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【medical-news】老年人轻微的跌倒也将导致严重后
“She’s 88 and tripped and fell yesterday,” the emergency room doctor told me when I answered the page. “She was on the floor about 15 hours when her family found her.”
“What did she break?” I asked.
“Nothing,” he said, as I recall. “But she’s too weak to stand, and we can’t send her home since she lives alone.”
The “little old lady found on the floor” is a staple of hospital admissions, and Martha, a patient in our group practice, was hardly the first I had cared for. The causes of falls in the elderly are myriad, as are the consequences. But frankly, they’re at the bottom of my list of fascinating new cases.
Often, my role as an internist consists mainly of arranging for physical therapy in the hospital and social work intervention if needed to ensure a safe discharge plan. It is much less exciting than, say, managing bacterial sepsis or a pulmonary embolism. Resigned, I drove over to the hospital to meet Martha.
In the emergency room, Martha’s nurse handed me the chart. “Her family is here,” he told me. “And I just got her lab results — her CPK is 32,000.”
This was interesting. Creatine phosphokinase, or CPK, is an enzyme found in muscle cells in the body. If a muscle is injured or inflamed, the level will rise. Small elevations are not usually worrisome, but large ones signify extensive muscle injury.
That injury, called rhabdomyolysis, was first described in survivors of the London blitz in World War II who, though rescued after a limb had been crushed or pinned under fallen masonry, later died of kidney failure. A British physician, Eric Bywaters, determined that the crushed muscle cells leaked the protein myoglobin into the blood, where it was then able to poison the kidneys. He published his findings in 1941.
The level of CPK in Martha’s blood was through the roof. Though she had not been pulled from rubble, by quietly lying on her bedroom floor for so many hours, her leg pinned beneath her, she risked complications as severe as those of any victim of a building collapse.
I went to examine Martha and found her surrounded by her concerned family. She was an alert, elderly woman who, according to her daughter, lived independently without difficulty. Her family lived nearby, saw her frequently and called daily. In fact, they had called her twice while she lay on the floor, unable to get up. Twice, Martha had answered the phone and said nothing about her predicament. “Typical,” her daughter told me. “She didn’t want to worry us.”
There was plenty to worry about now. Large intravenous infusions of sodium bicarbonate will sometimes prevent kidney damage in rhabdomyolysis, but this is easier said than done in an 88-year-old. The treatment could overwhelm her heart, resulting in a buildup of fluid in the lungs, which itself can be fatal. Hospital-acquired infections, delirium and blood clots were other lurking dangers. The potential for complications was daunting, as it so often is with elderly patients.
This was not going to be easy to communicate to her family. Martha looked well — tired after her ordeal but otherwise none the worse for wear. The tea-colored urine in the catheter bag was the only ominous sign of the assault on her kidneys. Her son and daughter had been relieved that there were no fractures. Before the lab tests came back, this was going to be a simple hospital admission for physical therapy.
The family listened as I explained the diagnosis, the treatment and the risks involved. Martha would be admitted to an intensive care unit where she could be monitored, especially for signs of heart failure.
Fortunately, Martha’s renal function remained stable after her hospital admission. This was in stark contrast to my last patient with rhabdomyolysis, who spent weeks in the hospital enduring uncomfortable dialysis until his failing kidneys recovered. Last year a patient in our practice died from complications of rhabdomyolysis.
But Martha was able to leave the hospital a week later, having avoided the complications of her injury and its treatment. Although the care she received was critical to her good outcome, I can’t help but think that pure luck was at play, too.
According to the Centers for Disease Control and Prevention, falls are the leading cause of death from injury among people over 65. An older person may seem independent, but friends and relatives should routinely survey homes and apartments for slippery surfaces, clutter or other fall-inducing conditions. Something as seemingly innocuous as a loose rug can lead to a dire medical outcome.
http://www.nytimes.com/2008/07/29/health/views/29case.html?ref=health 认领文章 For Elderly, a Little Fall, a Big Worry
对于老年人来说，轻微的摔跤，引起大麻烦
“She’s 88 and tripped and fell yesterday,” the emergency room doctor told me when I answered the page. “She was on the floor about 15 hours when her family found her.”
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作者:admin@医学,生命科学 2010-10-05 17:11
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