Prevention Prognosis and Outcome

For elderly patients who are discharged home after sustaining an injury from a fall, it is appropriate for emergency physicians to encourage them to work with their primary care physician to arrange for a social worker to conduct a home safety assessment to help prevent future falls. Chronic medications that may adversely affect the vestibular system, cause profound sedation, or produce postural hypotension should be identified; patients can then discuss alternative therapies or dosages with their primary care physicians.4 When discharging home a patient with a new medication prescription, emergency physicians should select drugs that are least centrally acting, least associated with postural hypotension, and have the shortest duration.

Among geriatric trauma patients who are hospitalized, the mortality rate has been reported to be between 15 and 30 percent. These figures far exceed the mortality rate of 4 to 8 percent found in younger patients.1 In general, multiple organ failure and sepsis cause more deaths in elderly patients than in younger trauma victims. 16 Geriatric patients also are more likely to die following minor traumatic events.17

Several markers for poor outcome in elderly trauma victims have been determined. Age greater than 75 years, Glasgow Coma Scale score of 7 or less, presence of shock on admission, severe head injury, and the development of sepsis are associated with worse outcome and higher mortality figures.18 The Injury Severity Score has been found by many investigators to have poor correlation with mortality rates.19

The ultimate goal in care of elderly trauma patients is to return them to their preinjury state of independent function. There are conflicting data on the ability of elderly patients to return to independent living. A study by Oreskovich and colleagues 20 showed a mortality rate of 15 percent among their geriatric trauma patients, and a dismal 12 percent of patients returning to their baseline independent state. Public debate has raised questions about the ethics and cost-benefits of trauma care for the elderly. However, DeMaria and colleagues2122 demonstrated that immediately after discharge, one-third of trauma survivors return to independent living, one-third return to dependent status but living at home, and one-third require nursing home facilities. Altogether, at long-term follow-up, 89 percent returned home after trauma and 57 percent returned to independent living. The findings of DeMaria and colleagues are supported by the investigation of van Aalst and colleagues, 18 who also showed that the majority of their elderly trauma patients regained an independent level of function.

Many questions regarding the ultimate outcome of geriatric trauma patients remain unanswered. In light of the investigations by DeMaria 21 and van Aalst18 and their colleagues showing that elderly patients can return to independent living after trauma and the study by Scalea and colleagues 8 demonstrating the beneficial effect of early invasive monitoring, it appears that aggressive resuscitation efforts for geriatric trauma patients are warranted.

In summary, the acute management principles of geriatric trauma continue to evolve. Emergency physicians must remain familiar with the various mechanisms of injury unique to the elderly trauma patient. Special management and treatment axioms, outlined in T.ab!ยง.,24.5:l, should be applied early when caring for the geriatric trauma patient.

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

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