Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

the okay. Hello. Good evening. I'm welcome to a tree to healthcare Siris minus Freddie. Cuba on. This is gonna be our session on circulation. So you'll be relieved to hear I'm not teaching again this week. Today we will have the wonderful job hair it presenting. I put it in his doctor ish on account of fact, he has past meds school, and it's finished. He just hasn't got is like a certificate yet. And start the whole doctoring bit yet. So he is sort of doctor adjacent. I guess we're going to describe him either way. Yeah, that my nerve, it's I put in every week about making the most off the session. Ah, do you take notes if you're interested? It's a really good way to instill things in your mind. It's really good way to help. Remember things on, makes sense of things. They're complicated. Do ask questions, please. We love answer your questions. A really good way for us to see how you're engaging that. But it's It's a really great way for you to sort of shape how you're learning. And finally, if you have any pets, you particularly enjoy all the bets you want to learn more about drops and email. We are more than happy to send on further resources or discuss our email. So, please, to do so. Um, if you have any queries, that's my email address. Most you should have it because that's how I send up joining Link. Please do email me. We also on instagram and Facebook that I am perpetually awful at updating and checking up. Um, but I they do exist on I am slowly trying to get better of these, but yeah, I do feel free to give him a follow. If you want to keep up to date, we post any new sessions on there so you can see what we're gonna do. That's the story about all that post to go out there at the moment, but I will try to prove having said that this is the current sort of format for the next couple of months. So a couple weeks ago, we had the airway and breathing session with myself that is finished recording that's available on the metal or via the link from last week. This week we have Josh doing circulation on. Then in two weeks' time, I think that works the two weeks' time. We'll be doing some clinical cases before finishing off the eight examination on this recent teammate with disabilities and exposure and then some more bids that are after. So stay tuned because good things coming up. That's my technical difficulty slide company. And, um, I've it has just joined yet. No, I don't know where he's gotten to let me poke him quickly. I can hear him some joint, but it won't be joining the moderator. That's not your joint. It's on. What is it? One second. Let me correct this one minute. Sorry. These are the joys of running anything via teams. It likes to sort of fiddle around occasionally. And it's decided that Josh conjoined as a remember, not as a presenter. So we're trying to fix that. So just bear with us for a second. It will be worth it once the to the difficulties finish, actually saying that I could do that slight. Yeah, I don't get to use a slide off to have it every week. Bella, Such one second. Okay, we found the issue. It is resolving standby most he's fiddling around, trying to join If there was any questions you wanted to ask before this session? Anything about last week or any of the previous stuff I know. Probably no one really will. But if you do feel free to ask them whilst, like I can see that he's there we go. Yeah, Any questions, please ask. I'll be hanging around as a moderator. More than happy to answer. When is that still just slides yet? I had mine, Yes, show slides. And then I could swap yours and mine around, right? I'm assuming it's trash. It's lights out. Yeah, I'm trying to be with you in a second. How is the Ah ha? That is now your slide and let me just brilliant it. It's It's not my face next to you. Um, let me do right. One, Uh, well, let's just me now. And that's what I want on over to you. And so over on on I've doesn't talk before that money. Joschka, I, um, Freddy's house make for my sins, but also a funnel year medical student soon to be F one button doctor on do every day to kind of talk to you about the circulation system, specifically kind of in an acute setting as sort of circulation is part of your 83 assessment. So I believe we have a breathing last time. So we're gonna go on do circulation this time. So we're gonna look at the anatomy and physiology of the circulatory system, the pathophysiology of shock on some fluid balance. We're gonna look at how to assess circulation, how to investigator on how to manage it. So secondary system looks a little bit like that. You got a heart pump in the middle. Um, where if lots of blood vessels going off, you got both arteries and capillaries, arteries taking blood away from the heart on D, um, veins taking blood, doctor. And that's it. Really. It's basically a pump and some pipes on D. Any surgeon will basically just tell you it is like that. Any medic will tell you otherwise. Then it's going to be complicated. But in between the arteries and veins, you have capillary networks, which is where you're kind of oxygen transfer into your tissues happens. So this is a heart. I hope you can kind of tell we have the right side of the heart here a lot of the time in medical diagrams. We will be looking at something as if it's the patient, so this might look to be on your left, but actually it would be on the patient's right. So you've got the right atria here, and that blood basically enters through the superior vena cava on the inferior vena cava into the right atrium. So this will be blood that's just returned from the body will be deoxygenated be Bloods, then mostly sort of fills by gravity more than anything and pressure into the right ventricle. However, then the atria can squeeze to push blood into the right ventricle just to kind of move the last bit of blood. Then the ventricles contract on blood is pushed up into the pulmonary artery, where it goes to the lungs. It's oxygenated again through the pulmonary veins into the left atrium, which again flows into the left ventricle and then out into the aorta on where it goes kind of around to the rest the body. So our choices mean for a little bit different, because they serve two different structures, Really, so are 22 purposes, so arteries are a lot thicker in terms of the wall they have a lot more muscle on day. Also have this elastic ated layer on all of this is designed to essentially deal with the really high pressures that are trees are gonna have to deal with because they're taking blood basically directly from the heart. So we need to be able to cope with this big pressure. Um, and this elastic player kind of helps with that because it can expand and contract a little bit in order to sort of cope with that. Then veins are have a slightly thinner wall. So they to you with a very low pressure circuit. And as a result, we have valves winner within our veins, which basically helps stop backflow down the body. Because the only thing keeping veins on the blood in veins flowing is your skeletal muscles contracting. Um, so you need those valves to kind of stop that backflow, and they both have smooth muscle, which basically means that they can be under some form of control at all times. So, through our, um, sympathetic parasympathetic nervous systems, they're your fight or flight and rest and digest nervous systems they can contract on violate to basically move blood to where we need it the most in terms of physiology of the heart. So this is a quite a complicated diagram. Looking at the cardiac cycle, basically everything that goes on, I'm definitely not gonna get through with this, but it's more just so off. Um, just for you to look at, really on to know that throughout the kind of cycle different pressures changed to this top line is the aortic pressure on what we've got here is basically the left ventricle contracts, which then basically shows thie, um, pressure and they oughta increase is again as eventual contracts the pressure in the ultra, the pressure of the ventricles increase. Um, you also then have the ECD cycles that's associated with that. But we'll get into that a second. It's in terms of electrophysiology of the heart. Um, it's quite simple, actually. So you have what is essentially the pacemaker of the heart, the Sino atrial node that's essentially within the right atrium and that generates your pulses of electricity, which will eventually become your heartbeat. So the's group of cells create your pulses of electricity which crosses across the right atrium and the right on the left atrium because the tissues there are conductive. However, electricity can't pass in. Dissolve the ventricle area because the kind of value between the atrium the ventricles is evidence insulated. You can't pass electricity through it as electricity is passed through the atria, the atrial contract. See a left around atria should contract at the same time, then the electricity. Then it goes into what's called the Atrioventricular node, or the 80 node, which is designed to basically funnel all the electricity into the ventricles. And the 89 puts on a slight delay to essentially stop your atria and ventricles contracting at the same time. Which is quite important because otherwise the blood would never go anywhere. Your the A V note then funnels electricity down the middle of the heart, the septum into the bundle of his and then two left and right bundles and then eventually into the back injury fibers, which allows the heart to kind of contract. And it contracts from Atria Sorry from Apex upwards, which is important because you want to basically make sure you're squeezing all of the blood out towards the aorta and towards the pulmonary vein, rather than just off into itself. So it contract from the atria up a fix up words. Um, this is of sore simplification of basically how control of the heart and BP, and that kind of thing works. So BP is uncalculated by looking at your cardiac alper times your systemic vascular resistance. Um so you're cardiac? Copper is essentially the amount of blood that your heart pumps out every minute or the volume of blood. And this could be calculated by the heart rate times a stroke volume. So the number of BPM, which is the heart rate times by the stroke volume, which is the amount of blood that the heart pump pump out in one company. So that's your kind of a cup. It's the amount of blood your heart can pump in one minute. How many have your systemic vascular resistance, which is essentially the resistance off your blood vessels in your body. So if your blood vessels have dilated, you reduce your systemic vascular resistance, and therefore your BP will reduce a swell because you're getting less blood back to the heart. Essentially, whereas if you constrict your, uh, vessels, your BP will go up on. We'll come back to this in terms of some pathophysiology. And if you have, like to look at shock, which is essentially the The reason for the circulation's off assessment. Existing and shock is very different. Medical drug is very different from that of emotional shock in which it's a life threatening circulatory failure, resulting in reduced organ perfusion, an end organ damage. That's a lot of kind of technical work words. I can break it up. It's a life threatening help. You could figure out amount. Hope you could figure that out. Basically, it's days. It's bad. It's dangerous. It can kill you. You've got a circulating failure. So something is stopping blood from reaching your tissues and specifically the end organs, which are organs which have a capillary network and these end organs. That's an example of some hair. So for something, your brain is what we call an end organ on. But if your brain doesn't get enough blood, you start to kind of get on a change in your mental status. And in order to assess this, you need to calculate a GCS on with patients who I have kind of worsening shot. You'd expect a reducing GCS now then you also have the kidneys. The kidneys are also take a lot of blood on the way. You'd be able to tell if they're not getting a blood is by looking at the urine output Onda. We'd expect a normal person to be making a half a mil of urine per kilo of their body weight per hour. And so for a normal person, let's say an 80 kg person would expect it to make it at least 40 million You're in an hour, Onda. However much that turns out to be in a day any less than that is like bad on. DWI can also look up some blood tests for the urea and creatinine, which are two things that the kidney normally excretes. But if the kidney is not working well enough that weren't excreting, so it will build up in the body and we can look for those to be built up on a blood test. The heart's also an end organ, so the heart doesn't just have it isn't just a pump, it also sends blood to itself. So if the blood count, if the heart constant blood to itself, you will start to get the death of the heart tissue. You might see this on an E C G, which will cover later on other tissues. For example, your muscle or your skin, or basically any organ in the body like a gut. When tissues don't get enough blood, they will resort to anaerobic respiration, which means respiration at or generating energy without using oxygen on. A byproduct of this is like eight, which we could measure on a blood gas or on a regular blood test on. But we'll cover. Gas is a little bit later. Onda lactate in itself is an acid is going to block the acid on, which can change the P hate off your blood. I met your blood a lot more acidic, which, if not compensated for, becomes a very bad thing because your enzymes in your body can't work with salt this low. PH. So then we leave on two types of shock. So what I'd like you to do is put in the comments kind of some types of shock that you can think off on. Then we'll talk through them as we go. It's a friend, if you when they pop up, if you can tell me. Yes, remind us. See, we got about 32nd delay, I think between speaking and anything popping out a way, a couple minutes, maybe that's almost seeing anything that yet. Um, think you've not got any? Maybe you could pick one. What do we pick a box? So I want to say a type of shock, Like a shock. Any chills? Hypovolemia. We can get 5000. So Hypovolemia shop is shock due to a low intravascular volume. So essentially you don't have enough blood in your blood vessels because it's gone elsewhere. It can go to lots of different places. It could go outside of the body, but we'll talk about bleeding a little later. They can also third space, which is essentially third. Spacing is tissue is the space that's around yourselves. And when this certain pathologies, your blood vessels, can become leaky on the fluid leaks into these spaces, which means you've got got left less to go back to your heart. So some big causes of this ah, things like burns. The burns. You can lose a hell of a lot of fluid. Diarrhea and vomiting, blood loss, urinary loss if you have certain conditions. Um, for example, diabetes insipidus, which is a condition where you whatever reason, you can't reabsorbed the water that you're excreting, um, potentially reduced in take over a long period of time. And so he didn't drink for a couple of days. You then start. It might start to get of hypo Very neck onda signs and symptoms. You kind of a pear dry. Um, but we'll cover kind of what that looks like. Later on, the treatment is give fluids, and again we'll cover fluids later. The buns themselves. Uh, pretty serious. Actually, a little about sunburn probably went to you much harm that even bigger. You can use a news a hell of a lot fluid very quickly that as a result, we need to replace that fluid. So we use a formula called apart from formula to calculate the amount of fluid we need to get. It's basically for males times the body weight in kilos times by the total body surface area off the done so 1% burn is roughly kind of the head size of the patients hand on bats. The amount of fluids that we will give in the 1st 24 hours. So and we also then give half of that fluid in the first eight hours on half of that fluid in the, uh next 16 hours. So if a patient has a 23% full thickness burns, which is almost like a quarter of their body covered in full thickness buttons and they weigh 75 kg, you're gonna be giving them almost seven liters of fluid in 24 hours. Know a normal person normally needs to liters, maybe 2.5, so you can see we're giving them a hell of a lot of extra fluid and liver of warning because there's some sort of grit in photos coming up. So maybe close your eyes for five minutes if you don't like them, so the different types of burns we can kind of. Dave, you have things that come up in an ongoing about Why not. So this is a second degree done, which is a super have a superficial but part of fitness bun on. You get these blisters classically in it. You have full thickness burns, which are pretty horrific on looking. Love it like this in your areas of black tissue. They might not be painful because you've actually destroyed the, um, the nerves that but you can also then get areas off partial thickness. But then also superficial burn around the full thickness bunch on that, pretty serious. And then you've got your sick visual bones because they come from the wrong lot of some reason and which are just kind of your red hearts burns, but no blistering, which they don't need extra fluids. Buy that formula. However, if you look at this person, you can appreciate that the whole of the tops of their arms around their neck, uh, bread on. But so this is gonna be quite kind of a decent done on. If someone does have a burn and you could have nearby, you confuse an app called the Mercy bones to essentially color in where the burners on a log what they have rather than sort of guessing with your hands. This is quite helpful. One to get if you are, for example, working in a pre hospital field or like an event first, ADA, it'll give you a good idea. If how about this patient's burns are on, it means that you can hand over to the emergency services got a lot quicker. Um, and then it has a major hemorrhage. Um, being that, lay off or just click through this. But people completed into lots of different places on one of those being the floor. If he phoned 999 and said, you have bleeding, you've probably got at 999 ambulance for this for some reason. Um, but then a small is breeding out onto the floor. You can believe in four other places. So you've got the chest on the abdomen, the long bones on the pelvis, the patient's consensually lose their entire blood volume into any one of these places on which is important to kind of have a good little is anyone left any comments or any types of shock? You know, someone has added so a top of hyperbole mixture, Was that done? They've added anaphylactic and septic well, so we can get an aflac to conceptive next. So, Alice, electric shock is a essentially another type of shock, which is caused by exposure to some sort of allergen on. This could be, for example, and not a bee sting. Um, I have a food, it's a medication. Could be anything really on. What you get is the's antibodies that produced against this. Um, this kind of think that you've ingested well then exposed to on these antibodies can cause that the release of histamine, which is a substance your body uses to kind of flare up for your inflammatory system and get ready to fight something that it doesn't particularly like. And you get these classic kind of signs off this urticarial rash, which this child has, so they're soft raised red rash. Um, you can also then get short of breath. You can get a week or other signs of our obstruction. For example, if it affects the mouth and tongue on kind of the tissues of the back of the mouth, you can start to get anyway swelling, and you could see how quite quickly this could become a massive emergency and this child's airway could collapse. So the treatment for this is given adrenaline, Um, or if you're American epinephrine, basically the second you suspect that on most patients who experienced this carry an auto injector with thumb on, it says on the side of the water, injected basically how to use it on do it's injected basically into the outer thigh and follow the instructions on the package. And don't put your thumb over. The top is the classic is basically all you need to know that if they think if you think someone's having this and they have their own auto injector, give it and then call ambulance, Um, I'm not probably need another dose or make your third dose. And if we look at kind of dark of physics equations from earlier, you can see how this is how and flex is going to affect the BP. So in our practice, you can get dilation off the blood vessels in the kind of arms and legs. So you got a decreased us, you know, resistance on bureau. So get an increased heart rate trying compensate for that. However, it will be a comfort compensate enough on. But you will get kind of a low bp. Um, then going on to septic shock absorber mentioned, um, sepsis have a has a lovely definition which I some reason have memorized, which is a life threatening organ dysfunction secondary to a dysregulated immune response to infection, which is actually means that you get an infection. It gets quite severe on your body. Suddenly saw. Forget sort of fighting. There isn't a massive overdrive, and in doing going through the overdrive, it starts to shut down some of your organs. And there's some stages off it that this definition isn't used to much now. But you can use this the's kind of definitions on the page to just the severity of it. Do you have a severe inflammatory response syndrome? Where, which is where you could have got two of the's OBs changes so either heart rate greater than 90 a temperature greater than 30 and less than 36 a respirator greater than 20 what or a white cell count greater than 12 or less than four? And that's kind of says then. Sepsis is when you have certain plus a source of infection, and then severe sepsis is when this infection gets really bad. So you drop your BP or your tissues start to kind of go into this anaerobic respiration of making lactic acid and septic shock is when you have severe sepsis and hypertension, despite giving fluids, and this can ultimately progress into multi organ luncheon syndrome, which is where you get multi multiple organs. Failing on do the best thing. Best way to kind of treat sepsis initially is to suspect it. There's a couple ways you can do that. So in the hospital we use, I think of the new school quite frequently, which is a way of turning patients obs into a semi arbitrary number. I am, which is essentially kind of determines how sick they are. It goes from zero up to solve 20 ish. I'm and is entry anyone above a certain level. Use a review by certain person. For example, anyone above the one should probably be escalated from the hate CF for a nurse, anyone about 44 to go to a doctor. Anyone of of an eight needs to go to like a senior doctor because they could be probably quite sick on. We'll get you to calculate this a little bit later in the quiz. Another way we can suspect it is by looking at the Q. So for school, which is a much more much graft smaller school, which incorporates the ultimate of state high respirator and a low BP, that infection has two or more of those that considered high risk for sepsis, so that just when he's we can kind of look and see how it risk patient is of sepsis. Of course, there's multiple other causes off kind of these derangements. However. What we important thing to do is to be able to think whether someone has sepsis and gift, um, good IV antibiotics as quickly as possible to someone developed what's called the sepsis six, which is supposedly six things that you need to do. Um, in the first hour of thinking about sepsis, Um, which could be a sickly give the patient the best chances. So these are to give high school oxygen. However, you'd probably only give this if the patient was high Proxicom or really and well, you want to take blood cultures, and you can also then measure a lactate at the same time. Um, you then want Teo. Give IV antibiotics as quickly as you can, but after the blood cultures, you don't want to give some fluids on measure the urine output that you're such a six. Any other causes of shock, then you can think off pounds and anymore being shared yet. Let's give it a minute. I'm just in case anyone does come up with one of the last two saying that to you left. Okay, um, thank you. The same. Wanted to mention also you just showed earlier if he wants Oh, sunburn. Oh, uh, just any any mild first degree. You know, peripheral, superficial bugs. Um, still cool them down because that's how you see people smothering them in and after some, and actually that's really most arising them. But it's actually not taking the heat out. And so they're going to continue to get worse burning. Um, that's his advice. A general people, when they get some burnt, is to a cold, cold shower cold. Bart's another school it off. Someone's come out with a cardiogenic for you. Uh, in which case we'll discuss cardiogenic while you were discussing it. Everyone think about one of the five might be so cardio cardiogenic shock. Um, kind of closing the name really cardio is that the shock is originating from the heart and essentially the heart stopping pumping properly. This could be you took out of things, so it could be due to a cardiomyopathy which is basically just a problem with the muscle of the heart. So, um, for example, in things like hypertrophic obstructive cardiomyopathy, which is a condition that young affect people think that on your heart becomes so big that you physically can't push blood part three parts of it because it becomes blocked by itself on diffuse. Can't push blood out of the heart. Then you're going to go into shock on, but you're probably gonna die pretty quickly. The second one is an arrhythmia. So if your heart's going to slow, if you think about this diagram above, if your heart was decreasing and they would get to a point where you can't increase your strength volume or your systemic vascular resistance enough to have to compensate for the BP drop so your BP is going to decrease. But at the same time, if your heart rate really increases, then, um, there won't be enough time for the blood to fill the ventricles before they contract. So your stroke volume will massively decrease, and as a result, your BP will decrease Onda size and symptoms of That's very much the same as all of the others. However, if the shock effects the left side of the heart. You can start to get a build up of fluid in the lungs like a pulmonary DMSO. Patients might present sort of really short of breath with a cough, um, kind of unable to lie down because they'll be so breathless. Um, and the best investigation instigations for these are kind of an e c g an echo to look at the structure of the heart. Another one is kind of mechanical issues. So for patient has heart failure, for example, on the heart physically isn't able to pump enough. Let's, then that would also cause a shock eventually and classically. The treatment for this is to get some of that fluid off thumb. So you give a diuretic, for example, frusemide, which is works to just basically get rid of fluids, um, and then treat the course. So if they have an arrhythmia, you want to either slow the heart down, will speed it up, put it back into the right rhythm. Um, if it's a cardiomyopathy, not too much, you can do about that, to be fair. And if it's something like a heart failure, you can start to treat the heart failure and in the meantime, you can give them if they require, you can send them to I t a and give thumb. Vasopressin is and I know trip which healthy basically help the heart pump a bit more strongly, never quicker if you need it on. But if it's really, really severe and I do, you can't fix it. Then you can consider something called extracorporeal membrane oxygenation, or ecg know which essentially is taking the blood out the body and using a machine to oxygenate and pump it around the body, which is a short term, basically, while you just wait for a transplant. Oh, and then the last one has anyone thought what it is yet? I have seen no post regarding it. It's the one that ever on the list or gets Yes, yes. Well, yeah. Um, now this one's got such a far any guesses from usually Urogenic. Yeah. So your injection last one, which is basically a caused by a spinal cord injury. So from the spinal cord, you have the normal notes, that kind of do sensation and Motorola Ramesh that you also have your nerves which, um, control your parasympathetic and your sympathetic nervous system's your fighter flight on Resting Digest and your sympathetic ones come out of sort of change. Um, from the spinal cord kind of quite high up. And if these are damaged us entirely lose your sympathetic drive to below this injury. So if you get an injury above t six, which is the six thoracic vertebrae, you've got some Michael the top thoracic in the middle lumber the bottom and then below that sacred and coccyx. But your sick thoracic vertebra. If you get injured above that, you will damage this sympathetic chain. And this means that the parasympathetic nervous system is basically out of control and unopposed and your on some lower body. So your blood vessels were massively dilated because that's kind of what the person for that it never system does. It wants to just sort of chill out so you'll get rather than the rest of them. We could be a a patient with kind of pale skin shut down. They will be boiling. Call Onda have warm pink perfused skin. However, that BP will be three. The floor on their heart rate will be three. The floor as well. Um, so you can kind of see by this diagram, your systemic vascular resistance will decrease because you're dilating blood vessels on. As a result, your BP will decrease because you can't increase your heart rate to compensate, because the heart's also under sympathetic parasympathetic control. If you don't have a sympathetic drive to your heart, it's going to slow down. Um, a missile generally occur kind of within 24 hours off a spinal cord injury, and it can last a couple of weeks. So basically, this patient needs to be on I t. U. So that is, all of our shocks covered. We can go into the assessment of circulation. So a very easy thing to do on what's done on the ward's all the time and basically doesn't require a doctor is patients observations. There's lots more observations. You wouldn't do that heart rate and BP. But these are the two things that off of relevant in circulation. More than anything, your respiration. Your sets will come in your breathing so it become before this on your temperature will come in your exposure. Your blood glucose will come in disability, but these the ones that occur in You're circulation kind of section on day from the BP. Yes, that's helpful. But what's more helpful is a thing called the mean arterial pressure, which could be calculated by using kind of going to times the diastolic BP, which is the smaller number plus the sympathy, uh, the systolic BP, which is the bigger number, and you divide that by three. On that, I'll give you an idea of the mean arterial pressure, which is basically the average pressure throughout the cardiac cycle in your arteries on. But it's better because it could give you an idea of whether your tissues are gonna be able to be refused. So I mean, after a pressure of less than 60 is not sufficient to perfused your tissues. So if you look up this monitor, um, under the BP section, which is a top, there's in breakfast. There's the mean, a tear a pressure, and it has basically been calculated for you by the machine, and they help for a number to look up. You then need to examine the patient, so it as per kind of medical school tradition, you always need to start examining patient from the end of the bed, you don't just off go straight in there and look at the chest or the hands you stunt. You take a step back and you just look at the patient and coat. Does this patient look on? Well, do they look? Wow, What else can you tell? So for example, if they're pale, this might suggest they have anemia or they're really poorly. Perfusing so got really low BP. You can look at that breathing and how well that breathing, Um, and you also might be able to see kind of a dimas. So the swelling in parts of the body suggesting that fluid overloaded You think I want to look at hands and arms? There's a few different things you can look up here so you can check the temperature. So in Urogenic shop, that will be war. But in normal people, be one. But other types of struck that we cool. You contract the capillary refill time, which is done by squeezing the fingertip for five seconds and then letting go and seeing how long it takes for the color to come back, less than two seconds is normal. Anything more again, consider guest. There might be shocked or shut down. You can look at the skin target, which is demonstrated in this photo here, which, um, is essentially kind of whether your skin goes back. It's It's off being bouncy and plump, a normal when you squeeze it, which gives an idea of whether the patient might be dry and not have enough fluids on board. That's what is this. You can also feel the radio pulse yourself. Does it feel regular? Does it feel like a bounding? Does it feel kind of I'm thready on? Do you notice it? Then check the rate yourself because I've never trust the's machines. Always feel it yourself, then go up to the head neck. There's a couple things you can look at. You look in the mouth to see whether the patient has a drying mouth or not again. This could give you a good idea of whether the patient is dry or no, and you can also look at the drink v p, which is the jugular venous pressure on its be basically the pressure within the into Forget the words out. The daily one of the drug kind of big blood vessels that takes blood back from your brain on this gives an idea of self the fluid level in the body and the pressures in the right heart all about on. You can see this big vein on this patient's neck of a long hair. This is normally won't come up this high. It will only come up soft. Maybe here. So this is just this patient has loads of fluid on board The question. Sorry how you use Feliz Cap refill because some people's can be naturally much slower and others much lower than other. Sorry, and it is normal for them. Yeah, this is true. Some people classically look. They have cold hands and feet anyway, which is why you do a couple refill not only on the lens but also centrally. So basically, everyone's can't refill on. That chest should be less than two seconds, but some people might have a cat refill in their hands of a bit longer than that. It's just sort of a useful gauge for most things because it could give you an idea. And again, the country full of, like three seconds or four seconds. We don't really care about But if it's getting on to like 567 even more, with them pretty worried, and even in people when it might be a little bit prolonged on, that's normal for them. It's not gonna be like 10 seconds plate today, Um, but then we can also do a central one. And again if the central one is prolongs, we know that that probably quite sick. But most people central one is gonna be essentially normal. If that answered your question. No, I think I think that's the question. So that's a moving onto the chest. You want to have a listen to the heart, you listen to it. Before different areas. We were kind of going too much detail. But you can listen for the heart sounds. You can listen to see whether it's fast or slow with it. There's anything other, anything else funky going on. But that's just something you'd listen to. If you are trained to you, say, then you can look at the legs, which would give you an idea of whether the patient is fluid, overloaded or not. So in this patient, you can see they've got what's called pitting edema. It's got big, swollen legs. When you press on it, it stays in forms This pit for a little bit. We should just like that loads the fluid on board. So to summarize part of that, um, you can look at the fluid balance of a patient. Well, the fluid status of a patient by looking at things like that Mucous membranes. So their mouth looking at the skin. Tergesen. Whether it stays up after you pincher that cat refill time, they're obs uh, what they urine output is like. And then if they're overloaded, they'll have kind of extra fluid on board in the high JVP and you can plot the ends and outs on a fluid balance chart. We should give you a good idea of kind of whether the patient is retaining fluid or getting rid of too much fluid or if you're not giving them enough on. Often, patients that are sick will be on one of these. So then to investigate circulation, there's a couple different things we can do a so pretty much every patient where were worried about, um, we'll get a cannula, which is a little kind of thin tube that goes into the vein is introduced with a needle and then the needles taken out and basically means that we can give whatever we like through this, whether it be fluent drugs on gets it into the patient. Really, really quickly. Let the different sizes. I'm ranging from these 14 gauge cannulas, which is huge down to 24 gauge cannulas, which are absolutely tiny on a no, I've never really seen it. 17. I don't even know that that's on here. But on a normal ward, you classically use yourself pinks and blues which your much smaller ones. But occasionally your grains that pinks and blues, the ones that use most on you cannot remember the border of thumb and how big they are based on occur by this lovely diagram. So if you think of kind of a flower and what is the gray field? But run with that? You got the sun at the top. So the sun is yellow, which is the smallest cannula. You think a blue sky next, which is the next one is cannula. You've got pink flower, which is the next months and a green stem. Next, Wallace, you think that's a great which is your kind of second biggest and then love at the bottom, which is orange, which is your biggest cannula myself. Memory, if you want. And then when we put in a cannula, usually we'll take some blood from it. So all patients will get any PC, which looks at their red blood cells, the white cells on their plate that's using knees, which looks at their sodium and potassium levels on in the kidney function. And then the liver function tests, which looks at the liver. But then also in certain situations you'd want to give you want to take other bloods. So in Subsys, you want to take a CRP, which is essentially just a marker of inflammation. It's not a very good one, but it's a information marquis who's track sepsis. You can take a lactaid, which is of a marker of whether your organs of perfusing right on a swab. There some blood cultures to see if we can grow anything to find the source of infection in 100 surgical emergency. For for patients going to theater, you want to take check their calculation and how well they can clot there blood on. Do you want to cross much or group and safe. It's across. Much is basically saying this is a sample of the patient's blood. Get me a bag of blood now there isn't gonna kill them. Essentially, a group in safe is his and sample of the patient's blood. I might eat blood for them later. Could you figure out what blood type they are on day Keep their type on record, just in case Any double it time, that is. The main difference is you think that keep coronary syndrome or things that heart attacks to get pregnant, which is a marker of whether the heart is starting to die on up you then for arrhythmias. You want to look at the cause of the arrhythmia so you can check kind of different irons and then also, thyroid function tests is high. Hyperthyroidism can cause your kind of some a fast readiness if you think about her pa. So they're coming out with eso short of breath. What else? Yeah, shows breath. Chest pain came on suddenly just been a long haul flight and you think that might have a p who did donor, which is a marker of whether they're kind of got clot going on. If they you think they don't know that, I asked. You can get overdosed on your tox screen, a car seat to my levels, that kind of there and then for anaphylaxis. You do you think, or the must sell tryptase, which is just a fancy word for saying, Here's an enzyme that is found in one of the cells. It's responsive. Friend of plexus. You know so many CT, which is electrocardiogram. So it's a way of looking at the heart, heart, electricity and having a good idea of what's going on. I won't go into this too much today that you basically put a lot of dots on the patient's just on it is that one of these big kind of diagrams on Deacon Look at the heart in different orientations, based on where the says what kind of differently on leads are on, you can get an idea of, like the rate rhythm, how big their heart is, whether it's growing in certain directions. Um, with, uh, think what Sutton conduction problems in the heart, you know, good idea based on this, and then you also want to have a good kind of idea looking at the source of infection so you might not do some of these in the circulation stage. But it's things you'd make a note off to consider for later. So here's some blood culture bottles where you take blood, put it in these bottles and then send it off and the lab will tell you if anything's grown, and it'll also tell you what antibiotics you can give to kill up. You'll see what they want to have a look at any lines, the patient house. So if they've got a long 10 central line or something to look around the site of that to see if that could be giving them a lot of, in fact bacteria introducing it right into the bloodstream. If you think I might have a stool problem, you can take a stool sample. You can get a sputum sample, you know, to get a urine sample or did a lumbar puncture, which is what's going on here on which looks at the CSF so you can look for like, um, things like meningitis and Catholic Church is on there, and we also like you are a BDs um, sire, an ABG or VG like the gas is within the blood. ABG is arterial. DBT is venous. So one second for the arteries was taking from the veins. In one of these levels from Jewish you put into this machine it generates big report like this, which at some point you learn how to have assess that. You can tell from this one very quickly going through it. The patient has a alcott IQ blood, so their blood is alkaline because they've got too many bicarb irons going on on. So this is what we call a metabolic alkalosis. Um, the oxygen is fine so that lungs are working. Okay, we can then look and see that surgeons find the test is from the chlorine is find the calcium was fine. That lactate is fine, but the glucose is up, so they're either so post meal or they're they have some sort of diabetes. Most likely good idea of what's going on with the patient based on this, um, and you learn throughout medical school and stuff, too. Um, interpreter. But if you want a very quick assessment off your bones or your left eight, you could do a gas. You have to wait for the lab processes going to management and what we want to do for things. So if you think the patient and sepsis, you can start accepting six, which we talked about earlier. If they don't have a circulation, which is a bad thing, you're gonna have to start CPR. If you can't feel a pulse and the patients not breathing, you're going to start CPR to get fluids. If you think the patient might be dry or if their heart rate's a little bit high to try and bring that down so different types of fluids we can give you got sodium chloride, which is also known a saline, and you also have classic isn't like Hartmann's solution. I'm other fluids, such as of Keloids, which big molecules on glucose exist. But we don't really use those in the acute setting, but these we can give. Usually, Um, Bolus is in a second patient, so we would give maybe 500 mL over 15 minutes and then reassess the patient and see if that's done anything. If they have heart failure, you'd want Teo give them a little bit last you for 2 50. That's basically everything really, that's how to do circulation. So I'm going to want a couple of questions now. So we have a patient here who is put on a strict fluid balance shot by one of the juniors on the fluid balance shot is given. Here in Orange would like to do is see if you can calculate that fluid balance, and we'll give you like, a minute. Also, to do that kick in the left. The lack as a hint. It's your end's minus your outs. Freddie should let me know what. So this is we get it from getting any. You should put your warning slide up. There's gonna be maps involved. We haven't a so gets like in the thing else. Wants to pop up a job where people comment on these. I always just get the it says Anonymous, So I have no idea whether it's the same person's, answered every question so far, or if it's lots of different people. But it always pops up to me, saying, and none of us, um heaven A. I probably go with an A, but I I can only see the tiniest faith writing on my screen, so I'm having to, like, stare intently at it to see what the numbers actually are. Uh, we gotta be you gonna and to be. It's can tell you the answer. The answer is a one of those got right. So you want to add up all of the ends how much the patients had in and take away the amount they've sort of lost. Whether that be through your stool, urine, vomit, whatever. Um, so this patient has basically after this day, they have an extra 480 melon board. Where for that May you have gone question too. There's even more matter. Um, say you have a patient who presents unwell with the following observations. They don't have COPD. You could see if you can calculate the new school. So to give you a couple of hence, you can ignore this scale too. This sp a to scale too. That's scribble it out. You can ignore that and then you want to look at, um what the patient's obs are your heart rate restaurant sseps that that consciousness, the BP, the temperature Compare those two column and then add up the total of all of those columns and I have no actually work this out, so I'll do it as we go. Oh, Uh huh. So let's put know where they're gonna work this one out of Should've given a maths warning. I will warn you as an odd amount of maths and healthcare. It always appears the beauty, the absolute beauty with the news with news is that normally the computer system will just count will just tell you what it is. Um, so you take a patient, sobs, you put them on the computer in the patient's notes and it will just come up and tell you what there are. What? What it calculates to a new school that this light floor with that is that it calculates it based on the standard chart, it won't take into account if they've got COPD, which is the second scale that just crossed out. Who had to take into account, for example, if there maybe palliative. So they've always had, you know, they're coming to the end of their life, so they always a bit unwell. It won't take it for a count of fact that maybe they're in athletes, so they always got a very low heart rate or that there. You know, they've got some sort of condition with a very fast heart rate. They give you a very standard basic one. And you get very annoyed when the computer keeps buzzing at you telling you that you got to go see the patient. You've already sin who's actually fine. But they just got very high news. Um, but this one's well, you don't tend to have to calculate manually unless you're a student. They love to give these to students. Or if your hospital doesn't have a computer counting and you're taking, I think fairly standard now. Was that for room Ward side? Maybe not in any. That's what you are. A lot of London hospitals still have this feeling northward. Having done, they will still have paper even in the office. Machines tend to tell you now. Yeah, but anything. That's, um that's yeah. I've done a the couch, but everyone else says, uh, probably a good idea to talk through how the scoring works on this one. Yeah, well, they, uh I I came to a nine. Did you come to a nine? I didn't come to a nine. Well, if you come to the front to 13. Oh, they're on oxygen. You got patient. Let's look at that to that. Respiratory right is 24 which is in this category. So they get on. That's good. He's a 10. They get to you for that. Um, they're rests. Yep. So that's respirator have done that. That subs, uh, 91 today. Score three for that That are on oxygen. Stay score, too. For that, they are the blood systolic. BP is 94. They scored two for that. Their heart rate is 120. Do they score? There are a lot that you don't score any further and the temperature is 38 6. So they school one for that. You've got this wrong again. They have scored nothing's 12, actually. That's 12. Yeah, I missed their on oxygen and I, for some reason, decided 91 noted to with the same number and gave him a two for their BP. Um, but yeah, that someone else going eight. So obviously there is, like, an art to work in these out. Clearly, Diver Josh nor I have quite mastered either I quite literally have medical degree. Exactly. Think the art may be sort of overarching themes here. Is that this the guide? It's not a hard and fast set of rules. And actually, if you calculate that they're in eight or nine versus then being a 12 or 13, actually, your management's not changing. Massively, You've gone there greater than seven. I need someone to have a look at them pretty quick. Um, so I would say it doesn't necessarily matter too much when you're in the high numbers like that, but does matter little bit more on that sort of lower numbers. Yeah. And also, they say, like, if any patients, schools or three for anything that will save trick is a review. Um, because you could have an unresponsive patient with normal obs you then wouldn't trigger reviewed by doctor by this, Um, so anyone would like the three, neither of you. But again, patients could be normally sitting it like with a BP of sort of 80/50. A little old lady with that, and they'll be absolutely fine. Um, but technically, no school is not the best system, but it's the system. Okay. You got a 30 year old female. He presents the any with a collapse on further questioning, found out she had food poisoning recently. Severe diarrhea. On examination. She has a promoted cut refill time. A high heart rate, a low BP but cool peripheries drive because memories and there's unwell. What's the most likely diagnosis here is no months in this one, I think should but diagnosis of avoid that carry house or whatever it was that caused it. But I think hurry has, Alicia said, carry houses. But they're very then don't not causing food poisoning very commonly on the way. The facts. I know, I guess it's just cooked a years and it's that it's highly stewed a lot of the time from occurring House on D eso I mean main perpetrator of all food products to cause food poisoning is chicken. So if you get that encourage, we also get lab and actually tends to be like fried chicken is worse because you don't cook it for long. If you could get like, crispy batter and know anything else, you have a hypovolemia as an answer here, uh, from an h Hello? Eight. Uh on. And that cereal thus far. So Welchol ballroom. It up on 100% of people Got that right. Very good. A fairly effective teaching. So this patient has essentially a lost a lot of fluid with this diarrhea, and now they're on. Well, under last question. So you've got 56 year old patient who presents with palpitations and chest pain. They a pair unwell on that pale and house? Um, difficulty breathing. The registrar's suggest is that they have cardiogenic shock. What's the most most important? Next step? I'm going to give you a clear head and did this. My question is, why is the registrar viewing this patient so early? What's coming up? We'll sorry all the rest of this hospital. Think Hunt that. That will be brownies in the room next door. Alright. Yes, yes. Everyone shows up for the sweets. Um, to detail. Okay. Um, muted. There is. I was reading the story. They say you've been Yeah, little bit means this is quite mean. It is. Quite. You love this for your questions. Don't you do like, a trick question? Yeah. Is ultimately all of these things. You want to do it at some point? Just what are you going to do first? this is quite common. Medicals Love it this way. They love to give you fall right on five right answers, and you just got to figure out which one is the first right answer. But you'll have things like What's the most important next step? What is the what is the most or what is the diagnostic A gold standard or best investigation today on that two completely different things? Usually, yeah, and that's always You could have many right answers in medicine, but they're for multiple choices like this. They love love to give you something difficult. Uh, we have a son has said, see, and then maybe be. But it's not. Yes, they are quite difficult to no, no treatment at the these air complicated everywhere, like a lot of academic institutions. A little love to catch you out. And that's all. The horror of the multiple choice question is that you get to pick one and you don't get to explain your rationale. Where have you got to write out an ulcer? Like if this was like a in 50 words, explain your management plan. Well, you could say, actually, you're going to do all of these and you go to in this order because of this reason? Yeah, on probably get full marks. But if you're going to go choice of which one you could do absolutely next and you forget one little factor or something. You know any books? Um, so, yeah, See? And then maybe be used with this person has gone for I reckon I'm going to end up going for a D because it's a new patient, you know, Correct answer. This's just highlighting that on you. Whenever you have a new patient, you should start under your full primary survey, which starts with assessing the airway. Doesn't matter what's going on with the circulation unless they're actively hemorrhaging all of that blood on the floor, you go straight to the airway. Assess that because guaranteed and early obstruction will kill them before whatever is going on here will kill them. So you want to prove that they don't have that move onto breathing? Is there any problem with that breathing? Because again, if they have a room with everything fell, killed them before this, and then you discuss this so generally in this situation you would assess the airway. You then probably listen to the heart you want to examine before you investigate. You gonna do any CT? Um, and then, uh, once that stabilized, you didn't take your history for being that order. Yeah, that was tricky and complicated, but for a reason. So thanks for listening. That was circulation in about an hour or so. Hopefully it was semi informative. And you come in quite a bit, actually thinking any questions at all? Yes. They always going questions. Please do. Popular shot. I have shared the feedback form in the chat as well. Keep it to go early. As always. We do really appreciate your feedback. Um, cold, you know, just put some sort of screen on second. Yes, we do really appreciate feedback. Your feedback is really good for us in order to figure out how we're gonna improve and continue to be. Yeah, better. And make sure that we're actually delivering things to you that I work delivering and not just yelling at the wall. Um, So please do ask questions and pleased to give feedback so that we can make everything better for you. That let me share a screen. Just so that's something pretty honest. on this story. Nose. It looks a bit weird. Uh, you have no questions, but thanks for the talk that Josh. Um, like I said at the beginning, if anyone does come up with questions later, are there particular bits about this you wanna ask about? Please do feel free to email. We can give you lots of lots of resources with medical. Just started. Well, just and I'm not even really a medical student, he's like a a finished medical students, but source of almost half, Doctor. Yeah, well, actually, actually, the slider have describe your existence. Is this Sorry? It's the only photo I had that I could find, if you know, is crap. Just more difficult to find photos off? Yeah, doctor ish. Josh, we are very good at finding resource about all sorts of weird niche things medicine, because that is largely what we do for our like lives. So please do ask questions if you cough, it's you want to ask about. Yeah. I'm not seeing any more queer, is there? Which case? I think we'll give it. I'll give you another 40 seconds. 30 seconds sort of thing, because anymore. Oh, okay. Yeah. How to maintain effective arterial blood volume in shock. Hello. I mean, it depends on the type of shock, like some of the shocks you will have. I get enough volume, um, but basically, initially, give him fluids. Um, if they're bleeding, give them blood because it's best to replace the blood with blood. Ultimately, give him fluids on day treat, any causes. So if they have anaphylaxis and all of that fluid is going into their tissues, treat that flax is in the blood, and the fluid should kind of go back again, but also then get fluids. Eso they have enough fluid in their secondary system. You have to pump If it's a heart problem, or if that hasn't worked, you can then give, uh, drugs to kind of control the heart. So vasopressin is on on the trips that just help the heart pump either more strongly or in a better rhythm or quicker or anything like that. They just sort of helps and then treat the cause, and it should all hopefully sort itself up. Yeah. Um, and then anything really to add to that is just if they're empty, fill them up. Basically, it's the simple procedure in anything with shock is if it's because they leaked a left fluid out over in blood vomiting, swept even like people have. You have been in like a marathon runners things that this concludes a lot of fluid in their sweat. I just refilled them is the simplest first bit, and that could be fruit drinking water, but obviously takes a while to get into the system, to be intravenous of I rub needle into a vein. It could be intraosseous. That's needle into the bone. Not for the faint hearted, um, and talking back up, but it's just said also blood. Best thing to replace blood is blood specimen to place like fluid losses in sweat is not the water. Um, you sort of want to replace, like for like if it's no other questions, call it their feet. That's quite nice. Want to finish on? Um, and then I'm coming back in two weeks. I think I believe you. I believe Josh is running our clinical cases session in on the 12th. I just didn't get confirmation from our speaker for the 26. I just don't know what his final exam is, cause I forgot to tell me and I've gotten so thank you, everyone for tendency Evening. We'll call it there. Thank you very much for very involved. Very good session. Um, see you again on the 12. Um, until then, everyone take care. Thank you for coming along tonight. Goodbye.