Planning Management Flashcards
Best pain killer for nerve pain
Tricyclic antidepressants - amitriptyline
10mg nightly (can go up to 25mg)
treatment algorithm for STEMI
ABC and O2 via 15l non-rebreathe mask (unless COPD) -> Hx, o/e, Inv, Diagnosed STEMI -> Aspirin 300mg oral -> Morphine 5-10mg IV with metoclopramide 10mg IV -> GTN spray/tablet -> Primary PCI (preferred) or thrombolysis -> B-blocker (e.g. atenolol 5mg oral) unless asthma/LVF -> transfer to CCU
Treatment algorithm for NSTEMI
ABC and O2 via 15l non-rebreathe mask (unless COPD) -> Hx, o/e, Inv, Diagnosed NSTEMI -> Aspirin 300mg oral -> Morphine 5-10mg IV with metoclopramide 10mg IV -> GTN spray/tablet -> clopidogrel 300mg oral and LMWH (enoxaparin 1mg/kg bd SC) -> B-blocker (e.g. atenolol 5mg oral) unless asthma/LVF -> transfer to CCU
Acute Left ventricular failure (LVF)
ABC and O2 via 15l non-rebreathe mask (unless COPD) -> Hx, o/e, Inv, Diagnosed LVF +/- cause -> Sit patient up -> Morphine 5-10mg IV with metoclopramide 10mg IV -> GTN spray/tablet -> Furosemide 40-80mg IV -> if inadequate response, isosorbide denigrate infusion +/- CPAP -> transfer to CCU
Signs and Treatment of unstable tachycardia (>125 bpm)
Shock, syncope, myocardial ischaemia, heart failure
Synchronised DC shock up to 3 attempts
if that doesn’t work, amiodarone 300mg IV over 10-20minutes and repeat shock, followed by amiodarone 900mg over 24hrs
diagnosis and Treatment of stable irregular narrow complex tachycardia (>125bpm)?
Probably atrial fibrillation
control rate with B-blockers or diltiazem
Consider digoxin or amiodarone if evidence of heart failure
Diagnosis and treatment of Regular rhythm, narrow complex tachycardia
(re-entry, paroxysmal) SVT
Vagal manœuvres
adenosine 6mg rapid iv bolus, If unsuccessful give 12mg, if unsuccessful again give further 12mg
continuously monitor ECG
if sinus rhythm restored record 12 lead ECG, give adenosine again if recurs and consider prophylactic anti-arrhythmic
If sinus rhythm not restored seek expert help
Possible diagnosis and treatment if narrow complex, regular tachycardia, no response to vagal manoeuvres and adenosine
Seek expert help
Possible atrial flutter, control rate with B-blocker
Possible diagnosis and management of irregular, broad complex tachycardia
seek help
Possible:
- AF with BBB, control rate with BB or diltiazem, consider digoxin or amiodarone if evidence of heart failure
- Pre-excited AF - consider amiodarone
- Polymorphic VT (e.g. torsade de pointes - give mg 2g over 10min)
Diagnosis and management of Regular broad complex tachycardia
VT - amiodarone 300mg IV over 20-60min then 900mg over 24hr
If previously confirmed SVT with BBB, give adenosine as for regular narrow complex tachycardia (6mg rapid bolus, then 12mg if unsuccessful, and further 12mg if unsuccessful again)
Anaphylaxis treatment algorithm
ABC and O2 (15l non rebreather, unless COPD) -> Hx, o/e, inv, and diagnose anaphylaxis -> Remove the cause ASAP (e.g. blood transfusion, stop) -> adrenaline 500 microgram of 1:1000 IM -> Chlorphenamine 10mg IV -> hydrocortisone 200mg IV -> asthma tx if wheeze -> amend drug chart allergies box
Acute exacerbation of asthma algorithm
ABC -> Hx, oe, ine, diagnosis acute asthma -> 100% O2 via non-rebreather mask -> Salbutamol 5mg neb -> Steroids: Hydrocortisone 100mg IV (if sever/life threatening) or prednisolone 40-50mg oral (if moderate) -> Ipotropium 500 micrograms neb -> theophylline (only if life threatening)
Acute exacerbation of COPD algorithm
ABC -> Hx, oe, ine, diagnosis exacerbation of COPD -> O2: if not peri arrest then 28% O2 non rebreather, review after 30min with and ABG -> Salbutamol 5mg neb -> Steroids: Hydrocortisone 100mg IV (if sever/life threatening) or prednisolone 40-50mg oral (if moderate) -> Ipotropium 500 micrograms neb -> theophylline (only if life threatening) -> antibiotic if infective cause (e.g. amoxicillin 500 mg 3 times a day for 5 days . can be increased to 1g 3x a day if severe)
Treatment of secondary pneumothorax
Secondary (patient has lung disease) then always needs treating - chest drain if >2cm/patient sob/>50 years old. otherwise aspirate
treatment of tension pneumothorax
tracheal deviation +/− shock
emergency aspiration required, but will need chest drain quickly.
Treatment of primary pneumothorax
if <2 cm rim and not SOB then discharge with outpatient follow-up in 4 weeks
if >2 cm rim on CXR or feels SOB then aspirate and if unsuccessful aspirate again, and if still unsuccessful then chest drain
How to assess severity of pneumonia
CURB65 to assess severity of community-acquired pneumonia and hence treatment: Confusion (abbreviated mental test score (AMTS) ≤ 8/10), Urea >7.5mmol/L, Respiratory rate >30/min, Blood pressure (systolic) <90 mmHg and age ≥65 years
For the patient with none or one of these then home treatment is possible; with two or more of these then hospital treatment with oral or IV antibiotics according to policy and severity is required; and with more than three of these then consider ITU admission.
Pneumonia treatment algorithm
ABC ->
Hx, o/e, inv. ∆ pneumonia ->
High-flow oxygen ->
Antibiotics (e.g. amoxicillin or co-amoxiclav) ->
Paracetamol ->
If low BP: or raised HR IV fluids as normal
PE treatment algorithm
ABC
Hx, o/e, inv. ∆ PE
High-flow oxygen
Morphine 5–10 mg IV, metoclopramide 10 mg IV
LMWH e.g. tinzaparin:175 units/kg SC daily
If low BP: IV gelofusine-> noradrenaline-> thrombolysis
GI bleeding treatment algorithm
ABC and 02 (15 L by non-rebreather mask unless COPD)
Hx, o/e, inv. ∆ acute GI bleed
Cannulae (x 2 large bore)
Catheter (and strict fluid monitoring)
Crystalloid/ colloid (in general crystalloid if normal/high BP and colloid (e.g. gelofusine) if BP low. once cross matched give blood)
Cross-match 6 units blood
Correct clotting abnormalities (If PT/aPTT > 1.5x normal range give fresh frozen plasma 9UNLESS due to warfarin, give prothrombin complex. if platelets <50 and bleeding give platelet transfusion)
Camera (Endoscopy)
Stop culprit drugs (NSAIDs, aspirin, warfarin, heparin)
Call the surgeons if severe
treatment of meningitis in the community
1.2g IM benzlpenicillin and immediate transfer to hospital
Treatment algorithm of bacterial meningitis in the hospital
ABC
Hx, o/e, inv. ∆ meningitis
High-flow oxygen
IV fluid
Dexamethasone IV unless severely immunocompromised
LP (+/– CT head)
2 g cefotaxime IV (give pre-LP if having CT head or prolonged LP
Consider ITU
NOTE: CT of head not always required before LP, as scanning can delay LP and therefore antibiotics
Treatment algorithm for seizures
Any seizure:
ABC (may need artificial airway)
Hx, o/e, inv. ∆ seizure
Put patient in recovery position with oxygen
Check for provoking factors (plasma glucose, electrolytes, drugs, sepsis)
If >5 mins
Lorazepam 2–4 mg IV or diazepam (IV) or midazolam (buccal) both 10 mg
If still fitting
after 2 min repeat diazepam
Inform anaesthetist
Phenytoin infusion
Intubate then propofol
Treatment algorithm management of an ischaemic stroke
ABC
Hx, o/e, inv. (include blood glucose and CT head to exclude haemorrhage), ∆ ischaemic stroke
If aged <80 years and onset <4.5 hours ago consider thrombolysis
Aspirin 300 mg oral
Transfer to stroke unit
name the conditions hyperglycaemia can cause
T1DM - DKA
T2DM - Hyperosmolar nonketotic (HONK) coma
How do you diagnose DKA
Diabetic
Check glucose - hyperglycaemia
Urine/blood ketone levels raised
ABG - acidosis (low ph) and maybe raised K
Diagnosing HONK (hyperosmolar nonketotic) coma
Hyperglycaemia - usually >35mmol/L
Osmolality over 340 mol/L (2x Na + 2x K + urea + glucose
non ketotic - no ketones in blood or urine
Management of hypoglycaemia (<3mmol/L)
If patient able to eat give sugar rich snack
if unable to eat (drowsy/vomiting) give IV glucose via a cannula, e.g. 100 mL 20% glucose (traditionally 50 mL 50% glucose IV but can cause extravasation). If unable to eat and no cannula give IM glucagon 1 mg
Management algorithm of hyperglycaemia
ABC
Hx, o/e, inv. ∆ DKA/HONK coma
IV fluid: 1 L stat then
1 L over 1 hour, then 2 hours, then 4 hours, then 8 hours (half this for HONK)
Sliding scale insulin
Hunt for trigger (infection, MI, missed insulin)
Monitor BM, K and pH
Treatment algorithm for AKI
ABC
Hx, o/e, inv. ∆ acute renal failure
Cannula and catheter, strict fluid monitoring
IV fluid:
500 ml stat. then 1 L 4 hourly
Hunt for cause (pre renal: dehydration. Intrinsic: ischaemia, nephrotoxic antibiotics: gentamicin, vancomycin, tetracyclines), radiological contrast, injury (rhabdomyalisis), gout, inflammation, cholesterol. Post renal: stone, tumour, fibrosis, prostate cancer, aneurysm, lymphadenopathy) and complications (fluid overload, hyperkalaemia, acidosis)
Moniter U&E, and fluid balance
treatment algorithm of poisoning
ABC
Hx, o/e, inv. ∆ acute poisoning
Cannula and catheter, strict fluid balance
Supportive measures (IV fluids and analgesia if appropriate)
Correct electrolyte distrubance
Reduce absorption (within 1 hour: gastric lavage, bowel irrigation if lithium/iron, charcoal)
Increase elimination (IV fluids plus N-acetyle cysteine if paracetamol level at 4+ hrs is over the treatment nomogram, Naloxone in opiates if low RR or GCS, Flumazenil if benzodiazepines
Psychiatric management
When to treat hypertension (on ambulatory monitoring)
if BP >150/95 mmHG or >135/85 mmHg if any of the
following are also present:
Existing or high risk of vascular disease (ischaemic heart
disease (IHD), stroke and peripheral vascular disease).
Hypertensive organ damage (intracerebral bleed, chronic
kidney disease, left ventricular hypertrophy and retinopathy).
Target BP on hypertension treatment
In patients aged less than 80 years, aim for <140/85 mmHg (for measurements taken at a clinic) and <135/85 mmHg (for ambulatory or home measurements).
In patients aged over 80 add 10 mmHg to the systolic values
management of chronic heart failure
- ACE-inhibitor (e.g. lisinopril 2.5 mg daily) plus beta-blocker (e.g. bisoprolol 1.25 mg daily).
- If inadequate increase doses as tolerated.
If still inadequate then add according to the severity:- Mild–moderate: add angiotensin receptor blocker (e.g. candesartan 4 mg daily).
-Moderate–severe (African–Caribbean patients): add hydralazine 25 mg 8-hourly and isosorbide mononitrate 20 mg 8-hourly.
-Moderate–severe (other patients): add spironolactone 25 mg daily
- Mild–moderate: add angiotensin receptor blocker (e.g. candesartan 4 mg daily).
Treatment algorithm for hypertension
Step 1:
Aged under 55 - ACEi or ARB
Aged over 55 or black/caribean family origin - CCB
Step 2:
ACEi/ARB + CCB
Step 3:
Add Thiazide-like diuretic (Indepamide, chlortalidone, xipamide, and metolazone)
Step 4: Resistant hypertension
Consider further diuretic (low dose spironalactone if K <4.5, higher dose thiazide like diuretic, BB or ARB. consider seeking expert advice
How to decide if stroke prevention needed for patient with AF, and how to treat
Prevent stroke: CHAD2DS2-VASc score
Congestive heart failure (or left heart failure alone) Hypertension
Age >75 (contributing 2 points)
Diabetes mellitus
Stroke or TIA before (contributing 2 points)
Vascular disease (e.g. peripheral arterial disease or IHD) Age 65–74
Sex (female).
score of 0 - 75mg aspirin daily
score of 1 - use aspirin or warfarin (aim INR 2.5)
Score 2 or more - warfarin ( aiming for INR 2.5
Control rate or rhythm: BB/CCB
NOTE: adverse features then utilise algorithm for tachycardia
When would someone require rhythm control treatment in AF, and how would they be treated
Who? – if young/symptomatic AF/first episode of AF/AF due
to treated precipitant (e.g. sepsis or electrolyte disturbance).
How? – cardioversion: electrical or pharmacological
(amiodarone 5 mg/kg IV over 20–120 mins). The patient will
require anticoagulation if more than 48 hours since onset
