One of the joys of working in medicine is the life long learning as an individual but also as a profession. On the back of new data from the TARN database reflecting the reality of clinicians, there has been much talk as to how to assess and treat older patients who have had trauma. First of all what constitutes a trauma call in itself is being reassessed – for those who have never been involved the BMJ visual summary explains it all. A prealert is sent to the hospital by the ambulance service so that a multidisciplinary team involving emergency medicine, surgery, orthopaedicas, anaesthetics and others are present on patient arrival in the ER should the ambulance crew be called to a patient who triggers any of the alarm parameters such as a low blood pressure or a high risk mechanism of injury. Previously a fall >2m was deemed to be needing a trauma call but the big change is that in older patients falls from less than 2m were found to be the leading cause of multiple trauma in older patients. The severity of the trauma is assesses retrospectively over the patients time in hospital with an ISS injury Severity Score calculated on the basis of injury to different parts of the body many of which will not be identified until CT scan or even later on the ward especially in older patients. The challenge is therefore how to triage parents to a trauma call when so many older patients are brought in for falls on the floor. New guidelines for both clinicians and patients are needed. Here below an example for clinicians from the Royal Free London.
Note that in older patients a systolic blood pressure of 110 and not 90 is a cause for alarm as is a GCS (Glasgow coma scale of assessing conscious level) of less than 15 even if it is their baseline. Importantly confusion can not be automatically attributed to baseline cognition issues (dementia) and delirium should always be considered as it can be fatal. The DTS calculator is a <20 second ER tool to rapidly rule out delirium as are the bCAM calculator or the CA2MS below- the important points to remember are that being quiet can still be delirium and controlling the basics such as analgesia and hydration help.
Download Delirium prompt card – Byram
Trauma patients are also often immobilised on their arrival so that their spinal cord is protected. This involves being taped into place between plastic blocks and being rolled in your entirety if you need to use a bedpan or vomit. A miserable if necessary experience at the best of times, for older patients a curved spine might make it even more uncomfortable and in the case of confused patients turn the whole experience into a very frightening experience. The jury is out as to whether the risks outweigh the benefits and it is always worth having the discussion as to whether full immobilization is needed and if so, to prioritise early imaging to remove blocks or collars if possible.
The easiest and most complete way to learn about this by listening to the MDTea podcast.…and further resources are available at the RCEM . HECTOR have been pioneering in looking at this and have a very complete guide as have Leicester who have a good introduction to the frail patient in general in the ED.
The Hearing Aid Podcasts
Presented by: Dr Iain Wilkinson Faculty: Pam Trangmar, Dr Cathryn Mainwaring, Susan Hendrickson, Rebecca Norton Release Date: 26th Feb 2019 Iain: Functional decline or lack of improvement is common in older adults with severe #frailty undergoing #TAVR or #SAVR.
Dr Alice Byram 