Evaluation and management Flashcards
1
Q
DVT evaluation and management
A
Hx
- DVT
- > onset/evolution
- > previous
- > family hx
- PE
- > pleuritic chest pain
- > dyspnoea
- > haemoptysis
- > syncope/prescynope
- Provoking factors
- > immobility
- > surgery
- > malignancy
- > trauma
- Warfarin
- > indication
- > dose/control
- > change of dose/brand
- > smoking/drinking/diet/new meds
Venous duplex ultrasound
- Whole leg
- > longer and more demanding
- > achieves diagnosis in one session
- Proximal
- > veins above calf
- > repeat in one week if negative
- VTE rate between tests
- > not significantly different
- Strongest sign
- > non compressibility
- additional signs
- > reduced flow
- > lack of respiratory variation
- > intraluminal echoes
Further investigations
- FBC
- > anaemia
- > platelets
- Coags
- > INR and aPTT before anticoagulation
- Urea/creatinine
- > anticoagulation baseline
- LFTS
- > warfarin control
- Antiphospholipid syndrome
- > lupus anticoagulant/anti cardiolipin/anti beta2 glycoprotein 1
- Consider (clots at young age/family hx)
- > protein C and S deficiency
- > antithrombin deficiency
- > prothrombin gene mutation PCR
Management
- Disposition
- > usually outpatient
- > inpatient if high bleeding risk/complications
- Site
- > proximal = anticoagulation for at least 3 months
- > distal = consider serial US ultrasounds
- NOACs preferred
- > no lead therapy
- > no monitoring
- > same efficacy/same tolerance
- Consider
- > high bleeding risk/severe renal disease = UFH
- > cancer = LMH
- > obese = heparin
Regimes
- UFH
- > IV bolus then infusion
- > monitor aPTT
- Enoxaparin
- > subcut
- > monitor platelets periodically
- Warfarin
- > start with LMWH/UFH
- > continue for 5 days + INR >2 for 24hrs
- > online clinical/genetic/nomograph tool to calculate initial/stable dose
- NOACs
- > no lead therapy
- > no monitoring required
- > apixaban = 7 day initiation
- > rivaroxaban = 21 day initiation
2
Q
Thrombocytopaenia evaluation and management
A
Hx
- PC
- > characterise onset/evolution of bleeding
- Precipitating factors
- > joint pain/stiffness/rash (autoimmune)
- > fevers/chills/rigors/lymphadenopathy (infection)
- > abdo pain/jaundice/nausea/stools and urine (liver)
- > weight loss/bone pain/fatigue (neoplasia)
- Past hx
- > autoimmune
- > liver disease
- > malignancy
- > surgeries/dentist challenges
- Family hx
- > bleeding
- > autoimmune disease
- Medications
- > any (antibiotics/anticonvulsants)
- > anti-platelet/coagulants
- > chemo
- > herbal
- > vaccinations
- Diet
- > vegetarian/vegan
- Social
- > sexual hx (HIV/hep C)
- > IVD
- > travel to malaria area
- > alcohol
Exam
- Skin
- > petechiae/ecchymoses
- > pallor
- Face
- > malar rash
- Mouth
- > mucosal bleeding
- Lymph nodes
- Abdo
- > hepatosplenomegaly
- > stigmata of chronic liver disease
- Joints
- > arthropathy
Investigations
- Repeat FBC
- > pseudo
- > pancytopenia
- Smear
- > pseudo = platelet clumping
- > ITP = normal
- > leukaemia = blasts
- > multiple myeloma = rouleaux
- > MAHA = schistocytes
- Coags
- > PT/aPTT
- Urea/creatinine
- > AKI in MAHA
- LFTs
- > infection
- > chronic disease
- HIV fourth gen
- Hep C antibodies
- Consider
- > ANA
- > B12/folate
- > vWD antigen/co factor ristocetin/factor VIII activity
Management
- General
- > avoid contact/collision sports
- > cease any contributing meds
- Corticosteroids
- > prednisone 1mg/kg for 3 weeks
- > dexamethasone 40mg for 4 days
- Chronic/relapsing
- > TPO agonist
- > splenectomy + IVIg bridging
3
Q
Evaluation and management dialysis peritonitis
A
Initial response
- Call for help
- Vitals
- > febrile
- > shock
- Primary survey
- > haemodynamically stable
Hx
- PC
- > abdo pain characteristics
- > fever/rigors
- > nausea/diarrhoea
- > cloudy peritoneal effluent
- Cause
- > change in technique
- > recent GI illness
- Past
- > bowel pathology
- > diabetes
- > immunosuppression
Exam
- Mental status
- > confusion
- General appearance
- > well/unwell
- > moving/lying still
- > cloudy dialysate effluent
- Abdo
- > tenderness
- > guarding/rigidity
- > percussion/rebound tenderness
- Catheter
- > erythema
- > oedema
- > tenderness
Investigations
- Obtain effluent dialysate
- > increased leukocyte count (polymorphs)
- > gram stain and culture (highly sensitive)
- Culture any pus from drainage site
- Blood cultures
- VBG
- > pH/lactate/electrolytes
- FBC
- EUCs
- > uraemia
- CRP
Management
- Admit
- IV access
- > fluids
- > analgesia
- Urgent renal consult
- > advice
- > education on proper technique
- > 1/4 lose catheter
- > 1/4 switch to haemodialysis
- Empiric antibiotics
- > seek expert advice
- > cover both gram positive/negative
- > third generation cephalosporin
- > consider vancomycin/gentamicin
- > intraperitoneal (dialysis bag) preferred to IV
- Reassess cell count in 48 hrs
- Adjust dialysis
- > more rapid exchanges ease pain
- > volume overload common (reduced filtration)
4
Q
Diabetes evaluation and management
A
Hx
- PC
- > polyuria/polydypsia/fatigue
- Screen for complications
- > chest pain/palpitations
- > blurred vision
- > numb feet/ulcers
- > urgency/dysuria
- > dry itchy skin
- Past
- > HTN/CVD/CVA
- > lipids
- > gestational/PCOS
- Family hx
- Medications
- > anti-psychotics/thiazides
- Social
- > smoking/drinking/drugs
- > diet and exercise
Exam
- BMI
- BP
- Pulses
- Lower limb
- > ankle reflex
- > pulses
- > vibration/monofilament (loss of protective sense)
- Dilated fundoscopy
- > microaneurysms
- > cotton wool spots
- > dot/blot haemorrhages
- > new vessels over disc (proliferative)
Investigations
- Diagnosis
- > random plasma glucose >11.
- > GTT at 2 hrs >11
- > fasting (8hrs) plasma glucose > 6.9
- > HbA1c > 6.5
- Unnecessary
- > C peptide
- > insulin/GAD65/ZnT8/Islet antigen antibodies
- > urinary ketones
- Urea/creatinine + UACR
- Lipids
- Consider
- > ECG
- > ABI
Management
- Goals
- > glycemic control = improves microvascular outcomes
- > reduce CVD risk = improves microvascular outcomes
- Education
- > refer to diabetes educator = lower HbA1c vs usual care
- > disease process/risks
- > components/goals treatment
- Diet
- > refer to dietician
- > low GI/consistent carbs/avoid sweetened beverages
- Weight loss
- > realistic/individualised goals
- > decreases insulin resistance
- Exercise
- > improves insulin sensitivity regardless of weight loss
- Psychological
- > refer to support groups
- > psychotherapy available for diabetes distress
- Glycaemic control
- > individualised targets (HbA1c 6-8)
- > first line is lifestyle
- > metformin 500mg TDS (start low)
- > SGLT2 inhibitor/GLP 1 agonist (reduces CVD mortality)
- > after 3 drug combo consider bolus insulin
- Additional
- > BP = ACEI preferred (reduces morality)
- > lipids = statin
- > aspirin = if high CVD risk + over 50
5
Q
Pleural effusion evaluation and management
A
Hx
- PC
- > dyspnoea
- > cough
- > pleuritic chest pain
- Associated symptoms
- > sputum
- > haemoptysis
- > fevers + sweats
- > weight loss
- > PND/orthopnoea
- > VTE risk factors
- Past
- > heart failure
- > liver disease
- > kidney disease
- > malignancy
- > thyroid
- > rheumatoid/SLE
- Social
- > smoking
- > occupational exposure
Exam
- Vitals
- > febrile
- > desaturation
- Inspection
- > cachexia
- > thyroid
- > JVP
- > oedema
- Lymphadenopathy
- Hepatosplenomegaly
- Cardiac
- > irregular pulse
- > displaced apex
- > S3
- Lungs
- > reduced breath sounds
- > decreased vocal resonance
- > stoney dullness to percussion
Bloods
- Glucose
- > compare to pleural fluid
- FBC
- > infection
- EUCs
- > kidney disease
- LFTs
- > cirrhosis
- Albumin
- Serum protein
- LDH
- CRP
- BNP/NT BNP
- MCS if infective
- > sputum
- > blood
- > pleural
Imaging
- CXR
- CT
- > useful in differentiated malignant vs benign
Thoracocentesis
- Gross observation
- > pale staw = transudate
- > blood = malignancy/trauma
- > milky = cylothorax
- Pleural fluid analysis
- > high cholesterol (exudate)
- > high triglycerides (chylothorax)
- > low glucose (infection/neoplasia/rheumatoid)
- > low pH (infection)
- > lymphocytosis (neoplasia/TB/lymphoma)
- > eosinophilia (low in malignancy)
- Lights criteria (any of following is present = exudate)
- > pleural/serum protein >0.5
- > pleural/serum LDH >0.6
- > pleural LDH >2/3 upper limit normal
Management
- HF
- > diuresis
- Pneumonia
- > antibiotics
- Malignancy
- > chest tube + pleurodesis
6
Q
Evaluation and management hypercholesterolaemia
A
Hx
- Complications
- > chest pain
- > palpitations
- > SOB
- > claudications
- Past hx
- > CHD/MI/CVA
- > HTN
- > diabetes
- > liver
- > kidney
- > thyroid disease
- Family hx
- > CVD risk
- > hypercholesterolaemia at young age
- Medications
- > thiazides
- > glucocorticoids
- > antipsychotics
- Social
- > smoking/drinking/drugs
- > diet and exercise
Exam
- Vitals
- > HR
- > BP
- Full cardiovascular exam
- > all peripheral pulses
- > heart sounds
- > bruit
- > peripheral vascular disease
- Familial hypercholesterolaemia
- > tendon xanthomas/xanthelesma
- > arcus
- Thyroid
- Hepatomegaly
Investigations
- Lipids
- > total cholesterol <4
- > triglycerides <2
- > LDL <2 (<1.8 for secondary prevention)
- > HDL >1
- > non HDL <2.5
- TSH
- > hypothyroid
- Urea/creatine
- LFTs
- Glucose
- > fasting
- > HbA1c
- Consider
- > ECG
- > ABI
Management
- Determine risk
- > heart foundations risk calculator (framingham risk equation)
- 5 year risk (low <10%/medium 10-15%/high 15>)
- Diet
- > increase plant sterol enriched foods
- > reduce unsaturated/trans fats
- > increase mono/polyunsaturated fats
- > increase fibre
- > decrease alcohol
- Statin
- > indication = high risk/existing CVD/ failed lifestyle
- > atorvastatin (high = 40-80mg/moderate = 10-20mg)
- LDL target not reached with max dose statin
- > add ezetimibe
- > add PCSK9 inhibitor
- Poor triglyceride control
- > add Fibrates
- General CVD risk modification
- > exercise
- > cease smoking
- > BP management
7
Q
Evaluation and management statin intolerance
A
Hx
- Dose of statin
- Indication
- > avoid ceasing immediately if high risk (where possible)
- Timing
- > onset 4-6 weeks after initiation (not >12 weeks or before)
- > onset after dose increase
- Nature of symptoms
- > bilateral (more than unilateral)
- > large muscle groups (more than non specific)
- > ache/weakness/sore/tender/cramping/fatigue (typical)
- > tingling/shooting pain/nocturnal cramps (not typical)
- > discoloured urine
- Other side effects
- > GI (usually transient)
- > headaches
- > poor sleep
- > dizziness
- Predisposing factors
- > fibrates/glucocorticoids/calcium channel blockers
- > underling kidney/liver disease
- > regular vigorous physical activity
- > substance abuse (alcohol/opioids/cocaine)
- DDx
- > viral = fever/resp or GI illness
- > PMR = joint stiffness
- > fibro = poor sleep
- > psych = mood
Exam
- BMI
- BP
- Inspection
- > rash
- > erythematous/swollen joints
- > swollen muscles
- > wasting
- Tone
- > significant stiffness
- Power
- > reduced proximal power
- Palpation
- > tenderness over proximal muscles
Investigations
- Dipstick
- > dipstick may show blood/protein
- EUCs
- > screen for AKI
- CK
- > rhabdo typically 5x ULN
- FBC
- > may show acute phase reactant
- CRP/ESR
- > may be elevated in inflammatory ddx
Management
- CK <5x ULN
- > cease statin for 2-4 weeks
- > if symptoms persist seek other causes
- CK >5x ULN or CK high with weakness
- > refer to cardiologist/nephrologist immediately
- > IV fluid volume expansion/monitor electrolytes
- > cease statin immediately for 6-8 weeks and CK normal
- > resume at reduced dose/switch to different statin
- > low dose potent statin (rosuvastatin 5mg)
- > intermittent dosing (alternate days/once or twice weekly)
8
Q
Headache evaluation and management
A
Hx
- Tension
- > bilateral, pressure
- > not throbbing or constricting
- > frontal or occipital most common
- > not worsened by activity
- > some nausea/vomiting (but not severe)
- > occasional photophobia/phonophobia (but not both)
- Migraine
- > often unilateral
- > throbbing
- > worsened by activity (and disabling)
- > aura/photophobia/phonophobia/nausea/vomiting
- Serious ddx (SNOOP4)
- > Systemic symptoms (fever/weight loss)
- > Neuro findings (altered mental status/focal signs)
- > Onset sudden/abrupt
- > Old during first occassion
- > Pattern = increasing frequency
- > Precipitating factors (emotions/orgasm/valsalva)
- > Positional aggrevation
- > Pain in neck/eye
- Past
- > migraine
- > PMR
- Family hx
- > migraine
- Medications
- > opioids
- > barbiturates
- Social
- > stress/sleep/skipped meals
- > mood/coping
- > substance/caffeine withdrawal
Exam
- Vitals
- > cushings
- > fever
- Cranial tenderness
- > SCM/traps/masseter
- Neurological exam
- > any deficit
- Fundoscopy
- > papilloedema
- Ears
- > OM + mastoid
Investigations if concerning
- MRI brain
- FBC
- > anaemia
- TSH
- Electrolytes/CMP
- CRP if consistent with giant cell
Management
- Tension
- > simple analgesia
- > approx 10 per month = low dose amitriptyline for prevention
- > relaxation/massage/physio/acupuncture/CBT
- Migraine acute relief
- > hydration
- > paracetamol/NSAIDs/caffeine + metaclopramide
- Severe episodes
- > early amlotriptan oral +- NSAID
9
Q
Macrocytic anaemia evaluation and management
A
Primary survey
->ensure haemodynamically stable
Hx
- Low cell count
- > fatigue/SOB/headaches/exercise tolerance (anaemia)
- > frequent infections/fevers (leukopenia)
- > easy bleeding/bruising (thrombocytopenia)
- Cause
- > recent GI bleed
- > weakness/paraesthesia (B12)
- > RUQ pain/bowel habits/jaundice/dark urine (liver)
- Past
- > liver
- > thyroid
- > GI surgery/coeliac/crohns
- > ulcers/gastritis
- > radiation or chemo
- Family hx
- > blood disorders/anaemias
- Meds
- > methotrexate/antibiotics/chemo
- > steroids/NSAIDs
- Social
- > alcohol
- > diet
Targeted exam
- Appearance
- > pale
- > jaundiced
- > petechiae
- Lymphadenopathy
- Mouth
- > puffy/beefy tongue with stomatitis (folate/B12)
- Abdo
- > hepatomegaly
- > stigmata chronic liver disease
- Neuro
- > decreased vibration sense/abnormal gait
Investigations
- Blood group and cross match
- FBC
- > pancytopenia
- > RDW (normal = MDS/abnormal = reticulocytosis)
- Reticulocyte count
- > 2.5x normal = haemorrhage/haemolysis
- > less than 2.5x = maturation disorder
- Smear
- > polychromasia = reticulocytes
- > megaloblasts + hypersegmented PMNs = megaloblastic
- > hyposegmentended PMNs = MDS
- Haemolysis
- > haptoglobin decreased
- > LDL increased
- Urea/creatinine
- > elevated creatinine = hypovolaemia
- > U:C >30 = upper GI bleed
- Coags
- B12
- > active
- Folate
- TSH
- LFTs
- Imaging depending on hx/exam
- > endoscopy
- > CT
Management
- Keep NBM
- Call for help
- > senior
- > haematology
- > blood bank
- IV access
- > adequate analgesia
- > consider fluids
- > consider RBCs (Hb <70)
10
Q
Evaluation of liver mass + management overview
A
Lesion characteristics
- > large (>1cm) is concerning
- > smooth margins typically benign
- > typically enhancement patterns
- > pattern of growth (previous scans)
- > hypervascular
- > arterial phase enhancement
- > wash-out in portal venous/delayed phase
Hx
- PC
- > RUQ pain
- > early satiety
- > weight loss
- Past
- > cirrhosis
- > hep B or C
- > bowel habits/dark urine and pale stools
- > other malignancies
- > upper GI bleed (variceal)
- Family hx
- > liver cancer
- > haemochromatosis
- Social
- > alcohol
- > drugs
- > sexual hx
Exam
- Appearance
- > jaundice
- > cachexia
- > encephalopathic
- Hands
- > palmar erythema
- > Terry nails
- > dupetrens
- > asterixis
- Arms
- > excoriations
- > bruising
- Face
- > fetor
- > parotid enlargement
- > scleral icterus
- Chest
- > spider angioma
- > gynaecomastia
- Abdo
- > distension/ascites
- > hepatosplenomegaly
- > distended veins
- Lower limb oedema
Investigations
- LFTs
- > transaminases/bili/al phos
- Synthetic function
- > albumin low
- > PT/INR prolonged
- FBC
- > thrombocytopaenia
- EUCs
- > hyponatraemia
- > hepatorenal syndrome
- Viral hepatitis panel
- AFP
- > over 200 increases likelihood
- Tumour markers
- > CEA = bowel
- > CA-19-9 = cholangiocarcinoma
- CT/MRI with contrast
- Liver biopsy
- > usually not needed if typical radiological features
- > use if large but not typical enhancement pattern
- Consider
- > chest/pelvis CT
- > bone scan
Management
- Approach
- > multidisciplinary
- > tumour + Patient factors
- Barcelona clinic liver stage
- > stage 0, A-D
- > guides management
- > ECOG
- > child pugh
- > radiology features
- Modalities
- > resection (early)
- > transplant (good fitness/poor MELD + Child Pugh)
- > transarterial chemo-embolisation (transplant bridging)
- > chemo (advanced)
- > palliation (end stage)
11
Q
Evaluation and management low back pain
A
Hx
- Red flags (TUNA FISH)
- > trauma
- > unexplained weight loss
- > neurological symptoms
- > age >50
- > fever
- > IVDU
- > steroids
- > hx of cancer
- Discogenic pain
- > axial pain
- > radicular
- > worse with sitting/relieved by standing
- > worse with valsalva/coughing/sneezing
- Cauda equina syndrome
- > bowel or bladder incontinence/retention
- > bilateral leg pain
Exam
- Vitals
- > fever
- Look
- > wasting
- > hip alignment/scoliosis
- Feel
- > spinal/paraspinal tenderness
- Power
- > L2-4 = weak hip adduction/flexion/knee extension
- > L4 = weak knee extension
- > L5 = weak dorsiflexion (heel walking) great toe dorsiflexion/foot inversion/hip abduction (on side)
- S1 = weak plantar flexion (toe walking)
- Reflexes
- > L4 = reduced patellar reflex
- > L5 = medial hamstring
- > S1 = reduced Achilles
- Sensation
- > L2-4 = anterior thigh and medial lower leg
- > L5 = lateral lower leg/first interspace webbing
- > S1 = posterior thigh/lateral foot
- > saddle anaesthesia = cauda equina
- Provocative tests
- > straight leg raise = L5-S1 (worse with dorsiflexion)
- > femoral stretch = L2-4
- > trendelenburg = L5 and weak glut medius
- > FABER = SI
- > FAIR = piriformis syndrome
- Abdo exam
MRI without gadolinium
- Indications
- > pain > 1 month
- > red flags
- Interpret with caution
- > asymptomatic lesions common
- modic classification (Type 1 - 3)
Management
- Disc herniation
- > 90% improvement within 3 months with non operative
- Cauda equina syndrome
- > emergency decompression
- Under 3 months duration
- > simple analgesia
- > physiotherapy/exercise/yoga/acupuncture
- > topical capsaicin
- > codeine if severe and uncontrolled
- > epidural long acting local anaesthetic injection for radicular
- Over 3 months duration
- > pain team referral
- > amitriptyline/pregabalin
- > laminectomy/discectomy (best when radicular/weakness)
- > spinal fusion when significant instability
12
Q
Dementia evaluation and management
A
Hx
- Collateral hx
- > unwell
- > cognition
- > function
- > personality
- > behaviour
- > mood
- > aggression
- > wandering
- Course
- > gradual (months to years) = degenerative dementia
- > sudden onset/stepwise = vascular
- > acute = endocrine/metabolic/brain lesion/meds/stroke
- > hyper acute = delirium
- ADLs
- > eating/bathing/toileting
- > money/shopping/cleaning/medications/transport
- Social
- > carer/caring
- > housing
- > advanced care directive/power of attorney
- > medical team
- Past hx
- > CVA/TIA/TBI
- > AF/HTN/diabetes
- > parkinsons
- Family hx
- > dementia
- Medications
- Lifestyle
- > alcohol
- > diet
MSE
- > alzheimers = learning/memory/executive function
- > lewy = hallucinations/variable attention/fluctuating course
- > vascular = delusions/depression/stroke syndromes
- > parkinsons = mood component and psychosis
MMSE
- Score <24 indicates impairment
- Insensitive
- > vascular dementia
- > MCI
- > younger and higher educational level
Neuro exam
Cardio exam
Neuro psych
-when findings equivocal
Investigations
- glucose
- EUCs
- CMP
- FBC
- B12/folate
- urinalysis
- MRI
Non pharm
- Referral
- > psychologist/psychiatrist
- > link to Alzheimers Australia
- Address behavioural symptoms
- > explain any caregiving actions
- > provide written instructions
- > address pain and comorbidities
- > lighting/clocks/calendars to track time
- > safe/familiar environment
- Environmental safety
- > home/driving/self care assessment by OT
- > evaluate patient and home falls risk
- > identification bracelets/trackers/motion detectors
Pharm
- Cholinesterase inhibitor
- > rivastigmine
- > increase/maintain cognitive function at baseline for 1 yr
- > need at least 2 month at max dose
- > maintain until severe dementia
- Aggression
- > citalopram
- > rispiridone
13
Q
Heart failure evaluation and management
A
Hx
- PC
- > onset evolution of symptoms
- > PND + orthopnoea
- > night cough
- Trigger
- > forgot meds
- > arrhythmia
- > infarction
- > infection
- > lifestyle (salt/water/exercise)
- > up-regulated (anaemia/hyperthyroid)
- > renal failure (NSAIDs/ACEI/ARBs)
- > embolism
- Past
- > heart disease (MI/valves/arrhythmias)
- > lung disease (COPD/OSA)
- > cardiac risk factors
Exam
- Height/weight/BMI
- Vitals
- > hypotension
- > tachycardia is worrying sign
- Pulse
- > AF
- > warm + wet or wet + cold
- Inspect
- > pallor
- > thyroid
- > PVD
- > peripheral oedema
- JVP
- > demonstrates overload
- > hepatojugular reflex
- Chest
- > effusion
- > crackles non specific
- > S3 (kentucky) specific
- Abdo
- > hepatosplenomegaly
Investigations
- ECG
- > arrhythmias/past MI
- Trops
- BNP or NT proBNP
- > low values have negative predictive value
- > distinguishes resp from cardio SOB
- VBG
- > glucose
- > electrolytes (hyponatraemia)
- > pH
- FBC
- > anaemia
- EUCs
- > AKI
- > hyponatraemia is severe
- > K for diuresis
- TSH
- Albumin
- > hypoalbuminaemia common in advanced
- CXR
- > cardiomegaly
- > cephalic vascular markings (stags signs) = pHTN
- > kurley B lines = congested interlobular septa
- > batwing opacifications = cardiogenic pulmonary oedema
- > pleural effusions
- Doppler echo
- > ejection fraction (HFrEF <40%/HFpEF >50%)
- > size/pressure of ventricles and atria
- > estimate pulmonary capillary wedge pressure
Management
- Admit to CCU
- O2
- > if desaturated
- IV access
- > GTN
- Diuresis
- > establish baseline weight
- > insert catheter
- > maintain outpatient meds + beta blocker if BP ok
- > goal is 1-2L/day HFpEF and >2L/day HFrEF (Cr/BP)
- > frusemide IV 2x outpatient dose
- > spironolactone maintains K
- Hypotension
- > dobutamine IV
- > noradrenaline if shocked
- Monitor
- > urine output + weight
- > K>4 + Mg>2 + Cr + Na
- Outpatient
- > ACEI + beta-blocker + ARB +- spironolactone
- > frusemide oral when overloaded
- > fluid <2L and salt <2g restriction
- > daily weight
- > exercise
- > HF nurse/continuous health screening
14
Q
Warfarin pre-op
A
Risk of ceasing warfarin
- Cardiac valve replacement
- > thrombotic event increases almost 4 fold
- Risk increased by patient factors
- > older age
- > history of VTE
- > AF/CCF
- > highest in first generation valves/lowest in aortic
Risk of bridge anti-coagulation
- prevent 3 VTE per 10,000 operations
- cause 300 major post op bleeds
Approach
- No firm guidelines
- > patient specific decision
- Continure warfarin for minor procedures
- > aim INR 1.5-1.8
- Cease warfarin major procedures
- > high risk = cease day 4-
- > low risk = cease day 5-
- Bridging heparins
- > low risk = none
- > high risk = UFH till -6 hrs/LMWH til -12hrs
- On day of surgery
- > INR >2 = postpone/FFP/haematologist
- Post surgery
- > low risk = start once tolerating oral
- > high risk = start LMWH 6hrs post/start warfarin when tolerating oral/bridge until INR >2 for 2 days
- Anaesthetic risk
- > extradural haematoma with epidural
- > cease heparin 6 hrs prior
- > cease LMWH 16 hrs prior
15
Q
Needle stick management
A
First aid
- run under water
- dress wound
- alert staff that you need to be relieved
Exposure risk assessment
- High risk
- > visible blood on needle
- > deep penetration
- > needle used on sources vessels
- Low risk
- > mucosal exposure
- > broken skin exposure
- > old sharp/no visible blood
- > needle not used on vessels (eg suturing/injection)
Source risk assessment
- Test source
- > testing and disclosing requires consent
- > fourth gen HIV/anti HBsAg + HBeAg/anti-HCV
- High risk
- > high/unknown viral load
- > known to be infected with BBV
- > high risk group but status/viral load unknown
- Low risk
- > low viral load
- > receiving anti-viral treatment with good adherence
Initial management
- PEP
- > for all potentially infectious exposures (up to 72hrs)
- > don’t delay for lab results for initiating
- > decision to continue made from lab results
Further management
- Source negative
- > cease all treatment
- Source unknown/cannot be tested
- > manage as if positive if high risk behaviours
- Source positive for HIV
- > percutaneous injury transmission <0.5%
- > PEP reduces risk by further 80%
- > test at 6 weeks and 12 weeks with 4th gen
- > before testing, safe sex/blood donation/breast feed
- > still able to work
- Source positive for HBV
- > no action required if response to vaccine
- > no vaccine = IvIg/vaccine (up to 30% transmission)
- > test at HBsAg at 6,12,24 weeks
- Source positive HCV
- > risk of transmission approx 2% (0 in Aus)
- > provide early treatment
- > RNA PCR at 6 wks/antibody at 6 and 12
