Geriatric Emergencies

Description

Geriatric Emergencies is a practical guide to the common conditions affecting older patients who present in an emergency to hospital or primary care. Beginning with the essentials of history taking and clinical examination, the book covers a comprehensive range of emergencies, emphasizing the different management approaches which may be required in older patients. Common geriatric presentations such as falls, delirium and stroke, are explored in detail in addition to more diverse topics such as abdominal pain, major trauma and head injury. Ethical considerations such as advanced care planning, palliative care and capacity assessment are discussed with practical tips on communicating with patients and their relatives. Geriatric Emergencies provides concise up-to-date guidance to the emergency management of the older patient. It is a recommended resource for all health professionals working in the acute environment, in which a large proportion of patients are aged over 65. Cover Title Page Copyright Contents Preface Acknowledgements List of Abbreviations Chapter 1 Introduction to geriatric emergency medicine Demographics Emergency presentations Frailty at the front door Comprehensive geriatric assessment (CGA) Pathways in geriatric emergency care References Chapter 2 Essentials of assessment and management in geriatric emergency medicine Introduction Triage and initial assessment Communication with older patients Positioning and body language Vision and hearing Communicating with the cognitively impaired Initial cognitive assessment History of presenting complaint Chronic versus acute symptoms Cognitive impairment Collateral history What to ask Whom to ask Systematic enquiry Social and functional history Medications and polypharmacy Examination General examination Specific areas of focus on examination Investigations Computed tomography (CT) scans in older patients When not to investigate Management How to make a problem list Active problems Inactive problems Discharging a patient from hospital Transitions of care References Chapter 3 Special skills in geriatric emergency medicine Pain in the older patient Pain assessment Management of acute pain Chronic pain management Palliative care in the acute setting Definition Background Identifying patients requiring palliative care General approach to the patient with palliative care needs Palliative care emergencies Addressing symptom management Communication with patient, carers and family Managing the dying patient in the emergency department Decision-making capacity When the patient lacks decision-making capacity Advance directives Cardiopulmonary resuscitation (CPR) Resuscitation decisions How to discuss resuscitation decisions Ceilings of care Critical care referral Take home messages References Chapter 4 Vulnerable adults and elder abuse Introduction Definition Background History Think about it Ask about it Examination Physical examination Specific areas of focus Investigation Initial investigations Management Documentation Referral Overview of an approach to patients where abuse is a concern Take home messages Useful links and resources UK (general) England Northern Ireland Scotland Wales USA Case Studies References Chapter 5 Chest pain and atrial fibrillation Part 1: Chest pain Introduction Background History Particular challenges in taking a history from patients with: Examination Physical examination: general Specific areas of focus on examination Investigations Initial investigations Further investigation Management General management Acute coronary syndrome Pulmonary embolus Aortic dissection Overview of an approach to a patient presenting with chest pain Part 2: Atrial fibrillation Atrial fibrillation Background Initial assessment History and examination Investigations Management 1. Haemodynamic compromise 2. Identify and treat precipitating causes 3. Improve cardiac function by rhythm or rate control Rate control Rhythm control 4. Preventing thromboembolism Further management Take home messages References Chapter 6 Dyspnoea Introduction Definition Background Initial assessment History Onset Comparison with baseline symptoms Associated symptoms Previous episodes Past medical history Drug history Social history Systemic enquiry Asthma in older patients COPD in older patients Cardiac failure Examination General examination Specific areas of focus on examination Investigations Initial investigations Further investigations If cardiac failure is suspected If an exacerbation of asthma or COPD is suspected Management Oxygen Type 2 respiratory failure in older patients Non-invasive ventilation (NIV) Invasive ventilation Recurrent presentations with COPD ‘the revolving door patient’ Discharging older patients with COPD Management of end-stage lung disease Management of cardiac failure Acute pulmonary oedema Cardiac failure with acute or chronic kidney injury Prognosis Take home messages References Chapter 7 Infection and sepsis Introduction Background Specific causes of infection Urinary tract infection (UTI) Respiratory tract infections Cellulitis Initial assessment History In suspected urinary tract infection In suspected pneumonia In suspected cellulitis Examination In suspected urinary tract infection In suspected pneumonia In suspected cellulitis Investigations In suspected urinary tract infection In suspected pneumonia In suspected cellulitis Management General management of the septic older patient Antibiotic therapy Admission Critical care referral Management of specific infections Urinary tract infection Respiratory tract infections Take home messages References Chapter 8 Falls and immobility Part 1: Falls Introduction History Examination General Specific areas of focus on examination Investigations Initial investigations Further investigations Management General Specific management considerations in older patients Soft tissue injury Fractures Head injury Prolonged immobility Overview of an approach to a patient with a fall Part 2: Immobility Introduction Background History Examination General examination Examining pressure ulcers Investigations Initial investigations Further investigations Management General management Pressure ulcers in older patients Patients with Parkinson’s disease Complications of a ‘long lie’ Hypothermia Take home messages References Chapter 9 Syncope Introduction Definition Background History Examination General examination Specific areas of focus on examination Investigations Initial investigation Further investigation Management General management Specific management considerations in older patients Overview of an approach to a patient presenting with syncope Take home messages References Chapter 10 Dizziness Introduction Definition Background History What is the nature of the dizziness? Precipitants of the dizziness Timescale Frequency of attacks Past medical history Medication and alcohol history Examination General examination Specific areas of focus on examination Investigations Initial investigations Further investigations Management General management Specific management considerations in older patients Criteria for admission of a dizzy patient Take home messages References Chapter 11 Major trauma Introduction Definition Background Initial Approach Airway and cervical spine immobilisation Breathing Circulation with haemorrhage control Disability Exposure and environmental control History Investigations General management Secondary survey and tertiary survey Rib fractures Cervical spine injuries Initial assessment Odontoid peg fractures Central cord syndrome Take home messages References Chapter 12 Fractures and back pain Fractures Introduction Definition and background Initial assessment Hip fractures History and examination Investigations Management Fascia iliaca compartment block (FICB) Facilitating surgery Ongoing care Pelvic insufficiency fractures History, examination and investigations Distal radial fractures Back pain in the older adult Immediate assessment Differential diagnosis History Examination Investigations Vertebral insufficiency fracture Diagnosis and classification Management Spinal cord compression and cauda equina syndrome History and examination Management Procedural sedation in the older patient Take home messages References Chapter 13 Skin trauma Introduction Background History and examination Tetanus status Specific injuries Skin tears Scalp and face lacerations Pre-tibial lacerations Burns Background Initial assessment Examination Management Take home messages References Chapter 14 Head injury Introduction Initial assessment Airway and cervical spine immobilisation Breathing Circulation with haemorrhage control Disability Exposure and environmental control History Examination Investigations Initial investigations Computed tomography (CT) head Computed tomography (CT) cervical spine Management Managing a head injured patient on anticoagulants Discharging patients with head injuries Take home messages References Chapter 15 Abdominal emergencies Introduction Background Initial assessment History Examination Investigations Specific causes of abdominal pain in the older adult Abdominal aortic aneurysm (AAA) Biliary disease Pancreatitis Biliary disease Pancreatitis Peptic ulcer disease Gastrointestinal haemorrhage Small bowel obstruction Large bowel obstruction Non-mechanical causes of bowel obstruction Constipation and faecal impaction Mesenteric ischaemia Appendicitis Diverticular disease Genitourinary causes Non-surgical or extra-abdominal causes of abdominal pain Non-specific abdominal pain Take home messages References Chapter 16 Diabetic and environmental emergencies Part 1: Diabetic emergencies Introduction Hypoglycaemia Hyperglycaemic hyperosmolar syndrome Diagnosis Management Part 2: Temperature homeostasis Introduction Hypothermia Definition Background Initial assessment History and examination Investigations Management Hyperthermia and heat illness Management Take home messages References Chapter 17 Acute kidney injury and metabolic emergencies Acute kidney injury Definition Background Initial assessment History and examination Investigations Management Complications Prevention of acute kidney injury Hyponatraemia Definition Background History and Examination Investigations Management Hypernatraemia Hypercalcaemia History and examination Management Take home messages Recommended resources References Chapter 18 Delirium Introduction Definition Background History Differential diagnosis Examination Physical examination: general Specific areas of focus on examination Assessing for and documenting delirium Investigations Initial investigations Further investigations Management General management Specific management considerations in older patients Legislation and delirious patients Medical treatments and other healthcare interventions Covert medication Wandering Absconding and restraint Restriction or deprivation of liberty (DOLS) Prevention of delirium Take home messages References Chapter 19 Stroke and transient ischaemic attack Introduction Definition Background Stroke categorisation Initial assessment of patients with acute stroke in the ED The FAST test Time of onset Past medical history Functional status Medications Examination General examination The national institute of health stroke scale Recommended resources Higher function assessment Investigations Initial investigations Further investigations Management General management of acute ischaemic stroke in the ED Specific management considerations in the older patients Further management of acute stroke Transient ischaemic attack Intracranial haemorrhage Background Management Take home messages References Index