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thanks very much. I was very kind introduction. So as rough says, I'm taking the you're up this year, too. Study emergency prehospital Immediate care. I've tried to put together a few questions about things. I think they're important in emergency medicine. Um, we got quite a good mix of, uh, tough ones, you know, easier ones. And so just general things that you should focus your vision. All so thank very much coming along. We'll get started. Got over a cold today. So please bear with me if I sound a bit bundle up. This first one is about a toxicology. So 48 year old lady is brought into any recess with a GCS off. We move that over the way, actually account. Uh huh. See, question. Yeah. If you go off this a second, do you want We stopped, stopped the whole a second and then put it back on when I finished the question. Okay, so she's brought into any research for the GCS of mine. The paramedics found an empty brown bottle of medication next to her. There's unlabeled. She has a visibly distended abdomen. She has red and flushed skin on be quite large people's on examination. Your observations are that she's got a new auction requirement. She's on 15 liters of auction. Vyron on MRI breather. Um, she's quite tachycardia. Tachypnea. She's slightly hypertensive. Non examination Scott, decrease Bible sons, which talks A drum is being displayed by this patient. Is it anti cholinergic cholinergic opioids symptomatic or sedative? You go. It should be the pole. I'll give you a minute or so on that one. So really, the pool was already launched. I couldn't see the question right then. So that was about a minute or so already some of you. And so I'll give you more time on the next one. But the answer that when it is anticholinergic So this is something that I was found quite confused and still due to this day. So there's a sort of a jolt way of remembering the symptoms of anticholinergic toxicology that the matters a hatter blind as a bat in red is beating those sort of things. But sometimes I find that a bit difficult to remember as well. Just don't know, so find it a bit easier to remember. What the cholinergic is is a bit of an alternative. So so if every every speck Pokemon and they're younger, But this is broken sledge on, you can use that happen. Um, salivation, lacquer mation, urination defecate in gi upset. Um, assist just basically all of the all of the fluids, all of the bodily fluids. So if you could try and remember that cholinergic is all the fluids and you could try and remember that article allergic Has he sort of weird constellation of symptoms opioid benzos and symptomatic. So bit easier to remember. Um, opioid classically is, we know have smaller people's patients quite like to be unconscious. A sir. You know, it's gonna have a respiratory depression kind of element to it. Um, Benzo similarly, and likely travel do saliva consciousness is also drugs. You know, the intention of drugs is to try and, you know, put people to sleep. But in this instance, they're likely to have normal or bigger people's instead on the chances are, you're probably gonna have a question on your sort of Pts or your exam asking you to differentiate between the toxic germs. So the way I see it as you got cholinergic an anticholinergic. And then these three and there may be sort of serotonin agent ones as well, which are another big topic in their own sympathomimetics. They're completely different to opioids and Benzo's They're gonna be, you know, playing on your sympathetic nervous system. They're gonna have an anxious sort of agitated patient, wanted to fight everyone. Um, I won't go into What's the things I could be taking because that's related to the next question. But they're gonna be completely different. They're gonna be tachycardia, take and yeah, hypothermic is well, so this as you're likely to have a least one question for exam that is about toxicology. There's always gonna be one little thing in the stem of the question that can differentiate where there is just the size of the people between opioids and Benzo's. Whether it's this sort of situation, that they're taking the drugs in as opioids and bends, there's more likely to be used in a sort of deliberate overdose. Sympathomimetics more like to be used in sort of recreational drug use, for example, to move onto the next one so related to the first stem that we knew is an anticholinergic drug. Which drug is a patient like happy to have taken your me to re launch give you a minute or so. Okay, bendable. They're so for this one is actually. See now, this is probably a bit more of an unusual drug. We may not come across before, but it's the sort of process of elimination here based on the last question. So we know that diazepam is quite a, you know. Well, no Benzo Tramadol is an opioid. Very selfish. Yes, I am tablets. So to me, that's sort of narrows it down to imipramine and period or stick me. Um and we know that pyridostigmine is a bit more of a sort of a cholinergic drug instead of memory. Mean is, uh, type of tricyclic antidepressant. And maybe that was a bit mean of me. Um, because I'm a trip to the is by far more sort of common tricyclic antidepressant. But it's definitely worth knowing if you are their class a few other drugs in that class. Because TC a overdose is by far and away the most common kind of question you're gonna get about anticholinergic know there's some other ones your lands, a peon oxybutynin atropine. But realistically, I don't think anyone's could be overdosing on oxybutynin, um, as a sort of, you know, for the bladder problems after pain patients probably likely to be prescribed that, but I suppose it could be in a acrogenic one. But TCS is, uh, her comma Colon energetic is a bit more interesting. So the cold allergic, toxic drome Um ah, stick means like pyridostigmine neostigmine of things like myasthenia gravis and I problems. You're gonna phosphates. Ah, quite interesting. The insecticides of fertilizers. Do you might like to get a farm in the stem of those questions or as a new of agent? Now, hopefully you want to come into any sort of new of agents in your normal practice, but you could have some sort of question about someone and come to a normal chocolate sarin on they cause that's a constellation of symptoms. Where there throwing up, urinate and defecate in sort of bronco area. Just lots of secretions. So if you come across that a question, then you know why opiates? I think we're all familiar with the common kind of opiate, you know, heroin, morphine or something, and sympathomimetics, which I was about to send. The last question is it's likely to be recreational drugs or things like cocaine on fat. Um, in speed, um, patients, they're gonna be taking those, um, a sort of a night out and then coming into any be very tachycardia and aggressive. So I guess the contacts in which you have taken, um, is it is quite important is I don't know which class they belong to. Okay, So final question about toxin drums is going back on what we know that it's an anticholinergic. On it was a member mean, what kind of pharmacological treatment would you want for this patient? You are One question about it was a contact the brown bottle. Not sure arrival. Get it. But just friend was asking us was a brown bottle. Could, um, imply that it was either quiet, Quite illegally. It could be that the pharmacist maybe been incompetent and rather given a blister pack, they give them in a bottle of a Sometimes people can get regular medications in a brown bottle, but also, I suppose, drugs in a brown bottle that are packaged a lot lot easier to take them in a sort of quick amount of time and overdose on them. And if you have to pop amount of a blister pack, so I think that's a few more questions coming in. But I think we will. And, uh, So most people went for East Sodium bicarb, So that is the correct answer. So interestingly for ti see a overdoses not quite the same as all other anticholinergic toxic terms. Sodium bicarb is the treatment for T C E O dark, but not other anticholinergics. And it has two functions. Um, TC is sort of cause problems, but I was a sodium blockade, which then starts to widen. Curious is and cause the CT problems. Eventually it was a cardiac arrest. Um, it also causes a metabolic. Acidosis is, well, the sodium bicarbonate has to actions by correcting the problem with sodium, a cracked in the metabolic acidosis. It works quite nicely, not too many side effects with that. Thankfully, other anti cholinergics, we're effectively seen as we're having drugs that cause an anti Colin sort of a fact were basically giving them a cholinergic sort of drug, like when you mentioned earlier fazer stick mean to treat that overdose call allergic poisoning. Quite interested in terms of chemical warfare and terrorism, it's certain people in students of soldiers and paramedics and in place where they're more likely to be. Chemical attacks carry atrophy. A zoo that is has an anticholinergic sort of a fact. Treat the colon. Urgent poisoning. You can also get pralidoxime back and treated. I'm not exactly sure how that works, but I know the oxygen class of drugs, a good for colon ergic drugs and also Benzo's as colergic poison Concordes seizures Just some interesting points of contacts. We talked about Flomax, an ill on the last slight as an anti doctor benzos and is a classic example. Westchester. But it's, ah, it's not always good, and it's not always used because lots of people who take Benzo's long term build up a tolerance to it. Um, and if you if they have a sort of baseline level of Benzo's in their body and you use something to reverse it, um, they're gonna have a seizure, basically because they used to have in a baseline level of that drug in their body. So it's only really good for those who've taken acute overdose, such as in a sort of hospital set. And whereas where over zealous CT doctor has given them too many benzos or if it could be proven in a deliberate overdose that they've just taken Benzo's. But in reality, that's not really the case. People take one of the drugs. They can get it. I have suicidal intentions, just an interesting thing for context. If the exam question does specify already taken benzos and they don't take them long term than Flomax, that's a good answer. Okay, interestingly, as well. Stop taking relevant question. But I am overdoses really bad. It can cause strictures. And GI bleeding is very difficult to reverse on this interest in antidote called desk Very oximeter that can reverse it. Just have, um, trivia on tch. Tricyclic antidepressants about for overdosing does have a very narrow therapeutic window as well. This vote doing the bottom right shows not an EpiPen button autoinject if all atropine and private doxy, um, in case you ever come across any chemical weapons. So the good thing about emergency medicine is, ah, particularly for your sort of off skis and ski exams. There's always the Gallup did your free card. It's always a B C D management. Um, identify and treat the problems that you come across them. You cannot say that for any. Any question is always a B C D. But for some specific interventions, we want any C G because it can cause a cure as prolongation. Benzo is that you have seizures or tea series. You may want to do a paracetamol level. As as I say, people might take a mix overdose. Want Identify if there's a metabolic acidosis activated Charcoal is, um, treatment has mentioned a lot in toxicology. I've never seen it used. I don't think it's particularly well used or often use because, um, it can only be used in the first hour. And very rarely do people present in the first hour, but also because it can cause quite profound vomiting. And if you aspirate that charcoal, it can cause, you know, horrendous aspiration pneumonitis. So it's generally only used. I think if Patient's been intubated on, has taken overdose in the first hour. So unlikely. Another thing for Truvia. If they've taken a TC overdose, you can give them IV glucagon glucagon on insulin therapy to to separate options are really good for TC, a overdose, but I can also be used for beater, blocker and calcium channel blocker overdose. And it's not just a bit of glucagon. You're basically given them the whole hospital supply of glucagon to try and help this hypertension. It's not being helped by adrenaline or any other kind of trips. You can also give loads of insulin on blood sugar out of balance. Each other out on that could be good in certain overdoses as well. Are interested more information there on that link, and I wanted to read more. Okay, then a bit of pediatrics. I've got my pediatric emergency exam on, uh, Friday, so I'll be interested to see. Haven't started this one. A 12 year old boy as injured his elbow while playing rugby. She was a left Supracondylar fractures got a nasty fracture on the boys in severe pain is eight out of 10 pain. So what is the most appropriate initial analgesia? Quite, it's little answers. So about a question from GJ, who says if patient gets to Assad's because of a wide and QRS in TC overdosed, you give mark sulfate first and then with sodium bicarb. So I guess that's probably goes back to the the AB CD principles, the life threatening problem there is with, um, sort of the CT changes. So I would say you probably want to give some mag sulfate. If you see in two or sides on, then I suppose if it does develop into a full arrest and and you're going through, you're a less algorithm to identify. The cause is toxins is obviously one of those reversible causes. You could be given sodium bicarb that, you know, that really is possible opportunity If, um, he has already been given to try and contract that arrest. So, yeah, I would probably want to give myself a dan's sitting bicarb. So in interest in the mix of answers on that one. So I guess Well, we're asking is a code. Um all is it. Are we gonna press, um, heroin of their nose in a child? Are we going to give them cement in OCS or just some sort of tablets? And interestingly, so enter Knox is the top answer, and then some paracetamol. So all of your obviously quite mean that you just want to give paracetamol the seven and eight out of 10 pain? Um, I agree. Maybe I was a bit mean. They're saying the initial analgesia, but there is evidence behind it. So Arnold's easier and kids is something that's really poorly done, perhaps more so in younger kids. We don't give them enough pain relief because they can't do a blaze. A swell we would hope in a 12 year old, especially they're playing rugby. They could tell you if they're in severe pain or not, but eight out of 10 pain. You know, this is about as we can get and, you know, as future doctors', it's not really our job to dog 12 people assessing their pain from a scale of 1 to 10, you have to go on what they're saying. So as you can see, they're on severe pain, it's, ah, you know, a big boom, a large bone fracture, anything like that. We need to be giving them appropriate analgesia so codeine can't give to under 12. We should we give to those over 12, I should say, and even those under 16 there's There's a really reluctance to give it to paracetamol neighbor Profin. You probably would be given paracetamol some point, but it's not be working straight away. You want to be given something strong, straight away if they're in this recipe, a pain enter Knox is a great analgesia. But as soon as you stop half in it, the pain is gonna come back. Well, this is only good for people who are having their sort of bones reduced, their being moved about any sort of thing that's gonna cause them sort of brief pain and knocks is good for it. I'm sure the kid probably would appreciate it, but intranasal day morphine. I can't seem a bit extreme, but it works very well. Um, as long as they're not sort of bummed up like I'm of the moment, it can be a very effective analgesia. No. So it happened the other day in this ah case very similar to the stem of the question. So I guess the more of the story here is, uh, don't be mean to people when you're given our knowledge easier. Would pen frocks play a role here? We've got questions. Comments? That's very, very good question. Pen through oxygen. Great analgesia. You can see it is these sort of green whistles friend who has not seen a usual on sports pictures. Um, they're kind of, um kind of anesthetic. gases. Methoxyflurane has very good final Jesus. It's not really come into this country wide spread very much yet is very common place in Australia. I think is that becomes Mork Common Place to see that be added to the guidelines. Right then. So this next question is about the c g. So I will give you, um, a minute or so just to have a look at this question. I have, like, this CCG. Then we move on to the question, then we'll have a look back of the city if you want, so I'll give you a second. Not interruptive. This thing is that I haven't got their own systems for doing it. Okay, I have time for the stool. Come back to in the second. So simple. Stem of the question. 42 year old female presented palpitations. 12. OTC is performed as you've seen. What rhythm does the show? Okay, so we'll go back, and we'll just sort of talk through it just for a few pointers. Um, what is the rate? Um, is there a Sinus rhythm? All that p waves might be useful. Um, and have a good luck. Other. Any other sort of interest in changes that may concern you. A Z Well, okay, let's go back to the options. And so is it a f flatter Sinus, Tacky, SPT, or CT? She was be pretty unanimous. And then stop that, then. And so seems to be a unanimous decision that it's an SPT on. That is indeed correct. Well, um, go back and have a look. Decent years to why, that is so, um, why was it not airport? Where was it? Not Sinus. Tacky. So I suppose if you look at the rate here is pretty fast without counting exactly. You know, there's around two big boxes around sort of 1 52 100 BPM was pretty fast. Um, P waves probably may be difficult to discern on this one. Oh, suggest if you look closely enough, maybe the V f maybe leads one. You know, they're all they're. They're all that it just hidden in the fact that it's it's going so quick. And there are people Aves probably needs to look closely to check of. It is regular, but, you know, just eyeballing it does appear to be have ah continuous interval between them on the curious is are perfectly now, so those are the hallmarks of an sgpt. On I quite like a rhythm is. I think it's interesting, you know, you can use common sense to get to the the answer most. The time it is. All you need is six questions. Really, this is when I put together before for any learning module. I did so and there is electoral activity. The BP was more than hundreds was a taxi. Curious is narrow. They are two R Interval is regular, so it's likely to either be a Sinus turkey on SPT. But I would suggest probably that a Sinus tackiest more like to have a normal A normal QRS landed instead. So that's the main differentiating factor. If you look back as well, just briefly, we can see that there's also some ischemic changes as well as a bit of ST Depression in the the anterior more into your lateral until after this, uh, the more you know the most in a lateral leads. There's a bit of ST Depression, so that shows that he's going so fast that ah, does it have a schemer going on? So that's not ideal. Um, I can send this out. Um, this anyone wants this, but, uh, there's lots of other examples of these kind of algorithms online is well, so falling on from that. We know it's in SPT this, Uh this lady's got She's stable. She hasn't got any signs of heart failure. Hemodynamic instability, Talking as we know the BP is fine. Really on. She's maintaining her SATs. So how we treat it and SPT in a stable patient. I mean, all the road carotid, Sinus mass. Sergeant atropine DC cardioversion. No treatment for vagal blue is an adenosine. So I've got a question of why wasn't Sinus tacky? So I suppose the QRS is more likely to be closer to no 0.12 seconds and Sinus tacky. You know, that was clearly quite a narrow, complex tachycardia. Um, also, I suppose, the history of palpitations. You're likely to get Sinus tacky. Really? If you know you've been working out or doing something, so it's likely to be a pathological process. And also there's a bit of acid depression points towards a. There's also quite fast for Sinus talking. Just come out of nowhere as well. We got a common says amazing algorithms. Well, thank you. Hold on to that. So we got pretty unanimous decision again That it waas he regal maneuvers the damn dizzy. That is correct. So let's go through some of the options. You are amiodarone, which is a very good anti arrhythmic, but it's a bit like sort of bleach for your heart. And we could cause some nasty side effects of fibrosis, of the loans and probably thyroid. So not always a good thing to give first line, but it will treat SPT is. If this sort of treatment refractory and cardiologists say so, know something you're probably gonna be doing first line. Any D corrupted Sinus massage is a kind of a good maneuver. I've never seen it done, but it is. It is done. Atropine is more for bradycardias. That's not right. DC cardioversion. If the patient had any signs of heart failure hemodynamic instability, you would be going for the electrical cardioversion kind of root. No treatment necessary. Well, I mean, you know, she's hard to going fast. You got a bit of skin make changes. We need to do something on vagal maneuvers. The dentist Very good for that. For the research Council has their own lovely algorithm. Maybe not nice to mind, but it's very easy to identify what the correct treatment is for these kind of tacky arrhythmias so we can see a narrow QRS, regular vehicle maneuvers and the vehicle maneuver you see done. A lot is, um, the Valsalva, but sort of combined with other other sort of techniques. So ways I've seen it done is give a patient a syringe and they'll tell a patient blow into an empty syringe. And as they blow into the syringe, they'll have know sort of flat on the bed on lifting patients legs up. So the patient's going from sort of sat up and flat Teo lying down almost sort of below 90 degrees. So doing that with the valsalva seems to correct a lot of expertise. Very interested in kids. If you have a next CT, they dump them into ice water. If if it's a baby, which can be quite brutal, is well, that works very well, is that they're strong David reflex on. If it doesn't work, then we move on to a Dana's mean, um, if the warm the patient, but, uh, they likely to have a sense of impending doom and is, if they're dying and you can give three different bolus is of that through a big cannula in the A CF and the converse is their arms. It goes in because has a very short half life. It works very well. And after that, this cardiology's problem then was very interested. SPT. It's very interesting. Um, obviously cardiology on emergency. CGs is a big topic. Think SPT is is probably one of the more sort of basic ones for mercy medicine. I wasn't to me and then put like a bicycle by for secular block on, but, yeah, lots of things to have a look at. So next question, a 21 year old female is brought into the d via, um, balance, falling a fight at a nightclub. She is hypertensive cardiac, and I fixed dilated pupils and shows a GCS of 10. What's going on? What is the most Procrit initial intervention? Is it dextrose hypotonic saline? The more dopey level to rast term or urgent you a surgical intervention? Reas asked about the last question. If the patient with the SPT had chest pain would you consider cardioversion for them? Well, I suppose lots of them do have chest pain, cause palpitations and arrhythmias can be quite painful. But because cardioversion has his own risks, cardioversion has a risk, you know, with the need for sedation. Um, you know, calling in the knee statist. Using these sort of powerful anesthetic drugs carries its own risks. So unless the patient's acutely and well with signs of heart failure or shock, you aren't likely to be cardioverted them unless there's certain circumstances in airflow. You may cardiovert him if they only recently got into a it s v t four, the algorithm. Now, I suppose this question that this essence is above a new surgical question and RAV is a bit of a but the newer surgeon. So you may disagree with me for this one, right? Because the most popular answer first one seems to be allergic knew of a surgical intervention. But I was a bit crafty. I used the principles of medical education question formation year on emphasized initial intervention. So I went for hypotonic saline. No, you know, it may seem a bit counterproductive will be weird to give their e salty water, too. Someone who's effectively code in and having the Christians reflex. But there is method in it. So think you've all correctly identified that there is a sort of a head injury that's been sustained, and it's quite so see us. A patient is sort of Conan if, uh, cushions reflexes. This happened. So we go back to these basic principles of management emergency medicine A B, C D. You can never go wrong with that. Really, if there's a bleed we want to try and a very steady choir problems. So, you know, we do want to believe no more friend. That's a big red flag. We do want to intubate them. Really? Um, that was in an initial version. The crash and intubation ventilation was in there, but I took it out because have ever disagreed with my friend about different things about the answers. But interest in the intubation is very good for head injuries. You hyperventilate them. You lower the carbon dioxide in the blood that can cause vasoconstriction. Take the blood away from the brain and reduce the swelling in the brain starts very good. We want to make sure we talk them up with blood and fluids. If they are hypertensive. Um, but there are hypertensive. He said. That's fine. You want to raise the head of the bed after try and reduce the pressure on the brain, and then we come to sort of medical management. So you may have come across mannitol before being a good treatment for acutely raised into cranial pressure. Hypotonic saline is just a good um, some people swear by hypotonic saline over amount of talk. Some people don't like monitor because it can lower your BP. But I was reading some papers yesterday in in preparation for this, and, uh, there's no consensus, sister, which one's actually better, But hypotonic saline is preferred. Maurine this country, I believe. And the way it works is it Ah, keeps your blood nice and concentrated. So, uh, the water from your blood does not move into the cerebral tissues. It stays intravascularly, um two brain doesn't swell even further and pushing on their clothes box and worst in the problem. Patients need to be sedated, people with head and just be very agitated. And what you don't want is, um, push the BP further and fighting staff. That's not good for them. So see your prophylaxis like 11. Trust time is good as well on honestly new surgical intervention. You need new research for intervention. But before any new research is going to take your patient, they need to be reasonably stable. They need to have a CT scan. Newer surgeons can be very, very reluctant. Teo even discuss a patient with a CT head, and they probably will want to know unless your CT had so try and manage them, resuscitate them, keep them stable, then send him for a CT head after you've given them the hypertonic saline. Um, Marjorie B C. D. And they're newer surgeons could do their job after that, then. Okay, so this is, ah, bit of pre hospital medicine as well, a sort of pelvic injuries. So 29 year old motor cyclists is attended to by paramedics after coming off his motorcycle around 50 miles. An hour is open. Fracture is left radius, and he's d gloved his left foot. He's conscious but drosy and looks pale. He reports severe pain over his pelvis on observations. He's tachycardia is hypotensive. It sat so sort of hovering around, you know, just about okay, and he's a bit Cola's well. So what you going to do in this instance? You're still prehospital in this instance? Are you gonna play Kendrick splint? Are you gonna passively warm in with a blanket? Apply a pelvic blind binder. Always either crest apply a pelvic binder over is greater trochanter or reduce his fractured left radius. Yeah, so there's a good site notes Generally good to avoid motorbikes in life is ah generally the reason why Yeah, love rtc's and have head injuries. But where? How much you? Yeah. So that seems to be, uh, people have gone with the fact that they're to pelvic binder options that be the correct answer, but which is it is over the island. Crestor is going over the top of the pelvis. Compress it that way, or is it more towards the legs to compress it more towards the bottom? Well, people seem to have gone to see, but it is actually over the greater trochanter interestingly, and, uh, having fractures quite bad. But luckily, easy interventions like pelvic binder on wants to be mentioning the comments coming. Big difference to survival. Pelvic fractures generally seen in high end you traumex quite strong collection of bones, but especially motorbikes. People come off the motorbike, straddle the handlebars and spits it pelvis in half. And it's not. It's not good big falls as well. If you fall until you know one leg more than the other. After a fall, you can fracture pelvis. Like all this is different kind of fracture cause more Rashier and fracture. And you can easily be quite hypovolemia like this patient's and die from pelvic fracture, the usually venous bleeding. Obviously you can record artery, and I expect you're sort of a water than your iliac arteries. Um, but generally, if you're not too, you're bleeding. Probably not going to survive very long. Uh, it could be very fragile. Previously, examination about pelvic fractures would be to try and uh, to rock the pelvis. But ah, if anyone's to do that, maybe just one person does that not, You know, if your men student asked the rock the pelvis because it makes it a dislodge, a clot and they continue bleeding. Be very gentle. Um, have a good examination cut their sort of motorcycle, this letters off. Couple of troubles. They've got off that need to examine the patient, even if they're cold. Um, need to look for any sort of blood. Maybe not pre hospital, but there may be signs of blood in place, like a rectum and the external genitalia That will be signs of ruptures or structures like you. We throw any vessels, and then the pelvic binder is, uh, applied of the greater TROCHANTER is a diagram shows there is very good a tampon. Are did the bleeding. Keeping the pelvis stable on a low is more stable. Transport in a very easy problem is, um um, obviously, it's probably gonna require some sort of definitive surgical treatment rather whether that sort of open surgery probably gonna require some sort of urological surgeon vascular surgery, But individual radiology quite useful as well. Kendrick splints What? He used femoral fractures rather than Thomas splints outside hospital. Um, yeah, they are quite good. Just, well, complicated. Put on. Can you point out the exact pelvic fracture in the X ray? So I suppose it's probably easier if you google a normal pelvic Axiron and you'll see where the pubic symphysis it is. There's a huge gap between, uh and also, if you look at the sacroiliac joints is well there's a big gap where they are. This is an open book fracture. So, um, or an anterior posterior fracture, where basically you fracture one point and then because the power of is is ah, closed ring like a parliament, you fracture at the back as well. So it's not great. One of the questions There's none fluid First and Binder, um, you know that they will be true. But, um, I think that's probably reason why I didn't put blood and fluids because, uh, we want some specific interventions. As Rachel says, C A B C. D is always true and major trauma, and there's lots of options that could be good for initial initial treatment. But pelvic binder It's sometimes put on with the catastrophic hemorrhage. First part of the major trauma, because patients could bleed out so quickly on as well come on to talk about is probably better to use blood and not fluids if you have it. Some more trauma. 48 year old male is brought in by ambulance, falling a fall from his horse while competing in a show jumping competition. The patient initially complained of pain on the left side off his rib cage in the back of the ambulance. The patient's GCS Is it irritated and is no unresponsive to pay one available to recess. He looks quite gray and cyanotic is not well is tachycardia. BP is not readable, so it's probably quite low. Is De saturated on days quite unresponsive to pain. What are we going to do initially? What's the most appropriate initial management? They're gonna pop a chest strain and the 2nd, 3rd intercostal space. Are you going to form a finger? Thora cost to me? Are you gonna perform intubation of insulation? Give him IV morphine or perform a resuscitated thoracotomy? This may be a contentious wasn't But I have I have the proof on the next light as well as motorcyclist is probably good to avoid horses as well. If you don't want a major trauma, so be very interested if well asleep. Oh, you could pop in the comments. What, you think it's sort of going on with the patient? You know what? What the sort of diagnosis is said Speak Yes. So people going for attention Pneumothorax market also said a hemothorax which could technically be true, is well because I haven't said about percussion. So let's go with the fact that either those could be true is the treatment is the same for both in this instance. So let's leave it there for that question. We've almost gone for intubation of ventilation, so it's actually a finger floor costumey, and I will tell you for way. So attention, pneumothorax is you All right, Lee picked out is quite bad. It's the sort of, well, reknown signs of it not always easy to elicit a hyper residence and turkey all deviation. No, it was easy to do, Um and then no, always present as well and then sort of stressful situations and always done. Chest pain and respiratory distress are better signs. Obviously, that could be a few things because they're lower SATs sort of quickly d separated is quite a sense of sign of it on decreased decreased breath sounds, as we say, Yeah, so it's a tension with or Axid patient is Perry arrests. You know their SAT 75 that BP's in their boots, so looking good. Traditionally, the answer to this would be a needle decompression authority. Ghosts and T's s not is preferred in stable patients, but it is not good to put them in in the sack. Mustard intercostal space in the midclavicular line. I don't know if any of you sort of have ever seen a needle. Um, a needle decompression. In fact, I was one of the chest was answering the needle. Decompression is basically popping a cannula in that space and pulling the needle part and just leaving the plastic tube in it can kick very easily. Even with the biggest kind of cannula. No big people, it may not reach their pleural space. You can get kicked very easily, and it's not good. You wouldn't put a chest strain in the 2nd 3rd Intercostal spaces Medical regular line. Because that is a bigger needle. Onda. You would want to put that in on the fourth to fifth intercostal space in the midaxillary line instead, in the sort of safety triangle around there. Chest rain. Usually good for this patient is perry arrest? Um, they're about to arrest if you don't do something. Um, so what you do instead you a finger? Thoracostomy Now you may have come across the finger Thought cost me before, but I was basically very simple. You use a scalpel to make a whole a very small hole inside the chest. Ah, stick finger in and give it a bit of a wiggle. And then either blood or AARP comes out and relieves whatever is causing the tension on. Then once you've done that, it's a lot quicker than pretty low chest re. Uh, it could be done easily. Prehospital e uh, it's got less a risk, and also it can be converted to a chest and very easily. So we're effectively doing is doing a nice quick procedure. Drain everything on resolving this tension as soon as possible. On the right is a picture off attention. You meth oryx shouldn't really ever x ray attention pneumothorax because they usually quite unstable. It should be a clinical diagnosis. So I haven't mentioned intubation of ventilation, which was the most popular answer. So attention. Pneumothorax is obviously a sort of build up of Aaron, a closed closer of circular sort of one way valve, isn't it? So pressure is building up building up. So I guess the reason I don't agree with that answer is two foes. The first is information takes time. So while you might be inclined to intubate them while they're de saturating. It takes time, and they may have a resting by the second. The ventilation, positive pressure ventilation is gonna push more air into that Pneumothorax was gonna push more into the sort of thoracic cavity and increase the size of the pneumothorax until it made the problem worse. So, in a traumatic cardiac arrest, instead of doing a B, c D, we do something called Hot, which is managing the basic courses of dramatic arrest. So that's hypoc CIA, um, pseudo oxygenation on. Then you look at sort of Tampa not intention you mouth or ACS. You go through different procedures until you've sold a traumatic Arctic arrest. So intubation of insulation may be good for the chest trauma. No good for attention with or ACS think thought cost him. Instead, our can learn, and it's very good for thrush Sick drama. Thoracic trauma is a huge, a huge of conversation topic. Huge topic, emergency medicine. And there's a lot of different differentials and different treatments. Just every so often recommend having Walker so another trauma one but a different kind of trauma. 19 year old man. Let's go for a 19 year old woman. This time we haven't been mentioned. Many women in the stem of these crashes, a 19 year old woman is brought into recess for in a high speed RTC with a cow. She appears pale and clammy, and there is a red mark on the distribution of seat belt across her abdomen. She's tachycardia, she's hypertensive, and she has quite a high oxygen requirement. What is the most appropriate pharmacological intervention and looks metoprolol morphy trying examine acid or vitamin K? Okay, to have some questions about the last time or exactly is a finger thought cost to me. So things that would cost to me um Ostomy is a hole just basically just a small incisional hole in the side of the chest in the side of pneumothorax, because into the flu or cavity that allows air on do blood or whatever else to escape in traumatic card, a grass finger thought cost of these Ah, um, done on either side, regardless of whether attention new, more is suspected. So, question still coming in so hot I could remember exactly the other things, but hot with to teases hypovolemia oxygenation tension pneumothorax in Tampa nard. So if there's been any sort trauma. It's good to try and solve those problems. I also didn't mention a thoracotomy. Normal people went for a thoracotomy. So, like a laparotomy, auth or a car to me is a big old hole in the chest and clam shell for Khatemi. An incision is under the ribs on the rib cage is lifted in any suspicion off, sort of penetrating trauma to the heart or any blood draw for the may be causing a tampon on. They're not done very often. The evidence shows they don't have a very good rate of survival and also traumatizes ever in the room because you basically don't open heart surgery on a patient in front of everyone not into the Inter. You probably want some cardiothoracic surgeons on standby if you're gonna try doing that anyway. Back to rule traffic accident. The couch. Also not good to crash into a cup. Majority of people go on for Detroit, exam it acid, and that is the correct answer. Comment earlier mentioned. Both Tronic simulcast had been good and drama, and it is indeed is a very good drug 1 g intravenous of tranexamic acid. We use a soon as possible in major bleeding. Again, major trauma is a huge topic. A B C D Are the things you may wish to consider a rapid sequence induction if they haven't got attention. Pneumothorax, um e fast scans fast can is focused abdominal sinografin trauma. But the fast has got a different meaning. It's basically looking for free fluid in the abdomen on for a new authorities. Um, to identify the site of leader is they're not stable for CT. Wanna get some large bore cannula You in some gray orange can really in the antecubital fossa. And if you can't get them in because they probably are quite carefully shut down, you may want to consider it drops. Yes, accidents into the, uh, tibial plateau of the humeral head. Quite useful replacing blood with blood in hospital. That's especially important because if the ambulance crew was given bags and bags of fluid, they likely to have a big choir. You opathy by the time they get into, um, any. Because they've donated their blood so much, it may also dislodge the clocks. It's not always good to give loads of fluids could actually the major average protocol, guess um O negative blood and recess soon as possible. Um, where you are in the country, you may have a helicopter emergency medical service that carries blood and flies, doctors or advanced paramedics Toe seat of trauma. Um, very good end whales in London and Scotland's and places where well, she's gotten where they maybe lot of rural people in London where they may be a lot of for a major trauma, A very useful and they carry blood lots of the time. I could do intubation on the road. IV morphine is good final. Geez, here with the caveat that I may drop his BP, you may want to consider which hospital the ambulance crew takes. Patients, too, is well, because there are major trauma centers. Adapted three sort of things. Um, not just take them to a small district General hospital where they're gonna no, will be very happy. This sort of incident. Interventional radiology could be consulted if patient is stable and responsive. Teo fluid or blood therapy. But if not, they're probably gonna need to go for urgent surgery. Ideally, with a CT, no citizen really wants to be operated without knowing where the bleeding is because we say after sound, all the site of star been can indicate that this is little map of the other major trauma centers. Okay, we're nearly that. This is a bit of a mean question, I'm afraid, um, surgery. In the comments on 11 year old girl, another pediatric one is brought into e. D by your mother with difficulty in breathing. Difficulty in breathing came on suddenly falling ingestion of a sites of coffee and water cake. The patient's face swollen and straight there is audible. What is the most appropriate immediate treatment? A dreaded 200 g 1000 drink, one of those a photomicrograph. I don't know what a 10,500 micrograms trending higher dose. One intensify was no hydrocortisone IV. So G. J has asked again about needle decompression. A second to cost a space for Cardiss Progress test. Well, I was agonizing a bit, but this one, um g. J. Because the guidance says for the best results. If you're going to do a needle, decompression should be done in the fourth to fit into car space Midaxillary line. It can be done in the second or third. If you think that they have a small chest wall. But in my opinion on do you know most Edie sort of people. I don't see why you saw a mess around on the second or third space. If there's risk of it dislodging if there's risk of new uh, vascular problems, Um, and there's risk of it, Yeah, not working. So if card is did pull after their PT, then I apologize. But it's not based on the current guidance. When do you do a needle decompression of a chest strain? Needle decompression can be done if patients are stable. Chest rains can also be done with the patient's stable pens. There. Quickly, you want to do it, but if they're Perry arrests, you wanna do a finger. Thought it cost me. Ideally, you could do either a needle decompression, which has strangest there. Stable is the red color distribution sign of bleeding internally. Um, generally, if it's causes a contusion on the skin, it's generally indicative of those likely to be trauma underneath. So maybe I'm not sure I sent it was saying that is, but I can generally the case and the see both signs usually causes splenic trauma. Interested it's So what we gone for? We've gone for a 200 micrograms of some people go on for 500 micrograms. The answers, in fact, 300 micrograms on. Yeah, I hate questions like Restoril. The answers are pretty much the same, but it's important thing to know this came up in my osteo last year. It's a thing you're gonna need to know threat to entire career because epi pens are not really found in hospital. Saturns vaccinated dinners. Well, if it doesn't vaccinate, you know, the adrenal comes in the vials and you have to draw it up. So you need to know the dose is effectively over 12. We give them no 120.5 mils 6 12, not by three meals and then under that, as you can see, um, generally, you can also give no 0.1 mills want mills cardiac arrest, Actually, those that the absolute doses front of faxes and you should never deviate from them. Um, steroids, antihistamine to ship used to be a bit sort of popular. And the anaphylaxis algorithms, it's not really done any more fluid. Recess starts. I'm not on the no food resist is on the algorithm. and should be done because it causes quite profound distributive shock. So, adrenaline first, please, Cardiac arrest is one in 10,000. For some reason, these are found in already drawn. A syringe is so you don't need to think about those too much easier to check giving it to the right age group, and you've given them 10 mills of 1 mg of adrenaline, and that's always one in 10,000. Instead, Kid's dose no 0.1 mils per kilogram friend was evident. Went flying calculations. So another topic and probably relevant for PT cause you look up on yourself. This is what these sort of auto injectors look like for cardiac arrest, say a certain like ration. Important to know, though. Last one last one on. But it's not too bad one. Hopefully, a 60 year old woman, 60 or female, attends the easy with Frank Hematemesis. Just marked epigastric tenderness were observations. Are she's tachycardia, Actually, hypertensive on she has an oxygen requirement is quite high. We want a 12 e d. C g and oh gee, um, which is quite a difficult one to say. Soft job, gastro. Do it in Oscopy when a friend of IV fluids UM, IV PPI or Transfusion of blood. Let's not 50. What's the recommendation of? I am over, IV says in the comments about the last one. So given adrenaline intravenously is quite high risk. It was only really done by people who are consultants or, like sort of experience given intravenous adrenaline issues, obviously is not in a truck. Um, foreign cardiac arrest. So in those instances, the risk of a benefit of given Adrenaline IV uh, the benefit outweighs the risk in anaphylaxis. Um, I am Adrenaline is appropriate treatment. It does the job anytime you're going to give intravenous adrenalin in anaphylaxis is if the intramuscular adrenaline hasn't worked and that's only gonna be done by senior colleagues. It says in the algorithms. Six senior help. So they should never ask you for to give I IV adrenaline and anaphylaxis. Okay, so, interestingly, on this run in a cup of G, I bleed. More popular Answer is IV fluids, but as we discussed earlier, it's more important, Teo, give blood. Well, you can maybe pre hospital if you don't have blood on you on your fluids, you know, do whatever you can to try to bring the BPH, but, uh, ideally and replace blood with blood IV fluid is not wrong per se. You know, if if that was one of the options for your management, you wouldn't be wrong. But blood is a better option out of those options. Jeopardy! I bleed and, you know, sorry to have her on the point, but you can get out of jail with, you know, with any emergency, um, circumstances scenario, they dcd major hemorrhage protocol again. Transfuse Want to want to one red blood cells, platelets and FFP. It's gonna be a negative. Um, because you're likely to have you're likely to have heart to sit across much done quickly enough. That's fine. Avoid replacing blood with fluids. Ideally, to avoid cardiomyopathy but can be done in conjunction is necessary. Oh, gee, ds are not really done. Um, when patients bleed and they need to be hemodynamically stable. So even though, um, gastroenterologists are going to be doing the exciting stuff, it's ah, Edie, that's gonna have to do the initial recess to get into it. Intubation is, you know, probably quite necessary in these patients because they're gonna choke on the blood. That's no, you won't um, get some large bore cannula in my flow. Oxygen. If torrential we did, and it won't stop. For example, you know, if they want some terrible anti coagulant you controversy, then you can use something called Sanctura. Can black, more bleeding more tube, which looks a bit like What, What is on the right? It's not. That's not like the one I seen before, but it's basically a long catheter looking thing that goes only down to the stomach. It's got one balloon for the esophagus, one balloons for the funding of the stomach, and you'd fleet it, um, so hang out in the mouth and it temples a bleed. Hopefully, um, probably don't be doing that on. Patients are conscious, but you may have to if if they bleed interentual e. But they're probably going to be unconscious if they bleed interentual. Anyway, I have the PPI. Some reason that's a bit of a contentious topic. I only people are good for gastric ulcer Acid bleeds, um, starting some of the guidelines, but that that does tend to be given so infusions of things like a map result and then too oppressive, strong antibiotics like calf tracks over varcia bleeds to avoid any sort of nasty infections as well. So before we we finished any questions about any of the any of the topics we've covered, Major have a political will be. Actually, it was probably That's right. So 2222, back to the major damage protocol. Interestingly, um, them around instead of, like, admin work comes down with a bag of blood. They don't run it. You know anything? They just didn't bring it in. Quite. They should walking in. Got interested. Um, so it takes time was right. But he does keep some bags of own egg in the department, for instance. Um, someone said that they were told the initial measure to give IV fluids is more practical while waiting. That is, um, possibly true. But a Zeiss a e d does carry blood and would be most appropriate if possible. How do you know Sangstat can Blakemore? Tube is in the right place. Us as an interesting question on be possibly one for a gastroenterologist, but I've never I've never actually seen one done. Um, I think in the in the more modern ones, they are sort of a balloon along the whole lens, so probably just Ah, seven in far as you can is probably gonna meet a bit of resistance after the, um, procedure for your sphincter. But don't quote me on that. Don't try it. Don't try it, please. Can you please talk about the management of burns? Burns is a big topic. Um, definitely want to look up for your your finals. The apartment formula is used for, um, working out IV fluids requirement and burns. Um, burning more than 15% off the body surface and adults can cause profound shock. More than 10% of kids who called her phone shock. You need sort of specialist to SRI treatment. First date needs 20 minutes of running under cold water on be wrapped into me like ling film. Um, as you come extremely painful, given things like enter knocks and IV. Morphine is very important. Even changed dressings on because a whole host of physiological problems So something worth something worth reading up about. When is permissive hypertension considered? Um so things like major trauma, permissive hypertension can be used to stop. It's a sort of internal bleeding. Mainly permissive hypertension can be done. Teo basically dislodging o'clock and causing more bleeding. Um, yeah, um, something to read up on that one as well. Low BP with open leg fracture. Would you reduce the fracture? Will give fluids first. Well, it depends on the on the sort of circumstance. Really. It depends if they're sort of newer vascular compromise. So open leg open fractures generally should be done in theater because you want to avoid any sort of infection getting into the wound on the on, the petitioning to be debrided as well around it, but