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

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:

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.¹⁰

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.

ECG

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.

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Optimising oxygenation

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.

Fluid resuscitation

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.

Resuscitation goals:

The main goal of fluid resuscitation in trauma is to preserve vital organ function until bleeding can be controlled.
In immediate trauma care aim for adequate vital organ perfusion (especially heart and brain) or a blood pressure greater than 90 mmHg systolic.
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.

Insert

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

Monitor

HR / RR / BP / SPO2 / GCS /Temp.
Reassess every 15/60 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 elderly population . In elderly trauma patients with cognitive impairment, staff should look for non-verbal clues related to pain. Ongoing pain decreases coughing, leads to shallow hyperventilation, reduced FRC and retention of sputum. This is of particular concern for the elderly trauma patient who is more prone to developing pneumonia leading to mortality. Effective pain management can be achieved with the use of opioid analgesia as well as consideration of intercostal nerve blocks, likely managed in the MTS.
Medications may have profound adverse effects which are not evident in the younger trauma patient - always think carefully about appropriate doses and liaise with Pharmacy colleagues.
Tetanus Prophylaxis: updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation.¹⁸

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 elderly population.¹⁹ Serial lactate measurements can be used to guide response to fluid resuscitation.
Hb levels at 10g/dL should be maintained to maximize oxygen carrying capacity and delivery, however indiscriminate blood transfusions should be avoided.⁶
A WCC response may not be mounted yet. Evolving sepsis may need to 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. Elderly patients can have delicate, thinner skin that tears easily combined with poorer healing ability which can lead to infection. 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. Suture simple wounds if time allows.

Psychological health

In the older patient the psychological impact may be under-appreciated and the patient may harbour terrible fears and concerns - these must be acknowledged and explored. They may also develop feelings of isolation and abject fear. Learn to talk with the elderly patient rather than at them. Ask them about their lives and about their past experiences - it takes five minutes of your time yet can be so important for the patient.
Liaise with inter-generational family members and remember the primary carer may also be quite elderly and in need of help - engage Nursing Staff and Social Work.
The priorities for further investigation and treatment may now be considered and a plan for definitive care established.