Other cases - mx Flashcards
VZV mx
Children
Adults
Immunocompromised/pregnant
Chickenpox
• Children
o Itching – Calamine lotion
o Pain – paracetamol (avoid NSAIDs)
o Inflammation – Diphenhydramine (anti-histamine)
o DO NOT use aspirin - Reye syndrome
- Liver gets affected by both varicella zoster virus + aspirin - toxic build up of ammonia
• Adults
o Anti-virals – oral Acyclovir, famcyclovir, valacyclovir if within 24h of rash onset
o if disseminated - IV acyclovir
• Immunocompromised or pregnant women exposed to varicella zooster
o Anti-varicella antibodies – varicella-zoster immune globulin (VZIG)
Shingles – if within 72h of appearance of the rash for 7 days
• Valacyclovir or famicyclovir (1st line)
• Acyclovir (2nd line)
- Varicella vaccine used to prevent chickenpox
- Zoster vaccine used to reduce zoster (more common in adults)
EBV infectious mononucleosis glandular fever mx
- Self-limiting infection
- Supportive care – paracetamol/ibuprofen, good hydration, antipyretics, analgesics
- Corticosteroids may be indicated for severe cases (e.g. haemolytic anaemia, severe tonsillar swelling, obstructive pharyngitis)
- Amoxicillin or ampicillin is contraindicated due to widespread maculopapular rash
- Recommended that the patient refrains from strenuous physical activity + contact sports in the initial 3-4 weeks of illness due to the potential for splenic rupture
Alcohol withdrawal mx
- Mild to moderate alcohol withdrawal symptoms – can be managed with supportive care only
- Acute drug treatment – benzodiazepine
• Glucose – if hypoglycaemic
o Glucose always given AFTER pabrinex as glucose metabolism depletes B1
o (some evidence suggests that prolonged glucose supplementation without addition of thiamine can be a RF for the development of Wernicke’s encephalopathy)
• Thiamine (pabrinex)
o Given to any patient who attends hospital with alcohol withdrawal (even mild)
o To prevent Wernicke’s
• Replace electrolytes
o Hypocalcaemia + hypokalaemia will not resolve until adequate magnesium replacement is given
• Long-acting benzodiazepines
o Chlordiazepoxide often used, but diazepam is also an option
o In patients who do not have significant hepatic impairment, delirium, dementia, or who can tolerate oral medication
• Short-acting benzodiazepine
o Lorazepam
o In patients who have significant hepatic impairment, delirium, dementia, or who cannot tolerate oral medication
• Alcohol withdrawal
o Supportive care + treatment of concurrent acute medical illness
IVF, electrolyte imbalances (Mg, K, Ca PO4)
Glucose
Thiamine (pabrinex)
- Glucose always given after pabrinex
o Benzodiazepine (either short acting (lorazepam) or long acting (chlordiazepoxide) depending on the state of the patient)
o Airway management
Delirium tremens mx
o Life-threatening medical emergency
o Supportive care + treatment of concurrent acute medical illness
IVF, electrolyte imbalances (Mg, K, Ca PO4),
Thiamine (pabrinex)
Glucose
- Glucose always given after pabrinex
o Short-acting Benzodiazepine [1st line]
Oral lorazepam or diazepam
IV lorazepam if cannot tolerate oral medication
o Airway management
o Antipsychotic [2nd line] – haloperidol, olanzapine
o Phenobarbital [3rd line]
o Rapid tranquilisation [4th line]
Seizues as a result of alcohol withdrawal mx
o Ensure a patent airway
o Benzodiazepine
Oral lorazepam or diazepam
IV lorazepam if cannot tolerate oral medication
o (check capillary glucose in all patients with seizures)
Anaphylaxis mx
o ABCDE o Call for help o Remove trigger o Lie patient flat + Raise patient’s legs o IM adrenaline 0.5mg of 1:1000 o Repeat IM adrenaline after 5 mins if no better o High flow O2 o IVF o IV Chlorpheniramine o IV Hydrocortisone
Opiate overdose
ABC (e.g. if hypotensive first give IVF before naloxone)
IV naloxone
Aspirin overdose
In all patients, first line therapy must include fluid resuscitation (corrects dehydration + electrolyte derangement)
Activated charcoal + gastric lavage – considered within 1h of patients ingesting the tablets Moderate poisoning – [salicylate] is 500-700mg/L – sodium bicarbonate infusion (alkalises the urine + excretion of salicylates from the kidney) Sodium bicarbonate first line would aggravate existing hypokalaemia – correct this first via fluid resuscitation Severe poisoning – [salicylate] >700mg/L – haemodialysis
Paracetamol overdose
if they present within 1h of the overdose - can give activated charcoal to prevent absorption
IV acetyl cysteine
Should be given within 8h of overdose
Can be given within 24h of overdose
In cases of delayed presentation, extreme overdose, staggered overdose + unconsciousness it is often appropriate to treat prior to taking a 4h paracetamol level
If patient is allergic to N-acetylcysteine, use methionine
Cellulitis + erysipelas mx
• Conservative
o Draw around lesion – to see if it grows or shrinks
o Monitor obs
o Oral fluids
o Rest, elevation, analgesia (paracetamol, ibuprofen)
• Abx targeted at the most common aetiologies (streptococci + Staph aureus) - Oral abx might need IV abx if severe
o Flucloxacillin 500mg QD – first line in uncomplicated infection (because it covers both strep + staph)
o Erythromycin/clarithromycin/doxycycline – if pt is penicillin allergic
o If MRSA – vancomycin
o If infection is near the eyes or nose – co-amoxiclav or clarithromycin + metronidazole (if allergic to penicillin)
• Erysipelas should be treated the same way as cellulitis
• Admit if
o High HR, RR, low BP, confusion (AVPU, GCS)
Breast abscess/mastitis mx
• Antibiotics (flucloxacillin/dicloxacillin, cloxacillin)
o Staphylococcus aureus is the most common pathogen - Abx against staphylococci should be used
o Flucloxacillin usually used as it is safe for the baby
• Drainage/aspiration of the abscess
o Any residual mass that remains will need a triple assessment
• US guided FNA
Therapeutic + diagnostic uses
• FBC + blood cultures - if systemic infection
Mastitis
• Effective milk removal (encourage breast feeding)
• Analgesia
• Abx
Gynaecomastia mx
- Management for: alleviation of tenderness/cosmetic appearance/anxiety regarding cause/treatment of underlying disease
- Refer if red flag symptoms
- Treat underlying cause (e.g. removal of medication, androgen replacement in testicular failure, weight loss)
- Tamoxifen (oestrogen antagonist)
- Surgical removal (if no underlying cause is discovered or gynaecomastia is long-standing with development of fibrosis)
- In prostatic carcinoma gynaecomastia is a common reason for poor treatment adherence (finasteride causes gynaecomastia) - prophylactic breast irradiation prior to treatment with androgen deprivation therapy / tamoxifen
Duct ectasia mx
Reassure + discharge
Surgical excision if necessary
Plionidal sinus mx
Asymptomatic
Symptomatic with abscess
Symptomatic without abscess
Asymptomatic
• Hair removal + local hygiene
Symptomatic with abscess
• Urgent surgical drainage
• Abx (co-amoxiclav)
• Pain relief (paracetamol)
Symptomatic without abscess
• Surgery – Karydakis technique (asymmetric flap), excision with curettage, unroofing with marsupialisation, partial lateral wall excision
• Abx (co-amoxiclav)
• Hair removal (laser)
Bell’s palsy mx
- High dose corticosteroids – prednisolone [if pt presents within 72h of onset of symptoms]
- Eye protection
For some patients
• Antiviral agents - reduce long-term sequelae of Bell’s palsy compared with a corticosteroid alone
o If severe palsy/complete paralysis on presentation
o Valaciclovir, acyclovir
• Surgical decompression – consider if positive ENoG and needle EMG
