Special Management Principles

Emergency physicians often are faced with the challenging task of assessing elderly trauma patients' cardiovascular status and reserve. First, recent work by Ma and colleagues15 has demonstrated that elderly trauma patients are less likely to be appropriately transported to trauma centers. Therefore, significantly injured older patients may have their injuries underappreciated yet present to nontrauma centers. The work by Scalea and colleagues 8 demonstrated that trauma physicians themselves frequently fail to recognize the severity of hemodynamic instability in geriatric patients. Therefore, early invasive monitoring has been advocated to help physicians assess the elderly's hemodynamic status. Scalea and coworkers showed that by reducing the time to invasive monitoring in elderly trauma patients from 5.5 to 2.2 h, and thus recognizing and appropriately treating occult shock, the survival rate of their patients increased from 7 to 53 percent. Survival was improved because of enhanced oxygen delivery through the use of adequate volume loading and inotropic support. These authors concluded that urgent invasive monitoring provides important hemodynamic information early, aids in identifying occult shock, limits hypoperfusion, helps prevent multiple organ failure, and improves survival. 8

The insertion of invasive monitoring lines seldom occurs in some emergency departments because of institutional practice and availability of equipment. Given the clear empirical evidence for the value of rapid assessment and early intervention, 8 every effort should be made by emergency physicians to expedite emergency department (ED) care of elderly trauma patients and prevent unnecessary delays. In the ED evaluation of blunt trauma patients, the chest radiograph, cervical spine series, and pelvic radiographs are necessary diagnostic tests during the secondary survey. After ordering this set of plain radiographs, emergency physicians must resist the temptation of trying to appease consultants by immediately obtaining plain films of every other body region that may have sustained minor trauma. While it is vital to be thorough in the diagnosis of occult orthopedic injuries, expending a great deal of time in the radiology suite, especially if off-site, may compromise patient care. Only a few radiologic studies, such as emergent head and abdominal CT scans, can take precedence over obtaining vital information from invasive monitoring, depending on the situation. Elderly trauma patients will benefit most from an expeditious transfer to the intensive care unit so that their hemodynamic status can be further monitored. After ensuring that their hemodynamic status has been stabilized, patients can be transported back to the radiology suite for further plain radiographic studies. If in doubt, extremities can be temporarily splinted.

In the ED, emergency physicians must make critical management decisions regarding volume resuscitation without the benefit of sophisticated invasive monitoring devices. Geriatric trauma patients can decompensate with overresuscitation just as quickly as they can with inadequate resuscitation. 9 Elderly patients with underlying coronary artery disease and cerebrovascular disease are at a much greater risk of suffering the consequences of ischemia to vital organs when they become hypotensive after sustaining trauma. During the initial resuscitative phase, crystalloid, while the primary option, should be administered judiciously because elderly patients with diminished cardiac compliance are more susceptible to volume overload. Strong consideration should be given to early and more liberal use of red blood cell transfusion. This practice early in the resuscitation would enhance oxygen delivery and help minimize tissue ischemia.

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