Category: frailty
#NoF – Beware Occult Hip Fractures
Studies suggest around 1% of hip fractures are missed on plain X-ray. So as usual you must combine clinical and radiological findings. Read more
Delirium in the ED
Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.
3 subtypes of delirium
- Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
- Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
- Mixed
Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!! Read more
Acute Behavioural Disturbance / Excited Delirium
Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.
- High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
- Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
- Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
- Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC
Refusing treatment = Mental Capacity Assessment [LINK]
| Drug | Route | Typical Dose (mg) | Onset (min) | Duration (min) | Warning |
|---|---|---|---|---|---|
| Midazolam | IV | 2-5 | 1-5 | 30-60 | Respiratory depression, IM unpredictable onset |
| IM | 5 | 10-15 | 120-360 | ||
| Lorazepam | IV | 2-4 | 2-5 | 60-120 | |
| IM | 4 | 15-30 | 60-120 | ||
| Haloperidol | IV | 5-10 | 10 | 180-360 | Arrhythmia Risk: Only if previously used OR ECG |
| IM | 10-20 | 15-30 | 180-360 | ||
| Ketamine | IV | 1-2mg/kg | 1 | 20-30 | Theoretical risk of worsening cardiovascular instability |
| IM | 2-4mg/kg | 3-5 | 60-90 |
PDF:abd
#NoF – Fractured Neck of Femur
BOAST Guidance
- #NoF patients (or other fragility fracture) who requiring CT Head (for head injury) also be performed a CT Neck
- Fragility fractures indicate the patient is at high risk of also sustain C-Spine injury.
- Also the pain is likely distracting and the patient is often over 65yrs old so Canadian C-Spine rules will not apply.
Hx/Exam
- Why did They Fall? – was this a collapse?
- Are they sick? – Co-morbidity/illness is common in this group and must be recognised
- Anticoagulants? – This affects treatment
- On Warfarin – If INR >1.5 (or unavailable) Vit-K 5mg
- Other injuries? – >65’s the most common mechanism of TARN major trauma is fall <2m
- Typically – Pain hip/buttock, shortened, externally rotated
- Atypical – Few signs (can they lift their leg & is rotation at the hip painful)
Silver Trauma
The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:
- The typical major trauma patient: has changed from a young and male to being an older patient.
- Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
- Triage/Recognition of ‘Silver Trauma’ is POOR
- Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
- The ED: Often seen by Junior Staff and endure significant treatment delays.
- Hospital: Much less likely to be transferred to specialist care.
- Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.
