Prevalence and characteristics of traumatic intracranial hemorrhage in elderly fallers presenting to the emergency department without focal findings.

OBJECTIVES: To determine the prevalence and associated characteristics of traumatic intracranial hemorrhage (ICH) in elderly fallers presenting to the emergency department (ED) without focal findings. DESIGN: Retrospective cohort study. SETTING: University-affiliated teaching hospital ED. PARTICIPANTS: Patients aged 65 and older presenting with a fall to the ED and undergoing a head computed tomography (CT) scan. MEASUREMENTS: Electronic medical records and CT scans of 404 consecutive patients were reviewed. Characteristics of patients with and without ICH were compared using unadjusted analyses. Patients taking warfarin, aspirin, or clopidogrel alone or in combination were compared with those not taking these medications. Multivariate logistic regression analyses were performed to determine variables independently associated with ICH. RESULTS: Forty-seven of 404 elderly fallers (11.6%) without focal findings had an ICH. Unadjusted analyses in these pilot data showed that warfarin was not significantly associated with ICH. Multivariate analyses indicated that elderly people living in at home were more likely to have ICH than those living in nursing homes or assisted living facilities (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.30-8.13) and that those with head trauma were more likely to have ICH than those without (OR=3.9, 95% CI=1.25-7.80). Aspirin was found to be protective (OR=0.49, 95% CI=0.24-0.98). CONCLUSION: ICH is common in elderly fallers presenting to the ED without focal findings. Anticoagulation alone did not appear to increase the risk of ICH, and aspirin was found to be protective, but prospective studies are needed to better assess this relationship.

Risk factors for death in elderly emergency department patients with suspected infection.

OBJECTIVES: To identify independent risk factors for death in elderly emergency department (ED) patients admitted for infection and to derive and validate a mortality-prediction rule for such patients. DESIGN: Prospective cohort study. SETTING: Tertiary hospital ED with 55,000 annual visits. PARTICIPANTS: ED patients aged 65 and older admitted for infection between December 2003 and September 2004 in the derivation cohort and October 2005 and October 2006 in the validation cohort. PRIMARY OUTCOME: 28-day in-hospital mortality. Data were extracted from charts, and multivariate logistic regression were performed to identify independent mortality predictors. A prediction model was constructed and then validated in a second cohort. RESULTS: Nine hundred thirty-five patients were included in the derivation cohort and 2,015 in the validation cohort. Mortality was 6% in the derivation cohort and 7% in the validation cohort. In the derivation cohort, logistic regression revealed five independent mortality predictors: respiratory compromise (respiratory rate >20 breaths per minute or hypoxemia) (odds ratio (OR)=4.0, 95% confidence interval (CI)=1.7-9.4), tachycardia (heart rate > or = 120 betas per minute; OR=3.2, 95% CI=1.6-6.3), cardiovascular failure (systolic blood pressure <90 mmHg despite fluid challenge or lactate > or = 4.0; OR=9.0, 95% CI=4.7-17), preexisting terminal illness (OR=5.7, 95% CI=2.2-15), and platelet count less than 150,000/mm3 (OR=2.7, 95% CI=1.3-5.6). Mortality increased with the number of factors: 0.51% for no factors, 3.1% for one factor, 14% for two factors, 47% for three or more risk factors. The c-statistic was 0.87 for the derivation model and 0.74 for the validation model. Almost 80% of patients in both cohorts were in low-risk groups (0 or 1 factor). CONCLUSION: A rule derived from five readily available variables predicts mortality in infected elderly ED patients and allows identification of a large low-risk subgroup.

Geriatric neurologic emergencies.

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.