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2
Scott-Brown, Martin. Dying from cancer. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0330.
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For many patients, dying from cancer has been an ever-present reality from the time they were diagnosed with incurable recurrent or metastatic cancer. Treatment may have delayed the inevitable, but there does come a point where aggressive management no longer improves the prognosis or can only prolong life that is of such a poor quality that it is not valued by the patient. It sometimes is easier to continue with treatment than to take the time with the patient to discuss the reasons why further treatment is not appropriate. For patients with advanced cancer and whose condition is deteriorating, a number of questions should be considered before initiating treatment aimed at prolonging life. Is this the final stage of a progressive deterioration or an acute event? Are the causes of this deterioration reversible? Are there any further oncological treatments that may improve the prognosis? What is the patient’s perception of their quality of life? Is there a realistic chance of return to a quality of life that will be of value to the patient? Is the patient dying? The ICU is usually not appropriate for patients with advanced cancer. Treatment of correctable causes (e.g. obstructive uropathy, chest infection) may still not be in the patient’s best interest if they recover only to face a period of further deterioration and distressing symptoms before they die. However, patients and their families must be included in discussions as to the level of further intervention and the reasons for stopping active treatment.
3
De Deyne, Cathy, and Jo Dens. Neurological assessment of the acute cardiac care patient. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0016.
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Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
4
De Deyne, Cathy, Ward Eertmans, and Jo Dens. Neurological assessment of the acute cardiac care patient. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0016_update_001.
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Many techniques are currently available for cerebral physiological monitoring in the intensive cardiac care unit environment. The ultimate goal of cerebral monitoring applied during the acute care of any patient with/or at risk of a neurological insult is the early detection of regional or global hypoxic/ischaemic cerebral insults. In the most ideal situation, cerebral monitoring should enable the detection of any deterioration before irreversible brain damage occurs or should at least enable the preservation of current brain function (such as in comatose patients after cardiac arrest). Most of the information that affects bedside care of patients with acute neurologic disturbances is now derived from clinical examination and from knowledge of the pathophysiological changes in cerebral perfusion, cerebral oxygenation, and cerebral function. Online monitoring of these changes can be realized by many non-invasive techniques, without neglecting clinical examination and basic physiological variables—with possible impact on optimal cerebral perfusion/oxygenation—such as invasive arterial blood pressure monitoring or arterial blood gas analysis.
5
Creed, Fiona, and Christine Spiers, eds. Care of the Acutely Ill Adult. 2nd ed. Oxford University Press, 2020. http://dx.doi.org/10.1093/med/9780198793458.001.0001.
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The new edition of Care of the Acutely Ill Adult enables nursing staff to develop an in-depth understanding of the knowledge required to care for patients whose condition is deteriorating. The book emphasizes the importance of systematic assessment, interpretation of clinical signs of deterioration, and the need to escalate the patient in a timely manner. Current evidence-based practice and up-to-date guidelines are included in each systems-based chapter and case studies are used throughout the book to enable nurses to apply knowledge to patient scenarios. In recognition of the dynamic nature of acute care delivery, new chapters have been included that focus on pain management and planning for care when recovery is unlikely. This book remains an essential purchase for any nurse working in an acute care setting.
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Noris, Marina, and Tim Goodship. The patient with haemolytic uraemic syndrome/thrombotic thrombocytopenic purpura. Edited by Giuseppe Remuzzi. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0174.
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The patient who presents with microangiopathic haemolytic anaemia, thrombocytopenia, and evidence of acute kidney injury presents a diagnostic and management challenge. Haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) are two of the conditions that frequently present with this triad. They are characterized by low platelet count with normal or near-normal coagulation tests, anaemia, and signs of intravascular red cell fragmentation on blood films, and high LDH levels.HUS associated with shiga-like toxins produced usually by E.coli (typically O157 strains) may occur in outbreaks or sporadically, with geographical variations in incidence. It is predominantly a disease of young children in which painful blood diarrhoea in a minority of infected patients is succeeded by microangiopathy and acute kidney injury. Management is supportive and recovery is usual, although permanent renal damage may lead to later deterioration. Older patients may be affected and tend to have worse outcomes. Neuraminidase-producing Streptococcus pneumoniae infections (usually pneumonia) very rarely cause a similar HUS.Atypical HUS occurs sporadically and is increasingly associated with defects in the regulation of the complement pathway, either genetic or autoimmune-caused. It may respond to plasma exchange for fresh frozen plasma. Recurrences are common, including after transplantation.TTP is associated with more neurological disease and less renal involvement, but HUS and TTP overlap substantially in their manifestations. The underlying problem is in von Willebrand factor (vWF) cleavage. The plasma metalloprotease ADAMTS13 is responsible for cleaving vWF multimers, a process that is important to prevent thrombosis in the microvasculature. Autoantibodies or rarely genetic deficiency may impair this process. Plasma exchange may remove antibodies and replenish the protease.
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Adam, Sheila, Sue Osborne, and John Welch. Cardiac arrest and cardiopulmonary resuscitation. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199696260.003.0006.
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Critically ill patients are at high risk of cardiac arrest, and the critical care nurse needs to recognize early signs of deterioration, understand what can be done to prevent arrest, and understand the different functions of cardiac arrest team members. This chapter outlines the pathophysiology associated with cardiac arrest, reviews the management of arrest, the practicalities of the techniques and drugs used in cardiopulmonary resuscitation, and the care of the patient and family following both successful and unsuccessful resuscitation.
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Price, Susanna, Brian F. Keogh, and Lorna Swan. Congenital heart disease in adults. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0060.
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The number of patients with congenital heart disease surviving to adulthood is increasing, with many requiring ongoing medical attention. Although recommendations are that these patients should be cared for in specialist centres, the clinical state of the acutely unwell patient may preclude transfer prior to the instigation of lifesaving treatment. Although the principles of resuscitation in this patient population differ little from those with acquired heart disease, the acutely unwell adult congenital heart disease patient presents a challenge, with potential pitfalls in examination, assessment/monitoring, and intervention. Keys to avoiding errors include: knowledge of the primary pathophysiology, any interventions that have been undertaken, residual lesions present (static or dynamic), and the normal physiological status for that patient-to determine the precise cause for the acute deterioration and to appreciate the effects (detrimental or otherwise) that any supportive and/or therapeutic interventions might have. Expert advice should be sought at the earliest opportunity.
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Price, Susanna, Brian F. Keogh, and Lorna Swan. Congenital heart disease in adults. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0060_update_001.
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The number of patients with congenital heart disease surviving to adulthood is increasing, with many requiring ongoing medical attention. Although recommendations are that these patients should be cared for in specialist centres, the clinical state of the acutely unwell patient may preclude transfer prior to the instigation of lifesaving treatment. Although the principles of resuscitation in this patient population differ little from those with acquired heart disease, the acutely unwell adult congenital heart disease patient presents a challenge, with potential pitfalls in examination, assessment/monitoring, and intervention. Keys to avoiding errors include: knowledge of the primary pathophysiology, any interventions that have been undertaken, residual lesions present (static or dynamic), and the normal physiological status for that patient-to determine the precise cause for the acute deterioration and to appreciate the effects (detrimental or otherwise) that any supportive and/or therapeutic interventions might have. Expert advice should be sought at the earliest opportunity.
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Javed, Jeffrey K., and Jason E. Moore. Respiratory Failure and Hypoxemia (DRAFT). Edited by Raghavan Murugan and Joseph M. Darby. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190612474.003.0006.
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Respiratory failure and hypoxemia are among the most common problems encountered by the rapid response team (RRT) and can lead to rapid patient deterioration and arrest. A brief, systematic approach focusing on treatment priorities such as airway patency, correcting hypoxemia, and supporting work of breathing, allows RRT responders to quickly provide the appropriate level of supportive care and narrow the complex differential diagnosis of acute respiratory failure. This chapter reviews a logical and efficient clinical diagnostic evaluation, therapeutic modalities including rescue treatments and mechanical ventilation, and transport considerations for this patient group. The pragmatic, problem-based clinical approach discussed in this chapter will help RRTs provide effective care for this group of patients.
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Farmer, Brenna M., and Neal Flomenbaum. Management of salicylate poisoning. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0317.
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Salicylates are weak acids that work as neurotoxins. The goal of management is to keep salicylates out of the brain and enhance elimination. Acute salicylate toxicity manifests as tinnitus, nausea, vomiting, and hyperventilation in a patient who takes a single large ingestion. Chronic salicylate toxicity is associated with long-term use, has a more insidious onset, and symptoms tend to be less severe, resulting in delayed diagnosis. It is more commonly seen in elderly patients. Therapeutic interventions for toxicity include gastrointestinal decontamination, serum and urine alkalinization, and haemodialysis. Mechanical ventilation may lead to clinical deterioration and death in a salicylate-poisoned patient due to worsening acidosis from respiratory failure. This results in severe acidosis, cerebral oedema, pulmonary oedema, and cardiac arrest.
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Bauzá, Graciela, and Ayodeji Nubi. Pathophysiology and management of thoracic injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0333.
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Mechanism, patient presentation, and physical exam are key elements to accurate and prompt diagnosis of thoracic injury. A high proportion of poly-trauma victims suffer thoracic injury which is associated with mortality of with 25-50%. Initial management is guided by ATLS principles of Airway, Breathing, and Circulation. The FAST (focused assessment with sonography for trauma) exam plays a key role in the initial evaluation of thoracic trauma. Most injuries to the thoracic cavity may be managed non-operatively or with bedside procedures with the caveat that patients with thoracic injury require close attention and monitoring in the ICU for potential deterioration. A high index of suspicion is paramount to successful patient care. When operative intervention is required it is often emergent.
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Evans, Charlotte, Anne Creaton, Marcus Kennedy, and Terry Martin, eds. Checklists. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198722168.003.0021.
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This section contains recommendations for management of acute patient deterioration, troubleshooting equipment malfunction and checklists for more complex interventions. The reference tools not only enhance the text, but deliver core information to the retrievalist in the most comprehensive manner just when required. To be used in the primary retrieval setting, referral centre, or during flight.
14
Herrera, Juan Yanez. Nursing Assessment of the Deteriorating Patients. Independently Published, 2022.
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15
Tahseen, Muhammad, and Richard L. Simmons. Evolution and Evidence for Rapid Response Teams (DRAFT). Edited by Raghavan Murugan and Joseph M. Darby. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190612474.003.0001.
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A rapid response system (RRS) is a program designed to respond in a timely, organized, and comprehensive manner to a patient’s urgent unmet medical need within a healthcare facility. The goals of the rapid response team (RRT) are to restore homeostasis, prevent further physiologic deterioration, and establish an optimal environment of care. RRTs are now in widespread use in the US because of the Joint Commission’s national patient safety goals, which required that healthcare organizations improve recognition and response to changes in a patient’s condition. Recent meta-analyses have now concluded that RRT is effective in reducing the incidence of cardiac arrests within hospitals. There is still controversy, however, on the impact of RRT on ultimate clinical outcomes, including mortality. In this chapter, we review the history and evolution of RRTs, rationale for its existence, its impact on patient outcomes, and current controversies.
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O’Brien, Alastair. Management of acute or chronic hepatic failure in the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0200.
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Acute on chronic liver failure is characterized by an acute deterioration of liver function in a patient with previously compensated cirrhosis secondary to a precipitating event. It is most commonly associated with a very poor prognosis and early identification of the precipitating cause is essential to successfully attempt to reverse decompensation. The most common precipitant is infection and a high index of suspicion is required. Other management is largely supportive with close attention to renal dysfunction being particularly important. All patients admitted to the intensive care unit with complications of cirrhosis warrant consultation with a transplant centre to determine whether they fulfil the criteria for transplantation and for expert advice.
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Lewin, Jan S., Michelle Cororve Fingeret, and Kate A. Hutcheson. Speech and Swallowing Impairment. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190655617.003.0011.
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Abstract: Patients with head and neck cancer face multiple, often severe psychological and functional problems associated with the diagnosis and treatment of their disease including alterations in or loss of human voice, disruptions in speech production, and deterioration of swallowing ability. These functional changes significantly compromise a patient’s body image and can occur as a result of the disease as well as its primary treatment, whether surgery, radiation therapy (RT), or both. Adjuvant treatments that include RT generally increase functional deficits and associated body image disturbance. Therefore, a thorough understanding of the functional effects associated with the given treatment modality or combination of modalities must be conveyed adequately to the patient. A multidisciplinary team approach and ongoing communication among clinicians is critical to successful outcomes. This approach includes the delivery of psychosocial interventions to facilitate coping with functional changes during active treatment and into cancer survivorship.
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Moore, Tracey, and Michael Macintosh. Caring for the Seriously Ill Patient: Assessment and Management of Sick and Deteriorating Patients, Third Edition. Taylor & Francis Group, 2030.
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19
Evans, Charlotte, Anne Creaton, Marcus Kennedy, and Terry Martin, eds. Retrieval platforms. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198722168.003.0005.
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Knowing your environment is essential to a successful retrieval. An overview of key operational characteristics of road and air platforms is necessary to perform well in the retrieval environment. Understanding capacity, speed, loading, pressurization, and safety features of each platform facilitates retrieval planning. Knowledge of how a particular platform affects patient access, equipment, internal environment, monitoring, and communications is vital to the retrieval practitioner. Tips and tricks to mitigate against the environmental stresses of providing critical care in difficult environments are included. An approach to sudden patient deterioration during transport is given for each platform.
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Eyre, Lorna, and Simon Whiteley. In-hospital transfer of the critically ill. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0004.
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While focus has traditionally been on the planning, logistics, and outcome of inter-hospital transfers of the critically-ill patient, attention is turning to in-hospital transfers. Numerically, more in-hospital transfers occur and there is growing evidence that these are associated with a high incidence of adverse events, and increased morbidity and mortality. Appropriate planning, communication, and preparation are essential. Patients should be resuscitated and stabilized (optimized) prior to transfer, to prevent deterioration or instability during transfer. Endotracheal tubes and vascular access devices should be secure. The minimum recommended standards of monitoring should be applied. All drugs and equipment likely to be required during the transfer should be checked and available. Critically-ill patients should be accompanied by personnel with the appropriate knowledge skills and experience to carry out the transfer safely and to deal with any complications or incidents that arise.
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Andrews, Peter J. D., and Jonathan K. J. Rhodes. Assessment of traumatic brain injury. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0342.
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Traumatic brain injury (TBI) accounts for the majority of traumatic deaths and most disability due to trauma in people aged less than 40 years old. Current trends suggest this burden of disease will increase dramatically over the next 20 years. Successful management of patients after traumatic brain injury requires recognition of patients at risk of deterioration, appropriate investigation, including imaging, and prevention of systemic and intracranial secondary injury processes. Unlike trauma affecting other body systems, outcome from TBI has not improved in the last 10–15 years. Assessment of a patient with traumatic brain injury includes clinical examination and diagnostic imaging both of which can be quantified or graded using scores such as the Glasgow Coma Score (GCS) and the Marshall score for grading cranial computed tomographic (CT) scans. Clinical examination and diagnostic imaging can both aid in prognostication (http://www.crash.lshtm.ac.uk/Risk%20calculator/).
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Evans, Charlotte, Anne Creaton, Marcus Kennedy, and Terry Martin, eds. Equipment and monitoring. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198722168.003.0006.
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The equipment and monitoring chapter in the Oxford Handbook of Retrieval Medicine benchmarks the standard of care delivered by the retrievalist while transiting through the retrieval environment. Continuous physiological monitoring alerts the retrievalist to potential patient deterioration. Core monitor functions are discussed in depth. Standard equipment such as syringe drivers are explained. In addition, a quick but comprehensive guide to ultrasound and blood gas analysis will be a useful refresher for the reader. Echocardiography findings are tabulated. Intraosseous access and recommended insertion sites are detailed. The chapter ends with sound advice regarding packaging of the equipment and the critically ill patient for optimal safe transport.
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Kelly, Jacinta. Nursing Acutely Ill Patients: Early Identification and Management of Deterioration. Taylor & Francis Group, 2012.
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Pisklakov, Sergey, Haitham Ibrahim, and Ingrid A. Fitz-James Antoine. Elevated ICP. Edited by David E. Traul and Irene P. Osborn. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190850036.003.0023.
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Perioperative management of a patient with elevated intracranial pressure (ICP) is of paramount importance in neuroanesthesiology. Should this clinical emergency remain unaddressed, disability and death will ensue. Suboptimal care of a patient with elevated ICP is associated with avoidable morbidity and predictable mortality unless timely medical interventions, a focused history, targeted physical findings and a high degree of clinical suspicion confirmed by selective imaging result in medical stabilization and more definitive neurosurgical intervention. This may require interinstitutional transport. Understanding the physiologic and pathologic concepts that underlie elevated ICP permit anticipatory interventions to avert inexorable deterioration. The etiology of elevated intracranial pressure is often multifactorial. The deleterious effects of rising ICP demand a clear understanding of the relationship between ICP, mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and cerebral autoregulation. Maintaining optimal CPP to prevent cerebral ischemia is the neuroanesthesiologist’s ultimate goal while managing a patient with an elevated ICP.
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Palmer, Ross, and Alison Smith. Ward post-operative care. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642663.003.0008.
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Standardized, evidence-based post-operative policies and procedures ensure that safe and effective person-centred care is provided, which is aimed at reducing the likelihood of post-operative complications. Close physiological monitoring is imperative and should incorporate the use of an early warning score such as the National Early Warning Score (NEWS). This ensures early recognition and response to patient deterioration, which is quickly escalated to an appropriate member of the health-care team. This chapter provides an overview of oxygen therapy, wound drains, the removal of sutures and staples, post-operative monitoring, early warning scores, escalation, documentation standards, and breaking bad news.
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Harley, Kim, and Richard Stock. Trauma and orthopaedics. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199642663.003.0020.
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The physiological response to traumatic injury protects the individual from deterioration in their condition, conserving body fluids and providing energy to catabolic cells. The trauma patient should undergo an ABCDE assessment, and a full history is also required. An understanding of the circumstances and the various forces involved at the time of injury may give an indication of the type, severity, and location of possible injuries. This chapter covers the assessment, types of injuries, immediate management, ongoing management, and complications associated with traumatic injury. This chapter also provides an overview of orthopaedic surgery and the conditions requiring surgical intervention.
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Merims, Sharon, and Michal Lotem. Skin problems in oncology. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0144.
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The skin may be adversely affected by any serious medical illness, often as a secondary process related to infection, trauma, nutritional deficiencies, and other factors. Disease-specific skin involvement occurs commonly in some conditions, and is best characterized in cancer. Skin of the patient with advanced cancer is unique compared to other organs of the body. While the sequela of metastatic spread to internal organs often is replacement of normal tissue and resultant organ failure, widespread replacement of skin with a neoplasm is uncommon. Yet, even a local disruption of skin integrity can cause deterioration in the quality of life, debilitation, and even mortality. Other aspects of neoplastic disorders affecting the skin discussed in this chapter include accumulation of abnormally produced metabolites, adverse effects to treatment, and paraneoplastic syndromes. It is important to give dermatological aspects of disease their appropriate attention, because these can be the ones that may be dealt with efficiently and improve the patient’s quality of life.
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Raine, Tim, James Dawson, Stephan Sanders, and Simon Eccles. Respiratory. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199683819.003.0008.
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Breathlessness and low sats emergencyBreathlessness and low satsStridor in a conscious adult patientCoughCall for senior help early if patient deteriorating.•Sit patient up•15l/min O2 in all patients if acutely unwell•Monitor pulse oximeter, BP, defibrillator’s ECG leads if unwell...
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Kozauer, Nicholas, and Karl Broich. Regulatory Issues in Cognitive Enhancement Treatment Development. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190214401.003.0016.
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Improvement of cognition by medicinal products is an accepted concept by regulatory agencies. In dementing conditions such as Alzheimer’s disease, improvement of cognition or slowing its deterioration is essential for approval, particularly in early and mild to moderate stages of Alzheimer’s disease. In conditions such as schizophrenia or major depression, treatment of cognitive impairment is not considered as a pseudospecific indication, and specific clinical trials for such an indication are underway. Assessment tools for measurements of change in cognition and its relevance in functional or global outcome parameters must be validated in well-described patient populations. Developers are strongly encouraged to request scientific advice by regulatory agencies early in their programs to avoid delays or setbacks due to methodological or policy issues.
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Subhas, Kamalakkannan, and Martin Smith. Intensive care management after neurosurgery. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0369.
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The post-operative management of neurosurgical patients is directed towards the prevention, prompt detection, and management of surgical complications, and other factors that put the brain or spinal cord at risk. Close monitoring is required in the first 6–12 post-operative hours as deterioration in clinical status is usually the first sign of a potentially fatal complication. The majority of patients do not require complex monitoring or management beyond the first 12 hours after elective surgery, although prolonged intensive care unit management may be required for those who develop complications, or after acute brain injury. Cardiovascular and respiratory disturbances adversely affect the injured or ‘at risk’ brain, and meticulous blood pressure control and prevention of hypoxia are key aspects of management. Hypertension is particularly common after intracranial neurosurgery and may cause complications, such as intracranial bleeding and cerebral oedema, or be a consequence of them. A moderate target for glycaemic control (7.0–10 mmol/L) is recommended, avoiding hypoglycaemia and large swings in blood glucose concentration. Pain, nausea, and vomiting occur frequently after neurosurgery, and a multimodal approach to pain management and anti-emesis is recommended. Adequate analgesia not only ensures patient comfort, but also avoids pain-related hypertension. Disturbances of sodium and water homeostasis can lead to serious complications, and a structured approach to diagnosis and management minimizes adverse outcomes. Post-operative seizures must be brought rapidly under control because of the risks of secondary cerebral damage and/or progression to status epilepticus.
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Ng, Bernardo, and Mauricio Tohen. Evidence-based treatment of mania. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198748625.003.0004.
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Bipolar mania can be one of the most challenging psychiatric illnesses to treat, as it requires the clinician to make rapid and accurate decisions; have a reliable way of evaluating progress and treatment response; and possess keen psychotherapeutic skills. Therefore, the importance of staying updated on the clinical evidence of the various treatment options, which serves as the basis to individualize treatment on the day-to-day progress or deterioration of the manic patient. This chapter presents a review available on the evidence of different psychopharmacological agents including typical antipsychotics, lithium, antiepileptic drugs and atypical antipsychotics, and FDA-approved dosages. This review also includes these agents’ effects on fertility and recommendations about their use during pregnancy and lactation. Bipolar disorder continues to be a complex psychiatric condition, yet the progress in treatment options for the manic phase has evolved such that we have more options than ever before.
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Quill, Timothy E., Paul T. Menzel, Thaddeus Pope, and Judith K. Schwarz, eds. Voluntarily Stopping Eating and Drinking. Oxford University Press, 2021. http://dx.doi.org/10.1093/med/9780190080730.001.0001.
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Voluntary stopping eating and drinking (VSED), though relatively unknown and poorly understood, is a widely available option for hastening death. VSED is legally permitted in places where medical assistance in dying (MAID) is not, and unlike U.S. jurisdictions where MAID is legally permitted, VSED is not limited to terminal illness or to those with current decision-making capacity. With adequate clinician and caregiver support, VSED is a compassionate option that respects patient choice. Moreover, the practice is not limited to avoiding unbearable suffering, but may also be used by those who are determined not to live long with unacceptable deterioration such as severe dementia. Despite the misleading image of “starvation,” death by VSED can typically be peaceful and meaningful when accompanied by adequate clinician/caregiver support. VSED is, however, “not for everyone,” and this volume provides a realistic, appropriately critical as well as supportive assessment of the practice. Eight illustrative, previously unpublished real cases are included, receiving pragmatic analysis in each chapter. The volume’s integrated, multi-professional, multidisciplinary character makes it useful for a wide range of readers: patients considering end-of-life options and their families, clinicians of all kinds, ethicists, lawyers, and institutional administrators. Appendices include recommended elements of an advance directive for stopping eating and drinking and what to record as cause of death on the death certificates for those who hasten death by VSED.
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Woodward, Sue, and Catheryne Waterhouse, eds. Oxford Handbook of Neuroscience Nursing. 2nd ed. Oxford University Press, 2020. http://dx.doi.org/10.1093/med/9780198831570.001.0001.
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The field of neuroscience nursing practice relates to a wide range of neurological disorders, many of which are progressive, deteriorating, life-changing, and life-limiting conditions affecting not only the patient but their families and carers. At the same time, the care of the patient following acute-onset injury and trauma presents different challenges in terms of support in critical care and ongoing rehabilitation. Brain damage and injury, irrespective of the causative factors, invariably can have a devastating effect on an individual’s physical, psychological, and cognitive functioning impairing their ability for self-autonomy and independence. The Oxford Handbook of Neuroscience Nursing begins to equip the practitioner with a basic knowledge of the complex needs and specialist management of this group of patients. It gives some insight into the patient’s perspective of living with a neurological condition and presents the best available evidence to inform practice and nursing care.
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Adam, Sheila, Sue Osborne, and John Welch. The critical care continuum. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199696260.003.0001.
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This chapter provides an overview of the development and expansion of critical care, to include early intervention and enhancement of recovery. This is based on the patient’s acuity and need for intervention rather than their location. It includes early recognition of, and response to, acute deterioration in patients in order to prevent irreversible organ damage or death. The use of tools such as the National Early Warning Score (NEWS) to identify these patients is described. The chapter covers the critical care outreach and medical emergency team concepts, as well as surviving sepsis and avoiding acute kidney injury initiatives. Peri-operative optimization to mitigate the impact of surgery and the need to follow up patients post-critical care admission to enhance recovery and prevent re-admission are also included.
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Raine, Tim, James Dawson, Stephan Sanders, and Simon Eccles. Cardiovascular. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199683819.003.0007.
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Chest pain emergencyChest painTachyarrhythmia emergencyTachyarrhythmiasBradyarrhythmia emergencyBradyarrhythmiasHypertension emergencyHypertensionHeart failureCall for senior help early if patient unwell or deteriorating.•Sit patient up•15l/min O2 if SOB or sats <94%•Monitor pulse oximeter, BP, defibrillator ECG leads if unwell...
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Chong, Ji Y., and Michael P. Lerario. Malignant Edema. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780190495541.003.0006.
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Large middle cerebral artery (MCA) and cerebellar strokes can cause rapid neurological deterioration and death from edema, mass effect, and herniation. Hemicraniectomy in select patients with malignant MCA syndromes is life-saving, but patients are often left with significant disability. Younger patients may derive the most benefit from hemicraniectomy. Cerebellar strokes can also cause obstructive hydrocephalus, which may exacerbate herniation and brainstem compromise. Surgical decompression through suboccipital craniectomy relieves posterior fossa pressure and reduces mortality in these patients.
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Beed, Martin, Richard Sherman, and Ravi Mahajan. Assessment and stabilization. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199696277.003.0001.
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Assessment and immediate management of an emergencyEarly further managementThe assessment and immediate management of critically ill patients follows the established ABC approach (Approach/Airway, Breathing, Circulation). What follows is a brief summary of the ABC approach adapted for patients within a critical care environment, further details on each system are considered in individual chapters. Any deterioration during assessment and resuscitation should prompt a return to ‘A’....
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Raine, Tim, James Dawson, Stephan Sanders, and Simon Eccles. Neurology and psychiatry. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199683819.003.0011.
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Coma and reduced GCS emergencyComa and reduced GCSAcute confusionDementiaAdult seizures emergencyPaediatric seizures emergencySeizuresNeurodegenerative disordersStroke/CVA/TIA emergencyStrokeFocal neurologyBack painHeadacheDizzinessAggressive behaviour emergencyMood disturbance/psychosisCall for senior help early if patient unwell or deteriorating....
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Raine, Tim, James Dawson, Stephan Sanders, and Simon Eccles. Gastroenterology. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199683819.003.0009.
Full textAbstract:
Abdominal pain emergencyAbdominal painGI bleeding emergencyAcute upper GI bleedsAcute lower GI bleedsNausea and vomitingDiarrhoeaConstipationLiver failure emergencyLiver failureJaundice Call for senior help early if patient deteriorating.•15l/min O2 if SOB or sats <94%•...
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Dare, Christopher J., and Evan M. Davies. Thoracic fractures. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199550647.003.012042.
Full textAbstract:
♦ Thoracic fractures are associated with severe trauma in young patients♦ Multiple injuries are common♦ Early fixation of unstable injuries is recommended to prevent neurological deterioration♦ Almost all surgery best carried out posteriorly♦ Long implants can be used♦ Anterior reconstruction may be required where the anterior column is deficient.
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Raine, Tim, James Dawson, Stephan Sanders, and Simon Eccles. Endocrinology. Oxford University Press, 2014. http://dx.doi.org/10.1093/med/9780199683819.003.0010.
Full textAbstract:
Hypoglycaemia emergencyHypoglycaemiaHyperglycaemia emergencyHyperglycaemiaSliding scalesDiabetes mellitusPituitary axisAdrenal diseaseThyroid diseaseCall for senior help early if patient deteriorating.• Blood glucose is normally >3.5mmol/l• Poorly controlled diabetics can have symptoms of hypoglycaemia with a glucose >3.5mmol/l.• Protect airway...
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Wise, Matt, and Paul Frost. Terminal care in the intensive care unit. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0153.
Full textAbstract:
In the UK, around 10%–20% of all patients admitted to the intensive care unit (ICU) do not survive while, in the United States, it has been estimated that 22% of all deaths occur in an ICU. Therefore, terminal or palliative care is as important as any of the life-saving interventions that occur in the ICU. The goal of palliative care is to achieve a good death. In the ICU, the switch from care with curative intent to palliation occurs when it becomes obvious that the patient is not responding to treatment. Typically, this is manifest by deteriorating physiology and escalating organ support in the setting of overwhelming disease or injury. It is predominantly expert opinion (consensus amongst treating medical and nursing teams) that determines the point at which the patient is recognized as not responding to treatment and, in fact, dying. This chapter covers the ethical considerations, communication, family disagreement, organ donation, withdrawal of therapies, care after death, and diagnosing death.
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Arroyo, Vicente, Mónica Guevara, and Javier Fernández. Renal failure in cirrhosis. Edited by Norbert Lameire. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0247.
Full textAbstract:
A major event in liver cirrhosis is the development of a progressive deterioration of circulatory function due to splanchnic arterial vasodilation and impairment in cardiac function. This feature determines a homeostatic activation of the renin–angiotensin–aldosterone system, sympathetic nervous system, and antidiuretic hormone. The splanchnic microcirculation is resistant to the vasoconstrictor effect of these systems. Therefore, the homeostasis of arterial pressure in cirrhosis occurs in the extrasplanchnic, mainly renal circulation. The activation of these systems produces renal fluid retention, which accumulates as ascites, and water retention and dilutional hyponatraemia. In the latest phase of cirrhosis, when circulatory dysfunction is severe, renal vasoconstriction is intense and patients develop type 2 hepatorenal syndrome (HRS) and refractory ascites.Type 1 HRS is an acute and rapidly progressive renal failure that occurs in the setting of a precipitating event, commonly an infection. Patients with type 1 HRS also present with rapid deterioration of liver function (encephalopathy, jaundice) and relative adrenal insufficiency. The mechanism of this multiorgan failure is an acute deterioration in circulatory function due to both an accentuation of arterial vasodilation and of cardiac dysfunction.There is no specific test for the diagnosis of HRS. The most accepted diagnostic criteria are those proposed by the International Ascites Club which are based on the exclusion of other types of renal failure. The course of renal failure following treatment of the precipitating event of HRS is another important diagnostic feature.The treatment of choice of tense ascites in cirrhosis is paracentesis associated with intravenous albumin infusion. Moderate sodium restriction and diuretics (spironolactone alone or associated with furosemide) are subsequently given to prevent re-accumulation of ascites. Diuretics are the treatment of choice in patients with moderate ascites. Patients with type 2 HRS and refractory ascites (not responding to diuretics) could be treated by frequent paracentesis or by the insertion of a transjugular intrahepatic portosystemic shunt (TIPS).Terlipressin plus albumin is the treatment of choice in type 1 HRS
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Cattran, Daniel C., and Heather N. Reich. Membranous glomerulonephritis. Edited by Neil Turner. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0062_update_001.
Full textAbstract:
A common rule of thumb in primary membranous glomerulonephritis (MGN) is that one-third of patients improve spontaneously, one-third progress, and one-third continue to have substantial proteinuria. The rate of spontaneous recovery may be near the truth, but MGN is usually an indolent condition and few studies have run long enough to give accurate outcomes for the remainder. However MGN is an important cause of end-stage renal failure. Treatment regimens that include cyclophosphamide or chlorambucil can improve the outcome of patients at greatest risk of deterioration, but their toxicity has limited their use in randomized studies to the highest risk patients. Steroids alone, and ciclosporin, do not improve long-term outcomes in these studies. Whether anti-B-cell antibodies offer additional benefits requires randomized studies. After confirming the diagnosis of primary MGN it is recommended to maximize supportive therapy and monitor for at least 6 months to give a clear picture of the long-term risk. For patients at lowest risk, supportive management and monitoring alone is recommended. Patients at medium risk (nephrotic range proteinuria but normal and stable glomerular filtration rate), or high risk (very heavy proteinuria, greater than 8 g/day or deterioration of glomerular filtration rate) may justify specific treatment directed at the immune response. For the medium-risk group it is not certain that it is required; for some in the high-risk group it may come too late. Overall outcomes in the high-risk group remain quite poor even with aggressive treatment.
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Verrips, Aad. Cerebrotendinous Xanthomatosis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199972135.003.0040.
Full textAbstract:
Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disease due to a defect in bile acid metabolism. Worldwide, more than 300 patients have been described. Mutations in the CYP27A1 gene result in sterol 27-hydroxylase deficiency leading to the accumulation of cholestanol in multiple body tissues. Premature cataracts, chronic diarrhea, tendon xanthomas, and neurological deterioration are the predominant clinical features. There are several disease stages, from being nearly asymptomatic in the early childhood years to severe disability in later stages of life. Adult CTX patients are often misdiagnosed initially, especially when tendon xanthomasa are absent. CTX should be considered in all patients with premature cataracts and in patients with neurological features such as spasticity, early-onset dementia, ataxia, or Parkinsonism.
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Price, Susanna, and Pascal Vranckx. Portable (short-term) mechanical circulatory support. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0030.
Full textAbstract:
Mechanical circulatory support can be used to resuscitate patients, as a stabilizing measure for angiography and prompt revascularization, or to buy time until more definite measures can be taken. In addition, there is experimental evidence that ventricular unloading of the left ventricle can significantly reduce the infarct size. Different systems for mechanical circulatory support are available to the medical community. Treatment options for mechanical circulatory support must be tailored to each patient in order to maximize the potential benefits and minimize the risk of detrimental effects. Intra-aortic balloon pumping is still the most widely used mechanical circulatory support therapy. The relative ease and speed with which this device can be applied to patients with a rapidly deteriorating haemodynamic picture have led to its widespread use as a first-line intervention among critically unstable patients. Where intra-aortic balloon pumping is inadequate, an immediate triage to a more advanced percutaneous (short-term) mechanical circulatory support may be warranted. Despite their extensive use, the utility of mechanical circulatory support devices in acute heart failure syndromes and cardiogenic shock remains uncertain. This chapter concentrates on the application of mechanical circulatory support relevant to the interventional cardiologist and cardiac intensive care physician.
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Price, Susanna, and Pascal Vranckx. Portable (short-term) mechanical circulatory support. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0030_update_001.
Full textAbstract:
Mechanical circulatory support can be used to resuscitate patients, as a stabilizing measure for angiography and prompt revascularization, or to buy time until more definite measures can be taken. In addition, there is experimental evidence that ventricular unloading of the left ventricle can significantly reduce the infarct size. Different systems for mechanical circulatory support are available to the medical community. Treatment options for mechanical circulatory support must be tailored to each patient in order to maximize the potential benefits and minimize the risk of detrimental effects. Intra-aortic balloon pumping is still the most widely used mechanical circulatory support therapy. The relative ease and speed with which this device can be applied to patients with a rapidly deteriorating haemodynamic picture have led to its widespread use as a first-line intervention among critically unstable patients. Where intra-aortic balloon pumping is inadequate, an immediate triage to a more advanced percutaneous (short-term) mechanical circulatory support may be warranted. Despite their extensive use, the utility of mechanical circulatory support devices in acute heart failure syndromes and cardiogenic shock remains uncertain. This chapter concentrates on the application of mechanical circulatory support relevant to the interventional cardiologist and cardiac intensive care physician.
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Price, Susanna, and Pascal Vranckx. Portable (short-term) mechanical circulatory support. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0030_update_002.
Full textAbstract:
Mechanical circulatory support can be used to resuscitate patients, as a stabilizing measure for angiography and prompt revascularization, or to buy time until more definite measures can be taken. In addition, there is experimental evidence that ventricular unloading of the left ventricle can significantly reduce the infarct size. Different systems for mechanical circulatory support are available to the medical community. Treatment options for mechanical circulatory support must be tailored to each patient in order to maximize the potential benefits and minimize the risk of detrimental effects. Intra-aortic balloon pumping is still the most widely used mechanical circulatory support therapy. The relative ease and speed with which this device can be applied to patients with a rapidly deteriorating haemodynamic picture have led to its widespread use as a first-line intervention among critically unstable patients. Where intra-aortic balloon pumping is inadequate, an immediate triage to a more advanced percutaneous (short-term) mechanical circulatory support may be warranted. Despite their extensive use, the utility of mechanical circulatory support devices in acute heart failure syndromes and cardiogenic shock remains uncertain. This chapter concentrates on the application of mechanical circulatory support relevant to the interventional cardiologist and cardiac intensive care physician.
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Orth, Stephan R. Smoking in chronic kidney disease. Edited by David J. Goldsmith. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0103.
Full textAbstract:
Smoking has been acknowledged as the number one preventable cause of death in most countries. The adverse effects of smoking on the kidney are less known. Prospective, population-based, observational studies, and evidence from experimental work indicate that smoking (a) is a relevant risk factor for chronic kidney disease (CKD) in the general population and (b) is associated with an increased risk of deterioration in renal function in CKD patients. The latter is especially true for patients with diabetic nephropathy or hypertensive renal damage. The conclusion is that smoking is an important renal risk factor and nephrologists should make greater efforts to motivate patients to stop smoking, not least because smoking cessation improves the prognosis of CKD.
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Wagner, Beth. Withdrawal of Respiratory Technology. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190204709.003.0012.
Full textAbstract:
Respiratory failure can be defined as the inability of the lungs to provide adequate oxygenation or ventilation to sustain life. Respiratory failure can lead to abrupt clinical deterioration and is extremely distressing for patients and families. Advances in technology over the past decade have produced many life-sustaining therapies for patients with respiratory failure. Examples include high-flow oxygen therapy, invasive and noninvasive mechanically assisted breathing ventilation, prostacyclin therapy, and extracorporeal membrane oxygenation (ECMO). The care of these complex patients necessitates policies and procedures to assure quality care in withdrawal. Standardized protocols for withdrawal of life-sustaining respiratory therapies provide structured guidance, reduce variation in practice, and improve family and healthcare provider satisfaction.