Acute Medicine 2015

Acute Medicine 2015

by Declan O'Kane

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Overview

From reviews:

"This new book by Dr O’Kane is a very useful and interesting book directed towards Medical registrars but also with many positive features for anyone from Medical Student to Consultants... [It] works through groups of emergencies according to speciality and organ grouping. This is helpful as it enables the reader to link the different differentials together well.  It also tries to signpost all the different conditions in relation to the Acute Medicine and General Internal Medicine curriculums.

There is also an excellent section on fluid prescription, outlining what each fluid option contains along with potential fluid prescriptions in relation to the daily needs of the human body. Each clinical problem is presented in a clear and logical format, beginning with the things to ask or think about when receiving a referral - much as junior doctors would do in a real clinical situation. 

The book also includes an excellent 'general management’ section, which covers important aspects of the assessment of mental capacity and considerations to make when discharging a patient - things which are often poorly taught in other settings. All of the clinical procedures are described in some level of detail - not enough to learn to do the procedure but enough to signpost as well as getting the reader to think about why it is needed and any associated risks." - Journal for Acute Medicine, October 2015

"O'Kane's Acute Medicine 2015 is a fantastic text for any doctor regardless of their grade. However, it is of particular use to the junior hospital doctor. The book covers a huge array of pathology and knowledge in a succinct and accessible way with easy to use chapters with superb explanations throughout. I am currently working in A+E and have found this book invaluable. In particular the chapters covering procedures and the excellent formulary have helped me on several occasions. All of this is accentuated by the size of the book, which is genuinely pocket sized. This book is an essential text for all junior doctors." - A junior hospital doctor

Acute Medicine is written for registrars, junior doctors and medical students working on the wards. It is a current and concise guide to hospital emergency medicine which provides:

• detailed management of acute medical and surgical emergencies, including in pregnancy
• general ward management issues
• descriptions of key procedures
• normal laboratory values
• drug formulary covering the common drugs you will use every day.

It is not just a list of instructions, but contains detailed pathophysiology and useful clinical pearls.
It is designed to be carried round in a pocket for easy reference.

Product Details

ISBN-13: 9781907904691
Publisher: Scion Publishing Ltd.
Publication date: 11/17/2014
Sold by: Barnes & Noble
Format: NOOK Book
Pages: 420
File size: 9 MB

Read an Excerpt

Acute Medicine 2015


By Declan O'Kane

Scion Publishing Limited

Copyright © 2015 Scion Publishing Limited
All rights reserved.
ISBN: 978-1-907904-69-1



CHAPTER 1

Adult Resuscitation


1.1 Introduction

• Ensure you are up to date with BLS and ALS courses. Be familiar with the excellent American Heart Association basic and advanced cardiovascular life support (ACLS) guidelines and European guidelines, which are freely accessible on the internet in pdf format.

• There is much in common in guidelines. The things that differ are due to a lack of evidence and so either way is defensible. It is difficult to perform trials on resuscitation and much is extrapolated from basic theory as well as laboratory and animal experiments.

• Guidelines are just that and experienced clinicians who know and understand the evidence or lack of evidence can deviate to a degree.


1.2 Running a cardiac arrest

• Resuscitating an unresponsive pulseless apnoeic patient can be stressful and it is never as simple as a basic algorithm suggests. It is not uncommon to find yourself trying to cope with a collapsed patient wedged in a toilet cubicle. All you can do is your best. Such a patient is certifiable as dead and you cannot make that situation any worse. In a small number of cases you can make a significant difference.

• Are you unsure of the rhythm – could it be VF? If so, do not hesitate to defibrillate. If there is any delay in defibrillation then get good quality CPR going at least using chest compressions. Survival depends on the immediate initiation of chest compressions and early defibrillation if there is a shockable rhythm.

• As soon as you arrive use the ABCs to quickly determine the basics – check the airway is not obstructed, look for breathing, palpate a major pulse, and commence chest compressions as quickly as possible; hopefully someone else will already have done so.

• Your concern is whether unresponsiveness is due to circulatory collapse or not. If unsure start CPR. It is probably less harmful to CPR a patient who turns out to have a pulse than to delay CPR in a pulseless patient. If possible let someone else do CPR as you take stock and look at the bigger picture. This is a very useful reason for the ABCs – to buy you some thinking and information-gathering time.

• Once you have the defibrillator leads on look at the rhythm and assess if it is shockable. If shockable then shock and treat for VT/VF. Go through the standard list of treatable causes ensuring effective CPR continues.


1.3 Is resuscitation appropriate?

• Always consider if resuscitation is appropriate. Is there a 'do not resuscitate' form in the notes? Is there an advance directive or community DNAR order? What was the patient's expressed wish?

• Is this VF due to a small inferior STEMI which is shockable, giving the patient many good years ahead, or an elderly patient with co-morbidities dying a 'natural death' from severe pneumonia and a large stroke, where the chances of a successful outcome are very poor?

• The aim is, fundamentally, to prolong life and not to prolong death/dying and to do what the patient would want us to do. If you can't be sure then continue. Reassess and take senior advice especially in a young patient/hypothermia/ overdose. Stop when continuing is considered futile.


1.4 General advice

• Emphasis should be on cardiac arrest prevention and so care should be instigated pre-arrest when reversible factors can be dealt with. If a patient is in extremis and pre-arrest, then call the arrest team.

• The ABC assessment allows you a moment to figure out what is going on and determine what you plan to do next. Let someone else manage these whilst you think.

• Delegate roles. If you are leading the arrest then ask others to get venous/ intraosseous access and obtain notes. Determine the ceiling of care. Contact your senior if unsure or unclear.

• Send away extra staff if there are demands elsewhere. Hospital business goes on and extra hands might be more productive seeing other sick patients and preventing cardiac arrests elsewhere.

• Stop once you all feel that continuing is futile. Thank the team. Complete audit sheets and record all in the patient notes. Arrange to talk with family. Do a self-debrief: anything you would do differently or better? Seek feedback and add to personal development plan.

• Favourable outcome likely from BLS/ALS: witnessed arrest; in-hospital; early effective CPR; shockable rhythm; early defibrillation; hypothermia (e.g. submerged in icy water).


1.5 Basic life support

Signs of impending or established cardiac arrest include unresponsiveness, irregular or absent breathing, impalpable pulse (can be difficult to palpate).


Basic life support algorithm.

Reproduced with permission from the Resuscitation Council (UK).

Assessment of a collapsed person: ensure safe to approach. Check for local hazards; particularly relevant outside hospital when there may be traffic, water, electrical or chemical hazards. Check if patient is unresponsive: shake patient by the shoulders and ask loudly "Are you all right". If patient responds then leave them in the same position unless in danger and assess further to determine what is wrong (consider ABCDE/oxygen/IV access). Get help if needed. Reassess regularly. If the patient does NOT respond then shout for help and turn the patient on their back and open the airway using head tilt (if neck is okay) and chin lift. Head tilt involves placing hand on forehead and tilting head back gently. Chin lift is done by using fingertip under the chin and lifting to open the airway. If there are concerns over neck injury use jaw thrust, where fingers at the angle of the jaw lift the mandible forwards whilst keeping the neck immobile.

Airway and breathing assessment: now keep the airway open and look for signs of breathing and for chest movements. Feel for air on your cheek. Difficult, noisy, irregular gasping breathing is seen with cardiac arrest and is not normal. Assess for a maximum of 10 s. If the person is breathing normally then place in recovery position and summon help – 999/911 or send a bystander or go yourself if no other choice. Contine to assess and be prepared to start CPR if deteriorates. If the person is not breathing normally then start CPR.

Start 30 chest compressions at 100/min: kneel by the side of the patient, place the heel of one hand in the centre of the chest (which is the lower half of the breastbone (sternum)) and place the heel of your other hand on top of the first hand. Interlock the fingers of your hands and ensure that pressure is not applied over the ribs. Keep your arms straight. Do not apply any pressure over the upper abdomen or the bottom end of the sternum. Position yourself vertically above the patient's chest and press down on the sternum at least 5 cm (but not exceeding 6 cm). After each compression, release all the pressure on the chest without losing contact between your hands and the sternum; repeat at a rate of at least 100/min (but not exceeding 120/min). Compression and release should take equal amounts of time.

Now give two rescue breaths: open the airway again using head tilt and chin lift. Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead. Allow the mouth to open, but maintain chin lift. Take a normal breath and place your lips around his mouth, making sure that you have a good seal. Blow steadily into the mouth while watching for the chest to rise, taking about 1 s as in normal breathing; this is an effective rescue breath. Mouth to nose breathing can also be considered where mouth to mouth not possible. Maintaining head tilt and chin lift, take your mouth away from the patient and watch for the chest to fall as air comes out. Take another normal breath and blow into the patient's mouth once more to achieve a total of two effective rescue breaths. The two breaths should not take more than 5 s in all. If you are unable to give rescue breaths then continue chest compressions uninterrupted. Where available bag–mask ventilation may be used.

Continue with 30 chest compressions at 100/min: then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions. Continue with chest compressions and rescue breaths in a ratio of 30:2. Stop to recheck the patient only if he starts to wake up, to move, to open eyes and to breathe normally. Otherwise, do not interrupt resuscitation.

Now give two rescue breaths: as detailed above. Continue this cycle until ALS started or BLS is continued. If you are unable to give rescue breaths then continue chest compressions uninterrupted.

Additional notes: if your initial rescue breath does not make the chest rise normally then before your next attempt: look into the patient's mouth and remove any obstruction; recheck that there is adequate head tilt and chin lift; do not attempt more than two breaths each time before returning to chest compressions. If there is more than one doctor present, another doctor should take over delivering CPR every 2 min to prevent fatigue. Ensure that interruption of chest compressions is minimal during the changeover of doctors.

Chest-compression-only CPR may be used as follows: if you are not trained, or are unwilling to give rescue breaths, give chest compressions only; if only chest compressions are given, these should be continuous, at a rate of at least 100/min (but not exceeding 120/min).

Do not interrupt resuscitation: until professional help arrives and takes over, or the patient starts to wake up (to move, to open eyes and to breathe normally), or you become exhausted.

Recovery position: the RC(UK) recommends the following sequence of actions to place a patient in the recovery position. Remove the patient's glasses, if present. Kneel beside the patient and make sure that both his legs are straight. Place the arm nearest to you out at right angles to his body, elbow bent with the hand palm-up. Bring the far arm across the chest, and hold the back of the hand against the patient's cheek nearest to you. With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground. Keeping 1.6 Adult choking algorithm 5 his hand pressed against his cheek, pull on the far leg to roll the victim towards you on to his side. Adjust the upper leg so that both the hip and knee are bent at right angles. Tilt the head back to make sure that the airway remains open. If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth. Check breathing regularly. If the victim has to be kept in the recovery position for more than 30 min turn him to the opposite side to relieve the pressure on the lower arm.


1.6 Adult choking algorithm

Usually occurs when eating and patient clutches neck/chest and may be unable to speak. Can be wheezing and stridor. May become unconscious.


If conscious with airways obstruction give five back blows then five abdominal thrusts

• If the patient shows signs of mild airway obstruction then encourage coughing, but do nothing else. But if patient shows signs of severe airway obstruction and is conscious then give up to five back blows. Stand to the side and slightly behind the patient. Support the chest with one hand and lean the victim well forwards so that when the obstructing object is dislodged it comes out of the mouth rather than goes further down the airway. Give up to five sharp blows between the shoulder blades with the heel of your other hand. Check to see if each back blow has relieved the airway obstruction.

• If this fails then give up to five abdominal thrusts. Stand behind the patient and put both arms round the upper part of his abdomen. Lean the victim forwards. Clench your fist and place it between the umbilicus (navel) and the bottom end of the sternum (breastbone). Grasp this hand with your other hand and pull sharply inwards and upwards. Repeat up to five times. If the obstruction is still not relieved, continue alternating five back blows with five abdominal thrusts.


If unconscious start CPR

• Help the patient carefully to the ground. Call an ambulance immediately. Begin CPR. Healthcare providers who are trained and experienced in feeling for a carotid pulse should initiate chest compressions even if a pulse is present in the unconscious choking victim.

• Following successful treatment for choking, foreign material may nevertheless remain in the upper or lower respiratory tract and cause complications later. Patients with a persistent cough, difficulty swallowing, or with the sensation of an object being still stuck in the throat should therefore be referred for an immediate medical opinion.


1.7 Advanced life support

Advanced life support algorithm.

Reproduced with permission from the Resuscitation Council (UK) 2010.


The ALS algorithm

Confirm cardiac arrest: unresponsiveness and absent or gasping breaths. Carotid pulsation can be unreliable and difficult to palpate which delays CPR. Start good quality CPR: even chest-compression-only CPR. Give high quality compressions to a 5 cm depth with full chest recoil. Early defibrillation is key with uninterrupted CPR unless there is clear ROSC. Continued CPR may augment return of circulation. Good CPR gives about 20% of normal cardiac output. There is a progressive metabolic acidosis. Survival after 30 min is uncommon; exceptions are hypothermia/drug overdoses. Patient should be placed on a hard surface or a board placed behind the patient. Once intubated or other ventilatory device then continue compressions at 100/min and ventilate the lungs at a rate of about 10 breaths/min.

Continue CPR: perform uninterrupted chest compressions while applying self-adhesive defibrillation/monitoring pads – one below the right clavicle and the other in the V6 position in the mid-axillary line. Shave hair if need. Anteroposterior electrode placement is also satisfactory to avoid pacemakers and ICDs and preferred for AF DC cardioversion. Plan actions before pausing CPR for rhythm analysis and communicate these to the team. Stop chest compressions; assess rhythm.


Pulseless VT.

• Confirm VF (or VT) from the ECG. Resume chest compressions immediately; simultaneously, the designated person selects the appropriate energy on the defibrillator (150–200 J biphasic for the first shock and 150–360 J biphasic for subsequent shocks) and presses the charge button.

• While the defibrillator is charging, warn all rescuers other than the individual performing the chest compressions to "stand clear" and remove any oxygen delivery device as appropriate. Ensure that the rescuer giving the compressions is the only person touching the patient.

• When clear, give the shock. Restart CPR without reassessing the rhythm or feeling for a pulse using a ratio of 30:2, starting with 30 chest compressions. Continue CPR for 2 min; the team leader prepares the team for the next pause in CPR.

• Resume chest compressions immediately and then give ADRENALINE 1 mg IV and AMIODARONE 300 mg IV while performing a further 2 min CPR. Repeat this 2 min CPR – rhythm/pulse check – defibrillation sequence if VF/VT persists. Give further ADRENALINE 1 mg IV after alternate shocks (i.e. approximately every 3–5 min). Precordial thump: only for witnessed arrest and where unable to immediately defibrillate.


(Continues...)

Excerpted from Acute Medicine 2015 by Declan O'Kane. Copyright © 2015 Scion Publishing Limited. Excerpted by permission of Scion Publishing Limited.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

1. Adult resuscitation
2. Early management of acutely ill patients
3. Ventilation of acutely ill patients
4. Shock
5. Acute breathlessness
6. Coma
7. Chest pain
8. Syncope
9. Weakness
10. Acute severe headache
11. Cardiological emergencies
12. Respiratory emergencies
13. Endocrinology and diabetes emergencies
14. Gastroenterology emergencies
15. Hepatology emergencies
16. Haematological emergencies
17. Acute infections
18. Renal emergencies
19. Neurology emergencies
20. Toxicology emergencies
21. Miscellaneous emergencies
22. Oncological emergencies
23. Skin emergencies
24. Ophthalmological emergencies
25. Medical problems in pregnancy
26. General management issues
27. Procedures
28. Normal laboratory values
29. Drug formulary (also see BNF)

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