Geriatric EmergenciesNadim Lalani MD

TriviaTrivia

What style of fencing is this?

FoilFoil 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

EpeeEpee 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

SabreSabre From 19th C

can cut and thrust

valid target area = everything above the waist (except back of the head &

hands)

Priority rules like Foil

ObjectivesObjectives Background

Geriatric Trauma

2 Common Presentations ALOC Infections

Elderly Abuse

No syncope. No weakness

Feel free to share … Q/A …fun and engaging

BackgroundBackground 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

Adverse OutcomesAdverse 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

List meds assoc with List meds assoc with Adverse outcomesAdverse 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.

CASECASE 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.

PhysiologyPhysiology 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

Other physiologyOther physiology

Other physiology Other physiology

Other physiology Other physiology

Geriatric TraumaGeriatric 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

Falls and MVC’sFalls 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.

Back to CaseBack 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?

Head injuriesHead 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

Acute/chronic SubduralAcute/chronic Subdural

Spinal InjuriesSpinal 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%

Central Cord SyndromeCentral 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.

Central CordCentral Cord

Chest InjuriesChest 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.

Abdominal InjuriesAbdominal 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

Pelvic InjuriesPelvic 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

Extremity InjuriesExtremity 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

Trauma SummaryTrauma 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!

Mental breakMental 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

Name the shotName the shot

link

Case 2Case 2 83 yo F sent in from NH confused…

Hx: COPD, Deaf, ? Dementia, OA, Diverticulitis.

1. Outline Key aspects of the history

2. Outline Key aspects of Exam

3. Ddx?

ALOC in the ElderlyALOC 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%

ALOC in the ElderlyALOC in the Elderly

EvaluationEvaluation 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.

Elder HistoryElder History

Elder ExamElder Exam

Poor Man’s DdxPoor Man’s Ddx“IS IT MEATh?”Iintracranial Hemorrhage Sstructural AbN /STROKEIinfection [mening,enceph or sepsis]TtraumaMmetabolic

[hypoGlycemia, hypo/hyper Na,hepatic,, hypoCa++, HypoMg++]E endocrineAanoxia/ischemia [cardiac arrest, severe hypox]Ttoxins/Drugs

[ASA, antiD, w/drawal]hhtn encephalopathy

Delirium? Dementia? Delirium? Dementia? Psychosis?Psychosis?

Know thisKnow thisDelirium 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

Delerium vs PsychosisDelerium vs Psychosis

Does this patient have Does this patient have delirium?delirium?

•Validated assessment of delirium•Sens 95% spec 95%•CAM should be documented on every chart

Back to caseBack to case

http://www.medvarsity.com

Eldery InfectionsEldery 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

Elderly Fever/bacteremiaElderly 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

Elderly fever/BacteremiaElderly fever/Bacteremia Most common complaints ALOC, Weakness, confusion and

decreased functional status

> 85yo more likely to present atypically

Urine >> resp >> unkown >> abdo

Back to caseBack to case

http://www.medvarsity.com

Questions:Questions: Should the patient be admitted?

What is the treatment for elderly CAP?

What about NHAP?

Elderly PneumoniaElderly 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

PneumoniaPneumonia

Pneumonia risk stratificationPneumonia 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

Pneumonia Severity IndexPneumonia Severity Index

Community AcquiredCommunity Acquired CAP:

1. S pneumo 50%

2. H.Flu & Moraxella

3. 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

Nursing Home Pneumonia = Nursing Home Pneumonia =

Hospital AcquiredHospital Acquired

Recognition that NHAP bugs are similar to HAP:1. S Pneumo

2. Gm Negs

3. AnO2

4. Staph

Outpatient? RespFQ or Clavulin +

macrolide

Inpatient? IV Levo or Ceft/Azthro

CaseCase 85yo F brought in by EMS c/o weakness and SOB

Fell 6/7 ago…doing 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

CollateralCollateral Level II “no heroics”

Lives with sis & B in Law [who’s a retired GP]

States “ I assessed her and thought she was okay … didn’t want to come to hosp as she doesn’t like it”

Was ambulating 2 days after fall then last 2/7 in bed not eating/ weak.

Doctors?

Elder Abuse & NeglectElder 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

Categories of elder abuseCategories of elder abuse Victims often subject to >1 type

1. Physical

2. Sexual

3. Emotional/psychological

4. Neglect

5. Abandonment

6. Financial/material exploitation

Risk factors for AbuseRisk factors for Abuse Caregiver rf’s

Alchohol/drugs Unemployed Stress/burnout No caregiving skills

Elder rf’s Female Financially dependant Immobility Hx Fam violence

Environment Living together Cramped Isolated

Institutional rf’s Low wages Poor work environmt Poor training Low staff-Patient ratio

Indicators?Indicators?

Screening P/e?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

Duty to ReportDuty to Report The Alberta Protection for Persons in Care Act 1998

Duty to Report [protected from reprisal]

Call SW

Call Police

ReferencesReferences

Questions?Questions?