PNEUMONIA

Chest Emergencies in Elderly

SITI NUR JANNAH SHAARI10-6-97

CLINICAL PRESENTATION• Fever• malaise• cough (unproductive), • delirium,• reduced concious level, • lethargy, • anorexia, • falls, • immobility dizziness• shock,coma, ARDS (rare)• Chest pain,dyspnea or high fever

are less common Fever is often absent but VD is common

• Tachypnea is sensitive sign ,with at least moderate hypoxemia

MOST COMMON PRESENTATION:-acute confusion or delirium-malnutrition (kwashiokor-like)

CURB 65Confusion – score 1Urea >7mmol/L – score 1Resp>=30 – score 1 SBP<90 or DBP< 60 -score 1Age >65yr – score 1

DIAGNOSIS

1.Clinical evaluation2. Lab• WBC may raised,normal

or low level• CRP- normal in early, very

high suggest pneumonia disease or severe sepsis

• ABG 3. Radio• CXR: reveal minimal

infective infiltrate• Associated problems can

reveal malignancy, effusion or heart failure.

4.Microbial evaluation• Blood culture • sputum gram stain and

culture (taken before give empiric therapy

5. Serology testing and urinary Ag test6. Bronchoscopy

CAP management

1. Empirical therapy according to guidelines till results of culture is out

2. All pt should be treated for possibility of atypical infection• Elderly patient ,diagnosed as pneumonia need to be admitted

to hosp (based on Curb65 2points by age and confusion)• Treatment includes: levofloxacin 750mg daily or Amoxicillin-

clavulinic acid 2gm twice daily+ azithromycin.• 3. If suspected MRSA, we should add Vancomycin

References• 1.http://www.atsjournals.org/doi/abs/10.1164/ajrccm.163.7.at1010#.

VtRo65x97IU• 2.http

://www.atsjournals.org/doi/abs/10.1164/ajrccm.156.6.9702005?src=recsys#.VtRo7px97IV

• 3. http://ageing.oxfordjournals.org/content/17/3/181.short• 4.Pulmonary Medicine, Chest Department,Alexandria Uni.• 5.Oxford handbook of geriatrics.• 6.Harwood-Nuss' Clinical Practice of Emergency Medicine, edited by Allan

B. Wolfson, Gregory W. Hendey, Louis J. Ling, Carlo L. Rosen• 7. Geriatric Emergency Medicine, edited by Joseph H. Kahn, Brendan G.

Magauran, Jr, Jonathan S. OlshakerGeriatric Emergency Medicine, edited by Joseph H. Kahn, Brendan G. Magauran, Jr, Jonathan S. Olshaker

Spontaneous Pneumothorax in elderly

Prepared by :Sharifah Nur Atiqah bt Sh Abdullah

Clinical Picture– unilateral pleuritic chest pain and dyspnoea.

Usually, in older patient, spontaneous pneumothorax is secondary with pre-existing chronic lung diseases (COPD or TB) and may also occur with asthma, bronchial carcinoma, infection, and esophageal rupture.

• Tachypnoea, tachycardia• Normal/hyper-resonant percussion note

with decrease air entry on the affected side.• Rarely, there may be a clicking sound at the

cardiac apex.

Classical symptoms

• Inability to speak, gasping, low SpO2• Tracheal deviation,• Tachypnoea, tachycardia, and

hypotension.

Severe symptoms

Investigation• Chest x-ray• ABG analysis• Thoracocentesis manometry• CT scan

Siti Nurul Afiqah binti Johari (10-6-95)

Clinical picture

Investigationsi. Laboratory: • ABG: might be normal, type 1 RF, severe hypoxemia, mild

hypocapnea• D-dimer

ii. ECG: Sinus tachycardia, Rt BBB, ST-T abnormalities

iii. Radiological:• Chest X-ray• CTPA• V/Q lung scan

What to consider in geriatrics?

• Sensitivity to the anticoagulant effect of a given dose increases with age

• Polypharmacy (include self med) increases risk of drug interactions which alter oral anticoagulant effect or which increase the risk of bleeding

• Increased prevalence of concurrent or intercurrent illness

• Decreased compliance or decreased access to monitoring

Prophylaxis• Patients who undergone

surgery, 4-6 weeks of LMWH or UFH

• Graduated compressive stockings and pneumatic compression devices

Treatment• LMWH prevents clot formation

and extension given SC 1/2x a day

• Long term anticoagulation after discharge is warfarin

• Thrombolytic therapy with massive PE who have significant pulmonary HTN, obstruction of multiple segments of pulmonary circulation, rt ventricular dysfx or systemic hypotension

• IVC filter in special circumstances

ACUTE PULMONARY EDEMA

SYARIFAH ANITH ATIQA SYED ROZHAN

DEFINITIONSudden accumulation of excessive fluid in the lungs caused by rapid rise of pulmonary capillary hydrostatic pressure.

DIAGNOSISExtreme dyspnea, restlessness, and anxiety with a

sense of suffocationOften preceded by productive cough (pink frothy

sputum)Diffuse diaphoresisPallor, cyanosismoist respirations (gurgling)

- By PE:• Pulse rapid and low volume• Elevated respiratory rate• Inspiratory retraction of intercoastal spaces• Diffuse rhonchi, wheezing , fine inspiratory rales

TREATMENT Treatment of cause 100% O2 by nonrebreather mask; upright position IV diuretic (eg, furosemide 0.5 to 1.0 mg/kg) Nitrates IV inotropes Morphine Ventilatory assistance