All posts by The Trauma Pro

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Urinary Tract Infection in the Elderly Trauma Patient

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Yesterday I talked about using a medical orthopaedic trauma service to provide better care to elderly patients with fractures. Many of these patients have multiple pre-existing diseases and are quite fragile. A recent paper from the Rhode Island Hospital shows just how fragile these patients may be.

Urinary tract infection (UTI) is one of the most common nosocomial infections, accounting for about 40% of all such infections. The vast majority are related to indwelling bladder catheters. It is so much of a problem that, in order to decrease federal spending in the US, Medicare now denies payment for care related to these infections.

This study looked at the relationship between UTI and bladder catheters and how this infection relates to overall mortality in older trauma patients. It was a retrospective review of 6 years of data from a single institution. After excluding patients who entered the hospital with a UTI, they found that 12% of their patients developed this infection and 72% were indeed related to catheters. Males had a significantly increasing risk of UTI with increasing age. And the risk of death from UTI increased about 7% per year after age 55.

Bottom line: Urinary tract infections are especially bad for the elderly. As part of your daily rounds on any patient, look at every tube and line and ask yourself “is that really needed any more?” If not, get rid of it before it kills your patient!

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Reference: The development of a urinary tract infection is associated with increased mortality in trauma patients. J Trauma ePub ahead of print, doi: 10.1097/TA.0b013e31821e2b8f, July 2011.

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The Medical Orthopaedic Trauma Service

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Our population is aging, and falls continue to be a leading cause of injury and morbidity in the elderly. Unfortunately, many elders have significant medical conditions that make them more likely to suffer unfortunate complications from their injuries and the procedures that repair them.

A few hospitals around the world are applying a more multidisciplinary approach than the traditional model. One example is the Medical Orthopaedic Trauma Service (MOTS) at New York-Presbyterian Hospital/Weill Cornell Medical Center. Any elderly patient who has suffered a fracture is seen in the ED by both an emergency physician and a hospitalist from the MOTS team. Once in the hospital, the hospitalist and orthopaedic surgeon try to determine the reason for the fall, assess for risk factors such as osteoporosis, provide comprehensive medical management, provide pain control, and of course, fix the fracture. 

This medical center recently published a paper looking at their success with this model. They retrospectively reviewed 306 patients with femur fractures involving the greater trochanter. They looked at complications, length of stay, readmission rate and post-discharge mortality. No change in length of stay was noted, but there were significantly fewer complications, specifically catheter associated urinary tract infections and arrhythmias. The readmission rate was somewhat shorter in the MOTS group, but did not quite achieve significance with regression analysis.

Bottom line: This type of multidisciplinary approach to these fragile patients makes sense. Hospitalists, especially those with geriatric experience, can have a significant impact on the safety and outcomes of these patients. But even beyond this, all trauma professionals need to look for and correct the reasons for the fall, not just fix the bones and send our elders home. This responsibility starts in the field with prehospital providers, and continues with hospital through the entire inpatient stay.

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Tomorrow: How bad is a simple urinary tract infection in the elderly?

Reference: The medical orthopaedic service (MOTS): an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures. J Orthopaedic Trauma, ePub ahead of print, doi: 10.1097/BOT.0b013e3182242678, Aug 27, 2011.

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What The Heck? Final Answer

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This one was a bit tricky. I chose it because it looks like there is an extra tube in the neck. You can see two stripes traveling from the mouth down the neck. The one closest to the cervical spine is in the esophagus, an orogastric tube. The other one passes anterior to it, in the trachea, so it is the orotracheal tube. But what about the tube shaped density that is located in the posterior pharynx that looks like it is angled forward toward the trachea? Did someone lose something?

If you think about it though, you should conclude it’s something weird. There is no radiopaque stripe on it, which rules out most common tubes. The only thing of that size and shape that comes to mind is a nasopharyngeal airway tube. However, these have a flange on the nasal end, so it couldn’t just pass inwards through the nose. And who in their right mind would put it in the mouth to be swallowed? Plus, the orientation of it is unusual, heading forward toward the trachea.

You have to look at the rest of the clues on the radiograph. It’s easy to get suckered if you just focus on the obvious. What are those objects located between the two tube stripes in front of C6? Surgical clips. What are those O-shaped objects at the angle of the mandible that disappear behind the XTABLE LAT marker? Surgical skin closure staples.

So this is a postoperative patient. If you follow the object, it actually moves toward the skin, and beyond! This patient was stabbed in the neck and underwent a surgical exploration with control of bleeding. A surgical drain was placed due to concern for leakage from the pharynx or salivary glands. The drain actually leaves the side of the neck, just anterior to the sternocleidomastoid muscle.

Remember to look at everything on a radiograph, especially if you don’t have the clinical story behind it. The eye normally focuses on the obvious, leading the viewer to make assumptions based on their expectations. This can easily get you in trouble, so beware! And don’t forget that you are looking at a 2-D image, so there is no way to tell where any object is in the third dimension. It may be in the front, the back, or under the patient in their clothing!