Advanced Trauma Life Support ATLS Student Course Manual 2018

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CHAPTER 11 n Geriatric Trauma
age, the incidence of osteoporosis increases linearly;
most individuals over the age of 60 have some degree
of osteoporosis. Mortality from pelvic fracture is four
times higher in older patients than in a younger cohort.
The need for blood transfusion, even for seemingly
stable fractures, is significantly higher than that seen
in a younger population. Older adults also have a much
longer hospital stay and are less likely to return to
an independent lifestyle following discharge. Fall
prevention is the mainstay of reducing the mortality
associated with pelvic fractures.
Special circumstANces
Special circumstances that require consideration in
the treatment of elderly trauma patients include
medications, maltreatment, and establishing goals
of care.
Medications
Beta blockers are used in approximately 20% of elderly
patients with coronary artery disease and 10% of
patients with hypertension. The inherent physiological
blockade of the expected response to hypovolemia may
provide triage and treatment obstacles. Anticoagulation
therapy, antiplatelet therapy, and use of direct thrombin
inhibitors pose significant problems for the bleeding
patient. Rapidly identifying the type of drug and then
instituting a reversal agent (if one is available) may
save the patient’s life.
Elder Maltreatment
When evaluating an injured elderly patient, team
members should consider the possibility of maltreatment.
Maltreatment is defined as any willful
infliction of injury, unreasonable confinement,
intimidation, or cruel punishment that results in
physical harm, pain, mental anguish, or other willful
deprivation by a caretaker of goods or services that are
necessary to avoid physical harm, mental anguish, or
mental illness. Maltreatment of the elderly may be as
common as child maltreatment.
Elder maltreatment can be divided into six categories:
1. Physical maltreatment
2. Sexual maltreatment
3. Neglect
4. Psychological maltreatment
5. Financial and material exploitation
6. Violation of rights
Often, several types of maltreatment occur simultaneously.
Multifaceted in cause, elder maltreatment
often is unrecognized and underreported. Signs of
maltreatment can be subtle (e.g., poor hygiene and
dehydration) and go undetected. Physical maltreatment
occurs in up to 14% of geriatric trauma admissions,
resulting in a higher mortality than in younger patients.
Physical findings suggesting elder maltreatment are
listed in n BOX 11-1.
The presence of physical findings suggesting maltreatment
should prompt a detailed history. If the
history conflicts with the physical findings or reveals
an intentional delay in treatment, immediately report
the findings to appropriate authorities for further
investigation. If maltreatment is suspected or confirmed,
take appropriate action, including removal
of the elderly patient from the abusive situation.
According to the National Center on Elder Abuse, more
than 1 in 10 older adults may experience some type of
maltreatment, but only 1 in 5 or fewer of those cases
are reported. A multidisciplinary approach is required
to address the components of care for victims of
elder maltreatment.
Establishing Goals of Care
Trauma is the fifth leading cause of death in patients
over the age of 65. Among trauma patients, the elderly
box 11-1 physical findings
suggestive of elder maltreatment
• Contusions affecting the inner arms, inner thighs,
palms, soles, scalp, ear (pinna), mastoid area, buttocks
• Multiple and clustered contusions
• Abrasions to the axillary area (from restraints) or the
wrist and ankles (from ligatures)
• Nasal bridge and temple injury (from being struck while
wearing eyeglasses)
• Periorbital ecchymoses
• Oral injury
• Unusual alopecia pattern
• Untreated pressure injuries or ulcers in nonlumbosacral
areas
• Untreated fractures
• Fractures not involving the hip, humerus, or vertebra
• Injuries in various stages of evolution
• Injuries to the eyes or nose
• Contact burns and scalds
• Scalp hemorrhage or hematoma
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