Foamcastini – Do We Make Saves?

ITUNES OR LISTEN HERE

We are at SMACC in Dublin – thanks to the Rosh Review, an excellent board review question bank.

Do We Make Saves?

Dr. Mervyn Singer “Is Survival Predetermined in the Critically  Ill?”

  • Many critical care studies are negative, but in some cases this may be because critically ill patients don’t have a uniform prognosis.
  • Dr. Singer argues that some people may be “destined to die” and some may be “destined to live.”  Interventions may be harmful or futile in one group but beneficial in the other.  For example, Dr. Singer references the CORTICUS trial of steroids in septic shock [1]. This was a negative trial.  Dr. Singer asserts that some evidence (of not great quality), purports that the sickest patients could benefit from steroids, while this same intervention could be deleterious in the healthier ones.
  • Problem: many of the studies that go back and re-analyze these groups looking at the sickest or least sick patients? They perform subgroup analyses, a form of data dredging that must be taken with a huge grain of salt.

Favorite Pearls

Dr. Suzanne Mason – “Acute Care of the Elderly”

  • Hospital admission may not benefit geriatric patients – interdisciplinary interventions involving nurses, consultants, pharmacists, physical therapy may be best.
  • If there is a single, free intervention that providers can do it’s assessing for polypharmacy. Polypharmacy in the elderly is a huge problem.  Check the patient’s medication list and beware adding new medications that may not be absolutely necessary.

Dr. Victoria Brazil – “So You Think You’re a Resuscitationist?”

  • The Dunning-Kruger effect is real in medicine and this is why we MUST have and provide feedback.  A review of the Dunning-Kruger effect can be found here.  Essentially, people tend to overestimate what they know (i.e. overly confident in their knowledge). The exception?  Masters tend to underestimate their knowledge.

Screen Shot 2014-03-15 at 9.36.53 AM

  • Our perception of reality is very skewed so, again, feedback is crucial. For example, Cemalovic and colleagues found that intubators underestimated the time they took to intubate: they estimated 23.5 seconds on average vs the 45.5 seconds intubation actually took. Additionally, they thought 13% of their patients desaturated during intubation but 23% actually desaturated [2].

Also, there was an excellent tribute to the late Dr. John Hinds, a reminder that by living profoundly, you can impact people across the world.

References

  1. Sprung CL, Annane D, Keh D et al. Hydrocortisone Therapy for Patients with Septic Shock. N Engl J Med. 358(2):111-124. 2008. [article]
  2. Cemalovic N, Scoccimarro A, Arslan A, Fraser R, Kanter M, Caputo N. Human factors in the emergency department: Is physician perception of time to intubation and desaturation rate accurate? Emergency medicine Australasia : EMA. 28(3):295-9. 2016. [pubmed]
PlayPlay

Episode 42 – End of Life

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We cover an EMcrit episode on Semantics of End of Life Discussions with Dr. Ashley Shreves as well as pearls from another favorite episode with her, Episode 93 – Critical Care Palliation.  We can’t do these episodes justice summarizing them so listen to them. (Update:  Apparently these podcasts were taken down due to personal reasons. From what we understand you may be able to obtain a copy by contacting the EMcrit site).

Screen who to have “the conversation” with looking for patients with signs of instability:

  • 85 y/o and older
  • dementia/frailty
  • advanced cancer/disease

Key conversational points:

  • Lead with, ” I’m so worried about (the patient).”
  • “What do you think your (mom/dad/etc) would say about how she is now?”
  • “Got it.”  Whether a family member agrees or disagree, let them know you heard them.

If a patient/family member are overly optimistic about the patient getting better one can try, “Many people find it helpful to talk about what would we should do if (the patient) doesn’t get better.”

Respect patient/family values that differ from yours.  If the patient’s family just wants the heart beating regardless, and that’s ok.  Per Dr. Shreves, this population is 5-10% and may be called “vitalists.”

Another key point Dr. Shreves emphasizes is that palliative care, comfort care, and allowing a natural death often mean escalating care – ensuring the patient is comfortable, clean, etc.

Core content 

We delve into core content on vertigo using Rosen’s Medicine (8e) electronic chapter, “End of Life,”  and Tintinalli’s Emergency Medicine: A Comprehensive Study Guide  (7e) Chapter 297 “Death and Dying.”

DNAR (Do Not Attempt Resuscitation) –  technically only speak to a patient’s wishes to receive CPR [3].  Problematic for several reasons, including:

  • Issue lies in the word “resuscitate,” which may be used to include fluids, antibiotics, vasopressors, advanced means of ventilation or, at the extreme, CPR.  The AHA guidelines have moved to DNAR from DNR but even this language isn’t clear.
  • Major societies are moving towards the language AND, Allow Natural Death [4].
    • AND is preferred because it describes what happens and is more clear, is kinder language laden with reduced guilt
  • The TRIAD II-IV studies surveyed EMS personnel, physicians, and medical students respectively and provided the participants with an advance care directive as well as case scenarios.  The participants then indicated whether a patient was a DNR or full code and the appropriate action.  Both physicians and EMS providers performed poorly and variably, indicating that the directives were not clear [5-7].

Palliative care and hospice are not interchangeable.  Palliative care has a more broad definition and

  • Palliative care: “An approach that improves quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual ” [1].  There is no time limit in this scenario.
  • Hospice care: subset of patients that a doctor has estimated likely has 6 months or less to live [1].

Opioid Equivalents

Many terminally ill patients or those at the end of their life are on chronic opioids.  While the opioid epidemic is a problem, this is not the appropriate population from which we should withhold appropriate analgesia. It can be difficult to convert between dosages to adequately treat a patient’s pain.  Here’s a free calculatorScreen Shot 2016-01-21 at 8.04.21 AM

References

  1. Online Chapter. End of Life. In: Marx JA, Hockberger RS, Walls RM eds.  Rosen’s Emergency Medicine, 8th e.
  2. Chapter 297. Death and Dying. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
  3. Dugdale DC. .Do Not Resuscitate Orders.”  MedlinePlus Medical Encyclopedia.
  4. Breault JL. DNR, DNAR, or AND? Is Language Important? Ochsner J. 2011;11(4):302
  5. Mirarchi FL, Kalantzis S, Hunter D, McCracken E, Kisiel T. TRIAD II: do living wills have an impact on pre-hospital lifesaving care? J Emerg Med. 2009;36(2):105–15. doi:10.1016/j.jemermed.2008.10.003.
  6. Mirarchi FL, Costello E, Puller J, Cooney T, Kottkamp N. TRIAD III: nationwide assessment of living wills and do not resuscitate orders. J Emerg Med. 2012;42(5):511–20. doi:10.1016/j.jemermed.2011.07.015.
  7.  Mirarchi FL, Ray M, Cooney T.  TRIAD IV: Nationwide Survey of Medical Students’ Understanding of Living Wills and DNR Orders. J Patient Saf. 2014 Feb 27.
  8. Gurwitz JH, Lessard DM, Bedell SE, Gore JM. Do-Not-Resuscitate Orders in Patients Hospitalized With Acute Myocardial Infarction. 2014;164.
  9. Adams DH, Snedden DP. How misconceptions among elderly patients regarding survival outcomes of inpatient cardiopulmonary resuscitation affect do-not-resuscitate orders. J Am Osteopath Assoc. 2006;106(7):402–4.
PlayPlay

Episode 19 – Environment: Mushrooms and Hypothermia

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We review the Tox Talk podcast, Episode 23 – Mushrooms.  Our favorite pearls:

Clitocybe, Inocybe – contain muscarine which stimulates muscarinic receptors (acetylcholine/parasympathetic), causing a cholinergic toxidrome. Think SLUDGE (salivation, lacrimation, urination, defecation, gastric emptying/emesis) and the Killer B’s (bradycardia, bronchorrhea, bronchospasm) or DUMBELLS (diarrhea/diaphoresis, urination, miosis, bradycardia, emesis, lacrimation, lethargy, salivation). Basically, cholinergic toxidrome: SMALL, WET, SLOW.

  • Memory aid: these mushrooms end in -yBE, akin to the “killer B’s” that make cholinergic toxicity deadly.

Gyromitra – (false morel) contains gyromitrin which can cause seizures, in addition to gastrointestinal upset and liver failure.  Treatment: pyridoxine (B6).

  • Memory aid: gyromitra named because they look like the gyri of the brain and, conveniently, make the brain seize through depletion of GABA.

Amanita phalloides – contains amatoxins which cause delayed gastrointestinal symptoms and liver failure., echoing acetaminophen toxicity.

  • Caution: this is different than the amanita muscaria ‘mushroom, which is tricky because that amanita muscaria has neither muscarinic properties nor the toxicity of amanita phalloides.

Bonus pearl: Coprinus species can cause a disulfiram like reaction.

FOAM article on mushrooms by Jo et al

The Bread and Butter

We summarize some key topics from the following readings, Tintinalli (7e) Chapter  ; Rosen’s 8(e) Chapter  – but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

Hypothermia starts at 35°C and then is categorized based on severity.

Pearls:

  • Ethanol + hypothermia = bad news.  Ethanol is the most common cause of excessive heat loss in urban areas as people tend to not take warming measures, may be homeless or without heat, and have impaired thermoregulation.  Hypothermia also slows alcohol metabolism, making people drunker for longer.
  • Elderly patients are more susceptible to hypothermia, particularly as they may not sense the cooler temperatures.  Some may also have impaired thermoregulation.
  • Have a low threshold

Diagnostics:

  • Get a temperature, on all patients.  This applies to patient’s “found down” as well as the chronic alcoholic who just seems really drunk.
  • If patients aren’t rewarming 1°C/hr and they’re above 32°C, consider: sepsis, cortisol deficiency, myxedema, ethanol.
  • The J wave or “Osborn” wave is found in many cases of hypothermia, often quoted at ~80%.  However, it is not pathognomonic for hypothermia.
From the Rosh Review

Treatment: Warm the patient.  Don’t call the patient dead until they’re warm and dead, which means their temp is above 30-32°C.

Screen Shot 2014-11-22 at 9.30.13 PM

Passive Rewarming – effective when the patient can still shiver (33-35°C).

  • Generates ~1.5°C of heat/hr

Active Rewarming – direct transfer of heat to the patient.

  • Indications: Cardiovascular instability, temp ≤30-32° C, inadequate rate of rewarming or failure to rewarm, endocrine problem, trauma, tox, secondary hypothermia impairing thermoregulation
  • Can be external or internal (which can be minimally invasive like IV fluids or quite invasive with things like bypass or pleural lavage).

Outcomes

  • Unlikely survival with a potassium > 12 mmol/L and recommendations are to terminate resuscitation for potassium >12 mmol/L and consider cessation for potassium between 10-12 mmol/L

FOAM Resources:

EBM Gone Wild on Prognostication

ScanCrit on ECMO in Accidental Hypothermia

EMCrit on Severe Accidental Hypothermia

Generously Donated Rosh Review Questions (Scroll for Answers)

Question 1.  A 40-year-old man with a history of substance abuse is brought in by EMS after being found unconscious outside of a nightclub in the middle of winter. It is unclear how long he was outside. He is unresponsive with a GCS of 3.[polldaddy poll=8469565]

Question 2.  What is the most common cause of death in hypothermic patients after successful resuscitation?

Question 3.

[polldaddy poll=8473489]

Question 4. What abnormal rhythm is common with temperatures below 32°C?

References:

Danzl DF, Zafren K. Accidental Hypothermia, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2013, (Ch) 140: pp 1883-1885.

Brown D JA, Brugger H, et al. Accidental Hypothermia. N Engl J Med 2012;367:1930-1938.

Mair P, Kornberger E, et al. Prognostic markers in patients with severe accidental hypothermia and cardiocirculatory arrest. Resuscitation 1994;27:47-54.

Answers:

1. D. When the serum potassium is greater than 12 mmol/L resuscitative efforts should be halted as the patient is unlikely to survive and further efforts constitute futile care. Accidental hypothermia is not an uncommon occurrence particularly in colder climates. It may occur in conjunction with substance abuse when an individual becomes impaired and is subsequently exposed to the outdoors. It can also occur as a result of drowning, avalanche and other trauma. Bio-makers other than potassium have been studied including serum lactate (B), pH (C) and clotting time. None have been proven prognostically reliable and therefore should not be used as a guide to determine if resuscitation should be continued. Hypothermic patients that present in cardiac arrest should be warmed to a minimum of 32°C (A) preferably via ECMO or cardiopulmonary bypass. However, if a hypothermic patient is warmed to 32°C and remains in asystole, recovery is unlikely and resuscitative efforts should be terminated. Other indications to cease resuscitative efforts include: obvious signs of irreversible death (e.g. major trauma), valid DNR order, conditions that are unsafe for the rescuer or provider, and an avalanche burial > 35 minutes in which the airway is packed with snow and the patient is asystolic.

2. Pulmonary edema.

2. C. Hypothermia. The ECG demonstrates the presence of J waves or Osborn waves which are seen in hypothermia. One of the first cardiac effects of hypothermia is bradycardia secondary to decreased firing of the cardiac pacemaker cells in cold temperatures. Osborn waves may appear at any temperature below 32°C. The waves are an upward deflection at the terminal portion of the QRS complex. They may represent abnormal ion flux in cold temperatures along with delayed depolarization and early repolarization of the left ventricular wall. As temperatures continue to drop, the ECG will demonstrate prolonged intervals: PR, followed by QRS and then QTc. Both diabetic ketoacidosis (A) and digoxin toxicity (B) may lead to hyperkalemia. In diabetic ketoacidosis, hyperkalemia develops as a result of the acidic pH in the blood and the transport of hydrogen ions intracellularly in exchange for a potassium ion. Digoxin toxicity poisons the cellular Na+/K+ ATPase resulting in elevated extracellular levels of potassium. The ECG manifestations of hyperkalemia begin with peaked T waves. Multiple other findings eventually develop including a shortened QT interval, ST depression, bundle branch blocks, widened QRS, prolonged PR interval, flattened T wave and ultimately a sine wave. Hyperparathyroidism (D) may lead to hypercalcemia. In hypercalcemia, the ECG shows a shortened QT interval, flattened T waves and QRS widening at very high levels.

4.  Atrial fibrillation.

PlayPlay

Episode 18 – Falls and Geriatrics

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We review Dr. Ken Milne’s podcast, The Skeptic’s Guide to Emergency Medicine Episode #89,  special episode on falls in the geriatric.  This episode is the first in the HOP (Hot Off the Press) series in which Dr. Milne has paired with Academic Emergency Medicine and the Canadian Journal of Emergency Medicine to review a paper, with the author, the same week the paper is published.

Why HOP is special:

  • Reducing the knowledge gap by disseminating hot-off- the press
  • Concurrent peer review from global audience.  Peer review is a flawed process and in this way, Dr. Milne takes his skeptical perspective to the paper and the author.
  • Key comments from social media will then be published in these journals, reaching the traditional academic readership.

Pearls from the Carpenter et al systematic review

Fall Statistics:

  • Fall Rates – > 65 y/o – 1 in 3 people fall per year; > 80 years old – 1 in 2 people fall per year
  • Elderly patients who fall and are admitted have a 1 year mortality of ~33% [1,3]. So, geriatric falls are bad, it seems logical to wish to predict who is going to fall.

Predictors of Falls:

  • The best negative likelihood ratio (-LR) was if the patient could cut their own toenails –LR 0.57 (95% CI 0.38-0.86) (remember, the target for a -LR is 0.1). This outperformed traditional assessments like the “get up and go test.”
  • Previous history of falls is a big predictor of falls.  Of elderly patients who present to the ED with a fall, the incidence of another fall by 6 months later is 31%.  Of those patients who present with a fall as a secondary problem,14% had another fall within 6 months.
  • The Carpenter instrument has a promising -LR of 0.11 (95% CI = 0.06-0.20) but has not been validated
    • Carpenter instrument: Nonhealing foot sores, self-reported depression, not clipping one’s own toenails, and previous falls

The Bread and Butter

We summarize some key topics from the following readings, Tintinalli (6e) Chapter 307 (This chapter was removed from the seventh edition) ; Rosen’s 8(e) Chapter 182 – but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

Abdominal Pain Abdominal pain in the elderly is much higher risk than the younger cohort. This is complicated by vague presentations.  Abdominal pain in the elderly often causes one to raise an eyebrow and ponder chest pathology such as an atypical presentation of ACS.  However, the converse can also be true.  Chest discomfort may really reflect intra-abdominal pathology.  Bottom line – presentations are vague and badness is common.

Geriatric abdominal pain stats:

  • Fever and WBC unreliable.  Per Rosen’s “Elders with potentially catastrophic intra-abdominal processes may not present with a fever or an elevated white blood cell count.”
  • Much higher risk than younger patients – 2/3 patients admitted and 1/5 go directly to the operating room.
  • Most common serious pathologies:  Biliary pathology (cholecystitis), small bowel obstruction, appendicitis.
  • Vascular pathologies such as abdominal aortic aneurysm (AAA) and mesenteric ischemia also have an important place in the differential given increased incidence in the elderly.

FOAM resources:

Polypharmacy  Elderly patients are often on a host of medications but have physiologic alterations that make them susceptible to increased adverse events.

  • 12-30% of admitted elderly patients have adverse drug reactions or interactions as a primary or major contributing factor to their admission and 25% of these drug reactions or interactions are serious or life-threaten
  • Garfinkel et al demonstrated that reducing medications in elderly nursing home patients may actually be better for their health.
  • Some of the highest risk medications, in general, for our elderly patients: diuretics, nonopioid analgesics, hypoglycemics, and anticoagulants.  A patient’s presentation (syncope, fall) may be a manifestation of a medication side effect.
  • There are many high risk pharmaceuticals in the ED, but be very cautious of: narcotics, nonsteroidal anti-inflammatory agents, sedative-hypnotics, muscle relaxants, and antihistamines.
    • NSAIDS – patients may have reduced renal function and due to loss of lean muscle mass, creatine may not be accurate and NSAIDs may tip the patient into renal insufficiency. These drugs may also worsen hypertension and congestive heart failure as a result of salt retention.  NSAIDs are also associated with gastrointestinal bleeding.  Be cautious – acetaminophen is the safer bet.
    • Narcotics – may predispose patients to falls (which are bad in the elderly).  These drugs may also constipate patients, which can cause abdominal pain.  Give guidance and make sure the patient has a solid bowel regimen.
  • Start low and go slow.  It’s much easier to add doses of medications than clearing excess medications.
  • Cautiously start new medications. Furthermore, as drugs may be responsible for the patient’s symptoms that brought them to the ED, review the medication list. If possible, consider discussing discontinuation of medications with the patient’s PCP.

FOAM resources:

Delirium – Delirium in the elderly ED patients is associated with a 12-month mortality rate of 10% to 26% [5].  Be wary of chalking up alterations in mental status to dementia or sundowning.

 

Generously Donated Rosh Review Questions (Scroll for Answers)

Question 1. [polldaddy poll=8443367]

Question 1. An 87-year-old woman presents to the ED after her caregiver witnessed the patient having difficulty swallowing over the past 2 days. The patient is having difficulty with both solids and liquids. She requires multiple swallowing attempts and occasionally has a mild choking episode. She has no other complaints. Your exam is unremarkable. [polldaddy poll=8443380]

Bonus Question: What proportion of elderly patients with proven bacterial infections lack a fever?

References:

1.Carpenter CR, Avidan MS, Wildes T, et al. Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review. Acad Emerg Med. 2014 Oct;21(10):1069-1082.

2. “The Elder Patient.” Chapter 182.  Rosen’s Emergency Medicine, 8e.

3.  “The Elderly Patient.” Chapter 307.  Tintinalli’s Emergency Medicine: A Comprehensive Review, 6e.

4. Garfinkel D1, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.  Isr Med Assoc J. 2007 Jun;9(6):430-4.

5. Gower LE, Gatewood MO, Kang CS. Emergency Department Management of Delirium in the Elderly. West J Emerg Med. May 2012; 13(2): 194–201.

Answers:

1.D.  Physiologic changes of aging affect virtually every organ system and have many effects on the health and functional status of the elderly. Compared to healthy adults, elderly patients have a decreased thirst response that puts them atincreased risk for dehydration and electrolyte abnormalities. Cell-mediated immunity (A) is decreased, which increases susceptibility to neoplasms and a tendency to reactivate latent diseases. Peripheral vascular resistance (B) is increased contributing to development of hypertension. Sweat glands (C) are decreased in the elderly, which puts them at risk for hyperthermia.

2.B.  Dysphagia can be divided into two categories: transfer and transport. Transfer dysphagia occurs early in swallowing and is often described by the patient as difficulty with initiation of swallowing. Transport dysphagia occurs due to impaired movement of the bolus down the esophagus and through the lower sphincter. This patient is experiencing a transfer dysphagia. This condition is most commonly due to neuromuscular disorders that result in misdirection of the food bolus and requires repeated swallowing attempts. A cerebrovascular accident (stroke) that causes muscleweakness of the oropharyngeal muscles is frequently the underlying cause.
Achalasia (A) is the most common motility disorder producing dysphagia. It is typically seen in patients between 20 and 40 years of age and is associated with esophageal spasm, chest pain, and odynophagia. Esophageal neoplasm (C)usually leads to dysphagia over a period of months and progresses from symptoms with solids to liquids. It is also associated with weight loss and bleeding. Foreign bodies (D) such as a food bolus can lead to dysphagia, but patients are typically unable to tolerate secretions and are often observed drooling. These patients do not have difficulty in initiating swallowing.

Bonus. Up to one half.

PlayPlay

Episode 18 – Falls and Geriatrics

(ITUNES OR LISTEN HERE)

The Free Open Access Medical Education (FOAM)

We review Dr. Ken Milne’s podcast, The Skeptic’s Guide to Emergency Medicine Episode #89,  special episode on falls in the geriatric.  This episode is the first in the HOP (Hot Off the Press) series in which Dr. Milne has paired with Academic Emergency Medicine and the Canadian Journal of Emergency Medicine to review a paper, with the author, the same week the paper is published.

Why HOP is special:

  • Reducing the knowledge gap by disseminating hot-off- the press
  • Concurrent peer review from global audience.  Peer review is a flawed process and in this way, Dr. Milne takes his skeptical perspective to the paper and the author.
  • Key comments from social media will then be published in these journals, reaching the traditional academic readership.

Pearls from the Carpenter et al systematic review

Fall Statistics:

  • Fall Rates – > 65 y/o – 1 in 3 people fall per year; > 80 years old – 1 in 2 people fall per year
  • Elderly patients who fall and are admitted have a 1 year mortality of ~33% [1,3]. So, geriatric falls are bad, it seems logical to wish to predict who is going to fall.

Predictors of Falls:

  • The best negative likelihood ratio (-LR) was if the patient could cut their own toenails –LR 0.57 (95% CI 0.38-0.86) (remember, the target for a -LR is 0.1). This outperformed traditional assessments like the “get up and go test.”
  • Previous history of falls is a big predictor of falls.  Of elderly patients who present to the ED with a fall, the incidence of another fall by 6 months later is 31%.  Of those patients who present with a fall as a secondary problem,14% had another fall within 6 months.
  • The Carpenter instrument has a promising -LR of 0.11 (95% CI = 0.06-0.20) but has not been validated
    • Carpenter instrument: Nonhealing foot sores, self-reported depression, not clipping one’s own toenails, and previous falls

The Bread and Butter

We summarize some key topics from the following readings, Tintinalli (6e) Chapter 307 (This chapter was removed from the seventh edition) ; Rosen’s 8(e) Chapter 182 – but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

Abdominal Pain Abdominal pain in the elderly is much higher risk than the younger cohort. This is complicated by vague presentations.  Abdominal pain in the elderly often causes one to raise an eyebrow and ponder chest pathology such as an atypical presentation of ACS.  However, the converse can also be true.  Chest discomfort may really reflect intra-abdominal pathology.  Bottom line – presentations are vague and badness is common.

Geriatric abdominal pain stats:

  • Fever and WBC unreliable.  Per Rosen’s “Elders with potentially catastrophic intra-abdominal processes may not present with a fever or an elevated white blood cell count.”
  • Much higher risk than younger patients – 2/3 patients admitted and 1/5 go directly to the operating room.
  • Most common serious pathologies:  Biliary pathology (cholecystitis), small bowel obstruction, appendicitis.
  • Vascular pathologies such as abdominal aortic aneurysm (AAA) and mesenteric ischemia also have an important place in the differential given increased incidence in the elderly.

FOAM resources:

Polypharmacy  Elderly patients are often on a host of medications but have physiologic alterations that make them susceptible to increased adverse events.

  • 12-30% of admitted elderly patients have adverse drug reactions or interactions as a primary or major contributing factor to their admission and 25% of these drug reactions or interactions are serious or life-threaten
  • Garfinkel et al demonstrated that reducing medications in elderly nursing home patients may actually be better for their health.
  • Some of the highest risk medications, in general, for our elderly patients: diuretics, nonopioid analgesics, hypoglycemics, and anticoagulants.  A patient’s presentation (syncope, fall) may be a manifestation of a medication side effect.
  • There are many high risk pharmaceuticals in the ED, but be very cautious of: narcotics, nonsteroidal anti-inflammatory agents, sedative-hypnotics, muscle relaxants, and antihistamines.
    • NSAIDS – patients may have reduced renal function and due to loss of lean muscle mass, creatine may not be accurate and NSAIDs may tip the patient into renal insufficiency. These drugs may also worsen hypertension and congestive heart failure as a result of salt retention.  NSAIDs are also associated with gastrointestinal bleeding.  Be cautious – acetaminophen is the safer bet.
    • Narcotics – may predispose patients to falls (which are bad in the elderly).  These drugs may also constipate patients, which can cause abdominal pain.  Give guidance and make sure the patient has a solid bowel regimen.
  • Start low and go slow.  It’s much easier to add doses of medications than clearing excess medications.
  • Cautiously start new medications. Furthermore, as drugs may be responsible for the patient’s symptoms that brought them to the ED, review the medication list. If possible, consider discussing discontinuation of medications with the patient’s PCP.

FOAM resources:

Delirium – Delirium in the elderly ED patients is associated with a 12-month mortality rate of 10% to 26% [5].  Be wary of chalking up alterations in mental status to dementia or sundowning.

 

Generously Donated Rosh Review Questions (Scroll for Answers)

Question 1. [polldaddy poll=8443367]

Question 1. An 87-year-old woman presents to the ED after her caregiver witnessed the patient having difficulty swallowing over the past 2 days. The patient is having difficulty with both solids and liquids. She requires multiple swallowing attempts and occasionally has a mild choking episode. She has no other complaints. Your exam is unremarkable. [polldaddy poll=8443380]

Bonus Question: What proportion of elderly patients with proven bacterial infections lack a fever?

References:

1.Carpenter CR, Avidan MS, Wildes T, et al. Predicting Geriatric Falls Following an Episode of Emergency Department Care: A Systematic Review. Acad Emerg Med. 2014 Oct;21(10):1069-1082.

2. “The Elder Patient.” Chapter 182.  Rosen’s Emergency Medicine, 8e.

3.  “The Elderly Patient.” Chapter 307.  Tintinalli’s Emergency Medicine: A Comprehensive Review, 6e.

4. Garfinkel D1, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people.  Isr Med Assoc J. 2007 Jun;9(6):430-4.

5. Gower LE, Gatewood MO, Kang CS. Emergency Department Management of Delirium in the Elderly. West J Emerg Med. May 2012; 13(2): 194–201.

Answers:

1.D.  Physiologic changes of aging affect virtually every organ system and have many effects on the health and functional status of the elderly. Compared to healthy adults, elderly patients have a decreased thirst response that puts them atincreased risk for dehydration and electrolyte abnormalities. Cell-mediated immunity (A) is decreased, which increases susceptibility to neoplasms and a tendency to reactivate latent diseases. Peripheral vascular resistance (B) is increased contributing to development of hypertension. Sweat glands (C) are decreased in the elderly, which puts them at risk for hyperthermia.

2.B.  Dysphagia can be divided into two categories: transfer and transport. Transfer dysphagia occurs early in swallowing and is often described by the patient as difficulty with initiation of swallowing. Transport dysphagia occurs due to impaired movement of the bolus down the esophagus and through the lower sphincter. This patient is experiencing a transfer dysphagia. This condition is most commonly due to neuromuscular disorders that result in misdirection of the food bolus and requires repeated swallowing attempts. A cerebrovascular accident (stroke) that causes muscleweakness of the oropharyngeal muscles is frequently the underlying cause.
Achalasia (A) is the most common motility disorder producing dysphagia. It is typically seen in patients between 20 and 40 years of age and is associated with esophageal spasm, chest pain, and odynophagia. Esophageal neoplasm (C)usually leads to dysphagia over a period of months and progresses from symptoms with solids to liquids. It is also associated with weight loss and bleeding. Foreign bodies (D) such as a food bolus can lead to dysphagia, but patients are typically unable to tolerate secretions and are often observed drooling. These patients do not have difficulty in initiating swallowing.

Bonus. Up to one half.

PlayPlay