Microsoft PowerPoint - Elderly_specialconcerns - 張志華.ppt

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庄錞蒋
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1 老人急重症醫療之陷阱特殊考量與處置 ( 風險機轉機轉用藥 ) 新光醫院急診科張志華 Objective Understand some of the pitfalls in the emergency and critical care of the elderly

2 The differential diagnoses Remember MIDSO M: Metabolic (electrolytes, glucose, endocrine) I: Infection / inflammation D: Drugs / drunk S: Structural lesions O: O2, others (e.g. psychi, seizure ) Falls Very common in the elderly Most falls in the elderly are the result of their accumulated defects and diseases Look for M: electrolyte imbalance, glucose I: occult infection (UTI) D: drugs / drunk S: stroke, chronic SDH O: elder abuse

3 Recurrent injuries Elderly patients tend to have recurrent injuries Look for underlying risk factors Chronic illnesses Functional impairment Injuries to femur, pelvis, and C-spine Elder abuse Gerald McGwin, Jr. Arch Surg. 2001;136: Elder abuse is not uncommon! If one does not look for abuse in elderly victims, it will generally not be detected or prevented from recurring Elder abuse is relatively common and often unreported and undiagnosed

4 Shock or not? 70kg, elderly male HR BP Cardiac output 150/min 60/40 1.8L/min 80/min 100/70 5.0Lmin 110/min 120/80 3.4L/min Shock Definition? Answer: Inadequate tissue perfusion

5 Inadequate tissue perfusion 1. Decreased tissue perfusion 2. Increased tissue metabolic demand Shock: Inadequate Tissue Perfusion supply demand 供不應求

6 Shock in the elderly Elderly patients will go from normo-tensive to hypotensive in a heartbeat Profound, life-threatening hypovolemia may occur in the setting of relatively normal BP BP Perfusion Shock signs Hypotension: SBP < 90 mmhg Drop in BP > 40 mmhg Conscious disturbance Oliguria (<0.5 cc/kg/h) Metabolic (lactic) acidosis

7 Urine output Watch urine output Acute oliguric renal failure is probably best prevented by maintaining as high urine output as possible (without using diuretics) and by avoiding nephrotoxic drugs

$Look for blood loss into Soft tissue spaces Subcutaneous Retroperitoneal Pelvic fracture =$

8 Occult blood loss Blood loss in the elderly often overlooked! Look for blood loss into Soft tissue spaces Subcutaneous Retroperitoneal Pelvic fracture = massive bleeding Pelvic wrap

9 Preload monitoring Elderly patients respond poorly to too much or too little fluid (narrow therapeutic window) Adequate preload monitoring (CVP or PCWP) The best guide to continued fluid therapy at the bedside is the hemodynamic response to the previous fluid boluses Heat loss Hypothermia can occur quickly and easily in the elderly reduced subcutaneous fat ABCDE: Environmental control Caution: Hypermetabolism to correct hypothermia can put great stress on the cardiovascular system

10 Acute confusion of the elderly Pitfall: assumption that confusion in an elderly patient is due to senility Senility confusion; should look for M: Metabolic (electrolytes, glucose, endocrine) I: Infection / inflammation D: Drugs / drunk S: Structural lesions O: O2, others (e.g. psychi, seizure ) Caution: tranquilizers to control restlessness Try O2 and look for causes of hypoxia Sedate cautiously! Use of tranquilizers to control restlessness in elderly patients Try O2 Look for causes of hypoxia

11 Bones of the elderly are brittle Osteoporosis and reduced activity of advanced age combine to increase bone fragility and the incidence of severity of fractures Look for occult fractures Hip bone Shin bone Pelvis Fracture with normal radiograph Occult fractures: Initial x-ray can be normal Femoral neck fracture: pain can be in the knee Anterior cartilaginous rib fractures not visible Up to 50% bony rib fractures not visible on CXR Normal radiograph no fracture Bed rest and give instructions to return Confirm with tomography, CT, nuclear scan or MRI

13 Day 4 The aorta of the elderly is brittle Blunt aortic injury may occur in the elderly in the absence of conventional s/s

Aortic injury/ dissection Plain chest radiograph: Widening of mediastinum Pleural effusion Pleural capping Depression of the left mainstem bronchus

14 Aortic injury/ dissection Plain chest radiograph: Widening of mediastinum Pleural effusion Pleural capping Depression of the left mainstem bronchus Loss of the paratracheal stripe Tracheal deviation NG tube deviation Blurring of aortic knob Displacement of intimal calcification >5 mm (calcium sign)

15 Silent MI Beware of silent myocardial infarctions The only symptoms might be mild hypotension or dyspnea without chest pain Serial ECGs and cardiac markers Sudden apnea in the elderly Ventilatory failure and respiratory arrest may occur suddenly due to inadequate ventilatory reserve On monitor(s) : ECG, SpO2, EtCO2 Keep family at bedside Check ABGs if needed

16 Malnutrition Many elderly individuals, even those who are obese, have subclinical malnutrition. Chronic malnutrition is relatively common and often undiagnosed The daily allowance for protein of 0.8 g/kg/day is probably inadequate for traumatized older patients Survey major organ systems The pre-op workup of elderly patients should be designed to discover the presence and severity of all major organ dysfunctions Blood, urine, stool Chest radiographs ECG, cardiac markers Endocrine Bleeding profiles

17 Adverse drug reactions are common A little medication goes a long way with the elderly Sedative/hypnotics/narcotics/antihistamine overdose Aspirin, NSAIDs UGI bleeding Aminoglycosides, NSAIDs, radiocontrast nephrotoxicity OHA hypoglycemia Misleading minor problem Distracting pains: abdominal pain, chest pain, fractures look for principal underlying problem Stroke, myocardial infarction, or seizures may result in falls or motor vehicle crashes look for co-morbidities Underestimating and under-managing COPD, CAD, CHF, bedsores, easy-choking, etc. may result in preventable morbidity/mortality

18 Liver and Spleen When to suspect liver or spleen injury? Fracture of lower ribs (# 9-12) Abdominal signs in the elderly The sensitivity of abdominal exam in elderly patients is not much better than flipping a coin... Reliance on the abdominal examination will often lead to missed abdominal injuries

19 ICH can be silent Cortical atrophy, common in the elderly, may act to delay the clinical manifestations of serious intracranial hemorrhage Elderly patient who is still awake after head trauma can have a large SDH or ICH Avoid prolonged immobilization Prolonged immobilization weakness, osteoporosis, muscle wasting Avoid optimal reduction of fracture fragments at the expense of mobility

20 Anemia in elderly is abnormal Normal hematocrit is essential to maintain adequate O2 delivery because of subnormal cardiac or pulmonary functions Keep Hct > 30 or Hb > 10 in critical patients Take home message Elderly old adults A.A.D. Always assume atypical presentation Always suspect elder abuse Always assume the most deadly diagnoses

21 Thank You References: 1. Robert F Wilson: Handbook of Trauma 2. William C Wilson: TRAUMA (Emergency Resuscitation, Perioperative Anesthesia, Surgical Management) 3. Gerald McGwin: Arch Surg. 2001;136: Dicker and Mackersie: Pitfalls in the Management of the Trauma Patient

Microsoft PowerPoint - 病歷書寫jack(figures)

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