The impact of traumatic injury can be devastating for patients and for family members and significant others. They are faced
Hemodynamic Instability
• Shock states in the emergency department
• Aggressive resuscitation
• Emergent surgery taking precedence over thorough sec-ondary surveys
Alterations in Consciousness
• Presence of drugs or alcohol intoxication confuses physical assessments and masks physical findings.
• Disoriented patients are challenging to assess.
• Agitation makes diagnostic testing challenging.
• Patients with altered consciousness cannot provide a history of the injury.
BOX 25-13 Factors Contributing to Missed Injuries
Many older adults take daily anticoagulants and/or anti- platelet medications to prevent thrombotic or embolic com-plications from preexisting medical conditions. Traumatic injury in conjunction with a prolonged International Nor- malized Ratio (INR) greatly increases the risk of major hem-orrhage. It is essential that systemic anticoagulation be corrected as soon as possible after admission, and when head injury is suspected, a CT of the head is urgently obtained.43
Trauma protocols are well-established for the manage-ment of young patients after injury. Clinicians increasingly are recognizing that these protocols must be individualized for the older trauma patient. The best outcomes for this patient population have been achieved through early, appro-priate, aggressive trauma care, with admission to a trauma center with resources and protocols to provide excellent care to injured adults regardless of age.43 Clinical practice guide-lines that discuss trauma diagnostic tests and procedures can be obtained on the websites of the major professional organi-zations that are listed in the Internet Resources Box 25-16.
one of relative independence to one that requires prolonged rehabilitation or skilled nursing care. Discharge planning early in the patient’s hospitalization is necessary.
The concept of limited physiologic reserve in the older trauma patient highlights the key difference between the younger trauma patient with normal physiologic reserve and the older patient with underlying physiologic derangements.
Age-related changes that occur in virtually every organ system may not produce evidence of organ dysfunction in the resting state. However, the ability of organs to augment func- tion in response to traumatic stress may be greatly compro-mised. Fluid resuscitation is an integral part of trauma resuscitation. Patients on chronic diuretic therapy may require more volume and potassium supplementation as a result of chronic volume and potassium depletion. The assess-ment and management of hypovolemic shock is more complex in the older trauma patient. Many older adults are taking beta-blocker medications, thereby limiting an increase in heart rate in response to blood loss; this obscures one of the earliest signs of hypovolemia—tachycardia.5 Loss of physio- logic reserve and the presence of preexisting medical condi-tions are likely to produce further conflicting hemodynamic data. The older patient’s lack of physiologic reserve makes it imperative that early nutritional support is initiated.
Brief Patient History
Mr. G is a 21-year-old man. He was traveling in the back of a pickup truck that collided with another vehicle. He was ejected onto the side of the road and now is not awake and is barely breathing. He was intubated by emergency services, placed in a collar, and immobilized.
Clinical Assessment
Mr. G is admitted to the emergency department with minimal signs of external injury except for some small abrasions to the side of his face.
Diagnostic Procedures
Admission CT scan shows a large subdural hematoma.
Radiography confirms appropriate placement of the endo-tracheal tube.
Baseline vital signs are blood pressure (BP) 110/60, heart rate (HR) 108 (sinus tachycardia), respiratory rate (RR) 30, temperature (T) 98.3° F, O2 saturation 88%, Glasgow Coma Scale 7.
Medical Diagnosis
Mr. G is diagnosed with subdural hematoma secondary to trauma.
Questions
1. What major outcomes do you expect to achieve for this patient?
2. What problems or risks must be managed to achieve these outcomes?
3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified above?
4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
5. What possible learning needs would you anticipate for this patient?
6. What cultural and age-related factors might have a bearing on the patient’s plan of care?
CASE STUDY Patient with Trauma
• Alterations in visual and auditory acuity
• Deterioration in strength and slower reaction times
• Diminution of cerebral skills
• Diminution of motor skills
• Exacerbation of acute or chronic medical conditions
• Medications that may interfere with safe driving
BOX 25-15 Factors that Predispose Older Adults to Motor Vehicle Crashes
Acute Illness
• Cerebrovascular accidents
• Dysrhythmias
• Syncope
• Diabetes
Cognitive Impairment
• Dementia
Neuromuscular Disorders
• Arthritis
• Lower extremity weakness
• Unstable gait Medications
• Antidepressants
• Benzodiazepines
• Diuretics
• Phenothiazines
BOX 25-14 Risk Factors for Falls in Older Adults
14. Alali AS, et al: Beta blockers for acute traumatic brain injury:
a systematic review and meta-analysis, Neurocrit Care 20(3):514, 2014.
15. National Spinal Cord Injury Statistical Center: Spinal cord injury facts and figures at a glance, 2013. https://
www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/
Facts%202013.pdf. Accessed August 17, 2014.
16. Como JJ, et al: Practice management guidelines for identification of cervical spine injuries following trauma:
update from the Eastern Association for the Surgery of Trauma practice management guidelines committee, J Trauma 67:651, 2009.
17. Bracken MB: Steroids for acute spinal cord injury, Cochrane Database Syst Rev (18):CD001046, 1, 2012.
18. Walters BC, et al: Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update, Neurosurgery 60(Suppl 1):82, 2013.
19. Kiraly L, Schreiber M: Management of the crushed chest, Crit Care Med 38(9):S469, 2010.
20. Battle CE, Hutchings H, Evans PA: Risk factors that predict mortality in patients with blunt chest wall trauma: a systematic review and meta-analysis, Injury 43:8, 2012.
21. Simon B, et al: Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg 73(5, Suppl 4):S351, 2012.
22. Mowery NT, et al: Practice management guidelines for management of hemothorax and occult pneumothorax, J Trauma 70(2):510, 2011.
23. Press GM, Miller S: Utility of the cardiac component of FAST in blunt trauma, J Emerg Med 44(1):9, 2013.
24. Bock JS, Benitez M: Blunt cardiac injury, Cardiol Clin 30:545, 2012.
25. Clancy K, et al: Screening for blunt cardiac injury: An Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg 73(5 Suppl 4):S301, 2012.
26. Neschis DG, Scalea TM, Flinn WR, Griffith BP: Blunt aortic injury, N Engl J Med 359:1708, 2008.
27. Kwolek CJ, Blazick E: Current Management of traumatic thoracic aortic injury, Semin Vasc Surg 23:215, 2011.
28. Moore CL, Copel JA: Point-of-care ultrasonography, N Engl J Med 364(8):749, 2011.
29. De Waele JJ, De Laet I, Kirkpatrick AW, Hoste E: Intra-abdominal hypertension and abdominal compartment syndrome, Am J Kidney Dis 57(1):159, 2010.
30. Stassen NA, et al: Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg 73(5 Suppl 4):S288, 2012.
31. Stassen NA, et al: Selective nonoperative management of blunt splenic injury: an Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg 73(5, Suppl 4):S294, 2012.
32. Schnüriger B, et al: Serial white blood cell counts in trauma:
Do they predict a hollow viscus injury? J Trauma 69:302, 2010.
33. Bjurlin MA, Fantus RJ, Mellett MM, Goble SM:
Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank, J Trauma 67:1033, 2010.
REFERENCES
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2. Wu V, Huff H, Bhandari M: Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: A systematic review and meta-analysis, Trauma Violence Abuse 11(2):71, 2010.
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4. Neumann T, et al: Does the alcohol use disorders identification test–consumption identify the same patient population as the full 10-item Alcohol Use Disorders Identification Test? J Subst Abuse Treat 43:80, 2012.
5. American College of Surgeons: Advanced Trauma Life Support, ed 9, Chicago, IL, 2012, American College of Surgeons.
6. Emergency Nurses Association: Trauma Nursing Core Course Provider Manual, ed 7, Des Plaines, IL, 2014, Emergency Nurses Association.
7. Hodgman EI, et al: Base deficit as a marker of survival after traumatic injury: consistent across changing patient
populations and resuscitation paradigms, J Trauma 72(4):844, 2012.
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http://www.cdc.gov/ncipc/tbi/TBI.htm. Accessed August 17, 2014.
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12. Cooper JD, et al: Decompressive craniectomy in diffuse traumatic brain injury, N Engl J Med 364:1493, 2010.
13. Brain Trauma Foundation: Guidelines for the management of severe traumatic brain injury, J Neurotrauma 24(Suppl 1):1, 2007.
American College of Surgeons (ACS): https://www.facs.org/
ACS—Advanced Trauma Life Support (ATLS): https://www .facs.org/quality-programs/trauma/atls
Emergency Nurses Association (ENA): www.ena.org ENA—Trauma Nurse Core Course (TNCC): http://www.ena
.org/education/ENPC-TNCC/tncc/Pages/aboutcourse.aspx Eastern Association for the Surgery of Trauma (EAST):
https://www.east.org/resources/treatment-guidelines
BOX 25-16 TRAUMA INTERNET RESOURCES
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37. Sara S, et al: Fat emboli syndrome in a nondisplaced tibia fracture, J Orthop Trauma 25(2):e27, 2011.
38. Bosch X, Poch E, Grau JM: Rhabdomyolysis and acute kidney injury, N Engl J Med 361:62, 2009.
39. Muntz JE, Michota FA: Prevention and management of venous thromboembolism in the surgical patient: options by
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