Title: Geriatric Emergencies

Title: Geriatric Emergencies

Time Required: 3 hours

Materials: Easel pad and markers, or board and chalk, power point projector and computer (with internet access).

A more in depth look at the geriatric population may be found at www.aarp.org, formerly known as the American Association of Retired Persons (AARP).

References

·  Maryland Medical Protocols for Emergency Service Providers

·  “Emergency Care” Daniel Limmer and Michael O’Keefe, 10th Edition, Brady Publishing

·  “Geriatric Emergencies: A Basic Review for Health Care Providers” by David A. Gruenewald, M.D.F.A.C.P. and Kayla I. Brodkin, M.D.; Published by the University of Washington School of Medicine

·  AARP –www.aarp.org

Motivation:

Today in the United States there are many more geriatric Individuals than ever before. The “Baby Boomers” are advancing in age and with that there is an increase in individuals with medical problems associated with getting older. As providers, we need to review the various injuries and illnesses specific to the geriatric population. As more and more individuals live longer, the population will continue to grow and with this comes an increase in our encounters as emergency medical service providers with the geriatric population.

Objective:

Given the information, resources and opportunity for discussion, at the end of this lesson, the student will be able to describe common geriatric emergencies, signs and symptoms and correct management of these conditions according to the Maryland Medical Protocols.

Enabling Objectives:

EO 1: Describe how to communicate with the geriatric patient.

EO 2: Describe the assessment of the geriatric patient.

EO 3: Describe some special considerations when dealing with the geriatric patient.

EO 4: Describe the various considerations to keep in mind during the initial assessment, focused history, physical exam and ongoing assessments.

EO 5: Describe the types of trauma that may be encountered by the geriatric patient.

Overview:

·  Communication

·  Assessments

·  Special Considerations

·  Trauma Considerations

·  Reasons Geriatric Patients Require EMS Care

I. Communicating with the Geriatric Patient

A.  Position yourself in front of the patient, so they may see you. You may need to kneel or crouch down to the patient to be at the patients same level

B.  If your patient is blind, place your hand on their arm, so they may know where you are

C.  Speak clearly to the patient, check hearing aids as needed

D.  If a patient has dentures, and is difficult to understand, ask the patient to put them in

E.  Ask the patient how they would like to be addressed

II. Assessment of the Geriatric Patient

Although the steps in assessing a geriatric patient are the same as for other patients, there are some additional considerations we should be aware of.

A. Physiological Effects of Aging

1. Arterial walls thicken – increased risks of heart attack, stroke, hypertension

2. Decreased cardiac output – diminished activity level, less tolerant of physical stress

3. Decreased elasticity of lungs – decreased ability to clear foreign substances from lungs

4. Decreased liver and kidney function – decreased blood clotting ability, increased toxicity from alcohol and medications

5. Diminished thyroid function – decreased energy and tolerance to heat/cold

6. Decreased muscle mass and weakened bones – less strength

7. Multiple medical conditions and issues – many medications, various physicians

8. May be alone, may have lost friends and family members – depression, loss of social support system

9. Loss of skin elasticity, smaller sweat glands – thin, dry, wrinkled skin

B. Assessment Implications

1. More prone to heart attack and stroke

2. More prone to falling

3. Higher risk of respiratory problems, such as infections and pneumonia

4. Common to suffer from abdominal pain, weight loss

5. Tendency to bleed, needs reduced doses of medication

6. More likely to fall and fractures more likely from minor falls

7. Increased risk of suicide

8. Increased risk of overall injury

III. Special Considerations during the Assessment process

A. Scene Size –up and Safety

1.  Notice the condition of the patient’s residence. This may give clues as to the patient’s physical and mental abilities

2.  Be aware of potential dangers to the EMS crew

3.  Is the temperature of the patient’s residence appropriate for the

patient’s well being

B. Initial Assessment

1.  Forming a general impression

a.  What is the level of the patient’s distress?

b.  What is the position of the patient?

c.  Is the patient sitting, lying, leaning forward, unconscious or conscious?

2.  Assessing mental status

a.  Does the patient exhibit abnormal behavior?

b.  Is this behavior normal for the patient?

c.  Are there caregivers who may assist you in determining what is normal for this patient?

3.  Assessing the airway

a.  There may be difficulty extending the head and neck of the geriatric patient due to arthritic changes in the neck bones

b.  You may use a jaw thrust to move the tongue out of the airway

c.  A patient may have dentures, which are potential airway obstructions if they are loose or ill fitting

d.  Usually you will only have to remove them in the unconscious patient

4.  Assessing Breathing

a.  Older patients are at a higher risk of airway obstruction

b.  Risk factors include dentures and poorly chewed food

c.  If unable to ventilate patient due to these conditions, initiate steps to relieve the foreign body airway obstruction

5.  Assessing Circulation

a.  Patient’s pulse may be irregularly irregular

b.  The patient may have an abnormal heart rhythm

6.  Identifying priority patients

a.  Older patients may not show severe symptoms in certain conditions.

b.  A patient’s priority may be difficult to determine

c.  Keep a high index of suspicion for serious conditions even if symptoms are vague or mild

IV. Focused History, Physical Exam and Ongoing Care Considerations

A. History

1.  There may be difficulties in gathering patient information due to speech difficulty or the patient’s level of understanding

2.  Speak slow and clear and be patient for answers if there is no immediate threat to life

3.  Establish a rapport with your patient

B.  Physical Exam

1.  Maintain your patient’s dignity

2.  Explain what you are doing to your patient and why

3.  Keep in mind your patients pain threshold. Is it high or low?

C.  Baseline Vital Signs

1.  As we age systolic blood pressure may increase

2.  Many patients take blood pressure medicines and there can be significant side effects

3.  Some side effects include weakness and dizziness, especially with standing or rising too quickly from a supine position

4.  The patient may have thin skin, which may tear easily

5.  The patient’s pupils may not be round and react well to light due to eye diseases, medications or surgeries

6.  Inquire as to whether the pupils are in a normal condition for the patient

D. Detailed Physical Exam

1.  Head and Neck

a.  Injuries to the head and face are common in falls or motor vehicle crashes

b.  There may be abnormalities to the head and neck due to changes in the spine. The neck may be stiff and the head may fall forward

c.  Immobilizing the patient may be difficult. Utilize folded towels or other materials to keep the head in its normal position. This will prevent hyperextension and make the patient more comfortable

2.  Chest and Abdomen

a.  Serious abdominal conditions may not cause great pain due to less sensitivity in this area

3.  Pelvis and Extremities

a.  The hip and proximal femur is commonly injured in falls

b.  These are more common in women due to loss of calcium as women age

c.  The fracture may be the cause of the fall rather than the result

d.  Bone weakening may cause fractures to other bones

4.  Spine

a.  Spinal injuries often occur from motor vehicle crashes

b.  Immobilizing patients may be very challenging. Make sure to keep the vertebrae in alignment and try to reduce the patient’s discomfort

E. Ongoing Assessment

1. Keep in mind that it is more common for the elderly to exhibit a slow steady decline in condition. Regular assessments during care for the geriatric patient will keep you aware of any sudden changes in your patient’s condition. By comparing your findings during your assessments, you will remain aware of trends that may be indicative of more serious problems.

2. Asessment Elements

a.  Reassess mental status

b.  Maintain open airway

c.  Monitor breathing

d.  Reassess pulses

e.  Monitor skin color and temperature

f.  Reassess vital signs (every 5 minutes for unstable patients and 15 minutes for stable patients)

g.  Assure that all appropriate care and treatment are being administered

V. Trauma Considerations

A. The death rate among elderly trauma patients has been shown to be higher than any other age group. The elderly are at a high risk for injuries from motor vehicle crashes, falls, burns and assaults.

B. Some other injuries that may be encountered as a result of trauma

1.  Spinal injuries

2.  Lung and cardiac contusion

3.  Adult respiratory distress syndrome

4.  Previous or new onset of myocardial infarction, dysrhythmias or congestive heart failure (may be caused by the associated trauma or cause the trauma the patient incurred)

5.  Shock is also a frequent occurrence and special attention must be paid when looking for early signs and symptoms

C. Some of the Common Reasons EMS Providers will Encounter Geriatric Patients

NOTE: For correct treatments of the following conditions, please refer to the Maryland Institute for Emergency Medical Services Systems “Maryland Medical Protocols for Emergency Services Providers”, listed in section III, under treatment Protocols.

1.  Pharmacology

a.  The elderly use more medications

b.  Medications are expensive and many elderly patients are forced between food and their medicine

c.  Medications have various adverse effects

d.  Drug interactions

2.  Shortness of breath

a.  Emphysema

b.  Congestive heart failure

c.  Cardiac problems associated with shortness of breath

3.  Chest Pain

a.  Angina

b.  Myocardial Infarction

c.  Pneumonia

d.  Aortic aneurysm

4.  Altered mental status

a.  Effects of medication

b.  Stroke

c.  Infections

d.  Hypoxia

e.  Diabetes

5.  Abdominal pain

a.  Abdominal aortic aneurysm

b.  Bowel obstructions

c.  Diverticulitis

6.  Depression and suicide

a.  Due to medical conditions

b.  Loss of friends and spouses

c.  Medication usage

d.  Biochemical imbalances

7.  Falls

a.  Whether from more serious problems or the fall itself

8.  Elder abuse and neglect

a.  Physical Abuse

b.  Psychological Abuse

c.  Sexual Abuse

Summary:

Given the information, resources, and the opportunity for discussion, at the completion of this lesson, the student will be able to list common conditions of the geriatric patient, signs and symptoms, special considerations and will be able to describe correct treatment for each of these conditions according to the Maryland Medical Protocols.

Review:

The Geriatric Patient

·  Describe how to communicate with the geriatric patient

·  Describe the assessment of the geriatric patient.

·  Name some special considerations you may encounter with the geriatric patient

·  Describe the various considerations to keep in mind during the initial assessment, focused history, physical exam and ongoing assessments.

·  Describe the types of trauma that may be encountered by the geriatric patient.