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Emergency physicians need to stay abreast with many of the unique injury mechanisms and clinical features associated with geriatric trauma patients, and apply special management principles when caring for them.
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Falls are the most common cause of injury in patients over 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 rank as the most common mechanism for fatal incidents in elderly persons through 80 years of age. Also, elderly pedestrians struck by a motor vehicle are much more likely to die compared to younger pedestrians. Emergency physicians should have a heightened suspicion for elder or parental abuse.
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The geriatric trauma patient should be viewed 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. Often, the time frame for obtaining information about the traumatic event, past medical history, medications, and allergies is quite short. 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. Medications, such as cardiac agents, diuretics, psychotropic agents, and anticoagulants, must be carefully listed.
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On physical examination, frequent monitoring of vital signs is essential. Emergency physicians should be wary of a “normal” heart rate in the geriatric trauma victim. 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.
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Special attention should be paid to anatomical variation 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.
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It would be a grave error to 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 hematomas. The rate of intracranial hemorrhage approaches 7% to 14% in anticoagulated patients with blunt head injury who are experiencing no or minimal symptoms. More liberal indications for computed tomography (CT) scanning are justified.
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Cervical Spine Injuries
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The pattern of cervical spine injuries in the elderly is different than in younger patients, as there is an increased incidence of C1 and C2 fractures with the elderly. Emergency physicians need to place special emphasis on maintaining cervical immobilization until the ...