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Hello, everyone. I hope everyone's well. Um I just wanted to apologize quickly about last week. Unfortunately, we had some illnesses. So, um we weren't able to do last week's session. However, uh when we're doing that today, so we're gonna be surgical emergencies too. So, looking into some more surgical emergencies and how to manage them. Ok. So this is just the updated um program with the dates. Um So everything's just gonna be pushed back one week. So, um it'll still be on Tuesday um at 630 but it'll just extend until the 14th of May now. Ok. So straight in with case one. So you've got a 72 year old female who's admitted to the general surgery ward with vomiting indigestion and severe abdominal pain past medical history. So she's got ischemic heart disease type one diabetes, osteoporosis, gastritis, and liver cirrhosis. She's also known to have alcohol excess drugs include aspirin, amLODIPine clopidogrel, naproxen, lansoprazole, insulin, cholecalciferol, and alendronic acid. So, quite a few there and overnight she becomes increasingly nauseated and has two episodes of dark coffee ground vomit. These are her observations. So, respiratory 17 heart rate, 100 and 17 So a little bit tacky blood pressure's 90/78. So it's a little bit low, um, temperature 37 4. So the question here is, what do you think the likely cause is here? So I'll put the pole in. Ok. So you've got a few varied answers here. So we'll run through them. So the answer we were looking for was, um, an upper gi bleed, we can run through it. So the presentation she's coming in with um the vomiting, indigestion, abdominal pain, um especially in the epigastric region that all would fit with sort of pancreatitis picture. Um I guess the real concerning thing here is that she's had two episodes of dark coffee ground vomit. Um and I can vomit with pancreatitis, but coffee ground vomit is normally what we look for with an upper gi bleed and should be concerning for that. Um, lower gi bleeds normally present with problems in the stool. So you might be seeing blood in the stool, you might see a drop in hemoglobin. Um You might see Frank blood in the stool, but again, if you're vomiting up some sort of dark uh coffee ground vomit, then that's more suggestive that we've got a bleed a bit higher up. And um, when we describe it as coffee ground, it, it's because it's normally got blood in it. Ok. Ok. So just to recap here, um, on her past medical history. So we've already said she's got ischemic heart disease and diabetes, osteoporosis, gastritis, and liver cirrhosis and drinks a little bit too much. And her drugs are listed there. Um, and if we're presuming she's ha having an upper gi bleed, the next question is which agent should have been stopped or when she came into hospital? Um, and now knowing that she's potentially having an upper gi bleed, which drugs also could be contributing to that. Ok. Ok. Good. So it looks like everyone's on the right lines here. So the answer here is a um so in the case of an upper gi bleed, we need to stop any, any sort of anticoagulants, antiplatelets, nsaids, corticosteroids, anything that will exacerbate the bleeding. So, um I think things like clopidogrel and aspirin are sort of ones that are quite common and easy to remember, but just remember about nsaids um and corticosteroids um as well. So I've just made a chart here which highlights the main drug classes um which increase your risk of bleeding and which ones you could should um consider withholding um during acute upper gi bleed. So, other drugs that we haven't yet mentioned are aldosterone antagonists. Um SSR RS and bisphosphonates. So the table on the right hand side shows um the risk of upper gi bleeding and interesting the com um actually shows the combined risks. So the patient was on an NSAID um an anticoagulant and low dose aspirin. So her risk is 6.9 times more than um someone who's not on those drugs. So that just highlights quite how much uh polypharmacy can actually affect this. So especially in hospital, you've gotta be on the lookout for this. Ok. So going back to our patients, so she's now hypotensive, she's tachycardic and she has had further episodes of hematemesis. So you now suspect this is an upper gi bleed and you pull the emergency buzzer to get help and you use the ABCD approach, which is how you should always um look at these emergency situations. So starting from a, she's maintaining her own airway, it's patent B looking at her respirate. That's OK. Um OO two SATS are all right, equal air entry bilaterally moving on to C. So her BP there is low, which is a late sign that she's probably having a GI bleed or a bleed from somewhere. So that's not, not good. She's tachycardic again, a sign that she's um bleeding, probably pulse is regular cap, refill time is long and she's cool peripherally. So this is showing this is sort of a late stage um of the gi bleed. Heart sounds are normal, always check the uh blood glucose and DGC S as well. So 15 out of 15 at the moment, she's not unconscious or anything and her pupils are nice. Um reactive abdomen is tender in the epigastric region. Um and there's the presence of Melina. So um at this point, they've then found that she's also got blood in her stool, um, that sort of sticky tarry, um Melina, which is classical as well, but no fresh blood and she's got soft calves. So things that you want to be thinking about, she, you know, take some blood. So you want a full blood count. You want using a coag LFT S BBg and a group and save you get my V access and you give her a stat bolus of 500 mils of plasma light or Hartmans depending on whatever you have in your hospital. And the question here is, what other medications would you prescribe? So this one's a bit trickier but we'll, we'll walk through it. Oh, I think I already gave you the answer. OK. So I think a few people maybe saw that there already. Sorry about that. Um So the answer here is d so there's a few bits we want to be giving. So, Tele Preen um causes vasoconstriction and that reduces the BP in the portal system. So we want to use it for anyone with a suspected variceal bleed. Um So we want to try and think with an upper gi bleed, what's, what sort of, what is the main cause of it? Um And with variceal bleeds, guidelines also suggest prophylactic antibiotics. So we give Coamoxiclav or Ciprofloxacin if they are penicillin allergic, which she's not. Um There is a little bit of variation on recommendations for PPIs. Um as a general rule, if you suspect someone's got a non variceal bleed, then you don't give them the IV PPI. Um But some places recommend PPIs before 24 hours and some people recommend p places recommend it. Um if you suspect a variceal bleed. So it's important just to have a rough idea of what your diagnosis is and to make sure to follow your local policy as always. So if you just talk through how to recognize and manage an upper gi bleed, um as we've mentioned before, we always use an A to E approach um be where they may be actively vomiting. So it's safest, safest to use nasal cannula. Um And we need to get some IV access and take some blood so we can assess the situation. Um And remember e we need to expose the patient and perform api so we're looking for signs of melena or fresh blood. Um and when taking bloods, it's also good to be aware of what you're looking for. So this is a one of the things they like asking in Aussies. Um You know why you're taking these, these specific bloods? So the full blood count will give us a hemoglobin. So that'll help tell us if it's dropped, you know, if this is a big gi bleed, if it is a gi bleed. Um And if we're gonna need to consider actually transfusing them, it'll also sharp um their platelets. So if they've got any problems with clotting, um and if we need to replace those, you using these, so that provides us with a urea, which is increased in upper gi bleed. Um And this is because the blood is actually digested into a protein um which is a metabolized into urea. So if you go to a sky high urea, then and that also is suggestive of an upper gi bleed, obviously, um if it in, in the right context, um not a coagulation for the I NR just to make sure it's normal, it's not super high because if it's high, we'd have to treat that. Um And correct it. LFT is to see if there's any liver dysfunction. Um And C A is actually useful for that as well because um the coagulation is affected in severe liver disease. Uh And of course, we want a grouping state and a cross match ready for any blood transfusion. Um And just a reminder of the causes um on the right hand side just to have in the back of your head, peptic ulcers. Um Duodenal ulcers might very common uh mallory w tears. So if they've been vomiting a lot, you can get bleeds from that esophageal varices. So you wanna be suspecting this if you've got any sort of deranged LFT S, um history of drinking or severe liver disease. Um And esophagitis is another one, there are a few other ones as well, but um just to have a few of the main ones in the back of your mind is always useful. Um, and the symptoms here, uh, so obvious ones are hematemesis, which is commonly described as coffee ground vomit. So you'll definitely be asked, um, in F one F two to go and look on er, a water at patient's vomit to see if it is actually coffee ground, um, Abelina, which is Tarry black stool. Um, and if it's a severe upper gi bleed, then they'll start to show sh signs of shock because um they're hypovolemic. So they'll be hypotensive and tachycardic. And at the latest stages, they also get reduced urine output. So just want to be aware of those things as well um to keep on top of everything. All right. And then this is just the gui nice guidelines for initial management of an upper gi bleeds. So the main thing being reversed with your ants and blood products. So obviously, it's important to have your um your bloods taken early so that you can have a look at the clotting and the I nr and the full blood count and everything to inform this. Um And in addition to it, er this, we also advise fluid resuscitation initially and senior help. So in the time it takes to get some of the um blood or the other blood products and we always advise giving some fluids again, if they've got severe heart failure, then it, you might give them a smaller bolus. But generally we like to give 500 mils of um something like plasma like or Hartman's. Um and there will be individual pathways in your own hospitals. So make sure you familiarize yourself with the local trust guidelines. Um And this is just a quick slide on the PPI S. So um not routinely offered before endoscopy um endoscopies as an initial treatment. Um And as I said, it depends on if you suspect it to be a variceal bleed or not. So, it's not the end of the world if we're not sure. But um if you think it might be an esophageal varice uh that's bleeding, then you would want to be giving them telera and the same here with the proton pump inhibitors. So, um that shows the B NF down there for um if you've got a bleeding, severe peptic ulcer, so you can give something like pantoprazole. IV. Um OK. And this just shows you what a guideline might look like. Um This is one from the highlands, but they have similar ones all over the UK. Um So in this management, this split is dependent on if they're hemodynamically stable or not. Um which is, which is quite a common way to manage it. Um So, resuscitation is the first thing we want to be doing if they're unstable. Um Doing all the things we've discussed. So, fluids taking bloods, monitoring, getting some senior help, seeing if you need to reverse anything, any anticoagulation. And then there's sort of a B bundle that you can add in for variceal bleeding. Again, both the things we've discussed that Terlipressin and the Comox Glav. Um and then the focus is mainly on getting uh the endoscopy, which is the definitive treatment. OK. So, back to our patient, we think she's having an upper gi bleed, she's hemodynamically unstable. Um And so she's gonna have an endoscopy immediately after resuscitation. There are two scores that need to be calculated around endoscopy and these are the Glasgow Blatchford score and the Rockall score. So the question here is what is the purpose of the Glasgow Blatchford score? The this yes, anyone got any ideas about the score at all? Mm. So OK, so you've got a bit of a spread here on some of the answers. So the answer here is a, so identifying low risk patients that don't require inpatient interventions. So they might still get an outpatient endoscopy, but they're not going to apply blood products and endoscopies straight away. Um So this is important because we, when we risk stratify patients, obviously, there's only a certain number of spaces for endoscopies and we need to prioritize the people who um it's life threatening. So those hemogen unstable patients who are requiring lots of blood products and reversal of their um anticoagulants and things like that. Those will be the people who are high risk. You will need to have an urgent endoscopy whilst they're an inpatient and blood and all those kind of things. Um And this is what stratifies um, people who sort of a little bit less urgently, who might be just bleeding a little bit. Um Obviously it's still, er, classified as an A gi bleed. It's still concerning, but um they're low risk patients. So here we've got both scores up. So the Glasgow Basford score uses er, hemoglobin, er, systolic BP, heart rate, the presence of Melina and syncope and then past medical history. Er so hepatic disease and cardiac failure. Um So it'd only be low risk if they scored zero. So it obviously needs to be hemody stable, which is what we mentioned. Er So that's not like our patients. So our patient here would score more than zero on a Glasgow batch Fords score. Um and then looking over to the right for the Rockall score. This gives you information on the severity with the risk of rebleeding and mortality. Um So there is a few different markers. We've got age comorbidities, presence of shock, source of bleeding in any major stigmata of recent hemorrhage. So this is more looking at actually their morbidity risk afterwards. Um and scores less than three are a good prognosis and more than eight a poor prognosis. So, if they're older with lots of comorbidities, they're in shock. Um And they've got recent uh bleeding, stigmata bleeding and then obviously that um worsens your outcomes. Are there any questions at this point? OK, we'll move on then this is just to recap er, the nice guidelines. So this suggests that you should do both scores. Um, so if you're working on a ward with endoscopies or in general surgery, um it's a useful thing to just know where to find um um what the score is because the surgeons and the gi consultants will want to know what the scores are. Um, so they suggest early discharges for patients with a Glasgow Bater score of zero. and on the right hand side, it gives us information on the timing of endoscopy. So the more unstable, the sooner they need the endoscopy, which makes sense. Um but the aim is to get an endoscopy within 24 hours for anyone who clinically needs it. Um er right, that's that. Ok. So moving on, we've now got case two, you've got a 54 year old female who's admitted following a horse riding accident where she sustains an open book fracture of her pelvis. So she has a pelvic binder on and she undergoes or if um she's in the hospital and one day postoperatively, she becomes breathless after this surgery. So you go and have a look at her and these are her observations. So she's tachypneic at 24 her O2 sats in 90%. So this is a bit low, especially for a 54 year old lady who was previously healthy heart rate of 100 and 20 So she's tachycardic BP, 100 and four of 82 on the low side and she's axial E CG is performed and it shows S one Q three T three change. Now, what is the most likely cause of this? Yes. OK. So you're getting a few answers in and whilst we're on this, can anyone tell me what the S one Q three T three change means? And which presentation it's linked to? So that will be quite helpful with getting this answer correct. If you know, feel free to pop it in the chat. Yeah. Ok. So we've got a little bit of a spread here, but most people have got the answer correct. So the answer is a pulmonary embolism. So the S one Q three T three change in an ECG um, is also known as the mcginn White sign and it's associated with right heart strain secondary to a pulmonary embolism. So you won't get it with every pulmonary embolism. But if you get a really big pulmonary embolism that causes right heart strain, you will see, um, this is what you see is, you see a, an S wave in lead one, you see AQ wave in lead three and at wave in we, er, in lead three, in about, at wave in lead three. So if you haven't heard of it before, that, that comes up a lot in exams. Um, and you have to see large S wave in S one in one Q wave and inverted T wave in lead three. So that's how you remember it. Um And only about 10% of people with PS actually present with this change. Um because the most common finding E CG finding with AP is actually sinus tachycardia. Um So that's more common. Um OK, fine. So we've obviously got someone with reduced oxygen saturation, sudden onset shortness of breath tachycardia and a characteristic E CG. So she's probably got a pulmonary embolism. Um, she's recently had surgery. So that's also uh you know, could, could happen. Um And we've talked through the S one Q three T three. and that shows evidence of right heart strain. So we suspect she's got a pe what is the most likely cause of her pe given that she's just had a recent surgery? Ok. So a bit split here between fat Embolus and DVT, which is what I expected. So the answer here is fat embolism. Um So the reason why it's a fat embolus is because she's had a large pelvic fracture um and surgery which predisposes you to a fat embolus. So, um big hip fractures and big bone fractures. So, tibia fractures, um femur fractures, things like that can lead to fat embolus. Um and that can cause a PE er DVT is the other sort of more plas other plausible option here. Um But we've got no mention of any swelling in her leg. Um so, it, you know, it's, it's difficult to know, I guess there wasn't anything saying she didn't have anything in her leg. Um, but the more common thing here would be a fat embolus. Um, DVT. If there was any mention obviously of swelling in her leg, then that would be the most common septic emboli is unlikely because she's, um, not septic at the moment. So she's not got a temperature. Um, and coagulopathy and dehydration on uh, unlikely. Yeah. Ok. So you think she's got a fat embolus, um, which has then resulted in a pe because of the nature of injury. So you had a large pelvic fracture. Um, so you ordered a C TPA and it shows she's got a pe. So how would you manage her pe? Yes. All right. So you've got a bit of a split again here. So the answer here is b so she's gonna need some oxygen because she's got low sats. Um, and we need some anticoagulation. So, um, it does vary from place to place what you anticoagulate them with. But um, like Heparin is never a bad shot. It's in the B NF. Um, er, so in Scotland for sure, we use Dalsy and we use treatment dose Darin if it's a confirmed pe and we use prophylactic din for patients who are, you know, in hospital with surgery with a risk of getting a clot. Um, in some places there is variation. So some places, um, for the treatment of pe might favor something like Apixaban. Um but that's obviously not an option here. So heparin infusion wouldn't be correct. Um The other option people put was aspirin, clopidogrel and O2 therapy. So obviously, the option there is correct. Um Aspirin 75 mg and clopidogrel, 75 mg, the only place that's really used um is in secondary prevention um in patients who have had myocardial infarctions. So, Nstemi sties um obviously they'll get loading doses um which are higher initially and then they'll be put on aspirin, 75 mg, clopidogrel, 75 mg once daily. So that might be where some people are getting a little bit confused with. Um but for a pe we just need to anticoagulate them because they've got a clot. Um So that does vary a little bit. But in this scenario, the only option that is that could be correct is the treatment dosed Aspar. OK. And this just shows again on uh the B NF. So er if you look up delta par, it comes up here, um you can see it, so treatment of D DVT treatment of pe and it does it by body weight. Um So you give them those units uh once a day and um normally prescribe it for three months to six months and they normally get reviewed in a, in a PE or DVT clinic and again, always follow your own trust like guidelines. As I said, some places prefer to use. Do a. Ok. So moving on to our next case, you've got a 29 year old gentleman who's admitted to the orthopedic ward following a road traffic accident. So he's sustained a right proximal tibial fracture and has multiple broken ribs. He's awaiting an or if tomorrow and is placed in a cast and prescribed analgesia. What medications would you want to prescribe him initially? So he's coming to the hospital. He's got quite a few, few breaks. Um, what things would we like to put him on, uh, whilst he's an inpatient in the orthopedic ward? So these kind of questions are useful for anyone who's gonna be working on an orthopedic ward. Um, you've got lots of patients who come in with sort of similar presentations and they'll all need a baseline set of medications whilst they're on the ward. Um, in addition to their regular meds. Ok. So you got a few question, a few answers here. So I think people have avoided A B and C which, um, is correct. So we'll go to the answer here. So the answer here is d um, so you can work through this in a few different ways. Um, in orthopedics, there's a few things, obviously, he's got broken bones, he's in pain. So we're gonna need him to give him some analgesia. We like to give baseline medication, something like a paracetamol four times a day to sort of give a little bit of um analgesia at baseline. Um and then something stronger, quite a lot of orthopedic was preference oxyCODONE over morphine, but it could be morphine as well. Um If you're giving you an opioid, you always need to give two other things which is some kind of antiemetic and some kind of um laxative because you can otherwise end up with people vomiting, they then get electrolyte disturbances or equally, you can get constipated that can put you into retention. So we always need to think about analgesia, a baseline one, a bit of a stronger one. And then we've got an antiemetic there. So the cyclizine and Macrogol and sna quite frequently, they are prescribed more than one laxative. You don't wanna be giving them tons of different laxatives, but um giving them one or, you know, two, they're both different types of laxatives. So, um that's not the end of the world and they're normally P RN so they can have them as they need depending on how constipated people feel. And then, um, we've said he's waiting on or if tomorrow, so he's probably gonna be fasted. So IV fluids again, we want to keep people hydrated, er, slow fasting fluids. Um, are not a bad idea, especially in someone who's 29 years old. Um, and we don't wanna overload him. So the other answers here that are incorrect. A there's no suggestion here that he needs a blood transfusion. Um B we're missing any kind of analgesia. C, we're missing analgesia. He doesn't need oxygen therapy. He's not got a cyclizine, he's not got any kind of laxatives. And then e we've got a little bit here, so we've got the morphine, we've got the Ondansetron. But, uh, we're missing the baseline, er, regular analgesia like paracetamol and we haven't got any fasting fluids or any laxatives. So, just try and think about all of the needs of the patient when you have to prescribe the baseline meds. Ok. So that evening, you were asked to review him because he's still got some pain. So on examination, he's slightly tachypneic, tachycardic blood pressure's stabler aporal and the right foot has reduced sensation on the dorsum and is very swollen and tender. So the question is, how would you, so you've got someone with a large tibial fracture? He's now in increased pain. How are we gonna manage them? Ok. Yeah, let's see. Ok. So most of the answers here, well done. Everybody looks like you've got the correct one. So the answer here is b we want to call a senior for a review of the compartment. So um contact the pain team for a review, obviously, in another scenario where it's just the pain and there's no concerns for compartment syndrome that might be correct, switching oxy to morphine again, we've discussed in previous scenarios um in other sessions, how moving from one opiate to the other can sometimes help with the pain. Um and increasing the dose of oxy. But again, the important thing here to recognize is that it's actually not just a pain review. Um He's got changes to his foot which are in keeping with compartment syndrome. So that is a medical emergency or surgical emergency even. Mhm. Yeah. So here are some of the symptoms to look out for. So it's sometimes referred to as the five ps. Um sometimes it's seven ps, but I think five of the main ps, um the main one that people remember is disproportionate pain. So if someone was ok before and you know, they, they've, they're on some analgesia and then they've got pain that's completely disproportional. No one can touch the leg, no one can touch the foot. Um They can't move an inch, then you've gotta be a bit more concerned. Ok. Um And also this is another reason why if you get sort of overnight, if you're on call and you get asked to come and see you do a pain review for patients, it can be easy to think. You just increase their pain meds. But it's also really important to actually go and assess the patient because if you didn't go and see the patient and you just increase their pain medication, you'd be missing something like this. Um The next p is pallor. So it normally is much paler than either side. And they also sometimes um describe paraestesia. So you might get numbness in the foot or the leg, depending on where um the compartment is. So, um, and you'd want to try and feel the pulse sometimes, er, it's so painful, you can't actually even try and feel for a pulse but it might be faint. Um, and then paralysis. So you might not be able to move that leg either. Um So the important thing with this is to, if you suspect it at all just to get someone else to come and have a look at it, you're not expected to be able to um be sure of yourself or treat it or anything like that, but you need to just be aware of the symptoms um and aware of the risk factors as well. So anyone with a big crush injury or a large bone fracture and restrictive casts can do it as well. So in this case, they had a large bone fracture and they were put in a cast as well. Um So those two things are risk factors for that and you can get a compartment syndrome in any of the compartments in your leg. Essentially, you get a swelling um of the muscles. Um and that leads to compression to the nerves and the blood vessels, which is why you get the pallor because you're compressing the blood vessels. Why you get the parasthesia and the numbness and the pain because you're compressing the nerves. Ok. So we get a senior review. Um and they come and see the patient because you're concerned about this compartment syndrome because of those five ps. Does anyone know what the definitive treatment for compartment syndrome is? All right. So we've got a few things going on here. We've got the fact that she's hallucinating and the fact that her pain is not well controlled. So we need to do two things really. In our decision, we need to stop her hallucinating and um improve her analgesia, increase her analgesia or change it to um improve her pain. Any other answers? Yes. Yes, I see. Ok. So the answer here is switch the morphine to oxyCODONE. So more people went for b so increase the morphine sulfate to 10 mg Q DS. Now that probably would help with the pain. Um If she wasn't hallucinating, that would be a good thing to do. You know, we've started at a low level. It's OK to increase the morphine, especially if she feels that when she takes the morphine, she gets a bit of relief from it. But at the moment and she's also hallucinating. So if we increase the dose of morphine, that's probably gonna make her hallucinations worse. And if she's hallucinating, you know, she might fall, um you know, you can get scared from that, but they, it's not great to have a someone hallucinating, they're not gonna eat and drink properly, they're not being able to do their rehab properly. Um And it's unsafe. So, um the most common cause of hallucinations, especially in surgical patients is morphine. Um So oxyCODONE less commonly um has that kind of side effect. Cyclizine can also cause um hallucinations, but it's far less common. So I would be inclined at first to switch the morphine. Ok. So she's been switched to oxyCODONE and you rereview her two hours later and she's no longer complaining of pain. So that's good. So again, if you ever change something with a patient with a pain medication, it may seem easy just to put the pain medication up or switch the pain medication and then leave them. But it's always good practice once you've changed your medication or increased medication or decreased medication to go and see how the patient's doing with that. Um So her obs are here, so her respirate is seven. So that's low. Uh oxygen is, that's 94% a little bit lower than we'd like. Probably because she's not breathing properly. Heart rate is 78 which is fine BP. 100 and 10 probably. It's probably all right. She's so, you know, it's, it's late in the day. Um She's lying down Aporia, so she's not septic GC, 13, out of 15 pupils are equal active to light and, but they are pinpoint pupils. So the question here is what is the likely cause of her reduced G CS? Ok. Some people seem to have got this one well done. The answer is e opiate toxicity. Um So this is a pretty classical history of an er, opioid toxicity. We've got, um, a patient who's likely opioid eve, um, who's, they're normally a, a bit older, um, and has been given some doses of, um, opioids. So she's got a reduced gcs, she's got respiratory depression and she's got pinpoint pupils. She is opioid toxic. So, again, when you're dishing out morphine or, um, oxyCODONE or any of these medications, um, it's easy to sort of think that everyone can just have them. And again, these are actually quite low doses that the patient's getting. Some people are opioid nave. Um, and especially if you're smaller and your kidneys don't work particularly well. Um, but it can just happen to anyone. You really can become opioid toxic quite quickly. And if that happens overnight, again, that's an emergency and it's not a situation that, um, you know, you want to overlook. So it's really important when you're giving out these medications just to go and check, have a look at the respirate, have a look and make sure you haven't, you haven't overdone it. So, yeah, we've discussed, she's got reduced respiratory effort, she's got reduced consciousness and she's got pinpoint pupils. So you're concerned she's opiate toxic. How would you manage this emergency acutely? So, again, this might be your job if you're um, the f one if you're on overnight, um, you might be called by the nurses to say, oh, we think this patient's opiate toxic. Can you go and have a look at them and you would need to have a look at that scenario and try and manage the patient. Got you. Ok, great. So everyone knows how to manage this naloxone. So, um if you come across a patient who has symptoms of opioid toxicity, um you know, some patients, if they're a little bit drowsy and sort of heading towards opiate toxicity, you can just either stop their opiates or reduce their opiates by a lot. Um If they're in this case, like this patient who's actually, you know, she's got reduced respiratory effort, she's, you know, got reduced consciousness. Um She, she's at risk here. Um We need to reverse it with the naloxone, ok? Um This is just a slide to highlight the signs of a toxicity. So, um we often think of these symptoms in A&E um with overdoses, but you need to be aware of genic opioid toxicity, which is actually far more common than you think. So, we're giving out all these opioids in the surgery. Um You need to be aware that you can actually um be overdosing them. And B NF here on the right. So that just shows uh naloxone up here and its indication um for acute opioid overdose, we've got the top tier of your management. So we give naloxone and we suspend all the opioids. Ok. So moving on um case five, so we've got a 71 year old gentleman who's admitted with necrotizing fasciitis, he undergoes an extensive emergency surgical debridement and you complete a POSTOP review. All right. So you've got his bloods here. Hemoglobin's looking normal, which is good white cells very high, but he has got an ati fasciitis. So that's sort of expected. Again, the C RP is very high. He's just had a surgery and he's got ati fasciitis. So, um, we'll probably wait for that to go down a little bit. Urea is also high. Creatinine is very high. Um sodium is a little bit on the low side and the potassium is 6.6. So he uh he's hyperkalemic. There's a lot of things going on here, but um we sort of are expecting his white cells and his CRP to be high, but his urine is creatinine high, which would suggest his kidney function isn't great. And he's got a potassium of 6.6 which is dangerous. So, what is the investigation required to determine treatment in this case? So that sounds like a bit of a silly question, but there's a specific um investigation that you need to do if you saw these bloods um to determine what sort of treatment we want to be giving this patient. Um And I, as I've said, it's, he's, we already know that he's um got an infection. So, um we're not trying to treat that at this point. So, looking at the other blood results, what sort of things we'd be wanting to check. It's a so ok, so, very good. So the answer is be here. Um So just running down through them, um, urine dip probably isn't gonna add much to clinically change in your management unless we sort of suspected she. Um he's got a uti um E CG is the correct answer because we need to determine the treatment for his hyperkalemia. Um So at 6.6 his potassium is the thing that we're really worried about. Obviously, he also does have an AK I um with a high creatinine there. Um But the most urgent thing that we need to be treating is the potassium because you know, that could put him into a um he could have an arrhythmia, he could rest BP. Um again, might give you some key a bit of an idea about his um AK I but he's, he's just had a, you know, undergone severe surgery. So um I don't think ABP would be the first thing to do. Chest X ray is not really relevant here. Um And magnesium level uh that was mainly put in um because it is useful um if the patient has hypokalemia, so lots of patients that um will have hypokalemia. And if you try and treat them with potassium, it doesn't work if they have a low magnesium. So that's useful. If so you've got a patient who's got hypokalemia, it's always good to do a magnesium level. To check if their magnesium is low and if that's low, you need to replace the magnesium. However, in this particular scenario, we've got a high potassium which is dangerously high. So you need an ECG to have a look and see if it's actually affected the heart. Does that all make sense? Ok. So we get an E CG and it shows e elevated T waves. But as I've said before, we've got a severe AK I and hyperkalemia and quite frequently those can go hand in hand. So at this point, he feels he's got shortness of breath, palpitations and some nausea. What is your immediate management? Now that we've seen these tool tented T waves on the E CG? OK. So this is the last question if anyone has any thoughts about what the answer is here. OK. Very good. So a lot of the answers here could have been correct, but the answer is completely correct is a um So this was a difficult question because obviously he has got an AK I, we'd want to treat that with some fluids. The IV plasma light is not wrong. Um But at this moment in time, we've got a patient who has hyperkalaemia and has ECG changes because of the hyperkalemia. So that's our priority. That's what we need to manage first. Then we'd manage his AK I. OK. So um that rules out e because we're not actually treating the hyperkalemia. D is also a good answer. So IV dextrose with insulin um and salbutamol nebs. Um So we've got some parts here, but we're missing the calcium gluconate, which is what we use to stabilize the heart when we get an E CG change. So, that's incorrect. Um And then C and B are missing a lot of the other meds needed to treat hyperkalemia, but they can actually be used as adjuncts themselves. So, if you get a hyperkalaemia guideline, you'll see these two sort of down the bottom, but they're not the first line things to go to. So, a is correct. Uh If we have E CD changes, we need to give IV calcium gluconate. Um So it stabilizes the heart by decreasing the membrane depolarization. So we wanna make sure that the heart is nice and stable. We're not gonna have any arrhythmias. Um We don't want the patient uh going into any kind of arrhythmia or arresting. So that's the main thing that we give and we only give that if the patient has changes on the um E CG and then the other things we need to be doing is we need to try and shift that potassium er back into the cells. So we do that with the insulin dextrose infusion and salbutamol nebulizers. Um So if anyone has any idea about how the salbutamol or the insulin glucose infusions, how they shift the potassium at all, feel free to write in the group chat, if not I can explain it. So the salbutamol um works, it's a beta agonist and it shifts the potassium across the membrane um because of its effect on the sodium potassium ATP pump. So it's one of these um sort of lucky fines essentially with the insulin glucose um infusion and salvage mons, they just happen to shift potassium in the right way. Um They're not specifically designed to treat hyperkalaemia, but the IV calcium gluconate is what stabilizes the heart. And then the other two treatments are how we shift the potassium quickly um into the cells to reduce the serum potassium. Ok. So um as always, we wanna get an E CG if you're concerned and hyperkalaemia, anyone with a raised hyper uh raised potassium, there are lots of reasons for having a high potassium, you know, sometimes it can be because um the sample been left around to coagulate. Um But the most important thing is to get an E CG just to be uh sure. Um and I have mentioned, so the guidelines do vary um as with everything across the board. So make sure you know what the guidelines are always have a look on your internet, but generally speaking, um they're in agreement that any potassium more than six warrants an E CG. So up to six, you know, we sort of look to see uh just keep checking it and monitoring the patient and then um if it's above six, then we want to get an E CG and these are the changes that we want to be looking at. So you probably all heard of PT waves tall, 10 to T waves. That's the sort of first change you can get. Um, but then once it progresses, everything sort of stretches out. So we get a widened pr interval, we get a wide CRS and that PT. Um, and then we get complete loss of the P wave and we get a sine wave. So if you see a sine wave pull the emergency buzzer, it's a medical emergency. That patient is very, very unstable then. Ok. Uh Now this is a bit small for you to see, I appreciate, but I just wanted to get up a guideline again to show you what a protocol might look like. Um So as always look at your own policy, but in this case, um they stratified it into mild. So um mild, moderate and severe. So mild is less than 5.9 moderate is up to 6.4 and severe is more than 6.5. Um And anyone with a potassium of six gets an E CG, which is what we discussed. Um And if there are E CG changes, they recommend IV calcium gluconate. So er you administer IV calcium gluconate over 10 minutes and then you recheck the E CG because we wanna see that, that calcium gluconate is stabilizing the heart. Um if they're moderate or severe. Um, we then go on to try and move the potassium as we've discussed with the insulin dextrose and the salmons. So, a useful point here is just to be aware that obviously, if you are giving insulin dextrose um infusions, we wanna be checking the blood glucose before we give it. Um and be mindful of that if you've got a diabetic. Um if you've got someone who's sort of got unstable blood glucose, um then it's just important to be aware that we are giving that patient insulin uh glucose infusion. Um And then you can see down the bottom here, we've got consider calcium resonium and sodium zirconium. So um some guidelines suggest it, some don't. Um It completely depends on where you're at. Um And as an fy one or a junior, you wouldn't be expected to start any of those kind of medications. Just want to um focus on getting that E CG raising your concerns to a senior and starting the initial treatment. Um ok. And these are all my references. So, um if anyone wants to look at any of those before, that'd be great. I can see in the chat just having a look through. If there are any questions, please let us know. Now, um we will be uploading the slides later so people can have a look at those and look at the references as well. Ok. And I'll just send the feedback form in there. Thank you all for coming. Um, as always, really appreciate you coming along and we hope it's useful. Um, we've got a few more, um, which are getting a little bit more specific in the next coming weeks. So we've got, um, a few sessions which really go into, um, helpful scenarios if you were to be taking on jobs as an f one in specific specialties, things like ent, um, and general surgery, orthopedics and pediatrics just to give you a bit of a heads up, um, on the normal sort of goings and the things that turn up, um, in those presentations. But thank you very much.