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See them. OK. So it should be like a blue title slide with the name of the presentation and, and my name as well. Perfect, lovely. Um So a little bit about the session. Um This is part of a series of lectures um which I've kind of devised um and have delivered so far that which aimed to kind of simulate your on call shift as a junior doctor. So an F one or FY two, they're based off of things. Um I've seen colleagues have seen um which I think have been good learning points um interactive above all because I think that's probably the best way to learn. Um and something that particularly a lot of the kind of senior year medical students might have been deprived of kind of earlier on in their um university careers of the pandemic. So um use the chat box to put in kind of guesses ideas, questions, um ask for clarity about certain things. Um There's no such thing as kind of a silly suggestion. Um And obviously all of your feedback and kind of how you answer dictates how I then kind of devise the next session on um to make it more useful for you guys. So, um, just get stuck in would be my advice. Um I'll pop in a little feedback form at the end and um, if as many of you as possible could fill it in, that would be, um, that would be great. It only takes a couple of minutes of your time. Um So thanks very much in advance for doing that. So, um, we'll start straight off. So you've clocked in um you've been handed the bleep and all of a sudden the bleep um screams at you that there's a cardiac arrest in day three. So it's a good start to your shift. Um Can anyone f in kind of what they understand by cardiac arrest? What is a cardiac arrest? What do we mean when we say that someone is arrested? So someone's saying am I any kind of advances on that heart rate of zero? Um fine. So um blood. Yeah. Ok. So a lot of kind of different um perspectives. Um So and no pulse. Yeah, definitely. So it's loss of a perfusing rhythm and a cardiac output. Um So the heart can still be in a rhythm. It's just a rhythm that's not compatible with um with life or with a pulse. Um So that complete loss of any electrical activity or any kind of mechanical activity of the heart, that asystole or flat lining is one kind of a cardiac arrest. Um But there are a lot of kind of different rhythms or there are four main different rhythms. We'll talk about that mean that someone will have lost their output and their pulse. Um So how would you guys kind of approach a cardiac arrest? Then you respond to the bleed, you run into the bedside. Um You're the first one there. Do you guys kind of have a structure or um an approach that you think you might use? Hm, a lot of different answers? Good. Um People have said A to e um and I have set a little bit of a trap that I was hoping you would fall into. Um this is something that was kind of covered when I was in medical school and I find it really useful. So um A to e is a great approach for someone who has a pulse. Um It allows you to identify in kind of order of fatality, the things which will cause them not to have a pulse. So if someone has an airway problem, that's the first thing that's going to result in them having a respiratory and a cardiac arrest, someone has a breathing problem, then if they're airway fine, that's the next thing that's going to cause them to lose their pulse, to lose their output and to go into cardiac arrest and see and so on. So it's great for someone who has a pulse. If someone has no pulse, A to e no longer is useful. The only things that are going to help someone who has no pulse are early cpr, early defibrillation. Um and, and good quality CPR and kind of all the post resuscitation care and early recognition that goes on prior to and after the arrest. Um because you can imagine going through an at e in someone who has no pulse, you know, is their airway patent. No, it's not because they're unresponsive and they're in respiratory arrest and they don't have a pulse. So they can't check their airway B. What's the resp rate? They don't have one. What are their target and what are the kind of oxygen saturations? They don't really have them? Um What's the BP, the heart rate? They don't have either of those. Um D what's the G CS? It's obviously three. And so a lot of your structure becomes kind of moot. So we'll go through kind of a better structure for someone who does not have a pulse. This obviously then changes. I mean, if you are um in a resuscitation kind of situation, someone doesn't have a pulse and they then regain a pulse. Absolutely. Then go through your A to e make sure you protected your airway. What, what are they then breathing up once they've regained kind of and respiratory effort, what's their BP and their heart rate? Get an ECG, a post kind of return of spontaneous circulation. ECG But as soon as they arrest again, you go back and you lose that and you go back into kind of your cardiac arrest algorithm which we'll talk through. So I've based this off of kind of resource council Advanced Life Support um guidelines and algorithms that you can kind of find on the internet. Um If you do get offered, kind of, I'll say before I move on, if you do get offered the chance to do A LS before you start fy one. Absolutely do it. Um You can end up kind of on the cardiac arrest team on your first shift as I did. Um And it's really useful to have kind of gone through that structure because I don't think it's something that is as familiar when you're in medical school. So the algorithm starts like this. So someone is unresponsive, they're not breathing. Normally, a lot of people have mentioned um calling 2222. So calling the resuscitation team um or the ambulance if you're out of the hospital. That's absolutely right. Um So 2222 is normally the um kind of way that you would call the crash team. You say that there's a cardiac arrest um in ward XYZ or in the CT room or in the corridor in between these two wards or in the car park. Um And you'll make sure that you kind of get the relevant people there. So after you call the resuscitation team, you um start CPR straight away. Um and then you'll get someone to attach the defibrillator, um or the monitor. So there's two kind of pads you can put them on, um, anteroposteriorly or anterolaterally as well. And I'll show you a picture of what that looks like. Um So kind of on the right hand side of the sternum here and then just kind of um to the left as well. Um Is your anterolateral positioning of the pads, um that will allow um monitoring of the rhythm because that will then um produce kind of a rhythm strip on the defib, but it will also allow you to deliver a shock if the rhythm is shockable. So you'll assess the rhythm. Um Can anyone kind of um think of kind of different rhythms? Um So if you keep them in your head, we'll go through them all. So I've got a rhythm here. Does anyone know what that is? Mm So ventricular fibrillation? Yeah. Absolutely. Right. And some people are saying atrial fibrillation. So the difference is that with atrial fibrillation, your kind of baseline will look like that, but you'll have very clear kind of ventricular normal complexes. Um There's no discernible kind of normal electrical activity and that rhythm is there. It, it's um it's, it's just kind of a squiggle. Um So that's ventricular fibrillation. Is that shockable or nonshockable? Shockable? Definitely. Yeah. So if you see this on the screen that you wanted to give a shock. Um Lovely, what about this and again, this is in the context of cardiac arrest. So, presuming this patient doesn't have a pulse BT. Absolutely. So it's a lot more kind of regular, isn't it? Um There's a clear kind of pattern to it, um which distinguishes it from VF you can get VT which is pulsed. Um but in the context of cardiac arrest, so always, if you see this rhythm on a rhythm check, check for a pulse because it can be compatible with an output. Um But particularly we're talking about pulseless VT. Um So is pulseless VT shockable or non shockable, again, shockable. So that makes up your two shockable rhythms are your VF and your BT Fabulous. You guys are doing great. What about this? I don't know if you guys can make that out very clearly. Um Maybe not. I don't know if it's blending in with the grid. Yeah. So that's Asystole. That's your kind of flat line that you see on um on TV and on your programs and everything. Yeah. And you're right, it's nonshockable. Someone said um in the chat definitely. What about this one? Again? I apologize for the kind of quality of the image. I don't know how well that's kind of coming up on your guys screens. A bit of a pause with this one. Fair enough. Um So this one is P Wave, Asystole. So you can see here you've got your P wave. So the Atria are contracting, they're doing something but there's no ventricular activity there that you can see. Um, so that's still kind of asystole. Um, it still won't be compatible with a pulse and it is also non shockable as you can imagine. Um, and then does anyone know what P EA would look like on a rhythm strip? Mm. Yeah. So a lot of different kind of answers in the chat box, which is good. Um, because it's heterogeneous. So it's any rhythm that kind of looks like it should be compatible with an output and a pulse, but there's no pulse there. Um So it can look like a bradycardia, it can look like normal rhythm. It can look very atypical, but you can see complexes and things. But if there's no pulse there, then we call that pulseless electrical activity. Um or pe is that shockable or nonshockable? Nonshockable? Lovely good. You guys are doing great, fabulous. Um So those are your four rest rhythms. So VF pulseless VT Asystole and P EA, you've got two shockable rhythms and you have two non shockable rhythms. So, working our way through the algorithm, you can see that once we've assessed the rhythm, if it's shockable, we deliver a shock and then we immediately resume CPR for two minutes. A big part of resuscitation is minimizing the interruptions to good quality CPR and that looks like having people switch in and out and it looks like having people straight back on the chest after your rhythm checks or after your shocks, if it's nonshockable, you're straight back on the chest doing CPR after that rhythm check. Cool. Um So alongside all of this, while you're, um doing your CPR cycles, while you're checking the rhythm, while you're delivering shocks. If it's a shockable rhythm, um, your team lead will be doing kind of three things, um, or delegating three things. We'll be addressing reversible causes. Um, as to why that person has had a cardiac arrest, they'll be doing things to manage that person's airway and oxygenation and to minimize kind of hypoxic injury. Um And there are obviously resuscitation drugs that are administered as part of kind of um a life support. So we'll go through each of those intern with reversible causes. We'll talk through this in more detail, but the reversible causes of the cardiac arrest can be broken down into four Hs and four Ts. Um So if that jogs your memory, we'll have a bit of a chat about that later on with airway and breathing. So, um initially, uh what I mean by definitive airway is something like an eye gel, um like a laryngeal mask, airway or an um an et tube and endotracheal tube if someone has a definitive airway. So either of those things, you can give continuous compressions if they don't and you're ventilating with something like a bag valve mask. Um You will need to give 30 chest compressions and then two breaths um throughout um the kind of resuscitation effort you'll be giving people 100% oxygen. Um And it's important to have waveform capnography as well. So that's a kind of kind of um leader transducer that goes in that detects the amount of expired carbon dioxide. Um And again, that's a good indicator of whether someone has um output and respiratory effort because they need both of those to um exhale CO2. And it also kind of shows you about the quality of CPR. So your um expired C OT will be higher in good quality CPR. And then with resuscitation drugs, does anyone know what we would give during a cardiac arrest? There's two main ones I'm thinking of. Mhm Adrenaline or epinephrine. Yeah. And amiodarone. Lovely. Um So you get IV access. If you can't get IV access, you go um for intraosseous access. Um and that's with an IO gun kind of either in the humerus or um or the shin. You give um adrenaline every 3 to 5 minutes and then you give amiodarone once um only in shockable rhythms and you give that after the third shock. Um Lovely. So reversible causes of cardiac arrest. We'll go through them all. Um But does anyone know any of the four Hs or the four Ts hypoxia? Lovely. We'll also talk through kind of how we address them as well. Hypovolemia. Yeah. Hypovolemic arrest, hypothermia, hyper hypokalemia. Yeah, lovely. And then any teas tamponade perfect tension pneumothorax, toxin and thrombosis. Gosh, you guys are great. Yeah, so definitely um hypoxia hypovolaemia. Um hyperkalaemia and metabolic are kind of grouped together in my head, hypo or hyperthermia. Um in some cases can cause cardiac arrest, thrombosis. Um by that, you mean kind of mis um cause I know someone kind of commented earlier that um a cardiac arrest was an M I and M I can be a cause of a cardiac arrest and that would fall under thrombosis tension, pneumothorax, um tamponade or toxins as well. So, um how do we address each of these or how do we kind of identify that that's what's caused the cardiac arrest. So, with hypoxia, obviously, you're delivering 100% oxygen, um you're ensuring that someone has um, a, a kind of definitive airway in place and you're giving them rest or someone who is giving them rest, um, at a, at a rate and someone's just commented, what does the f one usually do for the cardiac arrest call? I have a slide on that. Um It's coming very shortly. Um And we'll talk through kind of your role as the fy one within the cardiac arrest team because that was definitely something I wondered, um when kind of listening to these talks about cardiac arrest, but we'll talk through the theory kind of first and then we'll talk through what you do as an fy one. Um So with hypoxia, there might be a period where someone has had an asthma exacerbation. Um, there might be, um, they might have been kind of hypoxic on their oxygen shots prior to them arresting. Um, it tends to be kind of ap ea um or asystolic arrest as far as I know because there isn't a kind of primary cardiogenic problem. It's um the lack of hypoxia. Um, it's the lack of oxygen or the hypoxia um with hypovolemia. So these patients will either have loss of fluid or loss of blood. Um So look for kind of signs of major hemorrhage. So, is it a trauma that's coming in? Is it someone who's come in with an upper gi bleed? Is it someone who's got a known AAA? And they've got this really bad chest pain, it's been going on to the back and then they rest in the waiting room with loss of fluid. Um kind of think of your um your sepsis or your pancreatitis or your burns. Um and try to replace like for like so replace fluid with fluid. Um And when you go to your cardiac arrest, you'll often see someone just holding a bag of fluid with a pressure bag like this and pushing it through um kind of quickly as they can if it's blood, replace blood with blood and consider um obviously, in any cardiac arrest where you think um hypovolemia is the cause you'll be activating major hemorrhage protocol and you'll be trying to get as many blood products as you can. And that's normally kind of in a ratio of red blood cells to um plasma to platelets to kind of recreate the constitution of your normal blood that you're giving to that person. Um with hypo or hyperkalaemia kind of metabolic causes. Um So, um you'll see someone will be trying to get like a femoral stab or a radial um gas to just get like a, a blood gas they'll be sending off um kind of full panels of blood. Um just to kind of see if there's any metabolic cause and then correct anything that's reversible. So, um for hyperkalemia or hypocalcemia, giving your calcium gluconate, um giving your kind of medical management of hyperkalaemia if it's hypoglycemia, giving glucose et cetera and kind of correcting that. So, um when you take the gas and it comes back, the team leader will often just read that out to everyone and kind of go through every electrolyte and make sure that everything's ok and address everything that needs to be with um hypothermic arrest or hyperthermic arrest. Um So with hypothermic arrest, um make sure you have kind of low temp thermometers that can detect kind of lower temperatures. Um it's often a prolonged resuscitation. So, resuscitation efforts are ongoing until the person's temperature normalizes. Um And then it's only then where you kind of reevaluate kind of um when, whether to continue whether to stop resuscitation efforts. Um It's a bit of a crude saying, but it's often kind of commonly said that, you know, someone hasn't, isn't dead until they're warm and dead in the context of a hypothermic arrest. Um So you want to suspect these in kind of people who have drowned or with exposure? Um kind of pathology. They've come in and they've been hiking in the mountains, et cetera. Um So thrombosis then um with a CS obviously consider kind of PC. Um So referring them for angiography um with ongoing CPR via your kind of CPR machine or your lupus. Um consider that in kind of people who have risk factors for A CS, there's nothing else that you can kind of um detect or they've come in with um ST elevation on their ECG et cetera. Um or they might have briefly had kind of a return to spontaneous circulation, you can see ST elevation. So it's important to get a look inside their coronary arteries. Um consider whether it might be a pe in the context of kind of pulmonary embolisms that have caused cardiac arrest. Um Resuscitation is often prolonged, kind of 60 to 90 minutes. And then you use your kind of CP A machine or your lupus so that you're not kind of switching out two people for 90 minutes at a time. Um You can consider kind of thrombolysis. Um But that's obviously not a decision that's taken kind of um lightly and it's always kind of a senior decision that's been made. Um How do you detect a pe and cardiac arrest? Well, um some people kind of have skills and have done courses in point of care. Ultrasound. And so with massive P ES that have caused a rest, you get this like strain in your right ventricle, your right ventricle and an echo will often look bigger than the left ventricle, which is not how it should be normally. And so, um if you see someone kind of with an ultrasound probe just under the sternum, that's what they're looking for is right ventricular strain. And to consider whether it might be potentially a pe tension pneumothorax, then um so when they're kind of um bugging the patient up at the top end, you might hear the team leader ask, um if the person is kind of easy to ventilate, you might um hear the leader ask for someone to kind of listen to both sides of the chest to ensure there's bilateral air entry, have a look at the etcetera. Um You might also detect it on kind of point of care ultrasound. So when you put an ultrasound probe on the chest of someone who's had who's got normal lungs, sorry, you'll see the two pleura kind of sliding over each other and there'll be two white lines. Um And you'll see them moving that's lost in a new sox. So if you do suspect kind of potential pneumothorax, um it's needle kind of cardio, um needle thoracocentesis, sorry. So you'll get um a cannula and make sure it's one of the ones that bleeds back in order to release air. Um conventionally, they're kind of put second intercostal space, midclavicular line. But I now think guidance is moving towards kind of fifth intercostal space, um mid axillary line except in kids where it's still second intercostal space. Um But obviously kind of make sure that you follow local guidance on your seniors if you've got any concerns about that. And then obviously the definitive management after that, if that resolves kind of um uh the cardiac arrest is is inserting a chest strain uh with cardiac tamponade. Um So you're kind of traditional signs that you might have learned about in medical school that you see in people with tamponade who um have their own output, like raise J BP, muffled heart sounds, et cetera, they're all obviously absent. And so you have to kind of do a bit of detective work to work out whether or not you think it's the tamponade that's caused the arrest. Um Consider it in patients who have had kind of recent cardiothoracic trauma or surgery or they've come in after road traffic accidents, et cetera. Um And the way that that would be addressed would be a thoracotomy, obviously by a specialist and senior um clinician and then with toxins, kind of look at patients, um drug charts, look at their history. Um Is there any suspicion that they've ingested something that's caused the cardiac arrest. Um, and then kind of look into reversing that or addressing that with kind of guidance specific to that, um, toxin or that drug if necessary. Does all of that make sense? Um Does anyone have any questions about any of that? Not yet, I've just said a lot. So maybe kind of still processing, I'll keep an eye on the chat box just in case. Um, So cardiac arrest for fy ones, I know a couple of you were asking. Um So obviously the team leader will be coordinating the resuscitation efforts. They'll be thinking about the reversible causes. They'll be making all of the kind of decisions that guide the resuscitation efforts. Um So what's your role? So what I would say is as the fy one, you will more than often, more often than not be scribing. And so when you get to cardiac arrest, um obviously run straight to the patient in case you're the first one there. But if you notice that there are a couple of people already there which there might be run and grab a computer, start scribing, start looking at the patient's notes, etc. Um I'd encourage you guys to just kind of eyeball the situation. So we've talked through kind of what happens during resuscitation efforts and what things need looked for and done. So kind of have a look at what needs doing. So um is there an eye gel and does someone have an O2 mask on? Is someone bagging and providing breaths? Um Are there enough people to alternate chest compression? So, kind of a good two or three? Um, have a look at the patient's access and does it look like it's patent? Um Obviously, do they have like a blue cannula in the toe? Um If that's the case, then maybe kind of grab a, a cannula or two if you feel um competent and try and get some better access. Um Do we have the adrenaline and the amiodarone et cetera kind of at hand? And do we have flushes as well? Cause remember that person's not gonna have a circulation to kind of um get that drug administered. So putting through loads of flushes after you've given any drug is really important. And as I mentioned, kind of grabbing a computer to check the patient's background to check any investigations. Check. Recent imaging is als als always really useful as well as obviously checking their ceiling of care and things like that. Um Yep. So we've mentioned kind of scribing and documenting the arrest. Um And then after the person has returned to spontaneous circulation, um, often kind of as the fy one, you'll um have a bit of oversight because you'll not be the one who's trying to get IO access et cetera. And so you might be able to peel off and call anesthetics and intensive care and the parent team. Um and then consider whether there's any families that need updating as well and lis with the charge nurses and asking if you've got a relative's room and can they call the family in et cetera? Um So obviously, when anyone has a return of spontaneous circulation, um the main kind of concern is that during their downtime or during the period where they didn't have a pulse, um their organs won't have been um perfused as adequately as someone with their own circulation. And the real concern is kind of a hypoxic brain injury. And so all patients who have had a cardiac arrest, who have the spontaneous return of circulation, they're brought up to intensive care, they're sedated to reduce their kind of brain and metabolic demand. Um Things are kept kind of within really normal parameters. And the aim of all of that um is kind of that we can prevent the primary hypoxic brain injury. But the aim is to reduce secondary injury and it's for kind of neurop prognostication. Um So we know that kind of within the 1st 24 hours how a person is neurologically doesn't correlate very well with how they might do in the longer term or whether they're likely to survive to discharge etcetera. So that period of prognostication happens in the intensive care environment. And so as soon as you've got kind of return of a pulse, letting the intensive care team know that you've had someone who's had a cardiac arrest, um is really important and often that will be done by seniors. But again, it just depends, kind of how many people are there. What I will say is that every shift I've had on a cardiac arrest team, there's normally a brief at the start of the day, people assign rules, people make sure you're comfortable with your roles. And obviously, if you're ever asked to do anything that you're not comfortable with and kind of verbalize that at the, at the kind of start of your shift or at the start of the arrest. Um um The rest are often kind of a good opportunity to um to gain experience in these things. Um But obviously, it's important that you kind of um feel ready for that and you feel supported in that as well and patient safety is obviously the top priority. Um So what do you do if you're first onset, you know, you witness an arrest? Um I don't know about you guys, but this was something that particularly concerned me before I started my shift on the arrest team. Um So what do you do if you are called to see a patient? Um And you actually are the one who finds that they have arrested or you're um due to a cardiac arrest and you're the first one on the scene. So the first one you always do, if someone doesn't obviously look kind of responsive and alert and things as you check for a response so you shake them. Um You kind of shout um and try and kind of and get their attention, call their name and ask if they're OK. And if you've got any doubt that they're responsive, you shout for help. Um You obviously do that by physically shouting or you can pull the red buzzer if you're concerned that someone's not responsive. Um Then if the patient doesn't onto their back, move the patient onto their back um airway maneuvers. So kind of your head tilt and chin lift and your jaw thrust and then you look, listen and feel for signs of life. So um the way that they kind of would teach you to do that on A S is you'll move over um kind of so that your ears on, over their mouth and nose that you can um listen for any breath sign and you'll also be able to feel someone's breath on your cheek. You've got one kind of finger on the carotid pulse and then you're obviously looking towards their chest for any respiratory effort as well. Um Obviously for no longer than 10 seconds. And if you, if they don't have an output or if you are in doubt, then you treat that as a cardiac arrest. So you pull the red buzzer, you shout for help again and you verbalize that this person's had a cardiac arrest. Um So Resource council guidance, um I think I worried about this kind of what do I do if I'm alone, do I just leave that patient, et cetera? Um And resource council states that if you're alone, you leave the patient to go and get help and equipment and then you come straight back. Um So um pulling the buzzer will often kind of do that job for you where it will bring people to you, but you can kind of start compressions and things. But if you absolutely have to leave the patient to get the help that they need, then kind of do so as quickly as you can. Um closed loop communication is something that um is talked about a lot. Um But I find that it's kind of particularly relevant and it helps to distinguish kind of well managed arrest from arrest and are managed a bit um kind of the where the scope for improvement. Um So close new communication is where you ask someone to do something and you ask that person to come back and tell you that they've done that thing after they've done it. So can you go and put out a crash call by calling 2222, get the cardiac arrest to this ward and you come, can you come back and tell me when you've done that? And it's just a really useful way of kind of identifying any problems or any delays. Um And it sounds a bit kind of silly when you're saying all of it. But actually, it's really important to kind of know where everyone's up to and know what things have been done and what things haven't explicitly because obviously you can imagine that this is a very stressful situation. Um And people kind of have the propensity to, to forget things. So using closer communication. Yeah. Um, bringing the crash trolley if you haven't already. Um, obviously someone's doing compressions this whole time. Um, and then kind of apply the pads for a rhythm check. It's important as I said earlier that there's kind of minimal um interruptions to chest compressions. And so someone's often kind of doing chest compressions, they'll put the lateral pad on and then they'll just kind of put the anterior pad on and with kind of minimal um interruption and then straight back on the chest. Um So kind of the patient will need ventilation, they'll need oxygen administered. Um And obviously, that's kind of according to um to your skills and kind of um how comfortable you feel. Um So that can be with like a bug bulb mask, but you would need a really good seal on that or with an eye gel as well. Um A lot of hospitals and with their teaching are kind of really good in um kind of talking through inserting an eye gel. Some of you might have had that in clinical skills um at medical school, some of you might yet um and some of you who are offered the chance to do a s before you start will kind of be talked through how to insert an eye gel. Um Obviously, then once you've done it, you need to make sure that it's working. So um check that your ventilation is adequate, so check that you can see the chest will rise, um et cetera and um popping on your capnography as well. So starting a timer is really important and this will kind of dictate when you do your rhythm checks. Um plus minus administering um shocks and things if it's a shockable rhythm. Um So making sure that someone starts a timer as soon as they're free and then if you're still not the most senior on the scene, asking a colleague to kind of take over compression so that you can do what needs done. So insert an eye gel if you're competent or kind of step to the foot of the bed and think through what else needs done. Um I will say that um with the crash kind of team, if you put out a cardiac arrest, go early, help will get there quite quickly. Um This, this is probably um overkill in terms of what you will realistically need to do. It's definitely not kind of as far as I've gotten when I um have witnessed arrest kind of um myself, but it's always kind of good to think through what the next step is so that you can kind of be a part of that team and think, right, that person's doing that this person is doing this um subscribing it in a rest. Like what do you document? How do you document it? Because that will be what you do most frequently as an fy one. Um So you've obviously got your algorithm bits, your rhythm shocks and drugs. Um And I'll often just document kind of um times of things. So, um 09 31st rhythm check VF shock given, et cetera. Um The team will normally verbalize what rhythm it is or at the very least, whether it's shockable or non shockable if you're not too sure. And sometimes it's obviously really hard to tell. Um make sure that you kind of wield the computer um in such a way that you're not in anyone's way, but you can kind of see the monitor as well. Um And document kind of what drugs are given and when so, you know, 09 45 adrenaline given um 09 48 et cetera. Um And again, I just kind of have that in chronological order and I'll note the time um at the same time that different things are, are done, I'll then have um the HS and Ts in like a second separate paragraph and I'll flip between the paragraphs. So, um see what you see. So if you see kind of fluid being given or blood products being hung or someone saying, you know, I've activated the major hemorrhage protocol, put all of that in. Um, if someone's hypothermic, um, you might see bear huggers like a big inflatable kind of warm, um, blanket or you might see kind of active, um, you're more likely to some kind of active warming. So things like warm IV fluids or, um, gastric lavage or bla bladder lavage with warm fluids where they'll catheterize or they'll put an energy and they'll put nice and warm fluids in um ABG results as well. Um Any electrolyte replacement or gluconate or anything that's given. Um If you see someone kind of putting a probe either on just under the sternum here, they're checking for kind of right ventricular strain and they're checking for a pe if you see them, put it on the side of the chest, they'll be checking for the sliding to rule out a pneumothorax or if you see kind of someone getting out any al to play and reading labels and administering it or talking about al um thrombolysis or al to place, then document that as well. And then obviously your kind of nonclinical or human factory stuff as well needs to be documented. So if CPR is stopped, it's um always a whole MDT decision. Um and you'll see the team leader kind of think um verbalize that. So we have tried Xy and Z, we still don't have an output. The down time has been this many minutes um what do the team kind of think? Do they think we should continue resuscitation efforts or do they think we should stop? And obviously every one of them will have an opportunity to say whether they think that um resuscitation effort should continue or whether they should stop. It's also really important to document kind of whether the family are present as well. Um Some families will be or some families kind of want to see resuscitation efforts, but it does kind of help um you know, uh doctors updating the family, et cetera if they know whether or not the family were there actually during the resuscitation. So before we move on to the next bit, does anyone have any questions about cardiac arrest? I know that was a bit of a whistle stop tour. Um And obviously as I mentioned, um an fy three. So um I'm by no means kind of an expert in this, but that's just kind of my perspective of what I have learned is useful as an fy one on the cardiac arrest team. Ok. No questions for now. Fair enough. I'll keep an eye on the chat box anyway. So if any, if anything kind of comes to you just um fire it in. Um So the next bleep then um is from one of the staff nurses to say that your patients arrived on the medical admissions unit and they're wondering if you can come and clock them in. So this is my kind of clerking structure. Um Can anyone kind of think of different things that they might include when they're clerking someone into hospital or doing an admission clerking? Like within these kind of main headings? Yeah. Yeah. So the patient's ideas concerns expectations. Sure, definitely. Um So within the kind of presenting complaint, um admission problem, obviously, kind of how long it's been going on like your Socrates structure basically, but you can apply that to things that aren't paying necessarily. Um, so kind of how long it's been going on for whether it's been getting better, worse, et cetera associated symptoms. Um with their background, I like to kind of take a background of their medical history but also kind of how well um things are controlled. So they have diabetes, but are they insulin dependent and have they um got kind of end-stage diabetic nephropathy or is it actually just died managed? And they've got a borderline HBA1C. Um also kind of include your social history as well. So, and alcohol, smoking drugs as well as um people's exercise tolerance really important because if patients get kind of more unwell further down the line and they need to be considered for something like intensive care or um a high kind of dependency care or anything above ward level, it's useful to get a feel for what their functional baseline is and their, and their kind of frailty level. And it also helps to kind of triage them into an appropriate team, managing them. So someone's really frail and it might be a good idea to kind of have them kind of admitted under a care of the older person's, um, evaluation team or frailty team as opposed to someone's really fit and well, they might require something different. Um, so with their drug history, obviously their regular meds, their allergies and then consider which of the regular meds they should continue having, which of the regular meds actually need to be withheld, um, kind of based on what they've come in with. Um, and then you've got kind of your assessment. So your history and your exam, you've got investigations, you've got your differentials and your impression and then you've got your plan. So kind of including where is an appropriate person for that person, um, place for that person to have care and kind of really, you'll be making decisions about the plan and what your differentials are and what investigations you'll order as you're assessing them. And so all of these four kind of boxes meld into each other where you'll take a bit of a history and then your clinical assessment, um, you'll be kind of ordering investigations contemporaneously and things. Um, someone's put systems review as well, which I think is absolutely right. So, um, do your full kind of a to e but then make sure you've covered kind of cardio and respiratory, make sure you've covered fluid balance, make sure you've covered, um, gi and, and their kind of bile and things regardless of what they've come in with, have a look at their limbs for any signs of DVT, et cetera in every single patient. Just to kind of do a thorough, um, kind of review the full of all the systems. So this is the patient, um, that you're clerking in, um, and you can see an A&E note from, from me and it's not a very good one. So this person's been seen by Eva the um emergency department sho um the patient is a 20 year old female. They're normally fit and well she was brought in by ambulance after a collapse query cause at work. Um her blood glucose was 40 with the Northwest ambulance service G CS is now 14. Her heart rate's 30. Her BP is 98/56. Um respirate is 22 chest is clear. Um And so my plan was a bag of IV fluids. Um a couple of units of novorapid and I've made the decision to admit to the medics which is yourselves. Um So what do you guys want to know or what do you think might be going on? Mhm. Definitely. So drug history Systems review. Yeah. So this is what you find out when you go and take a history um from this 20 year old lady. Um so she's had three days of kind of nausea and vomiting. She's had a bit of abdo pain. Um, she's been polyuric as well. She actually thought that she had a UTI, so she's been drinking a liter of cranberry juice every single day. Um, she works in an office and she stood up from her desk this morning to go to a meeting. She felt really dizzy. Um, as soon as she got up and then she collapsed, um, with a loss of consciousness with her background, she's normally fit and well, she's never been to hospital, has never seen a GP, apart from, um, her smears, um, she's on no regular meds. Um, she drinks kind of two glasses of wine a week. She does Vape, um, she doesn't do any recreational drugs, um, exercise tolerance wise as I said, she kind of works in an office, um, but she's actually in a running club at the weekends. Um, she makes her to get in kind of 10,000 steps a day. Um, and she's quite fit and well, um, grand. So someone's kind of mentioned possibly type one or type two. and I think it's important to kind of bear that in mind. Definitely that the prevalence of kind of type two diabetes at earlier ages, um, is something to be considered. Um, let's say, um, this lady has had a height and weight. Um, she's got a BMI of 21. Um, she does exercise even though her job is kind of primarily sedentary. Um, so this is her A to E. Um So before we kind of move on, what do you guys think you might include in your A to E, what might you be worried about? What treatment might you give as you're going through? And again, it doesn't have to be in the at E order. Just kind of fire on what you're thinking. Um might need looked at from an investigation perspective or what might might be done from an intervention perspective, someone's put hyperglycemic earlier. So I imagine um ABM would be, would be useful. Yeah, check her glucose. Um Katie's worried about sepsis definitely, which could be a cause of DKA, which a couple of people have mentioned for sure and always kinda consider, could it be sepsis. Um Anyway, lovely. So I've got a couple of of um really solid suggestions. So with Katie's airway and with anyone's airway, you look, listen and feel for any threats to that airway. So um reduced gcs, any vomiting, any um blood, any facial trauma. Um You listen for um air entry primarily and then also for any kind of stride or a ster which might concern you about airway obstruction. Um and then you feel for any threats to the airway. So, um if your tea is deviated or you've got kind of lip swelling, um or you're concerned in the um context of A DK A, your main threats to that airway are gonna be vomiting um and aspiration kind of secondary to that vomiting, they might be a low G CS um because it kind of below a certain G CS. Um You lose your neurologic protective strategies for your airway. As always with um this patient, um with any patient, if you're concerned about the airway call, a senior call, anesthetics, use your airway maneuvers and your airway adjuncts if possible. And we talked through that kind of on a previous talk that I did about um about airway adjuncts, but I'm happy to field any questions if anyone has any with breathing. So, um this lady's got a respirate of 20. Um I'll elaborate on that slightly by saying that she does look like she's got kind of an increased work of breathing. Um But she's saturating, ok at the moment and we'll see her s and things later on um hyperventilation or that like kind of coal breathing that you're taught about in medical school is a really late sign. So don't always rely on that. Um And don't always kind of wait until it gets to that to treat it. So if CS are low or the patient is breathless, just apply high flow O2. Um So we see um this patient, you then retake observations, the heart rate's now 130 BP is now 87/49 and the cap refill time is about three seconds. So with DK A obviously dehydration, hypovolemia are concerns because of kind of how much fluid's been lost and through polyuria and IV fluid resuscitation is one of your three main kind of pillars of managing DK A. However, um there's a risk of cerebral edema with excessive fluid if someone develops cerebral edema in the context of BK A, that can carry a mortality of up to about 70% according to B NJ, it's kind of best practice. So if someone has any signs of that to reduce G CS confusion, drowsiness, escalate that to a senior urgently um with this lady. So her BM has gone from 40 to 37 with those four units of novorapid. Um with um DK A, you'll want IV insulin and you'll want an infusion and that will be fixed rate. So it'll be not 0.1 units per kilogram per hour. Um up to a max of 15 units per hour if the person was above 100 and 50 kg and with E um so the patient last vomited about an hour ago, um abdomen and calves are soft, nontender. So you can't see any signs of peritonism. You can't see any signs of DVT with DKA because of the hemoconcentration associated with the dehydration DK patients are really prothrombotic. So ensure they've got teds, um ensure they've got their kind of flutron or their um kind of compression and pneumatic stockings and ensure that they're prescribed DVT prophylaxis. So, um it in the hospitals I've worked in, it's been a little more likely with heparin. Um Yeah, so Katie's commented, fluids reassess and responding insulin glucose if needed, potassium, monitor, input and I put and check ketones definitely. And we'll talk through all of that in the, in the management slide. A few more investigations for you though before we get started. Um So Katie's mentioned that she's concerned about sepsis. Um You were as well and so you've ordered a chest X ray. Um We've ordered some bloods. Um and you've had a little look at what the obs have been doing. Um And you can see that the obs have been kind of taken 2 to 1 hours um interval in between them. Does anyone have any thoughts about any of those um investigations? So what does the chest X ray look like to you? What can you kind of see about the trend and the observations? What do you think of the bloods? Sodium's high? Yeah, definitely. So again, she's really dry, isn't she? So, yeah, so I'd say that's nice and central. Yeah, lactate is high. Ph is low. Yeah, definitely. So this person is acidotic. Your lactate is very high. Do you think there's a pneumonia on that chest X ray that could explain the DK? No, no takers. Good. No, not particularly. Um So your chest X ray is normal with the investigation. So a mild leukocytosis or raising your white cells is common in DKA. If it's really significant, then consider whether your infection has caused decay. Um low sodium and high potassium is common, but high sodium and low potassium indicates a severe decay. Um And again, that's to do with the kind of hemoconcentration and things your hypokalemia also makes it more difficult to manage because insulin will lower your potassium. Um And so that has to be considered and you have to kind of see your input if you're worried about a low potassium before you've started your insulin or during any other investigations that you guys might want to order. So you've done your chest X ray, done your bloods, you got your abs, no takers fair enough. It's been a long talk already. Um Yeah, so obviously kind of try to identify and address causes of DK and your investigations will help you in that. Um So it can be a first presentation of diabetes. Um, infection can be a cause. So consider chest urine abdo. So we've had a chest X ray, we've examined the abdomen. Um, patients who um are known diabetics um might not have been taking their insulin or kind of been taking insufficient insulin. Um Myocardial infarction is a really important um kind of differential to consider and there was a troponin in those bloods, but I would definitely manage that. Um marry that with an ecg um pancreatitis can cause it as well and we had anomalies which was normal for this lady. Pregnancy can cause it. So you'd definitely be wanting to get a serum beta HCG, um, trauma, particularly which this lady doesn't really report she had a bit of a single episode. Um, surgery can, um, kind of precipitate DK A. Um, and a lot of drugs kind of both prescribed and illicit can, um, can precipitate DK A as well. So it's always really important to take a robust history. Have a look at the person's DP records previous like medication, um, reconciliations and things from admissions if they've been in hospital recently are all really important um to identify what's caused the DKA um managing hyperglycemia and dehydration then. So people have kind of commented about insulin, they've commented about fluid and I think both of those are really important. So, um with IV fluids, so you wanna give boluses um like fluid resuscitation to achieve um a reasonable systolic BP. And then after that, you'll want to do kind of fairly robust um kind of fluid replacement after that. So a liter, over one hour, a liter, over two hours, et cetera. Um your insulin, as I said, is given during an IV infusion at a fixed rate of 0.1 units per kilogram per hour. Um And then when do you kind of stop it? So, um consider whether the patient's eating and drinking. Um if they're not eating and drinking, you'll wanna switch your fixed rate insulin infusion to your um variable rate insulin infusion. If they are eating and drinking, you can kind of either restart their normal subcutaneous insulin or if this is the first presentation of, um, diabetes and you'll want to get diabetes specialist nurses involved to kind of put them on a, um, subcutaneous insulin regime. You'll want to catheterize them and monitor the urine output to make sure that the fluid you're kind of giving is having an adequate response in terms of renal perfusion and urine output. And then any patient, whether they've got known diabetes or not will need a referral to the diabetes specialist nurses. And then I put a bit monitoring for complications. Can anyone think about any complications of DK A that you might get kind of in the short to medium term? Ok. People aren't too sure. Um if I give you guys kind of hints, we talked about one of them and it was associated with giving um fluids. Mhm Yeah. So kind of fluid overload. BT. Yeah, definitely because of the hemoconcentration. Yeah, people are um prothrombotic. So you want to give kind of your venous um thromboprophylaxis. Definitely. Yeah, lovely. And someone's mentioned cerebral edema and things as well. Fabulous. So we mentioned hypokalemia. Um so from the second liter of fluid, you'll be wanting to give potassium as well because you know that your insulin is gonna lower the potassium um with your insulin um being administered IV and that kind of a constant rate there is the risk of hypoglycemia and actually overshooting it. And so um if your BM. Um, or your blood glucose reduces to less than 14. Um, you'll have the insulin and you'll also have 10% glucose running until the patient's eating and drinking. Um, and that's normally kind of at least half meals. Um, venous thromboembolism is a huge risk. So, consider your DVT prophylaxis, your low molecular weight heparin. Um And then we talked about an aspiration risk as well. So if the patient is not following commands, they're persistently vomiting and you're worried about aspiration in certain energy and get all that aspirated out um to kind of reduce the risk of vomiting and aspiration. Um So, not all patients with DK will need it, but it's definitely something that you need to consider if that person is just not quite right or the G CS isn't quite right and you're not happy with it. Um And in some patients, actually, um ward level care or care on the M AU isn't appropriate. And so there are a lot of different um factors or parameters for what you'd call the HD or the IT and DK A. So really deranged biochemistry and that's normally like a profound acidosis, it's refractory to management, it's not improving. Um it might be electrolyte abnormalities. So if someone comes in hypokalemic and you know, they need insulin, but they might also need kind of central replacement of kind of potassium at a higher dose. Definitely a reason to call at the intensive care unit or the high dependency unit. Um, if someone's got a low G CS and you're worried about their airway, then, absolutely. Um, if you, um, if there are kind of patient factors and that mean that that person is particularly comorbid or if they're pregnant or they have cardiac or renal, um, kind of ii impairment or, um, uh, factors that you're worried about, um, or if they need organ support. So if they're needing kind of um medication or um drugs to maintain their BP, that can't be given on a HD or an ITE um that can be given outside the HD or it then definitely be um calling that person for a referral. Um These patients obviously can get quite sick. And so it's really important um with every patient that you clock in kind of think about where is the most important um place that you can manage them or where's the safest place you can manage them. Sometimes that's on the ward, sometimes that's on a monitored bed, but sometimes it's um the high dependency in it or the ITU. So always have that question in the back of your minds in terms of monitoring then. So this is from um BM J's best practice, um kind of algorithm on managing DK A. And I think um essentially it just kind of delineates that for the first kind of three hours you're monitoring everything. So ketones, glucose, bicarbonate, potassium and Ph. So that will be ketones and a and a blood gas. Um and then after three hours, some things you need to check every two hours, some things you need to check every hour. So ketones and glucose are and then your electrolytes, your ph um and your bicarb um every couple of hours after that, um that might change based on whether the person is improving or not improving or what seniors feel. Um But it's kind of a good um a good baseline to go off. So patient may um unfortunately remained kind of hypotensive, remained acidotic despite IV fluid resuscitation. And so she was admitted to the ICU for ongoing care. So she had her fixed rate insulin. Um she had insulin, um potassium replacement, she had fluid resuscitation. Um eventually after she was eating and drinking her um IV insulin was converted to a subcutaneous regime. She had education from the diabetes specialist nurses and she was discharged home five days later. Um So well done. You guys have saved your life and this is your final bleep of the night. It's been a really long shift. Um This is from one of the nurses on the medical admissions unit who says that she's worried about her patient who started slurring their words. Can you come and review them? So, um let's go and have a look at them. But what is kind of going through your head or what are you guys gonna do? How are you gonna approach this patient. Um, and the fact that they started slurring their words. Mhm. For sure. Ok. Pretty anonymous concerns about a stroke there. I agree. Um, so this is Patient B um, last night you can see at, um, nine o'clock he presented to the ed, he had um, a community acquired pneumonia, um which is a curb three. So, um, for those of you who don't know that your, um, severity kind of scoring system for pneumonia is where you, um can kind of stratify who needs admitted and who can be managed at home. Um Patient B was found to be um in the AF on the admission E CG which was new and they attributed it to um a pneumonia. So, after waiting for a few hours, they, um, were clocked in by the acute med team. Um, they were started on some antibiotics for the pneumonia. Um, so patient B then got a couple of hours sleep, he was woken for his morning obs at about 645 in the morning. Um, at that point, his sneeze was zero and his speech was ok. And then at half eight, a couple of hours later, a healthcare assistant brought him in breakfast, um, and he noticed a facial droop and a bit of an odd speech. Um, so he escalated to the nurse, um, who's now you and it's about 850 in the morning. So it's just before your morning handover. Unfortunately. So, um, again, kind of running through your, at E, I've done this very briefly because you've kind of correctly identified that the most kind of time intensive thing and the thing you're worried about is a stroke. Um, obviously you still kind of have to go through your at E first because, um, any airway problems will be, um, kind of fatal before any problems. Um, but we kind of know what's going on from that history, don't we? Or we know what the most likely differential is. So, again, kind of looking, listening and feeling for any threats to the airway. Um let's say at the minute, patient B um is a G CS kind of um 13. Um You can't kind of make out what they're saying, but um his eyes are opening spontaneously and he's following commands um with B um with a stroke, it's a bit like um an acute coronary syndrome in that you will only give oxygen um if the person is hypoxic, um very liberal kind of oxygen therapies associated with a higher mortality and stroke. And so keep an eye on the stats, definitely have your kind of oxygen mask nearby. Um But um kind of only give supplemental oxygen if the person stats drop below 93 um with C kind of monitor for atrial fibrillation. And we know that patient B had AF on the admission E CG which was new. Um And then kind of managing B you've taken your BP. Um, only kind of treat a high BP if there's any signs of end organ damage. So the person has chest pain or they have an A CS or they're encephalopathic. Um, or if the person, um, might be going for thrombolysis, you wanna keep their BP kind of below 1 85/1 10 and then we move on to D so this person needs a CT head, they'll need a glucose, obviously, because hypoglycemia can mimic kind of strokes um and monitor their G CS. Um It's really important once you guys kind of start at the hospitals to um ascertain what services you have. And if you have um a hyperacute stroke unit and a stroke team on, on site, then great. If not, it's always really good to ascertain where your nearest stroke center is and how you get in contact with them. Um, that stroke unit will need to evaluate them for treatment of their stroke. Um And in the meantime, you'll need to kind of repeat the CT if they show any signs of neuro worsening. So if their G CS drops or they have nausea, vomiting, really severe headache or raised um BP, um all of those um would make you concerned for um signs of a raised intracranial pressure. Um With e um obviously, with someone who has had a neurological injury, you'll be unsure as to kind of whether their neurological airway protective strategies are intact and their airway protective reflexes. So any stroke patient needs to be null by mouth until their swallows assessed by speech and language therapists. And then with regards to, um, kind of temperature, maintain kind of normal temperature, um, we know the kind of cooling doesn't help patients that might cause harm. So there's no point in kind of therapeutic hypothermia but definitely kind of treat any fevers with paracetamol. Anyone with any questions on that. No, not so far. You guys are wanting um your bed and talk about a big brother. I imagine I'll try and pop through the last bits quite quickly. So I've put this on, um, and I've screenshot of it from the DC app which I um highly recommend if one gets, um, this is your modified um NIH stroke scale. Um So you kind of input what the person's um, motor and sensory and cognitive deficits are and it gives you um kind of points which um allows you to stratify the severity of a stroke. Um It can be used to kind of guide ongoing management. Um And it's also kind of important to document in case there's any kind of deterioration or neuro worsening. Um And so it's really easy, kind of just have your phone out. Um It's uh the things that you would be doing during your neuro exam anyway. Um, but it kind of helps to just go through it and tick the boxes um contemporaneously and then I think the next slide is to do with imaging. So um you've ordered your noncontrast CT head. What are you guys kind of expecting to see or what do you guys um think it would be important to identify on that scan? Mm. So someone's put hemorrhage and ischemic. So, um if you have a hemorrhage, you'll be able to see that um blood is, is, is white on your CT. What about an ischemic stroke? Someone's put hypodensity. So you'll get density changes for sure. So we're still kind of mulling that over, I think hemorrhage or it could be a normal CT. Yeah, definitely. Um So these are taken from kind of a radio pia lecture on various CT changes during stroke. So CT can allow you to visualize either the actual clot itself um or kind of early changes in the parenchyma associated with ischemia or hypoxia, but it's not very sensitive. Um your CT head or your non contrast CT might be normal in kind of up to 30 to 40% of M MCA strokes within the first six hours. Um And the time from kind of the ischemic event to radiological changes on your CT can vary. So um in some areas with um kind of um different degrees of collateral circulation um and perfusion, it can vary. So, um you can see ischemic changes very early on if the stroke is somewhere like the lent of form of the cor nucleus to kind of ours. So for a cortical stroke, even at three hours after the um ischemic event, only 20% of cortical strokes will have changes on your CT. So I'll put on a couple of different things here and I'll talk you through them. The um third image from the le the left there is a hyperdense vessel sign and that's you actually seeing the clot. Um So as it kind of concentrates and condenses and solidifies, you'll see it as like a hyperdense kind of opacity on the CT, um you might see kind of early parenchymal changes. Um So the first two sides are the same scan, but one of them is in the stroke window and where the changes are a bit more obvious than on the left, which is the normal window. Um And then on the right, you'll see kind of a loss of the gray white matter differentiation. Um So if you compare it to the scan just to the left, so the last two images, the third one has greater kind of differentiation between the gray matter and the white matter and there's a bit more contrast, whereas on the right, it looks a lot more homogenous. Um This is obviously kind of just for your interest and as an fy one, if someone looks clinically like they're having a stroke, um you call the stroke team, you let them know that they're um having act and the stroke team will have a look at the imaging and decide what to do. Um But definitely they'll either be looking for a hemorrhage or not a hemorrhage. Um, and then they'll kind of treat the person as either an ischemic or hemorrhagic stroke based off of that. I just thought that was interesting. MRI obviously, um is a lot more sensitive and you can see changes on an MRI within minutes of a stroke, but obviously, it's less easy to attain than um act and delays that are associated with getting an M MRI. Um kind of aren't worth the delay in um treating um what looks like a stroke clinically. So it's only really used if the diagnosis is uncertain despite CT imaging and despite your kind of clinical impression and the stroke team's clinical impression and this is your definitive management. So, before I go through them, can anyone think of how you might treat a stroke or how the stroke team might treat a stroke after you refer them to them? Mhm. So you might be involving the neurosurgeons. Yeah, you might do a bit of thrombolysis. Yeah. And there's one more thing that can be considered, ok, might fall under the neurosurgery kind of bracket, I guess. Um So we've got thrombolysis, we've got thrombectomy and then we've got kind of other neurosurgical input. So thrombolysis is um your IV um kind of alop places in the UK or Europe. Um I think tecta is the one that they like in the States. Um You can give that if there's no contraindications, there's obviously no bleed on the CT. And if it's within kind of 4.5 hours of stroke onset, which someone's kind of rightly said, um on the um chat box B MJ, best practice says that you can consider it kind of between 4.5 to 9 hours if um your more detailed scanning. So your perfusion CT or an MR shows that there's salvageable tissue there. Um But that's obviously kind of a stroke team decision. So, contraindications to thrombolysis, can anyone think of any? Yeah. So hemorrhage is, is the most obvious one, isn't it? And we don't wanna make that any worse, recent surgery, definitely recent strokes, um, recent head trauma, um like severe kind of uncontrolled hypertension. Um If someone's got kind of a known aortic um dissection or an aortic aneurysm, um pregnancy kind of pericarditis, active peptic les or loads of different things. Um And again, kind of your stroke team will be really well versed in who's a candidate for Thrombolysin and who isn't. Um, as the fy one who kind of has a query stroke, obviously, after arranging immediate investigations and keeping that patient safe and doing your at e, it is helpful if you guys can kind of see anything in the history that might guide the stroke team management and rid that to them. Um Someone's mentioned kind of the size of infarction, um which is interesting and brings us on to our next point which is thrombectomy. Um So that's obviously kind of clot retrieval. Um offer it kind of as soon as possible in patients who were last seen, well, kind of up to 24 hours ago with no previous disability. Um and there needs to be potentially kind of salvageable brain tissue on imaging. Um So again, your CT perfusion or your MR will be helpful in kind of guiding that and then other neurosurgical kinds of input. So, um any patient who's had really big stroke, particularly kind of um middle cerebral artery or cerebellar stroke, any patient with a reduced G CS or any patient with that high stroke score that we were talking about earlier, um needs to discuss with a surgeon um to consider whether something um more invasive from a neurosurgical perspective is needed. Um And the BMJ mentions two things, it mentions kind of a decompressive craniectomy, which is obviously removal of kind of a piece of skull to relieve the pressure or a ventriculostomy. Um And the way the ventriculostomies work is your skull is obviously a fixed compartment and that can't expand. And so within that skull, you have brain um matter, you have um cerebrospinal fluid and you have blood both kind of within the vessels and if there's any bleeding and if the volume of one of those increases, um your brain can compensate to a certain extent Um And then after that point of compensation of volume, the pressure in your head starts to rise, which um obviously can lead to cooling is very dangerous. What the ventriculostomy allows you to do is that's a drain that goes into your ventricles. Uh that allows kind of ventricular fluid to be drained out to help reduce the volume of um CSF and to relieve some of that pressure, obviously up to a certain extent. Um Grand. So patient B um they were taken to the hyperacute stroke unit after you called the stroke team, after you arranged their CT imaging, after you kind of kept them safe with your at. Um they were a candidate for thrombolysis um because they were kind of last seen well about two hours prior and they didn't have any contraindications. Um They were thrombosed by the stroke team. They had full kind of secondary prevention work up. Um So they started on their statin um and their um anticoagulants and they had rehab and patient B made a really good recovery with only kind of a mild unilateral weakness. Um So well done. That's your shift on the medical admissions unit finished you hand over to the day team and you go to get some sleep. Does anyone have any questions before we finish? And while you guys think I'm just gonna fire in the feedback form as well, busy shift. Yeah, definitely. And some shifts will feel like this. Um What I would say is that all shifts and like, no matter how busy they are, um, you know, handover will come and you'll, you'll be able to go home. And I think, um, learning to kind of hand over effectively and succinctly is really good in kind of ensuring that you're able to leave work at work. And when your shift is over, you can kind of decompress and think about other things. Um, what I would say as well is that um you are never kind of on your own, particularly as an fy one. There's always people to escalate to, there's always help to ask for um whether within your team or um or outside your team as well. Someone said only three patients. Yeah, unfortunately. Um So thank you guys for your attention. Um Again, feedback for would be um very much appreciated. I'll hang about for kind of another couple of minutes in case anyone has any questions. And as I mentioned, this talk is obviously as a um part of a series of kind of acute medicine um shift talks. So if you guys are interested, um obviously you follow the mind, the bleep, um keep an eye out for any more talks. All right, looks like there's no questions, everyone's ready for the, for the beds and a bit of TV. Thank you so much for your attention guys. I'll see you all soon. All the best