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Oxford Handbook of Acute Medicine

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Oxford Handbook of Acute Medicine

Abstract

This title is a practical and comprehensive guide to the management of the acutely ill patient. It is a single source to the most up-to-date therapies and protocols. It presents the most recent treatment guidelines and evidence-based content that is up-to-date with the recent advances in clinical medicine. Topics covered include cardiac emergencies, respiratory emergencies, gastroenterological emergencies, renal emergencies, shock, neurological emergencies, infectious diseases, emergencies in human immunodeficiency virus, diabetes and endocrine emergencies, haematological emergencies, rheumatological emergencies, dermatological emergencies, psychiatric emergencies, drug overdoses, and practical procedures in acute medicine.
... The new coronavirus disease 2019 (COVID-19) may cause severe acute respiratory syndrome (SARS) [1,2]. It is an infection affecting humans, which started in China, in the region of Wuhan, in the province of Hubei. ...
... In addition, the treatment of tuberculosis is based on the use of anti-tubercular drugs [4,7,11]. Pulmonary tuberculosis patients benefit from an initial treatment of two months combining: isoniazid, rifampin, pyrazinamide and ethambutol [2]. These are molecules with intracellular and or extracellular actions acting on Koch´s bacillus. ...
... In addition, HIV infection causes immunodepression which is a risk factor for severe forms of coronavirus infection according to the literature [4]. Anti-tubercular drugs (especially, rifampin) are powerful enzyme inducers [2,4,8] that can reduce the effectiveness of chloroquine in our patient. And immunodepression induced by HIV infection can make COVID-19 infection severe. ...
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Infection with the new coronavirus has been declared an international health emergency. Its curative treatment is unknown and is the subject of several clinical trials. In addition, the concomitant association of COVID-19 with tuberculosis and the human immunodeficiency virus, hitherto never described, is potentially fatal. We report the illustrative case of a 32-year-old patient who presented this trifecta of infections and who did well under treatment with chloroquine and anti-mycobacterial drugs. This patient arrived at the ER with respiratory discomfort that had been evolving over a month with symptoms of flu and deterioration of her general condition. A chest CT scan revealed an aspect of lung miliary tuberculosis with isolation of Koch's bacilli in the sputum. A polymerization chain reaction (PCR) was positive for COVID-19 on a nasopharyngeal swab. HIV serology was positive. The course was marked by a spectacular clinical improvement and two negative COVID-19 PCR controls at the end of treatment (at days 9 and 10). Anti-tubercular drugs (especially, rifampin) are powerful enzyme inducers that can reduce the effectiveness of chloroquine in our patient. This therapeutic success may be linked to the effect of anti-tubercular drugs against SARS ncov-2, especially rifampin, inhibiting the formation of messenger RNAs of SARS ncov-2 or to the synergistic effect of chloroquine and rifampin. Researchers should explore the effect of these drugs on SARS ncov-2.
... In most HIV patients with diffuse pulmonary disease a definitive diagnosis is usually preferred over empirical therapy, however in the acute setting empirical therapy is often required until further information becomes available. 7 This therapy should be initiated as soon as possible, and ideally after blood and sputum samples have been collected. Therapy is primarily directed at treating the common bacterial pathogens and PCP. ...
... It should be noted however that in AIDS the inf lammatory response can be muted, and therefore the absence of white blood cells in the CSF does not necessarily preclude meningeal infection. 7 If a diagnosis remains elusive, then MRI may be more sensitive then CT in detecting various pathologies, including toxoplasma cysts. Lack of availability of MRI often precludes this from being a first line investigation. ...
Article
With increasing awareness, earlier diagnosis, and aggressive use of anti-retroviral therapy, more people with HIV are living longer so that the average survival time from diagnosis is now significantly better than what it was 10 years ago. As a consequence of this, more patients with HIV are now presenting to hospitals and emergency departments as acute medical emergencies either directly related to their HIV infection, or their treatment. 1 An awareness of the potential problems with which these patients can present to hospital, plus guidance on their management is essential to all acute care physicians. In this article we outline the general management of patients with HIV presenting as emergencies to hospital, and then systematically focus on some of the more common clinical problems which may arise.
... Therefore, patients may not give accurate answers to questions. Whilst the quoted mortality figures for delirium tremens vary (from < 5% to approximately 15%), untreated, it is a potentially life threatening condition [3,7,16]. Delirium tremens occurs 48-72 hours after the last alcoholic drink; however, other alcohol withdrawal symptoms may occur much sooner than this. ...
... [17,18] Status epilepticus is unusual in patients with alcohol withdrawal. [3] [NEW SCREEN] ...
Article
BMJ Learning E-Learning Module http://learning.bmj.com/learning/module-intro/cmt-alcohol-substance-dependence.html?moduleId=10060598&locale=en_GB An interactive case based module for medical trainees covering the identification and management of alcohol and drug misuse in a general medical setting. This module discusses the initial assessment, collateral history taking, diagnosis, and management of acute complications (including Wernicke’s encephalopathy) of patients with alcohol or substance dependence, as well as prescribing thiamine, alcohol detoxification, and opioid substitution therapy. Learning outcomes After completing this module you should have the knowledge and confidence to: Identify and investigate patients who are misusing alcohol and/or drugs (in a general medical setting) Identify and manage complications of alcohol and/or drug misuse including delirium tremens, liver disease, Wernicke’s encephalopathy, and Korsakoff’s syndrome Know how to correct features of malnutrition, including vitamin and mineral supplementation Practise safe prescribing of reducing regimens for alcohol detoxification, and opioid substitution therapy for opioid dependence (with input from your local substance misuse service) Appreciate the recommended management approach to pregnant patients who are misusing alcohol or opioids
... During the development of the AP system, the hazard list would be expanded and additional detail would be added. Further brainstorming with other domain experts (and more specialised experts) would be valuable (the Oxford Handbook of Acute Medicine [18] gives " abnormal platelet behaviour " as a possible cause for many different conditions, and various platelet-related disorders are discussed in [19]). As more sophisticated models became available, engineers would use a variety of hazard analysis techniques that work over these models. ...
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Some of the complex systems with which the CoSMoS project is concerned are safety-critical, and if such systems are ever to be built and operated then they will need to be certified safe to operate. By looking at how conventional safety-critical systems are developed, we can find basic principles for safety-critical complex systems – this may be harder or easier than non-safety-specialists expect. In this paper, we outline current safety engineering methods and illustrate them using an artificial platelet case study. We also summarise our previous work on us-ing simulation in safety engineering, and make some observations about applying simulation to very small systems.
... These manifestations usually only arise in the context of severe hypophosphataemia of <0.4 mmol/l. 3 The clinical consequences of hypophosphataemia can include skeletal muscle weakness, rhabdomyolysis, haemolysis, altered mental state and panic. ...
Article
A 22-year-old lady presented to the emergency department with dyspnoea and pleuritic chest pain. Life-threatening asthma, pulmonary embolus and pneumothorax were all excluded. However, investigations did show an unexplained hypophosphataemia and raised lactate, both of which were subsequently attributed to hyperventilation with a component of panic. Here we explore the mechanism of these findings and the management of hypophosphataemia.
... The symptoms of benzodiazepine poisoning may include drowsiness, slurred speech, nystagmus, hypotension, ataxia, coma, respiratory depression, and cardiorespiratory arrest [22]. All the patients in our study exhibited the above features except nystagmus, coma, and cardiorespiratory arrest with zero casualties. ...
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Objective: Deliberate self-poisoning is a serious global issue that contributes to significant morbidity and mortality all over the world. The present study was conducted with an objective to identify the common agents used for self-poisoning prevalent in South Odisha and to determine the common clinical features and outcome of such cases. Methods: This cross-sectional observational study was conducted on 200 patients with deliberate self-poisoning belonging to the age group of 15–70 years over a period of 2 years from August 2017 to September 2019 in Maharaja Krishna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India. All the above-mentioned patients admitted to the hospital, were treated with specific antidotes according to the poison ingested. Results were analyzed using appropriate standard statistical methods such as mean, standard deviation, and percentage. Results: Out of 200 patients, majority were female (65%, n=130) and 35% (n=70) were male; mean age was 38.9 (±16.8) years. Organophosphates, aluminum phosphide, glyphosate, organochlorines, and carbamates were the most common pesticides used as poisoning agents (74.5%, n=149) followed by plant poisons (7%, n=14) which included yellow oleander seed. Overall mortality in our study was 12.5%. Conclusion: Pesticides and plant poisons were the common agents used in our study for deliberate self-poisoning. Young persons, illiterates, and housewives were commonly involved in suicide attempts. Organophosphate caused majority of deaths.
... Other brain cells die because they are damaged by sudden bleeding in or around the brain. In stroke, "Time is brain," meaning that the sooner treatment begins, the better (NINDS, 2020; Ramrakha et al., 2019). ...
Thesis
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Background: Stroke is the most frequent life-threatening neurological disease and a serious public health problem; it is the third major public health problem and the fourth leading cause of disease burden in the world. Objectives: To assess the severity of stroke at admission and to evaluate the activity of daily living and functional outcomes after (90) days, and to identify the role of biomechanical parameters in acute stroke patients. Methods and Materials: A prospective study design was adopted from the 20 of October 2020 until to the 2 ty of November 2021 to achieve the objectives of the present study. The sample size was (127) patients (males and females), out of those participants (27) patients were excluded from the study sample. nd Results: The study found that (84%) of our strokes were ischemic and (16%) were hemorrhagic stroke. (40%) of ischemic strokes had a good functional outcome, (21%) had poor functional outcomes, and (23%) have been dies. However hemorrhagic strokes showed (12%) had a good functional outcome, (2%) had poor functional outcomes, and (2%) have been dies. Conclusions: Prediction of functional outcome in acute stroke patients essentially depends on the age, body mass index, stroke risk factors, family history for stroke, early detection of dyslipidemia, electrolyte abnormalities, as well as urea, creatinine, and the stroke severity. Recommendation: The study highlights a serious need for the implementation of training programs in different sites of the country through social media, mobile applications, and public centers; aimed at improving public awareness of the first signs, stroke risk factors, prevention strategies, and rehabilitation methods; for the community and patients’ families or caregivers. Keywords: Acute Stroke, Activity of Daily Living, Risk Factors, Biomechanical Parameters, Functional Outcomes.
... (The footnote to Table 5 details the numbers of biochemical data points for each analyte by group and timepoint.) Serum calcium was corrected for albumin (calcium corr ) by normalizing to an albumin concentration of 40 g/L: (21) Calcium corr (mmol/L) ¼ S Ca þ[0.02 Â (40 -S albumin )], where S Ca and S albumin are the serum concentrations of calcium (mmol/L) and albumin (g/L), respectively. ...
... Benzodiazepines are non-lethal unless combined with alcohol or other CNS-depressant drugs. The symptoms of benzodiazepine overdose include drowsiness, slurred speech, ataxia, horizontal gaze nystagmus, hypotension, coma, respiratory depression and cardiorespiratory arrest 88 . Some patients can have severe allergies such as anaphylaxis and angioedema 89,90 . ...
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There is a myriad of changes that can be produced in the eye by toxic drugs ranging from mild/no symptoms to severe loss of vision from endophthalmitis. The routes of administration include oral ingestion, smoking, nasal inhalation, intravenous injection, topical application or application to other mucosal surfaces. It is important to recognize certain clinical signs and symptoms in the eye produced by these toxins. This article describes in brief some of the ocular effects of commonly abused drugs. For identification of a particular poisoning, in addition to the clinical presentation, pulse, blood pressure, respiration and body temperature, pupillary size, pupillary reaction to light, ocular convergence and nystagmus can be useful indicators of the type of drug the patient is exposed to. Unmasking these features help the clinician in an early and accurate diagnosis of the offending drug as well as timely management.
... With the aim of successfully eliminating opioid toxicity, the first step in patient management is to establish an accurate history of their opioid usage, and the second step is to schedule appropriate naloxone therapy by monitoring the infusion dose [3]. Naloxone is a highly effective antidote, the use of which is potentially lifesaving [4][5][6]: however, its use may also introduce potential risks [7]. According to the current guidelines, naloxone treatment regimens should be based on balancing the need for treatment against the risk of inappropriate use. ...
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Background: The optimal goal of naloxone infusion in intensive care units is to ameliorate opioid-induced side effects in therapy or eliminate the symptoms of opioid toxicity in overdoses. Accurately monitoring and regulating the doses is critical to prevent adverse effects related to naloxone administration. The present study aimed to compare treatment outcomes when using two methods of intravenous naloxone infusion: an infusion pump or the standard method. Methods: This study involved 80 patients with signs and symptoms of opioid overdose. The patients were randomly assigned into two groups with respect to intravenous infusion of naloxone by either an infusion pump or the standard method. Results: Comparison of study parameters between the two groups at 12 and 24 hours after intervention showed significantly more compensatory acid-base imbalance in the naloxone infusion pump group. In the group that received naloxone by pump, only one patient experienced withdrawal symptoms, but withdrawal symptoms appeared in 12 patients (30.0%) in the standard intravenous infusion group within 12 hours and in seven additional patients (17.5%) within 24 hours of intervention. In the group receiving pump-based naloxone infusion therapy, no another complications were reported; however in the standard infusion group, the 12-hour and 24-hour complication rates were 55.0% and 32.5%, respectively. The length of hospital stay was 2.85±1.05 and 4.22±0.92 days for the pump and standard infusion groups, respectively (P<0.001). Conclusions: Naloxone infusion using an infusion pump may be safer with regard to hemodynamic stability, resulting in shorter hospitalization periods, and fewer posttreatment complications.
Chapter
Renal dysfunction is a common reason for requiring pharmacists to adjust their thinking when optimizing a drug dosing regimen. However, many pharmacists find this clinical task quite daunting as there are many factors to consider, such as whether renal clearance alone is affected, if renal metabolism is also affected, if there renal pathology to consider, if this an acute situation or more chronic or even both, and if renal replacement therapy indicated. But if each question is considered in a logical stepwise manner, then often this process becomes much easier to understand. There may still be unanswered questions at the end of this process, but usually there is a great clarity around these and whether they are going to impact the patient clinically.
Article
As 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors ('statins') are being increasingly prescribed for the prevention of cardiovascular disease, this case report describes adverse effects of statin therapy which can sometimes be fatal. It highlights the need for physicians to be aware of individual patient risk factors predisposing to statin induced myopathy. It also highlights the need for further research into cholesterol lowering drugs which do not have such side effects. When prescribing statins for patients, we must also explain potential side effects following initiation of therapy and with dose titrations.
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Hydrocortisone (HC) and dexamethasone (DXM) are used to treat preterm infants at risk for bronchopulmonary dysplasia (BPD). This may, however, affect their long-term neurological development. We aimed to determine the effect of HC and DXM therapy in preterm infants on neurological functioning as assessed by the quality of general movements (GMs) until 3 months after term. We found no difference in the quality of GMs between HC and DXM infants until term age. At 3 months, HC infants had a higher median motor optimality score (MOS) than DXM infants (25 vs. 21, P = 0.015). In the DXM group, MOS on the first day of treatment was lower than before treatment (10 vs. 11, P = 0.030). MOS decreased in DXM infants on the first day following treatment and at 3 months after term. This was not the case in HC infants. Our study suggests that neurological functioning at 3 months after term is better in infants treated with HC than in infants treated with DXM. We performed a longitudinal, observational study including 56 preterm infants (n = 17 HC, n = 17 DXM, n = 22 controls). GM quality, videoed before and after treatment, was assessed. In addition, a MOS was assigned to details of the GMs.
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The pre-hospital management of acute medical emergencies can be difficult. Critically ill patients must be evaluated quickly and accurately to ensure that immediately life-threatening problems are identified and treated. Figure 1 and Box 2 provide a structured method for rapid assessment in the pre-hospital phase. Although the majority of medically unwell patients will not require an aggressive resuscitation phase during the primary survey, the use of the structured approach in all patients will ensure that 'time critical' pre-hospital medical emergencies are identified. This approach also emphasizes that once immediately correctable problems have been treated, the priority is transfer the patient to the nearest resuscitation facility.
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This article has described a system of patient assessment that follows set patterns of information gathering leading to a working diagnosis. Developing and practising your own system takes time and experience. Many readers will have already developed their own methods of examination. Those who are new to clinical examination will need tuition and practice.
Article
It is becoming increasingly common to request computed tomography (CT) to rule out space occupying lesions before lumbar puncture (LP), even in patients with no clinical signs. Imaging trends within a busy district general hospital in Oxfordshire, UK were analysed with results used to clarify when imaging should be considered mandatory. Method: A retrospective six month sample was obtained comprising all adults considered for LP. Observed frequencies of abnormal examination findings compared with abnormal investigations were used to determine sensitivity, specificity, positive predictive, and negative predictive values to assess the validity of using a normal clinical examination as a basis for excluding CT. 64 patients were considered for LP. In total, 58 patients underwent LP, with a single patient receiving two. After an abnormal CT scan, six patients did not undergo a planned LP. In all six of these cases subarachnoid haemorrhage was detected, and in all cases this was considered a probable diagnosis. In no case was an LP precluded by an unsuspected space occupying lesion. Neurological examination showed a sensitivity of 0.72 (0.52 to 0.93), specificity 0.78 (0.64 to 0.91), positive predictive value 0.61 (0.41 to 0.83), and negative predictive value 0.85 (0.73 to 0.97). The high sensitivity and negative predictive values support normal neurological examination as an effective predictor of normal CT scan. This permits the recommendation in cases where subarachnoid haemorrhage is not suspected, a CT scan can be avoided provided there are no abnormal findings on physical or fundoscopic examination.
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