Passing the PSA Flashcards
Drugs to stop before surgery
I LACK OP insulin lithium anticoagulants, antiplatelets COCP/HRT K sparing diuretics oral hypoglycaemics perindopril and ACE inhibitors
When do you need to stop the OCP and HRT before surgery?
4 weeks
before surgery: when do you stop lithium?
day before
When do you stop potassium sparing diuretics and ACE inhibitors before surgery?
day of surgery
What are the 9 things we have to think about for safe prescribing?
- Is it the correct patient?
- Do they have any allergies?
- Did you sign the front of the chart
- Consider any contraindications for the drug I am prescribing
- consider the route
- consider the need for IV fluids
- consider the need for thromboprophylaxis
- need for antiemetic
- consider the need for pain relief
What does the mnemonic PReSCRIBER stand for?
Patient details Reaction (allergies) Sign the front of chart check for Contraindications to each drug check Route for each drug prescribe IV fluids if needed prescribe Blood clot prophylaxis if needed prescribe antiEmetics if needed prescribe pain Relief if needed
What two commonly prescribed drugs both have penicillin in them?
co-amoxiclav and Tazocin
What are the four classes of drugs you must know the contraindications for?
- drugs that increase the bleeding risk
- for steriods
- NSAIDS
- antihypertensives
What are the contraindications for anticoagulation?
bleeding
suspicion that they could be bleeding
ischemic stroke (because could bleed into stroke)
Erythromycin (enzyme inducer) increase the PT and INR
What are the SE of steroids?
eyes= cataracts, glaucoma
face- moon like facies cushingoid appearance
cardiovascular- heart failure
skin and bones- osteoporosis and skin thinning and infection
endocrine= diabetes
NSAID contraindications
No urine Systolic dysfunction Asthma indigestion Dyscrasia clotting abnormality
What are the SE of ACE inhibitors
dry cough, hyperkalemia,
SE of Beta blockers and CA channel blockers
hypotension
Should Beta blockers be prescribed in asthmatics?
nope
SE of calcium channel blockers
perpheral oedema and flushing
diuretics can cause?
renal failure
What two drugs can cuase gout
thiazide diuretics and frusemide
Spirolactatone can cause
cause gyncomastia
Iv potassium what is the maximum infusion rate?
10 mmol/hour
What are the two situations fluids are prescribed?
replacement
maintenance
Which fluid are you going to give patients?
0.9% normal saline
when would you give 5% dextrose to a patient
hypernatremic or hypoglycemia
What would you give your patient for fluid resus if the patient has ascites?
human albumin solution
In fluid resuscitation how do you know how much fluid to give?
HR, BP, urine output
500 ml bolus 0.9%
if heart failure 250 ml
If the patient is only oligouric how do you give the fluid?
give 1 litre over 2-4 hours than reassess the patient
How can you predict the fluid deficit?
reduced urine output will be decreased
500ml
reduced UO plus tachycardia 1 litre of fluid
plus shock- greater than 2 L fluid depletion
How do you prescribe maintenance fluids?
general rule: elderly 2 L
normal 3L
What do you give for daily maintenance?
1 salty 2 sweet
1 litre normal saline and 2 litres of 5% dex
With a normal potassium level what is the daily requirement for the patient K?
40mmol per day (20 mmol per bag)
How fast can you give maintenance fluids?
So to calculate this all you have to do is take the
amount of fluid you need to give and divide from 24 hours.
So if the patient is elderly then you are going to give 2L over 24 hours therefore 1 bag every 12 hours
if needing to give three litres than it is 24 divided by 3 is 8 hourly
What should you do before prescribing fluids?
check the patient’s U&Es
check that the patient is not fluid overloaded
check that the patient’s bladder is not palpable.
Most patients will be prescribed low molecular weight heparin why wouldn’t you?
bleeding or risk of bleeding
When should compression stockings not be prescribed?
in PVD, in celulitis
in skin grafting
mixed arterial and venous disease
acute stroke
If the patient is nauseated what do you prescribe?
cyclizine 50mg 8 hourly IV
What is the adverse Se of cyclizine?
fluid retention
When would you not rep scribe cyclizine?
in heart failure so metoclopramide 10 mg 8 hourly
If the patient is not nauseated what anti-emetic would you use?
PRN anti-emetic
cyclizine 50mg every 8 hours
metoclopramide 50 mg to 8 hourly
when would you aviod metclopromide?
patients with parkinson’s
young women—-> dyskinesia - acute systolic reaction
If the patient is in no pain, but the nurse asks you to prescribe paracetamol
PRN 1 g up to 6 hourly oral
mild pain chart up dose of paracetamol?
regular meds
1 g 6 hourly
PRN
codeine 30 mg up to 6 hourly
severe pain prescribe analgesia
co-codamol 30/500 2 tablets every 6 hours
PRN morphine sulphate 10 mg up to 6 hourly oral
What is the first line treatment for neuropathic pain?
amitriptyline (10 mg oral nightly)
pregabalin 75 mg 12 hourly
duloxetine 60 mg OD
Remember what does co-codamol have in it?
30/500
30 mg codeine
500 mg paracetamol
What is the max daily dose of paracetamol?
4 g
What antibiotic should not be given with methotrexate?
trimethoprim as it is also a folic acid antagonist
What antihypertensive can cause peripheral oedema?
calcium channel blocker
If you have a normal ejection fraction and peripheral oedema what do you need to consider before putting the patient on frusemide?
drug induced by calcium channel blocker
What are the causes for hyponatremia
dehydration
drips
drugs
diabetes insipidus
what are the causes of neutrophillia?
bacterial infection
tissue damage (inflammation, infarct, malignancy)
steriods
what are the causes of low neutrophils
viral infection
chemotherapy
clozapine
carbimazole (antithyroid)
what a re the causes fro thrombocytopenia?
reduced production: infection drugs (penicillamine- RA) myeloma myelodysplasia, myelofibrosis increased destruction: heparin hypersplenism DIC ITP heamolytic uremic syndrome TTP
high platelets
reactive: bleeding tissue damage (infection/inflammation/ malignancy) post-splenectomy primary: myeloproliferative disorders
If the patient is hypovolemic what are the causes of hyponatremia?
fluid loss (D&V)
addisons
diuretics
What is the patient is euvolemic what are the causes of hyponatremia?
SIADH
psychogenic polydipsia
hypothyriodism
hypervolemic but hyponatremic what is the cause?
heart failure liver failure renal failure nutritional failure thyriod failure (hypothyriodism)
What are the cause of syndrome of inappropriate ADH secretion?
small cell lung ca
infection
abcess
drugs
what are the cause of hypokalaemia?
drugs (loop or thiazides)
inadequate intake or intestinal loss
renal tubular acidosis
endocrine (sunshine’s and conns)
What are the causes of hyperkalemia?
drugs potassium sparing diuretics and ACE inh
renal failure
artefactual
diabetic ketoacidosis
What does raised urea indicate?
kidney injury or upper GI heamorrhage
What are the cause of AKI?
prerenal- dehydration, shock, sepsis, blood loss, renal artery stenosis
intrinsic- ischemia (acute tubular necrosis) nephrotoxic antibiotics gent vanc, tetracyclines contrast gout glomerulonephritis cholesterol emboli post renal lumen- stone or slough papilla wall tumour or fibrosis external - BPH, lymphadenopathy, aneurysm
If you want to determine whether or not the cause fo the renal injury is pre or post what can you do?
multiply the urea by 10 if it exceeds the creatinine than it is prerenal
If the patient has a raised creatinine but a relatively normal urea what can you do to differentiate between intrinsic renal and postrenal?
intrinsic renal
bladder and hydronephrosis not palpable
post renal may be
What do you look at in the LFTs to determine hepatocyte injury?
bilirubin
ALT
AST ALP
What do you look at in the LFTs to determine synthetic function?
albumin
coagulation profile
What can also raise the ALP
fracture liver damage cancer pagers disease pregnancy osteomalacia surgery
How do you interpret and change levothyroxine depending on the results on the tests?
TSH less than .5 decrease dose
if it is in the sweet spot of .5-5 then stay the same
if TSH is greater than 5 ask about complicance and then increase dose
what are the cause of pre hepatic LFT derangement
heamolysis
gilbert and crigler najjar
intrahepatic
fatty liver hepatitis cirrhosis malignancy metabolic wilson/ hemochromatosis heart failure
post hepatic failure
lumen: gallstone,
wall tumour
extrinsic pressure pancreatic or gastric ca
What are some drugs that can cause post hepatic obstruction?
flucloxacillin co amoxiclav
nitrofurantoin
steroids
sulphonylureas
primary hypothyriodism TFT look like?
T4 down
TSH up
secondary hypothyroid
T4 down
TSH down
primary hyperthyroidism
t4 up TSH down
secondary hyperthyroidism TFT
T4 up
TSH up
What are the causes of primary hypothyroidism
hashimotos
drug induced
causes of secondary hypothyroidism
pituitary tumour or damage
primary hyperthyroidism
graves’ disease
toxic nodular goitre
drug induced
secondary hyperparathryoidism
pit tumour
What a re the ABCDE signs of pulmonary oedema?
alveolar oedema kerley B lines cardiomegaly Diversion of blood to the upper lobes pleural effusion
When interpreting blood gases it is important to follow this routine?
check the inspired oxygen concentration
approximate the FIO2 take % oxygen minus 10 this should be at least the patients PaO2
check for respiratory failure type 1 type 2
check the acid base status
think about the causes
What is the causes of respiratory alkalosis
rapid breathing- disease or anxiety
respiratory acidosis causes
slow or shallow breathing
COPD and less commonly nueromuscular failure or restrictive wall abnormalities
What are the causes of metabolic acidosis
lactic acidosis
DKa
renal failure
ethanol methanol glycol intoxication
What are the causes of metabolic alkalosis
vomiting diuretics and conns syndromes
What are the most common drugs prescribed that have a narrow therapeutic index?
digoxin theophylline lithium phenytoin and vancomycin and gentamicin
What are the features of toxicity for digoxin?
confusion nausea and vomiting and visual halos and arrhythmias
lithium toxicity
early tremor tiredness arrhythmias seizures coma renal failure diabetes insipidus
Phenytoin toxicity
gum hyperplasia ataxia nystagmus peripheral neuropathy teratogenicity
gentamicin
ototoxicity and nephrotoxicity
vancomycin toxicity
ototoxicty and nephrotoxicity
What is paracetamol normally metabolisms by?
liver
How does paracetamol overdosing happen
limited hepatic stores of glutathione are quickly depleted
there is a toxic accumulation of NAPQI
causes acute liver damage
What is the protocol for Warfarin based on INR
less than 6 reduce dose
6-8 omit warfarin for 2 days then reduce
greater than 8 omit and give 1-5 mg oral warfarin
Target INR for most patients
target for heart valves
- 5 INR
3. 5 INR heart valves
What do you do for a major bleed if the patient is on warfarin
stop warfarin
give 5-10 mg IV vitamin K
give prothrombin complex
How does Ibuprophen contribute to renal injury?
it decreases blood flow to the kidneys by inhibiting prostaglandin (vasodilator) mimics pre renal failure causing increase in urea and creatinine and potassium
What antihypertensive drug can cause hyperkalemia?
ACE inh
What commonly prescribed antibiotic can cause warfarin levels in the blood to increase?
erythromyocin
Treatment for neutropenic sepsis
pip taz with gent
What antihypertensive drug class can cause hyponatremia?
ca channel blocker
What medication commonly given in uti should not be given in pregnancy?
trimethoprim
in an acute setting what should you give for CCF
furosemide 40 mg iv
name another loop diuretic besides frusemide
bumetanide
what is the commonly used ca channel blocker in af
diltiazem
what drug is good for neuropathic pain relief?
amitriptyline 10 mg nightly
What is the management plan for STEMI
ABC and O2 aspirin 300mg morphine 5-10 mg IV with metoclopramide 10 mg IV GTN spray primary PCI or thrombolysis Beta blocker atenolol 5 mg
Non- ST elevation MI
ABC and O2
aspirin 300 mg
morphine 5-10 mg IV with metoclopromide 10 mg IV
GTN spray
clopidogrel 300 mg and LMWH
Beta blocker atenolol 5 mg (unless LVF or asthma)
Left ventricular failure
ABCs and o2 sit the patient up morphine 5-10 mg IV with metclopromide 10 mg IV GTN spray frusemide 40-80 mg IV
What are the elements that are needed to managing a STEMI?
ABC and resus
history examination investigations confirming dx
aspirin dose 300mg oral
morphine 5-10mg IV with meclopramide 10 mg IV
GTN spray
primary PCI or thrombolysis
B blocker * atenolol 5 mg oral
What are the elements of treating a NSTEMI?
ABCS and resus dx NSTEMI asprin 300 mg oral morphine 5-10 mg IV with metclopromide 10 mg IV GTN clopidogrel 300 mg oral and LMWH enoxaparin 1 mg/kg BD SC
WHat are your management steps with acute left ventricular failure?
ABCs and resus
confirm the dx
sit the patient
morphine 5 mg IV with metoclopramide 10 mg IV
GTN spray *only if the patient’s bp is greater than 100 systolic
furosemide 40-80 mg IV
if inaquete response isosorbide dinitrate infusion.
plus or minus ?CPAP= pulmonary oedema
The patient is tachycardic what is your plan?
first determine sick or unsick? shock syncope myocardial infarction heart failure if so DC shock 3 times amiodarone 300 gm IV over 10-20 min r/p amiodarone 900 mg over 24 hours ————- stable qrs narrow regular vagal adenosine 6 mg then 12 not workin sh atrial flutter? b block if irregular control rate with block or diltiazem hf? digoxin ————— wide qrs irregular sh regular—- amiodarone 300 mg iv
Anaphylaxis pathway
ABCs and resus confirm and focused hx and exam remove cause ASAP iv access bloods fbc u&e mast cell tryptase immed after, 1 harm 6-24 h later adrenaline 500 micrograms of 1:1000 IM chlorphenamine 10 mg slow iv hydrocortisone 200 mg IV asthma treat wheeze 5 mg salbutamol
Asthma pathway
ABC 100% O2 salbutamol 5 mg NEB Hydrocortisone 100 mg IV (if severe) or Prednisalone 40-50 mg if moderate Ipratropium bromide 500 micrograms NEB theophylline (life threatening)
Treatment for pneumonia
ABCs high flow O2 antibiotics according to the CURB 65 score and if onset was in or out of hospital paracetamol for pain relief if low BP or tachycardic fluid resus
treatment for pulmonary embolism
ABCs sit up unless low BP high flow O2 Morphine 5-10 mg IV metoclopromide 10 mg IV LMWH tinzaparin 175 units per kg SC daily if low BP IV gelofusine noradrenaline thrombolysis
What is the management for a GI bleed?
ABCS cannula catheter (fluid monitoring) crystalloid cross match 6 units correct clotting abnormalities endoscopy stop culprit drugs like NSAIDS aspirin warfarin and heparin call the surgeons if severe
What are you looking for the in the clotting screen if a patient is bleeding? When would you replace?
platelets if less than 50 x 10^9
PT/APPT greater than 1.5 times the upper limit of normal
What is the treatment of bacterial meningitis?
ABCs
high flow O2
IV fluid
dexamethasone IV unless sevely immunocompromised
LP (plus or minus CT head)
2 g cefotaxime IV plus Vanc (using GAPP)
consider ITU
What is the treatment pathway for status epilepticus?
ABCs
put patient into the left lateral decubitus position with O2
check the glucose
take blood s and establish IV access
5-20 minutes:
lorazepam 4 mg IV over 2 min repeat at 10 minutes if no effect
inform the anaesthesist
Phenytoin infusion 20 mg/ kg IV at less than 50 mg per minute
intubation with propofol
Management of stroke
ABCs
blood glucose and CT head to exclude heamorrhage
if aged less than 80 and onset is less than 4.5 hrs thrombolysis
Aspirin 300 mg Oral for 14 days
transfer to the stroke unit
What is the treatment for hyperglycemia
ABCs IV fluids 1 L stat then 1 L over 1 hours then 2 hours then 4 hours then 8 hours sliding scale insulin hunt for trigger (infection, MI, missed insulin) monitor BM K and pH
What is he management of AKI
ABCs cannula and catheter fluid monitoring IV fluids and 500 ml stat then 1 L hourly hunt for cause and complications monitor U&Es and fluid compliance
what is the mgx for acute poisoning?
Abcs
cannula and catheter strict fluid balance
supportive measures
correct E- disturbance
reduce absorption (less than 1 hour- gastric lavage or charcoal)
increase elimination
psychiatric management
What medication do you give for paracetamol overdose?
N acetyl cysteine (paracetamol level at 4 hours is over the line on treatment)
What do you take for opiate poisoning?
Naloxone
What so you take for benzo overdose?
Flumazenil
Treatment for Heart failure
treat the underlying cause smoking cessation cardiac rehab B blockers and ACE inh EF less than 35% can add aldosterone anatongonist
What is the treatment for Parkinson Disease
levodopa and carbidopa
life style effecting
non lifestyle affecting
dopamine agonists (ropinirole)
monoamine oxidase inhibitors (selegiline)
On and off effect may need to add MAO B inh COMT inh, and dopamine agonists
Epilepsy management
generalised- Na valproate absence- Na valproate myoclonic - Na val tonic NA val focal- Carbamazepine or lamotrigine
What are the SE of lamotrigine
rash, rarely steven johnson syndrome
What is the SE of carbamazepine
rash, dysarthria, ataxia, nystagmus, hyponatremia
What are the SE of phenytoin?
ataxia, P neuropathy, gum hyperplasia hepatotoxicty
Na valproate
tremor teratogencity weight gain
When do you not give a laxative?
When there are evidence of obstruction
absolute constipation no flatus
abdominal distension
What is one of the side effects of Carbimazole?
neutropenia
What are the SE of carbamazepine?
This is a treatment for neuropathic pain. can cause neutropenia
What is Donepezil licensed for?
mild to moderate Alzheimer’s disease
What is me mantiene licensed for?
severe alzheimer disease
What are two drugs not to be prescribed in Parkinson’s
metoclopromide and Haloperidol because they are dopamine agonists
Should you prescribe an ACE inhibitor in pregnancy?
No it is tetratogenic especially in the first trimester
switc to labetalol
What are some common SE of tamoxifen?
increased risk of endometrial ca
messes with Warfarin leading to increased INR
hot flushes
increased risk of VTE
What time of the day should Gliclazide should be taken?
morning with breakfast
What medications should never be used with Methotrexate?
folate antagonists such as trimethoprim (which is also the reason this drug should not be used in pregnancy)
and co-trimoxazole
how do you look after patients on Warfarin?
initially weekly blood tests and then once stable blood tests monthly
What are the side effects of ACE inh
hyperkalemia
cough
monitor for CKI every 1-2 weeks do U&Es
What SE of SSRIs do you need to warn the patient of?
dry mouth
suicidal ideation
photosentivity
symptoms of serotonin syndrome agaitation, temperature, hallucinations
What is the weird thing you have to tell patients on bisphosphonates?
Tablet needs to be swallowed with a full glass of water and remain upright for 30 minutes afterwards.
Bisphosphonates are a once weekly preparation.
What creatinine clearance is deemed unsafe for patients who are going to be put on Gent?
less than 20 ml/min
