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Chapter 44 Geriatric Emergencies National EMS Education Standard Competencies Special Patient Populations Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. National EMS Education Standard Competencies Geriatrics Impact of age-related changes on assessment and care National EMS Education Standard Competencies Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies − Cardiovascular diseases − Respiratory diseases − Neurologic diseases − Endocrine diseases National EMS Education Standard Competencies Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies (cont’d) − Alzheimer disease − Dementia − Fluid resuscitation in the elderly National EMS Education Standard Competencies Normal and abnormal changes associated with aging, pharmacokinetic changes, psychosocial and economic aspects of aging, polypharmacy, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies − Cardiovascular diseases − Respiratory diseases − Neurologic diseases National EMS Education Standard Competencies Normal and abnormal changes associated with aging, pharmacokinetic changes, psychosocial and economic aspects of aging, polypharmacy, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies (cont’d) − Endocrine diseases − Alzheimer disease − Dementia National EMS Education Standard Competencies Normal and abnormal changes associated with aging, pharmacokinetic changes, psychosocial and economic aspects of aging, polypharmacy, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies (cont’d) − Fluid resuscitation in the elderly − Herpes zoster − Inflammatory arthritis National EMS Education Standard Competencies Patients With Special Challenges • Recognizing and reporting abuse and neglect • Health care implications of − Abuse − Neglect − Homelessness − Poverty − Bariatrics National EMS Education Standard Competencies • Health care implications of − Technology − Hospice/terminally ill − Tracheostomy care/dysfunction − Home care − Sensory deficit/loss − Developmental disability National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. National EMS Education Standard Competencies Special Considerations in Trauma Recognition and management of trauma in − Pregnant patient − Pediatric patient − Geriatric patient National EMS Education Standard Competencies Pathophysiology, assessment, and management of trauma in the − Pregnant patient − Pediatric patient − Geriatric − Cognitively impaired patient Introduction • Geriatrics: Assessment and treatment of disease in those 65 years or older • Geriatric patients account for 36% of all hospital stays in the United States. − Receive more care outside of hospitals Introduction • Old-age dependency ratio − Number of older people for every 100 younger adults − Used to: • Compare differences in age structure between time periods in a single society • Compare age structures between societies Introduction • “Graying of America”—describes increasing number of older Americans − As number of older Americans increases, need for physicians increases − Need for cost-effective/efficient services Introduction • Most prehospital geriatric patients will not reside in nursing homes. − Nursing home admissions increasing as numbers of elderly increase. − Countertrend—older persons maintaining independent lives Introduction • Considerations in deciding living arrangements: − Marital status − Financial resources − − − − Religious beliefs Ethnicity Gender General health Introduction • Grown children affected by decision − May seek help from • Medical social workers • Professional care managers • Discharge planners at health care facilities • Other private and public resources Introduction • Available services include: − Delivered meals − Personal care − Housekeeping − Transportation − Caregiver support Introduction • Financial situation affects living conditions/decisions − Older Americans are: • More likely to have assets • May have delayed retirement • More likely to have health insurance Introduction • Psychosocial factors influencing aging: − May feel useless or unproductive in society, leading to self-esteem issues − Might mourn/feel frustrated over loss of ability − May feel freedom, sense of accomplishment Introduction • Crisis of integrity versus despair: − Integrity—pride in accomplishments − Despair—haven’t accomplished goals • Bereavement over loss of friends and loved ones. − Leads to isolation and loneliness Geriatric Anatomy and Physiology • Aging process begins in late 20s, early 30s • Organ and tissue aging may be accelerated by: − − − − Genetics Preexisting disease Diet and activity levels Toxin exposure Geriatric Anatomy and Physiology • Aging rate varies from person to person. • Decrease in functional capacity is normal − Affects how body responds to illness © Photodisc Changes in the Respiratory System • Reduction of respiratory capacity in aging − Lung elasticity decreases − Size/strength of muscles decreases − Costochondral cartilage calcifies • Causes chest wall to stiffen Changes in the Respiratory System • Vital capacity decreases and residual volume increases. • Changes in blood flow distribution in the lungs results in declining partial pressure of oxygen (PaO2). Changes in the Respiratory System • Decreased sensitivity/CNS response to arterial blood gases changes • Slower reaction to hypoxia and hypercarbia • Limited lung volume and maximal inspiratory pressure • Limited chest expansion Changes in the Respiratory System • Ability to modify respiratory rate/tidal volume in response to changes is limited. • Defense mechanisms less effective − Cough and gag reflex decreased − Ciliary mechanisms slowed Changes in the Cardiovascular System • Cardiovascular system decreases efficiency with age − Heart hypertrophies − Cardiac output declines Changes in the Cardiovascular System • Arteriosclerosis adds to systolic hypertension, as a consequence of: − Diabetes − Atherosclerosis − Renal compromise Changes in the Cardiovascular System • Vascular stiffening occurs as collagen and elastin production changes with age. − Causes widening pulse pressure, decreased coronary artery perfusion, changes in cardiac ejection efficiency Changes in the Cardiovascular System • Aortic sclerosis—aortic valve thickens from fibrosis and calcification − Obstructs blood flow from left ventricle − Leads to aortic stenosis • Peripheral vessel walls lose elasticity. − Leads to higher blood pressure, other risks Changes in the Cardiovascular System • Heart’s electrical conduction system deteriorates over time. − Number of pacemaker cells decreases with age. − Bradycardia can occur. − Primary pacemaker can fail. Changes in the Cardiovascular System • Aging makes cardiovascular system more vulnerable to dysfunction − Heart less efficient at baseline − Effects of acute circulatory change much worse • Potential cardiac compromises should be recognized and treated quickly. Changes in the Nervous System • Normal neurological findings in elderly commonly include changes in: − Thinking (cognitive) speed − Memory − Postural stability • Brain decreases in weight and volume. Changes in the Nervous System • As mental function declines, so does regulation of: − Respiratory rate and depth − Pulse rate − Blood pressure − Hunger and thirst − Temperature Sensory Changes • Most sensory organs decline with age. − Decreased ability to see and hear − Decreased ability to taste − Decreased tactile sensation • Do not assume the elderly are deaf or blind. Sensory Changes • Vision problems affect 50% of seniors. − Most common visual disturbances in elderly: • Cataracts—hardening of lenses over time • Glaucoma—optic nerve damaged due to intraocular pressure Sensory Changes • Visual acuity decreases even without disease: − Difficulty seeing at night − Inability to adjust to rapid changes − Presbyopia (far-sightedness) − Difficulty differentiating between colors Sensory Changes • Gradual hearing loss is common with aging. − Presbycusis: Inhibited ability to discriminate between background noise and particular sound − Results in decreased ability to interpret speech − May threaten safety Sensory Changes • Hearing aids are very common assistive devices in the United States − Consist of microphone and amplifier − May fit in ear canal − Mainly battery operated © Maxx-Studio/ShutterStock, Inc. Sensory Changes • Meniere disease: hearing-related impairment − Two out of 1,000 people, onset in middle age − Symptom cycles last several months: • Vertigo • Hearing loss and tinnitus • Pressure in ear Sensory Changes • Other sensory changes: − Decrease in number of taste buds − Decrease in sense of touch − Sense of smell last to diminish Sensory Changes • Changes may make it difficult to produce speech that is loud enough, clear, and well spaced. • Sense of body position may become impaired. Changes in the Digestive System • Changes may be first noted in the mouth. − Fewer taste buds: lower appetite − Reduction of saliva: dry mouth − Dental loss: tooth and gum disease • Not directly from aging Changes in the Digestive System • Ill-fitting dentures may cause risk of: − Choking − Heartburn − Abdominal pain Changes in the Digestive System • Gastric secretions are reduced. − Esophageal sphincter weakens. − Slower gastric emptying Changes in the Digestive System • Slight changes in small and large bowel functions from aging − Rectal sphincter decreases in size, strength • Fecal incontinence − Increased constipation from slowing peristalsis Changes in the Digestive System • Constipation also caused, worsened by: − Some medications − Diet changes and decreased physical activity • Can cause straining bowel movements Changes in the Digestive System • Hepatic enzyme changes—some system activity declines and other systems increase. − Activity that detoxifies drugs declines, complicating drug absorption, leads to toxicity − If numerous medications, risk for hepatic damage or drug toxicity increases Changes in the Renal System • Kidneys are responsible for: − Maintaining fluid and electrolyte balance − Helping maintain body’s long-term acid-base balance − Eliminating drugs from the body Changes in the Renal System • Kidneys decline in weight with age. − Loss of function nephrons, causing smaller filtering surface − Decrease in renal blood flow by up to 50% Changes in the Renal System • Aging kidneys respond slowly to sodium deficiency, causing electrolyte imbalance. − Results in severe dehydration • Exacerbated by decreased thirst mechanism Changes in the Renal System • At risk of overhydration with large sodium loads − Aging kidneys have lower glomerular filtration rate − Capability of handling potassium reduced by same factors Changes in the Endocrine System • Elderly have greater risk for developing type 2 diabetes: • Difficulty metabolizing carbohydrates • Often have comorbid disorders (medications can affect glucose metabolism) Changes in the Endocrine System • Increase in antidiuretic hormone (ADH) as people age: − Causes electrolyte and fluid imbalances − May present as pedal or other peripheral edema • Menopause—decrease in hormone secretion Changes in the Immunologic System • Every immune system function affected by aging − More prone to infection and secondary complications − Infections manifest differently in older people. Changes in the Integumentary System • Wrinkling and resiliency loss in skin − Skin thinner, drier, less elastic, more fragile − Subcutaneous fat thinner, bruising − Elastin and collagen decrease − Skin more prone to tenting in skin turgor tests Changes in the Integumentary System • Sebaceous glands produce less oil, skin drier. − Sweat gland activity decreases. − Hair follicles produce thinner or no hair. − Follicles produce less melanin, causing gray or white hair. Changes in the Integumentary System • Atherosclerosis affects blood vessels. − Less oxygenated blood to skin • Producing new skin takes longer. • Fingernails and toenails thinner and more brittle Homeostatic and Other Changes • Process by which the body maintains a constant internal environment − Feedback principle—change in internal environment feeds back to induce corrective response Homeostatic and Other Changes • Homeostatic capabilities decrease with age. − Thirst mechanism • Dehydration − Temperature regulating mechanism • Absence of febrile response − Blood glucose regulatory system • Elevated blood glucose levels Changes in the Musculoskeletal System • Decrease in bone mass in men and women − Causes brittle, easily breakable bones • Joint problems − Tendons and ligaments lose elasticity. − Synovial fluids thicken − Cartilage decreases Changes in the Musculoskeletal System • Height decreases, posture changes − Intervertebral disks narrowing − Vertebrae compression fractures • Arthritic joints increase. • Muscle mass and strength decrease. • Muscles atrophy. Changes in the Musculoskeletal System • More susceptible to bone fractures from falls − Falls more likely because: • Joint stiffness • Loss of tendon and ligament elasticity • Muscle weakness • Difficulty with tasks requiring fine motor coordination or hand and finger strength Geriatric Patient Assessment • Illness not inevitable with aging − Getting old is not a disease, does not produce symptoms of disease by itself • Widespread incorrect belief that elderly people are hypochondriacs − Older patients tend to not complain, even with real symptoms. Geriatric Patient Assessment • Signs, symptoms altered from aging − MIs may not accompany chest pain − Pneumonia may not include fever. − Uncontrolled diabetes may present as HONK or HHNC. − Some afflictions present as delirium. Geriatric Patient Assessment • Debilitating health problems include: − Hypertension and heart disease − Arthritis − Cancer − Diabetes − Stroke or COPD Geriatric Patient Assessment • Multiple pathologic conditions: − Symptoms of one disease may hide or alter symptoms of another. − Disturbance in one body system may cause a domino effect. − May be difficult to determine which condition is causing which symptoms Scene Size-Up • Ensure scene safety. • Determine mechanism of injury or illness. • Be aware of factors affecting assessment: − Sensory alterations − Verbal communication skills − Mental and physical capabilities Primary Assessment • Use GEMS diamond to form a general impression. − G—Geriatric patient − E—Environmental assessment − M—Medical assessment − S—Social assessment Primary Assessment • Airway and breathing − Geriatric patients are predisposed to airway problems. − Ensure airway is not obstructed. − Anatomic changes lessen effective breathing. − Treat airway and breathing issues with oxygen ASAP. Primary Assessment • Circulation − If circulation is normally compromised, fewer reserves in a circulatory crisis. • Lower heart rate • Radial pulse difficult to find • Heart rhythm issues lead to irregular pulse. − Treat with oxygen as soon as possible. Primary Assessment • Transport decision − Provide transport to priority patients: • Poor general impression • Airway or breathing problems • Altered level of consciousness • Shock, severe pain • Uncontrollable hemorrhage History Taking • Use good communication skills. − Be respectful. − Speak slowly and distinctly. • Attempt a thorough history if possible. History Taking • Listen to patient, wait for answers. − Be patient. − Pay attention to tone for fear and confusion. − Be aware of nonverbal communication. • Explain plan. • Preserve patient’s dignity. History Taking • Comprehensive history includes: − Chief complaint − Present illness or injury − Pertinent medical history − Current health care status and needs History Taking • Determining chief complaint may be difficult because patients might: − Believe symptoms just part of getting old − Ignore legitimate symptoms because they don’t want to be labeled a hypochondriac − Underreport symptoms or report vague symptoms History Taking • If the chief complaint seems trivial, use a standard list of screening questions to evaluate major organ systems functions. − Follow up on any positive answers. History Taking • After deducing chief complaint, conduct history of present illness: − May be difficult to separate from chronic problems. Ask: • How does this differ from last week? • What happened today to make you call? History Taking • Obtain detailed history of medications. − Have patient list by name, dosing and frequency, and provider. − Obtain permission to bring medications to hospital. Secondary Assessment • Adjust usual methods to fit elderly patient. − Limit physical manipulation. − Be aware of body temperature. − Only remove clothing as necessary for inspection and palpation, and re-cover immediately. Secondary Assessment • Systematically check patient. • Postural BP changes vary with older people. − Marked BP changes and pulse rate—possible hypovolemia or overmedication • Normal BP tends to be higher. Secondary Assessment • Observe respiratory rate: − Tachypnea can indicate acute illness. − Take lung sounds in all fields. − Listen for carotid bruits, and note jugular vein distention. • Note any dentures. Reassessment • Reassess often—conditions deteriorate quickly. − Repeat primary assessment. − Reassess vital signs. − Reassess patient’s complaint. − Recheck interventions. − Treat changes. Respiratory Conditions • Top five causes of geriatric death include: − Chronic lower respiratory disease − Influenza − Pneumonia (most common) Pneumonia • Inflammation of the lung from infection by: − Bacteria − Viruses − Other organisms Pneumonia • Biggest impact on very young and elderly • Those considered at risk include: − The elderly − Those with underlying health problems − Those with a depressed immune system − Those who are generally immobile, confined to bed, or have conditions that limit deep breathing Pneumonia • Pneumonia symptoms in the elderly include: − Acute confusion (delirium) − Normal temperature − Wheezing instead of cough − Abdominal pain − Auscultated rhonchi in affected lobes Pneumonia • Treatment is supportive, including: − Fluids − Oxygen via nasal cannula or mask − Analgesics for fever Pneumonia • Preventive measures: − Pneumococcus vaccine • Booster doses after 3 to 5 years − Cessation of smoking − Respiratory exercises Chronic Obstructive Pulmonary Disease • Set of diseases characterized by bronchial obstruction and airway inflammation: − Chronic bronchitis − Emphysema − Asthma Chronic Obstructive Pulmonary Disease • Difficult to distinguish between diseases • Complicated by age-related loss of lung’s elastic tissue and decreased ability to fight infection − Baseline disability of COPD exacerbated Chronic Obstructive Pulmonary Disease • Preventative measures include: − Cessation of smoking − Avoidance of certain environmental pollutants − Immunization for influenza and pneumococcal pneumonia Chronic Obstructive Pulmonary Disease • Presenting symptoms: − Shortness of breath − Fatigue − Decreased activity level • Treatment: − Supplemental oxygen − CPAP − Bronchodilators − Inhaled or oral steroids − Antibiotics Asthma • Onset can occur in old age, with symptoms: − Shortness of breath − Chronic or nocturnal cough − Wheezing • If worsens with exertion, more susceptible to attacks. Asthma • Management is the same for all patient groups. − Except when cardiac disease coexists • Beta-adrenergic agents exacerbate cardiac symptoms. Pulmonary Embolism • Clot blocks blood vessel supplying lung − Results in irreversible damage or infarction − Commonly caused by deep venous thrombosis • Prevention is based on risk level. − Highest risk is surgical patients Pulmonary Embolism • Risk increases with age: − Increased immobility − Increased vascular stasis in lower extremities − Increased diseases associated with pulmonary embolus Pulmonary Embolism • Classic triad (dyspnea, chest pain, hemoptysis) is often altered or absent. − If suspected, check lower leg for: • Swelling • Erythema • Warmth or tenderness Pulmonary Embolism • Prehospital treatment supportive after ensuring airway and ventilation − Consider lysing the thrombus and the use of anticoagulation. − Rapid transport Cardiovascular Conditions • The heart’s lifetime workload affects the cardiovascular system throughout the entire body. • Heart attack or myocardial infarction is major cause of morbidity and mortality Myocardial Infarction • Death of part of the heart muscle from blockage of one of the coronary arteries • Chest pain may be absent or not as intense in elderly. • Elderly may report: − − − − − − Dyspnea Syncope Weakness Confusion Nausea Vomiting Myocardial Infarction • Major risk factors: − − − − − Tobacco use Hypertension Diabetes Obesity Lack of physical exercise − High cholesterol • Preventive strategies: − − − − − − Smoking cessation Healthy diet Blood glucose control Exercise Weight control Hypertension control Congestive Heart Failure • Most common reason for hospitalization in the older population • On the rise because: − People living longer − Getting better treatment for other diseases Congestive Heart Failure • Risk factors: − Gender − Ethnicity − Family history and genetics − Long-term alcohol abuse − Multiple medical conditions • Prevention: − − − − − − Smoking cessation Healthy diet Blood glucose control Exercise Weight control Hypertension control Congestive Heart Failure • Acute exacerbation results in pulmonary edema. − May present with dyspnea or orthopnea − Decreased oxygenation to all organ systems leads to mental changes. − Peripheral edema may indicate worsening CHF. Congestive Heart Failure • Presentation in elderly may mimic signs and symptoms of old age or other illnesses. • Acute exacerbation often linked to: − − − − Poor diet Medication noncompliance Onset of dysrhythmias Acute myocardial ischemia Congestive Heart Failure • Prehospital treatment same as with other populations − Need to familiarize yourself with medications and their implications for treatment − Complete evaluation of ETCO2 immediately. Congestive Heart Failure • Other treatment includes: − Fluid monitoring; avoidance of fluid overload − CPAP − If atrial fibrillation or flutter—digoxin or diltiazem − If atrial dysrhythmias—anticoagulation to prevent thromboembolism Dysrhythmias • Occur when heart electrical system has an interruption or malfunction − Causes heartbeats that are: • Too fast • Too slow • Irregular • Absent Dysrhythmias • In older population, usually result of: − Age-related heart changes − Existing cardiac disease − Adverse drug effects − Combination of factors Dysrhythmias • Classified where they originated in the heart − Tachydysrhythmias, bradydysrhythmias speed up or slow down heart − Premature beats alter regularity. − Atrial fibrillation increases risk of stroke, heart failure. Dysrhythmias • Bradycardias more common in elderly − Sinus abnormalities from aging conduction system − High-degree blocks produced by CAD. − Heart slowed by beta blockers or calcium channel blockers Dysrhythmias • Treatment same as younger adults • Survival depends on: − Prearrest health of patient − Early deployment of links in chain of survival Hypertension • More than 50% of elderly are hypertensive. • Controlling systolic and diastolic hypertension helps prevent stroke and MIs. Hypertension • Requires controlled blood pressure decline—often cannot be done in the field − Nitroglycerin for hypertensive emergencies highly debated • If rapid onset of systolic hypertension, use antihypertensive therapy Aneurysms • Weakness in artery produces balloon defect that weakens wall − Congenital or acquired − Contributing factors: • Hypertension • Atherosclerotic disease • Obesity Aneurysms • Can develop in brain, chest, or abdomen − New headache or change in chronic headache could indicate early cerebral bleeding. − Can cause stroke − Anticoagulants increase damaging effects. Aneurysms • Preventive measures: − − − − Proper diet Exercise Smoking cessation Cholesterol control • Asymptomatic until large or rupture • Early symptoms related to compression: − Difficulty swallowing − Hoarseness Aneurysms • Treatment of abdominal emergencies is surgery, so it is essential to: − Recognize problem early − Assess − Stabilize − Transport rapidly Traumatic Aortic Disruption • Also known as aortic dissection • Interior wall tears and blood collects between arterial wall layers. − Makes arterial wall prone to rupture. − Thoracic dissection can cause chest pain, and mimic cardiac ischemia. Stroke • More than 80% of all stroke deaths are in persons older than 65 years. − Leading cause of long-term disability − Risk doubles each decade after 35 years. Stroke • Reduce risk factors for prevention. − Improve diet. − Exercise. − Lower cholesterol. • Prehospital care includes: − Early recognition − Discovery of conditions that mimic stroke − Timely transport − Use of stroke assessment tool Stroke • Family members/caregivers give information about: − Baseline cognitive status, physical status − Personality − ADL • Evaluate patient’s ability to perform basic cognitive functions. Transient Ischemic Attack • Temporary disturbance of blood to brain resulting in sudden, temporary decrease in brain function − Symptoms same as stroke − Warning sign of future stroke − No long-term brain damage Neurologic Conditions • Normal age-related cognitive changes: − Relatively isolated − Not sudden or extreme Delirium • A symptom, not a disease − Temporary − Reflects underlying disturbance • Characterized by: − − − − − − − Disorganized thoughts Inattention Memory loss Disorientation Personality changes Hallucinations Delusions Delirium • Symptoms may mimic: − Intoxication − Drug abuse − Severe psychological disorders Delirium • Assess for recent changes in − Level of consciousness or orientation − Vital signs − Temperature − Glucose level − Medications Delirium • Often replaces or confounds typical presentations caused by: − Medical problems − Adverse medication effects − Drug or alcohol withdrawal Delirium • D: Drugs or toxins • I: Ictal (seizures) • E: Emotional • U: Undernutrition or underhydration • L: Low PaO2 • I: Infection • R: Retention of stool or urine • M: Metabolism • S: Subdural hematoma Delirium • Onset is abrupt (hours to days). • Usually resolves with treatment of underlying problem − Treatment may be complicated by uncooperative behavior. Dementia • Produces irreversible brain failure • Symptoms include: − Short-term memory loss, short attention span − Jargon aphasia − Confusion and disorientation − Difficulty retaining new information − Personality changes Dementia • May be caused by conditions that impair vascular and neurologic brain structures: − Infection − Stroke − Head injury − Poor nutrition − Medications Dementia • Two most common degenerative dementias: − Alzheimer disease − Multi-infarct or vascular dementia • 6% to 10% of elderly will eventually have dementia; risk increases with age. Dementia • Diagnosed when two or more cognitive or psychomotor brain functions are impaired: − Language − Memory − Visual perception − Emotional behavior/personality − Cognitive skills Dementia • Symptoms: − Progressive loss of cognitive function − Impairment of long- or short-term memory − Loss of communication skills − Inability to perform daily activities − Change in temperament and affect Dementia • No treatment, but can treat underlying medical problem • Obtain baseline abilities from caregivers. • Ask about new changes that prompted call. • Be cautious of patients. Alzheimer Disease • Most common form of dementia • Progressive function loss with subtle symptoms: − Lose things, have difficulty recalling names − Lose ability to think and reason clearly. − Forget identities and own experiences. Alzheimer Disease • About 4 million people diagnosed • Risk factors: − Family history − African American − Latino (earlier onset) − Less than 12 years of school Alzheimer Disease • Stages − Mild cognitive impairment • Forgetfulness • Difficulty in performing more than one task • Diminished problem-solving skills − Early-stage disease • Language problems • Misplacing items • Getting lost • Personality changes Alzheimer Disease • Stages (cont’d) − Progressed disease: − Severe or endstage, cannot: • Forget current events • Change sleep patterns • Understand language • Recognize close family members • Difficulty reading and writing • Perform self-care • Interact verbally Alzheimer Disease • Diagnosed by excluding other dementia • Prehospital treatment—supportive care and treating symptoms − Communicate slowly. − Check for other illnesses. − Consider antipsychotics if combative or dangerous. Alzheimer Disease • Daily medication may include: − Antidepressants − Cholinesterase inhibitors to prevent further decline • No single cause identified, not believed to be part of the normal aging process Parkinson Disease • Age-related neurologic disorder with two or more of these symptoms: − Resting tremor of extremity − Slowness of movement − Rigidity or stiffness of extremities or trunk − Poor balance Parkinson Disease • Caused by degeneration of substantia nigra, area of brain that produces dopamine • Wide range of functional loss, presenting as: − − − − Dyskinesia Dementia Depression Autonomic dysfunction − Postural instability Seizures • Incidence increased in elderly because of increase in risk factors: − Stroke − Dementia − Primary or metastatic brain tumors − Acute metabolic disorders Gastrointestinal Conditions • Constipation frequent problem, but should not be initial assumption in acute abdominal pain − Investigate causes with high mortality first. • Bleeding from acute abdominal aneurysm • Dead bowel from mesenteric ischemia Gastrointestinal Conditions • When assessing, ask for: − Food and fluid intake − History of abdominal complaints − Current bowel and bladder habits − Medications and supplements Bowel Obstruction • Large bowel obstructions likely from: − Cancer − Impacted stool − Sigmoid volvulus • Small bowel obstruction secondary to gallstones (cholelithiasis) Bowel Obstruction • Large and small intestine obstruction from: − Adhesions from previous surgery − Infection − Fascial defect (hernia) Biliary Disease • May present with or without small bowel obstruction, and include: − Cirrhosis − Hepatitis − Cholecystitis • Signs and symptoms: − Jaundice − Fever − Right upper quadrant pain − Vomiting or nausea Peptic Ulcer Disease • Main risk factors: − − − − Regular NSAID use Helicobacter pylori Other medications Stress • Main symptom: − Dyspepsia that improves immediately after eating Gastrointestinal Bleeding • Almost always from physiologic changes or pathologic processes • Decreased peristalsis increases likelihood of irritating substances damaging gastric lining. • Older patients often take medication that alters coagulation. Gastrointestinal Bleeding • Pathologic processes causing GI bleeding: − Ulcers and varices − Cancers of the GI tract − Diverticulitis − Cirrhosis − Bowel obstruction Gastrointestinal Bleeding • Esophagus: − Varicies and alcohol abuse − Violent vomiting, large amount of red, uncoagulated blood • Stomach: − Peptic ulcer disease − Red or darker, coffeeground emesis Gastrointestinal Bleeding • Bloody stool: − Bleeding from lower GI − Digested blood from stomach • Stool dark and tarry • Bright red blood in stool: − Diverticulitis − Large bowel obstruction − Anal fissures − Hemorrhoids Gastrointestinal Bleeding • Upper GI hemorrhage from: − Esophagus − Stomach − Duodenum • Older people more prone Gastrointestinal Bleeding • Lower GI hemorrhage— bleeding from colon and rectum − Hemorrhoids − Colon polyps − Cancer Gastrointestinal Bleeding • Risk factors: − History of previous lower GI bleeds − Signs or symptoms of colon cancer − Recent constipation or diarrhea − Use of blood thinners Gastrointestinal Bleeding • If hematocrit and hemoglobin decrease significantly during interfacility transport, may need to give blood • Severe lower GI bleeding requires immediate transport. Gastrointestinal Bleeding • Signs and symptoms from hypovolemia: − − − − − Agitation Dizziness Syncope Hypotension Changes in mental status • Signs and symptoms from underlying disease: − Jaundice − Hepatomegaly − Constipation or diarrhea − Pain with voiding − Abdominal pain Gastrointestinal Bleeding • Bleeding severity more important than cause in prehospital setting. − Slower bleeding • Pulse rate and systolic BP normal − Brisk bleeding • Hematemesis • Melena Urinary Tract Infections • Urinary tract infections most common hospital-associated infection causing sepsis. − Usually develop in lower urinary tract where normal flora grow in the urethra • More common in women − After age 50, risk increases for men. Urinary Tract Infections • Common risk factors: − − − − − − Diabetes Prostratitis Cystocele Urethrocele Kidney obstruction Indwelling urinary catheters • Present with: − − − − Fever Shortness of breath Poor urinary output Increased urinary frequency − Painful urination − Gastrointestinal symptoms Urinary Tract Infections • If indwelling catheter, check for: − − − − Sediment Opacity Color Presence of blood • Later signs and symptoms: − − − − Hypotension Tachycardia Diaphoresis Pale skin Renal Failure • Sudden decrease in rate of filtration through the glomeruli, leading to toxin accumulation in the blood • Develops if kidneys are no longer able to: − Excrete waste. − Concentrate urine. − Control electrolytes, pH, or blood pressure. Renal Failure • Risk factors: − − − − − − Diabetes Cardiac disease Pyelonephritis Hypertension Autoimmune disorders Polypharmacy • May need hemodialysis or kidney transplant • If hemodialysis is missed, can become an ALS emergency Renal Failure • Symptoms from missed hemodialysis treatment include: − Hypertension − Headache and fatigue − Anxiety − Anorexia and vomiting − Increased dark urination Renal Failure • Obtain a 12-lead ECG to check electrolytes. • Monitor: − All vital signs − ETCO2 − Breath and bowel signs • Transport to a facility with hemodialysis capabilities. • Administer fluids as necessary. • Treat any dysrhythmias. Incontinence • Few admit the problem, and fewer seek help. − Social and emotional impact • Can lead to: − Skin irritation and breakdown − UTIs Incontinence • As people age: − Bladder capacity decreases. − Sphincter muscle strength decreases. • Urinary sphincter pressure triggers need to urinate • Sphincter tone decrease means less indication of a full bladder. Incontinence • Treatment includes: − Bladder training programs − Medications − Physical therapy − Surgery (depending on cause) Incontinence • Be discreet and nonjudgmental. − If possible, help patients gather incontinence supplies before transport. − Cover patient until clothes can be changed. − Try to reduce time patients wear urine-soaked clothing during transport. Incontinence • Urinary retention opposite of incontinence − Difficulty or absence of voiding may come from many medical causes: • Benign prostate enlargement • Inflammation from bladder and UTI infection • Placement and removal of urinary catheter • Loss of bladder wall elasticity Incontinence • Temporary retention may lead to: − Pain − Abdominal distention − Acute or chronic renal failure Endocrine Conditions • Geriatric patients may present with: − Grave disease (hyperthyroidism) − Addison disease (hypoadrenalism) − Cushing syndrome (hyperadrenalism) − Osteoporosis − Diabetes Diabetic Disorders • Inability to oxidize complex carbohydrates because of impaired ability to produce insulin − Body cannot handle all the glucose in the blood. • People over age 65 years often have type 2 diabetes. Diabetic Disorders • Risk factors: − Normal aging contributes − Having more than one chronic disease − Family history − − − − Genetics Diet Obesity Sedentary lifestyle Diabetic Disorders • Causes two life-threatening conditions: − Hypoglycemia—blood glucose levels drop to 45 mg/dL or less − Hyperglycemia—blood glucose exceeds normal range of 70 to 120 mg/dL Diabetic Disorders • Geriatric patients at increased risk for hypoglycemia: − Confusion about medication doses or usage − Inadequate or irregular dietary intake − Inability to recognize warning signs due to cognitive problems − Blunted warning signs Diabetic Disorders • Symptoms of hypoglycemia: − Delirium − Mental status changes and confusion − Diaphoresis − Decreased respiratory effort • Symptoms of hyperglycemia: − − − − Fatigue Poor wound healing Blurred vision Frequent infections Diabetic Disorders • Symptoms of chronic hyperglycemia: − Polyuria (excessive urine output) − Polydipsia (excessive thirst) − Polyphagia (excessive eating) Diabetic Disorders • Geriatric patients more prone to HONK/HHNC • Risk factors for HONK/HHNC: − − − − − Infection Hyperthermia Hypothermia Cardiac disease or stroke Pancreatitis Diabetic Disorders • Signs and symptoms of HONK/HHNC: − Dizziness − Confusion − Altered mental status − Polydipsia Diabetic Disorders • Assess vital signs every 15 minutes. − Obtain a 12-lead ECG. − Monitor ETCO2 and ventilatory status throughout transport. − Monitor fluid resuscitation and electrolyte balance. Diabetic Disorders • Prevention lifestyle changes: − Dietary restrictions − Exercise − Controlling obesity • Long-term management: − Limiting carbs − Taking insulin and antihyperglycemics Thyroid Disorders • Many older patients are asymptomatic. • Manifests by general slowing of metabolic process from reduction or absence of thyroid hormone Thyroid Disorders • Signs and symptoms may look like aging: − Cold intolerance − Constipation − Dry skin − Weakness − Weight gain Thyroid Disorders • May require supplemental oxygen − Hypoglycemia—may need 50% dextrose (D50) − Hypothyroid—often diminished respiratory effort − Continued hormone level decrease may cause myxedema coma and physiologic decompensation. Immunologic Conditions • Infections can be severe and dangerous in the elderly. • Sepsis may occur. − Results from microorganisms in the bloodstream Immunologic Conditions • Patient may be: − Hot and flushed − Tachycardic − Tachypneic • Other signs: − Oral temp greater than 100.4°F or less than 96.8°F − Respiratory rate more than 20 breaths/min − Pulse rate more than 90 beats/min Toxicologic Conditions • Elderly prone to adverse reactions from changes in: − Drug metabolism—diminished hepatic function − Drug elimination—diminished renal function − Body composition—altered drug distribution − Responsiveness of drugs that affect the CNS Toxicologic Conditions • Body changes may affect medication use: − Vision decline leads to errors in administration of medicine. − May take more than normal doses: • Short-term memory loss leads to taking dose twice. • Inability to distinguish flavors Polypharmacy and Medication Noncompliance • Polypharmacy becomes problematic when medications interact: − Dosages not adjusted for multiple medications − Multiple organs affected − Increased likelihood of adverse reactions Polypharmacy and Medication Noncompliance • Chances of being hospitalized increases with number of medications. − Best dosage—lowest drug that achieves therapeutic effect • Medications may not be received because of caregiver theft. Polypharmacy and Medication Noncompliance • Noncompliance includes: − Failing to fill prescription − Administering medication improperly − Taking inappropriate medication Polypharmacy and Medication Noncompliance • Other issues: − Taking medication prescribed by different doctors who don’t know full medication regimen − Taking medication prescribed for someone else − Difficulty understanding drug regimen − Difficulty opening medication containers Pharmacokinetics • Toxic effects of drugs from aging-related alterations in pharmacokinetics • Predisposed to reactions by physiologic changes in body systems and composition − Medications affecting CNS most common source of adverse reactions. Pharmacokinetics • Reduction in nervous system response increases risk of adverse anticholinergic effects. • Reduced beta-adrenergic receptor sensitivity—most bronchodilators ineffective Pharmacokinetics • Diuretics, antihypertensive − Cause hypotension and orthostatic changes from reduced cardiac output, total body water decrease • Decreased glucose tolerance − Hyperglycemic effects from diuretics and corticosteroids Pharmacokinetics • Pharmacokinetics can be influenced by: − Diet − Smoking − Alcohol consumption − Other drug use Pharmacokinetics • Dosages often needs to be reduced in elderly. • Toxic effects present with: − Psychiatric symptoms − Cognitive impairment Drug and Alcohol Abuse • Alcohol is preferred substance of abuse among older people. • One third develop abuse problem after 65 years because of: − Loss of spouse − Declining health − Low self-esteem Drug and Alcohol Abuse • Prevalence attributed to: − Number of prescribed medications − Heightened vulnerability to abuse − Decreased body mass and total body water leads to higher blood alcohol concentrations. − Slower alcohol elimination from body Drug and Alcohol Abuse • Recognizing abuse can be difficult: − Well hidden or accepted by family and friends − Ask about issue—can complicate assessment Psychological Conditions • Depression not a part of normal aging. − Medical disease in about 6% of the elderly − May be normal, short-term reaction to event − Concern when persists for weeks • Sadness and restlessness • Fatigue and hopelessness Depression • Incidence growing in relation to progressive population aging • Treatable with medication and therapy • Can mimic effects of other medical problems Depression • Risk factors: − History of depression − Chronic disease − Loss of function, independence, significant others Depression • Elderly tend to not complain about feelings—may be difficult to recognize • Majority of elderly suicides in people who: − Were recently diagnosed with depression − Had seen primary care physician with month of event Depression • Completed suicide disproportionately high • A “way out” from terminal or debilitating illness or neurologic condition Depression • Behavioral crisis − Cannot cope − Overwhelmed • Behavioral emergency: − Significant risk of serious harm − Suicidal state − Potentially violent Mental Illness • If mental illness or psychotic episode, patient is out of touch with reality • Symptoms may include: − Angry or excited for no reason − Antisocial or loner behavior − Sleeping during day, awake at night Integumentary Conditions • Older patients at higher risk for secondary infection • Wounds take longer to heal. • Cumulative sun and toxin exposure increase chance of developing skin cancer. Herpes Zoster • Also known as shingles • Caused by reactivation of varicella virus on nerve roots − Commonly affects thoracic nerve and ophthalmic division of the trigeminal nerve Herpes Zoster • Symptoms: − Pain in affected area − Cluster of tiny blisters on reddened skin − Usually unilateral rash • Treatment: − Narcotic pain relievers − Antiviral medications Cellulitis • Acute inflammation in skin caused by bacterial infection. • Usually affects lower extremities © Dr. P. Marazzi/Science Photo Library Cellulitis • Symptoms include: − Fever and chills − Warmth, swelling, redness, tenderness, and enlarged nodes in affected area − Elevated white blood cell count − Presence of bacteria • Treatment includes: − Antibiotic therapy − Fluid intake − Local dressing on any open sores Pressure Ulcers • Occur from pressure applied to body tissue, resulting in lack of perfusion and necrosis • Possible risk factors: − Brain or spinal cord injury − Neuromuscular disorders − Nutritional problems Pressure Ulcers • Most commonly located on: − Lower legs − Sacrum − Greater trochanter − Glutes Pressure Ulcers • Classified as: − Stage 1—persistent skin redness that does not disappear when pressure is relieved − Stage 2—partial thickness lost; appears as abrasion, blister, shallow crater − Stage 3—full skin thickness lost, exposing subcutaneous tissue − Stage 4—full thickness and subcutaneous tissue lost, exposing muscle, bone Pressure Ulcers • More than 10% of US nursing home patients have some stage of ulcer. • Prehospital treatment mostly BLS − Monitor body temperature and vital signs. − Administer oxygen, IV line, and consider a fluid bolus. Musculoskeletal Conditions • Physical ability changes and affects confidence in mobility − Muscles atrophy and weaken. − Muscle fibers become fewer and smaller. − Motor neuron numbers decline. − Strength declines. Musculoskeletal Conditions • Stooped posture from atrophy of body’s supporting structures − 2 of 3 older patients will have some degree of kyphosis. − Lost height from spinal column compression Osteoporosis • Decrease in bone mass, leading to: − Bone strength reduction − Greater susceptibility to fractures • Influenced by: − − − − − − Genetics Smoking Activity level Diet Hormonal factors Body weight and structure Osteoporosis • Type I − Rapid bone loss occurring in women during years after menopause − Most common fractures: • Radius • Hip • Type II − In both men and women 50+ − Most common fractures: • Hip • Vertebrae • Vertebral fractures may lead to dorsal kyphosis Osteoporosis • Treatment: − Bisphosphonates − Calcium and vitamin D supplementation − Activity and low-impact exercise Arthritis • Progressive joint disease − Formation of bone spurs in joints, leading to stiffness − Thought to result from: • Joint wear and tear • Repetitive joint trauma Arthritis • Patients report pain: − Worsens with exertion − Worsens with temperature/humidity • Treatment includes: − Anti-inflammatory medications − Physical therapy Arthritis • Rheumatoid arthritis (RA): Long-term autoimmune disorder with inflammation of joints and surrounding tissue • Symptoms bilateral, affecting: − − − − − Hands Feet Wrists Ankles Knees Management of Medical Emergencies in Elderly People • Most prehospital care is supportive: − Pain relief − Palliative support − Treatment for emergency and chief complaint Geriatric Trauma Emergencies • Deaths from injury in people older than 65 account for one quarter of all trauma deaths in the United States. − 7th leading cause of death in the elderly • Slower reflexes and reduction in agility • Visual and hearing deficits • Equilibrium disorders Geriatric Trauma Emergencies • Less favorable outcomes in trauma because: − Changes in homeostatic compensatory mechanisms − Aging effects on body systems − Preexisting conditions Geriatric Trauma Emergencies • Successful treatment when trauma-related blood loss is compensated enough for: − Increased pulse rate − Increased respirations − Adequate vasoconstriction Geriatric Trauma Emergencies • Unsuccessful recovery likely if: − Decreased respiratory function − Impaired renal activity − Ineffective vasoconstriction Geriatric Trauma Emergencies • Most cases involve falls or motor vehicles − Increased mortality from falls related to: • Patient’s age • Preexisting disease processes • Complications related to trauma Geriatric Trauma Emergencies • Falls are divided into two categories: − Extrinsic causes: tripping or slipping − Intrinsic causes: dizzy spell, syncopal attack • Risk increases with preexisting gait abnormalities and cognitive impairment. Geriatric Trauma Emergencies • Home safety assessment by EMS − Check for: • Clear pathway to and from bathroom • Handrails in bathtubs and on steps • No loose rugs or other objects on floor • Wheelchair ramps with grip tape Geriatric Trauma Emergencies • Elderly are five times more likely to be fatally injured in a motor vehicle crash. − At higher risk for crashes due to: • Vision impairment • Errors in judgment • Underlying medical conditions Pathophysiology • Head trauma: increased fragility of cerebral blood vessels, enlarged subdural space − Hematoma often develops over days or weeks. • Headache is the early symptom. − As intracranial pressure increases: • Consciousness depressed • Patient drowsy Pathophysiology • Spinal cord injury and compression: arthritic spurs, vertebral canal narrows − Even a sudden movement of the neck may cause spinal cord injury. Pathophysiology • Chest injuries: rib brittleness, stiffening of the chest wall • Abdominal trauma often causes liver injury. • Orthopaedic injuries common results of falls. Pathophysiology • Burns have significant risk of morbidity and mortality, especially if: − Preexisting medication conditions − Weakened defense mechanism against infection − Fluid replacement complicated by renal compromise • Monitor hydration status. Pathophysiology • Internal temperature regulation slows with age: − Delayed ability to recognize temperature fluctuations • Heat gain/loss slowed by: − Atherosclerotic vessels − Slowed circulation − Decreased sweat production Pathophysiology • Thermoregulation affected by: − Chronic disease − Medications − Alcohol use • Half of hypothermia deaths are older people. • Hyperthermia death rates more than double in the elderly. Pathophysiology • Check for environmental emergencies in extreme hot and cold. • May need to keep patient compartment at higher-than-normal temperature. Assessment and Management of Trauma • Check mechanism of injury. • Check for possible medical problem before the trauma. • Initial management follows ABCs first. Assessment and Management of Trauma Assessment and Management of Trauma • Check for rib fracture when assessing breathing. • Obtain baseline BP. − Normal blood pressure may be hypotension in an older person. Assessment and Management of Trauma • Do neurologic status assessment according to AVPU scale. • Try to obtain complete history of event from patient and bystanders. Assessment and Management of Trauma • Obtain list of regular medications, especially those that may affect treatment: − Beta blockers − Antihypertensives − Diabetes medications Assessment and Management of Trauma • Conduct secondary assessment, watching for signs of injury to: − Head − Cervical spine − Ribs and abdomen − Long bones • Remember patient’s pain perception may be decreased. Assessment and Management of Trauma • Additional treatment based on injuries. − Be cautious about isotonic solutions. − Monitor cardiac rhythm throughout. − Preserve temperature. − Consider pain medication. − Immobilize the cervical spine before transporting. Elder Abuse • Any form of mistreatment that results in harm or loss to an older person − Physical − Sexual − Emotional − Neglect − Financial Elder Abuse • Average victim: − 80 years old − Female − Has multiple chronic conditions − Is unable to function on their own − Is dependent for at least part of their care Elder Abuse • Abuser is almost always known to the abused: − Often a family member − Often occurs in patient’s or caregiver’s home − Sometimes in long-term care facilities Elder Abuse • Clues: − Unexplained injuries that do not fit stated cause − Poor hygiene − Patient interacting with caregivers • Listen to patient’s concerns about their care. Elder Abuse • If stable but in unsafe situation, see if patient will allow transport. − If they refuse, suggest local adult protective services. − If immediately unsafe, notify law enforcement. Elder Abuse • Many states have elder abuse statutes. − Reporting suspected abuse may be mandatory. − Definition may vary state by state. − If suspected as cause of injury: • Objectively document observations. • Report findings and suspicions to receiving facility. End-of-Life Care • Paramedics will be involved with end-of-life care for patients. − Do not resusciate (DNR) does NOT mean “do not respond to the needs of a terminal patient” End-of-Life Care • Paramedics should: − Treat various disorders. − Administer medication. − Perform other treatments. − Be caring and concerned. End-of-Life Care • Community may have a local hospice: − Terminal care for patients − Support for families © Photofusion Picture Library/Alamy Images Summary • Elderly people constitute an ever-increasing proportion of patients in health care systems, especially the emergency area. • Health problems of the elderly are quantitatively and qualitatively different than those of younger people, and require special approaches. • The aging process is accompanied by physiologic function changes. Summary • With age, the respiratory capacity is significantly reduced because of decreases in lung elasticity and size/strength of respiratory muscles, calcification of costchrondral cartilage, and musculoskelatal changes. Summary • A variety of cardiovascular system changes occur as the person ages. The heart hypertrophies, arteriosclerosis develops, and the electric conduction system deteriorates. • Nervous system changes lead to a decrease in sense organ performance, leading to hearing and visual changes. Summary • Digestive system changes include a decrease in taste buds and a reduction in saliva and gastric secretions. • Geriatric patients may experience renal system changes that make it difficult to handle unusual challenges from illness, so acute illness is often accompanied by fluid and electrolyte balances. Summary • Endocrine system changes may lead to diabetes and thyroid abnormalities. • Nearly every immune system function is affected by aging, so the elderly are more prone to infection and secondary complications. Summary • Integumentary system changes include thinner skin and elasticity loss, causing more bleeding and skin to tear more easily. • Aging causes a progressive loss of homeostatic capabilities. • A decrease in bone mass accompanies aging, especially in postmenopausal women, so bones break more easily. Summary • Signs and symptoms of disease may be altered in older people. • The GEMS diamond was designed to assist in assessment and treatment of elderly patients. • The primary assessment addresses immediately life-threatening pathologic problems; the secondary assessment is a systematic assessment of the body. Summary • The physical exam of older patients may be difficult because of poor cooperation and easy fatigability. • More than 80% of all stroke deaths occur in persons older than 64 years. • Heart disease remains the leading cause of death among older adults in the United States. Summary • Delirium often replaces or confounds the typical presentation of a medical problem, adverse medication effect, or drug withdrawal. • Dementia produces irreversible brain failure. • Gastrointestinal problems in the elderly include peptic ulcer disease, small bowel obstruction from gallstones, and stomach or duodenal ulcers. Summary • The most common hospital-associated infection to cause sepsis in the United States is urinary tract infection. • An elderly patient with diabetes is at increased risk for hypoglycemia. • Older diabetic patients who tend to have high blood glucose levels are prone to hyperosmolar nonketotic coma (HONK) (hyperglycemic nonketotic coma [HHNC]). Summary • Elderly people are particularly prone to adverse drug reactions because of changes in drug metabolism, drug elimination, and body composition. • Alcohol abuse among the elderly is on the rise. A much smaller, but growing, segment of the elderly uses illicit drugs. • Depression in the elderly can mimic many other medical problems, such as dementia. Summary • Osteoarthritis is a progressive disease of the joints that destroys cartilage, promotes formation of bone spurs in joints, and leads to joint stiffness. • An elderly person is at higher risk of trauma because of slower reflexes, visual and hearing deficits, equilibrium disorders, and an overall reduction in agility. Summary • Most geriatric trauma is from falls or motor vehicle crashes. • Elder abuse is any form of mistreatment that results in harm or loss, and can be either physical, sexual, emotional, neglect, or financial. • Hospice care allows people with terminal illnesses to receive palliative care in their own homes. Credits • Chapter opener: © Glen E. Ellman • Backgrounds: Gold – Jones & Bartlett Learning. Courtesy of MIEMSS; Purple – Jones & Bartlett Learning. Courtesy of MIEMSS; Orange – © Keith Brofsky/Photodisc/Getty Images; Green – Jones & Bartlett Learning. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.