PSA Flashcards
How do you treat a hypo if the patient has an unsafe swallow
75ml 20% glucose over 15 minutes
How do you treat a hypo in an alcoholic
As normal but they also need thiamine
Which groups of patients is IM glucagon not effective in for treating a hypo
prolonged fasting
Alcohol induced hypo
Adrenal insufficiency
Sulphonylurea induced hypo
How do you manage HHS
1L 0.9% saline over 1 hour
How do you manage DKA
0.1unit/kg/hour insulin (50 units actrapid in 50ml saline)
500ml fluid bolus if BP<90 (maintenance fluids if not)
10% glucose once glucose <14
What two drug used in the treatment of hyperkalaemia need to be given via different access points
calcium and sodium bicarb form an insoluble precipitate if given through the same port
Allergic ADR to ACE-i
angioedema - this can occur months down the line
what other abx should be prescibed with caution in penicillin allergic patients
cephalopsorines - cefalexin, cefuroxime, ceftriaxone
carbopenems - meropenem
can fentanyl be prescribed to a morphine allergic patient?
yes and vice versa
what drugs are prescribed in micrograms
levothyroxine
digoxin
ADR of acetylcystine and what to do about it
bronchospasm and rash
give chlorphenamine and salbutamol
restart acetylcystine at a slower rate
ECG changes in TCA OD
long QT
wide QRS
Presentation of a TCA OD
hot, red, dry, blind, mad
hypokalaemia
respiratory depression
estimate of a child’s weight
(age +4) x2
do you dose gentamicin according to the patients actual or ideal body weight
ideal if they are obese
how do you treat AKI + sepsis + metabolic acidosis
sodium bicarbonate 1.26%
how does dabigatran effect PT/INR, APTT and thrombin time
prolonged APTT and thrombin time
how does rivaroxaban effect PT/INR, APTT and thrombin time
prolonged PT/INR
how does apixaban effect PT/INR, APTT and thrombin time
It doesn’t. Measure anti-Xa assay
How would you start someone on a DOAC
riv/apix don’t require LMWH
dab/edox require 5 days LMWH then stop LMWH and start doac i.e. NO bridging.
What common medications are cautioned in DOAC patients
CI: aspirin and clopidogrel (unless ACS)
caution: SSRIs
How do you manage a bleeding patient on a DOAC
TXA, FFP
dabigatran has a reversal agent
when can you restart a DOAC following surgery
12-48 hours depending on operation
How does LMWH effect coagulation tests
it doesn’t. Measure anti-xa assay
What common medications are cautioned in LMWH patients
NSAIDs
ACE-i and diuretics as risk of hyperkalaemia
How is unfractionated heparin monitored
APTT
how do you reverse unfractionated heparin
protamine
what analgesia should you avoid in pregnancy
NSAIDs and opioids
How long and what dose of folic acid is required in patients on antiepileptics
12 weeks of 5mg
emergency contraception in a patient on antiepileptic
copper IUD
double dose of levonorgestrel
Diabetes management in pregnancy
metformin is the only oral agent allowed
switch to insulin
Cardiovascular management in pregnancy
STOP: ACE-i, ARB, statins
START: labetalol, nifedipine, methyldopa
thyroid management in pregnancy
requirements are increased
drugs that lower the seizure threshold/provoke seizures
NSAIDS and tramadol
SSRIs, haloperidol, clozapine, benzos
ciprofloxacin
cyclizine
what contraception is acceptable in a patient on antiepileptics
IUD, IUS, depot
how would you start someone on morphine
IR morphine sulphate PRN up to 4 hourly. Once stable switch to MR preparation BD.
generally 10mg BD and 5mg PRN
If someones pain isn’t controlled how much would you increase their morphine by
30%
Name some indications and contraindications for specific oral diabetes medications
pioglitazone contraindicated in HF and hepatic impairment
CKD patient: generally gliclazide first instead of metformin
generally how much insulin would you start someone on
- 5 units/kg for adults
0. 3 units/kg for elderly
ADR of dapaglifozine (SGL2 inhibitor)
DKA
how would you set up a VRII
49.5ml saline + 0.5ml 50 units insulin into a syringe to get 1 unit/ml
What fluids are given alongside a VRII
0.45% NaCl, 5% dextrose, 0.15% K (20mmol)
How do you convert from VRII back to normal regime
insulin/oral agent given
meal
wait 30 minutes
remove VRII
How do you alter long acting insulin regimes before surgery
drop to 80% of the normal the day before and day of
How do you alter steroid regimes prior to surgery
give 25mg IV hydrocortisone at induction
give 100mg IV hydrocortisone over following 24 hours
what shouldn’t be co-prescribed with verapamil
b-blockers (including ocular preparations such as timilol)
2 ototoxic drugs that shouldn’t be co-prescribed
aminoglycosides and loop diuretics
which drug can cause lithium toxicity
ACE-i (reduce GFR so reduced excretion)
Which drugs can cause digoxin toxicity
verapamil
statins
amiodarone
liquorice (due to causing hypokalaemia)
ADR/interactions with St John Wart
reduced effect of warfarin and COCP
SSRIs = serotonin syndrome
MAOIs = hypertensive crisis
drugs/classes you should use with caution in liver impairment and why
risk of encephalopathy: constipating (opioids), electrolyte disturbance (diuretics), agitation and sedation (benzos/antipsychotics)
clotting abnormalities: anticoag/antiplatelets, thrombocytopenia (valproate)
Varices/haemorrhage: NSAIDs
Ascites: fluids retention (NSAIDs, steroids), fluids
contraception in over 40’s
POP
implant
IUS
contraception alongside HRT
IUS can protect endometrium if oestrogen only regime
POP in combined HRT
postpartum contraception
nothing for 21 days
COCP not <6 weeks and breastfeeding
IUS and IUD either <48 hours or >4 weeks
POP anytime
Things to remember about POP
irregular bleeding
effected by enzyme inducing drugs
Things to remember about implant
Any BMI (if obese replace early in 3rd year)
irregular bleeding
effected by enzyme inducing drugs
Things to remember about depot injection
takes a year for fertility to return
CI in adolescents as risk of osteoporosis
Things to remember about IUS
good for heavy bleeding
Things to remember about IUD
effective immediately
postpartum emergency contraception
day 21-28: EllaOne
>28 days: EllaOne or IUD
ACE-i are cautioned in who
PVD
atherosclerosis
asthmatics (not on BNF)
warn diabetics about risk of hypo’s
who needs a statin for primary prevention
10 year risk >10%
T2DM for >10 years OR >40 OR nephropathy
statins are contraindicated in who and interact with what?
pregnancy and intracerebral haemorrhage
erythromycin and clarithromycin - STOP the statin whilst on abx
ADR of loop and thiazide
loop = gout and alkalosis thiazide = gynaecomastia and impotence
what electrolyte abnormalities can cause digoxin toxicity
hypokalaemia hypomagnesaemia hypernatremia hypercalcaemia acidosis
maximum paracetamol dose
1g 6 hourly
what electrolyte abnormality can bisphosphonates lead to
hypocalcaemia
when can bisphosphonates be stopped
after 5 years if…
age <75
T score >-2.5
low FRAX risk
drugs causing hyponatraemia
SSRI TCA carbamezapine sulphonylureas vincristine cyclophosphamide
pre-surgery when do you stop ACE-I and K sparing diuretics
day of
where in the BNF do you find where to convert different steroid therapies
“glucocorticoid therapy”
common drugs CI with methotrexate
trimethoprim
co-trimoxazole
aspirin
management of methotrexate toxicity
folinic acid
how do you prescribe blood
1 unit at a time on 1 line
“packed red cells”
1 unit over 2 hours
ADR of citalopram
prolonged QT
SIADH
indication for fluoxetine or sertraline over citalopram
fluoxetine - teenagers
sertraline- post MI
a patient is on warfarin and needs an anti-depressant, what do you prescribe
NOT SSRI
Give mirtazapine
a patient is on an SSRI and needs ibuprofen for joint pain, what do you need to remember
PPI as increased bleeding risk
how do you go about stopping an SSRI
6 months of symptoms resolution then reduce dose over 4 weeks
Causes of lithium toxicity
hyponatremia
renal failure, dehydration, ACE-I/ARB, thiazides
NSAIDs
metronidazole
how do you manage lithium toxicity
rehydrate
dialysis
important bits about clozapine
needs dose adjustment according to smoking status agranulocytosis lowers seizure threshold constipation myocarditis
how to find antipsychotics in the BNF
“psychoses”
ADR of antipsychotics
extrapyramidal: tardive dyskinesia, dystonia, akathisia, parkinsonism impaired glucose tolerance prolonged QT stroke and VTE risk in elderly NMS reduced seizure threshold sedation and weight gain antimuscarinic - pee, see, spit, shit postural hypo impotence
how do you treat neuroleptic malignant syndrome
dantrolene
bromocriptine
which patients would you not use pioglitazone in
HF
which patients would you use a sulphonylurea first over metformin
normal/low weight
raised creatinine
what regime is used for DKA
Fixed rate of 0.1 unit/kg/hr
You use a 50 unit/50ml syringe typically
therefore rate is 0.1ml/kg/hr
complications of DKA management
hypokalaemia
cerebral oedema - monitor GCS
metformin is CI when creatinine reaches. Why
150
risk of lactic acidosis
what blood result would indicate diabetic nephropathy and therefore what needs monitoring
microalbuminaemia
albumin-creatinine ratio
how do you step down benzo’s and where in the BNF do you find this info
change to equivalent dose of diazepam then reduce this to zero
“anxiolytics and hypnotics”
Outline how you go from morphine to fentanyl
you can add equivalent patches together. So for 90mg morphine
30mg = 12 patch
60mg = 25 patch
therefore give 37 patch
Which hospital patients would you not give dalteparin to?
Ischaemic stroke patients - they can bleed into the stroke
when would you give FFP
if PT/APTT >1.5x normal
when would you give platelets
count <50
what contraception should a patient on enzyme inducing drugs avoid
Progesterone
what oestrogen is used for COCP and HRT
COCP = ethinylestradiol HRT = estradiol
in the BNF how would you look up information on the ring or patch contraception
ring = nuvaring patch = Evra
how do you avoid getting a bleed whilst on COCP
use a continuous regime i.e. taking packets back to back
describe cyclical and continuous HRT
cyclical: progesterone taken for last 14 days of each cycle
continuous: progesterone taken constantly
in which women is a continuous HRT regime not suitable
if <12 months since last bleed as causes irregular bleeding
How is the VTE risk of HRT minimsed
patch instead of oral
Risks associated with HRT
breast cancer endometrial cancer ovarian cancer Stroke and VTE IHD
progesterone HRT increases the risk of which HRT risks
breast cancer (especially if continuous regime) VTE
When do you stop HRT before surgery
4-6 weeks
How would you look up endometriosis and dysmenorrhoea treatment in the BNF
“sex hormones”
how do you manage vasomotor symptoms of menopause
fluoxetine or citalopram
how do you manage vaginal dryness in menopause
estriol - vaginal lubricant
What drugs should you be wary of in myasthenia?
Loads so check the BNF if they have a history of MG. Particularly careful with aminoglycoside abx, other abx, b-blockers, neuro/psych drugs
what drugs should you be wary of in epilepsy?
ciprofloxacin amino/theophylline mefenamic acid methylphenidate amphetamines
What drugs should you be wary of in HF
pioglitazone
NSAIDs and steroids
flecainide
verapamil
what should you do if a HYPOthyroid patient presents with…
TSH<0.5
TSH>5
<0.5: reduce dose of levothyroxine as you’ve overtreated
>5: increase dose
management of hyperkalaemia
10 units of actrapid in 100ml of 20% dex over 30 minutes
causes of hyponatraemia
diuretics
carbamezapine
citalopram
causes of neutropenia
clozapine
carbimazole
causes of thrombocytopenia
heparin
penicillamine
starting dose of statins for primary prevention
20mg (BNF says 20mg so remember this one!)
how can aspirin affect the blood
iron deficiency anaemia
drugs that cause urinary retention
NSAIDs and opioids
Benzodiazepines
anticholinergics and antihistamines
CCBs
drugs that cause confusion
opioids metoclopramide antidepressants and psychotics anticonvulsants anticholinergics (steroids, NSAIDs, B-blockers, digoxin)
what drugs can worsen statin induced myalgia
enzyme inhibitors
drugs that cause anaphylaxis
NSAIDs
Abx
IV iron infusion
morphine
what is an indication for stopping HRT
BP rise >160/95
What Hb level would indicate a need for transfusion
> 70
or <80 in ACS
maximum K infusion rate
10mmol/hr
in hyperkalaemia if there are still ECG changes after a first dose of calcium chloride what can you do
repeat every 15 minutes up to 50ml i.e. 5x
presentation of lithium toxicity
muscle weakness
polyuria and polydypsia
when would you consider stepping down asthma treatment
symptoms controlled for 3 months
what are the BP targets in HTN
<140/90
unless age >80 then it’s <150/90
what anti–hypertensives do diabetics start on
ACE-i regardless of age or ethnicity
first line POP
desogestrel (long pill free period in case of missed pill)
what fluids should you prescribe to a stroke patient
not glucose (risk of cerebral oedema)
where would you find info on sepsis in children
“blood infection”
what drugs should be stopped in PVD
CI: b-blockers
caution: ACE-I
blood glucose levels diagnostic of diabetes
fasting >7
random >11
HbA1C >48 (6.5%)
post-op fluids
often omit K unless it is low (K released from cell lysis in surgery so likely to be raised)
what may be causing low BP and urine output in a HF patient
dehydration
overload + LVF
which fluids should you use in liver failure
5% dextrose
saline worsens ascites
