Geriatric Pts aren't Old Adults

- Fractures can occur with Low energy!
- Two anatomical location
        - Femoral neck (blood supply threatened if displaced)
        - Intertrochanteric ( capsule instertion)

X-rays needed for operative planning
- Ap pelvis, AP and lat ofhip, femur, knee

Occult Fx
    - MRI > CT, but CT is still much better than X-ray.

Fragility Fx
    - Needs medical consult
        - Improves operative outcome.
        - Fragility fracture orderset required for Medicare payment!

How to Classify
    - Open, Displaced, Comminuted (all yes/no questions)
            - Displaced = unstable and hip replacement (total vs hemiarthroolasty depends on functional status)
            - Non-displaced / stable (vagus deform)= screws
                - Low rates of AVN, Infection, Out Of Bed quickly

Outcomes
    - Mortality - 25% 1 yr mortality
    - Function - you lose some fuctional status active vs community walker vs house walker vs bed bound

Pathophysiology
Based on 2 concepts
    - Increased hydrostatic pressure
    - Decreased oncotic pressure

CXR
- Upright films will detect effusions >400mL
- Lateral decubitus films will detect as little as 50mL of fluid

Fluid analysis
- Order: cell count, gram stain, culture, pH, protein, LDH

Exudate vs transudate - use Light's Criteria

    Transudates:
            CHF
            Nephritis
            Nephrotic syndrome

    Exudates:
            Infection
            Traumatic HTX
            Malignancy
            CT disorders

Management:

- Treat the underlying pathology!
- Avoid large volume taps (>1L) if CHF, renal or hepatic pathology
- Unstable - septic shock, tension hydropneumothorax

- If tapping:
    - Avoid NV bundle
    - Have patient lean over table
    - Use ultrasound

- When to tap:
    - Typically, these patients will not need a tap or tube in the ED.
    - If patients have persistent hypoxia in spite of other interventions, consider tap.
    - Severe respiratory failure.

Complications:
PTX
Infection
Hemorrhage
Rare - air embolism, sheared catheter loss

Kids are Different

- Larger heads, tongues, smaller nostrils
- Cricoid ring determines size of ET tube
- Bradycardia is a BAD SIGN.

Signs of Increased Respiratory Effort

- Assumed position
- Bobbing head
- If kids are pulling off their mask, they might need to be intubated.

Positioning

- sniffing position, sometimes achieved without any padding
- jaw thrust is preferred to chin tilt
- always use an oral airway, measure from angle of mouth to angle of jaw

DOPE for ETT problems

- Check ETCO2 waveform

- Dislodged
- Occluded
- PTX
- Equipment

Pitfalls

Not recognizing compromise early!

Not thinking to clean out the nose!

Not thinking in terms of axis alignment!

Timing Matters

1. Single episode - concerning for impending airway compromise - get help!
      a. Febrile? 
           - tonsills, abscess, mono, croup, tracheitis, epiglottitis, bronchiolitis

      b. Afebrile? 
          - airway foreign body

2. Recurrent 
     a. Inspiration 
           - obstruction is above the level of the vocal cords; 
                          - Ex, laryngomalacia - from bith; worse with supine. eating or upset

     b. Expiration 
         - below the vocal cords; 
                          - Ex, tracheomalacia in hypotonic kids; vascular anomalies

     c. Biphasic 
         - at the level of the cords (or just below) 
                          - Ex, subglottic stenosis/ hemangioma (get bigger over the first year of life before they start to shrink); 
                                   vocal cord dyfunction; esophageal foreign body

The Return ED Visit

• Learning points - everyone has biases - realize yours
• Errors in medicine do happen. Learn from these errors. Make a personal protocol/checklist to review all data before any major decision (admission vs discharge).

• Pneumonia - know what the risks are (we have a powerplan! - ED Adult pneumonia - community acquired)
• Provide excellent documentation in pneumonia patients. Clearly document risk factors (or lack of) for HCAP, MRSA, Pseudomonas. This will allow you to choose appropriate antibiotic coverage. 

"BB" Shot to Right Groin... 

• Xray showed "BB" above right inguinal ligament. 
• CT showed ballistic had moved further.
• Repeat films showed BB in the chest.

Bullet Embolism 
- Bullet embolism is extremely rare. 
- Requires multidisciplinary management. 
- Consider possibility if missile lays next to major vessels or bullets are found in unexpected locations. 
- Venous more common than arterial


FLU
1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure

• Vital signs are vital.
• Consider second visits as opportunities to not make the same mistake twice. Doesn't mean admit them; means re-consider the bad things.

Tamiflu is not magic... 

• When prescribing Tamiflu, know the evidence and pros/cons. Cost, side effects, limited efficacy, and possibility of causing resistance strains should all be considered. Have this discussion with your patients.

TRAUMA PATIENTS
- CT if there is abdominal tenderness or a seatbelt sign     - Seatbelt sign- Not just abrasions!  They have bruising / ecchymoses.
     - With Seat Belt Sign, incidence of hollow viscus injuries (17%); splenic injuries (10%)
 
- Things that are easy to miss on CT scan 
     - Diaphragm injuries - think about in abdominal pain w/ dyspnea or chest pain
     - GI tract injuries - free fluid; bowel in discontinuity 
     - Pancreatic injuries - difficult to tell difference between contusion and ductal injury -
            - Important because these need intervention and waiting will be detrimental; 
            - ERCP or  MRCP - definitive diagnosis 

ABDOMINAL PAIN IN THE ELDERLY 
- Have a low threshold for imaging elderly patients with abdominal pain
      - Abdominal pain in elderly - 60-70% admitted; 30% with surgical process; 10% with return ED visits; 5% mortality 
      - Exam is not as reliable!!

- CT: diagnostic in 85% of people who had emergent surgical process
                 - Contrast?  IV/ PO/ both/ CTA?- if concerned about vascular - get CTA
                       > Contrast allergy - only true contraindication - airway compromise
                       > CIN - Cr rising >0.5 mg/dL or 25% from baseline; 
                       > Most elderly people have risk factors Cr > 1.5-2.0 
                       > Consider no contrast - if giving contrast -  HYDRATE 
                 - Metformin 
                       > Manufacture warning - no metformin 48 hrs before or after IV contrast;
                       > Increased risk - contraindications to metfomin, preexisting renal dysfunction 

BOWEL OBSTRUCTION
- Diagnosis 
     - Dilated loops of small bowel - diameter > 2.5 cm; 
     - >50% difference in caliber before and after transition