Coumadin and the Elderly

[skyemt]

in a recent conversation i had with our ER director, he mentioned that he thought in general, elderly patients who fall are under-triaged by EMS.

he believed that elderly patients, on Coumadin or Plavix, are often SEVERELY under-triaged by EMS, and that it was going to become a bigger issue as the baby boomers age...

he had too many of the "granny fell down" stories, only to find out that a severe head injury was developing...

how are your elderly handled? i presume, for falls, asking about Coumadin or Plavix should be a high priority in the history taking...

do you agree with our ER director?

comments welcome...

 

[Onceamedic]

Totally agree. The epidural bleed (between the dura and the skull) is relatively easy to triage. There is a characteristic blow to the head, unconsciousness while the tracts reorganize, a period of lucidity, followed by ever decreasing level of consciousness as the bleed develops.

The one that is difficult for people is the subdural bleed, which is under the dura within the meninges. This is a slow bleed and develops over time. Level of consciousness can be difficult to assess in some of our elderly. These people are the ones that lay in bed for days and eventually die.

Any fall which results in a blow to the head in people on blood thinners needs to be checked out on a CT scan. (IMHO)

 

[Ops Paramedic]

It is sad the way in which our geriatrics are treated, sometimes by the EMS, but mainly by the staff at the old age homes. At times they homes want to get rid of these patients, they force us to load and go. Often hours or even days go by prior to the ambulance being called.

Seeing that they have "been there and done that", they have earned a lot of respect, and treatment should be on par with that of any other patient. As for the meds, the possibility is great that they will be on some form of medication that will interfere with the clotting cascade, hence you should already have a high index of suspicion. So yes, i would agree with your director, in the sense that these patients are often misdiagnosed and undertreated. Whether it will become a big issue...remains to be seen. With regards to the "triage" (Unless the director is refering to triage in the emergency room), is there a need to traige a single patient?

 

[paramedix]

As mentioned by Ops Paramedic, some cases, especially in old age homes reflect highly on this scenario.

It happens sometimes that the old people should fall and just "picked" up and placed in bed. Mostly of only days when granny isn't feeling well or not responding well the EMS guys are called in. I have had numerous of those cases before.

I definately agree that some EMS units do "under treat" their patients and do not recognize any possible problems with the patient. "The patient is old, let's just load 'em..."

As you mentioned, your history is just as important as your treatment. Technically, there cant be an injury if there is no history, so get that history and provide that treatment.

....good thread!

 

[Jon]

In PA, under the recent protocol change (2004), if you fall, strike your head in any way, and are on coumadin or other serious blood thinners, you almost automatically meet trauma criteria. It has become practice that while one of us is assessing the SNF or ECF Pt. who "fell", the other is checking the med list to make sure that we can BLS the fall to the local ED.

I've got NO problem taking a patient at high risk for an intra-cranial bleed to a facility that is set up to handle high risk patients. Other providers :censored::censored::censored::censored::censored: about it... but why? we are patient advocates, right?

 

[Ridryder911]

If they are on anti couaglant therapy, they get a CT scan. It is NOT major trauma and using trauma centers for such is an abuse to the system, if there is no s/s of ICP or LLOC.

Patient advocate you bet! One should not abuse the trauma system and Grannie should not get a $40,000 truama center bill.

R/r 911

 

[Jon]

If they are on anti couaglant therapy, they get a CT scan. It is NOT major trauma and using trauma centers for such is an abuse to the system, if there is no s/s of ICP or LLOC.

Patient advocate you bet! One should not abuse the trauma system and Grannie should not get a $40,000 truama center bill.

R/r 911

Rid,

PA is such a varied state... I think, to an extent, that Coumadin=trauma is the only way they can go to be sure that the patients get the treatment and assessment they need.... not everyone has a CT scanner.

 

[Airwaygoddess]

Medications

The use of anti-coagulants are used for a vast array of patients, it is true we most often see this medication with the elderly, but also remember that there are patients that can be younger and be prescribed this medication. A few of these types of patients would be heart valve replacements, history of DVT's and also chronic atrial fibrillation. It is so important to encourage the public to keep a list of their medications, along with pertinent medical information in their wallet, purse and in the glove compartment of their car. Education for the public increases the continuity of care for future patients that we will see in the long run.

 

[EMTMandy]

The use of anti-coagulants are used for a vast array of patients, it is true we most often see this medication with the elderly, but also remember that there are patients that can be younger and be prescribed this medication. A few of these types of patients would be heart valve replacements, history of DVT's and also chronic atrial fibrillation. It is so important to encourage the public to keep a list of their medications, along with pertinent medical information in their wallet, purse and in the glove compartment of their car. Education for the public increases the continuity of care for future patients that we will see in the long run.

Thank you for bringing this up... very excellent point. In fact, younger people on this type of therapy is more common than one might think.

 

[skyemt]

The use of anti-coagulants are used for a vast array of patients, it is true we most often see this medication with the elderly, but also remember that there are patients that can be younger and be prescribed this medication. A few of these types of patients would be heart valve replacements, history of DVT's and also chronic atrial fibrillation. It is so important to encourage the public to keep a list of their medications, along with pertinent medical information in their wallet, purse and in the glove compartment of their car. Education for the public increases the continuity of care for future patients that we will see in the long run.

excellent point, Airway... in our district, we have a large elderly community, and we have the issue of coumadin (or plavix) turning an unimpressive MOI into a serious emergency, if one is looking...

but, you are correct, there are many other than elderly who fit the same category.