80 Year Old Male: Fall

A previously well 80-year-old experienced a fall at his home where he lives alone. He was walking from the living room to the kitchen when suddenly he found himself on the ground, which he attributes to tripping on the runner rug in the hallway.

“My son has been telling me to get rid of that thing for years but I don’t like getting the carpet dirty.”

Unfortunately he injured his hip in the process and wasn’t able to get to the phone to call for assistance, spending two days on the floor until the Meals on Wheels volunteer came by. Skin is cool and dry and his mucous membranes are dry. He has severe pain and external rotation of his left hip. You cannot assess shortening because the knee and hip are both flexed, in a position of relative comfort.

Vitals upon your arrival are:

  • Heart rate: 45-65 bpm, irregular
  • Respiratory rate: 14 /min
  • SpO2, room air: 97%
  • NIBP: 179/93 mmHg
  • Temp, oral: 36.3 C (97.3 F)

While you are drawing up an initial dose of morphine your partner captures the following 12-lead.

What does it show? How will this affect your management?

80yo M - Fall

Measuring the satisfaction of patients admitted to the intensive care unit and of their families

Hola a tod@s, my dear friends.

Recently published in the online version of Medicina Intensiva, Dra. Holanda and the companions of Hospital Universitario Marqués de Valdecilla ICU  presents the following article.

The objective of the study was to know the degree of satisfaction of patients and their families during their stay in the ICU, in a period of 5 months. In their case, they used the Family Satisfaction Intensive Care Unit (FS-ICU 34) satisfaction survey.

A total of 385 surveys, 192 families of survivors, 31 families of deceased and 162 patients were obtained. Most of the relatives were satisfied with the care received and the decision making process (survivors: 83, 46±11, 83 and 79, 42±13, 58, respectively; deceased: 80, 41±17, 27-79, 61±16, 93, respectively).

Patients surveyed were very satisfied with the care received (84, 71±12, 85).

The authors conclude that the degree of satisfaction of parents and patients admitted to the ICU is high. Still, there are several points that should be improved, as the atmosphere of the waiting room and the atmosphere of the ICU in terms of noise, privacy, and lighting, as well as some aspects of the decision-making process, including hope supplied about the recovery of his family.

Excellent article, that soon we can compare with the results of our study at the Hospital in Torrejón.

Happy Tuesday!


Oxy morons. Avoid prescribing oxycodone

It has been interesting moon-lighting at another hospital to see how much oxycodone (common brands names: oxynorm and oxycontin) was being used professionally and recreationally.

I was out with a friend who told me he had been given 1 1/2 oxycontin tabs by an acquaintance a while ago and had been high as a kite for a couple of days.  Interestingly he said there was no “come down”.  Sounds like a very desirable drug of abuse.

In the ED everyone was prescribing oxycodone to everybody, from the ED reg to the ENT reg to the ortho house officer.

“… we are looking at a disaster in the making. We have been complacent about the warnings from the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin and cocaine overdoses. This is shocking and shameful …” Dr Jeremy McMinn* 

Oxycodone is more addictive and more expensive than morphine.

Oxycodone is no safer in renal failure than morphine.

Most people with morphine “allergy” were just given too much  and developed nausea, vomiting, dysphoria or an itchy rash from the histamine release caused by morphine.  It may be worth try a test dose of IV morphine to see if they can tolerate it, check with a senior first.

Generally in ED for analgesia we use paracetamol/acetaminophen and a NSAID such as ibuprofen.  For severe pain we will use a fast acting IV or IN opioid such as fentanyl to control the pain.  Once the pain is controlled if ongoing strong pain relief is required we will move to oral morphine (or IV if unable to take oral).  Oral morphine is available in fast acting and slow release forms.

In our hospital we have made oxycodone only able to be prescribed by order of a consultant, and I’m trying to have oxcodone removed from our ED.

As an aside, at the other hospital, as always, there was a granny who had bounced back into hospital because she had been discharged from the ortho ward on oxycodone, prescribed a bulk forming laxative but no stimulant laxative, and hadn’t crapped for a week and felt rotten.

It’s a shame that the resident who discharged her wasn’t working that weekend.  It would have been a good educational experience for him/her to come down, give the enema and readmit the patient.

This is a problem with all opioids, not just oxycodone.  Always prescribe a stimulant laxative when prescribing more than a few doses of opioids eg something with sennosides in it.  By the way sennosides are Category A (considered safe) in pregnancy.  Shame the resident wasn’t on that weekend.


*Dr Jeremy McMinn is a consultant psychiatrist and addiction specialist at Capital & Coast DHB. He is also the Co-Chair of the National Association of Opioid Treatment Providers and the New Zealand Branch Chair of the Australasian Chapter of Addiction Medicine








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PHARM PODCAST 101 : ED sedation -towards best practice



Hi Folks

On today’s show, we have Dr Reuben Strayer of EMergency Medicine Updates, Dr Nicholas Chrimes of ClinicalCred and Dr Andy Buck of EDExam discuss and debate the topic of best practice in ED procedural sedation. Nick argues the concerns of aspiration risk in emergency patients with likely full stomachs. Reuben discusses the ED literature around safety of procedural sedation as well as his best practice approach. Andy provides some clinical context with examples from his own ED work.

What do you do in the ED for procedural sedation? Do you think RSI is safer? Do you think ED sedation without RSI is safer? Post your comments!

Show notes:


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Filed under: Emergency medicine and critical care, FOAMEd, Interviews of interesting people, prehospital and retrieval medicine podcast Tagged: ED-sedation, itunes