Primary Survey


Using a systematic approach to trauma management remains the same in the elderly population. Comprehensive reviews are expected of the elderly patient and tertiary examinations can often be quite revealing- hence do them early and carefully.


Airway with cervical spine protection


 

Establishing and maintaining a patent airway to provide adequate oxygenation is the first objective.
Maintenance of an adequate airway can be complicated in the older patient due to dentition, tempero-mandibular joint arthiritis, nasopharyngeal fragility, macroglossia (enlargement of tongue) and microstomia (small oral aperture).

Assess for stability

  • Attempt to elicit a response from the patient.
  • Look for signs of airway obstruction (use of accessory muscles, paradoxical chest movements and see-saw respirations).
  • Incomplete, ill-fitting or broken dentures may need to be removed.Well fitted full dentures may be beneficial left in place until definitive airway control is achieved.

Attempt simple airway manoeuvres if required

  • Open the airway using a chin lift, jaw thrust and neck tilt. (Do not apply a neck tilt if a spinal injury suspected.)
  • Suction the airway if excessive secretions are noted or if the patient is unable to clear it themselves. Older patients may have a diminished cough and gag as well as hypertrophied mucous glands.
  • Care must be taken when placing an oropharyngeal airway (OPA)/nasopharyngeal airway (NPA) due to the nasopharyngeal friability of the older patient. 1
 
Secure the airway if necessary (treat airway obstruction as a medical emergency).
If intubation is necessary it should be performed by a clinician experienced in airway management due to the increased difficulty from the effects of arthritis.

Consider intubation early if any of the following apply

  • Ongoing airway obstruction is present despite OPA.
  • Adequate ventilation using a bag valve mask is not possible.
  • An inhalation injury.
  • Neurologically flaccid, decerebrate/decorticate posturing.
  • A requirement for definitive airway protection.
  • Altered level of consciousness, unresponsive to pain OR GCS < 8.
  • Evidence of decompensation/ respiratory distress requiring invasive ventilation/chest wall injury.
Decrease in pulmonary reserves may impact on the timing of intubation.
Prior to attempting intubation, always have a plan for managing a difficult airway or failed intubation. Alternate adjuncts should be checked and prepared to accommodate the challenging airway.
 
Maintain full spinal precautions if indicated
Elderly patients are twice as likely to have a spinal cord injury (SCI) as a younger person with the same mechanism of injury. Degenerative changes and stiffening of the lower cervical spine make higher (C1-C2 and odontoid) fractures likely.5
  • Maintain full spinal precautions if indicated. Remember that an arthritic cervical spine increases the risk for injury.
  • It may be necessary to place a towel or elevation device under the patients’ neck to maintain neutral alignment in the kyphotic elderly patient.9

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Breathing and ventilation


 

The elderly patient has a decreased respiratory reserve and an increase in chronic disease. The combination of fragile tissues and degenerative changes make this patient group less tolerant of pulmonary injuries with associated increased mortality. 10% of elderly trauma patients have rib fractures, and up to 50% of fractures in this group are undetected on x-ray. Those over the age of 65 with rib fractures have an increased mortality.10
 

Record the oxygen saturation (SpO2)

  • Administer high-flow oxygen to maintain oxygen saturations between 94-98% in the initial resuscitation period.
  • When managing patients who may be CO2 retainers the priority remains with maintaining oxygenation in the initial resuscitation period. This risk for hypoventilation as a result must be accepted and if it occurs intubation and mechanical ventilation may be necessary.

Assess the chest

  • Measure the respiratory rate and work of breathing.
  • Observe the chest movement, work of breathing including use of accessory muscles.
  • Auscultate the chest for air entry/ breath sounds. This will assist in the identification of thoracic injuries but also identify co-morbidities that may impact on management.
  • If breathing is inadequate first clinically exclude a tension pneumothorax by identification of the following:
  • Hypoxia.
  • Severe respiratory distress.
  • Shift in mediastinum or trachea to contralateral side.
  • Distended neck veins.
  • Absent or decreased breath sounds.
  • Hyper-resonance to percussion.
  • Tachycardia with peripheral vasoconstriction and in hypotensive shock.

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Circulation with haemorrhage control


 

The older person responds more slowly to insults in their cardiovascular system and finds it difficult to generate an adequate response. Normal blood pressure and normal heart rate may not indicate normovolaemia. It is important to consider other signs of poor perfusion while assessing the older trauma patient.

Assess circulation and perfusion

  • Check the heart rate, blood pressure and neck veins. A BP which appears to fall in the normal range may in fact be relative hypotension if the patient is normally hypertensive.
  • Inspect for any signs of haemorrhage and apply direct pressure to any external wounds. Consider the potential for significant internal bleeding related to mechanism of injury, which may lead to signs and symptoms of shock. Anticoagulants are common medications for the elderly. This must be considered early and appropriate tests conducted if available.
  • Insert two large-bore peripheral intravenous (IV) cannulas.
  • As the IV is inserted take blood for glucose, full blood exam, cross-match, urea electrolytes and creatinine, lipase, liver function tests, lactate and blood gas if available. Troponin should also be performed if any signs of chest trauma.
  • If intravenous access is difficult, obtain intraosseous access. Bone marrow aspirated from the IO can be used to X match blood and test BSL. Inform the laboratory that the specimen is taken from an IO. All medications and blood products can be safely administered through the IO line. Monitor IO continuously for signs of subcutaneous extravasation of fluids (“tissuing”) or failure of any kind. If this occurs, cease IO fluid administration and assess for compartment syndrome.
  • Asses for other signs of shock such as colour, warmth, capillary refill, conscious state and urine output. Consider a low or high respiration rate or deteriorating mental state as a marker of inadequate circulation.
  • Attach monitoring to assist in the early identification of deterioration and frequently assess.
  • If the older patient is demonstrating signs of shock then administer 20mls/kg of isotonic crystalloid fluid. Monitor the patient’s physiological response. Volume resuscitation may result in clinical oedema due to pre-existing cardiac conditions Take caution with the elderly, normally hypertensive patient on diuretics.

If necessary, perform a FAST scan

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 an intra-abdominal injury.
Elderly patients can be at risk of haemorrhage from even small pelvic or hip fractures. If the patient is hemodynamically stable and there are no signs of significant internal bleeding then it may be delayed until the secondary survey. 11
 

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Disability: neurological status


 

With the decreased brain mass elderly patients have a higher incidence of subdural and intraparenchymal haematoma. CT scanning can be a useful examination method and liberal use in the elderly patient may be beneficial, particularly if they are also on anticoagulant medication.5
Changes with age such as visual and auditory decline, as well as decreased cognition due to Alzheimer’s / underlying dementia can make assessing the GCS in the elderly patient difficult.

Assess level of consciousness

  • Perform an initial AVPU assessment (Alert, responds to Voice, responds to Pain, Unresponsive); check the pupillary response.
  • Test blood sugar levels.
  • Ensure that any alterations in level of consciousness are not related to a metabolic cause. Co-morbidities associated with the older patient place them at greater risk for abnormalities both causing and complicating management.

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Exposure/Environmental Control


 

  • Remove all clothing from the patient and assess to ensure there are no other obvious, life-threatening injuries present. A log roll can be considered at this stage or be left until the secondary survey.
  • Hypothermia can be detrimental in any trauma patients. Older patients are particularly at risk of loss of thermal regulation due to a decrease in dermal thickness and loss of vascularity. They have impaired ability to increase heat production and decrease heat loss by vasoconstriction.5
  • Patient temperature should be monitored repeatedly via tympanic or axillary methods. Continuous monitoring via, oral, nasopharyngeal or rectal routes may be beneficial if available.Beware of thermometers that do not read below 35 degrees.
  • Keep the patient normothermic by means of external warming, passive re-warming with blankets and a warm environment.  If available, the use of a forced air-warming machine is recommended.
  • Maintain modesty where possible (cover with sheet etc.).
  • In the elderly trauma patient skin is sensitive and pressure areas can evolve rapidly. Ensure regular pressure area care is attended to, especially where transfer may be prolonged.

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