Management of the elderly trauma patient poses some of the biggest clinical challenges we face in the emergency department. With age comes a host of complex management issues unknown in the young and previously healthy. If only elderly patients could point out the pitfalls to us – here is what they would say…
“I can go from normotensive to hypotensive in a heartbeat.”
Profound, life-threatening hypovolaemia may occur in the setting of normal blood pressure. Physiological reserve is minimal, and haemodynamic decompensation can occur quickly
“I respond poorly to too much or too little fluid.”
The therapeutic window for cardiac preload is narrow, and inadequate preload monitoring may lead to errors in volume resuscitation
My subdural haematoma hasn’t expanded enough yet to really affect my level of consciousness.”
Cortical atrophy, common in the elderly, may act to delay the clinical manifestations of serious intracranial haemorrhage. This haemorrhage may be clinically occult
“Trauma is not really my major problem.”
Stroke, myocardial infarction, and seizures may result from falls or motor vehicle crashes and delayed diagnosis of principle underlying problem
“I only look like I have adequate ventilatory reserve.”
Ventilatory failure & respiratory arrest may occur suddenly in conjunction with chest or abdominal injuries despite a benign outward clinical appearance
“I get demand ischaemia if I have too much pain or my haematocrit drops.”
Myocardial (demand) ischaemia may result from severe or prolonged pain or from transfusion threshold that have not been appropriately liberalized in the setting of coronary artery disease
“I can’t stand even a little shock or hypoxia… and neither can my myocardium.”
Even minor perturbations in perfusion, oxygenation, or vasoconstriction may lead to major cardiac complications
“My connective tissue just ain’t what it used to be..”
Decrease in connective tissue integrity with less “tamponade effect” for haemorrhage into soft tissues. Blood loss into soft tissue spaces, including subcutaneous loss, may be excessive and is often overlooked
“The sensitivity of my abdominal examination is better that flipping a coin… but not much.”
Clinical manifestations of serious abdominal injury in elderly patients are often minimal. Reliance on the abdominal examination often leads to missed abdominal injuries
“My bones are brittle…my hip bone, my shin bone, and my aortic bone!”
Blunt aortic injury may occur in the elderly in the absence of conventional signs or symptoms. A low threshold for CT imaging should exist
“A little medication goes a long way with me…”
Failure to adjust medication dosage, particularly sedative-hypnotics and analgesics, may result in serious complications
“I just haven’t been eating so well lately”
Chronic malnutrition is common and often undiagnosed
“Major trauma? Heck, I wouldn’t even tolerate a brisk haircut….”
Understanding and undermanaging comorbidities (eg, COPD, CAD, smoking, ETOH consumption) may result in preventable morbidity/mortality
“My injuries weren’t accidental.”
Elder abuse is common and often unreported and undiagnosed
Reference
Mackersie, R. (2010). Pitfalls in the Evaluation and Resuscitation of the Trauma Patient. Emergency Medical Clinics North America, 28 1-27. PMID: 19945596
About Kane Guthrie
