MANAGEMENT OF COMMON CONDITIONS Flashcards
(114 cards)
1
Q
ANGINA
what is the management?
A
SYMPTOM RELIEF
- GTN spray (if pain persists after 5 mins repeat dose, if pain remains after anther 5 mins call ambulance)
ANTIANGINAL MEDICATION
- 1st line = beta blocker or CCB
- 2nd line = combination of BB + CCB (nifedipine)
- long acting nitrate e.g. ivabradine
2
Q
ACS
Describe the initial management of ACS
A
- Analgesia - morphine + sublingual GTN
- Oxygen (if SpO2 > 94%)
- dual antiplatelets
- ALL patients = aspirin 300mg
- if PCI = prasugrel or clopidogrel
- if fibrinolysis = ticagrelor or clopidogrel
MONA
3
Q
ACS
What is the overall treatment for STEMI?
A
PCI - if symptom onset within 12 hours and access to PCI within 120 minutes
Thrombolysis e.g. alteplase or tenecteplase - If ineligible for PCI
4
Q
ACS
Describe the secondary prevention therapy for people after having a STEMI
A
- lifestyle changes
- manage CVD risks
- 12 months aspirin 75mg + ticagrelor if ACS was medically managed
- lifelong aspirin + 12 months ticagrelor/prasugrel if ACS treated with PCI
- ACEi
5
Q
What is the treatment for a PE?
A
massive PE = thrombolysis e.g. alteplase
non-massive PE =
- no renal impairment = apixaban/rivaroxaban
- renal impairment (CrCl<15ml/min) = LMWH or UFH + warfarin for 5 days, then warfarin alone
- active cancer = consider DOAC or warfarin
6
Q
HEART FAILURE
what is the management for chronic HF?
A
1st line = BB + ACEi (started one at a time)
If ACEi not tolerated, try ARB or hydralazine with nitrate
2nd line = aldosterone antagonist (SPIRONOLACTONE)
3rd line = cardiac resynchronisation therapy (CRT) or ICD insertion, digoxin (particularly in AF) or ivabradine
other options:
- fluid restriction
- loop diuretics (for symptom management)
- annual flu + pneumococcal vaccine
7
Q
HEART FAILURE
what is the treatment for acute HF?
A
- treat any underlying causes
- oxygen if SpO2<94%
- fluid restriction <1.5L
- IV diuretic (furosemide)
- inotropes/vasopressors (dobutamine)
8
Q
HTN
Describe the pharmacological intervention for someone with hypertension
A
IF <55 OR T2DM
1. ACEi/ARB
2. ACEi/ARB + CCB or ACEi/ARB + thiazide-like diuretic (indapamide)
3. ACEi/ARB + CCB + thiazide-like diuretic
4. if K+<4.5 add spironolactone, if K+>4.5 add alpha/beta-blocker
IF >55 + NO T2DM OR BLACK
1. CCB
2. CCB + ACEi/ARB* or CCB + thiazide like diuretic
3. CCB + ACEi/ARB* + thiazide-like diuretic
4. if K+<4.5 add spironolactone, if K+>4.5 add alpha/beta-blocker
*note ARB is preferred in african-caribbean/black ethnicities
9
Q
ATRIAL FIBRILLATION
Describe the treatment for atrial fibrillation
A
HAEMODYNAMICALLY UNSTABLE
- 1st line = synchronised DV cardioversion
STABLE
onset <48hrs
- 1st line = rate control (BB or CCB)*
- 2nd line = rhythm control (flecanide or amiodarone)
onset >48hrs
- 1st line = rate control (BB or CCB)* + anticoagulation for at least 3 weeks, then offer rhythm control if appropriate
*consider digoxin 1st line in patients with AF + HF, those who do no exercise or other drugs excluded
avoid CCB in HF
avoid non-selective BB (e.g. propranolol) in asthma
10
Q
ATRIAL FIBRILLATION
which medications are used for rate control?
A
1st line = beta-blocker (bisoprolol) or CCB (diltiazem/verapamil)
consider digoxin 1st line when AF + HF
2nd line = combination therapy with any two
- beta-blocker (bisoprolol)
- diltiazem
- digoxin
11
Q
ATRIAL FIBRILLATION
what medications are used for rhythm control?
A
if no structural/ischaemic heart disease = flecainide or amiodarone
if structural/ischaemic heart disease = amiodarone
12
Q
ACS
what is the management of an NSTEMI?
A
- anticoagulation = fondaparinux to most patients, unfractionated heparin if renal failure
- use GRACE score to work out if patient requires PCI
13
Q
CARDIAC ARREST
what is the management for shockable rhythms?
A
- shock ASAP then resume CPR
- rhythm check
- give 1mg adrenaline after 3rd shock + after alternating shocks
- give 300mg amiodarone after 3rd shock + 150mg after 5th shock
14
Q
CARDIAC ARREST
what is the management for non-shockable rhythms?
A
- no shocks given
- rhythm check
- adrenaline 1mg ASAP and after alternating cycles of CPR
15
Q
SVT
what is the management?
A
UNSTABLE
- synchronised DC shock (up to 3 attempts)
- if unsuccessful, 300mg amiodarone IV + repeat shock
STABLE
- 1st line = vagal manoeuvres (Valsalva, carotid sinus massage)
- 2nd line = adenosine 6mg, if unsuccessful give 12mg then 18mg
- 3rd line = verapamil or BB
- long term = catheter ablation
16
Q
VENTRICULAR TACHYCARDIA
what is the management of pulsed VT?
A
IF ADVERSE FEATURES PRESENT (HF, MI, shock syncope)
- 1st line = synchronised DC cardioversion (up to 3 attempts)
- 2nd line = amiodarone 300mg IV over 10-20 mins
IF NO ADVERSE FEATURES PRESENT
- 1st line = amiodarone 300mg IV
- 2nd line = synchronised DC cardioversion
if drug therapy fails
- ICD implanted
17
Q
TORSADES DE POINTES
what is the management?
A
IV magnesium sulphate
18
Q
BARDYCARDIA
what is the emergency management?
A
LIFE-THREATENING FEATURES
- 1st line = atropine 500 micrograms IV
- if response unsatisfactory repeat 500 micrograms atropine (up to max 3mg), or adrenaline 2-10 micrograms IV,
- arrange transvenous pacing
NO LIFE-THREATENING FEATURES
- if risk of asystole treat as above
- if not at risk of asystole, observe
19
Q
TACHYCARDIA
what is the emergency management?
A
ADVERSE SIGNS PRESENT
- 1st line = synchronised DC cardioversion (up to 3 shocks)
treat according to whether SVT or VT
20
Q
PNEUMONIA
What is the treatment for someone with mild CAP (CRUB65 score 0-1)?
A
oral amoxicillin at home
21
Q
PNEUMONIA
What is the treatment for someone with moderate CAP (CRUB65 score 2)?
A
consider hospitalising, amoxicillin (IV or oral) + macrolide (clarithromycin)
22
Q
PNEUMONIA
What is the treatment for someone with severe CAP (CRUB65 score 3-5)?
A
consider ITU,
IV Co-Amoxiclav + macrolide (clarithromycin)
23
Q
ASTHMA
What is the long-term guideline mediation regime for asthma?
A
- low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
- low dose MART
- moderate dose MART
- check FeNO + eosinophil level (if either is raised, refer to specialist).
- If neither are raised = LTRA or LAMA in addition to moderate dose MART
- if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA) - refer to specialist
24
Q
COPD
What are the treatments for COPD?
A
general:
- stop smoking (refer to cessation services)
- pneumococcal vaccine
- annual flu vaccine
step 1:
- SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide)
step 2:
- If no asthmatic / steroid response:
- LABA (salmeterol)
- LAMA (tiotropium)
- If asthmatic / steroid response:
- LABA (i.e. salmeterol)
- ICS (i.e. budesonide)
step 3:
- long term oxygen therapy
25
COPD
What is the treatment for an exacerbation of COPD?
MILD
- managed in community
- increased salbutamol
- oral antibiotics
- 5 day course prednisolone
MODERATE
- hospital admission
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
SEVERE
- hospital admission
- non-invasive ventilation (BiPAP)
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
26
PNEUMOTHORAX
What is the treatment for a primary pneumothorax?
PRIMARY
- small (<2cm) + asymptomatic = consider discharge
- if >2cm or breathless = aspirate with 16-18G needle
- if successful consider discharge + follow-up
- If unsuccessful insert chest drain + admit
27
TENSION PNEUMOTHORAX
What is the treatment for a tension pneumothorax?
Put out cardiac arrest call
Start high flow O2
Insert 14G needle at 4/5th intercostal space mid-axillary line
insert chest drain
28
TB
What is the drug treatment commonly used for TB?
RIPE
RI = 6 months
PE = for first 2 months
R = rifampicin
I = isoniazid
P = pyrazinamide
E = ethambutol
29
TB
Give 2 potential side effects of Rifampicin
1. Red urine
2. Hepatitis
3. Drug interaction - it's an enzyme inducer
30
TB
Give 2 potential side effects of Isoniazid
1. Hepatitis
| 2. Neuropathy
31
TB
Give 2 potential side effects of Pyrazinamide
1. Hepatitis
2. Gout
3. Neuropathy
32
TB
Give a potential side effect of Ethambutol
Optic neuritis
33
PNEUMONIA
what do the scores for CURB-65 mean?
Scores
0-1 = mild (outpatient treatment)
2 = admit to hospital
3-4 = severe, admit and monitor closely
5 = ITU transfer
34
PNEUMONIA
what is the management of HAP?
low severity = oral co-amoxiclav
high severity = broad spectrum abx (IV tazocin or ceftriaxone)
35
ASTHMA
what is the management of a severe/life-threatening asthma exacerbation?
- oxygen
- nebulised bronchodilator (salbutamol)
- corticosteroid (40-50mg prednisolone)
- ipratropium bromide
- IV magnesium sulfate
- IV aminophylline
36
ASTHMA
what is the management of a moderate exacerbation of asthma?
- salbutamol
- 5 days oral prednisolone
37
PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?
SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen
LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen
38
PNEUMOTHORAX
where is the needle for aspiration of a spontaneous pneumothorax placed?
- 2nd intercostal space midclavicular line
39
PNEUMOTHORAX
where are chest drains placed?
5th intercostal space mid-axillary line
40
PNEUMOTHORAX
what are the indications for surgical management?
- 2nd ipsilateral pneumothorax
- 1st contralateral pneumothorax
- bilateral spontaneous pnemothorax
- persistent air leak after 5-7 days chest drain
- pregnancy
- at risk profession e.g. pilots + divers
41
ANAPHYLAXIS
what is the management?
- IM adrenaline 500 micrograms
- give high flow O2
- antihistamine (chlorphenamine or cetirizine)
if no response after 5 mins repeat IM adrenaline + IV fluid bolus
no improvement after 2 doses of IM adrenaline = refractory anaphylaxis
42
ANAPHYLAXIS
what is the management of refractory anaphylaxis?
- start adrenaline IV (1mg adrenaline in 100ml 0.9% saline)
- rapid IV fluid bolus
43
ANAPHYLAXIS
when can patients be discharged?
AFTER 2 HOURS
- good response (within 5-10 mins) to single IM adrenaline
- complete resolution of symptoms
- has autoinjector + trained
AFTER 6 HOURS
- 2 doses of IM adrenaline
- previous biphasic reaction
AFTER 12 HOURS
- severe reaction (>2 doses IM adrenaline)
- severe asthma
- possibility of continued exposure to allergen
- presents at night or in area difficult to access in emergency
44
T1DM
what is the 1st line insulin regimen?
basal-bolus regimen
Basal = levemir (detemir) BD or Lantus (glargine) OD
Bolus = Humalog (lispro) or Novorapid (Aspart)
45
T1DM
what is a mixed insulin regime for T1DM?
given twice daily (may be used in those unable to tolerate multiple injections with basal-bolus)
EXAMPLES:
- novomix 30 (30% rapid, 70% intermediate)
- humalog mix25 (25% rapid, 75% intermediate)
- humalog mix50 (50% rapid, 50% intermediate)
- humulin M3 (30% short, 70% intermediate)
- insuman comb 15 (15% short, 85% intermediate)
46
T2DM
Describe the treatment pathway for T2DM
LIFESTYLE ADVICE
-
MEDICATIONS
1st line = metformin
if patient has HF offer metformin + SGLT2i (-gliflozin)
if HbA1c >58, commence dual therapy
1. DPP4i (linagliptin, sitagliptin)
2. Sulfonylurea (gliclazide)
3. Pioglitazone
4. SGLT2i (dapagliflozin, empagliflozin)
if HbA1c > 58 despite dual therapy, commence intermediate acting insulin or triple therapy
triple therapy = metformin + sulfonylurea + GLP-1 mimetic (liraglutide)
47
HYPOGLYCAEMIA
Briefly describe the treatment of hypoglycaemia
CONSCIOUS + CAN SWALLOW:
- fast acting carbohydrate (glucose tablets, glucose 40% gels, glucose liquid, fruit juice), repeat blood glucose after 10-15 mins
- long acting carbohydrate once blood gluucose >4mmol/L (biscuit, bread)
- IM glucagon or IV glucose 10% if patient does not respond to fast acting carb
REDUCED CONSCIOUSNESS/EMERGENCY
- IM glucagon
- IV 10% glucose 150-200ml
- long acting carbohydrate, once blood glucose is >4mmol/L (biscuit, bread, milk or normal carb containing meal)
in malnourished/alcoholic patients, IV glucose should be given alonside thiamine to prevent wernicke's encephalopathy
48
HYPOCALCAEMIA
what is the management?
calcium gluconate 10% 10-20ml
49
HYPERCALCAEMIA
what is the management?
sodium chloride 0.9% 1000ml over 4hrs
50
HYPERKALAEMIA
What is the treatment for hyperkalaemia?
CARDIAC MEMBRANE PROTECTION
- 10ml 10% IV calcium gluconate or calcium chloride given immediately
POTASSIUM REDUCTION
- insulin/dextrose infusion
- nebulised salbutamol
- potassium binders (sodium zirconium cyclosilicate or calcium resonium)
- sodium bicarbonate
- haemodialysis
51
HYPOKALAEMIA
What is the treatment for hypokalaemia?
POTASSIUM REPLACEMENT
- mild to moderate = oral supplements (Sando-K)
- severe = 20-40mmol IV KCl in 0.9% saline.
- the fastest rate of correction is 10mmol/hr so 1L bag with 40mmol KCl is run over 4hrs or more
TREAT UNDERLYING CAUSE
52
HYPEROSMOLAR HYPERGLYCAEMIC STATE
what is the treatment for hyperosmolar hyperglycaemic state?
FLUID REPLACEMENT
- IV 0.9% NaCl
- aim to replace 50% fluid loss in first 12 hrs
FIXED RATE INSULIN INFUSION
- do not use insulin initially due to risks of rapid correction
- IV insulin only used if there is ketonaemia or if blood glucose is not longer falling with IV fluids alone, otherwise do NOT start insulin
POTASSIUM REPLACEMENT
- if >5.5 in first 24hrs = no replacement required
- if 3.5-5.5 in first 24hrs = 20-40mmol/L KCl
- if <3.5 in first 24hrs = require senior review
ANTICOAGULATION
- LMWH unless contraindicated
-
53
DIABETIC KETOACIDOSIS
what is the management?
IV FLUIDS
- if SBP<90 500ml bolus of 0.9% NaCl over 15 mins + call for senior help
- if SBP>90 1L 0.9% NaCl over 1 hour, 1 litre 0.9% NaCl with kCl over 2hrs, 2hrs, 4hrs, 4hrs and then 6hrs
INSULIN
- fixed rate insulin infusion
- 0.1U/kg/hr
- once glucose <14mmol/L add 10% glucose + consider reducing insulin
- do not stop long acting insulin
POTASSIUM REPLACEMENT
- >5.5 in first 24hrs = no replacement required
- 3.5-5.5 in first 24hrs = 40mmol/L KCl
- <3.5 in first 24hrs = consider HDU/ITU
54
CROHNS DISEASE
What is the treatment induction of remission for Crohn's disease?
INDUCTION OF REMISSION
MILD (1st presentation/1 exacerbation in 1yr)
- 1st line = IV/PO glucocorticoid
- 2nd line = aminosalicylate (MESALAZINE)
- distal/ileocaecal disease = budesonide
MODERATE (>2 exacerbations in 1yr)
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
SEVERE (unresponsive to conventional therapy)
- 1st line = infliximab or adalimumab (anti-TNF)
- 2nd line = other biological agents
REFRACTORY
- surgery
55
ULCERATIVE COLITIS
What is the treatment for Ulcerative colitis?
INDUCTION OF REMISSION
PROCTITIS
- 1st line = topical aminosalicylate (RECTAL MESALAZINE)
- 2nd line = oral aminosalicylate
- 3rd line = topical or oral corticosteroid
PROCTOSIGMOIDITIS/LEFT-SIDED UC
- 1st line = topical aminosalicylate
- 2nd line = high-dose oral aminosalicylate or high-dose oral aminosalicylate + topical corticosteroid
- 3rd line = stop topical treatment, add oral aminosalicylate + oral corticosteroid
EXTENSIVE DISEASE
- 1st line = topical aminosalicylate + high-dose oral aminosalicylate
- 2nd line = stop topical treatment, add oral aminosalicylate + oral corticosteroid
SEVERE DISEASE
- should be treated in hospital
- 1st line = IV steroids (IV ciclosporin if contraindicated)
- 2nd line = add IV ciclosporin or consider surgery
56
VARICES
what is the treatment for gastroesophageal varices?
- ABCDE
- Rockfall Score (Prediction of Rebleeding and Mortality)
- Bleeding Varices - Terlipressin + Prophylactic Antibiotics (Ciprofloaxcin), Balloon tamponade (Sengstaken-Blakemore tube), Endoscopic Banding, TIPS
- Bleed Prevention - BB + Endoscopic Banding. Cirrhosis = screening endoscopy
57
DIARRHOEA
what is the management for diarrhoea?
- treat underlying causes
- bacterial treated with METRONIDAZOLE- oral rehydration therapy
- anti-emetics - METOCLOPRAMIDE
- anti-motility agents - LOPERAMIDE or CODEINE
58
C.DIFF
what is the treatment for c.diff?
1st line = vancomycin orally for 10 days
2nd line = oral fidaxomicin
3rd line = oral vancomycin +/- IV metronidazole
59
CONSTIPATION
what is the management for short duration constipation (<3 months)?
1st line
- lifestyle advice (increase fibre, increase exercise, fluid intake)
- bulking laxative (ispaghula husk)
2nd line
- if hard stool, difficult to pass = osmotic laxative (macrogol, lactulose)
- if soft stool, inadequate emptying = stimulant laxatives (senna, bisacodyl)
60
CONSTIPATION
what is the management for faecal impaction?
1st line = osmotic laxative (macrogol) +/- stimulant laxative (senna)
2nd line = suppository (bisacodyl/glycerol)
3rd line = enema (sodium phosphate)
61
CROHN'S DISEASE
what is the management for maintenance of remission in crohn's disease?
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
- post surgery = consider azathioprine +/- methotrexate
62
ULCERATIVE COLITIS
what is the management for the maintenance of remission in UC?
- proctitis = topical aminosalicylate or topical + oral aminosalicylate
- left-sided + extensive disease = oral aminosalicylate
- >2 exacerbations = oral azathioprine or mercaptopurine
63
C.DIFF
what is the management of recurrent infection?
within 12 weeks of symptom resolution = oral fidaxomicin
after 12 weeks of symptom resolution = oral vancomycin or oral fidaxomicin
64
STROKE
What is the treatment for an ischaemic stroke?
Immediate management:
- CT/MRI to exclude haemorrhagic stroke
- aspirin 300mg
Antiplatelet therapy
- aspirin 300mg for 2 weeks
- clopidogrel daily long term
Anticoagulation (e.g. warfarin) for AF
thrombolysis
- within 4.5 hrs of onset
- IV alteplase
- lots of contraindications (can cause massive bleeds)
mechanical thromboectomy
- endovascular removal of thrombus
65
STROKE
What must be done after alteplase treatment?
- Repeat CT head after 24h to check for haemorrhagic transformation
66
STROKE
What other treatment can be given in ischaemic stroke either alongside alteplase or after the time frame?
- Thrombectomy (mechanical retrieval of clot)
- Proximal anterior circulation stroke within 6h (with IV alteplase if <4.5h) or within 24h if potential to salvage brain tissue
- Proximal posterior circulation stroke within 24h (with IV alteplase if <4.5h) if potential to salvage brain tissue
67
STROKE
What other management is given for ischaemic strokes?
- Control BP
- 300mg aspirin OD 2w post-stroke + then lifelong 75mg clopidogrel
68
STROKE
What is the management of a haemorrhagic stroke?
- Stop anticoagulants if on any + warfarin reversal with vitamin K + beriplex
- Aggressive BP control (140–160mmHg systolic)
- Surgical decompression (either endovascular clipping or coiling)
69
STROKE
What medication and general management may be given in stroke prevention?
- Antiplatelets (lifelong clopidogrel or aspirin + dipyridamole if cardiac disease)
- Anticoagulation if have AF but wait 2w post-stroke
- Manage co-morbidities (HTN, DM)
- Cholesterol >3.5mmol/L diet + 80mg atorvastatin
- VTE assessment + monitor for infection
70
EPILEPSY
what is the treatment for generalised tonic-clonic epilepsy?
1st line = Sodium Valproate for Males & women unable to childbear,
2nd line = Lamotrigine to females of childbearing potential for myoclonic
71
EPILEPSY
what is the treatment for absence (petit mal) epilepsy?
1st line = ethosuximide
2nd line
- male = sodium valproate
- female = lamotrigine or levetiracetam
72
STATUS EPILEPTICUS
What is the step-wise management of status epilepticus?
PRE-HOSPITAL/EARLY STATUS (<10 MINS)
- in community 1st line = buccal midazolam (2nd line = rectal diazepam)
- in hospital 1st line = 4mg IV lorazepam (2nd line = IV diazepam)
two doses of benzodiazepine given 10 mins apart
ESTABLISHED STATUS (>10 MINS)
- alert on-call anaesthetist
- one of following: phenytoin, levetiracetam, sodium valproate
if one fails, try another agent on list
REFRACTORY STATUS (>30 MINS)
- phenobarbitone
- general anaesthesia with propofol, midazolam or thiopental
73
STATUS EPILEPTICUS
What considerations should be made in status epilepticus?
- Community – buccal midazolam or rectal diazepam as step 1
- If ?alcohol related treat with IV thiamine or Pabrinex
- If medication not working or no response ?non-epileptic
74
PARKINSON'S DISEASE
What is the management of Parkinson's disease?
- Lifestyle: education, exercise, physio, MDT
1st line:
- if motor symptoms are affecting QoL = L-DOPA (CO-CARELDOPA)
- if motor symptoms not affecting QoL = dopamine agonist (ROPINIROLE) or MAO-B inhibitor (SELEGILINE or RASAGALINE)
2nd line
- COMT inhibitor (ENTACAPONE)
- amantadine
- SC apomorphine (in advanced disease with severe motor symptoms)
- deep brain stimulation
75
TRIGEMINAL NEURALGIA
How would you manage trigeminal neuralgia?
Carbamazepine - suppresses attacks
Less effective options = phenytoin, gabapentin and lamotrigine
Surgery = microvascular decompression, gamma knife surgery
76
MIGRAINE
What is the acute management of migraines?
- PO (or nasal in paeds) triptan like sumatriptan plus paracetamol or NSAID
- Antiemetic like metoclopramide or prochlorperazine if vomiting occurs
77
MIGRAINE
What is the prophylaxis for migarines?
- Propranolol or topiramate are first line
- Topiramate is teratogenic + can reduce efficacy of hormonal contraceptives though
- Also, amitriptyline, botulinum toxin or acupuncture.
- 400mg OD of riboflavin (B2) may help
- NOT gabapentin
- Avoid indentified triggers (?headache diary)
78
MENINGITIS
You see a patient in General Practice with a non-blanching petechial rash and suspect meningococcal septicaemia.
What immediate treatment should be given whilst awaiting for hospital transfer?
- IM benzylpenicillin
79
MENINGITIS
What is the management of bacterial meningitis
- IV cefotaxime
- + amoxicillin to cover listeria (potential contraction in birth) in <3m
- Dexamethasone to reduce frequency + severity of neurological sequelae
- Adjust treatment according to sensitivities
80
EPILEPSY
what is the management for different types of seizures?
GENERALISED TONIC-CLONIC
- male = sodium valproate
- female = lamotrigine or levetiracetam
FOCAL SEIZURES
- 1st line = lamotrigine or levetiracetam
- 2nd line = carbamazepine, oxcarbazepine or zonisamide
ABSENCE SEIZURES
- 1st line = ethosuximide
- 2nd line (male) = sodium valproate
- 2nd line (female) = lamotrigine or levetiracetam
MYOCLONIC SEIZURES
- male = sodium valproate
- female = levetiracetam
TONIC OR ATONIC SEIZURES
- male = sodium valproate
- female = lamotrigine
81
RHEUMATOID ARTHRITIS
Describe the treatment for rheumatoid arthritis
PRIMARY CARE
- NSAIDs
- refer to specialist
- physiotherapy + occupational therapy
SECONDARY CARE
- DMARD (methotrexate, sulfasalazine or hydroxychloroquine)
- steroids can be given whilst DMARDs take effect
- biologics (abatacept, rituximab)
MANAGING FLARES
- NSAIDs
- intra-articular steroid injection
82
INSOMNIA
what would you prescribe to treat insomnia?
zopiclone 7.5mg oral nightly (3.75mg in elderly)
83
FEVER
what would you prescribe to treat fever?
paracetamol 1g QDS
84
PAIN
what are the medications prescribed for different levels of pain?
NO PAIN
- regular = none
- as required = paracetamol 1g QDS
MILD PAIN
- regular = paracetamol 1g QDS
- as required = codeine 30mg up to 6 hrly (or tramadol)
SEVERE PAIN
- regular = co-codamol 30/500 2 tablets 6hrly
- as required = morphine sulphate (10mg/5ml) 10mg up to 6hrly
85
PAIN
what are the steps of the WHO pain ladder?
STEP 1
- paracetamol
- NSAIDs (ibuprofen, aspirin)
STEP 2
- codeine
- dihydrocodeine
STEP 3
- morphine (oral/SC/IV)
86
NAUSEA
what are the options for anti-emetic when feeling nauseous?
regular antiemetic
- cyclizine 50mg 8hrly
- metoclopramide 10mg 8hrly
- ondansetron 4mg
87
NAUSEA
what are the options for anti-emetic when not feeling nauseous?
as required
- cyclizine 50mg 8hrly
- metoclopramide 10mg 8hrly
88
NAUSEA
when should metoclopramide be avoided?
- parkinson's disease (exacerbates symptoms)
- young women (risk of dyskinesia)
- bowel obstruction
89
VTE PROPHYLAXIS
what would you prescribe for VTE prophylaxis?
LMWH = dalteparin
if severe renal failure = unfractioned heparin (5000 units BD)
90
(PAEDS) PDA
What is the management of PDA?
- Monitor until 1y with ECHOs (treat early if Sx or heart failure)
- NSAIDs (indomethacin) facilitates closure of PDA as inhibits prostaglandins
- After 1y unlikely to resolve so trans-catheter or surgical closure to reduce IE risk
91
(PAEDS) COARCTATION OF AORTA
What is the management of coarctation of aorta?
- ABCDE if collapse
- Prostaglandin E1 infusion if critical
- Stent insertion or surgical repair
92
(PAEDS) RHEUMATIC FEVER
What is the management of rheumatic fever?
- Prevention by treating strep infections with 10d phenoxymethylpenicillin
- Specialist Mx (NSAIDs for joint pain, aspirin + steroids for carditis)
- Prophylactic 1/12 IM benzathine penicillin most effective to prevent recurrence (if not daily PO penicillin)
93
(PAEDS) CROUP
What is the management of croup?
- PO dexamethasone 0.15mg/kg 1st line, can repeat at 12h
- Nebulised budesonide (steroid)
- High flow oxygen + nebulised adrenaline (more severe/emergency cases)
- Monitor closely with anaesthetist + ENT input, intubation rare
94
(PAEDS) ACUTE EPIGLOTTITIS
What is the management of epiglottitis?
- Prevention HiB vaccine, rifampicin prophylaxis for close household contacts
- Do NOT examine throat, anaethetist, paeds + ENT surgeon input
- Intubation if severe, may need tracheostomy
- IV ceftriaxone + dexamethasone given once airway secured
95
(PAEDS) PNEUMONIA
What is the management of pneumonia?
- Newborns = IV broad-spec Abx (amoxicillin)
- Older = PO amoxicillin with broad-spectrum Abx (co-amoxiclav) if unresponsive or influenza
- Macrolides (erythromycin) to cover for mycoplasma, chlamydia or if unresponsive
96
(PAEDS) ASTHMA
What is the stepwise management of chronic asthma in <5y? (BTS guidance)
- 1 = PRN SABA
- 2 = add low dose ICS OR PO montelukast
- 3 = add other option from 2
- 4 = refer to specialist
97
(PAEDS) ASTHMA
What is the stepwise management of chronic asthma >5y? (BTS guidance)
- 1 = PRN SABA
- 2 = SABA + low dose ICS
- 3 = SABA + low dose ICS + LABA (only continue if good response)
- 4 = increase ICS dose (?LTRA or PO theophylline)
- 5 = increase ICS dose to high
- 6 = refer to specialist
- May need immunosuppression or immunomodulation therapy with specialist referral
98
(PAEDS) ASTHMA
What is the management of severe exacerbations of asthma?
stepwise approach:
1. salbutamol inhalers via spacer with 10 puff every 2 hrs
2. nebulisers with salbutamol/ipratropium bromide
3. oral prednisolone (for 3 days)
4. IV hydrocortisone
5. IV magnesium sulphate
6. IV salbutamol
7. IV aminophylline
8. call ICU
99
(PAEDS) ASTHMA
What is the management of asthma in <5 year olds (NICE guidance)
1. PRN SABA
2. SABA + 8 week trial of moderate ICS
3. SABA + low ICS + LTRA
4. Stop LTRA and refer to specialist
100
(PAEDS) ASTHMA
What is the management for children >5yrs old? (NICE guidance)
1. SABA
2. SABA + low dose ICS
3. SABA + low dose ICS + LTRA
4. SABA + low dose ICS + LABA
5. SABA + MART (including low dose ICS)
6. SABA + MART (including mod dose ICS) / LABA + moderate dose ICS
7. SABA + high dose ICS / theothylline + refer to specialist
101
(PAEDS) CONSTIPATION
What is the medical management of constipation?
- 1st = MACROGOL (osmotic) laxative like polyethylene glycol + electrolytes (Movicol)
- 2nd = stimulant laxative if no effect like Senna, bisocodyl ± osmotic laxative (lactulose) or stool softener (docusate) if hard stools
- 3rd = consider enema ± sedation or specialist manual evacuation
- Continue for several weeks after regular bowel habit then gradual dose reduction
102
(PAEDS) GORD
What is the management of uncomplicated GORD?
ADVICE
- Small + frequent meals, do not over feed
- Regular burping to help milk settle
- Keep baby upright after feeds
MEDICAL
- gaviscon mixed with feeds (if formula fed)
- thickened milk or formula
- PPI (OMEPRAZOLE)
SURGERY (very rare)
- fundoplication
103
(PAEDS) GORD
What is the management of more significant GORD?
- Acid suppression = H2 receptor antagonists (ranitidine) or PPI (omeprazole)
- Surgical Mx (fundoplication) if complications, unresponsive to intensive medical treatment or oesophageal strictures
104
(PAEDS) FEBRILE CONVULSIONS
What is the management of febrile convulsions?
- Period of observation, paeds referral if first seizure or complex
- Antipyretics have NOT shown to reduce risk of recurrence
- Education = stay with them, ensure safe, nothing in mouth, call 999 if lasts >5m, teach how to use PR diazepam or buccal midazolam if Hx of prolonged seizures (>5m)
105
(PAEDS) EPILEPSY
What is the management of generalised seizures?
- 1st line = sodium valproate
- 2nd line = lamotrigine, carbamazepine (TC), clonazepam (myoclonic)
106
(PAEDS) EPILEPSY
What is the management of focal seizures?
- 1st line = carbamazepine or lamotrigine
- 2nd line = levetiracetam or sodium valproate
107
(PAEDS) EPILEPSY
What is the management of absence seizures?
- Ethosuximide or sodium valproate
108
(PAEDS) EPILEPSY
What is the management of myoclonic seizures?
- 1st line = sodium valproate
- 2nd line = clonazepam
109
(PAEDS) MENINGITIS
What is the management of bacterial meningitis?
- Supportive = correct shock with fluids, oxygen if needed
- <3m = IV cefotaxime + amoxicillin (cover listeria from ?pregnancy)
- >3m = IV ceftriaxone + IV dexamethasone to reduce frequency + severity of hearing loss + neuro damage (NOT before 3m)
110
(PAEDS) ENCEPHALITIS
What is the management of encephalitis?
- IV aciclovir to cover HSV, Abx in case bacterial meningitis
- Supportive therapy in HDU/ICU if needed
111
(PAEDS) KAWASAKI DISEASE
What is the management of Kawasaki disease?
1ST LINE
- IV immunoglobulin (IVIg)
- aspirin
- follow-up echocardiogram
2ND LINE
- corticosteroids
112
(PAEDS) ANAPHYLAXIS
What medications can be given in anaphylaxis?
- IM adrenaline (EpiPen if community), repeat after 5m if necessary
- Antihistamines like chlorphenamine or cetirizine
- Steroids like IV hydrocortisone
113
(PAEDS) WHOOPING COUGH
What is the management of pertussis?
- Notify PHE
- Prophylaxis = vaccine (esp. infants + pregnant women) or if close contact macrolide (erythromycin)
- PO macrolides (azithromycin, clarithromycin) 1st line if onset <21d
- School exclusion for 48h following Abx or 21d from onset if no Abx
114
(PAEDS) CAH
What is the general management of CAH?
- Lifelong glucocorticoids (HYDROCORTISONE) to suppress ACTH > normal growth
- Lifelong mineralocorticoids (FLUDROCORTISONE) if there's salt loss,
- infants may need NaCl replacement
- Additional hydrocortisone to cover illness/surgery
- Antenatal dexamethasone controversial treatment, risks>benefits currently
