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Can everyone hear us? You can type in the chat if you can. It hasn't, it's just about to start. We're just having just let me know when you're ready for me to. Sure guys. Can you, can you hear us? Okay? Perfect. Are we good? Yeah, it seems like, yeah, it seems like we uh we're okay to go. Uh So hi guys, welcome to another uh Bleakney session today. We've got doctor recently, one of our respiratory consultants. Um she's going to be talking to us about acute presentations, uh low saturations and sort of running through the presentation, uh how to sort of investigate and manage. Um So hopefully you guys will learn lots. Um uh Yeah, so without further do I'll handle the Till Carucci. Thank you. So, my apologies. First off the slight technical error that issues I've been having um as mentioned already that the main focus of this, this presentation today's talk you through just how to approach that tricky bleep you will get as part of your training, but also all the way through your career about the patient that acutely drops their saturations. Um The main aim is to leave areas to kind of give you some tools to approach a getting saturations and then ultimately hopefully reduce the likelihood of any panic setting in. I think if you've got your nice tools in place, you're quite systematic about the approach, it really doesn't really matter too much what the underlying pathology is because you'll just have the tools to just get going. So the approach I tend to use and tell my juniors about really is trying to get as much information as possible before you actually go towards the ward that's called you or back in you or the tap on the shoulder. Just to get that nice systematic handover, most of the allied health professionals are all pretty much geared up to using s part as their way of handing over and I will run through the expert as we go through is a recurrent theme just so that kind of sticks a little bit more. But if you gleam as much information as you, you can from using an approach like that, you can kind of have some initial thoughts even before you've entered the ward. And then when you see that patient in front of you using the A B C D E system in order, kind of gleam together how sick they are, but also what the underlying diagnosis may well be and start your initial treatment, but also gleam very early on whether you need to escalate soon or escalate after review. And when you decided on your next steps. Um It's just literally the quick questions you're really going to ask yourself is do I escalate immediately or do I treat and then escalate to someone a little bit more senior for me for that additional opinion or do I treat and then come back and re review and it doesn't have to be you. I think sometimes people get hit up on the fact that takes can be so busy that they think, oh my God, the onus is only on me. But if you've got some really clear parameters, you can actually have the nurses do a few reviews it for you, not in terms of reviewing the patient's, but reviewing the observations and feeding back to you that you need to come back sooner than you'd anticipated. I think the thing to glean from, I think in my personal opinion, if there's been a change in saturations, that automatically means that a re review is required. And I think that's a misunderstanding that a lot of people go in thinking that actually if I've remedied the patient, I ought not to review that should be fine. But I think if there's been a change of saturations in particular, you ought to. So we have out favorite do the first case, I'll talk through. It also is about a seven pm. Bleep that you get from a frailty ward. It's from one of the nurses. I specifically chose seven PM because typically what's happened is the day team have managed to finally leave the ward about quarter to seven. The nurses are doing their rounds in preparation for handing over and they've all, that's the time that you get a flurry of random leaps about all the observations that have been detected that are slightly off. So in this case, it's a 90 year old woman. Um she is on the frailty ward, it's day five into her inpatient stay on the ward. And there's been a new record of low saturations and there's been a nice little polite coming review now, please. So what should you be doing next? Should you hang up and pretend you lost connection, stop whatever you're doing and run there now or encourage a handover in an easy to follow manners such as esper. So the beauty of s part I think is actually because everyone uses it. So even everyone from occupational therapists, physios year, um nurses through to doctors all the way up to senior levels. It's just, I mean that most people are well versed with and actually a lot of medical schools stop getting people thinking along those lines quite early on, but it's situation background assessment and then the recommendation and if you've got this going on the phone, you pretty much can leave with an idea of a what might be going on, but also some initial thoughts and what you might do first. So you're kind of set up. So from a situation point of view with the specific case, um the nurse is telling them, should tell you who they are, who the patient is in the care of the, of the award. There's a 90 year old woman E M saturations have gone down to 85% on air and there had been around 94% or thereabouts from most of the her admission so far, she's now been popped on a little bit of oxygen. So four liters, but the saturations are 93%. And her respirators 25 the background for this case is that she's been an impatient now for about five days and she's had severe constipation. She was vomiting a little earlier on in the day and the day team and organized and Abdul X Ray Richard showed some significant fecal loading and she's been given an animal with good effect. Ultimately, all she was actually waiting for some physio and AKI and occupational therapy assessment to support discharge planning. And so the assessment and it's quite actually normal for a nurse to say, I don't really know what's going on here. And I don't think it depends on how senior the nursing staff is or you know, the person that you're receiving, it won't might not always be the nursing staff you're receiving the handover from, they might say to you, it might be much more of a handover clinically so much in a way more of observations and what they've auscultated. But in this case, the nurse says, I'm not sure what's going on, but they've been, she feels quite a large number of ps lately. So she comes out with, do you think this could be a P doctor? Please come and see the recommendation and she really, really worried cause this patient hasn't needed any oxygen since she's been on. And there was a similar presentation which ended up being appear. So this is the point when you're walking off to the wards and you should be gathering some thoughts on route. So, you know, you're going to a care of the elderly ward, by definition, a lot of those patient's will be co morbid. So there are other organs that maybe potentially paying a part in this clinical picture. So for instance, your heart with the heart failure, arrhythmia element. Um thinking about whether this patient may have been a previous smoker of an element of COPD or even asthma, you know, they're also day five into a hospital stay. So they run the risk of having a pulmonary embolus or hospital acquired pneumonia. And there's this loose history of vomiting earlier. So could you actually be dealing with someone who's aspirated? So, on arrival, one of the key questions obviously going to ask yourself is responsive or on responses. So if they're unresponsive, you quickly look for signs of life. And if there's none of those, obviously, the crash call goes up if they're responsive, however, then you just really entering that nice structured A B C D E initial assessment. And the thing that most people like about this is, it's quite obviously, it's easy to follow. And if you get lost halfway through, you just go back to the whatever you started with and just work your way down and, and if you come up against some things are an initial airway issue, then you know that if they're not maintaining their airway, you need to call for help, the significant breathing concerns, you call for help. So at each step of the way, you can actually just assess whether you can cope with that situation. At that point in time. In this case, her airway is painting that she's speaking in full sentences. So there's no evidence of compromise and she's got saturations of 93% on four liters via a mask, she's breathing. Um um but using some of her accessory muscles and she does appear just from eyeballing her at the bedside to be quite short of breath. And on auscultation, you hear some right basil reputations. She's got a good volume pulse, it's regular, she's maintaining her BP. She is slightly tacky and a cat, but her cat refills less than two sex. So you know that she's periphery, well, perfused disability wise. Um Two G C S is 15, which supports the fact that at the moment, at least she's relatively stable. She's got BM of 5.6 and a low grade temperature, 37.8 environment. So they're little bit at the end where you're looking for any clues around the bedside or in the patient themselves. And she's got a vomit ball which is empty by her. So what would be the next steps? So as with most patient's, when they've got an acute dip in their saturations, things to consider be the chest X ray, the A B G. In this case, with the low grade temperature, the focal sign that you've got of the right basil crepitations and the potential, early suspicion of an aspiration. I think you should be doing blood cultures and bloods. I'd initiate the IV antibiotics and it also give a little fluid. Um but be cautious because in this co morbid group, even before you've gathered the collateral history, you've got to be thinking about whether there are other ailments of place such as, you know, your heart failure background, you go having given this initial management to look back at the notes and realize that from a co morbidities point of view, there's a really loose mild heart failure history. The reason I've said mild is there's no echo. There's a BMP from five years ago and there's a loose mention that the G P had noticed some peripheral edema and started around 20 mg of fruits might. So actually, from a 90 year olds perspective, she's doing really well, she lives alone and she's mobile with a stick the decisions you're making at this point are, aren't they stable? And all you'll need to do is optimize them at that present point in time rereview. But also look at the interval of their observations and see whether you can set slightly lesser parameters typically in the hospital setting where reviewing every four hours. But actually, if that, if you've just gone to see someone who's acutely drop their SATS, most people would say at least try and get the nurses to repeat the observations half an hour later and then half an hour again. So you've got this hour of a couple of observations if they're very, if they're even more, if they're worrying you a bit more than go for 15 minutes. Um And what you're looking for is, is there any deterioration that you can pick up quite early? Then the next question is, is, are they stable? But is there a potential to deteriorate? So, for these patient's you've optimized, but you're still not 100% comfortable. And so this is where you'd escalate to one of your seniors, whether that's an S H O or a registrar, depending on your level. And then you're, what the next level would be deteriorating despite treatment, sometimes you don't even get as far as treatment. So there'll be a part of your A B C D review that worries you enough that you'd start escalating earlier and that escalation can come in the form of getting your registrar or if you need more hands on deck and you're really worried about this patient calling the medical emergency team, which are pretty much geared up with usually a medical registrar, someone from the anesthetist background and someone from the site nursing, nursing background and one of the S H O S. So the results for this patient uh as follows, you've got this chest X ray, you've lost the right hemidiaphragm. So, you know, it's the right lower lobe pneumonia that you're dealing with, you've also partially lost that right middle lobe area as well. So, you know, which is the right heart border, so that, you know, there's potentially a pneumonia affecting two different lobes. The A B G on four liters shows what I would call a relative type one respiratory failure. So if you didn't know that this person was on four liters, you'd eyeball this and say, oh, that's okay, appear to is 10. However, when you, if you're giving someone four liters of oxygen to achieve that, ot you know that there's a relative deficit there and then you've got this E C G that doesn't show anything ischemic that confirms a sinus tachycardia. So overall, this is looking like putting this together that this this nine year old E M has an aspiration pneumonia. It's probably related to the earlier episode of vomiting that she had. She's got a relative to type one respiratory failure and you're treating her appropriately. But you're gonna ask the nursing staff to try and relieve visit the observation in 15, maybe 30 minutes time and let you know if there's any further deterioration, she certainly wouldn't be someone that I would leave about any further review. But I think on this basis, this occasion, you potentially get away without an escalation depending on how confident you're feeling. However, it's not always as straightforward as that. So one minor tweak later, so on the face of it, essentially the same patient, you got 90 year old E M, she's on the care of the elderly board and she lives alone. She's mobile with a stick and you know, the vomiting earlier and this new oxygen requirements. So it's actually the same handover. But when you go to review, she's slightly more less drought, so slightly more drowsy. So the G C S is 14 but her airway is patent. However, she's 93% on a 60% humidified venturi mask. She is still speaking rem accurately and um full sentences, but she is using accessory muscles and you can hear these right basil crepitations going. Her BP is a little lower. So it's 100 and 20/80 and she's still tacky. The cat refill is slightly more extended. So it's for sex and her temperature is 37.8. So still that kind of septic e picture. But are you the main thing to take away. Really is that the concern here is that the A A grading or the type one respiratory failure pitch is such so much more significant. She's getting 60% oxygen and only reaching target stats of 93 having had similar observations on air not too long ago. So your next steps here, the difference would be that the next steps. Yes, they would include the chest X ray, the A B G and the IV antibiotics. But the escalation should come much earlier here. You should definitely be reaching out to a registrar and actually arguably even considering the Met team. Well, let's tweak this up a little bit more. So again, the same case, 90 year old care of the elderly, independent vomiting earlier, new oxygen requirement. However, on this occasion, she's at the airway, she still has 93% on the 60% humidified venturi mask, apologies for the slight typo there. Um She's using accessory muscles. She's got bilateral crackles. Now on auscultation, BP is 80/16 and that's after two liters of oxygen, I mean two liters of fluid. Her heart rate's 100 and 40 BPM and her cat refill is sluggish G C S has dipped at this 400.12 and a temperature is 37.8. The environment just shows you again the vomit bowl from earlier. So overall the same clinical picture but just slight tweaks in terms of urgency. So, in particular homing in on a 93% stats on 65 60% humidified venturi mask and the low BP despite being fluid resuscitated with two liters is a big, big concern. And so this is the kind of patient with support of that lower G C S that you really really should be calling the medical emergency team. The concern here is now going beyond just the simple saturation issue to actually should we be even considering the bed spaces in moving up to higher units for things such as ionotropic support, maybe as well. Sign, moving on to another case, we've got case number two and this is, this case has come from 7 30 from one of the Oncology wards. So as you can see you're having a very busy twilight shift JB is a 2nd 76 year old man on the Oncology ward and he has new low saturations 85% on air and the nurses really worried and he's asking you to come as soon as you can. It's the same support processes really as case to. So the initial thing you need to really try and piece together is the S bar. So the handover which will hopefully give you some thoughts on route, then you're going to go to the bedside and do your A B C D E assessment, hopefully for some form of treatment and then an early recognition of review. And what kind of review is required for re review. So in this case, s bar wise situation um is that it's a staff nurse, George, he's on the Oncology Ward and he's calling about a patient called E M who's 76 year old sacks, saturations have gone down to 85% on air. The respirator 25 they popped him on a liter of oxygen and sat have picked up to 91%. The background to this patient is that he has been an impatient for a week. He's actually receiving chemotherapy for bladder cancer and he's starting, you've been starting to feel lethargic and short of breath. So he was admitted, nurses really baffled. He's not really sure what's going on, but he thinks that the day team has been worried about his heart. So the recommendation that he has got is please, please please come and see. He has just no idea what may be going with this patient. So your thoughts on route. Are you going to an Oncology Ward? And you know that this patient is on chemotherapy. One of the first things you should be asking yourself is, could this be a drug reaction of some description? There are some of these, the agents that we're using that can be caused interstitial lung type reactions. There are some that I've actually been linked according causing cardiomyopathies. Um One of the ones that's all can cause cardiomyopathy is that isn't really well recognized are the ones that end in IPs, so them on it. So the antibody, so monoclonal antibody type medications. Um but the other concerns you'd have about someone in a chemotherapy Oncology ward even is that they would be high risk for potentially having a P if there's an active cancer going on, but also hospital acquired infection. And not only your standard hospital acquired infections, but because of the immunocompromised status, it could be a whole host of additional bugs. Um Then you've got to add into the mix that actually they too could become morbid. So that because other things going on to heart failure, arrhythmia, CAPD asthma. So again, since the same kind of approach to assessment, so responsive or unresponsive, I'm going to go with responsive and use an A B C D E structured initial assessments. So airway wise, this gentleman's 88% on four liters via mask. He is speaking in full sentences from a breathing point of view. He again looks tack it nick. So breathless at the bedside with some accessory muscle use, he's wheezy bilaterally and there are some Kreps that you're noticing in the middle zone, but the patient sounds chesty from the bedside. So you know that bubbly, I don't know if everyone is familiar with it, but sometimes you can walk to her bedside and just here almost like someone's bubbling it from the chest. Um circulation wise. Um He's got very cold peripheries got regular pulse, there's BP is 100 and 50/80 and his heart rate is slightly tacky 120 disability point of view. Reassuringly, his G C S is still 15. His BM is 5.6 and he's a February. There's some really dilute urine in the capital. So what's your next steps? So similar to the first case chest X ray A B G blood, but looking back at the background, um, comorbidities, medications around the functional baseline, you can see that there's been concern about heart failure and maybe even a potential cardiomyopathy secondary to um the treatment is on for his cancer. And you know that the frusemide was actually increased from 40 B D up to 40 B D from once a day by the day team earlier, he's normally very independent. So your initial treatment is going to be just hedging bets actually with that kind of presentation of weeks, which may well be cardiac cui's crepitations that you're noticing. Um the increment in the diuretics that diuretics and nebulizers will be given quite early. But the decision you're going to have to make very quickly is are they stable re review and set, reduced interval of observations? Are they stable but potential to deteriorate and escalate or deteriorating despite treatment, so escalate early. So this is the chest X ray on admission. I mean, he wasn't in a good way initially. And, and you can see that there's evidence of a large heart is even a pacemaker in situ. Please ignore the sonata me wise, I've had to kind of adapting slightly. There's some bilateral effusions on um review. Then by the time you get the portable chest X ray done and don't be afraid ever to kind of push for the portable. If you're a tall concern about your patient, you can see that not only of the infusions got worse, he's got upper lobe diversion. And so actually, now you're much more of the lung fields have taken up on the X ray imaging by just fluid. There is a significant type one respiratory infection there there. I mean, it's relative because the P 02 looks on the face of it as it's as if it's okay, it's 10. But look at that venturi mask supplying 60% of oxygen. I would argue that this case, this is one of those times where you, you really have to be getting that extra level of review early. So ever that comes in the form of a medical registrar, if you're feeling quite out of your depth or just consider met calling, particularly if you're worrying one coming into early concerns of any elements of the A B C D E strategy. Typically, um the way I would approach it would be to give a dose of your diuretic like you're 40 mg get us are beautiful neb on board as well. Um If the BP is tanking at that point, try the really quick methods of just tilting the legs up slightly and to try and boost that BP quickly and just put out a medical emergency call to get more hands on deck. So that it's just not you trying to do chasing the portable chest X ray, getting the A B G the more pans. It's not even that. Sometimes it's not that that person is going to end up in a higher bed space, but you just need a more immediate response and that's where met teams come in. Very useful. Then case three is about the nine PM. Bleep, you've got a bleep from a concerned E A U nurse. He's very upset actually because several bleed, he's tried bleeping several times, but you can tell about nine PM, there's been a period of handover. So maybe that's why the delay for the bleep response E J is a 56 year old. Um though he has an admission chest X ray, which has no abnormality detected and inflammatory markers which were only mildly raised. So again, you're going to go for an ESP, are you going to go for your thoughts on route? Your A B C D approach the treatment that you're potentially going to start on a rereview, but deciding on the level of escalation that you'll need quite early on. So if we work through our S pa for this case, uh you're being called by an eau sister Christine 56 year old man who did not need oxygen admission, but they had to put him on four liters of oxygen to get him up after a little dip in his oxygenation. A little bit earlier. Earlier on in the day, his SATS had been 94%. He's admitted earlier with shortness of breath and treated for a lower respiratory tract. Infection is actually due to be discharged but developed new oxygen requirement in the evening whilst he was waiting his discharge letters, um E A U um Sister Christine's beside herself. I'm really not sure what's going on. And he just, he looks okay though. So one of the recommendations, can you come and see? And she's trying to work out whether I can still find a way of getting this gentleman home. He doesn't take any medications other than the antibiotics and they're really, really short on beds. I'd love to say this kind of conversation hasn't happened before it has. So you've got your thoughts on route E A U ward. It's a short stay ward. And then you've got to try to think actually was the initial diagnosis, right? Is there something that may have been happening? So sometimes some the history evolves as patient's have got a little bit more to think back on what they've said to the doctor or things that have come to light a bit later on. Could this be a peeing? Thank you. This be a pneumothorax for instance. So your initial assessment, responsive airway 92% on three liters via nasal cannula and he's speaking a complete sentences. He appears short of breath. And is this mild accessory muscle use crepitations noted in the left lower zone. So you can kind of see why they may have gone for the lower respiratory tract infection. Um It's got warm peripheries, regular pulse, his tachycardic though and his BP is 100 and 30/80 heart rate. 100 and 20 G C s is 15 B M 5.6. And he's a federal. Then he goes on to say that he had some left calf tenderness which has come and gone for about 2 to 3 days prior. Normally just, it just eases when he massages that left leg. So what are your next steps? Say again? I mean, something's changed. He's gone from not needing oxygen at all for his short stay in E A U to somebody needing oxygen. So you will need a chest X ray. You'd also need an A B G bloods and E C G. You confirm the background again. So call mobility is medication, functional baseline, but none of this yields anything. He's got no concerns. He's independent, still works in an office and he's never smoked. He's on antibiotics for the lower respiratory tract infection. And there are some crops that were mentioning the post tape board around in the left base, which is exactly where you've heard them but the concern you'd have here is this new bit of information that he's told you about, which is that the calf has been quite tender and sore and he's been massaging it to ease. A concern would be about pe So even before you've got all of this, assuming all being well from a bleeding risk point of view would be giving this gentleman treatment dose of low molecular weight, heparin the decision you'd have at that point though is, do you think this is the kind of person that you just stable re review and set reduced into bit like interval observations? I e tell the nursing staff to do another set of Bob's 15 or 30 minutes later. Um Would you be concerned is deteriorating despite optimal treatment or stable but potential to deteriorate? So you would escalate on that basis, we'll give it away slightly there. But the what you would, I would say that you would do really would be escalate. And the reason for escalating to someone like your registrar is, although when you go back to be slide before and you're looking at the signs of shock, the only real one that you can pick up at the moment is the tachycardia of 100 and 20. However, where he start to start showing signs of a low BP and stuff, the conversations you'd be having would be centered around, should we be from realizing this kind of patient? So you're trying to be on the lookout for any signs that he's developing more of a potential shock picture. So the registrar needs to be made aware. And if he's developing any of those pictures, then this is the kind of patient that we need to be escalating up and making the intensive team where in case you do go down the frontal isis route. So as you can see on the CT scan, there is evidence of clot affecting, um the contrast as it passes through both the right and the left. Um So he's got bilateral ps, there isn't any evidence of a saddle embolus. Um But this is definitely the kind of patient that would be teetering along. And you want to also put this kind of patient on a monitored bed. The next case I have for you is a bleep seven PM. I've told you already about the flurry of bleeps you tend to get at seven PM um from the respiratory ward this time, from a very concerned nurse, she's concerned about a 45 year old E M who has had worst thing, oxygen requirement and now appears drowsy. So again, you go for your normal step wise approach, which is your ESP are your thoughts on route, having gathered some thoughts because you've got a nice little systematic um approach, your A B C D E assessment and then decisions on whether to treat immediately or escalate immediately. And then if you do treat then what kind of review you would have to do thereafter. So in this case, the esper is as follows. So, Sister Becky calls you from the respiratory ward. Um E M 45 year old man is on higher oxygen and he's needed since he came in. Um, he's now on eventually 40% and he's been on 28% earlier and he just appears less chatty. The background is his day to on the ward. His oxygen requirement has been slowly going up. It's been on treatment for an ineffective exacerbation of COPD. His target SATS are 88 to 92 which is entirely appropriate. Um particularly because going out to recommendations is needed. Previous N I V in the past, he's been handed over to you already. Actually, by the day team who have only said that all you needed to do is review the chest X ray, but the chest X ray has not occurred as yet. Sister Becky is really worried. She's worried he's retaining because he's definitely a lot less chatty and she's even done a repeat sats and can see that his sats were sitting a little bit higher than they had intended. About 94% recommendation wise. She's very um well versed and she's obviously very experienced. She's turned the oxygen down and the sats are now sitting at 89 but it really just doesn't look well, she knows that he's had previous N I V on a recent admission. She's just started some PRN nebulizers, but she'd really think she ought to get here. Very good. So, what are your thoughts on route? I hate respiratory medicine being one of them. And why do they bleed me? And not the S H O or registrar be any other, particularly? I mean, you're going to get there and I think this is the kind of case that a lot of patient people would basically be particularly worried about. I think their concern is they're going to come in and see this peri arrests and situation. But again, I think if you take that step back and just think to yourself, right, responsive or unresponsive. So, you know, he's responding to yes, he's less chatty. But from a G C S point of view, you're still dealing with someone veggies ius of 12 airway wise, you're 88% on a venturi mask of 35% and he's speaking in, in complete sentences, he appears short of breath. You've got that accessory muscle use with purse lip breathing, which is characteristic of your COPD emphysema patient. You auscultate and you notice he's got reduced air entry on the right. He's got purse lip breathing, cold peripheries, but the pulse feels strong and, and then the BP is 110 over 80 he's tacky 100 and 30 in the respirator 28 Scott reduced G C S but he's a federal and around the bedside you've got the normal, the inhalers, your nebulizers, the target saturations written above the overhead bedside board. So what are your next steps? I think this is one of the scenarios where you're just going to just put the medical emergency team call out because not for any, for the main reason that you need more hands on deck. There's a lot going on with this one gentleman. You're going to chase the outstanding chest X ray or ask the nurses to help you do that and arrange for it to be done portable. You're just going to arrange for an A B G. Um And then you're gonna confirm some of the background so that when everyone comes on route, you're either there at that point doing things like the A B G or going off to try and get a little bit more collateral for them. So the collateral is as follows. He has COPD his previous N I V on an emission two months ago, but that's the first time he had an IV that was two months ago. He's not on N I V at home. So that's noninvasive, noninvasive ventilation. Um You did have a full prior to come in in actually, it's loosely documented in the initial uh the initial admission notes and the chest X ray on emission mentions rib fractures, but there's no pneumothorax on that chest X ray. He's on antibiotics for an ineffective exacerbation of COPD and the ward round mentions decreased air entry, widespread but more so on the right compared to the left. So the decision is that you're going to have to make of the usual one. So is this patient stable re review and set reduced interval observations stable but potential to deteriorate? Um So escalate, deteriorating despite treatment, I mean, you didn't even get to the treatment phase. So it's definitely one of those uh my apologies here should say stable. We should just say unstable but potential to deteriorates. You're gonna escalate earlier. So the portable chest X ray happens. And as you can see, yes, there are some rib fractures. Um You can also see that there is slight blunting of that right costophrenic angle. Um But most importantly, you have a pneumothorax on the right hand side. So it's likely that you may have had a pneumonia forex even on admission. And the reason that these saturations have been slightly dip have been continuously dipping since he came in bearing in mind. This is day two is that the pneumothorax has just been gathering speed. Um His A B G on 35% has A P 02 of seven PCO two of 10. So the wrong way around by cover 31. So he does have a chronic picture in the background. And so overall, it's fitting with a decompensated type two respiratory failure, but with the additional bonus of a pneumothorax. So then it's the case of what are your next steps. Well, that's why you call the medical emergency team. Really. What we would normally do an advocate here is that you cannot put this kind of patient on N I V because that would just make the pneumothorax even worse. So the first most important step would be to get control of the pneumothorax was said chest rain. Then once a chest rain is working and this has to be working, bubbling away. You can put the patient on N I V if still appropriate and then find the appropriate bed space for this person, which should be a bad space that can support N I V. And that normally comes in the form of an attachment to respiratory high dependency bed or in the form of an I T U level to bed. Say the next case comes back from E A U and it's in the early hours in the morning. So you're on a night shift, it's two am you get a bleed from the eau nurse, the E A noon eau nurses calling about a 25 year old who's got known asthma and has dropped her sats and she seems short of breath. But again, you're gonna approach it in your normal man. It's so esper thoughts on route A B C D E assessment are you going to treat? And what kind of review escalation plan are you going to have? So s far reveals the following. So staff nurse, Jacob from. Eau calls you. He's hauling about E M who's 25 year old man. Saturations have gone down to 89% on air respirator. 30 sat to 93% on four liters. So she's technique and she's got a new oxygen requirement. Oh, he's got a new oxygen requirement. Apologies. Um There's been a, the patient's been an inpatient now for three days and she's, they've been treated for an infective exacerbation of asthma. God. I'm really changing between sexes here. So my apologies for these typos due to go home but kept in as was still quite wheezy. So the war team wanted to continue nebulizers for another 24 hours and review the assessment and nurses come to is that patient had reviewed nebulizers earlier because they want to go home. Um I'm just reluctantly taken a nebulizer. Now, please, can you come and see um not needed any oxygen since they came into hospital? So your thoughts on route are probably, I really hope this is as straightforward as it sounds. I mean, she hasn't had a nebulizer. They're going to give her the nebulizer and going to feel much better in herself. So young asthma refused nebulizers give nebulizers is kind of thought you're gonna have on route simple or is it um airway wise, they're speaking in full sentences, breathing, minor accessory muscle use, saturation is 94% on one liter, air entry, bilateral, minimal, wheeze, no crepitations, respirator 22 circulation wise, they're warm and well perfused tachycardic, 110. But you know, they have just had the nebulizer BP 110 over 80. But again, they're young. So low BP is not totally unexplainable disability wise, G C S is 15 there a federal BM 5.6 as is everyone an environment wise is inhalers at the bedside, nicotine and he later noted at the bedside too. So your next steps are the chest X ray, the A B G, the E C G, you confirm the background, like you mentioned of all the other cases, comorbidities, medication, functional baseline. There are no concerns, independent still works as a teacher smokes three a day, but she's working on the smoking history, the treatments already been initiated. She's just finished nebulizers. And the what you're really left of is is this patient's stable, I'll come back and re review shortly or set some reduced interval observations with a view to being flagged up if there any concerns stable but potential to deteriorate. Um So I might well escalate up to one of my seniors. The chest X ray is as follows. So just the hyper expanded lungs that you expect to see and someone who's got asthma but otherwise not much on that new um chest X ray at all. And you've got a po two of 10 on one liter. So a very mild uh type one picture, but it's very, very mild and likely to respond to the nebs that I've been given sinus tachycardia. But then again, remember they've just been given nebulizers. So one major tweak later, however, two am you get a bleep from Jacob, the eau nurse. And it's about a 25 year old known asthma. No other significant past medical history and on treatment for an ineffective exacerbation has been on the high, this patient has now been on high frequency nebulizers, steroids and given magnesium earlier on in a day and the day team are happy that the patient has been improving. Key question on arrival. So I quote apologies for the backgrounders but is whether they're responsible and responsive. Um They are responsive airway and wise they are 93% on 40% via hidden humidified venturi mask, speaking in complete sentences in in complete sentences, um breathing wise appears short of breath, some accessory muscle use and the chest just appears quiet, hmm circulation wise, good volume, pulse, regular pulse, blood pressure, 120 over 80 tachycardia. A heart rate 130. But you know that they've been getting your high frequency nebs including salbutamol. The cat refill is less than two seconds. The G C S is a little down but nothing to write home about. So 14 am losing one from the eye B M 5.6 in L A febrile. The E C G continues shows some sinus tachycardia. So what are your next steps? You got the chest X ray, the A B G and the IV antibiotics in the pipeline. But I really think that this kind of patient escalation is the only thing and the big concerns you'd have with this patient is, oh, as follows, say they're known to have asthma and they've been getting quite high level treatment. So they've had the high frequency nebulizers. They've been given steroids at the time. Magnesium has been given. There's been an issue, a significant issue of bronchospasm. And what's typical of asthmatics is that little spiel that you hear about the day team are happy they've been improving. But for most asthmatics, it's that early morning dip that you will notice that yes, they've been lovely and stable throughout the day and then at two AM, three AM in the morning, they get classical dip. There is a good going type one respiratory failure here and relatively because 93% on 40% committed five century mask. But the most worrying sign that you would have here is a minor dip in gcs allowing for the fact that obviously it's two AM in the morning, but the chest appearing quiet, which is always a little bit of a concerning sign when you see in, in the context of an asthma background. So same chest X ray. Um but here the type one respiratory failure deficit is more apparent. The concern you'd have here is escalation because of a tiring asthma, sorry tiring asthma picture. And what gives that away is that the P CO2 is nudging upwards. You really should be seeing in an asthmatic then hyperventilating a lot more so blowing off CO2. So the minute you start to see that CO2 increment up slightly, you, your alarm bells should be ringing. There's a high risk here for intubation and that senior review, whether that's initially your registrar. Um But ultimately, I think in these kind of patient's getting that early met call out is very um important, particularly they've gone quite up on the treatment pathway already because the only thing that they haven't added into the mix from an asthma point of view for this patient is aminophylline at this point in time. So my question to you at this point of the talk is, are you feeling confident? I mean, so far we have looked at patients' with pneumonia, pulmonary Advil us COPD, exacerbations, pneumothorax, um exacerbating uh type on with an associated type two respiratory failure asthma exacerbation. But the approach is the same regardless you got your S pa. Um then you've got your thoughts on route about what might be causing the deterioration, your assessment and your accessory investigations such as your A P G, your chest X ray, your treatment and then your subsequent review level required, which you've established, you're Monica, like if you're really pushing hard here would be SATS. Uh Thank you for listening. Yeah, thank you so much, Doctor Richie. Um, does anybody have any questions at all? It doesn't seem like we'll give, we'll give it, we'll give it a couple of minutes to see if anybody pops up with any questions. But thank you so much for your time today. Um, it was really good and I hope everybody learned a lot from it. Um, okay. I think someone's asked about by the looks of things, the significance of the 90 um 3% with the 60%. And it's just the sheer amount of um option that you need to reach the 93. Imagine if someone's on 90 getting stats 93% on air and then suddenly they're needing 60% oxygen just to, to maintain those saxes. That's a big shift in a, a radiant. So if you do an A B G on that kind of person, assuming they're not retaining CO2 when I see things like P 02 of um 10, which on the face of it looks brilliant and fine. But actually if you're needing 60% oxygen too, just to get you up to 10, then that is a lot more concerning than if you had a peer to of 10 with on air where you're just getting 21% if that makes sense. And then someone else has asked for someone of p but as a past medical of hemorrhage or stroke, how can we navigate treatment with all. That's a tricky one. So you basically have to kind of way up. So someone has asked me about, I don't know if you all seen these questions, so I'll just read them out anyway. But if you know that someone's got a, you know, that someone's got to confirm pe but they've got a significant past medical history of hemorrhage stroke. How can you navigate using treatment dose? Um Things like Loma molecular weight, Heparin a lot of the time. Um your lady guarded by how long ago, you know, those things happen. So if there was a few years ago, um a lot of the time that you would give the treatment cause ultimately, the P is going to kill them unless you treat them. If you're worried that it's more recent and there's a high risk of bleeds, the way we normally go get around. Things like that is by using things like low molecular weight heparin because not long. So Heparin infusions so that you can turn the infusion often soon as you turn the infusion off, soon after you lose that kind of antique regulation effect. It doesn't mean you won't bleed, but it certainly tries to reduce the fallout from using it. But then you're still lot left of a semi untreated P And then nowadays you've got more targeted treatments like directly trying to dissolve clots, directly say, oh yes, someone's asked what dosage of low molecular weight happening is needed for such a suspected P M, it's weight dependent. So when you start on any trust, they will give you the sec criteria where they'll say patient's between such a, such weight, get a certain dose. And if you're on another weight bracket, you get a certain dose and if you another weight bracket gets certain dose, so it's very weight dependent. And pharmacy are all about giving your policy on day one of starting the job of what a treatment dose looks like and what prophylactic dose looks like, but it's very much limp geared around the weight any more questions. That's it. I don't think I missed any. I, I think that that might be it. Uh someone spot sofa below 45 is 2500 above. Oh, so the treatment is much higher. So basically, um the reason I'm not saying it cause it does vary a little bit actually depends on what kind of low molecular weight heparin you're using when your trust to be off there. But actually it will, it's um I'll give you an example. So sometimes they will say things like 75 under is 15,000 above 75 kg. It's 18,000. So I'm not saying that's the thing, but it's, that's the kind of range you're looking for, but it will be issued to you on day one and it's a prophylaxis. Is that, is that, is that answering your question anymore? I don't know if that's your because what you're quoting looks like prophylactic. So that's the doses you would normally have anyone on. Um, so anyone that's come into hospital is deemed to be higher risk of developing clots in their legs or in their lungs. So we normally have them on prophylactic dose and that's what you're quoting. But the treatment dose is much higher because at that point you're trying to treat rather than prophylaxis. Ok. Brilliant. I think that answers it. Any questions, there's no silly questions either. I'm not that kind of boss yet so you can ask me anything. No. Okay, good. Uh Thank you so much for your time, Doctor Richie. All right. Take care. Bye bye bye. Hey guys. Um Also just, just to let everyone know we're going to the session coming up next week. Um It's a radiology based session, um which is uh they will be covering chest. They're crazy up crazy sort of presentations that you might see on those. So we do join respect uh at the pier. Uh And that will keep you updated with guys to play the sessions as well. Uh We just posted pending for it. Uh We just supposed to make up for it as well. Please fill in the back row. It was second tender typically kills off. So just to repeat what teller said, we've got a couple of sessions coming up. Uh We've got hematology session and a rheumatology session coming up, um which are going to be really useful. Um And uh that's, that's going to be in January, but the next, um, next one will be next Thursday at seven where we've got a radiology registrar talking about what to look for when you're interpreting chest x rays and ABDO x rays. Um And um, they'll be going through some common presentations um that, that would be really useful for you as well. Um So please make sure you fill out your feedback form and you will receive your certificate of attendance and this feedback goes straight to doctor Ruchi. So she would find it very useful as well um for future sessions and you forgot any questions, just post it into the chat and we can pass it on to Doctor Ruchi. Um But we hope you found that you