Trauma Resuscitation - part 8 pptx

There is no doubt that prevention of hypothermia (and, thereby, maintaining normal haemostasis) is much easier than treating the haemorrhagic state in the presence of hypothermia. 11.3.4 Gastro-intestinal system Elderly patients often seem to mask the symptoms and signs of abdominal trauma. Although well recognized, it is difficult to quantify loss of gastro-intestinal tract function, resulting in an increased reliance on imaging techniques with the need for radiographic contrast and the potential for renal and other organ damage. There is also increased glucose intolerance, less muscle mass and, hence, less nutritional reserve. 11.3.5 Renal system As people age there is an ongoing and progressive loss of glomeruli with consequent loss of function. They are less effective at retaining water in the presence of hypovolaemia. These changes are secondary to both decreased antidiuretic hormone (ADH) secretion and decreased renin-angiotensin activity. There is also a worse outcome with acute renal failure in the elderly. In addition this population is more likely to be taking diuretics for co-morbidities, with consequent relative dehydration. 11.3.6 Neurological system As we age there is progressive atrophy of brain tissue, with consequent increase in the space available in the cranium, allowing greater movement of the tissues in the event of mechanical trauma and greater risk of subdural haematoma after relatively minor trauma. Coupled with this is the presence of amyloid plaques and a decrease in the levels of neurotransmitters. This may well lead to a progressive loss of cognitive function, memory loss and possibly dementia. Other associated co-morbidities include a higher incidence of Parkinsonism, atherosclerosis of the carotid arteries, stroke and transient ischaemic attacks. There has often been a progressive decrease in the senses with poor vision and hearing, with a greater dependence on glasses and hearing aids. The elderly are often confused just by changes in their environment and this situation can often be worsened by the interaction of drugs. It is also important to think about intracranial haemorrhage in the elderly, as both the cause and consequence of trauma. 11.3.7 Locomotor system and cutaneous disorders As well as the decreased muscle mass, there are degenerative changes within the bone and joints, as well as ligamentous ossification. This may well lead to a loss of flexibility of the skeleton, that can contribute to or worsen any potential injury. Over the years narrowing of the vertebral canal occurs, increasing the potential for a significant cord injury. With increasing age, there is loss of subcutaneous fat, connective tissue and a decrease in the elasticity of skin. Reduced vascular supply, coupled with ischaemic disease leads to an increased incidence of decubitus TRAUMA IN THE ELDERLY 235 ulcers and poor healing of both trivial skin trauma and major wounds. Previous treatment with corticosteroids may have caused a degree of localized atrophy. 11.3.8 Haematological system The most frequent haematological disorder encountered in the elderly is anaemia. Although there are many different causes, iron deficiency predominates. There is decreased immunity predisposing these patients to a much greater incidence of infection. 11.3.9 Endocrine There is a high incidence of diabetes mellitus with all its associated problems. The incidence of thyroid disease is greater, particularly hypothyroidism, which often goes undiagnosed in this group of patients. 11.3.10 Pharmacology Pharmacodynamics and pharmacokinetics are frequently altered in the elderly and may lead to exaggerated effects with many drugs. This is particularly true of anaesthetic, sedative and analgesic drugs and care must be taken. With many elderly taking medicines for multiple other conditions, that is, cardiovascular agents, there is much potential for interactions. 11.3.11 Co-morbid diseases As seen above the impact of co-morbid conditions can lead to profound problems in the assessment and management of any trauma victim, but is much more likely to be found in the elderly. With ageing, there is a gradual increase in the prevalence of co-morbid diseases, rising from 17% in the fourth decade to 70% by the age of 75 years. 11.4 Assessment and management Resuscitation of the elderly trauma victim should progress using the principles already described in Section 1.6.1. Optimization of resuscitation assumes a greater importance in the elderly, as over- resuscitation may result in problems just as severe as under-resuscitation (see Section 4.6.1). 236 TRAUMA RESUSCITATION 11.4.1 Primary survey and resuscitation Airway and cervical-spine control Elderly patients are often edentulous, but may occasionally have loose, inconveniently placed or very carious teeth. Along with resorption of the mandible and lax cheek muscles this may make maintenance of the airway more difficult. If intubation is required, arthritis of the temporo-mandibular joint may limit mouth opening. Soft tissues are more prone to injury, particularly the turbinates, which may bleed profusely. The airway nurse must take great care to provide cervical spine immobilization, even when the spine is clinically and radiologically intact, so that iatrogenic injury is avoided. Degenerative cervical spondylolisthesis, narrowing of the cervical spinal canal, and ligamentous instability in diseases such as rheumatoid arthritis, are more frequent than with younger trauma victims. Central cord syndrome occurs much more frequently in the elderly. Breathing In the elderly, it is often difficult to support ventilation using a facemask for the reasons already stated and a reduced respiratory reserve means that hypoxia ensues rapidly. Therefore mechanical ventilation with 100% oxygen should be started early bering that the chances of causing a pneumothorax are significantly higher in this group of patients. Repeated assessment of breath sounds and observation of the patient’s chest for equality of movement and the development of surgical emphysema are important to ensure early recognition of this complication should it occur. As soon as possible, serial arterial blood gases must be performed to ensure adequate oxygenation and ventilation. Because of the potential problems, the assistance of an anaesthetist should be sought early in the management of these patients. Circulation Warmed fluids must be used, and the patient’s response continuously and accurately monitored by the circulation nurse. The reduced fluid tolerance associated with means that both hypovolaemia and overload must be avoided. In addition to the vital signs and urinary output, invasive monitoring should be established early, using expert help if necessary, in order to optimize cardiovascular function. The insertion of a urinary catheter must be carried out in a strictly aseptic manner as these patients have an increased risk of developing infection. Dysfunction Anxiety, disorientation and confusion in the elderly trauma patient must be treated initially by ensuring adequate cerebral perfusion with oxygenated blood rather than assuming this is the patient’s normal mental state. In the conscious patient a nurse should be allocated to establish a rapport with the patient to provide reassurance and allay any anxieties. Impaired sensory function, particularly deafness, may produce inappropriate responses and make assessment difficult TRAUMA IN THE ELDERLY 237 Exposure and environment The susceptibility of the elderly to greater injuries from a given force means that they must always be completely undressed to ensure that injuries are not missed. However, they are also very prone to hypothermia (see above), so appropriate measures must be taken to prevent this being worsened or added to the patient’s list of problems. Generally, doctors tend to leave patients exposed, and it generally falls to the nursing members of the team to ensure that all appropriate measures are taken to prevent hypothermia! Early consideration should be given to the use of forced air-warming devices. 11.4.2 Secondary survey A full head-to-toe examination is warranted as a result of the inability of the elderly to withstand trauma. In view of the patient’s intrinsic immobility due to degenerative diseases and the possible frailty of the skeleton from osteoporosis, care should be taken to maintain the anatomical position that is normal for each patient. Extra care must be taken during log-rolling. Padding of bony prominences during transportation is essential to prevent skin breakdown. It is the responsibility of the nursing team leader to anticipate such complications and avoid them: patients will often not notice contact pressure because of decreased pain perception. AMPLE history This is particularly important in the elderly. One of the nursing members of the team must be detailed to gather as much history as possible. Polypharmacy is common and it is important that the medical team leader is advised as soon as possible what medications are being taken as these may have a direct bearing on either the patient’s response to injury or resuscitation. As patients get older they are more likely to have other diseases and information must be sought on site from the attending family, friends, ambulance personnel or previous hospital records. Occasionally it may be possible to obtain information directly from the patient. However, because hearing may be less acute, members of the team must remember to speak clearly to the patient, preferably looking directly at him as they speak, without shouting, allowing the patient to lip-read. They should watch the reaction during the conversation to ensure that the patient comprehends what is being said; the response to such communication will also provide further information on the patient’s sensory and cognitive abilities. Further useful information may be gained directly from the patient’s GP or other local hospitals, over the telephone if necessary. Sensory overload, short-term memory impairment and senile dementia are common in the elderly. They must be allowed an appropriate amount of time to process information and formulate answers to questions, particularly about the recent events rather than assuming they are incompetent or demented. Sensitivity to these concerns can greatly assist the patient in accepting many of the intrusive procedures associated with resuscitation and subsequent hospitalization, thereby helping to maintain self-esteem. Ethical and social implications The patient’s dignity must always be respected throughout the resuscitation period (whether conscious or not) and during admission procedures. This contributes significantly to the trauma victim’s emotional outcome, as fear of becoming dependent is a serious problem for the elderly patient. The interaction of injury, advanced age and pre-existing medical conditions creates a myriad of challenging issues beyond 238 TRAUMA RESUSCITATION clinical problems. Determining the survivability of injury in the elderly may not be immediately apparent, except in cases of overwhelming injury or cardiac arrest. The sudden nature of injury usually precludes any prior relation between the trauma surgeon and patient. Early frank communication with the injured patient, family and physicians about pre-injury advance directives, pre-injury quality of life and the impact of trauma on their lifestyle are required, so clearly determined goals of treatment can be established and extraordinary supportive measures are not mistakenly undertaken. Withdrawal of support at the request of the patient, family or physician may reflect humane medical care and occurs as often as in 12.5% of trauma deaths in the elderly. On the other hand, therapeutic nihilism based on age alone becomes a self-fulfilling prophecy, so early aggressive, directed care is required until such time as a comprehensive picture can be drawn and appropriate decisions made. At the same time these goals must be communicated to the entire care-giving team, and the effect of pre-existing conditions or disease must be considered through all phases of trauma care. 11.5 Summary The elderly comprise an increasing proportion of the general population with an increasing likelihood of being involved in trauma. The anatomical and physiological changes with age result in a different response to injury. Injury severity, age and co-morbid disease all contribute to the outcome in the elderly injured patient and consequently for similar injury severity scores, their outcome is worse. Early recognition and rigorous management of all pre-existing disease, along with the injury sustained, are mandatory to maximize the outcome in this group of patients. Age must not be used as an excuse for inadequate or inappropriate treatment. Further reading 1.Skinner D, Driscoll P & Earlam R (eds) (1996) ABC of Major Trauma, 2nd edn. British Medical Association, London. 2.Allen JE & Schwab CW (1985) Blunt chest trauma in the elderly. Am Surg 51:697. 3.American College of Surgeons Committee on Trauma (1997) Advanced Trauma Life Support for Doctors. American College of Surgeons, Chicago, IL. 4.Champion HR, Copes WS, Buyer D, et al. (1999) Major trauma in geriatric patients. Am J Public Health 79:1278. 5.McMahon DJ, Schwab CW & Kauder D (1996) Comorbidity and the elderly trauma patient. World J. Surg. 20: 1113. TRAUMA IN THE ELDERLY 239 6.Milzman DP, Boulanger BR, Rodriguez A, et al. (1992) Pre-existing disease in trauma patients: a predictor of fate independent of age and ISS. J. Trauma32:236. 7.Robinson A (1995) Age, physical trauma and care. Can. Med. Assoc. J. 152:1453. 8.Schwab CW & Kauder DR (1992) Trauma in the geriatric patient. Arch. Surg. 127:701. 9.Waldmann C (1992) Anaesthesia for the elderly. In: Kaufman L (ed.) Anaesthesia Review 9, pp 194–211. 10.Watters JM, Moulton SB, Clancey SM, et al. (1994) Ageing exaggerates glucose intolerance following injury. J. Trauma37:786. 11.Yates D (ed.) (1999) Trauma. British Medical Bulletin 55:4. 240 TRAUMA RESUSCITATION 12 Trauma in children S Robinson, N Hewer Objectives The aims of this chapter are to teach staff caring for the severely injured child: the specific anatomical and physiological features in children relevant to the management of trauma; how the management of traumatic injuries in children differs to that in adults; an approach to the assessment and treatment of the injured child; the features that may help in offering a prognosis following severe injury. 12.1 Introduction In 1999, 416 children under the age of 15 years died because of injury. Trauma is the commonest cause of death in children over the age of one year and the majority of children who die from injury do so before they reach hospital. The pattern of injury seen in the paediatric population differs from that in adults. Haemorrhagic shock and severe life-threatening chest injuries are uncommon and mortality is primarily related to head injury. It has been estimated the average ED can expect to see at most two to four severely injured children a year, therefore exposure to children with this degree of injury is an uncommon event for most doctors and nurses. Consequently, a methodical approach to the assessment and treatment of the injured child is crucial. This chapter will describe how such children can be assessed and their injuries treated. 12.2 Injury patterns in children 12.2.1 Head injuries Head injury is the commonest single cause of death in children over the age one year. The occurrence of severe cerebral oedema is between three to four times more common in children than adults. Cerebral oedema often occurs in the absence of contusion, ischaemic brain damage or intracranial haematoma (Figure 12.1). 12.2.2 Cervical spine injury The specific anatomy of the paediatric cervical spine accounts for the different pattern of injury observed in children (see Box 12.1). BOX 12.1 STRUCTURAL CHARACTERISTICS OF THE PAEDIATRIC CERVICAL SPINE Anatomical feature Effect Interspinous ligament and cartilaginous structures have greater laxity and elasticity Greater mobility and less stability Horizontal angulation of the articulating facets and undeveloped uncinate processes Greater mobility and less stability Figure 12.1 CT showing cerebral oedema 242 TRAUMA RESUSCITATION Anatomical feature Effect Anterior surface of vertebrae wedge shaped Facilitates forward vertebral movement resulting in anterior dislocation Underdeveloped neck musculature More susceptible to flexion and extension injuries Head disproportionately large Causes torque and acceleration stress to occur higher in C spine and more susceptible to flexion and extension injuries The incidence of spinal cord injury amongst paediatric trauma patients is low (1.5%). 60–80% of paediatric spinal injuries are in the cervical spine (compared with 30–40% in adults). The frequency of upper cervical spine injury (52% C1–4) is nearly twice that of lower cervical spine injury (28% C5–C7). Lower cervical spine injuries predominate in older children (age>8 years). Up to 50% of children with neurological deficit due to a cervical cord injury may have no radiological abnormality, ‘spinal cord injury without radiological abnormality’ (SCIWORA). Transient vertebral displacement with subsequent realignment to a normal configuration results in spinal cord injury with an apparently normal vertebral column. Mortality rates have been shown to be higher in younger children (<10 years) than in older children (30% vs. 7%). Major neurological sequelae are uncommon in children who survive. 12.2.3 Thoracic injury Chest injuries represent between 0.7–4.5% of all paediatric trauma and are predominantly due to blunt trauma. Thoracic trauma is a marker of significant injury and is associated with extra-thoracic injury in 70% of cases, with mortality related to the presence of these other injuries. As the child’s skeleton is incompletely calcified and is more compliant, serious underlying lung injury may occur without fracture of the ribs. Rib fractures are generally rare in paediatric trauma; children with rib fractures are significantly more severely injured than those without. Mortality increases in proportion to the number of ribs fractured. Isolated simple pneumothorax is relatively rare in children but tension pneumothorax develops more readily (Figure 12.2). Pulmonary contusion is the most common injury seen after blunt chest trauma and may occur in association with pneumothorax, haemothorax or post-traumatic serosanguinous effusion. Massive haemothorax is rare in children because blunt trauma rarely results in haemorrhage from major intrathoracic arteries. TRAUMA IN CHILDREN 243 12.2.4 Abdominal injury Children have proportionally larger solid organs that are more vulnerable to penetrating injury. The spleen is the most common solid organ injured in blunt abdominal trauma. Liver injuries are the second most common and occur in 3% of children with blunt abdominal trauma. Nonoperative management is the preferred method of treatment for solid organ injury as haemorrhage is generally self-limiting and responds well to fluid or blood transfusion. Figures from one paediatric trauma centre report only 4% of blunt liver injuries and 21% of blunt splenic injuries required operative management. The young child’s predilection to air swallowing, aerophagy, can lead to painful abdominal distension, making examination difficult and increasing the risk of regurgitation and aspiration. Repeated examination, observation and monitoring of the vital signs are essential in the child with a possible abdominal injury. 12.2.5 Musculoskeletal injury The paediatric skeleton contains growth plates and a thick, osteogenic periosteum whilst the bones are more porous and elastic. Fractures are consequently less likely to cross both cortices or be comminuted. Figure 12.2 Tension pneumothorax, right lung. Note marked displacement of the mediastinum 244 TRAUMA RESUSCITATION [...]... Paediatric Life Support—the practical approach BMJ Publications, London 28 The UK Trauma Audit and Research Network The University of Manchester, data 1994– 98 29 Wyatt JP, McLeod L, Beard D, et al (1997) Timing of paediatric deaths after trauma BMJ 314 :86 8 13 Trauma in pregnancy S Fletcher, G Lomas Objectives At the end of this chapter the trauma team should understand: the anatomy and pathophysiological... usual trauma team will provide the best maternal and fetal outcome Further reading 1 American College of Surgeons Committee on Trauma (1997) Advanced Trauma Life Support for Doctors American College of Surgeons, Chicago, IL TRAUMA IN PREGNANCY 265 2 Baerga-Varela Y, Zietlow SP, Bannon MP, Harmsen WS & Ilstrup DM (2000) Trauma in pregnancy Mayo Clin Proc 75(12): 1243 3 Cardona V & Hurn P (eds) (19 98) Trauma. .. (2000) ABC of Major Trauma, 3rd edn BMJ Books, London 7 Esposito TJ (1994) Trauma during pregnancy Emerg Med Clin North Am 12(1): 167 8 Maull KI (2001) Maternal-fetal trauma Semin Pediatr Surg 10(1): 32 9 Moise KJ & Belfort MA (1997) Damage control for the obstetric patient Surg Clin North Am 77(4): 83 5 10 Sufrue M & Kolkman KA (1999) Trauma during pregnancy Aust J Rural Health 7(2): 82 11 Tillett J &... Pediatr Adolesc Med 154(1):16 8 Doyle CJ (1 987 ) Family participation during resuscitation: an option Ann Emerg Med 16: 107 9 Gandhi RR, Keller MS, Schwab CW, et al (1999) Pediatric splenic injury: pathway to play J Pediatr Surg 34 (1):55 TRAUMA IN CHILDREN 255 10 Garcia VF, Gotschall CS, Eichelberger MR, et al (1990) Rib fractures in children: a marker for severe trauma J Trauma 30:695 11 Gross M, Lynch... pregnant patient to trauma; the assessment and management of the pregnant trauma patient 13.1 Introduction The arrival of a pregnant trauma patient in the resuscitation room is a relatively rare but frightening occurrence for all concerned The trauma team is presented with two patients, mother and fetus Consequently early obstetric involvement is vital Trauma complicates up to 7 8% of all pregnancies... pediatric blunt trauma patients Pediatr Emerg Care 17(5):324 15 Holmes JF, Brant WE, Bond WF, et al (2001) Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with abdominal blunt trauma J Pediatr, Surg 36(7):9 68 16 Kincaid EH, Chang MC, Letton RW, et al (2001) Admission base deficit in pediatric trauma: a study using the National Trauma Data Bank J Trauma 51:332... Pediatr Surg 25(9):961 24 Resuscitation Council (1996) Should Relatives Witness Resuscitation? Report from Project Team of the (UK) 25 Robinson SM, Mackenzie-Ross S, Campbell-Hewson GL, et al (19 98) Psychological effect of witnessed resuscitation on bereaved relatives Lancet 352:614 26 Roux P & Fisher RM (1992) Chest injuries in children: an analysis of 100 cases of blunt chest trauma from motor vehicle... blood Delayed gastric emptying Incompetent gastro-oesophageal sphincter Full stomach Aspiration risk ↑Renal blood flow ↑Glomerular filtration ↓Serum creatinine and urea Pre-eclampsia vs head injury Fractured pelvis=major trauma ↑ Blood flow No autoregulation Cardiovascular Gastrointestinal Renal Nervous Musculoskeletal Uterus/Placenta 260 TRAUMA RESUSCITATION Resuscitation of the mother is the optimal method... requiring cardiopulmonary resuscitation (CPR) at the scene or on admission, 254 TRAUMA RESUSCITATION 225 (24%) survived to discharge, of whom 36% had no functional impairment A systolic blood pressure below 60 mmHg on admission represented the single greatest predictor of fatality Those with a GCS . Optimization of resuscitation assumes a greater importance in the elderly, as over- resuscitation may result in problems just as severe as under -resuscitation (see Section 4.6.1). 236 TRAUMA RESUSCITATION 11.4.1 Primary. exaggerates glucose intolerance following injury. J. Trauma3 7: 786 . 11.Yates D (ed.) (1999) Trauma. British Medical Bulletin 55:4. 240 TRAUMA RESUSCITATION 12 Trauma in children S Robinson, N Hewer Objectives The. year 10 100–160 30–40 70–90 2 years 12 95–140 25–30 80 –100 3–4 years 14–16 95–140 25–30 80 –100 5 8 years 18 24 80 –120 20–25 90–110 10 years 30 80 –100 15–20 90–110 12 years 40 60–100 12–20 100–120