Therapeutic Handbook - GGC Prescribing

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Suspected SAHYESDoes the patient have any of the following?- Reduced level of consciousness- Focal deficit- Recurrent seizures- Recurrent vomitingConsider need for emergency anaesthesiaintubation and ventilation.NOImmediate CT scanCT scan within 12 hoursIs the CT scan +ve forSAH?NOYESRefer urgently to on-callneurosurgical registrar(Southern General).Central Nervous System< 12 hoursWaitNeurosurgical referral.If GCS < 14 refer urgentlyto on-call neurosurgicalregistrar (SouthernGeneral). Otherwise referASAP during normalworking hours.Consider differentialdiagnosis (previous page)and assess time sinceonset of headache> 12 hours but< 2 weeks> 2 weeksRefer for angiographyLumbar puncture - process immediately.Arrange urgent transport of cerebrospinal fluid (CSF) samplesto laboratory (see sampling requirements on next page).YESSampleXanthochromia +ve onspectrophotometry?NONot SAHPage 184Continues on next page
Sampling requirements for the Biochemical Investigation of SAH (CSF Xanthochromia):1. Spectrophotometric analysis of CSF for xanthochromia is useful in the diagnosis of SAHparticularly when CT is not conclusive.2. It is recommended that CSF is not sampled until at least 12 hours after a suspected event.3. The CSF sample should be centrifuged within 15 minutes of sampling. Phone the laboratory toensure a technician is available before taking the CSF sample.4. The CSF sample for xanthochromia analysis should always be the last fraction to be taken andthe volume of sample must be a minimum of 1 ml.5. Record on the request form:- the clinical indication for the request- the time of headache onset- the time of LP- if the differential diagnosis includes meningitis.6. Protect the CSF sample from light by placing it in a brown paper envelope.7. Analysis is done between 9 am - 5 pm weekdays, and Saturday and Sunday mornings. Theresult will be phoned to the ward.General managementConsider Medical ward / ICU / HDU / Neurosurgical ward (after discussion with the neurosurgeon)depending on the patient’s condition.Drug therapy / treatment options• TED supportive stockings• Isotonic fluids e.g.:sodium chloride 0.9% IV 3 litres over 24 hours (do not restrict fluid if hyponatraemiadevelops).• Ensure adequate analgesia e.g.:paracetamol +/- dihydrocodeine 50 mg IM or dihydrocodeine 30 mg orally every fourto six hours. (Avoid other opiates, NSAIDs.)• Nimodipine 60 mg orally or via NG tube every 4 hours for 21 days. Once tablet iscrushed for NG administration it is extremely light sensitive so must be administeredimmediately.• Ranitidine 50 mg IV three times a day or 150 mg orally twice a day as stress ulcerprophylaxis.Phenytoin if necessary for seizures (see page 192 for dosage calculations).Central Nervous SystemPage 185
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ContentsEditorial GroupAcknowledgem
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AppendicesAppendix 1 - Nicotine Rep
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AcknowledgementsA huge number of pe
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Summary of Major changes in Therape
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On discharge• As the discharge pr
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Other examples• Sevredol 10 mg ta
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Antiplatelets and anticoagulants:In
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non-Formulary medicines, a complete
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Quick guide to using the handbookWh
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Sections1. Resuscitation and Anaphy
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Section 1Resuscitation and Anaphyla
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Continued from previous page2. Adre
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Peri-arrest ArrhythmiasGeneral advi
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Broad QRS - continuedNarrow QRS - c
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Guidelines on Blood TransfusionThis
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Management of Major Haemorrhage(See
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Hospital Specific Information on Ma
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Table continued from previous pageG
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Assessment / MonitoringAKI stage I
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Section 2Drug Overdose and Toxicity
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Treatment of Paracetamol OverdoseTh
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Management of paracetamol overdose
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Lithium toxicityNormal range 0.4 -
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Management of DyspepsiaGastrointest
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Table continued from previous pageR
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Management of Gastroduodenal Ulcers
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Management of Upper Gastrointestina
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Post endoscopy continuedb. Arrange
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General management and treatment op
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- SAAG can differentiate ascites re
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General management and drug therapy
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Drug therapy• Unless contraindica
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Consider:• Serum caeruloplasmin,
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Section 4Cardiovascular SystemCardi
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Table 1 - Indicators of patients at
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Continued from previous pageIf the
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Diagnosis and Treatment of VenousTh
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Wells Clinical score should be util
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IV Drug Misusers• Given their cha
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Drug therapy / treatment options co
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RivaroxabanRivaroxaban is an oral d
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Diagnosis of VTE in pregnancy• If
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Referral of Patients to Anticoagula
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Reversal of Anticoagulant TherapyIn
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Elective admissions - Risk Stratifi
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Elective admissions - restarting an
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Suspected Acute Coronary Syndrome (
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If patient is for PPCI go to Box 1.
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Drugs for acute coronary syndrome /
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Secondary Prevention of Coronary He
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Cardiovascular SystemTroponin posit
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Atherosclerotic arterial disease is
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Algorithm for Cardioversion of AFSt
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Cardiovascular SystemVentricular ra
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Prevention of stroke / thromboembol
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Drugs for atrial fibrillation conti
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CPAP in cardiogenic pulmonary oedem
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Management of HypertensionCardiovas
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Cardiovascular SystemGeneral manage
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Management of Acute Stroke 3Transie
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Secondary prevention of stroke and
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Cardiovascular SystemPage 126
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Guidelines for Blood Gas AnalysisRe
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Respiratory SystemNext consider aci
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Management of Acute Severe Asthmain
Page 144 and 145: Management of Acute Severe Asthma i
Page 146 and 147: Management of Chronic ObstructivePu
Page 148 and 149: Acute Exacerbation of Chronic Obstr
Page 150 and 151: Treatment options continued• If p
Page 153 and 154: Step 4 - Initiation of NIVAIM = To
Page 155 and 156: Investigation of Unilateral Pleural
Page 157 and 158: Investigation of unilateral pleural
Page 159 and 160: General management• Oxygen as app
Page 161 and 162: Management of PneumothoraxIntroduct
Page 163 and 164: Management of StridorIntroductionSt
Page 165 and 166: Initial Management of Superior Vena
Page 167 and 168: Section 6Central Nervous SystemCent
Page 169 and 170: Analgesics for acute painSTEP 3STEP
Page 172 and 173: Analgesics for acute pain - prescri
Page 174 and 175: Management of Postoperative Nausea
Page 177 and 178: Management of Acutely Disturbed Pat
Page 179 and 180: Pharmacological Management - Patien
Page 181 and 182: Guidance on Night SedationPatients
Page 183 and 184: Management of Alcohol Withdrawal Sy
Page 185 and 186: Continued from previous pageUnable
Page 187 and 188: Continued from previous pageImporta
Page 189 and 190: Flow diagram for use with Hospital
Page 191 and 192: Continued from previous pageMethado
Page 193: Management of Suspected Subarachnoi
Page 197 and 198: Referral to Neurosurgical Unit cont
Page 199 and 200: Management of Status EpilepticusInt
Page 201 and 202: OtherInitiating Long-term Anti-epil
Page 203 and 204: Continued from previous page2. 'Top
Page 205 and 206: Decision making algorithm for the a
Page 207 and 208: Drug therapy / treatment optionsNil
Page 209 and 210: Section 7InfectionsInfectionsPage 1
Page 211 and 212: • In patients with sepsis -- Star
Page 213 and 214: Gentamicin and Vancomycin: Reducing
Page 215 and 216: IV-Oral Antibiotic Switch Therapy (
Page 217 and 218: Alert Antibiotic Policy(The full ve
Page 219 and 220: Table 1 - Alert Antibiotics continu
Page 221 and 222: Infection Management GuidelinesSeve
Page 223 and 224: Sepsis Source Unknown (not immunoco
Page 225 and 226: Table continued form previous pageI
Page 227 and 228: Table continued from previous pageE
Page 229 and 230: UTI in non-pregnant women Antibioti
Page 231 and 232: UTI in pregnant women Antibiotic Th
Page 233 and 234: Table continued from previous page
Page 235 and 236: Catheter-related UTI Antibiotic The
Page 237 and 238: Table continued from previous pageU
Page 239 and 240: Table continued from previous pageU
Page 241 and 242: Pneumonia(Also see page 148 for man
Page 243 and 244: Table continued from previous pageC
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Pneumonia (continued from previous
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InfectionsTable continued from prev
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Treatment of Clostridium difficile
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InfectionsSkin and soft tissue infe
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InfectionsSkin and soft tissue infe
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Central nervous system infectionsBa
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Meningitis Contacts• All suspecte
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Viral infectionsViral Encephalitis
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Guideline updated 11/10/13Genito-ur
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Genito-urinary infections (continue
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Patients with absent or non-functio
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MRSA Eradication Policy• In newly
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InfectionsDosage regimens for antib
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Gentamicin dosing guidelines (For p
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Step 2 continued from previous page
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Vancomycin dosing guidelines (For p
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Continued from previous page - If t
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B. Vancomycin continuous infusionSt
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Vancomycin - continuous infusion re
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InfectionsPage 274
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Management of Diabetic Ketoacidosis
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Endocrine System5. Signs of cerebra
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Assessment / monitoring• Glucose
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Important points1. This regimen is
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Diabetes therapy continued• Retro
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Insulin Sliding Scale (Not for use
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Management of HypoglycaemiaIntroduc
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Endocrine SystemContinued from prev
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Oral antidiabetic drugs continued3.
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Other InformationGeneral advice on
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Guideline updated 18/09/13Managemen
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Management of hypomagnesaemia in ad
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Management of Hyponatraemia• Earl
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Section 10Musculoskeletal and Joint
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Treatment optionsManagement of acut
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Treatment options continuedNSAIDs a
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Section 11Palliative CarePalliative
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Analgesic Step LadderStep 1: Mild P
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Opioid Conversion ChartThis is advi
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Palliative Care - SymptomsSee BNF,
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Table continued from previous pageP
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Management of symptoms present in l
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Section 12Oncological EmergenciesOn
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Malignant Spinal Cord Compression (
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Raised intracranial pressure in can
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Treatment /drug therapy continued5.
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N.B.• Laboratory TLS = > 2 labora
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• Avoid serum CA125 testing as it
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AppendicesAppendicesPage 339
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Appendix 2Preparation of Intravenou
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Glyceryl Trinitrate (GTN) infusionG
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Table 2 - Other drugsDrug Time to s
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Appendix 5Normal ImmunoglobulinsNor
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Drug MisuseHospital Liaison Addicti
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Outpatient Parenteral Antibiotic Th
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IndexPage 353
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AnticoagulantsIn treatment of VTE/P
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CiprofloxacinAlert Antibiotic Polic
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EEmergency sedationGeneral principl
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Hyoscine butylbromideIn palliative
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Mesalazine, oralIn inflammatory bow
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PhenytoinDosing and monitoring guid
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TeicoplaninDosing and monitoring...
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Notes
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Notes
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© NHS Greater Glasgow and ClydeAug
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Therapeutic Handbook - GGC Prescribing

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