chapter 4

Question 1

mx of a STEMI?

Answer 1

aspirin 300mg
Morphine 5–
10mg IV with
metoclopramide
10 mg IV
Primary PCI
(preferred) or
thrombolysis
β-blocker
e.g. atenolol 5 mg oral
(unless
LVF/asthma)

Question 2

what do you do insteadof PCI for NSTEMI?

Answer 2

aspirin 300mg

fondaparinux 2.5mg if they do not have a high bleeding risk/ arent going to cath lab

Question 3

Mx of acute HF?

Answer 3

Furosemide

40–80 mg IV

Question 4

What adverse features would make you deliver a DC shock in adults with tachycardia?

Answer 4

shock
acute HF
syncope
MI

Question 5

What are the differentials and mx for broad complex irregular tachycardia?

Answer 5

AF + BBB –> same treatment as narrow complex
Polymorphic VT –>
(e.g. torsade de pointes -
give magnesium 2 g over 10 m

Question 6

What are the differentials and mx for broad complex regular tachycardia?

Answer 6

VT –> Amiodarone 300 mg IV over 20–60 min; then 900 mg over 24 h
If previously confirmed SVT with BBB –> adenosine as for regular narrow complex tachycardias

Question 7

What is the mx for narrow complex regular tachycardia? e.g. SVT

Answer 7

vagal manoeuvres

Adenosine 6 mg rapid IV bolus;
if unsuccessful give 12 mg;
if unsuccessful give further 12 mg

if atrial flutter get expert gelp

Question 8

What is the mx for narrow complex irregular tachycardia?

Answer 8

Probable atrial fibrillation
Control rate with:
β-blocker or diltiazem
Consider digoxin or amiodarone
 if evidence of heart failure

Question 9

mx for anaphylaxis?

Answer 9

ABCDE
remove cause
adrenaline 500 mcg 1:1000 IM
clorphenamine 10mg IV
hydrocortisone 200mg IV

Question 10

mx of acute asthma?

Answer 10

100% O2 by nonrebreather mask

Salbutamol
(5 mg NEB)

Hydrocortisone 100 mg
IV (if severe/life threatening)
or prednisolone
40–50mg oral (if moderate)

Ipratropium (500
micrograms NEB)

Theophylline (only
if life threatening)

Question 11

mx for secondary Pneumothorax?

Answer 11

(i.e. patient has lung disease) then always needs
treatment: chest drain if >2 cm or patient SOB or if >50 years
old; otherwise aspirate.

Question 12

mx for tension Pneumothorax?

Answer 12

(i.e. clinical distinction but often
tracheal deviation +/− shock) then emergency aspiration
required, but will need chest drain quickly.

Question 13

mx for primary Pneumothorax?

Answer 13

` if <2 cm rim and not SOB then discharge with outpatient
follow-up in 4 weeks.
` if >2 cm rim on CXR or feels SOB then aspirate and if
unsuccessful aspirate again, and if still unsuccessful then
chest drain.

Question 14

mx for PE?

Answer 14

Morphine 5–10 mg IV,

metoclopramide 10 mg IV

Give LMWH before CTPA but once confirmed do a
DOAC e.g. rivoraxiban 15mg BD

Question 15

mx for GI bleeding?

Answer 15

x 2 cannula large bore
Cross match 6 units blood
Endoscopy
Stop antiplatelets/ coagulants
Check for clotting abnromalities: If PT/aPTT more than 1.5 normal range ⇒ give fresh frozen plasma (unless due to warfarin ⇒ give prothrombin complex (e.g.
Beriplex®)); if platelets <50 × 109
/L (and actively bleeding) give platelet transfusion.

Question 16

mx of meningitis?

Answer 16

LP +/- CT head (dont want to delay LP)
IV dexa
2 g cefotaxime IV (give pre-LP if having CT head or prolonged LP)

Question 17

mx of seizures?

Answer 17

Patent airway
Recovery position
check glucose, electrolytes, drugs, sepsis that could be provoking

Question 18

mx of status epillepticus (> 5 mins)?

Answer 18

10mg buccal midazolam
IV lorazepam 4mg, repeated after 10 minutes up to 3 doses if the seizure continues
Get anaesthatist
If seizures persist: IV phenobarbital or phenytoin
Intubate

Question 19

mx for a stroke?

Answer 19

CT to check for haemorrhage
If onset <4.5 hours ago consider thrombolysis with alteplase
Aspirin 300mg stat

Question 20

What is the criteria for DKA?

Answer 20

Diabetic (i.e. hyperglycaemia – BM often >30mmol/L)
Keto (i.e. check urine or blood ketone levels)
Acidosis (i.e. low pH on ABG).

Also watch out for increased potassium.

Question 21

What is the criteria for Hyperosmolar Hyperglycaemic State?

Answer 21

● Hyperglycaemia (usually >35mmol/L)
● HO (hyperosmolar: osmolality over 340mmol/L (calculated by
(x2 Na + x2 K) + urea + glucose)
● NK (nonketotic, i.e. no ketones in blood or urine).

Question 22

What is the mx of hyperglycaemia?

Answer 22

IV fluid: 1 L stat then 1 L over 1 hour, then 2 hours, then 4 hours, then 8 hours
Sliding scale insulin

Question 23

mx of hypoglycaemia?

Answer 23

if unable to eat (i.e. drowsy/vomiting) give IV glucose via a cannula, e.g. 100mL 20% glucose.

If unable to eat and no cannula give IM glucagon 1mg.

Question 24

mx of AKI?

Answer 24

500ml IV stat, 1L 4 hrly
Check causes and complications (hyperkalaemia, fluid overload, acidosis)
ABG, catheter, urinalysis, bloods

Question 25

Antidote to benzodiazepine OD?

Answer 25

flumazenil

Question 26

what is the mx for htn?

Answer 26

>150/95mmHG or >135/85mmHg + risk of CVD then give: <55 yrs or diabetes: ACE-i >55 yrs/ afro-carribean :CCB

Question 27

mx for chronic HF?

Answer 27

ACE-i + BB | + ARB --> nitrates --> spironolactone

Question 28

mx of AF?

Answer 28

Rhythm control: `Who? – if young/symptomatic AF/first episode of AF/AF due to treated precipitant (e.g. sepsis or electrolyte disturbance). How? – cardioversion: electrical or pharmacological (amiodarone 5mg/kg IV over 20–120mins). The patient will require anticoagulation if more than 48 hours since onset. Rate 1. Beta blocker (e.g. atenolol 50-100mg once daily) 2. Calcium-channel blocker (e.g. diltiazem 120mg OD) (not preferable in heart failure) 3. Digoxin load, then start 62.5-125mcg (only in sedentary people, needs monitoring and risk of toxicity)

Question 29

mx of stable angina?

Answer 29

GTN PRN RF modification - statin, aspirin + other RF modification Anti-angina drug: 1) BB 2) CCB Referral to cardiology for revascularisation

Question 30

mx of asthma?

Answer 30

1. Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes. 2. Add a regular low dose inhaled corticosteroid. 3. Add an oral leukotriene receptor antagonist (i.e. montelukast). 4. Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response. 5. Consider changing to a maintenance and reliever therapy (MART) regime. 6. Increase the inhaled corticosteroid to a “moderate dose”. 7. Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium). 8. Refer to a specialist.

Question 31

What is the mx of diabetic nephropathy and how is this checked for?

Answer 31

s checking an albumin–creatinine ratio (ACR) as (1) an early indicator of diabetic nephropathy, and (2) a predictor of cardiovascular disease, e.g. microalbuminuria (ACR ≥ 3mg/mmol) indicates the need for ion). an ACE-inhibitor. Ironically, ACE-inhibitors can worsen acute kidney injury but in the chronic setting (with careful monitoring) offer significant cardiovascular and renal prot

Question 32

Mx of Parkinsons?

Answer 32

If mild PD with limited benefit from levodopa yet then give dopamine agonist (such as ropinirole) or MAO-inhibitor (such as rasagiline) otherwise give co-beneldopa

Question 33

mx of seizures?

Answer 33

● Generalized seizures – sodium valproate ● Absence seizures – ethosuximide ● Focal seizures – carbamazepine or lamotrigine

Question 34

mx of Alzheimers?

Answer 34

● If mild/moderate dementia then treat with acetylcholinesterase (AChE) inhibitors; donepezil, rivastigmine and galantamine. ● If moderate/severe dementia then treat with NMDA antagonist (memantine).

Question 35

What blood test should be initiated before giving azathioprine

Answer 35

S-methyl | transferase (TPMT)

Question 36

Examples of DMARDs

Answer 36

methotrexate or | sulfasalazine or hydroxychloroquine

Question 37

Gve an examples of a stool softener and its indication

Answer 37

Docusate | Foecal impaction

Question 38

Gve an examples of a bulking agent laxativr?

Answer 38

Isphagula husk

Question 39

examples of stimulant laxative

Answer 39

senna | bisacodyl

Question 40

examples of osmotic laxatives

Answer 40

lactulose | phosopahate enema

Question 41

mx of hyperkalaemia?

Answer 41

``` 5–10 UNITS OF ACTRAPID® (or NOVORAPID®) IN 50ML OF 50% DEXTROSE OVER 5–15 MIN IV ``` calcium gluconate 10% by slow intravenous injection Neb salbutamatol

Question 42

What is the best anti-epileptic drug for pregnancy?

Answer 42

lamotrigine

Question 43

How do you decide on the first line PO hypoglycaemic drug for T2DM?

Answer 43

Sulphonylureas (e.g. glipizide or gliclazide) first line is patient is normal/ underweight or creatinine >150 Metformin first line if overweight and cretinine <150

Question 44

Mx of COPD exacerbation?

Answer 44

First: 24% oxygen in CO2 retainers salbutamol nebuliser ipratropium bromide 500mcg neb Then PO/ IV steroids IF fail to respond to treatment consider ITU referral and aminophylline

Question 45

Mx of bowel obstruction?

Answer 45

drip and suck with a NGT | If that doesnt work consider antiemetic - cyclizine or odansetron appropriate.

Question 46

What should you consider when doing fluids post AKI

Answer 46

After renal failure patients can experience a polyuric phase in which urine output is higher than input → dehydration + electrolyte disturbance. Normally fluid charts should have similar input and output (allow 10-15% difference due to insensible losses). Input may be higher than output in dehydration/ renal failure when we’re pumping them full of fluids. But vice versa is worrying. To decide on what to prescribe look at total output and divide that by 24 hrs e.g. 6L output - do 24/6 - 4 hrly fluids

Question 47

Rules for fluid prescrbing

Answer 47

Look at patient’s bloods!! If they are hypokalaemic replace with K+, if they are upper end of normal for sodium use 5% dextrose Potassium should never be given at a rate over 20mmol/ hr Maintenance: 30ml/kg/day; 1mmol/kg of K, Na and Cl, 50-100g/day glucose High calcium → give 0.9% sodium chloride, 1L in 4 hrs