drugs for take a practical guide to prescribing on day 1! dr. liz gamble
TRANSCRIPT
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DRUGS FOR TAKE
A Practical Guide to Prescribing on Day 1!
Dr. Liz Gamble
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OBJECTIVES
• Identify sections of the drug chart
• Prescribing abbreviations
• When not to prescribe
• Use of the BNF
• Use of hospital protocols
• Prescribe common / emergency Rx
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THE DRUG CHART
• FRONT– Patient details– Allergies– Once only medication– Drug doses omitted
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THE DRUG CHART
• MIDDLE– Regular medication
• BACK– As required medication
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ABBREVIATIONS
• Route of administration
• Timing
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How not to prescribe…..
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WHEN NOT TO PRESCRIBE
• Prescribing is not the answer
• You need to do something else first
• You could do more harm than good
• You feel it is not appropriate
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USE THE BNF & HOSPITAL PROTOCOLS
• Useful things in the BNF
• Hospital protocols
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Oxygen; general principles
• Aims to relieve hypoxia & maintain or restore a normal PaCO2
• Deliver a defined percentage according to patients needs
• Hudson mask or nasal cannulae give very variable FiO2
• Nasal cannulae become less efficient at flow rates > 3l/min
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Hudson mask: variable performance
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Nasal cannulae
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Oxygen delivery devices
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Venturi devices: fixed performance
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Monitoring oxygen therapy
• Use oximetry +/- arterial blood gases
• SaO2 of 93% is approximately equivalent to a PaO2 of 8kPa, below a SaO2 of 92% PaO2 falls rapidly
• Oximetry gives no information about PaCO2 or pH
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General rules
• Correct hypoxia with an appropriate delivery device
• Check ABGs if SaO2 <93% or suspicion of ventilatory impairment or acidosis
• Some patients (esp. COPD) with chronic hypoxia rely on hypoxic drive and will hypoventilate on high flow O2
• If hypoxia suddenly occurs check cylinder, tubing etc.
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Acute Severe Asthma
• Priorities– Treat hypoxia– Treat bronchospasm & inflammation– Assess need for intensive care– Treat any underlying cause e.g. infection,
pneumothorax
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Acute Severe Asthma: therapy
• Sit the patient up• High flow oxygen• Nebulized beta 2 agonists: salbutamol
5mg every 15-30 min if required• Add ipratropium bromide 500mcg 4-
6hrly if initial response poor• Steroids: hydrocortisone 200mg IV• Antibiotics if evidence of infection
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Severe asthma: iv bronchodilators
• Magnesium sulphate: 1.2-2g iv over 20 mins
• Salbutamol: 5-20 mcg/min infusion
• Aminophylline: loading dose 250 mg iv over 20 mins, then 0.5-0.7mg/kg/hr infusion
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Indications for ITU admission
• Hypoxia: PaO2 <8kPa despite FiO2 of 60%
• Rising PaCO2 or PaCO2 >6
• Exhaustion, drowsiness or coma
• Respiratory arrest
• Failure to improve despite adequate therapy
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Sepsis
• Body’s response to an infection• Infection is the invasion of the body by
microorganisms – can be local or widespread• Worldwide 1400 people die every day from
sepsis – projected to grow by 1.5% per year• Three forms of sepsis: uncomplicated sepsis
severe spesis
septic shock
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Sepsis
• Severe sepsis – sepsis with failure of one or more of the vital organs.
• Mortality from severe sepsis 30-50%• Septic shock – sepsis with hypotension that
does not respond to fluid administration• Mortality from septic shock 50-60%• Majority of sources of infection in severe
sepsis/shock are pneumonia and intraabdominal
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Surviving Sepsis Campaign
• In 2004 an international group of critical care and infectious disease physicians developed guidelines for the management of severe sepsis and septic shock
• Society of Critical Care Medicine, European Society of Intensive Care, International Sepsis Forum
• Introduction of the sepsis care bundle
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Care Bundle
• A group of interventions related to a disease process that result in better outcomes when executed together rather than individually
• 2 bundles – sepsis resuscitation bundle (6h)
sepsis management bundle (24h)
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Sepsis Resuscitation Bundle
1) Measure serum lactate2) Obtain blood culture prior to antibiotics3) Broadspectrum antibiotics within 3h of
presentation4) In the event of hypotension or lactate > 4
mmol/La) Deliver an initial minimum of 20ml/kg of
crystalloidb) Apply vasopressors for hypotension not responding
to initial fluid resuscitation to maintain MAP > 65 mm Hg
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Sepsis resuscitation bundle
5) In the event of persistent hypotension despite fluid resuscitation (septic shock) or lactate > 4 mmol/L
a) Achieve CVP > 8 mm Hg
b) Achieve central venous oxygen saturation (ScvO2)> 70%
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What can we do in MAU?
• Make prompt diagnosis• Measure lactate• Blood cultures• Antibiotics within 3 hours• Fluid challenge• ITU review early• Central line, try to get CVP>8mm Hg• Glucose control
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Community acquired pneumonia
• Non-severe: amoxycillin 500mg tds + clarithromycin 500mg bd. Penicillin allergic: moxifloxacin 400mg bd
• Severe: Co-amoxiclav 1.2g iv tds + clarithromycin 500mg bd. Penicillin allergic: levofloxacin 500mg iv bd
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Acute alcohol withdrawal
• Symptoms: anxiety, tremor, hyperactivity, sweating, nausea, tachycardia, hypertension, mild pyrexia.
• Seizures may occur• Delirium tremens (untreated mortality 15%):
course tremor, agitation, confusion, delusion, hallucinations
• Look for hypoglycaemia, Wernicke-Korsakoff, subdural haematoma, hepatic encephalopathy
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General Management
• Rehydrate (avoid saline in liver disease)
• IV pabrinex 2 pairs 8hourly
• Oral therapy: thiamine 100mg bd, vit B co strong 2 tabs tds, vit C 50mg bd
• Monitor glucose
• Check phosphate; give iv if <0.6mM
• Exclude infection
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Sedation
• Chlordiazepoxide 30mg qds for 2 days– Then 20mg daily (divided doses) for 2 days– Then 10mg daily (divided doses) for 2 days– Then 5mg daily for 2 days
– For fits lorazepam 1-2mg iv
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Acute coronary syndrome
• Symptoms resulting from myocardial ischaemia
• STEMI / NSTEMI / unstable angina
• Need continuous ECG monitoring and defibrillation facilities
• IV access
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General measures
• Aspirin 300mg stat
• Oxygen
• Diamorphine 2.5-10mg prn
• Metaclopramide 10mg iv
• GTN spray 2 puffs sl (unless low bp)
• FBC, U&Es, glucose, lipids, TnI
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Other measures
• Patients with STEMI: urgent reperfusion (thrombolysis or PCI)
• Patients with NSTEMI: clopidogrel 300mg stat then 75mg od, enoxaparin 1mg/kg bd
• Cardiology input• Correct K+• Treat arrhythmias, cardiac failure
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TACKLING PAIN
• Regular analgesia
• Regular paracetamol
• Regular co-codamol 30:500
• NSAIDS
• Morphine
• Other pains
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SIMPLE REMEDIES FOR MINOR PROBLEMS
• Nausea
• Constipation
• Cough
• Indigestion
• Leg cramps
• Insomnia
• Agitation
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JUGGLING BLOOD SUGARS
• Highs and lows
• Type 1 or Type 2?
• Adjusting insulin doses
• Sliding scales
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SCARY SITUATIONS
• What if you get there first?
• Additional management
• OSCEs
• Doses
• IV or IM?
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SCARY SITUATIONS
• Respiratory depression & pinpoint pupils• Severe heart failure• Myocardial infarction• Severe asthma• Hypoglycaemia• Possible meningococcal disease• Anaphylactic shock• Status epilepticus
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SUMMARY
• The drug chart
• Prescribing abbreviations
• When not to prescribe
• The BNF
• Hospital protocols
• Simple remedies for minor problems
• Common emergencies