DRUGS FOR TAKE

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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 gt 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 lt93 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 lt8kPa despite FiO2 of 60
• Rising PaCO2 or PaCO2 gt6
• Exhaustion, drowsiness or coma
• Respiratory arrest
• Failure to improve despite adequate therapy

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Sepsis

• Bodys 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 lactate
• 2) Obtain blood culture prior to antibiotics
• 3) Broadspectrum antibiotics within 3h of
  presentation
• 4) In the event of hypotension or lactate gt 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 gt
  65 mm Hg

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Sepsis resuscitation bundle

• 5) In the event of persistent hypotension
  despite fluid resuscitation (septic shock) or
  lactate gt 4 mmol/L
• Achieve CVP gt 8 mm Hg
• Achieve central venous oxygen saturation
  (ScvO2)gt 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 CVPgt8mm 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 lt0.6mM
• 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, UEs, 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 30500
• 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