Elderly MSK Neuro PPT Flashcards
(231 cards)
1
Q
who treats parkinsons
A
only a specialist with expertise in movement disorders
2
Q
First line Tx for PD with motor symptoms affecting QOL
A
levodopa
3
Q
treatment of PD with motor sx not affecting QOL
A
Dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO-B) inhibitor
4
Q
Best PD drug for motor sx
A
levodopa
5
Q
which PD drug best improves QOL
A
levodopa
6
Q
motor comps w PD drugs
A
> more motor side effects: levodopa
less motor se: dopamine agonists and MAOB inhib
7
Q
which PD drug class has the most SE
A
dopamine agonists e.g. excessive sleepiness, hallucinations, impulse control disorders
8
Q
PD - if the patient continues to have symptoms despite levodopa treatment od has developed dyskinesia ->
A
add dopamine agonist, MAO-B inhibitor, or COMT inhibitor as an adjunct
9
Q
dopamine agonists for PD - considerations
A
> more off time reduction
intermediate risk of adverse events
more risk of hallucinations
10
Q
MAO-B inhib for PD - considerations
A
> improves ADL
off time reduction
less SE and lower risk of hallucinations
11
Q
COMT inhibitors for PD
A
> Improve QOL
off time reduction
more side effects but lower risk of hallucinations
12
Q
amantadine and PD
A
Does not improve motor symptoms and no evidence in imp ADL
13
Q
there is a risk of… with PD drugs
A
acute akinesia or NMS if a medication is not taken or absorbed e.g. GE, do not give a drug holiday
14
Q
when to be cautious of an impulse control disorder for PD
A
> Dopamine agonist
history of impulsive behaviours
history of alcohol and smoking
15
Q
excessive daytime sleepiness w PD ->
A
do not drive. Adjust meds to control symptoms, modafinil can be considered as alt
16
Q
if there is persistent orthostatic hypotension with PD, what can be gien
A
midodrine
17
Q
? Should be considered for excess secretions with PD
A
glycopyrronium bromide
18
Q
what is levodopa prescribed w
A
> decarboxylase inhibitor eg. Carbidopa
prevents peripheral conversion of levodopa to dopamine outisde of the brain reducing SE
19
Q
Comm side effects of levodopa
A
> dry mouth
anorexia
palps
postural hypotension
psychosis
20
Q
end of dose weaning off - levodopa
A
> end-of-dose wearing off: symptoms often worsen towards the end of dosage interval. This results in a decline of motor activity
21
Q
on off phenomenon - levodopa
A
‘on-off’ phenomenon: large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period
22
Q
dyskinesias at peak dose - levodopa
A
dyskinesias at peak dose: dystonia, chorea and athetosis (involuntary writhing movements)
23
Q
what to do if a patient on levodopa is admitted to hospital
A
- do not acutely stop levodopa
- if they cannot take it orally, give a dopamine agonist patch as a rescue medication
24
Q
PD - dopamine receptor agonists e.g.
A
e.g. bromocriptine, ropinirole, cabergoline, apomorphine
25
PD - obtain an echo, ESR, CXR an creatine before stareting
bromocriptine or cabergoline - associated with pulmonary and cardiac fibrosis
26
what to warn patients about with levodopa
e potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence
27
MAO-B inhib for PD
- e.g. selegiline
- inhibits the breakdown of dopamine secreted by the dopaminergic neurons
28
Amantadine mechanism
mechanism is not fully understood, probably increases dopamine release and inhibits its uptake at dopaminergic synapses
29
Amantadine SE
ataxia, slurred speech, confusion, dizziness and livedo reticularis
30
COMT inhibitors for PD
> e.g. entacapone, tolcapone
> COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy
> used in conjunction with levodopa in patients with established PD
31
ROLE OF AM IN PD
> now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's disease
help tremor and rigidity
e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)
32
Acute Mx of migraine
1) triptain and NSAID or oral triptan and paracetamol
2) non oral preparation of metoclopramide or prochlorperazine and add non-oral NSAID or triptain
33
triptan prescribing in young 12-17 yrs olds
nasal triptan in pref to oral triptan
34
caution when using metoclopramide in young patients
risk of acute dystonic reactions
35
when is migraine prophylaxis Ix
occuring more than once a week, or prolonged or severe despite optimal acute mx, sig impact on QOL and daily function
36
migraine prophylaxis
> propanolol: avoid in asthma
> topiramate: avoid in women of childbearing age - teratogenic
> amitripyline
37
if the migraine prophylaxis drugs fail then what can be done
acupuncture
38
what can reduce migraine freq and intensity
riboflavin 400mg once a day
39
Mini prophylaxis for menstrual migraine
> frovatriptan 2.5mg or zolmitriptan
40
first choice triptan
sumitriptan
41
when are antiepileptics started
by neurologist after 2nd seizure
42
driving restrictions for epilepsy
- cannot drive for 6m following a seizure
- must be fit free for 12m before being able to drive
43
pregnancy and BF with AED
> Preg: most teratogenic
> BF: all safe except barbiuates
44
Uses of sodium valproate
generalised seizures in males
45
Adv effects of sodium valproate
> inc apperire and weight gain
> alopecia: regrowth may be curly
> P450 enzyme inhibitor
> hep, panc, thrombocytopenia
46
why should valproate not be used in women of reprod age
risk of neural tube defects in baby
47
carbamazepine is a P450
inducer. Valproate inhibits
48
first and second line for focal seizures
first: SV
second: carbamazepine
49
Carbamazepine SE
> Drowsy
> leucopenia, agranulocytosis
> siADH
> visual dist espec diplopia
50
key SE of lamotrigine
SJS
51
phenytoin is a P450 ?
inducer
52
SE of phenytoin
- dizziness and ataxia
- gingival hyperplasia, hirsutism, coarsening of facial features
- peripheral neuropathy
- enhanced vitamin D metabolism causing osteomalacia
53
Rescue medication used to terminate a seizure that continues on past 5-10 min
benzo such as diazepine - rectal, intranasal admin
54
Mx of status
ABC, airway adjunct, O2, check BG
55
first line drug for status epilepticus
> benzos:
> in the prehospital setting PR diazepam or buccal midazolam may be given
> in hospital IV lorazepam is generally used. This may be repeated once after 5-10minutes
56
If ongoing (or 'established') status it is appropriate to start
levetiracetam, phenytoin or sodium valproate - levetriracetam is quicker to give and less SE
57
refractory status mx
(no response within 45 min from onset) -> induction of GA or phenobarbital
58
summary of mx of status
- benzo: IV lorazepam x2
- second line: phenytoin, leve, SV
- ongoing after 45 min: GA
59
Short term mx of insomnia
> identify cause
> advise person to not drive whe sleepy
> advise good sleep hugiene
> ONLY CONSIDER USE OF HYPNOTICCS IF DAYTIME IMPAIRMENT SEVERE
60
SE of hypnotics
daytime sedation, poor motor co-ord, cog impairment
61
which hypnotics are used in the treatment of insomnia
> short acting benzos or non benzos - zopiclone, zolpodem, zaleplon
> use the lowest effective dose for the shortest period possible
62
which benzo is not recommended for insomnia
diazepam - but can be useful if insomnia is linked to daytime anx
63
prescribing hypnotics
> If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
> It is important to review after 2 weeks and consider referral for CBT
64
initial Mx of suspected viral meningitis
> whilst awaiting LP supportive Tx
> if there is suspicion of bac meningitis or encepahlitis start broad spectrum ab - ceftriaxone and aciclovir intravenously
> espec if risk factors e.g. elderly, IC
65
mx of viral meningiris
> usually self limiting, supportive mx
>aciclovir may be used if the patient is suspected of having meningitis secondary to HSV
66
altered physiology in the elderly
> decline in GFR
> reduced hepatic blood flow and phase 1 metabolism
> slower gastric emptying -> reduced drug abs
67
Pharmacokinetic changes in the elderly
> distribution - decreased total body water -> increased plasma conc of water soluble drugs
> reduced albumin -> more free drug
> increased fat mass -> prolongs half life of fat soluble drugs
68
drugs that the elderly are more likely to respond differently to
> benzos
> AP
> AD
> opiods
> warfarin, Acs
> NSAIDs
> PPI
> insulin
> steroids
69
where to find info about adjusting drug dosage for elderly pts
> BNF
> NICE
> stop/start criteria
70
Prescribing in the elderly - start slow, go slow
> reduced drug clearance - start at lowest effective dose and titrate up
> e.g. opiods or sedatives - start at 50% of adult dose
71
medication reviews for the elderly
> annual review for all elderly pts
> more freq reviews for multimorbitiy or high risk meds
72
avoiding in inapp meds in the elderly
> stop/start criteria
> e.g. benzos, NSAIDs
73
what is increased in the elderly
volume of dist of lipophilic drugs due to an inrease in proprortion of body fat
74
osteoarthrtitis - offer help with
all patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness
75
first line analgesic for OA
> Topical NSAIDs espec for OA of hand or knee
> second line: PPI and NSAID
> third line: opiate
76
What is not recommended for OA
> Do not offer paracetamol or weak opioids unless used infreq for short term pain
77
Other Tx for OA
> non-pharmacological treatment options include walking aids for knee and hip OA
> Intra-articular steroids if standard tx fails -> only effective for short term
> if consv mx fails -> refer for joint replacement
78
RA Mx
> DMARD monotherapy + short course of bridging pred
> usually methotrexate
> other options: sulfasalazine, lenflunomide, hydroxychloroquinine
79
monitoring req for methotrexate
Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis.
80
use of hydroxychloroquinine for RA
: should only be considered for initial therapy if mild or palindromic disease
81
Monitoring resp to Tx for RS
NICE recommends using a combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment
82
Mx of RA flares
steroids - oral or IM
83
RA - TNF-a
- inadequate resp to at least 2 DMARDs
- etanercept, inflixmab, aldalimumab
84
what is the risk of using TNF-a
reactivation of TB
85
ref for RA
> Urgent ref (even with - CCP ab) - small joints of hands and feet are affected, >1 JOINt, delay of >3 months in seeking medical care
86
Mx of gout
> first line: NSAIDs or colchicine
> the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled
> Consider oral steroids if NSAIDs or colchine are CI
87
What can be used if NSAIDs or colchine are CI in acute gout
> oral steroids
> intra-articular steroid injection
88
if a patient with gout is alr taking allopurinol…
cont it
89
colchicine main SE
Diarrhea
90
caution w colchicine use in
renal impairment - the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min
91
indication of urate lowering therapy
> all pts after first gout attack
> espec if >2 gout attacks in 12 m, renal disease, tophi, uric acid renal stones
92
urate lowering therapy
- allopurinol first line, after 2 weeks (lower initial dose if reduced GFR)
- GIVE COLCHINE COVER WHEN STARTING ALLOPURINOL - 6 months
- NSAID can be given if colchine not tolerated
93
summary of urate lowering therapy
1: allopurinol + colchine cover for 6m
> 2: febuxostat if allopurinol ineffective or not tolerated
> refractory: uricase , pegloticase
94
how is pegloticase given
can rapidly control hyperuricemia in refractory gout, given as infusion every 2 weeks
95
lifestyle mods for gout
> reduce alc + avoin in acute attack
> lose weight if obese
> avoid high purine foods e.g. liver kidneys seafood
96
other points for gout Mx
> stop precipitants e.g. thiazides
> losartan beneficial if also HTN
> increasing vit C can decrease serum uric acid levels
97
int of allopurinol
azathioprine, cyclophosphamide (reduced renal clearane, theophylline
98
WHO pain ladder
> paracetamol/ NSAID
> weak opiod e.g. coedine
> stong opiod e.g. morphine
99
first line for secretions at EOL
> hyoscine hydrobromide or hyoscine butylbromide is generally used first-line
> Glyopyronnium bromide may also be used
100
Mx of agitation and confusion
> first choice: haloperidol
> other: chlorpromazine, levomepromazine
101
In the terminal phase of the illness then agitation or restlessness is best treated with
midazolam
102
what should be done ASAP for suspected meningitis pre-hospital
IM benzylpenicillin
103
mx of meningitis pts - intial
> IV access → take bloods and blood cultures
lumbar puncture
> if this cannot be done within the first hour, IV antibiotics should be given after blood cultures have been taken
104
> 60 yrs - ab choice for meningitis
ceftriaxone + amoxicillin (or ampicillin) for adults
105
3m - 60 yrs ab choice in meningitis
ceftriaxone
106
Add ? If prolonged/ multiple ab use or travel to areas w highly resistant pneumococci
add IV vancomycin if recent prolonged/multiple antibiotic use or travel to areas with highly resistant pneumococci
107
what is used as an adjunct to ab in meningitis
IV dexamethasone (before or within 12 hr of first dose of ab)
> aoud in septic shock, mening septicaemia, IC, meningitis after surgery
108
mx of raised ICP w meningitis
get critical care input
secure airway + high-flow oxygen
IV access → take bloods and blood cultures
IV dexamethasone
IV antibiotics
109
mx of signs of severe sepsis or rapidly evolving rash - meningitis
> get critical care input
secure airway + high-flow oxygen
IV access → take bloods and blood cultures
IV fluid resuscitation
> IV ab
110
ab choice for under 3m meningitis
IV cefotaxime + amoxicillin (or ampicillin)
111
mx of listeria meningitis
IV amoxicillin (or ampicillin) + gentamicin
112
mx of meningococccal meningitis
IV benzylpenicillin or IV ceftriaxone
113
mx of meningitis contacts
> contact within 7 days before symptom onset
> oral ciprofloxacin or rifampicin may be used
114
under and over 3m ab choice
< 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime
> 3 months: IV cefotaxime (or ceftriaxone)
115
steroids in meningitis in kids
> don't normally give steroids if < 3m
> dexamethasone should be considered if LP shows: frankly purulent CSF, CSF WCC more than 1000, bac on gram stain
116
non pharm mx of alzheimers
> group CST for mild to moderate dementia, group reminisence therapy and cognitive rehab
117
mx of mild to moderate alz
> acetycholineesterase inhib: donezpil, galatamine, riastigmine
118
second line in alz
> mematine (NMDA antagist):
> moderate Alz with CI to ACHi
> add on in moderate or severe AD, monotherapy in severe AD
119
When should AP be used in AD
Antipsychotics should only be used for patients at risk of harming themselves or others, or when the agitation, hallucinations or delusions are causing them severe distress
120
WhaT not to use in depression in dementia pts
NICE do not recommend antidepressants in mild to mod depression
121
donezepil CI
bradycardia
122
anticholinergic SE
dry eyes, urinary retention, dizziness, cognitive impairment and falls
123
OA XR changes
PPT image
124
Nsaid SE
> Gastritis
> salt/ water retention
> hyponat/ hyperkal
125
coxibs SE
Less GI, more CVD SE
126
CI of NSAIDs
> GI bleeding/ulceration
> Severe heart failure
> Severe renal impairment
> Varicella zoster infection
> 3rd trimester of pregnancy
127
interactions of NSAID
Anticoagulants:
Warfarin
DOACs
Antiplatelet agents
SSRIs
Steroids
Bisphosphonates
Methotrexate
ACEi/ARB
Diuretics
128
cautions of NSAIDs
allergies, crohns, IHD, elderly
129
joint surgery for OA ix
> joint symptoms with substantial impact on QOL an refractory to non surg tx
130
how does colchiine work
prevent activation of migration and action of neutrophils within the joint space
131
colchicine inhibits
cyp450 -> interacts w macrolides, antivirals/ fungals, non-dihydro CCB, grapefruit juice
132
colchicine ix se ci
133
length of colchicine course
1-2 days after attack has resolved
134
how soon after an attack of gout do u arrange a repeat blood test to confirm high uric acid
4 -6 weeks
135
allopurinol indic
136
Allopurinol
- Mx: inhibits xanthine oxidase
- SE: SJS, skin reactions - higher rates in Korean, Chinese and Thai
- Patients at a high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele.
137
cautions of allopurinol
138
int of allopurinol
- azathioprine
- theophylline
- cyclophosphamide
139
who is high risk of developing rashes w allopurinol
Thai and east asians, SJS risk
140
agranuloytosis
fever, sore throat
141
allopurinol vs febuxostat
> same Ix and SE
> febuxostat has slightly less interacyion w 6-MP
> e.g. person on ACEi - give febuxostat > azathioprine
142
monitoring for gout after initiating urate lowering therapies
> every 4 weeks - monitor uric acid
> less than 360
143
multiple joint arthritis ->
refer to secondary care
144
sulfasalazine SE
> panc
> agranulocytosis
> hepati-renal toxicity
> orange secretions
145
interactions of sulfasalazine
> myelosuppression or nephrotox if used w other drugs w that risk
> reduces abs of digoxin
146
mesalazine carries higher risk of
panc
147
CI of infliximab
> severe infections
> mod/ sev HF
148
SE of infliximab
> infusion reactions - HSN, skin reactios
> inc risk of neutropenia and sepsis
> reactivation of infections e.g. TB
> increased risk of cancer e.g. lymphoma
149
What to do before starting infliximab Tx
> up to date w vaccines
> SCREEN/ TEST FOR TB
> contraception - 6 m after last dose
> monitor for hep B
150
what needs to be reg checked w infliximab use
skin - inc risk of sq cell carcinoma
151
how often is methiotrexate used
once a week
152
sign of GI toxicity with methotrexate use
> GI toxicity - stomatitis and diarrhoea = early signs -> DISCONTINUE
153
CI of methotrexate
> active infection
> ascites
> pleural effusion
> severe renal impairment GFR <50
> teratogenic
154
Int of methotrexate
> trimethoprim/ co-trimazole - bone marrow depression
> NSAID - reduced clearance - toxicity
155
consideraions w methotrexate use
> avoid liv e vaccines
> contraception
> CO-PRESCRIBE FOLIC ACID
156
monitoring req for methotrexate
> FBC, U&E, LFT weekly until stabilised then 2-3 monthly
157
Pre-screening test for methotrexate
> Bhcg
> FBC, LFT, U&E
158
contraception w methotrexate
6 months off the drug before conception
159
increasind dopamine levels ->
levodopa
160
reduce dopamine breakdown ->
> MAOB inhibitors - selegiline, rasagiline
> COMT inhibitors - entacopone, talcapone
161
which drugs act direcly on dopamine receptors
ropinirole
162
early PD
> Use dopamine agonists or MAO-B inhib before levodopa to avoid SE
> motor symptoms: levodopa
163
COMT inhibitors act as
adjuvants, prolongs effects of levodopa by preventing it from breaking down
164
use of anticholinergic in PD
> For disabling tremor
> help with rigidity, bradykinesia, speech and writing diff, gait, excessive salivation, depression
165
levodopa CI
> pregnant and BF
> psychosis
> severe pulm or CVD
> severe nausea/ GI motility problems
166
Levodopa can cause
heavy sleep, educate about driving and heavy machinery
167
Key SE of co-careldopa and co-beneldopa
impulse control disorders
168
levodopa interacts with
MAO inhibitors, general anaestheics, antihypertensives
169
levodopa - what to tell the pt
> SE
> do not stop abruptly - risk of NMS
> hypotension
> sleeping - driving/ work
170
preventing the wearing off phenomenon
> increase the dose or give smaller more freq doses
> prolonged release levodopa preparations - ideally taken at bedtime
> dietary adjustments: take levodopa 30 min before food or 1-2 hrs after
171
on off fluctatuons
patients may switch from severe dyskinesia to immobility in afew minutes - levodopa
172
Mitigating on and off fluctuations - levodopa
> combine levodopa with a dopamine agonist
> fewer doses of levodopa, liquid forms
173
Risks and benefits of PD Tx summary table
insert image
174
Management in hospital of PD
never abruptly discontinue parkisnons meds w/o specialist advice
175
Options to consider if patients have difficulty/ are unable to swallow
> crush tablets - do not do this with modified release drugs
> rotigotine patch, consider liquid, NG/ NJ/PEG tube
176
most commonly prescribed PD med for a NBM patient
dopamine agonist patch - rotigotine
177
NMS pathophys
sudden drop of dopamine in the hypothalamus/ nigrostriatal pathway
178
Signs and symptoms of NMS
rigidity, fever, altered GCS, autonomic dysfunction
179
what is req for epilepsy diagnosis
at least 2 unprovoked seizures occuring more than 24 hr apart
180
first line for focal seizures
lamotrigine or levetiracetam
181
first line for generalised seizures
> SV - not in women of childbearing potential
> in women: levetiracetam or lamotrigene
182
AED - use
monotherapy and switch drugs before combining - AED interact w each other
183
monitoring w SV
> Monitor LFTs before and during first 6m
> measure FBC b4 surgery to assess bleeeing risk
184
risks of SV in women
> neural tube defects in baby and neurodevelopmetal abn
185
AED - what should be done before any possibility of pregnancy
5mg (high dose) folic acid
186
Stroke - thrombolysis
> with alteplase
> if sx onset within 4.5 hrs
> AFTER EXCLUDING HAEMORRHAGIC STROKE WITH CT SCAN
187
Following throbolysis,
> repeat CT to check for haemorrhage
> then start aspirin after 24 hrs - 300mg for 2 weeks
188
additional stroke investigations according to UK guidelines
> ipsilateral carotid artery stenosis - USS doppler
> AF - Holter monitor
> structural cardiac disease - TTE
> do these ^ if they are well enough for the Tx
189
BP target w stroke
under 130mmHg systolic
190
what else needs to be started after a stroke
> atorvostatin - usually 40mg
191
stroke/ TIA and driving
> must not drive,
> Can resume driving after 1m if there has been sat recovery
> DVLA does not need to be notified unless there is residual neuro deficit 1m laeter - visual field defects, cognitive defects, impaied limb function
192
stroke and TIA - bus and lorry driving
must not drive and must notify DVLA, lience will be removed for 1 year
193
brundinski and kernigs signs are seen with
meningism e.g. SAH not just meningitis
194
initial meningitis Mx
> blood cultures, LP
> dexamethasone
> Ceftriazone or Cefotazime
> IF LP CANOT BE DONE IN THE FIRST HR THEN AB MUST BE GIVEN IMMEDIATELY AFTER BLOOD CULTURES HAVE BEEN TAKEN
195
intial management of meningitis wirh raised ICP
> critical care input
> blood culture
> IV ab
> delay LP
> arrange neuroimaging after stabilisation
196
intial mx od severe sepsis or rapidly evolving rash
> cci
> ab
> delay LP
197
when should LP be delayed
- severe sepsis/ rapidly evolving rash
- severe resp/ cardiac compromise
- sig bleeding risk
- sigs of shift of brain compt - CT scan before
LP: focal neuro signs, presence of papilloedema, cont/ uncontrolled seizures, GCS <12
198
cholestasis is common w
Co-amox, clarithryomycin, flucoxacillin
199
ab used in meningitis
> Iv cefriazone or cefotaxime
> chlorampgenicol if penicillin allergic
200
what can be given to help prevent/ treat cerebral oedema and act as an adjunct tx of bacterial meningitis
dexamethasone 10mg IV
201
viral meningitis vs encephalitis
> viral meningitis: inflammaition of meningies of brain and SC
> encephalitis: inflammation of the brain parenchyma
202
encaphlitis
> Flu-like symptoms, headache, psychiatric symptoms/altered GCS, seizure
> Caused by herpes viruses (HSV, VZV),MMR viruses.
203
encephalitis Tx
- IV aciclovir for min 14 days
- 21 days if IC
- repeat LP after Tx to confirm CSF negative after stopping
204
how are PC meds given
subcutaneous (would not give IM to cachectic pts)
205
which meds to discont at EOL
> steroids if on them short term
> antibiotics
> hormones
> AD
> diabetic drugs - excluding insulin in t1dm
> CVD drugs/ statins
> vitamins/ iron
> prophylactic LMWH
206
common ix for a syringe driver
> pers nausea and vomiting
> severe dysphagia
207
in someone with opiod induced resp depression what would u do first
rouse them, start O2, stop opiod, start naloxone
208
monteleukast can cause ? In paeds
night terrors
209
1g = ? Mg
1000
210
1mg =
1000 micrograms
211
1 microgram =
1000 nanograms
212
number of tablets required =
what you want/ what you’ve got
213
volume required =
what you want/ what you’ve got x volume its in
214
1% lidocaine =
1g in 100ml, so 10mg in 1ml
215
Ratios =
> 1 in 100 means 1 g in 100 mL
1 in 1000 means 1 g in 1000 mL
1 in 10,000 means 1 g in 10,000 mL
216
concentration =
> Means the number of grams dissolved in 100 mL of solution
i.e. grams per 100 mL.
> 10% is 10g in 100ml
217
deciding if a patient wirh AF needs AC
> Chadsasc score
> congestive HF
> HTN
> age > 75 = 2 points
> age 65-74
> diabetes
> prior stroke TIA or VTE -2
> vascular disease
> sex - female
218
chadvasc - scores
> 1 in males = AC
> 2 in females: AC
219
Bleeding risk scoring system
orbit
220
ORBIT score
> Haemoglobin <130 g/L for males and < 120 g/L for females, or haemtocrit < 40% for males and < 36% for females 2
> Age > 74 years 1
> Bleeding history (GI bleeding, intracranial bleeding or haemorrhagic stroke) 2
> Renal impairment (GFR < 60 mL/min/1.73m2) 1
> Treatment with antiplatelet agents
221
high bleeding risk ORBIT
4+
222
First line AC for reducing stroke in AF
> 1) DOAC
> 2) if DOAC CI or not tolerated, warfarin
223
new onset AF with no anticoag give
heparin at intiial presentation
224
palliative - N&V caused by reduced gastric motility
prokinetics like metolopramide and domperidone used
225
opiod related N and V Tx
ondansetron, haloperidol and levomepromazine
226
visceral N/V Tx
> Cyclizine and levomepromazine are first-line
Anti-cholinergics such as hyoscine can be useful
227
raised ICP N/V mx
> cyclizine first line
> dexamethasona can be used
> radiotherapy can be used
228
vestibular N/V mx
> cyclixzine first line
> metoclopramide or prochlorperazine can be used alt for refractory vestibular causes
229
mx of anticipatory nausea
> short acting benzo like lorazepam
> if benzos not ideal, use cyclizine
230
Mx constipation with opiods
> stimulant laxative such as senna
> add an osmotic laxative like lactulose or macrogol if colic is a problem
231
For people with opioid-induced constipation, consider ? as an option if other laxative treatments have been ineffective.
naldemedine
