[02/12 18:38] Luqme: MetabolicHypokalemia (K+ <2.5) - ecg stat to look for hypokalaemic changes - 1g kcl in 100cc NS in 1 hour or 2g kcl in 200cc NS over 2hour (according to K+ level) with continous cardiac monitoring - add kcl in drip if any, mist kcl 15mls tds/t slow k 600mg/1.2g od - off k supplements once k >4 - rp 1 hour post correction - rp cm Hyperkalemia (>5.5) - ecg stat to look for hyperkalsrmic changes - off k supplements - 10cc of 10% calcium gluconate in 10 minutes with cardiac monitoring + 50cc d50% glucose + 10 unit actrapid - t kalimate 5-10g tds - off kalimate once k <5 - rp 1 hour post chase - rp cm Hypoglycemia (reflo <4) - omit insulin - encourage pt take orally (sweets,bread with jem) - if too low (<3) with symptoms, give 20-50cc d50% then repeat reflo 30mins - if reflo 4-6, half the dose of next insulin Hyperglycemia (>20) - give iv 6-10 unit actrapid stat if pt already received insulin. If havent received yet, to serve insulin - if persistently high despite insulin to start top up regime based on bmi. Take vbg n urine ketone dipstick tro dka. CARDIO Chest pain - s/l gtn, maximum 3 times. If persistent pain to start iv morphine with iv maxolon. If persist despite morphine to start ivi gtn. - ECG stat. if suspected st elevation, to inform MO. Kiv thrombolyse. - take trop iearliest 3 hours post chest pain Hypotension - determine cause (septic/hypovolaemia, cardiogenic etc) - run 1 pint ns fast if no contraindication. If still low, for another try. - ivi noradrenaline if bp still low n adjust accordingly - regular bp monitoring - kiv add another intropes if low despite high dose 1st intropes Asystole - manual baging 15l/m (even for ventilated patient) - straighten bed n commence cpr - inform mo - transfer acute - v/s, reflo n cardiac monitoring - 2 large bore branula at least pink at big veins (fem/neck/cub fossa) - run 1 pint ns fast if no contraindications - prepare iv adrenaline (1mg every 5 mins) - prepare intubation kit - if patient survive, take abg, ecg, reflo, fbc, rp, lft, electrolytes, esr blood c&s (if infection is suspected), d dimer (if pe is suspected) - keep bp >90/60, map >60. - strict i/o via cbd - for inotropes if low bp - iv ranitidine 50mg tds to prevent gastric ulcer - rtf, start cf 50cc n increase accordingly (increasee 50cc if tolerate x3 to max of 300cc). Refer dietician. VT - inform mo - v/s n continous cardiac monitoring - if pulseless, for defib n 5 cycles of cpr. Repeat if unauccesful. - if pulse present but hemodynamically unstable, inform MO for urgent cardioversion n iv lignicaine - if pulse present, for iv amiodarone 1000mg over 24hours (read on Sarawak protocol for regime) Atrial flutter - v/s n continous cardiac monitoring - inform mo - if hemodynamically unstable for urgent dc shock n rate control meds. SVT - v/s to determine if haemodynamically stable or not - if hemodynamicaly unstable for cardioversion - if stable for carotid massage (if no bruit) n valsalva manouvre - if persistent, need to give iv adenosine 6mg n flush with 20cc ns. Contraindicated for ba patient. Second bolus 12mg can be given after 5mins with ns flush. - reassess n keep on continous cardiac monitoring - if persist consider another drug (verapamil etc) NEURO Fit - left lateral - remove dangerouus objects - fm10l/m - v/s n reflo - insert branula - iv diazepam 5mg stat if persist after 5mins. Can try 3x with 10mins gap. - if persist, inform mo n kiv iv phenytoin (loading n maintainance) - fbc, rp, lft, mg, ca, po4, rbs n kiv ct brain n lp if persistent fit. - monitor v/s, fit chart, gcs chart, behavioral chart n alcohol chart (if relevant) Gcs drop (<10) - v/s n reflo - inform mo - transfer acute - kiv intubation n referal to anaesth - determine cause - abg, fbc, rp, lft, electrolytes, esr, d dimer, urine feme c&s, tracheal c&s, blood c&s, cxr post intubation n ct brain depending on indications - treat according to cause Aggresive behaviour - approach calmly - ask help from security guards or male staff - iv haloperidol 5mg stat - 4 point restraints - refer psych if persistent aggresive behaviour GIT Nausea/vomiting - iv maxolon 10mg tds/prn - ors per purge - if significant loss for ivd n rp cm Diarrhea - ors per purge - may require lomotil - if significant loss, for ivd n rp cm Hematemesis - ensure its ugib, get a sample of vomit if possible - pr examination to look for malaenic stool - v/s (look for compensated or decompensated shock - if significant blood loss to insert 2 branula with fbc, rp, coag profile n gsh - iv tranexamic acid 1g stat n 500mg tds, iv/t omeprazole/pantoprazole. If worse, kiv start ivi ome/panto. - inform mo n kiv refer surgical RESP SOB - examine lungs n check v/s - determine cause - if intubated, check if ett dislodged or too deep - start np02/fm/hfm. If known case of copd to start vm. - w/out resp distress n keep sp02 >95% - if significant sob with sp02 drop for abg, fbc (tro anaemia), trop i (acs is suspected), d dimer (if bed ridden) - if ronchi - neb combivent stat, iv hydrocortisone 100 or 200mg stat n qid/tds 1/7 (then change to t prednisolone 30mg od 5/7). Reassess post neb, if worsening can try continous neb 1 hour. If worsening kiv ivi bricanyl. - if pe is suspected, to take d dimer n kiv ctpa if d dimer is elevated. Start s/c clexane 40/60 bd after d/w specialist - if pneumonia is suspected, to take fbc, rp, esr, crp, blood c&s n cxr. Start antibiotic depending on likely suspect - if sp02 still bad, for intubation n refer anaesth [02/12 18:39] Luqme: Common AntiHPT - available at hsnz 1. ACE inhibitor - indication: antiproteinuric agent in DM pt with Proteinuria; prioritize for DM pt with HPT; Pt with heart failure or CAD/IHD - to prevent LV remodelling. - T perindopril 2mg od ... max 8mg od (4mg or 8mg/tab) - T Enalapril 5mg od - max 20mg od (mayb given BD dose) ; 5mg, 10mg/tab - T Ramipril 1.25mg od , max 10mg od (2.5mg/5mg per tablet)- only use in CAD/IHD/Heart failure pt. Common side effects: hyperkalemia; may worsen renal fx esp in bilateral RAS (Renal artery stenosis) thus need to check creatinine 1-2/52 after start or increase dose; dry cough; angioedema [02/12 18:39] Luqme: ARB Indication: same as ACEi. Can use if pt unable to tolerate ACEi Contraindication: same as ACEi all list A Losartan (Cozaar): 25mg od . Max 100mg od (50mg/tab) use in gout pt for uricosuric effect Combination w HCTZ (Hyzaar) Valsartan (Diovan): 80mg od max 160mg od. Priority in heart failure pt. Combination w HCTZ (CO-Diovan); Exforge (Valsartan+Amlodipine) Irbesartan (Approvel): 150mg od. Max 300mg od. Combination w HCTZ: Co-Approvel Telmisartan (Micardis) 40mg od . Max 80mg od. Combination w HCTZ (Micardis Plus); [02/12 18:40] Luqme: Beta Blocker Indication: hypertension with CAD; antiangina; Add on Rx if not adequate BP optimisation; pt with chronic heart failure; anti arrhythmia (Rate control for AF) Contraindication: bronchoconstrictive disease (asthma, copd); peripheral vascular disease, Acute heart failure Common side effects: bradycardia, first degree HB, giddiness, hypotension, masking hypoglycaemia in DM pt (due to sympathetic blockade) Beta1 selective: Hydrophilic - T Atenolol 25mg od - max 100mg od (100mg/tab) Lipophylic - T Metoprolol 25mg BD - max 400mg Od (buat usual dose 100mg bd)...100mg/tab - may cross blood brain barrier and causing CNS side effects insomnia, nightmare T Bisoprolol 1.25mg od - optimum dose 10mg od *(given for chronic heart failure & CAD)*2.5mg & 5mg /tab Non selective Carvedilol Propranolol (use in hyperthyroidism, migrain prophylaxis, medical Rx for esophageal Varices; tremor related diseases) Labetalol (use in preggy pt) [02/12 18:40] Luqme: CCB Dihydropyridine: use as antiHPT - T Amlodipine 5-10mg od - T Nifedipine 10-20mg tds - T Felodipine 5-10mg od or Bd (max 20mg daily) # common side effect: pedal oedema, hypotension, giddiness Non-Dihydropyridine - T Diltiazem 30-120mg tds - T Verapamil 40-160mg tds # has antiproteinuric effect # for rate control meds given to pt who has contraindication to beta blocker # Contraindicated for pt w heart block [02/12 18:40] Luqme: Diuretics 5 groups - only thiazide used in Rx hypertension 1. Carbonic anhydrase inhibitor - acetazolamide (use in ophthal; benign intracranial hypertension) 2. Osmotic Diuretic - mannitol (use in as med rx in PT w increase ICP) 3. Loop Diuretic- Frusemide; bumetenide (use in fluid overload, APO, nephrotic syndrome); mayb use in CKD pt w Creat > 200 to control BP since thiazide diuretic become less effective. 4. Thiazide & thiazide-like diuretics - HCTZ 12.5mg od - 50mg od - indapamide (in coversyl Plus - combination w perindopril) - can enhance BP control if use in combination w other antiHPt - can precipitate gout attack and cause electrolytes imbalance esp in elderly 5. Potassium sparing Diuretic - Spironolactone - use in chronic heart failure, liver cirrhosis - Amiloride [02/12 18:41] Luqme: Utk Acute Coronary syndrome: medications yg Wajib Ada - DAPT (Double AntiPlt) common drugs - T Aspirin 150mg Od Plus T Clopidogrel 75mg od (Loading dose both 300mg Stat should b given upon diagnosis of ACS) Anticoagulant - kena rv Creatinine Clearance dulu - If CrCl <30 start IV heparin bolus 60u/kg followed by IVI Heparin 12u/kg) - if CrCl >= 30 - SC Fondaparinux 2.5mg stat then od. Biasa bg 3/7 tp boleh prolong the Rx sampai chest pain resolved. Utk ACUTE MI - IVI Streptokinase 1.5MU over 1hr Other meds - Wajib ada - Statin (eg Simvastatin 20-40mg ON or T Atorvastatin 20-80mg On or Rosuvastatin 10-40mg On - yg bold tu list A drugs....) Anti angina Long acting Nitrate (eg. T isosorbide dinitrite @ Isordil 10-20mg tds ;kalo pt cant tolerate Isordil sbb giddiness...boleh tukar T Isosorbide Mononitrite 30-120mg Od - Beta Blocker - to reduce heart Rate beta1 selective (eg. Bisoprolol 1.25mg-10mg od Or T Atenolol 25- 100mg od Or T metoprolol 25- 100mg Bd) SL Gtn 0.5mg prn (advice pt to take 1tab every 3-5min if dev chest pain....max upto 3tab...kalo x resolved terus pergi ke nearest clinic immediately. [02/12 18:42] Luqme: ANtibiotics inhibit Protein synthesis Tetracycline Doxycycline 100mg/tab Aminoglycoside all should be given via IV/IM - Streptomycin - Gentamicin - Amikacin Clindamycin [02/12 18:42] Luqme: EES Has prokinetic action [02/12 18:42] Luqme: ANtibiotics inhibit Protein synthesis Macrolide - Erythromycin (EES) - Azithromycin (250mg/tab...usual dose T 500mg OD x 3/7) - Clarothromycin [02/12 18:43] Luqme: Antibiotic: Beta lactam group - Benzatine Penicillin (IM) - Benzyl Penicillin (IV) - Penicillin V (oral) Aminopenicillin - Amoxycillin, Amoxy+Clavulanic acid [Augmentin], - Ampicillin, Ampicillin+Timectin [Unasyn] Penicillinase resistant penicillin - Cloxacillin Antipseudomonal Penicillin - piperacillin + tazobactam (tazocin) [02/12 18:44] Luqme: Cephalosporin 1st Gen 2nd Gen - cefuroxime, 3rd Gen - ceftriaxone (Rocephin); cefoperazone (cefobid)j, cefotaxime (claforan), Ceftazidime (Fortum)- Antipseudomonal 4th Gen - Cefepime (Maxipim)