Advanced Trauma Life Support ATLS Student Course Manual 2018

SPECIFIC INJURIES 221
table 11-6 physiological changes and management considerations: exposure
and environment
PHYSIOLOGICAL CHANGES WITH AGING
MANAGEMENT CONSIDERATIONS
• Loss of subcutaneous fat
• Loss of skin elasticity
• Arthritic skeletal changes
• Nutritional deficiencies
• Perform early evaluation and liberate patients from spine
boards and cervical collars as soon as possible.
• Pad bony prominences when needed.
• Prevent hypothermia.
Rib Fractures
Elderly patients are at increased risk for rib fractures
due to anatomical changes of the chest wall and loss of
bone density. The most common cause of rib fractures
is a ground-level fall, followed by motor vehicle crashes.
The primary complication in elderly patients with rib
fractures is pneumonia. In the elderly population, the
incidence of pneumonia can be as high as 30%. Mortality
risk increases with each additional rib fractured.
The main objectives of treatment are pain control and
pulmonary hygiene. Pain management can include oral
medication, intravenous medications, transdermal
Pitfall
Respiratory failure
develops following fall
with rib fractures.
Patient develops delirium
after receiving longacting
narcotic dose.
prevention
• Recognize the potential
for pulmonary deterioration
in elderly
patients with rib
fractures.
• Provide effective
analgesia.
• Ensure adequate
pulmonary toilet.
• Recognize the patient’s
comorbid conditions
and their impact on the
response to injury and
medications.
• Obtain medication
history and note
potential interactions.
• Use smaller doses of
shorter-acting narcotics
when needed.
• Consider non-narcotic
alternatives.
• Use transdermal local
anesthetics, blocks, or
epidurals when possible.
medications, or regional anesthetics. Narcotic
administration in elderly patients must be undertaken
cautiously and only in the proper environment for
close patient monitoring. Avoiding untoward effects,
particularly respiratory depression and delirium, is of
paramount importance.
Traumatic Brain Injury
There is overwhelming evidence to suggest that the
geriatric population is at highest risk for TBI-associated
morbidity and mortality. This increased mortality
is not necessarily related to the magnitude of the
injury, but rather to the elderly patient’s inability to
recover. To date there are few recommendations on
age-specific management of TBI. Delirium, dementia,
and depression can be difficult to distinguish from the
signs of brain injury. Management of elderly patients
with TBI who are undergoing anticoagulant and/or
antiplatelet therapy is particularly challenging, and
the mortality of these patients is higher.
Liberal use of CT scan for diagnosis is particularly
important in elderly patients, as preexisting cerebral
atrophy, dementia, and cerebral vascular accidents
make the clinical diagnosis of traumatic brain injury
difficult. Additionally, aggressive and early reversal
of anticoagulant therapy may improve outcome. This
result may be accomplished rapidly with the use of
prothrombin complex concentrate (PCC), plasma,
and vitamin K. Standard measures of coagulation
status may not be abnormal in patients taking newer
anticoagulants. Unfortunately, specific reversal
agents are not yet available for many of the newer
direct thrombin and anti-Xa inhibitors, and a normal
coagulation status may be difficult to achieve. (See
Table 6-5 Anticoagulant Management in Chapter 6.)
Pelvic Fractures
Pelvic fractures in the elderly population most
commonly result from ground-level falls. As patients
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