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You may be giving poor care to elderly trauma patients
Seemingly minor injuries can be devastating
If your ED patient sustained a few rib fractures, would you expect this to lead to rapid respiratory decompensation, pneumonia, and death? Minor injuries can have profound effects in the elderly, warns Avery Nathens, MD, division head of trauma and general surgery at St. Michael's Hospital in Toronto, Canada.
Trauma centers may not provide the same quality of care for elderly trauma patients as they do for younger patients, according to a recent study.1 Researchers analyzed data on 87,754 trauma patients of all ages treated at 132 facilities.
"We showed that a center that is high-performing for the young is not necessarily high-performing for the elderly," says Nathens. "We believe that the elderly require a different approach to care, given the physiology associated with aging and their associated medical problems."
The elderly have decreased pain sensation and delayed cardiovascular response, making abdominal injuries with risk for bleeding difficult to assess, says Joyce Fuss, RN, BSN, CEN, FNE, a senior partner at the Emergency Medicine Trauma Center at Indiana University Health in Indianapolis. "Many times, elderly patients will injure themselves at home and delay seeking care, not realizing how injured they are," she says.
Early action is key
The percentage of elderly trauma patients coming to EDs is "rapidly growing," according to Donna Sparks, MSN, RN, CEN, director of emergency services at Baptist Hospital Miami. "ED nurses need a clear understanding of normal age-related physiological changes, and how those changes impact the individual's response to trauma," she says.
For example, an elderly trauma patient may also experience an atypical myocardial infarction, says Sparks. "Anticipate admission of the geriatric patient if two or more ribs are broken," she adds.
Gabriela McAdoo, RN, trauma coordinator at Stanford (CA) Hospital & Clinics, says it is particularly important to recognize early indications for intubation. "This is important due to limited cardiopulmonary reserve for the elder patient presenting in shock," she says. To improve the care of elder trauma patients:
Identify shock earlier.
If elderly patients are on beta-blockers, they might not demonstrate tachycardia in response to blood loss, says Nathens. "They might also present with a normal blood pressure which, for a hypertensive patient, might be too low to support tissue perfusion," he says.
A good way to identify shock in elderly trauma patients is with the use of routine blood gases, says Nathens. "These can be used to identify a high base deficit or lactate, suggesting poor tissue perfusion," he explains.
Identify significant hypothermia.
This needs to be aggressively treated with body warmers and administration of warm intravenous fluids, says Nathens.
Develop protocols for the rapid reversal of the effects of anticoagulation.
This will allow bleeding to be addressed more effectively, Nathens explains.
Avoid missing subtle signs of distress.
Perform more frequent monitoring, and evaluate treatments more closely for effectiveness, says Fuss. "Remember that more elderly patients die from complications of trauma, than the trauma itself," she says. "Aggressive treatments are needed to prevent some of the comorbidities."
Don't be misled by "normal" vital signs.
Patients with chronic obstructive pulmonary disease might normally have increased work of breathing with increased respiratory rate, says Fuss, making it difficult to determine chest injury or respiratory distress.
Likewise, says Fuss, the vital signs of a patient who has a history of hypertension and takes beta-blockers might appear normal. "But when the nurse evaluates the trending, it will show the presenting blood pressure was initially high and the heart rate lower," she says.
Many times, "normal" vital signs in elders are signs of shock, says Fuss. "It is more important to know the patient's norm and monitor trending," she says. "Knowing what is 'normal' for that patient is key to making an accurate clinical judgment." (See sidebars on fluid resuscitation and pain management, below.)
Fluid may be overlooked in elder trauma patents
After a CT scan of an 85-year-old male involved in a motor-vehicle accident showed a Grade 2 liver laceration, the patient was placed in a holding area while waiting for an inpatient bed, recalls Joyce Fuss, RN, BSN, CEN, FNE, a senior partner at the Emergency Medicine Trauma Center at Indiana University Health in Indianapolis.
"The patient was brought in with two large-bore PIVs [peripheral intravenous lines]," says Fuss, one of the ED nurses who cared for the patient. "However, due to his age, lack of active bleeding, and noted normal vital signs, both lines were saline-locked. The patient was never given fluid."
Because multiple nurses were caring for the patient, says Fuss, no one noticed the patient had not urinated in more than eight hours, or the trending down in blood pressure and trending up in heart rate. This was because they stayed within the normal range, she adds.
The ED nurse notified the physician, and the patient was given two liters of 0.9 normal saline over the next two hours, says Fuss. "The patient finally voided a minimal amount of concentrated urine," she says. "The patient was then placed on IV [intravenous] fluid, and the blood pressure maintained in the 120s systolic."
Elderly trauma patients require close monitoring during fluid and blood administration for cardiac overload, according to Fuss. "Younger patients are administered fluid and blood rapidly with no hesitation, but many times elderly trauma patients will be under fluid resuscitated to avoid overload," says Fuss. She gives these tips:
If the patient has been stabilized and no IV fluid has been ordered, make sure the patient is provided fluid.
This is especially important if the patient is being kept NPO, says Fuss.
Administer fluid and blood through 20g PIVs.
"This can be done without difficulty until central access is obtained, versus trying to place large-bore PIVs and blowing all access," says Fuss. "Many times, the elderly have fragile skin and veins. This makes it difficult to get in large-bore IVs."
Monitor patients closely for signs of respiratory distress during rapid fluid resuscitation when the line is placed in the subclavian vein.
"A fragile and non-compliant vascular system leads the patient to increased risk for infiltration of trauma introducers," says Fuss.
Use small, frequent doses to manage pain
Manage pain in elderly trauma patients with small, frequent amounts of short-acting narcotics, advises Joyce Fuss, RN, BSN, CEN, FNE, a senior partner at the Emergency Medicine Trauma Center at Indiana University Health in Indianapolis. The younger trauma patient will tolerate longer-acting narcotics in higher doses to maintain pain control for longer periods of time, she explains.
"Due to varied clearance times, the elder patient needs more frequent monitoring to evaluate pain control effectiveness," says Fuss.
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