Prepared by :

Nurul Syazwani Binti Ramli

Geritric
Trauma
 Definition
Case
Referrences scenario

Outline
Summary Anatomy &
physiology of
aging
Trauma Mechanism of
Care geriatric
trauma
 What is GERIATRIC?
• Geriatrics individual who are ≥ 65 years old
• The geriatric trauma patient is 5 x more likely to die from
trauma than a younger patient who sustained a similar
mechanism of injury
• Geriatric trauma patient differ than younger patient due
to associated physiological changes that occurs with
normal aging, multiple comorbidities and prescription
drug regimen that present prior to their traumatic event.
 Morbidity and 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
 Case Scenario
• 79 years old male is brought to the ETD (green zone) after he
is found at the base of the stairs by his wife
• Vital signs:
– BP 110/60
– HR 64
– RR 30
– GCS 12
 Case Scenario
• 79 years old male is brought to the ETD (green zone) after he
is found at the base of the stairs by his wife
• Vital signs:
– BP 110/60
– HR 64
– RR 30
– GCS 12
 Case Scenario
• 79 years old male is brought to the ETD (green zone) after he
is found at the base of the stairs by his wife
• Vital signs:
– BP 110/60
– HR 64
– RR 30
– GCS 12
 Case Scenario
• 79 years old male is brought to the ETD (green zone) after he
is found at the base of the stairs by his wife
• Vital signs:
– BP 110/60 ?
– HR 64 ?
– RR 30
– GCS 12
 Case Scenario
• Past medical history
– Atrial fibrillation
– Hypertension
– Diametes
• Medications
– Atenolol
– Xarelto (Rivaroxaban )
– Metformin
• Exam
– Lungs clear
– Abdomen – non tender
– CNS:
• Sleepy
• Confused
• Opens eyes to voice
• Follows basic commands

– Extremity exam: tenderness to left hip area

 Pelvis X-Ray

Chest X-Ray
CT Brain CT
Abdomen
PATHOPHYSIOLOGY OF
AGING
 Cardiovascular System
• 50% of people > 65 years old have coronary artery disease
• Increased myocardial stifness
• Slowed electro-physiologic conduction
• Impaired response to catecholamines
• Increased afterload ( increased systolic blood pressure )
• Decresed stroke volume and cardiac output
• Instead of increased heart rate and cardiac output, elderly
respond with increased blood pressure ( HTN )

• Deceptively reassuring blood pressures

 Respiratory System
• Decreased chest wall compliance
• Decreased strength of respiratory muscles
• Decreased cough reflex
• Decreased alveolar surface area
– Decreased gas exchange
 Respiratory System
• Brittle ribs fracture easily
• Pulmonary contusion
• Aspiration or ventilator associated
pneumonia
• Acute Respiratory Distress Syndrome
( ARDS )
 Central Nervous System
• Progressive cortical atrophy
– 10% reduction in brain size by age 70
• Increased subdural space
• Subdural vein under more tension
• Risk for subdural hematoma increased
 Central Nervous System
• Dementia
• Cerebrovascular disease
• Decreased reflexes
• Peripheral neuropathy
• Impairment in balance
• Decreased visual acuity and peripheral vision
• Decreased auditory acuity
• Osteoarthritis  Spinal stenosis
• Increased risk of C-spine injuries and paralysis
• Maintain C-Spine precautions – especially
during intubation
 Renal Impairment
• Decreased glomerular filtration rate ( GFR )
• Renal artery stenosis
• Increased risk :
– Electrolyte imbalances
– Volume oveload
– Impared clearance of prescription drugs
• Urine output less reliable as an endpoint of
resuscitation
 Renal System
• A normal creatinine does not imply noral renal
function
• Creatinine clearance = (140 – age) x weight (kg)
• creatinine x 72
• Normal creatinine clearance
– Females 80-120 mm/min
– Males 90-130 mm/min
 Renal System
(secondary renal injury)
• Hypotension
• Intravenous Dye
• Aminoglycosides ( Gentamycin )
• Diuretics
• Vasopressors
 Gastrointestinal System
• Elderly tend to localize pain poorly and do not
always manifest peritoneal signs on exam
 Metabolism
• Thyroid and thymus gland fibrosis
• Decreased cell mediated immunity ( T- Cells )
• Glucose intolerance
• Malnutrition
• Increased risk of infection
 Integumentary System
• Skin atrophies with aging
• Decreased water content in cells
• Decreased subcutaneous fat
• Increased risk of hypothermia and decubitus
ulcer
 Musculoskeletal System
• Osteoporosis
• Decreased muscle mass
• Increased risk of fractures
– Ribs
– Proximal femur
– Hip
– Humerus
– Wrist
 Medications
• Cardiovascular medications
– Beta-blockers  prevent tachycardia
– Calcium channel blockers  prevent peripheral
vasoconstriction
• Anticoagulants
– Plavix , Pradaxa, NSAIDS etc
• Steroids  decreased immune response
• Diuretics
– Hypovolemia
– Electrolyte abnormalities
• Psychotropic meds  altered mental status
 Accessories
• Pacemaker – prevents tachycardia
• Hearing aids
• Glasses
• Dentures
 Suicides
• In the population over 85 years old, the suicide
rates are five-fold greater than in the general
populations
• Elderly have the highest success rate
• Firearms – 73%
 Elder Abuse
• Frequently overlooked and ignored
• Approximately 2 million abused per year
• Estimated 5 out of 6 cases go unreported
• Physical, emotional, sexual, financial abuse,
neglect
 Elder Abuse
( what to look for )
• Bruises of various stages
• Mechanism inconsistent with injury
• Clumps of hair missing
• Abrasions from restraints
• Bruises on inner arms and inner thighs
MECHANISM OF INJURY
 Mechanism of Injury
• Falls
• MVA
• Abuse
• Neglect
• Suicide
 FALLS
– 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
• Environmental Factors • Orthostatic
– poor lighting Hypotension
– new furniture – dehydration
– non-secured rugs – medications
– loose railings • Gait Changes
– stairs – propensity to trip or
• Syncope stumble
– cerebral hypo perfusion – feet not picked up as
high
– seizure
– men
– dysrhythmia
• wide-based
– hypoglycemia
– women
• narrow-based
 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
• 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
 MVA
• 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 (55-64
years old) followed closely by those over 74
• Causes
– Error in Perception
• Pathophysiology of aging and presence of acute
and chronic medical conditions
– Altered Reaction Time
 Abuse, Neglect and 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
 A medical “EVENT” may have
caused the trauma
• MI
• Arrhythmia
• Stroke
• TIA
• Hypotension
• Hypoglycemia
 High risk injury pattern
• Traumatic brain injury
• Chest wall trauma, rib fracture
• Solid organ injury  spleen injury
• Pelvic fracture
• C-Spine fracture
HOW CAN WE IMPROVE THE
TRAUMA CARE OF THE
ELDERLY PATIENT ?
 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.
 Case Scenario
• 79 years old male is brought to the ETD (green zone) after he
is found at the base of the stairs by his wife
• Vital signs:
– BP 110/60
– HR 64
– RR 30
– GCS 12
 Pelvis X-Ray

Chest X-Ray
CT Brain CT
Abdomen
 Summary
• Most geriatric trauma is from falls or MVA
• Elder abuse is any form of mistreatment that results in
harm or loss, and can be either physical, sexual,
emotional, neglect, or financial.
• Anatomic and physiologic changes in the elderly are
associated with increased morbidity and mortality
• The elderly are not able to compensate as quickly or as
efficiently as a younger adult
• Vital signs may be normal when the patient is actually in
shock
• A seemingly minor trauma can cause a severe, life
threatening injury in the elderly
• http://www.doh.wa.gov/hsqa/emstrauma/traumaguidelines.h
tm
• https://mtqip.org/docs/Geriatric_Guide_TQIP_20130109.pdf
• Browner, B.D. (2002) Emergency care and treatment of the
sick and ijured
• McSwain, N. E. , Frame, S. (2003) Basic and advanced
prehospital life suport.
Thank You