The elderly patient population is growing and will make up to 20% of the total population by 2030.  They make up to 51% of total ED visits, and this number is growing.  These patients are sicker, have higher acuity and require admission at higher rates.  For this reasons, these patients need special consideration.

Abdominal Pain
60% ED cases are surgical, 20% go directly to the OR
Have a lower threshold

Pitfalls:

• Relying on normal lab results
  
• Misdiagnosing mesenteric ischemia as gastroenteritis
  
• Relying too heavily on classic presentations of common illnesses
  
• Over-reliance on positive UA as indicating cause of acute abdominal pain
  
• Relying on classic findings and history to rule out appendicitis
  
• Expecting abdominal rigidity when considering a visceral perforation
  

Mesenteric Ischemia

• SMA embolus - pain out of proportion, nausea, vomiting, diarrhea.  Seen in atrial fibrillation, valvular disease, cardiomyopathy.
  
• SMA thrombosis - "Intestinal angina."  Seen in atherosclerosis, smokers.
  
• SMV thrombosis - less severe pain than arterial disease.  Seen in OCP use, hypercoagulable state.
  
• Non-occlusive mesenteric ischemia - nonreproducible abdominal pain, unexplained GI bleeding in ICU patients, abdominal pain after dialysis.
  

Trauma

• Higher prevalence of cervical spine injuries.  About 50% due to ground level falls
  
• Higher incidence of higher level cervical spine injuries.  45% C2, 15% C1 injuries
  

Infection

• Blunted/absent fever response in 30%
  
• 89% have infection when fever is present
  
• High incidence of asymptomatic bacteriuria.  Reconsider antibiotics for these patients.
  

References

1. One, et al. Detection of cervical spine injuries in alert, asymptomatic geriatric blunt trauma patients: who benefits from radiologic imaging? American Surgeon.2006.
   
2. Rosens
   
3. Chen P. Emergency rooms are no place for the elderly. The New York Times. 2014.
   
4. American Geriatric Society
   
5. US Department of Health and Human Resources
   
6. Lee J. Growth of senior specific EDs holds quality promise but raises cost issues.  Modern Heatlhcare.  2014.
   
7. Wang et al. Geriatric trauma patinets with cervical spine fractures due to ground level fall.  Journal of Clinical Medical Research. 2013.
   
8. Lamoschitz. Cervical spine injuries in patients 65 years old and older. American Journal of Roentgenology. 2002.
   
9. Spaniolas, et al. Ground level falls are associated with signfiicant mortality in elderly patients. The Journal of Trauma Injury, Infection and Critical Care. 2010.
   
10. Parker, Simon and Arash Afsharpad. Ground-level geriatric falls: a not so minor mechanism of injury. Case Reports in Orthopedics. 2014.
    
11. Platts-Mills, et al. A modern day purgatory: older emergency department patients with non-operative injuries.  Journal of American Geriatric Society. 
    
12. Row and Juthani-Mehta. Diagnosis and management of urinary tract infections in older adults. Infectious Disease Clinics of North America. 2014.
    

Submitted by Dr. Kristina Morgan, PGY-3

Case
48 year old male with alcoholism is injured after falling while riding a bull.  He reported to an outside hospital with right flank ecchymosis and pancreatitis.  He left AMA.  Two days laters he reports to the ED with confusion, fever, jaundice and tremors.  A CT of the abd/pelvis with contrast showed ascites and cholelithiasis but no other acute findings.  A non contrast head CT showed a small right posterior subdural hematoma.  The patient became hypotensive and tachycardia. 

Labs: 
Hemoglobin 5.3
WBC 5.4
Platelets 68,000
INR 2.2, PTT 42 (nl 24-36), fibrinogen 164 (nl 185-475)
Haptoglobin < 8

Diagnosis: Disseminated Intravascular Coagulation (DIC

• DIC is a systemic coagulopathy marked by endothelial damage, clot formation, fibrin degradation, consumption of coagulation factors and platelets, and secondary bleeding.
  
• Caused by sepsis, trauma, malignancy, to (amphetamines, MDMA), AAA, liver disease, heat stroke, burns, snake bites, pregnancy complications.
  
• These cause exposure to procoagulants (ie-tissue factor), causing thrombi formation leading to consumption of coagulation factors and platelets.
  

How to Diagnosis DIC
Clinical and laboratory diagnosis - no universally accepted diagnostic method

• Clinically diagnosis is considered in context of patient wick with primary problem (see above).  Patient will have bleeding diathesis (bleeding from orifices, IV lines) or may have signs of micro thrombosis (skin necrosis, end organ damage).
  
• Lab findings indicating possible DIC: thrombocytopenia, prolonged PT, decreased fibrinogen, elevated d-dimer
  

Differential Diagnosis

• Severe Liver Disease - also gives coagulopathy, thrombocytopenia due to decreased liver synthetic function.  If needed, factor VIII level may aid in diagnosis (decreased level indicates DIC - factor VIII partly made outside of liver).
  
• HIT (Heparin Induced Thrombocytopenia - thrombosis and bleeding, patients are not usually as sick, lack of other lab findings clinical context.
  
• TTP (Thrombotic Thrombocytopenic Purpura) - fever, intravascular hemolysis, thrombocytopenia (+/- renal failure, neuro symtpoms).  Will have normal coagulation factors.  If needed, may order ADAMTS-13 levels which will be decreased in TPP.
  

Management

• Treat underlying cause
  
• Early hematology consult
  
• Transfuse PRBC for symptomatic anemia, no clear target hemoglobin
  
• Transfuse platelet if < 10,000 (do NOT hold platelets if actively bleeding for fear of "fueling the fire")
  
• Treatment also depends if patient is primarily bleeding or clotting: 
  

1. If bleeding supersedes, transfuse FFP to keep INR < 1.5
   
2. Transfuse cryoprecipitate if fibrinogen < 100
   
3. Amicar (Aminocaproic acid) - limited evidence, inhibits plasmin, causing decreased fibrinolysis (not to be used alone as it can worsen thrombosis)
   
4. Tranexamic Acid - limited evidence, possibly useful with severe bleeding and hyperfibrinouytic state, no effect on mortality
   
5. If clotting supersedes, then PT/PTT goal > 1.5-2x normal range, may give heparin, although studies show no difference in overall mortality and may worsen bleeding
   

Back to the Case
The patient received 5 units PRBCs, 7 units FPP, 1 unit platelets, and 2 units cryoprecipitate.  He was given amicar 3 g IV q 6 hours over the first 24 hours.  He was managed in the ICU with close hematology, neurosurgical and GI consultation.  His levels improved as well as his clinical status, and he was discharged a few weeks later from he hospital in stable condition.

Summary

• No consensus on diagnosis or management for DIC
  
• Treat underlying cause, if able
  
• Early hematology consultation
  
• Give platelets for < 10k or if active physical site of bleeding/hemorrhage
  
• Give PRBCs for symptomatic anemia
  
• Give cryoprecipitate generally for fibrinogen < 50-100 initially
  
• Goal PT/PTT based on bleeding or clotting
  
• Decision for Amicar, TXA, or heparin made on individual basis
  

References
Up to Date, DIC retrieved April 2015
Robbins and Cotran, Pathologic Basis of Disease, 8th Ed
Levi M, et al. Guidelines for the diagnosis and management of disseminated intravascular coagulation. British Committee for Standards in Hematology. Br J Haematol 2009; 145:24.

Submitted by Dr. Andrew Wheeler, PGY-1

The PICHFORK (Pain in Children Fentanyl or Ketamine) Trial: A randomized controlled trial for comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries.

Andis Graudins, MBBS, PhD
Robert Meek, MBBS, MClinEpi
Dianna Egerton-Warburton, MBBS, MClinEpi
Ed Oakley, MBBS
Robert Seith, MBBS

Annals of Emergency Medicine, March 2015, Volume 65, Issue 3, pigs 248-254.e1

Intranasal use of medications is becoming increasingly popular in the pediatric population.  Medications that are helpful with pain or procedures can be administered rapidly without the need for the trauma of an IV.  While most of us are familiar with fentanyl and midazolam, now maybe there is another agent we could use.  and yes, that would be the drug that seems to have the most potential uses that keeps coming up, ketamine.

This study was randomized, controlled, double-blind, intention to treat study comparing intranasal fentanyl to intranasal ketamine for moderate to severe pain.  The primary outcome was median reduction of pain rating at 30 minutes after administration of study medications.  Inclusion criteria were patients aged 3-13 years weighing less than 50 kg (due to limitations of amount that could be given intranasal) with an isolated limb injury.  Moderate to severe pain was defined as greater than 6 on an age appropriate scale.  Exclusion criteria included patients with medication allergy, use of serotonergic antidepressants, nasal trauma or aberrant anatomy, or multiple trauma with head injury and loss of consciousness.

All qualified patients first receive ibuprofen following study drug administration, unless given in 4 hours prior.  Subjects received either intranasal ketamine at 1 mg/kg or intranasal fentanyl at 1.5 ug/kg.  A total of 80 subjects were recruited with a final number of 36 in the ketamine group and 37 in the fentanyl group.  Patients had similar baseline characteristics.

Their results showed similar pain reductions between both study groups at their primary outcome of 30 minutes, as well as secondary outcomes of 15 and 60 minutes following study drug administration.  However, ketamine was associated with more adverse events, which included dizziness and drowsiness.  Hallucinations and dysphoria were also reported in four and three patients respectively without mention of what those reactions actually entailed

Conclusions:  ketamine is an effective alternative intranasal analgesic for children with moderate to severe pain from limb injury, and I would have to agree with that assessment.  This was a relatively small study, however the results suggest that ketamine is an option and could potentially be used in the right patient.  So as they say "Keep Calm and Ketamine On."

http://www.annemergmed.com/article/S0196-0644(14)01363-8/abstract

Submitted by Dr. Michael Craddick, PGY-1