chapter 4 Flashcards
mx of a STEMI?
aspirin 300mg Morphine 5– 10mg IV with metoclopramide 10 mg IV Primary PCI (preferred) or thrombolysis β-blocker e.g. atenolol 5 mg oral (unless LVF/asthma)
what do you do insteadof PCI for NSTEMI?
aspirin 300mg
fondaparinux 2.5mg if they do not have a high bleeding risk/ arent going to cath lab
Mx of acute HF?
Furosemide
40–80 mg IV
What adverse features would make you deliver a DC shock in adults with tachycardia?
shock
acute HF
syncope
MI
What are the differentials and mx for broad complex irregular tachycardia?
AF + BBB –> same treatment as narrow complex
Polymorphic VT –>
(e.g. torsade de pointes -
give magnesium 2 g over 10 m
What are the differentials and mx for broad complex regular tachycardia?
VT –> Amiodarone 300 mg IV over 20–60 min; then 900 mg over 24 h
If previously confirmed SVT with BBB –> adenosine as for regular narrow complex tachycardias
What is the mx for narrow complex regular tachycardia? e.g. SVT
vagal manoeuvres
Adenosine 6 mg rapid IV bolus;
if unsuccessful give 12 mg;
if unsuccessful give further 12 mg
if atrial flutter get expert gelp
What is the mx for narrow complex irregular tachycardia?
Probable atrial fibrillation Control rate with: β-blocker or diltiazem Consider digoxin or amiodarone if evidence of heart failure
mx for anaphylaxis?
ABCDE remove cause adrenaline 500 mcg 1:1000 IM clorphenamine 10mg IV hydrocortisone 200mg IV
mx of acute asthma?
100% O2 by nonrebreather mask
Salbutamol
(5 mg NEB)
Hydrocortisone 100 mg
IV (if severe/life threatening)
or prednisolone
40–50mg oral (if moderate)
Ipratropium (500
micrograms NEB)
Theophylline (only
if life threatening)
mx for secondary Pneumothorax?
(i.e. patient has lung disease) then always needs
treatment: chest drain if >2 cm or patient SOB or if >50 years
old; otherwise aspirate.
mx for tension Pneumothorax?
(i.e. clinical distinction but often
tracheal deviation +/− shock) then emergency aspiration
required, but will need chest drain quickly.
mx for primary Pneumothorax?
` if <2 cm rim and not SOB then discharge with outpatient
follow-up in 4 weeks.
` if >2 cm rim on CXR or feels SOB then aspirate and if
unsuccessful aspirate again, and if still unsuccessful then
chest drain.
mx for PE?
Morphine 5–10 mg IV,
metoclopramide 10 mg IV
Give LMWH before CTPA but once confirmed do a
DOAC e.g. rivoraxiban 15mg BD
mx for GI bleeding?
x 2 cannula large bore
Cross match 6 units blood
Endoscopy
Stop antiplatelets/ coagulants
Check for clotting abnromalities: If PT/aPTT more than 1.5 normal range ⇒ give fresh frozen plasma (unless due to warfarin ⇒ give prothrombin complex (e.g.
Beriplex®)); if platelets <50 × 109
/L (and actively bleeding) give platelet transfusion.
mx of meningitis?
LP +/- CT head (dont want to delay LP)
IV dexa
2 g cefotaxime IV (give pre-LP if having CT head or prolonged LP)
mx of seizures?
Patent airway
Recovery position
check glucose, electrolytes, drugs, sepsis that could be provoking
mx of status epillepticus (> 5 mins)?
10mg buccal midazolam
IV lorazepam 4mg, repeated after 10 minutes up to 3 doses if the seizure continues
Get anaesthatist
If seizures persist: IV phenobarbital or phenytoin
Intubate
mx for a stroke?
CT to check for haemorrhage
If onset <4.5 hours ago consider thrombolysis with alteplase
Aspirin 300mg stat
What is the criteria for DKA?
Diabetic (i.e. hyperglycaemia – BM often >30mmol/L)
Keto (i.e. check urine or blood ketone levels)
Acidosis (i.e. low pH on ABG).
Also watch out for increased potassium.
What is the criteria for Hyperosmolar Hyperglycaemic State?
● Hyperglycaemia (usually >35mmol/L)
● HO (hyperosmolar: osmolality over 340mmol/L (calculated by
(x2 Na + x2 K) + urea + glucose)
● NK (nonketotic, i.e. no ketones in blood or urine).
What is the mx of hyperglycaemia?
IV fluid: 1 L stat then 1 L over 1 hour, then 2 hours, then 4 hours, then 8 hours
Sliding scale insulin
mx of hypoglycaemia?
if unable to eat (i.e. drowsy/vomiting) give IV glucose via a cannula, e.g. 100mL 20% glucose.
If unable to eat and no cannula give IM glucagon 1mg.
mx of AKI?
500ml IV stat, 1L 4 hrly
Check causes and complications (hyperkalaemia, fluid overload, acidosis)
ABG, catheter, urinalysis, bloods
Antidote to benzodiazepine OD?
flumazenil
what is the mx for htn?
> 150/95mmHG or >135/85mmHg + risk of CVD
then give:
<55 yrs or diabetes: ACE-i
55 yrs/ afro-carribean :CCB
mx for chronic HF?
ACE-i + BB
+ ARB –> nitrates –> spironolactone
mx of AF?
Rhythm control:
`Who? – if young/symptomatic AF/first episode of AF/AF due
to treated precipitant (e.g. sepsis or electrolyte disturbance).
How? – cardioversion: electrical or pharmacological
(amiodarone 5mg/kg IV over 20–120mins). The patient will
require anticoagulation if more than 48 hours since onset.
Rate
- Beta blocker (e.g. atenolol 50-100mg once daily)
- Calcium-channel blocker (e.g. diltiazem 120mg OD) (not preferable in heart failure)
- Digoxin load, then start 62.5-125mcg (only in sedentary people, needs monitoring and risk of toxicity)
mx of stable angina?
GTN PRN
RF modification - statin, aspirin + other RF modification
Anti-angina drug: 1) BB 2) CCB
Referral to cardiology for revascularisation
mx of asthma?
- Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
- Add a regular low dose inhaled corticosteroid.
- Add an oral leukotriene receptor antagonist (i.e. montelukast).
- Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
- Consider changing to a maintenance and reliever therapy (MART) regime.
- Increase the inhaled corticosteroid to a “moderate dose”.
- Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
- Refer to a specialist.
What is the mx of diabetic nephropathy and how is this checked for?
s checking
an albumin–creatinine ratio (ACR) as (1) an early indicator of
diabetic nephropathy, and (2) a predictor of cardiovascular disease,
e.g. microalbuminuria (ACR ≥ 3mg/mmol) indicates the need for ion).
an ACE-inhibitor. Ironically, ACE-inhibitors can worsen acute kidney
injury but in the chronic setting (with careful monitoring) offer
significant cardiovascular and renal prot
Mx of Parkinsons?
If mild PD with limited benefit from levodopa yet then give dopamine agonist (such as ropinirole) or MAO-inhibitor (such
as rasagiline)
otherwise give co-beneldopa
mx of seizures?
● Generalized seizures – sodium valproate
● Absence seizures – ethosuximide
● Focal seizures – carbamazepine or lamotrigine
mx of Alzheimers?
● If mild/moderate dementia then treat with acetylcholinesterase
(AChE) inhibitors; donepezil, rivastigmine and
galantamine.
● If moderate/severe dementia then treat with NMDA antagonist
(memantine).
What blood test should be initiated before giving azathioprine
S-methyl
transferase (TPMT)
Examples of DMARDs
methotrexate or
sulfasalazine or hydroxychloroquine
Gve an examples of a stool softener and its indication
Docusate
Foecal impaction
Gve an examples of a bulking agent laxativr?
Isphagula husk
examples of stimulant laxative
senna
bisacodyl
examples of osmotic laxatives
lactulose
phosopahate enema
mx of hyperkalaemia?
5–10 UNITS OF ACTRAPID® (or NOVORAPID®) IN 50ML OF 50% DEXTROSE OVER 5–15 MIN IV
calcium gluconate 10% by slow intravenous injection
Neb salbutamatol
What is the best anti-epileptic drug for pregnancy?
lamotrigine
How do you decide on the first line PO hypoglycaemic drug for T2DM?
Sulphonylureas (e.g. glipizide or gliclazide) first line is patient is normal/ underweight or creatinine >150
Metformin first line if overweight and cretinine <150
Mx of COPD exacerbation?
First:
24% oxygen in CO2 retainers
salbutamol nebuliser
ipratropium bromide 500mcg neb
Then PO/ IV steroids
IF fail to respond to treatment consider ITU referral and aminophylline
Mx of bowel obstruction?
drip and suck with a NGT
If that doesnt work consider antiemetic - cyclizine or odansetron appropriate.
What should you consider when doing fluids post AKI
After renal failure patients can experience a polyuric phase in which urine output is higher than input → dehydration + electrolyte disturbance.
Normally fluid charts should have similar input and output (allow 10-15% difference due to insensible losses). Input may be higher than output in dehydration/ renal failure when we’re pumping them full of fluids. But vice versa is worrying.
To decide on what to prescribe look at total output and divide that by 24 hrs e.g. 6L output - do 24/6 - 4 hrly fluids
Rules for fluid prescrbing
Look at patient’s bloods!! If they are hypokalaemic replace with K+, if they are upper end of normal for sodium use 5% dextrose
Potassium should never be given at a rate over 20mmol/ hr
Maintenance: 30ml/kg/day; 1mmol/kg of K, Na and Cl, 50-100g/day glucose
High calcium → give 0.9% sodium chloride, 1L in 4 hrs
