Geriatric Emergencies

295 Pages·2015·8.28 MB·English

by  Johnston

Geriatric Emergencies

Geriatric
Emergencies
Iona Murdoch
SpecialtyRegistrar(ST3)EmergencyMedicine
EastofEnglandDeanery
Sarah Turpin
SpecialtyRegistrar(ST4)GeriatricMedicineandGeneralInternalMedicine
SouthEastScotlandDeanery
Bree Johnston
DirectorofPalliativeCare,StJosephHospitalatPeaceHealth
ClinicalProfessorinGeriatrics,UniversityofCalifornia,SanFrancisco
Alasdair MacLullich
HonoraryConsultantinGeneralandGeriatricMedicine,RoyalInfirmaryofEdinburgh
ProfessorofGeriatricMedicine,UniversityofEdinburgh
Eve Losman
AssistantProfessor,EmergencyMedicine,UniversityofMichiganHealthSystem
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LibraryofCongressCataloging-in-PublicationData
Murdoch,Iona,1984-,author.
Geriatricemergencies/IonaMurdoch,SarahTurpin,BreeJohnston,AlasdairMacLullich,EveLosman.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN978-1-118-65557-3(cloth)
I. Turpin,Sarah,1985-,author. II. Johnston,Bree,author. III. MacLullich,Alasdair,author.
IV. Losman,Eve,author. V. Title.
[DNLM:1.Aged.2.Emergencies.3.EmergencyTreatment–methods.WB105]
RC86.7
616.02′5–dc23
2014034303
AcataloguerecordforthisbookisavailablefromtheBritishLibrary.
Wileyalsopublishesitsbooksinavarietyofelectronicformats.Somecontentthatappearsinprintmay
notbeavailableinelectronicbooks.
Coverimage:Mainfrontcoverimageofanemergencyservicerescuingavictimofanaccident:istock©
Seanshot;ambulance:istock©ScottKochsiek;emergencyroom:istock©Pgiam
Setin9.5/12ptMeridienbyLaserwordsPrivateLimited,Chennai,India
1 2015
Contents
Preface, vii
Acknowledgements, ix
ListofAbbreviations, xi
1 Introductiontogeriatricemergencymedicine, 1
2 Essentialsofassessmentandmanagementingeriatricemergencymedicine, 9
3 Specialskillsingeriatricemergencymedicine, 30
4 Vulnerableadultsandelderabuse, 51
5 Chestpainandatrialfibrillation, 62
6 Dyspnoea, 85
7 Infectionandsepsis, 100
8 Fallsandimmobility, 112
9 Syncope, 127
10 Dizziness, 137
11 Majortrauma, 146
12 Fracturesandbackpain, 158
13 Skintrauma, 179
14 Headinjury, 188
15 Abdominalemergencies, 200
16 Diabeticandenvironmentalemergencies, 220
17 Acutekidneyinjuryandmetabolicemergencies, 230
18 Delirium, 242
19 Strokeandtransientischaemicattack, 256
Index, 273
v

Preface
Thisbookwaswrittenaftertwooftheauthorswerediscussinghowdisastrousitcanbe
forafrailolderpersontopresenttohospitalunnecessarily.Conversationsoonspiralled
towhythiswasthecase,andontothemanyinadequaciesofahealthsystemdesigned
totreatsingleorganillnessnowdeliveringhealthcaretoapopulationofolderpatients
withever-growingpolypathologyandcomplexcomorbidity.
Thechangingdemographicsofourpopulationareanimmensetributetothesuccess
ofmodernmedicine.Withthesechangescomenewandexcitingchallenges.Howdoes
onedelivercaretoafrailolderpatientwithmultiplecomorbiditiesinanenvironment
designed for single organ illness and rapid discharge? How can a clinician gather the
complex but vital information about a patient’s medications, social network and care
needswhenundertimepressurewithmanyotherswaitingtobeseen?Howcanolder
persons be efficiently but safely assessed when they have so many active and inactive
problems?Whenaretheseaspectstaughtduringundergraduatetraining?
Thetreatmentofolderpatientsatthefrontdoorofthehospitalisnowthecorebusi-
nessofcliniciansworkingintheemergencydepartmentandacutemedicalunit.These
patients constitute the majority, rather than the minority, of clinical work in modern
medicine. Clinical outcomes are poor, with increased morbidity and mortality, if good
initial care is overlooked; the first few hours in hospital are precious and the stakes
arehigh.
Anessentialwayofimprovingthecareofolderpatientsintheemergencydepartment
isthrougheducatingandimprovingthecompetenceofallemergencypersonneltodeal
withthespecificneedsofthislargegroupofpatients.Thisisthepurposeofthisbook.
Thisbookisaimedprimarilyatjuniordoctors,althoughwehopeitwill beauseful
resource for any health care professional who encounters older patients in acute and
emergency situations. There is a strong focus around the emergency department, but
many of the presentations covered are frequent occurrencesat the acute medical unit
andingeneralmedicalandsurgicalwards.
Thetwointroductorychaptersplacethesubjectincontextandcovertheessentialsof
thoroughbutconcisehistorytakingandclinicalexaminationinolderpatients,relevant
to the emergency setting. Tables and diagrams provide clear and practical information
in relation to the work-up and management of each presenting complaint. Chapters
includetheclassiccommongeriatricpresentationsincludingfalls,deliriumandstroke;
the book also covers other emergencies such as head injury, abdominal pain, burns
and major trauma, which often require a different approach to management in older
patients. Throughout the text, ‘key points’ are used to highlight particularly relevant
piecesofinformationorusefultips,and‘takehomemessages’attheendofeachchapter
provideabriefsummaryoftheareascovered.
Thisisnotageneralmedicaltextbook:whilesomeemergenciesinolderpatientsare
managedsimilarlytothewaytheywouldbeinayoungerpatient,othersrequirediffer-
entapproachesandmanagementtechniques.Thecontentofthisbookwillreflectthese
variationsbyaddressingsometopicsingreaterdepththanothers.Thistextisdesigned
tocovertheparticularissuesandchallengesdirectlyrelevanttofrail,olderpatients.In
vii
viii Preface
somesituations,forexample,apatientwhohascardiacfailureandacutekidneyinjury,
there is no single ‘right answer’. Instead, good management decisions rely on experi-
ential knowledge, gained from years of practice, and the expert opinion and guidance
ofrespectedcolleagues.Wehopethetextreflectstheintricaciesofthesesituationsand
thatisservesasausefulaidintheoptimalcareofolderpeople.
IM,ST,AM,BJandEL