Considerations in the Older Trauma Patient
- Decreased physical reserves due to normal changes of aging
- Comorbidities
- 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.
Airway
Important Note
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.
Breathing
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
Circulation
Important Note
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
Disability
Important Note
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.
- Osteoporosis
- Osteoarthritis and resultant spinal stenosis, segmental immobility and kyphosis
Exposure and Environment
Important Note
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
Consequences:
More prone to:
- hypothermia
- skin and soft tissue infection
- rapid development of pressure ulcers
Discussion: Considerations in the Older Trauma Patient
Participate in the discusssion by posting a comment below
You must be logged in to post a comment
atypical presentation of ACS
Elderly male in cardiac arrest. Had difficulty inserting iGel, thought there was potential obstruction but could not visualise. At hospital found fractured C2 and C3 vertebrae
difficulty determining acute cognitive change vs baseline, difficulty interpreting vitals
cardiovasclar status may make the patient less tolerant of bleeding. Airway anatomy may be different. Analgesic choices may be altered by physiologic changes such as creatinine clearance
Elderly fall down steps bad head injury
No Collateral
No advanced directives can make intubation decision prior to CT difficult
Dosing of medication, and not knowing the PMHX
VS abnormal
– there may be a problem with the level of care, namely how far we should go and be interventionist.
– since patients often have heart problems, it is sometimes difficult to dose boluses
– I find that we often find several injuries when doing a panscan, even if the patient was rather asymptomatic
Unwitnessed fall with head injury, ALOC and stroke like symptoms. Which came first?
A common issue encountered when I was on the trauma service was a chicken-and-egg type scenario. Was the trauma the result of some acute or exacerbation of chronic medical condition or did the the individual have a medical complication following the trauma. For example, was the MVC the cause of her altered LOC or did they have a stroke which caused the MVC.
Not knowing the PMH or medication history of patient, pelvic injury resulting in internal hemorrhage.
66 y.o male s/p motorcyle accident aox3 complaining of right shoulder pain found to have pneumothorax, active bleeding of thigh. what blood thinners they on? pain level was not appropriate the degree of injuries
Fragile skin, spine board, difficult airway
Fragile skin, spine board
intubating a hemodynamically unstable patient on multiple meds that lower cardiac output and/or peripheral resistance
With the use of modern tools (indirect laryngoscopy), many problems related to ederly lack of mobility (spine or mouth) can be overcome.
–
unknown cause of trauma can lead to delays in evaluation of the initial cause
gosh that is an open ended question, i cant decide where to start. one thing that i think in general is particularly difficult, and can affect both minor and major traumas is the skin repair. ive had a range of severities of trauma all be affected by the combination of fragile skin that is impossible to utilize in the repair process (ie the edges youd normally stitch thru are so thin you cant sink a stitch into it) and the NOAC which is inevitibly on board is making it hard to keep the wound dry enough to get steristrips to stick on the edge (which can be the work around sometimes). the other main thing that comes to mind currently is knowing who to work up – there are SO many occult issues and in my current population, i end up finding so many unexpectedly worse issues in patients who are otherwise stoic and not acting like such a prob is present (mainly hip and rib fx, im constantly shocked by the way some pts present w those), you are always confronted w wondering if you just panscan every single elderly person who bumps into a table edge or not. and that leads to an associated legally fraught issue w the incidentaloma getting overlooked. so many nodules and liver lesions and thyroid spots are noted on the huge dictation of those scans, you have to be very careful not to miss that minor thing and make sure to get the follow up note sent to their primary care – but even though i have typed way over the limit of the box already that is just barely scratchign the surface of issues that have come up in my short tenure of managing elderly traumas….
nice
En experiencias que evidenciado con la reanimación del adulto mayor es el abordaje difícil de la vía aérea especialmente si se trata de una vía aerea anatómicamente y fisiológicamente difícil, además de poco tiempo de apnea disponible en la SRI, esto además de la reanimación con fluidos o hemoderivados ya que hay que tener presenta la tolerancia para evitar la sobre reanimación
Durante mi tiempo de ejercer como médico general no he tenido que reanimar a un adulto mayor en trauma, pero si manejo de vía de aérea en otras circunstancias y son cuellos rígidos que complican la alineación de los 3 ejes
Geriatric patients are always more difficult to care for you must maintain a high index of suspicion for occult injury
difficult intubation; difficult IV access. fragile bones
scalp laceration with occult bleeding onto backboard resulting in shock
Difficult intubation
Difficulty in achieving a normal heart rhythm, may be irregular due to age of the heart
difficult airway and intubation
difficult airway and indubation
e-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.
trauma resus on an older adult can be made complicated by multi-system involvement. even though younger trauma victims can have multi-system issues/injuries, I find that older adults often havew more issues d/t comorbidities/patho changes. increased bleeding and difficulty controlling bleeding. exacerbated med effects. greater risk of renal impairment, fluid overload. it gets complicated.
Vitals stable and so I was wondering why patient appeared to be doing so poorly. But later realised patient was on beta blockers and calcium channel blockers so vitals were falsely normal. Patient was a known hypertensive.
difficult intubation.the slow response by the team due to false ‘normal’ vital signs.
feeling of urgency downplayed in an elderly major trauma.
Untrained folks tend to Give full dose inductors while intubating, often leading to hypotension
ICH, cause or effect.
great topic
Broken teeth or dentures always threw me off.
abnormal rom in neck, large neck, small mouth
No teeth therefore hard to get a good mask seal
.
ok
Difficult intubation with kyphosis and C-collar with risk of neck injury, quickly can fluid-overload in CHF patient that may make breathing management more difficult.
difficult to c collar pts due to kyphosis, small stature etc
face trauma making airway difficult
Difficulties starting IV line
difficulty finding veins
ok head chest
rib/hip fractures. lower bone density
patient very gaunt, cheeks sunken and dentures
kk
strong answer
Hard to find veins for IVs
difficult a/w due to facial trauma, c-spine precautions
a/w complications d/t dentures and associated difficulty opening a/w in first place – made for difficult a/w insertion and abandoning ETT
airway difficulty with kyphosis
difficult a/w.
Elderly woman collapsed at home. CPR and Defibrillated x2 with ROSC. Intubated, sedation as patient not tolerating tube, IV obtained all done on patients living room floor with family screaming for us to save their mother. Lifted out of house to stretcher at bottom of front steps. 12 lead in back of ambulance revealed massive MI. Patient transported to cath lab for PCI. Cath lab staff upset that IV was not in L AC.
have not had to do a trauma vsa on older pt only younger
pt with curvature of spine, difficult to get a good mod. jaw thrust
ok
airway
a/w
Difficulty intubating.
difficult airways in the elderly are usually complicated by dentures, blood in the airway, and facial trauma.
hi
words
difficult positioning due to anatomy
ABCDE – easy to remember
difficult intubation due to kyphosis and smaller a/w in a petite older lady. difficult IV probably due to cort. steroid use
91M fell downstairs. Decreased GCS in the trauma immediately VSA upon transfer to bed. TTL decided to perform a thoracotomy.
an elderdly woman with a C2 fracture with dementia that I had to decide If I was transferring to my trauma referring center or opt for conservative care
Airway management (whether BLS or ALS management) difficult d/t arthritic joints (jaw, neck, spinal column) and kyphosis. I also had experience with a younger pt with paralysis from the waist down d/t spinal cord injury, who had a femur fracture. A sagar traction splint was applied to this pt to stabilize the fracture and help mitigate potential blood loss. The pt ended up developing pressure sores from the straps of the splint as they were not able to feel the discomfort developing. This learning point can be extrapolated to the elderly who often have a decreased pain threshold and decreased peripheral sensation.
Experienced difficulties inserting tube to a really anterior airway and due to their arthritis was unable to manipulate their head to visualize their cords
Altered LOA, staff unsure of baseline, staff unable to give report/history, medications altering vital signs making them appear WLN
Due to the frailty of the patient and how emaciated they were, it was difficult putting on a C-collar. The patient was tall and thin, emaciated. A pediatric collar would have been good circumferentially however it was not long enough. The adult cervical collar could not be tight enough to secure the cervical spine.
yes
Ok
good info
I know, at first I was thinking perhaps not okay, but then after some thought on the matter I came around to Okay!
k
.
none
got it
lack of history and poor historians.
Medication induced bradycardia
difficult intubation and difficult venocanulation.
sedation/analgesia more complex, injuries less obvious, high risk c spine
Older trauma patients with more complex injury patterns, more occult injury and more prone to delirium as a result of trauma.
No personal experience with this
k
Inabiltiy to open the mouth
.
Inability to open mouth
I have developed a very low threshold for imaging (CT and X-ray) based mostly on mechanism. I have found injuries I did not anticipate based on exam and history
Wow!
yes
Easily fractured
Break ribs almost always, Difficulty with BVM for dentures
–
K
Old people have Medical causes of their traumatic events complicating presentation. Had 80 yo run off the road, Bradycardic on arrival, Had long pause after arrival , needed pacemaker. Another similar, with peaked T waves on EKG, potassium was over 7.
ALMOST ALWAYS BREAK RIBS WITH CHEST COMPRESSION. SUBSEQUENT PNEUMOTHORAX OR TENSION PNEUMOTHORAX. B-BLOCKADE CAN INHIBIT EFFECTS OF PRESSORS, SPONDYLOSIS CAN MAKE INTUBATION DIFFICULT.
I agree breaking ribs is horrible. Considering that such a small percentage will be successfully necessitated and from that small percentage many will die from injuries from CPR.
I had a 70’s aged trauma patient brought in after an MVC that had left side weakness; he was actually a stroke alert. He had had a stroke while driving and lost control of his car. He ultimately went to the interventional radiologist and had successful clot retrieval and a good outcome.
okay great
Bolus fluids low BP
ok
k
Intubations are done by RT. I can prepare the pt for it
…..
Elderly gentleman in an MVA, came in decreased responsiveness,with respiratory distress. Attempts at intubation extremely difficult due to what appeares to be a mass made resus efforts. Anesthiology intervened and patientnwas transferred to ICU.
ok
RTs
commorbities, difficult intubation
ok
ok
ok
ok
ok
okay
ok
I have not had experience with trauma resuscitation of an older patient. However, I would imagine that chest compressions make cause more harm than good due to increased susceptibility to broken bones.
done
donee
…
…
ok
.
Intubation can be a struggle due to kyphosis or even brittle bones. Also vascular access, IVs or even IOs for that matter
..
medications
It can be difficult to know baseline mental status, PMH, and details of current trauma, especially if no family is around.
.
.
Conscious sedation (too large of dose) caused patient to loose airway and become hypoxic.
Elderly pt with a fall at home, pt and family unable to describe how or why fall occurred. Difficult to determine pt baseline mental status, polypharmacy, vital signs were more challenging to interpret.
Interesting
thats all
Nothing to add
x
head bleed in a patient anticoagulated for mechanical valve. Reversal put the patient at high stroke risk.
–
.
ok
Get off board asap
ok
ok
unknown medical history
Great information
Good infor
unknown PMH
unable to take Mhx from pt
Unknown medication and compliance with them
Very hard IV access
Lives alone
usually multiple trauma and several comorbidities ( heart lungs kidney problem)
ok
ok
Poor medical history including lists of medications taken for a fall/syncope/unconscious patient brought in by ambulance
When elderly people are sent in from nursing facilities without family or a full report and they are unable to provide information because they have dementia or don’t understand. We had a patient that was sent in from her home that was incubated, EMS did not even know that patient name so we could not pull information from previous visits…the patient was DNR. It’s hard when you save someone and then have to take them off the machines.
A very healthy 70s male who was an avid runner was struck peds vs MVC. Pt was alert and responsive in the trauma bay. Pt was not quickly recognized as having hemorrhagic shock with HR 110-120s. Trauma team delayed pt going immediately to OR and went to CT instead. Pt ended up going into DIC, which may have been avoidable with earlier recognition of shock in the older adult as pt was very active and healthy.
ok
o
Hard to communicate with patient due to multiple staff members, may be hunched over, get them off the board right away. May not be able to follow directions and may become confused.
hearing
rib fx, occult abd injury
Had a very, sweet older lady who was a volunteer at our hospital who got hit by a vehicle while getting off an RTA bus who said her leg “felt funny”. She was still wearing her little pink volunteer uniform. Sadly, unbeknownst to her at the time it had been traumatically amputated. That was a bad day.
hearing
when the patient is a poor historian and lack family support. difficult to ge a history
ok
backboard removal important but often overlooked
max 2hrs
diabetic patients most vulnerable
baseline status difficult to assess in the obtunded patient
history of previous intracranial bleed
heart failure and meds can lead to worsening prognosis
respiratory disease may affect compliance
remember ventilation issues may need intervention before securing the airway
Have not had an experience but could imagine possible difficulties with intubation, proper pain managemnet considering alterations with normal adult dosings, fluid resuscitation taking into consideration Hx of CCF or ESRD
unable to get in contact with family to determine their wishes
Homecare to ED nurse – time spent on spinal boards is important.
key point
understand
ok
.
deviated trachea, battery loss in Lucas during CPR, no back up battery
Balancing need for fluid resuscitation due to hypotension with known/severe CHF.
agree; always a consideration
beware ankylosing spondylitis when attempting to intubate
Correct fluid resuscitation, pain management
comments above are all relevant, just need to remember info being given and apply to practice
Patient fell down a flight of stairs ended up having severe and debilitating intracranial bleed with rapid decline in neuro function. Due to her age and severity no surgery was done.
roll over mvc, geriatric driver, ended up finding benzo’s in pt’s pocket.
frequent clinically occult injuries only identified on imaging
Pelvic fractures in combination with other co-morbidities
Elderly female who fell down a flight of stairs sustaining blunt head trauma, was on Warfarin for Afib hx, challenging extrication form small stair well, unconscious and suffered seizure in back of ambulance, multiple issues to treat, airway and seizure
Numerous times I have seen an elderly driver in an MVA seriously injured, creating complexity not only to search for injuries resulting from the MVA but to also not miss medical problems that may have potentially contributed to/caused the accident.
it important to know how age can negatively impact the in elderly, and how nurses should be aware of theses changes when assessing the elderly patient and incorporate the issue of ABCDE in their assessment.
.
Difficult to differentiate if there is altered mental status, and if it is related to dementia or the fall
.
fractured pelvic and shoulder
the question was I how do provide ADLs care without causing pain and discomfort
fractured pelvic and shoulder
my question was how do provide care ADLs care without further inflicting pain and discomfort
good info
.
important information.
.
ok
as much as major trauma is difficult in this age group, I find the “traumettes” most likely to miss things (little elderly lady, minor trauma/tumble, not much on imaging e.g. CXR often misses rib fractures, but then develops lung contusions, slowly gets worse while being managed on a regular unit rather than trauma unit due to the mechanism…
Difficult to r/o cervical spine injury with chronic DJD of spine. need to leave the collar on until MRI obtained. This agitated the patient.
Always difficult to differentiate acute altered mental status vs chronic dementia if no family members present.
have not had this experience yet, will review others comments
Had a patient who we managed to get a ROSC on three times before they were pronounced dead in hospital. Always wondered if we had done something different if we could have maintained one of those ROSCs
Elderly Man stabbed himself in the heart to get out of his nursing home. Highly unstable, but needed rapid transfer to the OR
Paciente obesa ,cuello corto y prótesis dental , difícil de intubación endotraqueal
have not experienced
although i would love to have an experience, i have yet to experience an older patient in some sort of trauma setting
Haven’t been in a Trauma Situation during Resucitations.
Haven’t experienced this yet.
ensure long term plan set
never experienced it
never experienced this
ok
85 year old with myelofibrosis and hepersplenism. Fell of a horse and had ruptured spleen and head injury GCS 8/15. Had pre-existing mandibular fracture and wired jaw, in shock with no visible peripheral veins.
Driver MVC extricated by fire using jaws of life. Pelvis pinned by wreckage, initially awake and responsive, loss consciousness with extrication. Coded en route to ER. Open book pelvic fracture, despite attempted massive blood product resus with level 1 infuser, unable to regain ROSC. Probably wouldnt have turned out any different in a younger person but highlights how much less physiologic reserve the elderly often have
I don’t work in ED so tend to see patients further down the line. Have had a few pts where injuries have been missed because their mechanism of injury has been felt to be insignificant
dementia
good examples
interesting
Difficult history living alone
multiple comorbidites
multiple underlying medical conditions and medications complicating all aspects of exam, as well as underlying chronic mental status changes vs new findings.
Sometimes it is difficult to have a decent history, and the polypharmacy makes treatment less than.easy.
elderly female with multiple rib fractures; initially well, but given risk, intubation and ventilation contemplated but concerns re: cardiac patient and use of meds with current poly pharmacy; initially observed with close reassessment; with need for narcotics for pain causing sig sedation, evident that needed mechanical ventilation to prevent respiratory failure
Many. Issues such as cardiovascular disease substantially alter VS and treatment options (much more cautious with fluid bolus)
dementia can make exam unreliable
Hydromorphon can lead to a delerium too in some patient …
have intubated some elderly with unknown goals of care that after discussing underlying Dx and Px with family with then withdrawn care. need GOC discussion early with frail patients in extremis
Agreed 1N7, review goc
Trauma Mvc , poor outcome , difficulty establishing goc
ok
Have seen multiple presentations of falls in elderly. Commonly injure face and hips. Almost always require CTB +/- C-spine to check for intracranial abnormalities +/- c-spine abnormalities. Commonly use anticoagulants.
Also of note is that I notice staff often quote observations as normal without thinking what this could actually mean in the elderly population.
never had an experience of that sort
yes
Inncouous all in elderly patient, C1 fracture.
Got called into a trauma – TTL was not in room, anesthesia had unrecognized esophageal intubation, team did not realize that the patient had actually undergone cardiac arrest.
Initiated ACLS and after 1 failed attempt at re-intubation while prepping the neck, established a surgical airway. Ptnt survived to the OR
rib fractures
Fractures
high risk of fracturing bones
agree
no
no i can’t, never experienced
great detail on the case study
agreed
great detail on the case study
helpful
k
Irregular heart rhythm on elder female, was admitted to hospital and died because of STEMI
patient’s pacemaker stopped working properly causing pt to code
These comments are very interesting to read. Have not yet encountered a pt in this situation
maintaining airway
ok
sometimes intubation is difficult because of changes in anatomy/function
helpful
Difficult vascular access
Elderly female, had a car accident. Passenger seat.
Stable when she arrived and later on but really i did not expected her to have that much of injuries.
Mainly complaining of pain everywhere but nothing objective at my exam. Many injuries found with the CT scan she had.
I should have been more suspicious
agree with above
importante perte de sang via saignement du cuir chevelu
have not been involved in any
Never had one that was difficult
havent actually been involved in one
Elderly male that gate fell on
initial vitals ‘normal’
cardiac arrest soon after
Difficult with lying patient flat due to neck issues. C-collars are not a patient satisfier.
Broken teeth, while intubation
Difficult IV access
My challenge in a recuss of an older person was when we made the decision to intubate because there was no goals of care disucssion documented; however, it was likely they would not recover.
during CPR left with broken ribs and dislocated teeth
Intubation in an elderly patient: dentures, on anticoagulant so friable mucous membranes which bled, limited neck mobility, dry mouth
Elderly lady came in with no complaint of a fall, however, found out from a relative that she didn’t mention it because she didn’t want to be removed from her home. After a CT Scah, blood was found in her cerebral spinal fluid. Prior to the scan, she couldn’t feel a catheter insertion. She ended up going home after medical management. Good outcome but could have been deadly.
4 Trauma patients arrived at the same time (2 cars, 2 passengers in each car). 91 year old lady self extricated, checked on scene by paramedics and thought she was ok, she wanted to just go home, but they said she should “get checked out” anyway. Slight SOB, vitals “normal”, no obvious complaints. Ended up having multiple (6-7 ribs on each side) rib fractures, bilateral pneumothoaces, and some vertebral fractures. Needed bilateral chest tubes and transfer to tertiary care trauma team.
85+ yr old male, fall from standing, stoking head on bumper of nearby car – came in with GCS of 8, high C-spine fracture causing resultant shock
ok
Occult bleeding, fragile bones, and subtle vital sign changes.
lack of history is frustrating
perfect.
lack of PMhx and mechanism of injury.
Hypotension post induction
The most challenging factor is lack of collateral history as to mechanism of injury- i.e. witnessed fall versus “found on the floor”. No medication history. No previous assessment as to normal mental status. No idea as to living conditions as per supports in the home if discharged.
elderly patient from dementia care who fell
head and facial injuries
alert but increasingly agitated
examination revealed very large bladder with over 2 litres
post cath agitation much improved.
Trauma in the elderly is often under-diagnosed, i think we sometimes forget that a ‘fall’ in the elderly equates to trauma. A very important point though is to try and consider the ACD in your resuscitation although this is not always possible and sometimes treat first may be the right thing to do, giving families more time to be with the patient if it is going to be a poor prognosis. Treating and diagnosing allows better prognostication.
demented patient with possible cspine fracture who was agitated and not following commands. required delicate intubation and sedation for management
Question of how aggressively to treat a very elderly patient. Often it’s not appropriate to intubate.
Patient known Trigeminal Neuralgia, very difficult intubation
?Which one better in this situation – Intubation/Tracheostomy?
elderly male presented with a gate falling on him
normal bp and spo2
significant chest injury with rapid decompensation and death
vitals do not correlate to patient
Unconscious elderly patient with no family member or friend to explain circumstances
no collateral history, multiple comorbidities, unknown clinical baseline
no clear history, no clear DNR/Full code status, no family members
Great over view
– Undiagnosed or poor management of pain associated with rib fractures could have catastrophic results for an elderly patient and complicate an easily manage condition with a potentially futile pneumonia.
One of the most common challenges in intubation is the lack of teeth and limited neck extension. removing of dentures could make the BVM ventilation so difficult; it is very helpful if two-person BVM attempt.
Difficult BVM while intubating
good review
everybody questioning family, not assessing patient’s mentation. Assuming geriatrics = dementia. When patient was alert and oriented x3, high functioning
good to know
elderly woman on warfarin for heart valve…minor head trauma (fall on ice)
turned into massive intracranial bleed very quickly after arrival in ED
I’ve had several times where I’ve seen the team become focused on a co-morbidity or finding concerning for a cause of the trauma during the initial ABCDE management phase. I.e. “are those inverted t waves on the monitor?” – maybe so, but I’m more worried about the open pelvis as a cause of the hypotension. People get fixated and loose track of basics sometimes.
great overview
1Formost issue I had to quickly solve was if ATLS was justified and was against the wishes of the patient/NOK.if advancedcare directive existed
2having solved that issue, next was the induction drugs.. Ineeded a very lesser qty than average adult and had to keep iimpending hypotension in mind
3controlled IV fluid resus as patient could have cardiac decompensatation
Older woman hit in a crosswalk, no LOC awake but aphasic. Challenging to get a story, do an assessment etc.
No teeth, also neck stiff
84 yr old woman, in otherwise very good health but anticoagulated, fall from walking, 3 stairs. Dev intraparenchymal bleed, intubation was very difficult due to very anterior airway and she actually needed much MORE sedation and paralytic than expected!
76 year old motorcyclist versus wall: obvious chest wall injuries but nil else on trauma examination. CT trauma series demonstrated occult injuries in every body region.
Good overview
good review
Intubation of a patient with no teeth making intubation more difficult
I practically work in a geriatric town full of elderly. Having low awareness in health care, they have never gone for medical check-up in there entire life until they are brought to ED for some acute/ life threatening issues. There we start to diagnose diabetes, acute kidney injury, COPD and the list continues. It makes the resuscitation more complicated.
Stiff neck, blood in airway. Sometime very dry mucous membranes
good examples
elderly trauma pt with hunch back and trying to figure out how to intubate him.
Elderly male, driver of a car rear ended at very low speed, awake but unresponsive to verbal and painful stimuli. he would later become quadriplegic from c spine injury. I’m very happy that I treated him as though the MOA was severe, as apparently it was.
anti-coagulated, cardiac pt, abnormal v/s
Cardiac impaired function when intubating.
.
–
it is hard to determine which of the myriad fun changes in the body old age has brought about in your patient
deplete volume status prior to trauma with pursuant blood loss contributes to overly aggressive drug choices and doses when smaller titrated doses my be more beneficial.
decrease RSI Rx by a third in elderly may be effective-good advice
Proper positioning is extremely important with everyone but especially with elderly with physical restriction’s of Cervical spine.
more likely to fluid overload this age of pt as their cardiovascular system is unable to handle it pump/electrical insufficiencies)
k
84 year old female, fell down stairs. Presented awake but slightly confused. Deteriorated in ED – large subdural haematoma. Also had pelvic injury that was initially missed due to lack of symptoms and normal vital signs.
inability to extend neck due to OA. poor jaw opening
i had intubated few elderly patients. Two of them i had encountered difficulty with intubation. one of the elderly patient had two false tooth which was blocking the visualization of the vocal cords, so i have to use the forceps to remove it and then i got through with the intubation.
Reduced cervical mobility with small mouth opening and big incisor teeth.
Difficult vascular access.
poor vein access, difficult intubation,
90 yr old female found unresponsive confused on the floor with significant facial oedema and ecchymosis in a pool of blood. Caregiver claims she fell…physicians suspected assault…patient and caregiver unable to give history as the caregiver was not around at the time. patient is a known hypertensive, unknown mechanism of injury, cognitive impairment during resuscitation, patient needed mild sedation for investigations
We had an 80 yr old patient known HTN and IHD, sustained a fall after having chest pain, had head injury as well. GCS 7/15. intubated. ECG and cardiac markers confirmed NSTEMI. CT showed intraparenchymal haemorrhage with significant midline shift. Concerns with how aggressive to be with resuscitation, overall prognosis, and discussion with family members with respect to these issues.
el abordaje del adulto mayor es muy complicado
she need a rapid blood transfusion and obiusly find for the site of hemorrhage
They are very complicated patient with many pathologies to be taken encuente
Very complex patient, lots of questions for feedback…
zzz
I once had an 88 yo male found on the side of the road after being hit by a car. Transferred in from a district health facility already intubated. Obvious head trauma, bleeding from the nose, ears and mouth profusely. Hb of 4. The blood bank facilities in my country are limited so I think I was only able to get one unit for him. He was too unstable to transport to the X-ray department and for CT Brain and C-spine. He likely had a basal skull fracture and intracranial haemorrhage. But no other obvious injuries anywhere. FAST scan normal. GCS 2 plus tube. He rapidly declined and subsequently died after an hour or two.
I think sometimes the hardest part is deciding when not to take aggressive measures to resuscitate because of limited resources or other support from specialties and because advanced directives and do not resuscitate orders are not recognized in my country.
I once had difficulty resuscitating a 80 yr old hypotensive MVA victim with a PH of CHF, and the question became how much IV NS needed before consideration was given to giving vasopressors.
Good points to remember when premedication for intubation
None
Initiating CPR on an aged arrest pt., the first compression fractured his ribs.
Not been involved with elderly trauma resuscitation so far
Cool.
kk
kk
have not been involved in a resusc
kyphosis and contraction make for difficult intubation
sedatives used for intubating caused profound hypotension
fortunately no recent geriatric resuscitations
Self inflicted GSW face
Needed to be prepared for back up intubation plan, awake intubation, surgical airway
difficult mouth opening can make intubation complicated
Broken teeth,O.A neck,friable skin,rib fractures are easily happened during aggressive resucitation in elderly pt.
tend to rely on pan ct because of uncertainties in clinical evaluation
Key point is early removal off backboards. Ulcers are a long term issue.
intubation at my hospital is done by RTs I only order the induction meds