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Hello. Everyone work into the weekly webinar Ease by mindedly, which are going to be one every Wednesday from a T 29. Um, today we're going to be joined by Dr Sam. So he's going to run the session on High Boxer. I have. We're going to have a Q and A section at the end run by Wendy. So please make sure he old questions in the question books during the session. And then if you think about anything at the end of the session, would have a dancer all the questions You can also have placed MT. Our mind a bleed webpage. The session is going to be recorded on. We will send out the link for UTI. Access the materials. If you're registered that mind a week, that's called, um, stash webinar registration. And I'm going to put that link in the in the Commons box in a second and so right that I do. I'm just going to hand in a T doctor. Some suits, Doctor back home box. Here. Thank you. Um, so today's organ I will be on high pox here. Um, on. We'll discuss a bit bit without the history investigations, Diagnosis and management, Um, about hypoxic emergencies. Onda just introduced myself. I'm enough to doctor looking in the West Wittman's I've had a respiratory placement, so I know a little bit about hypoxia. Um, Andi also, just add, uh, make sure that you really need that form The end, if you like a certificate, Uh, for proof that you attended, you'd be provided with that. So that's crack on. Um, if you've got any questions, you can post it throughout or at the end on I'll ask questions throughout and your future. Pop the answers into the chat box. So just to start with, then what? We'll go through like a mention I box your respiratory failure Couple of chest X rays, ABG on a few of my tips. Why I have lots of command isn't important. Um, I'm sure you you know, I proxy is life threatening, so we need to make sure that we're aware of what we can do on what did you cut for on. But don't be scared to put out on emergency Harry arrest call. If you're really concerned about patient, you don't know what to do or the 22 rating on. You're not too. Sure. How to, uh, And you need some help? Basically. Okay. So what is it can present with a few different ways. It can present on both things like agitation. You could read this saturations on. They have obvious difficulty of breathing Can be signed. The hypoxia, How you decisive it. How you would always assess a patient of Dr ABC the approach onda. Just remember that, um, with the high with oxygen, high pox here will kill before hypocapnia. So if you're worried about patients having the oxygen, make sure you start them, um, at 50 leading on Rebleed mosque to really pick the oxygen up on Ben. If you're thinking about them being a CO2 retainer exception which will discuss you can always titrate the extra down afterwards as you feel appropriate. Um, so bit about airway. I'm sure you're well aware, Had tilt on George thrust. So someone's airways compromised either what you do, you might use an adjunct like a nasopharyngeal airway or get gel. Um, I think I know is your breathing coughing? Except for these are all signs to be aware of. I'm not sure if you come across these patients But there's patients who have track your stories, and they're injected. Means there's a few indications for them. For example, patients who you might have encountered if you have been working and I to you so that patients who are being weaned off the ventilator may then require a track us to be to help with their breathing there because they need the extra support. So Tricastin, you will then be connected to the ventilation ventilator machine, and then they will be quite of the oxygen. Now talk with the breathing. So if there's an airway emergency here, patient desaturating, they look red flushed. Panitan. Think about her books here. Onda. How you going to manage it? Court of seniors, especially if you're not sure what to do bit earlier. Nothing. You know what to do. Track. You're still remember that the the stoma in the next, or Stoma is an opening. Still main the neck into the trachea allow Injected me is where there's the storm through the larynx. And just remember that in a track, your stomach patient there is still a connection between the mouth on do the windpipe, whereas on the lungs, whereas in a laryngectomy there's no connection between the mouth and the lungs. So if you're going to oxygenate a patient in a track estimate emergency, you know, oxygenate through the math on the storm A. When it comes to allow injectable patient, you could do both. But what's going to be useful is the extra. I'm going through the laryngectomy stoma because that's the one that's living to the lung. Okay, um, so just moving moment. Breathing from a position to provide oxygen and examination examination is really, really important. So I'm just having a quick overview on things. Remember your inspection part patient question and, um, auscultation some key things to look out. End of the bed. How are they? Are they using the accessory muscles? Intercostal muscles are the panting away? Are they now tired? Are they? Do they have a reduced restaurant? Terrific. Um, make sure that you have a listen to both sides of the chest and remember the lungs Start off at the front of the chest. A cake on Ben. They go posteriorly towards the back to the lower log to be better off listening to them at the back, particularly the, uh, the bases. They could hear for crepitation crackles here for any wheezes, particularly if the asthmatic or COPD per here for ways. If they do, you may may need to give him some nebulizers. Ah, that could be so beautiful. Could be a patrol p um, sometimes say nine. Next canal puts a creation because, Well, um is the tricky essential as a bit of pneumothorax. Um, Andrea, the important one checked there. Check the legs and my feet for peripheral edema. Could be a sign of fluid overload. In which case, you really need to make sure you're checking these things. Okay. Is there bilaterally of interest really, really important as well? Be sure to, uh, I will have a little chat about as well just moving on. But, uh, carbon dioxide, it's really, really important to be checking on the ABG. So it took me about a veggies and veggies. But CO2 is a really important parameter to check, because if a patient is retaining too much carbon dioxide, if there's someone who relies on the, um on that, uh, if they rely on the hypoxic drive their retaining too much carbon dioxide and then they retain too much oxygen they're going to type two respiratory failure, so we'll have a discussion about see or to a bit more, But just remember, that's really important one. So this is what I was just mentioning. So I'm sure you're well aware. Want oxygen saturation? Do patients need to be on Is 18 months true? Is it 90 40? 90. So, patients who you're going to consider putting their target that's your hands to 88 to 92 a low is what a risk of talked to respect for the all those who already have type two respiratory failure and your minds evening. Um, the reason being that if someone these patients who are risk of fracture is virtually failure, Um, and if you know what that is, pop into the chat box on, then we can check what that is. If you got that right and you can pop the difference between that and type one s, which is really good. I, um, remember that patients might rely on their hypoxic drive to breathe if they've been retaining carbon dioxide for a long, long time. Their body is used to that high carbon dioxide, and in other people we rely on, or they might rely on having high carbon dioxide for their breathing. Whereas if you, those who retain that carbon dioxide rely on having a not so high oxygen for their breathing. So that's why we need to aim with a lower target, and that would help them to keep up everything. And there's just some patients to be aware of who you might have to, um, reduce that target down for. But I always discuss with you seeing you that if you're if you're not sure, so question now, um, for you to answer and you can put chances in the chapter books and we can go through it. So I treated a 70 year old, got a background as stated, Increase your PT she's under ward you on the respiratory award or say your name you should cure it deteriorates. Tack it big. Um, she's got a high heart rate. I'm so tachycardia. Blood pressure's okay. Saturations are low on four liters breathless in distress, sweating on. You think you're having an investigation of a COPD? What would you do? How would you investigate? So she we crying a chapter books and we're going to that fine so really will move on. Um, I'm sure you guys probably got back to chest X rays, AVG Bloods. And you respect for example. Start with. I remember she really, really concerned. You can always ask for more help. Okay, It's better to have more people than then being concerned and doing everything yourself. Okay, so you do the ABG, and with regards to a BG's, I'll give you some of my tips in terms of doing them and how to be successful near the end of the webinar. Um, but you get these results. So which one of the four do you think it is? Um, what I did on the check box, you could do a B C d going from top to bottom. Bottom on Beacon. Go through it. So in terms of normals pH normally 7 to 7.25 to 7.3502 you can think about as being, um, greater than 11. Normal PICO chur 46 is a normal range and bicarb around 20 to 26. Um, so let's move on to the answer top to restrict radio plus respiratory acidosis. So well done. For those who got that right? I'm even thinking about it. If you guys are taking part in the questions and thinking about it on your feet, he'll be really good practice for you when it comes to really life and having to think when your feet. Um so it's a risk for just the doses because I'm having a high carbon dioxide. I'll show you the acid basically crazy in nature on that having that govern ducks I push is that equation to give the side. They make more age plus, and so they become more acidotic. As a result. It's because of that, too, by cubs. Pretty normal, Um, and we'll go through how that might change a cure down quite a bit. You also noticed that people edema, so a demain the feet man, it's up to the ankles was reduced. Erin treatable as a raised your GP. Breath sounds are diminished, diminished. So thinking about all of these things, how are you going to have the patient? And let's just say that the patient was pyrexia So a few things down on we can go through, uh, what you might do. Okay, so remember all the different parameters oxygen medications short term long term. What? What you do arm you want. So these are a few of the things that you might do. So 50 m mosque, initially to really get the oxygen from 80% Teo at least above 90% and then think about titrating it down. Maybe after a few minutes you use, uh, Ventura Mosque. And when you use that insurance last, don't just use the don't just ask the nurse or use that mature mask and leave. Make sure you're asking the nurse of whether he's doing that. Teo. Also look at the oxygen saturations while stoned. That been true? Most. So. Maybe they start on the 28% mosque. Are they saturating? Good enough on that was all other stuff saturating 85% in which case you'd have to go up. So make sure that titrate the oxygen mosque with situations few hours might start. Does I really quick acting 40 mg to get rid of that demon? Maybe if there's fluid in the longest, that's that's really going to help salbutamol nebulizers, eye drop, remember lines, or so maybe two months. You can go with 2.5 mg nebulized decade and that takes place over a few minutes. I patrol pin. You can go with 500 micrograms, uh, on and you can go like that and then the antibiotic cover. You may want to give Doctor Cyclen, but follow your guidelines if you think it's an infected exacerbation. So you had crackles or it's pyrexia on your word by infection prednisolone or all on. Also, actually, you may want to give a nightly antibiotic for quick acting, but again, look at your guidelines, especially if they can't swallow. You know you can't give them pee or so think about these different things because patients always different. It's always individual circumstances. You need to consider prednisolone sore steroid, so that's going to be quite important on did it can actually work within hours. Give that as a normal dose on. If they're particularly in well, you can think about giving an IV dose, but ask your seniors about that. You're considering doing that okay and senior put really, really important. So question. How long would you try maximum medical therapy for patient who is in type two? Respiratory failure before you consider moving on with your months meant so say you tried all these things on, but it's still not helping. How long would you try before you think about the next steps? Would you read it a few minutes? Hours? Are we talking days? Um, what do you think? And if you get this, uh, you really are doing well, Um, only one on giving the answer. So it's one hour really, really important. You have to try and sort the situation. I'm in one now as best as you can with the maximum medical therapy. So that might be back to back nebulizers. So you might give this. I'll beat one, and I drop your nebulizer. Once you have a look at them, you reassess they're not improving. You might give you another set of nebulizers and then another one. You This is what back to back is on, then after one. Or if they're still not doing well, then, um, do you think about what we call an IV, uh, which you may have heard of? It sounds for noninvasive ventilation, which is bypass. So that's going to help them a type two respiratory rate it because it gets rid of the common dockside. Onda also helps to oxygenate them. Um, particularly you would do that if the patient is still intact. Respect really A with that rescript transit doses. And it's not resolving. Okay, so let mentioned that's what an IV does now, in terms of examination findings, we can go through it, tack tactically. So what are you hearing? Are you using anything on day? Are you hearing any crackle? So the's the different differential. I won't go through each individual one, but some of the key wants to go through. I never quit going. So just a quick, quick overview. You are going to have a future webinar on just X rays, but just a quick one just to remind you. Remember, Dr A B C D E S o d for details are for rights or rotation at the clavicle. Symmetrical in their size. Inspiration. Can you see enough of the ribs? Um, picture on an exposure A B C D e a a a breathing circulation die from. And then everything else. This is just one technique. Good news on this is just a Nimitz. Often X ray. Anterior posterior ribs, uh, scapula and so on. So no. What do you think is going on here, type it in the chart box on our, um, and then we can go through it. So you have to look quite particular on DTaP. In what abnormality you think you can see on. Then we can go through that, Um, and again, if you if you get this than, uh, you're doing very, very well. Um, so see what you confined in this chest x ray. I'll give you a few seconds. Um, remember, look at your airway. Your breathing circulation die from and then Okay, so is it normal? Is there something going on myself? Uh huh. Right. So it's actually a case of retrocardiac pneumonia. So if you got that really, really well done, so you can see they're small rounded, Estrace or pass it is it's behind the heart. So why I found quite helpful is, um, if you can't quite see it. So over the bottom off the heart, where you can see the border between the heart and the diet from on the chest X ray, um, and a way that you can help to look is if you're on Paxil, which is the system. A lot of well, which it might, using your trust in that the image on Then you may be able to see the A pass it ease a bit more clearer, so that might be helpful. And just remember, look at the cost of chronic lung goes, look everything else so Well, then, if you got that, um, let's crack on, um, what is this just X ray show? A little bit easier. Let's say this is a 50 year old, a gentleman and he's got a background off attention on it's common rib cough for one week. Productive green sputum. So easy findings have. These are what the answers are. So you got consolidation in the right heart orders own, and therefore you can see that it's not very distinct. It's sort of, um, made it unclear, right? Not bored. And that's because of the pneumonia going on there and pneumonia. You could cause something as the money when you actually see on the chest X ray. Okay, you can see the left heart border quite clearly and you can see the diet from the costophrenic angles very clearly. Nice and sharp. So you're not too worried about consideration that so presenting this you could say the details. It's a P a chest X ray. It's a pa. If it was membrane ap, you can't really comment on the heart because it might be magnified. Um, is the new rotation know clavicles? A question metrical adequate inspiration. You consume enough ribs there? Um, going on too. You might want to start with the abnormality, See? Might say. Well, actually, the right heart board is not very clear. And I think that they might be some, uh, pneumonic changes there, so ah, possible right middle lobe pneumonia or middle zone? Should I say when you're describing Just express. My testicle is owns instead of lobes. So write me to his own, which is making the right lower border and clear. You can comment on the airway central. The heart is not enlarged. Diaphragm. You can see there and the cost rectangles on you can't say anything was like fractures. Anything like that on This is the last chest X ray. So what can you see here and all right, so, um, it's probably a chance box and we'll see where you could get. So this is the finding, this one so you can see consolidation on the left lower zone. Okay, um and you can see that the Christopher next our ankles are sharp. However, I would say on the left side, you may not actually class that shop, and you may be concerned that there is some lower left. His own consolidation is well, okay on. But remember that you want to come in on the writers. Also is the right Okay, exactly is that sure I remember you. You presented in a similar way. And remember, the scoring system is for pneumonia. So this is probably what the management will be based on to the Curb 65 score. Enough to be aware of is that patients often have a follow up chest X rays after they've been discharged 4 to 6 weeks after they started the treatment. And that's to check if there's any remaining consideration. Remaining problems on that could be particularly useful if there If, if there is something that's found, it could be quite suspicious for malignancy, because if something still hasn't cleared up and it was treated and managed, then you might want to start considering the indignance. See, that's one of the reasons that chest X rays are performed later on on, of course toe. Ensure that the morning held result so a bit about the curb. 65 score. I'm sure you're sure you're aware of water is the confusion. A urea of more than seven respiratory rate in more than 30 equal or more than 30 and it's a statin. Whether on a BP of the systolic is less than 90 or the diastolic is equal to or less than 60. Eso Funny hostile guidelines. Remember that some medications can cause phlebitis. If you're giving them IV and remember allergies, patients might be penalized JIC, so you might have to go with something that could make a lot. Now, just remember that when you're clocking patients, especially on the medical take, smoking history can be quite important. In fact, it's very, very important because patients on may come in with something else. Okay, but then you realize that the de saturating and you're getting concerned and you find out this is just just X ray. So out of the gentleman is common with confusion. You do a chest X ray because he's de saturating and you look at the lungs and you you, um you think it's abnormal? Okay, so what's have no one about this fall? Have a look and have a look at the A beauty. So you find out the smoking your history and he's got 40 pack year history. He's got a acid doctor to the age. Uh, it's pure two is No, um CO2 is high, and bicarb is high. So what does this show doesn't show acute or chronic compensation of the kidneys. Your free t o uh let us know what you think, and we can go through that. No, just going through them. I'm sure lots of you way but to get down, sir. So it's type two in structure failure type dockside. Low oxygen on D is actually respiratory acidosis again. Okay, now, with regard to the x ray, because see that the feels are hyper expanded. Okay, Could die from is flattened. You can see blunting of the angles because off the diaphragm beings off latin. Um, Andi, you can see these chronic changes in the lungs as well. On another really, really useful thing to do in practice is always compare with previous chest X ray, because if she thinks something's abnormal. You're gonna have a look at the previous one. I'm comparing, and it could be really, really useful for that. Um and just remember that in terms of blank of our course, we got now with you. So this bicarb is high. When would you get a higher bicarb? So you got high bicarb if your kidneys have been compensating for a while now, So if you've been retaining carbon dioxide on that acid basic wage in is going towards the right, which I will show you means you got more hate. Plus some more acidosis, your bloods more cirrhotic. So your kidneys will recognize that and you'll get more bicarb produced a PSA result to try an actinic were Librium. I'm to try and, um, neutralized acid that I said, uh, acidity, acidity. And that's why you'll find that in chronic patients with chronic respiratory failure or chronically, who are chronic retainers rather off carbon dioxide. You see, their bicarb is high. If there wasn't kind of competition and this was actually case, the bicarb would probably be normal or maybe a little bit low. And that's because the kidneys I haven't really had time to compensate because kidneys can tape I was today. They can take a long time to constant compensate. That's why you might not see compensation or patients. Okay, on that might be a sign of acute situation. Okay, Um, so a few more things and pulmonary edema. Just a quick, um, showing you the chest x ray. You've got the battering sign. Essentially, you got called you megaly and etcetera. So congestion a clue effusion. Just to be aware of your see a meniscus sign on. Have a look at that. If you're not sure what that is, it's sort of a curvature off fluid on Often. You might find that chronically in a patient who investigate, so be about the management. Set them up. Right. May remember that sitting upright can help with breathing furosemide. GTM sprays. The BP is okay. Remember to do a fluid balance on Make sure you measuring that. Asthma attacks. Really important reported. Want to know? Um, remember that their severity markings. So what's the big flow like? How is the response rate? How the hell right and really important want to be aware of Is that is that in the normal range when we say normal range. Remember that in asthma picture life threatening last month, um, normal range is bad sign. Okay, that's not be the case. Because if if it's normal, radium means that there's tiring. They're not getting rid of that, see, or two. And therefore, that's a bad sign. And that's a sign of life threatening us more. Okay, so just be very, very aware of that. If you see that on on any PT, um, Grammy of steroids, the NEBs on your seem use it should thinking about moving forwards in that management. Okay. COPD um, remember different differentials. How my present in your destinations, on your management. So again. So it's nebs oxygen as you may need it on departed cover. If you think it's an effective exacerbation on except your now a question for your work. Um, eight year old Ethiopia, the so exacerbation of COPD on CPAP for the past few hours now Tranxene on. By the way, I remember CPAP in a patient with type two. Respiratory rate is only go. It probably well just worsen the problem because it would just pumped the oxygen on. Won't retain won't take out the common duct. So that's why you need bypass and tap to respond trivia or a CPAP way I think about it. CPAP It's over one way. It's credible providing oxygen, whereas Byetta is providing oxygen and remove your garden. That said, Have a look at the screen. Have a look at these values. What's the first thing that you're going to do? So if we go through it, they have, ah, lower speculate. That's Ah, certainly blame sent Acidotic. Hi. So too high oxygen by culture Hyzaar The first thing to do is what we're just the oxygen. Clearly, the hypoxic drive is being suppressed here. Okay? And don't worry if you didn't get this one right, it's all about learning and learning for next time. So the hypoxic drive is being suppressed here because the way you can tell is the oxygen so high on the CO2 resulted the or, as a result, has become so high because the patient is probably relying on the hypoxic drive to breathe. But when I say I practically live, they rely on having a low oxygen than what we might consider is normal to breathe. Okay, Um, because of them having a really high option saturation. They're not breathing enough. So they were changing are covered oxide, and they'll really be poorly. Okay, to stop that oxygen or reduce at least get those sets. Doctor 88. See how they are and take it from there. These are just This's just a table, Okay? Comparing type one and type two respect failure, including acute, an acute on chronic. So you can see in the acute on chronic. Um, you can see that the by Kabul. We raised that convention, okay. And in acute, actually, the bicarb can be normal, rising from normal or if it's been a few hours, it could It could be slightly raised as well. But that's how you tell if it's acute or not. Acute Symptoms of sign of high proximal being through on diaper company. Don't think we said so. Headache change in behavior. Papilledema the extremities could be quite warm on the comatose. So just remember very, very, very important and thanks to be aware of, I think base our I mentioned our discussion with the the equation. So the bottom right to the screen you got the acid basically Asian, So hate plus plus hates your three minus makes a juicy or three and then that goes back into see or two plus a head to toe. But what I do in my head, I should think about about that the way around to put a stroke cause the hatred zero through hate to see or three and then hate plus plus his show. Three miners. Okay, um and these are just some table of your normals on what happens in what, so respectful of the doses alkalosis and in compensation. Okay. And again, feel free to pop any questions down now that could be picked up at the end. Or you can ask at the end of Well, no problem. Top one risk of failure. Um, like I mentioned here is where you just have a box here so you don't have high common oxide. You just have our low oxygen. Okay, on you condition really approximate or just hypoglycemic. So there's different grade things as well. So in terms of management, you think about how you can provide the oxygen and don't drink, or so are the fluid overloaded. Have they got a, um, exacerbation of some sorts of think about oxygen being controlled, except so this is an example is you've got the PA or 28.9. Which, of course, is low touch toes. Which failure, like a mentioned research antidote, is a very concerning sign in love with seniors in what you're doing Medical management. After an hour, make sure you re assess him with the ABG. They're not improving. They're probably need an IV now. Differences between ABG be you might get you might get touched or both. That case what? They're both what they both have in common. They provide you with a bicarb and elected. Okay, an ABG will provide you with the oxygenation. It's arterial blood leaving the heart. The tissues have not used it yet, so you'll get, um, normal and the high. Hopefully I but ah, normal oxygen value. Um, and the Theo too, will also be effective off what you want to see. So, uh, whether you're because your body is not used it and go to an oxygen values, you can use an intact in a DVD. However, the the blood is venous so exactly it's name. It will have a lower oxygen and a higher security. Um, and these require really used to assess the ms for triple. Yeah, As, um, I'm sure you understand. Fewer sides to go pneumothorax, mucus pregnant and effusion. So think about these times when there's no air entry on one side. Okay? It says normal of a second of that sounds. Is there a PT is a Yeah. Uh, is there a special to pressure? Remember about all of think about all of these things and the CDs are very, very important. Okay. I don't think about how they got I have They got faster. Yeah. Um, they are they having a cardiac event? I love veggies. Could be really useful. So remember, you almost remember to ask about a p will be common that you find as a doctor. Um, and as a health care professional, you might come across a lot of patients with peas. Remember to ask them about any sharp chest pain, which is pleuritic. So is it worse when you're breathing any hemoptysis start coughing up blood? Are they on any anticoagulant have come across patients who are already on anticoagulants, get a pee, and then they have to be changed to another anticoagulant. What's the most recently, you know? Remember your investigations. So what's the scoring system that you use? It's a well school. And I'm sure you know, you need to assess the risk factors within that scoring system which will go through, Do it Do timer, do a CT, pa. And if you really suspect pee, have a chat with the seniors and you might want to start them on therapeutic heparin as per your local policies and go from there with CT, clear and, um, a chest X ray there really important piece to without anything else. So bitching about what school. So these are from primitive tachycardia, signs of activity mobilization, but they didn't see any pus is on previous, Um, once you get that school, there's different races interpreting it, okay? And just go with whatever your trust chooses, or whatever you think is high risk, you should definitely Street continues on. Consider starting this and management or further investigations. If this scoring for more definitely consider a ct pH on more of a work up. I'm not saying you can. You can do that. So, uh, in terms of a BeeGees, remember that there's different bit of advice. Okay, that I give so feel the post might be superficial. Drawback is strange, etcetera sick. Let me take it to this find. So when I So when I started doing a B C's you, the thing is a BG and practice procedures you will always develop as you go up. So don't be concerned. If you're doing the BeeGees, you're not being You're not being successful the first few times. Okay, Takes practice on. Do you need to understand the anatomy and how to do the procedure? So remember to help pay using aseptic technique, etcetera. Remember the anatomy. So you got the radial artery on drum, but it can be superficial. It can be a little bit deeper. You've got your muscle tendon as well. Okay. And remember your radial artery. It can be quite lateral. All right, um, and it can be quite high up. Welcome in the in the forearm. So gold where you feel the post best. Okay, you can use two things to feel or one finger on you. You then put your needed in. Okay. Remember to do the test to check for radio on artery supply on Deconsal dating and speaking with the patient. Because this can be quite painful, even though it's quite it could be quite quick. It can be quite painful. And remember that just speaking to them the whole time to make them comfortable, okay and going and ankle, that's best for that. They're not any of that patient. Okay, Some patients, you might need to go quite sharp angles. Some patients you might not need to, um, so it really depends. And then, in some with some strangers, you might need to draw back first. Somewhere there's you might not need to. Okay, so it's all based on these different chips on these different things you think about when you get the blood. If you're shooting up automatically, probably arterial, and if it's a lighter color, it's darker. Taking its time might be mixed. Might be venous. Run the gas if the oxygenation is high, likely to be arterial if it's low likely to be in this. So these are the different things to be aware coming towards the end now. Okay, um, further treatment. Don't forget your circulation, disability and exposure. Um, if patients really deteriorating, remember that you need to contact the next of kin. No problem. Medical team could do that remember, Hypoxia kills. So get that iron flow oxygen soon Can, uh, then cheery and reassess. Okay, Reassess with the treatment you give and see what's working on. What is it? Okay, so I hope that was useful for everyone. Um, if you have a couple of minutes and, um please scan the QR code on, I think the, uh, the back will be posted in the chat box. You could click on that link a swell. That's not what you think on do. You can also get a certificate for attendance. That is your You know, doctors, whatever stage you're right. You can't. You about four years, uh, to show that she returned it. This teaching on just a big thank you to everybody out that was useful. Any questions, Please put them on the chart box and we can get right to them. And thank you very much sometimes just going to place the feedback link in the chaps at and they ever been to just wait a couple of minutes and an answer and you in questions. Got anyone? My house. Um, there is going to keep a couple of minutes, and I'm going to, um 122 under Q and a session in the second, um, but just want to remind everyone please join us next week for another session ground by Dr Busy. Um, thesis neck surgery. You sign up for the for the future for years and okay, regard any questions? Um, no, not so far. But if you guys have any questions, pop in the Facebook chat and I can read them out would be really useful and some token answer anything you need. But you obviously, if you can think of any later wrong, you can always posted on the YouTube Canada's well, not your questions over that. And if there are no questions, um, I think we're going to wrap it up here and thank you. Thank you very much, everyone on if you if you do have any questions, as when he said, Please do message us on mind thing or contact us by the age of Channel. He's doing this next week on base. Make sure you fit in the feedback for it, because if you do, you get the certificate off 1st 1st for constipation, and it's very informative for us to make sure decisions of me are even better for you. And so thank you very much. Everyone on the, uh let's see you next week.