QUICK HIT CORE CONCEPTS

• Quickly determine if patient is on "blood thinners"
• Do not rely on vital signs to assess risk.
• Consider shock index or age related shock index
• Lactate of 2.5 or greater indicates high risk
• Liberal use of CT scan as opposed to plain films
• Liberal admission policy.
• Use geriatric trauma triage score on admitted patients.
• Many admissions will need to go to ICU because of age and comorbidities
  

More Specifics

***Mortality in trauma increases dramatically with increased age, inc 7% mortality for each year over 65 in trauma

***Liver disease is the worst premorbid condition for trauma

***Standard trauma assessment is inadequate in elderly, particularly vital signs insensitive

***Falls: 10% significant injury, in geraitric population cervical spine fractures common

***Have decreased cardiac output, may not be able to mount adequate tachycardic response, may have occult shock.  Have consideration for peri-traumatic MI both prior to trauma or stress of trauma causing MI

***Pulmonary issues: Decreased reserve, increased risk ARDS and atelectasis, CO2 narcosis

***CNS: High risk of subdural, clouded by questionable baseline mental status

***Renal: Often baseline poor GFR, CT Contrast can cause significant injury

***Trauma triage poor in elderly: Age >55 should be at a trauma center

***CMC TRAUMA ACTIVATION for geriatrics

    ATC 1:: Age >65: HR>100, SBP<110

    ALERT:: Age >65 involved in MVC or fall from height

***MANAGEMENT

    Airway: Increased aspiration risk.  Consider dentures.  Consider high cervical spine risk and maintain proper imobilization.  Consider increased response to induction agents: decreased your dose.

    Breathing: Decreased reserved, rapid desaturation.  Use passive oxygenation.  Use ETCO2.  Consider increased risk of rib fractures.

    Circulation: Decreased response to catechols, on beta blockers; may not mount tachycardia appropriately.  Consider RELATIVE hypotension.

        --Journal trauma study shows HR >90 and SBP <110 significant increased in mortality

    Disability: Central cord syndrome more common in elderly, may have "Hand burning", will have upper extremity weakness and capelike paresthesia


***SHOCK INDEX

    HR/Systolic blood pressure

    Normal less than 0.6, realistic threshold <0.8

    More sensitive than HR or BP alone

    Even better: Shock index * Age should be <50

***If concerned about fluids, use repeated small boluses (250ml)

***Anemia: Follow serial hemoglobins and transfuse early.  Transfusion threshold controversial, starting thinking about it around 8 or persistent hypotension


***History: Keep in mind precipitating events, syncope in 10-15% of geriatric fall/MVC

***Identify blood thinner use!!  Coumadin, plavix, ASA, Anti 10A, anti thrombin

***CAREFUL chest exam: Must identify rib fractures, flail chest; XRAY low sensitivity for these.  Traumatic aortic dissection often does not have external signs of injury.

***Abdomen: Geriatric may NOT develop peritonitis despite significant intraabdominal injury

***LABS: Always get lactate; highly predictive of bad outcome

    >2 admit, >3 ICU, >4 call chaplain. (40% mortality in lact >4)

    Upgrade to ATC 2 if INR >2 or Lactate >2.5

***ECG Routine in geriatric trauma

***Careful with opiates in elderly, start low doses

***Head trauma:

    80% mortality if GCS<8

    Any anticoagulation with head trauma = scan

***Anticoag reverse>

    Coumadin, see protocol

    Antithrombin: May try FFP but pretty much screwed

    Anti Xa: PCCC may be beneficial (see protocol for dosing)

***Rib fractures: Risk of atelectasis, resp faulire, pneumonia

    Admit if >3 rib fx. Consult if 1 or more if frail, live alone, any concern really

***Elderly aorta

    Eggshell appearance distant from border of aorta may indicate dissection (Egg shell or Halo sign)

***Pelvic fx mortality 50% if hypotension, 90% if open. Eval for hemoperitoneum and aortic rupture

***Burns..

    Baux index: Mortality = age + TBSA.   

    Age >50 with bad burns, = burn center

**BEWARE Cold and quiet, elderly trauma patient!

HIGH YIELD CONCEPTS:

• “Neurogenic Shock” (Neurogenic Hypotension) refers to a loss of BP regulation (hypotension and bradycardia) following a complete SCI above the T5 level and is due to loss of sympathetic outflow to the systemic vasculature and heart.
• “Spinal shock” is a neurologic phenomenon that generally lasts < 24 hours in the acute phase of a SCI and is best described as a transient physiologic reflex depression of cord function below the level of injury, resulting in loss of all sensorimotor functions.
• A Central Cord Syndrome is the most common incomplete SC lesion, usually resulting from forced hyperextension in the setting of cervical spine DJD or spinal stenosis, and classically manifests as paresis mostly in the distal upper extremities with dysesthesias in a “cape-like” distribution.

Basics

• Spine - 2 column concept; flexion - crush the front open the back, extension, crush the back and open the front; axial load - Jefferson fracture = unstable; rotational injuries - unilateral facet is stable; bilateral facet injury is unstable; Distraction injury - can cause hangmans fracture
  
  
• Things to be aware of that can lead to spinal cord injury - Fracture, joint dislocation, ligamentous tearing, disc protrusion
  
  
• Neurogenic shock = functional sympathectomy - high cord injury - lose sympathetic innervation. Also have parasympathetics unopposed - results in bradycardia and hypotension; look at the bladder as well because urination is a parasympathetically innervated - spinal cord injury = brisk bladder reflex.
  

• Spinal shock - neurologic phenomena loss of all neurolgoic function in the acute phase of a SCI > lasts < 24 hrs

Management

• Optimizing return of neurologic function - immobilization - variable evidence; avoiding hypotension, hypoxemia, and hyperthermia
  
  
• Neurologic HPI - details of event causing injury, transient or persistent numbness weakness or paresthesias, neck or back pain, prior history of spinal stenosis - predisposes to central cord, arthritis, previous spinal fusion
  
  
• Airway management - intubate fast and early > C3-C5 = diaphragm; patient can recruit some accessory muscles but won't last long
  
  
• Make sure neurogenic hypotension is a diagnosis of exclusion in the trauma patient - these patient's shouldn't be tachcyardic with hypotension and they should have obvious signs of spinal cord injury
  
  
• Neurogenic hypotension - typically respond to Trendelenburg position & IVF
  
  

       >  Avoid phenylephrine as a pressor (concern over reflex bradycardia); Choose NE vs dopamine

• Acute complete cord injury - reduced sensation reduced muscle power
  
  
• Incomplete injury - various degree of motor function; sensation preserved more than motor; bulbocavernosus reflex & anal sensation spared
  
  
• Transient paralysis & spinal shock - younger athletes - will look like a complete injury & can have neurogenic hypotension
  
  
• Incomplete spinal cord lesions - central cord (most commons incomplete SCI) - forced hyperextension - paresis upper > lower;  anterior cord - flexion injuries - paralysis and hypalgesia below level of injury; preservation of posterior column - vibration pressure light touch and proprioception; brown sequard - penetrating lesions - ipsilateral motor paresis, loss of vibration pressure and all propioception; contralateral sensory hypesthesia
  
  
• C5 - elbow flexed, C6 wrist extension; C7 elbow extensor, C8 finger flexors, T1 - finger abduction; know your cord levels and dermatomes!
  

• "Jefferson bit off a hangmans thumb" - unstable C spine fractures
  
  

        - Jefferson - axial load - classic diving injury - unstable fracture

        - Bifacet dislocation

        - Type II odontoid fracture

        - Hangmans fracture - distraction & rotation injury - posterior element of C2 gets fractured & spondylolisthesis of axis

        - Flexion Teardrop - most serious of all Cspine fractures

• Infection -> Sepsis -> Severe -> Shock

• Diagnosis of sepsis = risk of in hospital death is 1 in 4 despite the best level of care
  
  
• Identification is harder that you may think
  
  
• Sepsis = "SIRS with a source" - suspected infection - don't always need to confirm source (1/3 of patients present without obvious source)
  

           > SIRS - HR, Temp, RR, WBC

           > 1/4 to 1/3 of patients with sepsis don't manifest 2/4 SIRS criteria
           > SIRS can be helpful when present but the absence of SIRS doesn't rule out sepsis                     

• Severe sepsis - end organ dysfunction - lactate, altered mental status, Cr elevation, decreased UOP, billirubin, coagulopathy, etc
  
  
• Important to properly identifty patients who meet severe sepsis criteria because it impacts care metrics and prognostication
  
  
• "Canary of end organ dysfunction" - the kidney -- threshold for AKI = 0.3mg/dL elevation from baseline
  
  
• Shock - mean hypotension (MAP < 65 or SBP < 90)  or relative hypotension (40 SBP or 20 MAP below baseline)
  
  
• PITFALL - well appearing hypotensives - be vigilant - people can present with hypotension with absence of hypoperfusion
  
  
• CODE SEPSIS CRITERIA - SBP< 90 after 2 liters or severe sepsis with lactate >4 with presumed infection & need for ICU care.  Goal of calling out code to antibiotics is < 60 min; goal to time to the ICU is 90 minutes
  
  
• 20% of patients in shock may not manifest elevated lactate
  
  
• 2 studies - sepsis with intermediate lactate range (2-4) -- despite care 1/3 of these patients are admitted to the ICU within 3 days
  

Epiglottitis?

• If you are VERY worried about epiglottitis (patient is drooling, in tripod position, etc), LEAVE THEM ALONE. Call ENT & Anesthesia and get them to the OR.

• If you are CONSIDERING epiglottitis, you can consider nasopharyngoscopy to look for gross abnormalities. Still a good idea to call ENT to help you out.

• A lateral neck x-ray isn't all that helpful in epiglottitis; it has low sensitivity and low specificity. Don't hang your hat on it.

• Cough is rare in epiglottitis. Drooling and a preference to sit up is not.

•   "Croup" that doesn't respond to croup therapy? Consider bacterial tracheitis.

- While epiglottitis is very rare in pediatrics in the era of immunizations, the rate is stable in adults.

**Kids... look great until they plummet.  Appear well until very close to decompensation.

INTUBATION - DO IT BEFORE IT IS TOO LATE
**Intubate early for children who are doing poorly, do not wait until they are becoming increasingly hypoxic and bradycardic!

**40% of infant cardiac output goes to work of breathing - tremendous metabolic requirement.  May need to intubate for non-respiratory reasons - use blood gases

**Consider ketamine for sick neonate needing intubation/sedation

INTUBATE THE STOMACH TOO!!
**Decompress belly if needed:  Infant diaphragm more horizontal, does not help with breathing as much.  Distended gassy abdomen will severely inhibit breathing.  Use NG TUBE

RESUSCITATE!! GIVE FLUIDS FAST!!
**FLUIDS: use up to 60cc/kg, one little bolus of 20cc/kg often gross under resuscitation.  60cc/kg is not the maximum... its the start

DON'T FORGET THE SUGAR!!
**Blood sugar: In infant it can drop from normal to low quickly.  Can have wide range of symptoms or be asymptomatic.

**sugar problems: infant brain uses 90% of glucose, head to body ratio MUCH higher in infant.  Healthy infant uses 6-8 mg/kg/min sugar as opposed to 2mg/kg/min in adult

**Sugar: High, keep checking.  Normal, start basal rate.  Low, give bolus!

GET ACCESS NOW!!
**IO: Difficult in infant, but it is DIFFICULT in the very young.  We often wait too long to go to IO.  Don't!

The BounceBack Patient
The "BounceBack" Patient offers use an opportunity... to either be as foolish as we were before or to make up for previous mistakes.

With all patient encounters (whether 1st encounter, 2nd encounter, or 102nd encounter) keep these simple rules in mind:

• History is Job #1
  OLDCAAR
  Spending a little more time up front on a good history will save you a lot of time later. 
  Your medical decision making is built upon the foundation of your hisotry and physical.  Make sure you have a strong foundation to build upon.
  
  
  • "When you hear hoofbeats... think Lions,Tigers, and Bears"
    This is a phrase shamelessly stolen from one of my mentors, Dr. Mattu... but it runs through my head constantly.
    Most of the conditions that we evaluate (gastroenteritis, viral syndromes) are able to be accurately diagnosed and managed by grandmothers.  You, however, are not paid to be a grandma.  You are paid to ensure you don't miss the Liond, Tigers, or Bears that are following the poor unsuspecting horse.
    In short, always think "worse first."
    
    
    • Chart Discrepencies - FIX THEM!
      In the view of the court, the EMS history carries the same weight as the RN history which is equal to yours.
      Make sure that you read all of the chart to ensure that you are not missing a key point.
      If there is a discrepancy, go ask the patient directly about it.  Your history taken twice and clarified outweighs all others.
      
      
      • Always address all complaints.
        This can be tough... yes... I have been there too.  But do a thorough H+P and you will likely be able to address many of the additional complaints without much more effort.  But ignore them at your own peril.
        
        
        • Read your own Words!
          This is critical... particularly if you are using a dictation system or Dragon. 
          Step back and ask if they picture you are painting is consistent with the plan you are constructed.
          Also, significant typos can be construed (by a lawyer) as an imprecise and inaccurate physician.
          

Important questions to ask:

1. Travel
2. Medications
3. Work
4. Other medical conditions
   

S&S - syncope, bleeding, dyspnea, trauma, fatigue, weakness

Workup- What to expect with hemolytic process:

- CBC (Hgb)
- peripheral smear (takes some time, but will often give definitive dx)
- retic count - increased
- haptoglobin - decreased
- bilirubin
- LDH - increased
- urinalysis
- Coombs (direct and indirect)
- Type and Cross

Intrinsic vs Extrinsic Hemolysis

- Intrinsic = structural or enzymatic defect

- Extrinsic = mechanical or toxic destruction


Key points

• osmotic fragility and Hgb electrophoresis are batched tests and may take time to return
  
• base decision to transfuse on clinical status, age, comorbities
  

Case 1 - Lower extremity weakness

• Generalized pain and BLE pain > numbness> weakness as well as urinary retention and epigastric pain; 2 weeks prior had vaginal hysterectomy with BSO.
• Physical Exam - LLE objective wekaness
  

DDX - Transverse myelitis, EDH abscess, viral myeltitis, trauma ,degerenative, vascular, toxic metabllites

• Admitted for MRI but, while admitted complained of chest pain > trop bumped, CTA showed aortic dissection

     > Learning points - DDimer cannot be used as a screening tool to rule out dissection
     > Stanford classification - A involves the aortic root, B is limited to the descending aorta
     > Prsenting sx of type B dissections- chest or back pain, abrupt onset of pain
     > Imaging - CXR - 56,5% are nl, TTE - usef for aortic root, CT best sensitivity and specificity

Therapy

• BP/HR control - reduce shear stress:  SBP < 100 is goal, HR < 60;   beta blockers are first line
• Type A = needs surgery, Typer B attempt medica control l
• Before initial beta blocker, listen for aortic insufficiency and use ultrasound to evaluate for pericardial tamponade as these patients don't do well on beta blocker
  

Case 2 - Fatigue - dyspnea

• Initially seeen in ambulatory area. Developed distress and moved to Major area. Called out as code sepsis.

a. Patient with worsening resp status and was started on heparin drip for possible PE.     
b. Admitted to hospital - heparin drip stopped and echo gotten - shows right heart strain
c. CTA showed massive Bilateral PEs

Predictors of Complications from PE

• Troponin
• Pulse ox
• BNP
• Echo findings
  

Massive PE = Unstable, sustained BP < 90 (for HTN and BP < 100)

Submassive PE - Rigth ventricle with dilitation and systolic dysfunction, CT - RV dysfunction, elevated BNP or troponin

Why this matters!

• 30 day mortality for 75-84 yrs old  = 11%, for those >84 yrs = 24%
• 50-70% of nursing home residents are exposed to antibiotics over any one year; increasing MDR in this population
• Risk fx: Alcoholism RR 9, COPD RR 4.2, immunosupp R 3.1, Heart disease RR 1.9, institutionalized RR 1.8
• Elderly may present atypically for pneumonia.  Latent, without chills, ill defined physical signs. 
  
• 50% of fever absent in elderly, and mortality is higher in this population
  

How about a Score?

• PORT score.  30 day mortality in >age 18. Exclude HIV, hospitalization in prior 7 days

    Step 1.  Identify low risk.  Age <50. No Hx Cancer, CHF, CVD, Renal disease, Liver disease. 
                 On exam AMS, HR>125, RR>30, SBP <90, Temp <35 or >40
    Step 2. Use MD Calc Check boxes.  

    Simple rule: With no high risk findings and women under 80, dischcarge and men under 70. 

• CURB65.  Useful for sicker patients, 37% of pts greater than 75 yo.
  

    C:Confusion
    Urea >20
    RR >30
    Blood Pressure - SBP <90, DBP <60
    Age >65

    More of these is higher mortality in 30 days


Blood Cx?

• IDSA Guidelines: ICU Admission, Cavitary infiltrates, Leukopenia, active alcoholism, severe liver dz, severe COPD, Asplenia, pleural effusion.
• If you get blood cultures, you need to a have reason
  

HCAP

• Don't necessarily need to treat everyone with healthcare exposure for HCAP
• Treat if risk of MDR.  Look up the criteria
• Common pathogens: Increased rated of gram negative bacilli, MRSA
  

• Treatment: Should reference IDSA guidelines, but in general need MRSA coverage + either 1 or 2 drug antipseudomonal therapy depending on risk

A phenomenal time was had by all who attended Dr. Bustin's Nerve Block Extravaganza!!
You can use this link while working to access the quick reference cards:
https://www.evernote.com/pub/smfoxmd/cmcnerveblocksdr.bustin