We continue our mini series of Geriatric Emergency Medicine with SILVER TRAUMA where we cover how to approach falling among elderly, common injuries and pain management. This post is a summary based on Emergency Medicine Cases and RCEM Learning.
”A 90-year old lady that trips in the garden and sustains a fractured neck of femur will be placed on a well-recognised pathway that will eventually have ortho-geriatric input. However, there may not be an early review of the postural hypotension that caused the fall, the delirium causing her to take the bins out at 03.00 on a February morning, or that she’s mistakenly taken too much warfarin the night before.”
General approach to silver trauma:
- Assessing the cause of the fall
- Assessing the injuries coming from the fall
- Establishing a safe discharge plan
- Addressing issues of prevention
Investigating the cause of the fall is something we are not as good at as assessing the injuries. So to get better at it, you have to do some research next time you face a fallen hero:
A, Fall investigation
– Any previous injuries from other falls?
– How often does the patient fall?
– When do the falls take place?
Is there any clear connections such as:
– Happens at night – postural hypotension
– In the morning running to the bathroom after intake of diuretic pill?
– In the evening after taking the sedative before going to bed?
– Don’t forget to ask about alcohol!
– Was it a fall or was it syncope?
Does the patient has a recollection of the fall? if so, syncope is less likely.
B, Disease investigation
A fall can be a symptom of another disease, for example:
– Acute Coronary Syndrome – with an atypical anginal pattern
– Dehydration or electrolyte imbalance
c, medication investigation
The list of drugs that are associated with a risk of falling, both directly and indirectly, is too long to write down here.
The National Board of Health and Welfare (Socialstyrelsen) has made a diagnostic check-list regarding medication and side effects among elderly patients. In the end of the document (page 38) you find nice and thorough tables of symptoms, direct causes, indirect causes and drugs that can cause those causes.
Injuries of silver trauma
- Most common: hip fractures and distal radius- and/or ulna fractures
- Compression fractures of vertebral columns can result from relatively little trauma and is easily forgotten when the pain from the hip is taking all the attention
- OBS! C-spine injuries may result from seemingly benign falls
- Knee pain may be referred pain from occult hip fracture
- Inspect the whole patient: old patients have fragile skin and sometimes poor peripheral sensation – check for wounds or ulcers
Management of nociceptive pain in elderly patients
1 – Paracetamol (acetaminophen in some countries) – the base of geriatric pain relief.
2 – Opioids – with careful consideration.
- Old people have a more permeable blood brain barrier which leads to more immediate effect
- Old people have fewer braincells which leads to greater effect from opioids.
- Many opioids are eliminated via the kidneys and old kidneys are not what they used to be.
Start low and go slow!
2 mg intravenous morphine have a time-to-peak-effect of 15 to 20 minutes – not only peak of pain relief but also peak of side effects such as sedation, hypotension and respiratory suppression.
A, Administer 2 mg and evaluate the effects after 15-20 minutes: if the patient still is in pain and does not demonstrate any of the side effects it is safe to give a little bit more.
B, Measure the pain before and after administration – it is one of the few opportunities where we can see the effects of our ordinations quite immediately.
C, NO kodein – weak analgetic effect and too large individual metabolism differences.
D, NO tramadol – can cause delirium, nausea and dizziness.
E, NO morphine or Oxycodone to patients with eGFR < 30 – Contact nephrologist for alternatives… But if you need to choose between them: choose Oxycodone.
- NO ibuprofen or naproxen to people with heart failure, kidney failure, history of gastric ulcus or moderate to severe hypertension.
- Some physicians think that COX-inhibitors should not be prescribed to people > 65 years of age…
next week: atypical symptoms and adverse drug effects
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