This single center study asked patients about barriers to health carrier after ED discharge (example transportation, lack of PCP, inability afford medications, trouble with ADLs) and then surveyed EM residents about those same patients' barriers. Resident physicians way under perceived barriers to care in their patients. ("20.4% of patients reported they had no primary care physician (PCP) and 9.8% of residents reported their patient had no PCP . Limited health literacy was identified in 59.0% of patients and reported by 37.6% of residents . Abnormal cognition was present in 53.6% of adults age ??65 and reported by 16.7% of residents .")
Another example of if you do not ask, you will not know. Be careful of assumptions.
This Canadian study looking at older patients presenting to EDs with suicidal ideation or attempt found most were female, arrived by ambulance from home, had poor social determinates of health, had a mental health history and attempts were by poisoning. Similar risk factors to other age groups. Mental health conditions donot tend to improve with age.
A good reminder to consider careful prescribing to older patients at the time of ED discharge.
From this study: “Nearly 1 in 10 older adults filled a high-risk GEMS-Rx medication within 3?days of ED discharge between 2017 and 2022. Despite a decline in GEMS-Rx medication fills over time, younger cohorts of older adults and females were more likely to fill a high-risk medication upon ED discharge.”
Click for Gems-RX list
Intuitively, both younger and older patients would have better outcomes at level 1 vs level 3 centers. This was true in younger patients in this large trauma database study. It was only true for older patients with traumatic brain injury and a high injury severity score. Is this a function of care delivery being better at level 3 or less geriatric focus at level 1 trauma centers?
This study looking at older patient contact with the health system within 30 days of ED discharge found an overall lower rate of follow up for those patients with dementia. Perhaps extra care at time of discharge in arranging follow up is warranted for older dementia patients.
This Canadian study found women, even when controlling for injury severity, socioeconomic conditions etc, were less likely to be admitted to a trauma center than their male counterparts. Further investigation into this bias is warranted.
These authors looked at outcomes related to patients who underwent prehospital cold water immersion for acute heat stroke in Phoenix. They found immersion dropped temperature and improved neurologic function. This is a great reminder to cool these patients as soon as possible and a prehospital cooling protocol is feasible and helpful.
This review article in the Journal of Trauma and Acute Care Surgery states:
“In obtunded patients, an adequate and normal high-quality CT supports collar removal without the need for adjunctive imaging.”
In a randomized multicenter trial comparing direct vs video laryngoscopy in trauma patient intubation, video had a higher first pass success rate and equal complication to direct laryngoscopy.
This single center prospective study asked residents to determine if their patient had barriers to post ED discharge health care such as having a PCP, transportation issues, affording medications, and need for assistance with activities of daily living. They then compared the physicians’ answers to patient’s answers and found: “Physicians had poor sensitivity for accurate identification of patient barriers.”
Some of our discharged patients are struggling more than we realize.
This multicenter study looked at trauma patients with a hemothorax who underwent early tube thoracostomy vs. being observed. They found volume of over 300 ml predicted observation failure. Those observed had shorter hospital stays and less ICU admissions. Twenty two percent of observation patients required tube thoracostomy. The failed observation group had similar outcomes except longer hospital stays.
Expert consensus recommends not prescribing these eight classes of medications to older adults mostly due to sedative affect and fall risk. 1. Benzodiazepines 2. Barbiturates 3. Muscle relaxants 4. 1st generation antihistamines 5. Sulfanylureas 6. 1st generation antipsychotics 7. Zolpidem 8. Metocloprimide
A recent study shows marginal improvement in not prescribing these medications to older ED patients.
This single center study looked at diabetic patients who had a POC glucose over 300 and POC ketone over 1.1 and reviewed their diagnosis vs the laboratory accepted diagnosis of DKA.
“The most recent international consensus laboratory definition of (non-euglycemic) DKA includes a glucose of >?250; a pH <?7.3 or a bicarbonate ??18?mmol/L; and a beta-hydroxybutyrate (BOHB) ??3.0?mmol/L or urine ketone strip ??2+”
This nice review article reminds us “The AO-Spine classification is the most frequently utilized system for thoracic and lumbar fractures, and it categorizes fractures into three types. Type A fractures are compression injuries. In these fractures, the assessment of the involvement of the posterior elements of the vertebral body is essential. Type B fractures are distraction injuries implying tension band involvement, whereas type C fractures are translational or dislocated injuries. The AO-Spine Upper Cervical Injury Classification System… In this classification system, type A injuries have no ligamentous involvement and are considered stable. Type B injuries have tension band or ligamentous injury and may be unstable. Type C injuries are characterized by significant translation and loss of anatomic integrity and are considered unstable."
These authors argue that bystander interventions in the early minutes (they call them the diamond minutes) can have an impact on trauma survival. Particular attention to External hemorrhage control; Airway opening and maintenance; Safe positioning of unconscious patients; Mitigation of early hypoxia and hypothermia could improve survival. We need to publicize this information and undo the years of teaching not to move these patients due to concern of secondary spinal cord injury. Many studies have dispelled that concern.
This article suggest that freeze-dried plasma (FDP) is an acceptable adjunct to whole blood for prehospital resuscitation of trauma patients. “FDP is pathogen-reduced, shelf-stable for up to two years at room temperature, lightweight, and rapidly reconstituted at the point of care.” This method offers an advantage when caring for patients in remote areas with long transport times and has been used by NATO and Canadian armed forces.
Of the 215 Norwegian patients on oral anticoagulation seen for a head injury and having a normal initial head CT, none developed delayed hemorrhage. Median age was 83 years.
Here are two techniques to remove a helmet from an injured motorcyclist. The first uses a cast saw to bivalve the helmet. A link for a video is also provided.
In 290 trauma patients diagnosed with dementia prior to injury, when compared to 3000 patients over age 65 without dementia and similar injury severity score, the dementia patients had a much higher rate of discharge to an institution instead of back to home living. This was particularly true of older women.
