Silent but deadly: The trauma we miss in geriatric care
Improve your patient assessment of traumatic injuries in geriatric medicine
EMS providers need to know that when it comes to trauma in older patients, even minor accidents can have devastating consequences. What healthcare providers miss or fail to consider can mean the literal difference between life and death for the elderly.
Americans over 65 years old comprise approximately 15 percent of the total population, yet they account for almost 40 percent of all ambulance transports and more than 25 percent of hospitalizations .
Despite the fact that these are some of our most frequently encountered and sickest patients, studies have shown that geriatric victims of trauma are consistently under-triaged . Many times this lapse occurs at the EMS level, resulting in significant increases in patient mortality .
Aging and disease
As the human body ages, it goes through many natural changes of anatomy and physiology, making older patients much more susceptible to poor outcomes from traumatic injuries. Additionally, co-morbid conditions and diseases, along with the medications used to treat them, can complicate care and lead to the following poor outcomes :
- Airway – The potential for aspiration increases as a patient ages due to decreased cough and gag reflexes and decreased activity of the cilia (the fine, hair-like projections that line and help clear the airway). Disease states like stroke and dementia can also further increase the chances of aspiration, making effective airway management especially important. Adding to the challenge, tooth decay and dental work, including devices such as dentures can make both BLS and ALS airway management even more of a challenge .
- Breathing – Lung compliance and vital capacity significantly decrease as a patient ages, while chronic obstructive pulmonary disease, asthma, pneumonia and other respiratory issues further rob older trauma patients of their ability to effectively ventilate or be ventilated .
- Circulation: Maximum cardiac output typically decreases 20-30 percent by age 65, making older patients less capable of compensating for shock than younger patients. Cardiovascular disease can further decrease the patient’s ability to deal with even minor blood losses. Blood thinners, such as those commonly prescribed for patients at risk for heart attack and stroke, make it more difficult for the body to stop bleeding; and medications used to treat hypertension, including beta blockers, can limit the heart’s ability to compensate for blood loss and hypotension. Cardiac injury and congestive heart failure also decrease the geriatric patient’s ability to deal with the large volume fluid resuscitation often associated with treating shock.
- Disability, neurological: As people age, brain mass decreases, expanding the subdural space and increasing the likelihood of traumatic brain injury and intracranial bleeding. Furthermore, blood flow to the brain decreases, presenting a low baseline of cerebral perfusion even before a traumatic injury occurs. Baseline mental status is critical information in elderly patients as it can be very difficult to discern between underlying cognitive decline and dementia, and trauma-induced confusion and delirium. Remember that aging alone does not cause mental status changes.
- Everything else: Unlike younger patients, a variety of factors contribute to what is considered “geriatric frailty,” making older patients more likely to sustain and suffer from even simple traumatic injuries. Slowed reaction time and diseases like osteoarthritis make it more difficult for the elderly to protect themselves from trauma. The loss of muscle mass typically associated with aging further reduces the patient’s ability to dissipate blunt force trauma, while diseases like osteoporosis make it more likely that they will suffer fractures and other injuries. Other co-morbid disease states, such as renal disease, liver failure, diabetes and others common to older patients can further decrease their ability to survive even minor- to moderate-traumatic injuries.
Improved geriatric trauma assessment
A thorough assessment of geriatric patients should include :
- The patient’s chief complaint
- Mechanism of injury
- Physical presentation
- Chronic conditions
- Any treatments for those conditions
- Baseline status
As older patients often suffer from chronic medical conditions, it can be a challenge to determine what emergent issues are related to these problems, what are related to the traumatic injury, and what problems may result from the interplay of illness and injury.
You may have been called for either a medical complaint or a report of traumatic injury, but that does not mean that this is the only, or the most significant issue to be addressed.
Keep this in mind as you survey the scene and, where possible, obtain assistance in gathering information about the incident, the patient’s living conditions, normal baseline, activities of daily living, and medical issues along with any medications or care being received, or that they should be receiving, but are not . Remain aware of signs of either physical elder abuse or neglect .
The first priority of initial patient assessment is to identify and begin treatment of immediate threats to life. While this is just as true for geriatric patients as anyone else, due to the potential frailty of the elderly, even minor incidents can present major consequences not initially obvious to EMS providers.
In addition, older patients may significantly downplay the severity of their injuries for reasons including not wanting to trouble others, fear of hospitalization, and diseases such as neuropathy and stroke that lower the patient’s awareness of their own pain and significant injury. This can often lead healthcare providers to fail to thoroughly assess and significantly under-triage elder victims of trauma. In short, they don’t say and we don’t look .
One amusingly memorable mnemonic can help EMS providers ensure thorough assessment of the most common mechanism of injury for older patients, falls. When an older patient falls, remember SPLATT .
- Symptoms: What are all of the symptoms associated with this event? What lead up to or immediately followed the fall?
- Previous Falls: How many? Is there a recent pattern? How many have resulted in EMS transport and/or hospitalization?
- Location: Exactly where did they fall and what did they land on? Don’t assume that where you found them is where they landed.
- Activity: What were they doing, or trying to do, when they fell?
- Time: How long ago did they fall? How long have they been on the ground?
- Trauma: Perform a thorough head-to-toe exam, searching for traumatic injuries, even the ones the patient may not be complaining about.
Whether from falls or other mechanisms of injury, it is crucial to identify priority patients. These include patients presenting with a poor general impression, who have a poor ability to control their own airway, are unresponsive, have a change from baseline mental status, have significant hemorrhage; or are presenting with shock (hypoperfusion), difficulty breathing, chest pain with systolic blood pressure <100 mm Hg, or have severe pain anywhere .
Vital signs can be deceiving when managing trauma in older patients. Heart rates above 90 and systolic blood pressures (SBPs) < 110 mm Hg are associated with increased mortality . A systolic blood pressure below 120 mm Hg may be hypotensive if the normal pressure is 170 mm Hg. Heart rates above 80 may be concerning in an elderly patient on beta-blockers .
Similarly, a victim of a fall may not have sustained a significant injury during the fall itself, but may have developed compression injuries or even rhabdomyolysis if they have remained on the floor or in one position for a long period of time.
The golden hour and the golden years
While the validity of the so-called “golden hour” is controversial, when it comes to geriatric patients, a rapid-but-thorough assessment is crucial. It can be complicated by the interplay of medical illnesses and traumatic injuries, difficulties in obtaining information about the patient’s baseline conditions, and a patient who may not wish to receive the care they need. While these are significant challenges for prehospital providers of all levels, it remains no less of a responsibility to make sure that our older patients receive the thorough and coordinated assessment that will help lead to quality prioritized care from EMS and the rest of the trauma team.
1. Center for Disease Control and Prevention. Emergency Department Visits by Persons Aged 65 and Over: United States, 2009–2010. National Center for Health Statistics (2013). Available at: https://www.cdc.gov/nchs/data/databriefs/db130.htm
2. Kozar RA, et al. Injury in the aged: Geriatric trauma care at the crossroads. J. Trauma Acute Care Surg. 78, 1197–1209 (2015).
3. Geriatric Trauma and Critical Care. (Springer New York, 2014). doi:10.1007/978-1-4614-8501-8
4. MD, H. M. F., FRCP, K. R. M. F. & FRCP, J. B. Y. M. Brocklehurst’s Textbook of Geriatric Medicine and Gerontology, 8e. (Elsevier, 2016).
5. American College of Surgeons. ATLS Advanced Trauma Life Support for Doctors - Student Course Manual. (American College of Surgeons, 2012).
6. National Association of Emergency Medical Technicians. Geriatric Education for Emergency Medical Services (GEMS). (Jones & Bartlett Learning, 2016).
7. Heffernan DS, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J. Trauma 69, 813–820 (2010).