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I live and we'll just wait for everyone to join. Yeah, I think we should start. So good evening, everyone. Welcome back to our fourth and final episode of the webinar series, emergency presentations for junior doctors, hosted by Doctor Abraham and Doctor Hardwick. Today we'll be learning all about anaphylaxis and hyperkalemia and how to treat them in emergency scenarios. So without further delay, I'll hand over to Molly. Hi guys um in case anyone is new, um my name's Molly. Um I'm uh one of the doctors gonna be presenting today. I'm based um in Liverpool in the UK and I work with John. So this is our final session today and we're gonna be cover covering anaphylaxis and hyperkalemia. So I'll start off with anaphylaxis. So anaphylaxis is one of these really scary things you don't see it very often, but when you do, you need to act really quickly. So it's really important that you're able to recognize it and follow the steps without having to look at any guidelines. You can just go for it. So we'll start by defining what it is. So it's a severe and life threatening type one hypersensitivity reaction. We'll go into that in a moment. But to have anaphylaxis, you have to qualify and have three things. So it's acute onset with a rapid progression. So if somebody is allergic to nuts, they're very likely to start having the reaction within a minute of ingesting the nut, they then will develop a life threatening airway and all breathing and all circulation problems. So it could be just an airway problem. It could be just a breathing problem or just a circulation problem or it could be all of them. And then finally, you will also have skin or more or mucosal changes. So you'll get something like an urticarial rash, which is like a red raised really itchy rash, which I'll show you a photo of in a second and you'll also get skin changes. So that might be angioedema where you get like swelling of um the lips or the eyelids. Um And then you'll also get swelling internally. So it'll be affecting the airway and the breathing. Um Yeah, so lip tongue, throat swelling rash. So this, so this is an example of angioedema. So this is a lady and on the right, you can see what her face is like when it's not swollen and then on the left you can see what it's like when she's experiencing an allergic reaction. Um on, I don't think she's quite an anaphylaxis otherwise she wouldn't be sat in her car taking the photo, but this is a severe allergic reaction with example of angioedema. And then at the top, the picture isn't crystal clear, but you can see this really kind of um red itchy rash. So that's urticaria and that can happen all over the body or in patches around the body. So what happens in anaphylaxis? So it's a type one hypersensitivity reaction and it can be to food or materials. So some people have a latex allergy, um other times it can be venom. So like bee stings and then finally can be drugs that we're giving people. So, penicillins are things that people are often allergic to. So when you're doing your drug history and you're speaking to a patient, it's a really, really quick question to ask is, are you allergic to any medicines? But it might actually say someone's like if they say, oh, I'm allergic to penicillin, you're then not gonna give them penicillin. So it's to go back to a bit of our physiology you have um IgE causes degranulation of your mast cells which releases lots of um histamine, trip days and cytokines. And so these all cause a systemic response which leads to lifethreatening, um problems with the airway breathing circulation that we just spoke about, particularly, I never really understood why it affects the circulation. But all these um uh inflammatory mediators depress the myocardial contraction. They cause vasodilation and they make the capillaries really leaky. So this combination of things puts the BP really low because you're losing fluid, the um veins are dilated and the heart isn't pumping as well. So this means that people can have real circulatory collapse in um in anaphylaxis. And so they'll be very volume deplete. So how does it present? So you generally, you'll have exposure to the allergen. So somebody starts their IV drip of penicillin and you get a rapid progression of symptoms. So generally, like we said, over minutes, so in an a reassessment airway, so, so you would get kind of like lip tongue, throat swelling, which could then lead to difficulty breathing. Um So that's then going to be, they might start to have a hoarse voice because of the swelling in the throat and they might develop a stridor because as the throat swells, there is less space for the air to travel through the airway and they get stridor, which is this, um, high pitched inspiratory noise caused by an upper airway obstruction because the air doesn't have um as much space to flow through could be. So they can have difficulty breathing. They'd be very short of breath. They might be breathing very fast because they're trying to catch their breath and they might have an audible wheeze. And what's really important, um, is tiring is a really bad sign because they're getting too tired to maintain their respiratory effort, which means that they're going to start to become cyanotic. And if they, you know, are consistently hypoxic, they are at risk of having a respiratory cardiac arrest. So that's really serious. And then in circulation, like we just spoke about, they can be very intravascular deplete. Um They can be pale and clammy because they're not perfusing their peripheries. They can be tachycardic and hypotensive and you'll have all the signs of um reduced end organ hypoperfusion. So they'll be dizzy, might be confused, agitated or have a reduced gcs. So those are all symptoms of having reduced blood flow, blood flow to the brain. Um And obviously, if they're not perfusing their heart properly, they'll go into cardiac arrest. And then d like we spoke about all the symptoms of brain hypoperfusion. These patients can often tell that something really bad is gonna happen to them. They can be very um anxious if they've had previous anaphylactic reactions. And they occasionally do say that they have this feeling of like, oh my gosh, something really bad is gonna happen to me. And then e when you're um looking at the whole body, they'll have skin or mucosal changes like we just saw. So you might see a rash and swelling. Um and the rash is usually very itchy and they've got this angioedema. So that's kind of the presentation and really this is all about the treatment. So this on the right is the anaphylaxis guidelines that we use in the UK. I appreciate it's very small there. But don't worry, we're gonna look at zoomed in sections of it. But so the the main message is that somebody with anaphylaxis can become very ill, very, very quickly. So as soon as you suspect they're having an anaphylactic reaction, you need to ask somebody to put out a cardiac arrest call because these people will arrest quickly. They've got two reasons that they might arrest, they might lose their airway and they have a hypoxic cardiac arrest or they could have like a hypovolemic cardiac arrest. So you need to call for help immediately if you suspect someone has anaphylaxis because you do not want to be on their, you, you do not want to be in that position on your own. So first thing you do call for help, you ask for a cardiac arrest call in all hospitals in the UK. We have um an Anaphylaxis kit which is in a yellow, um the yellow box. So you want the anaphylaxis kit because that's got the drugs that you need in it. And then you also want the Cres trolley. So that's the trolley with all of the airway adjuncts and the DFIB pads and stuff because you want that there in case they do arrest. So you need those things. So you need to call for help and you need all of those three things and then you can remove the allergen if possible. So obviously, if they've eaten something difficult to do anything about that, but if they're, you know, if it's latex and they've got gloves or something on, remove that if they've got a drip going with something that they're um allergic to stop the drip and remove it, so stop whatever is causing the um reaction if possible. And then you need to start following the algorithm which we're gonna go into now, just a bit on positioning. So, ideally, um you want to keep the patient lying down and elevate their legs because the idea of elevating the legs is that any of or some of the blood that's in the legs, when, when you elevate, the legs will be redirected to the thorax and it'll be used to perfuse the thorax in the head, which is obviously in this scenario, more important than perfusing the legs. Sometimes if patients have real difficulty breathing, they're really wheezy, they can sit up. But one thing you should never do is stand them up because they're already um so intravascularly deplete, they will not be able to perfuse their brain properly if they stand up. So lying down with elevated legs or at the most sat up. So let's just have a look. So this is the first part of the algorithm. So is it anaphylaxis? So you have a look and you, you can start doing your A to e assessment. But if you see that they, you know, they've got problems with their airway breathing or circulation. And on the right, you can see the, the kind of the life threating problems. So they've got hoarse voice. Stridor, working hard to breathe. They, they're wheezy. All that, all that stuff we spoke about. Then you're thinking anaphylaxis, you need to call them for help, call for help, lie down if possible, elevate the legs, if possible and if they can tolerate it. But obviously, um if you need to, you can sit them up. So that's the first part of the algorithm. The next part we're just gonna do the first pole, the ski piece of paper. That's um so I think the first pole is what is the most important drug to use? Anaphylaxis? Is that right? Yep. That's the first poll. And what have, what have people gone for? Um So the votes are slowly coming in. We'll just give them a couple of seconds to respond. Yeah. So um Im adrenaline uh one in 1000. Yeah, exactly. Um So you don't give IV adrenaline for anaphylaxis because you might put someone into cardiac arrest. So it's always im adrenaline one in 1000. So, and this is the most important drug. Recently, the UK guidelines were changed. Um So they don't include drugs like steroids or antihistamines. They only include adrenaline because that is the most important drug. So today we're only going to be talking about adrenaline because our UK guidelines do not include steroids or antihistamines. So, why is adrenaline good? Well, it's an alpha receptor agonist. So it reverses the vasodilation and reduces edema. And it also helps to dilate the bronchi. It increases the heart contraction and it stops further um inflammatory release. So you're stopping your antihistamines. So stopping your histamine and your leukotriene release. So that's why it's good. And what doses should we give? So it's always one in 1000 and in the UK, they come in little vials which is um one mg per milliliter. So they come in little um vials of a milliliter. So if it's an adult, you want half of that because you want 500 micrograms, you want half of the vial. So you want half a milliliter and that will be what you inject I am. If it's a child, you know, six to twe 6 to 12, even 300. If it's a child, six months to six years, you give them 100 and 50 micrograms. And if it's a child less than six months, then you would give them between 100 to 100 and 50 micrograms depending on how big they are. If they're, you know, if they're almost six months, you would give them 100 and 50 micrograms. If they're a newborn, you would give them 100. So again, this is only I am. Hopefully you guys would be familiar with this because it's one of those things that there should be the Anaphylaxis um algorithm in the Anaphylaxis kit. But it's the kind of thing that you need to know just off the bat. If you've got a hun, if you got a one mil um vial, you need half a vial to give the um im injection. So, and like we, like I said, so adrenaline is the most important thing to treat anaphylaxis and you should give it during the A two assessment. So it's like, it's like giving oxygen for breathing. If you think that this is anaphylaxis, you put out the call and you give them adrenaline. If you give someone adrenaline and they're having anaphylaxis, you could save their life. If they're not having anaphylaxis, it doesn't matter, the patient will come to very minimal harm. You know, pe people can deal with one dose of IM adrenaline, that's fine. But if you don't give it, that person might die because you haven't given it early enough. So it's, it would be better to give it and not to give it. And you know, if you're assessing them on a and you think gosh, this person is um you know, almost certain they're having an, you would give it to them. So that's just a note to say, give it early. So as you spoke about this is, this is the middle part of the algorithm. So you give your im adrenaline and you put it in the anterolateral aspect of the thigh in the middle section. And so you, you've given your dose and then you wait five minutes before you give the next dose if they need it. So in that time, in that five minutes, you put the timer on and you sit and you start your, a two assessment again. So how is the airway? If they need any help with the airway, you can put in an airway device like a Goode if needed and put oxygen on them and then it's really important to have them monitored, which is why you need your Cres trolley because you can, you can do, um, you can put the pads on and get um, an ECG, you can get BP and um pulse oximetry. So it's really important to have all of these and the monitoring on them. Then if they haven't responded to it, if they haven't started to get better. So that would be, you know, the swelling is starting to reduce their breathing is starting to get easier. You know, if they're not responding to the first dose of adrenaline, you can give them a second dose of adrenaline after five minutes. And if you're gonna give the second dose, you give an IV fluid bolus as well. So generally if, if they're a young fit adult, you know, say somebody like us, you could, they would be able to tolerate between 500 1000 mils because they're going to be really sally deplete. If it's an older person, you would um err on the side of caution. So you'd probably um more towards 500 or even 2 50 if they're really small. And then in a child, you do it based on their weight. So you give 10 mL per kilogram. So you've given your second dose of adrenaline and hopefully the whole team is there. You've got the cardiac arrest team with you, you've got your seniors with you. If there is no improvement despite two doses of im adrenaline, that is when. So there's a, there's another algorithm called the Refractory Anaphylaxis algorithm. And you would move on to that. At that point, we just, we'll touch on it really quickly because this will all be very senior led because hopefully you would have put out the cardiac arrest call right at the beginning when you suspected anaphylaxis. So everyone will be there. And so you would define refractory anaphylaxis if you haven't had an improvement despite two doses of IM adrenaline. And the aim of uh the Refractory Anaphylaxis pathway is helping to establish a IV adrenaline infusion. But essentially you just continue to give im adrenaline every five minutes while you're waiting for the, for the IV infusion to be set up, you keep giving them fluid bonuses because again, they're still gonna be deplete, they're still gonna need more fluid, you give them oxygen, you basically monitor them, support them until the IV infusion is going. So this is the refractory Anaphylaxis pathway. We're not going to go through it because like I said, this is very senior led. But essentially you there, you can see in the middle column they're going to be setting up an IV adrenaline infusion um and continue with the A two E and whilst that's happening, you just keep giving iron adrenaline every five minutes, give them oxygen if they need it and give them um fluids if they need it. So, so you treated what you think is anaphylaxis and now we need to think about confirming that it actually was anaphylaxis. Usually it's fairly obvious but it's always good to confirm it with a biochemical test. Does anyone know? I think the next poll will be, does anyone know what we measure to confirm anaphylaxis? So, um, it seems like, er, Mas trip and histamine both got around 30% of the votes. Great. So you guys are thinking along the right lines, but we've got this graph here. So you can see histamine is in red and tryptase is in blue. So, histamine spikes really quickly and comes down really quickly. So, given that this is a, an emergency, you're gonna have loads of people there and it's a bit hectic, it's unlikely that you're gonna be able to take readings in the first hour to show that they've had kind of a spike in their histamine. So we use Mars cell tryptase because it goes up a bit slower and down a bit slow. So, the aim of the, um, test is to prove this rise and fall of, um, the trip ase. So ideally you do it immediately post recess. So you do it immediately after, you know, they've had their adrenaline and they're starting to get better, then you would do 11 to 2 hours later and then you do their kind of baseline level more than 24 hours after the reaction. And that helps because after they've had this reaction, they will go to allergy clinic and the allergy clinic will want to see the rise and fall of the tryptase and they'll want to know the baseline tryptase level. So this is how you confirm it. And it's not, it's not really important in the management. It's not gonna affect what you do. It's just a bit of kind of academic work which will help the diagnosis after the event. And then just a note on biphasic reactions and delayed reactions. So sometimes people can have initial symptoms and they can have a second reaction which is called a biphasic reaction. And sometimes the biphasic reaction, the second reaction can be worse than the first reaction. So I know recently where John works, they had somebody who had um a delayed reaction and it was the young man and he unfortunately passed away despite them um doing all the correct management. Um but his second phase reaction was, was so bad that um unfortunately he died. So it's, it's really important if you've got people coming in with anaphylac or in with allergies and they've previously had, um, allergic or anaphylactic reactions they stay in and they're monitored for kind of up to eight hours because you need to make sure that they're not gonna have this second reaction. So you can't just send them home. You need to keep them in and monitor them if they're somebody who's really high risk. So, if they've previously had a bi fas reaction or a delayed reaction or there's someone with bad asthma or something like that, it wouldn't be unreasonable to keep them in for 24 hours. Um Each hospital and each region has their own guidelines, you just got to follow the guidelines in the hospital that you'll be working. Um But you certainly need to make sure that you're keeping them in to monitor them in case they have their second reaction and then kind of ongoing treatment. So hopefully, you know, they've recovered from their anaphylaxis, you've treated them really quickly and they're doing really well. So when they're getting ready to go home, they need to be given an EpiPen, which is like an autoinjector of adrenaline and they need to be shown how to use it because if they encounter um their allergen, you know, when they're out and about in their lives, they need to be able to inject themselves and get themselves to hospital as soon as possible and then they need to be sent to the allergy specialist. So, so these will be the doctors who will be testing to see what they're allergic to. Um, they'll be the ones using the Marsal tryptase to confirm that it was, um, an anaphylactic reaction. And then again, it depends on the hospital and it depends on the clinician. But sometimes there's a, there's some people would give some steroids or some antihistamines to help reduce, you know, ongoing inflammation if they remain wheezy and, and stuff like that, you can give some steroids. Um but not everyone does that. So it's just kind of again going with knowing that it's a potential and you can suggest it to your senior and see, see what they think. But but that's kind of a again, a hospital dependent thing. So we're just gonna finish this anaphylactic section with a question. So I'll give you a minute to read this question just because it's got a bit of writing and then we'll get the pole up. So if we just keep the pull down for a moment, great. So if we could start the pot, what's, what's everyone saying John? Um so it's a mixed bag. Really? We've got 40% of one straight through the adrenaline. Um 28% have just started the A two E um and just under 20% have suggested to just slow down the antibiotic confusion. Ok. So the, what I thought was what I deemed to be the correct answer when I was writing this question would be to ask the nurse to put out a cardiac arrest call. And that's a few reasons. That's because, you know, she's a young girl, she's having her first ever dose of penicillin, which is something that, you know, that people can be allergic to. It's an antibiotic that's commonly, you know, it's one of the most common allergies. Her lips and tongue have already started to swell. So it's, she's just started receiving the first dose and her lips and tongue are already starting to swell. Obviously, she's not having any difficulty breathing and her sats haven't dropped yet, but she is somebody who could potentially fall off a cliff very quickly and you do not want to be alone with her. So you need to ask the nurse to put out a cardiac arrest call. It doesn't matter if they arrive and five minutes later, she's absolutely fine. Everyone would rather that the arrest team were there because this girl has the potential to get very sick very quickly. So if it were me in this situation, I would ask the nurse to put out an arrest call and get the trolley and the Anaphylaxis kit, then I would while she was doing that, while she was bringing everything to me, I would do the, a two week assessment and obviously it doesn't take you very long. So while by the time she's back then you can start thinking about giving drugs. But it's just because the reason why the first step on the algorithm is putting out um uh an arrest call is because they can fall off the cliff so quickly. So that's the first question and then the second question. So, so the arrest call has been put out, the nurse comes back to you with the box. What are you gonna do now? So we'll just give you another third seconds to read it because I appreciate the answers are a bit. Um Wordy. Yeah. Ok. Do you wanna start with P so um 66% of people have stopped the IV infusion and 500 micrograms of im adrenaline. 1 1000. Perfect. So. Exactly. Right. So she, so we need to stop remove the allergen. So we're going to stop the infusion and then she's 14. So she's over 12. So she's going to get 500 micrograms of one and 1000. So that's our treatment. If she was younger. If she was less than 12, she, she'd get 300 micrograms and because she, it she's having an anaphylac, well, she's having the start of anaphylactic reaction because her lips and tongue are swelling. So she's, you know, if, if the external stuff is swelling, the internal stuff is also going to be swelling too, but she might not have Strida yet because it's not got to that point of swelling, but it will be swelling. Um So you would stop the infusion, you wouldn't slow it down because you don't want to continue giving her the thing that she's allergic to. So you've always got to stop the infusion or stop the allergen, um, and give the treatment, which is the adrenaline. So that is the end of my talk if I just um, I'll stop sharing and then John can share his screen. Um, good evening everyone. Nice of you to join us all. I'll um, I'll see if I can share my presentation. Ok. Right. Is that showing as such? Yeah, we can see that. Yeah. OK. Stuff. So we'll just give everyone probably 30 seconds or so to um stretch your legs, grab a drink of water and then we can um then we can begin. Right. So, so today I'll be speaking about um hyperkalemia and so just straight off the bat, we can, we can start off with the first part, which is actually what is the normal parameters when talking about serum potassium? So to be able to discuss hyperkalemia which has raised potassium, um It's good from the very get go if we have just a, a known reference value. So, um if we could cue the first poll moll your RSA responses are just coming in. Ok. That, but at the moment, um 88% say 3.5 to 5.5. Ok. That's good. That sounds like good news. So, yeah, so that's correct. It's 3.5 to 5.5 and anything above 5.5. Um We would deem as um hyperkalemia. So typically, as a doctor, this is something that you're going to be coming across on the wards and out of hours, um more often than not, it's going to end up being mild, which you can treat quite simply. But um every so often um it can become a case of moderate or severe and we worry about hypokalemia because it can lead to cardiac arrhythmia in the form of um VF or VT. So that would be ventricular fibrillation or ventricular tachycardia. And that can result in a cardiac arrest, um which can be fatal. So we can start off with um mild hyperkalemia as such. Um And when it comes to the, the causes of it, there's quite a few different causes which we can run through. So the pseudo hyperkalemia and this is probably the, the big one to watch out for the red herring. So, if you've had um the hemolysis of blood, so if it's been a bit of a difficult um blood taking um session, whether it's, it's ended up having the, the blood cells have hemolyzed and they released a bit of potassium. It's going to lead to um a false reading where the potassium's going to be slightly higher. So there's a few reasons why that could be where the bloods were hemolyzed. So if the tourniquets been on um too long, if there is a delay in the bloods reach from the lab, so they might have just sat in the pod for ages and the pod's not working and if you've used the wrong blood bottle, so we tend to use the, the user E bottle, um, which is a green one in our trust. But if you used the wrong bottle that's called Ed, um, then it can contaminate the sample, um, leukocytosis and then samples taken from limbs with IV fluids running. Um And that last one's happened to me. Um Definitely when I've been on call, when you're in the midst of doing things, you gone to take blood. Um And the potassiums came back, um ridiculously raised and turns out it was just because they had a bag of potassium chloride running. Um And I shouldn't have taken it off the, taken it on the other arm and the next is uh um exogenous. So that can be if they've got um oral supplementation that they've been taking for a couple of days and it's just remained on that prescription cause they had slightly low potassium and, and no one forgot to actually stop it and it can be the same with IV fluids if it was just to top them up and it's just been continued. Um And that can lead to um raised potassium and then you've got the endogenous reasons for hyperkalemia. So there's Tulis syndrome. So when you've got these tumor cells, when they um can burst and they can release um all these different weird and wonderful electrolytes of which potassium is one of them. Um same with rhabdomyolysis, crush injury and burns. So there's the breakdown of all these cells when they get injured. So, potassium's um released into the serum which can raise the potassium, then there's renal causes of high potassium. So you can get um A K or CKD. Um then there can be mineralocorticoid deficiencies. So, in something like Addison's um where there is a lack of mineralocorticoid. So if you don't have the aldosterone, which is usually helpful for um excreting potassium. So, as a result, if there's no um aldosterone or an insufficient amount, and then, then we're going to be left with high potassium. Um There's potassium sparing diuretics, you've got um spironolactone as well as Lerone. Um and that is going to uh work where it just continues to retain the potassium um serum. And then you've got different types of drugs like ace inhibitors, um like Arbs, nsaids and Heparin. And then also um we've got the shift between intracellular and extracellular. So, um different drugs can lead to that as well as acidosis. We're going to talk about um digoxin slightly later on when it comes to the treatment. But the way in which it works is it's a um sodium potassium A PS inhibitor. So you're going to be left with an increased amount of sodium in the cells. Um and that's going to drive calcium influx and it works as being a AAA cardiac um glycoside, so you can increase myocardium contractility. Um and because it's blocking the potassium from going into cells, um we can get hyperkalemia. So in terms of clinical symptoms, it, it's quite generic and, and general in the sense that there's not too many obvious signs and symptoms you'd see. So it would come across as general weakness, fatigue. Um once again, because potassium um is so important for the heart. Uh it can result in cardiac symptoms, palpitations, chest pain, um as well as shortness of breath. And then when it comes to our approach, so you've been called over by the nurse to go um see someone for hyperkalemia or the bloods have came back and the nurses rang you saying, OK, we've just received these results. What would we like to do about it? Um So we'll key to this, this next poll which is um when would you be concerned about um taking an ecg the the hyperkalemia just came back at what level or what minimum level of hyperkalemia would we be interested in taking um an ECG? So if you could cue the pole um mo your got the answers coming in just um just wait for a few more. So it looks like. So it's kind of a split between 5.5 and six. About 30% of people say 5.5 and 44% of people say six. OK, fine. So give or take those. I was expecting those two to come across as being the main answers. So, as per our local trust guidelines, um after 5.9 I would personally ask for an ECG um as well as what it says in our trust guidelines. So when you're looking at that moderate hyperkalemia, um if it's peace of mind for yourselves, then 5.5 upwards um is, is totally fine, it's worthwhile getting a VBG as well. So you'll be able to see your electrolytes very quickly. And, um, that first blood taking session where they, the bloods came back, um, it could be a case of and then in terms of lab investigations. So for the, for the repeating the sample, we'd like to repeat the ES and ES, uh, as well as the FBC S, we can exclude uh hemolysis. Um, it's also important as well to check the serum cortisol. So if they've got something like Addison's where the cortisol can be dropped, um, and as well as digoxin as well to exclude um, toxicity, so you can check the, the levels at which they, um have digoxin at. So between 5.5 to 6, as we had said, maybe wouldn't, we wouldn't get an ECG and you would just like to repeat the sample, um, the day after you can start them on um, some potassium supplements. As soon as we've hit six, it's 100% the case where we need to get an ECG and look for any ECG changes that the potassium might be causing. So at 5.5 you might not see anything at all. Um And then as we get slowly higher up, um we can see a few different changes. So the first one that we can see is a peaked T wave. So if you have a look at the T wave over here, which is the T waves in mild, as well as moderate and severe, they slowly start to become peaked. And the more hyperkalemic the patient gets and you get the pr interval, which also starts to prolong the further on with hyperkalemia. And last but not least you get a shortened QT interval and we also can see a loss of the P wave as soon as we start hitting those severe levels of hyperkalemia. So, between 5.5 to 5.9 what's the mainstay of treatment? Um So in terms of urgency, it's not the most urgent thing. We can just repeat the blood sample and start some oral potassium. Um So the first line would be sodium zirconium. Um And the second line would be calcium Rezum Q DS, that'd be four times a day. Um And that acts quite slowly. Um but it can um it can take, yeah, it can take a couple of days and it's something that we could um just repeat the, the day after. Um and the way in which it works is it binds to the potassium um in the gut and then it removes it in the stools. So that's the way um both sodium zirconium and calcium Zoi work. So now we moved on to moderate hyperkalemia. It's the case. Now we've got the ECG and now we want to be able to treat it. So, um this is at a time where it's urgent treatment, you've looked at the ECG changes and um if there is ECG changes, this patient is probably going to need cardiac monitoring um which will require um a case of using calcium gluconate. So, um if we could cue the next poll, um I think the question refers to you. How does calcium gluconate work for hyperkalemia? Um And the first option I think is talks about stabilizing a cardiac membrane. Next is to bring down the potassium or does it actually do both and see if we could cue that pole? Ok. Just getting the responses in. That's no problem. So at the moment, um it's a split between two and 3 41% of people think that it just stabilizes the cardiac membrane and 57% of people think that um it reduces the serum potassium and stabilizes the cardiac membrane. Ok. Yeah. So um for um calcium gluconate, it's just actually stabilizing the cardiac membrane. Um and it usually does that for around um 30 to 60 minutes and it works quite quickly. So, in the first couple of minutes, you'll actually see um the ECG changes um start to take over where they start to work and the T wave is no longer it peaks and maybe the P wave is slowly coming back. Um And so the main stay of it is because we're giving calcium gluconate, um we're just stabilizing um the cardiac membrane to prevent um cardiac arrhythmia in the form of VT or VFIB. Um and it doesn't actually have any effect on um the potassium. So in terms of the treatment, we can start off with 10 units of soluble insulin and that's added to 250 mils of 10% glucose. So, in our last session, we talked about how important this is to go with um insulin for DK A. Um because the insulin, not only is it pushing glucose in um it also along with the glucose, it also has in the um potassium by drawing it into the cells from the extracellular space. The next one is salbutamol uh as a nebulizer. So this works temporarily of pushing your potassium um in the extracellular space into the intracellular space. So you can give these five mg nebulizers up to four times. Um But it's also important to just monitor the heart rate. Um sodium's a co um as we'd mentioned already, it's one of those things that are going to take a bit longer in terms in terms of acting. Um But it's still important if to, to add along with um the treatment can do IV sodium bicarbonate if you're worried about acidosis and then um IBU and 80 mgs. So that can help with um the excretion of potassium um in the intravascular space. Um Sometimes if you're worried if they've got something like um A K and they've got to build up of potassium, you can even try um giving fluids to um increase the urine output and that can slowly um bring down the potassium. So it's all about judging the patient, what, what do they have and what they clinically look like and then it's severe hyperkalemia. So it's pretty much exactly the same treatment that we mentioned, moderate hyperkalemia. Um It's once again, it's urgent treatment, if not emergency, it is a medical emergency. So it's important to act quick um with all the sessions that we presented so far as Molly said earlier on in the talk, um really important to get help early on before things um get drastically out of control. Um And you'll thank your lucky stars that you've got the medical registrar or a consultant or just any senior doctor nearby to help you um with a patient that you're really concerned about and while you're waiting for them, then you can get the first step sorted. So at this stage, it's also important to have a chat with the critical care or the renal team um because their potassium's so high, they might require something like dialysis. Um or require being taken to ICU. Um And yeah, so once again, in these situations, if they've got something like CK D four or CK five, dialysis might be the only option. So, um as we've mentioned before, with severe hyperkalemia, um and moderate hyperkalemia, we're looking for those ECG changes and if they're there, let's get them straight onto cardiac monitoring. Um And then the next part is about digoxin. So, um this is one thing that we can look at to decide. Um we're gonna be giving calcium gluconate nevertheless, but um it depends on how fast we want to give it. So, if they're not on um digoxin, we can give 30 mils of 10% calcium gluconate and that can be a slow IV bolus um over 10 minutes. But if they are, then it would be 30 mils, 10% calcium gluconate this time in 100 mils of sodium chloride and that takes place over 20 minutes. Um It's one of those things that calcium gluconate, we're worried about excavation where it can leak out into um the rest of the skin and it can cause necrosis. So it's important to do it um to be able to administer this um using quite a large cannula. So calcium gluconate, as we've mentioned, we've got the insulin going. Um and we keep this running till we've got the potassium, that's less than 5.5 mils for at least four hours. Um We can use the salbutamol that works as a temporary measure to draw the potassium into the cells. Sodium zirconium, sodium bicarb and the fry and for both moderate and severe hyperkalemia, um It's important that we check the um serum potassium uh on the first hour, 2nd, 4th, 6th and 24 hours later. Uh once we started the treatment, um and if they're on insulin and we decides to give the 10 units of insulin, um you also want to watch out for the blood sugar because we don't want to drop it too much. Um, and that's half an hour, 60 minutes and 90 minutes. Um, after they've had um, this uh insulin glucose infusion, um, also important to prescribe the, um, hypoglycemic um, medications just in case, um, they drop their blood glucose. And this is just a quick overlook of the trust guidelines we have at our hospital um to manage hyperkalemia and it sort of touches on what we've spoke about where if it's between 5.5 to 5.9 it's not a medical emergency. It's something that we can sort of treat um with oral supplements and if they're nail by mouth, um, or they're not able to tolerate orally, we can give, um IV potassium. Um, a quick note in giving IVIV potassium. Um, the maximum that we can give in an hour is 10 milli MS per liter. Um So usually, um, that's something that we would be concerned about with. Um, hypokalemia. But for hyperkalemia, it's yeah, sodium zirconium or calcium reo which is going to drop um the potassium. I was just asking to go back and show you the previous slide. Yeah, absolutely. This one over here. Yeah, I think so. OK. Yeah. Was there a question attached to it or um was it just to have a look at it? Yeah, there is um it does acute versus chronic severe hyperkalemia change the treatment approach, especially when the patient presents as unstable, worse or stable. Like when would you consider hemodialysis? So it's one of those things where you look at the dialysis criteria and if it hits, I think I want to say it's about 6.5 and then you would just get on the phone to the renal. Um the, the doctor that's coming for renal or the renal team. And um they would then make the decision is this person a candidate for dialysis, whether it is acute or chronic and it can sometimes even present both where it can be acute and chronic. Um, quite important to speak to the renal team early on if you're worried about that. I hope that answers this question. Uh They said the one, the, the one before that so sorry, the one before that slid, that one, this one, I don't, I don't think there's any question attached to it. I think they just wanted to um see the slide. I'm not. And the, the session is also recorded. So, so if you want to go back, you can, you can go back and look at it. Yeah. Um I'm just quickly this does acute, this chronic, severe hyperkalemic change changes. Um Yeah, so it it would be, it would be a discussion with the renal team whether it is acute and this chronic. Yeah, so I'll quickly touch on hyperkalemia. Um and it's not as dangerous as hyperkalemia, but it is something once again um that you will have to deal with on the wards. Um So in terms of definition, we know the normal parameters are between 3.5 to 5.5. Um So for mild, um it would be 33 to 3.5 for moderate, 2.5 to 2.9 and for severe um 2.5 or below. So, um in terms of hypokalemia, it's, it's quite common in terms of, it's 20% of the, the hospitalized patients tend to have it. Um And um as we had discussed before, um potassium's the most common um intracellular ion and you've got sodium, which is the most common extracellular ion. So what are the different reasons behind why we have low potassium? So this can be due to poor dietary intake. Um Let's just say they're on TPN which is total parenteral nutrition and they might not be getting enough through the actual Feeded. Um or they might be having IV fluids which don't have enough potassium. So that would all come under the decreased intake. Um And then we've got trans cellular shifts if they've got metabolic alkalosis, um if the salbutamol insulin DK treatment, so this is all the things that have actually helped us with. Um our hyperkalemia treatment um could also be the cause for hyperkalemia. Um And then we've got a, a case of increased losses. So, um if we're going by renal causes, if they're on diuretics, um and if they've got low magnesium, which can be responsible for um transavia shift, um that can also um lead to a drop in potassium. Another one's G I causes. So they're throwing up um or if they've got diarrhea or a malabsorption, um they can get decreased um serum potassium. Um and the last one's cutaneous. So whether it's through less sweat and or through burns and they can use potassium. So, once again, with these symptoms, um they're quite generic symptoms um which involves something like muscle cramps, weakness, fatigue, um paralysis, constipation, respiratory failure, irregular heartbeat. So the respiratory failure and irregular heartbeat, but talking very sort of severe hypokalemia. But in the mild cases, you might see something like cramps or generalized fatigue or weakness. So it's quite simple when it comes to treating um hyperkalemia. Um if it's mild or moderate, we can give um Sanda K which is um oral potassium supplements and they can take two tablets. It can either be orally or through the n if they um can only um have their intake that way and that would be three times a day. And um if it's less than 2.5 we can consider giving um IV 40 milli MS of potassium chloride um and that can be every six hours. So, in terms of other considerations, so, um we should remember to give lower doses um for patients that have kidney disease, um always make sure to add on um, a magnesium to the bloods if you've got um potassium changes, um, as that can actually be the reason behind having hyperkalemia. So, if you treat the magnesium um, ions first, um then you can, um, correct the potassium and it's important. There is few cases where we should just carefully monitor the potassium levels. So if your patient's taking digoxin, if they've got hyperaldosteronism, secondary to renal artery stenosis or something like cirrhosis or nephrotic syndrome. And if they're losing a lot um by the G I tract, whether that's diarrhea, um, or vomiting and those that aren't getting enough intake. So if they're nail by mouth or they're receiving um, TPN, so that concludes um, our session for today. Um, really grateful for all of you for sacrificing your, um, evenings to attend this session or the previous ones, um, that you have and for those of you that have attended three of the four sessions, um, if you scan this QR code, um, and just fill out the details. Me and Molly can send you um an E certificate. Um So you might have had the chance to do it at the last session if you've attended three. But if this is your third session, you can scan that QR code and um we should be able to send one your way. And for each of the individual episodes, you should be receiving one from Medipap. And if there are any issues, you can um send us an email, I'll leave my email in the chat. I think shi can leave um the med email as well. But I think that all together does conclude our talks for today. So thank you all very much. There were just a few um there was just a question about um just could you um explain the bit about digoxin again? Yeah. So yeah, so we've got five minutes. So the way in which digoxin works is I think I mentioned it the, the very start with um the toxicity. So um it's a sodium potassium a ps um blocker. So by that result, we're unable to um push potassium into the cells. And so you're left with a higher intracellular sodium which leads to a higher influx of calcium, which is why digoxin is really good for being a cardiac glycoside. And we just want to be able to give a slow amount when it comes to digoxin toxicity um because we'd be worried about um extravasation, which is where it would leak out into the skin. And so we want to be able to give it at a slower rate. Um But in terms of treatment, if they're on digoxin, they would still be receiving um calcium gluconate to um stabilize the cardiac membrane. Is there any more questions in the chat? I didn't think so. I think that's it. So to end the webinar series, I'd like to say a huge thank you to John and Molly for having run these series and for having host them. We're very, we're very thankful to you for hosting this and to all the participants. Thank you for all of your time and for joining us and be sure to email us if you have any issues regarding the feedback forms. And thank you for joining us once again. Thanks for joining us guys.