REFERENCE RANGES

Haematology
WBC 3.7-10x109
RBC 4.5-5.5x1012
Hb 130-170 g/L
Hct 0.4-0.5 L/L
MCV 83-101 fL
MCH 27-32 pg
MCHC 315-345 g/L
RDW 11.6-14.6 %
Plt 130-430X109
ESR 0-15 mm/Hr
PT 10.9-14.1 seconds
INR 0.8-1.1
APTT 26.8-38.6 seconds
Biochemistry
Glu 3.9-6.1 mmol/L
Urea 2.5-6.6 mmol/L
Creat 60-120 umol/L
Na 135-148 mmol/L
K 3.5-5.3 mmol/L
Cl 98-110 mmol/L
HCO3 22-30 mmol/L
Phos 0.8-1.4 mmol/L
Albumin 35-47 g/L
Corrected Ca 2.2-2.6 mmol/L
Total Protein 63-80 g/L
Mg 0.74-0.99 mmol/L
T.Bil 3-20 umol/L
D. Bil 0-5 umol/L
ALP 26-88 IU/L
ALT 10-60 IU/L
AST 10-42 IU/L
Troponin 0-0.1 ng/mL
CK 22-269 IU/L
CK-MB Up to 6.5% of Total CK
Amylase 30-110 IU/L
TSH 0.27-4.2 IU/mL
Free T4 7.8-16 pmol/L
LDH 90-180 IU/L
PCT 0-0.5 ng/mL
pH 7.35-7.45
pO2 11-14.4 kPa
pCO2 4.6-6 kPa

GLASGOW COMA SCALE

The Glasgow coma scale (GCS) is an objective method used to describe a patient’s level of consciousness. It is mainly used for acutely ill patients and patients with traumatic brain injury (TBI). It is also used for repeated bedside assessment for the patients.

The GCS is divided into 3 categories: Eye opening (E), motor response (M), and verbal response (V). Therefore, GCS= E+M+V.

Important points to consider:

  • Choose the “best” maximum response

  • Do not assess the limb with an underlying musculoskeletal deficit, e.g. trauma or previous neurological disability

  • Non-intubated patients can have a maximum score of 15 and a minimum score of 3

    • However, in intubated patients, the suffix ‘T’ is added to indicate intubation. These patients have a maximum score of 10T and a minimum of 2T.

References:

  • Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975; 1(7905): 480-4.

  • Ameer Khalek. Keep it simple: acute GCS score as a binary decision. https://smhs.gwu.edu/urgentmatters/news/keep-it-simple-acute-gcs-score-binary-decision (accessed 17th November 2017).

Khalek, A. (2017, March 6). Keep it simple: acute GCS score as a binary decision. Retrieved from https://smhs.gwu.edu

INTERN SURVIVAL GUIDE

Third Edition

Executive Editors

Dalal Farman

Fahd A. al-Saleh

Managing Editor

Fatemah Khadadah

Editors

Rawan al-Yousef

Mohammad al-Hunaidi

Abdullah al-Awadhi

Dalal al-Ahmadi

Muneera al-Shaheen

Fatemah Fakhra

Editors of previous editions

Marwan Alqunaee

Abdulaziz Karam

Sulaiman Alrasheedi

Farah Albader

Fatimah Alabdulrazaq

Proof Reader

Dr Shamlan D. al-Qenaie

Assistant professor of (Applied) Linguistics and Translation

Department of English language and literature

Kuwait University

Reviewers

Prof Adel Ayed

Dean of the Faculty of Medicine, Kuwait University

Consultant Thoracic Surgeon, Chest Disease Hospital

Prof Sami Asfar

Professor of Surgery, Kuwait University

Consultant General Surgeon, Mubarak al-Kabeer Hospital

Dr Mervat al-Saleh

Associate Professor of Surgery, Kuwait University

Consultant General Surgeon, Mubarak al-Kabeer Hospital

Dr Ibtisam al-Bader

Assistant Professor of Surgery, Kuwait University

Consultant General Surgeon, Mubarak al-Kabeer Hospital

Prof Mousa Khadadah

Professor of Medicine, Kuwait University

Consultant Respirologist, Mubarak al-Kabeer Hospital

Dr Ebaa al-Ozairi

Associate Professor of Medicine, Kuwait University

Consultant Diabetologist, Mubarak al-Kabeer Hospital

Dr Saad al-Dosari

Assistant Professor of Urology, Kuwait University

Specialist Urologist, Mubarak al-Kabeer Hospital

Fatoumah Alabdulrazaq

Consultant Paediatrician

Head of Paediatric Casualty Department, Al-Amiri Hospital

© 2014, 2016, 2018 Intern Survival Guide Compilation Team

Kuwait

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the copyright owner.

First edition published: September 2014

Second edition published: January 2016

Third Edition Published: May 2018

ISBN:

First Edition: 978-99966-0-655-7

Second Edition: 978-99906-1-189-2

Third Edition: Pending Registration

The information contained within this book was compiled from reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage, or injury occasioned by any person acting or refraining from action as a result of information contained herein can be accepted by the team.

For inquiries, please feel free to contact us on:

internguidekuwait@gmail.com

PREFACE

“Any fool can know. The point is to understand.”

― Albert Einstein

It is with pleasure that I introduce this pocket guide. As the Dean of the Faculty of Medicine at Kuwait University, I have a personal connection to the guide - its potential readers are my current students.

This guide, a precise and concise one, is designed to guide interns through some of the most commonly encountered clinical challenges. I see it elevating the level of patient care by interns to an excellent standard. The reader will find herein routine clinical work explained, practical procedures described, common drugs used with doses, electrolyte disturbances, and other common clinical issues described to reflect current knowledge of problems and patient care.

The special notes on clinical activities serve to alert the interns to important information that would assist them in anticipating and predicting the various patient needs.

It also helps the interns in assessing individual needs unique to surgical patients by developing a plan of care according to international safe standards.

This booklet is not intended to replace a more substantive medical text but to supplement it. As the quote above suggests, you not only have to know but also to understand--- to understand is to know better; when you know better you’ll do better.

I hope the information presented here will serve as a generally applicable foundation upon which to build.

Prof. Adel Khader Ayed

Dean of Faculty of Medicine

Kuwait University

Kuwait

FOREWORD

Congratulations!

You’ve done it! After drudging through years of stress, late night study, exams, OSCEs, and endless PBLs you have successfully obtained an undergraduate medical degree! You are a star!

And now you are also an intern! You’re starting something entirely new. You may not feel entirely certain of what the internship year entails, certainly few of us did before actually starting. You might’ve never prescribed anything before and suddenly find yourself having to write down doses and quantities. You may also have finished medical school abroad and suddenly find yourself in an entirely new medical culture. You are expected to collaborate effectively with all sorts of healthcare workers ensuring your patients receive the best outcome. You’ll have to accommodate people with different personalities. Some you’ve never encountered before! – and to people from different backgrounds.

The first few months can be quite challenging. People who do extremely well are those who reflect on their specific weaknesses and ask for advice. Others may develop compensation strategies through persistently blaming a failing medical system. At the intern level, your role consists of navigating this medical maze, demonstrating your professionalism, encouraging and being there for your peers and colleagues, and, most crucial of all strongly advocating for your patients.

This is the third edition of our guide. Again, there is yet to be a formal educational programme at the level of interns. We hope with this book to fill a part of this gap in healthcare and medical education. We also hope to empower interns to make the effort to assume greater responsibility and become more independent in their practice. Again, we must reiterate that this is merely a guide and does not in any way alter or supplant the plan of someone more senior and experienced. We remain, as before, indebted to the people who have made this happen Dr. Medhat Mokhtar, Dr. Ebaa al-Ozairi and Professor Sami Asfar for helping us in both the first and second editions. Also for Dr. Mervat al-Saleh and Dr. Ibtisam al-Bader for making the second and third editions edition possible.

In the third edition we aimed to perfect what we did previously. We reviewed and updated all the content to the latest guidelines. Multiple additions were added to all the different sections of the book. We hope that the book will aid you on your endeavours in the wards.

Should you have any concerns or comments, regarding this book or intern year as a whole, or regarding other specific matters please feel entirely free to email, Instagram or tweet us.

Wishing you the best,

Your Survival Team

Above is a Quick Response (QR) Code, it is a type of matrix barcode used to store different types of electronic information. You will find these barcodes scattered in this book and each, when scanned, will provide a direct link to a location or electronic file. There are many scanning applications that can be found on the Apple App store and Google Play store for both iOS and Android devices, respectively.

Try it out, scan the above QR code and follow us on Instagram!

Abbreviations
ABG Air Blood Gas
ACE Angiotensinogen Converting Enzyme
ACS Acute Coronary Syndrome
A-fib Atrial fibrillation
ATLS Advanced Trauma Life Support
BP Blood Pressure
C/S Culture and Sensitivity
Ca++ Calcium
CBC Complete Blood Count
CRP C Reactive Protein
CVA Cerebrovascular Accident
CXR Chest X-ray
DVT Deep Vein Thrombosis
FFP Fresh Frozen Plasma
GTN Glyceryl Trinitrate
HF Heart Failure
HR Heart Rate
HTN Hypertension
IBD Inflammatory Bowel Disease
ICH Intracranial Haemorrhage
IM Intramuscular
INR International Normalised Ratio
IV Intravenous
JVP Jugular Venous Pressure
K+ Potassium
LFT Liver Function Test
LOC Loss of Consciousness
Mg+ Magnesium
MgSO4 Magnesium Sulphate
MOH Ministry of Health
Na+ Sodium
NGT Naso-gastric Tube
NSAID Non-Steroidal Anti Inflammatory Drug
OPD Outpatient Department
PCT Procalcitonin
PTH Parathyroid Hormone
RFT Renal Function Tests
RR Respiratory Rate
RRT Renal Replacement Therapy
SC Subcutaneous
SVT Supraventricular Tachycardia
TIA Transient Ischaemic Attack
UC Ulcerative Colitis
UTI Urinary Tract Infection

TABLE OF CONTENTS

1: STARTING THE INTERNSHIP YEAR 17
2: A NOTE ON DOCUMENTATION 37
3: CLINICAL ACTIVITIES 71
4: COMMON MEDICATIONS 97
5: COMMON WARD CALLS 133
6: IMPORTANT PHONE NUMBERS 201
7: ENDING THE INTERNSHIP YEAR 217
8: APPENDIX 219



GENERAL LAYOUT OF THE INTERNSHIP YEAR

Overall Layout:

Intern year is run by KIMS (Kuwait Institute for Medical Specialisation). After completing the employment process, which will take you a month or two on average, you need to register with KIMS. You then select the hospital you like to join. If it is full you will get allocated according to availability in other hospitals. The year consists of 4 months in General Medicine, 4 months in General Surgery, 1 month in Paediatrics, and 1 in Obstetrics/Gynaecology. You will have two months to do an elective of your choice. You can do these rotations in different order according to availability and preference.

Vacations:

  • Total vacation days: 30 days/year

    • You get 45 days a year, but can only use 30 if you are an intern or a resident

  • Sick leaves: 15 days / year

  • Excused absences: 4 days / month

You cannot take a vacation during the first 6 months of practice or during any one-month elective. You can, however, take time off between electives. If you do this, it will prolong your internship year by the same amount of time you took off. You have a total of one month’s leave during your first year, which if you take will result in the on-call allowance being deducted.

You also have 45 days total of study leave or leave for exam purposes. The last day of your vacation will be that of your exam.

Electives:

You need at least a verbal permission before applying for an elective at KIMS. You cannot do one block of two-month rotation. You will need to do two one-month rotations. It is not allowed to do electives abroad at intern level.

End of Rotation:

Make sure you have all your evaluation forms completed and signed along with your notes and discharge summaries. You then need to submit them to KIMS.

End of year:

There is a good amount of paperwork to be completed at the end of intern year. It would be wise to start a few weeks before the end of the last rotation. Your first step is KIMS followed by the Ministry of Health.

Pregnancy/Breastfeeding:

On call exemption:

  • You can be exempt from on calls starting at the seventh month of pregnancy until your child is 1-year-old. You must inform the ministry as your on-call salary (250 KD) will be deducted from your monthly salary.

Work leave during pregnancy:

  • You will be eligible for Medical-Council-approved leave from 7 months of pregnancy onwards. Without the council’s approval, you are not granted a leave.

Maternity leave:

  • As for maternity leave, you are paid a full salary for the first month post-delivery. For the following 3 months off, if you take the leave, you are paid half-salary.

Shorter work days for breastfeeding time:

  • You are granted 2 hours off at the beginning or at the end of the workday. You have this right until your child is 2 years old. You will still receive a full salary during this time.

CANMEDS FRAMEWORK

It is a framework that identifies and describes the abilities physicians require to effectively meet the health care needs of the people they serve. This is a very effective guide for the intern to know how to become a medical expert in his working life.

The CanMEDS roles:

  1. Medical Expert: integrating all CanMEDS elements in the working life

  2. Communicator: forming a trust-based relationship between you and the patient and his family members

  3. Collaborator: working effectively with other healthcare professionals

  4. Leader: As Engaging with others to contribute in and provide a high-quality healthcare system.

  5. Health Advocate: As understanding the needs of others and speak on behalf of them when required.

  6. Scholar: As committing to a life long continuous learning, teaching, and evaluation of evidence.

  7. Professional: by having a high standard set of ethical practices, behavior and maintenance of personal health.

Reference

http://www.royalcollege.ca/rcsite/canmeds-e

EMPLOYMENT PROCESS

Before starting the employment process, be sure to have realistic expectations about the process. You will hear many stories and anecdotes about how bad or good the process is. Take everything with a grain of salt, breathe, and start your journey.

Tips:

  • Before starting the process:

    • Have 15-20 copies of your personal photo (this may seem like an exaggeration, but by the time you finish, you’ll find that you have used them all).

    • Make multiple copies of your civil ID, passport, birth certificate, citizenship, transcripts, and diploma (if you have it at the time).

  • During the process:

    • Have a folder to hold all important documents and take it with you to everything. In the folder, be sure to keep extra copies of your civil ID, passport, citizenship, birth certificate, transcripts (in English & Arabic), diploma, bank statements, and plenty copies of your personal photo. You never know when you might need them and you can’t count on people having a photocopier. If you have everything handy, you will be able to complete each tedious task faster.

    • Document everything – take photos of the papers you receive. You never know when this might come in handy. It also protects you from anyone claiming they gave you a document they never did. Some documents are irreplaceable.

    • Map out your route. Google every location and make sure you are going to the right place ahead of time as traffic and short working hours will hinder your productivity.

    • Take contact numbers of people in the ministry, KIMS, and your hospital Health Area to follow up on things over the phone or double check what you need prior to making the long drives to them.

    • Start your days early in the morning to be able to run multiple errands in the same day.


Steps in summary:

In order:

  1. Obtain medical school transcripts & diploma

  2. Civil service commission

  3. Ministry of Health

In any order:

  • Medical Council Center

  • Bank of choice

  • Forensic Medicine Center

  • Ministry of Justice

  • For married doctors:

    • PACI

    • Kuwait Credit & Saving Bank

In order:

  1. KMA

  2. Medical Licensing Center

Once all the above is complete:

  1. MoH (twice)

  2. KIMS (twice)

  3. Health Area

  4. Hospital Director

  5. Secretary of Dept of starting rotation

Medical School Transcripts & Diploma

Kuwait Grads - Kuwait University (Registration & Admissions Office, Shuwaikh)

International Medical Grads - Ministry of Higher Education

Civil ID

You will receive:

Transcripts (English & Arabic)
1-2 days

Civil Service Commission

Office Hours: 8 AM – 1.30 PM

Civil ID

Transcript/Diploma

You will receive:

Application receipt to be given to MoH
30 minutes

Ministry of Health (MoH)

Office Hours: 7.30 AM – 1PM

3 x Transcripts / diploma

3 x Citizenship

3 x Birth certificate

3 x Civil ID

3 x Personal photos

For married doctors:

  • Marriage certificate

  • Spouse’s civil ID

  • Children’s civil IDs and birth certificates

  • Civil status document

You will receive:

A proposal to the medical licensing center

A request for the medical council for your health check

A request for the forensic center for proof of good standing
1 hour

Tips:

  • Arrive early

  • Remember the person who opens your file for you, take their contact information to follow up on your paperwork instead of going to the ministry. They will be responsible for your file in the Ministry

Medical Council Center

Office Hours: 9 AM – 1.30 PM

The request paper given to you from the ministry

Any proof of HBV vaccination (recent/during medical school)

3 personal photos

You will receive:

Proof of Health Status and Clearance to work

1 – 1.5 hours at the center (blood collection, physical)

7-10 days for documents to be ready (there is a high likelihood your results will be ready before then, so follow up on your results)

Steps:

  • Arrive before 12PM as they do not take blood sample after then. It’s advised to come early to finish early

  • Go to counter 25 to hand in your request. You will be directed to the medical room where your blood sample will be drawn. Women, they will ask you if you’re married or pregnant

  • You will be taken to a room to have your vaccination history taken, given boosters, and undergo a vision test.

  • You will be given: a chest xray and urinalysis request, and vaccination form

  • Get a chest xray report and urinalysis from your local clinic or hospital. You can go to the hospital’s vaccination room/preventive medicine department to get your vaccinations. Bring the results with you when you pick up your blood results

Kuwait Medical Association (KMA)

Office Hours: 8 AM – 2 PM / 4 PM – 9 PM

Proposal for medical license (given to you from MoH)

Copy of civil ID

Copy of citizenship

Copy of transcripts

Copy of diploma

3 personal photos

26 KD (annual membership fee)

You will receive:

Application paper to print your KMA ID (fill this out after obtaining your CME and Serial Number from MoH)
30 mins

***

You must go to KMA before going to the Medical Licensing Center

***

Medical Licensing Center

Office Hours: 9 AM – 1 PM

Copy of civil ID

Copy of citizenship

Copy of transcript / diploma

KMA membership

3 personal photos

20 KD

You will receive:

Your medical license

(keep this safe as it is not reproducible)

30 mins

3 – 5 days to receive your license

You can do the following steps in any order

Tip:

  • Do this while you wait a week for your Medical Council papers to finish

Bank Salary Transfer Certificate

Go to your bank of choice and request this certificate for the account to which you want your salary to be transferred

Forensic Medicine Center

The request paper from the MoH

Copy of civil ID

1 Personal Photo

You will receive:

Proof of good standing
30 mins

Ministry of Justice

2nd Floor, Ministries Complex. Office Hours: 8 AM – 2 PM

Civil ID

Spouse’s civil ID (if married)

1 KD (cash)

You will receive:

Proof that you do not have any real estate in your / your spouse’s name (this info is needed for the salary department in the MoH).
15 mins

For married Doctors only

The Public Authority for Civil Information (PACI)

Working Hours: 8AM – 1PM / 2PM – 8PM)

Location: Ministries Zone – Zahra, South Surra

Civil ID

1 KD (cash)

You will receive:

Proof of civil status
On the spot

Kuwait Credit & Saving Bank

Location: Kuwait City, Working Hours: 8 AM – 2 PM

Civil ID

1 KD (cash)

You will receive:

Proof that you and your spouse do not have a real estate loan
On the spot

Ministry of Health

Medical Council health clearance

Medical License

Proof of good standing (Forensic Medicine)

Salary transfer certificate

Proof of real estate status

For married doctors:

  • Proof of civil status

  • Proof of loan status

  • Marriage certificate

You will receive:

Employment Letter

Serial number

15 mins to hand in papers

5-7 days for your employment application to be approved

***

You must do the next step within 1 month of getting MoH Employment Letter

***

KIMS

Civil ID

Personal photo

Employment Letter

Submit your Employment Letter from MoH

Choose your hospital and rotation schedule

You will receive:

Proof that you and your spouse do not have a real estate loan
1 day (to receive your approval letter to give to your hospital)

At 8 AM on your starting date, go to KIMS to pick up your employment letter addressed to your hospital of choice. You can arrive late on your first day of work to finish your paperwork.

Health Area of your hospital of choice – submit the KIMS paper

Tip: take a staff member’s contact info to follow up on your salary by phone.

Secretary of the department of your first rotation – submit approval papers from the Health Area.

Congrats! You are now a practicing doctor!

After Employment you need to make sure that your initiation letter is sent from the hospital to the Ministry of Health to ensure receiving your salary. The letter will pass through these stops:

Head of Department -> Director of Hospital -> Head of Health Area -> KIMS -> MOH (Employment Department) -> MOH (Financial Department)

Your first salary should be received after the initiation letter passes through all check-points which may take up to 3 months, sometimes more. It is best to keep track from time to time to make sure everything is going according to plan.

EMPLOYMENT LOCATIONS

Ministry of Health

Address: Jamal Abdulnasser St, Sulaibikhat

Website: moh.gov.kw

Google maps location: http://goo.gl/maps/HbCJZ

Contact Number: 24878168 / 24878422

Kuwait Institute for Medical Specialisation (KIMS)

Address: Behbehani Complex, Jaber Al-Mubarak St, Kuwait City

Website: http://www.kims.org.kw/

Google maps location: http://goo.gl/maps/JX4U0

Contact Number: 2418782

Kuwait Medical Association (KMA)

Address: Street 102, Jabriya (Next to Mubarak Hospital)

Website: http://www.kma.org.kw/

Google maps location: http://goo.gl/maps/g3djW

Contact Number: 1881181

Ministry of Higher Education

Address: Sanabil Tower, Sharq

Website: http://www.mohe.edu.kw/site/

Google maps location: http://goo.gl/maps/qQaIp

Contact Number: 1882020

Civil Service Commission

Address: Airport Road, Shuwaikh

Website: www.csc.net.kw

Google maps location: http://goo.gl/maps/xV5Xj

Contact Number: 223333333 / 133

Ministry of Justice

Address: Ministries complex, Kuwait city

Website: https://www.kuwaitcourts.gov.kw/

Google maps location: http://goo.gl/maps/rQFcs

Contact Number: 22486248 / 22486256 

General Medical Council

Address: Sabah Health Area, Shuwaikh

Google maps location: http://goo.gl/maps/Qr6Nh

Medical Licensing Management

Address: Amr Bin Al-Aas St, Salmiya

Google maps location: http://goo.gl/maps/FzRlS

Hawali Health area

Address: Street 109, Jabriya (Next to Mubarak Hospital)

Google maps location: http://goo.gl/maps/FA0iL

Al-Asimah Health area

Address: Shamlan bin Saif St, Al-Nuzha

Google maps location: https://goo.gl/maps/nc6oqtEo6G72


Al-Farwaniya Health area

Address: Sabah Al-Nasser area (Next to Al-Farwaniya Hospital)

Google maps location: http://goo.gl/maps/7sfwf

Al-Ahmadi Health area

Address: Al-Hadiya (next to Adan Hospital)

Google maps location: http://goo.gl/maps/uiQO7

Al-Sabah Health area

Address: Sabah Health Area, Shuwaikh

Google maps location: http://goo.gl/maps/Qr6Nh

Al-Jahra’a Health area

Address: Bisher Bin Awanah St (Next to Al-Jahra’a Hospital)

Google maps location: http://goo.gl/maps/N4UDH

MINISTRY OF INTERIOR FINGERPRINT OFFICE

Al-Asimah + Hawali

Address: Khalid Ibn Alwalid St, Kuwait city

Google maps location: https://goo.gl/maps/y2RgShCKfCu

Al-Farwaniya

Address: 105 St, Block 5, Al-Farwaniya

Google maps location: https://goo.gl/maps/vY7hm3RVkW32

Mubarak Al-Kabeer

Address: 20 St, Block 3, Al-Adan

Google maps location: https://goo.gl/maps/y2RgShCKfCu

Al-Ahmadi

Address: 17 St, Block 4, Al-Mangaf

Google maps location: https://goo.gl/maps/HkyBgZTS8Hu

Al-Jahra’a

Address: Jada 1, St 3, Block 4, Al-Jahra

Google maps location:

http://goo.gl/Gng3x5

INTERN DUTIES

Duties that are required from an intern are listed below:

  • Participate as part of the team and to engage in educational discussions.

  • Clerical work (patient admissions, discharges, requests, and consultation).

  • Daily progress notes and patient follow up.

  • Ensure that correct diagnostic and therapeutic plans are followed.

  • Diagnose and treat patients under supervision.

  • Performing bed side procedures such as those listed in the clinical activities section.

  • History presentation during rounds.

  • Academic presentations with unit and department.

  • Evening and weekend rounds (in certain departments and hospitals).

  • Responding to ward calls.

  • Interpret findings and lab results and report to senior members of the team.

  • Liaise with other specialties and departments.

While on call, it is not your right or responsibility to do things you are not called for. If a patient/family member asks you to tell them their lab results, final diagnosis, give your opinion, you can discuss general things but when they go into detailed discussion you must politely state ‘I am the doctor on call, I am here for emergencies. Please discuss this with your unit doctors in the morning, I cannot override their authority.’

In the end, an intern is expected to be respectful, responsible, kind, honest and most important of them all to provide quality patient care in a professional environment.

INTERN EVALUATION

During each rotation of the internship year, the intern will be evaluated twice: midpoint during their rotation and at the end of the rotation. These are known as In-Training Evaluation Report (ITER) (ITER-MID and ITER-END respectively). The candidate will be assessed based on three main categories: Professionalism, Communication, and Patient care and Knowledge.

Professionalism
Availability Punctuality in attendance
Reliability Responsible, provide good care
Integrity Honest, admits errors, attempts at improvement
Appearance and behaviour Wears a visible ID card, Adheres to dress code (shirt, tie, white coat), Treat patient and family with dignity and respect
Communication skills
With patient Respectful, compassionate and clear
With team Respectful to level, effective information exchange
Patient care and knowledge
Information gathering skills

Proper clerical work and records updating

Accurate and identifies errors
Assessment and data analysis Proper investigations according to patient information and preferences
Clinical work and technical skills

Demonstrate appropriate knowledge base

Follow hospital policies

Proper coordination with health care professionals
Learning

Initiative to improve

Receptiveness towards guidance

Presentation at round and departmental meetings

The intern is marked based on the above-mentioned criteria. Each criteria is given a mark of 1-3 with an overall minimum of 10 and a maximum of 30. An intern must achieve 15 marks to pass the rotation. Below is the marking grade:

Pass Fail
Average Good Very good Excellent Poor
15-17 18-22 23-27 28-30 10-14

The evaluation form ends with a comment from the Consultant/Senior and must be signed by the intern, Consultant/Senior and hospital Intern Supervisor before submitting it to KIMS.

MEDICAL RECORD SHEETS (MR PAPER)

Documenting is the most important thing you will do as a junior doctor. It is also one of the first things that will be reviewed in medico-legal incidents. Thus, to protect your patients and yourselves you should make documenting a thriving habit!

You will use different medical record papers each assigned a different number and designed to serve a specific purpose. The different papers are mentioned in the table below and their titles are self-explanatory with respect to their function.

MR Number Function
MR-1 Outpatient record
MR-2 Unit summary sheet
MR-3 Casualty sheet
MR-4 Admission slip
MR-5 Consent form
MR-6 Referring letter
MR-7 Clinical history/Physical examination
MR-8 Clinical progression sheet
MR-9 Consultation sheet
MR-10 Operation sheet
MR-11 Paramedical sheet
MR-12 Treatment plan
MR-13 Discharge summary


SOAP NOTES

SOAP (Subjective, Objective, Assessment, Plan) is a unified method in writing and documenting a patient’s daily progression from admission to discharge. It organises and keeps all the relevant information in a consistent format regardless of who has written the notes.

Title:

  • Start with date and time, followed by your unit’s name and senior/consultant in charge of rounds.

Opening statement:

  • e.g. This is a 23-year-old female admitted as an acute appendicitis and is currently day 2 post her emergency appendectomy.

Subjective:

  • Write the patient’s own subjective reflection regarding their condition.

    • Are they well, not well, improving, or getting worse?

    • Are they symptomatic, tolerating oral fluids/diet?

    • Any new complaints?

    • Are they passing urine and stool/flatus?

Objective:

  • Write the objective elements of the patient that you would collect:

    • Vitals (BP, Temp, HR, RR, SpO2)

    • Input/output charts

    • Drain output (amount and type)

    • Physical examination

    • Lab results

Assessment/Active Issues:

  • Write the overall differential diagnosis of the above findings

  • Or write a quick one-line summary of the patient’s condition

  • In the Internal Medicine department, they tend to write down all the active issues of the patient in this section

Plan:

  • Outline the daily tasks to be completed

ON-CALL NOTES

You will see and review many cases during your on-calls thus your notes need to be clear and thorough to allow other treating units a smoother follow up of the patient.

If patient is unwell/unstable, ask for help!

First, write your unit’s name at the top along with the date/time:

  • e.g. Medical/Surgical Unit “X” On-Call

Then the opening statement:

  • e.g. I was called to see this 56-year-old male known case of type 2 diabetes and hypertension who was admitted on 29/10/2014 as a case of chest infection

Then write the reason for the call:

  • e.g. Reason for call was that the patient is complaining of chest pain

Then write what you see when you interview the patient:

  • How is the patient sitting? (e.g. upright)

  • Does s/he look well/unwell?

  • Is s/he connected to a monitor or/and O2 via facemask?

  • Vitals (BP, Temp, HR, RR, SpO2) + Random Blood Glucose

History of presenting complaint:

  • Focus history of the above-mentioned symptoms

Physical examination:

  • Focus on the main system of the complaint

  • Quick examination of all other symptoms

Investigations:

  • ECG

  • Lab results, etc…

Impression:

  • e.g., Acute Coronary Syndrome

Plan:

  • Clearly write all investigations to be sent (and why), medications to be given, and any further interventions needed.

  • Always contact senior members of the team

***Don’t forget to sign and stamp***

CONSULTATION/RADIOLOGY REQUEST

In urgent consultations contact the consulting doctor by phone along with paper consultation

Nearly every day as an intern in Kuwait you will be asked to send consults to the different departments and subspecialties. The definition of a consult is to seek information or advice from someone with expertise in a particular area. Thus, to get the information you need, your consult must be written correctly and should have a valid and relevant question to be answered. Writing “For your kind care and assessment” as many do is not sufficient. You need to guide the consulting service as to what is it you seek to avoid re-consults. Bear in mind that a radiology request is a consult.

Steps of writing a consult:

  • Step 1: Identifying the consulting service

  • Step 2: Background history

  • Step 3: Presentation

  • Step 4: Clinical course

  • Step 5: Relevant current investigations/management

  • Step 6: The question/request

***Lastly, thank the consulting team, sign and stamp, and add your/senior’s number in case they need to contact someone***


Example of a consult:

Respiratory unit

Dear colleague,

This is a 54 years old male with a known history of:

  • Hypertension (on amlodipine)

  • Diabetes mellitus type 2 (on metformin)

  • Total thyroidectomy for papillary carcinoma (on thyroxine replacement therapy)

Patient presented to the emergency department with haemoptysis associated with a progressively worsening cough and shortness of breath. Chest x-ray showed multiple opacities bilaterally. She was admitted and kept NPO, on IV fluids and empirical antibiotic cover. Before starting antibiotics full septic workup with AFB smears and cultures were taken. CT scan of the chest shows multiple foci in both lungs and a large mass in the right main bronchus. Advised for tissue sampling through bronchoscopy and PET scan for staging.

May you kindly see this patient for arrangement for bronchoscopy to obtain a tissue sample for histopathological assessment?

Thank you

Patient PACS number for Chest x-ray and CT: F563412

Dr. Intern, phone number xx-xxx-xxx

Signature and stamp


CLINICAL COMMUNICATION (ISBAR)

Communication is a critical and vital process in the medical field. A major emphasis is applied on patient-staff communication but where a lot of mistakes occur is among health care workers. As stressed upon in the communicator heading in the CanMeds framework. As in intern one of the many jobs that will be assigned to you is requesting the opinion or assessment of another service whether it’s arranging an urgent CT brain for a patient or calling the ICU team for assessment. At this point things can go horribly wrong for the intern and other staff in general.

There are many communication frameworks and protocols but the ISBAR is a simplified way of ensuring your patient doesn’t come to harm due to ineffective communication:

SBAR was first developed by the military, specifically for nuclear submarines. It was then used in the aviation industry, which adopted a similar model before it was put into use in health care. It was introduced to rapid response teams (RRT) at Kaiser Permanente in Colorado in 2002, to investigate patient safety. The main purpose was to alleviate communication problems traced from the differences in communication styles between healthcare professionals. SBAR was later adopted by many other health care organizations. It is among the most popular handover mnemonic systems in use

I Identify Who you are and what is your role? Patient identifiers (at least 3)
S Situation What is going on with the patient?
B Background What is the clinical background/context?
A Assessment What do I think the problem is?
R Recommendation

What would you recommend?

Risks- patient/occupational health and safety? Assign and accept responsibility/accountability

Below is an example of what a typical phone communication with the radiologist should be for arranging an imaging study for your patient.

I

Good morning Dr. John my name is Dr. Lulwa and I am an intern in Unit B from the medical department.

I am calling regarding Mr. X a 65-year-old gentleman in ward 8
S Today he started complaining of new onset left sided upper and lower limb weakness.
B He was admitted 3 days ago with community acquired pneumonia and is known to have DM type 2, hypertension and atrial fibrillation on oral anticoagulation
A On examination the power in both left upper limb and lower limb is 2/5
R May I arrange a CT brain to rule out a CVA

Keep it brief and to the point. Remember you are not the only person calling the radiologist so make sure your case is urgent and not routine that could wait for an appointment.

Reference:

  1. Pope, BB; Rodzen, L; Spross, G (March 2008). "Raising the SBAR: how better communication improves patient outcomes". Nursing. 38 (3): 41–3. doi:10.1097/01.NURSE.0000312625.74434.e8. PMID 18418180.

  2. Stewart, K. R. (September–October 2017). "SBAR, Communication, and Patient Safety: An Integrated Literature Review" (Vol. 26/No. 5): 297–305.

  3. Riesenberg, L. A.; Leitzsch, J.; Little, B. W. (2009). "Systematic review of handoff mnemonics literature". American Journal of Medical Quality. 24 (3): 196–204. doi:10.1177/1062860609332512. PMID 19269930.

DISCHARGE

1. Medications

  • Print the medications (It is preferable you do this first in order to avoid long waiting times for the patient, and because the pharmacy closes at 1/2pm)

2. Discharge Summary (See MR13 form in hospital)

  • Always start the discharge with:

    • Diagnosis: e.g. Exacerbation of Crohn’s disease

  • If surgical discharge add:

    • Operation: e.g. Small bowel resection on 14/4/2015

  • Followed by Steps 2-6 from ‘How to write a consult’ (pg. xx)

  • Follow-up clinical course from admission to the day of discharge and check whether patient is fit for discharge on the stated day or not.

  • Then you must write a plan for discharge

    • Plan: e.g.

      • Follow up in OPD with Dr. Khalid in 2 weeks

      • Continue Adalimumab (Humira) injections once every 2 weeks

      • Avoid NSAIDS

  • Medications: you must document all discharge medications

  • If using computerised system, it is advised to write/save the discharge summary on a word processing software before transferring to the Hospital Information System (HIS) to avoid lost data due to system failure.

3. Any Follow up appointments/OPD referrals or investigations to do

4. Discharge from the system in the computer: Go to ‘mode of discharge’ and select ‘routine’ (skip if no HIS system available)

5. MR4:

  • Fill in this form with the final diagnosis for the patient to take to the cashier with their Civil ID before they can go home.

  • Sick leave document should be printed before finishing the MR4 paper at the cashier

    • From 1-3 days the signature of only one doctor is needed

    • From 3-5 days the signature of two doctors is needed

    • If >5 days then signature of two doctors, one being a senior registrar, and the hospital director is needed

PRESCRIBING MEDICATIONS

During your intern year, you will be exposed to the prescription form, commonly known as the “unit-dose” in some hospitals. It is a unified form across all hospitals in Kuwait. In it, you write the medications to be dispensed to the patient during their in-hospital stay, along with the route and frequency. The form contains sections for regular medications, as required medications, medications with changing or variable doses, and once-off medications. The form also contains sections for writing a patient’s discharge medications, but the computer-based print-out is now commonly used in nearly all hospitals.

Rules regarding writing a medication in the prescription form:

  • Use generic names

  • Use clear handwriting and use capitalised letters

  • Clearly state the dose, route, and frequency (with times)

  • Write the date of starting the medication (especially for antibiotics)

  • PRN medications should be written in the “As required” section only and must specify directions (do not use S.O.S.)

  • Do not write “U” or “iU” for insulin, always write “Units”

  • Do not write “mcg” always write “micrograms”

  • Cross-out the entire row when discontinuing medications

  • Specify the exact strength or dose for IV, inhaled, or syrup preparations as different preparations exist

  • Date, sign, and stamp


Below are examples:

CONTROLLED MEDICATIONS

To control the use of certain medications the Ministry of Health developed different forms to keep track of these medications usage. The aim of these forms is to control the usage, to avoid over-use, and to monitor and prevent potential medico-legal issues. Below is a small list of medications under the umbrella of controlled medications:

Opiates:

  • Tramadol (brand name Tramal)

  • Morphine

  • Pethidine

Benzodiazepines:

  • Midazolam (brand name Dormicum)

  • Diazepam (brand name Valium)

  • Alprazolam (brand name Xanax)

The forms are divided per drug and are usually available with the nursing staff. These forms are self-explanatory and easy to fill. They are usually checked by the pharmacy staff during their routine medication stocking visit. As we mentioned before discrepancies are usually followed for medico-legal purposes.

Below are a few important tips regarding filling up these forms:

  • You must use clear handwriting using black or blue pens only.

  • Some forms provide both English and Arabic fields and some only provide Arabic. Arabic-only forms should be filled in Arabic only.

  • Medication names and doses should be written in English using capital letters.

    • Even on Arabic-only forms.

  • Each page is numbered and any lost pages are investigated. If a mistake was made you either cross is out and correct it or, if many mistakes have been made you need to cross out the entire page and start filling a new one.

    • Never rip a page from the controlled medications form book and throw it away.

  • Each form needs to be signed and stamped. If any discards are done, then the dose given and dose discarded should be stamped on the form.

  • Always fill these forms yourself and do not stamp on blank forms or forms filled by others, whether fellow doctors or nurses.

  • Any blank spaces need to be crossed to prevent tampering.

Below is an example of a controlled medication form:


DEATH CERTIFICATE

In the unfortunate event that a patient passes away a death certificate and associated forms are required to be filled by the treating or covering doctor. They are three forms in total. First, the Death Certificate in which you announce the patient’s unfortunate death and specify the cause. The second form is a notice to the public relations officers (PRO) informing him of the death so they can take all relevant actions. Third and final form is a burial declaration in which you give the mortician access for burial preparations.

The first form is divided into two main sections. Section one the patient’s details (and parental details if paediatric) and section two the cause of death. In section one you are only expected to fill the patient’s details (Parents if paediatric) the rest will be filled by the public relations officer (PRO). Section two contains two columns for those aged 1 week or more or less than 1 week. The majority of times you tend to fill forms for those 1 week and older. The form requires you to state a primary cause, an intermediate cause and original reason for admission.

  • Primary cause: The condition that caused death (must not be too general)

  • Intermediate cause: any co-morbidities or events that lead to the death

  • Admission diagnosis

Then you need to fill in other medical and surgical co-morbidities which were not directly linked to the cause of death.

Finally, you need to sign and stamp on all five carbon copies.

For form number two you need to fill the upper part only, the PRO handles the rest. For form three, you need to fill sections 1 and 2. These two forms are self-explanatory and easy to fill. Do not forget to sign and stamp all carbon copies.

The forms and areas to be filled are seen in the next page.

Form one:

Form two:

From Three:


INFORMED CONSENT

As a rule, all the following points should be taken into consideration when obtaining informed consent:

  • Capacity to consent. In Kuwait, a patient is deemed capable if above the age of 21 with the ability to fully understand and digest the information being told.

  • If younger than 21, the father’s consent is required. If the father is not present or cannot consent, then the paternal grandfather, then elder full brothers, then paternal half-brothers, then paternal uncles, then paternal cousins.

  • For a married female below the age of 21 years of age, consent is legally transferred to her husband unless he is below 21 years of age. If so, then follow the above statement.

  • For the elderly, those with a known history of reduced capacity before admission should have an appointed member of the family to be the legal responsible adult, thus in charge of consent. However, if deterioration of capacity happened during or after admission, then the son(s) are first in line for consent, then brothers, then cousins.

  • Indications, nature of the proposed intervention, risks, and benefits must be addressed. Risks should include the most common and the most serious complications of the intervention.

  • Appropriate current alternatives to the proposed intervention, including none.

  • Assessment of patient understanding of all the above (part of capacity to consent).

  • For any cancer surgery, the surgeon has to mention the possibility of recurrence of the Cancer despite complete resection, albeit small risk for lower stage cancers.

  • The intern should also document “the patient was given the opportunity to ask questions and they were all answered to his satisfaction”. This is required in order for the consent to be informed.

In all laparoscopic interventions, it is very important to mention the possibility of conversion to open technique. Furthermore, the prophylactic steps taken to prevent possible complications and management options for each complication, should it develop, must be appropriately addressed.

*** Consent is a procedure and not merely a signature on a piece of paper ***

إقرار الموافقة على العلاج

المقصود بها موافقة المريض او من ينوب عنه على إجراء عملية جراحية أو على تلقي علاج قد يصاحبه مضاعفات من الممكن ان تكون دائمة. والأصل ان المريض هو ولي نفسه متى ما كان قد اتم الواحد والعشرون سنة وهو بكامل قواه العقلية والذهنية. إلا أنه إذا فقد أحد هذين الشرطين فإن الموافقة هنا تنتقل حسب الترتيب الآتي:

أولا: تكون للولي قانونا وهو الأب ثم الجد (أب الأب) وإن علا ولا تثبت لغيرهم إلا بحكم قضائي فهنا يجب على الطبيب أن يأخذ الإقرار من والد المريض، اما إذا تعذر على الطبيب الوصول للأب يكون الإقرار من أي أحد من أهله مع إقرار بأنه اتصل على الأب وأخذ موافقته.

ثانيا: عند عدم وجود الأب، فإن الولاية هنا تكون للٌرب فالأقرب من العصبات، وهم قرابة المريض من الذكور اللذين ينتسبون إليه عن طريق قرابة الذكور، وترتيب الاستحقاق بالولاية هو نفسه ترتيب الاستحقاق بالميراث، وهو على الشكل التالي:

  • جهة الأبوة، ثم جهة الأخوة، ثم جهة العمومة. فعند عدم وجود الجد (اب الأب) وإن علا يكون ولي النفس هو الأخ الشقيق، ثم الأخ لأب، فإن لم يوجد أحد من الإخوة يكون ولي النفس هو العم ثم ابن العم وهكذا.

ثالثا: بالنسبة للمرأة المتزوجة التي لم تكمل سن الواحد والعشرون او كان بها عيب تنقصها الأهلية فإن الولاية تكون للزوج، فإن تعذر الوصول إليه تعود الولاية للترتيب الذي سبق بيانه في أولا وثانيا بشرط ان يكون محرما لها.

رابعا: إذا كان المريض قد فقد أحد شروط الأهلية ولم تعين المحكمة وصيا عليه، وكان لديه من الأبناء من هم بكامل الأهلية القانونية، فإنهم هنا يتولون الولاية للمريض، وبكون ترتيبهم بعد جهة الأبوة وقبل جهة الأخوة.

مستخلص من قانون الأحوال الشخصية

New consent forms:

Since 2017 the ministry of health has introduced the new consent forms. Now the consent for Anesthesia and the procedure are separate. The new forms now how separate and specific sections for the procedure details, indication, benefits, risks and alternatives. Each section must be filled and detailed to maintain adequate information exchange between the physician and the patient or surrogate.

The new forms also contain sections to consent for blood transfusions, digital photography and sending resected samples to histopathology assessment. Each of these sections must be filled along with the consent for the procedure.

The Anesthesia form contains the ASA grading of the patient and proposed anesthesia type and risk assessment. This form is to be filled and signed by the anesthesia team.

Make sure that all sections are filled properly and detailed with all the relevant information. If a surrogate is signed on behalf of the patient make sure to identify the type of relationship with the patient, full name and civil ID number.


COMPLICATIONS OF COMMON PROCEDURES

General Anaesthesia

  1. Nausea and vomiting

  2. Basal atelectasis

  3. Chest infections

  4. Respiratory depression

  5. Airway obstruction

  6. Hypothermia

  7. Somnolence

  8. Inability to void urine

Upper endoscopy (OGD)

  1. Sore throat

  2. Nausea and vomiting

  3. Damage to teeth

  4. Chest infections (due to reflux)

  5. Bleeding (e.g. biopsy site or friable mucosa) – (~0.1%))

  6. Perforation (1 in 5000)

Laparoscopic cholecystectomy

  1. Conversion to open (<1%)

  2. Infection (<0.1%)

  3. Bile duct injury <0.24%)

  4. Bile leakage

  5. Retained common bile duct stone

  6. Bleeding

  7. Chest infection

  8. DVT

  9. Wound infectio

Colonoscopy

  1. Bloating (25%)

  2. Abdominal pain/discomfort (5-11%)

  3. Perforation (<0.1%)

  4. Bleeding (immediate or delayed) – (0.1-0.6%)

Central Venous Catheter

  1. Pneumothorax (0.1-3%)

  2. Bleeding (0.1-2.1%)

  3. Arrhythmias

  4. Air embolism

  5. Thrombosis

  6. Central line associated bloodstream infections (CLABSI)

PEG Tube

  1. Ileus (1-2%)

  2. Leakage (1-2%)

  3. Infection (5.4-30%)

  4. Fistulae (0.3-6.7%)

  5. Inadvertent removal

  6. Aspiration (0.3-1%)

  7. Bleeding (0-2.5%)

  8. Peritonitis (0.5-1.3%)

ERCP

  1. Pancreatitis (1-5%)

  2. Bleeding (2-3%)

  3. Infection (1.5%)

  4. Perforation (0.1-1%)

Total/Partial Thyroidectomy

  1. Bleeding

  2. Airway obstruction

  3. Hypothyroidism

  4. Need for life-long treatment

  5. Hypocalcaemia

  6. Recurrent laryngeal nerve injury (voice change)

Appendectomy

  1. Wound infection (<3.4%, >40% if perforated)

  2. Abscess (<2.4%)

  3. Chest infection (<2.5%)

  4. DVT

  5. Ileus

Bariatric procedure

  1. Haemorrhage (0.11%)

  2. Leakage (0.74%)

  3. Infection (0.5%)

  4. DVT /PE (0.32%)

  5. Electrolyte imbalance (1.91%)

  6. Stricture/Obstruction (0.42%)

Thyroidectomy:

  1. Transient hypocalcemia (5-50%)

  2. RLN injury (1-2%).

  3. SLN injury

  4. Neck hematoma (1%)

  5. Infection (1-2%)

  6. Thyrotoxic storm

  7. Airway obstruction

  8. Scar formation (?keloid)

Hernia repair:

  1. Inferior epigastric vessel injury

  2. Hematoma formation

  3. Seroma formation

  4. Intra-abdominal injury

  5. Adhesion formation

  6. Chronic Pain

  7. Nerve injury

  8. Ischemic orchiitis

  9. Mesh migration/infection

Lumbar Puncture (LP):

  1. Post-lumbar puncture headache (32%)

  2. Failure to obtain CSF

  3. Localized bruising

  4. Bleeding

  5. Discomfort at puncture site

Intercostal drain (ICD):

  1. Bleeding

  2. Superficial site infection

  3. Deep organ space infection (empyema)

  4. Dislodgement of the tube

  5. Clogging of the tube

  6. Re-expansion pulmonary edema

  7. Injury to intraabdominal organs such as spleen or liver

  8. Injury to the diaphragm

  9. Injury to intrathoracic organs such as the heart or thoracic aorta


References:

  1. American College of Surgeons (ACS

  2. American Society of Gastrointestinal Endoscopy (ASGE)

  3. https://www.ncbi.nlm.nih.gov/books/NBK459199/#article-19390.s5

  4. http://cjasn.asnjournals.org/content/8/7/1213.long

  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4673556/

  6. https://emedicine.medscape.com/article/1582292-overview#a5

  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4113153/

  8. https://www.ncbi.nlm.nih.gov/pubmed/24064328

  9. https://emedicine.medscape.com/article/1534321-overview#a4

  10. https://emedicine.medscape.com/article/1819350-technique#c4

  11. https://emedicine.medscape.com/article/1829797-overview#a5

  12. https://emedicine.medscape.com/article/1891109-overview#a5

***

These are only a rough guide but not actual representation of Kuwait

***

NAMES OF COMMON PROCEDURES IN ARABIC

Procedure name in English Procedure name in Arabic
Central Line تركيب قسطره وريدية مركزية
Upper Endoscopy (OGD) منظار ضوئي علوي للمعدة والاثني عشر
Colonoscopy منظار ضوئي سفلي للقولون
ERCP منظار ضوئي للمعدة وقنوات المرارة مع إحتمال وضع دعامة
Appendectomy (open/Lap) إستئصال الزائدة الدودية عن طرق فتح البطن/المنظار تحت تخدير عام مع عمل اللازم
Laparoscopic Cholecystectomy إستئصال المرارة بالمنظار تحت تخدير عام مع احتمالية فتح البطن مع عمل اللازم
Incisional Hernia Repair إصلاح فتق جراحي في منطقة البطن تحت تخدير عام مع عمل اللازم
Inguinal Hernia Repair (Open/Lap) إصلاح فتق أربي أيمن/أيسر بالمنظار/فتح بطن تحت تخدير عام مع عمل اللازم
Para-umbilical Hernia Repair إصلاح فتق في منطقة السرة عن طريق فتح البطن تحت تخدير عام مع عمل اللازم
Total/Lobe Thyroidectomy استئصال الغده الدرقية (كامله أو الجزء الأيمن/الأيسر) تحت تخدير عام مع عمل اللازم
Parathyroid Adenoma Removal إستئصال الغده جارة الدرقية (الجزء الأيمن/الأيسر والسفلي/علوي) تحت تخدير عام مع عمل اللازم
Examination under Anaesthesia + Haemorrhoids/Fissure/Fistula فحص منطقة الشرج تحت تخدير العام مع عمل ربط أو إستئصال للبواسير/ إصلاح شرخ أو ناسور
Removal of Fibroadenoma of Breast إستئصال ورم حميد في الثدي الأيمن/الأيسر تحت تخدير عام مع عمل اللازم
Laparoscopic/open Sleeve gastrectomy تكميم المعدة بالمنظار مع احتمالية الفتح تحت التخدير العام مع عمل اللازم
Laparoscopic/open Gastric bypass تحويل مسار بالمنظار مع احتمالية الفتح تحت التخدير العام مع عمل اللازم
Right/Left/Total (Hemi-) Colectomy إستئصال كلي/الجهة اليمنى/يسرى للقولون تحت التخدير العام مع عمل اللازم
Intercostal drain (ICD) insertion وصع أنبوبة في الغشاء البلوري للرئة اليمنى/اليسرى
Percutaneous drainage of collection سحب تجمع في منطقة ---- تحت التخدير الموضعي/العام
Pilonidal sinus excision/lay open إستئصال كيس شعر في منطقة ----- تحت التخدير العام معل اللازم
Lipoma excision إستئصال كيس دهني في منطقة ---- تحت التخدير العام/الموضعي مع عمل اللازم

PATIENT HANDOVER

By Dr. Mohammad Behbehani

Proper handover saves lives and reduces burden of morbidity. When done correctly, it has shown to improve the amount of information retained from 2.5% when there is no written component, to 99% when a standardized format is used, according to research done by Bhabra et. al. at the Royal College of Physicians1. Further studies have shown that preventable, permanently debilitating incidents may be twice as likely due to improper handover as compared to lacking medical knowledge2. This section aims to provide the physician with an understanding of the importance, means of handover and best evidence-based approach.

As physicians, we aim at all times to provide the highest level of healthcare for our patients despite not being continuously present in hospital (although we may feel like we are). We are in control during the times we are physically present in the hospital. When outside, of which it is important to ensure details of the patient and our care plan is easily transferable to an on-call team.

The goal of implementing a formal handover process is to guarantee the provision of focused, standardized information to the on-call team. This allows any doctor in the on-call team to administer informed management that is in continuum with the main treating team’s medical plan for the patient, rather than offering treatment that may be unnecessary, repetitive, or, worse still, in direct opposition to the original medical plan. This, in turn, should help prevent avoidable complications and assist the on-call team predict and prepare for any foreseeable medical difficulties during their shift. By ensuring that the knowledge provided is up to date and detailed yet focused, the on-call team can have all relevant patient data available during emergency situations without need for time-consuming file review. Furthermore, by standardizing the handover process, all on-call teams will instinctively and uniformly know where and how to find the information they need, regardless of which main treating team they are receiving handover from.

There is both written and verbal handover. The recommended method to provide this information is in the form of a handover sheet. This sheet should be updated daily by the treating team. This review may be done on an individual basis throughout the day (i.e. with each team member updating the information for his/her assigned patients) followed by a brief re-evaluation by the treating medical team at the end of the workday. The handover sheet may also be edited as a team in an extended closing rounds held prior to the change in shifts.

It is recommended for the sake of uniformity that each department (e.g. Internal Medicine, Surgery, etc.) produce a uniform template for the handover sheet to be used by all units. Any specific orders, procedures or results that need close follow-up during the on-call shift should be highlighted under things to follow up on call, while any unstable/critically ill patients should also be pointed out. Ideally, after the document is fully prepared and edited, it should be made available in electronic form on a shared (e.g. “cloud”-based) service. If this service is not available, it should be physically given to a member of the on-call team by pre-designated team members (e.g. Registrar to Registrar).

References:

  1. Bhabra G, Mackeith S, Monteiro P, Pothier D. (2007). An experimental comparison of handover methods. Annals Royal College of Surg Engl 2007; 89(3): 298–300. (link: http://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf)

  2. Zinn C. 14,000 preventable deaths in Australia. BMJ, 1995, 310:1487. (link: http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf)

HANDOVER SHEET (SAMPLE)

IMPORTANT NOTE: The patient names below have been abbreviated for the sake of patient privacy. The room numbers were correct at the time of production of this document but are subject to change; please ensure correlation between medical history and bed number when assessing patients

BED NAME

CURRENT

DIAGNOSIS

 AGE D.O.A. DOCTOR NOTES
Ward X
1 A. A. ACS xx xx/xx/xx Dr. A

  • xx year-old xx (nationality) male/female, known case of: yy, yy, yy

  • Admitted as case of zz

  • Current Issue #1: XX - Seen by Unit xx, started on xx, latest labs xx

  • Current Issue #2: YY - On yy, follow-up yy
2 B. B. AKI xx xx/xx/xx Dr. B

  • xx year-old xx (nationality) male/female, known case of: yy, yy, yy

  • Admitted as case of zz

  • Current Issue #1: XX - Currently on xx, follow-up xx consultation

  • Current Issue #2: YY - yy D/C today, monitor yy
3 C. C.

Original Diagnosis: CVA

Currently

Social Stay

 xx xx/xx/xx Dr. C

  • xx year-old xx (nationality) male/female, known case of: yy, yy, yy

  • Admitted as case of zz

  • Current Issue #1: XX - Seen by Unit xx, started on xx, latest labs xx

  • Current Issue #2: YY - On yy

  • Current Issue #3: ZZ - Patient discharged medically, social worker consulted
Ward Y
1-1 D. D. Sepsis xx xx/xx/xx Dr. D

  • xx year-old xx (nationality) male/female, known case of: yy, yy, yy

  • Admitted as case of zz

  • Current Issue #1: XX - Patient on Dopamine, UOP low (if no response to fluid challenge send nephron consult), consider adding noradrenaline

  • Current Issue #2: YY - Blood C/S +ve, on Tx, f/u Micro consult
Ward Z
Casualty
Bed 4 E. E. Elective Admission PEG Tube Insertion xx xx/xx/xx N/A

  • xx year-old xx (nationality) male/female, known case of: yy, yy, yy

  • Admitted electively for PEG Tube insertion

  • Currently in casualty due to lack of beds in wards - arranged for transfer to Ward x

  • Current Issue #1:XX - xx D/C, xx labs sent
New Patient #: 1 Total Patient #: 4 + 1 (Casualty)

The names of patients that are critically ill or require close follow-up due to their general condition are highlighted above. Important issues that require urgent attention are underlined in the “Notes” section

***Copied, with permission, from “Standardizing Internal Medical Units in Kuwait Ministry of Health Institutions – Phase I: Doctors” by Dr. Mohammad Behbehani***


CHILD ABUSE AND SCAN TEAMS

The nature of our jobs, in almost every rotation, will potentially expose you to cases of abuse. In our culture, we might be weary of intervening in such cases. However, it is crucial to fulfill your role as the patient’s advocate when facing this issue. Fortunately, a more structured healthcare and legal approach has been implemented recently –including a new section in the Ministry of Health dedicated to Child Abuse. This should make you feel more comfortable that intervening is not as taboo as it used to be. In fact, intervention by healthcare providers is expected.

When suspecting child abuse, it is crucial to be weary of your approach to the case to avoid making fatal mistakes. Here are some dos and don’ts to protect yourself and most importantly, the patient.

DO’s:

  • Inform your senior about your suspicion

  • Act on your concerns. If in doubt, speak out

  • Treat any allegation seriously and delicately

  • Document everything that is said and done in the file

  • Keep everything confidential. Do not publicly speak about the case in the ward halls or at the counter

  • Call the SCAN team and inform them immediately. After calling them, you must fill out a special form as a referral letter

DON’Ts:

  • Do not bluntly state that you are suspecting abuse in front of the patient or companion/parents. Don’t even state it in English with your team – never assume that people don’t understand English

  • Don’t do nothing. By doing nothing, you have failed to protect the child from harm. It is your responsibility as a healthcare provider to advocate for your patients. Here, the most important thing is the child’s safety

  • Don’t waste time. Reporting to the SCAN team in a timely, effective, and confidential manner is vital to protecting the child

  • Don’t interrogate the child. When asking questions, stay neutral and try to gather as much information as you can without making the parents or the child feel threatened or interrogated

  • Don’t make the child or the parents feel responsible for the abuse

  • Don’t assume. Do not make judgements or assumptions based on the family or the child. Keep an open mind and gather enough information, in an unbiased manner, to confirm or deny your suspicion

SCAN Team:

SCAN: Suspected Child Abuse and Neglect Team

The SCAN team should be called when you suspect child abuse. There is a special form you must fill out as a referral. It is recommended that you refer to them even if you have the slightest doubt, and of course, after consulting your seniors. However, you are encouraged to call the SCAN team regardless of your senior’s opinion. When in doubt, speak out!

SCAN Team Numbers:

***For physician use only – Do NOT give these numbers outside of hospital staff***

Hospital SCAN Number
Sabah Hospital 98010172
Mubarak Al Kabeer Hospital 98010173
Adan Hospital 98010174
Amiri Hospital 98010175
Farwaniya Hospital 98010176
Jahra Hospital 98010177

Child Abuse Hotline: 147 (for the public)

Reference:

Kuwait National Child Protection Program

http://ec.europa.eu/justice/fundamental-rights/files/rights_child/standards_child_protection_kcsc_en.pdf

https://wikimedia.org.uk/wiki/Safeguarding_Policy/Procedures


MANAGING TRAUMA PATIENTS

*** we recommend you invest in taking the ATLS course as to the many benefits you shall receive, even if you will pursue a non-surgical specialty ***

During your time as an intern you shall come across many trauma related cases. Some of you might have already done the ATLS course and understand the following but for those who still didn’t have a chance this chapter works as a quick overview on how to assess and document in the trauma setting.

First, you should always be well prepared to facilitate the rapid progression of assessment and resuscitation of the patient. You must ensure that you wear the appropriate personal protective equipment to protect both the patient and staff. Ensure that during the full head to toe examination the patient is completely undressed, keeping in mind prevention of hypothermia.

Although the ATLS method is practical and concise, it can sometimes prove to be difficult to recall all the vital steps while managing a badly injured patient or in poly-trauma situations. Trauma sheets are available in most hospitals which were designed to ease the process by aiding physicians not to miss any important steps while attending to trauma patients, as well as helping in better documentation of patient plans and progress. So, in settings of trauma please ask for them.


Primary Survey:

The primary survey is aimed to identify the leading causes of death and try to manage them as quickly and efficiently as one can. It follows a structured flow commonly known as the ABCDE.

A) Airway and Cervical Spine immobilization

Assessment:

  • Ensure that the airway is patent

    • Commonly done by asking the patient their name

      • If they can converse with a normal voice, then the airway is patent and protected

  • Rapidly asses for airway obstruction

    • If in any doubts, consider a protected airway (i.e. endotracheal intubation)

Management:

  • Perform chin lift or jaw thrust manoeuvre

  • Clear the airway of foreign material

  • Insert an oropharyngeal airway

  • Establish a definitive airway (either via intubation or a surgical cricothyroidotomy)

  • Maintain cervical spine in a neutral position with manual immobilization

  • After establishing an airway immobilize the C spine with appropriate devices (i.e. C-Collar)

B) Breathing and Oxygenation

Assessment:

  • Expose the neck and chest

  • Determine rate and depth of respirations

  • Inspect and palpate the neck for pathologies such as tracheal deviation, use of accessory muscles and signs of injury

  • Percuss the chest for dullness or hyperresonance

  • Auscultate the chest bilaterally

Management:

  • Administer high concentration oxygen

  • Ventilate with a bag and mask

  • Alleviate tension pneumothorax

  • Seal open pneumothorax

  • Attach pulse oximeter to the patient or CO2 monitoring device to endotracheal tube

C) Circulation with hemorrhage control

Assessment

  • Identify source of bleeding

  • Identify potential sources of internal hemorrhage

  • Asses the patients pulse, skin color and measure blood pressure

Management

  • Apply direct pressure to external bleeding site

  • Insert two large bore IV cannulas

  • Draw blood samples for CBC, RFT, Coagulation profile and type and crossmatch PRBC

  • Initiate IV fluid therapy with crystalloid solution and blood replacement

  • Prevent hypothermia by using warmed fluids and body warmers

D) Disability

Assessment:

  • Determine patients level of consciousness via GCS

  • Check pupils size and reflex

  • Asses for any signs of lateralization and spinal cord injury

  • Exposure and Environmental control

  • Completely undress patient but prevent hypothermia

E) Exposure:

  • This involves stripping the patient from all covering clothes whilst maintain core temperature and checking for any major wounds, fracture deformities or abnormalities.

Adjuncts to primary survey

  • ABG analysis

  • ECG monitoring

  • Urinary catheter and nasogastric tube if no contraindication and monitor hourly urine output

  • Obtain AP chest and Pelvic XRAYS

    • Should be performed prior to shifting the patient

  • Obtain FAST and consider the need for DPL

Reassess patients ABCDEs on a regular basis and must be repeated prior to shifting the patient.

Secondary Survey

The secondary survey is a full head to toe examination involving full examination of all orifices including the ears, mouth and teeth. This involves examining the Head, face, ears, mouth, teeth, Neck, Chest, Abdomen, Perineum, rectum, external genitalia, limbs and CNS along with checking all peripheral pulses.

AMPLE History

A Allergies
M Medications
P Past History/Pregnancy
L Last Meal time and quantity
E Environment (Document trauma setting and if any delay to seeking medical assistance was encountered)

This history can be obtained from the patient, family or ambulance staff.

Try to Identify mechanism of injury from the history.

Adjuncts to secondary survey

  • Consider the need to obtain the following diagnostic tests if the patient’s condition permits, Spinal XRAYS, CT, Contrast uropathy, Extremities XRAYS, ECHO.

Remember to re-evaluate the patient on a regular basis and to continuously monitor their vital signs, urine output and response to treatment. Succinctly noting and documenting any changes in the patient’s condition and response to resuscitative efforts.

Reference:

  • Advanced Trauma Life support student course manual. Ninth Edition.

THE ELECTIVE SURGICAL ADMISSION

All surgical admission plans should be reviewed by the operating surgeon

  1. ADMIT to ward e.g. 18 – input casualty number into system and click transfer to ward, complete admission process from reception desk

  2. CONSENT

    • Bariatric surgery needs a special consent form from MOH

  3. ANAESTHESIA clearance

  4. TYPE AND SCREEN 1-2 units PRBC (To reserve if high risk of bleeding)

  5. INVESTIGATIONS

    • CBC, RFT, Coagulation Profile

    • LFT

    • Amylase

    • Thyroid profile/PTH

    • Bone profile

    • Pre-op ENT assessment

      for vocal cords

    • Cervical X-rays (AP and Lateral)

    • Chest X-Ray

    • ECG

6. IV FLUIDS

  • NPO from midnight

  • IVF rates (Note: use GIK if diabetic)

Thin Build Medium Obese/Overweight
80ml/hr DNS 100ml/hr DNS 120ml/hr DNS


  1. ANTIBIOTICS*:

Any surgery from skin down to fascia (PNS, Hernia, etc…) Clindamycin (Dalacin) 600mg IV or none if clean surgery
Laparoscopic Cholecystectomy Cefuroxime (Zinacef) 1.5g IV OR Cefotaxime (Claforan) 1g IV + Metronidazole (Flagyl) 500mg IV
Sleeve Gastrectomy Piperacillin-Tazobactam (Tazocin) 4.5g IV OR Cefuroxime (Zinacef) 1.5g IV OR Cefotaxime (Claforan) 1g IV + Metronidazole (Flagyl) 500mg IV

*Variation in antibiotic choice occurs between different units and hospitals

8. BOWEL PREPARATION

  • Should be considered for anal surgeries, e.g. haemorrhoids/fissures or colon operations, e.g. colectomies.

  • Options include:

    • Picolax (1 sachet @10 a.m., 12 p.m., 3 p.m., 6 p.m.)

    • Golytely (start @12 p.m. finish the container by 10-11 p.m.)

    • +/- Phosphate enema (2x @ 6 p.m. and 2x @4 a.m.)

9. THROMBOPHYLAXIS:

Consider if patient is immobile/is undergoing bariatric surgery, or is on-call to laparoscopic surgery (use may slightly differ between different units)

  • If Caprini Score > 3

    • Mini-heparin 5000 units S/C OR Clexane 0.4-0.6ml S/C (at induction of anaesthesia or 2 hours prior)

    • +/- sequential compression device (e.g. flowtron)

10. CO-MORBIDITIES

  • Consults for pre-operative management and clearance to be sent to the appropriate specialty

THE POST-OPERATIVE PATIENT

When approaching a post-operative patient there are certain things you need to check:

  • Wound (tender, erythema, discharge)

  • Drain (amount, content, dressing soaking, degree of suction)

  • Stoma output (amount and consistency)

  • Urine output (total or hourly)

  • Presence of post-operative nausea and vomiting (PONV)

  • Bowel functioning (passing of flatus or stool)

  • Clearance for oral intake (sips, fluids, diet)

  • Need for IV fluids (with or without K+ replacement)

Procedure Check
Inguinal Hernia Repair

Scrotal swelling and bruising

Passing of urine
Lap. Cholecystectomy

If drain placed look for bile,

Shoulder pain (R>L)
Open/Lap Appendectomy Wound infection or discharge
Lap. Sleeve Gastrectomy

Nausea and vomiting

Haematemesis

Tachycardia, Left shoulder pain
Thyroidectomy

Finger Paraesthesia/numbness

Peri-Oral numbness

Difficulty breathing, Drain output

Ca++ levels
EUA

Passage of urine and stool

Presence of blood or pus
Stoma (colostomy/ileostomy)

Functioning (watery, formed stool)

Blood (lumen or edge)
PNS and I&D Discharge or bleeding

Common ECG findings

ECG review is a daily and indispensable clinical activity no matter what area of medicine you end up in. Although this is called a 12 lead ECG you only use 10 leads, 4 for the limb leads and 6 for chest leads.

When recording an ECG ensure that:

  • All leads are in their correct place and secure

  • Ensure good contact with the skin (might need to shave hair or wipe off cream/lotion)

  • Input the patient’s data into the machine correctly

  • Ask the patient to lie as still as possible

  • Make sure no metal is in contact with patient

  • If patient was having chest pain during ECG recording record that on the ECG page

Recognizing life-threatening changes in the ECG is an important aspect of the intern life. Sometimes you will be the first line defense when the nursing staff calls you to review an ECG.

We will review the most common ACLS ECGs with a simple interpretation by dividing them into: Pulseless rhythms, tachyarrythmias, and bradyarrhtmias.

ACLS ECGs

Pulseless

Pulseless Ventricular tachycardia

  • No palpable pulse but broad complex tachycardia on the cardiac monitor

  • Monomorphic: uniform QRS complex morphology

Ventricular fibrillation

  • Bizzare shape chaotic ventricular thchyarrhythmia

Asystole

Pulseless electrical activity

  • It could be any organized rhythm but without producing a pulse


Tachyarrythmias

Supraventricular tachycardia

  • Narrow QRS complexes

  • P waves are maybe buried inside the QRS

Atrial flutter

  • Regular rhythm

  • Saw tooth waves

  • Absence of typical P waves

Atrial fibrillation

  • Irregularly irregular rhythm

  • Absence of P waves

  • Presences of fibrillatory waves


Bradyarrythmias

1st degree AV block

  • PR prolongation >200 ms (five small squares )

2nd degree AV block type 1, Mobitz 2, wenkbach

  • Progressive prolongation of PR interval ending with non-conduction P wave (no QRS after the P wave)

2nd degree AV block type 2

  • Intermittent non-conducting P waves WITHOUT progressive prolongation of the PR interval

Complete heart block

  • Complete absence of AV conduction

  • The P waves are not related to the following QRS

References:

https://lifeinthefastlane.com/ecg-library/

https://acls-algorithms.com/rhythm

PRACTICAL PROCEDURES

As a doctor you are expected to perform certain practical procedures such as inserting a Foley’s catheter or obtaining an ABG sample. These procedures are usually minimally invasive, however, proper technique is needed to avoid complications. As with any procedure consent should be obtained beforehand with proper explanation of benefits, risks, and alternatives. Signed consent is needed only in certain circumstances, like placing an NGT in a person with known oesophageal varices or inserting a Foley’s catheter for a virgin female. The following section outlines common procedures you will encounter on the wards.

URINARY CATHETER

Catheters can be 2-way (drainage port and balloon port) or 3-way (drainage port, balloon port, and continuous irrigation port). The latter usually used in patients with gross haematuria and bladder clots. Catheter types can also can be straight tip or coude (curved) tip. The latter usually used in patients with known BPH and enlarged prostate. The curve helps the catheter pass across the 90-degree curve of the bulbar urethra.

Before the procedure:

  1. Explain the procedure and the indication(s) to the patient

    1. Indications may include: acute urinary retention, urinary obstruction, pre operatively to empty the bladder, measuring output of a critically ill patient.

  2. Prepare the set:

    1. Appropriate size and type of catheter and a catheter bag

      1. Latex (for an estimated duration of less than 1-2 weeks)

      2. Silicone (for an estimated duration of less than 6-8 weeks)

    2. Syringe filled with sterile water (5-10ml) depending on the size of the catheter

    3. Chlorhexidine solution

    4. Sterile dressing pack (forceps, gauze, small trays)

    5. Lubricating anaesthetic gel (Xylocaine)

    6. Sterile gloves, gown, mask

Procedure (under aseptic technique):

  1. Wash hands then approach the patient and expose the area appropriately then position the patient.

  2. Prepare the sterile field then wear the sterile gloves.

  3. Male patients:

    1. Lying supine

    2. Hold the penis upright with sterile gauze using non dominant hand

    3. Insert the tip of the lubricant anaesthetic gel into the urethral meatus and apply

      1. Wait for a period of time (3-5 minutes) for the anaesthetic content to take effect

    4. Lift the penis to a perpendicular position and insert the catheter until urine flow is noted then keep advancing 3-4 cm further. If no urine is noted, apply pressure on the bladder. If urine is still not flowing, retract the catheter a few centimetres to straighten it in case of any kink and try again.

  4. Female patients:

    1. Placing soles of feet together and bringing up both knees as close to the chest and legs apart

    2. Separate the labia with the non-dominant hand

    3. Lubricate the tip of the catheter

    4. Insert the catheter until urine flow is noted (female urethra is shorter so urine will be noticed sooner on insertion of catheter)

  5. The balloon of the catheter need only be filled with water, and not normal saline. Precipitation of the salt in saline might damage the valve and prevent deflation of the balloon at the time of catheter removal.

  6. When inserting the catheter, advance to the hub provided a smooth course of insertion. It is important to ask the patient to relax the pelvic floor muscle and sphincter to avoid pushing against a tight sphincter, which may result in a false urethral passage. When clear urine drains, only then you can inflate the balloon with water – and not saline – to the balloon volume indicated on the balloon port. If no urine drains and the catheter recoils back, this probably means it is not in the bladder and there is a false passage. Deflate the balloon if inflated, pull back the catheter to avoid making the false passage bigger, and call the urologist on-call. When using a coude (curved) tip catheter, at the time of insertion the tip should be pointing towards the patient’s head

After the procedure:

  1. Fix the catheter to the urine bag

  2. Wash hands

  3. Document the procedure in the patient’s file

    1. State catheter size and type

    2. Initial urine output and output after 15 minutes

NASOGASTRIC TUBE (NGT)

Before the procedure:

  1. Explain to the patient the indication and the procedure of inserting a nasogastric tube:

    1. Indications: feeding, decompression for small bowel obstruction, upper gastrointestinal bleeding, stroke patients to prevent vomiting and aspiration

    2. Contra-indicated: severe facial trauma (consider orogastric tube)

  2. Gather the necessary equipment, including

    1. Gloves, gown, face mask

    2. NG tube (varying sizes), preferably frozen

    3. Lubricating gel, large syringe, collecting bag, and tape

    4. Stethoscope

Procedure:

  1. Approach and position the patient appropriately, if possible to upright position. Attach an oxygen saturation monitor to the patient.

  2. Examine the nostrils to check for any severe septal deviation, or history of nostril blockage

  3. Estimate the length of tube required by measuring the distance from the tip of the nose to the tip of the ear to the xiphoid, and keep one finger placed at that mark

  4. Lubricate the tip of the tube with gel and warn the patient before inserting the tube into the nostril

  5. Gently insert the lubricated tip into one nostril and slowly advance through the nasopharynx oropharynx, then ask the patient to swallow. With each swallow the tube should be advanced until it reaches the appropriately marked area

    1. If any resistance felt, gently withdraw the tube and rotate it with a downward movement. If the nose feels blocked, try the other nostril.

    2. To aid the patient in swallowing, you may give them sips of water if there are no contraindiciations

    3. Check the patient’s mouth as the tube may enter the oral cavity

    4. Be aware of the gag reflex as the tube first passes the oropharynx

    5. If the patient starts coughing, immediately withdraw the tube and keep an eye on the oxygen saturation as it will provide a rough idea whether the tube has gone through the trachea or not

After the procedure:

  1. Check placement of the tube

    1. Aspiration of gastric contents with the syringe

    2. Injecting air through the NGT and auscultation of the stomach to hear air gushing through

    3. Chest X-ray post insertion: check for the tip of the tube, which sitting comfortably in the stomach

  2. Wash hands, document the procedure in the patient’s file

    1. State tube size

    2. Type and volume of content

VENOUS BLOOD SAMPLING

Before the Procedure:

  1. Explain to the patient the procedure and indications

  2. Obtain express consent

  3. Prepare your set:

    1. Personal protective equipment (PPE)

    2. Sharps bin

    3. Vaccutainers and needles

    4. Tourniquet

    5. Alcohol swabs

    6. Cotton and plaster/band-aid for post procedure haemostasis

Procedure:

  1. Wash hand or use sanitiser scrub

  2. Comfortably position the patient in accordance with the desired vein (preferably in the non-dominant hand)

  3. Apply tourniquet and ask patient to clench fist

  4. Identify the desired vein to venepuncture

    1. At this stage you may re-adjust the tourniquet position if needed

  5. Thoroughly clean the area with the alcohol swab

  6. Approach the vein in a 450 angel with needle facing upwards

  7. Apply the vaccutainers and collect the desired amount of blood

  8. Remove the tourniquet first before removing the needle

  9. While removing needle apply a cotton swab at site of venepuncture to provide haemostasis

After the procedure:

  1. Dispose of all sharps in the sharps bin

  2. Clearly label blood samples with patients name and medical record number and send with appropriate sample request

  3. Wash hands

  4. Document the procedure in the patient’s file

ARTERIAL BLOOD SAMPLING (ABG)

Before the procedure:

  1. Explain to the patient the procedure and indications

  2. Obtain express consent

  3. Prepare your set:

    1. Personal protective equipment (PPE)

    2. Sharps bin

    3. ABG needle +/- Heparin

    4. Alcohol swabs

    5. Cotton and plaster/band-aid for post procedure haemostasis

Procedure:

  1. Wash hand or use sanitiser scrub

  2. Wear gloves +/- PPE

  3. Perform Allen’s test to check Radial and Ulnar blood flow, pick the one felt better

  4. Comfortably position the patient’s arm with palm up and wrist rested on a pillow and the hand slightly extended

  5. Thoroughly clean the area with the alcohol swab

  6. If using a heparinised needle, then draw 1ml of unfractionated heparin then eject leaving only a few drops in

  7. Approach the artery in a 450/900 angel with needle facing upwards

    1. If using an ABG without a plunger then wait until entire needle is filled

    2. If using a needle with a plunger then retract plunger with arterial blood is seen

  8. While removing needle place a cotton swab at site and apply moderate amount of compression for at least 2-3 minutes

  9. Apply dressing afterwards


After the procedure:

  1. Dispose of all sharps in the sharps bin

  2. Clearly label blood samples with patient's name and medical record number and send with appropriate sample request

  3. ABG sample should be transported in ice

  4. Wash hands

  5. Document the procedure in the patient’s file

ASCITIC FLUID SAMPLING

***This procedure is now preferably done under ultrasound guidance***

Before the procedure:

  1. Explain to the patient the procedure and indications (fluid sampling vs. fluid removal)

  2. Obtain express consent

  3. Prepare your set:

    1. Personal protective equipment (PPE)

    2. Sharps bin

    3. 16/18G needles or cannulas with a urine bag

    4. Alcohol swabs

    5. Cotton and plaster/band-aid for post procedure haemostasis

Procedure:

  1. Wash hands or use sanitiser scrub

  2. Patient should lay in a flat or semi-flat position

  3. Percuss the abdomen and determine the site of maximum dullness

    1. Try to avoid the superficial veins of the anterior abdomen

  4. Wear PPE

  5. Thoroughly clean the area with the alcohol swab

  6. Apply downward traction on the skin and then insert needle or cannula with needle facing upwards

    1. The traction will make the point of entry through the skin and peritoneum in different levels, thus once traction is released a proper seal is maintained

  7. If sampling fluid, then peritoneal fluid will evacuate under gravity and intra-abdominal pressure, no need for negative pressure by using a syringe

    1. Once finished remove needle and apply dressing to maintain haemostasis

  8. If indication is volume removal then remove needle and fix cannula then attach it to urine bag for drainage

After procedure:

  1. Dispose of all sharps in the sharps bin

  2. Clearly label fluid samples with patient's name and medical record number and send with appropriate sample request

  3. If drainage is the aim, patient position might be changed to maintain drainage of fluid

  4. Wash hands

  5. Document the procedure in the patient’s file

  6. Request appropriate investigations

    1. Gram stain + C/S +/- AFB/ZN stain

    2. Albumin and total protein (fluid and serum)

    3. Amylase

    4. Cytology + cell count and differential

SURGICAL DRAIN/CENTRAL LINE REMOVAL

Before the procedure:

  1. Explain to the patient the procedure and indications

  2. Obtain express consent

  3. Prepare your set:

    1. PPE

    2. Suture blade

    3. Dressing set with Betadine or alcohol for disinfection

    4. Sharps bin

Procedure:

  1. Wash hands or use sanitizer scrub

  2. Place patient in a comfortable position

    1. Flat for intra-abdominal drain

    2. Flat/ head down for central line removal

  3. Remove dressing

  4. Clean area with Betadine or alcohol

  5. Use suture blade to remove fixating sutures

  6. Ask patient to take a deep breath

    1. For surgical drain: make sure that drain is off negative suction and remove while patient is breathing in to minimise pain

    2. For central line: Remove drain after taking in a full breath and holding it to minimize venous cardiac return

      1. If patient is on BiPAP or SIMV, removal of line is in the positive/pushing phase

  7. Once drain/line is removed clean area thoroughly and apply dressing

After procedure:

  1. Dispose of all sharps in the sharps bin

  2. Wash hands

  3. Document the procedure in the patient’s file


PNEUMOTHORAX AND ICD MANAGEMENT

A pneumothorax is present when air is trapped within the pleural space, otherwise known as the space between the visceral and parietal pleura. A pneumothorax is usually diagnosed clinically with the aid of chest x-rays (PA and lateral) in addition to CT chest and any other necessary investigations to determine the underlying cause.

Mainstay treatment usually involves the insertion of a chest drain and treating the underlying cause. The decision of insertion of an ICD depends mainly on the clinical state of the patient in addition to the size of the pneumothorax, which is determined by measuring the rim present between the lung margin and the chest wall at the level of the hilum; small < 2cm vs. large ≥ 2cm. Those with symptoms of dyspnea and/or tachypnea with a visible pneumothorax of ≥ 2 cm warrants insertion of an ICD. If not, monitor the patient for the first 24 hrs with a repeat CXR +/- oxygen and follow up as an outpatient.

Underwater seal drainage system

After successful insertion of a chest drain, the drain must be connected to a special chamber known as an underwater seal chamber (image below). This special type of chamber will allow air to escape through the drain and prevent it from returning. You must ensure that the chamber is always kept below the level of the patient’s chest to prevent air from re-entering back into the thoracic cavity:

  • Make sure the water seal (B) is filled with water up to the 2 cm line. The presence of the water will allow you to identify any air leaks

  • Pour approximately 20 cm of water in the suction control chamber (A).

  • After insertion of a chest drain, place it on suction. This is done by connecting the wire from the wall suction onto the suction control chamber (E). Suction can be confirmed by the presence of smooth bubbling in the suction chamber. Suction can be turned on/off using the knob attached to (E).

  • Checking for air leak involves looking at the air leak monitor (C) to note for the presence of absence of bubbling.

  • continuous bubbling: persistent air leak

  • intermittent: the ball within the air leak monitor will oscillate

  • absence of bubbling: no air leak

    Patients with associated pleural effusions or haemothorax will have fluid or blood draining out via the chest drain, and this is collected within the collection chamber (D). The chamber is emptied as required and measured to determine hourly or daily output.

Removal of the ICD follows the same technique is removing surgical drains with the following precautions:

  • Patient must be placed in a 450 position

  • ICD to be removed while patient is in full inspiration

  • Proper sealing of the wound using either a stay suture or Sofra-Tulle gauze with gel to prevent air entry

PRE-PROCEDURE CHECKLIST

Endoscopy/Colonoscopy:

  • The day before:

    • Anesthesia consult for elderly or patients with major comorbidities (OSA, LVF, COPD, etc…)

    • Counsel & consent

    • Keep NPO from midnight

    • Check coagulation profile if underlying coagulopathy exist especially if intervention is likely

  • Rx to stop: antiplatelets, anticoagulants, NSAIDs, Iron, PPI therapy

Echo (TTE/TEE):

  • keep NPO 6 hours prior

  • IV fluids if the patient requires tight hydration control

  • counsel & consent

  • Anesthesia consult for elderly or patients with major comorbidities (OSA, LVF, COPD, etc…)

Ultrasound:

  • Carotid, Thyroid, Breast, Scrotal, Echocardiography:

    • No preparation is required

  • Gallbladder, Liver, Abdominal, Pancreas:

    • No food 6 hours prior to exam to distend the gallbladder

  • Pelvis/Bladder Ultrasound:

    • Drink entire 1 litre of clear liquids 1 hour prior to exam

    • Do not urinate (full bladder allows for a better study to assess the pelvis and adnexa)

CT without contrast (Plain):

  • No prep required

  • Consent for radiation exposure


CT with contrast (oral, IV, enema):

  • Check if the patient has any allergies to contrast

  • Check patient medications

  • Discontinue:

    • NSAIDs 2 days prior

    • Diuretics 24 hours prior

    • Metformin on the day and held for 48 hours after the procedure, if the patient is known to have AKI/CKD/GFR <30/undergoing arterial catheter study. Resume metformin only after RFT has been re-evaluated/normal

    • Metformin accumulation and precipitation leads to lactic acidosis and subsequently, contrast-induced nephropathy

  • To prevent contrast induced nephropathy:

    • Pre-procedure fluid hydration and to continue post contrast injection

    • Use of NaHO3 and N-Acetyl Cysteine are commonly used however the evidence don’t show any prevention benefit

  • Check RFT (creatinine and GFR) and screen for diabetes, HTN, or renal disease
    Routine creatinine testing prior to contrast administration is NOT necessary in all patients. Estimated glomerular filtration rate is a better predicator of renal dysfunction than creatinine alone

    • Major indications for screening:

      • Age > 70

      • History of preexistent renal insufficiency, diabetes mellitus, or hypertension

  • Oral contrast: CT abdomen/pelvis

  • Keep NPO from >6 hours

  • Two hours prior to exam, drink first bottle of liquid

  • 30 minutes prior to exam, drink ½ second bottle of liquid

  • Bring remaining ½ bottle to exam

  • Common reactions:

    • IV contrast: warm flushing in IV site, metallic taste in mouth, hives

    • Contrast enema: bloating

  • For patients at high-risk of adverse contrast reactions
    Premedication regime:

    • 12 hours prior: 50mg Prednisone / 32mg Methylprednisolone

    • 2 hours prior: IV fluids, 50mg Prednisone and/or 50mg Diphenhydramine

These dosages are a rough guide and different hospitals use different protocols. Thus, check with your radiology department prior to prescribing any pre-procedure pre-medications

MRI:

  • Abdominal: keep NPO

  • With contrast: stop medications as per CT guidelines

  • Without contrast: continue meds. No prep needed

All MRI requests require the physician to fill out a questionnaire to make sure no metallic or electronic devices are present which may interact with the MRI magnet. Make sure this questionnaire is filled accurately

Nuclear Medicine:

  • Thyroid Uptake and Scan, I-131 Whole Body Scan:

    • No multivitamins for 48 hours prior to exam.

    • No thyroid medications for 2-4 weeks depending on type, consult.

    • No seafood for 48 hours prior to exam.

    • No Iodine based contrast for 6 weeks prior to examination.

    • NPO 4 hours prior.

    • Must not be pregnant.

    • Some thyroid medications need to be stopped prior to exam.

  • Hepatobiliary Scan: NPO 4 hours prior to scan.

  • Gastric Empty: NPO at >8 hours

  • Nuclear Stress Test: NPO for 4 hours, consult about cardiac medications.

References:

  1. http://www.dcamedical.com/webdocuments/patient-exam-prep.pdf

  2. http://radiology.ucsf.edu/patient-care/patient-safety/contrast/iodinated

FLUID MANAGEMENT

Managing intravenous (IV) fluid therapy to prevent or correct problems with fluid and/or electrolyte status on the wards will be a daily task. Deciding on the appropriate amount, composition, and rate of IV fluids to be administered can be confusing. Yet, it is crucial to understand and perfect as errors in prescribing IV fluids and electrolytes are unfortunately common, especially in emergency departments and general medical and surgical wards, where some staff have less expertise than those in operating theatres and critical care units. Plus, the patient load can be unforgiving. This section aims to reduce, and hopefully prevent, such errors from happening.

Types of fluids:

The different IV fluids can be divided into two distinct groups, crystalloids and colloids.

  • Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules. 

  • Colloids contain larger insoluble molecules, such as gelatin and preserve a high colloid osmotic pressure in the blood.

Common crystalloids include:

  • Normal saline, Ringer’s Lactate, Hartman’s solution, Dextrose

Common colloids include:

  • Synthetic: Hetastarch, Dextran

  • Natural: Red blood cells, Fresh frozen plasma, Albumin

While there is some controversy regarding use of colloids vs crystalloids; in the non-critical care setting and in the setting of hypovolaemic shock, crystalloids are the mainstay of resuscitation. We recommend the use of lactated ringers in place of normal saline where possible as it is more physiological and less acidic than normal saline. However, if it will take time to obtain Ringer's lactate, use normal saline.

Crystalloids: Colloids:

  • Can exacerbate trans-mucosal fluid movement into the intestinal lumen

  • Are inexpensive

  • Easy to store with long shelf-life

  • Readily available

  • Very low incidence of adverse reactions

  • Varieties of formulations are available

  • Effective for use as replacement fluids or maintenance fluids

  • No special compatibility testing is required

  • No religious objections to their use

  • May have a longer duration of effect than crystalloids

  • Result in a net movement of fluid from the intestinal lumen to the blood

  • Much higher cost than crystalloid solutions

  • Small but significant incidence of adverse reactions (esp. anaphylactic reactions)

Routine maintenance

There are many formulas found in different books talking about the type and amount of fluids and at which rate it should be given. These formulas are helpful, yet decisions must be based on careful assessment of the patient’s individual needs.

Maintenance fluid formula:

  • Paediatrics (The Holliday-Segar Method):

    • For 0-10 kg = weight (kg) x 100 mL/kg/day

    • For 10-20 kg = 1000 mL + [weight (kg) x 50 ml/kg/day]

    • For > 20 kg = 1500 mL + [weight (kg) x 20 ml/kg/day]

    • Infusion rate (ml/hr) = total fluid volume per day ÷ 24 hours

  • Adults:

    • For first 10kg = 4mL/kg/hr

    • For second 10kg = + 2mL/kg/hr

    • For >20kg = + 1mL/kg/hr

For patients who are obese, adjust the IV fluid prescription to their ideal body weight. Use lower range volumes per kg (patients rarely need more than a total of 3 litres of fluid per day) and seek expert help if their BMI is more than 40 kg/m2.

Iatrogenic volume overload is quite common, therefore, one should be careful in patient who are/have:

  • Older or frail

  • Renal impairment

  • Cardiac failure

Common rates used in Kuwait:

1 pint = 500ml = 0.5L

Rate Total ml Total Pints/24hours
20 ml/hr* 480 ml ~ 1 pint
40 ml/hr 960 ml ~ 2 pints
60 ml/hr 1440 ml ~ 3 pints
80 ml/hr 1920 ml ~ 4 pints
100 ml/hr 2400 ml ~ 5 pints
120 ml/hr 2880 ml ~ 6 pints

*20ml/hr is also known as Keep Vein Open (KVO)

Common fluids used in Kuwait:

Name Na+ Cl- K+ Ca+2 Other components
Normal Saline 154 154 0 0 -/-
DNS 154 154 0 0 Dextrose 50g
D-0.5-NS 77 77 0 0 Dextrose 50g
D-0.25-NS 34 34 0 0 Dextrose 50g
D-5 0 0 0 0 Dextrose 50g
D-10 0 0 0 0 Dextrose 100g
Ringer’s Lactate 130 109 4 3 Lactate 28meq/L
Hartman’s 131 111 5 4 Lactate 29meq/L

Per litre (2 Pints)

MEDICATION DOSAGE LIST

Cardiovascular
Generic Brand Dose
Adenosine Adenocor

SVT 6mg IV in large vein over 2 seconds, if necessary followed by 2ND 12mg, 3RD 12mg (1-2 min apart)

(Can cut dose to quarter if given with dipyridamole)
Amiodarone Cordarone Oral loading dose: 200mg TDS for one week, then 200mg BD for further week Maintenance: 200mg OD
Amlodipine Norvasc/Istin HTN/ Angina Starting: 5mg OD/ Max: 10mg OD
Aspirin Jusprin

Primary prevention: 75-300mg OD

Secondary prevention (i.e. for ACS, CABG, PCI): 160-325mg OD
Atenolol Tenormin HTN 25-50mg daily // Angina 100mg daily. Arrhythmias: 50-100mg daily
Atorvastatin Lipitor Starting: 10mg OD/ Maintenance 10-40mg OD / Max 80mg OD
Bisoprolol Concor HTN/ Angina 5-10mg OD/ Max 20mg
HF Starting: 1.25mgOD/7, then 2.5mg/7, then 3.75mg/7, etc. Max 10mg
Candesartan Atacand HTN Starting: 4-8mg / Maintenance: 8mg / Max: 32mg Daily OD
Captopril Capoten HTN Starting: 6.25-12.5mg BD or TDS / Maintenance: 25-50mg BD / Max: 150mg Daily
Carvedilol Dilatrend HTN/ Angina Starting: 12.5mg OD/ Maintenance 25-50mg Daily
HF Starting: 3.125mg BD, Increased by 3.125mg every 2 weeks/ Max 25mg BD
Chlorthalidone Hygroton HF Starting: 25mg / Maintenance: 50 / max 200mg. Dose: once morning
Clonidine Catapres HTN 50-100microg TDS Max: 1.2mg/day
Clopidogrel Plavix Atherothrombotic prevention: 75mg OD ACS: 300mg initially, then 75mg OD
Dabigatran Paradaxa Prevention of stroke and systemic embolization in patients with non-valvular A.fib: 150mg BD (if patient at high risk of bleeding, elderly, receiving verapamil/amiodarone then Max dose is 150mg Once daily)
Digoxin Lanoxin Oral loading dose for AFib: 0.75-1.5mg over 24hrs in divided doses (rapid digitalization)
AFib Maintenance: 125-250microgram (according to renal function)// HF: 62.5-125microgram/day OD
Diltiazem* Tildiem
Bitildiem SR		 Tildiem (immediate release) Starting dose: 60mg TDS (BD in elderly)
Bitildiem SR (prolonged release) Starting dose: 90-120mg BD Max: 360mg/day in divided doses
Dipyridamole Persantin

coronary insufficiency: 150-225/day divided doses

Adjunct to oral anticoagulation for prophylaxis of thromboembolism associated with artificial heart valve: 300-600mg/day in TDS or QDS
Enoxaparin Clexane DVT Treatment: 1-1.5mg/kg Subcutaneously (S/C) every 24hrs until adequate oral anticoagulant
Prophylaxis: 40mg S/C OD or BD if high risk e.g. obesity, hip replacement, decrease to 30mg OD if CrCl<30
Furosemide Lasix

Fluid overload Oral dosing Starting: 40mg morning/ Maintenance 20-40 mg daily / max 80-120mg daily

IV furosemide to PO conversion is approx.. 1:2, i.e. oral dose is twice as much as IV dose due to bioavailability. Dose: By IM or slow IV or slow IV infusion initially 20-50mg then increased in steps of 20mg every 2 hours if required. Max 1.5g/day. (>50 mg by IV infusion only).
Glyceryl Trinitrate GTN Sublingual: 1 tablet under tongue, repeated as required, if no improvement with 3 Tabs, advice patient to seek urgent medical advice Spray: spray 1 dose under tongue and close the mouth.
Heparin (UFH) Heparin Treatment: IV loading dose for severe PE (75units/kg), then IV infusion 18Units/kg/hr. Prophylaxis: 5000units every 8-12 hrs
Hydralazine Apresoline

HTN 25mg BD / Max 50mg BD

HF Starting: 25mg BD/TDS Maintenance: 50-75mg QID Max: 300mg/day
Hydrochlorothiazide Esidrex HTN Starting: 12.5-25mg Max 50mg daily
Indapamide Natrilix SR 1.5mg daily in the morning
Isosorbide Dinitrate* Isoket R / Isordil / Isorem Angina: 30-120mg in divided doses. LVF: 40-160mg up to 240 divided doses
Isosorbide Mononitrate* Imdur Angina 60mg OD (AM) decrease to 30mg if headache occurs Max: 120mg OD in morning
Labetalol Trandate HTN Starting: 50-100mg BD Maintenance: 200mg BD/Max: 2.4g
Lercanidipine Lercadip HTN Maintenance: 10mg OD / Max: 20mg
Lisinopril Zestril HTN Starting: 10mg OD/ Maintenance: 20mg OD/ Max: 80mg // HF Starting: 2.5mg OD/ Max: 35mg OD
Methyldopa Aldomet HTN Starting: 250 TDS Max: 3g/day
Metoprolol Lopressor

HTN Starting: 50mg BD/Maintenance 200mg in divided doses/ Max: 400mg daily in divided doses

Angina/ Arrhythmias: 50-100mg BD or TDS
Nifedipine* Adalat LA (Long Acting) HTN 20-30mg OD, increased if necessary up to 90mg/day
Prazocin Minipress HTN Starting: 0.5mg BD or TDS up to 1mg BD or TDS Max: 20mg in divided doses
Propranolol Inderal

Prevention of secondary variceal bleeding: 40-80mg BD/ increase according to HR/Max 160mg BD

HTN: 80mg BD, Max: 320mg/day
Arrhythmias: 10-40 TDS/ QDS// Angina: 40mg TDS Maintenance: 120-240mg
Rosuvastatin Crestor Starting: 5-10mg OD/ Maintenance 10-20mg OD/ Max 40mg OD
Simvastatin Zocor Starting: 10-20mg OD/ Maintenance 20-40mg OD / Max 80mg OD
Spironolactone Aldactone Oedema/ ascites 100-400mg // HF: 25 mg Max 200mg in divided doses
Telmisartan Micardis HTN Starting: 20-40mg/ Maintenance: 40-80mg / Max: 80mg OD
Valsartan Diovan HTN Starting: 40mg/ Maintenance: 80mg/ Max 320mg Daily OD
HF Starting: 40mg BD / Max: 160mg BD
Verapamil***

Isoptin

Isoptin SR

HTN 240-480mg daily, 2-3 divided doses (usually BD)

SVT: 40-120mg TDS // Angina: 80-120mg TDS
NB: Isoptin SR Max dose 480mg daily in two divided doses.
Warfarin Coumadin Too complex to be summarized, (see warfarin page 109)
In case of rapid anticoagulant action, usual adult dose 5-10mg on 1st day, subsequent doses upon PPT or INR
Gastrointestinal Medications
Generic Brand Dose
Domperidone Motilium Antiemetic 10-20mg up to TDS Max: 80mg daily
Esomeprazole Nexium 20-40mg OD higher doses in Zollinger-Ellison
Hyoscine Butylbromide Buscopan PO 10mg up to TDS, before food (higher doses are possible in severe conditions)
Metoclopramide Primperan Anitemetic 10mg PO or IV up to TDS
Omeprazole Losec / Gasec / Risek 20-40mg OD higher doses in Zollinger-Ellison
Ondansetron Zofran Post-op N&V 8-16mg PO 1ST hr before anaesthesia, then 8mg // chemo-induced N&V 8mg BD/TDS (PO)
Pantoprazole Proton 40mg OD/ BD dose for H. Pylori and higher doses in Zollinger-Ellison
Rabeprazole Pariet 10-20mg OD higher doses in Zollinger-Ellison
Ranitidine Zantac

PO 150mg BD or 300mg at night for benign gastric/ duodenal ulceration

Prophylaxis of NSAIDS induced ulcers: 300mg BD

IV/ IM: 50mg TDS or QDS
Endocrine System
***(steroids doses vary widely according to indication)***
Generic Brand Dose
Carbimazole Neomercazole Starting: 15-40mg/day until euthyroid/ Maintenance: 5-15mg for 12-18months (Max 2 years)
Dexamethasone Dexone/Dexol 0.5-10mg po daily
Fludrocortisone Florenif 50-300microg/day
Glibenclamide Daonil Starting: 5mg / Max: 15mg (with breakfast)
Gliclazide Diamicron MR Starting: 30mg /Maintenance: 60mg /Max: 120mg OD (with breakfast) PO
Glimepiride Amaryl Starting: 1mg, increased by 1mg/ Max 6mg (with main meal) PO
Glipizide Minidiab Starting: 2.5-5mg with breakfast / Max: 20mg (divide doses >15mg) PO
Hydrocortisone Hydrocort 20-30mg po in divided doses
Levothyroxine Eltroxin Starting: 50-100microg/day Maintenance: 100-200microg/day PO
lower dose in elderly and IHD
Metformin Glucophage Starting: 500mg OD/ Maintenance: 500-1000mg BD/TDS usual/ Max 2g/day PO
Prednisolone Predsol Starting: 10-20mg po daily (Max: 60mg)/ Maintenance: 2.5-15mg
Sitagliptin Januvia 100mg OD PO
Anti-Epileptics
(the doses for epilepsy)
Generic Brand Dose
Carbamazepine Tegretol Starting: 100-200mg OD/BD / Maintenance: 0.8-1.2g in divided doses/ Max 2g/day
Gabapentin Neurontin

Starting: 300mg OD, day 2: 300mg BD, day 3: 300mg TDS.

Maintenance: 900-3600mg in divided doses/ Max 4.8g/day
Lamotrigine Lamictal Starting: 25mg OD for 14days, increased to 50mg next 14days etc / Maintenance: 100-200mg/day in divided doses
Levetiracetam Keppra Starting: 250mg OD, increase in steps of 250mg BD every 2 weeks/ Max: 1.5g BD
Phenytoin Epanutin Starting: 3-4mg/kg OR 150-300mg/day/ Maintenance: 200-500mg/day OD or BD (Max daily dose is 500mg)
Status epileptics loading dose: 10-15mg/kg at a rate not exceeding 50mg/min with ECG monitoring
Pregabalin Lyrica Starting: 25mg BD/ Maintenance: 300mg/day/ Max: 600mg/day in 2-3 divided doses.
Topiramate Topamax

Starting: 25mg for 7days, increased in steps of 25-50mg/

Maintenance: 100-200mg in divided doses. Max: 500mg
Valproate Depakin Starting: 600mg in 1-2 divided doses and increased in steps of 150-300mg to 1-2g/day/ Max: 2.5g/day
Immunosuppressant
Generic Brand Dose
Azathioprine Imuran Immune Suppressant 1-3mg/kg daily/ Transplant rejection 1-2.5mg/kg daily
Ciclosporin Neoral Dose regimen very complex, low therapeutic index with too many drug interactions, dose in transplant is organ specific and whether combined with other immunosuppressant drugs. Check with senior
Methotrexate Methotrexate RA 7.5mg once weekly; increased by 2.5mg every 6 weeks according to response with monitoring of LFTs, RFT test after every dose increase/ Max: 20mg weekly
Mycophenolate*** Cellcept/ Myfortic

Cellcept: 1g BD/ Max 1.5mg BD

Myfortic: 720mg BD
Tacrolimus Prograf Dose regimen very complex, dose in transplant is organ specific and brand specific. Check with senior
Joint and Inflammatory (Oral doses)
Generic Brand Dose
Allopurinol Zyloric Starting: 100mg OD then increased according to plasma uric acid. Maintenance 100-600mg/ Max: 900mg. Doses > 300mg should be divided. Don’t exceed 100mg in severe renal/hepatic impairment
Celecoxib Celebrex 100mg BD or 200mg OD/ Max 400mg mg/day
Diclofenac*** Cataflam/ Voltaren 25-50mg BD or TDS/ Max 150mg/day Note: Voltaren R 100mg given OD
Etoricoxib arcoxia 30-90mg/day/ Max 120mg OD for acute gout, for 8 days only)
Ibuprofen Profen/Brufen 400mg TDS/QDS/ Max: 2.4g/day for short term use only
Indomethacin Indocid 50-200mg/day in divided doses
Mefenamic Acid Ponstan 250-500mg TDS
Meloxicam Mobic 7.5-15mg/day
Naproxen Proxen 500-1000mg OD or 500mg BD
Respiratory System
Generic Brand Dose
Beclometasone Dipropionate Beclazone Inhaled 100-400microg BD, once inflammation controlled, reduce to lowest possible dose.
Budesonide Pulmicort Inhaled according to severity, 200-400microg as single dose in evening or BD/ Max: 800microg BD
Budesonide/ Formoterol Symbicort Inhaled 1-2 puffs BD, reduce to one puff OD once control maintained/ Max: 4 puffs twice daily
Fluticasone / Salmeterol Seretide Diskus (powder) one blister (250 or 500 microg) BD // Evohaler (aerosol) 1-2 puffs BD
Fluticasone Propionate Flixotide Inhaled 100-500microg BD/ Max: 1mg BD (dry powder/aerosol prep)/ Maintenance lowest possible dose
Ipratropium Bromide Atrovent Inhaled 1-2 puffs up to 3-4 times/ day Nebulized: 250-500microg repeated as necessary or 3-4 times/day for COPD
Montelukast Singulair 10mg OD/evening
Salbutamol Ventolin Inhaled acute attack: 2-10 puffs repeated every 10-20min until attack subsides/ Maintenance: 1-2 puffs up to 4 times /day Nebulized 2.5-5mg up to 4 times/day
Tiotropium Spiriva Inhaled 18microg OD (dry powder prep)

Anti-Microbial Agents
Doses listed are the range for most common infection, always confirm the dose for a specific indication

In particular, meningitis and endocarditis doses are higher than listed and should always be checked with a pharmacist
Generic Brand Dose
Acyclovir Zovirax PO 200mg 5 times/day or 400mg 3 times/day. IV 5mg/kg TDS/ Max 10mg/kg TDS for encephalitis
Amikacin Mikacin IM/ slow IV Multiple daily doses: 15mg/kg/day in two divided doses, monitor plasma level.
Once daily dose 15 mg/kg/day, then adjusted according to plasma level
Max 1.5g/day and max cumulative dose 15g dose reduced if combined with nephrotoxic ABx
Amoxicillin Amoxicillin PO 250-500mg TDS // IM 500MG TDS // IV 500mg TDS up to-1g QDS (if severe infection)
Azithromycin Zithromax PO 500mg OD for 3days or 500mg on 1st day, then 250mg for 4days. (7-10 days in lyme disease)
Genital infections (Chlamydia trachomatis): 1000 mg OD
Cefotaxime Claforan IV 1g BD, increased in severe infection to 8g in 4 divided doses
Ceftazidime Fortum IM / IV 1g TDS or 2g BD/TDS/ Max 2g TDS for severe infection (elderly Max 3g/day)
Ceftriaxone Rocephin IV / IM 1g OD severe infection: 2-4g/day (divide doses >2g)
Ciprofloxacin Ciprobay PO 250-750mg BD (depending on indication) // IV 400mg BD or TDS
Clarithromycin*** Klacid, Klacid XL PO Klacid: 250-500mg BD, Klacid XL: 500mg OD (1g OD in severe cases) IV 500mg BD
Clindamycin Dalacin C PO 150-300mg TDS or QDS (if severe up to 450mg QDS)
IV 0.6-2.7g/day in 2-4 divided doses (if severe up to 4.8g/day divided)
Co-Trimoxazole (Septrin, Bactrum) Septrin
Bactrim		 PO 960mg BD // IV 960mg BD, up to 1.44g BD in severe infection
Flucloxacillin Flucloxacillin Slow IV 250-500mg QDS (endocarditis: 2g QDS, with other ABx)
Fluconazole Diflucan PO Varies widely according to indication
IV invasive candida infection: 400mg on first day, then 200- 400mg daily (depends on severity)/ Max 800mg daily (in cryptococcal meningitis continue Tx for at least 8 weeks)
Gentamicin Gentamicin IM/Slow IV Multiple daily doses: 3-5mg/kg/day in three divided doses.
Once daily dose 5-7mg/kg/day, then adjusted according plasma level
dose reduced if combined with nephrotoxic ABx, monitor plasma level.
Itraconazole Sporanox PO Starting: 200mg BD then 100-200mg OD (duration of Tx varies widely according to indication, call pharmacy)
Levofloxacin Tavanic PO/ IV 500mg OD or BD
Linezolid (Zyvox) Zyvox PO/ IV 600mg BD
Meropenem Meronem IV 0.5-1g TDS, in meningitis and cystic fibrosis 2g TDS
Metronidazole Flagyl PO 200-500 mg TDS // IV 500mg TDS
Moxifloxacin Avalox PO/ IV 400mg OD
Piperacillin + Tazobactam Tazocin IV 2.25-4.5g TDS/QDS
Teicoplanin Targocid

Before prescribing this medication you must get approval from Microbiology/Pharmacy

Initial IV: 400mg BD for 3 doses, then 400mg OD (If Pt > 70kg; 6mg/kg q12d for 3 doses then 6mg/kg daily. Reduce the dose if combined with other nephrotoxic ABx (higher doses in some indications)
Tigacycline Tigacil Starting: 100mg, then 50mg BD
Vancomycin Vancomycin IV 1-1.5g BD (500mg BD or 1g OD in elderly),
Monitor plasma level: pre-dose plasma [conc] should be 10-15mg/L.
Reduce the dose if combined with other nephrotoxic ABx
Voriconazole Vfend PO 400mg BD for one day, then 200mg BD/ Max: 300mg BD
IV 6mg/kg BD for one day, then 3-4mg/kg every 12 hrs.

CLASS DESCRIPTION

Angiotensin converting enzyme inhibitors (ACEi)
Examples

Lisinopril ( Zestril )

with hydrochlorothiazide (Zestoretic )

Captopril ( Capoten)

Caution! Reduce renal perfusion, if SCr increases > 20% of baseline discontinue and suspect renal artery stenosis. Do not use in bilateral renal artery stenosis. Monitor renal function esp. if patient is taking NSAIDs as risk of impairment is higher.

SE: Angioedema, first-dose hypotension if initiated with diuretics, Hyperkalaemia (risk is greater if patient is taking K sparing diuretic e.g. spironolactone).
Pregnancy: Teratogenic, avoid in females of childbearing age.
Angiotensin receptor blockers (ARB)
Examples

Telmisartan (Micardis),

with hydrochlorothiazide (Micardis plus)

Valsartan (Diovan),

with hydrochlorothiazide (Co-Diovan)

Candesartan (Atacand)

Irbesartan (Aprovel)
Monitoring and precautions as per ACE inhibitors.
In practice ARBs are reserved for those intolerant to ACEI (developed angioedema, dry cough), may have advantage of lowering CVD independent of BP lowering effect.
Dihydropyridine Ca2+ channel blockers
Examples

Amlodipine ( Norvasc)

Nifedipine ( Adalat R)

Lercanidipine ( Lircadip)

Contraindications: Can cause angina, do not use soon after MI (within 1 month), can be used for angina prophylactically, but not if patient is unstable.

Side effects: Ankle swelling, headache, may increase digoxin level (monitor plasma digoxin) and severe hypotension in patients with fixed cardiac output (aortic/mitral stenosis, MI) as they are vasodilators.
Non-dyhydropyridine Ca2+ Channel Blockers
Examples

Verapamil (Isoptin)

Diltiazem (Tildiem , Bitildiem SR)

Unlike diyhdropyridine Ca channel blockers, verapamil acts mainly on cardiac conduction (negatively inotropic).

Administration: Start low to reduce risk of bradycardia and measure HR before increasing dose.
Contraindications: Avoid in 2nd and 3rd degree heart block, severe LVF and with B-blockers as there is an increased risk of severe reduction in cardiac output (heart block).

Interaction: Monitor for increase in digoxin level (digoxin dose needs to be reduced by 25%).
Beta-blockers
Examples

Atenolol (Tenormin) with Chlorthalidone (Tenoretic)

Propranolol (Inderal)

Metoprolol (Lopressor)

Carvedilol (Dilatrend)

Bisoprolol (Concor)

Labetalol (Trandate)

Administration: Do not stop abruptly; severe rebound symptoms can precipitate ACS.
In HF, only start once stable (no bradycardia/ not hypotensive)

Contraindications: Not with verapamil, not suitable for unstable HF (slows the heart)
Caution! May mask hypoglycaemic symptoms therefore care in diabetes, sweating may be the only symptom of hypoglycaemia in diabetic patients taking a B-blocker. Do not give in cocaine users as can cause unopposed alpha adrenergic action.
Nitrate vasodilators
Examples

Glyceryl trinitrate (GTN)
Isosorbide dinitrate (Isoket R/Isordil)

Isosorbide mononitrate (Imdur)
GTN is short-acting for intermittent symptoms. Consider imdur/isordil (long-acting) for frequent attacks, their effect is slower but last longer. Hold if SBP <100.
Prescribing: Sublingual GTN, limit the spray for those who can’t dissolve TAB e.g. patients on drugs causing dry mouth (antimuscarinics) will have reduced absorption of sublingual GTN. Patient can develop tolerance rapidly, NB: need nitrate free period (e.g. remove patch overnight, avoid prolong use of IV GTN, BD regimen is 8 hrs apart)
Caution With other vasodilators eg. sildenafil, vardenafil, etc.
SE: GTN can cause throbbing headache, give paracetamol
Other vasodilators

Hydralazine

(Apresolin)

 If used alone, causes tachycardia and fluid retention, given with BB. Avoid after MI until stable (tachycardia can provoke angina). Suspect drug-induced SLE if unexplained illness, weight loss, arthritis, etc. develop.

Prazosin

(Minipress)

 Used as add-on therapy in patient responses poorly to other drugs (e.g. chronic renal failure).
SE: Collapse, so give initial dose on retiring to bed.

Methyldopa

(Aldomet)

 Usually reserved for chronic hypertension in pregnancy. Risk of hypotension in patients already taking antidepressants.
SE: Liver toxicity, avoid in active live disease, haemolytic anaemia and rebound hypertension if stopped suddenly.

Clonidine

(Catapres)

 Not commonly used, poorly tolerated, risk of brady-arrhythmia. Taper over time to avoid rebound HTN.
HMG-CoA reductase inhibitors (Statins)
Examples

Atorvastatin (Lipitor)

Rosuvastatin (Crestor)

Simvastatin (Zocor)

Pitavastatin (Livazo)

Prescribing: Patients with hypothyroidism should receive adequate thyroid replacement before starting lipid-lowering agent (untreated hypothyroidism increases risk of myositis + hyperthyroid itself can cause dyslipidaemia). Combining statins with fibrates increases risk of S/E (monitor LFTs and CK).
Administration: Bedtime (peak time for cholesterol synthesis), but atorvastatin and rosuvastatin may be given any time owing to their long half-life.

Pregnancy: avoid, decreased cholesterol synthesis linked to foetal developmental abnormalities.

SE: Myalgias (muscle pains) are commonly reported with statins, myopathy and rhabdomyolysis are rare (the risk increases in elderly, renal impairment, high doses). If muscle symptoms (weakness, tenderness) reported or creatine kinase [conc] elevated 5 times upper limit suspect myopathy.
Diuretics

Thiazides


Hydrochlorothiazide (Esidrex)

Chlorthalidone (Hygroton)

Indapamide

(Natrilix Sr)

Metolazone (Metoral)

Prescribing: Better choice for HTN than loop. Commonly prescribed with ACEI or B-blocker in a combo formulation (e.g., Zestoretic, Tenoretic).

Metolazone: Particularly effective when combined with a loop diuretic (even in renal failure); profound diuresis can occur; monitor carefully. S/E chest pain, chills

They are ineffective if GFR< 20ml/min; in low GFR, it is not filtered to reach their site of action (DCT).
SE: Hyponatremia, hypokalaemia, (monitor esp. with high doses or if patient takes digoxin). Can exacerbate diabetes and gout (reduces uric acid excretion)
C/I: in pregnancy, thrombocytopaenia, jaundice, electrolyte disturbance

Loop Diuretics

Furosemide (Lasix)

Bumetanide (Burinex)

 Prescribing: Loops are potent diuretics, they are useful for fluid retention and are less effective for HTN because a profound diuresis may activate compensatory mechanism (RAS) which can increase BP later. They are short acting with a half life of 6 hours and are usually given twice daily.
SE: Hypokalaemia, Rare but serious ototoxicity (tinnitus, deafness) usually after rapid injection
Interaction: Loop diuretics may precipitate kidney failure in patients concurrently taking an NSAID and an ACE inhibitor "triple whammy" effect

Potassium-sparing Diuretics

Spironolactone (Aldactone)

Eplerenone (Inspra)

 Prescribing: For patients with severe symptomatic heart failure and an LVEF <35% despite optimal therapy with an ACE, BB and diuretic if K<5 and not on an ARB. Also indicated in ascites with fluid and Na restriction.
Caution! Ensure that patient is not hypovolaemic before starting diuretic therapy. Electrolyte imbalance is common. Check electrolytes before starting and on a continuous basis
Anti-Arrhythmics
Adenosine (Adenocor) Administration: To terminate SVT, given as bolus under ECG monitoring with resuscitation facilities.
SE: Bronchospasm described as a thump within the chest but this feeling is short, not C/I in asthma or COPD but verapamil may be a better choice due to severity of effect.
Amiodarone (Cordarone) Has long T1/2 (25 to 100 days) and needs loading dose for rapid effect.
SE: Impaired vision, STOP! May lead to blindness; thyroid dysfunction (hyper/hypothyroidism), pneumonitis (suspect if patient reports progressive shortness of breath or chronic cough), hepatotoxicity, cardiac toxicity and arrhythmias
C/I in pregnancy and breast-feeding.
Interaction: Inhibits warfarin metabolism (monitor INR), reduces digoxin excretion (measure digoxin level). Be prepared to reduce their doses.

Digoxin

(Lanoxin)

 Prescribing: Renal function is the main determinant of digoxin dose, use digoxin plasma [conc] for dose adjustment. Elderly usually need low maintenance dose (0.0625mg) due to renal impairment and increased cardiac tissue sensitivity.
Administration: Long half-life, need loading dosing for AFib, but not for HF. Care with IV infusion, rapid infusion causes cardiac arrhythmia, heart block
Toxicity: Suspect toxicity if level (> 1.5 microg/L). Symptoms: N&V, blurred vision, vomiting. Antidote for digoxin overdose is Digibind. Toxicity increases with hypokalemia, therefore care in those taking diuretics.
Interactions: Serious interaction with verapamil, diuretics, amiodarone, propafenone, NSAIDS.
Antiplatelets/ Anticoagulants
ASPIRIN (Jusprin)

Prescribing: Antiplatelet action achieved by small dose (75-81mg). Indicated in non-valvular Afib with a ChadsVasc of 1, for secondary prevention of stroke and MI. Also indicated in ACS in non-enteric form at a dose of 160-300mg.

Administration: Enteric coated tablets, given before meals.
Caution: May occasionally provoke bronchospasm in those with nasal polyps/ uncontrolled asthma.
Warfarin (Coumadin) Prescribing: Anticoagulant. Used whenever long term anticoagulation required, slow onset of action 48-72 hrs. Initially can cause hypercoagulable state, so typically started with heparin coverage.
Starting dose: The initial warfarin dose is usually 10 mg (5mg for elderly, high bleeding risk) loading dose for 2 consecutive days followed by 5 mg, and is adjusted thereafter based on INR. An alternative approach is to start with 5 mg per day until the target INR is achieved
Interactions: Too many to list! Please refer to page 167 For full list. Note: especially azole antifungals including topical preparations and anti-epileptics. Always check before starting/ stopping drugs
Clopidogril (Plavix) Prescribing: Anti-platelet. Prescribed with ASA in the context of ACS at 300mg loading then 75mg, if DES placed for 1 year. Also indicated for stroke in cases of treatment failure with aspirin, peripheral vascular disease
Dabigatrin (Pradaxa)

Indications: PE/DVT, non-valvular Afib to reduce risk of stroke, to reduce risk of VTE post hip/knee replacement surgery

Prescribing: Rapid onset of action, significant interaction with verapamil, amiodarone, clarithromycin and grapefruit (anticoagulant effect increases, monitor closely)
Caution: Contraindicated in patients with severe renal impairment (CrCL < 30 mL/min) and Limited data in moderate renal impairment, treat with caution. Not for patients with mechanical prosthetic heart valves
Ticagrelor (Brilinta)

Prescribing: In combination with aspirin for the prevention of atherothrombotic events in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Patients undergoing coronary angio within 48 hrs of admission or unstable angina or NSTEMI.

Alternative to clopidogrel in certain patients undergoing PCI.

C/I: active bleeding, history of stroke or TIA

Cautions: weight < 60kg, d/c at least 7 days before elective surgery if antiplatelet effect undesirable, elderly, patients with increased risk of bleeding, concomitant use of drugs that increase risk of bleeding.

S/E: Anaemia, GI haemorrhage, haematoma, haematuria, haemorrhage, rash.

Pregnancy: Only if potential benefit outweighs risk.
Dipyridamole (Persantine)

Indications: Adjunct to oral anti-coagulation for prophylaxis of thrombo-embolism associated with prosthetic heart valves
Prescribing: Not recommended alone, weak antiplatelet and usually combined with aspirin.

SE: Vasodilating effect in large doses (flushing, headache), effect increases if given with adenosine
UFH (Heparin) Less commonly used, replaced with LMWH. Risk of hyperkalaemia, HIT, requires monitoring with aPTT aiming to keep it 1.5-2 X the upper limit of control aPTT. The Advantage of UFH over LMWH is that it has a short half-life and can be given as an IV infusion, therefore the effect disappears quickly once the infusion is stopped. There is also an antidote if bleeding occurs in the form of Protamine.
Enoxaprin (Clexane)
 Prescribing: Commonly SC injection, dose per Kg based on indication (prophylaxis or treatment) OD or BD regimen owing to its long half-life. Unlike UFH, routine monitoring not required and S/E such as HIT are less likely.
Caution! Renally excreted therefore accumulates in renal failure (half-life prolonged). The dose will need to be adjusted.

Factor Xa inhibitors

Rivaroxaban (Xarelto) Apixaban (Eliquis)

Prescribing: Initial treatment or prophylaxis of DVT. Low dose rivaroxaban in combination with aspirin alone or aspirin and clopidogrel, for the prevention atherothrombic events following an ACS with elevated cardiac biomarkers. Tx should be started as soon as possible after px has been stabilized. The usually duration of treatment is 12 months (oral).

C/I: Active bleeding, ACS, recent GI ulcer, recent brain, ophthalmic or spine surgery, significant risk of major bleeding.

S/E: Abdominal pain, constipation, diarrhea, dizziness, dyspepsia, haemorrhage, headache, hypotension, nausea, pain in extremities, puritis, rash, renal impairment, vomiting.

Do not initiate in patients with very high blood pressure, can increase risk of cerebral haemorrhage if initiated in patients with severe uncontrolled hypertension

Bleeding risk: Assess patients for bleeding risk (haemophilia, thrombocytopaenia, recent trauma/bleeding, active peptic ulcers, liver disease etc.)

Risk of bleeding increases if patient takes drugs that induce GI ulceration (NSAIDs, steroids)

Pregnancy: Avoid oral anticoagulant, these cross the placenta and increase the risk of intrauterine bleeding, switch to LMWH.

Malignancy: The only anticoagulant that can be recommended for treatment of VTE in the setting of malignancy is LMWH
Dopamine Antagonists
Examples

Metoclopramide (Primperan)

Domperidone (Motilium)
Prescribing: Prokinetic and cannot be given in GI obstruction.
Contraindication: Metoclopramide is contraindicated in phaechromocytoma (hypertensive crisis).
SE: Metoclopramide crosses the BBB and has an anti-dopaminergic effect, therefore can cause parkinsonism. Domperidone is less likely to cross BBB, therefore parkinsonism is less likely. A high prolactin level may also cause galactorrhoea and gynaecomastia.
Proton Pump Inhibitors
Examples

Omeprazole (Losec/ Gasec)

Esomeprazole (Nexium)

Pantoprazole (Proton)

Rabeprazole (Pariet)

SE: There is an increased risk in acquiring C.Diff in patients taking antibiotics and PPIs, always revise the indications and consider withholding PPIs or switching to ranitidine if no clear indication present.
Interactions: Omeprazole, Esomeprazole inhibit CYP450 enzymes, potential drug interactions esp. warfarin, clopidogrel and phenytoin. Pantoprazole should be used in preference to these as it is least likely to affect CYP450.

Beware! Prolonged use without diagnosis is discouraged as it can mask symptoms of gastric malignancy

Prescribing: For patients on NGT, prescribe losec MUPS, capsule contents shouldn’t be crushed.
Thyroid Medications
Levothyroxine (Eltroxin)
 Administration: Once daily in the morning, preferably before breakfast.
Prescribing: Start low (50-100microg) and go slow (increase every 4 weeks), initiate at lower doses (25microg) in elderly and IHD. Dose demand increases in pregnancy.
SE: CV events, if patients developed angina once started, withhold thyroxine for 1-2 days, and investigate IHD, restart at lower dose. Levothyroxine interferes with glucose level, monitor glucose level more closely once starting replacement and be prepared to increase diabetes medications including insulin.
Carbimazole
(Neomercazole)

Prescribing: Reduces thyroid hormone production with no effect on hormones already formed. For rapid symptomatic relief use a b-blocker (propranolol).

SE: Agranulocytosis however prophylactic measurement of FBC is not recommended as the onset is rapid and without warning. Advice to report any symptom of infection e.g. fever, sore throat and seek medical advice urgently.
Steroids
Examples

Hydrocortisone (Hydrocort)

Fludrocortisone (Florenif)

Dexamethasone (Dexol/Dexone)

Prednisolone (Predsol)
Administration: Morning to minimize disruption of diurnal pattern of cortisol production, night doses can cause insomnia (late doses can be given for replacement therapy).
Prescribing: Steroid dose needs tapering if given for > 3 weeks. Steroids with mineralocorticoid action; Fludrocortisone (potent), hydrocortisone (mild), cortisone (mild) cause Na/ water retention. Do not use where water retention is not desired (e.g. cerebral oedema). Use pure GCS such as dexamethasone, prednisolone
Pregnancy: Seek advice, risk of foetal HPA axis suppression.
SE: Acutely: insomnia/psychosis, depression, hypertension, glucose intolerance – measure glucose frequently, avascular necrosis of hip, hypokalaemia, always monitor K level in cardio-patient, esp. if receiving diuretics/ digoxin. Chronically: Osteoporosis - If GCS considered for > 3 months bone protection is recommended, reduced immunity - beware of infection, HSV, live attenuated vaccine, Cushings’ syndrome.
Insulin

Soluble Insulin

(Actrapid)

Aspart (Novorapid)

Lispro (Humalog)

 All short acting, but Aspart and lispro are rapid acting too (faster onset and shorter duration than soluble) given with meals, while soluble insulin is given 15-30 min before meals (SC injection)
NPH (Novolin) Intermediate acting (biphasic) given twice daily ( once with breakfast, once with evening meal )
Glargine (Lantus ) Long acting insulin cause less nocturnal hypoglycaemia, given OD at bedtime.
Others

Insulin detemir (Levemir)

Insulin glulisine (Apidra Solostar)

Insulin glargine (Toujeo)

Prescribing:

1. Basal-bolus regimen: short acting given 30 min before meal or with meals TDS and long acting insulin given OD at bedtime which causes less hypoglycaemia.

2. Twice daily: given once with breakfast and once with the evening meal.

3. Once daily basal insulin: Typically once someone has failed on oral hypoglycaemics. Only one injection given at bedtime (some may be given in the morning) and provides 24 hour cover.

Advantage of TDS short acting over BD biphasic is it is more flexible and accounts for different meal sizes and times. Reserve BD biphasic for patients with fixed meal schedule. Don’t mix Lantus with Actrapid.

Hypoglycemia: Teach patients to recognise and respond to symptoms of hypoglycaemia; note that sweating may be the only symptom in patients taking B-blockers which blocks the body’s sympathetic response.
SE: Insulin is anabolic, therefore causes weight gain.
Caution! Insulin demand increases in stress or illness, encourage patient to continue insulin during illness despite reduction in meals, keeping fluid in illness more important than eating (ensure hydration) and advice patient for frequent glucose level monitoring.
Interactions: Insulin effect is reduced by steroid therapy and thiazide diuretics

A formal insulin education by an educator is the standard of care in someone starting insulin therapy or who demonstrates lack of knowledge in this regard
Oral Hypoglycaemic Agents
Metformin (Glucophage) First line for pharmacological management of pts with T2DM.
SE: Risk of lactic acidosis due to increased glycolysis. Risk increases with NSAID use. Excreted by kidneys, discontinue in kidney injury as accumulation increases risk of lactic acidosis.
Suspend metformin prior to a test requiring contrast.

Sulfonylureas


Gliclazide (Diamicron MR)

Glibenclamide (Daonil)

Glimepiride (Amaryl)

Glipizide (Minidiab)

 Second line along with DPP-4 inhibitors if not meeting targets at 2-3 months on metformin. Works only when pancreatic beta cell still has insulin reserve
Interactions: Their metabolism is inhibited by fluconazole (diflucan) and itraconazole, avoid this combination.
SE: Weight gain, hypoglycaemia. Glibenclamide (Daonil) has a long T1/2, higher risk of hypoglycaemia
C/I: Contain sulpha group therefore not for patient with sulpha allergy. Care in hepatic disease as they are hepatically metabolised.

DPP-4 Inhibitors

Sitagliptin (Januvia)

 Prescribing: Add on therapy to metformin if not at target HbA1c by 2-3 months. Less risk of hypoglycaemia than with sulfonylureas and less likely to lead to weight gain.
New Anti-Diabetic Agents

Glucagon-like peptide-1 receptor

(GLP-1) agonists

Liraglutide (Victoza)

Prescribing: Type II DM in combination with metformin or a sulfonylurea, or both, in patients who have not achieved adequate glycaemic control with these drugs alone or in combination.

C/I: diabetic gastroparesis, IMD, ketoacidosis, moderate to severe CHF.

Caution: History of pancreatitis, mild CHF, thyroid disease.

Pregnancy: Avoid

S/E: Abdominal pain and distension, bronchitis, constipation, decreased appetite, diarrhea, dizziness, gastrointestinal disturbances, N&V, hypoglycaemia, malaise, tachycardia.

SGLT-2 inhibitors

Dapagliflozin (Forxiga)

Empagliflozin (Jardiance)

Prescribing: Type II DM as monotherapy (if metformin inappropriate) or in combination with insulin or other antidiabetic drugs (if existing treatment fails to achieve adequate glycaemic control).

C/I: Ketoacidosis.

Caution: CVD, elderly, electrolyte disturbances, hypotension. Cases of serious and potentially life-threatening cases of DKA have been reported. To minimize risk, test for raised ketones in patients with symptoms of DKA, discontinue treatment if DKA is suspected, if confirmed, correct and monitor glucose levels. Advise patients on how to recognised symptoms of DKA and to seek medical attention if they develop.

Pregnancy: Avoid.

S/E: Back pain, constipation, genital infection, hypoglycaemia, polyuria, puritis, UTI.
Anti-Convulsive Agents
Carbamazepine (Tegretol)
 Caution: It induces its own metabolism, measure plasma drug level after 2 weeks from time of dose increase.
SE: Alert the patient to symptoms of blood, liver, skin dysfunction including fever, rash, mouth ulcers, bruising. Withdraw immediately in aggressive liver dysfunction or leucopaenia under cover of another antiepileptic drug.
Interaction! Many drugs, e.g. warfarin. It reduces efficacy of oral contraceptives.
Lamotrigine (Lamictal)
 SE: Skin reaction common (usually first 8 weeks), if severe (SJS) stop immediately esp. if there are any flu-like symptoms. Rare but serious bone marrow toxicity (aplastic anaemia) is possible, therefore, advice patient to report fever, sore throat, mouth ulcers, unexplained bruising, bleeding etc.
Interaction: Co-prescription with TCA reduces its efficacy.
Levetiracetam (Keppra) Prescribing: reduce dose in severe hepatic/renal impairment. Unlike other antiepileptics, has no significant drug interactions.
Phenytoin (Epanutin) Caution! Follows non-linear kinetics with low therapeutic window therefore a small increase in dose = large increase in plasma [conc]. This means a small increase in level may signify a much higher risk of toxicity. The best guide for dosing is plasma [conc.] Beware of drug interactions and always check before stopping, starting new medications that interfere or are metabolised by CYP450 enzymes.
SE: Suspect toxicity if any signs of confusion, N&V, slurred speech, nystagmus or blurred vision. Coarse face, acne, hirsutism, gingival hyperplasia (consider other drugs in young) and has an antiarrhythmic effect/ heart block risk if given IV (as in status epileptic) therefore is injected slowly with ECG monitoring. Although an anticonvulsant, seizures can occur at high doses secondary to hypoglycaemia induced by phenytoin itself.
Valproate (Depakine)
 Prescribing: Co-prescribe a folic acid supplement.
Interaction: Valproate can interact with phenytoin with unpredictable effect so avoid combination.
SE: GI side effects can be minimized if given with meals, causes oedema and weight gain as well as risk of liver toxicity, thrombocytopaenia, pancreatitis, alopecia and rashes.
Topiramate (Topamax) SE: Acute myopia (usually after 1 month of starting). Stop rapidly if affected. May lead to metabolic acidosis, cognitive changes, anorexia, diarrhoea/ constipation and nephrolithiasis to name a few from a long list.
Pregabalin (Lyrica)
Gabapentin (Neurontin)		 Not licensed as monotherapy for epilepsy. Maybe favourable because no drug interaction with other anti-epileptics or oral contraceptives. Has CNS depressant effect so care with other CNS depressants.
These are listed for long term control of seizures, for acute seizure please see the relevant Common Ward Call.
If one agent not effective; do not stop abruptly; taper the dose under cover of another antiepileptic. Avoid abrupt withdrawal which can lead to rebound seizures unless serious SE ensue
Beware: Antiepileptics commonly interact with each other.
Immunosuppressants
Azathioprine (Imuran)
 Prescribing: Start at low dose, build up to maintenance dose. Consider withdrawal if no improvement within 3 months.
Interaction: Serious interaction with allopurinol where the metabolism of azathioprine is significantly inhibited (reduce azathioprine dose by 75% if patient is also taking allopurinol).
Methotrexate
(Methotrexate)		 Prescribing: The usual dose is ONCE WEEKLY. Give folic acid 5mg on following day (not same day of methotrexate) to reduce haematological/GI SE.
SE: Pulmonary toxicity esp. RA patients/ neutropaenia/ liver fibrosis with long term use. If these occur stop the drug and give folinic acid (15-30mg q6h/24hrs).
C/I: Avoid in severe renal/hepatic impairment (accumulate) or in patients with large volume of ascites/ pleural effusion (accumulate in fluid and released later, toxicity).
Interaction: NSAID’s reduce its excretion with increased risk of toxicity.

Mycophenolate

(Cellcept, Myfortic)

 Prescribing: Better option for reducing transplant rejection but carries higher risk of infection and blood disorders. Avoid use with azathioprine (similar MOA) .
Beware! Cellcept and Myfortic brands are not interchangeable, strengths are inequivalent, do not switch. Myfortic is a gastroresistant formulation which claims to have less GI SE and is an option for patients with poor adherence due to N/V.
Tacrolimus (Prograf) SE: Hyperglcaemia, cardiomyopathy, nephrotoxicity and can worsen BP therefore not for patients with uncontrolled hypertension.
Interaction: Substrate for CYP3A4, large number of drug interactions.
Ciclosporin (Neoral)
 Caution: Highly nephrotoxic! Monitor kidney function, if serum creatinine/ urea increase during the first few weeks, adjust the dose in transplant patients after excluding renal rejection and discontinue in non-transplant patients.
Monitor BP, discontinue if patient develops hypertension refractory to drug treatment.
Interaction: It is a substrate AND INHIBITOR of multiple metabolic pathways. Avoid grapefruit and always check before starting or stopping any drug for patients receiving ciclosporin. Steroids increase plasma level of ciclosporin, this is quite important to note as they are often co-prescribed. Use with tacrolimus is specifically contraindicated.
Counselling: Advice patient to avoid excessive exposure to sunlight (risk of skin cancer). If acute visual disturbance occurs suspect benign intracranial hypertension and discontinue.
Prescribing: Should not be given to pregnant women, ensure adequate contraception in women of childbearing age. Requires dose adjustment in renal/ liver impairment.
Caution! Do not give live vaccines to patients receiving immunosuppressants. Be aware patient is at greater risk of infection.
SE: all have myelosuppressive SE, risk increases if co-prescribed with antifolate antibiotics (e.g. TMP-SMX). Advice patient to seek attention if any inexplicable bruising/ bleeding or sore throat.
NSAID’s And COX-2 Selective Inhibitors
Examples

Non-COX-2 selective:

  • Ibuprofen (Profen/Bruffen)

  • Diclofenac (Cataflam, Voltaren)

  • Indomethacin (Indocid)

  • Naproxen (Proxen)

  • Mefenamic Acid (Ponstan)

COX-2 selective:

  • Celecoxib (Celebrex)

  • Meloxicam (Mobic)

  • Etoricoxib (Arcoxia)
Prescribing: SOS doses are only as effective as paracetamol for intermittent mild pain (use paracetamol instead, safer option). For anti-inflammatory effect need to give regularly. Ibuprofen has a weak anti-inflammatory effect and is not very effective for acute gout.
Interaction: Reduce excretion of renally cleared drugs. Beware of renally cleared drug with low therapeutic indexes esp. ciclosporin, tacrolimus, methotrexate, digoxin and lithium.
Can cause water retention and antagonise diuretic action, withdrawal of NSAIDs will improve HF treatment and starting them can precipitate an acute exacerbation.
Pregnancy: AVOID as risk of intrauterine bleeding and closure of ductus arteriosus in utero.
SE: GI bleeding (use drug with lowest risk of bleeding (ibuprofen), indomethacin has higher propensity to induce GI bleeding compared to naproxen and diclofenac (Don’t co-prescribe regular NSAIDs with anticoagulants unless accompanied by a gastric protection). May provoke bronchospasm, however, is not necessarily contraindicated in in asthma, warn the patient to discontinue if any degree of worsening of asthma control occurs.
Inhalers

B-2 Receptor Agonists


Salbutamol
(Ventolin)
Salmeterol
Formeterol

 Prescribing: Salbutamol is short acting. The safest, most effective drug for an acute asthma attack. Salmeterol and formeterol are long acting and not for acute attacks. Tolerance can occur with long acting B2 agonist use.
SE: Hypokalaemia, tachycardia can occur with nebulized salbutamol, care in IHD.
Interaction: Increase risk of sympathetic SE (tachycardia) if combined with sympathomimetic drugs e.g. ephedrine (fludrex)

Muscarinic Receptor Antagonists


Ipratropium Bromide (Atrovent)
Tiotropium (Spiriva)

 Prescribing: More effective in COPD than B-agonist. Ipratropium is short acting while tiotropium is long acting.
The short acting ipratropium can be used for acute attacks in conjugation with salbutamol, as it takes a longer time to act and has less of a bronchodilator effect than salbutamol.
SE: Antimuscarinic effects so care in patients with glaucoma, acute glaucoma cases have been reported with nebulised ipratropium, protect eyes of patient with glaucoma if giving a nebuliser.
Caution: Can prolong QT, and cause hypokalemia which exacerbate QT prolongation

Inhaled Steroids
Budesonide (Pulmicort)

Fluticasone (Flixotide)
Beclometasone (Beclazone)

 Prescribing: Must be used regularly for maximum benefit, improvement within 3-7days.
SE: Hoarseness and oral candidiasis. LRTI in elderly COPD patients. Systemic steroid SE have been reported with prolonged high doses of inhaled steroids (nebulised). Do not use doses higher than necessary.

Beware! Increase bronchodilator use is sign of poor asthma control and suggests a need to review the treatment plan.

Prescribing: When introducing new agents starting with a single ingredient inhaler is preferred, this allows flexibility in dose adjustment. The combination products are appropriate for patients stabilised on individual components of the combination.
Administration: B2-agonist should be inhaled first followed by the steroid to increase delivery to the lung and reduce the risk of paradoxical bronchospasm.
Monitor: Hypokalaemia can be serious esp. in severe asthma with the use of B agonists, CS and theophylline. Monitor K in severe asthma.
Counselling: Explain to the patient that short acting B2-agonists only relieve symptoms (reliever), steroids alter pathology (inflammation) and need to be taken regularly to prevent worsening of asthma (preventer). Ensure people gargle following inhaled steroid use to avoid oral thrush.
Combination products: Symbicort (budesonide/formeterol) and Seretide (fluticasone/ salmeterol) are useful to ensure that long acting B2 agonists are not used without concomitant CS.
Anti-Microbial
Penicillins
Flucloxacillin
Amoxicillin
Penicillin G		 Renally excreted, accumulation of high doses (IV) produces encephalopathy and electrolyte disturbance.
Caution: Care in hepatic impairment, flucloxacillin can rarely cause cholestatic jaundice/hepatitis, up to 2 months after treatment.
SE: Diarrhoea, mild rash, C.diff colitis may occur.
C/I: Penicillin allergy
Piperacillin + Tazobactam (Tazocin)

Prescribing: A beta-lactam with antipseudomonal activity, Does not cover MRSA.

C/I: Penicillin allergy

3rd generation cephalosporins Ceftriaxone (Rocephine)

Cefotaxime (Claforan)

Ceftazidime (Fortum)

Prescribing: Cefotaxime is the drug of choice for meningitis (good penetration into CSF). Cefazidime has good activity against pseudomonas. Ceftriaxone has broad spectrum and longer half-life (once daily dosing).
Interaction: Can enhance warfarin effect, but the effect is inconsistent

C/I: Penicillin allergy
Macrolides
Azithromycin
(Zithromax)
Clarithromycin (Klacid)		 Similar spectrum to penicillin, alternative for patients with penicillin allergy. Not suitable for meningitis (no CNS penetration)
SE: Prolong QTc interval
Interaction: Clarithromycin is an irreversible CYP450 inhibitor with serious drug interactions
Metronidazole (Flagyl) For anaerobic, protozoa and C.Diff. infections.
Caution! Has a disulfiram-like reaction if used with alcohol. Reduce dose to one third once daily in severe live disease.
SE: Well tolerated, but peripheral neuropathy/ abnormal LFTs reported with prolonged treatment. Patient may report metallic taste with PO.
Interactions: Enhances warfarin action. Interacts with phenytoin and lithium.
Linezolid (Zyvox)

Prescribing: Never a first line drug. Resistant strains are emerging.

Use should be limited to vancomycin resistant pneumonia or severe MRSA skin and soft infection.
SE: Peripheral neuropathy (optic atrophy/ convulsions) and blood disorders including low platelets esp. if used > 28 days. Risk reduced by giving B6 (10mg) daily (should be routine with Zyvox). Advice patients to report any visual impairment (optic neuropathy),
Interaction: Linezolid is an MAOI so there is a risk of hypertension with drugs that increase catecholamine and dopamine (SSRI, TCA, MAOI, sympathomimetics etc.)
Co-Trimoxazole (Septrin, Bactrim)
 Prescribing: Although commonly used for UTI, should probably use another agent such as nitrofurantion or co-amoxiclav as co-trimoxazole has a big side effect profile (use should be limited to PCP pneumonia).
SE: Severe rash (SJS), crystalluria (ensure adequate fluid intake), hyperkalaemia, also has antifolate effect (suppresses bone marrow), which can be enhanced if patient also receiving another antifolate drug e.g. methotrexate.
C/I: Pregnancy (all trimesters), G6PD and haematological conditions.
Interactions: Increased bone marrow toxicity if given with azathioprine, phenytoin or methotrexate.
Quinolones

Levofloxacin (Tavanic)
Moxifloxacin (Avalox)
Ciprofloxacin (Ciprobay)		 Prescribing: Ciprofloxacin for UTI, no activity against Strep pneumonia. Respiratory quinolones include levofloxacin and moxifloxacin (good activity and concentrate well in the respiratory tract).
SE: QT elongation, hepatotoxicity (monitor LFTs), convulsions (lower seizure threshold, care in epilepsy), rare tendon rupture (risk increased in elderly with tendonitis or taking steroids).
C/I: Moxifloxacin has the greatest risk of QT elongation. Avoid quinolones if possible in patients with QT prolongation.
Clindamycin (Dalacin C) Prescribing: Concentrates well in bone and used for osteomyelitis.
SE: Highest risk amongst all antibiotics for antibiotic-associated colitis esp. if elderly and using it for >10days. D/C if severe diarrhoea develops.
Meropenem (Meronem) Reserved for second line or highly resistant organisms. Has broad spectrum coverage including pseudomonas. Does not cover MRSA. Not to be used in Type 1 penicillin allergy.
Vancomycin
(Vancomycin)
Teicoplanin (Targocid)

Prescribing: Gram (+) cocci and MRSA, Reserve for endocarditis and MDR bacteria. Never given orally except in severe C.Diff colitis.

Administration: IV infusion over 60-90 min, rapid IV injection may cause red man syndrome (fever, chills, rash)
Caution! Nephrotoxic and renally excreted, accumulates in renal impairment and worsens renal function, dose adjustment is required according to plasma [conc].
SE: Nephrotoxic and ototoxic, discontinue if tinnitus occurs
Interaction: Increased nephrotoxicity if given with aminoglycosides, furosemide, ciclosporin etc.

Aminoglycoside

Gentamicin

Amikacin

 Prescribing: For serious gram (-) infections. Gentamicin is first choice, reserve amikacin for gentamicin resistant gram (-) bacilli.
Dose: Calculated based on weight and renal function, then adjusted according to serum [conc], whenever possible don’t exceed Rx for 7days.
SE: Ototoxic and nephrotoxic (serum level should be <2mg/L before giving another dose), interferes with neuromuscular transmission (avoid in MG)
Monitor plasma [conc] level for dose adjustment.
Tigecycline (Tigacil) Active against MRSA and VREC but not pseudomonas. Reserved for complicated skin, soft tissue or abdominal infections by MDR strains.

Antifungals:

Fluconazole (Diflucan)
Itraconazole
(Sporanox)
Voriconazole
(Vfend)

Beware: Systemic fungal infections commonly an indication of immunosuppression, investigate the cause.
Prescribing: Fluconazole is always the first choice, itraconazole carries greater risk of liver/renal damage.
Renal impairment: Fluconazole dose, give usual first dose (mucosal candidiasis 50mg, invasive infection 400mg), then halve subsequent doses.
SE: Itraconazole may precipitate heart failure.

Interactions: Many! They inhibit CYP450 (check esp. warfarin)
Acyclovir (Zovirax) Poorly soluble and crystallises in renal tubules, keep patient hydrated. If po indicated typically give valaciclovir.
SE: Severe local inflammation at infusion site, nephrotoxicity.
Always ask about allergy history and specify the form of reaction. Most patients say they are allergic when they have only suffered simple, SE e.g. GI upset. Incidence of true allergy (anaphylaxis) is more likely in patients with atopic disease.
In renal impairment, the renally excreted antibiotic dose should be reduced esp. IV doses, because there is a risk of accumulation. Also IV antibiotic preparations contain large amounts of electrolyte (K, Na). As a rule of thumb, give the usual initial dose (to reach the desired plasma level), then reduce subsequent doses to prevent accumulation.
Combination Medications
Examples

Perindopril/Amlodipine (Coveram)

Valsartan/Amlodipine (Exforge)

Telmisartan/Amlodipine (Twynsta)
You can see each class description above
Miscellaneous
Allopurinol (Zyloric) Prescribing: Never start during an acute gout attack but do continue if attack develops when already on allopurinol. It is not a treatment for asymptomatic hyperuricaemia.
SE: Rash, nephrotoxicity.
Interactions: serious interaction with azathioprine (see azathioprine above)
Ranitidine (Zantac) Prescribing: Equally effective to PPIs for GORD, unless oesophagitis present in which case PPIs are recommended. Give BD if 24hr protection required.
Hyoscine Butylbromide (Buscopan)

Relieves bowel spasm, the GI relaxation effect is reduced if given with metoclopramide (prokinetic).

SE: Anticholinergic side effects esp. IV route (less likely with PO as poorly absorbed from GI).
C/I: In MG (anticholinergic), toxic megacolon, glaucoma.
Ondansetron (Zofran)

Prescribing: Antiemetic (5HT3 antagonist). For post- op N&V, once daily dose is usually sufficient, TDS dose reserved for chemotherapy induced N&V, where an antiemetic should be given prophylactically not PRN.

SE: Constipation, dizziness, and headache are common (slows post-op recovery), so limit its use. QT interval prolongation may occur.
Montelukast (Singular)
 Prescribing: For asthma prophylaxis. Not a steroid sparing agent and not more effective than inhaled CS, but has additive effect to CS. The benefit is seen in exercise induced asthma/ patient with rhinitis.
Interaction: Enhances warfarin effect.

Fenofibrate (Lipanthyl)

(Bezalip)

 Prescribing: Mainly decreases triglycerides.
Interaction: It increases the side effects of statins

WARFARIN ANTICOAGULATION

The decision to start Warfarin is made by a registrar or above, and is often a balancing act between risk of bleeding and benefit of anticoagulation.

Anybody starting on warfarin should be counselled prior, and the counselling documented. They should be informed regarding benefit, importance of taking medications at the appointed time and at the right dose, the risks of over and under-anticoagulation (including what symptoms to look out for), the need to monitor INR regularly, to be wary of certain foods, and wary of starting new medications. Double check to make sure the patient understands.

The loading dose for a Warfarin naïve patient is 5-10mg (unless elderly, increased risk of bleeding, hepatic impairment, CHF, CKD, in which case it may be prudent to start at lower doses).

Warfarin should be bridged with Heparin for at least 2 days after INR reaches therapeutic range. Occasionally, when anticoagulation is non urgent, Warfarin can be started without Heparin bridging. However, this decision is left to the discrepancy of a registrar or above.

Target INR on warfarin is 2-3, except for mechanical mitral valves and repeated thromboembolism whilst on warfarin, in which case the target is 3-4.

Most of the time you will be required to adjust Warfarin doses. A useful algorithm is shown on the following page.

*** If the INR is > 5, alert someone more senior ***

This topic cannot be adequately covered in one page, for further reading: BCSH – Guidelines on Oral Anticoagulation with Warfarin.

SEIZURES

Seizures are symptoms/manifestation of CNS and non-CNS related conditions. When treating a patient with seizures keep an open mind to what could be the underlying trigger. Below is a brief list of common CNS and non-CNS causes of seizures.

Secondary - Non-CNS Causes Primary - CNS Causes
Electrolyte disturbance Known epilepsy or first presentation
Eclampsia TIA, CVA, ICH
Hypoxia (MI, PE) Meningitis/Encephalitis
High BP (HTN Encephalopthay, ICH, Stroke) Trauma or head injury
Orbital cellulitis with extension to brain Space occupying lesion
Alcohol or drug intoxication or withdrawal Intracranial malformation

Reference:

  • Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. (2004). Ann Emerg Med, 43(5), pp.605-25.


AGITATION

Never attend to an agitated, angry or violent patient alone!

*** if you feel the environment is not safe activate code ***

Rapid assessment:

  • Ensure staff and patient safety

Think of a differential:

  • Delirium is disturbance in attention that occurs over hours to days representing a change from baseline and tends to fluctuate during the course of the day. Maybe due to a medical illness, substance abuse or drug side effect

  • Dementia: differentiated from delirium by careful history and exam

  • Alcohol withdrawal: History of alcohol abuse presenting with agitation, hallucinations, altered LOC. Life threatening presentations are seizures and delirium tremens.

  • Psychiatric illness: Mania, anxiety and psychosis

  • Poor communication: patient unable to sleep in a loud ward, not being updated by management and poor relationship between staff and patient

  • Other causes: Hypoglycaemia, Hypoxia, infection, drug overdose and intracranial lesion

Management:

  • Your first step in management is checking vital signs and if IV access available

  • Once safety has been secure management can be non-pharmacological or pharmacological and most commonly a combination of both

No- Pharmacologic

-Provide calm and quiet environment

-Use verbal techniques to address patients concerns help re-orient him. Be honest and straightforward offering supportive statements. Do no argue, condescend or command patient.

- Only use physical restraints if patient is at risk of harming themselves or others

- Assess vitals and check blood glucose levels
Pharmacologic

Indicated in severe cases ensuring no contraindications.

  • Haloperidol (Haldol) 1-2mg up to 5mg IV/IM or

  • Midazolam 2.5 – 5 mg IV/IM or

  • Lorazepam (Ativan) 1-2mg up to 4mg IV/IM

For more information on medications see section 4

After stabilizing the patient:

  • Document in the file time and reason of the ward call, your assessment and management and the senior you attended the case with.

  • Depending on clinical suspicion investigations are ordered:

    • CBC, RFT, Bone profile, LFT and ABG

    • Septic screen: PAN-C/S, CXR and LP

    • ECG: to exclude myocardial ischemia, arrhythmias, electrolyte manifestations

    • Drug level and toxicology report

    • CT or MRI brain to rule out haemorrhage, infarct or SOL

*** Never take any insults from patients at time of agitation personally and it should never alter your efforts in treating them. These words came out in a state of unawareness ***

References:

  • American Psychiatric Association, Diagnostic and Statistical Manual, 5th ed, APA Press, Washington, DC 2013.

  • Stern, T. (2010). he Assessment and Management of Agitation and Delirium in the General Hospital. Primary Care Companion to The Journal of Clinical Psychiatry, 12(1).

ACUTE OPIOID INTOXICATION

Reference:

  • Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2005; 23:589.

HEADACHE

DDx Features Investigations Management
Tension

Bilateral tight + band like pain with no associated features.

Waxes and wanes

 None

Simple Anelgesics:

Ibuprofen 400 mg PO

Paracetamol 1 gram PO

Perfelgan 1 gram IV

Naproxen 250 mg PO
Migraine Unilateral or Bilateral pulsatile/throbbing type of pain with known triggers +/- aura, N +V or teary eyes None

Acute:

NSAIDs or

Triptan combined with NSAID

Antiemetic if vomiting: Metoclopramide 10 – 20 mg IV
Cluster Unilateral stabbing pain occurring daily +/- teary eyes and runny nose None

Oxygen: nonrebreathing facial mask at rate 12 L/min patient in upright position for 15 mins

Triptan: intranasal Sumatriptan 20 mg contralateral side or s/c Sumatriptan 6 mg
Meningitis N+V signs of meningism, fever or petechial rash

↑WCC

CT head then LP

LP contraindicated if ↑ ICP

Antibiotics:

If community acquired then usually 3rd Generation cephalosporin:

Ceftriaxone 2 g IV BD

+

Vancomycin 15-20 mg per Kg IV every 8 – 12 hours

+

if > 50 yrs Ampicillin 2g iv 4rly against Listeria
Encephalitis Preceeding flu-like illness, altered LOC +/- neuro deficit or fever

↑ WCC +ve cultures, CXR if suspecting TB

CT Head/ MRI Brain (HSV), LP

 HSV +ve Acyclovir 10 mg/kg IV 8hrly
GCA (Temporal arteritis)

Jaw pain, unilateral headache

Visual changes, tender non pulsating temporal artery

↑ ESR + CRP

+/- normocytic anemia, low PLTs,

Temporal artery biopsy

Prednisolone (1 mg /kg/day) PO for 4-6 wks

+/- Aspirin 81 mg PO
Stroke Neurological deficit from history and physical exam

CBC, RFT, Coag Profile

ECG to r/o AF

CT Head +/- MRI

 Depends on whether hemorrhagic or ischemic
Hypertensive encephalopathy

Headache +/- visual symptoms

Altered LOC, dizziness, neuro deficits

BP >220/120

ECG (ischemia)

Fundoscopy Papilloedema

CT Brain: infarct vs hemorrhage

RFT/urine (AKI)

 See hypertension ward call
ICH Severe sudden onset headache, preceeding trauma, CSF otorrhoea, Skull fracture, neurological deficit, altered LOC a/ N +V CT Head

ABCE

Analgesia

ICU evaluation

ICP Control

Neurosurgical consult for possible craniotomy or evacuation
Brain Tumour Headache

Can mimic other headaches.

New onset neurological deficit or cranial nerve palsy

N+V, early morning headache. Aggravated by valsalva

 MRI brain with contrast Referral to Oncologist+ Neurosurgeon
Trigeminal Neuralgia Sudden, usually unilateral, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve CT or MRI brain to rule out secondary causes

Carbamezapine (Tegretol) titrated dose.

Or

Oxcarbazepine (Trileptal)
Acute herpes zoster and post herpetic neuralgia (PHN) Burning sharp or stabbing pain a/w unilateral vesicular rash in dermatomal distribution +/- trigeminal or cervical nerve involvelement

cultures, direct immunofluorescence testing and PCR

PHN pain persists >4 moths post HZV infection

< 72 hrs of onset of rash:

Acyclovir: 800 mg PO five times daily x 7 days

Valacyclovir: 1000 mg PO TDS X 7 days

Famciclovir 500 mg PO TDS x7 days

References:

  1. Dodick, D. (1997). Headache as a symptom of ominous disease. What are the warning signals?. Postgrad Med, 101(5), pp.55-6.

  2. Moore, R. (2014). Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. Pain, 155(11).

  3. Rozen, T. (2004). High oxygen flow rates for cluster headache. Neurology., 63(3), p.593.

  4. The International Classification of Headache Disorders, 3rd edition. (2013). Cephalalgia, 33(9), pp.629-808.

  5. Wood, M. (1996). Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Clin Infect Dis, 22(2), p.341.

SHORTNESS OF BREATH/DESATURATION

While on the phone, you should ask about:

  • Vitals and O2 saturation

  • Whether patient is on oxygen?

  • ECG

What to do:

DDx Acute/New SOB Acute-on-Chronic SOB

  • PE

  • ACS

  • Pneumothorax

  • Pleural Effusion

  • Anxiety

  • Cardiac Tamponade

  • Arrhythmia

  • Asthma/COPD exacerbation

  • CHF/Pulmonary oedema - very common

  • Pneumonia
History

Onset and duration of SOB

chest pain, cough, wheezing,

sputum production, palpitations
Exam

JVP, breaths sounds, added sounds

heart sounds for murmur/gallop

Look for signs of DVT

Chart/

Unit dose review

Past medical history

Recent operations or procedures

Medications that may cause bronchospasm

Review last CXR, ABG, Troponin levels
Invest.

ABG, CXR,

Troponin, CK-MB

D dimers if low suspicion of PE

Manag.

Manag. cont.

Get help

Sit patient up, Suction

Taper oxygen up face mask 100% non-rebreather

If desatting, urgent ABG

Notify ICU

Arrange for intubation/BiPAP if needed
Asthma/COPD CHF Exacerbation PE*
Consider adding new bronchodilator or increasing the frequency of current bronchodilators IV furosemide (lasix) stat, check potassium level and BP. Call For help if there is further worsening of SOB, drop in O2 stat Consider starting LMWH, before scheduling Spiral CT
Modified Wells Criteria for PE
Criteria Score
Symptoms and Signs of deep-vein thrombosis 3.0
Heart Rate More than 100 beats per minute 1.5

Recent immobilization or surgery

(more than 4 weeks)

 1.5
Previous PE or DVT 1.5
Haemoptysis 1.0
Active Cancer 1.0
PE more likely than alternate diagnosis 3.0
Total Score
=/< 4 PE unlikely
> 4 PE likely

ANAPHYLAXIS

Anaphylaxis is a generalized allergic reaction that could potentially be life-threatening, and it requires urgent diagnosis and treatment. The diagnosis of anaphylaxis is primarily clinical, therefore, early recognition of its signs and symptoms is crucial to prevent further complications. It is also important to remember that death from anaphylaxis can occur within MINUTES.

Signs and symptoms:

Skin Systemic

Generalized hives

Pruritus

Flushing

Swollen lips, tongue, uvula

Respiratory compromise

Reduction in SBP >30%

Persistent GI symptoms

(eg, abdominal pain, vomiting)

Management:

Immediate Management

Remove causative agent, if able to identify

  • E.g. ongoing IV medication, call for help, and give IM epinephrine

Inform Senior and ABCD

  • Airway management: If there is evidence of obstruction, intubate the patient immediately

  • If you feel the situation is unsafe or the patient is impending arrest then activate code blue

Intramuscular injection of epinephrine (delayed injection of epinephrine = associated mortality)

  • Give in mid-outer thigh (vastus lateralis muscles)

  • Dose: 0.01 mg per kg (max dose of 0.5 mg in one dose) – autoinjector is available in 0.15 mg and 0.3 mg forms

  • IM or SC 0.3-0.5 mL of 1:1000 dilution (1mg/mL) q5-20 min

  • Max is 0.5 mL per single dose

  • Repeat every 5-15 minutes (or as required). Most patients will respond to first 3 doses if given properly

If non-responsive to IM epinephrine, start epinephrine in the IV form.

  • HIGHER RISK OF ADVERSE CARDIAC EVENTS (Needs continuous electronic hemodynamic monitoring)
Post immediate management

  • If upper airway is not edematous, the patient should be supine with lower extremities elevated (pregnant patients on their left side)

  • Oxygen supplementation through non-rebreather mask at 15L/min

  • IV fluids – 0.9% isotonic fluids should be administered in normotensive adults (120 ml/hr)

    • If the patient is hypotensive, give 1-2L boluses of normal saline (may need to be repeated)

    • Followed by maintenance fluids

  • Keep patient is on continuous cardiopulmonary monitoring under direct observation
Follow up

  • Patients with moderate-severe anaphylaxis who do not initially respond to epinephrine should be admitted

  • A minimum period of 4-8 hours under observation for those with severe anaphylaxis

  • Prescribe and auto-injection upon discharge and educate the patient

  • May need to be referred to immunology team for further allergy testing and prolonged therapy

Special considerations and medications:

  • Transient symptoms of “fight or flight” response may be experienced initially.

  • Rarely, epinephrine may lead to ventricular arrhythmias, angina, MI, sharp increase in BP, pulmonary edema, and intracranial hemorrhage.

  • There are no contraindications to epinephrine but special attention should be given to the following patients who are at a higher risk for adverse effects: Cardiac patients, patients on MOA inhibitors/TCA/stimulant medications/cocaine, recent brain/aortic surgery, uncontrolled HTN.

  • Patients on BB may be resistant to epinephrine and may develop refractory hypotension. In this condition, glucagon may be added (1 to 5 mg slow IV bolus).

  • Salbutamol can be given for bronchospasm resistant to epinephrine (2.5-5 mg in 3 mL saline via nebulizer)

  • Adjunct medications: H1 antihistamines for urticaria, H2 antihistamine, glucocorticoid.

References:

1- Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117(2): 391.

2-Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10(4): 354.

Campbell RL. Diagnostic criteria for anaphylaxis. https://www.uptodate.com/contents/image?imageKey=ALLRG%2F72225 (accessed 14 December 2017).
3-Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62(8): 830.
-Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline for the treatment of anaphylaxis: cochrane systematic review. Allergy 2009; 64(2): 204.
4-Simons FE. Emergency treatment of anaphylaxis. BMJ 2008; 336(7654): 1141.
5-McLean-Tooke AP, Bethune CA, Fay AC, Spickett GP. Adrenaline in the treatment of anaphylaxis: what is the evidence? BMJ 2003; 327(7427): 1332.
6-Simons FE. Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened? Curr Opin Allergy Clin Immunol 2010; 10(4): 384.

CHEST PAIN

While on the phone, you should ask about:

  • Vitals and O2 saturation

  • Let them do an ECG by the time you arrive

What to do:

Must rule out

  • ACS

  • Pulmonary Embolism

  • Atrial Fibrillation

  • Pericarditis

  • Aortic Dissection

  • GI causes, e.g. Peptic ulcer disease
History

Pain history

Risk factors for ACS/PE
Examination

Cardiac examination (e.g. JVP, new murmurs, pulses,…)

Respiratory examination

Check for chest wall tenderness
Chart/Unit dose review

Past medical history

Recent operations or procedures

Review last CXR, ABG, Troponin levels
Investigations

ECG and compare with old ECG

Troponin, CK MB

ABG + CXR if there is a/ SOB

Call for immediate assistance if there is any drop in BP or saturation
Management ACS Atrial Fibrillation

If there is high probability of active ACS consider

Urgent cardiology consultation

(Call them!)

GTN (only if SBP>100)

Aspirin and Clopidogrel (Plavix) 300mg on spot

Morphine 5mg + Metoclopramide (Primperan) 10mg for pain

New-onset

Call for Cardiology assessment

Chronic

Check current medications for rate control

Can give a stat dose of Metoprolol (Lopressor) 50mg PO or 5mg IV or Digoxin 0.25mg po or 0.25-0.5mg IV, observe and repeat if needed (up to 1mg IV)

HYPERTENSION

Definitions:

  • Stage 1 = SBP 130-139 mmHg or DBP 80-89 mmHg

  • Stage 2 = SBP >140 mmHg or DBP >90 mmHg

    • based on the average of ≥ two properly measured readings in adults on no antihypertensive medication who aren’t acutely ill

  • Severe hypertension (> 180/120 mmHg)

***

Of note: there are new AHA guidelines in classifying hypertension which uses lower threshold for definitions. However, these guidelines have not been adopted by the majority

***

Investigating a hypertensive patient:

  • Urine Albumin:Creatinine ratio, RFT (?AKI)

  • Urine routine (hematuria, proteinuria, RBC, RBC casts)

  • Glucose, Sodium, and Potassium, CBC (anemia)

  • Toxicology screening (use of illicit drugs), Pregnancy test

  • ECG (LVF, MI) + Troponin, CXR (pulmonary edema)

  • Head CT if any change in GCS is documented

  • Consider CT angiography to rule out aortic dissection if chest pain, abdominal pain or discrepancies in BP or pulses

References:

  1. Enrico Agabiti Rosei, Massimo Salvetti, ‘Treatment of hypertensive urgencies and emergencies’, European Society of Hypertension, 7: No. 28, (2006).

  2. Prashant S, Anuj S, ‘Inpatient hypertension management’, American College of Physicians, (2014).

  3. Paul W, Robert C, Wilbert A, Donald C, Karen C, Cheryl H, et al, ‘2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and management of High Blood Pressure in Adults’, Journal of the American College of Cardiology, doi: 10.1016/j.jacc.2017.11.006, (2017), 139-144.

  4. https://guidelines.gov/summaries/summary/15712/clinical-practice-guidelines-on-arterial-hypertension-2007-update?q=shock

  5. https://emedicine.medscape.com/article/1952052-overview#a2

Hypertensive Urgency
Definition SBP > 180 mm Hg or DBP > 110 mm Hg without acute end-organ damage
Symptoms

  • Headache

  • Dyspnea

  • Chest pain
Signs

  • Measure BP (standing, supine, both arms)

  • Use appropriate cuff size

  • Measurement times should be timed accordingly to medication times

    • Post administration to avoid over medicating
Causes of acute increase in BP

  • Withdrawal or noncompliance with antihypertensive therapy

  • Poorly controlled or undiagnosed preexisting hypertension

  • Diet (high in salts and fat & >5 cups of coffee/day

  • Pain

  • Anxiety

  • Bladder distention

  • Antihypertensive medication withdrawal

  • Alcohol and narcotic withdrawal

  • Hypervolemia (saline infusion)

  • Postoperative state

  • Medications (e.g., corticosteroids, sympathomimetics, erythropoietin, cyclosporin).

  • Central nervous system disorders (e.g., head injury, stroke, brain tumors)
Management

  • Reinstitution or intensification of antihypertensive drug therapy

  • Treatment of anxiety as applicable

  • Monitor BP re-evaluate

Treat the patient and not just numbers

Always inform the senior of any change/addition of medications


Medications for Hypertensive Urgency:

Drug Dose Adverse events
Labetalol

Initial: 100 mg PO BD.

Increased by 100 mg BD every 2-3 days.

Usual dosage range: 200-400 mg PO BD.

Max: 2400 mg/day

Nausea.

Dizziness.

Heart block.

Bronchospasm.
Nicardipine

30-60 mg BD (extended release) OR

20-40 mg PO TDS

Dose modification if hepatic or renal failure.

Headache.

Flushing.
Hydralazine

10 mg PO QDS for 2-4 days.

Then 25 mg QDS daily for the 1st week.

Increase to 50 mg QDS from 2nd week on.

Adjust dose to lowest effective levels.

Hypotension.

Palpitations.

Conjunctivitis.
Captopril

12.5-25 mg PO.

May repeat SOS.

Hyperkalemia.

Hypersensitivity.
Amlodipine

Initial: 5 mg/day PO.

May increase by 2.5 mg/day every 7-14 days.

Max 10 mg/day PO.

Edema.

Pulmonary edema.

Headache.
Furosemide 20-80 mg PO divided BD.

Hyperuricemia.

Hypokalemia.
Hypertensive emergency
Definition SBP > 180 mm Hg or DBP > 120 mm Hg with acute end-organ damage.
History

  • Duration and severity of pre-existing hypertension

  • Medication history, Co-morbidities, LMP
Symptoms

  • Chest pain, Back pain

  • Dyspnea, Seizures, Visual disturbances
Signs

  • Retinal hemorrhages, exudates or papilledema

  • Distended JVP, Crackles on auscultation

  • Peripheral edema

  • Visual fields, Decrease in level of consciousness

  • Decrease in urine output

  • Focal neurologic signs, Abdominal mass, Bruits
Causes

  • As hypertensive urgency
Complications

  • Cerebral infarction, Pulmonary edema

  • Hypertensive encephalopathy

  • Congestive heart failure

  • Intra-cranial hemorrhage

  • Aortic dissection, Eclampsia, Acute MI
Management

  • Quickly initiate drug therapy targeted to the end organ affected.

  • Initial goal = partial reduction of BP by 20-25% within the 1st min up to 1-2 hours (avoiding ischemic complications such as MI & stroke).

  • Then lower to 160/100-110 mm Hg over the next 2-6 hrs.

  • If the patient is stable, gradually reduce pressure to a normal level over the next 24-48 hrs; otherwise consider ICU admission.

  • Once BP is controlled switch to oral treatment.

Caution

Avoid rapid reduction in BP when suspecting CVA


Medications for Hypertensive Emergency:

Drug Dose Adverse effects
Sodium nitroprusside

Initial: 0.3 mcg/kg/min

Titrate after 5 min as required

Max: 10mcg/kg/min

Avoid in neurologic emergencies.

Arrhythmia.

Hypotension.

Increased ICP.

Thiocyanate and cyanide toxicity (with prolonged use or renal or hepatic failure).
Labetalol

Initial: 20 mg IV over 2 minutes.

40-80 mg IV every 10 min.

OR 1-2 mg/min IV infusion.

Max: 300 mg

Nausea.

Dizziness.

Heart block.

Bronchospasm.
Nicardipine

Initial: 5 mg/hr slow IV infusion (50 mL/hr).

Increased by 2.5 mg/hr every 15 minutes.

Max: 15 mg/hr.

 Dose modification if hepatic or renal failure.
Esmolol

Loading: 0.25-0.5 mg/kg IV over 1 min.

0.05-0.1 mg/kg/min IV for 4 min.

May repeat loading dose or increase infusion up to 0.3 mg/kg/min if necessary.

Hypotension.

Injection site pain.

Nausea.
Hydralazine

20-40 mg IV/IM.

Repeat SOS.

Avoid in neurologic emergencies.

Hypotension.

Palpitations.

Conjunctivitis.

HYPOTENSION AND SHOCK

Definition:

  1. Absolute = SBP <90 mmHg; MAP <65 mmHg.

  2. Relative = Drop in SBP > 40 mmHg.

  3. Orthostatic = >20 mmHg drop in SBP or >10 mmHg drop in DBP with standing.

  4. Profound = Vasopressor-dependent.

Shock can be due to a multitude of causes:

Hypovolemic

Hemorrhagic

Non-Hemorrhagic
Distributive

Septic, SIRS

Anaphylactic, Neurogenic

Drug/Toxin and Endocrine shock
Cardiogenic

Myopathic, Arrhythmic

Mechanical
Obstructive Pulmonary, Mechanical

Combined/Mixed

When called to assess a hypotensive/shocked patient always consider what is the most likely cause and accordingly initiate the initial management

***

Never attend a hypotensive/shocked patient alone

***

Always inform your senior

***

For unconscious patients or patients who are unstable are impending on cardiac arrest

Activate Code Blue and follow the ACLS Guidelines

Management Overview for a shocked patient
History

Admitting diagnosis

Comorbidities

Possible causes of shock

Recent investigations, cultures, procedures
Assessment

Full head to toe examination (front and back)

CNS, CVS, RESP, Abdominal examination

Examine all orifices including PR exam to rule out GI bleeding

Examination of all drains and output (blood, pus, etc…)
Investigation

Blood: CBC, Coag, Electrolytes, RFT, LFT, Lactate levels, ABG, Troponin and CK

Cross matching: PRBC, FFP, Platelets, Cryoprecipitate

Cultures: Sputum, Blood, Urine, Stool, Drain outputs

Imaging: CXR, Ultrasound Chest/Abdomen/Pelvis, CT brain/Chest/Abdomen/Pelvis

Other: ECG and Echocardiogram
Possible interventions

Fluid Resuscitation

Blood product transfusion

Intubation and mechanical ventilation

CVC insertion for possible pressor support

Hemodialysis

Guided drainage or operative intervention

Endoscopy/Colonoscopy

SEPSIS

Definition:

Sepsis is a clinical syndrome that has physiologic, biologic, and biochemical abnormalities caused by a dysregulated inflammatory response to infection

Stages of sepsis:

Bacteraemia

  • presence of viable bacteria in the blood

Sepsis

  • life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic Shock

  • sepsis that has circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality than sepsis alone

Multi-Organ Failure

  • progressive organ dysfunction in an acutely ill patient, such that homeostasis cannot be maintained without intervention

Signs and Symptoms:

  • Symptoms and signs specific to an infectious source (eg, cough dyspnea may suggest pneumonia, pain and purulent exudate in a surgical wound may suggest an underlying abscess)

  • Arterial hypotension (eg, systolic blood pressure [SBP] <90 mmHg, mean arterial pressure [MAP] <70 mmHg, an SBP decrease >40 mmHg, or less than two standard deviations below normal for age). Because a sphygmomanometer may be unreliable in hypotensive patients, an arterial catheter may be needed. (See "Arterial catheterization techniques for invasive monitoring".)

  • Temperature >38.3 or <36ºC

  • Heart rate >90 beats/min or more than two standard deviations above the normal value for age

  • Tachypnoea, respiratory rate >20 breaths/minute

  • Signs of end-organ perfusion:

    • Warm, flushed skin may be present in the early phases of sepsis. As sepsis progresses to shock, the skin may become cool due to redirection of blood flow to core organs. Decreased capillary refill, cyanosis, or mottling may indicate shock.

    • Additional signs of hypoperfusion include altered mental status, obtundation or restlessness, and oliguria or anuria.

    • Ileus or absent bowel sounds are often an end-stage sign of hypoperfusion.

Investigations:

  • Same as above mentioned in hypotensive patients

Bed side assessment:

Systemic Inflammatory Response Syndrome (SIRS):

  • Temp >38°C or < 36°C

  • Heart rate > 90

  • Respiratory rate > 20 or PaCO₂ < 32 mm Hg

  • WBC > 12,000/mm³, < 4,000/mm³, or > 10% bands

A score ≥2 indicates presence of SIRS and if related to an infective process then sepsis

Sequential Organ Failure Assessment (Quick) qSOFA

  • GCS <15

  • Low blood pressure (SBP ≤ 100 mmHg)

  • High respiratory rate (≥ 22 breaths/min)

A score ≥2 is associated with poor outcomes due to sepsis

Management:

  • Notify Senior

  • ABCD

  • Maintain oxygenation

  • Fluid resuscitation and early use of blood products

  • Septic workup and starting broad spectrum antibiotics early (within the first hour)

  • CVP 8–12 mm Hg
    MAP ≥ 65 mm Hg

  • Urine output ≥ 0.5 mL/kg/hr
    Scvo2 ≥ 70%

    Source: http://www.survivingsepsis.org/Guidelines/Pages/default.aspx

ELECTROLYTE IMBALANCES

Hyperkalaemia (Serum K+ >5.3mmol/L)

Causes

Factitious

  • Prolonged inserted cannula

  • Haemolysed blood sample

  • Leukocytosis / Thrombocytosis

Excessive Intake

  • K supplements

  • Blood transfusion

  • High K diet

Extracellular Shift

  • Insulin resistance

  • Insulin deficiency, hyperglycaemia

  • Acidosis

  • Drugs e.g. Digoxin, non-selective B blockers

  • Tissue destruction:

(Haemolysis, Crush injuries, Rhabdomyolysis, Extensive burns, TLS, Vigorous exercise)

Decreased Excretion

  • Renal failure

  • Drugs e.g. spironolactone/ACEI/ARBs

  • Addison’s disease/ hypoaldosteronism

  • Type IV RTA e.g., 2ry to DM, UTI, SCD

Manag.

Manag.

Cont.

 Initial steps

  • Notify someone more senior

  • Do an ECG

  • Hold all medications that are associated with increased K+ levels
Stabilise/Protect the heart

  • 10ml of 10% Calcium Gluconate IV over 2 minutes
Increase intracellular shift of K+

  • 50ml of 50% Dextrose + 5-10units Actrapid IV

    • Omit dextrose if BS

  • 10-20mg nebulized Salbutamol (Ventolin)
Elimination of K+ from body

  • Lactulose 15ml bd

  • Small dose of furosemide (ensure not fluid depleted)

  • Ca++ Resonium* 15-30g tds (effect takes place after at least 4 hours)
Post treatment

  • RFT in 2-4 hours (Depending on the level of K+ and presence of ECG)

**Persistent elevated K+ levels +/- ECG changes is an emergency and may require urgent haemodialysis**

*Ca++ Resonium has been associated with severe constipation, bowel ischaemia and perforation. Thus, use with caution and should be given with laxatives

*ECG Changes include peaking of T-waves, flattened P waves, widening of QRS/PR interval, sine-wave formation, first degree, AVB, VF and/or asystole

Peaked T Wave Loss of P waves

Sine Wave Prolonged PR interval

Hypokalaemia (Serum K+ <3.5mmol/L)

Causes Renal Losses External Losses

  • Drug

    • E.g. Diuretics, Steroids, Aminoglycosides

    • Corticosteroid excess

  • Hyperaldosteronism,

  • Mg deficiency

  • Metabolic alkalosis

  • Vomiting, NGT suction

  • Barter’s syndrome

  • Fanconi’s syndrome

  • Renal tubular acidosis

  • DKA

  • Diarrhoea

  • Intestinal fistula

  • Laxative use
Intracellular Shift

  • Acute alkalosis

  • Drugs, e.g. Insulin, Salbutamol (Ventolin), Lithium

  • Hypothermia

  • Hypokalaemic periodic paralysis

Inadequate intake

(over 1-2 weeks)
Management

Mild

(K+ 3.1-3.5 + Asymptomatic)

  • Slow K 1x3 po

  • Repeat RFT next day

  • Always put a stop date when prescribing potassium
K+ <3.0

Moderate

(PAC, no PVC, no digoxin toxicity)

  • Notify senior

  • Slow K 2x3 PO OR 20mmol KCL in 200ml NS over 2 hours IV

  • Repeat RFT and Bone profile

Severe

(PVC with MI/digoxin toxicity or ECG changes*)

  • Notify senior

  • (KCL) 20-40mmol in 200-400ml NS respectively over 2-4hrs IV

  • Repeat KCL as necessary

  • RFT and Bone profile


*ECG changes include flattening of T waves, U Waves, Prolonged QT/QRS interval, A.Fib, Torsades de Points, ST Depression

Flattened/Inverted T waves and U waves

Hypernatraemia (Serum Na+ >145)

Always remember that hypernatraemia is not excess of sodium but a deficit of free water

Causes

Renal water loss:

  • Osmotic diuresis (high BG, loop diuretic, Mannitol, urea etc...)

  • Loop diuretics

  • Central/Nephrogenic diabetes insipidus

Non-renal water loss:

  • GI losses (vomiting, NGT drainage, diarrhoea)

  • Severe burns, fever

Water loss into cells:

  • Secondary to water shift intracellularly due to high osmolality after exercising or seizures

Sodium overload:

  • Sodium bicarbonate

  • Hypertonic solutions

  • Excess mineralocorticoids
History

Irritability, lethargy, confusion,

Delirium, coma, ataxia, vomiting

Diarrhoea, psychiatric disorders

Medications (Lithium, amphotericin, etc.)
Exam

  • Assess fluid status (Chest creps, LL Oedema, Ascites, Oligouria, Poor skin turgor)

  • Depressed reflexes

  • Hypothermia

  • Psuedobulbar palsy
Investigations

CBC, RFT, LFT, Bone Profile

Urine Na+, Urine Osm

Albumin, Uric Acid
Management

  • Treat underlying cause and replace free water deficit

  • If someone is also volume depleted (hypovolaemic) you need to replace volume first then free water

  • To calculate free water deficit: Na (serum) – 140/140xTBW

  • TBW (Total Body Weight) = 0.6 (men), 0.5 (women)

  • Aim for a rate of correction not more than 0.5mmol/L/Hr

Hyponatraemia (Serum Na+ <135)

Excess of water relative to sodium often related to high ADH appropriately or inappropriately

First thing to do:

Rule out causes of pseudohyponatraemia, such as:

  • High TG

  • High BS

  • Hyperalbuminaemia

Cause

of true

↓Na+

 Hypervolaemic
FeNa >1% FeNa <1%
Renal failure CHF, Cirrhosis, Nephrotic syndrome
Euvolaemic
Urine Osm >100 Urine Osm <100

SIADH, Hypothyroidism

Glucocorticoid def.

Psychogenic polydipsia

Beer potomania

Tea and toast diet
Hypovolaemic
Urine Na>20 , FeNa>1% Urine Na<10, FeNa<1%

Diuretics

Mineralocorticoid def.

Vomiting, Diarrhoea

NGT drainage, Pancreatitis
History

Fatigue, weakness, ataxia, confusion,

Lethargy, agitation, delirium, CHF,

Cirrhosis, renal disease, adrenal/pituitary dysfunction,

recent GI surgery, Thiazide/loop diuretics
Exam Assess volume status similar to Hypernatraemia table
Invest.

CBC, RFT, LFT, bone profile, Urine Na., urine Osm.,

albumin, uric acid
Manag.

  • Asymptomatic: correct serum Na at </= 0.5 mmol/L/hr

  • Symptomatic: RAPID correction serum Na @ 2 mmol/L/hr X 2-3 h using hypertonic saline until symptoms resolve
Hypervolaemic Euvolaemic Hypovolaemic

  • Salt and free water restriction

  • +/- loop diuretic

  • Treat underlying condition

  • Treat underlying cause

  • For SIADH: free water restrict + treat underlying cause

  • Volume replete with NS until dehydration parameters normalise

  • Aim for a slow rate of correction

Hypomagnesaemia (Serum Mg+ <0.7mmol/L)

  • An often overlooked cause of Low K+/Ca

  • Has potential to cause long QT and ventricular arrhythmias including Torsades de Pointe

  • Assess & treat underlying cause

  • MgSo4 2-4 g in 200ml NS IV over 2-4hours

  • Repeat Mg levels post correction

Hypercalcaemia (corrected Ca++ >2.6mmol/L)

Causes

  • Endocrine (Hyperparathyroidism, adrenal insufficiency, Vit D excess, Milk-Alkali syndrome)

  • Malignancy: MM, metastasis to bones, PTHrP secreting tumours (e.g. SCC of lung)

  • Medications: Lithium, Thiazides

  • Chronic granulomatous conditions: sarcoidosis, TB, histoplasmosis, amyloidosis

  • Other: Paget’s, FHH, CKD
History

Polyuria, polydipsia, N/V

dehydration, drepession,

confusion, coma, abdominal pain, constipation
Examination

General weakness

Epigastric tenderness

Depressed deep tendon reflexes
Investigations

Bone profile, RFT, Lipase, PTH

ECG

(shortened QTc, QRS widening, rarely BBB, high degree AV block)
Management

Needs more senior help/ Endocrinology advice

  • Initial steps include discontinuing medications which increase Ca e.g., Vit D, Thiazides, Lithium, promoting mobilisation and of course addressing the underlying cause.

  • The mainstay of therapy is adequate hydration with IV NS (4-6L/day depending on severity of hypercalcaemia).

  • Additional therapies e.g. calcitonin and bisphosphonates are best left to the discrepancy of someone more senior.

  • The evidence for use of loop diuretics outside the context of heart or renal failure is weak (Grade 2C)

Short QT on ECG Broad Complex arrhythmia

High grade AV Block


Hypocalcaemia (corrected Ca++ <2.2mmol/L)

Causes

  • Endocrine (true/pseudo hypoparathyroidsm)

  • Vit D deficiency (nutritional, sunlight deprivation, malabsorption, drugs)

  • Post Para-/thyroidectomy. Hungry bone syndrome

  • Chronic renal failure

  • Acute respiratory alkalosis (high pH causes more calcium to bind to albumin)

  • Malignancies (osteoblastic metastasis, TLS)

  • Other: pancreatitis, multiple blood transfusion, rhabdomyolysis
History

Weakness, muscle cramps,

Parasthaesia, depression, tetany
Examination

Paresthaesias

Chvostek’s and Trousseau’s sign
Investigations

CBC, Bone profile, RFT, LFT, Amylase

PTH, Vit D acc. to Hx and Exam

ECG: prolonged QTC
Management

Asymptomatic: Oral (Caltrate) 1-2g/day in divided doses

Symptomatic: Always notify someone more senior. 10% Ca++ gluconate (1-2g IV in 50ml of D5% or NS over 20 minutes). May require Ca++ infusion if severe.

If suspect Vit D +/- Mg+ may add each as appropriate

HYPOGLYCAEMIA

Definition:

  • Blood sugar equals or < 3.9mmol/l

    • New guidelines use a lower threshold for the definition but for the benefit of the patient and not to miss a hypoglycaemic episode we suggest to keep using the 3.9mmol/L cut-off

Causes:

  • Excessive, wrong time, or type of insulin

  • High dose of sulphanylureas

  • Missed meals

  • Alcohol ingestion

  • Renal failure

  • Sepsis

If unconscious or unable to tolerate oral intake

Step one:

  • If there is IV access: start 50ml of 50% dextrose IV

  • If there is no IV access: give 1 mg Glucagon IM or SC

Step 2:

  • If there is no response in 15 minutes

  • Repeat step one and establish an IV access until blood Glucose level is normalized and patient is more responsive

step 3:

  • Address the cause and manage accordingly

If conscious and able to tolerate orally:

Step one:

  • Give oral glucose 15-20mg orally

  • Or, glucose containing food/carb: juice or non-diet soda

Step 2:

  • Check blood sugar after 15 minutes: if still equals or <3.9mmol/l : repeat step one

step 3:

  • After normalization of Blood sugar: a meal or snack should be consumed.

Step 4:

  • Address the cause and manage accordingly

The cause of hypoglycaemia must be outlined. Insulin is usually the cause in an in-patient. Thus, hold/modify the dose as appropriate. In the rare case that it is not the cause then further investigations must be done to rule out liver disease, alcohol abuse, hypoalderonism, sepsis and other sources of insulin.

Reference:

http://care.diabetesjournals.org

HYPERGLYCEMIA (in the hospital)

Definition:

  • Fasting blood sugar level >7.8mmol/L, Or, Random blood sugar > 10 mmol/L in the hospital

  • Hyperglycaemia should be avoided in hospital care setting because it can cause electrolyte and volume disturbances

Causes in patients with documented DM:

  • Poor control

  • Stress (surgery, sepsis, severe illness)

  • Drugs (corticosteroids, thiazides, B-blockers, phenytoin, opiates)

  • Total parenteral nutrition

Approach:

  • First thing to do is to check if the patient is under any specific plan to control their BG, that being oral or insulin injections

    • When started on oral, it may take a few days for their BG to be controlled

  • Correctional insulin depends on the patient’s insulin sensitivity and is best estimated via their Total Daily Dose (TDD) of insulin

    • This varies from 0.5-1 unit/kg and occasionally more depending on body weight and renal function, the lower TDD

    • 100/TDD gives you the extent to which BG will drop with each unit of insulin

On average, these are the doses of Actrapid to administer:

Moderate TDD

Blood Glucose

Insulin

8-10

0

10.1-12

2

12.1-14

4

14.1-16

6

16.1-18

8

18.1-20

10

Otherwise, one should adjust the insulin regimen to minimize the need to give correctional insulin. Start with home basal insulin dose or calculating 0.2-0.3 units/kg/day (roughly 50%-60% of TDD) and adjust by 10-20% every 2 days to reach the target. Adjust the correctional insulin scale by 2 units/dose every 2 days if inadequate.

Hyperglycaemia Severity classification
Fasting 2 Hours post-Prandial

Mild: 6.1 to 11 mmol/L

Moderate: 11.1 to 22.5 mmol/L

Severe: >22.5 mmo/L

Mild: 11.1 – 16.5 mmol/L

Moderate: 16.6 to 27.5 mmol/L

Severe: > 27.5 mmol/L

Management:

  • Mild Hyperglycaemia: no urgent management. If not known to be diabetic, investigate.

  • Moderate Hyperglycaemia: check BG in the last 3 days. If he is on insulin, it should be adjusted.

    • Example: you were called because of BG 25 mmol/L:

    • FIRST: stat RBS measurement to confirm and urine dipstick to check for ketones

    • SECOND: give Actrapid 5 to 10 units S/C immediately. (your job during the on-call is not to put a plan for long term control of his DM but to prevent serious complications of hyperglycaemia such as DKA or HHS )

    • THIRD: monitor BG until normalization.

  • SEVERE Hyperglycaemia: IV Hydration and insulin

    • If the patient is unstable or had ketones in the urine:

      • Do ABG to check for acidosis and send RFT to check for electrolyte disturbances

    • If the patient is in the state of DKA or HHS: notify someone senior for help as soon as possible

      • As patient would require the initiation of an insulin infusion protocol

Important notes:

  • Remember to document in the file to notify the treating team in order to adjust the management plan

  • Always call for help if you are stuck

***

Prolonged use of sliding scale as the sole form of insulin is strongly discouraged

***

References:

  • On-call principles and protocols, Marshall Ruedy, 5th edition

  • American Diabetes Association in diabetes care 2017

Decreased Urine Output

Oliguria: Defined as urine output <0.5 mL/kg per hour (400 to 500 mL per day).

History:

  1. Assess duration of decreased urine output

  2. If there is an urge to void Think of outlet obstruction

  3. If patient is thirsty and has no urge to void Think of Volume depletion

  4. Catheterized patients: Sudden decrease in urine output could suggest catheter obstruction/kinking Flush catheter and re-assess

  5. Gradual decrease in urine output Pre-renal or renal (ATN) cause

Management:

Differential diagnosis:

  • From most common to least common

The RIFLE Criteria is then applied to assess the severity of the AKI and possible outcomes/need for dialysis

RIFLE Classification Creatinine criteria Urine output criteria

High sensitivity

High specificity
Risk Increased x 1.5; GFR decrease more than 25%. <0.5 mL/kg/hr for 6 hours
Injury Increased x 2 of 50% decrease in GFR <0.5 mL/kg/hr for 12 hours
Failure Increased x 3 or GFR increase of more than 75% <0.3 mL/kg/hr for 24 hours or anuria for 12 hours
Loss Persistent ARF more than 4 weeks
ESRD ESRD more than 3 months

References:

  1. Anderson RJ, Linas SL, Berns AS, Henrich WL, Miller TR, Gabow PA, et al. Nonoliguric acute renal failure. N Engl J Med 1977; 296(20): 1134.

  2. Eachempati SR. Oliguria. https://www.msdmanuals.com/professional/critical-care-medicine/approach-to-the-critically-ill-patient/oliguria#v925369 (accessed 2 December 2017).

  3. Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Madi AR. Oxford Handbook of Clinical Medicine, 8th ed. United States: Oxford University Press; 2010.

  4. McMahon BA, Phelan D, Murray PT, Marsh B, Power M. Oliguria and acute kidney injury. Barcelona: European Society of Intensive Care Medicine; 2010. http://pact.esicm.org/media/Oliguria%206Oct2010%20final.pdf (accessed 14 December 2017). 

  5. Sever MS, Vanholder R, Ashkenazi I, Biesen WV. Recommendations for the Management of Crush Victims in Mass Disasters. Nephrology Dialysis Transplantation  2012; 27.

FEVER

Definition

  • Oral at or over 37.7 °C

    • Make sure the patient didn’t have any recent cold/hot drinks

  • Axillary or tympanic Temperature at or over 37.2 °C

    • Make sure the patient didn’t undergo any recent strenuous physical activity

  • Rectal Temperature in the anus at or over 37.5–38.3 °C

What to do:

  • Rule out severe infection by looking for red flags (mentioned below)

  • Look for a focus – Full head to toe examination including all orifices and PR exam

  • If a recurrent episode of fever end

    • Send a septic workup – (CBC, CRP, PCT, CXR, Urine R/M, Urine C/S, Sputum C/S, Blood C/S, Wound swabs)

Unstable: Red flags: Stable:

  • ABC

  • Notify your senior

  • Aggressive volume repletion: give 20-40 ml/kg of crystalloids IV (repeat as required)

  • early antibiotics

*See Sepsis Chapter*

  • Ill looking patient

  • History of immunosuppression (e.g. Neutropenia, HIV, steroid therapy, malignancy…etc)

  • Hemodialysis

  • Asplenia/post splenectomy

  • Indwelling catheters

  • Hypotension

  • Siezures

  • Petechial rash

  • CNS symptoms (change in GCS)

  • Selective file and chart review, history, and physical examination looking for the cause

  • If no source is identified provide anti-pyretic medications and follow

  • If repeat episodes consider sending a full septic workup (mentioned above)

For sick patients after resuscitation:

  • Consider Lumbar Puncture (LP) sampling of CSF fluid in cases of suspected meningitis

    • Must rule out causes of elevated ICP – examination +/- CT scan of the brain

    • Send CSF samples for Gram stain and C/S, Glucose, Protein, PCR (Viral)

  • If high suspicion of meningitis, consider early administration of steroids and antibiotics

  • If patient is unstable/critical then consider ICU assessment for possible admission

***Document the event and your management in the file for the treating unit in order to be notified and manage accordingly***

References:

  • Laupland KB (July 2009). "Fever in the critically ill medical patient". Crit. Care Med. 37 (7 Suppl): S273–8

  • Barone JE (August 2009). "Fever: Fact and fiction". J Trauma. 67 (2): 406–9

  • Oncall principles and protocols, 5th edition

CONSTIPATION

Thought process

Your initial approach to constipation is to determine and differentiate constipation from obstipation. The latter consists of inability to pass both stool and flatulence which may lead to abdominal distension and vomiting of faecal matter or the more dangerous blind loop syndrome.

Obstipation is a surgical emergency while regular constipation is not
History

Detailed history regarding bowel habits:

  • Number of motions per day/week

  • Consistency of stool (hard, soft, watery), presence of blood

  • Straining or tenesmus

  • Pain during or after passing stool (fissure if throbbing pain)

  • Change in diet, amount of fibre intake

Overflow diarrhoea present?

Passing flatulence?

Bloating or abdominal distension?

Abdominal pain?

Vomiting? (faecal material)
Exam

Abdominal examination to look for any masses

Digital rectal examination (+/- proctoscopy) if clinically indicated:

  • Fissure

  • Rectum (empty or full of stool)

    • If stool present soft or hard

  • Mass or polyps

Chart

review

Previous episodes of constipation

Previous management

Change in medications

Known tumours or polyps of the GI tract
Invest.

  • Abdominal X-ray (supine vs erect)

  • CT abdomen if signs or symptoms of true constipation present

  • Proctoscopy +/- Sigmoidoscopy +/- Colonoscopy
Manag.

Depends on the nature of constipation and duration of presence:

  • Increase fibre intake, fluid and mobilisation

  • Laxatives once or regular

    • Bulking (normacol, movicol)

    • Osmotic (lactulose)

Obstipation is a surgical emergency thus inform your senior ASAP

DIARRHOEA

Def.

Definition:

Passing looser stool or an increase in the frequency of passing stool for an individual

Acute diarrhoea <2 weeks

  • Infection (viral, bacterial including C. Diff, parasitic etc)

  • Medication related (laxatives, stool softener, colchicine etc)

  • Mesenteric ischemia

  • Surgery (gastrectomy, bypass etc)

  • Faecal impaction with overflow diarrhoea

  • Early presentation of chronic diarrhoea

Chronic diarrhoea >2 weeks

  • Inflammatory (Crohn’s, UC)

  • IBS

  • Infection (amebiasis, C. diff etc)

  • Malabsorption (celiac, short bowel syndrome etc)

  • Metabolic (lactase def., pancreatic exocrine def. etc)
History

When did it start?

How many episodes?

Watery or frequent? Bloody?

Any recent change in medications? Any antibiotic use?

History of travel or ingestion of raw food?
Exam

Volume assessment:

  • Is the patient volume depleted? Do they look well?

  • Reduced JVP? (flat neck veins)

  • Low BP? Postural hypotension?

Elevated temperature? Sign if possible enteritis

Stool examination:

  • Watery stool? Or clear fluid?

  • Blood or blood streaks? FOB?

Chart

review

Previous episodes?

Previous triggers?

Use of broad-spectrum antibiotics?

Change in medications?

Previous electrolyte levels?
Invest.

If a patient experiences several episodes of diarrhoea, send for stool c/s stool routine and stool for C. Diff toxin.

During the on-call you should focus on investigating and treating:

  • The underlying cause

  • Volume depletion (RFT, BP, JVP)

  • Electrolyte imbalance (RFT)

  • Systemic infection (blood cultures x2, stool cultures and toxins to rule out C. Diff and other bacterial causes)
Manag.

  • Maintain hydration by giving normal saline 250-500 ml as a bolus in 1-2 hour and then either repeat or start maintenance fluids

  • Replace electrolytes as necessary

  • If patient is febrile then collect blood and stool samples and contact your registrar or senior regarding possibility of further therapy/ starting antibiotics

    • In the case of E. Coli o157:h7-related diarrhoea antibiotics can increase risk of haemolytic uremic syndrome (HUS)

NAUSEA AND VOMITING

Initial

Manag.

  • Sit patient up (turn to side if bed bound)

  • Use a basin or a waste bag to extract vomit

  • Suction any remaining material which might cause airway obstruction/aspiration

    • Provide O2 if any evidence of airway compromise

History

+

Exam

  • Identify any triggers

    • Medication, food, post anaesthesia, etc…

  • Distinguish vomiting from regurgitation/rumination

  • Onset (Acute vs Chronic)

  • Preceded by nausea? How long before?

  • Time of last meal

  • Content (food, bile, blood, mucus, faecal material)

  • Number of episodes of vomiting?

  • If bleeding did occur, was it after multiple episodes of vomiting?

  • Difficulty breathing

  • Evidence of bowel obstruction?

Chart

Review

Previous known triggers

Previous episodes

Previous management and whether it was successful
Invest.

CBC (if hematemesis)

RFT to assess urea/Creat and Electrolytes (hypochloremic hypokalemic alkalosis)

Amylase and Lipase

Pregnancy test for females of child bearing age

If ?bowel obstruction consider abdominal xrays
Manag.

  • Identify and remove triggers

  • Keep NPO + IV fluid replacement and maintenance

    • Fluid replacement with normal saline (0.9%)

    • with added Potassium as KCL as appropriate

  • Consider NGT placement if risk of aspiration or bowel obstruction is suspected

  • Supress the nausea and vomiting:

    • Metoclopramide 8-10mg IV STAT, or,

    • Ondansetron 4-8mg IV STAT

  • If vomiting persists then give regular metoclopramide and Ondansetron (can be both given up to TDS dosage)

    • Once vomiting subsided you can switch to oral form of medication and slowly taper down dose till cessation

To consider other causes of vomiting if vomiting persists

Examples:

  • Post op

  • Pregnancy

  • Vertigo

  • MI

  • Pancreatitis/Biliary disease

Reference:

  1. American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology. 2001; 120:261–3.

  2. Hasler WL, Chey WD. Nausea and vomiting. Gastroenterology 2003; 125(6): 1860-7.

  3. Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology 2001; 125(1): 263-86.

  4. Herlinger H. Guide to imaging of the small bowel. Gastroenterol Clin North Am 1995; 24(): 309-29.

GI BLEEDING

Def.

Bleeding anywhere from oropharynx to anus

Upper GI bleeding:

  • Bleeding occurring proximal to the ligament of Trietz

Lower GI bleeding:

  • Bleeding occurring distal to the ligament of Trietz

Initial

Manag.

Call your senior

  • Closely monitor airway, clinical status, vitals signs, cardiac rhythm, urine output, NGT output (if present). Provide supplemental O2. Keep patient NPO. Obtain ICU consultation if patient is unstable

  • Make sure that the patient does not aspirate if vomiting blood

  • Vital signs to assess severity: Tachycardia (10% blood loss, may be masked by beta-blockers), orthostatic hypotension (20% loss), shock (>30%)

  • Resuscitation: Insert 2 large-bore (18 gauge or larger) IV cannulas and ask nurses to collect blood samples (CBC, coagulation profile, group and cross-match for RBC and FFP)

  • Volume replacement with rapid bolus of isotonic crystalloids (1-2L) such as NS or RL – Repeat as needed until BP and HR normalize

  • Transfuse if hemodynamic instability despite crystalloids resuscitation, Hb <7mg/dL (or <9mg/dL in CAD patients). Avoid over-transfusion with patients with variceal bleeding

  • Reverse coagulopathy FFP and vitamin K to normalize PT. Keep plts >50,000

  • Gastrointestinal consultation and surgical consultation if severe bleeding.

  • Start IV PPI (loading then continues infusion – Omeprazole 80mg IV Bolus then 8mg/hour IV infusion)

  • If Variceal bleeding is suspected

    • Avoid NGT placement

    • With PPI start Antibiotic therapy (3rd Generation Cephalosporin)

    • Consider initiating beta blockers and Telipressin/Octreotide

History

+

Review

When did it start?

Other symptoms (e.g. pain)?

Sequence of symptoms?

Blood is fresh? Coffee ground? Or melaena?

Known blood disorder or liver disease?

Known GI disease? IBD? Malignancy?

Detailed medication history

Previous episodes?

Known triggers?

NSAID, antiplatelet, or anticoagulant use?

Known PUD, polyps, GI malignancy, IBD, diverticulosis?

Known blood coagulopathy, liver disease?
Exam

  • Vitals, JVP

  • Capillary refill time

  • Abdominal examination (tenderness, masses, hepatomegaly, surgical scars)

  • DRE: Fissure, Haemorrhoids, FOB, Masses
Invest.

  • CBC, coagulation profile

  • Grouping and Cross-matching
Manag.

  • GI bleeding is an emergency which may require endoscopy/colonoscopy or surgery

  • As an intern on-call your job is to call your senior and initiate the above mentioned initial management detailed above

Refrences :

  1. Sabatine MS. Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine, 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2014.

  2. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107(3): 345-60; quiz 361.

  3. Duggan JM. Gastrointestinal hemorrhage: should we transfuse less?. Dig Dis Sci 2009; 54(8): 1662.

  4. Saltzman JR. Rapid overview: Emergency management of severe upper GI bleeding in adults. https://www.uptodate.com/contents/image?imageKey=EM%2F72195 (accessed 14 December 2017).

FALLS

Roughly, about 30-40% of patients aged > 65 fall once each year. Major injuries requiring hospitalization occur in up to 5% of falls. Falls in hospital setting are more frequent and associated with higher morbidity than falls in the community. Usually only minor injuries result from fall such as bruises and scrapes. Falls mainly occur due to disruption of gait mechanism, balance and cardiovascular function mainly age related.

Risk factors: Risk of falling increases with an increase in number of risk factors

  • Past fall history

  • Lower extremity weakness

  • Female

  • Arthritis

  • Stroke history

  • Dizziness

  • Cognitive impairment

  • Anaemia
Medications:

  • Neuroleptics

  • Anti-depressants

  • Anti-psychotics

  • Benzodiazepines

  • Vasodilators

  • Anti-histamines

Evaluation:

Fall

ABCD

Vital signs

Focused History of event

Physical examination looking for major injuries

Investigations - CBC, glucose level guided by history and underlying comorbidities

Imaging only requested when suggested by history/exam
Post-Fall

History taking:

  • Activity at the time of fall

  • Precipitating symptoms such as dizziness, pain, imbalance

  • Where and when the fall occurred

  • LOC (associated with cardiac or neurological disease, orthostatic hypotension)

  • Information on previous falls should be collected to identify patterns, establish risk factors and target their modification

Physical Examination

  • Postural vitals

  • Targeted neurological examination

  • Gait

  • Visual acuity

  • Hearing

  • Examine extremities

There is no standard test for individuals who fall. However, Prevention is the best cure and all efforts should be aimed towards preventing falls from happening by incorporating walking aids, adjusting the environment and the inclusion of the occupational workers into the management process.

OVER-ANTICOAGULATION (WARFARIN)

Risk factors for bleeding

  • High intensity of anticoagulation (INR > 4)

  • Age ≥ 65 yo (exhibit greater than expected INR response to the anticoagulant effects of warfarin)

  • History of highly variable INRs

  • History of GI bleeding, hypertension, cerebrovascular disease, anemia, malignancy, trauma, or renal impairment

  • Certain genetic factors

  • Certain concomitant drugs

  • Long duration of warfarin therapy
Evaluation

History:

  • Intake of herbal medications, change in diet esp. increase in the intake of food containing elevated levels of vitamin K (such as green leafy vegetables) & any recently started, stopped or recent change in the dose of previous medications

  • Symptoms: Blood in stools or urine, hematuria, excessive menstrual bleeding, melena

Examination:

  • Vital signs: Tachycardia, hypotension

  • Petechiae, excessive bruising or persistent oozing from superficial injuries

  • Unexplained fall in hemoglobin
Comments

  • INR > 4 appears to provide no additional therapeutic benefit in most patients and is associated with a higher risk of bleeding

  • Maintenance of INR in the therapeutic range does not eliminate the risk of bleeding

  • Oral formulation of vitamin K may not be available
    You may administer oral doses of the parenteral preparation in juice or water

  • Oral vitamin K therapy may not be appropriate for patients with disorders that may affect the absorption of vitamin K such as biliary obstruction, liver insufficiency or other malabsorptive syndromes

  • For surgery that requires reversal of warfarin and that can be delayed 6–12 h, the INR can be corrected by giving IV vitamin K only

Important points to consider:

  1. Therapeutic INR can again be obtained by careful dosage adjustment.

  2. If rapid re-anticoagulation is indicated, heparin may be preferable for initial therapy.

  3. Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determinations every 1 to 4 weeks.

Inhibitor Inducer
Food & botanicals

  • Leafy green vegetables eg Spinach and broccoli (high in Vit K)

  • Alcohol

  • Anise & Dong Quai (potentiate anticoagulant effects)

  • Omega 3 fatty acids, garlic, ginger, Ginkgo biloba and Vit E (have anti-platelet properties)

  • Grapefruit (>24 ounces of juice)

  • Ginseng (anti-platelet properties and may inhibit coagulation cascade)

  • Fucus (Heparin-like activity)

  • St. John’s wort (interfere with drug metabolism)

  • Alcohol

  • Cigarette smoking
Drugs Amiodarone. Fluconazole. Metronidazole. Variconazole. Acyclovir. Ciprofloxacin. OCP. Virapamil. Amlodipine. Atorvastatin. Anti-TB. Ranitidin. Carbamazepine. Rifampin. Montelukast. Omeprazole. Phenytoin. Prednisone. Dabigatran. Heparin. Aspirin. Clopidogrel. Dipyridamole. Celecoxib. Diclofenac. Ibuprofen. Indomethacin. Mefenamic acid. Naproxen. Citalopram. Duloxetine. Escitalopram. Fluoxetine.

References:

  1. Mike M, Joost V, Campbell T, Andrew M, Mike L, ‘Guideline on the management of bleeding in patients on antithrombotic agents’, The British Committee for Standards in Haematology, 160: 1 (2013), 35–46.

  2. Warfarin Therapy - Management During Invasive Procedures and Surgery. British Columbia guidelines. 2015.

  3. Flowchart:
    BCGuidelines.ca: Warfarin Therapy – Management During Invasive Procedures and Surgery: Appendix A (2015).

  4. Amitava Dasgupta, Prescription or Poison?: The Benefits and Dangers of Herbal Remedies (Turner publishing company,2011).

  5. PL Detail-Document, How To Manage High INRs in Warfarin Patients. Pharmacist’s Letter/Prescriber’s Letter. May 2012.

  6. http://www.ptinr.com/en/home/warfarin-you.html

  7. Sigmund S, Hans H, Christoph B, ‘Optimal platelet inhibition after coronary stent implantation. Current status’, PubMed, 33(4), (2008), 244-53.

DIABETIC KETO ACIDOSIS AND HYPEROSMOLAR HYPERGLYCEMIC STATE

Definition:

  • DKA: is characterized by a triad of hyperglycaemia, anion gap metabolic acidosis and ketonaemia

  • HHS: severe hyperglycemia with little or no ketoacid accumulation with neurological abnormalities frequently present

DKA HHS
Mild Moderate Severe
Plasma Glucose mmol/L >13.9 >13.9 >13.9 > 33.3
Arterial pH 7.25-7.35 7.00-7.24 <7 >7.30
Serum Bicarbonate mEq/L 15-18 10-15 <10 >18
Urine Ketones + + + small
Effective serum osmolality (mOsm/kg) variable variable variable >320
Anion Gap >10 >12 >12 Variable
Alteration in sensoria or mental obtundation Alert Alert/Drowsy Stupor/Coma Stupor/Coma


Predisposing Precipitants

  • First onset type 1 DM – no residual insulin secretion

  • Young (usually)

  • Often the patients never previously diagnosed with DM i.e it is the presenting complaint in many cases

  • Poor nutrition

  • Female – dieting and skipping insulin

Sepsis

  • Usually a URTI or UTI

  • Often underlying precipitating insulin/trauma or surgery

  • Elevated stress hormones (cortisol and glucagon)

Inadequate insulin therapy

  • Non-compliance

  • Inadequate dose

  • Malfunction of insulin device

Iatrogenic/ drug

  • Steroid

  • Cocaine

Pregnancy
Insulin should never be stopped even when the intake of food is reduced during an illness in type 1 diabetics, as insulin requirements may even increase due to rising peripheral insulin resistance from counter-regulatory stress hormones such as glucagon


Management

Phase 1

Rapid Assessment

  • ABC Airway, Breathing and Circulation (Vitals!)

  • Mental status GCS neuronal dysfunction due to: hyperosmolality, hyperglycaemia and acidosis

  • Precipitating event Sepsis, MI etc

  • Volume status skin turgor, low JVP, tachycardia, dry mucous membranes, urine output if available

Phase 2

Investigations

  • Serum glucose

  • Renal Function test : check electrolytes, BUN and Creat, plasma osmolality

  • VBG, ECG

  • Depending on case: Septic work up, lipase/ amylase or troponin

Phase 3

MANAGEMNT VIA BASIC CONCEPTS

  1. Stabilise patient’s airway, breathing and circulation

  2. Obtain large bore IV cannula (> 16 Gauge) + cardiac monitor

  3. Monitor serum glucose hourly, basic SUE (including bicarbonate), VBG every 2-4 hours until patient is stable

  4. Determine and treat any underlying cause of DKA

  5. Fluid replacement regular re-assessment is critical, adjust dose as needed!

  • Fluids

    • Typical fluid deficit 5-6L

    • Give several litres of IV isotonic saline as rapidly as possible in patients with sign of shock

    • Use 0.9% NaCl 15-20 mL/ Kg/ Hour (i.e 1- 1.5 L per hour for an avg sized adult) in the absence of cardiac compromise for the first few to hypovolaemic patient swithout shock

  • Monitor serum Sodium

    • After intravascular volume is restored give 0.45% saline at 4 to 14 mL /Kg per hour if the corrected serum Na is normal or elevated. Continue 0.9% if serum Na is reduced

  • Monitor serum glucose: when reaches 11-13 mmol/L

    • Add dextrose to saline solution

  1. Potassium monitoring and replacement

  • Mointor serum K and have continuous ECG monitoring

  • No need to replace immediately priority is for fluid replacement then K

  • <3.3 mmol/ l

    • Hold insulin and give IV KCL 20-40 mEq per hour

  • 3.3-5.3 mmol/L

    • Add 20- 30 mEq to 1L of infusing IV fluid

    • Maintain serum K between 4- 5 mEq /L

  • >5.3 mmol/L

    • Patient stable: observe and repeat K level in 2 hrs

    • Stop any K infusion

Patient unstable, deteriorating or worse parameters in 2 hrs

Re-check

Consider cardio protection/ dialysis/ etc

  1. Insulin

  • Do not give insulin if initial serum K , 3.3 replete k and flud deficit first

  • Insulin 0.1 unit/ Kg IV bolus then continuous IV infusion 0.1 units/ kg per hour

  • If serum glucose does not fall by 2.8 – 3.9 mmol/L in first hour double rate of insulin infusion

  • When serum glucose reaches 11.1 mmol/L decrease infusion rate to 0.02 – 0.05 units/ Kg/ hr

  • Continue insulin infusion unitl ketoacidosis resolved, serum glucose < 11.1 and subcutaenous insulin is given

  1. Prophylactic SC Heparin or LMWH

  • DKA is a hypercoaguable state

  • Be sure to offer VTE prophylaxis .. LMWH/TED stockings

  1. IV ABs if warranted

  • Empiric ABs as guided by examination findings and local policy

10.Acidosis Correction

  • It will usually correct with rehydration alone

  • In severe acidosis (pH <6.9) Conatct ICU! Treatmen initially Sodium Bicarbonate 100 mEq + 20 mEq KCL in 400 mL sterile water over 2 hours, may be repeated if ph < 7

Potential

Complications

Cerebral oedema and osmotic demyelination

  • Typically occurs 8-24 hrs after starting fluid

  • If osmolality/glucose/Na is altered too rapidly the mortality from cerebral oedema or osmotic demyelination can approach 90%

  • Headache, lethargy, stupor, decreasing GCS/LOC all can be features of cerebral oedema

  • Beware of possibility of herniation if needed consider Mannitol

  • May also need IV DEXAMETHASONE!

  • Careful glucose and osmolar correction to prevent demyelinating


A note on Euglycemic DKA:

  • A condition in which serum glucose is normal or near normal

  • Conditions associated:

  • Patients with poor oral intake

  • Treatment with insulin prior to arrival to emergency department

  • Pregnant women

  • Drugs: SGLT2 inhibitors such as Canagliflozin, Dapagliflozin and Empagliflozin

    • The glucosuria these drugs produce can minimise or block the development of hyperglycaemia when insulin levels are too low to prevent the development of ketoacidosis.

  • Management often involves both insulin and glucose to reverse ketoacidosis.

References:

  1. Kitabchi AE, Razavi L.Hyperglycemic Crises: Diabetic Ketoacidosis (DKA), And Hyperglycemic Hyperosmolar State (HHS). In: http://www.endotext.org/diabetes/diabetes24/diabetesframe24.htm

  2. Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab 2015; 100:2849.

  3. Emmett M. Case 6: Diabetes and Acidosis. In: NephSAP: Nephrology Self-Assessment Program: Fluid, Electrolyte, and Acid-Base Disturbances, Sterns RH, Emmett M (Eds), The American Society of Nephrology 2013. Vol 12, No 3, p.191.

  4. Murthy K, Harrington JT, Siegel RD. Profound hypokalemia in diabetic ketoacidosis: a therapeutic challenge. Endocr Pract 2005; 11:331.

  5. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32:1335.

BLOOD TRANSFUSION REACTIONS

General management:

  1. Stop the transfusion – in all reactions

  2. Check the vital signs of the patient and make sure patient is stable

  3. Examine for fevers, chills, hypotension, bleeding at IV sites, haematuria, bronchospasm, evidence of volume overload, chest or back pain, rashes etc.

  4. Cross check the blood bag and products with the patient’s identifying information

  5. Notify the blood bank of the event.

  6. Send the remainder of the blood products back to the blood bank

Reaction Presentation Investigation Management
Haemolytic Transfusion Reaction (HTR) Fever/chills, dark urine, back pain, hypotension, DIC ABO and full antibody screen, CBC, coagulation screen, LDH, haptoglobin, bilirubin, blood film, DAT, urinalysis Aggressive hydration, diuresis, support DIC with blood products as necessary
Febrile Non- Haemolytic Transfusion Reaction (FNHTR) Fever/ chills Make sure no evidence of HTR, Sepsis, TRALI stop transfusion, give paracetamol IV . Pethidine if severe chills or rigors then resume the transfusion
Allergic Reaction Uriticaria Hold transfusion for 15-20 mins to see if signs of anaphylaxis e.g. hypotension/ bronchospasm develop. If no symptoms/signs of anaphylaxis, can resume and give diphenhydramine 25-50 mg IV +/- hydrocortisone 100mg IV
Anaphylaxis Swelling, hypotension, wheezing, Epinephrine 0.5ml of 1:1000 solution S/C or IM. If severe reaction epinephrine 0.5ml of 1:10000 solution IV.
Transfusion – Related Acute Lung Injury (TRALI) Hypoxia, fever, hypotension CXR, ABG Respiratory support
Transfusion Associated Circulatory Overload (TACO) Volume overload CXR, ABG

Oxygenation and ventilator support

Diuresis
Bacterial contamination and sepsis Fever, hypotension Send G stain and cultures of blood product and the patient after transfusion stopped and CBC

Stop Transfusion

Broad spectrum Ab and haemodynamic support

***

A fever is defined as >1 degree increase in temperature since starting the transfusion

***

Keep in mind there may be another process going on unrelated to the blood transfusion.

***

Reference:

  • Clinical Transfusion Medicine Committee of the AABB, Ann Intern Med. 2012;157(1):49

  • AABB Technical Manual, 17th, Roback JD, Grossman BJ, Harris T, et al (Eds), American Association of Blood Banks Press, Bethesda, MD 2011. p.237.

  • Bloody Easy: A Guide to Transfusion Medicine, by Callum JL et al

    • http://policyandorders.cw.bc.ca/resource-gallery/Documents/Transfusion%20Medicine/Bloody%20Easy%204.pdf

POST-OP CALLS

Post-OP Fever

Days 1-3 Days 4-6 Days 7 +

  • Atelectasis

  • Metabolic response to trauma

  • Drug reactions

  • SIRS

  • Line infection

  • Instrumentation of a viscus/tract causing transient bacteraemia

  • Chest infection

  • Superficial wound infection

  • UTI

  • Line infection

  • Chest infection

  • Suppurative wound infection

  • Anastomotic leak

  • Deep abscess

  • DVT

Investigations and management are the same as general fever


Post-OP Hypotension

Postoperative hypotension can occur relatively frequently in sick and elderly patients after an operation.

Causes of Postoperative Hypotension Clinical Features Immediate Management
Hypovolaemia - from inadequate fluid replacement, ongoing fluid losses, postoperative haemorrhage.

  1. Signs of poor peripheral perfusion; cold clammy extremities and pallor

  2. Tachycardia may be present but may be masked by Beta-blockers

  3. Low urine output (oliguria)

  1. Elevate the legs

  2. Give fluids: crystalloid or colloid

  3. Assess for bleeding (look at drains!)

  4. Measure FBC
Arrhythmias

  1. Irregular, slow or fast pulse

  1. Measure BP and assess perfusion

  2. Record and monitor ECG

  3. Correct underlying causes (e.g. potassium and magnesium)

  4. Treat arrhythmia according to type
Left ventricular failure – causes include over-infusion and perioperative myocardial infarction.

  1. Poor peripheral circulation

  2. Tachycardia

  3. Hypoxia

  4. Clinical evidence of pulmonary oedema

  1. Oxygen

  2. Fluid restriction

  3. Diuretics

  4. Inotropic support on HDU/ITU if necessary
Septic shock

  1. Raised cardiac output and vasodilatation in the early stages

  2. Vasoconstriction and reduced cardiac output when more advanced

  1. IV fluids

  2. CVP monitoring, inotropic support, HDU/ITU as appropriate

  3. Antibiotics after taking blood cultures

  4. Look for surgical cause


POST CENTRAL LINE INSERTION CXR

What are the things you should be aware of in the CXR?

  1. Confirm the tip is in the correct position. It should lie in the superior vena cava, outside the right atrium in order to prevent arrhythmias or atrial perforation

  2. Pneumothorax should also be excluded.

POST NGT INSERTION CXR

  • Sometimes the ward’s nurse will call you regarding checking the CXR ordered post-NGT insertion (only if tip radio-opaque)

  • All that is required is ensuring the CXR is something like CXR (1) below and not (2)!


USEFUL PHONE NUMBERS

Governmental Hospitals Number
Al-Amiri 22450005
Al-Sabah 24815000
Mubarak Al-Kabeer 25312700
Al-Adan 23940600
Al-Farwaniya 24888000
Al-Jahra 24575300
Maternity 24843100
Physical medicine and Rehabilitation centre (PMR) 24874350
Al-Razi 24846000
Ibin Sina 24840300
Al-Babtain 24810722
Hussain Maki Juma – Kuwait Cancer Control Centre (KCCC) 24849100
Abdulaziz Rashid Centre for Allergies 24849252
Psychiatric Hospital 24843900
Infectious Diseases Hospital 24870133
Private Hospitals No.
Al-Hadi Hospital 1828282
Dar Al-Shifa Hospital 1802555
Al-Salam Hospital 1830003
New Mowasat Hospital 25726666
AlRashid Hospital 25624000
London Hospital 1883883
Royal Hayat Hospital 25360000
Al-Seef Hospital 1881122

MUBARAK AL-KABEER HOSPITAL

Ward Direct Extensions
W-1 25311419 2100/2111
W-2 25336841 2200/2211/2212
W-3 25320268 2300/2311/2012
W-4 25311436 2400/2411/2412
W-5 25320093 2511/2512
W-6 25320316 2600/2611
W-7 25336834 2700/2711
W-8 25320294 2800/2811
W-9 25311439 2900/2911
W-10 25336835 3000/3011
W-11 25317035 3100/3111
W-12 25320264 3200/3211/3212
W-14 25336836 3400/3411/3412
W-15 25336837 3500/3511/3512
W-16 25320286 3600/3611/3612
W-17 25336839 3700/3711/3712
W-18 25311435 3800/3811/3812
W-19 25312057 1460/1461/1462
W-20 25312058 1470/1471/1472
W-21 25312067 1500/1501/1502
W-22 25312068 1532/1533/1534
W-23 25312962 1540/1541/1543
W-24 25312059 1570/1571/1572
W-25 25312217 1600/1611/1612
W-26 25312179 1579/1580
W-27 25312441 1772/1734/1735
W-28 25312447 1761/1762/1768
On-Call Number
Radiology 99220038
U/S (emergency) 50588696
Cardiology 97115584
Nephrology 99953458
OT Anaesthesia 96623469
ICU Ward 96623473


Casualty Extension
Resuscitation room 5262
Male observation 5257/5258
Female observation 5266
Orthopaedic 5260
Paediatric observation 5553
Radiology Extension
Main X-ray 6010/6003/6084
Casualty X-ray 5264
CT room 2679/2690
U/S room 6031
MRI room 6083/6079
Angio room 6084/6035/6034
Nuclear medicine 6042/6047/6053
Laboratory Extension
Biochemistry 2445
Haematology 2435
Microbiology 2471
Blood bank 5656
Toxicology 2461
Immunology 8-6520
Virology 8-6528
Operation Theatre Extension
Direct line 25311420
Reception 4072/2292
Recovery room 2248
OT Anaesthesia on-call 96623469
ICU Extension
Direct line 25312219/25318504
Room 1 (Medical) 5705/5707
Room 2 (Surgical) 5708
Isolation 5707
Other departments Extension
Vascular lab. 3911/3912
Gastro reception 1721/1722
Gastro ERCP room 1726
Echo/Holter reception/stress ECG 5455/5457
EEG/EMG room 2186/2187
Fundoscopy clinic 5456
ENT clinic 5650


AL-FARWANIYA HOSPITAL

Ward Direct Extensions
W-1 24898079 2100/2111
W-2 24881690 2200/2211
W-3 2488698 2300/2311
W-4 24882702 2400/2411
W-5 24882703 2500/2510
W-6 24883274 2600/2611
W-7 24892374 2700/2711
W-8 24880609 2800/2811
W-9 24898038 2900/2911
W-10 24897266 3000/3011
W-11 24882685 3100/3111
W-12 24802377 3200/3211
W-14 24891035 3400/3411
W-15 24890231 3500/3511
W-16 24882687 3600/3611
W-17 24809621 3700/3711
W-18 24882686 3800/3811
W-19 24805047 3900/3911
W-20 24880106 2020/2021
W-21 24880268 2121/2122
W-22 24883276 2222/2223
W-23 24880609 2323/2324
W-24 24880676 2424/2425
W-25 24882382 2525/2526
W-26 24883107 2626/2627
W-27 24880498 2727/2728
W-28 24880343 2828/2860
On-Call Number
Radiology 96623188
Resuscitation 96623171
Cardiology 96623145
Urology 96623150
Nephrology 96623146
OT Anaesthesia 96623172
ICU Ward 96623170


Casualty Extension
Resuscitation room 6534
Male observation 5519
Female observation 2419
Orthopaedic 5501/5552
Paediatric observation 6593
Radiology Extension
Reception 5966
CT room 5964/5969
U/S (Casualty) 5966/5971
U/S (OPD) 5974/2694
MRI room 5968
Nuclear medicine 5994
Gastrograffin room 2530
Operation Theatre Extension
Direct line 24881358
Reception 5714
Recovery room 5720/5719
Head nurse 5717
Laboratory Extension
Biochemistry 3366/3347
Haematology 3338
Microbiology 3348/3349/3350
Blood bank 5892/3341
ICU Extension
Direct line ICU-1 24893079
Direct line ICU-2 24882382
Room 1 5701/5702
Room 2 2525/2526
Isolation (ICU-1) 5721
Isolation (ICU-2) 2536
Other departments Extension
Endoscopy room

6508/6509/6528

15528
Echo 5528/2423
Histopathology 3339

AL-AMIRI HOSPITAL

Ward Direct Extensions
W-1 22415844 2100/2172
W-2 22451338 2200/2272
W-3 22454612 2300/2372
W-4 22448764 2400/2472
W-5 22448765 2500/2572
W-6 22465295 2600/2672
W-7 22436781 2700/2772
W-8 22467490 2800/2872
W-9 22467492 2900/2972
W-10 22469626 3000/3072
W-11 22400371 3100/3172
W-12 22468872 3200/3272
W-14 22431964 3400/3472
W-15 22432081 3500/3572
W-16 22451335 3600/3672
W-17 22451336 3700/3772
On-Call Number
U/S (emergency) 5088
OT Anaesthesia
ICU Ward 6155
Casualty Extension
Resuscitation room
Male observation 2063/2062
Female observation 2087/2093
Orthopaedic 2081
Paediatric observation 2040/2081
Laboratory Extension
Biochemistry 5006
Haematology 2168/2168/2174
Microbiology 2185/2214/2389/2189
Blood bank 2171 (22465292)
Histopathology 2192/2195
Radiology Extension
Main X-ray 5004
Casualty X-ray 2068
CT room 2163/2164
U/S room 2149/2157/5446
MRI room 7700/7712
Angio room 2141
Nuclear medicine 7667
Intensive care Extension
ICU Direct line 22436794
ICU Extensions 4040/5700
CCU Blue Reception 15-8330/15-8331/15-8832
CCU Blue Direct 2621/22272627
CCU Yellow Reception 15-8441/15-8442/15-8443
CCU Yellow Direct 2622/22272628
Other departments Extension
Gastro reception 7026/7229/7030
Gastro ERCP room 7113
Echo/Holter reception 7660/7610/7615
Uroflowmetry 2262/2263
EEG/EMG room 2032/2033
Fundoscopy clinic 2279/2277
PFT/Bronchoscopy 3555/2618
Operation Theatre Extension
Direct line 22436432
Reception 2115/4037
Recovery room 5003
Minor OT 2088


AL-ADAN HOSPITAL

Ward Direct Extensions
W-1 239467648 2100/2111
W-2 -/- 3500/3511
W-3 -/- 3600/3611
W-4 23965547 2200/2211
W-5 23965546 2400/2411
W-6 23949973 2600/2611
W-7 23940037 2700
W-8 23941628 2800/2811
W-9 23943548 2900/2911
W-10 23968347 3000/3011
W-11 -/- 3100/3111
W-12 23941636 3200/3211
W-14 23940746 3400/3411
W-15 -/- 4000-4044
W-16 -/- -/-
W-17 -/- 3700/3711
W-18 23960406 3800/3811
W-19 -/- -/-
W-20 -/- -/-
W-21 23966820 4100/4144
W-22 23966830 4200/4244
W-23 23966854 4300/4344
W-24 23966815 4400/4444
W-25 23966816 4500/4544
W-26 23966847 4600/4644
On-Call Number
OT Anaesthesia 96623261
ICU Ward 96623262
Casualty Extension
Resuscitation room 5284
Male observation 5222/5223
Female observation 5224/5283
Orthopaedic 5256
Paediatric observation 5262


Operation Theatre Extension
Prep room 5716
Reception (Transfer bay) 5726
Recovery room 5725
Head nurse 5701/5711
Radiology Extension
Main X-ray 64-143
Casualty X-ray 5254/5255
CT room 63-145
U/S room 63-138/63-189
MRI room 63-169/2065/2021
Fluoroscopy 63-144
Nuclear medicine 63-106
Laboratory Extension
Biochemistry 63-173
Haematology 63-168
Microbiology 63-183
Blood bank 63-177/63-168
Histopathology 63-184/63-187
Intensive care Extension
ICU Direct line 23946102
ICU Room 1 5700
ICU Room 2 5701
ICU Isolation room 5702
PICU 7584
SCBU 2217
NICU 2029
Other departments Extension
Endoscopy room 7121
Echo room 2186/63-218
Stress ECG 5267
ESWL department 5230/7177
Psychiatry OPD 7183
ENT OPD 7142


AL-JAHRA HOSPITAL

Switch number
24575300
Ward Extensions
W-1 2100/2120/2121
W-2 2200/2220
W-3 2300/2320
W-4 2400/2420
W-5 2500/2520
W-6 3050/3070
W-7 4900/4920
W-8 3250/3270
W-9 2900/2920
W-10 3000/3020
W-11 3100/3120
W-12 3200/3220
W-14 3400/3420
W-15 3500/3520
W-16 3600/3620
W-17 3700/3720
W-18 3800/3820
W-19 3900/3920
W-20 4000/4020
W-21 4100/4120
W-22 4200/4220
W-25 4500/4532
W-26 4600/4620
W-27 2800/2820
W-28 4800/4842
W-31 3150/3170
W-32 3250/3270
Casualty Extension
Resuscitation room 5770/5780
Male observation 5750/5760
Female observation 5256/5824
Maternity observation 5906/5907
Orthopaedic 5756
Paediatric observation 5681/5862/5866/5867
ENT 5758
Ophthalmology 5757


Radiology Extension
Reception (old bldg.) 5501/5541
Reception (new bldg.) 5809
CT room 5479
U/S room 5472/5497
MRI room 5802/5807/5468
Nuclear medicine 5845
Laboratory Extension
Biochemistry 5934/5935/5936
Haematology 5295
Microbiology 5303/5306/5309
Blood bank 2020
OPD Lab 5380
Urine routine 5305
Virology 8253/8244/2050
Intensive care Extension
NICU 4400/4420
SCU 4408
PICU 4700/4720
ICU 5330/5339/5700/5799
HDU 5489
CCU 4320/4300
Other departments Extension
Endoscopy room 5386/6228
ERCP room 5814
Echo room 5104
EEG room 5370
PFT room 5379
Operation Theatre Extension
OT Reception 6027/5284
Recovery room 5230/5231
Minor OT 5326


AL-SABAH HOSPITAL

Ward Direct
Surgical Block
W-1 2600/3380
W-4 2400/2411
W-5 2500/3617
W-8 3100/3120
W-9 2900/3776
W-11 2800/2818
Medical Block
W-1 4100/4716
W-2 4200/4452
W-3 4300/4735
W-4 4400/4423
W-5 4500/4502
W-6 4600/4628
Paediatric Block
W-2 6200/6320
W-5 6500/6512
W-6 6600/6612
W-7 6700/6712
W-8 6800/6812
Surgical Casualty Extension
Resuscitation room 5504
Male observation 5254
Female observation 5250
Doctors room 3977/3976
Medical Casualty Extension
Resuscitation room 4811
Male observation 5260
Female observation 4547
Doctors room 4748/5451


Radiology Extension
Medical X-ray 5960/3329/5998
Surgical X-ray 4449
CT room 4621/4726/3302
U/S room 4622/4732
MRI room 4784/4751/4752
Operation Theatre Extension
Direct number 24813847
Main OT Reception 5481/3953
Recovery room 3636/3946
Casualty OT 2200/2211
Laboratory Extension
Biochemistry 3236/3712
Haematology 3723/3724
Microbiology 3578/3674
Blood bank 3221
Histopathology 3570/3576

ENDING INTERNSHIP YEAR

Congratulations, you did it! You survived the internship year. Well done. However, it is only the beginning. Now you will embark on your toughest journey. The journey to specialisation. Some of you will remain to practice medicine and some will use their medical knowledge and experience and use it somewhere else. The choice is yours we wish you a great career.

For those who will remain to practice medicine here is what you will need to do:

  • After submitting your evaluation forms and casebooks, KIMS will issue you a letter of completion of the internship year

  • You should take this letter to the MOH, to the office of الوكيل المساعد للشئون الفنية

  • There you will choose your hospital and specialty and they will also issue a letter describing that you wish to pursue a position in this department of this hospital

  • After that you go to the director of the health area of your hospital and have your request signed

  • After that you should go to the director of the hospital then the head of the department

Like the process of employment you need to make sure that your letter of initiation of an assistant registrar position should return to the MOH. This will signify the end of this process and will update your data on their system so you will now receive the new salary.

Your raise should arrive depending on when you started your assistant registrar job. If before the July 1st, then it will come with your next salary. If after July 1st then with your raise will be deposited with your January salary of the next year.

***After becoming as assistant registrar make sure to update your license to practice medicine as you were only issued a temporary one***

Now you need to make the choice of pursuing a postgraduate training programme in Kuwait or outside. Each year KIMS will hold their application period or season, in which you will have the opportunity to apply for a postgraduate training programme in Kuwait.

The application process is simple and includes a special form from KIMS and will also require you to submit documents such as your college degree, transcript and letters of recommendation. A list of all the required papers are present on the application form. The application process usually consist of an exam and an interview. When all is done you should be called by KIMS to congratulate you for your acceptance. They will also require you to a contract which says that you will commit to the programme starting from 1st October and that if you ever desire to quit the programme after 1st October you will need to wait a full academic year before applying for new programme in Kuwait or outside.

If you choose to pursue a training programme outside Kuwait then it will have different requirements depending on the specialty and country of choice. The United States requires the USMLE, Canada requires the MCCEE, Saudi Arabia requires the Saudi licencing exam (SLE). At time of printing this book KIMS and the MOH has an agreement with the French MOH for seats for nearly all training programmes. The application process to France is streamlined and is handled by KIMS thus easier and cheaper. However, all other countries require you to handle all requirements and payments yourself and then submit your acceptance form to KIMS for approval. Continued medical education is a vital aspect of your career development, during your internship year and afterwards we recommend that you take the time and effort to attend and complete the following course; ACLS – Advanced Cardiac Life Support, ATLS – Advanced Trauma Life Support and BSS - Basic Surgical Skills. Also attending Conferences and workshops relating to your specialty of interest is also highly encouraged.

We hope that you found this book helpful and from the entire ISG team we wish you a happy and successful career


BLOOD VACUTAINER COLOURS

Colour Component Used for
Purple EDTA

Haematology analysis:

  • CBC

  • Reticulocyte count

  • Cell differential
Light Blue Buffered sodium citrate

Coagulation profile:

  • INR

  • PT

  • APTT
Yellow Plain (empty) with gel separator

Biochemistry:

  • RFT

  • LFT

  • Bone profile
Red Clot activator, Silicone coated (Blood clotting time: 60 minutes) Blood Grouping and cross-matching (usually coupled with a purple tube)
Pink EDTA Crossmatch tubes
Green Heparin Plasma chemistry
Light green PST II with gel seperator Plasma chemistry
Grey Naf/NaEDTA Glucose assessment
Black Buffered citrate ESR determination
Royal blue Clot activator/ K2EDTA Trace element, toxicology and nutrient determination

All tubes require a minimum of 8-12 inversions for sufficient mixing to allow accurate test results

IV CANNULA SIZE CHART

Gauge Colour Diameter Length Flow rate
14 Orange 2.1mm 45mm 300ml/min
16 Grey 1.7mm 45mm 180ml/min
17 White 1.4mm 45mm 125ml/min
18 Green 1.2mm 45mm 80ml/min
20 Pink 1mm 32mm 54ml/min
22 Blue 0.8mm 25mm 31ml/min
24 Yellow 0.7mm 19mm 22ml/min
26 Violet 0.6mm 19mm 15mi/min
Adapted from BD © ISO Product Brochure


EMERGENCY COLOR CODING SYSTEM:

An emergency code is a notification of an event that requires immediate action. Different institutions use different color coding systems, but the following is a common set up in Kuwait hospitals:

Code Definition
Code Black Bomb Threat
Code Blue Cardiac Arrest
Code Orange Chemical/Hazardous Material spill/release
Code Red Fire Emergency
Code White Workspace violence
Code Silver Weapon in Workplace