Geriatric Trauma - 2 Nursing CEs

Author: Kristi Hudson RN MSN CCRN

Written: 12/31/05

Updated: September 25, 2009

Course Description:

This course is designed to give an overview on the care and management of the geriatric trauma patient. Statistics regarding the incidents of trauma as well as leading causes of trauma to geriatric patients will be presented. Focus will be placed on the affects that age and co-morbidity have on treatment options that are available for geriatric trauma patient. Nursing assessment and resuscitation efforts for geriatric trauma patients will be the final focus of this course.

Course Objectives:

Upon completion of this course the student will be able to:

• State the leading causes of geriatric trauma
• Describe the affect that co-morbidities play in the care and management of the geriatric trauma patient
• Discuss the affect that advanced age plays in the care and management of the geriatric trauma patient
• Explain the normal “abnormal” lab values that are seen with most geriatric patients
• Describe specific nursing assessment findings for the geriatric trauma patient
• Have a better understanding of resuscitation efforts for the geriatric trauma patient

Geriatric Trauma Statistics:

• Trauma is the 8^th leading cause of death in people over the age of 65
• Motor vehicle collisions are the most cause of trauma in geriatrics 65-74 years old
• Falls are the most common cause of trauma in geriatrics 75 yrs and older
• Older patients have worse outcomes despite the severity of initial injury
• Geriatric trauma patients have a 15-30% mortality rate while younger trauma patients average a 4-8% mortality rate
• Geriatric trauma accounts for 33% of all trauma care dollars spent in the United States each year

Specific Causes of Injury With Geriatric Trauma Patients:

Motor vehicle collisions (MVC) – Most motor vehicle collisions involving geriatrics occur close to home, during the day and at intersections. Geriatric trauma patients are more likely to be found at fault during a MVC.  Drivers over the age of 75 have the highest mortality rate then any other age group (young or old). Alcohol use is only involved in approximately 6.6% of all MVC’s involving elders where as in younger drivers the percentage is as high as 23%.

Falls and Injury – Falls are the second leading cause of trauma to geriatric patients between 65-79 years old. At age 80 and above; falls become the number one cause of trauma for geriatric patients. It has been estimated that approximately 50% of all geriatric trauma patients that fall and present with traumatic fractures will die within 1 year of their injury.

Violent Assault – Although not often correlated with the geriatric population, assault actually accounts for 4-14% of all geriatric trauma. Up to 4% of geriatric trauma is caused by elder abuse (most often blunt trauma).  Geriatric trauma patients who present malnourished, disheveled, or with bruising should be carefully assessed for abuse. Other keys to recognizing elder abuse include:

• Long delays between trauma injury and presentation to the ED
• Inconsistent history
• Caregivers who insist on providing the history (rather then the patient)
• Frequent visits to the Emergency Department
• Frail patients presenting without a caregiver
• “Bounce back” admissions

Physical Effects That Age and Co-morbidity Have on the Geriatric Trauma Patient:

Neurologic – Differentiating between Dementia and Delirium can be difficult with the geriatric trauma patient. Dementia is a chronic gradual change in neurologic function whereas Delirium is a more acute change in neurologic function. Note that head injuries in geriatric trauma patients may be slow in onset due to the fact that elders have greater brain atrophy and actually more area between the brain and skull for swelling or bleeding to occur (subdural hematomas are 3 times more likely to occur then epidural hematomas). If neurologic function is altered and thought to be due to Delirium; all of the following should be suspected and ruled out:

• Blunt Head Trauma
• Sepsis
• Adverse Drug Reaction
• Hypoxemia (either cardiac or respiratory)

Cardio-pulmonary – The cardiovascular and pulmonary system most often causes the greatest barriers to treatment for the geriatric trauma patient. The effects that age and co-morbidity have with the geriatric patient maybe any of the following:

• Absence of tachycardia in the state of hypovolemia, pain and or anxiety (pt. may be on beta blockers, have a sick sinus syndrome or be less sensitive to catecholamine release)
• The geriatric trauma patient may have an acute cardiac issue (acute MI could be the cause of the trauma)
• A normal heart rate in light of traumatic injury should be very suspect
• Systemic vascular resistance is often increased with hypovolemia (in light of the inability to increase heart rate and/or contractility) which will produce a lower then normal cardiac output
• Lung compliance becomes less with age due to decreased alveoli function and  decreased  mucociliatory function  (This leads to hypoxemia and increased risk for pneumonia or other bacterial infections)
• Lung compliance may also be less due to chronic illness such as COPD or other obstructive lung disease

GI – The use of non-steroidal anti-inflammatory medications can increase the risk of peptic ulcer in the geriatric trauma patient. In addition geriatric patients are at greater risk for constipation so use of opioids should be carefully planned.

Renal – Loss of glomerular filtration/function is estimated to be 30-40% less in geriatric patients who are greater then 65 years old. This can lead to acute tubular necrosis or acute renal failure with traumatic injury.

Orthopedic - Osteoporosis leads to more frequent fractures (especially rib fractures with a MVC). The risk for cervical injuries also increases in geriatric trauma patients who are greater then 65 years old; with odontoid fractures being the most common.

Drug Sensitivities – The geriatric trauma patient is more sensitive to therapeutic and toxic drug levels. Because most geriatric patients have a decreased lean body mass, a decreased water volume and an increased amount of fat (proportional), the following should be considered before administering medication:

• Morphine which is a water soluble medication has a lower volume of distribution and a more rapid onset.
• Fentanyl which is a fat soluble medication may be distributed more widely and have a slower onset.
• Demerol should be avoided in the elderly because it produces a toxic metabolite (normeperidine) which has a very long half-life and can lead to dysphoria or seizures.
• Opioids with short half-lives such as Morphine, Hydromorphone or Oxycodon are better choices for geriatric trauma patients.
• Because of decreased muscle mass, IM injections should be avoided.

Normal “abnormal” labs seen in geriatric trauma patients:

Increased:

• BUN
• Glucose
• Fibrinogen
• Alkaline Phosphatase
• Uric Acid

Unchanged:

• Sedimentation rate
• Hemoglobin
• PT/PTT
• Most Electrolytes
• Aspartate Aminotransferase
• Creatinine
• WBC

Decreased:

• Albumin
• Calcium
• Creatinine clearance
• Phosphorus

Nursing Assessment of the Geriatric Trauma Patient:

• ABC – (airway, breathing, circulation)
• Cervical spine precautions (as with all trauma patients)
• Frequent Neuro assessment
• Vital signs (remember that a normal blood pressure and heart rate may not be indicative of the true injury). Monitor temp for signs of infection, pneumonia or sepsis (line sepsis is common in geriatric patients).
• Hemodynamic Values – (pulmonary artery catheter should be placed if injury significant), monitor the following:
  • Cardiac Output/Index (low values are a good indication of hypovolemia)
  • Systemic Vascular/Pulmonary Vascular Resistance
  • Oxygen delivery and consumption
  • PAWP (wedge pressure can be indicative of heart failure in light of fluid resuscitation)
  • SVo2 monitoring (measures tissue consumption of oxygen)
• Respiratory (wet lungs are a sign of fluid overload, heart failure or poor lung compliance). Other respiratory assessment includes:

§        Respiratory rate, rhythm and accessory muscle use

§        Monitor for atelectasis

§        Routine Chest X-ray (monitor for pulmonary infiltrates)

§        Pulse Oximetry Monitoring

§        ABG’s (if patient is intubated should be drawn frequently)

§        Draw Lactic Acid (helps measure oxygen debt)

• Gastrointestinal (Monitor NG pH as gastric acidity is a good indicator of GI tract resuscitation. Normal gastric pH of less then 7.5 can be indicative of some degree of mucosal anaerobic metabolism).
• GU (monitor intake and output as well as closely monitoring fluid resuscitation efforts).
• Other areas of assessment include:

§        Frequent monitoring of labs (especially Hgb/Hct and electrolytes)

§        Pain control (opioids as previously discussed)

§        Skin integrity (assess current injury as well as risk for pressure      ulcer development)

§        Assess for risk of injury (falls or other)

Resuscitation Efforts for the Geriatric Trauma Patient:

Resuscitation efforts for the geriatric trauma patient are similar to those of a younger trauma patient however; greater caution must be taken and usual monitoring parameters such as B/P and heart rate cannot be used as clinical indicators for hypovolemia. Resuscitation efforts should include the following:

• Fluid (Crystalloids)
• Blood Products (If no improvement in hypovolemia is seen after 1-2 liters of crystalloids)
• Dobutamine (to decrease SVR and improve Cardiac Output)
• Vasopressors (to assist with blood pressure)

Note: Aggressive hemodynamic management can help prevent serious secondary injuries such as Acute MI, Acute Stroke and multi-system organ failure.

References

Barishansky, R., M. MPH & O’Connor, K. BS EMT-P. (April 2009). Geriatric trauma: what to think about before assessing, treating and packaging. Retrieved on August 28, 2009 at:

http://www.jems.com/news_and_articles/articles/jems/3404/geriatric_trauma.html'

Blanda, M. MD. (2000). Geriatric trauma: Current problems, future directions. Retrieved on December 31, 2005 at:

http://www.saem.org/download/02blanda.pdf#search='geriatric%20trauma'

 

Cohen, S., S. (2003). Trauma nursing secrets. Questions and answers reveal secrets to safe and effective trauma nursing. Hanley & Belfus. Philadelphia.

 

Melander, S., D. (2004). Case studies in critical care nursing: A guide to application and review.

(3rd ed.). Saunders. Philadelphia

 

Meldon, S., W., MD. (2003). Geriatric trauma: Outcomes of older adults after trauma. Retrieved

on December 31, 2005 at:

http://www.saem.org

 

Scalea, T., M., MD (2000). Geriatric trauma. Retrieved on December 9, 2006 at:

http://www.femf.org/education/SBTS2000/scalea.htm

 

Wright, A., S., MD. & Schurr, M., J. (2000). Geriatric trauma: Review and recommendations. Retrieved on December 31, 2005 at:

http://www.wisconsinmedicalsociety.org/uploads/wmj/wright.pdf

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