Management of Acutely Ill Adult-Gerontology Patients
Stabilize, treat cause, then personalize
Acute management questions test bundles and timing. For septic shock: cultures, broad-spectrum antibiotics within 1 hour, 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L or higher, and vasopressors for MAP under 65 despite fluids. For COPD exacerbation: controlled oxygen targeting SpO2 88–92% when hypercapnia risk exists, short-acting bronchodilators, systemic corticosteroids, antibiotics when bacterial criteria are met, and noninvasive ventilation for respiratory acidosis. For acute decompensated heart failure: diuresis, vasodilators if hypertensive, and avoidance of NSAIDs; do not reflexively give fluids for low urine output without assessing congestion.
Exacerbations and episodic illness
Titrate therapy to measured physiology, not to a number alone. In DKA, give isotonic fluid, insulin infusion, and replace potassium before insulin if K+ is under 3.3 mmol/L. In older adults, reduce doses for renal function and interactions; review anticholinergics, sedatives, and hypoglycemia risk.
Terminal illness
Palliative care is symptom-focused and can coexist with curative treatment. Hospice eligibility generally requires a prognosis of 6 months or less if disease runs its usual course, plus functional decline. Treat dyspnea with opioids, use antipsychotics cautiously for delirium, and address goals of care early. A do-not-resuscitate order does not mean do not treat.
Traps
Treating a monitor or a laboratory value while missing the patient; giving too much fluid in heart failure; over-oxygenating CO2 retainers; using sliding-scale insulin alone in DKA; and failing to document code status. Questions often ask for the next action, so stabilize first.
Rule of thumb
ABCs, then reversible cause, then reassess in 15–30 minutes, then document goals and disposition.