Mrs. Popast
Mrs Popast is an 82 year old woman who was struck by a car going 30kph while she was crossing the road on the way home from the grocery store. She was brought to the ED by EMS. She arrived in the ED on a back board and with a collar. Her vital signs are 120/70, HR 92, Sat 100%, and she’s on a re-breather mask. She is awake and responding to your questions though not coherently. She seems disoriented, and she is complaining of “pain everywhere” and “I can’t breathe!”
Answer the questions below in the space provided.
- How do you interpret her vital signs?
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- What orders would you write for this patient?
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- What are her most likely injuries?
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Discussion: Mrs. Popast
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2 liters of saline? not even would do that in a younger patient
Importante en este caso conocer comorbilidades del paciente, además en este contexto paciente adulto mayor con taquicardia con índice de shock positivo iniciaría reanimación con hemoderivados y manejo del dolor y lo primero que descartaría sería sangrado como causa del shock
estos son unos puntos muy valido. estoy de acuedo con Jose, la senora propast puede tener muchas fracturas en el cuerpo-especficamente en los brazos, las piernas o la cadera. tambien estamos preocupados que tenga herida en la cabeza que puede causar hemorragia en el cerebro.
important to interpret vitals with background (comorbidities) of patient in mind
Correct
do not let vital signs in the elderly overlook traumatic injuries
I would start with one liter of fluids and closely monitor
Never save money or radiation on old people…… scan-o-rama
Pretty straightforward
ATLS has a geriatric chapter.
Challenging exam, Probably would pan scan
Probably would pan scan
Good case study to think of possible issues that arise with trauma patients
Estamos de acuerdo en el abordaje por prioridades, pero en contexto de trauma, sea un adulto mayor o no, si requiere reanimación, por hipovolemia, lo correcto es transfundir y detener el sangrado, la solución salina no solo aumenta la coagulopatía, sino que aumenta la acidosis, así que 2l de sol salina, me parece incorrecto.
kk
This is an interesting case study
Realize its hard to know whats going on with the patient without in depth tests
interesting case study
too much fluid, unnecessary NRB, all and all good cas estudy
interesting things to consider and rule out
interesting case study!
Very well done
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excellent case
clear spine to remove board and collar, and see what sats are without NRB may help with poss. anxiety resulting in “can’t breathe” complaint
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non rebreather isn’t nessessary
I concur.
Easy hard charger.
more injuries in the elderly , need more info to be sure
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Good case study
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nelly
good case study
Got it
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agree with always doing more than less in elderly, assume more injuries
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Multiple pathologies cna occur as a result of an MVA
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WIDE RANGE OF POSSIBLE DIAGNOSES WITH SPECIAL CONSIDERATIONS FOR AGE.
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good case
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Geriatric Community does not have reserve to compensate like average adult community.
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thorough trauma assessment
Perhaps 500ml NS and switch to blood product with trauma?
Older people get more injuries.
backboard
do a good work up.
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alright
good info
Trauma in elderly more complex than in the younger patient.
atls,panscan
in the elderly have to be careful with vitals since they can decompensate rapidly
great findings
interesting
I think cristalloïde quite contraindicated. If hypotension, blood
Likely the answer
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this is very helpful, makes you critically think
D’accord avec le commentaire sur le 2L de NS. Rien n’indique dans ce cas que c’est indiqué.
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Interesante el tema , es importante el examen físico del paciente anciano teniendo en cuenta todos los factores de riesgo
How would we establish a baseline without a patient’s history or drug history?
Doing a full head to toe assessment as you do the orders is important to check for visible injuries. Pain management is important as well.
Good set of questions
Would include pain management
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have high suspicion for injuries in elderly
same as younger pt only moreso
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important information
interesting
CBC, X-RAY
i would consider N/S at 100cc/hr for maintenance at this time. Not a bolus of 2L.
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elderly trauma
Good case
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monitor respiratory problems first
pedestrian Vs MVA common , cars / trucks need to slow down & be alert !
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1 my Priorities will be pain management.. I have no issues with using opioids as inadeaquate pain control is more of an issue than ? respiratory depression with opioid.
Further any NSAIDS is likey an isue with possible CHF/Renal compromise in these patient population. Opioid with good monitoring alo=ng perepheral blocks is the way to go
2extensive imaging inc CTB. I am not sure if I would be getting trauma CT unless some more features
3 re examination of other systems
4 olan admission for tertiatary survey
Agree with pain management, also close monitor with overdose in frail old person as it can precipitate delirium.
As already mentioned by others, the pain management is important too. This lady got hit by a car, actively complains of pain and seems confused (DDx pre-ex, head injury, PAIN?!). I would like to give her appropriate and adequate analgesia before making her go through imaging.
I work in small rural ER, …assess CABC , 2 large bore Iv, start bolus, secure airaway, draw bloods with IV start and transfer out to definitive care
monitoring Vital Signs, 2 large bore IV’s, blood work, Xrays, CT scan, Ultrasound, being aware of cognitive impairment (check with family members to get baseline)
Agree 2L bolus is way too much. Likely will pan-scan this patient so getting portable films first just slows down the process.
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Agree 2L NS bolus is too much. Judicious fluids initially with low threshold to transfuse blood products in trauma is a better approach.
I disagree too with the 2L of fluid… In trauma blood is the best choice (maybe starting with 500 cc is ok)
2 litres of saline is too much in this scenario
good advice
is 2 l too much
risk of fluid overload and worsening resp function
even for young patients, we are not advised to give so much fluids. We should give PRBCs… I think it’s even more true with old patients with underlying cardiac issues
Important to prioritize early and effective analgesia to prevent delirium
A through physical examination from head to toe with relevant laboratory investigations like CBC, Electrolyte, Blood grouping and cross matching, PT, INR, CT scan of Head, Neck, Chest and Pelvis with ultrasound of whole abdomen is required. I would avoid using narcotic analgesic which cause respiratory depression, 2IV lines, one liter normal saline, Pantoprazole and Paracetamol/Tramadol combination for pain relief.
Much harder to get what is good vital signs if pt had trauma outside of home and confused until one knows any medications that could influences pts “normal”. Also thorough head to toe using mechanism of injury as a guide for higher suspicion of expected injuries and regular reassessment for any changes would be helpful.
be cautious with the 2L of NS – this would not longer be the standard of care if I felt she was bleeding somewhere – I would use blood far more aggressively
good exercise
someone assigned to contact relatives – history – medication list
with head injury being likely, ct head
is she going into shock?
I would be careful in giving narcotics, close monitoring is more important. If there is clinical signs of skeletal or organ injury no question of giving pain medications. Some times small amount of pain medications can be problem.
This patient also needs coagulation studies and TAG
Level I trauma centers this patient gets pan CT of head, neck, chest and abdomen including pelvis
In some centers with new scanners patient are getting scans of the whole body in less than 3 minutes
Close monitoring of VS and frequent re-exams advisable.
i would be cautiois with IV fluids
I will routinelt perform CTB and C spine
serial FAST
good analgesia
alway will observe in hospital
Great
GOOD REVISION ON TRAUMA IN ELDERLY,VERY HELPFUL.
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seems like a lot of fluid
I thought we didn’t bolus bleeds anymore because we don’t want to dislodge a clot.
Also, you could fluid overload an elderly patient easily.
Gathering baseline (e.g. baseling cognition) is important here, as well as ongoing mental status monitorin
In the elderly, “normal” is a diagnosis of exclusion as elderly have different “normal” parameters in terms of physiology and anatomy. I would take the label of “normal” in elderly especially in this case as a red flag, and there are chances in missing some findings.
100% agreed with your comment
IN the elderly, physical exam and review of mechanism of injury are esp. important due to the possible cognitive impairment (acute or chronic) that prevents an accurate localization of pain or injury sites.
IN the elderly, physical exam and review of mechanism of injury are esp. important due to the possible cognitive impairment (acute or chronic) that prevents an accurate localization of pain or injury sites.
makes sense
One must maintain a very high index of suspicion…..and go hunting!
require a high level of suspicion
Elderly patients require a different approach to trauma care
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being hit by cars is not fun
sounds alarming.
depends on what the scan shows. treat according to that & VS etc
She has the potential to be critical! Sadly people may not become alarmed by those vital signs.
What do you call a smart unicorn?
The “A”corn.
as per trauma assess, increased likelihood of bone and organ damage with elderly
I assumed the pt was walking when she was struck, as opposed to using a walker/wheelchair etc
Consider complete head to toe survey. Focuses assessment on areas of injury. Consider MOI.
txa needed
Good case to highlight the importance of not relying on “normal” vital signs in the elderly given their decreased physiologic reserve and multiple medications.
I agree with the ATLS method of head and scan assesment
It is best achieved by classifying the patient
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A thorough assessment of the patient is required taking into consideration the age and the physiological differences .
through assessment is needed irrespective these vitals and also the fact that her PMH is unknown
A thorough trauma assessment is needed.
good to know head injury is the most common type of injury in older patients
She is complaining of pain everywhere, and she may well have multiple skeletal or organ injuries. However a physical examination has not been mentioned. She would appear to be sufficiently responsive to localize pain and tenderness on examination, which could help in assessing the necessity for radiological imaging of specific sites.
Most important to go through a thorough ATLS based protocol. A pan-scan of the head, Capone,chest, and and pelvis would be appropriate after stabilization
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assessment of her spine and removal of the backboard if indicated may help with her distress/discomfort
it is very critical when older people vitals change coz no reservoir for compensation.
Isn’t 2 litres of normal saline stat now obsolete?
IN the elderly, physical exam and review of mechanism of injury are esp. important due to the possible cognitive impairment (acute or chronic) that prevents an accurate localization of pain or injury sites.