Transcript Chapter 44: Geriatric Emergencies

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:
−
−
−
−
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Tobacco use
Hypertension
Diabetes
Obesity
Lack of physical
exercise
− High cholesterol
• Preventive strategies:
−
−
−
−
−
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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:
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−
−
−
−
−
−
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.