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Hi, everyone. Um, I'm not sure if you can see my screen at the moment. Is anyone able to see my screen? Hypo? We know your screen isn't visible at the It isn't okay. No, it's not. So you can't see my presentation at at the moment? No. Um Okay, let me try again. Uh, all right. Still nothing. Um, no. Can you see that share button right in the middle? Yeah. Yeah, I'm trying to say share screen and then entire screen. Yeah, entire screen. Yeah. Yeah. It's not letting me share it for some reason. Uh, if you want, you can send your presentation to me, and I will share it. Then I can move it. Okay? Yeah. Sure. Okay. Yeah, sure. Um, what's your email? The draw. Yeah. Yeah. Give us a few minutes, guys will be up and running. Okay. I just sent it to your new era. Hi, Bobby. Can you see my screen, right? Yeah. Yeah, I can see your screen now. Prayed I'll share it and let me know when to move. Yeah. Yeah. Great. Thank you. Great. Um, all right. Thanks a lot for coming, everyone. Um, for those of you who didn't come last time. My name is Pahlavi, and I'm an f Y two, uh, Wiggin infirmary. And I'm currently on general surgery. Um, just to get an idea about. I know last time there was a lot of foundation doctors and some medical students. Can you just put in the chat If you're a foundation doctor? Medical student Just so I know what level I'm pitching out, I'm assuming it will be around the same as last time. Is any you everyone able to use the chat? Okay. I can't really see, um, anyone using the chart the moment, but we will swiftly continue. Um, just just so you know, it's a fairly It's a fairly interactive session, and I got some good feedback. Glass time. Um, just just going into this, I will have some polls and things. Um, So please do, um, participate just to make it a little bit more exciting. Um, so these ask to see the patient sessions are basically, um, an interactive way, um, of trying to go about assessing the acutely unwell patient. So last time we focused on dyspnea. Um, this time we're focusing on abdominal pain and how to go about assessing, um, someone with acute abdominal pain. So next slide, please. Um, So the objectives are to develop a logical, standardized approach to assessing acutely unwell patient's. And these ask to see the patient sessions in general. Um, this, um, today's session is understanding the main differentials for abdominal pain and the acute setting and going about, um, understanding what the first line investigations are and how to manage these comments scenarios as an f y one slash f y, too, and then becoming more comfortable with escalating patient's developing appropriate escalation plans and being able to hand over patient's to your colleagues. Um, so in terms of an approach to abdominal pain, uh, in terms of taking the history, um, these are the sort of things you'd want to focus on. So you want to 1st 1st approach it with Socrates. So that's how I learned at medical schools. So site onset duration, progression of the pain if it started two hours ago or two days ago or two months ago, because it kind of makes your differential diagnosis very massively. Anything that makes it better or makes it worse. Um, there's a large number of associated symptoms of abdominal pain, and you can largely classify them into sort of upper gi and lower GI symptoms. But I've got all these like distension, vomiting, constipation, diarrhea. So any sort of change in bowel habit is quite an important one for abdominal pain. Um, Hemet, eh? Missus Molina, So sort of classified under PR bleeding, um, jaundice, pruritis, um, dysphasia, weight loss, fever, anorexia, more sort of generalized red flag symptoms. And then, in terms of past medical history, you've got, um, whether they've got crone's disease or any sort of IBD. Um, history of hepatitis. Do they have known gallstones? Any malignancies? Do they have reflux disease? Um, any recent trauma? Um, recent surgery or periods of immobility, especially in surgical causes. When you're considering, uh, if someone say got battle obstruction, if they had previous surgery, and they've got adhesions now or any complications, Um, any allergies they have, like any history, social history. So alcohol is a big one. Smoking is a big one, as always, occupation and in terms of just knowing what their baseline functioning is, um, and they're sort of diet to see what kind of lifestyle they lead. Any recent travel. Uh, and family history is important, sort of and knowing if they have a family history of GI disease or any malignancies. So, um, an approach to abdominal pain. Obviously, it's not limited to these right here, but I think it's a really good way of just, um, assessing each part of the abdomen. So you've got your right hypochondria. Um, you've got your liver so and gallbladder. So anything, Anything there. You've also got part of your lung. So there's there's lots of different causes. Um, you've got your lumber regions where you've got your kidneys. So any pollen, arthritis, renal stones? Um, a very typical give you typical pain in this region to your right and left iliac. Right? Iliac, obviously you've got appendicitis. Is is the probably one of the most common things you think about, um, on the left eyelid back you've got diverticulitis, which is what, quite a common left Eylea cause obviously, in both Iraq forces, you've got ovaries and females. You've got to think about ectopic pregnancies. You've got to think about hernias. Um, so an epic ass trick region you've got, um, pancreatitis is a big one. Peptic ulcer disease. So again, like I said they're not limited to these to these diagnosis, but I think I think they cover the vast majority of them. And I think it's a very good way to approach abdominal pain. If you can sort of localize one region, then you're narrowing it down quite quite well. Um, next slide, please. So, like, like all of, um, like our last scenario, we've got, like, our last session. We've got two scenarios. Um, so for this one, you're a surgical F way to on call. You have been referred a patient from A and E to Clark. Um, she's called Margaret. She's 72 year old female. Um, she's referred you to abdominal pain, nausea and vomiting. She's got a past medical history of atrial fibrillation. Type one diabetes, osteoarthritis of both knees. She's using a one currently, because she's tacky, cardiac at 110 BPM. Um, blood's should. There's some lab issues. Um, so it's one of those slow days in A and E where they're just referring people to you without all the blood tests. Her V b G shows of that day of 3.4 abdominal lecture has been requested but it's not been done yet. So you're still waiting on that. And they've just started on some IV fluids in A and E. Um, I've just got a poll, so I'm going to attempt to do the So can everyone see this poll? Is anyone not able to see the pole? Okay, okay. Yeah, Good. We've got five responses. Okay, Cool. So, no, it's six responsive. Okay, I good. Um, this was this was just basically a way to try and just get people thinking, um, so we've got 42% in good is the least like the bowel obstruction bowel ischemia. Okay, fine. So I think I think it's we can fairly say that this isn't enough information to say what the least likely differential is. Basically, that's that was the idea is trying to get at, um but I think given the history, God is possibly the least likely differential. Uh, next slide, please. Um, So what do you want to know? With any abdominal pain history? Obviously. You have to look at Look at all, Um what we what we talked about before. So the history says she's got one day history of worsening abdominal pain. It started centrally. Now it's progressively worsening but not localized. She can't really localize it to a particular region. She started feeling nauseous this morning. Vomited three times. Um, she opened her bowels this morning, had some diarrhea. She's had no PR bleeding, sort of reduced appetite. Since the pain started, she's feeling a little bit short of breath. No fever, however, no weight loss recently. No lower urinary tract symptoms. And she's not had her morning dose of bicep prolol. Uh, what else do you want to know? Obviously, you need to take a more extensive history when you're clerking. So, um, Amy obviously told you she's got a chill fibrillation type on diabetes. Osteoarthritis. You also find out she's got hypertension. Um, she's got a past surgical history she's got. She's had two C sections, but they were over 40 years ago, and she is on the following medication. She's got no known allergies. She's on warfarin. She's on a long acting insulin. She's on a short acting insulin. Um, she's on bisoprolol. I'm not a pian and ibuprofen, and, you know she hasn't taken her morning dose of Bystolic pillow. Okay, So what else do you want to know. Obviously, you want to know her sort. Baseline functioning what she does. She lives with her husband. She's quite independent. Um, she is a nonsmoker. Nondrinker, um and she mobilizes the walking stick due to pain. She's got osteoarthritis, so that's fairly reasonable. Uh, and she's got a family history of bowel cancer. Um, and her dad died at 68 from it. So, like I said in my last session, um, what I'm going to be hammering down Is this a DUI assessment? Because it's just so important because, in my opinion, you don't really miss things when you're doing an A to a assessment. If and if you feel like you're not getting the answers and then you just start again and you something, something, something will come up and you'll be able to find out what's going on. Okay, so in the eight we assessment age, she's got a patent. Airway breathing had trickier. Central, Um, she's got an increased work of breathing. She's using accessory muscles, so she's working quite hard. Her respiratory rate is 22 so a bit high, but she's not requiring any oxygen maintaining stats on room air. Um, when you examine a chest, um oscal on auscultation in bilateral air entry. She is tachycardic. Um, you know that she's not taken her morning dose of bisoprolol, but pulse is irregular. She's got a f So you know that heart sounds are okay. Her blood pressure's 100 over 67. So a little bit on the lower side. Um, but she's just come into a new so they have not done any input. Output monitoring. She's not catheterized. And you can't visualize any JVP, but she's alert her GCS is 15. Her pupils are equal and reactive to light, and her bm is 4.6. Um, when you look at her, she's quite high. Be a my lady. Um you think, huh? Abdomen looks a bit distended. You notice a C section scar. She is when you palpate her abdomen. She's sort of tender throughout. There's no like focal tenderness anywhere. Um, and you check the hernia offices because that's what you should do in any abdominal examination. And she's got her three by four centimeter right femoral hernia. And when you palpate, it is quite arithmetic and quite tender. And obviously you always examine the calves as well in a need to reassessment. Calves are soft nontender and her temperature 37.6. So, um, so just in the chat, do you guys want to just put what you think the most likely differentials are from this assessment? This isn't a poll. I think the poll is for something else. Like anyone. Got any ideas? Completely Fine, if you have no idea. But something would be nice. Okay, fine. Uh, incarcerated hernia. It was a really good one. Yeah, there is no right answer, by the way, because I think the multiple things are right in this case. Yeah. Okay, so these are the differentials that I came up with. Bowel ischemia is a really good one as well. Um, so strangulated femoral hernia, bile obstruction, al ischemia, perforated, viscous and intraabdominal sepsis. Now, I've got another poll, Um, that I would like you guys to try, um, what is less of a risk factor for a strangulated family hernia amongst the following? Yeah. Okay. Yep. So, so far, people have said male gender, which I think is correct. Female gender high, be a my chronic constipation. All pretty high risk factors for for, um strongly to family hernias in particular. Um, it's not as common in in men. Um, so yeah, these These are the most likely differentials. Um, it could be that one is causing the other. It could be that you've got a strangulated femoral hernia causing bowel obstruction by al ischemia. You get perforated, viscous and causes intraabdominal sepsis. Um, but we don't really know what's going on at the moment. So next slide. So, in terms of investigations for abdominal pain, I would say that these your pretty bog standard ones like my last session. I like to classify my investigations into bedside blood tests. Um, these are like surgical ones, and then you've got imaging. Um, so in terms of bedside investigations, you've got, um, your basic observations that you can do at the bedside, um, gives you a good sort of idea of how stable a patient is, You know, an E c g at the bedside. Um, I would always recommend that everyone does an E c G, especially in people with tachycardia, um, urine dipstick, especially in people with abdominal pain. I think it's it's so easily missed and really poorly documented generally, especially when you want to do, um, part urine dip pregnancy tests, and you have no way of proving that this person's harder pregnancy test done so in females. I would definitely make sure pregnancy test is done. Um, if they're young, um, and then you've got surgical blood, so I always try and get an F b C CRP. Use any LFTs and Emily's and a V B G, especially for the lactate. And then if you think that this person is likely to go to theater or they have say, um, they're on anti coagulation, then I would always get a coagulation screen, plus or minus a group and safe and cross match. If you're you've got a strong suspicion that they're going to go to theater cause you may as well get all the blood at once. Um, and then, in terms of imaging, I always like to get an erect Ristic Cherie. Um, not all the time, but on a lot of occasions that we can talk about why, um uh to identify any pneumoperitoneum and then an abdominal luxury, um, to identify any sounds of bowel obstruction. So again, I don't get an abdominal luxury for everything. Just just in in some situations that we'll talk about. So I do have a poll for the next one as well. So next slide, please. So this is, um, Margaret's E c G can. I'm just gonna put a poll up. Um, okay, So what does this E c g show? Okay, we're fairly back and neck. Okay, So this e c g is actually it. It probably is very difficult to work out. The rate just sat there from home, but the rate is closer to, like, 1 30. So, um, I would say this is atrial fibrillation with a fast ventricular response. Um, she does have a history of F, but she's she's she's quite ducky Kartik at the moment. Um, so, yeah, next slide. So her urine dip is clear. Um, hate. See, do you not done post menopausal, which is fairly reasonable. And her blood tests show? Um uh, so, no, if we just click on just the V B g. Yeah, and stop there. Um, that's fine. So you can see that she's got a low hb. Her white cells are raised. Her platelets are a little bit raised. She's hyponatremic. She's hypokalemic. She's got a raise. Durian creatinine. So she's got an a k. I, um we don't really know what her baseline egfr is, but I'm assuming it's off baseline. She's got a high crp. Her iron are 3.1 and her Phoebe G shows this. So my next question is, what does the V b G show? So if you guys can fill up the pole, Okay, I think everyone most, most people have got it right. There's a metabolic acidosis. Alkalosis. Sorry. Um, so you've got a raised ph of 7.5 to a low p A p a, CO2 and, um, HCO threes 29 the lactate. It's 3.8. Um So like I said, there's an AKI hyponatremia and hypochelemia. There's a metabolic alkalosis iss a raised lactate and raised inflammatory markers, And Margaret's Target I N r is 2 to 3 because she's on, um, warfarin for her af um, so it's like just pretty much in range for her, but may not be optimized for other reasons. So next one. So we've got, um, abdominal X ray and just can anyone just tell me what's going on here before we move on. I don't have a poll for this. What? What are we looking at here? Anyone? Yeah. What kind of bowel obstruction Is it? Small bowel obstruction. Yeah, that's great. Um so? Well, the next side will talk about, um the different kinds of bowel obstruction and how to identify the on the abduction day. But in this, you can see that it's more central, and you've got the prominent, um, Balvin convent A, um also called, like a circular Harris. And you can see, um, the line stretching across the Lumen of the bowel. And that's indicative of small bowel obstruction. And it's more central rather than peripheral, which would be more indicative of large bowel obstruction where you can see the house, Tre. Um, so next side. Oh, you've got, um, an erect chest victory as well. Just to see if there's any pneumoperitoneum. Which there is not in this case. And I've just got side on Abdo X ray interpretation as well. Um, so I learned it as BBC. So you first look at the bowel and other organs. You've got small bowel, large bow. You can't always see all of these things. You can just mainly see small and large bowel. If they're sort of prominent, you can see fecal loading. Um, you can sometimes see the liver edge and sometimes the gallbladder. You can see the standard stomach you can symptoms. You mostly see the so it's muscles. Um, on either side of the vertebra, you can sometimes see a kidney shadow. You can see renal stones and things. Sometimes you can see a spleen. And if there's a blue full bladder, you can see a bladder. Um, but the general rule for foul is the 369 rules. So 33 centimeters for the small bowel, three for the large bowel and nine for the cecum is the wolf of bowel width. Generally, anything above that is dilated. Um, then you can also see bones so you can see the ribs, vertebrae, sacrum, coccyx, pelvis, pelvis, proximal femur is in most Abdo X rays. And this the C is for calcification and artifact, so you can see contrast in sort of gastrograph. In studies, renal stones, all the different types of calcifications you can see, um, ureteric stents, surgical clips, etcetera. So that's just a very quick overview of, um, Abdo X ray interpretation and how to go about it. Um, so in in my eyes with this lady, we know she's got a small bowel obstruction from her Abdo x ray from a clinical assessment. She's got a strangulated femoral hernia or slash incarcerated femoral hernia. We don't really know, Um, but there are three real aspects in her management from from sort of junior point of view. Number one, I would say, is to escalate the situation. You're not going to be managing this on your own. So escalated to a senior. Whether it's a registrar or consultant, you need more help. Um, the second is you need some further investigation, and in this case, it would be some imaging, Um, so you would do an urgent CT, abdomen, abdomen, pelvis, with contrast, Um, and it's to determine exactly what the cause is defined. The anatomy. If you're going to plan to take up a surgery and to see what level of vascular compromise there is, so does she have necrotic bow? Um, and number three is probably how to stabilize and optimize that the theater, cause this is this is probably a surgical emergency and would need their to quite quickly. So you want to keep her nil by mouth? You'd want good IV access to too wide. Volcan Ula, give IV fluids, Potassium replacement of necessary arouse tube to drip and suck. So you want to decompress the bowel? Um, you want to start IV antibiotics? You'd want to give good analgesia antiemetics and optimize co morbidities as well. So if she's type type one diabetic, you'd want to start on insulin siding scale. And because the iron are is 3.1, you'd want to give her some vitamin K. Um, and you'd want to catheterize her and make sure you're monitoring her input and output strictly. Um, I said that that that is why I would say the immediate management would be, um and we've talked about this in the last session, but I just wanted to remind everyone that it's very important to make sure you have good escalation plan. So you're involving a senior early, if necessary or involving critical care outreach team. They're a very good sort of, um, point of contact between you and I. See you a lot of the time. Make sure that, um, you know what their d n a R status is especially in elderly people with multiple core morbidities. You want to know if therefore, um, resuscitation, They're full. Are they for full escalation? Always think about the ceiling of care. Um, involve the family, especially in this case, um, with obviously obviously with the patient's permission is very important. Um, but if they're for theater, then the family should really know about it. Um, things to also consider, um with patient's going for theater. Um, you need to know what the functional baseline is. What the clinical frailty score is. Um, I'm not sure how many of you have worked in surgery, but we're gonna We use the Neil a risk calculator quite a lot before we take people to surgery. And it basically calculates a morbidity slash mortality percentage to sort of where the risks and benefits of taking someone to theater and how likely they are to survive. Um, slash how co morbid. They meet they maybe afterwards, um, other things to do. Obviously you want to inform the ankle anesthetist, um, to do a pre op assessment and optimize them from their point of view. Inform the theater coordinator to prepare theater stuffed in the equipment and book book A theater, Um, the A's of the ICU staff. Um, in case they're likely to need icu input and monitoring postoperatively in ICU. Which does happen for quite a lot of these patient's who have bowel resections and and have a scheme Iqbal. And then obviously you want to go through the consenting process. And this is obviously done by the operating surgeon of the registrar. So, um, in terms of her ct abdomen, pelvis report, um, it comes back saying this small right femoral hernia containing a small bowel loop of the proximal Islay um moderate, dilated stomach and jejunum with a large amount of fluid and air fluid levels within the dilated small bowel loops. And there's a transition zone within the right femoral hernia. So these are actually two random images I have, um, they're not necessarily associated with this report. Um, but it's just an example of how, um, some more dilated small bowel loops would look on a c t a. P um, so it's sort of outlined in green and in the bottom image. You can just see that in the bottom image. What is circled in green is basically the femoral hernia. Um, but yeah, I'm not I'm not trying to convincing, that is, but, um yep, we can go to the next slide. So, definitive management. This patient is basically surgical. There's there's nothing you can really do in terms of conservative management. Obviously, you can put arouse tube in, um, drip and suck. Decompress the bowel. But ultimately, this lady needs a femoral hernia repair, plus or minus a bowel reception, plus or minus a stoma formation. Stone formation is always going to be something you warn the patient about because it's always a possibility. Obviously they try and avoid at all costs. But it's always there's always a risk involved in these surgeries. Um, but yeah, that's that's the end of the first case, guys. So if if anyone has any questions, that would be, um, now would be the time to ask regarding this case. You can also on meet your mix and ask if if that's any better. Okay, um, I will stop again, answer any questions at the end, so we'll move on to the second scenario. Um, so you're an F one in A and E and been asked to see the following patient. This time it's a young man called Andrew. He's 19 years old. He describes a two day history of pain and his abdomen. He's been experiencing malaise and had a cough. But otherwise we'll volunteers. No history. And that's all that. And he has told you. So what do you want to know? Obviously you want to take a full history. Um, he's had a two day history of pain around his umbilicus and bright side of his abdomen. It's progressively worsening. It's like an ache. It's an ache like pain that he described. It's non radiating. It's associated with nausea and vomiting. He's vomited twice this morning. Paracetamol improves the pain but has not tried anything else. It's a seven out of 10. He's had a cough for a week. It's nonproductive and dry. Increase in urinary frequency. No dysuria note. Urethral discharge. No change in bowel habit. What else do you want to know? So past medical history. He's normally fit and, well, um, drug history. He's on no regular medications, no allergies, social history. He lives at university. He's been drink socially. He admits to using recreational marijuana. He's sexually active. He's got a family history, and he's got no family history. Sorry. Um, so in terms of the differentials in a young person, obviously you think about other things. We can move on to the next side. That's fine. Um, so in a young person, the most likely is a large number of things. He could have a UTI. He could have abdominal migraine. Could be appendicitis. It could be pneumonia's cause he's had a cough. It could be liver capsule pain, because because of that and non specific abdominal pain is largely a diagnosis of exclusion. But a lot of the time you can't. You can't narrow down a cause for the abdominal pain. But in a young person, what are the most important things to exclude is he's got right sided abdominal pain, and it's important to exclude appendicitis. Diabetes is a very important one to exclude as well. Colecystitis. Pancreatitis. Um, I think I do have another poll. Um, yeah. So I've got this. Can you Can you can you guys see that pole? Oh, let me try again. Mhm. Let me try again. Okay. I don't know why it's not coming up, but basically, um, we can We can skip that one is not an issue. Um so obviously like like any. Like anything we've done in every scenario, we're going to an A to a assessment. So this time the airways patent, um, in terms of breathing the trickiest central. It's got an increased respiratory effort, his respirations 20 for So he's working quite hard. Um, but just as clear, Equal air entry bilaterally. Noize No crepitations. Um he's a bit Ducky Kartik. His heart rate's 110 but his pulse is regular. His BP is 110 over 72. He looks a bit dry. He's got reduced skin. Tug Dryden, mucous membranes. Again He's fresh into a and e so not catheterized. His GCS is 15, his pupils equal and reactive to light. His BM is 15 to quite high. His abdomen soft, generalized tenderness, more tender umbilical paraumbilical region no guarding or puritanism. No organomegaly and his calves a soft nontender and his temperature is 37.2. So in terms of investigations, obviously we're going through Bedside blood's the same. The same shebang of investigations. Um, in this patient, I think I'm less likely to get a coagulation screen and group and save. Unless I thought they were extremely tender and potentially parity, Knittig and I would I would still get an erect chest X ray. Um, okay. I think my poll has just come up now. I'm not sure if you guys can see it. Yeah. So, um, appendicitis is the most common abdomen related emergency. So we've got the e c g here, Um, which I think basically just shows Sinus tachycardia. Um, there's nothing. There's nothing much on there. Yeah, um, and then you've got the urine dip. It shows three plus ketones and a trace of leukocytes. Um, you've got the blood tests. Um, if you just go down until impression again. New era? Yep. Um, so Scott mildly raised white cells, slightly hypernatremia like, slightly hypokalemic. Because yours eight. Um so slightly high. Creatinine. Mildly high. His egfr is maybe a little bit off baseline if he's 19 years old. Um, crps a little bit high as amylase is a little bit high as well. However, is V b G shows a ph of 7.32 p. A CO2 of 3.3. Um, hates you three of 13 and basic cysts of minus 10 and a glucose level of 18 millimoles. And his lactate is 3.1. So let me get my pole up again. So, what does this V b G show? Okay. Yep. So the vast majority of got it right. It's a metabolic acidosis. So you've got a low pH. You've got a low bicarbonate level, and, um, in order to compensate for the low bicarbonate level, um, you've got some respiratory compensation on the patient's trying to blow off the p A. CO2 the CO2, and then you've got high glucose level and you've got a high lactate. Um, so you've got metabolic acidosis with partial respiratory compensation because the pH is still 7.32. So it's still acidotic. You've got mild rise and inflammatory markers. You've got mild increase in amylase. You don't know they could have a little bit of gastritis, and that can even cause an A a slight rise in families, But it's not a significant rise. Um, and then you've got a mild arrangement in the renal function. So, in terms of the diagnosis, um, if if the patient has diabetic ketoacidosis, Um, and there's certain criteria on how and what diabetic ketoacidosis is and what meets this criteria. So you need to raise capillary blood glucose of more than 11 millimoles per liter or known diabetes um, capillary ketones, more than three minimal pelita or key tones, more than two plus in the urine. And then you've also got venous pH of less than 7.3 or a venous bicarb of less than 15 millimoles per liter. So our patient's satisfied all these three criteria, and hence you've got diabetic ketoacidosis. But obviously it's a new presentation because he's not a known diabetic. Um, yep, next side. So in terms of immediate management, it's It really depends on the trust in terms of guideline, but always escalate to a senior early in terms of DKA because patient's can rapidly deteriorate because they lose a lot of fluid very quickly and it can be very life threatening. And I've seen I've seen some patient's go to I see you very quickly as well, so escalate very quickly to seniors. Um, you probably need more help. Any way to manage this? Um, and then next? Yep. So you need you need a good amount of IV access again. You need to wide Volcan Yala's, um and this is what differs All local guidelines are a little bit different, but they run off the same principles, so I will go through it with you. Um, pay. This patient is probably likely suitable for recess due to constant monitoring requirement and due to a high risk of deterioration and constant monitoring like Ali A B G, V BGs, they probably may need to be in recess or somewhere where nurses will have, like, 1 to 1 monitoring with him. And you need to monitor the potassium level. Um, and at some point, you need to call the diabetes specialist team. So DK management, like I said, varies from trust to trust. And there is usually a very, very comprehensive guideline in each trust. So I would definitely try and look into that. I went to Leeds University and we had, like, a very good one. So I've kind of based the principles of that off the l T H D guidelines. Um, but essentially the first thing you have to do is start the patient on a fixed rate insulin regime of 0.1 units per kilogram per hour. You need to give them good fluid resuscitation. Um, and there's usually a different fluid re regime, so you give them one bag of IV fluids over one liter. Then I think one bag over two liter one bag over two hours, Um, and then another bag over two hours and then another bag over four hours. So it's quite a lot of IV fluids. Within a short period of time, you need to monitor the potassium level. Um, because the moment you give insulin your sort of your driving potassium into the cells, so that means that serum potassium is going to drop. So you need to adequately replace the potassium um, from the second bag of IV fluids onwards and replace the potassium according to the potassium level. So if it's less than 3.5, then you need to most likely give more than 40 millimoles in the bag. Um, if it's between 3.5 and 5.5, then you give 40 millimoles. If it's more than 5.5, then you don't have to give any. Does anyone know how quickly you can give potassium just out of curiosity. It's not a pole or anything, but I just want to make sure people know if someone can pop it in the chart. Okay, You can You can give potassium a dexa a line. Um, I don't think it's usually part of the d K protocols. Um, but yes. Say that's right. You can give 10 millimoles of potassium in an hour. Usually not not faster than that. Um, in in DKA You You generally you don't really give, um, more than 10 millimoles in an hour. Oh, and Jun really as well. No. Over So 10 millimoles per hours. That is the quickest. You should really be giving potassium. Um, but a rule in DKA. Generally, these people are going to need vigorously monitoring. So that includes our levy BGs to check the potassium, the blood glucose, and there are specific targets that you need to meet and then adjust the insulin adjust. The amount of potassium are giving accordingly. So next slide. Yeah, So these are the treatment targets for DK. Um, you're aiming to achieve a fall of three millimoles more than three millimoles per hour, um, pelita per hour until the glucose is less than 14 Millimoles, uh, capillary ketones fall of 0.5 millimoles per liter per hour until it's zero less than 0.6 and you're aiming to rise the bicarbonate level, but by more than three millimoles per liter per hour until more than 15 millimoles. So these are the treatment targets and then next. So after the parameters recover to sort of normal, then your then your aim is to switch the patient to be on sub cut insulin and, um, when when they're able to eat and drink as well. But you continue the IV insulin for a short period of time and then just keep them on the subq insulin. However, if the patient's not eating and drinking, then you switch to a variable rate insulin, which is also called a sliding scale. Um, you make sure that the venous pH is more than 7.3 and blood ketones less than 0.6. And obviously make sure the diabetes specialist nurses also review the patient prior to discharge because they're very important in making sure the patient gets adequate care in the community and making the G P aware of their admission and what's gone on in any changes to any medications, especially in, um, known diabetics. But in newly diagnosed diabetics, then they play a key part in making sure they're established on a good insulin regime. Um, just something I'm I'm I didn't cover. Is that when When you're dealing with DKA in a known diabetic, make sure you keep them on that they're long acting. Insulin is very important because if you don't do that, then they almost always go back into DKA. Um, but yet like Like I said, earlier escalation is really important. So involve a senior early in this case, it would be the medical registrar, um, involved critical care outreach and the diabetes. No specialists recess if him oh, dynamically unstable. And they need monitoring. I was seeing younger patient's. You're less sort of worried about escalation status, and they are likely to be full, full escalation. But in people, for with multiple co morbidity, that's really important to, um even if they're young to consider escalation, status and what they want, they would want and involve the family. Um, so just some taking points from these two scenarios and abdominal pain as a whole, abdominal pain is not always an acute surgical abdomen, just like my my second case. Um, I think abdominal DK The presentation of DKA is most the vast majority of patient's do present with abdominal pain. So if you're on a surgical placement, then if someone has a history of diabetes, please do not discount DK. Ask for the urine dip for the ketones. Ask um for their B m level because it's very easy to to misdiagnose and by that time, the end of the surgical team. And they really shouldn't be, um, when in doubt, go back to the 80 we assessment, make sure you're covering every single section of the 80 assessment. Um, at medical school, I was taught D in a two e is don't ever forget the glucose because it's very neglected and people miss it a lot of the time. But it's a very, very simple test, and it's very easy to do. And it can answer all your questions, sometimes always considered patient's baseline function and co morbidities, especially when they're potential surgical candidates and how and that largely determines whether or not you take them to theater and always ask for help because you're never alone in managing these situations. Uh, even though you may think you are so always escalate, ask for help early if you're ever unsure. But that's all for today. Guys, if anyone has any questions, I'm very happy to answer. Um, there is a feedback link. I know. Um, a lot of people provided the feedback. Um, last time and it was very useful. And I tried to make it a little bit more interactive based on that, um, so please let me know what you thought this session. And if you have any suggestions for upcoming sessions that I'm very happy to take suggestions and I will try and tailor to what you want. Does anyone have any questions? You guys, you guys can claim your certificate by filling in the feedback form through the link provided. And if no one has questions, we're going to end this session now. Uh, thank you so much. Body. Thank you. Thank you. Any feedback is very much appreciated. Thank you.