much I were to, you know, walk up my flight of stairs at home. I just feel extremely tired and when I feel tired, my chest pain starts. So he's telling you that the more he exerts himself, the worse the chest pain is and it gets much better at rest. His pain is about a three out of 10 and he's putting it down to look, I am an old guy. I am no longer fit. I've got a little bit of a belly like the shortness of breath has got nothing to do with my chest pain. Stop trying to relate two things that are not related. So anyway, you found out that actually in England, well done, he's actually been seen by his GP and his GP has actually tried to help you as best as they can. So they started him on a GTN spray. They have organized an outpatient stress test, but because of NHS pressures, unfortunately, he has not gotten the appointment for it yet. They have discussed a healthy lifestyle and started him on some sort of medication to help him with some sort of fat. Um, if you guys know what medication I'm talking about or trying to hint here, you can put down in the chat box and, well, I'll basically just applaud you. I can't really give you anything else apart from sweets or anything. But regardless, he found some relief with the GTN spray. No, what is the most important thing when they do come in to emergency department is asking them? And it may sound blunt. But why are you in Ed today? Because what has become so severe about your chest pain that it's been going on for two months? It's three out of 10. You've seen your GP. But why are you here? And you find out that he's actually telling you, look, it's happening more frequently than I want it to be happening. It's happening with less and less exertion that I've noticed over the last month. And the most important question right now is I don't know whether you remember, but during the nursing Triad notes, it actually says he's needing a new GTN spray. So why are you needing a GTN spray? And how much of it are you actually using? And he's telling you that within Well, he's finished an entire can in about a week and a half. That is not normal. That means he's over using it. That means this is happening way too frequently and there are a few red flag signs that you can see with this. Yes. So, very quickly, I'm not going to ask you guys like what exactly we're going to do for a history. But these are the things that you're going to cover a past medical history. So he's got hypertension. He's known COPD, he's got a bit of osteoarthritis. He's a bit overweight and he's prediabetic, his medications, his amLODIPine inhalers and he's basically got this. Well, we think that he's been started on some statins social history. He's a 40 pack year man and recently traveled to London to go see his grandkids. He's got no relevant past medical history and his clinical frailty score is about a five and a rock good, very systemic inquiry. Very gene like generalized type of thing that you want to just ask him. He's got, he's denying any signs of palpitations, any heart failure type symptoms. He's got no cough, he's got no abdo pain. Um, MS K Neuro as well, coming back with nothing just tells you that. Yes, he's just generally just a little bit more lethargic. It's obviously got to do with the fact that he's exerting himself and he's, you know, obviously a bit more tired. So great. You've taken this. You've done a proper history. Very proud of you. You've been very efficient. Now, it's a physical examination. So one, you're an A&E you want to make sure that this patient is stable because they're in the waiting room. And what a waiting room is obviously is just chairs, lots of lined up chairs that are there. And you've got one health care like assistant that's there doing observations. So great. You got your observations ready. So everything looks just a little bit. All right, I would say, yeah, fine. His BP is about 100 and 50. But, but it sounds a bit, that's probably gonna be his baseline. Now, when you want to examine someone in any setting really, but especially in an A&E setting, there is a well, five letter thing that you'd like to use, what would you want to use. So there is a way that we examine people and especially in A&E and that's a hint in itself. That's a format that you would use to examine someone. So you put it down in the chat and I want it to be drilled into you this entire series. How we examine someone. Exactly. Yeah, I want you to do an A T and it is the quickest fastest, most efficient way to examine someone because an A&E ABC DE exam basically covers well, everything that you need to examine. And it also approaches the patient and the most likely way to kill someone and then it moves on and it moves on. If that makes sense, your airway would kill the patient first before you move on to breathing. And that's why it's designed that way. Very similarly, if you find a problem in a certain particular area, you can address that problem and move on or move backwards. But either way, if you address something or if you actually even notice something, it's better than missing something. So airway is patent, he's able to speak in full sentences. So why do I say that he's obviously not showing any signs of respiratory distress. He's got quiet air entry bilaterally. Home is a bit of a bit of a bigger guy. So sometimes that's just quite normal. He's got no wheeze, no crackles or crepitations. Listen to his heart sounds s one and s two without any other murmurs. His pulse feels regular in rate and rhythm and his cap refills about two seconds. He's got no pitting edema. Now for c sometimes it's a bit overlooked but always make sure that if they have a catheter, think about their urine output, it's really good to have an idea of their fluid balance and to see whether they're dehydrated, are they euvolemic or are they obviously hypovolemic? And are they a bit overloaded? No G CS 15 out of 15, he's a 74 year old guy that's alert. He's orientated at the time place in person and he's got pupils that are equal and reactive to light, feel his tummy abdomen, soft, non tender, his BM S are normal and his pain right now is zero out of 10. And that's really important because again, when you're seeing someone in an A&E setting and you're bringing them from the waiting room into what we call day rooms, which are just basically small rooms that do not have anyone actually having eyes in the patient apart from yourself. So nobody, if you leave that room, it's just a patient in that room alone. So sometimes it's really important because if you're worried that they're a bit critically unwell or unstable, you wouldn't want to necessarily leave them alone. So you know that this man has come in with chest pain, you know that it's zero out of 10. So you're just like that is fine. This is an appropriate location to actually keep this patient. So you have a history, you have your examination, you have your findings, let's put it all together because that's the point of it. This guy is coming in with chest pain, your junior doctor, it's time for you to decide what to do with all of this. So you go to find his ECG. So what happens is the healthcare system is meant to do it, help you. You can't find it because there are about 10 different ECG S without a label on it, which sometimes happens. So you don't know and you want to go see his bloods go and do all the nice things that we wanted to. We'll talk about later because I want you to tell me the answers later. But there aren't any bloods because your health care assistant couldn't get it because they were really tricky veins. So you bet there you be like, all right then. That's great. Let's go and make sure that this ECG is done. And suddenly one of the nurses that walked past you this room where you've kept your patient says, hey there doc your chaps in pain. Could you prescribe him some pain relief? Right? So here are your options. You've got some IV morphine and 10, 10 MGS of IV morphine say and you're allowed to be generous. You've got some oram that's an oral liquid solution of um morphine 10 mgs as well. You've got some paracetamol and you've got some codeine and um you've got none of the above. Maybe you give me a second. I am going to try and put up a pole like a pole and we'll see whether it actually works. Let's see. Oh Damn me, sorry guys. OK. So go and try and answer it. I'll just give you guys like just a few more seconds and then we can take it from there. Yeah, we've got about 50 people. So I'm hoping to get a little bit more than 22 responses. So the basically all you know, at this point is that he's complaining of some chest pain. And he normally commented to you that it feels like pressure and nurse has walked by and said, look, you chat over there sitting in this room is complaining of some pain. What painkillers can you give him? Oh, we got a 31. Do you think we can get 40? I feel like we can get 40. Come on, that's what I'm talking about. Come on, we got quite split votes. To be honest. That's quite interesting. Morphine. Nice. OK. So, all right, let's take it that. That's brilliant. That's great. That's fine. Well done guys. So very interesting. Right? No, you guys are not wrong. I don't want your patient to be in pain. 100% don't leave your patient in pain. But when someone that is chest pain and is complaining of pain, go review your patient first. So it's a bit of a trick question. Obviously, I am sorry for that. Nobody is technically wrong and we'll go through the reasons why and when that analgesia is actually appropriate. But as of right now, the fact is you don't have eyes on your patient and you don't know the type of pain that they're actually complaining of or how unstable they are. So first off, go review your patient. Hang on before you actually just randomly ask this nurse to just go and give paracetamol and codeine because if they're complaining of a full blown stemi, they're going to need something as strong as IV morphine 100% if they're complaining of something like this niggling chest pain that's over there. Definitely start with paracetamol and codeine and then move it up to Oramorph as well. You would give them combination. That's nothing wrong with that. So you go and you review and you reassess homa. So what happens? Homa doesn't look very well right now, to be honest with you and you ask them very importantly, repeat the observations and repeat your A to e and retake a history. And why do I say that? It's because the type of chest pain that he's having right now, he's actually clutching onto his chest. He's saying it just feels like a heavy, heavy person is sitting on me and I just don't feel like I can catch a breath right now. So what do you decide to do? You do an A te and you do the important things such as cannulated them and taking the bloods that you are going to do anyway and you get that heart tracing done as soon as possible and you give them analgesia. So if they're saying that their pain is a nine out of 10, I would definitely just first start with paracetamol codeine and Oramorph first before giving someone IV morphine, you just want to be mindful first because even if you've given them those three things and it's still not settled, you can give them IV morphine later just as quickly. But you also need to cannulate them before you give them intravenous morphine. That makes sense. What bloods do you want to be looking for? This person? Go and pop it inside the chat for me. There it is a very special marker that we want to check that we would love to check in any chest pain troponin. Yes, of course. We wanna check a troponin. I see. What kind of normal bloods would you just add on to that as well? Just in like in general? Yup. Exactly. You definitely want a full blood come. Obviously you do. Yeah. Anything. Uh the same. Yeah. Great use and knees. Yep. Use and knees. Beautiful. Thank you, Mo Yeah, that's great. Yes. But you guys, we all knew that use and el love to use for blood count CRP and for somebody that's 74 I would just add on a bone profile as well. Just always, it's just best in a magnesium when it comes to chest pain. Just because electrolytes tend to be very funny sometimes. And if you need to replace it, you might as well know all of them. So I've told you about what's changed with his presentation right now and how his chest pain itself has changed and how did I know that it was just through history? Uh Yes, the presentation is recorded so you can watch it on at all later as well. That's not a problem. So I want you to always consider your differentials when you're thinking about these things. So, at this point, what do you think his chest pain sounds like to you. What is your differential? A CS? Yes. 100%. Does anybody else anybody else? Are they thinking about anything else? Do you think it could be anything else? Are you worried about something? M I Yes. P yes. 100%. Yeah. Well, you guys are spot on because you're thinking about the things that are likely to kill your patient first. And that is 100% correct. That is an A CS thinking about PS as well. S 100%. Those are things that we will talk through as well. That's great. So, pleurisy brilliant, you wanna talk, think about the type of pain? Great. So what is going to happen now is we are going to talk about this patient? We're gonna talk about in different variations. We're gonna talk about homa based on his ECG S. OK. So we've got our first ECG. This is our first ECG. Can everyone see it? I think it just popped on now. So don't be too alarmed. All right. So what we're gonna do is we're gonna, we're gonna get this done in a systematic approach, at least. All right. What do you think the rhythm is like? Do you think it's regular or irregular? Yep. It's regular 100%. Yes. Beautiful. What do you think the rate is like if you were to calculate it? And how I would just advise you to calculate. It is obviously very rough for this. I know you don't have it. I would just go 300 divide it by the big boxes that are here. Yeah. Brilliant. Emma. Yep. 75. I, that is great. Great. Now, let's just look at each individual lead very quickly. Yep. So you guys just go, go through it. 123, you just go through a Vrabavf B, 123456. What did the P waves? The QRS complexes look like? Did they look normal or did they look abnormal? What do you think the CCG looks like normal? Exactly. Yes. This is a normal sinus rhythm. Yep. Yes. So AV R does have um inverted T waves. You will always find an A VR and V one that's actually very normal to have inverted T waves. So don't worry about that the to be normal. Um especially just because of depolarization, but that's a whole ECG talk in itself. So we'll just leave it as that, but always compare to previous ECG if you consent. But normally and physiologically, that's actually quite normal on your ECG S. So Homer has a normal sinus rhythm on his ECG. That's great. What does that mean for chest pain? There is a certain thing that you did when you cannulated him and you took his bloods. That would help you. Yeah. Possible. Angina. Yeah. That marker is really gonna help you right now as well to just help you differentiate what it is. So, what the troponin does is that, you know, the range is about 3 to 46 at the minute. And what are you gonna do with Homer right now, Homer is looking at you face to face and he's basically got a normal sinus rhythm. You're waiting for his troponins and your management plan is what? So he's calmed down now a little bit with this chest pain, he's a bit stable after you've given him a little bit of um paracetamol and codeine a little bit of or, and you can leave this patient in the waiting room. The reason why I say that is because leaving them in a room with absolutely nobody to have eyes on them. If they were to deteriorate, nobody would get to them. However, if you leave them in the waiting room where you've got a health care system there, someone actually can keep an eye on him. So if you were to deteriorate, it'll be a lot faster for us to escalate that wait for your bloods, for your troponin because that will definitely help us diagnose to see where exactly. And how bad do we think you know this Nstemi is or is it just a case of unstable Angina? Like you guys are actually rightfully saying, and let's say, for example, your troponin is under three stable, you consider other things and you consider other investigations as for your differential diagnosis, if that makes sense. And obviously, analgesia like you're saying, and there is something known as a heart score which will help you based on the troponins when it's in that, in between mark of eight and 100 and 20 that we are gonna talk about, does that all make sense? We'll talk about differentials later. But if anybody wants to possibly think in this scenario, let's say his chest pain had all settled in himself and he was just giving you this history of exertional chest pain that became worse, but he settled in himself. He's settled at rest right now. His troponin is under three. Is there another investigation that you'd like to do that you can easily do in a hospital setting to just help maybe find out if there was anything else going on a type of imaging, radiological imaging, it's got to do with his chest. Yeah, a scan chest x-ray. So I was leaning towards chest x-ray. But yes, if you do have an A&E registrar that's uh help you with the A scan, you could definitely do that as well, but a chest x-ray, definitely one of the easiest radiological tools that we can do to actually have a better idea of what's going on. So now let's talk about the heart score. So what exactly is a heart score? A heart score is actually there when you and you use it for cardiac sounding chest pain and there are no changes on the ECG and you've got this troponin in between eight and 100 and 20. And it is a risk stratification score especially for ed patients as to whether you admit them for assessment or you actually are ruling out an N sty. That makes sense. Ok. So, and how it works is because if your troponin is between eight and 100 and 20 you've got no changes on the ECG and the history is very convincing for a cardiac sounding chest pain, you calculate the heart score. It's based on their history. It's based on their ECG findings, their age, any risk factors that you know they have and what their troponin levels are like. So if their heart score is three or under and stemi is ruled out, if their heart score is over three, you would admit them to go to your acute medical unit, hopefully get a cardiology review or they could have gotten a cardiology review in your same day center and potentially just made alterations to their medications or just changed a few things with their GTN spray or follow up and they can go from that. Does that all make sense? Yeah. So if your troponin is under eight, you don't check the heart score, you can rule them out and you discharge them with safety netting advice. This is when emergency is a bit different, you are discharging a patient that has come to you with chest pain, you are probably ruling it down to the fact that it's probably something like stable Angina. It's probably something like unstable Angina and you're discharging them with the fact that look, it's not an N sty, it's not a stemi, it's not an MRI if it's becoming worse or even more frequent and you're finding it difficult. Please call 999 and you take it from there and that's why you say you can discharge them with safety netting advice. Ok. ECG two. Sorry to be mindful of the time as well. So we have got ECG two over here. I will give you guys maybe just about 30 seconds, minutes or so. No worries. But if you can point out anything that is quite obvious to you from this EC G, it's a bit bla yep. Brilliant. So I've got some people with different answers. Oh, yeah. Ok. Some people are saying ST elevation and ST depression. All right. So which leads are you seeing this in? Which let's focus on the depression? Because I feel like that stands out. Focus on the depression. Which leads. Are you seeing this in? Let's go. B two V three. Yep. Any to treat. Brilliant. Yes. So, oh, people are giving me. Yes, I like that. That's all good. Well done. And was it all right. So it's going up to the top? Can you see my cursor? That's all. Yes, you can. Ok. All right. We can see a little bit depression over here. Mark it, depression in two, in a VL in aVF and we've got it in V two, V three V four, V five. Does that all make sense? So, what is this? This is an inferior anterior lateral ST depression. This is an in sty, I know it was quite a few but it made it quite nice because it's quite global actually. It just, it wasn't in just two leads. So you guys mostly got it right? 100%. So does your troponin even matter? Yes and no reason being because you already have ecg changes to convince that. So you don't technically need to wait on your troponin to act. It just acts as a guide to understand the cardiac injury that has happened. If that makes sense, touch, relocate your patient, your patient's currently sitting in that room all by themselves without any eyes in them. You definitely don't want to put them back in the waiting room. You want to put them in a monitoring bay or recess bay especially so that they can get some cardiac monitoring on them. You can get some 1 to 1 or 2 to 1 nursing at least N semi protocol for trust guidance. And what that is is basically, yeah. Recess brilliant. Yes. And what you want to do is start them on some Aspirin 300 ticagrelor, 100 and 80 fonda changes as per your hospital protocols. People tend to see whether or not they need, you know, further investigations. And that Fondaparinux means if you can't get them to a tertiary center in 12 hours or so, you give them Fondaparinux. If not, you can hold on, hold off on it for a little bit. And I work in a smaller hospital. I work in a district general, so we normally have to call a tertiary center to let them know. And obviously please, please, please do not let your patient be in pain. They are coated. Please give them their GTN spray. Please give them their morphine. Make sure that they are comfortable as well. Be mindful though about um GTN and low BP cause that tends to tank their BP even more. That's just the only thing. And when it comes to medical optimization, especially you'll find out that, you know, you the cardiologist or yourself when you're in a medical ward or acute medical unit, you can optimize the beta blockers or the ace inhibitors and the statins. As for that, if they're stable, you don't technically always have to do this in A&E but it's something good to know now. 30 CG. OK. So we've got a third ECG over here if you guys can have a look and if you just look at the rhythm strip itself, I feel like you'd be able to have a, see what's going on right now, just pop in the leads, what you see and which leads they're in as well. Yes, you are right this time it's all done. Yes. Brilliant. Absolutely brilliant. Now, with that ST elevation, you guys are on the right track. Do you see any reciprocal changes with ST elevation? So that means with elevation sometimes what you can get is depression in other leads. V two and V three. Yeah. Do you guys see that? So if I bring my cursor around, what I'll do is see if I can find my cursor. Yeah, we see that. Obviously, we've got quite marked sc elevation 23 aVF you can see it especially here in the lidum strip. But what you can see is ST depression in your anterior leads. Yeah. And also for those that picked up obviously like you did while done. Emma is you can see the ST elevation in V five V six. So we've got an anterior uh sorry, an inferior lateral stemi with anterior ST depression. So this is a stem, right? I want you to act now and I want you to act fast. OK. So relocation of your patient stabilized, your patient, your patient's got a stemi. Now, I want you to take a deep breath because sometimes when you're staring at the patient right in front of you and you see this ECG people tend to freeze and that's completely normal. But I want to tell you that it's OK and it'll be all right. What you just need is more eyes on your patient and you just need more hands on your patient to make sure everything's going to be ok. So move them into a recess bay, a cardiac monitoring bay, make sure that they're hooked up to, you know, the telemetry or your three lead ECG. So you can see a continuous lead semi protocol. Ask for your trust guidance and your nurse will help you with that aspirin, ticagrelor analgesia from the perox. We've already talked about this 12 hour window to get PCI call your tertiary center. And if you're in a tertiary center, you would obviously bleep your cardiologist that is on call to speak to them and you take serial ECG. Does anybody know the reason for serial ECG? Oh, yes, definitely. Oh, well done. Well, yes, you reassure your patient. Explain to them what's going on as 100% what you should be doing. Yes. You wanna check for dynamic changes. Yes, 100%. So the reason you're doing serial ECG is to ensure that that ST elevation is not increasing and increasing and increasing because that's what can happen. And you're making sure that if that's happened, then you know how urgently you actually need to move them to a PCI facility. All right. So what is the acronym? Oh, you, you guys are get you guys are beating to it. What is the acronym that you do that we learn for like mis and M sty and things like that? It might have changed from my year of med school, but it starts with an N Yep. Brilliant, brilliant. Does anybody know the longer version of it? So it starts with Mone. Yep. You can go into with it 100% Monica. Oh, that's new to me. So, what I learnt was Monarch. So what it stands for is morphine oxygen. If they are hypoxic, you don't necessarily have to give it to them if they're not hypoxic, nitrate, your GTN spray aspirin. And we've already covered the dose with Ticagrelor reperfusion. Is your, your PCI. Basically, we've got Clopidogrel or Ticagrelor. This will follow as per your trust protocol, which of the two you'd give and Heparin is basically the FDA Perin. So EC G four, let's go. We've got this ECG and to answer Z I think you asked the question. I will be very honest with you for a chest pain history. There should never really be a delay in getting your ECG done and I would not necessarily just give them aspirin until at least just having a proper look at the ECG. But yes, let's go back to this ECG. Mhm OK. Someone thinks it's af is that what everybody thinks as well? Do you think that this rhythm looks regular or irregular when you look at this long lead is a, is a lead too, by the way. Yes, it is irregular, irregularly, irregular. Yeah, 100%. So I tend to especially when it looks at ECG, just tend to do a few, just small things to make it easier on myself. Just look at the rhythm, try and decide on the rate and then just look at each individual lead very quickly. So this is an irregular rhythm and very quick one to help you answer. Yep. Do you see any P waves? Anybody see any P waves in these? No, we don't see any PA. So yes, everybody was right. This is a F OK. Don't be fooled by these little dips. These are not P waves. All right. So brilliant. We've got a patient that's got a F over there. You've diagnosed you for S AF right now, you probably already have. But hey, ho, so what do you do with a patient that's just come in? Not known to have a F and has new af the first question you should always ask yourself in an ed setting. Is, are they stable or unstable? That is? Oh, well, then, yes. All right, is asking whether they're stable or they're unstable with it. And that's basically based on observation, what's their heart rate? What's their BP doing and their symptoms at the minute? What is the rate of that ecg? And are there any precipitating factors? And we'll talk just very quickly about af and we're gonna talk about how we're gonna manage it. So this means rate control versus any underlying causes behind it. And long term wise, we need to think about anticoagulation. So first when I talk about rate control versus underlying causes, what are causes that you can know that can make a f worse or push someone into a F. So it's very simple things that can push people into a very common things that can cause the heart to go into an irregularly, irregular heartbeat, thyroid. Yep, electrolyte, imbalance. Beautiful. Yes, infections. Great. M I, great. Yes, these are all perfect things and you want to be aware of it. Um Medication, infection, dehydration. Absolutely on you guys. Well done. The reason is because sometimes it's not just about rate control for every, well, every patient because if they've got underlying sepsis, you need to be treating the sepsis because that's not going to make it any better. It's going to make it worse or if they're dehydrated, that's also going to make it worse. So next question, long term anticoagulation. There are two scoring systems that we love. We love to use for new A F because we want to change them to a do A anybody. Remember what these scoring systems are? Yes. Wow, well done. Yes. So Chad Mask is there has that is also one but we tend to use an acute medicine Chess and orbit. Orbit is the one that's actually used because that helps us decide the risk of bleeding starting them on a do a so beautiful. So when we want to decide whether our patient is stable or unstable. We go back to a si know this is tachycardia that we're talking about. But just because we're talking about af and this falls under that there are four big adverse features on your A S algorithm that tells you that this patient is unstable. Do you remember what these four features are? And you've actually told me them like through infection, we just haven't, we haven't gotten that specific key word. So for adverse features and these are really important to remember because it changes how you look at them as stable or unstable. Am I shock? Beautiful syncope? Yes, we've got three of them. Actually, we've got M I shock syncope. And there's another one that someone told me about. So it is clinical features. When somebody's got cardiomegaly, they've got arotic cough, they've got pitting edema, they've got reduced ejection fractions, sometimes heart failure. Yes. So I want you guys to remember these four adverse features because they are so important in any A LS algorithm because this determines the approach that you're actually going to go for. So shock shock, basically sepsis or any type of shock. Really, we can break it down to different types. Syncope, Mrs, heart failure. And if you go into the unstable rhythm, this is when basically you're obviously they are critically unwell. You would not have to be dealing with this by yourself. This goes down your DC shocks attempt and you go down amiodarone route and you will have a cardiologist with you at that point in time for this scenario, let's say that he is stable and himself. We would go down to here and we are talking about rate control, rate control with a beta blocker or a calcium channel blocker. And in heart failure, you would choose di duction over a beta blocker. And that's when you think about your Reba score and your ABI score and your long term anticoagulation and you talk to them about stroke prophylaxis and understanding the risks with starting with the doac obviously, for the bleeding, any injuries with it and you take it from there last ECG I promise we're guessing there. Oh This is an interesting one, isn't it? Any take is out there? Thank you very much for answering. By the way, I really do appreciate it. You're making this very interesting, beautiful. So a lot of people have said yes or now I understand obviously, the Torside doesn't help obviously with this because it looks like it's polymorphic. But you would realize that torsos is actually pretty similar in most leads where it looks like a polymorphic squiggly line cross medical term, of course, but this is ventricular fibrillation. So what do you expect your patient to not have if they have an ECG like this? Yeah, I'd be not gonna lie. This is not something that I would love to see obviously, but check does your patient have a pulse and 03 get some help. You're not on your own. So what's the first thing you do when you feel for a pulse? And there is no pulse? Yes. You start CPR and you start it very, very quickly. There is no pulse. You don't think you feel one. You start CPR, you get some help. Yup. Pupil. Yes. Yes. It is a shock rhythm. But all I want you to do and all you will realize that you can do in the beginning is just start CPR so well done. You were that doctor and you've started that. That's great. So yes, you guys have already mentioned it to me. So that's brilliant. So I want you to be aware of what your A S guidelines are. VF is a shock rhythm. Well done. So we've got VF and pulseless VT and non shock is your pulseless electric activity or your asystole and it falls down either side. Um, in an ed setting, you will realize that things happen very, very quickly. This patient will be taken out of that room immediately moved on to a recess. Be you will have a handful of doctors with you and everybody will have a job to do. What's most important is redoing your A to E someone is going to be in charge of your shocks. Somebody is going to be in charge of your medications. Somebody is trying to get a gas for you and obviously someone is going through your hetch s and your TS. All right. So you will go through hetch and your TS is hypoxia hypervolemia. You've got hypo hyperkalemia and hypo hyperthermia. Your TS are your tension, pneumothorax, your toxins, like your electrolytes. You've got your cardiac tamponade and you've got your um thrombosis, your pe s that you're gonna go through. Yeah, very quickly. Bit dull. But it's basically epidemiology about how often you see chest pain. Um So this is just according to NHS England and Wales, we've got about 700,000 presentations to Ed. Um, about 2 to 4% of new attendances are basically chest pain. Sorry, you'll find that actually a majority of them, 70% of them are actually discharged from Ed itself because um you'd find that I feel like because resources are so stretched, you just causing an influx of patients to Ed with potentially non cardiac causes of chest pain, normal ecg S normal troponins getting discharge with safety netting advice or getting discharge. You're finding an increasing alarmingly rate of us discharging chest pains with nonspecific chest pain because what we've done is rule out life threatening causes like Mrs and STEMI and basically ruling out chances of it being a pe chances of it being infected. And you're saying, look, none of these causes are going to kill you. This is what ad is for. You're gonna need to have to go home. If it gets worse, you have to come back in again and that's just discharging with safety netting advice sounds a bit bleak, but unfortunately, that is what we're doing is ruling out lifethreatening causes of it and having the evidence to back that up obviously, and discharging them with safety netting advice and make them also helpful and account like accountable for their own presentation and understanding what it is. So we are finally at that point, it's close, I promise you what are differentials of chest pain that you can think of and you can think of plenty. I I'm 100% sure. With this crowd, you guys can definitely think of at least 10 different types of differentials for a chest pain. Beautiful. We've got gastroesophageal disease. We've got GERD, we've got MSK, we've got pericarditis, we've got pancreatitis. Brilliant. You took section, we've got pneumonia. We've got pe pneumothorax. Beautiful. 100%. Yes. You guys didn't need this talk, but thank you very much for attending. So, very nice little diagram that I have here basically breaks it down to cardiac and noncardiac. Oh, well, then you guys came up with more. So let's go through it very, very quickly. Just about some of the classical signs that you can see from these differentials. So we've covered obviously what Angina is unstable. Angina is basically having this chest pain on exertion. And um it, well, it basically relieving with rest mis we've covered it right now. Pericarditis. Is that inflammation of the lining? Pericard per pericardium. Sorry. And what patients typically present is basically this very sharp, severe retrosternal pain. And this pain is supposed to be worse with inspiration when you're taking a deep breath because it's touching the pericardium and it's actually relieved when you're sitting forward because that barrier is actually removed. Yeah. But then we go to our noncardiac causes. We've got GERD esophageal spasm. We've got peptic ulcer disease. So you're expecting to hear things like dyspepsia, you're expecting to hear, you know, reflux symptoms expect. Yeah, a bit more epigastric like areas you're not going to see, obviously, you know, as high a troponin. Hopefully you're not going to see any ECG changes with it. You're going to have a bit more G I symptoms with this as well. And then we go to non gastro, we've got a dissection and a dissection is basically a very classical tearing, extremely painful type of chest pain. You've got the classical different blood pressures in either arm. You've got um tingling history of it as well. It can also start very epigastric and umbilical and going there. Think about the type of epidemiology about that gentleman. That's about 50 years old sitting there, the history that risk factors that they have as well. You've got P um pe are basically hypoxic tachycardic, they're short of breath. There are classical features. Obviously, you've got S one Q three T three on ECG. It's neither here nor there, how sensitive or specific that is or how actually often you see that and uh we'll be covering pe on one of our talks as well because that's a whole talk in itself. Pneumonias. You've got your usual infective symptoms. You're thinking about your caps. You're thinking about your curb 65 productive cough bra inflammatory markers, your pneumothorax, we think about trauma. We think about when you're listening on the chest reduced air entry, nobody does percussion anymore. But if you do have a pneumothorax person, I advise you to do it hyper residence and chest x-ray will help you definitely with that. And musculoskeletal, which is actually a lot of what our patients actually get discharged with. It is unfortunately nonspecific chest pain that gets put down to muscle where it's 10, 10 on palpation. We've got costochondritis, we've got tender around just under your breastbone and on your sternum as well. And those are very, very common as you can see. Uh at the bottom, it basically shows in 2019, about 44% were nonspecific chest pain. 44 again around that were MS K if that all makes sense. Um How does myocarditis present again, very similarly to per uh very similarly to pericarditis? But that is basically just a little bit different only you'd find on like your echoes and things like that, that you can actually do to see any differences. But it'll just be again, very retrosternal type pain and you might have some muffled heart sounds with it as well. So, do you guys have any questions whatsoever, please uh do fill out the feedback form if that's all right. It right at the top. I will just um resend it in a second. Thank you very much for attending. We've got the entire series that's laid out for the next couple of months. Um So please join us at any point. Please fill up the feedback form. Appreciate it very much.