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Okay. Okay. So, um, obviously a mercy medicine is a huge topic because it goes over so many of the different medical specialties. Just very, very acutely. So there was a load of things that I wanted to put into the slides today as well as going over some Texan tricks for your Oscar is. So before we start, I just wanted Teo kind of see what things that you were hoping to get out of this session. So in the chance, if there's any of these topics that you'd like me to focus on more so I'm just because I'm aware that we've only got two hours and we need to get through many as possible Any of these topics that people would really like to focus on more this before we fast. Okay. Shock. Lovely. Intense. 80 assessment, surgical emergencies. Okay, great. Lovely. So lots of different things. Perfect. So we'll try and get through asthma. Now these as possible on if if you want any more information afterwards, please feel free to shout out and get in touch with me. I'll leave my email on the chat on. You can ask me for some more information. We can go through, but I've tried to pick. The very main topics are most likely to come in your exams. Okay, So before we start, I'm just gonna go through tackling the acute station. So I think my slides of got mixed up for a second. Hold on. Uh, do do do. Oh, I've lost my slide. That's okay. Well, so what I'm going to do is just go through some top tip. So the first slide that I had, which I've lost, unfortunately, that goes through how to take a history in your acute station. So for lots of medical schools, they're only goes through about it four minutes to take a history in this acute setting, because obviously these patients are acute. Um, well, you want to get a brief overview of what's going on before then going on to what you're going to do for your investigation. So one of the good ways of doing this is kind of thinking very, very briefly. And there is a There is a good way of doing this by using the acronym Ample. So am port looks at the patient's allergies. This is really important, because if the patient is critically on. Well, you want to quickly go in on get their allergy status, just in case in you to give anything to them. Very acutely. Your M is your medications again. If you want to give the patients any acute medications that side of the bed, you want to make sure that there's no contraindications. You want to take their their past. Medical history pee again. It's past medical history so quickly looking at what other co morbidities the patients have on. Then you've got your L, which is the last time that I ate or drank. This is important in the acute station because if patients are keeping and well, they might need to go to theater or they might need introvale bit later on. Who knows? It's a murder. See medicine. Things can escalate quickly, so getting a quick understanding of when they last eight and drank is really, really important. On Ben. He is the event. So what happened to the patients? So that's a little bit more about what kind of went on. So if it was a full, you want to look at your before, during and after to see if it's any kind of symptoms beforehand that are contributing to whatever happened before. For example, during what happened during the fall or fit was a seizure. Did they have any abnormal movements, whether any witnesses? Then after, how did they feel after, How did they get up off the floor? Did they get picked up that someone help him up? Did they get up themselves with a weight bearing any symptoms afterwards? For example, in epilepsy, they might have a post. It'll period. They might have not very good memory. So those are all things you want to think about in that he for ample, So I'll go through that one more time. It's a for allergies, em for medications, pee for past medical history l for last time that eight and drank and then eat for the event. So what happened? Why they here to see them? This is in my slides, and it will get sent out to you. I don't know why it is disappeared from here. Other things on history. If it's a female and they're of child bearing age with, for example, abdominal pain always take a gynecological history. So is there any chance that they could be pregnant as it could be an ectopic or a complication of this. And ST I, for example, um on you want to also think about anything else that might be relevant. So try and link your symptoms together. If they've got abdominal pain, always ask for, you know. Are they no vomiting? Do they have a passing passing flatus? So it'll be farting essentially on bar They are they going to toilet? Are the opening the bowel so important things to think of If they have shortness of breath, think about palpitations. You want to be thinking about your A C s? Who have you got any chest pain? You know, if the patient has a fever, have they got any other infective signs? So I want to be thinking about headaches. You want to be thinking about cough with sputum on you want to be thinking about You're in a swell so we'll move on, then two investigations during your during the skis. So osteo is when you go to talk about your investigations. It's always really important to have a structured approach, So the way I like to do it is I like to think about the the order in which I'm going to do these investigations. So firstly, you have the bedside. That's when you're right with the patient, and they could be done very, very quickly. So as you can see on the screen those things that just taking observations, taking urine, stool and sputum for cultures, or looking for any infections, any CG could be done really easily at the bedside as well. Congrat really important in some conditions I'll speak about later, and then things such as taking a blood glucose or B M and two tones if they're in DKA andan ABG could be done really quickly and can give you a lot of information in a short nap. Time about this acute. You're my patient and you got your B your your blood's so you're taking a step back and I'll you've got your blood. You going to send them off to the lab? So that's that extra level on top off the bedside. So that's as you can see lots of different blood tests, and we'll talk more specifically for each of those in different conditions later on. On the imaging later run. Take that further step back, send the patient for imaging. See what's going on inside on, then. Remember, any time you mentioned that you're taking a test or you or you are you are ordering anything you need to explain. Why, why? You're going to be doing these tests and we'll speak about this bit later on. Then going on to the management again and not structured approach is really, really important. And the way I like to do it is saying conservative medical and surgical. This then categorizes things in and shows that you're looking at patients holistically in a stepwise manner. So obviously, before you jump straight to surgery, you want to take the patient comfortable. For example, you want to give supportive care that will be covered in your conservative and medical management. And so it just means that you go in that step wise approach, and it helps you group things together when you're thinking under pressure in your skin. Okay, the next thing that you can have in your acute station is your a spot. So this is a tool that's used by many different organizations in the UK as well as abroad for handing over patient details on it. It helps you again to compartmentalize all of these different things you're speaking about. When you're talking over the phone to a colleague, so s Far Century stands for situation. Background assessment on recommendation on if we go through each by each. So we've got situation first. So this is basically a very brief overview off why you're calling so really important. You want to introduce yourself before anything, So hello. My name's oh, he and one of the medical students working in any on I've got a patient for you to hand over. Are you busy? Can you speak? So that's always a really good way to do it. So just making sure they're available to speak on that. You're you're telling me exactly why you're calling? Another thing is, well, tractor you're speaking to If you're speaking to another one of the medical students in, you know, on the ward or with the medical ranches on core, it might not be that useful. So always check your speaking to a swell. Then you may want a situation so very briefly explaining what's happening. So I've got an 82 year old female who I'm worried that is having a stroke so very brief off. You're gonna be saying exactly what you're worried about their straight away when you're calling them. So they have a bit of an understanding of why you're calling and they conjugate the urgency. And then you go into your background a little bit more about what's been going on. So you give the full history about the patient on the reason why you're actually a calling them. So you're here. You want to be saying things that they told you in the history, some of the past medical history and the medications that you're taking on anything that really builds up the picture in your A. That's your assessments, that this is where you tell them about what you found when seeing the patient. So staying your a b C d. E. Telling them all about the observations that you've seen within this assessment. And if you have done any tests just saying what these tests were on, what the most important and outstanding test results are that are relevant to the case and that can actually build the picture of what's wrong with the patient so you don't want to give them every single blood test just the ones that are important and abnormal. That builds to the case And why you're worried about the patient. And finally, the recommendation. What you want them to do That's really important. Eso to finish off saying I'd be very grateful for you to review this patient as I'm worried again. They're having a stroke. Um, please, can you come and see is in the next 10 minutes. So it's really you got to be really firm what you want on and see what they recommend. Okay, so now we'll move on to the primary survey. So I'm sure lots of you've done this with in medical school. But what we'll do is we'll go through the primary survey one more time. And what you can do it? Each part what intervention could do to solve any issues. So who can tell me what a stands for? I'm sure you all know what does a stand for on your A B. C. D. E. Assessment. If you can type it in the trap. Yep. Lovely. It stands for airway. So, airway, within a way you want to basically see, Does this patient patient Airway? Am I worried that they're going to essentially have no and way to breathe. So a great way of doing this is talking to the patient. So saying, Mister Jones, you okay? And if he responds and you know his airways patient and you can move on to be, if the patient isn't talking, then you might need to be a little bit more more, uh, kind of comprehensive with your assessment. So checking for the noise is whether the patient's gurgling, whether they have strider. So that's kind of like when you breathe in deeply that the sharp, high pitched sound that suggests that there's a really obstruction or partially way obstruction. If the patient's snoring or he can hear crackling and bubbling in the throat, then that's also secretions that can block the airway. So this is something you can do. You can also, if you think about your a less guidelines, put your face close to the patient's face and feel for the breath. Listen for the breath and look down the testis well, so if you're worried that the patient's airway may be compromised than what you want to do, first is your maneuvers. If you're not worried that the patient has a C spine injury and you're happy. Then the head tilt chin lift, which is century just lifting the head back on opening up that angle off the airway could be really effective. And then the jaw thrust is where you put your fingers on the back of the angle of the jaw foot kind of push it open, which helps without to moving the spine on. Then you got your airway a drink. So these are things you can place in the patient's airway to keep them open temporarily, just in case they do shut off. So you got a oral pharyngeal away, which is this one here and there, also called good ALS or abbreviated toe O P. A. R or pharyngeal airway, and they can be placed into the patient's mouth. They are only suitable if patients do not have a gag reflex. If they have a gag reflex, it will kind of irritate the bottom of the patients throat, and they won't be able to tolerate it, so you can try it if they don't tolerate it. Take out nasal pharyngeal airways. They go through the nose on. They're much more tolerated and very comfortable patients could be alert and have those in finally and I gel, which is a type of their way that is placed kind of super over the blotter. So above the glottis in the larynx on it essentially is halfway to a definitive airway s. So it sits there, you can leave it. You don't have to hold it in on. You can use that as well during your CPR to use a lot prehospital. And then finally, if you are really worried, for example, if there GCSF lower than eight or they're not breathing for themselves, you need anesthetics down a s, a p. You need to intubate the patient inventively so B is your breathing. So here you're essentially looking to see how well the patient is ventilating. And I like to think of this is the three easy. So you've got your effort. So how how much effort they're putting into their breathing? What's their respiratory rate like? Are they using their accessory muscles to draw in the air? They really struggling. Are they grunting? How they got distress in Children? Do they have recessions? Which is whereby the skin is kind of pulled in due to that increasing pressure, trying to draw everything in during inspiration. Then I like to think of efficacy so they're breathing. How what factors is having in the body. So I like to look at the SATs at this point to see how well the they are saturating on. Then, of course, your effect. So what is the patient doing her? Come, we off school, take a listen to the chest eso. Here you'll be listening for a rental. E. If there's no air entry, you might be thinking of something like a pneumothorax or kind of a whole collapse of the lung. Are there any added sounds, crackles or any crepitation in things that you might be wanting to listen out to? And then is there nothing? Are they not breathing where that's where you think they might be in cardiac arrest in escalate? Appropriately. So, of course, at this point, if you want to, if you're worried about the breathing, if they got sat lower than 94% or lower than 88% and COPD patients and give them oxygen 15% on on a 100% by a non rebreather mask, which is the one with the bag here to see is your cardio or your circulation. So here you're gonna be doing everything related to the heart. So you want to be doing your capillary refill That could be done peripherally using the thumb so you press down for five seconds and then you release and you count to see when the skin becomes back to normal. Color from being white and blanched on lower than two is normal. You can also do it centrally, so I when I'm with patients, I like to do it at the sternum. So this just means that if you are perfectly shut down, you're worried about blood loss. If it might be a bit slower in the hands, you can check it centrally on. It should respond more quickly, and it gives you more of an idea of how centrally shut down the patients are. Then you got your heart rate and your BP. Of course, these are things to see how well the patient refusing on. Then you might want to assess the other areas of blood loss. So if there's trauma, for example, you want to look at all of the areas that patients can bleed into, so you might want to have a feel of the abdomen. Have a quick look under the arms on around the chest to see for any bruising, but that will come later in the year. Assessment as well. So with your see if there's any issues, obviously you need your IV access A s a p. So you want to get your two white ball cannula in in both a A cf so the anterior cubital fossa on. If this fails twice, then you can use an Ioan Interosseous on this. Is this this device here? So it's a nail that is, or drill essentially, that drills into either the top of the tibia or into the humerus. A matter Century is another way of getting fluids into a patient when they have no veins, because they're just so, um, well. But that's only when you failed to cannulate twice, and they're very, very unwell. Fluid resuscitation, Obviously you can give your no 0.9 saline. 500 mL is a bolus as a fluid challenge and then carry on giving fluids. But if they've lost blood and that's important to replace blood for blood, so that's the major hemorrhage protocol. But if the patients are bleeding, then you can use lots of different devices. So, for example, this is a Sam's blintz, which is essentially a pelvic binder that helps to reduce the volume within the pelvis and bring it closed if they have any bleeding within the pelvis. That's a Kendrick splint here, so that essentially, if you've got a femur fracture, which is a huge fraction, you could bleed very lots and lots of your circulating volume through these about 22 liters of blood, then essentially helps to reduce it and put it back into place by pulling the leg, as you can see here on direct pressure. So if there's spurting blood, you could just put direct pressure on to it on, but we can see from there. Okay, so D is your disability. So here you could be looking at the mental state of the patient, so your AFP ooh, which is alert voice pain and unresponsive on your GCS, of course, is your glasses of coma scale, which I haven't gone into today. But if you'd like me to go through at the end, please feel free to ask at the end. Um, glucose. So you want to be thinking, Is this patient actually hypoglycemic? And that's why they're unconscious. And also, if you're thinking of things that just DKA so you can get that either one of the M or you can do a a BG and VBG on, then your temperature as well. And then he is everything else. So expose the patient from top to tail on. Look, absolutely everything look for any rashes, any injuries, deformities and bleeding because a lot of the time you might be focused on one issue that might be distracting is where is there might be something else that we're missing, so make sure to look at the patient in total. So what happens if this is not a medically and well patient? What happens if they had trauma? What happens if they've had a ninja? So there's a couple of extra things to think about. It mostly even starts right before you do any of the other steps you want to be thinking of here. So there's an extra see on the top of a B C D E. On that century stands for number one, controlling catastrophic hemorrhage so that's all of those things I spoke about and see. You just do them a little bit earlier because you want to look to see if the patient is bleeding out on. You. Look in these different areas, so you'd have bleeding on the floor, so that's when it's really obvious. They're spurting out blood and you can control it there. And then and then you want to think about the other places that the patients completed, so that's in the chest in the floor. Axe. Um so, for example, a hemothorax. And do you need a chest X ray to look for this abdomen? So that's why you'd want to feel the abdomen to look for any tenderness. And you can also do an ultrasound scan to our fast scan as well to look for free blood in the abdomen. That's something else have not gone into today. If you'd like to let me to speak about at the end of condo, the pelvis again, let me said that pelvic binder to close that volume to keep the BP from dropping because of bleeding into the pelvis and then femur and long bones again with that Kendrick splint to pull that leg back to normal. And then, if there's been any injury, think Come have a seat. Spine injury. So if they've had a full all, they've been in a huge accident. Think about fractures in the C spine because you go moving the spine. The mat can cause huge disability later on. So you have to mobilize immobilize the head so you'd have someone holding it so actively mobilizing it where you can use sandbags on sometimes collars. But these are very controversial and aren't used all the time. Okay, and that's the A B. C. D. So now we'll look at some of the less guidelines. So these are really important guidelines, and all of this information is on the recess council. But let's go through them step by step, just to show what you will need to know for your Oscar this well, as when you graduate junior doctors. So firstly you want to see is the patient breathing on are the unresponsive, so that goes back to your A B C D E. That's your first A and B section. So if they're not call for help immediately in our hospitals, it's 222 on the phone, but it will be some. It might be something else for where you work. But get help A s, a P. You might want to put our cardiac arrest crash call on. Then you want to do your CPR, so 30 compressions to two, which means 30 compressions to two breaths. And you want to get the defect on the patient at this point. So at this point, it's still 30 to to Even if you were in hospital, then what you want to do after you've attached the defect pants, you want to assess the rhythm and there's two different rhythms you could be in, as I'm sure you will know. So first you gotta struck a bill rhythm. So that's your your VFC, your ventricular fibrillation, which is where essentially the ventricles are just vibrating and not really beating in a synchronous form. So you're not getting any cardiac output, and then you've got your pulseless uh, HVT. So that's where your heart is pumping synchronous. But it's beating so so quickly that nothing is having a chance to get out of the heart. And that's why you can't feel a pulse. Um, these are really dangerous. So that's when you want to give one shock a DC cardioversion shock, using the defibrillator there and then assuming you see the rhythm. Then once you've done that, you go back to your CPR for two minutes, and after about two minutes is is over. You want to then check to see if the rhythm has changed. After that, you've got your non shock about rhythm. So that's the other side of the algorithm on a century. This is for PE's A, which is pulseless electrical activity. So there s E G might be completely normal, but they have no pulse, and they're not responding, so they're still in cardiac arrest. This can sometimes confuse people a lot, and then you're a systole. So that's where you have a complete flat line or a wiggly line when nothing is really is nothing really going on on here. That's when you give your adrenaline straight away on the dose of the adrenalin really, really important Not to get this mixed up with the anaphylaxis dose, which will speak about later 1 mg off one in 10,000. If you give the anaphylaxis dose, that's a huge dose on. It could be really dangerous to the patient. So that's your adrenaline on. Then you do your CPR and go back to the beginning so you don't give you a shock. The important things to know about the shock about rhythm a swell is you can give adrenaline, but only after you've given the third shot on then amiodarone as well. And that's basically helping to met medically cardiovert back to normal rhythm. So not just giving adrenaline and shocking them back into the rhythm but medically helping as well on. And then, obviously you want to be repeating this adrenaline every 3 to 5 minutes. Eso every other CPR cycle, essentially. So it's really important. Then, when you're thinking about cardiac arrest to think about your reversible causes. So what can we do while we are giving CPR that can help push the patient back into Sinus rhythm, So there's four hatreds, so we've got hypoc CIA hypovolemia hyperkal in your or Hypokalemia, and then hypo or hyper thermy a. So with high pox here, in terms of testing the patients not breathing, you can assume that they have no oxygen going around their body, so that's when you give them the oxygen ASAP. So you want to go, uh, intubate the patient. Once you're intimate patient, you don't have to do 30 to 2. You could just do continues chest compressions on Just give six breaths per minute. So about one breath every every 10 seconds, which is normal it within this cardiac arrest situation. So I'll just repeat that. So before you, before you get definitive Airway. So, for example, you're just doing a draw throat with the bag of mask you've not got a endotracheal tube in or a Nigel, then you need to do your 30 to 2. But once you have got your endotracheal tube in, that's when you could do continue CPR. You don't have to do 30 and then stop. You can carry on doing it, and you could just ventilate every 10 seconds. So six per minute. I hope that makes sense, because that was something that I didn't really understand. Why first understood, then, in terms of your management, as they say, your oxygen 100% you're aiming for. I'm just giving it throughout the arrest score. Then you've got your hypovolemia. So you want to be thinking Well, could this be a cause you want to be thinking? Is the patient really dehydrated? How they got sepsis. Have you been bleeding? These might be things you might be thinking. That might point towards this. Whatever is the arrest you want to try and get IV access is well as you can, Whether that's with the cannula, whether it's with the I owe, uh, drill, as I mentioned before, into the bone on even, you know, a CBP line, but not really done in an arrest situation. And you want to give them fluid. So you can have say that we're tackling that high level in your area and you might want to give blood in a hemorrhoid situation if they are hyper or hypo Kalinic. What you need to do during the arrest, it gets, um, blood and send it off to look at the ABG or VBG. So sometimes you might need to do a formal stamp, which is where you start into the into the femoral family artery because the small ones are so shut down. You're not really going to get anything at all because the heart isn't beating. You're not going to figure that pulse. So that's something that some of the more senior doctors get to do on. Once you have got back to you, obviously send it off for analysis. If they're hypokalemia, then you can start re infusing the potassium. But just to be careful not to give it to you quickly on, then the hyperglycemia. Then there's Sorry, hypo hyper calcemia cholemia. Then you need to think about you're following. You're hyper clean your protocol which is giving your calcium gluconate, which helps to stabilize the myocardium, your insulin and your dextrose. Yeah, act rapid. Um uh, this helps to basically kick all of the potassium into your cells out of the bloodstream and then your salbutamol nebulizer as well. That can help reduce it, but that's not really very much used in a cardiac arrest int. But if the patient is a lot, I well, and that's something you can consider and then finally, if they're too hard to to cold, you can see this by measuring their core temperature and also considering where they were found. If they were found outside in a really cold area, then you know they're going to be, you know, Hypo Firm it on. And you can also see some signs sometimes on HCG. But in an arrest, you won't have that. So just considering the clinical context on obviously warming them if they're too cold, so increasing the room temperature. Putting bear hug is on a long as it doesn't impact the Codec resuscitation. And then also, if they're hyper thermic, then you can consider calling. So ice packs reducing the temperature open. When those using fans flushing the patients, for example, with a catheter with cold fluids, all of these things can help reduce the temperature. Then you got your 40 is too. The first one is your from best, So that could be an M i or a P E on. What you need to do is consider the clinical context. And also you can do an echocardiogram so you could do an ultrasound of the heart to see. Really, you know, has there is a longstanding evidence here off some cardiac failure on the management. Um, I is a perfect attendance coronary intervention. So PCI. And yes, you can do these while the patients are actively in cardiac arrest with just something I found absolutely amazing s so they can actually do work on the coronary arteries while the patient is arresting. Although this is very ran, its should be a really, you know, very fit and healthy patient for them to try and salvage them on, you know, get them back into Sinus rhythm at this point and then p e. You can consider giving thrombolysis on at this point. If you do get from a license, then you need to do CPR for 90 minutes. This is standard, and if you go over that or sorry if you if you don't do it for that long, then it won't give it enough time to work. So you have to do it for a least 90 minutes before considering alternative option tension, the muscle or ex. So this is found when your oscal taking. So while the benefit test is giving the breaths, you can have a lesson. And if there's loss of breath sounds on one side, that could be an indication of attention. But also you could do an ultrasound of the off the lungs to see whether there's any air trapped in that pleural space, which is the e fast scan, and if you do a suspect This. You could do a needle decompression in the second intercostal space midclavicular line, or alternatively, in the fifth intercostal space in the anterior axillary line and then eventually put in a chest rain. Or you could do a thoracostomy, which is just essentially placing a hole directly into the chest wall and letting the air out. And that's something that is done a lot in trauma. Tamponade is when there's lots of fluids running the heart, stopping it from beating on. So this is where the fluid collects in the pericardium so you can look at this again using an ultrasound. So this is something you're both looking for this ultrasound on. If you do see this, then you can have a pericardiocentesis placing a needle into the chest and aspirating all that fluid back. And if not, you could do something called a clam cell thoracotomy, which is not done very often. And it's only in very severe situations, usually trauma traumatic arrests where they essentially open up the chest, they flip up the rib cage, and they can directly cut the pericardium and let the fluid out again. Not very commonly done on only and really, really severe situations. And then finally, toxin. So with this, you want to be thinking about what they had before they arrested. Have they have any EKGs that show signs of poisoning? What about the the BG? Do they have any drug screens? Can you take any collateral histories Like a drug charts on essentially the management for this is antidotes on continuing CPR. So that goes through our A. L s guidelines. Hopefully, that's, um, quite comprehensive for you and get it in your head. And if you have any questions, let me know later on, after you've got this return of spontaneous circulation. So once you're successful, then obviously ABCDE again make sure to keep reassessing the patient. You want to aim for that 94 to 98% oxygen. You want to do another EKG to see how the heart is doing, and you want to make sure they go to i d you because these patients are very poorly after a cardiac arrest and need one toe one help. Okay, so the other things I'm gonna go through our the tacky rhythm years section. So this is where patient has a heartbeat. That's going so so fast that there, But they need to be cardioverted back into normal Sinus rhythm. So what you do first is obviously you do your A B c d E approach, as we mentioned before, and you want to be looking for these life threatening features. And I like to think of these using the acronym Hess. So that's your heart failure, your ischemia, your syncope or your loss, loss of consciousness and your shock. So that's that's a nice way to remember it. Does the patient have any of these signs? If yes, you need to try and cardiovert them straight away because they are at high risk of going into that cardiac arrest. And we want to avoid that for this patient so you could go three shocks, understand, proceed or sedation. So you give the patients small amounts of anesthetic drug to help them become comfortable, and then you shot so you could drive three times. And if unsuccessful, you can give that amiodarone. Is that medical cardioversion that you can give, and you can also repeat the shock one more time. So now if the patient is stable, what do you do? Well, the first thing you do is you think you look at the QRS complex and think, Is this broad or is this narrow? So let's look at the board first. So if it's broad and it's irregular, any irregular rhythm, it's most likely to be some form of a. So if it's broad, there might be a bundle branch block that's causing it to be broad of the baby. Other issues that are causing it to be brought other complications of heart conduction. But essentially what you do is you treat it just like you would any other F, which will come onto in a moment. Other things it could be, so it could be polymorphic ventricular tachycardia. This is also known as to Sarge depart on. I'm sure you've seen this where it's kind of you see the squiggly lines that kind of bigger on, then smaller and then bigger again on what you do for this, you give your magnesium sulfate at 2 g, and this will help convert the patient back into Sinus rhythm. If it's regular, then it's most likely to be VT on. Obviously, these patients have a huge risk of it going on then into a pulseless VT. Which is a cardiac arrest. So what you need to do is give that amiodarone again, that medical cardioversion at the doses said here on. But if you think it's an ST T, which is a super ventricular tachycardia, so that's just where the atria are beating very fast. Travel in the ventricles and then you treat it just like on the other side of the algorithm, which will come on two now. So if it's narrow, then so now you've got a very fast beating heart with a very narrow QRS. Then now you want to be thinking about your vagal maneuvers. So what this is first is essentially, you're trying to trick the body into slowing down the heart by increasing the vagal nervous system. So you're trying to activate that parasympathetic nervous system lot different ways to do this, and I've seen lots of different techniques use the name any during my year last year, lots of them were the cardio at the carotid massage, so that's basically trying to trick her borrow receptors into thinking that the blood pressures are really, really high. So they wanted to reduce the heart rate on bring it down to help compensate other ways you can do it and get a syringe and blow through a syringe really, really hard while taking the legs up That can also do it on. And also if you got a very small babies, for example, or you've got access to ice buckets and you can dunk your head or or basically the baby into into very quickly into ice water, and I could help shock them back into that. So heart rate. If this is not effective, then you want to give a dentist seen. So Adenosine is a really fast acting quick drug that only last for about seven seconds in the in the body on essentially, what this will do will help essentially just stop the heart for a couple of seconds and then swap it back into you Sinus rhythm. So it basically restarts the heart in a way, So what you want to do is you want to give 6 mg first and see if it has an effect. Then you want to increase the dose to 12. If it's not worked and then finally, you want to increase it up to 18. This is the new dose. It used to be 6 12, 12. But recently, in the nice, guideline says he's changed to 18 to you can go up to that higher dose and then finally going on to looking at the Curis again. If it's narrow and it's irregular, then you want to think about a F So you want to give fetal buckers to reduce that heart rate, and you want to consider things that will essentially help to convert it back into normal rhythm. So digoxin or amiodarone? Um, and you can also think about obviously, if the patient has had it for more than 48 hours, they are at a huge risk of throwing a clot and having a stroke or a P E. So do you want to think about essentially anticoagulated with first for a week or so for for three weeks before then? Considering this if they are stable? Okay, so now going on to the other side, what happens if they got a really, really low BP? Sorry, I'm really, really low heart rate. Well, again, you're ABCDE. You want to be doing all the stuff that we mentioned before about a B C. D E. And then we want to be thinking about the headaches. So all of those life threatening at first signs of the shock or syncope this scheme here on the heart failure. So once we've done that, if yes, they do have signs of adverse science, you want to give your atropine. So atropine is a drug that's used to increase the heart rate back to normal rhythm. So you want to give that at 500 micrograms IV on Ben? What you do after giving that, has the patient actually had any improvement? If know you want to give more of this atrophy in and think about other things that will help squeeze the heart a little bit quicker to help it get the cardiac output out. So that's the isoprenaline your adrenaline at These are all things that are mighty you can help you with. Later on all you might want to be thinking about putting some pads on the patient's chest and actually electorally shocking the heart back into normal rhythm on you wanna get expert? How a swell and eventually you want to be thinking about putting a pacemaker in or getting Tranxene a spacing so pacing the heart through the blood vessels. So if you s they have had a satisfactory response or they're not unstable, that quite stable, then you want to think well, are the at risk of going into cardiac arrest in the hearts stopping? And these are all of the different things that that could be. So they might have also had a cardiac arrest in the past or the heart stopped. They might have a heart block. Um, and also, if they've had a ventricular pause Great in three seconds. So, yes, you want to be doing the same things. It's no. Just keep them in recess, keep them observed, and make sure they don't deteriorate. Okay, so that is the A less guidelines. I understand we've gone through that quite a lot, but hopefully that's giving you a good overview. So I will go to shop. So can anybody in the chat name me a couple of names of a couple of different types of shock that we can have? What different shock? Yeah, great. Lovely. Yep. You're all saying the right things. So we've got essentially Keiper really make shock cardiogenic obstructive and distributive on all of These essentially are inadequate tissue perfusion that leads to hypoc CIA there in ischemia and then eventually the organ death. So that's great. So we'll go through these so hypovolemia. So this is essentially where we've not got a left blood beating around the body. And there's two different types. You got your hemorrhagic on your nonhemorrhagic so your hammer object is bleeding. So all of these different causes cause the bleeding have a nonhemorrhagic. It is where you get shift or fluid within the blood. So either, from you know, diarrhea and vomiting physically losing fluid and not taking anything in DKA burns, where it's evaporated from the skin on pancreatitis, where they have this odd shift in fluid due to the kind of a systemic response in pancreatitis. So you get a loss of circulating volume, essentially on what the the body does to compensate for. This is number one. It be's it constricts, which means you get very cold peripheral peripheries so your hands are cold, clammy and blue on. You get tachycardia because the heart's trying to really increase that cardiac output. And if we remember, cardiac output is the heart rate times a stroke volume So how much blood is the essentially goes out of the heart for heart, be on the card it volume or the cardiac output kind of alongside the systemic resistance, which is your basic construction will help Teo affect the BP. So there's different classes of hemorrhagic shock on these are shown in this table here and essentially what this is. It's really important you don't need to. Those for asking is, but it might be useful for exams, but essentially, what the I wanted to show with this table is that you've got to lose a lot of blood to see a loss in your BP. So up to 40 and 40 plus percent of your blood volume lost. You actually show any drop in the BP. So if the patients got a low BP, that's a really late sign, and it's something to really think about. Other things obviously observers, you respirator. It goes up as you lose more blood. Your pulse pressure goes lower, which essentially means that BP gets low in lower and lower, and then also your urine output as well. It goes lower and lower until you're not passing any urine at all because your kidneys aren't getting enough blood. So how do you treat this so hemorrhagic? Obviously you want to give your blood, so activate the major hemorrhage protocol. If they're in class three or four, you want to be giving one toe 1 to 1 ratio off you're packed red cells your P R C. You're F F p, which is a century or leader of the components in your plasma on your platelets, which will help coagulate things. You want to be giving warm blood because warm blood helps to avoid cold, which is a part of the trial of death. Eso the tried of death is essentially coagulopathy acidosis on hypothermia. These are all of the things that were a century. Kill you in a bleeding patient, so give warm blood on. Also, you want to give calcium chloride if you're giving more than four units because that helps to essentially coagulate a bit better on your tranexamic acid as well. So this helps to caught the blood better on Do you give 1 g over 10 minutes? You got to think well as the past medical history. If they're on warfarin, you want to reverse that warfarin. So think about giving you vitamin K either or early or IV on your prothrombin complex or bury plaques, and that again helps to reverse the warfarin and help thumb clot. And you want to check your iron are because if you check the eye and I'll give you more specifics on what to give on what dose. Essentially, then you put your nonhemorrhagic shock. Well, essentially, you've lost fluid, so you just need to give that fluid back. So you want to give your bolus fluids of 500 mL of no 5000.9 saline. As we said before, a monitor that BP and treat to the specific cause, which will go on two later so cardiogenic shock very quickly will go through to cardiogenic. Shock is essentially where the heart stops working, and so you have a reduction in your put a result of chronic Fadia. So there's lots of different causes. So am most of drugs on a reason uses well under these the investigations that you need to do so you want to look at the EKG, check for a stimulant, your troponin. We'll get an X ray just to rule out anything else going on and you can do an echo, a swell to look for a cause, and then, depending on what that causes you, contract it. So again. If it's an MRI, you want to do your ah PCI trauma. You want to be thinking about referring them to cardiothoracic surgery on getting some surgery to help that infections. Obviously, you want to give antibiotics and start your sepsis. Six. Your breathing years. You want to revert them to Sinus rhythm as we mentioned before, and you want to stop. Your drugs are given to those other things you can do, which were bent more post graduate. But it's interesting to think about. So there's something called an intra aortic balloon pump, and this essentially is a pump That helps to, um, help with the contraction of the heart by by changing the pressure in the order to actually affect the after load. So it makes it easier for the heart to basically pump out during. Systole is also something called Echo, which is extracorporeal remembering oxygen, which essentially is a replacement for the heart in recent here, shock and then also thinking more long term, we can do transplants on. We can think about hell body, which your left ventricular assist device, which are a bridge to transplant on help with chronic cardiac failure. Then we've got obstructive shock. So obstructive shock is a reduced cardiac output and tissue perfusion Do Teo obstruction of the great vessels. So what we have around these vessels are we've got some sort of squashing external pressure that prevents the blood from being pushed out so these could be intrinsic within the heart so they could be valvular stenosis, so kind of problems with the the width of the vials when they're open on also some true Mirza as well. So atrial myxoma is where there's basically a huge tumor pressing in on the heart from the inside. Then you've got extrinsic. So this is tension in math or a cardiac tamponade of the most common. And you can also get some obstructive syndromes of the Venus Cavor either inferior assume periods Well on the most common. As I said with attention, you Mutharika, Kartik tampon on which we have already spoken about a little bit before. Some of the things to think about and you'll have the sides look over later um, and some of the the ways that they present. So as we said, the most important things about tension they're gonna have only cool chest sounds and expansion. They're gonna have hyper residence on percussion on. Also, the tricky is gonna be deviated away from the side of the pneumothorax. Due to that increasing pressure, we've already spoken how this is treated. Essentially getting that air out by putting a needle in a drain or your finger in there in a month or a cost me opening the chest up Codec tampon on, as we said, is fluid around the heart of the signs that known as Bextra I. And so that's where you have your increased respirator increased JVP, increased heart rate and then your muffled heart sounds a swell. So that's where you can't hit the heart because there's fluid in the way something investigations that you can see the CD. You can see there's a low curious voltage because there's something in way Oh, the hot, uh, electrical ultimate. And that's essentially whereby you have kind of a big your s and a small curious and a big us, and it's more curious again on that's just due to be kind of the fluid jiggling around in the heart as it beats. Then you've got a chest X ray to do an echo. And as we said, the management is sticking a needle and getting all the fluid out. Okay, distributive shock. So septic shock. Because there is an example anaphylactic diabetic ketoacidosis, toxic shock as well, which is not really support that well in medical school. Neurogenic shock on your Addisonion crisis. I'm gonna go through the first three and more detail and then we'll go into a little bit more about the others as well. So sepsis is a huge thing that is probably going to come up, come up in lots of your exams. It came up in my own ischium. It's really important. And essentially, this is a type of life threatening end all damage that's caused by the body not responding very well to infection. And so there's something called serves, which is systemic inflammatory response syndrome, whereby the body has this kind of internal inflammatory response that causes these symptoms. So a temperature heart rate, respirator on abnormal blood on your white blood cell. Count on how this relates to sepsis is that if the body has all of these symptoms as mentioned here because of an infection, that's when we call it sepsis. So it's essentially the body is not reacting very well to an infection, and so has a lot of these symptoms here. When it becomes a problem is when you have sepsis. So this inflammatory response on an infection and then you have some more complications, so your blood, the BP goes low. You have a lack of oxygen. Your liver starts to fail with coagulopathy and low albumin levels, or you have renal failure. Then essentially, this is where it becomes severe and when it become septic shock is when you have all of these symptoms. But they're not responding to resuscitation with fluids, so you have a very low BP that's not getting increased by your fluid resuscitation on your lactate, which is a measure of a ski mia. On organ death is really high. Four is a very, very high result, so that's when it becomes septic shock. So we're going to go through our management. I'm sure all of you know this. I'm gonna go through it really quickly, but any sick patient, your A B C D E escalate to a senior, and then you want to be thinking about other things, so you wanna be thinking about your sepsis. Six. So you know all of this, so it's your oxygen, your blood cultures. So I always try and do this before giving antibiotics, because then that means that you have exactly what the what the the bacteria is without getting influenced by antibiotics. And you can also take bloods of this time. Give your IV antibiotics broad spectrum. As per your local guidelines. You want to be giving fluids to help get that BP up a smudges you can, and you want to take a lactation well, so taken a BG or VBG. Make sure that the patients not too acidotic on you want to reassess. It's every two hours, but any urine outputs you can either catheterize the patient or monitor that input output charts on. That's what we should be aiming for is ear 0.5 mL per kilogram per hour on, of course, has a lot of you know this all needs to be done within one hour, and then other things you need to do. Don't forget your monitoring. So your news chance every 30 minutes to make sure they're not getting worse. You don't want them to go into an arrest. You want to give them arterial lines for the BP, your CV CBA. So that's your your central venous access. So that's essentially a central line, which is a great way to get into fluids very quickly straight to the heart and then go to I t u. These patients are very sick, so if they are getting worse 70 i to you. Okay, so we'll move on now. Two anaphylaxis, which is another type of distributed shock. And I'm sure all of you know anaphylaxis, but obviously you want to be doing your A B c d. E. You want to be looking for any issues within these and trying to treat them, so give him oxygen. If they've got a wheezy chesty, give themselves beautiful. If they've got a low BP, you want to give him fluids and you want to call for help was quickly as you can on the important things, as many of you know, is your adrenaline. So this is where you give 1 mg off one in 1000 adrenaline. And these are all the doses for the different age groups. I just recommend he sit down to learn. Then once you got them in your head, you remember them on. A very important thing to know is that in the 2021 guidelines, they've actually removed hydrocortisone and corn phentermine from the algorithm. So now they don't see that they have much of an effect in these patients on. Essentially, they don't help on slow down that process of getting adrenalin in. I am as quickly as possible. So that's the anaphylaxis guidelines. So diabetic ketoacidosis. So this is another way that we can have a distribute of shots on a century again your A B, C D. E. And you want to diagnose the DKA. So how do you diagnose it? So, firstly, you want to look for symptoms of DKA, so the patients are going to be nauseous. Vomiting will have. Abdominal pain will just be very kind of generally unwell. The shortness of breath they might have ketone smelling breath on. They'll have it usually have a history of diabetes unless they're very young, and it's the first diagnosis. So the test that you want to do two diagnosed DKA. If you suspect it on, they should form a part of your A B C D. Number one is your glucose. So if they've got a high glucose off 11.1 or more, or they have a history of of diabetes and consider if they've got ketone above three in the serum or on a urine dip above two, then this suggests. And then finally, on your ABG on your VBG. If you're very that should be 7.35. Sorry, but if you're lower than 7.3, then your acidotic And if you've got bicarbonate lower than 15, this is a diagnosis of DKA on How do you drink? Tip? Well, you follow the protocol. So here's the protocol that is used in the United Kingdom of the moment on in the slides of Put it in the comments section if you want to access it. But essentially, you want to give you a bolus fluid off not 0.9% saline over one hour, and then you follow the criteria, which is essentially just giving more fluids as per practical and then you want to give you insulin a swell to start bringing that down. So that's your 0.1 unit per kilogram per hour as part of your protocol, and that's a fixed rate, so you want to give that continuously until the patient gets better. Okay, so those are the three main types of just give you a shock, which is gonna come up in your exams but quickly go through the others. So toxic shock is one that's not very commonly. Oh, that's wrong. Sorry, this shouldn't say this. This is wrong. But toxic shock because essentially a type of shock. That is a dysregulated host response due to a dis really dysregulated shock due to a toxins that might be a lot of people know. For example, having a tampon in too long that can release a toxin on the body reacts. But also it can be due to a bacteria that release toxins. And that's the most common cause told on If I carry on there we go. There's the correct slide. So essentially the management for this is blood cultures, antibiotics, steroids, fluids on vasopressin is so this will help essentially just help with the fever, rash and hypertension. Which of the symptoms Urogenic shock? His spinal injury, which is essentially the sympathetic nervous system, is damaged due to spinal injury. And so patients get low BP with a normal heart rate on directly refill on. This is where the pick their skin is very pink, confused on. The males have pre a prison, but they just have hypertension so they don't have a normal picture off hypertension with the tachycardia on the cold and clammy skin. So it's something to think about, and you treat it just by monitoring the patient key from the comfortable and helping with retention and then finally, Addisonion crisis. So this is a form of kind of very severe ad. It's Addison's disease. We have low aldosterone leading to hyper clean me A on hypertension. So the management is giving steroids. So 100 mg of hydrocortisone IV or I am on then think about this hyper clean year that we've mentioned before. Okay, so I'm aware of the time. If everybody wants to take a quick break, fleas feel feel free to do so. It's three minutes past eight now, so we'll have your back at eight minutes eight minutes past day. If that's okay and we'll carryon. I understand that I'm going through this really, really quickly, but it's a lot to cover. And if we don't cover everything today, then feel free to have, like, a sides and you mail me afterwards. But hopefully this is helpful yet Please feel free to take a five minute break and then we'll get back quickly. But we'll go through some of the important parts of my card in function first. So as we know that the symptoms of an MRI, as they have you know, central, trusting, crushing chest pain that radiates the left arm and up into the jaw associate it with kind of financial of breath but clammy and a bit, um well with nausea, vomiting might be very sweaty and die for a six palpitations and impending doom. But one thing I want you to be aware off this. Be aware off. Those were those patients with a silent Am I. Not all patients will have these symptoms, um, easier. Generally middle aged women or diabetic patients on the reason for the diabetic patients is that because they are more prone to neuropathy with their diabetes. This can also affect the autonomic nervous system, so they won't feel the pain because they don't have the the the nerve supply, like other people may have on Also, their heart's not going to be much faster. They're not going to get more short of breath because they don't have that nervous system to react in that way. So be really careful. If you think someone's not quite right there a bit nausea and vomiting that they just don't feel very well. Always just check out. It could be an M I in these stations investigations to do, say, splitting it up again into the bedside, the bloods in the imaging, your observations first, Really important. Every patient ABCDE. Then you've got your E C g. Of course, you You know what you're looking for. An MRI. You want to be looking for ST Elevation? Your Q waves, which are pathological for for, uh, ski mia and your T wave inversion on also an ABG because the patients might be short of breath. And if that ischemic you might want to be looking for a lactate well for your blood and see so you want to excluding other causes of cardiac pain here. So in F B C and a CRP to look for a first day anemia that could be a cause of chest pain. Because you're not getting enough blood to be coronary artery, so could be causing pain on Also inflammation. Do they haven't infection that might be causing this? Or could it be, um, could it be a pericarditis, which will go on to later one? Also using these in your bone profile? Could it be an arrhythmia that's causing these issues that may be leading to of the chest pain and the lack of the fusion really important? One, of course, is the troponin. It's and it's really important. These are serial. What I mean by this is that they're taking it two sets of time number one being when they get straight into a any so straight away with the extra bottle. And then number two is about 3 to 4 hours later to see whether there's an increase decrease, whether it's staying the same, because if there is increasing, this is more likely that there's a scheme you're going on. And so it could be diagnostic for an M. I So if you also are thinking about an M I or something going on that you might want to be looking at risk factors as well. So seeing whether the lipids are high looking at their glucose levels on because the myocardial infarction is a central pain, it could actually be kind of like a pancreatitis type picture. So we want to be doing an an amylase and an LFT just to exclude other, more powerful causes off chest pain. And then finally, your imaging do your CT CT angiogram, which is actually looking at the vessels. If they're well enough on your chest X ray as well to exclude any other cause of cardiac pain or testing. And then, of course, you can split up into your A. C s. So you're cute Coronary syndrome. So unstable angina, as many of you know, is when you have a normal troponin, a normally see GI, but you've got this kind of m I sounding chest pain. Essentially, it's in stable angina on. They have no evidence of really a scheme ear. That's longstanding. Then we have an end stemi. So a non ST elevation am I So these are gonna have positive proponents. So they have increased after the four hours in the troponin levels. But there s a geez, come on, look normal or they might have some kind of STD depression. Some Q waves. So not really kind of classic of the chest m e. And finally, the stemming, of course, is gonna have a positive component as well as ST Elevation or new bundle Branch block. So, looking at the kind of X, um, the EKG off the, um I So an ST elevation is considered, what, more than one millimeter above the eyes of electrical line. Or, as I said, left bundle, branch block. That's new or symptomatic on. Also, we need to think that different areas of the heart to gonna localized to different parts of the C. G. And I'm sure you know this very well by now. But this diagram, I think, really shows it quite nicely about where the pain, where the pain all the ischemia is associated to on what s allies are associated. So I thought that was really good. One thing I wanted to mention that I really struggle with with m i t. Is this reciprocal changes and What this essentially means is that if you have an ST Elevation and some of the leads, then automatically you will have a ST Depression in the other leaves that are associative on the acronym that I used to remember this is pales. So, for example, if we take an anterior stemi So this is this year A. So you haven't ST Elevation in your anterior leads. Which, as you can see here are your green and your blue. So these ones over here on do also, of course, your yellow. So all of this section here, if you've got a like a necessary elevation here, then if you look at your eye so you're inferior leads. So over here they're gonna be in ST Depression. So the opposite. So it's like positive and negative and all the arrow show that if it's anterior will be inferior. You have an inferior ST elevation. You're gonna have a lateral ST Depression on. I'll show you an example of that in a second. And then you want to be thinking about Q waves and T weights so Q waves can be normal, but they are abnormal. If the one millimeters wide on two millimeters deep. And basically what it suggests is that suggests wall thickness ischemia that hasn't gone all the way through and t waves. This is where they invert, of course, On did it becomes permanent 24 to 40 hours later. So if you've got a patient trust pain, look at an oldie CG. See if it's new or old as it can help you with a diagnosis. So here is a E c G. I'm gonna give you about 10 seconds to have a look at it, and then we'll go through what we all think it is. So I'll give you 10 seconds if you want to pop in the chat Once you have had enough time to look at what you think it might be, anyone know what type of em I might be Okay, I'm gonna go ahead. So it's an anterior lateral. Am I? I'm sorry. The pictures a bit small, but as you can see here, these are the anterior and lateral leads, and we have a huge ST elevation more than womanly meter Above the eyes are active line. Well, this is almost tombstone in here on just to make a point about the reciprocal changes. If it's an anterior, where are the, um, the ST Depression is going to be. Does anybody remember? Yeah, great. Inferior. So you could see them here so you can see that it's swapped over on the other side. So that's something I really struggled to understand. But it can actually give you a clue as to if you've got the diagnosis right on the or skis. So that's something I always look out for. Um, it's pretty handy to know. So you all know this, but essentially the way you treated. Am I so acutely? You know, you give your Mona that's your morphine, your oxygen, oxygen, your nitrates or GT N on your aspirin, which is a tube just to increase the surface area so it could be absorbed through the buccal mucosa Bit easier. So once you've done all your vested a shins and you're looking, whether it's the same or in and stemi, you follow this kind of protocol, and I'm going to go through quite quickly, as I'm sure you will know it. But just a recap. If you have identified a stemi and you can get to a percutaneously coronary intervention Sweet within two hours, then you go go straight to the PCI center. You give your dual anti platelets so you've already given one, Which is your aspirin. Your second is your pass a grill on these are all taken from your your nice guidelines. And he also give heparin because this essentially helps to, uh, if in the blood a little bit so that when you're doing the intervention going through the arteries that you're not going to get blood clots, we will make it worse on your bail out GP I, and essentially what this is, it helps ups. It helps with the helps with preventing the clotting on it's given during the procedure on that. If not, you can give from a license. So this is where we essentially give a clot busting drug such as tenecteplase the alteplase to clock bust the issue. Um, then if we go to the other side, we've got just and stemi. So you want to give you a fund? A paradox. This is a form of heparin. Um, so essentially helps to thin the blood while we think about how bad this and stem years when we do this by calculating a grace score What the great school does, it sees how badly patients are, What? How much risk We are off having mortality after this semi, so 3% and less is considered low. And if it is, we can just give the dual anti platelet. So this is your take our law. And if they are high risk, then you need to think about PCI. If the unstable go straight away just like the end stemi. But if they are stable, then you can think about going in a couple of days time, still giving your dual anti platelet, and you're happier in for the procedure. Um, great. And then, as you know, with chronic management you want I think of it is the four raises just makes me remember aspirin. So you want to continue that lifelong your atenolol, which is you beat a blocker or any type of meter blocker. Your atorvastatin, which is your statin at a secondary prevention dose. So this is a higher dose than if someone was just on it for hypercholesterolemia. And then you're a singer bitter, so you're reducing the BP and your duty integrate as well. So we'll just go over quickly. Other kind of symptoms of chest pain. Eso that's going to be your pericarditis. So this is a century that inflammation of the pericardial sac on it is present very, very similar to to, UM, I, which is why it should be ruled out. But essentially, they have more pleuritic pain. It's so it's relieved, really sit forward. It's worse when they take deep breaths in and when they're lying down. And they may also have some flu like symptoms, which me suggested why they have had this inflammatory response. So you might have had a cough fever just not feeling very well on. Then they'll have on oscal take a shin. Sometimes it's very rare, but it's in the textbook. They might have a pericardial rub, which is essentially, that's really inflamed pericardium rubbing against the heart as it beats a mills who have high respiration, high heart rate investigations. You'd like to do so all of your inflammatory markers, your E C G on the the EKG was going to see in the corner here. Generally, throughout all of the leads, they'll have an ST elevation, which is saddle shaped, so it kind of up slopes a little bit more than in in in a stemi, and you'll also see there's an S T a P R Depression. So this is this part here is going to be lower than the others, and it's not very well did in this diagram. But it's essentially, this part becomes lower. There's lots of different causes for a pericarditis is some of them are showing here, so you might want to be thinking about specific tests. You could do so if you're thinking of an autoimmune disease. If you've not really found anything on the initial destinations, you might want to be thinking doing things like anti CCP on Rheumatoid Factor, which tests for root rheumatological test for rheumatoid arthritis. You might want to think about us are and some of the other inflammatory markers you might want to be thinking as well off drugs. So you might want to do it this drug screen and looking at the patient's medications on dress. Listen, dreams. That's when they have pericarditis. After they've had an M. I so think about the past medical history and then management again breaking up into conservative medical and surgical. You want to educate the patient and suggest the changes in their lifestyle that might help thumb on supportive cast, giving them analgesia and then to prevent this inflammatory process continuing. You want to giving NSAID so nonsteroidal anti inflammatories for two weeks, along with some gastric protection. So a proton pump inhibitor such as, um Metrozole and then Coltrasine so cultures seen is another anti inflammatory drug not too sure how it works, but it's also used for gout, so it's very good at helping to reduce the inflammation that's going on in the heart, and that's a long term of three months on. Then, if it's not getting better and you're still concerned, then you can give us steroid to reduce this information and also think about these causes and what you can do to prevent any other called any complications. And then, finally, if there's any effusions, as you said before, like tamponade or just a big effusion that's causing issues, we can pop a needle in and aspirated Vira pericarditis and pieces. Okay, so now it's moved to another big topic within emergency medicine, which is acute exacerbation of heart failure. This is a huge proportion. Patients that come into any in the UK on Benny of the symptoms, essentially just heart failure a lot worse. And these patients of decompensating, so they'll have short of breath, will be really working hard to get their air in. They might be because I'm not getting the air in very well. It might have agitation and confusion will be very sweaty and exhausted from trying to get as much air in. It's possible they'll have low SATs because a lot of the time they'll have pleural effusions on a demon in their lungs because they're so overloaded with fluid because the heart's not working. Um, they'll also have this F 3rd and 4th heart sounds, which are gallop sounds, and this is because the heart isn't pumping efficiently. So we're having these extra heart sounds with the blood filling. I'm not pumping out very well on. Refer Back to You, um, cardiology for the reasons why behind this, they may also have computations on the lungs because it's so full of fluid. With the edema on, they might have a raised JVP in the neck as well, and they'll have puffy legs very pitting edema in the legs. So to investigate these patients. You want to do a new straps, and if they are looking like they're shocked, do you want to get him to recess for cardiac monitoring on one toe? One attention you want to Then think about any CG. You want to be looking for causes that might have precipitated this heart failure. So looking for the M. I looking for tachycardia, looking for other reason years. ABG is really important. These patients, because they might be going into respiratory compromise on they might require an IV or bipap to help them with this thing struggles with that breathing, and then you want to be thinking about blood so again, your FEC and CRP to look for infection, going to be looking for a reviews that might be precipitating it with your bone profile and your views. And these you want to be thinking about anything else that might exacerbate that you're the heart failure. So liver failure, fibroid issues and you want to be looking at the risk factors as well as I said before, the important one is your BNP. So BNP is is essentially a diagnostic test for heart failure and in chronic heart failure. This will be very, very high. So in the acute setting, it's not as relevant is more used for monitoring and diagnosis on first incident. But it's something you can put in that specific to heart failure when you're in your ski Oscar. And then finally your imaging see a chest X ray to look for any other causes, and you might want to be looking for cardiomegaly as well. And then finally your echocardiogram so you can do an ultrasound of the heart to see if it's not beating very well. This Comptel you exactly. You can see the heart is in figure. Okay, so we'll go on to the acute exacerbation off heart failure. Treatment s o Anything you're dealing with in the most medicine, your A B C D is really important. So do that first and call a senior. If you're concerned, then I like to think of it as a B. C D. E is well for the rest of the treatment. So a is your airway optimization. Set the patient upright on. Make sure that the airway is nice and open. You'll be Is your breathing so oxygen? Give them plenty of oxygen try and get their SATs up. Teo, between 94 on 98% with a laundry breathing mask. Your C is the patient. Circulation is so overloaded. The very crackly on the chest, they're pitting edema on. Do this is making them work. So you want to be thinking about getting that off? So the way to do this is giving your diuretics, which is for a reason I'd which is first line ivy. So you can start that in the emergency department and help him get along that fluid off, and you might want to catheterize them at the same time. Then you got your GT and infusion. This is second line, but can help to reduce the fluid that's in the in the body. And it finally, you want to be thinking if they are in any for a long time or they're on the ward. You wanna be Kate in daily weights and showing that the patients are offloading that fluid and you want to have a very tight fluid balance. Then D is your drugs, so you give morphine and your anti emetic so morphine in heart failure isn't actually given for pain, but it's one of the drugs that is indicated in heart failure to actually help with the help. With their offloading, Onda helps to actually reduce that and respiratory drive to help him calm down a bit and get more. And then everything else is he so treat the underlying cause. Whatever is going on, um, and try and make sure that patient is, well, well looked after. And then finally, if the patient is acidotic on, they have a very high level of two. So, for example, if you're Type two respiratory failure, then you consider bypass, which is also known as non invasive ventilation to an IV. So this is essentially a great way off opening up the lungs while there's fluid in them, and getting the auction in and also getting the the or two out on this is only indicated in these patients. With these parameters, this is more chronic, so I'm going to skip over this, but you'll have the slides afterwards on. Essentially, it's just looking at your conservative medical and surgical treatment off your heart failure, which I'm sure has been covered in a previous session. But you could look at these afterwards. We'll move on to respiratory emergencies now, So the first one we're gonna look at is a P E or pulmonary embolism, which is obviously a clot or a thromboembolism within the pulmonary circulation. So the symptoms and so many of you know they're gonna have pleuritic chest pain that's relieved by sitting forward, worsened by inspiration or sharp coughs on they're gonna have a cough that's non productive. Nothing's coming up. They might have a bit of shortness of breath, and in some instances they might have to be have cough, cough up some blood so they'll have hemoptysis. Well, um, other things. So they're gonna have signs off shock and hemodynamic instability as well. If it's a really big P E and it's causing issues, some of the risk factors, I'm sure you know a Z you can see on the slide here The main common ones that we see obviously, um, ability and surgery. This happens all the time in hospital, which is why we give a thrombo prophylaxis on also things such as pregnancy, cancer and exogenous estrogen. You So hey, twenties on COPD is that should say See it? Yes, C o c p. So the combined or a separate or contraceptive pill? Not COPD eso. Does anyone know why these were extracted? Are important? And what can we do now? If we're thinking about a PED? Is there anything that we can calculate? Um, yeah, absolutely. Someone's got it in the chat. So what's really important in P E is performing a wells school so well, score is a century, a way in which we can decide what investigations are most acceptable and most appropriate for the patient in front of us for a p E on. Also, there's a different one for a DVT as well. But essentially it helps us decide. Should we do a d dimer or shall we do a CT pa? So this is the world's criteria here, and a lot of these risk factors are included within this score. Essentially, this is what it helps us decide. So if a score is four or below four, then we don't really think it's a P E. But we've tried to rule it out, and what we do by that is doing a d dimer on a d dimer is essentially a blood test that helps to look at how well the blood clots. And if the blood clots ah lot, then this d dimer It will be high because off the P e or any of the clot in the body. But because of this, it means that there's so many different causes cause a high deductible. So it could be pregnancy, trauma, DVTs and PE's. So even though it's it's a negative, that's great, cause we can rule out straight away. But if it is positive, well, it could be anything. So that's when we still need Teo. Think about doing a CT pa on If a P E is likely. So it's greater than four. And this is where we want to do our CT pa. Which is, of course, you know that shows is the pulmonary circulation Testim and shows is the courts. So in this case, we can essentially admit them and call give them anti coagulation on. If not, then we can do an ultrasound off the DVTs on golf the legs and see how they are in about a week's time. So in terms of our management so conservatively, want to educate the patients of what's going on? You got a call to your lungs very serious. You want to admit them to hospital and give them lots and lots of supportive care, your oxygen, your fluids, analgesia and the anti emetics on. Also, you want to be thinking about monitoring. You need them in recess because if they go off while they're in the department, you want the best team there to help thumb on. Make sure that they don't go into you a form on cardiac arrest. Then we want to be thinking about our long term management to stop this from progressing further. So this is now in the new guidelines in 2000 and 20 which is your first line is you're doac, so your direct acting anticoagulate her. So it's your picture van or rivaroxaban, and use that for three months. Um, you also can use this for six months if there's any signs of cancer or if the cause is unknown. The second line is warfarin, so this was the old guidance. But it's still bad, just in case these drugs are are not indicated or contraindicated. Then we give warfarin on. We give that alongside a low molecular weight heparin such as an ox, a pirate, just as a bridging therapy until the ionized high enough or they've been having it for five days. And if there are unstable as you spoke about before from bro Fumble Isis. And finally, there are some surgical things are not done very commonly, but we can retrieve the clot by a thrombectomy and we can put ivc. Filter is in if they have recurrent DVT is on me. This is done by interventional radiology. So if the pregnant does this have any effects? Well, yes, both in the investigation on the management investigations. Regardless, you always do a chest X ray before doing a CT pa because it is really important to exclude any other pathology even in a pregnant lady. Well, we're thinking about a CT, pa or VQ scan. I'm sure many of you have seen that there's lots of confirm conflict between which is better and pregnancy, but basically each of them has a different rest to the baby or the month. So a CT pa is with us for the mother because it increases the risk of breast cancer on the wiki scan actually increases the risk of childhood cancer later in life. So that's something really important to think about when you're diagnosed is in these patients. But one is not is not in the guidance above the other. It's, um it's just for information to know and then finally avoid warfarin. Ondo Axe in pregnancy because he's a teratogen it can not licensed on. You want to be using low molecular weight heparin throughout that three months or six months, so we're going to asthma very quickly, so we'll just first go through the categorization of asthma and what type of treatment they should have. So if they're having an asthma attack, there's lots of different parameters that suggest how bad it is. And if we started the foot that at the start with a moderate, then generally patients when you do a peak flow, which is blowing out into my list of isis and seeing how much capacity you've got, um, this is when it's between 50 and 75 of their normal range on SATs will always be a bit above 92. They will have no other real symptoms, but they aren't getting worse, and that's why they need to come talk school for treatment. Acute severe is when this man goes down to 50 descent to about 33% but they'll still have sat above 92. Then we start looking at the respiration, the heart rate, and we can see that the respirator is higher than 25 on. The heart rate is higher than 110 and they cannot complete full sentences. So we're getting really worried about these patients at this point. Then we get to the really bad life threatening, which is whereby the peak flow is now below 33. They're not getting any air out. It's all trapped in the lungs on they have SATs now that are dropping below 92 that are two levels will be normal. Um, Mr basically suggests that we'll talk about it in a minute when we look at near fatal, but it suggests that they are getting some air in, but they are high coccyx, and then we have also had mental state, so they're not getting enough oxygen. They're getting drowsy. Vory cyanotic, and they don't have a lot of effort because they get so exhausted. The have a silent tres because they're not passing any air I/O, and they may also then have shock sentence to hypertension and arrhythmias in the near fatal is one that you know to get high on. What what Why I was talking about this before is that when that seizure to gets high, it means that the patient isn't able to get any off the C or two out there, not hyperventilating anymore. They've started to accumulate all the C or two in their body. It can't breathe out. And so this is really, really worrying and even having a normal. So two is worrying because in an accident attack, we should be hyperventilating, which will make it low. So as it starts to build up, be worried. And then we have requiring ventilation with high and spiritually pressure's. So once you get a CT tube down on, they start requiring more pressure to push Aaron. This suggests that there's so much air trapped in the lungs because of the obstruction with the asthma, and so it there close to two passing away. So this is really serious in terms of the management. I'm sure you will know this to look both you quite quickly, but first thing you re assess the patient you review any investigations call for help. Really? And then you think about oxygen to give the patient auction gym cell beautiful. Next. So you want to give yourself beach more 5 mg. If mild, you can try inhalers, but generally it's given Met nebulized on. You can give them back to back. So what? That means it takes about 15 to 20 minutes to get salbutamol in once it's finished. Just put another one straight on on these, all driven by oxygen. Then you've got a patrol pee in. So that is another type off drug that helps to bronchodilate on this is given up 500 micrograms. This can also be given back to back. But we need to make sure that there is a max dose for this drug, which is 2 g every four hours and give it four times back to back stories. That is really important. So you can either give or really if they're well enough to do so of prednisolone on hydrocortisone as well at IV 100 and then finally was starting to think. Okay, this patient still not getting better, we need to ask further. So magnesium sulfate next week tops to visa dilate, um, and Bronchodilator e and then finally escalating to someone in 90 you can give these more complicated drugs so aminophylline on IV, so I'll be tomorrow. So I appreciate that was a quick run through, but we'll move on to the other side of the coin now, So the COPD So I'm sure many of you know COPD exacerbations. These patients will have really bad coughing. Shortness of breath will be really wheezy, and they might have an increase in sputum on a change in the color. They're not gonna be able to exercise as much as usual on that. Also, be really tired and confused as well. If they're not getting enough oxygen and some of the signs you might see they might have it accessory muscles to use because they're struggling to get their air out. They're gonna have a high respirator and the oxygen on. Also, they're gonna have Weezy Onda reduced a rent tree on auscultation. And finally, they're gonna have a long expiration period, many different causes that can cause COPD to be tipped into a next day. Shin mostly infection, which is the most common there can be, thinks that his allergies or kind of, you know, complications in the lungs on. Also, cardiac failure as well as metabolic disturbance is investigations so as per usual. But there's some of the things that you'd want to do would be obviously your news, your sputum culture to look for any bacteria and the CD to exclude anything else going on. Your ABG is really important in these patients for the acid base balance on, then also looking at blood cultures on theophylline levels as well, if there's any. If they're already on these because you want to give any more of the already at max dose because they can be quite dangerous on difficult to manage and an imaging look for any of the consolidations and infections or anything going on on the management is obviously giving oxygen, so making sure these patients are given auction if they're on exacerbation. If they're really, really um well, you still want to get it above, you know, 100%. But if they are coping quite well with their SATs, you want to aim between 88 to 92 as many of you know eso thinking about it, and she remastered to titrate that nebulize is the should be address because we again we want to aim for 88 to 92 we can give salbutamol like a tree PM just like an asthma stairways. Again, like an asthma. You want to give you hydrocortisone acutely and then for about two sets 1 to 2 weeks after you can give your long term steroids. And if there is a is any signs of infection such as any chest X ray changes or clinical signs of infection, such a fever or any change in the sputum, then you can give antibiotics and finally thinking about the more complex stuff. So again, your bipap just like we spoke about in in your heart failure on your IV bronchodilators. And this is again done by your idea consultants. Okay, and then another respiratory emergency. I know I'm going for He's quite quickly is your new math oryx. So these are the BTS guidelines of recommend. You go and see those online that could be Googled. This is what is used in the United Kingdom. So firstly, you want to consider is this patient having a primary or secondary pneumothorax? So essentially a second, you know, or authorities is categorized as a new one for X, as occurred in someone who is older than 50 years old. On also is a smoker off a long time. Also, you can do a chest X ray just to see if there's any underlying disease. And if yes, then it's a secondary with the wrecks. Still, follow this one first, so if they have a private, your thigh or ex, you want to do a chest X ray first, and you want to see what size is. So if it's over two centimeters or they're very, very short of breath, then you want to perform an aspiration. So, just like in attention pneumothorax, you want to place a needle rather than a cannula, probably a needle into the chest and just draw around the, um, Onda. Hopefully, they should get better, and if they have, they can go home. And then if they do not have a pneumothorax that's bigger than two centimeters, they can just go straight home and their reviewed in 2 to 4 weeks in in a outpatient appointment. So moving on to the other side if they have a secondary new muscle wrecks, as we said here. If it's large than two centimeters, then you go straight to a chest during on. You admit them. And this is also true for those ones on the prime in your mouth or Exide, where they have aspirated. But they're not any better. Um, if they are, then between 1 to 2 centimeters, then you aspirated first. If it's not successful, you jump to a chest ring on. If they are lower than one centimeter, you admit them still, because there are high wrists getting worse because they have come abilities on. Do you observe him for 24 hours? Okay, so moving swiftly onto G. I and surgical emergencies, I've only focused. It's, um, really common and really, really life threatening emergency. So all other things, such as a pen, decide it's and you call cystitis that could be covered by different session eso for the acute abdomen. Remember that each different part of the abdomen is related to different kind of call and come abilities and different complications. So this is a really good diagram silica in your own time and suggests where different things are going to be causing issues on investigation. Some of them really common ones when you're investigating acute because off abdomen pain and you don't know what's causing it. Think about your bedside so things that you do on top would be a pregnancy test. As I said it start to the section in those who acute, Um, well, on your bloods, think about your amylase because it might be pancreatitis. Group in save is really important, because if they're going to theater and you need to give blood, you need to know what group they asked. You can give, um, blood. I'm thinking about infections as well. So during your CRP, your LFTs as well to look for any liver or call a static pictures under any infections as well on then imaging. So what's different? Imaging Generally chest X rays important erect for obstructions on abdominal X ray. We don't like it in a any, but it is done, and it's diagnostic for a a bowel obstruction, but it doesn't really tell us much more. CT is much better. Um, ultrasound, MRC pee and ercp. So these are looking more at the kind of gold bladder liver area on. Also, ultrasound could be used for appendicitis is well so these other things you can think about requesting in your skis on skis, so cute Pancreatitis is the first I'm going to talk about. So it's really important because it can cause, too, that distributive shock weeks of book about before the shift and fluids into different areas, causing a R D s, which is acute respiratory distress syndrome. Um, on uh, that's really dangerous could be life threatening to patients, So these patients generally have epigastric pain. So in the center of the kind of abdomen at the top of the abdomen in the lower part the chest, it radiates to the back, and they might be nauseous and vomiting as well. They might be jaundiced if there's an obstructive picture with the gold bladder, and they also have these signs called Gray Turner and Collins Sign, which are basically bruising on the abdomen on on the flank as well. Investigations as we've mentioned before and you can have a like it is in your in time. And, of course, everyone knows that I get smashed. Acronym for the causes of pancreatitis. The glass go school is what's used. Teo recommend how bad that these patients are on what level of care they're required in the hospital on. But the treatment for acute pancreatitis on C is gonna be your IV fluids nil by mouth to rest the pancreas on nutrition. So you might want to give them vitamin replacement while they're not eating anything in terms of management. Medically, it's analgesia. An antiemetics on antibiotics usually aren't used unless there's active signs of infection going on. But mostly this is a supportive care. We wait for them to get better on if we have any cause that we know has caused the pancreatitis such a goal Stones, which is one of the most common alongside F in all or alcohol. Then we could do a lap coli as well. So a laparoscope icals cystectomy to take out the gallbladder and any stones on an E. Ercp is, well, so on endoscopic, retrograde, cholangiopancreatography tall Griffey. I think it sounds awful on essentially using a camera to then look at the common bile duct and cut open the sphincter that allow the stones out more easily. And then, if there's any complications of this, so any pseudocysts on kind of necrosis and we could do a neck resect me or we can open up the see resistance. Well, so now what? We want to bowel obstruction. So bowel obstruction. There's two different types. And I just wanted you to have a look at this diagram and in the chat. Can anybody see what What kind of bowel obstruction this might be. Yeah, great. Well, during guys, you're super this so small. Bowel obstruction. Yeah, absolutely. So the the symptoms of smaller, large bowel obstruction are generally quite similar, but there are some differences. So, uh, the main symptoms you get rebalanced ruction will be kind of colicky. Abdominal pain. That's really, really severe. That gets more severe, is time goes on. As more obstruction builds up behind the blockage, they generally get distention vomiting on constipated Asian. And when you listen to the abdomen, they're gonna have tingling high pitch bowel sounds, whereas a little bit off the bowel contents to go through that tiny obstruction site, which is why you hear high pitched sounds. So the main difference between small and large bowel is that if you have small bowel obstruction, the obstruction is really, really high in the GI tract. So you're gonna have early vomiting, so you're going vomit before you then have constipation. They were down on vice versa for large bowel obstruction investigations. As I said, a lab. Normal X rays usually enough to have a look at this. And if you have them erect, you can see whether there's any there stood up. You'll see whether there's any newer peritoneum was suggesting a perforation on As you will saw. This is small bowel obstruction because we have these lines across the bowel here, which are called valvular a convent. Ease on. This is, you know, on an anatomical for this area of the bowel, and generally it's usually greater than three centimeters, with the usual diameter off this part of all. In terms of treatment, it's dripping suck, which essentially accounts for drip, which is giving you fluids on Suck, which is putting in a N G tube and sucking out all of the bowel contents. Analgesia as well is really, really important because it's really painful. Antibiotics. If there's any sign of sepsis on the steps at six a. Z know, and if this isn't getting better by conservative medical management, small bowel resection maybe required to taking out that part of bowel that's really blocked up on forming an anastomosis or alternatively, bringing up stoma to the skin to help the bowel heal. So as many of you know, this is the second type of balance traction on. As you said, you've got the other one. So this is the other side. This is the large bowel at the same symptoms as before, but this time they have a really constipation because it's lower down. They can still eat a lot of food until it gets down to that lower distal blockage. Before then. It builds up too much and have later on in vomiting. Um, a liver symptoms are very similar, and investigations are the same. But when you do the abdominal X ray, you can see here that there's no valvular. A convent is crossing the bowel. It's all very smooth looking greater than six centimeters for the majority of the bowel. But if it's the cecum, that is, ah, quite lot larger anyway, So it's greater than nine centimeters, and as you can see, you've got the house to hear. Music kind of like the sections of bowel, that kind of scalloping on the edges, which you can't actually seem very well, is more here in this arm in this image because it's just so blocked in this patient. Here and again, the treatment is exactly the same. Drinking sucks. So you know, by mouth mg tube on fluids, analgesia on. Then again, your bowel resection if it's really bad. So that's a semi side for you on DA leaving on to volvulus. So this essentially is a type of bowel obstruction that is caused by twisting of the bowel. It presents very, very similarly. But these patients only have billions vomiting on Peritus. Um, because because they have a lack of blood supply to the blood, they become a schematic. Sorry, the black of blood supply to the bow, they become a schematic, and that irritates the peritoneum. So they're very they have rebound tenderness and guarding. Um, saying investigations is before. And as you can see here, this is the sigmoid colon that was wrapped around itself, giving the diagnostic coffee bean sign. And this year is the cecum that's wrapped around itself, giving this kind of fetal sign as well. On again. It's very similar to balance structure in treatment, but additionally to this especially If it's the sigmoid, you can use a flatus tube, which is essentially putting a rigid tube in TV into the the rectum on, essentially allowing a bit of a runny into the rectum to hopefully allow to flip the sigmoid colon. Additionally, you can do a sigmoidoscopy, so placing a flexible sigmoidoscope into the rectum and actually pushing in, uh, to try and kind of fill it up and flip it back around. And if this is not good enough, if there's a schematic, if they're really, really struggling, then you can do anergic laparotomy and you can reset the bowel again. So one of the last things gonna talk about surgically is the Triple A, so in a or tick aneurysm in the abdomen that's ruptured so the normal diameter should be about three centimeters. But when this gets bigger, it's called an aneurysm in the in the aorta. And when this this starts to leak or ruptures, the patients generally will come in with really severe pain in the abdomen radiating to the back. Um, if they can come in with shock because they're bleeding into the abdomen. So all of the signs we talked about before on, they might pass out. They might have a lot of consciousness and a cardiac arrest because of all those four pages and 40 easy mentioned before in terms off diagnosis. Well, you can get them to a CT scan to see it. That's fine, but essentially on examination, the patient really unwell. And if you feel the abdomen, you may have an expansive tile abdominal mass, which is where you feel the aorta beating, getting bigger, smaller like this on, but something that I felt before. And it's it's something. You've got a field, understand what it feels like. It's really weird. Um, in terms of management, it's a resuscitation is these patients were bleeding into the abdomen. They need to be resuscitated A s, a p. So you want to do your A B C D e. Call senior help on put out that active, uh, major hemorrhage protocol. You want to practice something called permissive hypertension and essentially, what this means is instead of trying to get the BP is high as you can, you want to kind of reduce it to about 100 systolic just because if you you give too much, you're any clots have already formed you're gonna push against it is going to hard, and he's probably have clots gonna pop. So you want to keep those clots? The first clot, they always say, is the best clot. So don't put the BP too high so that it ruins this and prevents clotting and encourages leading rather than actually doing any good management. Um, medically, you want to give analgesia antiemetics. You want to give fluid so that there are well supported on your try and examine casted. And then if you thinking about antibiotics, you can give comarket lower, but essentially just prevents any bacteria that might get into the system while this patient is an emergency search surgery. Yeah, the treatment is getting to theater as soon as possible on, uh, performing a repair, whether that's a graft. So stitching something onto the whole or doing an evil, which is an endoscopic procedure that puts a stent on kind of in cases, are on the inside of the aorta. Um, g I bleed. It's, um that's really important as well. And I understand we're running out of time, so please feel free if you want to leave. But I carry on eso essentially job lease that could be two forms upper and lower causes that listed on the screen here on the main differences in diagnosing these are going to be other symptoms. They're gonna have hematemesis vomiting up blood, whether it's dark and coffee ground bilious offic you lint on then also your Molina. So you're black Atari stores that you're that you're essentially getting rid off because you've digested all that blood throughout the rest of your GI tract. But your lower symptoms, obviously you're gonna have fresh red blood here. It's important to know whether it's mixed into the stores or it's coated the outside because this can tell us a little bit about where the bleeding investigations you want to do. So bedside observations. Any CG monitoring because they're losing blood as per usual. But you want to look at the stool to see whether it looks like Melena and this is a, uh, sorry, a very lovely picture on the screen there of what Molina looks like on you can usually smell it. It's got a very distinctive smell, a swell bloods. So you want to be looking for signs of blood loss and guilty Want to be looking at how well the patient coagulate, So an F B C is indicated for the hatred. Be user knees because urea is actually high when you digest a lot of blood, so consider just an upper GI. I believe coagulation because they're bleeding actively. You might want to replace things group and save, just in case you want to give them any blood and your ABG and your VBG to look for a scheme. You're due to this blood loss as well. And another thing I thought about. Well, LFTs, because this actually produces costing factors. This world imaging wise chest X ray and CT stands to exclude anything else and then an O g D. Which is a and just endoscopy from the from the mouth down. They can be not only diagnostic that therapeutic as well, and we might also want to think about things in history. Do they have any past medical history of anything that might prevent them from clotting? Are you using any drugs that can increase Patrick ulcers So and said Steroids' accessorize iron tablets. They can make the stool it very dark. They might mimic. Melena also smoking a Z Well, G, I bleed. So the management of these So if they're virusy So this is essentially whereby you have big swellings of the of the vessels within the within the esophagus. Then what you need to do is almost your A B C D e is usual your fluids on your red blood cells. You want to give red blood cells back to the patients, and the guidelines state that in viruses 70 HB is indicated on. You want actively the major hemorrhage protocol because even though it's not trauma there still bleeding the locking to replace it medically, they're given telepresence, which helps to prevent further bleeding on prophylactic antibiotics. And then, finally, they need to have an endoscopy to help either band them sclerosis, um, so kind of hard in the mall up by injecting since glories in therapy and then also tamponade. So direct pressure with the stand steak and black Blake. More troop, which is a big tube, essentially is inflated within the esophagus and tamponnaise, the lead scoring systems for virus. You'll bleed. The Glasgow Blackford School is here on this side of the screen, and that's done before your GED on. It's essentially it predicts whether they need an endoscopy IQ interventional, not on the Rachael School is after your GED and it basically schools to see how, how, how much risk of mortality there is any patients and how much likely they're going to beat again and then in a non variceal bleeds. So, for example, a peptic ulcer. You do the same your immediate So the bloods, you fluid your A B C d e. But, um, for a little bit higher in HB, I'm not too sure why this is. It's just the guidelines. And then, medically, you want to give your proton pump inhibitors instead of you turn a pressing, preventing any acid you want to give these antibiotics and again you want to go for and just be. And you want to inject adrenaline because we know that adrenaline, basically strict on, will help to stop the bleeding. Okay, so we're gonna go on to trauma, and then we're almost done, so I know we're running over. I apologies, but if you like to stay, please stay and you'll have the slides. It's not on the recordings, but we'll go on to how to describe a fracture in your skis and sq, so there's a step wise approach that I like to use. So firstly identify the patient's details. Make sure the patients details are correct and it's taken on the correct date on. Then you can start thinking about what type of image it is. So is it electoral oblique, a anterior posterior? Why view these old, different types of orthopedic views and then you want to think which limb am I looking at? Is it the arm? Is it? You know the leg? Um uh, where where am I looking at and what side left or right? And they want to think well, which bones are affected? So where is the fracture where what am I looking at? And then you want to describe the fracture itself? So here's a really good picture about a lot different types of fractures you can get. So depending on whether it's crossed such transversus linear, which is vertically oblique, which is kind of at an angle on displacement, of course, and a spiral fracture is well, so these are all things to think about, um, when describing fractures and finally are they displaced? So are they offended, which means that the ends don't meet any more other displaced, no longer in contact with the rest of the bone. So here's an example off a fracture description to first, I would say this is the patient's details taking on today. On the second thing, this is an AP view off the patient's left femur. So looking at the left femur, I can see there is a spiral oblique fracture going, but in the center, off the shaft that is offended on displaced. So that's how you would describe a fracture. So please refer back to the slides. Previously, just not this down on. Use this to practice before your osteo is really useful. So now I want to do a spot diagnosis. So this patient is an 86 year old patient who suffers from a full. She's in lots and lots of pains. You can't get up on weight there on her leg on her left leg. When you look at it is external, rotated and shortened on examination. What do you think this patient is suffering from? And anybody? Yes. Yeah, great. Well done. So yeah, it is a neck or femur fracture or enough So these are fractures, as you said off the neck off the femur, and they could be classified into intracapsular or extra crap. You know which, as you can see here, is that the neck here is the base of the neck. So anything up from there's intracapsular on below this kind of introductory line here that would be an extra capsule on. There is a classification system called the Gardeners Classifications, which essentially just describes the degree off displacement on. This corresponds to the risk of a vascular necrosis off this head so it can die if it doesn't get any blood supply, which can be cut off by the fracture. So it's caused by about both high and low, and your energy injuries generally falls and L D patients. But it can happen in young patients, for example, in high energy collisions, traffic accidents and things like that. And as we said before, that patient I mentioned had a presentation that was classic off eight north, so non weight bearing, shortened and externally rotated leg. This is because the extensive they don't have the bone to keep it straight, so they just pull it out around to the side on up. I have pain in the groin, but also might be in the knee because of the preferred pain to the patients. May actually come in. Think same of the knee hurts, but actually, it's the they're female. I've seen that many times in a any on when you roll the patient's leg on it put pressure on the bottom of the foot. It's really, really painful on. They're unable to lift the leg up and do a straight leg raise. So when you're looking at an X ray, these are the things you're looking at. This is known as the Shenton line, which is a smooth line that runs from be posterior aspect of the of the superior Ramos down the neck of the femur and down towards the shaft like this. And as you can see in this diagram, when it's broken, this means that they have in the femur, fracture something to the capital. No, the thing that's helpful to look out for is looking at the letter to counters which are here. If these are not in alignment and this consider Esther has been pulled up and out of the way, and as you can see. It's very slight in this diagram, but they're not very much in line with each other because of this faction, another over things in track for his trabecular pattern of the fumes. Primal neck. So this is the little lines you can see on here. As you can see, they're not the same either side something to check for, but it should be very obviously the shunt in line and then other investigations. Obviously, you want to do your observations and a B C D E blood on. Also, you could say that they need to go to theater. And if you're thinking this might be complicated and we need to put it back together, then you might be thinking of a CT is well so the management conservative Medical surgical. Conservatively, You want to keep the patient comfortable, so you want to give them IV fluids. You want to think about a patient to kind of education. You know we've broken your hip on. These are the complications, and rest of this later on, you might be thinking about social services at home and risk assessments for falls, occupational therapy and physio. Later down the line, medically you want to keep the patient comfortable again, analgesia and antiemetics and what's really great for neck. A femur fracture is something called fascia iliac a block and mentioned this in your skin and your cover school top marks because this is absolutely first line, which is essentially putting in a needle and injecting local anesthetic around into this fashion iliac compartment that affects the family nerve. And it will really help your patients. And then, finally, surgically, there's lots of different operations that could be performed so intracapsular so that will be intracapsular, so that will be again above the interest or paragliding. Depending on how old they are, they can either have it fixed, or they can have a half a hip replacement or hemiarthroplasty, where they just replace the head of the neck of the femur. And not, that's a tablet, Um, Andi. If it's displaced, they can also have these, but also a total hip. If they're young and mobile, where they have the acetabuloplasty as well, and then extracapsular, if it's ah, not displaced, then they could have a dynamic Keep screw on if it's a struggle truck. Um, Terek, which you can imagine, is the basically the shaft that make you have a screw right in the middle to keep airline head. Trauma will just go from very quickly because we are running out of times. They saw you have run out of time, but I'm sure any most of you know this. So you've got several could hemorrhage, subdural and extradural and all these related different kinds of bleeds. So several recognizes, obviously, am a spontaneous bleed within the parenchyma in the brain. It's the blood sits on the top of the off the off the brain between that Iraq current area, so they get a lot of manages, Um, because it is saying directly on the brain. The subdural, of course, is above. The jurors are sorry below the dura, but not quite in contact with the brain. And these could be chronic in lots of elderly patients, and they usually venous bleeds. They're finally extradural bleeds of these huge bleeds that strip the periosteum off the bone on have these kind of these lemon shape term bleeds. These are usually from high trauma. They are arterial bleeds, and patients don't really have Lisa periods, so they'll become conscious. They'll be fine for about 10 15 minutes, and then they will again becoming congested. Day them get worse, a lot quicker. These are the mice head trauma guidelines. I'd recommend you have a good read of the's is a bit much to go through tonight, but they're really, really important. And you'd really impress your examiners a few new these mostly just looking at whether they require had CT even in one hour or later in their admission. Okay, most important part is the management of head trauma. That's the A B C D E F g Hate I. So again, what we love our A b C D e z in most medicine and a is always airway. So think about your airway optimization considering your c spine. So just like we did send it to start be is your hypo hypoxia and hypercapnia. So what we need to do is we need to make sure that patients oxygen and so two levels are aimed at normal parameters. See, is your circulation so you want to get your BP or your mean arterial pressure normal, so you want to get it between 70 millimeters of mercury. So the reason for This is because if you have it too high, 120 then you're actually gonna be increasing the blood that you're putting into the brain, and that's going to increase that intercranial pressure. So you want it high enough so that the brain is getting blood and it's high enough to refuse the brain, but not too high that it actually causes more swelling and more damage. D Is your drugs so deep? Propofol infusion. So you want to put them to sleep. You want to sedate them so that they're more comfortable on that. You want to give anti epileptic drugs as well to prevent seizures. He is your temperature. So you want to have normal thermy to keep the patient nice and warm, but not too warm. I'm not too cold, either. On f is for free, the neck and what I mean by this is that a lot of the time when patients are very poorly united, you are in a any and recess on. They have neck colors on and they'll have tubes tied around the neck. This can actually reduce the blood that's leaving the brain, um, coming through the neck. So remove anything that's tied tightly around the neck on also pop the patient up for about 40 to 30 degrees on the bed to help that venous return. Getting the blood from the brain that will help with the ICP G is the blueprint. So maintain normal glucose levels because this will help the brain recover on. Hate is for your hypotonic saline or your mannitol. So these are your your very hypotonic solutions that essentially help to osmotic. We draw all of the water out of the brain at the blood brain barrier into the blood to help again reduce that a raised into cranial pressure on eye is interventions. So send them to your surgery and see if they can help. So make that referral on that. Is that on. Now, after that whistle stop till we're coming to our last last topic of the session. So I'm so sorry for over running, but hopefully you'll find this useful. So para settle over days, this is something that is so common in a knee. We had almost one every single day last year. Eso It's something that is really important to know and always comes up, especially in fifth year in your prescribing exam, it came up in mind. So something important to consider eso in terms of your parasitical overdose, it's really important to think about when the patient took the para settle. So that's time zero time off ingestion. But depending on how long is being, since they have taken that power settle toe when they're presented to you. That will show you how badly what, what kind of what kind of investigations you'll need to do and have. So let's start out below eight hours. So when the patient comes in between zero and eight hours, what you want to do is you want to take bloods after four hours of ingestion. So if the patient comes in three hours after taking the paracetamol, you want to take it one hour after they come into any because that's four hours and total after ingestion. Similarly, if they come in at seven hours, you want to take it straight away because it's already being four hours since they took the parent settle. That was something that I really struggled to get to grip it off when I'm first learning about topic. So once you've taken that four hour dose draw a parasagittal level bloods. You just wait for the results, but in some cases you might want to start the treatment for paracetamol, which is an acid tile 16 or knack for short. You want to start that sometimes before getting that bad level back. And that is either, if the parasitic more level cannot come back by eight hours. So for exact sample when the patient came in, it's seven hours and you take the paracetamol that level there and then you're not going to get it back before four hours because it's only an hour. So you're not gonna get it back, so you just start treatment straight away. Alternatively, if the patient has taken a very large dose of perceptible, so there are high risk of liver damage. So that's over 150 mg kilogram. Then you want to start, and I still Sistine Street to wait. Once you have cancer paracetamol level. But you either start treatment if it's above that level. So if we go back to this diagram here, if it's for example, seven hours on the level is up here, then you want to treat it. But if It's seven hours and down here, and you don't need to treat it. And as you can see, this part of the graft is blocked off in gray. Because, as we said, that four hour level is important. And before then, we don't look at the perceptible levels, so hope that makes sense. Okay, so then we got 8 24 hours. So in these patients, you take the blood straight away because it's definitely being after four hours now on. Then you can start the still Sistine if they have taken that large dose, just like in the other section. If it's less though, than this dose, so they haven't taken the amount, you've just await the results. You don't start it straight away. Want to get the levels back? If it's below the treatment line, you can stop it, especially if they're asymptomatic. If they're symptomatic off liver failure. So, for example, they have any quiet. Your apathy is they've got pain. Her patio, her Patrick tenderness. Then you carry on. Otherwise, you continue the stool system for 24 hours because this this treatment then I still Sistine takes multiple bags off fluids off the drug and it takes 24 hours to give Patients hate it because it causes lots of vomiting and really unpleasant abdominal pain on, then over 24 hours. So this is, well, it gets a bit gray area. You only start the treatment. So the Astelin 16 if the patient is symptomatic, so they're jaundiced. They've got hepatic tendernesses and said before, if their blood l t levels so their liver functions are raised because they're not doing very well or they have a coagulopathy so that I and R is greater than 1.3. That's when you would start the anastomosis ting. If there's no no other complications, though, well, they've have the is being over, you know, 24 hours ago. Now when they're fine and there's no parasitical in the body, then you can just leave them on some of them home. And that's a quick overview of paracetamol. Over. There is something I really struggled with, Um, but that's everything. I'm so sorry for any over, but I hope you found it really helpful. Um, it was a quick overview of absolutely everything