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PassMed Revision > Tuesday 17th > Flashcards

Tuesday 17th Flashcards

1
Q

Following a stroke all patients should be offered

A

an antiplatelet drug unless the person has an indication for an anticoagulant

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2
Q

Immediately after an ischaemic stroke is confirmed by brain imaging

A

Aspirin 300 mg daily for 2 weeks should be given immediately

  • Following this, clopidogrel 75 mg daily should be given long-term
  • OR modified-release dipyridamole alongside low dose aspirin
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3
Q

Antiplatelet: Acute coronary syndrome (medically treated)

A

1st: Aspirin (lifelong) & ticagrelor (12 months)
2nd: If aspirin contraindicated, clopidogrel (lifelong)

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4
Q

Antiplatelet: Percutaneous coronary intervention

A

1st: Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd: If aspirin contraindicated, clopidogrel (lifelong)

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5
Q

Antiplatelet: TIA

A

1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)

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6
Q

Antiplatelet: Ischaemic stroke

A

1st: Clopidogrel (lifelong)
2nd: Aspirin (lifelong) & dipyridamole (lifelong)

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7
Q

Antiplatelet: Peripheral arterial disease

A

1st: Clopidogrel (lifelong)
2nd: Asprin (lifelong)

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8
Q

Cyclizine

A

H1-receptor antagonist that acts by blocking histamine receptors in the CTZ
- safe to use in pregnancy

  • CI: cause a drop in cardiac output and an increase in heart rate. For this reason, caution should be employed in patients with severe heart failure
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9
Q

metoclopramide

A

Dopamine antagonists

  • pro-kinetics and should therefore be avoided in intestinal obstruction
  • used with caution in patients with Parkinson’s disease
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10
Q

Motion sickness

A

1st: hyoscine (e.g. transdermal patch) as being the most effective treatment. Use is limited due to side-effects
2nd: non-sedating antihistamines such as cyclizine or cinnarizine are recommended in preference to sedating preparation such as promethazine

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11
Q

Raised superior vena cava pressure

A

(e.g. secondary to a bad cough) may cause petechiae in the upper body but would not cause purpura

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12
Q

sumatriptan

A

5-HT1D receptor agonist

- acute treatment of migraine

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13
Q

ergotamine

A

partial agonist of 5-HT1 receptors

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14
Q

pizotifen

A

5-HT2 receptor antagonist

- prophylaxis of migraine attacks

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15
Q

Methysergide

A

5-HT2 receptor antagonist

- rarely used due to the risk of retroperitoneal fibrosis

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16
Q

cyproheptadine

A

5-HT2 receptor antagonist

- control diarrhoea in patients with carcinoid syndrome

17
Q

ondansetron

A

5-HT3 receptor antagonist

- antiemetic

18
Q

Factors which reduce BNP levels

A
  • aldosterone antagonists
  • ACE inhibitors
  • angiotensin-II receptor antagonists
  • beta-blockers
  • diuretics
  • obesity
19
Q

Increased BNP levels (>400)

A
  • left ventricular hypertrophy
  • MI
  • AF
  • pulmonary hypertension
  • hypoxia
  • pulmonary embolism
  • right ventricular strain
  • COPD
  • liver failure
  • sepsis
  • diabetes
  • renal impairment
  • women
  • older than 70
20
Q

B-type natriuretic peptide (BNP)

A
  • left ventricular myocardium in response to strain
  • increase renal excretion of water and sodium
  • relax vascular smooth muscle causing vasodilation
  • suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
21
Q

Acute ischaemic stroke

A

thrombolysis within 4.5 hours of symptom onset

22
Q

Confirmed proximal anterior circulation occlusion

A

thrombectomy within 6 hours

23
Q

Confirmed occlusion of the proximal anterior or posterior circulation

A
  • demonstrated by CTA or MRA and if there is the potential to salvage brain tissue
    > shown by imaging such as CT perfusion or
    diffusion-weighted MRI sequences showing limited
    infarct core volume
  • Thrombectomy can be offered up to 24 hours after symptom onset
24
Q

Management of acute stroke

A
  • blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits
  • blood pressure should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy*
  • aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded
  • with regards to atrial fibrillation, the RCP state: ‘anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke’
  • if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation
25
Q

Thrombolysis for acute ischaemic stroke

A

Alteplase should only be given if:

  • it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
  • haemorrhage has been definitively excluded (i.e. Imaging has been performed)
26
Q

Contraindications to thrombolysis: ABSOLUTE

A
  • Previous intracranial haemorrhage
  • Seizure at onset of stroke
  • Intracranial neoplasm
  • Suspected subarachnoid haemorrhage
  • Stroke or traumatic brain injury in preceding 3 months
  • Lumbar puncture in preceding 7 days
  • Gastrointestinal haemorrhage in preceding 3 weeks
  • Active bleeding
  • Pregnancy
  • Oesophageal varices
  • Uncontrolled hypertension >200/120mmHg
27
Q

Contraindications to thrombolysis: RELATIVE

A
  • Concurrent anticoagulation (INR >1.7)
  • Haemorrhagic diathesis
  • Active diabetic haemorrhagic retinopathy
  • Suspected intracardiac thrombus
  • Major surgery / trauma in the preceding 2 weeks
28
Q

Carotid artery endarterectomy

A
  • if patient has suffered stroke or TIA in the carotid territory and are not severely disabled
  • should only be considered if carotid stenosis > 70% according ECST** criteria or > 50% according to NASCET*** criteria
29
Q

splenic flexure

A

most likely area to be affected by ischaemic colitis
- splenic flexure marks the point where the majority of blood supplied changes from the superior mesenteric artery (SMA) to the inferior mesenteric artery (IMA)

30
Q

Ischaemia to the lower gastrointestinal tract

A
  • acute mesenteric ischaemia
  • chronic mesenteric ischaemia
  • ischaemic colitis
31
Q

Common features in bowel ischaemia

A
  • abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
  • rectal bleeding
  • diarrhoea
  • fever
  • bloods typically show an elevated white blood cell count associated with a lactic acidosis

1st: CT

32
Q

Bowel ischaemia: Common predisposing factors

A
  • increasing age
  • atrial fibrillation - particularly for mesenteric ischaemia
  • other causes of emboli: endocarditis, malignancy
  • cardiovascular disease risk factors: smoking, hypertension, diabetes
  • cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
33
Q

Acute mesenteric ischaemia

A
  • typically embolism > occlusion > e.g. superior mesenteric artery
  • Classically, history of atrial fibrillation
  • Abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings
  • Management: urgent surgery is usually required
    > poor prognosis, especially if surgery delayed
34
Q

Chronic mesenteric ischaemia

A
  • Relatively rare clinical diagnosis due to it’s non-specific features and may be thought of as ‘intestinal angina’
  • Colickly, intermittent abdominal pain occurs
35
Q

Ischaemiac colitis

A
  • acute but transient compromise in the blood flow to the large bowel
  • may lead to inflammation, ulceration and haemorrhage
  • Investigations: ‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
  • Management
    > usually supportive
    > surgery may be required in a minority of cases if
    conservative measures fail
    > Indications: generalised peritonitis, perforation or
    ongoing haemorrhage

PassMed Revision (13 decks)

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