MFE Flashcards by Alaa M.

Causes of delirium

DELIRIUMS

Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
Eyes, ears and emotional disturbances
Low Output state (cardio, resp)
Infection
Retention
Ictal (seizure activity)
Under-hydration/Under-nutrition
Metabolic disorders
Subdural hematoma, sleep deprivation

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Define Orthostatic hypotension

Decrease in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing when compared with blood pressure from the sitting or supine position.

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Lilliputian hallucination refers to the delusion of seeing tiny people / creatures

Alcohol withdrawal syndrome

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Constipation is a common cause of delirium in elderly inpatients, particularly in those taking _________ analgesia

Opiate

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There is likely a deprivation of liberty if..

The person is subject to continuous supervision and control and
The person is not free to leave

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Which drugs cause constipation?

Opiates, calcium channel blockers and some antipsychotics

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Medications for pain

Morphine
Diamorphine
Oxycodone
Alfentanyl (for those with renal failure)

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Medications for breathlessness

Therapeutic oxygen
Morphine
Midazolam

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Medications for nausea and vomiting

Levomepromazine
Cyclizine
Haloperidol
Metoclopramide

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Medications for restlessness and confusion

Haloperidol
Levomepromazine
Midazolam

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Medications for respiratory tract secretions

Hyoscine hydrobromide/butylbromide
Glycopyrronium

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Which drug classes cause delirium?

Anti-cholinergics, opiates, anti-convulsants, recreational

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Mx for constipation

Exclusion of underlying causes - colorectal cancer
Lifestyle modifications - increase dietary fibre, adequate fluid intake, adequate activity levels

First-line laxative: bulk-forming laxative first-line, such as ispaghula
Second-line: osmotic laxative, such as a macrogol

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A 67 year old man was electively admitted for a total hip replacement. On the third day postoperatively he is reviewed on the ward.

He is acutely confused with impaired concentration, agitation, tremor, sweating and tachycardia. He swats at his bed clothes as though trying to kill insects.

What is the underlying cause of his delirium?

Alcohol withdrawal - lilliputian hallucination refers to the delusion of seeing tiny people / creatures. This can be a sign of delirium tremens due to alcohol withdrawal

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Seizure threshold lowering drugs

Antibiotics: Imipenem, penicillins, cephalosporins, metronidazole, isoniazid
Antipsychotics
Antidepressents: Bupropion, Tricyclics, Venlafaxine
Tramadol
Fentanyl
Ketamine
Lidocaine
Lithium
Antihistamines

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Dementia alongside two of the three features: fluctuating attention and concentration, recurrent well-formed visual hallucinations, spontaneous Parkinsonism

LBD

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Breakthrough pain medication is calculated as…

Sixth of the total daily dose

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Medications that cause postural hypotension

Nancy Doesn’t Always Bring Lollipops And Apples

Nitrates
Diuretics
Anticholinergics
Beta-blockers
L-Dopa
Antidepressants
ACE inhibitors

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Medications associated with falls due to other mechanisms

BAAC DOO

Benzodiazepines
Antipsychotics
Anticonvulsants
Codeine
Digoxin
Opiates
Other sedatives

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Gastrointestinal disturbance (nausea, vomiting, abdominal pain), dizziness, confusion, blurry or yellow vision, and arrhythmias.

Acute digoxin toxicity

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Dry eyes, dry mouth, hypotension (often postural) and delirium

Side-effects of an anticholinergic drug such like amitriptyline

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If there is a bleeding ulcer, stop _______

NSAIDs

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If there is kidney failure, stop _______

ACE inhibitor

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If there is severe hyponatraemia, stop _______

Antidepressant

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ACE-i and CCB cause..

Postural hypotension

Thiazides can cause..

Dehydration

Amitriptyline can cause..

Anti-cholinergic side effects

Laxatives and anti-emetics can cause..

Diarrhoea

Signs to recognise when a patient might be dying

LAST BREATH Lethargy Altered mental status Skin changes (blue, mottled, cold hands and feet) Tablets and oral intake diminished Breathing changes (rattled, rapid, intermittent)

Treatable conditions that can mimic dying

Opioid toxicity Sepsis Hypercalcaemia Hypoglycaemia Uraemia/AKI

Which anticipatory medication is given in pain/SOB

Morphine

Which anticipatory medication is given in distress/agitation

Midazolam

Which anticipatory medication is given in nausea

Levomepromazine

Which anticipatory medication is given in respiratory secretions

Hyoscine butylbromide

If already established on background oral opioid..

Generally, use same opioid for background and prn Use approx. 1/6 background dose as breakthrough prn dose Switch background oral opioid to syringe driver if not managing to swallow

When giving opioids, if renal function severely impaired..

Consider alfentanil

Visual impairment with visual hallucinations in the evening/low light

Charles Bonnet syndrome

_______ can decrease the absorption of tetracycline antibiotics (e.g. doxycycline)

Oral iron (e.g. ferrous sulfate) *Give iron at least 3 hours before or 3 hours after tetracycline*

_____________ can prolong bleeding times and cause gastrointestinal toxicity. These effects are aggravated when given with anticoagulants (e.g. warfarin)

Naproxen, and other NSAIDs *Monitor INR + bleeding signs. Alter warfarin dose to ensure ref range*

Clarithromycin inhibits the CYP3A4 enzyme responsible for metabolising ____________, subsequently increasing the plasma concentration

Simvastatin *Withhold simvastatin while administering clarithromycin*

Methotrexate is a substrate for OAT1 and/or OAT3 so can compete with __________ which are involved in the active renal secretion of drug

NSAIDs *Avoid NSAIDs with methotrexate and use alternative analgesia*

Example of a beneficial additive/synergistic interaction

Ramipril inhibits the ACE enzyme from converting angiotensin I to angiotensin II, causing increased vasodilation due to inhibition of bradykinin breakdown Amlodipine causes the direct relaxation of the vascular smooth muscles *No action is required unless hypotension occurs*

Example of a harmful additive/synergistic interaction

Enoxaparin with apixaban *Additive anti-Xa activity. This increases the risk of bleeding*

Example of an antagonism interaction

Propranolol (blocks b2 which can make asthma worse) with salbutamol

Omeprazole with clopidogrel interaction

Omeprazole can decrease the antiplatelet effects of clopidogrel (give cimetidine instead)

SSRIs with NSAIDs interaction

Can increase GI bleading

Methotrexate with trimethoprim interaction

Risk of severe bone marrow suppression & subsequent pancytopenia (monitor FBC and give folinic acid as an antidote)

Verapamil with beta-blockers interaction

Additive cardiac depression effects (leading to bradycardia, asystole, sinus arrest) so never give verapamil in IV

ACE inhibitors with potassium-sparing diuretics (e.g. spironolactone/eplerenone) interaction

Increases the risk of hyperkalaemia and acute kidney injury

Which drug causes unexplained rhabdomyolysis?

Statins

Absorption of levothyroxine is reduced by...

Food and caffeine as well antacids, calcium and iron supplements)

Long-term side effects of taking omeprazole

Osteoporosis, Clostridium difficile infection, hypomagnesaemia and vitamin B12 deficiency

Omeprazole drug interactions

SSRI Clopidogrel Methotrexate

Key counselling point of taking amlodipine?

Dizzy so blood pressure monitoring will be required during treatment

Amlodipine drug interactions

Simvastatin - rhabdomyolysis Diltiazem and verapamil - arrythmias Ramipril - hypotension

Joint pain (arthralgia), muscle discomfort (myalgia), nausea & vomiting, flatulence, constipation and gastrointestinal discomfort

Atorvastatin

Excess dosing of causes symptoms of hyperthyroidism

Levothyroxine

Dizziness, flushing, palpitations, headaches, peripheral oedema (usually leg swelling) and headaches

Amlodipine

Dry cough Hyperkalaemia Angioedema

Ramipril

Rampiril drug interactions

NSAIDs - hyperkalaemia Lithium

Bisoprolol interactions

Verapamil, diltiazem and amiodarone - heart block

Gastrointestinal and taste disturbances Weight loss

Metformin

Don't mix _____ or _____ with ciprofloxacin or doxycyclin

Calcium or ferrous sulphate

P450 inducers

P450 inhibitors

| + Alcohol + Sodium Valproate

___________ is a calcium channel blocker. Common side effects include ankle swelling and facial flushing. There is some evidence to suggest this drug is protective against osteoporosiS

Amlodipine

_____________ can cause muscle pains and gastrointestinal side effects. It can also cause deranged liver function tests, however, it does not impact bone health

Atorvastatin

Which antipsychotic is given if a patient has PD?

Lorazepam If urgent then atypical antipsychotic: quetiapine and clozapine

MFE Flashcards

(68 cards)