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Flashcards in Chapter 4: Planning Management Deck (44):
1

Management of an acute sick patinet

ABC approach as part of ATLS protocol. AVPU.

A = assess for stridor + accessory muscles + central cyanosis → secure airway with head tilt/chin lift, then airway adjuncts e.g. NPA, OPA, I-gel, LMA, then alert anaesthetist if unsuccessful.

B = examine RR, SpO2, chest expansion; give high flow O2 via non-rebreather mask if low SpO2.

C = examine CRT, pulses + BP; 2 wide bore cannulae; cardiac monitor.

Take history (note if primary or secondary), examination + perform further investigations e.g. imaging.

2

Cardiovascular emergencies: STEMI

(management

STEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral Morphine 5-10mg IV + metoclopramide 10mg IVGTN spray/tabletprimary PCI (preferred) or thrombolysis B-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU

3

Cardiovascular emergencies: NSTEMI

(management) 

NSTEMI: ABC + O2 (15L) by non-rebreather mask (unless COPD) → Hx, O/E, Ix → Aspirin 300mg oral + Ticagrelor 180mg oral Morphine 5-10mg IV + metoclopramide 10mg IVGTN spray/tablet → LMWH OR FondaparinuxB-blocker e.g. atenolol 5mg oral (unless LVF/asthma) → transfer CCU.

4

Cardiovascular emergencies: Acute LVF

(Management)

Acute LVF: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → sit up → Morphine 5-10mg IV + metoclopramide 10mg IVGTN spray/tablet → Furosemide 40-80mg IV → if inadequate, isosorbide dinitrate infusion + CPAP → CCU.

5

Cardiovascular emergencies: Tachycardia

(management)

Tachycardia:

>125bpm. Many just sick with non-cardiac disease i.e. sinus tachycardia, but consider algorithm if not sinus rhythm.

ABC + O2 (15L) by non-rebreather mask (if hypoxic)→ Hx, O/E, Ix:ECG/BP/electrolytes (IV access) → identify + treat reversible causes

  • If adverse features (shock, syncope, MI, heart failure) → synchronised DC shock (up to 3x) → amiodarone 300mg IV over 10-20mins → repeat shock → amiodarone 900mg over 24h.
  • If stable, note QRS complex.
    • Narrow (<0.12s):
      • Narrow complex + regular = vagal manoeuvres → adenosine 6mg rapid IV bolus → try 12mg again x 2 (monitor ECG continuously) → if sinus rhythm restored, probably re-entry paroxysmal SVT needing adenosine if re-currence + consider anti-arrhythmic prophylaxis. → If sinus rhythm not restored, possible atrial flutter (consider rate control e.g. B-blockers).
      • Narrow complex + irregular = treat as AF → rate control (B-blocker or diltiazem), digoxin/amiodarone if HF.
    • Broad (>0.12s)
      • Broad complex + regular = VT → amiodarone 300mg IV over 20-60 minutes, then 900mg over 24h. OR SVT + BBB = treat as narrow (vagal/amiod)
      • Broad complex + irregular = AF + BBB → treat as narrow; pre-excited AF → consider amiodarone; polymorphic VT = Mg2+ over 10mins.

6

Cardiovascular emergencies: Anaphylaxis

(management) 

Anaphylaxis: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → remove cause ASAP → adrenaline 0.5mg 1:1000 IMchlorphenamine 10mg IVhydrocortisone 200mg IV → asthma if wheeze + amend drug chart allergies.

7

Respiratory emergencies: acute exacerbation of asthma

(management

Acute exacerbation of asthma: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → salbutamol 5mg + ipratropium 0.5mg nebulisedprednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV theophylline, magnesium sulphate, ITU.

8

Respiratory emergencies: acute exacerbation of COPD

(management)

Acute exacerbation of COPD: Same as asthma, but add antibiotics if infective exacerbations. T2RF more likely so give O2 via venturi mask at 24-28%, maintain SpO2 at 88-92%. NB: hypoxia kills quicker than hypercapnia so high-flow O2 if peri-arrest then review ABG.

 

ABC + O2 PERI-ARREST HIGH FLOW O2 AND REVIEW → Hx, O/E, Ix(ABG!)→ salbutamol 5mg + ipratropium 0.5mg nebulised → prednisolone 40-50mg oral and/or IV hydrocortisone 100mg IV +ABx! → theophylline, magnesium sulphate, ITU.

9

Respiratory emergencies: Pneumothorax

(management)

Primary… SOB + >2cm rim on CXR = aspirate x2 → chest drain; not SOB + <2cm discharge + OP follow-up in 4 weeks.

Secondary… always admit to treat; SOB + >2cm rim on CXR or >50 years old = chest drain; if not, then aspirate.

Tension… emergency aspiration, but will need chest drain quickly.

10

Respiratory emergencies: Pneumonia

(management) 

Pneumonia: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → antibiotics (e.g. amoxicillin or co-amoxiclav) → paracetamol → if low BP, or raised HR, IV fluids as normal.

11

Respiratory emergencies: Pneumonia

(Scoring system) 

CURB-65

Confusion; AMTS = 8 

Ureal >7.5 mmol/L

Respiratory Rate >30/min 

Blood pression (systolic) <90 mmHg

Age >/= 65yrs 

 

0-1 = home treatment

2-3=Hospital with oral/IV Abx

4-5=ITU admission

12

Respiratory Emergency: Pulmonary embolism 

(management)

Pulmonary embolism: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → morphine 5-10mg IV + metoclopramide 10mg IV LMWH e.g. dalteparin → if low BP, IV gelofusine, then noradrenaline, then thrombolysis.

13

Gastrointestinal emergencies: Gastrointestinal bleeding

(management) 

Gastrointestinal bleeding: ABC + O2 (15L) by non-rebreather mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC etc. + group and save + crossmatch 6U, GIVE colloid if low BP or O-negative blood if available) → catheter for strict fluid monitoring → correct clotting abnormalities (give FFP if PT/aPTT >1.5x N range, platelet transfusion if platelets abnormal) → camera (endoscopy) → stop CI drugs e.g. NSAIDs, aspirin, warfarin, heparin call surgeons if severe.

 

8Cs!

14

Gastrointestinal emergency: GI bleed

Coloid vs crystaloid Rx Which fluid when?

give crystalloid (e.g. 0.9% saline) if normal/high, or a colloid (e.g. gelofusine) if BP low; once cross matched, give blood 

15

Gastrointestinal emergency: GI bleed

Correcting clotting abnormalities: FFP/prothrombin/Platelets what/when?

If PT/aPTT >1.5xN => FFP 

^ UNLESS due to warfarin => prothrombin complex e.g. beriplex

If platelets <50 x 109/L (and actively bleeding) => platelet transfusion

16

Neurological emergencies: Bacterial meningitis

(management)

Bacterial meningitis: If GP setting, give 1.2g benzylpenicillin if suspicion.

Give antibiotics after LP, unless undue delay. Do a CT scan not always required before LP.

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → 2 wide bore cannulae (TAKE FBC, blood cultures, glucose etc. GIVE IV antibiotics e.g. 2g cefotaxime, IV fluids, IV dexamethasone) + LP (before antibiotics if possible, and after CT) → consider ITU.

17

Neurological emergencies: Seizures and status epilepticus

(management)

Seizures and status epilepticus:

initial: 1) ensure the airway is patent, (2) put in recovery position to prevent aspiration if patient vomits and (3) check for provoking factors (e.g. plastma glucose, electrolytes, drugs, sepsis)  

Status= seizure >5 mins, Rx patient to stop the seizure (status is technically defined as seizure lasting >30mins) 

 

ABC + O2 (15L) by non-rebreathe mask + airway manoeuvres/adjunct + recovery position (to prevent aspiration) → Hx, O/E, Ix →

if seizure for >5minutes, must give drugs lorazepam 2-4mg IV or IV diazepam 10mg or buccal midazolam 10mg → if still fitting after 2 minutes, repeat diazepam → inform anaesthetist → phenytoin infusion → intubate then propofol.

18

Neurological emergencies: Stroke

(management) 

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix (including CT head) → if ischaemic stroke = thrombolysis if <4.5h ago + <80years old → aspirin 300mg oral → transfer to stroke unit.

 

If CT shows haemorrhage of any type, discuss with neurosurgery immediately and do not give aspirin or thrombolysis.

19

Metabolic emergencies: hyperglycaemia in T1 vs T2 DM

Hyperglycaemia in T1DM = DKA; in T2DM = HONK.

20

Metabolic emergencies: DKA 

(management)

DKA… diagnose as hyperglycaemia, ketones in urine/blood, acidosis as low pH on ABG – watch out for raised K+.

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 1L/1h, 1L/2h, 1L/4h, 1L/8h → sliding scale insulin/fixed infusion → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.

21

Metabolic emergencies: HONK

(management)

HONK… diagnose as hyperglycaemia, hyperosmolar ((2 x (Na+ + K+)) + urea + glucose), non-ketotic (no ketones in blood or urine).

Same as DKA management, except half rate of fluids required.

 

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → IV fluid 1L stat, 500mL/1h, 500mL/2h, 500mL/4h, 500mL/8h → sliding scale insulin → find trigger (e.g. infection, MI, missed insulin) → monitor BM, K+ + pH.

22

MEtabolic emergencies: Hypoglycaemia

(management)

Hypoglycaemia: <3mmol/L. Conscious = sugar-rich snack e.g. orange juice + biscuits.

Drowsy/vomiting = IV glucose via cannula e.g. 100ml 20% glucose. If no cannula, give IM glucagon 1mg

23

Metabolic emergencies: AKI 

(management)

Acute kidney injury: ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → IV fluid 500ml STAT, then 1L 4-hourly → hunt for cause + complications → monitor U&Es + fluid balance.

 

causes: routine bloods, ABG, urinalysis, US kidneys, drug chart nephrotoxic

complications: fluid overload, hyperkalaemia, acidosis

24

Metabolic: Acute poisoning

(metabolic) 

ABC + O2 (15L) by non-rebreathe mask → Hx, O/E, Ix → cannula + catheter for strict fluid monitoring → supportive measures (IV fluids + analgesia if appropriate) → correct electrolyte disturbances → reduce absorption (if within 1h e.g. gastric lavage, whole bowel irrigation, charcoal) → increase elimination (generous IV fluids) → psychiatric management.

25

Metabolic emergencies: Acute poisoning

Specific Rx for 

  1. Paracetamol 
  2. Opiates
  3. Benzodiazepines

Specific:

  1. N-acetylcysteine for paracetamol over line of treatment after 4h on nomogram
  2. Naloxone if opiates been taken and now slow breathing or low GCS
  3. Fumazenil if benzodiazepines been taken.

26

Chronic CV condition: HTN

(management: who to treat/targets) 

Hypertension: Treat after ambulatory or home BP monitoring.

Treat if BP >150/95mmHg or 135/85mmHg if any of following present: existing or high risk of vascular disease (IHD, stroke + PVD), hypertensive organ damage (intracerebral bleed, CKD, LVH + retinopathy).

Target BP: if <80 years, aim for <140/85mmHg in clinic and <135/85mmHg ambulatory; if >80 years, add 10mmHg to systolic values.

Target BP in DM

  • if end-organ damage (e.g. renal disease, retinopathy) < 130/80 mmHg
  • otherwise < 140/80 mmHg

 

27

Chronic CV: HTN

(management) 

<55 = ACE-i;

>55 or black = CCBs

→ A + C

→ A + C + thiazide-like diuretic

→ K+<= 4.5 add spiro // K+>4.5 add high dose thiazide like Rx

--> consider alpha/beta blockers 

 

 

A=ACEi/ARB

C=CCB (nottol if oedema/evidence of HF, skip to D) 

D=Thiazide: chlorthalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) preference to a conventional thiazide diuretic such as bendroflumethiazide

28

Chronic CV: Chronic heart failure

(management)

Chronic heart failure: ACE-i (e.g. Lisinopril 2.5mg daily) + B-blocker (e.g. bisoprolol 1.25mg daily) → increase doses as tolerated

 

mild/mod → add ARB ( e.g. candesartan 4mg daily)

mod-severe, black → add hydralazine (25mg 8-hourly) + ISMN (20mg 8-hourly)

mod/severespironolactone (25mg daily).

29

Chronic CV: Atrial fibrillation

(management)

Atrial fibrillation: Prevent stroke + control rhythm OR rate.

  • Prevent stroke
    • Stroke prevention: use CHA2DS2VASc = CCF (or LVF alone), HTN, age > 75 = 2, diabetes, stroke or TIA = 2, vascular disease (e.g. IHD, PVD), age 65-74 = 1, sex – female = 1.
    • Score 0 = no treatment; score 1 + male = condsider anticoagulation Aspirin is no longer recommended for reducing stroke risk in patients with AF– not if female; score 2 = warfarin/NOACs aiming for INR 2.5.
  • Rhythm control:
    • Who? If young/symptomatic AF/first episode/due to treated precipitant e.g. sepsis or electrolyte disturbance.
    • How? Cardioversion = electrical or pharmacological (amiodarone 5mg/kg IV over 20-120minutes). Need AC if >48h since onset.
  • Rate control:
    • Who? Everyone else with HR > 90bpm.
    • How? B-blocker (e.g. propranolol 10mg 6-hourly) or rate-limiting CCB (e.g. diltiazem 120mg daily) → add digoxin (1st line if others CI, 62.5-125ug daily).

30

Chronic CV: Stable angina

(management)

Stable angina:

3 facets to first-line management:

  1. GTN spray as required (symptomatic relief)
  2. 2⁰ prevention (aspirin + statin +cv risks)  
  3. one anti-angina drug (B-blocker – CI = hypotension, bradycardia, asthma & acute HF OR CCB – CI = hypotension, bradycardia & peripheral oedema)

→ increase dose of B-blocker or CCB

→ 2nd anti-angina drug (ISMN (long-acting nitrate), nicorandil (K+-channel activator)

→ urgent revascularisation therapy (PCI or CABG).

 

even if controlled with medical management, routinely refer for consideration of revascularisation

31

CV

how to distinguish stable angina vs ACS

Features more likely to suggest N/STEMI: sweating + vomiting, at rest, >15 minutes, no response to GTN, raised troponin = N/STEMI so look at ECG to decide (NSTEMI can be ST depression or normal; NB – ST depression in V1-4 may be anterior ischaemia or posterior infarction),

if no troponin rise = unstable angina

occurs on exertion/emotion and ceases <15mins + responds to GTN, more likely stable angina

32

Chronic Resp: Chronic asthma 

management

Chronic asthma:

1. SABA + low dose ICS

2. SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)

Continue LTRA depending on patient's response to LTRA

3. SABA + low-dose ICS + long-acting beta agonist (LABA) +/- LTRA

4. SABA  + MART ( ICS + LABA in single inhaler) +/- LTRA

5. SABA + (medium dose ICS) MART (ICS + LABA) +/- LTRA

6. SABA +/- LTRA: 

  • + high dose ICS 
  • + e.g. LAMA/Theophyline
  • + seak help

33

Chronic Resp: COPD Management

COPD: smoking cessation + NRT (bupropion or vareniciline) + annual influenza vaccine + one off pneumococcal vaccine

→ SABA or SAMA as required

→ assess FEV1…

  • If FEV1 > 50%, LABA or LAMA (and discontinue SAMA).
  • If FEV1 < 50%, add LABA + ICS or LAMA.

If still poorly controlled, add LABA + ICS (combination inhaler) OR LABA + ICS (combination inhaler) + LAMA.

 

  • NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
    • the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
  • Mucolytics should be 'considered' in patients with a chronic productive cough and continued if symptoms improve

34

Chronic DM (T1/T2)

Management 

T1+2DM: 4 components =

  1. education & dietary/exercise advice
  2. CV RF management (aspirin 75mg daily, simvastatin 20-40mg daily)
  3. annual review of complications (check albumin: creatinine ratio → give ACE-I if microalbuminuria) 
  4. Blood glucose lowering therapy

in T1DM, start with insulin – never use oral hypoglycaemic drugs. e.g. long acting analogues glargine or NPH insulin humulin

In T2DM, if after trial of diet + exercise and HbA1c > 48mmol/mol…

  • Metformin 500mg
  • And:
    • sulphonylurea (e.g. gliclazide) 
    • Gliptin
    • Pioglitaxone
    • SGLT2 -inhibitor
  • 3 agents OR Insulin therapy 
  • 4th line: (if not tolerated and BMI>35) 
    • metformin + sulphonylurea + GLP-1 mimetic

35

Chronic Neurological: Parkinson's disease 

(management) 

Parkinson’s: 

mild PD and worried about finite benefit from levodopa→ Da agonist (ropinirole) or MAO-O inhibitor (rasagiline).

OTHERWISE: co-beneldopa or co-careldopa (i.e. levodopa + peripheral dopa decarboxylase inhibitor – benserazide or carbidopa),

36

Chronic Neurological: Epilepsy

(management) 

Epilepsy: means >2 seizures → most first seizures not treated with AED; choice reflects seizure type…

  • Generalised TC = sodium valproate;
  • absence = SV or ethosuximide;
  • myoclonic = SV;
  • tonic = SV;
  • focal = carbamazepine or lamotrigine.

Each drug has multiple S/Es but if choice of 2 given, SV’s teratogenicity + lamotrigine’s rash should help select most appropriate.

37

Common SE of neuroelipeptic drugs 

SV

Lamotrigine

carbamazepine

Phenytoin 

  • SV = tremor, teratogenicity, tubby;
  • lamotrigine = rash, rarely SJS;
  • carbamazepine = rash, dysarthria, ataxia, nystagmus, ↓Na+;
  • phenytoin = ataxia, peripheral neuropathy, gum hyperplasia, hepatotoxicity.

38

Chronic disease management: Alzheimer's disease

Alzheimer’s disease:

  • Mild/mod = acetylcholinesterase inhibitors,
    • only specialist can start
    • e.g. donepezil, rivastigmine, alantamine.
  • Mod/severe = NMDA antagonist e.g. memantine.

39

Chronic GI:  Crohn's disease

(management)

 

Two principles; induce remission or maintain remission (prevent flare) 

Induce remission…

  • mild = prednisolone 40mg daily oral
  • severe = hydrocortisone 100mg 6-hourly IV + supportive (e.g. IV fluids, NBM, antibiotics)
  • ^in either case, use rectal hydrocortisone too for rectal disease.

Maintain remission…

Azathioprine (check TPMT levels, risk of liver/BM toxicity) metabolised to 6-mercaptopurine. If TPMT low, use methotrexate.

40

Chronic Rheumatology: RA 

(management) 

Rheumatoid arthritis:

  • Combination of methotrexate + one other DMARD – usually sulfasalazine or hydroxychloroquine.
  • After failure to respond to 2 DMARDs,
    • severely active RA may be managed with TNF-alpha inhibitor e.g. infliximab.
  • During flare:
    • short-term glucocorticoids (e.g. IM methylprednisolone 80mg),
    • short-term NSAIDs (e.g. ibuprofen 400mg 8-hourly) + gastro-protection (e.g. lansoprazole)
    • re-instate DMARDs if dose previously reduced.

 

41

Symptom Management: Fever

treat underlying cause + paracetamol as antipyretic – same dose as for analgesia, maximum 4g in 24h.

42

Symptom Management: Constipation

treat underlying cause + laxative depending on cause and known Cis. Never give laxative if evidence of obstruction.

  • Stool softener = docusate sodium (high dose = stimulant), arachis oil (rectal);
    • CI = arachis oil→ nut allergy;
    • good for faecal impaction.
  • Bulking agents = isphagula husk;
    • CI = faecal impaction, colonic atomy;
    • can take days to develop effect.
  • Stimulant laxatives = senna, bisacodyl;
    • CI = bisacodyl → acute abdomen;
    • may exacerbate abdominal cramps.
  • Osmotic laxatives = lactulose, phosphate enema;
    • CI = phosphate enema → acute abdomen;
    • may exacerbate bloating.

43

Symptom Management: Diarrhoea

Diarrhoea: commonest cause GI infection (especially norovirus + C difficile) so don’t intentionally inhibit quick removal of infectious agents; chronic diarrhoea = loperamide 2mg oral up to 3-hourly or codeine 30mg oral up to 6-hourly (also relief of pain).

44

Symptom management: Insomnia

Insomnia: corticosteroids prevent sleep – so give in AM. Deal with aspects e.g. noisy environment first. Hypnotics can cause elderly to become very drowsy = risk of falls. If giving hypnotic, start with zopiclone 7.5mg oral nightly in adults (3.75mg in elderly).