5 Ways to Geriatricize Your ED

800px-Clock_CogsGeriatric EDs, or Senior EDs, have been popping up around the country. The idea behind them is that having a separate space, a distinct staff, and specialized protocols, can help provide better care to older adults. However, for many EDs and hospital systems this is simply not feasible. In this episode, Chris Carpenter (@GeriatricEDnews) presents five high-yield, low-cost ways that those of us working in non-senior EDs can take some of the principles of geriatric emergency medicine and apply them either to our own practice or implement them in our own EDs, without a lot of funding. For more about Geriatric EDs, check out this ALiEM blog post.

Continue reading

Posted in Systems and Administration | 2 Comments

Pulmonary Emboli in Older Adults

lungs-1.pngNot a day goes by that an Emergency Physician doesn’t at least consider PE in a patient who presents with chest pain, dyspnea, or syncope. We have become familiar with using risk stratification tools like the Wells Score and the PERC criteria. But what do you do in older adults? All of them will automatically NOT be PERC negative because of their age. In this episode, with PE guru Jeff Kline (@klinelab), we discuss the presentation of PE in older adults, including the demographics, diagnosis, and how treatment may differ from younger adults in small, sub-massive, and massive PEs.

Continue reading

Posted in Cardiology and Pulmonology | 2 Comments

Pearls and Pitfalls of Pain Management in Older Adults

cracked-heart.jpgPain 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.

Continue reading

Posted in Medications and Adverse Drug Events | Leave a comment

Dangerous Med Combos in Older Adults

weekly-pill-box.jpgLook 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.

Continue reading

Posted in Medications and Adverse Drug Events | 1 Comment

Hip Fracture Management Pathways in Older Adults

r2d2 hipHip 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!

Continue reading

Posted in Medications and Adverse Drug Events, Systems and Administration, Trauma | 4 Comments

Geriatric Toxicology Part 3 – Digoxin and CCBs

halos2Digoxin 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.

Continue reading

Posted in Medications and Adverse Drug Events, Toxicology | 1 Comment

Geriatric Toxicology Part 2 – Acetaminophen

Tylenol_rapid_release_pillsAcetaminophen 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.

Continue reading

Posted in Medications and Adverse Drug Events, Toxicology | 3 Comments

Geriatric Toxicology Part 1 – Salicylates

aspirinToxicologic 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.

Continue reading

Posted in Medications and Adverse Drug Events, Toxicology | 2 Comments

High Risk Medications and Adverse Drug Events

pillsAdverse 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.

Continue reading

Posted in Medications and Adverse Drug Events, Toxicology | Tagged , , , | 2 Comments

Dr Tintinalli on End of Life Care

image2bWhat 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.

Continue reading

Posted in Palliative Care | Tagged , , | Leave a comment