Download Case Review: Massive Crush Injury

Pam Wills-Mertz, RN
April 25, 2015
Disclosures:
 None
Objectives:
 Definition of geriatric, discussion of epidemiology
 Discussion of age-related changes that can mask
the severity of traumatic injury
 Discussion of how co-morbid conditions can change
outcomes
 Discussion of the risks of medication use in geriatric
trauma
 Discussion of common MOI
 Discussion of field triage
What is old?
Aging is:
 .... the normal, predictable, and irreversible changes
of various organ systems over the passage of time
that ultimately lead to death ….
Age is a state of mind…
So, what is old, elderly,
geriatric?
 Chronological age v. physiological age
 65 is a societal and social norm
 65 per EAST
 55 per ACS-COT, TNCC, PHTLS
 Mortality increases at 45 in males
Epidemiology:
 Average American life span has increased
by almost 30 years in the past century
 1900 = 47 years old
 2000 = 76 years old
 Climbing…..
 By 2050, people over age 64 will make up
over 20% of the US population
 Today it is 12%
So…
Why? How?
 Baby boomers
 Medical advances
 Active lifestyle
 More risk? Less risk?
Unique Characteristics:
 Age-related changes
in anatomy and
physiology
 Pre-existing diseases
and co-morbidities
 Medications
 Possibility of elder
maltreatment
Age-related Changes:
↓
Brain mass
Eye disease
↓
↓
Discrimination of colors
↓
↓
Depth of perception
Pupillary response
Respiratory vital capacity
Diminished hearing
↓Sense of smell and taste
↓Saliva production
↓Esophageal activity
↓Cardiac stroke volume and rate
Renal function
Heart disease and high blood
pressure
2- to 3-inch loss in height
Kidney disease
↓
Impaired blood flow to lower
leg(s)
↓
Stroke
Degeneration of the joints
Total body water
Nerve damage (peripheral
neuropathy)
↓Gastric secretions
↓Number of body cells
↓Elasticity of skin, thinning of
epidermis
15 – 30% body fat
Older
people
who
sustain
injuries are
more likely
to die as a
result of
them,
regardless
of the
severity of
injury.
Despite the
considerable
proportion of
trauma care
resources
consumed by
the oldest
people,
research is
directed
towards
needs of
younger ones.
More facts:
 Young trauma victims are male
 Older trauma victims are female
 Thinner bones
 More likely to fracture
 Mortality
 Peak 1 month s/p femur
 Higher mortality after injury
 A considerable time
 25% die within one year
Cardiovascular:
 Less Effective Pump
 Minimal Reserve
 Medication Effects
 Ischemia/Hypoxia
 Arrhythmias
 Cautious with fluids
Renal:
 Functional Changes
 Loss of Surface Area
 Diminished Renal Blood
Flow
 Progressive Decline in
filtration function
Respiratory:
 Lungs
 Decreased elasticity
 Decreased alveolar number and
function
 Decreased baseline p02
 Diminished respiratory reserve
 Musculoskeletal
 Kyphosis
 Decreased Chest Wall Strength
 Increased Chest Wall Rigidity
 Infectious Risks
 Increased Bacterial Colonization
 Decreased Force of Cough
 Decreased Clearance Rate
Central Nervous System:
(Functional Changes)
 Auditory
 Proprioception
 Cognition
 acquisition of new data
 memory - short and long
term
 Visual Acuity
 glare intolerance
 color perception
 visual fields
Nervous System:
 Structural Changes
 10% Reduction in Brain
Weight
 Loss/Degeneration of
Neurons
 Cerebral Atrophy
 Cerebrovascular Changes
 Confounding Factors
 Brain/Skull Relationship
 Cervical Spine
 Altered “Baseline” Mental
Status
Quick Tip:
 A complete interview and careful inspection of the
head is essential.
 Also, review medications for anticoagulants and ask
about the use of aspirin, vitamin E, gingko biloba or
other substances that may contribute to intracranial
bleeding.
 More to come…..
Musculoskeletal:
 Structural Changes
 Decreased Mass
 Degeneration of
Remaining Muscle
 Degeneration of Joint
Cartilage
 Osteoporosis
 Functional Changes
 Strength
 Range of Motion
 Mobility
 Pain
 Fracture-Prone
 Gait
Consider this:
Hospitalizations of older adults for trauma-related
injuries occur at twice the rate of the general
population
The mortality rate of older trauma victims has been
estimated at 6 times that of younger victims when
statistically controlling for severity of injury
 1/3 with an ISS > 15 will die
Older adults account for 33% of all healthcare
resources spent on trauma and for 25% of injury
fatalities
Morbidity & Mortality:
 Trauma -- 5th Leading Cause of Death
 Elderly account for 12% of overall traumas
 But… make up 28% of ALL trauma deaths


Physiologic changes impact morbidity & mortality
Medications impact morbidity & mortality
Trauma Risk Factors:
 Poor visual acuity
 Poor visual attention
 Overload of information
 Impaired reaction times
 Limited neck rotations
 Slower gait
 Medication side effects
 Alcohol consumption
Medications:
 Psychotropic Medications
 Antidepressants
 Sedatives
 Antihypertensives
 Beta-Blockers
 Calcium Channel Blockers
 Diuretics (volume depleted)
 Anticoagulants & Antiplatelets
 Coumadin, Aspirin
 Plavix
Anticoagulants &
Antiplatelets:  Aspirin
 Warfarin (Coumadin)
 Enoxaparin (Lovenox)
 Dalteparin (Fragmin)
 Tinzaparin (Innohep)
 Bivalirudin (Angiomax)
 Aragtroban (Acova)
 Dabigatran (Pradaxa)
 Fondaparinux (Arixtra)
 Rivaroxaban (Xarelto)
 Apixaban (Eliquis)
 Dipyridamole
(Persantine)
 ASA-dipyridamole
(Aggrenox)
 Clopidogrel (Plavix)
 Prasugrel (Effient)
 Ticagrelor (Brilinta)
 Eptifibade (Integrillin)
 Tirofiban (Aggrestat)
Reversible:
 Coumadin (Warfarin)
Falls are #1:
Falls Facts:
 Most Common Injury > 75 Years
 Injuries to head, pelvis & lower extremities are most
common
 90% are falls from standing

60% are at home
 Neurosensory Changes
 altered vision, hearing & memory cause impaired
obstacle avoidance
 Postural Instability
 prone to loss of balance


increased postural sway
slowed central processing
Falls:
Physiologic
Disabilities
Environmental
Hazards
Behavioral
Alterations
Falls:
 Environmental Factors  Orthostatic Hypotension
 poor lighting
 dehydration
 new furniture
 medications
 non-secured rugs
 Gait Changes
 loose railings
 propensity to trip or
 stairs
stumble
 feet not picked up as high
 Syncope
 cerebral hypo perfusion  men
 wide-based
 seizure
 women
 dysrhythmia
 narrow-based
 hypoglycemia
Falls:
 One out of every three persons over 65 years old will
fall in any given year.
 These falls result in fractures, admissions to the
hospital, loss of the ability to live alone and death.
 Women are more likely then men to sustain injuries
from falls because they have less muscle mass and
a greater likelihood of having osteoporosis.
Fast Facts:
 One half of all elderly who sustain a fall find
themselves unable to return home independently
 Many older adults reduce their activity after a fall and
report a fear of falling again
MVC’s are #2:
MVC Facts:
 Crashes are more likely in older versus younger
drivers under normal driving conditions.
 The highest death rate for victims of motor vehicle
crashes occurs in the lower age range of elderly (5564 years old) followed closely by those over 74.
Left Turns:
The most common kind of crash older drivers have is
when turning left into oncoming traffic.
More MVC Facts:




Close to Home
Daylight Hours
Good Weather
Causes
 Error in Perception
 Pathophysiology of aging and presence
of acute and chronic medical conditions
 Altered Reaction Time
Abuse, Neglect, &
Suicide:
 Older adults are more likely to be victims of abuse or
maltreatment if they are dependent or demented.
 Mandated reporters
 Be suspicious
 Elderly persons over 65 account for more than 18%
of all suicides.
 Growing problem
 Under acknowledged
Obtaining a History:
 Simplify!
 Time to respond
 One question
 Use simple sentences.
 Be patient.
 Personalize…
 Use touch, tone of
voice and eye contact
to maintain attention
and focus.
 Make allowances for
likely problems with
vision and hearing.
 Show, not tell.
 Have the patient show
you the site of pain or
discomfort.
 Ask the individual to
take your hand and
place it over any painful
area.
Field Response:
 Decompensation may
occur rapidly and
without warning
 Reduce field
stabilization time
 Serial vital signs and
monitoring
 “110 is the new 90”
 Increased mortality with
SBP < 110 and HR >90
Field Response:
 Arthritic changes
increase potential
complications
 Protect the cervical
spine
 Beware the “face plant”
Cervical Spine:
 Cervical Spine Injuries
 Just as in young trauma

Need rigid collar
 Higher instance for Central Cord syndrome

Due to age related narrowing of cervical canal and vascular
disease of spinal arteries
 Causes deficit of upper extremity strength and sensation
Field Response:
 Aging tends to increase
upper airway secretions
 Micro aspiration is
common
 Assist with airway
secretions
 Use suctioning and
airway adjuncts as
indicated
 Dentures!
Field Response:
 Changes of aging increase the
risk of compromised
oxygenation
 Monitor airway and
ventilatory effort
 Oxygenate early and
liberally in the absence of
COPD
 Normal PO2 may be
compromised due to normal
aging
 Maintain O2 saturation
>90%
Field Response:
 The elderly may have “room for rent” within the
cranium due to loss of brain mass.
 Elevate head 15 to 30 degrees
 Assume the worst
 Fear anticoagulation
 Work with their neuro baseline
 Pitfalls


Dementia
Prior CVA
General Approach:
 Pre-hospital
 Imperative to understand past medical history and
events leading to injury


Elderly have shown to be under-triaged
Comorbidities often are the inciting cause of injury
Thoracic Injuries:
 Chest
 Rib fractures are the most common injury

Rib fractures double mortality
 3 point restraint belts have shown to cause significant
chest trauma
 EKG remains the most sensitive method to predict
short-term cardiac complications
Abdomen / Pelvis:
 Abdomen
 In face of multi-system injuries, exam is unreliable

Recommend liberal use of diagnostics
 Pelvis
 Fractures are significant for high mortality
 Significant blood loss
Extremities:
 Extremity Trauma
 Like all other fractures in elderly



Little impact necessary for fracture
Overall isolated extremity injuries are tolerated well by the
elderly
 Femur is the exception
Liberal radiological diagnostics recommended
Pain Management:
 Myth: Elderly patients experience less pain
 Realities:
 Acute and chronic pain is common in the elderly.
 Pain in the elderly is often under diagnosed and
under treated.
 Pain is often responsible for agitation, delirium and
depression.
More on Pain:
 Narcotics - elderly are more sensitive to pain
relieving aspects.


MSO4 - still gold standard.
Altered pharmacodynamics
 NSAIDs - side effects more severe and common in
elderly.
Cutungo, C. (2011).
End of Life Decisions:
 When is enough, enough?
 Advanced Directives
 DNR
 Treatment in patient’s best interest
 Benefits of treatment must outweigh consequences
 Trauma is a game changer
Summary /
Recommendations:
 Advanced age is associated with increased mortality
at all injury levels.
 Higher ISS for comparable mechanism of injury.
 Fewer physiologic abnormalities than expected for
injuries
 PEC are associated with worse outcomes for each
level of injury
Summary /
Recommendations:
 Elderly trauma victims should be triaged to trauma
centers
 Lower threshold for activation of the trauma team for
elderly trauma patients
 Higher index of suspicion
 Studies support the geriatric trauma specialty
Conclusion:
 The physiologic, mental and psychologic effects of
aging can influence how you provide trauma care.
 In the case of both intentional and unintentional
injury, knowing the special needs of the geriatric
trauma patient can help you avoid further injury and
greatly increase the patient’s chance of survival.
Thank you!!