Chest Trauma

Chest trauma, both minor and severe, can compromise elderly individuals. In blunt trauma, there is an increased incidence of rib fractures due to osteoporotic changes. The pain associated with rib fractures, along with any decreased physiologic reserve, may predispose patients to respiratory complications. 12 More severe thoracic injuries, such as hemopneumothorax, pulmonary contusion, flail chest, and cardiac contusion, can quickly lead to decompensation in elderly individuals whose baseline oxygenation status may already be diminished.

Geriatric patients are more susceptible to developing hypoxia and respiratory infections following trauma. In the elderly, diminished elasticity of the lungs along with progressive changes in the chest wall can lead to a reduction in pulmonary compliance and in the ability to cough effectively. Total lung surface area decreases as alveolar and small airway support diminishes with advancing age. There also is reduced mucociliary clearance of foreign material and bacteria and increased colonization of the oropharynx with gram-negative organisms. All these factors result in an increased risk for elderly patients to develop nosocomial gram-negative pneumonia.9,!2

Also, the great vessels tend to be more rigidly fixed, allowing for easier disruption from transmitted forces.

The main therapeutic goal is aggressively maintaining adequate oxygen delivery. Frequent arterial blood gas analysis may provide early insight into elderly patients' respiratory function and reserve. Prompt tracheal intubation and use of mechanical ventilation should be considered in patients with more severe injuries, respiratory rates greater than 40 breaths per minute, or when the Pao2 is less than 60 mmHg or the PaCo2 is greater than 50 mmHg. While nonventilatory therapy helps to prevent respiratory infections and is always desirable, early mechanical ventilation may avert the disastrous results associated with hypoxia. 12

Emergency physicians should remember that chest trauma alone does not necessarily forecast a bleak outcome. In one series, most of the patients sustaining blunt chest injuries were discharged home to their preinjury level of independence.12

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