PPT Flashcards
What is a risk of giving heparin
Heparin induced thrombocytopaenia
What blood tests would you do before giving LMWH and why?
COAG screen and FBC
To ascertain baseline coagulation status and to ensure platelet count is normal before starting a heparin (risk of heparin induced thrombocytopenia)
What blood tests would you do before CTPA
UnEs
Assess baseline renal function
What drugs are used to anticoagulate someone with PE
LMWH along with vitamin K antagonist (warfarin) for 5 days (monitor INR)
Why is LMWH used first line for PE
Not many side effects (some risk of bleeding) and predictable half life
Difference between using anticoagulants or thrombolytics in PE
Thrombolyse if patient has massive PE and haemodynamically unstable
If a patient is on warfarin and experiences a major bleed what should you give them?
Stop warfarin
Give IV vitamin K 5mg (phytomenadione)
Prothrombin complex concentrate - if not available then FFP*
Co-trimoxazole tends to be used in elderly because..
Less association with pseudomembranous colitis (C.diff)
Verapamil should not be taken with B-blocker due to risk of..
Bradycardia, heart block or even congestive cardiac failure
Clarithromycin should not be given with..
Statin
Risk of rhabdo
When is amiodarone given over fleicanide for rhythm control in AF?
In patients with structural heart disease (such as ill-functioning valves)
How to check for end-organ damage in hypertension
Kidney function - Albumin-creatinine ration (ACR) from urine
Bloods - glucose, UnEs, creatinine, EGFR, serum cholesterol
Fundoscopy - retinopathhy
12 lead ECG
If ACE inhibitor is not tolerated (ie cough) give..
ARB (losartan/Candesartan)
Main SE of ACE inhibitors
Hypotension
Persistent dry cough
Hyperkalaemia
Angioedema
Avoid ACE inhibitors in patients with..
Renal artery stenosis
AKI
Pregnant or breastfeeding women
ACE inhibitors might be helpful in
CKD
ACEi drug interactions
K sparing diuretics, potassium supplements - risk of hyperkalemia
NSAIDs - risk of AKI due to hypotension
What should be done before starting an ACE inhibitor
Check electrolytes and renal function and repeat 1-2 weeks into treatment
Primary prevention in those who have a 10% risk of developing CVD
Statin 20mg
Statin MOA
HMG-CoA reductase inhibitor
Inhibits the rate-limiting enzyme in hepatic cholesterol synthesis
Statins SE
Headache
GI disturbances
Myopathy - rhabdo
Rise in liver enzymes (ALT)
Statins should be used in caution in patients with
Hepatic impairment
Pregnancy and breastfeeding (can affect fetal development)
Statins drug interactions
Drugs that reduce metabolism of drug (higher conc for longer) - amiodarone, macrolides (clarithromycin), conazole, protease inhibitors
Avoid grapefruit juice - affects CYP3A4 and reduces statin metabolism -> increased risk of myopathy
Which bloods need checking with statins
Checking LFTs at baseline, 3 months and 12 months
Risk of hepatic impairment
Stable angina - what medications would you start patient on?
Aspirin Statin Betablocker/Ca channel blocker Nitrate (GTN) Nicorandil
Beta blockers SE
Dizziness, fatigue Hypotension Erectile dysfunction Broncoconstriction (asthma) Raynaud's (Cold hands) Bradycardia/heart block Masking hypoglycaemia
Beta blocker contraindications
Uncontrolled HF
Asthma
Sick sinus syndrome
Verapamil (may precipitate severe bradycardia)
Ca channel blockers (Verapamil and Diltiazem) SEs
Headache and flushing
Tachycardia
Peripheral oedema
Constipation
GTN SEs
Hypotension
Tachycardia
Headaches
Flushing
Aspirin MOA
COX1 and COX2 inhibitor
Aspirin SE
GI irritation
Ulceration
Haemorrhage
Bronchospasm
NSTEMI management
Morphine - relieve chest pain Oxygen - if hypoxic Nitrates Aspirin 300mg Antithrombin therapy (Heparin immediately, Ticagrelor for 12mo, IV glycoprotein inhibitor for high risk patients
STEMI management
Aspirin
Clopidogrel
LMWH heparin
Oxygen
PCI
Thrombolysis
When is rhythm control favoured in AF
Younger than 65 years Symptomatic Reversible cause First presentation Lone AF or AF secondary to a corrected precipitant (e.g. Alcohol) HF secondary to AF
When is rate control favoured in AF
Older than 65
Hx of IHD
Rate control drugs for AF
Beta blocker
Ca channel blocker
Digoxin (only really used if pt has HF)
Rhythm control drugs for AF
Sotalol
Amiodarone
Flecainide
Amiodarone SE
Thyroid dysfunction (hypo and hyper) corneal deposits Pulmonary fibrosis/pneumonitis Liver fibrosis/hepatitis Peripheral neuropathy Myopathy Photosensitivity 'slate-grey' appearance Thrombophlebitis Bradycardia QT interval prolongation
Investigation for PE
Well’s score
Signs and symptoms of DVT PE is most likely HR >100 Immobilisation of at least 3/7 or 6/52 Previous PE or DVT Haemoptysis Malignancy
What treatments to initiate for PE
LMWH or Direct factor Xa inhibitor (apixaban)
For a massive PE should you use fractioned or unfractioned heparin
unfractioned heparin
However difficult to control INR
Blood tests needed prior to starting LMWH for PE
COAG screen and FBC
To ascertain baseline coagulation status and to ensure platelet count is normal before starting a heparin (risk of heparin induced thrombocytopenia)
Risk with heparin
Heparin induced thrombocytopenia (low platelets)
When is thrombolysis used in PE
If it’s a severe PE and patient haemodynamically unstable
Needed to break down clot immediately
What factors need to be considered when starting LMWH
Body weight to calculate dose
Pregnancy
Severe renal impairment
When starting warfarin you need to continue LMWH for 5 days - why?
Warfarin takes around 5 days to reach an appropriate level of anticoagulation
How to treat a high INR
Oral vitamin K
Major bleed on warfarin give
IV phytomenadione (Vitamin K)
Advantages of DOACs
No monitoring needed (predictable)
Disadvantages - no reversal agent yet
How long on warfarin if first episode of PE
3 months
Why does hyponatraemia occur in pneumonia?
SIADH
or other medications (thiazides, loop diuretics, spironolactone)
To correct hyponatraemia give..
IV fluids (NaCl or Hartmanns) and stop drugs contributing to hyponatraemia
ALWAYS check UnE’s
What type of healthcare acquired infections does broad spectrum antibiotics predispose you to?
C diff
MRSA
ESBL (Extended-spectrum beta-lactamases are enzymes that confer resistance to beta lactam ABX)
Which ABX predispose you to C Difficile
Clindamycin
Broad spectrum penicillins
Cephalosporins
Compliance
patient expected to stick to regimen prescribed by doctor, without question!
Concordance
A mutually agreed contract between doctor and patient, to take medicines in a way which suits both parties
Adherence
why a patient may not take medicines in the way agreed between doctor and patient (lack of understanding or doesn’t agree with what was decided)
Complete control of asthma is defined as..
No daytime symptoms, no night-time awakening due to asthma, no asthma attacks, no need for rescue medication, no limitations on activity including exercise, normal lung function
Asthma management
SABA
SABA + ICS
SABA + ICS + LTRA
SABA + ICS + long-acting beta agonist (LABA)
A low dose ICS should be used if
Inhaled SABA used more than 3x a week
Symptomatic 3x a week or more
Waking at night due to asthma at least once a week
Given an example of a LABA
Salmeterol or formeterol
Formoterol has a more rapid onset of action
Severe asthma
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
Life threatening asthma
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
SE of beta agonist (salbutamol)
Fine tremor
Tachycardia
Acute asthma treatment
Oxygen driven salbutamol nebuliser Ipratropium bromide Hydrocortisone IV Magnesium sulfate IV Aminophylline IV fluids
HF treatments
First-line treatment = an ACE-inhibitor and a beta-blocker*. Generally, one drug should be started at a time
second-line treatment= either an aldosterone antagonist, ARB or a hydralazine in combination with a nitrate
if symptoms persist cardiac resynchronisation therapy or digoxin** should be considered. An alternative is ivabradine.
Diuretics should be given for fluid overload
Normal INR
Patients on anticoagulants usually have a target INR between 2 and 3
VTE target INR = 2.5, if recurrent 3.5
AF target INR = 2.5
Mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
