Essentials of Care for - PowerPoint Presentation

Slide1

Essentials of Care for the “Elderly” Trauma Patient

Stacy Vincent, RNEmergency DepartmentEnloe Medical CenterChico, CASlide2

The Geriatric Tsunami

2000- population >65= 12.4%2050- 20.7%Trauma- 5th leading cause of death overall9th

leading cause of death in > 65 years

Geriatric Trauma pts. –

More likely to be admittedLonger and more complicated hospital staysConsume 1/3rd all health care dollars and 25% of all trauma care money.Slide3

Physiologic changes with aging

Progressive loss of functional reserve in each organ system.

Diminished

reserve +

concomitant disease → ↓ability of the elderly trauma patient to absorb physical insult and subsequently recover. Slide4

Physiologic changes with agingSlide5

Predictors of morbidity and mortality

Age↑ Age →↑morbidity and mortality rates after trauma. Co-morbidities80% of age>65 – at least one chronic medical condition50% have at least two. Severity of injury

Elderly

patients tend to sustain more severe injuries, and ISS is one of the strongest predictors of mortality. Slide6

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"Trauma is not really my major problem." Stroke, myocardial infarction, and seizures may result from falls or motor vehicle crashes and delayed diagnosis of the principal underlying problem. Slide7

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"Major trauma? Heck, I wouldn't even tolerate a brisk haircut..." Underestimating and undermanaging comorbidities (eg, chronic obstructive pulmonary disease, coronary artery disease, smoking, ethyl alcohol [ETOH] consumption) may result in preventable morbidity/mortality. Slide8

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"A little medication goes a long way with me..." Failure to adjust medication dosage, particularly sedative-hypnotics and analgesics, may result in serious complications. Slide9

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"I just haven't been eating so well lately." Chronic malnutrition is common and often undiagnosed. Slide10

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

“I pee all the time and I never make any pee….Slide11

Renal Changes

Cortical Mass LossHypertension, diabetes mellitus, and atherosclerosis accelerate these processes.

↓

GFR

(After the age of 40 years, the GFR decreases 1 ml/min/year) ↓ capacity to reabsorb sodium and to secrete potassium and hydrogen ions.

↓

ADH

response

↓

Thirst response

Watch fluid balance and acid-base status carefully especially

those requiring surgery, during which

massive fluid

shifts are expected. Slide12

Measurement of Renal Function in the elderly

BUN/Cr ≠ Kidney Function ↓ muscle mass → normal

serum creatinine despite a reduced creatinine clearance.

Age-adjusted formulas for creatinine clearance are much better

estimates of renal function in the elderly patient than serum creatinine levels. Potentially nephrotoxins

eg

. IV contrast dye,

should be used with extreme caution even if

serum creatinine

levels appear within normal limits.Slide13

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"I get demand ischemia if I have too much pain or my hematocrit drops below 29." Myocardial (demand) ischemia may result from severe or prolonged pain or from transfusion thresholds that have not been appropriately liberalized in the setting of coronary artery disease

.

"I can't stand even a little shock or hypoxia...and neither can my myocardium."

Even minor perturbations in perfusion, oxygenation, or vasoconstriction may lead to major cardiac complications. Slide14

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"I can go from normotensive to hypotensive in a heartbeat.“Profound, life-threatening hypovolemia may occur in the setting of normal blood pressure.

Physiologic

reserve is minimal, and hemodynamic decompensation can occur quickly

.Slide15

Cardiovascular Changes

LVH → myocardial stiffening→ ↓

diastolic

relaxation

and slowed ventricular filling→↓Stroke volume. Heart extremely sensitive to both hypovolemia and hypervolemia→

very

narrow therapeutic

window.

↓

inotropic and chronotropic

response to

both internal and external beta-adrenergic

stimulation

Progressive

deterioration of the

conducting system

by cell atrophy,

fibrosis

, and

calcification

.Slide16

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"I only look like I have adequate ventilatory reserve." Ventilatory failure and respiratory arrest may occur suddenly in conjunction with chest or abdominal injuries despite a benign outward clinical appearance. Slide17

Pulmonary Changes

Calcified Costal cartilage → chest wall rigidity → ↓

lung

compliance

. Respiratory muscle atrophy↑ reliance on diaphragm function and abdominal musculature for breathing. ↓ Forced

vital

capacity and FEV1

.

Fusion of adjacent alveoli

→ ↓

surface

tension forces → ↓pulmonary elastic recoil.

Thickening

of the alveolar

basement membrane

→ ↓ gas-diffusing

capability

→

V/Q

mismatch

+

↑

alveolar-arterial oxygen gradients

.

↓

airway sensitivity and

efficiency

of the

mucociliary

clearance

mechanism.Slide18

Musculoskeletal Changes

↓ muscle mass and strength. DJD in weight-bearing joints→ chronic

pain.

Postural compensation → altered

weight-bearing mechanics → injury. Osteoporosis → ↑ fractures esp. hip, pelvis, wrist, and ribs.

Vertebral

collapse

→ progressive kyphosis→ altered

center of gravity

→ balance disturbances

.

Women> Men.

Women

lose up to 35% of cortical bone mass

and 50

% of trabecular bone mass over their lifetime

;

men

lose about

one third less

.

Progressive

limitation of

movement→ ↑ risk of injury + complicated recovery.Slide19

Skin changes

Skin trauma is common. Thin skin → ↑ tears and lacerations even with relatively minor trauma. May be very difficult to repair and often require débridement

of devitalized tissue.

Prolonged

immobilization on a backboard or in a C-collar → decubitus ulcers of the back, buttock, or occiput. Tetanus prone due to lapses in immunization.Slide20

Mechanisms of Injury

Blunt Trauma. Falls. Same level. Multilevel. MVC. Pedestrian Vs Car.Violent Crime

Domestic Abuse

BurnsSlide21

CNS Changes

Cortical atrophy →↑ volume

of the subdural

space

→ allows for greater movement of the brain during traumatic impact .Relatively minor mechanisms of injury →↑ subdural and subarachnoid

hemorrhage secondary

to

greater shearing forces on parasagittal bridging veins.

Large volumes of blood may accumulate

intracranially

before symptoms of intracranial hypertension develop.

+ anticoagulant and/or antiplatelet medications.

↑predisposition to injury

↓ Vision

,

↓auditory function

,

↓reflex

timing

↓pain perception.

↓cognitive

ability, memory, and information

Also

may

obscure post-traumatic

evaluation.Slide22

Falls

Most common mechanism of injury in elders-40% of trauma in patients >65 years, Leading

cause of injury-related

death.

Risk factorsmedications (sedatives)cognitive and visual impairment, history of stroke

arthritis.

Most

falls occur at home and are same-level falls

.

25% - due to underlying

medical

problem

. Need appropriate medical screening.

Eg

. strokes

, syncope, near-syncope, medications, elder abuse, and hypovolemia (e.g., related to gastrointestinal bleeding, ruptured abdominal aortic aneurysm, sepsis, or dehydration).Slide23

Falls

Fractures- most common injuries –..in 5 to 10% of fall victims.≤10% of patients -major injury esp. head

injury.

+

anticoagulants → ↑ susceptibility to significant head injury. + Head CT in 16%, 1 in 50 require

neurosurgery.

The

greater the height of the fall, the more likely the patient is to have an abnormal CT scan,

Serious

head injuries may also be seen in patients who suffer a same-level fall.

Peri

-injury

mortality

=12

%,

50

% die within 1 year of the fall

,

often related to either recurrent falls or significant medical complications.Slide24

Head Injuries

Head injuries -most common cause of mortality directly related to trauma. Most common mechanism -falls. Epidural hematomas Rare because of the adherence of the

dura

mater

to the inside of the skull. Cerebral contusions up to 1/3rd head-injured elder patients Subdural hematomas more

common with age

.

Atrophied

brain is more mobile within the skull, and

head trauma

may result in shearing of

bridging

veins.

Variable Clinical Presentation- ALOC Vs Normal Neuro status. Slide25

Head Injuries

Mortality = 2X that of younger patientsMortality from subdural hematoma = 4 X than in younger patients.Often need Rehab.Head CT -diagnostic test of choice for brain injury

+ contrast study - if the injury is 7 to 20 days old and an

isodense

subdural hematoma is suspected.Magnetic resonance imaging (MRI-alternative in these patients when the injury is subacute and an isodense lesion is suspected.Slide26

Subdural Vs Epidural HematomasSlide27

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"My subdural hematoma hasn't expanded enough yet to really affect my level of consciousness." Cortical atrophy, common in the elderly, may act to delay the clinical manifestations of serious intracranial hemorrhage. This hemorrhage may be clinically occult. Slide28

MVC

2nd most common cause of trauma - 20 to 59%Mortality = 21%

.

Risks

Cognitive impairment, ↓ hearing and vision, and slower reaction.Most are daytime crashes occurring close to home. Single-vehicle

crash

– suspect medical problem.

Less

likely to involve alcohol, excessive speeds, or reckless driving than

younger

patients. Slide29

Auto vs Pedestrian

3rd most common cause of injury in elders- 9-25% Risk Factorspoor eyesight and

hearing

decreased

mobility and longer reaction times Fatality rate-30 to 55%.Standard time allotted for most crosswalks in the United States assumes a walking speed of 4 feet per second!Slide30

Violent Crime

10% of all geriatric trauma admissions. 6% of all assault victims in US5 X more likely to die Attacks primarily

involve blunt instruments.

Penetrating injuries

via knife or firearm are increasing in frequency - recently reported by the CDC to account for over 50% of assault related fatal injuries in the elderly.Slide31

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"My injuries weren't accidental." Elder abuse is common and often unreported and undiagnosed. Slide32

Domestic abuse

True magnitude clouded by variances in legal definitions and reporting accuracy. The National Aging Resource Center on Elder Abuse estimated in

1998 that

only 1 in 15 cases of geriatric abuse is reported.

Often a result of denial -victim as well as the abuser. >2 million cases per year in the US involving up to 6% of the elderly population.Reasons Longer

life expectancy

Altered

family dynamics

Financial difficulties

Females > males

> 80 = 2-3 X than those between

65 and 80.

Similar

to child abuse, detection mandates a

high degree

of suspicion, especially when there are signs of physical

injury or

neglect that are inconsistent with the mechanism described.Slide33

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"The sensitivity of my abdominal examination is better than flipping a coin...but not much." Clinical manifestations of serious abdominal injury in elderly patients are often minimal. Reliance on the abdominal examination often leads to missed abdominal injuries. Slide34

Abdominal Injuries

Depending on the mechanism of injury, up to 30% of elder trauma patients may suffer a significant intra-abdominal injuryAbdominal examination may be unreliable Mortality from abdominal injuries

= X 4-5 than younger pts.

FAST

CTSlide35

Pitfalls In Geriatric TraumaWhat the injured elderly would tell you (if they could)

"My bones are brittle...my hip bone, my shin bone, and my aortic bone!" Blunt Aortic Injury may occur in the elderly in the absence of conventional signs or symptoms. A

low threshold for CT imaging should exist. Slide36

Extremity Injuries

Musculoskeletal system - most commonly injured organ system By the age of 75 years, 30 to 70% of patients with osteoporosis - + fracture.↓

daily activities

May need admission Pain control Home support or rehabilitation.Slide37

Extremity Injuries

Upper extremity fractures are common. Distal radial fractures (50%) Proximal humeral fractures (30%) Elbow injuries (radial head fractures and elbow dislocations=15%).Slide38

Extremity Injuries

Hip fractures most frequent lower extremity fractures most common cause of admission in elder trauma patients.

Early mortality rate =

5

%Mortality for 1 yr. after hip fx. = 13-30% MRI for “occult” hip fracturesSlide39

Extremity Injuries

Tibial plateau fractures fall or MVC andmost commonly involve the lateral tibial plateau. Patellar fractures

fall

directly onto the

kneecapsunrise views of the patella may be the only way to visualize these injuries. Ankle fractures25% of all lower extremity fractures most commonly involve the lateral malleolus

treatment

often

a

walking cast.Slide40

Soft Tissue Injuries

↑ Skin tears Treatment difficult, and debridement of devitalized tissue and careful local care are often necessary.

Elder pts

frequently are not up to date with their tetanus

immunizations. Treatment - active + passive immunization (tDAP + TIG).Slide41

Burns

>90% of burns occur at homeLiving alone + decreased reaction times

→

deeper

and more extensive burnsFlame burns -50% of all burns + 20% of burn-related deaths. Some are cooking related; Scalds = 19%

Flammable

liquid burns

=

10%.

↑

mortality = 30%

Baux’s

formula (risk of mortality = age in years +

%

body surface area

burned).

Prognosis better since 1980s

↓

immunocompetence

Exacerbation

of underlying medical conditions

precipitated

by the stress of an extensive burn injury and its treatment.Slide42

Triage

Current guidelines suggest that age alone, in the absence of any diagnosable injury, is insufficient for activation of the trauma team. However, the threshold for activation should be lower in patients who show hemodynamic

instability or any potentially life-threatening injuries, such as

severe fractures

, abdominal trauma, or chest trauma.Slide43

Age as a trauma center triage criterion

One possible cause of the under triage of elderly trauma patients is the late presentation of physical findings indicating hypovolemia. Demetriades D, Sava J, Alo K, et al. Old age as a criterion for trauma team activation. J

Trauma

2001;51:754–6

63% did not meet the standard hemodynamic criteria for trauma team activationDemetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg

2002;89:1319–22.

↓

mortality

rate

when age >70

was added as a criterion for trauma team

activation.Slide44

Withdrawal of care

Withholding and withdrawing life support in hopelessly ill geriatric trauma patients is a necessity. The challenge is identification of the hopelessly ill patients.

Decisions

to limit ICU care should be based on the following

principles :1. Every patient deserves a precise diagnosis.2. The prognosis often is uncertain.3. Each decision should be based on a risk-benefit analysis for patients.4. Patient autonomy is paramount.5. Due deliberation prior to decision.6. Communicating with patients, families, and professional colleagues.7. Framing the discussion within families’ cultural context.

8. Achieving consensus before a final decision

.

Schecter

WP. Withdrawing and withholding life support in geriatric surgical patients

. Ethical

considerations.

Surg

Clin

North Am 1994;74:245–59.Slide45

Conclusions

Elder patients are more susceptible to injuries than younger patients and have a higher mortality rate for any given injury.Mechanisms of injury are different in elders than in younger patients.

Elder

patients are more likely

to sustain their injury from a fall, an MVC, or an auto versus pedestrian incident than from an assault.Physiologic changes that occur with aging alter the way in which these patients may manifest significant injuries as well as how they tolerate these injuries.Emergency

providers

must remember that

elder trauma

patients may have suffered a medical

event that

precipitated their trauma, or vice versa,

and evaluate

patients accordingly.

Resuscitation

of elder trauma patients requires

oxygen supplementation

, a lower threshold for

advanced airway

control (endotracheal intubation),

and aggressive

but judicious fluid and blood

resuscitation with

frequent reevaluation.Slide46

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