Rosen & Barkin's 5-Minute Emergency Medicine Consult (296 page)

TREATMENT

• Emphasis should be placed on airway maintenance, control of external bleeding and shock, immobilization, and immediate transfer to appropriate facility
  

• Airway—take into account anatomical variations when establishing an airway
  
• Breathing
  
  • Continuous pulse oximetry and capnometry helpful
    
  • Administer supplemental oxygen to maintain oxygen saturation >95%
    
  • Serial ABGs may provide early insight to respiratory function and reserve
    
  • Timely intubation in patients with ventilatory compromise and more severe injuries
    
  • Intubation indications: Respiratory rate >40 breaths/min, PaO
    ₂
    is <60 mm Hg or PaCO
    ₂
    >50 mm Hg
    
  • Adequate analgesia of chest wall pain is essential for optimizing ventilation
    
• Circulation—severity of hemodynamic instability often underappreciated by clinicians
  
  • Serial crystalloid fluid boluses of 250–500 mL
    
  • Early invasive monitoring has been advocated, better assess need for volume loading and inotropic support
    
  • Geriatric patients can decompensate from overly aggressive volume replacement
    
  • Strong consideration for early and liberal use of red blood cell transfusion
    
  • Target hemoglobin level is controversial, but many authors recommend 10 g/dL
    
  • Recognize the harmful effects and complications of red blood cell transfusions
    
  • Blood viscosity, infection, and impairment of immune response
    
  • Serial base deficit and lactate levels provide good initial measures of shock and can guide resuscitation decisions
    
  • Creatinine clearance reduced in elderly
    
  • Kidneys more susceptible to injury from hypovolemia, medications, and nephrotoxins
    
• Disability:
  
  • Head Injury: Age is an independent risk factor for morbidity and mortality
    
  • Age-related atrophy and mental decline may confound the evaluation of mental status
    
  • Anticoagulated patients with blunt head injury at increased risk for intracranial bleeds and delayed bleeding.
    
  • Strongly consider repeat imaging to detect delayed bleeds in anticoagulated patients
    
  • When indicated, initiate treatment for intracranial hypertension, maintain spinal immobilization, and obtain definitive airway
    
• Exposure: Completely undress patient, but prevent hypothermia
  
  • Age-related changes and medications make elderly more susceptible to hypothermia
    
  • Hypothermia not attributable to shock or exposure should raise concern for sepsis, endocrinopathy, or drug ingestion
    
• Common injury patterns:
  
• Head injury
  
  • Less prone to epidural hematomas
    
  • Higher incidence of subdural hematomas
    
• Cervical spine injuries
  
  • Propensity to sustain cervical spine injuries from seemingly minor trauma (fall from standing or seated height)
    
  • C1–C2 and odontoid fractures are particularly more common among elderly
    
  • Underlying cervical spine pathology, such as arthritis may predispose to spinal cord injuries
    
  • With hyperextension injuries, increased risk of developing a central cord syndrome
    
• Vertebral injuries
  
  • More susceptible to fractures, especially anterior wedge compression fractures
    
• Chest trauma
  
  • Rib fracture is most common; in geriatric patients these is an increased risk of pneumonia and mortality with each additional rib fracture
    
  • Hemopneumothrorax, pulmonary contusion, flail chest, and cardiac contusion can quickly lead to decompensation
    
• Abdominal trauma
  
  • Similar pattern of injury as younger adults
    
  • Paramount to recognize signs of hemodynamic stability early
    
  • Nonoperative treatment of hemodynamically stable blunt hepatic and splenic injuries has emerged as the trend
    
  • Should have high index of suspicion for internal injuries with associated pelvic and lower rib cage injuries
    
• Orthopedic injuries—more predisposed due to osteopenia and osteoporotic changes
  
  • Uniquely susceptible to pelvic and hip fractures
    
  • Goal of orthopedic injuries is to undertake the least invasive, most definitive procedure that will permit early return to function
    
• Anticoagulation—consider fresh frozen plasma, cryoprecipitate, and concentrated factor for significant bleeds depending on indications
  
  • Beware of fluid overload and thrombotic complications
    

• Early monitoring of pulmonary and cardiovascular systems must be instituted
  
• Prompt stabilization, early recognition of the need for operative intervention, and appropriate and expedient surgical consultation are paramount
  
• Definitive treatment is often surgical
  
• Elderly patients benefit from preferential transfer to trauma centers and aggressive, yet thoughtful care
  
• No reliable age-based criteria upon which to base decisions to triage away from care
  
• Good outcomes can be achieved with appropriately aggressive trauma care
  
• Equally important to limit intensive treatment to injuries which are survivable and allow potentially acceptable quality of life
  
• Seek existence of advance directives, living will, or similar legal document
  

FOLLOW-UP

• Most major trauma patients should be admitted for observation, monitoring, and further evaluation
  
• Lower threshold for admitting geriatric patients to ward, monitored settings, or ICU
  
• Elderly patients with polytrauma, significant chest wall injuries, abnormal vital signs, evidence of hypoperfusion should be admitted to the ICU
  

Patients with minor trauma and negative workup/imaging may be observed in the ED for several hours and then discharged

Follow-up should be determined by the types of injuries sustained and specialty care required.

Follow-up and referral should be determined by the types of injuries sustained and specialty care required

• Minor mechanisms of injury can produce serious injury and complication because of the effect of limited physiologic reserve, medication effects, and unrecognized hypoperfusion
  
• Frequent use of medications, especially β-blockers and anticoagulants complicate assessment and management
  
• Mistaken impression that “normal” BP and heart rate imply normovolemia.
  
• Geriatric trauma patients must be treated as both trauma and medical patients.
  

• Legome E, Shockley LW, eds.
  Trauma: A Comprehensive Emergency Medicine Approach
  . Cambridge, UK: Cambridge University Press; 2011.
  
• Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims.
  J Trauma
  . 2010;69:813–820.
  
• Fallon WF Jr, Rader E, Zyzanski S, et al. Geriatric outcomes are improved by a geriatric trauma consultation service.
  J Trauma
  . 2006;61(5):1040–1046.
  
• American College of Surgeons Committee on Trauma.
  Advanced Trauma Life Support for Doctors
  . 8th ed. Chicago, IL: American College of Surgeons; 2008.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Specific anatomic injuries
  
• Shock
  
• Airway management
  
• Multiple trauma
  

CODES

• V15.88 History of fall
  
• 797 Senility without mention of psychosis
  
• 995.81 Adult physical abuse
  

BASICS

• Naturally occurring analog of γ-aminobutyric acid (GABA)
  
• Used medically for narcolepsy
  
• Nonmedical uses:
  
  • Bodybuilding agent
    
  • Euphoric agent
    
  • Date-rape/predatory agent
    
• γ-Hydroxybutyrate (GHB) precursors (γ-butyrolactone [GBL], 1,4 butanediol [1,4-BD], GHV [γ-hydroxyvalerate], and GVL) have same effects as GHB.
  
• Onset of activity: 15–30 min after ingestion
  
• Duration of effect: 2–6 hr