Planning management

Question 1

Management of STEMI

Answer 1

“Acute treatment:
* PCI (if available within 2 hours of presentation) + (fondaparinux or unfractionated heparin)
or
* thrombolysis agents (e.g. alteplase, tenecteplase)

Plus (MONAC):
* Morphine (if in severe pain) & Metoclopramide
* Oxygen (if sats <94%)
* Nitrates (caution in hypotensive patient)
* Aspirin 300mg
* Clopidogrel 300mg/Prasugrel/Ticagrelor

Question 2

Management of NSTEMI

Answer 2

“Acute treatment (BATMAN):
* Beta blocker
* Aspirin 300mg loading dose
* Ticagrelor 180mg loading dose
* Morphine 5-10mg IV + antiemetic
* Anticoagulant - LMWH (fondaparinux)
* Nitrates e.g. GTN

Secondary prevention with lifestyle factors and medical management (6A’s):
* Aspirin
* Another antiplatelet e.g. clopidogrel, prasugrel or ticagrelor for upto 12 months
* ACEi
* Atenolol
* Aldosterone antagonist for those with heart failure
* Atrovastatin

Secondary prevention with revascularisation procedures:
* PCI: GRACE Score to assess for PCI - if medium (5-10%) or high risk (>10%) they should have PCI within 4 days of admission

Question 3

Management of acute LVF

Answer 3

Morphine
Oxygen
GTN
Furosemide
if inadequate response isorbide dinitrate infusion

Question 4

Pneumothorax management

Answer 4

• If secondary(i.e. patient has lung disease), then always needs treatment: chest drain if >2 cm or patient has shortness of breath (SOB) or if >50 years old; otherwise aspirate.
• If tension pneumothorax(i.e. clinical distinction but often tracheal deviation +/− shock), then emergency aspiration required, but will need chest drain quickly.

Question 5

GI bleed management

Answer 5

8C’s

Question 6

management of bacterial meningitis

Answer 6

A GP will normally give 1.2g benzylpenicillin if there is any suspicion

Note - A computerized tomography (CT) scan of the head is not always required before lumbar puncture (LP); scanning the patient can delay the LP and hence antibiotics.

Question 7

Management of seizures

Answer 7

Acute (status epilepticus - seizure failed to self terminate terminate) “Oh My Lord Phone the Anaesthetist”:
* Oxygen
* Midazolam (buccal or intranasal)
OR
* Lorazepam (IV)
* Phenytoin
* RSI of Anasthesia (profolol or thopentone) with intubation and ventilation
Note - Midazolam in children and Diazepam PR in community

Question 8

Management of ischaemic stroke

Answer 8

Question 9

Management of DKA

Answer 9

Question 10

Management of acute renal failure

Answer 10

Question 11

Management of hypoglycaemia

Answer 11

If the patient is able to eat, then give a sugar-rich snack, e.g. orange juice and biscuits. However, if unable to eat (i.e. drowsy/vomiting) give IV glucose via a cannula, e.g. 100 mL 20% glucose (traditionally 50 mL 50% glucose IV but can cause extravasation). If unable to eat and no cannula, give IM glucagon 1 mg.

Question 12

Management of acute poisoning

Answer 12

Question 13

chronic heart failure

Answer 13

Medical management (ABAL):
* ACEi (avoid in valvular heart disease) or ARBs
* Beta blocker
* Aldosterone antagonist (spironolactone or eplerone) when symptoms are not controlled with A and B
* Loop diuretics (furosemide or bumentanide)

Question 14

stroke prevention scoring system in AF

Answer 14

the CHA2DS2-VASc score where each factor contributes one point unless indicated:
* Congestive heart failure (or left heart failure alone)
* Hypertension
* Age >75 (contributing 2 points)
* Diabetes mellitus
* Stroke or TIA before (contributing 2 points)
* Vascular disease (e.g. peripheral arterial disease or IHD)
* Age 65–74
* Sex (female).

Generally if:
* Score 0 may not require anticoagulation
* Score 1 consider anticoagulation in men using apixaban, dabigatran etexilate, rivaroxaban, or a vitamin K antagonist (warfarin).
* Score 2 or more consider anticoagulation in men and women as described above.

Question 15

Bleeding risk tool used for anticoagulation in AF

Answer 15

Calculate the HAS-BLED score where each factor contributes one point unless indicated:
* Hypertension i.e uncontrolled BP
* Abnormal renal function (creatinine >200 umol/L or transplant or dialysis) Abnormal liver function (cirrhosis or bilirubin >2x normal or AST/ALT/ALP >3x normal)
* Stroke
* Bleeding tendency or predisporition
* Labile INR
* “Elderly” (aged >65)
* Drugs (e.g concomitant aspirin or NSAIDs) or alcohol

Generally if:
Score 0 = low risk of bleeding. Anticoagulation should be strongly considered.

Score 1–2 = low–moderate risk of bleeding. Anticoagulation should be considered.

Score ≥3 = high risk of major bleeding. Alternatives to anticoagulation should be considered.

Question 16

AF management

Answer 16

Rhythm control:
* Who? – MUST be <48 hours since onset if young/symptomatic AF/first episode of AF/AF due to treated precipitant.
* How? – cardioversion: electrical or pharmacological Flecanide (if no structural heart disease (HD)), or amiodarone (if has structural HD). Consider oral anticoagulation if high risk of recurrence of AF in 48 hour presentation period or if CHA2DS2-VASc indicates.

Rate control:
* Who? When presentation >48 hours.
* How? Start with (depending on the contraindications) either:
(1) beta-blocker, e.g. bisoprolol 2.5mg daily or (2) rate-limiting calcium-channel blocker, e.g. diltiazem 120 mg daily. If monotherapy does not control symptoms consider combination therapy with any 2 of the following – a beta-blocker, diltiazem, or digoxin.
* Digoxin monotherapy should only be considered in non-paroxysmal AF if person is sedentary. Amiodarone should NOT be used for long term rate control.

Question 17

Stable angina management

Answer 17

There are three facets to first-line management:
* GTN spray ‘as required’ (for symptomatic relief when required).
* Secondary prevention: consider aspirin, statin, and cardiovascular risk factor modification.
* One anti-anginal drug and, dependent on contraindications, either (1) beta-blocker (e.g. atenolol) (contraindications: hypotension, bradycardia, asthma, and acute heart failure), or (2) calcium-channel blocker (e.g. amlodipine or diltiazem) (contraindications: hypotension, bradycardia, and peripheral oedema).

Question 18

Asthma adult management

Answer 18

Long term management Adults:
1. Reliever: Short acting inhaled beta agonists (SABA) e.g. salbutamol as required
2. Preventer: low dose steroid inhaler (ICS)
3. Initial add on therapy: long acting beta agonist (LABA) combined with a low dose ICS inhaler
4. Additional add on therapies: medium dose ICS +/- leukotrine receptor antagonist (LTRA e.g. montelukast) or theophyllines or Long acting muscurinic antagonists (LAMA) e.g. tiotropium
5. High-dose therapies: high dose ICS (max 2000ug) + LTRA/theophylline/LAMA/beta agonist tablet
6. Specialist care: oral steroids +/- immunosuppressants e.g. omalizubmab (anti-IgE), mepolizumab (anti-IL5)

Question 19

asthma management in children

Answer 19

Long term management children:
1. Reliever: SABA
2. Preventer: very low dose ICS (>5 years old) or LTRA (<5 years old)
3. Initial add on therapy: LABA (>5 years old) or very low dose ICS (<5 years old)
4. Additional add-on therapies: low dose ICS +/- LTRA (>5 years old)
5. High dose therapies: medium dose ICS + theophylline
6. Specialist care: oral steroids +/- immunosuppressants

Question 20

acute COPD exacerbation management

Answer 20

“Acute exacerbation:
* antibiotics (amoxicillin or clarithromycin) if evidence of infection
* Oxygen - beware type II respiratory failure (88-92%)
* nebulisers (beta 2 agonists/anticholinergics)
* oral/IV steroids
* if not improving consider aminophylline infusions
* if still not improving consider NIPPV (e.g. BiPAP)

”

Question 21

chronic COPD management

Answer 21

Long term management:
1. Short acting bronchodilators: SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide) as required
2. Long acting bronchodilators:
* if they do not have asthmatic features they should receive a combined LAMA + LABA inhaler. Note if they are already taking a SAMA, discontinue and switch to a SABA
* if they have asthma they should have a combined LABA + ICS
3. Tripple therapy: LABA (salmeterol) + LAMA (tiotropium) + ICS (beclomethasone)
4. Specialist care: e.g. aminophylline or theophylline, long term prophylactic antibiotics (e.g. azithromycin), oral mucolytic therapy (e.g. carbocisteine)

Other (STOP and refer):
* S - Smoking cessation
* T - Travel advice: risk of pneumothorax in those with bullae
* O - Oxygen therapy: in those with chronic hypoxia, polycythaemia, cyanosis or heart failure.
* P - Pneummococcal and annual flu vaccination
* Refer for pulmonary rehabilitation

Question 22

Management of parkinsons

Answer 22

”* education
* encourage physical activity

dementia tx:
* cholinesterase inhibitors and memantine

Medical tx of parkinsonism:
* dopamine precursor: levodopa
* dopamine agonists: cabergoline, bromocriptine, pergolide
* COMT inhibitors: entacapone, opicapone
* MAOB inhibitors: selegline, rasagline, safinamide
peripheral AAAD (decarboxylase) inhibitors: cabidopa, benserazide (can be manufactured with L-dopa)

Question 23

Epilepsy chronic management

Answer 23

All seizures are managed with sodium valporate (first-line in males) then lamotrigine (first-line females) except focal seizures and secodnary generalised seizures which are managed in the reverse order

Question 24

Management of alzheimers disease

Answer 24

”* if mild/moderate dementia treat with Cholinesterase inhibitors e.g. donepezil, rivastigmine and galantamine
* If moderate/severe then treat with NMDA antagonists e.g. Memantine
Can use two drugs together
* Sx therapy: anxiolytics, antidepressants “

Question 25

Common side effects of antiepileptic medications

Answer 25

Question 26

inducing remission of IBD

Answer 26

Work up pyramid

UC can only use bottom tier

Question 27

treatment options for constipation

Answer 27

Question 28

chronic non-infective diarrhoea management

Answer 28

loperamide or codeine

Question 29

Name a dopamine antagonist safe to use in parkinsons disease

Answer 29

domperidone, another dopamine antagonist licensed for the treatment of nausea, is safe to use for patients with Parkinson’s disease as it does not cross the blood-brain barrier)