Geriatric Emergencies PDF
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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 Thiseditionfirstpublished2015©2015byJohnWiley&Sons,Ltd. 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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
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