![]() Case 1 - Is that Tube in the Right Place?
Case 2 - Locked-In
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![]() Organic vs Non-organic etiologies
Delerium vs psychosis:
Work-up:
Therapy:
![]() Definitions
- https://www.cia.gov/library/publications/the-world-factbook/ - http://www.doingbusiness.org/ - http://www.lonelyplanet.com
Pediatric Disaster Medicine and Triage - Noste
![]() Cyanide
![]() Gastric Perforation 13 yr old female w/ abdominal pain - recent admission for abdominal pain with EGD (with biopsies taken). Became hypotensive, tachycardic, lactate 3.5 - surgery consulted & CT showed gastric perforation.
Hypotension - Beta Block Toxicity 49 y/o male from rehab - was found obtunded and hypotensive w/ BP 60/20 > ESRD dialysis patient > Hypothermic w/ temp of 93, pulse 59, BP 60/18; answering questions > Labs relatively unremarkable, EKG basically unchanged, CXR with pulmonary vascular congestion > List of meds reviewed - a LOT of antihypertensives including 1600 mg of labetolol in the past 24 hrs
Wernickes Encephalopathy 57 yr old "drunk" from medic > Normal vital signs, hx of COPD cirrhosis GERD and no meds > Wide based gait & tremulous & confused; while at rest normal neuro exam > Wernickes Encephalopathy - got thiamine and got better - Thiamine i500 mg iV over 30 minutes - At risk patients - anyone prone to malnutrition - Clinical diagnosis - consider with 2/4 nutritionally deficient, ocular findings, encephalopathy, ataxia ![]() ACEP 2013 Guidelines DO’s 1. Take repeat blood pressures during your patient’s stay in the ED 2. Fast track patients with severely elevated blood pressures (>180/110) to a PCP 3. Start a patient on a maintenance oral antihypertensive if BP severely elevated a. BUT REMEMBER! i. Get a BMP ii.Think about their comorbidities DONT’s 1. HARMFUL! Do NOT give acute antihypertensives (i.e. clonidine, IV drugs) to asymptomatic patients. 2. Send home patient’s WITHOUT any follow up Limitations of ACEP 2013 Guidelines: Do NOT apply these guidelines to patients who have symptoms that may be indicative of a hypertensive emergency, pregnant patients, or patients with end stage renal disease. ![]() Pt with Syncope... what should you do? 1. Obtain 12 lead EKGs on patients of all ages with history of syncope. (Level A Evidence) 2. According to ACEP Clinical Policy on Syncope, Laboratory testing and advanced investigative testing (such as ECHO and CT Head) need NOT be routinely performed unless guided by specific findings in the history or physical exam (Level C evidence). 3. There are multiple Risk Stratification Tools for syncope, including San Francisco, Rose, OESIL, EGSYS, and Boston, which have varying levels of sensitivity and specificity. The Boston Guidelines are the newest set of guidelines which have highest sensitivity at 100%. 4. ACEP's Clinical Policy of Syncope state the following four criteria for considering patients "high risk" following a syncopal event: 1. Older age with associated co-mordities, 2. Abnormal EKG, 3. Hct < 30, 4. History or presence of heart failure, CAD, structural heart disease ![]() QUICK HIT CORE CONCEPTS
***Mortality in trauma increases dramatically with increased age, inc 7% mortality for each year over 65 in trauma ***Liver disease is the worst premorbid condition for trauma ***Standard trauma assessment is inadequate in elderly, particularly vital signs insensitive ***Falls: 10% significant injury, in geraitric population cervical spine fractures common ***Have decreased cardiac output, may not be able to mount adequate tachycardic response, may have occult shock. Have consideration for peri-traumatic MI both prior to trauma or stress of trauma causing MI ***Pulmonary issues: Decreased reserve, increased risk ARDS and atelectasis, CO2 narcosis ***CNS: High risk of subdural, clouded by questionable baseline mental status ***Renal: Often baseline poor GFR, CT Contrast can cause significant injury ***Trauma triage poor in elderly: Age >55 should be at a trauma center ***CMC TRAUMA ACTIVATION for geriatrics ATC 1:: Age >65: HR>100, SBP<110 ALERT:: Age >65 involved in MVC or fall from height ***MANAGEMENT Airway: Increased aspiration risk. Consider dentures. Consider high cervical spine risk and maintain proper imobilization. Consider increased response to induction agents: decreased your dose. Breathing: Decreased reserved, rapid desaturation. Use passive oxygenation. Use ETCO2. Consider increased risk of rib fractures. Circulation: Decreased response to catechols, on beta blockers; may not mount tachycardia appropriately. Consider RELATIVE hypotension. --Journal trauma study shows HR >90 and SBP <110 significant increased in mortality Disability: Central cord syndrome more common in elderly, may have "Hand burning", will have upper extremity weakness and capelike paresthesia ***SHOCK INDEX HR/Systolic blood pressure Normal less than 0.6, realistic threshold <0.8 More sensitive than HR or BP alone Even better: Shock index * Age should be <50 ***If concerned about fluids, use repeated small boluses (250ml) ***Anemia: Follow serial hemoglobins and transfuse early. Transfusion threshold controversial, starting thinking about it around 8 or persistent hypotension ***History: Keep in mind precipitating events, syncope in 10-15% of geriatric fall/MVC ***Identify blood thinner use!! Coumadin, plavix, ASA, Anti 10A, anti thrombin ***CAREFUL chest exam: Must identify rib fractures, flail chest; XRAY low sensitivity for these. Traumatic aortic dissection often does not have external signs of injury. ***Abdomen: Geriatric may NOT develop peritonitis despite significant intraabdominal injury ***LABS: Always get lactate; highly predictive of bad outcome >2 admit, >3 ICU, >4 call chaplain. (40% mortality in lact >4) Upgrade to ATC 2 if INR >2 or Lactate >2.5 ***ECG Routine in geriatric trauma ***Careful with opiates in elderly, start low doses ***Head trauma: 80% mortality if GCS<8 Any anticoagulation with head trauma = scan ***Anticoag reverse> Coumadin, see protocol Antithrombin: May try FFP but pretty much screwed Anti Xa: PCCC may be beneficial (see protocol for dosing) ***Rib fractures: Risk of atelectasis, resp faulire, pneumonia Admit if >3 rib fx. Consult if 1 or more if frail, live alone, any concern really ***Elderly aorta Eggshell appearance distant from border of aorta may indicate dissection (Egg shell or Halo sign) ***Pelvic fx mortality 50% if hypotension, 90% if open. Eval for hemoperitoneum and aortic rupture ***Burns.. Baux index: Mortality = age + TBSA. Age >50 with bad burns, = burn center **BEWARE Cold and quiet, elderly trauma patient! ![]() HIGH YIELD CONCEPTS:
- Bifacet dislocation - Type II odontoid fracture - Hangmans fracture - distraction & rotation injury - posterior element of C2 gets fractured & spondylolisthesis of axis - Flexion Teardrop - most serious of all Cspine fractures ![]()
> 1/4 to 1/3 of patients with sepsis don't manifest 2/4 SIRS criteria > SIRS can be helpful when present but the absence of SIRS doesn't rule out sepsis
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