Treatments and Prescriptions Flashcards
Post-stroke anticoagulation therapy
14 days high dose aspirin (300mg) followed by life long clopidorgel (75mg) unless patient has AF where you give anticoagulation (DOAC). Do not give anticoagulation in the first 14 days due to risk of haemorrhagic transformation
Mode of action of saline (i.e. principle of giving IV saline)
saline contains Na which increases the amount of sodium in the interstitial. This stimulates an increase in net movement of water OUT of the cells thereby increasing the amount of fluid in the interstitial
Why do we give fluids? (three main reasons)
Maintenance
Resuscitation - short term / emergent or long term (e.g. diuretic use)
Electrolyte imbalances
General rules for fluid replacement:
* Replace blood with ..... * Replace plasma with ..... * Resuscitate with .... * Replace ECF depletion with ..... * Rehydrate with ......
Replace blood with blood
Replace plasma with colloids
Resuscitate with colloids
Replace ECF depletion with saline (crsytalloid)
Rehydrate with dextrose
Why do we use colloids for resuscitation?
Shock requires fluids to be in the IV area which is why we use colloids as there is no movement of fluid into the interstitium, just into the IV space
Why do we use crystalloids (dextrose) for dehydration?
Dehydration is in all compartments before you want an increase in fluids in all compartments - crystalloids allow for an increase in net movement out of the cells into both IV and interstitium thereby rehydrating the patient more effectively
What is the calculation for “drip rate” (IV drug administration)
Drip rare = (volume (ml) / time (mins)) x drop factor = drops/minute
Define: drop factor (part of drip rate calculation)
Drop factor on back of giving set but it is:
* 20 for fluid
* 15 for blood
Osteoporosis
Bisphosphonates - if appropriate, max 5-8 years
Denosumab - must have adequate Vit D levels
Stat treatment for HTN crisis (not ITU situation)
Amlodipine 5mg
Long term management of peripheral vascular disease (lower limb ischaemia)
anti platelet therapy, stop smoking, exercise, diabetic control, HTN, statin
Indications for dual antiplatelet therapy
12 months after a stent (then swap to aspirin alone)
Stroke
Post-stent MI
What MUST you do with pre operative patients who are on oral steroids? Why?
Stop oral steroids and replace with IV - this is because long term steroid therapy will suppress natural adrenal function therefore the patient would go into crisis if the steroids are not replaced
First line antibiotic for UTI
Nitrofurantoin - 100mg, QDS
First line Abx for skin infections
Flucloxacillin - 500mg
What are the indications for therapeutic drug monitoring?
Lack of drug efficacy
Suspicion of poor compliance
Toxicity - suspected or for prevention
What are the essentials for drug prescriptions? (HINT: think PReSCRIBER)
Patient details REaction (allergies) Signature Contraindications (for each drug) Route of administration (for each drug) IV fluids required? Blood clot prophylaxis required? anti-Emetic required? pain Relief required?
How many items of patient information are required on a drug chart?
3 - name, DOB and hospital number
List the three major contraindications for anticoagulation?
Active bleeding
Suspected bleeding
Risk of bleeding - eg chronic liver disease causing increased PT
List the main contraindications for NSAID prescription? (HINT: think NSAID)
No urine (renal failure) Systolic dysfunction (heart failure) Asthma Indigestion Dyscrasia (clotting abnormality)
What are the only two indications for fluid prescription?
Maintenance - for NBM patients
Replacement - for dehydrated or acutely unwell patients
Which fluid should you prescribe in most cases? What class of fluid is it?
0.9% (normal) saline - crystalloid
If a patient is hypernatraemic which fluid should you prescribe?
5% dextrose
If a patient is hypoglycaemic which fluid should you prescribe?
5% dextrose
If a patient has ascites which fluid should you prescribe?
Human albumin solution
If a patient is shocked with low systolic BP which fluid should you prescribe?
Gelufusine
If a patient is shocked from blood loss which fluid should you prescribe?
Blood
If a patient is tachycardia or hypotension, how should you prescribe fluids?
500ml bolus then reassess
If a patient is oliguric without obstruction, how do you prescribe the fluid?
1L over 2-4 hours then reassess
Assuming a patient requires 3L of maintenance over 24 hours, which fluids and how much should you prescribe?
2 salty, 1 sweet… 2L normal saline plus 1L dextrose
If a patient has normal electrolytes, how much potassium should be added to saline?
40 mmol KCL over 24 hours - note, dextrose contains potassium
What is the normal maintenance fluid requirement for an adult? Is this the same in the elderly?
3L over 24 hours
No - the elderly require 2L
analgesia in mild pain
Paracetamol 1g 6 hourly (to a max of 4G in 24 hours)
Give PRN codeine 30mg up to 6 hourly
Analgesia in severe psi
Cocodamol 30/500 2 tablets 6 hourly
Give PRN morphine sulphate 10mg up to 6 hourly
First line treatments for neuropathic pain
Amitriptyline 10mg P.O. nightly
OR
Pregabalin 75 mg P.O. 12 hourly
List some drugs should you use brand names for rather than generic names?
Insulin
Inhalers
Certain psychiatric drugs
When should an inpatient antibiotic prescription be reviewed?
48 hours - when cultures are back
What is the general dosage rule for PRN analgesia dosing?
1/6th of regular dose up to 4-hourly
What is the target TSH for treated hypothyroid patients
0.5 - 5 mIU/L
If TSH is LESS THAN 0.5 in an hypothyroid patient on levothyroxine, what should you do?
Lower levothyroxine dose
If TSH is MORE THAN 5 in an hypothyroid patient on levothyroxine, what should you do?
Increase levothyroxine dose
Which drugs have a narrow therapeutic window and require monitoring?
(HINT: “guys with large dongles totally make perfect internet connections”)
Gentamicin (+ vancomycin) Warfarin Lithium Digoxin Theophylline Methotrexate Phenytoin Insulin Cyclosporine
What is the normal dose and regimen for gentamicin in patients with good renal function?
5 - 7 mg/kg IV OD
What is the dose regimen for patients requiring gentamicin with concurrent AKI?
1 mg/kg IV divided daily dosing every 12 hours
What is the dose regimen for patients requiring gentamicin with concurrent endocarditis?
1 mg/kg IV divided daily dosing every 8 hours
How do you treat major bleeds in warfarinised patients?
Stop warfarin
Give 5-10mg vitamin K IV
Give prothrombin complex
What should you do in the following situations in warfarinised patients?
1) INR < 6
2) INR 6-8
3) INR > 8
1) reduce dose
2) omit dose for 2 days then recommence on reduced dose
3) only dose and give 1-5mg ORAL vitamin K
Acute management of a STEMI
1) ABC approach
2) O2 (15L non rebreather) if low sats
3) Aspirin 300mg P.O.
4) Morphine (5-10mg) IV with metoclopramide (10mg) IV
5) GTN spray
6) Primary PCI
Acute management of NSTEMI
1) ABC approach
2) O2 (15L non rebreather) if low sats
3) Aspirin 300mg P.O.
4) Morphine (5-10mg) IV with metoclopramide (10mg) IV
5) GTN spray
6) Clopidogrel (300 mg) PO and LMWH (enoxaparin) (1mg/kg) BD SC
7) b blocker (atenolol 5mg P.O.)
Acute management of LVF
1) ABC approach
2) O2 (15L non rebreather)
3) SIT PATIENT UP
4) Morphine (5-10mg) IV with metoclopramide (10mg) IV
5) GTN spray
6) Furosemide (40-80 mg) IV
Initial acute management of adult tachycardia
1) ABC approach
2) O2 (15L non rebreather) if low sats
3) IV access (2x large bore cannulae)
4) Monitor - ECG, BP, SpO2, 12-lead ECG
5) Identify and treat reversible causes
Acute management of the unstable adult tachycardia patient (i.e. presence of shock / syncope / myocardial ischaemia / HF)
1) Initiate basic management of tachycardia (ABC, O2, IV access, monitor)
2) Synchronised DC shock - up to 3 attempts
3) Amiodarone (300 mg) IV over 10-20 mins
4) Repeat shock
5) Amiodarone (900 mg) IV over 24 hours
Acute management of stable narrow complex adult tachycardia patient
1) Initiate basic management of tachycardia (ABC, O2, IV access, monitor)
2) Determine if regular or irregular rhythm
Irregular rhythm = fast AF
A - rate control with b-blocker or diltiazem
B - if HF + digoxin or amiodarone
Regular rhythm
A - vagal manoeuvres
B - adenosine (6mg) IV bolus (repeat 2x if nec with 12 mg)
C - continuous ECG monitoring
Acute management of stable broad complex adult tachycardia patient
1) Initiate basic management of tachycardia (ABC, O2, IV access, monitor)
2) Determine if regular or irregular rhythm
Irregular = AF with BBB or Polymorphic VT
A - seek expert help
B - if in AF, rate control (b-blocker or diltiazem)
B - if polymorphic, give magnesium (2g) IV
Regular = VT
A - amiodarone (300 mg) IV over 20 - 60 min
B - amiodarone (900 mg) IV over 24 hours
Outline the hypertension management guidelines in patients < 55 years old
1) ACEi (or ARB if not tolerated) - eg: lisinopril 10mg OD (or candesartan 8mg)
2) + CCB - eg: nifedipine 30 mg OD
3) + Diuretic (thiazide-like) - eg: indapimide
4) Refer to expert - can add b-blocker
Outline the hypertension management guidelines in patients > 55 years old (or afro-carribean)
1) CCB (or thiazide-like if not tolerated) - eg: nifedipine 30 mg OD (or indapimide)
2) + ACEi (or ARB if not tolerated) - eg: lisinopril 10mg OD (or candesartan 8mg)
3) + Diuretic (thiazide-like) - eg: indapimide
4) Refer to expert - can add b-blocker
What kind of information should you give patients regarding treatments? (HINT: think ATHLETICS)
Action - MOA Timeline - when to take drug How to take - tablet/injection etc Length of treatment Efficacy window - how long before beneficial effects are seen Important side effects Complications Contraindications Supplementary advice - drug specific
Outline the stepwise management of chronic heart failure
1) ACEi (lisinopril 2.5mg) + B-blocker (bisoprolol 2.5mg)
2) + ARB (candesartan 4mg)
3) + Hydralazine (25 mg 8-hourly) + isosorbide mononitrate (20 mg 8-hourly)
4) + Spironolactone (25 mg)
5) Digoxin
6) Surgical intervention
What are the two methods of rhythm control in AF patients?
Electrical - synchronised cardioversion
Pharmacological - amiodarone 5mg/kg IV over 20-120 mins
At what HR should AF patients be rate controlled?
90 bpm
What are the drugs used to rate control AF patients?
1) B-blocker (propranolol 10mg 6-hourly)
OR
1) CCB (diltiazem 120mg)
2) Digoxin (if required or both above are CI)
What are the contraindications for b-blocker use in stable angina?
Hypotension
Bradycardia
Asthma
Acute heart failure
What are the contraindications for CCB use in stable angina?
Hypotension
Bradycardia
Peripheral oedema
Outline the stepwise management of stable angina?
1) GTN spray PRN
2) Secondary prevention: aspirin, statin, lifestyle modification
3) B-blocker (or CCB if CI)
4) + CCB (or nitrate - ISMN)
5) Refer for CABG
What is the prophylactic dose of LMWH (eg: enoxaparin)?
20-40 mg pre and post operative
What is the treatment dose of LMWH (eg: enoxaparin)?
1.5 mg / kg / 24 hours
Which anti-platelet drugs should be prescribed in the following situations:
(1) ACS
(2) Secondary prevention following stroke
(3) Secondary prevention following TIA
(1) Aspirin (300 mg) + Clopidogrel (300mg)
(2) Clopidogrel
(3) Aspirin
Describe the treatment for aspirin overdose
(1) Establish time of OD
(2) SAlicylate and paracetemol levels
(3) If within 1 hour = gastric lavage
(4) If high levels = haemodialysis
What is the only paediatric indication for treatment with aspirin?
Kawasaki’s disease
What is the maximum dose of aspirin in 24 hours?
4g / day
How long before surgery should aspirin be stopped if there is a significant bleeding risk?
7 days
Outline the management of anaphylaxis
1) ABC approach
2) 15 L O2 (non re-breather)
3) Remove cause
4) Adrenaline 500 ug 1:1000 IM
5) Chlorpehnamine 10 mg IV
6) Hydrocortisone 200 mg IV
7) Bronchodilators if wheeze
Outline the management of acute exacerbation of asthma
1) ABC approach
2) 15 L O2 (non re-breather)
3) Salbutamol: 2 puffs every 10 minutes up to 10 puffs
4) Salbutamol neb (5mg with O2)
5) Prednisolone (40-50 mg PO) or Hydrocortisone (100 mg IV)
6) Ipratropium bromide neb (500 ug)
7) Magnesium sulfate (1-2 g IV)
8) Theophylline (5mg/kg IV loading dose then 0.5mg/kg/hr IV)
What major treatment varies between acute exacerbation of asthma and COPD?
Oxygen therapy - unless the patient is peri-arrest, it is safer to start known COPD patients on 28% oxygen to prevent hypercapnia.
What should be added to management of acute exacerbation if it is an infective cause?
Antibiotic therapy - IV
What is the treatment for secondary pneumothorax?
Chest drain if >2cm, pt is SOB or >50 years
Aspiration otherwise
What is the treatment for tension pneumothorax?
1) Emergency aspiration (i.e. needle decompression)
2) Insertion of chest drain
When should you treat a primary pneumothorax?
If it is >2cm or patient feels SOB
What is the management for primary pneumothorax <2cm?
Outpatient f/u in 4 weeks
What is the management for primary pneumothorax >2cm?
Aspiration (max 2x attempts)
Chest drain if unsuccessful
What CURB-65 score is required for patients to be admitted?
> 2
Outline the management of PE
1) ABC approach
2) 15 L O2 (non-rebreather)
3) Morphine 5-10 mg IV + metoclopramide 10mg IV
3) LMWH (eg: tinzaparin 175 U/kg SC)
Outline the management of chronic asthma
1) Inhaled SABA PRN
2) + ICS daily
3) + Inhaled LABA or increase ICS dose
4) + fourth drug (eg: leukotriene receptor antagonist: montelukast)
5) + daily steroid tablet + referral to specialist care
What % FEV1 determines long-term COPD management?
50% - patients with an FEV1 >50% do not require daily inhaled steroids
Outline the management of COPD patients with FEV1 >50%
1) SABA / SAMA PRN
2) Add in LABA
3) Add in LAMA - must discontinue SAMA
Outline the management of COPD patients with FEV1 <50%
1) SABA / SAMA PRN
2) Add in LABA + ICS
3) Addin LAMA - must discontinue SAMA
Outline the management of acute GI bleeds (HINT: think 8 Cs)
1) ABC approach
2) 15 L O2 (non re-breather)
3) Cannulae - 2x large bore
4) Catheter - strict fluid monitoring
5) Crystalloid
6) Cross match - 6 units of blood
7) Correct clotting abnormalities
8) Camera - endoscopy
9) Culprit - stop culprit drugs (eg NSAIDs, aspirin, warfarin, heparin)
10) Call the surgeons
What is the Rx of bacterial meningitis in the community?
1g benzylpenicillin
What is the Rx of bacterial meningitis in hospital?
2g cefotaxime IV
Outline the management of status epilepticus
1) ABC approach
2) Place patient in recovery position + O2
3) Lorazepam (2-4mg IV) or Diazepam (10mg IV) or midazolam (10mg buccal)
4) Repeat if still fitting at 2 mins
5) Call for anaesthetic support
6) Phenytoin infusion
7) RSI - intubation + propofol
What is the first and most important step in the acute management of stroke?
CT head to see if there are any signs of haemorrhage
Outline the acute management of ischaemic stroke
1) ABC approach
2) CT head
3) If no evidence of bleeding + within 4.5 hours of symptom onset - thrombolysis
4) Aspirin (300mg PO)
5) Transfer to stroke unit
What is the major difference between the management of DKA and HONK?
Amount of fluid - HONK patients need 1/2 the rate of fluid of DKA patients
Outline the management of hyperglycaemia in the acute setting
1) ABC approach
2) IV fluids (0.9% saline) - if in DKA and BP < 90 systolic, give bolus
3) IV insulin - 0.1 unit / kg / hour
4) Look for trigger (infection, missed insulin etc.)
5) Monitor BM, pH and K - give dextrose and potassium after first hour
Outline the management of AKI
1) ABC approach
2) Cannulae - IV fluids
3) Catheter - strict fluid monitoring
4) Monitor
What are the three methods used to reduce absorption in cases of acute poisoning?
Gastric lavage - stomach pumping
Whole bowel irrigation - for lithium or iron
Activated charcoal
What are the conditions for gastric lavage?
Acute poisoning within 1 hour
In the following cases of acute poisoning, what treatments are given to increase elimination?
(1) Paracetemol
(2) Opioids
(3) Benzodiazepines
(1) IV fluids + NAC (N-acetyl cystine)
(2) IV fluids + naloxone
(3) IV fluids + flumazenil
What are the 4 basic principles of diabetes management (according to NICE guidelines)?
1) Education + diet/exercise advice
2) CV risk factor management
3) Annual review for complications
4) Blood glucose lowering therapy
What are the principles for CV risk factor management in diabetes?
If significant risk OR T2DM aged >40 (statin) / >50 (aspirin)
1) Aspirin - 75 mg daily
2) Statin - 20-40 mg daily
Why is the albumin-creatinine ratio good in monitoring for diabetic complications?
It is an early indicator for diabetic nephropathy and predictor of CV disease
What is the cut off for HbA1c in T2DM requiring hypoglycaemic medications?
> 48 mmol/mol (6.5%)
Outline the management of T2DM (in terms of blood glucose lowering therapy)
1) Diet and exercise
If HbA1c remains > 48 mmol/mol
2) Metformin 500mg
3) Increase dose to max tolerated
4) Add in sulphonylurea (gliclazide)
5) Add gliptin
6) Insulin
What are the treatment options for Parkinson’s disease?
In mild cases -
1) Dopamine agonists (eg: ropinirole)
2) MOA inhibitors (eg: rasagiline)
In moderate to severe cases -
2) Levodopa + peripheral dopa decarboxylase inhibiotr (eg: co-beneldopa or co-careldopa)
Name the anti-epileptic most commonly used in each of the following types of seizure disorder:
(1) generalised tonic clonic
(2) absence
(3) myoclonic
(4) tonic
(5) focal
(1) sodium valproate
(2) sodium valproate or ethosuximide
(3) sodium valproate
(4) sodium valproate
(5) carbamazepine or lamotrigine
What class of drug is used to treat mild Alzheimer’s disease?
Acetylcholinesterase inhibitors
Name the 3 acetylcholinesterase inhibitors are licensed for use in Alzheimer’s disease
Donepezil
Rivastigmine
Galantamine
What class of drug is used to treat severe Alzheimer’s disease?
NMDA antagonist
Outline the management of a mild acute flare up of Crohn’s disease
Prednisolone 30 mg PO daily
Outline the management of a severe acute flare up of Crohn’s disease
Hydrocortisone 100 mg IV 6-hourly
What is TPMT and why is it important? (hint: Crohn’s disease)
TPMT is the enzyme that metabolises 6-mercaptopurine (active agent of azathioprine) - 10% of the population have congenitally low levels therefore would experience toxicity on azathioprine treatment
TPMT levels must be checked before Rx with azathioprine is commenced
What is the major drug used to maintain remission in Crohn’s disease?
Azathioprine
If a Crohn’s patient has low TPMT levels, what alternative to azathioprine is used?
Methotrextate
What are the conditions for initiating TNFa inhibitors in RA?
Failure to respond to 2x DMARD
Outline the basic management of RA
Methotrexate + DMARD (eg: sulfasalazine)
Outline the management of RA during an acute flare
1) Short-term glucocorticoids (eg IM methylpred 80 mg)
2) Short-term NSAIDs (eg: ibuprofen 400 mg PO 8 hourly) with gastric protection (eg: lasoprazole)
What is the management of confirmed non-infectious diarrhoea
Loperamide 2mg PO up to 3 hourly
OR
Codeine 30mg PO up to 6 hourly
What is the first line antibiotic for skin infections?
Flucloxacillin (500 mg PO 6 hourly for 7 days)
Outline the management of acute pulmonary oedema
1) ABC approach
2) Sit patient up
3) Oxygen
3) Morphine (diamorphine 2.5-5mg) + metoclopramide
4) Furosemide (40-80 mg IV)
5) GTN (2 puffs)
6) Isosorbate mononitrate (2-10mg / hour IV)
What is malignant hypertension and how is it treated?
BP > 220 / 120 + signs on fundoscopy (haemorrhages, exudates, papilloedema)
Reduce BP to 100-115 mmHg systolic over 4-6 hours using b-blockers (or alpha blockers if phaeochromocytoma is suspected)
Treatment for hyperkalaemia
1) Actrapid (10 units in 100ml 20% dextrose) over 30 mins IV
2) Calcium gluconate
What must you check before starting a patient on vancomycin?
Serum creatinine - vancomycin is renally cleared therefore clearance is reduced in patients in renal failure
What must you check before starting a patient on a statin?
Serum ALT - statins are metabolised in the liver therefore must be used with care in patients with liver disease
CK - this should be checked in patients who have risk factors for myopathy
What must you check before starting a patient on methotrexate?
LFTs - abnormal LFTs are CI for treatment with methotrexate due to risk of cirrhosis
What must you check before starting a patient on olazapine (or other antipsychotics)?
Fasting blood glucose - risk of hyperglycaemia and diabetes
What test should be run before starting a patient on amiodarone?
Chest X-ray due to risk of pulmonary toxicity
What must you check before starting a patient on carbimazole?
Neutrophil count - risk of BM suppression (agranulocytosis) therefore must have good baseline
Why should patients on carbimazole immediately report a sore throat?
Sore throat is a sign of infection and carbimazole has high risk of BM suppression
What must you check before starting a patient on sodium valproate?
ALT - valproate is associated with hepatotoxicity therefore baseline and regular ALT is required
What conditions are required for a patient to be started on clozapine and what are the monitoring requirements?
Shchizophrenic patients must have failed on two other antipsychotics before clozapine can be started
Monitoring includes:
- Registration with clozapine monitoring services
- Baseline full blood count and regular monitoring (weekly for 18 weeks then less frequently) due to risk of fatal agranulocytosis)
What are the normal requirements for an average 70kg patient over 24 hours: fluid, sodium, potassium?
Fluid - 2.5 L
Sodium - 70 - 140 mmol
Potassium - 35 - 70 mmol
What is the generic rule for fluid maintenance for NBM patients over 24 hours?
1 salty + 2 sweet:
- 1L 0.9% saline + 20 mmol KCL (over 8 hours)
- 2 x 1L 5% dextrose + 20 mmol KCL (over 8 hours each)
What should you check before starting patients on IV fluids?
1) If there is any oral intake
2) Determine if there is any deficit or if this is solely maintenance
3) U&Es
Which fluids should you use in the following situations:
1) Extracellular loss (eg: due to D&V)
2) Normal dehydration (eg: due to pyrexia)
3) Blood loss
1) Hartmann’s (if not available - saline)
2) Normal saline (if not available - dextrose with salts)
3) Blood
With regards to fluids, describe the management of an acutely hypotensive patient
1) ABC approach
2) Fluid challenge - 250 - 500 ml saline (or Hartmann’s)
3) Monitor BP, UO and JVP
If the patient responds - put onto maintenance
If the patient initially responds but falls again - another challenge
Which fluid should you NOT give to brain haemorrhage patients?
Dextrose - osmotic therefore can cause swelling
Which fluid should you give to liver failure patients?
5% dextrose
