Transcript drugs for take - eis.bris.ac.uk

DRUGS FOR TAKE
A Practical Guide to Prescribing
on Day 1!
Dr. Liz Gamble
OBJECTIVES
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Identify sections of the drug chart
Prescribing abbreviations
When not to prescribe
Use of the BNF
Use of hospital protocols
Prescribe common / emergency Rx
THE DRUG CHART
• FRONT
– Patient details
– Allergies
– Once only medication
– Drug doses omitted
THE DRUG CHART
• MIDDLE
– Regular medication
• BACK
– As required medication
ABBREVIATIONS
• Route of administration
• Timing
How not to prescribe…..
WHEN NOT TO PRESCRIBE
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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
USE THE BNF &
HOSPITAL PROTOCOLS
• Useful things in the BNF
• Hospital protocols
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
Hudson mask:
variable performance
Nasal cannulae
Oxygen delivery devices
Venturi devices:
fixed performance
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
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.
Acute Severe Asthma
• Priorities
– Treat hypoxia
– Treat bronchospasm & inflammation
– Assess need for intensive care
– Treat any underlying cause e.g. infection,
pneumothorax
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 46hrly if initial response poor
• Steroids: hydrocortisone 200mg IV
• Antibiotics if evidence of infection
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
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
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
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
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
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)
Sepsis Resuscitation Bundle
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Measure serum lactate
Obtain blood culture prior to antibiotics
Broadspectrum antibiotics within 3h of
presentation
In the event of hypotension or lactate > 4
mmol/L
Deliver an initial minimum of 20ml/kg of
crystalloid
Apply vasopressors for hypotension not responding
to initial fluid resuscitation to maintain MAP > 65
mm Hg
Sepsis resuscitation bundle
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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%
What can we do in MAU?
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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
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
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
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
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
Acute coronary syndrome
• Symptoms resulting from myocardial
ischaemia
• STEMI / NSTEMI / unstable angina
• Need continuous ECG monitoring and
defibrillation facilities
• IV access
General measures
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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
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
TACKLING PAIN
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Regular analgesia
Regular paracetamol
Regular co-codamol 30:500
NSAIDS
Morphine
Other pains
SIMPLE REMEDIES FOR
MINOR PROBLEMS
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Nausea
Constipation
Cough
Indigestion
Leg cramps
Insomnia
Agitation
JUGGLING BLOOD SUGARS
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Highs and lows
Type 1 or Type 2?
Adjusting insulin doses
Sliding scales
SCARY SITUATIONS
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What if you get there first?
Additional management
OSCEs
Doses
IV or IM?
SCARY SITUATIONS
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Respiratory depression & pinpoint pupils
Severe heart failure
Myocardial infarction
Severe asthma
Hypoglycaemia
Possible meningococcal disease
Anaphylactic shock
Status epilepticus
SUMMARY
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The drug chart
Prescribing abbreviations
When not to prescribe
The BNF
Hospital protocols
Simple remedies for minor problems
Common emergencies