Planning and management Flashcards
Tx of STEMI (7)
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
Tx of NSTEMI (7)
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
Tx of LVF (left ventricular failure) (7)
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
CVS emergencies
Tx for asymptomatic irregular narrow QRS
Probable AF
- B-blocker or diltiazem
- If HF evidence, consider digoxin or amiodarone
CVS emergencies
Tx for asymptomatic regular narrow QRS
- Vagal manouvres
- Adenosine 6 mg rapid bolus
- If unsuccessful -> 12 mg
- Continuously monitor ecg
CVS emergencies
Tx for asymptomatic irregular broad QRS
- Seek expert help!
CVS emergencies
Tx for asymptomatic regular broad QRS
- Amiodarone 300 mg IV over 20-60 mins
- Then 900 mg over 24 hrs
CVS emergencies
Tx for symptomatic arrhythmia
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
Anaphylaxis tx (7)
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
Acute exacerbation of asthma Tx
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)
Acute exacerbation of COPD
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)
Tx of secondary pneumothorax (pt has lung disease)
- Always need Tx
- If > 2cm or SOB or >50yrs: chest drain
- Otherwise aspirate
Tx of tension pneumothorax
(Tracheal deviation and shock)
- Emergency aspiration and chest drain quickly
Tx of primary pneumothorax
- 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
Pneumonia Tx
1) ABC
2) High-flow oxygen
3) Abx (amox/co-amox)
4) Paracetamol
5) If low BP/raised HR give IV fluids
CURB65 score
- 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
PE Tx (5)
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
Define moderate acute asthma
- Increasing symptoms
- Peak flow >50-70% best or predicted
- No features of acute severe asthma
Define severe acute asthma
- Peak flow 33-50% best or predicted
- RR > 25/min
- HR > 110.min
- Inability to complete sentences in one breath
Define life-threatening acute asthma
- 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
Near fatal acute asthma
- Raised PaCO2 and/or need for mechanical ventilation with raised inflation pressures
Where should mod/sev/life-threatening asthma be treated?
- Mod: at home or primary care then response assessed
- Sev/life-threatening: immediate hospital referral
Tx of acute asthma
- O2 to maintain 94-98%, don’t delay if sats unavailable
- High-dose inhaled short-acting beta2-agonist (Salbutamol). Mild-mod can use inhaler metered dose, sever can use nebs.
- Oral Pred or IV/IM Hydrocortisone
- Ipratropium bromide - combined with neb
- IV aminophylline or Mg sulphate IV (peak flow <50%)
First-line management of dyspepsia (8)
- 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
When might you do endoscopy? (3)
- Dysphagia
- Significant acute GI bleeding
- > 55 yrs with unexplained weight loss and symptoms of upper abdo pain, reflux or dyspepsia
Drugs that cause dyspepsia (12)
- Alpha-blockers
- Antimuscarinics
- Aspirin
- Benzodiazepines
- Beta-blockers
- Bisphosphonates
- CCBs
- Corticosteroids
- Nitrates
- NSAIDs
- Theophyllines
- Tricylclic antidepressants
Short term Tx of dyspepsia
- Antacids
- Alginates
Long-term Tx of dyspepsia
- Test for H.pylroi is at risk
- PPI for 4 weeks
- If not, a histamine2-receptor antagonist (ranitidine, cimetadine)
H.pylori infection Tx
No penicillin allergy
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
H.pylori infection Tx
Penicillin allergy
ALL ORAL and 7 days
PPI + Clarithromycin + Metronidazole
How and when do you test for H.pylori?
- Urea (13C) breath test
- Perform against at least 4 weeks (ideally 8 weeks) after treatment
Bulk-forming laxative
MoA
Examples
For small hard stool when fiber can not be increase in diet
- Bran
- Ispaghula husk
- Methylcellulose
- Sterculia
Stimulant laxative
MoA
Examples
Increase intestinal motility, can cause cramp
Should be avoided in obstruction!!
- Bisacodyl
- Sodium picosulfate
- Senna
- Co-danthramer
Docusate sodium = stimulant and faecal softener
Faecal softeneners
MoA
Examples
Decrease surface tension and increasing penetration of fluid into faecal mass
- Docusate sodium
- Glycerol
Osmotic laxatives
MoA
Examples
Increase amount of water in large bowels, either by drawing it in or retaining it
- Lactulose
- Macrogols
Tx of short-duration constipation
- Bulk-forming laxative (ispaghula husk) and fluid intake
- Osmotic laxative if remain hard
- If stools are soft but inadequate emptying -> stimulant laxative
Tx of opioid-induced constipation
- Osmotic laxative (docusate sodium)
AND stimulant laxative (senna) - AVOID bulk-forming laxatives
- If not responding, consider Naloxegol
Tx of faecal impaction
- Hard stools: macrogol PO (macrogol 3350 w/KCl, NaCO3, NaCl)
- Soft stools: oral stimulant laxative
Chronic constipation
- Bulk-forming laxative + good hydration
- Osmotic - Macrogol or lactulose if remain hard
- Add stimulant if still inadequate
When should laxatives be stopped?
When regular bowel movements occur without difficult
Reduce them slowly. If on two, reduce and stop one at a time (stimulant first)
Tx of constipation in pregnancy
- Bulk-forming
- Osmotic laxative (lactulose)
- Bisacodyl or senna if need a stimulant
NB; SENNA SHOULD BE AVOIDED NEAR TERM OR IN HX OF UNSTABLE PREGNANCY
Tx of constipation in breastfeeding
- Bulk-forming
- Osmotic laxative
- Stimulant (bisacodyll or senna)
Tx of constipation in children
- Osmotic laxative (macrogol)
- Add stimulant or change to stimulantt
- Lactulose or docusate sodium
Reviewing patients on antidepressants
- 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
Antidepressants and hyponatremia
- Worse in elderly
- SSRIs mostly
- Drowsiness, confusion, or convulsions
Antidepressants and suicidal behaviour
- Children, young adults, and Hx of suicidal behavior are particularly at risk
- Monitor closely at beginning of Tx and after dose change
Serotonin syndrome
Features
Features:
- Neuromuscular hyperactivity (tremor, hyperreflexia, clonus, myoclonus, rigidity)
- Autonomic dysfunction (tachycardia, BP changes, hyperthermia, diaphoresis, shivering, diarrhoea)
- Altered mental state (agitation, confusion, mania)
Serotonin syndrome
Drug causes
- Antidepressants: MAOIs, SNRIs, SSRIs, TCAs, Lithium
- Analgesics: Tramadol, Pethidine, Fentanyl
- Antiemetics: Ondanserton, Metoclopramide
- Recreational: Cocaine, MDMA, amfetamine, LSD
- Others: St Johns Wort
First-line antidepressants
- SSRIs - Sertraline
Second-line antidepressants
- Switch to another SSRI
- Or Mirtazapine
- Tricyclics
- Venlafaxine (for more serious forms)
- MAOIs only to be prescribed by specialists
Third-line antidepressants
Only be specialists:
- Augmenting agent: lithium, olanzapine, quetiapine etc
- ECT
Tx of anxiety
- Short term: benzodiazepines, buspirone
- Long term: SSRIs (escitalopram, citalopram, paroxetine)
- Duloxetine and venlafaxine
- If not tolerating any of above: consider pregabalin
MAOIS cautions
- 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
Urgency incontinence
Cause
Features
Due to involuntary contractions of the detrusor muscle
- Involuntary leakage
- Urgency
- Frequency
- Nocturia
Urgency incontinence management
- Bladder training for at least 6 weeks
- Anticholinergic, e.g. oxybutynin, tolterodine, darifenacin
- Do not use oxybutynin in frail older women
Stress incontinence
Cause
Features
Due to loss of pelvic floor strength and/or damage to the urethral sphincter
- Involuntary leakage
- Exertion
- Coughing/sneezing
Stress incontinence management
- Trial pelvic floor muscle training for 3 months (at least 8 contractions, 3 times a day)
- Duloxetine
UTI Tx in pregnancy
- AVOID Trimethoprim until term
- AVOID nitrofurantoin at term
- 2nd line: Amoxicillin
Pyelonephritis Tx
- First-line: cefalexin or ciprofloxacin
- If need IV: ceftriaxone, cefuroxime, ciprofloxacin
Soluble insulin
SC times of onset, peak action and duration
IV time of onset, duration, uses
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
Rapid-acting
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
Insulin in pregnancy
- Generally increased in 2nd and 3rd trimester
Hyperkalaemia Tx
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
Intermediate-acting insulin
- 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)
Long-acting insulin
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
Type 1 Diabetes
Tx
- First-line = basal-bolus regimens (BD DETERMIR, OD if nocturnal hypoglycaemia concerns, OD glargine if not tolerating)
- Bolus first-line = rapid-acting insulin analogue
Type 2 Diabetes
Tx
- 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
Type 2 diabetes
HbA1c targets
- 48 mmol/mol (6.5%) if lifestyle/one drug not causing hypoglycaemia
- 53 mmol/mol (7%) if one drug causing hypoglycemia/two drugs
Which sulfonylureas should be given in elderly/renal impairment?
- Shorter-acting
- E.g. gliclazide, tolbutamide
Type 2 diabetes
Insulin and other antidiabetics
- Continue metformin but stop other drugs
Lactic acidosis symptoms
- Abdo/stomach discomfort
- Diarrhoea
- Fats, shallow breathing
- Sleepiness
- Muscle cramps and pains
Chronic COPD Tx
- SABA + SAMA
- SABA + LABA + ICS/LAMA
- SABA + LABA + whichever not used above
COPD exacerbation Tx
- 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
SABA examples
- Salbutamol
- Terbutaline sulfate
SAMA examples
- Ipratropium
LABA examples
- Salmeterol
- Formoterol
LAMA examples
- Tiotropium
- Glycopyrronium
ICS examples
- Beclometasone
- Budesonide
- Fluticasone
- Mometasone
Tx of IBD
5-aminosalicylic acid
- Sulfasalazine
- Mesalazine
- Methotrexate
- Cytokine modulators: infliximab, adalimumab
SEs of 5ASA’s
- Blood disorders
- Lupus-like syndrome
Crohn’s Tx
- 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
Which breathing aids are used for T1 and T2 RF?
- T1: CPAP
- T2: BiPAP
Antiemetic in bowel obstruction?
- Best solution is large bore NG tube
- Haloperidol is good
- PO are not effective as lack of absorption
CURB-65 score
C: Confusion U: Urea > 7.5 mmol/L R: RR > 30/min B: BP < 90 mmHg systolic 65: > 65 yrs
Bacterial meningitis TX
- 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
How to calculate osmolality
x2 Na + x2 K+ + urea + glucose
Osmolality levels in hyperosmolar hyperglycaemic state
> 340 mmol/L
CHA2DS2CASc score
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.
HAS-BLED Score
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.
