Simple steps reduce risks to elderly trauma patients

They are at much higher risk for adverse outcomes

If a patient comes to your ED with multiple rib fractures after a fall, would you be worried that the injury is life-threatening? The answer largely will depend on the patient’s age, says Kathleen Emde, RN, CCRN, CEN, trauma service coordinator at Overlake Hospital Medical Center in Bellevue, WA.

For young patients, the only treatment needed may be pain medication, with discharge instructions to follow up with their primary care providers should they develop any difficulty breathing or other problems, she explains. "However, in elders, multiple rib fractures constitute a serious threat to their health," says Emde.

Elders may develop hypoxemia more rapidly because they have less respiratory reserve, and they are more likely to develop pneumonia, she says.

Mortality rates are much higher in older trauma patients than younger patients with comparable injuries, says Sharon S. Cohen, RN, MSN, CEN, CCRN, clinical nurse specialist for emergency preparedness and former trauma clinical nurse specialist at North Broward Hospital District in Fort Lauderdale, FL. Mortality rates for trauma patients begin to increase at 45 years of age and rise sharply for patients older than age 55, increasing again for patients 65-74, says Cohen. The mortality rate for patients 75-84 years is more than double the rate for patients 14-24 years old, she adds.

"Because of this increased risk of mortality, elderly trauma patients need a focused exam that addresses all their pre-morbid conditions to complete the whole picture," Cohen says.

To significantly improve care of elderly trauma patients, do the following:

  • Alter interventions as needed to avoid harming the patient.

"Constant and frequent assessment and reassessment is needed to ensure that whatever is done has a therapeutic effect and not a negative one," says Cohen.

For example, laying an elderly person flat on a backboard may cause an increase in respiratory workload or distress that a 20-year-old would not experience, she says.

If a patient has underlying lung disease and sleeps with head elevated or in a recliner, then lying them flat will only cause respiratory problems, says Cohen. "If you really need them on a backboard, then put the bed in reverse Trendelenberg position to aid the respiratory effort," she says.

Many elderly are kyphotic, and lying flat is very difficult, as their head does not touch the backboard, says Cohen. To address this, put a towel roll under the patient’s head once the cervical spine has been cleared, she recommends.

Patients should be removed from backboards rapidly in order to prevent skin breakdown, adds Emde.

  • Remember that medications may put patients at greater risk for adverse outcomes.

Injured elders may arrive with comorbidities including respiratory, cardiovascular, and renal function problems, and they may be on multiple medications that can complicate their trauma care, says Cohen.

For example, if elder trauma patients are on a blood thinner, the patients are more likely to suffer a bleeding event after even a low-energy trauma mechanism than if they were not on the drug, she says. Patients on blood thinners need to be closely monitored for bleeding and blood loss with serial hemoglobin/hematocrit levels, frequent abdominal and neurological assessments, and abdominal computed tomography scan or ultrasound, Cohen says.

Also, many elderly are on beta-blockers that will not allow the heart rate to increase when the patient’s cardiac output begins to drop, which usually occurs as a trauma patient goes into shock, says Cohen. "This is the body’s way of compensating for a problem, namely hypovolemic shock," she says. "In the case of the elderly patient on a beta-blocker, the heart rate does not increase, and compensation is lost."

If no increase in heart rate is seen, you may not appreciate that the patient has internal bleeding and is going into shock, Cohen explains. "Shock, especially in the older person, can cause renal failure due to low flow — and now the cascade of multiorgan failure is in action."

  • Change policies to meet the needs of elder patients.

Your policies should reflect the fact that the injured elder is more complex than the younger patient with the same degree of injury, says Emde. "In our institution, we discussed this issue after we had an elder with multiple rib fractures admitted to the hospital."

The 69-year-old patient was admitted to the floor and rapidly decompensated before the pulmonologist arrived. He was transferred to the intensive care unit (ICU) and intubated, and he later died. After this event, the ED’s policy was changed to state that any person 65 years of age or older with more than two rib fractures must be admitted to the ICU or admitted to the floor with an immediate pulmonologist consultation, says Emde.

"Since we have been following this policy, we believe that our injured elders are being treated more aggressively and more appropriately," she says.

Sources

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

  • Sharon S. Cohen, RN, MSN,CEN, CCRN, Clinical Nurse Specialist, Emergency Preparedness, North Broward Hospital District, 303 S.E. 17th St., Fort Lauderdale, FL 33316. Telephone: (954) 355-4990. Fax: (954) 468-5270. E-mail: sscohen@nbhd.org.
  • Kathleen Emde, RN, CCRN, CEN, Trauma Service Coordinator, Overlake Hospital Medical Center, 1035 116th Ave., N.E., Bellevue, WA 98004. Telephone: (425) 688-5683. Fax: (425) 688-5101. E-mail: Kathleen.Emde@overlakehospital.org.