Avoiding Common Errors in the Emergency Department - Book 2

and determining degree and type of vertebral involvement, including
occult injuries.
3) MRI is the modality of choice for neurologic involvement or suspected
ligamentous disruption due to its superiority in imaging soft tissue.
Similarly, MRI is preferred in instances of VCFs from infectious or
malignant processes. MRI may also be useful in evaluating VCF age;
newer injuries are identified by increased signal intensity from water in
the vertebral body.
4) CT myelography for assessment of cord compression is indicated when
MRI is contraindicated, as in patients with pacemakers.

Simple VCFs rarely require more than conservative management: pain
control, physical therapy, and bracing as tolerated. Immobility raises the
usual concerns: DVT, infection, general deconditioning, and decreasing bone
density. Radiotherapy may provide significant pain relief for VCFs from
malignancy. Operative management is indicated for failure of conservative
therapy (pain), impending or existing neurologic deficit, or extreme spinal
deformity. Minimally invasive vertebral augmentation techniques
(vertebroplasty, kyphoplasty) are preferred.

KEY POINTS

Frailty—beware of more severe injury with seemingly low-impact
injuries.
Anchoring—the best way to miss a diagnosis is to make a diagnosis.
When a fracture is found, don’t stop looking for other injuries or
conditions.
Imaging modalities—consider advanced imaging (CT or MRI) if
negative plain films.
Treat pain—recognize and adequately treat pain.
Special units—when available, disposition the patient to a geriatric
care unit.

SUGGESTED READINGS

Alexandru D, So W. Vertebral compression fractures. Perm J. 2012;16(4):46–51.
Anders P, et al. Comprehensive geriatric care for patients with hip fractures: A

prospective, randomised, controlled trial. Lancet. 2015;385:1623–1633.
Beaudoin FL, et al. Ultrasound-guided femoral nerve blocks in elderly patients

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with hip fractures. Am J Emerg Med. 2010;28(1):76–81.
Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain:

Advice for high- value care from the American College of Physicians. Ann
Intern Med. 2011;154:181–189.
Hakkarinen DK, et al. Magnetic resonance imaging identifies occult hip fractures
missed by 64-slice computed tomography. J Emerg Med. 2012;43(2):303–307.
Kirby M, Spritzer C. Radiographic detection of hip and pelvic fractures in the
emergency department. AJR Am J Roentgenol. 2010;194(4):1054–1060.

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334

BE SURE TO BUILD A SAFETY NET
AROUND THE WEAK GERIATRIC
PATIENT YOU SEND HOME

ERIC M. LEFEBVRE, MD

Generalized weakness is a common presenting complaint in the ED for older
adults and can be frustrating to evaluate. The differential is broad, including
both life threats and less serious causes. An overall evaluation strategy built
around a careful history and physical exam, screening tests to exclude
common dangerous disease processes, and thoughtful discharge planning can
help give older adults the best shot at both avoiding the harms of
overtreatment and untreated disease progression.

The initial history and physical exam should focus on differentiating
acute neurologic process such as stroke or intracranial hemorrhage from
other causes of weakness and identifying what ancillary testing to pursue.
Inquire about acute changes, trauma, new medications, infectious symptoms,
cardiac complaints, and reduced oral intake. Collateral information obtained
from families, emergency medical services (EMS), or nursing home
personnel is often crucial. Pick up the phone and talk to someone who knows
the patient’s baseline and what happened today; you may save your patient
hours of unnecessary diagnostic testing. Pay attention to the medication list.
Polypharmacy is very common in the elderly, and about a third of older
adults taking five or more medications will experience an adverse drug event
each year. Common culprits are benzodiazepines, anticholinergics,
vasoactive medications, blood thinners, insulin, and sleeping aids.

A careful neurologic assessment with cranial nerve examination and
motor, sensory, cerebellar, reflex, and gait testing helps determine the need

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for head CT. On exam, search for signs of volume depletion or overload,
pneumonia, and abdominal pathology. Get a rectal temperature. Oral and
temporal temperatures can be unreliable in the elderly, and hypothermia is
almost always a marker of badness. Expose the patients and examine all of
their skin. It’s poor form to send home sacral osteomyelitis. If a systematic
screening for delirium using a validated tool is not part of your routine
assessment for older adults, add it. The Brief Confusion Assessment Method
(bCAM) is validated in the ED. If positive, be sure to search for the medical
cause of the delirium.

What’s that you say? Your exam is normal? They are not delirious. I can
send the patient home now, right? Not quite; there are some diseases that
cause generalized weakness that can be very hard to pick up on history and
physical exam alone. Hyponatremia, renal failure, anemia, myocardial
ischemia, and urinary tract infection (UTI) all come to mind. A basic
metabolic panel (BMP), hemoglobin, ECG, and a urinalysis (UA) with reflex
culture are probably the minimum necessary set of testing. Many providers
would advocate checking a troponin regardless of ECG findings given the
prevalence of atypical presentations of ACS in the elderly and low sensitivity
of ECG alone. Consider thyroid-stimulating hormone (TSH), erythrocyte
sedimentation rate (ESR), and calcium testing on a case-by-case basis. The
interpretation of a not-so-clean-catch UA in older patients can be
challenging. Many older adults have asymptomatic bacteriuria, and if the
patient is without signs of systemic illness, altered mental status, has no
fever, suprapubic tenderness, dysuria, frequency, or leukocytosis, it may be
safer to arrange close follow-up and wait for the urine cultures. Therapy for
UTI isn’t benign. The resultant Clostridium difficile– or fluoroquinolone-
associated delirium harms thousands of patients each year.

When the history, physical, and ancillary testing are unrevealing, it’s
time to do two things: road test the patient and build a safe discharge plan.
The goal of the ED evaluation doesn’t necessarily need to be the definitive
diagnosis of the patient’s pathology but rather to exclude dangerous disease
and build the patient a safety net large enough to get them to their next
encounter with the medical system. Before discharge to the community, the
patient should be able to locomote as well as preevaluation baseline (make
sure they use their usual assistive devices). Patients who can’t are at
increased risk of unplanned ED return. Inquire about the patient’s support
and resources at home. Does he or she have transportation, food, a way to get
in touch with his or her doctor, and someone to check on him if things don’t
go well over the next 24 to 72 hours? You may need to get creative to get
patients the care they need, but avoiding the cost and patient safety risk of an
observation admission adds real value to the patient’s ED stay. Oh and one

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last thing: print the labs, copy the ECG, and write three lines in the discharge
summary to the clinic doctor explaining what you think is going on. It will
make that “PCP follow-up, 1 to 2 days,” much more useful.

KEY POINTS

When assessing geriatric weakness, always inquire about acute
changes: trauma, new medications, infectious symptoms, cardiac
complaints, and reduced oral intake.
In geriatric weakness, consider a BMP, hemoglobin, ECG, and UA
with reflex culture the minimum necessary set of laboratory testing.
Consider checking a troponin regardless of ECG findings when
assessing elderly weakness
Always inquire about the patient’s support and resources at home
prior to considering discharge.

SUGGESTED READINGS

Gordon LB, Waxman MJ, Ragsdale L, et al. Overtreatment of presumed urinary
tract infection in older women presenting to the emergency department. J Am
Geriatr Soc. 2013;62(5):788–792.

Gregoratos G. Clinical manifestations of acute myocardial infarction in older
patients. Am J Geriatr Cardiol. 2001;10:345–347.

Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr
Pharmacother. 2007;5(4):345–351.

Han JH, Shintani A, Eden S, et al. Delirium in the emergency department: An
independent predictor of death within 6 months. Ann Emerg Med.
2010;56(3):244–252.e1.

Rowland K, Maitra AK, Richardson DA, et al. The discharge of elderly patients
from an accident and emergency department: Functional changes and risk of
readmission. Age Ageing. 1990;19(6):415–418.

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335

GRANDMA IS LOOPY: SPECIAL
CONSIDERATIONS FOR ALTERED
MENTAL STATUS IN THE OLDER

ADULT

CHRISTINE R. STEHMAN, MD

In the United States, about half of the emergency department (ED)
population is elderly (>65 years old). Most shifts include a geriatric patient
who either is altered or doesn’t seem to be thinking straight. This patient may
have dementia, delirium, or both. What can you do about it?

Dementia is slow-onset permanent cognitive decline. Delirium is a
potentially reversible breakdown in consciousness and attention with either
perceptual or cognitive disturbances. Delirium occurs in times of stress and is
common in elderly patients in the ED with approximately 10% meeting
delirium criteria. Delirium and dementia are interrelated: dementia is a main
delirium risk factor, and many delirious patients have underlying dementia.
While both delirium and dementia can cause loss of independence and
increased mortality, this chapter focuses on delirium.

While these patients seem complicated, three simple steps make proper
care easier by helping to identify the problem without worsening the
patient’s condition.

Step 1: Recognize the problem. Hospitalized delirious patients have
higher mortality rates, longer lengths of stay, and increased loss of
independence after discharge making early identification and treatment key.
However, the EP fails to recognize delirium in up to 83% of delirious
patients, leading to delayed or no treatment and increased mortality.

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Delirious, particularly in hypoactive delirium, patients often partially
compensate and “sneak” by EPs. To catch delirium, EPs must push past their
patients’ compensation using a tool to identify abnormal thinking. There are
a number of tools available, with the Brief Confusion Assessment Method
(bCAM) being preferred for the ED setting.

Delirium identification tools have four interrelated parts. Delirious
patients must have an altered (or fluctuating) mental status and symptoms of
inattention and either an altered level of consciousness or disorganized
thinking. First, EPs should speak to family or caregivers to identify an acute
alteration or fluctuation in mental status over the last day. If none exists, no
delirium is present. Next, evaluate attention by spelling, counting, stating the
months backward, or squeezing the provider’s hand at specific cues. No
delirium exists if the patient makes less than two mistakes. More than two
mistakes means, the EP should assess level of consciousness with the
Richmond Agitation Sedation Scale (RASS). Anything other than an alert
and calm patient (score of 0) indicates delirium may be present. Alert and
calm patients need an assessment for disorganized thinking. This involves
the patient following commands without demonstration or answering simple
questions (Does a stone float on water? Are there fish in the sea? etc.).
Delirious patients make more than one error.

Step 2: Identify and treat cause of delirium. Delirium has four main
risk factors: dementia, hypertension, alcohol abuse, and high severity of
illness. In addition, delirium can be triggered by many things. Multiple
mnemonics exist for these causes with ABCDEF probably being the easiest
because it addresses the reversible causes. A: analgesia as untreated acute or
chronic pain can lead to delirium. It is important to do a full examination
looking for injuries and tenderness, and a history of chronic pain should be
noted. B: bladder (urinary retention or infection) and C: constipation, both of
which can cause pain and delirium. D: dehydration commonly leads to
delirium because of decreased perfusion. Vital signs, skin, mucous
membranes, and electrolytes may suggest this diagnosis. E: environmental
factors such as noise, heat or cold intolerance, lack of vision or hearing aids,
poor sleep, restraints, or inability to get around can upset the fragile mental
balance of geriatric patients. Finally, F: pharmacy as many medications can
lead to delirium. Applying one mnemonic to any potentially delirious
patients can help identify potential causes and guide treatment and further
evaluation.

Step 3: Treat delirium. ED visits are loud, chaotic, and stressful for
even the healthiest patient. For patients who are under physiologic stress and
are not able to think normally, the ED can be torture. Delirium treatment
involves nonpharmacologic and pharmacologic therapies. Nonpharmacologic

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treatment is first line and involves minimizing the chaos of the environment.
The Hospital Elder Life Program (HELP) involves four goals and has been
shown to prevent and decrease the number of episodes and days of delirium.
HELP includes maintaining orientation to surroundings; meeting nutrition,
fluid, and sleep needs; promoting mobility; and providing visual and hearing
adaptations. Family members can help meet these goals.

Patience is key when caring for delirious patients. Speak slowly face to
face while making eye contact. Reorient the patient at the start of the
conversation and use short, simple, and, as necessary, repeated explanations.
Avoid physical restraints: they increase agitation, increase injury risk,
decrease mobility, and prolong delirium.

Hyperactive delirium patients who are agitated and at risk for self-harm
or severely interfering with treatment require pharmacologic treatment. First
line is the lowest starting dose of a neuroleptic agent (haloperidol 0.5 mg
PO/IM, ziprasidone 10 mg IM, olanzapine 5 mg PO). These agents may
decrease the severity and duration of delirium. Keep opioid and
benzodiazepine use to a minimum.

KEY POINTS

Recognize delirium, and if uncertain, treat as delirium.
Find and treat delirium cause.
Nonpharmacologic treatment works.
If agitated, antipsychotics help. Restraints don’t.
Avoid benzodiazepines unless in alcohol withdrawal.

SUGGESTED READINGS

Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderly
emergency department patients. CMAJ. 2000;163:977–981.

Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: Diagnosis,
prevention and treatment. Nat Rev Neurol. 2009;5:210–220.

LaMantia MA, Messina FC, Hobgood CD, et al. Screening for delirium in the
emergency department: A systematic review. Ann Emerg Med.
2014;63:551–560.

Rosen T, Connors S, Clark S, et al. Assessment and management of delirium in
older adults in the emergency department: Literature review to inform
development of a novel clinical protocol. Adv Emerg Nurs J. 2015;37:183–196.

Salvi F, Morichi V, Grilli A, et al. The elderly in the emergency department: A

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critical review of problems and solutions. Intern Emerg Med. 2007;2:292–301.

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336

THE GERIATRIC TRAUMA PATIENT
IS SICKER THAN YOU REALIZE

REBECCA MILLIGAN, MD AND MICHELLE RHODES, MD

The fifth leading cause of death in the elderly population is trauma,
accounting for 23% of all trauma admissions. When adjusted for injury
severity, geriatric patients have a higher level of morbidity and mortality
across all severity levels. Falls are the most common mechanism of injury
and are the most common cause of unintentional injury and death among the
elderly, followed by motor vehicle accidents.

Multiple factors place the geriatric population at a high risk for traumatic
events. Chronic illnesses predispose patients to weakness and
deconditioning. Impaired vision and gait instability occur frequently,
increasing susceptibility to falls. Medications like antihypertensives and
psychotropics are associated with trauma. Polypharmacy is linked with
increased risk of falls. Many of these patients are on anticoagulants, which
can cause injuries to be more severe and make resuscitation more difficult.

Geriatric trauma patients often are undertriaged because the mechanism
of injury is seemingly insignificant. Morbidity and mortality are improved
when a geriatric patient is taken immediately to a high-level trauma center
for care. Geriatric patients may report less pain for the same injury in
younger patients that may be falsely reassuring.

Identification of an underlining cause of your patient’s trauma is
essential. Was the fall with loss of consciousness actually syncope? Was the
single vehicle collision caused by an episode of arrhythmia or a seizure?
Even seemingly simple falls can be harbingers for future trauma and
morbidity. Efforts to prevent future events such as a home health safety
evaluation should be strongly considered.

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Advanced Trauma Life Support principles apply the treatment of the
geriatric patients, though with specific focus on occult injury and lower
threshold for trauma center referral and activation. Airway, breathing,
circulation, disability, and exposure/environment each have geriatric-specific
considerations in the older adult.

Anatomically, the geriatric airway can be difficult to manage. Edentulous
patients are difficult to ventilate with a bag-valve mask (BVM). If present,
leave dentures in place for BVM. During endotracheal intubation, be
prepared for potential for limited mouth opening and decreased neck
mobility. Utilizing the video laryngoscope for intubation is often a safer
approach in these patients.

Breathing and ventilation require careful attention. Comorbid disease
such as chronic obstructive pulmonary disease (COPD) as well as the aging
process decrease reserve. Remember preoxygenation, apneic oxygenation,
and be prepared for a more precipitous fall in pulse oxygen when intubating.
Elders are particularly prone to rib fractures and pulmonary contusions with
higher morbidity and mortality resulting from similar injuries sustained by
younger adults. Respiratory failure necessitating mechanical ventilation may
result in a geriatric patient, whereas a 20-year-old with the same injury may
be a candidate for discharge. Strongly consider admission for three or more
rib fractures.

The standard hemodynamic parameters are inadequate to determine
stability in these patients. Blood pressure increases with age, and the normal
parameters for an adult likely represent relative hypotension in the geriatric
patient. Increased mortality has been shown among geriatric trauma patients
with HR > 90 and systolic BP < 110 mm Hg. Early stages of shock can be
masked by the absence of tachycardia secondary to medications such as beta-
blockers. Do not defer fluid or blood resuscitation on the basis of
unsubstantiated concerns for heart failure and fluid overload. Many older
adults are volume depleted due to decreased thirst mechanism and diuretics.
Failure to recognize circulatory compromise and aggressively treat increases
mortality.

The brain normally loses volume through the aging process, which
allows for more brain movement in response to motion, and therefore, more
blood may collect in and around the brain before the patient exhibits
symptoms. Head CT scan should be used liberally in the geriatric patient.
Older patients may have significant intracranial injury despite minor
mechanism, normal mental status, and a normal neurologic exam. Both the
Canadian and NEXUS II Head CT rules suggest imaging if 65 years or older.
Similarly, even falls from low heights can cause severe cervical spine

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fractures with rates twice that of younger populations. Be cautious when
using C-spine rules to justify no imaging. The NEXUS criteria have been
validated in a cohort of geriatric patients with adequate sensitivity; however,
the Canadian C-spine rule considers age ≥65 years a high-risk factor that
necessitates imaging studies.

Pay careful attention to environmental exposure and environment. Skin
tears and abrasions are caused by less trauma and have greater risk for
infection. Older adults are also more prone to hypothermia in a cold open
room. Avoid iatrogenic hypothermia with warmed blankets and fluids.

A good secondary survey is key. Orthopedic injuries are common in this
population; pelvic and femur fractures have a higher incidence of morbidity
and mortality. Radiographs can miss occult fractures, and CT or MRI should
be used to evaluate for injuries if the patient continues to have pain despite
negative x-rays. As with younger patients, eFAST exam is useful for
hemopericardium, hemoperitoneum, and pneumothorax.

Although geriatric trauma patients have higher morbidity and mortality
for a given injury, with early recognition of injury, avoidance of undertriage,
and aggressive management and therapy, many can return to their preinjury
functional status.

KEY POINTS

Avoid undertriage
Identify and treat the underlining cause of traumatic event
Image liberally
Do not discharge elders with three or more rib fractures

SUGGESTED READINGS

American College of Surgeons, Committee on Trauma. ATLS, Advanced Trauma
Life Support for Doctors: Student Course Manual. Chicago, IL: American
College of Surgeons, 2012.

Bonne S, Schuerer DJ. Trauma in the older adult: Epidemiology and evolving
geriatric trauma principles. Clin Geriatr Med. 2013;29(1):137–150.

Hefferman DS, Thakkar RK, Monahan SF, et al. Normal presenting vital signs are
unreliable in geriatric blunt trauma victims. J Trauma. 2010;69:813–820.

Mack LR, Chan SB, Silva JC, et al. The use of head computed tomography in
elderly patients sustaining minor head trauma. J Emerg Med. 2003;24:157–162.

Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults:

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Epidemiology, outcomes, and future implications. J Am Geriatr Soc.
2006;54:1590–1595.

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337

A NORMAL PHYSICAL EXAM DOES
NOT EXCLUDE INFECTIONS IN THE

GERIATRIC PATIENT

DANYA KHOUJAH, MBBS, FAAEM

There are certain clinical features in emergency department patients that
immediately make us think “infection”—fever being a main one. A few
others are tachypnea, tachycardia, and localizing symptoms—such as rales in
patients with pneumonia or abdominal tenderness in a patient with
cholecystitis. It’s a detrimental mistake to depend solely on these features in
geriatric patients!

Geriatric patients tend to present atypically with infections. Symptoms
such as altered mental status, decrease in functional status, failure to thrive,
anorexia, vomiting, frequent falls, or “generalized weakness” are the most
common presenting complaints in patients with proven infection.

Fever in the elderly is a very specific finding and is caused by infections
90% of the time, with bacterial infection being the dominant cause with
viruses causing <5%. A temperature > 37.8°C in the elderly is associated
with markers of serious illness over 75% of the time, such as positive blood
cultures or death within one month.

The lack of fever does not exclude an infectious cause for the older
patient’s presentation. Less than 20% of elderly patients with proven
bacteremia report a fever prior to presentation, and up to 30% do not have
documented fevers at all in the ED. This is likely due to the lower baseline
temperature, in addition to a blunted fever response among older adults. It
has been proposed that baseline temperature decreases by 0.15°C per decade,
leading experts to suggest redefining fever in the elderly. Several studies

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have looked at investigating a lower fever threshold for the geriatric patient;
one study by Castle et al. showed that lowering the threshold of “fever” from
38.3°C orally down to 37.2°C increases the sensitivity of detecting infections
in the geriatric from 40% to 83% while maintaining a specificity of 89%. Of
note, the most accurate way to diagnose a fever is to label it as an increase
from the baseline temperature by 1.3°C (2.3°F) if a baseline temperature is
available, such as in nursing home patients. In addition, geriatric patients are
more likely to become hypothermic, which is an ominous sign as it is a
predictor of mortality in the presence of sepsis.

Tachycardia can be blunted in the elderly, either due to medications that
they are taking, such as beta-blockers, or simply due to their decreased
ability to mount a catecholamine surge in response to stress.

A sensitive clinical exam finding for an infection in the elderly is the
presence of tachypnea, especially in pneumonia. However, studies have
questioned the reliability of the triage vitals or electronic monitors in
calculating an accurate respiratory rate.

When trying to identify the source of an infection, physicians tend to
focus their workup around signs or symptoms that point toward a specific
organ system. In the elderly, this is neither sensitive nor specific. For
example, 20% of patients with pyelonephritis present with respiratory or
gastrointestinal (GI) symptoms. Cough is only present in 50% of older
patients with pneumonia. Abdominal tenderness is not necessarily present in
patients with intra-abdominal pathology. A quarter to a third of elderly
patients with cholecystitis, appendicitis, and diverticulitis will present to the
emergency department without any abdominal tenderness on exam.
Perforation can also occur without pain or fever. In addition, one-third of
emergency geriatric patients with bacteremia will not have an identified local
source of infection. That being said, a thorough physical exam needs to be
done, looking for skin lesions (specifically bed sores), ear involvement (such
as otitis externa), and soft tissue complications associated with prosthetic
devices.

In conclusion, be vigilant for subtle signs of infection in the elderly, and
don’t be fooled by a “normal” exam!

KEY POINTS

Have a high clinical suspicion for infections in the elderly as they
present atypically.
Fever is not sensitive for infections in the elderly.

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Redefine fever in the older adult consider an oral temperature in
excess of 37.2°C as your cutoff for fever.
Calculate the respiratory rate yourself to identify elderly patients with
tachypnea and therefore a possible infection.
Lack of abdominal tenderness does not exclude intra-abdominal
pathology (or even perforation) in older patients.

SUGGESTED READINGS

Caterino JM. Evaluation and management of geriatric infections in the emergency
department. Emerg Med Clin North Am. 2008;26:319–343.

Khoujah D, Shen CS. Systemic infections in elderly patients. Critical Decisions in
Emergency Medicine. 2013;27:12–21.

Marco CA, Schoenfeld CN, Hansen KN, et al. Fever in geriatric emergency
patients: Clinical features associated with serious illness. Ann Emerg Med.
1995;26:18–20.

Niederman MS, Ahmed QAA. Community-acquired pneumonia in elderly patients.
Clin Geriatr Med. 2009;19:101–120.

Roghmann MC, Warner J, Mackowiak PA. The relationship between age and fever
magnitude. Am J Med Sci. 2001;322:68–70.

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338

RESPECTING THY ELDERS:
DEFINING, DETECTING, AND
REPORTING ELDER ABUSE

PATRICIA BAYLESS, MD

Elder abuse is a difficult but important topic as the elder population increases
in the United States. According to the 2010 census, 14% of Americans were
65 years of age or older, with the proportion expected to increase as baby
boomers age. One of the fastest increasing demographic categories was
adults greater than age 85. The majority of these adults also reported
disability affecting their activities of daily living. The definition and
recognition of elder abuse have been difficult for health care providers and
other professionals. According to the National Center on Elder Abuse, only 1
in 14 cases are reported to appropriate authorities due to underrecognition.
How can we improve our recognition and understanding of the complexities
of elder abuse?

There are several types of abuse identified, including psychological or
emotional mistreatment, physical abuse, sexual abuse, neglect or
abandonment, financial exploitation, and self-neglect. The signs of neglect
may be much more subtle than bruises or fractures. The best single definition
for elder abuse has been accepted by the World Health Organization as
follows:

“Elder abuse is a single, or repeated act, or lack of appropriate action,
occurring within any relationship where there is an expectation of trust which
causes harm or distress to an older person.”

Caregivers committing abuse are very likely to be family members or
friends. Sometimes, the abuse is a continuation of long-standing

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dysfunctional relationships or develops as a response to changes in the
family’s living situation as a result of patient’s increasing frailty and need for
assistance. Profiles in cases of elder abuse show that many of these abusive
caregivers perceive a higher subjective burden of care required by the elder
patient including activities of daily living, financial support, and medical
care. Most research surveys are completed by mentally cognitive older
adults. It has been much more difficult to assess for adults with dementia,
thus underestimating the true incidence of the crime. Patients with dementia,
particularly those who are agitated or physically aggressive, are at higher risk
for abuse. Patients in nursing homes and other health care settings including
hospitals are not immune to elder abuse, though most abuse occurs in the
home setting.

Although we as health care providers and our colleagues in social
services consider ourselves well versed in the detection of elder abuse,
studies have shown otherwise. We are less likely to routinely ask the elder
patient about possible abuse and to question caregivers about the use of
excessive restriction for a patient with dementia. There are tools to improve
our detection of elder abuse. The Elder Abuse Suspicion Index (EASI) is one
of the easiest and most straightforward tools. Most ED triage protocols
incorporate questions to assess patient safety such as “Have you been hurt,
threatened or made to feel afraid?” This might provide the opportunity to
request additional screening or social service referral to discover elder abuse
much like we do for instances of interpersonal violence. Such an intervention
has not been studied.

Federal laws allow states to interpret how elder abuse is reported and
managed. Nearly every state has requirements for reporting to law
enforcement or an agency such as Adult Protective Services. There are
federal reporting requirements for nursing homes and other health care
facilities. Most states also include indemnification for reports made in good
faith by interested persons, health care providers, or other professionals such
as social workers. The more educated we are, the more likely we are to
identify and report. Penalties for failure to report also vary from state to state.
An online guide to your state’s resources including laws, agencies, and
statistics for elder abuse is available.

Self-neglect is a common form of elder abuse identified in the ED,
particularly among those with isolated social situations. Home health
agencies are a resource who can provide in-home evaluations and encourage
patient’s to accept resources that will assist them in maintaining their well-
being. It is also useful to provide behavioral health support and mental health
evaluation for capacity and/or competency.

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One of the major barriers in the management of elder abuse is
recognition and acceptance of the abuse by the cognitively intact adult who
may decline intervention. This is markedly different when compared to
endangered children who may be removed without their assent, more similar
to the dilemmas we see in instances of interpersonal violence. Care recipients
may be reluctant to leave a dangerous situation for fear of repercussions at
their home or relationships, loss of familiar surroundings, or lack of the
financial resource. Health care providers are sometimes reluctant to report
because of lack of knowledge about signs of abuse, lack of knowledge about
reporting requirements, fear of retaliation by caregiver, avoidance of possible
legal proceedings, and sometimes even empathy for the caregiver who has
the difficult task of providing care.

Our goal is to provide safety and security for the elder population. It is
important to improve our awareness in the ED and educate ourselves so we
may guard the health and safety of the most vulnerable of our elders.

KEY POINTS

Only 1 in 14 cases are reported to appropriate authorities due to
underrecognition.
Caregivers committing abuse are very likely to be family members or
friends.
One of the major barriers in the management of elder abuse is
recognition and acceptance of the abuse by the cognitively intact adult
who may decline intervention.
The Elder Abuse Suspicion Index (EASI) is one of the easiest and
most straightforward tools to screen for elderly patients being abused.

SUGGESTED READINGS

Bond MC, Butler KH. Elder abuse and neglect: Definitions, epidemiology, and
approaches to emergency department screening. Clin Geriatr Med.
2013;29(1):257–273.

Burnett J, Dyer CB, Halphen JM, et al. Four subtypes of self-neglect in older
adults: Results of a latent class analysis. J Am Geriatr Soc.
2014;62(6):1127–1132.

Cooper C, Selwood A, Livingston G. Knowledge, detection, and reporting of abuse
by health and social care professionals: A systematic review. Am J Geriatr
Psychiatry. 2009;17: 826–838.

1416

Levine JM. Elder neglect and abuse: A primer for primary care physicians.
Geriatrics 2003; 58:37–40.

Wiglesworth A, Mosqueda L, Mulnard R, et al. Screening for abuse and neglect of
people with dementia. J Am Geriatr Soc. 2010;58(3):493–500.

Yaffe MJ. Detection and reporting of elder abuse. Fam Med. 2010;42(2):83.

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339

HOW TO AVOID SNOWING
SENIORS: PAIN MEDICATIONS AND
PROCEDURAL SEDATION IN OLDER

ADULTS

LISA C. GOLDBERG, MD AND MICHELLE RHODES, MD

Older adults commonly visit the ED for acute pain. In many EDs, older
adults are less likely to receive appropriate analgesic medications when
compared to younger adults. This is at least partially explained by fear of
increased risk of adverse effects to pain medication seen among older adults.
Additional risk is derived from age-related changes in body habitus affecting
drug distribution, polypharmacy with drug-drug interaction, age-related
decline of P450 enzyme, and changes in renal and hepatic clearance. It is a
delicate balance between failing to control our elderly patients’ pain and
snowing them completely.

The goal of pain management in the geriatric patient is to assess the
severity of pain, select patient-specific analgesia, and effectively reduce pain.
Documentation of pain scores improves outcomes, with the Verbal Numeric
Rating Scale being the most commonly administered. Pain should be
assessed within 1 hour of arrival in ED, before and after treatment,
reassessed if the patient remains in ED > 6 hours, and a final reassessment
prior to discharge. It is important to assess for pain in cognitively impaired
older adults as well. There are several scores that can be used, but more
simply, one can look for painful facial expressions, grimacing, withdrawing,
or moaning. Family and caretakers are often aware of signs of pain and can
be asked as well.

1418

The American Geriatric Society (AGS) and World Health Organization
(WHO) recommend the use of nonopioid medications for mild pain (0 to
3/10). Acetaminophen has a good safety profile but is limited to 4 g per day
and not an appropriate choice for patients with hepatic issues. While
effective, NSAIDs are problematic in older adults with renal insufficiency,
gastropathy, heart failure, heart disease, or risk factors for heart disease. In
addition, NSAIDs have multiple important medication interactions. If
NSAIDs are to be used, older adults should be screened for
contraindications, and dosing should be done at the lowest effective dose and
for the shortest period possible.

For moderate to severe pain and in the absence of contraindications,
opioid medications are the way to go. A key saying in geriatrics “start low
and go slow” applies particularly well here. Starting with doses 25% to 50%
lower than the typical adult dose with frequent reassessments will keep your
older patients safe.

Oral opioids are typically used for moderate pain (4 to 6/10).
Hydrocodone is a good option, though limited in dose by its combination
with NSAIDs or acetaminophen in the United States. Oral morphine can also
be used, though with caution in renal insufficiency. If you are sending your
patient home with oral opioids, add a bowel regimen to prevent a return trip
for constipation and even disimpaction.

For severe pain (7 to 10/10) or those unable to tolerate oral medications,
parenteral opioids are required. Hydromorphone and morphine are great
choices but should be used with caution in the setting of liver dysfunction.
Fentanyl may also be used, but its short half-life requires frequent redosing.
Opioid medications to avoid in older geriatric patients include meperidine
and codeine. Codeine has variable metabolism making effect unpredictable,
and meperidine has cardio and neurotoxic metabolites.

Regional anesthesia in the form of nerve blocks using longer-acting
sodium channel blockade is a great option for the geriatric patient. Nerve
blocks may be used for fracture or dislocation reduction, abscess drainage,
and pain management pending surgical fixation. For hip and femoral neck
fractures in particular, they reduce need for parenteral opioids and have been
shown to be safe and effectively performed in the ED for geriatric patients—
both with and without ultrasound guidance.

Ultrasound guidance for femoral nerve blocks. Ultrasound improves
accuracy and reduces amount of local anesthetic needed. Emergency
physicians can easily gain proficiency in this procedure.

Procedural sedation in the geriatric patients requires caution for reasons
similar to those for pain management but can be done safely. The medication

1419

of choice should be based upon the procedure and patient’s comorbidities.
Propofol is often selected given its ease of titration with rapid effect and
recovery. Older adults require about half the usual dose. Ketamine has been
used with success in geriatric patients. Be sure to consider if the potential
increase in blood pressure and heart rate would be detrimental to your
patient. Etomidate can also be used safely with rapid recovery as long as you
don’t mind the myoclonus during your procedure. For many ED docs,
midazolam, typically in combination with fentanyl, is the only option for
sedation; however, the longer recovery time and risk of delirium is less than
ideal for older adults.

KEY POINTS

Assess and reevaluate pain with each intervention
Start low and go slow with medication dosing
Consider regional anesthesia
Consider individual patient factors when selecting sedation drugs

SUGGESTED READINGS

Hwang U. The quality of emergency department pain care for older adult patients.
J Am Geriatr Soc. 2010;58(11):2122–2128.

Hwang U, Platts-Mills TF. Acute pain management in older adults in the
emergency department. Clin Geriatr Med. 2013;29(1):151–164.

Ritcey B, Pageau P, Woo MY, et al. Regional nerve blocks for hip and femoral
neck fractures in the emergency department: A systematic review. Can J Emerg
Med. 2015;2:1–11.

Weaver CS, et al. ED procedural sedation of elderly patients: Is it safe? Am J
Emerg Med. 2011;29(5):541–544.

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340

THE CONSEQUENCES OF
GRANDPA’S LOADED MEDICINE

CABINET

RYAN GALLAGHER, MD AND STEPHEN THORNTON, MD

Consider for a moment a typical geriatric patient: he takes aspirin and
clopidogrel for his stented coronaries; metformin and multiple insulins for
his difficult to control diabetes; some combination of amlodipine, carvedilol,
furosemide, and hydrochlorothiazide for his hypertension (depending on
which ones he remembers in a given day); naproxen for his arthritis but
sometimes it upsets his stomach so he takes promethazine for the nausea and
some of his wife’s oxycodone/acetaminophen for the pain; and he is taking
some other medications too but the family forgot to toss them in his bag (and
they aren’t sure where some of them are anyway) before bringing him in
because he just doesn’t seem right after getting dizzy, falling, and hitting his
head.

Complications from polypharmacy are a significant concern for elderly
patients in the emergency department (ED). This is due to a combination of
inappropriate use of high-risk medications, adverse drug effects, and barriers
to taking medications as prescribed. Risk is directly related to the number of
antecedent medications and is increased when additional agents are added to
their regimen. Estimates suggest that 20% of Medicare beneficiaries have
five or more chronic conditions and that half take five or more medications.
Many drugs carry inherent risks that are increased in the elderly and even
more of a concern when potential interactions with other prescriptions are
considered. Elderly patients are also more likely to lack the ability to comply
with a medication regimen for a variety of reasons, including lack of social
support and high prevalence of dementia.

1421

Whenever possible high-risk medications should be identified and
avoided. Addition of any new medication should be carefully considered and
done cautiously. It is especially important to be sure that additional
medications are not being added to treat adverse effects of preexisting
medications, often referred to as the prescription cascade. It is estimated that
nearly 100,000 hospitalizations occur annually for adverse drug effects in
patients over age 65, predominantly due to unintentional overdose; the most
common agents involved are warfarin, insulins, oral antiplatelet agents, and
oral hypoglycemic agents.

We must also do our best to avoid giving out high-risk medications
ourselves. One retrospective study showed that 16.8% of geriatric patients
discharged from the ED are prescribed one or more potentially inappropriate
medication(s). General drug classes of concern include opioids,
antihistamines, nonsteroidal anti-inflammatories (NSAIDs), antidepressants,
antiepileptics, antipsychotics, and antibiotics. Of these, the top offenders
included promethazine, ketorolac, propoxyphene, meperidine, and
diphenhydramine.

The role of an ED provider in the management of chronic medications is
controversial and not well defined. Significant alterations to chronic
medication regimens in the ED should be made only in consultation with the
primary care physician or pharmacists. When evaluating an elderly patient’s
medication list, it is important to consider the indication for any preexisting
medication. Studies have suggested that as many as 60% of geriatric patients
are taking medication with an inappropriate or absent indication. Regardless
of whether or not any change is made in the ED, it is important to ensure that
patients who are discharged have a plan in place for follow-up with a
primary care provider to evaluate their medications.

The inherent risk of polypharmacy is further complicated in geriatric
patients by the fact that they are often less able to adhere to complex
prescription regiments. This increases the risk of adverse effects due to
inappropriate medication use. This is especially concerning for drugs that
have a narrow therapeutic index such as warfarin, digoxin, and phenytoin.4
Thus, it is important to not only consider the adverse effect of any added
medication but also consider whether the patient or his or her caregiver will
be able to administer the medication appropriately. Patient and caregiver
education is the key to ensuring the best chance that a medication regimen
will be followed. Consideration must also be given to follow-up, and
communication with the primary provider is very important as they will be
responsible for any future changes to the medication regimen.

In summary, the geriatric patient is at high risk for complications from

1422

polypharmacy due to the medications they are already prescribed, the
adverse effects of commonly used ED medications, and challenges to
following prescription instructions. In this at-risk population, the risks and
benefits of any additional medication should be carefully considered.
Adverse drug effects, medical necessity, and likelihood of appropriate
administration and follow-up should all be questioned prior to prescribing
any new medication.

KEY POINTS

Consider common adverse drug effects before prescribing additional
medications in the older adult
Identify and, when possible, avoid high-risk medications in the
geriatric patient
Discuss new medications with the patient and caregivers to ensure
appropriate administration
Ensure adequate follow-up for any changes made in the ED

SUGGESTED READINGS

Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for
adverse drug events in older Americans. N Engl J Med. 2011;365:2002–2012.

Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in
elderly people. Lancet. 2007;370:185–191.

Meurer WJ, Potti TA, Kerber KA, et al. Potentially inappropriate medication
utilization in the emergency department visits by older adults: Analysis from a
nationally representative sample. Acad Emerg Med. 2010;17:231–237.

Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific
guidelines for patients with multiple conditions. N Engl J Med.
2004;351:2870–2874.

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341

COMMUNICATING AND
UNDERSTANDING THE ELDER

PATIENT

COLLYN T. MURRAY, MD AND KEVIN BIESE, MD, MAT

There are a tremendous number of older adults seeking care in emergency
departments (EDs) (~19.6 million), and the CDC estimates a doubling of the
geriatrics population over the next 25 years. Providers need to be able to
communicate effectively with older adults to take good care of them. While
the hectic nature of the ED can limit patient-physician interactions,
approaching older adults with an established communication framework will
improve the care you provide.

COMMUNICATION QUALITY AND SPECIAL
CONSIDERATIONS

Preparation is the key for successful assessment of older adults. Start the
interview when you have a few uninterrupted moments. Though older adults
can take longer to interview, spending the extra time up front to discuss their
current complaints, previous experiences with the health care system, and
goals of care can ultimately help focus your treatment course. If you have
time and the patient is stable, review recent medical records as they often
contextualize the current ED visit. Ensure that the patient has hearing aids or
glasses. Consider supplying reader lenses and pocket talkers for your older
ED patients. Consider voice frequency. Lower-pitched voices are easier to
hear. Speak clearly with your mouth visible allowing for multiple
opportunities for comprehension. This is particularly important before

1424

completing cognitive assessments. Finally, sit down. It has been
demonstrated that patients believe that doctors have spent more time with
them when the doctor is sitting.

Providers must also remember that not all older adults are the same.
There are many vibrant older adults as well as those who demonstrate
cognitive decline; getting to know your patient will help identify care needs.
Symptom presentation can also differ. Physiologic changes associated with
aging, multiple comorbidities, and polypharmacy may lead to deviations
from textbook presentations of pathology. A high index of suspicion and a
thorough history and physical exam are necessary to identify acute illness.

COGNITIVE ASSESSMENT

Knowing your patient’s baseline mental status and performing cognitive
assessments of your patients are critical components of every interview of
older adults. It is dangerous to assume that delays in cognitive function,
limited responsiveness, or confusion are a patient’s “normal.” If a patient
presents with features of altered mental status, further investigation is
required. Contact family members or caregivers if the patient presents alone.
During questioning, determine the patient’s mental capacity, orientation
status, and if any acute changes have been noticed recently.

Last known normal and baseline mental status are also important
particularly in terms of stroke care and disease course. A number of tools
have been designed for fast, accurate assessment of mental status and
differentiating delirium (characterized by acute inattention) and dementia
(chronic memory loss). We recommend the Brief Confusion Assessment
Method (bCAM) for assessing delirium. This clinical tool is an adaptation
from the Confusion Assessment Method-ICU scale that assesses for delirium
through questioning aimed at identifying altered/fluctuating mental status,
altered level of consciousness (agitation), and disorganized thinking as
indicators for delirium. While features of dementia are slow to develop,
delirium points to an acute medical process requiring further investigation
and treatment. To assess for memory loss and possible dementia, we
recommend the Mini-Cog, a short assessment involving a three-item word
recall and clock draw test. The patient is determined to have symptoms of
cognitive impairment if they are unable to recall any of the stated words. If
the results are indeterminate (e.g., one or two words recalled), the patient is
asked to draw a clock. Errors in the clock draw are scored as indicators of
dementia. This measure has been validated across a number of settings and
correlates with the results of more in-depth assessments.

1425

PATIENT ADVOCACY

Beyond diagnostics, one of the most important responsibilities for a clinician
is patient advocacy. The geriatric population is at risk of and from frequent
interactions with the health care system, limitations in self-care, and financial
constraints. Serving as a voice for your patient can improve the quality of
each interaction. Involve the patient’s family or power of attorney in his or
her care. Remember to address these patients directly and work to
differentiate their wishes from those of their caregivers’ as it is estimated that
there is only 60% agreement between parties in cases involving severe
physical or cognitive impairment. Discussions should address goals of care
including desired workup, interventions, and result notifications. When
possible, discuss or prime future discussion of advanced directives, living
wills, and Do Not Resuscitate/Do Not Intubate (DNR/DNI) forms beyond the
brief cardiopulmonary resuscitation (CPR) discussion that happens in the
setting of acute illness. In doing so, unnecessary testing and hospital
admissions may be avoided ultimately improving quality of life. Case
managers are invaluable assets in knowing available community resources.
Providers should further take advantage of transition care teams and
advances in technology that allow for close follow-up after ED visits.

The current “graying” of our population is bringing elderly care to the
forefront of health care discussion. Though there are several factors that may
complicate the assessment of our geriatrics population, keeping in mind the
aforementioned considerations and cognitive assessment tools will allow
better, appropriate care delivery within and beyond the ED.

KEY POINTS

Put in the time up front
Know your patient’s baseline mental status
Use the bCAM and mini-COG assessments
Know and advocate for your patient

SUGGESTED READINGS

Borson S, Scanlan JM, Chen P, et al. The Mini-Cog as a screen for dementia:
Validation in a population-based sample. J Am Geriatr Soc.
2003;51:1451–1454.

Centers for Disease Control and Prevention. The State of Aging and Health in

1426

America 2013. Atlanta, GA: Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services, 2013.
Fried TR, Bradley EH, Towle VR. Valuing the outcomes of treatment: Do patients
and their caregivers agree. Arch Intern Med. 2003;163(17):2073–2078.
Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency
department patients: Validity and reliability of the delirium triage screen and
the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457–465.

1427

SECTION XXIII
WOUND CARE

1428

342

DEEP SUTURES: WHEN, WHY, AND
WHY NOT?

HOLLYNN LARRABEE, MD AND R. ALISSA MUSSELL, MD

When closing a wound by primary intention, the goals of wound
management include obtaining a functional closure with optimal wound
strength while maintaining a low risk for infection and minimizing eventual
scar formation. Multiple factors affect the clinician’s approach to wound
management: the location, length, and depth of the wound; the type of tissue
involved; the tension across the tissue; the level of contamination of the
wound; and the time elapsed since the injury occurred. Ideal wound closure
includes achieving apposition of the wound edges while minimizing tension
and avoiding inversion or dead space.

The two techniques employed for primary wound closure in the
emergency setting are percutaneous (skin) and dermal (deep) sutures.
Percutaneous sutures pass through both the epidermal and dermal layers of
the skin; dermal sutures pass through the dermis without ever penetrating the
epidermis. Both percutaneous and dermal sutures can be placed in an
interrupted or continuous fashion. The structural integrity of the repair is
determined entirely by the suture material that passes through dermis or
fascia. Sutures should not be placed within adipose tissue, as this layer
provides little to no support for wound closure.

Dermal sutures can be used alone or together with percutaneous sutures
for wound closure. Dermal sutures, alone, are indicated for closure of a
wound that will later be covered by a cast, or in special patient populations.
This includes patients who develop keloids, patients who have poor follow-
up for suture removal, and patients in whom suture removal will be
challenging or traumatic (infants). In addition, dermal sutures are often the
only technique available to close lacerations involving macerated or avulsed

1429

tissue, in which percutaneous closure is impossible. Deep sutures are also
mandatory to repair tissues such as galea, periosteum, muscle, or fascia.
While percutaneous sutures alone can close wounds under low or medium
tension, dermal sutures are a useful adjunct for gaping wounds or wounds
under high tension. Excessive tension across a wound interrupts capillary
blood flow to the wound edge and can delay healing and cause local
ischemia and cellular necrosis. Placing an interrupted dermal suture in each
quadrant of the wound will allow the wound edge to be brought together in
apposition while removing the tension across the epidermal surface. This
type of dermal placement will also reinforce the tissue enough to allow for
early suture removal, which can improve final cosmetic outcome.

When dermal sutures are indicated, proper placement and technique is
critical. To place a dermal suture, first introduce the needle close to the base
of the dermis and then pass through the more superficial layers of the dermis.
The second bite is performed by introducing the needle into the superficial
dermis of the opposite wound edge and exiting at the deep dermis fascial
plane. Both suture tails should remain on the same side of the cross-stitch, so
that the knot buries properly after tying.

Although all sutures have inherent potential to increase the risk of wound
infection, dermal sutures are associated with higher rates of infection than
percutaneous sutures. Research has demonstrated that buried absorbable
sutures increase the infection rate and degree of inflammation in
contaminated wounds, even with adequate irrigation. This effect is even
more pronounced with a continuous dermal closure, which not only uses a
large quantity of suture material but also creates a tight barrier that facilitates
infection spreading between the adipose and deep tissues and involving the
entire wound before any infection is clinically apparent. Conversely, dermal
sutures have little to no effect on infection rates in clean or noncontaminated
lacerations. While there are clear indications and many benefits to using
dermal sutures for laceration repair, in contaminated wounds, this has to be
balanced against the increased risk of infection. Current literature supports
using dermal sutures to close dead space only in noncontaminated or
minimally contaminated wounds using as few sutures as possible.

KEY POINTS

The primary goal of wound repair is obtaining a functional closure
while maintaining a low risk for infection and minimizing scar
formation.

1430

The structural integrity of any wound repair is determined by the
tension on the wound and the suture material that passes through the
dermis.
Indications for dermal sutures without percutaneous sutures include
wounds that will be covered by a cast, wounds in patients who
develop keloids, or patients in whom suture removal will be difficult.
Dermal sutures reduce tension across the epidermal surface allowing
for improved blood flow to the wound edges, early suture removal,
and improved cosmesis.
Dermal sutures are associated with higher rates of infection and
should be avoided in contaminated wounds.

SUGGESTED READINGS

Austin PE, Dunn KA, Eily-Cofield K, et al. Subcuticular sutures and the rate of
inflammation in noncontaminated wounds. Ann Emerg Med.
1995;25(3):328–330.

Berk WA, Welch RD, Bock BF. Controversial issues in clinical management of the
simple wound. Ann Emerg Med. 1992;21(1):72–80.

Hollander JE, Singer AJ. Laceration management. Ann Emerg Med.
1999;34:356–367.

Lloyd JD, Marque MJ, Kacprowicz RF. Closure techniques. Emerg Med Clin N
Am. 2007;25:73–81.

Mehta PH, Kunn KA, Bradfield JF, et al. Contaminated wounds: Infection rates
with subcutaneous sutures. Ann Emerg Med. 1996;27(1):43–48.

Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes,
Part II. Repairing tissue: Suturing. J Am Acad Dermatol. 2015;72(3);389–402.

1431

343

PITFALLS IN EMERGENCY
DEPARTMENT ABSCESS INCISION

AND DRAINAGE

DAVID WEIN, MD AND JESSE DUBEY, DO

Emergency department (ED) management of cutaneous abscesses has
traditionally included a generous skin incision, drainage, cavity
manipulation, packing, and close wound follow-up. Recent literature has
challenged these time-honored traditions and includes a movement toward
less invasive techniques, avoidance of packing, and a more conservative
approach to the use of wound cultures and antibiotics.

When considering an abscess for incision and drainage (I&D), keep the
differential broad and consider the use of bedside ultrasound to localize the
abscess cavity. The differential can range from simple folliculitis to a
furuncle, carbuncle, or even a complicated abscess with associated cellulitis.
Other diagnostic possibilities include arteriovenous malformations, lipomas,
lymph nodes, herniated bowel, myiasis, kerion, herpetic whitlow,
sporotrichosis, and cat scratch disease.

There are several pitfalls that should be avoided when caring for a patient
with a cutaneous abscess. First, do not rely on needle aspiration as a
definitive method to treat an abscess. A recent study demonstrated a low
success rate for needle aspiration compared with I&D. It is important to also
consider patient risk factors and comorbid conditions. The following
conditions are associated with higher rates of complications: perirectal
abscesses, anterior or lateral neck masses (from congenital cysts), hand
abscesses (excluding paronychias or felons), an abscess adjacent to vital
nerves or vessels, abscesses located in the central facial triangle, and breast

1432

abscesses. If any of the these are present, a surgeon should be consulted or
prompt follow-up for wound evaluation and definitive care be sought within
48 hours.

Another pitfall is the failure to obtain a wound culture when indicated.
Wound cultures are typically not required for a healthy patient in whom there
is no plan to prescribe post-I&D antibiotics. It is recommended that a wound
culture be obtained in the following settings: a severe local infection,
systemic signs, a history of recurrent or multiple abscesses, failure of initial
antibiotic therapy, extremes of age, immunocompromised state, or if they are
from a region of unknown Staphylococcus aureus susceptibility or an area of
rapidly changing susceptibility.

Not all patients with an abscess require antibiotic therapy. The Infectious
Disease Society of America recommends against routine use of antimicrobial
therapy in the young healthy population. If antibiotics are indicated,
suggested regimens are outlined in Table 343.1.

TABLE 343.1 COMMON ORAL ANTIBIOTIC TREATMENT FOR MRSA

Packing wounds remain controversial. Several small studies suggest that
there is no difference in healing time, wound recurrence, or wound
complications when the abscess is left open. A recent systematic review
suggested that packing wounds resulted in delayed wound closure. Patients
who may still benefit from packing include those with an abscess >5 cm in
diameter, diabetes, immunocompromising conditions, or a pilonidal

1433

abscesses. Multiple studies have been performed examining the difference
between primary and secondary closure of cutaneous skin abscesses. Current
literature favors a secondary healing process as the treatment of choice for
uncomplicated cutaneous abscesses.

Lastly, the “loop drainage” technique has introduced the possibility of
having one postoperative visit, painless removal of a drain, and the
possibility of only two small scars afterward. One initial “stab incision” is
placed at the abscess midpoint or the area where spontaneous drainage has
occurred. A hemostat is then utilized to break up loculations, and the abscess
is irrigated as typically performed. The distal margin of the abscess is then
probed followed by a second “stab incision.” The hemostat is then used to
traverse the entire abscess cavity subcutaneously, grasp the silicon vessel
loop or ¼ inch Penrose drain, and pull the loop through the abscess cavity.
The ends are then tied loosely, and the knot is moved from side to side on a
daily basis to allow continued drainage of the abscess until removal after 7 to
10 days.

KEY POINTS

Consider patient risk factors, comorbidities, and high-risk locations
prior to performing an I&D.
Wound cultures are not required for simple abscesses in the young and
healthy.
Antibiotics are not recommended unless cellulitis or other high-risk
features are present.
Packing the abscess cavity may delay healing and is associated with
more pain.
Consider the “loop drainage” technique, as this requires less follow-
up, produces less scarring, and increases patient satisfaction.

SUGGESTED READINGS

Gaspari RJ, Resop D, Mendoza M, et al. A randomized controlled trial of incision
and drainage versus ultrasonographically guided needle aspiration for skin
abscesses and the effect of methicillin-resistant Staphylococcus aureus. Ann
Emerg Med. 2011;57(5):483–491.e1.

Singer AJ, Taira BR, Chale S, et al. Primary versus secondary closure of cutaneous
abscesses in the emergency department: A randomized controlled trial. Acad
Emerg Med. 2013;20(1):27–32.

1434

Singer AJ, Thode HC, Chale S, et al. Primary closure of cutaneous abscesses: A
systematic review. Am J Emerg Med. 2011;29(4):361–366.

Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis
and management of skin and soft tissue infections: 2014 update by the
Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–e52.

Tintinalli J, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
7th ed. New York, NY: McGraw-Hill, 2011.

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344

KEEP IT CLEAN: PITFALLS IN
TRAUMATIC WOUND IRRIGATION

ANAND K. SWAMINATHAN, MD, MPH AND ELICIA
SKELTON, MD, MPH

Proper wound irrigation is crucial for infection prevention, removal of debris,
and promotion of proper wound healing. The goal is to remove all
contaminants and foreign material, while causing the least amount of damage
to the tissue. If irrigation is not done properly, detrimental outcomes to the
patient or the provider may result.

PERSONAL PROTECTION

Adequate personal protection is imperative when irrigating any wound. Prior
to preparing the patient, the provider should wear a face mask with eye shield
and gloves. Disposable gowns may be used based on the estimated risk of
provider contamination.

PREPROCEDURAL PREPARATION

Overall success is guided by preprocedural preparation. Appropriate
anesthesia is necessary to ensure proper irrigation. Irrigating wounds is an
uncomfortable procedure when performed properly. If patients are not
properly anesthetized, they may not tolerate high-pressure irrigation. The
wound area should be positioned in a way that allows the irrigant to
continuously run off, so that the wound does not soak in the irrigating
solution, an event that has been associated with increased risk of infection.

1436

SKIN PREPARATION

Cleaning intact skin surrounding the wound may be useful in reducing the
amount of nearby bacteria. However, cleaning solutions should never be
directly applied to open wounds. Commonly used cleansers such as
povidone-iodine, chlorhexidine, and hydrogen peroxide can be toxic to
wound tissue. Not only can these cleansers impair wound healing, they may
even promote bacterial growth by weakening host defenses.

Wounds that occur in areas of the body that are hairy may be particularly
challenging. Hair may obscure foreign bodies and may make it more difficult
to explore and repair wounds. Additionally, hair itself may serve as a
contaminant. At times, it may be beneficial to trim surrounding hair. Shaving
the area with a razor should not be done, as this can increase infection rates.

SCRUBBING

In excessively dirty wounds or in wounds with significant amount of foreign
material entrapped, it may be necessary to scrub the wound. If scrubbing is
necessary, it is important to avoid overaggressive scrubbing, as this can lead
to further tissue damage and poor wound healing. If the decision is made to
mechanically scrub, a fine pore sponge should be used to minimize the
amount of tissue damage.

IRRIGATION

Irrigation is most important in contaminated wounds and in areas that are
more prone to infection, such as areas that are poorly vascularized. Though
sterile saline is often used in wound cleansing, tap water irrigation has been
shown to be just as effective. Additionally, tap water is cost-effective and
may be easily obtained in large quantities (but it is important to note that
these studies apply to areas where potable water is available). There is no
added benefit to adding a wound cleanser or disinfectant to the irrigant.

IRRIGATION TECHNIQUE

The amount of pressure to use during irrigation depends on both the level of
contamination and the wound site. For clean wounds or wounds in areas of
loose skin, (i.e., eyelids, testicles) low pressure, 0.5 pounds per square inch
(psi), may be used. However, it should be noted that high-pressure irrigation
(≥7 psi) is more effective for removing bacteria and other foreign
contaminants. The most common and cost-effective method for low-pressure

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irrigation is the bulb syringe, which typically produces a pressure of 0.5 psi.
High-pressure irrigation can be achieved by using a 19-gauge needle or
catheter and a 35-mL syringe. High-pressure irrigation, however, is not
without risks and has been associated with tissue damage. It is conceivable,
although not proven, that under very high pressures, bacteria and foreign
matter could spread along the tissue plane and contaminate previously
uncontaminated areas. In order to optimize the effects of irrigation while
limiting tissue damage, pressures of 5 to 8 psi have been recommended.

Although the optimal amount of irrigation is unknown, it is typically
recommended to use at least 200 mL. Another recommended amount is
based on length of the laceration and calls for roughly 60 mL per linear
centimeter of the wound. More importantly, clinical judgment should be
used. It is generally better to overirrigate than to underirrigate. Contaminated
wounds and chemical burns will require more copious irrigation.

Finally, time elapsed since the wound occurred should be considered.
Waiting for prolonged periods of time to irrigate after the initial injury may
result in higher risk of wound infection. One study using an experimentally
contaminated animal model demonstrated a statistically significant reduction
in bacterial growth with early wound irrigation compared to later wound
irrigation. Overall, optimization of wound management should be based on
clinical presentation while keeping the key concepts and pitfalls of wound
cleansing highlighted in this chapter in mind.

KEY POINTS

Preparation and appropriate anesthesia are necessary to ensure proper
irrigation.
Cleaning solutions should never be directly applied to open wounds.
Avoid aggressive scrubbing, this can lead to further tissue damage and
poor wound healing.
Tap water has been shown to be safe and effective in wound
irrigation.
In order to optimize the cleansing effects of irrigation, copious amount
of irrigant and pressures of 5 to 8 psi have been recommended.

SUGGESTED READINGS

Atiyeh B, Dibo S, Hayek S. Wound cleansing, topical antiseptics and wound

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healing. Int Wound J. 2009;6(6):420–430.
Chatterjee JS. A critical review of irrigation techniques in acute wounds. Int

Wound J. 2005;2(3):258–265.
Edlich RF, Rodeheaver GT, Thacker JG, et al. Revolutionary advances in the

management of traumatic wounds in the emergency department during the last
40 years: Part I. J Emerg Med. 2010;38(1):40–50.
Hollander JE, Richman PB, Werblud M, et al. Irrigation in facial and scalp
lacerations: Does it alter outcome? Ann Emerg Med. 1998;31(1):73–77.
Lammers RL, Fourré M, Callaham ML, et al. Effect of povidone-iodine and saline
soaking on bacterial counts in acute traumatic contaminated wounds. Ann
Emerg Med. 1990;19(6):709–714.

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345

PLANTAR PUNCTURE WOUND
PEARLS AND PITFALLS

R. GENTRY WILKERSON, MD

Plantar puncture wounds are a common presentation to the emergency
department (ED). The management of these wounds is controversial due to a
lack of a robust body of medical evidence. Much of the current literature is
retrospective reviews of patients with wound complications. These wounds
often have a benign appearance at presentation and usually have a good
clinical course. However, in some cases, these wounds can have devastating
long-term outcomes despite appropriate medical care.

Evaluation should begin with a thorough history that includes time of
injury, type of penetrating object, type of footwear worn at time of injury,
and care rendered by the patient. It is also important to ask if the penetrating
object was intact if removed by the patient. An accurate immunization
history will determine the need for appropriate tetanus prophylaxis with
tetanus toxoid. Patients with no prior, or incomplete, tetanus immunization
require tetanus immune globulin.

The physical exam should determine the location of the wound and
assess the integrity of the surrounding soft tissue. Neurologic and vascular
function proximal and distal to the wound should be evaluated. Plantar
puncture wounds can be classified based on location of the foot into three
zones: zone 1 extends from the metatarsal necks to the toes, zone 2 extends
from the distal calcaneus to the proximal metatarsal neck, and zone 3
overlies the calcaneus. The external surface of the foot should be washed. If
the wound is large enough, the wound can be gently irrigated. High-pressure
irrigation should be avoided due to risk of causing injury to tissue and
potential for pushing retained foreign bodies or bacteria deeper into the
wound. Simple probing of the wound may falsely reassure the provider that a

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foreign body is absent and also may result in pushing the foreign body
deeper into the wound. For simple puncture wounds at risk for contamination
or retained fragments, it may be necessary to extend the length of the wound
and gently explore and irrigate the area. An appropriate regional nerve block
can facilitate wound exploration.

Any concern for retained foreign body mandates further evaluation. The
clinician should consider that the retained object might be part of the
footwear and not the penetrating object itself. Plain radiographs will detect
most metallic objects. Glass fragments larger than 2 mm should be visualized
regardless of the lead content of the glass. Ultrasound may have increased
sensitivity for detection of wood and other radiolucent objects. False
positives can occur with ultrasound as a result of trapped air within the
wound, presence of sesamoid bones, and calcifications. Other imaging
modalities include computed tomography and magnetic resonance imaging.

Patients who present shortly after injury do not require laboratory
studies. Patients who seek medical care in a delayed fashion typically do so
because of persistent, or increasing pain or signs of infection. In cases of
suspected infection, laboratory tests to consider are a complete blood cell
count, erythrocyte sedimentation rate, and C-reactive protein although no
laboratory test can rule out infection. In cases of osteomyelitis, a bone biopsy
with culture will help direct antibiotic therapy.

The overall risk of infection for plantar puncture wounds is 2% to 10%.
The risk of infection increases with increasing depth of wound, zone 1
location, presence of devitalized tissue, presence of retained foreign bodies,
delay in presentation >48 hours, and a history of diabetes. Providers must
determine the need for antibiotic therapy. The goal of antibiotic prophylaxis
is to prevent complications such as cellulitis, abscess, osteochondritis,
osteomyelitis, and pyogenic arthritis. The organisms commonly associated
with these infections are Staphylococcus aureus, beta-hemolytic streptococci,
and Pseudomonas aeruginosa. Pseudomonal infection is associated with
puncture wounds through rubber-soled athletic shoes. There are no
prospective, randomized trials assessing the efficacy of prophylactic
antibiotics. In one retrospective study of adult patients who developed
infectious complications, only half the patients received prophylactic
antibiotics. This suggests no benefit to prophylactic antibiotics in an
undifferentiated patient population. Patients with diabetes who develop
infectious complications have a much worse clinical course than patients
without diabetes. In one study, diabetics were found to have a 46-fold
increased risk of lower-extremity amputation. Despite the lack of prospective
data, diabetics may be a population that benefits from prophylaxis. If the
provider opts to begin antibiotics, then methicillin-resistant S. aureus and

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Pseudomonas coverage should be provided.
Patients with simple presentations of plantar puncture wounds can

usually be discharged. They should be provided with detailed wound care
instructions and given follow- up in 2 to 3 days for wound reevaluation.
Some patients may benefit from being given crutches and placed on non–
weight-bearing status until the first reevaluation.

KEY POINTS

Perform a detailed wound history.
Extension of the wound may be required to allow for appropriate
irrigation and exploration.
Plain radiographs may locate metallic objects and glass pieces over 2
mm. Ultrasound is superior for detection of other radiolucent objects.
Uncomplicated, plantar puncture wounds in healthy patients who
present early likely do not benefit from antibiotic prophylaxis.
Diabetics have a greatly increased risk of requiring amputation if an
infection develops.

SUGGESTED READINGS

American College of Emergency Physicians. Clinical policy for the initial
approach to patients presenting with penetrating extremity trauma. Ann Emerg
Med. 1999;33(5):612–636.

Chachad S, Kamat D. Management of plantar puncture wounds in children. Clin
Pediatr. 2004;43(3):213–216.

Eidelman M, Bialik V, Miller Y, et al. Plantar puncture wounds in children:
Analysis of 80 hospitalized patients and late sequelae. Isr Med Assoc J.
2003;5(4):268–271.

Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of Pseudomonas
aeruginosa in children with osteomyelitis following puncture wounds. J
Pediatr. 1985;106(4):607–609.

Rubin G, Chezar A, Raz R, et al. Nail puncture wound through a rubber-soled
shoe: A retrospective study of 96 adult patients. J Foot Ankle Surg.
2010;49(5):421–425.

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346

DO NOT BELIEVE THE ADAGE
THAT EPINEPHRINE CANNOT BE

USED FOR DIGITAL BLOCKS

FERAS KHAN, MD

Finger and toe injuries are common in emergency medicine. These wounds
are associated with an increased risk of bleeding, due to the vascularity of the
digits. Achieving hemostasis while providing adequate analgesia is essential
when treating these injuries. For most finger injuries (i.e., lacerations, nail
injuries, tendon repair), a digital block can be performed to achieve
analgesia. In addition to these injuries, an ingrown nail, felon, paronychia,
subungual hematoma, dislocations, and fractures may require a digital block
in order to provide appropriate treatment.

The digital nerve block is an injection of anesthetic at the base of a finger
or toe. It can allow for a minimum amount of anesthetic to be used to achieve
adequate pain control. In addition, the digital block avoids injection of the
anesthetic directly into the wound, which can distort the anatomy, be more
painful for the patient, and make repair more difficult. The standard teaching
for a digital block has been to use lidocaine, or another local anesthetic,
without epinephrine. It has long been believed that epinephrine decreases
circulation to the fingertips, leading to necrosis, and possible loss of digits.
Therefore, the common adage is to avoid using epinephrine when
anesthetizing patients to treat digit injuries.

The original data regarding epinephrine in digital nerve blocks come
from the late 19th to mid 20th century. There are multiple case reports of
epinephrine use that were associated with digital necrosis. The majority of
the studies were not performed in the emergency department, nor were they

1443

designed to determine the safety of epinephrine. Upon further review of these
cases, it is likely that digital necrosis occurred due to infection, tourniquets,
or older anesthetics such as cocaine and procaine. Furthermore, the amount
of epinephrine used was unclear in a majority of these cases. No cases of
digital necrosis have been reported with the use of more recent formulations
of lidocaine and epinephrine. In fact, a recent literature review, which
included 12 randomized control trials, found that epinephrine (1:100,000–
200,000) is safe for use in digital nerve blocks in most patients. Furthermore,
there have been no reported cases of patients with poor peripheral circulation
harmed by epinephrine, although the majority of studies excluded patients
with peripheral vascular disease. The author concludes that the risk of
vasoconstriction is overstated. There have also been retrospective cohort
studies in podiatric patients that had over 250,000 combined epinephrine
injections with no reported complications.

As aforementioned, achieving hemostasis is important in the evaluation
of digit injuries to allow for thorough exploration of the wound. The vascular
supply of the fingers is from digital arteries that run along the ulnar and
radial side of each finger. Each digit is innervated by four nerves, which arise
from the median or ulnar nerves. The toes have similar innervations that arise
from the tibial and peroneal nerves. The benefits of epinephrine include a
faster onset of anesthesia, as well as a prolonged analgesic effect. Lidocaine
(amide group) is the most commonly used anesthetic for digital blocks.
Lidocaine can be combined with epinephrine (lidocaine 1% or 2% with
epinephrine 1:100,000 or 1:200,000) for anesthesia. Since the digital arteries
run in close proximity with the digital nerves, it is possible to induce
vasoconstriction of the arteries, although this effect tends to wear off after 60
to 90 minutes. Longer-acting anesthetics, such as bupivacaine, can also be
used if a prolonged duration of action is needed (4 to 8 hours for
bupivacaine). For patients that are allergic to amide anesthetics, an ester
anesthetic, such as procaine, can be used.

In conclusion, it is safe to use epinephrine in digital nerve blocks in the
majority of patients. For patients with peripheral vascular disease, caution
should be used prior to any block.

KEY POINTS

Epinephrine in digital blocks can result in a faster onset and prolonged
duration anesthesia.
The data cited to avoid use of epinephrine in digital blocks were based

1444

on older case reports that had more plausible reasons for digital
ischemia.
Epinephrine can lead to a transient vasoconstriction of digital that has
no long-term complications.
Use caution with epinephrine for digital blocks in patients with
peripheral vascular disease or Raynaud syndrome.

SUGGESTED READINGS

Andrades PR, Alguin FA, Calderon W. Digital blocks with or without epinephrine.
Plast Reconstr Surg. 2003;111:1769–1770.

Denkler K. A comprehensive review of epinephrine in the finger: To do or not to
do. Plast Reconstr Surg. 2001;108:114–124.

Ilicki J. Safety of epinephrine in digital nerve blocks: A literature review. J Emerg
Med. 2015;49(5):799–809.

Kaplan EG, Kashuk K. Disclaiming the myth of use of epinephrine local anesthesia
in feet. J Am Podiatry Assoc. 1971;61:335–340.

Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with epinephrine: An old
myth revisited. J Am Acad Dermatol. 2004;51:755–759.

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347

WHEN ARE PROPHYLACTIC
ANTIBIOTICS INDICATED FOR

WOUNDS?

DALE COTTON, MD

The foundation of good wound care includes irrigation, exploration, and
selective closure. The decision to prescribe prophylactic antibiotics is an
important component of the comprehensive management of acute wounds.
Unfortunately, there is limited research to guide clinicians in prescribing
prophylactic antibiotics for acute wounds. As a result, clinical decisions are
often based on personal experience and common practice patterns. Overall,
the incidence of wound infection ranges from 4% to 6%, with the majority
caused by skin flora such as Staphylococcus aureus and Streptococcus
pyogenes. The decision to prescribe antibiotics should be based on the
likelihood that infection will develop, the consequences of infection, and the
adverse effects of antibiotics in the individual patient.

Patient and wound-specific factors should be considered when
determining the likelihood of the wound to develop infection. This represents
the most complex part of risk assessment and is the area most reliant on
clinician judgment. Patient factors associated with an increased risk of
wound infection include diabetes, vascular insufficiency, increased age,
obesity, renal failure, and immunosuppression (e.g., corticosteroid use, HIV).
Wound factors include distal location, prolonged time since injury, presence
of crushed or macerated tissue, and contamination of a wound.
Unfortunately, no strong data exist to indicate that prophylactic antibiotics
prevent infection in these settings. Shared decision making, good
communication with the patient regarding the treatment and follow-up plan,
and meticulous documentation are important in these scenarios.

1446

Healthy patients with clean, simple wounds do not benefit from
prophylactic antibiotics. Wounds involving deep structures (e.g., joints) or
associated with fractures are orthopedic emergencies and require specialist
consultation to assist with treatment. These wounds are at substantial time-
dependent risk of infection; thus, antibiotic prophylaxis should not be
delayed. Additional deep structure injuries that have a higher risk of infection
and should receive prophylactic antibiotics include extensor tendon injuries
or ear wounds with exposed cartilage.

Intraoral lacerations frequently become infected. Limited data suggest
that antibiotic prophylaxis is beneficial for intraoral wounds that extend from
the intraoral cavity to the external skin surface, are larger than 1 cm or
gaping, or are full thickness. Similar to dental infections, penicillin or
clindamycin are the most common antibiotics used for prophylaxis of
intraoral wounds.

Mammalian bite wounds are at substantial risk of infection due to the
mechanism of injury (puncture and crush), the wound location (e.g., hands),
and the inoculation of multiple organisms. Dog bite wounds to the distal
extremities and human bite wounds benefit from antibiotic prophylaxis. For
other bite wounds, the evidence is less clear. Carefully consider patient and
wound factors in the decision to prescribe prophylactic antibiotics.
Antibiotics with broad-spectrum activity, such as amoxicillin with clavulanic
acid, are commonly used for these wounds.

Environmental exposures pose unique infectious risks. Freshwater
injuries are associated with Aeromonas infection, whereas saltwater wounds
are associated with Vibrio vulnificus infection. Both gram-negative
organisms can cause aggressive infections and may not be covered by
antibiotics that simply target skin flora. Though these infections are
uncommon, it may be prudent to provide antibiotics against these organisms
if water exposure occurred. Soil contamination is another risk factor for
infection. These wounds are at risk of infection from Clostridium
perfringens, a gram-positive anaerobe that is the most common cause of gas
gangrene. Penicillin is appropriate prophylactic therapy when considering
Clostridia infection. Puncture wounds can introduce organisms into deep
subcutaneous tissues and should be considered for antibiotic prophylaxis.
There is an association of Pseudomonas aeruginosa infection with puncture
wounds through the rubber soles of athletic shoes. Ciprofloxacin is
traditionally used for antibiotic prophylaxis of puncture wounds through
athletic shoes.

Patients at risk for infective endocarditis (IE) can be challenging. At
present, no recommendations exist for wound antibiotic prophylaxis for this

1447