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Time until stuff. Oh, same. Here we go guys. We're going to start at seven. So if anyone is waiting around like feel free to get a drink or whatever I was uh I don't use the uh thanks Sarah. I've got it. Yes. Oh You know what? Mhm. Yeah. Huge. Yeah. Okay. Yeah and real back. Uh mm. Paper. Mhm. Yeah. Mhm. Mhm. Mhm. Okay. Okay. Hi guys. So thanks for waiting. If you can all hear us, hopefully if you can't please write in the chart uh and I hope we can all hear us. Um So we're yeah. Uh so uh my name is Alicia and I'm done. We're both fourth years and we're both on E M sock and so we'll be talking Tuesday about how you should approach chest pain from an emergency medicine point of view. So we're thinking more Simon situations with this. So I hope that's what you're expecting. So yeah, if you have any questions, feel free to put it in the chat all along. Um Also we're going to be asking questions, feel free to turn on your mic and uh answer the questions or if you want to just write in the chart that's fine as well, whatever works best for you. Okay. So um imagine we have a patient and he presents to you saying he has chest pain. Um What sort of approach would we take to managing this patient if you pop in the chat, it's general sort of Simon offered for any patient. Okay. Yeah. Okay. So as with every patient, we used the A B C D E approach. Um, so does anyone know if anyone can put in the chat? Sort of what things were looking at? Mainly for airway? I think he's given longer access to late as well. So it's like the main thing like that we're looking for, for the airway. I don't want you to because I don't want to be delayed or not. That's it. Yeah. Say check this patent, obviously, if they're able to talk to you, then you can take a quick history. Um, in emergencies. We use ample for history. Pneumonic. You tell them about it because, you know, you want to ask them that allergies. Uh, there's medications past medical history, the last meal and event history. So what happened? So that was allergies, medication past medical history, last meal and event history, uh, sample. And that's the same for any ABCDE approach. Yeah, it's just like a quick tour for history to sort of get the important information because obviously you don't care where they live if they've got a dog at home. Or anything when they're presenting, especially with chest pain. Um, so if breathing, thinking about sort of what observations we do, um, what examination we do and what investigations we do. So, what kind of things would you be looking at in the breathing section if you pop in the chart? Okay. Yes. A respirator, someone said, and one of observation. So, yeah, rising, rising full of the chest oxygen sats yet well done. Any investigations that you'd want to request? Is there any imaging bloods os quotation of the chest? Yeah, definitely. Chest X ray. Yep. And A B G. Perfect. So yeah, so we're looking um the main obs in the breathing sections like we said, the respirator um the SATS obviously sats whether there or not off of oxygen. Um Does it go up with oxygen uh in the respiratory exam? Obviously chest expansion, auscultation and percussion and then tracheal deviation? Because um that's quite a big thing for attention before X and then um in every Simon station, when you do the breathing section, always request a chest X ray and an A B G. So now moving on to circulation, like with every letter we split it into observations, exam and investigations. So what would be the observations that you'd be looking to take in circulation in see BP? Good. Anything else? Heart rate? Perfect. That's kind of. Yeah. And then with examinations, what you're thinking, Capri felt? Yeah, that's really important as well. Everyone forgets how refill, what examination things are we doing? Pulses. Yep. You wanna do pulse is, um, important, uh, in emergency situations to do femoral pulses. Um, as well. Auscultation. Good. Uh, yeah, it's kind of the basics of a cardio exam, ostentation. And then what investigations would you want to do as well for C E C G? Really good. Really important for chest pain. Anything else? So, temperature is a bit later on. So we'll leave that out here but well done. It is important FEC Yeah. Any other bloods, especially if we're thinking chest pain, troponin, troponin. Yes, good. And very important. So you guys got most of it as well. So BP, heart rate, C R T then do a cardiac um important to check JVP as well and check the peripheral pulses as well. Um And then E C G and insert a wide wall. Can you lift access and you want to FBC using these LFTs cutting and especially troponin. Um those are based on, you can do other things like um BMP and things like that. Um So we're moving on to d now. So someone's already mentioned temperature. So that is in disability as well. Anything else? So just put it in the trap for T O cardiac enzymes. That's good for C as well G C s of Poo. Really important. Yeah. Um and another one you can do is Pearl, which is seeing if pupils are equal and reactive to light as well. Uh So that's really important. There's one thing that's left in disability. Um If anyone can get it, it's very important. OK. Is nice. Don't ever forget Ducasse. That was really good, well done. And then um in terms of everything else, I'll just run through it because it's pretty specific. So when you're doing like Simon station, you always want in your everything else section, you always want to say that you escalate to a senior or refer for specialist advice. So basically, just feel free if you don't know what to do, just say you refer to a senior because quite often that's, that's what you can do and that's also what they're looking for. Um and then interventions so as things come up due, treat them, um and then things like pain relief as well, obviously, chest pain is painful. So make sure that you're giving them pain relief to try and keep them as comfortable as possible. Um And um you can give that and see the payment youth as well when, when you've taken bloods and things like that, they normally do that and see. So uh now we're doing a differential diagnosis of chest pain. So we've kind of split it up for you into cardiovascular, pulmonary gi and miscellaneous causes. So if you want to write in the chart as many causes, you can think you can split it into categories or you can say out loud, whatever is easier. But see if you can name as many as we have and when you're thinking about this thing, you always want to think what is the most life threatening as well? What do you want to rule out? So? Good? Am I pericarditis? Nice. Tampa Nadia. Good. Okay. Cardiac arrest. Yeah, I'm not really going to give you chest pain, but it is life threatening. So, obviously don't miss that. Um, someone said pneumonia, p pneumothorax, pleurisy attention, hemothorax, all really good rest causes yet dissection. God nice. Never forget the g eye causes. Yeah, obviously, it's not explicitly in the chest, but sometimes you can't like sometimes the patient can't tell the difference between where it is and obviously, things can radiate as well. Um So it's always important that you need to remember like the abdominal organs as well. Uh Soft deal rupture. Yeah, that would be one pericarditis. Someone said, yeah, these are all very good. Uh So we just revealed the side now. So, yeah, for cardiovascular, we said um acute um it's obviously heart attack. Um Angina precordial catch syndrome, pericarditis, myocarditis, aortic dissection. Obviously that the more that you said like camping on and things um for pulmonary. So pleur itis pneumonia, pneumothorax, asthma A PG lung cancer as well can sometimes cause pain if it's pressing on a nerve. Uh Yeah. So good esophagitis, esophageal spasm, gastritis, pancreatitis, peptic ulcer disease and acute colecystitis. Very important. Um and miscellaneous. So costochondritis you guys have put M S K causes in their fracture bone that's really important as well. Severe anemia, herpes zoster like shingles, uh sickle cell anemia, acute chest syndrome and panic attack is really important as well. Um But you always want to rule out the life threatening things first. Um Yeah, so, um these are the ones that we're going to cover today. Um The ones with the star have already been covered in the shortness of breath session. I think you can get the recording that. Um So we won't cover them again, obviously. So nice. So, uh this, so writing in the chat again. So we've got, if you're thinking a patient has aortic dissection, uh in what kind of things are you thinking for doing in the C section of the A B C D approach? Like interventions or specific investigations you want to do that haven't been covered already. BP. Yeah, that's really important and specifically with BP, what you're going to be doing for aortic dissection, BP in both arms. Yeah, that's really important because the difference in blood pressure can like help you with your diagnosis. So let's put CT that's really good. So you probably wouldn't do that first line when you're still in the A B C D approach, but you definitely want to do that later on, especially if you're thinking about operating. So if the BP were you did it and it was really high. Um, what might you give IV Lobitol? Really? Good. So you want to keep the BP in like a medium range? You don't want it to be too low, but you don't want it to be too high and aortic dissection is extremely painful. So, what else are you gonna give? Uh, so you want to give morphine Nancy as well? And then, um, what blood on top? So you put those bloods there any other bloods that you would like to take considering this is like a medical emergency, potentially a surgical emergency. It takes, I don't feel the child to come on over you like I'm gonna miss it group and save and cross match good. Uh That's good. So in your similar and make sure you say that because that's very important. Okay. And uh so we've got our uh so let's say we've done the CT CT or MRI angiogram for aortic dissection. Does anyone know how we class aortic dissections? So Stanford classification and any other? Yeah. Uh A and B that's good for Stanford. Good. So um the Stanford classification is the one that most people use. You've also got to bake you, but I don't really know about that one. And so the Stanford it's type A if it's anything before the left um Subclavian and then anything after that is type B. Um So you need to know that that's important. They could ask you questions on that and then generally, what's the management for aortic dissection? Um, if you're thinking as a junior doctor, what would you do? Surgical? Yes. Exactly. But, so if you're surgical, anything surgical, what you, as the junior doctor going to do, it's a bit bold. Uh, yeah, that's the, that is the, the audit route repair is the specifics of the surgery. But as a junior you've got a patient who needs surgery. What are you going to do for them then? Cool. Cardiology. Yeah. Referred vascular surgeons. Yeah. Uh they're really hungry on the thing. Sure, down. So if they're really hungry and thirsty and they're saying doctor please, can I eat by mouth? Most of them are really good. So, um so when you're approaching this chaotic dissection, you're going to do the A B C D approach and these are the specific things you do and make sure to refer to vascular surgeons uh like early when you're feeling like you think, you know, it's able to dissection, you'd like to check and keep the patient know my mouth cause that's really important as well and it won't delay their surgery in any way. So next, so next one we have for um cause of chest pain is acute M I, so um looking again at the 80 approach that we have on the side, um any specific things. So looking at the investigation sort of what are we going to see if they're having an acute M I is that stemi or understand me. Yes. So they will be sweating quite often. What about in the investigation? So under the C section, we've got the E C G in the blood, what kind of things are we going to see on those? So yeah, ST elevation or depression. So if it will come up, okay. So obviously in a stemi is in the name ST elevation, it will be in two or more leads that are looking at the same area of the heart. So like the one B T V three before things like that um in an N stemi, you can get ST depression and you can also get t wave inversion. They can come out in both a stemi or um or an end stemi. And it's also important to know that if there is a new left bundle branch book that isn't in any previous CCGS, they've never been diagnosed with it before. Um That could mean that they're having an MRI and it's just not showing up properly on the C G. And someone also said about Ukrainian. So you have elevated in both stemi and NSTEMI. Um if it's not raised or it's borderline raised, you repeat it in three hours and you see how it is then because obviously, if you have an N stem, you might have quite nonspecific E C G changes. So you can't guarantee um if the repeat one isn't raised or again, it's borderline, then you need to be thinking about unstable Angina because that won't produce such a raised entrepreneur. And then does anyone know the management of, of an acute Emmis of what we're gonna do? Right then for them to sort of manage them, their pain and things like that. Yeah, mona is one version. Um Okay, so we've got Batman which is slightly different. Um But again, it all covers all the same sort of things. So B for beta blockers, um A fasprin, I've put the doses that they're quite useful to remember, especially if you get the same man station. They do quite often want you to remember the specific doses like the loading in the maintenance um teeth to cangrelor. Um They're moving more towards that rather than clopidogrel. Um M for morphine again, just titrate for their pain that they're going to be in a lot of pain with this quite often unless they're diabetic, which is another thing to remember. Um quite often diabetics can produce with no chest pain. Um But they might have the C D changes. Um And then A for anti thrombotic. So in the end and then it's still to par in which is a low molecular weight heparin. Um And then N for nitrates, either sublingual or IV infusion. Um And then another thing just to remember for, do we need to know about mine over main or it's either fine. I was fine, to be honest, as long as you cover everything. Um, source of mine is morphine, oxygen night treats. Um, uh, but I, I've heard people use manak with like the c was clopidogrel but people more used to gargle now. So I would move towards but murmur just because it covers everything a bit more easily. Um, but I did use MU Night or romance people use as well. So either is fine, just look at what the current guidance is but this batman, if it covers current guidance at the moment, yeah, I don't know why they just decide. I think some research must have come out with something for to capillary clopidogrel. Um So for stem is, if it's less than two hours since onset, you can do PCI. So primary uh with the percutaneous coronary intervention. Um if it's more than two hours, then you need to do fibrinolysis first before you do the PCI. And then for an end stemi you need to work out the gray score. Um If you just Google, it comes up on like mg calcium things. Um If they come out as having high risk, you need to do PCI within 72 hours or conservative management. Um Yeah. Oh, nice. Ok. So now I'm moving on to acute pancreatitis. Uh now I'm not an explicitly um common cause of chest pain is very important. Um And it can radiate up. It mainly causes pain in the epigastric area, but it's important to know for emergency situations and important to rule out if you are suspecting in anyway. So we're going over it just in case. So um to diagnose acute pancreatitis, you need clinical features of acute pancreatitis bloods that support diagnosis and imaging. Those are three things you need. So, uh in circulation that do you know any things that we'll be doing interventions or investigations and see for acute pancreatitis. If you put that in the truck, obviously give us a shout as well a few years because you would have covered it yet. But if you have then go for it, I can give a guess it up. Um Remember this is chest pain. So there's always pain that can be solved. Lipase and amylase is really good. So, um and amylase will normally be like elevated about three times above the reference rate. Uh reference range and lie pays bone profile L D H as well as important and you can look for causes the pancreatitis as well. And then um you also want to make sure you have IV fluids as well. That's really important. Imaging CT. Yeah, that's really good. Uh And you want to make sure you give them analgesia because it is extremely painful again. And then, yeah, so you said a CT that's really important. You could also do an MRC P and an ultrasound. Um If you're not in your three yet, you will cover the senior three. So don't worry. But yeah, um the most important thing and very commonly tested in exams is the causes of acute pancreatitis. That's very high yield and has come up a lot in our end of your skis. So, if anyone knows any causes you can put it in the chat. Uh, the pneumonic that is used as I get smush. The, I get being the most common causes alcohol. That's a big one. And the alcohol is like ethanol. That's what it is in the idea. So cool stains guess scorpion help you don't see a scorpion in your exams. But it is very, um, that's the one I ever remember. Okay. It's fun. Uh scooping by any one place anymore. I know it's quite hard to like individually to write you out. Okay. So idiopathic gallstones, ethanol, alcohol or trauma and the most common the rest and not as common, but it's still important to know. So if you want to do an autoimmune screen, um, or if you want to ask if they've had an ERCP recently, these are all key questions. Um, the examiner or your patient in the future will be like, yes, why don't you ask that? Um, so the management of pancreatitis depends on the Glasgow school and you want to see how severe the pancreatitis is. So if you, you can give a Glasgow school and they'll come up with that, you want to think about nutrition. Do they need enteral feeding and treat the underlying cause? It's a lot of supportive management, but it needs to be identified because it's a medical emergency and it has quite a high mortality. So, yeah, but you will go through in the region. Course. So the next cause we're thinking about is severe anemia. So it is a bit of a rogue one but it can happen. Um So you can get severe anemia causing chest pain because it's similar to sort of a mechanism as an M I because the blood has such reduced oxygen capacity. Um You basically cause a ski me at the heart muscle. Obviously, it'll be more mild than an M I. Um But it still can happen. So, does anyone know the threshold for transfusion in terms of hemoglobin values for anemia? There's a very specific question. So I don't blame you if you don't know below seven. Yeah. So um we do in grams per liter which means I think seven is equivalent or roughly equivalent to 70. Um So yeah, any, any H threshold, so less than 70 if they don't have any a CSR like Angina and things like that or less than 80 if they do. Um And also obviously, if you do have the patient presenting um take a group in saving a cross match free unit of blood if they are below the above thresholds, so you can give them that, you know, blood as quick as you can. Uh anything else we need to remember from the blood? Like what other things do we need to look at if we've got a patient who's severely anemic reticulocytes? Yeah, that could show the cause yet. MCV. Um, any. So moving away from the full blood count, what kind of other bloods do we want to request when we've got an anemic patient? And quite often they will give you the cause is the most common causes. So, hematinic. Yeah, exactly. So, um, like say, don't forget them things like vitamin B 12 folate and iron, but obviously the building blocks of red blood cells. So if someone's anemic, that's the first place you look in terms of causes. Um I've also got a table here of causes according to N C V. Um if you want screenshot it because there's a lot for me just to go through right now. Um And there's also some little demonic there. So you can try and remember. Um So for microcytic, it's tails normocytic, just A B C D E and then macrocytic it's fat RBC. Um So if you can just real them off in and ask it would be pretty decent know, so feel free to screenshot that. And yeah. Okay. So uh moving on to another pretty rogue one but quite important. Um So this is acute chest syndrome in sickle cell. C's so sickle cell disease has many different crisis is um and this is uh an important one that can cause chest pain. So, what investigation would you like to do in be, um, if you're thinking someone has an acute chest syndrome and they have sickle cell disease. Okay. Extremely said to me. Chest X ray. Perfect. That's correct. Correct. And then, so you might see evidence of infiltration and then what bloods or investigations would you like to do and see, um, and, um, any things, any things or drugs you would like to give as well, um, considering this is extremely, extremely painful, morphine good. Uh, so you need to give morphine within 30 minutes of them presenting because it's extremely painful and you give it a sub cup date. And then what investigations would you be doing? Yeah, you can get some oxygen as well. Um, help and the investigations, you can think about them by thinking about how you might treat this. Um, that's not what things you would need to know for the truth. What happened. It's a big break. So I'm gonna see this. Oh, okay. Okay. A new blood. Um, so you want to be doing FEC group and save LDH knees, knees. Um, yes, renal function. In the case of dehydration, that's important group is safe if you're thinking about a transfusion because if they're sickling a good way to help that is to do a transfusion. Uh, and, and then you can just septic screen as well because that could be the underlying cause of the acute chest syndrome. So do viral pcr and sputum culture to see if you need to start step 66 and start treating that. Uh The management, I will just talk through it because it's quite rogue. But you're gonna give IV fluids and then an urgent exchange transfusion antibiotics, uh infection and you can give them BT prophylaxis. And if they're really hypoxic, you can give them CPAP, which is continuous positive airway pressure and invasive ventilation as well. The most important thing is giving the adequate pain relief within 30 minutes because pain can be, the pain is really, really bad in simple cell disease for any of the crisis. That is the main thing just to remember for like any Simon station. Really, if the patient's in pain, always morphine and an anti emetic along with it. So um quite often people say morphine and then to remember the dose is easily, they use metoclopramide with it. So it's 10 mg of both. It's just easier to remember. Um Yeah. So next thing we've got is our patient with chest pain. Now, the nurses come and found you and said he's got no pulse. Say what do we do next? Uh I mean, well, anyway, okay, so we go on life support. Um So obviously, if the patient's unresponsive, not breathing, normally you do doctor ABC. So check for danger. Um check if there is a response. So quite often it's good to give them a command because then they can actually do it. Obviously, if they can't open their eyes for whatever reason and they can still hear you if you've given them a command, like squeeze my hand or something like that, then they can actually do it. Um And then A B C is the same airway breathing circulation. So check that airway, make sure there's nothing blocking it just in case they have choked and that's the reason they stop breathing. Um Check breathing. So what and circulation at the same time? So what you want to do, you've got your patient led down, prop your cheek above their mouth, look down their chest for at least 10 seconds and at the same time, feel the carotid pulse. Um again, 10 seconds. So you're feeling if they're breathing on your chin, you're looking down the chest to see if it rises and you're also feeling the pulse at the same time. Um And then if none of that has produced any response, you need to put out a crash cause they're called four twos. Um and start CPR send someone to get the recess trolley and the defibrillator and then start CPR. So um 30 compressions to two breaths, just keep going until the defib comes back and then attach it nice. So once you've assessed the rhythm, see all hands off the body while you're assessing the rhythm from the detail and you need to basically assess the rhythm. See, is it shock Kable or non shock Kable? That's the way you care about. It doesn't matter anything else. So shock, Kable rhythms are VT and pulsus, uh pulses, BT and beer and non shock Kable pee which is pulses, electrical activity and a sisterly. So, uh if you're going to the shock of rhythm, so if you CVS fine, you start preparing to shock and if you CVT, you need to check a pulse, you need to do a two person, pulse check as well. So someone checks the femoral, someone checks the corrupted two different separate people. Um And then what if yours pulseless, you can carry on and charge the defect while you're charging the defect, the other person can continue doing CPR because you don't want to waste any time and um keeping an effort with the C P R and then everyone off auction away for shocking. If it's a non shackle rhythm, you continue CPR for two minutes and then you reassess the rhythm and that's the same after you shock, you continue for two minutes. Don't bother checking the rhythm again for the whole two minutes. Just continue CPR and then go back to reassess the rhythm. Okay. So does anyone know the causes of cardiac arrest? So if we start with the HSE, so it's remembered by four Hs forties. Um So if you just pop in the chat, any of the H is so hypoxia is one. Yeah, hype a firm yet. Yeah. Anyone think of the other t hyperkalemic? Yeah, it can be hyper hypokalemia and then there's one more. No worries. So, so yeah, like we said, we've got hypoxia hyperkalemia or it can be hypochelemia, hypothermia and yeah, hypochelemia as someone just said. Um so now what about the teas? Does anyone know toxins? Yeah, that's one thrombate. Yeah. From this. Yeah. Attention. Anyway. And then one more to do the heart Tampa. Not perfect. Got them. Yeah. These are just causes you just make sure you remember them for asking because if you do have like a defib station or something like, you know, at the end, when they ask you the questions, this could quite easily just be name me or you know, the four H is the forties. Um And then next we did just sort of like an Noski style thing for a defibrillation. Um It is just something you're gonna have to read. Um And it's just important to remember at the end when you do, if you do have a situation where you're doing the defense station and you do get a return of circulation, um, start the ABCDE approach, they'll stop you if you don't need to do it, but it's just good to offer it. Um And then also there's a list of investigations you need to request quite often. They will literally just ask you for all of them. So it will be an A B G A chest X ray 12 lead E C G full blood count LFTs using these clotting group and save glucose lactate and you need to send the patient. I see you um literally just learn them to read them all off. I know it's annoying but it's part. Yeah. Yeah. So that's all of the causes we're going to cover. If you have any questions, feel free to put them in the chat, put your mix on and there's also a feed that code. If you wouldn't mind filling that out, that would be great as well. Well, the feedback is in the chat as well. Yeah. Feel free to ask any questions. Uh Yeah, anything to be honest. Ask away uh what's to say? Thanks Alicia and thanks God um for also presenting. Um Also I thought it might be helpful to also point out that something I didn't know. Um But like you kinetics have a whole 80 E section as well. Um So if you just wanted to brush up on your 80 before like a cinnamon question, a placement, um your wish like check it out, I'll try and put the link in the, in the comment section. But other than that, thanks for coming guys. So with the morphine and anti emetic, you want to assess ample before you give anything to a patient anyway, and you would give the morphine and the anti emetic in the C section. You even be, it's important you check uh breathing before you give any pain relief or anything like that, especially with morphine as well. Because it's a respiratory depressant. So you don't want to give it too early and you find out that they're actually not breathing fast enough or something like that. Yeah, thanks guys. Keep the questions coming. If you do think of anything, honestly, it doesn't have to be about chest pain is whatever you'd like if you do feel like you need to ask any questions. No words. Yes, thanks guys. All right. We'll give it a couple more minutes and then yeah, we call it. Yeah, you have to say questions that we're, we're not whatever you uh three people at the feedback form, you get like a little certificate that says that like, you know, I attended and um I guess it looks a bit bit cool on your portfolio. Yeah, she said that it's a, it's such a good fight. It. Uh Yeah. Okay. They're not in pain. Uh It's just a way, let's see. All right. What you think? I'd call it a day. Yeah. Yeah. By division and the cool. Okay, bye.