Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY WITH RESUSCITATION 217
determinant of mortality, host factors also played a
significant role.
Common mechanisms of injury encountered in older
patients include falls, motor vehicle crashes, burns, and
penetrating injuries.
Falls
The risk of falling increases with age, and falls are the
most common mechanism of fatal injury in the elderly
population. Nonfatal falls are more common in women,
and fractures are more common in women who fall.
Falls are the most common cause of traumatic brain
injury (TBI) in the elderly. Nearly one-half of deaths
associated with ground-level falls are a result of TBI.
One-half of elderly patients suffering a hip fracture will
no longer be able to live independently. Risk factors
for falls include advanced age, physical impairments,
history of a previous fall, medication use, dementia,
unsteady gait, and visual, cognitive, and neurological
impairments. Environmental factors, such as loose rugs,
poor lighting, and slippery or uneven surfaces, play an
additional role in fall risk.
Motor Vehicle Crashes
In general, older people drive fewer total miles, on more
familiar roads, and at lower speeds than younger drivers.
They also tend to drive during the day. Thus most of
the elderly traffic fatalities occur in the daytime and
on weekends, and they typically involve other vehicles.
Contributing risk factors in the elderly for motor vehicle
crashes include slower reaction times, a larger blind
spot, limited cervical mobility, decreased hearing,
and cognitive impairment. Additionally, medical
problems such as myocardial infarction, stroke, and
dysrhythmias can result in conditions that precipitate
a collision.
Burns
MechANism of Injury
Burn injury can be particularly devastating in elderly
patients. The impact of age on burn mortality has
long been recognized; however, despite significant
declining mortality in younger age groups, the
mortality associated with small- to moderate-sized
burns in older adults remains high. In examining deaths
from structural fires, researchers find the elderly are
particularly at risk because of decreased reaction times,
impaired hearing and vision, and the inability to escape
the burning structure. Spilled hot liquids on the leg,
which in a younger patient may re-epithelialize due
to an adequate number of hair follicles, will result in a
full-thickness burn in older patients with a paucity of
follicles. Their aging organ systems have a major impact
on the outcomes of elderly burn patients; changes
in the skin are obvious, but the patient’s inability
to meet the physiological demands associated with
burn injury likely has the most influence on outcome
and survival.
Penetrating Injuries
By far, blunt trauma is the predominant mechanism of
injury in older adults; however, a significant number of
people over the age of 65 years are victims of penetrating
injury. In fact, penetrating injury is the fourth most
common cause of traumatic death in individuals
65 years and older. Many deaths associated with
gunshot wounds are related to intentional self-harm
or suicide.
As with all trauma patients, the application of ATLS
principles in assessment and management of older
adults follows the ABCDE methodology. Clinicians must
take into consideration the effects of aging on organ
systems and their implications for care, as outlined
in n TABLE 11-1. (Also see Effects of Aging on MyATLS
mobile app.)
Airway
Primary Survey with
Resuscitation
The elderly airway poses specific challenges for
providers. Given that older adults have significant
loss of protective airway reflexes, timely decision
making for establishing a definitive airway can be
lifesaving. Patients may have dentures that may
loosen and obstruct the airway. If the dentures are
not obstructing the airway, leave them in place during
bag-mask ventilation, as this improves mask fit.
Some elderly patients are edentulous, which makes
intubating easier but bag-mask ventilation more
difficult. Arthritic changes may make mouth opening
and cervical spine management difficult (n FIGURE 11-2).
When performing rapid sequence intubation, reduce
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