Palliative care incorrects

Question 1

acute pulmonary edema
LV systolic dysfunction with an ejection fraction of 20%
IV furosemide given as it is first step in pulmonary edema
patient sats 94% BP 74/50

Next step in management?

Answer 1

ionotropic support on the high dependancy unit!!! - eg dobutamine

patient has cardiogenic shock as cause of pulmonary edema (identified by presence of hypotension AND SPECIFICALLY BP <90/60. having an MI does not mean you have cardiogenic shock) in this scenario IV furosemide worsens already low BP

ionotropes important to increase cardiac contractility

you would not give IV fluids as her hypotension is not due to hypovolemic shock rather cardiogenic shock

bisprolol is used in chronic NOT cute HF as you need tachycardia in acute HF to maintain circulatory output

Question 2

when is BIPAP indicated?

Answer 2

when a patient is hypercapnic!!!

must be both hypercapnic and hypoxic

it is a type of non invasive ventilation

NIV Is used to correct repiratory acidosis

Question 3

acute HF treatment?

if patient fails to imporve and signs of type 1 resp failure on ABG what is the next step in management?

Answer 3

IV loop diuretic eg furosemide !
oxygen only if sats low
consider dobutamine if cardiogenic shock

CPAP

Question 4

which drug is first line for chronic heart failure?
second line?

Answer 4

ACE inhibitor (eg candesartan) AND beta blocker (bisoprolol and carvedilol only)

second line options:
aldosterone antagonists -> spirinolactone, epelerenone
SGLT2 inhibitors (flozins!!!) are used in HFrEF (<55%)

*IV furosemide is not used in chronic HF except when managing fluid overload

Question 5

a patient is on aspirin, ramipril, bisoprolol, artovastatin and is still having symptoms of chronic heart failure
what is most appropriate for improving patients prognosis?

Answer 5

1st line insufficient

thus add on spirinolactone!

Question 6

learn the NYHA class for congestive HF!! *4 = Worst = symptoms at rest. 1= best = no symptoms

Question 7

sings of cor pulmonale? (a type of right sided HF)

Answer 7

raised JVP, ankle oedema, hepatomegaly

Question 8

management of chronic HF in a patient that has already tried first and second line options. patient has a widened QRS and bundle branch block on ecg

what if the patient instead has a sinus rhythm >75 per min and a left ventricular fraction <35%

what if the patient is afro carribean?

Answer 8

Cardiac resynchronisation therapy - crt device (biventricular pacemaker)

ivabradine

hydralazine + nitrates

Question 9

64 year old, cough, hemoptysis, vague abdominal pain for 2 weeks. CXR shows multiple round large well circumbscribed masses in the lungs. most likely underlying diagnosis?

Answer 9

renal cell carcinoma

cannonball metasatses described!!

Question 10

what vaccine should be offered anually to patients with HF?

Answer 10

influenza vaccine

pneumococcal = 1 off

Question 11

name a cause of high output heart failure

Answer 11

severe anemia - eg following massive GI bleed

Question 12

name a finding on auscultation in HF

Answer 12

third heart sound

Question 13

chronic HF 1st line investigation?

what test is done next?

Answer 13

BNP = 1st line

transthoracic echo

Question 14

what medication must be stopped before initiating saculbitril-valsartan as a 3rd line treatment for chronic HF?

Answer 14

ACEs and ARBs.
36 hour washout period

Question 15

patient experiencing an exacerbation of chronic HF. so acute HF
BP 195/115 with history of HTN. IV furosemide helped but still breathless. what can be started in this patient?

Answer 15

glycerly trinate

can be given in acute HF if concominant MI, severe HTN!! or regurgitant aortic or mitral valve disease

Question 16

indications for stopping beta blockers in acute HF?

Answer 16

heart rate < 50/min, second or third degree AV block, or shock

Question 17

signs of left sided HF?

Answer 17

bibasal crackles on chest auscultation
cyanosis
displaced apex heart beat
pink frothy sputum

Question 18

A 70-year-old woman has attended a heart failure clinic. She was referred by her GP 2-years ago due to a systolic murmur, loudest in the second intercostal space, along the left sternal border.

Given the side of heart failure, what specific sign would you expect to elicit on examination?

Answer 18

hepatomegaly!!

patient had pulmonary stenosis!!! = risk factor for right HF

Question 19

first line treatment for managing secretions in palliative care? - may be described as gurgling or rattling sound and bowel colic

Answer 19

hyoscine butylbromide or hyposcine hydrobromide!!! - subcut or iv

also stop IV fluids

Question 20

patient with cancer and painful bone mets
stage 5 chronic kidney disease
what is drug of choice for management?

Answer 20

alfentanil, buprenorphine or fentanyl!! as patient has severe kidney disease. sublingual fentanyl is first line

if mild to moderate kidney disease = oxycodone drug of choice

note: in the absence of renal disease, morphine is 1st line in treatment of cancer pain!!

Question 21

nausea due to chemo is treated with?
nausea due to raised ICP is treated with?
nausea due to GI/billiary pathology is treated with?

Answer 21

arepitant
cyclizine (or dex second line brain mets)
metoclopramide

Question 22

learn how to convert between pain relief medications and calculate breakthrough dose

Question 23

in palliative patients increase morphine doses by 30-50% if pain not controlled

Question 24

metastatic bone pain can respond to analgesia (opioids specifically), radiotherapy OR?

Answer 24

Bisphosphonate infusion!!

Question 25

woman recognised to be dying with cancer. now confused and agitated.
management?

Answer 25

Midazolam!! -> subcut or IV

terminal restlessness management

*if patient is not terminal give haloperidol

Question 26

Treatment for hiccups in palliative care?

Answer 26

Chlorpromazine or haloperidol

Question 27

Treatment for painful mouth at end of life?

Answer 27

Benzydamine hydrochloride mouthwash