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Deep breath. Hi guys. Uh can you view it now? Mhm. Ok. Uh There seems to be some kind of an issue. Ok. Is it better now? Ok, perfect. So, ok, I already showed you guys the causes but if you are good name, a couple of causes that you think would cause the airway to be obstructed. Uh Yes, you wouldn't get access to the slides per se but the entire session would be on med all which you could view whenever you want to. Yes. Blood foreign body, what else? Ok. So let's quickly go through the causes for every obstructions or every compromise. So one would be lower gcs. Yes. Yes. Like somebody mentioned blood vomits, foreign body inflammation, any infection, any kind of trauma. So all this would be your top causes for. Ok. Why do you think somebody's airway is being compromised? So now you assessed so how you would assess the patient? So first, like I mentioned earlier, talking, so if the patient is able to talk to you, you know that the airway is patent sometimes when you go see them, they may not be unconscious, but you can see that they're really finding it difficult to breathe, some maybe choking, right? And then sometimes you can probably hear a wheeze. There could be the Stridor gurgling noise, use of accessory muscles. So you know that the airway is being compromised. So I just put a picture here to show that how I know all of us talk about or use of accessory muscles, use of accessory muscles. And we've learned it in anatomy, but I just want to refresh it. So that's why I put this picture to show you that if you look at these three muscles, at the tepes, the scaliness and sterno master. So normally when you look at each other, obviously, these muscles are not as prominent and you don't see them work. So when you see that these muscles are working really hard, becomes really obvious in the patient. And then you know that they're using accessary muscles and you know that that patient is having difficulty in breathing and or the airway is in the process of being compromised. So now the interventions, the first most important thing would be the head tilt and chin lift. You guys can see the picture that I put below. So this is how you would do the head tilt and chin lift. And the next one would be a jaw thrust and jaw thrust is so you wouldn't do a head tilt and chin lift if you're suspecting a trauma in a patient. So if there's trauma and you think that there is some kind of injury to the cervical spine. You would never do a head tilt and chin lift because it will only worsen the condition in those cases. You would always do a jaw test. And the way to do the jaw test is so you keep your thumbs on the cheeks, ok? And then the rest of the fingers behind the mandible on either side, like the picture and then you push it upwards and forwards. So that's how you open the airway once you've done that, ok? If you think that there is some kind of food there, et cetera that needs to be suctioned or it could be blood vomit is so you would use the suction, then you would use the different kinds of airways. You have the oropharyngeal airway like in the picture, the nasopharyngeal airway. I haven't put a picture of the laryngeal mask, but please do go look it up just so that you know how it looks and where you would use it and endo tube if you, if you need to intubate the patient, right? Or if you want to use Ambu bag, et cetera. So endo you tube and then always start the patient and cricothyroidectomy would be like really, really severe patients and I wouldn't recommend anyone to do it without any senior guidance. But that is also another way of the airway interventions that you will do and oxygen. So the minute you know that someone's unwell, even if they are able to talk to you, but they're still having difficulty in breathing, always, always give oxygen, you can stop it later once you're stable. But it, when they're unwell, even if they are responding to you, please make or even if the sats are fine, you know, sa when you check the, the SATS may be above 96 but always give oxygen till they are completely settled. So once the airway is open, give 15 L of oxygen to all patients via nonrebreather mask. And for COPD patients, we say ideally make sure the target is between 88 to 92. But it would also depend on if they are retainers or not, but that would be a whole different process. But I would say just keep it at 88 to 92 and you can always change it later once they are stable. So now can someone give me a couple of causes for breathing to be affected? Mhm Yes. So you mean any kind of infection? Ok. Mhm Yes. Very good. All right. Let's go through some of the causes. So again, low G CS like CNS depression, right? That would lead to respiratory depression in return really weak muscles, infection, asthma, co PD, pulmonary embolism, pleural e version, pneumothorax, hemothorax, flail chest because if they come posttrauma the flail chest, that is, I'll just put a picture there just to show you what exactly a flail chest is. So it's basically broken ribs. So these ribs can puncture your lungs and that could lead to hemothorax and more complications. And obviously, the expansion also would be affected when there are broken ribs. So that itself would cause difficulty in breathing. So these are some of the top causes you would think of for difficulty in breathing. So now once you know there is a cause you have to intervene, right? But before you intervene, you have to examine. So what do you do? So it's always look, listen, feel or we could also go by inspection. Palpation, percussion, auscultation. So on infection, you look. So even here like under breathing, you would, I would add the accessory muscles here as well. So infection look, if the chest is expanding equally. Is there movement is the use of accessory muscles? Look at, look at the trachea, if it's centrally placed or if it's deviated, right, then look at the stats, look at the respiratory rate, look for the symmetry, then the color if the patient looks sign or th or if they look OK. So that would be in your inspection or look after you do that would come your palpation. So, palpation again, you would feel for the trachea to see if it's deviated or not. After that. Look for any signs of tenderness, anywhere, trauma, pain, right. Then no palpation, you would also after palpation would come percussion. So percussion again, normal lungs would be resonant but if it's dull, you mean you know that OK, something is wrong or if it's hyperresonant again, you know, OK, something is wrong. The other thing, what we learned back in medical school was also something known as vocal phrag. So you ask the patient to say one, OK, and then you palpate simultaneously on either side and feel the vibrations. Then after you do the inspection, the palpitation, the percussion comes the auscultation. So you auscultate all the areas. So start with the supraclavicular clavicular infraclavicular, mammary, axillary, infra axillary and do the posterior ones as well. So, prescapular, interscapular infrascapular. So all these regions you will have to auscultate. But again, if the patient is acutely unwell, auscultating, the posterior side would be a little difficult but make sure you've auscultated all the areas on the anterior side. So this is the overview of the assessment of breathing. Um Do you guys have any questions regarding the breathing assessment? Ok. So moving on. So you've I you you have certain causes in your mind. Now you've assessed and then you probably know the next step would be an intervention, right? So the interventions here would be again. So you open the airway, you put the, you've done that intervention. So the next thing would be what could you do next? So maybe you just need to position the patient or you may probably just need to give something if there is uh they suspect a new or you put a brain in or if there is narrowing, if you can hear like a wheeze, you know, you need to give something to open up the airways. So you could probably give salbutamol basically Betagon is to open the airways. So these are some of the interventions next comes circulation. So again, causes would be as listed here. So firstly, you could think of anything related to the heart. So it could be arrhythmias or ACS, any electrolyte imbalances or maybe sometimes they're just having extreme blood loss or they're just hypothermic or it's probably because of some drugs they've consumed sepsis. Infection is a common cause for e everything. So always keep your first differential for anything as some source of infection or sepsis and then work through the rest of the causes as well. So now assessment of circulation again, look, listen and feel. So again, when you're looking, you look at the color right, then you assess like if signs of dehydration, you could look for the signs of dehydration. Once you've done that, examine the pulses, the BP, the CRT, then urine output. Again, also gives you an idea regarding the circulation. Then you could also look for, I mean, this would come under. So one thing I you all of us should understand is uh there could be an overlap between a few of these steps like air and breathing can be overlap like certain co I mean, certain presentations, same with circulation, disability and exposure. So you don't have to wait for exposure to actually look for or if they're actively bleeding from somewhere, right? When you've reached circulation itself, you probably pick it up or even earlier, depending on how profusely they're bleeding or how obviously they're bleeding. But it's the entire process is a combination of everything. So now the interventions for circulation will probably be change of position. Again, candidate the patient give fluids do the ECG monitoring. You could auscultate the heart as well. You could then you could do specific treatment if you know what exactly is happening with the patient. By the time you read circulation, no disability. Again, disability, some of the causes would be inadequate perfusion of the veins. So basically CNS, depression, certain drugs, low BMS. So if you remember like I mentioned before, so on disability, the three things you would rather do is the G CS score or the A VP will score and the BMS. So it's a GCS or ABP and BMS. So this comes under disability. So this is how you would assess disability interventions. So when you're doing this, always work through the first three steps, optimize your airway, your breathing, your circulation, keep monitoring the herbs throughout when you're doing this. If you know the cause, treat the underlying cause. If so here we know they're looking for the CNS depression. So if you know the causes for that treat that and most often it could be just low sugar levels. So when there's low sugar levels, make sure you correct that as well and comes exposure. So here again, you head to toe, look for any signs of swelling, rashes, bleeds, fractures, different kinds of trauma. If there's an open wound and you feel like you needs to be stitched up, all this would come under exposure. So to summarize the entire thing, you have to repeat ABCD throughout until the patient is stable. Once they are stable, you go to the secondary survey where you ask detailed history and go more in depth regarding the treatment investigations, et cetera. Ok. And so before you go into secondary survey, you could hand over the patient once the patient is stable. So that is also a very important part. So, so the patient has come to you stabilize the patient, refer the patient handover. So I'm just gonna give you a brief overview of what is expected in the handover. So always use the sbar approach for handover. That is the situation, background assessment and recommendation. So in situation, always identify yourself from that you're calling, identify the patient with the name of the patient and the date of birth and then what's been happening. So ta talk about the symptoms and onset of severity. So once you, so that will be your situation. So given the situation after that, you'll have to give the background as to like what the patient was diagnosed with some medical history. If you know it, if you don't know, they could always say patient was acutely unwell. I wasn't able to get history. But before you hand over, if the patient is stable, make sure you ask all these questions. So you do your secondary survey, then you get like more detailed uh background of the patient. So you understand what is happening and then when you hand over, it will be easy for you to explain the background and give the results of the test. Any new changes that you've noted what you've done, explain the interventions you've done, make sure you give an entire overview in a detailed manner, but also at the same time in a conscience manner. So only mention the important parts then would come your assessment. So assessment would be. So you explain as to as you were assessing the patient, what you found what you did, how the patient is doing now, et cetera recommendation would again be if they have any input for you, like after you've given the entire uh history and your management, if they would suggest something or if they were to take over the patient, they will take over the patient. And then basically, it's the continuation of a secondary survey. Is everything clear up till now. Any questions so far. OK. So now we just walk through a couple of cases and I want you guys to respond to me. OK. So there is a 35 year old female she's brought to the emergency department following a bee sting. So you know what's happened to her? You look at her, her SATS are 88 pulses, one not four BP is 90 by 50 respiratory rate is more than 25. So just looking at this picture, how would you approach this patient? So someone's just calling you and telling you that this is what has happened to the patient and this she looks really unwell. Could you please come and review the patient? So how would you approach this case? Yes, of course. So what would you do the first thing in airways? So how would you assess the airway? Ok. So in this case, the patient is able to talk to you, but they're not quite stable. So she just tells you that, you know, I was bit by a bee, that's all and she's not able to give you more. So what would the next step be? Are you happy with the size of 88%? Yes. You, you could always look for any obstruction. Yes, definitely. But you know that the sat 88 person and she yes, give oxygen. Yes. So basically when you go see her, you see that her face is completely swollen, she's finding it difficult to breathe and she has some sort of wheeze as well. So first thing, yes, you will give oxygen next. So airway you've kind of managed there. So you know the air is to giving oxygen, you're gonna monitor the sad you move on to breathing and in breathing. You see that she's using her accessory muscles. There's a wheeze. So here, what would you do, what would you consider give antihistamine because of allergy? Uh, yes. But do you think an antihistamine would work quickly because she's having, so there is respiratory compromise. There is her breathing is difficult. Her circulation is also ok. So her BP is dropping. So we saw earlier her BP was only 90 by 50 right? So you want something to act really quickly. Yes. EpiPen. Yes. So first thing, I mean, in an ideal situation, obviously, when you go to the patient and for someone tells you that they've had a bee sting, you go see them, you see facial swelling, difficulty breathing and you know, circulation, everything has dropped. So you will first immediate reaction would be to think of an allergic reaction to the bee sting. So you know that they're probably heading towards anaphylactic shock. So you would give an Epinephrine adrenaline. Yes. So you give that first, that should work. But if for some reason you've not thought of it at like as soon as you see the patient as you're doing the A two E assessment, so you do the airway, you manage the oxygen. So you know, ok, fine, then you look at the breathing, you know, there's some kind of narrowing of the airway. So you give some uh be uh sorry, some uh salbutamol et cetera, which is good circulation wise. Again, you know, BP is dropping and everything so you can give some fluids here, make sure that you always can the patient do routine blood as well. And while can the patient because you don't want to keep prick, pricking them. So that will come under circulation and disability. You see that there's rashes everywhere and this is when you notice this facial swelling, et cetera, blood sugars are normal. You do the AVP score or the GCS score. You see that, ok? Right now, the GCS is probably 15 on 15, but looking at the picture, you would probably, you are suspecting that it may drop, right? So at this point, you make sure that you'll give Adeline because the first think you should think of as following a bee sting or following something that's new and then it present with facial swelling, difficulty in breathing, et cetera. Always think of an anaphylactic reaction first, ok? And there's no harm in giving a and it's only gonna help your situation. So give that and then you can proceed with the A two E but in case you've forgotten to give that in the beginning as well, do the A two E at some point, you will definitely figure out that, ok, this is an allergic reaction. Do not forget to give the adrenaline. All right, somebody did mention antihistamines. Yes. But it, I wouldn't recommend that in such a severe case because it would take too long for it to work. If it's just a small, mild rash or something, then definitely give antihistamines, but not when you're suspecting someone is going into an anaphylactic shock. Ok. Any questions so far? Ok. All right. So now this next case, I want you all to work out the entire case for me. So tell me like how you would approach the airway, the breathing, the circulation, the disability, the exposure. Ok. So you have a 50 year old male, he's brought in by ambulance. He is conscious but appears a bit confused and disoriented. Ok. Respiratory rate is 24 sza 95 heart rate is 100 and 10 BP is 130 by 70. So how would you approach this patient? And also are you worried about the herbs or are you happy with the herbs? Correct? So you are slightly worried about the heart rate. What else? Yes, perfect. A two E assessment. So again, in this case, how would you first go check if the airway is patent or not? What would you do? Mm. Ok. So you asked the patient, the patient is not able to give you a proper answer, but they're talking, he is confused and disoriented. Ok. So would you just skip this step and move on to be or would you do something here? Yes, that's a very good thing, you could check his gcs and the G CS says it's uh 13 on 15, right? Ok. So, I mean, how, what, what was the first thing I mentioned in? So when we say airway causes for airway obstruction, we mentioned a few things and the first one was G CS or CNS depression, right? Maybe it's not obstructed at that moment like the SS are fine. This, but by the time you see the patient and you move on to B there is a chance that the airway would get obstructed because he's confused, he's disoriented and this is accurately, right? So like I mentioned earlier, see it's OK to skip this. What happens is if you don't do the interventions, it would lead to the deterioration of the patient. It's very good that you do the gcs first because he's confused and disoriented. But you know that the GCS is 13 on 15 now. So the minute we know it's 13 on 15, you know that gcs is low, right? And there is a chance that it will probably deteriorate further. So all we give oxygen. Yes. OK. You open your mouth to check for blood foreign body. All those causes are ruled out or what is causing the CNS depression. But you know that there is impairment and you need to make sure that the airway is not going to go into obstruction are the area is not going to get compromised. Agreed. So this is what I did mention earlier as well. So when someone's acutely unwell, even if the SS are fine, but you know that, ok, the CNS is not doing great. They're like confused and disoriented. Give oxygen first, you can always stop the oxygen. Once the patient is more stable, they're more alert, inactive. So, in airway, the main intervention of we open the airway, right? And if you need to put in any of the tubes, you'll have to put it in depending on the airway compromise. But give the oxygen, you can always stop the oxygen later. Once the patient is alert oriented, is able to give you proper answers, he knows what's happening. Ok. So you're not gonna be harming the patient. So it's just that you're protecting the airway, you know, the airway is patent, but there is a chance that he may not be taking in as much oxygen as required because the gcs is going low. So start giving oxygen, move on to breathing immediately. So then in breathing, like I said, infection look less and feel. So you go through that, but here the breathing is ok. I mean, there are no acute findings in the chest, so it's fine. You're still giving the oxygen breathing is shallow, but you don't hear any crackles or wheeze or anything. So there's no acute intervention at that point, you could get a chest X ray where, where you want to, but that would come much later because the sa are fine. So the lungs are not the main issue here, most likely. Next move you move on to circulation. Oh, ok. When you say the gcs is incorrect, what do you mean? So if the patient has had a stroke and the broken area is damaged? So it means so gcs has three parts, right though. Hello? Can you hear me? So, GCS, you have three things you look for. So one is the eyes, the W and the motor response, the G CS would definitely give you a true reflection in terms of the fact that so the patient, the BRCA. So if you like you mentioned, if it's a stroke and the Broca's area is affected, so it's something acute, right? So you know that the GCS is low. So when you know the G CS is low, you know that uh the indication of gcs mainly is to know if someone is acutely unwell or not. And then you know, they are acutely unwell and most often you have to think of the CNS causes. OK. The GCS is low, they're not responding. So why do you think this is happening? But also if you're talking about the stroke and the broke a the history would also be something suggestive of that. So they probably tell you patient was fine, he was talking, but suddenly there was slurring of speech this so you will automatically will think of. Ok. So maybe the patient was having a stroke, then you will do the entire c examination to see if there's any other compromise anywhere. Then obviously, you would go on to do a scan this, but your first suspicion would be a stroke because the history would also tell you that. And gcs would also tell you that, ok, the patient is acutely unwell, something is affecting the brain as well. If I'm making sense, I hope you understood what I'm trying to convey here. No. If you have any questions you could ask me, I'll try my best to help you if I know the answer. OK. All right. OK. So now back to this patient. So air is ok. Breathing, ok. There is, it is slightly darker and shallow circulation. Skin is a bit pale capillary, refill is slightly prolonged. So you just know that, ok, something is happening to the patient. He is unwell but it's not, you're not that worried as well because BP was ok. Heart rate was elevated. So, you know, something is affecting him. He is becoming drowsy now, disability. So we do the G CS. So here we know that the score is the team and then we do the other thing we do in disability along with GCS and ABP is blood sugars. Your blood sugars are also low. So what is your first instinct? Now, you know, ok, patient was confused, disoriented, obs are a bit affected but again, not extremely affected. And then when you do the GCS, you know that OK, the blood sugars are low. So what are you suspecting? What would, what would the first instinct to be? Yes, you have to correct the blood sugar levels. I'm not saying this has to be the cause but you know that this is deficit, so correct it if it's improving, you know that, ok, this is the cause if not, you have to continue the A two E assessment again and do further investigations, but yes, potential hyperglycemia. So especially patients who have been in the hospital for quite some time and if they are on insulin, right? And you know when they're in the hospital, they don't eat well and drink well because the food is not that great. So and obviously they're not keeping well as well. So you're not in the mood to eat and drink as much as you would expect someone to. So most often you're giving them insulin, et cetera. So most often there's hypoglycemia should also be something you always think of like once a month. E especially if it's in terms of acute confusion, disoriented, et cetera, always do the blood sugars first. Ok. So if once you correct the blood sugar levels, if the patient is improving, so you know that they were present in this manner because of low blood sugar levels. So give the correction, check the blood sugar levels every 10 to 15 minutes, right? And make sure that the blood sugar levels goes above four millimoles per liter. And then once that's happened, you don't have to give any more IV next dose. But you could probably encourage them to eat some like high sugary sorry food containing high sugar. But if not, if it's still less than four, continue giving the IV correction. So now this is the last case, I'm not gonna bore you guys anymore. But again, this is something we'll work together on. Ok. So 65 year old female Missus Johnson, she's all you know is she's brought in by the ambulance and then you go, she's like really unwell, right? Not in a state to respond to you. Very confused. Her SATS are low. She's using all her accessory muscles. Heart rate is high BP is really low and then you notice that your temperature is also high. So what, how would you proceed with this patient? Yes. Correct. So I VA is compromised but not compromised in terms of why you need to do the hectic chin lift. Then, I mean, the patient is not unconscious, but you know that they're clearly unwell and there is a chance that will be compromised. So, yes, oxygen correct. So then, so every you ok, you go, you examine, you check if the patient is talking patent, if they're not talking. And it's just a confused thing, you know that there is a potential partial obstruction or full obstruction. So head til chin lift jaw thrust, depending on how the patient is. If not just start the oxygen first, once the airways opened up. Ok. Yes, then becomes breathing. So breathing look less in fear. Mhm. So breathing when you're listening to the sounds you hear uh bilateral basal crackles. Mhm. Correct. So, ok. So breathing. Now you see that, ok, there is basal crackles, probably a bit of air entry on the right side. Ok. So what would you do here? Caution with fluids, give furosemide. OK. And why is that? Ok, guys, wait, let's go step by step. So every you've managed, you're given oxygen breathing chest, you hear some crackles and slightly reduced air entry on the right side. OK? Uh OK. All right. But you also know that the patient has had a temperature, correct? Yes, exactly. So look at the s first and then see the patient is hypotensive as well and I completely understand why somebody mentioned caution with fluids. Give furosemide because you're thinking of fluid overload. Yes, but the patient is also hypotensive. So you will have to give fluids with caution because you don't know if you don't know the background of the patient, if there's heart failure, if they're overloaded, but always look for signs of overload crackles. Yes. But also look for any peripheral edema, right? You'll have to get a chest X ray done, ok? But all that would come later. So that's your airway. Every we've done breathing, you know that OK, something with the lungs. So maybe you can get a chest X ray there, but then move on to the next thing, there's no active intervention in terms of like you don't have to put a chest pain immediately because pneumothorax is something that requires immediate treatment and breathing. Everything else can be done a bit later, right? So next thing you know that what you need to manage here is probably the BP because it's really low and the temperature is also high. So on the circulation like somebody mentioned, give, put in Cannulas, give IV fluids same time, give something to bring the temperature down, right? Because once you correct the temperature for all, you know, everything else will probably improve, right? Give fluids because the BP is quite low. You don't want the patient to go into shock, look for signs of dehydration as well on circulation. So look for the pulse, the capillary refill time, right? Look for if there's anything else that's causing the low BP, uh is she bleeding from anywhere else any other cause? So all this would come under same. And also now looking at this picture, your suspicion first like I did my calculation, right? So your the most the first thing you would think of looking at the obs and everything is OK. Seems to spike in temperatures, low BP, observative range. You're thinking of some kind of infection somewhere, right? Yes. Start antibiotics. Yes. Uh can someone tell me what is the sepsis six criteria, correct? What is the three in and what is the three out? And you've mentioned all of you have mentioned it at different times. So just if you could compile everything, yes, give oxygen correct. Give fluids correct out urine output, lactate blood culture. Perfect. So, ok, so give three take this. So you give oxygen, you give fluids, you give antibiotics, OK? And take, so you look for the urine output, measure the serum lactate and always do blood cultures. Is that fine with everyone? And how would you measure the urine? Would you just wait for the patient to pass urine when you're suspecting sepsis? And the patient is really unwell and you're thinking they're gonna go into sepsis, septic shock. How would you measure the urine? Yes, cat depress the patient. So the aim is when you are stabilizing the patient, always get help, don't do anything on your own. Like even when you're doing the A three assessment, if they're really unwell, like I'm talking about patients who are really unwell. Ok. So ask for help, delegate the jobs, right? So you know that they're really unwell. So they would need Cannulas, you would need someone to take blood, you would need someone to catheterize. So always make sure you delegate patient because you can't be doing, you can't be doing the thinking as well as the interventions, right? So make sure you are going, you have help and you have delegated the jobs. All right guys. So this was just a very uh superficial session on the E two E assessment. I would say, I mean, I didn't go into the depth of treating each of the conditions because that would be like separate classes, each uh condition. But I just wanted to give you a rough idea on how you would deal with patients who need the A two A assessment and how you would do it and make sure you always go step by step. It. You, you could do a few steps earlier than some, but don't miss out on any step because every step would require different kinds of interventions and it would play a major role in the overall improvement of the patient. OK. So that's it for today. And uh before you guys leave, please do fill in the feedback forms. And also I would be attaching the link for next week session, which would be hosted by one of my colleagues. Please do register for that as well. Thank you so much guys for attending today's session. I hope I have taught you guys something. Buh-bye. Have a great evening everyone and please do fill out the feedback forms before you leave.