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Says it's life events starting soon. Oh OK. I think you Yeah. OK. Yeah, I think it's working well. So where do we get to? I think we're going to have to start back to the beginning. Sorry about that. That's all right. OK. It's all right. Technical difficulties. So as some of you are seeing, then we have some technical difficulties your case today just to recap doing renal. So, nephrological emergencies, anything with the kidneys, I've put you in a pediatric case today just to get your brains thinking somewhere else, especially for the later years where you're going to start thinking of your histories. Um to think about what you're going to have as your challenges, what are going to be the challenges in the history, whether you've got an overbearing mother or a mother who doesn't really know what's going on, whether a child is very grown up and wants to talk to you. So you're always going to have these communication skills issues going through medical school. Um So this is your case. You've got a six year old presenting with brown urine. Um You want to start thinking in your head how long has this been going on for, as I say, because it's a kid. You don't know when did mum first notice it? So this is your presenting complaint as we always start or it just changes in the urine? The key things here about drilling into. So how long has this been going on? Getting this from the kids or taking the history from the patient themselves? It's getting darker. So you want to know specifically the color we've said brown, but is it, is there blood in it? Is there any sediment? Have they noticed any frothiness? Any other changes to the urine? You then want to know volume and frequency. So it's really worrying me here that they're passing smaller volumes of urine less frequently. This means they're a kid. Kids have really resilient so they can be sick for a long time before they start to show symptoms. So this is worrying me that this is an organ starting to shut down if this kid was three or four. The main thing is say the weight of the nappy. Um And how often are you having to change that nappy? That is how you're starting to get that fluid status assessment. I've said here about abdominal pain and dysuria because common things are common. And that is it a uti in this case, he's got no pain and no tummy pain. It'd be unlikely for it to be a uti you always want to do your systems review and you're looking at, he's feeling tired and unwell. He had a sore throat a week ago and that's resolved. Mum wasn't too worried about it. Now, this is something you really want to drill into about how they've been recently. Cos yeah, kids get all, all the ill, all the time and you don't wanna miss these things and making sure you've asked about. Were there any predisposing events what's been going on in your life recently? Getting that bigger picture? Because I was gonna say kids can compensate for a long time. So make sure you're not just drilling it on one symptom too quickly. This is the rest of your case. So as you say, with your history, you want to start off with your past medical history, kids usually don't have a lot going on. Uh But you want to know whether it's a new thing, old thing establishing whether there was anything from when there were at birth vaccinations is really, really important. I mean, kids as well. Again, they're not gonna be like your adult patients who've got loads of medications. So looking at more of the over the counters or if anything alternative has been given family history is really, really significant. So this one, the mum has sle so again, this should be automatically fagging. Is there something autoimmune going on? Cos again, these are the things, these are the trends, kids recognize these things early, final thing, the social history, the thing I haven't put on here. But what I really want to do, especially for the later years is to consider safeguarding, especially in a surgical head. This may be the only time you've seen the kid has something been going on for a long time that's been missed. And it's definitely something you should always ask and it shouldn't be offensive. And we ask all our patients, how are you known to social workers? Are there any concerns the kids in hospital? Check them while they're there? Like nine times out of 10, they will be fine. But you don't wanna be that one who misses it when you're too busy focusing on one small thing. So this is your history. I'll give you a bit of time now to think about that case and start building up some differentials in your head. So I'll just give you a couple of seconds to think about that before I start thinking about what's in mine in terms of the safeguarding, say you do with the child. Is that something that you would specifically try to think about when doing uh renal and nephrological just because of the relation to potential drug use and all these kind of things or just generally, is that always in your history, generally, in all my pediatric histories, as I say is something to always clear up. It could be, you know, you could just be having a kid who's come in with a very clear history of, they've had a fall and they've got a cup, you're not gonna be too concerned about that. But what if there's something else, what they've been coming in more frequently? It's something I would never miss and I think it's something as examined as we like. Ok, they've been, they're aware of that bigger picture. So I'd have it generally for all your histories. Ok. So, as, um, you should have, I hope three differentials in your head. I was gonna tell you mine, but I'm actually not gonna spoil it till later about what mine would be just to help build the examination next. So obviously, we've done this all before and we've gone through this all as a team. But what we do as our examination, it would be an abdominal examination. The main things here, you'd be blotting the kidneys, feeling for any masses. You want to make sure you're listening for any renal bru thinking about stenosis in this case and looking for any scars. I've got some other signs on here that not necessarily this patient has, but the kind of signs you'll be looking for in a renal patient that I saw very commonly when I was on the ward um as an F one in renal. So we've got on the top right hip periorbital edema. You're just looking for any gross edema. So we're thinking about an inability to cope with fluids. Um I don't know if any of you have ever seen the thing on the bottom left. Uh If you do see one go and feel it because it's really interesting. This is a fistula navy fistula that's obviously got larger over time as the vessel has been damaged. Um, really, really important to check his patent when it's been, uh when it's been put in any concerns how long it's been there. It's just to see and to get familiar with because there's some things you can never do with this arm that I've seen so many people do. You cannot take blood from that arm and you cannot put a BP cuff on it. And people always forget that in their renal one. When they go, oh, I'll take this from this arm. You can't put an, a large cannul on each of these fossa. This is one to protect you, protect this arm at all costs. Because once that fistula goes, they start to lose that access. You can't dialyze them any longer. It's really, really important to understand the importance of these fistulas to understand kind of how they work, what they do and what they feel like. So you can recognize it early and then on the bottom right hand side, these are the kind of scars you can get from a renal transplant. So make sure you when you do see one as well feel and still blocked because they still have their original kidney in place. But you'll also be able to find the new kidney in the anterior part of the abdomen. So these are the kind of things you look for on an examination. So you're finishing off your examination in this patient. There are some things that you always should do in a renal patient after you've done your abdominal examination. These are your bedside tests to start off with. So make sure you get a BP, you do a urine dip. These are the most important ones. Obviously, your bloods are gonna come out after this where you're looking at a renal profile as your main test. There are other tests we'll come on to that you should definitely do in your bloods. But the main things you should say in a patient who you're concerned about any kind of nephrological issue following your examination, I would want to make sure you have a full set of s with a BP, a urine dip and bloods including a renal profile are your main ways to start. So this is our patient's urine. How are you feeling about that? Would you be happy to see this? Is this normal? Is this just a dehydrated urine or is there something odd here? So some of you may know this as Coca Cola urine is what it is called, um which you start to be getting in the back of your head about nephritic and nephrotic syndrome. So, in nephritic, you're looking at hematuria with red cell casts, proteinuria and oliguria. Well, nephrotic is the proteinuria hypoalonemia and Edem edema. So slight differences between them. But if you've got blood and brown is usually to do with bilirubin in blood, then you know it's nephritic. So they are my main differentials in this case. So I'd start off with saying my first differential is nephritic cos, then you're broad and you've covered it and then you've got good postures and post strep. You also can then say you could potentially consider nephrotic. And then common is common. You could say a poly nephritis and a renal colic. So they would be my main differentials in this case. But when we're looking at a brown urine in someone who's got oliguria nephritic syndromes should be up there at the top. Say we requested some bloods as well as we can see, sodium is a bit borderline low, but it's fine and potassium is normal. But we've got a very high urea and a very high creatinine. You have to also remember this as a kid. So he should be processing things very fine. So this is very, very high. So we're looking at an acute kidney injury and grading these, you can do this on urine or on the creatinine itself. So this is where you look at the upper limits of normal or on the patient's baseline. Now, you may not have this patient's baseline as again, they are a six year old child. They're not gonna have regular bloods. So you're going to have to use the upper limbs of normal. Now, if you see on the right hand side in the black, these are reference ranges. We're at 583. So we're well beyond three. So we know Russian AKI I three and this is the little table that you should all have. A No for your MC QS. It's a very easy way to remember it, but this is how we can grade it. So we've got an acute kidney injury. So the first thing we're going to want to be doing is completing an AK I pack. Now, I don't know about this trust, but in the last two trusts I've worked in, there's been very set performers and that whenever you have an AK I to and above, we had to discuss with the nephrologist or with the renal physicians again, I've never worked and had another guy. I said George. So I don't know here. But the main thing you're saying in your exams is that if you are recognizing an AK II want to see what the cause is. So, looking at my prerenal intrarenal and post renal causes and discussing with the medical registrar to get advice is your safe answer and is the safe thing to do because that is, you know, these are severe injuries, they have the potential to deteriorate and cause long term damage. So you want to make sure you're managing this appropriately if you don't want to give fluids to someone where it's just gonna keep making them worse. So, make sure you've recognized that you're doing your bloods and contacting a senior early. Talking of this is from a my trust when I originally wrote this program, this is the Mid and South Eic Trust guideline. It's something I've used, but it's the things to assess, to make sure you're looking at sepsis. Thinking of the drugs that are nephrotoxic. So your ace inhibitors and your nsaids obstruction, getting a bladder scan was our usual one to make sure that it's not something simple like a catheter that's blocking it. Um And then looking for primary kidney disease, which is where you do further tests. So this may be a urine dipstick and doing some screening bloods. Now, I don't want to freak you all out. But technically, if you are worried about intrarenal kidney disease, these are the tests that I was told to perform as an F one. It's a lot of bloods. And then for example, for collecting urine for the bench Jones, you may need a lot of urine to collect that and getting those tests can take longer. But these are the kind of antibody screens you're looking for with your A N A anchors LDH being a very common one, peripheral blood film, your electrophoresis um and serum light free chains. Does anyone know what they're for? I will spoil it for the people online, it's myeloma. So that is the one we look for, which is why it can cause intrarenal disease. Um looking at your antibodies in this test because I did send off a primary scheme since a child to child should not go into AK it's not normal. He had low C three and I thought it was high. Now, at this point, this is where you've got to think intrarenal disease bloods are great. But what is the only way to prove there is something wrong within the kidney? And that's a biopsy and that's why we do it because if we have ruled out all prerenal and post renal causes and we are getting blood tests that are suggestive of an intrarenal disease in a pediatric patient, we need to understand histologically what has gone on. And the biopsy is the only way to do that scans can tell you so much, but the tissue analysis will tell you what it is. So, as I mentioned in my differentials, we've got someone who's got blood. So they found out on their urine dip with the brown urine and we've got someone who is oliguric. So, nephritic syndrome is my number one good posture is one of the common cause of the A Nephritic syndrome in a child who has got a history of autoimmune disease in their family such as the mum with S but the anti GBM was negative. So you're looking for your basement membrane. So we've excluded that cause there's another cause that I've never heard of, of Nephritic syndrome. But the main one, then we think you had a sore throat one week ago, we've got post strep glomeris. So this is your diagnosis in this case where the main management for this in kids cos 95% of them fully recover um is just supportive and you can give furamide if they are developing hypertension. But the main thing is just managing their symptoms, monitoring them during regular bloods, getting those seniors involved early. That is the most important thing. So in summary of this history, just some takeaway points with kids always think of the bigger picture, focus your history on the patient and always fit the cast a wider net than you would with adults. Cos adults are actually very much more health conscious or kids keep secrets, you never know. And there could be more going on at home. And that's why you should always consider safeguarding with your renal screens, making sure you're escalating early involving the appropriate teams completing the right paperwork as per your trust and considering all those three causes of pre intra and post renal, right? I think I've got enough talking. So time for some questions. So this is time for Mc Qs. So I want you all just thinking online. I'm gonna give you a good 90 seconds to think about each question just to help start help processing things through. So this is your first question. You got a 50 year old lady who's developed a cardio spasm was having her BP taken two years ago. She had a total thyroidectomy. What's the cause? No. Yeah. OK. So the answer for this one is D hypocalcemia. So this is the common signs that you can find in low calcium. So you've got to just think of your neuromuscular channels and your transport of calcium and what they're affecting. So this is why you get the tetany and the abnormal contractures. The reason this has happened, she's had a total thyroidectomy, obviously very close to the thyroid gland or your parathyroid glands. So this is why you're lacking your calcium. Um and that's why you can exclude all the other cases. Hypothyroidism doesn't commonly cause these kind of signs. And you've got to think of your tetany and that's why you do think of calcium as your main electrolyte causing this disturbance. Question two. So we've got a six year old man with bone pain in his back, ribs, femur and humerus. He's got a high esr high calcium, high urea, high creatinine and punched out lesions on his skeletal x ray. What does this patient have punched out lesions? So these are lytic lesions which look like if you see on the skull, the black spots, you know that. Ok. So the answer for this one is b myeloma. So uh punched out lesions are very common and one of the things you look for in myeloma, as I mentioned earlier, when you've got a intrarenal looking like acute kidney injury. That is new. So we've got a high urea and high creatinine. Um, you've got to consider your light chains in your urine. Um and in your blood serum testing, um highest e sr and bone pain again, are very suggestive of a cancer and that we're looking at quite centralized um, bone pain. So it's not in the long limbs, but yes, it's in the femur and he was in quite big bones. It's not spreading out. It's very much back ribs all around these areas, which we again would be very suggestive of your uh myeloma. But the key thing here is punched out lesions. It's a very typical sign you look for um in these kind of patients. So number three, we've got a 75 year old this time who's presenting with Frank hematuria. He tells you that three years ago, he was diagnosed with warts in the bladder. What investigation should you order? Ok. So the answer for this one is e cystoscopy. So, what we've got on the right hand is actually a picture from a cysto demonstrating this. So this is a papilloma, an early stage of transitional cell carcinoma. Uh these can be treated very early with cystoscopies. So any patient who's got Frank hematuria, these are the kind of patients she would be discussing with the urologist with where they can literally see what's going on and they can resect it there. And then in this kind of case, you kind of know, cos he's got the warts on the bladder, the other investigations such as a CTC, we worried about widespread cancer may be indicated, as I've mentioned before. Um, an abdominal x-ray may not be very useful. They're only kind of useful if you're looking for things such as a sigmoid volvulus or any um pneumoperitoneum. So in this case, it wouldn't really be in indicated, an ultrasound K UB if you're looking more for renal colic in a younger patient, but then act is also more indicated and more readily available out of hours and a urine midstream. If it's, it is more useful. If we're looking more for an infection, if we've got someone with branchio mauria, it's not gonna be able to pick anything up anyway, because it's just full of blood. Um So that's why in this case, the answer is e next question, where does fursemide act in the Nephron, ascending limb, collecting duct, descending limb, proximal convoluted tubule or distal. And this came up in my MRC S part A exam. So good question to know throughout your time. Yeah, this OK. So the answer for this one is a, you're sending limb and this is a picture you can all take a picture of on your phones. It's an easy one for Mc Qs. They ask it all the time I definitely had it in med school and I know as I say, I had it in my exam recently. It's just a very easy M CQ. They can ask question number five. You've got a 42 year old this time with fever, shortness of breath, hemoptysis, hematuria. Her e has come back as a high creatinine, high urea high chloride. She's got patchy hilar consolidation. A chest X ray and anti GBM are positive. What is the likely cause of her renal failure? And I may have already spoiled the answer to this one. So the answer as you may, I'm hoping you all got is B is good postures. The key things to look out for here you anti GBM is a bond or yes, it can be positive in other things. But we've got it in a picture of hemoptysis with chest X ray changes and blood in the urine. So we know it's Nephritic syndrome with the shortness of breath. She's probably got pulmonary edema as well and it's just a bond or kind of presentation, these kind of patients and final question, which of the following would you expect in chronic kidney disease? Ok. So the answer for this one is c decrease bone density. And the key things here are to think about the pathophysiology of what's going on. So, in chronic kidney disease, you've got to shut down of the kidney and what does it do? So, starting with a obviously we know EPO is related to the kidney. So that's why you have an anemia of chronic disease. So that's why a lot of people with chronic kidney disease require EPO because they've got anemia. So they're not gonna have an elevated hematocrit, they're gonna have lower density in their blood. So we know it's not that one question number B it's not gonna be a low creatinine because as we know chronic kidney disease, they're going to be slowly being able to not out filter their blood. So that's where that one goes. And then in regards to obviously, we think about the kidneys role in Vitamin D Um And so the issue is here is obviously, we can't activate it as part of the second stage of activation of Vitamin D So we know that's decreased because of the kidneys not being able to do that role. And because of that, then you get increased P th So the reason you get your decreased bone density is obviously because you've got less circulating and calcium in your bodies. But these are the main complications of chronic kidney disease. The things you want to look for is your electrolyte balances. So your sodium, your potassium and your acid, your H plus K plus and N A plus. These are the most important things in your role of your Nephron. And these are the scary things to look for because obviously, the effects they have. Yes, of course, calcium and phosphate is also very important and why it has the on the bones. But your main thing is obviously looking at your electrolytes. But you've got to think of all of these things of what you've got to be aware of with these patients because they are going to throw off their electrolytes. You can't just deal with them with loads of fluids and hope it gets better. You've got to think in the long run, all of these numbers are going to slowly go the wrong way. So to be aware of this in the future and with this in mind, obviously, today, it's a virtual event. So we'll see how this goes. This is going to be your acute case. You're acutely unwell patient. And this again is drawn from a real case that I did have. So I'm just gonna talk you through how I would manage this and how I did manage this back in an F one and the kind of spiel that I'm hoping you're gonna start picking up as these sessions have already been going on. So the nurses will come to you on the ward and they say doctor please, can you see this patient? Um I've just attached them to the cardiac monitor and it looks really weird. Can you just go and see them and you're going right? What do I do with this? But of course we're in an exam scenario. So we're going, ok. The nurses are concerned about this patient. So I'd want to review this patient immediately. I would ask the nurse to come with me to help with observations and providing with equipment, asking her to grab the patient's notes, any available results and any scans. I'd also want to bring with me a phlebotomy tray and cannulation preparation in a and the airway trolley. If I am concerned about that, I would then introduce myself to the patient and start my at e assessment starting with airway. So I'd speak to the patient. If they're speaking back to me, I would assume the airway is patent, then move on to breathing. And this is where I'm gonna talk to you about moving up the arm. So I start off with, I'd like to take the patient's hand, get arson to attach a saturations probe when patient is, if they tell me the stats are low. So in this case that 84% of this patient on a non rebreather mask with 15 L of oxygen, I would then want the nurse to kind of reassess the er the observations of the stats in particular. Let me know if the oxygen levels are coming up. If they are not, I'd want to make sure I'm considering speaking to the anesthetist early moving up the arm. I then want to get the respiratory rate of this patient. So it's 18. I'm not concerned. I then move across, looking at the neck, I palpate the clear to ensure it's central and then palpate the chest wall, looking for equal expansion. I would then percuss the chest in six regions across both lung fields and then auscultate in those same six regions. Making sure in this case, I want to listen to the patient's back. And then they'd say to me in this scenario, OK. On auscultation, you've got bilateral coarse crackles in the lungs. So I'm already thinking here, there's an airway compromise. Now, as I said, you don't move on until you're happy. What have we got? We've got something on a quotation. Ok. What do I need? I need a chest X ray and I need an ABG, I've already given oxygen as a drug. So I want to make sure I'm assessing that. So I'd ask the nurse to take an arterial blood gas and to be running that off. Make sure to take it while the patient was still on Roma. So, properly assess them, I'd also want to make sure I get a portable chest X ray. This is an unwell patient. So I want to make sure I'm getting this with the radiology early. I'm already doing a lot of tasks here as an F one, I would be calling for help if there was any on the ward as well. But I've already given the oxygen. The stats the nurse will tell me are coming up. I've got the chest X ray coming. I'm waiting for my arterial blood gas that is pending. I can now move on to circulation. So starting off with circulation, I say I want to take the patient's hand, getting their peripheral capillary refill and then take their heart rate, which is raised at 100 and nine. Moving up the arm. I want to make sure I get two wide or cannula in each antecubital fossa taking off bloods as appropriate. I've already got an arterial blood gas. so I'd be moving on to other bloods. In this case, I'd want full blood count, renal profile, CRP group saving cross match bone profile. And I consider as we're worried about the cardiac monitor, any other electrolytes such as magnesium and calcium, I then have moved up the arm again and I want to take the BP. In this case, it's quite, it's low but isn't a healthy though. So I'd make sure I'd be considering fluids, but I'd want to make sure I continue my circulation assessment. Um So then I'd move on to looking at the chest itself. I want to get a central papillary refill. We've already attached cardiac monitors, but I want to make sure that I'm keeping those attached and getting the formal 12 lead E CG. These are the things I can't hammer home enough just getting those into a pattern of doing it. I want regular cardiac monitoring and I want a formal 12 lead E CG to properly assess them. I'd also auscultate for heart sounds and that's pretty much all we need to do while I'm assessing this patient. I also noticed this in their arm. So what was the most important thing to do as I'm trying to hammer home in this case, I already spilled off that they've got two large reactor, antecubital fossa. I do not want this and I want to make sure that written that we do not use the A V fistula for anything. So we want to make sure no venous access, no BP cuff on that side. So, but circulation, I've got my bloods going off. I'm keeping an eye on the BP. I now get given my formal E CG which is this, this is a scary E CG. It is not a good E CG and it is one that is concerning me. So we can already say we've already looked at all of these things. You can't tell much. So I can't tell about a deviation. Can I really see ap wave? Yeah, I can, I can see PQ RST. But the main thing that obviously is drawing me along cos it is quite a regular tachycardic. I've got two large squares in between. So we're looking at about 100 and 50 I can move to my V one V six. Um There are, there are some changes there, there is some inversion, but then I move on to all of my other leads, which is obviously where my eyes are drawing, which is in obviously V two, V three and V four. Now, if some of you attended my cardiac session, the main thing I said is that if you can sit on it, it is hyperkalaemia. This is at wave that is massive. There is no other word for it. This is a massive 10 to 10 to T wave. We're losing the QR S we've got, can we really see at wave? Not really, we're losing that. This is someone who is very hyperkalemic uh funnily enough. This is the V BGI get back. So actually on room air, they're not too bad. Their PO two was 8.3 and their P CO2 is 5.2. So they're not actually in respiratory failure. So they've probably got just some edema, they're not acidotic, which is actually a surprise because we're saying someone we're concerned if they've got a fistula there in kidney disease. So again, technically, I'm a bit reassured because their bicarbonate is also normal, lactate, normal. So it's not a septic cause, but obviously, the potassium is something very, very high. So in the back of my head, I'm going and I know the treatments. But you can say at this point, I'd want to escalate this early if you're unsure about the treatments for hyperkalemia. But at this point, if this was my station, I'd be saying, right, I recognize the hyperkalemia on the ECG and suggested with the findings of an a V fistula. I'd want to be discussing early and discussing whether I want to start medical management of this or considering any acute hemodialysis. So this would be where I can look at salbutamol giving insulin with dextrose to help driving the potassium back into the cells, um or if we are going to dialysis, but the main thing here is recognizing this early and discussing it with your seniors. So obviously, we were discussing this earlier in my or if this was my ay station, this is probably where it would stop because I'd say at this point, I need to call my the medical spr as a matter of urgency while you're waiting for them to come and review where you've had this discussion, then you can say I would then complete my at E examination. What we've gone back through. We will go up to get a G CS or an AU, we've checked their pupils, their temperature, mild Pyrex and nothing too concerning and their BM is six again BM. Never forget your glucose. But in these patients, what do all chronic kidney disease patients have? Most of them? Either diabetes type two or hypertension. I always think of that and we move on to exposure where you want to make sure that you always check the limbs. So your final line should be that I would fully expose the patient while maintaining dignity is the line I like to use. It just shows that it respects the patient, but you're considering the whole patient and makes sure in mine, I was always examining the tummy and examining the legs and in this case, this patient has severe pitting edema. So that completes my A to e examination. I hope it, you've picked up kind of like the where you're gonna go about it with the main things. If I just flip back before we go through the management of what you're bringing with you, how do I set up the station? I've got a nurse coming with me. I want you to stay with me. I want you to bring with me the stuff. I want you to bring me all the notes so I can see the big picture of this patient. I want everything at the bedside, they sound unwell, but I want everything I need by me. So when I make the phone call, I have all the information present, introducing yourself. We don't go in assuming if you, when you eventually, hopefully the surgeons were among you do your atl S. They'll teach you in trauma, you go home with your hands in the c spine. But in a medical emergency, we're going in, we're seeing the patient as a whole. We're talking to them. You may have relatives with you. You'd be very worried saying I'd go and introduce myself to the patient just saying, I'd say check the airway and ensure it's patent. It just sounds like you've actually been on the wards and been doing it chest X ray, chest x-ray check, sorry, getting an ABG oxygen as a drug. Always, always consider it and titrate and recheck whenever you give it, recheck your observations E CG again and then the importance of checking for the fistula and what that means for your um interventions, assessing your ECG S. I'm hoping you're getting a lot more confident with that. And with that in mind, we can move on to hyperkalaemia. So this is my guideline from my old trust. I quite liked it. It was very straightforward. So in this case, we've got ECG changes, we've got peak T waves, we've got flatten or absent P waves, I'd say and a broad QR S definitely. So we're already in this where we want constant cardiac monitoring, calcium gluconate. Why do we give the calcium gluconate? Well, we're protecting the heart. 10 mils of 10%. I've never seen 30 mils of 10%. So I always say in my exams, 10 mils of 10% giving your insulin dextrose because obviously you want to drive the potassium into the cells but not making them hypoglycemic, especially if they're a diabetic patient and then salbutamol is great. But as well, if you've already got quite a tachycardic patient, remember that salbutamol will drive up their tachycardia. It's not the best one for driving the potassium into the cells. The main one you're giving is your insulin and glucose but in this case, you should always be considering dialysis because this is a patient who's already got a fistula ready to go and they've got edema. So the final thing to remember, what are your indications for acute dialysis ei ou so, acidosis sepsis. So, severe metabolic acidosis, severe hypo um Kalemia. So your high potassium is greater than 6.5 intoxication. So this is where you go to your poisons database and they will advise when you should be looking at certain levels. When you should be using this hemodialysis or hemofiltration to get the poisons out if you've got severe overload, which is refractory to er treatments. This is where the riser is just not working and uremia when you've got your encephalopathy. So that's when you're looking for your uremic flap. Um These are the cases where you always look to acutely dial as a patient ei ou easy to remember and very important in emergency when you're considering it. And that sparely is that I hope you will enjoy it and enjoying your time off. Some feedback would really be appreciated. So we can help gauge whether you prefer it in person or just online. Um And yeah, any questions, please let me know. Now, I don't see any questions on the chat a little bit. Oh, Someone asked if we could post the link of the feedback form on the chat for them to scan on the, on the screen. All right. I'll get that again. Have someone say.