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Yeah. Um ok, so guys we're going to move on to emergency now, bronchitis. So um I share my screen. Yeah, so share your screen, please give me a second. Oh, is that what? Yeah, you can see my screen, right? Yeah, I can see your screen. Can someone chat, chat? Tell me. Um I also guys if if if it does for you just please let me know straight away. Can you actually check? Can you see my slides moving? Uh Yeah. Uh Can you can you see your slides moving? Yeah, every everyone is fine. Ok, I'll start. Then we also wait. Let me just check. Can you see my laser point? And just, I just want to double check. I can see it. Can you guys see the? Uh Yes, we can. Ok, I'll stop. Hi, I am Barney. I'm a 14 month student. I am right now. My BSE course I'm doing cancer frontiers. I am one of the crash codes. I'm one of the phase one B crash code leads with Ashraf. So if you have any questions about the resources stuff, please message one of us or message one of us and we'll let you know, and all the slides and the content will be released after this session is done. So we are doing emergency for Bill and I put a picture in the hospital. This is the a and you went to unfortunately for him. But yeah, so the learning objective here, this one should be pretty short because my ca my case compared to the first one, there's, there's more rote learning, but I'm going to try and explain it. So it makes it easier for you to rot, learn. So we're gonna go through the surgical which you've already had a little brief um discussion on. Then we're gonna go through the A A three assessment. I'm just gonna give you what I think is a point from the A three assessment. Then you used to, you've already done this in year one, but I feel like it's good to have a refresher and the different types of stroke. This links to your cardio. You, you would have done it in year one. You would have done it again. Sepsis. I'm gonna tell you a bit about how to classify the different types of sepsis. Then I'm gonna tell you how to manage sepsis, an abdominal pain. This one will link to anatomy. I believe you're gonna start a abnormal anatomy soon. I believe you're doing some kidney. This will just be a little brief taste of it and then binding diverticular disease. I try to make this as simple as you can. It's just telling you the different types of diverticular disease and what you can manage them. Basically. Because for your level, you don't need to know the different antibiotics. You just need to know the different types and what they are, what they're called and how you manage them. Simply. So on the surgical, you've already had it meaning spa. So I'm just gonna try and skim through these slides. But how I remember the surgical is an iron to help you remember different causes for me, I personally don't need for the abdomen. I don't use it. What I use is like let, let me if, if they have the pain in the right upper quadrant or on the right top of the abdomen, I think what organs are there. So for that one, it would be like your liver, your gallbladder, your stomach, your, it's more in. And I think ok, what's with that? But for some people, I know if your, if your me a consultant were on the last, what's the cause of this? So the surgery of I picked was the one they had in their slides. Vitamin CDF vascular could be, stroke could be ti infective inflammatory, different ones have different things. So infection could just be like E coli es R salmonella in T could be your IVD tr obviously, if they are like a stab, if they fall down the stairs, autoimmune could be like autoimmune also does link back to inflammatory but autoimmune could be Crohn's Crohn's disease could be autoimmune encephalitis metabolic. This could be metabolic could be like diabetes. Cushing's idiopathic, sometimes idiopathic is what we call as doctors but sometimes different surgeries. Different treatments can make the patient better or worse, neoplasm cancer, congenital. These are like down syndrome, dually muscular dystrophy. This could be like gliobastoma like this could be like these are just conditions which are in the family, degenerative motor neuron disease MS environment. This could be substance misuse, smoking, alcohol, intoxication, functional I functional, I see functional like more like neurological like dementia. But different people have different things. What I want you to know from this slide is that a surgical and iron helps you remember different causes and you can use whatever you want. You don't even have to use it just be aware what a surgical is. And this is an example slide. You don't need to know any of these causes. This is an example s of bill sar. So Bill came in with a loss of loss of consciousness. So vas it could be stroke, ti inflammatory infection could be meningitis, diverticulitis, which is the main thing of this case, head injury, abdominal injury or a autoimmune encephalitis metabolic is diabetic use as a HSS. You don't need to know any of this. Now this is just giving you an example of what it's been used. Apply it, it gives you an example of this being applied to Bill I which is shock N which is um cancer or brain cancer, colorectal cancer C. This is just a random condition. I found that gives you lots of confidence you don't need to know these. This is just an example, the motor neuron disease, e alcohol abuse, drug overdose and epilepsy. So, from what these two studies, what I want you to know is that the subjective is something that could help you stratify different causes for like a symptom, like loss of consciousness, chest pain. But for your CSI, you just need to be a war room. Then finally, this is one I took from last year slide. This is just a abdominal surgical sip. This does look quite confusing. But let me explain. So the cell line here in yellow is basically, it's a different disease. It's so a vascular cell that could be lower. Gi gastrotest is your whole gastrotest. H BB is your liver, your pancreas, your gall bladder renal, that's obvious your livers, your renal, that's obvious your kidneys reproductive, that's like a reproductive organ. This is as an example, surgical slip again. You don't need to remember this. This is just to give you an example of how the surgical slip got from from this section. Why you want, you know, is a surgical slip is a way to help you stratify and find different causes. And it's what we use for more round before your CSI. Just be aware of it now onto the first question, I'm going to read it out. Um, how I done the question is a bit different to the previous lecture. I'm gonna give you the question first and if you don't know the answer, that's ok because I'm gonna explain it to you and you should know by the end of the section. But this is just try to test you out to see what, you know. So I'm gonna read the question. You're a medical student on placement in your local A&E department. The busy F one has asked you for help. They've asked you to find a G CS score on Willow and G CS is something which you should, it's something you have to wrote them, but it's something I've got in my CS and I know other second, other third years who did second year last year did get a G CS question. Willow was sleeping and only opens her eyes when he said hello to her. When you start talking to her, she responds with muffle noises that are not coherent words. You asked her to raise her hand and she does not respond. You apply slight pain for pressure on both sides of the shoulder, on the right hand, she can localize the pain. How on the left hand side, she does not move. Can you calculate D CS score? So if we could put it in the pole, if you have any questions, put it in the chart and, and these are your five options be, be pay special attention to what the ETV. Um this is just the score they've got in the eyes, the score they got in the voice, the score they got on the motor. Because what um ideally you, you have to be quite specific because if some things get trickier, you might work at the school but you might put the wrong options here. Let me know what they say and I'll tell you the answer at the end of this section. Any responses. Uh we've got one so far. Ok. It's uh two, two. Ok. Fine, fine, fine. We'll wait, we'll wait a couple of seconds. So whether there's enough responses and if you don't know this just gas, that's, that's always the best idea. Ok. Uh We've got 50% saying four yeah, 55% number and 11% saying 3 22% saying two and 18% same 10, that's good. That's a range. I expected a range because most of the answers say 10 and one says 11. But yeah. Ok, I'll tell you the answer at the end. So let's go over the A three assessment. So I know you've got like this PDF which gives you a lot of detail. I just took the main points I thought were important. But again, they could only ask you one question like what's the first thing? And what do you do? Airway breathing circulation? Which one are you doing? But I'll give you some tips. The first one for airway, if their G CS is under eight before you do anything, you have to intubate. That's something. This is just a fact. If the G CS is under eight, you intubate. Next you check if the airways is scar, how you do this, you just open that jaw and look at the airway, then you're here for breathing. So this isn't related to B LS. So snoring could be like they have OSA or they're just sleeping. It does happen a lot where patients just don't respond. They just in deep sleep, strid, it could be, they have an obstruction. Wheeze could be due co PD asthma and no breath. They're not breathing and check for Pa and Cynos pall is when they look pale and Cynos if they've got like Plu Ns. So over for assessment. Basically, you just wanna see if their area is clear if they're breathing. And if they've got adhes under eight, you need to be action, airway opening maneuvers. You've already done this in B LS, but it could be head tilt, chin lift or jaw thst suction. Now, this is quite obvious, but don't use your fingers, use a suction. I know this is an obvious thing, but in practice, you don't use your fingers, use suction intubate is basically they have a G CS underrate you intubate finally, on the um the breather on oxygen. We always, if they're in an 83 scenario, you always give them 15 L high f oxygen. Even if you know the oxygen shots are good, you still give them high f oxygen because you wanna make sure they have enough oxygen over. From what I want you to know from the slide is an assessment. You check if the airways clear here for their breathing and action, you make to try to clear the air way. If you can't, then you suction. And also if you think their GSS is under eight, you intubate them and you give them high oxygen. Now on your breathing, this is a bit more but this is like a Respi exam. You do, you look at the oxygen saturations, you do this. So you're looking through a probe. Yeah, respirate. So in practice, what you do respirate is you feel their pulse. Whereas if you tell someone that I'm gonna check their breathing and they'll stop breathing. Like if you, if someone says if someone tells you to like if someone says they go look at your breathing, you'll automatically be conscious. So you check their pulse so that they're not conscious, you ask them if they could talk or not. And now this is quite obvious, but if a patient is talking, you're pretty, you're pretty happy. You're like, OK, they're not immediately dying. You're like, OK, this is fine. Again, check for the sinus and the sweating, feel for chest sme starts in like your rest exam where you basically just grip around their chest to see if they're breathing properly, you feel for the trachea. So what that means is you get your three fingers like this and you just put it on your trach, you put it near your windpipe and you see if it is deviated. Now, if it is deviated, this is something you don't need to know. But I'll tell you anyway. So if it's deviated, like towards where you think the lung issue is, this could be a pneumectomy. This could be due to upper low collapsed fibrosis. You don't need to know this, but this is just act which will be helpful in your CPA. If it's deviated away from the b the lung, you think it's deviated away from the bad lung, this could be due to pneumothorax, co PD. And if I do Picassa listen to your chest, Picassa is basically just t out the chest like this and then listen to the chest, you just listen to a you through a pe. So problem with ses is basically you're just doing a Respi exam. If you think you're doing a Respi exam on a patient, I, if you think they have anaphylaxis, you give them I am. And if you think I and you have a chest strain, always burst. Important thing on this slide. You wanna keep the oxygen above 94%. Now, I know some of you will say well, but if there are carbon dogs that re re retainer, the answer is when you're in your A three E asessment, you don't have the time to know if their carbon dogs are retained on, you give them the 100% oxygen and once they're stabilized, you give them, you, you change the oxygen down and finally you intubate and in there if you think they can breathe. So on this slide, remember, an assessment is pretty much a re exam depend if they have anaphylaxis, you give iron adrenaline. If you think they have a pneumothorax, you give a chest strain or need to do compression depending on what type of pneumothorax. Oxygens have to always be over 90% and then you pay ventilate if you need to. If you have any questions, please put in the chart. But I think I'm trying to make it as simple as it can. Next we go on to circulation, circulation. This is cardiovascular exam. That's quite obvious. So you look at the cap refill time. There is a question that I remember my year that said my CSI was like they had a question was like, what's the, how many seconds do you hold on? Like the nail and how many seconds is under normal? So you hold the nail for five seconds and if it and cap for type under two seconds is normal, then you measure the heart rate for this one. You can't really control your pulse because you, so you can just tell them I'm measuring your pulse and you do an E CG, you look at the pulses around the body. You check their B EP and you just listen to the heart like a cardiovascular exam. Now with actions, if their BPS low, you give them IV flus to a cannula, you take blood and that's it. So for circulation, just me men remember cap refill time, you hold their nail down for five seconds like this 12345. Then you look at the um you, you can't for the two seconds to see if your refills, you check the heart rate. You do a three lead CG, you palpate the peripheral central pulses, you do their BP then onto disability. Now, disability is basically the first thing you need to do is check their blood glucose because as some people do, they say ABCD E FG, ABCD E FG. Don't ever forget the bloods because I know it's my son obvious. But a patient coming with an MRI could that could just be due to low glucose. Low oxygen. A patient coming with like a stroke could be due to low glucose, oxygen. That's always something you check the glucose, you check the temperature, you do A G CS, you check for pain and you see if there's any reversible causes to their reduced consciousness. So like low oxygen, low glucose if overdosed on opioids, action depends on what you find. So they have a low glucose, you give them IV glucose. If they're in pain, you give them painkillers straight away. And if you meet a patient, they're able to viral with you. And if they're in pain, you give them painkillers. So it's better for them. And if you have any issues you treat. So, from this slide, don't ever forget the blood glucose. That's the main thing now onto the G CS. So here's a little table now, I'm, I'm gonna give you like a pneumonic to help you remember it in the next slide, but I'll explain it. So for eyes, you have four points, spontaneous means when, when you come to the eyes are open speech, mean if you say hello, they open their eyes pain as you press on them like this really hard. That's when they open their eyes and no response, there's no response, verbal orientated. So they're like they could do a good conversation. They're not confused, confused. It would be like they don't know where they are, but they could still make a conversation in appropriate words. You ask them how the day is and they say something, they say something like they say a swear word, they say somethings sexual or something, they say something inappropriate to the comp they, they start laughing at you. It's like they, it's, it's bad incompetent with the sound test if it's like muffled and no response to nothing or with G CS, you can never get a score of zero. It's always to be and best mot a base. So if you ask them to tap their hands, they cap their hands like this, move to localized space. So if they press here, they're able to point and move your hand away. Flexion. If they bend forward, extend, no, a texture is withdrawal for pain. So they move away from the pain and a normal suture. If they bend their arms like this extend, they extend their arms fully out like this and then no response. Nothing. So I'm just like why I want you to know is you can never get a zero on the G CS. The minimum is three. He's I just remember that each sections dex is GC S3 to 8, severe brain injury. 9 to 12 is moderate and 12 to 15 is a mild brain injury. This is a rare lining sl most of my, this section is quite rare lady, but I thought I'd explain it to you now on to how I know the um how I remember the GC. So I like to use the eye or bed and voice. So let's talk the eyes ie for eyes are shut, no eye movement. Y you like a uh like a pricking object for pain. Ea pacing noise for e eyes, opener, noise and s spontaneous. So eyes for the eyes one then you have a voice. So voice V voiceless. Oh s so obscure. Sounds like muffle noises. I if inappropriate, see if I could use it. If, if elegant, it's a voice. And finally, old man. So you got obey localized, throw away, obey, they cut the highway, your protect localized, they're able to point the area, draw away. They move away from you bend flection, E extension and me response. Uh One last thing I want to mention when you're doing G CS, you wanna take the best score possible, let's say on the right hand side, they obey you on the left hand side and they do nothing. You're gonna take the best response for the right hand side legs. What eyes shut, one eye is open all the time. One eye shut, you take the best response for voice. Obviously, you take the best response. Now going on to exposure, this is just from your side. You're basically you've done to you 8080 deep. You're happy with the patient. They're all OK. Now I gave you a history. You look at their notes, you look at the lab results, you figure out what's going. So from the at assessment, I just want you to know what each step involves. I want you to remember. Don't ever forget the blood glucose and how to do your G CS score. So onto this question, the answer was for the reason why it was for, I'll explain to her first question is she was sleeping and only opened her eyes when you said hello. So that's already a three in the G CS score. Next, when she was talking to you, she had muffled noise about coherent words. So this is not voiceless but she goes. So that's a two. When you ask her to raise her hand, she doesn't respond. So it can't be a six. But on the right hand side, she can localize a pain. That's a five. On the left hand side, she can't move. And, but as I said before you pick their best response. So it's optional. If you have any questions, you can put them on chat. We're now going to our second question. You've got some questions in the, in the chat. Ok. You've got, uh, someone asking, what do you mean by anaphylaxis? I am, you know? Ok. So anaphylaxis is when someone has like allergic reaction. So, you know, people can be allergic to peanuts or something. So if someone eats something like peanuts or they're allergic to like fish, they eat it and they go into like this allergic reaction like, um, type one hypersensitivity. If you know from pom and they, they, they start swelling up, they can't breathe. And if someone has this, you just give them adrenaline. This was just an example in the, um, in the prereading you had, I think I, but it's basically, it's an example. They, they won't give it to you. Most likely they, it's just something for you to know, cos I answer the question, you would have learned to imp like type one hypertensity. It's an allergic reaction. Basically. That's all you need to know right now. And the next one is, can I ask when you give high flu oxygen? Even if the oxygen saturations are good? Ok. So when you're doing an A two E, you'll give it straight and any airway you give it and then one, then once you get your breathing, you'll check the oxygen. If the oxygen is 99 100 or above, if the oxygen is above 94 you'll stop it. But when you're at airway, you don't know what the oxygen is now in real life, you, you'll be doing all of this at the same time. You have different members of the team before an exam question. You would say you give the high for oxygen first, then check the oxygen sets and then you can turn it off. That's it. So in real life, you will know the oxygen side. But if an exam question in oxygen will go under the airway. Any other questions? If not, we're going to our next question. Is that fine? Uh Yes, we can do one. Ok. So next one, this one, I don't want you to be looking up any like news two things because in your CSI, I'm pretty sure you're not allowed to get your ipads out. It's only in the ta No, it's only in the T app I think. Is that right? I'm pretty sure that's right. I think so. Again, you're a medical student on placement in your local in A&E you're still in Hillingdon and everyone has asked for your help. They've asked for you to pull a news to score. And well, so here are his findings here. And can you please tell me the news to score and the frequency of patient monitoring and in your CSI, you will not have the youtube chart on you. So you have to do this for memory. So I will give you guys 30 seconds to a minute and let me know what responses come and try and remember the frequency of wondering when you get the score because you could get the score but pick the wrong option. Ok. And if there are any questions you can put in the chart. So uh do you have any responses? Uh it's, it's neck and neck right now with 15 for one and five? Yeah, four and 54 and five. Ok. Ok. Fine. Four and five. Ok, fine, fine. That's fine. That's good to know. Ok, that is fine. Ok. Ok. Four or five. Ok. That's fine. And now, and now it's uh I guess now 11 person for 23, another four and another again spread result. I expected this, I'll tell you the answer at the end. So here's the other little news tobe chart. I know this might sound a bit sad to say, but you just have to write on it. Like in, in real life, you'll have the new SU shot on you. You do, you won't be expected before your CSI. You just need to learn, learn it. So uh tips I have is if they are on oxygen, you add two straight away. That's my first tip. Second, if they're confused, you add three and my third tip is the SP O2 scale. It will only be specifically told you that can retention. Other than that you just have to roll on. I know, I know this is a bit sad. But yeah, next question. Uh Next, next slide I have is this is your, this is a bit more related to CPA. But if a patient on oxygen, you add two straight away. Next one, if a patient is not alert, so if they're confused, you add three to the score. Another one is if a patient has a score of five together or three in one section, you rule out sepsis. And finally, for CPA, remember to fill out the patient details. I know in your CPA station they'll try and rush you and this is a year down the line, but always fill out your name. Always sign it, always fill out the patient details. So again, with news to, it's one of the things you have to learn. They, they are good videos but you, you just have to learn now going on to the monitoring. What I remembered here was just the um I remembered here was just the um this, the hour I remember here was just the hours. Actually, the, just if it was zero, minimum, 1 to 4, minimum, 46 3, minimum one hour, um if it was the five or more, you may 1 hour later and if it was seven or more continuous monitoring vitals and then this is a small version. That's it. If you have any questions, let me know. But on this, it should be option two, II went to highlight option two. It was option two because they've they got six and it's hourly monitoring because they are confused which gives them three and their blood pressure's 90 under 60 which also gives them three. This should be hourly monitoring. We'll change it when we send the slides up. But yeah, I could understand why you'd pick the other options for, for five. I'm guess you and you would have thought confused. Well, instead of being three, it was just two and for BP, I was being a bit a bit sneakier. You think it, it was just just under 90. Yeah, this one, it should say three months ago, we'll change at this time. If you have any questions, let me know any questions or can I go carry on? You can tell? Ok, that's good. So again, another question, you're a medical student on placement in your local entire medicine ward or say you're at Child West, you've improved. Now, junior ward round you met Gill. Gill is a 55 year old man. You present to a cardiac company. So what cardiac company is if you didn't know it's basically you have blood around your heart. And yeah, that's it. And he has and they have been on the ward for a week after treating the cardiac tampon on Gil contracted a hospital acquiring infection. I went into sepsis. He was managed for sepsis with the seps with sepsis. Six. And I was OK. I'll tell you a bit more about sepsis, sepsis. Six. Later, the consultant unexpectedly talks to you. This does happen quite often and the consultant just talks to you and asks you a simple question. They want to know what two types of shock this patient had gone through and the order. So, can you please identify to the consultant? The simple question, what the best type of shock, what the two types of shocks are? And the order and please pick the best response clotting t basically just have blood around your heart. But if I explain a bit more, you might get the answer any questions. Let me know one thing, I'll say they, I think the diagrams they use to keep shock are really good. So I just use that, but I'll just explain it quite simply. So, yeah. Do you have any answers for this one? Uh there's a bit of distributive shock and hypovolemic shock. Then there, then there's hypovolemic shock and obstructive shock. And then most people have said obstructive shock and distributed shock. Ok. Ok. Ok. Again, a spread, I'll let you know the answer is ok. So let's go over obstructive shock. So a protective shock is basically when your heart can't pump, it's basically your heart's working, your heart has got normal contractility. You have, you haven't lost any fluid in the body. As you see, your heart can't pump. And this could be due to a massive pee. Like here, it could be due to cardiac tamponade or it could be due to pericardial. It could be due to cardiac tampon, but basically cardiac tamponade is where you have fluid around your heart and your heart can't pump your heart's working fine. Like if you get rid of the flu, the heart goes back to normal or you have a pe blocking your heart vessels. Now, in this type of shock, you will have high central venous pressure, but low cardiac output as your heart comes up. So on this side, what you want to know Obstructor show is basically something stopping your heart pumping your heart's normal, your heart's good. But let's say a stab wound, a massive P ea clot, something stopping your heart pumping. It's now on to distributive shock. This basically your heart's fine, your blood's ok. You, you haven't lost any blood, your heart's working good. However, you've got a wide to vasodilation and that this could be due to se this most likely is due to sepsis. So, in sepsis, your vessels vasodilate. So more immune cells can't beat the infection. But once in vasodilates, your perfusion of your tissues is low and that leads to shock. The descriptive shock is basically your heart's working fine. You haven't lost any blood, however, your vessels are all dilated and your blood caught, your blood reaches but not the right pre pre pressure. Finally. Uh No, not finally, we have two more but hyper shock. Basically, you've lost blood. You have a low cardio output because you have low blood and you have low venous special cos you have low blood, that's all you need to know. Your heart's working fine. You just have less blood and your vessels will be vasoconstricting. But you don't need to know that your vessels are fine. You just lost a lot of blood, basically hyper rhythm. You've lost your blood. I cardiogenic. Your heart's just failed. You have a low cardiac output because your heart's failed and this leads to high venous pressure because as your heart's failed, blood's not moving around and your blood vessels are getting blocked up. And this is something for CPA. You might see like a JVP, which is basically your internal drug. The range is really big because the fluid has gone back up. But in, in real life, you'll never actually see it they, they say it in, in, I know in, they said you'll always see it in entirely. I've only seen it once, but that's just a fun fact for you to today. So, and I decided to make a summary slide to just explain these all one more time. So cardio shock your heart examples of heart failure, heart attack, your g cardiac output because your heart has failed. It increased intravenous pressure because your blood is being backed up. Hypervolemic shock, blood loss due to stabbing bleeding, peptic ulcer due to cancer due to it could be ischemic ischemic colitis is of loads of cla that you just lost blood. This leads to low output low pressure. As you've lost blood, the trip to shock, this is due to like sepsis. Anaphylaxis again, like allergic reaction, your vessels are vasodilated, your heart's working fine, but once the blood gets to your tissue because the vessels are so big, not enough blood gets, you want to, not enough blood gets to your tissues. When you obstructive, something's blocking your heart from contracting and dilating properly. So, cardio shock, your heart's failed because your heart has not worked hyper bleeding shock. You lost blood to stabbing bleeding, peptic ulcers, distributor shock, you've lost distributed shock is due to sepsis. You have widespread vasodilation, optic shock is due to having a cardiac tampon or pe something's blocking your heart from dilating, contracting, leading to low cardiac output. Now, onto this question, it was number four obstructive because he had cutting t Yeah. So now let me preface, they would have had hypervolemic shock as well. They would have, they would have had hyper shock, but they would have lost. But however, I said the best answer and the best answer here was obstructive and distributive because when they had sepsis, that's distributive shock. So that means you could rule out all the four options. And the best answer here was obstructive. You could also say call you as well. But again, the best answer I know it's a, a bit of pain was option four. Any questions? Let me know because we've got another question after this. But yeah, so optional obstructive because you had cardiac and you had fluid in the heart leading to your heart and not being able to contract, then you had distributive shock, which was because sepsis widespread vasodilation. If you have any questions, let me know or I'll go into my next question, any questions or no. Uh There is one. Why is it not hypovolemic? As there is blood loss due to the staph? OK. As I said before, I in the question, so can you please identify the best answer? So let's say we say hyper, OK, let's say you could say hypervolemic, but then they do not have obstructive shock after they had sepsis, which was distributive shock. These questions when they say single best answer you're valid to say option two with the hypovolemic. But that's what the best answer out of the f the hour of the five because number four, a distributive shock which was sepsis. I hope that answers to your question. And this is also how S pa S work, you need to pick the best answer even if you're, you're like, I think it's two but four is a better answer. Does that help? Yeah. Uh Another one is why does sepsis cause distributed shock? Ok. So in sepsis, I think this will go back to year one point which you guys will know much better than I do. But so in sepsis, your body will vasodilate. Now, when you vasodilate, your vessels get really big, they become more permeable to like fluid leaving. And the reason why you want this in sepsis is because you want your macrophages, you want your neutrophils, you want your immune cells to leave their blood vessels and go beat up the infection. Now, if you have lots of um vasodilation throughout the body, that leads to distributive shock, the deci shock is basically vasodilation. And once you have vasodilation everywhere, your perfusion pressure drops down and you're in shock because your, all your tissues aren't getting enough oxygen and aren't getting enough fluid, aren't getting nutrients because they're vasodilated to beat up, beat up the infection. Basically, sepsis causes vasodilation leading to distributive shock. Does that answer that question? Let me know. Uh Yes, they said, thank you. OK, good. And another question on to sepsis. Now. So you're on F one you got promoted? Yes. Yeah. But you were downgrade. Hi. Hi. Is an ok hospital. But most people don't like it. I don't mind it. What I live close to and I had their own place. So, but anyway, so you're on F one doctor on call, you suddenly get a beep from one of the nurses. They start talking to you about a patient which you've never, which you've never seen and they want you to see the patient as soon as you can. Here are the key observations of the observation of bloods of the patient below your bloods is your observation, you can read them. Can you identify what classification of sepsis? This patient has, this is more acsi specific because in real, in real life, you would just, you would say this patient has sepsis. You'd say you'd say this patient has sepsis. But for your CSI, they want you to know the calcifications on the different stages of sepsis. Let me know what they say. And again, any questions, let me know. And also you're not expected to know like about the eeg G fr stuff. This is just I just gave you an example like a blood not working, which could be important. But yeah, let me know what answers do we have. So most are saying sepsis. OK. OK. And um you also got these uh so I'm saying severe sepsis and septic shock. OK. OK. 555. OK. That's good. That's good. OK. We'll see if you're right guys, if you're not. So let's go on to sepsis. So S IRS is basically, basically this is a systemic inflammatory response syndrome. This is when you don't have evidence of infection. And this is basically telling you if the temperature is above 38 or under 36 heart rate over 90 respirator, over 20 W BC over 12, under four, you just don't want this sepsis is you have all of this. And the signs of infection, severe sepsis is you have infection, you have all of this and there are signs of hypertension, hyperperfusion organ dysfunction. So in our question before, how the kidneys are working and septic shock was, you still have all these signs and you've given them fluid. So the answer to that question was septic shock. And now in real life, if someone's BP is under 9060 they were, they're in shock. But in this question, if I never said I gave them IV fluids, you'd be right with severe sepsis. But in the question, I mentioned they blood pressures under there, it was like, I think 9759 which is under the 9060 for shock. So they're on septic shock. But you guys were quite good with severe sepsis because it in real life, you, it would be shocked because their blood pressures under 60. But I can understand why you put severe sepsis or sepsis. Now, going on to the sepsis. Six, what you need to know is you give through take three. If the only thing you, if the t the thing, the main thing you remember is in sepsis, you give three, take three. That's the one of the most important things you can take from the section. So give three, you give them oxygen to keep their cells above 94 you give them antibiotics and you give them fluid to deal with that low BP to take three. If you take buds, take the lactate, take the urine. If the only thing you remember from my talk, remember cyp 66 because when you're in the scenario where you have a patient who's like using, I don't know, fif using 10, you don't know what's going on. Think of. Subs subs six. That, that, that's the first thing we wanna rule out. So subs six is give three, take three, you give oxygen, you give antibiotics, you give fluid, you take blood, you take Lactic, you take you in and now we've got a QR code. Sorry, I was wondering if you guys could scan it and then we go, I'll, I'll explain a bit more about why the answer was septic shock. So I'll give you guys a minute or two to scan the QR code and if you have any questions, you can put them in the chart on like the CSI or anything you could even ask about CPA. I don't mind. I also on, on CPA, it said actually it's ok exam because the, the, the, the examiners will tell you what to do. Like they do a, a per class. So it's fine. You don't need to stress about it. But, yeah, let me know when you get enough responses I'll carry on, uh, in the meantime, someone has asked. Um, yeah. Can you explain the difference between severe sepsis and septic shock again? Yeah. Sure. Oh I'll leave a QR code up, but basically for um severe sepsis you haven't given them. So in the example, the CS I wanted to know severe sepsis is they have low BP. They have organ dysfunction, they have um hyperperfusion, but you haven't given them any fluids yet. But once you give them fluids and they still have the low BP organs, fusion hypertension, then they're in septic shock in real life. When you go from sepsis straight to septic shock before your CSI. They're a bit more pathetic. But yeah, I hope that answers your question and we'll wait maybe a minute or two more. I can see how many responses you guys done. So I'll wait a bit, I'll wait a minute or two more PDE Any other questions? Please let me know, put in the chat and if you are and if you're asking while I was looking at my phone, it just has the feedback form on. So, yeah, we'll wait a couple more seconds. A we'll wait a minimum and the rest of us talk we should be done in about 10 or 15 minutes. So, yeah, uh, somewhat. Uh, so ask again by low BP after fluids. Does it mean below 110? So, uh, so BP, low, low BP after periods is if it's a under 90 systolic or 60 diastolic. Yeah, to me, I'm gonna wear another men because we've only on my form. We've only got two responses in the QR code and I know there's more than two of you guys here. See, I'll, I'll give it another minute. Any other questions, please let me know, do forgive me another 30 seconds. Sorry. Did someone ask um if their BP went up? How do we have septic shock since I thought that was despite adequate fluid? So you're saying you're so you're saying, so let's say their blood pressure's bit bad before and they, so if let's say you give them fluid and their BP is not above 90/60 they're still in shock. If their blood pressure's like 11 2075 they're not in shock anymore. So in the scenario, their BP was 97/59. I'm pretty sure. Yeah, it was 97/59 on basically your dialogue was under 60. So in my, they're still in shock does that answer your question? Does that answer that question? If not, I could go back to that slide. But yeah, did, did I answer that question? Uh mhm I think so. OK, fine. We'll carry on and again, this feedback code will be up, the QR code will be up again. So you could scan it then the people who haven't scanned it yet. Oh They said II thought we usually only look at SBP. OK. So yes. Um with that, yeah, you normally you do look at SBP but certain people look at 90 over certain people look at Dyo as well. That's something in third year they could trick you out with. But what I would mention is just remember 90/60 that's it. Just look at just have a beer while both cos in real clinical practice, you look at both. So yeah, we will go on to the, we'll go to the next slide. OK. So sepsis. This is just looking at the bloods from the side. Why you want, you know, is basically most of the bloods will be raised, they'll be deranged and some will be lower. This you could, you could look at your CSI slide but I'm just trying to tell you the bloods will just be messed up. Your C RP will be raised because of infection. Your urea will be raised because your kidneys are failing, your lactate will raised because you've been lactic acidosis. Your platelets are low because you're just not making enough platelets then a big shock because the dios under 60 I know this was quite a mean question. But again, 90/60 it's just something you, it's a number which by end of medical school, you will be stuck in here like 90/60. Like um what Oxford if you remember 90/60 like um oxygen shots has to be over 94. So they're still shock. Now, going to the last question, this is actually there are a few more questions in the OK, we could do that. Um uh So just one more thing to clarify. Does it just have to be low BP or organ dysfunction or hypoperfusion? Is it for septic? Is it for septic shock? Uh Yes, this is for septic shock. Let's say their BP is normal but they have organ dysfunction or they have hyperperfusion. They're still in septic shock. You need to have all three to be fixed. But in the, in the, in the, in the um in the calcification, severe sepsis with hypertension actually, no, with severe sepsis, it's still a severe sepsis is just the BP. The BP is, if the BP is normal, then you go down to severe sepsis. You're you're out of septic shock. So yeah, sorry. If the BP goes back to normal, you go back to severe sepsis. Any more questions and why are platelets fluid? That's a great. Ok. For platelets loaded, I'm pretty sure it's your, you know, your body starts making other, your bone marrow starts making white cells. It makes, starts making neutral macrophage. It switch the focus from platelets to others because platelets this again, you guys will know better than me. But I think they're, they'll go under the common any more questions or should I carry on? Uh, you can color? Ok. So with abdominal pain, this is these like three sides are quite rarely. Basically, this is a diagram. You'll learn anatomy later, but it's basically taking the different rans. Basically, you could either use like your right, upper quadrant, left, upper quadrant left, lower, right, lower, or you could use the nine, the nine quadrants. What I like to do, which I'll show you in the next slide is look at different organs. So in your right hypochondrial up, right? Um hypochondrial region, you basically, I like to look at it. So your liver, your gallbladder, your kidney and your swollen intestine there. Then that's how I like to know if they have pain in that area. Something's wrong with those organs. Same for your epigastric green, like your stomach, lyric liver, pancreas, duodenal spleen adrenal glands. That's how I like to know. I, how I like to do abdominal pain is. I look at the area where the pain is, see what organs are wrong and see what organs are wrong near it and then see what happened and then why can't I diagnose? And this is what, in third year you get lectures by Professor Sam, our dean and that's how he likes to do abdominal pain. He looks at the region thinks of what organs are wrong there. What organs are there? Organs are below it, above it and to the right and left a bit. And that's how you do pain now for you guys because you're having an ab abdomal anatomy. This is quite a ro you just wrote, learn it, but I, I'm pretty sure they won't mention it for you guys because you haven't done anatomy yet and how I like to remember what um things could go wrong is by the old. So right, upper quadrant, right, upper quadrant or your right hypochondrial. I it could be hepato hepatitis, liver, liver issues, GG issues, epigastric. It could be M I because your heart's above it, it could be ruptured AAA which is your abdominal atic aneurysm. You don't need to know the details right now. You will only need to learn 30. But this is just because they mentioned abdominal pain. You could also have like your a peptic ulcer for the left hand side is your spleen. So hispanic rupture trauma to the spleen and abscess to umbilical region like appendicitis, appendicitis also right, lower quadrant region. Again, your line is small through CPA through abdomen and through other years of med schools, a lumbar region could be a kidney kidney issues could be testicular issues in a male and ovarian issues in a female. Your left hand side again, same thing. Your left lower quadrant has diverticulitis which will come on to your next. It can also have other issues. And then your lower this region here could be due to your ladder from, from these three sides. I just want you to be aware of what organs are where and if there's a pain in that area, it could be due to that organ. So yeah, if you have any other questions with the abdominal pain, I know this is quite hard for you guys to learn right now. It's just try and try and learn it to where the organs are. Like you could just get a picture up of where the organs are in the abdomen and they'll help you up. Now on to our final question, this is very CSI E because they give you this x-ray right here and you think what's going on. So I'll read the question. You're a medical student on your gi placement. You're taking a history from a 65 year old man named John. John has been admitted because he has a recent diverticulitis attack. Now, he's complaining of not being able to pass stool since he's been in the hospital. He has to check his medication. He's on IV, fluids IV, antibiotics IV and is on morphine. Top man, symptom. After checking his medication, you do let me uh let me show you. Yeah. Yeah, let me escape. Did you do uh later? Ok. Let me share, show you screen. Yep. Ok. Yep. Give me a second. Um Do they see the sides moving? Let me know. Uh Yes, I was. Ok. So do you know what side it got stuck at? Was it like do you did they, can you tell me what side got stuck at? I mean, I actually it's fine because the most of the all three other sides were just saying the same thing. Yeah, it was, it was, it was literally just, it was the one with the quadrants. Oh, so OK, fine. So this slide is telling you where the different organs are. This slide just giving you different examples. As I said before, you just need just be aware of where the organs are and you'll be fine and you don't need to learn all of this. This is just, it's just to be aware. Now on to this question, you mean John, he's a 65 year old male man. He's coming in with a diverticulitis attack. He's been saying you can't pass stool, which is really important. But when a patient says they can't pass stool or urine, you have to be, you don't get worried but you just have to be aware because this could deteriorate into something really bad. So you take his medication. He's on morphine fluid antibiotics. They gave you this x-ray. Now in C SS I fashion. They're gonna give you an image that you're definitely getting an image where you think what's going on here. So I've given you an image here. I'm not gonna tell you a lot about it, but there's some air, there's some, there's some air in his abdomen. Is that normal? Is that not? Is he dying? That's up to you to decide. But my question again with um single best answer, how do we help John with his constipation? Do we do a flexible sigmoidoscopy to untwist us by and relieve the obstruction? Do we decide to get rid of the diverticulus diverticulitis? Do we stop his meds or do we wait to watch and think, you know what we're gonna do nothing right now because he's not dying. So guess if you don't know that's fine, you can pick one of these options and any questions. I mean, then I ps they're not gonna, they, they might if they give maybe I know in second year we did get one CSI where they had like an X ray or something, but they went through that x-ray. This is just in CSI fashion where sometimes they'll give you something where thinking you didn't know about it and then they say I know it links to this but they wouldn't be this. I mean, yeah, any questions, let me know and just pick one of the four ups have a guess. Let me know what they said, yeah, I guess you've got quite a few responses. Um Number one. Ok. Ok. Yeah. Yeah. Um, if you have said uh to period time someone has said stop the opioid, no, has said stop the opioids. To that person who stopped the opioids. I'm gonna spoil it. You are right. But I'll explain mine later. But also, yeah, I'll explain mine later. But to the person who says stop the, you are right? And just for you guys, you know, this is a normal X I was just the air is normal. I but I will show you an abnormal X ray. So you could understand why this is normal. So on diverticulosis, diverticulosis, basically, you have lots of out pouching, diverticular, that's it. Diverticulosis has no symptoms and you just have the outpouching and risk factors are you're old and you don't have enough fiber in your diet. And obviously, how do you manage it? More fiber, more fluid, less opioid, painkillers, more exercise. And if you need both for so, from this study, why you want to know if diverticulosis is, you have lots of out pouchings, they are not causing symptom and we can improve this by having more fiber, more fluid from exercise, then onto diabetic clear disease. So this is just a picture here showing these are your diverticular and they're typically in the sigmoid descending colon, you won't get them in the rectum because the rectum doesn't have the Ta Collie, which is a type of muscle. Again, you'll learn this anatomy. You don't need to worry about that. You just need to know you'll get them in descending col sigmoid you, that's where you typically will get them when you think of diverticulitis as normally in descending and sigmoid. So, onto divertic disease disease, this is where you have the out pot and you have symptoms. So, diabetic go no symptoms, diabetic disease, you have symptoms and these out pots are no infection and inflamed symptoms are a change in bowel habits, abdominal cramps, pains, constipation and bloating. So just need to know about the symptoms. Again. Say man, you my diverted a leave because of the infection. You can just tell them to have more fiber, more fluid intake, less, ok, painkillers, more exercise and more boor like stiff. Finally diverticulitis. This is when you're diverticula uninfected. So, in this, in this one, you have left sided pain because obviously I've said Sigma co which is on your left side, you've got nausea, vomiting, bloody, diarrhea, normal, diarrhea, fever, bloating, change your ball habits. Overall, you just need to be aware of these symptoms, investigations. You will never do a colonoscopy. That's one thing I want you to remember because it can cause perforations. You just do, you do it through examination and a CT scan and you'll see how race will type white blood cells. C RP. It's like this age, low fiber diet, obesity, obesity for all three of them. And then if they have a mild attack, let's say you're not worried about them. Their BP is not 90 under 60 they're not like having a high heart rate. You think you can manage them in the GP, you give them oral antibiotics and also you don't need to know the name of the antibiotics. But if you wanna know it's called me Metro desi, you'll only need to know this since that yet. You give them a liquid diet to help rest their bow and pain painkillers. But non opioid for severe attack, you make them know by mouth because then vomiting nausea, you don't want them to eat because they have to use the GI tract. So you give them IV food, you give them, you give them IV food or IVS, you give them IV fluids because you don't want to be dehydrated and give them IV antibiotics from this side. Diverticulitis. Basically, you have an infection on the diverticula and you imagine it depends if they are. If you're not worried, you give them antibiotics. If you are worried, you give them IV instead of oral, it's now onto the complications. So let's start with this one here. Basically, complications are could be perforation. So your diuretica gets inflamed and it makes a hole and if it makes a hole, you get a chest X ray here. So if you look at this chest x-ray, now this is more related to the C epa more that. But I thought it's, it's, it helps with your spiral lining as imperial love to say. So if you look at this X ray here by the end of second year, you'll know how to interpret an X ray or you'll know you'll be aware of it. You see this line, white line here, that's your diaphragm. And if you have a hole in your gi tract, you get the air under the diaphragm. That's all you need to know. Air under. This white line is basically a hole in your gi tract. Then for the obstruction, which is one of the complications. If you look here, you do, you see that there's a lot more air compared to the normal X ray. But secondly, you have these lines and it is quite a bad x-ray. But you see these um lines here, this is your large intestine. But again, this is quite, this is linking to CP. But it is something serious I could do and also you could get fistula. So that's where like a, a tract formed between your bowel and your bladder where you could get pooped through your um urethra or through your bowel and your vagina, you could get pooped through your vagina and your cervix, which is really bad. But the, these normally don't happen, but they are complications. It's under the complication to get perforation, you can get abscess, you can get obstruction and you get this here and here has a little chest x- with a, again, air under the diaphragm is basically air under the white line. You don't, again, this is just to help you link it to like CPA DI stuff. But this could come up in your serious F I really, again, we have the feedback home and also this gives me time to answer any questions. Do you have any questions when you lie down guys? So there's a loved one. Can I ask whether diver diverticulitis affects the small bowel too? No, diverticulitis normally doesn't affect the small bowel. It does not, it doesn't normally affect the small bowel any other questions and any more people who haven't done the feedback form because I'm pretty sure most of you haven't done it yet. Yeah, it's, it's, it's usually in the sigmoid. Yeah. No, normally, yeah. Normally sigmoid colon, you and descending colon, you won't get it in the rectum because it doesn't have the certain type of muscle. But this is OK. Um So someone else was the answer to the previous question to stop opioid painkillers. Yes. But yes, it was. But I again, I'll explain it in the next slide just waiting for any more response. Can you explain how perforation leads to abscess. Perforation needs to? Yeah. Yes. OK. So perforation is, let's say your diabetic gets infected. Now in real life, what would happen is you get an abscess first or a collection of pus then that leads to the pus blowing or perforation. But I guess with the other way is, let's say you are a diabetic guy, get inflamed and perforate straight away. An infection can form around the hole leading to an abscess. But typically you get an abscess, then you'll get a perforation. Annual questions. We need to be done guys. And I also scan the QR code, please. It will be really helpful to see why it could improve on. If not, we'll go on to the last question and here's the answer. It's to stop opioid medication are replaced with non opioid alternatives. So this is a normal X ray. We don't need to do any surgery and stuff. Basically, this is because we don't need to do any surgery because it is normal x-ray and we stop his opioids. As I said before, opioid painkillers are a cause of like diverticular disease. And we aim is to give him another painkiller and if he still has issues, give him a soar as well, give him like a laxatives. But yeah, that's everything. Thank you so much. I hope it was useful and all the slides and recordings should be uploaded to the me link by. I'm gonna guess around, but we'll do it as soon as we can and we'll let you, we'll let, we'll let um, we'll let your chat know as well, but you have, you had any questions, let me know and if you have any questions about CSI message me or Ashraf as well and we'll just leave the QR code up. But any more questions, let me know, I'll try to answer them. If not, I will stop sharing my screen. They did any more questions. No good. Uh Just wondering why is surgery unsuitable? Uh ok. Uh On this one? Ok. So side is unsuitable because there's nothing really wrong there. It's a normal X ray and you don't wanna go surgery straight away. But with surgery, this has like major impact on the quality of your life that will lead to not having a stoma. And if you don't know what a stoma is, it's basically a part of your bowel is like on your skin and your, you, you, you don't poop normally anymore. Your poop is through that back and because the X ray is normal and the, and if they've just currently come in and they're not in any signs of bowel obstruction, you, you're gonna try and ensure you don't wanna do any surgery. Like I know people say surgery straight away, you're gonna try to avoid it. So we just stop the opioids and pain medication. Any other questions. But yeah, basically because we're trying to be as in, in less invasive as possible. We're gonna try medical management. If that doesn't work, then try the flexible sig. If they had a bowel. If that doesn't work, then try surgery. But let's say this patient had like a BP, 90 under 9060 they were in lactic acidosis. If you do a chest X ray, they had a lot of bowel, then you'll have to do surgery straight to it. But, you know, they are like in need, but this patient is currently stable and he's just complaining about not being able to go to, to toilet any other questions. So, another one was, do you do surgery? Mostly only if the diverticulitis is repetitive, um, surgery, I think is last resort. So number one, you're asked them to do lifestyle changes, then you'll lead to surgery. No, you do lifestyle changes. You try to increase the water intake, their fiber intake, if that doesn't work and they get repeated attacks and they, the attacks are getting worse, then you do surgery. But surgery for diverticulitis is a last resort. And what would the follow on the X ray look like? Uh I think I should here. It's like this, you can just have a large bowel obstruction x-ray. And you're just like here you see these like lines are here, like in the other X ray, it was quite normal. You didn't see that much any other questions to add to that, that you can quite, you can see a lot of problems on it. So you can just search out. I think radio pia is a good radio P is a radio pia is a good one. Like, uh you got your, you also got a small barrel obstructions there. There's a lot, there's a lot, but radio pia is a good one, youtube video is always good. Yeah. Uh, is that because there's extra, hm. Someone asked her? Oh, no, no. So it, but again, because of the larger bowel obstruction, there's a lot of air in the large bowel. That's why you could see in a chest X ray. Normally there isn't that much air so you won't see it any other questions? If not, I'll stop sharing my story. I think um the final question is, is, is more for both of us where me do, do you find the recording? Ok. So on the recording, once we finish this event, we'll update it with the, um, we'll update it with the, with the side and powerpoint. And if you click on this link again, it should show you the recording, see you. And if it doesn't message, I believe it's in your year, Hannah and Ayush, I believe, I think they are the one a lead and they'll message back to us or message Vinnie and Simmy, they will message us as well. But yeah, they sh it should work. We'll, we'll update you with all the slides and recordings after the session is over. But yeah, I think that's everything. Ok. Thank you. I'll stop the recording. Ok? I'll stop sharing my screen