Oxford Handbook for the Foundation Programme [5th Edition] 9780198813538

Table of contents :
Cover......Page 1
Endpaper_Front......Page 2
Half-Title......Page 4
Published and forthcoming Oxford Handbooks......Page 5
Title......Page 6
Copyright......Page 7
Preface......Page 8
Dedication......Page 9
Acknowledgements......Page 10
Contents......Page 12
Symbols and abbreviations......Page 13
Introduction......Page 28
10 tips on being a safe junior doctor......Page 30
10 tips on being a happy doctor......Page 31
1 Being a doctor......Page 32
2 Life on the wards......Page 98
3 History and examination......Page 156
4 Prescribing......Page 200
5 Pharmacopoeia......Page 214
6 Resuscitation......Page 256
7 Cardiovascular......Page 276
8 Respiratory......Page 306
9 Gastroenterology......Page 324
10 Endocrinology......Page 358
11 Neurology......Page 374
12 Psychiatry......Page 400
13 Fluids and renal......Page 416
14 Haematology......Page 436
15 Skin and eyes......Page 454
16 Emergency department......Page 478
17 Procedures......Page 554
18 Interpreting results......Page 610
Appendices......Page 644
Index......Page 660
Endpaper......Page 691

Citation preview

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Presents a new Psychiatry chapter, and key topics including the medical certificate of cause of death

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Reflects the latest changes to the Foundation Programme curriculum and junior doctor contracts

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Updated in line with the latest guidelines

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Consultant editors: James Dawson, Stephan Sanders, Simon Eccles

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Tim Raine  |  George Collins Catriona Hall  |  Nina Hjelde

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of the year awards—4th edition 2015; 3rd edition 2012; 2nd edition 2009

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the foundation programme

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what you really need to know as a new doctor

  being a doctor and off the wards, from practical t e et on et guidance et n n n n how best to adapt to at the patient’s bedside to . . . .  2 life on the wards X X X X your new, day-to-day ok   3 history and examination ok ok life. ok o o o o survival guide to the.B With this indispensable B B w.B w.Programme you need never w Foundation   4 prescribing w w wbe alone the wards again. onw w w  5 pharmacopoeia t e  6t resuscitation et et eRaine n n n n . . . . feedback. your value We X   7 cardiovascular X X X Visit www.oup.com/uk/medicine/handbooks ok   8 respiratory ook ok ok Collins o o o book. this on comments your us give to B w.B w.B w.B Hall   9 gastroenterology w w book commended at the BMA medical Highlyw w w w

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Emergency topics Arrests Adult resuscitation E pp. 232–3 Obstetric resuscitation E p. 244 Neonatal resuscitation E pp. 242–3 Paediatric resuscitation E pp. 238–40 Trauma resuscitation E pp. 236–7 Emergencies Abdominal pain E p. 294 Aggressive behaviour E p. 370 Anaphylaxis E pp. 484–5 Bradyarrhythmia E p. 262 Breathlessness E p. 276 Burns E pp. 480–1 Chest pain E p. 246 Clotting abnormalities E p. 418 Coma E pp. 344–5 Diabetic ketoacidosis (DKA) E p. 330 Disseminated intravascular coagulation (DIC) E p. 417 GI bleed E p. 304 Hepatic encephalopathy E p. 318 High INR E p. 418 Hyperglycaemia E p. 330 Hyperkalaemia E p. 399–403 Hyperosmolar non-ketotic state (HONK) E p. 332 Hypertension E p. 268 Hypoglycaemia E p. 328 Hypokalaemia E pp. 399–403 Hypotension E p. 488–9 Hypoxia E p. 276 Limb pain E p. 458 Liver failure E p. 318 Overdose E p. 506 Paediatric seizure E p. 349 Psychosis E p. 378–81 Rash E p. 424 Red eye E pp. 440–2 Reduced GCS Epp. 344–5 Renal failure/kidney injury E p. 386 Shock E pp. 490–5 Shortness of breath E p. 276 Stridor E p. 290 Stroke E p. 354 Tachyarrhythmia E p. 254 Seizures E p. 348

Normal values Despite national efforts to standardise laboratory testing and reporting, exact ranges vary between hospitals, these figures serve as a guide. Haematology see E p. 580 Hb–men Hb–women

130–180g/L 115–160g/L

WBC

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76–96fl

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150–400 x 10 /l

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12–200micrograms/l B12 42–80µmol/l Folate

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4–11 x 109/l 2.0–7.5 x 109/l (40–75%) 1.3–3.5 x 109/l (20–45%) 0.04–0.44 x 109/l (1–6%) 197–866pg/ml 2–20micrograms/l

Clotting see E p. 581 INR PT Fibrinogen

0.8–1.2 11–16s 1.5–4.0g/l

APTTr APTT D–dimer

0.8–1.2 35–45s 48h during the average working week (Box 1.15), >72h in any consecutive 7d, or have £1000). may carry a risk of harm. X X kXsickness ok Locums Most hospitalsoemploy ok locum doctors to coveroostaff o or busy periods. They can be internal or external. Internal locums have B w.Bat the hospital and arewworking w.B additional hours w their substantive post w from the NHS are working away from their w w staff bank. External locums w base hospital (or do not have one), often on behalf of private locum agencies. There locum agencies that can register with; they are t are many eadvertised et youspending ekeyt often in BMJ Careers. To reduce on locums, two n n n . . . Xmeasures have been introduced. XThe first of these, caps on total X hourly ok rates, seems to have hadolittle oksuccess. The capped ratesoareokmuch lower o B than those previously.B such that trusts that enforce them have a wfillingoffered w.B much harder time rota gaps, resulting in unfilled slots and increased w w w strain on other clause allowing the w w doctors. An ‘exceptional circumstances’ w 15

cap to be broken has been widely used by many trusts, with several continuing to pay rates similar to or above those offered before the introduction of the cap. Rates of pay will vary and can still be negotiated, but an F1 can expect pre-​tax rates of £20–​30/​h, and F2s £25–​35/​h. The second new measure is a clause in the 2016 junior doctors’ contract specifying that those doctors planning to take locum work must initially offer their services for the proposed shift time to their employing trust staff bank. The trust must respond in a timely manner indicating if they require the doctor’s services. The doctor is under no obligation to take any extra shifts on, but would not be able to take an agency locum if the trust had offered staff bank work at an appropriate level (not a lower grade). Importantly, you should discuss locum shifts with your supervisor and include them in your work schedule to ensure contractual limits on individual and average weekly working hours (48h or 56h depending on if you’ve opted out of the EWTD) are not exceeded. Cremation certificates  The cremation form has two parts (E pp. 100–1). The first is completed by a ward doctor (usually the F1) and the second by a senior doctor, often from another department. Under arrangements prior to 2017, junior doctors were paid around £70 for completing the form; this fee is under review as part of ongoing reforms (E pp. 100–1). The bereavement office handles the forms and issues any cheques. Make sure you see the body, checking identity and that there is no implantable device that needs removing (E p. 100); they really do explode if incinerated. Gifts The GMC is clear in its message that you should not encourage patients or their families to give, lend, or bequeath gifts to yourself, others, or to organizations.16 If you are given a gift, then it is acceptable to take it as long as it has negligible financial value. If you are given money, then pass this to the ward sister to put into ward funds.

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w Making more money 41ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww Always check your payslips carefully, before storing them safely: make backups of electronic payslips and never throw paper copies away. They can be a useful record of tax, pension, and loan payments long after you have enjoyed spending the money. If you think a mistake has been made, contact the salaries and wages division of the HR office for your trust, quoting your assignment number (employee number). In the event of significant underpayment, you can request an interim payment be made pending the resolution.

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1 This is the total annual basic salary for your nodal pay point (‘1’ for FY1s, ‘2’ for FY2s). Latest updates are released as ‘Pay Circulars’ on the NHS Employers website Mwww.nhsemployers.org 2 This is the date when you are next due to go a point up the pay scale, usually 12 months of full time employment after your previous date (or date of first starting working as a doctor). When changing trusts mistakes can be made so always check this date is correct. 3 Your tax code shows the amount of income you are entitled to earn in the current tax year that you do not pay any tax on. This figure should be multiplied by 10 to give your total allowance. This will be the basic personal allowance for the tax year, as set by the government, adjusted to take account of any under- or over-payments you may have made in previous years. Each tax year runs from April to April. After your first tax year in paid employment, you will receive a P60 summarising your tax paid during that year with the code that should apply to you in the next tax year. A copy should also be sent to your trust, but if you move trusts around this time, the new trust may not receive the correct information unless you show them your copy of the P60. If your new trust does not know the correct code for you, they will use an ‘emergency’ code, set as the basic personal allowance, which may or may not be correct. The letter after the code should be an ‘L’ unless very specific circumstances apply to you. See also Mwww.hmrc.gov.uk 4 This will be approximately 1/12 of your basic annual salary. 5 This lists the pay you receive on top of your basic pay for additional hours over 40h, nights, and weekends. Details of how these are calculated are provided in the pay circulars and related junior doctor contract information available from the NHS employers website. Do check that the medical staffing department have provided correct details of your rota to the payroll team since early evidence from the introduction of the new contract would suggest a number of instances of errors in this regard. 6 Under the ‘Pay as you earn’ scheme (PAYE), your trust will automatically deduct your tax from your income each month. Both your basic pay and your pay for additional hours, nights, and weekends are taxable. In your first few months of employment, you may not pay any tax until your income has risen above the personal allowance for that year. Enjoy this while it lasts! 7 National Insurance contributions pay for certain state benefits, including your state pension. These are not optional, and will be deducted automatically, according to thresholds. The current rate is 12% of income over £157/week, though this is subject to annual review. 8 The NHS pension scheme remains a very good deal, although terms and conditions have been changed significantly in recent years and are subject to further negotiations. Your pension contributions are not taxed and will also be deducted automatically according to various earnings thresholds, unless you opt out of the scheme. Pension contributions are calculated from your basic pay (including any London weighting) - pay for additional hours, nights, and weekends is not subject to any deductions. See also Mwww.nhsbsa.nhs.uk/nhs-pensions 9 Repayment for any student loan is taken automatically from your pre-tax earnings when your income reaches a certain threshold. Although the landscape around tuition fees, repayment thresholds and interest rates is constantly changing, in 2017/2018 the minimum contribution is 9% of earnings above the threshold. Specific thresholds and repayment timings then depend on when and where you trained. If you trained in Scotland or Northern Ireland, or in England or Wales and started before 1st September 2012, repayments start in the April of the first year after you graduate (the start of the financial year) and are taken from any pre-tax earnings above an annual threshold of £17,775. In this case pay slips before April in the first year after you graduate may not contain loan deductions. If your course was in England or Wales but started on or after 1st September 2012, student loan contributions are taken as soon as you graduate on any monthly pre-tax earnings over £1,750 (equivalent threshold of £21,000 per year). You can repay faster if you wish. Keep a record of all payments you make and check them against annual statements. Errors are common when changing trusts. Payments that appear to have gone missing can be credited to your account easily if you can provide a copy of your payslips. See Mwww.studentloanrepayment.co.uk. 10 The numbers in this section will keep a tally of your total payments from that employer during the current tax year. If you change trusts, the numbers will be reset, but your tax thresholds should not be. 11 Your NI letter reflects the contribution group you fall into. For almost all of those in the NHS pension scheme, this will be ‘A’. 12 Pensionable pay does not include any pay for additional hours, nights, and weekends. 13 Pay dates will vary between trusts but are generally around the last Thursday in the month. It can be difficult to get paid on time at the start of employment with a new trust. 14 Trusts will transfer the money into your bank account by BACS transfer. These can take up to 3 working days. 15 Your taxable pay includes your basic pay (including London weighting) and pay for additional hours, nights, and weekends, less any pension contributions. 16 Don’t get too excited by this number… 17 …and try not to get too sad about this one… 18 ... because this is what you’re going to have to spend until next month comes around.

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42

Chapter 1

Being a doctor

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t t t .ne and debt X.ne .ne Money X X k years. ok level of medical graduate okdebt has increased markedlyoinorecent o Bo The B B . in tuition fee loans, On average, new FP trainees from England owe £40,000 w. if you wloans. sometimes up to £80,000 include maintenance Financial manw w w w have therefore changed drastically. w agement priorities This section is not w comprehensive but aims to give some important pointers and warnings. etclearance et et Debt n n n . . . XMost graduates have three different X types of debt: X ok (1) Short-​term High-​interest okdebts (eg credit cards ± overdraft, ok if at o o o full charge). Pay .these B B back first and as fast aswpossible. .B Try not to extend them w just because you have an income w w (2) Medium-​w term Commercial loans (eg a high w street bank graduate ww studies loan). These should be paid back next, as spare funds allow (3) Student-​ pay these back last. t et loans At very low ratesnofetinterest—​ n . .neatPay close attention to the annual .percentage rate (APR) and charges X X X k to any loan arrangement. free loans or credit can ok tachedin the oka cards ooensure Interest-​ owith short termB but you don’t get saddled high APR Bo help B . . later. Loans are aw competitive market so shop around—​ especially for ww offers the best rate. ww something like w w a car loan where the car dealer wrarely 17

Think ‘total cost’ not just ‘monthly repayments’.

Some basic rules for financial planning

t t t Short .neterm Clear debts with theXhighest .ne interest as soon as possible. .ne X X term  Try to accumulate ok Mediumsavings. ok about 1  month’s net salary ok as ‘emero o Bo gency’ B B . Scheme remains the best . available at present Long term The NHS wPension w w w and you will bew automatically enrolled in it unless you opt out. With this wyou could think about trying w taken care of, to save for the deposit on a w property (even if just £100/​mth). With interest rates currently low, home t is an attractive option if you t raise a deposit. Bear in mindnethatt ownership .neare large .necan there up-​front costs toX house buying (eg legal fees), youX will. be reX k sponsible for all maintenanceoand k k will not be able to take theoproperty with o o part of the country. .Bo Bo you when you movewto.Banother Financial advice ww w wwhave a salary that increases w Since you now incrementally and is virtually w guaranteed for life, finance companies will swarm round you like wasps roundetjam. Beware of some very slick et sharks—​their aim is only.ntoegett n n you to buy their products. There is no altruism here: . . X independent financialkadvice X is hard to obtain—​ask how X ok • Truly o ok independent they really are o o o B .Bwhat commission will be received .B for any • Firms must noww show w product you w choose, both to the individual who sold it to you as well as w w w ww to their company • Do not buy from the first or most persuasive salesperson, but take your time to consider what you really want and need.

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 Ercolani MG, et al. The lifetime cost to English students of borrowing to invest in a medical degree: a gender comparison using data from the Office for National Statistics. 2015;5:e007335.

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Money and debt

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t t t Financial .ne and other products .ne .ne X X X cover and incomekprotection E p. 12. Check if itkstill pays if ok Criticalareillness o o capable of doingoa less demanding job. Check o if it pays for all Bo you B B . . conditions you may get at work. w out a lump sum if you die;wonly w really makes sense w wpays Life insurance This w w w if you have dependants. Pension The NHS scheme is still better than commercial alternatives. You should etrevisit your retirement planning etat regular intervals through.nyour et n n . . career. You will also receive a state pension through your national insurXance (NI) payments. X kX ok BMA oknon-​clinical matters, eg wrongoosalary o o and HCSA  Protection for or poor B accommodation; thewtrade .B unions for doctors (E p.w12). .B Tax ww ww ww Now that you are earning a salary you will be paying tax. Most will be collected by PAYE (Pay As You Earn). tIf you have no other sources of etthen e(Box 1.17). If you have any.nother et n n income you can leave it at that . . X then you should ask for X X ok income ok a tax return and complete it. ok Tax codes E p. 41. o o o B Tax deductible It is possible .Byou paid on: claim back the income w.B(egtostethoscope); wtax • Job-​related expenses makew sure you keep receipts w w w ww • Professional subscriptions, eg GMC, BMA, MDU/​MPS, Royal College • Examination fees and course fees (previously not deductible, but HMRC has relented on this since 2012). Tax reclaims may be made through full self-​assessment, but this is not essential. If you pay tax through PAYE, simply send a letter to HM Revenue and Customs, Pay As You Earn, PO Box 1970, Liverpool. L75 1WX, stating your name, NI number, and detailing your professional expenses as listed above. You must also include details of any additional, undeclared income, including cremation forms. Your tax code for subsequent years will be adjusted accordingly. Tax returns A tax return is an online form asking for details of all the money you have received which may have tax owing on it. This includes your salary and other income whether earned (eg locum shifts or cremation fees) or unearned (eg lodger/​flatmate, bank interest, and dividend yields). • If you are asked to complete one then obtain a Government Gateway ID (Mwww.gov.uk) and password. This takes time, don’t leave it until January • Fill it in online and the maths is done automatically • Return it before 31 January otherwise you will be fined £100 (if 3mth late (depends on how late, and how much is due) • Claim your deductible allowances but also list your additional income. The Inland Revenue has been known to ask an undertaker to list all payments to doctors and then cross-​check. If your tax is simple then tax returns are not hard to do, otherwise pay a company/​accountant to do it for you.

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Box 1.17  Documents to keep safe for at least 7 years

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• P60—​sent every April to all employees • P45—​sent to you every time you change trust • Pay slips—​issued every month—​if electronic, then save copies • Record of additional income—​eg locums • Annual interest statements from bank, savings/​shares—​issued annually.

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wBeing a doctor

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Chapter 1

t t t .ne entitlementsX.ne .ne NHS X X k under ok a doctor working in theoNHS ok you have certain entitlements, odefined o Bo As B B your ‘Terms and Conditions Service’. Those relating to salary are discussed w.(E pp.of38–9). w.listed in ‘Pay and contracts’ Some others are here. Your first w w w w for any questions is your medical w staffing department point of contact and the w Foundation school. Always ask for copies of their written policies. et et et Accommodation n n n . . . X• Doctors in their first year after Xgraduation are no longer entitled X to ok free accommodation atotheir ok employing trust, except inoWales ok where, o for the time being .atBleast, funding for accommodation B .B is still available • Rooms may wellwbe available on site at a marketw rate and can w w be useful w when attached to a trust for a short w period that would ww otherwise make finding local accommodation difficult. Leave et entitlement et et n n n . . . • You are entitled to a total of 27d/​ y r of paid leave or 9d/​ 4 mth. You X also entitled to all bankkholidays X X or compensatory ok are o to workinonaddition—​ okholiday o o o days off if you are scheduled any part of a bank B B off, eg after working nights,wor.Bpre-​allocated • If a compensatory won.day w w to an extra day off ww annual leave falls a bank holiday, you arew entitled w • You are rarely allowed to carry leave over between jobs/​years • You need to give 6wk notice for leave; arrange this in good time and have your form signed by your consultant. There may be local allowances if rotas are received late or you are changing trust • If you need leave in a forthcoming post (eg getting married), write to let them know. Ask for the rota position which is off for those dates • Study leave is available for F1s but only for regular scheduled teaching. F2s have 30d per year that includes scheduled teaching but spare days can be used for courses/exams. Discuss leave with your supervisor.

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t paternity leave net t Maternity/​ newomen .nebe • .All are entitled to up to.52wk of maternity leave and must X X X to return to work ok allowed okafter this. Those who have worked ok for the NHS for 12mth by theo11th wk of pregnancy are theno entitled to full Bo B B . for 18wk, and any remaining pay for 8wk, halfwpay w.Statutory Maternity w w Pay for the remaining 13wk (pay calculators w available online ). Those w of pregnancy are w who havew worked for 4wk, you are absent from Bo • Ifareyouunlikely B .Byour . to bew signed off and will need to arrange to complete your w return. For practical reasons,wyour wwfoundation school training on your w ww may ask you to repeat the whole year—​ask your educational supervisor. Less than t full-​time/​flexible training edoctors et et n n n • .FP are entitled to train less than full-​time if they have a valid reason . . X X (eg having a baby orkillXhealth) list of valid ok • Aandcomprehensive okisreasons advice on how to o apply available from your Foundation o oo school. B B B . . w w ww ww ww 18

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Specialty training

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t t t .ne .ne .ne Specialty training X X X ok the FP you need tooapply ok for specialty training. Although ok changes o Bo After B B . 2 main options: are on the horizon (see at present there are w(ST). orBoxcore1.18), wjunior • Specialty training training (CT)—​m ost w w w interested indoctors ww • Academic w clinical fellowship (ACF)—​for those research, recruitment occurs earlier to allow unsuccessful applicants to apply for e regular t ST/​CT posts (E p. 66neandt Mwww.nihr.ac.uk). net n . . . Routes to CCT kXThe goal of specialty trainingokisXto award a Certificate of Completion kX of o o (CCT). This.allows onto the GMC’s specialist/​ Bo Training Bo you .Bo GP register and to become a consultant/​ GP. After the FP thereware 2 routes to CCT: w w   In some specialties (paediatrics, Run-​through w training ww GP, neurosurgery) ww competitive entry at ST1 leads to a 4–​8yr ‘run-​through’ programme within at single region, with no further competitive entry points. e  In other ‘uncoupled’ .specialties, et competitive et Core training entry at CT1 n n n . . Xleads to a ‘core training’ programme X followed by another application X to ok ‘higher specialty training’ o(cardiology, ok ok Core colorectal) on completion. o o B training programmes can be 2 years (Medicine, Anaesthetics, Surgery) .B w.B or 3 years (Psychiatry, Acute Care Common Stemw E pp. 48–9). w w CESR For those w who do not follow a straightforward w career path through ww to CCT, periods of time spent in training posts and experience gained may all be taken into consideration as part of an application to the GMC for a ‘certificate of eligibility for specialist registration’ (CESR). This route is especially useful for those who have spent considerable time overseas.

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The ‘Shape of Training’ report marks the evolution of a number of previous reports (‘Modernising Medical Careers’, ‘Time for Training’, ‘Foundation for Excellence’) examining how we can best adapt training programmes to the changing needs of society. Published in 2013 by Professor David Greenaway, it sets out a structure by which changes in patients (e.g. multiple comorbidities, complex conditions, ageing populations) and healthcare (rapidly shifting technologies and NHS restructuring) might be matched by medical training, without destabilizing current training and service delivery. In brief, the report advocates training clinicians who are more generalist, engaged, and adaptable to change. The 19 wide-​ranging recommendations include full GMC registration after medical school, broader and longer training programmes after the FP (e.g. women’s health, child health, mental health), transferrable competencies allowing easier transition between programmes, postgraduate opportunities to work in recognized related fields (similar specialties, management, education), and subspecialty ‘credentialing’ (subspecialization only after ‘Completion of Specialty Training’ as driven by patient and work-​force needs). Although officially independent, questions of political interference were raised after a Freedom of Information request uncovered minutes from a series of previously undisclosed meetings between representatives from the Department of Health, the GMC, and Professor Greenaway. The recommendations were accepted by the government. Organizations including the AoMRC and GMC have ongoing workstreams mapping out the practical implications of the report. Early changes are expected in the next few years, with longer-​term changes likely to take between 10 and 15 years.

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K  Box 1.18  The ‘Shape of Training’ report (SOT)

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wBeing a doctor

46

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Chapter 1

t t t .ne .ne .ne Specialty training applications X X X ok ok ok o o process Bo Recruitment B B . varies between specialtieswand. is rapidly evolving. The application process w w Most recruitment is organized nationally by the w w w appropriate Royal College ww or a ‘lead’ LETB using a web-​based application system. A small number of specialties still recruit through local applications. There is no limit to the number et of specialties you can apply.nto,etproviding you fulfil the eligibility ecri-t n n . . teria set out in the ‘person specification’. Begin preparing well in advance. X a specialty/​specialties (E kXp. 53) Considering personospecifications kX ok Choose o o o o and competition rates B .Bavailable at Mspecialtytraining.hee.nhs.uk. w.B eg GMC regis- w Check your eligibilityw  For applying to a training programme, w w tration, rightw to work in the UK, language skills, w prior experience. w Find suitable jobs  (E p. 52) These will be advertised by recruitment offices taccording to a nationally agreedt timetable. e the application form Paying.nclose e attention to deadlines. For et Complete sevn n . . X specialties a single application X portal called Oriel is used.kX ok eral ok applicants o interview; in Wait As applications are reviewed are shortlistedofor o o B B certain specialties (eg .GP) a further assessment is used .inBshortlisting. w  (E p. 58) You should receive wat least 5d notice, but Interview/​selection centre wwadhered to; you need to bring wwa long list of supporting ww this is not always documentation, including your portfolio (E p. 8). Formats will vary between a traditional panel-​based interview (eg core training programmes) or performing a number of exercises in front of assessors (eg GP). Offers Are made electronically through the UK offers system according to a coordinated timetable. You will be asked to rank all LETBs where you would accept a job; successful applicants are then allocated to LETBs in score order (you will be allocated to your highest preference that still has places when your turn comes). You then have 48h to review offers and decide whether to accept, hold, or reject. You may also elect to receive automatic ‘upgrades’ if a higher ranking choice becomes available. Re-​advertisement  To unfilled posts will take place in a 2nd application round. If you accept a job in round 1, you may still apply for a different post in round 2, but you need to inform all those concerned. Employment checks  And contract signing—​remarkably NHS employers claim to need up to 2  months after you start work to get around to issuing a contract and some manage to miss even this. Speak to your BMA representative in the event of contract problems.

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et et et n n n . . . X Xallowance can trust yourself when kX all men doubt you, But make ok Kfor ‘Iftheiryoudoubting okdreams too ... o If oyou can dream—​and not make your o o B B B master ... If you can meet with Triumph and Disaster And treat those two im. . w ... Yours is the Earth and everything w that’s in it, And—​ w postors just the w same w you’ll be a Man, my son!’ ww w which is more—​ The nature of a competitive jobs field is that not everyone will get their first t choice on first application. In thiseinstance, a miss and a mile are very etpost efart n n n . . . different entities and it is important to ask for feedback to establish how X of the mark you were andkX X to a you need to consider ok wide o whether okapplying o o o less competitive specialty. Discuss your options with your clinical and B B how else you may enhance .consider .B your CV. educational supervisors and w w ww ‘ ’ ww ’ ww ‘ Unsuccessful applications

19

  Rudyard Kipling (1865–​1936):  If , first published in Rewards and Fairies (1910).

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Career structure

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Fig. 1.2  Career structure for NHS doctors. VTS, Vocational Training Scheme.

t t t .ne structure X.ne .ne Career X X ok ok ok o o Bo B B w. w. w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww

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Chapter 1

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Being a doctor

t t t .ne .ne .ne Specialty training options X X X ok ok schemes that an F2 canoapply ok for (see are 21 different training o Bo There B B . clinical fellowships Table 1.3). In most specialties are also academic w. for ACFsthere w (ACFs). Applications occur before the main recruitment prow w w cess so thatw unsuccessful applicants can stillwapply for a regular training w post. Most ACFs allow for run-​through training, even in specialties that would etnormally have separate core.nand et higher specialty applications. et n n . . Acute care common stem (ACCS) X X X ok For trainees with an interest oinkacute specialties, ACCS provides ok a core 2yr o o o experience in acute medicine, B B and critical .B anaesthetics, emergency .medicine, wstreams care, with a furtherw training year spent in one of three (acute mediw w w cine, anaesthetics, emergency medicine). Choice of stream is determined at w w w the point of application to ACCS. Although the curricula and competences gained tare transferable between ACCS tstreams, it is not possible to move e career paths without further ecompetitive selection. et between n n n . . . X medicine CT1 and CT2kinXACCS specialties then a CT3 year X spent ok Acute o of CT3 it is theoretically possible ok to switch in acute medicine. At theoend o o B specialties from acute.B medicine to a general internal .medicine w w B specialty. w Anaesthetics CT1 and CT2 in ACCS specialtieswthen an extra CT2 year w w w w

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of anaesthetics; competitive entry to ST3 anaesthetics requires having passed the Primary FRCA (E p. 59). Anaesthetics can also be applied for directly as a 2yr core anaesthetics training programme. Emergency medicine CT1 and CT2 in ACCS specialties then a CT3 year of emergency medicine; competitive entry to ST4 emergency medicine requires having passed the MCEM (E p. 59).

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General practice has run-​through training coordinated through a nationwide application. The application consists of four stages: • Application form (establish eligibility) • Computer-​based testing (clinical problems and professional dilemmas) • Assessment centre selection (communication and written exercises) • Job allocation and offer.

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oo oo B B . . Successful applicants undertake 18mth spent in hospital specialties, folww wwthe MRCGP lowed by 18mth as a GP registrar during w which must be ww w completed to join the GP register and get a job. Core Core Medical Training etSurgery/​ et schemes. You apply for.ncore et n n . . These are popular uncoupled training X with most deanerieskallowing X choice of specific rotations X only ok training, o into post.aAfter ok (CT1–​ o o o after successful appointment 2yr of core training B B .B application for ST3 w CT2) there is a competitive in a. specific surgical or w w w medical specialty. To apply for ST3 in surgery you need full MRCS memw your interview; for medicalwST3 posts you need Part 1 ww bership before of MRCP to apply, but need full MRCP by the date of starting your ST3 t specialties other than those post.eItt should be possible to applyefor etin n n n . . . which you did your core training if you can demonstrate appropriate X kcanXarrange taster weeks, auditokorXresearch it helps if you ok competences; oapplying for. o o o in the subspecialty you are B B B . . w w ww ww ww

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t t t Table 1.3  .ne Specialty training programmes .ne at CT1/​ST1 (2018) X.ne X X Recruitment ok Specialty ok contact details ook o Bo Run-​through specialties B w.NIHR Trainees CoordinatingwCentre w.BMnihr.ac.uk ACFs w w Health Education WessexwMwessexdeanery.nhs.uk ww Cardiothoracic surgery t Midlands Meastmidlandsdeanery. et pathology Health Education eEast et Chemical n n n . . . nhs.uk X X X ok Clinical radiology London okrecruitment Mhttp://​www.lpmde.ac.uk/​ ok o o o B .B Community sexual and .B w Health Education East of England wMheeoe.hee.nhs.uk/​ reproductive health w w w National GP recruitmentwMgprecruitment.hee.nhs.uk ww General practice Histopathology London recruitment Mhttp://​www.lpmde.ac.uk/​ t and the Humber net et eYorkshire Neurosurgery Health Education n n . . Mhttp://​ w ww.yorksandhumberdeanery.nhs.uk/​ X X X. k k k o Obs and gynae Health ooEducation North West Mnwpgmd.nhs.uk oo Bo Ophthalmology w.B B . Health Education South West Mseverndeanery.nhs.uk w MaxFax surgery w w Health Education South West wwMseverndeanery.nhs.uk ww *

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*Source: data from Mspecialtytraining.hee.nhs.uk—​this website is the best starting point.

k ok Person specificationsook oo B B . . These list the required In making an w competences for thatwtospecialty. wprove that application, w youwwill need to provide evidence you have ww w achieved the specified competences. Consult these as soon as you anticipate an application to a scheme so that you can see what you need to etdetails are available at Mspecialtytraining.hee.nhs.uk et et do.n Full n n . . . If you are applying for an Academic Clinical Fellowship (ACF), you X to meet the criteria inkboth X the clinical person specification kX will for ok need o o o o o and level and the ACF person specification. B your chosen specialty B B . . w w ww ww ww

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wBeing a doctor

50

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Chapter 1

t t t .ne .ne .ne Specialty training competition X X X k varies, as does competition ok ospecialties ok for the for different o o Bo Competition B B . parts of the country. w. same specialty in different ww w applicants to view the ww Competition w ratios are published annually tow allow previous year’s ratios. These typically show the number of applications received for each specialty and the number of posts available; a compet is derived by dividing theneformer t (number of applications) eratio ebyt tition n n . . . the latter (number of posts). This ratio roughly represents the number X kX post (see Table 1.4). okX ok of people applying for each oavailable o o B .B candidates will stand a w .Boat getting a job Only the highest scoring chance w in specialties with for with a lower w a high competition ratio;meet wspecialties w competitionw ratio the applicant must still w the minimum require- w ments for the job to be offered it. Remember that applicants can apply for multiple et posts so the actual chances et of getting a job are higher.nthan et n n the ratio shown. . . X previous years, applicantskhave X had to factor in not only kcompetition X ok Inratios o by deanery. o recruito o o by specialty, but also The move to national B B element—​you can rankwall.Bdeaneries/​LETBs ment has removed w.this w wwithout disadvantaging ww where you w would be prepared to accept awjob your chances in any one region. After completion of the assessment process you will be ranked nationally, and assigned to your highest choice deanery that still has a vacancy when your turn in the queue comes.

t t t .ne .ne .ne X X X it is important tokconsider what your own priorities ok Thataresaid,adamant owant to stay in one particular okarea ofare.theIf that you o o Bo you B B . be very popular country, you may need to recognize that the area may wyou. happy wspecialty (eg London). Are to pick a less popular w w w w Equally, if you are determined w that you wanttotoincrease your chances? enter a w highly competitive specialty, are you willing to pick a region potentially t from your current home t the competition there is nmuch t mileseaway as .n These are decisions whichXshould .ne be talked through withXfriends, . e less? X supervisor. ok family, mentors, and youroeducational ok ok o in the UK Bo Specialty training B B w. to specialty training arewcoordinated w. Although applications throughout w the UK, within w each of the four countrieswa degree of local structure ww remains. EnglandtMspecialtytraining.hee.nhs.uk t e Ireland Mwww.nimdta.gov.uk e et Northern n n n . . . XScotland Mwww.scotmt.scot.nhs.uk X X ok Wales ok ok Mwww.walesdeanery.org o o o B w.B w.B w w w w ww t

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t t t .ne Competition ratios X .neST1 applications (2018) X.ne Table 1.4  for CT1/​ X ok ok okFill rate o o Applications Posts Competition Bo Specialty B B ratio . w. w w ACCS emergency 675 340 w 1.9 91% w ww medicine w Anaesthetics inc ACCS 1296 2.2 97% t surgery t 60110 e et Cardiothoracic 64 ne 6.4 88% n n . . . XClinical radiology X100% 267 3.8 k99X ok Community o1021 ok 100% sexual and 4 24.8 o o o B reproductive health .B w w.B w Core medical training 2343 1657 w 1.4 91% w w 1.3 ww Core psychiatric training 623 495 65% Core surgical training 1608 629 2.6 100% t et practice et 3857 n General 5097 .n 1.3 84% . .ne X X X Histopathology 174 95 1.8 72% k k ok oo 152 oo 100% 29 5.2 Bo Neurosurgery B B . . w w2.1 Obstetrics and 555 263 100% gynaecology ww ww ww *

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52

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t t t .ne .ne .ne Choosing a job X X X k ok okto choose you have securedoaotraining rotation, you still need o Bo Once B B which specific jobs to. do. There are also jobs outside.of specialty training wa local application process.wThis w section gives ideas w rotations that w have wfind w w about how to and choose jobs. Priorities Before looking for a job, write a list of factors that matter to etmaking this potentially life-​.cnhanging et decision. Important consideret younin n . . ations include: X X X ok Partner/​spouse Can they get oakjob nearby? ok o o o B Location Could you move? far would you commute? wfar.BawayHow w.B Family/​friends How are you willing to go? w w w w ww Career Is the job in the right specialty/​specialties? Duration Can you commit to several years in the same area? epayt  What banding and rota do.nyou et want or need? et Rota/​ n n . . X X vs district general. kX  Large teachingkhospital ok IfTypeyouof hospital ointentions then o o oo and rota have no firm career choose byBlocation B B . . since these will affect your life most over the next few w w months. Look w for suitable jobs wwon Mwww.jobs.nhs.uk, Mspecialtytraining.hee.nhs.uk, ww w deanery websites, or in the BMJ.

whereby net all job offers are madeXat.ntheetsame time. This allows you ntoeac-t . . X X highest ranked job k you applied for. Bear in mind ok cept thechange o thatafter ok that you your job rankings submitting your application. o o Bo cannot B B . Competition Medical are competitive; it isw important to maximize w. ajobs w w your chances of getting job. Apply for several specialties; rank as many ww w w regions as possible; check competition ratios and person specifications (E p. 51, Mspecialtytraining.hee.nhs.uk); consider a back-​up choice, eg a t t t lessncompetitive specialty or region. A good . e .ne CV also helps (E pp.X56–7). .ne X X a job Adverts give a true reflection of k a job. Phone ok Researching okandrarely odoing hospitals within the region ask to speak to the person job o o Bo up B B . available,the at the moment. Quiz. them on the types of placements hours, w w support, teaching, w conditions, and what theirwinterview w was like. Would ww they accept w the job again? Contacts  With HR departments andtstructured interviews, the days tof et just e jobs being a consultant phone .call n neaway have gone. There isXno.ndoubt . that some networking still occurs, with mixed results. Senior contacts are X X ok useful for tailored careeroguidance, ok CV advice, and giving orealistic ok views of o B where your CV can get you. .B w.B wonline w Accepting aw job  With a move towards unified, application prow w ww

Job offers A national timescale for FP and ST/​CT job applications exists

cesses, strict and automated rules are essential to ensure a rapid and fair allocation to posts. In order to allow for choice, under certain circumstances it may be possible to accept, or hold, an offer, and later upgrade, or apply to a different post, providing you notify all those concerned. Outside of this formal process, it is unacceptable to turn down a post you have already accepted unless you have an extremely good reason. The GMC take a clear position on your obligation to protect patient care by not compromising the recruitment process in this way, though notice periods vary by seniority.

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wSpecialties in medicine 53ww t t t .ne .ne .ne Specialties in medicine X X X ok Certificate of Completion ok of Training (CCT) can beoawarded ok in nuo Bo The B B merous specialties shown as follows. A  selection of. subspecialties are w. points: w also shown withw bullet w ww ww 20

Acute internal medicine Allergy Anaesthesia • Paediatric anaesthesia • Obstetric anaesthesia • Pain management Audiovestibular medicine Aviation and space medicine Cardiology Cardiothoracic surgery • Congenital cardiac surgery Chemical pathology • Metabolic medicine Child and adolescent psychiatry Clinical genetics Clinical neurophysiology Clinical oncology Clinical pharmacology and therapeutics Clinical radiology • Interventional radiology Community sexual health and reproductive medicine Dermatology Diagnostic neuropathology Emergency medicine (EM) • Paediatric emergency medicine • Pre-​hospital emergency medicine Endocrinology and diabetes mellitus Forensic psychiatry Gastroenterology • Hepatology General internal medicine General practice General psychiatry • Liaison psychiatry • Rehabilitation psychiatry • Substance misuse psychiatry General surgery • Breast surgery • Colorectal surgery • Upper GI surgery • Vascular surgery Genito-​urinary medicine Geriatric medicine • Stroke medicine • Orthogeriatrics Haematology

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 For more details on the career options available to doctors, including all of the above, see Want To Be A Brain Surgeon? (Eccles S et al.), Oxford University Press, 2009.

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• Reproductive medicine • Urogynaecology Occupational medicine Old age psychiatry Ophthalmology Oral and maxillo-​facial surgery Otolaryngology (ENT surgery) Paediatric cardiology Paediatric surgery Paediatrics • Child mental health • Community child health • Neonatal medicine • Paediatric oncology Palliative medicine Pharmaceutical medicine Plastic surgery Psychiatry of learning disability Public health medicine Rehabilitation medicine Renal medicine Respiratory medicine Rheumatology Sport and exercise medicine Trauma and orthopaedic surgery • Hand surgery • Spinal surgery Tropical medicine Urology Vascular surgery

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t t t .ne curriculum vitae .ne .ne Your X X X k ok oLatin ok of life’. In o o is a CV? This is a phrase which means ‘course Bo What B B . modern days it means advertise yourself to a w. a document by which you w w w potential employer: a summary of you. w w ww When will I use a CV? You will need a CV for many of the jobs you will apply locum agency, they will use your et for after graduating. If you.njoin etaalso etto n n CV when finding you work. You should upload your current.CV . X X annual review. X ok your ePortfolio in advanceoofokevery ok o o What is included.B CV? The most important to inB w in a w.Binformation clude are your contact details, a list of your qualifications (those already w w acquired andwthose you are studying for), any woutstanding achievements, ww a summary of your employment to date, and the details of your referees. Other tinformation can be included, buttdo not overcrowd your CV. e ebe a static piece of work—​it.should et n n n . . CV philosophy  Your CV should not X with you and reflect your X skills and attitudes. ItkisX ok evolve okandchanging o o oo it toimportant to keep your CV up to date, from time to time reformat freshen B B B . . it up. Use your CVw to demonstrate how you have learnt from your experiw w will be much more ww ences rather than wwjust listing them; a potentialwemployer impressed if you indicate you learnt about the importance of clear communication while working at a holiday resort, than by the actual job itself.

t net help HR departmentsXand needucational nead-t Getting supervisors can give . . . X X on writing a CV, and often you can find people’s CVs or templates on ok viceInternet ok‘CV’. ok by searchingofor Try to keep your CV individualized, so o Bo the B B . . do not simply copy someone else’s template. w w Before writing ww your CV  Ascertain what wwa potential employer is ww looking for when sending in your CV; check the essential and desirable criteriatand try to echo these. You needt to alter the emphasis in your CV t e the position you are applying to n communi.match .ne for, eg highlighting your X .ne cation skills or leadership experience. X X ok ok ok of CVs o  Your CV shouldolook impressive; for many jobs hundreds Bo Layout B B are received and yours tow be. clearly laid out and w. must stand out. It needsmost easy to follow.w The key information and your w important attributes w should standwout prominently. Think aboutw the layout before you start w writing. t for a basic CV (and an optional et  Two sides of A4 paper are eideal et Length n n n . . . X page); add more as yourkcareer X progresses. X ok front o the candidates okvery similar o o o Remember  For most jobs, applying will have B B .Bto be short-​listed qualifications and w so .the only way you may standw out w for interview isw via your CV. Make it as interesting as possible, without it w w ww looking ludicrous.

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contact telephone numbers (home, work, mobile), and email address are essential. You must state your type of GMC membership (full/​provisional) and number. Stating gender, date of birth, marital status, nationality, and other information is optional.

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Your curriculum vitae

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t t et an optional section. Some Personal .ne statement This isXvery.nmuch .nefeel X X a little about yourself andkwhere you ok it gives you an opportunityotoofeelkoutline it is an irritating waste of space. oo Bo see yourself in 10yr;wothers B B . . Education List your qualifications in date order,w starting with the most wand progressing backwardswin w recent or current time. Indicate where each ww w was undertaken, the dates you were there, and grade. Highlight specific coursest or modules of interest. GCSEt and A-​level results are less ime once you have graduated. .ne et portant n n . . X X kX you and work   List the placements ok Employment oF1kandexperience omost o o o have undertaken during the F2 years starting with the recent. B Include the dates, wspecialty, .B your supervising consultant, .B and address of w the employer; consider ww adding key skills that you wwattained. ww Interests An optional section which gives you a chance to outline what you liket to do outside of medicine. A twell-​written paragraph here can epotential employers that you.are einteresting as well as intelligent. et show n n n . . X kXyet got your name in print,oktryXto get a  If you haveonot ok Publications o o o put the letter in a medical journal (E p. 60). If you have got publications, B most recent first; ensure B B . . they are referenced in a conventional style (see w w Mwww.pubmed.com ww for examples). ww ww Referees Your referees should know your academic record as well as

your e t to interact with others.nState et their relationship to you (such et nability as .personal tutor) and give contact.address, telephone number, and.n email X X X to provide a reference, give them k a copy ok address. Ensure they are ohappy ok you when are applying for jobs. oo Bo of your CV, and tellwthem B B . . Headers and footers Having the month and w year in either a header w w or footer shows w the reader you keep it up to date. w ww Photographs Some people include a small passport-​sized photograph t near the start of theirneCV; t this is optional but not necesof themselves et .nerecommended. sarily Why should. your physical appearance be of.nreleX X X ok vance for selection for anyojob okoutside perhaps fashion and media? ok o Bo The finished CV B B  Use the spell-​ c hecker and get a tutor or friend to w. mistakes and make constructive w. criticism; read over it to w identify be prew pared to make wnumerous alterations to get it right. w ww Technical points Use just one clear font throughout. To highlight text of importance et use the underline, .bold e,tor italic features. When printing et n n n . . your CV use good quality white paper and a laser printer if possible. X X kX send a ok The covering letter Whenever ok you apply for a job, you omust o o o B covering letter withwyour .B CV and application form.wThis .Bshould be short and to the point. Indicate the position you are applying for and briefly say w w w why the job w appeals to you, and highlight whyw you are suitable for the job. w

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t t t .ne Foundation X .ne .ne Post-​ Programme CV X X ok ok J Flint ok o o Charles Bo Name: B B Address: w. 14 Abbeyvale Crescent ww. w McBurney’s Point w w ww McB1 7RH Home:t 0111 442 985 t e e et n n n . . . Mobile: 0968 270 250 X X X [email protected] ok Email: ok ok o o o Date of birth: 12 June 1994 B w.B0121231 (full) w.B GMC: w w w w ww Personal statement I am e ant outgoing doctor with an enthusiastic mature outlook. I have et yet et n n n . . . strong communication skills and experience of working independently, X as a team member andkXleader. I  am conscientious, trustworthy, X ok both o new skills. My long-​term aim oiskto practise o o o quick to learn, and to employ B .B the hospital environment.w.B an acute specialtyw within w ww ww Educationw

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2010–​2015 University of McBurney, McBurney’s Point, McB1 8PQ MBChB:         2015 BMedSci (Hons):       Upper Second Class, 2013

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F2 to Dr Fungi, Microbiology McBurney Royal Infirmary F2 to Dr Golfer, General Practice Feelgood Health Centre, Speakertown F1 to Mr Grimshaw, General Surgery McBurney City Hospital F1 to Dr Mallory, Gastroenterology McBurney City Hospital F1 to Dr Haler, Respiratory Medicine McBurney City Hospital

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k ok ooexperience oo Bo Postgraduate clinical B B . . wI developed my clinical and w w skills and became w During my F1 year practical ww confident with the day-​to-​day organization ofwemergency and elective ad- w missions in both medicine and surgery. Since commencing F2 I have built upon these skills and now appreciate the in the et running et wider role of the doctor teams et n n smooth of acute admissions and liaison with the community.n . . X to, and after, hospital discharge. X kX Formal skills I have include: ok prior ok • ALS provider (2016) oo o o B B • Basic surgical skills,.B w including suturing and fracture w.management. w w w w ww

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t t t Research .ne and audit X.ne .ne X X involved in akresearch project comparing capillary ok • I am currently o ok o gas analysis withoarterial blood gases in acute asthmatics Bo • Iblood B B undertook an audit of antibiotic prescribing on surgical wards to w.patients win.accordance investigate whether were being managed with w w w I presented the data at a departmental w ww trust guidelines. meeting and repeated the audit after 2 months, demonstrating increased compliance • During et my SSM I researched the.nroleetof caffeine on platelet function. et n n . . XInterests X X ok I am a keen rock and ice climber ok and have continued to improve ok my grade o o o B since leaving university. to Scotland .BI have organized several climbing wI am w.Btrips and one to the w Alps. interested in medical w journalism and have spent wJournal of Thrombophlebitis. ww a week in thew editorial office of the International Publications etCJ. Letter: Student debt. Students’ et Journal 2016;35(2):101 .net • Flint n n . . • Flint CJ and West DJ. Multiple Sclerosis X X in social class three. kJournal X of ok Social Medicine 2016;12(9):118 ok o o o o of platelet B • Lee S, Flint CJ andwWest .B DJ. Caffeine as an activator .B2014;54(3):99. w aggregation. International Journal of Thrombophlebitis ww ww ww References

Dr Ian Haler, Educational Supervisor, Department of Respiratory Medicine, McBurney’s Medical Centre, McBurney’s Point, McBurney, McB1 7TS Tel 0111 924 9924 ext 2370. [email protected]

t t t .ne .ne .ne X X X k ok oportfolio ok o o Bo Box 1.19  Thewpaper B B . w. evidence of your w Most interviews require a folder containing physical w w achievements. w Use the following structurewas a guide to gather evi- w dence long before interviews. Sections should be subdivided for ease of navigation. t t net print on high quality paper. Curriculum the.back, .ne vitae At the front or X .ne X X form For interviewers to refer back to. k ok Copy of application ok PGCerts, oPhD, etc. o o and qualifications  Diplomas, BSc, MSc,BMD, Bo Degrees B . Prizes, awards, andw grants Local/​national, undergraduate/​ w. postgraduate. w w Oral and poster presentations  Local, regional, national, w w or international. ww Books, abstracts, and other publications First/​last author or co-​author. Teaching experience Small group, lectures, or courses (with feedback). Clinical audit and quality improvement Results, reports, and presentations. Commitment to specialty Skills, membership exams, experience, etc. Courses and conferences attended Local, national, or international. References, testimonials, and feedback  Feedback/​ testimonials from patients and colleagues can show reflective practice and professionalism. Research projects Give a summary, your exact role, and any reports. Logbook of practical procedures Including supervised and unsupervised. Work-​place based assessments Notable DOPS, CBDs, and CEX forms. Management and leadership Trainee representation, committees, etc. Reflective practice To demonstrate that you learn through reflection. Achievements outside medicine Shows that you are well-​rounded.

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oo oo B B . . the interview itself; them as much notice wtry toforgiveinformation w as possible. Look at wwebsite w the recruitment about the format, questions, and ww w w what to bring; try to talk to previous applicants and arrange mocks. Interview at the interview plenty of time, allow for tall t with eoft delaysdayon Arrive eeven e sorts the roads or train, if this means you have to read n n . . .ncandiX X X the newspaper for an hour. Relax and be yourself with the other k ok before you are calledooin;kmost of them will have similar ooqualifications Bo dates B B and experience as yourself and will be just as nervous. Dress smartly in a . . w or skirt). You will simple suit andw tiew for men and suit for women w (trouser w specific instructions as to what w documentation to bring, ww normally receive which you should follow exactly; as a minimum, bring a copy of your CV (E pp.t54–5) and a summary printout from ePortfolio (E p. 8). t einterview  Relax. The worst.nethatt canyour n . .nenot The happen is that you are X X X k of the world. The formatoofk interviews job, which is notothe ok offeredbutthethere o 2–​3 end o to each of are usually interviewers; introduceB yourself Bo varies, B . . the panel and wait w to be offered a seat. For some posts there w will be a series of panels, each with ww a different brief (eg CV verification, ww clinical scenarios, per- ww

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Interview preparation Employers must allow you time off to attend

sonal skills), and you will rotate between panels. Take a few moments to think about the questions before answering and ask for a question to be rephrased if you don’t understand it. Always make good eye contact with all members of the panel and be aware of your own body language. Common questions  It is impossible to predict the questions you will be asked, but they are likely to include questions about your portfolio, relevant clinical scenarios, and current medical news/​issues. Many questions have no correct answer and will test your communication skills, common sense, and ability to think under pressure: • Talk us through your portfolio; what are you most proud of in it? • What is missing from your portfolio? • What qualities can you offer our training programme? • Why have you chosen a career in . . .? • What do you understand by ‘clinical governance’? • Tell us about your audit. Why is audit important? • If you were the Secretary for Health, where would your priorities lie? • How would you manage . . . [specific clinical scenario]? • Where do you see yourself in 5, 10 years’ time? • If you were the CT1 in the hospital alone at night and you were struggling with a clinical problem, what would you do? • Tell us about your teaching experiences. What makes a good teacher? Clinical scenarios Interviewers should not ask you specific medical questions (eg ‘What is the dose of . . .’); they can pose scenarios to discuss your management of a situation. These often focus on key issues such as communication, prioritization, calling for senior help when appropriate, multidisciplinary teams, and clinical safety. For some specialties, a few formal OSCE-​style stations may be included—​you should be told about this in advance.

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Membership exams

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t t t .ne .ne .ne Membership exams X X X k you will need to complete ok progress beyond the oSToyears okthe memo Bo To B B bership exams of your chosen specialty and meet the level w. exams w. appropriate of competency.wThe are difficult and w expensive (though often w E p. 43). Most membership w exams take place 2–​3 ww tax deductible times a year. You need to apply about 2–​4mth before each exam. In the past, e Foundation doctors have received t et advice not to sit membership et n n examinations—​ this may well allow.n focus on other areas of development . . X you may then miss earlykopportunities X X to start buildingkthis ok but o o aspect of your CV. o o o B Medicine Regionalwexamination .B .Band overseas; all centres throughout wUK w centres use the w same exams. The MRCP has three sections: w w ww • Part 1 Written basic science, £419, ≥12mth after graduation • Part 2 Written clinical, £419, 60 is abnormal),w listen w w the clavicles for fractures. w w beat, gently feel Abdo tPalpate (to exclude hepatomegaly, splenomegaly, masses), dese testes, patent anus, enlarged.nclitoris, et femoral pulses. et cended n n . . X feet Anterior hip creases X(symmetrical?), Barlow test k(flex X hip to ok Hips/​ oka click/​ o Ortolani o o 90°, press posteriorly, feelofor clunk if the hip dislocates), B test (after Barlow’swabduct .B the hips one at a timewwhile .B pressing on the greater trochanter with your middle finger, feel for a click/​clunk as the hip w w w w ww relocates), note repetition of these tests can cause hip instability, ankles (talipes, correctable or not), toes (number, shape, colour).

et et et n n n . . . make a note), posterior hip creases. Xdefects), buttocks (blue spots—​ X X ok Plot In the red book: weight, okhead circumference, examination. ok o o o B w.B w.B w w w w ww Turn baby over Spine (straight), sacrum (lumps, dimples, hair tufts, skin

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Chapter 3

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oo oo B B . . Basics Age in days w 1mth), weeks (until 2mth),w months (until 2yr), or w (until years, gender, gave the history, who was present. wwho ww ww Current state Feeding and drinking, weight gain, wetting nappies/​passing urine, tfever, bowels, crying, runny nose, e ears, drawing up legs, rash..net cough, breathing problems, et pulling n n . . X  Pregnancy problems andkmedications, X X 2/​40 at birthk(37–​ ok Birth o (NVD, induced,gestation o if4LSCS is normal), type of delivery ventouse, o forceps, o o B .Bspecial care, birthweight,wPROM, .B group B strep ask why), resuscitation, wmaternal (GBS), meconium, pyrexia during labour, vitamin K (IM or oral), w w w bottle, type of milk). w ww feeding (breast, Immunizations Check the child is up to date with vaccinations (Table 3.15); t or febrile beforehandneandt jabs will be postponed if the child iseunwell et often n n . . . children get a slight fever for 60mg w. for severe w. and prednisolone per day inflammatory w disease this must be w w wdose if they are converted tow an appropriate IV corticosteroid unable to w take regular PO doses (Table 4.5, Box 4.3). Long-​term steroid use should prompt (E p. 451). t etconsideration of osteoporosis eprophylaxis et n n n . . . X X Conversion of oralkprednisolone to IV hydrocortisonekX ok Table 4.5  o o o oo dose Normal prednisolone dose Suggested hydrocortisone B B B . . ≥60mg/​24h PO w 100mg/​6h IV w w 20–​50mg/​24h 50mg/​6hw IV wPOw ww ≤20mg/​24h PO 25mg/​6h IV t e et et n n n . . . X X X ok ok ok o o o B B w.conversion w.B Box 4.3  Steroid w w w w ww *

*If patients with known adrenal insufficiency, or those who have been on any dose of oral corticosteroids for >3wk present unwell, consider an initial dose of 100–​200mg hydrocortisone IV STAT, then d/​w senior as to regular steroid dose. If unable to tolerate PO administration, ensure equivalent IV steroids given, as per Box 4.3.

These are equivalent corticosteroid doses compared to 5mg prednisolone, but do not take into account dosing frequencies or mineralocorticoid effects: • Hydrocortisone 20mg; usually given IV 6–​8h • Methylprednisolone 4mg; usually given once daily • Dexamethasone 750micrograms; usually given once daily.

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t t t .ne .ne .ne Topical corticosteroids X X X ok oarek used in the treatment of omany ok inflammao steroids These Bo Topical B B . . tory skin diseases.w As with corticosteroids given w orally or intravenously, w w the mechanism of action is complex. Corticosteroids offer symptom- ww w w atic relief but are seldom curative. The least potent preparation (see Table  5.20 E p. 221) possible should be used to control symptoms. et of topical steroids often etcauses a rebound worsening etof Withdrawal n n n . . . symptoms and the patient should be warned about this. The amount Xbody parts is shown in Fig. 4.4. XAlwaysof kXsteroid needed to cover various k k o o o Bo wash hands after applying .Botopical steroids. .Bo w w Side effects Local thinning of the skin, worsening striae w ww acne, ww local infection, and telangiectasia, depigmentation, hypertrichosis, systemic rarely w adrenal suppression, Cushing’s syndrome (subsequent withdrawal of topical steroids et can precipitate an Addisonian et crisis). et n n n . . . Potency  E p. 221 for a list of the common topical steroids used X X arok ranged by potency. ookX ok o o B w.B w.B w w w w ww 2

t t t .neONE adult .ne .ne X X X ok unitfingertip ok ok o o (FTU)* Bo B B w. w. w w w w units (FTUs) ww Number of fingertip Aget Arm t Trunk Trunk (back)t Face e e &Leg &.hand foot (front) inc. buttocks & neck n n . .ne Adult X X X 4 8 7 7 2 ok Children: ok ok o o 3–6 months 1 1 1 1 1 Bo B B 1–2 years w. 1 w. 2 1 2 3 w w 3–5 years 1 2 3 3 3 w w ww 2 2 4 3 5 6–10 years Fig. 4.4 Amount topical steroid required t unit of(FTU) efingertip et to treat various body parts. *One ea t n n adult is the amount.n of ointment or cream expressed from . . X with a standard 5mm diameter X kXon the ok tube ok nozzle, applied from the distaloocrease tip of the index finger. o o Reproduced with permission from Long, C.C. and Finlay, A.Y. (1991) Clinical and B Experimental Dermatology, w.B16: 444–​7. Blackwell Publishing. w.B w w w w ww /2

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t t t .ne .netreatment X.ne Empirical antibiotic X X k ok ok   These will be your keyooresource o antibiotic guidelines for Bo Local B B .They are written to ensure wthe. most appropriate antibiotic treatment. w w w antibiotics are wused prior to knowing the pathogen w and its antimicrobial ww sensitivities. Always seek advice from the microbiologists if deviating from the guidelines; their choice of suitable antibiotic will depend upon likely t t et and its usual antimicrobial esensitivity, pathogen patient factors (agene and n n . . . coexisting disease), and drug availability. Some common infections and X kareXlisted in Tables 4.7–​4.9 (suitable kX for an antibiotic regimens ok suggested o o o o o healthy 70kg adult); more detailed options, including B otherwise .B choices for patients with penicillin allergies, are listed E p649. w w.B w w w  prior to commencing antibiotic w therapy is important as ww Taking cultures they allow subsequent therapy to be more specifically tailored. However, culturestshould not delay treatment in the e et septic patient. et n n n . . . XTable 4.7  Common exampleskX X ok Lower UTI Nitrofurantoin o or trimethoprim ok o o o B B or ciprofloxacin w.B Pyelonephritis Co-​ wa.moxiclav w Cellulitis w Flucloxacillin 1g/​6h PO/IV ww ww

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t t t .ne .ne(C. diff) .ne Clostridium difficile X X X k ok ok obacillus, o o   A Gram-​ positive spore-​forming anaerobic which Bo Bacteriology B B . colonize the gut. Exposure w . can asymptomatically to antibiotics alters the w w w balance of gut wflora, promoting C. diff overgrowth, w production of toxins that ww damage colonic mucosa, and subsequent symptomatic C. diff  infection (CDI). Transmission  Via the faeco–​oral route, after direct or indirect conet patients, eoft spores een-t tact between or ingestion lying dormant in the n n n . . . X X X C. diff is now regarded ok vironment. ok as a major cause of hospital-​ ok acquired infections (HAI), E pp. o 502–3. o o B B  Watery diarrhoea and .B Clinical features abdominal pain are w.of CDI wsevere common; feverwand leucocytosis are also seen; disease causes w w w w pseudomembranous colitis and toxic megacolon. Consider CDI in the dif- w ferential of unexplained fever and raised inflammatory markers in hospitalized Elderly and frail patients etolder adults. et are at especially high.risk etof n n n . . dehydration, recurrent disease, and mortality from CDI. X X arises. kX as soon as suspicion ofokCDI  Through stoolosamples ok Detection o o o Currently this involves a 2-​ s tage process, with a rapid, screening test for a B .B .B by a more C. diff protein (or w PCR for the C. diff toxin gene), followed spew cific immunoassay ww for the C. diff toxin. Speakwtowthe laboratory if there is ww 3

any doubt. Consider an urgent AXR to rule out toxic megacolon. Treatment See Box 4.4. Starts with metronidazole 400mg/​8h PO or vancomycin 125mg/​6h PO. Pay attention to fluid and electrolyte balance. Other regimens including higher doses of PO or PR vancomycin, IV metronidazole, or PO fidaxomicin may be required in patients who fail to respond or who relapse after initial treatment—​always consult local guidelines and the microbiologist. Faecal microbiota transplantation (FMT) is an effective treatment for refractory cases, offered in a few UK centres.4 Infection prevention and surveillance Barrier nursing, good hand hygiene, and cleaning of equipment is key to preventing transmission to other patients (the spores are resistant to alcohol hand gels so hand washing with soap is essential). Local infection prevention teams should be made aware of suspected and confirmed cases, for advice on how to prevent transmission.

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t t t .ne .ne .ne Pharmacopoeia X X X k local guidelines and formularies ok ocheck ok and to are advised to always o o Bo Users B B . consult the BNF when. prescribing drugs. w converting enzyme inhibitor. wDose w w ACEi $ Angiotensin-​   See Tables  5.1 w w and 5.2 on how to commence a patient on an  ACEi Indications  Heart failure, hypertension, diabetic nephropathy, prophylaxis of cardioet events  Caution  Pregnancy.nand et breastfeeding, patients already et vascular n n . . taking diuretics, renal artery stenosis/​ r enal impairment, aortic stenX hyperkalaemia, knownkallergy X to ACEi. May not be keffective X in ok osis, o o o o o African-​Caribbean patients  SE  Postural hypotension, B B cough, .Brenal impairment and hyperkalaemia, taste disturbance, and angio-​ w.dry wurticaria w w oedema. If cough w is problematic for the patient, w consider AT II receptor antagonist (E p. 190), or other antihypertensive agent.

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t t t Acetylcysteine (eg Parvolex .ne .ne)  $ Acetylcysteine helpsXreplace .ne X X necessary to k the toxic products formed ok the substrates oofeliminate ok when hepatic metabolism paracetamol is overwhelmed. o o Bo normal B B . is preferred): Dose In adults, 3 doses w.of acetylcysteine are givenorw(5% wglucose • 150mg/​kgw IVw infusion in 200mL 5% glucose 0.9% saline over 1h w ww • 50mg/​kg IV infusion in 500mL 5% glucose or 0.9% saline over 4h • 100mg/​kg IV infusion in 1000mL 5% glucose or 0.9% saline over 16h. t et  Mainly used in known .noresuspected et Indication paracetamol overdose n n . . X p. 509). It should be commenced X X in all patients ok (E okkg, thoseimmediately ok calculated to have ingested >75mg/​ with a staggeredooverdose, or a o o B blood paracetamolwlevel B on the nomogram .Babove the treatment threshold . in Fig. 5.1. Startw treatment within 8h of ingestion—​ do not wait for level if ww w w close to or after this time aswefficacy patient presents of acetylcysteine will w decline rapidly after 8h. Discontinue treatment if the plasma concentration is later reported as below the treatment line and patient is asymptomatic with etLFTs, creatinine, etpatients et n n n normal and PT. Discuss with acidosis, encephalop. . . X worsening renal function,korXPT prolongation with hepatologist X ok athy, o available locally). ok on call (or at nearest liver centre o if not o o B SE Flushing, rash, pruritus, nausea, and vomiting all relatively w.B urticaria, w.B are w w common during treatment. More severe anaphylactoid reactions (dBP, ww w w iHR, bronchospasm) should be managed as per E pp. 484–5 with infusion slowed or stopped.

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t t t Actrapid .ne  $ Insulin. See insulin. .ne .ne X X X k IV bolus;   $ Nucleoside ok Adenosine ok(antiarrhythmic).  Dose  6mgorapid orapid o needs repeated dose 12mg rapid IV bolus, then 12mg IV bolus Bo ifIndication B B . tachycardia  CI 2nd/​3rd-​dwegree . heart block,  Supraventricular sick w sinus syndromew(unless pacemaker fitted), longwQT syndrome, COPD/​ w w asthma Caution Pregnancy, recent MI, pericarditis, heart block, bundle branch block, accessory pathway, hypovolaemia, valvular lesions  SE Nausea, sinus pause, etbradycardia/​asystole, flushing,.nangina, et dizziness. et n n . . XAdrenaline (epinephrine); X anaphylaxis  $ Catecholamine. kXif inadok Dose  0.5mg/​STAT IM (0.5mL ok of 1:1000); repeat afteroo5min o o equate response  Indication B B   Suspected anaphylaxis; .Bif in doubt give w.and it  Caution  Cerebro-​ cardiovascular disease  w SE  iHR, iBP, anxiety, w w sweats, tremor, w arrhythmias. w ®

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t t et Amiodarone; arrhythmias  $ Dose .ne .neClass  III antiarrhythmic. X .nOral X X 8h PO for 1wk,kthen 200mg/​12h PO for 1wk, then ok loadingPO 200mg/​ o IV loading. Initially 5mg/​kg over ok20–​200mg/​ as maintenance dose; o o Bo 24h B B . then further infusion if necessary . of up 1to20min IVI (with ECG monitoring) 1.2g w w over 24h IVI Indication  SVT, nodal and ventricular tachycardias, atrial fibrilw w w VF (see above) CI  Bradycardia, w sinoatrial heart block, ww lation and flutter, thyroid dysfunction, iodine sensitivity Caution Pregnancy, breastfeeding, thyroid disease, hypokalaemia, heart failure, bradycardia SE N+V, taste et raised etelderly, et n n n . . . disturbance, transaminases, jaundice, bradycardia, hypotension, pulX toxicity, corneal deposits, X X ok monary ok skin discolouration Info Monitor ok LFTs and o o o TFTs every 6mth. B .B channel blockers. w.B wcalcium-​ Amlodipine See w w w  $ Beta-​lactam. Dose  500mg–​ ww Amoxicillin 1g PO/​IV 8h  Indication w Infection  CI  Penicillin allergy  Caution  Glandular fever, CMV infection, ALL/​e CtLL SE N+V, diarrhoea, rash. et et n n n . . . X XDose  500mg–​1g PO/​IV 6hkXIndication   $ Beta-​lactam. ok Ampicillin okCaution o infection, Infection CI Penicillin allergy    Glandular fever, o CMV o o B ALL/​CLL SE N+V,wdiarrhoea, rash. B .B . w Antacids/​alginates ww   Dose  See Table  5.3  wwIndications  Acid reflux ww

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t t t Antiemetics   Dose  See Table  5.4  .ne .neIndications  N+V see Table X5.5; .nenot X X effective k all causes of N+V  Caution kand SE  See ok all antiemetics areimportant o toforestablish the cause of N+V. o oo Bo Table 5.4 Info It is w B B . . w w classification Table 5.4 w Antiemetic ww ww Antihistamines Cinnarizine, cyclizine, promethazine t t IM Cyclizine Dose 50mg/​8h PO/​eIV/​ e et n n CI Heart failure .n . . X X SE Drowsiness, pain on injection, urinary retention, kX vision ok oblurred ok dry mouth, o o o B .B Phenothiazines droperidol, perphenazine, wChlorpromazine, w.B prochlorperazine, trifluoperazine w w w Dose Consult BNF; 10mg/​8w ww Prochlorperazine h PO, 12.5mg/​24h IM, 3–​ 6mg/​12h buccal CI Parkinson’s, epilepsy t e et hypotension, drowsiness, agitation et SE Extrapyramidal effects, n n n . . . X X X Domperidone, ok Dopamine ok metoclopramide ok antagonists o o o B .B 10mg/​8h PO/​IV/​IM w.B Metoclopramide wDose CI Avoid in patients 80yr, 133mmol/​L)B Caution in patients with significant bleeding Bo atinine B . dose before removing epidural risk. Wait 30h afterwlast and wait w. catheter w w 5h until next dose  SE Anaemia; bruising; haemorrhage; nausea Info No w w ww routine anticoagulant monitoring required (INR tests are unreliable).

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t t net Aspirin; .ne analgesic/​antipyretic .ne  $ NSAID.  Dose  300–​X9.00mg/​ X X 4g/​ 24h  Indication pyrexia  CI  As for k ‘Aspirin; ok 4–​6h PO; max ok‘Aspirin;  Pain, ofor Caution  As ofor antiplatelet’  SE  As ‘Aspirin; o Bo antiplatelet’  B B . . antiplatelet’. w w AT II receptor ww antagonists Dose See Table 5.7; ww commence therapy ww in the same way as starting an ACEi (E p. 184)  Indications Patients intolerant of ACEi; heart failure, hypertension, diabetic nephropathy, et of cardiovascular events  et Caution  Pregnancy and .breastet prophylaxis n n n . . Xfeeding, renal artery stenosis/​ X renal impairment, aortickinXstenosis, ok hyperkalaemia, known allergy ok to ACEi. May not be effective o o oo African-​ Caribbean patients .SE   Postural hypotension, renal impairment and B B B . w disturbance, urticaria andwangioneurotic w hyperkalaemia, taste oedema; cough can occur wwbut is less common than with ACEi. w ww Table 5.7  II receptor antagonists t et AT Dose e et n n n . Candesartan Initially 4–​8mg/​.24h PO up to max 32mg/​24h PO . X X 50mg/​24h PO up to max 300mg/​ ok Irbesartan Dose Initiallyoo75–​k1X ok24h PO o o B B 24h PO Losartan Dose Initially .100mg/​ w.B 25–​50mg/​24h PO up towmax w Valsartan Dose Initially 80mg/​24h PO up to max 320mg/​24h PO w w w ww Atenolol See beta-​blockers.

t t t .ne .ne inhibitor. See statins. X.ne Atorvastatin  $ HMG CoA X reductase X  k$ Anticholinergic.  Dose  500micrograms/​ ok Atropine; bradycardia ok oo3mg/​ o 24h Indication Bradycardia Bo STAT IV every 3–​5wmin;.Bmax B . CI Glaucoma, myasthenia gravis, pyloric stenosis, prostatic w enlargement Caution Down’s syndrome, ww GORD  SE Transient bradycardia, ww antimuscarinic ef- ww fects (constipation, urinary urgency and retention, pupil dilatation/​loss of accommodation, dry mouth). t et cardiac et Atropine; arrest  .$ Dose  3mg/​ n neAnticholinergic.  . .nSTAT X X X IV  Indication   non-​ s hockable cardiopulmonary arrest  Caution   None ok the arrest situation SE Asofor ok‘Atropine; bradycardia’ Infoo Atropine ok is noin o B longer recommended.B use in non-​shockable w for routineGuidelines). w.Bcardiopulmonary w arrest (see 2015 Resuscitation w w w $ Antibacterial. See mupirocin.w w Bactroban Beclometasone   $ Corticosteroid.t Dose  200–​400micrograms/​12h t  Chronic eIndication et n n n INH  asthma (step 2eBTS guidelines) Caution TB SE  Oral . . . X X bronchospasm (rare) Info X hoarse voice, paradoxical  Different ok candidiasis, okinterchangeable obekprescribed preparations/​devices areonot and should o o B by brand name. w.B w.B w w Bendroflumethiazide   $ Thiazide diuretic. w w Dose  Oedema  5–​10mg/​ ww ®

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t et ne  t$ Beta-​lactam. Dose  X Benzylpenicillin (penicillin .G) 0.6–​ .ne .n1.2g/​ X X 4.8g/​ 24h in k divided doses)  Indication  Infection; ok 6h IV (max ok of skin, endocarditis  CIo  o Penicillin allergy  Caution  History alo Bo throat, B B . . contraceptive pill, lergy SE Diarrhoea Interaction  Decrease effects of oral w w allopurinol increases ww risk of rash. ww ww Beta-​blockers  Dose  See Table  5.8  Indications  Generic indications include:  hypertension, angina, myocardial infarction, arrhythmias, heart failure, etthyrotoxicosis, anxiety, migraine et prophylaxis, benign .essenet n n n . . tial tremor; topically for glaucoma  Caution   Pregnancy, breastfeeding, X abrupt withdrawal especially X in patients with IHD (risk X of reok avoid ok AV block, oksymptoms o o o bound iHR/​ i BP), 1st-​ d egree DM (may mask B dglucose), COPD wCI.B  Asthma, uncontrolled heart w.Bfailure, marked w w w bradycardia,w dBP, 2nd/​3rd-​degree AV block, wsevere peripheral arterial w disease  SE Bradycardia, hypotension (especially postural), heart failure, bronchospasm, conduction disorders, peripheral vasoconstriction, t nightmares, insomnia),neim-t et fatigue, sleep disturbance e(often headache, n n . . .effect potence  Info  The cardioselective β-​ b lockers (Table 5.8) have less Xon β receptors but are not kcardiospecific X X k k and bronchoconstriction can o o opatients. oo (atenolol, occur in susceptible Water-​soluble β-​.bB lockers Bo still B . w excreted by the kidneys andwa dose reduction is nadolol, sotalol) are often necessary wwin renal impairment; thesewarewalso less likely to cause ww 2

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t t t Betamethasone cream See topical .ne .ne corticosteroid. .ne X X X k   200mg/​8h PO; modified-​ ok Bezafibrate  $ Fibrate.ooDose orkelease preo BNF  Indication  Hyperlipidaemias unresponsive Bo parations available,wcheck B B . w.primary biliary cir- w to diet and other measures  CI  Hypoalbuminaemia, w w rhosis, gall bladder w disease, nephrotic syndrome, w pregnancy and breast- w feeding Caution Renal impairment (see BNF for reduced dosing), hepatic impairment, hypothyroidism SE GI disturbance, anorexia, cholestasis. t et  See et n . .ne Bisoprolol beta-​blockers. .n X X X k (Eg Klean-Prep , oMoviPrep k ok Bowel cleansing preparations , oo o Bo Picolax , etc)w   $.B Laxative. Dose  Consult BNF.B or local guideline w Indications  Prior to surgery, colonoscopy or w radiological examination CI  Bowel obstruction, ww toxic megacolon  Caution w   Elderly, children, dehy- ww dration SE N+V, abdominal pain and distension, dehydration, electrolyte disturbance    These agents should tnot be used in the treatment of et Info et constipation (see also laxatives). .ne n n . . X X X ok Bricanyl  $ β agonist.oSee okterbutaline. ok o o B Buccastem  See antiemetics w.B (phenothiazine).ww.B w Budesonide w  $ Corticosteroid. Dose  100–​ w800micrograms/​12h INH; ww ®

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t t t .ne   $ Treatment ofXnicotine .ne dependence. Dose Commence .ne Bupropion X X before target smoking ok 1–​2wk ok cessation date, initially 150mg/​ ok 24h PO 6d, then 150mg/​12hoPO (max single dose 150mg;omax total daily Bo for B B dose 300mg)  Indication   Smoking cessation  CI  Acute w. severe w. alcohol or benzo- w diazepine withdrawal, hepatic cirrhosis,w CNS tumour, history of w w  Hepatic impairment, renalwimpairment, pregnancy and w seizures  Caution breastfeeding  SE Dry mouth, GI disturbances, taste disturbance, agitat t tion, e et .n anxiety.  $ Antimuscarinic.XSee.nhyoscine .ne X X Buscopan butylbromide. ok okD  $ Calcium salt. See calcium okcarbonate. o o Bo Calcichew /​Calcichew B B w.   $ Calcium salt.  Dose w  .See BNF Indication w Calcium carbonate w w w dCa   CI  iCa (urine/​serum), w eg malignancy Caution w Osteoporosis, History of renal stones, sarcoid, renal impairment  SE  GI disturbance, dHR,earrhythmias. t et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww ®

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t t et Calcium-​ Dose See Table 5.9 .ne channel blockersX $.nDihydropyridines. .ne X X   iBP, prophylaxis k CI  Unstable angina, k ok Indicationssignificant o of angina  o cardiogenic aortic ostenosis, acute porphyria  Caution Pregnancy, o Bo shock, B B . flushing, breastfeeding, heart .failure  SE  Abdominal pain, N+V, palpiw w tations, dBP, oedema, headache, sleep disturbance, fatigue  Info  The w w w relax smooth muscle and dilate w both coronary and per- ww dihydropyridines ipheral arteries. Nimodipine preferentially acts upon cerebral vascular smooth and is used in the prevention and treatment of ischaemic etmuscle et subarachnoid et n n n . . . neurological deficits following aneurysmal haemorrhage. X X ok Table 5.9  Calcium-​channel okblockers (dihydropyridines) ookX o o B w.B5mg/​24h PO up to max 10mg/​ w2.4hBPO Amlodipine Dose Initially w w w10–​20mg/​24h PO ww Felodipine w Dose Initially 5mg/​24h PO up to max Nifedipine Dose Depends upon preparation. Always specify specific brand consult BNF et for modified-​release (MR).npreparations; et et n n . . Nimodipine Dose 60mg/​ 4 h PO starting within 4d of subarachnoid X X X haemorrhage and ok okcontinue for 21d; IV preparationoavailable, ok o o consult BNF B w.B w.B w w Calcium-​cw hannel blockers  $ Verapamil, w diltiazem. Dose  See ww

B

Table  5.10  Indications  iBP, prophylaxis of angina; verapamil is also used in the management of tachyarrhythmias  CI  Left ventricular failure, bradycardia, 2nd-​or 3rd-​ degree AV dissociation, sick sinus syndrome  Caution Pregnancy, patients taking β-​blockers or other negatively chronotropic drugs, 1st-​degree AV dissociation, acute phase of MI  SE  Bradycardia, dBP, heart block, dizziness, flushing, headache, oedema, GI disturbance  Interactions Unlike the dihydropyridines, diltiazem and verapamil are negatively chronotropic and inotropic and should not generally be used in conjunction with β-​blockers or other negatively chronotropic drugs.

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t t t .ne Calcium-​channel blockers .ne(verapamil, diltiazem) X.ne Table 5.10  X X ok ok ok Dependsoupon preparation; consult. Always o specify specific Bo Diltiazem Dose B B brand for.modified-​release (MR) preparations;. consult BNF w 40–​120mg/​8h PO for SVT; wTypically ww Verapamil Dose 80–​120mg/​8h PO for w w ww angina prophylaxis; 80–​160mg/​8h PO for iBP; 5–​10mg over 5min IV with ECG monitoring for treatment of acute SVT (seek senior help before giving IV inotropes/​ t e et chronotropes) et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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t t t Calcium .ne chloride $ Calcium salt. .neDose 10mL of 10%; giveX1mL/​ .nemin X X  Emergency management of dCa  CI iCa  Caution ok IV Indication ok impairment  ok  History stones, sarcoid,orenal SE Peripheralovasodilatation, Bo ofdBP,renal B B . . gluconate. injection-​site reactions; more irritant than calcium ww   $ Calcium  salt.wDose ww Calcium w gluconate   10mL of 10%; give ww over 3min IV  Indication  Emergency management of dCa , iK CI iCa  tCaution  History of renal stones, renal impairment SE e vasodilatation, dBP, injection-​ et sitesarcoid, et Peripheral reactions. n n n . . . X X salt. Dose  15g/​6–​8h PO; XPR preResonium   $ ok Calcium okCalcium  otokmoderate) o o o parations also available (see BNF)  Indication   iK (mild B .B .B Monitor K . Caution Pregnancy,w breastfeeding  SE GI disturbance  wInfo w w Calpol  $w Simple analgesic. See paracetamol. w ww Candesartan See AT II antagonists. et  $ Imidazole antifungal. eSeet clotrimazole. et n n n Canesten . . . X X ok Captopril See ACEi. ookX ok o o B Carbamazepine .B $ Antiepileptic. Dose  Initially. B 100mg/​12h  PO; w wpreparations Increase  To max 2g/​24h in divided doses; PR w w w w tonic–​clonic, available (see  BNF) w Indication  Antiepileptic; generalized chronic w

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pain, eg trigeminal neuralgia (see BNF for dosing)  CI  AV conduction abnormalities, history of bone marrow depression, acute porphyria  Caution  Pregnancy, breastfeeding, cardiac disease, Hong Kong Chinese/​Thai origin, history of skin conditions SE N+V, dizziness, drowsiness, headache, ataxia, visual disturbance, cytopenias, hepatic dysfunction, skin disorders Interaction Enzyme inducer.

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t t ne tInitially  15–​40mg/​24h  X .ne .Dose .ne Carbimazole  $ Antithyroid. PO; Once X X k for 12–​ ok euthyroid  5–​15mg/​24h PO oask maintenance dose usuallyoogiven o Hyperthyroidism  CI   Severe blood disorders Caution Bo 18mth Indication  w B B . . Pregnancy, breastfeeding, hepatic impairment  SEw   N+V, pruritus, rash, w w agranulocytosis. w w Carvedilol See beta-​blockers. et  See cephalosporin. .net et Cefaclor n n . . X X X ok Cefalexin See cephalosporin. ok ok o o o B Cefotaxime See cephalosporin. w.B w.B w w Cefradinew  See cephalosporin. w Ceftazidime See cephalosporin.

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t t et Celecoxib inhibitor. PO.n (max .ne  $ NSAID/​COX2X .ne Dose 100–​200mg/​12hX X 4h in divided doses)  Indication  Pain and inflammation; ok 400mg/​2rheumatoid okand o kIHD,osteoarthritis ankylosing spondylitis  CI CVD, o o Bo arthritis, B B . Caution Pregnancy, breastfeeding, . HF, allergy to any NSAID  hepatic imw w pairment, renalw impairment SE GI disturbance/​w headache, dizziw w Decreases wbleeding,increases ness Interaction effects of antihypertensives, toxicity w of methotrexate, increased risk of renal impairment with ACEi, AT II antagonists, et or ciclosporin. et et n n n . . . Cephalosporin   Dose  See Table 5.11  Indications  Infections (with known X X X surantimicrobialok sensitivity (consult local guidelines)), ok orgicalsuspected okbe harmful o o o prophylaxis, other prophylaxis  Caution   Not known to B in pregnancy, present w.Bin breast-​milk in low concentration; w.B 0.5–​6.5% of w w w patients whoware penicillin-​allergic will display w allergy to cephalosporins w as cephalosporins contain a beta-​lactam ring as do the penicillins and carbapenems SE Diarrhoea (rarely antibiotic-​associated colitis), N+V, abet discomfort, headache, allergic etreactions  Info Cephalosporins earet dominal n n n . . . amongst the antibiotics which are most likely to result in Clostridium difficile X kX and clindamycin. Asowith kXall antiok diarrhoea, the others being oquinolones o o o biotics, it is important to consult local guidelines as infectious B different susceptibilities B agents have .Bdepending upon geographical .location. w w ww ww ww Table 5.11  Cephalosporins (consult local guidelines)

t t Firstegeneration net .n .n8he PO Indications UTIs, respiratory .tract Cefalexin Dose 500mg (250–​500mg) X X X k sinusitis, skin and soft tissue infections infections, otitisomedia, ok ok o o Bo Cefradine Dosew500mg B B . (250–​500mg) 6h PO Indications w.surgical prophylaxis but generally not used widely now w w w w ww Second generation Cefuroxime Dose 750mg (750–​1500mg) 8h IV, 500mg (250–​500mg) 12h PO; t Indications Gram-​positivenand t t .ne . e Gram-​negative bacteria; surgical .ne prophylaxis X X X ok Third generation ook ok o Bo Cefotaxime Dosew1g.(1–​ B2g) 12h IV Indications better Gram-​ B negative activity, w.bacteria but poorer coverage against Gram-​positive than w w cefuroxime; penetrates the CSF w w ww Ceftriaxone

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Dose 1g (1–​4g) 24h IV Indications better Gram-​negative activity, but poorer coverage against Gram-​positive bacteria than cefuroxime; penetrates the CSF

et et n n . . X Xor 2g/​12h IV; Indications better Gram-​ X 1g (1–​2g) 8hkIV ok Ceftazidime Dose o but poorer opkositive negative activity, coverage against Gram-​ o o o B bacteria.than w B cefuroxime; good activitywagainst w.BPseudomonas w w ww Cetirizinew  $ H antagonist. See antihistamine. Chloramphenicol; drops $ tAntibiotic. Dose 1 drop 0.5%/​2th t frequencyeye ereduce e TOP; as infection Continue for 48h n . .nisecontrolled. .nafter X X X symptoms resolve  Indication  Conjunctivitis, corneal abrasions, post ok surgery SE Transient stinging. ok ok eye o o o B w.B w.B w w w w ww 1

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t t et Chlordiazepoxide  $ Benzodiazepine. .ne .ne Dose See Table 5.12 Indications .nAcute X X X withdrawal treatment/​ rophylaxis  Caution  Pregnancy, breastfeeding, ok alcoholdisease, okprespiratory okrespiratory renal impairment, disease (sleep apnoea, o o Bo liver B B failure), reduce dose in the elderly, avoid abrupt withdrawal  w. confusion, w. SE  Respiratory w ­depression, drowsiness, ataxia, amnesia,w dependence Info Symptoms w w withdrawal tend to occur 12–​4w8h after the last alcoholic drink w of acute alcohol and usually subside 5–​7d after the last drink. A  reducing dose of chlordiazepoxide as a surrogate CNS depressant ethet acts et (which is the effect alcohol ehastto n n . . upon CNS) and it is uncommon.n for physical symptoms of withdrawal X if patients are treated with Xthis sort of regimen; always consider X ok present ok (E ok vitamin o o o supplementation in these patients p. 105); consult local guidelines. B .B w.B regimen for alcohol w Table 5.12  Chlordiazepoxide withdrawal (local w w w differ from this suggested regimen) w ww guidelines may Day 1 20mg/​6h PO Day 5 5mg/​6h PO e2 t et et Day 20mg/​8h PO Day 6 5mg/​8h PO n n n . . . X 3 X 10mg/​6h PO kX Day 7 5mg/​12h PO ok Day o ok o o o Day 4 10mg/​ 8 h PO Day 8 STOP B w.B w.B w w Chlorhexidine w  $ Antiseptic. Indication Skin w preparation prior to sur- ww

B

gery or other invasive procedures (eg vascular access, spinal/​epidural anaesthesia), surgical hand scrub, oral hygiene, antiseptic lubricant (eg Hibitane®)  CI Avoid contact with eyes, brain, meninges, middle ear and other body cavities SE Sensitivity, mucosal irritation. Chlorphenamine $ H1 antagonist See antihistamine. Cimetidine $ Antihistamine (H2 antagonist). See ranitidine. Ciprofloxacin $ Quinolone. Dose 500–​750mg/​12h PO; 400mg/​12h IV Indication Infections:  GI, respiratory, urinary  CI  Pregnancy, breastfeeding, allergy to quinolones  Caution Myasthenia gravis, seizures (reduced seizure threshold), adolescents/​ children, renal impairment  SE  N+V, diarrhoea, tendonitis (including tendon rupture) Interaction  NSAIDs increase risk of seizure, increase levels of theophyllines, increase nephrotoxicity of ciclosporin, increase effect of warfarin. Citalopram  $ Selective serotonin re-​uptake inhibitor. Dose  20mg/​ 24h PO (max 40mg/​24h) Indication Depression, panic disorder CI Active mania, QT interval prolongation  Caution  Pregnancy, epilepsy, cardiac disease, DM  SE  GI disturbance, anorexia, weight loss, dNa+, agitation Interaction MAOI within 2wk. Clarithromycin  $ Macrolide antibiotic. Dose  250–​500mg/​12h PO/​ IV  Indication  Atypical pneumonias, H.  pylori  CI  Allergy  Caution  Pregnancy, breastfeeding, hepatic or renal impairment, concomitant use with statins SE GI upset, irritant to veins. Clindamycin $ Antibiotic. Dose 150–​450mg/​6h PO; up to 4.8g/​24h IV in 2–​4 doses for life-​threatening infections (consult BNF) Indication Gram-​ positive cocci and anaerobes; osteomyelitis, intra-​ abdominal infections, MRSA  CI  Diarrhoea  Caution  Breastfeeding, acute porphyria  SE  GI disturbance, antibiotic-​associated colitis (namely C.  diff ), hepatotoxicity, arthralgia; discontinue drug if patient develops new onset diarrhoea Interaction Increases neuromuscular blockade.

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t et topical corticosteroids. .net Clobetasol .ne propionate cream .n See X X X ok Clopidogrel  $ Antiplatelet. ok Dose  Loading  300mg/​ oSkTAT  PO; o o o B Maintenance 75mg/​w2.4h BPO Indication  Preventionwof.Batherothrombotic events following MI/​ACS/​CVA  CI  Pregnancy, breastfeeding, acw   Hepatic impairment, wincreased w risk of bleeding, ww tive bleedingwCaution recent trauma/​surgery  SE  GI disturbance, bleeding disorders Interaction   Increased risk of bleeding with and anticoagulants; etpump et NSAIDsof clopidogrel. et proton inhibitors may reduce effectiveness n n n . . . X X Dose 1% cream 2–​3 applications/​ X kantifungal.  $ Imidazole ok Clotrimazole oinfections, ok   Avoid o o o 24h  Indication   Fungal skin vaginal candidiasis  Caution B contact with eyeswand.Bmucous membranes, can w .B condoms and damage w w diaphragms SE Local irritation. w w ww Co-​amoxiclav $ Beta-​lactam with clavulanic acid. Dose 375–​625mg/​ 8h PO;t1.2g/​8h IV Indication Infection; where amoxicillin alone is not ape CI Penicillin allergy  Caution et impairment, et propriate   Renal glandular.n fever, n n . . X infection, ALL/​CLL SE N+V, X X ok CMV ok diarrhoea, rash. ok inhibitor o o o Co-​ b eneldopa   $ Levodopa and dopa-​ d ecarboxylase B (benserazide). Dosew  .Initially B 50mg/​6–​8h PO, increased w.B to 100mg/​ w w w 24h or 100mg/​ t wice a week according to response; usual mainten- w w w ance dose 400–​ 800mg/​ day in divided doses  Indication  Parkinson’s disease  Caution Severe pulmonary or cardiovascular disease, psychiatric illness, endocrine disorders, pregnancy and breastfeeding SE GI disturbances, taste disturbances, dry mouth, anorexia, arrhythmias and palpitations, postural hypotension, drowsiness, dystonia, dyskinesia.

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oo B . w BNF  Indication w (carbidopa). Dose w  Depends upon preparation, wconsult w w Parkinson’s disease Caution Severe pulmonary or cardiovascular disease, w psychiatric illness, endocrine disorders, pregnancy and breastfeeding SE t mouth, anorexia, arrhythmias t GI disturbances, taste disturbances, e dry et .npalpitations, .n drowsiness, dystonia, dyskinesia. .ne and postural hypotension, X X X  $ Weak opioids with paracetamol.  Dose  8/​  Two ok Co-​codamol oktablets/​ o5k00mg o o 4–​6h PO (max eight 2 4h in divided doses); 30/​500mg Bo tablets/​ B B . . Two tablets/​4–​6hw eight tablets/​24h in divided doses) Indication w w PO (maxdepression, wileus; Pain  CI Acute respiratory paralytic codeine containing ww w w medicines should not be used in children under 12yr, or in any patient under the age of 18yr who undergoes removal of tonsils or adenoids for et of sleep apnoea  Caution et Pregnancy (especially delivery), et thentreatment n n . . . XCOPD, asthma, renal impairment, X hepatic impairment  SE N+V, Xconstiok pation Info Co-​prescribe olaxatives ok if using opioids for >24h. ok o o B Codeine phosphate B60mg/​4h PO/​IM   30–​ w.B   $ Weak opioid. Dose wCI. Acute (max 240mg/​2w 4h in divided doses)  Indication Pain  respiratory w w w medicines should depression, w paralytic ileus; codeine containing not be w

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used in children under 12yr, or in any patient under the age of 18yr who undergoes removal of tonsils or adenoids for the treatment of sleep apnoea  Caution Pregnancy (especially delivery), COPD, asthma, renal impairment, hepatic impairment; never give codeine phosphate IV SE N+V, constipation Info Co-​prescribe laxatives if using opioids for >24h.

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t t netβ agonist. Dose  500micrograms .ne .ne Combivent   $ Antimuscarinic.with X X X bromide with 2.5mg salbutamol/​ PRN NEB Indication ok ipratropium okairway ok  Prostatic o o and other reversible obstruction, COPD  Caution Bo Asthma B B . SE Antimuscarinic effects (commonly hyperplasia, glaucoma  wheadaches, w. dry mouth), w w fine tremor, tension arrhythmias. w w w w Corsodyl  $ Antiseptic. See chlorhexidine. Cyclizine et  $ Antihistamine (H antagonist). et See antiemetics. .net n n . . Dabigatran  $ Direct thrombin inhibitor. Indication and dose VTE X X prophy­ kXlaxis  after hip/​knee replacement k   110mg 1–​ 4h after surgery,ok followed by o o o If >75yr then 12h for 9 d (30B 1st B Bo 220mg/​ . doin hips) start 12–​24h after (30d . dose. initial dose is 75mg,wfollowed by 150mg/​12h for 9dw in hips). Treatment w of recurrent PE/​DVT Initial of DVT/​PE and wprophylaxis wwdose must follow at least ww 5 days treatment with a parenteral anticoagulant. 150mg/​12h. If >75yr, renal impairment or at increased risk of bleeding: 110mg/​12h. Prophylaxis of stroke et embolism in  non-​valvular.nAFetand 1 risk factor  (Such as previous et andnsystemic n . . stroke or TIA, symptomatic heart failure, DM, HTN, or >75yr): 150mg/​ 1 X X X 2h. ok If >75yr: 110mg/​12h. SEo Abdominal ok pain; anaemia; diarrhoea; ok dyspepsia; o o haemorrhage; nausea. .B Caution Avoid in patients with significant B .B bleeding risk. w Wait 6h after epidural catheter removal to restartwdabigatran.  Info  Dose changes if receiving or w verapamil. No routine anti- ww ww concomitant amiodarone w

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coagulant monitoring required (INR tests are unreliable). Dalteparin  $ Low-​molecular-​weight heparin. Dose  Consult BNF Indication  DVT/​ PE treatment and prophylaxis, ACS  CI  Bleeding disorders, thrombocytopenia, severe hypertension, recent trauma Caution  Hyperkalaemia, hepatic or renal impairment  SE  Haemorrhage, thrombocytopenia, hyperkalaemia  Interaction NSAIDs increase bleeding risk, effects increased by GTN. Desloratadine $ Antihistamine (H1 antagonist). See antihistamines. Dexamethasone $ Corticosteroid. Dose See BNF Indication Cerebral oedema (malignancy), suppression of inflammation/​ allergic disorders, diagnosis of Cushing’s disease, chemotherapy induced N+V CI  Systemic infection  Caution  Adrenal suppression, may precipitate tumour lysis syndrome in patients with some haematological malignancies SE Cushing’s syndrome, deranged blood glucose, osteoporosis, psychiatric reactions, raised WCC (specifically neutrophilia). Diamorphine  $ Opioid. Dose  2.5–​5mg/​4h SC/​IM/​IV Indication Severe pain, ACS/​acute MI, acute pulmonary oedema, palliative care CI Respiratory depression, paralytic ileus, raised ICP/​ head trauma, comatose patients, phaeochromocytoma  Caution  Pregnancy (especially delivery), COPD, asthma, renal impairment, hepatic impairment SE  N+V, constipation, respiratory depression, dry mouth Interaction MAOI Info Co-​prescribe laxatives if using opioids for >24h. Diazepam $ Benzodiazepine. Dose status epilepticus 5–​10mg over 10min IV (max 20mg) or 10–​40mg PR; Other short-​term usage 2mg/​8h PO (max 30mg/​24h in divided  doses) Indication  Seizures, status epilepticus; Short term Anxiety, alcohol withdrawal, muscle  spasms CI  Respiratory depression, sleep apnoea, unstable myasthenia gravis, hepatic impairment Caution Pregnancy, breastfeeding, history of drug abuse, respiratory disease, muscle weakness, renal impairment SE Drowsiness, confusion, muscle weakness.

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t t t Diclofenac .ne   $ NSAID.  DoseX  50mg/​ .ne 8h PO/​PR (max 150mg/​ .n2e4h X X doses)  Indication kPain, inflammation  CI  Pregnancy, peptic ok in divided o okischaemic disease, hepatic impairment, congestive heart failure, o o Bo ulcer B B heart disease, peripheral disease, cerebrovascular w. renalarterial w. GI disease,disease Caution  Breastfeeding, impairment, asthma, paw w w w tients with w significant risk factors for cardiovascular events (eg iBP, w ilipids, DM, smoking)  SE  GI disturbance/​ bleeding, headache, dizzit ness Info  Arthrotec is a preparation e oft diclofenac with misoprostol and e et n n n . . . may reduce GI side effects. X  $ Cardiac glycoside. kEmergency X Xover at loading dose 0.75–​ ok Digoxin o  0.75–​1.5mgIVover ok1mgdoses o o o least 2h IV  Rapid oral loading dose 24h in 3 divided PO B (typically 500micrograms .B PO initially, followed by 250micrograms .B PO 6h w w wtachycardic Maintenance ww later, and furtherw w 250micrograms PO 12h laterwif still dose 62.5–​125micrograms/​24h PO  Indications  Often 2nd-​ line agent in supraventricular tachyarrhythmias (commonly AF and atrial flutter), heart t t failure eCI 2nd-​or 3rd-​degree AV dissociation, e accessory conducting.npathet n n . . ways (eg WPW)  Caution  Pregnancy, recent MI, sick sinus syndrome, renal X X X elderly patients, or iCa   SE  N+V, diarrhoea, ok impairment, okdK , dMgdizziness, okyellow o o o bradyarrhythmias, tachyarrhythmias, blurred or B sion Therapeutic monitoring .B (Table 5.13) should be undertaken .B if toxicity is con-viw w w is poor Info Digoxin is ww sidered (usually presents with N+V) or if ratew control ww

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now rarely used for rapid rate control, with other agents often being used in preference (E pp. 256–61) or DC cardioversion (E p. 546). Digoxin is most often used in the chronic rate control of supraventricular tachyarrhythmias and in heart failure. Digoxin does not restore sinus rhythm, it merely slows conduction at the AV node, limiting the number of impulses passing from the atria through to the ventricles thus controlling ventricular rate. It also acts as a positive inotrope, increasing the force of ventricular contraction If rate not adequately controlled After loading with digoxin, discuss with senior or cardiologist.

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Optimum sampling time 6–​12h post oral dose 1–​2.6nmol/​L (0.8–​ 2microg/​L); typically takes 7d to get to steady state 2 Toxic >2.6nmol/​L (>2microg/​L). Toxicity can occur at levels 2micrograms/​L) oo if >2.6nmol/​ Bo ECG B B . . Tachy-​ wave inversion w and bradyarrhythmias. ST depression/​T-​ wwbradyarrhythmias) Complications wwiK , cardiac dysrhythmias (tachy-​ wand ww Management Airway, breathing, and circulation Continuous ECG monitoring t t e et Treat arrhythmias .ne n n . . Consider digoxin-​ b inding antibody fragments (DigiFab , see BNF) X X kX digoxin overdose if known or o suspected ok ok o o o B w.B w.B w w w w ww +

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t t t Dihydrocodeine  $ Weak opioid. .ne .neDose 30mg/​4–​6h PO (maxX240mg/​ .ne X X divided doses); 50mg/​ 6h IM  Indication  Pain  CI  Acute respirak 4–​Caution ok 24h indepression, oileus  ok delivery), paralytic   Pregnancy (especially o o Bo tory B B COPD, asthma, renal impairment; give w. impairment, hepatic Co-​ wp.rescribe never dihydrocodeinewIV  SE  N+V, constipation  Info w laxatives if wfor >24h. w ww using opioids Diltiazem channel blockers. t et  See calcium-​ eDose et n n n . . . Dipyridamole   $ Antiplatelet.   200mg modified-​release/​ X PO (max 600mg/​24hkinXdivided doses), non-​modified-​ Xrelease ok 12h o (see BNF)  Indication  Secondary ok preveno o o preparations also available B B .B and TIA, adjunct to oral .anticoagulation tion of ischaemicw stroke for w w w prophylaxis ofwthromboembolism associated with prosthetic heart w w valves  Caution  Breastfeeding, aortic stenosis, unstable angina, recent w MI  SE GI disturbance, dizziness, headache, myalgia  Interaction Increases t warfarin, decreases effectnofecholinesterase t effecteof inhibitors. et n n . . . X X X sodium See laxatives. ok Docusate ok Dose 1mg/​24h PO; increase okgradually to o o o Doxazosin  $ α antagonist. B .B .B 2–​4mg/​24h (maxw16mg/​24h)  Indication  Benign w prostatic hyperplasia, w w hypertension  CI   Breastfeeding, hypotension  Caution w w   Pregnancy, hepatic ww

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impairment SE Postural hypotension, headache, dizziness, urinary incontinence Interaction Increases effects of antihypertensives. Doxycycline  $ Tetracycline.  Dose  100–​200mg 12–​24h PO (consult BNF)  Indication  Respiratory tract infections, GU infections, anthrax, malaria prophylaxis  CI  Pregnancy, breastfeeding, renal impairment, age 75yr); Treatment of DVT/​PE and prophylaxis of  recurrent PE/​DVT  Caution  Mitral stenosis and prosthetic heart valves. Avoid in patients with significant bleeding risk.  SE  Anaemia; epistaxis; haemorrhage; nausea; pruritus; rash (rare = allergic oedema).  Info No routine anticoagulant monitoring required (INR tests are unreliable). Monitor LFTs for the 1st year.

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ok Enalapril See ACEi. oo ok Bo Enoxaparin  $wLow-​ .Bmolecular-​weight heparin.wDose .B oDVT/​PE prophyw laxis 20–​40mg/​ 4h SC (E  pp. 420–1); DVT/​w   1.5mg/​kg/​ ww2treatment w PE   treatment 24h SC; ACS   1mg/​kg/​12h Indication DVT/​PE treatment w and prophylaxis, ACS  CI  Bleeding disorders, thrombocytopenia, set t   Hyperkalaemia, hepatic vere ehypertension, recent trauma  Caution ethrombocytopenia, eort n n n . . . renal impairment  SE  Haemorrhage, hyperkalaemia  X kX risk, effects increasedoby GTN. kX ok Interaction NSAIDs increase obleeding o o o B Epilim  $ Antiepileptic. w.B See valproate. ww.B w w w ww ®

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t t t Erythromycin  $ Macrolide antibiotic. 50mg/​ .ne .ne Dose 500–​1000mg/​6h PO; .ne X X X in divided dose (typically 1000mg/​6h IV) Indication ok kg/​24h IVpneumonias. ok 500–​ okto Infection; Commonly used in patients allergic penicilo o Bo atypical B B . . renal impairment, lins CI Allergy Caution Pregnancy, breastfeeding, hepatic or w w concomitant usew w w with statins SE GI upset, irritantwto veins. ww Esomeprazole  $ Proton pump inhibitor. Dose  20–​40mg/​24h PO Indication GORD, H.  pylori eradication Breastfeeding  Caution t SE GICI  disturbance, et PUD, ecancer  et Pregnancy, hepatic impairment, gastric headache n n n . . . XInteraction Proton pump inhibitors kXmay reduce effectiveness ofoclopidogrel. kX ok Felodipine See calcium-​ocohannel o o blockers. B w.B w.BBNF as depends w Ferrous fumarate  $ Iron supplement. Dosew  Consult w upon formulation  anaemia  SE GI disturbance, w w Indication Iron deficiency w dark stools. Ferrous et gluconate  $ Iron supplement. et Dose  600mg/​8h PO.n(see et n n . . BNF) Indication  Iron deficiency anaemia  SE  GI disturbance, dark stools. X X kX  Iron ok Ferrous sulfate $ Ironosupplement. ok oIndication Dose 200mg/​8h PO  o o B deficiency anaemia wSE. GI B disturbance, dark stools.w.B w Fibrinolytic w drugs  $ Plasminogen activator. ww Dose and indications ww

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Depends upon specific agent, see Table 5.14 (also E p. 551) CI Recent haemorrhage, trauma or surgery, coagulopathies, aortic dissection, aneurysm, coma, history of cerebrovascular disease, peptic ulceration, menorrhagia, hepatic impairment; streptokinase should not be used again beyond 4d of first administration due to antibody formation and risk of allergic reactions  Caution  Pregnancy, following external chest compression, old age, hypertension SE N+V, bleeding, hypotension.

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In acute STEMI, fibrinolytic drugs should be used where primary cutaneous intervention (PCI) is not immediately available Alteplase Indications Acute MI, massive PE, acute ischaemic stroke Dose Consult BNF; given as an IV bolus followed by an IV infusion, followed by heparin infusion Reteplase Indications Acute MI Dose Consult BNF; given as two IV boluses 30min apart, followed by heparin infusion Streptokinase Indications Acute MI, DVT, PE, acute arterial thromboembolism, central retinal venous or arterial thrombosis Dose Consult BNF; typically 1.5million units in 100mL 0.9% saline over 1h IV. Do not repeat administration after 4d of initial dose due to risk of allergic reaction Tenecteplase Indications Acute MI Dose Consult BNF; given as an IV bolus, followed by heparin infusion Urokinase Indications Thromboembolic occlusive vascular disease; DVT, PE and peripheral vascular occlusion; occluded iv catheters and cannulae blocked by fibrin clot Dose Consult BNF

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t et ne tBPH  5mg/​24h  PO; male-​ Finasteride   $ Antiandrogen. .Dose .ne .pnattern X X X  1mg/​24h PO Indication  BPH, male-​pattern baldness  ok baldnessadolescents  o  kProstate okCI Females Caution cancer, urinary otract obstruco Bo and B B . testicular pain, sexual dysfunction. . tion SE Gynaecomastia, w w w See metronidazole. ww Flagyl  $ w Antibiotic. ww Flecainide  $ Class  Ic antiarrhythmic. Dose  Initial  100mg/​12h  PO; t5d; 2mg/​kg over 10–​30min slow reduce etto lowest effective dose over e3–​ et n . IV.n (max  150mg) Indication  VT, SVT  CI  HF, history of MI, heart.n block, X branch block  Cautionk  Patients X with pacemakers, AF kSEX  GI disok bundle o fatigue  Interaction o o ooof action inturbance, dizziness, oedema,   Duration B B B . . creased by amiodarone, fluoxetine, quinine; myocardial w w depression with w β-​blockers/​verapamil. ww ww w Flixotide  $ Corticosteroid. See fluticasone. t 500mg/​6h PO; 250–​2000mg/​ Flucloxacillin   $ Beta-​lactam. Dosee   250–​ et et n n n . . . 6h IV Indication   Penicillin sensitive infections, endocarditis, osteomyelitis X of flucloxacillin-​relatedkXjaundice, penicillin allergy  SEk  Diarrhoea, X CI ok History o o o o o ­abdominal pain CautionB impairment Interaction Decrease B .  Renal increases .B effects of oral contraceptive pill, allopurinol risk of rash. w w ww w w50–​400mg/​24h PO/​IV ww Fluconazole   $ Triazole antifungal. Dose ®

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Dependent on indication  Indication Fungal meningitis, candidiasis, fungal prophylaxis CI Pregnancy, acute porphyria Caution Breastfeeding, hepatic or renal impairment SE GI disturbance.

t t t .ne .ne .ne X X X Dose  50–​300micrograms/​ ok Fludrocortisone  $ oMineralocorticoid. ok ok o disease, other adrenal insufficiency, posBo 24h PO  Indicationw  Addison’s B B . . cover  Caution w tural hypotension  CI Systemic infection without antibiotic Adrenal suppression  ww SE Sodium and water retention, ww hypertension. ww Flumazenil $ Benzodiazepine antagonist. Dose 200micrograms/​STAT t t t IV, followed 100micrograms/​1min (max 1mg) Indication .ne by OD/​ .ne if required .ne Benzodiazepine toxicity CI Conditions dependent on benzodiazepX X X k   Benzodiazepine dependence, ok ines, eg status epilepticus  oCaution ok mixed o o arrhythmias. Bo OD SE N+V, dizziness, B B . . w Fluoxetine  w $w Selective serotonin re-​ uptake inhibitor. Dose  20mg/​ w 24h PO (max w 60mg/​24h)  Indication  Depression, w bulimia nervosa and ww OCD CI Active mania  Caution Pregnancy, epilepsy, cardiac disease, DM, bleeding disorders, glaucoma  SE GI disturbance, anorexia, weight loss, e, tagitation  et et n n n dNa Interaction MAOI within 2wk. . . . X X Dose  100–​500micrograms/​ X INH   $ Corticosteroid. ok Fluticasone ok asthma ok 12hCaution o o o (consult BNF)  Indication  Chronic (step 2 BTS guidelines) B .B TB SE Oral candidiasis, bronchospasm (rare). w.Bhoarse voice, paradoxical w w w w 24h PO before con- ww Folic acidw   $ Vitamin  B9. Dose  400micrograms/​ +

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ception and until week 12 of pregnancy; 5mg/​wk for preventing methotrexate side effects  Indication  Pregnancy, folate deficient megaloblastic anaemia, long-​ term methotrexate  CI  Malignancy  Caution  Never give alone for pernicious anaemia; can cause degeneration of spinal cord, undiagnosed megaloblastic anaemia SE GI disturbance.

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t t t Fondaparinux  $ Factor Xa inhibitor. .ne .neDose 2.5mg/​24h SC (2.5mgXloading .ne X X op)  Indication VTE prophylaxis and treatment, ACS   Active ok dose 6h post-​ ok Caution ok CIbleeding bacterial endocarditis    Pregnancy, breastfeeding, o o Bo bleeding, B B disorders, active PUD,. recent surgery, epidural/​spinal .anaesthesia, hepatic w or renal impairment  wwSE Bleeding, purpura, anaemia, wthrombocytopenia. w w ww Furosemide  $ Loop diuretic. Dose  Typically 20–​80mg/​24h PO/​ IV Indication (LVF, pulmonary resistant hypertent Oedema e Severe et oedema), et sion CI dK and dNa , hypovolaemia, renal impairment Caution n n n . . . XHypotension  SE  GI disturbance, Xhypotension, electrolyte disturbances X ok (dK , dNa , dMg ) Interaction ok Increases toxicity of gentamicin, ok digoxin, o o o B NSAIDs  Info IV doses B min (risk of at .80mg should be infused w deafness). w w w w $ Antibiotic. Dose 2% topical w Fusidic acid cream 3–​4 applications/​24h; w oral and IV preparations available (see BNF)  Indication  Staphylococcal t t penicillin-​resistant staphyloskin infections; IV treatment  Osteomyelitis, einfections ebreastfeeding, et n n coccal Caution Pregnancy, monitor LFTs .n SE GI . . X X X reversible jaundice. ok disturbance, ok ok o o o Fybogel  See laxatives. B w.B w.2B4h  PO; Continued w Gabapentin w $ Antiepileptic. Dose  day 1  300mg/​ w w w w +

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t t t .ne .ne .ne X X X ok Gentamicin  $ Aminoglycoside. ok Dose  Once daily  5–​7omg/​ okkg/​24h IV o Bo adjust to serum concentration; B B dosing regimens may be used w. Indicationother w. meningitis, (consult local guidelines)   Infection; w sepsis, endow carditis  CI Myasthenia gravis  Caution Pregnancy, w w breastfeeding, renal im- ww pairment  SE Ototoxic, nephrotoxic  Interaction Effects increased by loop diuretics, t et increases effects of warfarin. et n . .nenext dose is due (but check .nlocal X X X Levels are typically taken 1 hr before ok ok ok first) o o Bo guidelines B B . IV dose 9–​18micromol/​L (5–​10mg/​ Monitoring Peak 1hw post w.L) gentamicin Trough > venous). oDose ok  hyperteno 5–​ 1 0mg slow IV titrated to effect (can repeat Bo sion  25–​50mg/​12hwPO; B B . w.   Hypertension, w after 30min); Heart failure  25–​75mg/​6h  PO Indication w w heart failure  w CI  SLE, severe tachycardia, w myocardial insuffi- w ciency  Caution  Pregnancy, breastfeeding, hepatic or renal impairment, ischaemic cerebrovascular disease  SE Tachycardia, palpit heart disease, ehypotension, etafter et tation, SLE-​like syndrome long-​term, rebound .hypern n n . . Xtension on stopping therapy, kfluidXretention. ok Hydrocortisone cream o See topical corticosteroids. ookX o o B B w.B w.Dose Hydrocortisone IV/​PO  $ Corticosteroid.   Acute  100–​ w w 250mg/​6h IV; w Chronic  20–​30mg/​24h PO win divided  doses Indication ww Adrenocortical insufficiency, acute allergic/​ inflammatory reactions CI Systemic infection  Caution Adrenal suppression  SE Cushing’s syndrome, t t e e et DM, osteoporosis, dyspepsia. n n n . . . X X kX . Dose  Macrocytic anaemia  $oVitamin B ok Hydroxocobalamin okafterwithout o o o neurological involvement   Initially 1mg three times a week IM, 2wk B 1mg/​3mth  IM; Macrocytic B .B anaemia with  neurological .involvement   Initially w w w 1mg on alternate then 1mg/​ ww ww days IM until no furtherwimprovement, ®

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2mth IM Indication Pernicious anaemia, other macrocytic anaemias with neurological involvement  Caution Do not give before diagnosis fully established SE N+V, headache, dizziness.

t t t .ne .ne .ne X X X butylbromidek Anticholinergic. Dose 20mg/​6kh PO (max ok Hyoscine o  $20mg/​ 24h in divided doses); STAT IV/​IM repeated o ooafter 30min Bo 80mg/​ B B . (max 100mg/​24hw in.divided doses)  Indication  GI/​ G U w smooth muscle w spasm  CI  Myasthenia gravis  Caution  Pregnancy, glaucoma, GI obstrucw w whyperplasia, urinary retention wSE Antimuscarinic effects, w tion, prostatic drowsiness. t t t Hyoscine   .$ Dose Antiemetic neAnticholinergic. .ne hydrobromide900micrograms/​ .ne 300micrograms/​6h PO (max X 24h in dividedXdoses); X ok Excessive respiratory secretions ok  200–​600micrograms/​4–​8oh oSCk Indication o Bo Motion sickness, excessive B secretions CI.B Caution w. respiratory w Glaucoma Pregnancy, GI w obstruction, prostatic hyperplasia, urinary retention w SE  Antimuscarinic w effects, sedative Interaction w Decreases effects of ww sublingual GTN. t 6h PO (max 2.4g/​2n4hetin Ibuprofen 4e00mg/​ et   $  NSAID. Dose  200–​ n n . . divided doses)  Indication   Pain, inflammation  CI  Pregnancy, peptic X X. ulcer kXdisease  Caution Breastfeeding, k k hepatic or renal impairment, asthma, GI o o o SE GI disturbance/​ bleeding, headache  Interaction Bo disease  .Boincreases .Bo Decreases effects of antihypertensives, toxicity of methotrexate. w w w ww ww Insulatardw See insulin. ®

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t t t Insulin .ne   Dose When starting orXchanging .ne SC doses, liaise withXdiabetes .ne X diabetes nurse specialist); see Table 5.15 Indications ok team (eg ketoacidosis, ok infusion ok  DM,in hyperkalaemia, maintenance of oeuglycaemia o Bo diabetic B B critical care and post. MI  CI Hypoglycaemia  Caution May need dose adw breastfeeding, renal andwhepatic w. impairment, justments in pregnancy, see w w w BNF  SE Hypoglycaemia, local reactions andw fat hypertrophy at injection w site, rarely allergic reactions  Info Table 5.16 is not an exhaustive list of t insulins. In addition to these single preparations so-​calledebietmixtures et are also ofusedinsulin, n n n . . phasic of two different insulins and often .consist X a rapid-​or short-​acting insulin X X ok ofproportions). ok and a longer-​acting insulin ok(in different o o o B w.B w.B w w Table 5.15  IV infusions of insulins w w ww Indication t with 10units soluble insulinnet Hyperkalaemia 50mL of 50% glucose et eover n n (E pp. 399–403) (eg Actrapid ) .IVI . . 10min XSliding scale X X k k k 50mL of 0.9% saline with 50units soluble insulin (eg o o), often infused at 0–​7mL/​h depending oo upon the Bo (E p. 333) wActrapid B .Bo blood . patient’s sugar w ww ww ww ®

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Table 5.16  Properties of common subcutaneous insulins

t t t Type .neof insulin Example XOnset .ne Peak Max duration .ne X X ok Rapid acting ok 15–​30min 0.5–​1.25h o4–​o6hk o Novorapid Bo Aspart B . .B Lispro Humalog 15–​30min 0.5–​1w .25h 4–​6h w w Apidra w Glulisine w 15–​30min w 0.5–​1.25h 4–​6h ww Short acting t t 2–​3h t Soluble Actrapid 30–​60min 6–​8h .ne and long acting X.ne .ne Intermediate X X Insulatard 6–​10h 14–​ ok Isophane ok 2–​4h o1k8h o o Bo Glargine B B 3–​4h 8–​16h . 20–​24h . wLantus w 720h Detemir Levemir 3–​4h 8h w w w6–​w ww Ipratropium   $ Anticholinergic. Dose  Chronic  20–​40micrograms/​6h t e e t250–​500micrograms/​4–​6.h nNEB et INH (max 80micrograms/​6h); Acute n n . . Caution Glaucoma,X prostatic XIndication Bronchospasm; chronic X and acute  effects. ok hyperplasia SE Minimal antimuscarinic ok ok o o o B w.B w.B w w w w ww ®

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t et ferrous preparations. .net Iron .n See .ne X X X k ok ISMN $ Nitrate. See isosorbide oo mononitrate. .Book Bo ISMO $ Nitrate.wSee.Bisosorbide mononitrate. w w w Isoket  $ Nitrate. See isosorbide dinitrate.w w ww Isosorbide dinitrate IV infusion  $ Nitrate. Dose  2–​10mg/​h IVI Indication ventricular failure, ischaemic chest pain CI Hypotensive et  Left et Caution et n n n . . . conditions, hypovolaemia, aortic stenosis    Pregnancy, breastX hypothyroidism, recent X MI, head trauma  SE  Postural X hypook feeding, ok Info ok tolerance o o o tension, tachycardia, headache    Patients may develop B (tachyphylaxis) to w .B if infused for prolongedwperiods, .B though there nitrates w w are obvious risks about stopping a nitrate infusion; consult senior. w w ww Isosorbide mononitrate $ Nitrate. Dose  initially 20mg breakfast and lunchtime  then  40mg breakfast andt lunchtime PO (max 120mg/​24h et PO e of angina, adjunct in congestive et n n n in .divided  doses) Indication  Prophylaxis . . X failure  Caution As GTN kSEX Postural hypotension, tachycardia, X headok heart o tolerance (tachyphylaxis) toonitrates ok and ache  Info Patients may develop as o o B such it is suggestedwto.B B ensure patients have a nitrate-​f.ree period for 4–​8h w the effects of w to prevent this; w is usual to have this period overnight w itlikely ww when nitrates are least to be needed, hence prescribing them to be given at w ®

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t t t Istin .ne See calcium-​channel blockers. .ne .ne X X X ok Lactulose See laxative.ook ok o Dose   Initially   25mg/​ 2 4h Bo Lamotrigine  $wAntiepileptic. B B . . PO for  14d; w Then 50mg/​24h PO for 14d, increase by max 50–​ 100mg/​24h every 7–​ w 14d until seizures Indication Epilepsy Caution w wwcontrolled (max 500mg/​24h) ww Requires close monitoring of serum levels, pregnancy, breastfeeding, hepatictor renal impairment, avoid rapid e et withdrawal  SE  Rash/​.snevere et skin reactions, cerebellar symptoms, cytopenias. n n . . X X X k inhibitor. Dose  30mg/​24hokPO for 4–​   $ Protonopump ok Lansoprazole o 15mg/​24h PO maintenance    Prophylaxis Bo 8wk, B . H.  pyloriIndication .Boand treatment of peptic ulcers, w GORD, eradication, Zollinger–​Ellison syndr w w Caution  Breastfeeding, w w impairment, gastric ome  CI  Pregnancy  hepatic w ww cancer  SE GI disturbance, headache  Interaction Proton pump inhibitors may reduce effectiveness of clopidogrel  Info Also available as a FasTab t which in the mouth and isn useful edissolves et in patients who are NBM..net n . . X X X ok ok ok o o o B w.B w.B w w w w ww ®

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t t t Laxative .ne  Dose See Table 5.17 XIndications .ne  Treatment and prophylaxis .neof X X (E pp. 316–17)  the patient is k constipated ok constipation okCautionSE Confirm o Chronic consider causes of constipation   See Table 5.17  Info use o o Bo and B B . electrolyte imbalances andwgut. dysmotility. Ensure of laxatives can lead to w adequate water intake and increase fibre intake wwhere possible. Always w wwimpaction consider faecal and other causesw of obstruction before com- w mencing oral laxatives. Combinations of laxatives from different groups can be etused in severe constipation.n(egetlactulose and senna). .net n . X X ok Table 5.17 Laxatives ookX ok o o B Classification w.B w.B Bulk-​forming w Eg Fybogel , Normacol w w CI Difficulty in swallowing, w ww laxatives intestinal obstruction, colonic atony, faecal impaction SE Diarrhoea, flatulence, t e et abdominal distension, .net gastrointestinal obstruction n n . . X X 5mL spoons in water/​12h POkX 1 sachet or ok Fybogel ok twodocusate, o o o Stimulant laxatives Eg bisacodyl, glycerol, senna o B B B . . CI Intestinal obstruction, acute surgical abdomens, active winflammatory bowel disease, dehydration ww pain, N+V ww SE Diarrhoea, hypokalaemia, wabdominal ww ®

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Info Co-​danthramer should only be used in the terminally

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200micrograms/​24h PO at breakfast Indication Hypothyroidism CI Thyrotoxicosis Caution Pregnancy, breastfeeding, panhypopituitarism, adrenal insufficiency, cardiovascular disorders, DM  SE Hyperthyroid-​like symptoms; GI disturbance, tremors, restlessness, flushing Interaction Increases effects of TCAs and warfarin, decreases effects of propranolol.

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t t t Lidocaine .ne   $ Local anaestheticX(amide). .ne Dose  Local anaesthesiaX  1/​.n2/​e4% X SC (max 3mg/​kg (max dose 200mg)); Antiarrhythmic ok solution ok total ok Seeto Indication  Local anaesthesia, ventricular arrhythmiaso(alternative o Bo BNF B B . block, sinoatrial amiodarone)  CI  Myocardial w. depression, atrioventricular wimpairment, node disorders w Caution  Pregnancy, hepatic or renal epilepsy, w w w hypovolaemia  SE  Dizziness,wdrowsiness, confusion, severe hypoxia/​ tin- w nitus Interaction Increased myocardial depression with β-​blockers and other antiarrhythmics, increased risk of arrhythmias et et with antipsychotics. .net n n . . XLignocaine $ Local anaesthetic (amide). See lidocaine. kX ok Lisinopril See ACEi. ookX o oo B B B . . wsalt (mood stabilizer). Dosew wBNF Indication Mania, w Lithium $ Lithium  See bipolar disorder  hypothyroidism, w wwCI Pregnancy, breastfeeding,wuntreated Addison’s disease  Caution  Thyroid disease, myasthenia gravis  SE  GI upset, thirst, polyuria  Interaction  Diuretics, NSAIDs  Info  Lithium citrate et carbonate et interchangeable et and lithium doses are not simply d/​w senior/​ n n n . . . X X NPSA on stable regimens kXmonitor level every 3mth.okThe ok pharmacist; have published guidance o onothe ‘safer use of lithium’ andothis should be o B consulted before commencing w.B lithium therapy. ww.B w Monitoring w Optimum sampling time 4–​7d after w commencing treatment 12h ww 1

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oo oo B B . . w (antimotility). Dose 4mg Loperamide $Opioid PO initially then 2mg w w2w PO following every loose stool (max 16mg/​ 4h in divided doses) ww w w Indication Diarrhoea, control of high output stoma CI Pregnancy, IBD, any condition peristalsis should nott be stopped; constipation, ileus, t et where megacolon  Caution Hepatic impairment, promote fluid and electron . .ne can .ne lyte depletion in the young SE Abdominal cramps, constipation,X dizziness X X ok Info Loperamide should notobek used in infective diarrhoeas oorkdiarrhoea o Bo associated with IBD.w.Bo B w. w w Loratadine $ H antagonist. See antihistamine. w w ww Lorazepam  $ Benzodiazepine. Dose  Sedation/​anxiety  1–​4mg/​ 24h PO/​ IM/​IV; Seizures  4mg slow IVt (repeated once after 10min tif et Indication needed)   Sedation, seizures, status epilepticus  CI  Respiratory n . .nemyasthenia .ne X X X depression, sleep apnoea, unstable gravis, severe hepatic k breastfeeding, history of drug kabuse, reok Caution Pregnancy, ooweakness, oSEo  Drowsiness, Bo impairment  B B spiratory disease, muscle renal impairment  . . w w confusion, muscle weakness. ww ww ww

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t t et Magnesium sulfate  $ Magnesium  .ne .ne salt. Dose  2–​4g IV overX5–​.n15min X X followed by an infusion (see BNF) Indication Arrhythmias, MI, seok oftenasthma, oekclampsia, ok acute pre-​eclampsia/​ dMg   Caution Pregnancy, monitor o o Bo vere B B . N+V, hypotension, BP, RR, urinary output, w. hepatic or renal impairment  wSEwith thirst, flushed w skin  Interaction  Risk of hypotension calcium-​channel w ww blockers Infow  Magnesium sulfate 1g equivalentw to 74mmol. Monitoring Levels should be checked et et every 6h while on IV therapy or moreet n n magnesium urgently if indicated; Therapeutic range 1.7–​3.5mmol/​L .n . . X 1.0mmol/​L Normal plasma X X ok 0.7–​ okrangerange ok o o o 1.7–​ 3 .5mmol/​ L Therapeutic B .B w.B 2.5–​5.0mmol/​L w ECG changes (QRS widens) w w wL Reduction in tendon reflexesw ww 4.0–​5.0mmol/​ >5.0mmol/​L Loss of deep tendon reflexes t >7.5mmol/​ L Heart block, respiratory e et paralysis, CNS depression .net n n . . >12mmol/​ L Cardiac arrest X X X ok ok ok o o o B Maxolon  $ Antiemetic See.B metoclopramide. w.B (dopamine antagonist). w w w Mannitol w $ Polyol (osmotic diuretic). Dose w   0.25–​2g/​kg/​4–​8h over ww 2+

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30–​ 60min IVI (max 3 doses) Indication Cerebral oedema, glaucoma CI Pulmonary oedema, cardiac failure Caution Pregnancy, breastfeeding, renal impairment SE hypotension, fluid and electrolyte imbalance.

t t t .ne .ne .ne X X X k (antimuscarinic). Dose  135–​   $ Antispasmodic ok Mebeverine oIndication ok150mg/​8h o o (20min before food)    GI smooth muscle cramps; IBS/​diBo PO B B verticulitis  CI Paralytic w. ileus  Caution Pregnancy,wacute w. porphyria  SE Very w w rarely rash, urticaria. w w w Meropenem $ Carbapenem antibiotic. Dose 500–​1000mg/​8h IV (dose doubled in severe infections)  Indication   Aerobic and anaerobic Gram-​ t et and etCaution n n positive Gram-​negative infections    Pregnancy, breastfeeding, . . .ne X X X hepatic or renal impairment, sensitivity to beta-​ l actams  SE  GI disturbance ok okcolitis, headache, deranged LFTs. ok antibiotic associated o o Bo including B B . . formulation, conMesalazine $ Aminosalicylate. Dose Depends upon ww ww  Mild/​ sult BNF; POwand PR preparations available w Indication moderate ac- ww tive ulcerative colitis and maintenance of remission  CI Salicylate allergy, coagulopathies Caution Pregnancy, breastfeeding, hepatic or renal impairment SE GI upset, bleeding disorders.

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et et n n . . X  $ Biguanide. Dose kX Initially 500mg/​24h PO with ok Metformin oAfter ok breakfast; o o After 1wk  500mg/​12h  PO; further 1wk  500mg/​8hoPO if required B (max 2g/​24 in divided doses) Indication Type 2 DM, w.orBrenal impairment  w.Bpolycystic ovarian w syndrome CI Hepatic Caution  Ketoacidosis, potential w w w of lactic acidosis, iodine-​containing w contrast, general an- w increased risk aesthesia SE GI disturbance, metallic taste. et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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t t net Methadone  $ Opioid. Dose Usual .ne .nerange 60–​120mg/​24h PO;X.should X X given more frequently than 12h if on prolonged use; ok not bepatient’s ok usual oktheestablish dose fromothe dispensing pharmacy, o Bo the B B . information Indication Aid .in withdrawalpatient may not tell you accurate from w w opioid dependence, chronic pain CI Acute respiratory depression, paraw w w ICP/​head trauma, comatose w patients, phaeochromo- ww lytic ileus, raised cytoma  Caution  Pregnancy (especially delivery), arrhythmias, hepatic or renal impairment  SE N+V, constipation, etInteraction et respiratory depression, edryt n n n . . . mouth   MAOI within 2wk. X X kX10mg/​ ok Methotrexate $ Dihydrofolate ok reductase inhibitor. Dose o 2.5–​ o o o B wk PO (max 25mg/​ BIndication Rheumatoid arthritis, disease, ww.k)  w.BCrohn’s psoriasis, ALL, w non-​Hodgkin’s lymphoma  CI  Pregnancy, breastfeeding, w hepatic or w renal impairment, active infection, w immunodeficient syn- ww dromes  Caution  Blood disorders, effusions (especially ascites), peptic ulcer, ulcerative colitis  SE GI disturbance/​ ucositis, pulmonary fibrosis, et myelosuppression  et m NSAIDs, etri-t pneumonitis, Interaction co-​trimoxazole, n n n . . . X Info  Patients usually kXalso prescribed folic acidoduring kX treatok methoprim  ment with methotrexate.oo o o B Methylprednisolone   $ Corticosteroid. Dose 0mg/​24h PO; wI.MB(exceptionally, w 2.4h2–​B4for 10–​ 500mg/​ 2w 4hwIV/​ up w tow 1g/​ up to 3d) ww

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Indication Acute inflammatory disease, cerebral oedema (associated with malignancy), graft rejection  CI  Systemic infection  Caution  Adrenal suppression SE Cushing’s syndrome, DM, osteoporosis Interaction Duration decreased by rifampicin, car­bamazepine, phenytoin; duration of action increased by erythromycin, ketoconazole, ciclosporin.

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Metoclopramide $ Dopamine antagonist. See antiemetic.

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Metoprolol See beta-​blockers.

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t Anaerobic and protozoal infections, t Indication sepsis, Clostridium et abdominal .nediarrhoea Caution Pregnancy, .nbreastfeeding, .nealdifficile hepatic impairment, X X X taste, oral mucositis Interaction ok cohol use  SE GI disturbance, okmetallic ok Can o o levels, increases effects of warfarin. Bo increase lithium andwphenytoin B B . wIV. titrated to effect w Midazolam  w $ Benzodiazepine. Dose  1–​10mg w Indication Conscious CI  Breastfeeding, w w sedation, sedation in anaesthesia  w respiratory depression, sleep apnoea, unstable myasthenia gravis Caution Pregnancy, hepatic or renal impairment,thistory of drug abuse, respiratory etmuscle e confusion, muscle weakness. et disease, weakness SE Drowsiness, n n n . . . X X kXE analogue. Dose  treatmentok  800micro  $ Prostaglandin ok Misoprostol odose; o o o grams/​ 2 4h PO in divided  prophylaxis   200micrograms/​ 6 2h  PO B Indication Prophylaxis B treatment of peptic ulcers wCI. Pregnancy, B –​1breast.and w w feeding Caution cerebrovascular w Cardiovascular/​ wwdisease SE Diarrhoea. ww Mixtard  See insulin. et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww 1

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t t net antagonist. Dose  10mg/​ Montelukast   $ Leukotriene .receptor .ne .ne24h X X X in evening  Indication Chronic guidelines), allergic rhinok PO Caution ok asthmaSE(BTS okheadache,   Pregnancy, o breastfeeding    Abdominal pain, o Bo itis  B B rarely Churg–​Strauss. syndrome. w w. Morphinew   $wOpioid. Dose  2.5–​ 10mg/​ 4w hw IV titrated to effect; 5–​ ww 10mg/​4h IM/​SC  Indication  Acute severe pain, chronic pain, acute MI, acute depression, ileus, raised t LVF  CI  Acute respiratory t Cautionparalytic e e et ICP/​ head trauma, comatose patients    Pregnancy (espen n n . . . Xcially delivery), COPD, asthma, X arrhythmias, renal impairment, X hepok atic impairment  SE  N+V, okconstipation, respiratory depression, ok dry o o o mouth Info Co-​prescribe laxatives if using opioids for >24h. B w $.BOpioid. See oral morphine. w.B MST Continus w w w w ww ®

Mupirocin  $ Antibacterial. Dose  Apply to skin up to 3 times/​24h Indication Bacterial skin infections  Caution  Pregnancy, breastfeeding, renal impairment SE Local reactions; urticarial, pruritus, burning sensation, rash.

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et n . X ok N-​acetylcysteine $ Amino ok acid derivative. See acetylcysteine. ok o o o Naloxone  $ Opioid receptor antagonist. Dose  0.4–​ 2 .0mg IV/​ IM/​SC, B .B .B repeat after 2min w if needed (max 10mg) Indicationw  Opioid reversal during OD/​overtreatment  ww Caution Pregnancy, physical wwdependence on opioids, ww cardiovascular disease  SE N+V, hypotension  BNF Emergency treatment of poisoning. t t t Narcan .ne  $ Opioid receptorXantagonist. .ne Narcan is a brandXname .nefor X k See naloxone for opioid overdose ok naloxone that is no longer oused. ok or reo Bo versal of narcosis.w.Bo B w. Dose  30–​60mg/​ w Nefopam  $ Centrally acting non-​opioid analgesic. w w 8h PO (maxw90mg/​8h PO)  Indication Moderate w pain  CI Convulsive dis- w orders  Caution  Pregnancy, breastfeeding, hepatic or renal impairment, elderly,t urinary retention  SE  N+V, nervousness, urinary retention, dry t t e lightheadedness, may colour eurine pink. mouth, n n . . .ne X X X  $ Potassium channel activator. Dose 5–​10mg/​1k (max ok Nicorandil ok Indication o2handPOtreato o 12h in divided doses)    Angina prophylaxis Bo 30mg/​ B B .LVF with low filling ment (not 1st line)  w.CI  Breastfeeding, hypotension, wpulmonary pressures  Caution  Pregnancy, hypovolaemia, acute oedema, w w w w ww ®

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MI SE Headache, flushing, GI disturbance.

Nifedipine See calcium-​channel blockers. Nitrofurantoin $ Antibiotic. Dose 50–​100mg/​6h PO; take with food

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t t net Oramorph  $ Opioid. See oral.morphine. .ne .ne X X X ok Oseltamivir (Tamiflu o)k  $ Antiviral. Dose  Treatment ok of  influo o Prevention of influenza  75mg/​ 2 4h PO for 10d Bo enza 75mg/​12h POwfor 5d; B B . . Indication  Treatment of influenza if started withinw48h of the onset of wexposure prophylaxis of w w Caution  Renal im- ww symptoms, w post-​ influenza  pairment, pregnancy and breastfeeding (use only if potential benefit outweighs (eg during a pandemic))  et riskconvulsions, et SE  GI disturbances, headache, arrhythmias, thrombocytopenia. n n net . . . X X X   $ Antimuscarinic.  Dose  5mg/​8–​12h PO, increase k if reok Oxybutynin ok doses); opreparations (max 20mg/​24h inodivided modified-​release o Bo quired B B also available Indication. Detrusor instability; urinary frequency, urgency and w breastfeeding, bladderwoutflow/​ w. GI obstruction, incontinence CI Pregnancy, w w w Caution Hepatic or renal impairment, w myasthenia gravis  prostatic hyper- w plasia, autonomic neuropathy SE Antimuscarinic effects, GI disturbance. et  $ Opioid. Dose 5mg/​.n4–​e6th PO (max 400mg/​24h); 1–​.1n0mg/​ et Oxycodone n . 4h IV/​ S C titrated to effect  Indication  Pain; moderate to severe CI Acute X X rekXspiratory depression, paralytic k k ileus, chronic constipation, acute abdomen, o o o ICP/​ head trauma, or renal impairment ifo severe, acute Bo raised .Bohepatic .  B w w porphyria, cor pulmonale, comatose patients Caution Pregnancy, COPD, asthma, arrhythmias, impairment  SE N+V, con- ww ww renal impairment, hepaticww ®

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stipation, respiratory depression, dry mouth Info  10mg PO oxycodone is equivalent to 20mg PO morphine. 1mg IV oxycodone is equivalent to 2mg PO oxycodone. Info Co-​prescribe laxatives if using opioids for >24h.

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t t t Oxytetracycline   $ Tetracycline .ne .ne antibiotic. Dose  250–​5X00mg/​ .ne6h X X Acne vulgaris, k   Pregnancy, breastfeeding, renal ok PO Indication age o rosacea  CIstains okand bones) 180micromol/​L (>40mg/​wL)w ww w

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t t et Phenoxymethylpenicillin (penicillin V)  $ Beta-​lactam..nDose .ne .ne X X X PO  Indication  Oral post-​ splenectomy k infections, k (prophyok 0.5–​1g/​CI6 hPenicillin oCaution allergy    History of allergy oo SE  diarrhoea o Bo laxis) B B Interaction  Decrease .effects of oral contraceptive .pill, allopurinol increases risk of rash. ww ww w w Phenytoin  $ Antiepileptic. Dose  Epilepsy  3–​4mg/​kg/​24h PO increased gradually Status epilepticus loading kg IV at no t as necessary; ethan et dose = 20mg/​ et more 50mg/​ min with ECG.n monitoring, maintenance  =  100mg/​ n n . . X6–​8h thereafter IV (see BNF);kmonitor X level (see ‘Monitoring kphenytoin’) X ok Indication Epilepsy, status epilepticus  o CI Pregnancy, breastfeeding, o sinus hypoo o o B tension  Caution  Hepatic Bimpairment, avoid abrupt w withdrawal, .B acute porw.count  phyria; monitor w blood SE Drowsiness, cerebellar effects, hypotension, w arrhythmias,w purple glove syndrome, blood w disorders; Chronic use  coarse facies, hirsutism, gum hypertrophy Info As drug highly protein bound, may need to adjust monitored levels for low albumin (consult pharmacist).

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et et n n . . Trough 40–​80micromol/​ (10–​20mg/​L) X kXLL(>20mg/​ >80micromol/​ L) ok phenytoin 22 Toxic oAtaxia, ok o o o Signs of toxicity nystagmus, dysarthria, diplopia B w.B w.B w w Phosphatewenema See laxatives. w ww Phytomenadione  $ Vitamin  K . Dose  1–​10mg/​STAT PO/​IV det upon indication—​consultneBNF t and/​or d/​w haematologist t pending .ne Bleeding and/​or over-​ .ne Indication a.nticoagulation with warfarin Caution X X X ok Pregnancy, give IV slowly.ook ok o Bo Picolax  See laxatives. B B w. wwith. tazobactam. Dose w Piperacillin with tazobactam  $ Beta-​lactam w w wIndication  Severe infection, infection w in neutropenic patients w 4.5g/​6–​8h IV  (in combination with aminoglycoside) CI Penicillin allergy Caution Pregnancy, t renal impairment, history t breastfeeding, allergy SE Diarrhoea.et .ne  $ Antihistamine .neof penicillin .n Piriton (H antagonist). See chlorphenamine.X X X k k k o ooclopidogrel. oo See Bo Plavix  $ Antiplatelet. B B . . Potassium oralwsupplement  $ Potassium wsalt. Dose  Potassium w  Potassium loss CI ww chloride: 2–​4w g/​w 24h PO (two tablets/​8–​12h)  wIndication 1

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Serum potassium >5mmol/​L  Caution  Renal impairment, elderly, intestinal strictures, history of peptic ulcer SE GI disturbance, upper GI ulceration Info Check serum Mg2+ as this is also likely to be low in dK+.

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t t t Pregabalin .ne   $ Antiepileptic.XDose .n eEpilepsy  25mg/​12h PO Xincreased .ne X to 100–​1k50mg/​8–​12h (max 600mg/​24h divided k in600mg/​ ok every 7dPain/​bya50mg o12h increased every 3–​7d up otoomax nxiety 75mg/​ o Bo doses); B B 24h in divided  doses. Indication  Epilepsy, neuropathic pain, generalized w w. Renal anxiety disorder  CI Pregnancy, breastfeeding  Caution w w w w heart failure, avoid abruptwwithdrawal  SEimpairment, severe congestive  GI disturb- w ance, dry mouth, dizziness, drowsiness. et et See antiemetics. et Prochlorperazine  $ Phenothiazine. n n n . . . X X   2.5mg/​8h PO increased X   $ Anticholinergic. ok Procyclidine oinkdivided Dosedoses; o  5–​k10mgevery 3d up to max 30mg/​24h Acute dystonia IM/​ o o o B .B drug-​induced extrapyramidal .B symptoms IV Indication  Parkinsonism; w w CI Urinary retention, glaucoma, myasthenia w gravis Caution Pregnancy, w ww breastfeeding, hepatic or renal impairment, w cardiovascular disease, pros- w tatic hyperplasia, tardive dyskinesia SE Antimuscarinic effects. et  See beta-​blockers..net et Propranolol n n . . X X X100units  $ Heparin antagonist.  1mg IV neutralizes k ok Protamine ok50mg Dose o 80–​ o heparin IV in last 15min o (max at rate 10mg/​24h with food. Reduce dose in renal impairment. et et inhibitor. See statin. .net Rosuvastatin  $ HMG CoA reductase n n . . X X ok (r) tPA $ Plasminogen activator. ok See fibrinolytic. ookX o o B Salbutamol  $wβ.Bagonist. Dose  Chronic w airways .B disease  100–​ 200micro­gramsw aerosol/​200–​400micrograms w powder INH PRN (max wgrams/​24h in divided doses);w2.5–​5mg/​4h  NEB; Status ww 400–​800micro­

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asthmaticus 2.5–​ 5mg/​ PRN NEB; 250micrograms/​ STAT (diluted to 50micrograms/​mL) slow IV, followed by maintenance infusion of 3–​ 20micrograms/​ min (3–​ 24mL/​ h of the 50micrograms/​ mL solution), titrated to heart-​rate Indication Asthma; chronic and acute, other revers+ ible airway obstruction, eg COPD, iK   Caution Cardiovascular disease, DM, hyperthyroidism SE Fine tremor, nervous tension, headache, palpitation, muscle cramps.

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Salmeterol  $ Long-​acting β2 agonist. Dose  50–​100micrograms/​12h

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oo oo B B . . Senna See laxatives. ww ww w w w Seretide   $ Long-​acting β agonist with corticosteroid. Dose  25–​ w 50micrograms salmeterol with 50–​ fluticasone/​ 12–​ t (depends upon inhaler ndevice, t500micrograms 24h INH see BNF)  Indication  Asthma e e et n n . . . (E p. 279) Caution Cardiovascular disease, DM, hyperthyroidism, X SE Fine tremor, nervouskXtension, headache, palpitation, X ok TB  o voice, paradoxical bronchospasm ok muscle o o o cramps, oral candidiasis, hoarse (rare) B Interaction See salmeterol .B and fluticasone. .B w w w w Dose 50mg/​24h ww winhibitors. Sertralinew  $ Selective serotonin re-​uptake

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PO increased by 50mg increments at intervals of at least 1wk until desired effect (max 200mg/​24h)  Indication  Depression, OCD, panic disorder  CI Hepatic or renal impairment, active mania  Caution Pregnancy, epilepsy, cardiac disease, DM  SE  GI disturbance, anorexia, weight loss Interaction MAOI within 2wk, inhibits p. 450 enzymes.

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t t t Sevredol .ne  $ Opioid. See oralXmorphine. .ne .ne X X ok Simvastatin $ HMG CoA okreductase inhibitor. See statin. ok o o Bo Slow-​K  $ Potassium B B w. salt. See potassium oralwsupplement. w. w Sodium valproate  $ Antiepileptic. See valproate. w w ww Sotalol See beta-​blockers. et et diuretic (aldosterone .nantaget Spironolactone   $ Potassium-​ sparing n n . . X Dose 100–​200mg/​24hkPO X(max 400mg/​24h) Indicationk Oedema/​ X ok onist). o nephritic o heart ascites in cirrhosis/​malignancy, syndrome, congestive o o o B failure CI  Pregnancy, .Bbreastfeeding, hyperkalaemia, wCaution w.B hyponatraemia, Addison’s disease    Renal impairment, w porphyria  SE  GI disturbw w gynaecomastia, menstrual w irregularities Interaction ww ance, impotence, Increases digoxin and lithium levels; risk of iK when used with ACEi or AT II receptor et antagonists. .net et n n . . Statins  $ HMG CoA reductase inhibitor. Dose  See Table 5.18  Indications X X X ascular primary and prevention of cardio­ ok Dyslipidaemias, ok secondary ok vbreasto o o disease (irrespective of serum cholesterol)  Caution   Pregnancy, B feeding, hypothyroidism, w.B hepatic impairment,whigh w.Balcohol intake, SE w w Myalgia, myositis GI disturbance, w w (in severe cases rhabdomyolysis), w ®

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t t t .ne .ne .ne X X X ok Table 5.18 Statins ook ok o Bo Atorvastatin Dose B B . 24h PO w. Initially 10mg/​24h PO up to max w80mg/​ w Fluvastatin Dose Initially 20mg/​24h PO up tow max 80mg/​24h PO w Dose Initially 10mg/​24h PO upwto max 40mg/​24h PO ww Pravastatin Rosuvastatin Dose Initially 5mg/​24h PO et et up to max 40mg/​24h PO et n n Simvastatin Dose Initially 10mg/​ 24h PO up to max 80mg/​24h PO .n . . X X X ok Stemetil  $ Phenothiazine. okSee antiemetic. ok o o o B .B w w.B Streptokinase  $ Plasminogen activator. Seew fibrinolytic. w w w ww ®

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t et netIndications  Type 2 DM XCI.  nKeto­ Sulfonylureas   Dose  See Table .5.19  .ne X X  Pregnancy, breastfeeding, hepatic or renal impairment, k agents in obese ok acidosis  Caution oline okencourage should not be 1st-​ patients as will o o Bo porphyria; B B further weight gain  SE w.   N+V, diarrhoea, constipation, w. hyponatraemia, w hypoglycaemia,w hepatic dysfunction, weight gain  Info Hypoglycaemia rew w hours and must always w sulting fromw sulfonylureas can persist for many be treated in hospital; sulfonylureas should not be given on the day of surgery etdue to the risk of hypoglycaemia. et et n n n . . . X X X ok Table 5.19 Sulphonylureas ok ok o o o Glibenclamide Dose.B 5mg (2.5–​15mg) 24h PO mane Info.Long acting; use B cautiously w in the elderly wB w w Gliclazide w Dose 40–​80mg (40–​160mg) usually w 24h PO mane (max ww 320mg) Info Medium acting Glipizide Dose 2.5–​5mg (2.5–​15mg) et et usually 24h PO mane (max .net 20mg) Info Short acting n n . . X X g) divided throughout the daykPO X 0.5–​1.5gk ok Tolbutamide Dose o (0.5–​2acting o with meals Info Medium o o o B w.B w.B Symbicort   w $ Long-​acting β agonist withw corticosteroid. Dose  6–​ w w ww ®

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12micrograms formoterol with 100–​ 400micrograms budesonide/​ 12–​24h INH (depends upon inhaler device, see BNF)  Indication Asthma (E p. 279), COPD  Caution  Cardiovascular disease, DM, hyperthyroidism, TB SE Fine tremor, nervous tension, headache, palpitation, muscle cramps, oral candidiasis, hoarse voice, paradoxical bronchospasm (rare) Interaction See salmeterol and fluticasone.

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oo B . Synacthen  $ wSynthetic corticotrophin (ACTH). wwSee tetracosactide. ww w w Tamiflu  $ Antiviral. See oseltamivir. t t Tamoxifen  $ Oestrogen receptor antagonist. Dose Breast cancer 20mg/​ et for other 24h indications consult BNF receptor-​ .nPO; .ne Indication Oestrogen X .ne X X cancer, anovulatory k infertility CI Pregnancy oCaution k  Breas ok positive breast othromboembolism, o o increased risk of occasional cystic ovarian Bo tfeeding, B B . swellings in pre-​mw enopausal women  SE Hot flushes, w. vaginal discharge/​ w bleeding, menstrual suppression, GI disturbance  Interaction Increases efw w w w w fects of warfarin. Tamsulosin  $ α antagonist. Dose 400micrograms/​ 24h PO Indication etprostatic et et Benign hyperplasia  CI .Breastfeeding, hypotension, hepatic n n n . . Ximpairment  Caution  Renal impairment  X SE  Postural hypotension, X headok ache, dizziness, urinary oincontinence  ok okeffects of Interaction  Increases o o B antihypertensives.w.B w.B w Tazocin  $ Beta-​ lactam with tazobactam. Seew piperacillin. w w ww

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Pharmacopoeia

t t et  10–​20mg/​24h PO at bedtime Temazepam  $ Benzodiazepine. .ne .nDose .ne X X X dependency (max 4wk course) Indication ok or preoperative; ok common ok sleep preoperative oanxiety  CI  Respiratory depression, apo Bo Insomnia, B B . gravis, hepatic impairment  . Caution Pregnancy, noea, unstable myasthenia w w breastfeeding, w abuse, respiratory muscle weakw history ofSEdrug ww disease, ww ness, renal impairment   Drowsiness, confusion, muscle weakness. Tenecteplase  $ Plasminogen activator. t t See fibrinolytic. e e et n n Terbutaline   $ β agonist. Dose   500micrograms/​ 6h INH; 5–​.1n 0mg/​ . . X 12h NEB; oral preparationskXare also available, consult BNF XIndication ok 6–​ o airway obstruction, uterine ok relaxation Asthma and other reversible o o o B .B  Cardiovascular disease,wDM, .Bhyperthyroidism during pregnancy w Caution SE Fine tremor,w nervous tension, headache, palpitation, muscle cramps. w w w ww Tetanus vaccine and immunoglobulin E p. 451. t Tetracosactide (Synacthen )  $ e250micrograms etSynthetic corticotrophin (ACTH). et n n n Dose IV/​IM Indication  Diagnosis of Addison’s disease .Caution . . X X breastfeeding, allergic SE  Cushing’s syndrome, kX DM, ok Pregnancy, ok bedisorders  o o o osteoporosis Info Blood should sampled for cortisol pre-​ doose and again B at 30min post Synacthen guidelines). w.B dose (consultant local w w.B w Tetracycline w   $ Tetracycline antibiotic.wDose  250–​500mg/​6h PO ww 2

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et et n n . . X PO depending on severity BNF); ParenteralkX 2–​ 3 pairs ok 24h ok ) (consult  o o oo Indication of a­mpoules/​ 8h IV (Pabrinex (consult local guidelines) B B B . . Nutritional deficiency, especially alcoholism Caution  Reports of anaphylaxis with parenteral wwpreparations. ww w w ww Thyroxine $ Thyroid hormone (T ). See levothyroxine. Tinzaparin   $ Low-​molecular-​weight Dose  Depends upon et consult et heparin. et n n . . indication, BNF  Indication   DVT/​ PE prophylaxis and .n treatX CI  Breastfeeding, bleeding X X severe thrombocytopenia, ok ment  okCautiondisorders, okor renal o o o hypertension, recent trauma   Hyperkalaemia, hepatic imB .B thrombocytopenia, hyperkalaemia  .B Interaction pairment SE Haemorrhage, w w NSAIDs increase wwbleeding risk, effects increased wwby GTN. ww

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Pharmacopoeia

w 221

t t et Tiotropium   $ Antimuscarinic.n (anti-​M3). Dose  18micrograms/​ .ne .n2e4h X X X for inhalation also (see BNF) Indication Maintenance k available ok INH; solution o Renal ok hyperof COPD Caution impairment, glaucoma, o prostatic o Bo treatment B B trophy, cardiac rhythm w. disorders SE Minimal antimuscarinic w. effects. w Tirofiban w $w Glycoprotein IIb/​ IIIa inhibitor. Dose w   Initially  400nano- ww grams/​kg/​min for 30min IV; Then 100nanograms/​kg/​min IV for at least 48h (max 108h treatment) Indication  Prevention in unstable anetSTEMI et abnormalof MIbleeding/​ et gina/​ N patients  CI  Breastfeeding, cerebron n n . . . history of haemorrhagic stroke, Xvascular accident within 30d,kX Xsevere ok hypertension, intracranialoodisease  ok or renal Caution  Pregnancy, hepatic o o B impairment, increased .Brisk of bleeding, surgery orwmajor .B trauma within w 3mth SE Bleeding, reversible thrombocytopenia. w w w w Topical corticosteroids   Dose  Consultw BNF; guidance on applying w topical steroids can be found on E p. 180  Indications  Inflammatory conditions of the skin, eg eczema, dermatitis amongst etCI  Untreated et orcontact et n n n others  bacterial, fungal, viral skin lesions, rosacea, . . . X dermatitis, widespread X psoriasis Caution Useklowest X pook perioral ok plaque tency agent possible (Table 5.20) for shortest duration o ofotime to limit o o B side effects SE Localw Thinning .B of the skin, worseningwlocal .B infection, striae and telangiectasia, acne, depigmentation, hypertrichosis; Systemic Rarely w w w w ww

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B 222

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Chapter 5

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Pharmacopoeia

t t net  Acute infection  200mg/​X12h  Trimethoprim   $ Antibiotic. .Dose .ne .nePO; X X   100mg/​ 24h POkat  night Indication  Urinary k ok Prophylaxis oCaution  Pregnancy, breastfeeding, o tractrenalinfecCI  Blood dyscrasias  o o Bo tions  B B . SE  GI disturbance, rash, . hyperkalaemia im-In pairment, folate deficiency  w w teraction  Increases w phenytoin levels, increases wwrisk of arrhythmias with ww amiodarone.w Valproate Antiepileptic. Dose 300mg/​ 12h PO increasing by 200mg e3dt (max $2.5g/​ et Indication etCI every 24h in divided.n doses) Epilepsy: all forms n n . . acute porphyria Caution Pregnancy, XFamily history of hepatic dysfunction, X kXimpairment, ok breastfeeding, hepatic oroorenal ok (bleeding blood disorders o o B risk), SLE, pancreatitis   GI disturbance, sedation, headache, cerebellar .B decreased w.BSEblood wEffects effects, hepatotoxicity, disorders Interaction by w w antimalarials, wantidepressants, antipsychoticswand antiepileptics. ww Monitoring Trough 350–​700micromol/​ (50–​100mg/​L) et etLL(>180mg/​ et valproate 2 Toxic >1260micromol/​ L) n n n . . . X X X ok Valsartan See $ AT II oantagonists. ok ok o o B .B .B 6h PO; 1–​1.5g/​ Vancomycin $w Glycopeptide antibiotic. Dose 125mg/​ wvancomycin w w 12h IV; some centres use continuous infusions of (consult ww w w local guidelines)  Indication  Serious Gram +ve infections:  endocarditis, MRSA, antibiotic associated colitis  Caution  Pregnancy, breastfeeding, renal impairment, avoid rapid infusion, history of deafness, inflammatory bowel disease SE Nephrotoxicity, ototoxicity, blood disorders, rash (red man syndrome) Interaction Increased nephrotoxicity with ciclosporin, increased ototoxicity with loop diuretics.

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Pharmacopoeia

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t t t Warfarin   Loading  Typically .ne  $ Coumarin. DoseX .ne E p. 422; MaintenanceX .ne X PO dictated by the INR (though higherkdoses and ok 1–​5mg/​on24halternative oareknotpatient’s o days uncommon) Indicationo  Prophylaxis of o Bo dosing B . thromboembolism (atrial fibrillation, mechanical heart.B valves, etc), treatw w ment of venousw thrombosis or pulmonary embolism  CI Pregnancy, peptic w whypertension, ww Caution ulcers, severe bacterial endocarditis   Breastfeeding, w hepatic or renal impairment, conditions in which risk of bleeding is increased (eg GI bleeding, peptic ulcer, recent ischaemic et postpartum, etrecent surgery, et n n n . . . stroke, bacterial endocarditis), uncontrolled hypertenX recent SE Haemorrhage,krash, X alopecia Interaction Avoidkcranberry X ok sion oInfo Warfarin o of 0.5mg o o o juice (ianticoagulant effect)  is available in tablets B (white), 1mg (brown), w.B3mg (blue), and 5mg (pink) wbut.Bcheck which tab- w lets are stockedw locally. w w w w Zolpidem  $ Non-​benzodiazepine hypnotic. Dose  10mg/​24h PO at night Indication  Short-​term treatment of CI Breastfeeding, set impairment, t insomnia  ehepatic eillness, et vere psychotic neuromuscular respiratory n n n . . . X X X apunstable myasthenia respiratory failure,ksleep ok weakness, ok orgravis, o weakness, noea Caution Pregnancy, o hepatic renal impairment, muscle o o B history of drug abuse  disturbance, .B headache. w.SEB Taste disturbance, GI Dose w 3.75–​ w Zopiclonew  $w Non-​benzodiazepine hypnotic. 7.5mg/​24h PO ww w

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t t t .ne Resuscitation .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww Early warning scores  226 care  228 t Intensive e et et 2 Peri-​arrest  230 n n n . . . 2 In-​ h ospital resuscitation   231 X 2 Advanced Life Support kX (ALS)  232 kX ok o o o o o 2 Arrest equipment and tests  234 B .B 2 Advanced w.BTrauma Life Support (ATLS) w  236 w w 2 w Paediatric Basic Life Support  238 w ww 2 Newborn Life Support (NLS)  242 et 2 Obstetric arrest  244 .net et n n . . X X X ok ok ok o o o B w.B w.B w w w w ww

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Chapter 6

t t t .ne warning scores .ne .ne Early X X X k ok Early detection of the o‘unwell’ ok o o patient This has repeatedly been Bo shown B B . . to improvew outcome. Identification of suchw patients allows suitable w w changes in management, including early involvement of critical care teams ww w w or transfer to critical care areas (HDU/​ICU) where necessary. Identification ‘at-​risk’ patient t  Relies on measurement etphysiologicalof the egenerally etof n n n simple parameters, which deteriorate as the .patient . . X X RR, HR, BP, O saturation, more unwell; thesekinclude of kXlevel ok becomes o omight consciousness, and temp.oRemember that the sick patient not alo o B .BBox 6.1. ways look that unwell.B from the bottom of the bed. See w w w w Scoring of these w parameters Usuallywundertaken by nursing staff ww and it creates a means by which staff can more quickly identify clinical deterioration. In 2017, the Royal College of Physicians updated their et Early Warning Score (NEWS) et and published the NEWS2; et National n n n . . . shown in Fig. 6.1. There is currently no standardized version for pregnant X or paediatrics. Normal Xobservations are awarded akscore X ok patients okattract o for ofeach0, o o o while abnormal observations higher scores. The values B .B score reaches a physiological parameter w.Bare added together. If wthiswtotal w ‘threshold’ value w (≥5, or any individual parameter w scoring 3), the nursing ww 2

1

staff should increase the frequency of observations and alert a doctor to review the patient, depending on local policy/​guidelines.

t t et Trends .ne in physiological parameters .ne  Often more usefulXthan.none-​ X X Some patients k may have abnormal scoresokeven when ok off observations. obecause o o seem relatively ‘well’ For Bo they B Bmechanisms. . thresholds mayofbecompensatory these patients, higher agreed w by .senior doctors, but w bear in mind that w they are also likely to deteriorate w much more quickly. w Take care inwthe interpretation of NEWS. w For example, a patient with w ­severe chest pain can be very unwell yet have a NEWS of 0. See Box 6.2. t t t Patients closely .ne who should be X .ne monitored by suchXscores .ne Include: X ok • Emergency admissions,ounstable ok or elderly patients ook Bo • Patients with pre-​ B e.xisting disease (cardiovascular, respiratory, DM) w.B • Patients whow arew failing to respond to treatment w • Patients who w have returned from ICU/​HDU w or recent surgery. ww Box 6.1  et Key updates in NEWS2  etpatients might constantly.cross et n n . In.nthe original NEWS charts, COPD X thresholds for low oxygen X saturations. As with manykpersistent X ok alarm okdesensitized othis patient o o o alarms, users might become to high scores in B B B for saturations cohort. NEWS2w has. a separate row (“SpO scale w.2”) w if the patient w has been allocated to target saturations of 88–92% to w w ww 2

ensure that they are appropriately monitored. Additionally, in the original score a patient could be confused, but still be considered as not at risk since they were ‘alert’ on the AVPU scale. NEWS2 recognizes new confusion by allocating a score of 3 to this worrying feature as a new category, ‘C’, in addition to a similar score allocated for patients responsive to Voice or Pain only, or Unresponsive (hence CVPU).

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CVPU

≥131 111–130 51–90

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k oo oo B B . . Calling for help isw easily said in an exam situation,w but actually initiating the call is much wharder. It feels a little embarrassing w to have to cancel ww w w the arrest call since it was just a patient fainting, but it was still right to call for help. Remember, the cardiac arrest team can be called for peri-​ arrest patients where you simply need etsenior et many more pairs of hands.nand et n . some support. It’s better.n to prevent a cardiac arrest! Always X ‘Adult/​paediatric/​obstetric X X ok state ok cardiac arrest team tooWard ok A’, even o o if it’s a peri-​ a rrest patient. B w.B w.B w w w w ww 2  Box 6.2  Calling for the cardiac arrest team

B 228

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Chapter 6

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Resuscitation

t t t .ne .ne .ne Intensive care X X X ok section aims to provide oakbrief introduction to the decisions okinvolved in o o Bo This B B referring and accepting. a patient into ICU (Intensive Care w w. Unit). w w What does ICU offer that is different from ward care? w w ww • Close monitoring using non-​invasive and invasive devices (such as arterial and central venous lines) t et support erespiratory failure (some units ecant • .Organ for vascular, renal, or n n n . . X offer cardiac support too) kX ok • 1:1 nursing care and frequent, o intensive physiotherapy.ookX o o B .Bpatient will have Intensivists offer organ w.Bsupport and resuscitation; weach a parent team w overlooking their care who should visit on regular ward w w with ICU). ww rounds (thisw will most likely be your first encounter Admitting a patient onto intensive care  It can sometimes t intensivists ethat etaccept patients, ecer-t seem are ‘reluctant’nto but there are n n . . . tain questions that must be satisfied in order to ensure that a patient X X X can ok benefit from ICU. Patientsohave ok frequently described post-​otraumatic ok stress o disorder following prolonged remind B B us that it is a .B ICU stays; this serveswto.and tough environmentwwith frequent exposure to painful invasive procedw w ures. The decision w to commit a patient to awrigorous treatment pathway ww

B

is a complex process. A possible referral needs to be discussed with your consultant, as the decision to admit will be made by an ICU consultant who will often phone your consultant for further discussion. The information required Includes any known current/​previous wants and wishes, details of the current illness and underlying medical conditions, the response to treatment so far, and the general physical/​functional baseline. This is put together to decide on likely prognosis and trajectory, and therefore whether the benefits will outweigh the risks. What are the patient’s wishes? (Not always possible in the acute setting, but some patients are admitted to ICU electively following planned surgical procedures such as complex open AAA repairs.) The most difficult aspect of the decision is deciding how likely it is that the patient in front of you will go on to have a quality of life that they will find worthwhile. Is ICU really going to make a difference? (Eg ICU cannot entirely replace liver function, but it can support the respiratory system long enough to enable the body to recover from an infection.) Intensive care therapies can be aggressive and unpleasant. You need to ensure that the patient is motivated to endure this, but also has a good pre-​existing baseline to rely upon.

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et et et n n n . . . X X  is another aspect considered. Is the kXthefrequently ok Reversibility ohave okaspresenting complaint something that we chance of reversing (such infection)? o o o B B B Or is this new presentation just the natural sequelae of .their existing disease . w neurological disease process. For example, ww a patient with a degenerative ww and intensive antibiotics ww develops an w infection. ICU can offer organ support while the infection is being treated, but there is little that can be offered if the patient et is becoming breathless because et of diaphragmatic weakness. et n n n . . . If you need help with a sick patient  Call ICU—​ t hey may not X X nekXbut they can advise you on further ok cessarily need to take overoocare ok action. o o B w.B w.B w w w w ww

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Intensive care

w 229

t t t Indications for  intubation  Not intubated .ne .neall patients on ICU are X .ne X X 6.3), ICU offers patients support beyond just managing ok (see BoxPatients ok organ oarek unabletheto are only intubated in situations where they o o Bo airway. B B protect their own airway, will intubate ventilate w. or it may be that ICU what wis. calledand a patient in order to facilitate treatment (this is w ‘an induced w w terms). w ww coma’ in layman’s • Respiratory problems (eg hypoxia, hypercapnia, trauma) t cannot maintain airway, net • Neurological problems (eg low GCSeso et sedation n n . mandatory is required, .e.g. for agitation) X the work of breathing in cardiac X. kX• Physiological reasons (tooreduce k k o o respiratory failure, and acidosis, to prevent hypercapnic Bo failure, Bofor .Binoraised .and cerebral vasodilation ICP, e.g. head injury, w w w ‘neuroprotective meningitis). ww measures’, e.g. in severewencephalitis/​ ww Respiratory wean  Refers to the process of reducing ventilatory support in a patient who is on positive pressure ventilation, in order for the paetbe able to breathe unaided.nbyetthemselves. In a patient who ehast tient to n n . . been on a ventilator for a long period time, has COPD, or who is weak X X X ok and malnourished, this complex ok process may take severaloweeks ok or even o o months. There is no universal protocol. B w.Bstep-​down’ patientwon your w.B ward Receiving an ‘ICU w w w ww

B

When patients no longer need ICU level care, they are ‘stepped down’ to the wards. Generally, a written handover document from ICU should accompany the patient to the ward and sometimes a telephone handover as well. Some questions to consider: • What are the priorities of care for this patient and the next stages? • What happens if they deteriorate? Would ICU readmit them? ICU patients will often be discharged with a plan for re-​escalation • Physiotherapy plans • Have all the central venous and arterial lines been removed? • Are there any drugs prescribed that you are not familiar with? • Remember that there are teams from ICU in each hospital who help with psychological counselling after a prolonged ICU stay. Most hospitals have an outreach team who review step-​down patients.

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Chapter 6

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Resuscitation

t t et .nPeri-​ .ne .ne 2 a rrest X X X ok Call the arrest teamooif kyou are concerned about A,ooB,kor C (see Bo 3 E Box 6.2, p. 227);.call Do not w B for senior help early. w w.Bthink you have to w manage this alone. w w w w Check airway is patent; consider manoeuvres/​adjuncts 2 Airway with C-​spine control int trauma et e CALL ARREST TEAM .net n If no respiratory.effort— 2.n Breathing X X ok 2 Circulation If no palpable ok pulse—CALL ARREST TEAMookX o o B B ≤8—​CALL ANAESTHETISTw.B 2 Disability wIf .GCS w ww ww Airway w • Look inside the mouth, remove obvious objects/​dentures • Wide-​ bore suction under direct vision if secretions present et for et(stridor, et n n • .Listen signs of airway impairment snoring, gurgling, or.n no . X X X ok • air entry) ok ok o o Jaw thrust/​head tilt/​chinolift with cervical spine control in trauma B .B • Oropharyngeal w or nasopharyngeal airway as tolerated. w.B w w Breathingw w ww

B

• Look for chest expansion (does R = L?), fogging of mask (Box 6.4) • Listen to chest for air entry (does R = L?) • Feel for expansion and percussion (does R = L?) • Non-​rebreather (trauma) mask and 15L/​min O2 initially in all patients • Bag and mask if poor or absent breathing effort • Monitor O2 sats and RR • Think tension pneumothorax (in a trauma victim).

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Circulation

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• Look for pallor, cyanosis, distended neck veins • Feel for a central pulse (carotid/​femoral)—​rate and rhythm • Monitor defibrillator ECG leads and BP • Venous access, send bloods and perform ABG if time allows • 12-​lead ECG • Call for senior help early if patient deteriorating.

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Disability—​if GCS ≤8 or falling, CALL ANAESTHETIST • Assess GCS (E pp. 344–5) and check glucose • Look for pupil reflexes and unusual posture • Feel for tone in all four limbs and plantar reflexes.

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k ok Exposure oo oo Bo • Remove all clothing, B B check temp . . w including perineum and back w • Look all overw body for rash or injuries w with a blanket. ww ww • Cover patient 2  Box et 6.4  Signs of life .net et n n . . X X respiratory effortkX • Purposeful movement ok • Regular o ok o o o • Coughing • Speaking B .B • Opening eyes w w.B w w w w ww

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IN-​HOSPITAL RESUSCITATION

w 231

t t et .nIn-​ .ne .ne 2 h ospital resuscitation X X X ok ok ok o o Bo B B w. Collapsed/sick patientww. w w w ww et etand assess et Shout for HELP n n n . . . X X X ok ok patient ok o o o B w.B Signs of life? ww.B w w w ww et et et n n n . . . X X X NO YES ok ok ok o o o B w.B w.B w w w w ww

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CPR 30:2 With oxygen and airway adjuncts

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Assess ABCDE Recognise and treat Oxygen, monitoring, IV access

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Call resuscitation team if appropriate

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Apply pads/monitor t et Attempt et n defibrillation .n . .ne X X X if appropriateok ok ok o o Bo B B . wLife. Support wover Advanced Hand to w w w resuscitation w ww when resuscitation team team arrives t e et2015 guidelines. et Fig. 6.2  In-​hospital resuscitation algorithm; n n n . . . Reproduced with the kind permission of the Resuscitation Council (UK). X X X ok ok ok o o o B w.B w.B 2 Box 6.5 Common causes w w w w ww Arrhythmia E p. 254 Hypoxia E pp. 277–89 Myocardial E p. 250 Pulmonary et infarction et oedema E p. 278 et n n Hypovolaemia E p. 393 Pulmonary embolism E p. 284 .n . . X (UTI/​pneumonia) E p. 494 X X (idK ) E p. 398 ok Sepsis ok Metabolic oEkp. 285 o o o Hypoglycaemia E p. 328 (Tension) pneumothorax B w.B w.B w w w w ww +

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Chapter 6

Resuscitation

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t t et .nAdvanced .ne .ne 2 Life Support (ALS) X X X ok ok ok o o Check airway is patent; consider manoeuvres/​ Bo 2 Airway B B . w w. adjuncts with C-​spine control in trauma w w If no respiratory effort—​CALL 2 Breathing w wARREST TEAM ww If no palpable pulse—​CALL ARREST TEAM 2 Circulation t e et et n . Basic life support  Should be.n initiated and the cardiac arrest.nteam X kX arrest is suspected. okX ok called as soon as cardiac oroorespiratory o Advanced life support is centred around a .‘universal B Bo algorithm’ .Bon a This w w (Fig. 6.3) which is taught standardized course offered hospitals. w ofby amost w wwarrest team  This usuallywconsists The cardiac team leader w (medical registrar), F1, anaesthetist, CCU nurse, and senior hospital nurse: t to other members • Team leader—​gives clear instructions etprovides earterial et n n . • .F1—​ BLS, cannulates, takes blood, defibrillates if.n X trained, gives drugs, performs kXchest compressions (see Box 6.6) kX ok • Anaesthetist—​ obreathing, obag-​ o o o airway and they may choose to mask B .Binsert a laryngeal mask, or intubate .B (E pp.and-​556–7) ventilate the patient, w w • Nurses—​provide give drugs, perform chest ww BLS, defibrillate if trained, ww ww compressions, record observations, note time points, and take ECGs.

Needle-​stick injuries  (E p. 108.) Commonest in times of emer-

t the sharps box nearby nandetnever leave sharps on the bed. gency. neHave net . . . X X X  Can be veryk during a cardiac arrest. k antecuok Cannulation oto difficult o The fossa is the best place look first; alternatively try feet, hands, foreo o Bo bital B B arms, or consider external Take . jugular if all else fails. w . bloods if you are wallow successful, but w don’t this to delay the giving of drugs. w w Occasionally useful in cardiacwarrests, especially K which ww Blood tests can often be measured by arterial blood gas machines. Use a blood gas tto obtain a sample (the femoral t with a green needle (21G) syringe etis .neeasiest—​ .neaskartery often NAVY E p. 530) and a nurse to take the sample.n to the X X X k on the clinical scenario;oifkin doubt fill testsodepend ok machine. Other blood bottles o (E p. 531). Bo all the common blood B . on specific .Bo w Defibrillation Taught courses (eg ILS,wALS) and must not be w trained. The use of automated undertaken w unless ww external defibrillators ww or AEDs (E p. 546) is becoming routine in non-​clinical areas as rigorous trainingtis not required. e arrest drugs  These.nareet now prepared in pre-​filled.nesyr-t n Cardiac . X X 10mL (1:10,000), atropine X (epinephrine) ok inges: adrenaline ok 1mg in300mg okgive(several preparations available), amiodarone in 10mL. Always a large o o o B .Beach dose to encourage it intowthe.Bcentral circulation flush (20mL saline) after . w E inside back cover ww of this handbook for further wwemergency drug doses. ww +

Cardiac arrest trolleys Found in most areas of the hospital. Know

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where they are for your wards. Ask the ward sister if you can open the trolley and have a good look at the equipment within it as they differ between hospitals. They are often arranged so the top drawer contains Airway equipment, the second contains Breathing equipment, the third contains Circulation equipment, and the lower drawer contains the drugs and fluids. You’ll seldom need anything that isn’t on the trolley.

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CPR 30:2 Attach defibrillator/monitor Minimise interruptions

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ADVANCED LIFE SUPPORT (ALS)

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Non-shockable Return of spontaneous Shockable et(VF/Pulseless et et n n (PEA/Asystole) .n circulation VT) . . X X X ok ok ok o o o B w.B w.B w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w wAdvanced Life Support algorithm; w ww Fig. 6.3  Adult 2015 guidelines. Reproduced with the kind permission of the Resuscitation Council (UK).

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When you start to attend arrest calls as a foundation doctor, you can often feel out of your depth and a little useless. That’s not the case at all! Here is a list of incredibly useful things to start immediately when you arrive: • Announce that you will scribe (keep a timed record of drugs and shocks given) and communicate the need for the next dose/​shock loudly to your team • Be a tourniquet for your colleague, this steadies the hand during CPR so IV access is gained faster • Find the notes and start looking through the background so that you can educate the team on the patient’s clinical background which can give significant clues on why the cardiac arrest has taken place.

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2  Box 6.6  What can you do?

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Chapter 6

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Resuscitation

t t et .nArrest .neand tests .ne 2 equipment X X X ok ok ok o o Bo Airway B B . . Jaw thrust  Pull thewjaw forward with your indexw and middle fingers at w mandible. Pull hard enoughwtowmake the angle ofw each your fingers ache. ww Head tilt Gently extend the neck, avoid if C-​spine injury risk. Chin lift chin up with two fingers, avoid if C-​spine injury risk. et et Pull theairway et curved n n . .n the Oropharyngeal   (Guedel) A .rigid, tube; choose Xsize that reaches the angle ofktheXmouth from theplastic X k k tragus of the ear. o oo the tongue back, then.Brotate oo 180° Insert down to avoidB pushing when Bo upside . inside the mouth (do not insert upside down in children). w w Nasopharyngeal tube, not to be used with ww wwairway A flexible, curved plastic ww significant head injury. Choose the size that will easily pass through the nose (size 6–​7mm in most adults); insert by lubricating and pushing horit et into the patient’s nostril (not eupwards). et zontally Use a safety pin through n n n . . . the end to prevent the tube being lost. X X ok Suction Cover the hole onoothekXside of a wide-​bore suction okcatheter to o o B B Secretions in the parts ofwthe cause suction at the .tip. .Boropharynx that w can can be seen directly be cleared. A thinnerw catheter can be used to w clear secretions w in the airway of an intubatedwpatient. ww Breathing

t Non-​re mask A plastic mask with net a floppy bag attached; used netin .n ebreather acutely ill patients to give 780%X O. with a 15L/​min flow rate. X. X k to O ok Standard mask (Hudson mask) okA plastic mask that connectsoodirectly o O with a 15L/​ m in flow rate. Bo tubing; delivers 750% B B w.connects to the O tubingwviawa. piece of coloured w Venturi A maskw that plastic, delivering w either 24%, 28%, 35%, 40%, w or 60% O . Adjust the w flow rate according to the instructions on the coloured plastic connector, eg 4L/​tmin with the 28% Venturi connection. t e mask (Ambu bag) A self-​inflating netto Bag .nand .ne bag and valve that allows .you X X X into an inadequatelykventilating patient. Attach the O to k tubing ok forcebagO with o rate then seal the mask over othe a 15L/​min o flow patient’s o Bo the B B . stands at the head nose and mouth. Easiest person w. with two people; onew wsqueezes to get a firm seal with both hands while the other the bag. The w w wETT or LMA (E p. mask can bew removed to attach the bag to an 558). w Pulse oximeter Plastic clip with a red light that measures blood O saturt Do not rely on the reading ations. Clip onto the patient’s indexefinger. etthere et n n n . . . unless is an even trace on the monitor and the patient has a pulse; X on the different arm fromkX kX the BP cuff. ok use o o o o o Nebulizer This is a 3cm-​ igh cylinder that attaches beneath a mask. The B .Bhhalves cylinder is made of that can be untwisted wtwo w.Bso that the fluid to w w w be nebulizedw can be inserted. The nebulizerw can be connected to a pump w 2

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or directly to an O2 or medical air supply.

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ARREST EQUIPMENT AND TESTS

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t t t Circulation .ne .ne .ne X X X  (E p. 546) Successful requires ECGkmonitoring ok Defibrillation okand defibrillation o oo electrodes identify a shockable rhythm, delivery of current through Bo toattached B B . . to the chest wall. Previously, monitoring was performed w w and green to using ECG leads: red w to right shoulder, yellow to left shoulder, apex w wdeliver current. Most NHS ww (E p. 542). w Separate paddles were applied to trusts now use hands-​free adhesive defibrillation electrodes which are safer t double as monitoring leads (E p. and also edefibrillate et 543). et n n n . . Only if you have been .trained, otherwise many defibrillators X an automated mode (AED) X X ok have ok that can provide computerized ok rhythm o o o analysis and advice. B • Check the adhesive are correctly applied w.Belectrodes w.Bto the chest w • Switch the defibrillator to ‘monitor’ mode w w rhythm is identified, select required w defibrillation energy ww • If a shockable using the circular dial, then charge defibrillator using ‘charge’ button t to stand clear and stand clear • Tellestaff et yourself—​strive to minimize.net n n . . the interruption of chest compressions Xlatest possible moment kX which should continuekXuntil the ok • Check o o oo O , staff, B andoyou are clear (O , top, middle, bottom, self ) B • Check the B . . the rhythm is still shockable then press the ‘shock’ button to w w w Resume CPR, without w w to check rhythm. ww deliver thew charge. pausing

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Blood pressure Attach the cuff to the patient’s left arm so it is out of the way and leave in place. If it does not work or is not believable (eg irregular or tachyarrhythmia) then obtain a manual reading. Venous access  Ideally an orange/​grey venflon in each antecubital fossa; however, get the best available (biggest and most central). Remember to take bloods but don’t let this delay giving drugs.

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Glucose Use a spot of blood from the venous sample or a skin prick to get a capillary sample; clean skin first with water to avoid false readings. Examination GCS, pupil size and reactivity to light, posture, tone of all four limbs, plantar reflexes. Exposure Take all the patient’s clothes off; have a low threshold for cutting them off. Inspect the patient’s entire body for clues as to the cause of the arrest, eg rashes, injuries. Measure temp. Remember to cover the patient with a blanket to prevent hypothermia and for dignity.

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Arterial blood gas Attempts to sample radial artery blood in a patient in extremis may be futile and waste valuable time. Instead, attach a green (21G) needle to a blood gas syringe, feel for the femoral pulse (½ to ⅔ between superior iliac spine and pubic symphysis) and insert the needle vertically until you get blood. Press hard after removal. Even if the sample is venous, it can still offer useful information. Femoral stab  (E p. 530.) If no blood has been taken you can insert a green needle into the femoral vein which is medial to the artery (NAVY). Feel for the artery then aim about 1cm medially. If you hit the artery take 20mL of blood anyway and send for arterial blood gas and normal blood tests, but press hard after removal. ECG Attach the leads as shown on E p. 543. CXR  Alert the radiographer early so that they can bring the X-​ray machine for a portable CXR.

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Chapter 6

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Resuscitation

t t et .nAdvanced .neLife Support (ATLS) .ne 2 Trauma X X X k ok oquickly ok o  This is designed to and safely stabilize B theoinjured patient. Bo ATLS B The purpose of ATLS to provide definitive care all injuries, but to w. is notthreats w.ofthese. w w recognize the immediate to life and to address Remember ww w w to act immediately: 710% of trauma deaths arise from airway obstruction. As with ALS, in ATLS the patient’s care is delivered by a team which will etof a leader and various members. et Details of how to undertake eant consist n n n . . . ATLS course are given in Box 6.7; it is really useful if you are considering X X a kXcareer in the acute servicesoorksurgery. k o o Bo The primary wsurvey .Bo   This allows a rapid wassessment .Bo and relevant management threatening issue is found w to be undertaken. If a life-​ w ww this must bewtreated before moving on to the next step of the primary w survey. The primary survey is as follows: Airway with cervical spine prot ventilation and oxygenation tection et (E OHCS10 p. 782); Breathing: eCirculation et n n n . . . (E OHCS10 Chest trauma, p. 788); with haemorrhage conX (see Box 6.8 and E OHCS10 X Management of shock inktrauma, X ok trol ok examination; oEnvironment;p. o o o 784); Disability: brief neurological Exposure/​ B .B Reassess patient’s ABCDE Adjuncts to primary wsurvey; w.Band consider need w w w for patient transfer. w w w

B

The secondary survey  This follows once all life-​threatening issues

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have been identified and dealt with; the secondary survey is a top-​to-​toe examination looking for secondary injuries which are unlikely to be immediately life-​threatening. See Table  6.1 for a mnemonic to make sure you don’t miss anything. The secondary survey is as follows:  AMPLE history (Allergies, Medications, Past medical history, Last meal, Events leading to presentation) and mechanism of injury; Head and maxillofacial; Cervical spine and neck; Chest; Abdomen; Perineum/​ rectum/​ vagina; Musculoskeletal; Neurologic; Adjuncts to the secondary survey.

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t t t .ne Secondary survey mnemonic .ne .ne Table 6.1  X X X k ok oSecondary ok o o survey Bo Mnemonic B B Has w. Head/​skull w. w w My Maxillofacial w w ww Critical Cervical spine Care t Chest e et et n n n . . . Assessed Abdomen X X kX ok Patient’s oPelvis ok o o o Priorities Perineum B w.B Orifices (PR/​PV) ww.B Or w w w ww Next Neurological Management Musculoskeletal et et definitive care et Decision? Diagnostic tests/​ n n n . . . X X kX Journal, Hughes S.C.A, 23:661–​ from Emergency o Medicine ok Reproduced ok 2, 2006, o o o with permission from BMJ Publishing Group Ltd. B w.B w.B w w w w ww

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ADVANCED TRAUMA LIFE SUPPORT (ATLS)

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t et  It is highly unlikely the.nfounet Trauma .ne and the foundation .ndoctor X X X will be the first k to attend to a major trauma patient, ok dation doctor oinperson ohask sustained ATLS can be applied principle to any patient who o o Bo though B B an injury. Having a logical, wise approach to injured patients minimw. life-​tstep-​ wor. injuries izes the risk of missing hreatening complications which subw w w wbecome debilitating if left unrecognized w sequently may and untreated. If w you are working in the ED you will likely be involved in gaining IV access or t conducting parts of the primary tsurvey under supervision. Get perhaps ewith esurvey; ein-t n n n . . . volved conducting the secondary it is often poorly performed X the adrenaline of performing Xoff. This kX life-​saving interventions wears ok asbitallis essential ounconscious okto report o o o though, as the patient will be unable a B finger fracture, or damaged .B genitalia. .B w w ww ww ww 2 Box 6.7 ATLS course In thetUK, ATLS courses are coordinated Royal College oft e The course is currently.3 days et long,byandthedetails e n n Surgeons. of where . .nand X X X when courses are run can be obtained from the College (E p. 615 for k ok ok a long waiting list for places details). There isousually oo as this is a Bo contact B B . popular course; the .cost for the 3-​day course is around £600. w w The ATLS principles ww provide a structured wwapproach to managing ww

B

complex trauma patients by identifying the life-​threatening priorities and treating quickly. Keep an eye out for new research though as some of the ATLS teachings are not always what are done in practice (eg the ATLS approach to fluid management does not include hypotensive fluid resuscitation now used in many departments). Check with your local protocol over how trauma is best managed. For those who are especially interested in trauma management after sitting the ATLS, then consider the European Trauma or ATACC (Anaesthesia Trauma and Critical Care) courses when you are more senior.

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t et 6.8  On the floor and.nfour more? et .nBox .ne 2  X X X k is hypovolaemia and theoway k to think ok The main cause of shockoinotrauma o Bo about blood loss w B B is that it can accumulate on the floor and in . w. fracturefourcanother places. Long bones can harbour up to 0.75L andw a pelvic hide w several litresw of blood loss. Abdominal and chest w wounds can hold nearly ww your whole blood volume and will required immediate surgical intervention if suspected. See Fig. 6.4 for where tto look for occult blood loss. et e et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X Where to look for occultkX blood loss kXwith ok Fig. 6.4  o Handbook o2016, Reproduced from Baldwin, Oxford of Clinical Specialties, o o o B permission from Oxford University Press. w.B w.B w w w w ww

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Chapter 6

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t et et .nPaediatric .nLife .ne 2 Basic Support X X X k ok okis patent; consider manoeuvres/​oaodjuncts o CheckB airway Bo 22 Airway B . If w poor respiratory effort—​PAEDIATRIC w.ARREST TEAM Breathing w w ARREST TEAM 2 Circulation w If HR 2mm leads) or new LBBB; subsequent Q waves ±T-​wave.n invern n . . LV failure; Troponin WillX be raised Xsion (Fig. 7.1); CXR Cardiomegaly, kXsignsasofECG ok but treatment should not obeowithheld ok alone are findings and o history o B sufficient to make the.diagnosis and early treatment is vital. wforBreperfusion w.B Acute treatmentw  Aim by percutaneous coronary intervenw tion (PCI; angiography with stenting or balloon w w angioplasty) within 12h ww of onset and 2h of first presentation to ED so seek senior help. Give O (15L/​mtin), aspirin (300mg), a P2Y inhibitor ticagrelor, 60mg e or 600mg clopidogrel—​ eseet local (180mg et prasugrel, protocol), diamorphine n n n . . . X 5mg IV), antiemetic (Ekp.X188), and GTN (two puffs SL/​ Xmin until ok (2.5–​ o pain after three SL doses and onotk 5hypotenpain free; infusion if ongoing o o o B sive E p. 203). Consider if PCI cannot.B occur within 2h of w(E.Bpp. thrombolysis wbisoprolol first presentation 550–1). β-​blockadew (eg 5–​10mg/​ w w infarct size and mortalitywbut avoid in COPD, asthma, ww PO STAT) reduces 1

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12

hypotension, AV block, and heart failure. See Box 7.1. Secondary prophylaxis  dmodifiable risk factors (smoking, obesity, DM, iBP, ichol), β-​blocker, statin, anti-​platelets (aspirin indefinitely, P2Y12 inhibitor usually for at least 1yr), ACEi, and anti-​anginals (β-​blockers, amlodipine, nitrates, nicorandil, ranolazine, revascularization). Complications Dysrhythmias (AV block, bradycardia, VF/​VT), LVF, valve prolapse, ventricular septal/​free wall rupture, ventricular aneurysm, pericarditis, Dressler’s syndrome (E OHAM4 p. 154), and recurrent pain.

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Hours oo Days Weeks .BooMonths B . Fig. 7.1  Typical sequential w ww ECG changes followingwanwacute STEMI. w ww Box 7.1  Care after myocardial infarction • Bedtrest for 48h with continuous ECG symptom monitoring t e 12-​lead ECG and thorough.nclinical et andexamination • .n Daily of CVS/​RS.ne X• Thromboembolism prophylaxis X (E pp. 420–2) X ok • β-​blockade unless contraindicated, ok with uptitration ook o o B • ACEi/​angiotensin .IIB receptor antagonist, with uptitration .B • High dose statinw (eg atorvastatin 80mg PO OD)w w w • Discuss modifiable w risk factors and arrangewcardiac rehabilitation ww • Primary PCI patients are at lower risk of complications and have shorter patients twill require risk stratification andt et stays; thrombolysis consideration for inpatient angiography n . .ne in those with new dysrhythmias .ne X X X • Consider electrophysiological studies k ok okand 3mth to review symptoms, in OP clinic at o 5wk oo lipids+BP, Bo • Review B B and optimize cardiovascular risk (E OHCM10 p. 114). . . w w ww ww ww

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t t t 3NSTEMI (non-​ST elevation MI) .ne .ne .ne X X X and interventionkare often less ‘dramatic’ thankfor STEMI, ok K Diagnosis o ooas markedly 1yr survival is poorer.oHigh TIMI/​GRACE scores, as well Bo but B B . . raised troponins, ongoing pain, dynamic ECG changes, and a large area w all suggest higher risk w w of affected myocardium (Box 7.2); ask cardiology w w patients needing emergencywPCI (E OHAM4 p. 44). ww early to identify 2 Worrying signs LV failure, AV block, cardiac dysrhythmia, ongoing pain. Symptoms, et risk factors, and signs Overlap et with STEMI; patients are.older, et n n n . . more comorbid, and present more atypically. X X X ok Investigations  ECG  Can beonormal ok or show ST depression,ooT-​kwave invero of changes; CXR B sion/flattening/​normalization, .B or complete resolution w.Bfrom UA by raised w Cardiomegaly, signsw of LV failure; Troponin K Differentiate w w troponin (Tables 7.2 to local protocols, typically on w w and 7.3); taken according w presentation and 6–​12h after maximum symptom onset. Echo To assess for loss of viable myocardium, regional wall motion structural comt et of MI, et(eg PE,a­ bnormalities, plications and differential diagnoses aortic dissection). .ne n n . . X treatment O (15L/​min), aspirin X clopidogrel (300mg), diamorkX ok Acute ok(E p.(300mg), oSL/​ phine (2.5–​5mg IV), antiemetic 188), GTN (two puffs 5min until o o o B pain free; infusion ifwongoing B not hypo.B pain after three SL doses, w.provided tensive E p. 203), and anticoagulation (2.5mg w fondaparinux E p. 420). w w wbisoprolol 5–​10mg STAT) butw β-​blockade (eg beware patients with COPD, w 2

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asthma, hypotension, AV block, or heart failure. Consider glycoprotein IIb/​ IIIa inhibitors and urgent PCI if high risk/​chest pain despite GTN infusion. Secondary prophylaxis and complications These are broadly the same as in STEMI, though complications are less common.

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oo oo B B . . K  Box 7.2  Risk w ww stratification in ACS Estimation of in ACS allows assessment wmortality wwof the risks and benefits ww of interventions and careful targeting of resources to those patients who stand to the most. Many validated been developedt t benefit emajor et scoresInhave e from trial data, including the Thrombolysis Myocardial Infarction n n . . .nThe X X X (TIMI) score. However, many such trials had restricted entry criteria. k develok Global Registry of Acute Coronary ok Events (GRACE) algorithms owere o o Bo oped B B from a large registry . (94 hospitals, 14 countries, . 22,645 patients) w wNSTEMI, involving patients with all subtypes of ACS (STEMI, and UA). w w ww Risk scoresw can be calculated on admissionw (to predict in hospital and 6mth mortality) and on discharge (to predict 6mth mortality). t and a cardiology opinion for 2 High-​ Will need a CCUebed et risk patients et n n . . consideration of glycoprotein IIb/​ IIIa inhibitors and urgent PCI. .n X intermediate-​risk patients Require X observation to ensure painkXfree and ok Low/​ okrisk stratification o or CT o o oimaging clinically stable, then further stress B B .B to determine need forwithelective PCI. . coronary calcium w scoring, w ww ww ww

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t t et 3 .nUnstable angina .ne .ne X X X based on typical history ok K Diagnosis ok without raised troponin (EoOHAM4 ok p. 44). Worrying signs Featuresoof LV failure, cardiac dysrhythmia. Bo 2Symptoms, B B . and signs  These overlap withwother . forms of ACS; risk factors, w w w typically episodes of angina occurring on minimal provocation or at rest, w to GTN; more frequent and w more severe than patient’s ww with poor response ‘usual’ angina; few symptoms or signs between episodes of pain. t Investigations inversion/​flipping, dynamic et  ECG ST depression, T-​w.ave eflattening/​ et n n n . . ST/​ T -​ w ave changes over time, signs of previous MI; Troponins  −ve. X treatment  As for NSTEMI X(E pp. 251–2); analgesiak(morphine, X ok Acute ok(aspirin, o o o o GTN), antiplatelet agents clopidogrel), limit ischaemia (β-​ B .Bthrombus (fondaparinux).wRisk .B stratify, further blockade), and disrupt w w secondary prophylaxis as w management forw NSTEMI (E pp. 251–2). ww wand Stable angina (E OHCM10 p. 116.) K Frequently encountered in primaryecare, t retrosternal chest discomfort et predictably et n occurring upon exertion.n and relieved by rest and nitrates..n . X X X  Central, heavy chest ok Symptoms ok pain (lasting R), neurological deficits from carotid artery dissection. X X X ischaemia ok Investigations  ECG  Normal okor may show LV strain/​ ok (E o o o mediastinum >8cm (rarely irregularity B pp. 586–8); CXR Widened .Bseen),from w.B wdevelop of aortic knuckle and small left pleural effusion can blood w w tracking down; Echo May show aortic root leak, aortic valve regurgitation, ww w w or pericardial effusion. Urgent CT/​ MR angiography/​ transoesophageal echo. Acute treatment  Seek senior help. Hypotensive  Treat as shock (E pp. 490– t t e X-​match 6 units, analgesia e(IVt 5)..n Oe(15L/​min), two large-​bore cannulae, n n . . Xopioids). Hypertensive Aim to keep Xsystolic BP 75yr and stroke/​TIA. After assessing and reducing the bleeding risk, the stroke risk outweighs the anticoagulation risks for patients with AF and a CHA2DS2VASc score of 2 or more (‘consider’ anticoagulation in men with 1 point). 8

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t t t Atrial .ne flutter .ne .ne X X X tooth’ flutter waves reflecting activity, with ventricular k response ok K ‘Saw 150bpm. oksimilar atrial osuccessful o o Management to AF, except drugs less and Bo around B B . . 78). electrical and ablative cardioversion more so (E OHAM4 p. w w Supraventricular ww tachycardia (SVT)ww ww 2 Worrying signs Heart failure, hypotension, dGCS, or chest pain (E OHAM4 p. 68). et  Palpitations, et et n n Symptoms shortness of.nbreath, dizziness, ±chest pains. . . X factors Previous SVT, structural X X ok Risk ok cardiac anomaly, alcohol, iT ok . o Signs Tachycardia, anxiety,ohypotension if haemodynamicocompromise. B Investigations ECG Narrow .B complex tachycardia (unless wmay w.Bconcurrent BBB) w w w with P waves (which merge into QRST so be difficult to see), regular w rate usually ≥140; Further investigations w QRS complexes,  Only required if w diagnosis in question, otherwise initiate treatment as follows. t Acute etreatment   O , large-​bore IV access et (antecubital fossa). Monitor et n n n . . . rhythm on defibrillator: X manoeuvres (E p. 545)kX X ok • • Vagal o ok o o o Chemical (E p. 545). B Chronic treatment Ifwrecurrent, .B seek cardiology advicewas.Bmay require elecw w trophysiological testing of cardiac conduction ablation. w wpathways/​ ww 4

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t t et Wolff–​ .ne Parkinson–​White syndrome .ne (WPW) (E OHAM4 p. .n80.) X X X   This is a re-​ entrant ok Aetiologywhich ok tachyok o o results from an accessory Bo cardia B B . conduction pathway between the atria w(bundle w. w w and the ventricles of Kent). w w ww It classically appears as a short PR interval and a δ/​delta wave (shown by t t t arrowein .n Fig. 7.5). .ne .ne Treatment Avoid digoxin and verapamil. X X X ok Refer to a cardiologist oforokconsiderok o studies and Bo ation of electrophysiology B B Fig. 7.5  δ wave w.pathway. w. in WPW. ablation of accessory w w w w w w Table 7.5  Anti-​dysrhythmics commonly used in tachyarrhythmias t discussion with a senior.net 3These et drugs should only be used eafter n n . . (should LoadingX dose 300mg/​over 60min IVI via central Xline. line kXAmiodarone k k be given via a central followed by 900mg/​over 24h IVI via central o o o o12h PO forOR but can be given Bo 200mg/​8h PO for 1wk then 200mg/​ Bo vein, B . . peripherally in an w 1wk then Maintenance dose 200mg/​ w 24h PO emergency) ww ww ww Verapamil (avoid if patient 5mg/​over 2min IV; further 0.5–​1mg doses every on β-​blockers) 5min until target rate achieved (total maximum 20mg) OR 40–​120mg/​8h PO

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t t et OHAM4 p. 62.) Ventricular tachycardia (VT) .ne .n (E .ne X X X (>30s), k symptomatic, heart failure, ok 2 Worrying signs Sustainedorooabsent ok hypotenpulse (pulseless VT). o Bo sion, dGCS, chestwpain, B B . w.±chest pain, arrest. w Symptoms Palpitations, dizziness, shortness of breath, w w w trauma, hypoxia, acidosis, longwQT, electrolyte disturbances. w Risk factors IHD, Signs Tachycardia, anxiety, pallor, hypotension, dGCS, shock. et  ECG Broad complex .tachycardia, et P waves not before.nevery et n n Investigations . X rate usually  >150; bldsk  X X K ), urgent TSH, U+E (especially ok QRS, o  Check ok situation and  Mg ; Other investigations Should be directed by o clinical o o B though cardioversion.B w is main priority at this stage. w.B w w Acute treatment w  2 Call senior help. w ww 3 Pulseless VT Call ARREST TEAM. Commence BLS/​ALS (E pp. 232–3). VT with a et pulse O , large-​bore IV cannula et in antecubital fossa; restoration eort n n of.n sinus rhythm with either drugs (eg sotalol, amiodarone loading) . . X cardioversion (under sedation X X low GCS). ok DC oekxcitationunless ok o o o Either SVT with aberrancy/​ p re-​ or VT  Treat as VT. B .B w.Bmay need drug therapy w Chronic treatment This to w maintain sinus rhythm, w electrophysiological w studies/​ablation or implantable w cardioverter/​defib- ww +

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rillator (E OHAM4 p. 62). Try to keep Mg >0.9 and K >4.0.

t  VF (or other dysrhythmia), t tachycardia cardiomyopathy. t Complications .ne .ne .ne Torsades de pointes  X X X k axis (E p. 257). Develops ok This looks like VF but hasoaorotating ok on backo Bo ground of iQT interval B B Give Mg sulphate 2g/​IV (8mmol) win.small(Table 7.6). w. saline) over 15min (dilute volume, eg 50mL ofw0.9% ±overdrive w pacing (E OHAM4 p. 64). w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww 2+

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t t et .ne Causes of prolongedXQT.ninterval .ne Table 7.6  X X k rate ok QTc = QT/​√(RR interval)—​thisoallows ok correction of the QT interval forooheart on an ECG trace. Bo and is usually calculatedwautomatically B B . . 470ms (♀) are abnormal; values w w ww in between these are borderline. There is a dose–​response relationship between risk of cardiac death and prolongation of QTc.* et etsyndrome (autosomal dominant), et Congenital Romano–​W ard n n n . . . Jervell,X Lange–​Nielsen syndrome (autosomal X recessive ok ok associated with deafness) ookX o o B Drugs dysrhythmics (amiodarone, w.B Anti-​ w.Bsotalol,haloperidol, quinidine), psychoactives (thioridazine, w w fluoxetine), antihistamines w w (terfenadine, loratadine), ww antimicrobials (erythromycin, clarithromycin, fluconazole) t e et et Electrolyte disturbance dK , dMg n , dCa n n . . . Complete XSevere bradycardia X heart block, sinus bradycardiakX ok IHD ok myocarditis o Ischaemia, o o B B Subarachnoid haemorrhagew.Bo iintracranial bleed w. et al. J Am wwColl Cardiol ww ww

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t t et .nBradyarrhythmia .neemergency X.ne 2 X X ok ok ok o o Bo 2 Airway B B Check . airway is patent; consider manoeuvres/​ w w. TEAMadjuncts 2 Breathing w If no respiratory effort—​CALL ARREST w w If no palpable pulse—​CALL ARREST w TEAM ww 2 Circulation et for senior help early if patient ethas ‘adverse features’ (Fig. 7.6): et 3Call n n n . . . X X X ok 2 Adverse features/features ok ok o o o B • Systolic BP 3 s No

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t t t .ne .ne .ne Bradyarrhythmias X X X ok ok BP 140/​90, BPM w results of >135/​85, w and one or more of (i) cardiovascular disease, (ii) renal disease, (iii) a 10yr w w w w ww cardiovascular risk of >20%, or (iv) end-​organ damage (eg LVH, eGFR10cm across on AXR otherwise a CT, colonoscopy, or water-​soluble contrast enema may be requested to investigate the cause. Surgery is usually required except for: • sigmoid volvulus—​sigmoidoscopy and flatus tube insertion • faecal obstruction—​laxative enemas (E p. 207) • colonic stenting—​may be offered for tumour palliation • Paralytic ileus Loss of bowel motility can mimic the signs and symptoms of a mechanical blockage. It is a response of the bowel to inflammation locally (eg surgery) or adjacently (eg pancreatitis). The main distinguishing feature is the relative lack of abdo pain, although the pathology responsible for the ileus may cause abdo pain itself. USS abdo, contrast enema, or CT may be required to exclude mechanical obstruction. Treat conservatively with NBM, NG tube, IV fluids (E pp. 394–7) until the underlying pathology improves. Check and correct electrolyte abnormalities, including K+ and Mg2+ both of which may need to be replaced.

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t t t Adhesions .ne .ne .ne X X X  Previous surgery, abdominal k sepsis, IBD, cancer, endometriosis. ok Causes ointermittent oktenderness, o o Symptoms and signs Chronic abdominal pain and Bo may B B . develop bowel (distension, vomiting, w. constipation). wwobstruction Managementw  Analgesia and stool softeners; w maywneed operative division ww of adhesions, but this may lead to new adhesions forming. Bowel infarction (EeOHCM10 p. 620.) t etischaemia/​ ePRt n n n . . . Symptoms   Unwell, sudden-​ o nset severe constant abdominal pain, X PMH AF, MI, polycythaemia. kX kX ok blood; o o o o o Signs iHR (?irregular), generalized B tenderness .B±dBP, iRR, itemp, cold extremities, but few wspecific signs. w.B w w Investigationsw   blds  iWCC, iamylase, w metabolic/​ lactic acidosis; ww Sigmoidoscopy ±biopsy may show pale, ulcerated mucosa. Management resuscitate with IV fluids; analgesia, IV ABx (eg et   NBM, et anticoagulation et n n co-​ amoxiclav 1.2g/​ 8h IV), consider with IV.nhep. . X (E  pp. 420–2), surgicalkX X poor resection is often necessary.kVery ok arin o state prognosis—​clarify premorbid and consider ICU careoasoappropriate. o o B Appendicitis (EwOHCM10 p. .B 608.) w.B w w $ A common diagnostic challenge —​ c omplications w w can be severe if left ww 1

untreated, but 15–​40% of appendicectomy specimens are normal. Can occur in any age group; classical cases are easy enough to spot, variable anatomy and extremes of age can make presentation atypical. Differential UTI, diverticulitis, gastroenteritis, mesenteric adenitis, perforated ulcer, IBD, diverticulitis; Gynae Ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, salpingitis. Symptoms  Central, abdominal colicky pain worsening over 1–​2d then developing into constant RIF pain (sensitivity and specificity of 780%2), worse on moving, anorexia, nausea, vomiting, may have constipation, diarrhoea, dysuria, oliguria (all non-​specific and common). Signs  itemp, iHR, ±dBP, RIF tenderness ±guarding/​rebound/​rigidity, RIF pain on palpating LIF (Rovsing’s sign), PR tender on right (there is no evidence that this has diagnostic utility in adults, but failure to perform PR still considered negligent). Investigations iWCC, neutrophilia>75%, iCRP (a useful triad with negative predictive value >97% in adults, but beware children and elderly); bld cultures (if pyrexial), G+S; US and contrast-​enhanced CT reduce laparotomy rates, but this must be balanced against risks of radiation exposure and local resources. Management Surgery—​NBM, IV fluids, analgesia, IV ABx (eg co-​amoxiclav 1.2g/​8h IV). Laparoscopic approaches reduce scarring, postoperative pain, recovery time, and incidence of wound infections, but require more operative time and higher skill levels than open appendicectomy. If peritonitic, send for immediate surgery, otherwise reassess regularly while awaiting surgery. If diagnostic uncertainty, a short period of safe observation ±imaging can be informative.

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t t t Dyspepsia .ne  (E OHCM10 p. 252.) .ne .ne X X X persistent symptom referable to the upper GI tract.k ink ok $ Anypatients oulcer o Thisandwillrare o o with peptic disease, GORD, oesophagitis, Bo clude B B . upper GI malignancies, endoscopic w. as well as those without wsignificant changes. Aim to identify those at risk of significant pathology, and conw w w in those without. w ww trol symptoms Symptoms Burning retrosternal or epigastric pain, worse on bending and t t nausea, vomiting, nocturnal lying,ewaterbrash (excess saliva), acidereflux, et n n n . . cough, symptoms improved by antacids; symptom patterns are .poorly Xpredictive of endoscopic findings. X X ok Signs o(nok peritonitis), rarely epigastric mass. ok o o o  Epigastric tenderness B B hernia, medicaCommon risk factors Smoking, obesity, pregnancy, w.Bcalciumalcohol, w.hiatus w w tions (bisphosphonates, antagonists, nitrates, corticosteroids, NSAIDs). w w ww Investigations Urgent endoscopy if ‘red flag’ symptoms (chronic GI bleeding/​ iron deficiency anaemia, unintentional weight loss, progressive dysphagia, persistent et vomiting, epigastric mass).noret≥55yr and persistent/​unexplained et n n . . dyspepsia. Else test and treat for H. pylori (Box 9.3). Some reserve testing X those who fail empirical treatment X kXConsider full-​dose o PPI. ok for orkequired PPIwithfor1mth o o o low-​ d ose maintenance or as-​ those who respond. If sympB .Bendoscopy or 24h ambulatorywpH .Bmonitoring. toms persist, consider w w advice Weight loss, smoking Managementw  Lifestyle wwcessation, alcohol reduc- ww 3

tion, avoid foods/​drugs which exacerbate symptoms, especially NSAIDs. • GORD Antacids (E p. 187) PRN if mild; full-​dose PPI for 1–​2mth, then low-​dose or PRN PPI; H2 receptor blockers (eg ranitidine) less effective than PPI, but individual patients may respond better; surgical fundoplication (rarely) if severe • Oesophagitis As for GORD; frequency of surveillance if Barrett’s oesophagus detected requires specialist guidance • Peptic ulcer 1–​2mth full-​dose PPI. 95% of duodenal and 80% of gastric ulcers are related to H. pylori, therefore ensure eradication (see Box 9.3). Gastric ulcers are also associated with malignancy, therefore repeat endoscopy at 6wk to confirm healing. If symptom recurrence, retest, since eradication may require different or prolonged antibiotics, and re-​infection can occur • Gastric/​oesophageal malignancy Urgent multidisciplinary team referral for surgery/​palliation.

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K  Box 9.3 H. pylori infection and eradication • 13C-​urea breath testing reliably detects infection or confirms eradication and is widely used in secondary care; faecal antigen tests are used in primary care • CLO tests require a biopsy taken at OGD and rely upon pH indicator changes • A ‘wash-​out’ period of 2wk off PPI is needed for these tests; serological tests are less reliable, but can be used in a patient on a PPI • Treatment is with triple therapy for 1wk, eg lansoprazole 30mg/​ 12h PO, amoxicillin 1g/​12h PO, clarithromycin 500mg/​12h PO • Regimens containing metronidazole may increase resistance and may be better reserved for 2nd-​line therapy • 2wk courses increase eradication rates by 10%, but are not cost-​effective.

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t t t Diverticular disease (E OHCM10 p. .ne .ne 628.) .ne X X X = diverticulaek(out pouchings) in the large bowel. ok $ Diverticulosis o of diverticulae; acutely symptomatic. ok o o Diverticulitis = inflammation Bo $Symptoms B B . improves with   Abdominal sided, w. pain/​cramps (usually leftww bowel opening),wirregular bowel habit, flatus, bloating, PR bleeding. w w ww Signs itemp, iHR, ±dBP, LIF tenderness, ±peritonitis, distension. Investigations  blds iWCC, iCRP; CT/​colonoscopy direct visut et (necessary et causes Forof indirect/​ alization only to exclude other symptoms). .ne n n . . X X fibre diet, antispasmodics   Diverticulosis  kHigh-​ (eg kX analok Management osenna, E  o  NBM, mebeverine), laxatives (eg p. 207); Diverticulitis o o o B gesia, fluids and ABx amoxiclav 1.2g/​8h IV). .B w.(egB co-​perforation, w Complications  Obstruction, w w (usually painless). abscess, ww adhesions, strictures, ww ­fistula, PR bleeding Renaltcolic (E OHCM10 p. 638.) t e consider other causes.nofe abdominal pain, including.nAAA, et $ .n Always X­especially if no previous renalkstone X disease. kX loin to ok Symptoms Acute-​onset severe o unilateral colicky pain radiating ofrom o o o B groin, nausea and vomiting, B strangury (fresweating, haematuria, dysuria, w.B w.sensation quent, painful passage of small volumes of urinew with of incomw w iliac fossa or suprapubic painwsuggests another pathology. ww plete emptying);

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Signs iHR, sweating, patient restless and in severe pain, usually no tenderness on palpation unless superimposed infection. Investigations  Urine  Hb on dipstick (790% cases), nitrates suggest UTI, β-​hCG if ♀; blds FBC, U+E, Ca2+, urate; CT-​KUB Detects >99% stones. Management Analgesia (NSAID first, then opioids), if 55yr k pancreatitis; this remains widelyokused. The o 15 .× 10 /​L validated for gallstone-​r.elated In w w 1984, Blamey et al.* at the Royal Infirmary Ca (uncorr) w10mmol/​L in Glasgow modified w 8 of the 11 Ranson ww Glucose criteria and validated these for prognostic ALT >100u/​L use in both t alcohol and gallstone inducednet LDHet >600u/​L epancreatitis. acute n n . . . Urea >16mmol/​L X kXAlbumin kX 6cm, faecal suggests uninvolved mucosa; X X kX and ± colonoscopy  Shows appearances/​ lceration ok Sigmoidoscopy okof characteristic ouconsidered. o o o allows biopsy; CT/​MRI If concern abscess and if surgery being B Complications  Toxic wmegacolon, .B bowel obstruction, perforation, w.B malabsorp- w tion, fistulae, fissures, strictures, malignancy. w w w w w

B

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Table 9.8  Differentiating between ulcerative colitis and Crohn’s

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Treatment  This depends upon disease severity. Rehydrate and correct electrolyte imbalances; avoid antimotility/​antispasmodic agents. Systemically well patients with mild–​moderate UC (40yr presenting with altered bowel habit.

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I  Box 9.10  Causes of constipation covered elsewhere

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Chapter 9

t t et .nLiver .ne .ne 2 failure emergency X X X ok ok ok o o Bo 2 Airway B B . airway is patent; consider manoeuvres/​ wCheck w. adjuncts ARREST TEAM 2 Breathing w If no respiratory effort—​CALL w w If no palpable pulse—​CALL w ww ARREST TEAM 2 Circulation If GCS ≤8—​CALL ANAESTHETIST 2 Disability et et et n n n . . . X Altered mental state or coagulopathy X kX in the presence ofojaundice. ok $3Call okif patient deteriorating. o o o for senior help early B w.B w.B Airway w w wthe mouth, wide-​bore suctionwif secretions present ww • Look inside • Jaw thrust/​head tilt/​chin lift; oro/​nasopharyngeal airway if tolerated. et et et Breathing n n n . . . • 15L/​ m in O if SOB or sats 250 white cells/​mm3 or identification of organisms (E  pp. 564–5). Treatment  Prompt IV antibiotics: (eg Tazocin® 4.5g/​8h IV).

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oo B . w sclerosing cholan- w Causes Primaryw biliary cholangitis (E p. 325), primary ww gitis (E p. w 325), autoimmune hepatitis (type I and II—​see Table 9.12); w primary biliary cirrhosis and type I  autoimmune hepatitis may overlap. t fever, malaise, rash, jointnpain, t Symptoms have et   Often asymptomatic, may or.n symptoms of chronic liver disease. .neSigns Signs of chronic liverXdisease. . e X X   blds  Deranged LFT ±iPT, +ve autoantibodies (Table  9.12); ok Investigations ok   Autoimmune ok 30mg/​  And liver biopsy. Treatment hepatitis Prednisolone o o Bo USS B B .azathioprine; Other diseases E p. 24h PO initially then wcirrhosis, w. 325. Complications w Acute liver failure, hepatocellular carcinoma. w w w w w Table 9.12  Autoantibodies in autoimmune liver disease et biliary cholangitis Anti-​m.nitochondrial et (AMA) present in 95%.nandet Primary n . 98% X(780% ♀) Xspecific X ok Primary sclerosing cholangitisookAnti-​ ok (ANA), smooth muscle (SMA), antinuclear o o (770% ♀, 780% IBD) .B p-​ANCA B w w.Bantinuclear (ANA) Autoimmune hepatitis Anti-​smooth musclew (SMA), w type I (80% ♀) w w ww

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Autoimmune liver disease (E OHCM10 p268.)

Autoimmune hepatitis type II Anti-​liver/​kidney microsomal type 1 (LKM1) (mainly children; 90% ♀)

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net net 288.) net Haemochromatosis  (E OHCM10 p. . . . X X X recessive diseasekcausing excess iron accumulation.k ok $ Autosomal-​ o hyperpigmentation,  DM.ooSigns  Hepato  Fatigue, lethargy,oarthralgia, Bo Symptoms B megaly, signs of chronic liver disease, cardiac failure, or.B conduction defects, . w tanned skin. Investigationsw bldsw itransferrin saturation hypogonadism ±impotence, w w false-​negatives esp. in younger w (>60% in ♂ w and >50% in ♀ highly specific, butw ♀),iALT, iglucose, genetic testing (2 common mutations account for 70% of ECG Cardiomyopathy ort conduction delays; Liver biopsy (DiagCaucasian t patients); eseverity). et Treatment Venesection n (1eunit/​wk) until ferritin normalizes then nosis, n n . . . Xevery 3–​6mth; transferrin saturation Xor genetic screening of relatives.kX ok Non-​alcoholic fatty liver okdisease (E OHCM10 p.o285.) o o o B $ Spectrum of damage B from fat deposition in absence of.B other causes. . w hypertension, diabetes,wliver w failure. Investigations Symptoms and signs w Obesity, blds Full liver w screen to rule out other causes; HbA w ; USS ± elastography may ww show fat deposition and evidence of cirrhosis; liver biopsy.  Treatment Weight loss; manage et cardiovascular risk; monitor etfor transplantation. et n α .-​n antitrypsin deficiency (E.n OHCM10 p. 290.) . X Genetic disease with complexkinheritance X X causing liver and lung k ok $Symptoms o liver failure, o damage. and signs  Breathlessness, family history. Investigations o o o B blds dα -​antitrypsinwlevels, .Bgenetic testing; liver biopsy. Treatment w.B  Stop smoking, w COPD treatment. may need liver transplant, w w w w w 1C

1

1

Wilson’s disease (E OHCM10 p. 285.)

$ Autosomal-​recessive disease; copper accumulates in the liver and CNS. Symptoms Tremor, slurred speech, abnormal movements, clumsiness, depression, personality change, psychosis, liver failure, family history. Signs Kaiser–​ Fleischer rings in eyes, signs of liver failure. Investigations blds dcaeruloplasmin, dtotal serum copper, iserum free copper, genetic testing; Urine i24h copper excretion (especially if a dose of penicillamine is given); copper on liver biopsy. Treatment Lifelong penicillamine, may need liver transplant, screen relatives.

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$ Bacterial infection typically transmitted via exposure of skin cuts or mucous membranes to water contaminated with rat urine. Symptoms Recent contact with dirty water, high fever, malaise, anorexia, fatigue, nausea, vomiting, arthralgia, pharyngitis, conjunctival oedema, neck stiffness, photophobia, jaundice, bleeding and kidney failure. Signs Acute liver failure, meningism, bruising, tender RUQ, myocarditis. Investigations Urine Dipstick haematuria, culture; blds dHb (haemolytic), iurea, icreatinine, ibilirubin, iALT, serology. Treatment  Doxycycline 100mg/​12h PO or benzylpenicillin 600mg/​6h IV and supportive care of renal/​liver failure.

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$Predicting outcomes in chronic liver disease This is of considerable importance, not least in prioritizing use of organs for transplantation. The ‘Child’ scoring system originated in 1964 from attempts by Child and Turcotte to assess operative risks for cirrhotic patients undergoing porto-​systemic shunt surgery. Later modifications to include albumin and INR led to the ‘Child–​Turcotte–​Pugh’ score which is still widely used. With the advent of liver transplantation, more precise stratification of patients with advanced disease was needed: for the NHS transplantation programme, the UKELD (UK end-​stage liver disease) score is calculated from serum Na+, creatinine, bilirubin, and INR. The original description of the UKELD score (Neuberger J, et  al., Gut 2008;57:252) is available online at Mgut.bmj.com/​content/​57/​2/​252.abstract (subscription required, but many NHS trusts provide access through ATHENS). Online calculators for the Child score are widely available (eg Mwww.mdcalc. com). Information on the NHS transplantation programme, including liver transplants and a UKELD calculator is available at Mwww.organdonation.nhs.uk

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Chapter 9

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Pre-​hepatic Haemolysis, malaria. Hepatic  Paracetamol overdose, viral hepatitis, alcohol, chronic liver disease, Gilbert’s syndrome, pregnancy, medications (E p. 325), toxins (eg poisonous fungi), vascular disease (eg ischaemia, Budd–​Chiari), sepsis. Cholestatic  Choledocholithiasis, ascending cholangitis, pancreatic cancer, cholangiocarcinoma, primary biliary cirrhosis, 1° sclerosing cholangitis. Ask about  Tiredness, jaundice (+onset), abdo pain, itching, dark urine, pale stools, drowsiness, confusion, bruising, bleeding (skin, nose, bowel, urine), bloating, vomiting, rashes, recent infections (sore throat), weight loss, generalized aching, hair loss, darkening skin, joint pain; PMH Previous jaundice, gallstones, breathing problems, blood transfusions; DH Paracetamol and medications (E p. 325); FH Liver disease, recent jaundice; SH Alcohol, IVDU, tattoos, piercings, foreign travel, sexual activity (?abroad).

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t t t Gilbert’s .ne syndrome X.ne .ne X X disease causing mild, self-​ ok $ Benign autosomal recessive ok typically ok resolving o o during acute illness. Bo unconjugated hyperbilirubinaemia B B w. w. Choledocholithiasis w w $ Gallstonew in common bile duct, causing obstructive jaundice. w ww Risk factors ♀, pregnancy, DM, obesity, age. Symptoms Often none, preceding tbiliary colic, dark urine, pale  tstool. Signs  Jaundice, mild RUQ e Investigations  blds  iALP, eibilirubin; USS  Dilated bile .ducts. et tenderness. n n n . . X Xexclude pancreatitis and kcholangitis, X   Maintain hydration, ok Treatment oco-​kamoxiclav opermits diagprophylactic antibiotics (eg 1.2g/​8h IV); ERCP o o o B nosis and stone removal; cholecystectomy usually deferred until jaundice w.B w.Bclotting resolved. Complications  Pancreatitis, cholangitis, w hepatitis, defects. w w w ww Cholangitis $ Infection of the bile duct with Charcot’s triad: fever, jaundice, RUQ pain. t Signs  itemp, iHR ±dBP, et   Unwell, abdo pain, rigors, ejaundice. et Symptoms n n n . . . RUQ tenderness (Murphy’s  +ve). Investigations   blds   iWCC, iCRP, X X X ok ibilirubin; USS ?duct dilatation, ok stones. Treatment eg co-​aomoxiclav ok 1.2g/​ o o 8h IV; may need an urgent ERCP if gallstones are in the common B .B .B bile duct. w w Primary biliary ww cholangitis (E OHCM10 p. ww 282.) ww

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t t $ .Inflammation and fibrosis of intra-​ net .neand extrahepatic bile ducts.X.ne X X signs Chronic biliary obstruction leading to cirrhosis; IBD k UC, ok Symptomsinand780%, o790% oknot related of which but course of IBD o o Bo present B B to  PSC. Investigations.  blds  iALP, ±ibilirubin, iimmunoglobulin levels, w antibodies (SMA), antinuclear w.antibodies (ANA), anti-​smooth muscle w w w A1, B8 or  DR3; ERCP  Multiple w strictures; fibrosis on ww p-​ANCA, HLA-​ liver biopsy. Treatment  Trials of immunosuppressive agents have proven disappointing; acid can screen for osteoet(DEXA)ursodeoxycholic ethelp symptoms;(71% et n n n . . porosis and monitor for .cholangiocarcinoma per annum); X X X ok transplantation key, but disease ok recurs in 15% post transplant. ok o o o B Cholangiocarcinoma B  (OHCM10 E p. 286.) w.B w.(90%) $ Adenocarcinoma or squamous cell carcinoma of intra-​and w extrahepaticw biliary epithelium; strong relationship ww with IBD and PSC. ww Symptoms and signs Jaundice, pruritus, weight loss, dull RUQ ache. Courvoisier’s law  An tenlarged gallbladder in the presence of jaundice is not caused by e (suggests pancreatic or .biliary et cancer). et gallstones Investigations blds.iALP, n n n . X X biopsy. Treatment ­Surgeryk(10–​ X CA19.9; USS, MRCP,kERCP ok ibilirubin, oERCP + ±stenting. o 40%); else palliate: chemotherapy, o o o B w.B w.B w w w w ww

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control of secondary hyperparathyrG5 (ESRF) 90d. Combine eGFR discuss wishes and suitability for dialysis categories with ACR category (Box 13.2) or transplantation and make (A1 30mg/​mmol) for full classification. selling, fistula creation). Complications  Vascular disease, anaemia, dCa2+, renal osteodystrophy, iK+, fluid overload, immune compromise, peripheral neuropathy. Prescribing  E p. 174; avoid nephrotoxic drugs (eg metformin, NSAIDs, gentamicin); reduce doses/​frequency of renal excreted drugs (eg opioids, benzodiazepines, penicillins); see also E pp. 394–7 for fluids. Radiology  Avoid IV contrast imaging except in an emergency since this is nephrotoxic; discuss carefully with nephrology and radiology. Where e­ ssential, use IV hydration and monitor renal function closely.

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T  Box 13.2  Patients on dialysis

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Chapter 13

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Fluids and renal

t t t .ne .ne .ne Haematuria X X X ok ok ok o o Weight loss, frank blood, or clots (?maligBo 2 Worrying features B B w. (?nephritic syndromewE p. w.390). nancy); iBP, proteinuria w w w ww Think about  Macroscopic  UTI, tumours, stones; Microscopic with  red cells UTI, prostate tumour, recent catheterizat bladder, renal ornephritic eglomerulonephritis/​ et stones, eab-t tion, syndrome, endocarditis, clotting n n n . . . X X sickle cell, TB, schistosomiasis, trauma, strenuous k kX without red ok normality, oMicroscopic oexercise, PV bleeding (E pp. 510–13);  cells (haemoglobinuria) o o o B haemolytic anaemia,.B rhabdomyolysis, trauma, w myositis, w.B ischaemia;  Red w discolouration Rifampicin, beetroot. w w Ask aboutw  Urine colour and volume, clots,w dysuria, frequency, urgency, w fever, abdominal pain, hesitancy, poor stream, recent trauma or cathetert ization, weight loss, malaise, lethargy,emenstruation;  PMH Kidney disease, etprostate et n n n . . . stones, disease, cancer, clotting disorders, sickle cell; DH NephroX X X ok toxic drugs (eg NSAIDs, ogentamicin), ok rifampicin, anticoagulants. ok o o Obs  BP, HR, temp, fluid balance. B .B w.B w Look for iBP,w haematuria and proteinuria suggest nephritic syndrome (E w w w ww

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p. 390); inspect the urine; rashes, bruises, splinter haemorrhages, palpate for suprapubic or loin tenderness or masses; PR: enlarged prostate; PV bleeding. Investigations Urine Dipstick may not distinguish red cells and haemoglobin, microscopy (for red cell or protein casts), culture; blds FBC, U+E, LFT, Ca2+, ESR, CRP, clotting; consider G+S, autoantibodies (anti-​GBM, ANCA, ANA, anti-​DNA), complement, PSA, USS Urinary tract. Management Macroscopic (red/​pink urine) Resuscitate (E p. 492), if heavy consider inserting a three-​lumen catheter for bladder wash-​out, discuss with urology to exclude malignancy (IVU, cystoscopy, CT). Microscopic (urine looks normal, red cells on dipstick or microscopy): • With nitrites/​white cells Treat as a UTI/​pyelonephritis (E p. 498), check urine once infection has cleared to be sure haematuria has resolved • Without proteinuria This suggests urological tumour or stones (E pp. 301–2), refer to urology (urgently if >50yr) for CT-​KUB ±cystoscopy • With proteinuria This suggests glomerular pathology, refer to nephrology and check BP, urinary output, urine casts, autoantibodies, complement, urine protein:creatinine, 24h urine collection for protein, renal USS. Haemoglobinuria  Haemolytic anaemia (E p. 408), rhabdomyolysis (Box 13.3).

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recent ejaculation;  Extra-​renal causes  Orthostatic, hypertension, CCF; Primary renal disease Glomerulonephritis;  Multisystemic disease Vasculitis, lupus, endocarditis, myeloma, hepatitis C, pre-​eclampsia. Ask about  Recent exercise, vaginal discharge, pregnancy, dysuria, ­frequency, urgency, urine output, fever, haematuria, arthralgia or rash, malaise, lethargy, oedema, orthopnoea, recent URTI/​tonsillitis; PMH Kidney disease, iBP, heart disease, cholesterol, DM; DH Nephrotoxic drugs (eg NSAIDs, gentamicin). Obs BP, HR, RR, temp, fluid balance, blood glucose. Look for  Evidence of the underlying pathology:  oedema, basal creps, iJVP, suprapubic or loin tenderness, palpable kidneys or uterus, rashes/​ arthralgia, splinter haemorrhages. Investigations Urine Dipstick (protein, blood, nitrites, leucocytes; repeat early in morning to exclude postural proteinuria), check β-​hCG, microscopy (for casts), culture, electrophoresis, spot albumin:creatinine ratio—​a more practical initial investigation than a 24h collection for protein (E p. 605);  blds FBC, U+E, LFT, triglycerides, ESR, CRP, autoantibodies (anti-​GBM, ANCA, ANA, anti-​DNA), complement, cryoglobulins, serum electrophoresis; USS Kidneys/​urinary tract.

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The destruction of malignant cells during chemotherapy causes release of intracellular contents which may overwhelm renal elimination and extracellular buffers; the resulting metabolic derangement, together with the precipitation of uric acid crystals within the tubules, can cause AKI. Risk factors include pre-​ existing renal impairment with high-​grade tumours, lymphoma, or leukaemia. Onset is generally within 3d of chemotherapy, with oliguria, muscle cramps, tingling, weakness, tetany, and seizures. Blood tests will show iK+, iPO43−, dCa2+, iurate, iurea, icreatinine. Treatment  Involves recognition of at-​risk patients and prophylactic IV hydration and allopurinol started 24–​48h prior to therapy with careful monitoring of electrolytes during therapy. If the syndrome still develops, attempt hyperhydration with IV fluids, allopurinol, bicarbonate, K+ restriction, and PO43− binding under advice from the renal team. Dialysis may be necessary to prevent worsening renal failure, refractory hyperkalaemia, and ultimately arrhythmias and cardiac arrest.

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Chapter 13

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Fluids and renal

t t t .ne .ne .ne Glomerular disease X X X ok ok ok o o Bo K Box 13.5 Nomenclature B B w. w. w w To overcome those palpitations that you experienced as a student, w w ww ­remember that the wide range of primary and secondary pathologies ­affecting glomeruli all share a limited repertoire of clinical manifestations et syndrome). These pathological et processes also share a limited et (egnnephrotic n n . . . repertoire of histological features and in the absence of a definitive diagX nephrologists will oftenkrefer X X ok nosis, o instead to the patternoseen okon biopsy o o (eg membranous glomerulonephritis). B w.B w.B w w Glomerulonephritis w w ww $ Inflammation of the glomeruli triggered by an immunologic mechanism results in tissue damage, often with proliferation of basement membrane, t cells, or capillary endothelium. mesangial eimportant etassociated causes and clinical efea-t n n n . . . Some histological types and X X ok tures are listed in Table 13.2 ok(see also Boxes 13.5–​13.7).ookX o o B Table 13.2  Classification w.B of glomerulonephritisww.B w Biopsy w Presentation Causes w Management ww

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Minimal change (normal by light microscopy) Membranous

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Defined as >3g proteinuria/​ 24h with hypoalbuminaemia and oedema. Hypercholesterolaemia, dIgG, and hypercoagulability may also feature. Causes include primary glomerulonephritis as above (typically minimal change or membranous disease) but also extra-​renal causes including DM, anti-​GBM disease, malaria, pre-​eclampsia and drugs (eg gold, penicillamine, NSAIDs). Treatment is of the underlying cause along with diuretics, active treatment of infection, ±anticoagulants.

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Majority steroid responsive; very few progress to ESRF ⅓ stabilize with immunosuppression; ⅓ remit spontaneously; ⅓ progress to ESRF Primary disease may respond to steroids but significant progression to ESRF; secondary disease managed with ACEi Majority self-​limiting but 20–​40% progress to ESRF; ACEi ±steroids

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Haematuria (often 1L); urine dipstick and send for M,C+S; stool chart ±laxatives; urgent MRI spine if new lower limb neurology and diminished perianal sensation/​tone (E p. 361). Beware post-​obstructive diuresis: pay close attention to fluid balance and electrolytes. Once reversible precipitants addressed, attempt a trial without catheter (TWOC) with close monitoring for recurrence of retention. If this occurs, reinsert catheter and treat as chronic retention. Complications AKI, chronic obstruction.

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Symptoms Incontinence, dribbling, poor stream, recurrent UTI. Signs Palpable distended bladder (usually non-​tender), enlarged prostate. Investigations blds FBC, U+E, PSA, Ca2+, PO43−. Management  Do not catheterize unless in pain or anuric (acute on chronic retention); refer to urology to investigate cause; options include TURP, intermittent self-​catheterization, anti-​androgens (eg finasteride), or alpha-​blockers (eg tamsulosin). Complications Chronic kidney disease, recurrent UTI.

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Types of incontinence: • Stress Leakage on exercise/​coughing/​laughing • Urge Severe and sudden urgency (often due to detrusor instability) • Overflow Urine volume exceeds bladder capacity (eg chronic retention) • Functional Restricted mobility so unable to get to toilet in time. Causes UTI, detrusor instability, neurological problem (eg MS, DM), diuretics + reduced mobility; ♀:  uterine prolapse, weak pelvic muscles, pelvic mass; ♂: post-​prostate surgery. Ask about Urgency, frequency, leakage, dysuria, poor stream, haematuria, fluid intake (including caffeine consumption late in the day), effects on lifestyle, obstetric history, and previous pelvic surgery or trauma, DM, chronic cough, faecal incontinence. If acute presentation with new leg weakness, suspect spinal cord compression (E p. 361). Look for Abdo/​pelvic masses, prolapse (E pp. 158–9); assess leakage on coughing. Investigations  Urine  MSU, glucose, urinary diary, urodynamics studies. ♂: blds PSA (take prior to checking prostate size and nodularity by PR). Treatment  General  Weight loss, less caffeine, stop smoking, treat prolapse;  Stress incontinence  Fluid restriction, pelvic floor exercises, transvaginal tape;  Detrusor instability Behavioural therapy (bladder drill), tolterodine 2mg/​ 12h PO;  Overflow  See ‘Chronic urinary retention’ earlier in this topic; Functional Aid mobility.

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Chapter 13

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Fluids and renal

t t t .ne urine outputX.ne .ne Low X X ok ok ok o o Bo 2 Worrying features B B h (Table 13.3) . Low urine output 4hw orw despite adequate fluid, iHR,w systolic BP 60mL (>1mL/​ kg) >1600mL e e et n n n . . . Low urine output passive)

t t . .ne .ne X X X ok I  Box 16.9  Causesoof limb ok pain covered elsewhere ok o Bo Ulcers E pp. 438–9 B B . 463–5 w. 360–1 Swelling E pp. w Back pain/​sciatica E pp. Joint pain E pp. 466–71 w w w 426–7 wpp. 425–33 ww Cellulitis E pp. Rashes E Chronic limb pain E p. 466 Necrotizing fasciitis E p. 427 t p. 464 t E pp. 448–51 t DVTeE Trauma .n .ne .ne X X X ok 2 Osteomyelitis (EoOHCS10 p696.) ok ok o Bo Risk factors DM, immunocompromise, B B fractures, prostheses. w. pain, malaise (oropen w. focus). Symptoms Fever, bone fever without w w w ww Signs Bony tenderness, warm, red, swollen.w Investigations blds iWCC, iESR, iCRP, blood cultures; Imaging X-​ray (insensitive et since there are rarely changes et in the first 10d), USS (may.nshow et n n . . periosteal lifting), MRI (gold standard); Bone biopsy Where indicated. X X kX antiok Culture  Try to obtain a osample ok for microbiology prior otoostarting o biotics (by swabs, USS-​ guided aspiration, or bone biopsy in theatre). B w.B w.B for at least w Treatment High-​ dose antibiotics (discuss with w microbiology) w 6wk; often requires w central access; surgical drainage w of abscess if present. w Complications Septic arthritis, fracture, amputation, seeding to other sites.

et et et n n n . . . XSigns Well-​defined, painless, kshrivelled X brown/​black area. kX ok Treatment Debridement ooroamputation o altermay help preventoinfection; o B B . natively conservative.B management awaiting autoamputation. w w Complications Wet ww gangrene (an emergency: E p. ww 461). ww Dry gangrene $ Ischaemic muscle necrosis without infection.

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t et limb ischaemia .net 3 .nAcute .ne X X X This is an emergency; ischaemia k is irreversible after 6h. ok ok $ Worrying opurple, o signs dsensation; blanching mottling. Bo 2Causes Emboli, B . dissectingnon-​ .Bo thrombosis, aneurysm, trauma. w w w previous thrombo-​ ww Risk factors Arterial ww graft, peripheral vascularwdisease, emboli, AF, prosthetic heart valves, recent MI, dehydration, malignancy. Symptoms Unilateral painful, tingling, weak limb, worse on raising limb. Signs Absent et pulses, slow cap refill.n(compare et with opposite limb),.ncold et n . and pale (can be red if limb below heart), reduced power and sensation. X X X hand-​held Doppler will show a reduced ok Investigations A ok probe okor absent o o o pulse; angiography may demonstrate an obstruction. B Treatment This needs w.Burgent surgery—​call a vascular w.Bsurgeon who will w w w consider embolectomy, intra-​arterial thrombolysis, w w bypass, or amputa- w tion. Analgesia (eg morphine); IV access with IV fluids if dehydrated; may require heparinization (E pp. 420–2) pre-​or post-​op. et eiKt , renal failure, sepsis. .net Complications Amputation, gangrene, n n . . X X (wet) gangrenekX ok 3Gas o infection causing necrosisoand oksepsis. o o $ This is an emergency; Clostridium B Symptoms Unwell w .Bpainful extremities or wound. with w.B w Signs Pyrexia, systemic shock, tender brown/​w black area with blistering w w ww

B

+

and oedema, muscle necrosis, crepitus (from gas in tissue). Risk factors Ischaemia, DM, malignancy, surgery/​trauma. Investigations  blds  FBC, U+E, LFT, CRP, CK, blood cultures, clotting; ABG Acidosis; Gram stain Of pus or necrotic tissue; X-​ray May show gas (dark patches in soft tissues). Treatment Call a senior surgeon who will consider urgent debridement. Give 15L/​min O2, fluids and broad-​spectrum antibiotics upon urgent discussion with microbiology (eg benzylpenicillin 2.4g/​4h IV, clindamycin 600mg/​6h IV and metronidazole 500mg/​8h IV). Complications Amputation, sepsis, death.

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t t et .nCompartment .ne .ne 3 syndrome X X X emergency; calloak senior surgeon if suspected. ok ok $ This is anExcessive o pain following an injury or fracture, Bo Symptoms  B . cool peripheries. .Bodistal tingling, numbness or weakness, w w wworse on passive stretchingwofwa muscle, reduced sen- ww Signs Pain atw rest, sation (loss of two-​point discrimination), redness, swelling, slow cap refill; absent pallor are late signs. t pulse and e et casts, significant injury,.ncrush et Risknfactors Long bone fractures andnplaster . . Xinjury, vascular injury, anticoagulants, burns. X kX ok Investigations Clinical diagnosis; okblds FBC, U+E, CK, clotting;ooCompartment o o B pressure Is measured .byBinserting a manometer through .Bthe skin (eg Wick w>30mmHg catheter), pressures indicate need w forw urgent fasciotomy, alw w surgeons advocate avoiding wintervention if pressure is ww though some ±20mmHg of diastolic pressure. Treatment 15L/​ min O ; elevate limb (lietthe patient flat); analgesia; IV flut e remove plaster cast if present; et n n ids.n if e dehydrated (monitor urine output); . . X urgent fasciotomy. kX kX ok consider o iK , neurological damage,ooamputation. Complications Rhabdomyolysis, o o B w.B w.B w w w w ww 2

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Chapter 16

Emergency department

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t t t .ne .ne .ne Chronic limb pain X X X ok ok ok o o arterial disease (PAD) Bo Peripheral B B $ Chronic limb ischaemia w. causes intermittent claudication/​ w. critical ischaemia. w w w • Intermittent claudication $ Cramp in calf, thigh, w w or buttock on walking w a fixed distance, worse uphill, relieved by stopping or rest • Critical ischaemia $ Pain in limb at night, relieved by hanging legs out t arterial ulcers, dry gangrene. ebed; et et of n n n . . . XSigns Early Cool, hairless, pulseless limbs; X Late Pain and pallor onkelevation. X ok Investigations blds FBC, U+E, oklipids, ESR; ECG; ABPI (ankle–​ obrachial preso o o B sure index, see Box 16.10); .B Imaging CT or Dopplerwarteriography. .B wvascular Treatment  Address risk factors (exercise, stop smoking, treat w w w icholesterol); aspirin 75mg/​ w24h PO, avoid β-​blockers; ww DM, iBP and refer to vascular team for consideration of angioplasty or bypass graft. Complications Acute ischaemia, gangrene, et et rest pain, ulcers. .net n n . . X Box 16.10  Ankle–​bkrachial X pressure index (ABPI) kX ok K  o osystolic o o With the patient lying flat, o a Doppler probe is used to record the BP (ie B .Bthe pulse is occluded) in eachwarm.B(cuff around upper lowest pressure at which w arm, probe over artery) and twice in eachw (cuff around calf, probe wbrachial wtibial wislegexpressed ww over posterior and dorsalis pedis). The result as a ratio of the highest ankle pressure for each leg, to the highest brachial pressure.

t ankle posterior tibial pressureneoft126, dorsalis pedis pressure of 124,net Example: left .ne pressures . brachial of 138 and 142; ABPI = 126/​ 142 = 0.89 X X. Moderate PVD X0.5–​ k Normal k 0.8–​1.3 ok 0.8 o o o o 1.3 Bo Severe PVD B B . . Lumbar spinal wwstenosis ww w w w Symptoms Cramp in thigh or leg on walking, worse on walking downhill w or standing, associated back pain. See Table 16.5. t t often no neuro symptoms. t Signs Pain raise/​back extension, neMRI spine. .ne on straight legspine .ne Investigations Lumbar X-​ray .and X X X k injections, spinal decompression. ok Treatment Exercise, NSAIDs, oksteroid o(E p. o o cauda equina syndrome 361). Bo Complications Cordwcompression, B B . . w Table 16.5  Nerve entrapment syndromes ww ww ww Syndrome Symptom Carpal tunnel syndrome (median) Aching of wrist and forearm, tingling of et et index, middle, ±ring finger .net thumb, n n . . (wrist or elbow) XUlnar entrapment X Tingling of ring and little fingers,k±forearm X tunnel syndrome or ok Weak extension of fingers and ok Radial o thumb o o o posterior interosseous syndrome B .B .B Meralgia paraesthetica Tingling lateral thigh w w w w Common peroneal compression Weak dorsiflexion of foot w w ww For other causes of chronic limb pain see Box 16.11.

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I  Box 16.11  Chronic limb pain covered elsewhere

o

Osteoarthritis E p. 468 Peripheral neuropathy E p. 359 Limb ulcers E pp. 438–9

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t t t .ne swelling X.ne .ne Limb X X k ok ok loss, night sweats, pain, SOB, ochest pain. o o Weight Bo 2 Worrying features B B w. depend upon site (Table 16.6). w. Think aboutw  Causes w w w ww Table 16.6  Clinical assessment of limb swelling et etfailure, nephrotic syndrome, .net Pitting Bilateral: congestive cardiac n n . . dalbumin, early lymphoedema, X (arms/​legs)venous insufficiency, ktrauma, X kX k SVC/​IVC obstruction o o o o o Unilateral: cellulitis*, deep vein thrombosis, early o B B lymphoedema, trauma,. pelvic mass w.B venous insufficiency, w wlymphoedema, w Non-​pitting Bilateral: chronic congestive cardiac failure, w chronic venous insufficiency, trauma, w compartment syndrome ww Unilateral: lymphoedema, chronic venous insufficiency, trauma, t t mass compartment syndrome,e pelvic e et n n n . . . X X X ok ok ok o o o B Ask about Swelling Location, .B onset, duration, redness,wwarmth, .B pain (severity, wrash, radiation), associated history of trauma, insectw bites/​stings; Systemic sympw w toms Nauseaw and vomiting, pyrexia, sweating, w weight loss; PMH Recent op- w

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*The diagnosis of bilateral cellulitis is a rare one, and more usually represents a misdiagnosis (eg elderly with CCF, venous insufficiency and venous stasis eczema).

erations, fractures or immobility, cancer (±radiotherapy), DM, IBD, IHD, polycythaemia, thrombocytosis, thyroid disease; DH COCP/​HRT, steroids, amlodipine, drug allergies; SH Recent long-​distance travel, alcohol, smoking. Obs Temp, HR, BP, RR, sats, urine output, blood glucose. Look for  Swollen limb  Site, size, shape, colour, tenderness and temperature of swelling, evidence of trauma, skin breaks between toes (for leg cellulitis), nail condition, tortuous  veins; Systemic  Evidence of malignancy (eg cachexia, abdominal/​rectal mass, clubbing, lymphadenopathy); evidence of chronic liver disease (E pp. 319–23, eg ascites, jaundice, spider naevi); surgical scars (eg previous mastectomy/​axillary clearance), evidence of cardiac failure (E p. 274, bibasilar creps, wheeze); in ♀: gravid uterus, consider PV Tenderness, palpable masses. Investigations Target according to likely causes. Lymphoedema (E OHGP4 p. 1041.) $ Accumulation of interstitial fluid due to abnormal lymphatic drainage; may be congenital, or secondary to surgery, radiotherapy, malignancy, or filariasis. Symptoms Limb swelling, reduced mobility, recurrent infections. Signs Acute lymphoedema may be pitting, but as it becomes more chronic the tissues become woody and pitting is less likely. Chronic oedema from congestive cardiac failure can also become woody and non-​pitting. Risk factors Female sex, malignancy, breast cancer surgery (especially axillary node clearance), radiotherapy, family history, obesity. Treatment Medical Elevation of the limb, compression bandages, massage of the limb in a proximal direction (to aid fluid return), exercise, weight loss, antibiotics if 2° skin infection present; no evidence for use of diuretics; Surgical Excisional techniques available, but radical. Complications Cellulitis, ulcers, psychological problems, pain.

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w Emergency departmentw ww t t t Deep .ne vein thrombosis (EXOHCM10 .ne p. 578.) .ne X X k or pain. Signs Warm, red, tender, swellingoand/​ ok Symptoms unilateral okbelowswollen o o (eg leg >3cm compared to other calf measuredB 10cm Bo limb B . .obesity, recenttibial tuberosity), pittingw oedema. Risk factors  Age >60yr, surw wlong distance travel, oestrogen w(pregnancy, HRT, OCP), gery/​immobility/​ w w ww PMH or FH PE/​DVT, malignancy, thrombophilia, medical comorbidity (eg CCF, IBD, active inflammation). Investigations  blds  FBC, U+E, D-​dimer t 16.12 and Table 16.7). Assess (see e Box et the DVT probability (Risk.nscore et n n . . Table  16.7 ±D-​ d imer) to determine the need for further investigation X Doppler ultrasonography.kXIf suspected PE (E p. 284) perform X ok with o Commence parenteral anticoagulation ok ECG o o o and consider  ABG . Treatment  (eg B .B .B>4h. If confirmed enoxaparin 1.5mg/​ kg/​24h SC) if USS +ve or delayed w w DVT, start oral wwanticoagulation (E  pp. 420–2). wwComplications  PE, post-​ ww 464

Chapter 16

2,3

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thrombotic syndrome (chronic pain and swelling).

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K   Box 16.12  Pre-​test probability in DVT

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Symptoms and signs of DVT are non-​specific; likewise, the much over-​ordered D-​dimer blood test is a non-​specific marker of thrombosis. The application of clinical scoring systems, which combine established risk factors with reliable clinical findings, allow the identification of low-​risk patients, in whom a negative D-​dimer has a robust negative predictive value. In higher risk patients, Doppler ultrasonography is justified, regardless of the D-​dimer assay result. The Wells score (Table 16.7) has proven to be clinically reliable and is widely used in modified ‘2 level’ form.5 The following measures score 1 point each if present:

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t t et .nActive .ninepast 6mth, • Pitting oedemaX.ne X X • cancer (treatment ongoing or ok or palliative) ok okalong veins • Tenderness o o • Leg paralysed or in plaster Whole leg swollen Bo •• Recent B B .or major surgery within 12wk • w>3cm . calf swelling bed rest >3d w w w other calf ). (cf ww • Previous documented DVT w w • Visible collateral superficial veins (non-​varicose) Subtract t et 2 points if thereet alis another diagnosis etthat is as or more likely (eg cellulitis). n n . . .ne X X X k ok oDVT ok o o l evel Wells score Bo Table 16.7  Thewtwo-​ B B . w. Score Risk of DVT Management w w w w ww Unlikely (5.5%) D-​dimer test, if +ve USS, if –​ve unlikely to be DVT ≤1 Arrange USS; LMWH if delay in USS >4h ≥2 (28%) triskLikely t t e Where score ≥2 but USS −ve, perform D-​ de imer test: if +ve, repeat USS in 6–​8d. ne n n . . . X X X ok ok ok o o o Source: data from Wells, P.S. et al. NEJM 2003;349:1227–​35. B w.B w.B w w w w ww Source: data from Wells, P.S. . NEJM 2003;349:1227–35; a good recent summary available free at M asheducationbook.hematologylibrary.org/content/2013/1/457.long.

*Most hospitals will also have their own guidelines which you should consult, particularly regarding logistics of arranging USS through ambulatory pathways.

  See also thromboprophylaxis, E pp. 420–1; NICE guidelines at M guidance.nice.org.uk/​CG92   NICE DVT/​PE guidelines at M guidance.nice.org.uk/​CG144  Most radiology departments will only scan the leg veins above the knee, since below knee DVTs carry a much lower risk of PE; there is a low risk (1–​2%) of clot extension into more proximal veins—​for this reason, in those with a high pre-​test probability, a positive D-​dimer and a negative Doppler USS, consider repeat Doppler USS at 1–​2wk. 5   Wells PS, et al. NEJM 2003;349:1227; a good recent summary available free at M asheducationbook.hematologylibrary.org/​content/​2013/​1/​457.long 2 3

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t t t Venous .ne insufficiency X.ne .ne X X throbbingkleg pain, relieved by elevating k worse ok Symptoms Bursting/​ oor thrombophlebitis. Signs  Pain o legs, o o standing; previous DVT d by lifting Bo on B B . legs, red discolouration, Duplex w. swelling, varicose  veins. wInvestigations  ultrasound, D-​w dimer if DVT suspected. Treatment  Compression banw w w>0.8), varicose vein surgery. Complications Varicose w dages (if ABPI veins, w thrombophlebitis, ulcers, cellulitis. ectannula swelling ‘a tissued etcannula’ et Post-​ n n n . . . has not been inserted correctly XTissuing This is where an IV cannula X and kXor outside ok is sited only partially in theoovein ok meaning the vein altogether, o o cannot B that fluid or drugsw .B be infused/​injected. welevate .B the affected Treatment Remove cannula and re-​site if required, w w limb and givewsimple analgesia for pain. w ww If no improvement Consider possibility of infection of cannula site (E p. 426); assess swelling for collection—​if in doubtt request USS—​if present, start IV etco-​amoxiclav e drainage with surgeons..net ABx (eg 1.2g/​8h IV) and discuss n n . . X X X ok Baker’s cyst okin the popliteal fossa, mayoradiate ok to calf; o o Symptoms  Pain and swelling B similar to symptomswof.BDVT, common in osteoarthritis. w.Bhave calf swelling. w w w Signs Fluctuant swelling in the popliteal fossa; can also w w w Investigations Distinguishable from DVT by USS. Treatment Conservative (NSAIDs, ice packs).

t t t Angioedema .ne .ne .ne X X X and tok ivascular k submucosal oedema, 2° oinduced, ok $ Episodic subcutaneous occurring o inohereditary, idiopathic, drug-​ and o Bo permeability B B . antigen-​driven forms.. w w Symptoms  Colicky abdominal pain, shortness w breath (laryngeal oeww watery w(inofantigen-​ ww dema), dysphagia, diarrhoea, pruritus driven cases). Signs Well-​demarcated swelling (eg hands/​feet/​face), dyspnoea ±stridor t t (laryngeal/​ can lead toeairway urticaria.et .ne tongue swelling .n blds If compromise), .n Investigations Diagnosis made clinically; reaction was anaphylactic X X X k k k (from mast o dcomplement o then itryptase o cell degranulation), oo levels help diagnosis (‘Anaphylaxis’ E pp. 484–5). Bo confirm B B . . Treatment  Assess airway—​ if any concerns 3 request w immediate senior w ww (0.5mL wadrenaline help since IMw adrenaline (0.5mg) 1:1000 STAT) and ur- w w gent intubation may be required; nebulized salbutamol (5mg NEB STAT) or nebulized (5mL (5mg) of 1:1000 may also help; give t adrenaline tIV adrenaline) e e et antihistamines (eg chlorphenamine 10mg STAT) and steroids (eg hydron n n . . . (eg new Xcortisone 200mg IV STAT). Identify X and stop any likely precipitant kXconsider ok ACEi) and avoid in future;orequest ok C1 esterase inhibitor assays oand o o if severe/​frequent episodes and precipitating B referral to an immunologist w.B tranexamic acid and FFP ware.Ball used to prevent w cause not clear (androgens, w w attacks in hereditary w angioedema). See also Box 16.13. w w I  Box 16.13  Limb swelling covered elsewhere

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t eRenal et n n failure E p. 387 . . X X syndrome E p.k 390 ok Nephrotic Cirrhosis E p. 322 oo o Anaphylaxis E pp. w.B w.B484–5 w w w w ww

Cellulitis E pp. 426–7 Compartment syndrome E p. 461 Heart failure E p. 274 Pre-​eclampsia E p504 SVC obstruction E p. 289

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Chapter 16

Emergency department

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2 Worrying features Fever, weight loss, severe pain, rashes.

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Think about  2 Emergency Septic arthritis; Polyarthritis  Rheumatoid,

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osteoarthritis, ankylosing spondylitis, psoriatic arthritis, connective tissue disease (eg SLE), reactive arthropathy, rheumatic fever, polymyalgia rheumatica,  IBD; Monoarthritis  Septic arthritis, trauma, crystal arthropathy (gout, pseudo-​gout), monoarthritic presentation of polyarticular disease, leukaemia, endocarditis, sickle-​cell, haemophilia. See Table 16.8 and Boxes 16.14 and 16.15. Ask about Description of pain Site, relieving/​exacerbating actions, duration, other joint involvement; Inflammatory symptoms Morning stiffness, pain that improves with exercise but not rest, alternating buttock pain, nocturnal pain during 2nd half of night only; Systemic Fever, night sweats, weight loss, nausea, rashes, altered bowel habit, mouth ulcers, dysuria, visual disturbance, dry eyes or mouth, trauma; PMH  Joint pain, gout, haemophilia, sickle-​cell, trauma, IBD, heart problems; DH Steroids, anticoagulants, thiazide diuretics; FH Joint disease, IBD; SH Occupation, mobility, help at home, change in lifestyle due to symptoms. Look for E pp. 148–54 for specific joint examinations; always check the joint above and below; Look Resting position/​deformity, swelling, rashes, erythema; Feel Warmth, tenderness, nodules; Move Reduced range of movement (passive and active), crepitus; Systemic Finger clubbing, psoriasis (check nails and scalp), enthesitis (tenderness at tendon insertions eg Achilles), muscle tenderness, back flexion, sacroiliitis (pain on pelvic squeeze), gait, ulcers, lymphadenopathy, hepatomegaly, splenomegaly. Investigations  blds  FBC, U+E, CK, CRP, ESR, RhF, ANA; also consider:  sickle-​cell, urate, anti-​dsDNA, complement titres, antiphospholipid antibodies; Urine  Dipstick ±send for  casts; Imaging  X-​ray affected joints; Joint aspiration E p. 571 for what to send and how to interpret results.

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Systemic rheumatic disease  Inflammatory diseases affecting joints, with multiple extra-​articular manifestations; autoantibodies aid classification but role in pathogenesis unclear. Examples include rheumatoid arthritis, SLE, myositis, scleroderma, mixed connective tissue disease. Spondylarthropathies (seronegative arthropathies)  Group of chronic disorders with inflammation of the sacroiliac joint (sacroiliitis), vertebrae (spondylitis). All are associated with HLA-​B27; serum rheumatoid factor is usually negative (hence ‘seronegative’). Includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis and enteropathic arthropathies. Vasculitis Inflammatory destruction of blood vessels; may be 2° to other inflammatory or infectious conditions; 1° forms include giant-​cell arteritis, Churg–​Strauss syndrome, Behçet’s disease, polyarteritis nodosa, granulomatosis with polyangiitis (formerly Wegener’s granulomatosis). Crystalline arthropathy Crystal deposition in joints seen in gout and pseudogout; usually mono/​oligoarticular. Infectious arthritis  Joint infection, seen in septic arthritis; often occurs in already damaged joint. Also seen in disseminated gonococcal infection.

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K  Box 16.14  Classification of rheumatological disease (E  OHCM10 p. 540)

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t t t .ne Common causes of joint pain .ne .ne Table 16.8  X X X ok ok Examination Investigations ok o o Bo Rheumatoid History B B Symmetrical; Inflamed, swollenw.iESR, +ve RhF, w. arthritis typically hands and joints, early w erosive changes w w wrists; malaise deformity w ww Osteoarthritis Chronic onset; Non-​inflamed, Normal blds; joint t t typically in hands, dROM space narrowing, et e e n n hips and knees osteophytes .n . . XSeptic arthritis Fever, single joint, X X k k Tender, swollen, hot, o o red, unable to move iWCC/​ okCRP/​ESR, o o rapid onset +veo culture B B B crystals on Gout Acute Red, tender, w.onset, w.Urate w severe single joint swollen, tophiw joint aspirate w pain w ww Pseudo-​gout Gradual onset, Red, tender, CPP crystals on single joint pain swollen joint aspirate et et et n n n . . . Polymyalgia Elderly, symmetrical Muscle tenderness, iiESR, iALP X X ok rheumatica shoulder/​poelvic okpain pain on movement ookX o Ankylosing Back pain, B B stiffness, dBack flexion andw.iESR, –​ B ve RhF, w.male spondylitis young chest expansion HLA-​B27 +ve w w w iESR, –​ve RhF, X-​ ww Reactive w Lower limb pain, Inflamed joints,

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Fever, malaise, weight loss, rash, lethargy Rheumatic fever Sore throat, migratory joint pain, rash, fever IBD Migratory arthritis, abdo pain, diarrhoea, PR bleeding Leukaemia Weight loss, bruising, weakness Sickle-​cell Dactylitis in children, septic arthritis all ages Haemophilia Sudden onset, single joint in children

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Psoriasis, variable joint involvement

conjunctivitis, keratoderma blennorrhagica Psoriasis, nail changes, dactylitis

ray normal; throat/​ genital swabs for eg chlamydia iESR, –​ve RhF, erosive changes

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t .ne X o o erythema nodosum Distinctive ok colonoscopy o o Bo B B w. w.iiWCC, dHb Petechiae, bruises, w w w w ww lymphadenopathy Swollen, Sickle-​cell positive, t t hot,etender dHb e et n n n monoarthritis . . . X X kX iAPTT, ok ok Haemarthrosis, oIXdfactor o o o tender, swollen VIII or B w.B w.B w w w w ww I  Box 16.15  Causes of joint pain covered elsewhere Trauma E pp. 410 et 448–51460 etLeukaemia E p. et Osteomyelitis E p. IBD E p. 315 n n n . . . Sickle cell E p. 411 Haemophilia E p. 419 X X X ok ok ok o o o B w.B w.B w w w w ww

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w Emergency departmentw ww t t t Rheumatoid arthritis (E OHCM10 p. .ne .ne 546.) .ne X X X inflammatory disease 16.16) causing symmetrical ok $ Chronic ok (Boxassociated ok peripheral and systemic manifestations; with considerable morbidity o o Bo arthritis B B . . and mortality. w w Common joints PIP, and MTP joints, wrist, elbow, w knee, ankle. ww MCP, ww Risk factors Female sex (but worse prognosisw in males), family history. Symptoms Morning stiffness, malaise, fatigue, mild fever, weight loss. Signs Swelling, hand deformity, et bldsredness, etnodules (elbows). et n n n . . .  dHb, normal MCV, iESR, Rh factor +ve (70%), Anti-​ CCP Investigations  Xantibodies are very specific (98%); X X ok joint ok X-​ray Erosions, cysts, osteopenia, ok narrow o o space, deformity. o B .B .B corticosteroids, Treatment  Analgesia, NSAIDs, exercise, physiotherapy, w w disease-​modifying antirheumatic drugs (DMARDs) eg sulfasalazine, methow w w w trexate, azathioprine, ciclosporin should be w started at diagnosis ideally in w 468

Chapter 16

6

combination, biological therapies (anti-​TNFα eg infliximab), surgery (reconstructive, synovectomy, joint replacement, fusion). Flare ups Analgesia, splinting, corticosteroids (oral or intra-​articular). Complications Joint destruction, septic arthritis, antiphospholipid syndrome. Systemic manifestations  MI, pericardial or pleural effusions, pulmonary fibrosis, Sjögren syndrome, episcleritis, vasculitis, Felty syndrome.

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t following for ≥6wk supportsna ediagnosis t of rheumatoid arthritis net ≥4 ofethe .n stiffness >1h • Arthritis . of ≥3 left or right PIP, MCP, X . • Morning wrist, X X Symmetric arthritis elbow, knee, ankle, and MTP jointsk k • • Rheumatoid k o o o nodules o • Arthritis of ≥1 of PIP, MCP, wrist joints Bo • +ve rheumatoid factor .B • Typical radiographic changes .Bo w w et al ww ww ww Osteoarthritis t PIP joints. t Common hips, spine, DIP,eand et joints Knees, .nfactors Age, .ntrauma, .ne Risk female sex, previous obesity. X X X k stiffness on resting. ok worse with activity, ok Symptoms Painnone; odeformity, o o effusion, range of Bo Signs Initially B . X-​ray Loss ofreduced .Bmovement. joint space, subchondral sclerosis, Investigations blds Normal; w w bone cysts and osteophyte formation. ww ww ww Treatment  Exercise (especially strengthening of muscles near affected joints), weight loss, walking aids, analgesia (E pp. 88–91, eg paracetamol, t NSAIDs 2e inhibitors), steroid/​local anaesthetic et (topical before PO), COX-​ et n n n . . . joint injections; joint replacement if refractory to medical therapy. X kX chronic pain, joint destruction. kX immobility, ok Complications Disability, o o o o o Polymyalgia rheumatica B w.Baffecting muscles of neck,wshoulder, w.B hips, or thighs. w $ Symmetrical myalgia w Risk factors >50yr, w female sex, giant-​cell (temporal) w arteritis (E p. 365). w Reproduced from Arnett . Arthritis Rheum 1987 31:315, with permission from John Wiley and Sons © The American Rheumatism Association. 7

Symptoms  Bilateral morning pain and stiffness in proximal muscles lasting >1h, weight loss, fatigue, malaise, depression, mild fever. Signs Muscle tenderness, normal power; drange of movement (from pain). Investigations  blds  iiESR (typically >50mm/​h), iCRP, iALT, iALP, dHb, normal MCV, normal CK; temporal artery biopsy if suspect temporal arteritis. Treatment Prednisolone 20mg/​24h PO, gradually reduced (over months).

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t t et arthritis 3 .nSeptic .ne .ne X X X joints Single knee or hip. k ok Common ok joint, immunosuppression, iage, oDM, o o factors Joint disease, prosthetic trauma. Bo Risk B B . painful joint, swelling, fever.w. Symptoms Acute-​ow nset Signs Swollen, hot, w of movement. ww tender, red, painful joint,wdrange ww Investigations blds iWCC, CRP, and ESR, +ve blood culture; Joint aspiration iWCC, organisms on Gram stain, +ve culture; X-​ray As baseline. Organisms  et Staphylococci, Streptococcus et pyogenes; Gram  –​ve bacilli eort n n n . . . fungi in elderly or debilitated; TB. X X kXIV antiAnalgesia, urgent referral, high-​ doose ok Treatment  okorthopaedic o o o biotics for ≥6wk (seek urgent microbiology advice) after diagnostic joint B aspiration; may need B aspiration/​surgicalwwashout. .repeated .B w Complications Joint ww destruction, 2° osteoarthritis, wwsepticaemia. ww Gout (urate crystal arthropathy) Common et joints Monoarticular in 90%: eg et great toe MTP, ankle, knee. et n n Risk factors iage, male sex, thiazide diuretics, red meat, alcohol. .n . . X X ±fever; drange of movement. X onset painfulkjoint, ok Symptoms Acute-​ o painful joint; ok yellow o o o Signs Swollen, hot, tender, red, Chronic Tophi (white/​ B or skin coloured nodules of urate) over Achilles, elbow, knee, or ear. w.Bseptic w.EBSR/​ w w Investigations 2 Exclude arthritis; blds iWCC/​ CRP; Joint as- ww w w

B

piration –​ve birefringent needle-​shaped crystals; X-​ray Normal. Treatment Acute attack Rest, high fluid intake, reduce thiazide diuretics, alcohol, and red meat. Prescribe NSAIDs (eg diclofenac 50mg/​8h PO) or COX-​2 inhibitor (eg etoricoxib 120mg/​24h PO). Consider steroids (eg prednisolone 40mg/​24h PO for 3d, then tapered over 3wk). If NSAIDs contraindicated, then use colchicine (causes diarrhoea) but both NSAIDs and colchicine are problematic in renal failure; Recurrent attacks Allopurinol (100mg/​24h PO) reduces urate levels; do not start during acute attacks.

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t wrist, hips. t Common oligoarticular: knee, et joints Mono/​ .nfactors Age, .ne haemochromatosis. .ne Risk family history, trauma, X X X k intense. and signs  These are similar to gout, though oless ok Symptomsspontaneous okand o o onset self-​limiting, although can be triggered Bo Typically B B by trauma, surgery, wor. acute illness. w. w w Investigations 2 Exclude septic arthritis; blds iWCC/​ w w ESR/​CRP; Joint aspir- ww ation Weakly +ve birefringent crystals; X-​ray Calcification. Treatment Rest; NSAIDs (eg diclofenac 50mg/​8h PO); intra-​articular or et (eg prednisolone 40mg/​ e2t4h PO for 3d, then tapered.nover et oralnsteroids n . . X3wk); no effective prophylactickXtreatment. X ok Ankylosing spondylitis o ok o o o B Common joints Sacroiliac, spine. B Risk factors Male sex, HLA-​B27. w.B w.>1h, Symptoms Backw pain worst at night, morning stiffness heel pain. w w w w Signs Fixed spinal kyphosis, restricted chest expansion, heel tenderness w (enthesitis), pain on loading sacroiliac joints; uveitis. Investigations Clinical diagnosis, supported et et by radiology (MRI is most.nsenet n n . . sitive) demonstrating sacro-​ i liac disease.  X X kXsulfasalazine, biological therapies Exercise; NSAIDs, ok Treatment  osurgery. ok (anti-​ o o o TNFα eg infliximab); spinal B Complications Spinalwfusion, .B aortic regurgitation, pulmonary w.B fibrosis, re- w w w stricted ventilation. w w w

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470

Chapter 16

Emergency department

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t t t Reactive .ne arthritis .ne .ne X X X arthritis developingk1–​4wk after GU or GI infection.kMay occur ok $ aSterile oo and conjunctivitis. .Boo triad of urethritis, arthritis, Bo asCommon B . joints Asymmetrical affects large joints egw knee, ankle, hips. w w w Organisms Triggers include Chlamydia, Campylobacter, Shigella, and Salmonella. w w ww Symptoms Recent diarrhoea or GU infection; regardless of trigger, initial symptoms are often dysuria and urethral discharge; acute asymmetrical oligoarthritis et with malaise, fatigue.±fever; et heel pain, gritty eyes. .net n n . Signs  Bilateral conjunctivitis, swollen tender tendonX insertion X nailjoints, kXpoints (enthesitis), genital ulceration, k k thickening; vesicles, pustules or o o o o blennorrhagica). Bo plaques on genitals,wpalms .Boor soles of feet (keratoderma .Bnormal; w Investigations  blds  iWCC/​ESR/​CRP, X-​ray  Initially consider stool/​throat/​ enital swabs for causative organism. wgw ww ww Treatment  is mainly symptom control (treating the original infection seems tto have little effect on arthritis). rest, intra-​articular or e et NSAIDs, et oral steroids; sulfasalazine or methotrexate if severe or lasting >6mth; n n n . . . X chloramphenicol ointment/​ kX6h for eyes. (Doxycyclineo100mg kX PO/​ ok 1% oChlamydia.) 12h for 3mth if caused by o o o B Complications Recurrent/​ ankylosing.B w.B chronic arthritis, w spondylitis (5%). w w Enteropathic arthropathies  (see Box 16.17.) w w ww 8

K  Box 16.17  Enteropathic arthropathies

et in the context of bowel inflamnetrheumatological diseasesXare.nseen net These .mation, . X X as IBD, or afterka gastrointestinal infection. All share an asok sociationsuch o highlight a fascinating but poorly okunderstood with HLA-​B27 o and o Bo gut–​joint immunological B B Sacroiliitis, spondylitis,. and asymmetrical w. axis. w (inflammation of w hip or knee inflammation are accompanied by enthesitis w w points of insertion of tendons/​ligaments into bone). Treatment of any w w w underlying condition improves the arthritis. t arthritis (E p. 431.) net t Psoriatic .ne joints Five distinct patterns . of disease: .ne Common X X X k(often fingers/​toes + flexor otendons) k oligoarthritis ok • Asymmetricalpolyarthritis o(may o o resemble rheumatoidB but involves DIP) Bo • • Symmetrical B . (may resemble ankylosingwspondylitis) . Spondylitis ±sacroiliitis warthropathy w w • Asymmetric DIP with nail changes w w ww • Arthritis mutilans (widespread destruction of joints of hands). Risk factors Psoriasis (joint symptoms may present first), family history.t t t (of e e e Symptoms Vary with pattern; skin changes any form of psoriasis). n n . . (onycholysis); .nscalp, X X X Signs Nail ridging, pitting and lifting psoriasis (check k ok perineum, umbilicus); enthesitis, ok (swollen fingers). oEoSR/​Cdactylitis o Bo Investigations blds iWCC/​ B B . . RP, –​ve RhF and ANA; X-​ray Mild erow in hands; osteopenia sive changes especially less extensive w ww than rheumatoid. w w Treatment Rest, splinting; treat skin lesions w (E p. 431); NSAIDs, intra-​ w articular or oral steroids, methotrexate, ciclosporin; biological therapies (anti-​TNFα eg infliximab); reconstructive surgery. Complications Joint destruction, immobility, antiphospholipid syndrome.

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  The former term ‘Reiter’s syndrome’ is to be avoided, in light of the involvement of Hans Reiter (1881–​1969) in the Nazi party, eugenics, and ‘research’ in concentration camps.

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t t t Systemic .ne lupus erythematosus (SLE) .ne .ne X X X relapsing-​remitting, k multi-​organ inflammatory odisease; k joint ok $ Chronic, ocommonest o o represents one of the initial presentations of SLE. Bo pain B B Common joints Symmetrical w. or asymmetrical; PIP,wMCP, w. wrists, knees. w w (90%); African-​ C aribbean or South East Asian ethnicity. Risk factors ♀ w w w Symptoms  Systemic  Malaise, fever, weight  loss Musculoskeletal  Joint or muscle  Skin  Photosensitive malar rash, oral  ulcers et pain haematuria et or discoid et Renal Oedema, Neurological Seizures, psychosis Lung Pleuritic n n n . . . X pain, dyspnoea Cardiac Exertional X chest pain or pain onksitting X forok chest okpain, diarrhoea o wards (pericarditis) GI Abdo Haematological Pallor, freo o o B quent infections, recurrent B B miscarriage. . . w Signs Arthritis (swelling, ww tender), malar/​discoid wwrash, oral ulcers, altered ww mental state,w pericardial or pleuritic rubs, peritonitis. Diagnostic criteria are complex since SLE can so easily mimic other disease. Subsequently et it’s often a favourite.differential et diagnosis to make! .net n n . Investigations blds dHb/​ W CC/​ p lts, dC4±C3, ANA +ve X but X specific), dsDNA +ve (70%, kXhighly specific,iESR, k(95%, reflects disease activity), ok non-​ o o o o o anti-​Sm +ve (40%, most B protein, casts; .B specific), Rhf (+ve in 40%) U+E; .B Urine Blood, X-​rw ay Non-​erosive arthritis, pleuralw effusions; Echo Valve w effusion. vegetations, w pericardial ww ww 9

Treatment  NSAIDs, hydroxychloroquine ±oral steroids (for flares) in mild disease; methotrexate, azathioprine, mycophenolate in more severe disease; biological therapies (eg belimumab, rituximab). Complications IHD, stroke, antiphospholipid syndrome (10%). Drug induced Certain drugs can cause a lupus-​like syndrome that resolves promptly upon drug withdrawal; these include isoniazid, methyldopa, hydralazine, and diltiazem.

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$ This migratory polyarthritis occurring 2–​6wk after a streptococcal infection was previously a common cause of childhood mortality and structural heart disease, but is now rare in the developed world. Diagnosis This requires 2 major or 1 major and 2 minor ‘Jones’ criteria: • Major Carditis (new murmur, valve lesions, CCF); migratory large joint polyarthritis; Aschoff bodies (firm, painless nodules on wrist, elbow or knee); erythema marginatum (pink rings on trunk or limbs); Sydenham’s chorea (face or arms) • Minor Prolonged PR interval (if carditis not counted); arthralgia (if polyarthritis not counted); iWCC/​CRP/​ESR; fever, previous rheumatic fever. Treatment Penicillin, NSAIDs ±steroids (see Children’s BNF).

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Rheumatic fever

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Antiphospholipid syndrome (APS)

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  See this website for a summary: Mhttp://​www.rheumtutor.com/​2012-​slicc-​sle-​criteria

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B 472

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Chapter 16

Emergency department

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w

t t t .ne .ne .ne Neck lumps X X X ok Worrying featuresoWeight ok loss, night sweats, hardoirregular ok lump, Bo 2noisy/​ B B . difficult breathing, w. haemoptysis, dysphagia, wdysphonia. w w w  2 Malignancy (esp squamous w cell carcinoma) (primary, ww Think about metastases, lymphoma); Common Many of the lumps on E pp. 434–5; see Table 16.9 et for lumps found only.ninetthe neck. et n n . . X X kX of neck lumps ok Table 16.9  Location andoocauses ok o o B .B .B Location Causes w wcyst, w w Midline Goitre, thyroid isthmus mass, dermoid thyroglossal cyst w w ww Anterior triangle Lymph node, thyroid mass, salivary gland mass, branchial cyst, carotid artery aneurysm et triangle Lymph node, cervical erib,t pharyngeal pouch et Posterior n n n . . . X X X ok Ask about  Location, oonset, ok duration, change with time, okpain, other o o B .B infections, skin changes,wsystemic .B symptoms lumps, trauma, bites, wvomiting, (eg weight loss, fever), sore throat, cough, hoarse  voice; w w wlumps, cancer, radiotherapy, thyroid w problems; SH Foreign ww PMH Previous travel, smoking, alcohol intake; FH Thyroid disease, cancer.

t t t Look (E pp. 434–5) along with the .ne for Assess as for otherXlumps .nemovement .nefollowing:  movement on swallowing, on tongue protrusion, X X ok dentition, mouth ulcers, lumps okinside the mouth, lumps inothe oktongue, apo (?asymmetry), ear examination, facial Bo pearance of the tonsils B B . . nerve palsies. w w w If present for 10% et burns or patient deteriorating. et 3ne Call n n . . . Burns patients require specialist help for every step of their management X X X ok (Box 16.20). ok ok o o o B B Airway/​C-​spine .B wspine if C-​spine injury suspected w.(E p. • Immobilize the C-​ w w w to the face and neck, singedweyebrows, facial454) ww • Look for burns hair or nasal hairs, soot around the nostrils or in the sputum, facial swelling • Listen for snoring noises, stridor, hoarse voice. eIf tthese et et n n 3 above-​listed features.n of an inhalational injury are present, . . X intubation is essentialktoXprevent airway obstruction askthe ok EARLY oalert the anaesthetist early. oo X airway starts to swell and obstruct; o o B .B Breathing w.B wwcarboxyhaemoglobin levels w • 15L/​min Owuntil are known w ww 2

• Count RR; rapid breathing suggests inhalation injury • Monitor O2 sats and RR • Escharotomy if circumferential chest burns restrict breathing.

net net net . . . X X X ok Circulation ok ok access, send bloods for o o Bo • Venous B B FBC, U+E glucose, G&S and ABG if resp w. clotting, wgas. distress Carboxyhaemoglobin (CoHb)—​try the blood machine w w w ww • Give 0.9%w saline 1L STAT • Give morphine IV (eg 10mg titrated to pain) and cyclizine 50mg IV • Monitor leads t HR with defibrillator ECG t and BP for signs of shock. t .ne .ne .ne Disability X X X glucose ok • Assess GCS and check oklimb tone, and plantar reflexes. ok o o reflexes, Bo • Look/​feel for pupil B B . w. Exposure ww w w extent of 2nd-​/3​ rd-​degree burn, w see Fig. 16.5 ww • Measure the • •

• Cover the burn with cling film as analgesia, avoid creams • Check temperature—​keep the patient warm!

t

et et n n . . X fluid requirements ok • Calculate ok and adjust rate accordinglyoo(seekX‘Burns o o fluid resuscitation’) B .B urine output .B • Catheterize to monitor w w w w • CXR (for w trauma and baseline as signs of inhalation w injury after 24h) ww • Monitor circulation of all limbs with burns • Reassess, starting with A, B, C . . . et et et n n n . . . 2  Box 16.20  Serious complications X X ok Hypovolaemia E pp. 488–9ookX Coexisting trauma E pp. ok448–51 o o B .B 483 Limb ischaemia E p. .B 461 Carbon monoxide poisoning E p. Inhalation injuryw Ew p. 483 Restrictionw ofw breathing E p. 276 w w ww

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Further resuscitation

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BURNS EMERGENCY

w 481

t t t Measuring .ne the burn X.ne .ne X X are expressed as a percentage of the skin surface covered k by 2nd-​ ok Burn sizes ok onot o o degree burns. 1st-​ degree burns (erythema only) are counted. Bo orThe3rd-​ B B . chart in Fig. 16.5 works for children . and adults. Lund and Browder w w The palm (not wwincluding fingers) of a patient’s wwhand is about 0.75–​1% ww of their body surface area and this can be used for smaller burns. Alternatively the ‘rule of nines’ can be used for adults (see Table 16.11). et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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Fig. 16.5  Lund and Browder chart. Figures 1 and 2, the Lund Browder chart, in Lund C.C., et al. The estimation of areas of burns. Surg Gynecol Obstet 1944;79:352–​8.Reprinted with permission from the Journal of the American College of Surgeons, formerly Surgery Gynecology & Obstetrics.

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oo B . Table 16.11  Thew ‘rule of nines’ ww Head 9%

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Each arm 9%

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Each leg Trunk front Trunk back Perineum 18% 18% 18% 1%

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et et n n . . kX kX fluid resuscitation ok Burns ocalculate oresuscitation o o o The burn size is used to fluid requirement for B using the followingwformula: .B .B wover w w • (4 × weight (kg)) × percentage of burn = volume 24h (mL). w w ww Give half over the first 8h after injury (ie over 6h if presented at 2h): • (Volume over 24h (mL) ÷ 2) ÷ 8 = rate per hour (mL) t half is given over 16h:net Theeother et n n . . . • (Volume over 24h (mL) ÷ 2) ÷ 16 = rate per hour (mL). X X ok So for a 70kg man with 30% okburns the rate is 525mL/​hoforoktheXfirst 8h o o B then 263mL/​h forwthe.Bnext 16h. This is only a guide;wmonitor .B the volume status and urine output to maintain volume (E p. 394). There is a signifiw w cant risk of fluid w overload in these patients sowmonitor carefully. ww

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Chapter 16

Emergency department

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2 Worrying features HR >100, systolic BP 30, O2 sats 10% skin involvement.

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Think about  Life/​limb-​threatening E  pp. 480–1; Most likely  Cutaneous

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Depth Degree Colour

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Major burns (>10% skin surface.) Resuscitate as per protocol (E p. 481). Minor burns Cool with running cold water for 10–​20min as soon as possible after the injury. Offer analgesia (E pp. 88–91) and cover the burn with cling film until management has been determined. The following should be referred to plastics for assessment: • All burns to the face, hand, or genitalia unless small and superficial • All deep dermal/​full thickness burns larger than a postage stamp. Ask for their advice on dressings (often minimal as some dressings alter the appearance of the burn). See also Box 16.21.

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Full thickness 3rd White, brown, black, leathery No No No

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Treatment

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Partial dermal Deep dermal 2nd Pink, blisters Bright red, mottled Yes No Yes Yes Yes Slow

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Table 16.12  Classifying burn severity

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burns, chemical/​electrical burn, carbon monoxide poisoning, non-​accidental injury, associated injuries (fractures, wounds, eye/​ear trauma). Ask about Mechanism of burn, time of burn, explosions, smoke, cause of fire, place where fire occurred, duration of exposure, immediate treatment, falls/​jumping out of windows, trauma, breathing difficulty,  pain; PMH  Cardiac or respiratory problems, previous burns/​ trauma; DH  Allergies, tetanus status; SH  Smoking (COHb result), housing (do they have somewhere to go?) Look for 3 Signs of inhalational injury (E p. 483)—​get an immediate anaesthetic assessment if those features are present, degree of burn (see Table 16.12), colour, sensation, blistering, extent of burn, location of burn, circumferential burns, other trauma. Depth of burn is assessed by the appearance, blanching, sensation, and bleeding; it can be difficult to assess especially as different depths may be close together so that a patient may report pain in an area of full thickness burn. Burns will continue to evolve over 48h. Investigations blds COHb if fire occurred inside; Consider ABG, CXR.

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et et et n n n . . . X X X ok T Box 16.21 Tetanus ok ok o o o Burns can cause inoculation B w.B with tetanus; manage win.Bthe same way as w wounds (E p. 451). w w w w w

B

.B w ww

.B w w

w

w

Burns

w 483

t t t Dressings .ne .ne .ne X X X to plastic k surgery cover the burn oinkcling film. ok If referringaimstraight oburn o to keep the covered with a sterile and adherent Bo Otherwise B . be removed .Bonon-​in 2–​ dressing, which should for review andw redressing 3d: w • Silver sulfadiazine cream (eg Flamazine ) silverw has antibiotic effects to w w on 3–​5mm thick ww reduce thew risk of infection; it should be pasted • Paraffin impregnated gauze (eg Jelonet ) this is a non-​adherent dressing; it can applied over silver sulfadiazine cream etbegauze et can be used on top of Jelonet et n n n . . • .Sterile Gauze and crepe bandages X X X bag/​glove This can ok • Polythene okbe placed over a burn to theohand ok treated o o with silver sulfadiazine cream B • Paraffin wax/​Vaseline B difficult w.BThis can be applied oftenwfor w.areas w to dress. w w ww 3 Inhalation injury $ Inhalation cause delayed obstruction of the airway. t et of smoke canhoarse et dysphagia, n n . . .ne Symptoms Breathlessness, voice, confusion. X X X kor palate, facial hair or eyebrows, soot around the nostrils ok Signs Singed ok swelling odrooling, oo wheeze. neck burns, stridor, near the airways, Bo facial/​ B B . . Investigations  spirometry dPEFR; blds  iCOHb (see w‘Carbon monoxide wwAcidosis, poisoning’); w ABG  hypoxia, hypercapnia; ww ECG  Exclude dys- ww ®

®

®

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rhythmia/​ischaemia; CXR ARDS after 24h. Management Symptoms or signs should prompt immediate anaesthetic assessment and early intubation, high-​flow humidified O2, salbutamol. Complications Pulmonary oedema, ARDS, upper airway obstruction.

t t t .ne .ne .ne X X X k ok Carbon monoxide opoisoning ok o o Bo 3 B B $ This must be considered w. in all patients involved win .fire-​related injuries. w w w Symptoms Headache, w vomiting, malaise, lethargy, w dysrhythmias. w Signs Often none, O sats will be falsely high, cherry-​red lips (rare). t available on some gasnanalysers—​ Results COHb seek advice. >30% is conet have a COHb et .ne serious; very heavy smokers . may .nABG sidered of up to 15%; X X X acidosis; k ischaemia. ok May show metabolic o ECG To exclude dysrhythmia/​ ok for >24h o 15L/​minB Oo by tight fitting mask and reservoir Bo Management  B . . (use humidified Ow ); consider mannitol, ventilation, . whyperbaric O w w Complications Cerebral oedema, pulmonary oedema, MI, dysrhythmia. w w ww 2

2

2

3 Chemical burns

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$ These can be severe, especially if alkalis are involved. They should be washed in running water for at least 20min; larger burns may need fluid replacement as for thermal burns (E p. 481). Toxbase (E pp. 507–8).

k ok oo oo Bo 3 Electrical burns B B . . w dysrhythmias, cardiac damage w and severe muscle $ These can cause damage resulting wwin renal failure or compartment ww syndrome. ECG In all ww patients; blds FBC, U+E, iCK; Urine Dipstick if severe or high voltage (>1000V) et for blood (actually detecting etmyoglobinuria). et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

B 484

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Chapter 16

Emergency department

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t t et .nAnaphylaxis .ne (E OHCM10 p. 794.) .ne 2 in adults X X X ok ok ok o o Bo 2 Airway B B If airway . involved—​CALL ANAESTHETIST w w. TEAM 2 Breathing w If no respiratory effort—​CALL ARREST w w If no palpable pulse—​CALL ARREST w TEAM ww 2 Circulation et for senior help early if anaphylaxis et suspected. et 3 Call n n n . . . X• Sit patient up unless hypotensive, then lay flat with legs elevated X ok • 15L/​min O in all patientsookX ok o o B B • Monitor pulse oximeter, .B BP, defibrillator ECG leads w w.if unwell • Request full set of observations w w • Take briefw history if possible/​check drug chart w /​ask ward staff ww • Examine patient: look for early signs of anaphylaxis (see Box 16.24) • Establish et likely cause (Box 16.23).nandetstop further exposure (eg IV.net antibiotics) n . X X : (Box 16.22), 1:1000 kXsolution, 0.5mL (0.5mg) intramuscular ok • Adrenaline ok repeat after 5min if o nooimprovement o o B B , take bloods if time permits: • Large-​bore venous.access w cell w.B FBC, U+E,w mast tryptase (see ‘Investigations’) w w ww • IV infusionw of 1L 0.9% saline STAT

B

2

• •

• Consider nebulized β-​agonist for bronchospasm: • salbutamol 5mg, or • adrenaline 1:1000 solution, 5mL (5mg) • Re-​assess • Administer adjuncts to treatment: • antihistamine, eg chlorphenamine 10mg slow IV • hydrocortisone 200mg slow IV.

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2 Intramuscular adrenaline should be given if the diagnosis of anaphylaxis is likely but not if the symptoms are mild or the patient is well.

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t t et .nBox .ne .ne X X X 2  16.22  Adrenaline (epinephrine) preparations ok ok ok o o Bo 1:1000 Preparation—​ B B ( 1mg in 1mL ampoules) w. (0.5mg) IM in anaphylaxisww. Give 0.5mL w w w arrest drugs, or ww 1:10,000 Preparation—​ 10mL syringe in cardiac 10mL ampoule 1mg in 10mL t t who are NOT in cardiac-​ et 2 Only give IV adrenaline in e patients e n . arrest if you are trained to.n do so, for example under ICU or .n X X X anaesthetic supervision. ok ok ok o o o B .B w w.B w 2  Box 16.23  Common precipitants w w w ww Drugs Penicillins, muscle relaxants (used in anaesthetics), contrast media, blood products t e et et n n . . Environmental Latex, stings, eggs,.n fish, strawberries, nuts X X X ok ok ok o o o B w.B w.B w w w w ww

B

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w ww ANAPHYLAXIS IN ADULTS 485 t t et 3 .nAnaphylaxis .ne .ne X X X 20mmHg or ddiastolict>10mmHg upon standing; iHR (in et BPabsence e autonomic aetiology). .net most instances; of tachycardia suggests n n . . X X diagnostic. Other investigations standing BP kX Alsoas ok Investigations Lying/​ ok usually o456–7). appropriate to investigateo cause of syncope/​collapse (E pp. o o B see Box 16.25. w.B w.Band identify likely w Acute treatment  Ensure patient safety. Review medications w w precipitants; can for a drug without this side ef- w w these be stopped or changed w fect? Optimize control of DM. Identify and treat precipitating disease. Chronic ttreatment Advise simple lifestyle tchanges such as elevating the head ebed, getting out of bed/​chairs eslowly, and holding onto something et of the n n n . . . while standing. In autonomic neuropathy, consider graduated stockings X lower legs, increasing salt kandXfluid intake, and mineralocorticoids X ok for o ok (eg o o o fludrocortisone 100–​ 2 00micrograms/​ 2 4h PO). B Complications  Falls wand.Bsubsequent bone and soft w .B tissue injuries including w w intracranial bleeding and fractured neck of femur. w w ww T  Box 16.25  Assessing the hypotensive in-​patient

t tassess patients with low BP. Key factors t When asked .neon-​call, you will frequently beX .natoesudden .ne to help identify the acutely unwell include dBP (inspect recent obs charts), X X k those obs (itemp, iRR, ok other abnormal okdurine output, dGCS, iHR—​boinutothisbeware o blocker). Early warning scores (E pp. 226–7) can be helpful Bo ontientsa β-​with B B . .assessmentregard: paworryingw obs require urgent IV fluids and further (?current w w old in the bed opposite, diagnosis, ?sepsis,w ?shock E pp. 490–5), while the fit 30yr-​ w w ww who feels quite well with his BP of 90/​50mmHg, may safely be left to sleep. 3 Leaking aortic aneurysm (AAA) t t et abdominal (E 654.) .nOHCM10 p. .ne .ne X X X asymptomatic, gradually until their ok $ Most AAAswitharesudden ok andenlarging ok dramatic rupture an associated dismalo mortality. In the o Bo presentation B B . . USS screening UK, the NHS AAA screening programme offers all men at w w 65yr, allowing elective repair where necessary. w w w a ruptured/​leaking AAA: w ww 2 If you suspect • Fast-​bleep for senior help and vascular surgeon immediately • Activate protocol et major haemorrhage etand urgent X-​match 8units. back, et n n . . Symptoms Severe constant or colicky abdominal pain radiating to the.n X or feeling faint. kX X ok collapse, osmoking, IHD, icholesterol, known AAA. ok Risk factors iage, male, iBP, o o o B Signs Expansile abdominal .Bjust pulsating)—​ w.B mass (pushes hands apart, wnot examination willw not cause rupture; iHR, ±dBP,w iRR, pale, sweating, cool w wpulses in legs. ww extremities, distension, tenderness, dperipheral et n . kX

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Bo

Investigations None if unstable (if possible, bedside USS can quickly confirm diagnosis prior to theatre; urgent CT is best but consumes critical time). Management 2 Emergency O2 (15L/​min); Resuscitate Large-​bore IV access for bloods and STAT crystalloid/​blood (keep systolic BP 90–​100mmHg, but do not raise above this as irisk of leak from AAA); prepare to transfer to theatre or interventional radiology suite; observations every 15min. Those unfit for intervention require palliative care (E p. 93).

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B 488

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Chapter 16

Emergency department

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t t et .nHypotension .ne .ne 2 emergency X X X k ok ok oo o Bo 2 Airway B If.B airway involved—​CALL ANAESTHETIST w w. ARREST TEAM 2 Breathing w If no respiratory effort—​CALL w w If no palpable pulse—​CALLwARREST TEAM ww 2 Circulation et for senior help early if patient etdeteriorating. et 3nCall n n . . . X threatening Shock EkX X (hypovolaemic/​haemorrhagic, ok Life-​ o pp. 490–4 ok(brady-​or septic, cardiogenic, anaphylactic, neurogenic), dysrhythmia o o o B tachyarrhythmia). See w.BTable 16.13 for haemorrhagic shock. w.B Systolic 10 CFU/​ w w mL is the gold standard ww test in suspected UTI. While awaiting culture diagnosis, dipsticks allow testing for markers that may allow for a modest improvement in clinical diagnosis : to +ve in 730% confirmed UTIs, but • Nitrites et Many uropathogens reduce nitrate etnitrite; et n n n . . . highly specific. False −ves occur with organisms that do not reduce nitrate or polyuria X Xin 780–​90% confirmed UTIs; false +veskoccur X A marker for pyuria; +ve ok • Leucocytes ok causes omalignancy)with contamination (eg vaginal) or other of sterile pyuria (eg STIs, TB, o o o confirmed UTIs; false +ves occur with.B contamination from • Blood +ve in 770–​80%.B B eg menstrual bleeding, w renal stones w w organisms and cells in urine; +ve in 750% confirmed UTIs. • Protein Reflectw w w ww 17

5

Study data from UK primary care18 show that where clinical suspicion of a UTI exists, the presence of nitrites, leucocytes or blood can support a diagnosis, but that evaluation of protein provides no additional information. Combining test results increases sensitivity, but decreases specificity. Even when all tests are –​ve, 24% of symptomatic women will have a UTI confirmed by MSU culture. If UTI suspected, send an MSU for culture and consider delayed antibiotics or review appointments in case of false −ves.

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17 18

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B

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Pyrexia

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t t t Infective .ne endocarditis (IE)X (E .neOHAM4 p. 96.) .ne X X valve, valvular lesion (aortic >mitral), congenital ok Risk factors Prosthetic ok (IVDU, ok defect, lines, recurrent bacteraemia severe dental disease). o o Bo invasive B B . weight loss, fever, night sweats, Symptoms Fatigue, anorexia, w w. dyspnoea. Signs  Fever (90%), new murmur (85%), embolic w phenomena (30%), splinter w w wJaneway lesions, Osler’s nodes, w haemorrhages, Roth spots, conjunctival haem- w orrhage, iHR, warm peripheries, CCF, evidence of IVDU. Investigations For criteria, see Box 16.40; (iWCC, iNØ, t LFT, diagnostic eU+E, et to get blds FBC et n n n dHb), iESR/​CRP; bld cultures Try 3 sets (prior to commen. . . X ABx, even if patient is unwell) X different sites at intervalskX of >1h or ok cing oknon-​from owhich during temp spikes; ECG Often specific, monitor PR interval is proo o o B longed by aortic valve B B disease; CXR  Pulmonary oedema, septic pulmonary . . w (sensitivities are as w emboli if tricuspid disease; ww Echo Valvular lesion/​vsvegetation w follows: 96% w for transoesophageal echo (TOE)w 70% for transthoracic echo w (TTE) in native valve endocarditis and 92% for TOE vs 50% for TTE in prosthetic valve endocarditis. scan If pulmonary emboli CTPA is better etalso identifyV/​Qaortic etUrine suspected but et andn can root abscesses; dipstick Blood ±protein. MRI n n . . . head to look for cerebral emboli (even in the absence of neurological features). X treatment  2 Early referral XEmpirical kXto microbiology and cardiology. ok Acute openicillin ok organisms o o o treatment tends to include a and aminoglycosides. Likely B will change dependingwon.Bgeography, type of lesion, andwpresence .B of prosthetic valve. Give O aswneeded, paracetamol, and otherw supportive measures (anti-​ w w ww

B

2

emetics, IV fluids if dehydrated, diuretics if CCF). Further treatment Give antibiotics for 2–​6wk (patients need to be motivated as it’s often a long hospital stay). Up to 50% of patients undergo valve replacement; the main indications are heart failure, uncontrolled infection, and prevention of embolism. Advise on oral health; antibiotic prophylaxis is generally not recommended (E p. 177). Complications Valve destruction, cardiac failure, AV block, intracardiac abscess, embolism (to brain, limbs, lungs), septicaemia, death.

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Box 16.40  Duke criteria for infective endocarditis (IE)

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t —​2 major, or 1 major and 3 minor, t Definite minor criteria etornot5‘rejected’ .ne IEIE—​ .nbut .ne Possible findings fall short of ‘definite’ X X X IE—​firm alternative diagnosis ok Rejectedcriteria ok or resolution within 38°C oklesion, conjunctival haemorrhage) ok • Vascular (septic emboli, Janeway o o o B B Osler’s nodes, Roth spot,w+ve.Brheumatoid factor) • Immunologic (glomerulonephritis, w.blood • Microbiological (+ve cultures failing to meet major criteria) w • Echocardiographic findings consistent with IE butw notw meeting major criteria. w ww Reproduced from Hoen B, et al., ‘Evaluation of the Duke criteria versus the Beth Israel criteria for the diagnosis of infective endocarditis’, Clinical Infectious Diseases, 1995, 21(4):905–​9, by permission et of Oxford University Press and the.Infectious et Diseases Society of America. .net n n . X X kX ok Streptococcus viridans, Streptococcus obovis, ok Haemophilus oActinobacillus o o actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens,.Kingella S. aureus B Enterococci w.B wB w w w w ww 19

19

20

 

HACEK group ( spp, spp). or in absence of 1° focus. 20  Evidence of an intra-​cardiac vegetation or abscess, new valvular regurgitation, or dehiscence of prosthetic valve. 19

B 500

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Chapter 16

Emergency department

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t t t Neutropenia .ne .ne .ne X X X counts 150mg/​kg) 4wk, Abdo tenderness .+ve β-​hCG; dHb; w w empty uterus may be ±peritonism,w w shock w w PV bleeding ww seen on USS Miscarriage PV bleeding, crampy Open/​closed hCG +ve, t tproducts of β-​±gestational pain os, sac et e e n n conception . . .nif (or empty uterus X X X complete)kon USS k k o oo oo Menorrhagia Normal Normal Bo Dysfunctional B B . . uterine bleeding w w Visible on USS Fibroids Bulky uterus w wMenorrhagia w w ww Endometrial Postmenopausal Usually normal; Thickened cancer bleeding, abdo pain inguinal endometrium t t lymphadenopathy on USS; mass on et e e n n hysteroscopy .n . . XPelvic X X Abdominal pain,k vaginal Abdominal +ve genital k kswab o inflammatory discharge, dyspareunia o o(±pelvic tenderness, foul-​ cultures o o o B B on USS/​CT) disease discharge .abscess w.B or smelling w Normal Ectropion/​erosion w Intermenstrual Red ring or flare w w postcoital bleeding; use around external w os ww

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Intermenstrual or postcoital bleeding

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Family history, bleeding, May have bruises bruising, bleeding on tooth extraction

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Miscarriage E p. 517 Hypothyroid E pp. 340–1

k ok o (cervicitis,ovaginitis) oo Bo Infection B B . . $ Infection with candida that similar symptoms w or STIs (E p. 479); note can be causedw by a lack of oestrogen (atrophic wwvaginitis), allergy, or ww w w foreign body. Symptoms Itching, vaginal discharge, dysuria, superficial dyspareunia, abnormal etodour, small amounts of bleeding. et et n n n . . . Signs Vaginal or cervical erythema, swelling, exudates, discharge. X X kX510). ok Investigation Genital swabsoo(E p. ok o o B Treatment Treat thewcause, B .B eg antibiotics, antifungals, w.oestrogens. w w w w ww

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w Emergency departmentw ww t t et pregnancy (E OHCS10 3 .nEctopic .ne p. 262.) .ne X X X this in every woman child-​bearing age (usually 6–​9wk k ofacute k atbleeding. ok $ Considerpresenting ocollapse, o±PV with abdominal pain, o o Bo gestation) B B 2 If it ruptures, these. patients can deteriorate very quickly w pain, shoulder tip/​backwpain, w.PV bleeding, recent w w Symptoms Abdominal w dizziness; Ruptured ectopic Collapse, w shock, peritonism. w amenorrhoea, Risk factors  imaternal age, previous ectopic, tubal surgery, previous t ePtID, IUCD, assisted conception etechniques, et STIs/​ smoking. n n n . . . (75%) ±mass (50%); ifXrupture XSigns  Abdo  Unilateral iliac fossa kX pain(50%), k cervical excitation ok guarding; iHR  ±dBP; PV ooBleeding o oo (pain on cervical stimulation/​.mB anipulation). B B . Investigations  blds  wwβ-​hCG (serum and urine), wwFBC, G+S/​X-​match; ww Transvaginalw USS gestation sac ±foetal pole w in the adnexae, free fluid. 512

Chapter 16

27

Differentials Miscarriage, appendicitis, pelvic infection, ovarian cyst. Management 2 large-​bore cannula, IV fluids, and urgent referral to gynae; Medical Methotrexate increasingly used for small (1b) Chemotherapy and radiotherapy. Prognosis Overall 5yr survival 65%.

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  NICE guidelines available at Mguidance.nice.org.uk/​CG122

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Chapter 16

Emergency department

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t t t .ne .ne of pain .ne Gynaecological causes X X X ok Consider ectopic pregnancy ok if acute abdominal paino(E p. ok 512). o Bo 3 B B Pelvic inflammatory w. disease (PID) ww. winflammation $ Infectionw and of the upperw genital tract commonly with ww STIs (E p. 479) eg Chlamydia trachomatis or Neisseria gonorrhoeae. Symptoms Lower abdominal pain (90%), discharge (75%, may be t et vaginal et foul-​ semelling), intermenstrual/​postcoital bleeding (40%), pyrexia .(30%), n n n . . X dyspareunia, nausea,kvomiting, X X general malaise. ok dysuria, oPV Adnexal infertility, okexcitation. Signs Abdomen Tenderness; tenderness, cervical o o o B Risk factors Young age at first intercourse, multiple .sexual w.Bsmoking. w B partners, no w barrier contraception, w w w w ovarian cysts, ectopic w Differential diagnosis Appendicitis, endometriosis, pregnancy, other STIs, HIV, urinary tract infection. Investigations  genital swabs)  for  et excludeMSU; etM,C+S; blds  FBC, CRP, cultures; et n n . . USS (to ovarian cyst). .n X X X access for fluids, ok Management IV ok analgesia; consider removing okIUCD if syso temically unwell and giveo IV antibiotics (see local policy); o if stable give PO B B 12h PO and (eg ceftriaxone 250mg then metronidazole w1.2hBIMPOSTAT, wfor.400mg/​ w w doxycycline 100mg/​ for 14d). Refer to GUM contact tracing. w w ww 29

Complications Untreated may lead to chronic pelvic pain and infertility; tubo-​ovarian abscess, septicaemia, 2° infertility, ectopic pregnancy.

t t t 3 cyst/​torsion .ne neOvarian .Torsion .ne $ most commonly occurs with fibromas and dermoid cysts. X X X ok ooknset lower abdominal pain,oiliac okfossa pain Severe, sudden-​ o Bo Symptoms  B B radiating to the flank,. nausea, vomiting, fever. . w If cystic rupture, signs w Signs Abdo tenderness. of w haemorrhagic shock. w w hormonal stimulation ww Risk factors w Early pregnancy, women undergoing for IVF, fibromas, and dermoid cysts. t diagnosis Appendicitis, diverticulitis, t t Differential ectopic pregnancy, UTI. .ne .ne(to exclude pregnancy/​ .ne Investigations  blds  serum β-​hCG ectopic), X X X may i ok FBC, CRP (torsion ok inflammatory markers) oUrine  ok Dipstick o  USS. Bo ±MSU; Pelvic  B B . urgent laparosManagement 2 Immediate may w. referral to gynae asw wneed copy. IV accessw for fluids, analgesia. w w ww Complications Infection, peritonitis, adhesions, infertility (rare). Endometriosis et et et n n $.Endometrial tissue found outside.n the endometrial cavity that bleeds with . X menstrual period; called adenomyosis X if in the uterine muscle wall. kXpain before/​ ok the opelvic oorkconstantly Symptoms Painful periods, with periods o o o B .B (adhesions), deep dyspareunia, infertility, rectal pain..B wpelvic w Signs Generalized tenderness, fixed (retroverted) w w ww uterus, palpable ww et n . kX

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nodule on uterosacral ligaments; large uterus in adenomyosis. Investigations Laparoscopy (though it is a common incidental finding). Management  Medical  Preventing cyclical hormone changes can shrink ectopic tissue:  continuous combined OCP; GnRH agonists (eg goserelin, leuprorelin); Surgery Laparoscopic diathermy or excision of endometriosis and division of adhesions, bilateral salpingo-​oopherectomy ± hysterectomy.

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 NICE clinical summaries available at Mhttps://​cks.nice.org.uk/​pelvic-​inflammatory-​disease#! topicsummary

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Contraception

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t t t .ne .ne .ne Contraception X X X ok Options should be discussed okwith both partners where possible ok o o Bo $• Barrier B B methods Condoms, caps, diaphragm, femidoms. w. releasing w. containing plastic (Mirena ) orw copper-​ • IUCD Local progesterone-​ w device; Sidew effects Bleeding, pain, pelvic infection, w ectopic pregnancies, ww expulsion, perforation. pill Either oestrogen and • Oral contraceptive et et progesterone (COCP) or .net progesterone only (POP). n n . . X• Hormones by other routes eg implants X (3yr) and injections (3mth). X ok • Sterilization NB ♂ sterilization okis 10× more effective than ♀.ook o o B Contraceptive guidelines are available from the Faculty of wand.BGynaecologists. w.Bthe Royal College w of the Obstetricians w w w w w Oral contraceptive pills Side effects  Acne, altered menstrual pattern, breast tenderness, bloating, t mood changes, nausea, DVT/​ weightegain, et PE. et n n DM, hypertension,.n >35yr, BMI >30. Caution smokers, . . X Xbloating, breakthrough bleeding, weight gain, kXdepresok Problems Headaches, okhypertension sion, acne, breast tenderness, (check BP). oo o o B Education Stop smoking, .Bdiet, DVT risks, missed pillwrules .B(Box 16.49). See also Box 16.50. ww w w w ww ®

30

Box 16.49  Advice for missed pills

t then at the usual time; no extranpreCOCP If take the pill immediately et1Ifpill>2missed, et natenormal cautions. pills missed, take next pill time; alternative contraception .fornnext . . X X X 7d, start another pack without break if due to finish pack k ok unprotected oinklast 7d,aadvise o within 7d. If sexual intercourse emergency contraception. o o Bo POP If >12h since missed B B take pill immediately and then . take the next dose w. ifdose, at the normal time (even this means 2 pills in one day); w alternative contraception w w for 48 h. Emergency contraception only needed if unprotected sexual intercourse w w ww after missed pill and within 48 h of restarting POP. If patient develops vomiting or diarrhoea while on either pill, advise her to use t t t barrier .ne contraception until 7d afterXresolution .ne of symptoms. .ne X X and HRT (Ek OHGP4 p. 710.) ok Menopause osymptoms ok o helps alleviate menopausal (incl. hot flushes andovaginal atrophy). Bo HRT B B . on the irisk of PE/​DVT, stroke, Much attention has focused wassociated w. breast, ovarian, and w endometrial cancers with HRT. HRT should only be prescribed after a w w w for the shortest necessary w discussion of w these risks, at the lowest effective dose period of time, with regular review. t 16.50  Some common eBox etED presentations .net T  n n . . X Xpatients after unprotected sexualkintercourse. X contraception  Offered k ok Emergency omtoigraine, otesting. Copper Discuss Timings, LMP, risk ofo PE/​ future contraception, STI o o B .Bto 5d after UPSI; infection is awrisk.B IUCD  Can be inserted up so needs STI screen wprophylactic (E p. 479), consider antibiotics. IUCD isw most effective, but if not acw ceptable, offerw Medical treatment Ulipristal can be used wup to 120h after UPSI or levo- ww norgestrel up to 72h. Lost condom? Retained Tampon? Foreign object? PV examination first, then speculum to aid visualization. Remove the object with forceps. Consider antibiotic prophylaxis, especially if retained tampon as risk of toxic shock syndrome due to toxins released by staph (E p. 494). I can’t feel the threads of my coil anymore? This could suggest expulsion, if they are unwell with abdominal pain/​bleeding consider perforation. PV examination first, then speculum to aid visualization. If not seen, consider pelvic USS and if coil not seen then, request abdominal X-​ray.

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 Contraceptive guidelines from the Faculty of the Royal College of the Obstetricians and Gynaecologists Mhttps://​www.fsrh.org/​home/​

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Chapter 16

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t t t .ne pregnancy (1st .ne trimester) X.ne Early X X ok ok ok o o pregnancy Bo Diagnosing B B . Symptoms Missedw period, urinary frequency, nausea, w. vomiting, malaise, w w w nipple tingling/​ i tching, breast enlargement. w w w Signs Enlarged uterus. Investigations  Urine  β-​hCG usually positive from the first day of the etperiod; Serum β-​hCG only.nmeasure et if urine β-​hCG is +ve;.nuseful et missed n . for assessing 1st trimester complications (should increase by >66% X X X ok every 2d) Transvaginal USS gestation ok sac should be detectable okwithin the o o o uterine cavity from about B .B 5/​40 gestation. w.B consider who w Once pregnancy w confirmed  Give the news sensitively, w w is present (eg w relatives); start folic acid 0.4mg/​ w 24h PO (some patient w groups may need altered dose eg those on anticonvulsants, DM, BMI >30, previous children with neural tube et See Box 16.51. et defects); ask GP to refer.ntoethet midwife. n n . . XHealth promotion Exercise, nokXsmoking or alcohol, avoid unpasteurized X ok cheese, shellfish, and catofaeces o (toxoplasmosis). ok o o B See Table 16.22 for a.B w list of obstetric guidelineswavailable w.B from NICE. w w w ww Box 16.51  When to give anti-​D in rhesus (D) −ve women

12/​40 if bleeding persistswthis w.is repeated every 6wk until delivery w • Surgical orw medical terminations 20/​ .ne40: Anti-​atD 28/​ . e 72h of the following X.ne X X • Routinely 4 0 gestation ok • Antepartum haemorrhageook ok o External cephalic version (ECV) attempts Bo • • Abdominal trauma B B . wp.ositive baby (none if baby rhesus-​ wnegative). w w • Delivery of rhesus-​ w w ww Table 16.22  Selected NICE obstetric tguidelines t e e Web reference et n n n . . . Topic X X Mguidance.nice.org.uk/​ ok Routine antenatal care ookX okCG62 o o Hypertension in pregnancy Mguidance.nice.org.uk/​ CG107 B w.B w.B NG3 Diabetes in pregnancy Mguidance.nice.org.uk/​ w w w w ww Multiple pregnancy Mguidance.nice.org.uk/​ CG129 Mental health

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EARLY PREGNANCY (1st TRIMESTER)

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t t t Miscarriage .ne .ne .ne X X X ok $ Loss of pregnancy 0.3g/​24h) and may develop from ≥20/​40 gestation until 6wk post-​partum. Risk factors for pre-​eclampsia 35yr, 1st pregnancy, BMI >30, chronic iBP, DM, SLE, thrombophilia, PMH or FH, time between pregnancies >10yr. Symptoms epigastric pain, headache, vomiting, visual disturbance. Signs  Asymptomatic unless: Pre-​eclampsia  RUQ tenderness, oedema, papilloedema, hyper­reflexia, clonus. Investigations  Urine  M,C+S, urinary PCR (essential if dipstick ≥1+ protein); blds  In chronic hypertension ensure secondary causes of hypertension excluded (E pp. 270–3) and recent screening for baseline evidence of end-​organ damage (E p. 272); if suspect pre-​eclampsia: FBC (plts 110mmHg give hydralazine or labetalol IV (E p. 273). Once stabilized, establish close foetal monitoring and consider urgent delivery. There will be departmental protocols to follow. After delivery  Treat BP >150/​100mmHg (E p. 273), strict fluid balance, monitor FBC, U+E, LFT, observe for ≥5d.

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LATER PREGNANCY (2nd/3rd TRIMESTER)

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t t et (Haemolysis, Elevated 3 .nHELLP .ne liver enzymes, Low .ne X X X ok Platelets) oofksevere pre-​eclampsia. ook o Develops in 10% of cases Bo $Symptoms Upper B . pain, headache, malaise, w .B abdominal vomiting. w w w Signs RUQ tenderness, oedema, iBP. w ww Results dHb, w ibilirubin, iALT, dplts, iLDH, dhaptoglobin, proteinuria. Management  Resuscitate and stabilize BP, consider FFP/​plts/​blood transfut sion, urgent et delivery.haemorrhage (brain, eliver), et n n n . . . Complications DIC, eclampsia. X kX kX diabetes mellitus ok Gestational o o o o o Glucose intolerance.first 334–6). B $Screening  B detected during pregnancyw(E pp. .B Althoughw some advocate universal screening, current NICE guidw w ance is to w offer a 2h 75g oral glucose tolerance w test (OGTT) at booking to ww women with: previous gestational DM or baby >4.5kg, BMI >30, 1st-​degree relative with DM, South Asian, black Caribbean, or Middle Eastern ethnicity. t urine dipstick. Symptoms Often asymptomatic, glucoseeon et et n n n . . . Signs Large for dates, polyhydramnios. X kX kX L glucose ≥7.8mmol/​L after OGTT (oro≥5.6mmol/​ ok Investigations blds Plasma o334–6); o o o pp. self-​ m onitoring of capillary on fasting samples) (E B cose; Regular USS Towassess .B foetal growth. .B blood gluw Treatment Regular wwreview in diabetic antenatal clinics. wwDiet changes and exercise ww 33,34

will achieve good glycaemic control in 80%; start insulin or oral hypoglycaemics after 1–​2wk if this fails; stop treatment after birth and repeat OGTT at 6wk. Complications  Congenital abnormalities, stillbirth, pre-​ eclampsia, poly­ hydramnios, large baby, traumatic delivery; Neonate Birth injury (eg shoulder dystocia, brachial plexus trauma), respiratory distress syndrome, polycythaemia, hypoglycaemia, jaundice.

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2

breast pain. Look for  Abdo/​loin tenderness; PV  Uterine/​adnexal tenderness, lochia (period-​like discharge), breast tenderness, leg swelling. Investigations Urine M,C+S; blds FBC, CRP, G+S, bld cultures; Culture High vaginal swab, sputum, wound swab. Management According to the cause, always use local guidelines: • Wound infection Infection of tear or episiotomy: antibiotics (eg flucloxacillin 500mg/​6h PO and metronidazole 400mg/​8h PO) • Endometritis Tender uterus, offensive lochia (vaginal discharge): antibiotics (eg co-​amoxiclav 625mg/​8h PO; 1.2g/​8h IV if signs of sepsis) • Mastitis Tender, red breast: encourage to continue breastfeeding (to prevent milk stagnation), NSAIDs (eg ibuprofen 400mg/​6h PO), antibiotics (eg flucloxacillin 500mg/​6h PO). Breast problems (E p. 175 for prescribing in breastfeeding) Cracked nipples Nipple shields or emollient cream. Breast abscess Refer to surgical team for incision and drainage. Post-​natal psychiatric problems See Box 16.53.

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With the exertion and trauma of labour, dramatic hormone changes, and the immediate demands of motherhood, it is perhaps unsurprising that 85% of women experience mood disturbance during the post-​partum period. For most, this goes no further than transient and mild postpartum ‘baby blues’ 1–​ 10d after delivery, with rapidly fluctuating mood and irritability. 10% may experience postnatal depression, typically 6–​16wk after delivery; this resembles depression in any other adult (E p. 380) and may necessitate antidepressants (eg SSRIs given for a minimum of 6mth), counselling, or psychiatric referral. 3 Puerperal psychosis is a psychiatric emergency (affects 0.2% of women) typically presenting 3–​7d after delivery with acute psychosis (E pp. 378–81). Urgent involvement of peri-​natal psychiatrist required.37

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t t t .ne Procedures .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww Practical procedures 524  525 t Laboratories e et Skills 526 et Achievement of Core Foundation n n n . . . X Blood and injectionskX X ok o ok Taking blood (venepuncture)  528 o o o B B Femoral stab. 530 w 531 w.B Bloodw tubes w w w ww IV cannulation  532 Taking blood in children 534 Arterial blood gas (ABG) 536 t e et et n n SC/​IM injections 538 .n . . X IV injections 540 kX X ok o ok o o o Cardiology B .B ECGs andw cardiac monitors 542 w.B w w Exercise tolerance test  544 w w ww Chemical cardioversion (adenosine) 545

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Lumbar puncture (LP) 566 Others Normal vaginal delivery 568 Joint aspiration and injection 570 Local anaesthetic (LA) 572 Suturing 574 Reduction of fractures and dislocations 576

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Procedures

t t t .ne .ne .ne Practical procedures X X X ok ok seem easy and highly rewarding, ok but it hands, procedures o o Bo Intakesexperienced B B . new procedures can make w practice. Learning you. feel frustrated, emwabout barrassed, and guilty inflicting pain. When you are learning a new prow w w w if it is your first time, ask onewof your cedure, especially seniors to take you w through it and supervise you. Try to get as much practical experience as you can so t you can work more independently t and eventually teach others. ethat eyourself et n n n . . . Before starting  Always introduce and obtain informed conX (verbal or written, E kp.X31) before carrying out thekprocedure. X ok sent o what the procedure involves, o how it will o o o Explain in clear, simple language B .B and ask if they have any feel, and why it is w necessary, questions. Mentally w.B w w prepare yourself by thinking through each step of the procedure. w w ww The procedure As you perform the procedure take your time, plan ahead, tand be confident in your actions.tMake sure you and the patient are e eright position. Ask for an assistant—​ et as.comfortable as possible and in the n n n . . Xuseful if you have forgotten anything X (Box 17.1). X ok If things go well At theoend okof the procedure always clean oupkand always o o B .B Check the patient is alert,wcomfortable, .B dispose of your own and well. wsharps. w w If things go wrong  Ask for help early. Stay calm and reassure the ­patient ww w w

B

while you wait for help to arrive. E p. 32 if there is a serious problem. Writing in  the notes  Write your name, date, and time of the procedure. Document that you obtained informed consent, why the procedure was undertaken, if there were any problems during it, who supervised and/​ or assisted you, and what your management plan is, eg sending CSF sample for M,C+S. You should also document the details of any equipment used, such as putting the reference sticker from a urinary catheter wrapping in the notes. Always document patient comfort and plans for analgesia if required. Learning and assessment  You will start to learn practical procedures as a medical student. Increasingly, skills labs and simulated manikins are used for formal teaching, prior to your first supervised efforts on patients. Repetition and feedback will help shape your skills, along with reflection on your efforts: think about what you did well, what you could do differently, and how you would teach someone else doing the procedure. By the end of F1, you will need to be signed off as competent for the core 15 procedures listed in E Table 1.2 p. 9 and maintain and improve these skills through F2. You can record your progress using E Table 17.1 p. 526. F1/​F2 DOPS forms now receive much less emphasis, and are meant to provide feedback simply on the way you interact with a patient while performing the skill.

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• Gloves ± sterile • Needles (various sizes) • 0.9% saline • Antiseptic solution • Syringes • Local anaesthetic

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• Plenty of swabs—​you can never have too many • Dressings and tape • Specimen pots/​bottles • Kidney dishes/​galipots • Sharps bin.

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Box 17.1  Things to remember to put on a procedures trolley

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Laboratories

w 525

t t t .ne .ne .ne Laboratories X X X ok ok associated with a hospital:ook are six main laboratories o Bo There B . • Biochemistry wblood bank w.B • Haematologyw and w w w ww • Microbiology • Histopathology (including cytology) • Immunology et (only available in certain.nlarger et hospitals). et n n • .Genetics . X X samkXdeals with the processing oofkblood  This department ok Biochemistry o o o o for salt and mineral eg U+E, LFT, and hormone levels such as corB ples .Blevels, tisol, TFT, etc. It also with monitoring drug levels, wdeals w.egBsodium valproate w w w and ABG samples w if there is not a blood gas machine w in the clinical areas. In w general ‘gel’ bottles are used for biochemistry samples but check with your lab if you or taking blood for ant unusual test (E p. 531). et are unsure  This e samples for FBC, ESR, clotting et n n n . . . Haematology lab processes X G+S, and crossmatching. X also examines blood filmskX if there is ok studies, ok It disease, oanaemia, o o o clinical suspicion of haematological eg haemolytic leuB kaemia, or malaria.w.B .B w w w Microbiology with identifying bacteria, vir- w ww This specialty is concerned w

B

uses, fungi, and parasites in samples of various bodily fluids from patients. It examines specimens under the microscope to look for cells, cultures them in an incubator to try and grow pathogens, and if any bugs grow, it investigates which antibiotics can be used to kill them or prevent their growth. It deals with specimens such as blood, urine, faeces, CSF, and swabs taken from any site on the body. Microbiologists also use advanced molecular biology techniques to identify organisms that are difficult to culture, as well as assay antibiotic levels and are a useful source of advice when prescribing antibiotics for complex cases after discussion with your team’s seniors. They usually produce the hospital antibiotic guideline policy in combination with the pharmacists.

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t t t .ne .ne .ne X X X   This specialty deals with tissue samples, eg biopsies ok Histopathology ok operations okPathologists o o specimens removed during or post-​ m ortems. Bo and B B . . examine these samples macro-​and microscopically to determine the wwandboth ww They nature of thew tissue the underlying disease process. use different ww w slicing and staining techniques to examine specimens under the microscope to determine the disease process or progression. et etot assess the immune system efort n n n Immunology   This performs tests . . . X X or overactivity (autoimmune (immunosuppression) kXdisease); ok underactivity ok antibody oSamples o o o many of these involve measuring levels, eg ANA. for B antibody analysis usually .Bgo in plain tubes (E p. 531). .B w w Genetics This wwlab has two subdivisions: ww ww • Cytogenetics that look for chromosomal abnormalities, eg assessing an amniocentesis for trisomyt21 (Down’s) et geneticssample e in DNA, eg cystic fibrosis. et • .Molecular that look for.mutations n n n . X blood tube used for thesekX X tests varies between centres; ok The ois especially okthe sample o o o quality (fresh, free-​ fl owing) important for cytogenetics. B w.B w.B w w w w ww

B 526

.B w ww

Chapter 17

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ww

w

Procedures

t t t .ne .ne Foundation Skills .ne Achievement of Core X X X ok ok your personal progress towards ok achieving is for you to record o o Bo Table 17.1 B B . identified by the independence in all 15 the key practical procedures wby.theofend wshould GMC as required of F1. During F2w you and w w wskills. Links to relevant pageswin this handbookmaintain build on these are shown. w Table 17.1  et A record of your personal etprogress et n n n . . . X X dates and progresskX ok Skill ok Key o off First attempted oSigned o o B B B . Venepuncture w. ww E pp. 528–9 w w w ww IV cannulation E pp.t532–3 e IV medication and fluids .net et Giving n n . . X pp. 540–1 X X ok E ok ok o o o ABG B E pp. 536–7 w.B w.B w w Blood culture w w ww

B

E p. 529 IV fluid prescribing and infusion E pp. 394–7 Blood transfusion E pp. 412–17 Local anaesthetic injection E pp. 572–3 SC injection E pp. 538–9 IM injection E pp. 538–9 Perform and interpret an ECG E p. 542 Perform and interpret peak flow E p. 132

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Urethral catheterization (♂) E pp. 560–1 Airway care and adjuncts E pp. 234–5

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Urethral catheterization (♀) E pp. 560–1

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Achievement of Core Foundation Skills

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B 528

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Chapter 17

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Procedures

t t t .ne blood (venepuncture) .ne .ne Taking X X X ok ok ok o o Consent Verbal     Level F1     Difficulty 1/​ 5 Bo B B w. w. w w Indications w Diagnosis, monitoring physiological w state, therapeutic drug ww monitoring. Contraindications  Absolute Competent et et patient refusal, ipsilateral AV.nfistula. et n n . . can use any vein (eg hands, arms, feet, XSite Usually antecubital fossa but kXAV fistula 530)); never use a limb withoan ok and groin (femoral stab oEop.kX o o (dialysis) or an IV infusion. B w.B w.B w w Equipment  w Non-​sterile gloves, tourniquet,wantiseptic swab, vacutainer ww hub and needle, gauze, tape, sharps bin, blood bottles (E p. 531). Checks  comfortable, vein exposed, and not pulsing, et woolPatient etinto theaccessible, et n n n cotton to hand, no IV fluids .going limb of selected vein. . . XPatient position Upper limb X the patient upright, with arm kX ok extended ok  Sit otheir back. o o o and below the heart; Lower limb  Lie patient flat on B w.B w.B w w w w ww

B

Procedure Wash hands and wear non-​sterile gloves. Assess both arms and

select an appropriate vein. Tighten the tourniquet proximally and palpate along the course of the vein to assess its direction and depth. Swab the skin and allow it to dry; and hold the vein steady with your non-​dominant hand. Warn the patient and advance the needle into the vein at 20° to the skin; feel for the slight ‘give’ as you enter the vein and hold your position as you insert the blood bottle into the hub. Once the bottles are filled, unclip the tourniquet and gently cover the puncture site with cotton wool. Withdraw the needle, then apply pressure to the cotton wool. Press (or ask the patient to press) on the cotton wool for 2min (longer if bleeding) then tape it in place. Dispose of the needle and hub into the sharps bin. Label the blood tubes at the patient’s bedside, and complete the accompanying request forms. (See also Box 17.2.)

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Confirmation Blood flows freely into the bottle. Complications Pain, bleeding, haematoma, failure, infection. Safety Steady the patient’s arm on a pillow to reduce movement and risk

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of needle-​stick injury, dispose of needles into a sharps bin immediately, do not resheath them.

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et et et n n n . . . X Blood samples can be takenkfrom X when they are first kXinserted ok • • Central obe used tocannulae oneed venous lines can sample blood. You o will 2 o o B B B syringes and a 3rd with a suitable solution to flush the line (always check . . wsaline in it or just whether the w linew needs to be left with heparinized wsaline); wear sterile gloves, clean ww ww flushed with the port thoroughly with alcohol wipes, withdraw 5mL of blood in the first syringe and dispose of it;tnext withdraw the blood for your in the 2nd syringe, e flushing the line with the solution et sample et n n n before drawn up in the 3rd syringe . . . X X X and syringes can bekused veins which may ok • Needle o forForsmaller okcollapse from the suction from vacutainers. these veins use aosmall needle o o B B B . . (eg blue, 23G) or ‘butterfly’ (Fig. 17.1; E p. 535) but beware of w w haemolysis causing ww artificially iK and iLDH. ww ww Alternatives

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• If you are unable to obtain blood from the upper limb look at the veins in the leg/​foot; if you still cannot find veins ask your senior to try before considering a femoral stab.

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k ok Hints and tips oo o B B . . • In patients with w poor veins, spend a long time finding a w suitable vein rather than stabbing blindly w w w w • In children, use topical local anaesthetic, E pp. 534–5

• In adults, choose veins by palpation with the tourniquet on rather than their appearance; a bouncy vein is usually easy to take blood from • Tie the tourniquet tightly and ask the patient to clench their fist repeatedly with their arm below their heart; tap the vein to make it more prominent • It is best to use a green (21G) vacutainer needle for U+E samples to prevent haemolysis and spuriously iK+; if using a needle and syringe, aspirate blood slowly and gently. Only use blue (23G) needles for very fine veins • Pull the skin and vein taut to prevent movement away from the needle, especially in older patients • Going through the skin is the most painful bit, once under the skin you can take several attempts to manoeuvre the needle into the vein • If you can only obtain a small sample consider using paediatric tubes; see the minimum blood requirements E pp. 534–5 • If you decide to use a needle and syringe, never force blood into blood tubes; the results are spectacular, messy, and embarrassing.

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Indicated by a repeated/​persistent temp >37.5°C or one-​off ≥38.3°C when a causative organism or source is not already known. In suspected bacterial endocarditis Take 3 sets (6 bottles) from 3 separate veins. Procedure as for normal blood-​taking with needle and syringe except: • Wear sterile gloves (strict aseptic technique for central lines) • A set of blood cultures is two bottles (one aerobic and one anaerobic) • After using the antiseptic swab do not touch the vein again • Once the blood has been obtained replace the used needle with a fresh one • Flip off the culture bottle lids, swab the top with a clean antiseptic wipe, insert the needle and fill each bottle with 5–​10mL.

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Box 17.2  Procedure for taking blood cultures

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w wwblood using a butterfly needle. ww Fig. 17.1  Taking

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Taking blood (venepuncture)

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B 530

.B w ww

Chapter 17

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Procedures

t t t .ne .ne .ne Femoral stab X X X ok ok ok o o Bo B B Consent Verbal     Level F1     Difficulty 2/​ 5 w. w. w w w Taking blood when alternativewsites are not possible. ww Indications Contraindications  Absolute  Competent patient refusal; femoral artery bypass t graft or aneurysm. Relative t Local infection, coagulopathy. e Either efemoral et n n Site side of groin medial to.the artery (Fig. 17.2). .n . X X X ok Equipment Non-​sterileogloves, ok antiseptic swab, 10–​20mL syringe, ok 21G o o B .B sharps bin, appropriate bloodwbottles .B (E p. 531). green needle, gauze, tape, wcomfortable, w Checks Patient groin exposed, w cotton wool to hand. w Patient flat on their backwwith groin exposed. ww Patient position  t et  Wash hands and wear enon-​ et n n . . Procedure sterile gloves. Feel for the.n femX pulse and choose the sidekX kXthe skin where it is most prominent. o Swab ok oral ofingers o o o thoroughly then place your over the artery; warn the and B B backpatient .B 1cm medial to your fingers. .Pull insert the needle vertically on the syrw w inge as you advance ww and stop moving as soonwaswyou get flashback. Fill the ww

B

syringe then withdraw. Exert pressure over the area with cotton wool for at least 2min and dress it with a plaster once bleeding has subsided. Fill the blood tubes and label them at the patient’s bedside, dispose of the needle and syringe in a sharps bin and complete the accompanying request forms.

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Confirmation Blood flows freely into the syringe. Complications Pain, bleeding, haematoma, infection, failure; bright red,

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Pubic symphysis

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Inguinal ligament

Femoral nerve Femoral artery Femoral vein

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Pubic tubercle

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Fig. 17.2  Anatomy of the femoral region.

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Iliac crest

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pulsatile flashback suggests you hit the artery; continue to aspirate the required amount of blood as arterial blood can be used for all routine tests, but press firmly for ≥5min after withdrawing the needle to ensure haemostasis. Hints and tips To remember the anatomy of the femoral region, work in a lateral to medial direction and think ‘NAVY’: • Nerve (femoral nerve, most lateral) • Artery (femoral artery) • Vein (femoral vein) • Y-​fronts (vital undergarment, best removed prior to procedure).

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Blood tubes

w 531

t t t .ne .ne .ne Blood tubes X X X ok colours and contentsooofkthe various blood bottlesovary ok between Bo The B B . Use Table 17.2 as a guide towwhich . bottle is used suppliers and hospitals. wmake for each test and to sure the sample is suitable. Fill in the colour of w w w wand specific blood tests used inwyour hospital. blood bottles We have left w space at the bottom for other blood tubes. et et et n n n . . . Table 17.2 Blood tubes X X ok Colour Contents TestsookX ok Special instructions o o B .B .B EDTA wFBC, reticulocytes, 1mL minimum but aim w w w HbA , sickle screen, Hb to fill; gently mix to w electrophoresis, malaria screen w prevent clotting ww EDTA ESR Always fill to the line and gently mix to et et et n n . . prevent clotting .n X X Xalways k k EDTA Blood transfusion (G+S, 4mL minimum; o o o≥3k forms o o o crossmatch) handwrite B .B .B identification of patient w w Sodium ww D-​dimer, APTT, PT/​INR, ww Always fill to the line ww

B

1C

citrate

t .ne X k oo

thrombophilia screen, fibrinogen Glucose U+E, LFT, amylase, TFT, CRP, separating Cl–​, Mg2+, Ca2+, PO43−, HCO–​3, gel urate, LDH, total protein, digoxin, paracetamol and salicylate, lithium, other drug levels, tumour markers, β-​hCG, protein electrophoresis, cardiac markers Plain Some endocrine tests, drug levels, serology Fluoride Blood glucose, lactate, alcohol; oxalate CSF glucose, protein, oligoclonal bands

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and gently mix to prevent clotting 1.5mL minimum but aim to fill; try to use a green vacutainer needle to prevent haemolysis and inaccurate K+ result

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1.5mL minimum but aim to fill Blood fill to the line, mix gently; CSF 6 drops; mix gently

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gently, may need to ww Mix ww be transported on ice et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww Heparin

Some endocrine tests

B 532

.B w ww

Chapter 17

Procedures

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t t t .necannulation X.ne .ne IV X X ok ok ok o o Bo B B Consent Verbal     Level F1     Difficulty 2/​ 5 w. w. w w w w  Unwell patients, shock, IV w Indications fluids/​ drugs, blood product w transfusions, other routes of drug administration not tolerated. et et patient refusal, ipsilateral eAVt Contraindications  Absolute Competent n n n . . . X X X ok fistula. okof the hand on the non-​dominant ok arm are Site The forearm and back o o o B usually more convenient be used w.B sites for the patient, anbutemergency, wany.Bvein cannever (eg hands, arms, feet, legs), antecubital fossa in w use a w w w ww limb with an AV fistula (dialysis). Equipment  Tourniquet, non-​sterile et size, etgloves, antiseptic swab, cannulas et n n . . (appropriate see Table  17.3), cannula dressing, 5mL syringe.nwith X flush, cotton wool, blood X X ok saline ok collection tubes, and adaptor ok if blood o o o sample required, sharps bin. B Checks Patient comfortable, skin is clean and free wand.Bnot pulsing, wof.Binfection, vein ex- w w posed, accessible, cotton woolw ±syringe to hand. w w w Patient position Upper limb Sit the patient upright, with arm extended and below the heart; Lower limb Lie patient flat on their back.

t t t .ne .ne .ne X X X k both   Wash hands wear non-​sterile gloves. oAssess ok Procedure okandvein. o o and select an appropriate Tighten the tourniquet proximally Bo arms B B . course of the vein to assess . its direction and palpate along the and w w w w or topically prior ww depth. Local anaesthetic can be given intradermally w w to this procedure. Swab the skin with eg 2% chlorhexidine, allow it to dry then hold the vein steady with your non-​dominant hand. Warn the t and advance the cannula through t skin at 20° with the bevel patient et .ne upwards .ne fortheflashback, .nthe facing and proximally. Look then advance X X X k before withdrawing theometal k needle and needle a littleo further ok cannulafirmly o advancing the plastic cannula. DisposeB ofoyour sharp as Bo while B . bed-​side. Press with yourwthumb . over the tip of soon as possible w at the w the cannulaw inw the vein. w ww Taking blood If blood leaks out try lifting the arm, if still leaking remove the tourniquet. Attach the adaptor and each blood tube in turn, then et the tourniquet. et et remove n n n . . . Not taking blood  Remove the tourniquet. X X ok Place the cap on the end okof the cannula, secure withoothekX o o adhesive B .B2–​5mL 0.9% saline throughwthe .Bside port. dressing and flushwwith Date the dressing and ww document date and timewofwinsertion in the notes. ww Dispose of the needle into a sharps bin.

et et et n n n . . . X does not form a proximalksubcutaneous X X ‘bleb’ or cause pain. ok and o ok subcutaComplications  Early  Haematoma, tissuing (fluid/​drugsoenter o o B neous tissues), local damage, cellulitis. w.B air embolism; Late Thrombophlebitis, w.B w w w w ww Confirmation  Flashback seen, saline flush requires minimal pressure

B

.B w ww

.B w w

w

w

IV cannulation

w 533

t t et Safety .ne  Never reinsert the metalXneedle .ne into the plastic cannulaXonce .nyou X removed it as this increases of needle-​stick k and ok haveoffully okshear offtheandriskembolize, otheinjuries the plastic cannula o may steady patient’s o Bo bits B B arm on a pillow to reduce movement and the risk of. needle-​stick injury, winto. a sharps w dispose of needles bin immediately.w w w w ww Alternatives  Central venous cannulation (E pp. 548–9), alternative route oft drug administration (PO/​IM/​StC/​PR). e and tips e et n n n . . . Hints X comments under ‘TakingkXblood’ pp. 528–9 and Box 17.3kX ok • • See o o oofail to Start distally in a limbB ifByou B . ando work your way proximally . cannulate initiallyw w wto cannulate at the junctionwofwtwo veins • Veins are easier w ww • Try to avoid cannulae over a joint as these are uncomfortable and more likely to tissue et go through the wall of the.vein, etwithdraw a small distance until et • Ifnyou n n . . flashback recurs and try to advance the plastic cannula X confused patients and children, X kXa crêpe cover the cannulaowith ok • Inbandage okto theiralways o o o and tape the IV line skin to minimize auto-​ e B .B practice. .B xtraction and further cannulation w w ww ww ww

B

Table 17.3  Intravenous cannulae

t Colour .ne Blue X k oo Pink Green White Grey Orange

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t .ne X k

Size 22G 20G 18G 17G 16G 14G

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et

Flow rate (mL/​min) 31 55 90 135 170 265

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Use Small fragile veins IV drugs and fluids ±blood Blood, fluids, drugs Blood, fluids, drugs Rapid blood, fluids, drugs Rapid blood, fluids, drugs

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oo oo B B . . • Inspect cannula w for inflammation and w daily,it,looking wwreplace it every 72h ww • If asked to replace check cannula is stillwnecessary w • If blocked, try flushing the line gently with 0.9% saline and check the giving set isn’t kinked et the cannula if the surrounding et skin becomes red, swollen et • Remove n n n . . . or tender as a result of cannula insertion. X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

Bo

Box 17.3  Cannula care

B 534

.B w ww

Chapter 17

.B w w

ww

w

Procedures

t t t .ne blood in children .ne .ne Taking X X X ok ok ok o o Bo Never use a needlewand B B . syringe, never use a snapped .off/​broken needle. wDifficulty 3–​ Consent Verbal from parent ±child  Level F1  5/​5 w w w w ww Indications Diagnosis, monitoring physiological state, drug monitoring. et et refusal, preserving veins. .net Contraindications  Relative Parental n n . . X X think  Before you takeothe kXblood get all the equipmentokready, ok Planning o o about the amount of blood and which bottles you need, o work out where B .B staff will go, think aboutwdistraction .B and topical the child, parent(s), wand w w anaesthesia (eg EMLA ). w w ww Choosing a vein The appearance of the vein is more important than the feeltin very young children (they cantbe too small to palpate); common einclude hands, feet, and forearms. e Antecubital fossa and saphenous et sites n n n . . . Xveins should only be used if there Xis no chance of a long line being Xinserted. ok Heel prick ok ok o o o B .B • Age range Babiesw 2mm X segment depression in V1 X V3 (suggesting posteriorkinfarct) X ok ST ok tothrombolysis o 354) or o o o new LBBB. Acute stroke  meeting criteria (E p. B .B w.B  Absolute 3 PCI available wwithin Contraindications 2h, competent w w patient refusal, w active bleeding, CNS trauma, w neoplasms or arterio- ww venous malformations, previous intracerebral haemorrhage, ischaemic stroke tin previous 6mth, major trauma/​ within previous 3wk, etlastsurgery et n n n non-​ ceompressible punctures in .the 24 hours (eg liver .biopsy, . X puncture) Relative TIAkinXprevious 6mth, prolonged CPR, X ok lumbar o anticoagulation therapy, pregnancy, ok known bleeding disorder or current active o o o B dyspepsia or history.B of GI haemorrhage, sustained.B hypertension (sysw advanced liver disease, infective w endocarditis. Age w tolic BP >180mmHg), ww ww w is not a contraindication. Site Peripheral IV cannulae.

et net net (1%), other major bleed n(5%)), Complications   Bleeding (intracranial . . . X X X arrhythmias, hypotension, anaphylaxis. If hypotension ok reperfusion ok slow ok occurs treatment with streptokinase, the infusion down. o o Bo during B B . on your own. w. this procedure for the first wtime Safety Never perform w w w   Primary coronary intervention w (PCI) (E OHCM10 ww Alternatives p. 796); Intra-​arterial thrombectomy (E p. 354). t t eatwell-​monitored environment Hints .ne and tips Only undertake .nincannula .ne(ED resus, CCU, HDU). Bleeding from sites is common and patients X X X ok should be warned not tooworry ok about this. In the eventoofokmassive life-​ Bo threatening haemorrhage, B antifibrinolytics (eg tranexamic w. the process. w.B acid) and FFP w can be used to w reverse w w local policy for choice of thrombolytic w agent (see Box 17.5). w Agent Check et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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Thrombolysis

w 551

t t t .ne17.5  Agents and outcomes .ne in thrombolysis X.ne Box X X k ok oktenecteplase These are alloorecombinant reteplase,oand Bo Alteplase, B B tissue plasminogen activators; should be determined from the . w. Alteplase doses wfollowed BNF/​local guidelines. is given as a bolus by an infuw w w is given as two boluses. Tenecteplase w is given as a single ww sion. Reteplase bolus. Heparin is typically commenced following administration of all the ­recombinant (E p. 204). et thrombolytics et thrombolytic derived .from et n n n Streptokinase  A naturally occurring . . X X cause an antibody response X in the bacteria and asksuch ok streptococcal obe givenwillwithin okbut never patient so repeat doses can 4d of the first o dose o o B again after that. Much.B widely used these days. .B w lesstreatment w rhythm continu- w Monitoring  w During monitor cardiac wevery 5min. Reperfusion ww (including w ously and BP arrhythmias VT) are common and usually self-​limiting. Use ALS algorithm if persistent or t causeecompromise. et et n n n Desired outcome MI Eventual .normalization of ST segments and im. . X in chest pain. If symptoms kX and/​or ST segment ochanges kX perok provement ohelp; o o o sist seek senior cardiology a second thrombolysis dose or rescue B .BCVA Improved neurologicalwoutcomes .B compared PCI may be required. w to no treatment. ww If further deterioration consider ww possibility of acute ww

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bleed or possible need for intra-​arterial thrombectomy.

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B 552

.B w ww

Chapter 17

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Procedures

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Consent Verbal/​ written    Level F2    Difficulty 3/​5

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Indications  Diagnosis of effusion, aspiration of small pneumothorax, symptomatic relief.

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Contraindications Absolute Competent patient refusal; Relative Local

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infection, contralateral pneumothorax/​effusion, abnormal clotting. Site Simplest and safest sites are shown in Fig. 17.13, directly below the inferior angle of the scapula or in the posterior-​axillary line; choose an intercostal space two or three spaces below the top of the effusion. See Fig. 17.14.

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w.B w w w 10, 20, 50mL syringes, orange w (25G) and green (21G) ww Equipment 5, needles, ±intravenous cannula (14–​16G), 3-​way tap, 3 specimen containers, fluoride oxalate blood tubet (E p. 531), sterile jug/​bowl, 1% et andsterile e antiseptic swab. et lidocaine, gloves, dressing pack, n n n . . . X X Xequipside of the effusion clinically and on CXR;klay ok Checks Confirm oktrolley; ment out on clean treatment recruit an assistant. oo o o B Patient position See w.BFig. 17.13. w.B w w w w ww Procedure Wash hands and wear sterile gloves. Clean area thoroughly with eg povidone-iodine or chlorhexidine. Infiltrate 5–​10mL of LA with t t orange into subcutaneous and layers towards pleura, net .ne needle .nethen deeper .effect. avoiding neurovascular bundlesX(Fig. 17.15). Allow 2min to take X X a green needle ok Using either okon a 20mL syringe or a cannula, okgently ado the needle through the anaesthetized area over B theorib directly toBo vance B . in the pleural space, fluid isweasily . drawn into the wards the pleura.w Once w w syringe or a flashback will be seen in the cannula; if using the cannula then w w ww o

remove the needle, leaving the plastic component in place, and attach a syringe. Aspirate volume required and divide into specimen containers. If performing a therapeutic procedure use the cannula and attach a 3-​way tap with a 50mL syringe; withdraw and dispose of fluid into a jug. Once complete withdraw needle/​cannula and apply plaster to skin.

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oo oo B B . . Confirmation w fluid aspirated, always w get a CXR (?pneumow Pleural thorax and reassess the level of the effusion w if aw therapeutic procedure). w ww Complications Pneumothorax, haemothorax, pain, bleeding, damage to intercostal nerve, local or intrapleural infection, visceral puncture (liver, spleen, etkidney). et et n n n . . . Safety  Do not perform this procedure without supervision; take care XIf aspirating fluid (ie not pneumothorax) X not kXto allow air into the pleural ospace. k k o o o recommended. The use guidance isB Bo ultrasound . strongly .Bofo ultrasound to mark a spot for subsequent drainage attempts is not recommended. w w Alternativesw  Retry in a different rib space; radiology might perform a wunder ww ww diagnostic tap ultrasound guidance; chest drain for large effusions. Hints and tips Make sure you and the patient are comfortable before t and insert the local anaesthetic you start; try to anaesthetize the skinefully etat right et n n n . . . needle angles to the skin when infiltrating down to the pleura. X X of pneumothorax kisXa medical ok Aspiration ok  Tension pneumothorax oA small o o emergency and requires o immediate treatment (E p. 285). sponB .B(10/​mm3 is abnormal; same causes as leucocytes on dipstick. Bacteria These may be seen on simple microscopy and this is highly suggestive of a UTI; Gram staining may help identify the pathogen. The sample needs to be cultured for complete identification and for antibiotic sensitivities. Red cells >2/​mm3 is abnormal; E p. 388 for management of haematuria. Casts Hyaline and fine granular casts are not significant; dense granular, red-​cell, and epithelial casts suggest renal disease; white-​cell casts are found with pyelonephritis.

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Microscopy

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Urine samples should be ‘mid-​stream’ (MSU) to limit urethral contamination, alternatively they can be taken from a catheter (CSU).

Dipstick

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Urine tests

w 605

t t t Culture .ne and sensitivity X.ne .ne X X sent for microscopykare routinely cultured over 48h. k The culok Samples oif >100,000 colony formingoounits/​ o is said to be positive mL are Bo ture B B . is recultured in different mediums . to determine present. The sample w w the bacteria present w and their sensitivity towantibiotics. w A mixed culture ww (more than w one organism present) suggests a contaminated sample. Urine culture is not 100% sensitive or specific—​it can be wrong and ret t term catheters are frequently quire erepeating. CSU obtained from e long-​ et n n . . positive. Only treat if the patient is.n symptomatic. X X X ok Biochemistry ok ok o o o B Sodium concentrationw  This useful test in acute kidney injury. A  low .B isL)a suggests w.Beg hypovolaemia urine sodium (40mmol/​L) is seen ww in acute tubular necrosis or SIADH. It is also used in the assessment of hyponatraemia t (E pp. 400–1). net eosmolality ethet n n Urine  This is a measure of the concentration of the urine; . . . X range is 500–​800mOsmol/​ X kg. It is used in the investigation kX injuryof ok normal oofk diabetes okidney renal disease and diagnosis insipidus. In acute o o o B it can help distinguish prerenal failure (>500mOsmol/​ kg) and w.Bbetween w.B acute tubular necrosis (30mg/​24h is abnormal. Urine creatinine should also be measured to determine GFR. See Table 18.28 and also ‘Albumin:creatinine ratio (ACR)’.

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Catecholamines/​VMA If a phaeochromocytoma is suspected a 24h urine sample is analysed for total catecholamines, vanillylmandelic acid (VMA), metanephrines and creatinine. Toxicology  Urine can be screened for a wide range of recreational and medical drugs. Dipsticks give results in 70% plasma 0.5–​0.9g/​L

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k ok   It can take several but oodays for bacteria to grow oothe majority Bo Bacteria B B . . are positive within 48h. It may take a further 24–​48h to identify the type w w of bacteria andw its sensitivity to antibiotics. Liaise with a microbiologist. w w take wwgrowing TB Culture can weeks because it is a slow bacteria. It may w be possible to detect TB sooner using PCR. Talk to the laboratory technicians etand microbiologists. .net et n n . . Viral PCR  This should be requested at the time of submitting a sample, X X X if ok viral meningitis or encephalitis ok is suspected ok o o o B w.B w.B w w w w ww

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Autoantibodies and associated diseases

w 607

t t et .ne .nassociated .ne Autoantibodies and diseases X X X ok ok ok o o and associated diseases Bo Table 18.30  Autoantibodies B B w. Disease (% frequency w w. Autoantibodyw where known) w w ww Acetylcholine receptor Myasthenia gravis (80%) Antinuclear (95%), RA (32%), (76%), chronic active t JIAsyndrome et (ANA) SLE eSjögren et hepatitis (75%), (70%), n n n . . . systemic sclerosis (64%), normal ‘controls’ (0–​ 2 %) X X ok Anticardiolipin ok antiphospholipid syndrome ookX Primary o o B Anticentromere systemic sclerosis (70%).B w.BLimited w lupus, w Anti-​Ro Sjögren syndrome, subacute w ww cutaneous ww SLE (30%), systemic sclerosis (60%), interstitial pneumonitis Anti-​e Lat Sjögren syndrome et (65%), SLE (15%) et n n n . . . c-​ A NCA/​ A nti-​ M PO Granulomatosis with polyangiitis (formerly X X granulomatosis) (90%), MPA (11%), X Wegener’s ok okStrauss ok o o o Churg–​ syndrome B .BChurg–​Strauss syndrome (60%) p-​ANCA/​Anti-​ PR3w w.B w w dsDNA SLE (60%) w w ww ssDNA

net

SLE (70%), autoimmune rheumatic disease, inflammation Includes: anti-​Ro, anti-​La, anti-​Jo-​1, RNP, Scl-​70, anti-​Sm Autoimmune gastritis, pernicious anaemia Multi-​focal motor neuropathy, Guillain–​Barré syndrome, Miller–​Fisher syndrome Goodpasture syndrome

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Coeliac disease Myositis Primary biliary cholangitis (>95%) RA (50–​90%), SLE (15–​35%), systemic sclerosis (20–​30%), juvenile RA (7–​10%), polymyositis (5–​10%), infection (0–​50%) SLE and MCTD Diffuse systemic sclerosis (30%) SLE (30–​40%) Chronic active hepatitis (40–​90%), primary biliary cholangitis (30–​70%), idiopathic cirrhosis (25–​ 30%), viral infections (80%), ‘controls’ (3–​12%), autoimmune sclerosing cholangitis Hashimoto’s thyroiditis (>80%), Graves’ disease (50%) Graves’ disease (50–​80%)

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B 608

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Chapter 18

Interpreting results

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t t t .ne .ne .ne Cervical spine radiographs X X X ok ok are mainly taken inotrauma ok patients spine (C-​spine) o radiographs Bo Cervical B B . to this area that could result to exclude bony injury high spinal cord wdisability. whas. intheir damage and major The patient normally neck immow w w bilized with w blocks, stiff-​neck collar, and tapew when the images are taken, w which can make obtaining adequate views more difficult. et et et n n n . . . 2 If the patient’s history suggests a fracture you must proceed with X kXcan be present even when oplain kXC-​spine Significant neck injury ok caution. o o o o X-​rays appear normal. any doubt, discuss with your senior or a B .B If inmay radiologist as CT be necessary. Spinal wimaging w.Bcord injury can w w w still be present spinal cord i­njury w w despite a normal CT (SCIWORA—​ w without radiological abnormality). This is due to non-​ bony injury causing instability (eg injury to cartilage, or ligaments). E p. 455 for a t t e of patients for imaging..ne et selection n n . . X X ok The standard images taken oinka C-​spine series are: ookX o o B Bray taken from the side w.B • Lateral view—​an X-​ wan.X-​ • Long AP view—​ ray taken from the frontw w wan open mouth wshows C1/​C2 articulation ww • Peg view—​ AP view, which and the odontoid peg.

t t t .nethe image was taken. X.ne .ne when X X ok okview—​ABCDE approach ok o o the lateral Bo Interpreting B B . . Adequacy Is the X-​w ray penetration appropriate; canwyou see the vertebral w w bodies, spinous processes, and soft tissues clearly? Can the whole of the ww w w C-​spine be seen from C1 to the top of the T1 vertebral body? Is any part of the tview obscured by a radio-​opaque such as jewellery? e  Check all vertebral bodies.nhave et item Bodies smooth outlines and attached n net . .similar X X X spinous processes. All bodies below the level of C2 should be of ok and shape. Check forooanyk fragments of bone that have okbecome deo Bo size B B tached (avulsed); this. could suggest ligament injury. . wFollow the three curves inwFig.  w 18.17 and ensure w Curves (alignment) ww   Ligament w can cause they are smooth. injury or fractures disruption of w these arcs. Disc spaces et  These should be roughly.nequal et between each vertebral.nbody. et n . Widening suggests serious injury. X X X ok Everything else (soft tissues)o Abnormal ok ok soft widening of the prevertebral o o tissue or a localized .bulge B B suggests a serious neck injury .B (Table 18.31). Revisit the bodies,w curves, and disc spaces if therew is widening. w w w w ww Identification Check the radiograph for the name of the patient and

Table 18.31  Maximum normal width of prevertebral soft tissues

et 7mm et et n n n . . . X X X 22mm (roughly equal to ok ok the width of the vertebral bodies) ok o o o B w.B w.B w w w w ww C1–​4 C5–​7

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Fig. 18.17  Lateral (left) and long AP (right) views of the cervical spine.

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Interpreting the peg view

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Fig. 18.18 Peg view showing central location of the odontoid peg.

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B 610

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Chapter 18

Interpreting results

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t t t .ne .ne .ne Skeletal radiographs X X X ok ok ok o  Check the radiograph for the nameB ofothe patient and Bo Identification B . check if the image is of wthe. left or right side. when the image was wtaken; w wwcortex around the whole ww Bones Forw each bone follow the edge of the circumference, looking for steps, or cracks; does the bone look normal, or clearly tvery bowed or angulated around ta fracture? Check the consistency ebone epale et n n n of.the matrix itself; is it uniformly and very opaque (osteopenic), . . X dense and very mineralizedk(sclerotic); X X are there cysts (lyticklesions), ok orpatches o (sclerotic lesions oTable 18.32.or of more dense bone or callus)? See o o o B .B in question, eg w.B wbone Joints Always check the joint above and below the w w elbow and wrist w when looking at the radiuswor ulna. Does the joint look ww normal, are the bones involved in the articulation in their normal position, is the distance between these bones increased decreased? Re-​check for etin the cortex etthe jointor(intra-​ et breaks of the bones within articular fractures). n n n . . . X tissue signs  Soft tissue Xoedema is often subtly seenkXon some ok Soft okis overlying o o o radiographs, suggesting there swelling; thisBisoespecially seen B .B joints (wrists, hands, . around peripheralw bones/​ ankles, feet, etc). Very ocww black; this can arise ww casionally gas can wwbe seen on radiographs, andwappears

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from gas-​forming bacteria (classically Clostridium species), but also from open wounds. Bleeding and oedema adjacent to some joints gives rise to specific features; one of the best examples of these is the anterior fat pad sign of the elbow (Fig. 18.19). Small amounts of intra-​articular haemorrhage force a normally hidden fat pad to appear on the lateral elbow radiograph, anterior to the distal humerus. The presence of this sign strongly suggests there is a peri-​articular fracture. The posterior fat pad is often seen even in the absence of trauma/​injury.

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softer and more malleable than adult bones. The greenstick fracture is a fracture of the shaft of a long bone, but like a green twig, snapping it often only breaks just one cortex rather than both (the classical definition of a fracture is a break to both cortices). Greenstick fractures are most common in the forearm. Fractures at the growing ends of bones usually take on one of five forms (see Salter–​Harris classification—​Fig.  18.20) and must be managed carefully to ensure the bone continues to develop/​grow normally.

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Fig. 18.20  Long bone nomenclature (top) and the Salter–​Harris classification of growth plate fractures (bottom).

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weakened, usually where there is a cyst, metastatic lesion, or inherited defect. For cross-​references to specific bones/​joints, see Box 18.4.

k oo oo B B . . w bones/​joints covered w elsewhere I  Box 18.4  Specific ww ww153 ww Hip E p. 149 Elbow E p. Knee E p. 149 Wrist E p. 153 t 150 Ankle E p. Hand E p. 154 e et 151 et n n n . . . Foot E p. 150 Back E p. X ok Shoulder E p. 152 ookX C-​spine E p. 454 ookX o B w.B w.B w w w w ww

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w 613

t t t .ne Appendices .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww Useful numbers and websites 614 conversion 616 t Height e et Weight conversion 617 net n n . . . Body mass index (BMI)  618 X Driving regulations (2016) kX  619 kX ok o o o o o Interesting cases B .B  6201 622 Telephone wnumbers w.B w w Your wfirm’s timetable 1 623 w ww Telephone numbers 2 624 firm’s timetable 2 625 t et Your et Telephone numbers 3 626ne n n . . . Your firm’s timetable 3  627 X X X ok ok ok o o o B w.B w.B w w w w ww

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614 Appendices

t t t .ne numbers and .newebsites .ne Useful X X X ok ok ok o o organizations Bo Medical B B w. w. General Medical Council (GMC) wMwww.gmc-​ w • 0161 923 w 6602 uk.org w ww British Medical Association (BMA) • 020 7387 4499 Mbma.org.uk et Consultants et et n n n . . . Hospital and Specialists Association (HCSA) X 01256 771 777 Mwww.hcsa.com X X ok • Medical ok ok o o o Defence Union (MDU) B .B .B • 0800 716 376 Mwww.themdu.com w w w w • 24h help 0800 w 716 646 w ww Medical Protection Society (MPS) • 0800t136 759 Mwww.medicalprotection.org ehelp 0800 561 9090 et et • 24h n n n . . . X and Dental Defence Union X ok Medical ok of Scotland (MDDUS)ookX • 0333 043 4444 Mwww.mddus.com o o B • 24h help 0333 043 4444 w.B w.B w w Counselling lines w w ww

B

BMA Counselling Service • 24h help 0330 123 1245 (NB you do not need to be a BMA member to call) Doctors’ Support Network (mental illness) • Mwww.dsn.org.uk Sick Doctor’s Trust (alcohol and drug addiction) • 24h help 0370 444 5163 Mwww.sick-​doctors-​trust.co.uk

t .ne X k oo

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w 615

t t t (Royal) College of .ne .ne .ne X X X ok ok ok o Bo Anaesthetists w.Bo 020 7092 1500 Mwww.rcoa.ac.uk B w. Emergency Medicine 020 7404 1999 Mwww.rcem.ac.uk w w General Practitioners 020 3188 7400 w w ww Mwww.rcgp.org.uk Obstetricians and 020 7772 6200 Mwww.rcog.org.uk Gynaecologists t t e e0702 et n n . . Ophthalmologists 020 7935 Mwww.rcophth.ac.uk .n X X X ok Paediatrics and Child Healthook020 7092 6000 Mwww.rcpch.ac.uk ok o o Pathologists 7451 6700 Mwww.rcpath.org B w.B 020 w.B Physicians of London 020 7935 1174 Mwww.rcplondon.ac.uk w w ww Physicians ofw Edinburgh 0131 225 7324 w Mwww.rcpe.ac.uk Physicians of Ireland 0035318639700 Mwww.rcpi.ie t Mwww.rcpsg.ac.uk net et and Surgeons of 0141 .221ne6072 Physicians n . Glasgow X X X. k k k o Psychiatrists o 020 7235 2351 oo Bo Radiologists w.Bo 020 7636 4432 Mwww.rcpsych.ac.uk B . Mwww.rcr.ac.uk w Surgeons of Edinburgh 0131 527 1600 Mwww.rcsed.ac.uk ww ww ww Surgeons of England Surgeons of Ireland

net

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Selected learned bodies

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616 Appendices

t t t .ne conversionX.ne .ne Height X X ok okmultiply by 39.37 (12 inches otok the foot). (m) to inches (inch), o o Bo Metres B B Inches to metres, multiply w. by 0.0254. w. w w w feet inch ww m inch m w inch feet inch 1.36 4 5.5 66 5 6 t 53.5 t 1.67 e e et 1.37 54 4 6 1.69 66.5 5 6.5 n n n . . . X 54.5 4 6.5 kX 1.70 67 5 kX7 ok 1.38 o o 7.5 o o 1.40 55 4 7 1.71 67.5 o5 B B B . . 1.41 55.5 4 7.5 1.73 68 5 8 w w 1.42 56 ww 4 8 1.74ww68.5 5 8.5 ww 1.43 56.5 4 8.5 1.75 69 5 9 1.45 et 57 4 9 69.5 5 9.5 et et 1.76 n n . . .n 1.46 57.5 4 9.5 1.78 70 5 10 X1.47 58 4 10 kX X k k 1.79 70.5 5 10.5 o oo oo 11 Bo 1.48 58.5 w 4 .B 10.5 1.80 71 .B 5 1.50 59 4 11 1.81 ww 71.5 5 11.5 ww w ww

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t

Millimetres of mercury (mmHg) to kilopascals (kPa) kPa = mmHg × 0.113 Kilopascals (kPa) to millimetres of mercury (mmHg) mmHg = kPa × 7.519

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6 6 6 6 6 6 6 6 6 6 6 6 6

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72 72.5 73 73.5 74 74.5 75 75.5 76 76.5 77 77.5 78

Degrees Fahrenheit (°F) to degrees Celsius (centigrade °C) °C = (°F –​ 32) × 0.56 Degrees Celsius (centigrade °C) to degrees Fahrenheit (°F) °F = (°C × 1.8) + 32

Pressure

Bo

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w Weight conversion 617 ww t t t .ne conversionX.ne .ne Weight X X k per lb) ok to pounds (lbs), multiply okby 2.2046 (14lb to the stone; o16oz o o Bo kgPounds B B to kg, multiply. by 0.4536. w w. w w w w ww

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lbs 2lb 3oz 4lb 7oz 6lb 10oz 8lb 13oz 11 13 1 4 6 8 10 12 1 3 5 7 9 12 0 2 4 7 9 11 13 1 4 6 8 10 12 1 3 5 7 9 12 0 2 4 6 9

kg 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84

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618 Appendices

t t t .ne mass index (BMI) .ne .ne Body X X X ok ok ok o Bo BMI calculation w.Bo B . BMI status wWeight w w 3yr)* w ww Severe head injury/​intra-­​ ­cranial bleed Brain tumours and mets Neurosurgery Visual field defects and diplopia Visual acuity

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Incapacitating arrhythmia Stable arrhythmia AAA ≥6cm

Cease for 6–​12mth*

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Better than 6/​12 corrected with both eyes Unexplained Cease 4wk if low risk syncope or cause found; else cease for 6mth* Recurrent Once attacks severe vertigo controlled* Diabetes Diabetes on Must be able to insulin or oral recognize hypo and hypoglycaemic not had >1 hypo agents requiring assistance in past 12mth* Diabetes on Drive if well diet only Recurrent Cease until hypoglycaemia controlled

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Cease for 4wk after controlled* Drive if well Annual review required if 6–​6.5cm*; if ≥6.5cm, cease until repaired* Aortic stenosis Cease if symptomatic* Psychiatry and substance abuse Severe psychiatric Cease until stable for illness 3mth* Alcohol Cease until 1yr dependence abstinence* Opioid, benzo Cease for 1yr after + cocaine previous use* dependence Other recreational Cease for 6mth after drugs previous use* Other COPD Drive if well Sleep apnoea + Cease until symptoms narcolepsy controlled* Chronic renal Drive if well failure HIV Drive if well Temporary medical Drive if well; notify conditions/post-​ DVLA only if >3mth surgical recovery recovery required

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620 Appendices

t t t .ne .ne .ne Interesting cases X X X ok oork unusual cases which couldoobekused for a down any interesting o Bo Note B . case presentation. Downot.Binclude personally teaching or a Grand Round winformation. identifiable patient w w ww ww Hospital number et et et Details n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et number et et n n n . . . Hospital X X X ok Details ok ok o o o B w.B w.B w w w w ww

t t t .ne .ne .ne X X X ok ok ok o number Bo Bo Hospital B Details w. w. w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w Hospital number w w ww Details et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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622 Appendices

t t t .ne .ne .ne Telephone numbers 1 X X X ok ok ok o o Bo B B Hospital: w. Telephone: ww. w Extension Bleep w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww o

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Thursday

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w ww Your firm’s timetable 1 623 t t t .ne firm’s timetable 1 .ne .ne Your X X X ok ok ok o o Bo B B w. w. w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww

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624 Appendices

t t t .ne .ne .ne Telephone numbers 2 X X X ok ok ok o o Bo Hospital: B B w. Telephone: w. w w Extension Bleep w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww o

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626 Appendices

t t t .ne .ne .ne Telephone numbers 3 X X X k ok oTelephone: ok o o Bo Hospital: B B w. Extension w. Bleep w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww et et et n n n . . . X X X ok ok ok o o o B w.B w.B w w w w ww t t t .ne .ne .ne X X X ok ok ok o o Bo B B w. w. w w w w ww o

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t t t .ne Index .ne .ne X X X ok ok ok o o Bo B B w. ware.indicated by an italic t , w w Bold type indicatesw main references. Tables, figures, and boxes w w w f , and b following the page number. Academic Clinical activated partial et et A.net n n Fellowship (ACF)  45, thromboplastin time . . see abdominal aortic XAAAaneurysm X X (APTT)  418, 581 ok Abbreviated o48–​k9, 66, 69 ok Academic Foundation Actrapido 206t o o Mental Test Programme 6 acupuncture 91 B .B (AMT) 375t supervisors  3t acute abdomen  311t w.B academic w abbreviations and w w acanthocytes 407b acute care common stem symbols x–xxiv w w (ACCS) 48 ww acarbose 335t prescriptions 171 accelerated (malignant) acute cholecystitis  301–​2 ABCD resuscitation hypertension 268 acute confusional t t protocol 230 e e et accessory nerve (XI)  135t state  374–​5 n n n . . . equipment  234–​5 accident and emeracute coronary syndrome X score  356t X kXsee emergency (ACS) 248t, 249t ok ABCD2 ogency ok 251b ABCDE approach, o o o department risk stratification  C-​spine  608 B abdominal .B (eye)  145b STEMI 248t, 250 w.B accommodation accommodation (home)  44 w unstable angina  252 w aortic pulse  130bw ACCS (acute care w w acute kidney injury ww

B

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examination 128 masses 133t paracentesis  319–​20, 564–​5 wounds 120t X-​ray  602–​3 abdominal aortic aneurysm (AAA) 296t driving regulations  619 leaking 487 X-​ray  602 abdominal pain  294–​303 causes  294, 296t, 297b emergency care  294 referred 297f abdominoperineal (AP) resection 122 abducens nerve (VI)  135t ABG see arterial blood gases ABO blood groups  412t abortion (termination)  517 abrasions corneal 442 skin 141b, 450t abscess 141b, 435 breast  437, 521 groin 476 abuse adults  107, 373 alcohol see alcoholism substance  378, 619 academia 66

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(AKI) 386 fluid requirements  397 low urine output  393t urea and electrolytes 582t Acute Life-​Threatening Events 226b acute lymphoblastic leukaemia (ALL)  410t acute myeloid leukaemia (AML) 410t acute renal failure see acute kidney injury acute respiratory distress syndrome (ARDS) 278t, 289 Acute Trusts  3t acute tubular necrosis (ATN) 386b Addison’s disease  582t Addisonian crisis  338 adenosine 186 chemical cardioversion  545 ADH see antidiuretic hormone adhesions 299 adnexae 159b adrenal disease  338–​9 adrenal insufficiency  338 adrenaline (epinephrine) 186 anaphylaxis 484b children 240 local anaesthesia  572 newborns  242–​3

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common stem)  48 ACEi (angiotensin converting enzyme inhibitor) 184 acetylcholine receptor antibodies 607t acetylcysteine (Parvolex®)  185, 509 ACF (Academic Clinical Fellowship)  45, 48–​9, 66, 69 aciclovir 181t acid–​base disturbance 599t see also electrolyte imbalances acid-​fast bacilli (AFB)  505 acidaemia 598t acidosis 598t, 599t diabetic  330, 332 lactic 491t aclidinium inhaler  281t acoustic neuroma  475 acquired immune deficiency syndrome (AIDS) see HIV/​AIDS ACR (albumin:creatinine ratio) 605 acrivastine 189t acromegaly 270t, 337 ACS see acute coronary syndrome ACTH (adrenocorticotrophic hormone)  219 actinic keratosis  435

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B INDEX

630

.B w ww

.B w w

ww

w

t et adrenocorticotrophic peripheral blood .n net (ACTH)  219 allergy 171 .hormone .ne bloodX transfusion  416t film 407b X X life support local ok advanced okanaesthetics  573 pregnancy 519 ok o o (ALS)  232–​3 see also anaphylaxis sickle-​ cell disease/​ Bo advanced B B . allodynia 91b trauma life supw w. trait 411 port (ATLS)  236–​ 7 alloimmunization, blood w sideroblastic 407t w w w adverse drug w transfusion 413t w thalassaemia 407t, 411 reactions  170, 173 allopurinol  202, 214, 389b, vitamin B Yellow Card Scheme  173 469, 497b deficiency 409 adviceet ALP (alkaline et anaesthestist, et n n . . financial 42 phosphatase) 518t, 583t contacting 110 .n X care  575b α-​agonists  anaesthetics kX kX 266b ok AFwound see atrial fibrillation αo -​antitrypsin local  572–​ o o oo3 exams  59 B B AFB (acid-​fast bacilli)  505.B deficiency 323 membership . w α-​glucosidase affect (psychiatry)  164b operative wwpre-​assessment  age-​related macular inhibitors 335t 109–​10 ww ww degeneration 444 ALS see advanced life w anal fissure  308t, 309 Aggrastat  186 support analgesia  88–​91 aggressive ALT (alanine dying patients  95 t t t e e patients  107, 373 aminotransferase)  patient-​controlled .n 90e n n . . causes 370b 518t, 583t anaphylactic X X kX care  370 alteplase  shock  o 490, 491t ok emergency ok 186, 201t, 551b clinical o o o Mental Health Act Alu-​Cap  187t markers  491t B .B 484–​5 (2007) 371 hydroxide  187t anaphylaxis  w.B aluminium w aggressive Alvesco  281t blood w w w relatives  107, 373 Alzheimer’s disease  377b transfusion 413t, 416t w w w

B

12

1

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®

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agitation in dying patients 95 AIDS see HIV/​AIDS airway  230, 234 children 238 endotracheal  556–​7 laryngeal 558 newborns 242 obstetric arrest  244 stridor 290 alanine aminotransferase (ALT) 518t, 583t albumin 583t pregnancy 518t salt-​poor  565b albumin:creatinine ratio (ACR) 605 alcohol 176t and hypoglycaemia  329 poisoning 508t withdrawal 351t, 352 alcohol gel  15 alcohol withdrawal  372 alcoholic hepatitis  320 alcoholism  35, 106, 372 driving regulations  619 liver function tests  583t alginates 187 alimemazine 189t alkalaemia 598t alkaline phosphatase (ALP) 518t, 583t ALL (acute lymphoblastic leukaemia)  410t

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breathlessness 278t early signs  485b precipitants of   484b anatomical terms  79 aneurysm, abdominal aortic see abdominal aortic aneurysm angina driving regulations  619 microvascular 252b Prinzmetal’s 252b stable 248t,  252–​3 unstable 248t, 252 angiodysplasia 308t, 309 angioedema 465 angiography 112 angiotensin II receptor antagonists 190 angiotensin-​converting enzyme inhibitors (ACEi) 184 anion gap  599b anisocytosis 407b ankle anatomy 150f examination 150 ankle–​brachial pressure index (ABPI)  438, 462b ankylosing spondylitis 467t, 469 annual leave  44 Annual Review of Competence Progression (ARCP)  8 anogenital warts  435

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Ambu bag  234 amenorrhoea 159b Ametop® 535 amiloride 186 aminophylline  186, 279 amiodarone  186–​7, 259t, 266b AML (acute myeloid leukaemia) 410t amlodipine 193t, 273t amphetamines 508t ampicillin 187 amylase 583 ANA (antinuclear antibodies) 607t anaemia 105t,  406–​11 blood loss  408 breathlessness 278t of chronic disease  408 folate/​folic acid deficiency 409 full blood count  580t haemoglobinopathies  407t haemolytic 407t, 408 iron-​deficiency  407t, 409 laboratory findings  407t leukaemia 410 lymphoma 410 mean cell volume (MCV) 407t myeloproliferative disease 411 pancytopenia 411 paraproteinaemia 410

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B

.B w ww t Anoro .ne 281t antacids 187 X k antalgic gait  138t ®

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rheumatoid 433t, 467t, 468 septic 181t, 467t, 469 arthrocentesis (joint aspiration)  570–​1 Arthrotec® see diclofenac Asacol® see mesalazine ascites 564t paracentesis  319–​20, 564–​5 ascitic tap  319–​20,  564–​5 ascorbic acid see vitamin C aspart 206t aspartate aminotransferase (AST) 583t aspiration ascites  319–​20,  564–​5 joint  570–​1 pneumothorax 552 aspiration pneumonia  282 aspirin  189–​90 overdose 508t assault see aggressive patients; aggressive relatives assessments, workplace-​ based (WPBA)  617 associate specialists  68 Association of LGBT Doctors and Dentists (GLADD) 614 AST (aspartate aminotransferase) 583t asterixis 319 asthma 278t, 279 CXR 596 inhalers 279t, 281t respiratory function tests 600t asystole 263f, 267 AT II receptor antagonists 190 ataxia 366b, 367 ataxic gait  138t atenolol 191t, 273t athlete’s foot  430 ATLS (advanced trauma life support)  236–​7 atopic dermatitis  431 atorvastatin 218t atrial fibrillation (AF)  256, 257t, 257f, 258, 586 rate controlled  265t atrial flutter  259, 586 atrioventricular block see heart block atrophy, skin  141b atropine 190 audit 61 autoantibodies 607t

o w.B

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et n . X

INDEX

et

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o B . w

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Bo

t .ne X k

antipsychotics 381 anuria 392t anxiety 164b, 379t, 382 management 383b aortic dissection  248t, 253 aortic regurgitation  131t aortic stenosis  131t driving regulations  619 AP (abdominoperineal) resection 122 Apidra® 206t apixaban  189, 420t, 421 appendicitis 296t, 299 application forms Foundation Programme 616 specialty training  46 approved clinicians  164b apraxic gait  138t aqueous humour of eye 145b ARCP (Annual Review of Competence Progression) 8 ARDS (acute respiratory distress syndrome) 278t, 289 ariboflavinosis 105t arm pulse 130b see also limb arm’s-​length bodies  11 arrest see cardiac arrest arrhythmias bradyarrhythmias  264–​8 breathlessness 278t driving regulations  619 tachyarrhythmias  254–​61 transient 351t arterial blood gases (ABG) 235, 536–​7,  598–​9 acidaemia 598t, 599t alkalaemia 598t, 599t anion gap  599b base excess  599b normal ranges  598t pre-​operative assessment 109t pulmonary embolism 284 arterial cannulation  537 accidental 549 arterial ulcers  439 arthritis infectious 466b osteoarthritis 467t, 468 psoriatic 467t, 470 reactive 467t, 470

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antenatal care  160t antepartum haemorrhage 519 anterior chamber of eye 145b anterior circulation stroke 355t anterior corticospinal tract 137t anterior resection  122 anterior uveitis, acute  441 anthrax 501b anti-​arrhythmics  259t anti-​D  516b anti-​dysrhythmics  259t anti-​Jo-​1 antibodies  607t anti-​La antibodies  607t anti-​MPO antibodies  607t anti-​PR3 antibodies  607t anti-​Ro antibodies  607t anti-​Scl-​70 antibodies  607t anti-​Sm antibodies  607t antibiotics pneumonia 181t prescribing 181 septicaemia 181t antibodies autoantibodies 607t autoimmune liver disease 322t hepatitis B  321t anticardiolipin 607t anticentromere antibodies 607t anticoagulation  420–​2 atrial fibrillation  258 limb ischaemia  461 and surgery  110 antidepressants 380 antidiuretic hormone (ADH) syndrome of inappropriate secretion (SIADH) 400b antiemetics 188 antiglobulin tests  407b antihistamines allergy 189 antiemesis 188t antihypertensives 273t antineutrophil cytoplasmic antibody (ANCA)  607t antinuclear antibodies (ANA) 607t antiphospholipid syndrome  471, 607t antiplatelets, and surgery 110

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t autoimmune .ne gastritis 306t X k hepatitis 322

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transfusion see transfusion blood salvage  417 blood samples arterial blood gas (radial puncture)  536–​7, 598–​9 children  534–​5 femoral stab  235, 530 venepuncture  528–​9 blood tests 86, 109t,  580–​5 calcium see calcium cardiac arrest  232 cardiac markers  581 clotting 109t, 581 endocrine tests  585 full blood count  109t, 580 inflammatory response 581 liver function tests  583 phosphate 584 skin infections  425t urea and electrolytes 109t, 582 blood transfusion see transfusion blood tubes  531 BMA (British Medical Association)  11, 12, 43, 614 BMI (body mass index) 618 bodily fluids  14 body lice  430 body mass index (BMI) 618 boils 435 bone metastases 584t X-​rays  610 botulism 501b bowel cancer 313t, 317t gas 602 ischaemia/​infarction 296t, 299, 308t obstruction 296t, 298, 311t, 317t, 603t perforation 296t, 297, 602 preparation  111, 192 wall oedema  602 brachial artery gas  537 brachial pulse  130b bradyarrhythmias  264–​8 causes 262 drugs causing  266b ECG 265t emergency care  262

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β-​blockers  191 bradycardia 266b bezafibrate 192 liver disease  322 bicarbonate 598t sclerosing Bier’s block  572 cholangitis 607t biguanides 335t automated external bilateral paraesthesia  358t defibrillators (AEDs)  biliary cholangitis  322, 325 232, 235, 546 biliary colic  301 autonomy 28 biliary tree  602 AV (atrioventricular) block bilirubin 324b, 583t see heart block see also jaundice axial plane  79f biochemistry 525 AXR (abdominal chasing results  86b X-​ray)  602–​3 CSF 606 azathioprine 431 laboratory 525 urine 605 biotin see vitamin B7 BiPAP (bi-​level positive back pain  360–​1 airway pressure)  280b causes 360t bipolar disorder  379t mechanical 360t, 361 biros 15 see also spinal birth see childbirth bacterial skin bisacodyl 208t infections  426–​7 bisoprolol 191t Bactroban® see mupirocin bitemporal hemianopia  135f bag and mask  234 blast cells  407b Baker’s cyst  465 bleeding see haemorrhage Bamford stroke bleeding disorders  419 classification 355t bleep  15, 17 bank holidays  44 handling when tired  74 Bankart lesions  577 blepharitis 145b barbiturates 176t, 214 blister 141b overdose 508t blood Barlow test  165 dipstick test  604 barrier methods of pre-​op requests  109 contraception 515 blood clotting basal-​cell carcinoma anticoagulation 258, (BCC) 436 420–​2,  461 base excess  599b disorders  418, 419, 511t basic life support  230, emergencies 418 232,  234–​5 screen 109t, 581 paediatric  238–​40 vaginal bleeding  511t BCG vaccine  166t, 505 blood cultures  529b beclometasone 190 blood gases, arterial see inhaler 281t arterial blood gases bed managers  70 blood glucose see glucose behavioural blood groups  412t therapy  91, 380 blood loss 408 Behçet’s disease  466b full blood count  580t Bell’s palsy  359 where to look for  237b, bendroflumethiazide 190 237f beneficence 28 see also haemorrhage benign positional blood pressure 235 vertigo 367 children 240b benzodiazepines blood products overdose 508t cryoprecipitate 415b benzylpenicillin (penicillin G)  fresh frozen plasma  415b 191, 427 irradiated 413 bereavement 380 packed red cells  415b beriberi 105t platelets 415b

et n . kX

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w

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B

INDEX

632

.B w ww

w

ww

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B

.B w ww

.B w w

w

INDEX

w

w 633

t t t brainstem severity 482t carbimazole  194, 340 .ne .ne .ne dysfunction 345t, 346 tetanus carbohydrates 105t X X X lesions  358t monoxide ok neurological okimmunization 482b carbon ok o o cyst  473 treatment 482 poisoning 483 Bo branchial B B . breaking bad news  24w. Buscopan see hyoscine cardiac arrest w breaks  16, 74 butterfly needle  529f, 535 w children  238–​40 w w w w w breast drugs 232 abscess 521 equipment and C cancer 437 tests  234–​5 t c-​ANCA  607tet cracked nipples  521 newborn  242–​3,  518et e n n . .n C-​spine X-​r.ay see cervical obstetric  244, 518 Xexamination 143 X X spine  X-​ray lumps 437 resuscitationksee adk k o post-​partum o questions  372 olife support vanced oCAGE o236–​ calcium 105t, 584 Bo breastfeeding, B B problems 521 trauma  7 . . hypercalcaemia 403 w w trolleys  232–​3 w w hypocalcaemia 377b, 402 prescribing 175 cardiac arrest team  232 w ww calcium carbonate  192w breathing  230, 234 calling for the  227b calcium channel children 238 cardiac arrhythmias see blockers  193, 266b newborns 242 arrhythmias t t t e e calcium chloride  194 obstetric arrest  244 cardiac axis  586 .ne n n . . calcium gluconate  194 breathing masks  558 left deviation  588t X X kX calcium pyrophosphate 276–​89 right deviation  ok breathlessness  ocrystal oksee588t o o o arthropathy see causes  276, 278t cardiac failure heart B .B pseudo-​gout .B dying patients  93t failure Calcium Resonium  194 ww emergency care  w 276w cardiac markers  581 Calpol   see paracetamol post-​operative  w119 w cardiac monitors  542 ww

B

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®

breech presentation  519 Bricanyl® see terbutaline British Medical Association (BMA)  11, 12, 43, 614 Counselling Service  614 broad complex tachycardia 257t bronchiectasis 291 Bruce protocol  544 brucellosis 501b Brudzinski’s sign  345t Buccastem® see phenothiazines Budd–​Chiari syndrome 320 budesonide 192 inhaler 281t bulla 141b bullying 36 bundle branch block  588t ECG  589–​90f bupivacaine 573t bupropion (Zyban®) 192 burns 480 assessment 481 chemical 483 complications 480b depth 482 dressings 483 electrical 483 emergency care  480–​1 fluid resuscitation  481 Lund and Browder chart 481f rule of nines  481t

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see also ECG cardiac syncope  456t cardiac tamponade  493 cardiogenic shock  490, 491t clinical markers  491t cardiopulmonary resuscitation (CPR)  225–​44 ABCD system  230 advanced life support  232–​3 advanced trauma life support  236–​7 dying patients  95 early warning scores  226–​7 equipment and tests  234–​5 in-​hospital  231f intensive care  228–​9 newborn life support  242–​3 obstetric arrest  244 paediatric basic life support  238–​40 peri-​arrest  230 signs of life  230b cardiorespiratory arrest children  238–​40 confirmation of   96 equipment and tests  234–​5 newborn  242–​3 obstetric 244 trauma  236–​7

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Campylobacter spp.  312, 313 cancer blood (leukaemia)  410, 467t bone 584t breast 437 cervix 511t, 513 colon 313t, 317t endometrial 511t, 513 oesophagus 300 ovary 511t, 513 skin 436 testicular 478 candesartan 190t Candida albicans  430, 503t candour, duty of   32b Canesten® see clotrimazole cannulae care of   533b colours 533t intravenous cannulation 533t resiting of   426b cannulation 232 arterial  537, 549 children 535 intravenous  532–​3 post-​cannula swelling (‘tissued cannula’) 465 canteen 13 canthus 145b capacity 30 carbamazepine 176t, 194

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cardiotocography net .(CTG) 520b X k cardiovascular

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causes  246, 248t emergency care  246 musculoskeletal 248t, 253 chest X-​ray (CXR) 235 asthma 596 central lines  597 chest drains  597 COPD 596 diaphragm 597 interpretation  596–​7 lungs 596 mediastinum 597 nasogastric tubes  597 pleural effusion  596 pneumonia 596 pneumothorax 596 pulmonary oedema  596 trachea 597 chickenpox (varicella zoster virus) 428 Child–​Turcotte–​Pugh score 323 childbirth 520 foetal monitoring  520 neonatal resuscitation  242–​3 obstetric resuscitation 244 vaginal delivery  568 children see paediatric chin lift  234 Chirocaine® 573t Chlamydia trachomatis 479b chloramphenicol eye drops 195 chlordiazepoxide 196 chlorhexidine 196 chlorphenamine 189t chlorpheniramine see chlorphenamine chlorpromazine 188t choking 290f cholangiocarcinoma 325 cholangitis 324t, 325 primary biliary  322, 325 primary sclerosing  322, 325 cholecystectomy, laparoscopic 121 cholecystitis  301–​2 choledocholithiasis 325 cholera 501b cholestasis 324t liver function tests  583t cholestatic jaundice  324, 325 cholesteatoma 475 choroid 145b Christmas disease (haemophilia B)  419

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antibiotics 181t central lines  548–​9 CXR 597 venous pressure  394 central nervous system (CNS) examination  134–​8 central venous pressure (CVP) lines  394 cephalosporins 195 cerebellar ataxia  366b, 367 cerebellum 358t cerebral dysfunction  345t cerebrospinal fluid (CSF) 606 biochemistry 606 culture 606 lumbar puncture  566–​7 meningitis 606t microscopy 606 PCR 606 cerebrovascular accident (CVA) see stroke cerebrum 358t Certificate of Completion of Training (CCT)  45, 53 certificate of eligibility for specialist registration (CESR) 45 cervical (cervix) cancer 511t, 513 ectropion 511t, 512 erosion 511t polyps 511t, 512 cervical rib  473 cervical spine X-​ray  608–​9 anteroposterior view 609 peg view  609 cervicitis  511–​12 CESR (certificate of eligibility for specialist registration) 45 cetirizine 189t chaperones 167 Charcot–​Marie–​Tooth syndrome 359 Charcot’s triad  325 chasing results  86b chemical burns  483 chemical cardioversion 545 chemosis 145b chest drains  554–​5 CXR 597 removal 555 surgical 555b chest leads (cardiac monitor)  542, 543f chest pain  246–​53

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system  245–​74 bradyarrhythmias  264–​8 chest pain  246–​53 examination  128,  130–​1 heart failure  274 hypertension  268–​73 procedures  542–​51 tachyarrhythmias  254–​61 cardioversion 546 chemical 545 care, levels of  229b Care Quality Commission 11 career applications  46, 616 assessment 617 CVs  54–​7 exams 60 interviews 58 structure 47f carotid pulse  130b carpal tunnel syndrome 462t carvedilol 191t case-​based discussion (CbD) 9t case presentations  63 cash dispensers  13 casts, urinary  604 cataracts 444 catecholamines, urinary 605 catheters suprapubic 562 urethral  560–​1 cauda equina syndrome 360t, 361 cause of death  98–99, 102–​3 CbD (case-​based discussion) 9t CBD (common bile duct) obstruction 325 CBT (cognitive behavioural therapy)  91, 380 CCGs (clinical commissioning groups)  618 CCT (Certificate of Completion of Training)  45, 53 cefalexin 195t cefotaxime 195t cefradine 195t ceftazidime 195t ceftriaxone 240 cefuroxime 195t celecoxib (Celebrex®) 195 cellulitis  426–​7,  460t

ww

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B

INDEX

634

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.B w ww t chronic neinflammatory .rashes 431 X k chronic lymphocytic leu-

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colonoscopy  312, 315 colorectal polyps 308t, 309 colostomy  112, 123 coma  344–​7 brainstem function 345t, 346 emergency care  344–​5 Glasgow Coma Scale  345t, 346–​7, 347t hypoglycaemic 328 induced 229 combined oral contraceptive pill (COC)  515 Combivent® 198 comminuted fractures  449 commissioners 618 common bile duct (CBD) obstruction 325 common peroneal compression 462t communication 22 around death  97 breaking bad news  24 cross-​cultural  25 dying patients  94 ethical issues  28 with patients’ relatives 23 written 22 community-​acquired pneumonia 283f compartment syndrome 460t, 461 competition for jobs  50–​1,  52 competition ratios  50–​1,  51t complaints 33 complex partial seizures 352 compound fractures  449 compulsion 164b computed tomography (CT) 87 computer access  13 concussion 452 conduct, professional  22 confidentiality  24, 26, 29 images 29 interpreters 25 outside agencies  26 relatives 29 confusion acute  374–​5 assessment method 374b conjunctiva 145b conjunctivitis 442 Conn’s syndrome  339 consciousness, loss of  366b

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INDEX

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ww

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t .ne X k

clotrimazole 197 clotting see blood clotting clotting screen  109t, 581 activated partial thromboplastin time  418, 581 prothrombin time  581 clozapine 381 cluster headaches  363t, 365 CML (chronic myeloid leukaemia) 410t CMV see cytomegalovirus CNS (central nervous system) examination  134–​8 co-​beneldopa  197 co-​careldopa  197 co-​codamol  89,  197 co-​danthramer  208t co-​dydramol  89 co-​proxamol  89 coagulation point-​of-​care testing  418 defects  418, 419, 511t cobalamin see vitamin B12 COC (combined oral contraceptive pill)  515 cocaine 508t codeine 89 codeine phosphate 93t, 197 coeliac disease  433t cognition 164b cognitive behavioural therapy (CBT)  91, 380 coil, contraceptive  515 cold sore  429 colectomy 121 colitis ischaemic 307 pseudomembranous 313t, 314 ulcerative see inflammatory bowel disease collapse  456–​7 colleagues alcohol abuse  35 clinical incompetence  35 communication with  22 mobile phone numbers 13 problems with  35 psychological problems 35 recreational drug use  35 Colles’ fracture  576 colon obstruction 296t, 298, 311t, 317t, 603t perforation 296t, 297, 602

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kaemia (CLL)  410t chronic myeloid leukaemia (CML) 410t chronic obstructive pulmonary disease see COPD chronic pain  91 chronic plaque psoriasis 431 chronic renal failure 386b, 387 abdominal X-​ray  602 fluid requirements  397 low urine output  393t urea and electrolytes 582t chronic suppurative otitis media (CSOM)  475 Churg–​Strauss syndrome 466b, 607t Chvostek’s sign  402 ciclesonide inhaler  281t ciclosporin 431 cimetidine 176t, 189 cinnarizine 188t ciprofloxacin 181t circulation  230, 235 children 238 newborn 242 obstetric arrest  244 cirrhosis 322 primary biliary see primary biliary cholangitis citalopram 196 Citanest® 573t CK (creatinine kinase)  581 clemastine 189t climacteric 159b clindamycin  196, 427 clinical commissioning groups (CCGs)  618 clinical fellows  68 clinical governance  27 clinical incidents  34 clinical incompetence  35 clinical lectureships  66, 68 clinical markers clinical supervisors  3t clipboards 18 CLL (chronic lymphocytic leukaemia) 410t clopidogrel 197 and surgery  110 Clostridium difficile  14, 182 clothing theatre scrubs  116 ward dress code  15

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w

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t consent  .ne 24, 31 capacity 30 X k children 30

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ok

t .ne X k oo

o

t .ne X k

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ww

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t

t

ww

t .ne X k

D-​dimer  284 dabigatran  198, 420t, 421 dacryocystitis 145b dalteparin 198 DANISH (cerebellar signs) 366 dapaglifozin 335t day case surgery  118 DBS (Disclosure and Barring Service) certificate 12 DC cardioversion  546 de Musset’s sign  131t deafness 475 death and dying arrangements for  92 care of patient after death 97 certification of cause of death  98–​9,  102–​3 communication 97 cremation forms  40, 100–​1,  101b declaration of death  96 do not resuscitate (DNAR) orders  92

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o

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.ne X k

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et n . kX oo

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.n kX

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o

o

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w ww

et n . X

.n kX

post-​Foundation Programmes  56–​7 Cusco’s speculum  159 Cushing’s reflex  362 Cushing’s syndrome 270t, 338 CV see curriculum vitae CVA (cerebrovascular ­accident) see stroke CVP (central venous ­pressure) lines  394 CXR see chest  X-​ray cycling 13 cyclizine 188t cycloplegia 145b cyclothymia 379 cyproheptadine 189t cystocele 478t cysts Baker’s 465 branchial 473 dermoid 473 epidermoid 434 epididymal 478 ganglion 434 ovarian 514 thyroglossal 473 cytomegalovirus (CMV) CMV-​negative blood products 413 hepatitis 321 retinitis 503t

o w.B

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et

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ww

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t .ne X k

and surgery  110 topical  180, 220 cortisol 585 cough 93t, 291 counselling 91 helplines 614 miscarriage 517 court appearances  26 Courvoisier’s law  325 COX-​2 inhibitors  89 CPAP (continuous positive airway pressure)  288b CPR see cardiopulmonary resuscitation crabs 430 cracked nipples  521 cramps 105t cranial nerve examination  128, 135t craniotomy 112 crash calls 17 see also cardiopulmonary resuscitation creatine kinase (CK)  581 creatinine 582 pregnancy 518t creatinine clearance  605 cremation forms  40, 100–​1, 101b problematic implants 100b critical appraisal  64b critical illness cover  43 critical incident form  34 Crohn’s disease  315t, 406 cross-​cultural communication 25 crossmatching 419 crusting 141b cryoprecipitate 415b Cryptococcus neoformans 503t crystalline arthropathy  466, 466b crystalloids 395 CSF see cerebrospinal fluid CT (computed tomography) 3 CT-​pulmonary angiography 284 CTG (cardiotocography)  520b cultures blood 529b CSF 606 stool 315 urine 605 CURB-​65  282,  283f curriculum 617 curriculum vitae (CV)  54–​5

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difficult situations  31 foreign languages  25 informed 31 Jehovah’s Witnesses  417b constipation 93t, 316–​17, 602 causes 317t drugs causing  316 management 316b consultants 68 contact dermatitis  431 contacts and networking 52 continuing education  60 continuous positive airway pressure (CPAP)  288b contraception 515 missed pills  515b contracts  38–​9 controlled drugs discharge summaries  80–​1,  81t, 81f prescribing 175 conversion/​ conversion tables height 616 pressure 616 temperature 616 weight 617 convulsions in children  349 eclampsia 351t, 518 see also seizures Coomb’s test  407b coordination 137 COPD (chronic obstructive pulmonary disease) 278t,  280–​1 CXR 596 inhalers 281t severity assessment and treatment (GOLD guidelines) 281t cord compression 360t, 361 core training  45, 48–​9 corneal abrasions  442 coronal plane  79f coronary artery territories 588 coroner 102 referral to  103 Coroner’s Office  102 Corrigan’s sign  131t corticosteroids 91 inhaled 279t, 281t potencies 221t prescribing 176t,  179–​80

ww

o Bo

B

INDEX

636

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww t dying .nepatients  94–​5 fear of  92 X k post-​mortem  99

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et n . kX

et n . X

ok

B

t .ne X k oo

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t

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et n . kX

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t

oo B . w

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t .ne X k

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ww

t

o

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ww

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.ne X k

.ne X k

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o B . w ww

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o

o

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w ww

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ok Bo

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oo B . w

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o

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w 637

.n kX

coordinators 70 letters 16 planning 73b self-​discharge  22 summaries  80–​1 disciplinary procedures  32 Disclosure and Barring Service (DBS) certificate 12 discrimination 36 disease surveillance  501 dislocations 449 reduction  576–​7 dissecting forceps  115f disseminated intravascular coagulation (DIC)  419 disulfiram 176t diverticular disease  296t, 301, 308t, 313t dizziness  366–​7 DKA (diabetic ketoacidosis)  330, 332 DM see diabetes mellitus do not resuscitate (DNAR) orders 92 doctors’ mess  13 Doctors’ Support Network (mental illness)  614 documentation 12 discharge summaries  80–​1 fitness to work notes  82 history taking  129 investigation requests  86 medical notes  76–​8 referral letters  84 docusate sodium  208t domperidone 188t DOPS (direct observation of procedural skills)  9t dorsalis pedis pulse  130b double gloving  561 double vision  445 doxazosin 200 Doyen retractors  115f DPP-​4 inhibitors  335t drains, chest  554–​5, 597 dress see clothing dressings, burns  483 Dressler’s syndrome  250 driving regulations 619 droperidol 188t drug-​related conditions 433t bradyarrhythmias 266b constipation 316 diarrhoea 312 headache 363t liver failure  319 psychiatry 379b pyrexia 497b sinus bradycardia  266b

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

HbA1c 109t, 334b hyperglycaemia  330–​2 management 335t, 336 sick day rules  335 skin manifestations  433t type 1:  331, 334 type 2:  331, 335 diabetic foot  336 diabetic ketoacidosis (DKA)  330, 332 diabetic nephropathy  336 diabetic neuropathy  336 diabetic retinopathy  336 dialysis 387b diamorphine 93t, 198 diaphragm, CXR  597 diarrhoea  312–​15 causes 313t drugs causing  312 management 312b notification 501b overflow 313t diazepam  90, 178t, 198, 348, 349 children 240 DIC (disseminated intravascular coagulation) 419 diclofenac  88, 199 diet, and constipation  317t difficult patients aggression and ­violence  107, 370, 373 alcoholism 106 elderly 106 DIGFAST (mania signs)  379 dignity, patient’s  20, 28 digoxin 199 bradycardia 266b overdose 508t toxicity 265t, 265f dihydrocodeine 89, 93t, 199 diltiazem 193t diphtheria 501b vaccination 166t diplopia 445 dipstick tests  498b, 604 dipyridamole 200 direct antiglobulin (Coomb’s) test  407b direct observation of procedural skills (DOPS) 9t disability  230, 235 children 238 obstetric arrest  244 disc prolapse  361t discharge controlled drugs  80–​1, 81t, 81f

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referral to coroner  103 registration of death  102 thinking about  92 see also breaking bad news death certificate  98–99, 102–​3 reforms 102 Deaver retractors  115f debt  42–​3 debt clearance  42 decompensated chronic liver failure  322 deep vein thrombosis (DVT) 460t, 464 pre-​test probability  464b Wells score  464b defibrillation  232, 235, 546 dehiscence, wound  120t dehydration hypovolaemia 393t, 394t low urine output  393t urea and electrolytes  582t delayed primary closure  120 deliberate self-​harm (DSH)  507–​9 risk after  508b delirium 164b,  374–​5 delivery (birth) see childbirth delta wave  587 delusion 164b dementia 164b, 376–​7, 379t causes 377b support organizations 376b Department of Health  618 depersonalization 164b depression 379t, 380 antidepressants 380 colleagues 35 postnatal 521b derealization 164b dermatitis (eczema)  105t, 431 dermatology see skin dermatomes 137f dermatophytes 430 dermoid cyst  473 desloratadine 189t detemir 206t development, paediatric 167t dexamethasone 188t, 198 diabetes insipidus  337 diabetes mellitus  334–​6 driving regulations  619 gestational  334–​6,  519

ww

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.B w w

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t drugs .ne adverse X k reactions  170, 173

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Bo

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ok

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t .ne X k oo

t .ne X k

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t

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ok

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w

t

ww

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ok

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t

o

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et

ww

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examination 146 glue ear  475 otitis externa  475 otitis media  475 tympanic membrane 147f wax 475 earache 475

et n . kX

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.n kX

EDD (estimated due date) 160 edoxaban  200, 420t, 421 EDTA blood tubes  451t education, continuing  60 educational requirements 60 educational supervisors  3t efficiency 626 Eklira (Genuair)® 281t elbow anatomy 153f examination 153 elderly patients  106 falls 451b, 457 elective surgery  121–​2 electrical burns  483 electrocardiogram see ECG electroconvulsive therapy (ECT) 380 electrolyte imbalances  399–​403 calcium  402–​3 potassium  398, 399–​403 sodium  400–​1 electrolyte requirements 396 Elidel® 431f emergency department  447–​521 anaphylaxis  484–​5 burns 480 contraception 515 ENT  474–​5 falls  456–​7 groin lumps  476–​9 gynaecological pain  514 head injury  452 hypotension  486–​9 joint pain  466–​71 limb pain  458–​62 limb swelling  463–​5 neck injury  454–​5 neck lumps  472–​3 overdose  506–​9 pregnancy  516–​21 pyrexia  496–​505 shock  490–​5 trauma  448–​51 vaginal bleeding  510–​13 see also medical emergencies EMLA® 535 emotion 164b empathy  20, 24 ENA antibodies  607t enalapril 184t encephalitis 363t, 364, 501b antibiotics 181t

o w.B

t

o w.B

e X.n

et

e X.n

oo B . w

ww

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t .ne X k

early warning scores  226–​7 EBV (Epstein–​Barr virus)  321 ecchymosis 141b ECG (electrocardiogram) 109t, 235, 542 acute anterior myocardial infarction 593f acute coronary syndromes 81t acute inferolateral ischaemia 591f acute inferolateral myocardial infarction  592f acute posterior myocardial infarction  594f axis 586 bradyarrhythmias 265t, 265f coronary artery territories 588 delta wave  587 heart rate  586t interpretation  586–​8 J wave  587 left bundle branch block 588t, 589f left ventricular hypertrophy 587 P wave  587 pericarditis 253f position of chest leads 543f PR interval  587 pulmonary embolism 284 QRS complex  587 QT interval  261t, 587 rhythm 586 right bundle branch block 588t, 590f ST segment  587 T wave  587 tachyarrhythmias 257t, 257f U wave  587 ventricular tachycardia 595f Wolff–​Parkinson–​White syndrome 259f echocardiography 109t eclampsia 351t, 518 ecstasy 508t ECT (electroconvulsive therapy) 380 ectopic pregnancy  511t, 512 ectopic testis  476 ectropion (cervical)  511t, 512 ectropion (eyelid)  145b eczema (dermatitis)  431

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w

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breastfeeding 175 cards  171, 172f children 175 controlled  80–​1, 81t, 175 history 126 interactions  173, 176t prescribing see prescribing recreational 35 Yellow Card Scheme  173 see also prescribing dry gangrene  460 dry mouth  93t dsDNA antibodies  607t DSH see deliberate self-​harm DTaP/​IPV/​Hib vaccine 166t Duaklir® 281t Duke criteria for infective endocarditis 499b duloxetine 91 dumping syndrome  329 duodenal biopsy  314 DVLA (Driver and Vehicle Licensing Agency) 619 DVT see deep vein thrombosis dying patients  94–​5 agitation 95 analgesia 95 communication 94 food and fluids  95 identification of   94 investigations 95 nausea and vomiting  95 resuscitation 95 secretions 95 stopping medication  94 dysfunctional uterine bleeding 511t, 512 dysmenorrhoea 159b dyspareunia 159b dyspepsia 300 dyspnoea see breathlessness

ww

o Bo

B

INDEX

638

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww encephalopathy, net .hypertensive 272t X k end of placement

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Bo

et n . kX

et n . X

ok

B

t .ne X k oo

t .ne X k

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t

Bo

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w

ww

t .ne X k

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t

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ok

o

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et n . kX

o w.B

ww

t

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o B . w ww

F1-​level doctors  69, 624 advanced trauma life support 237 F2-​level doctors  69 facial nerve (VII)  135t Faculty of Medical Management and Leadership 11 faecal occult blood (FOB) 308 faecal softeners  208t faecolith 112 fainting (vasovagal attack) 266b, 351t, 456t falls  456–​7 causes 456b elderly patients 451b, 457 family aggressive  107, 373 communication with  23 confidentiality 29 history 126 as interpreters  25 fats 105t FB (foreign body), eye  442 FBC (full blood count) 109t, 580 fear of death  92 felodipine 193t femoral blood gas  537 hernia 477 pulse 130b stab  235, 530 fentanyl 93t ferrous fumarate  201 ferrous gluconate  201

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t

o w.B

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.ne X ok

F

.ne X k

.ne X k

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t

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o

o

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w ww

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ok Bo

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o

t

ok

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w 639

.n kX

of treatment  20 exposure  230, 235 expressed consent  31 external jugular vein  549f external rotation technique 577 extradural haematoma 363t, 452 extrinsic pathway  581 eye conjunctivitis 442 corneal abrasions  442 examination  144–​5 foreign body  442 gradual visual loss  444 movements 144 red eye  440–​2 subconjunctival haemorrhage 442 sudden visual loss  443

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

ERPC (evacuation of retained products of conception) 517 errors, medical  32, 170 serious 33b erysipelas 426 erythema infectiosum  429 erythema multiforme  432 erythema nodosum  432 erythrocytes see red cells erythromycin 176t, 200 Escherichia coli 312 esomeprazole 201 essential items  15 estimated due date (EDD) 160 ethanol see alcohol ethical conflict  28 ethics 28 euphoria 164b European Working Time Directive (EWTD)  38b evacuation of retained products of conception (ERPC) 517 EWTD (European Working Time Directive) 38b exam planning  60 examination 128 breast 143 cardiovascular system  128,  130–​1 endocrine system  139 eyes  144–​5 female reproductive system  158–​9 gastrointestinal system 133 head and neck  146 musculoskeletal  148–​54 neonatal 165 neurological  134–​8 obstetric  160–​1 oncological/​ haematological 142 paediatric  166–​7 psychiatric  162–​4 respiratory system  128, 132 skin  140–​1 urological  156–​7 examination, membership 59 excoriation 141b exenatide 335t exercise tolerance test 544 exertional headache  363t expectations 16 of patients  20

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review 10b end of year review  10b endobronchial intubation 557 endocarditis blood cultures  529b prophylaxis 177 infective 499bf, 499 endocrine system  327–​41 adrenal disease  338–​9 diabetes mellitus see diabetes mellitus examination 139 hyperglycaemia  330–​2 hypoglycaemia  328–​9 pituitary axis  337 thyroid disease  340–​1 endocrine tests  585 endometrial cancer 511t, 513 endometrial polyps  511t, 512 endometriosis 514 endometritis 521 endotracheal intubation  556–​7 complications 557 enoxaparin  200, 421 enteral feeding  104 enterocele 478t enteropathic arthropathies 470b Entonox® 568 entrapment syndromes 462t entropion 145b enzyme inducers  176 enzyme inhibitors  176 eosinophils 580t epidermoid cyst  434 epididymal cyst  478 epididymitis 478 epidurals 90 epilepsy 351t, 352 driving regulations  619 see also seizures Epilim® see valproate epinephrine see adrenaline episcleritis 441 epistaxis 474 Epley manoeuvre  367 ePortfolio  8, 10b Epstein–​Barr virus (EBV)  321 erosion cervical 511t gastric 306t oesophageal 306t skin 141b

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.B w w

w

ww

.ne X ok .Bo

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t ferrous .nesulfate  201 festinating gait  138t X k fetal see foetal

o

Bo

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ok

t .ne X k oo

o

t .ne X k

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t

ok Bo

Bo

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ok

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w

t

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t .ne X k

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et n . gabapentin 203X k GAD (generalized oo anxiety disorder) 382 B . gait 138t w

ww

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325, 602 ww gallstones  γ-​glutamyl transferase

et n . kX

(GGT) 583t ganciclovir 503t ganglion cyst  434 gangrene dry 460 gas (wet)  461

o

o B . w ww

ww

et

ww

o w.B

ww

t

.ne X k

.ne X k

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o B . w ww

.n kX

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o

o

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w ww

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F2 69 structure 3t, 614 Foundation Programme Office 3t, 614 Foundation Programme representative 3t Foundation training programme director (FTPD) 3t Foundation Trusts  618 foundation years  66 fovea 145b fractures 449 children 611 comminuted 449 describing 611t hairline 449 open/​compound  449 reduction  576–​7 Salter–​Harris classification 611f simple 449 vertebral collapse  360t, 361 X-​rays  610–​11 Fraser guidelines  30b fresh frozen plasma (FFP) 415b Friedreich’s ataxia  353 frontal plane  79f frontotemporal dementia 377b frusemide see furosemide FTSTAs (fixed-​term specialty training appointments) 69 full blood count (FBC) 109t, 580 full thickness wounds  450t fundal height  161f fundus 145b fungal skin infections  430 furosemide 203 furuncles 435 fusidic acid  203, 426 FVC (forced vital capacity) 600

o w.B

t

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et

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oo B . w

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t .ne X k

flutter, atrial  259, 586 fluvastatin 218t FOB (faecal occult blood) 308 focal neurology  357–​9 focal segmental glomerulosclerosis  390t focal seizures  352 foetal lie 161 monitoring 520 skull 569f foetor hepaticus  319 folate see vitamin B9 folders 18 folic acid  202 fondaparinux 202, 420t, 421 food dispensers  13 food poisoning (gastroenteritis) 501b foot anatomy 150f examination 150 forced expiratory volume (FEV1) 600 forced vital capacity (FVC) 600 forceps 115f foreign body, eye  442 formal admission 164b, 371 formal complaints  33 formoterol inhaler  281t forms application see application forms cremation  40, 100–​1, 101b critical incident  34 death certificate  98–​9, 102–​3 interesting cases  620 P45 12 P60 12 referrals 84 telephone numbers  622, 624, 626 timetables  623, 625, 627 foscarnet 503t fosinopril 184t Fostair® 281t Foundation Doctor  3t Foundation Programme  614–​15 applying to  616 concept 614 curriculum and assessment 617 F1  69, 624

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w

o w.B

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FEV1 (forced expiratory volume) 600 fever see pyrexia fexofenadine 189t FFP (fresh frozen plasma) 415b fibrinogen 518t fibrinolytics 201 fibroadenoma of breast  437 fibroadenosis 437 fibroids 511t, 513 fibroma 434 fidaxomicin 182 field block  572 fifth disease (slapped cheek fever) 429 financial advice  42 financial planning  42 finasteride 201 fingertip unit (topical drugs) 180f fissures anal 308t, 309 skin 141b fitness to work notes  82 fits see seizures fixed-​term specialty training appointments (FTSTAs) 69 Flamazine® 483 flapping tremor  319 flashing lights  445 flecainide  202, 259t flexible training  44 flexural psoriasis  431 flight of ideas  164b Flixotide® 281t floaters 445 flow volume loops  601 fluconazole 202 fludrocortisone 202 fluids balance 394 burns 481 challenge 395 dying patients  95 overload  393, 394t pre-​/​post-​op  113 prescribing  395–​7 requirements 396 sequestration 394 volume status  394 flumazenil 202 fluoride oxalate blood tubes 451t fluoroscopy 87 fluticasone 202 inhaler 281t

ww

o Bo

B

INDEX

640

.B w ww

w

ww

ww

t

.ne X ok .Bo

ww

B

.B w ww gas.transfer  net 601 gas (wet) gangrene  461 X k gastric lavage  506

o

Bo

et n . kX

et n . X

ok

t .ne X k oo

t .ne X k

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t

Bo

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oo B . ww

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t

oo B . w

t

t .ne X k

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t

o

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.ne X k

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o

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.B

w ww

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oo B . w

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o

t

ok

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w 641

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glucose separating gel blood tubes  451t glue (wound closure)  450 glue ear  475 glulisine 206t glycaemic control  336 glyceryl trinitrate (GTN)  203, 273t glycolipid antibodies  607t glycopyrronium 95 inhaler 281t glycosylated haemoglobin (HbA1c) 109t, 334b GMC see General Medical Council goitre  340, 473 gonorrhoea 479b synovial fluid  571b Goodpasture’s syndrome 607t GORD (gastro-​ oesophageal reflux disease) 296t, 300 GOSWH (guardian of safe working hours)  39 gout 466b, 467t, 469 synovial fluid  571b government 618 GP see general practice GRACE (Global Registry of Acute Coronary Events) 251b granisetron 188t granuloma annulare  432–​3 Graves’ disease  340 groin abscess  476 groin lumps  476–​9 epididymitis/​orchitis  478 femoral hernia  477 hydrocele 477 inguinal hernia  477 sexually transmitted infections 479b spermatocele 478 strangulated hernia 296t, 477 testicular cancer  478 testicular torsion 296t, 476 urogenital prolapse  478 group A streptococcal disease 501b group and save (G+S)  412 GTN see glyceryl trinitrate guardian of safe working hours (GOSWH)  39 Guedel airway  556, 557 Guillain–​Barré syndrome  359, 607t guttate psoriasis  431

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

GGT (γ-​glutamyl transferase) 583t GI see gastrointestinal bleeding; gastrointestinal cancer; gastrointestinal system; gastrointestinal tuberculosis giant-​cell arteritis see temporal (giant-​cell) arteritis gifts 40 Gilbert’s syndrome  325 Gillick competence  30b GLADD (Association of LGBT Doctors and Dentists) 614 glandular fever  321 glargine 206t Glasgow Coma Scale (GCS) 345t, 346–​7, 347t see also coma Glasgow score for acute pancreatitis 302t glaucoma acute angle closure  441 chronic (open angle)  444 headache 363t, 364 glibenclamide 219t gliclazide 219t, 335t glipizide 219t Global Registry of Acute Coronary Events (GRACE) 251b glomerular basement membrane antibodies 607t glomerulonephritis 390 glossopharyngeal nerve (IX) 135t GLP-​1 activators  335t glucagon 203 glucocorticoids see corticosteroids GlucoGel® 328 glucose 585 5% solution  396t children 240 CSF 606 fasting  334–​6 finger-​prick  329, 330, 331 impaired fasting  334–​6 impaired tolerance  334–​6 newborns  242–​3 oral tolerance test  585t requirements 396 sliding scales  333 urine (glucosuria)  604 glucose saline  396t

o w.B

ww

Bo

B

w

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gastric parietal cell antibodies 607t gastritis 306t gastro-​oesophageal reflux disease (GORD) 296t, 300 gastro-​oesophageal varices 306t Gastrocote® 187t gastroenteritis 296t, 311t, 313t gastrointestinal bleeding  304–​9 chronic 308 emergency care  304 lower GI bleeds  307–​9 upper GI bleeds  305–​6, 311t urea and electrolytes 582t gastrointestinal cancer  300, 308t gastrointestinal system  293–​325 abdominal pain  294–​303 constipation 93t,  316–​17 diarrhoea  312–​15 examination 133 jaundice  324–​5 liver failure  318–​23 nausea and vomiting see nausea and vomiting procedures  562–​5 gastrointestinal tuberculosis 505t gastrostomy 104 GCS (Glasgow Coma Scale) 345t, 346–​7, 347t Gelofusine® 417 General Medical Council (GMC) 3t, 11, 12, 614 registration certificate  12 general practice membership exams  59 specialty training  48 generalized anxiety disorder (GAD)  382 generalized seizures  352 genetics 525 genital herpes  429, 479b genital warts  479b genitourinary tuberculosis 505t German measles (rubella) 429 gestational diabetes  334–​6,  519

ww

o Bo

.B w w

w

ww

.ne X ok .Bo

ww

B

t gynaecology .ne causes of pain  514 X k cervical cancer  513

o

Bo

et n . kXH

et n . X

ok

t .ne X k oo

o

t .ne X k

ww

t

ok Bo

Bo

o

et n . kX

ww

ok

ok

ww

oo B . ww

w

t

oo B . w

t

t .ne X k

ww

.n kX

ww

et n . X

ok

o

ww

et n . kX

o w.B

ww

t

o

o B . w ww

ww

et

ww

o w.B

ww

t

.ne X k

.ne X k

et n . kX oo

o B . w ww

.n kX

ww

.ne X ok

et

o

o

.B

w ww

et n . X

.n kX

heart block  264, 265t, 265f complete (3rd degree)  265t, 265f, 267 Möbitz I  265t, 265f, 267 Möbitz II  265t, 265f, 267 heart disease fluid requirements  397 NYHA functional status 130t heart failure  274 with preserved ejection fraction 274b heart rate children 240b from ECG  586t heart sounds  131t heel prick  534 height conversion table 616 Helicobacter pylori 300b HELLP syndrome  519 liver function tests  583t HELPERR (shoulder dystocia) 520 hemianopia 135f hemiparesis 358t hemiparetic gait  138t Henoch–​Schönlein purpura (HSP) 432 heparin blood tubes  451t low molecular weight 420t, 421 thrombocytopenia 421b unfractionated  204, 420t hepatic jaundice  324 liver function tests  583t hepatitis 321 alcoholic 320 autoimmune 322 notification 501b hepatitis B virus (HBV) immunization  12, 14 needle-​stick injuries  108t serology 321t hepatitis C virus (HCV), needle-​stick injuries 108t hepatobiliary disease  296t hepatomegaly 133t hepatosplenomegaly 133t hernia femoral 477 inguinal 477 strangulated 296t, 477 herpes simplex virus (HSV)  429, 503t genital see genital herpes herpes zoster ophthalmicus 428 shingles 428

o w.B

t

o w.B

e X.n

et

e X.n

oo B . w

ww

Bo

t .ne X k

subarachnoid 363t, 364 subconjunctival 442 uterine 511t, 512 vaginal  510–​13 vitreous 443 haemorrhagic shock  489t haemorrhoids 308t, 309 haemostatic forceps  115f hair 15 hairline fractures  449 hallucination 164b haloes 445 haloperidol 204 hand anatomy 154f examination  128, 154 nerve supply  138t, 138f handover 22b happiness xxviii harassment, sexual  36 Hartmann’s solution  396t Hashimoto’s thyroiditis 341 haustrae 603t Hb see haemoglobin HbA1c (glycosylated haemoglobin) 109t, 334b HBV see hepatitis B virus HCAs (healthcare assistants) 70 HCO3− see bicarbonate HCSA (Hospital Consultants and Specialists Association)  11, 12, 43, 614 HCV see hepatitis C virus head examination 146 lice 430 tilt 234 head injury  452 driving regulations  619 guidance 453f headache  362–​5 causes 363t migraine 311t, 365 post-​dural puncture  365 Health and Social Care Act (2012) 618 Health Education England 11 Health Protection (Notification) Regulations 501 healthcare assistants (HCAs) 70 healthcare in the UK  618 hearing tests  146 heart attack see myocardial infarction

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HAART (Highly Active Anti-​Retroviral Therapy) 504 haematemesis  305–​6 haematocrit, pregnancy 518t haematological cancer  410, 467t haematology  405–​22,  525 anaemia  406–​11 anticoagulation  420–​2 bleeding disorders  419 blood transfusion  412–​17 clotting emergencies  418 examination 142 procedures  528–​41 haematoma 572 extradural 363t subdural 363t haematuria 388 haemochromatosis 323 haemoglobin (Hb) 580 pregnancy 518t haemoglobinopathies 407t haemoglobinuria 388 haemolytic anaemia 407t, 408 haemolytic transfusion reactions 413t, 416t haemolytic uraemic syndrome 501b haemophilia 467t haemophilia A  419 haemophilia B (Christmas disease) 419 haemoptysis 291 haemorrhage 419 antepartum 519 blood transfusion  412–​17 clotting emergencies  418 gastrointestinal  304–​9 haematuria 388 hypovolaemic shock  490, 491t, 492 major haemorrhage protocol 489b post-​partum  521

ww

Bo

.B w w

oo B . w

examination  158–​9 intermenstrual bleeding 510b menopause 159b, 515 ovarian cancer  513 uterine prolapse  478t

ww

o Bo

B

INDEX

642

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww et HHS n(hyperosmolar .hyperglycaemic X k state)  330, 332

o

Bo

et n . kX

et n . X

ok

B

t .ne X k oo

t .ne X k

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t

Bo

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et n . kX

ww

w

ww

t .ne X k

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et

oo B . w

ww

t

.n kX

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o

ww

et n . kX

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t

o

o B . w ww

313t, 315, 433t, 467t IBS (irritable bowel syndrome) 313t, 314 ibuprofen  88, 205 ICP (intracranial pressure) 311t, 363t, 364 ICU (intensive care unit)  228–​9 ID badge  13, 15 IDDM see diabetes mellitus: type 1 IE (infective endocarditis) 499 IgA-​endomysial antibodies 607t ileostomy 123 ileus 311t illusion 164b IM (intramuscular) injections  538–​9 images, patient confidentiality 29 imbalance  366, 367 IMCA (Independent Mental Capacity Advocate)  30 immunization BCG (tuberculosis) 166t, 505 DTaP/​IPV/​Hib vaccine 166t hepatitis B  12, 14 MMR (measles, mumps, rubella) 166t schedule 166t tetanus 166t, 451t, 482b

oo B . ww

t

o w.B

ww

.ne X ok

I

.ne X k

.ne X k

et n . kX oo

o B . w IBD (inflammatory bowel ww disease) 296t, 308t,

.n kX

ww

t

et

o

o

.B

w ww

o w.B

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ok Bo

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oo B . w

ww

o

t

ok

w

w 643

.n kX

effect on blood tests 584t hypopituitarism 337 hypopyon 145b hypotension  486–​9 abdominal aortic aneurysm 487 causes 488b emergency care  488–​9 post-​operative  119 postural (orthostatic)  487 hypothyroidism 105t, 341 dementia 377b skin manifestations  433t thyroid hormones  585t hypovolaemia 393t, 394t see also intravenous fluids hypovolaemic shock 490, 491t, 492 clinical markers  491t

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

hydrocele 477 hydrocephalus, normal pressure 377b hydrocortisone 179t, 205, 315 hydrogen breath test  314 hydroxocobalamin 205 hydroxyzine 189t hyoscine  90, 95, 188t, 205 hyperaldosteronism 339 hyperalgesia 91b hypercalcaemia 403 hyperemesis gravidarum 311t hyperglycaemia 330 emergency care  330 sliding scales  333 hyperkalaemia 398, 399–​403 hypernatraemia 401 hyperosmolar hyperglycaemic state (HHS)  330, 332 hyperosmolar non-​ketotic state see hyperosmolar hyperglycaemic state hyperparathyroidism 403 calcium and phosphate 584t effect on blood tests  584t hyperpathia 91b hypertension  268–​73 antihypertensives 273t causes  268, 270t emergency care  268 end-​organ damage  272t malignant 268 pregnancy 518 treatment 271b, 272, 273t hypertensive crisis  272–​3 headache 365 hypertensive encephalopathy 272t hyperthyroidism 340 skin manifestations  433t thyroid hormones  585t hyphaema 145b hypocalcaemia 402 dementia 377b hypochromia 407b hypoglossal nerve (XII)  135t hypoglycaemia  328–​9 emergency care  328 hypoglycaemic agents  335t hypokalaemia 105t, 398, 399–​403 hyponatraemia 105t,  400–​1 hypoparathyroidism 402 calcium and phosphate 584t

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Bo

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hiccups 93t Hickman line  104 Highly Active Anti-​ Retroviral Therapy (HAART) 504 Hill–​Sachs deformities  577 hip anatomy 148f examination 149 neonatal 165 histology 86 histopathology 525 history taking  126–​7 documentation 129 HIV/​AIDS  501,  504 needle-​stick injuries  108t opportunistic infections  502, 503t skin manifestations  433t hives see urticaria Hodgkin’s lymphoma  410t homonymous hemianopia 135f honesty 28 HONK see hyperosmolar hyperglycaemic state horizontal plane  79f hormone replacement therapy (HRT)  515 hospital-​acquired fevers  502–​3 hospital-​acquired pneumonia 282 hospital at night (H@N) 75 Hospital Consultants and Specialists Association (HCSA)  11, 12, 43, 614 housing 44 Howell–​Jolly bodies  407b HRT (hormone replacement therapy)  515 HSP (Henoch–​Schönlein purpura) 432 HSV see herpes simplex virus Hudson mask  234 Humalin® see insulin Humalog® 206t β-​human chorionic gonadotrophin (β-​hCG)  109t dipstick test  604 human immunodeficiency virus see HIV/​AIDS Huntington’s disease  353 hyaline casts  604 hydralazine  204, 273t

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.B w w

w

ww

.ne X ok .Bo

ww

B INDEX

644

.B w ww

.B w w

ww

w

t t et immunocompromise 502 injections .n intubation, .ne .ne opportunistic intramuscular  538–​9 endotracheal X556–​7 X X indications ok infections  502, 503t ointravenous  ok 540–​1 okfor  229 o joint 571b investigations Bo immunology 525 B B . patients  95 impaired fasting glucose subcutaneous  538–​9 w. inner wdying (IFG)  334–​6 w ear inflammation  475 pre-​operative  109t w w w w w impaired glucose tolerance INR (International requests for  86 (IGT)  334–​6 Normalized iodine 105t impetigo 426 Ratio) 418b ipratropium 205 t t impingement test  152 insensible fluide losses  394 irbesartan 190t e et n n n . . . implied consent  31 insight (psychiatry)  164b iritis 441 X ospital X insomnia  iron 105t kX ok in-​hresuscitation 231f ok 178, 383 instruments, surgical  115f iron-​deficiency o o oo B B incident reporting  34 .B Insulatard  206t anaemia 407t, 409 . w insulin  186, 205, 335t ww incisional irradiated blood wounds 141b, 450t products 413 ww12, 43 prescribing 333 ww income protection  sliding scales  333 w irritable bowel syndrome incontinence, urinary  391 insurance (IBS) 313t, 314 Incruse t 281t indemnity 12 t ischaemia e e et indacaterol inhaler  281t life 43 .n bowel 296t, 299, 308t n n . . indemnity insurance  12 intensive care  228–​ 9 brain  356, 619 X X kX chest Mental intercostal heart 591f ok Independent odrains  ok o o o Capacity Advocate 554–​5 limb 460t, 461 B .B (IMCA) 30 liver 320 w.B intermenstrual w indirect antiglobulin bleeding 159b ischaemic colitis  307 w w test 407b w internal jugular vein  549f w Isoket  273t ww

B

®

®

®

induced coma  229 induction 10b infarction bowel 296t, 299 heart see myocardial infarction infection control 14 full blood count  580t gynaecological  511–​12 opportunistic  502, 503t recurrent/​unusual  502–​3 skin see skin infections infectious arthritis  466b infectious mononucleosis 321 infective endocarditis (IE) 499 inferolateral ischaemia 591f infestations 430 inflammatory bowel disease 296t, 308t, 313t, 315, 433t, 467t inflammatory rashes  431 inflammatory response 581 informed consent  31 infusion intravenous 540 saline  242–​3 inguinal hernia  477 inhalation injury  483 inhalers 281t

t .ne X k oo

o

t .ne X k

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ok Bo

Bo

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w

t .ne X k

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.n kX

J wave  587 Janeway lesions  425 jaundice  324–​5 investigations 324t liver function tests  583t jaw thrust  234 Jehovah’s Witnesses  417 Jelonet® 483 Jervell syndrome  261t jobs accepting 52 applications  46, 616 choosing 52 competition for  50–​1, 52 CV  54–​7

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ww

et n . kX

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t

o

o B . w ww

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.ne X k

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t

o w.B

et n . X

isophane 206t, 335t isosorbide dinitrate  207 isosorbide mononitrate 207 itching 93t IUCD (intrauterine contraceptive device)  515 IV (intravenous) cannulation  532–​3 fluids  394–​7 IV (intravenous) fluids see IV (intravenous) fluids IV (intravenous) infusion 540 IV (intravenous) injection  540–​1 ivabradine 266b

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International Normalized Ratio (INR)  418b interpreters 25 interpreting results  579–​611 interstitial pneumonitis 607t intertrigo 430 interviews 58 intestinal fluid losses  397 intestinal obstruction  296t, 298, 311t, 317t, 603t intoxication 345t intracranial pressure (ICP) 311t, 363t, 364 intramuscular (IM) injections  538–​9 intrauterine contraceptive device (IUCD)  515 intravenous (IV) cannulation  532–​3 cannulae 533t intravenous (IV) fluids  394–​7 electrolyte composition 396t maintenance fluids  395–​7 resuscitation fluids  395 special cases  397 volume status  394 intravenous (IV) infusion 540 intravenous (IV) injection  540–​1 intrinsic pathway  581 introitus 159b

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ww

.ne X ok .Bo

ww

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.B w ww t discrimination 36 .ne interviews 58 X k lists 18

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offers 52 joint aspiration  570–​1 injection 571b pain 460t,  466–​71 X-​rays  610 ‘Jones’ criteria  471 journal clubs  63 junior doctors’ contract 38 dispute 39b junior specialty training registrars 69 justice 28

w

et n . kX

B

K net

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K + see potassium Kaiser–​Fleischer rings 323 Kaposi’s sarcoma  504 keratitis 441 keratoacanthoma 436 Kerley B lines  596 Kernig’s sign  345t, 362 Keshan disease  105t ketoacidosis, diabetic (DKA)  330, 332 ketones, dipstick test  604 ketotifen 189t kidney acute kidney injury  386, 393t, 397, 582t chronic renal failure 386b, 387, 393t, 397, 582t, 602 dialysis 387b fluid overload  393, 394t haematuria 388 hypovolaemia 393t, 394t low urine output  392–​3 proteinuria  389, 518, 604, 605t renal artery stenosis 270t renal colic  296t, 301 rhabdomyolysis 388b stones 602 knee anatomy 149f examination 149 Kocher’s artery forceps 115f Koplik spots  429 Korsakoff ’s syndrome  372, 377b kwashiorkor 105t kyphosis 360

ww

t .ne X k oo

t .ne X k

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t

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Bo

ok

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t

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t .ne X k

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t

o

o B . w ww

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et

ww

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t

.ne X k

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o B . w ww

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.ne X ok

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o

o

.B

w ww

o w.B

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ok Bo

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t

e X.n

o B . w

w

w 645

.n kX

swelling  463–​5 ulcers  438–​9 legionnaires’ disease  501b leprosy 501b leptospirosis 323 less than full-​time training 44 letters discharge  16,  80–​1 referral 84 leucocytes see white cells leuconychia 156 leukaemia  410, 467t leukaemoid reaction  407b Levemir® 206t levobupivacaine 573t levocetirizine 189t levomepromazine 95 levothyroxine  207, 341 Lewy body dementia  377b LFT (liver function tests) 583 lice 430 lichenification 141b lidocaine  208, 572, 573t maximum dose  573t life insurance  43 lightbulb sign  577 limb leads (ECG)  542, 543f movements 136t pain  458–​62 swelling  463–​5 ulcers  438–​9 see also arm ; leg limbus (eye)  145b limited systemic sclerosis 607t lines central  394, 548–​9, 597 CVP 394 Hickman 104 linitis plastica  602 lipase 583 lipoma 434 liraglutide 335t lisinopril 184t lispro 206t lists jobs 18 patient  18, 73f theatre 114 lithium 209 liver disease autoimmune 322 outcome 323 prescribing 174 vascular 320 liver failure  318–​23 acute 320 causes 318

o w.B

ww

et n . X

INDEX

et

chasing results  86b labour see childbirth labyrinthitis 311t, 367 lacerations 141b, 450t LACS (lacunar stroke) 355t lactic acidosis  491t lactulose 208t intolerance 317b lacunar stroke (LACS) 355t LAD (left anterior descending artery)  588 lamotrigine 207 Lange–​Nielsen syndrome 261t Langenbeck retractors 115f lansoprazole 207 Lantus® 206t laparoscopic cholecystectomy 121 laryngeal mask airway (LMA) 558 laryngeal oedema  465 laryngoscopy 557f last menstrual period (LMP) 160 lateral corticospinal tract 137t lateralizing signs  345t, 346 lavage, gastric  506 laxatives 207 bowel preparation  111 LBBB (left bundle branch block) 588t, 589f LCX (left circumflex artery) 588 learned bodies  614 learning 17 leave, annual  44 leave entitlement  44 left anterior descending artery (LAD)  588 left axis deviation  588t left bundle branch block (LBBB) 588t, 589f left circumflex artery (LCX) 588 left shift, FBC  407b left ventricular hypertrophy (LVH) 587 leg ischaemia 460t, 461 pain  458–​62 pulse 130b

o w.B

X.

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t .ne X klocal anaesthetics LAo see o labetalol 191t, 273t B . laboratories 525

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Bo

w L

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o Bo

.B w w

w

ww

.ne X ok .Bo

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B

et (Contd.) liver nfailure .chronic 397 X k

o

Bo

et n . kX

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ok

t .ne X k oo

o

t .ne X k

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t

ok Bo

Bo

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t .ne X k

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t

o

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o B . w ww

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.ne X k

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o

ww

.ne X ok

macula 145b macular degeneration  444 macules 141b magnesium 105t magnesium carbonate 187t magnesium sulfate  209, 279 magnesium trisilicate  187t maintenance fluids  395–​7 children 397 major haemorrhage protocol 489b malabsorption 313t, 314 malaria 501b, 502b Malarone® 502b malathion 430 male urogenital system 157f, 157 malignant hypertension 268 malignant melanoma  436b Mallory–​Weiss tear  306t, 306 malnutrition 105t mammography 437 mania 164b, 379 manic-​depression  379 mannitol 209 Mantoux test  505 MAOI (monoamine oxidase inhibitors)  176t Marcain® 573t Marjolin ulcer  436 massive blood transfusion 415 mastitis 521 maternity leave  44 Maxolon® 210 MDDUS (Medical and Dental Defence Union of Scotland)  614

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.B

w ww

M

.n kX

MDU (Medical Defence Union) 614 mean cell volume (MCV) 407t measles (rubeola)  429, 501b MMR vaccination  166t mebeverine 209 mechanical back pain 360t, 361 meconium delivery  165, 242 Médecins Sans Frontières (MSF) 614 mediastinum, CXR  597 Medical and Dental Defence Union of Scotland (MDDUS) 614 Medical Defence Union (MDU) 614 medical emergencies abdominal pain  294 acute limb ischaemia  461 acutely painful limb  458 aggressive patients  370 anaphylaxis  484–​5 antepartum haemorrhage 519 blood clotting  418 bradyarrhythmias 262 breathlessness 276 burns  480–​1 chest pain  246 coma  344–​5 compartment syndrome 461 eclampsia 518 gas gangrene  461 gastrointestinal bleeding 304 HELLP syndrome  519 hyperglycaemia 330 hypertension 268 hypoglycaemia 328 hypotension  488–​9 liver failure  318 membership exams  59 overdose 506 potassium levels  398 rashes 424 red eye  440–​2 seizures  348–​9 septic arthritis  469 strangulated hernia  477 stroke 354 tachyarrhythmias 254 testicular torsion  476 see also emergency department medical errors  32. 170 serious 33b

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et

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oo B . w

ww

Bo

t .ne X k

pleural tap  552 TLC 600 TRALI 413t LVH (left ventricular hypertrophy) 587 lymph nodes, neck  472f lymphadenopathy 410b, 435 lymphoblastic leukaemia 410t lymphocytes 580t lymphocytic leukaemia 410t lymphoedema 463 lymphogranuloma venereum 479b lymphoma 410

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ww

w

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Bo

.B w w

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decompensated chronic 322 drugs causing  319 emergency care  318 liver function tests  583t liver function tests (LFT) 583 liver ischaemia  320 LMA (laryngeal mask airway) 558 LMN (lower motor neuron lesions)  357–​8 LMP (last menstrual period) 160 LMWH (low ­molecular weight heparin) 420t, 421 local administrators  3t local anaesthetics (LA)  572–​3 allergy 573 concentrations 573t maximum dose  573t toxicity  572, 573t Local Education Providers 3t Local Education Training Boards (LETBs)  3t locums 40 loperamide 209 loratadine 189t lorazepam  209, 348, 349 children 240 losartan 190t loss of consciousness  366b see also coma; seizures low molecular weight heparin 420t, 421 low sats  276–​89 low urine output  392–​3 lower GI bleeds  307–​9 causes 308t lower motor neuron ­lesions (LMN)  357–​8 lumbar puncture  566–​7 anatomy 567f lumbar spinal stenosis 361t, 462 lumps breast 437 groin  476–​9 neck  472–​3 salivary gland  473 skin  434–​5 thyroid 473 Lund and Browder chart 481f lung CXR 596 pleural effusion  278t, 285, 596

ww

o Bo

B

INDEX

646

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww t medical .neethics see ethics Medical Examiner  102 X k medical notes  76

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Bo

et n . kX

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ok

t .ne X k oo

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Bo

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t

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t .ne X k

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.ne X k

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o

o

.B

w ww

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e X.n

ok Bo

ok

oo B . w

ww

o

t

ok

w

w 647

.n kX

montelukast 211 mood 164b mood disturbance  378–​81 causes 379t morphine  89, 93t, 211 oral 213 Morris retractors  115f Mosquito Halstead forceps 115f motion sickness  367 motor neuron disease (MND) 353 motor response, absence of   96 mouth anatomy 147f dry 93t examination 128 Movicol® 208t MPS (Medical Protection Society) 614 MRC (Medical Research Council) 614 MRCGP (medical exam) 59 MRCP (medical exam)  59 MRCS (surgery)  59 MRI 87 MS (multiple sclerosis)  359 MSE (Mental State Examination)  163–​4 MSF (Médecins Sans Frontières) 614 MST Continus® see morphine MSU (mid-​stream urine) 604 multi-​drug resistant tuberculosis (MDR-​TB)  505 multidisciplinary team  70 multiple sclerosis (MS)  359 mumps 501b MMR vaccination  166t mupirocin 211 Murphy’s sign  301–​2 muscle myopathy 358t pain  459–​60,  460t power, MRC grading 136t trauma, rhabdomyolysis 388b musculoskeletal system ankle 150 back  360–​1 elbow 153 examination  148–​54 foot 150 hand  138, 154 hip 148f, 149, 165 knee 149 pelvis  152, 602

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

microbiology  86, 525 Microlette® 208t microscopy CSF 606 urine 604 microvascular angina  252b mid-​level practitioners  69 mid-​stream urine (MSU) 604 midazolam  95, 178, 211, 348 midpoint review  10b migraine 311t, 363t, 365 see also headache miliary tuberculosis  505t Miller–​Fisher syndrome 607t mini-​clinical evaluation exercise (mini-​CEX)  9t Mini-​Mental State Examination (MMSE) 377b minimal change glomerulonephritis 390t miotics 145b Mirena® 512 miscarriage 511t, 517 types of   517t misoprostol 211 mitochondrial antibodies 607t mitral regurgitation  131t mitral stenosis  131t Mixtard® see insulin mizolastine 189t MMC (Modernising Medical Careers)  614 MMR vaccination  166t MND (motor neuron disease) 353 mobile phones  13, 15 Möbitz I block 265t, 265f, 267 Möbitz II block 265t, 265f, 267 Modernising Medical Careers (MMC)  614 Mohs’ surgery  436 moles 435 molluscum contagiosum 429 money  15,  42–​3 see also pay monitoring cardiac 542 foetal 520 monoamine oxidase ­inhibitors (MAOI)  176t monoarthritis 466 monocryl sutures  575t Monospot (Paul Bunnell) test 321

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anatomical terms  79t symbols used in  78 Medical Protection Society (MPS) 614 Medical Research Council (MRC) 614 medical students  69 medical teams  68–​9 Medical Women’s Federation 614 medications see drugs medicine, membership exams 59 meetings  9–​10,  10b melanocytic naevi  435 membership exams  59 membranous glomerulonephritis 390t Ménière’s disease  367 meningeal tuberculosis meningism 345t, 346 meningitis 363t, 364, 501b antibiotics 181t CSF 606t driving regulations  619 nausea and vomiting  311t meningococcal septicaemia  427, 501b menopause 159b hormone replacement therapy 515 menorrhagia 159b, 510b Mental Health Act (2007) 371 formal admission under 164b, 371 key sections  371t mental illness  163b Mental State Examination (MSE)  163–​4 meralgia paraesthetica 462t meropenem 210 mesalazine  210, 315 mesangioproliferative glomerulonephritis 390t metabolic acidosis  598t, 599t metabolic alkalosis 598t, 599t metformin  210, 335t methadone 210 methotrexate  210, 431 methylprednisolone 210 metoclopramide 188t metoprolol 191t MHA see Mental Health Act (2007) MI see myocardial infarction

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musculoskeletal system net .(Contd.) X k shoulder 152

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t .ne X k oo

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t .ne X k

N -​acetylcysteine  185, 509 Na + see sodium nabilone 188t naevi  133, 435 nail clippings  425t naloxone  89, 212 nappy rash  430 Narcan® 212 narcolepsy 351t Naropin® 573t narrow complex tachycardia 257t nasal see nose nasogastric feeding  104 nasogastric tubes  563 CXR 597 nasopharyngeal airway  234 National Confidential Enquiry into Patient Outcome and Death (NCEPOD)  xxvii, 614 National Early Warning Score (NEWS2)  226, 227f

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ok

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.ne X k

.ne X k

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o

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.n kX

nettle rash see urticaria neurodegenerative disorders 353 neurological examination  134–​8 cranial nerves  128, 135t gait 138t peripheral nerves  128,  136–​8 spinal tracts  137f neurology  343–​67 back pain  360–​1 coma  344–​7 dizziness  366–​7 focal neurology  357–​9 headache  362–​5 neurodegenerative disorders 353 seizures  348–​52 stroke  354–​6 neuromuscular junction 358t neuropathic pain  91 neuropathic ulcers  439 neuropathy 358t diabetic 336 neuroses 382 neutropenia 496 febrile 500b neutrophils 580t newborn life support  242–​3 NHS (National Health Service) 618 entitlements 44 indemnity insurance  12 Patient Safety Agency 117 pension scheme  12, 43 NHS Improvement  11 niacin see vitamin B3 NICE see National Institute for Health and Care Excellence nicorandil 212 nifedipine 193t, 273t night blindness  105t night sedation  178 night shifts  75 nil by mouth (NBM) 113 prescribing 170 nimodipine 193t nipples, cracked  521 nitrites, dipstick test  604 nitrofurantoin 181t, 212 nitroprusside 273t nits 430 NIV (non-​invasive ventilation) 280b NOAC (novel oral anticoagulants) 212

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et

e X.n

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ww

N

t .ne X k

National Health Service see NHS National Institute for Health and Care Excellence (NICE)  11 angina  252–​3 diabetes mellitus  336 GI bleeding  306 hypertension 271 pregnancy 516t pre-​operative assessment  109–​10 sepsis 495b nausea and vomiting  310–​11 antiemetics 188 causes 311t dying patients  95 palliative care  93t NBM see nil by mouth NCEPOD (National Confidential Enquiry into Patient Outcome and Death)  xxvii, 614 nebulizer 234 neck examination 146 injury  454–​5 lumps  472–​3 lymph nodes  472f vessels 549f necrotizing fasciitis  427 needle-​holders  115f needle-​stick injuries  108, 232 viruses associated with 108t nefopam  90, 212 Neisseria gonorrhoeae  479b Neisseria meningitides 427 neonates examination 165 meconium delivery  165, 242 resuscitation  242–​3 neoplasia skin manifestations  433t see also cancer Neopuff™ 242 nephrectomy 112 nephritic syndrome  390b nephrotic syndrome  390b nerves ablation 91 blocks 91 cranial  128, 135t entrapment syndromes 462t hand 138t, 138f peripheral  128,  136–​8

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wrist 153 myasthenia gravis  359, 607t myasthenic crisis  359 Mycobacterium avium-​intracellulare 503t mydriatics 145b myeloid leukaemia  410t myeloma 403 calcium and phosphate 584t myelopathy 358t myeloproliferative disease 411 myocardial infarction (MI) acute anterior  593f acute inferolateral  592f acute posterior  594f breathlessness 278t cardiac markers  581 care after  250b driving regulations  619 ECG changes  591–​2f non-​ST elevation see NSTEMI ST elevation see STEMI myocarditis 248t myopathic gait  138t myopathy 358t myringoplasty 112 myxoedema, pre-​tibial  433t

ww

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B

INDEX

648

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww et 586 nodal .nrhythm  nodules 141b X k non-​alcoholic fatty liver

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Bo

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ok

t .ne X k oo

t .ne X k

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t

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t .ne X k

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ok

o w.B P

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t

.ne X p-​ANCA  607t ok P wave  o 587 B . ww

o

ww

et

ww

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obsession 164b

w

t

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t

ww

t

.ne X k

.ne X k

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o B . w ww

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o

o

.B

w ww

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o

t

ok

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w 649

.n kX

opioids long-​acting  89 overdose 508t palliative care  93t strong 89 weak 89 opportunistic infections  502, 503t optic cup  145b optic disc  145b optic nerve (II)  135t, 135f optic neuritis  443 optic pathways  135f oral contraceptive pill  515 oral glucose tolerance test 585t Oramorph® see morphine: oral orchitis 478 organization 625 oropharyngeal (Guedel) airway 234 oropharynx 147f orthostatic hypotension 487 Ortolani test  165 oseltamivir (Tamiflu®) 213 Osler’s nodes  425 osmolality 605 osmotic laxatives  208t osteoarthritis 467t, 468 osteomalacia 105t, 402 osteomyelitis 460 osteoporosis 105t, 451b otitis externa  475 otitis media  475 otoscopy 146 outside agencies  11, 26 ovarian cancer 511t, 513 cyst 514 torsion 514 over-​examination  21 overdose  506–​9 aspirin 508t clinical features  508t emergency care  506 paracetamol 509 overload, fluid  393, 394t oxybutynin 213 oxycodone 93t, 213 OxyContin® see oxycodone oxygen saturation  227f OxyNorm® see oxycodone oxytetracycline 213

o w.B

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et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

obsessive–​compulsive disorder (OCD)  382 obstetrics arrest 244 examination  160–​1 membership exams  59 resuscitation 244 obstruction bowel 296t, 298, 311t, 317t, 603t common bile duct  325 portal vein  320 SVC 289 upper airway  601 occupational health  622 occupational therapists  70 OCD (obsessive–​ compulsive disorder) 382 oculomotor nerve (III)  135t OD see overdose oesophageal cancer 300 intubation 557 reflux 248t varices 306t oesophagitis  300, 306t oestrogens, and surgery 110 oldaterol inhaler  281t olfactory nerve (I)  135t oligomenorrhoea 159b oliguria 392t omeprazole 212 on-​call  19,  74 oncological examination 142 ondansetron 188t online reference sources 615 open fractures  449 operating theatre  116–​17 clothing 116 design 116 etiquette 117 pre-​operative assessment  109–​10 scrubbing up  116 staff  116 theatre lists  114 watching operations  117 WHO Surgical Safety Checklist 117 see also surgery (clinical) ophthalmology vision loss  443–​4 visual acuity  144, 619 visual disturbances  445, 619 visual field testing  144 see also eye ophthalmoscopy 145

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disease 323 non-​Hodgkin’s lymphoma 410t non-​invasive ventilation (NIV) 280b non-​maleficence  28 non-​rebreather mask  234 non-​ST elevation myocardial infarction see NSTEMI non-​steroidal anti-​ inflammatory drugs see NSAIDs non-​vitamin K antagonist oral anticoagulants  212 Normacol® 208t normal pressure hydrocephalus 377b normal vaginal delivery (NVD) 568 see also childbirth nose anatomy 147f examination 146 nosebleeds 474 nosocomial fevers  496 notes fitness to work  82 medical  76–​8 notifiable diseases  501 novel oral anticoagulants (NOAC) 212 Novomix® 333 Novorapid® 206t NovoSeven® 417 NSAIDs  88,  189–​90 NSTEMI 248t,  251–​2 nuclear medicine  87 Nurofen® see ibuprofen nurse practitioners  70 nurse specialists  70 nurses 70 nutrition  68–​9 dying patients  95 enteral feeding  104 parenteral feeding  104 refeeding syndrome  104 requirements 105t NVD (normal vaginal delivery) 568 see also childbirth nylon sutures  575t nystagmus 367 nystatin 212

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et 12 P45 .nform  P60 form  12 X k Pabrinex see vitamin B

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1

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ok

t .ne X k oo

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t

ok Bo

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ok

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.ne X k

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w ww

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Pediculosis corporis 430 PEG (percutaneous endoscopic gastrostomy) 562 pellagra 105t pelvis/​pelvic anatomy 152f examination 152 inflammatory disease 511t, 514 X-​ray  602 Pemberton’s test  289 pemphigoid 432 pemphigus 432 pen-​torch  15 penicillin G see benzylpenicillin penicillin V see phenoxymethylpenicillin pens 15 pensions  12, 43 Pentasa® see mesalazine peppermint oil  214 Peptac® 187t peptic ulcer  296t, 300, 306t percutaneous endoscopic gastrostomy (PEG)  104 perforation, bowel  296t, 297, 602 pericarditis 248t, 253 perindopril 184t peripheral arterial disease (PAD) 462 peripheral blood film 407b peripheral nerves block 572 examination  128,  136–​8 peritonitis, spontaneous bacterial 322 PERLA mnemonic  144 permethrin 430 perphenazine 188t personal limits  16 personal statements  55 personality disorder  164b, 379t, 382 pertussis vaccination  166t petechiae 141b pethidine 214 pH ABG 598t, 599b dipstick test  604 phaeochromocytoma 270t, 339, 605 pharmacists 70 pharmacodynamic drug interactions 173 pharmacokinetic drug interactions 173

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t .ne X k

overdose  185, 509 paraesthesia 105t, 358t paraffin impregnated gauze 483 paraldehyde 349 paralytic ileus  298, 317t paraphimosis 157 paraproteinaemia 410 parathyroid disorders  402, 403 effect on blood tests 584t parathyroid hormone (PTH) high  403, 584t low  402, 584t paratyphoid fever  501b parenteral nutrition (PN) 104 parking 13 Parkinson’s disease  353 Parkinson’s-​plus syndromes 353 paroxetine 214 partial anterior circulation stroke (PACS)  355t partial seizures  352 Parvolex® (acetylcysteine) 185 passivity (psychiatry)  164b past medical history  126 patch testing  425t paternity leave  44 pathology membership exams 59 Patient Advice and Liaison Service (PALS)  33 patient-​centred care  627 patient confidentiality see confidentiality patient-​controlled analgesia (PCA) 90 patient lists  18, 73f patients aggressive  107, 370, 373 communication with  23 dignity  20, 28 empathy with  20, 24 expectations 20 relatives see relatives Paul Bunnell (Monospot) test 321 pay  13,  38–​9 payslip 618f supplementing 40 PDS sutures  575t PE see pulmonary embolism peak expiratory flow rate (PEFR) 132b, 600, 601f Pediculosis capitis 430

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®

packed red cells 396t, 415b crossmatching 412t PaCO2 598t PACS (partial anterior circulation stroke)  355t PAD (peripheral arterial disease) 462 paediatric basic life support  238–​40 blood samples  534–​5 capacity 30 confidentiality 29 consent 417b developmental stages 167t examination  166–​7 fractures 611 maintenance fluids  397 neck injury  455 observations 240b prescribing 175 seizures 349 training exams  59 vaccination schedule 166t Paget’s disease  403 calcium and phosphate 584t pain  88–​91 abdominal  294–​303 back  360–​1 chest  246–​53 chronic 91 gynaecological 514 joint  466–​71 limb  458–​62 muscle  459–​60,  460t neuropathic 91 palliative care  93 WHO pain ladder  88t pain teams  90b palliative care 93 pancreatitis 602 acute 296t, 302 chronic 303 liver function tests  583t pancytopenia 411 panic attacks  382 panic disorder  382 pantoprazole 213 pantothenic acid see vitamin B5 PaO2 598t papules 141b paracentesis  319–​20, 564–​5 paracetamol 213

ww

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B

INDEX

650

.B w ww

w

ww

.ne X ok .Bo

ww

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.B w ww t pharmacopoeia  .ne 183–​223 see also prescribing X k pharyngeal pouch  473

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t .ne X k oo

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t

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o

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posterior columns  137t posterior interosseous syndrome 462t posterior tibial pulse 130b postgraduate courses  60 postmenopausal bleeding 159b postnatal depression  521b postural (orthostatic) hypotension 487 potassium 105t, 398, 582 hyperkalaemia 398, 399–​403 hypokalaemia 105t, 398, 399–​403 oral supplement  215 PowerPoint  62, 63 PPH (post-​partum haemorrhage) 521 PR interval  587 practical procedures see procedures pravastatin 218t pre-​eclampsia  518 pre-​hepatic jaundice  324 pre-​operative assessment  109–​10 drug chart  110 patients with medical problems 110 special circumstances 110 pre-​term labour  520 pre-​tibial myxoedema  433t prednisolone 179t, 215, 315 pregabalin  91, 215 pregnancy 1st trimester  516–​17 2nd/​3rd trimester  518–​19 anaemia 519 antenatal care  160t antepartum haemorrhage 519 breech presentation  519 delivery 520 diagnosis 516 ectopic 511t, 512 foetal lie  161 gestational diabetes  334–​6,  519 HELLP syndrome  519, 583t hypertension 518 miscarriage 511t, 517 NICE guidelines  516t normal ranges  518t obstetric examination  160–​1 post-​partum  521 prescribing 174

o w.B

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et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

aspiration of   552 CXR 596 tension 285 treatment  286–​7 Pneumovax® 336 PO43–​ see phosphate POCS (posterior circulation stroke)  355t POCT (point-​of-​ care testing), coagulation 418 poikilocytes 407b point-​of-​care coagulation studies 418 poisoning alcohol 508t carbon monoxide  483 food 501b paracetamol 509 police 26 POLICE (soft tissue injury management) 449 poliomyelitis 501b polyarteritis nodosa  466b polyarthritis 466 polymerase chain reaction (PCR), CSF  606 polymyalgia rheumatica 467t, 468 polyneuropathies 359 polyps cervical 511t, 512 colorectal 308t, 309 endometrial 511t, 512 polyuria 386b popliteal pulse  130b portal vein obstruction  320 positron emission tomography (PET)  87 post-​cannula swelling  465 post-​concussion syndrome 452 post-​dural puncture headache 365 post-​Foundation Programmes, curriculum vitae  56–​7 post-​mortem  99 post-​operative care 118 fluids 397 problems 119 wound management  120 post-​partum haemorrhage (PPH) 521 post-​traumatic seizures 352 postcoital bleeding  159b posterior chamber of eye 145b posterior circulation stroke (POCS) 355t

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phenobarbital 176t, 214 phenothiazines 188t phenoxymethylpenicillin  214, 426 phenytoin 176t, 214, 348, 349 phimosis 157 phlebotomists 70 phobias 164b, 382 phone confidentiality issues  29 mobiles  13, 15 useful numbers  13, 18, 622, 624, 626 phosphate 584 photophobia 445 physiotherapists 70 phytomenadione 105t, 214 Picolax® see laxatives Picture Archiving and Communication System (PACS)  610–​11 PID (pelvic inflammatory disease) 511t, 514 piercings 15 piles (haemorrhoids) 308t, 309 pioglitazone 335t Piriton® see chlorphenamine pituitary axis  337 placenta praevia  519 plague 501b plantar warts  435 plaques 141b Plasmodium spp.  502b platelet count  580t pregnancy 518t platelets 415b transfusion  414–​15 Plavix® see clopidogrel pleural effusion  278t,  285 CXR 596 see also pneumothorax pleural tap  552 PN (parenteral nutrition) 104 pneumococcal vaccination 166t Pneumocystis jirovecii 503t pneumonia 248t, 278t, 282 antibiotics 181t CXR 596 pneumonitis, interstitial 607t pneumothorax 248t, 278t, 285,  286–​7

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pregnancy net (Contd.) .prolonged 519 X k

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t .ne X k

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.ne X QRS complex  587 k QT interval  oo 587 B . w

o

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.ne X k

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psychosis 164b,  378–​81 causes 379t puerperal 521b psychotherapy 380 PT (prothrombin time) 581 PTH see parathyroid hormone Pthiriasis pubis 430 Pthirus pubis 479b ptosis 145b pubic lice  430, 479b public health, notifiable diseases 501 Public Health (Control of Disease) Act  501 publications  29, 60 puerperal psychosis  521b Pulmicort® see budesonide pulmonary embolism (PE) 248t, 278t, 284 clinical risk assessment 284b Wells score  284t pulmonary oedema 278t, 288 CXR 596 pulmonary rehabilitation 281b pulmonary tuberculosis 505t pulse 130b pulse oximetry  234 puncture wounds  450t pupillary reflexes  144 purpura 141b Henoch–​Schönlein  432 meningococcal septicaemia 427 pustular psoriasis  431 pustules 141b pyelonephritis  112, 498 antibiotics 181t pyloric stenosis  602 pyoderma gangrenosum 432 pyrexia  496–​505 hospital-​acquired (nosocomial)  502–​3 iatrogenic causes  497b post-​operative  119 post-​partum  521 septic screen  497 of unknown origin (PUO) 497 pyridoxine see vitamin B6

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ww

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t .ne X k

lumbar puncture  566–​7 respiratory  552–​8 trolley 524b urology  560–​2 prochlorperazine 188t procyclidine 215 prolene sutures  575t prolonged QT interval 261t PROM (premature rupture of membranes)  520 promethazine 188t, 189t prophylaxis endocarditis 177 tetanus 166t, 451t, 482b VTE 421 propranolol 191t protamine 215 proteins 105t CSF 606 urine (proteinuria)  389, 518, 604, 605t protestogens, and surgery 110 prothrombin 418b prothrombin time (PT) 581 Protopic® 431f Prozac® see fluoxetine PSA (Prescribing Safety Assessment) 5b pseudo-​gout  467t, 469 pseudo-​obstruction (paralytic ileus)  298, 317t pseudo-​seizures  351t pseudohyponatraemia 400 pseudohypoparathyroidism 402 pseudomembranous colitis 313t, 314 psoas muscle  602 psoriasis 431 psoriatic arthritis  467t, 470 psychiatry  369–​83 acute confusion  374–​5 aggression and violence  370, 373 alcoholism 372 anxiety disorders/​ neuroses 382 dementia 164b,  376–​7 examination  162–​4 insomnia 383 Mental Health Act (2007) 371 mood disturbance/​ psychosis  378–​81 psychiatry membership exams 59 psychogenic seizures  351t psychological problems  35

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rhesus negative women 516b termination of  517 Prehn’s sign  476 premature rupture of membranes (PROM) 520 prematurity 520 prerenal hypoperfusion 386b presbyacusis 475 presbyopia 145b prescribing 170 abbreviations 171 adverse drug reactions  170, 173 antibiotics 181 best practice  171–​2 breastfeeding 175 C. difficile 182 changes to prescriptions  171, 172f children 175 controlled drugs  175 drug cards  171, 172f drug interactions  173 endocarditis prophylaxis 177 enzyme inducers  176 enzyme inhibitors  176 liver disease  174 night sedation  178 pharmacopoeia  183–​223 pregnancy 174 renal disease  174 self-​prescribing  172b steroids 179 verbal 172b Prescribing Safety Assessment (PSA)  5b presentation, foetal  161 presentations  29,  62–​4 presenting complaint  126 pressure conversion  616 prilocaine 573t primary biliary cholangitis  322, 325 primary sclerosing cholangitis  322, 325 primary survey  236 Prinzmetal’s angina  252b prioritizing 74 procedures  523–​77 blood and injection  528–​41 cardiology  542–​51 core foundation skills 526 gastroenterology  562–​5

ww

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B

INDEX

652

.B w ww

ww

B

.B w ww t prolonged 261t .ne quadrantanopia 135f X k quadruple therapy

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R.ne

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syndrome 462t radiation proctitis  308t radiculopathy 358t radiography see  X-​rays radiology 87 membership exams  59 requests for  87 raised intracranial pressure (ICP) 311t, 363t, 364 ramipril 184t Ramsay–​Hunt syndrome 428 ranitidine  189, 216 Ranson criteria  302t rash  424–​33 bacterial infections  426–​7 emergency care  424 fungal infections  430 infestations 430 inflammatory 431 systemic disease  433t viral infections  428–​9 see also urticaria RBBB (right bundle branch block) 588t, 590f reactive arthritis  467t, 470 records see notes recreational drug use  35 rectocele 478t red cells CSF 606 transfusion 414 urine 604 red eye  440–​2 refeeding syndrome  104 referees 55 referral letters  84 referrals 83 registrars 68 Reiter’s syndrome see reactive arthritis relatives aggressive  107, 373 communication with  23 confidentiality 29 as interpreters  25

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.ne X SAD PERSONS k score 508b oo B . ww

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w 653

.n kX

retinal artery occlusion 443 retinal vein occlusion  443 retinopathy 336 retractors 115f rhabdomyolysis 388b rhesus negative  516b rheumatic fever  467t, 471 rheumatoid arthritis 467t, 468 skin manifestations  433t synovial fluid  571b rheumatoid factor  607t rheumatological disease see arthritis; joint: pain rhinoscopy 146 rib, cervical  473 riboflavin see vitamin B2 rickets 105t, 402 rifampicin 176t, 216 right axis deviation  588t right bundle branch block (RBBB) 588t, 590f right coronary artery (RCA) 588 right shift, FBC  407b rigors 351t ringworm 430 Rinne’s test  146 risk factors  126 rivaroxaban  216, 420t, 421 RNP 607t road traffic accidents  448b see also trauma Road Traffic Act  26 Rockall risk scoring system 305t Romano–​Ward syndrome 261t Romberg’s test  137, 366b ropivacaine 573t rosuvastatin 218t ROTEM® 418 rouleaux 407b Royal Colleges  11, 615 rubella (German measles)  429, 501b MMR vaccination  166t rubeola (measles)  429 rule of nines, burns  481t ruminations (psychiatry) 164b run-​through training  45 rupatadine 189t RV (residual volume)  600

o w.B

ww

et n . X

INDEX

et

ok

et n . X

ok

t .ne X k

relaxation 37 relaxation techniques  382b Relvar® 281t renal artery stenosis  270t colic 296t, 301 dialysis 387b failure acute  386, 393t, 397, 582t chronic 386b, 387, 393t, 397, 582t, 602 fluid requirements  397 stones 602 renal disease glomerulonephritis 390 hypertensive 270t nephritic syndrome  390b nephrotic syndrome  390b prescribing 174 research  26, 40, 66 funding 66 residual volume (RV)  600 resigning 36 respiratory acidosis 598t, 599t respiratory alkalosis 598t, 599t respiratory arrest children  238–​40 equipment and tests  234–​5 newborn  242–​3 obstetric 244 trauma  236–​7 respiratory function tests  600–​1 peak expiratory flow rate 132b, 600, 601f spirometry 600 respiratory rate  240b respiratory system  275–​91 breathlessness  276–​89 cough 291 examination  128, 132 procedures  552–​8 stridor 290 respiratory wean  229 responsibility 16 results chasing 86b interpreting  579–​611 serial 18 resuscitation see cardiopulmonary resuscitation resuscitation fluids  395 retention, urinary  391, 393t reteplase 201t, 551b reticulocytes 407b, 580

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(tuberculosis) 503t quality of care  27 Quincke’s sign  131t quinine  90, 216 Qvar® 281t

X ok rabies 501b pulse  130b o radial tunnel B radial

.B w w

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B

t safety xxv .ne with aggressive X k patients  107, 373

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ok

Bo

t .ne X k oo

t .ne X k

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ok Bo

Bo

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ok

ok

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oo B . ww

w

t

oo B . w

t

t .ne X k

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.n kX

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et n . X

ok

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ww

et n . kX

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t

o

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.ne X k

.ne X k

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.n kX

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.ne X ok

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o

o

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w ww

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.n kX

shingles (herpes zoster) 428 shock  490–​5 anaphylactic  490, 491t cardiogenic 490, 491t, 492 causes 491t clinical markers  491t complications  490–​2 haemorrhagic 489t hypovolaemic 490, 491t, 492 septic 393t, 490, 491t, 494 spinal C16.S8.1.1, 491t, 493 shoes 15 short Synacthen® test  585 shortness of breath see breathlessness shoulder anatomy 152f dislocation  576–​7 dystocia 520 examination 152 impingement test  152 shuffling gait  138t SIADH (syndrome of inappropriate ADH secretion) 400b sick day rules, diabetes 335 Sick Doctor’s Trust (alcohol and drug addiction) 614 sick sinus syndrome  267b sickle-​cell disease/​ trait  411, 467t sickle-​cell screen  109t sideroblastic anaemia  407t sigmoid volvulus  602 sigmoidoscopy  112, 312, 313, 315 silk sutures  575t silver sulfadiazine cream  483 simple fractures  449 Sims’ speculum  159 simvastatin 218t sinus bradycardia  264, 265t, 265f, 266 drugs causing  266b sinus rhythm  586 sinus tachycardia  256, 257t, 257f sinusitis 363t, 365 SIRS (systemic inflammatory response syndrome) 495b sitagliptin 335t Situational Judgement Tests (SJT) 5b

o w.B

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e X.n

et

e X.n

oo B . w

ww

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t .ne X k

children 349 description 350b emergency care  348–​9 first fit  351b post-​traumatic  352 Seldinger central line  548 Seldinger chest drain  554–​5 selenium 105t self-​discharge  22 self-​harm  508b self-​prescribing  172b Sengstaken–​Blakemore tube 306 senior specialty training registrars 68 senna 208t sensation 137 sensory ataxia  366b, 367 sensory loss  357–​8, 358t sepsis meningococcal  427, 501b severe 495b septic arthritis  181t, 467t, 469 antibiotics 181t septic screen  497 septic shock  393t, 490, 491t, 494 clinical markers  491t septicaemia 363t antibiotics 181t meningococcal 427 Sequential Organ Failure Assessment (SOFA) score, sepsis  495b Seretide®  217, 281t serial results  18 serious untoward incidents 32 seroconversion, HIV/​ AIDS 504 seroma of breast  437 seronegative arthropathies 466b sertraline 217 service provision  17b severe acute respiratory syndrome (SARS)  501b Sevredol® see morphine: oral sexual harassment  36 sexually transmitted infections (STIs)  479b SGLT2 inhibitors  335t ‘Shape of Training’ report (SOT) 45b sharps 14 needle-​stick injuries  108, 232 Shigella spp.  312, 313

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occupational health  622 prescribing  171–​2 sagittal plane  79f salary  13,  38–​9 salbutamol  216, 279t inhaler 281t saline 0.9%  396t saline infusion  242–​3 salivary gland lump  473 salmeterol 216 inhaler 281t Salmonella spp.  312 salt-​poor albumin  565b Salter–​Harris classification 611f Sando-​K® see potassium: oral supplement saphena varix  476 sarcoma 434 Sarcoptes scabiei 430 SBP (spontaneous bacterial peritonitis) 322 SC (subcutaneous) injection  538–​9 scabies 430 scaling 141b Scarf test (shoulder)  152 scarlet fever  501b schizophrenia 379t, 381 Schober’s test  151 scissors 115f sclera 145b scleritis 441 sclerosing cholangitis, autoimmune 607t scoliosis 360 scotoma 145b scrubbing up  116 scrubs 15 scurvy 105t seborrheic dermatitis  431 second-​degree (Möbitz) heart block 265t, 265f, 267 secondary generalized seizures 352 secondary survey  236 secretions in dying patients  95 suctioning 234 sectioning 164b, 371 sedation night 178 pre-​operative  178 Seebri® 281t seizures  348–​52,  456t adults 348 causes 348b, 351t

ww

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B

INDEX

654

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww t situational .ne syncope  457 Sjögren syndrome  607t X k SJS (Stevens–​Johnson

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Bo

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ok

t .ne X k oo

t .ne X k

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w

t

oo B . w

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t .ne X k

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.n kX

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ok

o

ww

et n . kX

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t

o

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et

ww

o w.B

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t

.ne X k

.ne X k

et n . kX oo

o B . w ww

.n kX

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.ne X ok

et

o

o

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w ww

o w.B

e X.n

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oo B . w

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o

t

ok

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w 655

.n kX

ST segment  587 stable angina  248t,  252–​3 Staphylococcus aureus cellulitis  426–​7 toxic shock  494 statins 218 status asthmaticus  216 status epilepticus  198, 202, 209, 214 Stemetil® see phenothiazines STEMI 248t, 250, 588t cardiac markers  581 ECG changes  592f, 594f thrombolysis 354b, 550 step-​down patients  229 steppage gait  138t stereotypy 164b sterilization 515 Steristrips™ 450 steroids see corticosteroids stethoscope 15 Stevens–​Johnson syndrome (SJS) 432 STIs (sexually transmitted infections) 479b Stokes–​Adams attacks 351t stomas 123 stones gallbladder 325 kidney 602 stool culture  315 STOP (surgical termination of pregnancy)  517 strabismus 145b strains 449 strangulated haemorrhoids 309 strangulated hernia 296t, 477 strangulation of bowel 298 streptokinase 201t, 551b stress causes 37 work-​related  36 stridor 290 stroke (CVA)  354–​6 ABCD2 score  356t Bamford classification 355t driving regulation  619 emergency care  354 students, medical  69 study expenses  60 study leave  44, 60 subarachnoid haemorrhage 363t, 364 subclavian artery  549f subclavian vein  549f

o w.B

ww

et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

SOFA (Sequential Organ Failure Assessment) score, sepsis  495b soft tissue injuries 449 signs 610 sore throat  474 SOT report (‘Shape of Training’) 45b sotalol 191t space-​occupying lesions 359 spastic gait  138t specialist registrars  68 specialties in medicine  53 specialty training  45, 49t applications 46 career structure  47f competition  50–​1 fixed-​term appointments 69 options  48–​9 recruitment process  46 specific gravity of urine 604 Spencer Wells forceps 115f spermatocele 478 spider naevi  133 SPIKES model  24 spinal anaesthesia 572 anatomy 151f cord compression 360t, 361 curvature 360 examination 151 shock  490, 491t, 493 stenosis 359 tracts 137f, 137t tuberculosis 505t spinothalamic tract  137t Spiolto® 281t Spiriva® 281t spirometry 600 spironolactone  217, 339 splenomegaly 133t spondylarthropathies 466b spondylitis 360t spondylolisthesis 361t spondylolysis 361t spondylosis 361t spontaneous bacterial peritonitis (SBP)  322 sprains 449 whiplash injury  454 squamous-​cell carcinoma (SCC) 436 ssDNA antibodies  607t ST elevation myocardial infarction see STEMI

o w.B

ww

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B

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syndrome) 432 SJT (Situational Judgement Tests) 5b skeletal X-​rays  610–​11 skin biopsy 425t cancer 436 examination  140–​1 lumps  434–​5 rashes  424–​33 scrapings 425t swab 425t skin infections 425 bacterial  426–​7 blood tests  425t fungal 430 tuberculosis 505t viral  428–​9 slapped cheek fever (fifth disease) 429 SLE (systemic lupus erythematosus) 433t, 467t, 471 sleep hygiene  178, 383 insomnia 383 night shifts  75 SLEs (supervised learning events) 9t slide presentations  62–​3 Slow-​K® see potassium: oral supplement SMA (smooth muscle antigen) 607t small bowel obstruction 603t smallpox 501b smartphones 15 smear test  513 smooth muscle antigen (SMA) 607t social history  126 social media  13, 15b social phobia  382 social workers  70 SOCRATES mnemonic 88 sodium 105t, 582 hypernatraemia 401 hyponatraemia 105t, 400–​1 urinary 605 sodium bicarbonate, newborns  242–​3 sodium citrate blood tubes 451t sodium valproate see valproate

ww

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.B w w

w

ww

.ne X ok .Bo

ww

B

subconjunctival net .haemorrhage 442 X k subcutaneous (SC)

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Bo

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ok

Bo

t .ne X k oo

t .ne X k

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t

ok Bo

Bo

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t

t .ne X k

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ok

o

ww

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o w.B

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t

o

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et

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t

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.ne X ok

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t-​PA (tissue plasminogen activator) 354b T wave  587 T3 585t T4  207, 340, 341 TAB (team assessment of behaviour) 3t tachyarrhythmias  254–​61 atrial fibrillation  256, 257t, 257f, 258, 265t, 586 atrial flutter  259, 586 broad complex  257t causes 254 chemical cardioversion 545 defibrillation 232, 235, 546 ECG 257t, 257f, emergency care  254 narrow complex  257t supraventricular tachycardia 256, 257t, 257f, 259 torsade de pointes 257f,  260–​1

ww

et n . kX oo

o B . w ww

.n kX

T

o

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w ww

et n . X

.n kX

treatment 259t ventricular fibrillation 257f ventricular tachycardia  256, 257t, 257f, 260 TACS (total anterior circulation stroke)  355t Tamiflu® see oseltamivir tamoxifen 218 tamsulosin 218 tax issues  43 TB see tuberculosis teaching  62–​4 medical students  65 team assessment of behaviour (TAB)  3t TED stockings  110 TEG® 418 Tegretol® see carbamazepine teicoplanin see vancomycin telangiectasia 141b temazepam 178t, 219 temperature conversion 616 temporal (giant-​cell) arteritis 363t, 365 visual loss  443 TEN (toxic epidermal necrolysis) 432 Tenckhoff catheter  387b tendon hammer  15 tendon reflexes  136t tenecteplase 201t, 551b TENS (transcutaneous electrical nerve stimulation) 91 tension headache  363t tension pneumothorax 285 terbutaline  219, 279t inhaler 281t terlipressin 306 termination of pregnancy (TOP) 517 terminology, surgical  112 testes cancer 478 ectopic 476 torsion 296t, 476 tetanus 501b immunization 166t, 451t, 482b tetracosactide (Synacthen®) 219 tetracycline 219 thalassaemia 407t, 411 theatre see operating theatre theatre lists  114 theophylline 220

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t

o w.B

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et

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oo B . w

ww

o

t .ne X k

symbols and abbreviations x–xxiv patient notes  78 prescriptions 171 sympathectomy 91 Synacthen® see tetracosactide syncope  366, 456t cardiac 456t driving regulations  619 situational 457 vasovagal attacks  266b, 351t, 456t syndrome of inappropriate ADH secretion (SIADH) 400b synovial fluid  571b syphilis 479b syringe drivers  90 systemic inflammatory response syndrome (SIRS) 495b systemic lupus erythematosus (SLE)  433t, 467t, 471 skin manifestations  433t systemic rheumatic disease 466b systemic sclerosis autoantibodies 607t limited 607t systems’ review  127

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w

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Bo

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injection  538–​9 subdural haematoma  363t, 377b, 452 substance abuse  378, 619 driving regulations  619 suction 234 suicide 508b sulfasalazine 218 sulphonylureas  218, 335t superficial thrombophlebitis 459 superior vena cava (SVC) obstruction 289 supervised learning events (SLEs) 9t suprapubic catheter  562 supraventricular ­tachycardia (SVT)  256, 257t, 257f, 259 surgery (career)  59 surgery (clinical) bowel preparation  111, 192 checklist 113 elective  121–​2 in-​patient preparation 113 instruments 115f operating theatre  116–​17 post-​operative care  118, 120 post-​operative problems 119 pre-​operative assessment  109–​10 terminology 112 theatre lists  114 watching operations  117 see also operating theatre surgical instruments  115f surveillance 501 sutures  450,  574–​5 materials 575t removal 575t size 575t SVC (superior vena cava) obstruction 289 SVT (supraventricular tachycardia)  256, 257t, 257f swabs 425t swallowing, stroke patients 356b swelling, limb  463–​5 Symbicort®  218, 281t

ww

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B

INDEX

656

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww t thiamine .ne see vitamin B thiazolidinediones 335t X k thiopental 348 1

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Bo

et n . kX

et n . X

ok

t .ne X k oo

t .ne X k

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t

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oo B . ww

w

t

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t .ne X k

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.n kX

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o

o w.B U

wwU+E see urea and

et n . kX

electrolytes U wave  587 UK Foundation Programme see Foundation Programme ulcerative colitis  315t

ww

t

o

o B . w ww

ww

et

ww

o w.B

ww

t

.ne X k

.ne X k

et n . kX oo

o B . w ww

.n kX

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.ne X ok

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o

o

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w ww

o w.B

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ok Bo

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oo B . w

ww

o

t

ok

w

w 657

.n kX

advanced trauma life support  236–​7 burns 480 dislocations 449 falls  456–​7 fractures see fractures head injury  452 neck injury  454–​5 soft tissue injuries  449 wounds  450–​1 traveller’s diarrhoea  312 treatment expectations  20 tremor, flapping  319 Treponema pallidum 479b tricyclic antidepressants  91 overdose 508t trifluoperazine 188t trigeminal nerve (V)  135t trigeminal neuralgia  363t triiodothyronine 585t trimethoprim 181t, 220 trochlear nerve (IV)  135t trolleys  232–​3,  524b troponins 88t, 581 Trousseau’s sign  402 trusts 618 TTOs/​TTAs see discharge: summaries tuberculosis (TB)  501b, 503t, 505 gastrointestinal 505t genitourinary 505t immunization 505 meningeal 505t miliary 505t multi-​drug resistant  505 pulmonary 505t spinal 505t synovial fluid  571b tubes, blood  531 tumour lysis syndrome 389b tuning fork tests  146 tunnel vision  445 tympanic membrane 147f type 1 diabetes  331, 334 type 2 diabetes  331, 335 typhoid fever  501b typhus fever  501b

o w.B

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et n . X

INDEX

et

e X.n

o B . w

ww

Bo

t .ne X k

Todd’s paresis  350b tolbutamide 219t tonometer 145b torsade de pointes 257f,  260–​1 total anterior circulation stroke (TACS)  355t total lung capacity (TLC) 600 total parenteral nutrition (TPN) 104 Toxbase 506 toxic epidermal necrolysis (TEN) 432 toxic shock  494 Toxoplasma gondii 503t TPN (total parenteral nutrition) 104 Tracey v Cambridge University Hospitals 2014 92b trachea, CXR  597 traction-​countertraction technique 577 trade unions  11 training 17b core  45,  48–​9 less than full-​time  44 specialty see specialty training training fellowships  66 TRALI (transfusion-​ associated lung injury) 413t tramadol  89, 93t, 220 transcutaneous electrical nerve stimulation (TENS) 91 transfer factor  601 transfusion  412–​17 ABO blood groups  412t complications 413t crossmatching 419 elective 414f emergency 414f Jehovah’s Witnesses  417 massive 415 platelets  414–​15 red cells  414 transfusion reactions  416 when to transfuse  413 transfusion-​associated lung injury (TRALI)  413t transfusion reactions  416 transient ischaemic attack (TIA) 356 driving regulations  619 transient loss of consciousness see seizures transverse plane  79f trauma  448–​51

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B

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oo B . w

third-​degree (­complete) heart block 265t, 265f, 267 third-​space fluids  394 thought insertion  164b throat, examination  146 thrombocytopenia 419 heparin-​induced  421b thrombolysis 354b,  550–​1 Thrombolysis in Myocardial Infarction (TIMI) risk score 251b thrombophlebitis, superficial 459 thromboprophylaxis 421 thyroglossal cyst  473 thyroid disease  340–​1 dysfunction and hypertension 270t function test  585t hormones 585t hyperthyroidism 340, 433t, 585t hypothyroidism 341, 377b, 433t, 585t lump 473 subclinical disease  341b thyroid peroxidase antibodies 607t thyrotoxic storm  340 thyrotropin receptor antibodies 607t thyroxine 585t TIA (transient ischaemic attack)  356, 619 time management  19 timetables  18, 623, 625, 627  TIMI (Thrombolysis in Myocardial Infarction) risk score  251b timolol 191t tinea corporis  430, 503t cruris 430 faciei 430 pedis 430 tinzaparin 220 tiotropium 220 inhaler 281t tirofiban 220 tissue forceps  115f tissue glue  450 tissue plasminogen activator (t-​PA)  354b ‘tissued cannula’  465 TLC (total lung capacity) 600

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.B w w

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B t ulcers 141b .ne arterial 439 X k leg  438–​9

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ok

t .ne X k oo

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vaccination see immunization vaginal bleeding  510–​13 causes 510b, 511t vaginal delivery 568 vaginitis  511–​12 vagus nerve (X)  135t valproate 220 valsartan 190t valvulae conniventes  603t valvular heart disease  131t vancomycin 181t, 182, 220 vanillylmandelic acid (VMA) 605 varicella zoster virus (VZV)  428, 503t varices, oesophageal  306t varicocele 476 vascular dementia  377b vascular liver disease  320 vasculitis 466b skin manifestations  433t vasopressin see antidiuretic hormone vasovagal attacks  266b, 351t, 456t vault prolapse  478t venepuncture  528–​9 venlafaxine 222 venous access  235 venous blood sample  537 venous eczema  431 venous insufficiency  465 venous thromboprophylaxis  421

o

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.n kX

venous ulcers  439 ventilation, non-​invasive  280b Ventolin® see salbutamol ventricular fibrillation (VF) 257f ventricular rhythm  586 ventricular tachycardia (VT)  256, 257t, 257f, 260, 595f ECG 595f Venturi mask  234 verapamil 193t, 259t verbal prescriptions  172b vertebral collapse fracture 360t, 361 vertigo  366, 367 benign positional  367 driving regulations  619 veruccas 435 vesicles 141b vestibular neuronitis  367 vestibular schwannoma 475 vestibulocochlear nerve (VIII) 135t VF (ventricular fibrillation) 257f vicryl sutures  575t vilanterol inhaler  281t violent patients  370 emergency care  107 viral exanthema  429 viral haemorrhagic fever 501b viral hepatitis see hepatitis viral skin infections  428–​9 visual acuity  144, 145b driving regulations  619 visual disturbances 445 driving regulations  619 visual field testing  144 visual loss gradual 444 registration of   444b sudden 443 vitamin A  105t vitamin B1 105t, 220, 348 alcoholism 372 vitamin B2 105t vitamin B3 105t vitamin B5 105t vitamin B6 105t vitamin B7 105t vitamin B9 105t deficiency 377b, 409 vitamin B12 105t deficiency 377b, 409 vitamin C  105t

o w.B

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low output  392–​3 microscopy 604 osmolality 605 proteinuria 389 tests  604–​5 toxicology 605 urobilinogen 324b urogenital prolapse  478 urogenital system  157f urokinase 201t urological system disorders 391 examination  156–​7 procedures  560–​2 urostomy 123 urticaria 141b, 432 blood transfusion  413t, 416t uterine leiomyoma see fibroids uterine prolapse  478t uveitis, acute anterior  441

k oo B . w V

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Marjolin 436 neuropathic 439 peptic 296t, 306, 306t venous 439 ulnar entrapment 462t pulse 130b Ultibro® 281t ultrasound 87 umeclidinium inhaler  281t UMN (upper motor neuron lesions)  357–​8 unconsciousness 366b unfractionated heparin  204, 420t unstable angina  248t, 252 upper airway obstruction 601 upper GI bleeds  305–​6, 311t causes 306t Rockall risk scoring system 305t urea and electrolytes 582t upper motor neuron lesions (UMN)  357–​8 urate crystal arthropathy see gout urea pregnancy 518t urea and electrolytes (U+E) 109t, 582 abnormalities 582t urethral catheterization  560–​1 urethrocele 478t urinary incontinence  391 urinary retention  393t acute 391 chronic 391 see also low urine output urinary tract antibiotics 181t X-​ray  602 see also renal disease urinary tract infection 498 dipstick tests  604 recurrent 498b urine biochemistry 605 culture 605 diabetes mellitus  604 dipstick tests  498b, 604 haematuria 388 high output  386b

ww

o Bo

B

INDEX

658

.B w ww

w

ww

.ne X ok .Bo

ww

B

.B w ww t vitamin D  .ne 105t vitamin E  105t X k vitamin K see

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ok

B

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Waldenström’s macroglobulinaemia 410 wards 13 cover equipment  18 daily duties  71 dress code  15 organization 18 rounds  72–​3 warfarin  221, 420t, 422 drug interactions  176t and surgery  110 warts 435 genital 479b Waterhouse–​Friderichsen syndrome 427 WCC see white cell count weakness 358t weals 141b Weber’s test  146 websites 614

ww

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ok

t .ne X k

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skeletal  610–​11 xanthochromia 606

Y

w

t

zaleplon 383 Zenker diverticulum  473 Ziehl–​Nielsen (ZN) stain 505 zinc 105t zolpidem  222, 383 zopiclone 178t, 222, 383 Zoton® see lansoprazole Zyban® see bupropion

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net . X Yellow Card Scheme  ok501b 173 yellow fever  o B . Z ww

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.ne X-​rays  87 X k abdominal o3o(AXR)  602–​ B . cervical spine  608–​9 wwchest see chest X-​ray

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wound glue  450 wounds  450–​1 abrasions 141b, 450t advice for patients  575b care of   120 cleaning 450 dehiscence 120t full thickness  450t incisional 141b, 450t lacerations 141b, 450t superficial 450t sutures  450,  574–​5 tetanus immunization 451t wrist anatomy 153f examination 153

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INDEX

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phytomenadione vitreous haemorrhage  443 vitreous humour  145b VMA (vanillylmandelic acid) 605 volume status  394 Voluntary Services Overseas (VSO)  614 Voluven® 417 vomiting see nausea and vomiting von Willebrand disease 419 VT (ventricular tachycardia)  256, 257t, 257f, 260, 595f VZV (varicella zoster virus)  428, 503t

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EMERGENCY ADULT DRUG DOSES

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