Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Oh, well, with all of you guys, they're already we probably should get started. Let me introduce the lovely Fatima and animal who will be leading today's talk on potassium derangement specifically looking at hyperkalemia and hypokinesia mia. Right. So, uh, thanks, Cash. With the introduction on go today, Webinar as part of the series is about potassium derangement. I'll go through them each and turn on globally body, and you'll be quite, uh, happy with the trying to manage this when you're doing your if one drop or indeed, any words based job. So, uh, just before we start. So last week retrialed kohut questions which proved to be popular in the feedback eso We're going to use that again. Um, as we mentioned last week, there's a little bit of a delay between us. Uh, doing this by a zoom and you guys here and get on Facebook. So mostly we're gonna be using this to test your knowledge before we kind of explain what the answers are. So throughout the talk, I'll have slides where the next question will be enabled on call Who, um, for you to join, you need to go on a heart doctor. I t. And we'll have a link over in the Facebook chat. Or use the kohut up and you need to enter this code. It's on the screen now. 879 1840 on. You should see a screen like this. So we've got couple of people, uh, joined already for more of you join in. Uh, that will be great. So I'll let you guys get on with that as a crack on. And then when the first question comes up, I'll shut to use Well, so just a quick shelter to our sponsors that mg you have been supporting us throughout this weapon or Siris on. But we also have a link as well in the trap for you to draw on. You obviously need indemnity covers an F one. And this is one of the biggest organizations that office that along with a lot of other, uh, you know, pucks, uh, another. Another housekeeping things. So on the mind, The bleak website We have really good course called sweet and salty. It's usually 9 99 but we all offering a giveaway. It's on diabetic and electrolyte emergencies online course. Really useful. So it's free to do in the give away. So you're just going on mine the brief dot com slash Give away on enter You'll be in with a chance. Right? So let's, uh, go on to question one. No, just stopped that. So this is gonna be on hyperkalemic on how you define it, so Oh, leave you the time to answer that? Um, obviously, there's maybe slight differences in the exact level, but broadly speaking, what is hyper clean? You're above what? Potassium level. So you can answer that separately as we crack. Um, so hypokalemia, we're going to go through the definition on the classification. Why is it important that you know about this? We'll go through. The cause is on what kind of symptoms you might expect in your patients on. Then we'll go on to what you actively need to do. If you've got a patient with hyperkalemic, the investigations you need to do on importantly, the management. So classification of potassium level that you're measuring with blood is an extra cellular potassium level, obviously on anything more than a week or 25.5 minimum per liter, or pending on where you are milliquivalents per liter, um, is considered a high protein is subdivided again. According to spare it IV. So mild will be anything up to 5.9. Moderate is from 6 to 6.4, and then severe is anything above or equal to 6.5. So why is it important to know about High Carina? It's one of the most common electrolyte disorders that I've person encountered and my colleagues have when we're covering the woods. Uh, it's probably can't think of a shift. Work didn't have to manage it, um, on D s. So it's important for you to know how to how to manage that, Uh, the all the second reasons. Most important one is that it can be life threatening, particularly with regards to how it can affect cardiac muscle, um, and therefore can even lead to cardiac arrest. The first thing is that it can be quite challenging because patients that tend to get hypokalemia might have a multitude of other medical problems on do beyond multiple drugs. They might have recurrent hyperkalemic A. If the underlying causes of managed, for example, um, and then then you're kind of stuck with figuring out how to how to get them better. But what I would say is about hypokinesia. It's one of those things where, as an F one, thankfully, there's clear guidelines on your Internet, your trust Internet, which is your number one source off what to use whenever you're encountering any issue as an F one or you've been higher. So you should know exactly what you need to go in that situation. But regardless will be going through kind of the general guidelines, uh, three to store. So go back to your question one c how everyone did so 5.5 was the correct answer. And most of you did get that. So we just have a look at the leaderboard. So we've got okay and then, uh, some flour and someone who's anonymous after that, um, and then we'll see how we get one. So we'll go on to question too. On this is asking what is pseudo hypoglycemia. So I got a multitude of options there. Um, if you think about the the terms pseudo creamier, break it down, think about what might mean, um on. Then you should hopefully be able to sort out which one is the correct answer But if not, that's fine. We're going to go through everything now. So you need to think about potassium in the sense that it's something you in just undergoes various reactions etcetera in the body on then is excreted. So there's clear pop, uh, situations doing that, probably in which you might be able to get a derangement off some sort. So we're going to go through the cause is based on that, Um, and of course, during the process of drawing blood getting it checked in the lab, for example, you can also introduce a, um a never, which is an artifact, which is the final final example. What example of how you can get a high purine, uh, so go through those in terms. Sorry, eso First one is increased intake. So maintenance potassium requirements on idol one minimal per kilogram per day. Eso If you're giving prescribing IV fluids on D, you know you're giving them away more than they need, Then that can be a cause of a hyper Climara in a similar way. TPN, um, Andi, even or a potassium So Sunday. Okay, which we'll talk about later, uh, which is used to treat low levels of potassium. Unfortunately, sometimes people don't stop it on patients. Just carry on taking them every day on the end, up with a high protein, the other source of 100 women can be with patients, for example, that I take the salt substitutes there might be wanting to reduce their sodium intake. Um, on a lot of these substitutes use taxi and chloride rather than sodium chloride. Uh, they can, you know, in In theory, take 22. Much of that, especially, we've got other risk factors for hypertension. You know that can be a cause. And then the final example here given is transfusions. Patients who take have rapid on large volume transfusions are also at risk off hypertension. You next, uh, category is decreased excretion or potassium, so potassium is mostly excreted by the kidneys. So obviously anything that causes renal failure up some sort bugs up on a K I or CKD. That reduces the glomerular filtration rate, and you'll get less potassium excretion. Similarly, it's really an angiotension aldosterone system that regulates how much calcium is in the body. Um, so anything such as Addison's, where you have how hypoalgesia organism or you have you have, Ah, potassium sparing diuretic aldosterone antagonist like spironolactone, eight inhibitors and ARBs. They will all act on that pathway and can cause a high potassium level. Other things you might not necessarily think about straight away off things like insides. They can also cause the hyperkalemic A through their action or a sodium potassium pump on in a district trimethoprim, which used to be very invoke. Ah, antibiotic for UTI is that still used, but that can also act as a millwright does, which is a case sparing diuretic. And it can cause the hypo killing you. So you just watch out for those drugs on the drug chart with these kind of patients. The other cause off a high potassium extra cellular potassium level is that you're getting released from intracellular stores. So cells, for example, that undergo tissue injury like in bones or hemolysis treatment isis off the chemotherapy, for example. When they lies, they obviously released their interests all your potassium low insulin levels, so insulin usually causes potassium uptake. So if you've got low into level low relative insulin levels like in DKA, you can also get a high potassium acidosis 100 irons on potassium are exchanged. So as yourselves tried to take in more 100 irons, they have Teo get rid of the potassium. Um, extra suddenly, Uh, and that's another cause. And then you have drugs like Peter blockers under docks in which again work on the sodium potassium pump, uh, on and socks on the phone and watch. Could also at the end, I'm Jake calls high potassium levels. So sorry. Long list of things much. So it be useful for you to maybe later come back and look at these on then. You've got kind of non exhaustive list, but this covers kind of the main culprits. Final thing is an artifact. So you can get this when there is any situation in which you're in vitro potassium levels. I just recorded by the lab are not a true representation off the in vitro levels, so you can have a humanized sample. You can have an old sample where you get potassium leak. You can have contamination. So the four blood count bottles contains EDTA on. Please, please, please, never try and send a sample to check your electrolytes. If you have mistakenly put it into an F B C bottle and decide to decanter into the your knees bottle. You'll get the wrong results. Uh, similarly is going to make you very worried one of the reasons. So just you discard that bottle and just do it properly with the you any bottle. In this example, it's the yellow top on other things. So leukocytosis rumba cytosis in the blood that can also cause high potassium levels. Um, on. Then, you know technical things when you're taking the blood. If they're having a drip through their arm with potassium in the fluids, you're obviously going to get a high reading. If you take blood from the arm, I'm finally read. It will be a spoke does sometimes happen. If you're taking blood from the wrong patient, you can usually tell because it will be quite different from the previous blood. But, you know, just double check that you've got the right patient. You're taking blood off, so we'll go like to the bathroom. We have got most people. Answer the correct answer. So it's high potassium due to an answer back on, we just have a look. Our Board Anonymous has gone up to the top on the some flour. I don't know who that is, What you're doing quite well. She's still like number two. Um, a couple of other people as well. So go on to your question three. So we know about the background of hyperkalemia how it can be caused, but what is the first priority in its management? So I don't want you to just think about how to treat hyperkalemic. But what is the thing that we're most worried about on how do you treat that? So kind of be alluding to this next time we discussed the symptoms, so symptoms. So you you get potassium reading from the lab. They either call you or your ass to chase bloods in the evening by the day team and you see Oh, God, they got a really high potassium level. You need to go see that patient check if they have any symptoms off. That high potassium level thing is that most of these patients will be asymptomatic, but that won't necessarily reflect. How about the potassium level wins other things that they can report or cardiac symptoms. For example, chest pain. Palpitations on again. Like you said, it can read to arrhythmias and arrest. Other muscles might also be affected. They might have fatigue weakness. I think things kind of vague symptoms, but it's important that you ask about them because that will help in deciding what management post where you go down. Investigation. So as we said, there's a lot of causes off, Ah, high potassium level. So you need to investigate. The first thing I'll mention is that if you think you have got on artifactual reading off this potassium, it just doesn't fit in with the previous blood test results. Or, you know, it's just It's just completely unexpected for this patient. If they haven't got any cardiac secretly so easy changes or symptoms than have a low threshold to repeat it, uh, it's very quick to do a B B g A venous got gas. You just straight away. Run it on. Check the potassium on that, Um, otherwise you can get on with treating and obviously could do these extra investigations to try and figure out what causes so competitive Blood glucose ketone levels for DKA. FBC count for the platelet level leukocyte level renal function. Obvious liver function failure can also cause hypoglycemia because sells taken Ms Potassium on CK creatine kinase to track your rupture months is and then again, digoxin is a cause of hyperkalemia. So you want to check up? If they're on it? Onda, then serum cortisol, what else? They're on if it's relevant. So I'm going to go into the PCG changes that you might see. So anyone with a hyper cleaner you need to do any CT. Typical thing that you probably learn up you need or school or whatever is you see tall tend to t waves. So that is most often uneasiness to see on the precordial leads. So that's be one through the six. But you need to remember that tall T waves are also normal variant. So it might just be that that's that's their know, the normal look of the STD. So you wanna make sure you compare it to a previous CCG, so you're not kind of more worried than you should be. You also get other changes as you go across that you see it you trace on the list I pop here is a reference for you to kind of come back to, um so you know what they're looking for so. But in general, you get flattening on the P wave, You get your prolongation. QRs is well, um, you can eventually get a sign wave pattern and it can progress to the system. So I got pictures up here. If you can see that off ECD changes that you can see. So I got normal example at the top and then with an increasing severity of hyper Climara you progress from a peek T wave to widen pee on cure essence rules on Finally, you can get a Sinus or dull wave, um, under arrest a systole, uh, eventually. But hopefully you will catch everything much earlier than that. This easy to trace is just to show the rocks in effect. So if patients are taking digoxin, then you sometimes can get this reverse tick sign, which you can see up on the screen. Now it's not a sign of toxicity. It it's just a finding that you can you can see on the c g if someone is on the docks in. So it's just useful to know that's what you might be able to see. So oh, go onto management. Sure. Um, yeah. So management as I said. You probably on your Internet, have a table or kind of a flow chart that you need to follow. Other said this is general, but if a patient's got severe hypokalemia, all they've got evidence of myocardial instability, which is on the CD changes. Sometimes even some guidelines say they've got symptoms. Then you need to follow this part Now. The main thing is that your initially temporarily trying to reduce the potassium level Um on then obviously, definitive management is treating the cause, but the emergency is focusing on that first and foremost, you want to be stabilizing the cardiac membrane because that's what you're worried about most obviously, they need to make sure they've had that you said you like we said, but also that they remain on cardiac monitoring. If they fall under this category of treatment, the way you stabilize the membrane is giving you calcium salt. So 10 mills of 10% calcium chloride IV or in some trust it it might be calcium calcium gluconate on the those might range for that 10 mills to 30 miles, so definitely just check your check your guidelines. So you've stabilized the membrane. No, what that calcium salt doesn't actually reduce your potassium, so you need to try and reduce it in the force. This way possible on the way to do that is on our next step, which is driving it into cells. Like we said, insulin can cause potassium optic, so that's what you give to patients. Typical prescription would be 10 units of extracted, and that will be in 100 mils off 20% off glucose. Another way to drive a taxi, um, into cells is using a beater agonist. So so beautiful. Nebulizers are typically used. Guidelines say, 10 to 20 mg, never personally given more than five. Um, you're a time, and then you can do back to back if needed. And then if these measures aren't working, there is an opportunity to give. Repeat dose is based on your guidelines off there certain amount of time. But if you know this, this patient's like Climara is just absolutely not amenable. To fund political management, you need to find a better way off removing, uh, potassium, and this is where a higher level of care is required. So you need to think about human filtration on dialysis. In any case, during this. If you're on this side of the pathway, you need to let your senior know so med wrench. Um, Andi, particularly. You know, if if you reach this state where you need to you level care, they can facilitate those kind of discussions. Finally, remember that you always need to recheck the potassium, typically after once two hours and also again at 4 to 6 hours. So you make sure you haven't got a rebound. I'm not that that's important. You might be triangle of this and think you've sorted out when you haven't so definitely really remember to recheck the potassium, so regardless off the severity. So if you've got a patient with mild to moderate hyperkalemic A without any cardia signs or symptoms, but also in the severe cases, you need to think about certain things to definitively treat the high potassium level. So try and identify the calls and treat it. If it's a drug that they're on, that's really obvious, and it's like to remove it or even change it, you know, do you? So if you all wanting to remove additional touchy, um, you can use diuretics or calcium. Arizona is an example off a GI tract potassium finder. But that does have some GI I toxic effects. So again, if you're doing anything like this, speak to a senior, they're kind of independently on. Also, that takes a few days to two chicken. The calcium was only, um so it is not is not the initial kind off treatment. Another way you can help is by reducing the potassium intake. So let the nurses know, but also document put down. You know, patients follow low potassium diet and that will restrict how much foods like potatoes been honors, not sexually. They can help. Finally, you can attempt to ship potassium. Interestingly, you're looking using things like bicarbonate. But again, not something you should discuss with a senior. Um, so just a quick summary diagnosis. You should make sure it's not spuriously raised potassium, obviously, um, but once once, you sure it's correct, then be aware off what level? What severity? The hyperkal in you is so mild, moderate or severe, then you need to investigate with certain blood to try and identify the cause. For example, repeat if you need to, um on also definitely during the CD when it comes to treatment. Like we said, if it's severe, some more than 6.5. All those easy to change is all their got symptoms. Start with the calcium soul to stabilize the heart than insulin, dextrose and so beautiful. If you trying to get a taxi, um, enter cells on, do you need to think about whether you need eye to your level? Okay, if these measures on on successful regardless and all patients, you need to try and treat the cause. Think about their diet on be considered calcium binders. Uh, definitely. Always. You need to remember to recheck the potassium levels. So I don't know, um, if we have any questions at a minute just in there, we could we could move the answer them before we go into hypo putting me on. But I'll just go back on the car food in the meantime, so we have bought yet. So, as I said, calcium salt is the the priority in managing hyper clean you out. So you need to make sure that you you stabilize the heart. So we've got all signed some flowers, gone out first place, um, anonymous. Still doing well, lures come up. Um, Onda couple of our list. So will I. Don't know. Do we have any questions? Yeah, we do. We have to. Questions come in. Who So the first one is? Um, you've mentioned calcium chloride on this use asks. You mentioned passing Florida. Could chloride? Why not calcium gluconate? So I think maybe if we could just go through what the difference is and maybe why they're different in different hospitals. Yeah, So I'm not going to claim to know that much about it, But in different hospitals, it's based on your guidelines, what is typically used. So as I said, if your hospital uses counting gluconate, use that if not, then use calcium chloride. Calcium chloride actually has three times theater off calcium. That calcium gluconate has, um and that's why I kind of alluded to it. So you used They're 10% solutions. You'd use 10 mills of calcium chloride. Um, on in some some places, they still use 10% or calcium gluconate. Some places. Because of that difference in calcium content, there might suggest 30 miles, so it just depends on what particularly is on your trust guidelines. What is available in your hospital? Um, there are some kind of difference. Other differences with them. I think I'm not gonna make any claims, but that it's just basically what your what your hospital has. That's what you end up having to use. Um, but I don't know if our cash has anything else to add. Uh, so that mister on that absolute perfect, just a Z said casting chloride has got three times the amount of calcium you can literally use either interchangeably. I tend to prefer Carson gluconate as an endocrine Reg just because it's less irritating the veins. But otherwise Fatemi you up 100% correct with exactly great question, by the way, Yeah, it's good question learns so. And the next question is, does the 10 units of act Rapid come ready made in the syringe with the glucose? Or do you have to mix it? Okay, so interesting question. I'm gonna admit that the thing is, you're as you as the doctor or no going to make up the preparation. You just prescribe it. If I'm honest, I've never actually stayed on until kind of watch the nursing stuff when they administer it. So I don't I don't actually, I can only imagine that it's not. It doesn't come together. They kind of dilute it on. Then in some places, you might have different volumes on percentages or the glucose solution that you use so again, you just need to worry about prescribing it. Someone will sort it out Cash again. I don't don't have you on a john thing. That's so I continually chip in there. They come as different solutions and always every place on they have to specifically make it up. Where they add in the insulin, usually into the infusion, you can give it separately and have both run concurrently. We often do say, to give it inside the infusion just to avoid the risk that only the incident goes through and that the, um that the dextrose doesn't go through with it because otherwise you might end up getting a patient with quite a severe hypoglycemic episode, which often does occur when, when you do give calcium, if you do give into the next race s Oh, yes, in most places they will have to give it separately. And you may vary, uh, theater down that you give depending on what what your trust policy is. They do. Check that out and just go along with what that says. Excellent. We've got one more question in this interim section. Batmah. Someone has asked if you suspect Addison's would you take a serum cortisol or schedule them for a morning serum? Cortisol? Um, again, I Cash is the expert on this, but you're a smart as I'm aware, you know, And what I do is I. That's not the first thing that would pop into my head. When I'm trying to treat or hyperkalemia. I try to treat it with the measures. Like I said, I wouldn't necessarily trying to all these investigations before that I would do a morning cortisol. But a cash cash is Is the pro on this so he can he can jump in again? Yeah, that's right. One of these are endocrine questions that that's my specialty. That's lives helping battler outwards of these questions. But just before I go into that, thank you so much. Total. The nurses who written on the comment is letting us know that you do have to mix there. It's really helpful to have this kind of multi disciplinary approach. Yeah, I'm gonna have all of you guys providing your insight. I'm on to the question about whether I do a court stole in the middle of the night or whether I would wait until the morning if you got a patient who you are very much suspecting, it's got dreams or insufficiency. Um, I eat a Are vomiting that possible? Drop away other features, so craving whatever else then I think it's very much worth doing a quarter soul in the middle of the night because ultimately you expect when they're vomiting and other things that they would have some sort of a stress response the best time to do a course always in the morning, because that's when we expect it to be the highest. And so a low course stone in the middle of the night isn't so helpful. But ultimately, if you got a patient having a having what you suspect in the adrenal crisis, what you need to do is get one and give them their treatment because you can't wait until the morning thought. Your do is just send a quarter sold off. Um, just to make sure that because if it comes back and it's absolutely plum normal, you're reassured that actually tapped that treatment wasn't necessary. But in the meantime, just to make sure they're safe, you'll start the treatment. You're giving him some fluids and you'll make sure that you sent off that quarter sold just so that, you know, at the end of the day whether you went down the right way or not. Once again, thank you, really in. Yet that's what we've got. One more. We got one more speedy question. Uh, when you do the act rapid and the glucose. Is it something you right up in the stacked part off the drug chart, the fluids part or the insulin part? So, you know, in the insulin part, um, probably the best place to write it is it. Sometimes the nursing stop want you to put it on the on the back, but sometimes they want you to put it on the stuff. To be honest, I just follow what? That what they told me on the stats side. Obviously they can, you know, appreciate that it's more urgent. So a zongs you make sure that it's prescribed some where the nurses are happy with the prescription, and they give it, which is again something I should have made sure to mention you once you prescribed things, you need to make sure that it's given. Sometimes, you know, other emergencies happen on the ward, and people kind of forget about it. So you definitely need to keep checking in that everything's been given. But when it comes to the prescription personally, I just kind of write it down. Let the nurses know. If they say no, you actually can you do on this side or just the Ritz? It's not something called Think about too much. I don't know animal. What was your experience? Agree with you? I think that mainly I'll probably go for the stat side. But sometimes nurses prefer it on the back on the fluid side, and I don't have a strong preference either way. So if the nurse in charge has a preference, I'll go with what he or she wants. Uh, that's a very sensible, lovely. So that's all the questions for this bent on. And then I'll come back with some more of the end. Cool. Thank you. Thanks so much. Um, and thanks, guys, for all the questions, um, so we're gonna go onto Hypokalemia and Hopefully, this will be a lot quicker because a lot of it is just the opposite of what we just talked about. But I'll try and highlight the key things that you need to think about. Um, there are different. So, um, we can go into that again. Same kind of structure give you classification and importance will go through the causes symptoms on. Then what? What you need to do? Investigations and management. So potassium levels in hypokinesia? No. You are expecting a level less than 3.5 minimum per liter on again. Mild moderate. Severe start 3 to 3.4 is mild moderate, 2.5 to 2.9 and then severe is less than 2.5. Again, it is something quite common on. Do you know, if you've got hyperkalemic patients and you over treat them, you might end up on this side. Um, and additionally, potassium derangement often comes in with kind of other electrolyte derangements. So you, uh, you may see this quite often, um, in conjunction with the other other abnormalities. Again, it's like threatening most people just considered kind of hyper clean as a main thing that can cause a rest. But it's important to know that hypokalemia can also do that on again. It can be challenging. As I said, you can end up. You're going between the two. Um, hyper hypo on. Um, sometimes, you know, if if there's an organic cause, it could become very tricky. And if you're trying to increase increase summers, potassium levels, General, so we'll go on to question for just before that. So bit cheekily tarsus because we haven't gone through it yet. But which off? The following is not because of hypo clean out. So you can think of this as which is a cools off hypercholesteremia. And seeing as we just went through that, you might you might be able to figure it out. So, um, just give you a time to answer that, uh, before we move on. So again, we've split up. The cause is according to the same kind of full broad groups. And artifact, though with hypokalemia is not as common. The only times reader can think off that can happen is if you've got the wrong patient or you're doing it from a drip harm where there's no potassium content. Um, so we're gonna go into that too much, but the other three will go through in detail. No so inadequate intake again. If you're not giving them enough through IV, TPN, all they just might have a poor oral intake. So this is something you need to think about in psychiatric patients. If they've got eating disorders they can often present with hypocalcemia. So sometimes we don't really pay too much attention to a patient psychiatric history on a medical ah wards. But it's something that you might need to take into account when they've got electrolyte abnormalities. Next one is you might just have increased excretion levels on that might be through the two main routes. So, as I said, Gee, I tracked classic things with example. Gastroenteritis, vomiting, diarrhea. If patients are taking too many laxatives as well cause the same thing, they might have malabsorption or high output stomach. So that's that could be fairly common in stomach patients on surgical woods, for example, renal causes so you can have a variety of genetic syndromes, um, again cons on Cushing's uh, you know, in contrast to the Addison's, causing the hyperckemia steroids as well. Things that pregnancy alone onda uh renal tribulus it OSIs. Uh, there's type four actually can cause a hyperkalemic about these types of mentions. 123 especially to can cause low potassium level again known non potassium sparing diarrhetics can, uh, cause, uh, low potassium levels on the one key thing you need to think about is magnesium levels as well. So if you have a low magnesium level, it can contribute to that low potassium on. In fact, if you're trying to treat the hypokalemia where you've also got low magnesium, you need to make sure you treat the magnesium first, because that will help in sure that you succeed in trying to treat the hypo. Continue. And then again, you know the opposite of Los Lost section or hyperkalemic A. You can also get an extra cellular to an intracellular ship or potassium. So alkalosis insulin, Um, and again, as we discussed adrenaline or be two agonist, I'm just gonna go back to question for so most of you got that right. Low insulin. Um, low magnesium was also popular, but wrong because it can cause hypoglycemia, so check there so sometimes stayed on top. Uh, but we've got new new people on the top five leaderboard. Um, and then we'll move on to question five. So which of the following is true regarding the relationship between potassium on digoxin? I'm just gonna let you think about that. Um, just sorry. I'm just having, uh, little the state supported more. Sorry about that. Just, uh, low charge. Right? So if you think about how digoxin works on the n a cape pump, you should be able to answer this, uh, but again will. Well, we'll get to that anyway. So, uh, moving onto symptoms again, it can be a symptom. Like how you clean your but you still can't get some cardiac symptoms and muscular symptoms, and they really are similar to hypoglycemia. So you definitely need that reading. You make a diagnosis or potassium high or low because they can be quite some time. You can get palpitations. You can get a rhythm ears. You can get flaccid paralysis, weakness, etcetera. Um, one other point of mentioned here is that a low potassium level can exacerbate drugs in toxicity. Um, on That's something to think about. If someone is on the digoxin and they have a low potassium that could make them exhibits symptoms off the doxy toxicity, which again off fairly similar to the symptoms you would get with hypocalcemia. Anyway, investigations rights of Bloods similar to last time. You know, you can look for all sorts of causes, but the key one I'm trying to highlight here is make sure you check back in easy. Um, as well. Anytime you have a meeting for a patient, you need to, um, also checked my magnesium, and you could just add it on at your lab. You don't technically need to take a repeat blood test if there's no other reason to. You can usually just ask your lab for various. You know, there's there's protocol. Maybe you have to print out a request or just do it on the system and you just ask them to add it on, um, on. Then, obviously, like I said, we see GI because you're looking for any changes. And the changes here, all different to the ones with hypocalcemia instead of a tool, tend to ti way you might get a flat on one. Uh, I also got usually it's much warmer trace after the team way, you could have ST Depression on again you can have longer intervals like appear on the beauty. So this is just a quick example here, where you conceive normal at the bottom on an example hypokalemia at the top. So you have a depressed ST segment. You can also have a flattening off the T wave on a you wave as well. Obviously, you need to take it into context. If you have a depressed ST segment. See, they're all the causes a blup on. Um, these are some of the findings on any city traced with hypocalcemia. So just go back to your question about potassium under doxainex. So that is correct. Too low. Potassium exacerbates the doxy and Doxy City, which we just mentioned. Um, most of you got that right. Um, if you think about it digoxin. It works by inhibiting the sodium potassium pump, which causes potassium in flocks on. If you got low potassium extracellular be, then you're reducing that constant trace ingredient even further. So they kind of work in harmony, um, to to try and inhibit that pump. So I'm gonna enable the final question after this GMC is call a puzzle. Okay, so it is quite titers there. Stalled playful on the, um on the last question. So last one, which of these is the most suitable prescription for Ward based IV potassium replacement via cannula? So think about what they have said. It's water based on, I'm saying is by a cannula so peripheral. So you need to think about concentration, right? Just general suitability off the prescription. So again, we're going to be going through that. So if you're not sure that's okay, it's still two column management, so seven away, too hyper 300 bucks to distinct pathways. It is moderate to severe hypocalcemia, or there's any evidence of my call, your instability. You need to get that test, um, up quicker. Then if it was just a mild form, So in that case, you use IV potassium. The things are not about potassium is that you can kind of decide a certain amount. You want to add more mixing with another bag, for example. They come in pre prepared, uh, preparations. Um, and it's usually in forms off 10, 20 or 40 millimoles per liter off normal saline with dextrose. Um 40. Minimal is her liter is typically the maximum concentration you can give peripherally um, Andi, you definitely don't want to be thinking about physiological fluids like Hartmann's or plasma like, because they only contain five minimal per liter. So that's that's not going to be useful in this situation. Standard. Well, right, I looked. You give her these foot. It is important as well. Usually you give up to about 10 minimal power much, um, at 20 minimal per hour. You definitely need to think about having continuous kind of monitoring on D. Sorry on. The last thing I've put on there is definitely. Like I said, if magnesium is low, then you want to treat that first in your hyper hypokalemia Internet guidelines. It will mention that as well. So you don't think of last thing is that if a patient doesn't fall within this kind of break it so they've only got mild, mild? Uh, probably the potassium you can still give be if they're not tolerating the oral treatment. So that's, you know, to your kind of discretion. Um, if you know they're vomiting or they're just they're just not doing well with the oral tablets. By all means give you the potassium, regardless, if you're on this kind of side of pathway or you need a rate higher than 10 minimum per hour. Again, discuss with your seniors. You've always got support as an F one. You're not kind of left to your own devices. If you're worried about something or something you've never done before. Anything. Seniors always happy to just hear you say, are just checking with new. This is what I've done. Is that okay? I'm sure I catch you agree with that. So if you could unload Mile, uh, hypokinesia meal on D You haven't got my cardio instability. You can very well just treat them with all so so oriole or sorry, Potassium. So Sunday. Okay, is the classic tablet that we use in the UK um, and typically prescriptions which either it can be on your guideline, or you can choose based on exactly how low the potassium is. One. It could be from one tablet once a day to two tablets three times a day. I think there are some places where they give two tablets four times a day. But I think once you've reached that stage, you just want you're going to think about giving IV rather than normal. Um, One key thing you need to remember is that if you ever prescribe this, please Christmas past stop for a review day, not 2 to 3 days because it happens on the Wood. Unfortunately, often where you know someone might prescribe them. Sound okay? And they just they'll think, Oh, you know, in two days I'll remember to cross it off, but no one ever does. And they end up with a hyperckemia on. So definitely put, put that stop. We'll review. And then again for all patients, as with hyperkalemic A. You're going to try and treat it definitively. So it's not a recurrent issue. We're gonna try and treat the underlying cause so quick. Summary There again, diagnosis is split into mild, moderate, severe investigations need to do bloods. You see, GI. I remember the magnesium level we talked about. If they've got moderate to severe, all they've got ECD changes symptoms as well. You want to give IV replacement, but again, like we mentioned the magnesium. Um, Andi, Regardless, if you're on the side or if you want a fall straight, you need to discuss with your senior on again. If they won't, you just got a mild level of hypocalcemia you could give them or or tablets, and they should improve with that. Definitely put a stop day on with all patients treatment cause so just hooked up a few links up here. So on the mind a bleep dot com web site. We've got articles for these hyper and hypokalemia. Well, I think probably be added on the chart as well. Um, and then I just like to life in the fast lane got called which, you know, I don't have any affiliation. It is just It's a useful place for CG looking at the CDs. Um, and I definitely still use it when I'm on the wounds. Uh, finally, the best source of information for what to do in any of this is your trust Internet. They're very good at telling you exactly what you need to do. Step by step. So that is the definitive thing you need to follow once you start working. Um, Andi. Yes. Thanks, guys, for listening. If it wouldn't be too much trouble for you would really, really appreciate some feedback. Well, like on the district on the, um, on the prescriptions already, I'm the chapped. I will for got up here on does a cure code. Uh, you will get a certificate if you feel it in which is good for your portfolio. It shows you've been learning, but also again, it will help us to improve and make things better for you each week. You guys mentioned you wanted polls. We try to include that. If you're still for it. You know you can. You can say that on the feedback. If you don't like it, you can say that as well. Anything else? It would be really useful for us to know. Because at the end of the day, we want this to be helpful for you. So there's ways we can do that. Please let us know. Um, obviously, this is something we also need for our portfolio. So we would highly appreciate if you could please give us people. Um, we'll take some questions. I'll just go quickly back to the kohut. Just a check. So, yeah. Sorry about sorry about giving you this question without explaining it. First 40 minimal potassium in a liter of five. Pretend 5% dextrose of eight hours is correct. Answer. It's actually better to give it in normal saline. What? Um, this is fine as well. It's a suitable prescription. The first answer. 60 minimal power liter. That's too high Concentration. Like we mentioned, um, to be giving peripherally 40 minimal and two hours. That's too quick to be just kind of getting on the world. Uh, that's 20 minute miles per hour. Um, and then see are kind of trick to you a little bit. I put 9% in a C l instead of 90.9%. So obviously that's incorrect. Um, on then? Yeah, I said so. Just check or leave the board GMC skirt. That's good on here. This all some problems for a second. That's still good there. And someone Someone's coming at the top. Is not JC Well done. Nicely done. It was It was hard questions I can't like. But, um, supposedly helps you learn when you get questions wrong. So those world aren't everyone who took part. Um, And again, Yeah. Thank you. Um, if we have any questions, otherwise we can do the feedback. Um, unless we we have, um, anything else to do about it? Yeah. So, while people just do the feedback, there's a couple of questions. So the first question is referring to community patients. So someone has asked if a patient is in the community and doesn't want hospital admission? Is there a way that you could treat them without them getting hospital admission? What's the best practice for treating them? Well, that's an interesting one. Trick your yeah, which I'd say so. The thing is high potassium or low potassium levels, for example. It depends how, just how severe is so it is on. Often you do have patients animal. I'm sure you agree. Sometimes on the water they might have slightly low potassium. And then, you know you can still discharge them from hospital. If it's, you know, it's safe to do so again. You discuss that with your seniors. It's not something you would personally decide on. Bring them back, for example, too. Ambulatory care, which is usually units that hospital have in which, uh, kind of some forms of hospital treatment, like IV antibiotics, etcetera are given to patients where you're trying to kind of minimize admissions so they might need IV antibiotics, but they don't necessarily need to be watched a little time, for example, so you just make them come in whenever they need the dose when you give it to them. And then similarly, if you've got a patient who is otherwise well fit for discharge, and you only need to kind of correcting off their potassium, we're just checking it and it's mild. He did send them home and tell them, You know, come back in a few days, we'll check, check the level off that we give you, for example, or a replacement in ambulatory care just to check. So I think it depends on it's hard to kind of give a general answer, but where it's safe to do so, you can treat them in the community. Yeah, I mean, that's yeah, I think that's very reasonable on. I think you raise a good point about that. You've always got senior support or the higher up you go. You've also got your peers as well on dumb thing, like a discharging decision or admitting decision will often be a team effort. A Z Well, uh, yeah, so I just don't see it as a one. You are not going to be deciding who gets admitted or who stays in the community or anything like that. Um, you know, that's that's definitely above your pay grade. So that's that's not something that you would be expected. Sorry, animal. It's your big sign releases, as as people are watching happened on. Then we got we got a nice question here. It's saying, What does f four mean? Okay, fine. Um, it's a kind of, uh, made up term, I guess. Well, it's not. It's not. It's basically when you're not on a training, Possibly so you do it. One of two, which is recognized training positions on at the end of that, you get your f p c c. I think it's called, um on. Then, um, you know, your technically s h o T. Level. At that point, people can go straight into training. So, like, you know, medical, I m t called course, it'll training or, um, you know, other things like office, um, ology or eight ccs. Whatever is, um all you can just decide not to be on a training, Possibly so you can carry on working in a trust grade position on a contract we can carry on working just as a locum. It's up to you. So it's some people like that. There's that freedom and flexibility. Some people want to do it for trying to still trying to figure out what training possibly they want to do away. They just, you know, they just once build up their portfolio because it gives you a bit of time to do. You got so last one of four is it's No, it's no any kind of training position, but you're still kind of working on shr level Pretty. And and then there's just a little disclaimer from the previous question about community. This's participant has said, I feel more connected with in communication with community and acute. Sorry for the difficult question. Bioness absolutely welcome all questions. But if there are any more questions, please just let us know Our email address is Invoka mind oblique dot com. You'll come straight to me so more than happy to answer any more questions that anyone's got. So please keep them coming on. But I do also look out for our next session on Xanax. Session is, um, hypoxic emergencies. As you can imagine, it's incredibly popular because the amount of patients that we all C and vitamin e you you know this as much as I do literally. Every day We called to a patient who's decent, chew, ating, and so is incredibly important topic wherever you are for you to attend this talk. So please, do you check it outside up on Let all your friends and family no to join in a swell moving on And we have to say the first thing we need to say It's a massive thank you too fat Amanda Annabelle, for paying on such a wonderful session today. You can see from the feedback already that people absolutely love this session. They love the coup so you can see how amazing a job fatter has done. So massive round of applause. I really don't say that about my gosh. I was going to so upset If I give her thank you animals were really In fact, I have tastic like cash for jumping in a while right moment. So don't don't where I'm just here in the background. Next, I think we have a wonderful talk from Daniel Tyler on, so we'll just let him take over the screen and he's gonna tell us all about the BMA and how incredibly helpful they are. So you really need want to turn up for this for this session? Because Daniel Tyler always gives a great session. Everything if I can. Um, you okay? I think should be on TV now. Wow. We'll build up I have is like it. Um, so yes. So just for may I will be very quick. Have you guys start? Stay on tear My, my bit Every ah, I cash would would have shared in the charts off some links that I sent over those guys. Eso Yeah, If you want to sign up here from the BMA using the Qvar code on the screen or there's links in the chart, it doesn't mean you're signing off the membership. Just it's just it's off the way. It was given you a free support back to you, regardless of whether you remember Not. So with that, you get ah f one employment guide, um, which is useful looking off the heads. July, we negotiate contracts so we know what's going to be in it. So it's off that guys that helps the break break the break, the contract down, I mean, also get students pull back. So it's featuring some relationships, tips and tricks as ex talk it If this is still soft relevance you that revision stuff. Eso There's something for you for the remainder of your studies. And obviously they're foreign guide, which is pretty pretty good. Doesn't matter again, if you remember or no, it's just some free guys we'd like you want to have when it comes to, um, one on Darvocet helping now where in medical school is like your echo to be in top corner from the presidential Well, so if you haven't done it, you can do while I'm talking. Or also the links the Knicks being shed CS on down onto about membership be any of the BMA. I'm sure your members or you've been member of some point or you you've heard of heard is this. You already said maybe you come into a school and on contract or eh? So you just just a little bit more of a refresher of what you get, Um and have you might find out saying you as well. So we're the leading trade union and fresh, especially for doctors. We act as the voice that profession representing you individually locally, so within your trust you could be going into a nationally on all trust on all the issues that affect you. So what is your job to look at? The patient's it zar job to look after you Eso like I mentioned. We do things like we negotiate that the genital to contract eso we're We're always talking to the trust and there's any issues for that because it says that that has sort of mountain. Your behalf eso were known indemnity company. So you said we do get this confusion sometimes. So we're not like m d u R N B s. We don't do a patient Complaints were here somebody to look after you. You're working conditions again. Things like pay contracts, your wellbeing and also your professional development. Eso going to f one We understand sort of things. You you might encounter some issues you might face, but hopefully no eso This could be anything from from again working hours or so later, Ships of senior staff or some responsibilities you might not feel comfortable with eso Just keep it in mind. We could take some of the pressure off if you if you're facing anything you feel we need support with we've seen most things before on does not much. We can't help it if we've got, like, said relationships with every trust in UK on bit zar job to make sure they look after you and then they're being fair to you. So, uh, you may have heard about contracting service, which could save you time. Bit of money s oh, probably the key to all of ours that you will need this year when we were going to have one. So we'll go. We'll take a contractor in five working days, comparing it to the national model on did There's any scraps sees we can help get inside. Um, not to be doomsday about everything, but some some trust. You sometimes slip some extra things into a contract or change the wording here and there, Not saying they always mean it. But we want to make sure your contract is is what we negotiate, what it should be. You're getting everything you should be getting. Um, 20% of contracts we checked last year were incorrect. So it's one in five bit depressing this that high. So it's too high for us, and we just we just want to check a many years possible. So would be great if you If you remember also, you could take a rose compliant by using our roads checker. So with that one you can enter in your rotor, it will flag up to us using our online tool little flag up to us if it's wrong. But again, your oh should be should be pretty standard. So that shouldn't really be an issue. Um, I'm guessing most you guys, they're finding streets. You're actually eligible for the form. BMJ said the doctor vision of the BMJ A magazine. Um so this is the liver every Friday. If you remember, you're not getting it. Just just get in touch centers, an email or phone as to upgrade. You have to pay any extra money. It's just a knob. 10 thing. Eso, Yeah, if you alternative is that if you if you don't want the paper version and you're getting it again, phone up or 17 email because you can't access a lot. He's of the BMJ on the BMJ up anyway, um so aspired membership. You also get access to our cynical and non clinical learning stuff say up for access to you to be mg a learning, which has over 1000 quick or non clinical models. There course is the models are on there, which is good good force of completing your people very when you begin. If one it's all very interactive and kept up today with practice changing developments, there's lots of audio and video video stuff on there as well. So so it's been more over simulated environment. Not too boring. So freaks module we do. You can print off. Sticker is proof of proof, learning as well be, um, a library is already closed. The moment still do. Two. Kobe it, but you can. You've got access to thousands of our online books, which you can, which you can get straight way through your fruit for the website on your phone or laptop eso. We've got serious of webinars, which free for members and their whole life for another year on various topics, and they're also available to view on demand if if you can't wash in life, um, maybe maybe early for this. But if you think about your specialty options already, you can use our especially explore it'll which which helps you get to have a picture of what suits you best. Eso With this one, it's it's not mine. Psychometric testing takes about 20 minutes in last course, lots of work balance questions, and then it will give you a pretty detailed report listing the specialties that, according to the answers you've given, I'm very, very easy to use. It covers all specialties and on the reports, always quite thorough of lots of graphs and diagrams explaining why, why you should choose this one up? Um, if any time you feel you need to speak to someone about your well being, we we got services, they're open 24 72 or shoots and doctors. You have two choices. You speaking to you counts little or peer support, doctor. So it is a telephone based service, but we do offer video causes. But if you prefer that on, but also make sure you speak to the same counselor what the doctor again if it's more than single causes service. Uh, these thesis is completely confidential of your school of your trust eso, And then there was a free of charge and opens everyone. That's regardless of whether you're in membership or no so get anyone's free to use it day or night. So just about off for me. If you're not currently member, there's there's even off today. If you use the the link that's being posted on Channel the QR code on the screen, you get some pound Amazon voucher for joining PSA memberships 3 lbs, 66 months. So you know, in a way, the voucher covers for three months. Um, if you're starting ah, in in July, you still pay that 3 lbs 66 a month that student rates would still join a student. You still pay that fruit to October, and then it goes up to 7 lb 80 a month after tax returns. That's not till October. So you remain paying 3 lbs 66 get your contract and get everything checked. Um, and that that's right. You pay. You must use the link on the screen or the QR code or the thinking a chat to get the the voucher. So don't just head to the website. It's quite special to the to that link. Okay. Uh, so yeah, again, we don't. This is how we started. You don't feel quite ready to sign that was fine, but just this take taking ourselves Ah, passport pack and then the the employment guide. It just means that we can stay in such a view on give you some more, more sort of stuff that that might be of used to you via email ahead of the F one. Eso yeah, that's it for me around off and And stop my sharing the job. Thank you. Be done. Thank you. So so much Daniel for covering all of that. Personally, I'm a member of the DMSO. I can't recommend them, or joining them for the first few months is absolutely helpful for getting that contract check Making sure if you're running into any issues that you get all of that sorted on all of the extra stuff because starting at one is very overwhelming ticket for the first three months, you don't really know what what you're doing. What you meant to be doing. What is is part of your role is in part of your role on just having that BMA to support you with any kind of pain issues, rotary issues or any other things that you get just helpful toe. Just make sure you got somebody looking after you and you're looking after many people. Perfect. That's the end of our session today. Once again, make sure you come and attend our box of emergencies. And absolutely make sure you fill in the feedback because we really want to prove this. Proved every session on go. So far as you can tell, every sessions better than last. So police feeling that be back so we can use your feedback to make sure that we carry on doing that. Thank you so much for attending and have a lovely night.