Review questions Flashcards
Bleeding (severe) in
- Dabigatran
- Xaban
- Warfarin
- thrombolytics
- Heparin
- Idarucizumab 2.5gram iv infusion 2h apart, consider + PCC also
- PCC 50 IU/kg (+ consider novoseven 90mcg/kg)
- iv vitamin K 5-10mg + PCC 50 IU/kg
- cryoprecipitate (up to 10 units per dose) + transamin x1 dose; monitor fibrinogen
- Protamine sulfate slow infusion (more effective for UH); eg for clexane, give at 1:1 dose if last dose clexane within 8h; give half dose if clexane >8h
New case - 50/M Malaise and slowing - workup / ddx
- Hypothyroid, adrenal insufficiency (& hypoglycemia)
- Parkinson’s (incl parkison plus and Wilson’s)
- Early dementia (consider CJD, NPH, autoimmune encephalitis)
- Malignancy
- Anaemia
- Heart failure and Lung disease (COPD / ILD)
- Drugs (incl hypnotics)
- Mood problem
Accidental hypothermia
- Defined as core temp < 35ºC
- Mild hypothermia 32-35 ºC, mod hypothermia 28-32ºC, severe hypothermia <28ºC
- Check cortisol and thyroid
- check blood gas, CK, toxicology and CTB
- Maintain ABC, may need fluid resuscitation and inotropes
- consider broad spectrum Abx and empirical hydrocortisone, especially if there is failure to rewarm
- Mild hypothermia - External rewarming
- Moderate hypothermia - External rewarming of truncal area only
- For severe hypothermia, for active external and internal rewarming
- warm IVF 38-42ºC , warm O2 42-46ºC
- endovascular rewarming catheter
- Aim rewarm till 35ºC
- consider not for rewarming of post-shockable arrest patients with spontaneous mild hypothermia >33ºC
AML-M3 management and complications
- high LDH, urate +/- DIC
- look for hyperleucostasis and tumor lysis
- ATRA + arsenic
- allopurinol to reduce urate levels (consider rasburicase if high risk)
- PCP prophylaxis
- aggressive transfusion as required (Plt / FFP / cryoprecipitate)
- antibiotics if fever
[] Hyperleukostasis
- WCC >100
- look for end-organ dysfunction - eg chest pain / SOB / hypoxia / MI / acute limb / acute bowel ischemia
- leukopheresis + HU if end-organ symptoms
- HU (+/- cytarabine) if no symptoms
- no transfusion until WCC <100
[] Tumor lysis
- hyperPO4 / urate / K, hypoCa (change >25%)
- aggressive fluid
- rasburicaase for established TLS
- may require dialysis
[] Differentiation syndrome / cytokine storm
(fever, APO, hypotension, AKI)
- Dexamethasone and supportive management
Anaphylaxis overview
Presentation
- acute mucocutaneous reaction + respiratory compromise / GI symptom / hypotension and shock
- or exposure to allergen + above symptoms
Management
- 0.5ml 1:1000 im adrenaline, repeat in 5min
- IVF and ABC
- consider iv adrenaline if refractory hypotension
- consider antihistamine (for mucocutaneous symptoms only)
- consider steroid to prevent late phase reaction
Blood x tryptase within 4h + >24h as baseline
Epipen before discharge
Conditions that prolong QTc
- HyopK, HyopMg, HypoCa
- Myocardial ischemia, post-arrest
- Hypothermia, raised ICP
- congenital long QT
- drugs
Drugs:
[] antiarrhythmics
- class IA - quinidine, procainamide
- class IC - flecainide
- class III - amiodarone
[] Psy meds
- antipsychotics (eg haloperidol, quetiapine, olanzapine, amisulpride)
- TCA (eg amitriptyline)
- other antidepressants (eg citalopram, bupropion, venlafaxine)
[] antibiotics
- quinines (hydroxychloroquine)
- quinolones
- macrolides (erythromycin, clarithromycin)
[] antihistamine (eg loratadine)
Anticholinergic poisoning and management
Eg with diphenhydramine, atropine / hyoscine, TCA, Artane (benzhexol) and benztropine, oxybutynin
Flushing (red as a beet)
Dry mouth, anhidrosis (dry as a bone)
Hyperthermia (hot as a hare)
Confusion (mad as a hatter)
Mydriasis (blind as a bat)
AROU (full as a flask)
TCA will also have signs of serotonin syndrome and widened QRS
Mx
- phytostigmine (AChE inhibitor) 0.5mg slow iv
(cf also used in MG)
- !! CI in TCA poisoning and asthma
For TCA - GL, AC if within time window; MDAC and urine alkalinization to reverse arrhythmia
Assessment of asthma control
Compliance, technique & environment; review diagnosis (eg COPD, EGPA)
GINA assessment
- daytime symptoms >2x per week
- night waking
- SABA reliever >2x per week
- activity limitation
ACT score (asthma control test)
Brain death prerequisites, timing of tests and personnel to conduct tests
Diagnosis of severe irremediable brain injury, with diagnosis of that underlying disorder
Exclusion of:
- CNS depressants / drugs
- hypothermia core temp <35’C
- severe metabolic and endocrine disturbances
- arterial hypotension
- locked in syndrome
Done by:
- 1x specialist with skill and knowledge in certifying brain death - ICU, CCM, Neurologist, NS
- 1x specialist, ideally with same qualification, should be at least 6y after registration
- Personnel certifying brain death should not be related to organ removal
Timing of tests
- 1st exam performed after all prerequisite criteria met, at least 4h after reaching GCS 3
- 2nd exam can be performed any time after 1st exam, so that the total period of observation is at least 4 hours
- Need at least 24 hours after an arrest
- Delay for at least 72h after rewarming if therapeutic hypothermia has been used
- time of death = when 2nd exam is completed, or after the confirmatory investigation
Brain death tests
- Both pupils fixed, >4mm, non-reactive to light
- Absence of bilateral corneal reflexes
- Absence of vestibulo-ocular reflexes (cold water to ear)
- No motor response within trigeminal nerve by pain sensation of any somatic area
- Absence of gag reflex
- Absence of cough reflex (suction catheter)
- Apnea - no resp movements when patient is disconnected from IMV, with oxygenation during the process
(ABG - PaCO2 >8kPa, pH <7.3; suggest PaCO2 rise >2.7 kPa above baseline
Carboxyhemoglobin
- elevated COHb level in VBG (levels do not correlate with severity), test by co-oximetry
- PO2 levels may be normal (but HbO2 is profoundly reduced)
- symptoms - headache, nausea, dizziness; chest pain (can have MI), syncope, tachycardia, SOB, confusion and seizures
Mx
- 100% O2 with NRM
- HBOT if LOC, COHb >25%, metabolic acidosis pH <7.25, end-organ ischemia (eg MI, confusion, resp failure)
Causes of cerebellar dysfunction
- tumor, stroke (localized)
- alcohol
- B12, thiamine, Wilson’s
- inflammatory - MS
- paraneoplastic
- degeneratie (SCA)
Causes of elevated PRL
- exclude pregnancy
- stress
- hypothyroid, ESRF
- antipsychotics (eg risperidone)
- PRLoma / stalk effect of non-functioning tumors
- macroPRL (need polyethylene glycol precipitation)
Causes of high AG metabolic acidosis
L - lactic acidosis (metformin, severe shock)
U - Uremia
K - ketoacidosis (DKA, alcoholism, starvation)
E - exogenous (salicylate, ethylene glycol, methanol, paraldehyde)
(Also includes CO, theophylline, cyanide)
Causes of hyperCa
High PTH
- 1’ hyperPTH
- 3’ hyperPTH
- consider Lithium and exclude FHH
Suppressed PTH
- Myeloma
- Malignancy - humoral hyperCa of malignancy, bone mets, ectopic vitamin D / PTH production
- Dehydration
- Drugs - Ca supplements, Thiazide
- Granulomatous disease (ectopic vitamin D)
Causes of hypoCa
- Drugs - bisphosphonates, denosumab, cinacalcet
- HypoPTH - post-op, hypoMg, congenital (ADH, autoimmune polyglandular type 1 (APECED), DiGeorge)
- Low vit D / active vit D (2’ hyperPTH)
(inadequate diet intake and sunlight exposure, liver disease, antiepileptics (25-OHD), low 1a-OHD - CKD, FGF23, hypoPTH and VDDR, end-organ resistance to vit D (VDDR2)) - Pancreatitis (saponification of Ca salts by FFA), tumor lysis (sequestered by PO4)
- Malabsorption syndromes (eg IBD)
- PseudohypoPTH
Causes of hypoK
1) Transcellular Shift
- insulin, thyrotoxicosis, refeeding
2) non-renal loss
- diarrhoea (acidosis) and vomiting (alkalosis)
- TTKG <3
3) Renal loss
- Acidosis - Type 1/2 RTA
- Normotensive - Barter, Gitelman
- drugs - steroids, liquorice, diuretics
- hypoMg
- Primary aldosteronism
- 2’ aldo
RAS, renin secreting tumor
Malignant HT, CHF (renal ischemia) - Suppressed aldo axis
Fluid overload
Causes of hypoMg
GI loss (renal FEMg <2.5%)
- PPI
- diarrhoea, malabsorption
Renal wasting
- loop diuretics and thiazide
- alcoholism
- uncontrolled DM
- other drugs - digoxin, amioglycosides, cisplatin
Causes of hypopit
- Pituitary adenoma with mass effect / Tx (TSS / RT)
- Other tumors with mass effect: RCC, craniopharyngioma, lymphoma, germ cell, metastases
- Hx of trauma / surgery / RT
- Vascular: apoplexy, sheehan (pituitary infarction after postpartum hemorrhage)
- Inflammatory: hypophysitis, sarcoidosis, histiocytosis, hemochromatosis
- Rare infections incl bacterial / TB / fungal
Causes of hypoPO4
1) Transcellular shift - refeeding, resp alkalosis, insulin
2) Non-renal cause
- malabsorption
- vitamin D deficiency
- alcoholism
3) Renal loss (high FEPO4, low TMP/GFR)
- FGF23 mediated - TIO, iv iron, congenital (XLHR)
- non-FGF23 mediated - 1’ hyperPTH, Fanconi, HHRH
Causes of pancreatitis
- Alcohol, Hypertriglyceridemia
- Gallstone
- Post-ERCP
- HyperCa
- IgG4
- drugs - DPP4, GLP1RA, azathioprine, 5-ASA, sulphonamide
- infections - mumps, Cox, salmonella
- idiopathic
Causes of Pericarditis and Pericardial effusion
Pericarditis
- Infection - Cox, adenovirus
- TB, fungal
- uremia
- SLE
- isoniazid, hydralazine
- Dressler
Pericardial effusion
- Pericarditis - Cox, adenovirus, TB, fungal, uremia, SLE
- Malignancy
- Hypothyroid
Myocarditis
- Cox, adenovirus, flu
- bacterial - mycoplasma, leptospira, rickettsia
- SLE, Kawasaki
- eosinophilic myocarditis
- clozapine, amphetamine
Causes of proteinuria and Ix
- Transient (eg orthostatic, exercise)
- UTI
- Secondary to DM, SLE
- Nephritic picture - IgA nephropathy, HSP, membranoproliferative, post-strep GN; ANCA, anti-GBM; SLE
- Nephrotic picture - Minimal change, membranous, focal segmental glomerulosclerosis; DM, SLE
Nephrotic:
- ANA dsDNA ENA C3 C4
- A1C
- HBsAg, anti-HCV (membranous)
- malignancy screen
Nephritic
- Similarly screen SLE
- ANCA anti-GBM
- hepatitis and cyroglobulin (membranoproliferative)
- ASOT
- Ig pattern (IgA)
24h urine protein
urine multistix, c/st, cast, dysmorphic cells
KUB for stones
USG and renal Bx
Cholinergic crisis
Agents
- insecticide (organophosphate)
- AChE inhibitors - Aricept (Donepezil), Rivastigmine patch, Pyridostigmine in MG
Presentation
- water from orifices - sweating, tearing, rhinorrhoea, salivation, urination, diarrhea, vomiting
- bradycardia, pinpoint pupils
- seizures and bronchoconstriction
Mx
- atropine to reverse toxicity
- consider pralidoxime to prevent aging of AChE
- consult Psy for suicide attempt (if appropriate)
Contraindications to lytics
[] Contraindications:
- Hx of ICH, malignant intracranial tumor, AVM / other structural lesion;
- active bleeding
- recent ischemic stroke / significant head trauma in 3m
- intracranial / spinal surgery in 2m
- aortic dissection (beware in inferior MI!)
[] Relative contraindications:
- uncontrolled hypertension
- other major surgery in 3 wks; recent internal bleeding in 2-4 wks; active PUD
- history of ischemic stroke >3m
- prolonged CPR >10min
- on oral anticoagulation (in the past 24h)
- pregnancy
Chronic diarrhoea ddx
- inflammatory bowel disease
- infections including CDT
infections in HIV - Giardiasis, cryptosporidiosis, MAC, CMV - chronic pancreatitis
- hyperthyroidism
- laxative use, orlistat, other med SE
- IBS
Common organisms for IE and Abx regime
iv Ampicillin 2g Q4H + Gentamicin 1mg/kg Q8H as initial antibiotic regime
- covers HACEK (Hemophilus and 4 other bacteria), viridans Strep, Strep bovis, MSSA and other enterococci
IVDA
- Staph aureus, may be MSSA or MRSA
- iv ampicillin for MSSA
- iv vancomycin 15-20mg/kg/dose
Prosthetic valves
- also likely to be MSSA or MRSA
- need consider adding Gentamicin and Rifampicin (900mg/day in 3 divided doses) as well
Common parki meds and their SE
1) L-dopa
- N/V, constipation if taken before meals
- postural hypotension
- on-off phenomenon
- long-term dyskinesia
2) Peripheral decarboxylase inhibitors
- eg Carbidopa
- add on to L-dopa (included in Sinemet)
3) Dopamine agonists
- non-ergot - ropinirole, rotigotine; ergot - Bct
- N/V, constipation, postural hypotension
- pathological gambling
4) MAO-Bi
- eg Selegiline, rasagiline
- neuroprotective effect in younger patients
- SE insomnia; risk serotonin syndrome
Other meds
- anticholinergics (eg benzhexol) for rest tremor
- Amantadine (NMDA receptor (antagonist) for L dopa dyskinesia
Contraindiations to HRT
- unexplained vaginal bleeding; CA breast, CA endometrium risk
- stroke / TIA, ACS, PE / DVT, thrombophilia
- active liver disease
- TG >5.6; uncontrolled DM / HT
- SLE, migraine with aura
- Caution in CV risk, active gallbladder disease,
Definition of resistant HT
- blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes with good compliance
- ideally, one of which should be a diuretic, and all 3 at their maximally tolerated dose
(Remember to check compliance)
Diagnosis for Autoimmune neuro conditions
1) GBS
2) Miller Fisher
3) MS
4) NMOSD
5) MG
1) GBS
- LP cytoalbuminologic dissociation (high protein, normal WCC)
- anti-ganglioside Ab
- NCS slow conduction / neuropathy
2) MFS
- LP cystoalbuminologic dissociation
- anti-GQ1B
3) MS
- CSF oligoclonal band
- McDonald criteria - attacks disseminated in time and space
4) NMOSD
- anti-AQP4
- Wingerchuk criteria; not fulfill MS criteria
5) MG
- anti-AChR
- anti-MuSK, anti-LRP4
- Tensilon test (risk bradycardia / asystole) / ice pack test
-fatigability in repetitive nerve stimulation
Diagnosis of AS and Ax-SpA
Modified new york criteria
1) Sacroilitis grade 3-4, AND at least 1 of:
2) (i) LBP >3 months improving with exercise
(ii) Limitation of LS movement in sagittal & frontal planes
(iii) Limitation of chest expansion
Ax-SpA
- sacroilitis / HLA B27 +
- inflammatory back pain / arthritis / dactylitis / enthesitis / uveitis / psoriasis / IBD / FHx / elevated CRP / good response to NSAID
Diagnosis of asthma
- clinical diagnosis
- VARIABLE symptoms of SOB / cough / wheezing
- eg by exercise / change in weather / URI; diurnal variation
PFT
- variability of lung function
- post-BD increase in FEV1 >12% and >200ml (not in acute attack)
Others incl - atopy march, daily PEF variability >10%, improvement of parameters after treatment; worse with provocation (eg exercise)
Diagnosis of dermatomyositis
- Dermatomyositis (DM) - classically with shawl sign, V-sign, gottron’s sign, Gottron’s papules, heliotrope rash
- borhan and peter criteria for DM and PM
- Elevated CK, Myositis panel (see below)
- EMG - show myopathic changes, presence of fibrillation potentials
- Skeletal muscle MRI - inflammation, myositis, fibrosis
- Muscle biopsy (should not be done on a muscle recently undergone EMG)
- Skin biopsy may be considered for amyotrophic cases
- Need to workup for underlying malignancy in dermatomyositis cases
- Possible associations with ILD, RA, Raynaud; consider overlap syndromes between SLE and SSc
- Antisynthetase antibodies - incl anti-Jo1; strong associations with ILD;
Ddx - hypothyroid myopathy, metabolic myopathy, drug-induced myopathy, SLE, etc
Diagnosis of DKA, difference from HHS and management
DKA:
- pH ≤7.30, HCO3 ≤15, AG >12
- presence of ketones (urine / beta-hydroxybutyrate)
- +/- RG >14
HHS
- POsm >320 (2xNa + glucose)
Management
- ICU care
- iv insulin (0.1U/kg/h)
- IVF with K+
- NaHCO3 50mmol if pH 6.9-7.0; 100 mmol if pH <6.9
- search for ppt (infection, MI)
- switch to sc insulin after resolution of ketoacidosis and patient can eat
Diagnosis of Multiple myeloma
- MM - plasma cell proliferation in BM >10% + monoclonal paraprotein production
- symptomatic MM - presence of CRAB / osteolytic bone lesion / plasma cell >60% in BM / very high free light chain
CRAB - hyperCa (>2.75), renal impairment (cast nephropathy) (Cr >177), anaemia (Hb <10)
Presentation
- elevated ESR;
- smear - rouleaux formation from paraprotein
- Immunofixation (isolated elevation of particular IgG) (check Ig pattern, free light chain, SPE +/- urine BJ protein)
- hyperCa, anaemia, renal impairment; urine protein; skeletal survey
Management:
- rehydration
- bisphosphonates / Denosumab for symptomatic bone disease / hypercalcemia
- IVIG for infection
- thalidomide; consider palliative chemo
Digoxin toxicity
Presentation, risk factors and Management
Presentation
- Digoxin use - reverse tick sign / scooped ST depression
- Digoxin toxicity - frequent PVC (most common) (including bigeminy), high grade AV block, bidirectional VT, AF with CHB / slow regular AF
- loss of appetite, N/V/D, blurred vision, halo, yellow-green discolouration
Risk factors - old age, renal impairment, hypoK
Management
- ABC, cardiac monitor, stop offending agent
- blood for digoxin level, RFT
- consider GL and activated charcoal (within 2h)
- Digifab (see below)
- HD may be necessary
- AVOID BB and TCP (may trigger more severe arrhythmias)
- atropine if bradycardia, lignocaine if tachycardia (0.5mg/kg iv push) and may consider MgSO4 (but most tachyarrhythmias are refractory to treatment if digifab is not given)
Digifab indications
- Digoxin level >10ng/mL, or injection >10mg
- hyperK >5
- brady/tachyarrhythmia not responsive to medical Tx
DM drug mechanism
Metformin - biguanide, improves peripheral glucose utilization (liver and muscle)
SU - binds to SU receptor on K-ATP channels, stimulates insulin secretion
TZD - PPAR-gamma inhibitor, alters genetic transcription related to insulin metabolism (to improve insulin sensitivy)
DPP4i - inhibits DPP which is the enzyme that breaks down GLP1 / GIP
GLP1RA - stimulates postprandial insulin secretion, reduces postprandial glucagon secretion, improves satiety and decreases gastric emptying
SGLT2i - inhibits sodium-glucose co-transporter, induces glycosuria and diuresis, reduces intraglomerular pressure, reduces preload, has endothelial modulating effect
Drugs that may worsen lupus / drug-induced lupus
- hydralazine, methyldopa, diltiazem, procainamide
- isoniazid, quinidine, minocycline
- chlorpromazine
- anti-TNF (esp. infliximab), interferons
empirical Abx for skin and soft tissue infection (not NF)
consider cefazolin 1 gram q6h
or ampicillin 2g q4h + cloxacillin 500mg q6h (simple infection; sepsis dose 2g q4h)
Pemphigus vs Pemphigoid
Pemphigus
- intra-epidermal lesions (more shallow)
- flaccid blisters
- more mucosal lesions
- associated with malignancy
- anti-desmoglein
- steroid + rituximab
Pemphigoid
- subepidermal lesions (deeper)
- tense blisters wtih urticarial plaques
- dermoepidermal junction Ig deposition
- can treat with super potent topical steroid (clobetasol propionate 0.05% cream)
- also consider systemic steroids, doxycycline, and other immunosuppressants
Pre-Tx and general management
- non-adhesive dressing
- fresh skin biopsy of lesion edge with immunofluorescence staining
- screening - G6PD, HBV / HCV, DM
CXR, Mantoux test / IGRA, TPMT / NUDT for AZA
Empirical Abx for CAPD peritonitis
Cefazolin / Vancomycin + Ceftazidime / Amikacin
with nystatin
with fluimucil if use aminoglycosdes
heparin flush into each PDF
Empirical Abx for septic arthritis
- consider cloxacillin or rocephin as initial Tx
- Cloxacillin + Rocephin if more frail / Hx of UTI
- Vancomycin + rocephin if known MRSA carrier
- doxycycline adjuvant for 7 days if known gonorrhoea arthritis
Empirical Abx for treatment of IE
- Ampicillin 2g q4h + Gentamicin 1mg/kg Q8H
Prosthetic valve
- cloxacillin 2g q4h + Rifampicin (300mg tds) + Gentamicin 1mg/kg Q8H
- MRSA - switch cloxacillin for Vancomycin 15-20mg/kg/dose
Exercise for weight loss
- At least 150min moderate intensity aerobic exercise per week
- spread over at least 3 days per week
- no more than 2 consecutive days of rest
Fever + dLFT
Obstructive
- cholangitis, biliary pancreatitis
- liver abscess
- cholecystitis
Hepatitic
- HAV, HEV, HBsAg, anti-HCV
- monospot, CMV
- rickettsia, malaria, dengue
- still’s disease
- DRESS
- fever in cirrhotic patient (includes SBP)
- the obstructive causes above
Fever in returning traveler
- CBC/dc LRFT RG clotting c/st
- CXR, NPS x flu, covid, resp virus
- smear for malaria
- serology for - dengue, rickettsia, Mpox (lesion)
- urine c/st
- stool c/st, ova and cyst
- consider - coxiella (q fever) serology, psittacosis serology, borrelia (lyme disease) serology
- cryptosporidia, giardia, strongyloides and coccidiodomycosis in diarrheoa
- others incl - legionella, TB, HAV and HEV, HIV
Four key elements of informed consent
- Competence (be aware of cognitive function and consciousness)
- Voluntariness (free will, independent decision making)
- Disclosure of information: pros and cons of choices including alternatives
- Understanding and acceptance of information and consequence
Assessing mental competence
1. Patient receive and understand information(s) – capable to comprehend.
2. Patient is asked to paraphrase – in order for the clinician to evaluate his/her understanding of the information, and correct any misconceptions.
3. Capable to analyse the decision(s) to make – seeing both sides of argument and appreciating consequence(s).
4. Patient make his/her own choice(s) with reasoning.
5. Patient has to express his decision(s) by means of communication understandable by others.
6. Capable to retain the information and decision, at least for a short period.
Gauging symptoms of COPD
mMRC (Modified Medical Research Council) and CAT (COPD assessment tool)
- mMRC 0-4 - 2 is slower than same age ppl or stop for breath on level walking; 4 is homebound and SOB with dressing
- Group B COPD is mMRC 2+ or CAT >10
GCA diagnosis and management
GCA Diagnostic criteria
- age >50
- headache
- high ESR +/- CRP
- temporal artery abnormalities (tenderness to palpitation, decreased pulse amplitude, presence of nodules)
- biopsy suggestive of GCA
Other features
- jaw claudication, sudden visual disturbance (AION)
- unexplained fever, anemia, other constitutional symptoms
- associations with PMR (symmetrical aching of shoulders and proximal muscle with elevated CRP / ESR and normal CK)
Workup
- elevated ESR
- consult eye - AION
- CTB - no lesion
- consult NS - temporal artery bx
- USG doppler temporal artery - halo sign (ddx ANCA vasculitis / severe atherosclerosis)
- high res MRI of cranial arteries if USG inconclusive
Management:
- consider treatment with high dose steroid (prednisolone or iv MP) while awaiting temporal artery biopsy result
- MTX ay be used as adjunctive therapy for large vessel vasculitis
- may consider Tocilizumab in specific cases
- PMR also shows dramatic improvement with steroids
General measures for acute poisoning
1) Gastric Lavage if ingested within 1h
- intubation needed if confused
- consent needed; powerful suction needed if alert
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, Lithium, valproate, paraquat
2) Activated charcoal
- 50-100g po, if ingested within 1-2h
- not for lithium, caustic agents, methanol
- special consideration - NOAC
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, valproate, paraquat
- contraindicated in ileus / bowel perforation
3) MDAC
- 1g/kg po, followed by 0.5g/kg q4h for 1-2 days
- for theophylline, phenytoin, digoxin, carbamazepine, valproate, salicylate, dapsone, sustained release medications
4) Whole bowel irrigation
- PEG 1-2L/h until clear rectal effluent
- can consider for lithium (cannot use AC)
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, valproate
- CI in ileus / bowel perforation
5) Urinary alkalinisation
- 1-2mmol/kg NaHCO3 iv bolus, then 50mmol 8.4% NaHCO3 in 500ml D5 q4-6h
- in salicylate (if high serum levels), TCA
- also consider for cocaine, phenobarbitone, MTX
- avoid over-alkalinization / hypoK
6) HD / CRRT
- methaol, lithium, salicylate, theophylline
- consider for paracetamol, carbamazepine, phenytoin, valproate, metformin, atenolol
Grading of COPD by FEV
GOLD 1 - FEV1 >80%
GOLD2 - FEV1 50-80%
GOLD 3 - FEV1 30-50%
GOLD 4 - FEV1 <30%
(cf diagnosis of COPD - by RATIO of FEV1/FVC <70%)
HCM features
- FHx (Autosomal dominant)
- PE: double apex, double carotid impulse, ESM over LLSB
- ECG: precordial leads LVH (V1+V5/6 >35mm) and deep Q over inf / lateral leads
- Echo: asymmetric septal hypertrophy, SAM of mitral valve, LVOT gradient >50 = serious (at rest or provoked)
- should also do holter to look for ventricular arrhythmias
HCM management
Adequate hydration
Avoid competitive sports
Avoid vasodilators (ACEi, nitrates)
Give beta-blockers / nondihydropyridine CCB
Avoid +ve inotropes (incl digoxin)
ICD if ventricular arrhythmias, or if massive LVH / unexplained LOC / apical aneurysm / EF <50% / FHx SCD
Surgical Tx (alcohol septal ablation / surgical myomectomy) if LVOT >50
Genetic counseling and family screening
HE precipitants
- excessive alcohol / protein intake
- constipation / vomiting
- infection
- GIB
- diuretics / large volume paracentesis
- vascular occlusion
Headache ddx
- worst ever / thunderclap - SAH
- injury - SDH, artery dissection
- vision - GCA, PCOM aneurysm
- raised ICP (tumor)
- fever / meningitis
- chronic tension type headache, migraine, cluster headache, trigeminal headache
- Other areas - acute glaucoma, sinusitis, dental pain, cervical spondylosis
Hemolytic Anemia Causes
(high retic, high indirect bili / LDH / urate)
DAT -
- TTP / HUS / DIC picture (see Plt +/- clotting)
- Malaria
- Mechanical valves
- PNH
- G6PD deficiency
- Spherocytosis
- Methemoglobinemia
DAT +
- ABOi
- Warm AIHA (40% idiopathic)
Infection (EBV, HIV), Lymphoproliferative (CLL, lymphoma), Autoimmune (SLE), Drugs (quinine, penicillin)
- Cold agglutinin
Infection (Mycoplasma, HIV), Lymphoproliferative (CLL, lymphoma), Autoimmune less common (SLE)
Hemoptysis, massive hemoptysis causes and management
Causes
- malignancy
- TB
- pneumonia (eg Klebsiella, MRSA)
- bronchiectasis
- pulmonary embolism, pulmonary artery rupture
- vasculitis (eg Anti-GBM, ANCA associated)
Management
- Protect airway
- Correct coagulopathy
- Antibiotics & transamin
- Bronchoscopy
- Urgent bronchial arterial embolisation
(Risk: Spinal cord infarction )
- Surgical resection
prolonged APTT causes
- APS
- hemophilia (factor 8 and 9)
- vWD (esp severe vWD)
- heparin contamination
- part of mixed picture (warfarin, DIC)
HLH
5 or more of:
- fever
- splenomegaly
- bicytopenia / pancytopenia (Hb <9, Plt <100, ANC <1)
- hyperTG or hypofibrinogenemia (TG >3, fibrinogen <1.5)
- hemophagocytosis in BM / spleen / LN
- low or absent NK cell activity
- ferritin >1123 pmol/L (usu favor >2200 for dx)
- serum IL2-R >2400 u/mL
Can be secondary to
- malignancy (eg lymphoma, some solid cancers)
- autoimmune disease (eg Still’s disease)
- infection (EBV, CMV, mycoplasma, salmonella, TB, malaria)
Mx with dexamethasone + etoposide
Need to treat underlying cause
Hypertensive emergency definition and management
Bp >180/120 with new end-organ damage
Lower Bp 10-15% in 1st hour
Then to 160/100 in next 6h
Then gradually to 130/80
Consider iv labetalol (20mg over 2min, then repeat every 10min) (CI in asthma)
Nitroprusside - 0.25-0.5mcg/kg/min and then titrate to max 10 mcg/kg/min
(CI in pregnancy and not for use >48h
iv hydralazine 5mg (avoid in dissection)
HypoNa workup and approach
1) Confirm not pseudohyopNa
- glucose, hyperTG, paraprotein; check Osmo
(Osmo = (2 x SNa) + Glu + BUN
2) Fluid status
2a) Hypovolemic
- dehydration (GI, consider diuretics)
2b) Hypervolemic
- fluid overload (cirrhosis, nephrotic)
2c) Euvolemic
(i) Rule out adrenal insufficiency, hypothyroid
(ii) Tea and toast diet (UNa >20, UOsm <200)
(iii) Primary polydipsia (very low UOsm)
(iv) Consider inadequate salt intake from tube feed (UNa should be <20, UOsm may be more a dequate)
Identification of potential organ donor
a) Definite diagnosis, irreversible CNS damage;
b) Brain death is imminent;
c) Put on mechanical ventilation;
d) GCS 3-5/15;
e) Both pupils fixed to light
Exclusion:
- Uncontrolled infection; Hx of HIV infection / risk factors for HIV, CJD
- Hx of iv drug abuse; case of intoxication
- Malignancy (except certain CIS / localized BCC)
- Uncertain cause of death
Interpreting lung function
1) Restrictive + low DLCO
2) Restrictive + high DLCO
3) Obstructive + low DLCO
4) Obstructive + normal / high DLCO
1) Restrictive + low DLCO
ie parenchymal disease
- ILD
- silicosis, pneumoconiosis
- pneumonitis
- lymphangitis carcinomatosis
2) Restrictive + normal DLCO
- volume loss - lobectomy / pneumectomy / collapse
- chest wall - kyphoscoliosis, neuromuscular disease, morbid obesity
3) Obstructive + low DLCO
- emphysema
4) Obstructive + normal DLCO
- asthma (high DLCO)
- bronchiectasis
Lignocaine dose for VF
1-1.5mg/kg iv push, can repeat 0.5mg/kg at 5-10min
Lignocaine dose for VT
0.5mg/kg iv push +/- repeat another dose
then infuse 1mg/min
only for VT, not for supraventricular arrhythmias
Line sepsis
Determining line sepsis
- 1 peripheral blood culture + culture of catheter tip
- growth of catheter hub at least 2 hours before growth is detected in peripheral blood
- colony count of microbes from catheter hub is > 3x greater than that of peripheral blood
Management
- removal of catheter (esp for S aureus, Pseudomonas, sepsis, endocarditis, persistent bacteremia, or subcut tunneled catheter)
- systemic Abx
- reinsert new catheter with negative blood cultures for at least 48-72h
- consult MID
Abx choice
- vancomycin for MRSA
- Tazocin for GNB
- if candidemia, consider micafungin, + consult eye + book echo and look for abscess + and remove catheter ASAP with alternate day blood cultures to document clearance
If not feasible to remove catheter
- need to review catheter salvage (consider antibiotic lock treatment) / guidewire exchange
- consult MID
Lithium toxicity
Presentation, risk factors and management
Presentation
- N/V/D, bradycardia
- confusion, agitation, coarse tremors
- NDI and hypothyroidism (Li effect) (inhibits thyroid hormone release)
Risk factors
- renal impairment
Management
- rehydration
- HD if Li >5, or Li >4 in renal impairment, or Li >2.5 if frank neurological symptoms
- BZD for seizures
Malaria presentation and management
Fever with TOCC + (and no prophylaxis eg malarone)
Headache, myalgia, anorexia; hepatosplenomegaly
Severe malaria
- confusion, convulsion, jaundice, bleeding, shock, ARDS
- Lactic acidosis, renal impairment, severe parasitemia (>10%), hypoglycemia,
Check basic bloods, clotting, ABG, lactate
Smear for malaria
Urinalysis (hemoglobinuria)
Management
- monitor GCS, fluid status, hemodynamic stability
- isolation in vector-free room
- severe falciparum - artesunate 2.4mg/kg at 0,12,24h + doxycycline 100mg BD
- uncomplicated falciparum - artequick
- vivax / ovale - chloroquine
- primaquine at the end to eradicate gametocytes
Malarone for malaria prophylaxis
Management if suspect TTP
Ix
- low haptoglobin, high retic, LDH, urate, bili
- measure ADAMTS13 level & activity (<10%)
Mx
- Plasma exchange + steroid (iv MP 1g/day x 3 days)
- contraindicated to any Plt transfusion
- may consider RTX (check hep B, CXR and Mantoux)
if not ADAMTS13 but Shiga toxin from ETEC –> likely to be HUS; supportive management only
Management of bleeding in:
1) ITP
2) vWD
3) Hemophilia
1) ITP
- prednisolone 1mg/kg/day (takes wks)
- lifethreatening bleed - IVIG 1g/kg/day x 3 days + iv MP 1 gram/day x 3 days
- may consider iv anti-D, transamin; Plt transfusion (critical bleeding)
- eltrombopag (thrombopoietin mimetics)
- RTX and splenectomy
2) vWD
- DDAVP can raise vWF levels in mild vWD (not useful if absent vWF)
- transfuse vWF concentrate, or recombinant vWF + factor 8
- or consider FFP + factor 8 + additional Plt transfusion for type 2 / 3 vWD
- consider transamin
3) Hemophilia
- Factor transfusion for factor deficiency
- Novoseven to bypass (esp if inhibitors)
90microgram/kg/dose every 2-3h until bleeding stops
- PCC transfusion
- DDAVP may be used for mild hemophilia
- consider transamin
Management of Variceal bleed
- ABC
- X-match
- correct coagulopathy (eg FFP and vit K1)
- SBP 90-100, transfusion aim Hb 7-9
- Terlipressin 2mg q4h (SE MI, PVD, ischemia)
keep for 5 days - Lactulose
- Rocephin
- Empirical pantoloc and thiamine
- Endoscopic ligation
- long-term prophylactic BB and elective banding
Metabolic syndrome components
- dysglycemia (FG >5.6)
- HDL <1 (M) or <1.3 (F)
- TG >1.7
- waist circumference >90 (M) or >80 (F)
- HT >130/85
Clinic new case - Patient with metabolic syndrome at OPD, suboptimal DM control at GOPC, how to assess initially
- NKDA, NSND
- FHx of DM / HT
- Duration of symptoms / History of DM / HT
- Current medications and compliance
- Any OTC meds that may worsen (eg steroid)
- Osmotic symptoms and weight loss
- Diet and exercise pattern
- Any Hx of chest pain / limb weakness
- BP/P, BW, BMI, waist circumference
- cushingoid appearance, thyrotoxicosis
- Heart murmurs and palpate pulses
- Check feet for pulses, wounds, edema (+/- ABI)
- Fundoscopy for DMR changes
- CBC LRFT FG A1C lipid TFT
- check albuminuria
- baseline ECG
- arrange up-to-date DMCS
Nitroprusside dose
0.5mcg/kg/min and then titrate to max 10 mcg/kg/min
Not to use in pregnant ladies / use more than 48h
NMS
- use of dopamine antagonists (eg antipsychotics, prokinetics) or withdrawal of dopamine / dopamine agonists (eg parki meds)
- Any two of : mental status change, rigidity, fever, or dysautonomia
Management
- withhold antipsychotics / resume PD meds
- aggressive supportive care for severe hyperthermia / rigidity
- monitor for widened QRS and risk of TdP
- benzodiazepine, dantrolene, bromocriptine, amantadine may be used (stepwise approach)
- lorazepam 1-2mg q6h or diazepam 10mg iv q8h
- dantrolene - skeletal muscle relaxant; associated with hepatotoxicity; for severe NMS; iv 2.5 mg/kg, repeat 1 mg/kg every 10min, then consider infusion
- bromocriptine - ergot dopamine agonist; may keep up to 10 days after NMS
- amantadine - NMDA antagonist; alternative to Bct
- ECT may be an option
- mean recovery time 7-11 days
- rechallenge of antipsychotic may be possible; wait at least 2 weeks, use lower potency agents, avoid lithium and dehydration
Normal AG metabolic acidosis causes and how to differentiate
1) RTA
2) CKD (elevated Cr)
3) Pancreatic / biliary drainage (see Hx)
4) Chronic diarrhea (see history)
5) Carbonic anhydrase inhibitors (Hx)
RTA
HyperK:
- Type 4 - hypoaldosteronism; low aldosteronism level
HypoK:
- Type 1 - distal RTA, fail to secrete acid, associations with Sjogren
High urine AG (which means high urine NH4, which means inappropriately high urine pH >5.2)
- Type 2 - proximal RTA, fail to reabsorb HCO3
Urine pH usually higher
Fanconi also loses amino acid, glucose, PO4, uric acid
Fanconi can be 2’ to:
- Light chain gammopathies; amyloidosis
- carbonic anhydrase inhibitors (eg acetazolamide, topiramate)
- other nephrotoxic drugs - tenofovir, aminoglycosides, oxaliplatin; heavy metal poisoning (lead, mercury, copper)
- can be idiopathic
- can be familial (AR transmission), or associations with glycogen storage disease, wilson’s disease, tyrosinemia etc
Obstructive vs restrictive lung disease on spirometry
- obstructive - FEV1/FVC <70%
- restrictive - FEV1/FVC >70%, and FVC <80%
Adult Onset Still’s Disease - diagnosis and Mx
Yamaguchi Criteria
[] Major (at least 2)
- fever 39’C for at least 1 week
- arthralgia / arthritis for at least 2 weeks
- non-puritic salmon colored rash on trunk / extremities
- WCC >10 (ANC >10)
[] Minor
- Sore throat
- lymphadenopathy
- Hepato/splenomegaly
- dLFT
- Negative ANA and RF
Need to exclude
- infections (HIV, TB, IE, parvovirus, yersinia, brucella)
- malignancies (eg lymphoma, MPN, solid cancers)
- other rheumatological diseases
- drug rash
Management
- NSAID
- Anakinra, or prednisolone if Anakinra is not available
(anakinra - anti-IL1R)
Osteoporosis med and mechanism
Bisphosphonate - binds to hydroxyapatite of bone and induces osteoclast apoptosis
Dmab - inhibits RANKL; need RANKL-RANK complex to activate osteoclast
TPT - PTH analogue, short term use stimulates osteoblast more than osteoclast
Rmab - sclerostin inhibitor; Sclerostin inhibits Wnt signalling which is needed for osteoblast differentiation
Raloxifene - SERM, agonist in bone to prevent bone loss; antagonist at endometrium and breast
Theophylline overdose
- Vomiting; HypoK, hyopMg
- seizures
- tachyarrhythmias, hypotension
- check theophylline level; cardiac mon
- GI decontamination with AC, MDAC / GL
- correct hypoK, hypoMg
- Give IVF and phenylephrine if hypotension (or noradrenaline)
- Give diltiazem, esmolol if tachyarrhythmias (note COPD)
- Give BZD to manage seizure; consider keppra; ** CI phenytoin
- consider HD if Ileus (ie cannot MDAC), or
theophylline >80 in acute or >60 in chronic cases, or >40 in elderly with severe symptoms, or if unstable
Panadol overdose
- check panadol level at 4 h, repeat testing if extended release formulations
- King’s college - pH <7.3, or INR >6.5 & Cr >300 & HE grade III/IV
- MELD >15
Mx
- AC if within 1 hour; may be inadequate for extended release
- NAC if panadol level above treatment line; may consider direct Tx if ingestion >8h while waiting for results
- NAC
loading 150 mg/kg in 200 ml D5 over 1h,
then 50 mg/kg in 500ml D5 over 4h,
then 100 mg/kg in 1000 ml D5 over 16h
- vit K1, laxatives, empirical Rocephin
- consult Psy for suicide attempt (if appropriate)
PHT causes
1) PAH - idiopathic, related autoimmune (eg connective tissue disease)
2) PH due to LH disease (valvular heart, HFrEF, HFpEF, congenital malformations)
3) Lung disease
4) Pulmonary arterial obstruction (chronic PE)
5) Unknown / multifactorial mechanism (eg sarcoidosis, hematological disorder, complex congenital heart)
PRES associations
- HT crisis, PET
- Acute / chronic kidney disease
- TTP / HUS
- Vasculitis (includes SLE, PAN)
- Immunomodulatory drugs, chemotherapy drugs (includes anti-VEGF incl Bevacizumab, Platin chemo, CyA / RTX / MTX / FK)
- iodine contrast (cerebral angiography)
- severe sepsis
Rhabdomyolysis management
- volume repletion (NS 1-1.5L/h if anuric), then 1D1S to maintain u/o 200ml/h
- continue fluid until CK <5000
- add NaHCO3 50 mmol/L to every other bag of IVF to keep urine pH >6.5;
Stop if ABG pH >7.5, or HCO3 >30 or hypoCa - dialysis for AKI
- Ca replacement should be avoided unless symptomatic
Risk factors for osteoporosis and Secondary Osteoporosis
- female; premature or early menopause
- older age
- Hx of fragility fracture; family Hx of osteoporosis or fragility fracture
- lower BW (<45kg)
- low Ca2+ intake, sedentary lifestyle, lack of sun exposure and vitamin D deficiency (aim >75nmol/L)
- smoking, excessive alcohol (>3 drinks per day)
- Vitamin D deficiency, hypercalciuria
- Endocrine: DM; hyperparathyroidism; hypogonadism (common); Hypercortisolism, Acromegaly, GH deficiency, Hyperthyroidism;
- Malabsorption syndromes (eg IBD, gastric resection, celiac disease)
- Chronic liver disease / cholestatic liver disease (eg PBC)
- Drugs: Alcohol; anti-epileptics, aromatase inhibitors (eg letrozole); TZD; glucocorticoids; +/- PPI
- Rheumat: AS, RA
- Hemat: Thalassemia, multiple myeloma
- COPD
- Misc - pregnancy, AN, bariatric surgery, HIV, chronic psychological stress
Salicylate poisoning
> 150mg/kg - potentially toxic
- hyperthermia, diaphoresis, tachycardia, tachypnea
- confusion, agitation/coma
- can have cerebral edema, and APO, hypotension in severe cases
- primary respiratory alkalosis and metabolic acidosis (usually predominantly acidotic in late stage)
Mx
- GL, AC, MDAC can be used depending on formulation
- urine alkalinization if high levels of salicylate (>2.9mmol/L)
- HD if fail urine alkalinisation or ESRF or very high salicylate level (>7.3 mmol/L)
Transfusion reactions
1) Fever
2) Hypotension
3) Desaturation
1) Fever
- febrile non-hemolytic transfusion reaction - temp rise <1.5’C and stable; (give panadol and restart infusion at slower rate)
- ABOi - hemolysis, hematuria, hypotension
- Anaphylaxis - bronchospasm, rash; give iv piriton, iv hydrocortisone; consider im adrenaline 0.5ml 1:1000
- Septic - Abx
- cultures, broad spectrum Abx, return blood to bank; gram stain of blood product
2) Hypotension
- ABOi
- Anaphylaxis
- Septic
+/- TACO
3) Desaturation
- TACO
- TRALI - usu 6h after transfusion; esp plasma containing product
- Anaphylaxis - bronchospasm
+/- ABOi, Septic
SBP diagnosis and management
- diagnostic tap - WCC >500, PMN >250
- not for large volume paracentesis
- stop beta-blockers
- iv rocephin 2g q24h (5-10 days)
- iv albumin 1.5g/kg/day on D1, 1g/kg/day on D3
- consider long-term prophylaxis if recurrent SBP (eg ciprofloxacin 500mg daily)
Scleroderma classification and features, and management
Localized scleroderma - eg morphea
Limited systemic sclerosis - CREST
- calcinosis, raynaud’s, esophageal dysmotility, sclerodactyly, telangiectasia
- associations with PAH
- anti-centromere
Diffuse systemic sclerosis
- diffuse skin involvement
- anti-Scl70, also associated with ILD
- renal crisis (may also have MAHA), joint involvement, myositis
Management
- Cold avoidance, hand warmers
- Raynaud - calcium channel blockers (eg nifedipine), PDE5i (eg sildenafil), topical nitrates
- avoid steroid (renal crisis)
- PAH - CCB, prostacyclin agonist (eg iloprost), PDE5i, endothelin receptor antagonist (eg bosentan)
- renal crisis - ACEi and bp control
- ILD - consider nintedanib
SE of common ASM - phenytoin, valproate, keppra, carbamazepine
- Phenytoin (Dilantin) - purple glove syndrome, arrhythmias (cardiac monitoring)
Long-term SE of CYP inducer, Hirsutism, Enlarged gums, Nystagmus, Yellowing skin, Teratogen, Osteopenia, Inhibit folate, Neuropathy - Valproate (Epilim) - hepatotoxicity (idiosyncratic), thrombocytopenia; Monitor hyperammonemia and LFT regularly
Long-term SE of Vomiting, Alopecia, Liver toxicity, Pancytopenia, Retention of fat, Oedema, Anorexia, Tremor, Enzyme inhibitor - Levetiracetam (Keppra) - Renal dose adjustment needed; GI upset
Increased SE of behavioral changes (less so for Brivaracetam) - Carbamazepine (Tegretol) - HLAB1502 risk of SJS; CYP inducer; other SE of neurotoxicity, INO / diplopia, teratogenicity, SIADH; avoid in absence seizures; mandatory to check HLAB1502 before starting (not mandatory to check for Oxcarbazepine (Trileptal) and phenytoin, but also suggest not to start if HLAB1502 +ve)
Serotonin syndrome
Use of serotoninergic agents + 1 of:
i) spontaneous clonus
ii) inducible clonus / ocular clonus with agitation / diaphoresis
iii) ocular / inducible clonus with fever and hypertonia
iv) tremor and hyperreflexia
- other features also include agitation, confusion, tachycardia, tachypnea, dry mucous membranes, ataxia, autonomic dysfunction
Management
- Discontinue serotoninergic agents
- GL, AC if within time window
- Supportive; hydration, cooling (panadol not useful)
- Benzodiazepine (for agitation, neuromuscular abnormalities, ↑ BP and heart rate)
- Cyproheptadine (H1 antagonist) if not respond to Benzo
- not to give beta-blockers (unopposed vasoconstriction of alpha)
- Often resolves within 24-36 hrs with supportive treatment
——————————————–
- SSRI - citalopram, fluoxetine; sertraline
- SNRI - venlafaxine, duloxetine
- TCA - amitriptyline, imipramine
- MAOi - selegiline, rasagiline (MAOBi); other inhibitors incl methylene blue, linezolid
- Stimulants - Amphetamines, mirtazapine (remeron) (increase serotonin production)
- Others - Tramadol, fentanyl, codeine, dextromethorphan, trazodone, bupropion, ondansetron, Triptans, lamotrigine
significant alcohol consumption definition
70g/week for women
140g/week for men
(ie <1 and <2 standard drinks/day respectively, 1 standard drink being 10g)
Six step to break bad news:
SPIKES
S: setting up the interview: arrange for some privacy; involve significant others, sit down,
making connection with patients, manage time constraints and interruptions
P: assessing patient’s perception e.g. what is your understanding of the reasons we did chest
tap?
I: obtaining patient’s INVITATION. How would you like me to give the information about the
test result?, Would you like me to give you all the information or sketch out the results and
spend more time discussing the treatment plan?
K: giving Knowledge to patient: unfortunately I ‘ve got some bad news to tell you
E: addressing patient’s EMOTION with EMPATHIC responses
S: Strategy and Summary
Status epilepticus management
- ABC, airway protection
- check h’stix
- iv ativan 4mg stat (over 2min), or iv diazepam 5mg stat, or im midazolam 10mg stat
ASM
- levetiracetam 20mg/kg loading (eg 1000mg), then 1500mg Q12H, with renal dose adjustment
- valproate 20mg/kg loading (eg 1200mg), then 600mg Q8H
- phenytoin 15mg/kg loading, max 1 gram, then 100mg q8h
Other agents
- lacosamide
- midazolam and propofol infusion
- ketamine
Ix cause of seizure (eg CTB / LP) and monitor with EEG
STEMI initial management
- assess hemodynamic stability; any s/s heart failure; monitor cardiac rhythm
- assess any frank contraindications (eg active major bleeding)
- Aspirin ASAP loading 160-320 mg chewed / crushed, non-enteric coated formulations
- CBC/dc LRFT clotting TnI CE (consider A1C and lipids also)
- then Ticagrelor 180mg loading (or Clopidogrel 600mg loading)
- for PPCI patients, give 50-70 IU/kg heparin up to max dose 5000 IU heparin, then adjust according to ACT
- for TNK patients, if age <75, Enoxaparin 30 mg iv bolus, followed in 15 min by 1mg/kg sc Q12H (renal dose Q24H); give up to 8d till PCI
- beware NOT for nitrates if suspect RV infarction (reducing preload will lead to shock)
NOT for beta-blockers if in fluid overload
Therapeutic hypothermia indications, process and passive rewarming
Overview / indications
- Post-arrest (out of hospital arrest) ROSC patients with initial rhythm VF or pulseless VT, with significant brain injury (eg suspicions of cerebral edema)
(though may also be beneficial for patients with nonshockable rhythm / in-hospital arrests)
- Intubated with treatment initiation within 6h of arrest, at coma at time of cooling and able to maintain SBP >90mmHg with/without inotropes
- Exclude patients with recent major surgery, with sepsis, coma from other non-cardiac causes (eg drug intoxication), and other bleeding tendencies
- May achieve lower mortality and improved neurological outcome
Process
- temperature to be maintained 32-34 ºC
- surface cooling with ice packs (not directly in contact with skin) and cooling blanket
- internal cooling with intravascular heat exchange device, infusion of 500-1000ml cold saline at 4ºC given as a bolus (risks pulmonary edema)
- not for rewarming of hemodynamically stable patients who develop spontaneous mild hypothermia (>33ºC ) after resuscitation from cardiac arrest
- duration of cooling should be 12-24h
- prefer MAP >80 mmHg with help of vasopressors (eg noradrenaline); maintain SpO2 >94%
- NOT for nutrition during initiation, maintenance or rewarming phases of therapy
- monitor any bradyarrhythmias
- neuromuscular blocking agents and sedation if shivering (EEG monitoring needed to review any masked seizures)
Passive rewarming
- start at 24h after the initiation of cooling
- aim 0.3-0.5 ºC per hour, will take around 8-12 hours total
- set water temperature in cooling device to 35ºC
- maintain paralytic agent and sedation until temperature reaches 36’C
- monitor for hypotension secondary to vasodilation
Thrombocytopenia causes
** Always think TTP if low Plt + Anemia or AKI **
(May also have hemolysis picture)
Rule out platelet clumps
Production
- usu as part of pancytopenia picture (eg MF, AML, aplastic anemia)
Destruction
- ITP (primary vs secondary to APS / SLE, malignancy, infection eg HIV / CMV)
- MAHA - HUS / TTP, HIT; DIC
- SLE
- malaria, rickettsia, dengue
- hypersplenism (destruction and sequestration)
- drugs - heparin, amiodarone, digoxin
Thyroid storm management and mechanisms
- PTU blocks thyroid hormone synthesis (inhibits organification of iodine) + blocks peripheral T4 → T3 conversion
- Iodine blocks thyroid hormone release (Wolff Chaikoff); escape 10-14d
(at least one hour after thionamide given to prevent the iodine from being used as substrate for new hormone synthesis) - Inderal slows heart rate, reduces oxygen demand of myocardium; reduced catecholamine binding to beta-adrenergic receptors; minor effect to inhibit peripheral T4 → T3 deiodination and conversion
- Steroid for any (relative) adrenal insufficiency, blocks peripheral T4 → T3 conversion
- fluid resuscitation and acetaminophen for fever
- NSAIDs are contraindicated as they will increase peripheral deiodination to T3
- Salicylates are contraindicated as they will compete for T4 carrier proteins leading to transient increase T4
- Lithium carbonate can inhibit proteolysis of colloid and limit the release of pre-formed thyroid hormone into the bloodstream
- cholestyramine binds thyroid hormones in the gut during enterohepatic circulation, prevents reuptake
Toxicology lightning round (2) - specific Tx for
1. Beta-blocker and CCB
2. Sulphonylurea
3. Valproate
4. Carbamazepine
5. Methanol & Ethylene glycol
6. Cyanide
7. Organophosphate
8. Paraquat
9. Household product (eg dettol)
10. Pulmonary irritant (eg HCl and chlorine gas)
11. Snake bite
- iv calcium gluconate 3g over 2min
iv glucagon 2.5mg over 1 min
iv insulin 1U/kg + dextrose
lipid emulsion and methylene blue if refractory shock
atropine for bradycardia, inotropes incl NA - D50 0.5g/kg bolus through central line;
im glucagon 5mg x1; sc octreotide 0.5mg if refractory hypoglycemia - Levocarnitine iv or po 100 mg/kg (max 6g), then half dose q8h - if encephalopathy, hepatotoxicity, hyperNH3 or massive overdose or Valproate levels >3120 umol/L
May also consider naloxone and HD - None…
- Ethanol infusion, or Fomepizole
Folinic acid for methanol; Thiamine 100mg, pyridoxine 50mg q6h for EG
may consider HD - Hydroxycobalamin; or Na nitrite + Na thiosulphate
- See cholinergic;
Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement
Consider pralidoxime in organophosphate poisoning (AChE reactivating agent) - immunosuppression with iv MP and CYC (at HKPIC), and charcoal hemoperfusion
- WBI and GL may be contraindicated
- Beta-blockers for bronchospasm and IMV for ARDS
- Antivenom and tetanus vaccine
Toxicology lightning round - specific Tx for
1. Digoxin
2. Lithium
3. Panadol
4. Salicylate
5. Cholinergic
6. Anticholinergic
7. Opioid
8. BZD
9. TCA
10. Antipsychotics
- Digifab - digoxin >10 ng/mL, digoxin ingested 10mg, hyperK >5, refractory arrhythmia
- None… HD if Lithium levels high
- NAC - if panadol level above treatment line
iv vit K1, laxatives, empirical rocephin; consider transplant - None… GL, AC, MDAC, urine alkalinization, HD
- Atropine 0.6mg iv (anticholinergic), repeat and double dose every 5min until clinical improvement
Consider pralidoxime in organophosphate poisoning (AChE reactivating agent) - Phytostigmine iv (AChE inhibitor); CI in asthma
- Naloxone, 0.4mg iv if drug naive, 0.1mg iv if chronic user
give once every min up to 2 mg total - Flumazenil, iv 0.2mg, give every 30s, up to 1-2mg in total
reverse respiratory depression - None… Urine alkalinization for wide QRS;
For Serotonin syndrome
- give BZD (eg ativan 2mg q6h)
- cyproheptadine (12mg then 2mg every 2h)
CI flumazenil and phytostigmine - Benztropine 1mg iv for dystonia
For NMS
- regular BZD (eg ativan 2mg q6h)
- dantrolene (iv 2.5mg/kg, repeat 1mg/kg, then consider infusion)
- consider bromocriptine (2.5mg tds)
Treatment of autoimmune neuro conditions
1) GBS
2) MS
3) NMOSD
4) MG
1) GBS
- FVC monitoring
- IVIG / plasmapheresis
2) MS
- steroid
- plasmapheresis
- contraindicated for anti-TNF
- Natalizumab, Fingolimod
3) NMOSD
- pulse steroid
- IVIG / plasmapheresis
- contraindicated for anti-TNF
- long-term immunomodulatory meds
4) MG
- FVC monitoring
- pyridostigmine
- IVIG / plasmapheresis
- risk of worsening if steroid used
- long-term immunomodulatory meds
- thymoma excision
Treatment of PCP
- iv septrin (higher dose) 21 days; may consider oral for mild cases
- Suggest steroid in severe case
- or clindamycin + primaquine
- or pentamidine (iv only, SE of hyper/hypoglycemia, arrhythmias)
VTE screen
- antiphospholipid antibodies (LA, anti-β2-glycoprotein Ab, ACL)
- protein C / protein S / antithrombin III deficiency, Factor V Leiden deficiency
- MPN - ET, PCV
- OCP / HRT, steroid
- malignancy
- nephrotic syndrome
- immobilization
What are nonpharmacological treatment of COPD
- quit smoking
- pulmonary rehab
- vaccination (influenza, covid, pneumococcal, shingrex, pertussis)
- LTOT
What are the causes of pancytopenia and how to work up
Production problem
- B12 / folate deficiency
- BM suppressing drugs (eg azathioprine, MMF), including chemotherapy (HU, cytarabine)
- Aplastic anaemia following post-viral infection (eg parvovirus, hepatitis)
- PNH
- MDS
- BM infiltration from hematological malignancy
Destruction
- hypersplenism
- autoimmune disease
Check
- CBC/dc LRFT CaPO4 urate LDH clotting smear (hemat malignancy)
- B12, folate
- parvovirus serology
- PNH will have hemolysis picture (high bili / LDH / urate / retic, with low haptoglobin), confirmed by flow cytometry
- autoimmune markers
- check for splenomegaly
- BME
What is advanced directive
- Formal legal document regarding refusal of life-sustaining therapies (CPR, ventilation, artificial nutrition)
- Mentally competent patient (rule out delirium and mood problem)
- 2 witnesses, one must be doctor; neither can be beneficiaries
- Applicable only when patient has lost capacity to make decisions and is terminally ill, or irreversible coma
- Requires the original printed document to work
- Can be revoked anytime if patient still mentally competent
- Cannot be made by proxy
- Cannot invalidate the AD by family members / doctors when patient loses capacity
When to apply guardianship & powers of guardian
- Conflicts between family members / between family and healthcare providers, that may lead to inappropriate accommodation or failure to get appropriate medical Tx for patient
- When patient refuses to their proposed care (eg placement)
- When patient is suffering abuse / neglect / exploitation, and their interests are not being protected sufficiently
Powers of Guardian
- decide placement
- bring patient to a specific place and use reasonable force for the purpose
- require the patient to attend to attend their appointments / training
- consent to medical or dental treatment if the person concerned is incapable of doing so
- to allow access of care to be given to HCW
- to mobilize from the person’s private funds (max HK$17,000 per month currently) for the maintenance of the person (any greater funds → apply at high court)
Withholding NOAC & warfarin for elective surgery
Minor risk
- eg dental extraction, cataract, joint injections, pleural tapping, endoscopy without biopsy
- withhold 12-24h before procedure, resume 6h post-procedure if hemostasis achieved
Low risk
- eg chest drain / pleural biopsy, endoscopy Bx, tumor ablation, PPM
- withhold 24h before procedure (48h if Dabigatran with CKD), resume 24h postprocedure if hemostasis achieved
High risk
- eg LP, endoscopy with polypectomy; major ORT / eye / cardiac surgery
- withhold 48h (96h if dabigatran with CKD), resume 48h post-procedure if hemostasis achieved
Warfarin
- withhold 5 days before procedure
- therapeutic clexane bridging at 1mg/kg q12h when INR <2, last dose clexane >24h before procedure
- resume clexane 12-24h post-procedure (or 48-72h if high bleeding risk)
Clinic assessment for poor bp control
- FHx of HT / secondary HT
- current drug regime and drug compliance
- Snoring
- Paroxysmal symptoms of headache / dizziness
- weight changes
- Cushingoid
- Palpate pulses, radiofemoral delay
- ballotable kidneys, renal bruit
- CBC LRFT RG A1C lipid
- urine for proteinuria
- CXR / ECG
- overnight oximetry
- renin/aldosterone, ODST, 24h urine metanephrines
- USG kidneys / MRA renal arteries
Zoster post-exposure prophylaxis
- give VARICELLA vaccine within 5 days
(eligible if not pregnant and not immunocompromised) - VZIG is available for patients not eligible for Varicella vaccine and at high risk of severe VZV infection (eg immunocompromised patients, pregnant women)
Zoster vaccine
Target
- age >50 (esp >60y)
- immunocompromised adult patients
- usually wait 1y after an episode of zoster
Shingrex - recombinant vaccine
- 2 doses im
- CI - Hx of GBS, CVID, MS, pregnancy, patients on potent immunosuppressants (esp elderly)
(Note this is different from chickenpox vaccine)
General measures for acute poisoning
1) Gastric Lavage if ingested within 1h
- intubation needed if confused
- consent needed; powerful suction needed if alert
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, Lithium, valproate, paraquat
2) Activated charcoal
- 50-100g po, if ingested within 1-2h
- not for lithium, caustic agents, methanol
- special consideration - NOAC
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, antipsychotics, TCA, SSRI, valproate, paraquat
- contraindicated in ileus / bowel perforation
3) MDAC
- 1g/kg po, followed by 0.5g/kg q4h for 1-2 days
- for theophylline, phenytoin, digoxin, carbamazepine, valproate, salicylate, dapsone, sustained release medications
4) Whole bowel irrigation
- PEG 1-2L/h until clear rectal effluent
- can consider for lithium (cannot use AC)
- can use for salicylate, beta-blockers, digoxin, theophylline, SU, valproate
- CI in ileus / bowel perforation
5) Urinary alkalinisation
- 1-2mmol/kg NaHCO3 iv bolus, then 50mmol 8.4% NaHCO3 in 500ml D5 q4-6h
- in salicylate (if high serum levels), TCA
- also consider for cocaine, phenobarbitone, MTX
- avoid over-alkalinization / hypoK
6) HD / CRRT
- methaol, lithium, salicylate, theophylline
- consider for paracetamol, carbamazepine, phenytoin, valproate, metformin, atenolol
Mechanisms of lipid lowering med (incl fenofibrate)
Statin - HMG CoA reductase inhibitor; rate limiting enzyme in cholesterol synthesis
Bempedoic acid - ATP Citrate lyase; upstream enzyme in cholesterol synthesis
Ezetrol - Niemann pick C1 like 1 protein; reduces absorption of cholesterol from intestines
PCSK9i - inhitbits the enzyme that degrades LDL-R, thus promoting LDL uptake into cells
Cholestyramine - bile acid sequestrant, limits reabsorption of bile salts (bound to LDL-C)
Fenofibrate - PPAR-a agonist, downregulates apoC3 (which is an LPL inhibitor) and thus increases VLDL catabolism
Heat stroke / heat exhaustion
Heat exhaustion - depleted salt and water
Heat stroke - over-heating body; hot and dry; significant CNS features, metabolic acidosis and respiratory alkalosis
- Check ABG, CK, lactate, urine myoglobin and toxicology
- Remove clothing, fanning, cooling blankets
- can stop cooling measures when temp 38-39’C is reached
- Oral fluid and salt replacement if possible (25g NaCl in 5L water)
- BZD if seizures
- avoid all alpha-agonists (vasoconstriction impairs cooling)
Cyanide poisoning
- inhibits oxidative phosphorylation
- widespread tissue hypoxia
- tachycardia, tachypnea, confusion, seizures, arrest
- lactic acidosis
- reduced arterio-venous O2 gradient
- high blood cyanide level
Early antidote if significant acidosis, reduce AVO2 gradient
- hydrocobalamin
- or sodium nitrite + sodium thiosulphate
