Very Geri’s heavy day today @ #EuSEM2018 but lots to think about, and even squeezed in a bit of USS

 

Geriatrics

Gait is an observation

• Timed Up and Go test – get up from chair walk 6m turn and come back, over 10s is a marker of frailty
• Also mortality – same predictive value as RR>25 or sBP of 90mmHg

Sepsis in the >70’s

• WE miss it! – because screaning is poor (NEWS/MEWS/qSOFA/etc all have an area under ROC 0.5-i.e. rubbish)
• WE under-treat it ! – we are scared of giving too much fluid (DON’T BE, give up to 2l but in small bolus according to response)
• sBP in higher in the elderly – Dutch study mean sBP 140mmHg in >70’s
  • Odds Ratio (OR) of hospital mortality in elderly sepsis
    • sBP >140mmHg (OR = 1) i.e. no increased mort
    • sBP 139-120mmHg (OR = 2) i.e. mortality doubled
    • sBP 119-100mmHg (OR = 3)
    • sBP <100mmHg (OR = 4) – on current guidance this is were we get excited when the chance of death has quadrupled?
• Other things that increase Odds of mortality in elderly sepsis
  • RR >25bpm (OR = 2.4)
  • Ur > 8mmol/l (OR = 1.9)
  • CRP >100 (OR = 2ish)
  • Lac >3.5 (OR = 3.6)

#urosceptical

• Is it really a UTI? – without symptoms of UTI such as fever dysuria, frequency we shouldn’t blindly treat the dipstick. 6% of men and 17% of women >65yo will have (asymptomatic bactourea)
• Catheters KiILL –  catheterising an elderly patient carries a 1% mortality, 10% will get catheter associated infections. Treat the cause and question if it is needed.

Troponin & AMI

• >85yo only 40% of AMI present with Chest Pain
• CP is more likely to be severe and more likely to die – Obviously
• Base-line Troponin increases with age  – study showed women 65yo base-line trop was 24 rising to 53 by 85yo (this was similar for men)
• Age-Adjusted Trop? – NO, unlike D-Dimer evidence shows too many missed AMI’s, also an elevated trop for any reasons a predictor of mortality.
• Is it just an elevated base-line? – maybe, but serial troponin will tell you (AMI is dynamic so depending on timing you will see increasing trop, or a fall if they present very late)
• What type of MI?
  • Type 1 – plaque rupture (a classic MI) – needs ACS meds
  • Type 2 – supply and demand problem (i.e. fast AF, hypoxia, sepsis) – treat the cause
  • However, what came first the pulmonary oedema or the elevated trop (i.e. did a type 1 cause failure or tdid the failure cause at type 2) there is no easy way to find out.

 

Falls

• We only see 1/4 of falls in ED – it may feel like we see every single fall but across our patch there will be 28’000 elderly falls a year (65-80 1:3 will fall each year, >80 1:2 will fall)
• Postural BP Pitfalls – not just 2 quick BP’s
  • Do BP @ 0, 1, 3, 5 min
  • Monitor HR – look for reflex tachys
  • Be aware of transient drops – if you monitored an art line instead you would see drops in the BP that last seconds that can cause the patient to fall.
  • Is the patient symptomatic? – if the patient is symptomatic even without a postural drop (found) its likely a transient drop you have missed and we need to consider reviewing their hypertensive meds
  • Don’t admit ALL postural drops – in the elderly population it’s very common if you’re asymptomatic and have nothing else to cause admission you probably don’t need  admission.
• Phtobia – a fear of falls (not problems with bright light) sets off a spiral of decline[ fall>fear>reduction activity>weakness>falls]
• Look for a cause and the look for a second – there are 4 common reasons to fall, if we look we might modify the risk
  • Proprioceptive failure – neuropathy, joint problems, spinal issue
  • Muscle Strength
  • Visual problems – do the glasses fit, have the right prescription, are they clean
  • Vestibular – what drugs are we giving to make them unsteady?
• Prevention – evidence shows it takes 50 hours of physio to prevent a fall, or £3000 of investment to prevent a single fall in the community (thats £84 million a year just in our patch).
• They will fall again – as prevention is very difficult we must except they will fall again, physio can help but don’t forget the pragmatic stuff.
• When to stop anticoagulants due to recurrent falls– evidence apparently suggests the benefits of anticoagulants is only lost if you fall >300 x a year [but it needs to be individualised to the risks of the patient and what they fear most, strokes of bleeds]

Delirium

• Look for delirium! – 4AT an 6-CIT seem like reasonable tools
• Hyperactive, Hypoactive & Mixed types– hyperactive has the best prognosis because we have to pay attention and treat it.
• Look for the medical causes
• Use common sense – avoiding catheters, getting family to them, maintained a normal sleep-wake cycle, quiet – Can reduce delirium by 30%. (easier said than done)

Silver trauma

• 2017 trauma demographics in UK changed – the most common Major trauma (ISS >15) type was Female, >65 & fell <2m (previously male, young, RTC)
• Trauma triage doesn’t pick up  – comes to us, seen by juniors and picked up late
• Should there be 2 pathways? – High energy (traditional) and Low energy (current)
• Low threshold for scans
• 30% of over 80yo with major trauma have a good outcome.

London major trauma – worth a look

www.geriemeurope.eu

 

Ultrasound

POCUS for heart failure

• Combining clinical hx/exam with focus +LR 37, -LR 0.03
  • clinical only +LR 8.6 -LR 0.2
  • POCUS only +LR 14, -LR 0.1
• Bilat B lines in 2 zones each side
• BNP’s– BNP +LR 9, ntpro BNP +LR 3
• Delayed echo is fine – recommended by ECS 2017
• pocusireland
• thepocusatlas

TOE in Resus

• mostly irrelevant to us as we don’t have
• BUT – RV dilatation common in cardiac arrest and doesn’t always mean PE

Finding intra abdominal air

• Interesting technique that could be good but will need time and training