Treatment algorhtytms (including NPC) Flashcards
Peptic Ulceration with H.Pylori (PPI)
esomeprazole 20 mg PO bd 7/7
Peptic Ulceration with H.Pylori (Abx)
Amoxicillin 1 g PO BD 7/7
Peptic Ulceration with H.Pylori (Abx 2)
Clarithromycin 500mg PO BD 7/7
Peptic Ulceration with H.Pylori (penecillin allergy)
Metronidazole 400 mg PO BD 7/7
Oral iron supplementation
Elemental iron 100 to 210 mg
PO
OD
STEMI: high risk of mortality or recurrent cardiovascular event (STAT) Antiplatelet
Aspirin 300 mg PO then 100-150mg OD
NSTEACS: high risk of mortality or recurrent CS event (STAT) Antiplatelet
Aspirin 300 mg PO the 100-150 mg OD
STEMI: high risk of mortality or recurrent cardiovascular event (STAT) P2Y12 inhibitor
PCI: clopidogrel 600 mg then 75 mg OD
Fibrinolysis: clopidogrel 300 mg then 75 mg OD
NSTEACS: high risk of mortality or recurrent CS event (STAT) P2Y12 inhibitor
Clopidogrel 300-600 mg the 75 mg OD
NSTEACS: high risk of mortality or recurrent CS event (STAT) IV anticoagulation
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
NSTEACS: high risk of mortality or recurrent CS event (STAT) Betablocker
Atenolol 25 mg up to 100 mg OD
Metoprolol 25 mg BD to 100 mg BD
NSTEACS: intermedicate risk of mortality or recurrent CVS event
Aspirin
OR
P2Y12 Inhibitor
NSTEACS: Low risk of mortality or recurrent CVS event
Aspirin
Long term ACS antiplatelet
Aspirin 75-100 mg OD
AND
Clopidogrel 75 mg OD (for 1 year)
Long term ACS Betablocker
Atenolol 25 mg to 100 mg OD
Metoprolol 25 to 100 mg BD
for 1-3 years
COPD exacerbation: Bronchodilator
Salbutamol 100 mcg up to 10 times (Q3hr)
OR/AND
Terbutaline 500 mcg 1-2 times
OR
Ipratropium 21 mcg up to 6 times
COPD exacerbation: Oral corticosteroids
Prednisone 30 to 50 mg PO OD mane 5/7
COPD exacerbation: Antibiotics
Avoid augmentin Amoxicillin 500 mg PO Q8h 5/7 OR Amoxicillin 1g PO Q12h 5/7 OR Doxycylin 100 mg PO OD 5/7
Post operative Nausea and vomiting: No prophylaxis given
5-HT3–receptor antagonist: Ondansetron 1-4 mg
Post operative Nausea and vomiting: Prophylaxis given
Dexamethasone 2-4 mg IV
OR
Droperidol 0.625 mg IV
Acute Pulmonary Oedema: GP setting
Furosemide 20-80 mg IV/IM Q20 min (+/- high flow O2)
Acute Pulmonary Oedema: GP setting (if first line ineffective)
Add GTN 400 micrograms sublingual spray Q5min Max 1200 mcg
OR
GTN tablet subling 300-600 mcg Q5min max 1800 mcg
MIND BP
Acute Pulmonary Oedema ED/CCU: First line
Furosemide 20-80 mg IV Q20 min
Acute Pulmonary Odema ED/CCU Addition to first line
GTN infusion
10 mcg/minute IV
Double the rate Q5min according to response
Acute Pulmonary Oedema: Anxiety
Morphine 1-2.5 mg IV once only
Acute Pulmonary Oedema: AF
Amiodarone 300 mg IV over 30-60 minutes
Acute Pulmonary Oedema: No response to first line management
Dobutamine 2.5-15 mcg/kg/minute IV
Valvular Atrial Fibrillation Stroke prevention
Warfarin
dose targeted to INR
Non-valvular AF Factor Xa inhibitor (CrCl >/= 25 mL/min, No bleeding risk factors)
Apixaban
5mg
PO
BD
Non-valvular AF Factor Xa inhibitor (CrCl >/= 25 mL/min, >/= 2 bleeding risk factors)
Apixaban
2.5mg
PO
BD
Non-valvular AF Factor Xa inhibitor (CrCl >/= 50mL/min)
Rivaroxaban
20 mg
PO
OD
Non-valvular AF Factor Xa inhibitor (CrCl 30-49 mL/min)
Rivaroxaban
15mg
PO
OD
Non-valvular AF direct thrombin inhibitor
Age < / = 75
CrCL >/=50
Dabigatran
150mg
PO
BD
Non-valvular AF direct thrombin inhibitor
Age < / = 75
CrCL 30-50 mL/min OR increased bleed risk
Dabigatran
110mg
PO
BD
Non-valvular AF direct thrombin inhibitor
Age >/= 75
CrCL >/=30
Dabigatran
110 mg
PO
BD
Parentral Iron (Ferinject) IV injection
Ferinject=ferric carboxymaltose
Max 1000 mg per week
IV injection: slow infusion (100mg/min)
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
Parentral Iron (Ferrosig,Ferrum H)
Iron Polymaltose
1000 mg
over 5 hours
COPD Exacerbation IV corticosteroid
Hydrocortisone
100 mg
IV
Q6h
Long term ACS: ACEi indications
If LV failure or dysfunction, Previous MI, DM, HTN, Anterior infarct, elevated HR
Long term ACS: Aldosterone antagonists indications
LV dysfunction, heart failure, DM
Medications to avoid in Heart failure
- NSAIDs (COX2 inhibitors)
- Corticcosteroids
- negative inotropes (verapamil,diltiazem)
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
ACEI Side effects
- Hypotension
- Renal impairement
- Hyperkalaemia
- Dry cough
- Angiooedema
ARB side effects
- Hypotension
- Renal impairement
- Hyperkalaemia
Aldosterone antagonist side effects
-Severe hyperkalaemia when using in kidney impairement
Beta blocker principles
- Not to start until stable and euvolemic
- Start at lowest dose and double every 2-4 weeks
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
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
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
HFrEF Aldosterone antagonsts
Eplerenone 25 mg PO OD to 50 mg
Spironolactone 25 mg PO OD to 50 mg
HFrEF Loop Diurectis
Furosemide 20-40 mg PO OD
Bumetinide 0.5- 1 mg PO OD
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
DKA Fluids BP >90 mmHg systolic
0.9% Sodium Chloride
DKA Fluid BP <90 mmHg systolic
0.9% sodium chloride over 10 to 15 minutes
DKA Insulin
Soluble insulin in 0.9% NaCl (1 unit/mL)
Infuse at 0.1 unit/kg/hour
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
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
ACEI Cautions
Hypotension
Kidney impairment
Hyperkalemia
ARBs for Hypertension
Candesartan 8-32 mg
Irbesartan 150-300 mg
Losartan 50-100 mg
ARB’s cautions
Hypotension, Kidney impairment, hyperkalemia
CCB for hypertension
Amlodipine 5-10 mg OD
Felodipine MR 5-20 mg OD
Nifedipine MR 20-120 mg OD
Cautions for CCB
Peripheral oedema (due to redistribution, not fluid retention)
Thiazide for hypertension
Chlorthalisone 12.5 mg to 25 mg OD
Indapamide 1.25-2.3 mg OD
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
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
LMWH for VTE prophylaxis
CrCL >30 mL/min
Dalteparin 5000 units SC OD
Enoxaprin 40 mg SC OD
LMWH for VTE prophylaxis
CrCL <30 mL/min
Enoxaparin 20 mg SC OD
Unfractionated heparin for VTE prophylaxis
5000 U SC Q8-12h
VTE prophylaxis following hip/knee surgery
CrCL >50 mL/min
Dabigatran
110 mg 1-4 hours after
220 mg OD
VTE prophylaxis following hip/knee surgery
CrCL 30-50 mL/min
Dabigatran
75 mg 1-4 hours after
150 mg OD
VTE prophylaxis following hip/knee surgery
CrCL > 25 mL/min
Apixaban
2.5 mg PO BD
VTE prophylaxis following hip/knee surgery
CrCL >15 mL/min
Rivaroxaban 10 mg PO OD
LMWH cautions
Renaly cleared
Heparin cautions
Heparin-induced thrombotic thrombocytopenia
Digoxin caution
Renaly cleared
Metformin caution
withhold in acute illness/renal impairment
contraindicated when crCL<30 ml/min
Benzodiazepines in elderly caution
Benzodiazepines are not to be used first-line in elderly
Risk of digoxin toxicity
Hypokalaemia
Hypomagnesemia
Hypercalcemia
Hypoxia
Indications for emergent cardioversion in AF
Active ischemia
Shock or hypoperfusion
Severe heart failure
hypotension where other measures have failed
The first-line goal for new AF
Rate control
Indications for anticoagulation prior to cardioversion in AF
If AF for >48 hours
If the duration of AF is unknown
Emergent Treatment for AF (indications and options)
Clinically or hemodynamically unstable
IV rate control or cardioversion
Urgent treatment for AF (indications and options)
Symptomatic but stable
IV rate control
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
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
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
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
Torsade de pointes management
Magnesium sulfate 2g over 10 minutes
VT management
Amiodarone 300 mg IV over 20-60 minutes
then 900 mg over 24 hours
Narrow complex regular tachycardia
1) vagal maneuvers
2)Adenosine 6 mg rapid, if unsuccessful
12 mg, if unsuccessful
give 12 mg
Narrow complex irregular tachycardia
Possibly AF
give BB or diltiazem
consider digoxin/amiodarone if evidence of HF
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
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)
Secondary Pneumothorax management
Aspirate unless:
>2 cm, SOB or >50 yo - chest drain
Tension pneumothorax management
emergency aspiration and chest drain
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
Assessment of Community-acquired pneumonia
CURB 65 Confusion Urea >7.5 Resp rate >30 BB (systolic) <90 Age >65
Pneumonia Algorithm
ABC Hx Ex High flow oxygen Antibiotics paracetamol IV fluids if low BP or raised HR
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
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)
Bacterial meningitis algorithm
ABC History, exam investigations high flow oxygen IV fluids Dexamethasone unless immunocompromised LP +/- CT 2g ceftriaxone IV
Seizures algorithm
ABC (may need an airway)
recovery position
History and investigations (provoking factors)
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
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
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
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
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
When to treat hypertension
BP >150/95 or
> 135/85 if coexisting:
vascular disease
Hypertensive organ damage
Target blood pressures for <80 yo
<140/85 (<135/85 at home)
Target blood pressure in patients over 80
add 10 mmHg to systolic values
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)
Indications for rhythm control in AF
Young
symptomatic AF
First episode
AF due to a treated precipitant
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
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
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
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
COPD first line
SABA or SAMA PRN
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
COPD when FEV1<50
PRN SAMA/SABA
1)LABA+ICS (or LABA+LAMA) or
LAMA (discontine SAMA)
2)LAMA+LABA+ICS
First-line for epilepsy with focal seizures
Carbamazepine
Lamotrigine
First-line for epilepsy with generalized Tonic-clonic seizures
Sodium Valproate (avoid in women of childbearing age) Lamotrigine
First-line for epilepsy with generalized absence seizures
Ethosuximide Sodium valproate (avoid in women of childbearing age)
First-line for epilepsy with generalized Myoclonic seizures
Sodium valproate
Topiramate
Levetiracetam
First-line for epilepsy with generalized Tonic and atonic seizures
Sodium valproate
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
Maintaining remission in IBD
Azathioprine
6-mercaptopurine
Management of Rheumatoid arthritis
Methotrexate + DMARD
Management of Rheumatoid arthritis flare
Short term glucocorticoids
Short term NSAIDs
Managing fever
Paracetamol
Chronic non-infectious diarrhea management
loperamide 2 mg up to 3 hourly
Codeine 30 mg up to 6 hourly
Management of Insomnia where sleep hygiene and conservative measures are ineffective
Zopiclone 7.5 mg nocte
3.75 mg nocte in elderly
Pharmaceutical cardioversion in AF
1) Flecainide
Amiodarone
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
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
Antiepileptics in pregnancy
Lamotrigine has best saftey profile
Dyspepsia
Start with antacids such as Magnesium carbonate, aluminium hydroxide etc for quick relief
PPIs and H2 antagonists take longer to act
Management of short duration constipation
bulk-forming laxatives unless symptomatic
Management of constipation with difficulty passing a soft stool
Stimulant e.g. senna
Constipation with hard stool
Stool softener e.g. docusate
Opioid-induced constipation
osmotic
stimulant
bulk-forming should be avoided
Contraindications to osmotic laxatives
bloating
Hypercalcaemia of malignancy
Zoledronic acid, Pamidronate
care that patients are adequately hydrated
Roundworm, threadworm
Mebendazole
Inducing remission in patients with ileocecal Crohn’s disease
budesonide when glucocorticoid is contraindicated
