Referral to the ER and Surgery in the Elderly Flashcards
ED referrals
o If you can refer directly to definitive care and avoid the ED you should.
o Patients sent to the ED for lack of social support suffered a 1-year mortality of up to 34%
ED visits generally
o In the first 3 months after an index ED visit: 5% of discharged elder ED patients will die, 20% will require hospital admission, 20% require another ED evaluation, 10% to 48% suffer decline in functional abilities. This high incidence of poor outcomes despite PCP follow-up suggests a complexity of need that far out spans the episodic ED visit
o These outcomes suggest the underlying issue is not the acute event for which the ED was designed, but a quiet ongoing process
ABCs of an ED visit
o A for Airway compromise: the inability to move air through the mouth, nose, and upper airway into the lungs, as seen in stridor, mucosal edema, unconsciousness, anaphylaxis, and foreign body.
o B for Breathing : includes evaluation of respiratory rate. Danger exists at the extremes of <10 breaths/min or 30 and over breaths/min, or if the O2 saturation is <93% on room air.
o C for Circulation : includes signs of decreased organ perfusion such as diaphoresis, new altered mental status, and cyanosis. Shock can be heralded by pulse <50 beats/min or >120 beats/min, or by a systolic BP <90 mm Hg.
o D for (neurologic) Disability : noted by new decreased mental status, Glasgow coma scale47 <13, or stroke-like symptoms.
A: airway/SOB
o Acute shortness of breath
o DDX: requiring ED includes myocardial ischemia/infarction, COPD, congestive heart failure (CHF), pneumonia, pulmonary embolism, bronchitis, and dysrhythmia
o If you cannot exclude a life threatening cause of dyspnea, or you cannot stabilize an acute exacerbation of disease, your patient needs the ED!!!
COPD exacerbations
o most often triggered by a viral or bacterial infection, cold weather, narcotic use, CHF, or anemia, among other triggers.
o The most life-threatening components of an exacerbation are hypoxemia and hypercarbia
COPD treatment: to ED
o Noninvasive positive pressure ventilation (NPPV): Indicated for moderate to severe exacerbations as determined by worsening tachypnea >25 breaths/min, dyspnea with accessory muscle use, moderate to severe acidosis (pH<7.35), or hypercapnia (PaCO2 > 45mm Hg)
o Mechanical ventilation: if a patient continues to deteriorate despite all the above interventions, endotracheal intubation is the next required therapy.
Syncope
o vasovagal or orthostatic hypotension syncope (or drug induced orthostasis) with a correctable cause has no increased risk for future adverse events
o For orthostatic hypotension, hydration and re-evaluation is prudent.
o any patients with structural heart disease, heart failure, abnormal ECG, anemia, or symptoms not consistent with benign causes of syncope are at high risk for adverse effects and should be hospitalized.
Head trauma
o Cerebral atrophy—even in the presence of apparently normal cognitive function—is common in elderly or old people. The brain (close to liquid at normal temperatures) moves more in the event of a car crash or fall, increases the chance of hemorrhage.
o Also free space, intracranial hemorrhage (ICH)—by failing to cause raised intracranial pressure—produces little or none of the expected neurologic clinical picture but, the mortality rate is 30% to 80%, even for a fall from standing height.
head trauma and the ED
o Even in minor head trauma, vomiting indicates increased risk of ICH. Anticoagulation dramatically increases morbidity, mortality and difficulty of treatment.
o Expedient trauma evaluation of apparently stable elders improves survival.
o In elderly trauma, severe organ damage can occur at normal blood pressures, and the death rate goes up if the systolic is less than 110.
Trauma prompting an ER visit
o risk of injury/death increases after age 55 years
o SBP <110 might represent shock after age 65 years
o low impact mechanism (e.g., ground level falls) might result in severe injury
o high risk of rapid deterioration in anticoagulated patients with head injury
Stroke
o An acute stroke is a time critical process in which “time is brain.”
o The 2012 American Heart Association/American Stroke Association (AHA/ASA) guidelines for the management of acute stroke has increased the time for rtPA administration to 4.5 hours from symptom onset.
o A door to needle time of <60 minutes is emerging, Interventions delivered early in the course of stroke can prevent or decrease damage to critical brain structures preserving function.
Stroke diagnosis
o Physical exam can vary from gross unilateral paralysis to subtle findings easily overlooked
o Traditional symptoms of stroke include unilateral paralysis of face, arm, legs, sudden confusion, aphasia, memory deficits, severe headache, or dizziness.
o Atypical symptoms may include loss of consciousness, pain, palpitations, altered mental status, and shortness of breath.
o Most popular scales used by EMS systems are: Cincinnati Prehospital Scale (CPS: 66% sensitve) and the Los Angeles Prehospital Stroke Screen (LAPSS 91% sensitive).
o most common mimics are: seizures, confusional states, syncope, toxins, neoplasms, subdural hematomas. Hypoglycemia can also cause neurologic deficits and must always be excluded
o history should focus on time of onset of symptoms given tPA administration depends on the length of duration of symptoms.
stroke: diagnosis/management
o Presentation of hemorrhagic versus ischemic stroke can be identical
o point of care glucose right away to exclude hypoglycemia
o If identified begin transfer to the closest stroke center
o oxygen, obtaining IV access, or giving fluid to hypotensive patients is appropriate as long as it does not delay the transfer process.
acute abdomen: causes
o In general, there are four main categories of a surgical acute abdomen: o (1) peritonitis o (2) perforated viscus o (3) bowel obstruction o (4) vascular
Sepsis definition
o difficult to quantify due to inconsistency in the definition of sepsis
o infection frequencies in ED elders as follows: pneumonia (25%); urinary tract infection (22%); and sepsis and bacteremia (18%)
o Vital signs consistent with serious illness are: T >39.4°C (102.9°F), RR > 30, P >120
o Clinical findings associated with serious illness were WBC >11 or presence of an infiltrate
o Shaking chills, DM, major comorbidities, AMS, abdominal pain, and vomiting are all predictive of bacterial infection
SIRS (systematic inflammatory response syndrome
o Scale: sepsis, severe sepsis, and septic shock
o SIRS: defined as having at least two out of the four following criteria: Heart rate >90, Respiratory rate >20 (or PaCO2< 32), Temperature <36°C or >38°C (<96.8°F or >100.4°F), Leukocyte count (WBC) >12 or <4, or with >10% bands
sepsis: sliding scale
o Sepsis is defined as having SIRS along with a suspected source of infection.
o Severe Sepsis is defined as sepsis plus either cardiovascular organ dysfunction or acute respiratory distress syndrome or dysfunction of two or more other organs. (NO LONGER EXISTS)
o Septic Shock is sepsis along with hypotension of systolic BP < 90 despite appropriate fluid resuscitation (at least 40cc/kg).
sepsis: diagnosis
o ABCs and check vital signs
o risk stratify
o Physical exam: source of infection hypoperfusion? dry mucous membranes, hypoxia, poor capillary refill, and other signs of shock or organ failure
o Ancillary testing: CXR, UA C&S, CBC, CMP, blood gas, lactate, and ECG
o CRP may be used as an early marker for infection in elderly adults but not specific!!!
sepsis: management
o Administer oxygen, control temperature, and address analgesia as needed
o Treat Focal infections, if not sepsis, defer ED.
o Antibiotics: Direct therapy for known source, or empiric therapy for unknown source ASAP
o If septic: transfer to ED, where they will…
o aggressive IVF, broad abt, +/− intubation, central venous pressure monitoring through placement of a central line, and hemodynamic management.
o In shock, both vasoactive and ionotropic agents are used, possible blood transfusions
