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We only have a few people. Hopefully some more. Wait maybe five minutes. Oh, it's just, it's only five. Good evening. Everyone who can uh can someone just let me know if you can hear us, please? Someone could just put a drop a message in the chart. I think people can see us. We'll just give it a couple of minutes and then we'll get started. Ok. All right. I know we get side. Yep. All right. So good evening everyone and welcome to teaching things. Today, we're gonna be discussing the doctor ABCD E AN assessment and this is an assessment you use for any acutely unwell patient. Um My name is Harish Baba and I've got with me. Yeah, my name is um we are 2/5 year medical students at UCL. Um And yeah, so today we're gonna be talking through this. So just before we get started. So if you haven't been here already, um Welcome to teaching things. We give weekly tutorials, uh focus on core presentations, diagnostic techniques, um interpreting various um like x-rays, et cetera. Uh We always have a doctor to review through our slides. So we make sure we're not you know, blind leading the blind. And we always keep you updated about our upcoming events by email and group chats. And please, if you haven't already do follow us on medal so that you can get these updates and you are aware of our future things. Um So, ok, so today we're gonna be talking about the doctor ABCD algorithm, the structure of this assessment, basic treatments and interventions that you give during each step of the pathway and some important red flags. And then we're gonna go over some of the common emergencies we may come across when doing this assessment and also the sbar handover, um which some of you may have heard of already and this is a really valuable tool um in these things. Uh But yeah, more on that later and just a quick note, this assessment and our presentation today is mainly regarding adult patients and how you would go about treating an acutely unwell adult patient. Though the structure might be identical for pediatric patients, certain treatments and interventions might be different. So we won't be covering that today. Things like fluids that you give. Two Children and babies are slightly different and the calculations are different. Um And also please please do use the chat function. Um Please do use the channel to answer questions and we will be bring some S PA S up throughout and I'm gonna put one up now, please just answer whenever you can uh all right. Can you hear me? All right because Paul's just said there's no sound. Yeah, I saw that comment. Um Yeah, Paul uh can you hear us? OK, because um I can hear you. All right. I ad has said that she can hear us. If not, we'll see what we can do. Hopefully it should be OK. OK. But anyway, just to carry on. So what is the do ABCD E algorithm? So this is danger of response, airway, breathing circulation disability and then everything else. So uh what this assessment does is we, the danger of response is just an initial, just, you know what's going on around the patient and then you're going through airway through to everything else. And this is really because this assessment you will do all the time, whether it's on wards, whether it's in the A&E uh whether it's in surgery wherever you can, you can do this assessment all the time. And it gives you a broad overview of the acute problem and you do this in an order of what will kill the patient first. So what that means is if you see an acutely unwell patient and first thing you do is measure their BP, they might not be breathing, they might not have an airway and that's gonna kill the patient first. The BP is kind of, you know, it's, it's further down the list of what's most important to you and it allows you to identify any major problems that require immediate treatment, intervention or investigation. And then you can refer to the appropriate teams as you need to and what's a good way to practice this assessment. Well, this is something you're gonna be doing all the time, especially when you first qualify. You'll be doing this assessment constantly for almost every day and some good ways to practice are just, you know, with your friends go through the structure. Um Give, give each other scenarios, practice each step of the pathway and making sure you're asking and looking for all the necessary things, go to the hospital and practice in your A&E s practice on the wards. And also a valuable thing which I got taught by an anesthetist once was you can practice on patients who are very well. So I, for example, I was in surgery and the anesthetist asked me to perform an ay on the patient on the table. And you can actually comment quite a lot because you can talk about how their airway has been maintained by where by an intubation, et tube or something, you can talk about what might be going on in terms of their breathing and their lungs, their respiratory system, their cardiac cardiovascular system. So it's a really good way to practice and I would definitely recommend that. Ok. So first of all, uh just gonna go through a couple of the initial steps. So you were a junior doctor on call in the emergency department and a nurse has called you over to assess a patient who she is worried about because they're acutely unwell. What is the first thing that you want to do? So you're not near the patient at all? What is the first thing you want to do? Does someone wanna drop a message in the chat? So the first thing you want to do when you get called by a nurse or by some member of staff is you just wanna introduce yourself? You wanna say hi. My name is Harish Baba. I am a junior doctor. Can you please tell me more about the patient and what has happened? It's a really good way. It's a really good way of just getting a very brief understanding of who is this person and why are they calling me and what's going on? Ok. What might you wanna find out? Well, you wanna know who is the patient? Have they got any known past medical history? Have they got any allergies that you need to be aware of? If you know that they've got a latex allergy, you need to make sure you're putting the right gloves on. If you know that, you know, they've got, um, asthma co PD diabetes type one or type two. It might give you a g rough direction of what might be happening. And you know, you can start to think of those differentials in your head. You also wanna know what can the nurse tell you already about what has happened and what is going on? Has the nurse witnessed them deteriorate and therefore she can tell you exact or she or he, or anyway, they can tell you exactly what has happened in what, um, order and where are you in the hospital? That gives you a good understanding of, you know, what's going on? Have they just been brought in by the ambulance? And because they've been in a car crash, are they in a POSTOP surgical ward? And therefore, you know, you might be thinking how could they have a pulmonary embolism? And yeah, so all of it can provide valuable information and direction for your assessment and you can start to make sure you're kind of picking and choosing and getting out the right um information from the patient. And this is also a good opportunity to make sure that the nurse is available to assist you in your examination because you can't always assume that they are free and that they are able to come straight with you. Ok. So you can just say something like, ok, I'm gonna go ex ex examine this patient. Now, can you please assist me? It's a very nice way and just make it kind of builds that rapport between you and the nurse. Ok. So first we're gonna talk about danger and response and I'm gonna hand over to an Yep. So um after, after this sort of introduction. The next thing we want to do is so this is part of the doctor, part of the doctor ABC acronym uh as we can say, so what do we want to say? So, first of all, in terms of looking for danger, um yeah, brilliant. So what you want to do, first of all, and it might sound obvious, but it's a very, very important step to do. So just have a brief look around in the surrounding area to see. Is there anything that might cause harm? Not only to the patient, but also to yourself, you know, just make sure there's no sharps and there's no sort of spillages or anything like that, just take that moment to have a look. And if this is an exam scenario, just explicitly mention, you know, you're just quickly checking for danger and doesn't need to be anything more than that. And uh yeah, as it says, it's a great opportunity to show that you show your a aseptic techniques with washing your hands and uh donning your PPE great. And um as Harry's kind of said, so a very important thing is to, you know, introduce. So this not only sets the tone but it's also professional and it really allows us to um it allows us to also understand, you know what state the patient is. So when we introduce ourselves, just, you know, first of all, introduce, say your name. So hello, my name is I'm one of the, you know, f one doctors here to assess you. Can you hear me? And then um this kind of also bleeds into the response part of things. And um this is actually a very crucial point because if there's no response at this point, then you need to think. Well, ok, so do we need to consider something, do we need to consider ba S at this point? Because that is something which would be a life um saving intervention and we need to recognize this at an early stage. So yes, very, very important and always important to do it first. And uh yes. So um as as far also said, it is important to see how much of a history we can get from the patient. And if there's any information that could be very valuable to um that could be very valuable to set our background. So I've just got a question here. So for, for danger, do you need PP? OK. So yeah, so I guess in when it comes to actually checking for danger, it doesn't actually need PP per se, but it's a good opportunity for you to actually don your PP. So in within that window, say it's an exam scenario and OSK scenario, that would be a good window of time to, you know, turn the PPE but I understand your question in the sense that is it part of the danger step? Arguably not, but it's an ideal part of the step in the, er, acronym in the whole procedure for you to turn the PPE. So, yeah, I agree with that. And also depending on the hospital, you might realize that the PP is already like outside the cubicle. So you might be putting it on anyway. And it might just be, as you're putting your gloves on, as you're tying your apron, you're having a quick scan around the patient's bed to see. Is there some wires in the way that you need to be aware of? So it's you, you ki in real life, you kind of do it simultaneously, but it's just a good point in time that you wanna make sure. Have I got my PPE and have them checked for danger at the same time. Yeah. Yeah, pretty much. Yeah. So I think when it comes to real life scenarios, there is gonna be that sort of flexibility. So um yeah, just definitely take the structure but al al always remember in real life there is that room for maneuverability depending on the situation. So yeah, guys, so have a go at this point. So how do you check for response? So yeah, have a go. It's not a trick question. OK. Six responses. Great. OK. So yes, excellent. Thank you very much. Yeah. So yeah, talk loudly. Shake the patient and TRP squeeze. Yeah, these are the right things to do. So yeah. So this also indicates to the extent of which the patient may be unconscious. You know, if, if, if you talk loudly, the next step might be to shake the patient, then it might be to um do a trap. Squeeze. This might be, you know, very important step to recognize at what level of consciousness the patient might be. So, yeah, so just more on some response. Ok, so what kind of responses may you expect? So I guess in, in the ideal world, you know, the patient would be just talking freely as, as it says here and alert. And that would be quite reassuring because it means that, you know, at least, um you know, the patients are able to respond and um yeah, so the other thing is if the patient is able to respond but otherwise is not alert. Yeah. So this could this could indicate possibly, you know, we could investigate this further down the line, but it's always something to be concerned about if you know, if the patient isn't as alert as you'd expect them to be confused and m blame again could be red flags. Definitely good to have a look at um, you know, gauge this early on an early stage. And uh yeah, so sometimes what could be the case is that they may be unconscious, but ultimately, they may be just responsive to the pain. So this kind of feeds into when we talk about G CS. So G CS is something we do. A bit later on in the um stages or Yeah, exactly. I have to. Yes, but this gives us an initial nice assessment before we dive into this. So it's a very important. Exactly. Yeah. And yeah, of course. So patient may also be unresponsive and unconscious. So in this case, what would we want to do? So I think in the next few slides, there's a big point about, you know, calling for help, you know, if we recognize these sorts of red flag signs, very, very, very important thing to do within, you know, not in, not only in real life, so not only in exams, but also in real life is to recognize this and call for senior help as soon as possible. And just another point on that. So if they are responsive to pain and this is something we will go over again later, responsive to pain is equivalent to A G CS of eight and therefore you need immediate anesthetic support. So 2222 f believe the anesthetist or the itu because we might need to get a definitive airway and we will be talking about what is the definitive airway slightly later on. Yeah. Yeah. So when we go on to airway that will come on. So yeah, just general points then. So we will go on to the A two E in a lot more detail. But I think one of the most important things with the A two E is structure. Now, when it comes to structure, we follow a template through all of the, you know, from ABC. And this, this, this allows us to think in a very systematic manner. So the first thing, what do we wanna do in each step? And it's kind of similar to what you do in an examination. For example, first thing is is that you want to look, you want to look to see what can you actually see. And this can sometimes be one of the most important stages and within each subsection. So within airway, within breathing, within circulation, you know, you'd always start to look and say, what can I see in, in regards to airway, what can I see in regards to breathing? What can I see in regards to circulation? And uh that's a very, very, very good way for you to sort of fall back on making sure that you don't f forget any of the key details. Then feeling. Yes, this is very important as well. Obviously, this depends on which um part of the assessment it is and they will have different sort of different sort of uh examination or techniques that you'd need to do for each stage. Listen again. Yes, this will come on to this as well. So when it comes to breathing and circulation, these are very, very important measurements again, very, very important at each stage. Um I think because there's so many measurements that we could possibly take in an A to e, having this sort of structure within each of the letters in the A to E is very, very important. So you don't forget any of them. And what we'll show you today is we'll, we'll show you some pneumonics to sort of help you guys remember these um things that you need to measure because I'll be honest, like when I first learned it, like it was a lot And although it makes sense to do these things, having that pneumonic is a nice little thing to fall back on to make sure that you don't forget because you're gonna be quite stressed. It's, it's a high pressure situation. That's what this is and a to be. So it's always good to have these sort of easy ways to remember things in the background. So, yeah, and then the other thing is, you know, once you've measured, you're gonna have an, you're gonna have a evaluation of what this means and then adequately, you're gonna be treating this as well. So we'll go through this for each stage as well. And then the most important thing of course is after you've treated, you need to make sure to reassess to make sure you see if what your intervention is, has actually made a difference. Um because which is very important and it's something which I think is very easy to forget. So definitely, definitely do not forget to reassess at the end. So just remember this structure and this will definitely give a lot more clarity. Yeah, definitely, we will reemphasize reassessment throughout this presentation. Um It's really, really, really important like you don't wanna give the patient oxygen and then, you know, you've gone through circulation and you realize that they're sat, they're actually still saturating at 62% for example. So you really need to make sure you're reassessing. It's really, really important, you need to make sure whatever treatment you've given has it actually made the difference that you want it to make. Ok. So yeah, like I said, you, this order comprehensively allowed you to assess and identify immediate issues and something that I mentioned earlier and again, something we will reiterate a lot through this assessment, you have to have to always call for help, ok? You need to always call for help and you need to do it at an appropriate time. And one way that we like to think about it is a good rule of thumb. If you have to, if you measure a abnormal observation and if you have to give some form of intervention, you can safely say that you need some senior support. So what that might mean is if you need to give the patient oxygen, if you need to give the give the patient some kind of airway support, um fluids, anything like that, if you feel if you need to give that, you should be calling for help and some values that you might want to think of if they're saturating less than 94%. If their respiratory rate is greater than 25 less than about eight. If their BP is very hypertensive or very, very hypertensive, these are all things where you would think, OK, I might need some senior support here because things could get very bad, very quick. OK? So always keep that in mind, always, always call for help. But also sometimes you do need to use your judgment. For example, you don't wanna call for help straight away and realize that you don't know what to tell the medical registrar because you have no idea what's going on. So sometimes you might need to take an extra second to just get a full picture so that when you do call for help, they know exactly what's going on. So always do use your judgment but remember you have to call for help, ok? So first let's move on to airway. Yeah, so yeah, very important point there. So um yeah, going on to airway then. So with the airway. So this is the first thing you wanna look at as how you said, you wanna do it in the in the basis of what's gonna kill the patient first. So this is a very important thing to do. This is the way to stop. So first of all, you know how we talked about the response. Now, if the patient is talking to you and making noises and essentially able to hold a conversation with you. That is very reassuring. The reason why is that, that means that there is the airway must be patent. You know, there's no sort of obstruction, hence why they're able to talk to you. So that would be something which initially, you would make sure to make, um, you know, see if the patient is actually responding for you to go through. Um, no, sometimes what you need to do is essentially airway. What we're essentially looking for is we're either looking for obstruction. And we're also looking for signs of anaphylaxis because, you know, when you look, that is something we should observe for as well. So when it comes to, when it comes to the structure, then let's start with look. So first of all the things we might wanna look out for is, as we said, swollen lips, tongue, what does this mean? This is more this sort of anaphylactic picture, as we said, this is something which you need to recognize very, very early on. So this would be something you'd pick up on the look stage. And, um, it's definitely something to, you know, keep the eye of the other thing is obvious obstruction. So now, you know, if the patient isn't responding or is clearly obviously unable to sort of speak or respond due to some sort of obstruction, then of course, then it tells you that you know, you need to intervene at this stage. But like sometimes what you can actually look for is you can literally look for any foreign bodies or if there's any sort of vomit or any sort of phlegm saliva, anything that is actually you can clearly see is obstructing um the airway that that's something you'd look for at this stage as well. So following the structure, the next thing is, yeah. So check, checking the presence of Yeah, so yeah, I put in a chair. Yeah, I did. You definitely Right. You wanna see there's any food chewing? I Yeah, definitely. Very, very important. Of course, of course. Yes. Yes, very good. Um Yeah. So for the next bit, yeah, feel, you know, arguably this can come under breathing as well but you know, it's very, very important. Yeah. Feeling for air is very important. Yeah. So um you know, it's, it's, it's a very simple step but it's something we can quickly do just to ensure that you can actually breathe and then listening. This is another very important thing. So now sometimes you not, you might not be able to actually see the actual obstruction right now what we said with the flem live sometimes. Yes, it might be, you know, spilling out of the mouth and it might be very obvious. But other times it, the obstruction might be a lot deeper in the airway. Now, that's why the listening stage is very important. So listening for things like stride or gurgling, snoring talk or like any sort of talking or struggling to talk that would indicate that there is something in that airway that is making them struggle to talk, causing these noises like Stridor or go. So it would indicate our intervention at this stage. Yeah. And just for people who just, you know, forget what the difference between Stridor and Wheezes. Wheeze is something in the lower airways preventing air from coming out. So you, it's kind of like a, it's on expiration. So there's something and usually, you know, it's your asthma, it's your co PD making it difficult to breathe out. Whereas Stridor is something preventing you from breathing in. So it's that inspiration, Inspiratory Stridor. So just remember that kind of distinction. If it's in, if it's Stridor, it's more likely in the upper airways. It's something b something blocking it. If it's gurgling, it suggests some kind of phlegm and saliva. Like I know you mentioned, snoring suggests that the patient is kind of leaning back and their vocal cords are kind of blocking the airway. OK. So that just remote just to kind of give an idea of what those, where those noises might be coming from. Yeah. Yeah. Very important. Very important. Yeah. So what interventions might we want to do? So essentially, when we split these things, we wanna talk about it in terms of obstruction first. So very easy, very easy maneuver. So head tilt head tilt, chin lift. So this is something which you may have learned in clinical skills. Uh you know, it's essentially a very easy way to just open up the airway. Now, there's also another thing called a draw thrust. A draw thrust is an alternative way which you can essentially open up somebody's airway. But this would, this would be used if somebody had signs of a cease spine injury. Um So of course, this could be quite difficult to get this information sometimes. But it's something that you would want to ensure. You find out if you can, if, if the patient has notes, for example, or if the patient is able to talk or if there's any way that you can get this information, that would be very, very important to decide whether you wanna do a head tilt, chin lift or a jaw thrust procedure in order to, you know, open up that airway. And if you're ever in doubt, go for the draw thrust because you don't wanna, you don't wanna, you know, risk causing spinal damage. Of course, of course. Yeah. So as we said, you know, sometimes you can get these things like phlegm or vomit, saliva, all these sorts of secretions that might actually obstruct the airway. So what can we do for that? So we can use something called a Yanker soccer. So, suction. So suction can essentially, you know, remove all of this. So it's quite straightforward. The other thing is Mac Google forceps. So this is a very cool shaped forceps as you can see up in this, um, top corner here, the top here. So essentially what it is, it, it literally just is a instrument that allows you to pick up an obstruction deeper in the, um, airway and essentially prevent it from going down any further. But this does need to be done very, very carefully and you should only really do it if you can actually see where it is because if you can't see where it is and you're just sort of poking down, there is a serious risk of, you know, pushing even further down, causing more obstruction and ultimately causing way more harm. So just make sure to be very careful with that. And the other thing is, you know, the airway adjunct that you can use to keep the airway with the, the airway patent. So you've got these things, you've got, you called NPA, which is the nasopharyngeal. You've also got the oropharyngeal. Um So the key things here is that with a NTA, so the nasopharyngeal, so this is what goes through the nose down into the airway. What you need to make sure to do is me essentially make sure there's no signs of basal scroll fracture. These signs could include something called, uh so the, these signs include the battle sign which is like um an injury on the side. So like almost on the mastoid side of the head, you can get these things called, so they're called, recognize. It's essentially like bruising around the periorbital region. So that's another thing to sort of look out for clinically and other things you can sort of look out for is maybe bleeding through the ears, maybe bleeding through the nose. And all, all, all of these are signs of basal skull fractures. So this is something you'd clinically evaluate, make sure you're not seeing any of these signs at all before inserting something like a nasopharyngeal. Uh The other option is the ordu and as you can kind of see, it is quite, it, it would be quite unpleasant to, you know, stop that down somebody's throat if they're conscious. So it's uh yeah, it's, it's more, it, it, you'd be more likely to use it if the patient is unconscious as, you know, as it would tr trigger the gag reflex and being extremely uncomfortable for the patient. And yeah, finally. So the other thing you, we're sort of looking out for in airway is the anaphylaxis. So with anaphylaxis, you know, this is a, this can be very, very severe. So you wanna treat this as soon as possible. So what you'd wanna give is intramuscular adrenaline, nt 0.5 mL at a concentration of 1 to 1000. And as, as Harish and um me talked about, it's very, very important to call for help. You know, if you've recognize these signs, if you see these swollen depths, these you know, these rashes you wanna call for help as soon as possible. So that is when you call you double two, double two and also your anesthetic support. Yeah, go for it. So yeah, we just want to talk about what is a definitive airway. Can anyone tell me what a definitive airway is and what we mean by definitive? If anyone can put that in the chart? Yeah, just take your time, put it in the chart, we can talk about it, just give it a sec. So this is something you will come across quite often, whether it's, you know, anesthetic, whether it's a three anything. So what we mean by definitive airway is basically, it's, it's endotracheal intubation. So what you can, what it is and if you look at the picture, you can kind of see it though. It might be slightly small. An endotracheal tube is a tube that you, I'm sure all of you have probably heard of and seen before and you insert it through the mouth and it goes into the trachea and it sits below the larynx and below your vocal cords. And then what you do is you insert that it has a balloon cuff at the end, you inflate that balloon and therefore you cannot pull it out is basically stuck there. And it's, that's what we call a definitive airway. Ok. And what that means is, you can't get any aspira down there. So you're, you know that that airway will be maintained no matter what if the patient vomits, if they, you know, cough up blood from the stomach, from some ulcer, for example, you know that it is not gonna go into the patient's lungs and it's not gonna affect their breathing. Ok. And when might this be necessary, like we mentioned back earlier during response, if they are only responding to pain, if they have a G CS less than or equal to eight, you might need to get a main, an a definitive airway. So like we said before, you need to fast ble the anesthetist and it support for emergency intubation and ventilation support. Ok. So, always remember that GTs of eight you need, you might need intubation. So you need to call for help immediately. And yeah, like we've mentioned before, reassess is really, really important is my airway. Now, patent is the patient gonna have any risk of further obstruction? Ok. Really, really important. OK. And that leads us on nicely to breathing. So what are some of the main presentations you may encounter when you come to breathing? Some of the biggest ones is just, you know, shortness of breath, difficulty in breathing, tachypnea, um slow breathing, low oxygen saturations, coughing up either phlegm blood mucus. OK. And what might some of the main diagnoses be? Well, this is a variety of things and I have just remember this is not an exhaustive list ok. Some things which you wanna get very early, tend to pneumothorax. If you don't treat that early, that can cause the patient to go into respiratory failure, pneumonia. And the biggest thing with pneumonia and any infection in any of this is you really, really need to identify sepsis as soon as possible. Sepsis can kill. And the earlier you get, you notice it and the earlier you tr treat it, the more likely the patient will recover and do well. Other common things, pulmonary embolisms, opiate overdoses and exacerbations, co PD, exacerbations and also just something is like something like an anxiety attack can cause a patient to, you know, if they have really hyperventilating and they have really, they can really a um you know, they get all that carbon dioxide out, it can cause really bad problems for patients. Ok. So back to our structure, look, first of all, what are we looking for? What we're looking for to see is the patient sweating. Do they look cyanosed? Can you see blue around their lips and maybe even on their fingers, do their fingers look blue, any purse, lip breathing and nasal flaring and use of accessory muscles. So if you haven't seen this, so nasal flaring, their no nostrils just look really wide and uh they're trying to get as much air in as they can personally breathing. It's a way to increase the pressure of um the air in the lungs. So they can maintain as much oxygen as possible. Use of accessory muscles and tripoding. Are they kind of hunched over their hands on their knees? They're really going up and down, like, really trying to get as much air in as possible. And do they just re look really restless and short of breath? You know, when you physically look at the patient, do they, can you clearly tell they are working really hard to breathe? Ok. So next thing feel, so you wanna feel is there any deviation of the trachea? Because um as a lot of you might know, it might suggest some kind of tension pneumothorax, it might suggest a really um large pleural effusion or it might suggest some kind of hemothorax. Are they bleeding into their chest? And you wanna feel like literally around their chest. How is their chest expanding? Is it symmetrical? Is one side not expanding that? Well, you wanna have a listen though. So you wanna percuss the chest. Can you hear any dullness? Is there potentially some fluid there, is there air there is there hyperresonant? And you wanna have a listen to your breath sounds. Is there any consolidation? Is there any crackles? You wanna, it's quite quick that you can do this and um you wanna identify these things as soon as possible. Ideally, if you can, you'd wanna do this on the back, like on the patient's back. But that's not always possible because you know, patients might not be very agile, they might not be very mobile, they could be unconscious or you might, you know, you might be worried about ac spine injury. So in most cases, you probably will listen from the front. But if you can, listening from the back will always be better and measure. So there's a lot of things that you can do for measuring in breathing and I like the acronym. So crap. OK. So I'm gonna go through this. So s so a sputum sample, if the patient is coughing up a lot of phlegm, you might wanna consider a sputum sample so that you can culture it to see what bacteria or what, what might be causing this cough. O2 saturations. Well, how much are they saturating? Is it less than, and what the values you're always looking for? Is it less than 94%? OK. And obviously, you also have your CO PD patients where they might be saturating slightly less and you might not be worried, but you want to find that out chest X ray. Now, the chest X ray is really, really useful and it can show you so many things, it can show you whether there is a pneumonia, it can show you whether there's a a pleural effusion, it can show you whether the patient's got really severe pulmonary edema or um pneumothorax or something. So chest X ray can be really, really useful and in somewhere like a A&E you can get a chest X ray done within like 10 seconds cos that will come straight to you. So it's a really, really useful tool, respiratory rate, like I mentioned earlier is their respiratory rate really, really high. Are they really opic? And the, the values that we typically look at is a value greater than 25 or a value less than eight, that's between those values. You're kind of, you know, it's OK. OK. Greater than those values or lower than eight, you start to get worried and finally a coup last couple ABG and ABG again, it's a really, really quick um investigation you can do every single A&E has an ABG machine. It takes about 10 seconds to analyze and it gives you an incredible amount of information. Um If you haven't seen an ABG before, um it gives you the patients po two P CO2 bicarb. So you can find out their Ph so you can find out if they're acidotic or alkalotic. It gives you electrolytes, it gives you your glucose ketones and lactate. So it has so much, so much valuable information and usually it can just be done from a, a venous blood gas as well. It doesn't have to be arterial though in a breathing setting. If you're worried about something like asthma or CO PD, you may want to get an arterial sample and finally, a peak flow and a peak flow is very, very useful in someone, especially a young patient who's presenting with acute asthma because it can show you how severe it is and it was that can tell you how much treatment they might need. So it's always best to use your judgment for this. You know, you're not always gonna need to use a sputum sa always gonna require a sputum sample or a peak flow. The other four you typically will do in most cases, but it's always best to use your judgment as you might not always need to do it. OK? And we have an S VA here. So please have a go at this. I'm gonna t it up now. Well, OK, maybe I'm starting to see some responses coming through. OK? OK. Good. Yeah. So the majority of you so far have gone for start the patient on 15 L of oxygen and a couple of you have gone for start the patient on 4 L of oxygen. So you're, you're, you're all right. You do need to start the patient on oxygen. We are worried and you know, some of you might think, well, you know, they could have CO PD, they could be like, you know, the their target sets might be 88 to 92 and you would be right. However, it a 24 year old patient, the chance of them having CO PD is quite low. So you're not gonna do that straight away. And the biggest thing is hypoxia kills. OK. So the right answer would be start the patient on 15 L of oxygen via a non rebreather mask. And I'm just gonna go through the others. So asking the patient to sit up and take deep breaths and this would be really useful. And if anything, you would get the patient to do both of them, however, you need getting them to sit up, it increases their thorax capacity and they can get deeper breaths. It is a good tool and you would probably wanna do this. If you can sign the patient on 4 L of oxygen via a nasal cannula, it could work, it could work and it might help and it might bring their saturations up. However, you don't wanna risk at such a low um level of oxygen and you just wanna, you wanna give them the maximum. So always, always, if you see a patient who's hypoxic, put the start them on 15 L straight away, ok? And this is gonna be your most common treatment in this part of the assessment, starting the patient on 15 L. So 15 L high flow oxygen by a non rebreather mask. Other things you might consider, you might consider bronchodilators. So your salbutamol, your ipratropium bromide might be a nebulizer. And for a patient who's asthmatic, you would definitely wanna be selling these things if you notice that they've got a wheeze bilaterally, um they're really, you know, really tachypneic, you can see them struggling to breathe starting them on bronchodilator is very, very important. You might wanna start them on antibiotics if you can confirm that they've got a pneumonia. Um, and you know, you're starting to worry about something like sepsis. You might wanna start them on antibiotics. And there are some cases where you might wanna start on a lower percentage of oxygen. This could be a ventral mask, it could be a nasal cannula. And the thing is like, I've been saying, hypoxia kills first. So I would always recommend you start as high as you can. So you start with your 15 L and you titrate down as you find necessary. Ok? And the only time you might wanna start low and your target saturations will be 88 to 92 is only if you can confirm that the patient is actually a CO2 retainer. So a lot of CO PD patients might, might not be a CO2 retainer. And therefore, if you target them at a lower saturation, they will die from hypoxia. Ok? So an easy way to do this is look at your ABG. So if you look at your ABG and you look at the specifically at the bicarb, if the bicarb, the typical range is around 22 to 28 I believe might be slightly different. Um depending on where you, where you are. If it's in that kind of 28 29 30 if your bicarb is 28 29 30 it does suggest that the patient is a CO2 retainer. It takes a while for that bicarb to get that high. So if you see a high bicarb, it suggests that the patient is retaining CO2. So it's a really good thing to look out for um in an ABG. And if you do notice that they are do have a high bicarb, then you can go back to the patient and you can put them on a lower um oxygen rate, oxygen flow rate and you can change your target saturations. OK. So just remember that, always start high titrate down. And as we mentioned, always, always reassess has my oxygen saturations improved. Is the airway still patent? Has there been any change? OK. It's always important to check. Is the patient deteriorating at all? If the oxygen sats haven't improved, it could suggest there's some other issue going on, have the lungs suddenly collapsed. Have this, has the patient stopped breathing? OK. These are all things you wanna be thinking about? OK. So we have, yeah, go for it. So, yeah. All right. So we have a case here and uh just just, I think this is very important because, you know, we've done a lot of talking about steps of, you know, breathing airways, which is all great. But I think it's best if we sort of put it into practice and just show you guys how, how is it actually done when you know, we get a patient a case and somebody who's presenting with, you know, these acute. So first of all, this is the case. Very importantly, we're just gonna say it's a 19 year old patient who's come in, you know, struggling to breathe short of breath and that's about it really. So come to A&E So Harris, what would you do? First of all, how would we, what would we do? What was the assessment for breathing for you this patient? So we're gonna, we're gonna say we've done all the airway assessment. The airway is Ben and we know there's no obstruction. Ok. So we're just gonna start with breathing. So the first thing I'm doing, I'm just gonna look at the patient, I'm just gonna see, can I see any cyanosis? Can I see any clear difficulty in breathing? Which I can, I can see some clear short of breath. I'm just looking at the patient and I can see that they're using their accessory muscles, they're kind of tripoding and I can see they're quite sweaty from a lot of increased work of breathing and I'm just gonna have a feel of, of the patient's chest. So I'm just noticing that I'm feeling their trachea, there's no deviation. So I'm not worried about any kind of pneumothorax and I'm feeling their chest expansion and it's equal and symmetrical though. It is very rapid uh respiratory rate from what I can see. So I know that it's sm metrical. So I'm not again, not worried about something like a pneumothorax and I'm just gonna have a quick listen. Um and I can hear that they've got a bilateral uh expiratory wheeze and you know, this is quite worrying. So I'm II think I would, I'd like to get some measurements. I'd like to measure their oxygen saturations, measure their respiratory rate. And I'd also like to request an ABG and a chest X ray. OK. Um For those of you who want to in your own time, you can watch this youtube Link. It does give you an example of what these breath sounds sound like. OK. So interventions wise, what have we got? So the ABG showed low P AO two and low PA CO2. So it's showing that the patients hyperventilating, not struggling to get their oxygen. And you know, they're releasing their CO2 a lot, their peak expiratory flow rate is showing 35% of predicted. So it's showing they've got some kind of severe exacerbation and their X ray is completely normal. But what do you think is going on? I think it is quite obviously, which most of you probably would have guessed it's acute exacerbation of asthma. And we can tell they've got a bilateral wheeze, they've got a really high respiratory rate. Their po two is low. So we know that they've got asthma. So what would I like to do? How would you manage this? Could someone does someone wanna say how they would manage this. Yeah. Amazing. So I want to start the patient on 15 L of high flow oxygen via a non rebreather mask. And I'd also like to start the patient on nebulized salbutamol and a proprium bromide. And I'd probably do this in a burst therapy for those of you who don't know what that is. It's giving each of these similar like one after the other. Um And you give about three rounds of that. Ok. And I'd also like to call for medical registrar for senior review and starting uh things like steroid treatment. Ok. Amazing. Ok. And some of you might ask and wonder, do I have to follow this exact order of this assessment every single time? And I would say for the majority of situations. Yes, it's a good way because you don't miss anything and it gives you all the information you need. However, there's certain situations where you think, where you think, you know, I'm really, really worried about this. I wanna check for this straight away and an important one is sepsis. So for example, I've noticed in a patient, let's say I've noticed that they're coughing up um phlegm, they're really hypoxic, they're really tachypneic and they just look really unwell. So, you know, I I'm thinking, you know, I'm quite worried that they might be septic. So I might think straight away, can I get up my BP? Can I get a heart rate? And can I measure their temperature. Let me see. Do I, am I worried about them being in shock and am, am I worried about them being septic shock? And I might think. Ok, fine, let me start the sepsis six right now. It can't wait. And another one is something like a pe or heart failure if I'm worried that they're tachycardic and I can hear dullness in their chest. I might wanna check their legs to see if they have any signs of a DVT or they're particularly edematous. So I can start my treatment early. OK. So it's always important. Use your judgment and always remember if you do do this, you should always go back to your structure so that you don't miss anything. It's always, it's always important to remember. Some things might be a distraction. OK. Amazing. Yeah. So, yeah, we're gonna go on to circulation now. So I think now we'll be quite familiar when it comes to the structure. So we're gonna go through in a very similar fashion. And um yeah, so what common presentations may we see in our? Hold on one second. I think I might have it disconnected. But yeah, first of all, what common presentations may we encounter? Um So I'm just waiting for her to get back on. Just bear with us a second guys as far as I Yeah, so um excellent, great. So, yeah, first of all, what do we want to see presentations wise? What do we essentially um expect to see. So the thing with A two B is A as in, at least for, not only just for exams, but also in real life, these are the most important things that you might see. So, first of all, you know, when it comes to circulation, um you might identify something such as chest pain, so it chest pain again, you may have identified this before. But within this structure, it makes sense to, you know, think about things like chest pain within. So there's also tachycardia, bradycardia, uh there's hypertension, hypotension and there's things to do with pulses and there's also cyanosis and oliguria. So the thing is a lot of these things, the reason why we put this in circulation is because of the assessment that we do in circulation, we'll typically identify these um presentations within this section. So great. So what diagnosis would these mean? So as a result of these observations, we may see things such as, you know, you know, with the chest pain, it could be things such as obviously your A A CS. So this could be things like your sties, your enemies. Also, it also could be angina as well, stable and unstable. Um aortic dissections will definitely very important to consider and we talk about different ways we can make sure we can identify this within the circulation, part of the algorithm as well, uh decompensated heart failure as well. So this is also something which we could pick up um tachycardias, bradycardias, and brady arrhythmias. Again, things which we would want to pick up in this stage and atrial fibrillations will again, another very important and common presentation. Actually, uh sepsis. Again, I know we bang on about sepsis quite a lot, but sepsis is something we definitely, definitely, definitely do want to identify and it's something which we want to identify as soon as possible. So we can, you know, address this very quickly. So great. Ok, so we're gonna go through, go through it in the same sort of way which we did for our breathing then. So 1st, 1st and foremost, look what are we looking for. So you've got the patient right in front of you and the kind of things that you want to look for is first of all this j just their general appearance. So are they, is the patient pale, is the patient, you know, gray, are they sweating? Um you know, are they, are they flushing or anything like that? Another thing you can see is, you know, you can test for their JVP, you know, tell, tell the patient to turn 45 degrees and just to see if there's any sort of raised JVP. Um you can also look for mucus membranes just to see if the patient may be dehydrated. So if there's any sort of, yeah, dehydration signs at all. So these are all things that you would, you know, just collect information on upon inspection essentially. So that that's your look stage. And yeah, so for fuel, so when it comes to feeling um the the, yeah, so these are the most important things. So temperature, I know we are gonna be measuring this as well. But it's also very important to just, you know, literally examine the temperature. You know, you can literally just feel for temperature to see if it literally just feels that the peripheries are, you know, colder or if they're warmer. You know, it's very important to just clinically find these things because uh they can be very significant in our diagnoses and also the treatments, pulses will come on to pulses as well. Pulses are very important actually. Um definitely, definitely, definitely pay very close attention to posts and do not forget to do so at all. Um And then, yeah, capri full time. Again, another thing which you do not want to think it's very simple, but it's very, gives us a lot of information. So yeah, very important. Yeah, just a note on those. So it's something like temperature and cup refill. If you notice that their peripheries are really cool. It suggests that they've got poor circulation. It suggests that they might be hypotensive, same with capillary refill time if their capillary refill time is really long, you know, greater than 323 seconds. Again, it suggests poor circulation and it will get you worried. So these are red flags that you wanna look out for. Of course. Yeah, I think, uh, yeah, a lot of, a lot of the things we're looking out for here does tie in with the things that you'd see in post, even with pulses, which we'll talk about soon. So, yeah, heart sounds, you know, this is your standard, I guess it kind of ties in with your all sort of, um, cardio exam kind of things. But it's very important things, you know, like things like murmurs, third heart sounds. And also another important thing is sometimes people forget this but lung basis as well. Now, lung basis, why would you wanna look at this, this, this things such as in heart failure, you know, this back up of fluid you wanna hear if there's any sort of crackles in those lungs, which could indicate that there's this sort of backup of fluid in the lungs, pulmonary hypertension. And this could give us a better clue as to what the reason for the patient uh feeling this way might be. And uh yeah, pericardial Rob as well, very. Um, that's something that you, you could look out for as well. Now, the next bit is our measure. So in circulation, there is quite a lot to measure and uh the pneumonic in breathing was sore. And here it's another pneumonic called be. So this is something which helped us quite a lot just to remember all the different things that we'd want to measure within, you know, within the circulation stage. So B yeah, B is first of all your BP. So I know we talked about this. So, but BP is very, very important, right? Very, very important reading and tells us a lot of things. So is the patient hypotensive or hypertensive and that can give us some very key clues as to what might be going on. Next thing is urine output. So urine output again, is a very good sign of or it it it gives us a very good clue as to um how the patient's hydration status and circulation may be like has the patient produced enough urine or is the patient in retention or is the patient producing a lot of urine? All these different things can tell us different things about the hydration status and also just in general, the patient's well being which we'd want to act on as possible. So the other thing is temperature. I know we talked about temperature in few, but this is an actual measurement of temperatures. This this could be tympanic temperature. And this could, this is the stage at which we could actually recognize whether the patient actually for for example, might have a fever. Now, this would indicate, well, this could tell us that possibly there could be some sort of sepsis arised. And again, this would then channel us channel our management as well. So you, you wanna be thinking in the back of your mind about things like sepsis six when it comes to the management, which we'll talk about in due course. Uh So c is your capri? So again, I know we've covered that within, see within few. So I know there is a bit of overlap, but this structure definitely makes sure that you don't miss these things. So capri for why is this important? Because if it's less than two seconds, that suggests that the patient has got enough, good, enough circulation to get that blood flow all the way around to the capillaries. So get it right to the peripheries. Now, the thing is you can also do a central capiri but peripheral one is also is also equally important. Um Now, if the gap before is too long, then you wanna think about things like, OK, so could this patient be dehydrated and think about how you'd, you'd, you'd address that as well? And, and then the other thing is heart rate so very, very, very important. Um you know, is, is the patient bradycardic is, is the patient tachycardic or is the patient possibly unstable. So this could this would be important information that you'd want to combine with the BP as well. And finally, it makes sense to have an E CG reading as well. You know, with a lot of these uh issues with it, it with a lot of these presentations, there may be abnormal E CG findings. Um I'm already it says it already. If you're thinking about chest pain, you want to exclude things like a stemi or an end Demi those, those are the ones which are, are very, very, you know, they're very, the mortality is very high and you wanna make sure you recognize this as soon as possible. So you, you can intervene adequately. So E CG is very important and uh yeah, great. Yeah, just uh one thing about BP you might want to do is important sometimes to check in both arms. And the biggest thing we're looking for there is aortic dissection, aortic dissection is something you wanna find out as soon as possible. And typically you find differences in BP between both arms. So yeah, just you might just think about it, you might wanna consider doing that. Yeah, that's an important point as well. Yeah. And then typically that kind of patient would be presenting with an excruciating sort of tearing sort of pain which you know, should give you that sort of clue. But regardless any sort, you, you do wanna check that out just in case. Um because you'd be surprised how sometimes people can miss that. Um Yeah, so pulses again, very, very important. And I think this is something we just overlooked when it comes to at es and it's a very, very simple thing that you can do, which gives you a lot of information. So what can you do with the pulses first of all, you can see things like the rate, the rate is very important because it tells us if the patient is bradycardic, tachycardic and the heart rate was also gonna help with that. But it's also very, you know, useful to just get that from the pulse as well. Uh You can also check if it's regular or irregular. Why is this important irregular pulse? This could indicate some sort of atrial fibrillation And the patient may have presented these things like palpitations. And that then gives us a very good clue as to what this may be. So it's, it's just all about putting these pieces of the puzzle together to formulate that diagnosis that would allow us to, you know, make sure we treat it in the right possible way. Um And then again, coming back to this sort of aortic dissection example. So to see if there's any sort of radio radial delay. So between the two pulses on either. Um so either radio pulse, is there a delay on either side? So you'd wanna put, you don't want, you do wanna check both of the radio pulses simultaneously. See if they're in sync, if not have in the back of the mind, could it be a dissection? And you'd wanna combine this with your reading with the BP as well just to, you know, add some gives, gives them more clues essentially for active dissection. And then, yeah, so we talked about bradycardia. And then of course, of course, very, very important to combine these findings with an E CG. What it does is it gives us extra evidence and extra clues that it is a certain arrhythmia or that it is an atrial fibrillation or it is a tachycardia. So it's just about accumulating this sort of evidence and clue as to what diagnosis this may be. And um the other thing to note is that if you do, if you do um identify some sort of arrhythmia, always, always refer to the adult a list algorithm as well. So that's a whole different topic, but that's something which would tie in very nicely with this stage of our at E and of course, definitely, definitely, definitely do not, do not forget to get immediate senior support, always, always escalate when you do see any of these red flags. So we'll go through these in a little bit more um specific detail. But yeah, that's ultimately the most important thing for health. So treat. So within treat when it comes to circulation, you wanna think? OK. So what kind of things have I looked out for? So a lot of what we've looked out for was to do with things like dehydration. So and also we wanna, we, we wanna have a look at what the blood, what may, what clues there might be in the blood itself. So what you wanna do is you wanna insert two wide broad cannulas one in each antecubital fossa. So this is one of those phrases that you just sort of have to know. Um you know, when me and her are rising for our OSC, it's just something that just essentially you need to kind of just stick in your head, just remember it. Um It's a bit of a mouthful, but it's very important. So what do you wanna do with these cannulas? So in one of one of the Cannulas, what you wanna do is you want to take blood and what kind of bloods do we wanna take? So we'll talk about this in a second and then the other one you want to, well, if the patient need, you would want to give fluids and let's talk about what and how much. So, yeah. So the other thing is that you may also need a urinary catheter. So this, this may be in a situation where the patient is in retention and also it gives us to monitor the urinary rate is monitoring. The urinary rate is very, very important as well. And it also gives us very, very good clues as to what may be going on within the patient's circulatory system. And um this could also be a good time to get urine dipstick, you know, just to see if there's, if there's some sort of vague presentation, it's always good to, you know, check for maybe a UTI or anything else that might be going on which maybe not too sure of. Um other other thing is to know is you, you wanna think about what size of the cannula and also what color. So colors may vary. So depending on what hospital you are, but usually what we're thinking of is 14 g and 16 g Cannulas. And in this case, we've got the orange ones being 14 and you've got the gray ones being 16, but these may vary. Cool. So you know how we talked about the bloods. Now, let's actually talk about what is it that we want to take. So this the thing with blood, this blood is very, very versatile. We can look at a whole load of things which gives us a whole load of clues. Now, what do we wanna look for? First, most important thing is obviously a full blood count using these is very important. Good chance to get your L FTC RP clotting blood cultures as well are very important. So for example, if we are suspecting sepsis, especially if they've got some sort of fever, you do definitely wanna get your blood cultures because this would allow you to go from a bit more broad spectrum antibodies to more narrow spectrum where to actually treat what might be causing this infection. Uh You might want cross match as well depending on if there's been bleeding or not. Uh groups, groups say cross match and then lactate and ketones again. And then if, if you if you don't have an ABG, this may be a good opportunity to get that. You may also do, wanna do things such as a bone profile, thyroid function test and magnesium too. So, uh, as you can see here, you've got all of these different colored tubes and uh each of them would show what each of them would be for the different parts of the bloods. So, yes. And what do we give for fluids then? So I think I want to sort of track back and think fluids when, why do we want to give you fluids? It's ultimately because they're probably gonna be, if, if, if you identify, find signs that suggest that they are dehydrated. So what you wanna give is you wanna give a bonus and this bolus is usually. So what we wanna give for adults is a 500 mL bolus of usually nt 0.9 er percent saline. Sometimes it can be hard as well and this has to be a stat bonus or in other words, you could say that this is in less than 15 minutes and essentially, yeah, this is should be given a, a really. So yeah, very important, very important in, in intervention and yeah, pretty simple to do that. So uh yeah, another important point to say is that as you, there, there are exceptions essentially. So you may want to give 250 ml so it's slightly less lower bonus er, in cases such as, you know, if, if it may be an elderly patient where the circulatory system may be a little bit more sensitive or especially heart fail, but you don't wanna push them in to even more sort of edema and more sort of pulmonary hypertension by putting more fluid in because the heart is already unable to sort of pump fluid all all around. If you're putting even more fluid in this, you need to think about what that might do in in the in the case of um pulmonary edema, for example. So it's always a balance. You need to think about it in terms of your patient. Never, never forget that. I think it's very easy to get bogged down into, you know, these algorithms and remember, you know what to do in each step, but always remember each patient is different. So do consider them and as we know, reassessment very, very important. So you definitely definitely, definitely wanna look back and I think this is one of the most important, like all of all of the decisions are important. I think circulation is very important to make sure you actually have reassessed because you've given say you've given this fluid, say you've done this intervention, you wanna see has it actually worked or do you need to give more bonuses or do you need to stop? So this is the thing, right? You need to look at your BP, you need to look at your heart rate. So see, are they still unstable and go from there? So here's a little s pa so have a go guys. Um We have OK. The OK. So I can see we've got a bit of a mixed response here. Um There's actually two right answers for this and the two right answers that we would suggest is itu referral and m considering major hemorrhage protocol. Um Those of you chose vasopressors, you're not actually wrong. This is definitely required. However, in this scenario that you are a junior doctor, you are probably a bit unlikely to start those vasopressors because of, you know, they're quite, you need, you need to monitor those drugs very carefully. So the first thing you probably want to do before you start things like vasopressor is definitely contact ICU the patient is decompensating. They're gonna need a support and maybe considering have they got abdominal bleeding somewhere or just bleeding anywhere that you haven't realized. And so you wanna consider, do they need to get an immediate blood transfusion? So your major hemorrhage protocol um waiting 20 minutes would be not the greatest idea, cos the patient could deteriorate further if they're actively bleeding and you wait 20 minutes, they will probably bottom out and they will probably die waiting 20 minutes, I would not recommend at all. Yeah, cool. So yeah, again, back to the reassessment stage. So what you wanna see is, for example, if the patient is still hypotensive if their BP is too low, what you can do is you can give up to, you know, four Botts, which would be in total of 2 L of fluid. Now, the intention with this is that, you know, you want to make sure you're restoring that circulation, increasing that BP again. And um if you suspect that this reason why it's not actually improving is bleeding, then you might, you, then you'd consider the major hemorrhage protocol. So thinking about, you know, how could we actually, you know, how, what could we do to make, make sure that the patient isn't losing too much blood. And then of course, you'd want to, as I mentioned. So like considering it support is also an important thing. So just think about the patient and it's very, very um specific to each clinical scenario. And that's the main thing I think I'd like you guys to take away from here. Uh Yeah, so we got, we got, so here here, we've got another case here. Yeah. So we've got a case of a 59 year old patient. And um so are you, can you tell me how you would assess just their circulation? So we've, they've done their breathing, we've done their um airway, just their circulation. So what I'd wanna do is first of all, look at the patient and look at their appearance rates. How, how we said are they pale? Are they sweaty? Are they flushing are they gray just to, just to look at their general appearance, look at their peripheries. And, uh, what I can see is that the patient has clammy peripheries. Fine. Ok. Now, moving on to the feeling stage, now I want to, you know, feel for pulses. It's very important, as we said. And, uh, I'd also want to feel for, you know, just your general things that you feel for you in your cardio exam, maybe feel just to see if there's pl apex B and er you feel for temperature as well. And upon doing this, what's, what's what we found is that it's a regular pulse and then also the pulse is about 100 BPM. Um So that's fine and then I'd also listen to your heart sounds and heart sounds seem to be ok. Now, the next thing I'm gonna do is I'm gonna have a, well, I'm gonna measure the, so what we're gonna do is we're gonna measure. So as we said, what do we start with? It's our U ea um pneumonic for this, isn't it? So, b blood pressure, BP, as we can see is our 1 55/1, 17. So slightly high, isn't it? Um So you're an out. So you, you, you might not have this, but it's something which you may wanna consider temperature again, is not something we have in this case, but you may wanna consider this depending on the patient um cap full time. So we have that. So cap refill time is three seconds. And uh yeah, it's not, it should be less than two seconds. So it's, it's a little bit higher than what we'd expect. So, something to note and uh finally our heart rate. So yeah, we know that it's about 100 BPM. So we've kind of already said we've kind of already looked at that from our pulse rate and uh finally, we'd want to do an E CG and when it comes to E CG, now we've got the E CG back. So sometimes it might take a bit of a while. But, you know, now the EC GS come back and what we see is widespread flattening and inversion of the T wave. And there's also some ST depression in leads 123, V four, V five and V six. So guys, like just from this information, any ideas as to what might be going on just from our assessment. So, what we've done is we've gone through this whole, look, look, few, listen, we've measured and that's where we are at the moment. So after we've done this, where do we think we stand? What does the patient, what do you think the patient might have? What are our sort of differentials? So we wanna just put that in the chart, take your time. Well, what's, what's something we definitely need to rule out? That's like the most important thing. OK. So we'll move on. It's fine. So what do we wanna do? So, as we said, with the measure stage, so with the, with the intervention stage, we want to do this, we wanna put in those two Cannulas in the two anti fossils, right? Fine. And let's actually talk about in this case, what we'd actually want to do. So when it comes to cannulation, uh we've talked about the cannulation. And then we'd want to also alongside all of the standard things that we'd wanna do in a blood test because one of our differentials here is clearly gonna be something like a Nstemi or a Stemi or some sort of acute Coronary syndrome. We wanna make sure to look at our top level, top level. And when we look at a top level, top level is clearly elevated, isn't it? It's 96. And uh other things that would be pointing towards this sort of end picture is our one centimeter, one millimeter of ST depression and also our T wave flattening and inversion. So, putting this all together alongside the chest pain that the patient has um come with. This automatically makes us think yes, it may be an A CS and that's why we'd want to act very swiftly in order to treat this uh adequately. So what do we do for A A CS then? So this is very, very, you know, we can stick to the basics but these are very important things that you'd want to do in a case of a CS. So, pain relief, what are you gonna do for pain relief? Morphine, morphine is a very, very important thing to give because there's intense pain in the chest. 5 mg of intravenous morphine is needed. And then uh the other thing is nitrates is arguable, arguable. Um So you can give nitrates to the patient which um as long as the patient isn't hypotensive, then it's something which would be of benefit for the patient. Um you know, a allowing these sort of arteries to sort of, you know, vasodilate. It will definitely help in this case. Uh And as is very important, your 300 mg of aspirin, never forget that it's very, very important. And uh oxygen also if required would be given. So we would have also already looked at the SATS ideally in the breathing stage. So yeah, that's something which we would give dependent on what what oxygen level the patient is. So the next bit is what do we wanna do beyond this because this is our acute, this is our acute management. So what we'd wanna do is we definitely want to refer to cardiology. Now, cardiology will be doing things like the grade scoring. So you might have heard of this. So this allow allows us to make a decision regarding what the next subsequent treatment is gonna be for this patient. So whether they need a PCI or if it's more of a conservative sort of treatment, this is essentially decided by grade scoring. So I'm not gonna dive into that, that's more cardiology, but something to be aware of at this stage because that's the next steps that are gonna be taken. Um And then another thing to just know is that di diuretics are not needed because there's no sort of sign of pulmonary edema. So, pulmonary edema have, what kind of signs would you think you'd wanna think about things like crackles in the lungs? You know, if you're looking to listen to the cases, for example, um again, the patient doesn't seem to be hypovolemic as well. Again, this is guided by our readings that we've made in the measure stage. So, fluid resuscitation is not necessarily indicated at this stage. It's great. So moving on to disability. So thankfully, this disability isn't, isn't l as long as the other ones. Um but it's also it, it is very, very important. So this is split a little bit differently. So it's split into three parts. So the first bit is looking at the pupils. So this is a very important thing. We wanna examine the pupils to see if they were, they are equal and react. So if you, you wanna see, for example, if you shine a light into those pupils, are they equal and reactive to light, that is a very, very important thing to do. Very simple test, you know, you can just use a pen to shine it in either eye and you wanna see, are they both equally, you know, dilating and er, sorry, um constricting and are they all both actually reactive to light? Now, the things that you wanna look out for here? So in terms of red flags is pinpoint pupils. So this is commonly associated with um opiate overdose. So pinpoint pupils, you know, you're putting, so you're looking at, you're examining the actual pupils and if they are very small, both eyes, then essentially it it could be an indication of an opioid overdose dilated, could suggest um increased in intracranial pressure, which again is something which you'd want to ensure you get senior management too. So y at, at the stage of an A two E, this is the kind of thing, the red flag kind of thing that you want to identify as soon as possible. Now, things that you may, you may want to consider giving is things such as man. So of course, as a junior doctor, this may not be the easiest thing for you to prescribe. And hence why the importance of calling for help when you see things like this. Um In the meantime, you may think about things like hypertonic saline that could be another option. And um as we said, you know, make sure to get that senior support and of course, itu involvement would always definitely be welcomed and very would be very useful in this case. So great. That's that's one part of the disability. The second part is very simple, but glucose, glucose is very, very important. So sometimes you might just literally get an unconscious patient or a patient who may present as somewhat drunk, which can sometimes be mistaken, wasn't which where hypo things like hypoglycemia can sometimes be mistaken for other things. So definitely, definitely, definitely look at the patient's glucose. So sometimes even seizures could be caused by things like a hypo, things like a hypoglycemia. Um So very simple, you know, you just do your blood glucose just on the finger, just get a little bit of blood and then you can just quickly get a reading for the glucose, which will give us a whole lot of information. And also we can just rule things out, you know. Um So yeah, glucose is very important and then AV Q and also G CS is a very quick and easy and important way to measure essentially the the patient's state. So we kind of talked about this at the start actually with um you know, the response stage. So AAV Q is a little bit more simple. So a literally is the patient awake. B would suggest that, you know, the patient is able to respond to verbal stimulus at least um P is they're not able to respond to verbal stimulus and they're not awake, but they're able to respond to painful stimulus. So it's like the level beneath that and then you means it's completely, you know, they're not responsive at all. Uh G CS is a little, a little bit more complicated. I think it's probably best if you guys just take a look at that yourself, I think it comes up again and again, you know, only in ba s it would come up in your life and also in ACY. So no matter where in, in your medical sort of uh path or journey you are, I think it's very important to know the G CS. Um but essentially, it's, it's, it's split into things uh 33 sections as well. So that, that looks at eye that looks at eye move, that looks at movement, um motor movement that looks a bubble response and also examines what uh the response of the eyes is as well. So yeah, very important. And, and the other thing is, yeah, I would say stay on the slide and how men, there's quite a lot as well. So if the G CS adds up to less than 88 or less, then that's a indication for immediate immediate anesthetic interventions. So always, always, always do not forget that. So, yeah, the other thing is um yeah. So for example, yeah, again, reassessing with the patient after any sort of interventions. For example, if the patient is having a hypo and you've given them, you know, IV DEX, if you've given Dextrose or any sort of, um, sugar to sort of raise it up, just check again. Is, has that actually increased the sugar or maybe it's not done it, maybe it's not done the trick. So, definitely, definitely, definitely follow that up. Make sure it's actually doing what we intend to do. So, so, yeah, great. So, the next, I think we have a case. Yeah. So, I mean, we'll just, for time's sake, I think we'll just go through this a bit quicker. So we've got a case of 73 year old man who was found unresponsive, they were in for cellulitis, but they were gonna be discharged and you know that they have a past medical history of type two diabetes and on your assessment of disability, you notice that they're not really, they're only really responding to pain. Um, they people become reactive but they completely blood glucose is 1.9. So he, what do you think is happening? And what would you want to do? Yeah. So WW what we're seeing here is, you know, we've got this, we've got this, um, you've got this capillary blood glucose that we've had a look at. But um, before this, not just the fact that they're unresponsive, then you wanna think what kinds of things there could be. And I think the main thing here that stands out is within the past medical histories before you even do any sort of assessments, the fact that the patient is on insulin makes you think? Ok, so there is that potential that there could be something wrong with the glucose that would allow them to be unresponsive. So, already you're sort of thinking along the lines of a hypo. So, um having done the assessment, as you can see, the blood glucose is 1.9. So this is likely what might be going on. That might be the reason why the patient is unresponsive. Yes. Ok, great. So what do we wanna do then? So what can we do? So it's quite simple, you know, like if the patient has a low glucose level or low sugar level, you wanna get that sugar level back up. So what do we wanna do? The best option is to give intravenous dextrose either 10% or 20%. And this is, this should increase the sugars and what has it done? It has made the sugars come up to a nice 4.2 you know, closer to the, to the into the range of what it should be and it's also improved the level of consciousness. So it's, so that's, that's our, that's our reassessment stage. And um yeah, so again, do not forget you're double three, double two and yeah, very important for any anesthetic support if you need. So, yeah, yeah. So just towards the end of the assessment, so you wanna do everything else and you wanna do your asar so everything else, what does this mean, it's essentially just you've done the emergent things you've figured out, ok, this patient is relatively stable. Now, let me, and they, you know that there's no respiratory causes, their airway is fine and you know, their car, their circulation is fine, but they're still very unwell. So this is the point where you might think, let me figure out what else might be going on. So what you wanna do, fully expose the patient top to toe examination. Look at the um you know, you, this includes things like a neuro exam. Obviously, always respect the patient's dignity. Don't expose them unnecessarily. Things like you're looking for jaundice, edema, any obvious bleeding or bruising somewhere. Have they got a DVT that you might not have noticed do an abdominal exam? Have they got any fullness and tenderness? Is there any abdominal distension? Could there be any signs of abdominal bleeding? You might wanna do apr exam? They might be in severe abdominal pain? You might think, oh, could they be severely constipated? Could there be an obstruction? So you might wanna do something like APR exam um to see if there's any like impaction, if there's any, like if it's just completely empty. Yeah. So it's really important to do a bit of everything. Ok. And then you wanna do a full reassessment, you wanna go back through everything, has anything changed? And is there anything else that I need to intervene in? And you also wanna do your handover and we do this in the way, which a lot of you may have heard already. It's an sbar and what does an sbar stand for the situation, the background, the assessment and the recommendation? So basically what is going on, what is relevant to the patient that might have caused this to happen and from what you've your assessment, what is your assessment of the patient? How are they, what's going on and what do you think is happening? And what do you think you need to do? And why are you calling this person to tell them that they need to come and review this patient? Ok. So we've got an example here and I'm not gonna read through all of it, but essentially something you might say is so hi, my name is Harish Barber. I'm a junior doctor and always you wanna confirm who you're talking to? So you're saying, ok, I'm talking to the medical registrar. So you're gonna tell them, I've got this 64 year old who's come in with chest pain. Um and they've just had a POSTOP for a hem um hemiarthroplasty three days ago and I'm suspecting that they might have a pulmonary embolism and on, on assessment, their airway was patent, they were um breathing quite fast. Their saturations were 93%. Um I gave them some oxygen, their circulation was er fine. However, they were quite tachycardic and their E CG showed sinus tachycardia otherwise they were completely, their glucose and eyes were normal and they were alert and II could see a erythematous, er, calf, um, on their, on their left calf. I think that they have a pulmonary embolism. And I'd like to, um, you know, get a C TPA and I'd like to, um, start some analgesia and anticoagulant, uh, potential treatment. Can you please come and review this patient, um, as soon as possible? And that's a good way. So it took me about 30 seconds and I've told the, the person I'm talking to exactly what they need to know. Ok. So some tips I always say the most important thing with an sbar is and the person you're talking to wants to know why do I need to prioritize your patient first? Ok. So something which you should always do is say I have a patient with suspected whatever you think your diagnosis is, you can say hi. I have a 63 year old patient with suspected sepsis, ea CSD K, whatever it might be. If you tell them that straight away, their alarm bells will be ringing and be like, ok, I need to come see this patient straight away if you start with saying, oh, I have a patient with chest pain um or I have a patient who's short of breath and then you go through everything and eventually you then say, um I think they have a very like life threatening asthma, exacerbation they're gonna be like, why did you not tell me this straight away? I would have come running to you. OK. So it's really important. Tell them the problem straight away. That is your situation. OK. Then you can go through your quick summary of who the patient is. Any relevant background. I know relevant background is important because you don't wanna give them a whole history of their life. A lot of patients, especially some more elderly patients are gonna have a very extensive medical history. You can't spend long to go through all of that. It's just what's around. If they are in DK A, it's relevant that they might be a diabetic. If they um are in ATS, it's relevant that they are have, you know, hypertension and heart failure, all of these things. OK. So use your best judgment in that sense, give a quick summary of your A three assessment. What have you done? What have you given the patient? It's always important to know so that they can plan their own management and then tell a good question to ask. Is is there anything you would like me to do in the meantime? And they might suggest certain things they might say. Ok, well, go ahead and order that scan, go ahead and order that um medication, prescribe this, prescribe that. OK. And they might say, oh, make sure you check for XYZ and observe and monitor. OK. So it's really important to kind of ask the person you're talking to, what do they want you to do? Ok. And then completing your assessment, how do you go about completing your examination? Well, like we've said throughout, do a full reassessment, make sure that nothing has changed. Make sure you don't need to intervene further. Ok. Update any drug charts and fluid charts. There's a good chance that you've probably given them some medication. You've probably given them some fluids and you might not have had time to prescribe this or document this. So update those charts, make sure that everyone knows that you've given these things, document your examination, what have you done? And you know, this isn't just to so that other people know it's also to protect yourself of this is how my patient presented and this is what I found. So in the future, if something did change, they can't say, oh, you didn't notice this cos then that would be on you. So always document what have you done? What have you found? So that everyone knows that, you know, this is what the patient was like at this point in time. Contact any relevant wards. You know, if, if patient's got ct if if a patient needs to go into surgery, contact the wards, tell them that they might need a bed opening up, contact itu contact all of these people, contact the family. You know, if they are unconscious, you might need to let the family know And so all of these things are just like, they're kind of like a bit more real life things. And in an exam setting, it's important to state that you would do all of these things just to show that you have good practice as a doctor. Ok. And have it, feel free to read through this list. It's just some common acute presentations. You've probably seen a few of them in our slides already. Um And like I said, it's not really an exhaustive list. Um And our slides will be uploaded. So you'll be able to go through all of these again. But these are some common things that you might come across and you should be aware of how to manage if you came to you straight away. And then finally, just a quick summary. So what have we gone through? We've gone through the do ABCD algorithm. Always remember our structure. Look, feel, listen, measure, treat and importantly, always reassess, look out for your red flags. Always call for help when it's appropriate and use your SBAR method and do practice this with your friends and even on your family, you can just practice it. Um And it's really important, the more you do this, the more slick it gets and it just becomes second nature. So yeah. Have you guys got any questions? I know we've talked to you a lot, but please drop us a message if you've got any questions and we're happy to answer them. Um Also just drop to the feedback form in the chat. So if you could please please fill that up, that would be amazing for us. Um So that we know what to do different in the future perhaps. But yeah, any other comments from you? A Yeah, thank you. Thank you guys for joining. And hopefully this is useful for you guys and uh just let us know in the feedback if there's anything, you know, bits and pieces, which maybe we could have done better or just tell us the bits that went well, bits that we need to improving. And uh yeah, feel free to ask any questions. Um Yeah, we'll, we'll stay on for another few minutes if you guys have any questions if you. But yeah, otherwise thank you very much for joining and my name was Harish and with me, I had, yeah, my name is and we both medicals at UCO. So, yeah. Ok. Thank you very much and keep an eye out that you from teaching things. Ba I'm gonna stop broadcasting.