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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Urgentreferral
PathologicalECGfindings Pasthistoryofheartfailureorsuggestivefindingsonexamination ExertionalTLoC Family history of sudden cardiac death in people aged <40 years and/or an inherited cardiac condition Neworunexplainedbreathlessness Aheartmurmur.
Routinereferral
AllpatientswithTLoCunless:
Alreadyreferredurgentlytocardiology
Diagnosedwithvasovagal(simplefaint),situationalsyncope,ororthostatichypotension
Historyisconsistentwithepilepsy.
Table9.2AdditionalcardiovascularinvestigationsintheassessmentofTLoC
Typeof investigation
Indications
Cardiacarrhythmia investigations
AmbulatoryECG(Holtermonitoring):
IfTLoCseveraltimesaweek Ifevidenceofconductionabnormalityon12-leadECG
External event recorder (with facility for patient to indicate when a symptomatic event has occurred):
IfTLoConceevery1–2weeks
Implantableeventrecorder:
IfTLoCinfrequent,i.e.lessthanonceevery2weeks
Exercisetesting Referforexercisetestingurgently(within7days)ifTLoCoccurredduringexercise(unless
contraindicatede.g.suspectedASorhypertrophiccardiomyopathy)
Tilttest Performifsuspectedvasovagalsyncopebutmultipleepisodesaffectqualityoflife(checkif
syncopeisaccompaniedbyasystole)
Carotidsinus massage
TestinasaferoomwithECGrecordingandresuscitationequipment:
Offerifsuspectingcarotidsinussyncopeorunexplainedsyncope>60years Diagnose carotid sinus syncope if it reproduces syncope due to marked bradycardia/asystole/hypotension
Source:datafromNICECG109.
Neurology
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• Refer for neurology review if suspecting stroke, epileptic seizures, psychogenic non-epileptic seizures,orpsychogenicpseudosyncope.
Some trusts have specialist syncope clinics—see local guidelines for further advice on referrals.
Furtherreading
1.KatritsisD,GershB,CammA(2016).Syncope.In:ClinicalCardiology:CurrentPracticeGuidelines (pp. 743–57). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199685288.003.1517_update_004
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Part2
Careoftheelderly
Delirium
Dementia
Falls
Hipfractures
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Chapter10
Delirium
Guideline:NICECG103(Delirium:prevention,diagnosisandmanagement):
https://www.nice.org.uk/guidance/cg103
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Delirium is a common neuropsychiatric syndrome that results in a sudden change in a person’s mental state. Patients with delirium have longer hospital stays, increased mortality, andincreased risk of requiringinstitutionalplacement.There is also a higher risk of hospital-acquired complications, such as pressure sores and falls. Delirium consistsofthreeclinicalsubtypes:
Hyperactive delirium (25%)—patients who have heightened arousal, restlessness, agitation, or aggression Hypoactivedelirium(65%)—patientswhobecomemoresleepy,quieter,orwithdrawn Mixeddelirium(10%)—characterizedbypatientswhomovebetweentheothertwosubtypes.
Clinicalfeaturesofdelirium
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Maybereportedbythepatient,carer,orarelative Decline in cognitive function—worsened concentration, slow responses, disorganized thinking, confusion Alteredperception—visualorauditoryhallucinations Declineinphysicalfunction—reducedmobility,restlessness,agitation,changesinappetite Changesinsocialbehaviour—lackofcooperationwithreasonablerequests,withdrawal,changes inmoodorattitude Alteredsleep–wakecycle.
Diagnosis
Riskfactors
Age≥65years Cognitiveimpairmentand/ordementia Currenthipfracture Severeillness.
History
Acollateralhistoryismandatory Askaboutcognitiveandfunctionalbaseline Askaboutclinicalfeaturesofdelirium(listedearlierintopic) Ask about any possible precipitants such as falls, infection, urinary retention, constipation, dehydration,andpain Includedrughistoryandalcoholhistory.
Examination
Check consciousness level (Glasgow Coma Scale (GCS) or ‘Alert, Voice, Pain,Unresponsive’ (AVPU)scores)
ScreenforcognitivedysfunctionusingatoolsuchastheAbbreviatedMentalTestScore(AMTS)
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Assessforanysourcesofinfection Perform rectal examination to assess for constipation and examine for urinary retention, e.g. palpablebladder,suprapubictenderness Neurologicalexamination.
Investigations
Toruleoutprecipitatingfactorsanddifferentialdiagnoses:
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Bedside:oxygensaturations,bloodpressure,temperature,urinalysis,ECG Bloods:FBC,CRP,U&E,LFT,calcium,TFT,haematinics,glucose,bloodcultures Imaging: chest X-ray. Consider a CT head to rule out differential diagnoses such as stroke, subduralhaemorrhage,oraspace-occupyinglesion.
Clinicalassessment
If indicators of delirium are identified, carry out a clinical assessment based on the Confusion AssessmentMethod (CAM)2 where the following threepointsare needed to fulfiladiagnosisofdelirium:
Acuteonsetandfluctuatingcourse Inattentionandeasilydistractible Disorderedthinkingoralteredlevelofconsciousness.
Diagnosticand Statistical Manual ofMental Disorders3, fifth edition (DSM-5) criteria
canalsobeusedinthediagnosisofdelirium.
Management
Observepatientsdailyforchangesorfluctuationsintheirusualbehaviourandbeaware thatdistressisascommoninpatientswithhypoactivedeliriumasthosewithhyperactive delirium.
Managetheunderlyingcauseorcombinationofcausesoftheirdelirium(Table10.1).
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Table10.1Managementofunderlyingcausesofdelirium
Precipitatingfactors Management
Environmentalfactors
Avoidmovingpeoplebetweenwardsorroomsunlessabsolutelynecessary Provideappropriatelighting,avisibleclock,andacalendar Reorientate them, explainingwhere they are, why they are in hospital, andwhat your roleis Facilitateregularvisitsfromfamilyandfriends Encourageactivitieswhicharecognitivelystimulating Donotpreventsleepatnight;reduceloudnoises,brightlights,andmedicationroundsif possible
Fluidandelectrolyte abnormalities
Encourageoralintake Keepafoodandfluidchart
Perform a Malnutrition Universal Screening Tool (MUST)4 score to assess nutritional statusandinvolvedieteticsifappropriate Ensuredenturesfitcorrectly ConsiderelectrolytereplacementorIVfluidsifpoororalintake
Infection
Assessdailyforclinicalsignsofinfection Considertheuseofbloodstomonitormarkersofinflammation Avoidunnecessaryurinarycatheterization
Drugs
Reviewandrationalizeallmedications
Urinaryandfaecal retention
Catheterizeifurinaryretention>500mL Considerlaxativesifconstipated Keepastoolchartandfluidinput/outputchart
Pain
Analgesia Assess for non-verbal signs of pain if patients have difficulty communicating, e.g. Abbeypainscore
Sensoryimpairment
Removeearwax,ensurehearingaidsareworkingandfittedcorrectly Ensurespectaclesarewithinreachofthepatient
Hypoxia
Treatunderlyingcauseof hypoxiaand provideoxygen therapyiftargetsaturationsare notbeingmet
Postoperative
Encourageearlysupervisedmobilizationwithappropriatemobilityaids
If thedelirium does notresolve, re-evaluateforunderlyingcauses,butalso consider
assessingforpossibledementia.
Managementofaggressionandagitationindelirium
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First,identifyandtreattheunderlyingcauseifpossible Useverbal andnon-verbal techniquesto de-escalate the situation.Only considermedications if thereisnoeffectwithbehaviouralapproaches If the patient is considered to be a risk to themselves or others, consider giving short-term antipsychotics (e.g.haloperidolorally (PO)/intramuscularly(IM)0.5–1mghourly, maximum3mg in24hours).Callforseniorhelpifhigherdosesarerequired Avoidusingantipsychoticdrugsforpeoplewith:
Parkinson’sdisease Lewybodydementia ElongatedQTc>470ms Alcoholwithdrawal
Instead consider giving a benzodiazepine (e.g. lorazepam 0.5–1mg PO/IM 1–2 hourly maximum4mgdaily)
Alwaysstartwiththesmallestdoseandtitrateupwardsuntilthedesiredsedationisachieved ChecktheECGforaprolongedQTcintervalbeforeandafterstartinghaloperidol Monitor sedated patients with regular observations, with particular attention being paid to respiratoryrateandoxygensaturations.
Furtherreading
1. MacLullich AMJ, Marcantonio ER, Meagher DJ (2017). Delirium. In: Michel JP, Lynn Beattie B, MartinFC,etal.(eds)OxfordTextbookofGeriatricMedicine,3rded.(pp.363–72).Oxford:Oxford UniversityPress.Availableat:https://doi.org/10.1093/med/9780198701590.003.0049
2.GuysandStThomasNHSTrust.ClinicalGuidelines:ThePrevention,RecognitionandManagementof Delirium in Adult In-Patients. Available at: https://www.guysandstthomas.nhs.uk/resources/our-
services/acute-medicine-gi-surgery/elderly-care/delirium-adult-inpatients.pdf
1HodkinsonHMEvaluationofa mentaltestscore forassessmentofmentalimpairmentintheelderly.
Age and Ageing 1972;1(4):233-8. PMID 4669880.
http://ageing.oxfordjournals.org/cgi/reprint/1/4/233.
2 Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the
confusionassessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15;113(12):941-8.doi:10.7326/0003-4819-113-12-941.PMID:2240918.
3AmericanPsychiatricAssociation.Diagnosticand statistical manualof mental disorders (5th ed.).
2013https://doi.org/10.1176/appi.books.9780890425596
4https://www.bapen.org.uk/screening-and-must/must-calculator
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Chapter11
Dementia
Guideline:NICENG97(Dementia:assessment,managementandsupportfor
people living with dementia and their carers):
https://www.nice.org.uk/guidance/ng97
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Dementiaaffectsapproximately850,000peopleintheUK,withoneinsixpeopleoverthe age of 80 years having dementia. Dementia encompasses a wide range of progressive neurological disorders where there is adecline in cognitive function which impairs the memory, ability to reason, and ability to communicate. It can also cause personality changes.Allthesymptomsmayimpairactivitiesofdailyliving.
Dementiasubtypes
Alzheimer’sdisease(60%ofcases)
Excess deposition of beta-amyloid plaques causing progressive neuronal damage and loss of acetylcholineneurotransmitters Frontalandtemporallobesofthebrainareparticularlyaffected Early impairment of episodic memory (short-term memory loss, repeated questioning, difficulty learningnewinformation).
Vascular
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Causedbycerebrovasculardisease,withorwithoutaclinicalhistoryofstroke Patientswithcardiovascularriskfactorsareparticularlyatrisk Mayhaveastepwiseprogressionintheseverityofsymptoms(mayhavefocalneurologicalsigns likehemiparesisorvisualfielddefects).
Mixed
A mixed picture of both Alzheimer’s disease and vascular dementia—autopsy studies have revealedthistobemorecommonthanvascularaetiologyalone.
Lewybody
Depositsofalpha-synucleinprotein(Lewybodies)withinneurons Repeatedfalls,visualhallucinations,andfluctuatingcognitionmayoccur Parkinsonian motor features and autonomic dysfunction (postural hypotension, difficulty swallowing,andincontinence/constipation).
Frontotemporal
Significantfrontotemporalbrainatrophyonimaging Personalitychangeandbehaviouraldisturbance(apathy/social/sexualdisinhibition)oraphasia Hyperoralityanddietarychanges,particularlywithapreferenceforsweetfoods,iscommon Othercognitivefunctionsmaybepreserved—patientstypicallyscorewellonneuropsychological testsearlyinthecourseofthedisease.
Creutzfeldt–Jakobdisease(CJD)
Consider if rapidly progressive dementia. Typical symptoms involve intellect and memory changes, speech, balance and personality changes, and abnormal jerking movements.
Diagnosis
History
Elicitcognitive,behavioural,andpsychologicalsymptoms Itisimportanttonotethetimelineofeventsandtheimpactofsymptomsondailylife Collateralhistoryiscrucial.
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