- Decreased physical reserves due to normal changes of aging
- Increased attention to special care needs (medication management, cognitive impairment, occult shock)
Issues in ATLS Resuscitation
Click the tabs below to review your ABCDE’s of ATLS resuscitation.
If you’re using Rapid Sequence Induction, remember that older people will have faster onset of sedation (due to the more permeable blood-brain barrier). They will also have a prolonged effect of most opioids, benzodiazepines, and etomidate (due to changes in Volume of Distribution and decreased renal clearance.) A dose decreased by a third may be effective and safe. To learn more visit the Medication Management module.
Age-related changes affecting intubation:
- Difficult mouth opening (TMJ arthritis, general systemic stiffening),
- Cervical arthritis causes decreased mobility,
- Variable dentition and presence of dentures,
- Big tongue,
- Fragile easily damaged mucus membrane
Nonetheless, standard management remains early intubation to establish an airway AND if evidence of shock.
Age-related changes affecting ventilation:
- Decreased respiratory reserve (because of both normal aging and the effect of disease);
- Decreased chest wall musculature
- Fragile bones mean easily broken ribs
- Decreased chest wall compliance causing more devastating pulmonary contusion
A common pitfall in assessment of Circulation is to interpret “normal” vital signs as representing normovolemia. A systolic BP of 120 in an older person with essential hypertension likely represents hypotension. A concomitant HR of 90-100 may be the maximum tachycardia that the older medicated heart can mount.
Significant blood loss can be occult – femur fracture, pelvic fracture, retroperitoneal blood – especially if anti-coagulated.
Age-related changes affecting cardiac output:
- Significant decrease in maximum heart rate ( = 220 – age),
- Decreased response to adrenergic catecholamines because of reduced responsiveness of membrane receptors
- “Stiff pump” causes diastolic dysfunction and therefore cardiac output much more dependent on atrial filing
Non-age-related changes affecting cardiac output:
- Maximum rate further decreased by medications: Beta-blockers and Calcium channel blockers
- Diuretic therapy can produce a chronically contracted vascular volume
Subdural hematomas are likely especially in the presence of anticoagulant medication; symptoms may be slow to develop; cervical spine injuries are common and often occult because of OP and OA; central and anterior cord syndromes are more likely because of spinal stenosis; difficult to detect on cervical plain films and low threshold for CT should be the standard.
Age-related changes affecting brain and spinal cord injuries:
- Cerebral atrophy and increased CSF – brain is somewhat protected from contusion
- Resultant stretching of parasagittal bridging veins easily injured with minor impact and accel/decel injury
- Loss of intervertebral disks makes the vertebral column stiffer shifting force to the facets, ligaments and muscles and more fragile bone.
- Osteoarthritis and resultant spinal stenosis, segmental immobility and kyphosis
Exposure and Environment
The key point is to get the older patient off the back board as soon as possible!
Age-related changes affecting injuries:
- Skin and connective tissue lose cells, strength and function – skin is thinner, less vascular and less able to thermoregulate
More prone to:
- skin and soft tissue infection
- rapid development of pressure ulcers