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
- MRI > CT, but CT is still much better than X-ray.
- 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
- Mortality - 25% 1 yr mortality
- Function - you lose some fuctional status active vs community walker vs house walker vs bed bound
Based on 2 concepts
- Increased hydrostatic pressure
- Decreased oncotic pressure
- Upright films will detect effusions >400mL
- Lateral decubitus films will detect as little as 50mL of fluid
- Order: cell count, gram stain, culture, pH, protein, LDH
Exudate vs transudate - use Light's Criteria
- 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.
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.
- 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
Not recognizing compromise early!
Not thinking to clean out the nose!
Not thinking in terms of axis alignment!
1. Single episode - concerning for impending airway compromise - get help!
- tonsills, abscess, mono, croup, tracheitis, epiglottitis, bronchiolitis
- airway foreign body
- obstruction is above the level of the vocal cords;
- Ex, laryngomalacia - from bith; worse with supine. eating or upset
- below the vocal cords;
- Ex, tracheomalacia in hypotonic kids; vascular anomalies
- 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
"BB" Shot to Right Groin...
- 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
1st presentation - viral symptoms. 2nd presentation - viral symptoms. 3rd presentation (within 24 hours) - SHOCK with Resp Failure
Tamiflu is not magic...
- 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
> Manufacture warning - no metformin 48 hrs before or after IV contrast;
> Increased risk - contraindications to metfomin, preexisting renal dysfunction
- Dilated loops of small bowel - diameter > 2.5 cm;
- >50% difference in caliber before and after transition
- Acute Obstruction Series X-rays - help if diagnostic; not so much if "normal" or "non-specific"
- If an obstruction series is nondiagnostic and you suspect bowel obstruction, get a CT
- PO contrast may add functional info, but often difficult to get into the patient... and not necessary.
- PO contrast is almost never needed in CT scanning
- Diverticulitis - fat stranding; bowel wall thickening - CT with IV contrast best image
- Appenditicits - senstivity 90% with no contrast; 100% with contrast
- Mesenteric ischemia - CT angio is the best
- Acute cholecystitis - cholesterol vs pigment stones can be seen on CT
- Ultrasound is the first best test for suspected gallbladder pathology
- Generally don't need imaging.
- Consider imaging if changing clinical picture; not typical; no classic pancreatitis risk factors (to r/o malignancy)