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yesterday's content in case anybody's wondering where yesterday's content that will be posted today and today's content will be posted tomorrow on the medal page as well. So just look for today to see yesterday's video recording as well a slides on going to the next, like Kitty. So So, uh, if you haven't done so already and we keep hammering away about it to get a latest information about what the six PM Siris is doing, what events you've got Post sit up and what's going on. And to get questions to console that you're learning. Please join the Instagram, Facebook and Twitter pages on. Please spread the word about it on. Also, if you haven't done it already, please make a metal account. It's how we get feedback for providers. The only thing we ask for what this free teaching is feedback, which is so useful to provide us because they can add that to put four deals and it helps us on. Also, the more people would get, the more sponsorships we can get, the better we can get the six PM Siris and provide you with more providers, more content. Uh, we're going to the next slide kitty? Yep, and just a very quick thank you to our sponsors, the MD you at and he's been there with us since the beginning to get the six PM Siris off the ground. Once everybody finishes medical school, we all need some sort of indemnity insurance. Legal advice on other supports of support, which the end you provides. So if you're interested in joining the M d U, there's a QR code at the bottom, right? And if you join, if you haven't really done so, you can get a pocket prescribed book revision cards, which I've deviously used. This also foundation program book help with queries about that on Without further ado, Let's get started all over to you, kitty. Okay, that's good. Sorry. Question one on the night shift. Your call to say, a 23 year old with no no asthma who the nurses report is struggling to breathe has been decent aerating and sounds very wheezy. The nurses have already put the patient on oxygen and give us a given her some for I'm milligrams. I'll be small nebulizers. Despite this, the patient apparently worsening. What would you do next? So just that on the right hand side. There. There's the your 80 assessment of a patient on it. It's a, um on a 50 m on reprieve mask big of some further 5 mg albuterol NEBs. See, Hard recall. So 900 mg and day drug room No. 5 mg every six hours or you don't know. Just said results. Okay, so I'll leave this slide on, um, so the correct answer must see hydrocortisone. 100 mg. So the patient for thinking about how this picture is really been treated, the patient's already been given the step one and step two. So that was the oxygen on to the nebulizers of the asthma treatment algorithm. So the next step would be to give him a steroid spaces either IV hydrocortisone, like we've had here or here. Prednisolone This patient actually seems quite sick. I think so. I think I ve is better. Option could help get it under control of it. Faster. So I like to run bird in it. Um, how you guys from bread? I like to member my, um, like, house treat asthma with this little acronym here. So about oh, shipmates ever of oxygen. So a good way of doing that. You can drive the nebulizers with the oxygen. Is that kind of puts two in one. That's factor back. A nebulized albuterol, hydrocortisone IV or pa Prednisolone on them. Maybe able to I So the trip cream? Um t see, if I lean on, then Mm magnesium and then a escalates or he fancy help, which also works quite well. That's important. That you thinking? Actually, we need to get some more singing. Well, probably more. You've got to get rid of the outreach. I see you involved in that point cause you probably already informed his senior doctors if you are just enough one at this point, but quite good way to remember it. Um, I just popped on the right hand side, so I find it quite useful How to classify aspirin severity. So there's that the chest acronym, which is quite useful if you think back to the question she did have a couple of things. She was a bit hypotensive. Just talking cardiac. He had dropping saturations. Um, yeah, I think asylum. It's not always help for this one because I don't actually think that in many situations on the ward's, it's almost getting polio would attempt to peak flow. But that is the competition definition orbit. So quite useful. I think if everybody is happy in the office, that question Oh, Okay. Teo, you're also see a 32 year old man in the emergency department who was coming with blurred vision following a big night out yesterday. Your PSA reports having some palpitations. There's E c g. Shows, Sinus tachycardia. Since his arrival in the day, the nurses report is past year in 4 to 5 times and his initial blood showed a disease. Knees are sodium of 137, a potassium of 4.7, your ear of 14.5 and creatine 176. How would you treat his high BP? So again, we've got already to the assessment on the bottom there. So a this operative 5 mg be a Beatle, 20 mg three. Listen, I'll try nitrate 30 micrograms. D nicardipine 5 mg on a don't know. Okay, so, um, the correct answer was, um, the labetalol 20 mg. So this patient had a systolic pressure over 220 on his diastolic BP was over 120 he had some evidence of end organ failure. He was year in 18. Quite loss. Um, Polly area on. Also, his renal function was starting to not be within the normal limits. So we can call this. This is actually a little dryness of militant hypertension. So that's that actually notices their systolic BP over to 20 diastolic over 1 20 with evidence of end organ failure. So in this case would be too low would be our choice of treatment. Um, I think on a lot of people stop a little, which I think actually is postoperative. Very, very useful to me is a lot and kind of acute high blood pressures. But this is very, very high on, in which case I'm going to be towards the first choice. I think not because of where I work is well, they have a like a pro form of when you start the beetle on. Do you get that over initially? And then you sort of reassess, and then you can keep giving it for quite a few Go. So we've script know Gates. So militant hypertension is a medical emergency, especially in a case like this. What? You've got progressive organ dysfunction. You know that those kidneys are really risk. Think how much blood flows to the kidneys, so really so that's entree damage. It's quite worrying. So obviously the main treatment is one of reduce the be pace. That's the aim for trying to do here to protect the organs on. But we have to be quite careful off is you can't drop their BP off very suddenly because I actually also risks. I'm causing some damage to the organs, such the kidneys and things like that. So you have to reduce it by 25% within an hour on, then aimed to slowly bring it down to what they're normal. BP is over next 24 48 hours. So again, that's just protecting the organs stopping and organ damage. Um, so I don't have anybody picked up on that. They're in the question itself. This man had had too much cocaine saps he had his people's like that and leave the big night out. And that's not a cause of malignant hypertension. Um, just want to point out. So I think if it was happy, we can move on to next question. Okay, Um, so Okay. Three, a 67 year old man is admitted to the emergency department with sudden onset dysphasia on Phil Paralysis of the right hand side. His wife reports that the symptoms came on about two hours ago and she brought him in straight away. A CT head shows complete occlusion of the left carotid artery. What would be the next appropriate step? Um, a intubation of ventilation be on insulin infusion. See aspirin. 300 mg d multiplayer is and we don't know. Oh. Oh, sorry. Room. Okay. So I sorry, I quickly quick from that slide. So, Beyonce, that this one is an integration of ventilation. So this man has presented with an acute total anterior circulation strike so prior to preventing the his treatment, which would be the old place he needs to be stabilized. So in his little 80 his defense was seven. I was a general rule. We say, if it's eight, the intubate. So actually, supportive care is really important. In this case, this man has had a stroke, but the first, the major of Maine treat main The first thing we think about is go back to the 80 you've got today on d is. It's got a low GCS is always gonna be a risk. There's no point thrombolysis somebody who can't maintain their own airway. So therefore, first point of treatment would be intubation and ventilation. Um, so yet this case, his, um, CT scans confirmed his escape make strike. Um, so that'll it first line treatment that's supportive care then was given me all to place. And then if he's, um, eligible or it's a appropriate you might bender mechanical from back to me on. Then you give him a big dose of aspirin, the 300 mg within 24 hours off the escape mix. Strike the common rule of the eligibility criteria from back to me. But there is some quite useful. You can look on the BMJ best practice. It's got all the details on there really, really useful. I didn't want to have put too much information with bits and bobs on this one, but quite good. Want to look up? Um, if everybody is ready, we could move on. So Okay, so far, you were called to see an 86 year old woman on the war's who's complaining to the nurses about feeling her heart rate. So in essence of the very helpful and on a set of observations which shows the patients tachycardia 135 BPM on because of this have done a 12 lead EKG to review. It shows a narrow, complex, regular tachycardia. You're in the medical registrar have been done in a what can you do in the meantime, so a give them 15 liters normally breathe oxygen. Six A beef 6 mg of the den is een see tom milligrams of demos een Dietz Invega NuvaRing or eat Don't know. Okay, so maybe this one was, um, too easy fuel, But so yeah, the right question. Right? Answer was de vagal maneuvers. So I'm just going to skip the next side. Here s so this is the up to date resource council for Kentucky cardio. So he's really, really useful. I think they come up on exams. It's important to know this kind of stuff. So in this in this patient, it says that there 80 and except stature, so we looked on dot um is a curious narrow. Um So then, is it gonna be broad? Or is it whatever and then you could move on and see that it's vagal. Believe us. In this case, it's one of those things. You probably run them a medical registrar. You probably actually don't want to be giving a dentist mean by yourself without the, uh um Mezrich Dad say the right answer the vagal me, the situation you go, which is great. Um, yeah, that was probably That's quite a quick one. But this is a really good thing to know and learn when it comes up on. I think it's really useful. Actually, when you actually practicing, that's in this office. So we if it runs, body will move off. Okay? Sorry. Number five, um, affected two year old woman with a history of poorly controlled Crone's disease presents an emergency department with a 24 hour history of headache, fever, drowsiness on on examination, your wrist pain in her lower back when you flexed her hit and ask her to extend. Honey, you believe she's septic. So you commend sepsis. Six. On what would be your next management step? A lump puncture, be CT head see, and politics D dexamethasone antibiotics and we don't know. Okay, So the right answer to this one is D. So this patient has got clinical diagnosis off men enjoyed to bacterial meningitis. You have a fever, headache, drowsiness, Andi, he on examination. You have elicited Kernig's sign That was the with the pain in the lower back. When you flex the hip and extend the knee, that's Kernig's, um so by you start. So if we're thinking back to our when I was talking about the previous question would be is supported. Always supported care first. So in this case, you started steps of six. So you started that supported CO already? Someone thinking about treatment. So what you're going to do first is you want to give him steroids. Course the steroids really important in the treatment of meningitis. They help some of the swelling, so there's going to be swelling around the spinal cord on. Actually, they really, really help with. That's a good anti inflammatory on. Then you're going to give him some antibiotics as well. Um, so I skip next one. So, um, it's a medical emergency in which there's life threatening information of the meninges, So that's why I'm gonna give those steroids in. The UK is usually caused by strep. Um, a nice area, and he he must less type deed. It's more common in older patients or does the immunocompromised. So in this question, I wanted a young person, but I get these crone's disease and it was poorly controlled. So she's like, you gonna be on some, um, you know, compromising drugs. So that's river a risk factor there. So if it's suspected, you have to start treatment really, really quickly, it's really, really serious. Other investigations. You going to do a blood cultures? I'm going to do a lumbar puncture unless they've got signs are high intracranial pressure, in which case you might do a CT had first to make sure back when you do the lumbar puncture, you're not gonna. When they get that opening pressure, you're not gonna have everything dropped down. With Cone on supportive care. As always, it's really important. I'm gonna push it in this. A month's confirmed you're gonna follow local guidelines, the specific antibiotics. That's always a really good one to do in, especially in osteo as well. To ask if they asked little would start antibiotics using the local guidelines. So what? You probably do in a case that less if It's so clinical Diagnosis of meningitis. What you want to do is start them off on some empirical antibiotics. I mean, broad spectrum, just to make sure they've got got some in them. And then later on, when you got all of your your stuff back from your numbers puncture at that point, you could do something little sip this specific, can't even speak. Okay, Right. Well, hold it there for 42nd break s so we could go through the questions. Oh, funny. Not funny. Seconds for five minutes. Is, um yeah, we'll hold off. I just never No, no, don't just have a look at the questions. So I think somebody was asking about would you into it, even if they're a M B shows, no red flags. So I'm assuming you met that in regards to the patient that had the hemorrhagic stroke. So with hemorrhagic stroke, they're sort of a spectrum of how do I say sort of consciousness with it, depending on how much is raise your intracranial pressure, what's been squished and what's been sort of affected. So just because the airway is okay in that moment of time, it doesn't mean that it can't progress on to someone losing their airway, if that makes sense. So what's really important with things like strokes are like, Oh, is not just assess the airway by itself, but the GCS and what the GCS does over time i e. If someone already has a low GCS, but they're still maintaining their airway, that's be still be something you'd consider for intubation to reason. Being is because of the potential of the scheme extra okay, sort of hemorrhagic stroke to evolve and cause further issues down the line. If that makes sense, it wouldn't necessarily be safe if we think that's appropriate. In that same breath, if someone's okay initially and then all of a sudden they even dropped their GCS by two, then you've got to start thinking about is you know, you know, again securing so so Jesus of eight is a good number. But also it's the trend that's really important to recognize as well. If that sort of makes sense, I hope that answers that first question that that's a kitty. Yeah, I think so. I think if they have got allergies, yes, and you are concerned actually, in this this particular on it had a huge stroke. Actually, you don't want to be a intubating somebody. It necessarily emergency. If you think, Oh, I've got a GCS, it potentially could go over. It's probably actually think like down the line. I might have to. It's almost better to do it rather than have to do it in a complete Russian emergency down the line just cause it's safe for the patient and in. So I know you saw. I don't know if you're asking, for example, the whether you're asking for sort of practice on the ward. But if we're talking about, If we're talking about anybody who's airway that you're concerned about, you'd immediately vulvar seen and involve anesthetics and whoever it is, because you're not going to be at your stage as an F one journal going to be, you know, managing the airway alone, If that makes sense, are making that decision so it would mean involving other people I've seen. The important things is to escalate if that sort of makes sense. But yes, would you be even So, what I'm saying is, even if their airway is fine, I you know the saturations are fine. They're not snore Anything if they're GCS is reduced. Still, buy a significant amount or if it's trending downwards, even if their airways maintained you still consider information so it's not in. It's what it's not black or white. If that sort of makes sense, come in to the next question. Can you give aspirin before you head off to fumble? Isis. So normally you normally you wouldn't want to give them more bleeding drugs on top of it if you're going to decide to from belies. So the decision to from Belies, you know, has made a multiple factors. There's a full checklist for it, which I can't go free talk because we have stroke nurses and doctors that go through those things. But it's a full check list of what's Contra indicated in a formal ISIS list. And before any of those decisions are made, someone has to go for the CT. Scan it to see if a stroke is a schematic, a hemorrhagic because, you know, if you give aspirin are magic trick, you make it worse. But to my understanding, if you're planning on from belies ng some somebody, you'll make the decision rapidly, quickly off that they've had their CT head. If that sort of makes sense, and then you're going to fumble eyes and better than give them aspirin before that is that that's a kitty. Yeah. Um, and let's have a little look. Could you go back to the vignettes again? Yeah, yeah, it's a little So I've seen someone else a bit lower down is didn't notice the Kernig's science. I didn't want to actually say Kernig's. So this is actually testing your knowledge of the over what it is. So it's a pain in the lower back when you flex their hips and ask them to extend the knee. And that would and that And if pain, if you're less pain on that, then that would be a positive Kernig's sign. Sorry, I think I was probably just No, no, no, no. It's all getting it. It's all it's all looking features of meninges and guys. I use something, you know, inflaming the inflaming the meninges along the line, which you know where the typical things they talk about in meningitis. Bacterial. And it's like things like, you know, well, not necessarily bacterial meningitis, because you convert, see in in brain and hemorrhagic strokes and things as well, because blood can irritate the see CSF or the lining. But, you know, photophobia next. If nous you know Karnik sign Brudzinski sign, it's It's all those signs that you sort of be looking at assess these patients and you're also very important in in sort of. I guess we can talk a little bit, but then they try to see how see how we're sitting here now. So in regards to meningitis, in terms of things that I've I've personally seen on the ward, so and give you example So meningitis, a spectrum of things, bacterial being the most serious. But there are other types of meningitis i e. Viral meningitis. It tends to, you know, be managed conservatively and resolve. And then you can have people that can have an careful like this on top of it, which, which, you know you treat the patients will, you know, typically come in with headaches, features of meninges and whatever it is. And then the will do the usual things, such as the bloods examine them and we're looking for signs of raced intracranial pressure. So you often have somebody do it for the oscopy or something else to make sure there's no papilledema because that would be a contraindication to you doing an LP because he is very important for figuring out whether it's bacterial or viral. Thea other thing that forms sort of part of the assessment of sort of seeing if there's a reason to create a pressure seeing if there's something else going on within the brain. Is a city had so often we would, you know, do CT heads for for patients? Ast Part of assessment. Four reason to kind of pressure, but for not scabies justice important, important or getting a for my assessment to make sure there's no popular Dema because just because it's a normal CT head doesn't mean that they don't have raised intracranial pressure on. Then you know you'd obviously choose to do the L P. So you're working out whether this is viral or bacterial based on the cell counts. So you know, if it's bacterial typically eats up, all the sugar will be sort of a high looks are white cell count. It particularly terms, neutrophils and other things in terms of with the court. Fully nuclear P M ends point. I never say the nuclear polymorphous. And then if it's viral, typically the shingle reserve. You can have high lymphocytes, high protein, and that would be sort of one of the things that you'd be looking at and you're on. Also, get a throat swab if you think it's back to your meningitis because you know it's often the sort of organisms that sort of causative, you know. Ah, what's the word I'm looking for here? So which which which, Which one meant which, which I'm looking for the brand negative diplococcus I meningococcal, which, which will know that what was the name again? Same group as gonorrhea in Syria That's always been injected This so the serum in it, it's is often a causative organism. Brand negative. The cock I you know, you could think of Staph aureus structure caucuses. Well, so you have two very for me. Examine these patients before you sort of do anything else. And then somebody was asking about when is dexamethasone contra indicated and meningitis. So I think one of the sort of cautions important questions that you have to be careful is is when they're septicemia. When whenever septicemia with it. I'm not saying it's necessary. Complete contraindications. But you'll need to be careful because if they have bacterial meningitis with meningococcus septicemia, you know sepsis, then giving them dexamethasone whilst they would, you know, produce information around the sort of meninges it could potentially cause them to become more septic because you've, you know, died down the immune system by giving them steroids as well. So that's that's something to consider. I guess that I can think of is anything that you can think of. Kitty No con thing about hadn't really thought about that. I think it is often just I think it's more just I had already still about that. I was just thinking that you want to protect their protect them and the meninges. Yeah, it's Yeah, it's more of a caution rather than the exact Contra indication says only in this off the LP results. So yeah, you wouldn't often do until after the LP result results. I guess I'm just trying to think of it off my head because we've had that recently with a patient. Have you administer dexamethasone before hand? I'm just like it's best practice. It says it. Give it before. If you feel like you could be a clinical diagnosis. I'm just typing. I'm just having a little thing. So if if they are, I'm just I mean, I think if if you think it, really, if you're 100% sure know hundreds of the 90% sure prior to the open that is back to you I you know, they've got raging inflammatory markers which you usually wouldn't see in a viral meningitis. They've got obvious signs of, you know, sort of manages it on sort of having sort of infection. Then I think you would. I have to have a little look at that. I'll come back towards the end of that. Yeah, that's actually helpful. I think that's what I read that that was helpful thing to look. Actually, I guess it's because often mind my my knowledge is a little bit on. It screwed because what I see more, most commonly is people come in with sort of either headache. That's not been very. It's a meningitis that we've often over investigated or something. It's coming with viral meningitis I've rarely seen. I've seen very few you case of bacterial meningitis by myself over these, but I have not done with many kids to be fair. Warning adults. Yep. Okay. Okay, So she's going to next question. Yeah, that's more Well, just just writing a normal question. Just so we I'm just questioning. Let's have a little looksee legion upset. I'm pretty sure. Low dose. So Yeah. So that's why it's it's more of Ah, caution. Because it's the high doses of particularly you want to, uh, want to avoid, but it's It's more of a caution if that makes sense. Leah, you are right. So the particular worry is is higher doses of dexa dexamethasone rather than the lower doses to specify that. Sorry. So okay, that's scary. Western six. Okay, cool by the nurses to see a 56 year old male patient on the ward who is having profuse coffee ground. Boy it on arrival. The patient is still profusely vomiting. Dark red form. It's you perform in a tree and find the observations as below. You saw this in emergency and call your senior here, ask you to resuscitate the patient. You start the patient on oxygen. What would you like to do next school? Okay. Nice guys. Um, yeah. Correct. Answer is on. Be IV crystalloid. Um, this I actually, all of these answers could be right back. Guys up. Different Western people don't really. Well, so we'll see more knowledgeable with me, Elise. Arms could be right back to the observations back to 80. So we just go back and look at them. Actually, this patient is really unstable. They're tacky. Cardiac. Their BP is quite low, and things just aren't looking very good. You know, talking. And I don't see very distressed. They're groggy. A slow cap refill time. They're gonna be a bit this is shutting down peripherally. So actually, you've called received on the right saying and you start them on oxygen already. Actually need to resuscitate this patient. The thing that we really need to do now to get that circulating volume up. So you probably would want to give uncross much blood on in this scenario, I think you probably put out a major. What I would pound a major hemorrhage going hospital. So then you can get that uncross much blood quite quickly. But in the meantime, you can give some IV crystalloids, um, Harland's or something like that just to increase that second thing value. Protect the organs while still waiting for the senior to arrive. Young cost much blood and things like that. Um, so yeah. Um, well done. I will skip good here. So I find a pretty obvious quite couple of night shifts people seem to use in the middle of the night s O differentials. Peptic ulcer disease. Esophageal very sees a memory vice tear all very common things that we see. Um, see it actually quickly. And keep them stable, as you possibly can for the arrived of your seniors. Do you want to put in two large bore cannula? So, ideally, as big as you can go, doesn't in examined. Probably say great, But in reality, when people start to shut down, the likelihood of being out to get to graze in is probably quite difficult. You want to get some blood very, very quickly. Once daily VBG. Because he stopped look at things like they're lactate. We need a bit more about that hemoglobin immediately. You want to give him IV fluids really important, as I said before, and yet then you want to give them uncrossed match red blood cells. When you take those bloods that I said about before. You're gonna want to get, um, a group and save so that you could get him some some cross, much flood you're gonna give him IV and that result Probably give him an infusion of fat on. Actually trying them attack 20 Gramick Acid is always a good thing to get in this kind of thing. Often when they come through the emergency department emergency department of always given tonic family tronic, sonic, I said to the patient before you got there it's a good thing to start doing that. Yeah, you're doing really well. No questions well done. And everyone's happy you can meet all got, uh, got a tip it today. Absolutely. So exactly it's Kitty was saying in terms of the management, you know, acute bleed A B school and create a B C D. It's always gonna be the right thing to do if the patient is so so you're saying the most full thing is whether the he more dynamically stable or not, is how quickly you're going to be doing things. And where do they get a same day? Urgent? Oh gee d base of your immediate emergency sort of Oh G d t see if there's something to find and things to consider is whether it's a very see or non variceal bleeds, because sometimes things like turn the press and 80 it unlocks conform part of the treatment, especially in variceal bleeds, which would be people that have whatever reason you know, got high, sort of precious good things to consider. Be, for instance, are Colics. You've got sort of and stage liver disease cirrhosis, and they've got, you know, back pressure because they get capital. Do so variceal sort of viruses wouldn't be sort of a soft a Ghous. Other things to consider is if the patient is stable. Are you hemodynamically stable or not? Have a you know, read know low BP arena different that you can calculate to assess their risk score in terms of how quickly they need know Gee, if they're relatively okay and it's not sort of really bad, like this is a blood food school. Ah, blood from scoring will sort of help you determine how bad the upper GI I bleed is so things there that were considerate things like urea. Because if someone has an upper GI, I bleed. It's a big protein meal on essentially what it does is it means it will increase your blood. Really you really, disproportionately to. Even if they have an a k I. If I could make a raised area. But if the areas on up by a ton, that would suggest that either sort of there's an A k I or something else going on or someone's ingesting more protein than usual in a part of that conform a blood meal, which could be from simply bleeding into your gut if that makes sense, so that's some other things to consider. Is what? Yeah, I was thinking, I'm actually going tomorrow. If you see a low hemoglobin and a raised urea, you always always need to start thinking about a bleed or something that's got She comes up a lot and they might not be showing. It's a worth noting that, Okay, um, that's question. A 50 year old male has been brought into the emergency department in a remote district General Hospital with acute, crushing central chest pain that radiates into his left arm. Started on our and a half ago is easy. GI shows ST elevation in leads to three and a V s. The patient was given a GT and spray and analgesia six in the ambulance. What would be the most appropriate next action? So, as always, guys, either a fondaparinux an aspirin. Um, I'm capital grille. Be dirt opponent. See, a vascular clopidogrel and d give is, um, oxygen. Okay. Okay. So, um right answer is a, um, wonder paradox. So this is a clinical diagnosis of Nestea elevation. And I said, I've got a question. Chest pain. I got you see, changes and assess symptoms of ischemia. So, in a remote hospital, primary PCI, it's not always available within two hours. That's the kind of window that you want to do. And so decent real isis first. Then they could be transferred to a center to have a PCI within the next 24 hours. Um, so, um, don't opponent, Ms Cause, actually, you got clinical diagnosis of a standard. It's just it's probably gonna be raised, and then the second will be raised, and you want to get going with the treatment. Um's actually want this one. So this is, um I promise, um, on the, um because of the M Day website, I think It's really, really useful. It's a good one to remember, cause actually, there's lots of different ways of doing it. People might not be appropriate for PCI. I work in a remote hospital where we don't have a Grammy PCI. So actually, this is really useful. Um, be, uh, essentially this patient. We were less than 12 hours. We couldn't give it, so it was less than 2 to 3. So we decided they're eligible for for Brittle. I says so. Yes. So we gave that, and then we also gave him two clopidogrel on. Then you transfer them, and then they could have that done within the rest of 24 hour period. Does that make sense? Hey, that's okay. I've seen a couple questions. It was sorry. It was Yeah, I agree that it was found a clock on aspirin, as it says on here. Um, I should have, um but I didn't want and put on the second answer. So sorry. That was confusing. Um, happy We can't move. All. Um okay. So question eight following the ward round. Know checking some blood tests when you see an anomaly. Gerald, a 74 year old who's got some deranged knees. It's ideally 142. His potassium is seven. It's frightening. Is 245 is your area is 15.2. You're immediately worried. So you go to assess the patient, inform in a tree and ask for any CT. It shows Sinus rhythm with a long, gated curious complex until tented t waves. What is the most important first line treatment? Okay, so you gave us You know, they have this. Say you have the correct answer is IV calcium gluconate. So this patient very severe had clean you with the C j E C T changes. So our first line of treatment want to protect the myocardium prevent any sort of further arrhythmias. Therefore, when you give them very quickly, give him some IV treatment. Um, so the main changes in like probably my concern me see, J is you get a prolonged PR interval. You get flattened or absent. P waves tool tend to t ways on a wide QRS. Eso actually in one mr there, you need to get that IV calcium gluconate really, really quickly. Um, and the patient, when he transferred to ht you for cardiac monitoring until that's resolved. Um, so the reasons that we get you can get hopefully now, um is it could be drug related. Um, DKA a metabolic acidosis. CKD. Okay, I, um so, in less severe cases, you might give him a little customs. Any of the ticket says of a very mild one on the IV into the deck straight on the nebulized albuterol. Also really, um, use in the treatment of hyper clena. Actually, in this case, this patient was it was very, very severe on did starting to become of incompatible life. So what you want to do is make sure that you protect the heart on to make sure that you're not going to get anything of funny rhythms on. Say, that was what you do. In that case, I actually think that's my last question. Say yes. Let me postop the feedback and then we'll go through the remainder of the questions. I think we're about a C s. We go for the remainder. The questions, uh, let's suppose that feedback and further so thank you very much, Kitty, please. Guys fill out the feedback form. It's It's the only thing that we ask that because it really helps us in terms of just making it available. The slides will be available tomorrow. So yesterday, slides and video, which is a nephrology part one, will be available today. And then we post Sit up and I'll try and add some tidbits about the questions that were asked as well. Such the dexamethasone and a few other things is when is the stuff we can add in the little little vignettes? Or make sure that's on there and they'll be available tomorrow. Today stuff will be available tomorrow. Um, let's post of the feedback link, and then let's go through the rest of his questions. Um, I think I have you. Have you had? It was Oh, you have link. Okay. Okay. Bro was gonna put a physical, uh, chatting Sorry as well as secure. Give people. Both options are available in the FBI page, so the content is on metal. So we post eso. So when you complete the feedback, which is the link hair or post? Um, in canal. Uh, so then he posted feedback link. Now you go when you could be the feet by, you could use a joint medal and make sure you could catch up content. And what that does is once you could catch up, content it. Once I post up the stuff tomorrow, it will let it will tell you that it's available. And then we'll let you. We'll get you access it. Hi. I wasn't able to. Then you're going to be available so yesterday stuff will be posted this evening, If that makes sense. So the content. So whatever lecture we do, the content will always be a major event made available the next day and clean the video as well as the, uh even if you hadn't registered for it when you go on the event page on Facebook, the medal link to that event pages on there. So that's how you be able to access the stuff, if that makes sense. So coming back to the A. C. S question love a good A C s questions. So I don't know about Katie's hospital, but my hospital I'm lucky in that we are a primary PCI center. So corn was apartment PC. I sent it so we don't have to worry about sort of from the lice necessary. So So there's a spectrum of things with a C s guys where we worry about how much blockage there is and how much potential of cardiac damaged is going to be a stemi meaning ST Elevation being the worst, a part of the A. C s and then an end stemi an unstable angina being or crescendo decrescendo and Dina being in sort of a similar category in that, uh, they all sort of inquire very investigations. And eventually, if you can, a sort of angiogram to look at the heart Now a stem is the most urgent thing that goes immediately to sort of the cath lab, depending on what if it's within the time within the time, limit the time from a time. And if you can get someone to a primary PCI center on time, you consider from my license. I'm sorry, I think I think so. For the paradox is, it's a type of low molecular weight heparin, So fingers like No, no, it's all good. So good. So things that are like from belies is considered are so I don't know what specifically used in an m. I say things like, you know, multiple a structure kind. Is there a specific types of ones that you use for an M. I. Now, if you're going to medically manage it, and my e from the licenses Contra indicated, and you can't get them to a PCI lab, then you do the treatment that you've commenced for an end similar to an end stemi an unstable angina, which would be a mixture of thing. So it would be aspirin, some sort of another sort of plate antiplatelet drugs such as a psychological or clopidogrel. It depends on where you are at your trust, and then you add in some form of anti coagulation, such as from the paradox, if that makes sense and that would medically, medically managing the patient into either going to choose to do something else. So often in my hospital, when we have patients with on end same, they have to have fits so against any meaning. They may or may not have the CT changes, but they've got physical damage. I either troponin is are raised or unstable angina, in which there may be sort of normal proponents. However, the history is very suggestive of a cardiac issue. Then you would give them those sort of free things. I do antipain a fire people, uh, anti coagulation often, if that makes sense, I hope that answers that that's very long winded A C s. It doesn't make sense. Yeah, I'm hoping I'm s gonna answer back, but we'll see if that makes sense. So just to confirm that this patient was a totally Centrum option C b correct. What was option Seek option C. Was the aspirin around? So So yes. So at my trust off, you know, you so those things that you need to be so when it's in a sense, that things that you need to be doing in the beginning and giving them some aspirin and property is going to be the right the right answer and tell until you get them to a PCI labs soon as possible. So, yes, you would be giving him those things. Yes, I said questions I just kind of wanted to face on the medical. It was probably a long winded. No, no, no. It's all good. It's all good. Why is, um, wh picked over warfarin or so I think it's just easier to manage with. So So let's put it this way in acute in an acute sort of situation, starting someone on warfarin. You don't know if that I and I was going to be high enough in that moment because you want them to be anticoagulated with warfarin. It takes time to work. That's why you wouldn't pick warfarin an issue unless they're already on warfarin, which would make things a little bit more complicated if that makes sense, in which case you could do bridging and other things and stopping them over. But it gets a little bit more complex. Well, let's suggest that they're not on any anti coagulation issue from the paradox is easy to pick because it works more quickly. You don't have to look at the eye, and I mess with it on. It's just simply to do on, you know, you could give a door way. Don't usually normally do diet. What my trust. We don't We don't know me do doac cedar unless they're already on a dose pack. If that makes sense, so usually the chose is a low molecular weight heparin. If they're not on anything else, I hope that sort of answers your question. A. But yeah, it gets complex if they're already on if they're already on anticoagulation, it gets a little bit weird from them. Uh, I'm not gonna go from how can you find according for the sessions, you registered football unable to attend. So, as I mentioned, when you go to our events patient, Facebook, all of eso, Aleve ENTs from this Siris that we've had the medical, you know, the medical medicine for finals on the foundation doctors. When you go in the specific event page, the medal event page is the metal link is on there. So that will lead you to that event page where the contents posted, If that makes sense. So that's how you get access to it. And that's the easiest way to do it. Brother talking lot of my voice is drying up. Um, no worries. And yeah, we'll try and add some stuff today. I had some of the questions have been osteo power point. One quick question. I trust they give anti coagulation to reprimand, bro. Who is that? The same everywhere. So my trust no, we don't often use tear up to rough abandoned that bill. I'm trying to remind myself what sort of it's always the ones that I forget in terms of anticipated. I think it's the GP free. A slash to be inhibitors, my trust. No, I haven't seen it. Used to. I can't speak about. I can't really speak about those trust. It's going to be different in different places from time to time. But I think the safest thing to say is usually do anticipate the therapy and some sort of alum wh But too rough for bands slash zero is still going to be another anti pain agent. If that makes sense, although I don't know if it would cover as a dual anti platelet agents, that makes sense, and it might be one of the new ones, so pass on that one. But I'll have to have a little look. And I'll see if I can answer that question for tomorrow, because I think that's quite interesting. Nico, I hope that was helpful ish. Okay, fine. I think getting anything else that you one Thanks. I know. I know Brill. So please join us tomorrow, guys. Where near? We will do her second teach doctor in every path. Um, and you didn't eat yesterday on a follow gee which will make us today's content will make that available today on Don't forget he's also gonna be the another doing another acute medical teach A soon as well do computer will take ago and work in the same way. Yes. So, uh, the I always forget I always forget how how they work. So just remind me so aspirin is, you know, it's it's cox inhibit irreversible. A situation of the cox enzyme, which is why it makes you bleed e which would cover it yesterday. But I better go pee. Sort of take a growing All these other ones they're supposed to be p always forget. Do you remember P Y? It's a pain to 12 or something? Yes, I'm always trying to remind myself so. But they do work in the same way that that is correct. Platelet aggregation activation like Red girl. If you're going to say which one's more bleeding? I can't speak for personal, but I can't grow tends to be more bleeding than carpet a girl. So they all have sort of different. They all have a little bit of a different strength slash Half life is well to look at, but they all have the same. The same function. They're working the same way in regards to play that. Yeah, inhibition, bro, I think will post the link one more time. Just so people get into the feedback length, give it two more minutes. And when the oh, thank you for Kitty, Uh, and be seeing you soon, so you please fill out the feedback for kids. Do you guys make sure to do that? Goes in a portfolio? We'll get it. To have become a niece is for acute some point. And yeah, we'll try, and I'll try and answer the questions that because we had some interesting questions, I'll save some of these and I'll make sure the other meter on the slide to answer him tomorrow. That in the dexa left for some question broke. Brennan. Okay, I think we will end it there. See tomorrow, guys at six pm the usual time. And, you know, all the links are post on on Facebook as usual, but yeah, it was up from six PM, same time tomorrow. Guys. Thanks, kitty, but