1. 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

2. 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

3. THE DRUG CHART FRONT Patient details Allergies Once only medication
Drug doses omitted

4. THE DRUG CHART
MIDDLE
Regular medication
BACK
As required medication

5. ABBREVIATIONS
Route of administration
Timing

6. How not to prescribe…..

8. 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

9. USE THE BNF & HOSPITAL PROTOCOLS
Useful things in the BNF
Hospital protocols

10. 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

11. Hudson mask: variable performance

12. Nasal cannulae
                                                                                                                                       

13. Oxygen delivery devices

14. Venturi devices: fixed performance

15. 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

16. 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.

17. Acute Severe Asthma Priorities Treat hypoxia
Treat bronchospasm & inflammation
Assess need for intensive care
Treat any underlying cause e.g. infection, pneumothorax

18. Acute Severe Asthma: therapy
Sit the patient up
High flow oxygen
Nebulized beta 2 agonists: salbutamol 5mg every min if required
Add ipratropium bromide 500mcg 4-6hrly if initial response poor
Steroids: hydrocortisone 200mg IV
Antibiotics if evidence of infection

19. 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 mg/kg/hr infusion

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. 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%

27. 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

28. 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

29. 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

30. 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

31. 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

32. Acute coronary syndrome
Symptoms resulting from myocardial ischaemia
STEMI / NSTEMI / unstable angina
Need continuous ECG monitoring and defibrillation facilities
IV access

33. 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

34. 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

35. TACKLING PAIN Regular analgesia Regular paracetamol
Regular co-codamol 30:500
NSAIDS
Morphine
Other pains

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

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

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

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

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