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Right? OK. We'll start now. Hi guys. It's me, Luke again. We're doing the second in the series of deteriorating patients, um, deterioration. So let's just move so swiftly on. This one is quite dense. Uh I've packed a lot into it. So keep an open mind. Um, and if there are points which uh, I haven't gone over in depth, then that's your opportunity to look into it in your own time. Ok? And you can ask me in the next session, the next session if you have any questions on that as always questions, save them to the end, make a note to them. Um, and we will start. Ok. So let's go ahead. So, hey guys, um, the aim of the series, you know that we, we've gone through the first part, we've talked about an at new score G CS, the basic survey examination, what we expect to find. Um Now we're gonna look at working out the cause is looking at the common causes for deterioration, uh and initial investigations and further examination after you, you know, you assess or you think that this is an underlying cause. So that's basically it. So we just want to discuss what are the most common causes for deterioration, how to recognize them and how to treat them, which is quite straightforward. Um So, you know, talk about a to e the reference values very important. What's the common heart rate, BP, uh blood glucose respirate, um uh oxygen saturations. Uh We discussed them the initial management, putting oxygen on getting some fluids in. I'll explain that a bit later. Discuss the scoring system uh for serial monitoring and changes in consciousness escalation. And SB ad we won't really touch, we'll touch on that escalation in certain scenarios uh in terms of different departments or specialists um and senior support, but we won't go into that anymore. Sbar we won't talk anymore. I expect you to uh revise that when it comes closer to your graduation time, uh how to properly hand over. Um So we're gonna go through a to e the common reasons. So let's start with airway a lot of this. We've already discussed anyway, in my earlier talk on like introduction to A S and at, you know, we have a foreign body. Um you know, we have blood in the airway can be a result of trauma hematosis. If someone is coughing up blood, you know, the uh they might be, they might have taken lots of nsaids, gastric ulcers may have formed leading to bleeding and coughing up that blood uh up, there's vomit secretions. Um We've talked about these things uh we talked about, you know, anaphylaxis and infection. Um and, you know, tumors are a thing. Uh if there's any esophageal tumors, it can impact on the trachea. Um So, yes, uh Lary laryngospasm, we talked about asthma. Um and even intubation can cause laryng uh laryngospasm. So, um yeah, now with depressed uh levels of consciousness, you know, you have to think about opioid overdose. We commonly give uh morphine or cocodamol opioids uh in a hospital setting for pain relief. But if you give too much, it can uh reduce the consciousness uh due to the reduction in uh respiratory drive as well. So, uh we have to consider that stroke and then trauma as well. Now, breathing asthma, we should all know what asthma is. Um It's a hypersensitivity reaction to a perceived allergen. And as discussed earlier, you know, these attacks can be fatal in a comorbid patient or even not in a comorbid patient in a young person if they're not tended to and they're having a serious attack, they can die um exacerbation of CO PD. So, um you know, we have um uh you should be aware about CO PD, especially in smokers, thick mucus production, you know, uh fibrosis, picture obstruction of the airway, uh like intermittently uh causes exacerbations of uh acute exacerbations. However, also if, if there's infection, then that's also gonna, that's an insult and that can cause one too uh due to the resulting inflammatory changes. Um Now remember CO PD patients uh are CO2 retainers. So they have a lot more CO2 within them, which gives them a type two respiratory failure element if not managed appropriately because they have a high, if you do an ABG on a COPD patient, you'll see that they have a raised CO2 SP CO2 in the blood um as well and a reduced oxygen, there's more CO2 in the lungs. However, on top of an insult, it, uh this can drop the oxygenation uh if it's been used up to fight an infection and increase the CO2 element more. Right? So, there's, that's what type two respiratory failure is where both the oxygenation is impeded and the CO2 is increased and not decreasing as a result in that sense, right? Um pneumothorax uh will get into the British Thoracic society uh in a sec. But uh essentially lung collapse. It can be caused by trauma, lung diseases, even mechanical ventilation, even a small tear in the in the lung tissue can just leak uh air into uh the thoracic cavity and cause uh pneumothorax. Um and pneumonia. We've discussed many times which you'll be familiar with it and it can exacerbate as sep as sepsis. Now, when we're treating these, you know, asthma, we need bronchodilators, we need corticosteroids, um and other agents that can be discussed with a senior, but the common ones will be salbutamol hyper proprium, um and corticosteroids to remove any or um uh you know, effusions that may be occurring with CO PD. We need bronchodilators again and corticosteroids again for effusions and antibiotics. Uh But this is the first kind of line. There are serious consequences for not getting rid of CO2 and improving oxygenation in a, in a large uh in a, in a very chronic CO PD patient. So that might involve something called noninvasive ventilation. It might result in the patient requiring mechanical kind of input with a bipap machine uh before stepping up to intubation. If that hold on one second. Am I just talking? Mhm. I didn't check. Uh Can you guys hear me? Just uh oh II think my internet just disconnects and reconnects. Can you uh someone just typing if you can hear me? And I'm sorry, my internet is probably acting up. Uh just remind me, just tell me where we left off some. Did we? Where did we get up to? Goodness me? All right. Give me one second. Let me just try and fix something here. Mm OK. Guys, my internet is acting up, right? Can people hear me now? Yeah, we can hear you and this better. Can people hear me now or we got up to pneumothorax? Is that right? Let me read. Let me, let me rejoin the call, right? Can people hear me right? OK. Let's restart it then. Yeah, chat's a bit delayed for me. Uh OK. Fine. Shall we continue? Now. Yeah, sure. Go ahead, Luke. So we go up to a pneumothorax. Ok. Sorry about that. So, yeah, with pneumothorax, we will feel, you know, one unilateral chest pain worsening on inspiration, sudden shortness of breath and peripheral cyanosis. Uh It's quite sudden, generally speaking. Um So let's move on. So this is the British Thoracic Society guidelines. Uh Right. So this is a protocol I pulled online and you can see in the protocol for asthma, there's mild, severe and life threatening at that at the bottom uh row, you see treat as BT S guidelines. There's a certain, you know, step by step protocol. Uh that's uh there er for asthma. So these are something you, this is something you can, you can look into and research a bit more. But essentially, you know, the main thing at your level when you start work is some um you know, nebulizers and uh some corticosteroid. Uh but nebulizers hopefully to kind of pull them out of bronchospasm. Um And you know, escalation as appropriate. Uh OK, so treatments wise for acute asthma, we must, you know, start the bronchodilators with corticosteroids, you know, you can use magnesium sulfate, but at that point, you should, you know, contact the senior for guidance at the very least ensure that the first line has been attempted. Uh It not only, you know, assesses whether second line treatment is appropriate and it ensures treatment to the patient which will impress any senior like um on your first job because you know, if you just see someone with asthma and run, tell a, tell a doctor and don't like tell uh actually start the nebulizers, then um that makes you look a bit foolish. You need to know that this is asthma and you need to know what we need to start treatment. Uh Cortico, yeah, corticosteroids. So, you know, if you are isolated and alone, then you know, you can call the consultant, call the registrar, if not possible. Then the respiratory consultant, if you can't get through to your own consultant is fine for advice as you need help. And if they're severe, then you know, push the crash buzzer, call double two, double two for urgent support and it's always safe to be sure while rather than wasting precious time. Um Now with co PD exacerbations, you want bronchodilators and cortic steroids but consider saline nebulizers, sodium chloride. Uh because these also help decongest and thin the mucus um which is pretty useful in mucus plugging. Uh can kind of help prevent an acute exacerbation with pneumothorax. You need uh needle decompression and chest strain, but this is again with senior support. Um And you know, at the very least you can order a bedside X ray because that will help the diagnosis um and pneumonia. We know you have to treat uh a sepsis six and consult microbiology with uh you know, you need to get a uh ascertain that it is a pneumonia by getting a viral throat swab, getting a sputum sample, um by getting a urine sample, you need to rule out a uti originating infection. Um You can get some pathogens or uh originating in the urine that can present in the lungs as well. So we need to rule them out. Um, so let's move on to circulation. Now, there's a lot of stuff here because circulation is very, very important sepsis in the top left like I already covered it, sepsis. Six. Again, ABG you or VBG A venous blood gas cos um practically, if you're able, if you have a cannula, well, if you have a blood collection, you know, needle in a vein, taking blood anyway, you can just get a VBG need uh a VBG syringe and with draw some blood and a and then at the very least it can be ran to the machine to get a lactate, the lactate. Uh You should remember is to find out the degree of ischemia or infection due to the shock or infective picture, right? Um Fluid overload, we'll talk about in the next slide, but it's essentially the patient has received too much fluids or there's reduced renal output suggestive of a possible AK I. Um So you need to, you know, determine the cause. Is it, you know, over prescription, is there poor, you know, monitoring uh of the fluid balance? And we'll talk about that in a bit so fast atrial fibrillation. A patient can present normally and incidentally, we can find uh atrial fibrillation but fast atrial fibrillation is a, is a, is a more serious scenario that requires rate and rhythm control. So they usually present with tachycardia and irregularly irregular rhythm. That is how you describe atrial fibrillation on an ecg uh palpitations, chest tightness, lightheadedness because the heart is actually beating quite quickly, it's fast. Uh They're gonna feel like very tight in the chest and lightheaded. Um And possibly, you know, might also have the syncope, there might be reduced, peripheral perfusion with a variable S one and auscultation. So the first sound uh because there's a uh it might be a bit variable in intensity because the filling is uh of the ventricles is affected uh because of the random atrial contractions. So, the main thing is we need to treat the underlying trigger. Is it something is, does the patient have a complex cardiac background? Um or is there something else going on that's aggravating the heart? Is there electrolytes imbalance? Um And we'll consider, what kind of side tackle should we tackle the rate or the rhythm itself? But in a fast atrial fibrillation, we need to attack the rate, we need rate control first for attacking the rhythm because the rate will stay, the rate control will stabilize the patient quicker just having atrial fibrillation with a normal um heart rate is better and you can be stable with it. Right. So, a pulmonary um oh, we actually, before I do, uh we're going back actually cos I want to talk about AK I in the second part. So acute renal impairment. Um The main thing here is if the patient doesn't get enough fluids and is dry, this will damage the kidneys leading to the AK I uh I know we're talking about overprescription but also just bear with me on under prescribing and hypervolemia, which is a circulatory uh concern. Um So it will damage your kidneys leading to AK I and impact electrolytes, secretion urine output. And uh therefore, there's some retention of fluids, right? If there is dysuria or painful urination and the patient can't pass a urine but feels the urge. Think of acute urinary retention. You want um a catheter uh in that patient ASAP. And you know, if the patient is, has got a catheter but is passing frank hematuria, then this is extremely urgent because this is suggest they're bleeding internally from their bladder that's or, or, or somewhere along the um uh tract. Um So, uh when we're also assessing for acute retention, you want uh a bladder scan, an ultrasound scan of the bladder to determine how um many mils of urine there is. Now a quick question. Does, can anyone tell me, um can anyone tell me how much your urine, uh the bladder can hold normally? All right. How much urine can the bladder hold? Take a guess is fine as well. Well, it's not like it's nothing excessive. It's actually more reasonable. It's roughly depending on the person 400 to uh 600 mL. So if a nurse rushes to you and yeah, exactly. That. Uh Thanks for that. So, yeah, if 400 to 600 depends on the patient and the size et cetera. Uh male or female, that'd be very variability. So, if a nurse comes to you rushes and says this patient can't pass a urine immediately, ask them for a bladder scan, you need to ascertain if there is a lot of urine in the bladder, a patient can have, you know, pa can have problems passing urine anyway, but that may not be in acute retention, that will kind of assess the degree of emergency, right? Anyway, moving back. Um So where were we uh with atrial fibrillation? So, yeah, pulmonary embolism. So there's a clot in the vasculature of the lung. It depends where uh depending on where it is, it can have a more serious or more mild effect in comparison. Um Now, if the patient has a sudden deterioration in the absence of infective signs, like no productive sputum, they can still have mild paria um in pe. So that's not enough. But you know, I have to look at the other clinical signs of infection. Um then uh you need to consider a CT PA a CT pulmonary angiogram. But you need to ensure that the clinical picture kind of supports it. So, you know, tachycardia, tachy, tachypnea, hypertension, hypotension with a raised JVP venous pressure, you'll see uh uh like an engorged uh jugular vein, uh be on the, on the right because of, you know, the right side of the heart that's can back up and congestion, right. So there's raised JVP, pleuritic chest pain, uh reduced breathing sounds, you can still have, it can still be clear in the chest, but you may hear some variability there. But to help you with that, um you know, you can use something called the wells score wel LS. Well, wells score on med CALC, it's the calculation to kind of score up and tally up how serious the pe is if there's hemoptysis as well, very, very, very strong indication of a possible pe. Um So uh you know, use these things, you even they themselves on medal site that positive score, the incidence is still 28%. So when you're discussing with a radiologist, you need to kind of explain to them quite clearly why you think it's a pe or they may disagree with you and say we're not really keen on doing it. It doesn't really sound like pe to me. I would ask for these like I need you to investigate more and rule it out with a pe. They also, they ask for D dimer depending on the trust and the hospital, but there's a, it's not really a great correlation uh for D dimer as well. I'm not going to get into that but look into it a bit more. Um now, hemorrhage quite an obvious one. Tachycardia, low BP, pale and clammy, reduced consciousness. You need to, when you're in your 80 you need to uh identify as the cause of the bleeding. Yeah. Are they a postoperative patient? They might have internal bleeding as well. It may not be an external, it might be PV, it might be pr we discussed this and you should be ready to trigger the major hemorrhage protocol. When you start work, you'll kind of get to grips with that. So don't panic too much, but essentially it's a quick protocol to get uh universal blood from the blood bank in the hospital straight to the patient immediately. Um as an emergency. Uh now a CS you know, acute coronary syndrome, heart attacks, um these kind of pictures where you have central crushing pain, it can radiate to the back, left arm, uh down to the stomach. It can vary in different places depending on the area of the attack on the heart itself, it can radiate in different directions. Um Now, if a patient has known Angina, then they also you, you have to also think is this unstable angina. Um when it comes to management, they, if they had a previous heart attack or angina or complicated cardiac history, they may, they may have a GTN spray a glycerol trinitrate spray, a sublingual spray already prescribed and uh, you know, find out if they've used it and make a note of it. How many sprays they've been given? Get a 12 lead ECG and review for presence of ST elevation or depression and semi stemi. Uh and if not unstable angina atrial fibrillation, whatever you want to find out if there's an M I get an ABG for lactate as usual and oxygenation. Um PA CO2 and O2 for your awareness and form bloods including a troponin co troponin is a protein released by heart muscle when they're damaged. So it's a good kind of measure to say if there's any cardiac ischemia uh occurring. Uh the mainstay is, you know, you need to treat the pain because they are, they will be in pain. Some may not be, there might be a silent M I. Patients may not actually have any pain. And when you do another E CG, you might find an ST uh depression or something to suggest that they had a silent M I but you know, give analgesia with some morphine, uh give nitrates the GTN uh aspirin antiplatelets, commonly used clopidogrel because when there's myocardial ischemia, the heart is no longer pumping effectively, that can give rise to a clot. Um and also in the vasculature of the heart, if there is a blockage, if that blockage is as a result of a bleed or something else or a clot that is formed uh as a result of say atrial fibrillation underlying. If the atria are pumping irregularly, there's stasis of the blood, a clot will form, goes down, pumps up, gets into the coronary arteries and blocks itself there. That's the main reason why we need some um anticoagulation to kind of break it up. And if it doesn't work, then we need to consider PCI, which is an invasive um stenting or, you know, um or catheterization, more specifically of that occluded vessel to try and open it up. And if that doesn't work or if you know, the main stay is as soon as it's recognized from the bed to the catheter lab where this occurs 100 and 20 minutes max. However, if this has occurred after a long period of time and you're just realizing it now and um it's all you've been waiting and it's been more than 100 and 20 minutes, then you need to consider thrombolysis with a more serious medication like out of place. And then also with acute Coronary syndrome, you have to think about stroke, do perform a fast test, uh f ast facial droop on one side, um you know, limb, weaker limb weakness on one side, um speech slurring and it's time to call, you know, emergency services or recognize the symptoms of a stroke because it can be also um that this picture can still um uh link with a stroke. So fluid overload you know what types of fluid I'm not gonna go too much into it cos it's its own topic. To be honest. Med school really never emphasized the importance of balancing fluids in patients, although they've covered electrolytes here and there. Uh, in physio, er, physio physiology and pathophysiology. Um, if a patient was hospitalized, they need to have a supported oral uh, diet including fluids. However, if they can't orally take in any fluids, then you need to give them IV fluids. Now you can do your own research. There's loads of good uh resources to pull from for uh more information but generally speaking, the these are the types of fluids. Um mm So we give sodium chloride naught 0.9%. Uh We can give Hartman's solution which is a balanced ratio of electrolytes. Uh or it's also called called plasma light because it's, it mimics plasma uh in its content without being plasma um by containing a little bit of sodium uh and a little bit of glucose that it and um as well as some potassium and chlorine, it's quite balanced. You can get what we tend to call maintenance fluid, which is a smaller concentration of sodium chloride with 4% glucose. Um And that this can be with or without potassium chloride, which is important because if a patient has too much or too little, you might want to supplement or not supplement them with uh potassium chloride. And finally your 5% dextrose infusion. This is useful in diabetics, um uh diabetic patients and it also has uh use when someone has too much um uh calcium, there's different applications of this, right. Um So use common sense uh you can do your research into it. But the general consensus is, you know, is the patient dry. If they can't eat or uh or tolerate orally, then yeah, they need fluids. So are they dry mucous membranes? Check the tongue, uh if they're dry as well, check uh uh capillary refill time if they have hypertension, hypotension. Um if they are dry, you know, can they drink oral fluids? Normally, you can just advise them to drink it. It's always better to avoid giving IV fluids. Cos you're inje um fitting a cannula, that's a potential site of infection. But you also have to consider, do they have heart failure? What type of heart failure do they have? If they have congestive or, you know, right sided heart failure, then you don't want to give them too much fluids. Cos they can uh just present the excess fluid, er, won't benefit them and they can present with uh pleural effusion or edema. Uh Do they have electrolyte imbalances? Like I said, do they have abnormal urine output? Do they have any chest drains? Do they have any postoperative abdominal drains? If they do they should get some fluids overnight or, you know, during the day? Um Do they have an infection? They should get some kinds of fluids. There's different rates we choose to give fluids in, uh, per hour and that's usually dependent on their weight. Um, but also you can choose if they've had a lot of fluids and, um, you know, they, uh, you just want to give them something because they can't tolerate anything orally. You can put it at a slower rate. Use your common sense. Right. So, let's see. Here's a fluid chart on the right. Well, it's a big chart. A lot of tables was quite simple. You can see the general, um, the general kind of um things here. So we have input here. We have output, we have it takes into consideration oral ng or peg feeds, percutaneous, endoscopic gastrectomy, uh gastrostomy feed. If they can't, if they can't take anything orally, uh we have intravenous, uh subcutaneous is not really that common. Main thing is intravenous and they note the hourly rates, uh or, or of them and any flushes, the, the this can look like a different, this can look and appear differently in different hospitals, right? Um The, you're noting the time, the volume and the type of fluid um and the hourly total and there's usually a running total to help you calculate the, the total input. And then we have, you know, the output with the main thing here being uh urine bowel, uh stool, um, or, or if they have a stoma, if they don't, if they are not passing stool through the back passage, they'll have a stoma maybe. Uh, you need to check, uh, for that. Usually nurses will take these, but you also have to be vigilant and check this to make sure it's being recorded accurately if they've aspirated or vomited, if they have any drains and then all these are tallied up and you can calculate the total balance if they're dry, if they're negative or if they're positive, you can still have a lot of fluid in and a lot of fluid out and be positive. But that might be necessary to have a lot of fluid going in if they have a renal impairment. So there's a lot of variability and importance on accurate measurements and knowing how to prescribe fluids and what is the indications and contraindications, right. So just to briefly talk about this, um this is uh fast af I'm not gonna go into EC GS, plenty of resources out there, do your own research. You can look up example ECG 12 lead EC GS and you know, practice yourself. This is something I don't really, shouldn't really need to teach you uh in the sense that you can't already find information online when you start work, you know, you as af one will be, you know, clerking patients and doing a 12 lead E CG on them and getting a baseline and assessing them for any irregularities, right? So look into how to do an E CG and how to interpret it. Um It's a basic uh skill which, you know, it will come with practice. Even I've met F twos who aren't that great at, at EC GS. But if you come out of Bulgaria, go to a UK hospital and you know, a are accurate with your EC GS, you'll oppress everyone having not been taught in the UK, everyone has the UK people will tend to have some kind of notion to um uh international uh students, even if they're English, if they've studied abroad, they might have some preconceived notions. So always aim to impress right? The general points, I can explain, you know, the questions we are, I like to ask them in questions. So is there electrical activity, we can see there's a wave form, there is uh what is the rate? Well, usually you count the large squares and you know, kind of work it out that way or a quick rule of thumb is there's, you know, 300 100 and 50 100 there's a way of breaking it down. So it for every square between the very square between the peak of the P QR S, the R to R interval. Um So here's 300 you can say it's 100 and 50 it might be 100 and 75. But if you look at the whole thing, you know, is the rhythm regular. Well, no, there's some variability in the R to R interval duration like this one's quite long. But over here it's a bit narrow. So it's irregularly irregular, right? Um So this is atrial fibrillation and you know, other questions is the QR s complex broader, narrower. Is there atrial activity? You know, these are things you can look into your own time, but this is af essentially variable R to R intervals are a good kind of sure fire sign if, if you are able to take away anything from this confusing E CG. So let's move on uh for disability. Uh we have, you know, hypervolemia, hypoxia, hypercapnia. We've kind of inferred this with CO PD and other things that, that we've already discussed. But hyperglycemia and hypoglycemia in diabetics, please, please please uh read up on diabetes management. It's criminally overlooked and uh love doctors including myself at times. We just forget and we don't really think too much about it and we just call the endocrinologist for advice, but you should know the basics. Ok. So with hyperglycemia, you'll see, you know, polyurea, polydipsia dehydration, altered mental status, but this comes with nuance right? There can be degrees of hyperglycemia. A nurse might be taking serial BM measurements and say, oh, diabetic patient already on a treatment of a regiment of uh insulin blood sugars are quite high, but, but he's stable, he's stable. Ok. You know, he's got hypoglycemia, he's got diabetes. Do we intervene? Jump down the throat immediately or is it better to wait and see if it settles. Did they have a meal? You know, there are different variabilities uh variables to take into consideration. We want a urine dip for glucose and ketones. We want to rule out DKA in type one diabetic ketoacidosis. Um And we need to rule out hypo osmolar hyperglycemic state HHS, which is the type two form. Um You know, shout for help if you're not sure as always when you're assessing the patient uh or if you need a hand in hyperglycemia, we see the autonomic kind of response. So, sweating, tremors, palpitations, anxiety and um out of mental status, they're running out of sugar cells are running out of energy and the most sensitive of that will be the cells in the brain. So you'll see uh hypoglycemic coma, convulsions, mental status, reduced consciousness. You know, if mild you can give some glucose tablets, uh tablets ask to drink, uh have a sugary drink and recheck the blood sugar if severe though, give her dextrose infusion uh and give an er im glucagon uh with some more monitoring to see if it's stable again with senior support. Now, with seizures, seizures, we should all know what seizure is. Um But you need to know status epilepticus, you know, you need to know if it's convulsive or non convulsive. If a seizure. If a known epileptic is having a seizure, more than five minutes immediately suspects status epilepticus. It's a more severe event um you know, or either that or if they're having multiple seizures without full recovery, uh if there's any confusion or unresponsiveness after a suspected seizure as well, that's an area of status epilepticus. I had a stroke patient who'd come in, uh who also had a um a status epilepticus, but he was still showing confusion signs which muddied the waters because with stroke, you can have an element of it, but it's not common to have confusion with stroke. So, you know, it was status epilepticus, even though he was aware and alert, it's a a non convulsive form where he was quite confused about what all had gone on. Um So, you know, stroke trauma, any uh cns infection, men, meningitis. Um you know, and also you need to take into consideration hypoglycemia can also induce status epilepticus as well as electrolyte imbalances with hypernatremia. And also, you know, alcohol dependent withdrawals are awful. Um And if you or drug abuse, you know, if you get a patient with who's a suspected drug user, you need to uh perform uh gene wars uh or a fast alcohol screen. So, you know, I'll show you that in a sec, but it helps kind of uh get an understanding of alcohol or drug consumption. And with alcohol, you need to also look at the uh vitamin levels uh because you want to pre prevent wen encephalo encephalopathy. So, um so vitamin um uh Vitamin B you want to also look at as well. So with that, you want IV LORazepam, there are different forms for different patients. There's rectal, if, if, if they're unconscious uh or if they're not tolerating, if they're convulsing, uh you then move on with neuro input uh sodium valproate and le uh tiac infusions if that doesn't settle. Um And you want a CT head, you want an Mr head, you want um uh uh you know, um some CSF fluid analysis, uh if, if there's a infective element to it, like meningitis, you know, raised intracranial pressure, you know, or other neurological consults like a stroke, you know, you need to do a fast, like I said to present as an A as an acute coronary syndrome. So get a CT head if you have any suspicions, like we, like we mentioned with drugs, if they have a, if they're presenting with an overdose, you need to check if they have any allergies, check if they're known IV drug user. Um And you know, and if they've taken something suspected, you know, you might need to use charcoal, you can consult the toxicology protocol uh for the guidelines there, depending on the drug, there's one very hospital as well and there might be other iatrogenic causes uh that we might have given them too much uh uh opioids uh causing a deterioration like I said earlier. So here is uh like a um like a G MOS type um or, you know, um, like a epileptic kind of, you know, symp, it's, the GMO is kind of management. So, you see here. Mm. We see, you know how they kind of break it down. So, if they have had previous withdrawals, uh, if they were severe and if they've had a high g, more score and, you know, you kind of break it down. It kind of guides you to give LORazepam or diazePAM. Um, or, and PEX, which is a vitamin supplement to prevent Wernick encephalopathy. There are alcohol withdrawal guidelines, you can look up as well. And at the bottom, you see, you know, uh what GMOs is, you're kind of looking for these signs and you're looking for these kind of uh patient groups and if there's any other things present with the patient and there's different differentiations for that, each hospital will have their own kind of drug, drug and alcohol team to kind of give you advice. So there'll always be people to help you out. And also actually at the top, uh it's also very important to ask what kind of alcohol they drink. You know, there are certain backgrounds of people who drink stronger things than others. Uh be regulars at a pub, they might just buy kegs or, or like, you know, six packs and drink them all in and then have spirits, you know, you'll find a lot of different type of people, many different types of people. Uh ok. Uh So, yeah, that was very quick, very, very, very quick. So I just wanted to go through, um, it's very packed, but I wanted to try and keep it brief around an hour. So to give you, uh, some, uh, some a, a test, we'll just go through some cases will probably end around uh, 720. Um, but I think these will be helpful for you and it, um, and I'll break it down as well to give you an idea. So we have a 58 year old woman presenting with sudden or not short onset shortness of breath, pleuritic chest pain and hemoptysis. She has a history of recent knee surgery two weeks ago and is tachycardic with mild hypotension. So, you know, what do you do? What do you, what do you think it is and how do you manage the patient? Right. So let's break it down to save you time. Um, let's break it down. We have a 58 year old woman fine. Um, but they're presenting with sudden shortness of breath and pleuritic chest pain. But the key factor here is hemoptysis. There is a history, you know, there's a recent surgery, wood surgery, there is an element of, you know, bleeding risk, right? That's your clue. Um So there's a recent surgery two weeks ago, this patient's tachycardic. So raised heart rate, ok. And mild hypertension. If a nurse comes to you asking, um, tells you this, you then need to go and you know, assess the patient. So, you know, we look at the, at um so a patent talking in short sentences, you can hear they're kind of struggling for um um they're struggling to breathe a little bit, but it's not a physical thing. They just have shortness of breath. Look at uh look at b so respirate is 28 that is quite high, that is quite significantly raised. Um And there's uh oxygen despite this is 89. So they're hyper hypoventilating. Um uh hyperventilating, sorry. Uh They're 89% but they're on air alone, right? And uh they've got reduced sounds. When you auscultate, you can hear breathing sounds, but when you auscultate, there's kind of reduced sounds uh on the right middle lobe, but there's no crackles or crepitations, there's no wetness or, or dullness there. Um Overall, it's, it's fairly clear, right? So that's not really helping you, you know, the lung, uh um oxygenation is affected, but there's nothing avert that you can hear. There's just some uh reduce sounds, but you don't know if they have that. They might have some underlying smoking. You don't know. Ok. So circulation raised heart rate again, elevated 118, but the BP is 95. Normally 100 and 20 or so. It's 95. It is hypotensive. It's called peripheries and there's no uh edema. And um there's uh I didn't add it here, but let's say capillary refill time isn't great either, uh, when you pinch their finger and let go, it comes back around 2.5 or three seconds, let's say. But the clear thing here is you look at the neck and you see there's a raised JVP. It's quite engorged disability wise. G CS 15, R 15, they're alert, but they're fairly anxious. Obviously, the blood sugar is 7.2. That's fine an exposure when we have a look at the legs and look at the e everywhere else. There's no other signs of the abdomen or thighs. There's no problem uh with uh with the genitals um and look at the calves mainly and there's no calf swelling or issue with the knee joint itself. When you check, there's no signs of bleeding um or inflammation. Ok. What do you think it can be? Any guesses don't feel? No guess is too stupid. It's best to guess. Uh and let me know as well and hopefully, you know, we can just break it down. Ok, Nick. Hi, thinks it's pe anyone else? Well, I hope I broke it down quite clearly and gave you good kind of hints. But yes. Uh it's um ap, right. So, after surgery, like I said, there's a usually a short period of time where no anticoagulation is used as it's a bleeding risk if you give someone anticoagulation after just coming up from vita all the staples or sutures or, or, and, or, you know, or, you know, sites where they have gone in and done their work might just bleed. Uh So there's a kind of grace period before restarting. Um Even if they, if the patient has, uh, has been, you know, given a doac a direct oral anticoagulant like Apixaban or Rivaroxaban. If they're on that for cardiac reasons before surgery, it's usually withheld and then, you know, a low molecular weight, uh Heparin is used such as Delta Parn, um, or they might use an infusion of um Heparin. Each hospital will have a kind of guideline on that. But that's the general consensus and thought process behind that. So let's have a look see. So we do a wells score and if you, you don't need to know the score right, you need to know what the wells score looks for. And if you look up after the session, you'll learn it too. I look up med CALC. So the recent surgery is a big, big indicator. Um because after surgery, there's a, there is a clot risk you have to be aware of, there's tachycardia. So the heart's trying everything it can to pump more blood around, but there's hypotension. So there is clear some kind of back up because the pressure itself isn't that strong hemoptysis. So with a pe you know, um there's an element where, you know, if they're trying to breathe, there could be some micro vascular tears due to the congestion and that can present with some hemoptysis that's a good indicator as well. There are other things on the well school looking at pe um Right. So the gold standard, we want a C TPA um to identify this, we explain our clinical findings, we explain the wells score and we are suggestive that it's a pe we discuss with the discuss this with the radiologist for an urgent CT PA. They agree, they do it and you have a look at the report or you have a look at the scan. Usually for you guys, you just need to look at the report and see what they say. Um And it confirms APAC a pe the management plan. So what do we do? We need, first of all, before they go down, we need to make sure they get well oxygenated or they'll deteriorate quicker. So give some high flow oxygen with a mask and maintain above 94%. We need to give them some fluids before hypotension. Um consider a Hep heparin or a doac anticoagulation, but this will involve a CIA because there are certain nuances depending on the situation. Um And you know, you want an E CG, you want to rule out atrial fibrillation because atrial fibrillation can cause a clot that causes a pe. So someone can, may have a pe after surgery, but they may also have af which is what caused it, which is more important after the episode for management. You need to determine if it's an identifiable cause of the pe if it's the knee, then that's the risk of the surgery, POSTOP complication. But if it's atrial fibrillation that changes things and more investigations need to be looked at, uh, need to be investigated, more, investigate, more investigations need to be ordered and look and this needs to be looked into cos this patient will most likely then be started on a long term anticoagulation plan with Apixaban or another DOAC you want form of blood. So, like I said D dimer has been historically used, but there's evidence to kind of contest whether it's relevant for pe best to all put it on anyway. Um And you know, again, ABG, you want to know the lactate, uh how much, how much oxygen is in the blood, how much CO2 is in it. The ph electrolytes electrolytes can also trigger the atrial fibrillation as well. Um And so you want to rule that out C RP for any uh ischemia or inflammation as well as you know, infection if you want to rule that out and the full blood counts for uh hemoglobin as well if especially if they're having hemoptysis. So that was the first case case two, a 65 year old man presents with central crossing, chest pain, radiating to the left arm and jaw. He feels nauseated and clammy. Past medical history includes hypertension and type two diabetes. So again, what do you do? What do you recognize, think and how you manage. So any guesses, your clues will be the central crushing chest pain and the left arm and jaw. Yeah. So it's quite clearly. Nm I guys, right. So let's break it down. So we do an A to a anyways patent, he's able to speak but uncomfortable because of the pain, breathing wise, he's got raised respiratory rate of 22 and, you know, oxygenation is 95. So his lungs are, are actually doing its job. Um It's on air. Um And there's no crack or wheeze, it's clear sounds when you have a listen. All right. So circulation wise, heart rate is 100. Um and his BP has 100 and 40/85. He's pla pale and clammy. Now, the main thing here is you want a 12 lead E CG, like I discussed earlier, the E CG shows ST elevation in leads two free and F when you study your EC GS study ST Temi and N sties. These leads are quite key when it comes to ST elevation. It's more obvious, so to speak, disability wise, he's fine, he's conscious, he's just a bit anxious. Um And his blood sugars are normal and it's important to check them because he's type two diabetic. You don't want to uh confuse things or even if he does have a high blood sugar, you need to also factor that into your diagnosis cos then you'll have other things to uh you need to consider when managing the patient. If he had a high blood sugar, then you need to also give insulin, right. So that's another step. And another diagnosis with exposure, there's no cough, swelling, no edema, no other signs of bleeding or any other cons to your concern um relevant to the presentation. So yeah, it is a semi. So what we do here, you know, we need to manage the treatment, uh we need to manage the symptoms. So give some pain relief. A good uh kind of acronym is uh monarch. So, morphine oxygen nitrate, uh nitrates uh aspirin and clopidogrel, you need morphine for the pain, oxygen uh um to keep, you know, to keep them well oxygenated if indicated. Um nitrate uh nitrates, like I said earlier, when we talked about it, the sublingual g uh glycerol trinitrate for pain and preload reduction. It has elements on preload to help hemodynamic stability, aspirin and clopidogrel as anticoagulation uh to kind of uh have an effect on breaking up the the perceived clot. It can be um it may not be a blood clot in that sense, it might be a fatty clot. So, if they do not uh improve uh in that acute frame, you know, you need to call the catheter lab for urgent PCI um percutaneous um kind of catheterization. Um or like I said earlier, thrombolysis, if it's too late and this is all senior led. So, discuss with them and how you escalate. This is, you know, you know, sorry to bother you, say medical reg I've got this patient. He's, he's, you know, uh this is old. He's, these are the clinical signs. This is my at e uh I believe he has uh looking at the ECG, I think he a stemi. Um, my plan is, you know, to treat it the, the, the symptoms with morphine oxygen, et cetera. We might need to consider calling the Cath Lab. Um um if anything's more serious uh for any intervention there, um maybe um you know, heparin, if it at this point, if we don't have time or if it's better, certain clinicians or seniors might prefer different methods, they might have done research. So always ask them uh what they would prefer, but you're eliciting what you're seeing, you've assessed them, you're reporting back what you've assessed and what your suspicion is and what you suggest the man plan is, you know, as a handover as an escalation. Now, after this episode, there's long term management, this person has had a heart attack. So we need, you know, bisoprolol beta blockers, ace inhibitors, statins, things to reduce um fatty, uh build up of plaque and all the rest of it. You can look into it. Uh But it's quite common um knowledge of that you should have. They also may use uh long term dual antiplatelet therapy called DAPT dual antiplatelet therapy. It's common in stroke. Uh for tia S trans uh, transient ischemic attacks bear in mind, you know, with acute coronary syndromes, you have to also rule out stroke. So, in your, um, in your assessment, you need to do, perform fast test just to see if they don't have any stroke symptoms because you might also want uh a CT head, right, the last one, before we round things up. Um, if it will let me hold on for some reason, it's not showing on here. Hold on one sec. Let me end this and give me one second and we should be back, right? Everyone should be able to see this. Can you see this? This is case free? Mhm. 72 year old man with a history of COPD presenting with increased shortness of breath, wheeze and productive cough. He reports purulent sputum and has a 50 pack year history. Now, do you know how to calculate, uh, p pack years? You should, uh, you should know, um, and also, you know, when assessing patients and clerking patients, um, you should also ask if they smoke, if they drink, um, and work out roughly their frequency in years. So if they usually smokers will usually say I smoke this many packs a week or per day and you just simply multiply the number of packs you smoke per day by the numbers of years that you have smoked, right? That gives you quite an insight into, uh, their smoking habits and therefore you can kind of um assess the degree of CO PD uh if they have known CO PD. So what do we do here? We do the A two ea patent coughing with greenish brownish sputum. So it's productive re wise, you know, respirate is 30 saturations are 88% on air. There's a diffuse, wheeze, reduced air entry bay. Well, the wheeze and the air entry are kind of kind of typical for CO PD, but the saturations and the respirate is a bit worse and more severely impacted even though you know, the accepted level is 88 to 92. If they are having, you know, some kind of respiratory problems which they would associate as not normal for them uh for CO PD, which is something new to them, then it's something a bit more serious. So don't be confused. We do an ABG right. Here's your key factor. Now, I don't expect you to remember that. Uh You know, right now the references, but I'm gonna tell you that the PH is acidic CO2 is quite, quite escalated, quite high. Um Oxygen is quite low. So we have a lot of CO2, we have reduced oxygenation and we have an acidic um blood. So it's suggestive of a seemingly type two respiratory failure. Uh picture heart rate is 92 blood pressure's 100 and 30/80. There's good perfusion. So that's OK. E CG shows, wait. No, that's wrong. Ignore that this patient does not have an ST elevation. That's a mistake. Um G CS is 15 out of 15, he's alert, but tiring blood sugars are 6.5. So it's again normal and exposure when you look at his chest, you know, it's quite hyper inflated, quite barrel chested. And he's, there's a lot of accessory muscle use rather than any, rather than the regular kind of ventilation. There's no peripheral stenosis or peripheral edema, but he's tiring, he's respiratory, you know, there's respiratory tiring here. So what do you think it is exacerbation? Right? It's quite clear. So, with this, how do we treat the symptoms? You know, we want controlled oxygen therapy, maintaining 88 to 92 we want some nebulizers trying to open the airways up. You know, if there's, if there's a lot of sputum Sabine neb nebulizers can't hurt, give some uh IV corticosteroids um in case there's any effusion as well, antibiotics in this case, uh because of the purulent sputum, you'll run it off as a hospital acquired pneumonia until proven. Um So how it usually works is if a patient presents act actually, in this case, if this patient presented to the hospital with these symptoms, you would actually treat with um as a community acquired pneumonia rather than a hospital acquired because there's differences in um in in the causative agent, especially in hospitals, there might be resistance as well. So each hospital will have a kind of generalized uh protocol for these types of pneumonia. And if they vomited, there's an aspiration pneumonia protocol as well. You know, we do the ABG, it's showing types of respiratory failure and respiratory um because of the respiratory acidosis and increased CO2 and reduced oxygen, right? So um hold on one second, give me one second. I just had an important call on. All right, sorry about that. Um So as we were saying, yeah, we showed this on the ABG. So we want to repeat that to see if things have improved and if they haven't, uh you know, you want to consider noninvasive ventilation, possibly with most likely with bipap. If these initial treatments don't work, you need to discuss this with a senior and ask should I refer to respiratory for uh to uh and escalate the patient to HD U or ITU or the respiratory department for an IV? All right, and post acutely, there's antibiotic, antiviral treatment if they do have an infection, chest physiotherapy to clear the sputum. Um and you know, smoking cessation advice as well. So yeah, guys, thanks for this. This was basically it got some resources here. So, you know, look up the asthma attacks, look up British Thoracic Society guidelines. There's also UK kidney.org, they have guidelines for renal management. They're really, really good. Uh Gee medics is always for the general F one kind of things. Oxford Medical education also has some very good resources and information on prescribing and other things as well. You know, look up how to read an E CG now uh because I worked in Scotland, right? Decisions is the kind of generalized database for some guidelines. So I've attached one here for the Gene wars. Um just look it up, right? Decisions.co dot nhs.uk for more information. And I hope that has helped thank you guys. Any questions at all? The whole idea of this was the kind of, you know, give you guys a breakdown of the common ways we can assess patients at e and use that to kind of understand what they might have and how to manage and, and escalate and treat it. Everything I've talked about today, you know, in your own time, look it up, um watch this back if things don't are not clear to you on the reasoning or why things are happening, what clinical signs uh specifically uh correlate to different things and look it up in your own time, do some research and I hope hopefully things will be more clear. Um Yeah, and there's always, you know, you can contact me on Instagram or uh email me or get in contact with the boys who can pass it on to me. Um I'm always here to answer any questions. Um However, however, e even if they are silly ones, right? Like thank you very much, uh we'll see you again next week, same time guys.