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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 26, 2017

Falls Assessment - Part 2

Several studies report that falls are the most common reason for geriatric trauma. Injuries in elderly tend to be more severe as compared to young even with similar mechanisms and severity. While evaluation an elderly with a fall, we also need watch for complications of prolonged immobility as well such as rhabdomyolysis, pressure sores, dehydration. 

What makes them fall?
  • CNS – slower nerve conduction, slower reflex response, poor co-ordination, decreased proprioception and vibration sense
  • MSK – arthritis, decreased muscle mass 
  • CVS - Arrythmias, Orthostatic drop
  • Visual impairment
  • Medications:  antihypertensives, sedatives, diuretics, autonomic meds, Anticoagulants complicate things further and lead to worse outcomes
  • Infections and related weakness
  • Environmental Hazards 


Here is a list of risk factors that can precipitate a fall:



Elderly are often poor historians
Ask next of kin, paramedics, neighbours, other informants and witnesses to get a better history. Do not rely 100% in a 90 year old with dementia. Follow this rule in cognitively impaired, 

IF IT WAS NOT WITNESSED, IT WAS NOT MECHANICAL 


Mechanical Fall v/s Syncope
Mechanical Fall (Simple Fall) is referred to a fall due to environmental reasons (tripped, slipped, loose rugs etc.) but not as a result of primary CNS, CVS. MSK etiology. 

Common causes of syncope elderly are:
1. Cardiac syncope (ECG every patient who comes with a fall esp if it was unwitnessed)
Advise or arrange follow up with Holter monitoring in unexplained falls. 

2. Orthostatic hypotension (Symptoms are more important than numbers)
In older people baroreceptor function and adrenergic sensitivity is less. Medication such as beta-blockers, calcium channel blockers complicate the picture further. 

3. Carotid sinus hypersensitivity  (neck massage and look for a drop in HR)

4. Micturition/defecation/cough syncope


Fall examination
  • Sensorium (Document Baseline)
  • GCS
  • Pallor, Pedal Edema, Calf Tenderness
  • Vitals: Fever, tachycardia, tachypnea, Low sats, Hypotension, postural drop
  • Massage carotid (if no bruit) to look for coated hypersensitivity 
  • RS/CVS/Abdo (suspect abdominal catastrophes, pneumonia)
  • Vision
  • CNS- Speech, Pupils, Joints ROM, Strength in limbs, gait assessment (if possible)
  • Skin - hidden abscesses, sores
  • AMT
  • Head to toe exam like secondary ATLS survey 
Delirium and tachypnea are two big signs of underlying infection



Assessing dependence and ADLs 
Assessment of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) – will help to determine how functionally independent the person was before the fall. This is helpful to plan discharge and assessing their functional abilities. 

Activities of Daily Living
  1. Transferring
  2. Toileting
  3. Bathing (first to be lost)
  4. Dressing
  5. Feeding (last to be lost)
  6. Continence
Instrumental Activities of Daily Living
  1. Meal preparation
  2. Housekeeping
  3. Medication management
  4. Finances
  5. Transportation/Driving
  6. Shopping
  7. Phone and use of technology

Assess function, need for carers and Mobility
At our shop, we are blessed in this regards as we have out super-efficient STARRS (Short -Term Assessment, Rehabilitation and Reablement Service) team to handle these issues for us. They often arrange home visits to double check if everything is okay. 


Falls Labs (with some clinical judgement) - Do not order everything for everyone
More testing leads to more false positives, unnecessary further work-ups and possible harm. 
  • CBC, CRP, Renal Function, Coags (if on Anti-Coagulants)
  • ECG
  • CT based on exam/suspicion of injury (Head, Spine, Chest, Abdo) 
  • Relevant X Rays (CXR, Pelvis, Others)
  • Urine dip
  • Cultures/Lactate if infectious ethology is suspected

DO NOT TREAT ASYMPTOMATIC BACTERIURIA (DON'T EVEN DO A URINE DIP IF THEY ARE ASYMPTOMATIC AND COGNITIVELY INTACT)


Imaging elderly
Have a low threshold for imaging (CT head/spine and CXR and Pelvis X ray) even in minor trauma. There are no long-term consequences of radiation exposure in this elderly. And remember, CT is just a snapshot, safety net them regarding the possibility of delayed subdural in future. 


Discharge Planning
New injuries may have a significant impact on the older person’s ability to function. Try and see things from their perspective or think - would you be happy to discharge your grandmother is she comes in with a similar problem?" For instance, they may not be able to climb two-floors with a knee injury, she may not be able to eat, cook with a sub on her dominant hand.

Preventing Falls
Small efforts towards prevention can make a huge difference. 
  • Document frequency and situation and look for a similar pattern
  • Request a thorough Geriatric Assessment (for Bone and Muscle weakness, Depression, Mobility, CNS) in case of frequent falls
  • Assess balance and gait as part of your physical exam (they might need walking sticks or frames for support)


Further Reading:
Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emergency Medicine Clinics. 2006 May 1;24(2):413-32.


Posted by:

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

     @EMDidactic


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