TRANSPORT OF THE GERIATRIC PATIENT

Markus Dorsey- Hirt RN CFRN

Chief Flight Nurse/ Chief Nursing Officer

REMSA/ Care Flight

Reno, Nevada

DISCLOSURE• I am a salaried employee of REMSA/Care Flight

• I have no potential conflict of interest with this presentation

CONSIDERATIONS: ELDERLY AND THE COMORBIDITIES

• > 55 years of age = ↑ morbidity & mortality

• mortality risk ↑’s/ annum by 6.8% after 65 years of age

• ↑ Comorbidities/ Confounding Complications

• MedicationsAnticonvulsantsTCAsAntihypertensives (ß Blockers, Calcium Channel Blockers, Ace Inhibitors)SSRIsAntipsychoticsBenzodiazepinesAnticoagulantsAntiplatelet agentsGlucocorticoids

• Drug half life and distribution can be affected by slowed metabolism, increase in adipose tissue vs. lean body mass and renal and hepatic insufficiencies

Pharmacological Considerations

Optimizing Care and Resources

• High suspicion of injury ↔ Low threshold for trauma team activation

• Low impact injuries can cause significant injury

• Assess contributing factors related to trauma:•Cognitive changes• Recent illness/dehydration• Pneumonia/Flu• Cerebrovascular event• Syncope• Coagulopathy – anticoagulant therapy • Skeletal injury – secondary to fall ? Primary neurologic insult• Diminished spatial awareness• Diminished pain response/ awareness

Caution: Undertriage!Improved outcomes with transport to Trauma Centers

Transport Considerations:

Getting the patient the right care – transport to the appropriate destination – via the right transport mode

What are your current resources?

General ConceptsFundamental Assessment Parameters

• Vital Signs•Thermoregulation - optimization of core temperature

• Hypo or Hyperthermia • often 1st clinical sign of infection

• Pulse• underlying cardiac arrhythmia/ pathology

• Blood Pressure• orthostatic hypotension vs. hypertension

• Respiratory Rate • ↑ RR

PRIMARY ASSESSMENT / RAPID TRAUMA ASSESSMENT

CONSIDERATIONS

ABCD’s of the Elderly Trauma Patient

Life Threats!

•Lower threshold to immobilize

• Difficult to apply due to:Physiologic Changes: Osteoporosis/arthritis/degenerative changes May need padding to support anatomical anomalies

• Injuries can occur with low impact/ minor mechanism of injury (Fall from standing)Type II Odontoid fracture common cervical spine injury Central Cord Syndrome secondary to hyperextension injury with underlying spondylosis

Cervical Spine

Elderly Kyphotic Trauma Patient

Maintain C-Spine

AIRWAY / BREATHING

• Limited ability to open mouth/ Airway Anomalies ↔ Complicate BVM & Intubation•Temporomandibular arthritis• Dentures/ loose dentition

• Poor physiologic reserves / Overall poor functional capacity•↓ Chest wall compliance •↓ chest wall elasticity/ poor recoil•↓ diaphragmatic efficiency (kyphosis, osteoporosis, pain acute and / or chronic)•minimal impact → increased work of breathing → fatigue

• Respiratory Rate•↓ Vital Capacity/Functional Residual Capacity/Forced Expiratory Volume•↑ Respiratory Rate secondary to ↓Tidal Volume (RR< 10 BPM ↑ mortality)•↓ Chemoreceptor/mechanoreceptor sensitivity → diminished physiologic response to

hypoxia/hypercapnia

• Breathing • Assessment: effort/ fatigue/chest wall bruising/crepitus

• Early supplemental 02 administration

• Lower threshold to take airway

• NIPPV (COPD)

• Assess effectiveness of BVM

• Assess need for Medication Assisted/ RSI Intubationconsider need to intubate for agitation/ combativeness

• Common - reflux – have suction ready

Interventions

• Peri-intubation Hypotension & Hypoxemia → Cardiovascular Collapse  Optimize: 

Apneic Oxygenation NIV techniquesIV Fluid loading (consideration of comorbidities E.G. right heart failure) Hemorrhagic Shock – RBCsVasopressor use early utilizationPush dose epinephrine vs vasopressor infusion 

• IntubationApneic Oxygenation – preoxygenation can be difficult with BVM due to facial structure and age-related muscle mass changes Consider laryngeal mask airway/supraglottic airwayFriable tissue / structures Cervical bony structures / osteoporosis Caution: intrinsic high airway pressures Consider DSI vs. RSI May have to intubate due to uncooperative patient Keep HOB elevated, if possible

Intubation

Circulatory

• Hear Rate present? Tachycardic vs Bradycardic?

•heart rate accurate indicator of shock?

• Medications → blunt sympathetic response → ↓ HR

• Elderly heart - ↓ catecholamine sensitivity

CIRCULATORY

•Early & Aggressive resuscitation with isotonic fluids/ blood

• REASSESS after IVF bolus/ bloodSkin perfusionBP (MAP)Lung Sounds – crackles

• Consider pre-existing Co-morbidities:Heart DiseaseHeart Failure Renal Dysfunction

• Permissive hypotension – studies indicate that the elderly population may be particularly prone to complications resulting from fluid overload, e.g. ARDS

• Definition of permissive hypotension not clearly established in this population

HEMORRHAGE

• Assessment of early clinical indicators of SHOCK delayed Capillary Refill Time cool skinearly mottling

• Vital signs (BP and HR) can be unreliable indicators

• Hypoperfusion can exist in the normotensive elderly patient

• Consider mechanism and assess for:a. Overt shock (external exsanguination)b. Occult Shock (chest, pelvic, extremity trauma)

Note: Ultrasound is a vital tool to assess for shock in the elderly! Even with normal range VS !

▪ Baseline Hypertension common → False sense of security. Small incremental changes in BP/ MAP can be indicative of shock

▪ Trend vital signs frequently / every 5’ in the Acute PhaseReassess post intervention and baseline VS

▪ Medications → inhibit physiologic response e.g. ß blockers can inhibit tachycardia resulting from hemorrhagic shock elderly patients have ↓catecholamine response, further blunting stressor response

• Thorough and repeated circulatory assessment for subtle changes in perfusion/shock indictors Mental status changes (mild confusion, somnolence, agitation)Delayed CRT (central and peripheral)

Circulation: Assessment Application

DISABILITY

• Can be challenging especially without presence of primary care giver or family presenceWhat is the baseline?Important to attempt to obtain baseline cognitive statusExam difficult with presence of cognitive / behavioral changes

• GCS can be less accurate – severe intracranial injury can be present with relatively normal GCSGCS < 9 approx. 80% risk of death or major disability

• Can suffer severe intracranial injury (subdural [acute on chronic]) without demonstration of neurological deficits

PRIMARY ASSESSMENT PEARLS! Intervene Early!

• Vital Sign trends

•Consider supplemental oxygen EARLY!!!!

• Consider airway adjuncts – patency

• Assess:Fatigue/ Significant airway or pulmonary involvement

• BVM • Caution – risk of pulmonary barotrauma• PEEP effect on cardiovascular status • Monitor ETC02

Secondary Assessment Elderly Trauma Patient

Expose / Fahrenheit

•Focus on potential injuries that are not obvious

• Expose all body surfaces

• Maintain thermoregulation

• Pain decreased pain perception → increased risk of missing occult  injuriesChanges in MS (Frequent assessment throughout primary and secondary assessments)Respiratory changes Trending of VSworsening symptoms

PNEUMONIC: SAMPLE

Vital to obtain information ASAP

Especially baseline cognitive status

Medications

Last seen normal

Immunization StatusCommunity and Nursing Home acquired pneumoniasInfluenza

Get Full Vital Signs & HISTORY

• Head TBIStroke (Primary event to trauma)Intracranial bleedCraniofacial injuries

• Cervical SpineRestricted motion can be caused by underlying age-related changes/trauma

• T-L-S SpineAssess for step-offsPenetrating TraumaSurface Trauma – ecchymosis/ bleeding

• Rib / Clavicle FracturesCan impede respiratory effort → impaired oxygenation/ ventilation

Injuries detected during Secondary Survey Systematic Cephalocaudal Assessment

•Chest≤ 3 rib fractures – severe injuryRib Fractures most common → pneumonia/VAP/↑ mortalitypneumonia/pulmonary contusions/respiratory failure

• Abdominal Traumalaxity of abdominal wall muscles diminished pain sensation

• Ultrasound – POC diagnosis and intervention

Musculoskeletal Injuries Pelvis / Hips/ Extremities

Most Common injury in geriatric population & can be associated with ↑ morbidity & mortality

•Pelvislateral compression fractures commonMinor Trauma – pubic rami, sacral ala fractures

• Hip FracturesOccur with low level/ low impact MOI High suspicion of injury/ bleeding

•Skeletal InjuriesCommon Sites:

distal radius/ ulnaproximal humerusclavicular

Associated with decreased mobility/ ability to participate in ADLs → increased mortality

•DermalThinner more fragile skin- skin tears & infectionPad bony protrusions and backboards

•Pelvic Injury assume unstable until proven otherwise – high risk of bleeding

•Interventions: Mitigate hemorrhage Pelvic binderHemorrhage protocols

•Skeletal InjuriesAssess CSM

consider baseline post intervention → immobilization/ splintingHematoma → document margins and time

Interventions: Skeletal Injures

Pain Control•Observational Studies indicate elderly patients do not receive adequate pain control secondary toDecreased sensory capacity

•Pain TreatmentOpioidsFentanyl - 25 mcg-100 mcg IV

effective pain controlRapid onsetShort durationless likely to cause histamine release which can cause hypotension

NSAIDs Avoid → risk for impaired renal function and GI complications

General Dosing Guidelines•consider smaller doses followed by titration(30-50% dose reduction)

•Physiologic Response: ↓ renal and liver function and lower % body fat

PEARLS Elderly Trauma Patient

1. Vital Signs • Data trending is more indicative and should be done frequently – every 5” acute phase• Blood Pressure

“Normal BP” → Actual hypotension in elderly

2. Collaborate with destination hospitals to develop/ revise existing trauma protocols

3. Consider transport to major trauma designated hospitals: studies support better outcomes

4. Standardized patient care hand-off forms important for ongoing assessment regardinglongitudinal care comparisons

5. SAMPLE is vital to the accurate assessment and ongoing care of the elderly patient

6. ELDER ABUSE Assess for potential Does the story/ MOI fit the environmental scene and injuries ?

References

Geriatric trauma: Initial evaluation and treatment. Retrieved from: https://www.uptodate.com/contents/geriatric-trauma-initial-evaluation-and-management?search=elderly%20trauma&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Geriatric Trauma Guideline University of Minnesota Medical CenterRetrieved from: https://mail.google.com/mail/u/0/#search/MHirt%40remsa-cf.com/FMfcgxwDrbsZnNJBJpcgkjTstqssmnvV?projector=1&messagePartId=0.2

Vital signs in older patients: Age – related changes. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3102151/