Three large scale multi-centre trials into Severe Sepsis and Septic Shock:ProCESS (USA), ARISE(Aus), ProMISe(UK), all showed the same thing. What works is good early resuscitation (Not the fancy stuff from ICU – however, that does have its place later on).
As we all know frailty and care of older patients is becoming a more and more important in the ED. The elderly population is growing rapidly and as you age your health costs shoot up.
The study day not only highlighted several import areas of care within ED, but also how relatively small interventions/conversations can make significant differences.
Think Home First:
What is stopping them going home?
What tests will guide your decision making? (don’t just investigate because you can)
Get them up (you don’t need to wait for physios)
Do the easy stuff: Feed, Water, Toilet, Communicate
DON’T create barriers: e.g. catheters, exessive testing
Ask for help: Local service are your friend
Topics
Population & Costs
Increasing aging population:
Costs as we age:
Life Expectancy
Life Expectancy:
Average life expectancies are often longer than you imagine and after 100yrs life expectancy increases!
80yr woman – 10yr
85yr woman – 7yr
90yr woman – 5yr
99yr woman – 2yr
However, Clinical frailty score is often more predictive.
Frailty Trajectory and Life Expectancy
Study shows that the rate of change in frailty has a significant impact on life expectancy. People with “Stable” growth in frailty score remaining at their base line but the faster the CFS changes more impact that has.
So its worth asking how things have changed over the last year.
Trauma
Frailty has a significant influence on recovery and mortality in relation to both “MINOR” and “MAJOR” trauma.
Rib injury is probably more important than most of us realise – suggesting 15% increase in mortality for every rib a frail person fractures. JRCALC have since updated guidance to recommend “rib spring” rather than “gentle palpation” in examination.
Silver Trauma Review Clinic:
Mater hospital Dublin have introduced a review clinic for patients following significant traumas.
Mater hospital – Adult only ED
90’000 attendances/yr
10.5WTE ED consultants
Major Trauma Centre
Silver Trauma Review Clinic
Weekly clinic sees 10 patients/week
Follows up: trauma patients discharged with non-operative management or post admission
Team: EM, Geris, Frailty ACP, Physio
Main work: Thoracic, Spinal, humeral, pelvic injuries
Requires access to DEXA and MRI (they MRI all spinal injury through clinic not only to age but also find other diagnosis)
“Decisions about not resuscitating a patient, or about putting a DNACPR notice on a patient’s record, are made by doctors and do not need patient consent. This can be an immediate clinical decision made when a patient is seriously unwell, or a decision that goes on a patient’s records in advance and affects treatment at a later stage. But it is a legal requirement for doctors to consult with a patient about a DNACPR decision if they have capacity, and with their next of kin otherwise.”
But our communication needs to be clear to patients and families, not just saying “they are sick” but how sick. And not just what we are not going to do but what we are going to do for the patient.
Preparation:
Ensure Anticipatory Medication prescribed
End of Life trolly (Dandilion trolly – QLD)
Syringe driver kit
Paperwork
Black towels – to hide blood loss (reduces distress)
Taste for pleasure – mouth care with things people actually like (families can bring)
We all recognise the importance of ensuring patients with Parkinson’s disease (PD) get their medication, but..
What do you do if the patient can’t swallow?
We will need to work out what alternative routes we could use, for example dispensable via NG or patches, and what dose. For an ED clinical it is most likely beyond us and we need help! However, that may be extremely difficult to get especially Out of Hours
Excellent website that can give you options – select the patients normal regime (initially just one line but you can add as many as needed) and press calculate. It gives you a dispensable and patch dose, which can help the discussion with pharmacy about where we can get it. (however, no calculator is perfect)
C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss. Unfortunately reported miss rates range from 4-30%. [IJO 2007]
Patients presenting with AHF have a high mortality 4-10% in-hospital and 25-30% at 1yr, and 45% if re-admitted. So rapid diagnosis a treat is essential.
AHF Triggers
there are many triggers for AHF, which if recognized and treated with help improve outcomes
Aortic Dissection (AD), is uncommon (1 AD:200 ACS) but is…Rapidly FATAL! Unfortunately recognising aortic dissection is difficult with a clinician pickup rate of 15-43%. Read more
