Download CBT435: Abdominal Pain

CBT701-EMT11 – Geriatric Medicine
© 2010 Seattle / King County EMS
Introduction
• With advancing age various organ systems in body begin to fail
or show decreased function
• Elderly have less reserve in their organ systems
• Loss of function (for example renal, cardiac, endocrine or
respiratory function) makes person more vulnerable to injury or
illness
• It is estimated organ systems lose approximately 1% of
capacity per year starting at about 30 years of age
• Consider the following:
–
–
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Increasing cholesterol will lead to more heart attacks
Decrease in cardiac output will lead to more falls and syncopy
Decrease in lung elasticity lead to more respiratory infections
Decrease in bone and muscle mass leads to more falls and
fractures
– Multiple medical conditions leads to increased medication
interactions
© 2011 Seattle / King County EMS
Introduction
• Good way to approach elderly patients –
assume they are more vulnerable to injury or
illness
• Examples:
– Pneumonia in someone 80 years of age is likely to
be far more serious than in someone age 25
– Fall in someone 85 may be very serious whereas
in a younger person the fall may lead to no harm
© 2011 Seattle / King County EMS
Course Objectives
1.
2.
3.
4.
5.
6.
7.
Identify unique characteristics of the elderly patients.
Identify examples of diminishing stroke volume in the elderly
patient.
Identify factors that affect outcome of the elderly patient in
trauma.
Identify signs and symptoms of dementia and or the
pathophysiology.
Identify signs and symptoms of cardiovascular emergencies.
Identify emergency care for a traumatized elderly patient.
Identify emergency care for the medical elderly patient.
© 2011 Seattle / King County EMS
Terms
Diuretic - A drug such as Lasix (furosemide) and HCTZ
(hyrdrochlorothiazide) used primarily to treat hypertension and
congestive heart failure. Diuretics may cause dehydration, making
the patient more susceptible to syncope or heat stress.
Dysrhythmia - Irregular or abnormal heart rate, also sometimes
referred to as cardiac arrhythmia.
Elderly - There is no general agreement when a person becomes
“old”. The common use of a calendar age to mark the threshold of
old age assumes that everyone ages at the same rate which is not
true.
Metabolism - The process by which cells take in energy (food
and oxygen) so they can function. All bodily functions such as
digestion, muscle contractions, and breathing require energy. Heat
is a by-product of these processes.
© 2011 Seattle / King County EMS
New Terms
Bradypnea - Slow breathing. It is defined as a respiratory rate of
less than 10 breaths per minute. Things to consider are ingestion
of central nervous system (CNS) depressants (eg, narcotics,
benzodiazepines), stroke, or per terminal conditions.
Dementia - (meaning "deprived of mind") is a serious loss of
brain function that lead to problems in memory, thinking,
language, behavior, and judgment. Dementia may be progressive
or stable. The incidence of dementia increases with advancing
age.
Elder Abuse - Harmful treatment toward an elderly person,
includes physical, sexual, or emotional abuse, financial
exploitation, and neglect.
© 2011 Seattle / King County EMS
New Terms continued
Hematemesis - Vomiting blood. The source is generally the
upper gastrointestinal (GI) tract. This can be confused with
hemoptysis (coughing up blood). The spectrum of upper GI
bleeding varies from occult (meaning not readily seen) bleeding
that presents as anemia to acute, life-threatening hemorrhage
resulting in hypotension and shock. Sources of life-threatening
upper GI bleeding include peptic ulcer disease, esophageal
varices, and Mallory-Weiss tears.
Huntington's disease, chorea, or disorder (HD) - Progressive
neurological genetic disorder, which lead to loss of muscle
coordination and some cognitive problems. Its onset is typically
in middle age. It is the most common genetic cause of
abnormal involuntary writhing movements called chorea and is
much more common in people of Western European descent.
© 2011 Seattle / King County EMS
New Terms continued
Hyperosmolar nonketotic state (HKS) - An uncommon type of
diabetic coma. It has a high mortality. Other commonly used names
are hyperosmolar hyperglycemic nonketotic coma (HHNKC) or
hyperosmotic non-ketotic coma (HONKC). Patients with this condition
have very high sodium caused by severe dehydration.
Neglect - Failure of a caretaker to provide goods or services necessary to
avoid physical harm or mental anguish, such as abandonment, denial
of food or health related services. It can be intentional of unintentional
through ignorance or lack of training.
Vulnerable Adult - adults age 60 and older who cannot care for
themselves. Also, includes adults age 18 and older who, have a legal
guardian, are developmentally delayed, live in a DSHS licensed facility,
receive in home care services, or have a personal care aide who is
paid for their services.
© 2011 Seattle / King County EMS
CARDIOVASCULAR
AGING
© 2011 Seattle / King County EMS
Heart Disease
• Almost all cardiac diseases more common in
elderly
• Includes higher incidence of coronary heart
disease, congestive heart failure,
cardiomyopathy & heart dysrhythmias
© 2011 Seattle / King County EMS
Valves in the Heart
• Valvular heart disease leads to heart failure
by causing impaired cardiac filling and then
chronic volume overload, which results in
secondary heart failure
• Infection can cause endocarditis (infection of
the heart valves)
– More likely to occur in older persons
– Increase is due to number of factors including
higher number of prosthetic valves & increased
hospitalizations with associated hospital-acquired
infections in the elderly
© 2011 Seattle / King County EMS
Degeneration of the Cardiac Conductive
System
• Heart contraction – initiated by signal coming
from SA node in atria
– Signal then travels to AV node by special
conducting cells
– Signal then conducted through bundle of His to
bundle branches in ventricular walls which in turn
signal muscle fibers in walls to contract
© 2011 Seattle / King County EMS
Degeneration of the Cardiac Conductive
System
• Block occurs when signal
cannot progress or its
progress delayed
• Three degrees of block
– 1st degree (slow
conduction in the atria)
– 2nd degree (Mobitz 1 and
2) (partial block in the AV
node)
– 3rd degree (complete
block in the AV node)
• Stokes Adams
Syndrome: slowing of
heart & often leads to
syncope
• Patient may become
pale before fainting
– Normally syncope short
lived
• Seizures may occur with
associated fall in blood
pressure
– Often less than 30
seconds in duration
© 2011 Seattle / King County EMS
Stroke Volume
• Stroke volume (SV) – volume of blood ejected with
each contraction
• Ejection fraction (EF) – blood ejected by left ventricle
during contraction divided by total volume of left
ventricle
• Normal EF is approximately 60-65%
Video explanation available at EMS
Online:
http://www.emsonline.net/geriatric2011/
strokevol.asp
© 2011 Seattle / King County EMS
Congestive Heart Failure
• In heart failure, heart cannot
pump enough blood through body
• Can affect right, left, or more
commonly both sides of heart
• Can be chronic or acute
• Common symptoms of heart
failure include:
– Shortness of breath or difficulty
breathing
– Feeling tired
– Swelling of the lower legs
– Elevated jugular venous
pressure
© 2011 Seattle / King County EMS
Coronary Implications
• Aging heart has diminished stroke volume, increased
atherosclerosis, increased calcification in the valves
& less effective conduction
• Results may present as angina, myocardial
infarction, heart failure, atrial fibrillation, aortic
stenosis
• Elderly patients often do not present with typical
symptoms of acute myocardial infarction
– May be due to loss of sensory fibers though exact reasons
are not known
© 2011 Seattle / King County EMS
Coronary Implications
• Acute myocardial infarction in elderly may
include any combination of following
symptoms:
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Fatigue
Shortness or breath
Syncope
Hypotension
Be especially alert to atypical symptoms of MI in
elderly patients
© 2011 Seattle / King County EMS
RESPIRATORY
SYSTEM
© 2011 Seattle / King County EMS
Emergencies
• Older patients more likely to have conditions
like emphysema & heart failure (pulmonary
edema) and/or combination of these diseases
– Less ability to compensate compared to younger
patients
• Acute pulmonary edema often a result of
acute myocardial infarction (MI)
© 2011 Seattle / King County EMS
Pneumonia
• Common & significant health problems for
elderly
• Fourth leading cause of death in this age
group
• Nosocomial (hospital acquired) pneumonia
fairly common among older patients
– Especially for thoracic or abdominal surgery, on a
respirator, or undergoing tube feeding
• Serious underlying illness – major risk factor
for developing pneumonia in elderly
© 2011 Seattle / King County EMS
X-ray of lungs with pneumonia
© 2011 Seattle / King County EMS
Pulmonary Embolism
• Pulmonary embolism
(PE) – obstruction of
pulmonary artery caused
by blood clot
– Travels to pulmonary
artery from another
location (atria or lower leg)
• Incidence of PE
increases with age
© 2011 Seattle / King County EMS
Risk factors:
• Prolonged bed rest
• Underlying cancer
• Recent surgery
Video DVT & PE:
http://www.emsonline.net/geriatric2011/
pulmonary.asp
Asthma
• Typically chronic disease
caused by episodic
bronchospasm
(constriction) of lung’s
small airways
• Treated with two kinds
of medicines:
Nebulizers often prescribed
© 2011 Seattle / King County EMS
–Quick-relief medicines to
stop bronchospasm &
reduce inflammation
–Long-term control
medicines to prevent
recurrence
NEUROVASCULAR
SYSTEM
© 2011 Seattle / King County EMS
Disorders
• Disorders & conditions of neurovascular
system include:
• Blood vessel aneurysms in brain
• Stroke syndromes
• Vascular malformations of brain & spinal cord
• Dementia (Alzheimer’s type dementia is most
common) typically associated with atrophy of
brain cells
– Exact causes of dementia largely unknown
© 2011 Seattle / King County EMS
Delirium
• State of confusion that can
last days, weeks or even
months
• Associated with
hospitalization & may last from
hours to days
• Onset of delirium usually
fairly sudden
• Can be treated & often
temporary, even in people with
advanced illness
© 2011 Seattle / King County EMS
Precipitating cause of delirium
include:
• Drug side effects
• Dehydration
• Pain
• Urinary or other infections
• Poor vision or hearing
• Strokes
• Bleeding
• Heart problems
• Breathing problems
Dementia
• Show signs of disorientation
– May not know what day of week, day of month,
or even what year it is
– May not know where they are
– May not know relatives or people around them
• Often loss of memory especially short term
memory
• Progressive & largely untreatable
© 2011 Seattle / King County EMS
Alzheimer’s Disease
• Caused by series of small strokes
• Two most common types of dementia
– Vascular dementia
– Alzheimer’s Disease
• People with advanced Parkinson's disease
may also develop dementia
© 2011 Seattle / King County EMS
Alzheimer’s Disease
• Alzheimer’s type
dementia has no cure
• Most common type of
dementia & accounts for
up to 70 percent of cases
• As many as 5.3 million
Americans living with
Alzheimer’s type dementia
• Sixth-leading cause of
death in United States
© 2011 Seattle / King County EMS
Video Information re: brain changes:
http://www.emsonline.net/geriatric2011/
delirium.asp
Strokes
• Stroke (also known as a cerebral vascular accident –
CVA) is a medical emergency
• Occurs when blood flow to portion of brain stops
• Two major types of strokes
– Ischemic strokes –blood clot in vessel or artery in brain
(80%)
– Hemorrhagic strokes – blood vessel bursts & bleeds into
brain (20%)
• Blood supply to brain is interrupted, cells begin to die
due to lack of oxygen, glucose & other nutrients
© 2011 Seattle / King County EMS
TIAs
• Transient ischemic
attacks (TIAs) – blood
supply to brain
temporarily interrupted
• Symptoms of TIA
resolve within 24 hours
• While person is having
stroke symptoms –
impossible to distinguish
stroke from TIA
© 2011 Seattle / King County EMS
Thrombolytic Therapy & CVA
• Selected patients with CVA can benefit from
rapid thrombolytic therapy designed to
dissolve clot causing CVA
• Effective thrombolytic therapy – should be
given within 4.5 hours of onset of stroke
– Hospital requires one hour for evaluation & CT
this means symptoms onset to arrival at hospital
should generally be <3.5 hours
• Most hospitals in King County designated as
stroke centers & equipped & staffed to
rapidly make diagnosis & treat acute CVA
© 2011 Seattle / King County EMS
Thrombolytic Therapy & CVA
FAST Narrative to
rapidly determine if
patient has
experienced a stroke
A short telephone
report to the hospital
should include items
1— 4
© 2011 Seattle / King County EMS
Signs/Symptoms
Record
1
.
Face: Is it symmetrical?
YES/NO
Face: Is it symmetrical?
YES/NO
Speech: Is it slurred or
abnormal?
YES/NO
Time: What time was
patient last known to be
normal?
Note Time
2
.
Is the patient on
Coumadin (Warfarin)?
YES/NO
3
.
Glucometry. Glucose
should be over 60.
Severe hypoglycemia can
present like a stroke.
Check/Note reading
4
.
Glasgow Coma Scale
Score
Note Score
5
.
Time of hospital
notification
Note time
6
.
Time you left the scene
enroute to hospital
Note time
Glasgow Coma Scale Score
• Means of measuring & monitoring level of
consciousness
• Calculate score based on best eye, verbal, &
motor response
– Lowest score possible is 3, highest is 15
– GCS part of Code CVA
© 2011 Seattle / King County EMS
Glasgow Coma Scale Score
Glasgow Coma Scale
Eye Response
Best Verbal Response
Best Motor Response
Spontaneously opens - 4
Oriented and talking - 5
Obeys commands - 6
Opens to voice - 3
Disoriented and confused
-4
Locates pain - 5
Opens to pain - 2
Inappropriate words - 3
Withdraws from pain - 4
No response - 1
Incomprehensible - 2
Flexes to pain - 3
No response - 1
Extends to pain - 2
No response - 1
© 2011 Seattle / King County EMS
Parkinson's Disease
• Disorder affects part of brain that controls
muscle movement
• Symptoms may include:
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Trembling of hands, arms, legs, jaw & face
Stiffness of the arms, legs & trunk
Slowness of movement
Poor balance & coordination
• People may have trouble walking, talking or
doing simple tasks
• Disease slowly progresses
© 2011 Seattle / King County EMS
Huntington's Disease
• Huntington's disease (also known as
Huntington’s Chorea) – progressive disease
causes brain cell damage leading to
uncontrolled movements & mental
deterioration
• Inherited disease
• Signs & symptoms typically develop in middle
age
• Disease usually progresses slowly though it
can progress rapidly in younger patients
© 2011 Seattle / King County EMS
GENITOURINARY
SYSTEM
© 2011 Seattle / King County EMS
Disorders
• Geriatric patients experience general decline
in renal function
• Renal filtration falls average of 50% between
ages of 20 & 90
• Kidney mass decreases by 20%
• Many drugs eliminated through renal
filtration
– Underlying renal dysfunction often cause of
decreased drug efficacy & other medicationrelated problems in older patients
© 2011 Seattle / King County EMS
Disorders
• Urinary incontinence, inability to maintain bladder
control, more common in older patients
• Some causes of incontinence in the elderly are:
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Decrease in bladder capacity
Involuntary bladder contractions
Decreased ability to delay voiding
Medications that affect bladder control
Decline in sphincter muscle control
Prostate cancer
Severe dementia
© 2011 Seattle / King County EMS
ENDOCRINE
SYSTEM
© 2011 Seattle / King County EMS
Diabetic Issues
• Incidence of type 2
diabetes increases with
age
• Complications of
diabetes include:
– Kidney failure
– Blindness
– Heart disease
– Stroke
– Lower extremity
amputations
© 2011 Seattle / King County EMS
Type 2 Diabetes
• Type 2 diabetes associated with older age, obesity,
family history of diabetes, history of gestational
diabetes, impaired glucose metabolism, physical
inactivity & race or ethnicity
• More children have been diagnosed with type 2
diabetes
• Believed obesity & insulin resistance are to blame
• Unknown if resistance is due to obesity itself or a
combination of inactivity & increased consumption of
refined sugars
© 2011 Seattle / King County EMS
Hypothyroid Issues
• Approximately 0.5% to 5% of older adults
have hypothyroidism
• 5% to 10% have subclinical hypothyroidism
• Most cases in elderly people due to chronic
autoimmune inflammation of thyroid
© 2011 Seattle / King County EMS
Hypothyroid Issues
• Symptoms of
hypothyroidism often
nonspecific in older adults
& may include:
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Dry skin
Slowed thinking
Weakness
Constipation
Anemia
© 2011 Seattle / King County EMS
• Symptoms usually have
insidious onset & slow
rate of progression
– Result, diagnosis of
hypothyroidism often
missed
• Elderly patients with
mild hypothyroidism may
become severely
hypothyroid if they
experience serious illness
MUSCULOSKELETAL
SYSTEM
© 2011 Seattle / King County EMS
Disorders
• Osteoporosis common in
geriatric patients (especially
women)
• Often loss of total muscle
mass
• Falls common & often result
in fractured hips or collapsed
vertebrae
• Hip fracture – 10th leading
cause of hospital admission in
elderly
– Most result from falls at
home
© 2011 Seattle / King County EMS
Osteoporosis bone
resembles Swiss cheese
OTHER GERIATRIC
ISSUES
© 2011 Seattle / King County EMS
Trauma
• Trauma more serious in elderly compared to younger
patient
• Falls leading cause of trauma
– Falls can lead to moderate to severe injuries, such as hip
fractures & head trauma
• Elderly patients on Coumadin (anticouagulant)
– Fall or experience trauma (such as a motor vehicle accident
with a head strike)
– Very high risk of internal bleeding
– Must be evaluated in hospital
© 2011 Seattle / King County EMS
Polypharmacology
• Use of three or four
medications – important
risk factor for falls in
geriatric patients
• Use of multiple
medications also lead to
mental confusion or other
undesirable side effects
© 2011 Seattle / King County EMS
Elder Abuse/Vulnerable Adult
• As an EMT, under Washington State law (RCW
74.34.035) mandated reporter of suspected elder
abuse
• Who is a vulnerable adult?
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60 years or older
Functional, mental or physical inability to care for self
Found incapacitated
Has developmental disability
Receiving services from home health, hospice, or licensed
home care agency
– Receiving services from an individual provider
© 2011 Seattle / King County EMS
Elder Abuse/Vulnerable Adult
•
•
•
•
Signs of abuse and neglect include:
Unexplained injuries or behavior
Reports of physical, mental, or sexual abuse
Reports of being abandoned or deserted without basic necessities
•
Failing to provide basic life necessities, not taking action to prevent
harm or pain
•
•
•
•
– Lack of food, hydration, clothing, proper housing (heat), or hygiene
– Lack of physical aids like hearing aids, dentures, or eyeglasses,
wheelchairs, canes
Failure to provide safe living conditions
Untreated injuries or health problems
Intentionally taking advantage of a vulnerable adult either financially,
or personally
Undue influence or coercion
© 2011 Seattle / King County EMS
Elder Abuse/Vulnerable Adult
• Injuries can result from following behaviors &
actions:
– Pushing, striking, slapping, burning, biting, or pinching to
severe beatings
– Restraints with ropes or chains
– Force-feeding
– Incorrect positioning - creating pressure sores
– Improper use of restraints or medications
If you encounter any of these environments or injuries & you suspect
abuse, call Department of Social and Health Services (DSHS) at 1800-562-6078, your local police, or Adult Protective Services
© 2011 Seattle / King County EMS
Case Studies
Video Case Study #1
http://www.emsonline.net/geriatric2011/case1.asp
Video Case Study #2
http://www.emsonline.net/geriatric2011/case2.asp
© 2011 Seattle / King County EMS
Summary
Diminishing stroke volume in the elderly patient
• Stroke volume (SV) is volume of blood ejected with each
contraction
• Ejection fraction (EF) is blood ejected by left ventricle during
contraction divided by total volume of left ventricle
• Normal EF is approximately 60-65%
Pneumonia
• Most common & significant health problems for the elderly
• Fourth leading cause of death in this age group
• Serious underlying illness is major risk factor for developing
pneumonia in the elderly
© 2011 Seattle / King County EMS
Summary
Signs and symptoms of dementia
• Disorientation – may not know timeframes, where
they are, who their relatives are
• Memory loss, mostly short-term
Strokes
• A stroke (also known as a cerebral vascular accident
– CVA) is a medical emergency
• Strokes occur when blood flow to a portion of the
brain stops
• Require rapid evaluation & rapid transport
© 2011 Seattle / King County EMS
Summary
Polypharmacology
• Use of multiple medications
• Can lead to mental confusion
Elder Abuse/Vulnerable Adult
• Mandated reporter of elder abuse
• Signs of abuse & neglect include:
– Unexplained injuries or behavior
– Reports of physical, mental, or sexual abuse
– Lack of food, hydration, clothing, proper housing (heat), or
hygiene
– Lack of physical aids like hearing aids, dentures, or eyeglasses,
wheelchairs, canes
– Failure to provide safe living conditions
– Untreated injuries or health problems
– Undue influence or coercion
© 2011 Seattle / King County EMS
Questions
EMS Online
Guidelines and Standing Orders
http://www.emsonline.net/downloads.asp
Susan Kolwitz
Program Manager
Email support: [email protected]
Dr. Mickey Eisenberg
Medical Director
Ask the Doc: http://www.emsonline.net/doc.asp
© 2011 Seattle / King County EMS