A Practical Guide to Prescribing on Day 1! Dr. Liz Gamble DRUGS FOR TAKE A Practical Guide to Prescribing on Day 1! Dr. Liz Gamble

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

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 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 4-6hrly 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 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 > 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 5) In the event of persistent hypotension despite fluid resuscitation (septic shock) or lactate > 4 mmol/L Achieve CVP > 8 mm Hg Achieve central venous oxygen saturation (ScvO2)> 70%

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

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 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 Regular analgesia Regular paracetamol Regular co-codamol 30:500 NSAIDS Morphine Other pains

SIMPLE REMEDIES FOR MINOR PROBLEMS Nausea Constipation Cough Indigestion Leg cramps Insomnia Agitation

JUGGLING BLOOD SUGARS Highs and lows Type 1 or Type 2? Adjusting insulin doses Sliding scales

SCARY SITUATIONS What if you get there first? Additional management OSCEs Doses IV or IM?

SCARY SITUATIONS Respiratory depression & pinpoint pupils Severe heart failure Myocardial infarction Severe asthma Hypoglycaemia Possible meningococcal disease Anaphylactic shock Status epilepticus

SUMMARY The drug chart Prescribing abbreviations When not to prescribe The BNF Hospital protocols Simple remedies for minor problems Common emergencies