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PSA > Planning and management > Flashcards

Planning and management Flashcards

1
Q

Tx of STEMI (7)

A

1) ABC and O2 non-rebreather 15L
2) Aspirin 300 mg PO
3) Morphine 5-10 mg IV with metoclopramide 10 mg IV
4) GTN spray/tablet
5) Primary PCI (preferred) or thrombolysis
6) Beta-blocker e.g. atenolol 5 mg PO, UNLESS asthma/LVF
7) Transfer CCU

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2
Q

Tx of NSTEMI (7)

A

1) ABC and O2 non-rebreather 15L
2) Aspirin 300 mg PO
3) Morphine 5-10 mg IV with metoclopramide 10 mg IV
4) GTN spray/tablet
5) Clopidogrel 300 mg PO and LMWH (e.g. enoxaparin 1mg/kg SC)
6) Beta-blocker e.g. atenolol 5 mg PO, UNLESS asthma/LVF
7) Transfer CCU

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3
Q

Tx of LVF (left ventricular failure) (7)

A

1) ABC and O2 non-rebreather 15L
2) Sit patient up
3) Morphine 5-10 mg IV with metoclopramide 10 mg IV
4) GTN spray/tablet
5) Furosemide 40-80 mg IV
6) If inadequate response, Isosorbide dinitrate infusion +/- CPAP
7) Transfer CCU

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4
Q

CVS emergencies

Tx for asymptomatic irregular narrow QRS

A

Probable AF

  • B-blocker or diltiazem
  • If HF evidence, consider digoxin or amiodarone
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5
Q

CVS emergencies

Tx for asymptomatic regular narrow QRS

A
  • Vagal manouvres
  • Adenosine 6 mg rapid bolus
  • If unsuccessful -> 12 mg
  • Continuously monitor ecg
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6
Q

CVS emergencies

Tx for asymptomatic irregular broad QRS

A
  • Seek expert help!
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7
Q

CVS emergencies

Tx for asymptomatic regular broad QRS

A
  • Amiodarone 300 mg IV over 20-60 mins

- Then 900 mg over 24 hrs

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8
Q

CVS emergencies

Tx for symptomatic arrhythmia

A

Symptomatic = shock, syncope, MI or HF

  • DC shock (up to 3 attempts)
  • Amiodarone 300 mg IV over 10-20 mins and repeat
  • Followed by 900 mg over 24 hrs
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9
Q

Anaphylaxis tx (7)

A

1) ABC and 15L O2 non-rebreather
2) Remove cause ASAP, e.g. blood transfusion
3) Adrenaline 500 mcg of 1:1000 IM
4) Chlorphenamine 10 mg IV
5) Hydrocortisone 200 mg IV
6) Asthma Tx if wheeze
7) Amend drug chart allergies box

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10
Q

Acute exacerbation of asthma Tx

A

1) ABC
2) 100% O2 non-breather
3) Salbutamol 5 mg nebs
4) Hydrocortisone 100 mg IV (severe) or Pred 40-50 mg PO (moderate)
5) Ipratropium 500 micrograms NEB
6) Theophylline (if life threatening)

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11
Q

Acute exacerbation of COPD

A

1) ABC
2) O2 non-breather (USE WITH CARE IN COPD - use 28% and take ABG after 30 mins, unless peri-arrest, then high flow)
3) Salbutamol 5 mg nebs
4) Hydrocortisone 100 mg IV (severe) or Pred 40-50 mg PO (moderate)
5) Ipratropium 500 micrograms NEB
6) Theophylline (if life threatening)

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12
Q

Tx of secondary pneumothorax (pt has lung disease)

A
  • Always need Tx
  • If > 2cm or SOB or >50yrs: chest drain
  • Otherwise aspirate
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13
Q

Tx of tension pneumothorax

A

(Tracheal deviation and shock)

- Emergency aspiration and chest drain quickly

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14
Q

Tx of primary pneumothorax

A
  • If <2cm and not SOB then discharge w follow up in 4 weeks

- If > 2cm or SOB then aspiration, if unsuccessful aspirate again, then chest drain if still unsuccessful

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15
Q

Pneumonia Tx

A

1) ABC
2) High-flow oxygen
3) Abx (amox/co-amox)
4) Paracetamol
5) If low BP/raised HR give IV fluids

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16
Q

CURB65 score

A
  • Confusion (AMT<8/10)
  • Urea > 7.5 mmol/:
  • Respiratory rate > 30
  • BP systolic > 90mmHg
  • Age > 65 yrs

1: home treatment
2+: hospital treatment (PO/IV Abx)
3+: consider ITU

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17
Q

PE Tx (5)

A

1) ABC
2) High flow O2
3) Morphine 5-10 mg IV and metoclopramide 10 mg IV
4) LMWH
5) If low BP give IV fluid bolus -> contact ITI -> consider thrombolysis

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18
Q

Define moderate acute asthma

A
  • Increasing symptoms
  • Peak flow >50-70% best or predicted
  • No features of acute severe asthma
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19
Q

Define severe acute asthma

A
  • Peak flow 33-50% best or predicted
  • RR > 25/min
  • HR > 110.min
  • Inability to complete sentences in one breath
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20
Q

Define life-threatening acute asthma

A
  • Peak flow < 33% best or predicted
  • SpO2 <92%
  • PaO2 < 8kPa
  • PaCO2 normal (4.6-6)
  • Silent chest
  • Cyanosis
  • Poor resp effort
  • Arrhythmia
  • Exhaustion
  • Altered conscious level
  • Hypotension
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21
Q

Near fatal acute asthma

A
  • Raised PaCO2 and/or need for mechanical ventilation with raised inflation pressures
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22
Q

Where should mod/sev/life-threatening asthma be treated?

A
  • Mod: at home or primary care then response assessed

- Sev/life-threatening: immediate hospital referral

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23
Q

Tx of acute asthma

A
  1. O2 to maintain 94-98%, don’t delay if sats unavailable
  2. High-dose inhaled short-acting beta2-agonist (Salbutamol). Mild-mod can use inhaler metered dose, sever can use nebs.
  3. Oral Pred or IV/IM Hydrocortisone
  4. Ipratropium bromide - combined with neb
  5. IV aminophylline or Mg sulphate IV (peak flow <50%)
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24
Q

First-line management of dyspepsia (8)

A
  • Healthy eating
  • Weight loss
  • Smaller meals
  • Eat evening meal 3-4 hrs before bed
  • Raise head of bed
  • Smoking cessation
  • Reduced alcohol consumption
  • Assess for stress, anxiety, depression
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25
Q

When might you do endoscopy? (3)

A
  • Dysphagia
  • Significant acute GI bleeding
  • > 55 yrs with unexplained weight loss and symptoms of upper abdo pain, reflux or dyspepsia
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26
Q

Drugs that cause dyspepsia (12)

A
  • Alpha-blockers
  • Antimuscarinics
  • Aspirin
  • Benzodiazepines
  • Beta-blockers
  • Bisphosphonates
  • CCBs
  • Corticosteroids
  • Nitrates
  • NSAIDs
  • Theophyllines
  • Tricylclic antidepressants
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27
Q

Short term Tx of dyspepsia

A
  • Antacids

- Alginates

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28
Q

Long-term Tx of dyspepsia

A
  • Test for H.pylroi is at risk
  • PPI for 4 weeks
  • If not, a histamine2-receptor antagonist (ranitidine, cimetadine)
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29
Q

H.pylori infection Tx

No penicillin allergy

A

ALL ORAL and 7 days

  • x1 Proton pump
  • Amoxicillin
  • Clarithromycin OR metronidazole

2nd line
Same as above but whichever Abx was not used

3rd line
PPI + Amoxicillin + Tetracycline

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30
Q

H.pylori infection Tx

Penicillin allergy

A

ALL ORAL and 7 days

PPI + Clarithromycin + Metronidazole

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31
Q

How and when do you test for H.pylori?

A
  • Urea (13C) breath test

- Perform against at least 4 weeks (ideally 8 weeks) after treatment

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32
Q

Bulk-forming laxative
MoA
Examples

A

For small hard stool when fiber can not be increase in diet

  • Bran
  • Ispaghula husk
  • Methylcellulose
  • Sterculia
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33
Q

Stimulant laxative
MoA
Examples

A

Increase intestinal motility, can cause cramp
Should be avoided in obstruction!!

  • Bisacodyl
  • Sodium picosulfate
  • Senna
  • Co-danthramer

Docusate sodium = stimulant and faecal softener

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34
Q

Faecal softeneners
MoA
Examples

A

Decrease surface tension and increasing penetration of fluid into faecal mass

  • Docusate sodium
  • Glycerol
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35
Q

Osmotic laxatives
MoA
Examples

A

Increase amount of water in large bowels, either by drawing it in or retaining it

  • Lactulose
  • Macrogols
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36
Q

Tx of short-duration constipation

A
  1. Bulk-forming laxative (ispaghula husk) and fluid intake
  2. Osmotic laxative if remain hard
  3. If stools are soft but inadequate emptying -> stimulant laxative
37
Q

Tx of opioid-induced constipation

A
  1. Osmotic laxative (docusate sodium)
    AND stimulant laxative (senna)
  2. AVOID bulk-forming laxatives
  3. If not responding, consider Naloxegol
38
Q

Tx of faecal impaction

A
  • Hard stools: macrogol PO (macrogol 3350 w/KCl, NaCO3, NaCl)
  • Soft stools: oral stimulant laxative
39
Q

Chronic constipation

A
  1. Bulk-forming laxative + good hydration
  2. Osmotic - Macrogol or lactulose if remain hard
  3. Add stimulant if still inadequate
40
Q

When should laxatives be stopped?

A

When regular bowel movements occur without difficult

Reduce them slowly. If on two, reduce and stop one at a time (stimulant first)

41
Q

Tx of constipation in pregnancy

A
  1. Bulk-forming
  2. Osmotic laxative (lactulose)
  3. Bisacodyl or senna if need a stimulant

NB; SENNA SHOULD BE AVOIDED NEAR TERM OR IN HX OF UNSTABLE PREGNANCY

42
Q

Tx of constipation in breastfeeding

A
  1. Bulk-forming
  2. Osmotic laxative
  3. Stimulant (bisacodyll or senna)
43
Q

Tx of constipation in children

A
  1. Osmotic laxative (macrogol)
  2. Add stimulant or change to stimulantt
  3. Lactulose or docusate sodium
44
Q

Reviewing patients on antidepressants

A
  • Review every 1-2 weeks at the start of Tx
  • Tx should be continued for 4 weeks (6 weeks in elderly) before considering a switch
  • If partial response, continue for another 2-4 weeks
45
Q

Antidepressants and hyponatremia

A
  • Worse in elderly
  • SSRIs mostly
  • Drowsiness, confusion, or convulsions
46
Q

Antidepressants and suicidal behaviour

A
  • Children, young adults, and Hx of suicidal behavior are particularly at risk
  • Monitor closely at beginning of Tx and after dose change
47
Q

Serotonin syndrome

Features

A

Features:

  • Neuromuscular hyperactivity (tremor, hyperreflexia, clonus, myoclonus, rigidity)
  • Autonomic dysfunction (tachycardia, BP changes, hyperthermia, diaphoresis, shivering, diarrhoea)
  • Altered mental state (agitation, confusion, mania)
48
Q

Serotonin syndrome

Drug causes

A
  • Antidepressants: MAOIs, SNRIs, SSRIs, TCAs, Lithium
  • Analgesics: Tramadol, Pethidine, Fentanyl
  • Antiemetics: Ondanserton, Metoclopramide
  • Recreational: Cocaine, MDMA, amfetamine, LSD
  • Others: St Johns Wort
49
Q

First-line antidepressants

A
  • SSRIs - Sertraline
50
Q

Second-line antidepressants

A
  • Switch to another SSRI
  • Or Mirtazapine
  • Tricyclics
  • Venlafaxine (for more serious forms)
  • MAOIs only to be prescribed by specialists
51
Q

Third-line antidepressants

A

Only be specialists:

  • Augmenting agent: lithium, olanzapine, quetiapine etc
  • ECT
52
Q

Tx of anxiety

A
  • Short term: benzodiazepines, buspirone
  • Long term: SSRIs (escitalopram, citalopram, paroxetine)
  • Duloxetine and venlafaxine
  • If not tolerating any of above: consider pregabalin
53
Q

MAOIS cautions

A
  • Do not start another antidepressants for 2 weeks after MAOI
  • Do not start MAOI within 2 weeks of stopping previous MAOI, 7-14 days after stopping tricylic, 1 week after stopping SSRI
54
Q

Urgency incontinence

Cause
Features

A

Due to involuntary contractions of the detrusor muscle

  • Involuntary leakage
  • Urgency
  • Frequency
  • Nocturia
55
Q

Urgency incontinence management

A
  • Bladder training for at least 6 weeks
  • Anticholinergic, e.g. oxybutynin, tolterodine, darifenacin
  • Do not use oxybutynin in frail older women
56
Q

Stress incontinence

Cause
Features

A

Due to loss of pelvic floor strength and/or damage to the urethral sphincter

  • Involuntary leakage
  • Exertion
  • Coughing/sneezing
57
Q

Stress incontinence management

A
  • Trial pelvic floor muscle training for 3 months (at least 8 contractions, 3 times a day)
  • Duloxetine
58
Q

UTI Tx in pregnancy

A
  • AVOID Trimethoprim until term
  • AVOID nitrofurantoin at term
  • 2nd line: Amoxicillin
59
Q

Pyelonephritis Tx

A
  • First-line: cefalexin or ciprofloxacin

- If need IV: ceftriaxone, cefuroxime, ciprofloxacin

60
Q

Soluble insulin

SC times of onset, peak action and duration
IV time of onset, duration, uses

A

SC:

  • Inject 15-30 mins before meals
  • Onset of 30-60 minutes
  • Peak action 1-4 hrs
  • Duration of 9 hrs

IV:

  • Instantaneous onset
  • Half-life of a few minutes
  • Therefore may be used in DKA or peri-operatively
61
Q

Rapid-acting

A

Examples: insulin aspart, insulin glulisine, insulin lispro

  • Onset of 15 minutes
  • Duration 2-5 hrs
  • Administered immediately before meals
  • Advantage over soluble insulin due to improved glucose control, reduction in HbA1c, reduction in hypoglycaemia
  • Do not use during/after meals, (poorer glycaemic control, high post-prandial-glucose conc and subsequent hypoglycaemia
62
Q

Insulin in pregnancy

A
  • Generally increased in 2nd and 3rd trimester
63
Q

Hyperkalaemia Tx

A

PROTECT THE HEART

- 10 ml Calcium Gluconate 10%, slow IV over 3-5 mins, titrate and adjust to ECG improvement
- If taking digoxin → mix with 100 ml of glucose 5% and administer slowly over 20 mins

REDUCE SERUM-POTASSIUM CONC

- Withdraw K supplements or drugs that could cause hyperkalaemia
- IV injection of 5-10 units soluble insulin (Actrapid) with 50 ml glucose 50%, given over 5-15 mins (drives potassium into cells)
- Potentially salbutamol nebs - use in caution if ischaemia heart disease or history of arrhythmias

RID THE BODY OF EXCESS POTASSIUM

- Oral calcium Resonium: ion-exchange resin which binds potassium and promotes its elimination from body. 15 mg TDS-QDS short-term only.
- Stop when 5 mmol/litre or below as continues to fall post-treatment termination
- Co-prescribe laxatives as can cause constipation

If potassium concentrations remain high or ECG changes persist despite treatment → may require dialysis

64
Q

Intermediate-acting insulin

A
  • Isophane insulin (insulin with protamine)
  • Mimic effect of endogenous basal insulin
  • SC: onset 1-2 hrs, max 3-12 hrs and duration of 11-24 hrs
  • Can be given one or more daily injections, or mixed in syringe with short-acting (biphasic insulins)
65
Q

Long-acting insulin

A

EXAMPLES: Insulin detemir, insulin glargine, insulin degludec

  • Mimic endogenous basal insulin secretion
  • Duration may last up to 36 hrs
  • Steady-state level after 2-4 days to produce constant insulin cover
  • determir and glargine are OD, degludec can be BD
66
Q

Type 1 Diabetes

Tx

A
  • First-line = basal-bolus regimens (BD DETERMIR, OD if nocturnal hypoglycaemia concerns, OD glargine if not tolerating)
  • Bolus first-line = rapid-acting insulin analogue
67
Q

Type 2 Diabetes

Tx

A
  • Lifestyle changes
    First-line
  • Metformin (weight loss, CVS benefits, does not cause hypoglycemia, GI SEs)
    2nd lines to add:
  • Sulfonylureas (weight gain, hypoglycemia)
  • Pioglitazone (not in HF)
  • Dipeptidyl peptidase-4 inhibitor (linagliptin, sitagliptin)
    3rd line = triple therapy or insulin
68
Q

Type 2 diabetes

HbA1c targets

A
  • 48 mmol/mol (6.5%) if lifestyle/one drug not causing hypoglycaemia
  • 53 mmol/mol (7%) if one drug causing hypoglycemia/two drugs
69
Q

Which sulfonylureas should be given in elderly/renal impairment?

A
  • Shorter-acting

- E.g. gliclazide, tolbutamide

70
Q

Type 2 diabetes

Insulin and other antidiabetics

A
  • Continue metformin but stop other drugs
71
Q

Lactic acidosis symptoms

A
  • Abdo/stomach discomfort
  • Diarrhoea
  • Fats, shallow breathing
  • Sleepiness
  • Muscle cramps and pains
72
Q

Chronic COPD Tx

A
  • SABA + SAMA
  • SABA + LABA + ICS/LAMA
  • SABA + LABA + whichever not used above
73
Q

COPD exacerbation Tx

A
  • O2 (use ABGs to determine target)
  • Salbutamol nebs
  • Pred short course
  • Aminophylline if no response to salbutamol nebs
  • NIV if required

If need Abx:
- FL: Amoxicillin, clarithromycin or doxycycline

74
Q

SABA examples

A
  • Salbutamol

- Terbutaline sulfate

75
Q

SAMA examples

A
  • Ipratropium
76
Q

LABA examples

A
  • Salmeterol

- Formoterol

77
Q

LAMA examples

A
  • Tiotropium

- Glycopyrronium

78
Q

ICS examples

A
  • Beclometasone
  • Budesonide
  • Fluticasone
  • Mometasone
79
Q

Tx of IBD

A

5-aminosalicylic acid

  • Sulfasalazine
  • Mesalazine
  • Methotrexate
  • Cytokine modulators: infliximab, adalimumab
80
Q

SEs of 5ASA’s

A
  • Blood disorders

- Lupus-like syndrome

81
Q

Crohn’s Tx

A
  • Corticosteroid (pred/methylpred/hydrocortisone)
  • If not tolerated, Budesonide
  • 5ASA’s less effective but fewer SEs
  • Budesonide and 5ASAs not ok for severe presentations
  • Add on Tx if 2+ inflammatory exacerbations in 12-months: AZATHIOPRINE can be added to corticosteroid or budesonide in acute flares to induce remission, or as monotherapy to maintain remission
  • Methotrexate only used to maintain remission if required it to induce remission
82
Q

Which breathing aids are used for T1 and T2 RF?

A
  • T1: CPAP

- T2: BiPAP

83
Q

Antiemetic in bowel obstruction?

A
  • Best solution is large bore NG tube
  • Haloperidol is good
  • PO are not effective as lack of absorption
84
Q

CURB-65 score

A 
C: Confusion
U: Urea > 7.5 mmol/L
R: RR > 30/min
B: BP < 90 mmHg systolic
65: > 65 yrs
85
Q

Bacterial meningitis TX

A
  • Benzylpenicillin in community
  • Consider adjunct dex once in hospital
  • Cefotaxime in penicillin allergy
    In hospital: cefotaxime or ceftriaxone (+ amoxicillin/ampicillin if > 50 yrs)
  • Consider adding vancomycin
86
Q

How to calculate osmolality

A

x2 Na + x2 K+ + urea + glucose

87
Q

Osmolality levels in hyperosmolar hyperglycaemic state

A

> 340 mmol/L

88
Q

CHA2DS2CASc score

A 
CHA2DS2VASc score
C: Congestive HF
H: HTN
A: Age > 75 (2 points)
D: DM 
S: Stroke or TIA (2 points(
V: Vascular disease (PAD/IHD)
A: Age 65-74
S: Sex (female)

0: may not require anticoagulation
1: consider anticoagulation in MEN using apixaban, dabigatran, etexilate, rivaroxaban, warfarin. Consider bleeding risk.
2: consider anticoagulation in MEN AND WOMEN as described above. Consider bleeding risk.

89
Q

HAS-BLED Score

A 
HASBLED
H: HTN
A: Abnormal renal function (Cr > 200, transplant or dialysis) or abnormal liver function (cirrhosis, bilirubin >2x normal or AST/ALT/ALP > 3x normal)
S: Stroke
B: Bleeding tendency or predisposition
L: Labile INR
E: Elderly (> 65 yrs)
D: Drugs (aspirin or NSAIDs or alcohol)

0: Low bleeding risk, anticoagulation should be strongly considered.
1-2: Low-mod risk of bleeding, Anticoagulation should be considered.
>3: High risk of major bleeding. Alternative to anticoagulation should be considered.

PSA (8 decks)

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