mild traumatic brain injury in the geriatric population cynthia blank-reid, rn, msn, cen trauma...
TRANSCRIPT
Mild Traumatic Brain Injury in the Geriatric
Population Cynthia Blank-Reid, RN, MSN, CEN
Trauma Clinical Nurse Specialist
Temple University Hospital
Philadelphia, PA
Definitions
• Geriatrics
• Mild traumatic brain injury
• Positive Outcome
Geriatric Trauma—Epidemiology
• 5th leading cause of death over age
• 25% of trauma deaths• Persons >65 = Fasting
growing age group
Epidemiology
Rapid growth in elderly population - 65 or older currently represent 12% (30 million)- expected to rise to 20% (52 million) by 2020- will be 22% of population by 2030
High rate of fatalities from trauma- 28% of fatalities in those over 65- 6 times more likely to die
Chronologic Age vs. Physiologic Age
Geriatric Mechanisms of Injury
• Falls
• Motor vehicle crashes
• Pedestrian struck by motor vehicle
• Assaults
• Co-morbid disease may be precipitating factor for injury
Risk Factors
• Poor visual acuity
• Poor visual attention
• Overload of information
• Impaired reaction time
• Slower gait
• Medication side effects and interactions
• Alcohol consumption
Higher Mortality
• Higher mortality rate due to:– Age-related deterioration– Decreased stress tolerance and physiologic
reserve– Greater complication risk– Pre-existing chronic disease– Pre-existing nutritional deficits
Anatomic/Physiologic Differences in the Older Adult Trauma Patient
Neurologic
Loss of neurons in cortex Cerebellum Hippocampus
Changes in neurotransmitter systems: Dopaminergic Cholinergic Catecholamines Glutamatergic
Neurologic
• Brain weight of decreases 6 to 7%
• Brain size decreases
• Cerebral blood flow declines 15 to 20%
• Nerve conduction slows up to 15%
Neurologic
Pupil size diminished pupillary light reflex Slowed motor reaction time Gait tends to be short-stepped and guarded Ankle jerk is lost Vibratory sense in legs is diminished
Neurologic
• Bridging veins susceptible to injury
• Higher incidence of coagulopathies and anticoagulation therapy
Respiratory
• Hypoxia
• Loss of pulmonary reserve
• Reduced cough reflex
• Blunt trauma: Although rib fractures are considered a minor injury, they are major in the elderly
Cardiovascular
• Atherosclerosis• History of hypertension• Cardiac output decreases
with aging• Elderly patients need early
hemodynamic monitoring
Musculoskeletal
• Hip fractures increase with age
• Femoral neck fractures occur spontaneously
• Arthritis limits mobility, flexibility
• Degenerative changes make radiographic diagnosis difficult
Renal
• Impaired ability to concentrate urine
• Decreased glomerular filtration rate
• Slight increases in blood urea nitrogen and creatinine expected; changes considered when using contrast media and certain drugs
Integumentary
• Skin provides less cushion against mechanical forces
• More susceptible to shearing-type forces
• Impaired ability to tamponade
• Loss of thermoregulatory ability
Additional Changes
• Inadequate nutrition and pre-existing malnutrition leads to weakened respiratory muscles and ventilatory fatigue
• Slowed peristalsis and gastric motility
• Decreased BMR
• Total body water is decreased in the elderly so patients are at greater risk for hypovolemia
Additional Changes
• Medication effects – Shock may be present with normal vital signs
• May have pre-existing anemia
Psychosocial
• End-of-life decisions
• Specific directions for withholding or withdrawing treatments
• Guidelines for making treatment decisions– Patient’s right to self-determination– Patient’s best interest– Benefits of treatment outweigh adverse outcomes
Geriatric Head Injury Pearls• With aging, the brain undergoes progressive
atrophy and decreases in size by 10% between ages 30 and 70
• Subtle changes in cognition and memory make evaluation of MS difficult
• Lower incidence of epidural hematomas • Higher incidence of subdural hematomas • The increased “dead space” within the skull
may delay symptoms of ICH• Low threshold for Head CT
Types of Mild Traumatic Brain Injury in the Elderly
Types of Mild Traumatic Brain Injury in the Elderly
• Concussion
• Contusion
• Epidural
• Subdural
• Skull Fractures
• Penetrating
So What Do You Do?
• Concussion
So What Do You Do?
• Contusion
So What Do You Do?
• Epidural
So What Do You Do?
• Subdural
So What Do You Do?
• Skull Fractures
So What Do You Do?
• Penetrating
Prognosis and Outcome
• Markers for poor prognosis at admission:
- Age > 75
- GCS of 7 or less
- Presence of shock on admission
- Severe head injury
- Development of Sepsis
Prognosis and Outcome
• Mortality rate of 15 to 30% for hospitalized patients
• Debate over ethics and cost-benefits of trauma care for elderly
• Conflicting data on ability to return to independent living
Nursing Care of the Geriatric Trauma Patient—Assessment
History
• Does the patient have pre-existing medical conditions?
• What medications does the patient take?
• What were the events that led up to the injury?
• What was the patient’s functional status/neurologic status before?
• Does the patient have advance directives?
Nursing Care of the Geriatric Trauma Patient—Assessment
Inspection• Mouth for loose teeth,
partial plates, dentures• Skin: look carefully
for pressure areas, ecchymosis
Palpation• Bony prominences of
spine
Nursing Care of the Geriatric Trauma Patient—Assessment
Auscultation• Apical heart rate and blood pressure• Abnormal heart sounds (valve disease, fluid
overload)• Tachycardia as a response to shock may not
be seen• A normal blood pressure may be indicative
of shock
Diagnostic Procedures
Laboratory Testing• Electrolytes• Cardiac enzymes,
troponin• Therapeutic drug
levels• Coagulation profiles
Other Studies• Electrocardiogram• Echocardiogram• Carotid ultrasound
Factors Complicating Assessment
• Presence of multiple pathologies– 85% have one chronic disease; 30% have three
or more– One system’s acute illness stresses other’s
reserve capacity– One disease’s symptoms may mask another’s– One disease’s treatment may mask another’s
symptoms
Nursing Care of the Geriatric Trauma Patient—Planning and Implementation
Interventions• Airway
– Remove dentures, partial plates– Carefully consider need to intubate
• Spinal immobilization– Pad bony prominences– Remove immobilization as soon as possible
• Breathing– Administer supplemental oxygen
Nursing Care of the Geriatric Trauma Patient—Planning and Implementation
Interventions• Circulation
– Consider early placement of pulmonary artery catheter
• Initiate laboratory studies early.• Keep patient warm• Administer medications in doses
recommended for older adults
Assessing for Maltreatment
• Higher risk for maltreatment
• High index of suspicion
• Inconsistent history, unexplained injuries
Assessing For Maltreatment
• Unexplained – Bruises or burns
– Fractures
– Head injury
– Malnutrition
– Dehydration
• Signs of confinement
Assessing For Maltreatment
• Lack of medical attention
• Caregiver disinterest• Unusual interaction
between patient and caregiver
• Evidence of over-medication
Evaluation and Ongoing Assessment
• Assess vital signs frequently.
• Monitor cardiovascular and pulmonary response to resuscitation.
• Monitor temperature frequently.
The Distractors
• All those things that get in the way of allowing us to genuinely believe that there could be a head injury.
Dementia/Altered Mental Status
• Distinguish between acute, chronic onset• Never assume acute dementia or altered mental
status is due to “senility”• Ask relatives, other caregivers what baseline
mental status is
Dementia/Altered Mental Status
• Head injury with subdural hematoma
• Alcohol, drug intoxication, withdrawal
• Tumor
• CNS Infections
• Electrolyte imbalances
• Cardiac failure
• Hypoglycemia
• Hypoxia
• Drug interactions
Possible Causes
Cerebrovascular Accident
• Emboli, thrombi more common• CVA/TIA signs often subtle—dizziness,
behavioral change, altered affect• Headache, especially if localized, is significant• TIAs common; 1/3 progress to CVA• Stroke-like symptoms may be delayed effect of
head trauma
Seizures
• All first time seizures in elderly are dangerous• Possible causes
CVA
Arrhythmias
Infection
Alcohol, drug withdrawal
Tumors
Head trauma
Hypoglycemia
Electrolyte imbalance
Syncope
• Morbidity, mortality higher
• Consider– Cardiogenic causes (MI, arrhythmias)– Transient ischemic attack– Drug effects (beta blockers, vasodilators)– Volume depletion
Depression
• Common problem
• May account for symptoms of “senility”
• Persons >65 account for 25% of all suicides
• Treat as immediate life threat!
Rehabilitation of the Geriatric Mild TBI Patient
• Will they qualify?• Will they be taken?• Will it matter?• Does it matter?• What works and what doesn’t work.
Tips and Pearls
• Assume limited physiologic reserves
• Minor injuries may be life-threatening
• “Stable” patients may quickly become unstable
• Low threshold for head, neck, and abdominal CT
• Early invasive hemodynamic monitoring
Tips and Pearls (cont.)
• Early, aggressive O2 and mechanical ventilation
• Overresuscitation is as detrimental as inadequate resuscitation
• Liberal use of blood transfusion • Consider patient’s environment and
social situation
Prevention
• Discharged patients:
- Home safety assessment
- Carefully review medications
- Suspend driver’s license?
Summary
• Aggressive treatment approach
• There is no such thing as a mild head injury or minor trauma with the elderly
• Consider triage to trauma center