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How many people in the room? Yes. And you talk people just waiting two more minutes and see how it, how are you guys? So we're just, we're just waiting on a lot more people to join up. Um Could you just drop in the chart if you can hear us? Oh, perfect. Good stuff. Okay. So we'll just give it until um around seven o'clock. Yeah, we'll just give it a couple of more minutes and then stop. It's good. Okay. What? Yeah. Hi, everyone. Can you all hear us? I think one person's replied yes. So we'll just assume everyone can hear us. I'm having, I'm one of the I M T S in Guilford Hospital. We've got Maya, hello. Um One of our F threes and tell a one of our F twos were all at the Royal Sorry County Hospital were putting together a webinar series called The Bleak Me webinar series. It's aimed at fourth years, fifth years and F Y by ones and twos. Essentially, it's all about what to do if you get bleeped in the middle of the night and you don't know what to do. Um And we've got our first speaker today, Doctor Shannxi, he's one of our specialist cardiology registrars, um who's worked at the Royal sorry before and he's now at ST George's. Um he's kindly offered to present the first session. So, um this will be very interactive, so feel free to spam the chat, um ask questions during the session. Um And well, one of us will keep an eye on the chat, uh look for your questions as well and we'll feed them back. So, um if you're happy to start, you can everyone hear me, I'll just check if everyone can hear me and then I'll start. Yeah, we can hear you from our end. Yeah. Okay. Um So yeah, thank you for the introduction. My name is Amir um Cardiology Registrar, South London Beanery. And today I'm going to be uh running you through bleeps that you might receive when you're on call on the ward, wherever it might be with a patient who is experiencing chest pain. So the outline of the talk, um first of we're going to talk about actually taking the call itself. Um and what that means and how to, you know, prepare for that and how to approach that. And then we get onto a little bit more meaty stuff with reviewing the patient and what actually needs to be done. Um And then we'll go through a few case studies where we go through examples and see what you guys think. Um And then we'll very briefly touch on peri arrests, um and chest pain, uh situations related to perry arrest, which you may encounter. And then we'll have a bit of Q and A and you feel free to ask what you want. So my, my two rules here, please ask questions either during the presentation or at the end and ask me to slow down or speed up if you feel, you know, one way or the other. And no question is a stupid question and no answer is a stupid answer, especially if it helps you to understand better. So I'm I'm a big believer of that. Um I don't think any learning environment should be um you know, a place where people feel that they can't speak up or they can't answer things or they can't say things. So no judgment here whatsoever. Um uh You know, it's a very safe environment. Okay. So, yep, by the way, this sign, if that comes up, that means I want some interaction and we're gonna do interaction today, just buy in the chat. Um So, you know, feel free to, if I'm asking questions or you have comments, feel free to put, put them in the chat, especially when that, when that sign comes up. Okay. So learning objectives just very quickly to be able to review a patient experiencing chest pain and come up with a differential to be able to manage important chest pain presented presentations, we won't be able to obviously go through every single one, but I'll try and highlight the more important ones. Um and to recognize chest pain presentations that can lead to perry arrest and to recognize when to escalate, which is particularly important for you guys starting your journey in F one F two or even, you know, medical students to know when to ask for help. Um And what do you want to be asking for? It's, you know, when I started as F one, I was lucky in some sense because I had some seniors who are very, very open to me seeking out help and others not so much, but I think it's important for you to know where your limitations lie and where you as an F one um need help. Um So that, that's hopefully I'm going to cover a little bit of that today and hopefully that will help ease your mind. So taking, taking the call, um, so taking the call when it first, when you first get the phone call from whoever it is, whether it's chest pain or anything else, um Don't panic, stay calm. I remember when I was on call first day, um multiple bleeps and you're going to get bothered by loads of people, some asking for really, um you know, basic things like prescribing paracetamol and some, a little bit more serious. So whatever happens and doesn't matter how many phone calls you get, try to stay calm as much as you can because when you're in a moment of panic and anxiety things um just get more stressful. Um I'm not sure if you've heard of this, but the S Bar handover, um it's basically the way we try as medical professionals to handover patient's to others. Um And it's split up in situation background assessment recommendation. Um Now, obviously because you're going to be taking the call, you're not going to be handing over the patient. It's the person at the under the phone, which is in this scenario, a nurse who's going to be handing you over what the situation is. So sometimes they might not follow this but try and ask questions so that it fits this structure. So you want to find out what the situation is. I Mr X is experiencing chest pain, what the background is? What if they come into hospital for? How long have they been for in hospital for what the nurses assessment is? Have they done any basic observations? Have they done any E C G s and what the nurse wants from you? So do they want you to actually come and review the patient? Are they really stressed, really worried or is it something that you know, they've had some musculoskeletal pain in the shoulder and it's just flaring up and they just want some analgesia. So it's important for you to have a structure even when you're not the one um making the call but receiving the call. So take your time to ask relevant questions and think about the scenario. Um Don't feel rushed, the number of times that the person on the other than the phone is making me feel rushed as a cardiology registrar, they want answers. They want a plan of Axion. Don't rush. Just take your time. Ask the questions that you want to ask. Think about it. If you're unsure, you can always say, look, I'll get back to you. Obviously, in these scenarios, the patient's need to be assessed. So you would, you know, you, you might not ask all the questions that you want, but think about it as you're going to talk to the patient, give clear instructions that you want from the person on the other end of the phone as to what you would like next. So whether that be an E C G BP, bloods, basic obs whatever it is that you need that they can do for you, um then give them clear extra instructions because there's no point wasting time. If things can be done while you're getting to the patient or if you're busy seeing another patient and you'll get to them, then things can be, you know, done while you're waiting, sorry, while the patient's waiting to be seen, be prepared to not get the full picture from the phone call. So sometimes when you get phone calls, the person on the other and the phone doesn't even know the situation or the background of the patient that well and they just want you to come. So just be prepared for that, that sometimes you either might get incorrect information or not the full picture. Um Don't ignore concerned colleagues. Um That's, that's a lesson you will learn um that, you know, if nurses are concerned, if colleagues are concerned, um it's best to address those concerns because they're, they're speaking from experience. Um If you can, if you have an electronic system, read the notes beforehand or when you get there, um and in your mind as you're walking towards the patient, try and have a plan of Axion, um try and have an idea of what you're going to do when you get there. So are you going to speak to the patient? You're going to speak to the nurse, you're gonna flick through the notes, you're gonna look at all the CGs called chest X rays, whatever it is. And also from the information you have gathered from the nurse or whoever it is over the telephone, you might even start putting together differential as to what you might think is going on. Um Don't let that cloud your judgment so that when you get there, you're only thinking of one particular differential obviously have a broad mind, but it's, it's, you know, it's good to start thinking as soon as you have some information as to what this could be. And then you add more information to that um you know, to, to that structure in your mind. Um uh and then build from that. So, um if you do need to escalate, do escalate, so if over the telephone, it sounds like this person is having a peri arrest, then you ask the nurse to put out a peri arrest call. Um because you want to, you know, no one's gonna, no one's going to tell you off for putting a peri arrest call out for someone who you think is very, very sick. Um Alternatively, if the, if you don't think, you know, they're, they're terribly sick and you can see them, then it's best that you see the patient yourself first before you escalate to your registrar or to your S H O for further advice and help. However, if there's nothing wrong and I, I would never say anything to my juniors if they called me up to sit, to tell me, look, I'm just going to go and review Mr Thomas on this ward. I've just been told that they've got chest pain. I'm going to go see the patient first, but I thought I just let you know. Um, so that I can ask you for advice later on and that's just, you know, making me aware of the patient. Um And again, if you feel out of your depth at any point, you escalate as well. Okay. So those are just some, some rules. I uh you know, tell my juniors that you can't see the patient yourself first before that's better. But if you do need to escalate, do not hesitate. So now getting onto reviewing the patient, um so uh read the notes, so look at the presentation why they actually in hospital, um what their past medical history is, um get a hand over from the nurse when you actually get to the ward. Um and ask for what their observations are hoping that they would have done the observations before they called you. And if they hadn't, then you would have told them to do the observations as you're walking to the patient and also ask for BP in both arms as well. We'll come onto exactly why. But that's something that people forget, um, speak to the patient yourself, think of what questions you wanna ask. So it's just like going back to med school, you know, when you're in a ski station or Pacer station, whatever it is, the history taking. What are you going to ask? Right. You know, they've got chest pain. What do you want to know about this chest pain? Socrates is always, you know, a good, um, something to fall back on and as you develop your clinical skills, you will adapt the Socrates to, you know, what you, what works for you. But you know, where is the pain? When did it start? Have you ever had this pain before? How can you, how would you describe the pain? Is it sharp? Is it pleuritic? Is it like a pressure sensation? Is it like a dull sensation? Obviously don't put words in their mouth, open ended to close ended questions. I'm sure you know, this, does the pain spread anywhere else? Are there any associated or alleviating factors? Is it there the whole time or does it come and go? Does it go? Does it come about when you're walking when you're doing stairs when you're sleeping? Anything that makes it worse? And then, you know, the severity out of 10, the last s is just for you have an idea of, you know, how bad it is. Um, you know, because the patient might say might look quite comfortable, but if they're telling you this pain is nine out of 10, then, then, you know, something's not right? Because why you sitting there so comfortable. Um So ask about their past medical history that there might not be in the notes because we don't always get a full picture in our notes, their social history, smoking, alcohol, drugs, et cetera, any family history of cardiovascular disease or any other disease, actually, because chest pain is not solely a cardiovascular problem. Um, and always ask about the cardiovascular risk factors. Um So again, that's, you know, smoking, diabetes, hypertension, family history, renal disease, that kind of stuff. So when you examine the patient, because that would be the next step, um, make sure you assess the pulse and um this is why we do BP in both arms as well. Okay, because of dissection, aortic dissection. So when you assess the pulse, you always assess both radial pulses at the same time to see if there's any delay. And while the patient is lying flat, assess their femoral pulse as well as their radial pulse to assess for any radio femoral delay. If there is a noticeable delay and a patient's complaining of, you know, chest pain, then that could very well be a dissection. And I'm not saying it always is because, you know, elderly patient's to have a lot of atherosclerotic disease in their arteries. And there might be a tiny, tiny delay, but generally, if it's a noticeable delay, then that that's not normal, um assess their JVP because you want to assess their fluid status. You also want to, you know, assess what if there is any other cardiac physiology problem going on. Um Fluid status is very important. Cap refill, hydration, urine output, input skin turgor edema, the basic things that you would have come across. Um and then do the chest examination, full chest examination, not just listening to the heart sounds. You wanna listen to the lungs, you want to look at the chest. Is there any evidence of trauma, any, you know, rib deformities? Um uh you know, that kind of stuff. Um Listen for air entry, look at chest wall movement, look at trick, you'll deviation percuss if you need to the full chest examination and don't forget the abdomen, right? Because a lot of chest pain can sometimes just be abdominal pain. So always examine the abdomen as well. You don't have to do a full, you know, head to toe examination. You've come here to assess the patient who is complaining of chest pain. Unless you have any reason to investigate other parts, other bodily systems, just focus on the task at hand. Um And at this point, you would ask, you know, you would think about and ask for any extra tests such as, you know, an E C G or bloods from the nurse to put the patient on cardiac monitoring. If you know, if they're having palpitations or, you know, you've assessed their radial pulse and you think it's going 100 and 50 BPM, get a blood gas. If you think, you know, if they're oxygenation is falling to assess their um uh saturation to assess their carbon dioxide levels, they're lactate blood sugars, you know, gives you a lot of information, a simple V B G. Um And you're doing a B G if you're concerned about oxygenation um and get a chest X ray, get a chest X ray for someone who's complaining of chest pain. Um You want to make sure you don't miss out anything serious. Um Yeah, so those things are important. Um other things to come up with, right? So once you've, once you've established a little bit of a history. You've done an examination, you've read through the notes. Um Now you're starting to hopefully come up with a differential and to what, what you think that this could be. So come up with an impression, I was, when I started F one, I remember I was very hesitant to come up with an impression and I was just, you know, plan of actions, this, this, this um but it's actually a good habit to get into. Um, because it makes you think what is the problem here and then it makes you think, what do I need to do next about these problems? Um And if your impression is wrong, it's okay. Don't worry, you know, you're, you're, you're still learning your, you know, your, that's part of being a doctor as well. We do make mistakes, but it's just about, you know, no one's gonna string you up for it because, you know, most impressions are very, very sensible. Um So yeah, do come up with the impression. So you start to think what the plan of actions and obviously, you know, you can um discuss this with the senior, which is what I'm going to get into next. So formulate once you've made the impression formulated management plan, how you're gonna target that and then the three ways or the sorry, the three reasons why you would discuss with the senior senior number one, if there's any uncertainty at all it's better to be safe. Number two, if you think that this is a significant differential. Um, so it's not just, you know, gastritis, it's, you know, you think they're having, they're having a heart attack, for example, you know, that's a significant differential that should be discussed with the senior, um, or if the patient is unwell. So those are three reasons why you would escalate and discuss the case with the senior if you still want to discuss with the senior and it doesn't meet those three criteria, it doesn't matter, get up called, get on the phone and call your senior, not a problem. Um Once you've come up with a plan, discussed it, you put the plan in place, make sure you do review the patient again uh later on in your shift or you hand it over for your colleague to review them um and also chase up any results as well. Um And then act on any updated information. So you've ordered a chest X ray, make make sure you chase that up, check it. If there's something on there that you need to act on, then act on it, right? So differential, this is where I want you to get a little bit interactive. So just mention it in your in the chat. So what I want you to do is I'm going to give you body systems. Um And I want you to think of what differentials that a patient can have if they're complaining of chest pain. Okay. And as we go through them, we'll also think of the things that we might ask all the things that we might see. Okay. So, cardiovascular, let's start off with that differentials for chest pain with regards to the cardiovascular system. Just fire away if, if you are. Yeah. Am I? Yeah, keep going, keep going. Aortic dissection. Yep. Vagina. Yeah. Acs. Yeah. Pericarditis. Yeah. Good. Vasospasm. Good tamponade. Yeah. Okay. Yeah. Arrhythmia. Good, good. Okay, cool. So, I've got a C S Angina. Yep. So acute coronary syndrome or stable Angina. So, you know, the classical, the three criteria of angina is, it's a typical chest pain history, you know, center the chest or left sided, crushing, lights and sensation with radiation to the jaw, to the shoulder down, your arm gets better with rest and is worse on exacerbation. So that is the criteria of angina. 33 aspects. And then A C S is someone who's got acute coronary syndrome and they've got either got a stemi on end stemi or unstable angina. Um So the questions you want to ask is, you know, where is the pain radiating? What are your cardiovascular risk factors? You smoke? Are you diabetic? Have you ever had this before? Associated symptoms with shortness of breath, nausea, sweating, clamminess. You know, you want to look at the E C G. You want to do a troponin test. You want to make sure the blood pressure's okay, that kind of stuff, arrhythmia, again, palpitations, dizziness, pre syncope, syncope, um feeling of like pounding sensation or, you know, uh what's the other word I was going to say? Uh forgot it, but don't worry. Yeah, you know, classical symptoms and signs of arrhythmia, pericarditis or myocarditis. So, especially in young patient's, um people have had recent flu infection, viral symptoms. Um, they've had fevers, they've had, you know, they're just feeling generally unwell. Um, you know, even after COVID, for example, does it, the pain change on position? Is it worse on breathing in? For example, when you listen to the chest, can you hear a pericardial rub? Um What's the BP doing? Um that kind of stuff? A pericarditis for dissection, rip roaring, chest pain, radiating through to the back BP differences. People feeling rather awful. There's a radio radial delay, radio femoral delay, um you know, their blood pressures tanking. Um And then aortic stenosis is another cause for chest pain. So, patient's who come in with, you know, significant chest pain and either, you know, or you don't know, but you can hear in their chest, a really loud injection systolic murmur and these patient's troponin is always up and doesn't mean that they've had A C S and it's probably just the aortic stenosis. But, you know, that's, that's something that is commonly missed, right? Respiratory. Uh let's see what you guys can do. So, respiratory causes of chest pain, Pe Yep. Pleuritis. Yeah. No, Mr Thorax. Yeah. Good pneumonia. Yeah. Good COVID. Yeah. Cool. Okay. I think you, you guys have got most of it. So, pneumothorax, what would you be looking for to someone who's very breathless all of a sudden, someone who might have risk factors for a pneumothorax, um, on examination, unequal air entry deviation of the trachea. Um, you know, they might be as per medical school examinations. A very tall thin basketball player who suddenly has shortness of breath. Um, pe, yeah, you're looking for pleuritic chest pain. So, pain, worse on inspiration or coughing with risk factors. So, uh, they're either on the contraceptive pill, they've had a long haul flight, they've got leg swelling. Um, but some people don't have any risk factors and they can still have a p but think about the tests that you would order, what would you order? You'd probably, you know, want to do a blood gas, make sure the oxygen is okay. You want to do a chest x ray. Um, you'd want to send off a D dimer but think, but also, you know, when you are coming up with your differential and your plan of Axion don't limit your differential to a single one that this is definitely, unless it's blindingly obvious. Um, you know, try and think what else this could be and what other tests I can do to rule out other things as well. So when you send off a blood test with someone. You, you are suspecting a pe, don't just send off a D dimer. Think of what other bloods you might want to do. Um, infection and pleurisy as well. Okay. So, abdominal causes, what do you think? Yeah. Asthma, exacerbation. Yeah. That's a good honest job. It kind of falls under pleurisy and infection again. This is not an exhaustive list. This is just, uh, the ones that I think are important to not miss good. Yeah. Suffered. Your rupture, esophagitis. Good reflux spasm. Yeah, that's a good one. I don't think I've got spasm, pancreatitis. Yeah. It's a very good one. Yeah. Appendicitis. Yeah. Yeah. I guess that, you know, you can get radiation with the pain to more centrally. That's where it starts, doesn't it? Okay? Good. So, I've got G I rupture. Yeah. And I think about if you think it's a G I rupture, where could this be a soft agiel stomach intestinal? And therefore, what exams, what tests are you gonna order? Um, so that someone with gi ruptures gonna have really quite significant intense pain. They're going to be very tacky cardiac. Their BP might look, you know, not very good. It might look someone who, you know, if you've ever seen someone have a heart attack, it might look like they're having a heart attack but it might not be a heart attack and then you give them blood thinners and then it's, it's an absolute disaster. But Yeah. Um, dyspepsia. Good. Yep. So, you know, again, timing of the pain. Does it come on before eating after eating when you get hungry? Is it worse when you eat chili food, spicy food? Is it worse when you, you know, eat quite close to bedtime? Is it relieved by milk? That kind of stuff? You know, these are questions. You wanna ask someone with epigastric pain when you press down in the epigastrium and they're quite tender that could very well be reflux. You get ulcerative disease there as well. Bowel obstruction or bowel ischemia can also cause significant abdominal pain as well. And you want to look at the lactate, are they vomiting, not passing wind? Um, so just think about all these things. Um, and then, you know, peritoneal infections as well. So, peritonitis, um, any kind of infection. So, you know, Curtis cystitis, appendicitis, all these things can, can definitely cause abdominal pain. Um, musculoskeletal haven't, I've only got two bullet points in there. So, can you think of any musculoskeletal causes of chest pain? Costochondritis? Yeah, that's the one where wastewater med school isn't at T etc syndrome, costalcondritis. Yep, and trauma. I think there's only two, I've got so muscular pain, um, and trauma or fracture and then, yeah, costochondritis kind of cut falls into that as well. So, you know, be wary. Um, if you really think that this is muscular pain and nothing really else, then you don't necessarily need to go all gone. Um, guns out and start investigating for everything under the sun, but that, that really is dependent on a good history. Um, and, uh, you know, a good examination as well. So if, you know, you can take clear history, the pain is very, very reproducible. It's in a particular area you press down. It's very painful when they move that area, it's painful. Um, and there's no, you know, worrying cardiovascular symptoms or respiratory symptoms. Um, then, you know, you're probably dealing with muscular pain rather than anything else. But yeah, good history and a good examination. Okay. So I hope, I hope that was helpful. So we've got, we've got another 25 or so minutes. We'll go through some case studies. Um, so again, remember no stupid questions or answers. We're here to learn. I don't think reading through, I didn't read out every single, um, answer that people have said that I can't think of, haven't seen anything that is not very, very reasonable. Um, so well done. Um, so yeah, let's go through some case studies. So, case one. So what I want you to do is at certain points during the case, I'm going to ask you, what are you going to do next? And I just want you to write, okay. Um, even if I don't read it, it's good for you to, you know, think what you would do and write it down. So you're the f one, you're the day shift on the respiratory ward. It's a fairly easy day. It's, well, actually, no, it's not an easy day because at 3 30 you've just started having your lunch. That's probably a normal day, by the way. Um, and it's been a really long war drowned. It hasn't been taxing, but it's been long. You then get bleeped from the nurse just as about, you're about to munch into that pasta, that missus S is having chest pain and she suddenly dropped her sats. What are you going to do? So tell me what you're going to do. So you're on the phone, you're on the phone to the nurse and she's saying Mrs S is having chest pain and she suddenly dropped her sats. What are you going to say to her? What are you going to ask her? What are you going to do next? Yeah. Okay. Yeah. So ask them to hand over by Esper. A lot of the nurses may not know what that is. OBS Yeah. A T E if it's, it depends if it's a nurse, they might not be able to do an A T E assessment because that's not, that's more of a doctor's job, I guess. But yet they might be able to give you some idea of an 80 assessment. Yep, SATS levels. Previous sats. Yeah. Good, good request for obs quick check through notes E C G. Start on oxygen background, past medical history. Good. All very good. Yeah, introduce yourself. Is it? Yeah. Okay, good. Okay. So all good suggestions. Um So I think the first thing you're going to do is stop eating your lunch. That's the first thing you're going to do. Um You're gonna get more information from your, from the nurse. So ask uh when did the chest pain start? What is, has the pain, how's the patient describing it? Get previous SATS? You're absolutely right. But what if they're saturation target is 88 to 92 because they're a COPD patient and they dropped their SATS from 93 to 88. And the nurses really stressed and worried. But you know, or you know, he's the nurses just come on shift and he's very stressed and worried and thinks, oh God, that's, that's a drop. So it's good to know what the previous saturation. What is the patient saturation target? Then once you've got the information you need, you then decide if a peri rest needs to be put out or if you're gonna go review the patient and this patient does need an urgent review because they have genuinely dropped their SATS. Okay. Um And you ask basic task for the nurse to do so give oxygen if they are not meeting their saturation target, do obs and an E C G. I think those are the basic things that you can request at this stage. Um You could, you could ask for a V B G for example that it's unlikely they'll do an A B G, um, with regards to bloods, you can ask for bloods. But I think it's always better to go and see the patient and then get a better idea of what bloods you want. Unless, unless you're pretty certain of what the diagnosis is or you have a good suspicion of what the diagnosis is from the phone call. Right. So this is the information that you get when you get there. So the patient is relatively stable, but they're saturating 86% on air. Their respirators 28 they have high work of breathing, but they are not in pain by the time you come and see the patient okay. They're no longer complaining of any chest pain. You read the notes. There are 73 year old lady who presented to a and E with breathlessness and we use two days ago. Past medical history includes heart failure, cabbage, hypertension, airway disease, COPD. Hi haters hernia and she is a current smoker. She is currently being treated for infective infective exacerbation of COPD and decompensated heart failure with antibiotics and nebulizers and steroids for her infection and direct explore her heart failure. So you review the patient, she describes a sudden onset, sharp right sided chest pain and feeling really breathless. The chest pain has got a lot better, but she's feeling really breathless. So what more information do you want? In addition to everything I've just said, what other information do you want? Yeah. What does the pain feel like? Yep. Is she tacky? Yep. You want a blood gas? Good. Yep. Someone said chest x very good. Yeah. So more about the pain. Good. Yeah. You want to know the character of the pain? Yeah. Food status. Good. That's always a good thing to know about. Has this happened before? What was she doing at the time? Yeah. Good. What on examination? Good. Yeah. All good suggestions. Okay. So this is her examination. So heart sounds and normal. She's tacky cardiac running at 100 and 20 BP is okay for her. Actually, that's not a low BP. That's normal BP for her. Um She's got reduced air entry on the right side and she's got Kreps and crackles all over. She's dropping her sats as you are examining her and her respirator is climbing. You asked the nurse to run a gas because you've just done an A B G on her. She's now on four liters of oxygen in order to keep her saturation above 94%. And her ph are 6.48 P CO2 is 4.4. Sorry, that should say 7.48, not 6.48 P H is 7.48 P CO2 is 4.4 P 02 is 7.31 and lactate is 2.1. So um just based on that blood gas just very, very quickly. Uh fastest finger first. What's the main problem on that? Blood gas? Ph is 7.48, not 6.48 lactate. Um, not the lactate lactate is not that high. Uh, depends which center you're in but 2.1 can be the cut off. Yeah, the P 02, the P 02 is very low. So P 27.31 um is significantly low for someone who is already on oxygen. Even if they're not on oxygen, it's low because appear to you should be above eight. So yeah, people have said type one respiratory failure. Um okay. So what next, so think about, I don't want you to tell me the differentials in your mind. I want you to tell yourself you're differentials and then think what tests am I now going to order? What information do you not have that you now want? So yeah, whoever whoever the people wrote type one respiratory failure, you're, you're totally correct, by the way, she's in Taipan respiratory failure. So what investigations do you want next? Based on? Even if you don't have a differential in your mind, just what investigations do you want. But it does help if you're if you're thinking along the lines of certain differential good. Yeah, so I think two people have written chest X. Very good. Yeah, you definitely definitely want a chest X ray here, don't you? They're dropping the saps. Yeah, you've heard, you know, things in the lungs which shouldn't be there. Um, and someone's requesting E C G. Yep. Um, CT PA, I mean, potentially. But, uh, I think you want to do the basics first. But yes, CT PA is not a bad shout if you, if you are concerned that this patient has a pe, um, that's something you can do but you, they probably the radiologist would want to know more information first. Um And yet we want to work on redeem, etcetera. Okay. So that's the EC gene um very quickly if someone can tell me if there's anything exciting or anything, um significantly acutely abnormal on that E C G, uh You don't need to report it, you don't need to, you know, go through all the details because there's lots going on in that E C G. But just say, I guess the main thing that you're worried about on that, you see G, okay. It's a difficult E C G. It's not an easy one. I've given you a very difficult one. So, um I mean, the, the two main things are the tachycardic. It's actually sinus rhythm. It's not any other arrhythmia, it's sinus rhythm. Um There's no ST elevation is actually just left bundle branch block and that's why whenever you get an E C G, it's always good to compare it to previous E C G. This lady has got known left bundle branch block Um And so this isn't any different from her normally CG other than the fact that it's going a little bit faster. So it's sinus rhythm with old left bundle branch block. Um And it's just tachycardic. So this is Sinus tacky. Um Now that's a chest X ray again, fastest finger first. What is the main abnormality on there? There's lots of things going on there. But what is the main abnormality? I think that I think the messages are coming to me slightly with a slight delay. Okay. Some people are saying that palmer edema. Some people are saying consolidation. Anyone got the right answer. Yeah, Joanna, you're kind of on the right um the right track there. Yes. So, Amy, well done. It's a pneumothorax. Um There's lots going on here. You can see the cabbage wires here. You can probably there might be a bit of consolidation. Yeah, there's a lot of pollen redeemer as well. You can see all this lung fields, pollen redeemer and this lung has got palm redeem as well. But can you see this massive pneumothorax sitting right at the top of the right opposition of the chest, all this, you know, complete uh Yeah, well, not complete translucency, but it's, it's significantly more translucent than the other parts of, of, of the X ray. So that is a big right sided apical pneumothorax um sitting right there and that might be extending down to the right mid zone as well. But you can see the bottom part of the lung. So probably the low zone is sped and someone who's got a history of COPD, chronic COPD with, uh, you know, being a smoker, they could very well have, you know, a few bully on the chest that just, you know, one of them just burst, one of them may have just burst and caused a pneumothorax. So that's the cute abnormality in this lady. and that's why she's tacky cardiac and that's why she had chest pain and that's why she's feeling really, really quite awful. Um So, you know, if you, if you had put this lady, for example, given her A C S treatment without any further, you would have, you would have missed this. If you had treated her for anything else, you would have missed this pneumothorax. So it's always good to get all the information that you need to put it together and then work out what is going on. No one expects you to look at a patient and then just diagnose the problem. Um That's very rare. It only happens on house, doesn't happen in real life. Um So unless I guess obviously, unless something is blindingly obvious, um it's good to, you know, um get everything in order before you make your differential, right? So how do we deal with this oxygen? Avoid non invasive ventilation or nasal high flow? So if then type on a spiritual failure, do not put them on a CPAP machine. Um tension pneumothorax there acutely unwell rapid deterioration. Shocked with tra Curiel deviation how you treat tension pneumothorax, you give them a large bowl of in flint into the second intercostal space. Midclavicular line followed by a chest train. If it's a spontaneous primary pneumothorax, I someone with no known underlying lung disease. And if they're short of breath or the pneumothorax rim is two or more centimeters, you want to aspirated otherwise you monitor and sometimes patient's even go home. And if it's spontaneous secondary pneumothorax, are you someone with known underlying lung disease? And they're short of breath or the rim is two or more centimeters, they pretty much get chest train otherwise aspiration. However, these days, pretty much everyone gets a chest drain, but this is where you escalate to, you know, the med reg, the I T U reg the respiratory reg, you know, whatever it is okay. Um And in the uh for the sake of time, I'm going to go through the next one myself and then we'll do interaction in, in the third one. So night shift would cover it's nine o'clock. You've just finished your hand over a long list of patient's to see, get bleed from the nurse. Mr T is complaining of chest pain. It's heart rate is 100 and 40. What do you do? Get more information from the nurse? Decide if it's a very arrest, prioritize the patient to review and do basic tasks. So ask the nurse to do jobs and an egg. So when you get there, the patient looks breathless and is a little clammy. You read the notes an eight year old, they presented with some super pubic pain and fever this morning to a any. They've got a past medical history of N stemi type two diabetes, prostate cancer. There currently being treated for your oh sepsis with antibiotics and fluids. You review the patient, they're complaining of palpitations, they're breathless, they're feeling hot and cold and they've got this dull, left sided chest tightness. What more information do you want? So, think about it, but I'm going to tell you the, what some more information so you can build up the story. So you, when you examine the patient, you can tell that the heart sounds are going really fast and you're not sure if there might be a murmur as well. You count, it's around 100 and 83 BPM. BP, steady lungs are clear. JVP is slightly elevated. There's some generalized abdominal pain but not too bad. No guarding no rigidity and we've got a little bit of a low grade fever. So, what do you want to do next? Um, so tell me just if you can quickly, right? Uh, one or two investigations that you want to do next. And A B G. Okay. That's reasonable. Yeah. Yep, E C G, I think, I think that's a, that's a good shout. So this is the E C G um not gonna ask uh you to report or anything but just have a quick look. Um And I'll tell you what's going on on that E C G in a second, see if you can work it out yourself. So this is a pretty fast E C G uh definitely going more than 100 BPM, um Probably going around 100 and 80. Um And uh there's no obvious P waves and the rate is irregularly irregular. So this patient is in fast af um and they've got big QRS is in, you know, uh entirely. So they probably got an element of left ventricular hypertrophy. But uh second purposes, this is atrial fibrillation, fast af right. So fast af how do you treat fast? Af right. Normally there is an underlying condition that triggers the af in acutely unwell patient's sometimes not always. But if there is, you should always treat the underlying condition first. That is always the first advice I give. So if the infection, give them fluids, give them antibiotics, if they're in pain, give them analgesia do basic blood tests. You want to see what the kidneys are doing, what the blood's doing. You want to assess all the electrolytes, the bone profile, the magnesium um and the thyroid function as well. You want to assess the troponin. Bit controversial. It depends um If there, if there is chest pain, then it's reasonable to get a troponin. Um But, you know, if you don't think the heart attack is triggered off this h population is quite clear. Um, you know, trigger for it, given the fact that the patient is in your oh, sepsis don't necessarily have to. But, you know, I would leave that to your judgment. Um, uh I think in, in royal, sorry, we, we tended to always do troponin. Um So, yeah, I mean, uh so the first thing you want to do is rate control the af um So for the first step is always a beta blocker uh or a calcium channel blocker, but bisoprolol, unless there's any significant intolerance to it, then the second step, if you can't get the rate controlled with bisoprolol, um add on digoxin and you know, there's a proper way of loading people on digoxin. You either give them 500 micrograms or 250 micrograms to begin with. Um depending on their kidney function and their, you know, their body weight. But then make sure you repeat this after six hours. So they get adequate loading dose if the heart rate still above 100 and 10 and then you give them a maintenance dose. The number of times I've seen someone had one dose of digoxin and that's it. And they, you know, they've never had a repeat and they don't have maintenance dose is, is frustrating because then I get causing the patient's still in A F, what do I do? Um And then the third step, if you can't get the heart rate controlled with those two drugs, then you escalate as a patient may need amiodarone, right? And then the next part of managing A F is rhythm control. So in the acute setting, follow a less, less guidelines for tachycardia who needs a shock. And you can also use other anti arrhythmics like amiodarone with senior input. And then the third part of managing A F is to anti calculate as per the chads Vascor and the has bled score. Um Even if it's just a single one off episode, this is very rare. Um instances I think the only one I can really think of is if someone is obviously a very high risk leader or if after cardiac surgery where you expect there to be a little bit of a fibrillation. Otherwise, even if it's a one off episode of A F and they've got a high Chads Vasko and a low has bled score, then you would anti calculate. OK. Case three, I'm a bit wary of time. Um might not have time for your quiz. Is that all right guys? I hope so. I'll carry on, stop me. If it is, you can carry on going well, just finish up after your cases are done. It's all good. Okay, fine, fine. So case three again, I'll just quickly go through them rather than asking for interaction. Just because of time. So f one on call you on the clerking shift, the medical reg asked you to see a patient at 11 o'clock in the morning. It's a 46 year old admitted to any with chest pain palpitations, shortness of breath, which started yesterday while she was walking. The dog doesn't have any significant past medical history. She's a little bit overweight and hyperthyroid. Her SATS are low for her 92% on air. She slightly tachycardic at 100 and three BP is okay. Respirators, okay. She's not federal. So, Amy a really busy they referred to the medics for query A CS. They've given us some aspirin and they're awaiting the bloods, which is a very common situation. So, um that's the scenario, right. They've ordered a chest X ray which is come back as this. Um It's fairly clear there's no significant consolidation. Um The heart is a little bit globular but it's, you know, it's not too bad. There's nothing really else going on. Okay. Then the nurse has you in E C G. Um You can read the E C G. It's fairly straightforward, I guess there's sinus rhythm. Um No significant, there's a uh no significant other really other things. Um maybe a little bit of early bundle, uh not much going on. Um is a little bit of tea way flattening, inlayed three. Um and a little bit of it looks like by phasic T waves and lead V two and V three. But I think that's just lead placement. I think the T waves are okay there. So that's the E C G you've got, um, and then the blood's finally come back. So white cell count is 11 CRP is 23 Egfr 67 Troponin 3 20 D diamond 950 for, um, if you quickly right in the chat, what do you think is your main differential hair? Yep. Correct. Well done. So, Pommery embolism uh would be the main differential hair. She's got risk factors. Um So she's overweight. I think that's really the only risk factor here. Um Chest X ray's okay. Her E C G is a little bit tachycardic. It had a little bit of um if you, so I don't want to say otherwise giving the game away, but in lead one s one, a little bit of Q wave deflection and lead three, a little bit of T wave flattening and lead three. Um uh it's not, it's not a hugely convincing MG for pe but it's, it's the blood's really, she's dropping her sats and her D dimer is nearly 1000 for someone her age. You would expect it to be less than 500. Now, people are thrown by the troponin being 320. But if you have a good, if you have a not good, sorry if you have a big enough pe causing enough strain on the heart, your troponin will go up. Um And there was a paper that suggested that if you're D dimer is, I think nearly two or 2.5 times the limit of your troponin, you want to rule out to pe before you think about A C S. So some people will see these bloods and start A C S and I think that would be wrong. I think it would, you would want to cover for a pe first unless there are any other convincing evidence for, for an M I. But yeah, that sounds like a pe. So how are you going to treat it? You're going to give them oxygen, you're going to do a well score and in her case, it's 4.5. Um reason for that is P is number one diagnosis and she's a bit tacky. Um You're gonna give treatment dose, low molecular weight heparin. If there are no contraindications, you want to get CT PA as soon as possible, you want to assess for any potential cause. So go back to the patient, ask her, you know, has she noticed any swelling in her legs? Has she been immobile? Ask her for any things that might indicate cancer, weight loss, bleeding from anywhere, etcetera. You want to get a Doppler of the ultrasound of the legs. You want to keep her on a cardiac monitor and you want to closely monitor the BP in case you need to thrombolysis her but generally patient's do. All right if you do those things. Ok. Case four, um, surgical F one on weekend. Uh, you're sitting around in the mess at seven o'clock, you get a bleep from a chilled out nurse who says one of your patient's complaining of chest pain. Can I just have some paracetamol? So first of all, don't just prescribe the paracetamol, get more information from the nurse and they open up and say, oh, very sudden onset chest pain. He's feeling a bit clammy is a bit sweaty, that's not normal. You need to go and review that. Um So you want to get some basic obs bloods and an E C G. So you get to the patient, they look uncomfortable but they don't want to create a fuss. They think it's indigestion. You read the notes is an 85 year old admitted the upper abdominal pain and nausea last night past medical history of being a hypertension. CKD, an ex smoker. They are being treated under the surgeons for colecystitis because the LFTs and the CRP was mildly deranged and there was no other obvious cause of his pain. When you review the patient, there's a pressure like sensation in the middle of the chest. He describes radiating to the neck, started after a heavy lunch and got worse in the evening and he's mildly short of breath. So, what more information do you want to answer that for you? You've done an examination and it's all normal heart sounds normal, BP is good. Chest is clear. No edema, third status is good. So, what do you want to do next? What basic tests do you want to do next? If anything at all or do you want to say this is nothing and walk off? Yeah, E C G. It's a good show. So that's the E T G here. So, looking at that E C G, does that help you diagnose what this patient has? Do an Abdul exam? Yeah, absolutely. That's right. Joanna. Um T wave inversion. Yeah. Okay. You want to order some troponin is good. Yeah, but my question to you is if you look at the C C G, can you say what the differential is or not differential? Sorry. Can you say what the diagnosis is? Just looking at the C C G? You can, you can answer yes. No. By the way, I'm not asking you to tell me okay. One person says no, one person says yes. OK. Everyone else, I'll let you decide well, what you would do in, in the next two seconds. Um because the answer actually is no, you cannot say just based on the C C G what the diagnosis is. Yes, there is T wave inversion in the inferior leads. You're absolutely right. But you don't know if this is new or old. You don't know if this is dynamic. It could be old. They might not be acute in this incident actually was. But just looking at the E C G, you cannot say if this patient is having a heart attack, which is what I think some people may have been thinking. So how are you going to manage this case? You're thinking that this could be a heart attack, right? So you want to do serially CGs, you want to put them in Cardiff monitor, you want to get urgent proponents and repeat them as well and they come back as very high 9000 respectively then, okay. You've got pretty much conclusive evidence that this patient is having an M I. They've got typical chest pain, they've got risk factors, they've got an elevated troponin and they've got E C G changes. There's not much else you need um in order to treat this as A C S provided, there's no other contra indication to them having blood thinners. Okay. So, you know, sometimes we can miss dissection as well. So be be very, very careful if you think that this is dissection, don't treat it as A C S. You want to give some aspirin, you want to give another anti platelet, you want to get a refund. Er you want to start them on a small dose of beta blocker Ramipril, give them a statin, give them PPI book an echo, get a cardiology review, get a senior review. Definitely for this patient. Get a chest X ray as Well, sometimes you might want to get a chest X ray before um you start a C S or you want at least give the start the aspirin before the chest X ray. But it all depends on what you think. If there is any other differential going on here, if you think this is bond or my cardio infarction, then fair enough. But if you think this is something else, then it's important you rule out any other um course. Um If they've got ongoing chest pain, you start G T N infusion and then you can call the cardiology on call if it's out of hours. But generally, they only want to be disturbed if the, if the patient has uncontrollable pain, hemo dynamic compromise, ventricular arrhythmias, loud murmurs, progressive E C G changes, recent PCI or their own polymer edema. Um So those are generally the reasons why cardiology, uncle would be interested overnight. Um Right. So last case very quickly, your night would cover middle of the night to get a bleep from the nurse. Mr said is complaining of severe chest pain and the BP is dropping. You want to get more information and asked that nurse to do basic tasks, right? You get to the patient patient very uncomfortable holding his chest. You quickly flick through the notes. 64 year old admitted with a few hours ago with chest pain, they've got hypertension, little bit of weight A F they've been treated for acs because the troponin has gone from 75 to 100 and 14 with chest pain. Um, so the, the any department and the medical team of treated as A C S and the patient is on uh duac for the A F and also dual anti platelet as um for their A C S as well. You review the patient, they've got tearing central chest pain radiating up to the neck there, sweating and feeling really, really sick. You examined them, they've got soft, early diastolic murmur. The BP in the right arm is different to the left arm, but otherwise the examination is okay. What do you want to do next? So if you were in this position, what would you do next? The very first thing you would do next? Ok, bit silent. So I'll just tell you the answer. Um Right. So you obviously wanted, I think an E C G would be the first thing you do, right? You see that and you start panicking, don't panic. You can see inferior ST elevation quite significant there. Um And lateral ST depression. Now, if you were to put that together, you might think this patient is having a myocardial infarction. Um But if you look at the history and the examination that you've done a little bit more detail, you can see there's a huge discrepancy between the right and left arm BP and their chest pain sounds a bit ominous, radiating to the back tearing sensation. That is not right. So instead of thinking, oh, this is just an A C S were giving them medications that's just called cardiology. This patient is having an aortic dissection and what's happened is that they've dissected into their right coronary artery resulting in ST elevation in inferior leads. And this is an example of someone who is unfortunately been treated the wrong diagnosis because they've seen opponent and think, oh, that must mean a heart attack when it doesn't have to. So this patient is about to arrest, their BP is falling. They're not doing well. They've got a critical um potential critical diagnosis. You want to put a peri arrest out, you want to give them some oxygen, you want to organize a CT a autograph immediately, absolutely immediately. You want to stop all blood thinners and maybe speak to hematology when you get some time to try and reverse it, give some fluids to resuscitate them, get their BP up, do some urgent blood, including a blood gas hemoglobin group and save cross match two units. This guy is, you know, bleeding through his chest. Um and then once you have all that information, you can speak to cardiothoracic. So on call. But to be honest, even before the CT, if you're suspicious, I would give them a call and let them know what you think is going on. And then once the dissection is confirmed, if, if they've still made it, then you want to blue light transfer the patient immediately, okay. So quickly moving on in the last two minutes. Um perry arrest situation. So the peri arrest is the moments just prior to cardiac arrest. Um they can be avoided with early recognition and intervention. Now, some examples of pre arrest ventricular arrhythmias shocks drop in oxygen saturation, sudden drop in G C S large hemorrhage or acute stroke. And it's important to recognize and act fast call for help and do an A B A T E approach. Um for the purpose of this talk, we're just going to focus on the chest pain cause of perry arrest. So I'm not going to go through this because you all know 80. Um I'm sure you've covered it many, many times. Um So chest pain causes that are life threatening that can lead to perry arrest include my coddle infarction, ventricular arrhythmias, tension, pneumothorax, pulmonary embolism, aortic dissection and gi rupture. So if you have any one of those six in front of you just be wary, this patient could get sick very quickly. Um And it's really important that you um that you act fast and you put a pair of arrest out and you do the basic things that you need to do. Um And again, it's about the 80 approach. Yeah, make sure the airways patent, make sure that oxygenation is good. Um Make sure you have a blood gas, you've done blood you've done in E C G, you've given them medications that they might benefit from. So, rate control for, um, fast heart rhythm, fluids, for BP, um, uh, anti calculation if, if you, if they've got a pe, um, that kind of stuff. So that, that is, that is all very, very important. It's something I just want you to go and reflect on after this session. Um, as to the different causes of chest pain that can lead to Perry arrest and just envision yourself in that position being the f one on the ward for all these cases that we've discussed as well as Perry arrest situations and think, right? What do I want to do next? What information do I now want and how am I going to put that into place? Okay? And you always being, being at your level, you always have the luxury of having seniors who you can ask help for and if they're able to come or you're unable to get through to them and you're worried about this patient and they're deteriorating. Um As I said, no one is going to tell you off for putting a peri arrest out. Um So it's always doing what you think is in the patient's best interest. Okay? Um So that's, that's my talk. Sorry. It dragged on a bit, but I'm happy to take um happy to take questions and answers and I'll stop sharing my screen. Uh huh. Yeah, I think it looks like the chat thing on my phone was a bit slower than the online system. So sorry if I don't pick up or you're, we'll let you know if there's any questions coming up. Thank you very much for the talk. I mean, it was very good. I'm sure all our doctors online fan that really useful. We did definitely. Um, guys, if you have any questions, just post them in the chat. No worries guys. Your best welcome. Uh Of course, just, just as a reminder, guys, if you fill out the feedback form um that we've just linked in the chat, um If you fill out the feedback form and submit it as soon as you submit it, you'll get us a difficult for attendance. Um Make sure that you're following us on Instagram to keep, keep informed of the next few sessions as well that I think everyone's saying thank you for your session. It was very useful. Don't have any questions yet and then if that's a good sign or a bad sign, it's a good sign. Oh, there is following. Is there a Troponin Rice criteria to classify as M I? Um Yes, there is. Um And you can find it if you type in E S C or European Society of Cardiology Troponin um pathway. Then that gives you an idea as to what the first troponin, what to do in the first troponin. The first hour troponin, the different changes, the three hour troponin, etcetera. Generally, a lot of hospitals have their own pathway. Um Interestingly, I didn't see one at Royal Sorry, but there was in my previous trust um as to what to do if you have abnormal troponin. Um But the caveat for all of these pathways is or guidelines is that they are just guidelines. So an abnormal troponin, even if it rises and falls or whatever does not necessarily have to mean a myocardial infarction. It could be many, many other things. And it's important to think about the other possible causes of raised troponin when you're evaluating a patient. The other thing is that some heart attacks don't always classically follow a typical rise and fall. Um Some of them are very, you know, small changes. Um and some of them can be missed. M I so patient's who may be feeling unwell for a few days had check spain a few days ago and decided to come into hospital and then you can see the troponin coming down, but they actually have had a heart attack a few days ago. So for example, that's um that's one example. So the everything always has caveats and it's based on your clinical judgment. But yes, there are particular pathways and guidelines to assess the troponin changes and um what you can do about it. Um If you see trop rise in patient's with fast air for some arrhythmia, do you necessarily need to start treatment? It's a very good question and a very controversial question. Um It depends, um I think there's necessarily a right answer for this. Um I think my practice is um if I see a troponin rise, which is um in accordance with someone who is undergoing a fast arrhythmia, um and therefore having rate related ischemia, either heart is beating so fast that it's unable to fill the coronaries and supply the blood and therefore they're having an element of ischemia. Um Then, and it's explainable, then I wouldn't necessarily treat them as A C S and I'd, I'd and to coagulate them if they're in fast air, for example, um and get them, get on top of their rate control and rhythm. Um However, there are some things that may point you towards um uh treating for ACS as a particular cause of the arrhythmia or um as a yeah, as, as a cause of the arrhythmia or a complication of the, of the M I things like convincing chest pain history. Um If the chest pain preceded the palpitations, um if there are, you know, if there's, there's significant E C G changes um of ischemia, a dynamic ischemia. Um uh or if the troponin is not in keeping with, with the arrhythmia. So someone who, you know, it depends where you are, which hospital, what troponin you have. But if the troponin is really very high, um for someone who's just in an arrhythmia, um then you might be missing an A C S. So that's why I said, you know, query troponin on the presentation as to whether you do that test. Uh most people do. Um And uh you know, there's, there's no harm in doing a troponin has provided you can interpret it correctly. And I think troponin is quite a difficult test to interpret. Um Given a patient's clinical picture, there's lots of things that can cause it. So, I'm sorry, there's no right answer. Um If I see a tropp rise in fast af am I going to think it's just a F or am I going to think? Is there a C S? It depends on many, many factors, some of which I hope I've shared with you today. Hillary's cool. I think uh I don't, I don't think there are any more questions. I'm not sure. Thank you so much. Um Again, thank you very much. Um Guys, again, um Make sure you feel that the feedback form because that will all go to Amir and they'll be very helpful for us and for future sessions. So please do fill that out and you'll get your certificate. Um And our next session will be next week um uh gonna be with doctor toss on a geriatric session um on delirium. So do you join us for that? All right. Well, good night everyone. Thank you very much for joining us. Thank bye.