Elderly Demented Pt s/p "Fall"

• First, define and characterize the "fall" as best you are able. 
  
• Be careful focusing only on mechanical issues.  Was this Syncope?
  

• Learning point - abdominal aortic aneurysm
  

        - rare before age 50,
        - family hx is the greatest risk factor - increases risk 10 fold
        - smoking is the most important modifiable risk factor

            - Triad of pain, hypotension, pulsatile mass = 10%
            - 60% of patients with ruptured AAA - normal vitals signs
            - bedside US - sensitivity/ specificity 98%

Sore Throat After Intubation

• Post intubation sore throat - usually gone by 5th  day -- persistent pain warrants concern.
  
• Common traumas
  

            - dental injury or lip abrasion
            -  foreign body
            - vocal cord laceration
            - tracheal or esophageal perforation

Is that a Pneumothorax

    > Pneumothorax ex vacu - forms adjacent to atelectatic lobe, results from bronchial obstructions - do not treat with chest tube - relieve but fixing obstruction

Mechanism of GI injury
Damage is due to multiple factors:
- tissue contact time
- pH and concentration
- ability of caustic to penetrate tissues
- presence of absence of food in stomach
- titratable acid/allkaline reserve (TAR)
            - amount of neutralizer needed to titrate pH of caustic to physiologic pH of tissues
            - higher TARs produce more damaged tissue


Alkalis
- injury is due to LIQUEFACTION NECROSIS - bad because injury keeps penetrating until neutralized or penetration of organ occurs - can get esophageal and gastric injuries

  > Sodium hydroxide
  > Sodium hypochlorite (household bleach) - worry about ingestion of larger amounts or higher concentrations
  > Ammonium hydroxide (toilet bowel cleaner)
  > Household detergents - usually dont cause GI injury but massive ingestions can be bad

Acids
- + ion causes COAGULATION NECROSIS - ulceration and perforation can occur; can get gap or nonanion gao acidosis; both esophageal and gastric injuries as well as pylorospasm


Classification of caustic injury of esophagus

     Grade I - hyperemia
                        - diet as tolerated, early D/C (likely need to be brought in initially for obs)
     Grade II - ulcerations and exudates
     Grade III - necrosis and deep ulcerations

* Be aware - these people can have an initially benign presentation
* Don’t use presence or absence of oral pharyngeal lesions to determine damage distally


Management

- Hydration
- Steroids for airway edema (not research base)
- CBC, lytes, VBG, coags
- Not unusual to have GI bleed early on, but check type and cross
- Airway - manage early (WEAR MASK), get good visualization

- No NG tube for alkali ingestions, but with acid ingestions use w/in 30-60 min, don't do charcoal unless bad ingestion (ex, Zinc Chloride)

- Endoscopy for all intentional ingestions
        - perform in first 12-48 hrs, up to 96 hrs is safe
        - unless they ingest very concentrated products or large amounts - then scope immediately
        - If you do not scope - observe for 6-12 hrs with serial exams and small sips of water

        - Contraindications to endoscopy
                - perforation, supraglottic or epiglottic burns (concern for perforation if you scope)
                - if can’t do endoscopy - perform esophagram and upper GI series 24 hrs after ingestion - use water soluble contrast initially

Sequelae
- scarring
- motility issues
- gastric outlet obstruction
- tracheoesphogeal fistulas
- strictures which SIGNIFICANTLY increases risk for Cancer - need lifelong monitoring