Keywords: analgesia, headache, opioids (PubMed Search)
Primary headaches (not secondary to a life-threatening disease) can be challenging to manage. Remember the following pearls:
Things that DO NOT work: IV fluids, 5-HT3 Antagonists (aka Zofran), diphenhydramine (aka Benadryl), opioids
Things that KINDA work: oxygen for all headaches, sphenopalatine ganglion block (4% lido spray)
Things that PREVENT recurrence: dexamethasone for migraine headaches
Keywords: MRI, neuro exam, bladder, gait (PubMed Search)
Gorter K. Influence of laminectomy on the course of cervical myelopathy. Acta Neurochir (Wien) 1976;33(3Y4):265-281
Keywords: discharge planning, elderly (PubMed Search)
Elderly patients (mean age of 84 years) living in the community who are seen and discharged from the Emergency Department due to illness or injury are at increased risk for further disability and functional decline for at least six months after their visit. This is associated with increased mortality, cost and need for long term care in previously self-functioning individuals. * When appropriate to discharge from the ED, we should consider discharge planning that includes coordination with care management services to be sure these individuals have adequate home support systems in place and access to close outpatient follow-up.
*It should be noted that the risk is even greater after inpatient hospitalization.
Nagurney, Justine M. et al., Emergency Department Visits Without Hospitalization Are Associated With Functional Decline inOlder Persons, Annals of Emergency Medicine, 2016; 69(4): 426 – 433. doi.org/10.1016/j.annemergmed.2016.09.018.
Keywords: spinal cord, physical exam, assessment (PubMed Search)
Back pain with lower extremity symptoms can be concerning for cauda equina. Some pointers regarding the H&P:
None of these symptoms independently predicts cauda equina syndrome with an accuracy greater than 65%.
Bottom Line: do not depend on any one finding to reliably exclude or confirm cauda equina.
Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). 2000;25(3):348-351; discussion 352
Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690-697. (Review article)
Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg. 2007;21(2):201-203
Keywords: older adults, CrCl, GFR, weight (PubMed Search)
Serum creatinine decreases with age with the decrease in lean body mass. However, the number of functioning glemeruli and kidney function decrease with age as well, making the creatinine an unreliable indicator of renal function in older adults.
The solution? Calculate the creatinine clearance (CrCl) (or GFR) for a more accurate assessment of the renal function. You can use simple equations such as the Cockroft-Gault equation which incorporate the body weight and age.
CrCl (mL/min) = (140-age) x lean body weight (kg) x (0.85 if female)
serum creatinine (mg/dL) x 72
Cockcroft DW, Gault H, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41. doi:10.1159/000180580.
Wiggins J, Patel SR. Aging of the kidney. In: Halter J, Ouslander J, Studenski S, et al., eds. Hazzard’s Geriatric Medicine and Gerontology. 7th edition. New York, NY: McGraw-Hill; 2017. http://accessmedicine.mhmedical.com/content.aspx?bookid=1923§ionid=144525776.
Keywords: stroke, thrombolytics, tPA (PubMed Search)
Powers WJ et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49. DOI: 10.1161/STR.0000000000000158
Keywords: diplopia, imaging, radiology, CT, ophthalmology (PubMed Search)
Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:
Diplopia + cerebellar signs and symptoms
6th CN palsy + papilledema
Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)
3rd CN palsy (especially involving the pupil)
Compressive lesion (aneurysm of posterior communicating or internal carotid artery)
Diplopia + thyroid disease + decreased visual acuity
Optic nerve compression
Diplopia + facial or head trauma
Fracture causing CN disruption
CT head (dry)
Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis
Unilateral, decreased visual acuity
Orbital apex pathology
CT orbits with contrast
Uni- or bi-lateral, normal visual acuity
Cavernous sinus thrombosis
C.N.: cranial nerve
Margolin E, Lam C. Approach to a Patient with Diplopia in the Emergency Department. 2018 Jun;54(6):799-806
Keywords: CSF, lumbar puncture, infectious diseases (PubMed Search)
Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.
Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:
1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results
2. positive CSF VDRL OR positive CSF FTA-ABS test result
3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)
4. clinical symptoms
This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.
Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.
Halperin JJ. Neuroborreliosis and Neurosyphilis. CONTINUUM 2018;24(5):1439–1458
Keywords: weakness, sensory symptoms, MRI, LP (PubMed Search)
Frohman EM, Wingerchuk DM. Clinical practice. Transverse myelitis. N Engl J Med. 2010;363(6):564-572.
de Seze J, Lanctin C, Lebrun C, et al. Idiopathic acute transverse myelitis: application of the recent diagnostic criteria. Neurology. 2005;65(12):1950-1953.
Keywords: wounds, trauma, procedure (PubMed Search)
Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.
1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.
2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.
This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.
Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip Combination for the Management of Lacerations in Thin-Skinned Individuals. The Journal of Emergency Medicine. 2011;40(3):322-323. doi:10.1016/j.jemermed.2010.05.077.
Keywords: shingles, weakness, infection (PubMed Search)
Keywords: HoH, stethoscope, trick of the trade (PubMed Search)
Is your older patient hard of hearing (HoH)? Instead of shouting, get a stethoscope. Put the ear buds in your patient's ears and talk into the bell. It is a hearing amplifier you carry with you.
Bonus pearl: If you use the disposable stethoscopes, then the patient can keep it in their room and use it whenever anyone wants to talk to them.
Keywords: infarct, paralysis, numbness (PubMed Search)
An infarct of the spinal cord is technically considered a stroke
The most common risk factor is a recent aortic surgery. Can also occur with straining and lifting (rare)
Patients will present with symptoms of spinal cord involvement with a hyperacute onset (less than 4 hours)
Although the “classic” presentation is anterior cord syndrome (flaccid paralysis, dissociated sensory loss (pinprick and temperature), preserved dorsal column function), patients may present with loss of all functions below the level of infarct due to spinal shock, confusing the clinical picture.
The most common level is T10
Rabinstein AA. Vascular myelopathies. Continuum (Minneap Minn). 2015;21(1 Spinal Cord Disorders):67-83.
Keywords: guidelines, protocols, safety, delirium (PubMed Search)
Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.
Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)
Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:
communicate a consistent choice
understand (and express) the risks, benefits, alternatives and consequences
appreciate how the information applies to the particular situation
reason through the choices to make a decision
There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry.
Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time
Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.
Rodgers JJ, Kass JS. Assessment of Medical Decision-making Capacity in Patients With Dementia. Continuum 2018;24(3):920–925.
Keywords: fever, infection, physiology (PubMed Search)
Older patients are less likely than their younger counterparts to mount a fever in response to an infection. One explanation is that their basal temperature is lower. Some experts suggest redefining fever in older patients to match this decrease of 0.15C per decade. Therefore, your 80 year old patient would be considered “febrile” if their temperature is above 37.3C, rather than the traditional 38C.
Roghmann MC, Warner J, Mackowiak PA. The relationship between age and fever magnitude. Am J Med Sci. 2001;322(2):68-70
Keywords: myelopathy, myelitis, physical exam (PubMed Search)
Lhermitte’s phenomenon is as a sign of cervical spinal cord demyelination. It is considered positive if flexion of the neck causes a tingling sensation moving down the limbs or trunk, and may be reported as a symptom or elicited as a sign. This is due to stretching of the dorsal column sensory fibers, the commonest cause of which is multiple sclerosis. Other causes include other myelopathies, such as B12 deficiency, radiation and toxic (due to chemotherapy) or idiopathic myelitis. Its sensitivity is low at 16%, but its specificity for myelopathy is high at 97%.
Kempster PA, Rollinson RD. The Lhermitte phenomenon: variant forms and their significance. J Clin Neurosci 2008;15(4):379–81.
Khare S, Seth D. Lhermitte's Sign: The current status. Ann Indian Acad Neurol. 2015 Apr-Jun; 18(2): 154-156.
Keywords: pneumonia, infection, delirium, atypical (PubMed Search)
- Half of elderly patients presenting with pneumonia will manifest signs of delirium
- Tachypnea is the most reliable and earliest vital sign abnormality
- Classic symptoms are not often helpful at predicting severity of illness
- Symptoms are unreliable
- Cough (63-84%)
- Dyspnea (58-74%)
- Fever by history (53-60%)
- Fever at arrival (12-32%)
- Pleuritic chest pain (8-32%)
- Sputum (30-65%)
Caterino JM. Evaluation and management of geriatric infections in the emergency department. Emerg Med Clin N Am 2008;26:319-343.
Keywords: palliative, advance directive, end-of-life (PubMed Search)
25% of U.S. health care spending goes to the 6% of people who die every year. ICUs account for 20% of all health care costs. A new study has shown that patients with POLST (Physician Orders for Life-Sustaining Treatments) forms are less likely to receive unwanted life sustaining treatments when compared to patients with traditional Do-Not-Resuscitate orders (http://www.ohsu.edu/polst/). Using the POLST did not impact the degree of comfort care received for symptom management and helped individuals make more informed choices about the type and level of end-of-life care they wish to receive.
Keywords: stroke, altered mental status, gender, sex, confusion (PubMed Search)
Patients may present atypically with ischemic strokes, reporting symptoms such as face or hemibody pain, lightheadedness, mental status change, headache and non-neurological symptoms.
Up to 25% of patients will have these symptoms.
Women are more likely than men to present with these atypical (or “nontraditional”) symptoms, especially altered mental status.
Labiche LA, Chan W, Saldin KR, Morgenstern LB. Sex and acute stroke presentation. Ann Emerg Med. 2002;40(5):453-460.
Lisabeth LD, Brown DL, Hughes R, et al. Acute stroke symptoms: comparing women and men. Stroke. 2009;40(6):2031-2036.