High-Risk Conditions Part IV: Dangerous Patient Populations

High-Risk Conditions
Part IV:
Dangerous Patient
Amal Mattu, MD, FAAEM, FACEP
Program Director, Emergency Medicine Residency
Co-Program Director, Emergency Medicine/Internal
Medicine Combined Residency
Professor, Department of Emergency Medicine
University of Maryland School of Medicine
Baltimore, Maryland
At the conclusion of this presentation, each participant should be able to…
1. List atypical presenting symptoms and signs of deadly illnesses that lead to
misdiagnoses and delays in diagnoses in elderly patients.
2. Describe high-risk illnesses in pregnant patients.
3. Describe common pitfalls in pediatric patients that lead to malpractice.
Elderly Patients
Pharmacologic issues
• Polypharmacy and drug interactions
o Elders account for 30% of prescription drugs used in the U.S.
o The average elderly person takes 4-5 prescription drugs and 2 over-thecounter medications daily
o Upon discharge from the ED, 30-50% are prescribed at least one
additional medication
 12-20% of these prescriptions are considered “potentially
inappropriate” based on patient’s age or potential serious drug
o Adverse drug reactions are a primary or major contributing factor in 3-8%
of all admissions of elders
o Nearly 20% of elderly patients brought/sent for emergent psychiatric
evaluation have symptoms caused by drug reaction or polypharmacy
• Pharmacokinetics
o Alterations in pharmacokinetics can occur due to decrease in hepatic blood
flow and microsomal enzyme activity, decreases in body composition
(decreased total body water and lean body mass and increase in adipose
o Decreased drug elimination may occur due to renal changes
• Drugs to avoid when possible
o Sedatives/hypnotics: increased risk of falls
 Benzodiazepines
 Barbiturates
o Analgesics/muscle relaxants
 Opiates
 Cyclobenzaprine
o NSAIDs: increased risk of GI bleed and acute renal failure, even with
short courses
 Indomethacin is especially risky, ibuprofen least risky
o Anticholinergics: delirium, urinary retention, constipation, fecal impaction
 Antidepressants, diphenhydramine, hydroxyzine, promethazine,
cyclobenzaprine, antihistamines
• Be extra careful with
o Drugs with a narrow therapeutic range
 Digoxin
 Theophylline
 Warfarin: huge red flag!
 Lithium
 Quinidine
o Potential drug interactions with commonly prescribed ED medications
(risk increases with the number of drugs)
 Ciprofloxacin or TMP/SMX with warfarin: increased INR
 NSAIDs with oral steroids: increased risk of peptic ulcer
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NSAIDS with sulfonylurea medications: increased risk of
Macrolides or quinolones with Class IA or Class III antiarrythmics
(e.g. amiodarone): combined prolongation of QTc
Macrolies or tetracycline with digoxin: increased digoxin level
• Elderly trauma patients have higher mortality, increased length of stay, and increased
complications compared to the younger cohort
o Seventh leading cause of death
o Consume approximately one-third of all trauma health care resources
o Five times more likely to die from trauma compared to younger patients
with the same injury severity scores
o Mortality rates increase with advancing age (starting at age 45 and
continuing to age 85 years)
• Three mechanisms account for 75% of all injury-related deaths
o Falls: most common mechanism
o Motor vehicle crashes: second most common mechanism
o Pedestrian-MVC: 50% case mortality rate
 Twice the mortality rate of younger age groups
• Common pitfalls
o Lack of aggressive treatment and resuscitation because of
 “Normal” vital signs
 Low injury severity scores
 Less severe mechanism of injury
o Failure to recognize shock
 Prevalence of pre-existing hypertension
 Lack of tachycardic response
 Base deficit and lactate levels can be useful in identifying early or
occult shock
o Failure to diagnose early occult head and spine injuries
 Subdural hematomas (SDH) occur with trivial or even no history
of trauma
• Increased risk secondary to brain atrophy (10% atrophy
with age)
• May mimic stroke, dementia, functional decline, or gait
• SDH may be delayed
• Liberal use of CTs recommended
 Cervical spine injuries
• Occur after minor trauma (falls in approximately 70%)
• Often involve C1 or C2
• May present as central cord syndrome
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Abdominal Pain
• Acute cholecystitis
o The most frequently diagnosed surgical cause of abdominal pain in the
o Mortality rate 10-14%
o Often present atypically
 Parker, et al (Acad Emerg Med, 1997)
• Nausea/vomiting absent in 50-60%
• Fever absent in 56%
• WBC count < 10,000 in 40%
• 13% afebrile and had all normal labs
• 16% had no RUQ or epigastric pain
• 5% had no abdominal pain at all
o Elderly patients are unlikely to improve with conservative therapy
o Complications (e.g. gangrene, perforation) are much more rapid and more
 Resulting mortality is 15-25%
o Early operative treatment is recommended
Acute Appendicitis
o 8% of all appendectomies occur in the elderly
o Accounts for 5-6% of all acute abdominal emergencies in the elderly
o High rate of delayed or incorrect diagnosis
• Up to 25% are initially sent home from the ED
 Higher morbidity and mortality in the elderly
o Overall mortality rate in elderly is 20%
o Elderly account for 50% of all mortalities
o Horattas, et al (Am J Surg, 1990)
• 96 patients with surgically proven appendicitis
• At time of admission, only 51% were thought to have appendicitis
• At time of surgery, appendicitis was a consideration in only 70%
• At time of surgery, 72% had already perforated
o Confounding factors
• Delay in seeking medical care
• Up to 20% will present after three days of symptoms
• 8% will present after seven days of symptoms
• History can be misleading
• Classic migratory pattern is absent in up to 60%
• Nausea and vomiting are absent in 50-60%
• Anorexia is absent in 65%
• Description of the pain is often vague or poorly localized
• Physical examination can be misleading
• Fever is absent in up to 50%
• Guarding and rebound are absent in 50%
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• Right lower quadrant tenderness is absent in up to 20%
Tests can be misleading
• WBC count is < 10,000 in 20-45%
• Bilirubin is elevated in 17%
• Up to 15% have > 30 WBCs/hpf + RBCs on urinalysis
• Abdominal x-rays may contribute to misdiagnosis or delays
in proper diagnosis
Ruptured abdominal aortic aneurysm
o Even when rapid diagnosis is made and the patient is taken immediately to
the OR, mortality is up to 70%
o Rate of initial misdiagnosis is as high as 30-40%
o Only 5% of patients with a ruptured AAA have a prior known AAA at
o “Classic triad”
• Abdominal and/or back pain
• Hypotension
• Palpable, pulsatile, tender abdominal aorta
o In reality…
• Abdominal pain is absent in 20-30%
• Back pain is absent in 50%
• Hypotension is absent in 65%
• Tachycardia is absent in 50%
• Palpable aorta is absent in 30%
o May simulate renal colic
• Is the most common misdiagnosis
• Sharp, sudden pain in flank, often radiates to groin
• Microscopic hematuria
o May present with syncope (18%)
o X-rays have poor sensitivity
Pregnant Patients
Every woman of childbearing age should be suspected of pregnancy
o In one study, 10% of women with bleeding/abdominal pain who were
pregnant had denied any possibility of pregnancy
Always suspect and workup ectopic pregnancy
o Up to 10% with present with vaginal bleeding only
o Either bleeding or pain should prompt workup for EP
o “Normal” HR is common in ruptured pregnancy
o Know your treatment protocol ahead of time if using methotrexate!
 OB or ED responsible for methotrexate?
 Who does follow-up?
 Consult and repeat U/S liberally!
Remember the VS changes in pregnancy
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Amal Mattu, MD
o Increase 10-15 beats/min at rest
o BP decreases in 2nd trimester, then approaches baseline at term
o Don’t forget about hypertension!
 BP > 140/90 or SBP increase > 30 from baseline or DBP increase
> 15 from baseline
 Higher risk of developing eclampsia
Image patients when necessary!
o You will be MUCH more likely to be faulted for NOT performing the
imaging test
o Main risk of fetal anomalies when > 5000 mrad cumulative dose
 CXR: 0.02-0.07 mrad
 Pelvis xray: 150-200 mrad
 VQ: 100-500 mrad
 CTA: 100-900 mrad
 CT abdomen and pelvis: 3000-5000 mrad
o For suspected PE, CTA is test of choice
o For suspected appendicitis, U/S or MRI is test of choice (when available)
Always monitor patients in third trimester (or second half of pregnancy) for abruption
with minimum 4 hours of cardio-tocographic monitoring (CTM) if blunt
trauma…even mild trauma
o Abdominal pain, tenderness, and vaginal bleeding may be absent with
placental abruption
Perimortem C-section  begin by 5th minute of pulselessness
o For patients > 24 weeks EGA (~ fundus palpable 4 cm above umbilicus)
o Maximizes chances of survival for both mother and fetus
o Now in AHA guidelines…more likely to be faulted for NOT performing
than for performing
o Review the procedure (quick…not neat or fancy!) and have a protocol in
place with consultants
Transfer…what is “active labor?”
o Document, document, document discussions with consultant, receiving
facility, and patient
Pediatric Patients
Otitis media, viral syndrome, gastroenteritis, and colic…the favorite diagnoses of
defendant physicians
o Otitis media
 Don’t create false diagnoses just to explain away a fever or as an
excuse to give ABX
 Debate exists as to whether OM can produce high fevers
 OM should not cause toxicity, meningismus, etc.
o Viral syndrome
 Common (convenient) diagnosis in cases of meningitis,
intracranial bleeds (e.g. from abuse)
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Amal Mattu, MD
 Should not cause toxicity
 Document “wellness” before discharge
o Gastroenteritis
 Common (convenient) diagnosis in cases of appendicitis and
meningitis (if vomiting)
 Should not cause toxicity
 Do NOT diagnose unless there is gastritis + enteritis!
• 1-2 episodes of diarrhea is very non-specific
• Diagnosis is more specific when there are multiple episodes
of watery diarrhea
• Ideally vomiting/diarrhea precede the onset of abdominal
pain; abdominal pain eases after episodes of diarrhea
o Colic is a diagnosis of exclusion
Double- and triple-check medication dosages and concentrations
o Beware lbs vs. kgs when dosing
Meningitis mishaps
o Never use a WBC to decide if LP is needed!
o Never use response to antipyretics to decide if LP is needed!
o Early ABX when Dx suspected…< 30 min door-to-needle
o Simple febrile seizures  brief-lasting, generalized, brief post-ictal
period, well-appearance afterwards
Newborns with fever get full septic workup, regardless or appearance
Recommended reading if you enjoy learning from “pitfalls”
Mattu A, Goyal DG (eds). Emergency Medicine: Avoiding the Pitfalls and
Improving the Outcomes. London, Blackwell Publishing, January 2007.
Questions or Comments?
Contact me: [email protected]
Amal Mattu, MD
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Amal Mattu, MD