Chapter 4: Planning Management

Question 1

Management of an acute sick patinet

Answer 1

ABC approach as part of ATLS protocol. AVPU.

A = assess for stridor + accessory muscles + central cyanosis → secure airway with head tilt/chin lift, then airway adjuncts e.g. NPA, OPA, I-gel, LMA, then alert anaesthetist if unsuccessful.

B = examine RR, SpO2, chest expansion; give high flow O2 via non-rebreather mask if low SpO2.

C = examine CRT, pulses + BP; 2 wide bore cannulae; cardiac monitor.

Take history (note if primary or secondary), examination + perform further investigations e.g. imaging.

Question 2

Cardiovascular emergencies: STEMI

(management)

Answer 2

STEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → primary PCI (preferred) or thrombolysis → B-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU

Question 3

Cardiovascular emergencies: NSTEMI

(management)

Answer 3

NSTEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → LMWH OR Fondaparinux → B-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU.

Question 4

Cardiovascular emergencies: Acute LVF

(Management)

Answer 4

Acute LVF: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → sit up → Morphine 5-10mg IV + metoclopramide 10mg IV → GTN spray/tablet → Furosemide 40-80mg IV → if inadequate, isosorbide dinitrate infusion + CPAP → CCU.

Question 5

Cardiovascular emergencies: Tachycardia

(management)

Answer 5

Tachycardia:

>125bpm. Many just sick with non-cardiac disease i.e. sinus tachycardia, but consider algorithm if not sinus rhythm.

ABC + O2 (15L) by non-rebreather mask (if hypoxic)→ Hx, O/E, Ix:ECG/BP/electrolytes (IV access) → identify + treat reversible causes

• If adverse features (shock, syncope, MI, heart failure) → synchronised DC shock (up to 3x) → amiodarone 300mg IV over 10-20mins → repeat shock → amiodarone 900mg over 24h.
• If stable, note QRS complex.
  
  • Narrow (<0.12s):
    
    • Narrow complex + regular = vagal manoeuvres → adenosine 6mg rapid IV bolus → try 12mg again x 2 (monitor ECG continuously) → if sinus rhythm restored, probably re-entry paroxysmal SVT needing adenosine if re-currence + consider anti-arrhythmic prophylaxis. → If sinus rhythm not restored, possible atrial flutter (consider rate control e.g. B-blockers).
    • Narrow complex + irregular = treat as AF → rate control (B-blocker or diltiazem), digoxin/amiodarone if HF.
  • Broad (>0.12s)
    
    • Broad complex + regular = VT → amiodarone 300mg IV over 20-60 minutes, then 900mg over 24h. OR SVT + BBB = treat as narrow (vagal/amiod)
    • Broad complex + irregular = AF + BBB → treat as narrow; pre-excited AF → consider amiodarone; polymorphic VT = Mg2+ over 10mins.

Question 6

Cardiovascular emergencies: Anaphylaxis

(management)

Answer 6

Anaphylaxis: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → remove cause ASAP → adrenaline 0.5mg 1:1000 IM → chlorphenamine 10mg IV → hydrocortisone 200mg IV → asthma if wheeze + amend drug chart allergies.

Question 7

Respiratory emergencies: acute exacerbation of asthma

(management)

Answer 7

Acute exacerbation of asthma: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → salbutamol 5mg + ipratropium 0.5mg nebulised → prednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV → theophylline, magnesium sulphate, ITU.

Question 8

Respiratory emergencies: acute exacerbation of COPD

(management)

Answer 8

Acute exacerbation of COPD: Same as asthma, but add antibiotics if infective exacerbations. T2RF more likely so give O2 via venturi mask at 24-28%, maintain SpO2 at 88-92%. NB: hypoxia kills quicker than hypercapnia so high-flow O2 if peri-arrest then review ABG.

ABC + O2 PERI-ARREST HIGH FLOW O2 AND REVIEW → Hx, O/E, Ix(ABG!)→ salbutamol 5mg + ipratropium 0.5mg nebulised → prednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV +ABx! → theophylline, magnesium sulphate, ITU.

Question 9

Respiratory emergencies: Pneumothorax

(management)

Answer 9

Primary… SOB + >2cm rim on CXR = aspirate x2 → chest drain; not SOB + <2cm discharge + OP follow-up in 4 weeks.

Secondary… always admit to treat; SOB + >2cm rim on CXR or >50 years old = chest drain; if not, then aspirate.

Tension… emergency aspiration, but will need chest drain quickly.

Question 10

Respiratory emergencies: Pneumonia

(management)

Answer 10

Pneumonia: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → antibiotics (e.g. amoxicillin or co-amoxiclav) → paracetamol → if low BP, or raised HR, IV fluids as normal.

Question 11

Respiratory emergencies: Pneumonia

(Scoring system)

Answer 11

CURB-65

Confusion; AMTS = 8

Ureal >7.5 mmol/L

Respiratory Rate >30/min

Blood pression (systolic) <90 mmHg

Age >/= 65yrs

0-1 = home treatment

2-3=Hospital with oral/IV Abx

4-5=ITU admission

Question 12

Respiratory Emergency: Pulmonary embolism

(management)

Answer 12

Pulmonary embolism: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → morphine 5-10mg IV + metoclopramide 10mg IV → LMWH e.g. dalteparin → if low BP, IV gelofusine, then noradrenaline, then thrombolysis.

Question 13

Gastrointestinal emergencies: Gastrointestinal bleeding

(management)

Answer 13

Gastrointestinal bleeding: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC etc. + group and save + crossmatch 6U, GIVE colloid if low BP or O-negative blood if available) → catheter for strict fluid monitoring → correct clotting abnormalities (give FFP if PT/aPTT >1.5x N range, platelet transfusion if platelets abnormal) → camera (endoscopy) → stop CI drugs e.g. NSAIDs, aspirin, warfarin, heparin → call surgeons if severe.

8Cs!

Question 14

Gastrointestinal emergency: GI bleed

Coloid vs crystaloid Rx Which fluid when?

Answer 14

give crystalloid (e.g. 0.9% saline) if normal/high, or a colloid (e.g. gelofusine) if BP low; once cross matched, give blood

Question 15

Gastrointestinal emergency: GI bleed

Correcting clotting abnormalities: FFP/prothrombin/Platelets what/when?

Answer 15

If PT/aPTT >1.5xN => FFP

^ UNLESS due to warfarin => prothrombin complex e.g. beriplex

If platelets <50 x 109/L (and actively bleeding) => platelet transfusion

Question 16

Neurological emergencies: Bacterial meningitis

(management)

Answer 16

• Bacterial meningitis: If GP setting, give 1.2g benzylpenicillin if suspicion.*
• Give antibiotics after LP, unless undue delay. Do a CT scan not always required before LP.*

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC, blood cultures, glucose etc. GIVE IV antibiotics e.g. 2g cefotaxime, IV fluids, IV dexamethasone) + LP (before antibiotics if possible, and after CT) → consider ITU.

Question 17

Neurological emergencies: Seizures and status epilepticus

(management)

Answer 17

Seizures and status epilepticus:

initial: 1) ensure the airway is patent, (2) put in recovery position to prevent aspiration if patient vomits and (3) check for provoking factors (e.g. plastma glucose, electrolytes, drugs, sepsis)

Status= seizure >5 mins, Rx patient to stop the seizure (status is technically defined as seizure lasting >30mins)

ABC + O2 (15L) by non-rebreathe mask + airway manoeuvres/adjunct + recovery position (to prevent aspiration) → Hx, O/E, Ix →

if seizure for >5minutes, must give drugs → lorazepam 2-4mg IV or IV diazepam 10mg or buccal midazolam 10mg → if still fitting after 2 minutes, repeat diazepam → inform anaesthetist → phenytoin infusion → intubate then propofol.

Question 18

Neurological emergencies: Stroke

(management)

Answer 18

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix (including CT head) → if ischaemic stroke = thrombolysis if <4.5h ago + <80years old → aspirin 300mg oral → transfer to stroke unit.

If CT shows haemorrhage of any type, discuss with neurosurgery immediately and do not give aspirin or thrombolysis.

Question 19

Metabolic emergencies: hyperglycaemia in T1 vs T2 DM

Answer 19

Hyperglycaemia in T1DM = DKA; in T2DM = HONK.

Question 20

Metabolic emergencies: DKA

(management)

Answer 20

DKA… diagnose as hyperglycaemia, ketones in urine/blood, acidosis as low pH on ABG – watch out for raised K+.

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 1L/1h, 1L/2h, 1L/4h, 1L/8h → sliding scale insulin/fixed infusion → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.

Question 21

Metabolic emergencies: HONK

(management)

Answer 21

HONK… diagnose as hyperglycaemia, hyperosmolar ((2 x (Na+ + K+)) + urea + glucose), non-ketotic (no ketones in blood or urine).

Same as DKA management, except half rate of fluids required.

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 500mL/1h, 500mL/2h, 500mL/4h, 500mL/8h → sliding scale insulin → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.

Question 22

MEtabolic emergencies: Hypoglycaemia

(management)

Answer 22

Hypoglycaemia: <3mmol/L. Conscious = sugar-rich snack e.g. orange juice + biscuits.

Drowsy/vomiting = IV glucose via cannula e.g. 100ml 20% glucose. If no cannula, give IM glucagon 1mg

Question 23

Metabolic emergencies: AKI

(management)

Answer 23

Acute kidney injury: ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → IV fluid 500ml STAT, then 1L 4-hourly → hunt for cause + complications → monitor U&Es + fluid balance.

causes: routine bloods, ABG, urinalysis, US kidneys, drug chart nephrotoxic
complications: fluid overload, hyperkalaemia, acidosis

Question 24

Metabolic: Acute poisoning

(metabolic)

Answer 24

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → supportive measures (IV fluids + analgesia if appropriate) → correct electrolyte disturbances → reduce absorption (if within 1h e.g. gastric lavage, whole bowel irrigation, charcoal) → increase elimination (generous IV fluids) → psychiatric management.

Question 25

Metabolic emergencies: Acute poisoning

Specific Rx for

1. Paracetamol
2. Opiates
3. Benzodiazepines

Answer 25

Specific:

1. N-acetylcysteine for paracetamol over line of treatment after 4h on nomogram
2. Naloxone if opiates been taken and now slow breathing or low GCS
3. Fumazenil if benzodiazepines been taken.

Question 26

Chronic CV condition: HTN

(management: who to treat/targets)

Answer 26

Hypertension: Treat after ambulatory or home BP monitoring.

Treat if BP >150/95mmHg or 135/85mmHg if any of following present: existing or high risk of vascular disease (IHD, stroke + PVD), hypertensive organ damage (intracerebral bleed, CKD, LVH + retinopathy).

Target BP: if <80 years, aim for <140/85mmHg in clinic and <135/85mmHg ambulatory; if >80 years, add 10mmHg to systolic values.

Target BP in DM

• if end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
• otherwise < 140/80 mmHg

Question 27

Chronic CV: HTN

(management)

Answer 27

<55 = ACE-i;

>55 or black = CCBs

→ A + C

→ A + C + thiazide-like diuretic

• → K+<= 4.5 add spiro // K+>4.5 add high dose thiazide like Rx*
• –> consider alpha/beta blockers*

A=ACEi/ARB

C=CCB (nottol if oedema/evidence of HF, skip to D)

D=Thiazide: chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) preference to a conventional thiazide diuretic such as bendroflumethiazide

Question 28

Chronic CV: Chronic heart failure

(management)

Answer 28

Chronic heart failure: ACE-i (e.g. Lisinopril 2.5mg daily) + B-blocker (e.g. bisoprolol 1.25mg daily) → increase doses as tolerated

• mild/mod* → add ARB ( e.g. candesartan 4mg daily)
• mod-severe, black* → add hydralazine (25mg 8-hourly) + ISMN (20mg 8-hourly)
• mod/severe*→ spironolactone (25mg daily).

Question 29

Chronic CV: Atrial fibrillation

(management)

Answer 29

Atrial fibrillation: Prevent stroke + control rhythm OR rate.

• Prevent stroke
  
  • Stroke prevention: use CHA2DS2VASc = CCF (or LVF alone), HTN, age > 75 = 2, diabetes, stroke or TIA = 2, vascular disease (e.g. IHD, PVD), age 65-74 = 1, sex – female = 1.
  • Score 0 = no treatment; score 1 + male = condsider anticoagulation Aspirin is no longer recommended for reducing stroke risk in patients with AF– not if female; score 2 = warfarin/NOACs aiming for INR 2.5.
• Rhythm control:
  
  • Who? If young/symptomatic AF/first episode/due to treated precipitant e.g. sepsis or electrolyte disturbance.
  • How? Cardioversion = electrical or pharmacological (amiodarone 5mg/kg IV over 20-120minutes). Need AC if >48h since onset.
• Rate control:
  
  • Who? Everyone else with HR > 90bpm.
  • How? B-blocker (e.g. propranolol 10mg 6-hourly) or rate-limiting CCB (e.g. diltiazem 120mg daily) → add digoxin (1st line if others CI, 62.5-125ug daily).

Question 30

Chronic CV: Stable angina

(management)

Answer 30

Stable angina:

3 facets to first-line management:

1. GTN spray as required (symptomatic relief)
2. 2⁰ prevention (aspirin + statin +cv risks)
3. one anti-angina drug (B-blocker – CI = hypotension, bradycardia, asthma & acute HF OR CCB – CI = hypotension, bradycardia & peripheral oedema)

→ increase dose of B-blocker or CCB

→ 2nd anti-angina drug (ISMN (long-acting nitrate), nicorandil (K+-channel activator)

→ urgent revascularisation therapy (PCI or CABG).

even if controlled with medical management, routinely refer for consideration of revascularisation

Question 31

CV

how to distinguish stable angina vs ACS

Answer 31

Features more likely to suggest N/STEMI: sweating + vomiting, at rest, >15 minutes, no response to GTN, raised troponin = N/STEMI so look at ECG to decide (NSTEMI can be ST depression or normal; NB – ST depression in V1-4 may be anterior ischaemia or posterior infarction),

if no troponin rise = unstable angina

occurs on exertion/emotion and ceases <15mins + responds to GTN, more likely stable angina

Question 32

Chronic Resp: Chronic asthma

management

Answer 32

Chronic asthma:

1. SABA + low dose ICS
2. SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
   * Continue LTRA depending on patient’s response to LTRA*
3. SABA + low-dose ICS + long-acting beta agonist (LABA) +/- LTRA
4. SABA + MART ( ICS + LABA in single inhaler) +/- LTRA
5. SABA + (medium dose ICS) MART (ICS + LABA) +/- LTRA
6. SABA +/- LTRA:

• • high dose ICS
• • e.g. LAMA/Theophyline
• • seak help

Question 33

Chronic Resp: COPD Management

Answer 33

COPD: smoking cessation + NRT (bupropion or vareniciline) + annual influenza vaccine + one off pneumococcal vaccine

• → SABA or SAMA as required*
• → assess FEV1…*
• If FEV1 > 50%, LABA or LAMA (and discontinue SAMA).
• If FEV1 < 50%, add LABA + ICS or LAMA.

→ If still poorly controlled, add LABA + ICS (combination inhaler) OR LABA + ICS (combination inhaler) + LAMA.

• NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
  
  • the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
• Mucolytics should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve

Question 34

Chronic DM (T1/T2)

Management

Answer 34

T1+2DM: 4 components =

1. education & dietary/exercise advice
2. CV RF management (aspirin 75mg daily, simvastatin 20-40mg daily)
3. annual review of complications (check albumin: creatinine ratio → give ACE-I if microalbuminuria)
4. Blood glucose lowering therapy

in T1DM, start with insulin – never use oral hypoglycaemic drugs. e.g. long acting analogues glargine or NPH insulin humulin

In T2DM, if after trial of diet + exercise and HbA1c > 48mmol/mol…

• Metformin 500mg
• And:
  
  • sulphonylurea (e.g. gliclazide)
  • Gliptin
  • Pioglitaxone
  • SGLT2 -inhibitor
• 3 agents OR Insulin therapy
• 4th line: (if not tolerated and BMI>35)
  
  • ​metformin + sulphonylurea + GLP-1 mimetic

Question 35

Chronic Neurological: Parkinson’s disease

(management)

Answer 35

Parkinson’s:

mild PD and worried about finite benefit from levodopa→ Da agonist (ropinirole) or MAO-O inhibitor (rasagiline).

OTHERWISE: co-beneldopa or co-careldopa (i.e. levodopa + peripheral dopa decarboxylase inhibitor – benserazide or carbidopa),

Question 36

Chronic Neurological: Epilepsy

(management)

Answer 36

Epilepsy: means >2 seizures → most first seizures not treated with AED; choice reflects seizure type…

• Generalised TC = sodium valproate;
• absence = SV or ethosuximide;
• myoclonic = SV;
• tonic = SV;
• focal = carbamazepine or lamotrigine.

Each drug has multiple S/Es but if choice of 2 given, SV’s teratogenicity + lamotrigine’s rash should help select most appropriate.

Question 37

Common SE of neuroelipeptic drugs

SV

Lamotrigine

carbamazepine

Phenytoin

Answer 37

• SV = tremor, teratogenicity, tubby;
• lamotrigine = rash, rarely SJS;
• carbamazepine = rash, dysarthria, ataxia, nystagmus, ↓Na+;
• phenytoin = ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity.

Question 38

Chronic disease management: Alzheimer’s disease

Answer 38

Alzheimer’s disease:

• Mild/mod = acetylcholinesterase inhibitors,
  
  • only specialist can start
  • e.g. donepezil, rivastigmine, alantamine.
• Mod/severe = NMDA antagonist e.g. memantine.

Question 39

Chronic GI: Crohn’s disease

(management)

Answer 39

Two principles; induce remission or maintain remission (prevent flare)

Induce remission…

• mild = prednisolone 40mg daily oral
• severe = hydrocortisone 100mg 6-hourly IV + supportive (e.g. IV fluids, NBM, antibiotics)
• ^in either case, use rectal hydrocortisone too for rectal disease.

Maintain remission…

Azathioprine (check TPMT levels, risk of liver/BM toxicity) metabolised to 6-mercaptopurine. If TPMT low, use methotrexate.

Question 40

Chronic Rheumatology: RA

(management)

Answer 40

Rheumatoid arthritis:

• Combination of methotrexate + one other DMARD – usually sulfasalazine or hydroxychloroquine.
• After failure to respond to 2 DMARDs,
  
  • severely active RA may be managed with TNF-alpha inhibitor e.g. infliximab.
• During flare:
  
  • short-term glucocorticoids (e.g. IM methylprednisolone 80mg),
  • short-term NSAIDs (e.g. ibuprofen 400mg 8-hourly) + gastro-protection (e.g. lansoprazole)
  • re-instate DMARDs if dose previously reduced.

Question 41

Symptom Management: Fever

Answer 41

treat underlying cause + paracetamol as antipyretic – same dose as for analgesia, maximum 4g in 24h.

Question 42

Symptom Management: Constipation

Answer 42

treat underlying cause + laxative depending on cause and known Cis. Never give laxative if evidence of obstruction.

• Stool softener = docusate sodium (high dose = stimulant), arachis oil (rectal);
  
  • CI = arachis oil→ nut allergy;
  • good for faecal impaction.
• Bulking agents = isphagula husk;
  
  • CI = faecal impaction, colonic atomy;
  • can take days to develop effect.
• Stimulant laxatives = senna, bisacodyl;
  
  • CI = bisacodyl → acute abdomen;
  • may exacerbate abdominal cramps.
• Osmotic laxatives = lactulose, phosphate enema;
  
  • CI = phosphate enema → acute abdomen;
  • may exacerbate bloating.

Question 43

Symptom Management: Diarrhoea

Answer 43

Diarrhoea: commonest cause GI infection (especially norovirus + C difficile) so don’t intentionally inhibit quick removal of infectious agents; chronic diarrhoea = loperamide 2mg oral up to 3-hourly or codeine 30mg oral up to 6-hourly (also relief of pain).

Question 44

Symptom management: Insomnia

Answer 44

Insomnia: corticosteroids prevent sleep – so give in AM. Deal with aspects e.g. noisy environment first. Hypnotics can cause elderly to become very drowsy = risk of falls. If giving hypnotic, start with zopiclone 7.5mg oral nightly in adults (3.75mg in elderly).