Flashcards in Referral to the ER and Surgery in the Elderly Deck (49):
o If you can refer directly to definitive care and avoid the ED you should.
o Patients sent to the ED for lack of social support suffered a 1-year mortality of up to 34%
ED visits generally
o In the first 3 months after an index ED visit: 5% of discharged elder ED patients will die, 20% will require hospital admission, 20% require another ED evaluation, 10% to 48% suffer decline in functional abilities. This high incidence of poor outcomes despite PCP follow-up suggests a complexity of need that far out spans the episodic ED visit
o These outcomes suggest the underlying issue is not the acute event for which the ED was designed, but a quiet ongoing process
ABCs of an ED visit
o A for Airway compromise: the inability to move air through the mouth, nose, and upper airway into the lungs, as seen in stridor, mucosal edema, unconsciousness, anaphylaxis, and foreign body.
o B for Breathing : includes evaluation of respiratory rate. Danger exists at the extremes of <10 breaths/min or 30 and over breaths/min, or if the O2 saturation is <93% on room air.
o C for Circulation : includes signs of decreased organ perfusion such as diaphoresis, new altered mental status, and cyanosis. Shock can be heralded by pulse <50 beats/min or >120 beats/min, or by a systolic BP <90 mm Hg.
o D for (neurologic) Disability : noted by new decreased mental status, Glasgow coma scale47 <13, or stroke-like symptoms.
o Acute shortness of breath
o DDX: requiring ED includes myocardial ischemia/infarction, COPD, congestive heart failure (CHF), pneumonia, pulmonary embolism, bronchitis, and dysrhythmia
o If you cannot exclude a life threatening cause of dyspnea, or you cannot stabilize an acute exacerbation of disease, your patient needs the ED!!!
o most often triggered by a viral or bacterial infection, cold weather, narcotic use, CHF, or anemia, among other triggers.
o The most life-threatening components of an exacerbation are hypoxemia and hypercarbia
COPD treatment: to ED
o Noninvasive positive pressure ventilation (NPPV): Indicated for moderate to severe exacerbations as determined by worsening tachypnea >25 breaths/min, dyspnea with accessory muscle use, moderate to severe acidosis (pH<7.35), or hypercapnia (PaCO2 > 45mm Hg)
o Mechanical ventilation: if a patient continues to deteriorate despite all the above interventions, endotracheal intubation is the next required therapy.
o vasovagal or orthostatic hypotension syncope (or drug induced orthostasis) with a correctable cause has no increased risk for future adverse events
o For orthostatic hypotension, hydration and re-evaluation is prudent.
o any patients with structural heart disease, heart failure, abnormal ECG, anemia, or symptoms not consistent with benign causes of syncope are at high risk for adverse effects and should be hospitalized.
o Cerebral atrophy—even in the presence of apparently normal cognitive function—is common in elderly or old people. The brain (close to liquid at normal temperatures) moves more in the event of a car crash or fall, increases the chance of hemorrhage.
o Also free space, intracranial hemorrhage (ICH)—by failing to cause raised intracranial pressure—produces little or none of the expected neurologic clinical picture but, the mortality rate is 30% to 80%, even for a fall from standing height.
head trauma and the ED
o Even in minor head trauma, vomiting indicates increased risk of ICH. Anticoagulation dramatically increases morbidity, mortality and difficulty of treatment.
o Expedient trauma evaluation of apparently stable elders improves survival.
o In elderly trauma, severe organ damage can occur at normal blood pressures, and the death rate goes up if the systolic is less than 110.
Trauma prompting an ER visit
o risk of injury/death increases after age 55 years
o SBP <110 might represent shock after age 65 years
o low impact mechanism (e.g., ground level falls) might result in severe injury
o high risk of rapid deterioration in anticoagulated patients with head injury
o An acute stroke is a time critical process in which “time is brain.”
o The 2012 American Heart Association/American Stroke Association (AHA/ASA) guidelines for the management of acute stroke has increased the time for rtPA administration to 4.5 hours from symptom onset.
o A door to needle time of <60 minutes is emerging, Interventions delivered early in the course of stroke can prevent or decrease damage to critical brain structures preserving function.
o Physical exam can vary from gross unilateral paralysis to subtle findings easily overlooked
o Traditional symptoms of stroke include unilateral paralysis of face, arm, legs, sudden confusion, aphasia, memory deficits, severe headache, or dizziness.
o Atypical symptoms may include loss of consciousness, pain, palpitations, altered mental status, and shortness of breath.
o Most popular scales used by EMS systems are: Cincinnati Prehospital Scale (CPS: 66% sensitve) and the Los Angeles Prehospital Stroke Screen (LAPSS 91% sensitive).
o most common mimics are: seizures, confusional states, syncope, toxins, neoplasms, subdural hematomas. Hypoglycemia can also cause neurologic deficits and must always be excluded
o history should focus on time of onset of symptoms given tPA administration depends on the length of duration of symptoms.
o Presentation of hemorrhagic versus ischemic stroke can be identical
o point of care glucose right away to exclude hypoglycemia
o If identified begin transfer to the closest stroke center
o oxygen, obtaining IV access, or giving fluid to hypotensive patients is appropriate as long as it does not delay the transfer process.
acute abdomen: causes
o In general, there are four main categories of a surgical acute abdomen:
o (1) peritonitis
o (2) perforated viscus
o (3) bowel obstruction
o (4) vascular
o difficult to quantify due to inconsistency in the definition of sepsis
o infection frequencies in ED elders as follows: pneumonia (25%); urinary tract infection (22%); and sepsis and bacteremia (18%)
o Vital signs consistent with serious illness are: T >39.4°C (102.9°F), RR > 30, P >120
o Clinical findings associated with serious illness were WBC >11 or presence of an infiltrate
o Shaking chills, DM, major comorbidities, AMS, abdominal pain, and vomiting are all predictive of bacterial infection
SIRS (systematic inflammatory response syndrome
o Scale: sepsis, severe sepsis, and septic shock
o SIRS: defined as having at least two out of the four following criteria: Heart rate >90, Respiratory rate >20 (or PaCO2< 32), Temperature <36°C or >38°C (<96.8°F or >100.4°F), Leukocyte count (WBC) >12 or <4, or with >10% bands
sepsis: sliding scale
o Sepsis is defined as having SIRS along with a suspected source of infection.
o Severe Sepsis is defined as sepsis plus either cardiovascular organ dysfunction or acute respiratory distress syndrome or dysfunction of two or more other organs. (NO LONGER EXISTS)
o Septic Shock is sepsis along with hypotension of systolic BP < 90 despite appropriate fluid resuscitation (at least 40cc/kg).
o ABCs and check vital signs
o risk stratify
o Physical exam: source of infection hypoperfusion? dry mucous membranes, hypoxia, poor capillary refill, and other signs of shock or organ failure
o Ancillary testing: CXR, UA C&S, CBC, CMP, blood gas, lactate, and ECG
o CRP may be used as an early marker for infection in elderly adults but not specific!!!
o Administer oxygen, control temperature, and address analgesia as needed
o Treat Focal infections, if not sepsis, defer ED.
o Antibiotics: Direct therapy for known source, or empiric therapy for unknown source ASAP
o If septic: transfer to ED, where they will…
o aggressive IVF, broad abt, +/− intubation, central venous pressure monitoring through placement of a central line, and hemodynamic management.
o In shock, both vasoactive and ionotropic agents are used, possible blood transfusions
what is new with sepsis
o "Sepsis" refers to organ dysfunction due to infection.
o "Severe sepsis" as a term is no longer used (that is "sepsis" has replaced "severe sepsis").
o Septic shock refers to circulatory failure (i.e., need for pressors after volume repletion).
o SIRS is no longer used formally due primarily to nonspecificity for infection.
the new sepsis screening
o Three measures: altered mental state, respiratory rate >22, hypotension (SPB< 100), one point each (two points or more considered positive and indicative of sepsis if infection suspected)
o Designed to be done quickly and at bedside (e.g. ED triage, inpatient wards), and to prompt speedy evaluation and administration of antibiotics within one hour.
o Patients meeting criteria for SIRS may or may not progress to sepsis/shock, and so qSOFA identifies a sicker group of patients.
what is involved in treatment of +SOFA
One hour of triage:
– lactates, routine labs at least drawn, blood cultures drawn, fluid bolus started, antibiotics started (iv push for beta-lactams).
– If hypotensive or lactate > 4, 30 mg/kg crystalloid bolus iv.
Three hours of triage: Above should be completed.
Six hours of triage: vasopressors for fluid unresponsive hypotension, and subsequent documentation of volume status and tissue perfusion. Bundles: order sets should be used.
surgery and the elderly
o Preoperative Assessment
o Post-Operative Care
Preoperative assessment: cardiac risk
o History and Physical Check List: Coronary Artery Disease, Prior Myocardial Infarction, Congestive Heart Failure, Arrhythmias, Pacemaker, Orthostatic Intolerance
perioperative cardiac evaluation for noncardiac surgery
o Clinical Markers
o Functional Capacity
o Surgery Specific Risk
Surgery in the elderly: perioperative managment
o Focused History and Physical
o Laboratory Evaluation
o Medication Review
o Cognitive, Social and Functional Status
o Nutritional Assessment
Perioperative management: medications that increase risk
o Sedative Hypnotics
o Antiseizure Rx
When to stop Rx pre-op
o 7 Days
o 7 Days
o Slow Taper
o 48 Hours
o Night before
pre-op nutritional assessment
o Appetite Change
o Weight Loss
o Special Diet
o Poor Dentition
o Consider Nutrition Boost Two Weeks Pre-op
perioperative complications: COPD
o STOP SMOKING: 48 hours-8 weeks, Use Transdermal Nicotine Replacement
o Pre-op Education: Deep-breathing Techniques, Cough, Incentive Spirometry
perioperative complications: CHF
o Stabilize: ACE Inhibitors, ARBS, Spironolactone, Digoxin
o Beware: Dehydration/Volume Depletion, Electrolyte Disturbance
perioperative complications: HTN
o Preop hypertension leads to intraoperative blood pressure fluctuation
o Mild to moderate hypertension should not delay surgery
o In elective surgery, control 2-4 weeks pre-op
o Emergency surgery, IV Rx
perioperative complications: DVT
o Risk increases with age
o High risk procedures: Orthopedic procedures, Total Hip Replacement (20-50% Risk)
o Elastic Stockings
o Low Dose Unfractionated Heparin
o Low-Molecular weight Heparin
o Intermittent pneumatic compression
perioperative care: warfacrin management
-D/C 5 days before surgery
-Allow INR to fall below 1.5
-No preop heparin required
-Resume warfarin 12-24 hours post-op
-D/C warfarin 4 days before surgery
-Allow INR to fall below 1.5
-Use IV heparin if warfarin cannot be resumed with 48 hours
-Require concomitant heparin therapy
-D/C warfarin 4 days before surgery
-When the INR drops to less than 2.0, begin heparin
-Resume heparin 12-24 hours post-op
perioperative care: diabetes
o Goal: glucose 100-200 through perioperative period
o Postpone elective surgery if >300
o Utilize insulin post-op (1/2 dose)
o Restart oral hypoglycemics when full diet is resumed
o Provide Effective Pain Management
o Encourage mobilization
o Prevent pressure ulcers
o Remove urinary catheters
o Beware delirium!!!
o Monitor for DVT
o Encourage patients to perform ADLs
postoperative delirium risk
o Surgery: cardiac, hip, thoracic, AAA repair, opthamological, emergency
o Intraoperative Factors: pre-existing dementia, Parkinson’s, low cardiac output, hypotension, anticholinergic medications
o Post-op: hypoxia, visual/auditory impairments, polypharmacy, ETOH
postoperative care: delirium
o A very significant problem: In Hospital 10-15%, Perioperatively 5-73%, Critically Ill/ICU >60%
o Outcome: Predicts cognitive decline, 26% mortality at 6 months
o Adds $16,303-$64,421 cost!
postoperative care: medical issues
o Silent Ischemia (Highest risk within 48 hours post-op, Monitor with serial ECGs)
o Venous Thromboembolism
o Urinary Tract Infections
mortality and surgery
o postoperative mortality rates
o 1.6% for nonelderly, 9.7% for elderly (age 65-79), and 17.8% for super elderly (age ≥80).
o age ≥80 increased the odds of death 2.7-fold
o postoperative complications with extremely high mortality rates in elderly: stroke (50% mortality), acute renal failure (60% mortality), cardiac arrest (70% mortality) and coma lasting more than 24 hours (100% mortality).
o Emergency surgery (for diverticulitis): postop mortality compared to nonelders is 6 times greater for ages 65 to 79, 11 times greater for ages 80 and older
informed consent: criteria
o The decision must be voluntary and free of coercion
o The patient must be given adequate information to make a decision, in lay terms, in a language they understand
o The patient must have capacity
medical decision making (MDM) capacity criteria
o Ability to communicate a choice
o Understand the relevant information
o Appreciate the medical consequences of the situation
o Reason for treatment choices
MDM: communicate a choice
o Have you decided to follow my recommendation?
o Can you tell me what the decision is?
o What is making it hard for you to decide?
MDM: understand the relevant information
Tell me in your own words what I told you about
-The problem with your health now
-The recommended treatment
-Possible risks/discomforts and benefits
-Risks and benefits of no treatment
MDM: appreciate the situation and its consequences
o What do you believe is wrong with your health?
o Do you believe in your treatment?
o What is the treatment likely to do for you?
o What will happen if you are not treated?
o What are the risks of being treated?
MDM: reason about treatment options
o How did you decide to accept or reject the recommended treatment?
o What makes your option better than other options?
Surrogate decision makers
o Family (Spouse, Partners, Children, Siblings)
o Ethics Committees
o Decision making for the unbefriended elderly
surrogate decision makers
o Powers of Attorney (Health Care, General)