Elderly patients today have an increased risk for trauma from an increasingly active life style and from impaired motor and cognitive functions.
Thirty percent of persons over 65 years of age fall each year; of these falls, 6 percent result in fractures, 10 to 30 percent result in significant trauma, and 7 percent lead to mortality. Falls from a standing position account for half of all rib fractures in the elderly population.
Trauma Incidence/morbidity/mortality Fifth leading cause of death Mortality rates markedly increased Post injury disability more common
When caring for elderly patients, consider the various changes and underlying conditions which may affect your care, such as: Cardiovascular considerations Respiratory considerations Renal considerations
Factors contribute to the difficulties in initial assessment and resuscitation of the elderly patient: -Pre-existing medical conditions, prosthetics, altered mental status, and the effects of medications and normal age-related changes in physiology. - All systems experience decline with advancing age, and this impacts the patient’s “physiologic reserve” in the face of trauma.
Mortality is increased across all phases of the death curve in the elderly: prehospital, early, and late. Early mortality can be reduced by aggressive resuscitation, liberal radiographic evaluation, early monitoring, and surgery. Late mortality is reduced by meticulous attention to changes in patient status. Complication rates of 33 percent are reported in the elderly, compared with 19 percent in younger patients. Cardiovascular events (23 percent) and pneumonia (22 percent) are the most common and significant complications.
In the emergency department, the two most useful scores are the Trauma Score (TS) and Revised Trauma Score (RTS). The TS assesses blood pressure, respiratory rate, respiratory effort, Glasgow Coma Score (GCS), and capillary refill to produce a minimum score of zero and maximum score of 16. The RTS is similar, but does not account for respiratory effort or capillary refill (scores 0–8).
Airway Supplemental oxygen -Early airway such as nasopharyngeal and oropharyngeal airways. - Endotracheal intubation should be considered early in patients who have demonstrable signs of shock, significant chest trauma, or mental status changes
Breathing Aging has a myriad of effects on pulmonary function. Primarily, these changes can be classified as anatomic changes that increase susceptibility to trauma and physiologic changes that diminish protective responses to injury.
Circulation The first critical step is to quickly identify and control life-threatening bleeding. External bleeding is usually obvious. Internal bleeding must be rapidly diagnosed in the elderly.
Trauma is the leading cause of death in the elderly. Factors include: Osteoporosis Reduced cardiac reserve Decreased respiratory function Impaired renal function Decreased elasticity in the peripheral blood vessels
Management The elderly have increased mortality across all categories of the trimodal death curve: immediate (ie, at the scene), early (ie, within the first 24–48 hours), and delayed (ie, after 48–72 hours).
Remember that blood pressure and pulse readings can be deceptive indicators of hypoperfusion. Leading causes of trauma in the elderly include falls, motor vehicle crashes, burns, assault, and syncope. Observe the scene for signs of abuse and neglect.
Head Injury Common, even with minor trauma Increased ICP signs develop slowly Patient may have forgotten injury
Burns People age 60 and older are more likely to suffer death from burns than any other group except neonates and infants. Factors include Higher mortality than any group except infants Preexisting disease Thin skin Poor immune response Reduction in organ system reserve Inability to meet metabolic demands of burn injury Increased risk of shock Fluid administration critical to prevent renal failure
Physical or psychological injury of older person by their children or care providers Knows no socioeconomic bounds
Management Do NOT confront family Report suspicions to ER physician, law enforcement Reporting is mandatory
Priorities of trauma care for older patients are similar to those for all trauma patients Special consideration should be given to the older patient’s: Transport strategies should be given special consideration