Emergency and Urgent Care Livestream Course April 22-25, 2020 3/27/2020

Day 4 - Saturday, April 25, 2020 - (Session times are based off the Eastern Time Zone) CME Credit 7:55 – 8:00 am Announcements – Alan Ehrlich, MD

8:00 – 9:00 am Interventions to Abandon in the ER & UC – Paul D. Simmons, MD, FAAFP; Mark A. Graber, 1.00 MD, MSHCE, FACEP 9:00 – 10:00 am Acute Abdominal Pain - Paul D. Simmons, MD, FAAFP 1.00

10:00 – 10:15 am Break

10:15 – 11:15 am Animal Bites and Stings – Paul D. Simmons, MD, FAAFP 1.00

11:15 am – 12:15 pm Assessment of the Acutely Ill Elderly Patient – Alan Ehrlich, MD 1.00

12:15 pm Course Adjourns

Interventions to Abandon in the ER & UC

Paul D Simmons, MD, FAAFP Mark A. Graber, MD, MSHCE, FACEP Disclosure

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME session.

• Vu Kiet Tran, MD, MBA has disclosed a relationship with Elvium on the topic “Acute Pain Management”.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives

1. Discuss the evidence for avoiding the use of the tests or procedures identified by the AAFP list of Fifteen Things Physicians and Patients Should Question. 2. Identify additional medical strategies and practices that may have not added value for patients. 3. Educate patients and staff on the value and benefit of appropriate evidence-based diagnostic tests and procedures. Stop sending pregnant patients for V/Q scan

Both chest CT and V/Q scanning are acceptable imaging options and involve acceptable radiation levels (Obstet Gynecol. 2011;118:718). The D-dimer is not a routine part of a chest pain workup! Stop doing them on everyone. 25% of CTs are false positive.

Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol 2015 Aug; 205:271. Syncope: Just like death except you get better.

(Choosing Wisely, ACP, ACEP) (www.choosingwisely.org) Don’t do a head CT for patients with simple syncope.

•Syncope requires either: −Both hemispheres to be knocked out −or the reticular activating system •Syncope is a brain perfusion/oxygenation problem. Any other reasons not to do CT scan besides cost, etc.? CTs cause Cancer

•What we know about radiation: −Even a single brain CT in an infant can cause a learning disability. −1:500 women and 1:600 men will develop cancer as a result of an abdominal CT at age 20. −One study estimated that roughly 29,000 future cancers could be attributed to CT scans performed in the US in 2007 alone −(see UpToDate for the data on abd CT and future cancers) CT scan and radiation risks

•Children/young adults: greater Cancer risk −tissues are more radiosensitive −more years of life to develop radiation induced cancer •Est. lifetime risk of cancer from one 64 slice Chest CT −20 y/o female = 1 in 142 −40 y/o female = 1 in 284 −60 y/o female = 1 in 466 −80 y/o female = 1 in 1338

Einstein AJ, et al. JAMA 2007; 298: 317-23. Careful with that oxygen, Eugene Oxygen seems harmful in MI if O2 >94% JAMA. 2010;303(21):2165.

Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction Circulation (http://circ.ahajournals.org/content/early/2015/05/22/CIRCULATIONAHA.114.014494)

Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 19 Dec 2016 Anything new on this front? Glad you asked! A new practice guideline. Should we use oxygen in any ill patient? Siemieniuk RAC et al. Oxygen therapy for acutely ill medical patients: A clinical practice guideline. BMJ 2018 Oct 24; 363:k4169. (https://doi.org/10.1136/bmj.k4169) Recommendations

•Overall oxygen increased mortality •The upper limit for peripheral capillary oxyhemoglobin saturation

(SpO2) should be ≤96% (strong recommendation). Moderate evidence suggests higher levels are associated with excess mortality. •For patients with acute myocardial infarction or stroke, oxygen

should not be initiated when SpO2 is ≥93% (strong recommendation), as hyperoxia can be harmful; •Those at risk for hypercapnic respiratory failure should be maintained at lower targets (i.e., 88%–92%); •A few conditions, such as carbon monoxide poisoning or sickle cell

crisis, warrant SpO2 targets approaching 100%. Stop using fluid for resuscitation of traumatic hemorrhage (sort of) Owattanapanich N et al. Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: A meta-analysis. Scand J Trauma Resusc Emerg Med 2018 Dec 17; 26:107. (https://doi.org/10.1186/s13049-018-0572-4)

Initial Care of the Severely Injured Patient NEJM 2019, 380;8 Main Points from NEJM Review Essentially Verbatim •If active bleeding…. −Normotensive patients should receive no fluid resuscitation

−Hypotensive patients should have fluid resuscitation withheld until systolic blood pressure approaches 80 mm Hg systolic

−“[When get to] 80mm Hg careful, small-volume boluses of blood or plasma (250 to 500 ml) should be given to maintain systolic blood pressure between 80 and 90 mm Hg.” −Mortality RR 0.5-0.7.

• There is definitely publication bias. Talk to your surgeon. Stop using steroids for acute urticaria.

Barniol C et al. Levocetirizine and prednisone are not superior to levocetirizine alone for the treatment of acute urticaria: A randomized double-blind clinical trial. Ann Emerg Med 2017 May 3; [e-pub]. (http://dx.doi.org/10.1016/j.annemergmed.2017.03.006) What we already know:

•Even 1 week of prednisone is enough to increase infectious complications, thromboembolic disease as well as falls and fractures (probably subclinical myopathy)

Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017;357:j1415. This study

•100 patients with < 24 hours of hives randomized to levocetirizine 5mg or levocetirizine + prednisone 40 mg X 4 days. •Outcome was itch score and relapses No difference in any outcome.

•No difference of itch score of zero at 2 days (62% vs. 76% favoring placebo). •Relapse after stopping meds 30% vs. 24% (again favoring placebo) •Recurrence: 12% vs. 14% (favoring steroids). UpToDate says to skip the steroids unless there is angioedema.

Feel free to use diphenhydramine or hydroxyzine if desired and tolerated. Stop referring for thrombolysis in patients with a DVT.

Enden T, Haig Y, Kløw NE, et al.; CaVenT Study Group. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012; 379(9810):31–38. •Transfusion was 11.1% vs. 6.5% in the anticoagulation group •Pulmonary embolism was 17.9% vs. 11.4% •Vena cava filter placement was 34.8% vs. 15.6% •P<0.1 •Intracranial bleeding, length of hospital stay, and cost were also more favorable with standard treatment. Why would we try try this? Within 2 years many get post thrombotic syndrome.

Vedantham S et al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 2017 Dec 7; 377:2240. This paper:

•691 patients with symptomatic proximal DVT •Yes or no pharmacomechanical thrombolysis •24 months no difference in postthrombotic syndrome 47% •Moderate-to-severe PTS occurred more often in the control group (24% vs. 18%), and severity of PTS was significantly greater in this group at all visits between 6 and 24 months.

•However, quality-of-life measures were similar in both groups. •6 had major bleeding. •Yes, a bit less post-thrombotic syndrome (NNT 16) •But no difference in quality of life. •So…use only when there is phlegmasia (which is basically a compartment syndrome). •Consistent with Chest guidelines: Use only when there is impending gangrene. Stop using steroids for bronchitis

Hay AD et al. Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: A randomized clinical trial. JAMA 2017 Aug 22; 318:721. •Looked at patients with lower respiratory tract infection but no pneumonia (bronchitis) •401 adults, mean age, 47 [SD, 16.0] years −63% women −17% smokers −77% phlegm −70% shortness of breath −47% reported wheezing; (only 6% wheezing on exam) −46% chest pain −42% abnormal peak flow Patients with COPD or asthma or who “needed” antibiotics excluded. −Randomized to prednisolone 40 mg for 5 days or placebo and followed for 8 weeks. −No difference in moderate or bad cough at 5 days, symptom severity or peak flow. −But…only 6% were wheezing. PDS

Stop Using Steroids for Wheezing in Preschool-Aged Children Scenario You’re seeing a four-year-old girl with one prior episode of wheezing in the ED.

She’s given albuterol nebulizers and a dose of dexamethasone, and admitted for observation.

The next day, she’s clinically better, needing a neb only every 4 hours. Another dose of dexamethasone is given and she’s discharged.

Did the dexamethasone do anything to alter her course? Probably Not…

A LOT of preschool children wheeze – but many of these are viral- induced, not asthma.

Trials on the benefit of systemic steroids in preschool-aged kids with wheezing (and no diagnosis of asthma) have had MIXED or NEGATIVE results.

Why? Because there are many causes of wheezing in this age group. Who This Does NOT Apply To

• Asthmatic kids DO benefit from systemic steroids (fewer and shorter hospitalizations) – but this is ASTHMA – atopy, multiple presentations, multiple triggers, hyperresponsiveness, etc.

• Wheezing kids with eczema may benefit more (an atopic phenotype).

• The good news is: up to 90% of wheezing preschoolers do NOT persist in the asthma phenotype by the time they start school! So What Should You Do Instead?

• Don’t routinely give steroids to mild to moderate wheezing preschoolers.

• Consider them, though, in atopic kids – more evidence of benefit.

• Use an asthma prediction tool, like the modified Asthma Prediction Index to predict risk of future asthma – high-risk kids may benefit. Stop using Pedialyte for “dehydration” Apple Juice for Dehydration??!!

Freedman SB et al. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: A randomized clinical trial. JAMA 2016 Apr 30; [e-pub]. (http://dx.doi.org/10.1001/jama.2016.5352) Single blind non-inferiority trial

•647 children (aged 6−60 months). •Gastroenteritis and minimal dehydration received −1) half-strength apple juice→ whatever the kid would drink. −2) apple-flavored electrolyte maintenance solution. •The primary outcome was treatment failure within 7 days: −intravenous rehydration −hospitalization −unscheduled visit to a physician −treating physician's request to cross over to other study arm −weight loss ≥3% or Clinical Dehydration Scale score ≥5 at follow-up Who are we talking about when we talk about “mild”? We are talking about normal kids. Not listless, irritable, etc.

•Did not include kids < 8 kg. •6 months-60 months •68% had no signs of dehydration (Huh??). •80% “looked normal” •Treatment failure was significantly lower in the juice/preferred fluids group: − (16.7% vs. 25.0%); −Intravenous rehydration at the index visit (0.9% vs. 6.8%) and within 7 days (2.5% vs. 9.0%). −Juice/preferred fluids was most beneficial in children ≥24 months of age (treatment failure rate, 9.8% vs. 25.9%). My take on this:

•We should continue to use rehydration solution for anyone who really needs rehydration. •If they are fine with mild or no signs of dehydration like 68%-80% of these kids, ½ strength apple juice is fine. Don’t CT closed head injury in kids unless they meet high risk criteria

See PECARN Rules PECARN RULES FOR HEAD CT IN TRAUMA < 2 years of age. PECARN RULES FOR HEAD CT IN TRAUMA > 2 years of age. PDS

Stop drawing procalcitonin for respiratory illness Montassier E et al. Guideline-based clinical assessment versus procalcitonin-guided antibiotic use in pneumonia: A pragmatic randomized trial. Ann Emerg Med 2019 Apr 11; [e-pub]. (https://doi.org/10.1016/j.annemergmed.2019.02.025) •235 patients with “lower respiratory tract” infection. Randomized to treatment based on procalcitonin or guidelines without procalcitonin, •Procalcitonin: Encouraged discontinuation of antibiotics when PCT levels were <0.25 µg/L, and strongly encouraged discontinuation for levels <0.1 µg/L.

•Clinical assessment–discontinuation of antibiotics if pneumonia was deemed clinically unlikely at 24 hours or the patient had been afebrile for ≥48 hours and had no more than one other vital sign abnormality at day 5. •Patients' median age was 67 years, 41% were female, and 40% had severe pneumonia. •Adherence to the protocol was 76% in patients randomized to PCT- guided care. •Antibiotic duration (the primary outcome) did not differ

•The clinical assessment–guided group less >5 days (24% vs. 14%). •There was no difference in clinical cure at 30 days (92% each group) or adverse events. As mentioned in another lecture, the infectious disease society and thoracic disease society do not recommend in their guidelines Do not draw (any) procalcitonin unless there is an evidence- based algorithm in place. https://www.choosingwisely.org/clinician-lists/ascp- procalcitonin-testing/ (2018)

And, they need you to do it so they can make their boat payments. PDS

Stop Doing LPs on Infants with Bronchiolitis Scenario

You’re seeing a 22-day-old full-term, previously healthy boy.

3 d hx of cough, nasal congestion, labored breathing, dec oral intake

T 101.3F (rect); P 112; R 54; retractions and diffuse wheezing

ED/UC workup: normal CBC, normal UA, CXR w diffuse peribronchial thickening. Blood cx and cath urine cx pending.

Do we need to do an LP to complete the “sepsis workup”? The Problem

• Some clinical guidelines recommend LP on ALL febrile infants < 60 days old • Guidelines vary institution to institution • Risk of serious undetected infection varies inversely with age • Risk of meningitis in febrile newborn < 60 d old is <1%

• But bronchiolitis also common! Up to 11% of febrile infants <90 d old present w bronchiolitis. What is NOT a Low-Risk Febrile Infant?

• Prematurity • Co-morbidities (e.g., congenital disease, immunosuppression) • Recent antibiotic administration (?may mask signs?) • Very young, e.g. < 7-14 d old ?? (data unclear)

The data is actually unclear in these cases, and it may be wise to err on the side of LP, but benefit is uncertain. What Should You Do Instead?

• Use a risk stratification tool: Rochester Criteria has NPV >98% for meningitis; PECARN rule for kids 29-60do has NPV 99.9% −Both in MDCalc and available elsewhere

• Get an RSV or viral panel − Multiple retrospective and prospective trials have shown it’s EXTREMELY unlikely for a low-risk febrile infant to have both a known viral infx AND meningitis (one study 1749 pts, no meningitis cases)

• Admit for observation without an LP

• Remember that LPs aren’t harmless: 19% traumatic taps, 87% false pos CSF cultures in one study PDS

Stop Getting Routine Blood Cultures on Children Admitted with Community-Acquired Pneumonia Scenario

You’re preparing to transfer (UC) or admit (ED) a hypoxic, febrile child who’s had a productive cough and has a leukocytosis and RLL infiltrate on CXR.

Do you need to grab blood cultures before starting antibiotics? Why You Don’t Need Blood Cultures

• 66% of childhood pneumonia is VIRAL • Typical bacteria (+/- virus) are seen only in 7% of cases

Vaccination works (again)! Pneumococcal conjugate vaccination has dramatically (1) decreased the incidence of bloodstream infection with pneumonia (2.5%) and (2) decreased penicillin resistance (~90% pneumococcal isolates are sensitive, with regional variation).

So you’d have to culture 667 kids to find one that needs something other than ampicillin/amoxicillin. Who This DOESN’T Apply To…

Kids with COMPLICATED PNEUMONIA (definitions differ, but…)

• Admitted to the ICU (Brits use this as the definition) • Moderate to large effusion or empyema • Abscesses or necrosis • Need for a pleural drainage procedure • “Metastatic complications” (i.e., seeding, like osteomyelitis)

These kids are at higher risk for unusual bugs (e.g. Staph) and bacteremia. What Should You Do Instead?

• Get cultures only on kids with COMPLICATED pneumonia

• Start IDSA recommended amoxicillin or ampicillin

• Culture those who don’t improve as expected AES Question PDS Question 1

A “best cutoff” orthostatic vital drop for dehydration is:

A. Pulse of 10 or systolic BP systolic 20 B. Pulse of 20 or systolic BP drop of 10 C. Just add them up: 30 and 30 64 D. It has never been tested in dehydration. E. I never really knew the answer to this. I just make it up each time the nurse asks.

Choose 2….. Don't bother with orthostatics.....almost ever.....

•30 beat per minute −Only 22% sensitive for moderate blood loss specificity 98% (1150cc blood loss) −97% sensitive for large blood loss •Severe orthostatic dizziness (to the point you cannot do orthostatics) is a better indicator Data: Orthostatics

•Measurement of orthostatics 100 patients after donation of 450 ml of blood. −Sensitivity of a change of pulse of 20 for detecting blood loss was only 9%. −Sensitivity 10 mm Hg decrease in diastolic pressure 17% •Anything else is hopelessly nonspecific. •Capillary refill and skin turgor useless in adults •Has never been tested in dehydrated patients without blood loss

McGee, Steven MD et al. Is This Patient Hypovolemic? JAMA 1999;281:1022 (March 17) Stop admitting patients for PE (well, some of them anyway)

Peacock WF et al. Emergency department discharge of pulmonary embolus patients. Acad Emerg Med 2018 May 14; [e-pub]. eSPEED Investigators of the KP CREST Network SO Ann Intern Med. 2018;169(12):855. Epub 2018 Nov 13. American College of Emergency Physicians and American College of Chest Physicians recommend early discharge for Low Risk Patients

How do you know if they are low risk? Modified HESTIA criteria:

•Any POSITIVE response mandates admission for PE treatment. •If all are negative, check the pulmonary embolism severity index (PESI): https://www.mdcalc.com/pulmonary-embolism-severity- index-pesi •If it is low, send the patient home. HESTIA criteria

•Hemodynamically unstable by clinician judgment •Thrombolysis or embolectomy needed •Active bleeding or high risk for bleeding: GI bleeding or surgery ≤2 weeks ago, stroke ≤1 month ago, bleeding disorder or platelet count < 75/L, uncontrolled HTN (sBP > 180 or dBP > 110) •Oxygen needed to maintain SaO2 > 90% •PE diagnosed while on anticoagulation •Requiring IV pain medication HESTIA criteria continued

•Medical or social reason for admission (e.g., concurrent infection, poor/no support system) •Creatinine clearance < 30 mL/min by Cockcroft-Gault •Severe liver impairment •Pregnant •Known history of heparin-induced thrombocytopenia This study

•114 low risk by HESTIA criteria randomized to standard care or discharge on rivaroxaban −Followed for 90 days. −Outcomes were bleeding, recurrent thromboembolic event, death. •Results: No difference in any outcome at 90 days −4.8 hours in the hospital versus 28.8 hours −Cost: $1500 vs. $4300 Second study

•822 vs 821 patients •All of Kaiser Permanente sites. •Watched in ED (<24 hours) until stable. •Discharged. •No 90 day differences. And, d-dimer is fine in pregnancy

Righini M et al. Diagnosis of pulmonary embolism during pregnancy: A multicenter prospective management outcome study. Ann Intern Med 2018 Oct 23; [e-pub]. (https://doi.org/10.7326/M18-1670)

Valente AM and Economy KE. Diagnosing pulmonary embolism during pregnancy: Which test is best? Ann Intern Med 2018 Oct 23; •395 pregnant patients −Risk stratified (revised Geneva score) and d-dimer in those with low to moderate probability, (see MD-Calc) −If d-dimer <500 mg/ml no further evaluation (high sensitivity) −If >500 or high risk Geneva score, full court press • Doppler, CT, •7% had PE, •Missed none at 90 days, none lost to follow-up, none died. •14% avoided radiation. If they have a POSITIVE CT-angio, what is the likelihood the patient has a PE? Hutchinson BD et al. Overdiagnosis of pulmonary embolism by pulmonary CT angiography. AJR Am J Roentgenol 2015 Aug; 205:271. Background

•PIOPED II (2018) showed that CT −High specificity for PE (in high risk patients) - 83% sensitivity. -False negative in 1% of patients with low to moderate pretest probability (based on Wells, etc.) -What about false positives? •937 CT-angiograms for rule out pulmonary embolism. Of these, 174 (18%) were read as positive. •They had 3 additional chest radiologists review all of the films. •They were blinded to the results. •26% of the time, all three radiologists read the CT as negative. •They claim breathing was the most problematic problem. •Also subsegmental and lower lobe PE, single PE. What this means to us?

•If you have low risk patients, and see a positive CT for a subsegmental PE, it may be false-positive. •Do you really want to anticoagulate these patients given real risk of hemorrhage (more later…)? •Don’t work up “no risk” patients. PERC RULES

•Age <50 •Pulse < 100 •SaO2 >94% on room air •No hemoptysis •No estrogens •No prior DVT or PE •No surgery or trauma within 4 months •No unilateral leg swelling Summary of other slides:

• Some (many) patients with PE can be discharged (supported by ACEP and Am Col Chest Phy)…..see data below. • Use the PERC rules (listed below). Answer Key

1. D and E © 2019 American Academy of Family Physicians. All rights reserved. All materials/content herein are protected by copyright and are for the sole, personal use of the user. No part of the materials/content may be copied, duplicated, distributed or retransmitted in any form or medium without the prior permission of the applicable copyright owner.

Acute Abdominal Pain

Gastrointestinal Emergencies

Paul D Simmons, MD, FAAFP St. Mary’s Family Medicine Residency Program Grand Junction, Colorado Disclosure

• Vu Kiet Tran, MD, MBA has disclosed a relationship with Elvium on the topic “Acute Pain Management”.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives

1. Discuss advanced diagnostic techniques available in an urgent care setting and effective use of available diagnostic and therapeutic tools. 2. Compare treatment options for patients with common GI conditions such as diverticular disease, upper and lower GI bleeding, visceral perforation, and aortic aneurysm. 3. Explain the appropriate evaluation and disposition of patients diagnosed with suspected GI malignancies in the urgent care setting. 4. Perform a differential diagnosis utilizing evidence-based recommendations and guidelines, including Choosing Wisely criteria for diagnostic imaging modalities, and appropriate scoring systems and tools. 5. Provide initial management for a patient presenting to the ER or UC with acute abdominal pain. Ahead:

1. Rational use of diagnostic testing (from physical exam to imaging) in the evaluation of urgent abdominal complaints.

2. Differential diagnosis, evaluation and treatment pearls and updates for: − Diverticular disease − Upper and lower GI bleeding − Perforated viscus − Abdominal vascular emergencies A Case • 26-year-old woman presents to your rural emergency department complaining of 6 hours of worsening RLQ pain, nausea without vomiting, and chills. No vaginal bleeding or discharge. She is sexually active with a history of irregular menstrual periods.

• VS: 100.3 F, P 90/min, R 14/min, BP 110/70 mm Hg

• Gen: Mildly ill-appearing, not diaphoretic. CV/Pulm: Normal.

• Abd: Tender RLQ with voluntary guarding but no rigidity nor masses.

https://commons.wikimedia.org/wiki/Category:Medical_treatment_ • Pelvic: Tenderness with bimanual exam of the R adnexa, o/w in_art#/media/File:A_young_physician_feeling_the_pulse_of_a_y unremarkable. oung_woman,_a_pain_Wellcome_L0013913.jpg AES Question Question 1

Let’s take a poll. How useful is an abdominal and pelvic physical exam (if done correctly) in diagnosing this patient?

A. Extremely useful. B. Somewhat useful. C. Sometimes useful, sometimes useless. D. Rarely useful. E. Not at all useful. AES Question Question 2

Let’s take another poll. At this point, which imaging test would you want?

A. Abdominal/pelvic CT without contrast. B. Abdominal/pelvic CT with IV contrast. C. Abdominal/pelvic CT with only PO contrast. D. U/S abdomen. E. Transvaginal U/S of pelvis. F. Plain KUB X-ray view of the abdomen. Physical Exam for the Diagnosis of Abdominal Pain AES Question Question 3

You are examining a 22-year-old man with abdominal pain and are concerned he may have peritonitis (if asked by a pesky Bayesian colleague, you’d say the history suggests an 70% probability of peritonitis). You perform an abdominal wall tenderness test, which is NEGATIVE. How likely is it now that he has peritonitis? A. 20% B. 25% C. 30% D. 35% E. Physical exam doesn’t work this way – you can’t put numbers on it! It’s a feeling! Some Useful Physical Exam Maneuvers for Abdominal Pain

Rigidity for peritonitis +LR 3.6 Positive abdominal wall tenderness test (Carnett sign) AGAINST peritonitis +LR 0.1

McBurney point tenderness for appendicitis +LR 3.4

Murphy sign for cholecystitis +LR 3.2

Visible peristalsis for SBO +LR 18.8 Distended abdomen for SBO + LR 9.6 Hyperactive bowel sounds +LR 5.0

McGee S. (2018), - 45% -30% -15% 0% +15% +30% +45% Evidence-Based Physical Diagnosis, 4th ed. pp. 0.1 0.3 0.5 1 2 5 10 445-456 Appendicitis: A Study in the Imperfect Art of Diagnosis

The Red Arrow Sign. CT abdomen image of acute appendicitis by WikiCommons user James Heilman, MD, creative commons license. At https://commons.wikimedia.org/ wiki/Category:CT_images_of_appendicitis#/media/File:Ap pendicitisMark.png Barriers to Practice How Good Are Vitals and Labs? Vitals are vital, but… • Temperature and laboratory data are often not helpful in distinguishing surgical from non-surgical disease in the elderly, very young or immunocompromised. • Like most physical exam findings, VS are more helpful if they’re abnormal, but normal VS don’t rule out serious disease.

About 25% of acute appy cases have normal WBC counts. [Am Fam Physician 2008, Apr 1;77(7):971-8]

Elderly patients don’t present “typically”: retrospective cohort, n = 231 > 65yo; temp, CBC, CMP, H/H did not predict surgical abdomen, and 13% of surgical pts had normal labs. [Fam Med 1996 Mar;28(3):193] AES Question Question 4

Which of the following statements about the use of procalcitonin in diagnosing acute appendicitis in children is TRUE? A. Procalcitonin may be elevated in acute appendicitis, but the combination of CRP and WBC performs better. B. A normal procalcitonin essentially rules out appendicitis, even with a classical clinical presentation. C. Procalcitonin often drops in acute appendicitis, and an undetectable level is suggestive of the disease. D. None of the above are true. What about newer tests? CRP? Procalcitonin? Lactate?

- The combination of WBC ≥ 10k and CRP ≥ 8 mg/L is useful both if

present (+LR 23) and if negative (-LR 0.03). Br J Surg 2004 Jan;9(1):28

- CRP alone is sensitive, but not specific enough to differentiate between surgical v non-surgical disease - Dig Surg. 2015;32(1):23-31. Epub 2015 Jan 28

- PCT does not perform as well as WBC and CRP in diagnosing appy in children, and isn’t sensitive enough to rely upon - Am J Emerg Med 2010; 28:1009 and Br J Surg 2013 Feb;100(3):322 - Lactate not as useful as WBC > 12k and CRP > 3 for appy in children - Am J Emerg Med. 2010 Nov;28(9):1009-15. doi: 10.1016/j.ajem.2009.06.004. Epub 2010 Mar 9 The Point:

Do use labs in combination with history, exam and imaging, but don’t be completely reassured by normal results.

Even using risk scores like Alvarado or the Appendicitis Inflammatory Response (AIR) score: PPV = 50-79% but NPV = 90-95%

Practice thinking in Bayesian, probabilistic terms rather than black-and-white terms. Imaging Appendicitis: The Gold Standard? The ACR Appropriateness Criteria

• Go to: https://www.acr.org/ Clinical-Resources/ ACR-Appropriateness-Criteria

Then, click on:

See The Complete List…

Screenshot of site referenced above. Screenshot from site referenced in prior slide Screenshot from site referenced on prior slide. Ultrasound vs CT for Appy? • General rule: (+) U/S is useful for ruling IN appy, but a negative U/S should probably not rule OUT appy if high clinical suspicion.

Bedside POCUS by experienced ED clinicians can likely rule in appy in adults (sens 84%, spec 91%) and children (sens 95% and spec 95%). Acad Emerg Med 2017 May;24(5):578 and Am J Emerg Med. 2018 Jul 14.

Still...CT is more sensitive than US for appendicitis, esp in adults.

Radiology 2006 Oct;241(1):83; Ann Intern Med 2004 Oct 5;141(7):537; Radiology 2008 Oct;249(1):97

But what about a stepwise approach to minimize radiation exposure? US → CT

• Optimal strategy for working up possible appy? – Maximize sensitivity while minimizing radiation – US followed by CT if US not diagnostic. – Prospective study of 1021 non-pregnant, adult patients (mean 47yo, 55% women) with non-traumatic acute abdominal pain – All got upright & supine XR, US and CT – 6 mos later, expert panel determined final dx and compared 11 permutations of diagnostic strategy (sens and spec) – Sensitivity highest (97%) with strategy of US first, followed by CT only if US neg or inconclusive. Would have reduced CTs by

50%! BMJ 2009 Jun 26; 338:b2431 What About in Urgent Care?

Some thoughts:

With any possible evolving acute abdomen, you do with what you have:

• Clinical judgment (history, physical and lab data) • Serial exams (available in some settings?) • Phone a (specialist) friend and close follow-up! • Consider adding to your toolbox with POCUS Acute GI Diseases Pearls and Updates First of all, treat acute abdominal pain…

• Historically, some were taught not to aggressively manage pain for fear of “masking” exam findings or pathology. • Cochrane 2010: Early opioid analgesia did not mask physical exam findings nor impair diagnostic accuracy. • Acad Emerg Med 2012 Apr: Patient-controlled morphine analgesia may better control pain (compared to physician-managed pain control) without leading to more adverse events. A Case

You’re seeing a 50-year-old man presenting with one day of acute left lower quadrant pain, nausea and chills.

His vital signs are normal except for a temp of 100.5 F and a pulse of 101.

He is very tender to palpation of the LLQ but no masses are felt, and there is no involuntary guarding. AES Question Question 5

Which of the following statements about diet and diverticular disease is TRUE?

A. There is strong evidence that a high-fiber diet reduces one’s risk of developing diverticulosis. B. There is strong evidence that avoiding seeds, nuts and corn reduces one’s risk of having recurrent diverticulitis. C. Experts recommend a low-fiber diet during an acute diverticulitis attack, but a high-fiber diet afterward. D. None of the above are true. Lower GI Bleeding LGIB: Stops spontaneously in 75% DDx: diverticulosis; hemorrhoids; angiodysplasia; IBD; ischemic colitis; postpolypectomy; less common - colon cancer, fissures, AVMs, endometriosis.

Dx and Tx: Colonoscopy - can detect a “0mL/min” bleed AND r/o other dx! • Timing? Urgent Endoscopy Does Not Improve Outcomes in LGIB • Urgent (< 24 h) colonoscopy resulted in more therapeutic interventions, but no differences noted in frequency of bleeding source identification, adverse events, rebleeding, transfusion or mortality. Gastrointest Endosc 2017 Feb 4; [e-pub]

- Small trials suggest endoscopic tx = IR treatment • Am J Gastroenterol 2005 Nov;100(11):2395 Barriers to Practice - Diverticulitis AGA Guidelines re: Acute Diverticulitis: Strate LL et al. Gastroenterology 2015 Oct 7.

• About 20% of patients with acute uncomplicated diverticulitis will have a recurrence, and most recurrences are not complicated. • Routine use of broad-spectrum antibiotics for uncomplicated acute diverticulitis may reduce complications and recurrences; the latter remains uncertain. • The risk for a major complication from elective surgical resection after recovery from acute diverticulitis is about 10%. • Factors that may reduce the risk for recurrence include a high-fiber diet, avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs), avoidance of aspirin, and regular use of probiotics. • Rifaximin may prevent recurrences, but the data are limited. • Data on avoidance of seeds, nuts, corn, and popcorn are extrapolated from the data on prevention of first episodes, which suggest that nut and popcorn consumption improves outcomes whereas corn consumption may have a negative effect on outcomes. • ***There are still huge gaps in our knowledge about diverticulitis tx and prevention. Diagnosis of Diverticulitis: • In patients with prior hx of diverticulitis, “typical presentation” of LLQ pain, tenderness w/wo fever is adequate for diagnosis. Mild symptoms don’t require imaging. – Japanese, Korean and Thai populations have a higher rate of R-sided diverticulitis.

• Testing: *don’t forget the hCG in women 6-60! – CT with IV contrast usually appropriate test – US can be used if CT contraindicated or unavailable – CRP >50 in pt with LLQ pain and no vomiting highly suggestive; 55% of pts have high WBC – X-ray mainly helpful in ruling out other conditions (eg, SBO) and complications (eg, perforation) Most can be managed outpatient. Admit if: sxs of peritonitis; unable to tolerate PO; suspected complicated disease.

Oral or IV antibiotics [SOR B or SOR C for L-sided only] • ciprofloxacin/levofloxacin + metronidazole PO or IV • TMP/SMX +/- metronidazole PO • ceftriaxone + metronidazole IV • amoxicillin/clavulanic acid PO or ampicillin/sulbactam IV

But…abx may not improve outcomes (emergency surgery, abscess, perf or recurrence) in uncomplicated L-sided diverticulitis! Cochrane Database Syst Rev 2012 Nov 14;(11):CD009092 and Br J Surg 2011 Jun;98(6):761

Oral antibiotics may be as effective as IV for uncomplicated dz [SOR B] Colorectal Dis 2009 Nov;11(9):941 (non-blinded RCT) https://commons.wikimedia.org/wiki/File:Diverticulitis.png

CT-guided drainage of large abscesses [SOR B] Lukewarm Off The Presses!

•van Dijk ST et al. Long-term effects of omitting antibiotics in uncomplicated acute diverticulitis. Am J Gastroenterol 2018 Jul; 113:1045 •Peery AF. It's actually a little complicated: Antibiotics for uncomplicated diverticulitis. Am J Gastroenterol 2018 Jul; 113:949. Withholding Antibiotics? Background: Two RCTs from Sweden and the Netherlands: antibiotics did not improve outcomes in patients with uncomplicated diverticulitis during 6 to 12 months of follow-up (Br J Surg 2012; 99:532; Br J Surg 2017; 104:52).

Dutch trial of 528 patients w first episodes of relatively mild, uncomplicated diverticulitis, 2-year follow-up results. −Diverticulitis recurred in 15% of patients in both the antibiotic and no-antibiotic groups. Incidences of complicated diverticulitis were not significantly different between groups (3.3% and 4.8%, P=0.403); sigmoid resection incidences also were similar (5% and 9%; P=0.085). −Caveats: 10% loss to follow-up.

• The AGA guidelines (2015) recommend SELECTIVE, not ROUTINE, use of antibiotics for uncomplicated diverticulitis…but will we in the US change our practice? AES Question Question 6

You are evaluating a 47-year-old man with active variceal UGIB. His pulse is 120/min, his BP is 75/palp, and his mentation is decreased. Which of the following statements about blood transfusion is most accurate?

A. He should be transfused immediately if his hemoglobin is < 7 mg/dL. B. He should be transfused immediately if his hemoglobin is < 8 mg/dL. C. He should be transfused immediately if his hemoglobin is < 10 mg/dL. D. What are you waiting for? Transfuse him now! Upper GI Bleeding ABCs: Airway: aspiration risk! Fluid resuscitation: two large-bore IV/IOs, crystalloid x 2 L, blood products thereafter if needed NGT? Controversial – doesn’t improve patient-oriented outcomes, may improve field for the endoscopist. https://commons.wikimedia.org/wiki/File:Blood_transfusion_Wel lcome_L0024143.jpg • When to transfuse? Ann Intern Med 2012 Jul 3;157(1):49 – Ongoing heavy bleeding means you can’t use hgb thresholds to decide – trending may help. – AABB transfusion guidelines have been pushing a more conservative threshold of ≤ 7g/dL for most medical patients, including ICU patients, unless symptomatic CV disease. – AASLD/AGA 2007 guideline: shoot for hgb ≥ 8 g/dL, BUT avoid overtransfusion→distention of varices→more bleeding – Baveno 2015 guidelines: hgb goal 7-8 g/dL, guided by adequate tissue perfusion Upper GI Bleeding – Review of DDx

Most common: • Esophageal and gastric varices (not only EtOH – also hep C, fatty liver these days!) • Peptic ulcer disease (NSAID use? H pylori history?) • Mucosal erosions (esophagitis, gastritis, duodenitis) • Mallory-Weiss tears

Less common: • Angiodysplasias / AVMs • Malignancy • Dieulafoy’s lesion (large, tortuous, eroded arteriole) Intervention: earlier (<24 hrs) is better for non-variceal UGIB [SOR B] Within 12 hours if: tachycardia, hypotension, bloody emesis or bloody nasogastric aspirate in hospital. Spiegel BM. Gastrointest Endosc. 2009 Aug;70(2):236-9. However, comparisons of urgent (<12h) vs early (<24h) endoscopy have found no difference in outcomes.

Peptic ulcer: Endoscopic coagulation, including non-bleeding visible vessels [SOR A] Most GI docs like IV PPIs, though not an evidence-based practice Variceal bleeding: Octreotide (or somatostatin) and continue 3-5 days after treatment Non-selective B-blocker, prophylactic abx (ceftriaxone 1g/d x 7d or FQ) Balloon tamponade an option (<24 h) until definitive tx available Endoscopy within 12 hours best [SOR A, also AASLD/AGA guideline] A Case

You’re seeing a 33-year-old man with an unfortunate history of severe ulcerative colitis.

Over the past three days, he’s had worsening LLQ abdominal pain, anorexia, bloating and nausea. He is now febrile with a T 102.3 F, a pulse of 110, and an exquisitely tender abdomen.

While you’re waiting for a call back from your surgeon, your portable chest X-ray returns showing free air under the diaphragm. Perforated Viscus Diagnosis: suspect if peritonitis, pain out of proportion, hx of diverticular dz, obstruction - dx by imaging (XR, CT, US) ABCs, decompression, Foley, IVF resuscitation Boerhaave’s syndrome (esophageal rupture): • SQ emphysema, Hamman’s crunch. • A surgical emergency!

Antibiotics vs. intestinal and oral flora • ampicillin/sulbactam, piperacillin/tazobactam • 3rd generation cephalosporin + metronidazole • carbapenem (if high resistance rates in your area)

Surgery: • Free air • History and exam suggestive of peritonitis Image open access from National Library of Medicine, Takeuchi N, • Abscess drainage Nomura Y, Meda T, Iida M, Ohtsuka A, Naba K - Case Rep Med (2013) Abdominal Aortic Aneurysm

***Screen all ever-smoking men >65 yo https://commons.wikimedia.org/wiki/File:Abdominal_aorta_2.jpg (>100 cigs in lifetime) – Yes, Medicare pays for it.

Hx: CAD risk factors; abdominal or flank pain

Exam: expansile, pulsatile epigastric/LUQ mass +LR 8.0

May mimic: • Nephrolithiasis (even with hematuria!) • Diverticulitis • GI hemorrhage • Musculoskeletal back pain • Pain can refer to chest, back or even scrotum Intestinal Ischemia and Infarct

Think about it in vasculopaths, age > 60, pts with arrhythmias, on vasoconstrictive meds/drugs, clotting disorders. • CT: bowel wall edema and thickening, pericolonic stranding with or without ascites, double halo or target sign, thrombus causing complete arterial occlusion, pneumatosis coli associated with bowel infarction

Include it in your DDx for LGIB! Ullery BS et al. J Emerg Med 2004 Jul. • 90% of pts with colonic ischemia had bleeding vs 11% of non- colonic ischemia. Image from Tom Hash via MedPix (NLM), at • Pain more common with non-colon ischemia (89%) vs colonic ischemia (10%) https://medpix.nlm.nih.gov/case?id=83f514a1-ccde-443f- b1ec-938ffa112853 Review → Retention

• Acute appendicitis: hx, exam, labs not good enough alone.

• Acute lower GI bleed: usually stops on its own; no rush on endoscopy.

• Acute diverticulitis: not everybody needs imaging and antibiotics.

• Acute upper GI bleed: ABCs, variceal and PUD treated differently.

• Perforated viscus: POOP, ABCs, decompress and surgery.

• AAA: screen for it, and think of it in your DDx.

• Intestinal ischemia: vasculopathic risk factors, LGIB in elderly. This Afternoon:

We’ll Apply Knowledge AND Talk About Some Unusual Causes of Abdominal Pain! Practice Recommendations

• The physical exam is more useful than we give it credit for – at least the useful parts.

• Use the ACR Appropriateness Criteria to select the right imaging test for your patient.

• Getting an ultrasound before a CT for appendicitis can avoid 50% of CTs!

• Repeat, uncomplicated cases of diverticulitis don’t necessarily need (a) imaging or (b) antibiotics

• Don’t forget those pregnancy tests in reproductive-age women!

• Transfusion thresholds are lower nowadays – aim for hgb between 7 and 8 mg/dL.

• Don’t over-resuscitate patients with variceal bleeding!

• We should be screening all ever-smoking men >65 yo for AAA.

• Include mesenteric ischemia and infarction in your DDx for LGIB. Thank you!

E-mail: [email protected] Answer Key 1. no right answer 2. no single right answer, but ACR Appropriateness suggests A, B or D 3. C 4. A 5. C 6. D © 2019 American Academy of Family Physicians. All rights reserved.

All materials/content herein are protected by copyright and are for the sole, personal use of the user.

No part of the materials/content may be copied, duplicated, distributed or retransmitted

in any form or medium without the prior permission of the applicable copyright owner.

Animal Bites and Stings

Paul D Simmons, MD, FAAFP St. Mary’s Family Medicine Residency Program Grand Junction, Colorado Disclosure

• Vu Kiet Tran, MD, MBA has disclosed a relationship with Elvium on the topic “Acute Pain Management”.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives

1. Categorize treatment strategies for patients with mammalian bites including considerations for appropriate wound management, use of prophylactic antibiotics and post-exposure rabies prophylaxis. 2. Compare and contrast clinical manifestations and initial management of common venomous bites and stings including black widow and brown recluse spiders, scorpions, and common North American snake bites. 3. Identify tick bites based on the skin manifestations (acute and chronic) associated with various tick-borne infections. 4. Counsel patients and families on methods to protect from pet related hazards. AES Question Question 1

How many animal bites occur in the US every year?

A. 400,000 – 500,000 B. 1-2 million C. 3-6 million D. 8-10 million Epidemiology

•2-5 million animal bites per year •Other – 2-5% in US Small animals (rabbits, ferrets, raccoon, •1% of Emergency Department fox, etc.) visits Large animals (large cats, bear) •10-20 animal bite fatalities – Farm animals Monkeys mostly dogs Reptiles •Lack of standard reporting Fish: shark, barracuda •Dog bite – 80-90% Human •Cat bite – 5-15% •Stings Bee Scorpion Jellyfish General Considerations

• Clean skin surface • Irrigate wound – NS or tap water fine (no need for additives) − 20 ml or larger syringe – “the solution to pollution is dilution!” • Explore the wound and debride dead tissue • Evaluate neurovascular injury and tendon injury (prior to anesthetic) • Radiographs for bone injury and/or foreign body (tooth) • Evaluate need for vaccination: − Tetanus − Rabies • Report Bite – Depends on state and local laws • Wound Closure? • Antibiotics? AES Question Question 2

A 48-year-old female presents to your urgent care clinic after being bitten on the right hand by her cat yesterday. She cleaned the bite with soap and water. Would you prescribe a prophylactic antibiotic?

A. No, because this bite is unlikely to get infected. B. Only if there is associated erythema and drainage. C. Only if her tetanus is not up to date. D. Yes, because cat bites are considered high risk for infection. Bites at High Risk for Infection

• Venous and/or lymphatic compromise • Bite to the hand • Near prosthetic joint • Cat bites • Puncture wounds I WILL • Crush injury KILL YOU! • Delayed presentation ≥ 6-12 hours arm or leg ≥ 12-24 hours for face Image of young European predatory killer, by Wikicommons user Alvesgaspar, creative commons license. • Diabetes or immunosuppression AES Question Question 3

In general, what type of bite would require the most aggressive antibiotic treatment if infection developed?

A. Dog B. Cat C. Human D. Vampire (former human) E. Zombie (former human) Tetanus prophylaxis is going to come up, so…a quick review:

• Provide a booster vaccination if: − history of < 3 doses or uncertain number of doses − history of ≥ 3 doses and • last dose was > 10 years ago • last dose ≥ 5 years ago and wound/injury is more severe than clean minor wound • Give postexposure tetanus immune globulin if • the patient has a history of < 3 doses or an ?? number of doses w complicated wound

• What about Tdap? • Tdap preferred to Td for persons aged ≥ 11 years who have never received Tdap • One dose of Tdap recommended as part of catch-up series if pt aged ≥ 7 years without complete immunization Canis familiaris Dog Bite

•80-90% of animal bites – spread across all breeds •Fatal bites – most commonly Pit Bull and Rottweiler breeds over last 2 decades (rare) •70% - Victim knows dog •50% - Unprovoked •Children most common victim (M>F) −Head and neck •Adolescents and adults −Extremity bites more common

Image (top): Google.com - https://www.flickr.com/photos/denverjeffrey/277207152 Image (bottom): Google.com - https://pixabay.com/en/dogs-dominance-behavior-dog-bite-567257/ Dog Bite - Treatment

•Clean skin surface •Irrigate wound – NS or dilute iodine solution −Can’t be overdone… •Exploration of wound and debridement of dead tissue −Make the chaotic wound something you recognize! •Evaluate neurovascular injury and tendon injury (prior to anesthetic) •Radiographs for bone injury and/or foreign body (tooth) Wound Closure

• Secondary intention – Traditional approach But: Study of 169 dog bites in 96 people – no difference in rate of infection (7.6% vs 7.8%) Another: 145 animal bites (dog 61%, cat 31%, human 8%) – all primary closure – 5.5% infection

Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med. 1988;5(3):156-161. Chen E, Hornig S, Shepherd SM, Hollander JE. Primary closure of mammalian bites. Acad Emerg Med. 2000;7(2):157-161.

• Primary closure = cosmetic • Bite at high risk of infection = Secondary closure Image of horizontal mattress sutures by Wikicommons user Orem, creative commons. • Skin adhesives should be AVOIDED. Antibiotic Prophylaxis for Dog Bites

• ~7% infection • Bacterial Coverage (FYI): Pasteurella canis • For any wound closed in clinic S aureus • Antibiotics: Streptococci Amox/clav 875 mg BID Capnocytophaga canimorsus Doxycycline • Emerging Clindamycin + FQ • Septicemia, meningitis, endocarditis • Esp Patients w/ Splenectomy and Alcohol Clindamycin + abuse sulfamethoxazole/trimethoprim • Tetanus

Image (top) – Google.com - https://commons.wikimedia.org/wiki/File:Dog_bite.JPG Image (bottom) – Google.com - https://www.flickr.com/photos/naz66/4630596156 Rabies Prevention in US (Treatment is palliative.)

• All wounds cleaned immediately with soap and water (90% effective in experiments!) • If animal healthy and can observe for 10 days No treatment unless animal develops sx • Rabid or suspected rabid dog Immediate HRIG and vaccine • HRIG 20 U/kg x 1 (infilt + IM glut) • No previous vaccination: Vaccine – Days 0, 3, 7, and 14 • Previous vaccination: Vaccine – Days 0, 3 • Vaccine in different anatomic area (delt or thigh)!

• Unknown (cannot capture animal) “Furious Rabies” image, by Wellcome Images via Wikicommons, Contact public health officials creative commons license. Prior slide was about the USA

Pre- and postexposure protocol recommendations vary by country, see the CDC and World Health Organization web pages for the most current international recommendations. Felis catus Cat Bite

•8-10% of animal bites •Adult women •Extremities •Most reported as provoked bites •49% risk of infection overall Vs 7% for dogs

Image (top) – Google.com - https://pixabay.com/en/photos/tooth/?cat=animals Image (bottom) – Google.com - https://www.flickr.com/photos/sirexkat/3325432577 Cat Bite - Treatment

• Wound care same as dog bite • Bacterial coverage (FYI): • Deep puncture wound – Pasteurella multocida – High risk for infection ≈ 80 % – Streptococci – Infection within 24 hours of – S aureus bite – Risk for osteomyelitis – Neisseria • Antibiotics – Moraxella – Amox/clav 875 mg BID – Capnocytophaga canimorsus – Cefuroxime 500 mg BID • Tetanus prophylaxis – Doxycycline 100 mg BID – No cephalexin Homo sapiens Human Bite • Would Care • Bacteria (FYI) – Viridans strep (fist-to- • Tetanus mouth) – Staph epidermidis • Antibiotics – S aureus – Corynebacterium, – Prophylaxis: Manly pugilistic image via Eikenella, Bacteroides Wikicommons, public domain. • Amox/clav • Clindamycin + Cipro or TMP- SMX (Pen allergy) – Infected: Polymicrobial • Ampicillin/sulbactam (Unasyn) • Cefoxitin • Piperacillin/tazobactam (Zosyn) Clinched Fist Injury

•Get radiographs •MCP Joint •Capsule and tendon injury •Treat as open fracture Other Mammalia Chiroptera

•Main concern: rabid bats in all states except HI •Catch bat (if safe!) for observation: −https://youtu.be/_YhnV5WJQBA (how to catch a bat) −DO NOT kill it – a felony! •Can’t be caught: rabies post-exposure prophylaxis (i.e. vaccine +/- HRIG) for all bites, scratches or mucous membrane exposures •What about possible exposure (e.g. wake up in a room with a bat!)?: PEP recommended! Public domain image, WikiCommons, at •Whom to call: local health dept or CDC https://commons.wikimedia.org/wiki/File:Sq uare-townsend-fledermaus.jpg Rodentia

•Squirrels, rats, mice, hamsters, gerbils… •Good wound care is key •Domestic rodents: −Lepto and ringworm (Trichophyton) in pet rats −Case report of tularemia from hamster (2004) −Salmonella from feces (2004) •Wild rodents: Lepto, hantavirus, RBF(not that one) −Rat bite fever: rare; S. moniliformis – tx with PCN

Image by Wikicommons user Vindaloovincent, at https://commons.wikimedia.org/wiki/ File:Brother_Rats.jpg Map by bobisbob, at https://en.wikipedia.or g/wiki/American_blac Ursidae (Da Bears!) k_bear#/media/File:A merican_Black_bear_ map.png •In North America, black and grizzly bears are main concern. •Trauma is the primary killer (see predatory fish below): good ATLS! •One case report of grizzly bite bacteriology: “Serratia fonticola, Serratia marcescens, Aeromonas hydrophila, Bacillus cereus,

and Enterococcus durans.” No Image public domain, at abx resistance, no anaerobes. https://commons.wikimedia.org/wiki/File:Black_bear_lar ge.jpg Equus (Da Colts/Broncos!) •Most zoonoses fecally-transmitted (Salmonella, Campylobacter, etc.), mosquito-borne (equine encephalitis), or aerosol-transmitted (brucellosis, Q fever). •Generally crush and grind, not puncture. •Horse bites can (super-rarely) transmit rabies. •Good wound care, monitoring for infection (skin flora, Gram positives)

Image public domain at https://commons.wikimedia.org/wiki/Categ ory:Horses#/media/File:500px_photo_(146 134087).jpeg Viperidae and Elapidae Image: Google.com - https://www.youtube.com/watch?v=CtjpaIlL9mY Snake Bites

•Envenomation −Globally 1.2 million annually • Hundreds of thousands have long term injury • 20,000 – 100,000 deaths annually −US 4,000 – 6,000 annually (mostly drunk young men) • 70% require antivenom • 5 deaths • Identification of snake (sometimes difficult) Snake Bite – Nonvenomous

•Wound care •Abx not usually required •Amox/clav or ceftriaxone can be used for prophylaxis and/or treatment. Snake Bite – Venomous

•Coral Snake •North America Can be painless bite Rattlesnake Local effect to flaccid Copperhead paralysis Water Moccasin Antivenom shortage Coral

•Pit Viper Bite Map, public domain, at Edema of limb, compartment https://commons. syndrome wikimedia.org/wiki /File:USA_Coral_ Shock Snake_Range.png Coagulopathy and bleeding Allergic Rxn to venom Image: Dr Jeffrey Roberts, with permission AES Question Question 4

A 38 y.o. male presents to the emergency room after a snake bite. Initial treatment options could include?

A. Tourniquet B. Incision and irrigation with normal saline C. Cryotherapy to the bite area to denaturize the venom D. IVF – NS General Tx – Venomous Bite

• First Aid (minimize lymphatic flow to central • Pain Control circulation) • Labs: Splint / immobilize PT/PTT Limit ambulation Fibrinogen NO pressure immobilization, incision/sucking/etc. CBC CMP • IVF CK (rhabdo) • Monitor for anaphylaxis UA (rhabdo) • Prepare to manage airway • Wound care • Monitor for compartment syndrome Image: Dr Jeffrey Roberts, with permission AES Question Question 5

A 38 y.o. male presents to the emergency room after a snake bite. When is antivenom considered a treatment option?

A. Patients with snake bites in the United States should always receive antivenom, because not administering the antivenom could prove fatal. B. Antivenom should never be given for snake bites in the United States due to the adverse reaction associated with the antivenom. C. The decision to administer antivenom should be based on objective findings of a bite with systemic symptoms. Treatment – Venomous Bite

• Antivenom - Objective signs of envenomation (not just a bite) −Systemic envenomation • N/V, metallic taste • Shock • AMS −Rapidly increasing or major swelling −Lab abnormalities (coagulopathy, hemolysis…) −Blistering or bleb formation −Some controversy: early administration may speed limb recovery – always call an expert to guide you!

• Anavip (new Oct 2018) – less delayed coagulopathy [5-10% vs 30%], fewer repeat doses Images: Dr Jeffrey Roberts, with permission Other Reptiliae Bearded Dragons

•Salmonellosis, Campylobacter, Yersinia… (from handling, not bites) •Rarely bite; they are venomous technically, but not harmful to humans

Image creative commons, by Wikicommons user Ssfadia, at https://commons.wikimedia.org/wiki/File:Bearded_Dragon_Lizard.jpg Iguanas

•Have dozens of sharp, serrated teeth and a strong bite •Crushing and lacerations is the problem; can leave teeth behind in wound; tail whip → welts, abrasions •Venom is not harmful •Consider amp/sulbactam or amox/clav for complex wounds, tetanus update

Image in public domain, at https://commons.wikimedia.org/wiki/File:Animalia_nova,_ sive,_Species_novae_lacertarum_quas_in_itinere_per_B rasliliam_annis_MDCCCXVII- MDCCCXX_jussu_et_auspiciis_Maximilani_Josephi_I._B avariae_regis_suscepto_BHL4227448.jpg Latrodectus, Loxosceles, and Theraphosidae Spider Bite

•Most (80+%) “spider bites” aren’t: MRSA •2 medically relevant in US: −Widow – 5 species (3 most common) • Latrodectus mactans – East • Latrodectus hesperus – West • Latrodectus variolus – North • Female - Black w/ red hour glass on abdomen • Latrodectus geometricus – South – orange/yellow hour glass −Brown Recluse – “Fiddleback” • South-Central US

Image: Dermatlas.net - Visit 895 - © Richard Usatine, M.D. Males only eaten by females if: (a) confined Widow Bite and (b) undernourished. There’s a lesson in there •Usually outdoors somewhere. •Pinprick (up to half painless!) •α-latrotoxin ➔ release of ACh and catechols Howdy! •Muscle spasms – chest and/or abdomen −Nausea – Piloerection −Weakness – Elevated BP −Diaphoresis – LN pain (axilla/inguinal) •Rarely life threatening •Resolves 2-3 days

Image: Paul D Simmons, MD, personal collection. Widow Bite - Clark’s Grading System

•Grade 1 •Grade 3 Local pain Abnormal VS -  BP; Tachycardia VS WNL N/V Asymptomatic Headache •Grade 2 Muscle pain • Chest pain – bite on upper ext • Abd pain – bite on lower ext VS WNL Diaphoresis Widow Bite – Treatment •Good first aid, ice pack to bite •Benzodiazepines – spasm •Pain control (ice packs, analgesics) •IV Ca gluconate not commonly used, but may rapidly help severe cramping •Antivenom (reserve for Clark 3, very young or old) −≤ 48 hours −Severe pain despite tx −Allergic reaction possible Brown Recluse

“More than 2000 brown recluse (BR) bites are reported to poison control centers each year, but if epidemiology and confirmed cases are any indication, most of them are due to something else. […] From the entomological perspective, it borders on the ridiculous to claim that dozens of people have been bitten by BR spiders when none can be found. They are not that reclusive.” - Jerome Goddard, “Physician’s Guide to th Arthropods of Medical Importance, 6 ed.” Image from Wikicommons user Emmanuel Boutet, released to public domain. Brown Recluse

• Usually indoors – dark places – •Treatment South-Central US only Wound care w/ minor • Bite (sometimes painless) ➔ debridement tender, red halo ➔ necrosis Antihistamines (not steroids) (40%) Dapsone – controversial • Prevent neutrophil • Sphingomyelinase D I’m shy. degranulation – Activity decreased by cold • Test for G6PD deficiency • Systemic Sx rare (→ hemolysis) – Hemolysis – Coagulopathy – Measles-like rash Image: Juckett, Gregory MD. Arthropod Bites. Am Fam Physician. 2013;88(12):841-847. Tarantulas

•Another spider that gets a bad • Treatment rap for little reason. – Wound care, good first •Bite only if deliberately aid provoked or roughly handled. – Analgesia •Distribution: SW US – none – Tetanus prophylaxis east of Mississippi. •Lifespan: 15-20 years! • Abdominal hairs can •Diet: arthropods, small vertebrates. cause hives – treat with topical or (rarely) •Bites range from almost painless to deep, throbbing PO steroids. Image public domain, from pain. Wikicommons user Russel Howe Hymenoptera Stings

Image: Casale, TB and Burks, AW. Hymenoptera-Sting Hypersensitivity. N Engl J Med 2014; 370:1432-1439 Hymenoptera - Bee, Wasp, Fire Ant

•Local reaction −Wound care −Remove stinger −Topical antihistamines, corticosteroids •Systemic Allergic Reaction −Children 1% −Adults 3% •Anaphylaxis −Epi plus supportive care −40-100 deaths annually

Image: https://en.wikipedia.org/wiki/Bee_sting#/media/File:Stechende_Biene_12a.jpg*** Africanized Honey Bees

•Strain brought from Africa to S America to improve honey production. •Now in S and W US •More aggressive, stay angry longer, massive stinging behavior (400-1000 stings/attack) in defense •Venom identical to normal bees, but massive stinging → increased toxicity

Image: https://en.wikipedia.org/wiki/Bee_sting#/media/File:Stechende_Biene_12a.jpg*** Scorpiones Scorpion

• Complex, multi-protein venom Burning pain • Treatment: Pruritus and erythema Catecholamine effect – Wound care Children: Nystagmus – Symptom Tachycardia/Tachypnea management Muscle fasciculation, abd pain – Antivenom for • Only one dangerous species in US: systemic Centruroides exilicauda (AZ, SE CA, neurotoxicity NV, S UT, SW NM). (58% serum sickness!) This scorpion was IN • No, they can’t jump. Leave them be. MY GARAGE! Carcharodon, Galeocerdo, and others Predator Fish Bites

Image: https://www.flickr.com/photos/98585738@N07/10346101216*** Predator Fish Bites

•Treatment depends on severity of bite (ATLS!) −Basic wound care −Major tissue injury and loss −Shock

Image of super-friendly, harmless shark via Wikicommons user Terry Goss, creative commons Medusozoa Jelly(fish)

• Local pain • Rarely fatal −Box jellyfish −20-40/yr - Philippines • Sting contact marks • Treatment: −Remove tentacles (gloves!) −Hot water (not urine or meat tenderizer, probably not acetic acid), may try cold packs if hot water not available…controversial area. −Monitor CV and Resp −Antivenom for extreme cases

Image: Jellyfish (Pacific Sea Nettle) – Google.com - https://en.wikipedia.org/wiki/Jellyfish Image: Jellyfish sting – Google.com - https://www.flickr.com/photos/quinet/6052293114 Best Practice Recommendations

•Counsel patients on bite and sting prevention: don’t underestimate animals nor do anything stupid in nature. •Wound closure – Evaluate risk for infection •Prophylactic antibiotic – Evaluate risk −Amox/clav will cover many of these scenarios •Screen animals for rabies •Remember tetanus •Envenomation – Evaluate for antivenom (not everyone needs it!) References • Aziz H, Rhee P, Pandit V, Tang A, Gries L & Joseph B. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015 Mar;78(3):641-8. • Chen E, Hornig S, Shepherd SM, Hollander JE. Primary closure of mammalian bites. Acad Emerg Med. 2000;7(2):157-161. • Clark, Dwayne. Common Acute Hand Infections. Am Fam Physician. 2003 Dec 1;68(11):2167-2176. • Clark RF, Wethern-Kestner S, Vance MV, Gerkin R. Clinical presentation and treatment of black widow spider envenomation: a review of 163 cases. Ann Emerg Med. 1992;21(7):783. • Day MJ. Human-Animal Health Interactions: The Role of One Health. Am Fam Physician. 2016 Mar 1;93(5):344-346. • Del Brutto OH. Neurological effects of venomous bites and stings: snakes, spiders, and scorpions. Handb Clin Neurol. 2013;114:349-68. • Dominguez TJ. It’s not a spider bite, it’s community-acquired methicillin-resistant Staphylococcus aureus. J Am Board Fam Pract. 2004;17(3):220- 226. • Ellis, Robert and Ellis Carrie. Dog and Cat Bites. Am Fam Physician.2014;90(4):239-243. • Gilbert, DN et al. The Sanford Guide to Antimicrobial Therapy, 45th edition. Antimicrobial Therapy, Inc. 2015. • Henton J & Jain A. Cochrane corner: antibiotic prophylaxis for mammalian bites (intervention review). J Hand Surg Eur Vol. 2012 Oct;37(8):804-6. • Juckett, Gregory MD. Arthropod Bites. Am Fam Physician. 2013;88(12):841-847. • Kennedy SA, Stoll LE & Lauder AS. Human and other mammalian bite injuries of the hand. Evaluation and management. J Am Acad Orthop Surg. 2015 Jan;23(1):47-57. • Krau SD. Bites and stings. Epidemiology and treatment. Crit Care Nurs Clin North Am. 2013 Jun;25(2):143-50. doi: 10.1016/j.ccell.2013.02.008. • Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med. 1988;5(3):156-161. • Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop. 1987;220:237–40. • Quan D. North American poisonous bites and stings. Crit Care Clin. 2012 Oct;28(4):633-59. • Quinet B & Grimprel E. Antibiotic prophylaxis for bites in children. Arch Pediatr. 2013 Nov;20 Suppl 3:S86-9. • Weinstein, Scott MD et al. Envenomations: An Overview of Clinical Toxinology for the Primary Care Physician. Am Fam Physician. 2009;80(8):793– 802. • Strimple, PD et al. Report on envenomation by a Gila Monster (Heloderma suspectum) with a discussion of venom apparatus, clinical findings, and treatment. Wilderness Environ Med. 1997 May;8(2):111-6. • Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconstr Surg. 1991;88:111–4. Thank You! [email protected] Answer Key

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Assessment of the Acutely Ill Elderly Patient

Alan Ehrlich MD, FAAFP Associate Professor of Family Medicine and Community Health University of Massachusetts Medical School Executive Editor, DynaMed Disclosure

• Vu Kiet Tran, MD, MBA has disclosed a relationship with Elvium on the topic “Acute Pain Management”.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. Learning Objectives

1. Determine the appropriate testing to be done for common symptoms that occur in the elderly including abdominal pain, syncope, and change in mental status. 2. Determine the appropriate setting for treatment based on prognostic factors specific to an elderly populations. 3. Determine appropriate treatment plans that take into consideration risks from medications in an elderly population. 4. Recognize changes in mental status and appropriately assess potential causes. Why Do We Care

•Elderly use emergency services more often •More likely to have serious illnesses •Less likely to have classic symptoms •Decreased physiologic reserve •2.5-4.6 X higher risk for hospitalization •5 X higher admission rate to an ICU •Function is often the most important outcome Vital Signs

•Reduced ability to adapt to physiological stressors •Single measures less reliable than serial measurements •Comparison to “patient’s normal” more important than “normal normal” •More significant when frailty present Blood Pressure

•BP increases with age −74% of women and 61% men 65-74 −83% women and 69% men ≥ 75 •Systolic pressure more affected than diastolic •Orthostatic hypotension common −30% of older outpatients −50% of nursing home residents

Chester JG, Rudolph JL. J Am Med Dir Assoc. 2011 June ; 12(5): 337–343 Pulse

↓ Maximal HR ↑ Resting HR ↓ HR variability ↓ Response to sympathetic stimulation

Chester JG, Rudolph JL. J Am Med Dir Assoc. 2011 June ; 12(5): 337–343 Temperature

•Lower core temperature •Altered response – reduced fever response •Subtle rise from baseline may be significant •Temp in NH residents rarely > 101 •Fever is a sign of something serious, even life-threatening

Chester JG, Rudolph JL. J Am Med Dir Assoc. 2011 June ; 12(5): 337–343 Respiratory Rate

•PFTs worsen with aging ↓FEV1, VC, TV ↓ Chest wall compliance ↑ Work of breathing •↑ Baseline RR, ↓ physiologic reserve •Decrease response to hypoxia and hypercapnia •RR > 27 has high predictive value for serious adverse events

Chester JG, Rudolph JL. J Am Med Dir Assoc. 2011 June ; 12(5): 337–343 Orthopedic Changes

•↑ Incidence of osteoporosis •Nonunion, delayed union, and failures of operative fixation more common with osteoporosis or osteopenia •Sarcopenia results in ↓ strength, balance, coordination, and overall endurance •Fragility fractures −Spine, distal radius, proximal femur −30% of patients with fragility fractures died within 1 year and 71% within 2.1 years of the event •80% of women would rather be dead (utility=0) than have loss of independence and ↓QOL associated with admission to NH due to hip fracture

Salkeld G et al. BMJ. 2000 Feb 5;320(7231):341-6 A Fate Worse Than Death

80% of women aged ≥ 75 years reported they would rather be dead than have loss of independence and ↓QOL associated with admission to NH from hip fracture

Salkeld G et al. BMJ. 2000 Feb 5;320(7231):341-6 Other Physiologic Considerations

System Changes Cardiovascular Stiff arteries and veins ↑Peripheral resistance ↓ Response to beta agonists Respiratory ↓ Protective cough, Muscle strength, Gas exchange, Functional alveolar SA ↑ V/Q mismatch, Residual volume GI Impaired drug metabolism Constipation, loss of sphincter control Renal ↓ GFR, Total body water, Thirst, Ability to conserve sodium Neuro ↑ Brain atrophy (worse after 70) ↓ Memory

Alvis BD, Hughes CG. Anesthesiol Clin. 2015 Sep; 33(3): 447–456. Mary

•Mary is a 73 y.o. retired school teacher who comes in with productive cough for 2 days, some chills, and fatigue. No fever. She has Type 2 DM and HTN both controlled with medication. She has stage IV CKD with her last GFR = 25. No hemoptysis, vomiting, diarrhea, or chest pain. No flu exposure and she had a flu shot.

•VS = Temp of 98.8, pulse 110, RR 18, BP 150/84 and pulse ox 94% •Exam notable for some fine rales on the right, no wheezing •CXR shows RLL pneumonia •Abnormal Labs: BUN 32, creatinine 1.4, glucose 270, sodium 132 AES Question Question 1 Which of the following would be your next step?

A. Initiate oral antibiotics and treat as an outpatient with azithromycin for 5 days. B. Initiate oral antibiotics and treat as an outpatient amoxicillin 1 gram 3 times a day PLUS doxycycline for 7 days. C. Give 2 grams ceftriaxone IV, followed by outpatient therapy with oral levofloxacin 500 mg for 7 days D. Admit to the hospital for treatment of her pneumonia Pneumonia severity index (PSI) Risk Class I

•Age < 50 years •No history of −Neoplastic disease −Heart failure −Cerebrovascular disease, renal disease or liver disease •Normal mental status •SBP ≥ 90 mm Hg, Pulse < 125, RR< 30, and 95 ≤ Temp < 104 degrees

Fine MJ et al.NEJM 1997 PSI Score Patient's age (in years) (-10 for females) +10 points Nursing home resident Heart failure, cerebrovascular disease, renal disease

Pulse ≥ 125 per minute, PaO2 < 60 mm Hg (O2 saturation < 90%) Glucose ≥ 250 mg/dL, hematocrit < 30%, Pleural effusion

+15 points Temp ≥ 104.0 or < 95.0 degrees +20 points Liver disease Altered mental status RR ≥ 30 per minute, SBP < 90 mm Hg BUN ≥ 30 mg/dL, sodium < 130 mmol/L +30 points Neoplastic disease Arterial pH < 7.35

Fine MJ et al.NEJM 1997 PSI Risk Classes II-V

Point based scoring system Class II ≤ 70 points Class III 71-90 points Class IV 91-130 points Class V > 130 points

Fine MJ et al.NEJM 1997 Mortality Based on PSI Risk Classes

Risk Class 30 day 30 day 30-day mortality mortality Overall Outpatients Inpatients Mortality I 0% 0.5% 0.1% II 0.4% 0.9% 0.6% III 0% 1.2% 0.9% IV 12.5% 9% 9.3% V 0% 27.1% 27%

Fine MJ et al.NEJM 1997 CURB-65

•1 point for each of the following: −Confusion −BUN ≥ 20 mg/dL −Respiratory rate ≥ 30/minute −SBP < 90 mm Hg or DBP ≤ 60 mm Hg −Age ≥ 65 years •Risk of 30-day mortality by CURB-65 score −1.5% for 0-1 points −8.3% for 2 points −23% for ≥ 3 points

Lim WS Thorax 2003 IDSA/ATS Recommendations

•Candidates for outpatient treatment may be identified using prognostic models (such as PSI) and severity-of-illness scores (such as the CURB-65 criteria) •PSI preferred over CURB-65 •Always supplement objective criteria or scores with physician judgment of subjective factors •Hospitalization or intensive in-home health care services (where available and appropriate) usually warranted for patients with CURB-65 scores ≥ 2

Metlay JP et al. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67 Bill Bill is a 82 y.o retired auto mechanic who comes in because of abdominal pain. He has mild-moderate dementia and is not sure of the details of how long this has been going on. He lives with his son who brought him in who indicates that he started complaining of the abdominal pain last night. He took some acetaminophen and was able to go to sleep but he woke up this morning complaining of the pain again.

His son indicates there was no fever last night but his father complained of feeling cold. He has been eating OK but he never really eats a lot at this point. He had some nausea last night, but there has been no vomiting or diarrhea. The son indicates his father seems a little more confused today. Bill

When you ask where the pain is he indicates it’s not really bothering him that much. When pressed he points to the epigastric region.

PMH notable for HTN, CAD, DJD, BPH. Meds include Lisinopril, HCTZ, Metoprolol, Atorvastatin, and ASA

VS: BP 144/82, pulse 72, RR 14, Temp 98.4 Exam notable for an absence of abdominal tenderness, normal bowel sounds. No HSM. No rebound or guarding. Negative Murphy sign. Rectal exam is negative for occult blood. AES Question Question 2 Which blood test(s) should be ordered? A. CBC B. Basic Metabolic Profile C. LFTs D. Amylase or Lipase E. All of the above Test Results

•CBC: WBC = 12.5 (normal 3.8-10.8), H/H = 14.2/43.1 No left shift. •BMP, AST, ALT, Alk phos and Amylase all normal •ECG with no acute changes AES Question Question 3

What is your plan?

A. Reassure patient and son that since he is feeling better he can go home and follow up with his PCP tomorrow or ED if getting worse B. Obtain imaging in the morning and have him return/go to ED if pain returns C. Obtain imaging now D. Obtain surgical consult AES Question Question 4

Of the following tests, which is the best imaging test to order first

A. Flat and upright plain x-rays B. Abdominal CT C. Abdominal MRI D. HIDA scan Imaging with abdominal pain

•126 patients ≥ 65 years old presenting to ED with acute abdominal pain who had CT −Highly accurate when surgical condition present −High degree of consistency between radiologists •104 patients ≥ 65 years old presenting to ED with abdominal pain for 1 week −Diagnostic certainty increased from 36% to 77% −CT affected decision to hospitalize in 26% of cases −CT affected the need for surgery for 12% of cases

Reginelli A et al. International Journal of Surgery 12 (2014) S181eS186 Esses D et al. Am J Emerg Med. 2004 Jul;22(4):270-2. CT Results

CT shows gallstones, gall bladder distention, some gall bladder wall thickening, subserosal edema Report reads findings consistent with acute cholecystitis Patient referred for surgical evaluation Abdominal Pain in the Elderly

•Difficulties in diagnosis −Communication problems −Atypical symptoms −Altered pain perception −Lab findings may be normal •WBC normal in 30% of older adults with acute surgical conditions •Have lower threshold for CT •Have lower threshold for admission

Yeh EL at al. Clin Geriatr Med 23 (2007) 255–270 Most common diagnoses

• 360 persons ≥ 60 years old • Nonspecific cause 14.8% presenting to ED with acute • Urinary tract infection 8.6% abdominal pain • Bowel obstruction 8% • 209 (58%) admitted • Gastroenteritis 6.8% • 63 (18%) had surgery or procedure • Gallbladder disease 6.5% • 5% case fatality rate • Diverticulitis 6.2% • Constipation 5.9% • Cancer 5.6% • Pancreatitis 3.9% • Ischemic bowel 1.2% • Appendicitis 0.6%

Lewis LM et al. J Gerontol A Biol Sci Med Sci. 2005;60(8):1071–1076 Notable Causes of Abdominal Pain in the Elderly

Cause Noteworthy Features Acute Appendicitis Up to 5% of cases; Only 75% have RLQ pain Fever & ↑ WBC may be absent Diagnosis commonly missed at initial presentation Acute Pancreatitis More commonly gallstone than EtOH; 1/3 may be idiopathic Acute Mesenteric Postprandial pain; Suspect if other vascular disease Ischemia Pain out of Proportion Bowel Obstruction Large bowel obstruction more common than in younger patients Abdominal Aortic Suspect if hypotension or pulsatile mass Aneurysm Back, flank, or groin pain are also clues Acute Diverticulitis Lower threshold for imaging even in patients with prior episodes

Yeh EL at al. Clin Geriatr Med 23 (2007) 255–270 Medical Causes of Abdominal Pain

•Acute myocardial ischemia - consider in elderly patient with upper abdominal pain •Pneumonia •Herpes Zoster •Fournier’s gangrene •Hypercalcemia •Rectus sheath or retroperitoneum hematomas if anticoagulated •Addison’s disease Change in Mental Status

•Abnormal processing of content Delirium Dementia •Abnormal arousal Drowsiness Stupor Coma Alex

Alex is a 78 year old resident of an assisted living community. He was found wandering on the grounds this morning by the staff and seemed confused. He is brought in to see you for evaluation.

His PMH is positive for Type II DM, CAD, Mild CKD, Afib, and Prostate cancer treated with prostatectomy 10 years ago.

Medications include metformin, canagliflozin, lisinopril, metoprolol, and apixaban Delirium vs. Dementia Delirium in the ED

•Delirium overlooked in ED in up to 75% of patients −Features often mistook for normal aging −May be hyperactive or hypoactive −Hypoactive more commonly missed •3 screening tools validated in the ED −bCAM −Richmond Agitation Sedation Scale −CAM-ICU •4AT can assess delirium in any setting without training

Pérez-Ros P, Martínez-Arnau FM. Diseases. 2019;7(1):14 Delirium Associated with Mortality

•628 patients ≥ 65 years old in ED screened with CAM-ICU •108 (17%) diagnosed with delirium •6 month mortality 37% with delirium vs. 14% without •Independent predictor of 6-month mortality (hazard ratio = 1.72; 95% CI 1.04-2.86)

Han JH, Shintani A, Eden S, et al. Ann Emerg Med. 2010;56(3):244–252 4AT

Alertness AMT4: Age, date of birth, place Attention: Months of Acute change (name of the hospital or building), the Year Backwards or Fluctuating current year (MOBTY) course Normal = 0 No mistakes = 0 7 months or more No = 0 correct = 0 Sleepy < 10 1 mistake = 1 Starts but scores < 7 Yes = 4 seconds and months or refuses = 1 normal when aroused = 0 Abnormal = 4 2 or more mistakes/untestable = 2 Untestable = 2

4 or above = Possible delirium with or without cognitive impairment 1-3 = possible cognitive impairment 0 = delirium or severe cognitive impairment unlikely

https://www.the4at.com/ Richmond Agitation Sedation Scale

Description Score Moderate drowsy, briefly awakens with eye contact to voice -2

Mildly drowsy, not fully alert, but has sustained awakening -1 (>10 seconds) Alert and calm 0 Restless, anxious but movements not aggressive or vigorous +1

Agitated, frequent non-purposeful movement +2 Aggressive; very agitated, pulls or removes tubes or catheter +3

Overtly combative, violent, immediate danger to staff +4 Delirium Triage Screen

•Assess using RASS •Assess attention (spell LUNCH backwards) •If either abnormal, proceed to bCAM

S. Lee et al. American Journal of Emergency Medicine. 2019 Oct 8 Brief Confusion Assessment Method (bCAM) 1. Is there an acute alteration in mental status from the patient’s baseline or fluctuating course? 2. Inattention: Months of the year backwards Dec-July (1 error OK) 3. Is the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Rate this patient’s level of consciousness? −Alert (normal) −Vigilant (hyperalert) −Lethargic (drowsy, easily aroused) −Stupor (difficult to arouse) −Coma (unarousable)

Delirium if 1 AND 2 positive PLUS either 3 or 4 abnormal S. Lee et al. American Journal of Emergency Medicine. 2019 Oct 8 Causes of Delirium

Medications, medications, medications! Other causes • Anticholinergics • Hypoxia, Hypercapnia • Antihistamines • Hypovolemia • Anti-inflammatory drugs • Abnormal Na, K, or glucose • Sedative/hypnotics • ↑ blood urea nitrogen (BUN) • Cimetidine • Metabolic acidosis • Corticosteroids • Infection • Diuretics • Pain • Opioids • Constipation/Urinary retention • Catheters or other invasive devices • Restraints Management of Delirium

•Address underlying cause •Avoid adding new causes •Involve family in treatment •Maintain eye contact •Keep in quiet environment with few distractions •Avoid restraints •Consider medication: Haloperidol or atypical antipsychotics (quetiapine, risperidone, olanzapine); benzos are less effective

S. Lee et al. American Journal of Emergency Medicine. 2019 Oct 8 AES Question Question 5

Which of the following is true regarding patients ≥ 85 with MI

A. < 60% have chest pain as their chief complaint B. ECG is nondiagnostic with non-STEMI nearly half the time C. About 1/3 of patients will have LBBB D. All of the above CAD in the Elderly

•High prevalence of atypical features •Worse outcomes •Acute myocardial infarction presentation is often atypical, presenting as −Shortness of breath −Syncope −Nausea and vomiting −Fall •Clinical trials often exclude typical elderly patients •Risks and benefits of interventions must carefully weigh comorbidities, functional status and QOL The Triple Whammy

Elaine is a 82 year old woman who was eating lunch on her patio. She got up to get the mail and before she got too far she passed out. As she fell she hit the side of her head as she landed. Her neighbor saw what happened and came over to help her. She was responsive by the time the neighbor arrived but was dazed for a few minutes. She is now brought in for evaluation.

She has a mild headache but otherwise feels OK. No nausea or vomiting. Her PMH is significant for HTN, DM, COPD and osteopenia. She is on lisinopril, metformin and respiratory inhalers.

Her exam is notable only for a contusion in the parietal region. No laceration and her neuro exam is normal. Heart sounds normal. AES Question Question 6

As you contemplate evaluating her for syncope, a possible TBI, and a fall you decide to focus on the syncopal episode first. Which of the following is the most likely cause of syncope in elderly patients?

A. Neurally mediated syncope (carotid sinus hypersensitivity, post micturition, vasovagal) B. Orthostatic hypotension C. Postprandial hypotension D. Cardiac arrythmia Causes of Syncope in 231 Elderly

•Reflex syncope (neurally •Cardiac syncope -15% mediated) – 44% Tachyarrhythmias Vasovagal: prolonged standing, pain, Bradycardia emotional stress Structural abnormalities (AS) Carotid sinus sensitivity Myocardial infarction, PE Situational: postmicturition, coughing, •Drug-induced – 5% defecation •Unexplained - 10% •Orthostatic hypotension – 22% •Postprandial 6%

Ungar A et al J Am Geriatr Soc. 2006 Oct;54(10):1531-6 Evaluation

•History and Physical −Is the loss of consciousness attributable to syncope? −Is there a history of cardiovascular disease? −Are there clinical features to suggest a specific cause of syncope? −What medications is the patient on? •Orthostatic BP measurement •ECG •CBC and troponin often done but do notnaffect decision in most cases Causes Warranting Hospitalization

• Arrhythmias and conduction disorders −sustained or symptomatic ventricular tachycardia, (SVT, conduction disorder, such as Mobitz type II or 3rd degree AV block, or bradycardia −malfunction of pacemaker or implantable cardioverter defibrillation (ICD) −inheritable cardiovascular disease associated with arrhythmia • Cardiac or vascular conditions −cardiac ischemia, severe aortic stenosis, hypertrophic cardiomyopathy, aortic dissection −pulmonary embolism −acute heart failure, moderate-to-severe left ventricular dysfunction • Noncardiac conditions −severe anemia, gastrointestinal bleeding −major traumatic injury due to syncope −persistent abnormal vital signs AES Question Question 7

Having evaluated the syncope, you conclude it was likely a combination of postprandial hypotension and orthostatic hypotension. You turn your attention to her head injury. Her exam is normal except for a bruise at the point of impact. No bruising behind the ear or around the eyes. Which of the following actions would be best at this time?

A. Reassure patient and discharge to home with follow up with PCP in the next few days B. Obtain skull films to rule out fracture C. CT scan to rule out intracranial pathology D. Admit to hospital for overnight observation TBI Risk Factors Canadian CT Head New Orleans Rule Criteria Vomiting ≥ 2 episodes Any Age ≥ 65 years ≥ 60 years

Anterograde amnesia > 30 minutes before impact Any

Signs of trauma Sign of basal skull fracture Trauma above the clavicle Suspected skull fracture GCS score < 15 2 hours after injury Arrival at ED Dangerous mechanism + Drug or alcohol intoxication * +

Seizure + Headache +

Stiell IG et al. Lancet 2001 Haydel MJ et al. NEJM 2000 Falls and Head Injury

•Annual incidence of fall in people over 65 is 33% •Half of elderly with falls go to the ED •Falling on level ground accounts for up to 80% of cases of traumatic intracranial bleeding •5% of falls in the elderly will have IC bleed

de Wit K et al. Injury. 2019;S0020-1383(19)30832-0 Assessment After a Fall

• Thorough history of the circumstances • Prior fall history • Medication review with special attention to vasodilators, diuretics, antipsychotics sedative/hypnotics • Orthostatic BP • Neuro exam −Gait −Peripheral motor and sensory evaluation −Have high index of suspicion for cervical cord or c-spine injury especially if there are any upper limb abnormal neuro findings • EKG, CBC, BMP • Safety assessment Ann Emerg Med. 2014 May;63(5):e7-25 Assessment for TBI

•5% risk of bleeding after a fall •Increased risk for bleeding −Vessels more fragile −Cerebral atrophy common −Anticoagulation or antiplatelet agents •Traditional signs of traumatic brain injury may not be evident •Baseline dementia or acute delirium may mask symptoms •Intracranial bleeding can occur without head trauma •Bleeding may be delayed •Have very low threshold for CT Ann Emerg Med. 2014 May;63(5):e7-25 Risk For Delayed ICH

•Delayed ICH: Normal cranial CT scan followed by finding of traumatic ICH on repeat imaging •77 patients (mean age 80) on anticoagulation evaluated after fall from standing height or less −20% had positive initial CT scan for ICH −Positive scans in 30% on warfarin vs. 14% on NOACs −51% had a repeat head CT at median 8 hours after 1st scan −9.6% of these positive for ICH, all on NOACs

Cocca AT et al. J Emerg Med. 2019 Dec;57(6):812-816 Practice Recommendations

•Elderly present differently than younger patients •Always consider adverse effects of medication •Elderly patients often have higher mortality risk •Use standardized assessment tools/risk calculators •Function is often the most important outcome Answer Key

All materials/content herein are protected by copyright and are for the sole, personal use of the user.

No part of the materials/content may be copied, duplicated, distributed or retransmitted

in any form or medium without the prior permission of the applicable copyright owner.