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Respiratory Emergencies

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Summary

Join Dr. Walid, a medical professional at Harlands Hospital, as he presents an interactive session on respiratory emergencies. From acute bronchitis, asthma, and COPD to pneumonia, pneumothoraces, pulmonary embolisms, and respiratory failure, Dr. Walid will discuss and explore these conditions, their symptoms, and treatment, which are a crucial part of any medical professional's knowledge. Engage in practical case studies, ask questions, and learn how to respond to these types of emergencies as they occur in real-time. Not only could this assist in your present placements or acute medical assignments, but it could also prepare you for unexpected patient occurrences when on ward cover or general duties. Shed light on the common presentations and learn to discern between illnesses with similar symptoms, like asthma and COPD. This session promises to be immensely beneficial for your day-to-day medical practice.

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Description

Mind the Bleep's Finals Series brings you Respiratory Emergencies - an ED perspective on managing acute respiratory presentations.

Dr Waleed Paracha (FY2) will run through common respiratory presentations, conditions and their management in the acute setting.

Please share feedback at https://app.medall.org/feedback/feedback-flow?keyword=d06ccea94d472dabf462853f&organisation=mind-the-bleep to enable us to continue delivering high quality sessions!

Learning objectives

  1. Understand and identify the common types of respiratory emergencies and understand their manifestation in patients.
  2. Interpret patient assessment and history along with investigation findings to accurately diagnose the category of asthmatic conditions, like severe, life-threatening or near-fatal asthma.
  3. Discuss and choose the correct course of treatment for the identified asthma category, including the administration of drugs like salbutamol or nebulized ipratropium.
  4. Explain the differences in the presentation of asthma and COPD and identify key symptomatic differentiators, such as pack-year smoking history or chronic shortness of breath.
  5. Assess when a pulmonary exacerbation might be due to a bacterial infection, as opposed to a viral infection, and understand the role of administering antibiotics in such cases.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone. Can everyone see me in here and just pop in the chart if you can. Yeah, there we go. I think it was just to press live. Um I think we're still waiting on another moderator. However, if they don't come in like the next two or three minutes, we'll get started. Mhm. Someone should be joining in the next two minutes. I just got a text about it so then we can get started. Yeah. All right. We'll just get started then and um they'll join whenever they're able to. So, hello everybody. My name is Walid. I'm a fy two doctor at Harland's Hospital part of U HB. Um I'm currently doing a job in cardiology, but I've also worked in acute med and in respiratory and today I'm just gonna be doing a talk on respiratory emergencies. So, respiratory emergencies are something that you'll encounter whether you're on ed or as part of the acute medical team. So that's basically involving any medical job that has on call commitments. The one of the most common presentations that you will see is respiratory related. So before we get started, I just wanted to say that I'll try and make this as interactive as possible as well. So um utilizing like a chat feature, there'll be a couple of questions in there, just feel free to ask any questions at any time as well. I think the moderators joined as well now. So we're good to go. So based off the UK MLA curriculum, these are the conditions that are listed as core respiratory emergencies. So that includes acute bronchitis and respiratory failure, which are often kind of secondary to the other ones in there and then asthma and COPD. So your obstructive airway diseases and then also pneumonia, which is very common and then pneumothoraces and pulmonary embolisms that you kind of want to know what to look out for as well. And then finally, you've got respiratory arrest, which is more down your A LS algorithm um which we won't really be touching on in this talk. Um But it's important to know that that can be the end result of uh these conditions and it's something that we'll look into a vote, of course. So with that, we'll move on to the first case. Um just before I do that, just to confirm everyone can hear me and there's no issues with that also gets me to use the chat feature to see if it's working. Yeah. Yeah. II can hear you. All right. Excellent. So let's get started then. So the first case is something that you'll see quite commonly a 19 year old male presenting with a background of asthma and presenting with shortness of breath. So in the history, you get the fact that there's a one day history of progressive shortness of breath and he's been generally feeling under the weather before that for a few days. So as with any patient, you want to in the acute setting approach it with an A two E assessment and I've written one out there. Um, I'll give you about 30 seconds to just read through that. And then my question is gonna be what are some investigations that you'd kind of want to do in this scenario based off the history that you've got and the assessment. So just drop any suggestions in the chat box and then we can kind of talk about some that I thought of. Mhm. Yeah. Yeah. Yeah. So that's all pretty reasonable. And um with regards to someone who has come in with a background of asthma, I think a peak flow is a really good child as well. So I've outlined three that are kind of pertinent to this case. Of course, you do an ECG as well as you've mentioned and it would probably show tachycardia given the heart rate is 113. Um So these are the investigations that you find. So we've done an ABG which has shown a, an acidotic picture, a respiratory acidotic picture and then you've got a peak flow there and a chest X ray. So with all of these kind of investigations in mind and given what we saw on the previous slide, how do you think we might categorize, uh what's going on here? And that'll kind of also help us with management. Does anyone know what kind of guidelines we use to try to categorize this? I don't know if there's a function of like opening your mic on this as well if anyone wants to just shout out or otherwise you can just drop it in the chat. OK. So yeah, we're looking at P flow reduction for sure. Anything else that kind of will be criteria that will guide us to what we're looking at here. Any other investigation, findings, perhaps I'll just pop up the previous slide as well in case there's anything in that? Yeah, so that's really good. Yeah. So the way we kind of classify asthma um especially using the BT S guidelines is into your moderate, your acute uh your moderate, acute asthma, your acute, severe asthma, your life threatened asthma and then near fatal asthma. Now, kind of looking through this, we can see what are we trying to pick up on that will kind of guide us to how bad is this asthma exacerbation because that's what we're looking at here. So we'll have a look at um the observations first of all. So we've got rests of 23 with O2 sets of 93 on air. So we're not, we don't have an oxygen requirement right now, which is good. You can hear a wheeze on the chest and the breathing is labored. So again, you're kind of worried about tiring there. Um with regards to d that's really important is the struggling to complete sentences as well, which gives you a good marker as to kind of how they're dealing with this. Um and how bad it is and then some of the um further investigation findings, you've got a 42% peak flow rate and then that PA CO2, so we're not um we're not on oxygen and the PA is O2 is 08.7. But we are looking at a potential type two respiratory failure picture coming along. Another important thing to note about this is what we've got right now is a respiratory acidosis, which is kind of a bit late stage for asthma. So originally, if you can kind of think about the exact mechanisms of it with asthma, you're going to be breathing a lot more kind of having a higher respirate and that's actually going to cause respiratory alkalosis first because you're kind of blowing off the CO2. And it's only as you tire is when you start, you know, getting hypoxic as well as keeping in the CO2 as well. So, although that CO2 is normal, that's actually a bad sign and that's reflected quite well in the guidelines. So as you can see here, although the peak flow is 33 to 50 which would be acute severe. The rest are actually below 25. I think the heart rate is above 100 and 10 and that inability to complete sentences does tick the criteria for acute severe. The reason why this is actually a life threatening exacerbation is because of that normal P CO2. So that's really important to look out for in these scenarios. And it's something that once you're kind of as part of the acute medical team or in ep that's something that we always do keep an eye out on because that's a really good marker for OK. This is a life threatening asthma, exacerbation and we need to manage it as suck. So, speaking of management, um what are some of the things I would use to manage? I think someone mentioned one already a bit earlier. But what would be the management in this scenario or you've got a life threatening asthma in front of you? Yeah. So we'll definitely start with some salbutamol. Definitely anything else? Yeah, you give at least one dose, a stat dose of a steroid. OK. And then that's kind of a nice ladder that's been put there um by Emily there. So, and that's kind of exactly what I've got on the next slide. So with regards to the acute management of asthma, and now I probably should have said this at the start, but not only is this useful in kind of your placements or your acute medical placements. But also if you're doing a ward cover as part of any medical surgical job, you might be, you know, get a bleep at 2 a.m. three AM. Oh, this patient has got really breathless and you do want to be able to initiate that initial management before escalating to a senior. So with asthma oxygen, if hypoxic, so this guy is 93% he's tiring a bit. So maybe we would think about it in this scenario, nebulized salbutamol and nebulized ipro bromide would be your mainstays. And that's what you'd kind of start with, with regards to nebulizers with salbutamol, you can give it as continuous over half an hour, but not everywhere has that. So then in which case, you'd kind of get back to back nebs um a stack dose of pred or IV hydrocortisone depending on if they're able to tolerate it orally. And then after that, we move on to a single dose IV magnesium sulfate infusion, um or as you mentioned, the and things like that. However, then you're getting into the realm of, you know, clearing that with um uh a senior first, whether that's the med reg or wherever your registrar is at that time and then also antibiotics if suspecting a bacterial infection is the trigger. But I'm I'm very kind of I'm saying that right at the bottom in the sense that often what you will get is a viral exacerbation of asthma. In fact, I'd probably say that's one of the most common things I've seen in the past few months, especially is people getting a viral infection on a background of asthma. And then having that very similar history that I was just talking about, of feeling under the weather for a few days. And then the asthma gets exacerbated and they have this progressive shortness of breath which is often not relieved by inhalers. A similar presentation that you'll get is CO PD. So an infected exacerbation of CO PD will often present similarly. Um and it does look like asthma in the acute setting, you'll have a wheezy chest, you'll often, you know, have uh the patient having difficulty breathing. Um And then if you do a blood gas, you might see uh an type two respiratory failure, stuff like that. But in terms of differentiators between aspirin and CO PD in that acute scenario, I guess the things that you'd be looking out for is significant smoking history. So, um with CO PD, you will often see it in people who have been long term smokers with a high pack year history of smoking. You will also have and this is not true for all cases, but with CO PD, especially in people who have poorly managed CO PD, they may have chronic shortness of breath which has just got worse and that's why they've come in rather than having this acute onset shortness of breath when they're usually completely, you know, breathless, um not breathless at baseline and then seasonal dial variation, which are kind of hallmarks of asthma and then having a productive cough at baseline already is also something that would make you think CO PD for asthma with CO PD. Um in terms of management with that chest X ray or whether you go to CT chest afterwards, there can be changes on that imaging such as malignancy or bronchiectatic changes. So that's something to kind of look out for. But again, I guess that's a bit further down the line. Um But I mean, I guess with the malignancy, you might see that in the short term as well. So it is an acute thing to look out for. Now management similar, you, you are gonna give that five day course of steroids, you are gonna give your nebulizers. Um However, the only other thing to know is controlled oxygen therapy because with COPD, um there is a risk of hypercapnia and although that's not to say if a person is hypoxic, you don't give them oxygen because of course, it's um hypoxia is gonna be a lot more severe than the hypercapnia in the complete acute setting. However, at the same time, you do want to titrate the oxygen based on the saturations and then also use stuff like scale two for CO PD, which is 88 to 92% rather than your traditional 94 to 98. Any questions about that at all before we move on? All right. So we'll move on to our, we'll move on to our second case now then, um, which is about a cough. So, an 82 year old female presenting from a care home with a fever and a worsening productive cough for three days. I'll give you again about 30 seconds to read through the A three assessment and then similar question, what would be some relevant further investigations? Ok. Ok. So similar to previous, um, a lot of the investigations will overlap because we are looking at kind of respiratory in particular. Um And also there's some kind of Hallmark investigations that you would do in your A two E anyway, um especially guided by that. Let's have a look at what people are saying. So, yeah, chest X ray sputum culture. Yeah, big fan of Sputum culture. That's something that you will find is really important. Actually in um if you've sent off a Sputum culture in a day in a two days, you'll be able to actually target what's causing it a lot better. So it's really important to send that Sputum culture as soon as you can. Um just put it as part of your initial management plan alongside some of the other things you guys are mentioning. So, um these are some of the investigations that you do straight away in this scenario and it's fairly similar to the last time. So this is the results that you've got based on um what you guys have said. So we've got an ABG there which is showing an acidotic picture. You've got some blood results that you'll get in a couple of hours time. Um And then you've got a chest X ray. Now forgive the mouse on the screen, which might be giving away what we're looking at on the uh chest X ray. But um at the same time, based off that now that does validate some of the stuff you guys are saying about that kind of sepsis pathway. Um But in terms of the underlying cause here, what is that chest X ray showing? Yeah, so you're seeing some kind of right mid low zone consolidation, my lower zone consolidation. Um So that would be consistent with a pneumonia exactly. Now, similar to the previous one, an 82 year old coming in from a care home with pneumonia is a fairly common presentation that you'll see. So you just need to be able to know what to look out for. And in terms of this presentation, again, the management is based on how you categorize it. So does anyone know how we classify people who present like this in terms of their condition? What is a scoring system that we would use in this scenario? 65. Exactly. So based off what I've given you so far with regards to the history, the examination findings and then your investigations. What is the C A score for this lady? I'll show you the next screen as well. Yeah, I can go back to the last screen as well. Um, so there we go. Ok. So we've got a three. Does everyone agree with three or has anyone else got any other answers? Take care? So, we've got a couple of threes. Um, I've been a bit sneaky here actually and what I put in is a, as you can see on the D section, you've got, um, a V four, which is usually confused speaking. So, um, perhaps that's a bit sneaky. But yeah, what, what I've tried to get out of here is, um, a bit of confusion there as well. Um, that's completely fair if you know, that was not made clear enough, but with regards to the other three scores, you're all correct. So you've got, um, U urea more than seven on the screen. Um, you've also got, have an achy too and you've also got that diastolic BP being just below 60. Um, so you've actually got a curb for pneumonia in this scenario. Um, regardless of whether it's three or four, the management would be the same, um, as each score tends to correspond to mortality risk. So if it's a score of zero, you've got a low risk of death. So less than 1% 1 to 2 is intermediate and then three or more is high risk and what that does for us is help kind of guide our management. So with someone with a score of three or more, um what tends to be the management in this scenario? Yeah, so it's a hospital admission. So generally in terms of the antibiotics themselves, that's as per trust guidelines. Um but when it comes to management of ci I'm a big fan of, of Floy like this, I think this is from our trust guidelines at U HP. Um But basically, if you've got that score of 0 to 1, then it's usually home with antibiotics. However, again, you've got to look at the patient holistically in terms of other comorbidities that may be destabilized because of this cap or if there are social issues, then you might consider admitting and antibiotics in hospital. Um Moderate severity is almost like a case by case scenario. Um So, but generally you do admit with AC two and then oral or IV antibiotics and then three or more is IV antibiotics. So our, our trusted IV Comox with um oral c uh Clarithromycin. Um and then I believe it's levo if you're allergic uh Levofloxacin. So and then also, as someone mentioned earlier, you want their microbiological investigations. So, sputum cultures are really important if you've got someone like this lady who want to get blood cultures as well and then urgent senior review with it consideration. Um Of course, with it t consideration, you have to factor in a lot more factors as well. Um, such as the patient themselves, whether they'd be suitable for it, but generally as like a blanket statement, you should consider, um, it referral as well. So, going back to the patient, as many of you rightly pointed out as well, this patient does have a pneumonia, but it seems like they've got a sepsis secondary to the pneumonia as well. So it's a septic picture you've got here. Um, so the management of it, you want to do your sepsis six. So you'd want to get fluids, antibiotics and oxygen. And then, um I probably should have asked this to be honest rather than move into the slide. But um, then you want to get, you know, catheterization to get accurate fluid impact and put monitoring uh blood cultures and then lactate as well, which we took a bit earlier on the um, and it was 2.43. Yeah. So it was raised, uh which is kind of what you would expect in a septic picture. Sorry, I know I'm kind of moving uh forwards and backwards through the slides here. Um uh As we mentioned earlier, sputum cultures, viral swabs and then uh urine for legionella as well. And then looking out for atypical pneumonias, um, they're rarer, of course, but you might see something like hypernatremia and legionella or a hemolytic anemia in um mycoplasma. Now saying that you can have a legionella pneumonia without the hypernatremia, you can have hypernatremia without legionella pneumonia. But it's just something, you know, more for, I guess, textbooks rather than, uh, what you'll see. But it's good to look out for, especially in patients who are, you know, immunocompromised or are at higher risk but often stuff like travel as well. Yes, sir. We'll move along to the third scenario. Then. Um, this one is a 29 year old male with a significant smoking history who's got sudden onset chest pain worse than taking a deep breath and similar to the previous ones. This is your examination findings. So that's a good question. So, are the antibiotic given for pneumonia also appropriate for sepsis? Um, so it depends kind of if you've got a source for the pneumonia like uh sorry, a source for the sepsis, like you do in this scenario, you know, it's chest sepsis and, you know, it's um, a pneumonia based off that X ray. Then you will give the antibiotics for that. Um, with sepsis, you can give kind of broad spectrum antibiotics if you are not sure. Um, and that again is as per the trust guidelines. So often we do give, you know, you'll see people get like tazocin um, in the initial management. And then when you know, it's a pneumonia, you can kind of switch that management to Comox and Clari. Uh But again, it's very much dependent on trust guidelines. So it, it differs where you are. Um, yes, the antibiotics can often be appropriate. Um, but that's similar for pretty much any infection. You'll see when you work in. Um, you want to, you'll have antimicrobial guidelines for your trust. Um So it's best to follow them and that's a really good question, by the way. So not a naive question at all. Um OK, we've already got, we've already got some answers for the third one. So uh nice. Yeah. So based off um the a three assessment I've written there, do we have signs of tension there? OK. And what would be some signs of tension that you'd kind of be looking out for in this scenario? Yeah. Yeah. So that's the kind of textbook one is you're looking for tracheal deviation because that shows that, that our area is pushing it. So with regards to um whether there's tension there, um also the patient isn't hemodynamically unstable. So that's kind of what you'd also see uh with a tension pneumothorax because you can imagine if there's so much pressure of the air building up there that will affect kind of everything around it as well and you'll get some um hemodynamic compromise. I've got a slide coming up on the tension side of things a bit later. But in this scenario, what we have is in the absence of tension symptoms, um we've got an ABG and we've got um a chest X ray here as well. So uh I don't know how well that image is being shown here. But can anyone see what's going on in that chest X ray? I was reluctant to put this X ray in just because it might be quite difficult to see. Um especially if the image is being predicted as a bit grainy. But yeah, so if you just kind of really pairing close, you can see that there's that right side, it actually isn't just lower zone, you can kind of trace it up. You've got that plural lining there, um comparative to the outside and then you've got a lot of markings past it on that right side and that kind of extends all the way to the top. Um There is on the right side, it is hard to tell, I appreciate that. Um But yeah, so we've got that on the right side there. So that's your pneumothorax, right. And that can be measured. Um And with regards to management of pneumothorax, I was conscious of time as well uh because we did start a tiny bit late. So I'll just show you the guideline, which I'll read through because I appreciate that this is tiny writing uh on a screen, but if you want to get the slides, it might be a bit easier to see. So previously, the management of pneumothorax used to be based off kind of the primary or secondary nature of a pneumothorax um as well as being based off kind of the exact sizing of it being a major factor and now that's kind of changed um as per the BT S guidelines in 2023. And instead we're looking out for high risk characteristics. Um So of course, the first one being hemodynamic compromise, uh which is attention pneumothorax, which I'll, we'll get to in a second, um, or significant hypoxia, which we don't have in this scenario, uh bilateral pneumothoraces, which we again do not have in this scenario. Uh We don't have underlying lung disease either. Um And the patient isn't, you know, above 50 years of age with a significant smoking history, um hemopneumothorax, which is usually secondary to trauma. Uh There's no history of trauma in this gentleman either. So, what we're looking at is a pneumothorax without the high risk characteristics. And based on that you can kind of go through the flow sheet and um see whether we need to intervene or not. Um And that can be either through an ambulatory device, uh whichever a new thing uh like a pulmonary vent. Um sorry, a pleural vent should I say? Um that's not available everywhere and that can be kind of like an outpatient procedure. Um Depending on whether, you know, if the patient's really not keen to have needle aspiration done, then that can be an option. You can often manage it conservatively if you know the um factors like the size of it, uh they still use two centimeters. So the size of it isn't necessary to intervene. Um, or, you know, the patient just does not want intervention and that's fine. Um, with regards to needle aspiration, that's something that you can do and then see them in a couple of weeks in a clinic to see whether that's done the job. But, um, if it's, you know, a larger uh pneumothorax or it's causing loads of symptoms, then you, you go to a chest strain. Um, and then that's kind of like the mains stone management there. Of course, if we have high risk characteristics such as the ones listed there, that's the big red box in the top corner. By the way, I would appreciate that was far too small to see and probably the most important thing on the slide. So I try to, you know, make it a bit bigger on the side, but I'm still having difficulty reading that. So it might just be me. Um But yeah, that's about that. So attention pneumothorax. So as you guys uh mentioned, tension pneumothorax is a medical emergency even more so than a pneumothorax is, that's something that you've got to do something about right there. And then um with regards to the x-ray you, if you have, you know, if you're lucky, you will never see an X ray showing a pneumo a tension pneumothorax because it shouldn't happen. Uh The moment that's suspected you need to try to decompress it. I'm not gonna kind of um read out the entire, you know, second intercostal space, midclavicular line, that stuff. That's kind of, you, you know, you've got to have it down just to say we're about off the tongue um for acies and things like that. Uh But that's how you're gonna relieve the tension immediately and then that's usually followed by a chest drain to try to get rid of the rest of the. Um Yeah, so that's tension authorities. Um And I think the diagram kind of shows why you would have that hemodynamic compromise and why it is such a medical emergency and that tracheal deviation is going to come a bit later as you said. But at the same time, you, you tend to, if you've got attention, pneumothorax, you will see trach alleviation as well and that's one of the signs you'd be looking out for, for sure. Um, ok, so let's move on to our next case. Ok. So next up, we've got a 58 year old female who's got sudden onset chest pain, which is worse on taking a deep breath. So similar to the previous case and I've given a bit of background uh this time which whenever you see in any question, in any scenario, you've gotta think, why have they put that there? Um It usually has some sort of relevance. So in this scenario, what would be suspected? I've not asked for investigations there, um because it's kind of similar to the previous, but what are we suspecting in this scenario. What are we looking out for? Yeah, we will do a op. Yeah, exactly. So we're looking at a scenario where we need to rule out a pe, now, what would be a risk factor based on, you know, this history, uh, that would make you think of that in particular, there's actually a couple of things there that point towards p being a likely diagnosis. Yeah. So you've got your recent surgery, Uh the observations also with your tachycardia um that points towards that as well. Now, in this scenario, um you guys are correct. So it's a pe so the initial management is guided by he hemodynamic instability. Yeah, so recently treated cancer as well. Um That's one of the criteria on the welsh score as well. So not only do you have a recent hysterectomy but it was for a cancer as well. So that actually takes two boxes on that Welsh score as you rightly pointed out. So that's the well score and now it's quite easy to um hit for just because um any alternative diagnosis being less likely the M pe like it is in this scenario would mean that you would score a three there. Um But the initial management is based off whether they have hemodynamic instability. So system hypotension, obstructive shock or cardiac arrest. And then in these scenarios, you're looking at with thrombolysis with something like alter plays. Um But if there's no hemodynamic instability, the risk is assessed using a well score for this lady. Do we have hemodynamic instability? Yeah. So based off that uh definition that we talked about the earlier we actually do have hemodynamic instability here. So we would consider thrombolytic therapy. Of course, it's with senior support and often there's kind of contraindications to that um which I may have included in the next slide, but I may not have. So if I haven't, I'll come back to it. Um, and then if not, then you do your well score. Uh, if we were to do a well score on this lady, what would the score be based off the information we know. So, of course, we don't know if she has hemoptysis or not. So we can't give her the point of that trying to figure it out myself. Uh 4.55 0.5. Uh I've got, yeah, we've got seven here. That's correct. So actually, um 4.5. Yeah, seven. That is correct. Um So regardless we would be doing, you know, a C TPA and giving therapeutic usually a low molecular weight heparin or um in some places you give a doac in the interim. So these are kind of the investigations that you'd be looking to do, um in this scenario. So an ECG will show most likely sinus tachy. Although I have seen, um, just a couple of weeks ago, I did see a S one Q three T three which was quite cool. Um, but generally you will see sinus tachy, um, the DDIMER will be elevated. Although in this scenario, the ddimer isn't the most reliable source of information. Does anyone know why? That might be the case? Yeah, exactly. So, a recent surgery, um, recent malignancy, um, basically the D dama can be raised by a lot of things. Although with a rise of 7600 you definitely would be considering, uh, some sort of clots. However, at the same time, you can get D diers like that from, you know, a recent surgery or a recent malignancy. Um, infection can also often raise a DDIMER. And um another important thing that you'll probably find a lot in your practice is that you will find a lot of D diers being raised and, you know, dopplers being done and things like that. Um But infection can also raise ad dimer. So D dimer is very, very kind of uh nonspecific. But the guidelines do say, um especially if that wa score is below four and you've got an elevated D dimer, you should consider C TPA. So it's important to do and it's just something that should be in your management plan. A bedside echo would show right heart uh raised right heart filling pressures. That's just because of the strain uh being put on the heart. And then, um with regards to that CT PA right there, that's probably the most kind of classic image that you'll see um what is that called? Does anyone know what that's called or what we're even kind of looking at there? Yeah. So that's a sandal Emla, uh which is cha characteristic of a massive pe basically. Uh So that's what we're seeing in this scenario as well. So, um with regards to the management of this, for this lady, uh you would be looking at likely just anticoagulated her. Uh in terms of thrombolytic therapy, there are quite a long list of contraindications for it as well, which are important to know. Um I don't think I've included it, but I'll, I'll comment on it at the end then. Um but we'll move on. Uh We looking at time wise. OK. Got a couple of minutes left. So these are some presentations which weren't mentioned earlier in the um introduction section as part of the UK MLA guidelines. Uh Sorry, UK MLA um curriculum, but these are something that, you know, you should be uh looking out for as well. So you've got uh pleural effusions. So what you can see in the first X ray, you've got um a larger left sided pleural fusion and then a smaller right sided one. The way we, the i, the reason it's probably not in respiratory emergencies is because regardless of what you do, you will have to take, you know, uh a tap, take a sample and then send it off. Um And then that might take some time and often it's secondary or it is secondary to something else. Uh, and then, you know, in terms of exudates, you'd get that because of an infection or a malignancy or anything like that. Um, or a, or a pee, in fact, and then with regards to transudates, you'd get that because of renal causes or um, cardiac causes. So, stuff to do with actually the volume, um, in terms of pulmonary edema, again, that's probably not in that emergency section just because, oh, although I do think it is uh especially on cardiology right now, uh you the management for that being, what would be the management for pulmonary edema? Actually. Um I'm just talking a lot now, I've just realized. So if someone wants to tell me the management for pulmonary edema or like kind of the mainstay of management, um you know, there's other things as well. But yeah, so I viv diuretics um in terms of causes for pulmonary edema, you're looking at um heart failure being quite a common cause and then you're looking at diuretics as well as optimization of that heart failure management. Another thing that you'll see often um depending on where you're working is infective exacerbations of things like I LD, bronchiectasis. The only difference that you need to keep in mind with regards to bronchiectasis and ILD is they can be caused by um kind of more uncommon bugs. Um And the management for these infective exacerbations often involve prolonged courses of antibiotics. So instead of your standard five days or seven days for bronchiectasis, you tend to give two weeks of antibiotics um due to their chronic changes. And again, you'd want to get respiratory input uh whenever you're managing conditions like that. And then finally, um I've just popped this one in at the end. Uh because the session is called respiratory emergencies and anaphylaxis tends to present in its hyperacute form as a respiratory issue because, well, the patient is struggling to, you know, um breathe in these scenarios. So it's something to kind of always have in mind as well. Um And that also feeds into that a LS algorithm stuff we were talking about a bit earlier with um respiratory failure. So I think that's about everything. Um timing wise, we are looking good as well. Uh So with that in mind, um I think that's about everything. I've got a nice feedback slide at the end. Uh And I think this is the QR code. So if everyone could just fill in a quick feedback form, I'd really appreciate that as well. Um And with that, if there's any questions, feel free to drop it in the um chat as well. Yeah, I just want to let everyone know as well. Um I've put the feedback form um in the chat. So you get all the feedback from that will lead as well. Yeah, excellent. And um certificates will be handed out to everyone who attended as well. So, yeah, thank you all for attending and thank you will leave for the uh for the lecture. It's actually really informative. I've even learned some stuff as well and I actually got ed as my next rotation. So that would be really useful. So, thank you. No, that's great. Thank you. Uh What did the black dots and arrows on the last R HD image indicate? So I'm assuming that's just looking at. Hm. That is interesting. It, it is just a congested kind of pulmonary edema picture. Um And pulmonary edema X rays often have that kind of uh congested picture with that fluid in the fissure. Um, but I don't know what the arrows are actually specifically pointing to. I'm assuming it's just like the patchy white parts which are kind of the fluid, er, giving it the congested picture in the absence of anything else. Have you got any idea what they might be referring to that? I II think just to add, um, is it II can't see it well enough, but they, they, they look like uh bronchogram, but I'm not too sure. Yeah, potentially. Um, it, it's very difficult to discern though exactly what it is because they're in kind of like areas where there's a divide between the hyper dense and hypo. Do you know what I mean? Those kind of weird areas they're pointing to? So I'm not too sure myself. No, I think you might be right. Um I've had to kind of zoom in 100 times into the screen and then completely pair in. So that's what my camera is showing right now. Um But yeah, I think so. It may be and maybe either way that patient definitely has some level of pulmonary edema. We, we can, we can, we can say that for sure. So probably for a fide infusion in that scenario, I'd say rather than um just some doses. All right. Excellent. Any other questions at all? I think that's it from the chat to be honest. Yes. But um yeah, that thanks again for, as I said, for the really useful session. Um I hope you guys um had some use from it on a Friday night. I know it's probably not ideal on a Friday night to be um, you know, in a teaching session, but I know finals are coming soon. So, um hopefully it'll be useful to you and you've learnt something. Um And yeah, thanks again waid. All right. Excellent. All right. Thank you guys. Bye.