Dramatic changes in care are needed for elderly trauma patients in your ED

Provide optimum care to this vulnerable population

If an 11-year-old girl comes to your ED with a radius-ulnar fracture, she is X-rayed, casted, and discharged home — a minor injury with minor inconveniences. However, when an 85-year-old woman sustains the same fracture, this injury can have a devastating impact on her quality of life, and the care she requires in the ED is dramatically different.

"What if this patient needs both arms to lift herself out of a chair, and she uses a cane with the casted arm? Her mobility now becomes restricted and unsafe," says Pat Manion, RN, MS, CCRN, CEN, trauma coordinator at Genesys Regional Medical Center in Grand Blanc, MI. It is suddenly very difficult for the woman to dress independently, bathe, toilet, cook, grocery shop, drive, or open pill bottles, she adds.

For the optimum care of this vulnerable elderly woman, it is vital to have social workers and case managers in the ED to assist with discharge planning and also have admission to a 23-hour observation unit for a physical therapy consult or possible admission to acute inpatient rehabilitation, says Manion.

"We need to remember that all things are not created equal when comparing injuries between an elderly patient and a youthful patient," she underscores.

Women older than 65 are the group that is hospitalized most often as a result of an injury, according to a new study from the Boston-based Harvard Injury Control Research Center.1 While hospitalization rates for serious injury are decreasing in younger age groups, they are increasing for older patients, the researchers found.

Falls are the most common reason for injury-related ED visits for patients age 65 and older, according to new statistics from the Atlanta-based Centers for Disease Control and Prevention (CDC). Approximately 2.7 million older adults were treated for nonfatal injuries in hospital EDs in 2001, and 62% of the injuries were from falls.2

To dramatically improve care of elderly trauma patients in your ED, you must take the following steps:

• Be aware that medications may affect vital signs.

Patients taking beta-blockers will have decreased blood pressure and a slowing of their heart rate, says Jean M. Marso, BSN, RN, trauma coordinator at University of Colorado Hospital in Denver. "Therefore, their vital signs may not correlate hemodynamically," she explains.

Changes in pulse and blood pressure as indicators of hypovolemic shock are not as reliable in the elderly patient, says Marso. Another concern is that blood pressure tends to rise with age, and many older patients have a degree of hypertension that may be unrecognized, she adds.

"These are the patients that are not on blood pressure medicine," Marso says. "Therefore, a normotensive blood pressure reading in an elderly patient may actually be a significant drop from their average blood pressure."

Remember that blood pressure is indicative of perfusion, and decreased tissue perfusion may occur at what you perceive to be a normal blood pressure reading, she advises.

• Realize that detrimental effects resulting from care received in the ED may occur later in the patient’s stay.

You may not observe any adverse outcomes from inappropriate care while an elderly trauma patient is still in your ED, but that doesn’t mean that life-threatening problems don’t occur, warns Marso.

"These may occur later in the patient’s stay, often in the intensive care unit [ICU]," she says. "ED nurses often do not learn of this."

For example, fluid overload is a common occurrence during the resuscitation of ED patients, she says. "Elderly patients are more susceptible to fluid overload due to physiological changes related to underlying disease states resulting in decreased cardiac output, decreased pulmonary reserve, and impaired renal function, says Marso. There is an increased risk of volume overload due to the patient’s cardiovascular compromise because of age and possibly reduced kidney function, she adds.

Fluid overload can manifest itself as acute respiratory distress syndrome, and there is increased morbidity and mortality associated with this condition in the elderly patient, notes Marso.

"Hypothermia is another culprit that tends to occur in resuscitation of trauma patients," she says, adding that geriatric patients are even more prone to the detrimental effects of hypothermia than younger patients.

Acidosis resulting in coagulopathies is one of the problems that can ensue from hypothermia, and the effects typically are noted in the ICU, says Marso. "Special consideration to measures for prevention of hypothermia are of paramount importance for all trauma patients, but especially for the very young and old," she says.

• Increase skin care measures to prevent breakdown from use of backboards and cervical collars.

Closely monitor the length of time the patient has been on the backboard, Marso emphasizes. "Do not forget about time spent in the field," she adds. "Advocate for early removal of spine boards when it is safe to do so."

Pad bony surfaces with heel protectors, and use proper-fitting cervical collars to avoid inflicting pressure on tissue surfaces inappropriately, recommends Marso. For example, collars that ride up and over the chin and rest on the cheekbones fail to provide correct immobilization to the cervical spine, she says. They also can abrade the skin, which puts the patient at risk for skin cellulitis, Marso adds.

• Administer appropriate pain medications.

"There are certain issues with pain management and control in the elderly trauma patient that must be taken into consideration," says Manion. She recommends the following:

— Avoid use of meperidine.

This drug is not recommended for the elderly for pain control due to the possibility of normeperidine toxicity, especially if the patient has coexisting congestive heart failure or renal impairment, says Manion. Use of meperidine may cause agitation and confusion because normeperidine produces central nervous system excitability with apprehension, tremors, delirium, and seizures, she explains.

— Be aware of potential side effects of non-steroidal anti-inflammatory drugs (NSAIDs) and narcotics. NSAIDS may produce increased confusion levels in the elderly, notes Manion. These drugs are contraindicated in patients with renal insufficiency and may increase the risk of gastrointestinal bleeding, she adds.

The use of narcotics could exacerbate the tendency toward constipation in this population because of underlying decreased peristalsis, overuse or abuse of laxatives, and decrease in total body water, says Manion.

Although it’s not necessary to avoid use of narcotics and NSAIDs in all elderly patients, you must watch for potential side effects and know the contraindications for specific comorbidities, Manion advises.

— Consider oral medications first.

Use acetaminophen for mild to moderate pain, and consider the use of opioids such as oxycodone hydrochloride for severe pain, advises Manion.

"This drug has gained much notoriety for its addictive potential," she notes. "Often, older patients must be taught not to be afraid of using such drugs."

Intravenous administration is recommended for more immediate pain relief, says Manion. "Morphine, when titrated slowly, is an effective and safe medication for use in the elderly," she says.

In general, intramuscular injections should be avoided in the elderly because of tissue injury, altered drug absorption, and discomfort for the patient, adds Manion.

When administering analgesics to elderly adults, it is important to start at low doses and gradually titrate upward while monitoring and managing side effects, hence the adage "start low and go slow," she explains. "This takes into consideration the slower circulation times in many of our elderly patients," says Manion.

References

1. Shinoda-Tagawa T, Clark DE. Trends in hospitalization after injury: Older women are displacing young men. Injury Prevention 2003; 9:214-219.

2. Centers for Disease Control and Prevention. Public health and aging: Nonfatal injuries among older adults treated in hospital emergency departments — United States, 2001. MMWR 2003; 52:1,019.

Sources

For more information on improving care of elderly trauma patients, contact:

  • Pat Manion, RN, MS, CCRN, CEN, Trauma Coordinator, Genesys Regional Medical Center, One Genesys Parkway, Grand Blanc, MI 48439. Telephone: (810) 606-7891. Fax: (810) 606-9515. E-mail: Pmanion@genesys.org.
  • Jean M. Marso, BSN, RN, Trauma Coordinator, University of Colorado Hospital, 4200 E. Ninth Ave., Mail Stop: A021-630. Denver, CO 80262. Telephone: (303) 372-8905. Fax: (303) 372-0267. E-mail: jean.marso@uch.edu.