PSA ALL Flashcards
(228 cards)
1
Q
in an average healthy adult with no extra losses, what are the maintenance requirements for fluids
A
25-30ml/kg/day of water
1mmol/kg/day of sodium, chloride and potassium
50-100g/day of glucose to limit starvation ketosis
2
Q
what is the normal amount of fluid loss per day
A
1ml/kg/hour
3
Q
when you are replacing fluid, what uring output should you aim for
A
a minimum of 0.5ml/kg/hour
4
Q
what is the quantity of fluid loss fro GI system
A
normally minor but can be considerable in D&V so quantify such losses
5
Q
what is the normal quantity of insensible losses
A
500-800ml per day
but higher if pyrexic and sweating or if having open cavity surgery
6
Q
sweating results in which electrolyte loss
A
sodium
7
Q
diarrhoea and increased stoma output result in which electrolyte loss
A
sodium, potassium and bicarbonate
8
Q
vomiting causes what type of electrolyte loss
A
sodium, potassium, chloride and hydrogen ions loss
thus leading to a hypochloraemic metabolic alkalosis (sometimes accompanied by a mild
hypokalaemia)
9
Q
fill in this table with some signs of hypo and hypervolaemia
A
10
Q
fill in this table with some signs of hypo and hypervolaemia
A
11
Q
what four things should you consider when choosing a fluid and rate for fluid replacement
A
type of fluid loss
renal function
cardiac function
concomitant electrolyte abnormalities
12
Q
how will IV NaCl 0.9% distribute itself once administered
A
isotonic with plasma and stays almost entirely in extracellular compartment
25% of the volume will go into the intravascular compartment
75% of the volume will go into the interstitial compartment
13
Q
how much glucose is in 1000ml of glucose 5%
A
50 grams as it’s 50g/L of glucose
14
Q
fill this in please
A
15
Q
how does glucose 5% distribute over the various fluid compartments
A
distributes across all compartments according to their various contributions to total body water
16
Q
name 5 colloids
A
blood
dextrans
gelatin (e.g. gelofusine)
human albumin solution
hydroxyethyl starch
17
Q
what are the drawbacks of colloid
A
higher cost
small but well established risk of anaphylactoid reactions and anaphylaxis
18
Q
what are the 5 Rs of prescribing fluids
A
Resuscitation
Routine Maintenance
Replacement
Redistribution
Reassessment
19
Q
fluid resuscitation NICE recommendations
A
- 500ml 0.9% NaCl over less than 15 minutes
- monitor MAP, urine output etc to see if they are responsive
20
Q
how do you calculate someone’s maintenance fluid and electrolyte requirements
A
- 25-30ml/kg/day
- 1mmol/kg/day of sodium, chloride and potassium each
- and 50-100g glucose a day
- special considerations in:
- older adults
- frail
- renal failure
- cardiac failure
- malnourished at risk of refeeding
21
Q
what are two complications of fluid overload?
A
dilutional hyponatraemia
and
pulmonary oedema
22
Q
therapies for fluid overload
A
- stop IV fluids
- furosemide
- causes diuresis and venodilation
- sublingual nitrate
- causes a reduction in preload - effect seen in 5 minutes
- IV nitrate
- provides an excellent and titratable pre and afterload reduction
- must monitor BP as hypotension would mean you need to stop the infusion.
- provides an excellent and titratable pre and afterload reduction
23
Q
dose of IM adrenaline for anaphylaxis in adults over the age of 12
A
500 micrograms (which is 0.5mL of 1:1000 adrenaline)
can repeat after 5 minutes
24
Q
dose of IM adrenaline for anaphylaxis for children aged 6-12
A
300 micrograms (which is 0.3mL of 1:1000)
25
dose of IM adrenaline for anaphylaxis in children aged younger than 6
150 micrograms (0.15mL of 1:1000)
26
factors that may contribute to non-adherance
* social/economic factors
* therapy related factors
* condition related factors
* patient related factors
* health system factors
27
what is the definition of adherance
the extent to which a patient's behaviour matches the agreed recommendations from the prescriber
28
how do you estimate a child's weight
* 0 to 12 months = (0.5 x age in months) + 4kg
* 1 to 5 years = (2 x age in years) + 8kg
* 6 to 12 years = (3 x age in years) + 7kg
29
how many milligrams (mg) in 1g
there are 1000 milligrams (mg) in 1g
30
how many micrograms in a milligram
there are 1000 micrograms in a milligram
31
how many nanograms are in a microgram
there are 1000 nanograms in a microgram
32
what does %w/w mean
percentage weight per weight
therefore hydrocortisone 0.5%w/w contains 0.5g hydrocortisone in 100g of the cream
33
what does %w/v mean?
weight per volume
in a sodium chloride 0.9% w/v solution contains 0.9g of sodium chloride in 100ml
34
what does %v/v
volumer per volume
in 1%v/v there is 1ml of actual drug in 100ml of the final product
35
what does 1:1000 mean
1:1000 means 1g in 1000mls
so 1:1000 adrenaline has 1mg per ml
36
gentamicin should be dosed according to a patient's \_\_\_\_\_
ideal body weight
37
how do you calculate body surface area
BSA = weight(kg) X height (cm) / 3600
38
if converting oral morphine to fentanyl patch but their daily morphine is between the doses available of fentanyl patches what do you do
they need to be prescribed a fentanyl patch that is either slightly more or slightly less potent than their morphine dose
it is normal practice to use the lowest dose in the conversion range and then adjust according to response and tolerance
an immediate release preparation should be prescribed for breakthrough pain if required
39
how does the subcut dose compare to the oral dose of morphine
the subcutaneous dose of morphine is half the oral dose
40
where do you find the opiate conversion charts
medicines guidance \> prescribing in palliative care
41
where do you find the steroid conversion charts
treatment summary \> glucocorticoid therapy
42
where do you find the benzo conversion charts?
treatment summary \> hypnotics and anxiolytics
43
what would an enzyme inducer/inhibitor do to INR in patient taking warfarin
inducer: INR drops
inhibitor: INR rises
inducers cause increased metabolism and elimination of warfarin and vice versa with inhibitors
44
mnemonic for remembering enzyme inducers
* PC BRAS
* Phenytoin
* Carbamazepine
* Barbituates
* Rifampicin
* Alcohol
* Sulphonylureas
45
Enzyme inhibitors mnemonic
* AODEVICES
* Allopurinol
* Omeprazole
* Disulfiram
* Erythromycin
* Valproate
* Isoniazid
* Ciprofloxacin
* Ethanol (acute intoxication)
* Sulphonamides
46
patients who are on long term steroid therapy and surgery/sick day rules
* commonly have adrenal atrophy so can't mount an appropriate stress response to surgery
* therefore BP may drop during surgery which is dangerous
* so sick day rules are to double steroid dose when sick to meet increased steroid requirement
* and in surgery they should be given IV steroid at induction
47
mnemonic for remembering which drugs should be stopped near surgery
* I LACK OP
* Insulin (they'll be nbm so sliding scale started instead)
* Lithium (day before)
* Anticoagulants/antiplatelets
* COCP (4 wks before surgery)
* K-sparing diuretics (day of surgery)
* Oral hypoglycaemics (they'll be nbm so sliding scale started instead)
* Perindopril and other ACE inhibitors
48
two antibiotics that contain penicillin
co-amoxiclav and tazocin
49
mnemonic for remembering the safety considerations of NSAIDs
* NSAIDs
* No urine (i.e. renal failure)
* Systolic dysfunction (i.e. heart failure)
* Asthma
* Indigestion
* Dyscrasia (clotting abnormality)
Aspirin is kind of exempt to the above since it is generally used at relatively low doses for the management of cardiovascular and cerebrovascular disease
50
mnemonic for remembering the side effects of steroids
* STEROIDS
* Stomach Ulcers
* Thin skin
* Edema
* Right and left heart failure
* Osteoporosis
* Infections (candida)
* Diabetes
* cushing Syndrome
51
how to think about the side effects of anti-hypertensives
* in three groups:
* hypotension
* including postural hypertension (earliest symptom)
* can be caused by all antihypertensives
* divide them into two mechanistic categories:
* bradycardia
* beta blockers and some CCBs
* electrolyte disturbance
* ACE inhibitors
* diuretics
* individual drug classes have specific side effects
* ace inhibitors
* dry cough
* hyperkalaemia
* B blockers
* worsen acute heart failure (but help chronic)
* cause wheeze in asthmatics
* diuretics
* can cause renal failure
* thiazides can cause gout
* potassium sparing diuretics can cause gynaecomastia
52
how to decide what fluid to give in fluid replacement
* give all patients 0.9% saline unless:
* they're hypernatremic → 5% dextrose instead
* they're hypoglycaemic → 5% dextrose instead
* they have ascites → human albumin solution instead
* they're shocked for bleeding → blood transfusion but crystalloid first if no blood available
53
as a general rule never prescribe more than ________ L of fluid for a sick patient
as a general rule never prescribe more than 2L of fluid for a sick patient
54
how to decide how much fluid and how quickly to give it in fluid replacement
* if tachycardic OR hypotensive
* give 500ml bolus immediately (\<15mins)
* unless Hx of heart failure then give 250ml
* then reassess them
* BP, urine output and HR
* as general rule don't prescribe more than 2L
* if only oliguric (\<30mL/hr)
* then give 1L over 2-4hrs
* then reassess them
55
IV potassium should not be given at a rate more than \_\_\_\_mmol/hr
IV potassium should not be given at a rate more than 10mmol/hr
56
three things to check when prescribing fluids in real life
* patient's U&Es to know what to give them
* check they're not fluid overloaded
* raised JVP
* peripheral/pulmonary oedema
* ensure bladder isn't palpable (obstruction)
57
as a general rule how much fluid do adults and the elderly need per 24 hours
adults require 3L/24 hrs
elderly require 2L/24hrs
58
quick and easy way to provide adequate electrolytes to an adult
* "1 salty, 2 sweet"
* generally require 3L per day
* 1L 0.9% saline
* 2L 5% dextrose
* to add potassium (depending on U&Es)
* pts need roughly 40mmol per day
* so put 20mmol in two bags
59
which patients should not be prescribed compression stockings
those with peripheral arterial disease (absent foot pulses) as it may cause acute limb ischaemia
60
which patients to remember should not be on LMW heparin or other anticoagulants
* patients who are bleeding or at risk of bleeding
* this includes those who have had a recent ischaemic stroke within the last few months
61
who should not have metoclopramide
* patients with parkinson's disease
* Metoclopramide is a dopamine antagonist so may exacerbate symptoms
* young women due to the risk of dyskinesia
62
which antiemetics to use if patient is nauseated
* regular antiemetics:
* cyclizine
* 50mg 8hrly IM/IV/orally
* good first line
* note causes fluid retention (don't use in cardiac cases)
* metoclopramide
* 10mg 8hrly IM/IV if heart failure
* metoclopramide first line in cardiac cases due to fluid retention that cyclizine causes
* ondansetron
* 4mg or 8mg 8hrly IV/oral
63
which antiemetics to use if the patient is not nauseated
* as required medications
* cyclizine
* 50mg up to 8hrly IM/IV/orally
* for most cases but cardiac ones due to fluid retention
* metoclopramide
* 10mg up to 8hrly IM/IV if heart failure
* remember to avoid in parkinsons
64
what is the maximum dose of paracetamol in patients \<50kg and what is it otherwise
in patients \<50kg it is 500mg 6hrly
in other patients it is 4g in 24hrs
65
if someone has no pain what analgesia should you prescribe them
* PRN:
* paracetamol 1g up to 6hrly oral
* ibuprofen 400mg up to 8hrly oral
66
if someone has moderate pain what analgesia should you prescribe them
* regular:
* paracetamol 1g 6hrly oral
* PRN:
* codeine 30mg up to 6hrly oral
* ibuprofen 400mg up to 8hrly oral
67
if someone has severe pain what analgesia should you prescribe them
* regular:
* co-codamol 30/500, 2 tablets, 6hrly, oral
* PRN:
* morphine sulphate 10mg/5ml, 10mg up to 6hrly, oral
* ibuprofen 400mg up to 8hrly oral
68
what is the first line treatment for neuropathic pain
amitriptyline 10mg oral nightly
or
pregabalin 75mg oral 12hrly
69
what analgesic for painful diabetic neuropathy
duloxetine 60mg oral daily
70
if you can't use metoclopramide in parkinson's what drug could you use instead
domperidone
metoclopramide and domperidone are both dopamine antagonists
domperidone doesn't cross the BBB though
71
why do ACE inhibitors cause a cough
ACE breaks down bradykinin
bradykinin accumulation causes the cough
72
why do ACE inhibitors cause hyperkalaemia
they reduce aldosterone production and thus reduce potassium excretion in the kidneys
73
why does ibuprofen affect kidney function
* inhibits prostaglandin synthesis
* this reduces renal artery diameter
* this leads to reduced kidney perfusion and function
74
why do ace inhibitors reduce kidney function
reduce angiotensin II activity necessary for preserving glomerular filtration when renal blood flow is reduced
75
what is the presentation of antimuscarinic toxicity (oxybutynin)
pupillary dilation with loss of accommodation
dry mouth
tachycardia (after a transient brady)
can cause confusion in the elderly
lower dose recommended in the elderky
76
why shouldn't you take trimethoprim while on methotrexate
trimethoprim is a folate antagonist and so is methotrexate
it is a direct contraindication to patients taking methotrexate due to the risk of bone marrow toxicity
77
calcium channel blockers can cause which symptom which often gets treated with diuretics
they can cause peripheral oedema
this is often mistaken for heart failure
this is then mistakenly treated with a diuretic
both the diuretic and the calcium channel blocker can be discontinued
78
why should calcium channel blockers not be used with beta blockers
risk of bradycardia and hypotension
79
two common drugs that can precipitate bronchospasm in asthmatics
* beta blockers (contraindicated in asthmatics)
* NSAIDs (used in asthmatics if strictly necessary and with caution)
* sort of ignore aspirin for this as it does it very rarely
80
the patient has asthma and is on ibuprofen but the question does not state that she has a wheeze - should you stop the NSAID?
the ibuprofen can be continued as it suggests that the asthma is not nsaid sensitive - proceed with caution.
81
causes of microcytic anaemia
iron deficiency anaemia
thalassaemia
sideroblastic anaemia
anaemia of chronic disease
82
causes of normocytic anaemia
anaemia of chronic disease
acute blood loss
haemolytic disease
chronic renal failure
83
causes of macrocytic anaemia
B12/folate deficiency
Excess alcohol
Liver disease
hypothyroidism
84
causes of hypernatraemia
* causes all begin with D
* dehydration
* drips (i.e. too much IV saline)
* drugs (e.g. tablets with too high sodium content)
* diabetes insipidus
85
causes of high neutrophils
bacterial infection
tissue damage (inflammation/infarct/malignancy)
steroids
86
causes of low neutrophils
viral infection
chemotherapy or radiotherapy
clozapine
carbimazole
87
causes of high lymphocytes
viral infection
lymphoma
CLL
88
causes of low platelets
* reduced production
* viral infection
* drugs
* penicillamine for RA
* myeloma
* increased destruction
* heparin
* hypersplenism
* disseminated intravascular coagulation
* idiopathic thrombocytopenic purpura
* thrombotic thrombocytopenic purpura
* haemolytic uraemic syndrome
89
causes of high platelets
* reactive
* bleeding
* tissue damage (infection/inflammation/malignancy)
* postsplenectomy
* primary
* myeloproliferative disorders
90
causes of hyponatraemia
* first you need to assess their fluid status
* hypovolaemic
* fluid loss (especially diarrhoea/vomiting)
* addison's disease
* diuretics
* euvolaemic
* SIADH
* psychogenic polydipsia
* hypothyroidism
* hypervolaemic
* heart failure
* renal failure
* liver failure
* nutritional failure causing hypoalbuminaemia
* thyroid failure (hypothyroidism)
91
causes of SIADH
* mnemonic SIADH
* Small cell lung tumours
* Infeciton
* Abscess
* Drugs (carbamazepine and antipsychotics)
* Head injury
92
causes of hypokalaemia
* mnemonic: dire
* Drugs (loop diuretics and thiazide like diuretics)
* Inadequate intake or intestinal loss (D&V)
* Renal tubular acidosis
* Endocrine (cushing's and conn's syndrome)
93
causes of hyperkalaemia
* mnemonic: dread
* Drugs (ACE inhibitors and K-sparing diuretics)
* Renal failure
* Endocrine (addison's)
* Artefact (very common due to a clotted sample)
* DKA
* note that when insulin is given to treat DKA the K drops so it needs hourly monitoring +/- replacement
94
what two things could a raised urea indicate
* kidney injury
* upper GI bleed
therefore if they have a raised urea with a normal creatinine (i.e. they don't have pre-renal failure) then look at the Hb to make sure they haven't had an upper GI bleed
95
why might a raised urea indicate an upper GI bleed
* if Hb broken down by gastric acid it will form urea
* this urea will them be absorbed
* the same thing will happen if you eat a big and bloody steak
for the same reason, a high protein diet can cause an elevated urea - it is product of amino acid breakdown
96
what is classed as an elevated urea:creatinine ratio and what are the causes
* Elevated ratio: \>100:1
* Causes:
* Prerenal renal failure - hypovolaemia, sepsis, renal venoconstriction
* Dehydration
* Protein load - GI bleed (especially upper GI), high protein diet
* Catabolic state - trauma, sepsis, starvation, corticosteroids
97
what is classed as a reduced urea:creatinine ratio and what are the causes
* Reduced ratio: \<40:1
* Causes:
* Severe liver failure
* Low protein intake - low protein diet, malnutrition, malabsorption, alcoholism
* Muscle breakdown - body building, rhabdomyolysis
* Pregnancy
98
what biochemical disturbance will you see with a pre-renal AKI
* increased urea:creatinine ratio
99
what percentage of AKIs are pre-renal, intrinsic renal and post-renal
* pre-renal: 70%
* intrinsic renal: 10%
* post-renal: 20%
100
causes of pre-renal aki
dehydration
shock
blood loss
renal artery stenosis
101
causes of intrinsic renal aki
* mnemonic INTRINSIC
* Ischaemia (due to pre-renal AKI causing necrosis)
* Nephrotoxic antibiotics
* Tablets (ACEI, NSAIDs
* Radiological contrast
* Injury (rhabdomyolysis)
* Negatively birefringent crystals (gout)
* Syndromes (glomerulonephritides)
* Inflammation (vasculitis)
* Cholesterol emboli
102
common cause of AKI in RAS
renal artery stenosis and AKI is commonly caused by drugs such as ACEIs and NSAIDs
103
name 3 nephrotoxic antibiotics
gentamicin
vancomicin
tetracyclines (e.g. those ending in cycline)
104
causes of post-renal aki
* obstruction
* in lumen
* stone
* in wall
* tumour
* fibrosis
* external pressure
* BPH
* pelvic mass
* prostate cancer
105
causes of a raised alk phos
* mnemonic ALKPPHOS
* Any fracture
* Liver damage
* Kancer
* Paget's disease of bone
* Pregnancy
* Hyperparathyroidism
* Osteomalacia
* Surgery
106
what are the causes of pre-hepatic jaundice and what is the pattern of LFT derangement
* causes
* haemolysis
* gilbert's syndrome
* crigler najjar syndrome
* LFT derangement
* increased bilirubin alone
107
what are the causes of intra-hepatic jaundice and what is the pattern of LFT derangement
* causes
* fatty liver
* hepatitis
* cirrhosis
* malignancy
* metabolic
* wilson's
* haemochromatosis
* heart failure (causing hepatic congestion)
* LFT derangement
* raised bilirubin
* raised AST and ALT
108
causes of post-hepatic jaundice and what LFT derangement will you see
* Causes
* in lumen
* stone
* drugs that cause cholestasis such as:
* flucloxacillin
* co-amoxiclav
* nitrofurantoin
* steroids
* sulphonylureas
* in wall
* tumour
* PBC
* PSC
* extrinsic pressure
* pancreatic or gastric cancer
109
which drugs can cause cholestasis
flucloxacillin
co amoxiclav
nitrofurantoin
steroids
sulphonylureas
110
what can cause hepatitis and cirrhosis
* alcohol
* viruses
* hep a-e
* cmv
* ebv
* drugs
* paracetamol overdose
* statins
* rifampicin
* autoimmune
* PBC
* PSC
* autoimmune hepatitis
111
when making or reviewing a prescription which things could be wrong with it
* mnemonic: prescriber
* PReSCRIBER
* Patient details
* Reaction
* Sign the front of the chart
* Contraindications
* Route
* IV fluids may be needed
* Blood clot prophylaxis may be needed
* antiEmetic if needed
* pain Relief if needed
112
how to check the quality of a film
* PRIM
* Projection
* normally PA (PA if no label)
* if AP heart will appear larger
* Rotation
* if distance between spinous process and clavicles is equal then no rotation
* Inspiration
* 7th anterior rib should intersect diaphragm
* Markings
* if red mark then radiographer has spotted an abnormality
113
what size should the heart be on a CXR
it should be less than half the width of the lungs
114
Why might a patient with a normal PaO2 on an ABG actually be hypoxic. How can you roughly calculate an appropriate PaO2 for a patient on oxygen?
if they are on oxygen then they may have a ‘normal’ PaO2 but you would expect them to have an even higher one. to work out whether they are hypoxic in an approximate way then you can do the following:
* subtract 10 from the FiO2
* if this number is lower than the PaO2 in kPa then the patient is not hypoxic
e.g. if a patient is on 60% oxygen with an PaO2 of 30kPa they are actually hypoxic because you would expect a PaO2 of 50kPa at least
115
things that can cause type two respiratory failure
* CO2 retaining COPD
* neuromuscular failure
* restrictive chest wall abnormalities
116
causes of metabolic alkalosis
vomiting
diuretics
conn's syndrome
117
fill this in
118
name 6 common drugs that require monitoring
digoxin
theophylline
lithium
phenytoin
gentamicin
vancomycin
119
features of digoxin toxicity
* confusion
* nausea
* visual halos
* arrhythmias
120
features of lithium toxicity
* early:
* tremor
* intermediate:
* tiredness
* late:
* seizures
* arrhythmias
* coma
* renal failure
* diabetes insipidus
121
features of phenytoin toxicity
gum hypertrophy
ataxia
nystagmus
peripheral neuropathy
teratogenicity
122
features of gentamicin toxicity
ototoxicity
nephrotoxicity
123
features of vancomycin toxicity
ototoxicity
nephrotoxicity
124
when is gentamicin levels checked
6-14 hours after the last gentamicin infusion was started
125
which nomograms should you use for which dose of gent treatment
* 7mg/kg dose: hartford nomogram
* 5mg/kg dose: urban and craig monogram
126
how should you act when checking gent levels
* if point falls in q24hr area then continue at the same dosing interval
* if point falls in the q36hr area then change to 36hr dosing
* if the point falls in the q48hr area then change to 48hr dosing
* if the point rests above the q48hr area then repeat the gentamicin level and only re-dose when the concentration is \<1mg/L
127
how to manage a patient who is over anticoagulated on warfarin depending on their INR and whether they are bleeding
128
why do ace inhibitors cause renal failure
* efferent vessels leaving the kidney rely on angiotensin II to constrict
* this increases blood pressure in the kidney to a sufficient level for glomerulofiltration
* therefore ACE inhibitors reduce pressure in the kidney and cause renal damage and renal failure
remember, the effect of this will be more in patients who have RAS or who are taking NSAIDs (except aspirin) which can constrict the renal artery
129
when the INR is above the target range but below 6, how should you act
reduce dose of warfarin
130
what is the most common regimen for neutropenic sepsis
combination of piperacillin, tazobactam and gentamicin
131
common side effects of carbamazepine
neurological effects
GI upset
oedema
hyponatraemia due to an antidiuretic hormone like effect
132
how does digoxin work
increases vagal tone
thereby reduces heart rate
also increases contractile force by acting directly on the myocytes
133
when addisonian patients become sick what should they do
increase their intake of steroids to provide adequate cortisol for the stress response
134
main thing in acute heart failure with pleural and peripheral oedema
furosemide is the mainstay of treatment of oedema in heart failure
in the acute setting it should be IV
135
main thing in acute heart failure with pleural and peripheral oedema
furosemide is the mainstay of treatment of oedema in heart failure
in the acute setting it should be IV
136
fill this in with the management steps
137
draw out the treatment algorithm for adult tachycardia with pulse
138
management of anaphylaxis
* ABC and O2 (15L) by non-rebreather mask (unless COPD)
* remove cause asap
* give adrenaline 500 micrograms of 1:1000
* if no response after 5 minutes
* repeat dose of IM adrenaline
* give fluid bolus
* if persisting wheeze give asthma treatment
* if no response despite two rounds of IM adrenaline it's considered refractory anaphylaxis and early critical care support should be sought
* after stabilisation consider cetirizine or chlorphenamine
139
fill in this table with the different features of the different severities of asthma
140
6 steps in the management of acute asthma
1. ABC
2. 100% oxygen by non-rebreather mask
3. salbutamol NEB
4. hydrocortisone IV (if severe/life threatening) and prednisolone oral (for all cases of acute asthma)
5. ipratropium 500micrograms NEB
6. aminophylline or magnesium sulphate in those with severe or if there has not been a good initial response to bronchodilator therapy (only under senior guidance)
141
what is the treatment for pneumothorax
* if secondary then they always need treatment
* chest drain if \>2cm or pt SOB or \>50yo
* otherwise aspirate
* if tension pneumothorax
* needle or cannula into 2nd intercostal space in the mid clavicular line on affected side
* if primary
* if \>2cm on CXR or SOB then aspirate
* if unsuccessful aspirate again
* if still unsuccessful then chest drain
* if \<2cm and not SOB then discharge with outpatient follow up in 4 wks
142
how to assess severity of pneumonia and how that affects treatment
* CURB65
* Confusion (AMT\<8/10)
* urea \>7.5
* Resp rate \>30
* Blood pressure systolic \<90
* Age \>65
none or one of these things then they can be managed at home
two or more they need to be admitted
more than 3 and ITU admission should be considered
143
CAP treatment
**Low severity**
* ***Oral** first line*:
* [Amoxicillin](https://bnf.nice.org.uk/drug/amoxicillin.html).
* Alternative in penicillin allergy or amoxicillin unsuitable (e.g. atypical pathogens suspected): [clarithromycin](https://bnf.nice.org.uk/drug/clarithromycin.html), [doxycycline](https://bnf.nice.org.uk/drug/doxycycline.html), or [erythromycin](https://bnf.nice.org.uk/drug/erythromycin.html) (in pregnancy).
**Moderate severity**
* ***Oral** first line*:
* [Amoxicillin](https://bnf.nice.org.uk/drug/amoxicillin.html).
* If atypical pathogens suspected: [amoxicillin](https://bnf.nice.org.uk/drug/amoxicillin.html) **with** [clarithromycin](https://bnf.nice.org.uk/drug/clarithromycin.html) **or** [erythromycin](https://bnf.nice.org.uk/drug/erythromycin.html) (in pregnancy).
* Alternative in penicillin allergy: [clarithromycin](https://bnf.nice.org.uk/drug/clarithromycin.html), or [doxycycline](https://bnf.nice.org.uk/drug/doxycycline.html).
**High severity**
* ***Oral** or **Intravenous** first line*:
* [Co-amoxiclav](https://bnf.nice.org.uk/drug/co-amoxiclav.html)**with** [clarithromycin](https://bnf.nice.org.uk/drug/clarithromycin.html) **or** oral [erythromycin](https://bnf.nice.org.uk/drug/erythromycin.html) (in pregnancy).
* Alternative in penicillin allergy: [levofloxacin](https://bnf.nice.org.uk/drug/levofloxacin.html) (consult local microbiologist if fluoroquinolone not appropriate).
144
what is the benzo antidote
flumazenil
145
treatment for myoclonic seizures
valproate in men
levetiracetam in women
146
treatment for tonic seizures
valproate for men
lamotrigine for women
147
for focal seizures treat with
carbamazepine or lamotrigine
148
for absence seizures treat with
ethosuximide or valproate
149
what do you treat with for generalised tonic clonic seizures
valproate or lamotrigine
150
what side effects does lamotrigine have
rash
rarely: stevens johnson syndrome
151
what side effects does carbamazepine have
rash
dysarthria
ataxia
nystagmus
hyponatraemia
152
what side effects does phenytoin have
ataxia
peripheral neuropathy
gum hyperplasia
hepatotoxicity
152
what side effects does phenytoin have
ataxia
peripheral neuropathy
gum hyperplasia
hepatotoxicity
153
what side effects does sodium valproate have
tremor
teratogenicity
weight gain
154
what side effects does levetiracetam have
fatigue
mood disorders
agitation
155
what is azathioprine used to treat and what is a special consideration in some people
crohns
10% of the population have low reserves of the enzyme that break it down so get abnormal accumulation when it is given in normal doses
this enzyme is called TPMT
check TPMT levels before starting treatment
if levels are deficient/absent then use methotrexate instead
if levels are low (but not deficient) then start azathioprine at a low dose
156
never give a laxative if there is
evidence of obstruction
157
in the acute setting furosemide should be given by which route?
IV not oral
158
what are anti-muscarinic side effects
* dry mouth with difficulty swallowing and thirst
* dilation of the pupils with difficulty accommodating and sensitivity to light - i.e. blurred vision
* increased intraocular pressure
* hot and flushed skin
* dry skin
* bradycardia followed by tachycardia, palpitations and arrhythmias
* difficulty with micturition - urinary retention
* constipation
159
carbimazole and carbemazepine both cause \_\_\_\_
neutropenia
160
name two drugs that can precipitate parkinsonian symptoms even in patients that don't have parkinson's
metoclopramide and haloperidol
they do this because they're dopamine antagonists
161
IV or sublingual GTN
if patient's pain doesn't subside with sublingual GTN then you can try IV but IV is never used as first line
this is because sublingual normally works just as well, is cheaper and does not require the intensive monitoring that iV does
162
considerations for contraception if patients are taking enzyme inducing drugs
parenteral administration is preferred
163
ramapril and pregnancy
ACE inhibitors are teratogenic and if a patient is already taking ramipril they should be converted to labetalol
164
which diabetes drug is associated with lactic acidosis
metformin
165
what time of day should sulfonylureas be taken and why
in the morning because of their risk of hypos
if taken at night there's increased risk of nocturnal hypos
166
hallucination, increased temperature and agitation on citalopram
serotonin syndrome - life threatening complication of SSRIs and they should go to hospital immediately
167
a 1% solution is equal to what
1g in 100ml
168
what time of day should you give an ace inhibitor and why
at night since they can cause postural hypotension
169
what time of day should you give an ace inhibitor and why
at night since they can cause postural hypotension
170
insulin prescription in hyperkalaemia
* 10 units of short acting insulin
* (actrapid or novorapid)
* in 100ml of 20% dextrose
* over 30 minutes IV
171
which antiepileptic drug has best safety profile in pregnancy
lamotrigine
172
which antiepileptic should you not give in hyponatraemia
carbemazepine because it can cause an SIADH and may drop the sodium further
173
which diabetes drug for if they're overweight or underweight
normal or underweight → sulphonylureas
if overweight → metformin
174
do not use metformin in patients with a creatinine above what
150mmol/L
175
what are the two classic side effects of vancomycin and gentomicin
nephrotoxicity and ototoxicity
176
what blood tests should you do before starting a statin
* full lipid profile
* liver enzymes
* if more than 3 times normal then exclude from statin therapy
* repeat at 3 and 12 months of treatment
* creatinine kinase if thought to be at high risk of
* FH of muscular disorders
* personal history of muscular toxicity
* high alcohol intake
* renal impairment
* hypothyroidism
* elderly
177
when is the recommended sampling time for lithium
12 hours after the last dose
178
toxic effects are likely to manifest with lithium at what level
above 1.4mmol/L
179
what are the classic side effects of ace inhibitors
hypotension
electrolyte abnormalities (hyperkalaemia and hyponatraemia)
AKI
dry cough
180
side effects of B blockers
hypotension
bradycardia
wheeze in asthmatics
worsens acute heart failure (but helps chronic)
181
what are the classic side effects of calcium channel blockers
hypotension
bradycardia
peripheral oedema
flushing
182
what are the classic side effects of heparin
haemorrhage (especially if renal failure or \<50kg)
heparin induced thrombocytopenia
183
what are the classic side effects of warfarin
haemorrhage
note that it also has a pro-thrombotic effect in the few days that it takes to start working that's why it needs to be bridged with heparin until INR exceeds 2
184
side effects of digoxin
nausea
vomiting
diarrhoea
blurred vision
confusion
drowsiness
affected by potassium
185
how does potassium affect digoxin
digoxin acts on the Na/K ATPase in the myocyte wall to slow heart rate
therefore changes in serum K levels change the effect of digoxin
low potassium increases digoxin effect
high potassium limits digoxin effect
186
side effects of amiodarone
* interstitial lung disease (pulmonary fibrosis)
* thyroid disease (both hypo and hyper)
* it's structurally related to iodine hence amIODarone
* skin greying
* corneal deposits
187
haloperidol side effects
dyskinesias
drowsiness
188
clozapine side effects
agranulocytosis
189
NSAID side effects
* NSAID
* no urine (renal failure)
* systolic dysfunction
* asthma
* indigestion
* dyscrasia
190
rate statins in order or their risk of myalgias
simvastatin \> atorvastatin \> pravastatin \> fluvastatin
191
what are the classic side effects of statins
myalgia
abdo pain
increased AST/ALT (can be mild)
rhabdomyolysis
192
management of statin induced myalgia
* exclude rhabdo with CK level and urine dip
* otherwise if symptoms are unacceptable or CK very high (\>2000)
* ensure needs statin
* reduce dose
* change to different statin with lower risk of myalgia
193
if low gcs and diabetic what drug side effect should you think of
lactic acidosis from metformin
194
name some enzyme inhibitors
* **AODEVICES**
* Allopurinol
* Omeprazole
* Disulfiram
* Erythromycin
* Valproate
* Isoniazid
* Ciprofloxacin
* Ethanol (acute intoxication)
* Sulphonamides
* also
* grapefruit juice
* ketoconazole
195
name some enzyme inducers
* **PC BRAS**
* Phenytoin
* Carbamazepine
* Barbiturates
* Rifampicin
* Alcohol (chronic)
* Sulphonylureas
196
which antibiotic must not be given to people taking methotrexate and why
trimethoprim
both are folate antagonists
taken together they can lead to bone marrow suppression, pancytopenia and neutropenic sepsis
197
why does metformin cause lactic acidosis
because it acts on the liver to stop gluconeogenesis in order to control hyerglycaemia
lactate is usually taken up in gluconeogenesis and therefore lactate can build up in patients taking metformin
therefore metformin can cause a lactic acidosis
198
why do sulphonylureas cause hypoglycaemia
give some examples of sulphonylureas
they act on the pancreas to increase release of insulin
therefore they increase insulin levels and can cause hypoglycaemia
e.g. gliclazide, glipizide, tolbutamide
199
all heparins can contribute to what electrolyte abnormality
hyperkalaemia due to the inhibition of aldosterone synthesis
200
are antiplatelet treatments usually stopped before surgery?
yes they are usually stopped one week before surgery
201
SSRIs can cause which electrolyte imbalance and why
hyponatraemia due to inappropriate ADH secretion
202
what should you do about INR on the day before surgery
if more than 1.5 on the day before surgery then give phytomenadione (vitamin K) 1-5mg PO using the IV preparation
203
when is the POP effective after an enzyme inducer
progesterone only preparations have their efficacy reduced by enzyme inducing drugs such as topiramate or erythromycin
therefore an alternative method of contraception should be used during treatment and for 4 weeks afterwards
204
what blood change is expected after starting an ace inhibitor
a small rise in creatinine \<20% is expected after starting an ace inhibitor and does not require investigation or a change in prescription
just repeat U&Es in a week
205
three drugs that can reduce lithium excretion
* ACE inhibitors
* diuretics
* particularly thiazides
* if a diuretic must be used then loop diuretics are safest
* NSAIDs
206
why should candesartan be suspended in AKI
because, in a similar way to how ACE inhibitors are nephrotoxic, ARBs are nephrotoxic
207
can you use trimethoprim in folate deficiency
yes for a short course and with caution
208
why must you not stop steroids suddenly
because if on long term systemic steroid therapy they may have developed adrenal insufficiency
209
should men use contraception while taking methotrexate?
yes and for 6 months afterwards
210
which electrolyte is most likely to be artefactally abnormal
K+
211
if there's severe hyperkalaemia but none of the DREAD features (apart from artefact) are present then what should you do
give calcium gluconate AND recheck the biochemistry
212
Metformin in renal impairment
* contraindicated if eGFR \<30
* give short acting sulphonylyurea such as gliclazide instead
* caution if eGFR \<45
213
angio-oedema related to the build up of bradykinin can occur months after initiation of treatment with which class of drugs:
ACE INHIBITORS
214
Why must statins not be used in liver disease
the liver disease could affect its metabolism
215
what time of day are statins taken
at night since that's when most cholesterol metabolism takes place
215
what time of day are statins taken
at night since that's when most cholesterol metabolism takes place
216
name a dietary restriction with statins
grapefruit - it's an enzyme inhibitor and therefore increases statin toxicity
217
what should you do with your statin dose if you need to take an enzyme inhibitor such as clarithromycin
stop the statin because enzyme inhibitors increase toxicity and side effects of statins
218
methotrexate monitoring
* blood tests every 1-2 weeks until stabilised
* then every 2-3 months
* to monitor:
* FBC
* LFT
* U&E
be advised to report symptoms of infection particularly sore throat
219
during an episode of sickness what should happen to steroid dose
it should be doubled (sick day rules)
220
if someone can't take their oral pred due to being too nauseous what should you do?
* they still need steroid therapy since they may have adrenal insufficiency
* us the glucocorticoid therapy section to convert it to IM hydrocortisone
221
a 1% solution contains how many grams in 100ml
1G IN 100ML IS A 1% SOLUTION
222
how to choose between tramadol and codeine
* based on side effects
* both have typical opioid side effects
* tramadol more likely to cause agitation/hallucinations particularly in the elderly
* cocodamol more likely to cause constipation
* so if they have diarrhoea then this is a good shout
223
what time of day should laxatives be taken
night
224
what laxative is stool is soft
not osmotics - try a stimulant such as senna or bisocodyl
225
how long can consolidation take to clear on a chest x ray
6 weeks
226
when should tacrolimus levels be measured
at their trough so just before the morning dose
