Ian M. Carrese PA-S2 South University PA Program July 29, 2012

1. Ian M. Carrese PA-S2South University PA ProgramJuly 29, 2012 Geriatric Emergencies: a look at altered mental status, abdominal pain and congestive heart failure

2. Format for Presentation Three case studies of emergent or urgent geriatric patients One each with a chief complaint of AMS, abdominal pain and CHF I’d like to make it somewhat interactive and ask questions along the way Feel free to comment or ask questions throughout the presentation

3. Altered Mental Status An 80 y/o female presents to the ED with acute altered LOC and lethargy for the past 2-3 weeks CBC, CRP, blood glucose, CXR and CT of her brain are all normal However, her 12-lead EKG shows SB with low voltage QRS complexes. Cardiac enzymes are WNL She has a GCS of 10/15, VS are unremarkable except for a pulse of 56, rectal temp of 96.8° F and B/P of 170/90 PE is unremarkable except for delayed reflexes and sluggish bowel sounds

4. AMS: What should we do now? I ordered a BMP, U/A with C+S and ABGs The BMP was significant for hyponatremia with a serum Na+ of 123 mEq/L Urinalysis showed high amounts of WBCs, and gram negative rods ABGs: 7.32/50/68/27/8/90% on 2L O2 via NC

5. Further investigation and treatment While examining her, I also noticed thinning eyebrows and extremely dry skin, as a shot in the dark, I added on a TFT (thyroid function test) This showed a TSH of 100 mIU/L, Free T3 and T4 were undetectable Although her GCS was 10, she was not adequately protecting her airway and she was markedly acidotic (respiratory) so I chose to intubate and hyperventilate her slightly to blow off some CO2 Remember the ABCs, and don’t think too hard!

6. Treatment continued This patient also had a raging UTI, so I gave her a dose of Cipro 500mg IV which should cover most gram negative rods (most likely E. coli) I am not familiar with the use of IV Levothyroxine in myxedema coma patients, but it seemed to be warranted given her mental status, VS, and physical exam, so I gave her a small dose of 200mcg IV (normal dose is 200-500mcg IV) She was also started on ½ NS at 100mL/hr to gently correct her hyponatremia She was stabilized with these interventions and admitted to the ICU for further treatment and close observation

7. Discussion The DDx for AMS in the elderly is enormous Hypoglycemia is one of the most common causes of AMS and is also one of the most easily corrected Her labs and CT ruled out renal and hepatic failure although she did have a serum Na+ of 123 mEq/L CNS infections were also ruled out given a normal CBC and CRP With a history of 2-3 weeks of lethargy an acute drug intoxication/overdose could safely be ruled out

8. Discussion continued Metabolic and endocrine etiologies should have been explored given her hypothermia, hyporeflexia, bradycardia and low voltage QRS complexes Her TFTs showed a massive primary hypothyroidism Hypothyroidism alone rarely causes myxedema coma, but this patient had a concomitant UTI which exacerbates her endocrine condition The foundation of treatment of myxedema coma is IV Levothyroxine

9. Case #2: Abdominal Pain A 65 y/o gentleman with a long history of ETOH abuse and end stage cirrhosis of the liver presents to the ER after having vomited a large amount of blood This is his first ever episode of hematemesis despite having several esophageal varices ligated a few years ago He is pale, lightheaded, slightly jaundiced and ill-appearing

10. Abdominal Pain Continued After having his varices ligated, he was started on Propranolol prophylactically, but still continued to drink half of a liter of Jim Beam daily despite being diagnosed with a cirrhotic liver He also is non-compliant, but manages to take his Propranolol daily as it is his only medication

11. Physical Exam Findings and Labs Vital signs are normal except for an increased pulse at 90 bpm. His B/P is 100/70 Lungs are CTA and his CV exam reveal no murmurs, rubs or gallops His abdomen reveals mild distension with a moderate to large amount of free fluid In general he looks sick, has mild jaundice and icterus

12. Physical Exam Findings and Labs A CBC reveals a WBC count of 12,500 (and a slight shift to the left), H/H of 8.2 and 26 and platelets are 80,000 PT/INR is 23.6 and 2.0 LFTs show that AST, ALT and ALP are all elevated at 252, 137 and 321, respectively Total Bilirubin is 3.2 with an Albumin level of 2.6

13. Diagnostic Studies An abdominal U/S shows a moderate amount of free fluid and liver parenchymal disease

14. How are we going to manage this patient? IV Octreotide 50mcg IV times one dose and then IV daily for four more days IV antibiotics: I chose to give him Cipro 500mg IV and Flagyl 500mg IV IV PPI: Pantoprazole 40mg IV I did not chose to give additional β-blockers IV because he was lightheaded and his B/P was only 100/70 Admit to a floor bed as long as bleeding was controlled and he was hemodynamically stable

15. Discussion Similar to AMS in the geriatric population, the DDx for abdominal pain is daunting Given his history of esophageal varices, ETOH abuse and liver cirrhosis, this was likely an acute esophageal bleed Esophageal varices account for a small percentage of UGI bleeds, but are associated with a 60-70% mortality rate after one year Most die from complications related to the underlying hepatic syndromes, not exsanguination

16. Discussion Again, always remember the ABCDs of the primary survey. This patient could maintain his airway, was breathing and had adequate signs of perfusion It is quite often that patients with esophageal varices develop concomitant bacterial infections, so it is important to prophylactically treat with a round of antibiotics initially IV Octreotide (Sandostatin) is key in managing variceal bleeds as it is a potent splanchnic vasoconstrictor

17. Discussion I chose to give him a dose of IV Protonix, but after further research, I learned that IV PPI therapy is contraindicated in pre-EGD patients. Current guidelines recommend against IV PPIs although there is no data that they affect the outcome or findings of the endoscopy Endoscopy and ligature of the varices is the gold standard treatment for this type of hemorrhage and it should be initiated within 12 hours of presentation

18. Case #3: CHF Exacerbation A 69 y/o female presents to the ER with a 3-4 day worsening of SOB, cough with frothy pink sputum and a ten pound weight gain She says she couldn’t afford a medication she called “Cardol” and ran out of her Lasix last week She is pale, diaphoretic, tachypneic and agitated While attempting to get additional history she becomes cyanotic and loses consciousness Luckily you are in an emergency room and have the assets to intubate and ventilate her

19. Physical Exam Findings and Diagnostics Now that she is intubated, her respiratory rate is now controlled at 22/min Pulse is 102 bpm, regular with a B/P of 163/94; she is afebrile Physical exam reveals an S3 and S4, marked JVD with hepatojugular reflux. Rales are auscultated throughout all lung fields except the apices and there are diminished sounds in both bases EKG shows sinus tachycardia with Q-waves in leads I, V2 and V3 and a prolonged, “double-humped” P-wave. There are no acute changes

20. Diagnostics continued BMP is unremarkable except for a mildly elevated BUN/Cr at 29 and 1.5, respectively CBC shows a mild normochromic, normocytic anemia with an H/H of 9.1 and 27 BNP is extremely elevated at 3,721 PCXR shows patchy, diffuse infiltrates, Kerley-B lines, blunting of the costophrenic angles and cardiomegaly

21. More Diagnostics Echocardiography shows no valvular abnormalities other than a trivial amount of MR, left ventricular hypokinesis and an LVEF of 30%

22. What should we do next? STAT Cardiology consult for a possible trip to the cath lab and PCI? Start a NTG gtt? Start an inotrope like Nesiritide? Diurese her with a Lasix gtt?

23. Management of an Acute CHF Exacerbation Initiation of intravenous NTG at 10mcg/min helps reduce B/P, afterload and symptoms An alternative to NTG is Nesiritide (Natrecor) which also results in vascular smooth muscle relaxation by stimulating the production of cGMP (very similar to how NTG works) NTG and Nesiritide are not given in concert The patient is in obvious pulmonary edema and needs to be started on diuretics: Furosemide 80mg IV times one, then start a gtt at 0.1mg/kg/hr

24. Management Continued Furosemide gtt may be doubled every two hours in order to achieve adequate diuresis. Max dose is 0.4mg/kg/hr If her hypertension does not respond to IV NTG (little improvement at a gtt titrated up to 50mcg/min), IV Nitroprusside (Nipride) is an option Also, if she needs additional inotrope support, IV Dopamine started at 5-10mcg/kg/min As long as a patient is not in profound cardiovascular collapse, Dobutamine can be used in conjunction with both NTG and Dopamine

25. Management Continued Although she did have LV hypokinesis on echo, she had no chest pain and no acute changes on her EKG PCI is not emergently needed at this point It doesn’t hurt to consult cardiology to help manage her inotrope therapy Initial EKG have been shown not to demonstrate acute ischemic changes (however, it does look like she had an old anterior infarct), so serial EKGs are warranted

26. The Differential Diagnosis for Dyspnea • It is enormous in magnitude, similar to both AMS and abdominal pain • Drug-related alveolar edema seen in ARDS should be considered, but given her brief history of being without both “Cardol” and furosemide should point you towards heart failure • You later find out from a family member that she meant Carvedilol

27. More DDx The usual suspects: acute bacterial pneumonia, PE, MI, COPD, acute asthma and acute allergic reactions A high index of suspicion and objectivity should be maintained in order not to miss something like an acute IgE mediated reaction causing anaphylaxis and respiratory failure

28. Questions or Comments? Works Cited: O. John Ma, MD, David M. Cline, MD. Emergency Medicine Manual, Sixth Edition. American College of Emergency Physicians. McGraw-Hill Medical Publishing Division. 2004. Epocrates iPhone application