#EuSEM2018 – Day 2

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

 

 

Leave a Reply

Your email address will not be published. Required fields are marked *

fifteen + 11 =

This site uses Akismet to reduce spam. Learn how your comment data is processed.