Treatment algorhtytms (including NPC) Flashcards
1
Q
Peptic Ulceration with H.Pylori (PPI)
A
esomeprazole 20 mg PO bd 7/7
2
Q
Peptic Ulceration with H.Pylori (Abx)
A
Amoxicillin 1 g PO BD 7/7
3
Q
Peptic Ulceration with H.Pylori (Abx 2)
A
Clarithromycin 500mg PO BD 7/7
4
Q
Peptic Ulceration with H.Pylori (penecillin allergy)
A
Metronidazole 400 mg PO BD 7/7
5
Q
Oral iron supplementation
A
Elemental iron 100 to 210 mg
PO
OD
6
Q
STEMI: high risk of mortality or recurrent cardiovascular event (STAT) Antiplatelet
A
Aspirin 300 mg PO then 100-150mg OD
7
Q
NSTEACS: high risk of mortality or recurrent CS event (STAT) Antiplatelet
A
Aspirin 300 mg PO the 100-150 mg OD
8
Q
STEMI: high risk of mortality or recurrent cardiovascular event (STAT) P2Y12 inhibitor
A
PCI: clopidogrel 600 mg then 75 mg OD
Fibrinolysis: clopidogrel 300 mg then 75 mg OD
9
Q
NSTEACS: high risk of mortality or recurrent CS event (STAT) P2Y12 inhibitor
A
Clopidogrel 300-600 mg the 75 mg OD
10
Q
NSTEACS: high risk of mortality or recurrent CS event (STAT) IV anticoagulation
A
Enoxaparin
CrCl >/=30 mL/min 1 mg/kg subcut BD
CrCl < 30 1 mg/kg subcut OD (or unfractionated heparin if kidney failure or high bleeding risk 60 U/kg then 12 U/kg/hour
11
Q
NSTEACS: high risk of mortality or recurrent CS event (STAT) Betablocker
A
Atenolol 25 mg up to 100 mg OD
Metoprolol 25 mg BD to 100 mg BD
12
Q
NSTEACS: intermedicate risk of mortality or recurrent CVS event
A
Aspirin
OR
P2Y12 Inhibitor
13
Q
NSTEACS: Low risk of mortality or recurrent CVS event
A
Aspirin
14
Q
Long term ACS antiplatelet
A
Aspirin 75-100 mg OD
AND
Clopidogrel 75 mg OD (for 1 year)
15
Q
Long term ACS Betablocker
A
Atenolol 25 mg to 100 mg OD
Metoprolol 25 to 100 mg BD
for 1-3 years
16
Q
COPD exacerbation: Bronchodilator
A
Salbutamol 100 mcg up to 10 times (Q3hr)
OR/AND
Terbutaline 500 mcg 1-2 times
OR
Ipratropium 21 mcg up to 6 times
17
Q
COPD exacerbation: Oral corticosteroids
A
Prednisone 30 to 50 mg PO OD mane 5/7
18
Q
COPD exacerbation: Antibiotics
A
Avoid augmentin Amoxicillin 500 mg PO Q8h 5/7 OR Amoxicillin 1g PO Q12h 5/7 OR Doxycylin 100 mg PO OD 5/7
19
Q
Post operative Nausea and vomiting: No prophylaxis given
A
5-HT3–receptor antagonist: Ondansetron 1-4 mg
20
Q
Post operative Nausea and vomiting: Prophylaxis given
A
Dexamethasone 2-4 mg IV
OR
Droperidol 0.625 mg IV
21
Q
Acute Pulmonary Oedema: GP setting
A
Furosemide 20-80 mg IV/IM Q20 min (+/- high flow O2)
22
Q
Acute Pulmonary Oedema: GP setting (if first line ineffective)
A
Add GTN 400 micrograms sublingual spray Q5min Max 1200 mcg
OR
GTN tablet subling 300-600 mcg Q5min max 1800 mcg
MIND BP
23
Q
Acute Pulmonary Oedema ED/CCU: First line
A
Furosemide 20-80 mg IV Q20 min
24
Q
Acute Pulmonary Odema ED/CCU Addition to first line
A
GTN infusion
10 mcg/minute IV
Double the rate Q5min according to response
25
Acute Pulmonary Oedema: Anxiety
Morphine 1-2.5 mg IV once only
26
Acute Pulmonary Oedema: AF
Amiodarone 300 mg IV over 30-60 minutes
27
Acute Pulmonary Oedema: No response to first line management
Dobutamine 2.5-15 mcg/kg/minute IV
28
Valvular Atrial Fibrillation Stroke prevention
Warfarin
| dose targeted to INR
29
Non-valvular AF Factor Xa inhibitor (CrCl >/= 25 mL/min, No bleeding risk factors)
Apixaban
5mg
PO
BD
30
Non-valvular AF Factor Xa inhibitor (CrCl >/= 25 mL/min, >/= 2 bleeding risk factors)
Apixaban
2.5mg
PO
BD
31
Non-valvular AF Factor Xa inhibitor (CrCl >/= 50mL/min)
Rivaroxaban
20 mg
PO
OD
32
Non-valvular AF Factor Xa inhibitor (CrCl 30-49 mL/min)
Rivaroxaban
15mg
PO
OD
33
Non-valvular AF direct thrombin inhibitor
Age < / = 75
CrCL >/=50
Dabigatran
150mg
PO
BD
34
Non-valvular AF direct thrombin inhibitor
Age < / = 75
CrCL 30-50 mL/min OR increased bleed risk
Dabigatran
110mg
PO
BD
35
Non-valvular AF direct thrombin inhibitor
Age >/= 75
CrCL >/=30
Dabigatran
110 mg
PO
BD
36
Parentral Iron (Ferinject) IV injection
Ferinject=ferric carboxymaltose
Max 1000 mg per week
IV injection: slow infusion (100mg/min)
37
Parentral Iron (Ferinject) IV infusion
```
Ferinject=ferric carboxymaltose
Max 1000 mg per week
IV infusion 200-500 mg in 100mL NaCl
over 6 minutes
500-1000mg in 250 mL NaCl
over 15 minutes
```
38
Parentral Iron (Ferrosig,Ferrum H)
Iron Polymaltose
1000 mg
over 5 hours
39
COPD Exacerbation IV corticosteroid
Hydrocortisone
100 mg
IV
Q6h
40
Long term ACS: ACEi indications
If LV failure or dysfunction, Previous MI, DM, HTN, Anterior infarct, elevated HR
41
Long term ACS: Aldosterone antagonists indications
LV dysfunction, heart failure, DM
42
Medications to avoid in Heart failure
- NSAIDs (COX2 inhibitors)
- Corticcosteroids
- negative inotropes (verapamil,diltiazem)
43
Principles of HFrEF management
1) ACEI/ARB + BB
2) ACEI/ARB + BB +Aldosterone antagonist
3) Switch ACEI/ARB for ARNI
4) Add loop diuretic for symptom control as needed- titrate to effect
5) Symptoms of hypotension- reduced the ACEI/ARB first
6) Switch patients taking other BB to cardiac BB
44
ACEI Side effects
- Hypotension
- Renal impairement
- Hyperkalaemia
- Dry cough
- Angiooedema
45
ARB side effects
- Hypotension
- Renal impairement
- Hyperkalaemia
46
Aldosterone antagonist side effects
-Severe hyperkalaemia when using in kidney impairement
47
Beta blocker principles
- Not to start until stable and euvolemic
| - Start at lowest dose and double every 2-4 weeks
48
HFrEF ACEIs
Captopril 6.25 mg tdx to 75 mg BD
Enalapril 2.5 mg PO OD to 20 mg OD
Lisinopril 2.5 mg PO OD to 40 mg OD
Perindopril erbumine 2 mg PO OD to 8 mg OD
Quinapril 5 mg PO OD to 20 mg OD
49
HFrEF ARBs
Candesartan 4 mg PO OD to 32 mg OD
Losartan 25 mg PO OD to 100 mg OD
Valsartan 40 mg PO BD to 160 mg BD
Irbesartan 75 mg PO OD to 300 mg OD
50
HFrEF BBs
Bisoprolol 1.25 mg to 10 mg OD
Carvedilol <85 kg 3.125 mg PO BD to 25 mg BD;
>85 kg 3.125mg PO BD to 50 mg BD
Metoprolol SR 23.75 mg OD to 190 mg OD
51
HFrEF Aldosterone antagonsts
Eplerenone 25 mg PO OD to 50 mg
| Spironolactone 25 mg PO OD to 50 mg
52
HFrEF Loop Diurectis
Furosemide 20-40 mg PO OD
| Bumetinide 0.5- 1 mg PO OD
53
HFrEF ARNI
Sacubitril 49 mg PO BD + Valsartan 51 mg PO BD
increase dose every 2-4 weeks to
Sacubitril 97 mg PO BD + Valsartan 103 mg BD
54
DKA Fluids BP >90 mmHg systolic
0.9% Sodium Chloride
55
DKA Fluid BP <90 mmHg systolic
0.9% sodium chloride over 10 to 15 minutes
56
DKA Insulin
Soluble insulin in 0.9% NaCl (1 unit/mL)
| Infuse at 0.1 unit/kg/hour
57
Principles of Hypertension management
```
1) start with a single drug
ACEI (HFrEF, kidney disease)
ARB
CCB (angina)
Thiazide
Patients over 55 or of African/Caribbean descent: Thiazide/CCB first line
2)BP goal not met add the second drug of different class
3)increase the dose of one drug
4) increase the dose of the second drug
```
58
ACEI for hypertension
```
Captopril 12.5-50 mg BD
Enalapril 5-40 mg OD
Lisinopril 5-40 mg OD
Quinapril 5-40 mg
Perindoril 4-8 mg
```
59
ACEI Cautions
Hypotension
Kidney impairment
Hyperkalemia
60
ARBs for Hypertension
Candesartan 8-32 mg
Irbesartan 150-300 mg
Losartan 50-100 mg
61
ARB's cautions
Hypotension, Kidney impairment, hyperkalemia
62
CCB for hypertension
Amlodipine 5-10 mg OD
Felodipine MR 5-20 mg OD
Nifedipine MR 20-120 mg OD
63
Cautions for CCB
Peripheral oedema (due to redistribution, not fluid retention)
64
Thiazide for hypertension
Chlorthalisone 12.5 mg to 25 mg OD
| Indapamide 1.25-2.3 mg OD
65
Thiazide cautions
Not to be used first-line for under 65-year-olds due to risk of DM
Avoid in gout
Avoid in metabolic syndrome
66
Principles of VTE prophylaxis
1) LMWH is prefered over UFH
2) UFH for patients with severe kidney impairment or likely to need a rapid reversal
3) Hip or knee replacement: rivaroxaban, dabigatran, apixaban
4) If patients have a history of HITT do not use heparin
5) If patients have low platelets don't use pharmacological prophylaxis
6) Patients already on anticoagulation don't need extra VTE prophylaxis
7) Patients can continue antiplatelets but need additional VTE prophylaxis
8) Patients on Warfarin with INR >2 should not be given prophylactic heparin
67
LMWH for VTE prophylaxis
| CrCL >30 mL/min
Dalteparin 5000 units SC OD
| Enoxaprin 40 mg SC OD
68
LMWH for VTE prophylaxis
| CrCL <30 mL/min
Enoxaparin 20 mg SC OD
69
Unfractionated heparin for VTE prophylaxis
5000 U SC Q8-12h
70
VTE prophylaxis following hip/knee surgery
| CrCL >50 mL/min
Dabigatran
110 mg 1-4 hours after
220 mg OD
71
VTE prophylaxis following hip/knee surgery
| CrCL 30-50 mL/min
Dabigatran
75 mg 1-4 hours after
150 mg OD
72
VTE prophylaxis following hip/knee surgery
| CrCL > 25 mL/min
Apixaban
| 2.5 mg PO BD
73
VTE prophylaxis following hip/knee surgery
| CrCL >15 mL/min
Rivaroxaban 10 mg PO OD
74
LMWH cautions
Renaly cleared
75
Heparin cautions
Heparin-induced thrombotic thrombocytopenia
76
Digoxin caution
Renaly cleared
77
Metformin caution
withhold in acute illness/renal impairment
| contraindicated when crCL<30 ml/min
78
Benzodiazepines in elderly caution
Benzodiazepines are not to be used first-line in elderly
79
Risk of digoxin toxicity
Hypokalaemia
Hypomagnesemia
Hypercalcemia
Hypoxia
80
Indications for emergent cardioversion in AF
Active ischemia
Shock or hypoperfusion
Severe heart failure
hypotension where other measures have failed
81
The first-line goal for new AF
Rate control
82
Indications for anticoagulation prior to cardioversion in AF
If AF for >48 hours
| If the duration of AF is unknown
83
Emergent Treatment for AF (indications and options)
Clinically or hemodynamically unstable
| IV rate control or cardioversion
84
Urgent treatment for AF (indications and options)
Symptomatic but stable
| IV rate control
85
Rate control in AF
Preferred where >48 hours or if uncertain duration of onset
1) Beta-blockers (Metoprolol,)
CCB (verapamil and diltiazem)
2) Digoxin when the rate is not controlled by BB or CCB or if heart failure with AF
86
STEMI algorithm
1) ABC and O2 15L by nonrebreather (unless COPD)
2) History, exam, investigations and diagnose
3) Aspirin 300 mg oral
4) Morphine 5-10 mg IV with Metoclopramide 10 mg IV
5) GTN stray/tablet
6) PCI/thrombolysis
7) Beta-blocker unless LVF or asthma for 3 years
87
NSTEMI algorithm
1) ABC and O2 15L by nonrebreather (unless COPD)
2) History, exam, investigations and diagnose
3) Aspirin 300 mg oral
4) Morphine 5-10 mg IV with Metoclopramide 10 mg IV
5) GTN stray/tablet
6) clopidogrel 300 mg oral or LMW Heparin for 48 hours/till cardiac catheterisation
7) Beta-blocker unless LVF or asthma for 3 years
88
Acute LV Failure algorithm
```
ABC and O2 15 L by non-rebreather unless COPD
History, exam investigations
Sit patient up
Morphine 5-10 mg IV with metoclopramide 10 mg IV
GTN spray/tablet
Furosemide 40-80 mg IV
if inadequate response
Isosorbide dinitrarte infusion +/- CPAP
```
89
Torsade de pointes management
Magnesium sulfate 2g over 10 minutes
90
VT management
Amiodarone 300 mg IV over 20-60 minutes
| then 900 mg over 24 hours
91
Narrow complex regular tachycardia
1) vagal maneuvers
2)Adenosine 6 mg rapid, if unsuccessful
12 mg, if unsuccessful
give 12 mg
92
Narrow complex irregular tachycardia
Possibly AF
give BB or diltiazem
consider digoxin/amiodarone if evidence of HF
93
Anaphylaxis algorithm
```
ABC and 15L O2 via rebreather
History and exam
Remove cause
Adrenaline 500 mcg of 1:1000 IM (Q5 min)
Hydrocortisone 200 mg IV
Continuing respiratory deterioration: IV bronchodilators
```
94
Acute exacerbation of asthma/COPD algorithm
ABC
Hx and Exam
100% (28% for COPD) O2 by nonrebreather
Salbutamol 5 mg nebs Q20 min for up to an hour/6-12 puffs Q10-20 min
Hydrocortisone 100 mg IV (if severe/life-threatening)
OR prednisone 40 mg oral (if moderate) (5 days)
Ipratropium 6 puffs via spacer Q20 or 500mcg nebs Q4-6h
IV Magnesium sulfate
IV aminophylline (only in life-threatening)
95
Secondary Pneumothorax management
Aspirate unless:
| >2 cm, SOB or >50 yo - chest drain
96
Tension pneumothorax management
emergency aspiration and chest drain
97
Primary pneumothorax management
<2cm and not SOB discharge with follow up in 4 weeks
>2cm or SOB aspirate, if unsuccessful aspirate again and if unsuccessful again then chest drain
98
Assessment of Community-acquired pneumonia
```
CURB 65
Confusion
Urea >7.5
Resp rate >30
BB (systolic) <90
Age >65
```
99
Pneumonia Algorithm
```
ABC
Hx Ex
High flow oxygen
Antibiotics
paracetamol
IV fluids if low BP or raised HR
```
100
Pulmonary embolism algorithm
```
ABC
Hx Ex Ix
High flow oxygen
Morphine 5-10 mg Iv with 10 mg metoclopramide
LMWH
if low BP give colloid
```
101
GI bleeding algorithm
```
The 8 Cs
ABC and O2 15 L
Hx, Ex, Ix
2 large bore Cannulae
Catheter and strict fluid monitoring
Crystalloid if normal BP
Cross matched 6 units of blood
Correct clotting abnormalities (FFP/prothrombinex in warfarised/ platelets if low)
Camera- Endoscopy
Stop Culprit drugs (NSAID, Aspirin, warfarin, heparin)
```
102
Bacterial meningitis algorithm
```
ABC
History, exam investigations
high flow oxygen
IV fluids
Dexamethasone unless immunocompromised
LP +/- CT
2g ceftriaxone IV
```
103
Seizures algorithm
ABC (may need an airway)
recovery position
History and investigations (provoking factors)
104
A seizure lasting more than 5 minutes algorithm
Lorazeoam 2-4mg IV OR
10 mg Diazepam IV OR
10 mg Midazolam buccal
```
Still fitting after 2 minutes
repeat diazepam
inform anesthetics
Phenytoin infusion
Intubate then propofol
```
105
Stroke algorithm
ABC
History, exam, investigations (including Blood glucose and CT head to exclude hemorrhage)
If <80 and onset <4.5 hours ago consider thrombolysis
Aspirin 300 mg
106
DKA algorithm
```
ABC
history, exam, investigation
IV fluids: 1L stat then
1L over 1 hour
then 2 hours
then 4 hours
then 8 hours
Sliding scale insulin
find trigger
monitor K, glucose, and pH
```
107
Hypoglycemia algorithm
If able to eat give a sugar-rich snack like orange juice or biscuits (10-20g glucose)
Unable to eat: IV glucose: 100 mL 20% glucose
IM glucagon 1 mg in unconscious patients with no IV access
108
Acute Kidney Injury algorithm
```
ABC
History and exam
Cannula, catheter, and strict fluid monitoring
IV 500 mL stat
1L 4 hourly
look for cause and complications
Monitoring U&Es and fluid balance
```
109
When to treat hypertension
BP >150/95 or
>135/85 if coexisting:
vascular disease
Hypertensive organ damage
110
Target blood pressures for <80 yo
<140/85 (<135/85 at home)
111
Target blood pressure in patients over 80
add 10 mmHg to systolic values
112
CHA2DS2 VASc
```
Congestive heart failure
Hypertension
Age >75 (2 points)
Diabetes mellitus
Stroke or TIA previously (2 points)
Vascular disease
Age 65-74
Sex (female)
```
113
Indications for rhythm control in AF
Young
symptomatic AF
First episode
AF due to a treated precipitant
114
Methods for rhythm control in AF
Cardioversion
Electrical (with need anticoagulation if more than 48 hrs from onset)
Amiodarone 5 mg/kg IV over 20-120 minutes
115
Stable angina algorhithm
1) PRN GTN spray
secondary prevention: aspirin, statin, etc
one antianginal drug depending on contraindications (BB or CCB)
2)increase BB or CCB dose
3)Add long-acting nitrate or potassium channel activator
4)Refer for PCI or CABG
116
Chronic Asthma Algorithm
1) SABA (salbutamol)
2) Add inhaled steroid 200-800 mcg (starting at 400 mcg) (e.g beclomethasone)
3) Add inhaled LABA (salmeterol or formoterol) and asses control
Good response- continue
Benefit but still inadequate control- continue LABA and increased inhaled steroid dose to 800 mcg
No response to LABA- stop LABA and increase IHCS dose to 800 mcg and trial other therapies
Trail: increased ICS to 2000 mcg/day
Add forth drug leukotriene receptor antagonist/ SR theophylline/omalizumab/tiotropium
Low dose daily steroid with high dose ICS at 2000 mcg
117
Type 2 DM Algorhitm
1) If overweight Metformin 500 mg UNLESS
-low weight
-Creatinine >150
use Gliclazide 40 mg
2)If HbA1c >48 then increase dose to maximum
3) If HbA1c still >48 :
-Metformin add sulphonylurea
-Sulphonylurea add gliptin
4) If HbA1c still >48 add insulin
118
COPD first line
SABA or SAMA PRN
119
COPD when FEV1 >50
```
After PRN SAMA/SABA
1)LABA or
LAMA (and discontinue SAMA)
2) LABA+ICS (or LABA+LAMA)
3)LAMA+LABA+ICS
```
120
COPD when FEV1<50
PRN SAMA/SABA
1)LABA+ICS (or LABA+LAMA) or
LAMA (discontine SAMA)
2)LAMA+LABA+ICS
121
First-line for epilepsy with focal seizures
Carbamazepine
| Lamotrigine
122
First-line for epilepsy with generalized Tonic-clonic seizures
```
Sodium Valproate (avoid in women of childbearing age)
Lamotrigine
```
123
First-line for epilepsy with generalized absence seizures
```
Ethosuximide
Sodium valproate (avoid in women of childbearing age)
```
124
First-line for epilepsy with generalized Myoclonic seizures
Sodium valproate
Topiramate
Levetiracetam
125
First-line for epilepsy with generalized Tonic and atonic seizures
Sodium valproate
126
Treatment of IBD flare
1) local aminosalicylate/local corticosteroid
2) local aminosalicylate+ local corticosteroid
3) oral aminosalicylate
4) add oral prednisone or MR budesonide (Crohn's affecting ileum/colon)
5) Hydrocortisone 100 mg Q6h IV
127
Maintaining remission in IBD
Azathioprine
| 6-mercaptopurine
128
Management of Rheumatoid arthritis
Methotrexate + DMARD
129
Management of Rheumatoid arthritis flare
Short term glucocorticoids
| Short term NSAIDs
130
Managing fever
Paracetamol
131
Chronic non-infectious diarrhea management
loperamide 2 mg up to 3 hourly
| Codeine 30 mg up to 6 hourly
132
Management of Insomnia where sleep hygiene and conservative measures are ineffective
Zopiclone 7.5 mg nocte
| 3.75 mg nocte in elderly
133
Pharmaceutical cardioversion in AF
1) Flecainide
| Amiodarone
134
Chronic asthma standard dose ICS and doses
Beclamethasone dipropionate 400-500 mcg/day
(Qvar is beclamethasone dipropionate extrafine= 200 mcg/day_
Budesonide 400 mcg/day
Fluticasone propionate 200-250 mcg/day
135
Hyperkalaemia algorithm
1)Insulin and dextrose- actarapid or novorapid
10 units actarapid in 100 mL 20% dextrose over 30 minutes
1) Calcium gluconate
2) salbutamol
3) Calcium resonium
136
Antiepileptics in pregnancy
Lamotrigine has best saftey profile
137
Dyspepsia
Start with antacids such as Magnesium carbonate, aluminium hydroxide etc for quick relief
PPIs and H2 antagonists take longer to act
138
Management of short duration constipation
bulk-forming laxatives unless symptomatic
139
Management of constipation with difficulty passing a soft stool
Stimulant e.g. senna
140
Constipation with hard stool
Stool softener e.g. docusate
141
Opioid-induced constipation
osmotic
stimulant
bulk-forming should be avoided
142
Contraindications to osmotic laxatives
bloating
143
Hypercalcaemia of malignancy
Zoledronic acid, Pamidronate
| care that patients are adequately hydrated
144
Roundworm, threadworm
Mebendazole
145
Inducing remission in patients with ileocecal Crohn's disease
budesonide when glucocorticoid is contraindicated
