'Normal' values may signal life-threatening trauma for elderly

ED nurses are at high risk of overlooking dangerous signs

If you go by typical "normal" lab values or vital sign ranges when caring for elder trauma patients, you may miss a life-threatening injury, says a new study.1 Researchers looked at the base deficit of 74 ED patients ages 65 and older and found that this measure was a good predictor of life-threatening injury. This finding underscores that early identification of serious injuries is especially important in elders, adds Shahriar Zehtabchi, MD, the study's lead author and associate director of research in the Department of Emergency Medicine at Kings County Hospital Center in Brooklyn, NY.

"The most important take-home message from our study is that elderly patients are very different from other age groups and have to be treated differently," says Zehtabchi. So-called "normal" lab values or vital sign ranges might be accurate for younger patients, but they may be misleading for older patients, he explains.

Determine the elder trauma patient's baseline values for blood pressure, lactate, and base deficit levels, advises Zehtabchi. He gives the example of a previously hypertensive elderly patient with an average blood pressure of 180/95, who comes to the ED with a blood pressure of 130/80 — an indication of a significant risk of internal bleeding for this particular patient, though it would appear as "normal" if you didn't know the baseline.

"This is a significant drop in blood pressure," says Zehtabchi. "However, one can only detect this drop if he or she knows the patient's baseline blood pressure, or at least pay attention to the history of hypertension."

The same is true for a base deficit, which could go from +4 at baseline to -2 after a traumatic injury for an elder patient, he says. "Ignoring the patient's baseline may mislead the clinician to interpret the base deficit as normal, since -2 is within the normal range."

Don't miss subtle signs

"With this group of patients, we are often 'missing the boat,'" says Sheri Cook, RN, CEN, emergency services educator at Tallahassee (FL) Memorial Hospital's Bixler Emergency Center.

"I realize that the comorbidities in this group are large," says Cook. "But I have done many case studies on elder trauma patients. And even with their many health issues, they can have successful outcomes with proper care, frequent evaluations, and follow-up."

A too-brief physical assessment can cause nurses to miss subtle signs such as decreased lung sounds, heart murmurs, and absent bowel sounds, says Theresa A. Cesiro, RN, MSN, director of emergency services at St. Bernadine (CA) Medical Center. "Another mistake is not thinking the mechanism of injury through, to alert the nurse to address specific systems or areas of thorough examination," she says.

Your medical and medication history can change your interpretation of what is seen during assessment, says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN. "Since the older adult typically has less cardiovascular and pulmonary reserve, it is important to act with a critical eye to what is happening with this patient," she says. "It is often harder to recognize the older adult in trouble."

For example, the patients may have low blood pressure because they are on antihypertensive medications, or they may be hypovolemic from shock, says Somes. "They may not develop the classic tachycardia as part of a response to shock because they are on beta- or calcium channel blockers, keeping the heart rate slow," says Somes. "Geriatric patients are also less able to vasoconstrict due to atherosclerosis, so they do not 'do' the compensation mode very well."

Additionally, geriatric patients have a tendency to be dehydrated, which may be due to lack of fluid intake, diuretics, or lack of subcutaneous fatty tissue, says Somes.

The hypotensive state also will stress the heart more quickly in the geriatric patient, leading to cardiac complications not necessarily seen in the younger patient, adds Somes. "Acute myocardial ischemia, or infarction, is not an uncommon complication of the geriatric patient who is volume depleted and not perfusing the coronary vessels adequately," she says.

The geriatric patient's pulmonary system is typically stressed as well, says Somes. "Pain due to injury may lead to inadequate respiratory effort, or excess fluids poured in by well-intentioned emergency workers," she says. "Chronic pulmonary pathology, seen in most older adults to some extent, leads to poor oxygenation of the lungs and ultimately cellular hypoxia."

Confusion can be new, old, or subtle, and may be very difficult to identify, says Somes. Due to the normal atrophy that takes place in the brain, blood can collect and not even produce symptoms for several weeks to a month, she explains. "These symptoms may be misidentified as a stroke instead of head trauma," says Somes. "The classic pupillary signs may be due to new pathology in the brain, related to old surgeries, or other changes related to aging."

For this age group, an Injury Severity Score is not predictive of outcome, so be cautious and overestimate possible injuries, advises Cook. "Frequent reassessment and close monitoring are essential," she says. Keep in mind that normal vital signs aren't necessarily normal for this age group, adds Cook. "Many in this age group are hypertensive, so blood pressure within normal limits could mean a decrease in circulating volume," she says. "Plus, with the extensive use of beta-and calcium channel blockers and the blunted response to catecholamines, many times geriatrics cannot mount a tachycardia even if they need to."

Hemodynamic monitoring sooner instead of later saves lives, emphasizes Cook. "The elderly patient will have a much worse outcome from occult shock than their younger counterparts," says Cook. "Transfuse sooner instead of later, to prevent a secondary ischemic event including stroke or myocardial infarction."

To improve care of elder trauma patients, do the following:

• Don't miss signs that the patient is not perfusing oxygenated blood to all parts of the body.

This may be a ventilation problem, or it may be a perfusion problem, or it may be both, says Somes. "Overhydrating and overoxygenating the older adult may lead to problems," she says. "Both will lead to lung issues as we fill up the lungs with fluid or overwhelm the respiratory drive with too much oxygen."

• Don't assume that changes in level of consciousness or diminished heart and lung sounds are normal.

"A baseline must be established before that assumption can be made," says Cesiro. If you wrongly assume that a change in level of consciousness is sudden, your patient could have a bleed or seizure that is missed, or the patient could be diabetic and hypoglycemic, says Cesiro.

"If you assume that diminished heart and lung sounds are due to trauma when it's actually not, the patient could have a missed cardiac contusion, pericarditis, aortic tear, or myocardial infarction," says Cesiro.

• Remove patients from backboards quickly.

"At our facility, we triage our geriatric population as a Number 1, so that we can remove them from the backboard as soon as possible," says Somes. "We know that skin breakdown starts to occur within as little as an hour and that backboards are notorious for this."

Reference

  1. Zehtabchi S, Baron BJ. Utility of base deficit for identifying major injury in elder trauma patients. Acad Emerg Med 2007; 14:829-831.

Sources

For more information about caring for elder trauma patients in the ED, contact:

  • Theresa A. Cesiro, RN, MSN, Director of Emergency Services, St. Bernadine Medical Center, 2101 N. Waterman Ave., San Bernardino, CA 92404. Phone: (909) 883-8711. E-mail: theresa.cesiro@chw.edu.
  • Sheri Cook, RN, CEN, Emergency Services Educator, Bixler Emergency Center, Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308. Phone: (850) 431-4167. E-mail: Sheri.Cook@tmh.org.
  • Joan Somes, PhD, MSN, RN, CEN, FAEN, Staff Nurse/Department Educator, St. Joseph's Hospital, 69 W. Exchange St., St. Paul, MN 55102. Phone: (651) 232-3000. E-mail: somes@blackhole.com.
  • Shahriar Zehtabchi, MD, Department of Emergency Medicine, State University of New York, Downstate Medical Center/Kings County Hospital Center, Clarkson Avenue, Box 1228, Brooklyn, NY 11203. Phone: (718) 245-4790. Fax: (718) 245-4799. E-mail: szehtabchi@yahoo.com.