Initial Assessment and Management

Committee on Trauma Presents

Geriatric

Trauma

Case Scenario

● A 79-year-old male is brought to the ED after he was found at the base of the stairs by his wife.

● Initial vital signs: RR 32; Pulse 64; BP 110/60; GCS score 12

What issues should you consider in managing this patient?

Objectives

● Describe characteristics of the elderly patient that affect trauma management.

● Discuss the relevance of comorbidity and medication.

● Explore the potential for elder abuse.

Special Considerations

●Age-related changes in anatomy and physiology

●Preexisting diseases and comorbidities

●Medications

●Possibility of elder abuse

What are the special issues to consider in treating elderly trauma patients?

The Problem of Elder Trauma

●Increase in proportion of world population by 2050 will be 20% or 2.5 billion

●Increased mortality and morbidity

Majority can return to preinjury status with appropriate

management

Decline in Function with Age

Brain mass

Eye disease

Depth of perception

Discrimination of colors

Pupillary response

Respiratory vital capacity

Renal function

2- to 3-inch loss in height

Impaired blood flow to lower leg(s)

Degeneration of the joints

Total body water

Nerve damage (peripheral neuropathy

Stroke

Diminished hearing

Sense of smell and taste

Saliva production

Esophageal activity

Cardiac stroke volume and rate

Heart disease and high blood pressure

Kidney disease

Gastric secretions

Number of body cells

Elasticity of skin, thinning of epidermis

15%–30% body fat

Unique Characteristics

What are the unique characteristics of elderly trauma?

●Fall

●Burn

●Alcohol

●Pedestrian vs. vehicle

●Motor vehicle crash

Leading

Causes of

Injury

Unique Airway Problems

●ABCDE

● Priorities are the same

● Decreased reserve requires early intubation

●Factors affecting airway management

● Dentition (dentures)

● Nasopharyngeal mucosal fragility

● Cervical arthritis

Unique Breathing Problems

●Diminished respiratory reserve

●Use of supplemental oxygen

● COPD

● ‘Hypoxemic respiratory drive’

●Chest injuries poorly tolerated

●“Minor” chest injuries with major effects

Unique Circulatory Problems

●Decreased cardiovascular function and reserve

●Cautious fluid administration

● Increased BP, decreased HR, and loss of renal function with age

●Anticoagulants and other medications

●Pharmacologic effects

● Catecholamine effects and dysrhythmias

Drugs That Affect Resuscitation

●Beta blockers

●Antihypertensives

●NSAIDS

●Anticoagulants

●Corticosteroi

ds

●Diuretics

●Hypoglycemi

cs

●Psychotropic

s

Unique Neurologic Problems

●Acute and chronic subdural hematomas

●Altered sensorium secondary to cerebral atrophy, hypoperfusion, and medications

●Spinal osteoarthritis, leading to frequent spinal column and cord injuries

Cervical Spine MRI

Unique Exposure Problems

●Abnormal thermoregulatory mechanism

●Increased sensitivity to hypothermia

●Increased risk of infection

●Tetanus immunization status

Unique Musculoskeletal Problems

●Most frequent cause of morbidity

●Susceptible to certain fractures

●Osteoporosis

●Preexisting deformities complicate evaluation

●Immobility can lead to complications

Recognizing Elder Abuse

●High index of suspicion

●Patterns of injury

●Multiple types

● Physical

● Emotional

● Confinement

● Intimidation

● Poor hygiene

Strategy for Elder Abuse

●Don’t query in presence of possible

abuser.

●If abuse is suspected, remove patient from abusive environment.

Failure to recognize and report

Pitfalls

End-of-Life Decisions

●“When is enough, enough?”

●Advance directives?

●Right to self-determination paramount

●Treatment only in patient’s best interest

●Benefits of treatment outweigh adverse consequences

Summary

●Trauma in the elderly is increasing globally.

●Treatment priorities are the same.

●Evaluation and management affected by:

●Anatomic and physiologic changes

●Comorbid conditions and medications

●Consider elder abuse