Emergency Department Pain Management in the Older Adult.

Pain assessment and management in older adults is complex and requires evaluation and consideration of the type of pain, the acuity of the condition, comorbidities, and medications. Many older adults do not receive appropriate therapy for painful conditions in the emergency department (ED). This brief review article is focused on pharmacologic agents, drug-drug interactions, drug-disease interactions, and approaches in the management of painful conditions seen in older adults in the emergency department. Recommendations for specific painful conditions such as fragility fractures are discussed.

Emergency Department Length of Stay Is Associated with Delirium in Older Adults.

INTRODUCTION: Incident delirium in older patients is associated with prolonged hospitalization and mortality. A recent study suggested an association between emergency department (ED) length of stay (LOS), time in ED hallways, and incident delirium. In this study we further evaluated the emerging association between incident delirium with ED LOS, time in ED hallways, and number of non-clinical patient moves in the ED. METHODS: We performed this retrospective cohort study at a single, urban, academic medical center. All data were extracted from the electronic health record. We included patients aged ≥65 years presenting to the ED and admitted to family or internal medicine services over a two-year period. Patients admitted to any other service, transferred from another hospital, discharged from the ED, or who underwent procedural sedation were excluded. The primary outcome was incident delirium, defined as a positive delirium screen, receipt of sedative medications, or use of physical restraints. Multivariable logistic regression models including age, gender, language, history of dementia, Elixhauser Comorbidity Index, number of non-clinical patient moves within the ED, total time spent in the ED hallway, and ED LOS were fitted. RESULTS: We studied 5,886 patients ≥65 years of age; median age was 77 (69-83) years; 3,031 (52%) were female, and 1,361 (23%) reported a history of dementia. Overall, 1,408 (24%) patients experienced incident delirium. In multivariable models, ED LOS was associated with development of delirium (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, per hour), while non-clinical patient moves [OR 0.97, (95% CI 0.91-1.04) and ED hallway time [OR 0.99, 95% CI 0.98-1.01, per hour) was not associated with development of delirium. CONCLUSION: In this single-center study, ED length of stay was associated with incident delirium in older adults, while non-clinical patient moves and ED hallway time in the ED were not. Health systems should systemically limit time in the ED for admitted older adults.

Frailty Status and Related Factors in Elderly Patients in Intensive Care for Acute Conditions in China.

Objective: Frailty is a complex age-related clinical disorder characterized by the decreased physiological capacity of multiple organ systems, leading to increased susceptibility to stressors. Because the clinical manifestations of frailty are heterogeneous, accurately diagnosing the degree of frailty and its predisposing factors is important. We investigated the prevalence of frailty and the related risk factors in elderly patients in emergency departments (EDs) in China using a clinical frailty scale (CFS) and a comprehensive geriatric assessment (CGA) tool.Methods: Elderly patients who were scheduled to be discharged from the acute ward of an ED within one week were recruited. They were asked to complete a set of surveys using CGA forms, comprising a CFS, a Nutritional Risk Screening 2002 form, laboratory tests for albumin level and body mass index, a Mini-Cog test for cognitive status, Barthel's activities of daily living index, an instrumental activities of daily living (IADL) assessment, a Geriatric Depression Scale-15 (GDS-15) assessment and a Cumulative Illness Rating Scale-Geriatric assessment.Results: Frailty prevalence in the recruited elderly patients was 33.33%. Frail elderly patients (CF≥5) also had more comorbidities, higher depression scores, and nutritional risks along with lower body mass indices, weight, quality-of-life scores and physical function scores. Cognitive impairment, depression, and education level were found to be the main impact factors on frailty.Conclusion: Frail elderly patients had greater cognitive problems and higher levels of depression besides physical dysfunction, which further aggravates frailty in older patients.

Cervical Spine Injuries in Older Patients with Falls Found on Magnetic Resonance Imaging After Computed Tomography.

INTRODUCTION: In this study we aimed to determine the rate of traumatic abnormalities on cervical spine magnetic resonance imaging (MRI) after a normal cervical spine computed tomography (CT) in older patients with ground-level falls. We hypothesized that MRI is low yield following a normal physical examination and normal CT after a ground-level fall. METHODS: This was a retrospective cohort study of patients 65 years and older evaluated with a cervical spine MRI following a ground-level fall. Inclusion criteria included age 65 years and older, ground-level fall, normal cervical spine CT followed by a cervical spine MRI. We abstracted data following accepted methodologic guidelines. Patients with any focal neurological finding were considered to have an abnormal neurological examination. Imaging studies were considered to be abnormal if there was a report of an acute traumatic injury. The primary outcome was a traumatic abnormality identified on MRI. We described data with simple descriptive statistics. RESULTS: Eighty-seven patients with a median age of 74 (interquartile range [IQR] 69, 83]) years had an MRI following a normal cervical spine CT. Median emergency department length of stay was 8.2 hours (IQR 5.3, 13.5). Sixty-four (73.6%) patients had a normal neurological examination on arrival; eight of these patients (12.5% (95% confidence interval [CI], 5.6-23.2%) had an abnormal cervical spine MRI. Twenty-three patients (26.4%) had an abnormal neurological examination on arrival; two of these patients (8.7%, 95% CI, 1.1-28%) had an abnormal cervical spine MRI. Overall, 10 patients (11.5%) had an abnormal cervical spine MRI. One patient underwent operative intervention due to an unstable injury. Of the remaining nine patients with acute findings on cervical spine MRI, there were no other unstable injuries; two patients were managed with cervical orthosis, and seven patients had no additional management. CONCLUSION: In this study of older patients with ground-level falls and normal, atraumatic, cervical spine CT, a small portion had traumatic abnormalities on MRI, with few requiring further intervention. Further study is required to identify criteria to determine when MRI should be performed in older patients after a ground-level fall.

Comparison of Video Versus Direct Laryngoscopy: A Prospective Prehospital Air Medical Services Study.

OBJECTIVE: Videolaryngoscopy (VL) in the prehospital setting remains controversial, with conflicting data on its utility. We compared C-MAC VL (Karl Storz, Tuttlingen, Germany) versus direct laryngoscopy (DL) in the prehospital setting, recording the grade of the glottic view, first pass success (FPS), overall success, and equipment functionality. METHODS: We conducted a prospective observational study with a convenience sample of 49 adult patients who were intubated by flight crew nurses and paramedics using the C-MAC videolaryngoscope from April to November 2013. We compared Cormack-Lehane (CL) grades of view for DL and VL, intubation success rates, and equipment functionality. RESULTS: CL grades 1 or 2 were obtained with 24 patients (49%) with DL and 45 patients (92%) with VL. Of the 25 patients (51%) who had a CL grade 3 or 4 view on DL, 22 of those patients (88%) converted to a CL grade 1 or 2 with VL (P < .001). There was an overall success rate of 96% and an FPS rate of 71%. The C-MAC videolaryngoscope was functional during intubation 100% of the time. CONCLUSION: VL improved glottic visualization compared with DL. The FPS and overall intubation success rates were similar to other published prehospital studies using VL. The C-MAC provided reliable, high-quality video despite demanding prehospital conditions.

Geriatric Emergency Medicine Fellowships: Current State of Specialized Training for Emergency Physicians in Optimizing Care for Older Adults.

Improving emergency department (ED) care for older adults is a critical issue in emergency medicine. Institutions throughout the United States and Canada have recognized the growing need for a workforce of emergency physician (EP) leaders focused on clinical innovation, education, and research and have developed specialized fellowship training in geriatric emergency medicine (GEM). We describe here the overview, structure, and curricula of these fellowships as well as successes and challenges they have encountered. Seven GEM fellowships are active in the United States and Canada, with five offering postresidency training only, one offering fellowship training during residency only, and one offering both. The backbone of the curriculum for all fellowships is the achievement of core competencies in various aspects of GEM, and each includes clinical rotations, teaching, and a research project. Evaluation strategies and feedback have allowed for significant curricular changes as well as customization of the fellowship experience for individual fellows. Key successes include an improved collaborative relationship with geriatrics faculty that has led to additional initiatives and projects and former fellows already becoming regional and national leaders in GEM. The most critical challenges have been ensuring adequate funding and recruiting new fellows each year who are interested in this clinical area. We believe that interest in GEM fellowships will grow and that opportunities exist to combine GEM fellowship training with a focus in research, administration, or health policy to create unique new types of highly impactful specialized training. Future research may include exploring former fellows' postfellowship experiences, careers, accomplishments, and contributions to GEM to better understand the impact of GEM fellowships.

Emergency Department Pain Management Following Implementation of a Geriatric Hip Fracture Program.

INTRODUCTION: Over 300,000 patients in the United States sustain low-trauma fragility hip fractures annually. Multidisciplinary geriatric fracture programs (GFP) including early, multimodal pain management reduce morbidity and mortality. Our overall goal was to determine the effects of a GFP on the emergency department (ED) pain management of geriatric fragility hip fractures. METHODS: We performed a retrospective study including patients age ≥65 years with fragility hip fractures two years before and two years after the implementation of the GFP. Outcomes were time to (any) first analgesic, use of acetaminophen and fascia iliaca compartment block (FICB) in the ED, and amount of opioid medication administered in the first 24 hours. We used permutation tests to evaluate differences in ED pain management following GFP implementation. RESULTS: We studied 131 patients in the pre-GFP period and 177 patients in the post-GFP period. In the post-GFP period, more patients received FICB (6% vs. 60%; difference 54%, 95% confidence interval [CI] 45-63%; p<0.001) and acetaminophen (10% vs. 51%; difference 41%, 95% CI 32-51%; p<0.001) in the ED. Patients in the post-GFP period also had a shorter time to first analgesic (103 vs. 93 minutes; p=0.04) and received fewer morphine equivalents in the first 24 hours (15mg vs. 10mg, p<0.001) than patients in the pre-GFP period. CONCLUSION: Implementation of a GFP was associated with improved ED pain management for geriatric patients with fragility hip fractures. Future studies should evaluate the effects of these changes in pain management on longer-term outcomes.

Respiratory Emergencies in Geriatric Patients.

Acute dyspnea in older patients is a common presentation to the emergency department. Acute dyspnea in older adults is often the consequence of multiple overlapping disorders, such as pneumonia precipitating acute heart failure. Emergency physicians must be comfortable managing patients with acute dyspnea of uncertain cause and varying goals of care. In addition to the important role noninvasive ventilation (NIV) plays in full resuscitation, NIV can be useful as a method of providing supportive or nearly fully supportive care while more information is gathered from the patients and their loved ones.

Feasibility of the preoperative Mallampati airway assessment in emergency department patients.

BACKGROUND: Multiple predictors have been proposed to assist in identifying patient features that would predict difficult airway management. The Mallampati score (MS) has been shown to be useful in the preoperative assessment of patients being intubated in the operating room. OBJECTIVE: We sought to define the feasibility of this assessment in the Emergency Department. METHODS: A prospective, observational study was performed on all patients being intubated at a university Level I trauma center over a period of 6 months. We recorded and calculated the proportion of patients who were successfully assessed using the MS. Reasons given by individual intubators for failure to assess were recorded. We also tracked patient characteristics between groups and complication rates. RESULTS: Of 328 patients, 32 (10%) were excluded due to incomplete data. Among the remaining 296, 58% were intubated for non-trauma indications, 70% were male, and the mean age was 45.9 years. Only 76 of 296 (26%) (95% confidence interval 21-31%) were able to have the MS performed. Lack of patient cooperation and clinical instability were listed as factors that precluded evaluation in patients whose assessment was unsuccessful. The frequency of procedure-related minor events did not differ significantly between the assessed and non-assessed groups. Major events included two cricothyrotomies in the non-assessed group. CONCLUSIONS: We were unable to perform a Mallampati assessment in three-quarters of our patients requiring emergency intubation. These findings call into question the feasibility of the standard Mallampati assessment in the practice of Emergency Medicine.