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Geriatric Emergencies

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Title: Geriatric Emergencies


1
Geriatric Emergencies
  • Nadim Lalani MD

2
Trivia
  • What style of fencing is this?

3
Foil
  • From 17th C
  • Lightest weapon
  • valid target restricted to torso
  • Strict rules as to priority of hits and thus
    scoring
  • Must connect with point
  • 4.9 N x 15msec

4
Epee
  • From 19thC
  • Heavier to simulate more real combat
  • valid target area entire body
  • double touches are allowed.
  • Contact with end
  • 7.5 N x 1msec

5
Sabre
  • From 19th C
  • can cut and thrust
  • valid target area everything above the waist
  • (except back of the head hands)
  • Priority rules like Foil

6
Objectives
  • Background
  • Geriatric Trauma
  • 2 Common Presentations
  • ALOC
  • Infections
  • Elderly Abuse
  • No syncope. No weakness
  • Feel free to share Q/A fun and engaging

7
Background
  • Elderly 15-20 of ED visits and increasing
  • Have longer ED length of stay and consume more
    resources
  • More likely to arrive via ambulance and be
    admitted 40 ED admissions
  • More likely to have medical rather than surgical
    admit
  • Atypical presentations are the norm esp gt85yo
    oldest old
  • Most common causes
  • Cardiac ? Ischemic HD, dysrhythmia CHF
  • Syncope
  • CVA
  • Pneumonia
  • Abdominal disorders
  • Dehydration
  • UTI

8
Adverse Outcomes
  • Elderly pts that are sent home have signif risk
    of AOs
  • Risk factors for adverse outcomes
  • Decline in Baseline function
  • Recent admit
  • Lives alone
  • No social Support
  • Polypharmacy gt 3 meds
  • Certain diseases CV, DM, dementia, depression
  • Mortality 10 ? 3 mo after ED visit
  • 25 ED bounce-back and 25 post-D/C admit rate
  • Incumbent on EPs to identify and manage this
    risk

9
List meds assoc with Adverse outcomes
  • 12 ? 30 elders admitted in whole/part due to
    drug reactions or interactions.
  • Altered pharmacokinetics pharmacodynamics
  • Worst offenders
  • cardiovascular meds ? diuretics ? NSAID ?
    hypoglycemics ? anticoagulants.
  • Speaks to the fact that we shouldnt be fiddling
    if we can help it.

10
CASE
  • 70 yo trying to put up Christmas lights.
  • Fall off roof.
  • EMS ? can we go to PLC?
  • List 3 physiologic considerations in caring for
    the elderly trauma patient and how they change
    you management.

11
Physiology
  • Generally more severe response to any given
    mechanism
  • Airway
  • Edentulous ? cant bag.
  • Reduced oral diameter and neck extension.
  • Breathing
  • Reduced FRC, compliance and chest wall expansion
    ? Desat QUICK
  • Circulation
  • Limited capability to increase CO
  • Might not vasoconstrict Due to cardiac meds
  • Result is that these pts cannot tolerate shock
  • Disability Exposure
  • Dura attached to inner table ? less EDH but MORE
    SDH
  • Spinal stenosis
  • Osteoporotic ? trivial trauma ? fracture

12
Other physiology
13
Other physiology
14
Other physiology
15
Geriatric Trauma
  • Injury significant cause of death due to
  • Physiologic differences
  • Injury patterns
  • gt 80 trauma 4 fold mortality cf younger
    trauma pts
  • Falls 40 ? MVC auto vs ped ? other assault
  • Gimme 3 risk factors for falls
  • RFs
  • Meds narcotics, cardiac meds
  • Hx CVA
  • Cognition
  • Visual and hearing impairment

16
Falls and MVCs
  • Falls
  • ¼ due to underlying medical condition
  • Most common injury is s occurring in 5
  • Even with minor mechanism, absence of clinical
    findings does not rule out injury.
  • Low threshold for radiography
  • MVCs
  • NB Single-vehicle Accidents ? need to r/o medical
    cause
  • Mortality as high as 20
  • Am Coll Surg recommendations anyone gt 55 goes to
    trauma centre.

17
Back to Case
  • 70 yo Male in collar on spine board.
  • VS 80, 110/45, 30, 90, 370, c/s 5.0, GCS E3,
    V4, M6
  • AMPLE ? on BB/warf for AF. HCTZ for HTN has RA
  • C/o numb fingers, L chest wall pain.
  • O/e Tender L CW, Abdo non-specific tender but
    soft. Cannot do pelvis because RT is doing a
    fem-poke
  • Doctor?

18
Head injuries
  • Much higher mortality ? 1/5 SDH do not survive
  • 75 admit rate
  • Indications for warfarin reversal?
  • What if he tripped, fell, small abrasion
    forehead. GCS 15. No deficits? Management?
  • Minimal mechanism coumadin Normal exam 7-
    15 serious intracranial hemorrhage.
  • ULTRA LOW THRESHOLD FOR CT

19
Acute/chronic Subdural
20
Spinal Injuries
  • Most common mech is a fall
  • Degen joint dis ? reduced mobility ? brittle
    spinal column
  • Most common level of injury is C1-C3
  • Most common injury is Type 2 Odontoid
  • Overall mortality 15

21
Central Cord Syndrome
  • Two places where spinal cord is large relative to
    canal
  • C5-T1 brachial plexus L2-S3 lumbosacral
    plexus.
  • Limited space Hyperextension injury ? cord gets
    pinched by inward bulging of ligamentum flavum ?
    central contusion
  • Clinically
  • Bilateral motor weakness of upper extremities gtgt
    lower extremities
  • distal muscle groups gtgt proximal muscle groups.
  • Can have burning dysesthesias in upper
    extremities.
  • Variable prognosis ? goes by age
  • gt 50yo ? only 30 regain bladder function 50
    regain ambulation.

22
Central Cord
23
Chest Injuries
  • Falls gtgt MVC cause broken ribs
  • Increased incidence of solid organ injury
  • CANNOT tolerate
  • huge risk of respiratory failure and Pneumonia
  • BOTTOM LINE Elderly rib fractures ? Low
    threshold for admit.

24
Abdominal Injuries
  • Seen in 30 older trauma patients.
  • Mortality 25
  • Even with careful selection, Non-operative
    management only 75 success.
  • Unreliable exam Liberal use of CT

25
Pelvic Injuries
  • Falls ? break pelvis ? also bleed more
  • Rami gtgt acetab gtgt ischium
  • Aggressive management
  • Binder
  • Warm Fluids
  • Blood
  • Consider embolisation
  • GLF no on xray cannot walk?
  • Needs MRI

myweb.lsbu.ac.uk
26
Extremity Injuries
  • Low mechanism osteoporosis Fracture!
  • Perform really good tertiary survey EVEN FOR
    MEDICAL PATIENTS
  • Case of syncope on park bench ? when went to
    check for pedal edema ? ouch! ? had ankle on
    Xray!
  • Low threshold for radiography

27
Trauma Summary
  • Go into elder mode
  • Liberal use of radiography
  • Think of elder-specific issues central cord
  • Elder Airway ? Edentulous, reduced mouth
    open/neck mobility
  • Elder Breathing ? rib fractures signif
    morbidity
  • Elder Circulation ? meds will hide shock. PELVIS!

28
Mental break
  • Quiz Which of these are new features on the Wii
    Tiger Woods 2009 All Play game?
  • Online play
  • All-play mode for beginners
  • 11 swing
  • Create your own avatar
  • Juggle the golf ball on club

29
Name the shot
link
30
Case 2
  • 83 yo F sent in from NH confused
  • Hx COPD, Deaf, ? Dementia, OA, Diverticulitis.
  • Outline Key aspects of the history
  • Outline Key aspects of Exam
  • Ddx?

31
ALOC in the Elderly
  • Prevalent in the ED.
  • Associated with adverse outcomes
  • Poorly recognised and even more poorly documented
  • EPs assume that dementia is being managed ?NOT
  • Still high rate of mis-diagnosis of delirium
  • Mortality 20

32
ALOC in the Elderly
33
Evaluation
  • Difficult
  • Average elderly pt has 3 medical conditions. NH
    patient 10
  • Will end up using more tests
  • Despite this need to bite the bullet and be
    meticulous and thorough
  • H/x should be exhaustive a la Pediatric hx
  • P/e should be more meticulous.
  • NB they have benign presentations despite
    catastrophic path.

34
Elder History
35
Elder Exam
36
(No Transcript)
37
Poor Mans Ddx
IS IT MEATh? I?intracranial Hemorrhage
S?structural AbN /STROKE I?infection
mening,enceph or sepsis T?trauma M?metabolic
hypoGlycemia, hypo/hyper Na,hepatic,,
hypoCa, HypoMg E? endocrine A?anoxia/ischemia
cardiac arrest, severe hypox T?toxins/Drugs AS
A, antiD, w/drawal h?htn encephalopathy
38
Delirium? Dementia? Psychosis?
39
Know this
  • Delirium
  • Sudden onset
  • Fluctuating course
  • Reduced or clouded LOC
  • Disordered attention
  • Disordered cognition
  • Impaired orientation
  • Visual hallucinations
  • Transient delusions, poorly organized
  • Asterixus/tremor
  • Dementia
  • Insidious onset
  • Stable course
  • Alert
  • Normal attention
  • Impaired cognition
  • Impaired orientation
  • Hallucinations usu absent
  • Delusions absent
  • No abN movements (usu)

Dr. Kowal 2003
40
Delerium vs Psychosis
41
Does this patient have delirium?
  • Validated assessment of delirium
  • Sens 95 spec 95
  • CAM should be documented on every chart

42
Back to case
http//www.medvarsity.com
43
Eldery Infections
  • Higher risk due to physiologic changes
  • Higher morbidity and mortality cf younger pts
  • Can be difficult to sort out due to
  • Vague presentation ? ALOC weakness
  • Atypical features and low sensitivity of serum
    markers
  • Co-morbidities

44
Elderly Fever/bacteremia
  • 10 of ED visits
  • When present almost always bacterial
  • Absence of fever not reassuring.
  • Afebrile bacteremia in 20
  • NH patients in particular do not seem to mount a
    febrile response.
  • Should prompt a thorough search
  • CBC, BC, Urine Culture and CXR
  • ¾ will end up being admitted

45
Elderly fever/Bacteremia
  • Most common complaints ? ALOC, Weakness,
    confusion and decreased functional status
  • gt 85yo more likely to present atypically
  • Urine gtgt resp gtgt unkown gtgt abdo

46
Back to case
http//www.medvarsity.com
47
Questions
  • Should the patient be admitted?
  • What is the treatment for elderly CAP?
  • What about NHAP?

48
Elderly Pneumonia
  • Leading cause of death. Particularly prevalent in
    gt85.
  • Atypical presentations esp in NH patients ALOC
    more likely
  • CAP mortality is 10 overall
  • NHAP ? much higher mortality

49
Pneumonia
50
Pneumonia risk stratification
  • Risk Stratification by Pneumonia Severity Index
  • Validated score based on 14 clinical and 7 lab
    variables
  • Group 1 score lt51 Low risk ? mort only 0.5
    ? outpatient rx
  • Group II 51-70 mort 0.9 ? Same ? outpatient rx
  • Group III 71-90 mort 1.2 ? intermediate risk
  • consider for outpt rx if theyre only in group on
    the basis of age, one comorbidity or one abn
    finding.
  • To be safe ? short admit for group III
  • Group IV gt91 points 9 mort ? admit
  • Group V gt130 points 27 mort ? admit

51
Pneumonia Severity Index
52
Community Acquired
  • CAP
  • S pneumo ? 50
  • H.Flu Moraxella
  • Atypicals mycoplasma ,chlamydia , legionella ?
    15
  • Post influenza S aureus
  • Management
  • Outpatient no co-morbidities? ? usual meds Zpack
    etc
  • Comorbidities? ? resp fluoroquinolone GATi,
    GEMI, LEVO, MOX

Sandford 2008
53
Nursing Home Pneumonia Hospital Acquired
  • Recognition that NHAP bugs are similar to HAP
  • S Pneumo
  • Gm Negs
  • AnO2
  • Staph
  • Outpatient?
  • RespFQ or Clavulin macrolide
  • Inpatient? IV Levo or Ceft/Azthro

54
Case
  • 85yo F brought in by EMS c/o weakness and SOB
  • Fell 6/7 agodoing better for 2/7 now
    non-ambulatory
  • Pmhx Htn, ? Silent MI, Tremor, OA
  • M HCTZ, ASA, Primodine, Tylenol, Zopiclone
  • O/e HR 110, BP 90/60, RR 30, SpO2 70 RA, 35.0
  • L arm grossly ecchymotic. Swollen L wrist
  • R leg short/ext rotated ? deformed crepitus
  • Obvious decubitus sores

55
Collateral
  • Level II ? no heroics
  • Lives with sis B in Law whos a retired GP
  • States I assessed her and thought she was okay
    didnt want to come to hosp as she doesnt like
    it
  • Was ambulating 2 days after fall ? then last 2/7
    in bed not eating/ weak.
  • Doctors?

56
Elder Abuse Neglect
  • Global Health Problem est 200,000/y in Canada
  • Mean 78 y, 2/3 are women
  • Most victims live with perps ? 2/3 perps are
    family
  • Only 1/14 cases actually reported
  • Definitions
  • Domestic abuse
  • Institutional Abuse
  • Self-neglect

57
Categories of elder abuse
  • Victims often subject to gt1 type
  • Physical
  • Sexual
  • Emotional/psychological
  • Neglect
  • Abandonment
  • Financial/material exploitation

58
Risk factors for Abuse
  • Caregiver rfs
  • Alchohol/drugs
  • Unemployed
  • Stress/burnout
  • No caregiving skills
  • Elder rfs
  • Female
  • Financially dependant
  • Immobility
  • Hx Fam violence
  • Environment
  • Living together
  • Cramped
  • Isolated
  • Institutional rfs
  • Low wages
  • Poor work environmt
  • Poor training
  • Low staff-Patient ratio

59
Indicators?
60
Screening P/e?
  • Physical Abuse
  • Contusions bilateral arms grab marks
  • Burns
  • Imprints of weapons/ligatures
  • Multiple fractures
  • Sexual Abuse
  • Genital tears
  • Evidence of STI
  • Neglect
  • Hygeine lying in feces?
  • Bed sores

61
Duty to Report
  • The Alberta Protection for Persons in Care Act
    1998
  • Duty to Report protected from reprisal
  • Call SW
  • Call Police

62
References
63
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64
(No Transcript)
65
Questions?
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