see: [EMA Carpenter et al 2017. Major trauma in the older patient](x-devonthink-item://B02BA97E-8419-4708-BEB9-0D590114945C), [Rosen Geriatric trauma](x-devonthink-item://D574B7B8-4A82-4113-807A-33EC6314EE1C) see also: [[Airway]], [[Peri-intubation collapse]], [[Ventilator strategies]], [[Geriatric resus considerations]] # Geriatric trauma resus considerations tables #tables ## Impacts of aging on trauma assessment and management | | impact of aging | clinical implications | | ----------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Airway | - ↑ edentulous<br>- arthritis of TMJ and C-spine | - possibly difficult airway due to ↓ mouth opening / neck mobility<br>- BVM may be difficult without dentures in situ | | Breathing | ↓ resp muscle strength, vital capacity, compliance of chest wall<br>↑ residual volume | - early supplimental O2 and resp support<br>- incentive spirometry (reduce atelectasis) | | Circulation | ↑ peripheral vascular resistance<br>- ↓ tachycardia response to hypovolaemia<br>- reliance on stroke volume for rise in CO<br>- increased 1' and 2' cardiac ischaemia<br>- increase use of anti-coagulant and anti-platelet medications | - delays in recognition of shock<br>- base deficit \< -6 may indicate shock<br>- low threshold for CT<br>- need early fluid resus to augment ventricular filling | | Disability | - cortical atrophy → increase risk of SDH | ↑ ICH in setting of normal GCS | | Exposure | premorbid malnutrition | ↑ risk of [[Hypothermia]], pressure injuries, infection | **Modifying factors in geriatric trauma assessment** ***Hx*** - less reliable due to underlying cognitive impairment - ↑ complex comorbidities - complex physiology altering medication eg beta blockers, anticoagulation - ↑ reliance on collateral history from family or support workers - ↑ risk of having had multiple falls ***Exam*** - BP may be falsely reassuring if pre-existing HTN - may not have tachycardia if on beta blockers or CCBs - increased baseline autonomic dysfunction (eg PKD) - less physiological reserve ***Investigations*** - increased risk of ICH - increased risk of vertebral and rib fractures - may not communicate pain → lower threshold for imaging ## comorbidities in older adults and effect on mgmt in trauma | comorbidity | effect | | ---------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | cardiovascular disease | - [[ACS]] may cause a fall or MVA. adrenergic surge from trauma may also cause ACS.<br>- ↑ [[Aortic dissection]] with blunt chest trauma<br>- ↓ peripheral perfusion 2/2 PVD<br>- [[Pulmonary oedema]] from IVF / blood | | CKD | - opiate and abx doses<br>- volume depletion sensitivity | | dementia | - difficult history and exam<br>- ↑ delirium from trauma and hospitalisation<br>- cannot express pain or ask for PRN analgesia → need regular analgesia | | frailty | ↑ mortality from minor injuries<br>likely to require rehab / NH placement, need SW, allied health, etc | | joint replacements | periprosthetic fractures may present with minimal deformity | | neurovascular disease | prior CVA may make exam difficult<br>risk of CVA with hypotension | | osteoporosis | ↑ fracture risk<br>- XR have decreased sensitivity<br>- prior atraumatic compression fractures may obfuscate acute injuries<br>- may be able to ambulate with acute hip fractures | | rheumatoid arthritis | - associated cervical spine disease leads to fractures<br>- joint deformities can be mistaken for acute fractures | | spinal diseases | - degenerative disc disease ↑ endplate fractures, [[Cervical spine trauma radiology#central cord syndrome]]<br>- spinal stenosis can be associated with [[SCIWORA]] | ## common medications that affect trauma assessment and mgmt | medication | effects | | ---------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | [[Anticholinergic toxicity\|anticholinergics]] | - falls, confusion, delirium<br>- urinary retention , constipation | | antihypertensives and diuretics | - orthostatic hypotension and falls<br>- AV nodal agents may blunt ability to mount tachycardia response to bleeding<br>- normotension can be a sign of blood loss | | anticoagulants and antiplatelets | - increase risk of spont bleeding<br>- may need [[Warfarin, DOAC, heparin reversal]] | | steroids | ↑ risk of fractures<br>↓ wound healing<br>refractory hypotension if withheld | | hypoglycemic agents | - can be cause of falls<br>- NPO may cause iatrogenic [[hypoglycaemia\|hypoglycemia]] | | opiates and sedatives | - increase risk of falls and MVAs<br>- may affect GCS assessment<br>- withdrawl can present oas tachycardia and confusion | # Common injuries in older adults - [[traumatic brain injury|TBI]] - [[Cervical spine trauma radiology|C-spine trauma]] - thoracic trauma - fragility fractures # OSCE - [Cabrini 2025 st 6](x-devonthink-item://B9230BF7-FB88-41FF-9E71-73E522647348)