Mrs. Smith
Mrs. Smith is an 82 year old woman who fell on the sidewalk while walking home from the grocery store. She was brought to your ED by EMS – ambulatory in from the ambulance. Her vital signs are stable, and she is awake and responding to questions. She is joking with nurses but complaining of right shoulder pain.
- How do you interpret her mental status?
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- What orders would you write for this patient?
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- Suggest two concerning causes of her fall that would likely require hospital admission.
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Discussion: Mrs. Smith
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It is also appropriate to call power of atorney or to check pharmacy databases to help expand your understanding of polypharmacy in this population
We need to consider hypoglycemia from erroneous medication use, versus malnutrition.
syncopal episode from polypharmacy, dehydration, malnutrition
Good discussions noted above
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Importante en este caso establecer diagnóstico diferencial de su caída, descartar causas cardiogenicas, neurológicas, infectó metabólicas, por lo que no nos debemos de concentrar solo en el manejo de dolor y trauma, debemos de estratificar el riesgo que pueda presentar de eventos potencialmente mortales
alcohol abuse needs to be addressed in fall patients
Great discussion!
understand that we need to closely consider age in patients and how that affects their risks
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1mg hydromorphone? Are you joking?
Good case
Important to think of the cause of the fall and not just treat the symptom of “fall”
agreed
Look harder in geriatrics for cause of fall
Case is quite vague – however important to maintain a high level of clinical suspicion for underlying medical cause of falls
This patient would not have been walked inside of the ED from the ambulance as she is over the age of 65 with a fall from standing. PT would be collared and brought in with SMR precautions
collared, but thankfully no longer immobilized on a board
good case study
Always maintain high index of suspicion
I don’t know who “EMS” is referring to. Did the Firefighters driver her to the hospital? Doubtful considering they barely go to any medical calls these days. I believe the word you are looking for is “Paramedics.”
another good case study and important things to consider
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You guys did great work
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perfect
Excellent.
thank you
need more info
another good case study, and that’s the bottom line
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Good review of things to consider in falls involving elderly
We need to consider how she fell, did she slip, feel dizzy, vertigo, syncopal episode
Follow up with family or NOK to inquire about patients full history
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understanding baseline cognitive function important
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done
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J
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not enough information
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I forgotten about dizziness
More than two things to consider.
This scenario does not give enough history to really make a true discussion of treatment.
Done
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Seen often in ED setting
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asd
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thought provoking questions
Helpful
what medications is she taking
Would need to follow up with test results and make sure the patient had proper home care also. I agree with PPERRn that sometimes it is the amount and types of medications given to patients that can cause them to fall, or when they do not get their blood pressure medications changed when their body weight or health has changed.
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joking ofter a cover, look closer
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Family involvement to determine baseline is important here. Adequate and fast pain control to reduce the changes of delerium
great exam
good
Better history, imaging, admission for social work reasons.
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oh yeah, forgot about fall as a symptom of cardiac syncope (if there was no warning or if rhythm abnormality — new atrial fibrillation or bradycardia).. not so sure about dilaudid… may be too strong…
I agree…i usually see this cause an O2 de-saturation….i would not want to ‘muddy the waters’ for her metal status exam either.
Some ppl have noted use of tylenol, we also have to be careful as elderly may not remember when took last and use much more (or less) than recommended dosage
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I also would try to avoid narcotics in this patient unless the pain was severe. In a patient joking with nurses, I would give acetaminophen 1 g, sling, ice pack and reassess. I would even consider ONE dose of IM ketorolac (even though that can be questioned)… but not dilaudid 1 mg.
agree
I would not give narcotics at this time as I would see how she responds to Tylenol and also watch for changes in her MS that could be masked if given narcotic meds
good point
I disagree with automatic administration of hydromorphone, especially this dosage, in an elderly person. If narcotics are indicated I would start off with a small dose of fentanyl to see the patient’s reaction, before going to hydromorphone. I would not likely administer 1 mg as a starting dose to almost anyone
Agreed. Especially with elderly getting drop in BP, nausea and vomiting frequently happens. I would try Tylenol 1gm and toradol 15mg IM/IV
syncope, dizziness
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agreed
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i wouldnt give morphine to an elderly lady with the reason “less pain so less chance of delirium”, in itself morphine can cause delirium as well
Muy interesante e instructivo el tema
this part was my favourite, so useful!
this was quite help full
Okay good. Didn’t think of the polypharmacy cause
I disagree with the statement that anyone on blood thinners who strikes their head requires a CT simply because of exclusion criteria to a study. There is such a thing as clinical gestalt and thorough neurologic exam. I also disagree to giving an 82yo F 1mg of Dilaudid off the bat, as well. IV Tylenol is greater, consider a lower dose of an opiate – need to review her meds, other medical problems.
got it
good
great answers
The learning points are excellent for the most part.
I disagree about the liberal use of CT head.
Just because the patient cannot have ICH ruled out by a rule, doesn’t mean that they have to have a CT.
Surely there is room for careful physical exam, observation and clincial judgement.
Dogmatic adherence to rules leads to the situation we have now of overreliance on technology, low positive rates for CT’s of all kinds, expense and overcrowding in ed’s.
The learning points are clear and helpful; the questions are vague and ordering tests with no clinical information or the little information provided is difficult.
poorly worded questions and very little history
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Needs a cognitive screen – many, many choices – more important to do it than worry which one is best
good info
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pain meds
Nice
Thanks
The possibility of changes in electrolytes or medication changes. She may have a Urinary Tract Infection. Getting as much information is important when assessing the elderly.
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helpful if you provided details of physical exam
There would need to be a thorough incident history why the fall, and any recent fall history beyond this episode. Also try to get a good sense of patient medications and any reason for concern there.
It is very important to consider all aspects of this patient including social status, capacities at home, community support injunction with underlying cause and consequences of fall in making the decision regarding the disposition of the patient.
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shoulder x-ray should be helpful
blood sugar
has there been any cognitive change
Many things are possible, patient needs to have complete history, medications, physical exam and then proceed with injuries. She may have shoulder injury, as alluded we need to make sure she does not have major trauma or major medical problems
common scene in the ED
hydromorphone, while very effective analgesic, may change mental status exam.
the patient may appear well settled but mau harbour serious underlying cause
maybe just a fall
Great cases
yes
She may also be having an MI and just presenting differently.
Distracting injury might be a consideration in this case. Mrs Smith is having a right shoulder. There is a possibility where a cervical injury/ fracture is missed because the focus is on the right shoulder pain. As fall is a common presentation to ED, a checklist of causes of fall in elderly may be good in not missing any sinister diagnosis.
Good case to highlight the numerous precipitating causes of falls in older patients. Important to obtain focused falls history in the ED to avoid missing serious causes.
potentially a long list
There are numerous!
Be hyper-vigillant with elderly trauma, and with the causes of trauma!
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there is not enough information here in her history for these questions
sometimes trauma lite can also be trauma.
lots to consider here
Good reminder that even seemingly unremarkable events can involve significant underlying events.
What do you call a Unicorn with large Eyelashes?
U-Ni-Brow!
agree w manatee
I would be inclined to administer Tylenol first and then after a full evaluation of tests possibly prescribed alternative analgeesia
Asses for cardiac causes and neurological status (rule out TIA / CVA). Asses BGL and examine for mechanical causes. Determine if there are new medications or medications combo’s that could cause LOC or vertigo.
needs admisison
Good case to highlight the numerous precipitating causes of falls in older patients. Important to obtain focused falls history in the ED to avoid missing serious causes.
allowed better address the patient
se deben de descartar causas sistemas de las caídas
Very common ED presentation
one mg of hydromorphone in an 82 year old seems like an awfully big dose, I don’t agree with that recommendation.
1 mg hydromorphone po is equianalgesic to 5 mg of po morphine or 2.5 mg of po oxycodone (i.e. half a Percocet). It’s certainly reasonable to be cautious in opioid dosing in the elderly and “go low” is a good guide. However I think we often overestimate the “bigness” of the doses we are giving. I fyou want to start lower, that’s reasonable — just remember to go back at 45 minutes to assess the effect of your “awfully big” or “awfully small” dose.
I too agree with hsohrabi, I would lean on the side of recommending that patient receive 1g of Tylenol with 0.5mg of Hydromorph to start, with a re-evaluation in the next 30-45 min, using a pain scale.
The more information that can be obtained the better the intervention.
A lot of the falls could just be simple mechanical falls too
It’s true that sometimes a fall is “just a fall.” A wise geriatrician once pointed out that for a fall to be classified as a “mechanical fall” in an 80 year old, you should be able to say “yes” to the following question: “Would this same fall have happened in a healthy 25 year old??”! The answer is almost invariably “no” and that there may (or may not) be some modifiable issues that caused THIS fall in THIS older person. It’s our job to identify what led up to the fall.
Agreed, especially since most falls in older adults are multifactorial, so need to consider the patient’s meds, functional status, meds, vision etc. I don’t like the term “mechanical fall” as it focuses on the possible predisposing mechaism e.g. icy or cracked sidewalk, but there are always other things we need to consider when investigating a fall.
We see a large number of elderly with alcohol related problems. They are often ashamed and do not want to talk about their drinking habits with ER staff
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falls in elderly needs complete exam and assessment.
all possibilities have to be considered when an elderly person comes in post fall. The joking by the patient can be a defence mechanism so the health care professional doesn’t pry into their private life
Often see patients in the ER post fall as a result of poly-pharmacy…either interactions or simply not having had a medication reviewed completed to check the appropriateness of the medication they are taking and/or the dose and frequency of which they are taking them.
Agreed. I once had a patient who was in ED with falls and a blood sugar in his 30s after his pharmacy was not aware of patient’s recent discharge from hospital (another example of the need to communicate across transitions of care), so were not sending the blister packand this resulted in the patient not getting any of his diabetes meds, not to mention others. Patient also did not have any other supports in place to f/u on this and since he had a cognitive impairment, he was not too concerned about it and did not follow up with the pharmacy after his discharge home.