EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAIN Module # 2

1. EMERGENCY CARE FOR THE ELDER WITH ABDOMINAL PAINModule # 2 Ed Vandenberg MD CMD Geriatric section OVAMC & Section of Geriatrics 981320 UNMC Omaha NE 68198-1320 evandenb@unmc.edu Web: geriatrics.unmc.edu 402-559-7512 Updated 1120-06 Adapted from Bill Lyons, M.D. & (from R. M. McNamara, M.D. for SAEM)

2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. LEARNING OBJECTIVES Module 1 & 2 • List the unique features and ( atypical) presentations of abdominal pain in elders • Identify priorities for initial triage • List initial management to stabilize • List appropriate historical information to elicit • Describe appropriate physical exam • List appropriate and timely lab and diagnostic evaluation • Describe the presentation and approach to: • Ruptured AAA • Mesenteric ischemia

4. CASE UPDATEFrom last module REVIEW OF CASE • 70 yo male with Diffuse Abdominal pain X 4 d and syncope today. • Appearance: pale, diaphoretic, VS BP 96/70 HR 110 RR 22 T 37.6, SaO2 95% RA • Aorta not enlarged or tender NEW DATA ON CASE • After IVF, supine BP 118/72 • HR 100 • ECG  borderline sinus tach, but no acute process apparent

5. FURTHER HISTORY TO OBTAIN? • Now that patient is more stable, • What additional history should be sought? • What are confounding factors in obtaining an accurate history from (some) elders with abdominal pain?

6. Time of onset Mode of onset Progression Location Character Radiation, referral Influencing factors Prior episodes Associated symptoms IMPORTANT HISTORY

7. Capacity of historian Time of onset Mode of onset Progression Location Character Radiation, referral Influencing factors Prior episodes Associated symptoms Patient is alert, no signs of delirium – history reliable How do you assess for delirium? Pain began 4 days ago Steady worsening Mainly lower abdomen, R>L “Not too bad”, rated 7/10 ( Positive John Wayne sign) No migration, radiation, Car ride made it worse No prior episodes What does “car ride made it worse” mean to you? Case Update

8. Deliriumthe Definition • I) Change in Cognition that has an: -Acute Onset -Fluctuating course. • II) Altered Level of Consciousness - “Inattention” • III) VariousCognitive domains can be affected • IV) Has a Medical Cause.

9. Car ride pain: suspect peritonitis Delayed presentations common Example appendicitis 20% over 3 days PAIN ASSESSMENT Level ( 1-10 scale) FUNCTION SIGNIFICANCE OF HISTORY

10. Factors complicating diagnosis of intra-abdominal disorders in the elderly (1), (2), (3), (4) Alterations in baseline laboratory, radiological and physical findings Preexisting conditions alter presentations Delayed presentation by patient More serious illness on presentation

11. CONFOUNDING FACTORSin DIAGNOSING ELDERS • Aging physiologic changes • Altered pain perception • Stoicism • Reluctance to report symptoms • Communication problems • Memory deficits and other mental status changes

12. PHYSIOLOGY and AGING Key changes with age that are behind these altered presentations. A) Thermoregulation: B) Cardiac-Autonomic system C) Volume regulatory D) Immune dysregulation E) Central nervous system

13. Our pt’s Vital signs BP 96/70 HR 110 RR 22 T 37.6 What’s wrong with these vital signs? ALTERED PRESENTATION IN ELDERS Depending on pt’s baseline BP and orthostatic changes determines significance HR > 90 (especially if on beta-blocker indicates significant stress)   RR > 20  Temp > 37.4 (99.4F) po in elders is elevated CASE UPDATE

14. SUDDEN ONSET OF ABDOMINAL PAIN What is your differential diagnosis? • Vascular accident • Rupture or dissection of AAA • SMA embolus • Perforation of viscus • Volvulus

15. ABDOMINAL PAIN IN ELDERS • Severe: think serious (vascular event or perforation) • Consider any pain important; under-reporting is common • Appendicitis: may lack anorexia • LBO: 1/5 report diarrhea • Mesenteric ischemia: ½ have diarrhea

16. CASE DEVELOPMENT • One episode vomiting, limited PO intake • 2 loose stools yesterday • No GU symptoms • PMH: CHF, hernia repair • MEDS: digoxin, Lasix, metoprolol • Social EtOH, no smoking • What is significance of his CHF history as it applies to his abdominal pain?

17. ACUTE MESENTERIC ISCHEMIA • Risk factors Low CO, especially CHF is associated with? Non occlusive SMA ischemia Atherosclerosis & low flow ( CHF) is associated with? SMA thrombosis: Atrial fibrillation or recent MI is associated with? SMA embolus: Hypercoagulable state is associated with? Venous thrombosis:

18. ACUTE MESENTERIC ISCHEMIA • Presentation: • Severe pain, initially visceral • Gradual onset (SMA embolus may be sudden) • Can be refractory to opiates • Prior episodes possible • GI emptying common: ½ diarrhea • Severe pain, but normal exam • “Hard signs” too late!

19. ABDOMINAL EXAM IN ELDERLY PATIENTS • Look for subtle signs! • Why? • ↓Visceral pain perception, • ↓awareness & decision making ability when ill, • delayed immune response • How do you decide if an area is painful? • Face and fingers • Peritonitis • May lack rigidity and guarding • Only 21% of perforations had rigidity! • Evaluate peritoneal signs with: Cough, rock, jar, light percussion • Routinely palpate aorta • Rectal exam, hernia check

20. CASE UPDATE EXAM • Decreased bowel sounds • Mild tenderness throughout, somewhat greater in lower abdomen • Not rigid; mild increased muscle tone in lower abdomen • Aorta non-tender and normal in size Jar bed &/or rock pelvis mild discomfort • Normal femoral pulses, back, skin, heart, lungs, rectal; no hernias

21. DIFFERENTIAL DIAGNOSIS • What diagnostic possibilities should be considered for this patient?

22. DIFFERENTIAL DIAGNOSIS *Major life threats • Ruptured AAA* • Acute mesenteric ischemia* • Myocardial ischemia/MI (ACS)* • Dissecting aneurysm*

23. DIFFERENTIAL DIAGNOSIS ADDITIONAL Ddx • Appendicitis • Diverticulitis • Cholecystitis • Perforated PUD • Obstruction (SBO, LBO) • Pancreatitis • Abscess

24. The End of Module One on the EMERGENCY CARE FOR THE ELDER WITH ADOMINAL PAIN

25. Post-test • An 86-year-old man who lives in a nursing home has had fever, emesis, and vague abdominal pain for 36 hours. Medical history includes hypertension, coronary artery disease, diabetes mellitus, mild dementia, and an acute myocardial infarction 1 month ago. Today, temperature is 37.5C (99.5F). Pulse rate is 102 per minute, and rhythm is regular; respirations are 20 per minute. Blood pressure is 100/66 mm Hg. Coarse breath sounds are heard bilaterally. The abdomen is tender, especially in the right mid-abdomen. Laboratory studies reveal a leukocyte count of 16,000/µL and mild dehydration. Liver function tests, cardiac enzymes, and urinalysis are normal. Electrocardiogram shows nonspecific ST–T wave changes, and chest radiograph is normal. Abdominal films show ileus. The patient’s advance care plan requests hospitalization and management of reversible medical and surgical illnesses but not cardiopulmonary resuscitation. Which of the following is the most appropriate next step? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

26. Which of the following is the most appropriate next step? A. Serial abdominal examinations and radiographs B. Serial electrocardiograms and measurements of cardiac enzymes C. Bowel regimen for constipation D. Empiric antibiotic treatment in the nursing home E. Urgent surgical evaluation

27. Answer: E. Urgent surgical evaluation This patient may have a ruptured appendix or other intraabdominal infection and thus may require surgical intervention. Appendicitis typically occurs during the second and third decades of life; a second peak is seen in men age 80 and over, who have a 6% to 10% mortality rate. The condition occurs in less than 10% of the population, but this group accounts for 50% of related deaths. Symptoms consist of vague abdominal discomfort; rebound tenderness and guarding are absent in more than half of elderly patients. Diagnosis and surgery commonly are delayed because of the indolent nature of the initial symptoms. Thus, 70% to 90% of patients have a ruptured appendix at the time of surgery. Severity may be related in part to pathophysiologic changes that occur in the appendix with aging.

28. Serial abdominal examinations and radiographs may have been appropriate initially, but the patient now needs more aggressive management. The recent myocardial infarction warrants consideration of recurrent ischemia and infarction, but the clinical picture now suggests an infectious cause. A bowel regimen for constipation is not indicated for this acute illness.Antibiotic coverage is appropriate as adjunct therapy but should be given in the hospital rather than the nursing home. End

29. References Rothrock SG, Greenfiled. Acute abdominal pain in the elderly:Clues to identifying serious illness. Emerg Med Reports 1992;13:185-192. de Dombal FT. Acute abdominal pain in the elderly. J Clin Gastroenterol 1994 Dec;19(4):331-335. Lowensten SR. Care of the elderly in the emergency department. Ann Emerg Med 1986 May;15(5):528-535. Singal BM, Hedges JR, Rousseau EW, et.al. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med 1992 Jul;21(7):802-807.