0. International Trauma Life Support, 6e
Trauma in the Elderly 18
Key Lecture Points
Review 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.

1. Trauma in the Elderly
NOTE: In U.S., has wealth of information. QuickFacts (quickfacts.census.gov) and American FactFinder (factfinder.census.gov) allow you to get detailed demographic information for states, counties, and cities.
NOTE: Check national census data.
“Elderly”
Often understood as being 65 years or older, but chronological age is not most reliable definition of “elderly.”
More appropriate to consider biological processes that change with time, such as fewer number of neurons, decreased functioning of kidneys, and decreased elasticity of skin and tissues.
Discuss aging population in your area.
United States:
U.S Census: 12% of population aged 65 years and older—expected to double in next 25–30 years.
Age group 85 and older now fastest-growing segment of population.
More than 30% of all patients transported by ambulance are older than age 65.
© Pearson

2. Overview Changes that occur with aging Assessment of geriatric trauma
How changes affect assessment of geriatric trauma
Assessment of geriatric trauma
Management of geriatric trauma

3. Trauma in the Elderly
Fatal 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 death
Falls
Fractures of hip, femur, humeral/wrist, head injuries
Motor-vehicle collisions
Higher incidence of collision
Thermal injury
Inhalation, scalding, flame burns, electrical injury
NOTE: 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 decreased
Hearing decreased
Postural instability
Arthritis
Fragile skin and blood vessels
Fragile bones
A 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
Decreased
Pulmonary circulation 30%
Alveolar exchange
Capacity and work rate
Chest wall movement
Inhalation time
Vital capacity due to increased residual volume
NOTE: 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.
Airway
Potential obstructions due to caps, bridges, dentures, and fillings. Gums shrink with age, causing dentures to become loose.
Respiratory system
Decreased alveolar exchange means decreased carbon dioxide and oxygen exchange.
Decreased inhalation time leads to rapid breathing.

7. The Aging Body
From 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 edema
Circulation decreased
Cardiac output and stroke volume decreased
Conduction system degenerates
Heart valve efficiency decreased
Arteriosclerosis
Peripheral vascular resistance increased
Systolic hypertension
Circulation 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 skull
Brain arteries harden, narrow, lose elasticity
Unrecognized injury
Blood flow to brain decreased
Sensory responses decreased
Pain tolerance increased
Altered mental status
Changes 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 deteriorates
Subcutaneous tissue decreased
Afebrile with infection
Mechanisms 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 decreased
Blood filtration decreased
Immune system
Infection
Malnutrition
Sepsis
Immune response decreased
Decrease 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.

12. The Aging Body Musculoskeletal system Postural changes Fractures
Kyphotic deformity of spine
Slight flexion of knees and hips
Muscle strength decreased
Fractures
Advanced osteoporosis
Bone density decreased
Subcutaneous tissue decreased
NOTE: Emphasize importance of neutral alignment/positioning specific for that patient (pediatrics, adults, and geriatrics).
Exhibit changes in posture.
Decrease in total height due to narrowing of vertebral discs, slight flexion of knees and hips, and decreased muscle strength.
Result in kyphosis or kyphotic deformity of spine (“S” curvature of spine often seen in stooped elderly).
NOTE: Need to pad SMP accordingly.
More susceptible to fractures.
Advanced osteoporosis—a thinning of bone resulting in a decrease in bone density.
Diminished subcutaneous tissue.
Decreases protection from falls and blunt trauma.
Decreases ability to respond to temperature changes.
Weakening in strength of muscle and bone from decrease in physical activity.
More susceptible to fractures with only a slight fall.
© Pearson

13. The Aging Body Gastrointestinal system Overall system changes
Malnutrition
Decreased ability to metabolize medications
Overall system changes
Prolonged illness and recovery time
Decreased total body water leads to dehydration
Gastrointestinal system
Decreases 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 time
Increased risk of intracranial and other bleeds
Antihypertensives and peripheral vasodilators limit constriction response
Increased risk of shock
Beta-blockers limit tachycardia response
Missing red flag signs of hypovolemia
Anti hyperglicemic agents
Increased risk of hypoglicemia
Many 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, renal
Chronic illness complicates trauma care
Difficult to distinguish
Bones fracture more easily
Major bone fractures can be life-threatening
General 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.

16. Assessment Do not underestimate severity Die from less-severe injuries
May not report important symptoms
Pain response, hypoxia, hypovolemia vary
Multiple illnesses
Communications
Geriatric patient assessment, as any assessment, must take into account priorities, interventions, and life-threatening conditions.
You must search for important signs or symptoms. The patient may minimize or even deny symptoms out of fear of becoming dependent, bedridden, institutionalized, or even of losing a sense of self-sufficiency.
You may have difficulty communicating with patient. This could result from patient's diminished senses, hearing or sight impairment, or depression. The geriatric patient nonetheless should not be approached in a condescending manner. Do not allow others to take over reporting of events from patient who is able and willing to communicate reliable information.
Explain any actions, including removing any clothing, before initiating physical assessment.
© Pearson

17. ITLS Patient Assessment
ITLS Primary and Secondary Surveys
Anticipate complicating factors
Peripheral pulses difficult to evaluate
Many layers of clothing
Chronic disease vs. acute problem
Nonpathologic rales
Loss of skin elasticity and mouth breathing
Dependent edema
Variation in normal vital signs
Use 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 area
Indications that unable to provide own care
Alcohol or medication abuse
Signs of violence, abuse, neglect
Notify proper authorities
Gather medications and take to hospital
Better to verify history in area where patient unable to overhear—otherwise, implying that patient is incompetent.
Abuse and neglect of elderly are common.

19. Initial Assessment Initial level of consciousness Chest injuries
Clarify baseline mental level before trauma
(get collateral information from family)
Preexisting condition or trauma
Check blood glucose
Chest injuries
More likely serious
Spinal precautions
Arthritis and kyphosis
Initial level of consciousness has more significance with elderly patients than with younger patients, because subsequent health-care providers may attribute a decreased level of consciousness to a preexisting condition rather than to trauma.
This is less likely to occur if you clearly indicate that:
Family and bystanders report this is an abnormal presentation, or
Patient was clear, lucid, and cooperative at scene.
Airway is likely to be partially obstructed.
Be alert to possible teeth fragments due to decay and gum disease and dental devices such as caps, bridges, dentures, and fillings.
Chest injuries more likely to cause serious problems in older people with poor pulmonary reserve.
Be especially alert to problems with chronic lung disease.
Usually have borderline hypoxia even when not injured.
Briefly notice heart sounds so you will have a baseline for changes such as development of muffled heart sounds.
Take extra care when performing SMR on geriatric trauma patient including padding void areas that may be exaggerated due to aging process.
Kyphosis will require padding under shoulders and head to maintain neck in usual alignment.
Do not force neck into neutral position if it is painful to do so, or if neck is obviously fused in a forward position.
Remember: SMR needs to be in an anatomically neutral position specific to each patient to be neutral for spinal cord and airway. Although texts often recommend age ranges (including ITLS), SMR is principle-driven. Appropriate padding should be used for all age groups and situations (elderly, American football shoulder pads, infants, obesity, etc.).
© Pearson

20. Critical Transport Decision
International Trauma Life Support, 6e
Low threshold for early transport
Same 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 failure
Frequently assess pulmonary status
Lung sounds
Cardiac monitoring
Pulse oximetry
Capnography
Do not withhold fluid if needed
Volume 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 difficult
Physiologic processes of aging
Frequent concurrent illnesses
Medication effects
Limited compensation mechanisms
Respiratory and circulatory support essential
If 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.