SHORTNESS OF BREATH

Question 1

What is the step wise approach to manageing asthma in the community? (not acute asthma attack)

Answer 1

1. Offer a SABA as reliever therapy to adults (aged 17 and over) with newly diagnosed asthma.
2. Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over) with
   
   1. symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
   2. asthma that is uncontrolled with a SABA alone.
3. If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a LABA in addition to the ICS and review the response to treatment in 4 to 8 weeks.
4. If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA as maintenance therapy, offer a LTRA in combination with the ICS

Question 2

What are the signs of a life threatening asthma attack?

Answer 2

• pefr <33%
• o2 sat <92%
• Cyanosis
• Hypotension
• Exhaustion
• Silent chest
• Tachypnoea

+ altered consciousness and arrhythmia

Question 3

What is the single key feature of a near fatal asthma attack?

Answer 3

Raised PaCO2

Question 4

Any one of which criteria (4) is enough to make a diagnosis of acute asthma attack?

Answer 4

• PEF 33-50% best or predicted
• Respiratory rate >25/min
• Heart rate >110
• Inability to complete sentences in one breath

Question 5

What is the management of acute asthma attack? (include doses)

Answer 5

• 15L hgh flow oxygen
• 2.5-5mg salbutamol in an oxygen driven nebuliser every 20 mins for up to 4 hours +/- ipratropium bromide (50ug) (every 20 minutes for 3 doses)
• Oral prednisolone 40mg or IV hydrocortisone 100mg
• 2g of magnesium sulphate over 20 minutes mixed with 0.9% NaCl
• Aminophylline under consultant review
• Escalate to ITU

Question 6

What quick score should be used in the community when assessing a patient with ?pneumonia? What actions does each score correlate to?

Answer 6

CRB65

C-Confusion

R- respiratory rate >30

B- Blood pressure sys<90 or dia<60

65- 65 or older

0- manage in community

1-2- consider hospital referral

3-4- immediate hospital referral

Question 7

In the in hospital setting what extra parameter can be added to CRB65

Answer 7

U for urea over 7mmol/L

Question 8

What is the first and second most common causative agent of CAP?

Answer 8

1. Strep pneumoniae
2. haemophilus influenzae

Question 9

Give 3 causative agents of atypical pneumonia?

Answer 9

• Legionella
• Mycoplasma
• Chlamydophila

Question 10

What are the 3 most common causative agents of a HAP?

Answer 10

1. pseudomonas aeruginosa
2. staphylococcus aureus
3. enterobacteriaceae

Question 11

What are 3 mainstay drugs used in acute pulmonary oedema in a haemodynamically stable patient?

Answer 11

1. Oxygen
2. Furosemide
3. Nitroglycerin

Question 12

What are 3 mainstay drugs used in acute pulmonary oedema in a haemodynamically unstable patient?

Answer 12

1. Oxygen
2. Vasopressor (dopamine)
3. Inotrope (dobutamine)

Question 13

What is the mainstay of treatment for haemodynamically compromised bradyarrhythmia?

Answer 13

• Atropine 500mcg IV
  
  • Repeat atropine 500mcg every 3-5 minutes to a max. of 3g
• Adrenaline2-10mcg/min IV
• Escalate

Question 14

What is the mainstay of treatment for haemodynamically compromised tachyarrhythmia?

Answer 14

• Synchronised DC cardioversion up to 3 shocks
• Amiodarone 300mg IV for 20 minutes
• Repeat shock
• Amiodarone 900mg over 24 hours via central line

Question 15

What is the time frame from onset of acute AF to consider medical or mechanical cardioversion?

Answer 15

48H

Question 16

Which is preferred over rate or rhythm control afetr 48 hours? Which medications can be used for the preferred option? What factors determine which medications are used?

Answer 16

Rate control is preferred

• IF NO HYPOTENSION / NO CCF: Bisoprolol 2.5-5mg PO / Metoprolol 2.5-5mg slow IV (repeat dose up to 10mg total)
• IF HYPOTENSION / CCF: Digoxin 250-500 micrograms PO/IV STAT then repeat after 6 hours (reduce dose in renal impairment /elderly

Question 17

What score can be used to determine if a patient in AF should receive anticoagulation? What scores correlate to requirement for anticoagulation?

Answer 17

CHA2DS2VASc

• Congestive heart failure (1)
• Hypertension (1)
• Age 65-74 (1)
• Diabetes (1)
• Stroke/TIA (2)
• Vascular disease (1)
• Age over 75 (2)
• Sex female (1)

Women- score of >/=2

Men score of >/=1

Question 18

What is the opposing risk calculator to CHA2DS2-VASc?

Answer 18

• HASBLED
• Hypertension: (uncontrolled, >160 mmHg systolic) 1
• Abnormal renal function: Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L 1
• Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal 1
• Stroke: Prior history of stroke 1
• Bleeding: Prior Major Bleeding or Predisposition to Bleeding 1
• Labile INR: (Unstable/high INR), Time in Therapeutic Range 1
• Elderly: Age > 65 years 1
• Prior Alcohol or Drug Usage History (≥ 8 drinks/week) 1
• Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs) 1

Question 19

What is the management of an SVT? (both physcial and medical)

Answer 19

• Valsalva manouevre
• adenosine

Question 20

What 4 drugs are absolutely crucial in managing an acute excerbation of COPD?

Answer 20

• antibiotics
• oxygen
• corticiosteroids
• SABA neb

Question 22

Give the 3 main drugs, doses and routes involved in anaphylaxis management

Not including fluids or oxygen

Answer 22

• Adrenaline IM doses of 0.5ml 1:1000 adrenaline (500 micrograms)(repeat after 5 min if no better)
• Hydrocortisone 200mg IM or slow IV
• Chlorphenamine 10mg IM or slow IV