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Oxford Handbook of Acute Medicine FOURTH EDITION Punit S. Ramrakha

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of age or seniority, for clinicians directly involved in the early diagnosis and management of patients who present acutely, this book will provide a concise aid. The clear and up-to-date content of this text reflects the experience of the authors, and I am personally delighted to provide a forewo...

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,OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Acute Medicine

,ii

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,Oxford Handbook of
Acute
Medicine
FOURTH EDITION

Punit S. Ramrakha
Consultant Cardiologist
Buckinghamshire Hospitals NHS Trust
and Hammersmith Hospital
London, UK

Kevin P. Moore
Professor of Hepatology
Royal Free and University College London
Medical School
University College London, UK

Amir H. Sam
Consultant Physician and Endocrinologist
Hammersmith Hospital,
and Reader in Endocrinology
Imperial College London, UK

1

,iv

1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Punit S. Ramrakha and Kevin P. Moore 1997, 2004, 2010, 2019
The moral rights of the authors have been asserted
First edition published 1997
Second edition published 2004
Third edition published 2010
Fourth edition published 2019
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2018941855
ISBN 978–0–19–879742–5
Printed and bound in China by
C&C Offset Printing Co., Ltd.
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.

, v

Foreword to fourth edition

The first edition of the Oxford Handbook of Acute Medicine was published
in 1997. Since then, acute medicine has evolved as a fully established spe-
cialty within the UK, and over 95% of hospitals now have an acute med-
ical unit. Importantly, acute medicine is developing in Europe and Australia
as part of providing high-quality care for patients presenting as a medical
emergency to hospital. Such patients now constitute the largest group of
patients occupying inpatient hospital beds. It is imperative therefore that
all staff are trained in the management of acute medical emergencies and,
importantly, have easy access to information to support the management of
this acutely unwell subgroup of patients. This textbook is clearly structured
and is supported by useful diagrams and algorithms, and hence the informa-
tion is readily accessible. The practical procedure section is comprehensive.
While many practising clinicians will not be required to undertake all these
procedures, they will be involved in discussion on these issues with patients
and relatives, and this text will be an invaluable guide.
The handbook series from Oxford University Press already provides
useful information to many clinicians working in clinical practice. Irrespective
of age or seniority, for clinicians directly involved in the early diagnosis and
management of patients who present acutely, this book will provide a con-
cise aid. The clear and up-to-date content of this text reflects the experi-
ence of the authors, and I am personally delighted to provide a foreword
to a book which will undoubtedly help support the growing number of
trainees working in the field of acute medicine.
Derek Bell
Professor of Acute Medicine
Imperial College London

,vi

vi

Preface

The management of acute medical emergencies is the most demanding and
rewarding aspect of medical training. The aim of this handbook is to give
confidence to junior doctors to manage acute medical problems effectively
and safely. This edition has been updated to ensure that every aspect of
the care recommended is in line with current clinical guidelines. The fourth
edition of the Oxford Handbook of Acute Medicine includes summary boxes
for the key points in the management of common medical emergencies.
These concise and practical ‘management key points’ can be a useful guide
to junior doctors in the emergency department. The layout of the book
reflects clinical practice: assessment, differential diagnosis, immediate man-
agement, and some aspects of long-term therapy. Throughout the book,
the text commonly exceeds that required for the management of specialist
problems by the generalist. This is deliberate, but intended, to provide the
doctor with an understanding of specialist interventions, so that they are
more conversant with what is possible and what is happening to their pa-
tient. We have included a new section on acute medicine and the older
patient.
A word of advice—patients who present acutely ill are frequently scared
and need to be kept informed and to feel safe, however busy you are. Being
admitted to hospital means you lose control of your life. Thus, it is our duty
as their doctor to make all of our patients feel safe and cared for, and to
keep them informed of plans and what is happening to them.

, vii

Acknowledgements

We would like to thank all of the contributors who provided initial drafts
of chapters which have evolved over time, as well as friends and col-
leagues who gave up their time to read a chapter and verify its accuracy.
We would also like to thank OUP for their encouragement during the re-
writing of this book. PSR is indebted to Sanjana, Aarav, and Dhruv for their
support and motivation. KPM is indebted to Janet, Alice, and Thomas for
their continued patience when the portable computer accompanied family
holidays. Finally, we would like to acknowledge the environment at the
Hammersmith Hospital where we trained and learned that acute medicine
is both interesting and fun.

,vii

, ix

Contents

Specialist reviewers x
Symbols and abbreviations xii

1 Cardiac emergencies 1
2 Respiratory emergencies 171
3 Gastroenterological emergencies 227
4 Renal emergencies 289
5 Shock 327
6 Neurological emergencies 347
7 Infectious diseases 469
8 Emergencies in HIV-positive patients 505
9 Diabetes and endocrine emergencies 545
10 Haematological emergencies 607
11 Rheumatological emergencies 659
12 Dermatological emergencies 691
13 Psychiatric emergencies 711
14 Drug overdoses 739
15 Practical procedures 783
16 Differential diagnoses of common presentations 863
17 Acute medicine and the older patient 891

Appendix 907
Index 915

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