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Hey, good evening everyone. My name is Raha. Say I'm President here at Meath International and I would like to welcome you all to the first episode of our highly anticipated webinar series emergency presentations with junior doctors. We're privileged to have two physicians here with us today. Doctor Abraham and Doctor Hardwick teaching this webinar series and they will be sharing their expertise and insights in emergency A to e assessment and chest pain. So without further adi delay or warm welcome to our speakers, thank you both for being here and for sharing your knowledge with us. Hi, everyone. I'm John. Thank you so much for the warm welcome room share. Um I've got Molly over here in the chat as well, so maybe she can introduce herself. Hi, everyone. Um My name's Molly. I er work with, we work um in the UK up in Liverpool and we're very excited to give you this talk this this evening. All right guys. So we will share the screen uh bear with any technical difficulties for the first episode, we'll try to iron them out. Um So, all right, let's have a look here. It was working before I promise you that. Um is it a day? So it's not, it's not popping up under powerpoint anymore like that. Is that, yeah, just start, start the, so that showing anything we can see. Ok, so, so we'll talk about a bit how the session is going to work out. So there's going to be two sessions, two topics per session. Um So they usually going to be around 60 minutes of which I'll speak for half an hour and then Molly is going to do a different topic which will last another half an hour. Um We'll try to do A Q and A at the end where you guys can ask any questions in the chat. Um All together, there's going to be four sessions um over the course of the next two weeks. Um at the end of each session, we will do an anonymous feedback form that you guys can fill out. Um And um as soon as you've completed that, then an automated E certificate should be sent to your inbox. Uh And if you come to three of the four sessions, we'll send you a full series E certificate um for attending the, the workshop. So without further ado um I'll be talking about the A two assessment um for the first half and while you were going into chest pain afterwards. So the at two assessment, airway, breathing, circulation, disability, and exposure. So the whole idea behind A two is that we want to be able to have a systematic approach to dealing with a um unwell patients. And it's something day one of being a junior doctor all the way to being a consultant is something you're going to be using um day in day out to deal with any unwell patients. So it involves doing clinical assessments. Um and while you're doing it alongside, you can do investigations as well as interventions. The whole idea behind is that we're improving and seeking to improve clinical outcomes for acutely unwell patients. And then what about a diagnosis? So more often than not when you start doing an A two E by the end of it, you might not have a definitive diagnosis, but um, you'll probably have narrowed it down to a couple of different differentials. Um And then you can take it from there and it usually takes a while before you've come up with. Ok, this is definitely what we're dealing with. Um, but it helps put you in the right area of what you think might be going on. So a two week, I think quite a few of you already in fine year of med school. So this will be recapping a lot. Um But we do have quite a few students who are in first year and it's probably a couple of weeks in. So we'll be covering sort of everything from basics and a lot of recapping for the fine year students. So you've got a two. And so the way in which it works is we'll start off with this initial assessment and at any point that you feel like you're stuck or don't know what to do, it can be always quite helpful to be able to reassess and go back to the start, um, from airway and work your way down. It's important to treat along, um, treat as you go along during each step. So let's just say we've done airway and we're on to breathing and um someone's oxygen has dropped. So the SATS are around 90%. We can always put some oxygen on um and treat as you go along. So we sort that out before we move on to the next part and then we should assess the effects of the treatments we've put the oxygen on has actually improved anything. Um Let's you say someone's BP has dropped a little and we've given them some fluids, has the BP sort of picked up as such and then recognize when to escalate. So being junior doctors, me and Molly over this last year or so have been in these situations where you're dealing with quite an unwell patient and sometimes you can only deal with what's in your scope, your level of expertise. And so it's better to escalate earlier on before things sort of go out of hand and use all members of the team. So more often than not when you're dealing with unwell patients or nurses ask you to come assess a patient. Er, you might have a nurse with, you might have a couple of health care assistants. So if you're able to delegate a few tasks or you're asking for help with, with certain um, procedures or certain tasks, then the likelihood is that the overall outcome um of the patient is going to improve um when you're working altogether. So the new score, so when it comes to dealing with um acutely unwell patients, you've got the nurse that just rang you on the phone and said, can you come see my patient? They look quite unwell and um early on you can ask them what's their new score. So for those that don't know, it's the national early warning score. And so we've got the table on the right hand side that you guys can see. And so it's made up of different physiological parameters that we're interested in. So it's got respiratory rate, it's got oxygenation sats. Are they on any supplemental oxygen, the temperature systolic BP, heart rate and level of consciousness. So if we add them all up together, we get a new score and it can sort of tell us how quickly we need to come assess the patient or to review them. We've asked the nurse when we're heading there for an up to date set of observations. So I suppose they're scoring 1 to 4. It's a prompt assessment by the ward nurse and either they can increase the frequency of observations or they can escalate to the medical team. You'll usually be phoned about these. And um it can be for just advice or it can be to review the patient. Then if we move to the next step above, if there's scoring a 4 to 5 or three in a single parameter, so this one nurse can be quite worried. And so you'll be asked to come review the actual patient on the ward and then you can decide on changing the obs frequency, come assess them and then um can decide to escalate there. And then um it's the same with MUS five or six. It's also considered an urgent review and then MUSE seven plus would be considered a met call. So that's when the medical emergency team are called and the nurse puts out a met call bleep um where the whole team of um the junior doctors, the SHS and the medical registrar usually arise. So back to the A two weeks, you're going to the actual patient bay. Um and there's a few things that you're sort of thinking about, but just before you can start the A two assessments, um get your personal protective equipment on. So whether that's gloves, mask apron, um you can put that on um just before you enter the patient bay bedside assessment. So I suppose you're walking onto the, walking onto the bay, you can even eyeball the patient from afar. So either they can be, um, sat there talking to their neighbor, joking around, giggling and having, um, a good time and then as soon as you see them all of a sudden all the symptoms start to come out, um, or it could be the case that they're actually looking really poorly and unwell just from eyeballing them and they're slumped over and they don't look very well at all. Um, So it can also provide really helpful information even before you've spoke to the patient. So you've gone over. Um Unless you say patient's awake, perfect. They're talking in full sentences. You can ask how they are good to go, but let's just say they not really responsive, they could be unconscious, they might collapse. Um So I suppose they're responding and talking in sentences. Perfect. We can move on with the A two assessment, as you said, short sentences. You're not too happy with the way in which they're talking. Um Maybe their, maybe their airway is slightly compromised. You can still continue with the A two assessment, I suppose there's failure to respond. Um You tried shouting their name, you've tried sort of shaking them by the shoulders and there's still nothing. You've tried a sternal rub or a trap squeeze. Um Then it's probably a marker of critical illness and you need to act quite quick. So what we have is look, listen and feel it takes around 30 seconds. But you won't be able to look at whether the patients actually breathing as such. If their chest is rising and falling, you gonna listen over their mouth and their nose to hear. If there's any audible breath sounds and simultaneously you wanna feel for their carotid pulse. So this should all take around 30 seconds or so. And let's just say that unconscious unresponsive there, absent breathing, then you can start CPR get help quite immediately. So, what we want to do is um we want to call the crash team and it depends in, in every hospital. But um in hospital that me and Molly work, it's double two, double two and you tell them to bring the crash team and then you start your CPR. It's also important to get the monitoring going. So there's other people around you, you can get the crash trolley, start getting an ECG, put some um oxygen on um get BP, get IV access and a really quick note about the LI listen field. So in my presentation, I've put it as 30 seconds. But I think also in the, in the um A LS recess guidelines, it's actually 10 seconds. So um 10 seconds should be more than enough um before you decide to start CPR. And if it's not a cardiac arrest or they're not in respiratory arrest, you can proceed to the ABC DE assessments. So this quick diagram of how it actually looks when you're doing the, look, listen and feel. Um So you push their head back, you've got your ear um over the uh mouth to see whether you can hear anything. Um You're looking towards the chest to see whether you're seeing any movement of the chest. Um and simultaneously you're feeling for a carotid pulse. So if you move on to airway, the assessment, like we spoke about not breathing, not responding, unconscious, cardiac arrest, that's start CPR, then there's signs of airway obstruction and this is actually also um a medical emergency. So it's quite important to call for help quite early on. So what that can be is paradoxical, chest and abdominal movements. So if you've got this seesaw like movements, um meaning they're working hard, it could be a sign that there is um some type of airway obstruction if they're using their accessory muscles. So you've got per lips, they're working quite hard. Um We can also see central cyanosis. So this will look like bluish discoloration of the mucous membranes. I suppose it's complete airway obstruction. So you won't actually hear any breath, sounds from the mouth or nose. And then there can be partial airway obs extraction. So the air entry can be quite quiet or it can also be noisy. So you might hear snoring or gargling and if they're talking in full sentences, the airways patent um and we can move on to um the breathing um for the A two assessments. So, what are some interventions and maneuvers that we can implement when things start to go wrong. So the first one, we can start off with suction. So there can be um all types of secretions as such that can be inside the oral cavity. So everything from gastric contents to blood to actual secretions that could be compromising the airway. If we happen to suction, suction them out, then um it might actually remove any airway compromise next to the simple airway clearance maneuvers. So we've got the head tilt, chin lift, got the jaw thrust. Next, we can use the um oropharyngeal. Um Our nasopharyngeal airway use an eye gel or a laryngeal mask airway and last but not least intubation. So as a junior doctor, all of this can sound quite daunting. But if you look at the first couple of days with suction and simple air clearance, um using an op or an NP, these are stuff that you can sort of do while you're waiting for for anesthetics. When it comes to an eye gel or LMA or intubation, there's probably going to be senior support at that point and you and you probably should have already called for help. Um When you're moving on to probably number three, number four, number five of these interventions. So it's sort of what the airway suctioning looks like. Um Usually they're found bedside or you can even find um um a portable suction such and um if there's any gastric saliva secretion blood or other debris, we can um just suction it out. Then there's the head tilt, chin lift and jaw thrust. So the idea behind this is to basically push the tongue forward and prevent it from falling back. So for the head tilt, chin lift, um what we want to do is we want to tilt the patient's head back. So we've got one hand pushing down on the forehead and then with the other two fingers, we want them just under the chin. And so that it's pulling up the jaw and then we can use the jaw thrust, the jaw thrust is when we're worried about um, patients that have, there's a concern of injury to the cervical spine. So that can be for patients that um have been admitted in a um a road traffic accident where there's been um, some sort of concern that it could have been an injury to the spine. So instead of using the head tilt chin lift, which could exacerbate those injuries, we can use the jaw thrust. So the way in which we want to be able to do that is we get two fingers under the angle of the jaw and that's on both sides and you're sort of resting your thumbs and probably the inside of the then are eminent on the actual cheeks. And if you lift forward, it should also push the tongue up, then we've got airway adjuncts. So we got the nasopharyngeal airway as well as the oropharyngeal airway. So we've got a NP, we've got a NP, um which is, um, used to bypass upper airway obstruction. And that's at the level of the nose, Nazi pharynx in base of the tongue. And this is usually better tolerated um, in partly or fully conscious patients, then the oropharyngeal airways and it's usually between size six or seven, the orphan airway and that sits just between the tongue and the hard palate. Um So if there's any obstruction of the soft palate that can relieve it, um Usually this isn't as tolerated, well as the NP um and should be quite cautious with um any aspiration or gagging. We've also got supraglottic devices, we've got eye gels as well as uh L MA S. Um at this point in airway, you would have um escalated to see it. So I'll move um on to the, the next slides. Um I think we could be a bit short on time this evening. So what can we see in terms of examples of airway interventions, treatments? What, what are the, the, the main sort of pathologies that can be seen? So, if we've got secretions in the airway, we can push the patient to the left lateral position. Um Anaphylaxis is one of those me medical emergencies where um adrenaline will be required. Um If they've got Stridor, then we're going to need anesthetic or ent support there. Foreign bodies in the airway. Um use the choking pathway also worthwhile getting t or anesthesia involved. So, if we move on to breathing, so in terms of vitals, you want the oxygenation sets, you want the res rates. Um, do you wanna inspect them? See what they look like? Are they cyanotic, are they short of breath? They're coughing up something? Uh Do they show, are they showing signs of stridor then have a feel of the actual chest? Is there any tracheal deviation? So sometimes it can be pushed away, the trachea can be pushed to one side. Um If there's something like a pneumothorax or it can be pushed towards one side. Um I suppose the patient's had a lobectomy, chest expansion is there reduced chest wall movement and that can be for a variety of reasons. Uh Once again, if it's both sides and the chest wall movements decreased, um on both sides, it could be a sign of pulmonary fibrosis. Um And if it's asymmetrical, chances are it could be a pneumothorax, pneumonia, um pleural effusion, then we move on to percussion, see whether it's hyper or dullness. So, hyper resonance would show um uh pneumothorax, whereas dullness would show um a fusion where we can see some um fluid in the, the bases of the lung and last but not least listen to the actual chest. Is it bronchial breathing? Which can be showing a sign of consolidation? Do we have reduced? Sounds? Maybe there's fluid at the base of the lungs, they can be wheezy in the case of asthma or COPD, they can be having either coarse crackles or fine crackles as well. So how do we investigate? So we can get an ABG chest x-ray from the get go. Um, and then if the oxygen is on the lower side, we can stick a bit of oxygen on. So that'll be a 15 liter non rebreathe. And that's if you're quite un sort of unsure or concerned about the patient and we can always wean down. So if we start with a 15 liters, non rebreather, um we can always wean down for the patient. Um We want to target sets 94 to 98% for those who are worried about type two respiratory failure. So, um a lot of COPD patients, but it's not limited to them. We wanna aim for saturations of 88 to 92. Um And we put them on a venturi 28% or 24%. Um We can also think about CPAP or NIV, which is another form of ventilation, but that's something that can be discussed with seniors. Um And you'll be given help with it. So we've got different sorts of oxygen devices. We've got nasal cannula, simple face mask, venturi, and non breather, the main ones that you're going to be dealing with. So at this point, what are the different pathologies that we see when it comes to uh the bee part? The breathing part of the A two assessment, usually it can be exacerbations of COPD and asthma. And so the treatment is quite similar, um where we get oxygen on, give them nebulizers in the form of salbutamol or um ipratropium start some steroids, um and consider magnesium and asthma. Um pneumothorax, as you've already mentioned, which requires uh needle chest decompression as well as pneumonia where they could require IV antibiotics as well as fluids move on to circulation. Heart rate, that's what we're interested in. Normal range is between 60 to 100 as well as BP and see what the blood pressure's doing. Um If they're on the low side is the diastolic value itself low, that could indicate arterial vasodilation and, and that could give us a picture that anaphylaxis could be happening as well as sepsis if they've got a narrow pulse pressure. So this is the difference between your systolic and diastolic. Um that could show arterial um vasoconstriction which could uh indicate the patient could be in shock. We check their fluid balance as well and their urine output. We're hoping and, and hoping for around 0.5 mils per kilogram per hour, check the capillary refill time. So we want to be able to press on the actual finger for five seconds um where it's blanching and then release and it should be less than two seconds. You can also check it centrally um as well. And um it should also be less than two seconds, then check the pulse rate. You want to check the rate, quality regularity and equal as well as looking at your hands, um, whether they're pale Mutt. Um, and then listen to the heart. Are there any murmurs? Um, are there quiet? Um, heart sounds? So what can we do there? And then in terms of investigations and procedures, so see if we can get a 12 U DCG, get some IV access earlier on. Um two cannula are ideal, but at least one IBX is better than no access. Um And while you're getting the IV access, see if you can get bloods off them as well as well, well as the VBG, so for the bloods, it would be, the standard would be full blood count, EE LFs and CRP. And depending on the clinical, you can get um plus or minus um more bloods, it might require a bladder scan or catheterization if you're worried about obstruction or urinary retention, um always consider a pregnancy test um in females. And what can we do in terms of intervention? So, if they're losing a lot of blood, we can consider a blood transfusion. Um If they're slightly hypotensive, you can start off with a 500 mil stat of either Hartman's or sodium chloride. Um And if you're worried about overload, um then you can start off with 250 mils and you can do this up to four times if that's still not helping. You can start discussing it with senior and they might need inotropes or any vasopressors. So typical examples of, of circuitry um interventions or treatments. So, I suppose it external hemorrhage just get pressure onto that immediately. Um ac ss so acute coronary syndrome, um you can do mono which I'll let Molly talk about um later on. Um if we're worried about sepsis, we can start the sepsis, six proforma, um flash palm edemas, we've got um a lot of fluid in the lungs. We're going to need diuretics as well as a good fluid balance. Um If it's atrial fibrillation, um we can treat the underlying cause more often than not and they might need um rhythm versus rate control. So they might need cardioverting, but they could require bicep or um digoxin. Um And last, but not least pulmonary embolism, they could be a, a candidate for thrombolysis. So, onto the um the disability um of the A two assessment. So you've reviewed and treated um as such, the abcs um have a look at their drug shots. Are there any reversible drug induced cause of depressed consciousness? Um have a look at their pupils the size and quality um as well as their reactivity to light. Are they pinpoint or are they dilated? Um So we'll talk a bit more about uh what pinpoint would would mean and why they'd be dilated or examples of that? Um Are the pupils asymmetrical in size. So that could be an intracerebral pathology. They could be having a stroke or a space occupying lesion. Um We can also do an A two score or a gcs and gcs is probably more useful um And it's graded out of 15. So you've got is four verbal, five M to six. The lowest can only be three out of 15 and max is um 15 out of 15. Um also important to check the blood glucose. Um And I phrased them to also check the ketones as well. Um check the temperature and what could we do in terms of intervention? So, I suppose the hypothermic, we can put a bear hugger on if there's any reversal agents. Um if appropriate, if they've just um had something quite recently. So naloxone can be used if we're um suspecting an opioid overdose. Uh flumazenil can be used if there's a benzodiazepine overdose. I suppose that blood sugars are running a bit on the low side. Uh If it's less than four milli MS and that we can give 50 mils of 10% glucose IV. And we can keep repeating this up until it's 250 mils. Um And we can move the patient into the lateral position if their airway is not protected. Um And sometimes let's just say that we're not happy with their gcs. Um We can consider um a CT head to rule out for any bleed or space occupying lesions. So examples of this um that we can come across for the disability. So DK A so they, um they've got high glucose um and the ketones are raised and they're showing acidosis. It's something that we're going to cover in one of the future topics, but the main stem is going to be fluids as well as insulin. Um We can also do an um for the opioid overdose. Naloxone is the main treatment plan and then seizures. We're all about protecting the airways, making sure the head's safe and Benzos are gonna be uh the port of call for treatment. So, finally onto e um, which is exposure. So we want to be to inspect as well at the front as well as the back. The number of times we've been in clinical situations where we've done exposure, we've checked the abdomen, we've checked the calves and only really later on we've rolled the person over and they've actually had a big hematoma on their back or they've had, um, Melena. So have a look at surgical wounds or any hematomas, any active bleeding or discharge, um, any rashes. Um, have a look at the IV lines. Are they erythematous. Is there any discharge from them? Maybe that could be a source of infection? Um, have a look at the cat if they've got a catheter on any drains check, uh, whether there's any fluid loss, any blood loss. Um, and they can give you a good idea of whether there's an infection going on. Um Melina, like I've just spoken about important to, to roll the patient over. Um, and that could mean if it's Melina, it could be query. Uh an upper G I please and check the abdomen as well as calves. Um Does it look more distended, uh than usual, other calves, hot tender, swollen, query DVT and then palpate afterwards. So, for the actual abdomen, is it rigid? Are they showing sort of rebound tenderness? Does it look really distended and, and showing signs of peronism? Um are the calves tender? So, are we worried about um a potential DVT that's going to require a ultrasound scan? So in terms of interventions, we want to control the bleeding, how much and at what rate. So we want to be able to take those factors into um into consideration. Um If we see that there's a wound um important to take um or uh important to take a culture swab um with infection start sepsis. Six. So you wanna take blood cultures, you wanna be able to get a lactate, put some oxygen on start IV antibiotics and then consider other focused history um as well as whether a secondary survey is needed last but not least other consideration. So we're gonna take a full clinical history from um the patient as well as any next of care and any friends, any family. Um look at the latest blood trends, any recent x-rays or CT that they've had. Um, and then most recent observations were they stable half an hour ago and now they've just popped off or have they been getting continually um, unwell over the last couple of days, we gonna analyze different trends, gonna check the blood. Has there been any change in the hemoglobin renal function, electrolytes or uh inflammatory markers? The drug charts that we've mentioned quite important for disability to see whether they're on anything new and then document once you've done the A T assessment, if you document what you've seen, it's going to be helpful for the next clinician that um comes to see the patient check with their seeing of care status. Is are they just for the ward or are they for full escalation to ICU? And last but not least whether they've got a DNA CPR um plan in place. So they're no longer for resuscitation or they are so summary for the resource council. So a two E to assess and treat a patient, you're going to be able to do that complete initial assessment and then reassess periodically treat lifethreatening problems. As you move along during each part of the assessment, check the effects of your treatment, recognize when you need extra help and call for help. Uh early on. Then us all members of the team like we've spoken about and that is me done in half an hour. I'll um I'll pass it over to Molly now. Perfect. Thanks. So do you wanna just have a little moment to stand up and stretch and put any questions in the chat? Um John, I think there was one question it just said for pregnancy test and circulation. Are you thinking about a rupture ectopic? Yeah. So um for a pregnancy test on the whole, we could, we could either put it and see or we can put it even in EFC in it. But yeah, it's, it's something for um the abdomen. If we're worried about lower quadrant pain, it's something that we can definitely include in our differentials the number of times. Um I think in A&E where I'm working at the moment where you're going through your list of differentials and really later on someone said, oh have they had a pregnancy test and turned out to be an ectopic? So um it's something that we should do as a part of uh a full assessment. So you can either do it as a part of circulation or exposure. Nice John. Do you mind if I share my screen for the presentation? And then you can let me know if there's anything in the chat? Sure, sure will do. Cool. I will. So um can you see that uh not yet? Not yet. Uh Do you uh maybe or do you want to share it? And then I could also share as well. That should be fine and then I'll just um tell you how to click through. I I'll try one more time. Um Let me just, mm, I don't know if this will work. Um Can you see that? Yes. Yeah. Perfect. Yes. That's all right. Yeah, the first screen's up. Cool. Next one. Yeah. Sure. Can you do that? Yeah, that's working. Um So I hope everyone's had um a good stretch and is ready for the chest pain part. Um So my name is Molly and we're gonna be going through the management of chest pain and specifically um my card infarctions and it's kind of aimed at the level of how you want to be as an F one or a junior doctor in your first year approaching this kind of situation. So the management we're going to be going over is the management that your seniors are going to expect you to be able to do and they're gonna be expecting you to call them for anything more than this. So we'll start off with the basics. So a really, really common bleep when you're on the ward or you're in A&E is doctor, my patient has chest pain and there's loads and loads of different stuff that can cause chest pain. Just take a moment. I mean, I've already mentioned the obvious one but just take a moment to think of two or three other important causes of chest pain apart from A CS um that might cause um that you might be worried about. So, obviously, acute Coronary syndrome, really important you've also got to think of bad things like aortic dissection. Obviously, people can die very quickly of these ps. Again, people can die very quickly and pneumothorax, especially if it's skin tension and it's getting worse that can cause significant chest pain and lead to death. So, those are the four biggies and then there are lot loads of other causes of chest pain. So I've got a list. It's not even completely comprehensive but stuff like pericarditis, tamar, um, chest infections, pneumonia can cause chest pain, um, esophageal rupture and um, reflux. So there's loads of stuff that can cause chest pain and it's a really a broad topic. So you've got to keep your mind quite broad because lots of differentials, like I said today, because it's so broad, we're just gonna focus on one topic and it's just a topic which is really important to know about. And that is ST elevation myocardial infarction. And we're gonna be calling it a stemi today because obviously that's a bit of a bit of a mouthful. So I'm sure you guys have done loads of physiology and we're not gonna go massively into the etiology of um why people have heart attacks. But I think it's important my, in my mind, when I was at med school, I was thinking fine, someone gets like an atherosclerotic plaque which ruptures and occludes coronary artery, which then gives them an mi I which is true. That is a type one mi I but there are, there are five types of MS. So it's remembering that there are also other things that can cause MS. So like I said, type one would be, you know, you rupture of a atherosclerotic plaque which then occludes an artery causing an M I. Type two would be if you have lack of oxygen supply to the heart for a different reason. So example would be say someone is taking cocaine and they have a coronary artery spasm. So the coronary artery spasms, blood is not able to flow to that area of the heart, which then causes the heart to become ischemic. Similarly, if you have arrhythmias, um which don't um allow the heart to pump properly, the heart can be hypoperfused and can you can start to have an mi So those that's type one, type two, type 34 and five are a bit more niche. So type four is um you know, during percutaneous coronary intervention and type five would be when you're having a CABG done. So they're quite niche, but type one and two are certainly things to bear in mind. And like I said, we're not gonna go too much into it, but it's important to know the risk factors because if you're going to see a patient and you know, roughly the risk factors for a disease, you'll be able to kind of pick out the diseases which are going to be applicable to them. So for example, if you know that they're a smoker who has diabetes and they're on a load of statins, they're a man and their dad had a heart attack when he was 40. You know, that that person is way more likely to be having a heart attack than, you know, a 21 year old girl who's really fit and healthy doesn't smoke but has chest pain. So it's just knowing the risk factors is really useful for like being able to differentiate who's likely to have a disease and who's not. So like I saw a woman the other day who had chest pain and she'd had like a really extensive cardiac history. So I was so much on it with performing all of the stuff that we're going to talk about in a bit because I knew that her risk for having a heart attack was so much higher than somebody else who was her age. Um And she was a female. So it's just like knowing the risk factors and just bearing them in mind when you're thinking about your differentials. So we'll go into a bit of a scenario. So you're called by the ward and the nurse says to you, oh doctor, I've got a 65 year old woman. She was admitted two days ago because she broke her leg, but she's got really bad chest pain. And you say, ok, how long has it been going on for? She says it's about 10 minutes and you go. Right. Ok. What else is going on with her? Does she have any other medical conditions? And the nurse reads you out the list. So, you know, she's got ischemic heart disease. She had a previous heart bypass in 2015. She's got type two diabetes and she's a smoker. So she's got loads of risk factors for having a heart attack. So you're already thinking, ok, somebody who's got a lower risk factor for a heart attack and they've got chest pain. So the the alarm bells are going, she was fine on her news score. That was three hours ago. So I think this is where our first poll comes up. Um So if uh John or someone could activate that, what would you ask the nurse to do? I don't think you can select multiple options. But if you just select one of the options and then don just let me know the most common answers. So has the actual poll showed up? Yeah, so form ECG S came in with 71%. Perfect set of OS. Perfect. Great. So I think it's, it's really important because when you're on the phone and you're talking to a nurse, you've got to be thinking, ok, I'm going to see this patient. But what can that nurse do while I'm on my way to that patient? And you guys are exactly right. So you definitely want an ECG on this person and you definitely want an up to date set of s what you shouldn't ask the nurse to do is give them stuff before you've seen them. So they shouldn't be giving any aspirin before you go and see them because you haven't assessed, they might just have reflux. So don't, unless you, um, have done a really thorough assessment where, you know, the patient before, don'tt ask the nurses to give stuff on the phone necessarily, it's quite situation dependent, but in general, don't ask them to do that. So you're on your way to the ward and you're walking through the hospital and you're thinking, gosh, what am I gonna ask this patient? What am I going to talk to them about? So you go over in your head, the chest pain history. I don't know. Um if you guys have been taught this, that this was really hammered home to us at medical school and I find it so helpful in F one and that is Socrates and I've got a photo of our mate Socrates um to help us remember. So it's pretty simple. So it's just sight onset, character, radiation, associated symptoms, timing, exacerbating and relieving factors and severity. I often, I often ask it in that order because I find you go through the system quite well. Sometimes it's good to ask associated symptoms last because there's quite a lot of them and it can be a bit confusing to jump from the chest pain that you're doing then to associated symptoms and back. Um But it's really good to use the structure and use it however you like using it. So if we think about the classic presentation of an M I, if we try and put it into Socrates, cause I find that quite helpful. Um Where's it gonna be? So, sight is gonna be central onset. It's generally gonna have quite a sudden onset but it can come on and kind of get worse over a few minutes. It's gonna be a crushing chest pain. It's gonna feel like something is heavy on their chest. Sometimes patients will describe they feel like there's a weight on their chest or someone's sitting on their chest. I once had a patient say it's like there was an elephant on their chest. So it's, it's a heavy, it's a heavy pain. Sometimes it can radiate into the neck, it can go into both sides and then into the left arm associated symptoms. It's really having an MRI is obviously really, really painful to the point where people feel sick with the pain. So they can feel nauseous and they can vomit because with the heart attack, their heart is not functioning as well. So they might get symptoms of the rest of their body, not getting enough blood. So that would be not enough blood getting around the body that's going to be shortness of breath, not enough blood getting to the brain that's going to be dizzy, they not enough blood getting to their peripheries that's going to be like, um, cold, pale clammy, those kind of things. Um, and also in association you can ask them, have they previously had, um, like Angina or heart attacks before timing? It's not really relief by time and actually it might be getting worse over time, exacerbating and relieving factors. Um, if they were to be moving around that would make it worse. Hopefully they're just lying in their bed. Um, it might be relieved by GTN if there's somebody who's known to have Angina and um, you give them the GTN spray that might help them and then severity, like I said, it's quite severe often, you know, seven or seven or more out of 10, but we'll touch on it at the end, you can get people who have Silent MRS as well. So, so even if they're not in loads of pain, it's, it's important if they've got the rest of the symptoms to take them to take them seriously. So you thought great. I'm gonna ask them all these questions when I get to the ward and then you think, oh, what am I gonna do if it's anything else? So you think pe would be if it's worse on inspiration? So, um, chest pain and if it's tearing through their back and it's more likely to be a dissection kind of thing. And then in your A E assessment. So like John, just said, airway, breathing, circulation, disability, everything else. So airway is usually fine. B like we said, they might be a bit short of breath c they're probably gonna be pale, sweaty, cold clammy, like we mentioned because their heart's not going to be pumping very well. They might have signs of heart failure. Um So they might have a bit of edema. Their JVP might be raised and cause their heart is trying to compensate for everything that's going on. It can go either way it could start beating really fast or it could start beating slowly. So they could um be tacky or Braddy, they always check the blood glucose because it's really important and lots of this stuff, cold, clammy, sweaty can, can be signs of hypoglycemia as well. So it's really important to do your blood glucose. And then e um usually they're visibly in pain, but it's also important to say somebody having an mi I can have a completely normal A to assessment and you might not have to make any interventions when you're doing the basic A to E. Um So just because they say they're in pain and they look fine that they could still be having an M I. So how do you diagnose it? So, the diagnostic criteria for an M I would be new ECG changes. So for a stemi, it's going to be the chest pain, the new ECG changes and um uh troponin rise. So the ECG changes there's the main one which everyone thinks about, which is in the name. So that's the ST elevation and there's also a new um left bundle branch block. So, and it has to be, we're gonna go over ECG S in a second, but it has to be in what we call two contiguous leads. So those are two leads which are supplied by the same coronary artery and we'll go over that in a second and the amount of ST elevation depends where you are in the heart. And if you're a man or a woman, so if you're in V two or V three, those leads. If you're a man, the elevation has to be more than two millimeters, which is two small squares or if you're a woman 1.5 millimeters, which is 1.5 small squares. Whereas if you're in any of the other leads, so like the limb leads, which would be like lead one lead, two, lead three. It's just more than one small square. So it depends where you are and it can be when you're, when you're at the beginning, it's scary seeing sc elevation. So get the ECG and go to your senior and they will help you look at it. Um And it's good to work it through with someone else. Um But that's really what you're looking for and we're going to go over this again in a second, but you can have reciprocal changes. So in you can have an ST elevation in one section of the heart and in the section kind of mirroring it on the other side of the heart, you can have ST depression and that again will help you work out um where the ischemia is happening and then cardiac enzymes and this is your troponin. And you're looking for a dynamic change. So you're looking for a great greater than 20% change and that can be an increase or a decrease in troponin. And again, we'll talk about that in a second. So these are the ECG territories. Um Now, I don't know how familiar people are with these territories, but they're quite um important to know mainly because they can tell you where the heart attack is happening. So they can tell you where the blockage is. So V one and V two are the septal leads V three, V three and V four are the anterior V five B six lead one and A VL are lateral and V 23 and aVF are inferior. So these, this is a lot of pictures. But if we start in the top right hand corner of the screen, you can see you've got the aortic valve and then the two main coronary arteries come off just after the aortic valve. So you've got your RCA the right coronary artery and the LC, the left coronary artery, the left then splits into the left circumflex, circumflex and the left anterior descending or the lad. And then if you go to the picture on the bottom left, you can see that the, um, the LA D comes down the front of the heart and supplies the anterior bit the, and the right coronary artery supplies the right ventricle. And then if you look at the bottom, right, you can see that the left circumflex artery comes round and supplies the back of the left atrium and the left ventricle. So it's quite important to remember when you're looking at the ECG S. So I think there's a pole for this one. If we're looking at the an interoceptor leads, which is V one to V four. Does anyone know what or select the answer? Which, which um coronary artery do you think supplies this territory of the ECG and John, you can tell me what people say. So most people have put the lad. Yeah, that's perfect. Yeah. So the left anterior descending would be anteroseptal. And I think the next question is um which coronary su surprise is the lateral leads and let me know what, what people say. So this is a split. You've got 51% for lad and then 35% left circumflex. Yeah. So this one, so the lateral leads are supplied by the left circumflex artery. And then um because if you look back at the photos, so the lateral side, so you can see the left circumflex is supplying, it's difficult cos these pictures don't show quite the orientation of the heart, but in the orientation of the heart in the body, the bits in red supplied by the left circumflex, they're actually on the lateral side. So the lateral leads are the less circum and then the inferior leads. So hopefully, people will be able to get this one on the next pole. Let me know what everyone says to him. So, um 97% right circum perfect. And it's important to say that you guys are right most of the time, it's the right coronary artery which supplies the inferior leads. But some people have an anatomical variation and it's actually fairly common variation as trans variations go. So 18% of people it will be supplied by the left coronary. So sometimes in your exams, they might try and catch you out with that, but usually right coronary artery. Perfect. So and then just a quick note on reciprocal changes. So ST depression, so reciprocal changes would be ST depression in the leads, opposite those with ST elevation. And this can be used just to confirm that you've got true ST elevation. So, so you've got like an anterolateral stemi, you're gonna have inferior ST depression. So depression in the yellow section and elevation in the other sections and that's true with all of them. So similarly, if you have an inferior Emmy, you're gonna get lateral ST depression to as a reciprocal change from your inferior ST elevation and the poster Emmy, you can't. Obviously, we've got no area on an ETG which shows us the posterior side of the heart. If you were to put on some extra stickies and put them on the back to create a the um seven and eight, you would see ST elevation posteriorly, you can see anterior ST depression and that might make you think of a posterior sty. So with next poll, what do people think this ECG shows and which coronary artery is involved? Let me know what the poll says, John. So it looks like it's left anterior, descending 77%. Yeah, exactly. So you've got ST elevation and I acute T waves. Um and then you've got, if you look in lead three and the bottom left, you can see that you've got reciprocal um changes in, in terms of ST depression in lead three. So you guys are right. So that would be the um LD, you can see it there and then next pole, what do people think is happening in this one? John, let me know what people say. So 55% have picked left circumflex. Ok. So this is a slightly trick question. So you can see that we've got ST elevation in the anterolateral. So we got it in VV. Well, V two to V six as well as one and A BL. So you know that you've got the anterior and the lateral involved and it this is. So you can see in the bottom bit of this picture, you've got the left coronary coming off, then you've got the left sale and the left anterior descending. So if you've got like a proximal lad clot or even before the split, so at in the left coronary artery, it's going to affect the anterior and the lateral territories. So you can have both an anterolateral stemi and that would be what this ecg would be indicative of cool and then a tiny bit on troponin. So troponin is released um when cardiomyocyte are damaged or dead and they're generally released quite quickly. Um when somebody has a stemi, so they go up quickly and they come down quickly, which is why we're looking for change. So if you get somebody who has, you know, you go and see them like in this scenario and you're gonna get to them within the 1st 10 minutes of their chest pain, take the um troponins at zero hours, three hours and six hours. And similarly, if you have somebody who's presenting 12 hours into their chest pain, still take the troponins 03 and six, because you're looking for this um 20% or more change. And even if it's a um uh downward change, you could, they could be on the downward slope of the curve. So just because the troponin is reducing, that's not necessarily a good thing. It might show that they've had a heart attack, 12 or 16 hours ago. So always do zero troponins. And it's worth noting that troponin isn't only raised in half sac. Anything that's going to cause strain on the heart is going to raise your troponin. So if you've got a big pe which is putting strain on your heart, your troponin is going to go up if you've got bad heart failure, pericarditis, myocarditis, all of those things will raise your troponin. So just be aware of other things. Cool. So back to our scenario, nearly done. So, um the nurse has, as you guys correctly asked for, the nurse has done OS and an ECG. So first of all, you're just gonna speak to the patient just to see how they're getting on. So they say, oh gosh, doctor, you know, I feel like someone's sitting on my chest but maybe just some indigestion, but I am actually feeling a bit sick. I'm not feeling breathless, not coughing, my legs, feel no cough, my breath and my legs feel fine. So you think, ok, it, so you know, it sounds like this crushing central chest pain, they're feeling sick. Um You ask her just to confirm her past medical history and she says, yeah, I do get chest pain sometimes. So that is indicating her ischemic heart disease, but it's usually helped by my spray. So you're thinking, ok, she's got GTN and she said she's had an operation on her heart. So that confirms that she's had the CABG. So you know that she's having what sounds like cardiac chest pain and she's got an extensive cardiac history. You do you start your a two assessment? So you look at her from the end of the bed and why are you talking to her? You think? Gosh, she really doesn't look very well. She's quite clammy and sweaty and pale. She's just not looking great, you know that her airway is patent because she's talking to you, her breathing. So the nurses done hers, her SATS are lovely, 96% on air. Her respiratory rate is 22 and the chest is equal when you listen to it. Just a quick note, somebody asked a question earlier about um oxygen in COPD patients. So in any scenario, you wanna any emergency scenario, you want to try and maintain someone sat 94 to 98 unless they're known to retain CO2. In which case you'd aim 88 to 94. So uh yeah, 88 to 92. Sorry. Um So um but not all COPD patients are retainers. So they need to have had an ABG which shows that they're retaining. So you need to be pretty confident that you know that they're a retainer. And in an emergency scenario, hypoxia is gonna kill somebody before CO2 retention is gonna kill them. So even if they are a known CO2 retainer and they are acutely hypoxic, put 15 liters on them get their sats up and then you can titrate them down because the hypoxia is gonna kill them before the CO2 retention is. So, in any acute scenario, get the oxygen up. And if you wanted to, in breathing, you could get a chest x-ray to look for signs of heart failure. So in terms of her circulation, her heart rate's about 100 and five, it's regular blood pressure's all right. No added heart sounds. Um and she's, she's doing ok. It's important to get some IV access. And when you put the canyon in before you put anything through them, take some bloods off them. So you can get a BBg, take your, drop, your all important bits and then you can do the rest of your bloods in terms of D and E her BM is normal, her temps fine. She's GCS 15 and the rest of her exposure is fine. So this is the ECG that the nurse has done for you. I think there's another poll. Um But which coronary artery do you think people, do you think, do people think is affected in um in our patient who, who we've gone to see? Do you want to just let me know John, what people think? Um I can't actually see a pole here. Don't worry, that's fine. I'll, I'll let you guys know you've done enough poles. So um this would be so you can see this ST elevation in 23 and aVF. So that's going to be an inferior, um, semi and that would be supplied by the right coronary artery most of the time. Um So we've done that inferior stemi, so immediate management of a stemi, you've looked at this lady, you've assessed her, you've done a really good job of doing her ECG and her bloods and you think, oh, my goodness. I think this lady's having a sty and that is a really scary moment for you. So the, this is the point that you need to ask for help because you can start the emergency management while help is on its way. But you want to know that somebody is coming because the rest of the management is now time critical. So you wanna call your reg and then start the um emergency management, which we're gonna talk about in a second because if you do the management and then call the reg, there's gonna be a bigger delay. So call for help and then you're gonna do your emergency management. So this is, this is why we got a picture of the Mona Lisa to try and give you a bit of a visual prompt. But um so, so heart sex are really painful and we want people to be pain free. So, morphine, if you feel comfortable giving IV morphine, you can give IV morphine when somebody is having a heart attack because it's so painful. A note on IV morphine. You know, if you don't feel comfortable using it. That's fine. You can give them oral morphine. Always start low and build up to give them as much as they need. So, if they're a tiny, tiny old person, you can start with like a 1.25 mg, they might need more, but start low. If they're a, a normal size person, you could give them like a 2.5 mg and see how they go. And the same with oral morphine, titrate it up as you need it. And if you don't feel comfortable giving IV morphine, that's absolutely fine. You can give them oral, just make sure that they are well controlled in terms of their pain and often they feel a bit sick because they're so in pain. So give them an antiemetic. I always tend to think metoclopramide because it works well with the morphine in the m part of mona. So make sure they're pain free oxygen if they need if they need it. So our lady, her SATS for 96%. So you wouldn't put any oxygen on her because she's OK. Um nitrates. So give um some GTN spray, see if that helps to relieve that pain, it will help to vaso um dilate a bit and then finally, aspirin. So you can give them 300 mg of aspirin. So that's your mona and that is really what your seniors are gonna be expecting you to do before they get there. Finally, the ongoing management. So this is really going to be senior led because it depends on the area that you're in. It depends what your hospital offers. It depends how the patient is, what their functional baseline is, all of that stuff. So, in the UK, if you have a STEMI the ques, the big question is, can they get you to PCI within two hours? If the answer is yes, then they will give you depending on the, the surgeon and the center and the stent that they're gonna in insert, they'll give you a second antiplatelet. They'll give you either un fractioned heparin or low molecular heparin. And they'll give you some additional G PB two B GP two B or three A inhibitors. If you're not going, if you know, if you can't, if they can't get you to PC within two hours. So you're in the middle of nowhere, then the reg or the senior, the consultant will think about giving some clot busting drugs. So they'll, they'll do the clot busting drugs and then they'll hope to get you to PCI within two hours, 2 to 24 hours. Sorry. So this is why this is all very senior led. As a, as a junior, you will not be doing this, you'll be helping them do it. Um But it's kind of very dependent on where you are and the local guidelines and like I said, so that especially the second antiplatelet of choice if you're having PTI will depend on the stent that's being inserted and then just a very quick note on atypical presentations of I, so you can get people who have silent m I especially um elderly people or people who are diabetic. You have neuropathy. They can, they might not actually have any chest pain, but if they're sweaty, clammy, pale, short of breath, they just don't look. Well as part of your A to E assessment, you should be doing an ECG anyway within C. So hopefully that will show you some ECG changes. Um And that'll get you thinking, you know, is this person having a heart attack, but it's one of those things to have in the back of your mind, you don't always have to have chest pain to have a heart attack. Um So yeah, so that's a presentations. So the key take home message is utilize your A T assessment, do your early. So, ideally while you're on the way to see the patient, use your troponins to look for the um dynamic change and use your mona for immediate management and that is that great. So I'll stop sharing and we can answer any questions that anyone's got. So I think there's one question for you, Molly by Doctor Addy. Um You can scroll up to the chat but it goes um what can stem your A CS look like in specific leads in patients with preexisting pericarditis with pan ECG ST elevations. Yeah. So, so that obviously it's much harder to, um, to see an ST elevation mi, I mean, it, you'd be unlucky to have pericarditis and then have an mi, I guess, you know, it, it can happen. Um, it's not something I've seen as a junior and I think if you're suspecting that somebody is having a stemi whilst also having pericarditis, that would be something you get your senior involved in quite early because that's quite niche and probably very serious. So I think, um, you know, you'd be, you'd be getting a senior quite early with that. Any, just a few more questions? I think. So. Someone said, what about Heparin? So, yeah, so like I said, it would depend on um what kind of PC you're having, what stent you're having inserted, what that, um what that Truss or that center, which type of um Heparin they like to use. So either some places use low molecular heparin, some places use un fractioned heparin. Um And then what did Tom say, Tom said with nitrites? You also have to be careful. Yeah. So it depends. So if the person is really hypotensive, you wouldn't give them um GTN. But that's why you've done your A two re assessment um before. Um And it's all about being sensible. So you, if you know that, you know, we all know that GTN can cause hypotension. So you wouldn't give it to a hypotensive patients. So it's just about um you know, following the structures that you've got, but also using your, your mind in, in the moment, um Somebody said is Thrombin two used instead of mona. I've never heard of Thrombin Two. I've only ever used Mona. But if, if you're taught um Thrombin two in your um wherever you, you are going to uni or wherever you work, then um use whatever um system that they use. And again, we, we use morphine in the UK where we are and all everyone I know we give morphine for a sting. I don't know about you John. Yeah. So I think with a lot of this, I remember when I was studying in RIGA depending on whatever the national guidelines are in place for you guys, wherever you're studying or clinically practicing, they definitely differ from country to country. So from the talks today, we're pretty much using the UK guidelines. Um but I would definitely refer to the ones in place in your home country. Um First before using any of the, the ones that we've suggested. Um So someone was asked, would you, could you use IV nitrates over sublingual GTN? You could, you'd be you, the thing is if you're gonna give an IV nitrate infusion, you're gonna want someone in a monitored situation. Are you, you're going to want them on HT or ICU? So you wouldn't be setting up a nitrate infusion on the ward. So initially you'd probably give them GTN. And if your senior, um, deemed that a nitrate infusion was required, then you would do that. But you wouldn't go straight in with IV nitrates. Would you agree, John? Yeah, I'd probably say start off with GTN sublingually as opposed to. Yeah. Yeah, I, um, what's better cloy? Ticagrelor pure. So, again, it completely depends often. Um, it depends on what stent is being inserted. Um, and that's why we didn't, I didn't specify, I just had a second antiplatelet because it will depend on the stent and the local guidelines in my practice. Most commonly, I've seen Ticagrelor used, but I also know that um some places use pros more. Um But again, it depends which um which stents being inserted, which area you're in. And if you're sending a patient for PC, they also say you've gene that, that, that the new PC, the register is referring them the center or the, the people who are going to do the PC will say which one is needed and which one they want to use. So I don't know if any of them are particularly better than others. I think it's just kind of differences across trusts. Um And then in which situation is um, clot, busting drugs indicated. So that's if you can't get to PCI within two hours, then they would use the clot, busting drugs, they would try and bust it with those and then you would, they would try and get you to PCI within the next 24 hours. So I think that's most of the questions. We, we do really appreciate guys that um there's a lot of information um in both those talks. So, um I think you're able to sort of rewatch the talks. If you can, I'll hand over to Risha now. You'll be able to close this out for this session. Yeah. So to conclude a huge thank you to Doctor Hardwick and Doctor Abraham for teaching us today and we will have our second session on Wednesday. So please register for that as well and tune in for that. And thank you for joining us today. Bye guys. Thank you. Thank you guys.