Transcript Document 7188251

Geriatric Emergencies
March 20, 2008
Mark Scott
Objectives
 Physiological changes of aging
 Polypharmacy
 Approach Atypical Presentations
 Chest pain
 Abdominal pain
 Geriatric Trauma
Geriatric Patients are Challenging
(McNamara et Al, Annals Emerg Med 1992)
 Survey of 485 Emergency physicians
 45% had difficulty diagnosing and treating elderly pts.
 Difficult presentations included: chest pain,
dizziness/vertigo, fever without focus, headache, trauma,
altered LOC, and abdominal pain)
 Majority believed lack of research and CME, and time
spent during residency were inadequate.
Geriatrics
 Rapidly expanding subset of the population
 >65 incr from 12% to 20% of population
 >85 will grow by 500%
 Utilize more medical resources
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We use 90% of healthcare resurces in last 10 yrs of life
Spend more time in ED
More likely to receive ancillary tests
Higher admission rate
Higher use of ambulance
Geriatrics
 Have higher morbidity
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From cardiac ds.
Abdominal emergencies
ICH
Sepsis
Trauma
 More likely to present atypically
Physiological Changes of Aging
 Cardiac
 Elevated BP
 Decreased HR
 Decreased CO
 Respiratory
 Reduced compliance and func reserve
 Decreased mucociliary clearance
 MSK
 Increased calcium loss from bone
 Decreased muscle mass, cartilage
 Neurologic:
 Increased wakefulness
 Decreased brain mass, cerebral blood flow
 Impaired balance
Physiological Changes of Aging
 Other
 Endo
 GI
 Eyes
 Renal
 Skin
- Blunted B-adrenergeic response
- Increased NE, PTH, Insulin
- prolonged transit time
- decreased splanchnic blood flow
- Decreased Ca, Fe absorption
- presbyopia, cataracts, IOP
Case 1
86 M “weak and dizzy”
HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained
ground level fall with no LOC.
PMHX: MI, OA, BPH, afib
Meds: ASA 81mg po od
Ramipril 5mg po od
Atorvastatin 20mg po od
Acetaminophen 500mg po q6h
lorazepam 1mg po hs
warfarin 4mg po od
dimehydrinate 25mg po q6h
Could a medication be the cause this presentation?
Beer’s Criteria (Fick et Al, Arch Int Med, 2003)
 Guidelines for inappropriate, in-effective, and dangerous
medication for age >65yrs.
 Development based on extensive evidence and expert
opinions
 Revised over past 10 yrs
 Identified 48 medication/classes to avoid, and
 20 medications contra-indicated for specific conditions
Beer’s Criteria (Fick et Al, Arch Int Med, 2003)
 List includes:
 Indomethacin (CNS effects)
 Ketorolac (GI bleeds)
 Muscle relaxants (sedation)
 Amitriptyline (anticholinergic Sfx, Fall risk)
 Diphenhydramine (anticholinergic SEs)
 Long acting Benzos (sedation and falls)
 Meperidine (CNS toxicity)
PolyPharmacy
 Persons over the age of 65 are taking an average of 4.2 Rx
meds and 2.1 OTCs.
 Over 30% will develop an adverse drug-related event.
PolyPharmacy (Hohl et al, Ann Emerg Med 2001)
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Chart review of 283 .>65 pts presenting to the ED
ADRE occurred in 10.6%
31% had at least 1 PADI
Most common culprit meds: NSAIDs, Abx, anticoagulants, diuretics,
hypoglycemics, B-blockers, Ca-channel blockers, chem Tx agents.
 ADRE are under-diagnosed and can lead to serious morbidity.
Back to Case 1
86 M “weak and dizzy”
HPI: 4 d hx of n/v/d taking gravol for nausea. Sustained
grouud level fall with no LOC.
PMHX: MI, OA, BPH, afib
Meds: ASA 81mg po od
Ramipril 5mg po od
Atrovastatin 20mg po od
Acetaminophen 500mg po q6h
lorazepam 1mg po hs
warfarin 4mg po od
dimehydrinate 25mg po q6h
Case 2
76 M Epigastric pain and fatigue x 12hrs
HPI: mild orthopnea, no asso’d sx
PMHX:DM, blind
RF: no HTN, 40pack year hx smoke, N lipids, no
FMhx
ROS: N bowels, no RFs for PUD or colon CA, no
surgical hx.
Meds: none
PE: T 36.8, HR 92reg, RR20, BP 145/87, 96%RA
Abdo soft, non-tender, no organomegaly
Case 2 - ECG
Myocardial Infarction in the Elderly
 Elderly are more likely to have silent or atypical
presentations of MI
 Mortality from MI is higher in the geriatric population
MI in the Elderly
(canto et Al. JAMA 2000)
 Prospective observational study of 434877 pts from 1674
hospitals
 33% did not have CP, more in the elderly subset
 Pts without CP had longer delay to hospital presentation, in
hospital mortality, less likely to receive thrombolysis of
PCI, and less likely to received medical therapy.
MI in the Elderly
(canto et Al. JAMA 2000)
Suspect MI in patients presenting with:
 Atypical chest pain: arm,
jaw, abdominal pain (+/nausea)
 Acute functional decline
 Dyspnea
 Syncope
 Confusion
 Vomiting
 Weakness
 CHF
 Fatigue
Case 3
81 M Severe generalized Abdo pain
HPI: sudden onset 2hrs ago, 9/10 periumbilical, nonradiating. Emesis x1, no bowel or bladder symptoms
ROS: no melena/hematochezia
PMHX:HTN, OA, smoker, appy 70yrs ago
Meds: HCTZ, ibuprofen
PE: T 37.4, HR 105reg, RR20, BP 106/75, 98%RA
Abdo soft, diffusely tender, no peritoneal signs, no
organomegaly, +FOBT
Abdominal Pain in the Elderly
 ED physicians rate abdo pain in elderly as one of
most challenging presentations.(McNamara et al, 1992)
 Symptoms often vague or atypical
 Wide ddx
 Abdo pain associated with much higher morbidity
and mortality in elderly.
Abdominal Pain in the Elderly
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75% will get a diagnosis in the ED
63% will be admitted
20% will go to the OR
60% of causes of abdominal pain in elderly are
surgical
 6-8x the mortality compared with younger pts (brewer
et Al 1976)
Use of CT in Older Patients with acute
abdominal Pain
 Prospective Obs study of 337 pts over the age of 60 with abdo pain
 Objectives:
 Prevalence of use of CT in this population
 Describe most common diagnostic findings
 Determine proportion of CT scans in this population
Hustey et al 2005
 CT ordered for 37%
 57% of results were diagnostic
 31% non-diagnostic
 12% normal scans
 75% of pts with diagnostic scans had medical or surgical
interventions
 5.6% of pts had medical intervention with normal CT
 0% of pts with normal CT had surgical intervention
CT Results of elderly pts. presenting with
acute Abdo pain (n=71)
Findings
SBO or ileus
# of abdo CT scans, n
(%, 95%CI)
13 (18%, 10-29%)
Diverticulitis
13 (18%, 10-29%)
Urolithiasis
7 (10%, 4-19%)
Cholelithiasis/systitis
7 (10%, 4-19%)
Abdo mass
6 (8%, 3-18%)
Pyelonephritis
5 (7%, 2-16%)
Pancreatitis
4 (6%, 2-14%)
Appendicitis in the Elderly
• Atypical presentations are common
• Storm-Dickerson et al. (Am J Surg 2003) Case
series of 113 patients 60 or older
 30% had no RLQ AP
 67% afebrile
 26% no WBC and 56% had no left shift
 54% of time admitting diagnosis was wrong
(21% dx = diverticulitis and 16% bowel
obstruction)
Require high index of suspicion and lower
threshold for CT
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Ischemic Colitis
Mesenteric ischemia
Venous disease
(mesenteric venous thrombosis)
Arterial disease
Occlusive
(Superior mesenteric artery obstruction)
Non-occlusive
(low flow state)
thrombotic
embolic
Mesenteric Ischemia
4 types:
• Superior Mesenteric Artery occlusion most common
• Acute emergency (bowel infarcts in 2-3hrs)
• Pain out of proportion, pain prior to emesis
• Peritoneal findings are a late, ominous sign
• Thrombotic (15%): RFs for vascular disease, trauma, infection
• Embolic (50): RFs for embolic CVA (Valvular HD, recent MI,
arrhythmias)
• May also occlude vessels of colon
• Lower abdo pain, hematochezia
Mesenteric Ischemia
Investigations:
• Serum lactate 90% Sn (even better if serial lactate). SP
~67%.
• CT scan 85-92% Sp, but only 71-77% Sn
• May see wall thickening >3mm, or pneumatosis intestinalis)
• May have +WBC or +FOBT, metabolic acidosis
• Angiogram is imaging of choice (Sn 88-98%, Sp 95%)
• If considering - perform early, even with only moderate pain.
Mesenteric Ischemia
Mesenteric Ischemia
Acute Mesenteric Ischemia Angiography
 Considered the gold standard
 Invasive and time consuming
 Early and aggressive angiography has been shown to
decrease mortality from acute mesenteric ischemia (Boley
et al. Surgery 1997)
 Must be willing to accept many negatives to implement
 >90% Sn and >95% Sp
Mesenteric Ischemia
Mesenteric Ischemia
4 types con’t:
• Mesenteric Venous Thrombosis (think Abdo DVT)
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10%
Occurs in younger patients
Amenable to diagnosis with noninvasive CT
Lower mortality
Treated with immediate anticoagulation
Non-occlusive Mesenteric Ischemia (think abdo shock)
 25%
 Associated with low flow states (e.g. CHF) which improves with improvement of
CO
Possible Approach to Imaging
 Low to Moderate Risk
 Screen with CT scan and confirm
indeterminates with Angiography
 High Risk
 Emergent angiography
(RL)
Mesenteric Ischemia - Treatment
 Resuscitation
 Empiric antibiotics
 Superior Mesenteric Artery Embolism
 Angiography, intra-arterial thrombolytics, vasodilators
 Embolectomy, bowel resection
 Superior Mesenteric Thrombosis
 Graft, bypass, bowel resection, +/- thrombolectomy
 Mesenteric Venous Thrombosis
 Anticoagulation with heparin
 Thrombolectomy, bowel resection
 NOMI
 Papaverine infusion with angiography, +/- resection, +/- ASA
Mesenteric Ischemia
 Overall mortality >60%
 More lethal than MI or CVA
 Mesenteric artery thrombosis > mesenteric artery
embolism > mesenteric venous thrombosis
Case 4
74 F unrestrained passenger MVC (car vs.
tree)
HPI: distracted driver drove into tree at
60kph. Head-on collision, no loc. c/o
central chest pain.
10 Survey: seat belt sign to chest,
otherwise nil
Vitals: HR65, 130/60, 22, 94%RA, c/s
5.2
PMHX: HTN, OA, hyperlipidemia
Meds: Ramipril, Metoprolol, lipitor,
ibuprofen
Geriatric Trauma
 Only 12% of total trauma is >65yrs but,
 25% of hospitalization, 36% ambulance transfers, and
25% total trauma costs
 Much higher mortality in elderly
 1 yr mortality following traumatic hip # is 50%
 Case fatality rate for MVC vs pedestrian (>65) is 53%
Geriatric Pts . . .
 Have unreliably “Normal” vitals in setting of shock
 Take medications to blunt compensatory mechanisms
 More prone to development of morbid conditions
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ICH
Fracture
Difficult airway
Sepsis, particularly pneumonia
Anemia
Cardiogenic shock
 Early invasive monitoring and rapid correction of
shock state improves survival
 Small study but good design
 Highlights importance of high index of suspicion
and aggressive management.
Summary
 Geriatric pts confer much higher morbidity and
mortality
 Polypharmacy is here to stay! Be aware.
 Atypical is typical for common presentations
 Fever, MI, abdo pain, etc
 Have lower threshold for invasive investigations
and aggressive management.
References
1.
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McNamara et Al. Annals of Emerg Med. Volume 21, Issue 7, July 1992,
Pages 796-801
Tintinelli
Amal Mattu. EM Rap: Abdominal Emergency in the Elderly. May 2006