University Hospitals EMS Institute

06/16/2026

For the next two weeks, this newsletter will focus on geriatric trauma. Last week, geriatric orthopedic injuries were discussed, including the impact of falls and classic fracture patterns. This week, the focus will be on delirium.

Delirium commonly develops in hospitalized patients, especially in older patients and trauma patients. Up to 30% of hospitalized patients will develop delirium, and in the ICU, delirium may be present in up to 80% of patients. Delirium can also develop in the outpatient setting from similar inciting factors and may be encountered when responding to older trauma patients in the field, which can be difficult to distinguish from a traumatic brain injury.

Delirium is an acute disorder of cognitive thinking and attention. Delirious patients may be disoriented, have trouble maintaining their attention, have disorganized thinking, suffer from hallucinations and sleep disturbances, and have rapid behavior changes. The onset of delirium is within hours or days of changes to predictable patterns, medication changes, traumatic events, or a new medical illness. While some symptoms may overlap, delirium is different from dementia, which is a slow, chronic, and progressive decline in memory and cognitive function associated with permanent brain damage. Delirium has acute and reversible cognitive changes, while dementia is progressive and permanent. Recognizing this difference is key to prevention, treatment, and discussions on prognosis with family.

The triggering factors for delirium overlap with the most frequent treatments, so appreciating predisposing factors and triggers is key to delirium treatment. Predisposing factors for delirium include advanced age, frailty, anemia, malnutrition, substance abuse, depression, and social isolation. Triggers include being post-operative, anticholinergic medications, psychoactive drugs, being in the ICU, infection, electrolyte imbalance, sleep alterations, immobilization, and being in a foreign environment. Identifying and preventing triggers that manifest into delirium is a mainstay of many age-friendly hospital programs that focus on reducing delirium prevalence.

Treatment for delirium is either non-pharmacologic or pharmacologic, with non-pharmacologic measures always preferred. First step non-pharmacologic treatments for delirium include simple, low-cost, low-intensity actions like restoring the sleep-wake cycle by keeping lights and sound on during the day and a quiet and dark environment at night, frequent reorientation of the person, date, time, and situation, ensuring patients have their glasses and hearing aids, ensuring family participation in care, and early mobility.

One of the most important non-pharmacologic treatments for delirium is to stop medications that trigger delirium. When a patient is delirious, FTD (First Think Drugs).

This requires a review of the medication administration record and stopping deliriogenic medications, which are often newly prescribed in the hospital. These medications include anticholinergics (diphenhydramine, scopolamine, etc.), benzodiazepines (lorazepam, diazepam, etc.), narcotics, and muscle relaxants (cyclobenzaprine, baclofen). In addition, home medication dosing for some commonly used medications (anticonvulsants, antidepressants) for older patients, especially those with impaired renal function, may be inappropriate, and consultation with a geriatric medicine specialist or pharmacist may be helpful. In addition, accidental discontinuation of essential home medications that an elderly patient has taken for years can lead to delirium, making reviews of home medications essential for older trauma patients.

Pharmacologic treatments for delirium mirror the triggers for delirium. Antibiotics should be prescribed for infection, electrolyte abnormalities corrected when altered, and non-narcotic pain medication prescribed to treat pain, with low doses of narcotics used only when indicated. Antipsychotic medications, such as haldol, should only be administered when the patient is a danger to themselves or health care providers.

Next week, the topic will be geriatric traumatic brain injury.
Thank you,

Joseph Posluszny, MD

06/16/2026

06/08/2026

For the next three weeks, this newsletter will focus on geriatric trauma. Last week, our coverage of geriatric trauma triage included how the unique physiology and recovery of older patients make their triage and subsequent care challenging. This week, we'll focus on the all too common geriatric orthopedic injuries.
Falls Fracture Patterns

Next week, the topic will be delirium, a common complication in geriatric care.
Thank you,

Joseph Posluszny, MD

06/05/2026

Welcome to UH EMS-I’s Pharmacy Phriday. In this installment, we continue to look at medications provided in both the regular drug box and the mini, or “EMT,” drug box. This week’s medication is nitroglycerine (NTG).

Nitroglycerine is a common vasodilator supplied in our drug boxes for use by all levels of providers in acute coronary syndromes (ACS) and by the AEMT and Paramedic providers in congestive heart failure (CHF)/pulmonary edema.

For cases of ACS, NTG can be administered by all providers via the sublingual (SL) route (Note: EMT Basics must first receive online Medical Direction). The SL tablet is placed under the tongue, and the medication diffuses into the blood through the tissues under the tongue. The adult dose of 0.4 mg (400 mcg) can be repeated every five minutes, up to three total doses. In the UH protocols, the use of NTG for the pediatric patient is not recommended. Remember to ask the patient if they had self-administered NTG before EMS’s arrival, and the effectiveness of the medication if taken.

An additional indication for using NTG within the protocols is for patients with CHF/pulmonary edema. In these cases, patients need the excess fluid removed from their lungs as quickly as possible. This can be accomplished by applying positive airway pressure with CPAP and creating vasodilation with the use of NTG. (Note that the Basic EMT cannot administer NTG to these patients but can still use CPAP as a treatment.)

The dosing of NTG in these respiratory cases remains 0.4 mg (400 mcg) every five minutes, but the maximum dose does not apply to the CHF/pulmonary edema patient. NTG would be administered until the desired effect is achieved, i.e., improved respirations and perfusion, or a contraindication, such as hypotension, occurs.

Some guidelines reference the use of IV NTG in the continued care of patients experiencing acute pulmonary edema, such as “flash pulmonary edema” or a condition known as Sympathetic Crashing Acute Pulmonary Edema (SCAPE). These patients have a narrow time window where the provider can intervene, prevent the need for intubation, and improve patient outcomes significantly. The early use of non-invasive ventilation, such as CPAP, combined with continuing NTG (in our case, sublingually) until symptoms are corrected, is often seen as a cornerstone in the treatment of these patients. The exception to using this combination of treatments of NTG and CPAP in the pulmonary edema patient is the presence of hypotension. In those cases, the provider is directed to the Cardiogenic Shock Protocol and the use of Push Dose Epi.

As NTG can cause vasodilation and result in hypotension, the provider must first check — and continue to reassess — the patient’s blood pressure. Protocol guidelines indicate that NTG can be administered only if the systolic pressure is >120 without an IV or >110 with an IV. Although a right-sided infarct does not preclude the use of NTG, a 12 lead ECG should also be obtained before administration when possible. An IV should be established if the patient exhibits signs of a right-sided infarct, as these patients are often dependent on preload for adequate perfusion. In cases of hypotension following NTG, place the patient in the Trendelenburg position and administer a Normal Saline bolus.

An additional contraindication to the use of NTG includes the use of erectile dysfunction (ED) or pulmonary hypertension medications/products within the last 48 hours. Most are aware of the use of medications such as a phosphodiesterase type 5 inhibitor like Sildenafil, Tadalafil, etc., for ED symptoms. These same medications are sometimes prescribed for pulmonary hypertension to promote selective smooth-muscle relaxation in the lungs.

Side effects from the administration of NTG are secondary to the hypotensive effects of the medication. Patients may complain of dizziness, weakness, palpitations, and syncope. Profound hypotension may occur in patients with preload-dependent conditions, as mentioned above. The patient may also complain of a persistent, throbbing headache. This common side effect, often encountered by the provider, is due to venous pooling in the cranial space, resulting in increased intracranial pressure. Be sure to monitor your patient and document your findings.

06/01/2026

In this episode of the Pre-Hospital Paradigm Podcast, Scott, Dr. Hill, and Wes are joined by Kelly Montgomery as our guest to discuss stroke patient care.

We will be live from North Ridgeville Fire Department Monday, 6/1 at 7:00pm. Join us and bring your questions!

06/01/2026

For the next four weeks, this newsletter will focus on geriatric trauma. Caring for older trauma patients is becoming significantly more common as the population ages. Understanding the unique physiologic response to injury, injury patterns, and complications of recovery for older patients is now a mainstay of trauma care both in the field and in the hospital. The topics for the next four weeks will be:

1) geriatric trauma triage
2) geriatric orthopedic injuries
3) delirium, and
4) geriatric traumatic brain injury.

Trauma triage focuses on getting the right patient to the right location at the right time. While seemingly straightforward, many variables come into play to ensure appropriate triage, and as a result, over- and under-triage are common. Over-triage (upgrading response to minor injuries) ensures that every patient sees the quickest and highest level of care, but overloads the trauma system and wastes resources needed for the most injured patients. Under-triage (downgrading major injuries) delays the most appropriate care. To ensure the most accurate triage, the American College of Surgeons Committee on Trauma (ACS-COT) has established triage criteria that focus on mechanisms of injury, mental status, and physiologic parameters. Advanced age and comorbidities can lead to baseline alterations in mental status unrelated to injury and blunted physiologic responses to trauma and blood loss. As a result, standard triage criteria may not match the degree of injury suffered by older trauma patients and lead to mistriage. The ACS-COT Guidelines (below) recognize these age-related physiologic differences with higher systolic blood pressure and lower heart rate thresholds for trauma patients over 65 years old.

Source: Trauma Systems: National Guidelines for the Field Triage of Injured Patients https://www.facs.org/quality-programs/trauma/systems/field-triage-guidelines/
Knowing when to immediately transfer a patient from a lower level or non-trauma hospital to a Level 1 trauma center is difficult. This process is called re-triage. Delays in re-triage can lead to significantly higher rates of patient morbidity and mortality as need for re-triage is often related to need for hemorrhage control. While associated with significant patient health outcomes and trauma system costs, re-triage has not been well-studied. University Hospitals and Case Western Reserve University School of Medicine have partnered with three other trauma systems (Northwestern, University of Texas Houston and Duke) in a multi-site, NIH funded five-year research study addressed at improving re-triage entitled, Criteria for Re-Triage to Improve Trauma Induced Coagulopathy and hemorrhage associated Lethality (CRITICAL). An essential component of building evidence-based re-triage guidelines is to ensure that they are practical and feasible for the entire healthcare team including paramedics, EMS, transport teams, transfer center nurses, emergency medicine nurses, APPs, physicians, and trauma surgeons. As a result, the research team will be reaching out to EMS providers throughout Northeast Ohio to participate in surveys and focus groups aimed at collecting your thoughts, experiences, and opinions on re-triage.

Triage not only occurs in the field but also in the trauma bay and when the patient is hospitalized. Individual hospitals must determine the emergency medicine/trauma team response level when a patient arrives. For hospitals in low trauma, high geriatric areas, full trauma team activation may be necessary for many geriatric trauma activations. For high trauma volume centers, this may be overwhelming and unnecessary. Once hospitalized, trauma centers triage to identify those patients with higher rates of complications, longer lengths of stay, and higher chances of loss of independence. Typically, trauma centers will screen patients for frailty via a series of questions about medical history, activities of daily living, health and mental attitudes, social and family support and nutrition. Frail patients are then given additional resources to help avoid negative outcomes. Additionally, older trauma patients can be screened for sarcopenia which is a weakening of whole-body muscle mass that is closely associated with poorer outcomes. Sarcopenia can be quickly measured by determining the psoas muscle thickness on a CT scan.

In the end, triage is all about trying to get the right patient to the right place at the right time, and geriatric patients have a unique set of challenges in this process.

Next week, the topic will be geriatric orthopedic trauma.
Thank you,

Joseph Posluszny, MD

05/29/2026

Congratulations are in order for Jeremy Chepes, Jonathan Ivaskovic, and Joseph Stuart, who were sworn in yesterday as full-time members of the Madison Fire District.

05/29/2026

05/29/2026

05/29/2026