Crash injuries may be missed in the elderly — know the complexities

Triage, assessment adjustments required for this population

A review of the literature has revealed that injuries in the elderly resulting from motor vehicle crashes has been underdetected, and resulted in patients being inappropriately treated or assigned to nontrauma centers. The article was published in the January 2010 issue of the Journal of Emergency Nursing.1

"As this population is rising and becoming more independent [i.e., more likely to continue traveling], there will be increased demand for them to be assessed, and we must look at certain things that make them present differently," says lead author Jenelle M. Weber, MS, RN, who began her paper while at The Pennsylvania State University. Weber submitted her paper after assuming her current position as a nurse with the Johns Hopkins Health System in Baltimore. "It is important that ED nurses understand the physiologic changes that occur with aging, comorbid conditions, and making sure they're not missing anything in their treatment," she says.

This issue must be brought to the "front page" of ED care, asserts Scott Magley, MD, FACEP, an emergency physician with Conemaugh Health Systems in Johnstown, PA, who previously directed a trauma center and an ED. "Taking care of geriatric patient is a unique type of care, and we are just now starting to get comfortable with geriatric medicine and the comorbidities these patients have," Magley says.

There is increased complexity involved in taking care of these patients, he says. "They present not only with diabetes, hypertension, or heart disease, but they may be taking aspirin, clopidogrel bisulfate, and warfarin, which can cause them to become unstable or for them to appear to be stable, and then later you find something has to be addressed," Magley says.

In other words, Magley says, you must go beyond the assessment of perfusion, such as blood pressure and pulse rate, performed on younger trauma patients and consider whether the patient is taking any medications that might cause them to bleed, or if they are taking a beta-blocker. "Normally, when people start to bleed [internally], the body responds with an increased heart rate, but when they're on beta-blockers, they do not mount a tachycardia. They stay in a very slow rate," he says. Normal heart rate does not mean the patient isn't bleeding.

Similarly, blood thinners can lead to delayed presentation of bleeding into the brain or spinal cord. "There can be a delayed neurological deficit, and there could be a mass lesion," Weber says.

"It's important for these factors to be part of the assessment; you need to know if these patients are diabetic or if they have COPD, for example, and what meds they're on. It's important to include them in the assessment in part because they can have increased mortality if they have these comorbidities and experience a traumatic injury."

This altered assessment should extend to pre-hospital triage, the authors noted. EMS personnel should be educated to consider trauma center transportation for senior patients with any significant mechanism of trauma. "Certain studies indicate a tighter injury severity score [ISS] is more appropriate for older adults," says Weber.

Treatment must be customized

Elderly victims of automobile crashes should receive a completely different type of care in the ED than younger adults, says Magley.

"When we do pediatric trauma, we use specific meds and equipment for the size and age of that child," he says. "What we're suggesting is that in geriatric trauma, there has to be a modification." Some facilities bring in pediatricians when there is pediatric trauma, Magley says. "I can see having the primary care doctor or geriatrician more involved down the line," he says. "Trauma patients should not only be screened for vitals, but if they're above age 55, I think you should screen them for comorbid conditions as well."

For these patients, the ED should do the same assessment, reassessments, and paperwork every time, Magley says. "The manager needs to build into the protocol what's required to be documented on the computer screen or on the medical record," he says. "When the patient is 55 or older, it should set off a 'bright light' in the mind of the provider that signals this is a different type of patient."

When reassessing these patients, "you should look back at the chart and see if they have comorbidities, or if they are on something where you could have a hidden injury that is just now becoming manifest," he says. In other words, "you set up a system so you do not have any adverse cases or problems," Magley says.

Reference

  1. Weber J, Jablonski RA, Penrod J. Missed opportunities: Under-detection of trauma in elderly adults involved in motor vehicle crashes. J Emerg Nurs 2010; 36:6-9.

Sources

For more information about assessing and treating elderly victims of automobile crashes, contact:

  • Scott Magley, MD, FACEP, Emergency Physician, Conemaugh Health Systems, Johnstown, PA. Phone: (814) 472-4238.
  • Jenelle M. Weber, MS, RN, Johns Hopkins Health System, Baltimore. Phone: (814) 322-6854. E-mail: jweber22@jhmi.edu.

Clinical Tip

Older trauma patients need coagulation testing

If you're treating a car crash victim who is on warfarin, the key for an ED nurse or doctor is to follow through with a baseline prothrombin time (pro-time) (or the International Normalized Ratio [INR]) coagulation test, says Scott Magley, MD, FACEP, an emergency physician with Conemaugh Health Systems in Johnstown, PA, who previously directed a trauma center and an ED. In some select circumstances, anticoagulation would be reversed.