Abstract
Elderly patients have limited respiratory reserve and often decompensate rapidly and unexpectedly. Liberal early endotracheal intubation should be considered. Good preoxygenation should be a priority whenever possible.
General Principles
Blunt trauma, especially due to falls, is the most common mechanism of injury in the elderly population.
With similar mechanism, the type and severity of injuries differ compared to other adults.
Geriatric patients have decreased physiologic reserve and an increased incidence of comorbidities. The prognosis is worse than younger patients with similar injuries.
In elderly trauma patients, the initial vital signs are often misleading, and undertriage is very common. The prehospital triage and trauma team activation criteria should be more liberal than in younger trauma patients.
Cardiac medications can influence physiologic response, and anticoagulants can exacerbate bleeding complications, especially in head trauma.
Early trauma team involvement and early intensive monitoring have been shown to improve outcomes in elderly trauma patients.
Presentation and Primary Survey
Always follow ATLS principles, having in mind age-related specific problems.
Airway
Elderly patients have limited respiratory reserve and often decompensate rapidly and unexpectedly. Liberal, early endotracheal intubation should be considered. Good preoxygenation should be a priority whenever possible.
Remove any dentures to prevent dislodgement and airway obstruction.
Degenerative disease, rheumatoid arthritis, or previous surgery may result in limited range of cervical spine motion, and endotracheal intubation may be more challenging (Figure 14.1 A,B).
Breathing
Elderly patients have decreased respiratory reserve. Consideration for early intubation is recommended in the presence of multiple rib fractures or lung contusions, even if the initial oxygenation is normal.
Circulation
Elderly patients often fail to respond with tachycardia, even after severe trauma, due to atherosclerosis, poor response to endogenous catecholamines, cardiac medications such as beta blockers, and cardiac pacemakers (Figure 14.2 A,B).
Hypertension is a common comorbidity in geriatric patients and blood pressures that may be considered normal in younger patients may represent hypotension in this population. Hypotension in geriatric patients might be more appropriately defined as a systolic blood pressure of <110 rather than <90 mmHg and heart rate >90 rather than >120 beats/min.
Many older patients are on diuretics, which result in chronic hypovolemia, thus increasing the risk of cardiovascular collapse, even after modest blood loss.
Older patients, with reduced left ventricular compliance and loss of vascular elasticity, are more susceptible to volume overload and pulmonary edema.
Perform liberal cardiac diagnostic studies, such as EKG, troponin, and echocardiography.
Disability
Pre-existing deficits such as dementia or sequelae from prior strokes may complicate the neurological evaluation and should be considered during the primary and secondary surveys.
Imaging
Cross-sectional imaging should be liberally used in the geriatric population. Occult injuries are common, and diminished physiologic reserve cause the elderly population to be less tolerant of missed injury or delayed diagnosis.
Advanced age, along with diabetes mellitus and chronic kidney disease, is a risk factor for contrast-induced nephropathy (Figure 14.3).
Atherosclerosis and decreased ability for vasoconstriction can limit the physiologic response to hemorrhage, making early angioembolization or operative intervention a priority.
Clinical decision rules commonly used to limit radiation exposure and imaging overuse, such as NEXUS II or the Canadian CT Head Rule, specifically exclude older patients from their algorithms.
Figure 14.1 A,B Trauma patient, 82-year-old female, with no acute traumatic cervical spine injuries but with kyphotic curvature, degenerative disease, and multilevel disc disease (A). Trauma patient, 89-year-old female, with degenerative disease of the cervical spine (B).
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