pam wills-mertz, rn april 25, 2015. disclosures: none
TRANSCRIPT
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Pam Wills-Mertz, RN
April 25, 2015
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Disclosures:None
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Objectives:Definition of geriatric, discussion of epidemiologyDiscussion of age-related changes that can mask
the severity of traumatic injuryDiscussion of how co-morbid conditions can change
outcomesDiscussion of the risks of medication use in geriatric
traumaDiscussion of common MOIDiscussion of field triage
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What is old?
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Aging is:.... the normal, predictable, and irreversible changes
of various organ systems over the passage of time that ultimately lead to death ….
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Age is a state of mind…
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So, what is old, elderly, geriatric?
Chronological age v. physiological age65 is a societal and social norm65 per EAST55 per ACS-COT, TNCC, PHTLSMortality increases at 45 in males
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Epidemiology:
Average American life span has increased by almost 30 years in the past century1900 = 47 years old2000 = 76 years oldClimbing…..
By 2050, people over age 64 will make up over 20% of the US population Today it is 12%
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So…
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Why? How?Baby boomersMedical advancesActive lifestyle
More risk? Less risk?
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Unique Characteristics:
Age-related changes in anatomy and physiology
Pre-existing diseases and co-morbidities
MedicationsPossibility of elder
maltreatment
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Age-related Changes:↓ Brain mass
Eye disease
↓ Depth of perception
↓ Discrimination of colors
↓ Pupillary response
↓ Respiratory vital capacity
↓ Renal function
2- to 3-inch loss in height
Impaired blood flow to lower leg(s)
↓ Degeneration of the joints
Total body water
Nerve damage (peripheral neuropathy)
Stroke
Diminished hearing
↓Sense of smell and taste
↓Saliva production
↓Esophageal activity
↓Cardiac stroke volume and rate
Heart disease and high blood pressure
Kidney disease
↓Gastric secretions
↓Number of body cells
↓Elasticity of skin, thinning of epidermis
15 – 30% body fat
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Older people
who sustain
injuries are more likely to die as a result of
them, regardless
of the severity of
injury.
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Despite the considerable proportion of trauma care resources
consumed by the oldest people,
research is directed towards needs of
younger ones.
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More facts:Young trauma victims are maleOlder trauma victims are female
Thinner bonesMore likely to fracture
MortalityPeak 1 month s/p femurHigher mortality after injuryA considerable time25% die within one year
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Cardiovascular:
Less Effective PumpMinimal ReserveMedication EffectsIschemia/HypoxiaArrhythmiasCautious with fluids
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Renal:
Functional ChangesLoss of Surface AreaDiminished Renal Blood
FlowProgressive Decline in
filtration function
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Respiratory:Lungs
Decreased elasticityDecreased alveolar number and
functionDecreased baseline p02Diminished respiratory reserve
MusculoskeletalKyphosisDecreased Chest Wall Strength Increased Chest Wall Rigidity
Infectious Risks Increased Bacterial ColonizationDecreased Force of CoughDecreased Clearance Rate
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Central Nervous System:(Functional Changes)AuditoryCognition
acquisition of new datamemory - short and long
term
ProprioceptionVisual Acuity
glare intolerancecolor perceptionvisual fields
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Nervous System:Structural Changes
10% Reduction in Brain Weight
Loss/Degeneration of Neurons
Cerebral AtrophyCerebrovascular Changes
Confounding FactorsBrain/Skull RelationshipCervical SpineAltered “Baseline” Mental
Status
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Quick Tip:
A complete interview and careful inspection of the head is essential.
Also, review medications for anticoagulants and ask about the use of aspirin, vitamin E, gingko biloba or other substances that may contribute to intracranial bleeding.More to come…..
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Musculoskeletal:
Structural ChangesDecreased MassDegeneration of
Remaining MuscleDegeneration of Joint
CartilageOsteoporosis
Functional ChangesStrengthRange of MotionMobilityPainFracture-ProneGait
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Consider this: Hospitalizations of older adults for trauma-related
injuries occur at twice the rate of the general population
The mortality rate of older trauma victims has been estimated at 6 times that of younger victims when statistically controlling for severity of injury 1/3 with an ISS > 15 will die
Older adults account for 33% of all healthcare resources spent on trauma and for 25% of injury fatalities
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Morbidity & Mortality:Trauma -- 5th Leading Cause of Death
Elderly account for 12% of overall traumasBut… make up 28% of ALL trauma deaths
Physiologic changes impact morbidity & mortality Medications impact morbidity & mortality
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Trauma Risk Factors:Poor visual acuityPoor visual attention Overload of informationImpaired reaction timesLimited neck rotationsSlower gaitMedication side effects Alcohol consumption
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Medications:Psychotropic Medications
AntidepressantsSedatives
AntihypertensivesBeta-BlockersCalcium Channel BlockersDiuretics (volume depleted)
Anticoagulants & AntiplateletsCoumadin, AspirinPlavix
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Anticoagulants & Antiplatelets:Warfarin (Coumadin)Enoxaparin (Lovenox)Dalteparin (Fragmin)Tinzaparin (Innohep)Bivalirudin (Angiomax)Aragtroban (Acova)Dabigatran (Pradaxa)Fondaparinux (Arixtra)Rivaroxaban (Xarelto)Apixaban (Eliquis)
AspirinDipyridamole
(Persantine)ASA-dipyridamole
(Aggrenox)Clopidogrel (Plavix)Prasugrel (Effient)Ticagrelor (Brilinta)Eptifibade (Integrillin)Tirofiban (Aggrestat)
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Reversible:Coumadin (Warfarin)
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Falls are #1:
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Falls Facts:Most Common Injury > 75 YearsInjuries to head, pelvis & lower extremities are most
common90% are falls from standing
60% are at home
Neurosensory Changesaltered vision, hearing & memory cause impaired
obstacle avoidancePostural Instability
prone to loss of balance increased postural sway slowed central processing
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Physiologic
DisabilitiesEnvironmental
Hazards
Behavioral
Alterations
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Falls:Environmental Factors
poor lightingnew furniturenon-secured rugsloose railingsstairs
Syncopecerebral hypo perfusionseizuredysrhythmiahypoglycemia
Orthostatic Hypotensiondehydrationmedications
Gait Changespropensity to trip or
stumblefeet not picked up as highmen
wide-based
women narrow-based
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Falls:
One out of every three persons over 65 years old will fall in any given year.
These falls result in fractures, admissions to the hospital, loss of the ability to live alone and death.
Women are more likely then men to sustain injuries from falls because they have less muscle mass and a greater likelihood of having osteoporosis.
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Fast Facts:
One half of all elderly who sustain a fall find themselves unable to return home independently
Many older adults reduce their activity after a fall and report a fear of falling again
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MVC’s are #2:
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MVC Facts:
Crashes are more likely in older versus younger drivers under normal driving conditions.
The highest death rate for victims of motor vehicle crashes occurs in the lower age range of elderly (55-64 years old) followed closely by those over 74.
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Left Turns:
The most common kind of crash older drivers have is when turning left into oncoming traffic.
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More MVC Facts:Close to HomeDaylight HoursGood WeatherCauses
Error in Perception Pathophysiology of aging and presence
of acute and chronic medical conditions Altered Reaction Time
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Abuse, Neglect, & Suicide:Older adults are more likely to be victims of abuse or
maltreatment if they are dependent or demented.Mandated reportersBe suspicious
Elderly persons over 65 account for more than 18% of all suicides.Growing problemUnder acknowledged
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Obtaining a History:Simplify!
Time to respond One questionUse simple sentences.Be patient.
Personalize…Use touch, tone of voice
and eye contact to maintain attention and focus.
Make allowances for likely problems with vision and hearing.
Show, not tell.Have the patient show
you the site of pain or discomfort.
Ask the individual to take your hand and place it over any painful area.
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Field Response:Decompensation may
occur rapidly and without warningReduce field
stabilization time Serial vital signs and
monitoring “110 is the new 90”Increased mortality with
SBP < 110 and HR >90
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Field Response:Arthritic changes
increase potential complicationsProtect the cervical
spineBeware the “face plant”
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Cervical Spine:Cervical Spine Injuries
Just as in young trauma Need rigid collar
Higher instance for Central Cord syndrome Due to age related narrowing of cervical canal and vascular
disease of spinal arteries Causes deficit of upper extremity strength and sensation
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Field Response:Aging tends to increase
upper airway secretionsMicro aspiration is
commonAssist with airway
secretionsUse suctioning and
airway adjuncts as indicated
Dentures!
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Field Response:Changes of aging increase the
risk of compromised oxygenationMonitor airway and
ventilatory effortOxygenate early and
liberally in the absence of COPD
Normal PO2 may be compromised due to normal agingMaintain O2 saturation
>90%
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Field Response:The elderly may have “room for rent” within the
cranium due to loss of brain mass.Elevate head 15 to 30 degreesAssume the worstFear anticoagulationWork with their neuro baselinePitfalls
Dementia Prior CVA
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General Approach:
Pre-hospital Imperative to understand past medical history and
events leading to injury Elderly have shown to be under-triaged Comorbidities often are the inciting cause of injury
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Thoracic Injuries:Chest
Rib fractures are the most common injury Rib fractures double mortality
3 point restraint belts have shown to cause significant chest trauma
EKG remains the most sensitive method to predict short-term cardiac complications
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Abdomen / Pelvis:Abdomen
In face of multi-system injuries, exam is unreliable Recommend liberal use of diagnostics
PelvisFractures are significant for high mortalitySignificant blood loss
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Extremities:Extremity Trauma
Like all other fractures in elderly Little impact necessary for fracture Overall isolated extremity injuries are tolerated well by the
elderly Femur is the exception
Liberal radiological diagnostics recommended
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Pain Management:Myth: Elderly patients experience less painRealities:
Acute and chronic pain is common in the elderly.Pain in the elderly is often under diagnosed and
under treated.Pain is often responsible for agitation, delirium and
depression.
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More on Pain:Narcotics - elderly are more sensitive to pain
relieving aspects. MSO4 - still gold standard. Altered pharmacodynamics
NSAIDs - side effects more severe and common in elderly.
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Cutungo, C. (2011).
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End of Life Decisions:
When is enough, enough?Advanced DirectivesDNRTreatment in patient’s best interestBenefits of treatment must outweigh
consequencesTrauma is a game changer
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Summary / Recommendations:Advanced age is associated with increased mortality
at all injury levels.Higher ISS for comparable mechanism of injury.Fewer physiologic abnormalities than expected for
injuriesPEC are associated with worse outcomes for each
level of injury
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Summary / Recommendations:
Elderly trauma victims should be triaged to trauma centersLower threshold for activation of the trauma team for
elderly trauma patientsHigher index of suspicion Studies support the geriatric trauma specialty
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The physiologic, mental and psychologic effects of aging can influence how you provide trauma care.
In the case of both intentional and unintentional injury, knowing the special needs of the geriatric trauma patient can help you avoid further injury and greatly increase the patient’s chance of survival.
Conclusion:
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Thank you!!