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OK. Ok. I think hopefully we should be recording now. Uh We're probably gonna make a start in the interest of time. So um hello. Yes. Uh Welcome to the me rhythm exam lecture series. Uh Thank you for joining uh on this Thursday evening. If you're here or if you're watching this recording, then I hope your vision is going well and good luck. Er I'm Nixon, I'm currently 1/4 year medic er at er I'm insulating in management. Um So if you guys have any questions about medicine, acute medicine or management specifically, I've popped my emails in the top right corner as well. So more always more than welcome to contact me there. Um So today's lecture er is, is really a quick whiz through acute medicine and specifically er everything to do with substances. What happens when you have too much? What happens when you don't have enough? And some of the in betweens now in true imperial fashion, we will be using ment meter throughout this. So I've popped the men meter code up here. Uh It's 35584067. So if you guys are live and you want to join a mentee, then please feel free. You're more than welcome to, to join the up there. I'm gonna flash the code up again one more time later on. So for now I'm just gonna keep going. Um session structure wise. Er, again, three main categories I wanna go through. There's quite a lot to cover. So we're, we're gonna go quite quickly. If at any point you have any questions, please, please, please uh don't hesitate to just stop me or write a message and chat and I will be more than happy to answer that. So firstly, overdose is what happens when you have too much of a substance. And here we're looking at three main things, opioid overdose, paracetamol, overdose and aspirin, overdose. And then on the opposite spectrum, what happens when you don't have enough when you withdraw from things? So alcohol and vitamins are the main things and we're talking about alcohol withdrawals, vitamin deficiencies. And then finally, uh we've got everything kind of in between. So you've got anaphylaxis bite things, tobacco smoke, really one, I just kind of fit into the other two. So three main categories if you like and, and a main sub er conditions. So hopefully these are good for ticking stuff off your conditions list. Um You know, let's keep it structured, you know, for every condition, I'll kind of go through five things, you know. So what the condition is as a definition, maybe some background on it some of the risk factors, the signs and symptoms, investigations and management. So all really important stuff like company and S PA S. Um I think, you know, condition not so much will come up, but it's nice to have some background into it. So yeah, we'll try and stick with the structure as, as close as possible. Um, and for that, we'll be doing SBA S and for that purpose, we have a ment meter. Now, I appreciate that that QR code is probably far too small for you guys to scan. So I'm gonna give you the the codes at the top as well. It's 35584067. So I'm just gonna actually type that in the chat as well. So we have a, a record of that uh fantastic. And if anyone needs to need the code again, it's it's in the chat, but for the sake of time, let's keep going. Um Well, I mean, yeah, we do need a ment meter now actually. So first thing is actually I'm gonna present the the meter um after we start with an SBA. So hopefully you guys can see my mentee, I in just a second when I get this tech to work. Um So my meter is here, it should now be live and it should now hopefully see uh a question which is I'm gonna paste into the chat. It's a 24 year old man is found lying on the pavement at the side of the road. Paramedics note he's barely conscious, breathing very slowly and has pinpoint pupils. They also note track marks on his left arm. What is the next most appropriate step for management? And here we've got, uh, 55 responses. So it's IV, thiamine CPR, oral Naltrexone, IV, naloxone and intubation and ventilation. So, out of these five, management steps, what is the most appropriate thing to do and what I'll perhaps I'll do for the sake of time. I'll give you guys a minute to do this. Uh, you guys should have the options up. So I'm just gonna flick back and present the, er, I'm gonna present the, um, vignette so you can see that properly. So here's a vignette. Again, you've got our best part of 45 seconds to respond and if I see, yeah, I see free responses, I'm just gonna go straight in for it. So, again, have a look at the vignette. Think about what's, it's trying to give you in terms of information, uh, and think about how you want to answer this. Ok. And that's time. Um, I didn't see any responses on ment. So, um, that's ok. No worries. I think maybe ment will say for the next question and then we'll see how that goes there more informally. If you guys also wanna put the answers in the chat, that's perfectly fine. But for the sake of keeping the, the the lesson going. Er, the answer for this one is hopefully somewhat obvious. It's IV naloxone. Er, I know I've kind of thrown you guys in the deep end here with like a question to start off with, but I think it's always nice to start off a question and then go through why that question we got the right or wrong answer for that one. So this is AAA case of opioid overdose, which we'll have a look at in a second um II in more detail, but this is essentially what we call a second order question. You first have to find out what's wrong with the patient. And then that's step one and then step two is diagnosing the patient or giving the management for it. Sorry. So let's jump straight into the content. Then um the first one, opioid overdose what we just saw from the patient there. Now, what is it? I mean as the name suggests, it's going to be um when you have too many opioids, when you consume too many opioids. And an important distinction for this is to understand the difference between opioids and opiates. So, opiates are naturally occurring compound opioids are synthetic. There's a lot of overlap these days, but just a small distinction. But the main thing to take away from this is that these opioids work by depressing your C NS and specifically depressing your respiratory centers. So the signs and symptoms you'll see from this are kind of reflective of that and about a very common one here, morphine, you see, used very commonly as analgesia. Um and that, that's just a, a great example of an opioid that's used a lot of medicine. Now, risk factors. So in terms of risk factors, acute medicine, risk factors are quite distinct or different from a lot of the other conditions it works in because most of the time, especially when we're dealing with substances, I want you to try and think of these risk factors as almost the mechanisms for how these substance. Er I'll say substance abuse issues occur for want of a better word. So, you know, as we go through out, you'll see this more and more, but these risk factors are in times risk factors, but a lot of the time actually just mechanisms for how to occur. So in this case, I mean, if, if a patient has a history of intravenous drug use, that's usually a good condition of it. And uh that's also a good risk factor for it. Er polypharmacy. It's another one. a really interesting one is when you have inpatients with pan patient controlled analgesia, what this essentially is is it's when you have patients who are unwell and in hospital beds, they're in quite a lot of pain and you they have the option to get analgesia in the form of opioids. So, you know, morphine, great pain killer, but this is patient controlled. So, they have a little button, they press it whenever they feel like they're in pain and it administers some, so some morphine and they feel better. Now, the issue with this is that, you know, they start going haywire on the button, they get loads of morphine in and you start getting this opioid overdose territory. Um, so that's, er, a kind of, I wouldn't say it's common but it's not terribly uncommon and that's kind of one of the ways you can see this over good over this happen comes up like that in questions a lot of the time as well. So that's kind of why I put it there. Um, but yeah, that, that's opioid overdose in terms of the, the condition, what it is and the risk factors. Now, the signs and symptoms, um whenever I do, er, these conditions, I always try and imagine or, or have a picture of what it looks like. Cos I'm a very visual learner. So I've took the picture on there but if we were to go through it in terms of like a proper list, um, six key signs and symptoms, I won't to remember. But the idea is that this is the picture of a person who's barely conscious, barely breathing, realistically, looks like they're dead. Um, but on the brink of death, so very low, very drowsy, reduced consciousness is one and a decreased pi rate again, lending itself to the idea that these, these opioids depress your cns, they depress your um respiratory centers. And then if you think as a progression, if you're not breathing much, you're gonna get cyanosis and that manifests as blue lips. Some of the other things you see um you also see on the face, a very characteristic thing I love to emphasize is pinpoint pupils. This is, this comes up so much in in question, Vignette, you almost get sick of it. Um so this is always a telltale sign er, of opioid overdose, watering eyes less common, but needle track marks or any sort of evidence of IV drug use in the past, as you can see in this picture here, that's usually a good sign, uh, not a good sign per se but a sign that the patient has gone on opioid overdose. Um, and, and, you know, these are pretty telltale signs and because they're pretty telltale signs, investigations wise, it's usually a clinical diagnosis. You know, it's hard to mistake this for other things. However, you know, we always want to be sure of things and for opioid overdose, like for lots of the things in this, in this, in this lecture is.