Early Management

Determining the events surrounding the trauma and whether it was related to a neurologic or cardiac event is crucial to help guide management.

Diagnostic imaging

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 older patient has suffered a low impact fall with head strike a lower threshold for CT scanning of brain and cervical spine should be adopted. Any patient who is on oral anticoagulation is at high risk of developing a significant intracranial haemorrhage from even minor head injury mechanisms.

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:

• Balancing the risk/ benefit of immobilisation, considering the mechanism of injury, comorbidities and clinical assessment.
• Balancing the risk / benefit of sedation to maintain immobilisation and facilitate safe imaging. ⁽¹⁹⁾

eFAST should be performed in all elderly patients with trauma from moderate to severe mechanisms, especially in "unstable" patients. eFAST does readily detect intraperitoneal/pleura bleeding and should be performed as part of the primary exam.

ECG

An electrocardiogram should be completed on all older trauma patients to identify any pre-existing 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.

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Optimising oxygenation

Due to a decreased respiratory reserve, it is vital to optimise oxygenation in this cohort of patients. Older patients are more prone to complications of hospitalisation such as hospital acquired 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 regions of atelectasis and adequate pain control.

Volume Replacement

Avoidance of hypovolaemia in trauma is a cornerstone of management. Close monitoring and caution should be taken with the elderly patients with a history of CCF on diuretics.
Resuscitation goals:

• The main goal of fluid resuscitation in trauma is to preserve vital organ function until bleeding can be controlled
• For patients with obvious severe and ongoing bleeding, type O blood should be transfused immediately. ⁽³⁰⁾
• In immediate trauma care aim for adequate vital organ perfusion.
• The assessment of hypovolemic shock is difficult during the early phase of major trauma care. The clearest signs of end-organ hypo perfusion include decreased urine output, acidosis, altered conscious state and elevated lactate level.
• If possible, all blood/fluid administered to a major trauma patient should be warmed with a fluid warmer.
• Do not hesitate to contact ARV for advice in regard to volume replacement.

Insert

• Consider a gastric tube, however, this is contraindicated in suspected base of skull fracture.
• Urinary Indwelling catheter – measure 1/24, aim for 0.5 – 1.0 mL/kg/hr. Perform urinalysis to check for blood.
• Discoloured, brown urine may indicate myoglobinuria, a sign of rhabdomyolysis.

Monitor

• HR / RR / BP / SPO2 / GCS / Temperature
• Reassess every 15 minutes or more frequently if indicated.
• Fluid Balance Chart – keep an accurate record of input / output

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Administer

• Analgesia: Adequate pain control is an essential component of the initial management of trauma in the older population. In older trauma patients with cognitive impairment, staff should look for non-verbal clues related to pain. Ongoing pain decreases coughing, leading to shallow hyperventilation, reduced FRC and increasing the risk of pneumonia. Effective pain management can be achieved with the use of opioid analgesia as well as consideration of regional anaesthesia.
• Opioid analgesia such as morphine and fentanyl are ideal first line options. Opioids have significant side effects (sedation, respiratory depression, urinary retention, nausea, etc.) and should be combined with early regional anaesthesia e.g. Femoral nerve block for NOF fracture or, chest wall blocks for rib fractures.
• As mentioned, medications may have profound adverse effects on elderly patients at loser doses as compared to younger trauma patients. Doses should be carefully considered and support from Pharmacist colleagues sought.
• Tetanus Prophylaxis should be updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation.⁽³¹⁾

Monitor blood results

• Serial blood gas assessment of pH and lactate levels provide good monitoring of tissue oxygenation, circulatory status, and response to resuscitation. An elevated lactate on admission indicates occult hypoperfusion and leads to a greater risk of mortality in the older population.⁽³²⁾
• Serial lactate measurements can be used to guide response to fluid resuscitation.
• In patients with critical bleeding requiring massive transfusion, haemoglobin concentration should be interpreted in the context of haemodynamic status, organ perfusion and tissue oxygenation. (Australian Blood Authority)
• Trends of Hb levels are a better marker for monitoring of ongoing blood loss.
• A WCC response may not be mounted yet. Evolving sepsis should remain a concern.
• INR / APTT/ PT should be assessed early in the clinical course and reversal considered if haemorrhage is suspected, particularly in Intra Cerebral Haemorrhage (ICH). Early recognition and correction of coagulation defects is crucial, including the reversal of drug induced anticoagulation. Patients with an elevated INR may benefit from the use of Fresh Frozen Plasma (FFP) / Prothrombin Complex Concentrates (PCC) and Vitamin K. (See Oral Anticoagulants in Trauma guideline for detailed discussion).

 

Wound Care

In a major trauma patient, early wound closure (pre-transfer) is not a priority unless there is significant active bleeding. Older patients often have fragile skin that tears easily. Achieving haemostasis can be challenging; this is often compounded by concurrent use of antiplatelet and/or anticoagulant therapy. (33) It is important to gain haemostasis through pressure and elevation where possible and remove any gross contamination by irrigation of the wound. Simple dressings with saline, gauze, combine and moderate compression bandages are generally adequate. Steri-strip or suture simple wounds if time allows and adequate re-approximation is possible.

 

Psychological health

The experience of sustaining a significant injury can be traumatic for all patients regardless of age. However, in the older person, a multitude of environmental, cognitive and medical factors combine to cause psychological distress and delirium. The abrupt change of setting, ongoing pain, medications and underlying cognitive impairment are some of the many factors that can contribute to the onset of delirium. In keeping with this, prevention and management is also multi-faceted and includes early assessment and a focus on optimising analgesia.⁽³⁴⁾

Gentle re-orientation and reassurance will help to mitigate the psychological disruption of sustaining a traumatic injury.

Older persons, particularly in Australia, have often lived extraordinarily full lives; the transfer to hospital provides a perfect opportunity to explore these.

The patient may be the primary carer for their partner, and their ongoing safety must be considered. Discuss with family members and GP to ensure this. The priorities for further investigation and treatment may now be considered and a plan for definitive care established.

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