Geriatric Trauma: A Case Study Eider-specific interventions could improve outcome for the elderly trauma patient. By
CAROL
ANN
MITCIIELL/KATIILEEN
GALLO/CATtlERINE
lders in America constitute the fastest-growing segment of the population. They currently represent 11% to 12% of society, and by the year 2025 this proportion is expected to increase to approximately 25%. Trauma is the fifth leading cause of death in the elderly, who account for 25% of yearly trauma fatalities. For those under 65 years of age, mortality rates from trauma range from 4% to 8%. This vast discrepancy in survival cannot be explained by age alone. The geriatric trauma patient is different, and health care providers must be knowledgeable about how elderly patients differ from younger adult patients so that safe, competent care can be given. Older trauma patients present a complex challenge to the trauma team because "old age is in and of itself a physiologic alteration that makes the elderly patient less able to respond to the stress of injury. 'q Physiologic reserves decline consistently from the age of 30 years; the cardiac, pulmonary, and renal reserve capacities and the homeostatic mechanisms are especially compromised. 2 Elders are more susceptible to cardiogenic shock and cardiac rupture and experience arrhythmias more frequently than do younger trauma victims. 3 Also, arrhythmias are more difficult to treat, thus compromising the blood supply of organs already compromised by age, disease, or trauma. Further, decreased hepatic and renal function increases the potential for drug toxicosis and electrolyte imbalances. Elders are less likely to be able to mount adequate metabolic responses because they frequently do not have sufficient nutritional reserves and usually have decreased total body fluid levels, 1 which often lead to loss of nitrogen needed for protein synthesis and to dehydration. Elders are also more prone to deep-
TURNES
E
CAROL ANN MITCHELL, EdD, RNC, is professorand chair in the Department of Adult Health Nursing, SUNY at Stony Brook, New York. KATttLEEN GALLO, MS, RN, CCRN, CEN, is a clinical assistant professor,and CATHERINE TURNES, BS, RN, CCRN, is a master's degree candidate at the same institution. 34/1/38034
210 Geriatric Nursing July/August 1992
vein thrombosis, especially if the femur is fractured. According to Rothbaum (1982), prolonged bed rest after trauma leaves the elder at higher risk for atelectasis, pulmonary embolism, and social isolation compounded by paradoxic effects of medications. The latter two often manifest themselves as acute confusional states or psychosis. Falls, resulting in hip and skull fractures, are frequently the consequence of confusional states. In addition, herpes zoster may occur (with a 50% chance in the group over 85 years) after trauma. The herpesvirus is reactivated as an acute viral infection by trauma and a less effective immune system, 3 adding another complication to an already complex situation. Present chronic illnesses and other comorbid factors further complicate assessment and management. 4 Specifically, elders suffer disproportionately from functional disabilities: physical, cognitive, emotional, social, and economic. These disabilities are not the result of disease or trauma hut rather are a consequence of treatment, or lack thereof, s that is based on the myth that most elders' functional decline is just normal aging. 6 Had activities been initiated to preserve or minimize loss of function or had an accurate history of functional ability been obtained before the trauma event, disabilities and expenditures for trauma care for the elderly would be considerably less. Ross et al., 7 studying the cost of elder care,
found that elderly trauma victims had an average hospital stay of 4 days longer, an average hospital charge that is more than double, and a mortality rate greater than that of younger victims. Further, a major and expensive difference was that most elders did not regain their independence; their functional disabilities required institutionalization or considerable assistance at home. Unfortunately, the age of a trauma victim may affect the speed and type of trauma management because younger members of the trauma team may assume that the older person does not have a chance at survival. Without an accurate history one does not know whether the elder was a marathon runner, in better condition than most young Americans, or severely disabled. Many do survive but with serious functional losses resulting from a lack of focused interventions necessary for maintaining or restoring functional abilities, not resulting from the traumatic event. Although elders may have disproportionately greater risks for experiencing multiple stressors simultaneously, they also have well-developed coping resources that can be drawn on to sustain and restore them to the same or nearly the same level of function) The goals of trauma treatment for the elderly victim are essentially the same as those for the younger victim; however, the elderly require a different approach to assessment and management. The goals include stabilization, preservation of remaining tissue, and conservation of structural and cognitive integrity as well as energy to preserve mental, social, physical, and economic function. The following case study illustrates definitive trauma care through the trimodal peaks of trauma morbidity and death (1) in the field, (2) in the emergency department, and (3) during the recovery and rehabilitation period for a 67-year-old woman involved in a motor vehicle accident.
TRIMODAL TRAUMA PEAKS FOR MORBIDITY AND MORTALITY • First p e a k - - F i r s t hour: the " g o l d e n h o u r " • Second p e a k - - N e x t 2 hours • Third peak--Days to weeks
The T r a u m a Event First Peak, Wednesday, 18:15 to 19:15: Field Treatment. A 67-year-old white woman was driving a fourwheel-drive vehicle at approximately 35 mph in a rural area when her vehicle was struck on the passenger side by a truck traveling at a speed of 45 mph. The collision staved in the passenger side approximately 24 inches. Compartmental intrusion of 18 inches on the driver's side of the car or 24 inches on the opposite side is evidence of high impact. 8 The patient's vehicle flipped over three times, crushing the roof and driver's side. The time was 18:15. The emergency medical service system (EMS) was activated via citizen's band radio and the team arrived at 18:30. The driver and another occupant were found in the car with three-point restraints intact.
Fifteen minutes of the "golden hour" had elapsed, the time during which the first of three peaks for morbidity and death occur. A patient's resuscitation must be completed and definitive care initiated within the first 60 minutes after injury.9 During this golden hour establishing an airway, ventilating the lungs, stabilizing the cervical spine, controlling hemorrhage, and starting fluid resuscitation have the highest priority. The "jaws of life" were used to extricate the victim from the vehicle. A primary survey (i.e., airway, breathing, circulation, and a brief neurologic assessment) was conducted by the EMS crew. Cervical spine precautions were maintained with a Philadelphia collar. Research suggests, however, that optimal cervical neck immobility is obtained by bracing the head with sandbags and then taping across the forehead and over the sandbags, attaching them tb the backboard. This technique is far superior to the cervical hard collar, l° Johnston ll notes that a third of all cervical injuries are not detected at this point and that older people are more susceptible to cervical spine injuries because of degenerative changes. The patient's vital signs were blood pressure of 88/50 mm Hg, pulse of 110 beats/min, and shallow and labored respirations of 36/min. A nasal airway was inserted and supplemental oxygen administered with a 100% nonrebreather appliance. She was placed on a long board, and rapid fluid resuscitation was started with Ringer's lactate delivered via a large-bore catheter. She was placed in military antishock trousers (MAST), which were inflated. The use of MAST on patients with suspected head injuries and blunt chest trauma is controversial because they produce increased intrathoracic and intracranial pressure. 12 Elders do not have the cardiac reserve, as do younger patients, to sustain volume deficits. The cardiovascular system is unable to respond adequately to the onset of a major stressor. Therefore fluid volume deficits resulting from bleeding, third-space fluid shifts, and hypovolemia must be treated within minutes) 3 In addition, chronic hypovolemia is frequently found in the elderly because of commonly occurring disease states such as malnutrition, chronic infection, malignancies of the gastrointestinal tract, and metastatic disease. Thus the elderly trauma victim needs to be monitored closely) 4 A secondary survey revealed that the right eye was laterally displaced and the inferior orbital and maxillary bones were depressed. The right clavicle was fractured, a common occurrence resulting from the force of the threepoint seat belt restraint. Crepitus was heard along the right side of the chest with decreased breath sounds, suggesting fractured ribs. Simple fractures in elders pose special problems because preexisting lung disease or agerelated changes such as decreased residual capacity and decreased tidal volume are likely), 15 Multiple head, trunk, and extremity contusions and abrasions were found also. At 18:50, while the EMS crew was preparing her for transfer to the nearest level I trauma center, the patient went into cardiopulmonary arrest. Advanced cardiac life support was initiated and the patient responded well. Once stabilized, she was airlifted to the level I trauma Geriatric Nursing July/August 1992 211
center. Ideally, the patient who has sustained multiple trauma should be delivered to a facility where resources are matched to the patient's needs. Highly trained trauma experts are necessary for the care of the severely injured and for elders less severely or moderately injured, l A facility that has the capabilities matching the patient's needs will have a greater chance at decreasing morbidity and mortality.16 Second Peak, 19:15 to 19:50: Emergency Department. On arrival at the emergency department the patient was triaged to the trauma room. Her blood pressure was 90/56 mm Hg, and the cardiac monitor revealed sinus tachycardia at 120 beats/min. The Glasgow Coma Scale score was 8/15 and the trauma score was 9/16. Eight points or less on the Glasgow Coma Scale indicates severe head injury or coma; the lower the trauma score, the higher the mortality rate. 12, 17 She continued to be ventilated manually. One nurse conducted a rapid primary survey while another prepared for a central line insertion by the trauma physician. Blood samples for routine analysis and arterial blood gas analysis were drawn. Ideally, the geriatric trauma patient should undergo invasive hemodynamie monitoring and optimization as early as possible to identify possible and probable hypoperfusion states (a common but often missed problem). 18 A Foley catheter was inserted after the urinary meatus was found to be unremarkable for blood. The small amount of dark-amber urine obtained was positive for microscopic blood. Lower cervical spine palpation elicited a positive pain response. Deformity was noted along the right lateral side of the chest. The abdomen and pelvis could not be assessed with the MAST in place. The left wrist was splinted for obvious deformity and shortly thereafter casted for a Colles' fracture. The patient was logrolled to complete the secondary survey. Posterior visual inspection of the head, trunk, and extremities revealed multiple contusions and abrasions. Histories of comorbid factors and functional status could not be obtained immediately because family members were not available. The patient received tetanus toxold intramuscularly and 1 gm cefazolin sodium intravenously. Other emergency diagnostic studies were initiated. Cross-table lateral cervical spine films revealed a nondisplaced fracture of C5 on C6. Chest, abdomen, and pelvis films were obtained. The chest x-ray film revealed right rib fractures of 3, 4, 5, 6, 7, 8, and 9, with a hemopneumothorax. The abdominal film revealed free air. A 36F chest tube was inserted and 500 ml fresh unclotted blood was obtained. The patient continued to be hypotensire (blood pressure of 80/40 mm Hg) despite fluid replacement. The abdominal compartment of the MAST was slowly deflated and a deep peritoneal lavage was performed. The return was positive. Peritoneal lavage is a relative contraindication in elders because a higher proportion of such patients have undergone one or more abdominal operative procedures. 14 The patient was transferred immediately to the operating room for an exploratory laparotomy. Findings from this procedure revealed a grade III liver laceration. 19 Third Peak, 19:50 to Discharge. The patient was transferred to the postanesthesia care unit where she remained 212 Geriatric Nursing July/August 1992
for 24 hours. During that time, a computed tomographic scan was obtained to evaluate possible head injuries. The scan was remarkable for a small area of parenchymal bleeding in the right temporal region. Administration of intravenous corticosteroids and mannitol was initiated. The patient responded with an increased level of consciousness.
Simple fractures in elders may pose special problems because of preexisting lung disease or age-related changes such as residual capacity and decreased tidal volume. The cardiac monitor showed intermittent premature ventricular complexes. Cardiac enzymes were elevated (creatine phosphokinase of 808 [normal range, 0 to 225] and lactate dehydrogenase of 777 [normal range, 60 to 220]), suggesting a cardiac contusion. Three sets of elevated enzyme measurements are needed for a positive diagnosis. Blunt injury, such as a chest contusion, poses special problems because myocardial and pulmonary contusions may not cause symptoms to appear until days or weeks later. 2° Other factors complicating assessment, treatment, and recovery from chest contusion include premorbid lung and cardiac disease, body weight, and age-related changes that make the elderly more fragile. The patient was treated with a bolus of lidocaine, 75 mg pushed intravenously, and a continuous drip of lidocaine, 4 gm/500 ml 5% dextrose in water, at a rate of 2 mg/min. She was transferred to the surgical intensive care unit where she remained for the next 4 days. These 4 days were clinically uneventful except for the patient's increasing agitation. After hypoxia and expanding cerebral lesions were ruled out, the medical team solicited the patient's family for any comorbid factors that could cause the agitation. The daughters revealed that their mother was a social drinker with possible alcoholism. A diagnosis of delirium tremens was made. Alcohol dependence is frequently overlooked in the elderly, especially elderly women. Alcohol complicates head injury by further increasing the permeability of the blood-brain barrier, which not only affects intracranial pressure but increases contact with leukocytes. This increased contact stimulates an immune response and decreases protection against viruses and other blood-borne substances. 21 Another factor to consider in the elderly victim of head injury is the potential for increased risk of dementia from severe head injury. Interventions to manage the patient's delirium tremens included careful fluid monitoring to prevent dehydration and nutritional monitoring. Physical and nonchemical restraints were used occasionally to prevent injury; family members' presence calmed her, which helped control ar-
rhythmias and decrease intracranial pressure. 22 Pharmacologic interventions included multivitamins, especially thiamine and minerals, and barbiturates to decrease agitation and potential for seizures. She was successfully extubated on day 5 and was tolerating sitting in a chair for short periods of time. The Philadelphia collar was changed to a sternal-occipitalmandibular immobilization (SOMI) brace. The head and neck are stabilized with braces to the suboccipital and mandibular regions, and extra immobilization is provided by fabric touch fastener straps that encircle the head superior to the occiput and across the forehead. She was transferred to a medical-surgical unit on day 6.
Alcohol dependence is {requently overlooked in the elderly, especially elderly women. During the critical and intermediate care phases, many of the interventions initiated in resuscitation were continued. Fluids were carefully monitored to avoid overloading the damaged heart and lungs and to reduce chances for development of adult respiratory distress syndrome. Mild analgesia was used to control her pain and provide comfort, thus reducing metabolic requirements. In addition, other interventions were intensified to reduce physiologic losses. These included measures to maintain skin integrity, nutritional stability, and musculoskeletal function. Calf and thigh measurements were obtained daily to monitor for thromboembolism. Cognitive retraining was instituted to elicit behavioral responses that anchored her to her family and her life. Carefully controlled stimuli were introduced to improve sensory function. These included calling her name, orienting her to place and time, and playing her favorite music. Her family brought pictures to the hospital and told her stories to stimulate recall. These strategies have been found to affect outcomes positively for head-injured patients. 23 Rehabilitation for this patient was focused primarily on prevention of functional loss and complications, maintenance of remaining functional abilities, and restoration to as full a cognitive, personality, and preevent functional status as possible. Typically patients who have suffered head trauma may experience cognitive, motor, sensory, and personality alterations for a brief time or for the remainder of their lives. This patient had cognitive and personality changes. She had concentration difficulties, a shortening attention span, short-term memory deficits, agitation, disinhibition, fear, anxiety, and, at times, socially inappropriate behavior. The nurses and her daughters developed a plan of care used in the hospital and the home to reintegrate her into her own world with confidence. This care plan was invaluable during home care as other family members and community nurses became involved in her care. She gradually began to answer the telephone, receive visitors, assume her own care, and direct others in the care and application of the SOMI brace, as well as her activities of daily living. She eventually participated in counseling for alcohol abuse.
Today, she manages her own home and land again, drives, and has come to accept some of her cognitive and personality changes. She thinks it is great to be alive, just as most older people do. Summary Major advances in health care have made it possible for a greater number of people to live to advanced age and thereby be exposed to the same risk of injury as the younger segment of the population. Elderly trauma victims, however, possess unique needs that must be addressed. Comorbidity, the aging process, and its relationship to the response to injury, as well as ethical and moral dilemmas such as "do not resuscitate" decisions and cost of care, need to be investigated.24 Although advanced age clearly predisposes one to an increase in mortality, mortality has also been correlated with complications that develop during the hospital stay. Trauma, especially involving the elderly, is a rich area for nursing research, and a refined knowledge base contributes to improving the quality of trauma care. J REFERENCES I. Martin R, Teberian G. Multiple trauma and the elderly patient. Emerg Med Clin North Am 1990;8:411-20. 2. Medalie Jtt. An approach to common problems in the elderly. In: Calkins E, et al, ¢ds. The practice of geriatric medicine. Philadelphia: WB Saunders, 1986:47-59. 3. Matteson MA, McConnell ES. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988. 4. Kauder DR, Schwab CW. Comorbidity in geriatric patients. In: Maull KI, Cleveland HC, Strauch GO, Wolferth CC, eds. Advances in Trauma. 1990:5. 5. Warshaw GA. Functional disability in the hospitalized elderly. JAMA 1982;248:847-50. 6. Brody EM, Kleban MH. Day to day mental and physical health symptoms of older people: a report on health logs. J Am Geriatr Soe 1983;29:442-9. 7. Ross N, Timberlake G, Rubino I_J, Kerstein MD. High cost of trauma care in the elderly. South Med J 1989;82:857-9. 8. American College ofSurgcons, Task ForceoftheCommitteeonTrauma.Optimal hospital resources for the care of the injured patient. Bulletin American College of Surgeons 1986;71:10. 9. Whitehorne M, Cacciola R, Quinn ME. Multiple trauma: survival after the golden hour. Journal of Advanced Medical-Surgical Nursing 1989;2:27-39. 10. Adelstein Wo Watson P. Cervical spine injuries. J Neurosurg Nurs 1983;15:65-71. I 1. Johnston RA. Management of old people with neck trauma. BMJ 1989;299: 12. Cardona V, Hum PD, Mason PB, Scanlon-Schilpp AM, Veise-Berry SW. Trauma nursing: from resuscitation through rehabilitation. Philadelphia: WB Saunders, 1988. i 3. Sommers M. Rapid fluid resuscitation: how to correct dangerous deficits. Nursing 90 1990;54-9. 14. Demarest GB. Geriatric trauma. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. Norwalk, Connecticut: Appleton & Lange, 1988:645-59. 15. Respiratory emergencies. Helping patients with rib or sternum fractures. Nursing Now Series. Nursing 87 1987;Oct:32c-h. 16. Trunkey DD. Trauma. Sci Am 1983;249:28-35. 17. Ingersoll G, Leyden D. The Glasgow coma scale for patients with head injuries. Crit Care Nurse 1987;7:6-32. 18. Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990;30:!29-36. 19. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR. Organ injury scaling: spleen, liver and kidney. J Trauma 1989;29:1664-6. 20. May C. Respiratory emergencies: what you should know about chest contusion. Nursing Now Series. Nursing 87 1987;Sept:32R-T. 21. Graves AB, White E, KoopsellTD, Reifler BV, Van Belle G, Larson ER, Raskind M. The association between head trauma and Alzheimer's disease. Am J Epidemiol 1990;131:491-501. 22. Hendrickson SL. lntraeranial pressure changes and family presence. J Neurosci Nurs 1987;19:14-7. 23. Kate K. Response of head-injured patients to sensory stimulation. West J Nurs Res 1989;11:20-33. 24. Mitchell CA, Shurpin K, GaUo K. Trauma nursing research: the state of the art revisited. Journal of Advanced Medical-Surgical Nursing 1989;2:65-72.
Geriatric Nursing July/August 1992 213
CAROL
ANN
MITCIIELL/KATIILEEN
GALLO/CATtlERINE
lders in America constitute the fastest-growing segment of the population. They currently represent 11% to 12% of society, and by the year 2025 this proportion is expected to increase to approximately 25%. Trauma is the fifth leading cause of death in the elderly, who account for 25% of yearly trauma fatalities. For those under 65 years of age, mortality rates from trauma range from 4% to 8%. This vast discrepancy in survival cannot be explained by age alone. The geriatric trauma patient is different, and health care providers must be knowledgeable about how elderly patients differ from younger adult patients so that safe, competent care can be given. Older trauma patients present a complex challenge to the trauma team because "old age is in and of itself a physiologic alteration that makes the elderly patient less able to respond to the stress of injury. 'q Physiologic reserves decline consistently from the age of 30 years; the cardiac, pulmonary, and renal reserve capacities and the homeostatic mechanisms are especially compromised. 2 Elders are more susceptible to cardiogenic shock and cardiac rupture and experience arrhythmias more frequently than do younger trauma victims. 3 Also, arrhythmias are more difficult to treat, thus compromising the blood supply of organs already compromised by age, disease, or trauma. Further, decreased hepatic and renal function increases the potential for drug toxicosis and electrolyte imbalances. Elders are less likely to be able to mount adequate metabolic responses because they frequently do not have sufficient nutritional reserves and usually have decreased total body fluid levels, 1 which often lead to loss of nitrogen needed for protein synthesis and to dehydration. Elders are also more prone to deep-
TURNES
E
CAROL ANN MITCHELL, EdD, RNC, is professorand chair in the Department of Adult Health Nursing, SUNY at Stony Brook, New York. KATttLEEN GALLO, MS, RN, CCRN, CEN, is a clinical assistant professor,and CATHERINE TURNES, BS, RN, CCRN, is a master's degree candidate at the same institution. 34/1/38034
210 Geriatric Nursing July/August 1992
vein thrombosis, especially if the femur is fractured. According to Rothbaum (1982), prolonged bed rest after trauma leaves the elder at higher risk for atelectasis, pulmonary embolism, and social isolation compounded by paradoxic effects of medications. The latter two often manifest themselves as acute confusional states or psychosis. Falls, resulting in hip and skull fractures, are frequently the consequence of confusional states. In addition, herpes zoster may occur (with a 50% chance in the group over 85 years) after trauma. The herpesvirus is reactivated as an acute viral infection by trauma and a less effective immune system, 3 adding another complication to an already complex situation. Present chronic illnesses and other comorbid factors further complicate assessment and management. 4 Specifically, elders suffer disproportionately from functional disabilities: physical, cognitive, emotional, social, and economic. These disabilities are not the result of disease or trauma hut rather are a consequence of treatment, or lack thereof, s that is based on the myth that most elders' functional decline is just normal aging. 6 Had activities been initiated to preserve or minimize loss of function or had an accurate history of functional ability been obtained before the trauma event, disabilities and expenditures for trauma care for the elderly would be considerably less. Ross et al., 7 studying the cost of elder care,
found that elderly trauma victims had an average hospital stay of 4 days longer, an average hospital charge that is more than double, and a mortality rate greater than that of younger victims. Further, a major and expensive difference was that most elders did not regain their independence; their functional disabilities required institutionalization or considerable assistance at home. Unfortunately, the age of a trauma victim may affect the speed and type of trauma management because younger members of the trauma team may assume that the older person does not have a chance at survival. Without an accurate history one does not know whether the elder was a marathon runner, in better condition than most young Americans, or severely disabled. Many do survive but with serious functional losses resulting from a lack of focused interventions necessary for maintaining or restoring functional abilities, not resulting from the traumatic event. Although elders may have disproportionately greater risks for experiencing multiple stressors simultaneously, they also have well-developed coping resources that can be drawn on to sustain and restore them to the same or nearly the same level of function) The goals of trauma treatment for the elderly victim are essentially the same as those for the younger victim; however, the elderly require a different approach to assessment and management. The goals include stabilization, preservation of remaining tissue, and conservation of structural and cognitive integrity as well as energy to preserve mental, social, physical, and economic function. The following case study illustrates definitive trauma care through the trimodal peaks of trauma morbidity and death (1) in the field, (2) in the emergency department, and (3) during the recovery and rehabilitation period for a 67-year-old woman involved in a motor vehicle accident.
TRIMODAL TRAUMA PEAKS FOR MORBIDITY AND MORTALITY • First p e a k - - F i r s t hour: the " g o l d e n h o u r " • Second p e a k - - N e x t 2 hours • Third peak--Days to weeks
The T r a u m a Event First Peak, Wednesday, 18:15 to 19:15: Field Treatment. A 67-year-old white woman was driving a fourwheel-drive vehicle at approximately 35 mph in a rural area when her vehicle was struck on the passenger side by a truck traveling at a speed of 45 mph. The collision staved in the passenger side approximately 24 inches. Compartmental intrusion of 18 inches on the driver's side of the car or 24 inches on the opposite side is evidence of high impact. 8 The patient's vehicle flipped over three times, crushing the roof and driver's side. The time was 18:15. The emergency medical service system (EMS) was activated via citizen's band radio and the team arrived at 18:30. The driver and another occupant were found in the car with three-point restraints intact.
Fifteen minutes of the "golden hour" had elapsed, the time during which the first of three peaks for morbidity and death occur. A patient's resuscitation must be completed and definitive care initiated within the first 60 minutes after injury.9 During this golden hour establishing an airway, ventilating the lungs, stabilizing the cervical spine, controlling hemorrhage, and starting fluid resuscitation have the highest priority. The "jaws of life" were used to extricate the victim from the vehicle. A primary survey (i.e., airway, breathing, circulation, and a brief neurologic assessment) was conducted by the EMS crew. Cervical spine precautions were maintained with a Philadelphia collar. Research suggests, however, that optimal cervical neck immobility is obtained by bracing the head with sandbags and then taping across the forehead and over the sandbags, attaching them tb the backboard. This technique is far superior to the cervical hard collar, l° Johnston ll notes that a third of all cervical injuries are not detected at this point and that older people are more susceptible to cervical spine injuries because of degenerative changes. The patient's vital signs were blood pressure of 88/50 mm Hg, pulse of 110 beats/min, and shallow and labored respirations of 36/min. A nasal airway was inserted and supplemental oxygen administered with a 100% nonrebreather appliance. She was placed on a long board, and rapid fluid resuscitation was started with Ringer's lactate delivered via a large-bore catheter. She was placed in military antishock trousers (MAST), which were inflated. The use of MAST on patients with suspected head injuries and blunt chest trauma is controversial because they produce increased intrathoracic and intracranial pressure. 12 Elders do not have the cardiac reserve, as do younger patients, to sustain volume deficits. The cardiovascular system is unable to respond adequately to the onset of a major stressor. Therefore fluid volume deficits resulting from bleeding, third-space fluid shifts, and hypovolemia must be treated within minutes) 3 In addition, chronic hypovolemia is frequently found in the elderly because of commonly occurring disease states such as malnutrition, chronic infection, malignancies of the gastrointestinal tract, and metastatic disease. Thus the elderly trauma victim needs to be monitored closely) 4 A secondary survey revealed that the right eye was laterally displaced and the inferior orbital and maxillary bones were depressed. The right clavicle was fractured, a common occurrence resulting from the force of the threepoint seat belt restraint. Crepitus was heard along the right side of the chest with decreased breath sounds, suggesting fractured ribs. Simple fractures in elders pose special problems because preexisting lung disease or agerelated changes such as decreased residual capacity and decreased tidal volume are likely), 15 Multiple head, trunk, and extremity contusions and abrasions were found also. At 18:50, while the EMS crew was preparing her for transfer to the nearest level I trauma center, the patient went into cardiopulmonary arrest. Advanced cardiac life support was initiated and the patient responded well. Once stabilized, she was airlifted to the level I trauma Geriatric Nursing July/August 1992 211
center. Ideally, the patient who has sustained multiple trauma should be delivered to a facility where resources are matched to the patient's needs. Highly trained trauma experts are necessary for the care of the severely injured and for elders less severely or moderately injured, l A facility that has the capabilities matching the patient's needs will have a greater chance at decreasing morbidity and mortality.16 Second Peak, 19:15 to 19:50: Emergency Department. On arrival at the emergency department the patient was triaged to the trauma room. Her blood pressure was 90/56 mm Hg, and the cardiac monitor revealed sinus tachycardia at 120 beats/min. The Glasgow Coma Scale score was 8/15 and the trauma score was 9/16. Eight points or less on the Glasgow Coma Scale indicates severe head injury or coma; the lower the trauma score, the higher the mortality rate. 12, 17 She continued to be ventilated manually. One nurse conducted a rapid primary survey while another prepared for a central line insertion by the trauma physician. Blood samples for routine analysis and arterial blood gas analysis were drawn. Ideally, the geriatric trauma patient should undergo invasive hemodynamie monitoring and optimization as early as possible to identify possible and probable hypoperfusion states (a common but often missed problem). 18 A Foley catheter was inserted after the urinary meatus was found to be unremarkable for blood. The small amount of dark-amber urine obtained was positive for microscopic blood. Lower cervical spine palpation elicited a positive pain response. Deformity was noted along the right lateral side of the chest. The abdomen and pelvis could not be assessed with the MAST in place. The left wrist was splinted for obvious deformity and shortly thereafter casted for a Colles' fracture. The patient was logrolled to complete the secondary survey. Posterior visual inspection of the head, trunk, and extremities revealed multiple contusions and abrasions. Histories of comorbid factors and functional status could not be obtained immediately because family members were not available. The patient received tetanus toxold intramuscularly and 1 gm cefazolin sodium intravenously. Other emergency diagnostic studies were initiated. Cross-table lateral cervical spine films revealed a nondisplaced fracture of C5 on C6. Chest, abdomen, and pelvis films were obtained. The chest x-ray film revealed right rib fractures of 3, 4, 5, 6, 7, 8, and 9, with a hemopneumothorax. The abdominal film revealed free air. A 36F chest tube was inserted and 500 ml fresh unclotted blood was obtained. The patient continued to be hypotensire (blood pressure of 80/40 mm Hg) despite fluid replacement. The abdominal compartment of the MAST was slowly deflated and a deep peritoneal lavage was performed. The return was positive. Peritoneal lavage is a relative contraindication in elders because a higher proportion of such patients have undergone one or more abdominal operative procedures. 14 The patient was transferred immediately to the operating room for an exploratory laparotomy. Findings from this procedure revealed a grade III liver laceration. 19 Third Peak, 19:50 to Discharge. The patient was transferred to the postanesthesia care unit where she remained 212 Geriatric Nursing July/August 1992
for 24 hours. During that time, a computed tomographic scan was obtained to evaluate possible head injuries. The scan was remarkable for a small area of parenchymal bleeding in the right temporal region. Administration of intravenous corticosteroids and mannitol was initiated. The patient responded with an increased level of consciousness.
Simple fractures in elders may pose special problems because of preexisting lung disease or age-related changes such as residual capacity and decreased tidal volume. The cardiac monitor showed intermittent premature ventricular complexes. Cardiac enzymes were elevated (creatine phosphokinase of 808 [normal range, 0 to 225] and lactate dehydrogenase of 777 [normal range, 60 to 220]), suggesting a cardiac contusion. Three sets of elevated enzyme measurements are needed for a positive diagnosis. Blunt injury, such as a chest contusion, poses special problems because myocardial and pulmonary contusions may not cause symptoms to appear until days or weeks later. 2° Other factors complicating assessment, treatment, and recovery from chest contusion include premorbid lung and cardiac disease, body weight, and age-related changes that make the elderly more fragile. The patient was treated with a bolus of lidocaine, 75 mg pushed intravenously, and a continuous drip of lidocaine, 4 gm/500 ml 5% dextrose in water, at a rate of 2 mg/min. She was transferred to the surgical intensive care unit where she remained for the next 4 days. These 4 days were clinically uneventful except for the patient's increasing agitation. After hypoxia and expanding cerebral lesions were ruled out, the medical team solicited the patient's family for any comorbid factors that could cause the agitation. The daughters revealed that their mother was a social drinker with possible alcoholism. A diagnosis of delirium tremens was made. Alcohol dependence is frequently overlooked in the elderly, especially elderly women. Alcohol complicates head injury by further increasing the permeability of the blood-brain barrier, which not only affects intracranial pressure but increases contact with leukocytes. This increased contact stimulates an immune response and decreases protection against viruses and other blood-borne substances. 21 Another factor to consider in the elderly victim of head injury is the potential for increased risk of dementia from severe head injury. Interventions to manage the patient's delirium tremens included careful fluid monitoring to prevent dehydration and nutritional monitoring. Physical and nonchemical restraints were used occasionally to prevent injury; family members' presence calmed her, which helped control ar-
rhythmias and decrease intracranial pressure. 22 Pharmacologic interventions included multivitamins, especially thiamine and minerals, and barbiturates to decrease agitation and potential for seizures. She was successfully extubated on day 5 and was tolerating sitting in a chair for short periods of time. The Philadelphia collar was changed to a sternal-occipitalmandibular immobilization (SOMI) brace. The head and neck are stabilized with braces to the suboccipital and mandibular regions, and extra immobilization is provided by fabric touch fastener straps that encircle the head superior to the occiput and across the forehead. She was transferred to a medical-surgical unit on day 6.
Alcohol dependence is {requently overlooked in the elderly, especially elderly women. During the critical and intermediate care phases, many of the interventions initiated in resuscitation were continued. Fluids were carefully monitored to avoid overloading the damaged heart and lungs and to reduce chances for development of adult respiratory distress syndrome. Mild analgesia was used to control her pain and provide comfort, thus reducing metabolic requirements. In addition, other interventions were intensified to reduce physiologic losses. These included measures to maintain skin integrity, nutritional stability, and musculoskeletal function. Calf and thigh measurements were obtained daily to monitor for thromboembolism. Cognitive retraining was instituted to elicit behavioral responses that anchored her to her family and her life. Carefully controlled stimuli were introduced to improve sensory function. These included calling her name, orienting her to place and time, and playing her favorite music. Her family brought pictures to the hospital and told her stories to stimulate recall. These strategies have been found to affect outcomes positively for head-injured patients. 23 Rehabilitation for this patient was focused primarily on prevention of functional loss and complications, maintenance of remaining functional abilities, and restoration to as full a cognitive, personality, and preevent functional status as possible. Typically patients who have suffered head trauma may experience cognitive, motor, sensory, and personality alterations for a brief time or for the remainder of their lives. This patient had cognitive and personality changes. She had concentration difficulties, a shortening attention span, short-term memory deficits, agitation, disinhibition, fear, anxiety, and, at times, socially inappropriate behavior. The nurses and her daughters developed a plan of care used in the hospital and the home to reintegrate her into her own world with confidence. This care plan was invaluable during home care as other family members and community nurses became involved in her care. She gradually began to answer the telephone, receive visitors, assume her own care, and direct others in the care and application of the SOMI brace, as well as her activities of daily living. She eventually participated in counseling for alcohol abuse.
Today, she manages her own home and land again, drives, and has come to accept some of her cognitive and personality changes. She thinks it is great to be alive, just as most older people do. Summary Major advances in health care have made it possible for a greater number of people to live to advanced age and thereby be exposed to the same risk of injury as the younger segment of the population. Elderly trauma victims, however, possess unique needs that must be addressed. Comorbidity, the aging process, and its relationship to the response to injury, as well as ethical and moral dilemmas such as "do not resuscitate" decisions and cost of care, need to be investigated.24 Although advanced age clearly predisposes one to an increase in mortality, mortality has also been correlated with complications that develop during the hospital stay. Trauma, especially involving the elderly, is a rich area for nursing research, and a refined knowledge base contributes to improving the quality of trauma care. J REFERENCES I. Martin R, Teberian G. Multiple trauma and the elderly patient. Emerg Med Clin North Am 1990;8:411-20. 2. Medalie Jtt. An approach to common problems in the elderly. In: Calkins E, et al, ¢ds. The practice of geriatric medicine. Philadelphia: WB Saunders, 1986:47-59. 3. Matteson MA, McConnell ES. Gerontological nursing: concepts and practice. Philadelphia: WB Saunders, 1988. 4. Kauder DR, Schwab CW. Comorbidity in geriatric patients. In: Maull KI, Cleveland HC, Strauch GO, Wolferth CC, eds. Advances in Trauma. 1990:5. 5. Warshaw GA. Functional disability in the hospitalized elderly. JAMA 1982;248:847-50. 6. Brody EM, Kleban MH. Day to day mental and physical health symptoms of older people: a report on health logs. J Am Geriatr Soe 1983;29:442-9. 7. Ross N, Timberlake G, Rubino I_J, Kerstein MD. High cost of trauma care in the elderly. South Med J 1989;82:857-9. 8. American College ofSurgcons, Task ForceoftheCommitteeonTrauma.Optimal hospital resources for the care of the injured patient. Bulletin American College of Surgeons 1986;71:10. 9. Whitehorne M, Cacciola R, Quinn ME. Multiple trauma: survival after the golden hour. Journal of Advanced Medical-Surgical Nursing 1989;2:27-39. 10. Adelstein Wo Watson P. Cervical spine injuries. J Neurosurg Nurs 1983;15:65-71. I 1. Johnston RA. Management of old people with neck trauma. BMJ 1989;299: 12. Cardona V, Hum PD, Mason PB, Scanlon-Schilpp AM, Veise-Berry SW. Trauma nursing: from resuscitation through rehabilitation. Philadelphia: WB Saunders, 1988. i 3. Sommers M. Rapid fluid resuscitation: how to correct dangerous deficits. Nursing 90 1990;54-9. 14. Demarest GB. Geriatric trauma. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. Norwalk, Connecticut: Appleton & Lange, 1988:645-59. 15. Respiratory emergencies. Helping patients with rib or sternum fractures. Nursing Now Series. Nursing 87 1987;Oct:32c-h. 16. Trunkey DD. Trauma. Sci Am 1983;249:28-35. 17. Ingersoll G, Leyden D. The Glasgow coma scale for patients with head injuries. Crit Care Nurse 1987;7:6-32. 18. Scalea TM, Simon HM, Duncan AO, et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990;30:!29-36. 19. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR. Organ injury scaling: spleen, liver and kidney. J Trauma 1989;29:1664-6. 20. May C. Respiratory emergencies: what you should know about chest contusion. Nursing Now Series. Nursing 87 1987;Sept:32R-T. 21. Graves AB, White E, KoopsellTD, Reifler BV, Van Belle G, Larson ER, Raskind M. The association between head trauma and Alzheimer's disease. Am J Epidemiol 1990;131:491-501. 22. Hendrickson SL. lntraeranial pressure changes and family presence. J Neurosci Nurs 1987;19:14-7. 23. Kate K. Response of head-injured patients to sensory stimulation. West J Nurs Res 1989;11:20-33. 24. Mitchell CA, Shurpin K, GaUo K. Trauma nursing research: the state of the art revisited. Journal of Advanced Medical-Surgical Nursing 1989;2:65-72.
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