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Geriatric Emergencies

Geriatric Emergencies. Nadim Lalani MD. Trivia. What style of fencing is this?. Foil. From 17 th 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. Epee. From 19thC

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Geriatric Emergencies

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  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 >85yo “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 AO’s • Risk factors for adverse outcomes: • Decline in Baseline function • Recent admit • Lives alone • No social Support • Polypharmacy [> 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 EP’s 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 shouldn’t 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  can’t 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 • > 80 + trauma = 4 fold mortality cf younger trauma pts • Falls [40%]  MVC [auto vs ped]  other [assault] • Gimme 3 risk factors for falls: • RF’s: • Meds [narcotics, cardiac meds] • Hx CVA • Cognition • Visual and hearing impairment

  16. Falls and MVC’s • 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 • MVC’s: • NB Single-vehicle Accidents  need to r/o medical cause • Mortality as high as 20% • Am Coll Surg recommendations anyone > 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 >> lower extremities • distal muscle groups >> proximal muscle groups. • Can have burning dysesthesias in upper extremities. • Variable prognosis  goes by age • > 50yo  only 30% regain bladder function & 50% regain ambulation.

  22. Central Cord

  23. Chest Injuries • Falls >> 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 >> acetab >> 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] • 1:1 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 • EP’s 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. Poor Man’s 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 • [ASA, antiD, w/drawal] • hhtn encephalopathy

  37. Delirium? Dementia? Psychosis?

  38. 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) Know this Dr. Kowal 2003

  39. Delerium vs Psychosis

  40. Does this patient have delirium? • Validated assessment of delirium • Sens 95% spec 95% • CAM should be documented on every chart

  41. Back to case http://www.medvarsity.com

  42. 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

  43. 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

  44. Elderly fever/Bacteremia • Most common complaints  ALOC, Weakness, confusion and decreased functional status • > 85yo more likely to present atypically • Urine >> resp >> unkown >> abdo

  45. Back to case http://www.medvarsity.com

  46. Questions: • Should the patient be admitted? • What is the treatment for elderly CAP? • What about NHAP?

  47. Elderly Pneumonia • Leading cause of death. Particularly prevalent in >85. • Atypical presentations esp in NH patients [ALOC more likely] • CAP mortality is 10% overall • NHAP  much higher mortality

  48. Pneumonia

  49. Pneumonia risk stratification • Risk Stratification by “Pneumonia Severity Index” • Validated score based on 14 clinical and 7 lab variables • Group 1 [score <51] = 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 they’re only in group on the basis of age, one comorbidity or one abn finding. • To be safe  short admit for group III • Group IV [>91 points] 9% mort  admit • Group V [>130 points] 27% mort  admit

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