Pain is the number one reason why people seek care in the Emergency Department (ED). One major goal of acute care is diagnosing the cause of the pain, but another is helping relieve the suffering associated with pain. In older adults, some of the risks of pain management with opioids are amplified, such as the risk of sedation and falls. With NSAIDs, there is a higher risk of acute renal insufficiency and electrolyte abnormalities, as well as cardiovascular risks with longer treatment. How should we approach acute pain management in the ED, and on discharge in older patients? In this podcast episode, Tim Platts-Mills, an expert and researcher on pain in older adults talks us through some ideas for non-opiates, opiates, and other adjuncts. We discuss some of the risks of over-treatment and under-treatment, and introduce the idea of the allostatic load created by chronic pain.
Pearls and Pitfalls of Pain Management in Older Adults
Dangerous Med Combos in Older Adults
Look twice at the med list before you prescribe these!
Two distinguished guests join me this month, David Juurlink (@DavidJuurlink) and Bryan Hayes (@PharmERToxyGuy), to discuss medication interactions. There are many medications that we commonly prescribe in the ED that can have potentially deadly side effects when combined with other medications that a patient is already on. It is important to always check the patient’s medication list prior to writing a new script. We present two examples of clinical cases in which commonly used medications could prove dangerous in combination with other medications: cellulitis and a community-acquired pneumonia. We discuss potential side effects from medication interactions (with a little pathophysiology thrown in), and some alternative medications that may be safer.
Hip Fracture Management Pathways in Older Adults
Hip fractures are a common injury among older adults and have a staggering one-year mortality of 20-30%. In this episode we discuss a multi-disciplinary pathway to improve the acute care of patients with hip fractures. It can help standardize care, improve pain control, decrease pain-related delirium, reduce the time from the ED to the operating room, and decrease the hospital length of stay. Also, if you have never heard of the fascia iliaca compartment block for pain management in patients with hip fractures, this could be practice-changing for you!
Geriatric Toxicology Part 3 – Digoxin and CCBs
Digoxin and Calcium Channel Blockers are both medications that can cause unstable bradycardias. Patients who overdose on them can present extremely ill-appearing, and require rapid intervention and stabilization. In this final geri-tox episode, Dr. May Yen talks about identifying and managing patients, particularly older adults, with these overdoses. Who needs digibind? How much insulin is used in high-dose insulin euglycemic therapy? What are some last ditch efforts for severe calcium channel blocker overdoses? We also drop some board review pearls. For example, those halos classically associated with cardiac glycosides such as digoxin seem to be much more prevalent on board exams than in real life. Comments or thoughts? Feel free to leave comments below, or connect on twitter @gempodcast.
Geriatric Toxicology Part 2 – Acetaminophen
Acetaminophen overdoses can be deadly if they are not rapidly identified and treated. While the treatment is relatively simple, there are still subtleties and ambiguities. How do you identify who needs treatment? Which patients should be transferred to a facility that has liver transplantation capabilities? What are “line-crossers”? In this episode, May Yen talks us through some of the finer points of identifying and managing acute and chronic acetaminophen overdoses, particularly as it relates to older adults.
Geriatric Toxicology Part 1 – Salicylates
Toxicologic emergencies can present differently in older adults compared with younger patients. The physiologic changes of aging make older patients more prone to accidental overdoses because of a narrowed therapeutic window. In this podcast, toxicology-trained Emergency Physician, Dr. May Yen, talks about why older adults are at risk for therapeutic misadventures. We then discuss the management of acute and chronic salicylate toxicity. Patients with severe salicylate overdoses can be some of the sickest and most difficult to manage patients in the ED.
High Risk Medications and Adverse Drug Events
Adverse drug events (ADEs) are a major problem among older adults who present to the Emergency Department. ADEs come in 5 types. 1 in 6 hospitalizations among older adults involves an ADE, and half of the hospitalizations for ADEs are deemed preventable. What medications should be used with caution or avoided in older adults? What are safer alternatives? In this podcast we discuss the types of ADEs, which patients are at greatest risk, the highest risk medications, alternatives to the high-risk medications, and ways to prevent ADEs. Leah Hatfield, an ED pharmacist, shares her wisdom.
Dr Tintinalli on End of Life Care
What does Dr. Tintinalli do when she has a dying patient and a family who needs help to make decisions and understand the options? – She gets involved. She calls the PCP. She gets palliative care on the line. She advocates for the patient to help make sure their wishes are understood and honored. There comes a time when you go from prolonging life to prolonging death. Knowing when that point is can be hard. Listen to hear her thoughts in this post from 10/2015.
Diagnosing and Managing Delirium in Older Adults
Welcome to GEMCAST! In this inaugural episode, first published 09/2015, Kevin Biese talks us through some practical tips for preventing, identifying, and managing delirium in older adults in the Emergency Department.
Delirium is incredibly common among older adults in the ED, but is easy to miss. It is also an independent predictor of 6 month mortality. How is it diagnosed? Why does it matter that we identify it? How can you prevent it? How do you safely treat symptoms of agitation in an older adult? How can you differentiate it from dementia in the acute care setting? – Take a listen.
