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Trauma in the Elderly Nathanael Wood, MD Albany Medical Center March 21, 2007 Case Study 1 83 year-old female Driver, belted, no airbag deployment Parking lot speed, minimal auto damage No complaints Highest HR en route: 90 Lowest SBP en route: 110 Boarded and collared PMH: HTN, osteopenia PSH: Cholecystectomy Meds: Lopressor, calcium Social: Non smoker, non-drinker Vitals on Arrival to ED HR 95, BP 115/85, RR 18, T 98, O2 97% RA Primary Survey A: Patent B: Breathing comfortably, equal breath sounds b/l C: Radial and femoral pulses equal, strong D: No deficits Secondary Survey General: Awake, alert HEENT: NC/AT Neck: hard collar, NT CV: RRR, pulses equal/strong throughout Lungs: CTA BL Abd: soft, NT, ND, bowel sounds present Extremities: no deformities, no tenderness, FROM Neuro: Non focal examination, A&O X3 ED Course Neck cleared using NEXUS criteria, hard collar removed No imaging indicated Pt refused analgesia Signed out to next resident: Needs to ambulate, likely d/c soon ED Course, continued Patient unable to ambulate CT Abdomen, pelvis… Grade 3 liver laceration Admitted to hospital for observation D/C after two days ED Course, continued Then, one day after d/c… Neck discomfort. Back to ED. CT neck… C5 fracture D’OH! How did we miss all that? Unlucky? Different physiology? Medications? The “Elderly” What is “Elderly” or “Geriatric”? 55? 65? 70? Depends The “Elderly” 12% of the population is over age 55 36% of all ambulance transports 25% of hospitalizations >85, fasted growing age group The “Elderly” In 2000, 35 million aged 65+ By 2030, 70 million aged 65+ 20% of US population 70% of ambulance transports “Geriatric” > 70 Exhibits significant anatomical or physiological characteristics associated with advanced aging. Trauma in the Elderly Fifth leading cause of death, > 65 years Significant cause of morbidity. Minor trauma may result in functional decline. Older patients have worse outcomes despite lesser injury severity. Types of Trauma Falls MVAs Violence Burns Falls Falls and the Elderly Leading cause of elder trauma Occur in 1/3rd of independent elders More common in nursing home residents 10% of falls result in significant injury Severity/frequency increases with age May be a symptom of general decline 50% 1 year mortality if hospitalized for a fall MVAs MVAs and the Elderly 13-15% of all MVAs Higher incidence of 2 vehicle MVAs Pedestrian-MVAs Mortality MVAs and the Elderly: Patterns Intersections Good weather Close to home During daylight Geriatric Abuse & Neglect Geriatric Abuse & Neglect Physical, psychological injury of older person by their children or care providers Knows no socioeconomic bounds Geriatric Abuse & Neglect Contributing factors Advanced age: average mid-80s Multiple chronic diseases Sleep pattern disturbances leading to nocturnal wandering, shouting Family has difficulty upholding commitments Geriatric Abuse & Neglect Primary findings Trauma inconsistent with history History that changes with multiple tellings Burns Burns and the Elderly More likely to suffer injury Unable to evacuate burning structures Cognitive impairment Decreased coordination Older homes (wiring, smoke detectors, etc.) Burns and the Elderly High mortality rates 50% BSA burn <65 years, 50% fatal >65 years, approaching 100% fatal Effects of Aging Cardiovascular System Speed, force of myocardial contraction decreases Cardiac conducting system deteriorates Resistance to peripheral blood flow rises, elevating systolic blood pressure Blood vessels lose ability to constrict, dilate efficiently What effects will these changes have on ability to compensate for shock? For heat and cold exposure? Respiratory System Respiratory muscles lose strength; rib cage calcifies, becomes more rigid Respiratory capacity decreases Gas exchange across alveolar membrane slows Cough, gag reflexes diminish increasing risk of aspiration, lower airway infection What will be the consequences of these changes during chest trauma? Musculoskeletal System Osteoporosis develops, especially in females Spinal disks narrow, resulting in kyphosis Joints lose flexibility, become more susceptible to repetitive stress injury Skeletal muscle mass decreases What effect do these changes have on incidence and severity of orthopedic trauma? Packaging? Backboards? Intubating? Long term outcomes? Nervous System Brain weight of decreases 6 to 7% Brain size decreases Cerebral blood flow declines 15 to 20% Nerve conduction slows up to 15% What effect will decreased nerve conduction have on pain sensation and reaction time? How will brain degeneration change the effect of head trauma? Gastrointestinal System Senses of taste, smell decline Gums, teeth deteriorate Saliva flow decreases Cardiac sphincter loses tone, esophageal reflux becomes more common Peristalsis slows Absorption from GI tract slows What effects can these changes have on the nutrition of older persons? How does this change the response to traumatic injury? Renal System Renal blood flow decreases 50% Functioning nephrons decrease 30 to 40% What effect will these changes have on ability to eliminate drugs from the body? Integumentary System Dermis thins by 20% Sweat glands decrease; sweating decreases What effect will this have on: Severity of burn injuries? Wound healing? Cold and heat tolerance? Geriatric Assessment Factors Complicating Assessment Variability Older people differ from one another more than younger people do Physiological age is more important than chronological age Factors Complicating Assessment Response to illness Seek help for only small part of symptoms Perceive symptoms as “just getting old” Delay seeking treatment Trivialize chief complaints Factors Complicating Assessment Presence of multiple pathologies 85% have one chronic disease; 30% have three or more One system’s acute illness stresses other’s reserve capacity One disease’s symptoms may mask another’s One disease’s treatment may mask another’s symptoms Factors Complicating Assessment Altered presentations Diminished, absent pain Depressed temperature regulation Depressed thirst mechanisms Confusion, restlessness, hallucinations Generalized deterioration Vague, poorly-defined complaints Factors Complicating Assessment The Organs of the Aged Do Not Cry! Factors Complicating Assessment Communication problems Diminished sight Diminished hearing Diminished mental faculties Depression Poor cooperation, limited mobility Factors Complicating Assessment Polypharmacy Too many drugs! 30% of geriatric hospitalizations drug induced Anti-hypertension drugs (beta-blockers) may mask early signs of shock Diuretics (Lasix, HCTZ) may make pt relatively dehydrated History Taking Probe for significant complaints Chief complaint may be trivial, non-specific Patient may not volunteer information History Taking Dealing with communication difficulties Talk to patient first If possible, talk to patient alone Formal, respectful approach Position self near middle of visual field Do not assume deafness or shout Speak slowly, enunciate clearly History Taking Do NOT assume confused or disoriented patient is “just senile!” History Taking Obtain thorough medication history More than one doctor More than one pharmacy Multiple medications Old vs. current medications Shared medications Over-the-counter medications Physical Exam Examine in warm area May fatigue easily May have difficulty with positioning Consider modesty Decreased pain sensation requires thorough exam Physical Exam If they say it hurts, it probably REALLY hurts! EXAMINE CAREFULLY Physical Exam Misleading findings Inelastic skin mimics decreased turgor Mouth breathing gives impression of dehydration Inactivity, dependent position of feet may cause pedal edema Rales in lung bases may be non-pathologic Peripheral pulses may be difficult to feel Trauma Head Injury More likely, even with minor trauma Signs of increased ICP develop slowly Patient may have forgotten injury, delayed presentation may be mistaken for CVA Decreased brain mass increases risk of ICH What change in the elderly accounts for increased ICP’s slower onset? Cervical Injury Osteoporosis, narrow spinal canal increase injury risk from trivial forces Sudden neck movements may cause cord injury without fracture Decreased pain sensation may mask pain of fracture Hypovolemia & Shock Decreased ability to compensate Progress to irreversible shock rapidly Tolerate hypoperfusion poorly, even for short periods Hypovolemia & Shock Hypoperfusion may occur at “normal” pressures Medications (beta blockers) may mask signs of shock Cardiac and renal disease make fluid resuscitation more risky. Why can older persons be hypoperfusing at a “normal” blood pressure? Positioning & Packaging May have to be modified to accommodate physical deformities Environmental Considerations Environmental Considerations Tolerate temperature extremes poorly Contributing factors Skin changes Cardiovascular disease Endocrine disease Poor nutrition Drug effects Environmental Considerations HIGH INDEX OF SUSPICION Any patient with altered LOC or vague presentation in hot or cool environment Which came first? Which came first? Trauma or… MI? PE? CVA? TIA? Dementia? Intoxication? Spontaneous fracture? Summary The elderly are coming. Minor mechanisms can create major injuries. No complaint does not mean no injury. Minor injuries can cause major morbidity. What came first: injury or the trauma? CV disease and medications can mask early signs of shock. Lower threshold for transport to trauma center. Questions? Thank you.