C2 Flashcards
Risks of being afro-carribean with CVD
higher risk of high blood pressure, type 2 diabetes
HBP has risks associated – heart failure, stroke, myocardial infarction, kidney damage over time.
is aspirin the primary prevention for CVD?
No, aspirin is indicated for secondary prevention (so if have previously suffered stroke etc then aspirin helps, if not no point).
Primary:
. initially lifestyle advice - increase water intake, exercise, cut back on salt and takeaways, reduce red meat, avoid alcohol and smoking, weight management
. statin if QRISK >10%
- measure baseline LFTs within 3mnths and at 12mnths
hypertension pathophysiology
Increased systemic vascular resistance, cardiac output and vascular stiffness.
Beta 1 - causes increase in cardiac output
alpha 1 on smooth muscle - vasoconstriction and so increased vascular resistance
aldosterone system - renin released which makes angiotensin II (vasoconstrictor) and also causes aldosterone production - sodium and water retention, increased blood v and cardiac output
Hypertension diagnositcs
if clinical bp is between 140/90 mmHg and 180/120mmHg, offer ambulatory bp to confirm diagnosis.
When using home monitoring:
. take 2 readings at least 1 min apart and seated
. bp measured twice daily, ideally in morning and evening
. do for 7 days
QRISK
Hypertension treatment
1st line - ACEI / ARB (if acei not tolerated, ie cough)
- have TDM2 and of age or <55yr old and not African
2nd line - + CCB or thiazide like diuretic
3rd line - ACE/ARB + CCB + thiazide like diuretic
Afro-Caribbean ethnicity –>
- CCB
- ACEI/ARB/thiazide - prefer ARB
- ACEI/ARB + CCB + thiazide like diuretic
Reduce BP to below 135/85 mmHg for under 80s
why are non-rate calcium channel blockers preffered in Carribean pts?
they have a low renin state and lower cardiac output in Caribbean ethnicity reducing the effectiveness of ACEI.
If low renin state anyway, then ACEI will have less of an effect
pathophysiology of AF
irregular and abnormally fast heart rate (108bpm). Higher risk of stroke
Ventricles have irregular contractions causing a high heart rate due to the SAN no longer being the pacemaker and instead multiple cells of the atria fire off electrical signals resulting in irregualr, fast heartbeat
AF diagnosis and causes
diagnosis --> . perform 12-lead ECG . use CHADS-VASC stroke risk score >2 . ORBIT bleeding risk score . HAS-BLED >3 indicates caution is warranted when prescribing oral anticoag
causes –>
. hypertension, alcohol, poor INR control on warfarin
AF symptoms and treatment
symptom = breathlessness, palpitations, dizziness, chest discomfort
treatment=
. DOAC - stroke prevention (chad-vasc score 2 or 1 in men)
. rate control 1st line for AF - beta-blocker or rate-limiting calcium channel blocker as monotherapy
. digoxin in a sedentary lifestyle
- slows the heart down and better at controlling ventricular rate at rest
why is DOAC preferred over warfarin?
. warfarin has increased need for INR testing (INR 2-3)
. high number of interaction with food and other drugs w/ warfarin
. must be taken exact same time each day
. requires you to carry Warfarin book
. DOACs are safer and require less monitoring and altering
how to switch from doac to warfarin
- start warfarin whilst still on apix at a standard dose and check INR (>2) after 2 days and then apixaban can be stopped (can take 5-10 days for this).
- once stabilised, carry on with therapy and monitor.
- Contact anticoag clinical regarding monitoring.
- counsel on risks of interactions associated with warfarin and INR testing required regularly.
If INR is above range, what does it mean and how is it reversed pre-surgery?
> 3 - blood clots more slowly than wanted so increased risk of bleeding (INR and vit K will help decrease this) as want to reverse INR to 1.5 pre-surgery
- 5mg Phytomenadoine IV injection = diluted with glucose and given as an infusion, can take 6-8 hours to work.
- if emergency and cant delay surgery, then give dried prothrombin complex with phytomenadoine
risks with NIL by mouth
no food/fluids for 6hrs beforehand (diff for diff surgeries)
. dehydration - can result in AKI (
which meds can be given or omitted during surgery:
zopiclone, atorvastatin, warfarin, paracetamol, hypromellose eye drops, amlodipine, bisporolol
o Zopiclone isn’t needed (can be given the night before to help her sleep)
o Atorvastatin – omit as long-term benefit
o Warfarin - omit due to INR and surgery
- Warfarin should be stopped 5 days prior to the surgery or procedure.
- In most instances, warfarin treatment can be re-started as soon as the person has an oral intake.
o Paracetamol – can give IV if required and will need more analgesia anyway
o Hypromellose eye drops – can be given
o Amlodipine/bisoprolol – put on hold and surgery decreases bp slightly and bp not too high
prophylactic antibiotic prescribed post-orthopaedic surgery
single dose of IV cefuroxime alone or IV flucloxacillin+gentamicin 30 mins before procedure
how do you correct low K levels orally?
SANDO K = fizzy potassium tablets
. monitor k
. may not be eating a lot so low levels
anit-emetic reccomendations for PONV
- A combination of 2+ antiemetic drugs that have different mechanisms of action
- When a prophylactic antiemetic drug has failed, PONV should be treated with drug from a different class.
- ondansteron (5ht3 antagonists), dexamethasone, haloperidol, cyclizine, prochlorperazine. (cyclizine most likely to be used)
ONDANSTERON + DOMPERIDONE = risk of prolonged QT period so avoid in heart issue pts
How to restart warfarin post-surgery
No anticoag on day of surgery
. start LMWH (enoxaparin 40mg once) 24 hours after surgery - short acting)
- as warfarin takes longer for effects
- stopped when INR >2 (can take 4/5 days)
. also start warfarin 24 hours after surgery
How is pain managed after surgery?
. paracetamol or opioids – NOT NSAIDS
- Inflammation important part of fracture healing process
- Increase risk of second hip fracture
How does PCA work?
Monitoring required
o Loading dose initially
o Then bolus dose
o Lockout – interval between bolus doses (patient cannot administer more during this period)
o If in acute constant pain, may have a background infusion
• Monitoring with PCA
o Respiratory rate
o Sedation score (AVPU – Alert, Voice, Pain, Unconsciousness)
o How many times they have administered?
How do you treat opioid overdose?
Treat with naloxone (opioid antagonist)
- treat symptoms of OD but may increase pain - risk of arrhythmias and death (pain reversal put pt in shock)
‘Opioids induce respiratory depression via activation of μ-isopioid receptors at specific sites in the central nervous system including the pre-Bötzinger complex, a respiratory rhythm generating area in the pons.’
How to manage opioid-induced constipation
start laxative as prophylaxis:
. lactulose (takes 48hrs to work and requires pt to drink lots of fluid)
- not ideal for pts just off surgery and less mobile
. dulcolax (bisacodyl - stimulant laxative) and docusate (stool softner)
oral rifampicin dosing and counselling
– 0.6-1.2g daily in 2-4 divided doses – on an empty stomach
- Shouldn’t give alone to reduce the chance of resistance occurring
- Changed from IV to oral as good oral bioavailability
- Can stain urine, contact lenses etc.
is there an interaction between rifampicin and warfarin
Yes - induces warfarin metabolism via CYP
. Increase warfarin dose – monitor INR, however many risks with increasing so we STOP WARFARIN (until rifampacin course is over) AND GIVE LMWH INSTEAD.
Swapping antibiotic is another option however this is what microbiology has advised
what is a T-score?
A T-score shows how much your bone density is higher or lower than the bone density of a healthy 30-year-old adult. Means she has osteopenia- low bone density.
(Osteoporosis defined as a T score of minus 2.5 or lower)
