PSA misc Flashcards
what blood thinners to be avoided in pregnancy ?
DOACs
(apixiban, edoxiban)
what drug combination makes up tazocin ? so keep in mind if patient has what allergy ?
- piperacillin with tazobactam
(so beware if patient has penicillin allergy)
what opiates to be used in renal dysfunction ? (3)
Fentanyl, alfentanil and buprenorphine
name a contraindication to tramadol ?
epilepsy (lowers seizure threshold)
what antibiotics is contraindicated with methotrexate use ?
Trimethoprim, co-trimoxazole
- Potentially fatal interaction (due to severe bone marrow suppression) between MTX and trimethoprim. Interaction also applies to co-trimoxazole
how often is methotrexate prescribed ? what is prescribed alongside it ?
methotrexate is always taken weekly
- folic acid taken on a different day
what are the 6 rights of medicine administration ?
- right patient
- right medicine
- right route
- right dose
- right time
- right to refuse
when is a second check required for drug administration ?
- controlled drugs
- injectables (the prep of drugs for parenteral administration should be double checked)
- medicine given under section 62 of MHA
when should an SSRi be administered ?
in the morning
- not at night as can affect sleep
when should aledronic acid be taken ?
- Take alendronic acid first thing in the morning, before you have anything to eat or drink and before you take any other medicines.
- Stay sitting or standing for 30 minutes so the medicine does not irritate your food pipe
when should levothyroxine be taken ?
once a day in the morning, ideally at least 30 minutes before having breakfast or a drink containing caffeine, like tea or coffee
when should a statin be taken ?
before going to bed
name some medications where timing of administration is important ? (4)
- antimicrobials
- insulin
- nitrates (need to have at least 8 hrs nitrate free)
- meds for Parkinson’s disease
where in the bnf can you find info for what dilutant should be used for an IV drug
directions for administration
name some indications for the use of warfarin ?
- after prosthetic heart valve insertion
- prophylaxis of embolisation in RHD and AF
- prophylaxis and treatment of VTE + PE when DOAC not appropriate
- TIA
what is target INR for DVT and AF ?
2-3 (2.5)
name some warfarin inducers (reduced warfarin effect)
- carbamazepine
- rifampicin
- phenytoin
- azathioprine
- st johns wort
give some examples of warfarin inhibitors (warfarin increased effect)
- amiodarone
- clarythromycein
- SSRI
- fluconazole
- omeprazole
what type of drug is warfarin ?
Vitamin K antagonist
(Inhibits vitamin K dependent clotting factors II, VII, IX,X)
what type of drug is apixiban ?
Direct factor Xa inhibitor
why type of drug is Dabigatran ?
thrombin inhibitor
what type of drug is morhpine ?
mu opioid receptor agonist
how is morphine excreted ?
really excreted - can accumulate in renal impairment
- need to know renal function and weight
in what presentations are opioids contraindicated ? (3)
- acute abdomen
- respiratory depression
- head injury
morphine 10 mg = how much oxycodone
morphine 10 mg = 5 mg oxycodone
(oxycodone is good in renal impairment)
what is normal blood glucose range ?
6 – 10mmol/L (acceptable range = 4-12mmol/L)
what are the four key components of pharmacokinetics ?
- absorption
- distribution
- metabolism
- excretion
(ADME)
name the enteral routes ? (4)
- oral
- sublingual
- buccal
- rectal
name the parenteral routes ? (3)
- SC
- IM
- IV
to which cardiac rhythms should you administer DC shocks ? (2)
- ventricular fibrillation
- pulseless ventricular tachycardia
in cardiac arrest, how often do you repeat adrenaline doses ?
3-5 mins
if IV route is not feasible in cardiac arrest, what other route could be trie d?
intraosseous
CPR. what is the rate of chest compressions to breaths ? what depth of compressions ? what rate ?
30:2
5-6cm
100-120 bpm
(delivered on lower half of sternum)
what are the non-shockable rhythms in cardiac arrest ?
- asystole
- pulseless electrical activity (PEA)
how often should you check the cardiac rhythm during a cardiac arrest ?
every 2 mins
patient has had cardiac arrest. Was in VT. what do you do after 3 shocks ?
- give IV dose of adrenaline 1mg
- give single dose of IV amiodarone 300mg
- repeat doses of adrenaline every 3-5 mins
what do you do when non shockable rhythm is detected during cardiac arrest ?
- give 1mg IV adrenaline
- give 2 ins CPR before next rhythm check
causes of cardiac arrest
what are the 4Hs and 4Ts ?
- Hypoxia
- Hypovolaemia
- Hypo/hyperkalaemia
- Hypothermia
- Tamponade
- Thromboembolism
- Toxins
- Tension pneumothorax
what is given for managment of hyperkalaemia ?
- calcium gluconate
- insulin + dextrose
which medications can cause cardiac arrest ?
- opioids
- benzodiazepines
- TCAs (amitriptyline)
what’s an important ADR reaction of carbimazole ?
bone marrow suppression
what do you search on bnf to find info about steroids ?
glucocorticoid therapy
what is the action of methotrexate ?
antagonist of folic acid
DOAC ADR ? (3)
- bleeding
- anaemia
- Nausea
what things does a patient taking amiodarone need to be counselled about ?
- sunscreen
- breathing problems
- vision problems
- liver toxicity
methotrexate ADR ?
- stomatitis
- SJS
- TEN
- interstitial pneumonitis
ACEI ADR ?
- cough
- low BP
- renal impairment
- hyperkalaemia
- angioedema (can occur after years of being on the drug all ok)
name some rate limiting CCB ?
- diltiazem
- verapamil
(the other ones are called Dihydropyridine CCB - amlodipine)
CCB ADR ? (4)
- abdo pain
- flushing
- headache
- peripheral oedema
what dose of statin for secondary prevention of cardiovascular events ?
80 mg
(this is the max statin dose)
Name some SABAs (2)
- salbutamol
- terbutaline
name some LABAs (4). what do they end in ?
end in -rol
- olodaterol
- formoterol
- salmetarol
- indaceterol
name some ICS (5) what do they end in ?
end in -asone/-onide
- beclametasone
- budesonide
- mometasone
- cicelsondie
- fluticasone
name some LAMA (4). what do they end in ?
end in -ium
- tiotropium
- Umeclidindium
- Glycopyronium
- Aclidinium
what route are patches administered ?
transdermal (not topical)
what are the 3 options for emergency contraception ?
- copper IUD
- levonorgestrel
- ulipristal
ulipristal contraindications
- breast/ovarian/cervical/uterine cancer
- severe asthma controlled by oral glucocorticoids
is parenterally or oral administration associated with worse anaphylaxis ?
parenteral is generally more severe
- with median cardiac arrest time from first symptom onset only 5 mins
common causes of allergic drug reactions ? (6)
- penicillins + other beta lactams
- NSAIDs
- muscle relaxants
- chlorhexidine
- opioid analgesics
- radio contrast media
what should be administered for a mild-mod drug allergy ?
fast acting oral antihistamine (chlorphenamine)
what is the adrenaline dose for an adult in anaphylaxis ?
500micrograms IM
- 0.5mL of 1mg/mL (1:1000)
when can IV route be used for adrenaline ?
should only be prescribed and administered by specialist physicians. pulse oximetry and ECG monitoring throughout
- may cause life-threatening arrhythmias and hypertension
what drug class and example can be used to help treat the skin symptoms of allergic drug reactions ?
non-sedating antihistamine (cetirizine)
what drugs should be prescribed following resolution of severe anaphylactic reaction ?
- prednisolone for up to 3 days
- non-sedating antihistamine for up to 3 days
- ensure allergy is documented
- yellow card scheme
when should you take timed blood test sample after an anaphlacit reaction ? what are you looking for ?
mast cell try-take as soon as possible after emergency treatment has started AND 1-2 hours after the onset of symptoms (but no later than 4)
if a patient has received treatment for anaphylaxis, how long should they be observed for ?
6-12 hours
in what time frame is activated charcoal useful ?
it binds may poison in the GI tract, helping to reduce absorption
- only likely to be useful if given within one hour of ingestion
what is is used in Mx of paracetamol poisoning ? what route ? what time frame ?
IV acetylocysteine (within 8 hours of paracetamol ingestion)
what is is used in Mx of iron poisoning ?
Desferrioxamine
(you can get lucid interval in iron overdose)
what is is used in Mx of benzodiazepine poisoning ?
Flumazenil
what is is used in Mx of methanol and ethylene glycol poisoning ?
fomepizole
what is is used in Mx of BB toxicity ?
glucagon
what is is used in Mx of warfarin poisoning ?
phytomenadione (vit K)
when take plasma-paracetamol conc in suspected paracetamol overdose ?
take a sample between 4 and 15 hours post-ingestions
- gives indication of severity of poisoning and the degree of liver toxicity
when can acetyl cysteine be commenced before the palms-paracetamol concentration is known ?
- more than 8 hrs elapsed since overdose
- staggered overdose
- doubt over the time of paracetamol ingestion
what does 1% lidocaine mean. for calculation purposes
1g per 100mL
what are the two main fluid compartments ? what can this be further divided into ?
- intracellular
- extracellular
- interstitial
- intravascular
difference between crystalloids and colloids
- crystalloids are essentially solutions of mineral salts
- Colloids contain larger water-insoluble molecules
what amount of K, Na and Cl mmol/kg/day
1 mmol/kg/day of potassium
1 mmol/kg/day of sodium
1 mmol/kg/day of chloride
approximately what % of total body weight in adults is made from water ?
50-60%
of a 70kg man: how much today body water ? how much in inctracellular? how much interstitial ? how much intravascular ?
42 litres total body water
- intracellular (65% TBW): 28L
- interstitial (35% x 75%): 10.5L
- intravascular (35% x 25%): 3.5L
what vol of water is approximate to insensible fluid losses
800 mL per day
how much water needed per day ?
25-30 ml/kg/day of water
(around 2 - 2.5 litres per day)
20-25ml/kg/day for elderly, renal impairment, malnourished
so go with 25 !
how much glucose required per day ?
50-100 g/day of glucose to limit starvation ketosis
what counts as red flag sepsis ?
- NEWS2 score > 7
- NEWS2 score 5 or 6, plus: lactate >2, other organ failure (AKI), patient looks very unwell, patient is actively deteriorating
what counts as amber flag sepsis ?
- NEWS2 score 5 or 6
- NEWS2 score 1 - 4 , plus: lactate >2, other organ failure (AKI), patient looks very unwell, patient is actively deteriorating
what is cryptic shock
patients present with a high lactate concentration in the presence of a normal blood pressure
what do you search bnf for to find things about the pill and HRT ?
conracep
(the pill, HRT, emergency contraception)
what do you need to know about in a patient who you are prescribing the patch for contraception ?
their weight
>90kg it is not as effective
when should you start the COCP ?
start on day 1 of menstrual cycle
what are the withdrawal bleeds on the COCP ?
- withdrawal bleeds occur during hormone free interval, not menstruation
- withdrawal bleeds can still occur during pregnancy (cannot rely on this for pregnancy status)
what are rules for COCP and POP before surgery ?
- COCP needs to be held for 4 weeks before major surgery
- POP does not need tube held prior to surgery
emergency contraception: levonorgestrel.
what time window ?
how many times per cycle ?
how BMI effect ?
- 72 hour window (3 days)
- more than once per cycle is allowed, but increase SE risk
- double dose required in high BMI
emergency contraception: ulipristal.
what time window ?
how many times per cycle ?
how BMI effect ?
contraindications ?
- 120 hr time window (5 days)
- more than once per cycle is allowed
- can be used in high BMI
- CI: breast/ovarian/cervical/uterine cancers, severe asthmas controlled by oral glucocorticoids
which is more effective: ulipristal or levonorgestrel ?
ulipristal
what is HRT ? what hormone ?
a small dose of oestrogen for alleviating the symptoms of menopause given if premenopausal or postmenopausal
- given with progesterone if the woman has a uterus
when cyclical or continuous progesterone for HRT ?
continuous not to be used in perimenopause or within 12 months of last period
- progesterone free period causes withdrawal bleeds
(so usually initial: oestrogen plus cyclical progesterone)
HRT comes in many formulations. what a good one to remember with lots of formulations ?
estradiol with norethisterone
- tablets, cyclical patch, continuous patch
name some crystalloids ?
- sodium chloride
- Hartmans
- dextrose 5%
(NaCl, Hartmans can be used for resus)
what pads rhesus fluids ?
sodium chloride 0.9% 10Ml/kg over <10 mins
what is maximum infusion rate of potassium ?
10mmol/hr
what does potassium 0.3 % mean ?
potassium 0.3 means there is 40mmol potassium in 1 litre, or 20mmol potassium in 500ml
(0.15% is the paediatric value)
adult hypoglycaemia mx ?
150ml glucose 10% in less than 15 minutes
(glucose 10% x 15 mins = 150mls)
what info do you need to submit a yellow card ?
- identifiable patient
- identifiable reporter
- a suspect reaction
- a suspect drug
what is type A drug reaction ? (4)
dose-related
common, predictable
related to the pharmacology
unlikely to be fatal
(like digoxin toxicity, or constipation with opioid analgesics)
what is type B ADR ?
type b (bizzarre)
- not dose related (within therapeutic dose range)
- uncommon, unpredictable
- not related to the pharmacology
- often fatal
what is the yellow card scheme ?
the yellow card scheme in the UK collects spontaneous reports of suspected ADRs
mx of conscious person with diabetes ?
mild hypo can be reversed in about 10 mins with 15 - 20g of a quick acting carbohydrate
- then check blood glucose after 10 - 15 mins
- if still remains <4 mmol/litre after 3 cycles, then administer IM glucagon
mx of conscious confused person with hypo ?
same as mild but give 2 tubes of 40% glucose gel (squeeze into the mouth between the teeth and gums)
tamoxifen SE ?
- increase risk of blood clots
- hot flushes
what are the sick day rules for steroids ?
double steroid doses to avoid adrenal insufficiency
when does the BNF suggest gradual withdrawal of systemic corticosteroids for patients ?
- received more than 40mg prep daily for more than one week
- received more than 3 weeks treatment
- recently received repeated courses
what fluids should be avoided in patients who have had a stroke ? why ?
5% glucose should be avoided due to the increased risk of cerebral oedema
what route of oxygen should be administered in patients who are critically ill (anaphylaxis, shock) ?
oxygen should initially be given via a reservoir mask at 15l/min
(hypoxia kills)
describe the oxygen managment for COPD patients ? prior to blood gas ? then what ?
- prior to blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92%
- adjust target range to 94-98% if the pOC2 is normal
how many mmol of sodium in one litre bag of 0.9% normal saline ?
154 mmol
if large vols of saline are used, what blood gas is there risk of ?
increased risk of hyperchloraemic metabolic acidosis
what is the maximum concentration of potassium chloride that can be administered via peripheral route ?
40 mmol/litre
(infusions exceeding this should be given vie central IV route
what is the max rate of infusion of potassium per hour - normally ? in emergency ?
- shouldn’t no normally exceed 10 mmol/hour
- up to 20 mmol/hour in an emergency situation
what is given to protect the heart in hyperkalaemia ?
10 ml of calcium gluconate 10 % solution, by slow IV injection over 3-5 minutes
what impact does renal function have on gentamicin ?
any impairment in renal function can cause reduced elimination of gentamicin form the body and a high serum-gentamicin concentration as a result.
how quickly should gentamicin infusions be done ?
via IV infusion over at least 60 mins
what is used to calculate doses of gentamicin ?
- calculated using the actual body weight
- unless patients weight is 20% heavier than IBW or has BMI more than 30
when should you measure vancomycin levels ?
measure levels after 36-72 hours (3-6 doses)
how often should HbA1c levels be monitored in T1DM ?
every 3 - 6 months
which drugs may exacerbate heart failure ?
- thiazolidinediones (Pioglitazone)
- verapamil (negative inotropic effect)
- NSAIDs/glucocorticoids (can cause fluid retention)
- flecanide
what is the therapeutic range of lithium ? when should you take this measurement ?
range = 0.4 - 1.0 mmol/l
take 12 hours post-dose
what drug can be given to reverse the effects of warfarin ?
phytomenadione
how is digoxin excreted ?
renal excretion
(digoxin has long half-life of 20-50 hours which can extend to 100 hours in renal dysfunction)
what is the form of lithium that is oral tablets ?
lithium carbonate
(lithium citrate is oral liquid)
what electrolyte imbalance exacerbates lithium toxicity ?
sodium depleted
what is the general rule with antidepressants and breast milk ?
if a medicine enters the CNS (antidepressant) it will enter the milk
describer aspects of a drug that are associated with reduced passage into breast milk ?
- high molecular weight
- high protein binding
- low lipid solubility
- Lower pH
what can be given to stop milk supply
cabergoline 1 mg
which analgesics are safe during breast feeding ?
- paracetamol
- NSAIDs
- NOT Opioids (only prescribe for short time)
what is the first line treatment of depression in breast feeding mothers ?
SSRIs (sertraline)
how to you adjust the gentamicin dose when the trough levels are too high ?
the interval between the doses should be increases if the trough levels are raised ? (switch from QDS to BD)
which medications are usually prescribed weekly in the UK ?
- bisphosphonates
- methotrexate
if large volumes of 0.9% saline are used, what is there risk of ? what acid/alkalosis ?
hyperchloraemic metabolic acidosis ?
therapeutic drug monitoring. when do you test ciclosproin levels ?
trough levels immediately before dose
therapeutic drug monitoring. the do you test digoxin levels ?
at least 6 hrs post-dose (so often immediately before next dose is given)
how to you adjust peak and trough levels when too high ?
- if the trough (pre-dose) level is high the interval between the doses should be increased
- if the peak (post-dose) level is high the dose should be decreased
what drugs are contraindicated in severe liver disease ?
- NSAIDs
- ACEI
- paracetamol
- co-amoxiclav, flucloxacillin
- methotrexate
- amiodarone
what dose of acutely ingested paracetamol can lead to lever damage ? in what time frame ?
150 mg/kg in less than one hour
a decrease in first-pass metabolism has what effect on the oral bioavailability ?
increase the oral bioavailability of some drugs (even to 100% - same as IV)
describe how to calculate maintenance fluids over 24 hrs in kids. by weight
100ml/kg for the first 10 kg
50 ml/kg for the next 10kg
20 ml/kg for every remaining kg
how should bisphosphnoates be taken ?
tablets should be swallowed whole with plenty of water while sitting or standing, to be taken on an empty stomach at least 30 minutes before breakfast
how to you calculate fluid deficit in children ?
deficit = % dehydration x weight (kg) x 10
which drugs should be used with caution in patients with ischaemic heart disease ? (3)
- NSAIDs
- oestrogens (COCP, HRT)
- varenicline
which drug is licensed for use in milk to moderate Parkinson’s disease dementia ?
rivastigmine
what mode stabilisers recommended for med naive patients for mania or hypomania ?
- haloperidol
- olanzapine
- quetiapine
- risperidone
1st 2nd 3rd line for bipolar
- 1st: lithium
- 2nd: valproate, olanzapine
- 3rd: carbamazepine, lamotrigine
how long until lithium is effective ?
can take 10 - 14 days to be effective
(take 4 - 7 days to reach steady state)
what effect on kidneys do ACEI have on?
inhibit vasoconstriction of efferent arterioles
signs of digoxin toxicity ?
- confusion
- nausea
- visual halos
- arrhythmia
signs of lithium toxicity ? in stages
- early: tremor
- intermediate: tiredness
- late: arrhythmias
signs of gentamicin and vancomycin toxicity ?
- ototoxicity and nephrotoxicity
how to you alter warfarin when: INR 5 - 8 with no bleeding ?
omit warfarin for 2 days then reduce dose
how do you alter warfarin when: INR > 8, no bleeding ?
omit warfarin and give 1-5mg PO vit K
how do you alter warfarin when: INR 5-8 and minor bleeding ?
omit warfarin and give 1 - 5mg IV vit K
how do you alter warfarin when: INR > 8 and minor bleeding ?
omit warfarin and give 1-5mg IV vit K (same if INR 5-8)
do you stop metformin before surgery ?
yes - it is stopped the day of surgery ?
do you stop aspirin for surgery ?
yes - anti platelets and anticoagulants (heparin) and COCP should be stopped
metformin contraindication ?
severe renal impairment (eGFR < 30, because increased risk of lactic acidosis)
when should nitrofurantoin be avoided ?
should be avoided when eGFR less than 45
