By Sylvia Foley, AJN senior editor
Frank Jones, age 83, arrives at a local trauma center after falling down a flight of stairs in his home. Initially diagnosed with two fractured ribs, a fractured ulna, and a fractured tibia, he’s admitted to the ICU. At first, things seem to go well—his electrolytes and bloodwork appear to be within normal limits, and his vital signs are stable. But the next day he becomes increasingly unstable. What’s going on?
Trauma is currently the seventh leading cause of death in older adults—and older adults are more likely to suffer complications and die than are younger ones. But as author Christine Cutugno points out in this month’s CE, “The ‘Graying’ of Trauma Care: Addressing Traumatic Injury in Older Adults,” advanced age isn’t a predictor of trauma outcome. Many trauma-related complications are preventable.
What guides current care? While standards of care for geriatric patients and for trauma patients exist, as yet none have been specifically developed for and tested in geriatric trauma patients. Until that happens, Cutugno writes, “nurses will need to be guided by measures known to prevent iatrogenic complications in other patient populations.”
To that end, Cutugno first reviews common mechanisms of traumatic injury in older adults and discusses the effects of aging and comorbidities. She points out that older adults usually have poorer physiologic reserves and are less able to maintain homeostasis. Their compensatory responses may be inadequate. The drugs taken to manage many comorbidities can mask warning signs. In short, it can be challenging for nurses to recognize when a geriatric trauma patient is in trouble.
Cutugno, who was a critical care RN for more than 30 years and directed hospital critical care divisions for 20 years, offers several examples. For instance, normal atrophy in an aging brain can create more intracranial space; this means that more blood can accumulate before symptoms of trauma become evident. The resulting delayed recognition of deterioration, she cautions, “will lead to predictably negative outcomes.” Another example: beta blockers, used to treat various conditions from hypertension to cardiac arrhythmias, can alter physiologic responses to shock; that’s what happened in the case of Mr. Jones (a composite case). Because beta blockers slow the heart rate, tachycardia wasn’t present as an early sign of hypovolemia, and an opportunity for early intervention was lost.
But regardless of patient age, trauma care priorities remain the same. After evaluating a patient’s ABCs (airway, breathing, and circulation), it’s important to conduct a secondary head-to-toe assessment “to identify and evaluate any injuries that aren’t immediately apparent or life threatening, with the goal of preventing further disability.” The author provides a system-by-system look at potential problems and offers prevention strategies for trauma-related complications. She also outlines some evidence-based approaches for improving outcomes.
Cutugno closes with a call for change: “If we subscribe to the philosophy of the trauma care community that most trauma is preventable, then we must ask what more can be done.” The answer, at least in part, is more research specific to geriatric trauma patients and better preparation for all responders, including nurses. The article is free online. And if you have worked with older victims of trauma, please consider sharing your experiences in the comments.