PSA Revision Flashcards
Effect of a P450 inducer?
Increase metabolism of P450, therefore drug exerts less of an effect
Effect of a P450 inhibitor?
Reduced metabolism of P450, therefore drug exerts more of an effect.
Examples of P450 Inducers ?
Increased enzyme activity, decreased drug concentration
- PC BRAS
- Phenytoin
- Carbamazepine
- Barbiturates
- Rifampicin
- Alcohol (chronic excess)
- Sulphonylureas
Examples of P450 inhibitors?
AODEVICES
- Allopurinol
- Omeprazole
- Disulfiram
- Erythromycin
- Valproate
- Isoniazid
- Ciprofloxacin
- Ethanol (acute intoxication)
- Sulphonamides
Drugs to stop before surgery - COCP?
4 weeks before surgery
Drugs to stop before surgery
- Lithium
Day before
Drugs to stop before surgery
- Potassium sparing diuretics and ACEi?
Day of surgery
Drugs to stop before surgery
- Warfarin/heparin)
- Antiplatelets
- Variable.
Generally Warfarin is stopped and bridged with LMWH.
Drugs to stop before surgery -
Oral hypoglycaemic drugs and insulin?
Patient is NBM before surgery.
Metformin should be stopped because it will cause lactic acidosis.
In all cases - a sliding scale should be started instead - hourly blood glucose monitoring and adjust hourly dose.
Mnemonic for drugs to stop before surgery?
I LACK OP
- Insulin
- Lithium
- Anticoagulants
- COCP/HRT
- K-sparing diuretics
- Oral hydoglycaemics
- Perindopril
Management of long-term corticosteroids (pred) before surgery?
Increase steroid requirement
At IOA, patient should be given IV steroids.
Drugs to stop for a patient with haemoptysis?
Aspirin (Antiplatelet)
Enoxaparin (LMWH)
Drugs to stop patient is hyperkalaemic?
ACEi
IV fluid with K should be stopped.
Also patient is receiving 6g of paracetamol so should be stopped.
Common pitfalls for prescribing?
Ensuring we have correct patient’s prescription/drug chart
Noticing and recording allergies
SIgning the front of the chart.
Considering contraindications for each drug we prescribe.
Consider the route for each drug we prescribe
Consider the need for IV fluids.
Consider need for thromboprophylaxis
Consider need for antiemetics
Consider need for pain relief.
What is the PReSCRIBER mnemonic?
Patient Details Reaction Sign the front of the chart check for Contraindications to each drug Prescribe Intravenous fluids if needed Prescribe Blood clot prophylaxis if needed Prescribe antiEmetic if needed Prescribe pain Relief if needed.
When working on a new chart what must you write?
3 piece of patient identifying information on the front
- Patient Name
- DOB
- Hospital Number
Reactions for drug charts?
Check allergy box to include any drug reaction
Don’t forget that co-amoxiclav and Tazocin both contain penicillin.
Contraindications in drug charts? - Bleeding
Consider whether it is contraindicated.
Drugs that increase bleeding (aspirin, heparin and warfarin). Should not be given to those risk of bleeding (liver disease).
Prophylactic heparin is contraindicated in acute stroke - risk of bleeding.
Be wary that enzyme inhibitors AODEVICES can increase PT and INR.
Contraindications for drug chart - Steroids?
Side effects -
- Stomach ulcers
- thin skin
- Oedema
- Right + left heart failure
- Osteoporosis
- Infection
- Diabetes
- Cushing’s syndrome
Contraindications for rugs - NSAIDS?
- NSAID
- No urine (renal failure_
- Systolic dysfunction (heart failure)
- Asthma
- Indigestion
- Dyscrasia (clotting abnormality)
Aspirin, whilst not technically an NSAID. It is not contraindicated in renal or heart failure.
Antihypertensives - SE?
Hypotension that may result from all groups of antihypertensives.
Bradycardia = beta blockers + CCBs .
Electrolyte disturbances with ACE and diuretics.
Individual drug classes have specific side effects
- ACEi = Dry cough
- Beta-blockers = wheeze in asthmatics
- CCB = Peripheral oedema and flushing
- Diuretics = renal failure. Loop diuretics can also cause gout.
Spironolactone causes
Route for patients?
if vomiting = antiemetics should be given by non-oral routes = IV/IM/SC
E.g Cycline 50mg 8hrly IV or PO
Metoclopramide 10mg 8 hrly.
If a patient is nil by mouth should still receive oral medication.
When are IV fluids prescribed?
As replacement for dehydrated/acutely unwell patient
As maintenance in patient who is nil by mouth.
Which fluid to prescribe?
- 9% saline UNLESS:
- Patient is hypernatraemic or hypoglycaemic: then give 5% dextrose instead.
- Has ascites: give human-albumin solution instead.
- Shocked with systolic BP <90: give gelofusine instead as it has high osmotic content so stays IV, thus stays intravascularly, maintaining BP for longer.
- Is shocked from bleeding: give blood transfusion, but a colloid first if no blood available.
How much fluid and how fast? - tachycardic or hypotensive
If tachycardic or hypotensive give 500ml Immediately in 10 mins
250ml if heart failure.
Then reassess patient, especially HR BP and urine output to assess response + speed of next bag.
How much fluid and how fast - oliguric (not due to obstruction)?
IL over 2-4hrs.
Then reassess HR, BP and urine output.
How volume depleted is a patient with reduced urine output (<30ml/h)
500ml of fluid depletion
How volume depleted is a patient with reduced urine output (<30ml/h) plus tachycardia?
1L of fluid depletion
How volume depleted is a patient with reduced urine output (<30ml/h), tachycardic plus is shocked?
Indicated >2L of fluid depletion.
Maintenance fluids requirements over 1 day?
Adults = 3 IV fluid per 24hrs Elderly = 2L per 24hrs
Adequate electrolytes are provided by 1L of 0.9% saline and 2L of 5% dextrose.
1 salty and 2 sweet.
K+ = Bags of 5% dextrose or 0.9 saline containing KCL can be used. Patients require roughly 40mmol KCL per day = 20mmol KCL in 2 bags.
Never give IV potassium at more than 10mmol/hour.
How fast to give maintenance fluids?
If 3 L = 8hrly bags
If 2 L = 12hrs bags.
In real life - check patients’ U+E, confirm what to give.
Check patient is not fluid overloaded (increased JVP, peripheral and pulmonary oedema.
Ensure patient’s bladder is not palpable.
Blood clot prophylaxis?
Prophylactic LMWH - dalteparin 5000 units daily s/c.
Compression stocking to prevent VTE.
If a patient is bleeding or at risk of bleeding (recent CVA) - they should not be prescribed warfarin or heparin.
Patients with PAD should not be prescribed compression stockings.
Antiemetics for patients that are nauseated?
Regular antiemetics
- Cyclizine 50mg 8hrly IM/IV/ oral. Most cause fluid retention.
- Metoclopramide 10mg 8hrly IM/IV.
Antiemetics for non-nauseated patients?
PRN antiemetics
- cyclizine 50mg IV/IM/oral.
- Metoclopramide 10mg up to 8hr IM/IV.
Cyclizine (anti-histamine) for most patients except cardiac cases when its safer to give metoclopramide.
When to avoid metoclopramide?
Crosses the BBB
Patients with Parkinson’s diseases due to risk of exacerbating symptoms
young women due to risk of dyskinesia - unwanted movement especially acute dystonia.
Pain relief for patients?
No pain = PRN paracetamol 1g 6hrly.
Mild pain = Paracetamol 1g 6 hourly oral regularly. Codeine 30mg up to 6hourly oral.
Severe pain = Co-codamol 30.500, 2 tablets 6-hourly oral.
Morphine sulphate: 10mg up to 6 hourly oral.
Morphine in order of effectiveness
- Morphine sulphate (oramorph)
- Subcutaneously
- intravenously.
Ensure only 4g of paracetamol is being prescribed.
Management of neuropathic pain?
Nerve damage usually shooting, stabbing or burning.
First line = Amitriptyline (10mg oral nightly) or pregabalin (75mg oral 12-hourly).
Duloxetine (60mg oral daily) indicated in painful diabetic neuropathy.
Bendroflumethiazide and potassium?
Leads to hypokalaemia by increasing potassium excretion.
Remember that ACEi can lead to increased Potassium.
Lisinopril and potassium?
Causes kyperkalaemia through reduced aldosterone production and thus reduced potassium excretion in the kidneys.
Loop and thiazide = hypokalaemia.
Aldosterone antagonist and ACEi cause hyperkalaemia.
NSAIDS and indigestion?
Inhibits prostaglandin synthesis therefore risk of influencing inflammation and ulceration.
Oral steroids inhibit epithelial renewal thus predispose to ulceration.
NSAIDS and renal failure?
NSAIDS reduce renal artery diameter and thereby reduce kidney perfusion and function.
ACEi - reduce ACEi and stop aldosterone.
Ibuprofen and asthma?
Must stop as contraindicated!
Trimethoprim and methotrexate?
Avoid as risk for bone marrow toxicity. Therefore stop the trimethoprim.
Methotrexate and sepsis?
Must exclude neutropenic sepsis.
Furosemide and sodium?
Hyponatraemia and Hypokalaemia.
Amlodipine side effect?
Peripheral oedema.
incorrectly treated with furosemide therefore stop amlodipine.
When patient has a high INR what should you stop?
Both warfarin and heparin.
Verapamil and beta blockers?
Risk of bradycardia and hypotension.
Make sense to stop the verapamil causing the peripheral oedema.
Beta blockers and asthmatics?
Contraindicated due to bronchospasm.
NSAIDS used with caution.
Normal cardioprotective and treatment dose of aspirin?
75 mg daily
Stroke dose = 300mg daily.
Microgynon?
CI in patients with migraine.
Increases risk of stroke too.
Prophylactic heparin in stroke?
CI following stroke.
Novomix is given incorrectly
Never given IV
All insulin is given IV except for sliding scales.
Clozapine worrying side effect?
Antipsychotic. - Agranulocytosis resulting in neutropenia.
Causes of a microcytic anaemia?
IDA
Thalassaemia
Sideroblastic anaemia
Causes of normocytic anaemia ?
Anaemia of Chronic Disease
Acute blood loss
Haemolytic anaemia
Renal failure (chronic)
Macrocytic anaemia cause?
- B12/folate deficiency
- Excess alcohol
- Liver disease (non-alcohol)
- Hypothyroidism
- Haematological disease beginning with M: myeloproliferative, myelodysplasia, multiple myeloma.
Hypovolaemic Hyponatraemia causes?
Fluid loss (especially diarrhoea/vomiting)
Diuretics
Addison’s disease
Euvolaemic hyponatraemia causes?
SIADH
Psychogenic polydipsia
Hypothyroidism
SIADH = Small cell lung cancer, Infection, Abscess, Drugs (carbamazepine, antipsychotics) and Head injury.
Hypervolaemic hyponatraemia causes?
Heart failure Renal failure Liver failure Nutritional failure Thyroid failure
Causes of hypokalaemia?
DIRE
- Drugs (loop and thiazide)
- Inadequate intake or intestinal loss
- Renal tubular acidosis
- Endocrine (Cushing’s and Conn’s syndrome) - excess aldosterone
Causes of hyperkalaemia?
DREAD
Drugs, Spironolactone, ACEi Renal failure Endocrine: Addisons Artefact (due to clotted sample) DKA (insulin to treat DKA potassium drops requiring regularly hourly monitoring.)
Causes of hypernatraemia?
All begin with D
- Dehydration
- Drips (IV saline)
- Drugs (effervescent tablet preps or IV prep with a high sodium content).
- Diabetes insipidus (effectively the opposite of SIADH)
Causes of high neutrophils (neutrophilia)
Bacterial infection
Tissue damage
Steroids
Causes of low neutrophils?
Viral infection
Chemo and radiotherapy
Clozapine
Carbimazole (antithyroid)
Causes of high lymphocytes (lymphocytosis)?
Viral infection
Lymphoma
Chronic Lymphocytic Leukaemia
Causes of low platelets? Thrombocytopenia
Reduced production
- Infection (viral)
- Drugs (penicillamine (rheumatoid)
- Myelodysplasia, myelofibrosis, myeloma.
Increased destruction
- Heparin
- Hypersplenism
- DIC
- ITP
- HUS/TTP
Causes of high platelets?
Reactive
- Bleeding
- Tissue damage
- INflammation, malignancy
- Post-splenectomy
Primary
- Myeloproliferative disorder)
Causes of a raised Urea?
Could indicate AKI
Upper GI bleed.
Therefore a patient with a raised urea and normal creatinine who is not dehydrated (look at haemoglobin for a GI bleed).
Causes of an pre-renal AKI?
Prerenal - Urea rise»_space; creatine rise. eg urea 19 and creatinine 110.
Dehydration
Sepsis /Blood loss
Renal artery stenosis
Multiple urea by 10. If it exceeds creatinine then this suggests prerenal aetiology.
Causes of a renal AKI?
Urea rise «_space;creatinine rise, bladder or hydronephrosis not palpable.
Due to ischaemia - due to prerenal AKI, causing acute tubular necrosis)
Nephrotoxic antibiotics - Gentamicin, vancomycin, tetracyclines.
Tablets (ACEi, NSAIDs)
Radiological contrast
Injury
Negatively birefringement crystals (gout)
Syndromes (glomerulonephridites)
Inflammation (Vasculitis)
Cholesterol emboli
Causes of a postrenal AKI?
Urea rise «_space;creatinine rise, bladder or hydronephrosis may be palpable depending on level of obstruction.
In lumen: stone or slough papilla.
In wall: Tumour, fibrosis,
External pressure: Benign prostatic hyperplasia, prostate cancer, lymphadenopathy, aneurysm.
Causes of a raised Alk Phos
Any fracture Liver damage K(Cancer) Paget's Pregnancy Hyperparathyroidism Osteomalacia Surgery
Pattern of prehepatic jaundice and cause?
Raised isolated Bilirubin
Cause: Haemolysis, Gilbert’s and Crigler-Najjar Syndrome
Pattern of intrahepatic and cause of jaundice?
Raised AST/ALT and raised bilirubin
Cause: Fatty liver Hepatitis & Cirrhosis (due to 1) alcohol 2) Viruses (Hep A-E, CMV, EBV) 3) drugs (paracetamol, statins, rifampicin)
Malignancy
Metabolic: Wilson’s disease/haemochromatosis
Heart failure
Pattern of post-hepatic jaundice and causes?
Bilirubin increased
ALP increased
In lumen: Stone (gallstone), drugs causing cholestasis (Flucloxacillin, co-amoxiclav, nitrofurantoin, steroids, sulphonylurea)
In wall: tumour (cholangiocarcinoma), PBC, PSC.
Extrinsic pressure: pancreatic or gastric cancer, lymph node.
TFTS?
Might be asked to change levothyroxine dose according to TFTs results for patient with hypothyroidism.
Use TSH as a guide.
Target range ~0.5-5mlU/L.
If TSH range <0.5 - Decrease dose as it is being suppressed.
If TSH 0.5-5 = Nil action - same dose
If >5 = Increased dose.
increased by smallest increment offered.
Interpretation of Chest X-ray?
PRIM
Projection (PA/AP).
Rotation - Distance between spinous process and clavicles.
Inspiration - 7th anterior rib transects diaphragm.
Markings
Structure
- Heart should be less than 50% of width of lungs.
- Look for effusion, pneumonia, oedema.
- Trachea should be central and if not consider collapse (towards) or pneumothorax (away).
Interpretation of arterial blood gases?
Subtract 10 from the FiO2 and if the PaO2 exceeds this calculated number then the patient is not hypoxic.
Presence of respiratory failure
Type 1 (most common) - Low or normal PaCO2 (fast/normal breathing) and can be caused by anything that damages the heart or lungs causing SOB.
Type 2 - Less common - High PaCO2 (slow shallow breathing) - Low oxygen. Blue bloaters of COPD - less commonly neuromuscular failure or restrictive chest wall abnormalities.
How to check ABG?
Look at pH.
Then look at PaCo2 to indicated respiratory cause.
If only HCo2 is abnormal this is a metabolic cause.
If both increased or both decreased this indicates compensation. If pH normal fully compensated. If abnormal partially compensated.
If both PaCO2 and HCO3 are abnormal but in opposite directions then there is coexistent metabolic and respiratory disease.
ECG rate?
Rate:
Divide 300 by number of large squares between each QRS.
Normal 60-100 bpm. <60bpm.
Rhythm
- P waves. Is it in sinus rhythm
Think about first, second or third degree HB.
QRS - complex. Normally <3 small squares.
If >3 then BB is present.
Height for LVH.
ST segment
- if elevated then: Infarct or pericarditis
- If depressed then ischaemic or digoxin.
T waves
- Height :if more than 2.s QRS then Hyperkalaemia likely.
- INversion: normal in aVR and I leads. In other leads suggests old infarction/LVH.
Common drugs that require monitoring?
Digoxin Theophylline Lithium Phenytoin Vancomycin
When adjusting these drugs?
Move up in the smallest possible increment. this is when response is inadequate and low serum drug level.
If adequate response to drug - normal or low serum drug level then no change required.
If adequate response to drug and high serum drug level then decrease the dose.
If there is evidence of toxicity then omit the drug.
(only exception is gentamicin where a high serum level without signs of toxicity) should pre-empt a decrease in frequency by 12hr rather than reducing the dose e.g changing from every 24hrs to every 36hrs.
Signs of digoxin toxicity?
Digoxin = Confusion, nausea, visual halos and arrhythmias
Lithium toxicity?
Early: tremor
Intermediate: tiredness
Late: arrhythmias, seizure, coma, renal failure and diabetes insipidus
Phenytoin toxicity?
Gum hypertrophy Ataxia Nystagmus Peripheral neuropathy Teratogenicity
Gentamicin toxicity?
Ototoxicity and nephrotoxicity
Vancomycin toxicity?
Ototoxicity and nephrotoxicity
What to do generally if there is evidence of toxicity?
Stop drug (± find alternative) Supportive measures (IV fluid) Give antidote
Gentamicin monitoring?
Aminoglycoside for severe infections.
Doses calculated according to patients weight and renal function. High dose regimen of 5-7 mg/kg once daily.
Patients with severe rena lfailure or endocarditis receive divided daily dose of 1mg/kg 12hrly (renal failure) or 8hrs in endocarditis.
Important because of gentamicin can cause ototoxicity and nephrotoxicity
Regimen monitoring for gentamicin?
Measure gentamicin levels are particularly times such as 6-14hr after last gentamicin infusion is started.
Use a nomogram.
f the resultant point on the graph falls within the 24 h area (q24h) then continue at the same dose; if it falls above the q24h area then change the dosing interval as follows:
- if point falls in the q36h area change to 36-hourly dosing
- if point falls in the q48h area change to 48-hourly dosing
- if point rests above the q48h area repeat the gentamicin
level and only re-dose when the concentration <1 mg/L.
Management of a paracetamol overdose?
N-acetyl cysteine.
IV fluids.
Use the paracetamol nomogram. If the plasma paracetamol level is below the line the patient does not require NAC. If above they do.
Paracetamol relies on glutathione therefore when this is used up, there is accumulation of NAPQI.
Warfarin excess management?
Warfarin inhibits synthesis of Vit K dependent clotting factors (II, VII, IX, X).
Prolongs the prothrombin time from which the INR is derived.
Targets for INR in most patients is 2.5 unless there is recurrent thromboembolism while on warfarin or metal replacement where it becomes 3.5.
if there is a major bleed causing hypotension or bleeding
- Stop warfarin
- Give 5-10mg IV vitamin K
- Give prothrombin complex
INR <6?
Reduce warfarin
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
INR 6-8?
Omit warfarin for 2 days then reduce dose
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
INR >8
Omit warfarin and give 1-5mg oral vitamin K.
If minor bleeding with INR >5 IV instead or oral vitamin K 1-3 mg.
Vitamin K admin complicates the reintroduction of warfarin so only given when there is presence of bleeding or an INR exceeding 8.
When deciding whether to stop ACEi and NSAIDs for high K and renal failure?
Stop both as they both can cause raised K. Can always restart again.
Ibuprofen - decreases renal blood flow by inhibiting prostaglandins that normally dilate blood vessels flowing in the kidney.
Neutropenic sepsis management alongside hyperkalaemia
Give PipTaz, Gentamicin, Paracetamol and Stop lisinopril.
Hyponatraemia and confusion?
Stop patient’s carbamazepine and furosemide, both contributing to the hyponatraemia.
Trimethoprim in pregnancy?
Contraindicated in pregnancy - predisposed to neural tube defects. OCP during pregnancy is contraindicated!
Digoxin and heart rate?
Bradycardia
Addison’s that are sick on steroids?
Increase for sick day rules.
Asthma drugs contraindicated?
Bisoprolol
Ibuprofen
Withhold salbutamol inhalers when they are giving nebs.
Management of acute heart failure?
Furosemide is the mainstay for acute heart failure and is administered IV.
Atrial Fibrillation management in patient with asthma and peripheral oedema?
Can’t use Beta-blocker
Can’t use Calcium Channel Blockers due to risk of peripheral oedema. (Amlodipine not really used, but diltiazem is used).
Therefore digoxin.
How are as required doses of morphine sulphate (oramorph) calculated?
one sixth of the total daily dose. - 1/6th of 30mg. Given up to every 4-6 hrs.
Management of STEMI?
ABC + O2 (15L) with non-rebreather
Hx/oe/inv. Diagnose STEMI
Aspirin 300mg
Morphine 5-10mg IV with metoclopramide 10mg IV
GTN spray
Primary PCI or thrombolysis
B-blocker e.g atenolol 5mg oral (unless asthma/LVF).
Transfer to CCU
Management of NSTEMI?
ABC + O2 (15L) by non-breather mask.
Hx/oe/ diagnose NSTEMI.
Aspirin 300mg oral
Morphine 5-10 mg IV with metoclopramide 10mg IV.
GTN spray
Clopidrogrel 300mg and LWM heparin 1mg/kg bd SC.
Beta- blocker
Transfer to CCU.
Management of LVF
ABC + O2 (15L) by non-rebreather mask.
Hx/oe/ diagnose NSTEMI.
Aspirin 300mg oral
Morphine 5-10 mg IV with metoclopramide 10mg IV.
GTN spray
Furosemide 40-80mg IV
If inadequate response, isosorbide dinitrate infusion ± CPAP
CCU
Management algorithm for adult Tachycardia?
Assess using ABCDE approach
Give oxygen + obtain IV
Monitor ECG, BP, SpO2, record 12-lead ECG.
Identify and treat reversible cause (electrolyte abnormalities).
Adverse features? = Unstable
- Shock, syncope, MI, HF.
If unstable give DC shock up to 3 attempts.
Then Amiodarone 300mg IV over 10-20mins and repeat shock followed by:
Amiodarone 900mg over 24hr.
If there are no adverse features and narrow QRS.
- If the rhythm is irregular it is AF. = B-blocker or diltiazem or consider digoxin or amiodarone.
If there narrow QRS and regular = vagal manoeuvres, adenosine 6mg rapid IV bolus, if unsuccessful give 12mg. If unsuccessful give another 12mg.
Monitor ECG continuously.
If sinus rhythm restored
- re-entry paroxysmal SVT.
- Record 12 lead ECG sinus rhythm
- If recurs give adenosine again and consider choice of anti-arrhythmic prophylaxis.
If Broad QRS with regular rhythm
= VT = Amiodarone 300mg IV over 20-60 mins. Then 900mg over 24hr.
If previously confirmed
- SVT with BBB. Give adenosine as regular complex tachy.
If irregular QRS - Seek expert help.
Management of anaphylaxis?
ABC H/exam Remove the cause ASAP (blood transfusion) Adrenaline 500micrograms 1:1000 IM Chlorphenamine 10mg IV Hydrocortisone 200mg IV Asthma tx if wheeze. Amend drug chart allergies box.
Management of acute exacerbation of asthma
ABC History of asthma 100% O2 by non-rebreather Salbutamol 5mg NEM Hydrocortisone 100mg IV or prednisolone 40-50mg oral (if moderate) Ipratropium micrograms neb) Theophylline (only if life threatening)
Management of pulmonary embolism?
High flow oxygen
Morphine
LMWH
If low BP - IV gelofusine –. Noradrenaline –> thrombolysis
Managemet of GI bleed?
ABC History IV Cannulae Catheter (and strict fluid monitoring) Crystalloid Cross-match 6 units of blood Correct clotting abnormalities Camera Stop culprit drugs (NSAIDs, Aspirin, warfarin, heparin).
Metabolic emergencies? - DKA
To diagnosis
- Diabetic )- hyperglycaemia - BM often >30mmol/L
- Keto (check urine and blood ketone)
- Acidosis (low pH on ABG).
IV fluid 1L stat then 1L over 1 hr, then 2hrs, then 4 hrs, then 8hrs.
Sliding scale insulin.
hunt for trigger (infection, MI, missed insulin)
Monitor BM, K, pH.
Metabolic HONK coma?
Hyperglycaemia (usually >35 mmol/L)
HO (Hyperosmolar: osmolality over 340mmol/L (2x (Na +K) + urea + glucose)
Manage same as DKA but half the rate of fluids.
Hypoglycaemia?
BM blood glucose <3mmol/L.
Give them a high-sugar snack.
Otherwise give IV glucose via a cannula 100ml 20% glucose.
If unable to eat and no cannula give IM glucagon 1mg.
Acute poisoning?
ABC
Cannula and catheter, strict fluid balance.
Supportive measures
Correct electrolyte disturbance
Reduce absorption - gastric lavage, whole bowel irrigation (if lithium or iron) 3) charcoal.
Increase elimination - Generous IV fluid +
- N-acetyl cysteine (if paracetamol level at 4hrs or more is over the line on treatment nomogram).
-Naloxone (if opiates have been taken and there is now slow breathing)
- Flumazenil (if benzodiazepine have been taken).
HTN management?
Treat BP >150/95 or >135/85 if any of the following are also present
- Existing or high risk of vascular disease, stroke, peripheral vascular disease.
- HTN organ damage.
Target blood pressure on treatment
- Patients aged less than 80 yrs aim for <140/85. and <135/85 for ambulatory or home measurements.
If patient is over 80 add 10mmHg to systolic values.
Under 55 = A Over 55 or black = C A + C A + C + D A + C + D + diuretic, alpha blocker or b-blocker.
IN the chronic setting of microalbuminuria due to diabetes what do you monitor and how do you treat it?
ACEi (ironically can worsen AKI but in the chronic setting offers cardiovascular + renal protection.
Measure the albumin-creatinine ratio.
Parkinson’s management
Most commonly used regimen - co-beneldopa or co-careldopa
If question presents a patient with very mild Parkinsons who is particularly concerned about finite period of benefit from levodopa - give a dopamine agonist (ropinirole) or MAOi (rasagiline).
Epilepsy drug side effects
- Lamotrigine?
Rash - Rarely Steven Johnson syndrome.
Epilepsy drug side effects? Carbamazapine?
Rash Dysarthria Ataxia Nystagmus Decreased sodium
Epilepsy drug side effect - pheytoin
Ataxia
Peripheral neuropathy
Gum hyperplasia
Hepatotoxicity
Sodium valproate?
Tremor
Teratogenicity
Tubby (weight)
Alzheimer’s disease?
MIld = Acetylcholinesterase inhibitors.
- Donepezil, rivastigmine, galantamine.
Management of Crohn’s - does the question talk about inducing remission or maintaining remission?
Treat acute flair with prednisolone 30mg daily.
Treat severe flare with hydrocortisone. 100mg 6-hourly IV.
Treat rectal disease with rectal hydrocortisone.
Maintaining remission?
Azathioprine is a pro-drug metabolisted to 6-merceptopurine.
Therefore check TPMT levels before starting either drugs. If too low consider starting methotrexate instead.
Giving hypnotic to patient on ward?
Start with zopiclone 7.5mg orally nightly in adults.
Management for constipation in the ward?
Stool softener - Docusate sodium, arachis oil. Good for faecal impaction.
Bulking agents - Isphagula husk. Faecal impaction, colonic atony. takes days to develop effect. Dont use in faecal impaction.
Stimulant laxative - Senna, Disacodyl - Don’t use in acute abdomen.
Osmotic laxatives - Lactulose, phosphate enema. Don’t use in acute abdomen.
Asthma management - patient has salbutamol tremor and uses his inhaler more than 2x a week.
Should be stepped up to beclamethasone 200micrograms 1 puff 2x a day + counsel about salbutamol overuse.
Shouldnt need to increase dose of salbutamol inhaler.
Patient has skin infection?
Prescribe flucloxacillin 500mg 6 hrly for 7 days.
Management of acute pulmonary oedema?
Furosemide 40mg IV
Which two drugs are known to have antimuscarinic side effects out of
- Omeprazole
- Cyclizine
- Amitriptyline
- Ibuprofen
- Enoxaparin
Cyclizine - antihistamine with some known antimuscarinic side effects
Amitriptyline - Tricyclic antidepressant - used at lower doses to treat neuropathic pain with known antimuscarinic side effects.
Side effects of carbimazole?
Drug-induced neutropenia (sore throat, bone marrow suppression)
Carbamazepine can also cause neutropenia.
Patient is ?Alzheimer’s and is taking a drug that in making his symptoms of parkinson’s
Metoclopramide and haloperidol
Both can precipitate Parkinson’s
Does Domperidone cross the BBB?
No
Patient with STEMI who is allergic to opioids? What painkiller do you give?
GTN Spray 2 puffs sublingual
Treatment of DVT with raised D-dimer - suggestive of PE?
LWM heparin (enoxaparin, tinzaparin or dalteparin) TREATMENT DOSE = 15,000.
Prophylaxis dose = 4,000 units daily.
Pregnant woman asked for advice regarding HTN management ramipril during pregnancy?
She cannot take it during the first trimester. It is advised to convert to labetalol before conception.
Patient with tamoxifen and is being warned of the risks?
Tamoxifen increases risk of VTE, and swollen leg could suggest a deep vein thrombosis which needs urgent medical attention.
Patient on gliclazide
This is a sulphonylurea
High risk of hypoglycaemia.
Patient must not miss meals as this will increase risk of hypoglycaemia.
Should not double up dose next time
Missed meals do not improve blood sugar control.
Taken in the morning - bedtime will increase risk of nocturnal hygoglycaemia.
Methotrexate management for a patient?
Regular monitoring of WBC is required given risk of neutropenia.
Methotrexate should only ever be taken once weekly.
Infection risks are much higher given its effect on WBC
Folate antagonists such as trimethoprim and co-trimoxazole should never been taken with methotrexate as they increase its effect.
Folic acid should be used alongside methotrexate to limit its toxicity to bone marrow.
Advice when using warfarin?
Warfarin carry significant risk of bleeding. Risk is reduced if the INR is regularly monitored.
Alcohol affects metabolism of warfarin and makes monitoring difficult.
Patients that want to drink should do it over a week, least impact on INR.
Warfarin tablets are colour coded. White (0.5mg), brown (1mg), blue (3mg) and pink (5mg).
Initially weekly blood tests needed then performed monthly.
What cautions should patients be told about when going on ACEi?
High risk of hyperkalaemia
Cough is common
If patient is vomiting or diarrhoea - risk of AKI
Both ACEi and diuretics can cause renal failure.
It is important to monitor renal function following initiation of ACEi
Patients on long term steroids?
Increases risk of DM
Increase risk of osteoporosis.
If taken for more than 3 months then give prophylactic treatment.
Small risk of gastric irritation and gastric duodenal ulceration in steroids therapy. H2 antagonists or PPI should be considered.
Never stop steroids abruptly due to risk of addisonian crisis.
Patients on steroids are at risk of HTN so should be monitored regularly.
Patient on citalopram after being diagnosed with depression? What should she know?
Takes 6 weeks before there is any improvement
Citalopram makes you more photosensitive and precaution should be taken in sunlight.
Antidepressants can still be suicidal and should seek help immediately. Furthermore a small proportion of patients will actually feel work immediately after.
Symptoms of serotonin syndrome which is a life threatening complication of SSRIs. Should attend hospital immediately.
SSRIs can cause a dry mouth.
Patient with new T1DM - how should you advise her?
Depends on consciousness hypoglycaemia should be treated with carbs + glucose tablets.
HbA1c gives an average glucose control over 3 months. Diabetic patients should target an HbA1c of 48mmol/mol or less.
When unwell, increased basal dose as required. Failing this will lead to the risk of DKA.
Poor glycaemic controls increase risk of microvascular and macrovascular complications.
Failure to rotate injection sites can lead to lipodystrophy.
Advice when taking bisphosphonates?
Reduce risk of fractures but do not prevent them.
Alendronic acid is once weekly prep.
Calcium salts reduce the absorption of bisphosphonates and should be taken at the same time of day.
Food should be avoided 2 hrs after taking alendronic acid as it reduced absorption.
Needs to be swallowed with a full glass of water and remain upright for 30 mins afterwards.
Calculations for PSA - How many mg are in 1ml of 1% lidocaine?
1% means 1 in 100. 1% means 1g in 100ml.
1g in 100ml in 1ml there is 0.01g or 10mg.
Therefore 2% solution contains 2g in 100ml.
Microgram?
10^6
1% means what?
1g in 100ml
4ml of furosemide 50mg in 5ml is given to a patient. WHat dose has been given?
50mg/5ml = 10mg/1ml.
Therefore 4ml x 10mg/ml = 40mg.
Now you want to give the same patient 75mg
7.5ml.
This is because 50mg/5ml = 10mg/ml.
75mg x 1 ml / 10 = 7.5ml.
11 yr old girl weighing 30kg requires a 2mg/kg slow IV bolus dose of antibiotics. Ampoule contains 80mg in 2ml. What volume is required?
30 x 2 = 60mg
60mg/80mg = 0.75 = 1.5ml
When should you not give ‘high dose’ regimens of gentamicin?
When patients have a creatinine clearance of <20ml/min.
If patient is hypernatraemic what fluid do you prescribe and how much?
5% Dextrose 1hr.
Treatment prescription for Pulmonary embolism?
Dalteparin 15,000 units S/C OD = treatment dose.
Enoxaparin 120mg or 12,000 units S/C OD.
Tinzaparin 14,000 units S/C
Dose of HF medication ACEi?
Enalapril 2.5mg ON starting dose.
Lisinopril 2.5 ON
Perinodopril erbumine 2.0 mg OD
Ramipril 1.25mg ON
Can cause Postural hypotension therefore given in the evening.
For HTN only give ARBs if ACEi cannot be tolerated.
First line treatment for acute asthma?
Salbutamol nebs 5mg STAT.
Terbutaline nebs 10mg STAT - correct dose for acute asthma.
Ipratropium nebs 250/500micrograms Neb STAT. Cannot be given more than 4-6/day.
First line pain management in stable angina?
GTN spray Glyceryl trinitrate
2 sprays SUBLINGUAL.
Remember Morphine is used for ACS.
Patient with AF first line treatment has asthma.
Diltiazem - Patient has AF. Suggests he needs rate control due to his age.
Give 120mg OD using modified release prep.
Verapamil 40-120mg OD 8hrly.
Digoxin should be used in patient whom beta or CCB is inadequate or contraindicated.
Drug to reduce potassium in hyperkalaemia?
Actrapid with glucose 10 units of NOVORAPID in 100ml of 20% Dextrose over 30 mins IV.
Hyperkalaemia secondary to renal failure. First potassium lowering therapy is insulin and dextrose.
Insulin causes cellular uptake of potassium and then dextrose is given to prevent subsequent hypoglycemia.
Management of focal epilepsy?
Lamotrigine 25mg OD PO.
Lamotrigine or carbamazepine. However this causes SIADH therefore is not appropriate here as sodium would likely drop further which itself may provoke seizures.
Patient with T2DM with high creatinine management?
Gliclazide 40mg OD with first meal.
When selecting first oral hypoglycaemic drug for diabetic patients, generally pick metformin if overweight or a sulphonylurea if normal/underweight. A creatinine of >150 should also preclude using metformin.
Could also use tolbutamide
Glipizide
Glimepiride
When prescribing statins what would you check?
CK level baseline should be checked in patients with risk factors for muscular disorders, muscular toxicity, high alcohol intake, renal impairment, hypothyroidism and elderly.
If there are no risk factors then a baseline check of CK is not most suitable, therefore check ALT.
Statins are metabolised in the liver, so hepatic impairment will increase their level and risk of myopathy.
If ALT or AST is raised more than 3 time normal range then statins are contraindicated.
What to check in bloods before a patient is prescribed vancomycin?
Renal - serum creatinine.
Clearance is reduced in patients with renal dysfunction. Must be taken into account when choosing a dosing regimen for vancomycin.
Two classic side effects of vancomycin are nephrotoxicity and ototoxicity.
Phenytoin levels?
If pre-dose trough is within normal range? If there are no seizures then yes must be normal and within range.
Monitoring lithium levels?
Sampling time for lithium is 12hr after last dose.
Normal reference range is 0.4-0.8mmol/l and toxic effects manifest over 1.5mmol/L.
FBC are not routine in patient on lithium.
Routine lithium is performed weekly after initiation and after each dose change until concentrations are stable. Then every 3 months.
Sodium depletion is known to increase the risk of lithium toxicity and patients are advised to avoid making changes in their diet that would lead to increased or decreased sodium intake.
Monitoring methotrexate levels
Known to cause fatal blood dyscrasias. Monitor FBC ar regular intervals is imperative, but once therapy has been stabilised, FBC can be monitored every 2-3 months.
According to BNF, CXR is not required, but may be required later on if pulmonary toxicity is suspected.
Due to liver cirrhosis risk, methotrexate should not be started if liver function tests are abnormal.
If sudden drop in WBC or platelets - Methotrexate should be reduced.
Methotrexate is predominately renally excreted and toxicity is more likely in presence of renal dysfunction.
What to monitor on a patient with olanzapine?
Hyperglycaemia and diabetes can occur in patients prescribed antipsychotic drugs, particularly olanzapine. Fasting blood glucose must be tested at baseline and at regular intervals thereafter.
Baseline ECG prior to commencing an antipsychotic drug is only usually indicated in patients with CVS or associated risk factors. §
What to check in a patient being prescribed the OCP?
HTN is known to increase risk of arterial disease associated with contraceptive medication.
When monitoring patients on amiodarone?
T3, T4 and TSH must all be included in a measurement of thyroid function in patients taking amiodarone. T4 may be raised in absence of hyperthyroidism.
Check X-ray owing to risk of pulmonary toxicity with amiodarone.
Monitor Transaminases throughout duration of therapy.
Patients with carbimazole?
If evidence of sore throat check FBC and neutrophil count.
This is due to carbimazole-induced bone marrow suppression and thus agranulocytosis.
Gentamicin regime for multiple daily dose?
1hr peak serum concentration should be 3-5mg/L for the treatment of endocarditis.
Both pre and post dose levels must be checked at regular intervals.
Principally excreted renally. Patients with renal dysfunction are at increased risk of toxicity thus monitoring of renal function is required at regular intervals in patients on gentamicin.
Monitoring of ACEi?
ACEi are known to cause hyperkalemia, hyponatraemia and in some cases AKI. U+E checked at baseline and after every dose.
Monitoring Digoxin levels?
Predominantly renally excreted and patients with renal dysfunction are at increased risk of toxicity.
Plasma digoxin concentration is not measured unless toxicity, non compliance or inadequate effect are suspected.
Sodium valproate monitoring?
Associated with hepatotoxicity and liver function should be measured at baseline as well as regular intervals through therapy.
