Volume 2

Essential Guide to Acute Care

Regular features, Volume 2, Issue 3, Pages 75 - 107 (2003)

At last! A book that addresses the needs of every junior doctor faced with the management of acutely sick patients. Concise and readable, its format allows the reader to absorb the principles of human physiology, and to apply them to everyday situations involving critically ill patients. With each chapter being dedicated to a separate physiological ‘insult’, Cooper and Cramp open with a brief outline of what happens under ‘normal’conditions. This is followed by a summary of how physiology adapts under disease conditions. In this way the authors cover oxygen therapy, acid base disturbance,fluid balance, circulatory failure, sepsis, acute renal failure and coma. There are also chapters on identifying the patient at risk, and optimising physiology in the preoperative patient. With a distinct ‘anaesthetic slant’, the layout and emphasis are different to that with which most physicians will be familiar. This is however to its advantage, as it effectively bridges the traditional gap between medicine and critical care.

Unlike many texts, the authors have ignored the minutiae and have concentrated on the most relevant and applicable information. Well illustrated throughout, the reader is guided towards establishing a logical approach to the ill patient. With self-test questions relevant to each chapter, it becomes a valuable learning tool. ‘Mini- tutorials’ in each chapter highlight controversies, such as the relative merits of crystalloid versus colloid in f luid resuscitation, or the use of sodium bicarbonate in the treatment of metabolic acidosis.

The size of the book lends itself well to being carried in the white coat pocket. However the layout of the text makes it more suited to evening reading, rather than as a bedside reference. Some algorithms summarising the key points of each chapter might have added to the practical uses of the text.

Although this book will not help in passing the MRCP examination, it will hopefully make its readers into safer, better clinicians. If you ’ve ever been faced with a sick patient, a blank mind and a room full of expectant faces, then this is the book for you.

Dr Stuart Henderson Specialist Registrar in Medicine Southampton University Hospitals NHS Trust

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Society for Acute Medicine Autumn Meeting October 3rd /4th

Conference Report, Volume 2, Issue 3, Pages 75 - 107 (2003)

The regular autumn meeting of the society for acute medicine was hosted this year by Dr Martin Culshaw at Queen ’s Medical Centre in Nottingham. As in previous years, the meeting was spread over two days with the conference dinner at the Nottingham Hilton hotel on the evening between. This was Derek Bell ’s last meeting as President of the society, and in taking over the helm, Paul Jenkins paid tribute to his achievements over the past three years during the after dinner speeches. Emergency Care Tsar, Professor Sir George Alberti, opened the meeting with an enlightened view of the current, and future state of emergency care in the UK. Entitled ‘Emergency Care – nightmare or sweet dreams’ ,he left us in no doubt that the high profile of ‘front-door ’medicine would continue over the next few decades. Derek Bell followed, in his role as clinical lead of the Emergency Services Collaborative, with a summary of the achievements of the Collaborative to date.

The first afternoon comprised three workshops, followed by a plenary session at the end of the day. Liz Myers and Mairi Pollock facilitated the group examining the role of nurse practitioners and nurse consultants at the front door, concluding that such roles need to be developed and encouraged, with the need to standardise practices and training. With contributions from John Heyworth, president of the British Association of Emergency Medicine, Martin Culshaw facilitated the group looking at the interface between A&E and Acute Medicine. The need for close working between these two allied disciplines was emphasised, along with the importance of examining the possibility of dual accreditation in A&E and Acute Medicine. The third group discussed ambulatory care in acute medicine. George Strang from South Glamorgan commented that most patients who were ‘walking, talking sense, eating, drinking and continent’ could be managed in an ambulatory setting. The group echoed the sentiment that large numbers of patients currently admitted to hospital could be maintained in the community, provided the appropriate staff, support and facilities were available.

Management of the septic patient in the ITU setting, the importance of a proactive approach to alcoholism and early management of renal failure comprised the clinical programme over the two days, delivered, respectively, by Dr Paul Glynne, Dr Stephen Ryder and Dr Paddy Gibson.Two excellent presentations of local innovation in Nottingham concluded the meeting. Dr Tim Jobson, specialist registrar in Gastroenterology, described an ingenious database developed at Queen’s Medical Centre designed to improve the quality and learning experience gained from mortality and morbidity meetings in the Acute Admissions Unit. This was followed by a presentation of the modifications made to the MEWS scoring system to render it more sensitive to the needs of acute medical patients. Sister Jane Woollard, critical care nurse educator at Queens Medical Centre described how their modifications had improved both sensitivity and specificity of the score when used on the MAU.

At the annual general meeting of the society which followed the main meeting, Mike Jones was elected to the position of Vice President, while Rhid Dowdle takes over as Secretary. The need for representation of allied health professions on the committee was again emphasised and calls for nominations of such individuals were re-iterated. The twice yearly meeting structure is planned to continue for the foreseeable future, although the Spring meeting will, in future be predominantly clinical in its focus, with more emphasis on organisational issues in the Autumn meeting. The date for the next meeting was confirmed as 22nd and 23rd April 2004, the meeting being held in Bournemouth, hosted by Dr Martin Taylor and Dr Tanzeem Raza. We will eagerly await the publication of the programme, which it is hoped will be on the Society website (www.acutemedicine.org.uk) by the end of December. Further details and application forms for this meeting will be available from society administrator Audrey Deuchars Edinburgh Royal Infirmary, 51 Littlefrance Crescent,Edinburgh EH16 4SA

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Syncope in the Hospital

A Case to Remember, Volume 2, Issue 3, Pages 75 - 107 (2003)

Abstract

A case is presented in which a man with anomalous coronary artery anatomy and thrombotic oronary stenoses had an episode of syncope. Further subsequent presyncopal events coincided with ventricular tachycardia on ambulatory ECG; stenting of the lesions eliminated further symptoms. The importance of seeking prognostically significant cardiac causes of syncope is discussed.

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A guide to the initial management of hypercalcaemia

Clinical Reviews, Volume 2, Issue 3, Pages 75 - 107 (2003)

Abstract

With the widespread use of multiple channel biochemical auto analysers hypercalcaemia has become a common incidental finding. The approach to managing a patient with hypercalcaemia requires an understanding of the principles of calcium homeostasis, knowledge of the potential differential diagnoses and the clinical judgement to know when therapy is appropriate. This article aims to provide a guide to the initial investigation and management of patients presenting with hypercalcaemia.

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Acute Management of Guillain-Barré Syndrome

Original Articles, Volume 2, Issue 3, Pages 75 - 107 (2003)

Abstract

Guillain-Barré Syndrome (GBS) is an acute inflammatory polyneuropathy. Typical presentation is one of ascending tetraparesis with aref lexia. Variant forms of GBS include ataxia and ophthalmoplegia with aref lexia; patients with preserved ref lexes may mislead the unwary. Diagnostic dilemmas may be solved with neurophysiology and lumbar puncture.

Emergency management requires assessment of airway, breathing and circulation. Regular monitoring of respiratory, and bulbar function is essential and any deterioration in neurological function should prompt treatment. Treatment with intravenous immunoglubulin shortens the length of illness.

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Dysphagia for the acute physician

Original Articles, Volume 2, Issue 3, Pages 75 - 107 (2003)

Abstract

Dysphagia (subjective difficulty in swallowing) is a common clinical problem, particularly in the elderly population. Ideally, patients should be assessed promptly in the appropriate outpatient setting, but frequently they will be admitted on an acute medical take due to ‘total’ dysphagia, dehydration, debilitation or possible aspiration. A careful history and examination can usually elucidate the site of the lesion and its possible cause, and thus direct initial management. This article will concentrate on the role of the acute physician in the assessment of patients with dysphagia within the first 48 hours of presentation.

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Editorial

Editorials, Volume 2, Issue 3, Pages 75 - 107 (2003)

It could be said that the past 12 months have been an exciting time in the field of acute medicine. In addition to the high profile afforded by the publication of Reforming Emergency Care and the ongoing Emergency Services Collaborative, the significance of the recent acquisition of subspecialty status for Acute Medicine cannot be understated. This, in turn has enabled approval of a new competency-based training curriculum by the JCHMT. Hopefully within the next few months, specialist registrars in General Internal Medicine with Acute Medicine will be appointed to the first few numbered posts in this discipline. Clearly a rapid expansion in posts of this nature will be required in the next few years in order to meet the enormous demand for consultants in Acute Medicine. Recently, in common with other medical specialties, hospitals have experienced difficulties in recruiting suitable applicants for such posts resulting in many vacancies across the UK. One challenge for those of us already working in the field is to maintain enthusiasm for the concept, while we are waiting for the trainees to mature into competent consultants.

This edition includes another varied selection of reviews. Community acquired pneumonia may be of particular relevance over the remaining winter months, although hopefully the brief mention of SARS in this paper will now only be of historical significance. Patients with hypercalcaemia, dysphagia and Guillan Barre syndrome may be less frequent attenders, but nonetheless often create management dilemmas with which the admitting physician needs to be familiar. In a departure from our previous format, we have included two case reports this time, both highlighting an important clinical scenario. Power kite flying may not be a familiar activity for many readers, but the outcome described by Merrison and colleagues justifies its inclusion as ‘a case to remember’. Mark Mallett, on the other hand, reminds us that syncope can, on occasions, reflect significant underlying pathology, even in an apparently healthy member of the hospital portering staff. Once again we would like to encourage similar submissions for future editions of the journal.

After several years of association with CPD Acute Medicine and its predecessor, it is with great sadness that this edition is Paul Jenkins ’last as sub-editor. We wish him well as he moves on to new challenges in his role as President of the Society for Acute Medicine, and gratefully acknowledge all of his hard work in establishing the journal.

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MCQ Questions Vol 2 No. 2

Regular features, Volume 2, Issue 2, Pages 39 - 74 (2003)

· The following must be assessed in all patients attending hospital with suspected asthma exacerbations:
1. PEF.
2. Pulse & Respiration rate.
3. Clinical history & Speech.
4. Chest X ray.
5. Arterial Blood Gases.

· The following characteristics may identify a patient at risk of fatal or near fatal asthma:
6. Hospital admission within the last year.
7. Repeated A&E attendances.
8. Non compliance with treatment .
9. History of self discharge from hospital.
10. Requirement for 3 or more classes of asthma medication.

· The following treatments are of established value in the management of acute asthma:
11. Antibiotics.
12. Anticholinergic bronchodilators.
13. Intravenous aminophylline.
14. Intravenous Magnesium.
15. Heliox.
16. NIV.

· The Folling indicate a severe asthma excerbation:
17. PEF < 33%. 18. PaO2 < 8 kPa. 19. Normal PaCO2. 20. Respirations > 25 / min.
21. Pulse > 110/min.

· The following features excludes a severe or life threatening asthma exacerbation:
22. Normal pCO2.
23. PEF > 75%.
24. Pulse < 110/min. 25. Resps < 25/min. 26. Able to talk in full sentences. (A F A Merrison & N J Scolding) · Steroid treament should be given to patients with MS: 27. at the time of all relapses. 28. at the time of relapses and disease progression. 29. as soon as possible for significantly disabling relapses. · If steroids are given they should be given orally: 30. following intravenous steroid therapy. 31. if intravenous therapy is impracticable. 32. for disease progression. · Beta-interferon treatment is available for patients with MS who: 33. have two or more relapses in two years and are able to walk 100 metres unaided. 34. with secondary progressive disease. 35. following a single episode of optic neuritis. · Bladder problems in MS are best managed by: 36. Permanent catherisation. 37. Anticholinergics for detrusor instability. 38. Intermittent self catherisation if high residual volume. · When managing spasticity, it is worth considering the following points: 39. Baclofen may induce muscle weakness. 40. Neutropaenia is a common problem with tizanidine. 41. Selective injection of botulinum toxin may be helpful. (S I Kharkoo & W MC Rosenberg) · In the setting of an acute variceal haemorrhage: 42. An INR of 1.8 is associated with a high mortality. 43. Individuals with non-cirrhotic portal hypertension have a better prognosis than those with cirrhotic portal hypertension. 44. Grade I hepatic encephalopathy is an indication for endotracheal intubation and ventilation. 45. Therapeutic endoscopy achieves haemostasis in >90% of cases.
46. Isolated gastric varices respond better to endoscopic therapy than oesophageal varices.

· The sengstaken-Blakemore tube:
47. Has a serious complication rate of up to 35%.
48. Can be passed unaided by a single operator.
49. The oesophageal aspirate port should be spigoted.
50. The oesophageal balloon should be inf lated with 300mls of air.
51. Should be left inf lated and on traction for no more than 24 hours.

· With reference to drugs used in the management of a variceal haemorrhage
52. The main objective of pharmacotherapy is splanchnic vasodilatation.
53. Octreotide is preferable to terlipressin.
54. Antibiotics are of no value.
55. Vasopressin should be used in combination with nitrates.
56. Because of the danger of anaesthetic agents in liver disease there is a high threshold for elective endotracheal intubation and ventilation.

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