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Fab. So can everyone see that? OK, just pop in the chart. If there's any issues, there can't see anything in the chest. I'm hoping it's all visible and fine. Um I introduced myself very briefly um in that first little introduction, but my name's Ramya. Um I'm an F two doctor in Newcastle upon Tyne. Um And I'm here today to talk about EC GS, everyone's favorite. So the learning objectives for this evening are to refresh and recap knowledge of steps of ECG interpretation. So that's essentially the theory. There's gonna be a lot of just very basic things. What do, what do you do when you get handed an ECG? Essentially, um The second learning objective is to build our confidence in identifying signs of ischemia on EC GS obviously really common that you're handed an E CG for someone with chest pains. So what are we looking out for there? Especially when we're in the middle of the night on call. The third objective is we're going to try and apply our knowledge. We're going to work through three little on call scenarios. Um One of them is a surgical on call scenario. The other two are medical on call scenarios and those I hope will be really interactive. So the first part of the session is going to be quite a lot of just talking through things, not too much of interactivity. It's just the theory that we're refreshing and recapping. But hopefully the second part will be loads of participation from yourselves. I'd like you to be active in the chat with any suggestions, questions throughout the talk to be honest, but especially in that last half of the session. Um It's also important to say what this will not be. Um It will not be a complete and exhaustive guide to E CG interpretation. That will be absolutely impossible to go through um in a talk that's meant to be just under an hour. Um So instead this will just be a few little common things that you'll almost certainly see at some point when you're on call fab. So the basic steps of what do we do to interpret? An E CG. Um So the way I do it is eight steps. Um This is essentially the geeky medics approach, um which I used in medical school and still use to be honest now. Um And so we're just gonna go through each of these eight points um and recap what we do as part of them. Right. First step. Have you got the right E CG in front of you? Have you got the right patient sounds really basic but ec GS need a patient's sticker or identifier put on them. Um They're often unlabeled when they come out of the machine. So just make sure you've got the right patient's EC G really easy to, to mess that one up. Um And the other part, which is really important is, is this the most recent ECG, is this the correct time? Um And as part of that, try and see if you can find any previous EC GS to compare to something which I've learned in my job this time as my F two job in Gastro is about calibration. And basically our ECG machine on the ward seems to act up in terms of its calibration. So it's really important to just check at the bottom that you've got the paper speed set to 25 millimeters per second. And that your calibration of the voltage is 10 millimeters per millivolt. Um So currently our machine is giving us 20 millimeters per millivolt. And so everyone looks like they've got hyperkalaemia and big tented T waves. So um just really important to check those very basic things. The second thing we look at is the rate. So is it regular? If it's regular, then the way I do this is 300 divided by the number of big squares in the interval between two R waves. If it's irregular, then you can essentially count the number of QR S complexes you've got on the rhythm strip and times that up by six third step is what rhythm have we got? We've done a bit of that as part of, right? Um But is it regular, is it regularly irregular? For example, a second degree heart block or is it irregularly irregular? And the most common that you'll see would be af as part of that, um I will say I still use the paper method sometimes for this, it's not always super obvious what the rhythm is. So for those of you don't know what the paper method is. Um essentially getting a scrap bit of paper um marking on the interval between the first two R waves on the rhythm strip and then just popping that along the rhythm strip and seeing if that R interval is constant throughout or whether it changes at all. So that can just be a really simple and basic way, apologies for my voice at the moment. Um Trying three. So next thing is access and I think a lot of people get really hung up about this. Um But the easiest way to do this is look at lead one and look at lead two normal axis. You're looking, they're both positive, they're both both pointing up in left axis deviation. The QR S complexes are leaving each other. So left is leaving, there's the easy way of remembering that. So as you can see on that little little diagram there, so you've got left leaving um right axis deviation. Um the QR S complexes look like they're pointing towards each other. So, right, is returning towards each other and that's just a dead easy, really quick way of doing axis. No, the next thing we look at are the P waves. So are there P waves, if no, we're thinking af potentially when you're looking at the P waves, if they are present, are they each followed by a QR S, do they look normal? Do they look kind of flat or a bit peaked? And if there's no P waves, is there any atrial activity at all? Um For example, flutter comes under that as well. And when we look at the P waves, we can also at the same time, assess the pr interval, the pr interval should be 3 to 5 small squares on the ECG. Um When we've got first degree AV block, you get a longer pr interval of more than five small squares and that's fixed. So it's the same lengthening every time in second degree block, we've got the two different types of that. So type one like sometimes called wen back. Um And that is where you get progressive prolongation of that pr interval until a QR S complex has dropped in type two second degree block, you've got a constant pr interval and you've just got random dropping of the QR S complexes. And finally, in third degree block, there's just no relation whatsoever between the P and the QR S complexes. That's if the pr intervals longer, if the pr interval is short. Um That essentially just means that the sinoatrial node is closer to the A B node. Um So in some ways, so basically, the waves are getting there faster from those. So that could be um due to an accessory pathway, think of things like Wolf Parkinson White syndrome as part of that. So I've got a little diagram here just to show what we've got a first degree block that long pr interval. But it's the same every time mo it's type one or we back a V block where you've got progressive prolongation of the PR interval. QR S are dropped after that. And then you go back to the beginning for progressive prolongation. Um type two Mobitz type two where um you've got a prolonged pr interval. Um but you have these sort of random dropping of the QR S um and then the third degree block um which is usually a little bit more obvious actually where you've just got absolutely no relation whatsoever to um between the pr the, between the P waves and the QR S complexes that moves as nicely onto the QR S complex as themselves. Um Are they narrow or do they look broad? Um If they're broad, is there a left bundle, branch block or a right bundle? Um And the little mnemonic that we get taught at med school still applies. So, William and Marrow. So for those, you don't know that you get a W sort of looking wave in V one in a left bundle and an M in V six. Um So William, so left bundle branch block and then marrow. So um an M in V one and a W in V six. and that would be a right bundle. Um You can look at whether the QR S complexes are small, whether they're tall, if they look really tall, that can be a sign of hypertrophy. Are there any delta waves at all? So you get this sort of delta wave here that you can see a slurred up stroke on that QR S complex. And that can be um part of Wolff Parkinson White syndrome, for example. Um And are there pathological Q waves and this sort of deep Q wave for the R and S? Um and that can be a sign of current or previous myocardial ischemia as part of assessing the QR S, we should also take a look at the QT interval. Um You should always use the QT corrected intervals AQ TC. Um And I'd recommend just using a calculator. There's plenty of online calculators that you can use for this to correct for the heart rate. Um The QTC is prolonged if it's over 440 in men or 460 in women. And there's many, many different courses of long QT, it can be congenital, it can be due to lots of medications. Um So there are some medications obviously that before you start, you want to get an ECG for this QTC, for example, OLANZapine off the top of my head. Um Short QT C um is less than 350 that can be, um, in some electrolyte abnormalities as we'll go on to see. So the ST segment, so this can be one of the most important things you're looking at on an ECG um looking for ST elevation and depression. So for elevation, um you're looking for a significant amount of elevation of more than one millimeters and two or more limb leads that are continuous with each other or over two millimeters and two or more chest leads. And then in terms of ST depression, you're looking for ST depression that's bigger than half a millimeter in two or more continuous leads. And for reference, each of the little squares in the incision corresponds to about a millimeter. So that's an easy way of doing that. A and then finally, you've got the T waves. So are they tall? So are they more than five millimeters in the limb leads? And 10 millimeters in the chest leads tall T waves can be a sign of electrolyte problems as we'll go on to see. Are they inverted? So T wave inversion, I think we can get quite bogged down on. It's quite a nonspecific sign. Um I've listed some there ischemia is the one thing that you should worry about. So if you have got a patient with chest pain, you do look for T wave inversion there. Um Inversion is normal in a VR and V one. So that's just something to bear in mind not to panic too much if you're seeing it there. But obviously, if you're seeing T wave inversion elsewhere, that's not a normal thing. T waves can also be biphasic. Um So there's two types of biphasic T waves. So in ischemia, they go up and down. Um there's a syndrome called Wellans syndrome, um which can cause these biphasic T waves and it's a chest pain syndrome, um which you need to look out for if you're looking for these little biphasic T waves. Um And then in hypokalemia, you get a down then up pattern, which is that second ecg there on the screen. Um So biphasic few waves can be in two different forms. All the T waves flattened. Um That can be caused by ischemia. It can also be caused by um lots of electrolyte abnormalities. Um And then finally, U waves um that's a wave just after the T wave that you're looking for. Um And that can occur in hypothermia and some electrolyte abnormalities. F So that was just a little whistle stop tour of an E CG. It, there was a lot of just recapping to be honest. Um And probably a lot of it that people know already, but I think it's good to just have a baseline that we're all on the same page, um just going forward into some of the cases. So the next part of the session is all about chest pain. Um So let's say you're on call, you called to see a patient with chest pain and you asked for an E CG very rightly. And what kind of things are you guys looking for on that E CG? If you could pop some ideas in the chat, that would be absolutely great. Some that we've already had a chat about as part of going through the EC GS. Yeah. Yeah, absolutely. Yeah, lots of messages. This is great. It's nice to see you guys interacting in the chat. I like this fab fab fab. So ST elevation depression new left bundle. Perfect. Well remembered there and T wave inversion. Yep, as we were chatting before. Oh, that's lovely. Yep. Any Q waves as well, especially Q waves that are new from before. Definitely. And when we are looking for all these changes, um we are looking and bearing in mind the ECG territories that we can see in front of us here. So you want to have a good idea of this in your head when you're looking at an ECG for someone with chest pain. Um because especially if those changes are corresponding to territories, they're more likely to be very significant. Obviously, they can be significant anyway, but it should make you a bit more worried, especially if they're sort of localizing to the territories. Yeah. Absolutely. Bear in mind where they occur ie the affected diarrhea. Exactly. Yeah. So, um, the territory is there. So, I've popped an E CG up. I know it's always really hard looking at EC GS on screens. Um, but I suppose electronic records and all that nowadays. Um, so if you guys wouldn't mind just having a little look at this E CG, your hand did this for someone with chest pain. What are you thinking in your head when you see this E CG? Yeah, we're getting some, some good bits in the chat there. Yes, dummy. Yeah, the two waves do look a little bit tall but I think when we're looking, we're looking at the ST segment. They're perfect. So, yeah, I've done a bit of circling of the key things, but you've got ST elevation there in septal and anterior leads. Yeah. So well done. Everyone who got that. That's perfect. You've also got some in the lateral leads there and you've also got reciprocal ST depression um in lead three. If you can see. Is it well done on that one? I've got another one for you guys have a look at. What are the things that are worrying you on this E CG? Definitely. Yeah. Yeah. Wonderful. Well done. This is a bit more subtle. Definitely lovely. Well done guys. So yeah, T wave inversion there. So especially in that V five and six, as you guys pointed out. Um You can also see it there in lead two, there's a bit two wave inversion there as well. Um And it seems to be sort of in the lateral leads. Um But to be honest, you're looking, if that's new T wave inversion from previous ECG um that should prompt you to consider an ischemic cause really, especially if that's a patient with chest pain. Who you've done that CG on. OK. Correct. What about this E CG here? Any ideas and honestly just have a go as well, like it's very sort of nonjudgmental and very safe environment to just have a go at interpreting some EC GS. Yeah. The QR S has stayed like pretty tall. Yeah, I Troy. Yeah, they're a bit tachycardic. Absolutely not sure. Too much about the biphasic T wave on that one, but it's a good thing to have in mind. Definitely. OK. Any other ideas? Yeah. ST depression. I, that one might come up there. So, yeah, you've got widespread ST depression on this G um So that should, yeah, widespread well done there in the chat. Um And so this should make you think about the subendocardial ischemia or just basically call Aenia moment on there. So that is, yeah. So quite a a worrying E CG to have handed to you fab. What about this one here? It's a little bit trickier and looks like he is in the chap. OK. Stemmy and stemmy. Yeah. Tortilla Waalia. SD Depression got quite a few different ideas in the chat there. Just really good. So these are bits that are circled. So I think the, probably the mo more obvious thing when you're looking at this E CG is you can see the ST Depression quite obviously there. Um, so that's in Leeds. Three Navy and then D3. So that would make you think, ok, inferior and stemi. Yeah, or someone popped in the chat. But so ST Depression doesn't tend to be localizing to territories. So it's a bit of a tricky CG. This one, there's actually ST elevation somewhere and that ST elevation is in a VL. So essentially when you see ST depression that seems to be localizing to the territories, always look for any ST elevation elsewhere. So this ECG is actually a stemmy E CG. Sorry, I don't know, I just clicked over there. Um But yeah, this E CG is a stemmy. Absolutely. So you should have a little look for any elevation as well. But yeah, just maybe a bit of an interesting one and something to make you guys think. Um That, yeah, so ST Depression that localizes, look for some ST elevation as well. So when I get handed a chest pain E CG, there's my sort of top tips and things I'd like to pass on to you guys. So how is the patient should always be the first question. So you will have done this to death. But your A BCGA ABCD E approach is really key and that will often determine what you do. So taking a really good history and doing a really good examination that is still really important. Even when you've got the ECG in front of you, look at the whole EC G as we saw with that last one, the little bit of a tricky one there. Um Don't be distracted by the most obvious change that you can see. Just look through everything in that systematic way and try not to sort of focus on the most obvious part. Um The main things to look out for on a chest pain, E CG as we've discussed is ST elevation of depression T wave, flattening or aversion, biphasic T waves and new left bundle. And as we've sort of pointed out before, we always just try to find a previous E CG for comparison. Um ideally, actually from when they were more well and hopefully not so long ago. Um So when you are on a surgical job, a really good sort of resource you have are the outpatient anesthetic assessments. So they've obviously come in to have an anesthetic assessment for an elective surgery. For example, they would have done an E CG as part of that or even their pre op anesthetic assessment like it will have an E CG. So, um do just have a little look back and it's usually that they were more well at that point and generally like recent enough. So in the last like month or two is usually good. Um Just as a comparison and you're looking for obviously new changes from that um, other top tip, which can be sometimes a little bit more difficult to do is just not to be afraid to ask for another E CG. So if you've got a really squiggly E CG for want of a better word and the patient's been moving around loads and it's really hard to interpret anything. Just don't be afraid to ask your colleagues, the nursing staff if, ask whether we could get another E CG possibly if we can try and calm the patient down and, and reattend because especially when you've got some chest pain, you don't want to miss things and E CG changes can be there. And so we, we don't want to miss them. So getting a good E CG is part of that. So don't be afraid to ask for another one. Takes a little bit of assertiveness sometimes. But yeah, OK. I'm just gonna have a quick drink of water cause I can feel my voice going inhaler. You have a little look at this. So this is the first of our three cases this evening. Um So in this case, you are the surgical F one on call overnight. Um This is probably many of you to be honest at the moment. Being the surgical f one overnight, I've done it many, many a time. Um, and it can be super busy, but you are called from the Colorectal Ward. Um, about a 45 year old lady. She's day five. After having a right hemicolectomy, she's had that hemicolectomy cos she's got colorectal cancer. They took out a tumor. Um, she's had increasing abdominal pain overnight on day five. She's got a past medical history of Crohn's. She's got colorectal cancer as we know and she's also a type two diabetic. These are the observations that the nurse tells you about and that's the reason that you've been called to see her along with that abdominal pain. So she's got a temperature and she's tachycardic. Her sats are all right and her respirate is OK and her BP is holding. So in the chat, what are you guys gonna do next? Not a trick question at all. Unlike that last E CG. So yeah, lovely. A to E assessment. People are talking about doing bloods and cultures. That's fab really good thoughts there. Get an E CGI mean it is an E CG talk. So yeah, absolutely. Some imaging of the abdomen. Yeah, absolutely. You might think about that potentially cause we're, we're overnight. You might be thinking more along the lines of an urgent ct in this case, sepsis. Six lovely, really, really good things coming up in the chat there have chest X rays. These are the basic things that you, you should be doing first. So going and seeing the patient doing your A two E assessment, getting a set of bloods BBg, try and get blood cultures along with that if you can an E CG um and consider escalating this to a senior immediately because as someone's rightly said, sepsis is what you are thinking here. So you have gone and seen your patient. Um She's got significant tenderness to her right lower quadrant. Um She's guarding, she looks unwell. So what all someone's asked, why do we get a VBG and an ECG. So the VBG, to be honest, I would get that because you'll get a really rapid set of bloods, essentially, you'll get a PH and you'll get a lactate and that could be really useful when you've got someone who looks pretty unwell. Um Even if you're not sure what is causing that, getting a ph and a lactate can just give you an indication of how unwell someone is. Um, surgeons also definitely look at a lactate. Um when they are sort of thinking about how sick somebody is, whether they need to take them to theater overnight, which is a bit of a giveaway for this case to some extent. Um An E CGI would get that because she's tachycardic and this um so she's going at 100 and 35. So I think it would be very reasonable to get an E CG as part of all of this. So as we were talking about with the VBG, um she's got a lactate of 3.1. It's a classic thing you've sent off all the other bloods, but they're all pending in the lab. So you've sent them off as urgent, but they're still not really being done. Um What are you most worried about in this patient as a diagnosis? She's day five after a hemicolectomy, she's got increasing abdominal pain sepsis. Definitely. What could be a source of her sepsis leak or hit the nail on the head there. So we are worried about a leak POSTOP causing sepsis. Yeah, anastomotic leak. Yeah, she's had a hemicolectomy. You, you can go and have a look at the op note to see whether she's got an anastomosis there. But you'd be if she does, you're worried about an anastomotic leak POSTOP and definitely sepsis there which is caused by that. So, oh, they've done the E CG that you requested as well. I have a little look at that for a second or two, but what I'm gonna do is put up a pole um as part of this. So what is the main finding on that? Eg Can you guys see the poll? All right, I've not used them for myself before when doing this. Oh, wonderful. Oh, it looks like you guys are responding to it. So II think you can see it. So someone's thinking it's sinus tachy. Um have a look. Um, because it looks a little bit irregular. Yeah. Getting lots of responses in the PCH is great. Perfect. Yeah, someone's just asked as part of this case. Would you think of small bowel obstruction as your differential? Yeah, it should be on there on your differential. Some, with increasing abdominal pain. Um, usually you'd be thinking that if they're vomiting as well. Definitely. Um, you can ask about bowels as part of that. Um, have they opened their bowels POSTOP so that if they haven't, if they're not passing wind, if they're vomiting, that's definitely part of your differential in that case. That's a really good thought. Yeah, I think given the temperature tachycardia as well and that really awful guarding that you felt when you've examined it. I think you're probably more along the lines of a sepsis and anastomotic leak, but it's really good to think about all the differentials fab. So we've got some responses in the pole and just close that now. Yeah. So most of you have gone for this being af it's really hard on a screen to look at EC GS, which is, is very tricky. Um, when we want to run a session for EC GS, of course, and make that really accessible to you guys. Um, I couldn't see any P waves on this E CG. Um, I'm not sure if you, if you guys would agree, but this looks pretty much like af um, it's rapid So we say it's af with rapid ventricular response or fast af oh, a few people think that they can see P waves. Yeah, I couldn't see any P waves on this. And this is an AF E CG from the lovely E CG resources website. Life in the Fast Lane, which I would highly recommend they put this down as a, a fast AF E CG as well. Um But yeah, I mean, I would say irregular, irregular as part of it. And yeah, there's at wave, someone's put in there. So yeah, you can definitely see T waves which, as you rightly said, might be confused with the T waves there. So yeah, as you say, it's af with a rapid ventricular response, um We've already sort of talked through the features of AF in, in answering that question there. So irregularly irregular, no P waves, um not as obvious in this E CG, but sometimes it can be quite sort of squiggly like. So you can get an absence of that nice straight isoelectric baseline. Um And you can sometimes see fibrillatory waves, maybe that's something that some of you guys are seeing when you're looking for P waves. Um but they're not proper peak waves, they're not defined. So we looked at this lady's past medical history as part of that. She had Crohn's, she had type two diabetes and colorectal cancer, but she's not got any known diagnosis of af um it's likely that her af in this case, is driven by her abdominal sepsis. Um And we've rightly queried an anastomotic leak here that requires immediate senior escalation. They might, may want to put her through a CT scanner overnight and potentially even take her to theater overnight. So you need to be get letting a surgical reg know. Um In the meantime, you will have initiated your sepsis six. Um So we've got a good surgical on calls talk, hopefully coming up later in this series, which I'll tell you a little bit more about managing this kind of stuff. But senior escalation of the sepsis six is the cornerstone of it. Um in terms of treating treatment of the af here, um there's different schools of thought on it. So I would seek senior advice in a case of someone who's septic like this um regarding whether they want to rate control this person, um especially if they are likely to be taking them to theaters overnight. Um You might want to get the anesthetist involved in that sort of advice. Um Things that we might give for rate control are bisoprolol and metoprolol, beta blockers. Metoprolol works a little bit faster. Um Bisoprolol um can be given as a little tablet, very low dose 1.25 mg or 2.5 mg if they're new to beta blockers. So very low doses to start off with usually um if there's contraindications to beta blockers, um you might be advised to give a calcium channel blocker. Um And if someone's BP is low, um, you're often advised to give digoxin, but I would seek advice in this scenario because you've got a very unwell lady in front of you who you're anyway gonna be calling someone about. Um So I would also seek advice on what we do here. Um As we say, this is af driven by sepsis. Um And so it has a, a clear cause. Um However, if, for example, this lady went to theaters overnight, um and you essentially treated the cause of her sepsis, then and if a month down the line, she's recovering on the ward, um or hopefully not still there, but um maybe a week down the line, um she's still in af um despite the fact she's potentially not septic, then that should prompt you to consider other causes. Like does this person just have af is there any structural abnormality? It's good practice to get an echo. Um And if they are still in af a week or two down the line from this episode, um you should be considering anticoagulation at this point as it's likely they just have af that hasn't been picked up. So that's that case. So you've moved on. Oh, would you treat? Yeah. So that was a good question there in the chat. Um I hope I answered that a little bit um in terms of treating it. So there are just different schools of thought, some people have said just treat it to me. Some people have said you need to treat the cause. So it should hopefully resolve when you treat the sepsis. But obviously, if someone is in af going up quite a high rate, they may want to give a small dose of beta blockers. So discuss with your registrars, um especially if there's planning for theaters. Does that answer that question a little bit? Yes, perfect. So we've moved on. You're now the medical F one and you're on the evening shift and at five o'clock you get a call um, from ward five, care of the elderly and this is the call that you get. So Doris, she's come in with a full five days ago. She's got a lower respiratory tract infection and an AK I she's been having daily bloods, but there's a lab problem. So the bloods that this F one sent earlier, they aren't back yet and they have asked you to chase the bloods and looks like the lab machines are all now up and running. So hopefully they're, they'll be getting processed. Um And you just get that handover and not much else. So what are your first steps after getting that hand over? Ok. Just pop ideas in the chat. Chase the blood. Yeah, definitely chase the bloods. But these are all kind of more practical things that I thought about. It's just we all we know. Is there someone called Doris somewhere on ward five we think. Um yeah, chase the bloods. Um We want to find out who is the patient actually. Um and all the bloods actually in progress. Um and potentially a little bit more background about them. So what do they have a past medical history? Any previous bloods? So how worried are we about these bloods that we're chasing? How urgent are they? Um Yeah, clarify why she needs bloods and what to check? We've hit the nail on the head there. Absolutely. So why is she getting these bloods? What what are we doing once we actually have the blood results? Is there an action plan at all from anyone senior or junior to be honest about what we want to do? Um So potentially you're asking these things over the phone as well. Um But you know, any case you've got to check them yourself anyway, the amount of times that I've been handed over bloods to chase that haven't actually been taken or aren't in progress or have been lost along the way is quite ridiculous. To be honest, how many times that's been handed over? Um So yeah, just a few little practical points there, which is non E CG related. So this is the information that you find out. So this is Doris's information looks like she's been prepped for discharge. I'll let you have a little read through. Thankfully, the bloods are in progress here taken about an hour ago and these are her previous years news from yesterday, she's very mildly hyperkalaemic. She's got an A I but maybe potentially coming up to baseline. Uh, so you found out all this information and looks like today's user, these are back. So these are her bloods. I'm just gonna pop a pole up. What's your first step? Lovely. Getting some nice responses on the poll there. Yeah. Lovely. Yeah. Absolutely. Yeah, I'll stop the pole now. It looks like most of you have gone for doing an E CG um First, which dead giveaway isn't it? That this is an E CG talk again. But yeah, you're absolutely gonna do an E CG now with all the rest, they're not wrong answers at all. Um Doing a repeat set of obs and repeat set of bloods given that was an hour ago. They're also very valid giving fluids because her ak I has worsened on those most recent set of bloods. You've been asked to chase all very, very relevant things, but it's just about what is your first step there? And y your first step is you've seen that this lady is hyperkalemic now at 6.4. Yeah, absolutely. Do an E CG. So what are we looking for on the ECG? So I've put this in order of what actually happens um in hyperkalaemia. Sorry, there we go. Um in hyperkalaemia. So the first step are the tall tented T waves the best seen on the chest leads. Um, and that is the first sign that, um, probably the one which we're all most familiar with looking for as the hyperkalemia worsens and its effect on the heart worsens. We get changes to the P wave. So widening, flattening and the pr interval gets longer. And then finally the P waves become absent and the QR S widens and you get some really strange looking QR S complexes and severe hyperkalaemia. Um at a very late stage, you can get Brady arrhythmias and conduction blocks. Hopefully we're picking things up before it gets to this stage, but just something to bear in mind. And one of those little diagrams that I really like from the website Life in the Fast Lane, um is this idea of hyperkalemia, high potassium pulls the E CG up. So you get peak T waves, er and TP wave flattening flat P wave flattening, that's a bit of a tongue twister there. Um So the whole E CG gets essentially pulled up. So I thought that was just a nice way of thinking about it. Um And remembering it so perfect. So this is the E CG that we get from this patient. What can you guys see on this E CG? Just pop some ideas in the chat. Yeah. Tall T waves. Lovely. Yeah, you can see some tall T waves there. What are your next steps? Now, after getting this E CG and you've seen these tall T waves. OK. Protect the heart. Yeah. Pretty good things. Calci gluconate. Yeah. Lovely well done guys. Yeah, calcium gluconate, insulin dextrose. Lovely. So great ideas there in the chat. So just check on the patient. Potentially we've only just chased these bloods. Um go and check on the patient, check for any palpitations, any chest pain. Um on your at e for example, in this patient, you find there's just dry mucous membrane. She's not been drinking much. She's only had one glass of water today. Um Follow your trust hyperkalemia protocol. Um So this will be different in different hospital trusts, but it usually consists of protecting the heart, as you guys have, rightly said, with calcium gluconate or chloride, um giving salbutamol nebs and insulin dextrose which drive potassium back into the cells. So, following your trust hyperkalemia protocol is the best way to go with this. And as part of that, you'll be repeating bloods at intervals as per the protocol to check for rebound hyperkalemia because about 4 to 6 hours after the potassium can come back up after treating it. So you need to be quite vigilant for that. Um You can repeat bloods on a VG if you want a faster result. Um But it's good practice to also just send off some lab bloods as well for a lab value. Um She's also obviously got a worsening AK I on those bloods that we've seen. So just double checking her meds is good practice at this point. So is she on any nephrotoxic that have been missed? Things like Ramipril, for example. Um Is she on Metformin where there's an increased risk of lactic acidosis if she continues that with a cracking ak I um I, are they on digoxin as well? That might need a review? Um, potentially when you review her medications. In this case, you see she's not had any fluids from the IV route in the last 24 hours. Um, you might look at her fluid status and consider prescribing some IV fluids. Um, another interesting bit is, is she on oral potassium replacement? Um because that was, it recently happened to me where I've treated someone for hyperkalemia, but actually, it was driven by the fact that they'd been on SAN. Ok, oral potassium replacement without a stop date on there. So just double checking. Are they just taking oral potassium? Is that what's driving it up? Obviously, in this case, she's got a worsening AK I um that is likely to be the driving factor there in um pushing her potassium level up, um monitoring a urine out purchase with that worsening AKI is always good practice. Um And if you're worried about any of that, um if you're, if you, if you do your at and you're worried about that patient escalating to a senior, it's always appropriate. So, hyperkalemia is an emergency situation. Um So informing a senior is not a wrong thing to do. Um And if at any point you are confused, that's the right, definitely the right thing to do. F so you're still the evening f one and your next call is from the Gastro ward. You called about a 40 year old man and he's been admitted with vomiting. They think it's likely, oh, just having a little look. What do I mean by assessing fluid status? So we can, I think this was part of one of the other talks that is um part of this series on fluid prescribing but assessing fit. Are they clinically dry or are they clinically overloaded or are they euvolemic in the middle? Um So looking for signs like tachycardia, dry mucous membranes, um might alert you to somebody who's clinically dry, um overloaded. It's fairly obvious. Have they got pulmonary edema? Have they got pitting edema on their legs? For example. And euvolemic are they sort of normal hydration status as well? So that's just very briefly, but hopefully we'll have a bit more on that as part of this series if that's something that people want. So hopefully that answers a bit of that. Um moving on to the next case, um as I'm aware, we're running out of time slightly. So your next call is from the Gastro Award 40 year old man with vomiting. Think it's likely gastroparesis due to s type one diabetes and you're told over the phone that he's vomited again a couple of times his heart rate has increased. Will you prescribe some anti sickness, please? What would you want to ask over the phone about this gentleman? Ok. Is there a baby cha is your IV Ondansetron more about his vomiting or especially BP? Well done with that? Yeah, absolutely. What's the contents vomit? Is this? What kind of vomit? I mean, I'm, I work on a liver water at the moment. So lots of hematemesis. Yeah. Is cheap potentially. Yeah. Yeah. So you've got some more information over the phone. So those are the observations. Thankfully, the BP looks all right, actually, but it's a little bit tachycardic. Um is temperatures all right. That's all right. Yeah, definitely. Looking at VBG there. So his BM is 11, his ketones are normal. Um, he's just told the nurse he's vomited a couple of times earlier this evening. This one's much larger volume. There wasn't any blood in it. Um, he's been norm managing normal diet and fluids earlier today. Um, he had some IV metoclopramide this morning. Um, that worked really well. It's now 11 pm. Um and he's not had bloods done for three days as we thought he was improving clinically. So that's the sort of thing that you get over the phone, right? Like I say, so you've got some next steps. People have mentioned an E CG is slightly tachycardic. You probably wanna review the patient, do a bit of an au you can give him some IV metoclopramide, he's had that this morning. Um but he's not had any for looks like about 12 hours. Um So you can definitely give us a further dose, especially if that's helped earlier in the day. Um And as someone's mentioned VBG for acidosis, so you are also worried that this is a type one diabetic or are they in DK A for example, they, I mean, they, the BMS are fine, ketones are fine but potentially thinking about doing that VBG for acidosis and I would seek advice from seniors cos this is a type one diabetic who's vomiting as well. Do they need a variable, right? Insulin infusion or a GK I if they're unable to eat at all? Um These are just things that should be popping through your head and we're taking some bloods and doing a VBG and that's the E CG that you get. Um and what electrolyte abnormality here are you most worried about? If you were to see this E CG, you've sent your bloods but you haven't got the blood results back. Nice. Well done guys. Yeah. Hypokalemia. Yeah, definitely, definitely hypokalemia there. Very worried about someone's mentioned T wave inversion. Yeah. So yeah, this is severe hypokalemia. Yeah. T wave pulled down. Well remembered. Absolutely. And this ECG shows very severe changes of hypokalemia. So, I mean, if you were to see this ECG and if even before your bloods are back, to be honest, um hopefully you've got A BBg that's got given you an interim potassium result. But this is the kind of hypokalemia that needs itu input. Really. Um This person's got ST depression T wave inversions. You can see U waves in there as well, these kind of up strokes after they inverted T waves. Um And sometimes you can see a long qu interval. It's well, it's well identified in the chart there guys. So hypokalemia is potassium less than 3.5 ECG changes usually only start to manifest when you get a potassium less than three. And as you guys remembered, hypokalemia, low potassium pushes the ECG down. So you get T wave inversion, ST depression and this prominent U wave. So that second diagram that just shows the T followed by the U um which can be quite good to remember. So just remember that biphasic little sign in terms of potassium replacement and treating this, you can give oral potassium replacement sound OK. Up to two tablets, T DS, you don't have to give two tablets, T DS. It tastes pretty horrible. So very mild hypokalemia. Yeah. And someone's already mentioning the IV, which is great. So you can give it at its maximum rate, 10 millimoles per hour on a ward usually. And even at that sort of rate, your nurses might get a little bit twitchy about it, to be honest. Um So, I mean, if you've got an ECG like that and really severe hypokalemia, um you'll be calling itu for central replacement um with monitoring of like telemetry, monitoring of an ECG trace same very rapidly. Other, just common electrolyte abnormalities are hypercalcemia and hypocalcemia. Um So these give sort of opposite ecg changes. I always remember in my head. So, hypercalcemia, shortening of QT lengthening of QR S hypocalcemia, prolonged QT and a shortened QR S. Um And the other one that you might come across on the wards um are, is, is hypomagnesemia and that can cause arrhythmias on an E CG, for example, S VT. So these are common electrolyte abnormalities as well that cause E CG changes. I thought to be honest, the potassium stuff was more likely to come up on an on call scenario and that's obviously what this talk is mostly about, about things that you might see on call. Um This sort of stuff is you are more likely seeing your day to day job and, and so I just pop them there for reference. Um definitely worth a bit of further reading after this talk. So in terms of my top tips for AC GS um use a systematic approach every time. So you're not missing things and just never be afraid to run it past someone else. If you're unsure when you're on call, you always have other people around as an F one, which is really lovely. So you've got seniors, you've got other juniors, you've got your sho you might even have another F one there if you're lucky. Um And so just don't be afraid to run it by all those other people when on call. Um There's also the cardiology on call team, usually in every hospital, if you're worried about an E CG, just give them a ring if, especially if someone's got chest pain and you think there's ECG changes there comparing to previous EC GS is really key um that can just help you or misplace spot the difference there of changes. Um And changes that weren't there on a previous E CG. Um just flagging that up to someone is often the best way to start um escalate early for chest pain and electrolyte abnormalities with ECG changes. Um I mean, if you've got electrolyte abnormalities where you are, where you have ECG changes, um it's usually quite a severe sign. So just making sure you're involving a senior really early on um for those can be helpful and just practice helps. Um EC GS are hard. A lot of people struggle with them. Um I definitely do it as an F one and it's just practice to be honest and getting that, getting your confidence levels up. And the only way to do that is just to look at lots of ECG S. So just trying to work through them when you're less under pressure when you're on your day job, for example, looking at ECG S whenever someone has one on the ward is a good way to just start off and discussing with a senior and checking that you're interpreting it, right. So just keep on practicing. Um I hope this talk has helped a little bit in terms of the strategy and just some common cases there as well that here are some little references um and further resources that you might want to have a look at. So there's a geeky medics, how to read an E CG, which is really, really good and comprehensive Life in the Fast Lane. That's where you'll find all the EC GS in this presentation and loads more that you can practice on. Um And the mind, the beli pages for electrolyte abnormalities are really good there as well. So we've got pages of hyperkalemia, hypokalemia and atrial fibrillation. So corresponding to these cases. So there's pages up there that are worth just having a little look at. I've popped the feedback form in the chat. Um I'd be really, really appreciate it if you could fill it out. It's super, super useful for us and helps us guide what we do in this series a little bit more. Um So this talk came about due to feedback from the first talk we had on chest pain when people wanted to learn more about EC GS. So it does work giving the feedback. I hope it's been useful. Thank you all so much for coming this evening. A apologies for my voice being lost at points in this talk. Um And I'm happy to answer any questions if you just pop them in the chat. Um Otherwise, thank you so much and I hope you have a lovely rest of the evening. Oh, it's lovely to see you. Thank you as much chat. Thank you all so much for coming. Oh, that's interesting question. Does a potassium below 2.4 always show ECG changes. So I think a potassium that's that low is likely to, it's really hard to say always cos we're talking about the human body, of course, and people are different and that is just the way it is. But I think someone with a potassium below 2.4 they'd be very highly at risk of having E CG changes. I think people would probably be surprised if they didn't. Um So that's my answer to that one. I can't say always cos people are always different. Um But I hope that helps with your question there and ask for the question about the recording and the power point. So yes, we will post our recording as catch up content. Um And obviously, the powerpoint will be part of that. We don't sort of send out the powerpoint as a separate thing, but the recording will be available as catch up content on Medal. We're also trying to post to our youtube page as well. So you'll have access to that. So, OK, that no problem just gonna stop the recording.