Review Flashcards
Urinary incontinence - Types, treatments
- Stress Incontinence
- Urethral sphincter unable to prevent flow of urine in the setting of increased intra-abdo pressure
- Can be damaged during pelvic surgery or rads
- In women, often due to external (lower urethral) sphincter damage to the pelvic floor
- Modest incontinence
- Poor evidence for pharm treatment
- Antimuscarinic (Tolterodine 2-4mg PO qDaily - poor evidence) - Urge incontinence
- Inability to control urine flow when detrusor contracts
- Often without warning
- Often caused by bladder wall inflammation (infection, tumour invasion, drugs, radiation)
- Often large volume as bladder may completely empty
- Catheters very uncomfortable
- Beta-3-agonists preferred (mirabegron) due to lower side effect profile
- Solifenacin (anticholinergic)
- Oxybutynin (smooth muscle relaxant, decreases detrusor instability) - Overflow incontinence
- Occurs when bladder fills to capacity but cannot contract properly (neuro damage, drugs, outflow obstruction)
- Causes of outflow obstruction include constipation, prostatic hypertrophy, stricture, or tumour
- Small, frequent volumes of urine without control
- High risk of infection with retained urine
- Treat with alpha adrenergic blockers in men (Terazosin or doxazosin, 1mg qDaily, increase to up to 10mg qDaily) or intermittent cath - Total incontinence
- Complete loss of sphincter function due to tumour invasion or spinal cord injury
- Consider self-catheterization or indwelling catheter
Interactions with methadone
Increase methadone levels (Inhibitors):
- Fluconazole
- Haldol
- Verapamil
Decrease methadone levels (INDUCERS)
- Dexamethasone (>16mg/day)
- Antiepileptics
- Carbamazepine, Phenobarb, Phenytoin (could cause opiate withdrawal)
What enzyme metabolises methadone
- Hepatic metabolism (Mainly CYP3A4, also 2B6 and others to a lesser extent)
- Moderate inhibitor of CYP2D6 and CYP 3A4
Serotonin discontinuation syndrome
HANGMAN: H - headache A - anxiety N - nausea G - gait instability M - malaise A - asthenia (fatigue) N - numbness (paresthesia)
Opioid side effects that resolve with time
- Somnolence/sedation (resolves over days to weeks)
- Nausea/vomiting (resolves over days - if it persists, likely not to resolve)
- Urinary retention
- Respiratory depression
Steps for conversion of oxycodone to morphine
- Current opioid regime and total daily dose
- Oxycodone to morphine = multiply by 1.5 for morphine equivalence dose
- Dose reduction for incomplete cross tolerance
Celiac plexus block complications
Immediately following:
- Diarrhea (typically transient, rarely necessitating PO opioid)
- Orthostatic hypotension (typically transient, rarely necessitating PO ephedrine 30mg TID)
Catastrophic:
- Paraplegia (rare occurrence) due to ischemic spinal cord injury from injury or spasm of the artery of Adamkiewicz
- Aortic dissection
- Generalised seizures
- Circulatory arrest
Developmental stages and understanding in children
- Infancy (0-2)
- World experienced through sensory input, working on attachment, regulation, and trust in caregivers
- Will be aware of tension, separation, unfamiliar, and absence
- Use familiarity, routine, and structure for comfort - Early Verbal Childhood (3-6 years of age)
- See death as reversible, not personalised. Magical thinking is a hallmark
- Provide concrete information about the state of being dead, address the concept of guilt (not your fault, can’t catch cancer)
- Ask how they think their loved one got sick and dispel misconceptions - Middle childhood (7-12 years)
- Aware of finality of death, causality
- May struggle with unfairness, abstract/spiritual issues
- Vulnerable to worries about their health or others, may request graphic details about death and decomposition, may benefit from learning about the illness - Adolescence (>12 years of age)
- More adult understanding of universality of death, existential/spiritual issues
- Anticipation and worry about the future
- May be more self-absorbed about personal implications
- May struggle with existential issues
- May engage in risky behaviours
Metabolism of codeine
CYP3A4 - Norcodeine
UGT2B7 - Codeine-6-glucuronide (main metabolite)
CYP2D6 - Morphine (further metabolised to Normorphine, M-6-G, and M-3-G
*M6G has analgesic effects, while M3G does not and is felt to contribute to neurotoxic adverse effects
EPS and antipsychotics (levels of risk)
- Typical antipsychotics (most likely)
- Haldol at higher doses
- Chlorpromazine
- Prochlorpromazine - Methotrimeprazine (somewhere in the middle)
- Atypical antipsychotics
- Risperidone (worst offender, more risk with doses > 6mg/day)
- Quetiapine (most sedating, low risk)
- Olanzapine (low risk) - Other drugs
- Maxeran
- SSRIs
- SNRIs
- NDRIs
DSM Criteria for Delirium
- Disturbance in attention
- Acute, change in baseline, fluctuates
Must have one disturbance of:
- Memory deficit
- Disorientation
- Language
- Visuospatial ability
- Perception
- Not better explained by a neurocognitive disorder
- Evidence it is caused by medical condition
Formula for corrected calcium
(40-patient albumin)*0.02 + Measured calcium
Treatments for hypercalcemia
Treatments for hypercalcemia:
Mild (< 3 and asymptomatic or mildly symptomatic)
- Avoid thiazide diuretics, promote PO fluids, avoid calcium supps and vit D
Moderate (3 – 3.5 and asymptomatic or mildly symptomatic)
- Avoid thiazide diuretics, promote PO fluids, avoid calcium supps and vit D
Severe (>3.5, or changes in sensorium)
- IVF
- Calcitonin 4 IU/kg (check serum calcium in a few hours to ensure calcitonin sensitive, then repeat q12h) discontinue after 24 – 48 hrs)
- Zoledronic acid (denosumab if renal function poor)
Cancers that cause cord compression
Breast cancer
Prostate cancer
Multiple Myeloma
Lung cancer
Renal (less commonly)
Treatment of ongoing hematuria
- CBI in hopes of clot formation (generally first line)
- Rads
FIRST:
- Watch to ensure the bladder outlet does not become obstructed which can lead to urosepsis, bladder rupture, and renal failure
- If a clot occurs, use a hematuria catheter (large diameter, stiff) to evacuate and ensure all clots removed prior to CBI. May require cysto if clots cannot be evacuated.
Other:
- Alum bladder irrigation (avoid in renal impairment or with very large bladder tumours)
- Silver nitrate 0.5-1% instilled for 10-20 minutes (risk of ureteral stenosis)
- Radiation (if from a malignant source)
- Percutaneous transcatheter arterial embolization (if severe)
- PO TXA (caution re: clot formation as may lead to obstruction)
Causes of intractable hiccups
- Intracranial neoplasm
- Esophageal tumour
- Gastric distention
- Bowel obstruction
- Thoracic lymphadenopathy*
- Uremia
- Pancreatic CA
- Drugs (opioids, dexamethasone, chemotherapy - carboplatin)
(UTD * = more common)
General causes: Central - Vascular (stroke, aneurysm) - Space occupying lesions (tumour, abscess) - Head trauma - Encephalitis - Neurodegenerative (MS, PD)
Peripheral
- Esophageal (dilatation, achalasia, tumour, food impaction)
- GI (distention, gastritis, reflux, SBO, ascites, peritoneal traction)
- Hepatic (liver mets/primary Ca, abscess, cholecystitis)
- Iatrogenic (benzos, opioids, steroids, chemo)
- Respiratory (diaphragmatic irritation - pna, effusion, subphrenic abscess)
- Toxic/metabolic (renal failure, EtOH, lytes, hypoadrenalism)
- Infectious (herpes zoster, GI candidiasis)
- Cardiac (MI)
- Psychological
Tenesmus treatment
- Opioids
- Topical or oral Calcium channel blockers (diltiazem gel or nifedipine)
- Belladonna and opium suppositories
- Steroids (radiation proctitis)
- Antispasmodic - Buscopan
- Topical analgesics - rectal enema of lidocaine 2% gel
- NTG if a fissure
