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ESSENTIAL Management Flashcards

(23 cards)

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1
Q

Chronic Asthma management

A
  1. SABA
  2. +Low Dose Inhaled Steroid (200ug 2/d, <12:100ug)
  3. +LABA
    +Increase Inhaled Steroid
  4. +Leukotrience antagonist
    OR Theophylines
    +Increase Inhaled Steroid
  5. Oral steroids (consider immunosuppressants?) (RESP physician)
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2
Q

Acute asthma attack management

A

1. Quick investigations

  • PEF
  • Oximetry
  • SpO2 <92% or Life threatening ⇒ ABG

Moderate (likely GP)

  1. Oxygen high-flow (Sp94-98%, 6-8L or 40-60% flow rate)
  2. SABA via large-volume spacer
    • Adult 4 then 2 every 2m
    • Child 2 then 2 every 2m
    • Repeat every 15m depending on responce
  3. Prednisolone tablet 40mg (max 60mg) for 5d
  • Follow up next day/ sooner + 1wk
  • Worsening ⇒ Admit + Severe

Severe

  1. Oxygen high-flow (SpO2 94-98%, 6-8L or 40-60% flow rate)
  2. Salbutamol 5mg + Ipratropium 500ug via Oxygen-driven nebuliser 6-8L/min Oxygen
  3. Prednisolone tablet 40mg (max 60mg)
    OR Hydrocortisone (preferably Sodium Succinate) 100mg slow IV bolus

No improvement 15-30min

  • Salbutamol Neb 5mg every 15-30min
  • Ipratropium 500ug 4hrly

Still no improvement ⇒ Life threatening

Life-threatening

  • Magnesium Sulphate 2g
    + 50ml NaCL 0.9% IV infusion/ 20min
    • 2nd dose discuss with consultant respiratory physician
  • Speak to Critical Care Unit (CCU) + transfer if continued deterioration
    • Transfer to CCU: Doctor accompanying prepared to intubate (anaesthetist)

Further investigations

  • Chest XR (if not responding; exclude pneumothorax/ consolidation)
  • U+Es (green top for accurate K+)
  • FBC
  • Theophyllines - therapeutic levels 10-20mg/L

Subsequent

  • Admit to respiratory ward
  • Correct fluid & electrolytes (especially K+)
  • Maintain Sp02 >94%
  • Nebulised Salbutamol 2.5mg + Ipratropium 250ug 6hrly
  • Prenisolone daily dose
    OR Hydrocortisone 6hrly
  • Continue regular inhaled/ oral Preventer Medications

Pre-Discharge

  • Sort discharge medications
  • Check inhaler technique

Discharge + Follow-up

  • Discuss reason for exacerbation
  • Send GP details (inc potential best PEF)
  • GP Follow-up within 2d
  • Oral Steroids for 5d or until improved
  • Inhaled steroid added to regular meds
  • Ensure PEF meter (prescribable) and advise to record morning + evening before inhalers
  • Written Personal Asthma Action Plan
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3
Q

Chronic COPD management

A

COPPPD-abct

  • Cessation smoking, exercise etc
  • O2 LTOT [3]
  • Pulmonary function tests
  • *P**neumococcal polysacharide + annual influenza vaccine
  • *P**ulmonary rehab

Drugs (abct)

  • Antimuscarinic 1. SAMA (Ipratropium) OR
  • *B2 agonist** 1. SABA (Salbutamol)
  • 2. LAMA (Tiotropium) OR
  • *2.** LABA (Salmeterol) (ONLY FEV1>50%)
  • 3. Corticosteroid Inhaled + LABA OR
  • *3. LAMA + LABA**
  • 4. Theophylline

Mucolytics: Chronic productive cough

Cor pulmonale: Loop Diuretics, LTOT

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4
Q

Acute COPD exacerbating management

A
  • Oxygen SpO2 88-92%
    CI >24% O2 must NOT be given unless ABG confirm no CO2 retention
  • Doxycyline 200mg PO (d1) ⇒ 100mg/d thereafter
    Cant swallow: Co-Amoxiclav 1.2g IV 8hryl
    +Penicillin allergic: Clarithromycin 500mg IV by infusion into larger proximal vein 12hrly [CI with Simvastatin]

Bronchodilators

  • Salbutamol 2.5mg or Terbutaline 5mg via air-driven nebuliser 4-6hrly
  • ⇒ Ipratropium bromide 500ug via nebuliser 6hrly
  • 4hr no improvement ⇒ Aminophylline infusion

Corticosteroids

  • Prednisolone 30mg PO daily (or increase maintanence by 30mg)
  • Hydrocortisone 100mg slow IV bolus 6hrly

Sputum ⇒ Physiotherapy

Monitoring

  • PEF
  • ABG
  • Sputum volume + conversion to purulent to mucoid
  • Subjective dyspnoea
  • Objective exercise tolerance

Subsequent Management

  • Admit to ward
  • Improving after 48hr
    • Continue ABx until sputum mucoid
    • Prednisolone same dose 7-14d then return to normal
    • PaO2 >7.3kPa or SpO2 >92% stop oxygen but monitor
    • Review mediations, inhaler technique, smoking cessation
    • Advise GP to arrange influenza vaccination
  • Not improving
    • Consider resistant organism
    • Consider underlying disease
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5
Q

Respiratory Failure types + causes

A

Type 1 = Low PaO2, normal PaCO2

  • Asthma, pneumonia, pneumothorax, PE, oedema, fibrosis

Type 2 = Low PaO2, low PaCO2

  • COPD exacerbation, neruomuscular/ dystrophy, encephalitis, respiratory depressants
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6
Q

Resp Failure management

A

Type 1

  • Oxygen via nasal cannulae 2-6L/min (SpO2 94-98)
    or Simple Face Mask 5-10L/min or 24-60% Venturi mask
  • SpO2 <85% Reservoir mask 10-15L/min

Type 2

  • 24-28% Venturi mask (SpO2 88-92%)
    Aim for lowest dose Venturi mast possible
  • pH <7.35 (resp acidosis) ⇒ NIV (senior help)
  • pH <7.25 ⇒ IV

Treatment for specific conditions

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7
Q

VTW treatment

A
  1. LMWH/ Fondaparinux for 5d+ AND INR >2.0 for 24hr
    2, within 24hr start WARFARIN
    -Provoked 3month
    -Unprovoked 6months

CANCER
- LMWH 6months + compression stocking 2yrs

Unprovoked = screen for cancer
-exam, CXR, FBC, Ca2+, LFTs, urinalysis
+/- >40yr CTCAP/ mammography

USS review in 1 week

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8
Q

VTW inestigation

A

Two level Wells score
2+ = USS <4hrs, negative do D-Dimer
Cant do USS <4hr, do D-Dimer + LMWH treatment

0 or 1 = D-Dimer, positive USS <4hrs
Cant do USS <4hr, LMWH/ treatment

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9
Q

Exacerbation of chronic bronchitis

A

C larithromycin

A moxicillin

T etracycline

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10
Q

Uncomplicated CAP

A

Amoxicillin

PENAL: Doxycycline or Clarithromycin

Staph suspected (post flu): Flucloxacillin

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11
Q

Pneumonia possibly Atypical

A

Clarithromycin

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12
Q

HAP

A
  • Co-amoxiclav
  • Cefuroxime

>5d

  • Piperacillin with Tazobactam
  • Cephalosporin broad (eg Ceftazidime)
  • Quinilone (eg Ciprofloxacin)
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13
Q

Lower UTI

A

Trimethoprim

Nitrofurantoin

Alternative:

  • Amoxicillin
  • Cephalosporin
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14
Q

Acute pyelonephritis

A
  • *Cephalosporin** broad
  • *Quinolone**
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15
Q

H Pylori

A

7d

  1. PPI
  2. Amoxicillin 1mg
  3. Clarithromycin 500mg OR Metronidazole 400mg
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16
Q

C. difficile

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A

All 10-14d, stop at 10d if asym. Fails move up.

  • Nurse in side room until 72hr symptom free

Mild-mod

  • Metronidazole 400mg PO 8hrly 10-14d

Severe [WCC>15,Cr>50%,temp>38.5,COLITIS]

  • Vancomycin 125mg PO 6hrly

Lifethreatening [hypotension, ilius/ megacolon, severe on CT]

  • Vancomycin 500mg PO 6hrly
    + Metronidazole 500mg IV infusion 8hrly
17
Q

MRSA

  • What is it
  • Screening protocol
  • Management
Study These Flashcards
A

What

  • Methicillin-Resistant Staphylococcus Aureus (MRSA)
  • Resistant to Penicillins + Cephalosporins

MRSA screen 2-4wks prior admission in ALL;

  • + MSSA (Full Staph) screen: Implant/ high risk surgery
  • Swabs
    • Anterior nares (nasal)
    • Any skin lesion
    • Catheterised: CSU (Catheter Specimen of Urine)
    • Productive cough: Sputum
    • Staph screen/ patient tagged: Perineum swab

Blind management

  • >65yrs+transferred from carehome/hospital
  • MRSA Hx in past 6months

Management min 5days and rescreen d7

  • Single room
  • Nasal: Mupirocin 2% 8hrly
  • Skin: Chlorhexidine 0.1% + Neomycin 0.5%
  • Wash body daily
  • Infection
    • Vancomycin, Teicoplanin, Linezolid

ESBL, MGNB, CARB screen

  • ALL patient (unless hasnt been in hospital/ abroad for 1yr)
  • Rectal swab (stoma/ unable: stool sample)
  • Catheter: CSU
  • Management: Microbiologist

ESBL: Extended Spectrum Beta-Lactamase-producing Bacilli

MGNB: Multi-resistant Gram-Negative Bacilli

CARB: Carbapenemase-producing Gram-negative Bacilli

18
Q

Dehydration vs Shock
Paediatrics

Study These Flashcards
A

Dehydration vs Shock

  • I Increased RR
  • S Sinus tachy
  • H Hypotension
    • ​Normotensive
  • O Oligouria
  • C Cold extremities
    • ​Warm extremities
  • K Klammy. Mottled + Pale skin
    • Reduced turgot
    • Colour unchanged
    • Dry mucus membranes
    • Sunken eyes
  • S Slow capillary refill + Weak pulses
    • Normal cap refill
  • + Confusion/ Coma
    • Altered responsiveness (irritable) + Unwell
  • + Cyanosis
  • + Acidosis
19
Q

Immediate treatment
No clinical dehydration

Study These Flashcards
A
  • Continue breastfeeding/ milk
  • Encourage fluid intake
  • NO fruit juices/ carbonated drinks
  • Low osmolarity ORS
20
Q

Immediate treatment

Clinical dehydration (including hypernatraemia)

Study These Flashcards
A
  • 50ml/kg low osmolarity ORS /4hrs
    + ORS for maintanence, often and small
    • Supplement with milk/water
    • Continue breastfeeding
    • Cant take: NG tube
  • Monitor regularly
  • Deterioration/ red flags/ keeps vomiting
    • Intravenous Therapy for rehydration
21
Q

Immediate treatment

Shock signs

Study These Flashcards
A
  • Rapid IV infusion 20ml/kg 0.9% Sodium Chloride solution
    • Still shocked: Repeat
      • Still shocked: Paed Intensive Care Specialised
22
Q

Intavenous rehydration calculations

Maintanence + Deficit

Study These Flashcards
A

Maintanence /24hr

  • 100ml/kg (first 10kg)
  • 50ml/kg (second 10kg)
  • 20ml/kg (thereafter)

Deficit /24hr (48hr if hyPER-nataemic)

  • 50ml/kg (dehydrated/ 5%)
  • 100ml/kg (shoked/ 10%)

Sodium cant change more than 1mmol/L /HOUR

Ideally 0.5mmol/L /hour

23
Q

Signs of hypernatraemia

Study These Flashcards
A
  • Nausea, Vomiting
  • Headache, Irritability
  • Altered consciousness, Seizure
  • Apnoea
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