Transcript Nate Wood - Adirondack Area Network

Trauma in the Elderly
Nathanael Wood, MD
Albany Medical Center
March 21, 2007
Case Study 1
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83 year-old female
Driver, belted, no airbag deployment
Parking lot speed, minimal auto damage
No complaints
Highest HR en route: 90
Lowest SBP en route: 110
Boarded and collared
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PMH: HTN, osteopenia
PSH: Cholecystectomy
Meds: Lopressor, calcium
Social: Non smoker, non-drinker
Vitals on Arrival to ED
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HR 95, BP 115/85, RR 18, T 98,
O2 97% RA
Primary Survey
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A: Patent
B: Breathing comfortably, equal breath
sounds b/l
C: Radial and femoral pulses equal,
strong
D: No deficits
Secondary Survey
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General: Awake, alert
HEENT: NC/AT
Neck: hard collar, NT
CV: RRR, pulses equal/strong throughout
Lungs: CTA BL
Abd: soft, NT, ND, bowel sounds present
Extremities: no deformities, no tenderness,
FROM
Neuro: Non focal examination, A&O X3
ED Course
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Neck cleared using NEXUS criteria, hard
collar removed
No imaging indicated
Pt refused analgesia
Signed out to next resident: Needs to
ambulate, likely d/c soon
ED Course, continued
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Patient unable to ambulate
CT Abdomen, pelvis…
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Grade 3 liver laceration
Admitted to hospital for observation
D/C after two days
ED Course, continued
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Then, one day after d/c…
Neck discomfort.
Back to ED.
CT neck…
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C5 fracture
D’OH!
How did we miss all that?
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Unlucky?
Different physiology?
Medications?
The “Elderly”
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What is “Elderly” or “Geriatric”?
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55?
65?
70?
Depends
The “Elderly”
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12% of the population is over age 55
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36% of all ambulance transports
25% of hospitalizations
>85, fasted growing age group
The “Elderly”
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In 2000, 35 million aged 65+
By 2030, 70 million aged 65+
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20% of US population
70% of ambulance transports
“Geriatric”
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> 70
Exhibits significant anatomical or
physiological characteristics associated
with advanced aging.
Trauma in the Elderly
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Fifth leading cause of death, > 65 years
Significant cause of morbidity.
Minor trauma may result in functional
decline.
Older patients have worse outcomes
despite lesser injury severity.
Types of Trauma
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Falls
MVAs
Violence
Burns
Falls
Falls and the Elderly
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Leading cause of elder trauma
Occur in 1/3rd of independent elders
More common in nursing home residents
10% of falls result in significant injury
Severity/frequency increases with age
May be a symptom of general decline
50% 1 year mortality if hospitalized for a fall
MVAs
MVAs and the Elderly
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13-15% of all MVAs
Higher incidence of
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2 vehicle MVAs
Pedestrian-MVAs
Mortality
MVAs and the Elderly: Patterns
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Intersections
Good weather
Close to home
During daylight
Geriatric Abuse & Neglect
Geriatric Abuse & Neglect
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Physical, psychological injury of older
person by their children or care providers
Knows no socioeconomic bounds
Geriatric Abuse & Neglect
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Contributing factors
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Advanced age: average mid-80s
Multiple chronic diseases
Sleep pattern disturbances leading to
nocturnal wandering, shouting
Family has difficulty upholding commitments
Geriatric Abuse & Neglect
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Primary findings
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Trauma inconsistent with history
History that changes with multiple tellings
Burns
Burns and the Elderly
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More likely to suffer injury
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Unable to evacuate burning structures
Cognitive impairment
Decreased coordination
Older homes (wiring, smoke detectors, etc.)
Burns and the Elderly
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High mortality rates
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50% BSA burn
<65 years, 50% fatal
 >65 years, approaching 100% fatal
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Effects of Aging
Cardiovascular System
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Speed, force of myocardial contraction decreases
Cardiac conducting system deteriorates
Resistance to peripheral blood flow rises, elevating
systolic blood pressure
Blood vessels lose ability to constrict, dilate efficiently
What effects will these changes have on ability to
compensate for shock?
For heat and cold exposure?
Respiratory System
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Respiratory muscles lose strength; rib cage calcifies,
becomes more rigid
Respiratory capacity decreases
Gas exchange across alveolar membrane slows
Cough, gag reflexes diminish increasing risk of
aspiration, lower airway infection
What will be the consequences of these changes
during chest trauma?
Musculoskeletal System
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Osteoporosis develops, especially in females
Spinal disks narrow, resulting in kyphosis
Joints lose flexibility, become more susceptible
to repetitive stress injury
Skeletal muscle mass decreases
What effect do these changes have on incidence and
severity of orthopedic trauma?
Packaging? Backboards? Intubating?
Long term outcomes?
Nervous System
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Brain weight of decreases 6 to 7%
Brain size decreases
Cerebral blood flow declines 15 to 20%
Nerve conduction slows up to 15%
What effect will decreased nerve
conduction have on pain sensation and
reaction time?
How will brain degeneration change the
effect of head trauma?
Gastrointestinal System
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Senses of taste, smell decline
Gums, teeth deteriorate
Saliva flow decreases
Cardiac sphincter loses tone, esophageal reflux becomes
more common
Peristalsis slows
Absorption from GI tract slows
What effects can these changes have on the
nutrition of older persons? How does this change
the response to traumatic injury?
Renal System
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Renal blood flow decreases 50%
Functioning nephrons decrease 30 to 40%
What effect will these changes have on
ability to eliminate drugs from the body?
Integumentary System
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Dermis thins by 20%
Sweat glands decrease; sweating decreases
What effect will this have on:
Severity of burn injuries?
Wound healing?
Cold and heat tolerance?
Geriatric Assessment
Factors Complicating Assessment
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Variability
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Older people differ from one another more
than younger people do
Physiological age is more important than
chronological age
Factors Complicating Assessment
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Response to illness
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Seek help for only small part of symptoms
Perceive symptoms as “just getting old”
Delay seeking treatment
Trivialize chief complaints
Factors Complicating Assessment
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Presence of multiple pathologies
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85% have one chronic disease; 30% have
three or more
One system’s acute illness stresses other’s
reserve capacity
One disease’s symptoms may mask another’s
One disease’s treatment may mask another’s
symptoms
Factors Complicating Assessment
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Altered presentations
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Diminished, absent pain
Depressed temperature regulation
Depressed thirst mechanisms
Confusion, restlessness, hallucinations
Generalized deterioration
Vague, poorly-defined complaints
Factors Complicating Assessment
The Organs of the Aged Do
Not Cry!
Factors Complicating Assessment
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Communication problems
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Diminished sight
Diminished hearing
Diminished mental faculties
Depression
Poor cooperation, limited mobility
Factors Complicating Assessment
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Polypharmacy
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Too many drugs!
30% of geriatric hospitalizations drug induced
Anti-hypertension drugs (beta-blockers)
may mask early signs of shock
Diuretics (Lasix, HCTZ) may make pt
relatively dehydrated
History Taking
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Probe for significant complaints
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Chief complaint may be trivial, non-specific
Patient may not volunteer information
History Taking
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Dealing with communication difficulties
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Talk to patient first
If possible, talk to patient alone
Formal, respectful approach
Position self near middle of visual field
Do not assume deafness or shout
Speak slowly, enunciate clearly
History Taking
Do NOT assume confused or
disoriented patient is “just senile!”
History Taking
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Obtain thorough medication history
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More than one doctor
More than one pharmacy
Multiple medications
Old vs. current medications
Shared medications
Over-the-counter medications
Physical Exam
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Examine in warm area
May fatigue easily
May have difficulty with positioning
Consider modesty
Decreased pain sensation requires
thorough exam
Physical Exam
If they say it hurts, it probably
REALLY hurts!
EXAMINE CAREFULLY
Physical Exam
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Misleading findings
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Inelastic skin mimics decreased turgor
Mouth breathing gives impression of
dehydration
Inactivity, dependent position of feet may
cause pedal edema
Rales in lung bases may be non-pathologic
Peripheral pulses may be difficult to feel
Trauma
Head Injury
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More likely, even with minor trauma
Signs of increased ICP develop slowly
Patient may have forgotten injury, delayed
presentation may be mistaken for CVA
Decreased brain mass increases risk of ICH
What change in the elderly accounts for
increased ICP’s slower onset?
Cervical Injury
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Osteoporosis, narrow spinal canal increase
injury risk from trivial forces
Sudden neck movements may cause cord
injury without fracture
Decreased pain sensation may mask pain
of fracture
Hypovolemia & Shock
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Decreased ability to compensate
Progress to irreversible shock rapidly
Tolerate hypoperfusion poorly, even for
short periods
Hypovolemia & Shock
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Hypoperfusion may occur at “normal” pressures
Medications (beta blockers) may mask signs of
shock
Cardiac and renal disease make fluid
resuscitation more risky.
Why can older persons be hypoperfusing at a
“normal” blood pressure?
Positioning & Packaging
May have to be modified to
accommodate physical deformities
Environmental Considerations
Environmental Considerations
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Tolerate temperature extremes poorly
Contributing factors
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Skin changes
Cardiovascular disease
Endocrine disease
Poor nutrition
Drug effects
Environmental Considerations
HIGH INDEX OF SUSPICION
Any patient with altered LOC or vague
presentation in hot or cool
environment
Which came first?
Which came first?
Trauma or…
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MI?
PE?
CVA?
TIA?
Dementia?
Intoxication?
Spontaneous fracture?
Summary
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The elderly are coming.
Minor mechanisms can create major injuries.
No complaint does not mean no injury.
Minor injuries can cause major morbidity.
What came first: injury or the trauma?
CV disease and medications can mask early
signs of shock.
Lower threshold for transport to trauma center.
Questions?
Thank you.