Planning management Flashcards
Management of STEMI
“Acute treatment:
* PCI (if available within 2 hours of presentation) + (fondaparinux or unfractionated heparin)
or
* thrombolysis agents (e.g. alteplase, tenecteplase)
Plus (MONAC):
* Morphine (if in severe pain) & Metoclopramide
* Oxygen (if sats <94%)
* Nitrates (caution in hypotensive patient)
* Aspirin 300mg
* Clopidogrel 300mg/Prasugrel/Ticagrelor
Management of NSTEMI
“Acute treatment (BATMAN):
* Beta blocker
* Aspirin 300mg loading dose
* Ticagrelor 180mg loading dose
* Morphine 5-10mg IV + antiemetic
* Anticoagulant - LMWH (fondaparinux)
* Nitrates e.g. GTN
Secondary prevention with lifestyle factors and medical management (6A’s):
* Aspirin
* Another antiplatelet e.g. clopidogrel, prasugrel or ticagrelor for upto 12 months
* ACEi
* Atenolol
* Aldosterone antagonist for those with heart failure
* Atrovastatin
Secondary prevention with revascularisation procedures:
* PCI: GRACE Score to assess for PCI - if medium (5-10%) or high risk (>10%) they should have PCI within 4 days of admission
Management of acute LVF
Morphine
Oxygen
GTN
Furosemide
if inadequate response isorbide dinitrate infusion
Pneumothorax management
- If secondary(i.e. patient has lung disease), then always needs treatment: chest drain if >2 cm or patient has shortness of breath (SOB) or if >50 years old; otherwise aspirate.
- If tension pneumothorax(i.e. clinical distinction but often tracheal deviation +/− shock), then emergency aspiration required, but will need chest drain quickly.
GI bleed management
8C’s
management of bacterial meningitis
A GP will normally give 1.2g benzylpenicillin if there is any suspicion
Note - A computerized tomography (CT) scan of the head is not always required before lumbar puncture (LP); scanning the patient can delay the LP and hence antibiotics.
Management of seizures
Acute (status epilepticus - seizure failed to self terminate terminate) “Oh My Lord Phone the Anaesthetist”:
* Oxygen
* Midazolam (buccal or intranasal)
OR
* Lorazepam (IV)
* Phenytoin
* RSI of Anasthesia (profolol or thopentone) with intubation and ventilation
Note - Midazolam in children and Diazepam PR in community
Management of ischaemic stroke
Management of DKA
Management of acute renal failure
Management of hypoglycaemia
If the patient is able to eat, then give a sugar-rich snack, e.g. orange juice and biscuits. However, if unable to eat (i.e. 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 of acute poisoning
chronic heart failure
Medical management (ABAL):
* ACEi (avoid in valvular heart disease) or ARBs
* Beta blocker
* Aldosterone antagonist (spironolactone or eplerone) when symptoms are not controlled with A and B
* Loop diuretics (furosemide or bumentanide)
stroke prevention scoring system in AF
the CHA2DS2-VASc score where each factor contributes one point unless indicated:
* 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).
Generally if:
* Score 0 may not require anticoagulation
* Score 1 consider anticoagulation in men using apixaban, dabigatran etexilate, rivaroxaban, or a vitamin K antagonist (warfarin).
* Score 2 or more consider anticoagulation in men and women as described above.
Bleeding risk tool used for anticoagulation in AF
Calculate the HAS-BLED score where each factor contributes one point unless indicated:
* Hypertension i.e uncontrolled BP
* Abnormal renal function (creatinine >200 umol/L or transplant or dialysis) Abnormal liver function (cirrhosis or bilirubin >2x normal or AST/ALT/ALP >3x normal)
* Stroke
* Bleeding tendency or predisporition
* Labile INR
* “Elderly” (aged >65)
* Drugs (e.g concomitant aspirin or NSAIDs) or alcohol
Generally if:
Score 0 = low risk of bleeding. Anticoagulation should be strongly considered.
Score 1–2 = low–moderate risk of bleeding. Anticoagulation should be considered.
Score ≥3 = high risk of major bleeding. Alternatives to anticoagulation should be considered.
AF management
Rhythm control:
* Who? – MUST be <48 hours since onset if young/symptomatic AF/first episode of AF/AF due to treated precipitant.
* How? – cardioversion: electrical or pharmacological Flecanide (if no structural heart disease (HD)), or amiodarone (if has structural HD). Consider oral anticoagulation if high risk of recurrence of AF in 48 hour presentation period or if CHA2DS2-VASc indicates.
Rate control:
* Who? When presentation >48 hours.
* How? Start with (depending on the contraindications) either:
(1) beta-blocker, e.g. bisoprolol 2.5mg daily or (2) rate-limiting calcium-channel blocker, e.g. diltiazem 120 mg daily. If monotherapy does not control symptoms consider combination therapy with any 2 of the following – a beta-blocker, diltiazem, or digoxin.
* Digoxin monotherapy should only be considered in non-paroxysmal AF if person is sedentary. Amiodarone should NOT be used for long term rate control.
Stable angina management
There are three facets to first-line management:
* GTN spray ‘as required’ (for symptomatic relief when required).
* Secondary prevention: consider aspirin, statin, and cardiovascular risk factor modification.
* One anti-anginal drug and, dependent on contraindications, either (1) beta-blocker (e.g. atenolol) (contraindications: hypotension, bradycardia, asthma, and acute heart failure), or (2) calcium-channel blocker (e.g. amlodipine or diltiazem) (contraindications: hypotension, bradycardia, and peripheral oedema).
Asthma adult management
Long term management Adults:
1. Reliever: Short acting inhaled beta agonists (SABA) e.g. salbutamol as required
2. Preventer: low dose steroid inhaler (ICS)
3. Initial add on therapy: long acting beta agonist (LABA) combined with a low dose ICS inhaler
4. Additional add on therapies: medium dose ICS +/- leukotrine receptor antagonist (LTRA e.g. montelukast) or theophyllines or Long acting muscurinic antagonists (LAMA) e.g. tiotropium
5. High-dose therapies: high dose ICS (max 2000ug) + LTRA/theophylline/LAMA/beta agonist tablet
6. Specialist care: oral steroids +/- immunosuppressants e.g. omalizubmab (anti-IgE), mepolizumab (anti-IL5)
asthma management in children
Long term management children:
1. Reliever: SABA
2. Preventer: very low dose ICS (>5 years old) or LTRA (<5 years old)
3. Initial add on therapy: LABA (>5 years old) or very low dose ICS (<5 years old)
4. Additional add-on therapies: low dose ICS +/- LTRA (>5 years old)
5. High dose therapies: medium dose ICS + theophylline
6. Specialist care: oral steroids +/- immunosuppressants
acute COPD exacerbation management
“Acute exacerbation:
* antibiotics (amoxicillin or clarithromycin) if evidence of infection
* Oxygen - beware type II respiratory failure (88-92%)
* nebulisers (beta 2 agonists/anticholinergics)
* oral/IV steroids
* if not improving consider aminophylline infusions
* if still not improving consider NIPPV (e.g. BiPAP)
”
chronic COPD management
Long term management:
1. Short acting bronchodilators: SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide) as required
2. Long acting bronchodilators:
* if they do not have asthmatic features they should receive a combined LAMA + LABA inhaler. Note if they are already taking a SAMA, discontinue and switch to a SABA
* if they have asthma they should have a combined LABA + ICS
3. Tripple therapy: LABA (salmeterol) + LAMA (tiotropium) + ICS (beclomethasone)
4. Specialist care: e.g. aminophylline or theophylline, long term prophylactic antibiotics (e.g. azithromycin), oral mucolytic therapy (e.g. carbocisteine)
Other (STOP and refer):
* S - Smoking cessation
* T - Travel advice: risk of pneumothorax in those with bullae
* O - Oxygen therapy: in those with chronic hypoxia, polycythaemia, cyanosis or heart failure.
* P - Pneummococcal and annual flu vaccination
* Refer for pulmonary rehabilitation
Management of parkinsons
”* education
* encourage physical activity
dementia tx:
* cholinesterase inhibitors and memantine
Medical tx of parkinsonism:
* dopamine precursor: levodopa
* dopamine agonists: cabergoline, bromocriptine, pergolide
* COMT inhibitors: entacapone, opicapone
* MAOB inhibitors: selegline, rasagline, safinamide
peripheral AAAD (decarboxylase) inhibitors: cabidopa, benserazide (can be manufactured with L-dopa)
Epilepsy chronic management
All seizures are managed with sodium valporate (first-line in males) then lamotrigine (first-line females) except focal seizures and secodnary generalised seizures which are managed in the reverse order
Management of alzheimers disease
”* if mild/moderate dementia treat with Cholinesterase inhibitors e.g. donepezil, rivastigmine and galantamine
* If moderate/severe then treat with NMDA antagonists e.g. Memantine
Can use two drugs together
* Sx therapy: anxiolytics, antidepressants “
Common side effects of antiepileptic medications
inducing remission of IBD
Work up pyramid
UC can only use bottom tier
treatment options for constipation
chronic non-infective diarrhoea management
loperamide or codeine
Name a dopamine antagonist safe to use in parkinsons disease
domperidone, another dopamine antagonist licensed for the treatment of nausea, is safe to use for patients with Parkinson’s disease as it does not cross the blood-brain barrier)
