PSA Flashcards
Overall framwork
Patient details
three pieces (name, DOB, NHS number)
Reactions
Alergies and the REACTION
co-amox and tazocin = penicillin
Sign
Contraindications
- see seperate
Route
see seperate
IV fluids
see seperate
Blood clotting
-see seperate
AntiEmetics
-see seperate
Pain Relief
- see seperate
Contraindications Overview
- Drugs that increase bleeding (aspirin, heparin, warfarin) should not be given to bleeding, suspected of or at risk of (eg increased PT in liver disease).
- contraindicated in acute ischaemic stroke (bleeding into stroke) no heparin thromboprophylaxis for 2 months (duuration varies in uk)
Enzyme inhibitor eg erythromycin can increase earfarins effect (PT and INR)
- Steroids - ‘STERPODS’ mneumonic
- NSAIDs (NSAID mneumonic)
- Antihypertensives
a- overall
b- 2 main categories
c- individual class SEs
Steroid SE/ contraindications
Stomach Ulcers
Thin Skin
oEdema
Right and left heart failure
Osteoporosis
Infection (including candida)
Diabetes ( commonly causes hyperglycaemia and uncommonly pregresses to diabetes)
Cushing’s Syndrome
Extra
Proximal myopathy (weakness) in longer term use
NSAIDs SEs and contraindication
No urine (renal failure)
Systolic dysfunction (hear failure)
Asthma
Indigestion (any cause)
Dyscrasia (clotting abnormality)
BUT Aspirin is not contraindicated in renal or heart failure or in Asthma
Enzyme Inducers
Griseoflavin - antifungal
Carbamazapine
Rifampin
Phenytoin
Chronic Alcohol Use
Barbituates
Cyclophosphamine
Suphonylureas
St John’s Wort
PC BRAS
Phenytoin
Carbamazapine
Barbituates
Rifampin
Alcohol (chronic excess)
Sulphonylureas
Enzyme Inhibiters
CP450
Quinidine
Metronidazole
Omeprazole
Isoniazid - TB tx
Grapefruit Juice
Ethanol (acute useage) - saturated by toxins
Erythromycin
Cimetidine - histamine H2 receptor antagonist
Sulfonamides
Indinavir (HIV protease inhibitor)
Valporic acid aka valorate (vault pro lemon)
Verapamil
Amiodarone
Ketocanazole
AODEVICES
Allopurinol
Omeprazole
Disulfaram
Erythromycin
Valporate
Isoniazid
Ciprofloxacin
Eethanol
Sulphonamides
Antihypertensive SEs
Common causes of K+ and Na+ imbalances
High K, low Na -> spironolactone, ACEi, NSAIDs
Low K, high Na (or low Na) -> loop and thiazide diuretics, steroids
What to consider when prescribing IV fluids to replace
Which one - 0.9% NaCl (crystalloid)
UNLESS-> ascites= HAS
hypernatramia or hypoglycaemia = 5% dex
bleeding = blood or colloid ( gelofusine) first
How much/how fast - if hypotensive or tachycardic = 500ml stat (250ml if heart failure) - then reasses
if only oliguric give 1L over 2-4 hrs - then reasses
Predict fluid depletion
Oliguric =500ml
Oliguric + tachycardia = 1L
Oliguric + Tachycardia + shocked = >2L
- reduced urine output (oliguric if <30 mL/h; anuric if 0 mL/h) indicates 500 mL of fluid depletion
- reduced urine output plus tachycardia indicates 1 L of fluid depletion reduced
- urine output plus tachycardia plus shocked indicates >2L of fluid depletion.
As a general rule never prescribe more than 2L of IV fluid for a sick patient. The effect on the patient and thus the rate of subsequent fluids should be reviewed regularly.
Maintenance fluids: which and how much
Maintenance: which fluids and how much?
Adults: 1 salty, 2 sweet over 24hrs
Elderly : 2 litres over 24hrs
K+ determined by U&Es
• As a general rule, adults require 3 L IV fluid per 24 hours and the elderly require 2L
Adequate electrolytes are provided by 1 of 0.9% saline and 2L of 5% dextrose (1 salty and 2 sweet).
To provide potassium, bags of 5% dextrose or 0.9% saline containing potassium chloride (KCL) can be used but this should be guided by urea and electrolyte (U&E) results, with a normal potassium level, patients require roughly 40 mmol KCI per day (so put 20 mmol KCL in two bags)
Maintenance Fluids: how fast
Adults: 8hrly bags
Elderly 12 hrly
Check:
- U&Es
- Overload signs
- Bladder NOT palpable (fluids due to decreased output)
Maintenance: how fast to give fluids • if giving 3 L per day = 8-hourly bags (24 3).
giving 2L per day = 12 hourly bags (24 2).
- If In the PSA it will not be possible to assess the patient; however, every time you prescribe fluids in real life, you must:
- Check the patient’s U&E to confirm what to give them.
Check that the patient is not fluid overloaded (e.g. increased jugular venous pressure (JVP), peripheral and pulmonary oedema).
• Ensure that the patient’s bladder is not palpable (signifying urinary obstruction) if giving replacement fluids because of reduced urine output’.
Blood and clot prophylaxis
To prevent thromboembolism pretty much everyone receives :
Remember LMW heparin eg enoxaparin
and
Compression Stockings
But remember the contraindications
Antiemetics
Cyclazine good firt line treatmet except cardiac cases
Metoclopramide is contraindicated in PD (worsenign of sx) and young women (dyskinesia)
Route
Vomming? - Antiemetics from non oral route and procede with PO
-Only change route if long lasting vomitting predicted.
If a patient is vomiting, antiemetics should be given by non-oral routes (L.e. N/M/SC). However, if vomiting is predicted to last a short time (which it usually is), changing the route of other prescribed medicine is usually not necessary and can be difficult, especially in the case of drugs for which the non-oral dose is different). Conveniently, the doses of the common antiemetics are the same regardless of the route (or taken, e.g. cyclizine 50mg 8-hourly, metoclopramide 10 mg 8-hourly It is very important to remember that a patient who is ‘nil by mouth’ should still receive their oral medication, including prior to surgery (see Chapter 1).
Pain relief
po Morphine breakthrough dose, do 1/6 of total daily dose
conversion of weak opiods to morphine you divide by 10
never increase background by more than 50%
po morphine to po oxycodone = divide by 2
po morphine to sc morphine = divide by 2
po oxycodone to sc oxycodone = divide by 1.5
Patches if they don’t want to be hooked up (buprenorphine or fentanyl - convert using NICE chart)
NSAID - any stage
Neuropathic: Amytriptyline 10mg nightly or pregabalin 75mg 12 hrly
Diabetic Neuropathy: Duloxetine 60mg PO daily
An NSAID (e.g, ibuprofen 400 mg 8-hourly may be introduced at any stage regularly or ‘as required’ if not contraindicated (as discussed earlier under Contraindications). With neuropathic pain (t.e. pain arising from nerve damage or disease and usually described as ‘shooting’, stabbing’ or ‘burning) the first line of treatment is amitriptyline (10mg oral nightly) or pregabalin (75 mg oral 12-hourly): duloxetine (60 mg oral daily) is indicated in painful diabetic neuropathy
Common Traps
Co-amoziclav and tazocni both contain penicillin
Metaclopramide in PD and young women
IV potassium should not be more than 10mmol/hr
Co codamol contains paracetamol - can only have 4g each day
Don not give vrapamil ( a CCB) with beta blockers as can cause bradycadia or asystole and maybe hypotension
WBC interpretation
Hyponatraemia Causes
SIADH
Small cell lung tumours
Infection
Abscess
Drugs (esp. carbamazepine and antipsychotics)
Head Injury
Hyper/okalaemia Causes
Intrinsic AKI
Platelet Drangement Causes
Thyroid
Drug Specific Monitoring
When monitoring note:
Clinical State (?toxicity)
Serum Levels
Drug Dose
How to respond
Inadequate response but low serum levels = increase dose
Adequate response but low serum levels? = do nothing
Adquate response but elevated levels? = decrease dose
Toxicity?
1 stop the drug (?find alternative)
2 supportive measures eg IV fluids
- Antidote if available.
Paracetamol Overdose
antioxidant flutathione is quickly depleted
toxic NAPQI builds up
N-acetyl cysteine (NAC) Replenishes Glutathione
Paracetamol Nomograms
measure at least 4 hours after ingestion
Need NAC if levels above the line
staggered dose or unknown time of ingestion NAC tx is advised
Start acetylcysteine before levels if >150mg/kg paracetamol
Gentamicin Monitoring
IV aminoglcoside abx for severe ifxns
Once Daily regimen monitoring
normally high dose (5-7mg/kg) regimen with once daily regimen monitoring
timnig of measurements depends on local guidelines
use hartford 7mg/kg nomogram and increase interval if needed
Divided Daily dosing
Divided daily dosing for renal failure 1mg/kg (12hrly) and endocarditis 1mg/kg (8hrly)
might need to adjust dose for this method
Antipsychotic Monitoring
BNF recommendations
Common Doses
Sertraline 50mg OD
Enoxaparin 20mg S/C OD for moderate risk ppx (40mg high risk)
Levonorgestrel 1.5mg stat within 72hrs
Ulipristal 20mg stat within 120 hrs
APIXABAN PE/DVT 10mg OD for 7d then 5mg
APIXABAN AF 5mg OD (reduce to 2.5mg if >80 + other things)
APIXABAN post surgery ppx = 2.5mg
LACTULOSE 15ml BD
ACS + stroke mx
Acute Resp Mx
Misc Acute mx
AKI + Acute poisening mx
COPD MEDED
If they have Asthma too it should have already been diagnosed
Bronchitis - low o2 leads to hypertension and RHF
Emphysema - damaged aveoli and co2 retension - cachexic and prolonged forced expiration
Diagnose - Spirometry. .. . . the other stuff is for acute
Asthma: raised eosinophil count +/- diurnal variation +/- peak flow varition over time (at least 400ml)
FEV1/FVC = <0.7
FEV1 of predicted for severity
->80% =mild stage 1
50-79 = moderate stage 2
30-49 = stage 3 severe
<30% = stage 4 very severe
Simplified drugs
Non asthmatic = SAMA + LABA + LAMA
Asthmatic = LABA + ICS (can add in LAMA if refractory
Mucolytics for productive cough
SABA = Albuterol (can also use SAMA first line in uk but need to switch to SABA for second line)
LAMA = ibatropium (2ND line ICS+LABA instead if asthmatic features)
LABA- ending in -alol
COPDER - long term management
O2 and smoking cessation = only things that prelong life (and colume reduction surgery in some patients
O2 - 88-92%
- -long term - IX if FEV1 <30%/cyanosis/raised JVP*
- 2 ABG 3w apart offer if <7.3 kPa or 7.2-8 and peripheral/pulmonart oedema or polycythamia*
Exacerbation
ECG, ABC, CXR important to see if anything else causing
Add ABX if sputum looks infected. Cycle between doxycycline (ruin teeth) and azithromycin (QT prolongation so check ECG first)
- azithromycin used for prophylaxis in UK
- amoxicillin, doxycycline or clarithromycin for acute in UK
Causative organisms
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
IX
The following investigations are recommended in patients with suspected COPD:
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer
full blood count: exclude secondary polycythaemia
body mass index (BMI) calculation
Ventilation
Non invasive ventilation benefits pts with pH 7.25-7.35
Invasive ventilation if pH <7.25
Arhythmias
Palpitations? - exclude arrhythmias with Holter Monitering (24hr potable 3 lead ecg)
fast = tachycadia?
Narrow = <3 boxes (0.12s) - wide is >
Adenosine = 6mg then 12 then 12 (IV adenosine needs to be infused via a large-calibre vein or central route)
Ventricular Fibrillation
MC cause of death following an MI
SVT
no p waves, HR>150, regular
if haemodynamically stable do vagal manouvres
if this fails give IV adenosine 6mg>12mg>12mg (veramapril if asthmatic)
AF
no p, irregularly irregular, <150
- chaotic background and flutter sawtooth
Torsades de points = turning of points around heart therefore changing amplitude
V-tach - monomorphic, wide complex, fast rhythm
Diltiazem (CCB) can be used instead of beta blocker in asthmatics
AF MX
stable or unstable (haemodynamically) (DC cardioversion if unstable)
rate control off if 48h and give if >48hr
(sotalol, amiodarone, flecainide)
- if CHF then use digoxin in acute setting if already on beta blocker . . rate limiting CCB contraindicated in excerbation HF
stable and decide to cardiovert? (beneficial in young, non CAD, low risk)
<48hr - heparinise and give DC cardioversion (anticoag not needed after unless CHADVAS score) or amiodarone
>48hrs either anticoag 3 weeks before and 4 weeks after DC conversion or TOE to exclude left atrial appendage (LAA) thrombus then can heparanise and DC cardiovert immediatelly
if previous cadioversion failure should have 4w amiodarone before DC cardioversion
CHA2DV2ASC - determine anticoag strategy:
0- non aspirin no longer recommended
1- consider for males
2 - offer anticoag (NOAC or Warfarin)
HASBLED score if starting warfarin - high risk =>3
Slow
Narrow and wide not as important here
PACE if too slow or unstable
Atropine helps for the first two - maybe 3rd
Idioventricular rhythm has no p waves as only ventricles contracting
stability - American Heart Association, includes systolic blood pressure < 90 mm Hg, altered mental status, cardiac ischemia, or severely decompensated heart failure due to the underlying rhythm.
Hypertension Mx
ACEi - enalapril, lisinopril, perindopril and ramipril.
ARBs - candesartan, irbesartan, losartan, valsatan
CCBs - amlodipine, felodipine and nifedipine.
Diuretics - indapamide and bendroflumethiazide.
Bendroflumethiazide
first, check for:
- confirm elevated clinic BP with ABPM or HBPM*
- assess for postural hypotension.*
- discuss adherence*
Step 1 treatment
patients < 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A)
angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough)
patients >= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C)
ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line
If CCB give peripheral oedema it can be switched for 2nd line indapamide to relieve symptoms
Step 2 treatment
if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic
if already taking a Calcium channel blocker add an ACE-i or ARB
for patients of Afro-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an ARB in preference to an ACE inhibitor
(A + C) or (A + D)
Step 3 treatment
add a third drug to make, i.e.:
if already taking an (A + C) then add a D
if already (A + D) then add a C
(A + C + D)
Step 4 treatment
NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice
if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker
Asthma
Not all wheezing asthma but should always consider
Ominous = lots of air trapping and not much room for air movement
PFTS = spirometry
ach agonist = Methacholine
Negavite Spirometry does not exclude asthma: ix further with fractional exhaled nitric oxide (FeNO) testing
Tx
Bronchoconstricion with bronchodilators
Inflammation with anti-inflammatories
Stabalisers can be used for athletic asthma as you can take pre-emptivly (cromolyn/ nedocromil)
short course of prednisolone for acute episodes (eg 5day hx of wheeze and cough and already on medicaiton)
Adult Tx
2- jump in here if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
Salmeterol = LABA aka a ‘controller’
Child 5-16 tx
The same as adult but stop LRTA at 4
Jump to 2 if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking
8 week trial:
After 8-weeks stop the ICS and monitor the child’s symptoms:
if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely
if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy
if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS
Exacerbation
Life threatening:
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
Nebs = Ipratropium (muscarinic antagonist)/ salbutamol
PEFR = peak espiratory flow rate ( they should know their best)
All patients to receive PO prednisolone
Oxygen through non rebreath
MDI = metered dose inhalors
Rescue medication :
Racemic adrenaline neb, subq adrenaline, IV magnesium all used to try and prevent intubation
Grades
1 - intermitent
2/3/4 = intermittent
- mild
- moderate
- severe
Refractory = tx not working
Adult Corticosteroid Doses
<= 400 micrograms budesonide or equivalent = low dose
400 micrograms - 800 micrograms budesonide or equivalent = moderate dose
> 800 micrograms budesonide or equivalent= high dose.
Paeds Corticosteroid Doses
<= 200 micrograms budesonide or equivalent = paediatric low dose
200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose
> 400 micrograms budesonide or equivalent= paediatric high dose.
Maintenance and reliever therapy (MART)
a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required
MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
Diabetes
Who
CVD RFs : old fat and hypertensive
Thrush: sore itchy foreskin in men
polyuria, polydipsia, blurred vision
How
The randam blood glucose is useful for the T1DM who comes in with all the sx
The tests are better as they go down.
HbA1C measures glycosylated end products so is therefore an average over 90 days
But cannot r/o diabetes as haemaglobinopathies affect levels
IFG/IGT
Impaired fasting glucose = FPG >6.1 but <7.0 mmol/L and should be offered OGTT to r/o DM
Impaired glucose tolerace = Pre-diabetes
T1 DM
AI desruction of pancrease
old person with normal BMs last year presenting with polydisia, polyuria and very high BMs is same as young
GAD and IA-2 are antibodies
Tx with insulin
Monitor at least 4 times a day, including before each meal and before bed
Pre-Diabetes
Mx
lifestyle modification = weight loss, increase exercise, change diet
At least yearly F/U blood tests
Metformin for their FPG or HbA1c is progressing towards T2DM
T2DM
Mx
Check HbA1c q3-6 months then every 6 months when stable
- Lifestyle: target = 48 mmol/mol
- Add metformin: target = 48mmol/mol
- If >58 add another drug: target = 53 mmol/mol
- If still >58 add another or consider Insulin
Keep metformin when starting insulin and consider the others
If metformin not initially tolerated then:
First try modified release meformin
- Lifestyle: target = 48 mmol/mol
- Add another drug: target = 48mmol/mol
- If >58 add another drug: target = 53 mmol/mol
- If still >58 consider Insulin
Drugs
Metformin: the diarhoea will go away
Sulfonylureas (pick as cheap and been around ages): watch out for the hypoglycaemia esp in CKD pts- increases insulin expression
TZD = thiazolidinedione = pioglitazone : can cause CHF
GLP1 mimetic (exenatide) criteria = BMI>35 and unable to lose weight or <35 but insulin would have significant occupational implicatons . . . only continue if a 1% HbA1c reduction or weight loss of 3% in 6 months
SGLT-2i can cause DKA so avoid
Alpha Glucosidase inhibitors mean that glucose not absorbed so dirahoea and smeel flatulance
RF modification
Htn: 1st line ACEi
<80 target 140/90 clinic (135/85)
>80 target 150/90 (145/85)
Antiolatelets offered
Lipids = QRISK2 score = atorvastatin 20mg ON
Retinopathy - sudden vision loss = vitrious haemorhage
Nephropathy
All diabetic patients require annual screening for albumin:creatinine ratio (ACR) in early morning specimens
ACR > 2.5 = microalbuminuria
Mx: Start ACEi
diet restrict protein
gd control of BP, BM, Lipids
Neuropathy
1st line: amitriptyline, duloxetine, gabapentin or pregabalin
2nd- try another one of the drugs
- tramadol can be used as rescue therapy
4 - refer to pain mx clinic]
Charcot Foot
Mild pain considering of joint dysruption
swollen, red and warm
Sick Diabetic
cont normal insulin regime and check BMs regularly
MODY
maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. Sulfonylureas (e.g. gliclazide) are the optimal treatment in HNF1A-MODY.
Small bowel bacterial overgrowth syndrome (SBBOS)
DM at ro this
excessive gut bateria
sx: chronic diarhoea, bloating, flatulance, abdo pain
dx: hyrodogen breath test
tx: rifaximin and DM control
Dietary advice
encourage high fibre, low glycaemic index sources of carbohydrates
include low-fat dairy products and oily fish
control the intake of foods containing saturated fats and trans fatty acids
limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake
discourage use of foods marketed specifically at people with diabetes
initial target weight loss in an overweight person is 5-10%
Calculations
1% means:
1g in 100ml or 10mg in 1 ml for w/v calculations
1g in 100g for w/w calculations
40mg dose of 80mg/2ml solution
2ml x 80mg = xml *40mg
Adrenaline 1in1000 for anaphylaxis, 1 in 10,000 for CPR
1 in 1000 means mg = ml
Insulin Types
Rapid-acting insulin analogues
the rapid-acting human insulin analogues act faster and have a shorter duration of action than soluble insulin (see below)
may be used as the bolus dose in ‘basal-bolus’ regimes (rapid/short-acting ‘bolus’ insulin before meals with intermediate/long-acting ‘basal’ insulin once or twice daily)
insulin aspart: NovoRapid
insulin lispro: Humalog
Short-acting insulins
soluble insulin examples: Actrapid (human, pyr), Humulin S (human, prb)
may be used as the bolus dose in ‘basal-bolus’ regimes
Intermidate-acting insulins
isophane insulin
many patients use isophane insulin in a premixed formulation with
Long-acting insulins
insulin determir (Levemir): given once or twice daily
insulin glargine (Lantus): given once daily
Fluid makeup
In the 2013 guidelines NICE recommend the following requirements for maintenance fluids:
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis
So, for a 80kg patient, for a 24 hour period, this would translate to:
2 litres of water
80mmol potassium
Warfarin Mx
*as FFP can take time to defrost prothrombin complex concentrate should be considered in cases of intracranial haemorrhage
Major bleeding whatever the INR: - stop warfarin, give intravenous vitamin K 5mg, prothrombin complex concentrate
Octilex = corrects factors 1972
Contraindicated in breast feeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
Therapeutic Drug Monitoring
Lithium
range = 0.4 - 1.0 mmol/l
take 12 hrs post-dose
Ciclosporin
trough levels immediately before dose
Digoxin
at least 6 hrs post-dose
Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if:
adjustment of phenytoin dose
suspected toxicity
detection of non-adherence to the prescribed medication
Common Drug Monitoring
