Chapter 39 Special Considerations in Trauma

Chapter 39 Special Considerations in Trauma
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Objectives Image source: Microsoft clipart

Trauma in Pregnancy

Mechanisms of Injury Effects of trauma on the fetus depend on:
Length of the pregnancy (age of the fetus) Type and severity of trauma Severity of blood flow and oxygen disruption to the uterus

Mechanisms of Injury [Insert figure 39-10]

Mechanisms of Injury Falls
Become more common after the 20th week of pregnancy Center of gravity shifts as the size of the abdomen increases Image source: Microsoft clipart One in four pregnant women experiences a fall during pregnancy, becoming more common after the 20th week of pregnancy. A woman’s center of gravity shifts as the size of her abdomen increases during pregnancy and her pelvic ligaments loosen. As a result, a pregnant patient must readjust her body alignment and balance, which increases her risk for falls and injury. Some of these falls are a result of slippery floors, hurrying, or carrying objects.

Mechanisms of Injury Intimate partner violence
Physical abuse can result in the following conditions: Blunt trauma to the abdomen Severe bleeding Uterine rupture Miscarriage Premature labor Premature rupture of the amniotic sac For some women, pregnancy is a time when intimate partner violence starts. Physical abuse can result in the following conditions: Blunt trauma to the abdomen Severe bleeding Uterine rupture Miscarriage Premature labor Premature rupture of the amniotic sac

Mechanisms of Injury Burns
A thermal burn of more than 20% of the mother’s body surface area increases the risk of fetal death. In cases of electrical burns, the likelihood of fetal death is high, even with a rather low electrical current. A thermal burn of more than 20% of the mother’s body surface area increases the risk of fetal death. In cases of electrical burns, the likelihood of fetal death is high, even with a rather low electrical current. This is most likely because the fetus is floating in amniotic fluid and has a low resistance to the current.

Anatomic and Physiologic Changes
Diaphragm becomes elevated Resting respiratory rate increases Movement through the gastrointestinal tract decreases Mother’s blood volume circulates through the uterus every 8 to 11 minutes at term. Uterus begins to rise out of the pelvis and becomes susceptible to injury. Anatomic changes occur during pregnancy that affects nearly every organ system. In the respiratory system, the diaphragm becomes elevated and the mother’s resting respiratory rate increases because of the enlarging uterus. During pregnancy, the speed with which food and liquids move through the gastrointestinal tract decreases, increasing the risk of vomiting and aspiration after trauma. The mother’s blood volume circulates through the uterus every 8 to 11 minutes at term. As a result, the uterus can be a source of significant blood loss if injured. Before the 12th week of pregnancy, the uterus is protected by the bones of the pelvis. After the 12th week of pregnancy, the uterus begins to rise out of the pelvis and becomes susceptible to injury. By the 20th week, the uterus is at the level of the umbilicus and at 34 to 36 weeks it reaches the costal margin. Thus the risk of trauma to the mother and fetus increases as pregnancy progresses. As the uterus increases in size, the mother’s abdominal organs are displaced superiorly. This displacement decreases the likelihood of injury to the mother’s liver, spleen, and intestines but increases the likelihood of uterine and fetal injury.

Increased plasma volume Increased volume of red blood cells Heart rate gradually increases by as much as 10 to 15 beats/min During the first 6 months of pregnancy, systolic blood pressure may drop 5-10 mm Hg. Diastolic blood pressure may drop by mm Hg. During the last 3 months of pregnancy, blood pressure returns to near normal. Early in the pregnancy, the mother’s body begins to produce more blood to carry oxygen and nutrients to the fetus, resulting in an increased plasma volume and an increased volume of red blood cells. Her heart rate gradually increases by as much as 10 to 15 beats/min during pregnancy. During the first 6 months of pregnancy, the mother’s systolic blood pressure may drop by 5-10 mm Hg. Her diastolic blood pressure may drop by mm Hg. During the last 3 months of pregnancy, her blood pressure gradually returns to near normal.

Changes in vital signs during pregnancy can make it difficult to detect shock When shock occurs: Blood is shunted from nonvital organs to vital organs Uterine arteries constrict Decreased perfusion to the uterus You will recall that an increase in heart rate is one of the earliest signs of shock. The changes in vital signs that typically occur during pregnancy can make it difficult to detect shock, particularly in late pregnancy. When shock occurs, the mother’s blood pressure is preserved by the shunting of blood from nonvital organs, such as the uterus, to vital organs. Constriction of the uterine arteries decreases perfusion to the uterus, potentially compromising the fetus to save the mother. The fetus will often show signs of distress before any change in maternal vital signs. In fact, the healthy pregnant patient can lose 30% to 35% of her blood volume with no change in vital signs. However, her condition will rapidly worsen when blood loss exceeds this amount.

Patient Positioning The uterus grows from a pre-pregnancy size of 70 g to a term pregnancy size of about 1000 g. When a woman in late pregnancy is placed on her back, the weight of the fetus compresses major blood vessels, such as the inferior vena cava and the aorta. This compression decreases the amount of blood returning to the mother’s heart and lowers her blood pressure (supine hypotensive syndrome). As a result, the amount of oxygen and nutrients delivered to the fetus is decreased. A woman who is 20 weeks pregnant or more should be positioned on her left side. Positioning the patient on her left side shifts the weight of her uterus off the abdominal vessels. If the patient is immobilized to a backboard, tilt the board slightly to the left by placing a rolled towel, small pillow, blanket, or other padding under the right side of the board. Doing so will shift the weight of the patient’s uterus and decrease the pressure on the abdominal blood vessels.

Abruptio Placentae [Insert figure 39-8A]
If the placenta is partially separated, bleeding may be minimal (dark red) or absent.

Abruptio Placentae [Insert figure 39-8B]
If the placenta is completely separated, severe hemorrhage can occur (bright red bleeding).

Uterine Rupture Tearing (rupture) of the uterus Possible causes:
Strong labor for a long period Most common cause Abdominal trauma Severe fall Sudden stop in a motor vehicle collision A ruptured uterus is the tearing (rupture) of the uterus. Uterine rupture can occur when the patient has been in strong labor for a long time (the most common cause) or when the patient has sustained abdominal trauma, such as a severe fall or sudden stop in a motor vehicle collision.

Restraint Systems Women should use automobile restraints while pregnant. Correct seat belt use can significantly reduce both maternal and fetal injury. Image source: Microsoft clipart Women should use automobile restraints while pregnant, whether driving or riding as a passenger. Correct seat belt use can significantly reduce both maternal and fetal injury following motor vehicle crashes. Studies have shown that unbelted pregnant women are twice as likely to experience vaginal bleeding and two times more likely to give birth within 48 hours of a crash than properly belted pregnant women are. Fetal death is three to four times more likely to occur when pregnant women are unbelted. Injuries can occur if restraints are improperly worn. In a motor vehicle crash, uterine rupture can occur if a lap belt is worn too high over the pregnant uterus. Wearing a lap belt without a shoulder strap can result in compression of the uterus with possible uterine rupture or abruptio placentae. During pregnancy, correct positioning of the lap belt is underneath the pregnant abdomen across the hips and high on the thighs. The shoulder strap should be positioned snugly between the breasts and off to the side of the pregnant abdomen.

Penetrating Trauma Gunshot wounds are more common than knife wounds.
Maternal outcome is usually favorable Fetal death rate is high Image source: Microsoft clipart Penetrating trauma in pregnancy is usually the result of gunshot or knife wounds, of which gunshot wounds are more common. Abdominal stab wounds during pregnancy usually occur in the upper abdomen above the umbilicus. Stab wounds to the lower abdomen are more likely to injure the uterus. Although the maternal outcome of penetrating trauma in pregnancy is usually favorable, the fetal death rate is high.

Cardiac Arrest Diaphragm elevated during pregnancy
May be necessary to ventilate using less volume Chest compressions should be performed higher on the sternum Slightly above the center of the sternum If the patient is 20 weeks pregnant or more, Perform chest compressions with the patient tilted 15° to 30° to the left Cardiac arrest in the pregnant trauma patient poses some unique challenges. Because the pregnant patient’s diaphragm is elevated during pregnancy, it may be necessary to ventilate using less volume. Chest compressions should be performed higher on the sternum, slightly above the center of the sternum. If the patient is 20 weeks pregnant or more, it will be necessary to perform chest compressions with the patient on a backboard tilted 15° to 30° to the left to offset the problems associated with supine hypotension.

Assessment of the Pregnant Trauma Patient

Patient Assessment Scene size-up Evaluate mechanism of injury
Remember that you have two patients to consider – the mother and the fetus. Assess ABCs while maintaining spinal stabilization Never withhold oxygen from a pregnant trauma patient.

Patient Assessment Short on-scene time
Rapid transport to trauma center ALS intercept or air medical resources may be needed Image source: Microsoft clipart

Patient Assessment (If the mechanism of injury involved a motor vehicle crash) Were you wearing a seatbelt? Lap belt and shoulder strap? Did you feel the baby move before the trauma? After the trauma? Did you experience any direct trauma to your abdomen? Are you experiencing any contractions? Are you experiencing any vaginal bleeding?

Patient Assessment Did your water break? If yes, what color was it?
When was your last menstrual period? What is your due date? Have you received any prenatal care? Is this your first pregnancy? How many babies are expected? Do you have any medical problems (diabetes, high blood pressure)?

Emergency Care

Emergency Care Put on appropriate PPE. Keep on-scene time to a minimum. If spinal injury is suspected, immobilize the patient to a long backboard. Tilt the board to the left if the patient is 20 weeks pregnant or more. Establish and maintain an open airway. Administer 100% oxygen. Continue monitoring oxygenation using pulse oximetry. Control external bleeding. Put on appropriate PPE. Keep on-scene time to a minimum. If spinal injury is suspected, immobilize the patient to a long backboard and tilt the board to the left if the patient is 20 weeks pregnant or more. Establish and maintain an open airway. Have suction equipment within arm’s reach. Administer 100% oxygen. If the patient’s breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered. Continue monitoring oxygenation using pulse oximetry. Control external bleeding by applying direct pressure to the wound with a sterile dressing. If blood soaks through the dressing, apply additional dressings and reapply pressure. If signs of shock are present or if internal bleeding is suspected, treat for shock. Protect the patient’s modesty and provide emotional support. Keep the patient warm.

Emergency Care Generally, the pregnant trauma patient who has a heart rate of more than 110 beats/min, chest or abdominal pain, loss of consciousness, or is in her third-trimester of pregnancy should be transported to a trauma center. Follow your local protocols. Reassess at least every 5 minutes en route. Transport promptly. Generally, the pregnant trauma patient who has a heart rate of more than 110 beats/min, chest or abdominal pain, loss of consciousness, or is in her third-trimester of pregnancy should be transported to a trauma center. Follow your local protocols. Reassess at least every 5 minutes en route. En route, relay the patient’s due date, injuries, vital signs, and care provided to the receiving facility. Doing so allows time for appropriate healthcare professionals and equipment to be mobilized and ready for the patient’s arrival. Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

Pediatric Trauma

Mechanisms of Injury Motor vehicle-related injuries
Car-pedestrian incidents The injury pattern seen in a child may be different from that seen in an adult. For example, if an adult is about to be struck by an oncoming vehicle, he will typically turn away from the vehicle. This results in injuries to the side or back of the body. In contrast, a child will usually face an oncoming vehicle, resulting in injuries to the front of the body. In a motor vehicle crash, an unrestrained infant or child will often have head and neck injuries. Restrained passengers often have abdominal and lower spine injuries. Child safety seats are often improperly secured, resulting in head and neck injuries. Contributing factors to pediatric motor vehicle–related injuries include failure to use (or improper use of) passenger restraints, inexperienced adolescent drivers, and alcohol abuse. Deaths resulting from pedestrian injuries are common among children 5 to 9 years of age. The child is unable to judge the speed of the traffic and typically bolts out into the street. Children are often injured while chasing a toy, friend, or pet into the path of an oncoming vehicle. A child struck by a car is likely to sustain injury to the head, chest or abdomen, and an extremity (Waddell’s Triad). The vehicle first strikes the left side of the child. The bumper contacts the left femur, and the fender strikes the left side of the child’s abdomen. The child is thrown against the vehicle’s hood or windshield. The child is thrown to the ground, striking his head on the pavement as the vehicle comes to a stop. The child is then often run over by the vehicle.

Mechanisms of Injury Bicycle-related injuries Drowning
Fire-related injuries Penetrating trauma Falls Sports-related injuries Abuse and neglect Bicycle-related injuries often involve head trauma, abdominal injuries (from striking the handlebars) and trauma to the face and extremities. Sports injuries often involve injuries to the head and neck. Drowning is a significant cause of death and disability in children younger than 4 years of age. Alcohol appears to be a significant risk factor in adolescent drowning. Most fire-related deaths occur in private residences, usually in homes without working smoke detectors. Smoke inhalation, scalds, and contact and electrical burns are especially likely to affect children younger than 4 years of age. Injuries caused by a firearm include an entrance wound, exit wound, and an internal wound. Most guns used in unintentional shootings are found in the home and often found loaded in readily accessible places. The presence of a gun in the home has been linked to an increased likelihood of adolescent suicide. Falls are a common cause of injury in infants and children. Infants and young children have large heads in comparison to their body size, making them more prone to falls. Note the distance of the fall, the surface on which the child landed, and the body area(s) struck. Any fall more than 10 feet or more than 2-3 times the child’s height should be considered serious. Concrete and asphalt are associated with more severe injuries than other surfaces. Children who land on hard ground or concrete sustain more severe injury than those who hit grass, even when the heights of the falls are similar. If the child fell from a height or was diving into shallow water, suspect injuries to the head and neck.

The head is large and heavy compared with body size Blood vessels of the face and scalp bleed easily When the head is struck, it jars the brain Brain bounces back and forth Causes multiple bruised and injured areas Children are prone to head injuries because their heads are large and heavy when compared to their body size. The younger the child, the softer and thinner the skull is. The force of injury is more likely to be transferred to the underlying brain instead of fracturing the skull. The blood vessels of the face and scalp bleed easily. Even a small wound can lead to major blood loss. When the head is struck, it jars the brain. The brain bounces back and forth, causing multiple bruises and injured areas.

Shaken baby syndrome Also called abusive head trauma May cause brain trauma Can lead to severe brain damage or death Never shake or jiggle an infant or child. Shaken baby syndrome (also called abusive head trauma) may cause brain trauma. The National Center on Shaken Baby Syndrome defines shaken baby syndrome as a term used to describe the group of signs and symptoms resulting from violent shaking or shaking and impacting of the head of an infant or small child. Shaken baby syndrome occurs when an infant or child is shaken by the arms, legs, or shoulders with enough force to cause the baby’s brain to bounce against his skull. Just 2 to 3 seconds of shaking can cause bruising, swelling, and bleeding in and around the brain. It can lead to severe brain damage or death. Never shake or jiggle an infant or child.

Chest Soft, pliable ribs May have significant injuries without external signs Signs of blunt trauma to the chest and abdomen may be hard to see on the body surface. The younger the patient, the softer and more flexible his ribs are. Therefore, rib fractures are less common in children than in adults. However, the force of the injury can be transferred to the internal organs of the chest, resulting in major damage. The presence of a rib fracture in a child suggests that major force caused the injury. Bruising of the lung (pulmonary contusion) is one of the most frequently observed chest injuries in children. This injury is potentially life threatening.

Abdomen More common site of injury than in adults Often a source of hidden injury The abdomen is a more common site of injury in children than in adults. The abdomen is often a source of hidden injury. In fact, abdominal trauma is the most common cause of unrecognized fatal injury in children. The abdominal organs of an infant or child are prone to injury because the organs are large and the abdominal wall is thin. As a result, the organs are closer to the surface of the abdomen and less protected. In infants and young children, the liver and spleen extend below the lower ribs. Their location gives them less protection and makes them more susceptible to injury. A swollen, tender abdomen is a cause for concern.

Pelvic fractures Uncommon in children Extremity trauma Common in children Managed in the same way as for adults Pelvic fractures are uncommon in children. However, when they do occur, they are often the result of the child’s being struck by a moving vehicle. Because the pelvis contains major blood vessels, you must be alert for signs of internal bleeding and shock. Extremity trauma is common in children. The younger the child, the more flexible his bones are. When a child has multiple injuries, fractures are often missed. Assessing non-displaced fractures in young children can be difficult because they cannot verbalize well. If a child is not walking on an injured extremity or using an upper extremity during normal activity, suspect a fracture until proven otherwise. Fractures of both thighs can cause a major blood loss, resulting in shock. Extremity injuries in children are managed in the same way as for adults.

Patient Assessment Scene size-up Evaluate the mechanism of injury
Put on appropriate PPE Comfort, calm, and reassure the patient Keep on-scene time to a minimum. If major trauma: Request ALS personnel to the scene or consider an ALS intercept Do not delay transport for ALS arrival. When arriving on the scene, complete a scene size-up before beginning emergency medical care. Evaluate the mechanism of injury before approaching the patient and put on appropriate PPE. Be sure to comfort, calm, and reassure the patient throughout your assessment. Keep on-scene time to a minimum. In situations involving major trauma, request an early response of ALS personnel to the scene, or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival.

Patient Assessment Perform a primary survey
Assume that any patient who has an injury above the collarbones has a spinal injury and immobilize accordingly. Provide padding under the torso of infants and young children to maintain the cervical spine in a neutral position. As you approach the patient, form a general impression and assess the child’s appearance, work of breathing, and skin color. Perform a primary survey to determine the presence of life-threatening injuries. If the child is not alert or the mechanism of injury suggests that the child experienced trauma to the head or neck, stabilize the child’s spine. Assume that any patient who has an injury above the collarbones has a spinal injury and immobilize accordingly. An unresponsive infant or child should always be immobilized, especially when the cause is unknown. Remember that you may need to place padding under the torso of infants and young children to maintain the cervical spine in a neutral position.

Patient Assessment Airway Keep the airway open and clear of secretions
Gurgling or stridor may indicate an upper airway obstruction. Vomiting is common Keep young infant’s nasal passages clear Use jaw thrust maneuver to open airway Making sure the child’s airway is open and clear of secretions is the most important step in managing a trauma patient. Gurgling or stridor may indicate an upper airway obstruction. Vomiting is common in the pediatric trauma patient. Make sure suction is within arm’s reach. Suction the mouth as needed with a rigid suction catheter. Because a young infant breathes primarily through his nose and not his mouth, be sure to keep the nasal passages clear. If the patient is unresponsive, use the jaw thrust maneuver to open the airway. Insert an oral airway to help keep the airway open.

Patient Assessment Carefully assess rate and depth of breathing.
Rates that are too fast or slow can indicate respiratory failure. Look for signs of increased work of breathing. Give supplemental oxygen to all pediatric trauma patients. A pulse oximeter should be routinely used and continuously monitored in any trauma patient. Because inadequate breathing is common in the pediatric trauma patient, carefully assess the rate and depth of the patient’s breathing. The respiratory rate of an infant and child is faster than that of an adult. Rates that are too fast or slow can indicate respiratory failure. Look for signs of increased work of breathing, such as retractions and accessory muscle use. If the child’s breathing is inadequate or there is no air movement, assist breathing with bag-mask or mouth-to-mask ventilation. Remember to ventilate with just enough force to produce gentle chest rise to reduce the risk of gastric distention. Give supplemental oxygen to all pediatric trauma patients, even if there is no apparent breathing difficulty. A pulse oximeter should be routinely used and continuously monitored in any trauma patient.

Patient Assessment Control obvious bleeding if present.
Check for signs of shock Mental status Heart rate Peripheral versus central pulse quality Skin color Capillary refill time If the child is 6 years of age or younger Control obvious bleeding if present. Check for signs of shock by assessing the child’s mental status, heart rate, peripheral versus central pulses, and skin color. In an injured child, delayed capillary refill time (if the child is 6 years of age or younger), cool distal extremities, and decreases in peripheral versus central pulse quality are generally more reliable signs of shock than blood pressure. This is because a healthy child can maintain a normal blood pressure until he has lost 25% to 30% of his total blood volume. The extremities of a young child may appear mottled in response to cold. Remember to keep the child warm. If signs and symptoms of shock are present with a closed head injury, look for signs of other injuries (such as internal bleeding) that may be the cause of the shock.

Patient Assessment Assess the child’s mental status AVPU scale
Glasgow Coma Scale Obtain patient’s vital signs Vary by age A slow pulse rate indicates hypoxia until proven otherwise. Normal vital signs in an injured child can be deceiving. Assess the child’s mental status using the AVPU scale and follow with a repeat assessment using the Glasgow Coma Scale. Repeat your mental status assessment each time you repeat the patient’s vital signs. Obtain the patient’s vital signs, recognizing that respiratory rates, pulse rates, and blood pressures vary by age. A blood pressure in children younger than 3 years of age is unreliable. Remember to assess a brachial pulse in infants. Regardless of age, a slow pulse rate in an infant or child indicates hypoxia until proven otherwise. Normal vital signs in an injured child can be deceiving. It is essential to obtain vital signs frequently and look closely for changes in the child’s respiratory rate, heart rate, and blood pressure that may indicate impending respiratory failure or shock.

Patient Assessment Obtain a SAMPLE history.
Remember to talk to your patient. Keep the family informed. Obtain a SAMPLE history from the patient or family members. Throughout your assessment and delivery of emergency care to the patient, remember to talk to your patient. Keep the family informed of what you are doing and where the patient will be transported for further care.

Emergency Care Put on appropriate PPE.
Keep on-scene time to a minimum. Request an early response of ALS personnel to the scene or consider an ALS intercept. If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard Establish and maintain an open airway. Give oxygen. Put on appropriate PPE. Keep on-scene time to a minimum. Request an early response of ALS personnel to the scene, or consider an ALS intercept while en route to the receiving facility. Do not delay transport for ALS arrival. If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard. Provide padding beneath an infant and young child from the shoulders to the hips during immobilization to prevent flexion of the neck. Establish and maintain an open airway. Give oxygen. If the patient’s breathing is inadequate, assist his breathing with a bag-mask device connected to 100% oxygen. Monitor oxygenation with a pulse oximeter. Consider the cause of a slow heart rate in a pediatric patient a sign of hypoxia and assist ventilation as needed.

Emergency Care Promptly seal an open chest wound with an airtight dressing. Control external bleeding. If signs of shock are present or if internal bleeding is suspected, treat for shock. Keep the patient warm. Do not remove penetrating objects. Manage avulsed or amputated parts as other soft tissue injuries. Reassess at least every 5 minutes. Promptly seal an open chest wound with an airtight dressing. Tape the dressing on 3 sides. If signs and symptoms of a tension pneumothorax develop after an airtight dressing has been applied, release the dressing. Reassess the patient’s airway, breathing, circulation, and mental status. If the patient’s breathing returns to normal, replace the airtight dressing and again secure it in place over the wound by taping it in place on 3 sides. Control external bleeding by applying direct pressure to the wound with a sterile dressing. If blood soaks through the dressing, apply additional dressings and reapply pressure. If signs of shock are present or if internal bleeding is suspected, treat for shock. Keep the patient warm. Do not remove penetrating objects; rather, stabilize in place with bulky dressings. Manage avulsed or amputated parts as other soft tissue injuries. Extremity injuries should be stabilized by immobilizing the joint above and below the fracture site. In the critical patient, this should be done en route to a trauma center as time permits. Remember to assess pulses, motor function, and sensation in the affected extremity before and after immobilization. Reassess at least every 5 minutes. Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

Trauma in Older Adults

Mechanisms of Injury Falls are the most common cause of injury in older adults. Most falls occur at home and are low-level falls (falls from a standing height). Injuries to the head, pelvis, and lower extremities are common. Falls are the most common cause of injury in older adults. Most falls involving older adults occur at home and are low-level falls (falls from a standing height). Injuries to the head, pelvis, and lower extremities are common. Fractures sustained during a fall usually involve the hip, femur, and wrist. Factors that increase an older adult’s risk of falling include the following: Older age Female gender Sedative use Impaired vision Syncope Arthritis Lower extremity weakness Balance difficulties History of stroke, previous fall Environmental hazards (rug, stairs, lighting, uneven ground)

Mechanisms of Injury Motor vehicle crashes
Injuries similar to those of younger patients Increased incidence of sternal fractures from seatbelts. Pedestrian versus vehicle incidents High death rate, usually from a severe head or major vascular injury Motor vehicle crashes involving older adults often occur during the daytime, close to home, and at an intersection. Factors increasing the risk of MVCs in older adults include decreased hearing and vision and slower reaction time. Injuries sustained by older adults in MVCs are similar to those of younger patients except adults over 65 years of age have an increased incidence of sternal fractures from seatbelts. Pedestrian versus vehicle incidents involving older adults are associated with a high death rate, usually from a severe head or major vascular injury. The older adult is frequently struck within a marked crosswalk or walks directly into the path of an oncoming vehicle. Factors increasing the risk of pedestrian versus vehicle incidents include poor eyesight and hearing, decreased mobility, and longer reaction times.

Mechanisms of Injury Burn injuries Death rate in older adults is high
Any older adult who has experienced a burn injury should be triaged to a burn center, if available in your area. Most burn injuries in the older adult occur at home. Although the frequency of burn injuries is lower in older adult than in younger patients, the death rate from burn injuries in older adults is high. Any older adult who has experienced a burn injury should be triaged to a burn center, if available in your area.

Possible Signs of Elder Abuse
Bruises, black eyes, welts, lacerations, rope marks Bone fractures, skull fractures Untreated injuries in various stages of healing Older adult’s report of being hit, slapped Physical signs of punishment Signs of being restrained Older adult’s sudden change in behavior Caregiver’s refusal to allow visitors to see an older adult alone

Higher risk of cerebral bleeding following head trauma Increased risk of falls Reduced blood flow to organs A “normal” blood pressure in an older adult who is usually hypertensive may actually represent hypotension. Changes associated with aging in the pulmonary, cardiovascular, neurologic, and musculoskeletal systems make older adults susceptible to trauma. As the brain shrinks with age, there is a higher risk of cerebral bleeding following head trauma. Loss of strength, sensory impairment, and medical illnesses increase the risk of falls. Skeletal changes cause curvature of the upper spine that may require padding when stabilizing the spine. Cardiovascular system changes associated with aging include thickening of the blood vessels, decreased vessel elasticity, and increased peripheral vascular resistance, which contribute to reduced blood flow to organs. There is often a marked increase in the systolic blood pressure and a slight increase in the diastolic blood pressure because of increased peripheral vascular resistance. In some situations, a “normal” blood pressure in an older adult who is usually hypertensive may actually represent hypotension.

Medications may include: Cardiac drugs Diuretics (“water pills”) Sedatives, antidepressants Anticoagulants Older adults often take multiple medications including cardiac drugs, diuretics (“water pills”), sedatives, antidepressants, and medications that affect blood blotting. Tachycardia, an early indicator of shock, may not be evident in the older adult taking cardiac medications such as beta-blockers and calcium channel blockers. The patient who is taking a diuretic may have a decreased blood volume even before an injury occurs. Sedatives and antidepressants can alter mental status, increasing the older adult’s risk of injury. Many older adults who have a history of stroke, an irregular heart rhythm, or who have had a heart valve replaced are prescribed anticoagulants (such as aspirin, Coumadin, Plavix), which affect the blood’s ability to clot. Anticoagulants can worsen bleeding, such as in situations involving internal and external hemorrhage and intracranial bleeding.

Patient Assessment Scene size-up Evaluate the mechanism of injury
Put on appropriate PPE Scan your surroundings Conduct a scene size-up and ensure your safety. Put on appropriate PPE and evaluate the mechanism of injury before approaching the patient. If you have been called to the patient’s residence, take a moment to scan your surroundings. Is the home well kept or littered with trash? An untidy home may be a symptom of decreased mobility, depression, or lack of interest in self-care. Falls leading to trauma must be investigated as to the reason for the fall and the information relayed to healthcare professionals at the receiving facility. Is the temperature in the room reasonable based on the time of year, or too hot or too cold? A cold home in winter or very warm home in the summer may be a symptom of a fixed income and rising electric bills.

Patient Assessment Remove dentures if they do not fit well.
Cough reflex may be diminished Suction as needed Use a pulse oximeter to monitor oxygenation. Older adult’s pulse may be irregular Slower than expected heart rate may be caused by prescribed cardiac medications. As you approach the patient and form a general impression, note the patient’s appearance, work of breathing, and skin color. Fractures of the spinal column are common in older adults. If trauma is suspected, carefully assess the patient’s airway while maintaining spinal stabilization. Keep in mind that the older adult may wear dentures that, if ill fitting, may cause an airway obstruction. If they do not fit well, remove them. An older adult’s cough reflex may be diminished, so suction as needed to keep the airway open. Assess the patient’s rate, depth, and rhythm of breathing. Give 100% oxygen, assisting ventilation as needed. Use a pulse oximeter to monitor oxygenation. Assess the patient’s circulatory status and control hemorrhage with direct pressure, if present. When assessing the patient’s pulse, note its rate, rhythm, and quality. Bear in mind that an older adult’s pulse may be irregular, and a slower than expected heart rate may be caused by prescribed cardiac medications.

Patient Assessment Assess level of consciousness using the AVPU scale
Follow the AVPU assessment using the Glasgow Coma Scale. Obtain a Revised Trauma Score and document your findings. Initially, assess the patient’s level of consciousness using the AVPU scale. Assessing the mental status of an older adult trauma patient can be challenging, particularly if the patient has a medical condition such as Alzheimer’s disease. In situations like this, it will be difficult to determine if the patient has an altered mental status that is “new” versus what is “normal” for the patient. If a family member or caregiver is available, ask what is normal for the patient and compare their response with your assessment findings. Follow the AVPU assessment with one using the Glasgow Coma Scale (GCS). Obtain a Revised Trauma Score and document your findings.

Patient Assessment Expose the patient as necessary.
Respect the patient’s modesty. Keep him covered as much as possible to maintain warmth. Treat any life-threatening injuries before proceeding to the secondary survey. Generally, it is a good idea to do a head-to-toe examination of any older adult who has been injured. Expose the patient as necessary, remembering to respect his modesty. Because the older adult’s ability to regulate body heat production and heat loss is altered, it is important to minimize the areas of the body exposed, keeping him covered as much as possible to maintain warmth. Treat any life-threatening injuries before proceeding to the secondary survey. Generally, it is a good idea to do a head-to-toe examination of any older adult who has been injured, including repeated vital sign assessments. A thorough examination is important because even minor injuries in an older adult can be significant. Carefully assess the patient using the DCAP-BTLS memory aid to ensure injuries are not missed. Remember to look for medical jewelry that can provide valuable information regarding the patient’s history.

Emergency Care Put on appropriate PPE.
Keep on-scene time to a minimum. Cervical spine precautions Establish and maintain an open airway. Administer supplemental oxygen Continue monitoring oxygenation using pulse oximetry. Control external bleeding. Put on appropriate PPE. Keep on-scene time to a minimum. If spinal injury is suspected, maintain manual in-line stabilization until the patient is secured to a long backboard. The musculoskeletal system is the most commonly injured organ system in older adult trauma patients. Nontraditional immobilization techniques and extra padding may be necessary to adapt to musculoskeletal changes, such as curvature of the upper spine. Establish and maintain an open airway. Because respiratory difficulty can develop quickly, make sure that airway adjuncts and suction equipment are readily available. Administer supplemental oxygen to all older adult trauma patients. If the patient's breathing is adequate, apply oxygen by nonrebreather mask at 15 L/min. If the patient's breathing is inadequate, provide positive-pressure ventilation with 100% oxygen and assess the adequacy of the ventilations delivered. Continue monitoring oxygenation using pulse oximetry. Control external bleeding by applying direct pressure to the wound with a sterile dressing. If blood soaks through the dressing, apply additional dressings and reapply pressure. If signs of shock are present or if internal bleeding is suspected, treat for shock.

Emergency Care Do not remove penetrating objects.
Manage avulsed or amputated parts as other soft tissue injuries. Do not touch protruding organs. Keep the patient warm. Reassess at least every 5 minutes. Do not remove penetrating objects; rather, stabilize in place with bulky dressings. Manage avulsed or amputated parts as other soft tissue injuries. Every effort should be made to locate the amputated part. Do not touch protruding organs. Carefully remove clothing from around the wound. Apply a large sterile dressing, moistened with sterile water or saline, over the organs and wound. Secure the dressing in place with a large bandage to retain moisture and prevent heat loss. Protect the patient’s modesty and provide emotional support. Keep the patient warm. Transport promptly. Reassess at least every 5 minutes. Record all patient care information, including the patient’s medical history and all emergency care given, on a PCR.

Trauma in the Cognitively Impaired Patient

Cognitively Impaired Patient
Cognition Mental functioning Cognitive impairment A change in a person’s mental functioning caused by an injury or disease process Affects a person’s ability to process, plan, reason, learn, understand, and remember information Cognition refers to mental functions including memory, learning, awareness, reasoning, judgment, and the ability to think, plan, form and comprehend speech, process information, and understand and solve problems. A cognitive impairment refers to a change in a person’s mental functioning caused by an injury or disease process. A cognitive impairment affects a person’s ability to process, plan, reason, learn, understand, and remember information.

Examples of conditions that may involve cognitive impairment Alzheimer’s disease Vascular dementia Down’s syndrome Autistic disorders Traumatic brain injury History of a stroke

Signs and symptoms vary Patient may be confused or easily agitated Some patients bang their heads. Others injure themselves or are unafraid of danger, making them more susceptible to trauma. Some patients have difficulty communicating and interacting with other people. Although signs and symptoms vary, a patient with a cognitive impairment may be confused or easily agitated. Some patients bang their heads. Others injure themselves or are unafraid of danger, making them more susceptible to trauma. Some patients have difficulty communicating and interacting with other people. The patient may seem withdrawn, may not make eye contact with you, and may become agitated if they are touched. The degree of cognitive impairment varies. Many patients attend school, maintain a job, and are cared for at home. Others may be bed ridden or under nursing home care.

The patient may be an unreliable historian Past medical history Events of trauma Adult patient may not be legally able to consent to treatment

Can you tell me why you called us today? What is the patient’s name? How does the patient normally communicate? How aware is he of the environment? What are his usual motor skills and level of activity? What is his usual sleep pattern and appetite? Does he have any problems with his sight? Does he have any problems with his hearing? Family members and caregivers often are important resources that should be tapped when you are called to provide care to a cognitively impaired patient. They will know the patient’s medical history. They will also know if the patient’s vital signs, assessment findings, or capabilities are different from normal. This information can help you assess the urgency of the patient’s condition.

Generally, it is helpful to have a caregiver present during the physical exam. Ask for the patient’s name and use it when providing patient care. Ask the patient’s family or caregiver to describe the patient’s normal mental status. Attempt to take the patient’s vital signs when he is calm. Generally, it is helpful to have a caregiver present during the physical exam. Ask for the patient’s name and use it when providing patient care. Ask the patient’s family or caregiver to describe the patient’s normal mental status. Then ask if the patient’s behavior today is different from usual and if so, how the behavior is different. The AVPU and Glasgow Coma Scales may not be accurate for these patients. While enlisting the help of the family, attempt to take the patient’s vital signs when he is calm. Patients with mild to moderate cognitive impairment can often communicate the presence of pain through verbal or nonverbal communication and rate the intensity of their pain. Careful observation of the patient’s posture and facial expressions can be helpful when determining the presence or absence of pain. Family members or caregivers can also provide important information about changes in the patient’s behavior that might indicate the presence of pain. Attempt to make the patient as comfortable as possible during transport.

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Chapter 39 Special Considerations in Trauma

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Chapter 39 Special Considerations in Trauma

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