Geriatric Trauma

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Geriatric Trauma

• Resuscitation Management

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Areas for Discussion

• Pain
• Fluids
• Skin issues
• C- spine stabilization

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Pain Assessment

• Pain Scales

0 2 4 6
8 10
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Pain Assessment

• Acute, Chronic, Concurrent
• Acute pain resulting from traumatic injury
• Chronic pain resulting from pre-existing
  conditions (eg. Arthritis)
• Concurrent pain chronic pain with an acute pain
  syndrome superimposed upon it (eg, arthritis
  rib fractures)

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Pain Treatment

• Nonpharmacologic Approaches
• Comfort measures, touch, reassurance
• Pharmacologic Approaches
• Absorption Distribution Metabolism
  Excretion AGING PROCESS
• heightened and prolonged effect of medications!
• Renal failure present? Caution with Morphine
• Chose fentanyl, hydromorphone, or oxycodone
• START LOW, GO SLOW
• Reduce dose by 25-50 titrate up
• Polypharmacy -The Brown Bag
• Concurrent pain

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Pain Treatment

• Epidural analgesia
• Ideal choice for rib fractures
• Optimal pain control, NO opioids sedative effect
• Improves ventilatory function
• Improves pulmonary hygiene
• Decreases
• mortality rates16 to 4
• Instances of pneumonia 19 to 8
• Occurrences of ARDS 14 to 6
• Check for pre-existing comorbidities

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Fluids

• Decreased physiologic reserves
• Limited compensatory response
• BP 90mmHg has a mortality rate of 82-100
• Base deficits -6
• Hypo-perfusion increased mortality
• Serum lactate 2.4
• Stable Vital Signs ? hemodynamically stable
  patient
• Limited ability to rapidly accept intravascular
  volumes

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Fluids

• Fluid administration
• 250-500cc warmed isotonic crystalloid boluses
• Frequent reassessments
• Early blood product administration if unstable
• Hemorrhage may be more pronounced
• Invasive hemodynamic monitoring
• Suggested end points in resuscitation
• Normalization of
• Base deficit (/-3)
• Serum lactate level (0.5-2.2mmol/L)

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Skin Issues

• Physiological changes affecting management
• ? thin
• ? dry
• ? subcutaneous tissue
• ? thermoregulatory control
• ? mast cells/inflammatory response

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Skin Issues

• Overall result
• Poor wound healing
• Prone to hypothermia
• Increased length of stay
• Increased risk of hemorrhage
• Increased risk of skin breakdown

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Skin Issues

• Management
• Frequent repositioning
• Maintain normothermia
• Monitor for signs of infection
• Frequently assess for breakdown
• Pad bony prominences high risk areas
• Remove spine board soon as appropriate

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C - Spine Stabilization
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C - Spine Stabilization

• The Facts
• Geriatric pt. twice as likely to have upper
  cervical fractures as non-geriatric pt.
• Falls from standing or seated height primary MOI
• Injury commonly occurs at C1-C2
• Frequently unstable
• May not have neurological symptoms
• May not have radiographic evidence of fracture
• Can be difficult to immobilize!

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C - Spine Stabilization

• Management
• Think outside of the box for immobilization

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C - Spine Stabilization

• Immobilization
• Consider pre-existing conditions such as...
• Kyphosis pathological curvature of the spine
• Spondylosis degenerative osteoarthritis of the
  spine
• Accommodate for physical deformities
• Do not force into a midline position
• Pad pressure points

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Summary

• Age should not limit therapy
• Understand physiologic changes
• Provide early, aggressive treatment
• Differentiate geriatric injury patterns
• Identify special needs for appropriate treatment

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Questions?
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• References
• Torso Trauma in the Elderly. Clinical Geriatrics.
  2010Vol 18-Issue 318-24
• Cervical Spine Injuries in the Geriatric Patient.
  Clinical Geriatrics. 2010Vol 18-Issue 2
• Geriatric Trauma. Thomas M. Scalea, M.D., FACS,
  FCCM, TMS/emasyllabusKmaullpointcounterptger
  i. May 2000
• Trauma in the Elderly Patient. Archives of
  Surgery. 2003Vol 138
• Special Considerations in Geriatric Injury.
  Current Opinion in Critical Care. 20039535-539
• Geriatric Trauma. UPMC Trauma Rounds. Winter
  2009-2010
• Upper Cervical Spine Injuries in Elderly
  Patients. Australian Family Physician. Jan/Feb
  2009Vol 38, No.1/2
• Pharmacological Treatment of Pain in the Elderly.
  Age. Vol 11, 88
• Opioid Analgesics for Persistent Pain in the
  Older Patient Part I. Clinical Geriatrics.
  2010Vol 18-Issue 3
• Pain. Merck Manual of Geriatrics. 2009-2010.
• Managing a Traumatic Wound in a Geriatric
  Patient. Ostomy Wound Management. Vol52-Issue 4
• Geriatric Trauma. Howard A. Werman, M.D.
  Medflight of Ohio