Treatment of cardiac diseases 1

Angina and Non-STEMI Acute STEMI P. Embolism Aortic dissection

CCS Pre-Hospital Prophylaxis
Treatment of predisposing factors of DVT Surgical
Emergency O2 Prophylactic anticoagulation in patients at Stanford A is a surgical emergency
Morphine 10 mg risk
Rest + Nitrates
Lidocaine 100 mg
Long term Atropine 1 mg
• General (Risk factors + Advice) Pre-hospital Fibrinolysis
Therapeutic
Medical
• Drugs If PPCI can not be done within 120 min
General
Anti-anginal Nitrates – B. Blockers – CCBs Pain – Pethidine 50 mg
Anti-platelets Aspirin – Clopidogrel
Hospital management Avoid Morphine IV opioids
New Ranolazine – Nicorandil – Ivabradine General Dyspnoea – O2
Comorbidities, rest, and light diet, and stress
• Invasive (PTCA – CABG) Failure (HF)
ulcer prophylaxis
Refractory chest pain Shock Hypertension
First-line management Managed by Morphia or Nitrates
Specific
Normotensive + Normal HR Decrease cardiac load management
Ranolazine + Ivabradine Nitrates and BB Hemodynamically unstable Maintain SBP < 100-120 and HR< 60
Reduction of LV remodelling
Hypertensive + Normal HR
ACE.I, MRA, and BB
Fibrinolysis
BB OR Non-DHP CCB
Normotensive + Bradycardia Medical revascularization CDT BB Esmolol – Labetalol
Pulmonary embolectomy
Ranolazine Mechanical revascularization Nicardipine
Hypertensive + Bradycardia
Both should be used with
Hemodynamically stable Nitroprusside
DHP CCB Anticoagulants
Antiplatelets
medical and mechanical Anticoagulation
Non- ST elevation ACS revascularization
Initial (1-10 days)
Emergency Early complications management
NOACs – LMWH – Fondaparinux

Rest + Heparin + Anti-platelet Post-Hospital Long term (3-12 months)

NOACs – LMWH – Fondaparinux – Warfarin
Long term management Indefinite
• B. Blockers + Nitrates Complications First episode of proximal DVT or Symptomatic PE
• Anti-platelets Rehabilitation with low to moderate risk of bleeding
• Lipid lowering agents Risk factors
• PPIs Decrease risk of recurrence IVC filter if anticoagulants are CI
 Treatment of cardiac diseases 2

Mitral stenosis Aortic stenosis Rheumatic fever Infective endocarditis

Medical Medical Prophylactic Prophylactic

Prophylaxis against R. Activity and IE Prophylaxis against R. Activity and IE Primary Correction of underlying cardiac lesion
Symptomatic for complications Symptomatic for complications Prophylactic antibiotics
• Treatment of pharyngeal infections
Dental and URT
• Tonsillectomy in chronically infected
Amoxicillin
tonsils
GIT and GU
Secondary Ampicillin + Gentamycin
Penicillin G Cardiac or catheterization
Surgical Surgical 1.2 M monthly IM for 5 years or till 25 Cefotaxime

“Replacement”
years of age whichever is longer
Erythromycin Therapeutic
Indications 250 mg/12 h orally
Medical
• Valve area less than 1 cm Indications Therapeutic Specific
• Marked symptoms despite OMT • Severe symptoms
• Embolization
Rest Streptococci
• Pressure gradient more than 50 Penicillin G + Gentamycin
mmHg Diet S. Aureus or HACEK
Types Light with less salt Cloxacillin + Gentamycin
• Commissurotomy • Valve area less than 0.8 cm Antibiotics Fungal
• Replacement Penicillin G Amphotericin B
1.2 M units single IM General
Erythromycin Rest
250 mg/12 h for 10 days Diet
Balloon dilatation Balloon dilatation Anti-inflammatory Complications
May be used in some patients indicated for • Children as an alternative to surgery
Aspirin for Arthritis Surgical
commissurotomy • Elderly who cannot undergo surgery
Replacement of damaged valve
Corticosteroids for Carditis Replacement of infected prosthesis
Add aspirin during withdrawal
Add ACTH single IM in the last week FAR2 72
Treatment of chorea
 Treatment of cardiac diseases 3

AF SVT Digitalis toxicity Heart failure

“Better refer to book”
During the attack the attack Stop digitalis General
Haemodynamically unstable Haemodynamically unstable Physical and emotional rest
Low BP with features of hypoperfusion Low BP with features of hypoperfusion
Diet
DC shock DC shock
Or Overdrive pacing Or Overdrive pacing Correct hypokalaemia
Haemodynamically stable Haemodynamically stable Stop drugs causing hypokalaemia (Lasix) Drugs
RHYTHM CONTROL [what’s in favour?] Carotid sinus massage Give K – orally or IV Vasodilators
Pharmacologic cardioversion Pharmacologic cardioversion
Propafenone (Rytmonorm) – 1st line in AF Diuretics
Adenosine – 1st line
4 tabs (150 mg each) – 2 tabs after 6 hours can
be administered if no response 6 mg prefilled syringe rapid IV bolus (very Digitalis specific
short duration of action) repeated up to Digitalis
Electric cardioversion DC shock
Ablation (Pulmonary vein isolation) 30mg (5 syringes)
antibodies (DIGIfab)
• Oral anticoagulants should be given 4 weeks Verapamil (Isoptin) – 2nd line Beta blockers
before and after cardioversion 5mg infusion. Can be repeated up to 3
• Digitalis should be stopped
RATE CONTROL [what’s in favour?]
doses
Electric cardioversion DC shock
Treatment of Treatment is tailored according to the
type of HF (HFrEF or HFpEF)
BB, CCB (Non-DHP), or Digitalis
Prevention of future attacks
Prevention of future attacks manifestations
• Drugs: Class IA, IC or III
• Drugs: Class IA, IC or III
• Intervention: RFCA or surgery
Vomiting
• Intervention: RFCA or surgery Metoclopramide
• Treatment of the cause
• Treatment of the cause
THE INTEGRATED ABC PATHWAY
1. Anticoagulation: CHA2DS2-VASc score to
SVT with wide QRS
Arrhythmia
determine the need of anticoagulant (INR
Suggests the presence of an accessory Lidocaine or Epanutin
target 2-2.5. NOACs are 1st line except in Anti-arrhythmic drugs
valvular disease or prosthetic valve, pathway (WPW) and usage of
Warfarin is the only option) HAS-BLED aforementioned drugs will cause blockage Atropine
score estimates major bleeding risk in the AV node and render the accessory For Heart block and Bradycardia
patients on OAC pathway unaffected. Hence, their usage is DC
2. Better symptom control contraindicated. Amiodarone in this case Should be generally avoided except in fatal
3. Concomitant disease management will be the drug of choice (blocks both arrhythmia e.g., VF
AVN and the accessory pathway)
NB. Left atrial appendage closure by coiling
can be done to prevent embolization
 Treatment of cardiac diseases 4

Hypertrophic
Cardiomyopathy Pericarditis MVP
cardiomyopathy
Treatment of Heart Treatment of Heart NSAIDs Surgery
failure failure Corticosteroids
Mitral valve replacement if associated with
severe MR
ACE.I. BUT avoid positive inotropes In patients not responding to NSAIDs
BB
Diuretics
Complications Prophylaxis
CRT Anti-arrhythmic drugs for arrhythmia
Against infective endocarditis
ICD to prevent sudden death Cause Anti-arrhythmic
Complications
Anticoagulant drugs Relief of LVOT
Anti-arrhythmic drugs
obstruction Propranolol
Effective for chest pain
Cause Medical
Thyrotoxicosis Negative inotropes
Hypothyroidism CCB
BB
Reassurance
Surgical
Transplantation Septal myectomy
In refractory cases Ablation
Transcoronary Ablation of Septal
Hypertrophy (TASH)
Injecting alcohol into the blood vessel
supplying the septum
 Treatment of chest diseases 1

COPD Bronchial asthma Bronchiectasis Pneumonia

General General Drainage General
Stop smoking and avoid pollution Avoid triggers Rest and nutrition
Either by physical therapy or through
Vaccination against influenza and Immunotherapy
pneumococcal infection
bronchoscopy Symptomatic
Analgesics
Bronchodilators Antipyretics
Complications
Type II RF and Infections
SABA
LABA
Antibiotics Bromhexine
K iodide
Codeine for sedation
Non-selective B agonists According to C&S
O2 if needed in severe cases
Xanthines

Dilators
1st line – SABA OR SAMA
Receptor antagonists
Muscarinic antagonists
Antihistamines
Symptoms
Analgesics
Antipyretics
Complications
Pleural effusion management

Antileukotrienes Bromhexine
2nd line – LABA OR LAMA (stage I and II)
K iodide
LABA + ICS OR LAMA (III and IV)
3rd line – LABA + LAMA + ICS
Beneficial in aspirin induced asthma
Bronchodilators
Antibiotics
Symptomatic
Expectorants
Steroids Complications
Drainage of pleural effusion
Outpatient
1st Zithromax 500 – single daily
Mucolytics 2nd Doxycycline 100 – twice daily
O2 therapy Prophylactic drugs Surgery 3rd Augmentin 2 g twice daily
Disodium cromoglycate – Ketotifen - Not responding 4th Tavanic 750 mg single daily
Surgery Omalizumab - Severe haemoptysis Hospital
- localized
LVRS or transplantation Augmentin + Zithromax
In refractory severe cases

Stepwise management Treatment usually takes 5-7 days after

which discontinuation can be done
provided that the patient is afebrile, on
Status asthmaticus no supplemental O2 and with no more
than one clinical instability factor
 Treatment of chest diseases 2

S. Mediastinal
Pleural effusion Pneumothorax ILD B. Carcinoma
syndrome
Cause Simple (closed) Cause Non-small cell
In TB, anti-tuberculous drugs
with CS are used Conservative O2
In malignant effusion, Small amount of air
pleurodesis using intrapleural Minimal symptoms As a symptomatic relief Operable
tetracycline may be used Intercostal tube Pneumonectomy or lobectomy
If dyspnoeic Complications May be followed by
RVF and RF radiotherapy
Open
Non-operable
Aspiration Adhesive external dressing
In emergency situations Chemotherapy
Complications Radiotherapy
Intercostal tube

Cause
- Neurogenic shock
- APO In the 5th space and surgical
- Air, blood, or fluid wound repair is the definitive
- Injury management

Tension Steroids Small cell

Chemotherapy
Needle Radiotherapy
In the 2nd intercostal space Cyclophosphamide
immediately in emergency
Both are used in IPF (Hamman-
Rich syndrome)
Intercostal tube
Definitive management

VATS
Chemical pleurodesis
 Treatment of Endocrinal diseases 1

Hypothyroidism Hyperthyroidism Acromegaly Panhypopituitarism

L- thyroxine Anti-thyroid drugs Surgery Cause

50 ug/day
Increase 50 every month
Average maintenance 200 Radiotherapy
RAI Replacement
High risk: start with 25 ug
GH
Subclinical hypothyroidism Medical L-thyroxine
Hydrocortisone
TSH 4-10: follow up every 3 m
TSH >10: 25-50 ug/day Surgery Somatostatin analogues
Octreotide, Lanreotide Oestradiol
GH receptor blocker Testosterone
Myxoedema Thyroid storm Pegvisomant

Dopamine agonist
coma I GAVE Bs Bromocriptine

I – IV fluids
G – Glucose Symptomatic
IV hydrocortisone A – Arrhythmia – Acetamin. Hypertension
V – Ventilatory support Hyperglycaemia
L-thyroxine E – Electrolyte disturbance

B – Block synthesis
Symptomatic B – Block release
Hypothermia B – Block conversion
Hypoglycaemia B – Block Beta
Hypoventilation
HF
 Treatment of Endocrinal diseases 2

Hyperparathyroidism Tetany Cushing’s syndrome Addison’s disease

Surgery Acute attack Surgery Replacement

Parathyroidectomy
Adrenal tumour Glucocorticoid
IV Ca. gluconate Adrenalectomy followed by low dose Hydrocortisone 15-30 mg/day
Medical 10 mg – 10% solution over 10 minutes steroids until the other gland regains its (Double during stress)
Cause infusion function
Mineralocorticoid
Sensipar (Calcimimetic agent) Pituitary tumour Fludrocortisone 0.1 mg/day
In between Removal (Beware Nelson syndrome)

Acute Ca supplementation Ectopic ACTH (Paramalignant)

Removal of operable tumours Cause
Hypercalcaemic Ca gluconate
Vit. D
e.g., Anti-TB

crisis Radiotherapy
If surgery is contraindicated or not
Fluids Cause curative Addisonian crisis
Alkalosis
IV saline + Furosemide Hyperphosphatemia Aggressive IV fluids
Hypermagnesemia Medical Saline + Glucose
Inhibit steroidogenesis
Ca lowering agents Mitotane
Ketoconazole Hydrocortisone
Chelation (Bisphosphonate) Metyrapone Bolus 200 mg then 100 every 6 h till GIT
Calcitonin manifestations subside then shift to oral
Corticosteroids
Anti-shock measures
In life-threatening Dopamine

Haemodialysis
IV PO4
Precipitating factors
 Treatment of Endocrinal diseases 3

Prolactinoma Pheochromocytoma Insulinoma Osteomalacia

Medical Surgical Surgical removal

Treatment of choice if possible
Cause
Bromocriptine
Dopamine agonist Vitamin D deficiency
1.25-1.5 mg orally initially increased Calcium preparation
gradually every few days to 5-10 mg daily
in divided doses
Medical 1-2 g per day elemental calcium
By combined alpha and beta Calcitriol
blockers
Cabergoline Pre and post operative and when surgery
Another better more tolerated option is not possible
with longer duration of action
RTA
Surgical K citrate
- Drug intolerance NaHCO3
- Persistent visual field defects Corrects acidosis and bone disease
- Resistant to medical therapy

Follow up Coeliac disease

By PRL level and MRI
Treatment should last 12-24 months Gluten diet is restricted
 Treatment of haematological diseases 1

Iron deficiency anaemia Megaloblastic anaemia G6PD Sickle cell anaemia

Cause Prophylaxis Transfusion Transfusion
e.g., Ancylostomiases B12: after gastrectomy, short gut, DM, If needed during the attack
and pregnancy
Replacement Folic acid: Haemolytic anaemia Hydration
Hydration
Aim: correct- replenish Therapeutic Causes
“Criteria of successful therapy”
B12 Causes Precipitation
Diet Hydroxocobalamin (or cyanocobalamin)
500-1000 micro / IM / day for 2 weeks

Oral iron
Then once / week until anaemia corrected
Then once / month for life
Precipitation Folate
Indications – Dose – Side effects Avoid oxidative stress
Folic acid Treatment of infection
Vitamin E
Chelation
Parenteral iron 1-5 mg / day oral ± Splenectomy
Indications – Dose – Side effects Parenteral therapy may be needed in MAS

Transfusion
Specific
Very rarely resorted to
Folate
Crisis
Blood transfusion Prophylaxis
Hb<7 Cause Avoidance of cold – AB in infection
Severe symptoms Therapeutic
HF
PA Chelation Analgesic – O2 – Fluids – NaHCO3 – Blood
NB. In combined Folic acid and B12 transfusion or exchange
deficiency, replacing Folic acid alone will ± Splenectomy Vaccination
aggravate the condition.
Folic acid will stimulate BM synthesis
Increase HbF
which will consume the already- Hydroxyurea – Azacytidine
debilitated B12 stores
BM transplantation
Gene therapy
 Treatment of haematological diseases 2

AIHA Aplastic anaemia ITP TTP

Transfusion Cause Observation Prednisone

Stop the offending drug If platelet count > 30.000
Immunosuppressives in T-cell mediated In children
Hydration aplastic anaemia
Causes Caplacizumab
Drugs Monoclonal antibody that targets von
Precipitation Supportive Willebrand factor (vWF)

Folate Anaemia: transfusion Prednisone

Chelation Thrombocytopenia: Fresh blood 1 mg/kg/day for 2-4 weeks then tapered Plasmapheresis
after improvement
Granulocytopenia: Isolation – treatment
± Splenectomy of infections
Immunosuppressants
Only in severe refractory cases G-CSF
Cyclophosphamide - Azathioprine – Splenectomy
Vincristine In resistant cases
BM stimulation
Specific Androgen
IVIG

Warm Prednisolone Danazol

EPO
Glucocorticoid G-CSF Platelet transfusion
Rituximab Severe OR Emergency surgery
IVIG
Splenectomy BM transplantation Plasmapheresis
Cold
Avoid coldness Splenectomy
Cyclophosphamide or cyclosporine Improves 70-90%
Indicated in steroid resistant or dependant
Rituximab
or acute resistant serious haemorrhage
 Treatment of haematological diseases 3

Multiple myeloma CLL CML Lymphoma

Supportive Supportive Supportive Stages I and IIA

Bone disease
Anaemia
Transfusion
Anaemia
Transfusion
Radiotherapy
Radiation Infections Infections
Bisphosphonate Antimicrobials or Vaccination Antimicrobials or Vaccination
Allopurinol Hyperviscosity Hyperviscosity Stages IIB
Leukapheresis Leukapheresis
To prevent urate nephropathy
Infections
Immunotherapy Immunotherapy Radiotherapy
BCG – Levamisole – MABs – Desensitization BCG – Levamisole – MABs – Desensitization
Antibiotics TLS TLS
Chemotherapy
Anaemia Fluids - Allopurinol Fluids – Allopurinol
Transfusion Large number of patients have a disease that runs a 6 cycles
very benign course. Hence, they would not benefit
EPO
Hyperviscosity
from treatment
Indications of treatment
Specific
Plasmapheresis • Falling Hb or Platelet count Stages III and IV
• Progression to a later stage
• Painful enlargement of LNs or spleen Drugs Chemotherapy
Specific • Increase in the rate of lymphocyte Busulfan 12 cycles
production
chemotherapy adds the benefit of managing Imatinib Radiotherapy
Standard Specific Used in stable phase (Blast cells <10%) Supplemental
associated AI diseases e.g., AIHA

Combining corticosteroids with

Melphalan Combination Blast crisis should be managed as AML

Prednisolone Chemotherapy (mostly using methotrexate and 6-MP)
50% response rate Chemotherapy regimen
Chlorambucil or Cyclophosphamide
Corticosteroids Allogenic BMT Hodgkin’s disease
Combination Prednisone or Prednisolone • More advanced disease ABVD
VAD • Uncontrolled state If failed BEACOPP
Vincristine – Adriamycin – Dexamethasone Nucleosides • Intolerance to Imatinib
• If the patient wishes to attempt
Fludarabine – Pentostatin – Cladribine NHL
permanent cure
Thalidomide This procedure carries a 30% mortality risk CHOP
BMT in young patients
 Treatment of hepatic diseases 1

Liver cirrhosis Budd-Chiari syndrome 1ry Biliary cirrhosis Wilson’s disease NAFLD

Restrict copper Treatment of the

Medical
Cause
Accordingly
Acute
Fibrinolytic therapy
Cause cause
Antidiabetic
drugs for DM
Followed by
Anticoagulant
Cholestyramine
Pruritus
Penicillamine Statins
Increases urinary copper may be used to manage
Bile salts sequestrant
excretion dyslipidaemia
Complications Chronic Ursodeoxycholic acid
LCF Anticoagulant Cholestasis
Portal hypertension Increases bile flow K sulphide Gradual reduction of
HCC Replacement of fat-soluble Precipitates copper in intestine weight
vitamins
Intervention
NB. Although the condition is
Transplantation Angioplasty with stent, TIPSS
mostly AI, steroids are not
The only curative treatment in preferred as they may aggravate
Other manifestations of
cirrhosis the already present osteoporosis Wilson’s disease Complications
e.g., Parkinsonism LCF
Portal hypertension
HCC
Complications Complications
LCF LCF Complications
Portal hypertension Portal hypertension LCF Transplantation
HCC HCC Portal hypertension The only curative treatment in
HCC cirrhosis

Transplantation Transplantation
The only curative treatment in The only curative treatment in Transplantation
cirrhosis cirrhosis The only curative treatment in
cirrhosis
 Treatment of hepatic diseases 2

Ascites HRS Portal hypertension Pyogenic liver abscess

Treatment of the cause Prevention Silent varices Antibiotics
HF-Nephrotic syndrome-TB … Endoscopic screening
Treatment of ascites in liver cirrhosis Avoid precipitating factors Propranolol or Nadolol
Broad spectrum
• Excessive diuresis – tapping Band ligation
General • Diarrhoea – vomiting – bleeding
Active bleeding
•
Rest -Diet - Follow up Severe infection
Admit Percutaneous US-
Removal guided drainage
Plasma expansion Resuscitate
Diuretics Nearly replaced open and
Spironolactone 400 – Lasix 120 IV Albumin Ryle – line – fluid – Catheter
laparoscopic drainage
Mannitol IV – Dopamine IV VC drugs correct coagulopathy
Albumin IV Terlipressin – octreotide – norepinephrine – IV vitamin K and FFP
midodrine
May be used to correct hypoalbuminemia Prevent encephalopathy
Tapping Enema -lavage – Neomycin 1 g/6h
C.I. in severe LCF, encephalopathy and renal failure Resistant cases – Lactulose
Refractory TIPSS Stop bleeding
Not responding to spironolactone 400 + Lasix 120 for 2 weeks Dialysis 1. Endoscopic sclerotherapy or
Dilutional hyponatraemia – add Na Usually in patients awaiting transplantation band ligation
Lack of salt restriction – achieve proper restriction 2. Drugs
Severe hypoalbuminemia – add IV albumin Vasopressin
SBP – treatment of SBP Transplantation Glypressin
Somatostatin
Terminal 3. Balloon tamponade
Le-Veen shunt 4. TIPSS
DIC – hypervolemia – Pulmonary oedema – Infection
TIPSS
Hepatic encephalopathy – stenosis
History of bleeding
Ultrafiltration and reinfusion Repeated sclerotherapy
Transplantation Surgery
• Shunt
• Porto-caval disconnection
SBP Cephalosporin Ciprofloxacin • Transplantation
 Treatment of hepatic diseases 3

Acute fulminant LCF Acute viral hepatitis Sclerosing cholangitis Obstructive jaundice HCC

Mainly supportive Rest Symptomatic

ICU admission Until
• Symptom-free
Pruritus
Ursodeoxycholic acid
Surgery
And care of comatose Carries the only hope for cure
• Not tender Strictures
• Bilirubin below 1.5 ERCP stent insertion Hemihepatectomy
Complications LCF -
-
Child A
No metastasis
Management
Hypoglycaemia
Renal failure
Diet - No vascular invasion
• Low fat (nauseating) - No portal vein thrombosis
Bleeding
• Free protein intake unless - Confined to one lobe

Cause
liver failure occurs
Immunosuppression
• High Carbohydrate Transplantation
Encephalopathy Steroids - Child C
Enema
Lactulose Symptomatic + -
-
No metastasis
Single lesion less than 5
Neomycin 1 g/6h Pruritus Azathioprine or Tacrolimus cm or 3 lesions each less
Cholestyramine than 3 cm Milan Criteria
Charcoal Nausea
Domperidone
haemodialysis Transplantation Palliative
Complications -
-
TACE
US-guided intralesional
Cholestatic hepatitis
Cause alcohol
Large doses of N-acetyl cysteine
Corticosteroids - US-guided intralesional RF
in acetaminophen toxicity - US-guided intralesional
microwave or laser
Prophylaxis ablation
Transplantation Hygienic measures - Systemic chemotherapy
Immunoprophylaxis
After exposure
Vaccines
(HBV and HAV)
 Treatment of Rheumatic diseases

Osteoarthritis FMF Gout Sarcoidosis RA SLE SSc Myopathy

General Initial Acute Steroid DMARDs ALL: HCQ Complications Steroids
Weight reduction NSAIDs Methotrexate
physiotherapy Colchicine Steroids Leflunomide Skin
Oral – IV - Intraarticular Sulfasalazine
Steroids Immuno-
Medical Colchicine
suppressive
Other csDMARDs P.HTN MTX
Mild:
NSAIDs Non- Sildenafil Cyclophosphamide
Chronic Non-steroid bDMARDs
NSAIDs
responders Methotrexate ILD
Glucosamine (5-10%) Hydroxychloroquine tsDMARDs Cyclophosphamide
sulphate
Allopurinol Infliximab
Anakinra Febuxostat Steroids Renal
Surgical Severe:
Infliximab Low dose during ACE.I
Arthrodesis Pegloticase initiation or Steroids IVIG
Arthroplasty changing DMARD Steroids precipitates
Probenecid or pregnancy renal crisis
Others Benzbromarone Rituximab
Intra-articular Lesinurad NSAIDs Immuno-
hyaluronan injection Symptomatic relief suppressive Symptoms
Less commonly
Gold Raynaud’s
Asymptomatic Penicillamine CCBs – a blockers
Only if: Azathioprine bDMARDs
FH Cyclosporin Belimumab Myositis
Level > 11 Rituximab Steroids

Surgery Arthralgia
Severe life- NSAIDs
Synovectomy
Joint replacement threatening: GORD
Plasmapheresis PPIs
 Treatment of Kidney diseases

Tubulointerstitial Polycystic
CKD AKI Nephrotic Nephritic nephritis kidney
Workup Screening of offspring
DIET Catheter DIET REST Stop should be done using US
CVL The causative agent By the age of 30, 90% of
Fluid • K-rich diet Until hypertension, oedema and
Avoid nephrotoxic drugs oliguria subside patients with adult
Salt • Protein Is better polycystic kidney disease
Pre-renal: Give fluids Steroids
Protein – CHO – Fats
Post-renal: Obstruction
restricted despite
hypoproteinaemia DIET will have cysts detected by
SYMPTOMS • K-rich diet
Prednisolone 60 / day 2-4 US

• GIT DIET SYMPTOMS • Protein Is better restricted

weeks
Before renal failure
• CVS • Hypovolemia despite hypoproteinaemia
• Chest Fluid
• Conservative
• Endocrine Salt
•
Oedema
Hypercoagulability
SYMPTOMS For ARF Antihypertensive
• Metabolic Protein – CHO – Fats • Oedema
• Infections
• Blood
• Skin SYMPTOMS •
•
Hyperlipidaemia
Proteinuria
•
•
Hypertension
hyperkalaemia RRT Antibiotics
Hypervolemia For UTI
RRT Hyperkalaemia
Hypertension
SPECIFIC Antibiotics May be needed
Low protein
Indications of For PSGN
Heart failure
Steroids Penicillin G Cause Diet and regular follow up
dialysis Hyperphosphatemia Ab for pyelonephritis of renal functions
2 mg/kg/day – 6 weeks 1.2 m SINGLE IM
Clinical Hypocalcaemia
Acute pulmonary oedema 1.5 on alternate days – 6 Oral penicillin V
Anaemia
500 / 12 / 10 days US-guided
Pericarditis
Preoperative
Acidosis
Anorexia NV
Immuno- Erythromycin aspiration
Persistent vomiting or 40 / kg / 10 days
diarrhoea
RRT suppressive Complications
If cysts are compressing
Coma or Convulsions
Deterioration of health Same as CKD except agents ARF - APO
HTN encephalopathy
Embolization
Lab indications K>7 Usually in steroid In heavy haematuria
Urea > 200
Creatinine > 8 (7 in DM)
pH< 7.15
+ Hypercatabolic RF
• Creatinine increasing
resistance
Cyclophosphamide RRT After renal failure
Cyclosporine Pulmonary oedema – ARF
HCO3 < 15 more than 1 / day Mycophenolate mofetil
• K increasing > 0.8 / day Severe Hyper K – HTN (sev)
Cr. Cl < 15 ml/min
K > 5.5
Chlorambucil
Levamisole
Rituximab
Acidosis RRT
 Treatment of neurological diseases 1

Ischemic stroke Haemorrhagic stroke TIA Paraplegia

General General
Skin, diet, fluids, breathing, bowel, urine Antiplatelets Skin, diet, fluids, breathing, bowel, urine
Symptomatic In non-cardioembolic TIAs Symptomatic
Early: Use Mannitol to decrease ICT Aspirin 300
Late: Physiotherapy
Late: Physiotherapy Plavix 75

Revascularisation Control
Chemical and mechanical
hypertension
Anticoagulant
In cardioembolic TIAs

Cause
Not enough clinical trials to determine
Control hypertension certain values of optimum BP in Warfarin (target INR 2-3)

Non-rtPA candidate haemorrhagic stroke

<220/120 (in absence of TOD)
Monitor and treat symptoms
>220/120 Decrease ICT Cause Managing risk factors
Labetalol 20 Nicardipine 15/h Nitroprusside Patient in 30 degrees in bed
rtPA candidate Mannitol IV to decrease oedema
same (180/110)
Neuroprotective agents
Surgical
Dextrophan – Emlimomab Antifibrinolytic endarterectomy
Antiplatelets therapy In carotid artery stenosis more than 70%

TXA or EACA
Aspirin 300
Plavix 75 Carotid angioplasty
Surgery and stenting
Anticoagulant Evacuation of hematoma provided it is
not intraventricular
If associated with AF
Stroke in evolution

Cause Managing risk factors

 Treatment of neurological diseases 2

GBS MS Parkinsonism Epilepsy Myasthenia Gravis

General Symptomatic and Anticholinergic General Anticholinesterase
Rest – Vitamins – Physiotherapy physiotherapy Avoid triggers Neostigmine 15
TREMORS Moderation of physical activity Pyridostigmine 60
Atropine (rarely used) Ketogenic diet (acidosis raises
Immunomodulation Parkinol threshold of nerve stimulation)
Artane
DMAMS Cogentin Drugs Corticosteroids
IVIG Begin with a single agent
Add-on until improvement Prednisolone
Interferon-beta Stop only when the patient is symptom-free for 2-3 (If not responding to anticholinesterase)
Alemtuzumab L-Dopa years and EEG is normal

Natalizumab Many peripheral side effects Immunosuppression

Glatiramer acetate Barbiturates 600 Azathioprine
Prednisone L-dopa + Carbi-dopa Broad spectrum Cyclophosphamide
Immunosuppression Valproate 1500 (If not responding to Steroids)
1 mg/kg/day
Sinemet Broad spectrum
MAC regimen BRADYKINESIA – RIGIDITY Carbamazepine 600
Plasmapheresis Methotrexate Grand-mal Irradiation or surgical
Azathioprine Dopamine agonist Phenytoin 600
Cyclosporine Bromocriptine
thymectomy
Cyclophosphamide Grand-mal
Corticosteroids Trivastal
Clonazepam 6
Myoclonic
Acute relapse Amantadine HCl
Respiratory failure Dopamine reuptake inhibitor
Succinimide 1000
STEROIDS Petit-mal
MYASTHENIC
For 2 weeks Muscle relaxants
1st week – IV prednisolone
STATUS EPILEPTICUS CRISIS
1 g per day
2nd week – Oral prednisone • Step 1: Phenytoin + Diazepam • IM prostigmine
1 mg/kg/day Surgery • Step 2: Barbiturates • Plasmapheresis
In severe cases • Step 3: General anaesthesia • Mechanical ventilation
NB. plasmapheresis may be Thalamotomy
beneficial Pallidectomy
 Treatment of neurological diseases 3

Migraine SAH Meningitis Disc prolapse PN

During attack Acute management Prophylactic Conservative
1st line Monitor Isolation Rest in a bed with hard boards
Constant hemodynamic and neurological
Combination analgesic follow up (GCS should be frequently Chemoprophylaxis under the mattress for 2-4 weeks
• Paracetamol 250 + Aspirin measured) usually relieves pain
Rifampicin 600 – for 2 days
250 + Caffeine 65 ICT For contacts Analgesics
• Antiemetic Ventriculostomy, Mannitol or diuresis
Immunoprophylaxis Usually, NSAIDs
• Metoclopramide Oral or IV BP control
2nd line Below 160 mmHg
Meningococcal live attenuated Weight reduction
vaccine Physiotherapy
NSAIDs Using Labetalol and Nicardipine
Naproxen 500 Seizure control After recovery from acute attack
3rd line Using AEDs Curative Avoidance of sudden flexion
Antifibrinolytic therapy

Cause
Sumatriptan 100 oral
Also available SC and Nasal spray TXA or EACA
Antibacterial
Ergotamine is another option but less However, may increase the incidence of Ceftriaxone
used due to side effects cerebral ischemia
Cefotaxime
Aneurysm Crystalline penicillin (or Surgical
In-between attacks ampicillin) Indications
Rebleeding is associated with
Beta-blockers • Persistent symptoms
70% mortality Chloramphenicol • Recurrent attacks
propranolol 120 daily
Metoprolol
Surgical clipping • Sensory or motor affection

Anticonvulsants Endovascular coiling Steroids Removal of prolapsed nucleus

pulposus
Valproate 500 Severe cases (WFS)
Topiramate
Medical TB (under-cover of anti-TB drugs)
Indications
Anti-depressants • Should be delayed
• Cannot be performed
Amitriptyline 150 daily • Non-surgical (haemorrhagic disease)
• Multiple
• Huge or inaccessible

CCB and Methysergide Measures

• Avoid precipitating factors
• Analgesics
+ Avoid triggers • Complications