Presentation on theme: "Trauma in the Elderly NOTE: In U.S., www.census.gov has wealth of information. QuickFacts (quickfacts.census.gov) and American FactFinder (factfinder.census.gov)"— Presentation transcript:
0 International Trauma Life Support, 6e Trauma in the Elderly18Key Lecture PointsReview pathophysiology of aging by systems.Stress that when doing field triage, geriatric patients have more injuries and worse outcomes than younger patients who are subjected to the same mechanisms.Review patient assessment, and relate how aging affects assessment and interventions.Discuss potential problems with spinal motion restriction in elderly patients.
2 Overview Changes that occur with aging Assessment of geriatric trauma How changes affect assessment of geriatric traumaAssessment of geriatric traumaManagement of geriatric trauma
3 Trauma in the ElderlyFatal outcomes more likely, even if injury is relatively low in severity.Physiologic and anatomic changes of aging increase risks for trauma as well as increase complications and mortality.
4 Trauma in Elderly Age impairs body's response Trauma is major cause of deathFallsFractures of hip, femur, humeral/wrist, head injuriesMotor-vehicle collisionsHigher incidence of collisionThermal injuryInhalation, scalding, flame burns, electrical injuryNOTE: Data based on U.S. population by U.S. National Safety Council.Geriatric patients tend to respond to injury less favorably than younger adult population.Little research on poor response of geriatric patient to trauma.Existing literature is retrospective in nature and offers little explanation for more adverse outcomes experienced by elderly.
5 Trauma in Elderly Higher risk of injury Reflex response time increased Eyesight and peripheral vision decreasedHearing decreasedPostural instabilityArthritisFragile skin and blood vesselsFragile bonesA number of aging processes contribute to increased risk of injury to geriatric patient.Increase in falls has been linked to physiological changes of aging process—decrease in function of special senses, syncope, transient impairment of cerebrovascular perfusion, alcohol ingestion, or medication usage.Alterations in perception and delayed response to stressors may also contribute to injury.
6 The Aging Body Airway Respiratory system Potential obstruction DecreasedPulmonary circulation 30%Alveolar exchangeCapacity and work rateChest wall movementInhalation timeVital capacity due to increased residual volumeNOTE: Closer look at image on next slide. Included here to emphasize that respiratory system changes do not just occur in lungs.Aging is gradual process whereby changes in bodily functions occur.Changes are in part responsible for greater risk of injury in geriatric population.AirwayPotential obstructions due to caps, bridges, dentures, and fillings. Gums shrink with age, causing dentures to become loose.Respiratory systemDecreased alveolar exchange means decreased carbon dioxide and oxygen exchange.Decreased inhalation time leads to rapid breathing.
7 The Aging BodyFrom previous slide: Airway potential obstruction also due to decreased airway clearance, decreased laryngeal reflexes, decline in mucolary clearance, and decreased ciliary action (which also increases chance of infection).From previous slide: Decreased pulmonary circulation combined with loss of elastic recoil leads to ventilation/perfusion mismatch.From previous slide: Decreased alveolar exchange means decreased carbon dioxide and oxygen exchange. This is due to decreased numbers of alveoli.From previous slide: Decreased chest wall movement is due to stiffening of chest wall with declining strength of chest muscles.From previous slide: Decreased pulmonary circulation, rapid breathing, and decreased alveolar exchange lead to hypercapnia due to resulting altered chemoreceptor response.From previous slide: Decreased pulmonary circulation, rapid breathing, and decreased alveolar exchange lead to arterial hypoxemia with reduced PO2 levels.Increased work of breathing leads to increased anterior-posterior diameter.
8 The Aging Body Cardiovascular system Congestive heart failure and pulmonary edemaCirculation decreasedCardiac output and stroke volume decreasedConduction system degeneratesHeart valve efficiency decreasedArteriosclerosisPeripheral vascular resistance increasedSystolic hypertensionCirculation reduced due to changes in heart and blood vessels.Cardiac output and stroke volume may decrease.Conduction system may degenerate.Ability of valves of heart to operate efficiently may decline.These changes may predispose patient to congestive heart failure and pulmonary edema.Arteriosclerosis occurs with increasing frequency in course of aging process.Blood pressure may normally be higher in elderly.Significant change may occur in a patient when normal blood pressure of 160 mmHg drops to 120 mmHg as a result of trauma.
9 The Aging Body Neurological and sensory function Subdural hematoma Brain shrinks, dura mater adherent to skullBrain arteries harden, narrow, lose elasticityUnrecognized injuryBlood flow to brain decreasedSensory responses decreasedPain tolerance increasedAltered mental statusChanges occur in brain with age.Increased risk of subdural hematoma due to space or an increased distance between brain and skull.Instead of protecting brain during impact, space allows an increased incidence of following trauma.Decreased pain tolerance can result in failure to identify areas of injury.Other signs of decreased cerebral circulation due to aging process may include confusion, irritability, forgetfulness, altered sleep patterns, and mental dysfunctions such as loss of memory and regressive behavior.May be decrease in ability, or even an absence of ability, to compensate for shock.
10 The Aging Body Thermoregulation Hypothermia Afebrile with infection Temperature control mechanism deterioratesSubcutaneous tissue decreasedAfebrile with infectionMechanisms to maintain normal body temperature may not function properly.May not respond to infection with a fever, or may not maintain normal temperature with injury.Patient with broken hip lying on floor in room with temperature 64o Fahrenheit/18o Celsius can experience hypothermia.
11 The Aging Body Renal system Immune system Drug toxicity Infection Nephron function decreasedBlood filtration decreasedImmune systemInfectionMalnutritionSepsisImmune response decreasedDecrease in number of functioning nephrons in kidneys of geriatric patient can result in a decrease in filtration and a reduced ability to excrete urine and drugs.May be less able to fight off infection.A poor nutritional state will be more susceptible to infection from open wounds, IV access sites, and lung and kidney infections.Geriatric trauma patient who is not otherwise severely injured may die from sepsis from an impaired immune system.
13 The Aging Body Gastrointestinal system Overall system changes MalnutritionDecreased ability to metabolize medicationsOverall system changesProlonged illness and recovery timeDecreased total body water leads to dehydrationGastrointestinal systemDecreases ability to absorb nutrients due to decreased saliva production, esophageal motility, and gastric secretion.Constipation and fecal impactions common.Decreased ability to metabolize medications due to liver enlargement from disease processes.Prolonged illness and recovery time.Decreased total body water and total number of body cells.Increase in proportion of body weight as fat.Loss in capacity of systems to adjust to illness or injury.
14 Medications Drug interaction problems Anticoagulants increase bleeding timeIncreased risk of intracranial and other bleedsAntihypertensives and peripheral vasodilators limit constriction responseIncreased risk of shockBeta-blockers limit tachycardia responseMissing red flag signs of hypovolemiaAnti hyperglicemic agentsIncreased risk of hypoglicemiaMany geriatrics take several medications that can interfere with their ability to compensate after sustaining trauma.
15 Important Points General organ systems less effective Especially cardiovascular, pulmonary, renalChronic illness complicates trauma careDifficult to distinguishBones fracture more easilyMajor bone fractures can be life-threateningGeneral organ systems may not function as effectively as in a younger adult.Especially cardiovascular, pulmonary, renal.Chronic illness complicates trauma care.Difficult to distinguish.Bones fracture more easily.Major bone fractures can be life-threatening.The ability for elderly to compensate is hindered by many of the things discussed in previous slides.
17 ITLS Patient Assessment ITLS Primary and Secondary SurveysAnticipate complicating factorsPeripheral pulses difficult to evaluateMany layers of clothingChronic disease vs. acute problemNonpathologic ralesLoss of skin elasticity and mouth breathingDependent edemaVariation in normal vital signsUse same ITLS Patient Assessment approach for elderly, but anticipate possible complicating factors.Loss of skin elasticity and presence of mouth breathing may not necessarily represent dehydration.Dependent edema may be secondary to venous insufficiency with varicose veins or inactivity rather than congestive heart failure.Pay attention to deviation from expected ranges in vital signs and other physical assessment findings in geriatric patient.An injury that is isolated and uncomplicated in young adult may be debilitating in older adult due to overall condition, lowered defenses, or inability to keep effects of an injury localized.
18 Scene Size-up Verify history with reliable bystander Observe surrounding areaIndications that unable to provide own careAlcohol or medication abuseSigns of violence, abuse, neglectNotify proper authoritiesGather medications and take to hospitalBetter to verify history in area where patient unable to overhear—otherwise, implying that patient is incompetent.Abuse and neglect of elderly are common.
20 Critical Transport Decision International Trauma Life Support, 6eLow threshold for early transportSame indications for immediate transport apply for elderly as well as for younger patients, but remember that you may not have as dramatic a response to injury in elderly, so you should have a low threshold for early transport.If one of the critical conditions is present, immediately transfer patient to a long backboard (vacuum backboard is recommended) with appropriate padding, apply oxygen, load patient into ambulance, and transport rapidly to nearest appropriate trauma facility.
21 Ongoing Exam Monitor IV fluid administration response May precipitate congestive heart failureFrequently assess pulmonary statusLung soundsCardiac monitoringPulse oximetryCapnographyDo not withhold fluid if neededVolume infusion may precipitate congestive heart failure in patients with underlying cardiovascular disease.Frequently assess patient's pulmonary status, including lung sounds and cardiac rhythm.All elderly patients should have cardiac monitoring, pulse oximetry, and capnography, if available.
22 Summary Increasing number of elderly patients Evaluation and treatment more difficultPhysiologic processes of agingFrequent concurrent illnessesMedication effectsLimited compensation mechanismsRespiratory and circulatory support essentialIf altered mental status, it is always helpful if there are family members or friends who can give you pertinent history.If not abusing alcohol or drugs, most common cause of altered mental status is hypoglycemia.Report suspicion of elderly abuse.Although mechanisms of injury may be different from those of younger adults, prioritized evaluation and treatment are the same.As a general rule, elderly patients have more serious injuries and more complications than younger patients.