Advanced Trauma Life Support ATLS Student Course Manual 2018

PRIMARY SURVEY WITH RESUSCITATION 219
the doses of barbiturates, benzodiazepines, and other
sedatives to between 20% and 40% to minimize the
risk of cardiovascular depression.
Key physiological changes and management
considerations of concern to airway assessment and
management are listed in n TABLE 11-2.
Breathing
Changes in the compliance of the lungs and chest wall
result in increased work of breathing with aging. This
alteration places the elderly trauma patient at high
risk for respiratory failure. Because aging causes a
suppressed heart rate response to hypoxia, respiratory
failure may present insidiously in older adults.
Interpreting clinical and laboratory information can
be difficult in the face of preexisting respiratory disease
or non-pathological changes in ventilation associated
with age. Frequently, decisions to secure a patient’s
airway and provide mechanical ventilation may be
made before fully appreciating underlying premorbid
respiratory conditions.
Key physiological changes and management considerations
in assessing and managing of breathing
and ventilation are listed in n TABLE 11-3.
Circulation
Age-related changes in the cardiovascular system
place the elderly trauma patient at significant risk for
being inaccurately categorized as hemodynamically
normal. Since the elderly patient may have a fixed
heart rate and cardiac output, response to hypovolemia
will involve increasing systemic vascular resistance.
Furthermore, since many elderly patients have
preexisting hypertension, a seemingly acceptable
blood pressure may truly reflect a relative hypotensive
state. Recent research identifies a systolic blood
pressure of 110 mm Hg to be utilized as threshold
for identifying hypotension in adults over 65 years
of age.
It is critical to identify patients with significant
tissue hypoperfusion. Several methodologies have
been and continue to be used in making this diagnosis.
These include base deficit, serum lactate, shock index,
and tissue-specific end points. Resuscitation of geriatric
patients with hypoperfusion is the same as for all
other patients and is based on appropriate fluid and
blood administration.
The elderly trauma patient with evidence of
circulatory failure should be assumed to be bleeding.
Consider the early use of advanced monitoring (e.g.,
central venous pressure [CVP], echocardiography
and ultrasonography) to guide optimal resuscitation,
given the potential for preexisting cardiovascular
disease. In addition, clinicians need to recognize that
a physiological event (e.g., stroke, myocardial infarction,
dysrhythmia) may have triggered the incident leading
to injury.
Key physiological changes and management considerations
in the assessment and management of
circulation are listed in n TABLE 11-4.
table 11-2 physiological changes and management considerations: airway
PHYSIOLOGICAL CHANGES WITH AGING
MANAGEMENT CONSIDERATIONS
• Arthritic changes in mouth and cervical spine
• Macroglossia
• Decreased protective reflexes
• Edentulousness
• Use appropriately sized laryngoscope and tubes.
• Place gauze between gums and cheek to achieve seal when using
bag-mask ventilation.
• Ensure appropriate dosing of rapid sequence intubation medications.
table 11-3 physiological changes and management considerations: breathing
PHYSIOLOGICAL CHANGES WITH AGING
MANAGEMENT CONSIDERATIONS
• Increased kyphoscoliosis
• Decreased functional residual capacity (FRC)
• Decreased gas exchange
• Decreased cough reflex
• Decreased mucociliary clearance from airways
• Limited respiratory reserve; identify respiratory failure early.
• Manage rib fractures expeditiously.
• Ensure appropriate application of mechanical ventilation.
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