AIP Flashcards
What do leads are present for anterior, lateral, inferior and posterior MI?
- V1, V2, V3 - LAD, anterior MI
- 1, aVL, V5, V6 - circumflex, lateral MI
- 2, 3, aVF, RCA, inferior MI
- V1, V2, V3 ST depression, RCA, posterior MI (also bradycardia)
What investigations needed for ACS?
o Observations including ECG
o Bloods
FBC, U+Es, LFTs and clotting, CRP
Troponins T and I (3x normal limit, rising), CK, AST, LDH
o Imaging
CXR to exclude differentials
What is the management of STEMI?
Morphine (for pain), cyclizine for nausea, oxygen if <94%, GTN 2mg unless hypo, aspirin 300mg oral and prasugrel (P2Y12 antag), unfractionated heparin before PCI(within 2 hrs)- transfer to CCU.
If fails or triple vessel - do CABG, graft from long saphenous vein or internal mammary artery
thrombolysis - 12 hour - alteplase - repeat ecg after 90min. <50% better = PCI needed still
Post MI complication? (DARTH VADER)
Death, Dressler’s, Arrhythmia, Aneurysm, Rupture, Recurrence, Tamponade, HF/CCF, Valve disease, Embolism
Fever, pleuritic pain relieved by leaning forwards, raised ESR
Dressler’s syndrome tends to occur around 2-6 weeks following a MI
Treated with NSAIDs
o Bradycardia
AVN block can occur following inferior MI as the RCA supplies the AVN leading to bradycardia
Persistent ST elevation
Aneurysm after MI
o Tamponade
Beck’s triad of raised JVP, low BP, muffled heart sounds
o Acute fall in BP
Cardiogenic shock following acute LVF - (inotropes and vasodilators eg. Noradrenaline)
o Systolic murmur and pulmonary oedema
Acute mitral regurgitation due to ischaemia of papillary muscle causing fluid backlog
POOR SOD (Pour away/stop fluids, sit up, oxygen, loop diuretic IV Furosemide)
Secondary prevention of MI (ABCDE)
o Conservative
Exercise, Mediterranean diet, less alcohol, smoking cessation, cardiac rehabilitation, HTN/DM management, avoid sex for 4 weeks, avoid driving for 4 weeks if not treated with PCI (1 week if treated with PCI)
o Medical ABCDE
Ace inhibitor Ramipril 10mg OD
BB (Atenolol)
Cholesterol (Atorvastatin 80mg OD)
Dual AP therapy (Aspirin 75mg OD for life + another antiplatelet (clopidogrel, ticagrelor, prasugrel) 12 months)
ECHO +/- Eplerenone Aldosterone antagonist eg. Eplerenone/Spironolactone if LV dysfunction (EF < 50% on echo_
NSTEMI and UA mangement
Conservative
* Scans (stress ECG, myocardial perfusion scan)
* GRACE score to determine risk of death or MI within 6 months)
* If low risk <3% then conservative
* Diet, exercise, cardiac rehabilitation, HTN/DM management
Medical
* Medium or high risk GRACE score >3%
o Aspirin plus Fondaparinux if PCI not planned immediately
o Then angiogram and PCI or CABG within 3 days/72 hours
When to do an angiogram?
* Hypotensive – immediate
* GRACE score >3% - angiogram within 3 days
* GRACE score <3% - angiogram after 3 days
Causes of Interstitial Lung Disease
Idiopathic Pulmonary Fibrosis
Iatrogenic
Nitrofurantoin, methotrexate, amiodarone
Inflammatory
Sarcoidosis -> Erythema nodosum, uveitis, hypercalcaemia
Infective
- TB
Toxins
- Coal, silicosis, asbestosis
- Farmers’, bird owner
Autoimmune
SLE, RA
What are the signs and symptoms of Interstitial Lung Disease?
- Signs and symptoms
o Gradual onset sob, non-productive cough, haematemesis, wheeze, chest pain, fever and myalgia
o Occupational history - smoking, farming, dust, birds, asbestos, coal
Examination
o Finger clubbing, cyanosis, wheeze, fine end-inspiratory crackles, tachycardia, RHF
What are the investigations needed for Interstitial Lung Disease?
Observations
Temp, BP, HR, RR, sats
o Blood tests
FBC, U+E, LFT, CRP, ESR
Antibodies RF, anti-CCP, ANA, dsDNA
Bedside
ABG, peak flow, spirometry, ECG
Restrictive pattern with FEV1/FVC > 0.7 and reduced total lung capacity
o Imaging
CXR, HRCT (honeycombing, nodular opacities, BHL, ground-glass changes), lung biopsy
Management of Interstitial Lung Disease?
o Conservative
Smoking cessation
Avoid triggers - dust, allergens, coal, asbestos, bird droppings
Seasonal influenza vaccinations
Physio
LTOT
o Medical
Corticosteroids (if symptomatic) - not for EAA
Pirfenidone (antifibrosis) - especially for IPF
o Surgical
Lung transplantation
What are the causes of PE?
Cause
o Thrombosis from DVT
o Fat embolism (surgery), amniotic fluid (pregnancy), tumour (cancer), air (trauma)
Pathophysiology
o Causes reduced blood flow to lungs resulting in VQ mismatch
o A massive PE will increase right ventricle afterload and cause right ventricular failure leading to haemodynamic compromise
PE presentation
Symptoms
Pleuritic pain and haemoptysis
Isolated SOB/dyspnoea/cough
Circulatory collapse and LOC (a massive PE)/light headedness
Signs
DVT (cause)
Hypotension, raised JVP, parasternal heave (RV failure)
Tachypnoea (most common sign), Tachycardia
Decreased O2 (VQ mismatch)
PE Investigations
NOTE: IF PE SUSPECTED, START DOAC IMMEDIATELY
Observations
Bloods: FBC, U&Es, LFTs, clotting, CRP, d-dimer, troponin
Bedside: ECG (Sinus tachycardia, S1Q3T3)
Wells PE is used to determine the investigations used
o D dimer IF WELLS SCORE IS <4
If negative, then stop DOAC
If positive, then CTPA or VQ
If PE suspected, start DOAC
If Wells PE <4, do d dimer
D dimer negative then stop DOAC
If Wells PE >4 or D dimer positive, then do CTPA (gold standard)
If CTPA contraindicated (renal impairment or contrast allergy) then do VQ scan instead
If CTPA or VQ is negative, stop DOAC
If CTPA or VQ is positive, continue DOAC
WELLs Score for PE
Wells PE is used to determine the investigations used
Suspected DVT: 3
PE most likely diagnosis: 3
Tachycardia: 1.5
3 days immobilisation in past 30 days: 1.5
Hx of thrombosis DVT/PE: 1.5
Haemoptysis/coughing blood: 1
Malignancy/cancer: 1
PE management
Immediate
A to E and stabilisation
Senior input as the patient is unwell
Conservative
If PESI score is low, can be managed as outpatient
Medical
Start DOAC immediately if PE suspected (Rivaroxaban, Apixaban)
* If provoked: 3 months DOAC
* If unprovoked: 6 months DOAC
IF ANTIPHOSPHOLIPID SYNDROME OR SEVERE RENAL IMPAIRMENT (<15/min): LMWH plus VKA (Warfarin) instead
IF MASSIVE PE WITH HYPOTENSION: thrombolysis with 50mg Alteplase bolus is first line
Surgical
IF REPEATED PEs: can try an IVC filter to stop clots getting into pulmonary circulation
PE in pregnancy management
PE in pregnancy
D-dimer cannot be used as it will be raised
If leg symptoms, do leg USS first
If PE suspected, do CXR
If CXR normal, do leg USS
If normal, do VQ scan (preferable to CTPA)
Consult obstetrician
What are the causes of COPD excarcebations
Most common cause is H.Influenza (annual influenza vaccine) and S.pneumoniae (one-off pneumococcal vaccine), or Moraxella
Rhinovirus is the most common viral cause
Investigations for COPD exacerbations?
Observations
* Temp, BP, HR, RR, sats
Routine bloods
* FBC, U+Es, LFTs and clotting, CRP
Bedside
* ABG, peak flow, ECG
Sepsis six and infection screen
* UOP, lactate, blood cultures, sputum culture
Imaging
* CXR
o If consolidation then pneumonia, otherwise infective exacerbation of COPD
What is the management of COPD Excacerbation
Immediate
* A to E assessment and stabilisation
* Senior input as this is an unwell patient
* 15L non-rebreathe mask if life threatening, otherwise Venturi titrated to 88 - 92% O2
* REPEAT ABG to assess for hypercapnic respiratory acidosis (need NIV)
Medical
* OSHIT AE (NV)
* Nebulised SABA salbutamol (2.5mg) +/- SAMA Ipratropium (0.5mg)
* Prednisolone 30mg for 5 days (40mg in Asthma exacerbation)
* IV theophylline with senior input
* Oral antibiotics ONLY IF purulent YELLOW or GREEN sputum or signs of pneumonia
o Amoxicillin (not if penicillin allergy) or clarithromycin (not if long QT syndrome) or doxycycline
* Non-invasive ventilation
o If respiratory acidosis <7.35, then NIV needed in an ITU setting (better outcomes than ET)
o Bilevel positive airway pressure with IPAP and EPAP
o Next step up could be intubation and ventilation
What are the different types of bowel ischaemia?
o Acute mesenteric ischaemia
o Chronic mesenteric ischaemia
o Ischaemic colitis
What are the causes of mesenteric ischaemia?
Mostly arterial embolus due to AF, as well as MI, IE
Venous due to hypercoagulation, tumours, infection
Also, non-occlusive due to hypovolaemia and blood vessel constriction (COCAINE –> acute mesenteric ischaemia)
Blocks the small bowel
Investigations for mesenteric ischaemia
Observations
Bloods – FBC, U+Es, LFT, CRP, lactate (ischaemic)
Bedside – urinalysis, ECG/echo
Imaging
* CXR and AXR (may show thumb printing due to oedema and inflammation)
* CT Angiography is gold standard
Management of mesenteric ischaemia?
Immediate
* A to E
* Senior input
* Morphine, Oxygen, anti-emetic, NBM
Medical
* Antibiotics
* Possibly thrombolytics or heparin
Surgery
* Embolectomy or angioplasty if bowel if viable
* Emergency laparotomy with resection usually required due to necrosis or sepsis
Chronic Mesenteric Ischaemia causes investigation and management
o Atherosclerosis of gut blood vessels
o Post-prandial (after food) colicky, transient pain
o Intestinal angina, (also have TIA, angina etc)
o Examination
Upper abdominal bruit (atherosclerosis)
o Investigation
Bloods, ECG, CVD RFx, ANGIOGRAPHY is gold standard
o Management
Surgery
* Angiography and stenting (stent)
* Bypass graft
Ischaemic Colitis (large bowel ischaemia usually in spenic region - watershet between inferior and SMA supply
Presentation, investigation, managment
o Can lead to inflammation (thumb-printing), ulceration (bleeding in colonoscopy), and haemorrhage (loose stool with blood)
o Presentation
Acute abdominal pain in LIF, transient, less severe than acute mesenteric ischaemia, N/V/D, loose stools with BLOOD
o Investigations
CXR and AXR
CT
Colonoscopy: blue swollen mucosa with bleeding
Barium enema: thumb-printing (mucosal oedema and inflammation)
o Management
Usually conservative (acute mesenteric ischaemia needs urgent surgery usually)
* IV fluids and rest
Surgery
* If perforation, necrosis, strictures
What is epilepsy?
- A tendency towards unprovoked seizures (2 or more within a year)
- Seizures are synchronised neuronal discharge leading to disturbance of consciousness, behaviour, emotion, motor function, or sensation
What are the causes of seizures?
o The majority of cases are idiopathic
o Vascular (stroke, hypertensive encephalopathy, pre-eclampsia), infection (encephalopathy/meningitis), trauma (head injury or cranial surgery), toxins (hepatic, alcohol, TCAs), autoimmune (vasculitis), metabolic (hypoglycaemia, hypocalcaemia, hyponatraemia), neoplasm, neurodegenerative, CNS (tuberous sclerosis, hamartomas)
Epilepsy differentials
o LOC
Vasovagal syncope: short post-ictal period but CAN be associated with twitching/jerking
Cardiac syncope
o Seizures
Febrile convulsions
* Recurrent tonic-clonic seizures in children <5 due to viral infection
Alcohol withdrawal seizures
Psychogenic non-epileptic seizures/Non-epileptic attack disorder (NEAD)
* Female, mental/psychiatric health, pelvic thrusting, crying, gradual onset
* No tongue biting or raised serum prolactin
* Important to refer to psychiatry
Classifiction of epilepsyy
Generalised
* Motor:
o Stiffening (tonic - contraction and cyanosis)
o Loss of tone (atonic drop attacks)
o Jerking (clonic, myoclonic)
o Tonic-clonic/Grand mal (stiffening/contraction and extension, back arching, then jerking)
* Non-motor:
o Absence/Petit mal (child unresponsive staring for 10 seconds with eyelid fluttering and no loss of tone)
Focal
* Motor:
o Twitching, jerking
o Automatisms (brief unconscious behaviours): lip licking, rubbing hands
o Spreading from one area to another: Jacksonian march
* Non-motor:
o Auras: thinking, sensation, emotion, experience (Déjà vu, Jamais vu)
If it lasts more than 5 minutes: status epilepticus
Other seizure syndromes in children: West’s syndrome, Lennox-Gastaut, benign Rolandic, juvenile myoclonic
Seizure history
o Onset: trigger, prodrome, onset
o Character: duration, awareness, motor symptoms (rigid jerking/myoclonic, stiffness/tonic, tonic-clonic, floppy body/drop attack (atonic), absence, automatisms (lip licking, rubbing hands), changing (Jacksonian march))
o Associated symptoms: Aura, light headedness, dizziness palpitations, LOC, seizures, cyanosis, incontinence, trismus/lateral tongue biting, frothing at the mouth, >2 minutes post-ictal phase confusion, fatigue, headache, myalgia, speech difficulty, Injuries (shoulder dislocation), Brief period of ipsilateral paralysis/weakness: Todd’s post-ictal paresis (key stroke ddx)
Ix for Epilepsy
o Observations
o Bloods
Routine, glucose
o Bedside
Urinalysis, ECG, 24-hr ECG, lying and standing BP, tilt table
o Imaging
CT
MRI
LP
EEG
Immediate and conservative Mx of Epilepsy (including DVLA informing)
o Immediate
A to E
Senior input
o Conservative
Ketogenic diet (high fat, low carb)
Must inform DVLA and Cannot drive for 12 months after a seizure
Generalised(same as myoclonic and tonic seizure) and focal seizure medication
Generalised seizures
* Sodium valproate is 1st line (NOT for women of child-bearing age)
* Lamotrigine is 2nd line (for females)
myoclonic female - levetiracetam
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Starting treatment
* Only started after a confirmed diagnosis - after a second seizure
* Start with monotherapy and gradually titrate up to maximum
* Consistent supplier
* Baseline FBCs, U+Es, and LFTs before starting
Stopping medication
* If seizure-free for 2 years, consider SLOW withdrawal over 2-3 months
* Relapse risk is highest in first year
Tx for Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Surgical treatment for epilepsy
Vagal nerve stimulation
DBS
Surgical focal resection
GBS signs and symptoms
o Acute ascending neuropathy due to campylobacter infection in the past week leading to cross-reaction of antibodies leading to demyelination
- Signs and symptoms
o Ascending neuropathy from the lower limbs
o Sensory: reduced sensation
o Motor: weakness and reduced reflexes (LMN)
GBS Ix
o Observations
Temp, BP, HR, RR, sats
o Bloods
FBC, U+Es, LFTs, CRP, lactate, glucose
o Bedside
Diagnosis: Nerve conduction studies are diagnostic
Cause: Infection screen (blood, sputum, stool, urine, LP cultures), urinalysis
Impact:
* LP will show raised protein
* Spirometry is important - reduced FEV1/FVC is an indication for ITU admission
Cauda equina: DRE
Claudication: ABPI
Peripheral neuropathy: B12, folate, glucose
Mx of GBS
Immediate
A to E assessment and stabilisation
Senior input
Monitor spirometry for the need for ventilatory support
Medical
Plasma exchange or IVIG to remove the autoantibodies
DVT prophylaxis
Stroke Differentials
o Todd’s paresis (post epilepsy weakness)
o VITAMIN CDEF
o TIA, amaurosis fugax, cerebellar
o Carotid/vertebral artery dissection
Bamford classification of strokes
Stroke recognition scoring tools
General public: FAST criteria
Medical professionals: ROSIER score (FAST + LV) - Recognition Of Stroke In ER
o Severity of a stroke
* NIH Stroke Severity Scale (NIHSS)
* 11 items: Face, arms, legs, aphasia, dysarthria, visual fields, gaze palsy, inattention, consciousness, ataxia
Stroke Examination findings
o CN exam (visual inattention, visual field defect), upper limb, lower limb (UMN lesion - acutely diminished tone, and absent reflexes, weakness –> becomes hypertonic, hyperreflexia, spastic paralysis, Babinski positive), speech (receptive or expressive aphasia, dysarthria), cerebellar (DANISH)
o General examination (AF, carotid bruit - carotid dissection is an important cause)
o Special test: Hoover’s test to differentiate organic/psychogenic cause (if organic, when asked to raise normal leg, the supposed weak leg will flex at the hip)
Cerebellar Signs (DANISH)
dysdiadochokinesis
ataxia
nystagmus
intention tremor
scanning dysarthria(stuttered speech)
heel-shin test positivity
Ix for strokes
o Observations
o Bloods
* FBC, U&Es, LFTs, ESR/CRP
* CK, glucose, lipids
* NOTE: IF ‘young’ <55 year old with no obvious cause: thrombophilia and autoimmune screening is indicated (syphilis serology, antibodies, clotting)
o Bedside
* ECG, urinalysis, BP lying standing
o Imaging
* CT head
* Urgent NON CONTRAST CT head if within 4.5 hours (candidate for thrombolysis - to exclude haemorrhagic), taking anticoagulants (DOACs, warfarin), GCS <13, getting worse, meningism (headache, neck stiffness, photophobia, N/V, Kernig (pain on extending knee when hip flexed), Brudzinski (knees bend when head is raised lying down)), or severe headache (SAH)
* Indicated in ALL suspected stroke within 24 hours
* Diffusion weighted MRI is gold standard (done at QE)
* Carotid doppler (stenosis, dissection)
Mx of stroke
o Overall: Imaging, medication, surgery, secondary prevention. CT angiography within 4.5 hours, Aspirin 300mg for 2 week and Clopidogrel 75mg for life, Thrombolysis with alteplase if within 4.5 hours, Thrombectomy within 6 hours (24 if viable penumbra), Carotid endarterectomy if >70% stenosis. Then Anticoagulation if AF after 2 weeks, Atorvastatin if high cholesterol after 2 days,
o Immediate
* A to E assessment and stabilisation
Maintain oxygen, fluid status, temperature, glucose (IV insulin)
Senior input
o Conservative
* Physio, OT, SALT, MUST score +/- NGT/PEG
o Medical
* Aspirin 300mg oral or rectal (if dysphagia) ONCE HAEMORRHAGE EXCLUDED
Different to MI: Continued for 2 weeks DAILY 300mg Aspirin
Then 75mg Clopidogrel daily indefinitely
OR Aspirin PLUS MR Dipyridamole if Clopidogrel not tolerated (diarrhoea, constipation)
* Thrombolysis with Alteplase (tPA) ONCE HAEMORRHAGE EXCLUDED
IF 1) within 4.5 hours from onset and 2) Once haemorrhage excluded on non-contrast CT head and 3) No contraindications - seizure, head injury, uncontrolled HTN, INR >1.7, GCS <8, abnormal blood glucose, rapidly improving signs
* Anticoagulation and statins
If AF: start ANTICOAGULATION 14 DAYS AFTER THE STROKE
If cholesterol >3.5mmol/L: start ATORVOSTATIN 48 HOURS AFTER STROKE
o Surgical
* Thrombectomy (PLUS Aspirin and thrombolysis)
Within 6 hours
Within 24 hours IF evidence of salvageable brain matter “viable penumbra” (small infarct volume on CT angiogram or MRI)
* Carotid endarterectomy if >70% stenosis (continue antiplatelets due to risk of clot)
TIA definition and key differential
NEW DEFINITION: transient neurological dysfunction caused ischaemia without infarction
Hemiparesis, hemisensory loss, cortical signs (dysphagia), vision (monocular loss, amaurosis fugax, hemianopia), cerebellar signs
Key differential is hypoglycaemia
Management
Conservative
* Not allowed to drive until seen by specialist
* If dysphagia, consider a variable rate insulin
* Specialist neuro rehab ward
Medical
* Same: 300mg aspirin once bleed excluded
* 75mg Clopidogrel for life
* OR If Clopidogrel not tolerated (diarrhoea), then Aspirin plus MR Dipyridamole
Referral criteria
* IF repeated “crescendo” TIAs, carotid stenosis, or AF: urgent referral
* IF TIA in the past 7 days: referral within 24 hours
* IF TIA >7 days ago: referral within 1 week
Surgical
* Same: IF carotid stenosis (doppler US) >70% occlusion : carotid endarterectomy - to remove atherosclerosis
Falls Ix and Mx
Observations
Bloods including glucose, lipids, clotting, CK
Bedside urinalysis, ECG
Imaging consider CXR, AP and Lat hip XR
Management
Immediate
* A to E
* Senior input
* MDT discussion
Conservative
* Physio, OT, MUST score (NGT or PEG)
* Close follow-up with GP
What is counted as a paracetamol overdose?
> 4g a day
1 dose <1 hour or staggered over 1 hour needs NAC
Dx is with Nomogram, Tx is with charcoal, NAC, and vitamin K, KCH criteria is used for transplantation
How does paracetamol overdose present
o The first 24 hours there is some nausea, vomiting, and abdominal pain
o After 24 - 72 hours there is jaundice, RUQ pain, hypoglycaemia, encephalopathy, as well as increased INR
o A key feature is lactic acidosis
Paracetamol OD Ix
o NOTE: if paracetamol overdose is likely from the history, initiate treatment before results come back
o Observations
o Bloods
FBC, U+E, LFTs, clotting, glucose, plasma paracetamol
o Bedside
ABG (lactic acidosis), ECG
Mx of Paracetano,
o Immediate
A to E and stabilisation + ABG to assess acidosis
Senior input
Plot plasma paracetamol on Nomogram
o Conservative
Refer to psych liaison team
o Medical
Consult TOXBASE for latest guidelines
IF WITHIN 1 HOUR: activated charcoal
Antidote is NAC N-acetylcysteine AKA Parvolex
Also, a 10mg single dose of vitamin K
- NAC guidelines
o Indications:
Paracetamol above treatment line on the Nomogram (>150mg/kg at 4 hours (OR if staggered overdose, persistent high LFTs or detectable after 24 hours)
o Infusion over 21 hours
Bag 1 (150mg/kg in 200ml 5% glucose 1 hr) (repeat blood tests after first bag - stop NAC if fine)
Bag 2 (50mg/kg in 500ml 4hrs
Bag 3 (100mg/kg 1000ml 16hrs)
o Commonly causes NON-IgE mediated mast cell release anaphylactoid reaction - urticaria rash and facial flushing (not angioedema)
Treated by stopping the infusion then restarting at a lower rate. 50mg/kg over 4 hours
If bronchospasm or O2 saturations fall, give nebulised salbutamol
IM adrenaline or a peri-arrest call is UNNECESSARY
KCH criteria for liver transplantation
o Arterial pH <7.3 at 24 hours after ingestion
o OR ALL OF these 3:
PT >100 seconds (11 - 13.5) or INR >6.5 (0.8 - 1.1)
Creatinine >300umol/L
Grade 3/4 encephalopathy (1: irritability, 2: confusion, 3: incoherence, 4: coma) - asterixis is at grade 2
What do you need to examine in a pre op anaesthetic examination?
Neck movement limitation/jaw opening limitation/dentures
Airway assessment: use Mallampati classification and note BMI
See all soft palate and uvula
See half of uvula
See a small gap at end of soft palate
Can only see hard palate
Back examination (if having spinal/epidural): look for skeletal malformations
Pre op multisystem examination what do you need to check in general, hands, neck, check, abdomen, calves
General: GCS, limb movements
Hands: cyanosis, warm peripheries, cap refill, peripheral pulses
Neck: JVP, carotid bruits
Chest: heaves/thrills, chest expansion, percussion resonance, lung and heart sounds
Abdomen: tenderness, masses/organomegaly, bowel sounds
Calves: swelling/tenderness, oedema
Pre op investigations
Tests that may be required for patients having surgery include:
Blood tests: FBC, U&Es, LFTs, clotting, group and save
ECG
Other tests may be considered in advance
Pregnancy test (if chance of pregnancy)
Echocardiogram (if murmur/heart failure/cardiac symptoms)
Spirometry (if significant lung disease)
Pacemaker check(if have pacemaker)
TFTs (if on known thyroid disease)
When do you need to stop warfarin, DOAC, LMWH, unfractionated heparin, aspirin/clipidogrel/pasugrel, insulin, oral hypoglycaemic, diuretic, steroid, COCP
Warfarin 5 days
DOAC - 24 hr (48 for major surg)
LMWH - 24 hr
Heparin - 4 hr
Aspirin - 7 days
Insulin - avoid morning dose
Oral hypoglycaemic- avoid on day of operation
Diuretics - on the day
Steroid - change to hydrocortisone
COCP - 4 weeks
What do you need to correct before surgery?
INR - if >1.4, 5-10mg Vit K repeat INR in 6 hrs, if still hgih then prothrombin complex concentrate - discuss with haem,
INR due to liver - 10mg IV vit K, repeat INR in 6 hours
Blood transfusion - <9g/dl,<10g/dl if elderly
Platelet concentrate if platelet <50 x 10^9
correct electrolytes
Correct iron - iron tablet or infusions
