Ian M. Carrese PA-S2 South University PA Program July 29, 2012

GERIATRIC EMERGENCIES: A LOOK AT ALTERED MENTAL STATUS, ABDOMINAL PAIN AND CONGESTIVE HEART FAILURE

Ian M. Carrese PA-S2South University PA Program

July 29, 2012

Format for Presentation

Three case studies of emergent or urgent geriatric patients

One each with a chief complaint of AMS, abdominal pain and CHF

I’d like to make it somewhat interactive and ask questions along the way

Feel free to comment or ask questions throughout the presentation

Altered Mental Status

An 80 y/o female presents to the ED with acute altered LOC and lethargy for the past 2-3 weeks

CBC, CRP, blood glucose, CXR and CT of her brain are all normal

However, her 12-lead EKG shows SB with low voltage QRS complexes. Cardiac enzymes are WNL

She has a GCS of 10/15, VS are unremarkable except for a pulse of 56, rectal temp of 96.8° F and B/P of 170/90

PE is unremarkable except for delayed reflexes and sluggish bowel sounds

AMS: What should we do now?

I ordered a BMP, U/A with C+S and ABGsThe BMP was significant for hyponatremia

with a serum Na+ of 123 mEq/LUrinalysis showed high amounts of WBCs,

and gram negative rodsABGs: 7.32/50/68/27/8/90% on 2L O2 via NC

Further investigation and treatment

While examining her, I also noticed thinning eyebrows and extremely dry skin, as a shot in the dark, I added on a TFT (thyroid function test)

This showed a TSH of 100 mIU/L, Free T3 and T4 were undetectable

Although her GCS was 10, she was not adequately protecting her airway and she was markedly acidotic (respiratory) so I chose to intubate and hyperventilate her slightly to blow off some CO2

Remember the ABCs, and don’t think too hard!

Treatment continued

This patient also had a raging UTI, so I gave her a dose of Cipro 500mg IV which should cover most gram negative rods (most likely E. coli)

I am not familiar with the use of IV Levothyroxine in myxedema coma patients, but it seemed to be warranted given her mental status, VS, and physical exam, so I gave her a small dose of 200mcg IV (normal dose is 200-500mcg IV)

She was also started on ½ NS at 100mL/hr to gently correct her hyponatremia

She was stabilized with these interventions and admitted to the ICU for further treatment and close observation

Discussion

The DDx for AMS in the elderly is enormousHypoglycemia is one of the most common

causes of AMS and is also one of the most easily corrected

Her labs and CT ruled out renal and hepatic failure although she did have a serum Na+ of 123 mEq/L

CNS infections were also ruled out given a normal CBC and CRP

With a history of 2-3 weeks of lethargy an acute drug intoxication/overdose could safely be ruled out

Discussion continued

Metabolic and endocrine etiologies should have been explored given her hypothermia, hyporeflexia, bradycardia and low voltage QRS complexes

Her TFTs showed a massive primary hypothyroidism

Hypothyroidism alone rarely causes myxedema coma, but this patient had a concomitant UTI which exacerbates her endocrine condition

The foundation of treatment of myxedema coma is IV Levothyroxine

Case #2: Abdominal Pain

A 65 y/o gentleman with a long history of ETOH abuse and end stage cirrhosis of the liver presents to the ER after having vomited a large amount of blood

This is his first ever episode of hematemesis despite having several esophageal varices ligated a few years ago

He is pale, lightheaded, slightly jaundiced and ill-appearing

Abdominal Pain Continued

After having his varices ligated, he was started on Propranolol prophylactically, but still continued to drink half of a liter of Jim Beam daily despite being diagnosed with a cirrhotic liver

He also is non-compliant, but manages to take his Propranolol daily as it is his only medication

Physical Exam Findings and Labs

Vital signs are normal except for an increased pulse at 90 bpm. His B/P is 100/70

Lungs are CTA and his CV exam reveal no murmurs, rubs or gallops

His abdomen reveals mild distension with a moderate to large amount of free fluid

In general he looks sick, has mild jaundice and icterus

Physical Exam Findings and Labs

A CBC reveals a WBC count of 12,500 (and a slight shift to the left), H/H of 8.2 and 26 and platelets are 80,000

PT/INR is 23.6 and 2.0LFTs show that AST, ALT and ALP are all

elevated at 252, 137 and 321, respectivelyTotal Bilirubin is 3.2 with an Albumin level of

2.6

Diagnostic Studies

An abdominal U/S shows a moderate amount of free fluid and liver parenchymal disease

How are we going to manage this patient?

IV Octreotide 50mcg IV times one dose and then IV daily for four more days

IV antibiotics: I chose to give him Cipro 500mg IV and Flagyl 500mg IV

IV PPI: Pantoprazole 40mg IV I did not chose to give additional β-blockers

IV because he was lightheaded and his B/P was only 100/70

Admit to a floor bed as long as bleeding was controlled and he was hemodynamically stable

Discussion

Similar to AMS in the geriatric population, the DDx for abdominal pain is daunting

Given his history of esophageal varices, ETOH abuse and liver cirrhosis, this was likely an acute esophageal bleed

Esophageal varices account for a small percentage of UGI bleeds, but are associated with a 60-70% mortality rate after one year

Most die from complications related to the underlying hepatic syndromes, not exsanguination

Discussion

Again, always remember the ABCDs of the primary survey. This patient could maintain his airway, was breathing and had adequate signs of perfusion

It is quite often that patients with esophageal varices develop concomitant bacterial infections, so it is important to prophylactically treat with a round of antibiotics initially

IV Octreotide (Sandostatin) is key in managing variceal bleeds as it is a potent splanchnic vasoconstrictor

Discussion

I chose to give him a dose of IV Protonix, but after further research, I learned that IV PPI therapy is contraindicated in pre-EGD patients. Current guidelines recommend against IV PPIs although there is no data that they affect the outcome or findings of the endoscopy

Endoscopy and ligature of the varices is the gold standard treatment for this type of hemorrhage and it should be initiated within 12 hours of presentation

Case #3: CHF Exacerbation

A 69 y/o female presents to the ER with a 3-4 day worsening of SOB, cough with frothy pink sputum and a ten pound weight gain

She says she couldn’t afford a medication she called “Cardol” and ran out of her Lasix last week

She is pale, diaphoretic, tachypneic and agitated

While attempting to get additional history she becomes cyanotic and loses consciousness

Luckily you are in an emergency room and have the assets to intubate and ventilate her

Physical Exam Findings and Diagnostics

Now that she is intubated, her respiratory rate is now controlled at 22/min

Pulse is 102 bpm, regular with a B/P of 163/94; she is afebrile

Physical exam reveals an S3 and S4, marked JVD with hepatojugular reflux. Rales are auscultated throughout all lung fields except the apices and there are diminished sounds in both bases

EKG shows sinus tachycardia with Q-waves in leads I, V2 and V3 and a prolonged, “double-humped” P-wave. There are no acute changes

Diagnostics continued

BMP is unremarkable except for a mildly elevated BUN/Cr at 29 and 1.5, respectively

CBC shows a mild normochromic, normocytic anemia with an H/H of 9.1 and 27

BNP is extremely elevated at 3,721PCXR shows patchy, diffuse infiltrates,

Kerley-B lines, blunting of the costophrenic angles and cardiomegaly

More Diagnostics

Echocardiography shows no valvular abnormalities other than a trivial amount of MR, left ventricular hypokinesis and an LVEF of 30%

What should we do next?

STAT Cardiology consult for a possible trip to the cath lab and PCI?

Start a NTG gtt?Start an inotrope like Nesiritide?Diurese her with a Lasix gtt?

Management of an Acute CHF Exacerbation

Initiation of intravenous NTG at 10mcg/min helps reduce B/P, afterload and symptoms

An alternative to NTG is Nesiritide (Natrecor) which also results in vascular smooth muscle relaxation by stimulating the production of cGMP (very similar to how NTG works)

NTG and Nesiritide are not given in concertThe patient is in obvious pulmonary edema

and needs to be started on diuretics: Furosemide 80mg IV times one, then start a gtt at 0.1mg/kg/hr

Management Continued

Furosemide gtt may be doubled every two hours in order to achieve adequate diuresis. Max dose is 0.4mg/kg/hr

If her hypertension does not respond to IV NTG (little improvement at a gtt titrated up to 50mcg/min), IV Nitroprusside (Nipride) is an option

Also, if she needs additional inotrope support, IV Dopamine started at 5-10mcg/kg/min

As long as a patient is not in profound cardiovascular collapse, Dobutamine can be used in conjunction with both NTG and Dopamine

Management Continued

Although she did have LV hypokinesis on echo, she had no chest pain and no acute changes on her EKG

PCI is not emergently needed at this pointIt doesn’t hurt to consult cardiology to help

manage her inotrope therapyInitial EKG have been shown not to

demonstrate acute ischemic changes (however, it does look like she had an old anterior infarct), so serial EKGs are warranted

The Differential Diagnosis for Dyspnea

It is enormous in magnitude, similar to both AMS and abdominal pain

Drug-related alveolar edema seen in ARDS should be considered, but given her brief history of being without both “Cardol” and furosemide should point you towards heart failure You later find out from a family member that she

meant Carvedilol

More DDx

The usual suspects: acute bacterial pneumonia, PE, MI, COPD, acute asthma and acute allergic reactions

A high index of suspicion and objectivity should be maintained in order not to miss something like an acute IgE mediated reaction causing anaphylaxis and respiratory failure

Questions or Comments?

Works Cited: O. John Ma, MD, David M. Cline, MD. Emergency Medicine Manual, Sixth Edition. American College of Emergency Physicians. McGraw-Hill Medical Publishing Division. 2004.

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