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Prescribing - PSA > Acute management > Flashcards

Acute management Flashcards

1
Q

How do we treat STEMI?

A
  1. ABC and O2 (15L) non re-breathe mask
  2. Aspirin 300mg oral
  3. Morphine 5-10mg IV + Metoclopramide (antiemetic) 10mg IV
  4. GTN spray/tablet
  5. Primary PCI (preferred) or thrombolysis
  6. Beta-blocker e.g. atenelol 5mg unelss LVF/asthma
  7. Transfer to CCU
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2
Q

How do we treat Non-STEMI?

A
  1. ABC and O2 (15L) non re-breathe mask
  2. Aspirin 300mg oral
  3. Morphine 5-10mg IV + Metoclopramide (antiemetic) 10mg IV
  4. GTN spray/tablet
  5. Chlopidogrel 300mg oral + LMW heparin e.g. enoxaparin 1mg/kg bd SC
  6. Beta-blocker e.g. atenelol 5mg unelss LVF/asthma
  7. Transfer to CCU
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3
Q

How do we treat acute left ventricular failure?

A
  1. ABC and O2 (15L) non-rebreathe mask
  2. Sit patient up
  3. Morphine 5-10mg IV + metoclopramide 10mg IV
  4. GTN spray/tablet
  5. Furosemide 40-80mg IV
  6. If inadequate response, isosorbide dinitrate infusion +/- CPAP
  7. Transfer to CCU
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4
Q

How do you treat a patient with tachycardia + unstable adverse features?

A

Adverse features:

  • Shock
  • Syncope
  • Myocardial ischemia
  • Heart failure

Treat with:

  1. Synchronised DC shock up to 3 attempts
  2. Amiodarone 300mg IV over 10-20 min and repeat shock
  3. Amiodarone 900mg ove 24h
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5
Q

How do you treat a tachycardic patient that is stable or with no adverse features?

A

Broad QRS (>0.12s)

  • Irregular rhythm: Seek help!
    • Could be AF with BBB, Pre-excited AF, Polymorphic VT
  • Regular rhytm:
    • VT: amiodarone 300mg IV over 20-60min then 900mg over 24 h
    • SVT with BBB: Adenosine as for regular narrow complex tachy cardia

Narrow QRS (<0.12s)

  • Regular rhythm:
    • Use vagal manoeuvers
    • Adenosine 6mg rapid IV bolus, if unsucessful give 12mg; if unsuccessful give further 12mg
    • Monitor ECG
      • If sinus rhythm restored: probable re-entry paroxysmal SVT:
        • record 12 lead ECG in sinus rhythm
        • if recurs, give adenosine again and consider anti-arrhythmic prophylaxis
      • Sinus rhythm not restoref:
        • SEEK HELP
        • ? atrial flutter - contral rate with beta blocker?
  • Irregular rhythm:
    • Probable AF
      • control rate with beta blocker or diltiazem
      • consider digoxin or amiodarone if evidence of HF
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6
Q

How do we treat anaphylaxis?

A
  1. ABC and O2 (15L) non-rebreathe
  2. Remove the cause ASAP e.g. blood transfusion
  3. Adrenaline 500micrograms of 1:1000 IM
  4. Chlorphenamine 10mg IV
  5. Hydrocortisone 200mg IV
  6. Asthma Rx if wheeze
  7. Amend drug chart allergies
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7
Q

How do we treat acute exacerbation of asthma?

A
  1. ABC
  2. 5mg nebulised salbutamol via O2 6L/min
  3. 500 microgram ipatropium bromide
  4. Prenisolone 40mg (inh with salbutamol) or IV hydrocortisone
  5. If not responsive take to HDU and give IV
    1. Salbutamol
    2. Aminophylline
    3. Magnesium sulphate
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8
Q

How do we treat exacerbation of COPD?

A

VENTS

  1. Venturi mask 24-28% O2 4L/min- sats 88-92%
    1. check with ABG
  2. Nebulisers SAMA and SABA
    1. 5mg Salbutamol
    2. 500microgram Ipratropium
    3. stop LAMA while on SAMA
    4. Air driven not O2
  3. Theophylline IV if poor response
  4. Steroids
    1. 30mg prednisolone for a week

If infective exacerbation:

  • Add sputum culture
  • Antibiotics:
    1. Amoxicillin: 500mg TDS x 5 days
    2. Doxycycline: 200 mg on first day, then 100 mg once a day for 5-day course in total
    3. Clarithromycin: 500mg BD x 5 days
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9
Q

How do we treat pneumothorax?

A
  1. If secondary pneumothorax (i.e. patient has lung disease)
    1. If more than >2 cm, >50 years old or SOB - chest drain
    2. otherwise - aspirate
  2. If tension pneumothorax (i.e. clinical distinction but often tracheal deviation +/- shock)
    1. Emergency aspiration required
    2. followed by chest drain
  3. If primary: determine if patient needs treatment
    1. <2cm rim and not SOB then discharge with outpatient follow up in 4 weeks
    2. >2cm rin on CXR or feels SOB then aspirate and if unsuccessful aspirate again, and if still unsuccessful then chest drain.
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10
Q

How do we treat pneumonia?

A

Use CURB 65

  • Confusion
  • Urea >7mmol/l
  • Respiratory Rate >_30 breaths/min
  • BP<90mmhg systolic or <60mmhg diastolic
  • >65 years of age

If:

  • 1 = mild
    • Treat with amoxicillin
  • 2 = moderate
    • Treat with amoxicillin + erythromycin
  • 3 or more = severe
    • Co-amoxiclav + erythromycin
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11
Q

How do we manage PE?

A
  1. ABC
  2. High flow oxygen
  3. IV morphone 5-10mg, IV metoclopramide
  4. LMWH e.g. tizaparin 175 units/kg SC daily
  5. If low BP, give IV
    1. Gelofusine
    2. Noradrenaline
    3. Thrombolysis
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12
Q

How do we manage acute GI bleed?

A
  1. ABC and O2 (15L non rebreathe)
  2. Cannulae - 2 large bore
  3. Catheter and strict fluid monitoring
  4. Crystalloid (NaCL) if BP normal/high, or colloid (gelofusine) if BP low; once cross matched, give bloods
  5. Cross match 6 units of bloods
  6. Correct clotting abnormalities:
    1. If PT/aPTT more than 1.5x normal range: give FFP (unless due to warfarin: give prothrombin complex e.g. Beriplex)
    2. If platelets <50 x10^9/L (and actively bleeding) give platelet transfusion
  7. Endoscopy
  8. Stop culprit drugs e.g. NSAIDs, Aspirin, Warfarin, Heparin
  9. Call surgeon
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13
Q

How do we manage bacterial meningitis?

A
  1. ABC
  2. In community - 1.2g benzylpenicillin
  3. High flow oxygen
  4. IV fluid
  5. Dexamethasone IV unless severely immunocompromised
  6. LP (+/-CT head)
  7. 2g cefotaxime IV (give pre LP if prolonged LP or if CT head)
  8. Add amoxicillin if >50 years or <3 months
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14
Q

How do we manage seizures and status epilepticus?

A
  1. ABC - ensure airway is patent
  2. Put in recovery position with oxygen
  3. Check for provoking factors e.g. plasma glucose, electrolytes, drugs and sepsis)
  4. After 5 mins
    1. Lorazepam 2-4mg IV or diazepam 10mg IV or buccal modazolam 10mg
  5. After 2 min
    1. Repeat diazepam
  6. Inform anaesthetist
  7. Phenytoin infusion
  8. Intubate then propofol
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15
Q

How do we manage stroke?

A

If CT shoes haemorrhage - disucss with neurosurgery immediately.

Do not give aspirin or thrombolysis

  1. ABC
  2. CT head to exclude haemorrhage
  3. If ischaemic stoke, BP<185/110, aged <80 and onset <4.5: consider thrombolysis - alteplase
  4. Aspirin 300mg oral after 24 hours for 14 days
  5. Transfer to stroke unit
  6. Secondary prevention:
    1. Clopidogrel 75mg 1st line
    2. statins
    3. HTN management
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16
Q

How do we manage diabetic ketoacidosis?

A

Diagnostic criteria: all three of the following must be present

  1. capillary blood glucose above 11 mmol/L
  2. capillary ketones above 3 mmol/L or urine ketones ++ or more
  3. venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L

Management: within first 60 mins

  1. Give fluids - 0.9% sodium chloride
    1. If BP<90mmhg sys, give 500ml 0.9% NaCl stat until BP>90
    2. BP >90mmhg, give 1L 0.9% Na CL over 1h
    3. Consider K+
      1. >5.5 - Nil
      2. 3.5-5.5 - 40mmol/L
      3. <3.5 - senior review
  2. Give fixed rate insluin infusion
    1. 50u in 50ml saline at rate of 0.1u/kg/hr
  3. Search for tirgger
    1. Infection
    2. MI
    3. Missed insulin
  4. Monitor hourly BM, and ketones, bicarb, K+ and pH
  5. Next hour
    • 0.9% sodium chloride 1L with potassium chloride over next 2 hours
    • 0.9% sodium chloride 1L with potassium chloride over next 2 hours
    • 0.9% sodium chloride 1L with potassium chloride over next 4 hours
    • Add 10% glucose 125ml/hr if blood glucose falls below 14 momol/L
17
Q

How do we manage acute kidney injury?

A
  1. ABC
  2. Cannula and catheter - strict fluid monitoring
  3. Fluids:
    1. 500ml stat then 1L 4 hourly
  4. Hunt for cause
    1. Drugs: ACEi, ARBs, NSAIDs
  5. Monitor complications
    1. Salt - peripheral oedema - furosemide
    2. Water - pulmonary oedema - furosemide
    3. Electrolytes - high K+ - 10% calcium gluconate 10ml, 10u actrapid in 20% dextrose
    4. Acidosis - treat cause/sodium bicarbonate
    5. Toxins - Uraemic encephalopathy, neuropathy, pericarditis
18
Q

How do we manage acute poisoning?

A
  1. ABC
  2. Cannula and catheter + strict fluid balance
  3. Supportive measures
  4. Correct electrolyte disturbance
  5. Reduce absorption
    1. Gastric lavage
    2. Charcoal
  6. Increase elimination
    1. Paracetamol - N-acetylcysteine if above treatment line
    2. Opioids - Naloxone if slow breathing or low GCS
    3. Benzodiazepines - Flumazenil

Prescribing - PSA (9 decks)

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