GERIATRIC PATIENTS (TRAUMA)
TRAUMA PATIENTS
GENERAL CONSIDERATIONS
There is no scientific definition of the age at which a patient should be considered “geriatric”. For years it has been 65. Recent data has made some training programs drop the age to 55 where the anatomic and physiologic changes of age become clinically important. Geriatric patients pose new issues and need to be handled differently. Their vital signs, mental status, use of anti-coagulants, and more complicated medical history are just a few considerations.
1. A thorough history of past and present medical conditions needs to be obtained.
2. Current medications, particularly anti-coagulants (Eliquis, Xarelto, Warfarin) and anti-platelet drugs (Plavix), should be reviewed.
3. Vital signs may be inadequate while appearing within normal limits.
a. Geriatric patients have limited capacity to raise their heart rates when stressed. Tachycardia may be occurring at rates of 90.
b. Geriatric patients very commonly have uncontrolled high blood pressure. Systolic blood pressures below 120 mmHg may indicate hypotension and commonly accepted levels of 90 mmHg may represent severe hypoperfusion
4. Thermoregulation is reduced due to muscle atrophy, malnutrition, neurological dysfunction and some medications. Provide passive warming measures with blanket and ambulance heaters.
5. Signs of hypotension and hemorrhagic hypovolemia should be cautiously resuscitated with NS/LR at a rate of 10 cc./kg. as a bolus. This can be repeated as needed. The goal blood pressure is not as clear in geriatric patients, but 90 mmHg is probably a reasonable one.
6. Head trauma in a patient on anti-coagulants is at higher risk for bleeding.
7. Spinal trauma is more likely to be complicated due to arthritic and degenerative changes making securing the spine more commonly needed. C-spines should be carefully evaluated.
8. Bones are generally more easily fractured in geriatric patients.
9. Geriatric patients may have exaggerated responses to medications such an analgesic. Start low and repeat to achieve your goals. Titrate Ketamine, if used, to pain control and discontinue until needed again.
10. Be prepared to manage confusion or disorientation with calm reassuring care.
11. Be vigilant for a medical emergency that could have preceded the trauma or be the cause of it.
12. Evaluate “lift assist” patients thoroughly. Hidden trauma is common. An underlying medical condition is commonly the cause for a “lift assist”.
13. Falls, even from standing, represent a unique problem with a substantial one-year mortality. Ground level falls should be considered significant in the geriatric patient.
14. Consider MIH referral for home evaluation for safety and follow-up.
15. Have a lower threshold for transport to a trauma center in geriatric patients.
GERIATRIC TRAUMA ACTIVATION CRITERIA
1. Ground level fall for patients on anti-coagulants
2. Systolic blood pressure less than 110 mmHg.
3. Heart rate above 90.
4. Shock Index greater than 1.0.
5. Ground level fall patients not on anticoagulants with Glasgow Coma Scale less than 14 and signs of head trauma.
TRAUMA PATIENTS
GENERAL CONSIDERATIONS
There is no scientific definition of the age at which a patient should be considered “geriatric”. For years it has been 65. Recent data has made some training programs drop the age to 55 where the anatomic and physiologic changes of age become clinically important. Geriatric patients pose new issues and need to be handled differently. Their vital signs, mental status, use of anti-coagulants, and more complicated medical history are just a few considerations.
1. A thorough history of past and present medical conditions needs to be obtained.
2. Current medications, particularly anti-coagulants (Eliquis, Xarelto, Warfarin) and anti-platelet drugs (Plavix), should be reviewed.
3. Vital signs may be inadequate while appearing within normal limits.
a. Geriatric patients have limited capacity to raise their heart rates when stressed. Tachycardia may be occurring at rates of 90.
b. Geriatric patients very commonly have uncontrolled high blood pressure. Systolic blood pressures below 120 mmHg may indicate hypotension and commonly accepted levels of 90 mmHg may represent severe hypoperfusion
4. Thermoregulation is reduced due to muscle atrophy, malnutrition, neurological dysfunction and some medications. Provide passive warming measures with blanket and ambulance heaters.
5. Signs of hypotension and hemorrhagic hypovolemia should be cautiously resuscitated with NS/LR at a rate of 10 cc./kg. as a bolus. This can be repeated as needed. The goal blood pressure is not as clear in geriatric patients, but 90 mmHg is probably a reasonable one.
6. Head trauma in a patient on anti-coagulants is at higher risk for bleeding.
7. Spinal trauma is more likely to be complicated due to arthritic and degenerative changes making securing the spine more commonly needed. C-spines should be carefully evaluated.
8. Bones are generally more easily fractured in geriatric patients.
9. Geriatric patients may have exaggerated responses to medications such an analgesic. Start low and repeat to achieve your goals. Titrate Ketamine, if used, to pain control and discontinue until needed again.
10. Be prepared to manage confusion or disorientation with calm reassuring care.
11. Be vigilant for a medical emergency that could have preceded the trauma or be the cause of it.
12. Evaluate “lift assist” patients thoroughly. Hidden trauma is common. An underlying medical condition is commonly the cause for a “lift assist”.
13. Falls, even from standing, represent a unique problem with a substantial one-year mortality. Ground level falls should be considered significant in the geriatric patient.
14. Consider MIH referral for home evaluation for safety and follow-up.
15. Have a lower threshold for transport to a trauma center in geriatric patients.
GERIATRIC TRAUMA ACTIVATION CRITERIA
1. Ground level fall for patients on anti-coagulants
2. Systolic blood pressure less than 110 mmHg.
3. Heart rate above 90.
4. Shock Index greater than 1.0.
5. Ground level fall patients not on anticoagulants with Glasgow Coma Scale less than 14 and signs of head trauma.