GEMCAST

Dr. Alisha Benner discusses tips for palliative care in the ED.

see www.gempodcast.com for show notes, references, information, and to leave comments! Follow @gempodcast on twitter.

This podcast uses sounds from freesound.org by Jobro and HerbertBoland.

Image credit: https://commons.wikimedia.org/wiki/File:Dante_Gabriel_Rossetti_-_Study_of_Dante_holding_the_hand_of_Love.jpg

Ophthalmologist Dr. Bryan Hong continues to discuss his approach to some of the common eye emergencies that bring older adults to the Emergency Department.

see www.gempodcast.com for show notes and information and to leave comments.

This podcast uses sounds from freesound.org by Jobro and HerbertBoland.

Image credit: https://pixabay.com/en/eye-black-reds-female-red-color-1574829/

Ophthalmologist Dr. Bryan Hong talks about his approach to some of the common eye emergencies that bring older adults to the Emergency Department.

see www.gempodcast.com for show notes and information and to leave comments.

This podcast uses sounds from freesound.org by Jobro and HerbertBoland.

Image credit: https://commons.wikimedia.org/wiki/File:A_selection_of_glass_eyes_from_an_opticians_glas_eye_case._Wellcome_L0036581.jpg

Leah Hatfield discusses the new oral anticoagulants, and how to reverse them in cases of life threatening bleeds. To leave a comment and for the shownotes, see https://gempodcast.com/2016/09/30/how-to-reverse-oral-anticoagulants/

Tony Rosen discusses how to identify elder abuse and ways to intervene.

Elder abuse is a common and under-recognized problem among older adults. In the Emergency Department, we are uniquely positioned to identify patients who may be at risk. In this episode, Tony Rosen, an Emergency Physician and researcher with fellowship training in Geriatric Emergency Medicine, who works at Cornell in NYC discusses what constitutes elder abuse, its prevalence, how to identify it, and what to do when you suspect it.

For State requirements, see here: http://www.napsa-now.org/wp-content/uploads/2014/11/Mandatory-Reporting-Chart-Updated-FINAL.pdf

Please see https://gempodcast.com/2016/08/26/how-to-identify-and-intervene-in-cases-of-elder-abuse/ for the full show notes and references.

Amal Mattu talks about ACS presentations, workup, and management in older adults, and why the atypical is typical!

For the full shownotes and references, and to leave a comment, see: https://gempodcast.com

Chest pain is one of the most common reasons why people present to the ED. The chief complaint of Chest Pain typically triggers an automatic EKG, and potentially a workup for acute coronary syndrome. However, many patients who are having ACS do not present with chest pain. Instead, they may have dyspnea, diaphoresis, nausea, vomiting, abdominal pain, or other non-specific symptoms. Which patients are most likely to present this way? Older adults. And the older the patient, the more likely they are to be chest-pain free when they present with an NSTEMI or STEMI. So it is up to the medical provider to be vigilant, consider possible angina equivalents, and order the right workup.

Dr. Mattu talks us through some of the statistics of how often MIs occur without chest pain with age, how EKG interpretation may differ, and how management should differ vs how it does differ. Patients presenting with atypical symptoms are less likely to receive an aspirin or thrombolytics/PCI, and their mortality is higher.

Selected References:

1. Mattu A, Grossman SA, Rose PL. Geriatric emergencies - A discussion-based review. Wiley Blackwell; 2016.

2. Glickman SW, Shofer FS, Wu MC, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J. 2012;163(3):372-382. http://www.ncbi.nlm.nih.gov/pubmed/22424007

3. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the global registry of acute coronary events. Chest. 2004;126(2):461-469. http://www.ncbi.nlm.nih.gov/pubmed/15302732

4. Cannon AR, Lin L, Lytle B, Peterson ED, Cairns CB, Glickman SW. Use of prehospital 12-lead electrocardiography and treatment times among ST-elevation myocardial infarction patients with atypical symptoms. Acad Emerg Med. 2014;21(8):892-898. http://www.ncbi.nlm.nih.gov/pubmed/25155289

5. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: A scientific statement for healthcare professionals from the american heart association council on clinical cardiology: In collaboration with the society of geriatric cardiology. Circulation. 2007;115(19):2549-2569. http://www.ncbi.nlm.nih.gov/pubmed/17502590

6. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822. http://www.ncbi.nlm.nih.gov/pubmed/22357832

This podcast uses sounds from freesound.org by Jobro and HerbertBoland.

Image credit: https://pixabay.com/en/pulse-trace-healthcare-medicine-163708/

Chris Carpenter, one of the authors of the Geriatric ED guidelines, presents 5 high-impact, low-cost ways to make your ED and your practice more geriatric-friendly.

For the full show notes with references and to leave comments, see: https://gempodcast.com/2016/06/29/5-ways-to-geriatricize-your-ed/

Geriatric EDs, or Senior EDs, have been popping up around the country. The idea behind them is that having a separate space, a distinct staff, and specialized protocols, can help provide better care to older adults. However, for many EDs and hospital systems this is simply not feasible. In this episode, Chris Carpenter (@GeriatricEDnews) presents five high-yield, low-cost ways that those of us working in non-senior EDs can take some of the principles of geriatric emergency medicine and apply them either to our own practice or implement them in our own EDs, without a lot of funding. For more about Geriatric EDs, check out this ALiEM blog post. https://www.aliem.com/2014/geriatric-emergency-departments-coming-hospital-near/

The full geriatric ED guidelines are available here: https://www.acep.org/geriedguidelines/

To learn more about many of the Geriatric EM ideas and concepts discussed here, check out the Geri-EM.com site, where you can also get free CME.

For the references see: https://gempodcast.com/2016/06/29/5-ways-to-geriatricize-your-ed/

This podcast uses sounds from freesound.org by Jobro and HerbertBoland. Image from https://commons.wikimedia.org/wiki/File:Clock_Cogs.jpg

Jeff Kline talks about PEs in older adults. What's different and what's the same for older vs younger patients? Find out here!

See gempodcast.com/2016/06/02/pulmonary-emboli-in-older-adults/ for a full description, links, and to leave comments!

Not a day goes by that an Emergency Physician doesn’t at least consider PE in a patient who presents with chest pain, dyspnea, or syncope. We have become familiar with using risk stratification tools like the Wells Score and the PERC criteria. But what do you do in older adults? All of them will automatically NOT be PERC negative because of their age. In this episode, with PE guru Jeff Kline, we discuss the presentation of PE in older adults, including the demographics, diagnosis, and how treatment may differ from younger adults in small, sub-massive, and massive PEs.

Selected References:

1. Zondag W, Vingerhoets LM, Durian MF, et al. Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function. J Thromb Haemost. 2013;11(4):686-692. http://www.ncbi.nlm.nih.gov/pubmed/23336721

2. Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: A one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795. http://www.ncbi.nlm.nih.gov/pubmed/26113241

3. Kahler ZP, Kline JA. Standardizing the D-dimer assay: Proposing the D-dimer international managed ratio. Clin Chem. 2015;61(5):776-778. http://www.ncbi.nlm.nih.gov/pubmed/25816812

4. Kahler ZP, Beam DM, Kline JA. Cost of treating venous thromboembolism with heparin and warfarin versus home treatment with rivaroxaban. Acad Emerg Med. 2015;22(7):796-802. http://www.ncbi.nlm.nih.gov/pubmed/26111453

5. Zhang Y, Zhou Q, Zou Y, et al. Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia: A prospective cohort study. J Thromb Thrombolysis. 2015. http://www.ncbi.nlm.nih.gov/pubmed/26370200

6. Sharp AL, Vinson DR, Alamshaw F, Handler J, Gould MK. An age-adjusted D-dimer threshold for emergency department patients with suspected pulmonary embolus: Accuracy and clinical implications. Ann Emerg Med. 2016;67(2):249-257. http://www.ncbi.nlm.nih.gov/pubmed/26320520

7. Kirschner JM, Kline JA. Is it time to raise the bar? age-adjusted D-dimer cutoff levels to exclude pulmonary embolism. Ann Emerg Med. 2014;64(1):86-87. http://www.ncbi.nlm.nih.gov/pubmed/24951413

8. Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, part 2: Diagnostic approach. J Emerg Med. 2015;49(1):104-117. http://www.ncbi.nlm.nih.gov/pubmed/25800524

9. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-780. http://www.ncbi.nlm.nih.gov/pubmed/18318689

Image credit: http://anthrocolors.deviantart.com/art/Lungs-for-fresh-air-edited-298950224

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

Tim Platts-Mills shares his pearls about pain management for older adults in the ED.

See here to leave a comment:

https://gempodcast.com/2016/05/02/pearls-and-pitfalls-of-pain-management-in-older-adults/

Pain is the number one reason why people seek care in the Emergency Department (ED). One major goal of acute care is diagnosing the cause of the pain, but another is helping relieve the suffering associated with pain. In older adults, some of the risks of pain management with opioids are amplified, such as the risk of sedation and falls. With NSAIDs, there is a higher risk of acute renal insufficiency and electrolyte abnormalities, as well as cardiovascular risks with longer treatment. How should we approach acute pain management in the ED, and on discharge in older patients? In this podcast episode, Tim Platts-Mills, an expert and researcher on pain in older adults talks us through some ideas for non-opiates, opiates, and other adjuncts. We discuss some of the risks of over-treatment and under-treatment, and introduce the idea of the allostatic load created by chronic pain.

Selected References

1. Hwang U, Platts-Mills TF. Acute pain management in older adults in the emergency department. Clin Geriatr Med. 2013;29(1):151-164. http://www.ncbi.nlm.nih.gov/pubmed/23177605

2. Platts-Mills TF, Esserman DA, Brown DL, Bortsov AV, Sloane PD, McLean SA. Older US emergency department patients are less likely to receive pain medication than younger patients: Results from a national survey. Ann Emerg Med. 2012;60(2):199-206. http://www.ncbi.nlm.nih.gov/pubmed/22032803

3. Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc. 2010;58(11):2122-2128. http://www.ncbi.nlm.nih.gov/pubmed/21054293

4. Terrell KM, Hui SL, Castelluccio P, Kroenke K, McGrath RB, Miller DK. Analgesic prescribing for patients who are discharged from an emergency department. Pain Med. 2010;11(7):1072-1077. http://www.ncbi.nlm.nih.gov/pubmed/20642733

5. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med. 2005;352(13):1324-1334. http://www.ncbi.nlm.nih.gov/pubmed/15800228

6. Siddall PJ, Cousins MJ. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg. 2004;99(2):510-20, table of contents. http://www.ncbi.nlm.nih.gov/pubmed/15271732

7. Jakobsson U, Klevsgard R, Westergren A, Hallberg IR. Old people in pain: A comparative study. J Pain Symptom Manage. 2003;26(1):625-636. http://www.ncbi.nlm.nih.gov/pubmed/12850645

8. Elliott AM, Smith BH, Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet. 1999;354(9186):1248-1252. http://www.ncbi.nlm.nih.gov/pubmed/10520633

9. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE study group. systematic assessment of geriatric drug use via epidemiology. JAMA. 1998;279(23):1877-1882. http://www.ncbi.nlm.nih.gov/pubmed/9634258

This podcast uses sounds from freesound.org by Jobro and HerbertBoland

Image credit: https://pixabay.com/en/heart-3d-stone-white-pain-old-1463424/

Bryan Hayes and David Juurlink explain why several common meds we use in the ED can cause dangerous complications for older patients.

See http://gempodcast.com/2016/03/30/dangerous-med-combos-in-older-adults/ to leave a comment.

Look twice at the med list before you prescribe these!

Two distinguished guests join me this month, David Juurlink (@DavidJuurlink) and Bryan Hayes (@PharmERToxyGuy) to discuss medication interactions. There are many medications that we commonly prescribe in the ED that can have potentially deadly side effects when combined with other meds that a patient is already on. It is important to always check the patient’s medication list prior to writing a new script. We present two examples of clinical cases in which commonly used medications could prove dangerous in combination with other medications: cellulitis, and a community-acquired pneumonia. We discuss potential side effects from medication interactions (with a little pathophysiology thrown in), and some alternative medications that may be safer.

References:

1. Baillargeon J, Holmes HM, Lin YL, Raji MA, Sharma G, Kuo YF. Concurrent use of warfarin and antibiotics and the risk of bleeding in older adults. Am J Med. 2012;125(2):183-189. http://www.ncbi.nlm.nih.gov/pubmed/22269622

2. Ho JM, Juurlink DN. Considerations when prescribing trimethoprim-sulfamethoxazole. CMAJ. 2011;183(16):1851-1858. http://www.ncbi.nlm.nih.gov/pubmed/21989472

3. Fralick M, Macdonald EM, Gomes T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: Population based study. BMJ. 2014;349:g6196. http://www.ncbi.nlm.nih.gov/pubmed/25359996

4. Juurlink DN, Mamdani M, Kopp A, Laupacis A, Redelmeier DA. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;289(13):1652-1658. http://www.ncbi.nlm.nih.gov/pubmed/12672733

5. Juurlink DN. The cardiovascular safety of azithromycin. CMAJ. 2014;186(15):1127-1128. http://www.ncbi.nlm.nih.gov/pubmed/25096666

6. Wright AJ, Gomes T, Mamdani MM, Horn JR, Juurlink DN. The risk of hypotension following co-prescription of macrolide antibiotics and calcium-channel blockers. CMAJ. 2011;183(3):303-307. http://www.ncbi.nlm.nih.gov/pubmed/21242274

Sound credits: This podcast uses sounds from freesound.org by Jobro and HerbertBoland