Transcript Emergency Medicine: A Comprehensive Study Guide.

Precise Evaluation of the Geriatric
Patient Adult in the ED:
An interactive case series
Kevin Biese MD, MAT
Kristen Barrio MD
Nikki Waller, MD
Ellen Roberts PhD, MPH
Jan Busby-Whitehead, MD
With Support from The Donald W. Reynolds Foundation,
John A. Hartford Foundation & American Geriatrics Society
© The University of North Carolina at Chapel Hill, Center for Aging and Health
The Overview
• Overview Geriatric Emergency Medicine
(GEM)
• The Precise Evaluation game
• Frequent GEM pitfalls
– Trauma, delirium, triage, care transition,
abdominal pain
• Wrap up with key GEM take home points
• Discussion
Why Geriatrics:
Phenomenal growth
Why Geriatrics:
Unsustainable costs
Precise Evaluation: The game
Kevin Biese MD, MAT
Kristen Barrio MD
Nikki Waller, MD
Ellen Roberts PhD, MPH
Jan Busby-Whitehead, MD
Center for Aging and Health
With Support from The Donald W. Reynolds Foundation,
John A. Hartford Foundation & American Geriatrics Society
© The University of North Carolina at Chapel Hill, Center for
Aging and Health
Precise Evaluation: The answers
Kevin Biese MD, MAT
Kristen Barrio MD
Nikki Waller, MD
Ellen Roberts PhD, MPH
Jan Busby-Whitehead, MD
Center for Aging and Health
With Support from The Donald W. Reynolds Foundation,
John A. Hartford Foundation & American Geriatrics Society
© The University of North Carolina at Chapel Hill, Center for
Aging and Health
Acute Abdominal Pain in the Elderly:
Significant Mortality and Morbidity
• ≥65 years old (yo) and come to the ED with acute
abdominal pain
– 50% admission
– 33% surgery
– Mortality 10% (similar to ST elevation myocardial infarction)
Kizer KW, Am J Emerg Med 1998; 16: 357-62.
Geriatric Abdominal Pain: Different Causes
Final Diagnosis
Biliary Tract
Nonspecific
Age <50
6%
40%
Age > 50
21%
16%
Appendicitis
Bowel Obstruction
Pancreatitis
32%
2%
2%
15%
12%
7%
Diverticular
Cancer
Hernia
Vascular
<.1%
<.1%
<.1%
<.1%
6%
4%
3%
2%
Gyn
Other
4%
13%
<.1%
13%
Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York: McGraw-Hill; 2000.
Case 1 Ultrasound
Case 1: Cholecystitis
• #1 abdominal surgical emergency in elderly
• Incidence increases with age
• Often only epigastric pain (foregut innervation is
visceral)
• LFTS often not helpful
• Ultrasound is study of choice
Cholecystitis: Are LFTs Helpful?
Trowbridge RL. JAMA. 2003; 289(1): 80-86.
Case 2
Insert picture of CT scan with mesenteric ischemia
Case 2
Insert picture of CT scan with mesenteric ischemia
Case 2: Mesenteric Ischemia
• Classically pain out of proportion to exam
• Risks include atrial fibrillation, hypercoagulable,
low-flow, increasing age
• Arterial (usually) or venous
• Embolus or thrombosis
• Sometimes “intestinal angina”
• Usually superior mesenteric artery
• Multi-detector CT scan 77-90% sensitive
• Elevated lactate is a late finding (check >1 time)
Newman TS. AmSurg. 1998; 64: 611-16.
Horton KM. Radiographics. 2002: 22; 161.
Emedicine 2006
Case 3: GI Bleed - Syncope
• DO A RECTAL EXAM
Case 4: Fall/Pain Management
• Pain related complaints are common among elderly
patients
– Approximately 7 million US ED visits/year are due
to acute pain in patients >65
• Persistent pain has been associated with functional
decline, falls, death
Platts-Mills TF, Esserman DA, Brown
DL, Bortsov AV, McLean SA. Ann
Emerg Med. 2012 Aug;60(2):199206.
Case 4: Fall/Pain Management
• Studies have reported that pain is
undertreated in elderly patients
– One recent analysis showed >1/2 of all patients >75, 1/3rd
with severe pain that presented with a pain related
complaint were not given analgesic
– Patients >75 approx 19% less likely to receive pain meds
than pts aged 35-54 years
Platts-Mills TF, Esserman DA, Brown
DL, Bortsov AV, McLean SA. Ann
Emerg Med. 2012 Aug;60(2):199-206.
Case 4: Fall/Pain Management
• Strategies for treating pain
– Involve patient and the family in treatment
options
– Consider non-pharmacologic approaches
– Scheduled acetaminophen
– Start low and titrate slow with opioids and avoid
preparations with acetaminophen
– Anticipate side effects ( especially constipation,
nausea, tiredness) if going to prescribe opioids
– Ensure close follow-up
Kapo JM. Persistent Pain. In: Pacala JT, Sullivan
GM, eds. Geriatrics Review Syllabus. 7th ed.
New York: American Geriatrics Society; 2010
Geriatric Trauma: Mechanisms
• Falls - most common
– Balance, strength, vision
– Often worse than they seem
• MVC – most fatal
– Judgment, vision, reaction times
– Crash fatality rates are much higher
• Burns- 1/5 of all burn unit admissions
– Mortality estimate = age + % burn
Geriatric Trauma: Complicating Factors
• Past medical history
– Cardiac and pulmonary disease limit physiological
response to stressors
– Vital signs are difficult to interpret
• Medications
– Anticoagulant use
– Beta blockers
• Cause of the event
– MI, syncope, stroke,
hypoglycemia, suicide attempt
Geriatric Trauma: Triage
• Geriatric trauma patients are under-triaged
pre-hospital, in violation of paramedic
protocols
• Improved outcomes with lower threshold
for trauma activation for geriatric trauma
• Focus on trauma triage!
Ma, J Trauma, 1999
Demetriades, 2002
Rib Fractures
If >65 with 3 or more rib fractures, admit;
if >6 rib fractures, ICU
Bergeron, J Trauma 2003
Case 4
• What would have compelled you to obtain a
head CT?
Insert picture of CT scan with subdural hematoma
Warfarin and Elderly ICH
• Blunt head trauma on warfarin no symptoms,
7-14% with ICH
• Beware DASH (Delayed Acute Subdural
Hematoma) – consider observation even if
negative head CT (especially INR >4)
• Patients frequently supra-therapeutic INR
– 11% with INR >5 =Check INR
• Risk of spontaneous ICH on warfarin 0.35.4%
• Frequent medication interactions
– (>700 interactions including fluoroquinolones)
Callaway, Emerg Med 2007
Aggressive Warfarin protocol
82 patients/ 19 with ICH
Initiation of reversal from 4.3 to 1.9 hours
Mortality from 48% to 10%
Ivascu, J Trauma 2005
Case 5:Delirium 2° ASA Toxicity
• Delirium:
– Acute onset with fluctuating course
– Need to know the baseline
• Call the referring facility
– Vital sign of older adults
Case 5: CAM
http://jajsamos.files.wordpress.com/2011/03/cam-delirium-flow-chart.jpg
Mini - Cog
Rapid assessment cognitive impairment
Less subject to language and education
Detects mild impairment
www2f.biglobe.ne.jp
Benzodiazepines for Acute Agitation
• Avoid entirely if possible
– see Beers Criteria Table 2
– Appropriate if being used to treat alcohol
withdrawal
• May cause a paradoxical reaction in the elderly
– Increasing agitation and anxiety
– May lead to prescribing cascade (ie. antipsychotic
use)
• Long-acting
– Prolonged half-life in older adults (days)
• Benzodiazepines are lipophilic
– Sedation, aspiration, delirium
– Increased risk of falls and fractures
Beers criteria Table 2: JAGS 2012 Apr;60(4):616-31
Case 5: Treating agitation
Consider non-pharmacologic
treatment first
Rule out delirium
Avoid physical restraints
Use oral route if possible
Use lowest effective dose and
repeat if needed (60 min)
Benzodiazepines within 1-2 hours
of IM olanzapine are
contraindicated
Avoid benzodiazepines unless
seizures or withdrawal
Cardiac history required with IM
ziprasidone
Increased risk of QT prolongation
with haloperidol given IV
Reorientation
Modify environment
Attend to basic needs
Risperidone ≤ 1 mg PO
Olanzapine 2.5-5 mg PO/IM (NO BZDs with IM)
Quetiapine ≤ 50 mg PO
Haloperidol 1-2.5 mg PO/IM
Ziprasidone 10-20 mg
IM
Haloperidol 0.25-1 mg
IV
Lorazepam 0.5-1 mg
(PO, IM, IV)
Tintinalli J, et al. Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York: McGraw-Hill; 2014
Case 5: ASA Toxicity
• Tinnitus, N/V, confusion, pulmonary edema
• Mixed metabolic acidosis and respiratory
alkalosis
• Chronic toxicity more common in elderly and
often missed
• Possible etiology of delirium
Take Home Points
• GEM is its own subspecialty with unique and
evolving knowledge base and skills
• To avoid pitfalls
– Be wary - don’t under triage (particularly trauma and
always “blood thinners”)
– Acute abdominal pain is often life threatening
– Utilize Mini Cog and ICU CAM
– Delirium means something is wrong
– Treat pain, intelligently
– Treat agitation, gently
– Prepare for care transitions
• You can be an excellent physician by taking extraordinary care of your older patients