94 year old man was brought in to the ED after being found down in his bathroom at a nursing home. He is complaining of right hip pain and has not been able to put weight on that leg since the fall.

94 year old man was brought in to the ED after being found down in his bathroom at a nursing home. He is complaining of right hip pain and has not been able to put weight on that leg since the fall. X-rays show a right displaced femoral neck fracture. You’re called to the ED after “ortho” sees them and requests a “pre-op eval”.

Most of the history you get comes from a CNA at the nursing home facility, who is not very familiar with the patient. The CNA is unaware of history or meds but does endorse the patient has dementia and walks around sometimes with use of a walker.

PMH from the EMR: HTN, CAD, DM2, Hyperlipidemia, dementia, heart murmur.

PSH: CABG over a decade ago, nothing else relavant.

Meds: Pending….

All: None

SH: Lives at a SNF, walks with a walker, used to smoke not sure how much or when. Family is en route but not picking up their phones.

PE:

Vitals: Temp 99.2, HR: 98, RR: 16, BP 168/96, Sat 92% on RA, Pain 8/10 in right hip.

PE: General: He is awake and alert in obvious pain. He knows his name, and the year, but isn’t sure where he is or why.

HEENT: Atraumatic, unremarkable

MSK: He has pain, bruising about the right hip.

Skin: Scattered ecchymosis in various stages of healing. No lacerations.

Pulm: Unremarkable

CV: Irregularly Irregular, Normal S1/2, No S3/4, he has a holosystolic murmur rated at 4/6 which radiates up the carotids. No diastolic murmur is appreciated.

Now…. Ortho wants to take him to the OR right this second because there is a fracture that must be fixed… In this case, the surgery would be a for a hip hemiarthroplasty.

What would be your next step? Labs, EKG, CXR, etc?

What do you make of that murmur? What is the most likely cause? Is it a big deal or we don’t really care much? ***Hint: we care 🙂

Now anesthesia wants an echocardiogram. Why do you think they care? What is an echo going to show? How does his blood pressure impact surgery? Intra-op do we want high pressures? What are you concerned about with low blood pressure and aortic stenosis?

His echo shows severe aortic stenosis…. Please discuss the grading for a murmur 1-6 as well as the stages and clinical manifestat