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You could skip and look at the answers for the M CQ. But I mean, um it's probably best, best just to give it a crack yourself, see how you get on. Um As I say, this won't be covering everything and it's not holistic, it's more of a focused approach than what mostly comes up in the MC QS and what I and the couple of the MC Qs that I'll give you, um I think are wee tricky ones, you know, um we all know the sort of management of anaphylaxis and uh it's, I guess it's the wee wee questions that could catch you out. Um So if you are getting them wrong, don't be disheartened. It's just uh I'm sort of being a wee bit of a, being a wee bit of a dick asking hard ones, right? So medical emergencies, uh this is the breakdown or the rough breakdown of um what your exam will be based on if you can see here. Uh Emergency medicine is at least eight questions. Um So it's a decent enough chunk. Um But also I guess with that with medical emergencies, there's going to be an emergency presentation of most specialities. So GI S will have their, their bleeds. Uh you know, cardia will have their mis. So even though it says it's at least eight questions, it will come up in more ways in the moment. Um We're gonna just briefly fly through it. Um And again, um I'll send you these slides if you, if you want and you can just use it um as a, I guess as a signpost. Uh but we'll talk about the A LS stuff. Uh The real emergencies, talk about cardio emergency briefly and then move on to some respiratory. So this is your A LS algorithm. You've seen it all uh or you've all seen it before. I'm sure. Um The main thing uh with it is chest compressions and then whether the rhythms shockable or nonshockable. So these are examples of your shockable rhythms in MC QS of past. They, I don't think they've ever given you a rhythm strip when the patient doesn't a cardiac arrest arrest. They usually just tell you what the rhythm is, but it's important to just familiarize yourself with it. So, ventricular fibrillation on the left just looks like a bunch of squiggles and VT your ventricular tachycardia is irregular. So you can see it's regular because there's an equal distance between each of these peaks and it's broad, complex. So the electrical signals are originating from the ventricles, um which is why it's broad. So it's a regular, broad complex tachycardia So that's the two shockable ones. Two non shockable are asystole. Uh, so Asyst looks like a straight line. It's not completely straight. If it's completely straight, then your leads aren't connected. Um, it should just look like a bit of AAA mild wave. Um, and then P EA is pulse stands for pulseless electrical activity. So basically, it just looks like a nor normal. Um E CG. Um, but whoever palpating the pulse can feel. Well, so those are your non, well, for shockable. The main thing is that you shock. So that's your first treatment. You shock, it's unsynchronized because they don't have a pulse. Um And that I guess can be M CQ. So they would give you a patient is brought on cardiac arrest. Um Their E CG shows particular fibrillation. What's your immediate management? And it'll be to shock them. It's important to remember that after the third shot, you give drugs and you give both amiodarone and adrenaline because uh because it is shockable. Uh you can give amiodarone to try and switch to the rhythm. Um and you give adrenaline because they're in cardiac arrest. And then, although I don't think you'll be asked this, it could be, you know, relevant for MC Qs, you then give the drugs every 3 to 5 minutes or an easy way to remember that is every other cycle for nonshockable. Um The treatment is just adrenaline immediately. Uh No aone and drugs every other cycle. So, again, very empty cable. They'll ask you that instead of that, that previous question, instead of them being in V fib, they're in P ea, what's your immediate management? So, don't bother with the shock straight them on the adrenaline. So, here's a little practice M CQ. Um, you can read it in your own time and they'll give you like, 30 to 40 seconds to answer it because that's probably what you would get. And uh the exam, I think so, take your time. So uh 73 year old man collapses, uh it doesn't really matter why he collapsed, but essentially he has no pulse E CG shows as like what's the most appropriate next step in management. So, a bit of a tricky one and I only asked this because I think I got asked that in our fourth year exams and I was stuck between two answers whether to start chest compressions or call the cardiac arrest team. Um And the correct answer is they actually call the arresting. Now, I think I got this wrong j because I thought that was pretty uh um well, slides remain available. Yeah, certainly I can send them on. Um Absolutely. Um The But yes, so it's the call, the cardiac resting. I thought that was pretty um illogical, you know, because you're sort of leaving the patient. But um if you look at the algorithm again, the call resuscitation team comes before the CPR, ideally, you'd have two people um and someone else will be doing the job for you. But if you're going purely by algorithms which your M CQ will be marked upon. Um again, this has come up a bit weird. Um But this is the Inhospital resuscitation algorithm. And again, if there's no signs of a pulse in this cardiac arrest over on this left hand side, um The first step is the call and collect, so call the resuscitation team before you give CPR. Um So I thought that's a good one to keep in in your mind because it could be a question to trick you out. Uh call the cardiac team uh before you start chest compressions. Um fair enough grand. So next question uh I'll give you a wee minute to read this. Mm mm. So elderly patient on the oncology award has a cardiac arrest start comparison of the research team team are contacted, rhythm shows V et so ventricular tachycardia immediately your head should be thinking what side of the algorithm it goes on. So it goes on the shock, shockable side. Um They've um already I guess told you that by saying that that there's been three shocks given um after the third doc which two medications are indicated. Um I see Hanna's put in there. Yep, that's spot on. So the answer is c so that's only testing. Just do you know the doses um of your cardiac arrest drugs? And for most cases in finals you don't need to know specific doses. Um, I don't like, they're not testing you on, on that. Uh, they're just testing you if you know the drugs, but when it comes to cardiac arrest, um, and the, the A LS drugs, they do expect you to know the doses. Um, so it's 300 of amiodarone and 1 mg of adrenaline. Uh, they also may be a bit cruel and word it as well. 10 mils of one in 10,000 adrenaline because that's what it comes in. It's like a 10 ml vial of one in 10,000. Um But it's important that, you know, those doses off the top of your head, I think they, they, they have asked before um doses and they certainly could ask again. Um So that's that question. Uh Next one. So have we read this? So a wee bit uh it, it's a wee bit uh lousy of me to ask you this one because again, these aren't normal cardiac arrest situations, but I thought it be, it's better to get out if I thought that if I was sitting in finals and I always, um thought this in my, in my revision was always trying to prepare for the tricky questions, you know, uh prepare for the ones that aren't as straightforward. Um But um I see a couple who said that you said the right answer, maybe it was only tricky for me like, but uh it's, it's good to keep these wee scenarios in your head just in case they try to trick you out. Um Because if you're prepared for the worst, then all the barn door questions are easy. Um You know, and you, you get a comfortable pass. So tricky question, 63 year old male uh has a cardiac arrest um Before he gets a, an angio, his heart rate is 164. and the E CG shows ventricular tachycardia. So it doesn't have a pulse. Uh But he has VT A, they asked me what's the, the, I guess the, the best next step. Um So today give adrenaline B, amiodarone, C uh one shock D3 successive shocks or e give adrenaline and amiodarone. So I guess you can rule three of them out immediately because, because it's in the shockable rhythm and you have shockable side of the album and you haven't given them a shot yet, then you know, all the drug options are gonna be wrong because you need to at least wait, wait until the third shock. Um So it's between C and D if you had said either it would have been fair enough. Uh because it is a tricky one, but the actual answer is D um So you give up to three shocks in succession when there's a witnessed cardiac arrest. Um So look out for that in the stem or the question stem whether someone's seen it. Uh I think usually they would give this, um, type of question of somebody being in the Cath Lab. You know, I don't think they'll say that someone witness a cardiac arrest, um, while the patient will go in the toilet or something, you know, it'll usually be in the Cath Lab or some specific situation, um, like that. Um, but just keep in the back of your head. If it's a witness one, you can get three shots before moving on. Good stuff. All right, another one here. So 55 year old fella um again, cardiac arrest. Um The usual cracker E CG now shows the fib um A LS started several attempts. A canulation are made not successful. What's the next step to take? Um So again, this is just um trying to test your knowledge outside the algorithms, I think for finals, I just learned the algorithms inside out and back to front just so that they were in my head. This is just trying to prepare you for the ones that aren't in the algorithms, you know. Uh So yes and as correct the answer is E there's and osseous line insertion. Uh The, the, the reason being is just because it's quick, easy access, um vascular access. Um And the, you know, you're not gonna give adrenaline through a et tube and you won't have time to put a central line in. Um So eas easy answer, just remember if they can't give vascular access, they go in osseous and another question they could ask about the osseous is where, um uh you know, where could you get uh intraosseous access? And so usually that's the anterior of the tub um or the humeral head. Um Either I guess or, or right. Um And I think we got that, that in finals or four here. So remember those two sites of intraosseous access. So, the next up, uh I guess emergency would be anaphylaxis. So this, I think will be really obvious on the questions then that they're having it. So they'll either tell you state specifically that they're having anaphylaxis or you'll have to work it out because they've started IV penicillin and they've got a bilateral wheezing a big mad rash and some of that swelling. But it should be pretty obvious. The main thing on this algorithm, they've scrapped all the steroids and antihistamines is just give im adrenaline. Um So usually if the, if they haven't said about giving im adrenaline, that's gonna be the answer. This is another one where you need to learn the doses. Um So this is uh sorry, hold on, let me go back. So um learn the doses and also learn the doses per age group because they differ and you could, well, you know, as part of your pediatric um part of the finals, um get asked about a pediatric anaphylaxis and need to know it. So that's the dosage there. So it's 0.5 mils, one in 1000 for adults, 0.31 in 1000 for 6, 12 year olds and 0.15 for 66. Um, the, the main thing, uh, for Acies, as I said before and the feedbacks is to remove the trigger. It's something that you can really easily forget in the, in the heat of the moment. Um, and I guess at the same time, remember that for MC Qs, uh, because if you look up at the top right here, I know I've put a big mad blue circle on it, but just above that top of the blue circle, it says remove trigger if possible. So that it comes above given Im adrenaline in the algorithm. So if queens uh were to ask you in an M CQ, what's your, you know, your next step in management uh removing the trigger if it's still in situ um is, is more correct than giving im adrenaline because it comes before it. Um The other thing that I've put in there, uh Just again, thinking about possibilities is they might try tricky and say that they've already given two doses of IM Adrenaline in the community or something like that. Um It's just, you know, you don't need to know the refractory anaphylaxis um guidelines inside out. But it's just to be aware that if IM adrenaline two doses fails, then you move to IV adrenaline. Um And I don't think they'll expect you to know the doses for that. Just know, be aware that that is the next step. Um And then obviously a really good M CQ topic would be. What blood would you send um, to confirm Anaplex and its mast cell tryptase. Um So another questionnaire. So 20 year old fella, um, gets sudden facial swell and urticaria and breathing difficulties after eating some shellfish. So that is no, that is, you're bound to anaphylaxis. They'll really make it obvious. II think they would be, they've had a recent trigger. Um And then they get all these uh um al al aller allergic like symptoms. Um So this is just testing. Do you know the doses? Um And you have to see a couple of right answers there on the, the chat. It's c so half a mil of one and 1000 because he's a 20 year old fella if it was a two year old. Um You know, boy, it'd be 0.15 10 year old, 0.3. But for any adults, it's 0.51 in 1000 and it's just important to remember as well they put in which I think they will do. Um One of the options was 0.5 mils of one in 10,000. Uh and it's easy to get the anaphylaxis and uh cardiac arrest ones mixed up. So just remember one in 1000 um for uh for anaphylaxis. So move on quickly to the tachycardia. So that's the algorithm there again. The, you, you can look at the algorithms in your own time. I'm sure you have looked at them before. Um This is uh your approach to someone that's um unwell with the tachycardia. So the main things that I get from the algorithm, is it stable? Unstable? Is it broad versus narrow or is it regular versus irregular? Those are the three questions you have to ask yourself. So the first one, is it stable or unstable? If they're unstable, then you can just forget completely about the broader complex or you know, narrow or whether it's regular or regular, your mind's already made up. You don't need to worry about it. You know what the treatment is so unstable or signs of unstable tachycardia are shock, syncope. M IE and heart failure. But obviously in an M CQ, they're not gonna give you, they're not gonna say this patient is in shock or this patient has syncope or no, this patient has myocardial ischemia. They'll give you a symptom or a sign and you have to put the pieces together um to uh you know, to somebody that, oh this is an unstable one. So they'll slip in their observations, they'll not say anything. They just say their heart rate's 180 their blood pressure's 80 systolic. And then as soon as you see that you should think, um it's an unstable tachycardia. Um for syncope, it'll either be the patients lightheaded or they have a low G CS or they've had a moment of unconsciousness for ma it'll usually be, they have chest pain, like very severe chest pain or chest discomfort. And then for heart failure, it's a bit of a, a tricky one. they usually put it in as that the patient has by basil crackles on auscultation, which I thought it is a bit of a stretch. But uh that, that's the way it, it comes up in the previous um the previous MC Qs like the past papers um is that the patient will have bibasal crackles. And then that's when you're supposed to realize that they're probably in flash p edema from heart failure second to their tachycardia. So look out for those four symptoms. If you see any of those, it's up to three synchronized shocks is your treatment. So it's synchronized because they have a pulse. So you want um you want to, you know, get it in line with the pulse or else you're when you put them under the cardiac arrest. Um But yes, so three shocks, then amiodarone, then another shock, then amiodarone again. So three shocks, amiodarone, one shock, amiodarone. Um Those are the doses of amiodarone with it. But I don't think you'll need to know that it's just in case you, you want to keep it in a logger. Um So any tachycardia, if you see any of those four symptoms, you're straightly shopping, don't worry about whether it's regular or broad or no, if none of those symptoms, um, are present, what they'll most likely do is they'll either, uh, tell you, um, what the, the, the rhythm is. So they'll tell you that it's S VT or AF or they'll show you an E CG. So for a narrow, regular, um, tachycardia, it'll usually be supraventricular tachycardia or S VT. Uh, this looks pretty similar to sinus tachy, except your, their heart rate will be much faster. So sinus tachy usually, you know, goes to about 150 anything over 150 up to like the 1 71 80 mark is usually S VT if it's narrow and irregular. Um It's usually vas F or, well, it most certainly is vas f um the treatments for these for S et uh is vagal maneuvers. So let's say they're blowing in their syringe and tipping them upside down um or giving their neck a wee massage. Um and then adenosine. So I would, I would probably learn these three doses. Um just because they could maybe give you uh a history where they've had one dose of adenosine already. And then they ask what's the, the next best step in management? So then they might give you three different doses of adenosine and you're supposed to know that it's gonna be 12 mg the second time. So it just goes up in sixes. So six for the 1st 12, for the 2nd 18, for the third. Um another one another wee M CQ, but it's just to be aware of it in asthmatics. Um So it's contraindicated in asthmatics. Uh So you wouldn't give it. Uh And, or because it, it can worsen bronchospasm and then if all else fails, so vegan maneuvers fail, adenosine has been tried three times in F um then you shock them, even if they're stable or unstable, you, you give them a shock and again, this one's synchronized because they have a pulse uh for FF it's usually as beta blocker or calcium channel blocker. Um Let me see. So these are C GS, they have been um asked before. So they'll give you an ECG like this um and ask you what, what's the, the diagnosis? So they'll not ask you the treatment or anything. They'll just ask you what like a spot diagnosis. So the S VT is partly know that the QR S complexes are narrow. So it wasn't like that VT that we seen earlier. These are skinny complexes and they're regular. So the space in between each one is um is equal and then as you can see from the space in between. So, you know, to work out the heart rate from an A CG, you take, you take the space in between the two R waves and divide by 300. So if you do that, this boy is nearly sitting at like 250 or something. So that is a uh like a barn door S VT, like that won't be sound as tacky. Um, and the second thing with S VT to sort of differentiate from cytostat is that usually the P waves and T waves sort of morph into one. And so you see there, you know, like you, you can't really discern between AP or T wave. Um, so that's another sign that it's S VT and then af just looks a wee bit like a mess. So you can see that there's 1.5 squares between the first, then there's two and then one and then a wee bit of a one. so they'll be, they'll not be, um, equidistant and then also you'll not get any true discernible P waves. Um, so S edsa wee bit trickier to spot a FSA wee bit easier to spot, but those are the hallmarks of them. Uh, let's see. Can pain be silenced in elderly diabetic? See it masking classic, like symptoms. Yeah. I mean, it could certainly, um, as in, I'm guessing you're talking about for, you know, like the myocardial ischemia part of the unstable tachycardias certainly could. Um, but I think thankfully you'll not have, you'll not get asked about that in finals. You know, that would be very cruel to give you a silent m ie and an unstable tachycardia. Uh So don't be stressing it. Um, for maybe clinical practice. Yeah, like it's something to keep in mind. Um, and you would certainly be getting senior help. Obviously, you know, if you had an unstable tachycardia to be dealing with. But for the purposes of finals, everything I think will be pretty barn over. They'll let you know the symptoms of the patient and they'll, they'll lead you down the garden path if they, if they, if they want you to shop them. So that was narrow complex, um, quickly broad, complex. Uh So we talked about it earlier. So there's broad, regular and broader, regular, broad, regular is that VT that we were talking about as you see, those are big and wide compared to the, let me see, you see the narrow ones there, nice skinny complexes and these are big and wide ones. So that's your VT. So the thing with BT is obviously, that's a cardiac arrest for them, but it, they will state if the patient doesn't have a pulse in the M CQ, if they state that the patient does have a pulse, um then you're going down this treatment algorithm which is amiodarone um VT when it comes up with a pulse will most likely be unstable. So you might have the shock anyway, but it's just if you get an M CQ, they ha tell you that they have VT or they show you this ECG um they say that the patient has a pulse and there's no adverse features. Like we talked about the low BP, chest pain, um Bibras crackles or low G CS, then you actually don't shock them. You just give them Amiodar um broad or regular will either be af with bundle branch block, but just completely ignore that. Don't even give it a second thought because you'll not get asked about it. Um What you could get asked about is polymorphic VT, which is Torsades de pointes. I don't know if you've ever heard of that. Um It's, um, it comes up quite a bit just because it's got a fancy name and, um, everyone knows that, like, or, uh, if you have a long Q ti think it was, um, and you get started on something that prolongs the QT, um, it flaps you into it. That's why I always heard about it, but it's something to keep in mind. That's what I think you would get asked about more rather than the af with bundle branch block. Um, so this is your tour de Pointes. Um, I guess when I of faith it's so it's supposed to be, I don't know if it means twisting of points or twisting of ribbons or something, but I was taught that it looks like a ribbon twisting upon itself. And I guess like if you really tried, you could see that it gets low, low, there's big complexes and then they shorten down and then begging up again, shorten down. But that's, that's what that looks like. So you can, you can at least appreciate the difference. The VT looks pretty regular and all the RS complexes look the same whereas this, um it's not really a V fib, you know, because you do have some big um complexes in there. Um But it's also not a VT because it gets a wee bit shorter at times. So that's polymorphic VT or Torsades de pointes. And I think you could get asked about this because it is a specific treatment. And so it's not amiodarone, it's um M GSO four, which is short for magnesium sulfate. Um So that's a really quick run through for tachycardia. It's a stable, unstable. If it's unstable, just forget about all the rest. Just you're shopping them. If it's, if it's stable, then you have to worry about whether it's narrow, broad, regular or irregular. So here's a WE M CQ free. Uh give you like 30 seconds to answer this. So I guess this is fresh in the head. So probably is a wee wee bit easier to the answer. But um yeah, so 30 year old man, unresponsive ecg shows a broad, complex polymorphic tachycardia and patients diagnosed with Torsades de Pointes. Now, in the N CQ, they mightn't give you that wee last nugget and say that they were diagnosed with Torsades de Pointes. They might say broad complex polymorphic tachycardia. And that's why I put the question in there. Um It's, it's just so that you are sort of familiar with the language. Um And that, that broad complex polymorphic um should equal torsades de points in your head. But yes, the management is a magnesium sulfate. Um You don't give amiodarone in these, it's magnesium for the specific one. It's the only tachycardia I think you give magnesium for. So Brady Cardia is a wee bit easier. Um Essentially, uh that's the algorithm there. We will not spend too much time on it, but it's uh essentially if it's unstable. Um which again is your same symptoms. So the low BP, the chest pain, the low G CS or the bibasal crackles and auscultation. Um You give a atropy 500 mcg. It's a pretty similar name, the adenosine. So it's important to try, remember the difference between the two because they're very easy, mixed up. Um So if it's unstable, so I say with those four symptoms or if it has any of these specific high risk features. So Asystole means just no heartbeat. Uh Mobitz type two is the 2 to 1 block. And I always remember that just because uh you know, type two is the same as 2 to 1 block, obviously, like um if you're being pedantic, it could be a 3 to 1 or 4140 to 1 block and that's still MOS type two. But just for the um the sake of remembering things and you remember 2 to 1 block is MOS type two if it's complete heart block um Or if there's a ventricular pause of more than three seconds, uh even if they are stable, you would still give atropy, I think they will um specify in the question. So I don't think they'll try to be fussy about that. I think they'll tell you that the patient has complete heart block or they'll have, you know, they have a 2 to 1 block or no, they'll state those high risk uh features specifically in the question I'd say. Um So you give atropine up to 3 mg, so six boss um or, and then a, if atropine has failed, uh then you go on to pacing so it can be transcutaneous pacing with the DF pads. Um And if that fails uh transvenous pacing, but don't worry about it. And that's just a wee diagram of uh type two. So you see here the P um pr distance stays the same, it doesn't get any bigger or any smaller. Um But then just suddenly there's a wee P wave without a QR S complex and here's an example of a complete heart block. So this has come up before um both of these and the MC Qs. Um So you could get a bradycardic patient and it'll not ask you about the treatment, but instead ask you to try to work out what type of heart block it is the way I always worked. It was um just made a mark at each P wave and made a mark at each R wave and see if there was any relationship between them. So here you can see quite clearly that the P waves have a relationship with the QR S complexes. So it's not complete heart block, but then you see its drops. So you would know it's a type two. This one, if you made your remarks, um You'll see that the A are pretty regular but they're not talking to the QR S complexes at all. You know, there's, they're completely different rhythms. Um So that's complete our block grant. Here's another question. So 78 year old man treatment for symptomatic Bradycardia, he's had several boluses of atropy. Uh And he's still a bit unwell, blood pressure's 84 so very low. So again, your uh the alarm bells should be ringing. This is an unstable patient. Uh and heart rate's 34 patients confused and sweating. So the confusion is also a sign, I guess of syncope and because it has a reduced G CS and cold and clammy extremities, what's the most appropriate step in management? So the answer for this one is external pacing. So he's had several boluses of atropy, um doesn't specify how much, but uh it's quite clear that the atropine is not working. And so the next step on the algorithm uh if you look at it is um uh it's way down there and it's terrible writing. But uh essentially, if atropine is not doing the trick, um it's, you have to move on to pacing. Uh And I II threw that one and I think it's came up before um a BREO patient and just asked you the first line treatment which is atropine. But I threw this one in because I think that if they're trying to be tricky, they could ask you what's the next step a after atropine and it's pacing. Um Sinex give you like 30 odd seconds for so 65 year old man saying the A and EEC G shows S VT. So you're on your Tachycardia algorithm. He's tempted to blow in the syringe, the GS of a doctor and this terminated the S VTA short while later, he's in another episode of palpitation of breathness. Gin has CT on the A CG. Heart rate's 100 and 80 BP, 8565 most appropriate me of management. So again, just trying to think of tricky ways to ask us the, the man had S TT and it obviously was a stable S VT cause blowing into the syringe is one of those vagal maneuvers after a while he goes back into it and his heart rate is 100 and 80. And again, it's that wee key nugget that the blood pressure's 85 or 65. So they'll not say that the patient's shot, but they'll just give you an observation and um make the extra link and realize. Um So yes, Hannah's spot on the answer's C it's DC cardioversion synchronized and I just put un unsynchronised cardioversion in there as well. They try to trick people out. Um Just remember that if they have the pulse and it's not a cardiac arrest that's synchronized. Um So, yep, good stuff. So cardio cardiology very briefly. Um The, I don't know why I put Warfarin in there. I II was gonna talk about the bleeding patient, but I don't think we have time. Um So it'll be a CS is your main cardio cardio emergency. And the way they usually ask it is they'll give you an ECG and ask you what's the diagnosis? Um And more often than not, it's usually either pericarditis or stemi. Um This is just the A CS um algorithm for tr diagnosis. So, if they have ST elevation stemi, uh so if they have non ST elevation, um you have to send off troponins and if the pros are high, it's an antemi troponins are normal, unstable angina. Um If it's a typical history, this is an E CG. Um can I'll give you a wee couple of seconds to come to your own conclusions as to what you think's going on. So this uh is a example of an anterior stemi and you can see it most pronounced in the V two lead. Um It's got very marked ST elevation uh and then you can also appreciate if you look at the inferior leads of the lead three and lead VF there's very minor ST depression. So there's reciprocal changes and that's what you'll find in any sort of ischemic event. If there's ischemia, you know, if there's ST elevation of the anterior leads, there'll be reciprocal depression of the other leads. Whereas um if it was say an E CG of pericarditis, you would have ST elevation in all of the leads. And here is something that you probably have learned this or no, have it um on the horizon to learn. But I would really recommend learning this, um, which is the distribution of the c the different leads. Um, because it's so M CQ and it has been asked before and what territory the M I is. So they'll, you know, they'll give you that E CG that I just showed you, but they'll, uh, I know you could be pretty confident, but like it seems like an M I to me, but then they'll, all the options will be myocardial infarction and they'll ask you different territories. Um And in others, we good thing to learn is what artery supplies, which because I don't think that they'll ask that and they haven't asked it before, but it's something that they could ask. Um, or it's something in the ay that you could show off. You know, if you seen that it, it was a anterior semi, uh you could get extra no brownie points for saying it's most likely an in fortune of the, the, the lad, you know, so the treatment for it hasn't been asked before. Um, certainly from the practice papers I seen and from the Queen's ones that I have, um, um, sort of notes for, but it's just to, to keep in your head for, as in case they ask you. Um, and it's now moat. So if it's a stemi it's primary PC and moat sounds from morphine to oxygen GT Aspirin, um, and tag and if it's an Nstemi or, um, unstable Angina, it's usually just uh mona and that primary PCA but not been too long on it. I don't think, um, you'll need to know it too much. The thing that does come up on MC QS and on a couple of past papers I've seen is complications of ma. So it'll tell you that a patient has had a myocardial infarction, you know, um, some period of time ago and they'll ask you, um, they'll give you some symptoms and ask you for a new diagnosis. So the ones that I think could be asked is heart failure, um which, you know, will just present as I say as the, it, it'll be more of a chronic history, um like bit of leg swelling, peripheral edema. Um but of uh parts of the nocturnal dyspnea and some orthopnea, uh it could be pericarditis. So they may give you an E CG POST M I and again, it'll be that C shaped S TL through all leads and more specifically pr depression. Um So if you see that uh, in any E CG, which is a, you know, a, a dip between the P wave and the start of the PR S complex. Then that's no pathognomonic for pericarditis. And on auscultation, they'll hear a rub and say, like it's walk, they say it's, um, like walking through snow, um, or something. Um, but it'll be like muffled heart sounds or you'll hear a rub. Um, more tricky ones that I think could come up is uh left ventricular wall rupture. Uh So if the, if the heart's infarcted in any part, uh uh the dead tissue is more prone to actually popping or rupturing. Uh and wherever it ruptures gives off different symptoms. So if it, if the left ventricular wall ruptures, not the septum, but the wall itself, then you'll bleed into the pericardic pericardium. And so what that'll present as is like a tamponade. So it'll give you a patient had an M IE two weeks ago. Um Now they presented with that be X triad. So, no BP, you raised ABP and muffled heart sounds. What's the diagnosis? And it's a wall rupture. If they give you, uh if the rupture happens in the septum, you'll get a ventricular septal defect. So I don't know if you remember from your peds uh placement, but A VSD gives you a pan systolic murmur. Um So that will be what will be in the, the, the questions stem and then uh what has come up in the, I think there was a 2022 piper or the 2023 piper is a papillary, papillary muscle rupture. Um So essentially, if the muscle becomes infarcted, uh and ruptures, then you'll get a new murmur. Um because obviously the pul muscles hold the valves taught. And so if that ruptures, um then you'll get mitral incompetence. Um So you'll get a patient that all of a sudden has a new murmur. So it'll most likely be med systolic and there'll be in flash pulmonary edema. So that's the two things you look out for in your questions then. So uh here's a wee question. So patients thrombosed inferior M ie 72 year old man has now developed signs of left ventricular failure. So another word for heart failure, his BP drops to 100/70. Uh He has new early to mid systolic murmur and crackles by Baisley. What's the most likely diagnosis? So that is an example of your papillary muscle rupture. So all of a sudden, a man who is well, um gets after having an M ie gets new heart failure. Uh The air lady med systolic murmur is uh as well how you been describing mitral regurg. Um And that's, that's, I guess the pary muscles in the uh in the left ventricle, that's the, the valve that they'll be holding. Um And then the crackles by Baley showing you that he's in pulmonary edema secondary to the mitral regurg. So if he's in mitral regurgitation, uh the, there's going to be a back pressure to the left atria and as a consequence, back pressure to the pulmonary vasculature. Um, so just keep that in mind it's come up before. Um, um, so Dressler syndrome, er, is, it's, this will be probably thrown in there as one of the options. Um, and it's similar enough to the pericarditis. Um, and it could, again, that could be an answer. Uh, essentially all it is is, uh, pericarditis roughly around four weeks after an M I or 2 to 4 weeks. Um, that it's just, it's just another name for the beard. Um, but it's treated with nsaids, I think. Um, so usually what if they were gonna ask about Dresler syndrome? They would ask, they would specify a timeframe. So they would say, um, a patient presents, you know, four weeks post M I, and they'll have, um, a temperature of like 3738 and they'll have, uh, the pericardial rub that, uh, we're talking about, um, on auscultation and then if they show you an E CG with it, it'll probably be the saddle shaped ST elevation. Um, so just keep that in mind actually. Yeah, it's good. It's good. It's good. You asked that. Um, it's another word for pericarditis post M I essentially grand. So now fly on are over time because of the, um, technical difficulties. And I'm sure that you all have loads of revision to get, get on with. Um So I'm sorry for keeping you late, but very quickly respiratory emergency presentations. It will only really be one of these uh three or four conditions and it only ever has been for emergency. So it's asthma slash CO PD, uh a pulmonary embolism or a pneumothorax. So, asthma, the main things do you know for that? I've thrown that in with CO PD because the treatment's the same. Um And they'll present the same, the only difference will be um the past medical history. It'll say in the question, it'll say that the patients either, you know, a 60 year old who smokes like a train, um or uh it'll be like a, you know, 20 to 40 year old that has a past medical history of asthma. Um So you'll be able to know what condition they have, but the treatment is the exact same. Uh the thing uh for asthma specifically to learn is this these uh qualifications of lifethreatening asthma? So they very uh very um handily f on the new of Chase 3392. Um And I guess I say learn these because they could ask you about what severity is the asthma attack. Uh And the way I always learned, it was just learn the life-threatening ones. And if you don't see any of those in the question stem, then it's most likely just a severe um asthma attack. Um So if you learn all of these, you don't really need to learn the, the other classifications of the different asthma attacks because you, you sort of have a benchmark to go off if that makes sense. Um So the, the, the signs of life threatening asthma is cyanosis. So they'll say that the patient's blue or confusion. So they say they have a low G CS hypotension again. So there'll be a low BP um and a arrhythmia. Um So they, I think they can get quite bratty with asthma if I remember correctly. Um But that'll not likely come up. Um The main one I think is exhaustion um at the bottom and it, you might be thinking like how you, how can you tell someone's exhausted? Uh The way that they'll do it is they'll give you an ABG and it'll look pretty innocent because the P CO2 is normal. Um But if they're really trying to blow off the, even the respirate is like 50 they have a normal P CO2, then that indicates that they're not blowing off their, their um CO2 as much as they should. Uh So that's classified as a lifethreatening uh asthma attack. So if you see a normal P CO2 in any asthmatic patient, um it's, it's going to be life threatening. So that's good for your excuse, but it's also good for your oy, because it could come up, uh you know, in acute asthma and I think it has come up as a poem station before. Um So if they show you an ABG during your oy, you know, really emphasize when you're looking at it and you see the normal P CO2 S talk about how that's such a worrying sign. Um And you know, you're gonna escalate and get senior help really quickly because the patient's really unwell. Um So the treatment is oh shit me. Um which again, very handy in the manic to learn. I would learn, I haven't put the doses in because I don't want to be pies with information, but it would be handy to learn the doses um for your o if it comes up again. Um Don't worry about theophylline doses, but the first four certainly. And it's pretty easy to remember because Subbu is five mgs. Um and therapi is 500 mgs and there's no maximum dose. So you would just say that you would just give them back to back to back until the patient gets better. Um, hydrocortisone is just a one off dose. Uh and it's a 100 mgs. Um But yes, so, oh shit me. Uh oxygen, salbutamol, hydrocortisone, ipratropium. Those are your first four that you would give in any asthma attack? Um The other three, I would, I just ignore theophylline. Don't really give that. Uh they don't really give that anymore but be wary of magnesium. So it's come up, I think in 2020 maybe or 2021. Um the uh an asthmatic patient got all of the first four treatments and then asked, what's your next step of management? And the answer they gave you theophylline or magnesium. Uh and the answer was magnesium because you don't really give theophylline unless you're uh very senior. Um So keep that in mind um two bottom ones there because these have both come up uh in past MMC QS, if an asthmatic has a high P CO2, so has type two respiratory failure, then they need intubated. Um that no, there's no, there's, you're not gonna get them back with nebs. Um and it has come up before being asked and in intubation was one of the, the, the answers. Um And then also CO PD people with type two respiratory failure. So a high CO2 and a low Ph. So um if they're now decompensated, then you put them on BIPAP or no. Um So CO PD people can have type two respiratory failure, the full life and not be worried about it because their ph is normal because they're compensated because they're always type two respiratory failure. Um But it's important that if you see in a question that they have a low PH, um then it's an indication for uh further step in management like N or BIPAP. Um pe will present with uh pruritic chest pain and shortness of breath. That'll be your two key ones and they'll also um put on a bit about the chest x-ray being clear or the, the sounding of the chest being clear, it'll be one of the two. so keep an eye out. Someone has pl chest pain and short of breath, but there's nothing on the chest x- it's bar or most likely gonna be a pe um, the ABG O used to be type one respiratory failure because they're able to blow off their CO2. Ok. Uh They just have a big blood clot, not allowing them to get oxygenated in their past medical history. They'll usually have, you know, like tongue cancer, um, or like a recent surgery. Um, so they usually tee you up and, you know, uh, give you, give you clues that it's pe um, the investigations. Um, I don't, you'll not need to know the well score off by heart. Uh, but the main investigation for it is the C TPA. I don't think they'll make you calculate the way it well score. I think the answer will most likely just be C TPA and you can just stick it down. Um, but this is just in case, you know, if you're asked about it, no, this is the breakdown. You work out the well score. It's how you send them for a C TPA. Slow. You do a DDIMER. If the D dier is positive again, go for a CPA and if it's negative, think of something else, er, the treatment for it is a do whack. So a fan or uh rubber fan um grant and then again, pneumo. So pneumothorax will again present with periodic chest pain and shortness of breath, but this will have chest pains. So they'll either have reduced air entry wherever their chest pain is or um on the chest X ray, you'll, they'll mention that, you know, you can see a pneumothorax again, ABG will be type one resp failure. Uh The past medical history is typically just a young smoker. So they'll say he smokes weed or cannabis or whatever. Um uh and um or they could have another lung condition like COPD and asthma both um increase your risk for pneumothorax in uh investigations a chest x-ray. Uh and they're usually pretty um recognizable on it. Uh and the treatment. So if it's attention pneumothorax, if it mentions about, uh you know, their blood pressure's going low or, uh you know, there's a shift in the trachea, then the treatment's emergency decompression. Um for the rest of the pneumothorax, I wouldn't worry too much about the treatment because the guidelines are um are a wee bit melty. Uh And they're not very clear, you know, it's, it's a choice between patient, um what the patient wants and the choice between what the clinician wants and it's all very airy fairy. So I don't think it's very questionable. Um But what to know is that if the patient is not really symptomatic of it and it's found incidentally, then the treatment is always conservative. Um But that's the guidelines and if you um have a look or you can have a look at them if you want, but I mean, ii don't think they'll ask it. Um So we'll move on. Um So if you were given a chest xray like this for a patient that was, uh you know, acutely short of breath, um What would you think? I'll let you just answer in your own time. You don't have to write down or anything. But essentially the, the big thing is if you look, there's complete asymmetry um of the lungs um on the right, there's no real lung mars and you can see just beside the heart there, it almost looks like an extension of the heart, but that's the lung border. So it's completely collapsed lungs. So that's about right pneumothorax. Um And I can't remember, I think I might have pulled this from a past paper. Usually the pneumothorax that they ask are this obvious. You know, it's a really obvious, it's not like subtle or anything. Um And then it's also important just to look at the trachea in these or the media sta and just make sure it's central. So this media standing looks pretty central to me. So it's just a noncomplicated pneum. It's not um not tensioned or anything. So, here's another uh question. I don't know why they've come up late and underlined. Um But 78 year old mans come in with an infective exacerbation of CO PD. He's treated with oxygen, bronchodilator, steroids, antibiotics, two hours after admission. And that's his blood. Guess what's the next management step? So, the answer is, it's very subtle, subtly highlighted there, the first bullet point. So it's bipap. Um, and I've just highlighted the reason why it's because the ph is low. If the ph is low, uh, in a patient that had no, the question stems talked about them having CO PD. Uh then they've decompensated, they're very unwell, they're, their CO2 is rising above their normal level um and they're becoming acidotic. So the only way that you're only going to get that back up is by giving them N um So I've been a bit cheeky and um not given of as an answer, but instead a bit more specific. Um uh And the only reason is just because I think though it's better for you to be prepared if they do try throw you a bit in the exam. So for you use BIPAP for type two respiratory failure and you use CPAP, the third option there for um type one respiratory failure mainly. So I always think B is two. So bipap type two makes sense. Um So you don't give CPAP because you want it without getting bogged down on the actual specifics of N essentially COP DS um aren't oxygenating well, because they don't have good ventilation. So, because all of their um bronchioles and, um, alveoli are all, um, uh, distended in emphysematous. Er, there's an element of obstruction, um, um, when they, when they become unwell and so when they're taking big deep breaths in and out, they're not really getting the air out as such, it sort of just getting trapped in, um, so continuous. Uh, or CPAP is good for trying to push stuff out of the lungs because it gives you a bit of pressure in the alveoli. You know, to say if you had pulmonary edema CPAP would be good because it gives you a constant pressure uh in the small airways of the lungs and pushes the fluid out. Whereas in this case, or in AC O PD case, it's ventilation is the problem. So they're not getting breaths, sending breaths out. So what BIPAP does is it gives you a big pressure um when you're taking your breath in and a and a low pressure when you're taking it out. Um And it's the, the difference in those two pressures um is I guess it's called your, your tidal volume. Um So it, it's your, your level of ventilation. So without getting too balled down in it, uh You don't really need know. Woo for finals. Um it's all, it's, I would just focus on um BIPAP for CO PDC PAP for, for type one respiratory failure. Um Is that fair enough? Uh when do you use venturia and somebody? So you use ventura? Um you use ventura. Um I guess all the time, you know, like that, that um questions stem, uh I said controlled oxygen therapy, which is another word for ventura, you know, um The, it's important that I think it was asked before, uh to, I think it's even as far back as 2010 maybe. Um about whether to give, you know, a really six CO PD or 50 L or a venturia mask. I think in it, the in the short term hypoxia will kill um quicker than hypercapnia will. So I think the correct answer is they always, you know, treat them, you know, an emergency, really hypoxic patient with 15 L, um normal breather. Um But if no, if it's just a question like this where someone has an exacerbation of CO PD, um you would always start with like a venturia mask. So, um they, they use it all the time really. But in this case, an injury mask won't help because the problem isn't actually the oxygen getting into the lungs. It's that the patient can't ventilate, you know, they can't breathe in and breathe out and that's what the two pressures um of bipap do. Um It allows them to get the air in and the different pressure on the expiration allows them to get their air out. Um But again, don't be stressed about it. Um All you need to know for your finals is just Decom type two, stick them on the and don't, don't think about it because you'll just melt your head. You have too much to think about already. Um, grand. So, next fella, um, it's a 29 year old man has a sudden onset doesn't end shortness of breath and pruritic chest pain. So, again, most of them will present like this, um, these emergency presentations and you just have to work out, um, what pathology it is. So, he's a young man that's a smoker. So it should sort of give you a, a hint as to what's going on. Um The question tells you that he has a pneumopar. So it's not asking you the diagnosis, but I guess it's good to work through the sort of the diagnostic method. Um So has a chest X ray that shows that pneumothorax um aspiration is successful, is discharged, follow up by X x-ray uh shows a complete resolution. Uh And what's the single most important piece of advice to reduce as risk for further pneumothoraces? So I've, I've thrown this question in um because this has come up before. Um I know it's not a medical emergency question but um Queens um or well, I guess it's the, it's the UK wide test now, but you know, they love GP questions or they love um lifestyle advice questions. So, while we're talking about this topic, I think it's worth noting. Um so avoid flame to avoid contact sports, um stop smoking, rest fuzzy or be wary for rest infections. The answer is to stop smoking. Uh, I don't think that's how I, that, that blue writing is messing it up, but take my word for it. The answer is stop smoking. And so I've, I've put this in because if you get a question like this in any respiratory condition, um, and they're asking you about lifestyle advice and stop smoking is one of the answers that that will like 99.9% of the time be the right answer. Um It was asked before and one of the CQ si was I was looking at but it was framed more of like a respiratory infection was the the thing that they were trying to prevent or you know, someone's bronchiectases or someone's CO PD, what was the best um lifestyle advice? It's always stop smoking, always stop smoking. Um Grant. So I think this may be the last question. Um 50 year old man, he's acutely short of breath. Um He admitted the hospital three hours ago with uh acute CO PD improved following oxygen treatment, salbutamol pred chest X ray was clear. Um heart rate was 122 BPS 88/50. So you went low. Uh rest rates were 30 saturated eight. He uh has reduced expansion of the upper right chest, mild wheeze throughout the chest and reduced breath sounds over the right apex. What's the most likely explanation for the deterioration? So, again, these are a wee bit tricky, I think. Um or maybe you are, find them easy in which case, like brilliant. But I, I'm, I'm trying to ask tricky ones on purpose. Um So the answer to this one is D so pneumothorax. So this um person with CO PD uh came in had a clear chest xray, but it's, um, it says that I guess he's had a, an acute deterioration post coming in. So his heart rates went up. SAS have went down and respirate have went up. I guess the key thing that diagnoses, this is the the examination findings. So, although you'll never check for reduced expansion of the upper right chest in real life, um The queens love it and the, the test providers love it. Um, reduced expansion. Um makes you think that they're not ventilating as well. And then especially this, see, there were just breath sounds over the right apex every time I've seen a neor thorax come up, um It's always talked about how there's just breath sounds over the apex. And because in it, when you think about um you know how your air sort of collects, you know, it rises to the top. So if you do have a pneumothorax, you get the biggest gap at your apex. Um So if you see that, you know, we just bre signs over any apex, um always think in your mind is um it could be a pneumothorax. Um And so the thing is as well with this is that the patient has CO PD. And so if a patient has CO PD or say, like asthma, uh, because they're obstructive lung diseases, your air can get trapped and if they get trapped, they can, uh, you know, uh, inflate, um, and put pressure on the alveoli which makes them more prone to pneumothoraces. Um, so that, uh, that's that in a nutshell, um, that's a quick run through. So I wasn't able to get through everything. That's, uh, the main ones, you know, like your A LS cardio and ra, um, the, those are the main topics you get asked about. They'll, they'll not be, they'll not stray far from those. Uh, and I've searched through like seven years with past paper questions and I couldn't find anything, um, emergency wise on those topics that wasn't covered in the lecture. Um, if that's my email there, I've put it in the chat as well if you want these slides and if you want that wee oy thing, um, certainly give me an email, I'll send it out. Um, I hope, uh, it was somewhat worthwhile and you've got something out of it. Um, um, there will be another part of these medical emergencies, one of my colleagues will be talking about it, um, at some other stage. Um, uh, so they can go through different specialities. But yes, certainly. Um, any questions, even if you don't want the slides or anything just help me up there. Um, I'll try and answer. Um, all right, have a good, uh, have a good evening, sorry for running over there. Um, I'll see you all later on.