Emergency physicians need to be aware of the many unique mechanisms of injury and clinical features associated with geriatric trauma patients and apply special management principles when caring for them.
Falls are the most common cause of fatal and non-fatal injury in people ≥65 years of age. Syncope, which has been implicated in many cases, may be secondary to dysrhythmias, venous pooling, autonomic derangement, hypoxia, anemia, or hypoglycemia. Motor vehicle crashes are the second most common cause of injury in the elderly and are the leading cause of death. Elderly pedestrians struck by a motor vehicle are much more likely to die than younger pedestrians. Intentional injuries and those caused by neglect should also be considered.
Evaluate the geriatric trauma patient as both a medical and a trauma patient. Since elderly patients may have a significant past medical history that impacts their trauma care, obtaining a precise history is vital. Family members, medical records, and the patient's primary physician may be helpful in gathering information regarding the traumatic event and the patient's previous level of function. Document medications, such as cardiac agents, diuretics, psychotropic agents, and anticoagulants. Investigating the cause of a fall may uncover serious underlying medical causes or prevent future trauma.
On physical examination, frequent monitoring of vital signs is essential. Avoid feeling reassured by “normal” vital signs. A normal tachycardic response to pain, hypovolemia, or anxiety may be absent or blunted in the elderly trauma patient. Medications such as β-blockers may mask tachycardia and delay appropriate resuscitation. Blood pressures are also misleading in the elderly patient. Because of the high incidence of underlying hypertension, consider using a higher cutoff for hypotension than in younger patients. In blunt trauma patients ≥65 years, mortality increases when systolic blood pressure dips below 110 mm Hg and heart rates exceed 90 beats per minute.
Pay special attention to anatomical variations that may make airway management more difficult. These include the presence of dentures, cervical arthritis, or temporomandibular joint arthritis. A thorough secondary survey is essential to uncover less serious injuries. These “minor” injuries may not be severe enough to cause problems during the initial resuscitation, but cumulatively may cause significant morbidity and mortality. Seemingly stable geriatric trauma patients can deteriorate rapidly and without warning.
DIAGNOSIS AND DIFFERENTIAL
Never assume that alterations in mental status are due solely to any underlying dementia or senility when evaluating the elderly patient's mental status. Elderly persons suffer a much lower incidence of epidural hematomas than the general population; however, there is a higher incidence of subdural and intraparenchymal hematomas in the elderly than in younger patients. The rate of intracranial hemorrhage approaches 7% to 14% in anticoagulated patients with blunt head injury who are experiencing no or minimal symptoms. Order non-contrast head CT for patients who ...