3 Geriatric Trauma—Epidemiology 5th leading cause of death over age25% of trauma deathsPersons >65 = Fasting growing age groupSlide 31Our population is living longer and are more active due to advances in health care. 12.5% of the population is aged 65 or older. For this age group, trauma is the fifth leading cause of death. Older adults account for 25% of trauma deaths. The older adult trauma patient is more likely to die than a younger patient. This is often not because of the primary injury but because of secondary complications. An aggressive treatment approach needs to be initiated to prevent secondary complications from occurring.Seriously injured older adults are less likely to be taken to trauma centers for care. The American College of Surgeons has established guidelines to consider triaging trauma patients over 55 years of age to trauma centers.
4 Epidemiology Rapid growth in elderly population - 65 or older currently represent 12% (30 million)- expected to rise to 20% (52 million) by 2020- will be 22% of population by 2030High rate of fatalities from trauma- 28% of fatalities in those over 65- 6 times more likely to dieChronologic Age vs. Physiologic AgeAlthough elderly are LESS likely to be involved in trauma compared to other age groups, they are MORE likely to have fatal outcomes when injuredPhysiologic age describes the actual functional capacity of the patients’ organs in the physiologic sense.Comorbid diseases such as DM, CAD, ESRD, arthritis and pulmonary diseases can decrease physio reserve, making it harder to recover. Physiologic reserve describes the various levels of functioning of the patients organ systems that allow them to compensate for traumatic injuries.Example: 65 yo w/DM, arthritis, and COPD may have less physio reserve and thus an older physio age than an 80 yo with no PMH
5 Geriatric Mechanisms of Injury FallsMotor vehicle crashesPedestrian struck by motor vehicleAssaultsCo-morbid disease may be precipitating factor for injurySlide 32Falls are the most common injury. Often these falls are from the same level. Changes in visual acuity, sensation, and proprioception may be contributing factors.Motor vehicle crashes are the second most common mechanism. Delayed reaction time as well as changes in visual acuity play a role.Pedestrians struck by a motor vehicle represent the third most common mechanism of injury. Alterations in mobility make it difficult to cross the street quickly. Hearing impairment and visual changes also make it more difficult to hear and see traffic.Co-morbid diseases can precipitate factors that result in injury. These factors include such things as syncope, postural hypotension, and cardiac dysrhythmias. Falling may be caused by dehydration, urinary tract infections, pneumonia, MI or side effects from medications. All these factors need to be considered and appropriate diagnostic testing ordered.
6 Risk Factors Poor visual acuity Poor visual attention Overload of informationImpaired reaction timeSlower gaitMedication side effects and interactionsAlcohol consumption
7 Higher Mortality Higher mortality rate due to: Age-related deteriorationDecreased stress tolerance and physiologic reserveGreater complication riskPre-existing chronic diseasePre-existing nutritional deficits
8 Anatomic/Physiologic Differences in the Older Adult Trauma Patient
9 Neurologic Loss of neurons in cortex Cerebellum Hippocampus Changes in neurotransmitter systems:DopaminergicCholinergicCatecholaminesGlutamatergic
10 Neurologic Brain weight of decreases 6 to 7% Brain size decreases Cerebral blood flow declines 15 to 20%Nerve conduction slows up to 15%
11 Neurologic Pupil size diminished pupillary light reflex Slowed motor reaction timeGait tends to be short-stepped and guardedAnkle jerk is lostVibratory sense in legs is diminished
12 Neurologic Bridging veins susceptible to injury Higher incidence of coagulopathies and anticoagulation therapy
13 Respiratory Hypoxia Loss of pulmonary reserve Reduced cough reflex Blunt trauma: Although rib fractures are considered a minor injury, they are major in the elderly
14 Cardiovascular Atherosclerosis History of hypertension Cardiac output decreases with agingElderly patients need early hemodynamic monitoring
15 Musculoskeletal Hip fractures increase with age Femoral neck fractures occur spontaneouslyArthritis limits mobility, flexibilityDegenerative changes make radiographic diagnosis difficult
16 Renal Impaired ability to concentrate urine Decreased glomerular filtration rateSlight increases in blood urea nitrogen and creatinine expected; changes considered when using contrast media and certain drugs
17 Integumentary Skin provides less cushion against mechanical forces More susceptible to shearing-type forcesImpaired ability to tamponadeLoss of thermoregulatory ability
18 Additional ChangesInadequate nutrition and pre-existing malnutrition leads to weakened respiratory muscles and ventilatory fatigueSlowed peristalsis and gastric motilityDecreased BMRTotal body water is decreased in the elderly so patients are at greater risk for hypovolemia
19 Additional Changes Medication effects May have pre-existing anemia Shock may be present with normal vital signsMay have pre-existing anemiaSlide 34Aging results in a loss of pulmonary reserve. There is decreased strength in the pulmonary muscles, and a reduced cough reflex. There may also be a long history of smoking. Any degree of hypoxemia may be detrimental to for the older adult. Supplemental oxygen must be administered to prevent hypoxia.The cardiovascular system is also not as responsive. The heart does not pump as effectively and atherosclerosis limits the ability of the vessels to respond in stress.For those patients on beta blockers, calcium channel blockers, or afterload reducing medications, the effect of these medications limits the heart’s response to shock. Shock may be present with normal vital signs. Heart rate may not increase to compensate for hypovolemia, or the increase is limited. The usual blood pressure may be hypertensive, creating a false sense of security for the nurse evaluating the patient whose blood pressure is within normal range.The patient may have pre-existing anemia. Blood transfusion should be considered early in the resuscitation to maintain the oxygen-carrying capacity of the blood. Early placement of pulmonary artery catheters and aggressive management of hemodynamic parameters in the older adult are recommended.
20 Psychosocial End-of-life decisions Specific directions for withholding or withdrawing treatmentsGuidelines for making treatment decisionsPatient’s right to self-determinationPatient’s best interestBenefits of treatment outweigh adverse outcomes
21 Geriatric Head Injury Pearls With aging, the brain undergoes progressive atrophy and decreases in size by 10% between ages 30 and 70Subtle changes in cognition and memory make evaluation of MS difficultLower incidence of epidural hematomasHigher incidence of subdural hematomasThe increased “dead space” within the skull may delay symptoms of ICHLow threshold for Head CTGrave error to assume that altered MS is due to underlying dementia.Elderly have a lower incidence of epidural hematomas – attributed to relatively more dense fibrous bond between the dura mater and inner table of the skull.However there is a higher incidence of subdural hematomas in the elderly, b/c as brain mass decreases there are greater stretching and tension of the bridging veins.
22 Types of Mild Traumatic Brain Injury in the Elderly
23 Types of Mild Traumatic Brain Injury in the Elderly ConcussionContusionEpiduralSubduralSkull FracturesPenetrating
30 Prognosis and Outcome Markers for poor prognosis at admission: - Age > 75- GCS of 7 or less- Presence of shock on admission- Severe head injury- Development of SepsisArrange for a social worker to conduct a home safety assessment
31 Prognosis and OutcomeMortality rate of 15 to 30% for hospitalized patientsDebate over ethics and cost-benefits of trauma care for elderlyConflicting data on ability to return to independent livingConflicting data – 12% vs. 57% returning to independent livingCost of hospitalized geriatric trauma patients 3 times greater for those over 65
32 Nursing Care of the Geriatric Trauma Patient—Assessment HistoryDoes the patient have pre-existing medical conditions?What medications does the patient take?What were the events that led up to the injury?What was the patient’s functional status/neurologic status before?Does the patient have advance directives?Slide 36History-taking in the older adult should include the following questions:Does the patient have pre-existing medical conditions? Often these can cause precipitating factors that lead to injury.What medications does the patient take? Ask specifically about anticoagulant/antiplatelet agents such as warfarin (coumadin), aspirin, or clopidogrel (plavix). Consider early initiation of clotting studies.What were the events that led up to the injury? Did the patient feel dizzy before the fall? Did he pass out or have palpitations?What was the patient’s neurologic status/ functional status prior to the injury? Did the patient live alone? Walk without assistive devices? Was someone else assisting with care?Does the patient have advance directives?
33 Nursing Care of the Geriatric Trauma Patient—Assessment InspectionMouth for loose teeth, partial plates, denturesSkin: look carefully for pressure areas, ecchymosisPalpationBony prominences of spineSlide 37When assessing the patient, the mouth should be inspected for loose teeth, partial plates, or dentures that may obstruct the airway. These should be removed.Skin should be observed carefully, looking for pressure areas, ecchymosis, or skin tears. Bony prominences should be padded.The bony prominences of the spine should be palpated for pain and tenderness as well as deformity. Remember that deformity may also be due to the aging process or pre-existing arthritis. The brittle spine fractures easily. Collaborate with the physician to determine need for imaging of the spine.NOTE TO INSTRUCTOR: Older adult having procedure done to skin
34 Nursing Care of the Geriatric Trauma Patient—Assessment AuscultationApical heart rate and blood pressureAbnormal heart sounds (valve disease, fluid overload)Tachycardia as a response to shock may not be seenA normal blood pressure may be indicative of shockSlide 38Auscultate apical heart rate and blood pressure. Listen carefully for signs of fluid overload such as an S3. Additionally, note murmurs which may indicate valvular disease.Medications such as beta-blockers or cardiac glycosides may decrease the heart rate or limit the heart’s sympathetic response to hypovolemia. Tachycardia as a response to shock may not be seen in these patients.Hypertension is frequently seen in older adults. A normal blood pressure in the setting of trauma may be indicative of shock in the patient with a history of hypertension.
35 Diagnostic Procedures Laboratory TestingElectrolytesCardiac enzymes, troponinTherapeutic drug levelsCoagulation profilesOther StudiesElectrocardiogramEchocardiogramCarotid ultrasoundSlide 39An older patient’s injury may be the result of a reaction to other symptoms that presented before the injury. Diagnostic studies should be done to rule out other factors such as myocardial infarction, dysrhythmia, stroke or arterial insufficiency.Laboratory studies may include electrolytes, cardiac enzymes, therapeutic drug levels, and coagulation profiles (PT, PTT, INR).Other studies that may be appropriate include electrocardiogram, echocardiogram, and carotid ultrasound.
36 Factors Complicating Assessment Presence of multiple pathologies85% have one chronic disease; 30% have three or moreOne system’s acute illness stresses other’s reserve capacityOne disease’s symptoms may mask another’sOne disease’s treatment may mask another’s symptoms
37 Nursing Care of the Geriatric Trauma Patient—Planning and Implementation InterventionsAirwayRemove dentures, partial platesCarefully consider need to intubateSpinal immobilizationPad bony prominencesRemove immobilization as soon as possibleBreathingAdminister supplemental oxygenSlide 40When intervening to control the airway in an older adult, remember to remove dentures and partial plates so they do not obstruct the airway. Carefully consider the need to intubate. Intubation increases the risk of pneumonia. Other alternatives may be implemented such as BiPap.For patients with spinal immobilization, bony prominences should be padded to reduce the risk of pressure ulcers. Remove splints, backboard, and cervical collar as soon as injuries are ruled out.In relationship to breathing, remember that the older adult cannot tolerate hypoxemia and supplemental oxygen should be administered to prevent hypoxia.
38 Nursing Care of the Geriatric Trauma Patient—Planning and Implementation InterventionsCirculationConsider early placement of pulmonary artery catheterInitiate laboratory studies early.Keep patient warmAdminister medications in doses recommended for older adultsSlide 41Aggressive care of the elderly trauma patient is important. In the initial management, fluid resuscitation should not be withheld. Hemodynamic monitoring devices such as pulmonary artery catheters or central venous pressure monitoring can assist in determining appropriate fluid balance, adequacy of fluid resuscitation, and preventing fluid overload.Lab studies should be sent promptly after arrival. Special attention should be paid to those patients who are on medications for anticoagulation. Reversal of the anticoagulation may need to be initiated emergently prior to surgery.The older adult trauma patient is prone to hypothermia due to the changes of aging. Trauma rooms should be kept warm, wet clothes removed, and warm blankets applied. Temperature should be monitored closely during the resuscitative stage.Analgesics and medications should be given in doses recommended for older adults. Dosages may need to be decreased due to altered organ function.
39 Assessing for Maltreatment Higher risk for maltreatmentHigh index of suspicionInconsistent history, unexplained injuries
40 Assessing For Maltreatment UnexplainedBruises or burnsFracturesHead injuryMalnutritionDehydrationSigns of confinement
41 Assessing For Maltreatment Lack of medical attentionCaregiver disinterestUnusual interaction between patient and caregiverEvidence of over-medication
42 Evaluation and Ongoing Assessment Assess vital signs frequently.Monitor cardiovascular and pulmonary response to resuscitation.Monitor temperature frequently.Slide 43Patients from these special populations require frequent re-evaluation and ongoing assessment.Vital signs should be assessed frequently. For pregnant trauma patients, this includes fetal heart rate and monitoring of uterine activity.The cardiovascular and pulmonary response to resuscitation should be evaluated.Monitor temperature frequently especially in pediatrics and the older adult populations.
43 The DistractorsAll those things that get in the way of allowing us to genuinely believe that there could be a head injury.
44 Dementia/Altered Mental Status Distinguish between acute, chronic onsetNever assume acute dementia or altered mental status is due to “senility”Ask relatives, other caregivers what baseline mental status is
45 Dementia/Altered Mental Status Possible CausesHead injury with subdural hematomaAlcohol, drug intoxication, withdrawalTumorCNS InfectionsElectrolyte imbalancesCardiac failureHypoglycemiaHypoxiaDrug interactions
46 Cerebrovascular Accident Emboli, thrombi more commonCVA/TIA signs often subtle—dizziness, behavioral change, altered affectHeadache, especially if localized, is significantTIAs common; 1/3 progress to CVAStroke-like symptoms may be delayed effect of head trauma
47 Seizures All first time seizures in elderly are dangerous Possible causesCVAArrhythmiasInfectionAlcohol, drug withdrawalTumorsHead traumaHypoglycemiaElectrolyte imbalance
49 Depression Common problem May account for symptoms of “senility” Persons >65 account for 25% of all suicidesTreat as immediate life threat!
50 Rehabilitation of the Geriatric Mild TBI Patient Will they qualify?Will they be taken?Will it matter?Does it matter?What works and what doesn’t work.
51 Tips and Pearls Assume limited physiologic reserves Minor injuries may be life-threatening“Stable” patients may quickly become unstableLow threshold for head, neck, and abdominal CTEarly invasive hemodynamic monitoringOne study (Scalea) demonstrated that trauma surgeons themselves frequently fail to recognize the severity of hemodynamic instability in geriatric patients – reducing the time to invasive monitoring from 5.5 to 2.2 hours, and recognizing and treating occult shock, survival rate went from 7 to 53%.
52 Tips and Pearls (cont.)Early, aggressive O2 and mechanical ventilationOverresuscitation is as detrimental as inadequate resuscitationLiberal use of blood transfusionConsider patient’s environment and social situationTransfusions will enhance oxygen delivery and help minimize ischemia.Administer crystalloid judiciously b/c diminished cardiac compliance can lead to CHF.
53 Prevention Discharged patients: - Home safety assessment - Carefully review medications- Suspend driver’s license?Arrange for a social worker to conduct a home safety assessment
54 Summary Aggressive treatment approach There is no such thing as a mild head injury or minor trauma with the elderlyConsider triage to trauma centerSlide 44The care of special populations that have experienced trauma requires knowledge of their unique anatomic and physiologic differences. Trauma in pregnant, pediatric, and older adult patients must be treated differently.Assessment, intervention, and evaluation must be guided by the unique response to traumatic injury.It is recommended that nurses who care for pediatric patients attend the Emergency Nurses Association’s Emergency Nursing Pediatric Course (ENPC).For those interested in more education related to the care of older adults, it is recommended that nurses take the Geriatric Emergency Nursing Education (GENE) Course.