Treatments Flashcards
HUS Treatment
Supportive CVS /renal
- fluid resuscitation reduces need for RRT
- Treatment e.coli /shigella with ciprofloxacin, avoid anti motility for diarrhoea as increases shiga toxin exposure
- eculizumab as a complement (C5) inhibitor
- Plasma exchange for atypical (non infectious)
-
TTP treatment
Plasma exchange with Octaplas for >=2 days after plt recovery
High dose steroids
Rituximab
Low dose aspirin once plt >50
Supportive measures (do not give plts as will worsen thrombus unless life threatening haemorrhage)
How does NAC work in paracetamol OD?
Metabolism of toxic metabolite of paracetamol by glutathione in the liver is overwhelmed and glutathione stores depleted. NAC restores glutathione levels and can act as a secondary substrate for toxic metabolite
What is the mechanism of adrenaline?
Adrenaline is a catecholamine that is a strong alpha and beta agonist that is a mixed ionotrope, chronotrope and vasopressor.
- Beta 1 receptor action increases contractility and heart rate
- alpha 1 receptor action causes increased vasoconstriction
- beta 2 receptor action causes bronchodilation and vasodilation at certain vascular beds such as the skeletal muscle
Indications for transplant in ILD
Age less than 65
Not intubated (increases mortality by 3x)
TLCO <40%
Lipid emulsion dose
20% solution
1.5ml/kg bolus
15ml/kg/hr
How do milrinone and glucagon work in beta blocker and calcium channel blocker overdose?
Acts via indirect sympathomimetic effects
Increase myocardial cAMP
Positive ionotropy and chronotropy
Anaphylaxis treatment
ABCDE
IM adrenaline = 0.5mg adrenaline bolus up to 2x
IV Bolus can be given but infusion titrated to response
Treatment of bronchospasm
- adrenaline Nebs
- salbutamol / aminophylline infusions
DKA
ABCDE
+
specific
- fluid resuscitation with saline
- potassium replacement
- ketones treated with FRII (0.1unit/kg/hr)
+ treat underlying cause
Treatment of hyperthyroidism
Supportive management
- ABCDE
Specific
- beta blockade (propranolol)
- propylthiouracil / carbimazole
- Steroids (reduces conversion of T4 to T3)
- iodide (inhibits synth and release of T3/4)
- plasmapheresis / plasma exchange / haemodialysis
Treatment of hypothyroidism
Mainly supportive
Steroids
Incremental doses of IV thyroid hormone
Anaphylaxis
Supportive
- ABCDE
- early intubation, treat bronchospasm, fluid resuscitation and vasopressors / ionotropes
Specific
- remove trigger if possible
- adrenaline prevents mast cell degranulation
- antihistamines and hydrocortisone are second line
Ensure mast cell tryptase sent at 0,1 and 24 hours for confirmation of diagnosis
Warfarin patient emergency bleeding
Prothrombin complex concentrate
TCA overdose
Low threshold for diagnosis in intoxication with sinus tachycardia (could narrow with bicarbonate and be diagnostic)
General supportive (ABCDE)
- can have seizures (higher risk if QRS > 100)
- severe resp acidosis may need intubation
- often fluid resistant hypotension
Specific treatment
- Sodium bicarbonate (bolus and infusions)
- lidocaine (sodium channel competition)
- lipid emulsion in severe scenarios
Key consideration of paediatric trauma management
Non accidental injury
Paediatric resus haemorrhage doses
TXA 15mg/kg
RBC / FFP 5ml/kg
Crystalloid 5ml/kg
After 20ml/kg blood products
-> 10ml/kg plts + 0.1ml/kg calcium chloride
Cryoprecipitate 10ml/kg
COVID-19
ABCDE
- Steroids
- IL-6 inhibitor (tocilizumab)
- Antivirals (remdesivir for high risk, molnupiravir for outpatients)
- Neutralising monoclonal antibodies and JAK inhibitors are new therapies
VAP bundle
Head up 30 degrees
Oral chlorhexidine
Daily sedation holds
VTE
Ulcer prophylaxis
Subglottic suction
Contraindications for lung transplant
- recent history of malignancy (2 years)
- poorly controlled significant dysfunction of another organ system
- uncorrected coronary artery disease
- unstable acute medical condition
- uncorrectable bleeding disorder
- poorly controlled infection or TB infection
- obesity (>35) or thoracic deformity
- risk of non complicance due to personal or psychiatric conditions or lack of social support
- previous thoracic surgery is NOT a contraindication
Common indications for lung transplant
- cystic fibrosis
- ILD (poor prognosis)
- pulmonary hypertension (ideally pre cor pulmonale)
- heart lung transplant
- re-transplantation
- new progression to early lung adenocarcinoma being transplantable but with full staging CTs, biopsy and a back up recipient if mediastinal LNs found
Indications for liver transplant
Acute (better prognosis)
- paracetamol toxicity
- hepatotoxic drugs
- acute viral hepatitis
- unknown
- trauma
- budd-chiari syndrome
Chronic liver disease
- PBC, PSC and biliary atresia
- alcoholic liver disease (demonstrated abstinence)
- autoimmune
- chronic viral disease
- malignancy
Metabolic
- Wilson’s disease
- haemachromatosis
- alpha 1 antitrypsin deficiency
General transplant contraindications
PMHx
- recent history of malignancy
- poorly controlled significant dysfunction of another organ system
- uncorrectable bleeding disorder
- risk of non complicance due to personal or psychiatric conditions or lack of social support
- obesity
Acute
- unstable acute medical condition
- poorly controlled infection or TB infection
Management of Infective endocarditis
ABCDE resuscitation
MDT management with cardiology, CTS micro
- guide investigation and diagnostic confirmation
Antibiotics related to culture ideally
- consider stopping antibiotics if stable and culture negative
Empiric :
- vanc and gent for native valves
- vanc, rifampicin and gent for prosthetic
Investigate and treat embolic phenomenon
Surgery
- intracardiac prosthetic involvement
- acute MV/AV regurgitation
- uncontrolled infection
- high risk of systemic emboli
- vegetations >10mm with emboli
- vegetations >10mm with severe valve dysfunction
- isolated large >15mm vegetations
IE prophylaxis
Only for most high risk (NICE 2016)
- acquired valvular heart disease
- HOCM
- previous endocarditis
- previous valve replacement
- congenital heart disease
Only for High risk dental procedures e.g. extraction or subgingival instrumentation
Transplant graft rejection
Plamapheresis
High dose steroids
IVIG
Antiproliferative agents
Minimised by optimum HLA matching
- ischaemia and reperfusion upregulate graft HLA-antigen expression
Transplant immunosuppression
Induction agent
- basiliximab (targets activated T cells via IL-2 receptor)
- often associated with high dose steroids
Maintenance
- calcinurin inhibitor (cyclosporin or tacrolimus) can cause nephrotixicity
- MMF and azathioprine
Side effects
- immunosuppression
- cell lysis and cytokine release
- haemodynamic instability
- infection
- malignancy
NB if the graft fails, immunosuppression is often discontinued.
Prophylaxis
- PCP
- CMV
- vaccinations
Anticoagulation for non occlusive MI
Fondaparinux 2.5mg (VTE prophylaxis dose) showed improved mortality (OASIS trial)
In NICE guidelines
But can increase thrombotic events if going for PCI so not for STEMI/occlusive MI patients
Methaemoglobinaemia
Remove offending agent
Methylene blue if >20% or symptomatic
- reduces haemoglobin back to Fe2+
Contraindications for methylene blue
- in G6PD deficiency it can precipitate haemolysis
Refractory cases
- exchange transfusion
- hyperbaric oxygen
Treatment of hepatic encephalopathy
Treat cause
Reduce ammonia production and absorption
Nutritional support
Prevent complications with airway protection etc
Chronic hep b treatment
Lamivudune
Toxic alcohol ingestion
Fomepizole - alcohol dehydrogenase blocker which prevents glycolic acid build up and metabolic acidosis
