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We're just waiting for everyone to join. Um ok, I think we can start now. So, welcome back everyone to the third episode of this series on new oxygen requirements and hyperglycemia. Um We're here today with doctor Abraham and doctor Hardwick who've been teaching the series and I'll hand over to them. Um Hi everyone. My name is Molly. Um So John and I are going to be presenting a new oxygen requirement and hyperglycemia um today. So I'll just share the um screen, just get this up. Great. Um Can you guys see that? Yeah, yeah, you can see that. Great. Perfect. Um So, like I said, um first of all, we're going to start off with um new oxygen requirement. Um And my name is Molly, if you haven't been before, the aim of today is that we're going to be teaching kind of what you will need to know to be in your first job as a doctor. So what in the UK, we would call an F one like a foundation one. And in other places you might go in as an H but um it's, it's what you're going to need to know and we're going to be talking about, um, how to interpret some common tests around York SRE requirement and um, a bit of treatment and when to escalate to your seniors. So hopefully it'll be helpful for you. Um, so why is it important? It's really common, like, like a lot of the other stuff that we've, um covered, it's really common that you'll be on call and you'll be called about somebody who, who is suddenly needing some oxygen. And it's an important one because it can signify some really um some emergency presentations and there's lots of differentials to think about. So some differentials and I've tried to order them in things that are quite common that you, that you might see. So lots of the time when people are in hospital, unfortunately, you pick up infections, it's just the nature of where you are. Um So they can be bacterial infections. Um So lower respiratory tract infections and pneumonias, sometimes you can think of them as the same thing. And I guess in the essence that there is um infection in the lung, but a lower respiratory tract infection will not have any x-ray changes, whereas the pneumonia will. So you'll be able to see um kind of consolidation on a chest x-ray if you've got pneumonia compared to you won't with a respiratory tract infection. So, you know, you can have bacterial infections, you can have viral infections, you might get flu or COVID um in hospital, people can have exacerbations of their preexisting conditions. So, asthma or COPD, um people have sat around for a long time and even though we try and stop them getting pulmonary embolisms, sometimes it does happen, people can develop pleural effusions, pneumothorax, sometimes the drugs we give people can um put them into respiratory depression. So for example, opiates. So somebody um has had too many opiates, the respiratory drive will be depressed and then other things kind of outside the respiratory system like heart failure. So if you've got somebody um with pulmonary edema, they might develop an oxygen requirement. And as we touched on in the first session, um oxygen requirement and shortness of breath can be a sign of myocardial infarction. So that's just something to be keeping at the back of your mind that you've got other systems at play, not just the respiratory system. So approach assessment, I think you guys are gonna think that I'm repeating myself, but it's the just the the absolute classic of taking your history, doing your a two re assessment, creating a differential diagnoses. So lots of your differentials are gonna be what we've just spoken about. Um and then thinking about your immediate investigations to, you know, differentiate your differentials um and then any immediate interventions that you want to be putting in place to stabilize this patient. So thinking about some of the immediate investigations that you can do with regards to kind of new oxygen requirement and, and respiratory presentations. One of the most obvious ones would be an ABG because it's gonna give you a really accurate, um, impression of what's going on and how their oxygenation is. It's gonna tell you other things as well such as the, um, HB. Like are they, have they dropped their HB massively and that's what's making them breathless. Um You can order a chest x-ray, obviously that's really useful. You can have a little look about what's going on and I don't know what it will be like for you guys when you're working. But if it's an emergency scenario and you're with a patient that you're really worried about, you can ask for a chest x-ray, like a portable chest x-ray to be brought up to the ward. So you do it there and then, and you can see the chest x-ray result there and then um so that's really good because you, you will have assessed the patient and you immediately get a chest x-ray. So that can be really helpful. Um So that's kind of in um B and then in C you can think about an ECG bloods and if you think there's maybe an infect cause you can be doing blood cultures. So these would all be really helpful because say you've got a pe, somebody's got a pe which is causing to have a new oxygen requirement that will also show signs on an ECG. So it's all kind of fitting together. Um, and then sometimes, you know, again, if you think they might have a pee, you could do a CT pa. Um, and then if you think maybe they've got like a say on a chest x-ray, you see that they've got a big, um, pleural effusion and it might need draining, then somebody a bit more senior than you might come along and ultrasound the chest and just have a look at the effusion and then they can pop a drain in if they need to. But these are some of the immediate things that you might think about doing. So I thought that we could have a quick think about a BG interpretation because it can be um, slightly complicated and it's often something that I find, I forget and have to re go over, but it is useful to have at the tips of your fingers for when you're working. Um, because it can be a really useful test and you use it quite often, especially in um, emergency scenarios. So throughout the whole of this, a BG bit, we're gonna have the reference ranges in the top corner so you can see them. All right then. So we'll jump in. So the first thing you're going to look at is the um, partial pressure of oxygen in the blood. And this is the most important thing to look at first because hypoxia is what's going to kill the patient the quickest they will, you know, they will potentially have a hypoxic cardiac arrest if we are not oxidated them properly. So this is always the first thing you're going to look at. So how do you tell if they are under oxygenated? So you, so if you look at our reference ranges on the um right hand side, you can see that normal oxygenation is between 10 and sorry, 11 and 13 kira scales. So if somebody has um oxygen less than 11, then you're thinking they're hypoxic, obviously, it's a bit difficult if they've got oxygen. So say they've got an oxygen mask on which is delivering 36% oxygen. It's hard to tell whether they're actually um under oxygenated. So the general rule of thumb is that they will be under oxygenated if they're 10 kg girls, less than, than the percentage inspired oxygen. So for example, if you've got somebody on a 40% oxygen mask, their oxygen should be roughly 30 kg girls if it's less than that, that indicates that they're hypoxic. And just as a quick reminder, one liter of oxygen is about 24%. So normal room air is 21%. So we're breathing 21% now or hopefully you are um and then um one liter is about 24% and then you goes up in roughly in four, so two liters, 28 3 liters, 32 and four liters, 36. So first thing you need to do are they hypoxic. Do we need to a put them on oxygen or b turn that oxygen up? And so when you're looking at the oxygen, if their oxygen is low, they will be in a type of respiratory failure. But you need to see what type of respiratory failure they're in. So type one respiratory failure is a failure of oxygenation. So that means that the body is not oxygenating the blood properly because you're gonna have a low oxygen. So your pa two will be low, but your body is able to breathe off the CO2. So the PA CO2 will be normal. So this would be things like pulmonary edema because you're not able to oxygenate the lungs properly. And in really, really extreme scenarios, you know, say the patient um is really not doing well on the ward. You've given them lots of diuretics, but they still got lots of pulmonary edema and they need to go to ICU or have more respiratory support. You would treat type one, respiratory failure with CPAP. So CPAP is continuous positive airway pressure and the way so I worked in a spiritual and the way that we would describe it to patients before they went on it, it would be like sticking your head out of the car window when you're driving really fast. It's like having continual air just being blown at you, but really, really high pressure and that high pressure kind of keeps the airways open a bit and it helps to oxygenate them. So, so that, so CPAP is just basically forcing loads of air at them. And that's what you use to treat extreme type one respiratory failure and then type two respiratory failure is when you have low oxygen and high CO2. So this is now a failure of ventilation. So this is an issue with getting the oxygen in and getting the CO2 out. So this would be things like COPD um and extremes of COPD and other type two respiratory failures would need to be treated with bipap. So um this was this is by ventilatory pressure, um ventilation. So they have a higher pressure when they're breathing in to force air into their lungs and they have a lower pressure when they breathe out to help them expire and get the CO2 out. So that is um type one and type two respiratory failure. So, try and keep those in your head because we'll be using those later. Um So we've done first, the Mr RBD interpretation. So we've looked at the um oxygenation and then you wanna look at the PH and there's a few things that can affect the PH. So it's normal, as you can see from the reference range would be 7.35 to 7.45. This can be altered by two mechanisms, either respiratory mechanism or metabolic mechanism. So, respiratory, you've got carbon dioxide and this is an acidic gas. So when carbon dioxide dissolves in the blood, it becomes carbonic acid. So that's acidic. So if you have more CO2, it's going to be more acidic and the ph is going to go down. If you've got less CO2, you've got less acid and the ph is gonna go up. And similarly, in the metabolic section, you've got your bicarbonate ions. So HCO three and they are um a base. So they're gonna mop up any um hydrogen ions. So the more bicarbonate you have, the more alkali it's gonna be because it's removing all the acid. Whereas if you have a less bicarbonate, it's gonna be more acidic because you've got less bicarbonate to soak up all the um H plus ions. And so the PH can be normal due to compensation. So say you say you've got um a metabolic acidosis which means, so say you've got low bicarbonate ions, which means you've got lots of H plus ions. So your blood is a bit more acidic. The body tries to compensate and normalize the Ph by breathing off more co2. So it's getting rid of the acidic gas, which then will bring the Ph back up to normal. So you can have compensation by the opposite system. So similarly, if you've got too much CO2, if you're retaining CO2 for some, for some reason, um the body will over time compensate by increasing the number of bicarbonate ions to mop up all the acidity or the H plus ions from your excess CO2. So you can have compensation and the respiratory system can compensate almost immediately because you can just change the rate of Alvear ventilation. So the rate of breathing, whereas um the amount of bicarb an takes a few days to change because um it's to do with the renal excretion and the renal production of bicarb ann. So that can take a bit longer. So that's your ph, you're looking to see whether is it acidotic or is it alkalotic or is it normal? So we've looked at the oxygenation and then the Ph, so then you would look at the um PA CO2. So this tells you how much um carbon dioxides in the blood. So this is where we come into some of the um other stuff. So we know that um like we just spoke about CO2 is an acidic gas. So if we look at this table, you can see if the ph, we'll start with the top line if the ph is less than 3.7 0.35. So you know that they're acidotic. If it's a respiratory acidosis, the PA CO2 will be high. So the amount of CO2 in their lungs is gonna be high and that would be something like um so that means that you're not breathing off your oxygen properly. So that would be something like um say you've got an opiate overdose and you've got respiratory depression, um or you've got COPD and you're retaining oxygen. So that would be when you would have a respiratory acidosis and then a respiratory alkalosis is the opposite. So the PH is high. So it's greater than 7.45 and your PCO two will be low. So you've got less of the acidic gas, which means that the PH is going to be higher and this would happen. So you're breathing off your CO2 really quickly. So if you're, if somebody is having a panic attack and they're hyperventilating, they're going to be blowing off all their CO2, which is then going to make their um ph higher. So that's kind of a respiratory acidosis and a respiratory alkalosis. And then like we're talking about, you can have um compensation from the metabolic system. Um and with the metabolic system, it takes, takes a few days to properly compensate. So um you can have a normal Ph with a high P with a high CO2 in the blood and a high bicarbonate. So that suggests that at one point you start, this person started retaining CO2 and their blood became alk sorry acidotic. So the body then responded by increasing bicarbonate ions to normal out the PH. So that would be a fully compensated respiratory acidosis and then kind of conversely a respiratory alkalosis with metabolic compensation would be um lower amounts of CO2 with lower amounts of bicarbonate. So we're going to move on to the next thing, but just to recap, we've looked at the oxygenation, then you look at the PH and then you look at the PCA PA CO2 because you've looked at the PH and you can see that it's either normal deranged or, um, and then you can start looking at the cause. So the pa you could be the first cause and then the second course would be the bicarb ions. So higher bicarbonate is gonna have a higher ph because they're going to be mopping up all the hydrogen ions and a lower bicarbonate is going to be a lower ph because there's more hydrogen ions around. So, again, very similar concept, if you've got a metabolic acidosis, you're going to have a low bicarbonate. Um which means that there's, if your bicarbonate is low, there's lots of hydrogen ions around. So the blood is gonna be acidotic and the inverse is true. So if you've got a high amount of bicarbonate, the blood is gonna be more alkalotic because um the bicarbonate is soaking up all the hydrogen ions similarly. Oh sorry, this should say the bottom line should say metabolic acidosis with respiratory compensation. So those two bottom lines should both say with respiratory compensation. Um So if you have a re uh again, if you have um a respiratory compensation, you're um either gonna be retaining more CO2. So if you've got a metabolic alkalosis, you're gonna be retaining more CO2 to try and um lower the PH. Whereas the inverse is true, if you have a metabolic acidosis, you're gonna be um breathing off more CO2 to try and increase the PH A it. Great. And then the last thing is base excess. So it's just a marker of acidosis or alkalosis. So, if your base excess is really high, so if it's greater than, so the normal range is minus two to plus two, if it's high. So if it's more than plus two, it means you've got um high bicarbonate. So you've probably got a primary metabolic alkalosis um or a compensated respiratory acidosis. So, anything which makes your um bicarb high is gonna um give you a high base excess and kind of the reverse is true. So, anything which is lowering your bicarbonate will um reduce the base excess. So that would be something like a primary metabolic acidosis. So, say your kidneys aren't working very well and you're just peeing out all of your um bicarbonate, then um you're gonna have a low base excess. So it's a bit um it can take a moment to get your head wrapped around, but you look at the oxygenation first, see if they need any oxygen. Then you look at the Ph, see if it's deranged, then you look and see why it's deranged. So, is it a metabolic or respiratory acidosis? So you, oh sorry, uh derangement. So, you look at the um carbon dioxide and the um bicarbonate and then you look at the base excess. So we're gonna practice, um, there's uh, so the first poll, if you just wait a moment before you put it up just to let people um, read it. So we'll just give people I'll time you roughly a minute just so you can read it and think about it. The question's gonna be, what does this A BG show to just take a moment to read it? OK. Rem So if you start the pole and let me know what people are saying in the poll, so um 70% of people have just picked option B which is respiratory alkalosis. Perfect. So that's exactly right. So if we go through the steps, you can see. So one, the oxygenation is all right. So they don't need any oxygen two, the Ph they're slightly alkalotic. So you can see that they, their blood is, is got um not enough hydrogen ions in it. So then you look at the PAC two. So that's a bit low. So that makes you think, OK, this is a, this could be a respiratory alkalosis because you've not got enough um acidic gas in the blood. And then you look at the bicarbonate and you think, yeah, that's normal. So that's not going to be affecting the Ph. So you can confidently say that this is a um this is a respiratory alkalosis and um this kind of, this would be a picture of something we should be quite classical, this um this presentation because this is kind of describing a panic attack. So this person is waiting for a surgery, they are young. So chest tightness is unlikely to be an M I, but they're feeling short of breath, they've got tingling. Um and they've got a uh a respiratory alkalosis which implies that they're hyperventilating so well done. 70%. Got it right. That's great. Um We'll go on to the next one. So again, if we just hold off, putting the pole on there just to give people a bit of time to have a look at it. Great. So if we start the poll and just see what people think. So um 64% metabolic acidosis with partial respiratory compensation. Perfect. Yes, that's exactly right. So um the oxygenation is normal, the Ph is acidotic. So you then go into like the PA Co2 which is low. So that means there's less acidic gas. So that means that the respiratory system is trying to compensate. So they're trying to breathe off um all of the acidic gas because something else is making the blood more acidic. And then you look at the bicarb, which is low. So that means that you've got less bicarbonate to mop up the hydrogen ions. So you, that means you've got lots of hydrogen ions, which means that it's a metabolic acidosis and it's partially compensated. So the respiratory system is trying to compensate, but it's not quite getting there. So it's partially compensated. And that means that the ph is still deranged, but the res respiratory system is trying to compensate. So we're done. So we'll move on from a BGS now and we'll just have a quick touch on CO2 retention and COPD because there's a lot, a lot of people make the mistake of thinking, oh, they've got COPD. That means we need to target lower SAT s for them. And that is not necessarily true. So normal SATS, we would target 94 to 98. So that would, you know, hope to be all of us. And if they're a person who retains CO2, then you would target 88 to 92%. And this is because of um ventilation, fusion mismatch and the Haldane effect. Now, I think this is a, this concept is a bit too complicated to explain in this. But there's um I've asked John, he'll just post a link now um in the chat to a good um website called Life in the Fast LA, which explains it really well. Um because um it's quite complicated so you guys can just have a read about that, but we'll talk about how you know that somebody is a CO2 retainer. So if somebody's retaining CO2, they're gonna chronically have higher levels of CO2 in their blood, which means that they've got more acidic um gas in their blood. So the um the body will compensate by increasing the amount of bicarbonate. So it's gonna be, and their PH should be normal. So they should have a fully compensated respiratory acidosis with type two respiratory failure. So they're gonna have low oxygen saturations 88 to 92. Their PH is gonna be normal because it's fully compensated. The CO2 is gonna be high and the bicarbonate is gonna be high. And because the bicarbonate is high, the base excess is high. So if you've got somebody with a high bicarbonate and increased base excess, that indicates that they're chronically retaining CO2 and that they would be a candidate between 88 to 92% that you would need to get an A G. And see that you couldn't just say this person has COPD, we're gonna target low saturations. You have to have proof that, that, that is correct and their retainer, otherwise, you're just gonna be um keeping them hypoxic and withholding oxygen from them when they need it. Great. So now we're gonna go on quickly to the immediate management of a new oxygen requirement. So obviously, the first thing you would do would be put oxygen on somebody if their sats are low. So wean um according to their target sats and as you've just spoken about, um your SATS will depend on whether you retain oxygen. And then it's kind of thinking about the cause of their um oxygen requirements. So, if they've got an infection, you give them antibiotics. If they're wheezy, say they've got asthma or COPD, you can give them nebulizers, steroids. IV, magnesium can also help with the uh with the wheeze. And if you need to, you should escalate because, um, obviously hypoxia kills quite quickly. So if you're not getting anywhere with someone, you need to be calling for help. So we've got a scenario now, um, we've got an 89 year old woman, she was admitted following a form a few weeks ago and she's now deemed medically fit for discharge, but she's waiting for a package of care at home, which means she's waiting for a few people to come in and help her with her breakfast and her lunch and her dinner. But she's been well, she's been well in the hospital and she's just waiting to go home. You're on call and you've been asked to see her because the nurse says she has a new oxygen requirement. So she's needing a bit of oxygen. So you ask the nurse and they say that she has a past medical history of COPD type two diabetes and anxiety. So you say, ok, what medicine is she on? And these are the medicines. So she's on enoxaparin, which is a um low molecular weight heparin to stop people getting pulmonary embolism in hospital. She's on a triple therapy inhaler for her COPD. She's on glipiZIDE for her diabetes. She was some paracetamol senna to help her bowels move and she's on some morphine and Ondansetron. So I think it's the third pole now. So if we could pop that up and the question is, what would be your differentials in this situation as you, as you're walking to go and see this patient? What's kind of going through your head and just, just let me know. Um, so the votes are still coming in Molly, but around 40% have put exacerbation of COPD and then the next one with 24% is P OK. Great. So this is a bit of a trick question really? Because they are all completely plausible um differentials and any of them could be true. So she's been hanging around in the hospital, she could have easily got a pneumonia again. She's been hanging around in the hospital. She's probably been sat still. And even though we've been giving her an oxy injection, she still could have got pe she could easily have an exacerbation of her COPD. We might have been giving her too many opiates. Um So she might have had loads of morphine which could be depressing her respiratory drive and increasing her oxygen requirement and easily she could have, you know, she could be feeling anxious. So those are all very plausible differentials and those should all be going through your head when you go and see her. So when you do go and see her airways patent, her SATS are 85% on roa her respiratory rate is high. It's 24. And when you listen, you can hear some, some crepitations at the right base and the right mid zone. So you're thinking, oh and because you're doing your A T assessment really? Well, like John spoke about on the first talk, you're gonna do your interventions as you go along. So you put some oxygen on her, you take an ABG and you order one of those portable chest x-rays like I spoke about earlier. So you're thinking great, that's all that's all happening. You move on to see. So her heart rate is 85 her BP is 100 and 20/87 and her heart sounds one and two are normal and she's not got any added sounds. So, but you think you know, this lady she's got she needing quite, you know, she's needing a bit of oxygen and she doesn't look well from a re spirit point of view. So it's very reasonable to pop a cannula in her, take some bloods and you also wanna do an ECG to make sure our heart is ok. And then in terms of disability, she's got a bit of a temperature um but her gcs and her blood glucose is fine. So you give her a bit of paracetamol to help with her fever and then the rest of her examination is fine. So her abdomens are fi abdomen is fine and her calves are fine. So you get the AB BG back and this is what it shows. The, the next poll will be. Um what does this A BG show? So we'll just give people, I'll give you kind of 10 seconds to have a look at it and then um sure if you pop the pole up, so pop the polyp when you're ready. R sure if that's OK. Have we got many results, John? Um Yeah, so it's basically a toss up between option one and option two. OK? Um Around um 30% have put option one and then 30%. Option two. Yeah, which is acute on chronic type two respiratory failure with partial um metabolic compensation or respiratory compensation. Perfect. So let's break this down. So we start by looking at the oxygen, the oxygen is low and then so the oxygen is low. So we know we're in at least type one respiratory failure and you look at the CO2 and that's high. So you so you know that we've got low oxygen high CO2. That means we're in type two respiratory failure. So and we've already put some oxygen on her, which is great. This ABG was taken while she was still on rema. So then you look at the PH so the PH is low. So you know it's acidosis and you know that it's not fully compensated because it's low. There's no complete compensation. And then we need to look at why it's low. So you can see that the CO2 is high. So that would give you a low ph. So you can think this is, this is probably at this point, this is a um respiratory acidosis. And then you look at the bicarb and the bicarb is also high and we know that the bicarb takes at least a few days to change. So this implies that this lady has had chronically high CO2 um because the bicarb has changed to go up. So it implies that she has an acute on chronic type two respiratory failure with um partial metabolic compensation. All right then and then her bloods come back as well and she's got high white cells and a high CRP. So at this point, what is your um oh sorry uh five would be what would be the targets that for her, this should be quite a quick one. So um we've got 63% 88 to 92%. Perfect. Yeah. So we know that she's a Co2 retainer. So you should aim 88 to 92 on her. So you get your portable chest x-ray and this is the um result. So you can see that in the bottom right corner kind of in the um lower right zone, you can see there's some consolidation. So it makes you think, ok, well, she's got a new oxygen requirement. She's been set in hospital. She's got um raised white cells, raised CRP. You heard crackles, you can see the consolidation on the chest x-ray. She's probably got a hospital acquired pneumonia in the right lower lobe. So you think then how am I going to treat that? So if they're really unwell, you should activate the sepsis. Six. So you do your classic sepsis six. So you give three. So you're giving oxygen IV fluid and antibiotics. In this case, she, her BP was actually fine. So you might not need to give her any fluids, but you might just need to watch her closely and give antibiotics. As per the guidelines in your hospital, each hospital will have different antibiotics because different bugs are more prevalent and then you need to take three. So take some blood cultures. Hopefully you already have the lactate from your ABG and just ask the nurses to monitor her urine output other stuff you can do to sit her up. It might help her um, oxygen requirement. She sat up, she can fill her lungs a bit more. It's always important to get a sputum sample to see what she's growing. If she's, we know this lady has COPD, you didn't hear any wheeze when you listened, but in a different scenario, if she's wheezy, um you could give her some nebulizers and some steroids and treat her as um, a bacterial exacerbation of her COPD. Um And then if these people are not improving, you need to escalate. So anyone who's got an oxygen requirement that you are treating, but it's not getting better. You need to ask somebody for help because they can deteriorate quite quickly. So you can run plans past your seniors and ask them for help if they're not getting better. So that is the end of my talk. Thank you for listening. I think John is gonna um share his talk now. Yeah, let's give that a go. Um Thank you for that talk, Molly. It was a good recap on new oxygen requirements. So um everyone can sort of stretch their legs for 30 seconds to a minute. Um and then we can dive into the next talk. So I'm just gonna share the presentation now if all your room, she could let me know um if it's showing up. Yeah, we can see that. Yeah. Ok. So um for the second part of the talk, um we're going to be discussing hypoglycemia today. Um and it's something as a junior doctor, you're going to come across um quite frequently when um you're doing your ward round and even when you're out of hours. Um and sometimes if it's just sort of regular hypoglycemia, you can give them some quick acting insulin, but um other times it can lead to um certain um hypoglycemic emergencies. So this slide from before, which is DK A HHS. Um Some of you find your students will know these letters mean. Um, if you've just started med school, um, they are just a random jumble jumble of letters, but by the end of the talk, um, hopefully you'll know what they mean and, and what you can do in terms of assessment and management of these conditions. So we'll just start off with a case study. This happened actually a couple of weeks ago while I was in, um, A&E. So we've got this 45 year old chap, um, that's been brought in by the ambulance, um, had a couple of episodes of vomiting, um had some abdominal pain. Um, when you see them, they're looking quite dehydrated, clammy and sweating, um, breathing quite rapidly and shallow and um the breath smells of pear drops and uh they came in known type one diabetic. So it's like what we had mentioned, we've said it a few times, but really for all these types of emergencies, um you want to be able to do an A two e early on. So look at the airway, it patient, we're able to talk in full sentences. So we're happy with that so we can move on to breathing. So the chest sounds quite clear. Um Oxygen is maintained, it's at 95% respirators, 20 we move on to circulation and once again we go through it, heart sounds are normal, slightly tacky. Um BP is on the lower side and the ECG shows tachy sinus tachy. Um So at this point, we treat as we go along as mo you mentioned in the first part of the talk. Um and what we've mentioned early on in the a assessment. So you want to get some access in early on, um get the bloods while you're getting access to the VBG um and start some fluids. As you see, they're quite sinus tacky, the BP is slightly low. Um and then we move to um disability and usually a lot of our answers can be answered in the first part of ABC. But in this scenario, certainly, when we move to disability, we see that the blood sugars are 33.5 really raised through the roof. Temps are fine. Um G CS is 14 out of 15. Um And it's a good idea at this point with the B MS being so high. Um ask um the nurse or, or whichever colleague you're with to um take the ketones as well as the urine dip moved to uh exposure. And so as we've mentioned before, there's a fruit Yor on breath. Um in terms of the abdomen, it's soft, lacks, there's a bit of generalized abdominal discomfort, but they're not guarding, they're not Peric calves are looking soft, nontender. So, um we're able to run the BG quite quickly. The bloods in the lab are going to take quite a while. So the blood sugars come back. Um And as we said before, it's 33 mils per liter and the normal is between um 4 to 11. The ketones is at 3.5. Um The ph is 7.25. So um with Molly's to Tart already, we're looking at it, it's more so on the acidotic side, bicarbonates 14 and the ketones are plus plus. Um So if we could start the first poll, um I believe the, the question is, what do we think is the diagnosis at the moment? So give you a couple of, couple of seconds to think about. What, what type of hyperglycemic emergency are we dealing with? So, we've got 85% of people saying DK A. That's good to hear. Yeah. So we're looking at DK A. Um, and it's one of two, hyperglycemic um, emergencies. So, um, this sort of the, the main bulk of this talk, I'll be, I'll be chatting about DK A as, it's something I've, I've seen quite commonly on the ward. Um, I think I've only had to deal with HHS once um, as a junior doctor but DK A, it's one of those things that, um, you'll see quite frequently in terms of the hyperglycemic emergencies. So DK diabetic ketoacidosis. So, um in diabetes, it, it is one of those serious complications and it is an emergency which is why we need to be able to assess and manage it. Um, quite immediately. It's probably the most common in, in type one, diabetics. It can be seen in type two. And it's in those that have got absolute insulin deficiency and the onset compared to HSS is um it can happen quite quickly over the space of, of hours. Uh whereas HHS can be uh over days, um several days at a certain time. And then in terms of the pathophysiology of what's actually happening with DK A. So as we've mentioned before, in type one diabetics, there is a complete lack of insulin and the pancreas is unable to produce any. So for the body to be able to have some sort of energy stored to the cell, it seeks to break fats down instead. And as a result, when you break the fats down into free fatty acids, um of which ketones uh are present, um the ketones are in the blood and as a result because they're acidotic, these free fatty acids, uh we get into metabolic acidosis. So if we have a look at this diagram over here, it sort of illustrates it quite well. So we'll start off with insulin, you've got a lack of insulin. Uh And as a result, we're unable to push um any of the glucose into the cells. So we're left with hypoglycemia, um insulin the whole as well. Um It inhibits the lipase enzyme. So if we don't have any of uh if we don't have any insulin, um the lipolysis is going to be increased as a result, we're going to be breaking fats down. And so we've got increased free fatty acids, um of which are ketones. And so we're left with ketones in the blood and then they get weed out, which is why we end up seeing ketones in the urine. Um And because it's ketoacidosis that results in lactic acidosis. So, in this DK a trial, we're looking at um three different things here. It's so hyperglycemia, which we've touched on. We're looking at acidemia, um as well as ketonemia. Another thing to bear in mind is while we've got hypoglycemia and you've got all this extra sugar that's in the um that's in the blood. Um As a result, it's going to get weeded out, which is why we see glucosuria and we get this phenomenon of osmotic diuresis. So all the fluids being pushed into the vascular space, which is why liters and liters are weed out the system um until you get polyuria and this triggers receptors with this receptors in CNS. Um which is why uh we get polydipsia, which is this feeling of uh excessive thirst. So why can it start? So, with all these different um causes um they result in um increased stress, increased cortisol, which as a result can um shoot the glucose all the way up. Um with the exception of say it's poor compliance with, with insulin, um sometimes patients can present to hospital without a diagnosis, type one diabetes, but also in the ones that have um diabetes, diabetes they haven't been taking that insulin properly, which is why their blood sugars are really raised. So for infection, it can be anything from chest abdominal urine. Um And so we get an increase in blood sugars as a result and it can push them into DKA um developmental changes. So, growth spurt of puberty, once again, increased cortisol. It's something that we see um poor compliance with insulin that we've mentioned surgery. Another one that's going to raise um cortisol as well as menstruation. So in terms of clinical symptoms, it's, it's what we had sort of mentioned before. Um where you get abdominal pain, there's this hyperventilation, which is also known as C breathing, which is this rapid and shallow breathing, um, nausea and vomiting. So you've got fruit that is as a result of the, the ketones, um, you know, signs of volume depletion. So they tend to look uh very dehydrated, lethargic fatigued, uh and not very well on the whole. So we're back to our, um, a two assessment. Uh, we're concerned about yet diabetic emergency. Um One question that we actually would be good to pose at this point is we've had a look at the criteria which is DKA um based on the different BG values and we've got our criteria here. So the blood glucose should be over 11, um or they should have known diabetes. Um If they've got blood ketones over three or if they've got urinary ketones, which are over two plus and if their venous ph is less than 7.3 and, or they've got their bicarb, which is less than 15 and it's important that we have all three to be able to, um, give a definitive diagnosis of, um, DK A. So I pose a quick question to the crowd. Is there ever a situation where, um, we can see DK A? But, um, there isn't actually high blood glucose. So I think that's one of the polls. Is that something that um is 100% needed all the time or is it something that can um that is not always the case. Have you got the to pull up the pole's up? Just waiting for some responses? We've got four so far. OK. We can give, we can give the crowd a bit of time. I think someone had mentioned it at the very start of um of the lecture today. So we've got 89 responses now and um 67% of people say no, no. OK. Yeah. So it's a case of something called euglycemic DKA. So it can be a bit confusing considering we've just said, OK, these are the three diagnostic criteria. Um And we're happy to roll at that. It's just with the caveat of um we can get something called euglycemic DK where the blood sugars are actually within range. But you've got these raised ketones and the PH is reduced. Um And it can be caused by SGL two inhibitors. So these can be your empagliflozin, your canagliflozin, dapagliflozin. Um and these can sometimes disguise the actual um blood sugars being raised and they're usually con contraindicated um in patients with DK and they, and they need to be stopped and it's a case of um pushing fluids in it and it can take a while before the DK can, can be resolved. So the next part is once again, escalate early on, seek help from your seniors. It, it, it can be quite a lot to deal with if it's the first time and it's something you're not po potentially familiar with. Um So if you're unable to get IV access, um that's the first thing. The next is if they've got severe DK A, so there can be a few different reasons um uh behind what would constitute a severe DK. So if the blood ketones are over six, the bicarb is less than five, their ph is less than 7.1 the potassium is less than 3.5 the GCS is less than 12. Um And then if you've got the vitals that are, that are really out of range and that you're worried about their oxygen less than 92%. Um If their BP is completely tanking as well as their heart rate is completely on the other end. So they're looking quite hemodynamically unstable. Um If they're pregnant once again at DK A, um it's going to increase the mortality of both the mother and fetus, um, and heart renal or liver failure. So, um, one of the mainstays of treatment is gonna end up being fluids. And so, um, we wanna be able to watch out for something like fluid overload and we also want to be able to tackle um, the acute kidney injury that could be posed with TK A. So, um, we'll do the next poll, which is, so you've got DK A, what are the two main things that, um, we want to be able to do in terms of treatment for DK A? So I think the options mentioned definitely different types of um, insulin delivery got a few results just waiting for a few more. So about 57% of people say variable rate, insulin infusion and IV fluids and oh, it just changed. So now 41% say fixed rate, insulin and IV fluids and 55 say variable rate, insulin fluid and IV fluid. Ok, fine. So, um, when it comes to fixed rate in and a variable, a variable rate or it's formally know sliding scale, um, for DK, we want to be able to give them a fixed rate of insulin to begin with. And when we start considering a VR, um, it's a case of whether they're unable to, so they came out of the DK A and um, whether they're able to eat or drink or they're able to, if they're not able to tolerate um, anything orally. Then we can consider putting them on, um, a sliding scale type of insulin. But to begin with, we want to give them fixed rate insulin, a certain amount, um, along with IV fluids. So it's fixed rate insulin and we want to give IV fluids, um, plus minus potassium. So it's easy to break this down in terms of the DK A, what are we gonna do in the first hour? Um And that's usually the one that you could find yourself being in before um, your seniors arrive. And so this is the one that's quite critical and if you get the basics, right, um, of the 1st 60 minutes, um the rest can be sort of taken care of later on when you've got more hands to help with. So if we start with the actual fluids, um you go by looking at their systolic BP. So if it's over um 90 we can start off with one bag of sodium chloride, 0.9% over an hour. So it's fairly straightforward. And if that under 90 then we can start off with 500 mils stat just to pick up that BP. And it's just very much like an A two E um assessment. If you saw someone with a systolic BP under 90 slightly tacky, you would give them some fluid as a stat to see whether that would pick back up and then when it comes to the fixed rate IV insulin infusion, um it's good to know roughly how much insulin we want to be able to give. So the equation that we use is we want to give 0.1 units per kilogram per hour and 10% glucose. So for example, we've got a 70 kg chap. Um we've got 0.1 units per kilogram per hour. So um we want to times that by 70. So we're getting seven units per hour. Um and it's always important to keep whatever long acting insulin they're on. So it can come under different brand names. You've got Lantus Levemir Tou Tresiba. Um and it might be different in, in your native countries, what they use or what the brand name of the long acting insulin is or the intermediate one. but we keep this running the whole time while we've got the fixed rate insulin. Um and that's because we're trying to prevent rebound hyperglycemia. Um once we remove the fixed rate insulin, so we've still got a steady stream of um insulin to be able to push the glucose into the cells and then prescribe hypoglycemia treatment if necessary. It's, it's something uh as a junior doctor as soon as um you're dealing with anything diabetes related or hyperglycemia related. Um just in case we end up giving too much for whatever reason, it's always good to have um hypoglycemia treatment prescribed just in case, um, their blood glucose drops below four. Um, also a fairly obvious one, but it's still, uh, it's still very important is to see whatever else they're on. There could be other different medication that is, um, currently dropping their BM. So it's important to suspend and stop this for the time being. So we've done the A two E, we've given BT prophylaxis um in DK A and even HHS, they're at a higher um likelihood of um getting a clot. So important to prescribe your um enoxaparin or if they're already on any blood thinners, um We wanna be able to check the um blood glucose pretty much every hour as well as the ketones. We take a VBG. So we're checking the ph, the bicarbonate and potassium. So that's very much in the first hour, 1st 60 minutes. Um You've given that at least certain before you start and the next day you take another BBg. So that's the second hour and you keep doing this and then you move on to doing it every two hours and you should see a steady improvement um in the ph um slowly rising again, um as well as making sure that the potassium is within range. So um as a reminder with insulin, but also pushing in um the glucose, but also potassium gets pushed into the cells. And so um in the blood stream, if we don't replace the potassium, we're going to end up making the patient hyperkalemic, which is why we need to add potassium along with our IV fluids. So we've now reached the 60 minutes to six hours sort of timeframe. And this is where we can start thinking about adding potassium um to the fluids. So, exactly. So it's replacing potassium whilst the acidosis and um ketonemia improve. Um we've got the long acting insulin on the go, which is good and we should be seeing every so hour, every so hour that the ketones are dropping by around 0.5. And um in terms of potassium supplementation, it can vary depending on what your um trust guidelines are. The one that in the ones that we use at our hospital. Um based on that BG if it's within range. Um So you've got 3.5 to 5.5. Um then you can give 40 mil moles if it's over 5.5 and they're hyperkalemic, then we don't need to put any more potassium in the fluids. Um And if it's below 3.5 which is the um below the normal range, um then we would still give 40 millimoles, but um also seek um help from um any of your seniors. Um And in terms of um the actual maximum amount of potassium that we can give, it's limited to around 10 millimeters per hour. So this table is a rough guide slash idea of how much fluid should be giving over what time period So, as we mentioned, in the first hour, we can give a Lisa and then for the next, um, four hours, we would give two bags and we sort of slowly, um, continue giving lies just over a slower period of time. Um, in these DK patients, it might feel like you're just hammering them with fluids. But, um, they've probably lost, I think I was reading a study yesterday. 6 to 7 liters is quite normal, which, which sounds like an astonishing amount, but it's very important to make sure that we're hydrating the patient. Um, flushing out the ketones and bringing the, the glucose down. So, between the six hour to 12, um, 12 hour time frame. Oh, I think my laptop is frozen. Do you want me to print it or are you happy to just do or is it still showing anything? Yeah, it says 6 to 12 hours. Ok. We can see that we can see all of that. Can you see? Yeah, we can see that. Oh, so you can see 6 to 12 hours now, right? Yeah. Ok. Good news. So, um, 6 to 6 hours to 12 hours. Um, it's the same goal we're trying to avoid. At this point. We've given the insulin, we given the IV fluids with the potassium. Um, and we, at this stage it's nicely coming down. We want to just avoid any hypoglycemia. You start to see the glucose starting to drop below 14. Um, we wanna instantly start glucose 10%. Um And we wanna do 100 and 25 miles per hour. So that's an eight hourly bag and that's alongside the current IV fluids that you've got going on. Um We've got the fluids, you've got the insulin also watch out for any signs of overload. So we are cautious in those patients with renal failure or heart failure, kidney failure for that matter. Um and um the reason why we give it at a slow but controlled level is to watch out for things like pulmonary edema or cerebral edema. So the 12 hour mark, it should be starting to resolve. Um So the ketones uh would have came down below less than 0.6 in the blood. Um ketones are one or negative and that means, you know, that your DK has resolved and then in terms of what to do, they're on that fixed rate insulin. Um How are we going to be able to wean them off or transition them um back to their normal um insulin regime? So we can do that at their actual meal time if they're able to eat and drink. Um And the way in which we would do this is we'd stop it an hour after they've had their regular short acting insulin. Um because we would just be concerned about um hyperglycemic. You want to just continue to give them their insulin if they're not eating and drinking as we mentioned before. Um, and the DK is resolved, then we can push them on to a variable rate insulin infusion and then I'm just going to briefly touch on HS si know it's just after 7 p.m. there's a few slides, um, and we can just talk about the main sort of basics. So it's actually the mortality rate is 20%. So it is considerably more than DKA, it doesn't present as, as frequently and in terms of onset, um it, it's a couple of days whereas the DK can only be several, several hours. So once again, looking at severe hyperglycemia over 30 not necessarily any ketoacidosis, the ketones are less than three. The PH is above 7.3 the bicarb is over 15. Um The mainstay of this is looking at the hyper if they've got hyperosmolality. So that's something you can check in the blood and if it's over 320 then alarm bells should be starting to ring that. Ok. This could be HHS. And they're usually um very uh volume depleted. Um And this is just AAA quick diagram of if you look at the differences between DK A to HHS. So, um we've got hypoglycemia which is in both um ketosis and DK A but there's none um in HHS or, or it's not that frequent. Um We've got high serum osmolality in HHS. Um and DK to metabolic acidosis. Um occasionally you can get a combined picture um where you might need to start um fixed rate insulin for HHS. But um typically we don't start off with that. Um And in terms of the actual pathophysiology. Um So you've got hypoglycemia once again. Um But with HHS, you've got this level of osmotic diuresis, which is um very powerful. So once again, there's a huge amount of volume depleted and you've got these counter regulatory hormones. So, as we had mentioned before, all of these things can shoot the um blood glucose apps, the Cortisol, epinephrine, uh Glucagon, um et cetera. So what can um trigger all of this? It's, it's very much a case of dehydration and, and poor fluid intake. Um similar to DK, you've got infection sepsis, ACS stroke. Um All of these things are going to lead to dehydration, a patient. Um We've got slow onset polyuria, polydipsia and weight loss often very dehydrated. There's going to be metabolic disturbances. Um And focal neurology is something quite seen, seizures can present themselves um in HSS as well as a drop in gcs. So in terms of just a generalized management plan for these patients escalate early doors, um we want to be able to um decide, OK, are they going to be for it or are they going to be for critical care? So there's a few different criteria. So if the osmolality is over 350 if the sodium is over 100 and 60 ph, less than 7.1 gcs is less than 12 once again with their vitals, if they're completely out of whack, and they're very hemodynamically and stable. It's worthwhile just having a call to someone from critical care to see whether they would be a candidate um for um it or HD. Um if they've got close to little or no urine output, um or if they're hypothermic. So, overall general assessment and management. So we've done our A two E um in terms of fluids, you want to start off with 0.9% cell line, one liter over the first hour and after the hours occurred, at that point, you will have senior support um in terms of insulin in this situation, um It's only if they've got significant ketonemia, um or if they've got two plus um ketones. Um and we're looking to give between 0.05 to one units per kilogram per hour. So that's just based on trust guidelines and every hour it should um drop the glucose slash ot by three. It's important to check the use and taking BGS regularly once again, potassium replacements. There is a high likelihood of clots once again. Um So important to prescribe um any VT prophylaxis and occasionally depending on the cause of this HHS if it's sepsis, um get your IV antibiotics running. So that is everything from today's talk. Um It was just a quick point certificate. Uh I think for those of you here that, that have attended. Um Now three of our talks. Um then if you're able to scan this QR code and just fill out a quick survey, um, it should be able to ping into our inbox and we'd be able to give you a certificate saying that you've completed um at least throughout the four E si so we can send you an E certificate. Um if you scan that and um fill out the survey on Google forms. Um We'll just check if there's any questions in the crowd. I know that we finished quite late this evening. I've been trying to answer them as we go along. So I don't think there are any unanswered ones from your talk. And there were a few, I didn't know if I'm sure would be able to help. There are a few people just saying they hadn't had feedback forms from the first session. Um I don't know if that's um, something that you'll be able to help with. I'm sure. And with the feedback forms, um could everyone just make sure that they've sent if they can just send us an email at Medi Health International at gmail dot com? I'll put it in there now as well and into the chat box. Um If you guys can send us an email and then we can work on that, but make sure to get your certificates, you have to fill out the feedback form to get them and you have to have watched at least 80% of each of the webinars. I'll put the Instagram uh we in now six. Yeah, somebody said that their feedback went into their um junk or their trash mail. So um maybe just making sure, check that. Thank you. Um So everyone's saying thank you in the chat. Um We're very grateful for you guys for coming and we've got the final session um on anaphylaxis and hyperkalemia, which are both emergencies and they're on um Wednesday. Um So we'll try not to overrun on Wednesday, but thank you for coming and um yeah, we'll hopefully see you back on Wednesday. Bye everyone. Thank you so much guys. Take care, have a nice evening wherever you all are. So I'm just gonna send this message into the chat box so everyone can get the email. Ok? I sent a message to the chat box. Um Thank you guys so much for joining us today. Please join us again on Wednesday for the final episode and thank you to Molly and John for teaching us today as well. Hi, everyone. See you guys for around.