The Geriatric Patient The EM Perspective Advice from a neophyte
Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.
Mrs. Nagy 78 F Renal Colic U/A +rbc s Mr. Jagr 85M AMS U/A +LE/N Mr. Gulyas 75 M Gen Malaise BP 110/75
65
Geriatrics
20% List the challenges of a geriatric patient in the emergency department. Identify specific key elements in investigation of a geriatric patient in the emergency department.
Differences...let me count the ways
I can go from normotensive to hypotensive in a heartbeat. Things Geri-pts say My subdural haematoma hasn t expanded enough yet to really affect my level of consciousness. Trauma is not really my major problem. I get demand ischaemia if I have too much pain or my haematocrit drops or I can t stand even a little shock or hypoxia and neither can my myocardium. The sensitivity of my abdominal examination is better that flipping a coin but not much. A little medication goes a long way with me Major trauma? Heck, I wouldn t even tolerate a brisk haircut. My injuries weren t accidental.
Differences not many > 65 yrs < 65 mo ED Hx? Exam? Labs? ED Hx? Exam? Labs?
Don t look now, but that gentle lapping at your toes is the first hint of the silver tsunami coming soon to an emergency department near you. -Dr. Diane Birnbaumer
~ 25%
> 65 yrs 75%
> 85 yrs 85%
Hospital > 65 yrs 20% > 85 yrs 30%
Half of all calls! Trauma Cardio/Respiratory LOC Abdominal pain AMS
Besides the ABC s Need to have the talk Surprising answers
Advice #1 Clinical atypical is typical
worst-first approach
Clinical atypical is typical Late presentation -physiology -fears independence/ death History will be difficult VS Bloodwork
Clinical atypical is typical Acute Cholecystitis WBC 40% LFTS 30% Afebrile 50% Appendicitis/Diverticulitis WBC 50% Afebrile 50% Exam: non-specific ACS AMS
Advice #2 Get to know your surgeon
Get to know your surgeon 50% 30%
SBO.50% diarrhea POOP: Pain Out Of Proportion AAA Extraabdominal Causes Forget Dg s Gastro Constipation Renal colic Abdo Pain NYD
Advice #3 Get to know your radiologist and learn US
Radiology A picture is worth the 1000 words.but 60% 50%
CDR s No man s land
Mrs. Nagy 78 F Renal Colic Mr. Jagr 85M AMS Mr. Gulyas 75 M Gen Malaise
Nemeth Dogma Don t diagnose a diagnosis of exclusion Befriend a radiologist Befriend a surgeon
Dizzy Dix-Hallpike It is a misconception that vertigo that is worsened by head/body movement (including Dix-Hallpike maneuver) is the result of a peripheral cause such as BPPV. However, the exacerbation of symptoms with head movements have been reported in all causes of vertigo (Kubo, 1988). Others experts argue that patients with dizziness from ANY cause will feel worse with certain position changes (Kerber, 2009). Therefore, the characteristic that distinguishes BPPV is not simply an exacerbation of vertigo by head movement, but rather, vertigo that is triggered by positional changes, lasts less than one minute, and then returns to normal between attacks (Kerber, 2009). otic symptoms (hearing loss, tinnitus, ear fullness, etc.), which strongly suggests peripheral etiology however recent hyper-extension injury ortrauma associated with neck pain Hard focal neurological signs (i.e., hemiplegia, hemisensory loss, ataxia, dysarthria, ophthalmoplegia, etc.) clearly point to a central etiology, but unfortunately are found in only approximately 50% of patients with posterior strokes
Dizzy Nystagmus of peripheraletiology is generally found to be horizontal in nature and unidirectional Head Impulse testing, bi-directional Nystagmus, and Test of Skew. In their prospective, crosssectional study, they performed the HINTS exam at the bedside of 101 patients in an academic hospital stroke center to try and differentiate between those patients with central versus peripheral etiologies of their vertigo. Later they confirmed their diagnoses using MRI with diffusionweighted imaging. They concluded that the presence of either a normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, OR skew deviation was 100% sensitive and 96% specific for stroke. Patients with central vertigo must have at least one of the 5 Ds (Dizziness, Diplopia, Dysarthria, Dysphagia and Dysmetria) or long tract signs. Stroke may present as isolated vertigo with only minor gait disturbance without any of the 5 Ds or long tract signs. #2: Unidirectional nystagmus is always a sign of peripheral vertigo. While unidirectional nystagmus usually points to a peripheral cause, it can occur with central causes of vertigo. Unidirectional nystagmus does not, on it s own, rule in a peripheral cause. If nystagmus is definitely multidirectional, or purely vertical with no rotatory component the cause is almost certainly central. The HINTS exam can help differentiate a peripheral vs. central cause of acute vestibular syndrome, although this is not perfect
4 types of vertigo (based on duration of symptoms): Less than 60sec: Positional event (MARKEDLY worse with movement) Minutes (few to 30): If not positional: migraine (in young, low-risk patients) or TIA/CVA (in older, at-risk patients) Many hours: Vestibulopathy, Ménière s disease Days: Labyrinthitis, or stroke Crossed syndromes, consisting of ipsilateral cranial nerve dysfunction and contralateral long motor or sensory tract dysfunction are highly characteristic of posterior circulation stroke CT but MRI!!