Management Guidelines Flashcards
Acute Asthma
D/c PEFR >75% 1h, or stable on meds for 24h
A to E + AMPLE: oxygen, ABG, CXR, PEFR, ECG, lactate, K+
salbutamol: 5mg Neb +/- ipratropium (500mcg)
oral prednisolone 40-50mg for 5+ days
(?magnesium IV 1.2-2g 20mins)
(?aminophylline)
must inform med reg of all acute asthma patients
severe/LT: SBAR to ITU
Acute Asthma Severity
Moderate: 50-75% PEFR
Severe: sentences, abn HR/RR, 33-50% PEFR
Life-threatening: LOC/effort, silent chest, hypoTN, hypoxia (T1RF) <33% PEFR
Near-fatal: hypercapnia
Chronic Asthma
1) SABA prn
2) SABA + ICS (200-800; 400)
3) SABA + ICS + trial LABA +/- ^ICS
4) SABA + ICS + LABA + LTRA/theo/increase ICS (1000-2000)
5) SABA + ICS (2000) + LABA + 4th + PO steroids
step up if: night symptoms, SABA >3/week, exacerbation <2y
step down if 3/12 stable (25-50% less ICS)
ACTION PLAN
COPD
PEFR: 30/50/80
1) SABA/SAMA
2) SABA/SAMA + LAMA/LABA +/- ICS (<50%)
3) SABA + LABA + LAMA + ICS
* LABA + ICS combihalers
ABx for infective exacerbations xanthines (ICS CI) mucolytics (carbocysteine) LTOT (chronic hypoxia) NIV (IPAP/EPAP)
STEMI
FBC, U&E, glucose, lipids, trop, d-dimer, ECG, CXR, VTE
PCI (<12h)/thrombolysis (<24h)
aspirin + clopidogrel 300 mg ea.
morphine 5-10mg + metoclop 10mg IV
GTN 2puffs/1 tablet prn
secondary prevention: ASCAB (clop 1/12 -12/12 if stent)
NSTEMI/Unstable Angina
triple Tx: aspirin + clopidogrel + LMWH (1mg/kg bd)
morphine + metoclopramide +GTN
high risk: angioplasty +/- PCI/CABG, clop 12/12, GIIb-IIIa inhib
secondary prevention: atenolol (or RL-CCB) + statin + ACEI
Angina
FBC, U&E, LFT, lipids, glucose, TFT, ESR/CRP
ECG (rest/ex), Echo, scintigraphy, angiography, CT/angioplasty
symptoms: GTN spray, lifestyle, nicorandil (K+)
disease modification: BB/ACEI (DM)/CCB, BB+CCB, PCI/CABG
CVD prevention: lifestyle, statin, HTN (ACEI/BB), aspirin
Heart Failure
FBC, U&E, LFT, TFT, trop (?MI), BNP
CXR, ECG, echo, MRI/PET/RNA, catheter, Fx-testing
acute pulm. oedema: IV loop, IV GTN, morph+meto CHECK SBP >100
symptoms: furosemide
modification/prevention: BB + ACEI, add dig/spiro (3rd)
AF/VTE: digoxin + warfarin
CRT/pacing/LVAD/transplant
Tachycardias
SVT: vasovagal (carotid massage, valsalva), adenosine 6mg; BB/CCB/amio/dig (2nd)
VT: amiodarone
*WPW: don’t block AVN; give flecainide or procainamide
*HD unstable = DC CARDIOVERT
Bradycardia
unstable (shock, syncope, ischaemia, HF): atropine 500mcg IV , transcutaneous pacing
AVB-1: none
AVB-2: pacemaker if Mobitz-2
AVB-3: pacemaker
Trifasicular block (RBBB + LAD + AVB1): pacemaker
AF
rate: beta-blocker or diltiazem; dig/amio if CCF
only shock if young and recent onset (otherwise clot risk)
rhythm (Sx control): sotalol, flecainide, amiodarone
prevention: warfarin (CHADSVASC)
PTX
primary <2cm: none (f/u only)
primary >2cm: aspirate, then drain if needed
secondary <2cm: aspirate?
secondary >2cm: chest drain + oxygen
trauma or ventilated: chest drain
tension: decompress (2ics) + chest drain
recurrent: pleurodesis, blebectomy, pleurectomy]
oxygen if breathless
Hyperkalaemia
calcium gluconate 10% 10-20mL over 10 mins
insulin + glucose infusion
fluids +/- dialysis (renal advice)
DKA
FBC, U&E, ABG, glucose, b/c, ketones, CXR
fluids!!! 0.9% NaCl + K (from 2nd bag)
insulin fixed rate infusion (0.1/kg); add glucose at <14mM
potassium
fix other electrolytes, check for complications (oedema, hypokalaemia, bicarb, phosphate)
stop insulin infusion once normal Ix, E+D, s/c insulin working
*HHS: slower fluids, 0.05/kg insulin
H. Pylori PUD
scope if >55yo or ‘ALARMS’ (anaemia, lost wt, anorexia, recent, melaena, swallowing)
scope: Bx, gastrin (?ZES), Tx (adr/sclerosant/diathermy/clip)
triple therapy:
PPI + clarithromycin + metronidazole/amoxicillin
GI haemorrhage
A to E + escalate (med reg, gastro, crash team)
FBC, U&E (Ur), LFT, coag, ABG (Hb, L), XM 6 units, UO, ?MTP
Pre-scope: resus, Blatchford score, ?transfuse
Scope: Forrest classification + Rockall score; Tx (adr/clip/cautery)
Re-bleed: inverventional radiology (CT angio + embolise)
Varices: airway (high risk), XM 6 units, vit K +/-FFP, lactulose (enceph)
terlipression 2mg + ABx (big impact on survival)
Endoscopy (Banding), TIPPS if refractory, SB tube
IBD
FBC, CRP/ESR, LFTs, U&E, b/c, stool, iron/B12/folate
colonoscopy + biopsy, AXR, MRI
Crohns:
1) remission: steroids (IV if severe); topical
2) maintenance: azathioprine (steroid sparing), anti-TNF, MTX
UC:
1) remission: 5-ASA+steroids; IV if severe; topical
2) maintenance: 5-ASA; immosuppressants if severe
surgery: cure in UC, recurs in CD
CRC/surgery
colostomy: H or APR
end ileostomy:
panprocto/total
loop: Ant Res., bowel rest
*common SE: leak/stoma, wound, ileus/obst/stricture, pelvic damage
R Hemi: ileum to distal 1/3 TC; temp stoma; Ca, FAP, volv, div, CD, perf; common + hernia SE
L Hemi: distal 1/3 TC to sig/rectum; temp stoma; Ca, FAP, volv, div, CD, perf; common + hernia SE
Total: sigmoid, colon; STOMA vs. POUCH; UC, FAP, CRC; common + pouchitis, loose stool
Panprocto: anus, rectum, sigmoid, colon; ILEOSTOMY; UC, Ca, FAP; common SE + impotence/retro ejac
Hartmann’s: emergency sigmoidectomy, temp reversible STOMA, rectum oversewn;
Ca, volvulus, perf, 3Is; common SEs
Ant. Res: rectum, sigmoid; anasto +/- LOOP; cancer, diverticulitis; common + LARS (freq, urgency, incont)
APR: anus, rectum, sigmoid (2 scars); STOMA; anal/low rectal Ca; pelvic mm/nerve damage
acute pancreatitis - severity
Ix: bloods, ABG, AXR, eCXR, CT, ?ERCP
‘PANCREAS’: modified Glasgow in first 48h (3+ = severe)
PaO2 <8kPa
Age > 55yo
Neuts: wcc > 15
Calcium <2mM
Renal: urea > 16
Enzymes: AST >200, LDH >600
Albumin: <32g/L (bleeding)
Sugar: hyperglycaemia >10mM (loss of function)
*Ranson: Ax and 48h; hct, BE, BUN, fluid sequestion
*Apache II: clinical, age, comorbidity
AKI
Pre-renal: fluid balance + status; rehydrate
Post-renal: USS, PR, abdo; treat cause (e.g. stones)
Renal: UA, MC&S, biopsy; refer to renal
Treat complications: hyperK, uraemia, met acidosis, pulmonary oedema
Daily fluid balance, U&Es, weights;
Find and treat cause
renal stones
UA, MC&S; USS/XR, CT, IVU/Radioisotope (fx)
Diclofenac 75mg IV/IM (or 100mg PR), ?Abx (sepsis)
fluids (slow)
Medical: nifedipine, alpha-blockers, prednisolone;
Nephrostomy or JJ stent: drainage
ESWL: 3-10mm stones
Ureteroscopy + lithotripsy (complications)
Percut. nephrolithotomy (PCNL): large stones
Nephrectomy: non-functional but symptomatic
*urgent: infection/sepsis, pain, vom, AKI, bilat/no function
epilepsy
status: FBC, U&E, LFT, clotting, BM, Ca, [AED], tox, cultures
5M: IV loraz 2-4mg (0.1/kg) over 2mins; repeat 10m;
or IV/PR D, or buccal M (10mg)
25M: IV pheny 20mg/kg (10mg/mL, max 50mg/min); BP + ECG!!
ITU + GA if refractory
absence: valproate or ethosuxamide; lamotrigine 2nd
tonic-clonic: valproate; lamotrigine (2nd)
focal: lamotrigine/carbamazepine; valproate/levetriacetam/topiramate (2nd)
Overdoses
General: oxygen, IVI, monitor (incl. UO + ECG), activated charcoal (<1h)
Paracetamol: NAC (treatment line) opiates: naloxone (IV/IM) BZD: flumazenil if iatrogenic and pure beta-blockers: glucagon TCA: bicarbonate (if SVT/VT)
HTN
UA/MSU, FBC, U&E, LFT, Ca, lipids, ECG, CXR
CVD risk score + HTN stage = Tx decision
s1: 140/90; Tx if CVD risk >30%, or organ damage
s2: 160/100; treat
s3: 180/110; treat
diet and lifestyle; RF-mod (wt, ex, salt, fat, sugar, cigg, alc)
A/C, then A+C, then A+C+D, then add AB/BB/2nd D
AAA
ALWAYS RULE OUT IN ABDO PAIN: USS
monitoring (3-5.5cm): USS/duplex annually
monitoring (>5.5cm): CT 6/12
elective op (>5cm or >1cm/year or Sx): EVAR or open
ruptured: resus + theatre asap if unstable; ABx PPx (cef + met)
ECG + bloods (amylase, Hb, XM 10-40, clotting) + UO
stable: CT
surgery: clamp aorta + Dancron/trouser graft; 40% mort (100% unRx)
Hip fractures
Intracapsular: Garden Classification
I: incomplete; screws (ORIF)/DHS
II: complete, undisplaced; screws (ORIF)/DHS
III: complete, partially displaced (<50%); hemi/total
IV: complete, displaced (>50%); hemi/total
Extracapsular: DHS or intermedullary nail (subtroch)
CPR Algorithm - shockable
pVT/VF
CPR 30:2, 2 minute cycles
‘COACHED’ + shock
witnessed: 3 immediate shocks, then 2min CPR
unwitnessed: start CPR immediately
adrenaline 1mg IV (1:10,000) after 3rd shock, then alternate shocks amiodarone 300mg (in 20 ml 5% glucose) after 3rd shock; rpt 150 mg after 5th
*4H and 4T
CPR Algorithm - non-shockable
PEA/asystole
CPR 30:2, 2 minute cycles
‘COACHED’ + shock
adrenaline immediately/after first round, then alternate cycles
- 4H: hypo/hyperthermia, hypoxia, hypovolaemia, hyper/hypokalaemia
- 4T: thrombus, tension, tamponade, toxin
Sepsis
SIRS + infection: HR >90, RR > 20, temp 36/38, wcc 4/11
3 IN: fluids, oxygen, ABx (WITHIN 1 HOUR)
3 OUT: UO (catheter), lactate (ABG), blood cultures (pre-ABx)
CVA
bloods, BM, BP (monitor but don’t treat), CXR, ECG, doppler/angio
CT/MRI: ?thrombolysis, cerebellar, ?Dx, hge risk
scores: HAS/CHAD, ACBD (TIA), VTx, Bamford
thrombolysis: expert team, <3h, no CI, CT (no hge); 0.9mg/kg IV tPa
antiplatelets (once hge ruled out), HTN, statin
NBM until swallow tested
IVI but don’t overload (cerebral oedema risk)
TIA
ABD2 score: age (>60), BP (140/90), clinical (speech/weak2), duration (>1h =2), DM
RF: anti-HTN, anti-plt, anticoag, carotid endarterectomy (>75% stenosis)
no driving 1/12
Aortic dissection
Debakey I: proximal/asc and descending; 60%; Stanford A
Debakey II: proximal, asc only; 10-15%; Standford A
Debakey III: distal/desc only; 25-30%; Stanford B
CXR, MRI/CT/TOE, ECG (?MI); XM 10
anti-HTN: SBP 100-110 (labetalol/esmolol/CCB)
Type A: surgery - stent or replace
Type B: medical unless complications (organ/leak/rupture)
Benign breast disease
fibroadenoma: 1/3 regress, 1/3 progress, 1/3 same; can excise (size/Sx)
* triple assessment! E1-5, U/M1-5, C1-5 (Bx)
fibrocystic/adenosis: anti-inflam, hormone/cellular
cysts: aspiration +/- hormones (if recurrent/multiple)
breast pain: life, NSAIDs, primose oil, tamoxifen, bromocrip, danazol
*lifestyle: caffeine, chocolate, bra support, diet
Malignant breast disease
cancer: R-status (Oe/PR/Her), TMN, grade; prognosis
wide local + RDT (stop local recurrence)
mastectomy: large, central, multifocal, widespread, late
reconstruction: implants/expanders, prosthesis, DIEP/TRAM/LD flaps
CTX: high risk (nodes, high grade); FEC-T, MTx etc.
Nodes: sampling (4+), clearance, sentinel node Bx
Endocrine: anti-Oe (tamox), anti-aromatase (anastrazole), anti-LH
MAB (Herceptin)
CT Scan indications in head injury (1h and 8h)
GCS <13, or <15 2h later focal neuro Sx (nn/brain/sc deficit) persistent headache or vomiting >1x BOS# features (Battle, Raccoon, Oto/rhinorrhoea) coagulopathy/anticoagulation
seizures
>65yo + LOC
retrograde amnesia
skull fracture
LOC Patient Management (Ix, DDx)
FBC, U&E, LFTs, CRP, clotting, ABG, BM
ethanol, tox, [drug], b/c, MC&S, ?malaria
CXR, CT-head, LP (if not CI)
trauma, hypotension/hypoxia,
toxins/drugs, electrolytes, glucose, hormones, organ failure
seizure, trauma, CVA, ICP, ICH
Pneumonia
cultures, bloods, CXR, urine Ag, atyp/viral serology, ABG
CURB65 (AMT<8, Ur >7, RR >30, BP<90, >65yo)
0/1: mild; home, PO ABx (amox/clarithro/dox)
2: mod; ?Ax, PO/IV ABx (amox + clarithro/dox)
3+: severe; Ax, longer IV ABx (co-amox/ceph + clarithro)
?staph: fluclox; ?MRSA: vancomycin
legionella: cipro + clarithro
chlap: doxy/clarithro
aspiration: ceph + met
***F/u CXR at 6-8 weeks
TB
RIPE for 2/12, R+ I for 4/12 (6/12 total; longer if ERD/CNS)
bone: excise abscess + RIPE 6-12/12
Rifampicin: P450 inducer, hepatorenal, TPenia, ‘flu’, orange
Isoniazid: hepatorenal, leucopenia, peripheral neuropathy
Pyrazinamide: arthralgia, liver, gout/porphyria (CI)
Ethambutol: VA and colour vision (optic neuritis)
Antiplatelets (secondary CV risk reduction)
ACS: aspirin lifelong + clopidrogrel 4/52 - 12/12
TIA: aspirin + dipyridamol (200mg BD)
Ischaemic stroke: aspirin (300mg OD) 2/52 + clopidogrel lifelong
