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Hi, everyone. Can you hear me? Some could just, is it ok if someone could pass into the chart, if they can, they can hear me. You're able to. Oh, thank you so much Charlotte. So, hi, everyone. Uh Thank you for coming on tonight and I hope vision is going well. So for the next hour and a half, this is going to be an MCP based revision revision session covering the core topics in anesthesia and critical care that you need to be examined on. And some of you might have met at their training even last week will be leading all of this. Um, before I hand you guys over to him, I just want to let you know that he'll be posting a feedback form, a QR code, um, feedback form at the end of the session and we really appreciate it. If you could fill that out. Also, the session will be recorded so you guys can come back and be watching in your own time. And so that's all for me. So you can go ahead and have, thank you very much for that. Um I think it was a bit of, there's a little bit of reverb or something. Um, yeah, thank you very much for that introduction. Um, and thanks for having me, um, and in inviting me along. So, um, my name's Matt, I'm one of the anesthetic ct threes. Um, currently based at the Royal Infirmary in Edinburgh. Um, and been asked to come along and do some, er, teaching and chat about, um, some finals revision for topics that might be relevant to anesthetics and critical care, which could come up, um, in finals. So see if I can get this to work. Yeah. So we'll start with a little plan for the evening. So I'm just going to run through, this is going to be M CQ question based because I find it's the most, the best way to touch on as many topics as possible and also give you a little bit of M CQ practice. There's going to be a few polls that are going to pop up in the chat. So please use that because it gives me an idea of what sort of lines people are thinking on and whether there's any particular, um, things that I need to try and explain more. It also gives me an idea of what sort of level the questions are aimed at. If there's spread across all answers, then it's obviously quite a difficult question. If there's one that everyone's going for, then it's obviously something that everyone knows. So I'm most of the topics that I've taken from here, I taken from question banks or from my own head, I've tried to relate them to the UK MLA content map. And so hopefully this should be quite relevant and I'll bring up some topics that we can touch on and do a little bit of quick teaching um about and run through. Um, what I'm not going to cover is OSK revision. I think it's quite difficult to do that in a um scenario like this. And the best thing to do in terms of OSK is just to run through um things in person with either your flatmates or friends or things like that and just get into the habit of doing your A three, doing your examinations, but it's quite difficult to do it right now. So I'm just going to leave that out for tonight. Um, a couple of disclaimers, as I said, a lot of the questions are from my own head really or from a question bank. So, um it's difficult to try and find the right level to pitch them at. Some are a little bit easier. Some are a little bit harder. Um Some are designed to be harder. So I know it's coming up to finals and you probably have done a lot of revision and don't be discouraged by any of these because some of them will probably be quite hard. And if they are, um, don't worry because anesthetics in critical care is a very, very small area of the curriculum that's covered. Um, and there's a little bit of overlap with some of the A&E stuff and surgical stuff as well. Um, and I've tried to pitch them at the right level, but some of them are a little bit hard and, um, I'll definitely go through things in a little bit more detail if necessary, but hopefully generate some good discussion points if there is anything that pops up, just let me know in the chat is probably the best way of answering questions as we go, I've got it up on the side. So hopefully I'll try and keep an eye on that. Um And that's probably most things to say. So we'll start, we're gonna try and get a poll going as well start with some learning objectives. So men are gonna cover some er acute or emergency conditions which present in anesthesia in critical care and try and explain some of the management. There's a lot of questions on a sa grading that come up in some question banks. So I'm just gonna touch on that very briefly. Cos it's very easy to examine. There's very set sort of um categories for things. Um, drugs and anesthesia and critical care are gonna touch on a little bit as well. And also one thing that I find is quite examinable and also useful as an fy one is doing a med R and thinking what drugs am I going to think about? In the perioperative period. And how am I going to alter that or admit or take drugs out? And what am I going to change them for? And what are the rules regarding some of those drugs? So hopefully that is useful as well. So we'll start with question one. I'm going to try and activate this poll. So if you could all, I'm gonna start pulling and uh, I'm going to answer later and hopefully that's come up in the chart. So this question, uh, a nurse on the ward asked you to attend immediately as a patient is becoming well following the administration of antibiotics is audibly wheezy and BP is unrecordable. What is the most appropriate treatment for this patient? I'm gonna give you about 30 seconds. I'm gonna start a timer. So you don't get too bogged down and, um, running out of time for these things and we don't run out of time at the end. I can see in the polls we've got a few people going for D 22 responses and I think there's how many of us are there? It's 44. OK. So we've got about 50% so far, right? That's 30 seconds. I'm gonna be tight with this timing so we can keep it to time. Um, so, uh, put it off. Now the answer is D um I am adrenaline 500 mcg. I'm going to go on to talk about this a little bit more. And do a bit of teaching on anaphylaxis. So obviously, the clinical scenario is anaphylaxis. It's a antibiotic. Um It's being administered audible wheeze from the end of the bed and hypotension, which is a cardinal feature of anaphylaxis. So a little bit about anaphylaxis itself. It's a type one hypersensitivity reaction. It's primarily ig me mediated or there, there are some non IG pathways but you don't need to get too bogged down in that ultimately, it's mediated through mast cells and degranulation, which then causes a release of all these inflammatory mediators throughout the circulatory system and then causes the clinical features that we see on the right of um particularly hypotension stridor. If we think about it in an A two E sort of scenario, you're going to have stridor and sort of airway compromise from um capillary leakage and airway swelling. From A B point of view. You're gonna have wheeze bronchospasm from all the histamine release, um and probably desaturation um from a sea point of view, you're gonna have um like you said, hypotension and tachycardia um from all of the inflammatory response that's going on. Um And you may even get a total cardiovascular collapse if it's an IV drug that's been administered and potentially even cardiac arrest, can you very quickly. So, it's important to know about the immediate management of anaphylaxis. And the most important things to be aware of, particularly on the ward would be antibiotics and then potentially latex as well. Um, are the ones that you're most likely to come in contact with. All the other stuff is stuff that we might see in theater. Um, no one's gonna be administering neuromuscular blockers. Um, and the other stuff, yeah, is primarily used in theater. So, er, there's some very useful resources that I'm gonna use for a lot of the emergency scenarios on, er, the resuscitation council and they've got some really good guidelines. So this is one of um a few that we're gonna go through. So, anaphylaxis and this is the most recent up to date version. Um It's changed in the last few years and it used to include things like hydrocortisone, chlorphenamine, um salbutamol and things like that to treat all of the symptoms of anaphylaxis. But the, the sort of main focus at the moment is on adrenaline because that is the only thing that is gonna reverse um the process. So obviously treating in an a to e manner. But the most important thing is Adra and they try and emphasize that more nowadays and in particular, if you're on a ward, um or if you don't have any experience of giving IV adrenaline, which I wouldn't expect anyone to giving intramuscular adrenaline is the mainstay of treatment. So 500 mcg is the dose that we pop down there. Another way of thinking about this sometimes um people talk about concentrations of adrenaline. So one in 1000 adrenaline is one mg in one mil. So half a mil of one in 1000 is what you would be giving. Um, if you're thinking about it in that sense, so either 500 mcg or naught 0.5 mils of one in 1000 adrenaline and IM and they've also included fluids because as we said, they're usually quite hypotensive following an anaphylactic reaction. So getting as much fluid in as possible is definitely advisable. And then beyond that, you can think about other things. So, hydrocortisone, chlorphenamine, um, salbutamol if necessary. Um I'm trying to think what else. There's probably others that I've forgotten. But, um, the main focus is on adrenaline, um, and giving that adrenaline as early as possible as quickly as possible. Ok. So that's so anaphylaxis question, we're gonna stop the poll and yeah, if there's any issues, then just post in the chat and let me know, move on to the next one. So, question two. I start the poll for this one as well. There you go. Should be good cardiac arrest. So you're on the FF one on the cardiac arrest team. You called to a cardiac arrest. The patient has had a witnessed arrest with an initial rhythm of VF. He's received one shock at 100 and 60 joules. Um And the next rhythm check, the month shows VF again, chest compressions are restarted. What is the next step in the management? So again, we'll give 30 seconds, start going through some answers. 18, so far, that's 30 seconds coming up any more any more. Right? That's 45. So we'll, we'll move on quickly. Uh ok. So this one answer is d give a shock at 200 joules. So, and a little bit more spread on that one. But uh mostly um the, so uh cardiac arrest, the most important thing in cardiac arrest is um, first of all recognizing it. So checking the pulse, if there is no pulse start compressions early, um and getting help obviously and getting the arrest trolley in because and as soon as you have that arrest trolley in the first thing you do is attach them up to the pads because one of the most important things is, well, the most important thing is identifying which side of the algorithm you're on. Are you on the shockable side or are you on the non shockable side? Because the treatment differs um a reasonable amount depending on where you are. So this patient, we go back um witnessed cardiac arrest in VF um So on the non shockable sides of the algorithm. So VF, he's had one shock and we've immediately gone back to CPR for two minutes after two minutes, you're then gonna reassess the rhythm on the monitor. Um And he's in VF again, so we're still on the shockable side and there's probably been about three minutes total. Um We would then shock again. And if you go onto the A S algorithm again from the Resuscitation Council, um You'd be advised to try a higher energy shock because um it's still a shockable rhythm. The worry is that if you've got particularly someone with a lot of soft tissue mass that you might not have delivered a shock to the heart, so increasing the amount of joules to try and achieve that, it's definitely wise um and definitely giving a shock is what we would do in that situation. I think we've also put C and E um you definitely want to do something at this point and definitely give a shock whether that's 100 and 60 or 200 joules. Um So I wouldn't recheck the rhythm in two minutes giving adrenaline potentially, but I would do that during your chest compressions, you're gonna have to stop chest compressions to give the shock, which is ultimately what this patient needs is to be shocked out of the f um adrenaline will help more in the non shockable side and you're gonna give that every 3 to 5 minutes. So you'd give a shock in this scenario, restart compressions and then think about giving you extra drugs. So adrenaline would probably after that. Um amiodarone, you'd usually go after the third shot. I think it is. Yeah, and atropine not really necessary, but no one's put that. So that's good. Um Brill, right. We'll swiftly move on and if there's any issues, just let me know in the chat and try and answer anything. Uh, question three, you're on the F I one covering stroke ward overnight, you get this polyp up. Um, you need to review a patient who's complaining of dizziness when you arrive at your heart rate of 34 and a BP of 75. Over 40. The ECG is, has shown what is the most appropriate management. Ok. So I'm going to switch to the E CG now. Hopefully we do 30 seconds there and then we'll go back and er, see you where at? So I got about 30 seconds there. I'll just go back to the question. So I can see the ANS in a few seconds. So how many ounces have you got? 13 so far? 1327 it's gone up. Ok. So answer is a atropine. Um So the ECG shows complete heart block. Um You can see there's P waves and then there's ventricular ectopics and there's absolute, there's complete dissociation between the two. So there's no connection between the atria and the ventricles. Um And the underlying rhythm here is probably around 30 I'm not going to get too bogged down on that if it's this patient who's got a heart rate of 34. So we've got a Bradycardia and um hypotension. Um And so the initial management of this is again, the resource council has some very nice guidelines and a very nice flow chart that we're going to look through So obviously assess with an A to a approach as you would with any um unwell patient. Um get IV access and get your E ECG like we've done there, treat reversible causes eg electrolyte abnormalities. You can get severe bradycardias with hyperkalaemia. So it's important to rule that out. Um if possible. So you'd get a venous blood gas or something along that lines just to rule that out, evidence of life threatening signs. And yes, there's shock here and a low BP and he's been dizzy, which indicates it's pretty thinkable and possible. He's going to be thinkable very soon. Um So atropine 500 mcg is the initial treatment of choice. Um Atropine works very, very quickly. Um It's a anticholinergic so it blocks your parasympathetic input to the heart. So you get unopposed sympathetic action on the heart. So your fight or flight response. So should give you a tachycardia and hypertension which should counteract your bradycardia and hypotension that you have. Um And again, there's you can repeat that up to six doses, definitely be getting help in this situation, putting out a medical emergency because the patient has the potential to arrest in front of you and you're giving atropine, there's a potential that they're going to need to go to a CCU at the very least for some monitoring and possibly even some pacing as well. So get help early in these scenarios and and don't leave the patient. That's all. Ok. Let's uh stop that one. Why is the answer? Not DDC cardioversion? So, um shocking this patient will not um turn their rhythm into sinus rhythm. There's a complete disconnect between the atria and the ventricles and the ventricle rate is an escape rhythm. So it's just the ventricular natural rate that is perfusing this patient. And if you had a tachycardia um such as an SVT or AF you could then shock the patient um back into sinus rhythm. But complete heart block, you can't do that. You have to speed them up um rather than slow them down and put them into a normal rhythm. So you try and speed up the heart rate with atropine, you try and speed it up with isoprenaline infusion or adrenaline um or you can transcutaneously pace, which is maybe what people are getting confused about. Transcutaneous pacing is not DC cardioversion. DC cardioversion is synchronized to the R wave of the ECG. And it's in order to shock out of an abnormal rhythm. That's usually that is a tachycardia, not a bradycardia. Transcutaneous pacing will be where you put pacing pads on the patient and you are delivering a shock um at a rate of 60 to 80 BPM to try and encourage the ventricles to contract every single time you shock them. Um So it's not a pleasant thing for the patient whatsoever, but if they are in complete asystole, it will keep them alive until someone puts a pacing wire in and then paces them uh via that route rather than through their skin, which is quite painful. Um So, transcutaneous pacing for bradycardia, not DC cardioversion, DC cardioversion sort of comes into its own in terms of tachycardias and cardiac arrest management, usually in the form of VF or VT, the shockable rhythms that you can shock. Hopefully, that answers the question right. Next one. So um I didn't think I stopped that one. I did. So. Next pole question four. That's good. Um So this is a niche area, but you can't do an anesthetic without talking about it. Um So I've included it in case this comes up 23 year old female presents for an elective la laparoscopy. She's never had surgery before, during a procedure. It's apparent that her CO2 is high and becomes really difficult to manage is also becoming progressively tachycardic and is having um arrhythmias underneath the Japs. She's found to be sweating profusely. What was the most likely diagnosis and give 30 seconds for that seems to be a favorite of the question banks. These misdiagnosis, right? 33 responses, 30 seconds. So let's um stop things there. So the answer is d malignant hyperthermia. Um Although very, very rare people seem to like to ask about this. Um It's an extremely rare complication of anesthesia. Um However, sometimes the descriptions of it don't do it justice. So hopefully he'll talk about it a little bit more. The management of this is definitely beyond finals level. So don't worry about it. I think the key is in recognition and knowing a little bit about it rather than the actual treatment if it does come up at all. So it's a progressive life threatening hyperthermic reaction occurring during general anesthesia. It's an inherited condition and it's autosomal dominance. So usually these patients will have a significant family history of problems with anesthetics and they might have even had testing themselves, which is through a muscle biopsy. So they usually know about it if there's a risk in the family. Um, it's very rare. It's important because it kills people and mortality is 4% if it's treated well. If it's not treated, it's up to sort of 70 80%. Um which is pretty devastating things which can trigger it. So, volatile anesthetic agents, the most important things which we, we do use routinely nowadays. So it's important to know that um and those are all the volatile gasses that are in sort of routine use, particularly sero flooring is probably the main one that we use nowadays. Um And succin medium is also a trigger. That's a neuromuscular blocking drug. So it's a muscle relaxant. It's going out of fashion quite a lot because there's a lot of side effects such as malignant hyperthermia or muscle spasms and bradycardias and hyperkalemia. So it's not used as much nowadays, but it's still a trigger. So it's important to know about in terms of the description of it isn't usually done too well in question, banks have found. So the most important thing is they, they go into this hypermetabolic state which then causes loads and loads of carbon dioxide generation. So you get a rise in your tidal carbon dioxide, um which is really difficult to manage. And if the patient isn't paralyzed, they'll be breathing away with high respiratory rates as well. They get increasingly tachycardic and the rise in body temperature and muscle rigidity that everyone talks about is a very late sign actually. Um but it kind of the cardinal symptoms of it. So, and this the sort of muscle rigidity and the hyperthermia which kills patients in terms of you get, you know, enzyme dysfunction, you get rhabdomyolysis and hyperkalemia, electrolyte imbalance, acute renal failure and arrhythmias. So that's why it's such an important thing to be, be aware of, but you won't see this anywhere outside of, of a theater. So whether it will come up in finals is questionable. The the treatment is with Dantrolene, which you don't need to know anything more about that. Um It's I can't even remember what type of drug it is, but it takes a long time to make up and it's really fussy. Um But that's the treatment for it. How would you differentiate between malignant hyperthermia and neuroleptic magic malignant syndrome in terms of symptoms, it's quite difficult. Um I think malignant hyperthermia is definitely more pronounced, um, neuroleptic malignant syndrome. The main thing that you would see in someone who's asleep is that their temperature was up and they'd be quite sweaty and they might be a bit rigid as well. So, but I think malignant hypothermia would be much more pronounced in terms of the cardiovascular and respiratory effects and also much more rapid in onset. Um, neuroleptic malignant syndrome is also very rare. I don't, I think I've seen it once and it's not been in theater, it's been in it and it tends to be patients who are on a lot of antipsychotic medicines. Um, and who then get extra sort of serotonin inhibitors. So they go into this sort of, it's not serotonin syndrome but it's a similar, um, sort of clinical syndrome to that. Um, but it is difficult to tell the difference between them. I think. Um, if you're in theater, I would say it's more common that it's going to be malignant hyperthermia and it's difficult not to treat that because it's so dangerous. If it's neuroleptic malignant syndrome, then you would probably still, and you're worried about malignant hyperthermia, you'd still treat them as malignant hyperthermia and then prove sigh of relief afterwards when it wasn't. Um, but, er, it's something that you don't part, it's very difficult to, you know, in a patient who's asleep in the operating theater. Um, in terms of neurotic malignant syndrome is something that's more, um, associated with chronic medicines and um an acute change in that rather than someone getting an anesthetic. Um Hopefully that's useful. Probably not a very satisfying answer. Right. Um Question five, how are we doing for time? We might have to start to ramp through these. So you're an obstetric F I one covering the labor ward overnight. You're asked to urgently review a patient who's very recently had an epidural site. She's just received a top up and stated she had loud ringing in her ears. As you arrive, she's had a seizure, she's now unconscious. She's got a strong palpable pulse. What is the appropriate management of this patient? Ok. OK. Right. That's 30 seconds. At least we'll leave it there a bit of a spread here, which is interesting. So um this is a patient who has good going history for local anesthetic toxicity. Um The treatment of that, the specific treatment is 20% lipid emulsion. Um That's the specific treatment. I think people are saying LORazepam, midazolam a bit of a spread all over the place. So, um I understand why people have put the benzos because she's had a seizure, she's no longer seizing. Um And with that history, you wouldn't be giving her more benzodiazepines. Um The reason I've chosen this scenario is this is probably one of the more common scenarios that people get local anesthetic toxicity. You don't tend to get it with injecting lidocaine directly into blood vessels which people talk about. Um We use bupivacaine and fentaNYL in epidural. So, bupivacaine is a long acting local anesthetic, which is very cardiotoxic. Um and the repeated doses that people get over time can accumulate and cause local anesthetic toxicity. The other thing with this is that um she's just had an epidural in and what might have happened is the epidural catheter is in a blood vessel and as soon as she's been given that dose, um she gets the symptoms as described. So the treatment is intralipid or 20% lipid emulsion this so local ANP toxicity is um an important thing to be aware of. Um, and as I've said, it can be either systemic absorption from er, the use in usually nerve blocks um or sort of ongoing um nerve catheters where you can sometimes get direct IV injection of local anesthetic, but that's usually mitigated by um a good technique of injecting the anesthetic. Um There's very, and we also use local anesthetics. IV um a reasonable amount of the time we use them in theater for colorectal cases. IV lidocaine, we use them in beers blocks to do regional anesthetic where we literally inject 40 mils of lidocaine through a cannula, but make sure there's a tourniquet, stopping it going into the systemic circulation. Um The things which cause local toxicity are more to do with the repeated dosing and giving too high a dose of patients who shouldn't be getting that higher dose in terms of recognizing it there are neurological and cardiovascular signs. And everyone talks about this, they start off with an excitatory stage which then progresses to a depressive stage. Cns signs usually come before cardiovascular signs. So the cardinal early warning signs are of perioral tingling and tinnitus. Um So that's why we ask everyone who we inject a local into their epidural and tell me if you get any ringing in your ears or tingling around your lips, cos it tells you very quickly whether it's in the wrong place that then progresses to seizures. So more excitatory response and then to complete unconsciousness in terms of the depressive stage of the neurological symptoms. Cardiovascular toxicity also takes a sort of similar um course. So you get excitation. So you get hypertension, tachycardia as your heart is excited and pumping harder and faster, that then progresses to myocardial depression, hypotension, massive vasodilation shock and arrhythmias. Um and it can progress to cardiac arrest as well. The treatment is to manage ABC S as you would with any unwell patient, make sure their airways open, give high flow oxygen, give fluids if necessary, start CPR if they have arrested. And the specific treatment is intralipid, which is a big bag of lipid emulsion, which works in a couple of ways, but it's probably beyond the final curriculum. But you just have to know that as a specific management for anyone who has local aesthetic toxicity, um that was probably everything I was gonna say with regards to that, don't get too bogged down with how it works or anything like that, just know that um patients become very excited and then very unwell um very quickly. Um and it can occur in any administration of local anesthetic. Um, so the administration of local anesthetic and these symptoms should raise your suspicion for local anesthetic toxicity. Um If patients are actively seizing, yes, give them some benzodiazepine and that is reasonable. Um If they've gone beyond that onto the sort of unconscious stage and giving a benzodiazepine won't stop that. You need to treat the cause. What is the dose of lipid emulsion? Don't worry about that. That is AF RCA primary question that you don't need to worry, you need to know where it might be kept, which would usually be on the arrest trolley or it would be in a specific location in a department, but you definitely don't need to know the dose unless you are doing the primary F RCA. Um can paracetamol mass hypothermia? Um potentially. Um but the important thing if you've got, uh if you've got someone who's significantly hypothermic, um paracetamol won't mask that. It'll probably mask a temperature of like 38 0, 38 1. If someone's ragingly hypothermic at 40 degrees, it's not going to stop that from happening. Um Same with sepsis. Um I think you've got someone who's really, really septic, they will be, they will have a high temperature despite their paracetamol. So definitely give it, don't worry about masking that. Um Right. Move on swiftly. So, question six, we'll start the poll. Um 23 year old male is brought a resource finger RTA. He's concerned about head, chest and lower limb injuries on arrival. He's given a painful stimulus, his eyes are closed, he's grunting and his right arm moves to the area of stimulation. What is his G CS score? Very easy question for people to examine in an M CQ scenario? Um So be aware of G CS because it's categorized and the responses are quite specific, right? A little bit re we go another few seconds. 17, so far, 20 23 26. You at 30. There you go. 30 right? Let's pause there. So bitter spread mainly between B and C. Um Both equal. The answer is C Yeah. So um we can break this down quite easily. Here is a lovely chart. So G CS um is now at 15, it's based on three responses, er eyes opening, verbal responses and a motor response um to usually a painful stimulus. Uh if someone is deeply unconscious to give you the most accurate um response. So if we go back to this chap, er painful stimulus, his eyes remain closed. So that's a one Bianca, hopefully they will be um we'll, I'll ask Kayla at the end, I can post some useful resources in the chat at the end as well. So um stay tuned for that. Um Yes, eyes closed to painful stimulus. That's a one he's grunting. So, um if he says absolutely nothing, no response. That is a one incomprehensible. Sounds like a grunt would be a two. So he's got an E one V two so far and we said that he's localized, um, he's moved his right arm to the area of stimulation. So he's localizing to pain. So it's a five. So one plus two plus five is eight if I am not mistaken. Um Yeah, very useful to revise this because it's very easy for people to put a question in an M CQ which talks about G CS because it's very specific um of what we can ask and it's just adding things up. Thanks. Thank you. Um So yes, E one V two M five. You just have to learn it unfortunately and I don't have any fun acronyms or anything like that. Um Knowing that there's four for eyes, five for response and six for motor does help. So it makes eyes a little bit easier to figure out. It's always the ones in the middle that are tricky with these, but the more that you read it and the more you do questions on it, the more you'll be able to remember it. I'm just going to quickly touch on head injuries. I've got a few CT S because it's sometimes easy for people to examine on this. Um Is it reasonable to use A two in an at E situation. It is reasonable to use AF U in an A two E situation. In a nosy scenario, they may then go on to ask you what is the G CS of this patient um given your assessment. So it's also very useful to know the GCS score um and particularly head injuries. The Glasgow coma scale was developed for patients with a head injury. So it's something that if you're ever going to speak to a neurosurgeon about, they will want to know what the GCS is um because it influences their management heavily, it also influenced the anesthetic and it management heavily as well whether we're going to intubate the patient or not. So G CS of eight or less, um we would intubate. So we need to know what the G CS is and also the neurosurgeons do like to know what the motor score is. Um So it's definitely worthwhile knowing you can use NF P see if you get away with it and don't get questioned further. Um But I would say it's also very useful to know what G CS scores are. Um On the left hand side, we've got subdural hemorrhage. Um And you can tell that it's usually um this sort of I've written the words down um it's not convex, this is convex, no convexity. Yeah, this is convexity. I might have to double check that I've not got my notes in front of me. Um usually shallow subdurals from tearing of bridging veins in young people. It's usually due to high energy trauma in old people. It can be due to very innocuous injuries. So it's always useful to think about subdurals in elderly people who've had a fall and are confused because they might even the smallest knock can cause tearing of these bridging veins on here, which may cause a subdural in the middle. You've got an extradural hemorrhage. Um This lentiform or biconcave, sometimes they might give you the um the description and not the picture, which is quite annoying, but that's how they would describe it. Uh Extradural is definitely the most um important of the intracranial bleeds in terms of management, they will neurosurgeons will decompress this as soon as possible because it's usually from a meningeal artery tear which will not stop bleeding. Um unless it's under a massive amount of pressure in which case your brain is also under a massive amount of pressure. Um So this is a neurosurgical emergency. Um They will want to do something about this very quickly subdurals. If it's causing mass effect, they all want to do something about that as well. And if it's causing someone's gcs to be um less than eight and they needed intubated, they'll definitely want to do something about it. Um On the right hand side is subarachnoid hemorrhage, you can get traumatic subarachnoid hemorrhages as well as nontraumatic subarachnoid hemorrhages. The traumatic ones are slightly better in outlook. It's usually from bleeding in the intraparenchymal space adjacent to the subarachnoid space. And you can tell there's a subarachnoid because you get these blood in the so and the basal cisterns as well. Um These are not usually surgically managed. Um, unless, you know, I don't not usually surgically managed, so just leave it there. Um Otherwise I get bogged down in neurosurgery, which is not what I hear about. Um So yes. So ct scans to know about that next question, we stopped that one. Yeah, so 45 year old males brought to A&E having been found on the street, unresponsive on arrival as airways maintained with the jaw frost and an oropharyngeal airways respiratory eight and he's got sets of 98% on non re masks, cardiovascularly. OK. G CS is three with pinpoint pupils and he's a little bit cold. He receives three, lots of 400 mics of naloxone whereas G CS remains three. What is the most appropriate next step in managing this patient? I 30 seconds. Let me get on 20 responses. So far. 21 28 we'll probably leave it there. So majority have answered B the answer is B so this is a patient who's probably taking a mixed overdose um of opiates and who knows whatever else. Also, it's quite important that he's been found on the street unresponsive. So we don't know whether he's actually had a big head injury as well, which is causing this. He's had a good amount of naloxone and that is a lot three syringes worth. So, giving more I don't think is going to change the situation for this patient. Um, flumazenil will reverse um benzodiazepine overdose, but it's not recommended to give it in acute overdoses like this can precipitate seizures. Sodium bicarbonate is reserved for um cardiotoxic medications, particularly amitriptyline overdoses. Um It's not going to change anything here. Um You wouldn't insert in nasopharyngeal airway cos again, there's a risk that he could have had a head injury and he's already got an airway with a oropharyngeal and tolerating it well, and yes, further dose, noone is not going to change anything. So, rapid sequence induction um is the key. So a little bit about airway management. This is your sort of hierarchy with, we ignore tracheostomy of airway management. So, in terms of things that you can do head tilt, chin lift is your initial simple maneuver. If that doesn't work, giving someone a jaw thrust or if you've got concerns about the c spine, give them a jaw thrust. OK. Um If they are still unconscious or not very responsive, using a nasopharyngeal can be useful that comes with some caveats though. Um sizing them, you have to go from the tip of the nose to the corner of the ear. Um I think usually is a seven or an 86 or seven. OK. I've not got my notes in front of me and we don't use these very often in um anesthetics. So I'm not too familiar with them contraindications, basal skull fractures, nasal fractures, you don't want to stick one of these in if there's any risk of that caution as well, if patients are coagulopathic, because even though it might fit very well, nasal mucosa is very friable. And if you put it in, in someone who's chic and you get a big nose bleed, someone who's unconscious, you're going to get them aspirating. It's not a good scenario to be in. Um So yes, avoid in those situations or airways or GDS sizing from coronary mouth to the tragus or to the mandible or the incisors to the mandible. Um very useful. The problem is will a patient tolerate it if they're tolerating it, it's usually not a good sign, they're deeply unconscious and they don't have a gag reflex. So, but sticking one in will definitely help your airway. Um Next step, supraglottic airways. So I've got an LMA here, which is sort of the old style of sgot airways, which are being superseded by eye gels here. Um These are both the larynx, they're very good at getting soft tissue out of the way. They're very good if you can get one to sit nicely at being able to ventilate someone through them, what their drawback is is that they don't protect against aspiration in terms of gastric contents coming up, they do not, they do form a little bit of a seal but not good enough to stop potential aspiration. So the only way to be sure that someone's not going to aspirate is to put an endotracheal tube down which in the bottom line, um rapid sequence induction. Some people get confused by that. All that means is that we're going to put a tube in as quickly as possible as soon as the patient is asleep, to minimize the risk of them aspirating some stomach contents. So you use fast acting drugs to get them off to sleep and get them paralyzed as quickly as possible and get a tube in as quickly as possible. And it's the mainstay of um intubating someone in the emergency scenario. Um Yeah, that's all there is to say about that. I think tracheostomy have included there because it's there is a way of managing an airway. It's a very advanced way of managing an airway. You'll see it in itu on patients who have been in itu for at least a week who are trying to wean from a ventilator. Um You may also see it in patients who have head and neck cancers or go cancers who come in acutely stridulous. They might get taken straight to the theater and the ent surgeons doing awake tracheostomy, which sounds really horrendous, but they put lots and lots of local in, they're doing a tracheostomy. And then as soon as that's in, put them to sleep and then take them to ITU afterwards. Um So those are the main places that you'll see tracking. You won't see it really outside of an itu most of the time. Right? Question number eight. Start pulling. Um So 35 year old male brought to A&E swallowing a fall from height. He's conscious, he's talking in full sentences. His breath sounds are normal throughout. He's got good sats on 4 L and ari rate of 20. He's peripherally warm and he's got a normal cap refill. However, he's bradycardic and hypotensive. He's got normal heart sounds. His abdomen is soft and nontender. He's got a bit of bruising on his right flank and chest wall. His gcs 15, I'm talking to you, but he's unable to move his legs. He's got marked deformity of both ankles. What's the most likely cause of his low BP? And we're doing one so far 17. So far, I'm getting a few more responses and then a femur. Yeah. OK. 31. So stop, stop that. Right. So the majority have gone for ea couple for D maybe one or two for C. So the answer is e neurogenic shock. So there's a question about different forms of shock and how they are going to manifest. So it's a very boring slide with a lot of definitions on here, but it's useful to at least know how these things may present. So shock is essentially inadequate. End organ perfusion where mitochondria aren't able to utilize oxygen. So you get tissue hypoxia, you get lactic acidosis and you get end organ dysfunction. Ok. And there's various causes of this. Um The main ones that I mentioned there will run pretty quickly. So, septic shock is, as I've said, inadequate end organ perfusion in the setting of acute infection. And that's usually manifested through a systemic phase of dilatation. So they get warm peripherally. Um and they have good pulses, but because they're so vasodilated, um they can't maintain their BP because it's all pooling in the venous system. Um you also get capillary dysfunction. So you get this third spacing effect that everyone talks about, but no one really understands. So you get leaky capillaries, you get um tissue edema, which makes them even more intravascular deplete. And hypotensive anaphylactic shock is a very similar syndrome where you get similar um issues with a phase of dilation. So they might be peripherally warm and have good pulses, but they might have a terrible BP. Um and they might be a bit um leaky as well in terms of their capillaries, but that's in the setting of a allergic trigger. Um Cardiogenic shock is something that you may or may not have come across and essentially it's reduced cardiac output. So, hypertension hypotension and they may be tachycardic, they may be bradycardic, but it's due to a cardiac pathology. So, either acute Steny is the most common whereby the heart is not pumping adequately enough to be able to generate a pressure or severe cardiac failure again, where the heart's contraction is so um limited that you cannot get blood, leaving that heart to be able to generate a BP. So then you don't get perfusion to the er peripheral tissues because of that. Um so the cause of that is usually an acute um cardiac event, neurogenic shock, which we're talking about here is inadequate perfusion in the context of a central cause. So usually it's due to a spinal pathology, a high spinal injury, at least at the level of thoracic level, didn't, did I put there um unable to move his legs. So usually you get sympathetic input from your thoracic spine which innervates your heart. So that's again your fight or flight response, it's in your thoracic part of your spine. So if you get a high spinal injury, like a cervical injury up here or even a high thoracic injury, you knock out all of the sympathetic response. So you get unopposed parasympathetic. So you get bradycardia hypotension because there isn't the innervation from the spine, telling the heart to speed up and go faster essentially. And this patient has clearly got a spinal injury. He's fallen from a height, he's got no um sensation. I haven't put anything about sensation actually, but he's unable to move his legs. And so he's obviously got motor um weakness. So we will have a sensory level as well, which I'd imagine would be at the thoracic sort of level. And you get a bradycardia and hypotension from that type of injury in the acute setting. Hypovolemic shock is always worth noting in cases of trauma because bleeding is very, very common in traumatic injuries. However, the thing which points away from this is the fact that he's peripherally warm with a good cap refill. So he's intravascularly um well filled. Um he's not deplete in any respect. If he was, he might be cold peripherally, he might have a prolonged cap refill time. However, here he is not the hypotension and bradycardia is purely down to the fact that he has no sympathetic innervation from the spine which has been injured. Yeah, hypervolemic shock is essentially usually due to bleeding or severe dehydration. Um So it's a quick run through of shock onto a little bit of management of specific, one specific type of shock, the one that we see most commonly. Um So Paul again, question nine. So a 64 year old lady is brought into A&E with suspected urosepsis. She's tachycardic and hypotensive with a lactate of five and her urine output is 10 mils per hour. She has her sepsis, six done. So, blood cultures are taken. She is given a lot of fluid and she started on antibiotics. Um following the above her heart rate is slightly better, but she still remains hypotensive. Her lactate has come down and her urine output remains the same. What's the most appropriate next step in management? Six so far? 13. Ok. 25. 27. See, when we hit 30 I'll stop, stop falling 28. Right in the interest of time will stop and move on. So most people have gone free, which is the correct answer. So, start or dre infusion, this is something that I wouldn't expect anyone to do as an F I one, but it's worth being aware of what actually happens to these patients after you've filled them up with fluids. And what if you're going to speak to an ITU registrar on the phone as an F I one? Ah, what are they actually going to do to the patient? And what do they want to know? So, um she's had adequate amounts of fluid resuscitation. Um, however, remains hypotensive. A couple of people have said uh extra fluid, extra fluid's not gonna help. In this case. I think all you're gonna do is put her at risk of pulmonary edema. Um, the lactate has come down. Um, but the BP is still low and that is due to vasodilation rather, rather than um intravascular depletion. A couple of people have said has, has, is an option. It's some people, there's a big debate still about whether HA is useful or not. The only evidence to say why HA is useful is in patients with chronic liver disease or who've had a recent liver transplant. Um As soon as they come back from theater, it's not validated for any of the patients. Um at all. So don't go down that route unless it's a specific liver patient. Um intubating them won't help their BP, it will make them worse actually. So we wouldn't be doing that unless there was other reasons such as they were extremely hypoxic or unconscious. Um They've had some antibiotics. So, noradrenaline is the drug of choice, particularly for septic shock. Some resources, the surviving sepsis campaign is the main place of resources in terms of managing sepsis. And noradrenaline is the first line vasopressor infusion. You need an arterial line to start. So invasive arterial monitoring, you also need a central line to be able to deliver it. Um So these patients will come up to RT U, they'll get an arterial line, a central line in the start and it's not something that you'd be expected to initiate as an I one, but you certainly should be aware of that. It's the first line treatment for septic shock. And OK, next question. This is a difficult question. OK. Don't get discouraged by it. It is difficult. I'm sorry for putting this in, but it gives us something extra to talk about in terms of asthma. Uh Did I just start that? Yeah, it's going up now, right? Um 26 year old female presents to A&E with shortness of breath background of asthma takes a steroid inhaler and a salbutamol reliever. She appears in distress. She's got a respiratory rate of 35 and she's hypoxic. Her peak flow is 30% predicted she receives oxygen, salbutamol ium steroids, magnesium sulfate, all with minimal effect. What is the mechanism of action of the drug used in the next stage of treatment? 834. So this is, it's a difficult question. It's I'm ask you wanting to know what the sort of 3rd, 4th line treatment of acute asthma risk and then tell me how that drug works right? At responses so far, need a few more, a little bit of it spread but not, not too uh 24. OK. So most 58% for d 20% for a eight and eight for B and C 3% for a stop today. Yeah. So the answer is d so difficult question but reasonable amount of people are, right? So that's encouraging um acute asthma. The treatment next step, staging treatment is um IV Aminophylline Aminophylline, which is a phosphodiesterase inhibitor. You might just need to know that and nothing else. Um But this is something that they might start an A&E but certainly if we went down, we'd be starting this and doing it in itu. Um So a quick run through acute asthma because it's, it's a core topic in respiratory A&E itu it crops up everywhere and you'll get asked on the chronic management. Theophylline Aminophylline Aminophylline is the drug. Um it's the same class as theophylline. Um Some places might use theophylline. I don't know. But Aminophylline is certainly the one that I've, I've used, you give a bolus and then you give an infusion after that. Don't ask me about the dosing of that because it's usually worked out on body weight rather than you need a calculator. So it's patient specific, but Aminophylline does get broken down to theophylline, I think in the blood. So it's sort of a pro drug. Um No, so asthma initial assessment um as you would with any unwell patient, the key things for asthma are peak flow. So less than 33% is life threatening or near fatal asthma. Um So 30% is a life threaten. Um acute asthmatic attack. ABG S are also very useful, which I haven't put down there, particularly the um CO2. So a low CO2 is what you would expect a normal or high CO2 is a bad sign in an asthmatic. Um and we should pro I review um start with nebulized treatments. So, salbutamol ipratropium if it's a severe or life threatening attack, steroids, um talk about prednisoLONE, 40 to 50 mgs or IV hydrocortisone is an alternative if someone's very unwell, not able to swallow. IV magnesium is the next step. So 2 g usually as a bolus over 1520 minutes. And then beyond that, definitely, if someone's getting magnesium, they usually call itu to come and have a look at them because these patients can go off really quickly. And so you need to be involved. Aminophylline is then given as an infusion. We can also use um IV salbutamol as well on top of the nebulizers, which is a beta two agonist. Um and then adrenaline if things are really going badly, um because you get that bronchodilating effect from the beta two agonism from adrenaline as well. Um, last resort is intubating these patients. These are the one type of patients that you don't want to intubate because it makes them worse rather than better. Um So we do absolutely everything to avoid that. Um Unless they have a respiratory arrest or a cardiac arrest, in which case, they will be intubated, but otherwise you try and stay away from it as much as you can. Um There's some good guidelines on nice that I've put at the end to go through your acute asthma management and it's definitely one that can present in a osk scenario for acutely unwell patients. So it's worth knowing the treatments really well, getting to grips with the drug doses as well, particularly the nebulizers and the steroids and then being aware of when to call for itu help also good stuff, right. We're running a bit by in time. So you might have to try and pick up, but we'll see. Uh next one question 11. So some pain. Um 57 year old female just returned to high dependence, unity unit following arthrotomy for a perforated appendix. We asked to review because she's very sore background includes alcoholic liver disease, hypertension type one, diabetes, CKD five and peripheral neuropathy. Which of the following drugs should we avoid in this patient? In terms of their analgesia. Quite a lot of information there. 15 responses, 19 22 looking good. All right, I'm gonna stop the pulp. So most people have gone for D which is the correct answer. So the most important thing here is that she's got KD five significant renal impairment. So giving her morphine cause it to accumulate um and become opioid toxic. A couple of people have said a if she's just got alcoholic liver disease and not cirrhosis or she's not acutely decompensated, paracetamol is still very safe. The main thing you have to watch out for is the weight. Um In that case, if they are just got a bit of alcoholic liver disease, then it's fine to use paracetamol. Um fentaNYL is a good drug in this scenario because it's not really excreted. Um And it has quite a short half life. So it's quite Turri a kine we can use as well. Um It's not impacted by the renal function so we can use that. But morphine is the key. Um It's the breakdown products of morphine which are not um which are excreted greenly, which you have to be careful of like question 12. Um Stop that. Yeah. So moving on quickly, 84 year old ladies day one following a right hemicolectomy for colorectal carcinoma. And it was very challenging, surgically, multiple adhesions from previous operation. She's on paracetamol and oxyCODONE PCA with a 1 mg bolus. She's been very sore overnight in her lower abdomen. It's got a respiratory rate of nine and she's drowsy but Rous. Well, but she's still in severe pain. She's been using 6 mg of oxyCODONE per hour. What's the most appropriate next step in management? Ok. Yeah, they split so far. See. Mm, big split all over the place. Interesting. That's 2019. So far a few more. And we'll stop. Interesting. Interesting there. He's at 24 any more. I stop in there. Ok? You're gonna stop polling now. So, right. Bit of spread 28% for a 26% for a 23% for d 34% for e the answer is e OK. This is, um, more of a teaching note, ah, which is an important aspect of pain and pain management. So, the lady has had a difficult surgical procedure. So she's at risk of surgical complications. She's on a pretty good analgesic regimen already, paracetamol and oxyCODONE, um, with a 1 mg bolus for an 84 year old, um, will be working very well and you'd be cautiously going up on that, very, very cautiously. She's already a bit opiate toxic. You can see from her respiratory rate being nine and a bit drowsy, but she's still very sore. Uh, and she's using a reasonable amount of oxyCODONE. So she's getting what a milligram every 10 minutes giving this lady 400 MS of naloxone will make her extremely sort of 400 mg is a big dose of naloxone. You should really, if you're worried about someone who's um, on opiates and is opiate toxic, you should give it in small increments of 40 to 80 um MS at a time because you completely wipe out all existing opiate attached to her opiate receptors by going forward from M IV. So she'll be extremely sore if you give that to someone and she's not at a point where she needs sno. So she's a bit drowsy with a borderline low restriction. Ok. Um increasing the oxyCODONE dose. I think most people thought it was not a good idea because she's already a bit on that borderline. Starting a background infusion as well. Isn't gonna do anything extra analgesics or potential. Um Ketamine is an option but also comes with plenty of rest in an 84 year old lady. Um particularly the, the sort of C NS side effects of hallucinations and delirium. Um What we would probably try and do is change her opiate first and see whether that made anything better. The most important thing is this lady is very sore after a surgical procedure which was difficult. Um You have to be sure before you start to load her up with analgesia that's going to mask any um, signs and symptoms that she does not have a surgical problem for which she needs to go back to theater. Um because she could definitely have something as previous adhesions. It was a difficult operation and the surgeons would have been uptight about that after they'd finished. You need to discuss it with her surgical wrench, um who needs to examine them and decide whether they need to get any imaging or not and do that before speaking to someone about increasing their algesia to sort of mask the underlying problem in a way. So uh the same goes for things like compartment syndrome. So, tibial plateau fractures, tibial fractures who have had a fixation in theater who go back to an orthopedic ward and then are really, really sore. They need to be seen by an orthopedic surgeon because they're at high risk of compartment syndrome. And if they were, if you miss that, they're going to need an amputation, don't just load them up with painkillers. Um you need to be seen by a surgeon to rule out a surgical pathology. So that's my teaching point for this one is um don't give massive doses of naloxone, give it slowly in small increments. Um And to make sure you if there is a potential surgical problem, speak to the people who are going to solve that rather than us who are just going to mask it So that's that a little bit about pain management, which I'm sure you'll be well versed on. This is the wh O pain ladder, which you can read in your own time afterwards. But essentially start with things which are low risk but, but can do um, but can work well, be cautious with nonsteroidals, particularly in elderly patients, particularly in anyone with renal disease because it can cause renal dysfunction, especially in the acute period. Young people who are fit and well. Um, and don't have any intolerances to nonsteroidals like asthma or peptic ulcer disease. Nonsteroids are a very good option but avoid them in older people and people with renal disease, weak opioids, anyone who's having surgery should usually have a weak opioid while they're in hospital. Um Usually dihydrocodeine is the sort of mainstay. Um If people are requiring more than that, think about Oramorph as the next step or if they can't have or oxyCODONE ir or things like fentaNYL patches. If they, if they've got no kidneys whatsoever, fentaNYL patches are really good option or if they are very old as well. OxyCODONE, morphine can be quite Delio um in the assessment, the patient presents with opioid overdose. How do we give naloxone? I would say you'd get 400 mcg in 10 mils and you'd give a meal at a time and observe the response and it's, it's going to work very quickly. Um If someone is totally uh if they've come in from A&E and they're totally asleep. Um, and they've had an overdose of opioids and you can give her 400 straight away. Um, the GC S3, like the chapel has been about before. Give him 400 if you're in the surgical ward and someone's had surgery and they're on opioids, give it slowly and assess it regularly because they will wake up, but they will be very sore. Um, so, yes, that's my advice. Um Yeah, so like Oramorph oxyCODONE immediate release, fentaNYL patches are options and then if they're still so beyond that, you can think about using IV preparations or um subcu preparations if nurses are happy with that. Um So for example, if someone's got a IV, they're not going to be absorbing anything. Um And subcu analgesia is good for that. You don't need a cannula and they can do it that way. Morphine. I don't know if you can give oxyCODONE that way or fentaNYL patches as well. So, a little bit on pain won't get too involved at it. All right. So next question, 13, 65 year old lady is scheduled for an elective umbilical hernia repair. She's got a past history of CO PD um hypertension and osteoarthritis. She takes Lisinopril paracetamol, topical Ibuprofen, a daily trim inhaler. She got no allergies. She does not need any mobility. A however, she struggles to walk more than 100 yards without getting short of breath. Her daughter is very helpful and does all of her shopping. What is her A SA score? So, a SA score is quite easy to examine because you're quite well categorized. There is some discrepancy in people's scoring of a SA score just because of the fact that it is borne out of um America and it was used to essentially work out how much anesthetists were going to get paid and you get paid more for a higher A SA score. So it can be subjective, but there are some good categories to try and get people into 17. So far a little bit longer. 18, 21 in the interest of time, we're gonna stop the pole and we'll move on. OK. Majority have gone for C and I would agree with you that A SA three for this lady. So, um the keys of this question are that and she has COPD and hypertension, which would automatically get you to any medical condition. If they smoke at all. If they're a heavy drinker, they get her to, if someone's fit and well, nonsmoker, no alcohol, you get one, it's very difficult to get one. patients with significant smoking history will score two. It's difficult to give someone one. Not sure I'd be a one. She's got CO PD. The, the key between differentiating between two and three is the functional status of the patient. So someone might have mild COPD, but it doesn't limit them in any of their daily activities. They take their inhalers, they go out, they do the shopping, they're not bothered by it really apart from a bit of shortness of breath, if they're climbing a hill. Um, this lady has got significant functional limitation from her CO PD. She can't walk more than 100 yards without getting short of breath. Therefore, she is a three rather than a two. there was a quick schematic to show you so asa one normal healthy, no problems whatsoever. AA two, you have mild systemic disease. So well controlled asthma, smoking, well controlled hypertension, well controlled diabetes, people who have these conditions but are living essentially a normal life. A SA three is when you start to get um functional limitations from these or significant histories of um systemic diseases. So having had a big heart attack, having had a big stroke, having badly controlled diabetes, having badly controlled hypertension, having end stage renal failure on dialysis. And these are all tip you into a three into a fall is people who you really don't want to go anywhere near in terms of anesthetizing them. So people who have had a very recent heart attack, a very recent stroke who are having a heart attack. And as you speak to them or they've got really bad valve disease, particularly aortic stenosis is one that we really worry about anesthetizing because of the effects of the stenotic valve and the effect of anesthesia on the hemodynamics. And it's also a big perioperative risk for morbidity and mortality, severe aortic stenosis. So, um patients with severe osteo stenosis are worth knowing about. And then a SA five is basically people who aren't going to live unless they have this operation, which is usually referred to usually reserved for rup to AAA S intracranial bleeds, um sepsis due to abdominal um pathology in the face of multimorbidity or um massive physiological derangement therapy and very well patients right, moving on this builds on the last one. so just gonna pull going. So this perioperative investigations, uh 50 year old seven year old man presents for an elective, right? Hemicolectomy. So, major surgery, um, he's got mild asthma which is well controlled, no previous hospital admissions and no other past medical history. What's the most appropriate investigations to order this chat? If it comes to pre assessment clinic, there's some really good, nice guidelines on this which if this is something that you feel you aren't too strong on to read up on, it is difficult to get it into your head. I find you just reading tables and learning things for the sake of it, but it can crop up every now and again. Um, only in this M CQ scenario, I wouldn't expect it to be an OS scenario. But unless you're doing preoperative assessments, which I have heard might be the case in some places. And 20 so far, I noticed that we're now at eight o'clock. So we're significantly. Like I'll keep going until either tells me to stop. Uh, right. 25 responses. Ok. Good split. Very good split. Interesting. Interesting. Indeed. We stop there. So, a gentleman who's a SA two, he's got a bit of asthma but it's very well controlled. He's having major surgery. Ok. The anus c and I can see why people have gone further down. Um, but I'll try and justify myself and use some guidelines to justify myself. So it's not just my opinion. Um, so he's relatively fit and well, he's in A SA too. And the things with these preoperative investigations are all divided by the complexity of surgery and the A SA grade. So he kind of has to know a bit about both. So this is just a snippet from this nice guideline that I was just talking about. This is for major or complex surgery. So the most complex that you can get, it's either minor, intermediate or major. Um, and these are the tests that you may get preoperatively. This isn't including group and saves things like that. That's a separate entity that I'm actually not going to cover today. Um, so a SA two trap, major surgery, he's got asthma which is well controlled, full will count. Yes, because there's a potential for blood loss hemostasis not routinely. He's not very any reason to have deranged clotting factors and he's not at risk with a hemicolectomy of having massive massive amounts of blood loss which are going to um, cause him to be um coagulopathic. In which case, you would test intraoperatively rather than um preoperatively, he may get a spinal, which is maybe why people have thought about this. But if he's got good platelets and he's got no other reasons to have er, l um coagulation abnormalities dot Don't need um, a coag renal function. Yes, he's having major abdominal surgery with big fluid shifts. So at risk of an AK I ECG as well. Yes, he's having major abdominal surgery which can precipitate cardiac events postoperatively. So, a routine ECG to make sure he doesn't have any cardiac comorbidities or even as a baseline is recommended for these patients. Lung function, arterial blood gas, chest X rays are not routinely required. Um, unless you have patients who are significantly affected by their respiratory disease. Like the lady before, if she was going for um, a big colorectal operation, a SA three can't walk more than 100 yards. You might consider getting P FT S for her, maybe a blood gas and probably a chest X ray. But for this 57 year old gentleman who's just got well controlled asthma, he does not need a chest X ray. Um, so that is the justification for sea here. The guidelines I've got at the end, I'll try and post them in the chart as well to look at it is pretty dry stuff. Unfortunately. Um, but these things can prop up in terms of what medications you might ask for. You probably won't get penalized in an osk scenario for saying that you would want coag as well. You probably won't get penalized for saying you might consider getting a chest X ray. Um That's because I don't see mention. So if you feel like you'd want them, then say them in an osk scenario, you won't get negatively marked for that. Ok? But in an M CQ like this, we're asking specific ones which are related to guidelines. Um, this is the correct answer. Ok. Just cos I don't see it mentions is M RSA swabs routine for anything. I'm pretty sure everyone who gets admitted to hospital gets M RSA swabs. Um Nowadays, elective emergency, everyone gets them just because of the risk of mainly for placement and infection control. More than anything. I might be a bit cynical with that. But I guess if you're carrying MRSA as well and you develop a wound infection, it changes the antibiotic management. But pretty much everyone who steps foot in the hospital gets MRSA shots. Yeah. Right. Are we up to 15? Right. So, um, more preoperative assessment. 62 year old male presents for his electrical cystectomy. He's got a past history of hypertension, which of his normal medicines should be avoided on the morning of surgery. This is the first of a series of questions on perioperative medicine management. The most important ones I think. Well, the most ones are likely to come up. So you're 18 so far, getting a little bit longer, reasonable spread. Ok. So 24 we'll pause there, see where we're at. 25. So majority have gone for B uh, which is the correct answer. So, Losartan, um angiotensin receptor blocker, uh bisoprolol beta blocker, amLODIPine calcium channel blocker, doxazosin, er alpha blocker and a 10 or another beta blocker. Um, Losartan, uh angiotensin receptor blockers and angiotensin ace inhibitors are uh need to be stopped on the day of surgery. Um They can cause hypotension, but more importantly, they can cause a higher risk of AKI due to the effects on the renal intrinsic um blood flow and the hemodynamic effects of that. Um All the others can put you at risk of hypotension. However, they also have protective effects. So you don't want to avoid that. And particularly beta blockers in patients with cardiac past medical histories, beta blockers are very important. Um If someone is hypotensive on the ward following their surgery, by all means stop the beta blocker. Ok. If someone is normotensive or they're coming in for surgery, give the beta blocker, it's cardioprotective, it helps to prevent postoperative cardiac events and postoperative MS. So beta blockers strongly recommend giving them amLODIPine is pretty innocuous, innocuous as well. So definitely give that if the BP is fine. Doxazosin is maybe a bit more potent. Um but for an elective day case patient, you would still give them a doxazosin, which is what this cholecystectomy would be. It would be a day case. So you would go home the same day. So he would get his normal medicines, Ace inhibitors. Arbs, stop them for surgery. Restart them either if they're staying in post surgery when the risk of AKI has gone away. So usually if someone's had a big operation that will be after at least two or three days, if it's active, sort of about colorectal, um, give it a couple of days, maybe three days, depending on what's happening with the patient. And if it's an emergency, they shouldn't be on it anyway because of the risk of AKI. Um, so yes, ace inhibitors, ARB S don't give them everything else in this list. It's fine. Right. Diabetic medicines are tricky, tricky, um, topic because there's so many of them even I have to look this up. It's tricky, but it's very easy for people to ask questions on them, especially in this scenario. So 56 year old male admitted to a surgical ward the day before, which is a bit odd, but we'll go with it. He has a background of type two diabetes and hypertension. He's on Metformin, Glucozide Ri atorvastatin. On the morning of his surgery, the nurse asks you whether they should give his morning dose of bide. He's first on the list at 9 a.m. And what's the appropriate response? Yeah, few responses so far. Four, this is from a popular question bank. So people might have seen it before. We'll just go all the way to and see. Yeah. Thank you, Carla. It's very useful. Um, right. How is that? 26? We will stop there. So majority have gone with C a few for D and a couple for A and B. The answer is C, so here we begin. Um, I weigh into all of the diabetic drugs and what to do with them around surgery, which is, is difficult and it's a big um, topic. Thankfully, there's this nice little table which summarizes things really well, which is taken from, I think it's the Center for Perioperative Perioperative Medicine Management. But I've got the link at the end. Um, for anyone who wants to read it essentially boils down to this. There is also a really nice table for insulin and what to do with those as well. Um, which is nowhere near as straightforward as this. So I've not ventured into that. Um So most common drugs that people are on, um, for type two diabetic type two diabetes and Metformin and uh the sulfonylureas. OK. You do start, I'm starting to see more people on these SGL T two inhibitors so they may crop up. Um And these ones are sort of hanging around as well. Maybe pioglitazone. These two, I don't see very often at all. A carbosin nin um Metformin essentially is you take it normally unless you're taking it three times a day, which is a massive amount. Um, I can't remember seeing anyone taking Metformin three times a day. So, if they're taking it twice a day or once a day, they take it as normal. Ok. That's totally fine sulfurea. The key with these is that they, there is a risk of hypoglycemia. There isn't much of a risk of hypoglycemia with Metformin, but with these ones, there is a risk of hyperglycemia and hypoglycemia under anesthesia is not a good combination. Um, so if people are taking them once a day, just, um, don't give it them, uh, don't give it on the morning of surgery if they're taking it twice a day and they're gonna be eating in the afternoon like a day case, um, operation, then you don't give it to them in the morning, but you do give it to them in the afternoon. Um, and if they're in the, only if their surgery is in the morning, if the surgery is afternoon, just don't give it them at all because if you give them the morning dose and it comes to the afternoon, they've not eaten anything the whole day and they've got a drug which is going to drop their blood sugar levels and then don't want to have an operation with that on board. That's the key to thinking through this is, is it gonna drop the blood sugar? Um, and are they going to be asleep when that's a risk. Next ones, these SGL T two inhibitors, the flosin just don't give them, um, at all. The main risk with these is euglycemic, euglycemic ketoacidosis, which is worsened by starvation. So what we do to everyone who comes for an operation don't give them anything to eat. So this puts them at risk of getting this ketoacidosis and then all the rest of them. Uh, these are so rare, essentially don't give them if they're not eating. Um, these ones are all normal. The key ones are this one because it's gonna drop your um blood sugar and these two, but they're very rare and this one because it's gonna give you um e glycemic ketoacidosis. So again, it's another table that summarizes everything really nicely, but unfortunately, you just have to learn it. Um There's no way around it, I'm afraid, but at least this is, this is nice. I like this right. Last um medicine management. So, antiplatelets and anticoagulants which always causes um confusion and I'm not sure I've been able to delineate it much here because um, there's various guidelines which say various different things, but hopefully, if I give you some general rules, then that will help. Um, so which of the following is false with regards to stopping anticoagulant medicines, preoperatively for elective abdominal surgery, which is a low risk for bleeding. So a hernia repair. Um, all that. Um ok. And see you got various drugs there, antiplatelets, um, and anticoagulants as well, and this is for elective stuff. So, emergency stuff is usually guided by the anesthetists or the surgeons because there's things that the surgeons don't want people to be on because it puts their risk of causing bleeding higher. There's things that as anesthetist, we don't want people to be on. It puts people at risk of bleeding from stuff that we do, particularly giving people spinal anesthetics. And we don't want people on any anticoagulants um because that increases your risk of hematomas and paralysis. So there's separate reasons for each of them. But in this case, you'll be getting a general anesthetic and low risk for bleeding, a reasonable spread. So far, 17 responses, let me get a couple more 18 interest of time marching towards half eight. So I'm gonna stop there spread across the board, um which probably shows how badly it is taught and have bad. Um It is to find some um reasonable and consistent guidelines. So um I just run through, I'll answer that question one second. So 26% for a 31% for B 10% for C 26% for D 5% for e so the correct answer. So the, the, the statement that is false is B OK, all of these um are what you should be doing for the various ones apart from clopidogrel, um Clopidogrel, we'll get onto it. It is very annoying to try and manage for operations. Um So this is a lovely slide with lots of words on the table. This is all from the same um recommendations which is from the British Society of Hematology. I think. So, that's the best piece of evidence that I could get to bring all of this together. Uh We'll go through each one. So a continue aspirin. So low risk surgery, uh in terms of bleeding, um patients should continue their aspirin. Ok. Here in the. So, right, it says that use for secondary prevention of cardiovascular disease, aspirin at a low dose can be continued for most noninvasive, most invasive noncardiac procedures including your actually on anesthesia including spinals. So we're happy to put spinals in patients who are on aspirin, 75 mgs, high dose aspirin, a different question. Um If the perceived breathing risk is high aspirin can be admitted from day three to day seven with no net judgment, that's a surgical decision and that will be a decision that is made by a consultant surgeon. So don't worry about this last bit in straightforward procedures with low breeding risk and patients who are on low dose aspirin continue it because it also helps with mitigating the risks of perioperative um cardiac um events such as an M I OK, let's go back clopidogrel, stop clopidogrel, five days of surgery. So it's actually seven days. Um there's limited evidence available in relation to the safety of spinals patients receiving ADP receptor antagonists. Therefore, it's recommended that all such agents be discontinued seven days prior to procedure. And surgeons also say that because the key with Cyl is it's non reversible. It binds to platelets and it stops them from functioning very well. All right, the lifespan of platelet is between seven and 10 days. So you give the time that it takes for those platelets to be cleared and new ones to come to be um generated so that they actually have the potential to clot. That's the reasoning behind it. Um Clopidogrel and spinals tend to avoid it. Um Clopidogrel and operations tend to be bloody. So if there is an opportunity to stop it, we will stop it. If not, then we have platelets on hand to give, if there is lots of bleeding to try and replace all of the nonfunctional platelets that could play role is acting on. Um So that seven days for AC is the general rule Apixaban. Now there's more and more do a which are popping up and as a result, there's more and more various guidelines how to manage these. In general, Apixaban is the most common. One on the left here is a table. Um It's usually 24 to 48 hours depending on the creatinine clearance. So if someone's got impairment of renal function, we give it at least 48 hours. If someone's got normal renal function, then it's 24 hours for a low bleeding risk. And you increase that to 48 to 72 hours in, um, operations which have a high bleeding risk. They've also included, um, the rest of the, um, Dox here, um, as well. Essentially they're very similar, um, to Epix. So 24 to 48 hours, 24 to 48 hours in low breathing risk. Um, depending on the renal function, bigger trial as well with a bit more of a spread and then 48 to 72 in high bleeding risk um patients. But um usually if they're going for an operation that's high bleeding risk and planned, they'll be seen by a consultant, anesthetist preoperatively who will do that. Um Does the potential for spinal anesthetic increase your likelihood of wanting a pre op co I screen? Depends on the patient. And if there is a good reason for them to have coagulopathy, like they are on, they have been on Warfarin, they have been on um Apixaban or any, do a if they have chronic liver disease and might have coagulopathy because of that. If they have low platelets, for whatever reason, it's an extra piece of information that we can use to decide whether we should do a spinal or not because there's cut offs of around 75 for platelets and giving a spinal. So anyone who's between 75 and 100 we'd usually like a bit more evidence than just a one off um platelet count to decide whether or not we stick a needle in someone's back. Um So it's useful but it depends on the patient. Um Mostly, what else did we say? Sorry, I got sidetracked Warfarin free to five days prior to surgery and check in R and that's pretty standard. So in the middle here, Warfarin stopped five days before an elective procedure. Um if it needs to be discontinued, which is most operations that aren't under sort of local anesthetic and patients with a high risk for clotting. So anyone who's got a higher in R target, who's had previous clots on Warfarin, who's got mechanical heart valves, things like that need to be bridged, which I'm not going to go into here is you speak to hematology and they give you a plan and you do the plan, ok? And you don't need to know that for what specifically you're going to do in terms of that. But essentially they get Delta Power in at various doses, either side of their operation and hematology are heavily involved with that. But Warfarin, you should stop it and you need to check an inr when they come in because it's very unpredictable in terms of how it's excreted in particular patients who don't have the best kidneys. So before you do anything, you want to know that has definitely normalized the inr before you do any operation. And I think I wrote about Delta power in there. Prophylactic delta power in. So 5000 units is the usual. Um you can give that, um, within 12 hours of surgery. Ok. And that's for spinal anesthetics and for operations as well. Um, you have a 12 hour window after that, which you can't really do anything. So, hence usually why it's given at 6 p.m. I think, because then at 6 a.m. and anyone who's getting surgery the next day can still have their operation, but also can have their Darin the night before. Um, but if they're in that evening, um don't give them the DS par at 6 p.m. if they're gonna come to the theater after that immediately, right? A few more questions. We're almost there. Um These are very niche topics but for some reason, they come up in the anesthetic section of the UK MLA um content map. So, and this is useful if you're um on an orthopedic ward, usually. Um so 84 year old man scheduled for a fixation of his neck fe fracture. He's got a past medical history of hypertension, severe aortic stenosis, severe mi regurg ischemic heart disease, reflux and lumbar back pain. His drug history includes lansoprazole, aspirin, paracetamol, Lisinopril, and amLODIPine. Which of the following is the most significant contraindications, spinal anesthesia. It's quite niche may be worth knowing about. We'll, we'll see. Mhm. It's unlikely that you get asked a question like this in the finals, but it gives us an opportunity to discuss something. Yeah. Nine. So for 14, how long have we got left? 30 people So we'll go with 1416. Ok. So majority is saying c correct answer is c severe aortic stenosis and severe aortic stenosis in itself is a risk factor for increased perioperative mortality and morbidity. Um It's becoming more and more common with an aging population and it's a good, it's something that people get asked about a lot during acies and you might have to identify the murmur. Um It's also important for us as an aesthetic. So it's degeneratively a condition of the aortic valve, calcification of the leaflets. And um because of that you get significant changes within the heart itself, you can get uh hypertrophy, uh dilatation changes in pressure across the valve which all increase your risk of having an M I or cardiac arrest, preoperatively, spinal anesthesia. Uh so severe aortic um stenosis is a contraindication to spinal anesthesia. As a spinal drops your BP and it causes a spiral of cardiovascular collapse with the stenotic valve. It's important to know because a lot of patients who come in with fractured neck of feur who are old and in care homes may have underlying aortic stenosis, severe aortic stenosis, um which is the reason for them falling and if they have a murmur, then it's definitely er important to get that quantified um before the operation because sometimes not necessarily in neck femur fracture management, there may be an opportunity to get that um aortic stenosis optimized before they come to theater. Um So, discussion with cardiology on whether they can get an emergency tavy, um is sometimes useful or if it's in the elective setting, then we'd usually postpone any routine surgery or planned surgery before someone has their aortic valve replaced. So I'm not going to go into too much more than that. Just know that severe aortic stenosis is a bad thing for anyone having an operation or anyone in general because it can cause sudden death due to arrhythmias due to anything that may be present in a lot of people coming into the hospital. And it's worthwhile quantifying if someone has a significant murmur that sounds like aortic stenosis. Um One more thing which is quite niche but also worthwhile knowing about. So central male has come back to the ward following his knee replacement, which had a spinal for he's had a background of previous ta which is on for um he's complaining of severe back pain and his legs have not returned to normal for him. The operation eight hours ago, he examined and found that he has a sensory deficit below the level of L3 and one out of five power in both legs. What's the most appropriate imaging to request? You're gonna have to be quick to finish before half eight. This is the second last question. OK. Mixed between MRI No imaging and CT so far 10 responses. Um Let's see any more any more. There we go to stop now. So majority have gone for C 66% or a few for ea few for B you would definitely get an MRI for this gentleman. I guess the reason people are thinking no injury necessary is the spinal still, um, having its effect which is causing these symptoms eight hours ago, uh, spinal would have worn off by this time and, um, patients would be starting to have normal power in their legs at that point. The fact that he's got severe back pain as well is a marker that he potentially um has a pathology which is causing this. So, epidural hematoma is the worry here or spinal hematoma and she is bleeding within the spinal canal which is then putting pressure on um the spinal cord which is causing the neurological deficit. Um You need an MRI to accurately image the spine and see these hematomas as the most sensitive imaging modality for anything involving the spinal cord CT. Uh you can see really, really big epidural hematomas on there, but it's not the best imaging modality. Um You can have an MRI having just had a knee replacement. These the implants nowadays are MRI compatible things which aren't more to do with heart valves, pacemakers, ICD S and particularly people who've been metal workers who have metal in their eyes. It's important to know about. But an MRI for any spinal pathology, in terms of the cord itself is the most important thing you don't want to delay getting this. You want to speak to the neurosurgeons asap with this chap because it's only gonna get worse and he needs an operation to decompress his spine. Last one um drug calculations. So you are assisting your laparoscopy. Um The patient is 65 kg. The surgeon has asked the anesthetist how much levobupivacaine, which is a long acting local anesthetic they can use for infiltration. In the end the max dose they can get is 2 mg per kilogram. What's the, what is the most amount of levobupivacaine? This patient can get 271 tens of uh maybe 10 more seconds, 10 more seconds. We'll see. This is the last one. Thank God. Right. We'll leave it there for now. So the correct answer is b which the majority of people have got. This is something that tripped me up a lot in finals. In terms of working out. This is essentially the working. So the key thing is at the top here, 1% solution means that you have 1 g of a drug in 100 g of solution. OK. That's 1% 100 g equals 100 mils. Um So therefore, you have 100 mg in 10 mils and 10 mg per mil. And that is a 1% solution. 10 mg per mil naught 0.5% is 5 g per mill. The max dose of patient is 100 and 30 mg 2 mg per kilogram. Um 100 and 30 divided by five, gives you 26 MS. OK? If it was not 0.25% it would be double that. So it would be 52 MS. Um and that's, that's the maths. Um So yes, this is the key bit for any of these questions. 1% solution. Just think 1 g in 100 g is 1% 1% of 100 is one and then just work it out from there in terms of how much is per mil. Um And then once you've got this, just change it to whatever solution you're trying to work out. And this is a little bit extra that's thrown in, in terms of max doses. But if you stick to this, then you should be able to work it out, right? That's it. That's the last question I done. Um I've just put up the learning objectives again. Hopefully everyone's still with me. I've not sent you to sleep or um had to go get some dirt. Um So we've ran through some initial management of some acute scenarios. No 0.5 is 5 mg per mill. Sorry. Did I mistype that? I mistyped that. Yeah, it's 5 mg through. Well, thanks for being uh more awake than I was when I wrote this. So, yeah, sorry about that. It's 5 mg per mil. Um So yeah, we talked about some management for acute or emergency conditions that we see in anesthesia and ICU we've ran through the A SA system very quickly. Um, hopefully given you some categories for that. We've talked about some drugs that we use in anesthesia and we've talked about some medicines and, um, what to do with them during the perioperative period. Um, only one last thing to say is good luck. Everyone is gonna do brilliantly. Ok? You've got this far, you've done all of your revision. Um, everyone goes through this exam and comes out the other side. Ok. It's very daunting to think of it. But, um, giving you all the revision and turning up to this tonight, um, 100% you'll do brilliantly. Just believe in yourself, believe in all the revision that you've done, um, and try and keep the nerves in check and you'll be absolutely grand. Ok? Um, I've got some feedback here which I'd be very, very grateful if you could fill out, just take a picture of this QR code and, um, fill out the Google form. It helps me to figure out what's worked and what hasn't worked, what's relevant, what's not relevant, um, whether my questions are any good, whether they're absolute rubbish. Um, and can help me to tell this in the future, sorry that it's gone on for so long. I was aware I was probably going to run out a bit long. This is probably too long. So if you tell me that it's too long a session, I totally agree with you and I'll try and cut it down in the future. Um, the other thing is don't get too bogged down in anesthetics and I, to you, um, there is plenty of other stuff in terms of finals, which will come up and A&E GP, um, general surgery, general medicine, there's a lot of important stuff that you shouldn't neglect there. Focus on that. This is hopefully an extra little bit to try and supplement any revision that you've done and potentially just identify some really small areas that maybe need brushed up on. But don't go crazy. Um, with all of the information that I've given you today, don't get really bogged down in it. Um There's only so much that you can retain, there's only so much that can be asked. So do what is best for you in terms of just reminding yourself of things that um are important. I'm going to hopefully the resources that I've used. They're all on here and I'll try and get them on to the chat so that people can just copy and paste them onto a word document. Oh, I can send off the slides after the session so they'll have access to this. Mm, I just, just, these are all in here in the chat chat. Sorry. Sorry. And um good question. It's quite a large topic. Essentially there is some guidance in the resources that I've just posted on. Um, if you scroll down to the management of diabetes in the Perioperative period. There is a link there to the Center for C Park Center for Perioperative um care, which has a really good guideline, which has those tables that I had in for the um, the management of uh what's it called the oral hypoglycemic medicines? And there is tables in terms of insulin. In terms of that, my one line would be if patients are hyperglycemic, they need a sliding scale if patients have um, good control of their diabetes, um, then you can manipulate their, um, subcu insulin. Um, and by how much you change that is dependent on what type of operation they're having and what their blood sugar is on the day. Usually, if it's a day case surgery, you'd still give the long acting insulin and you'd probably omit the insulin, which people are taking with meals. If that's a type one diabetic, if it's a type two diabetic and they're getting too like BD dosing, you would make sure they have their, um, insulin the night before, maybe half their insulin on the morning of surgery. Um, because they're going to be fasting, but it's very patient dependent and it's very dependent on what operation they're going to be having and how soon after that they're going to be eating and drinking normally. Um, so I'd point you towards the resource of, um, the center of perioperative care which, um, if you feel you need to do more reading into that, go into that because it's quite a large topic that is very variable and it's quite difficult to write a question that will encompass it. Hopefully, that's a reasonable um, answer for you. And thanks for taking the time out of the evening to the session and I hope everything sounds useful. So, as I mentioned earlier, we'll make the slides and the recording available. You should get a notification on this. I think maybe your email, you sign up to the session, but otherwise you can just double check our middle page and it will be up to see tonight. Um Otherwise, if no one has any other questions, I hope everyone has a good evening and good luck with us.