Rosen & Barkin's 5-Minute Emergency Medicine Consult (295 page)

• Pantoprazole: 80 mg (peds: Dosing not approved) IV bolus followed by an infusion of 8 mg/h for 72 hr
  
• Octreotide: 50 μg (peds: 1–2 μg/kg) bolus, then 50 μg/h (peds: 1–2 μg/kg/h) IV
  
• Somatostatin: 250 μg (peds: Not established) IV bolus and 250–500 μg/h for 2–5 days (not available in US)
  
• Vasopressin: 0.4–1 IU/min (peds: 0.002–0.005 IU/kg/min) IV
  
• Nitroglycerin: 10–50 μg/min (peds: Not established) IV
  
• Vitamin K: 10 mg (peds: 1–5 mg) PO/SC/IV q24h
  

FOLLOW-UP

• Active bleeding
  
• Age >65 or comorbid conditions
  
• Coagulopathy
  
• Decreased hematocrit
  
• Unstable vital signs at any time
  

• Resolution of UGIB with negative nasogastric lavage and EGD
  
• Minor or resolved LGIB
  
• Stable hematocrit >30 or hemoglobin >10 g/dL
  
• Otherwise healthy patient
  

Consider referral to gastroenterologist for outpatient colonoscopy and/or EGD

• Patients discharged from the ED should have close follow-up within 24–36 hr
  
• Give strict discharge instructions to return if further bleeding or other concerning symptoms (lightheadedness, dyspnea, chest pain, etc.) occur
  
• Patients with UGIB should be discharged on a PPI, and advised to avoid caffeine, alcohol, tobacco, NSAIDs, and aspirin
  

• 10–15% of UGIB present with hematochezia
  
• Consider GIB in patients presenting with signs of hypovolemia or hypovolemic shock
  
• Common pitfall: Failure to adequately resuscitate with crystalloid and blood products
  

PUD is the predominant cause of GIB in elderly and has a higher associated mortality.

• Das AM, Sood N, Hodgin K, et al. Development of a triage protocol for patients presenting with gastrointestinal hemorrhage: A prospective cohort study.
  Crit Care
  . 2008;12:R57.
  
• Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer.
  N Engl J Med
  . 2008;359(9):928–937.
  
• Johansson PI, Stensballe J. Hemostatic resuscitation for massive bleeding: The paradigm of plasma and platelets—a review of the current literature.
  Transfusion.
  2010;50(3):701–710.
  
• Pallin DJ, Saltzman JR. Is nasogastric tube lavage in patients with acute upper GI bleeding indicated or antiquated?
  Gastrointest Endosc.
  2011;74(5):981–984.
  
• Wolfson AB, Hendey GW, Ling LJ, et al., eds.
  Harwood-Nuss’ Clinical Practice of Emergency Medicine
  . 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
  

CODES

• 533.40 Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction
  
• 535.51 Unspecified gastritis and gastroduodenitis, with hemorrhage
  
• 578.9 Hemorrhage of gastrointestinal tract, unspecified
  

BASICS

• Geriatric specific considerations and approach to the elderly trauma patient
  
• Should be used in conjunction with the accepted standard treatment of traumatic injuries (see trauma, multiple)
  
• Advanced age is a known risk factor for adverse outcomes following trauma
  
• Generally age >65, age not well defined, difficult to target due to discrepancies between physiologic and chronologic age in individuals
  

Most common mechanisms:

• Falls—most common cause of injury in patients of age >65, often occurs on an even, flat surface
  
• Motor vehicle crashes—2nd leading cause, most common fatal etiology
  
• Pedestrian—motor vehicle collisions, diminished cognitive skills, poor vision/hearing, impaired gait contribute to increased incidence
  
• Burns—higher fatality rate than young adults with same extent of burn
  
• Violence—less common mechanism than in younger ages, have heightened suspicion for elderly abuse, an under recognized issue
  
• Elderly more susceptible to serious injury from low-energy mechanisms
  

DIAGNOSIS

• Triage to major trauma center is determined by local protocols
  
• Injured patients with potential need for surgical, neurosurgical, or orthopedic intervention should be transferred to major trauma center
  
• Threshold for scene triage or transfer to trauma center should be lower for elderly
  

• The same pattern of assessment using primary survey (ABCDE) and secondary survey should be used with geriatric patients as with younger patients (see trauma, multiple)
  
• Normal vital signs can lead to false sense of security
  
  • Hypoperfusion often masked by inadequate physiologic response, underlying medical pathology, and medication effects
    

Primary survey (ABCDE)

• Airway, cervical spine—establish and maintain a patent airway with C-spine immobilization
  
  • Anatomic variation in elderly can lead to more difficult airways (dentures, cervical arthritis, TMJ arthritis)
    
  • Failure to recognize indications for early intubation is a common mistake
    
• Breathing—maintain adequate and effective breathing and ventilation
  
  • Weakened respiratory muscles and degenerative changes in chest wall result in diminished effective ventilation
    
  • Blunted response to hypoxia, hypercarbia, and acidosis delays onset of clinical distress
    
  • Lower threshold to intubate elderly patients
    
• Circulation—ensure adequate perfusion
  
  • Vigilant hemodynamic monitoring, heart rate, and BP do not always correlate well with cardiac output
    
  • Geriatric patients often have impaired chronotropic response to hypovolemia
    
  • Cardiovascular response may be blunted by rate controlling meds (β-blockers, Calcium channel blockers)
    
  • Baseline hypertension, common in elderly, may obscure relative hypotension
    
  • Bleeding made worse by antiplatelet and anticoagulation medicines
    
• Disability—rapid neurologic evaluation to assess for intracranial and spinal cord injury
  
  • Brain atrophy may delay onset of clinical symptoms from compressive effects
    
  • Grave error to assume alterations in mental status due solely to underlying dementia or senility
    
• Exposure—patient should be undressed completely
  
• Secondary survey
  
  • After the primary survey has been completed
    
  • Stabilization at each level
    
  • Complete physical exam from head to toe
    

• The geriatric trauma patient should be viewed as both a trauma and a medical patient
  
• Elderly patients can have significant comorbidities, past medical history, medications, and allergies are essential
  
• Comorbid medical conditions may have precipitated the traumatic event
  
• Consider hypoglycemia, syncope, cardiac dysrhythmia, CVA, UTI, etc.
  
• Details of the mechanism, initial presentation, and treatment rendered should be elicited from EMS personnel
  
• Concurrent medical conditions impede compensation, confound interpretation of severity and response, and complicate resuscitation.
  

Should follow primary and secondary surveys

• Primary and secondary survey
  
• Cervical spine and chest imaging are mandatory for victims of major traumas
  
• Pelvic radiographs should be performed with clinical suspicion of pelvic trauma or with hemodynamic instability
  
• CBC, ABG, blood type
  
• Electrolytes, renal function, serum glucose
  
• Urine dip for blood, UA if dip shows positive result
  
• Coagulation profile
  
• Base deficit, lactate
  
• Ethanol screen
  

• Liberal use of head CT is recommended for elderly with closed head trauma
  
• Nexus criteria has been validated in ages >65; however, cervical spine imaging needed in majority of geriatric traumas. CT scan emerging as study of choice for high suspicion, high-risk mechanism or age related changes likely to limit plain films
  
• Significant blunt and penetrating chest trauma requires objective evaluations of the heart and great vessels with echocardiography, CT scan, angiography, or direct visualization.
  
• Blunt abdominal trauma requires objective evaluation, modality depends on patient’s condition
  
• Hemodynamically stable patients should have an abdominal CT with IV contrast
  
• Ensure adequate hydration and assess baseline renal function prior to contrast load when clinical status permits.
  
• Unstable patients should have FAST exam or diagnostic peritoneal lavage
  
• CT with contrast is a valuable diagnostic tool for abdominal trauma, but predispose to risk of contrast related renal impairment
  
• Extremity injury:
  
  • Radiographs
    
  • Suspected vascular damage requires angiography or duplex ultrasound