Geriatric neurologic emergencies

Geriatrics is an important subspecialty within the field of emergency medicine and represents a burgeoning area of practice. The special vulnerability of elderly patients to neurologic disease and injury and the comparative subtlety of clinical presentation mean that physicians should have a lower threshold for laboratory studies, radiologic imaging, consultation, and admission. Transferring appropriate patients to tertiary centers that offer specialized trauma and neurologic and neurosurgical care greatly enhances survival and functional outcomes.     

Geriatric polytrauma

BACKGROUND: compared to a younger population, the treatment of geriatric trauma victims is known to be associated with a higher mortality and morbidity. The objectives of this study are to assess the clinical course and outcome of multitrauma patients aged 65 years and over. In addition, a direct comparison between the geriatric trauma patients and the younger collective is performed. METHOD: our study includes all multitrauma patients treated between 1992 and 2001 at a major urban trauma center. The major issues of this analysis are: injury severity, injury pattern, preclinical hemodynamics and intubation rate, operative treatment, ventilation time, outcome as well as incidence of multiorgan failure (MOF) and adult respiratory distress syndrome (ARDS). Out of these results, adults over 65 years of age (group B, n = 45) are compared to the younger group, ranging from 16 to 64 years of age (group A, n = 369). RESULTS: The preclinical intubation rate was comparable in both groups (A: 73.2%, B: 68.9%). Significantly more cases of group B were primarily shocked (A: 29.0%, B: 48.9%). The mean ISS was comparable in both groups (A: 34.0; B: 32.1). The younger group showed a significantly higher incidence of spine injuries (A: 21.1%; B: 6.7%). The number of emergency procedures (A: 24.2%; B: 24.4%) and operations during the first 24 hours (A: 70.2%; B: 60.0%) was comparable in both groups. The older group showed a lower number of reconstructive operations (A: 57.6%; B: 35.6%). Geriatric trauma patients had a longer ventilation time compared to their younger counterparts (A: 13.0 days, B: 20.0 days). During ICU-therapy, the ARDS rate was comparable (A: 16.0%, B: 15.6%). In contrast, the incidence of MOF was significantly higher in group B (A: 7.1%; B: 17.8%). The older group showed a significantly higher mortality rate (A: 26.8%; B: 53.3%) as well as early mortality during the first 24 hours after admission (A: 16.3%, B: 31.11%). CONCLUSION: Despite similarity in injury severity and a comparable injury pattern, elderly multitrauma patients initially presented a higher rate of hemodynamic instability, had to be ventilated longer and had a higher mortality.     

Geriatric trauma

Elderly trauma patients present unique challenges and face more significant obstacles to recovery than younger patients. Despite overall higher mortality, longer length of stay, increased resource use, and higher rates of discharge to rehabilitation, most elderly trauma patients return to independent or preinjury functional status. Critical to improving these outcomes is an understanding that although similar trauma principles apply to the elderly, these patients require more aggressive evaluation and resuscitation. This article reviews the recent developments in the literature regarding care of the elderly trauma patient.     

Dermatologic emergencies

Primary care physicians are the gatekeepers of the medical community. They are the physicians to whom patients first present, and they are often the physicians with whom patients have the longest lasting relationships. Primary care physicians, as a result of these long-term relationships, have been endowed with a unique responsibility to the health of their patients. By the very nature of their practice, primary care physicians do not have the resources to treat emergent life-threatening conditions. They must, however, be able to diagnose these potentially life-threatening conditions and be able to stabilize and appropriately refer a patient for urgent evaluation by specialists or emergency physicians. There are many types of emergencies encountered in the outpatient setting, ranging from cardiac to toxicologic. As important as recognizing signs and symptoms of cardiac ischemia is the ability to recognize potentially life-threatening dermatologic disorders or dermatologic manifestations of life-threatening systemic diseases.     

Aortic emergencies

Aortic emergencies present a diagnostic and treatment challenge for emergency physicians. Both acute aortic dissection and abdominal aortic aneurysms can be difficult to recognize, and a missed or delayed diagnosis may be fatal. A high clinical suspicion and rapid patient evaluation are important. Although many patients ultimately require surgical intervention, early and aggressive attention to hemodynamic stability by the emergency physician can provide a window to definitive treatment.     

Genitourinary emergencies

An awareness of pitfalls and perils in diagnosis of traumatic injuries to the genitourinary tract, and indications and contraindications for studies and instrumentation, will help diagnose these sometimes underdiagnosed injuries and help minimize morbidity. Suspicion of testicular torsion should lead to prompt urologic consultation, and priapism also should be promptly treated to preserve function. The treatment of acute urinary retention consists of prompt bladder drainage with attention to etiology and methods.     

Respiratory emergencies

This article is intended as an overview of emergencies that could and often do present to the physician's office, especially when a hospital emergency department may not be nearby. It is not intended as an in-depth view of every problem but should be considered as a presentation of essential management in the emergency phase of treatment. The reader is directed to the references for more in-depth information on these topics.     

Penile emergencies

The penis is a very sensitive organ and even minor injury or discomfort may cause a patient to seek emergency evaluation. Emergency practitioners must be most concerned with the entities that, if left untreated, can result in ischemia and necrosis of the penis, namely ischemic priapism, paraphimosis, and entrapment injury. Any penile trauma should be considered an emergency until proven otherwise. This article discusses emergent penile complaints in adults, with emphasis on the most serious and common conditions.