Category: Uncategorized

RCEM – Frailty in the ED

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.

  1. 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)
  2. Do the easy stuff: Feed, Water, Toilet, Communicate
  3. DON’T create barriers: e.g. catheters, exessive testing
  4. 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)
  • Reduced admissions.
  • EMJ
Syncope

A really common presentation elderly patients that can be tricky with a higher baseline probability of cardiac causes.

80% is on the history:

  • However, both memory of events & prodromal symptoms are often reduced in older patients
  • Look for causes “What was different that day”
  • Witnesses are really important – the elderly will tend to down play and may confabulate if memory is an issue

Investigation:

sBP takes longer to improve after standing as you get older. Recovery in <45s tends to be good.
  • Heart sounds – Murmurs
  • Neurological 
  • LSBP
  • Bloods inc BM
  • ECG
  • Get up and Go – to look at gate etc.

Get up and Go test

Causes – the frail often have more than 1

  • Orthostatic Hypotension
    • Drugs, Drugs, DRUGS
    • Volume
    • Autonomic failure: Diabetes, Amyloid, PD, Adrenal insuf etc..
    • Alcohol

 

 

  • Reflex (neurally mediated)
    •  
    • Vasovagal
    • Situational – cough, micturition, post exercise, eating
    • Carotid sinus Syndrom
  • Cardiac Arrhythmia
    • Sinus node, AV conduction, Tachy, device malfunction, inherited
    • ALWAYS interrogate devices if they have one
  • Structural Heart Disease
    • Is there a murmur?

Syncope Pathway – Reduces LoS

Delirium

4AT = NEWS for the Brain

 We miss Delirium in 50% of cases & when we do miss it we are 70-80% confident that we were right – so use 4AT 

 

Then PINCH-ME

We often over test look for the simple things first they are the most common.

Parkinson’s

Link to pdmedcalc.co.uk

 

End of Life

“Wasting a dying persons remaining time is WRONG”

Most patients would prioritise time with love ones rather than fruitless time with us.

Recognise

  • History: CFS, co-morbidities, exersize tolerance, ADL’s Residential status
  • Trends/Trajectories: what has happened since arrival and what has happened ob=ver the last few months?
  • Differential diagnosis: what is the prognosis and are the treatments desirable?

Outcomes

Emergency Laparotomy: CFS is more predictive than age

 

Covid:

 

In-hospital CPR: frailty can predict outcome in UK trial

 

Do Not Resuscitate Decisions  

Ombudsman states: End of Life

  • “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)

Think -TB

The prevalence of Tuberculosis in our region is increasing and has significant issues for both the patient and public health if we miss it.

Symptoms

  • Cough
  • Fever
  • Night Sweats
  • Lymphadenopathy
  • Weight loss

High-Risk factors to consider

Characteristics

  • Previous/Latent TB
  • TB Contact
  • Immunocompromised
  • Substance Misuse
  • Homeless/Prision
  • Pubs – esp. Vulcan Hudds

Travel/Ethnicity

  • Eastern Europe
  • India/Pakistan
  • East Asia
  • Africa

CXR Changes

  • Upper Lobe Consolidation
  • Hilar Lymphadenopathy
  • Cavities

Actions

  • Provide 3 AFB samples – Ideally performed in ED/Ward (but if patient fit for discharge and unable provide samples in ED give patient pots and request which they return to their GP.
  • Don’t Commence TB treatment – unless instructed by respiratory team
  • If admitted isolation requested
  • If discharged Patient told to isolate and if must go into public wear face mask
  • Contact TB team:
    • Huddersfield/Halifax – Based on GP postcode
    • In-Hours: either through Switch board or as EPR referral
    • Out of Hours: Though EPR referral
    • They will ensure appropriate notification of Public Health

Huddersfield

  • Dr Anneka Biswas
  • Chantelle Lashington
  • Deborah Howgate

Halifax

  • Dr Nicholas Scriven
  • Mary Hardcastle
  • Manjinder Kaur

Head Injury

Background

  • Defined as any traumatic injury to the head other than superficial facial injuries.
  • The commonest cause of death and disability in people age 1-40 in the UK.
  • Account for 1.4 million ED attendances each year, 95% of these are minor head injuries that can be managed in the ED.

Read more

Concealed Illicit Drugs

Background

Those suspected of concealing illicit drugs often present near ports and borders however they can present to any ED or be brought in by the police.

Body Packers – Swallow large quantities of well packaged drugs to smuggle them into countries or institutions.  These are often well manufactured with a low risk of rupture but the potential for serious toxicity if rupture occurs.

Body Stuffers – Swallow small quantities of poorly packaged illicit substances often at the point of arrest to conceal them. These have a much high risk of package rupture but involve smaller quantities of substances.

 

Investigations

Authorisation for an intimate search or radiological investigation must come from an inspector or higher with written consent from the patient.

Intimate searches must be carried out by a police surgeon but require immediately available resuscitation facilities therefore may be conducted in the ED. ED physicians should not handle the drugs at any time.

AXR or low dose CT scanning can be used to detect concealed packages in Body Packers.

 

General Management

Try to obtain a history of what and how much has been concealed

Look for toxidromes suggestive of package leak – treat as per Toxbase

  • Cocaine: Tachycardia, hypertension, agitation, diaphoresis, dilated pupils, hyperpyrexia, seizures, chest pain, arrhythmias and paranoia.
  • Heroin: pinpoint pupils, respiratory depression, decreased mental state, decreased bowel sounds
  • Amphetamines : – Nausea, Vomiting, Dilated Pupils, Tachycardia, Hypertensions, Sweating, Convulsions and the development of non-cardiogenic pulmonary oedema

 

Toxicology screens (urinary/blood) should not be used to guide management or discharge decisions (Level 5 evidence).

 

Body Stuffers & Pushers should be observed for signs of toxicity for a minimum 8 hours, consider activated Charcoal

Body Packers with positive imaging who are asymptomatic can be discharged back to police custody for monitoring. Bowel preparation such as Cleanprep or movicol can be used.

 

Body Packers with signs of cocaine or amphetamine toxicity or signs of obstruction/ileus require urgent surgical intervention.

Body packers with signs of Heroin toxicity should be treated with Naloxone infusion as per toxbase guidelines

All patients transferred to police custody should receive a discharge letter, including
Suspected Internal Drug Traffickers.

 

Algorithms

 

 

 

Full RCEM Guide

Hyperkalaemia

Remember: is it a haemolysed blood sample? (you can do an iSTAT)

Severity

  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit

Read more

Hypertensive Disorders in Pregnancy

  • New onset hypertension after 20 weeks of gestation (systolic blood pressure > 140 and/or diastolic blood pressure > 90)

And either

  • Proteinuria (urine protein:creatinine ratio ≥30mg/mmol)

Or

  • Other features of pre-eclampsia1:
    • AKI (creatinine ≥ 90)
    • Liver dysfunction (ALT>40)/epigastric/RUQ pain
    • New severe persistent headache without an alternative diagnosis
    • Persistent visual disturbance
    • Haematological complications (platelets <150/DIC/haemolysis)
    • Neurological complications (clonus/stroke/seizures(eclampsia))
    • Pulmonary oedema
    • Uteroplacental dysfunction (fetal growth restriction/placental abruption/intrauterine death)

Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.

Eclampsia- This is pre-eclampsia that has progressed to seizures

Risk Factors:

Clinical features of pre-eclampsia:

  • Asymptomatic hypertension (picked up on screening or incidentally when presenting with another issue)
  • Headache (usually frontal)
  • RUQ or epigastric pain (also a symptom of HELLP syndrome)
  • Nausea and vomiting
  • Oedema (common but not specific). Especially if rapidly increasing and involving face and hands.
  • Visual disturbance (flashing lights in the visual fields or scotomata)
  • Shortness of breath (uncommon but can occur due to pulmonary oedema)
  • Hyper-reflexia and/or clonus

HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.4

Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.

Management of Pre-eclampsia:

 

  • Contact obstetrics early
  • Manage the patient in an area with close monitoring if pre-eclampsia with severe features
  • BP management:
    • Labetalol first line unless unsuitable or contraindicated3 (e.g. asthma)
    • Nifedipine MR second line
    • Methyldopa third line (not used postpartum due to risk of depression)
  • Careful fluid balance monitoring
    • Fluid restriction to reduce the risk of pulmonary oedema
    • Monitor urine output if severe
  • Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia

Definitive management:

Definitive management of pre-eclampsia is ultimately delivery of the fetus.   Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.

 

ED Management of Eclampsia:

  • Ask for help early from ITU and obstetric teams
  • ABC approach, manage in left lateral position
  • Airway and breathing assessment with high flow oxygen
  • If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
  • Magnesium sulphate IV is treatment of choice for seizures – 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
  • Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.3
  • Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery

Full NICE guidance is available here

Opioid Toxicity

Opioid Toxicity causes:

  1. Drowsiness
  2. Respiratory Depression – Hypo-ventilation and decreased respiratory rate
  3. Pupillary Miosis

Other Symptoms may include (but are not diagnostic or opioid toxicity):

  • Nausea and vomiting
  •  Neuropsychiatric features including nightmares, anxiety, agitation, euphoria, dysphoria,
    depression, paranoia and hallucinations
  •  Urticaria and pruritis
  •  Convulsions
  •  Hypotension and bradycardia
  •  Hypothermia secondary to environmental exposure

Naloxone is the antidote to Opioids however as these are commonly co-ingested with other depressants. full reversal of symptoms may not occur with treatment.

In acute opioid toxicity, the aim of naloxone administration should be reversal of respiratory depression and maintenance of airway protective reflexes, not full reversal of unconsciousness.

 

Opioid Toxicity Treatment

Naloxone infusion if required is based on the total dose given to obtain Respiratory rate of 10

Link to the full guidance is here

 

Neuro-Obs

Neurological Observations MUST include the following:

  • A full set of NEWS2 observations
  • ACVPU assessment (alert, new confusion, voice, pain, unresponsive)
  • GCS (Glasgow coma scale)
  • Pupillary responses
  • Assessment of Limb power

Head Injury – Level 1

Head injury is witnessed, reported, suspected, or cannot be excluded.

  • There is any new onset of neurological symptoms or deterioration.
  • The patient complains of pain / tenderness to the head
  • Extra consideration should be given to patients currently prescribed anticoagulant medication at the time of the fall.

Post fall Neurological Observations must be completed for at least 12 hours and at the above intervals as a minimum:

During this time If there is any deterioration in the patient’s condition including level of consciousness, pupil reaction, limb power, cardiovascular observation you must revert to ½ hourly neurological observation and seek URGENT medical review.

Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep

Head Injury – Level 2

Admitted with Head Injury

  • With a sudden deterioration in their level of consciousness
  • Who are unconscious on arrival to hospital
  • Post first seizure

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must revert to ½ hourly neurological observations and seek URGENT medical review. Patients should be reviewed if no change in condition at 12 hours to ascertain if neurological observations are still indicated – this decision must be documented in the medical notes.

Under no circumstances should Neurological observations be omitted because the patient is asleep.

Intracerebral/Subarachnoid Haemorrhage OR Stroke
  • Acute Primary Intracerebral/Subarachnoid  haemorrhage
  • Any other Ischaemic stroke 
  • Post Thrombolysis /Thrombectomy for Stroke patients only

During this time If there is any deterioration in the patient’s condition, including level of consciousness, pupil reaction, limb power or cardiovascular observation you must seek URGENT medical review and revert to ½ hourly neurological observations as a minimum, or ¼ hourly, if still within the first 2 hours post thrombolysis.

Under no circumstances should Neurological observations be omitted because the patient is asleep.

Suspected Cauda Equina Syndrome CES

1. Red Flags: Has the patient developed any of the following?

  • Difficulty initiating micturition or impaired sensation of urinary flow
  • Altered perianal, perineal or genital sensation S2-S5 dermatomes – area may be small or as big as a horses’ saddle (subjectively reports or objectively tested)
  • Severe or progressive neurological deficit of both legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
  • Loss of sensation of rectal fullness
  • Sexual dysfunction (achievement of erection or ability to ejaculate, loss of genital sensation)

If Yes to ANY proceed to 2.

If NO to ALL consider other diagnosis and possibility of GP follow-up

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