How to meet the needs of elderly trauma victims
Mortality of geriatric trauma patients is twice that of younger patients with equivalent injury severity, notes Kari Nash, RN, CEN, MICN, associate trauma coordinator at Loma Linda University Medical Center (CA).
For example, in 1997, people 70 and older accounted for 5% of all individuals injured in traffic collisions but accounted for 14% of all traffic fatalities, she reports. Mortality often occurs later in the older population due to pre-existing conditions and complications related to these conditions, as well as the injury itself, Nash notes.
"For this reason, early and aggressive management is essential. This starts with appropriate field triage and early transport to a trauma center. This can help to prevent or at least reduce the deleterious effects," she says.
Here are some ways to improve care of elderly trauma patients:
• Ensure early evaluation and intervention by a trauma surgeon.
At Loma Linda, the hospital’s trauma team is activated for all patients 75 and older.
"These criteria are based on age alone, even if by the pre-hospital report the patient is stable, thought to have no significant injuries, or the mechanism of injury is minor," Nash reports.
The need for this criteria was brought to light after a case review of two elderly patients treated at the ED. "According to the field report, these appeared to be minor trauma patients," Nash recalls. "But during the transport time or shortly after arrival in the ED, their status deteriorated, and they required rapid lifesaving intervention. Our nurses felt a strong need to have more aggressive guidelines in place for the management of geriatric trauma."
Having these guidelines in place allows a trauma surgeon to be in the ED to immediately to assess the patient rather than calling him or her when the patient’s condition has become critical and precious time has been lost, Nash explains.
• Know increased risks for the elderly trauma patient.
"The elderly patient is at much greater risk of injury and death related to both underlying medical conditions and the normal physiological changes that accompany age, says Nash. "They have very poor tolerance to the hemodynamic instability and increased physiological demand that are associated with traumatic injury."
Conditions such as decreased bone density and coagulopathies or anticoagulant therapy make them more prone to fractures and increase risk of hemorrhage, she says.
"They are prone to cerebral bleeds related to weakened vasculature. The stress response of the trauma triggers a normal physiological reaction which may, in turn, lead to complications with underlying problems," Nash explains.
Patients with coronary artery disease may experience chest pain caused by the increased myocardial demand from the release of norepinephrine. "Still, other patients may exhibit these stress-related complications later in their course, as with the diabetic whose blood sugar becomes out of control during hospitalization," she notes.
• Consider cause of the trauma.
Consider what caused the trauma, stresses Nash. "Find out if there was any precipitating event that may have contributed to the cause of the incident such as chest pain, dizziness, or syncope," she says.
Determine when a patient’s loss of consciousness occurred. "If it was prior to the event, further evaluation will be required to determine the cause," such as acute MI, dysrythmia, stroke, transient ischemic attacks, hypoglycemia, or abuse, says Nash.
These underlying causes can often be life-threatening themselves, and at minimum, can complicate the injury. "At times, it is these underlying disease processes that are the more critical problem for the patient."
• Don’t overlook other medical problems.
The complete assessment of the patient is often complicated by unrelated conditions.
"For example, a male patient in his 70s was flown into our facility after being hit by a car. The presenting complaint was altered level of consciousness," Nash recalls. "The patient was very confused upon arrival and somewhat combative. He was unable to provide us with any medical history or demographic information."
After a complete work-up and a negative head CT scan, no injuries were identified. "The police department was finally able to locate family and the rest of the story became clear," says Nash. "The patient had a history of Alzheimer’s and had wandered away from a day care center. The patient was at his normal baseline and ended up being discharged home from the ED."
• Know risks of diagnostic tests.
Diagnostic tests are an essential part of a complete evaluation but pose increased risks for elderly patients. IV contrast used for CT scans can lead to worsening renal insufficiency and contribute to the onset of acute renal failure, says Nash.
As with any trauma victim, surgery may be the only life-saving option, but for the elderly patient, the risk/benefit ratio needs to be carefully weighed. "This same patient may be considered too high a risk and not a candidate for even a minor elective surgery," explains Nash.
• Facilitate treatment.
Nurses can facilitate the patient’s rapid flow through an often lengthy and exhausting battery of exams, tests, and treatments.
"Increased length of time on a backboard may contribute to issues with skin integrity, respiratory complications, and joint discomfort," Nash stresses. "Early removal of the backboard is important even if the spine cannot be cleared."
For more information about caring for elderly trauma victims, contact:
• Kari Nash, RN, CEN, MICN, Loma Linda University Medical Center, 11234 Anderson St., Room 8700 G, P.O. Box 2000, Loma Linda, CA 92354. Telephone: (909) 824-0800 ext. 42980. Fax: (909) 824-4219. E-mail: KNash@ahs.llumc.edu.