Cervical spine, chest and pelvic x-rays may be performed as part of the early assessment of a major trauma patient, where available and the patient condition allows. Use of plain films should be liberal as long bones easily fracture and older patients do not always have the same sensation of pain relative to the injury.
Where an elderly patient has suffered a low fall with possible TBI and is taking OAC’s, a lower threshold for CT scanning should be adopted. Any patient who is on OAC’s is at high risk of developing a significant intracranial haemorrhage from even minor head injury mechanisms. CT imaging of the brain should be performed on all elderly patients with a history of head injury.
In multi-system trauma, consideration should be given to whole body CT scanning, especially where there is a distracting injury. If likely transfer to a MTS, decisions regarding timing of CT scanning should be discussed with ARV so as to avoid it being repeated. Careful consideration of the risks versus benefits may need to occur prior to contrast-enhanced radiological investigations.
Patients who are unable to comply with immobilisation for assessment and imaging should be reviewed early by a senior clinician who will consider the following:
Consider the need for FAST (Focused Assessment with Sonography in Trauma) if available and if staff are trained in its use. FAST is used primarily to detect pericardial and intraperitoneal blood, and it is more accurate than any physical examination finding for detecting intra-abdominal injury. FAST should be performed in all elderly patients with trauma from moderate to severe mechanisms.
An electrocardiogram should be completed on all elderly trauma patients to identify any preexisting abnormalities or whether the trauma was related to a cardiac event. Hypotension in the context of trauma may exacerbate the potential for cardiac / cerebral ischaemia - chest pain may in fact be an anterior infarct as opposed to related to the insult of injury.
Due to a decreased respiratory reserve, it is vital to optimise the elderly patients’ oxygenation. Elderly patients are more prone to complications of hospitalisation such as pneumonia, so methods should be implemented early on in the course of treatment to improve oxygenation and ventilation. The goal of treatment should focus on maintaining adequate oxygenation levels while considering baseline function. Encouraging deep breathing and coughing to avoid atelactic regions and adequate pain control.
Avoidance of hypovolaemia in trauma is a cornerstone of management. A balanced approach to fluid replacement is important, especially in establishing early treatment goals.17 Close monitoring and caution should be taken with the elderly patients with a history of CCF on diuretics.