Primary Survey


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


Airway

 

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, temporo-mandibular joint arthritis, 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.(17)
 
Secure the airway if necessary (treat airway obstruction as a medical emergency).
If intubation is necessary it should be performed by the most experienced clinician present.

Consider intubation early if any of the following apply:

  • Altered level of consciousness, unresponsive to pain OR GCS < 8.
  • Ongoing airway obstruction is present despite OPA.
  • Adequate ventilation using a bag valve mask is not possible.
  • Evidence of decompensation/ respiratory distress requiring invasive ventilation.
  • An inhalation 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.

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    Airway challenges and recommendations in the elderly patient: (17)
  • Loose teeth prone to breaking off - have McGill’s forceps available
  • Dry oral cavity prone to bleeding - use device with less force and consider lubrication
  • Limited epiglottis movement increasing risk of aspiration - consider awake FFB
  • Decreased neck movement due to arthritis - use video laryngoscopy

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    Maintain full spinal precautions if indicated
    Degenerative changes and stiffening of the lower cervical spine make higher (C1-C3) fractures likely.
    • Maintain full spinal precautions if indicated. Remember that an arthritic cervical spine increases the risk for injury. (8)
    • It may be necessary to place a towel or elevation device under the patients’ neck to maintain neutral alignment in the kyphotic elderly patient.(18)
    • Seek advice from ARV or MTS regarding managing older patients who require spinal immobilisation but are also agitated, distressed or confused (delirium).

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    Breathing

     

    The older patient has a decreased respiratory reserve and may have underlying chronic lung disease. The combination of fragile tissues and degenerative changes make this patient group less tolerant of pulmonary injuries with an associated increased mortality. After an event involving trauma, 10% of older patients have rib fractures, and up to 50% of fractures in this group are undetected on x-ray.(19) The number of ribs fractured is directly related to mortality: if more than six ribs are fractured, the mortality rate is 33%.(20)
     

    Record the oxygen saturation (SpO2)

    • Administer high-flow oxygen to maintain oxygen saturations ≥94% in the initial resuscitation period.
    • When managing patients who may be CO2 retainers the priority remains with maintaining oxygenation in the initial resuscitation period. The risk of hypoventilation as a result must be accepted and if this does occur 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. A tension pneumothorax has the following features:
      • Hypoxia
      • Absent or decreased breath sounds.
      • Severe respiratory distress.
      • Distended neck veins.
      • Persisting hypotension
      • Tachycardia
      • Shift in mediastinum or trachea to contralateral side.
    • Hyper-resonance to percussion.

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Circulation

 

As mentioned, vital signs parameters may be altered in the older patient. The presence of normal blood pressure and normal heart rate measurements may not equate with normovolaemia. Greater emphasis should be paced on the trends of vital signs and being vigilant for other signs of hypoperfusion

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 usually 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 older persons and exacerbate blood loss.
  • Insert two large-bore peripheral intravenous (IV) cannulas.
  • As the IV is inserted take blood for glucose, full blood exam, coagulation studies, 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 or concern for an ACS.
  • If intravenous access is difficult, obtain intraosseous access. Bone marrow aspirated from the IO can be used to cross 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.
  • Assess 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, administer blood products to maintain perfusion. If blood products are not immediately available, administer small amounts (250ml boluses) of isotonic crystalloid fluid to maintain permissive hypotension as required. Monitor the patient’s physiological response. Excessive volume resuscitation may result in acute pulmonary oedema due to pre-existing cardiac conditions.

If necessary, perform an eFAST scan

Consider the need for an extended Focused Assessment with Sonography in Trauma (eFAST) if available and if staff are trained in its use. eFAST is used primarily to detect intraperitoneal bleeding, pericardial and pleural injury. In experienced hands eFAST has a high sensitivity and specificity. (21) If the patient is hemodynamically stable and there are no signs of significant internal bleeding then eFAST scan may be delayed until the secondary survey.
 

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Disability

 

Decreased brain mass in older patients results in a higher incidence of subdural and intraparenchymal haematoma, with delayed onset of symptoms. Neurological examination may be complicated by an underlying cognitive impairment, dementia or delirium. Therefore, clinicians should have a lower threshold to proceed to CT scan in this cohort.

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 baseline level of consciousness are not related to a medical cause. It is worth remembering that seemingly standard doses of medications, such as opiates and benzodiazepines, may lead to drowsiness in older patients.

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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 all trauma patients. Older patients are particularly at risk of loss of thermal regulation due to a decrease in dermal thickness and loss of vascularity. There is an impaired ability to increase heat production and retain heat by vasoconstriction.(5)
  • Patient temperature should be monitored repeatedly via tympanic or axillary methods. If available, continuous monitoring via, oral, nasopharyngeal or rectal routes should be considered. 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.
  • In the older 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 and/or spinal precautions are in place.

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