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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, June 19, 2017

Falls in Elderly

Definition

An event that leads to a conscious subject unintentionally coming to rest on ground or a lower level, not as a result of a overwhelming hazards or a major intrinsic event. e.g. – not due to trauma, seizure or syncope. A recurrent fall is defined as 2 or more falls occurring within 6 months, which need extensive evaluation for etiology.

Epidemiology
  • 1/3 rd. of young old (60-79 yrs.) and ½ of the old old (>80yrs) have at least 1 fall annually
  • Women starts falling between 65 - 69 yrs. whereas men after age of 80
  • More than half of the fall occur at home in which bedroom and bathroom are the commonest place.
    Etiology
  1.      Acute Illness (UTI, Pnemonia, Skin/Soft tissue, Abdomen, Other Infections)
  2.      Environmental Hazards (Slippery floor, absence of grabbers, low chair, high bed, dim bulbs, poor walking aids)
  3.      Medications (Anticholinergics, Antihistaminics, BZD, TCA, See Beer's Criteria)
  4.      CNS and Neurodegerative (CVA, TIA, Vertigo, Seizures, Dementia, Parkinsons, Myelopathy, Cerebellar causes, Postural Hypotension)
  5.      Miscellaneous (ACS, PE, Syncopy, Vision and hearing issues, Arthritis)

Why is it important?
The world is invariably heading towards an era of exponential rise in elderly population than adults and adolescent group of population. Most ED's in US, Australia, UK, European nations and off course developing nations like India as well are already flooded with elderly population. As such GEM trained specialist are very meniscal in numbers around the world, we need very broad minded thought process and knowledge on Geriatrics to prepare ourselves. 
  •      Triaging errors  - the triage nurse will obviously triages fall patients to trauma bay, in addition the registrar or attending who lacks experience in handling Geriatric case will just focus on consequences of fall such fracture NOF, IT, SDH or minor abrasion and lacerations and forgets to work up the patient based on query in the mind – what precipitated the fall?
  •      Subsequently patient will be seen by Orthopaedics/Neurosurgery fellows with minimal geriatric experience. Patient is managed conservatively or surgically and discharge from the ward without looking at the precipitating event. This might lead to subsequent falls and vicious cycle continues.
  •      ED is the first point of contact and we need to ensure patients take the appropriate route or see the appropriate specialist on admission. 



Focused Clinical Examination in fall

A good history, keeping the various causes of fall in back of mind should be elicited from patient or care taker especially drug, social and financial history which lead to diagnosis in 90 % of cases. So spend more on it rather than on a detailed clinical examination.I agree eliciting history from an old or a care taker is a pain and very tough but believe me it pays off.
  • Check whether patient is in Delirium using CAM score (Google it)
  • GCS is not good tool to assess sensorium in elderly non traumatic patient
  • Pulse – any arrhythmia, most common is AF in the OLD
  • BP – if patient is ambulant checking postural drop (Peripheral neuropathy with autonomic dysfunction, Neuro - cardiogenic  syncope etc)

Also do general physical examination just like working up any other case
  • Auscultation – check for any AS murmur (most common), carotid brute
  • Focussed Abdo and RS examination
  • Detailed neuro exam in ED is not possible but a focused Lower limb neurology such motor power, DTR, sensory examination including JPS , gait and cerebellar signs

Labs
  • A detailed history and examination will dictate what additional investigation to be done to answer the question in mind apart from trauma series of x-ray and CT brain
  • Beware most elderly will be on some or other blood thinners
  • Most of them need a broad work up to rule out infection.



ED Management
A good EP should always focus on the Q in the minds like Sherlock Holmes till you get that answer and of course managing injuries plus other consequences of fall which is obviously known by every one.



Disposition from ED
  • Elderly who are not fit to get discharged as a consequence of fall (#, Head injury, ACS etc) should be referred to respective units for further Rx
  • All stable elderly with falls before discharge has to be addressed by physiotherapist (PT) or occupational therapist (OT) who may not be there in most Emergency Departments 
  • The PTs assess neurology of patient and prescribe appropriate exercises and walking aids while OTs check safety of patients house or old age home whether it is elderly friendly environment such non slippery floors, comfortable bed and chair etc.
  • Those patients who does not have care taker at home or home safety is an issue should not be discharged rather admitted to Geriatric inpatient ward until social problems are sorted out or else they will definitely bounce to ED with another fall
  • A Geriatric clinic appointment should be arranged in the next couple of day for a comprehensive geriatric assessment.



Take home
  • During all the stages of working up, ask yourself - what could have precipitated this fall? Spend more time on history (next of kin, nursing home, paramedics)
  • Have a low threshold for admitting elderly with unexplained events
  • Keep the thought process broad with all differentials and causes in mind
  • Some times you may not be able to get that answer, that's okay – make sure you are not missing any thing gross.


Author:

     
        
  Rishal Rahman MBBS, FEM (Vellore), MRCEM (UK)
  MD (Geriatrics)
  Associate Professor
  Department of Emergency Medicin
  Christian Medical College
  Vellore, Tamil Nadu 
  India
     
     Rishal is dual certified in Emergency Medicine and Geriatrics. He is currently practicing as a Consultant in Emergency Medicine at Christian Medical College, Vellore. CMC Vellore has been one of the pioneers of Emergency Care in India that caters around 200 critically ill patients/day. In addition to General EM, his interests also include Geriatric EM, Geriatric Neurology, Academics and dealing with complexities of Geriatric Medicine such a poly-pharmacy, poly-morbidities and medication management. Rishal often swifts between the mindsets of an ED Doc and an in-patient Geriatric Consultant based on his work environment to ensure optimal patient care.

Monday, June 12, 2017

Wernicke's Encephalopathy

Wernicke’s encephalopathy (WE) is a neuropsychiatric disorder which arises as a result of thiamine deficiencyIn 80% of cases, the diagnosis is not made clinically prior to autopsy and inadequate treatment can leave the patient with permanent neurological sequelae and can possibly lead to Korsakoff syndrome. Therefore over-dignosis is preferred over under-diagnosis. Just like several other disease entities, Wernicke’s encephalopathy can be precipitated by other clinical diseases such as sepsis. 


Many physicians consider this only restricted to alcoholics which is not the case. Especially among non-alcoholics, the diagnosis is missed. 

WE is a result of thiamine deficiency, which can occur in ANY nutritionally deficient state. 


Classic Triad

The classic clinical triad of Wernicke’s encephalopathy consists of mental status changes, ophthalmoplegia, and gait ataxia. Complete triad is present only in about 10% cases. Other signs of disease such as hypothermia, vestibular dysfunction, and other ocular abnormalities can be presentOut of the eye signs, nystagmus is the most common ocular abnormality, not complete ophthalmoplegia. 

Reliance on the presence of the clinical triad as the sole criterion for disease is often inadequate and may lead to under diagnosis.



Risk Factors for WE:
  • Alcohol Abuse (inadequate dietary intake, reduced GI absorption, and decreased hepatic storage)
  • AIDS
  • Malignancy
  • Hyperemesis Gravidarum
  • Post Surgical Patients
  • Post Gastric Bypass



Thiamine Deficiency Syndromes





Why thiamine is so important?
Thiamine is a cofactor for several essential enzymes. Because thiamine-dependent enzymes play an important role in cerebral energy use, deficiency may initiate tissue injury by inhibiting metabolism in brain regions with high metabolic requirements. A decrease in their activity may lead to increased buildup of toxic intermediates. Lactate accumulation occurs both in the brain and serum because pyruvate cannot enter the Krebs cycle. 


Malnutrition + elevated lactate - Think thiamine deficiency


CNS lesions

The lesions of Wernicke’s encephalopathy occur in a symmetrical distribution in structures surrounding the third ventricle, aqueduct, and fourth ventricle. MRI is the imaging of choice. The mammillary bodies are involved in up to 80% of cases; atrophy of these structures is specific for Wernicke’s encephalopathy. However, empiric treatment is a norm in ED. 


Korsakoff Syndrome
Korsakoff syndrome refers to a persistent state of mental dysfunction characterized by memory impairment associated with confabulation. 


Differential Diagnosis
  • Intracranial Hemmorhage
  • Stroke
  • Cerebral Venous Thrombosis
  • Delirium Tremens
  • Hepatic Encephalopathy
  • Intracranial Space Occupying Lesions
  • Cerebellar Disease
  • Meningitis
  • Marchiafava-Bignami disease (demyelination of the corpus callous due to nutritional deficiencies)

Treatment

Low suspicion of disease - a minimum of 100 mg IV
Highly suspected disease - 500 mg IV

Administration of thiamine improves disease to some degree in almost all cases; however, persistent neurologic dysfunction is common. 


All patients presumed to have Wernicke’s Encephalopathy or at risk of developing Wernicke’s Encephalopathy should receive two pairs* of vials of Pabrinex in 100 ml of crystalloid i.v. over 30 minutes initially in A&E.


*(1 pair = ampoule 1 + ampoule 2). Pabrinex is available as 5ml or 10ml pairs of ampoules. 


IV thrice daily dosing is generally continued for 3-5 days for an established diagnosis and then oral Thiamine 100mg OD is continued for a month. On extremely rare occasions, Thiamine may cause allergic reactions and anaphylaxis. 


Glucose before thiamine Myth!

Iatrogenic exacerbation of Wernicke’s encephalopathy can occur with prolonged glucose or carbohydrate loading in the absence of adequate thiamine. A single acute administration of glucose does not appear to cause this effect. Urgent administration of glucose should not be withheld pending thiamine administration. 


IV Fluids to sober them up?
There is no evidence that intravenous fluids expedite sobriety in patients with acute alcohol intoxication. Read more on REBELEM and St.Emlyn's


References:
  1. Reuler JB, Girard DE, Cooney TG. Current concepts. Wernicke’s encephalopathy. N Engl J Med. 1985;312:1035-1039.
  2. Watson AJ, Walker JF, Tomkin GH, et al. Acute Wernicke’s encephalopathy precipitated by glucose loading. Ir J Med Sci. 1981;150:301-303.
  3. Zimitat C, Nixon PF. Glucose loading precipitates acute encephalopathy in thiamin-deficient rats. Metab Brain Dis. 1999; 14:1-20.
  4. Zimitat C, Nixon PF. Glucose induced IEG expression in the thiamin-deficient rat brain. Brain Res. 2001;892:218-227. 59. Hack JB, Hoffman RS. Thiamine before glucose to prevent Wernicke encephalopathy: examining the conventional wisdom. JAMA. 1998;279:583-584. 
  5. https://www.medicines.org.uk/emc/medicine/6571
  6. Donnino MW, Vega J, Miller J, Walsh M. Myths and misconceptions of Wernicke’s encephalopathy: what every emergency physician should know. Annals of emergency medicine. 2007 Dec 31;50(6):715-21.


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic

Monday, June 5, 2017

Non-Specific Weakness in Elderly

In a busy Emergency Department, it can be very challenging to obtain a detailed history and perform a complete physical exam. Our evaluation done in ED is quite often very focused. Patients are classified as "sick" v/s "not sick" or "admit" v/s "home". Seasoned physicians usually take only a few minutes to make this judgment but what happens when history is nebulous and exam is compromised due to frailty, low sensorium, cognitive issues etc. What happens when you are dealing with delirious octogenarian? Such scenarios are very demanding and consume significant amount of our time. And if this was not enough, imagine how would you proceed your evaluation when the presenting complaint is this:

Doctors, I am just not feeling right or  I am feeling weak

Evaluating weakness can be a daunting experience with a limited history and compromised exam. It is hard to define and there are a myriad of causes which can lead to this chief complaint. Current Literature reports that 1/5 elderly present to ED with a non-specific complain of weakness. More than half of these patients develop a significant illness within 30 days. 

Just like delirium and dizziness, "weakness" can also be multifactorial due to a combination of factors such as dehydration, medication side effects, depression, infections etc. Getting collateral history (Social Circumstances, Baseline Mental status, Mobility) from family, carers, paramedics, old records forms a crucial component of assessment to get a holistic picture. Onset of time (Acute v/s Chronic) and focality (Focal v/s true generalised weakness) are two important clues guiding further work up.




Neuro examination forms the cornerstone of physical exam. Literature suggests that the most common etiology for weakness in elderly are infections, metabolic issues and malignancies. Therefore, initial testing should be geared towards these issues. 



Investigations
  • FBC, ESR
  • CRP
  • Blood/Urine Cultures
  • Renal Function
  • Liver Function
  • TSH
  • CT/MRI Head (based of history)
  • ECG
  • CXR
  • Blood Gas - Includes Blood Glucose and Lactate (based on history)
  • Urine Analysis
  • POCUS (Assess Cardiac Contractility, IVC, Consolidation)

Common Causes of Weakness in Elderly (not a complete list)
  • Infections (Respiratory, Genitourinary, Skin, Abdomen)
  • Metabolic (AKI, Dehydration, Na/K/Mg/Phosphorus)
  • Malignancy
  • Endocrine (Thyroid, Adrenal, DM)
  • Neuro (Stroke, TIA, Myasthenia Gravis, Neuropathy, MS)
  • CVS (ACS, Heart Failure, Anemia)
  • Medications (Steroids, Diuretics, Hypnotics)
  • Autoimmune (Myopathies, PMR, Vasculitis)
  • Deconditioning


Do not jump to diagnosis of UTI, exclude other possibilities first and treat Urine Infections ONLY if patient is symptomatic. 


Take Home
The evauation of each patient should be individualised. For instance, Head Imaging may not be required for each one of them. A detailed history is imperative to ease further course of care. It is reasonable to start with quick bedside tests such as blood sugar, ECG, CXR, POCUS and then proceed with further work-up. Physical exam can classify weakness in terms of focality and onset to dictate what imaging/labs are preferable. 


Further Reading
  • Anderson RS, Hallen SA. Generalized weakness in the geriatric emergency department patient: an approach to initial management. Clinics in geriatric medicine. 2013 Feb 28;29(1):91-100.
  • Chew WM, Birnbaumer DM. Evaluation of the elderly patient with weakness: an evidence based approach. Emergency medicine clinics of North America. 1999 Feb 1;17(1):265-78.
  • Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical infectious diseases. 2010 Mar 1;50(5):625-63.
  • Nickel CH, Nemec M, Bingisser R. Weakness as presenting symptom in the emergency department. Swiss medical weekly. 2009 May;139(17-18):271-2.
  • Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, Laifer G, Bingisser R. Patients Presenting to the Emergency Department With Non‐specific Complaints: The Basel Non‐specific Complaints (BANC) Study. Academic emergency medicine. 2010 Mar 1;17(3):284-92.

Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic


Monday, May 29, 2017

Atypical is typical - Geriatric Pearls

The percentage of world's populations over 60 years of age will double from 11% to 22% from 2000 to 2050. As Emergency Physicians, we need to ensure that optimal care is provided to this aging population. As "kids are not just small adults", the first rule in Geriatrics is that “Elderly are not just old adults". 

Geriatric population continues to increase across the world and so is the number of Geriatric ED visits. Quite often, half of the ED is occupied by elderly. It becomes a challenge to gather history from this subgroup of patients due to various reasons (sensory impairment, cognitive impairment, multiple active problems). They present late, come with subtle presentations, have an increased length of stay, frequently end up getting admitted, undergo more investigations and still face a higher mortality. Hospitals are now coming up with specially equipped "Geriatric EDs" to cater the needs of elderly.  


This post mentions a few pearls highlighting the key differences between adults and elderly: 


Abdomen
  • About 1/3rd of elderly patients presenting with abdominal pain need surgery. There mortality rates are seven times higher than younger populations. 
  • They are less able to localize abdominal pain, less likely to produce guarding or react to rebound trigger due to poor muscle mass. They may not even complain of abdominal pain in cholecystitis, diverticulitis, or appendicitis. Don't be surprised if you end up diagnosing ACS, Diverticulitis, Intra-abdominal sepsis with a chief complaint of "weakness"!!
  • Older people are less able to wall off intra-abdominal infection so they develop peritonitis earlier, even without localized pain initially. The may not give you a textbook history of disease and exact sequence of events due to underlying memory loss. 
  • Elderly have thin gastric mucosa and increased acid secretion so they are more likely to bleed or perforate with minimal triggers.
  • Older people may not even mount a significantly increased WBC count even in the presence of a severe infection. 



Dermatology
  • Elderly are often less aware of pain (poor pain perception) from a skin or soft tissue infections. it is imperative to do a thorough skin exam and look for hidden abscesses, bed sores. 
  • Infections are easy to start, present late and slow to heal.


Genitourinary

  • Close to 50% of old people have white cells and bacteria in their urine as a normal finding. Do not overcall UTI since white cells and bacteria in the urine are likely normal findings. The diagnosis of UTI should be based on new symptoms referable to the urinary tract – frequency, dysuria – OR new weakness, confusion, or falls that cannot be otherwise explained after a thorough workup.
  • An elevated erythrocyte sedimentation rate (ESR) can be normal in older people. In women (age +10)/2 and in men age/2 will gives the upper limit of normal. 
  • A normal serum creatinine may indicate significant kidney disease. Calculate eGFR. 



Cardiopulmonary
  • Chest pain is rare in elderly presenting with ACS. They often present with weakness, confusion, nausea or just feeling unwell.  Thus diagnosis can be delayed as symptoms sound less concerning and ECG changes are less definitive. 
  • Beta-adrenergic stimulation is markedly decreased with age. Tachycardia may be minimal or absent with physiologic stress. Medications such as beta blockers mask symptoms of volume loss, sepsis.
  • Hypotension does not develop until much later in a hypovolemic or septic situation. 90/F with a BP of 130/80 could be in cryptic shock!
  • Because of weak chest musculature and decreased airway innervation, cough is not a frequent presenting symptom of pneumonia. They may not even de-saturate until a lot of lung is not functioning;
  • Troponin and D-dimer can be difficult to interpret in elderly population unless “negative.”



Immunological

  • The immune system produces fewer cytokines, leukotrienes and other inflammatory markers. A fever may be a very late response to infection. They can also get hypothermic with sepsis. Therefore, sepsis can present with a normal or low body temperature.
  • With an infection, they often present with atypical features like "delirium" and "tachypnea" without any other obvious features of sepsis. 70% of delirium is initially “hypoactive,” which can delay its detection in the ED.






Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic