Anaesthetics - SurgEazy
Summary
This teaching session for medical professionals offers an in-depth exploration of the essentials of anesthesia, specifically focusing on patient airway assessment. Attendees will learn the different components of airway management, including the ABCDE method, the use of various tools such as airway masks and respirators, the interpretation of various sounds such as snoring and gurgling, and the importance of assessing conscious level, among other skills. Attendees will also benefit from a quiz and gain insight into how anesthesia applies to medical school, hospital practice and research.
Learning objectives
- Understand the essential role of anesthesiology in medical practice.
- Examine common methods for airway assessment on patients.
- Demonstrate the ability to use a variety of tools and techniques for airway management.
- Develop the skills to assess and manage an acutely deteriorating patient.
- Understand the differences between sound, snoring and gurgling and the implications of each.
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That's fine. Hey, Wonderful. So, yeah. Okay. Serve today. Um, I'm representing the anesthetic National Taking Society along with the president Saskia Wits who, unfortunately, can't be here today, But she's very kind. They prepared the slides. So I'm going to go through today. The very essence or anesthetic, which is Ah, 80 assessment. But of course, going into very great debts into a respect. So, um, that's the balls of introduction about ah society. So I'm on an aesthetic natural teeth in society where we are a national TV in society on Arrow is really to focus on is a bring high standard teaching to improve, um, undergraduates on your knowledge and skills in terms of anesthetics on in terms off knowledge of peri operative and on. But we are hoping, Teo, um, so allow students to gain more insight into anesthetics as a specialty on go on, go off. Course not just that, um, we're aiming to develop students knowledge and skills for common challenges as they progress during their medical careers. Um, so what? We upped that it's a society. So we organized teaching programs. Eso we organize. We organized a sessions on insight into anesthesia as a specialty, um, key anesthetic topics. And so our knowledge on I see you on. But we also have a mental ship steam as well on helping students who are interested in medical education at you, learning how to organize a teaching program. And we also bench it into a more research respect in organizing a journal club on it by weekly basis. So anesthesia on but would say it's really a specialty that's not very much talked about your medical school on by myself used to want to be a sergeant on. But until foundation you one. And when I really realized you know the need statist by every by the side of every surgical specialty, Um, and they're really the person who new cup of the patients in holistic manner during every operation, and they look half the patients from, you know very they old babies to very old. And you know that this elderly people, um and they're not just those who sit down and sit coffees because that's part of what they do. Also, that can be found. A result arrest, emergency situations and her operative CABG clinics. A swell. I see the desk. I see you. So it's such a very specialty on that Incorporates both skills on very solution alleges so on. But you may or may not know, but on the seizure is the largest specialty in hospitals. On go. It is a great specialty. Two during on under, the anesthetist had to be the happiest doctors around. So yeah, for mention yes. So not coming to our session today? Um, I'm learning Object this So now we will be going through, um 80 assessment with a focused on patient's airway. So what we're looking at are on science of symptoms or obstruction. I mean, we will go through with you Your some common that side that we used to assess that way on dcaa Many investigations used as well. And we with any extra different types of I was a joint onda when and how they use on but with and go to, um on the details. So preoperative assessment as well as he told atrial assessment. That's well, So you had any contents off the concessions today. So as I mentioned that way management and then 80 s x men and we will have a procession quiz as well to test your knowledge, Onda. How is that relevant to you? So, of course, for medical school is Onda. Understand? A lot of medical schools has two on ability, toe assess and acutely deteriorating patient. So 80 assessment is very essential in the US and also as you graduated from medical school on. But when you first start out on a ward so on, do you often find yourself being one of the early wars doctors on day? Indeed, the first responders to those acute, acutely deteriorating I mean on you know, you just have to be prepared for these situations have me. So So that's why it is very important. It's not easy, but you're actually in the situation requires off skills, knowledge and just general experience as well to know if it's your the details. So 83 and six months, depending on what situations you're in the second offense can defer slightly. So in most cases on a normal ward, you would go through Eddie to eat. So airway breathing, circulation, disability and exposure, however, in a more for message creation. So if in the future you have a job in trauma and orthopedics, you will find them used to a slightly different, um, alk over them, uh, which before the 80 also include hemorrhage on C spine. And so because these patients tend to have very severe at blood loss, which they can instantly from, um, Andi. Also see spineless well, which can resulting if it's not protected on patients. Cancer from, um, reversible damage and neurological damage. So there's a to start a different angle. Um, but mostly used is medical 80 years nation year. Okay, so first of all, we will go through your way. So in a lot of places, on your normal medical patients, you will find a way we'll be Peyton and actually on. It's a lot more nuanced with the law, different equipment, which we were going to. So first of all, how's be sex and away and let's find it useful had to pacify things to make it easy to remember. So when I had done assessment like that classified into the feel listen, measure So what, you personally and so we see you look into the mouth for any obvious obstruction, have other things you would look for are so paradoxical chest movement. But we we often court, see, sold movement in severe airway obstruction cases, and it's off drooling. Um, that's operative pounds in patients with hepatitis and who have a very similar inflamed artists on that prevent them from swelling this saliva and and the important thing to a sets. Um, is that GCS or consciously this level? Uh, you may have heard of already, but it's just CS is eight or below. Then you would need to integrate the patients. Um, after look, you then can feel the patient on we can do, um, you can hold your year to the patient's mouth, a few for that breath, cheat on your teeth, have any and then again coming with the field feeling I also listen for any normal person. Um, it's off the useful to different shapes, the meaning before meaning off different words, which can be quite similar. So we it's often experiment tree on, but more of a. It's a lower airway obstruction where stride all tend to happen during the expiration fit based on backorder sponsors. Two more open up the airway obstruction on statin, which also makes a snoring kind of sound. Um, the sound you looking for gurgling, which often when this obvious fluids in the mouth. Um, in case is such as pulmonary edema. Um, okay. Other things like measure and treat. We will go through these on, but the important thing. Look at you and listen. So that will show with me. If he always compromise, Do this to choose here. So initial response. Obviously, that's the top off the 80 year, six weeks. So if airways not clear and you are the only person usually not as a medical student hasn't won and get some help because the patient could be I immediately and if the patient's been responsive, a basic check for post check for science apply. There's nothing or if you're not sure and dial call out and the rest call so ms Hospitals double to double T. And then, um usually at this point, there will be some form of senior. Had doctors coming with topia on the one East this often do, we would move on to something new muscle and adjusts to help secure the airway and recovery position. It's often very helpful, especially for patients who have omitting on, appear like they're conscious. I would say most cases just try to keep them still, um, uh huh. Never forget your back and mask. We will go to that later. Teo. Now you saw a patient on their airway is compromised. What are you going to do? Um, Sue? Firstly, I'd go to a few of the maneuver it's on, but you probably have heard. Um, so become a one. Is Chinle it on? But what that does is that the tongue up of the way, um, I so away remains patent. Um, most adults, you hold the head, um, you saw left up there, chin. So it looks like they're in the sniff. The morning acquisition, however, for babies and Children can defer slightly, so they tend to have a big head. So what that does is that when they lie flat, that neck tends to blacks a little bit. So what you actually need to do is to put something under the shoulder or under that back to encourage extension off the net. Um, that's because of the big. So now when do you do not perform head to toe to this? Um, so, actually, if you're suspecting any sort of c spine injury or any sort of former jaw thrust is often very useful. Um, how have. But this is quiet, Invasive procedure if you imagine yourself during the drawer for us started. So if the patient tolerates it and things that they need information on this is very uncomfortable today. So, uh, what you can do here on. But what you do is you put two fingers over the mandible on angle off the mandible on. Did you try to lift it up at the same time with some? You try to push it down the mouth. So so that trying to kind of push the mouth open on D. It's very easy to say, but actually quite hard to do. So I think if you're interesting, this technique, they're enjoying one of the least. It's more than happy for you to try it out, especially when their niece that ties in the patient's, um, they actually use this technique on murders patients that any so tight. So, yeah, so I had to turn this. The door thrust, especially and see is you're suspecting that See, find is compliment any questions so far in the truck, and we instead use um, hands in front of the mouth to reduce the rest of the schools. Mm. Not sure what it needs. Okay, everyone say, um, no, they were junks. So you you will probably have seen or an array off depends all equipment it using clinical practice. I'm what I often find useful is to just kind of go around and have a look at these equipment and the officer finding most arrest release on. So I'm sure if you, a chemo pill student, asked a senior doctor there will be more than willing to show you and a lot of the equipment also have some very interesting markings on them. So it's also helpful to just have a look and find out what they mean. Um, I think anesthetics is quite cool in that there's a lot of different toys to play around with, so why not just play with them and find out what they do? And so, yeah, So what? We will fix you on eso first. One of the most important equipment, especially in in emergency situations, is how our our months on. So what's what that normally does. So that's a face mask that you put over the patient's age. Um, and you normally use the um, draw thrust technique to try to hold it in place on great a good seal. Now if the patient's not really breathing or if they're not breathing enough, say if they've got opiate toxicity, then you a system in generating that breath by pressing on the back have to. A similar sort of thing is often find connected to a necessity machine. Um, so I haven't got a picture here, but it's called of water circuit. Um, so that allows the initiative to ventilate the patient as well twice a minute to this back. Um, but yeah, it's very useful piece of kids in emergency situation, especially when pages not really breathing, but not really breathing there. Now we come to our nasal Angela away. Um, so that is a very useful I don't in that off. Then you can use it in patients who are conscience and so, as you can see, a constant different sizes and how you measure it, it's from the tip off, the nurse to the pregnancy off here, I mean, and often another way to measure it. It's just kind of see the the Amitiza off the tube and see if it fits the nostril. Um, now, the important thing to remember with this is that it's country indicated. And in patients who have phasal school for any signs of azo school just so revision, if you know it already different signs all day. So school practice, say your trip, you know, and, uh, they got CSF run over here CSF coming off there and nurse or years and Actos sign I would bursting over there. My store presents. Um, if it's got blood coming out of the years or if they've got a mask bump on the head have with yeah, So if they have these signs, then, um, you can't really use an empty eight. I think, if in doubt that use it basically, um, to next one on which will be used. I was in water in competition, and key is a over and your airway also know as a bell, it's invented by mistake. It all has to me on very Telekast piece of kids. Um, so what? This is that once you insert the get out into the mouth that they come out of the way Somehow Hands of keeps the airway open family to the important thing to remember with Pick it out. Is that, um do you measure it on the incisor to the angle The mandible? Um so we often say hard to hard. That's how you measure the good, though having Onda importantly, if the patient can tolerate a good hour away, that means they will need to be intubated because it's very uncle. So to have on patients will often have gag me effects. Oh, okay, so that's the gets out a yes, different sizes of go hand commonly use eyes 2 to 4 but it's important to measure it before Onda normally use a bigger one. And for just to be safe say I were doing going up the ladder kind of invasiveness away. Now we come to our l m A. So that's the orange Oh moss My way. Um so you may have seen it used during operations Onda patients must be I'm just Oh, any styes with them to tolerate this. And so it's basically a true that you shock through the mouth and they protect s'more give more hour protection. And so once you shop the you want you to incomplete the balloon at the end of the enemy in order words, just baiting things. Um, so have a look around any scientist and see if they have this around. Um, it's gradually being faced outs. Nowadays, I think only some kind of quite experienced any statistic used these ones. Um, so on. That is because we have gels, which I would say, uh, in a way better And is it to use so the difference between my gel So this is I think it's very clever. So it's bought a thermal active morning at the end of it. Um, so it's very easy to just show up into the patient's miles on demoting mode around nicely found a way and creates a very good to see you. And at the same time, it's called simple, uh, extra tubing, which you can put soon, Okay, suction catheters. And that allows you to kind of get rid of extra secretions and things. And it's very helpful in operations or emergency situations. Okay, so now we come, Teo, crumple a crime out in the kill you, which is, um, pretty much the top of the, uh in terms of the way. So, um, so here is it run down. How to insert it and and the QT so very much you won't be doing that as a junior doctor. Usually, unless you and on a static training, you won't be putting walking. That's I mean, when I was a student, one of them you cities a muscle taught me how to do it. So don't be afraid to kind of just ask and let them teach you how to do it. Um, so essentially you, which putting was called living with it through their mouth, lift it up, and then she took the 28 haven't it? Sounds very easy, but it's quite hard to do, actually. Um, so if we have a look at the tube, it's actually quite cool, and it's got a lot of markings on it. So, um, yeah, essentially is a tube with a cuff that you can play tough. Um, which keeps the tube in place. Um, yet next time, have a look at the numbers. It's very helpful. Okay, so one thing that I would like very suit is how do you end up at the positioning often 82. Um so So the her sexual on the left side shows the correct positioning off et tube. Where's the right side shoes? It's like, incorrect. So if you look at the left side, it should say it's slightly above the carina Where the eye with your bride into two. However, if on the right side um, you may be able to tell that the tube has gone suddenly truthful on. But what that does is that it normally goes to the right wrong bronchus. Um, because the right side it's much, much more straight on day shorter as well. Um, so what that does is that risk? Um, it risks only ventilating the right side. Right lung asi can see the left side. It's still become very a pay cut on, but the lung itself has collapsed because it's going down too far. Okay, so because of that typically after out of every intubation, uh, especially, and I see we wouldn't do a chest X ray just to check the positioning hum. Who was. You know, you normally do a chest X ray in a C. It's important. So how do you check for correct positioning too? Um so firstly, USS clinically looking at each has itself to look at the rise and fall. Um, and I have a listen to make sure there's breath sounds drew out. Lung fields are good side, and I also see the missing off the endotracheal chew on. Also, the the most important thing to check is the end title. See a tube. So here you can see is an eight easier to trace on. But what that measure is is essentially the CEO to coming out as patients of breathing out having. And it's definitely one of the most accurate way off measuring on the position, laying off the truth. You know, just wanna They're through one of the important concept in anesthetics. Um, what exactly is a definitive away? So what we've talked about so far and just before the ET tube, everything has been a non definitive I ways. So itchy two are the only off definitive a way that we have to go so far. Essentially, what that means is that the truth itself is position below the vocal cords. Um, so even the elementary or the eye general, they're what's considered simple prophic rays on in that they're above the both, of course. So the difference is the other May Jo's and still allow a degree off. So a lot a risk of aspiration and from your stomach Contin um so other forms off definitive, always on a shown here. So the typical one is our over to go to, which is our end of our trip. You choose and the two can only go through the mouth. But there's also another one that goes through the nose. That's world on day. Finally, we've got our surgical airways on. Do you have your quite hope I would I want to me, which is normally done in a very urgent situation and on track just me as well, which can be done in the urgent or an elective and situation. So we will treat it all that. So that way I'm a don't. That's what I saw. A difference, okay? Saved as any questions on Why is NPH indicated in basal school fracture and essentially so it's kind of inserting a nasogastric tube in the income ready for two in one patient. Is those full fracture. It's quite a big tube to shove into someone's nose. Um, if there's a risk of feet school basting fractured, then you the trip coming in contact with the actual bring content or the CSF sooner risks are patients getting, you know, manage itis or and it'll damage to the brain itself and said that that's a reason. So how do you tell the cycles I want to me, apart from the tracheostomy? So because I bought me on as you can tell him name, it's Eskom aids in the clock without remembering. So that's between your quite good cartilage and your viral cartilage. So now truck just me tend to sit slightly lower. Uh, you feel the neck where below The quite quote is where your actual truck, your your readings start so that that will be positioned to, uh, on. But so that's how you tell in the patient. How do you choose whether to use, uh, quick with our trust me or track just me so quick with Rodney? It's normally use in an emergency situation, especially when you say if you're trying to intubate the patient and you fail on the patient's chief aspirating front of you, then you won't need to do and very urgent such. But I wait so quite cough. I want me is good in that it's very easy to be easy to locate the landmark, um, on at the same time, the amount of blood loss will be much less compared to the truck. Just me. So with a track, your ostomy, it's normally picks. Hunted D. Um, there's two different types you can during the attack by normally ent surgeon or on me. I see you on That's the only done, but and I see you register our consultants, so that takes time to do so. I can imagine an emergency situation just can't Can't do it that time Make, uh, the questions. There's the fact of me damaged the track here. To some extent. Yes, it does. Um, that's the name of the game, but it normally heels quite quickly. Um, so, you know, patients we see you know, as you follow up clinic will have a scar off track your knee scar. Um, it might be very helpful to look at the neck during all Skied some. Some patients might happen as well. Um, how many days does it take for person to recuperate from it? Um, so normally I would say I don't really know the cup. Look it up, but normally say we when we take out the track Your same tube. We're just a dressing over it on If the patient complete properly, then there's no problem. Kind of having a whole, but with a dressing over it. Um, any other questions? Yeah, I not see Sorry. Is it okay? That should make a quick announcement. Yeah, sure. Okay. Thank you very much. Thank you. Sorry to interrupt everyone. Just a quick announcement from Osteo. Easy. Just gonna post a Google form on the trap on this. Just it's better in some extra feedback on the session in the series and the collaboration itself. Eso really, really appreciate. If you fill this form out, please do it. Really? Just help us improve our future sessions and upcoming Siris s. Oh, thank you. Please fill out a form, guys. Who? I can't get rid of the chat books. Yeah, All right. So with both regimen hutzell and with joints. Um, so now we will go to the airway assessment on which is a key thing that most unused just do. Um, so we really like a crimson anesthesia on one of them is a lemon. So that's how you assess away. So how or look experiment on S O Essentially, what you're looking for in an airway assessment is anything that's much make the intubation process difficult. Why you're doing it on Go If you imagine a patient, Um, I think that's going to make it more difficult. Uh, so things that you can see so that includes if they have a racial net, uh, if they have been treating teeth or draw or sometimes if they have receiving teeth and two as well. Um, if they're quite large size, um, if they have a very big booty, be it, that's all. It's difficult. I'm even without the eight on. Okay, I am for my little Patty. So we will go to the malpractice school later. Um oh, for obstruction. So that's for looking into the mouth for anything and that might obstruct them. Their airway eso that also includes a B city which might be linked to obstructive sleep apnea, have any as well on lastly, assessing their neck moves mobility. Um, because when you interviewed the patients, you tend to extend the neck to kind of facilitate me a few, um, on the alignment off the and way. So I skipped he here, so it validates. So there are a few parameters that we look for essay. We get I ST what's called 33 to rule, uh, which is quite cool. So if you look at the flow to hear how we assess the patient, we use a think so essentially making this into the mouth to see if it's, um, into what's called a high omental distance between high Oh Berry. We cancel. Feel it, Um, And the tip of the the mental, which is called the mental and lastly, two fingers. So that is between your higher hired burn and the fibroid on cartilage so that it's your bowel. I would, um, Mr just to say that again. Three, three, 33332. And yeah, um, so that is not a minute. And so now my patio school. This is something I think very useful to remember. So we have four schools. We essentially ask the patients to have been a mouse and sit up. Um, and then we looked at that. I saw that, um, essentially cost one is when you can see the income until for some of it, including the uvula, uh, past two is when you can sort of see the uvula. Um, on cost. Three is when you can only see the base of the uvula. And class four is when you can't see anything at all. So essentially, the opening gradually gets smaller and smaller and weather. Um, yeah. So the difference between one and two is that one. You can see the tip of the uvula. Okay, So, uh, so we've talked about already on so the main course would be beastie, especially in patients with a recipe. Um, there will be some patients, actually, a few patients I've seen They need to be a needs. The eyes, even when they have over, find your cancer and makes it difficult in terms of obstructing the way I haven't. I think everybody's like benches and things like that on Dema, especially in patients with bones. The airways can get very swollen on, difficult to intubate to neck mobility with book out on day. So key conditions to remember are ankylosing spondylitis. That makes it difficult to move your neck a 60. Okay. So I think it's important to say the word assessment is really a rough ID or how difficult the intubation process will be. And in fact, a lot of times difficult intubation may not translate. And a normal airway assessment was not translate to an easy intubation. Um, you may or may not have heard off the story off Elaine Bromley. Um, so she is one of the most talk and tragic, um, anesthetic case in history reading. So essentially, she is a lady who was in her thirties and who, normally, if it's on well on D, I was undergoing an elective ent procedure. I think it was for sinusitis and on day, going into the pre op assessment of how it was completely normal, so everyone was showed about the operation. It's a very simple procedure to do. However, when it came to intubation on, it became very difficult. So the first consultation the census try. So if you met, it's on it didn't work out. Yeah, they're in court, a different and the PSA test. You also tried, um, they couldn't accept the tube. So then court the ent surgeon on day or three. Often we're trying to intubate her on by by this point, her oxygen saturation was 40% on. It was 20 minutes in. So now, if you know the, uh, go with, um um, you should really be thinking or doing a surgical away at this point. So the nursing, the day it's nest father side. I'm kind of brought up a theater kitchen to the team, and I'm hesitated in the process. So eventually, after 40 minutes, they did manage to put in the airway on her. Saturation did come up from 40% Teo 98% um, in this tissue. Happily, the surgeon happy completed the procedure. Andre put the patient to recovery until they realized that she's suffered a irreversible, uh, hypoxic brain injury. She's unfortunately passed away, Um, 13 days later. So it is a very tragic case on in our anesthetic community. Um, which really emphasized the anesthesia is not just about the technique, intubation and but more importantly, management off all sorts of human factors on such a situational awareness and flattening over hierarchy. Um, communication on just, you know, general known technical skills. Um, So, uh, and here's a link. If you want to read more about it into the case and no. So so in terms of airway and you see how We've done a very good online course on different types of airway, which goes into more bets on different algorithms, emergency situations that we encounter. And so it is what it in the It's a it's got six weeks, same six sessions. And so if you're interested in anesthesia, have a look at this court and it's free Okay to that. So that's possible on already. So have a look. Any questions? So, uh, just looking at the question is this malpractice score used anyone into a thing or so with the non definitive our guts to. So the mother passed this voice mainly used, uh, doing pre assessment. So yes, it's mainly used for intubation. Uh, especially if the patients undergoing a undergoing surgery. I mean, if it's an emergency intubations and we don't really use a school, Okay, so now it's a complete are 80 assessment. Um, so we'll get to be everything. So again, pulling our structure in terms of look for you listen and measure. So now you assess the airway. You're looking at the patient in pencil, that breathing So first commitment. I think it's very important that just step back and look at the patient in comes off the bigger picture opposite. If they're really in respiratory distress, you will spot it straight away. Um, but other things we look for include them. That's pink breath in the use of accessory muscles or any her slip breathing. Which office? In finding COPD patients, Um, you so trick your deviation. Um, that's I would say, not very commonly performed or wouldn't be the first thing I would think about. Yes, that's in breathing. I'm on like some suspected. And you were correct. Um, chest expansion Very important. Um, occasion, which is off the very useful to, um, especially when you're suspecting and it's all fluids or consolidation and listen to the chest. Um, I also find it difficult to differentiate between different sounds on different chest sounds. Some you to reduce it wonderful and insult helping you with that. Um, and it was a practice makes perfect. Um, Onda, Of course, if there is an ox machine by your side, which there might not be on the wood and you would measure the oxygen saturation, um, especially rates, you know, always count. Um, yeah. So in terms of managing a breathing, So if you are on the wart on the patient. Excited. Pretty really, really hard. Fast breath. What would you do? And so with any patients with millipede consents and it's hard to sit up. So one of those is that helps to expend the chest, expand the chest, Um, on Also get that tummy out of the way so it helps. So it allows gravity to help with the chest extension process. Um, 50 m long. Repeat the full mosque. So, um, often in another station, we can be quiet kind of, I don't know, quite stingy without oxygen levels. But if you think they're really, really hard and these that raging, then the most useful thing is to give. It's all my contracting beaches. Um, it's never too, so you can always come down on the oxygen level. Okay, so typically in asking patients, or if you think and it's off, lower airway obstruction at and so peaceful want a patrol, peons realize, is a helpful onda hydrocortisone, which often slightly later on, I have room on when you're assessing the patient. It's helpful to do an ABG, um, and it's useful to do friendship between Type one and type two respiratory pay via. So if you know, type two is when they start to retain tier two. Um, and why do we want to differentiate? The two is because usually if the entire tourist brutal failure and things that they you will need to get, I see you involved to consider, You know, so invasive or long invasive ventilation. Um, lactate is often get to see us. Well, to see essentially how sick they are and on often a chest X ray would be useful. Um, it's easy to say it, but often on the ward it's quite difficult to get a portable chest X ray on. You will really have to sell your case really hard. Um, but if you sound like the patients dying from you, they will come and do a chest X ray for you to see with circulation. So again, although the structure, um, most useful thing is really to just look at the patient, um, looking looking pale, it might suggest that there, you know how this hey would be compromised and have you feel off your patient in terms of their temperature. Um, often, they might feel sweaty or they might be very cold having a few off the post and 20 per 40 month. I listen to the chest. This well on go oversea measure, there was a patient, um, 12 lead. STDs can be very helpful. Um, I've purposely you don't probably easier GI and found that patients actively having this many. So that was super helpful. Having to find out, Have a little No, this is not only on the I see, uh, that occasioning on inwood situations. It's usually you usually very sports measure that you're in active as well to assess their state off. Kind of a definite status. So malignancy. So here we're assuming case off patient who's have hypertenses, um, tacky cause it and looks like they're losing a lot of blood or losing a lot of fluid on. So what we normally do is that we would kind of, um, insert two large abul cannula. IV access would take some blips. Um, on if they're hypotensive. It's off the various school to give a fluid Bullis on day so that what that means is that you normally give 500 mils Oh, crystalloids saline. Hartmann's, um really quickly of the 15 minutes and then you would reassess that BP to see if they respond to the fluid. Um, on. If they're actively bleeding, then I remember to activate your massive hemorrhage for school on britches. Different hospitals have different, you know, different out within two. Yeah. Come into D, um, so be disability. Um, so once you assess your a to sinese, I'm going to be. And so what that includes is consciousness level. So after you GCS on do think a temperature chest well, especially if they're Rx it by the to constantly ecstatic screen. I remember grupos on, but that's one versus putting Teo spot and manage it well. And when they look at the pupils as well, um, so everything else from head to toe express the patient anything that might be causing a cute deterioration. Okay, so that's the bread and butter off of 80 assessment eso finally, um, more difficult to on the set It I'd like to go through an opera. Your assessment? Um, so this is something that's not talk very much during medical school, but I think it's very important. Um, as you may know, if you're interesting surgery, it's every soul operation is a massive kind of hit or massive tumor to the patient. So, um, you really need to make sure that the patient is it enough to go through this so called trauma on surgical procedure. Um, remember before, um, I didn't ophthalmologist job on, but my role was in pre assessing the patient's pre op. So a lot of the patients they are very elderly aunt have multiple comorbidities on by the operations. Kind of very simple, like a cataract operation. But we have to do a very in depth pre op assessment to insure that they're fit enough for surgery. So he'd house off real process mint, Um, extra year. So essentially, you want to find out his details Exactly what, what operation? They have to go through exactly why they're going to the operation. I'm these type of, and this is easy as that they would be happy with and also that the surgeons would be happy with, and obviously he things like that Current health status. Um, we often like toe assess their count exercise tolerance, which is very helpful. And also important thing is sleep apnea, which can affect the success of intubations so But the things as you would in the normal medical history things Medco on drug history. Uh, it wasn't the anesthetic history on be previous anesthesia. Any intolerance to it? And that's very helpful Family history, especially if you have a history or malignant hypothermia. It's important to me. So during the pre op assessment, we normally do so the multi system assessment. So multi system examination as well, and just to look for any signs that might prevent the patients. I'm from having the operation lasting. More specific, the anesthesia? A. So I mentioned before, mainly, or I would assessment. And finally, you would also look at their ACUs. Well, if you're having a spinal or epidural procedure. So um yeah, it's a crazy um, so this issues doing any sort of pre op on a second assessment? And it's a very useful school. Um, house and incentives how sick the patient is. Um, family. Um, in most cases, if the patient's well on, haven't A s a great one, and you would have to go through the operation. Um, if yes, it's getting something more than you would so awesome patients to take somewhat tests before the operation. Um, I think one I think was, um, book has to take. Is there coagulation? Um, because any sock tumor to the patient during operation on my resulting excess bleeding on. So you want to find out through that? So, yeah, as everything was going to do today. So we've many gone through on focused every management and went through houses, steps in a way to pencil. I woulda junks. Well, so your briefly went to 80. Assessment on day 15. Start out three. All assessment. So that's everything for me. Um, any further questions? Yeah. Okay. Thank you, guys, and can see for amazing session. That was That was brilliant. Thank you. Just take away your medication. So I'm left with, um I'm address our presidents asperity my address on our aunts Keeping email address eso If you have any questions regarding unset it or public how the globe, a house or any career you can email us. Um, yeah,