Geriatric patients are the fastest growing age group in the United States. The people who are 65 years and older account for 11% of the total population. Trauma is the ninth leading cause of death for those 65 years and older and the fifth leading cause of death for all age groups (Dechert et al., 2009). Because of impaired motor and cognitive functions, geriatric patients are at increased risk for trauma. Low-velocity mechanisms can cause significant traumatic injuries. Geriatric patients have a lower physiological reserve to respond to traumatic injuries and therefore have a higher morbidity and mortality rate (Dechert et al., 2009). Preexisting medical conditions (PMCs) in geriatric patients at the time of trauma produce a greater percentage of morbidity and mortality. With increasing age, there are increased incidences of comorbidities.
A study by Wutzler et al. (2009) describes the association of increased in-hospital mortality and specific PMC in posttrauma geriatric patients. There were six specific PMCs that predispose the geriatric patient for increased mortality posttrauma: peripheral arterial occlusive disease Stage IV; heart disease; hepatitis/liver cirrhosis; carcinoma/malignant disease; coagulation disorder; and obesity (Wutzler et al., 2009). The study found that the association of preexisting peripheral arterial occlusive disease Stage IV had a higher mortality rate posttrauma in geriatric patients. The stated hypothesis for the increased risk of mortality was decreased blood, oxygen, and nutrients circulated to the wounds and fractures for healing (Wutzler et al., 2009).
Geriatric trauma patients are undertriaged, with a higher incidence in the population aged 85 years and older (Rushing & Scalea, 2010). The degree of trauma based on mechanism and presenting physiological signs can be underappreciated in geriatric patients. Therefore, an inadequate prehospital assessment may be made and improper hospital transfer completed. Rushing and Scalea (2010) reported decreased mortality rates in trauma patients older than 80 years who were treated at Level I and II trauma centers (8%) compared with those who were treated at acute care hospitals (56%). Providers should keep a low threshold for transferring geriatric trauma patients to Level I and II trauma centers.
The patient of this case study was chosen because of the complexity of injuries and PMCs. The nurse practitioner had the opportunity to evaluate, diagnose, treat, and admit the patient to the trauma surgeon's service while working alongside the emergency physician.
“I fell, hit my head and I have left hip pain.”
HISTORY OF PRESENT ILLNESS
An 87-year-old Hispanic man was transferred to the emergency department (ED) of an acute care hospital via ambulance with a complaint of a fall, left hip pain, and hitting his head. Bleeding from the occipital scalp laceration was controlled. A brief loss of consciousness was witnessed prior to arrival. The patient presented alert, awake, and responded appropriately. The patient reported standing from his wheelchair, losing balance, and falling backward. The quality of the pain to his left hip was severe, and he rated the pain a 10 out of 10. He denied a headache. The patient had not stood or walked since the fall. There were no other complaints of pain or injury. The patient had no known drug or food allergies. See Tables 1–3 for past medical history, past surgical history, and current home medications.
The patient was 5 ft 6 in. tall (66 cm) and weighed 137 lb (62.14 kg). He was a retired widower with stepchildren, had no biological children, and was orphaned at 6 years of age. He had been living independently until he was previously hospitalized for dehydration, weakness, frequent falls, and other multiple health issues. The patient was discharged from the previous hospital to a local skilled nursing facility, where he had resided for 2 months. No family history could be obtained. His friends were at the ED bedside.
He had smoked one pack of cigarettes per day for 60 years and drank alcohol (beer) approximately 12 cans per day, but he reported cessation of both for the past 4 years. No use of recreational drugs.
REVIEW OF SYSTEMS
No rash or lesions.
There was an occipital scalp laceration with hematoma. Denied dizziness or headache.
Denied visual changes, pain, photophobia, blurred vision, diplopia, spots, floaters, itching, or discharge from the eyes.
Denied pain, tinnitus, vertigo, hearing loss, or discharge from the ears.
Denied nasal discomfort, nosebleeds, sinus trouble, rhinorrhea, or congestion of the nose.
Mouth and Throat
Denied bleeding, swelling from the gums, or oral pain.
Denied pain, stiffness, or range-of-motion difficulties from his normal range of motions. Denied difficulties in swallowing or masses in the neck.
Denied chest pain, chest pressure, cough, or congestion.
Denied palpitations, skipping beats, or racing heart rate.
Complained of nausea. Denied abdominal pain, nausea, or vomiting. Denied recent injury or trauma. Denied weight loss or gain.
Upon standing from wheelchair had lost balance, felt weak, and fell. Hit the back of his head and left hip. Denied vertigo, seizure activity, motor or sensory deficits, memory loss, or problem with speech.
Denied urinary burning or frequency. He does experience nocturnal and occasional incontinence. Denied polyuria or hematuria.
Temperature, 98.4°F (36.8°C); pulse, 76 beats per minute; respiration rate, 18 per minute; blood pressure, 102/49 mmHg; oxygen saturation, 98% on room air.
The 87-year-old man appeared stated age. He was frail and thin.
Occipital scalp laceration 6 cm in length, through to the galea with a 10 × 10-cm2 hematoma. The bleeding had been controlled. There were no signs of bony deformity, step-offs, or crepitus.
Pupils were 2+, PERRLA with EOMs (extraocular movements) intact. Vision was not assessed. The patient did wear glasses. No nystagmus.
No deformity of the external ears. The tympanic membranes bilaterally were clear of blood, hemotympanum, cerumen, or foreign bodies.
The nose was without obvious deformity; no bleeding or hematomas were noted. The nasal septum was midline. Facial bones are nontender to palpation and stable with attempts at manipulation.
Mouth and Throat
The mouth was clear of lacerations or deformities. The patient did wear upper or lower dentures that were present and intact.
A rigid cervical collar was in place. There was no vertebral point or paraspinal tenderness. There was no step-offs or palpable muscular spasms. The neck was supple, with no jugular vein distention, thyromegaly, or lymphadenopathy. The trachea was midline. There were no carotid bruits. Nexus criteria were used in the assessment of the cervical spine.
The chest was atraumatic without surface trauma. There was symmetric chest expansion with mild use of accessory muscles. No deformities of the chest wall. Nontender without crepitus or deformity. No palpable subcutaneous air. There were bilateral anterior and posterior breath sounds that were clear to auscultation bilaterally with good tidal volume.
Heart rate was 76 beats per minute that had a regular rate and rhythm. There were no ST- or T-wave changes on 12-lead electrocardiogram. There were S1, S2, and S3 heart sounds without rubs or gallops. There was a systolic murmur 3/5 over the apex. The peripheral pulses were 1+.
A nontender abdomen, flat, no organomegaly, masses, and no bruit. The bowel sounds were slow but present in four quadrants. No vomiting or diarrhea.
No back contusions, ecchymosis or abrasions are noted. Nontender without step-off or deformity to firm midline palpation. No CVAT or flank ecchymosis. Pelivis: Tender to palpation; unstable to compression. Femoral pulses strong and equal?
Rectum had a positive anal tone/wink and was hemocult negative for blood. There was no blood visually at the urethral meatus, atraumatic, and cremasteric reflex intact. Midstream urine collected was cloudy and amber colored.
The patient was alert, awake, oriented ×2, disoriented to place. The Cranial Nerves 2–12 were intact. Motor strength in the upper extremities was within normal limits, decreased strength in lower extremities, and painful elevation of left lower extremity. The patient was not ambulatory in the ED. Reflexes slowed but were present (1+) brachial/patellar.
No surface trauma. Full range of motion without limitation or pain. Good strength in all extremities. Sensation to light touch intact. All peripheral pulses are intact and equal.
Body temperature, 97.2°F (36.2°C); pulse, 102 beats per minute; respiration rate, 32 per minute; blood pressure, 82/48 mmHg in the right arm and 80/40 mmHg in the left arm; oxygen saturation, 94% on 2-L nasal cannula.
The patient's vital signs were deteriorating despite receiving 2 L of normal saline intravenous fluids and 2 units of packed red blood cells (PRBCs) via two large-bore intravenous accesses in the upper extremities. The patient was becoming more tachypneic, tachycardic, and uncomfortable. The patient was orally intubated with a size 7.5 endotracheal tube. The ventilator settings were as follows: assist-control mode with a ventilator rate of 20, tidal volume of 700 ml, PEEP (positive end-expiratory pressure) of +5, and FIO2 (fraction of inspired oxygen) of 100%. The patient's oxygen saturation increased to 100% once intubated. A central line was placed. The patient was continued on normal saline intravenous fluids to help maintain circulation. Two additional units of PRBCs were ordered and given. The patient's systolic blood pressure continued to hover around 90 mmHg systolic and a heart rate of 90–100 beats per minute after interventions. Dopamine was then started at 5 mcg/kg/hr, which was titrated and maintained by the registered nurse for a systolic blood pressure of 90 mmHg. A pelvic binder was placed in an attempt to stabilize the pelvic fractures. A warming unit was used to assist in normalizing body temperature. The occipital scalp wound was injected with 1% lidocaine with epinephrine (10 ml), cleansed, irrigated with saline, and stapled for closure. Neurologically the patient was somnolent but arousable.
Became rounded, without bowel sounds, and firm to palpation. A nasogastric tube was placed to decompress the stomach of air and for oral contrast medium.
Ongoing Vital Signs
Body temperature, 98.6°F (37°C); pulse, 106 beats per minute; respiration rate, 20 per minute. Blood pressure continued to hover around 90 mmHg systolic, and oxygen saturation 100% once intubated. Arterial blood gases: pH, 7.35; pCO2, 37; paO2, 191; HCO3, 20. The venous lactic acid value was 2.8 (normal range = 0.5–2.2). See Table 4.
- A single-view anterior/posterior chest radiograph was negative for lobar consolidation, effusion, or pneumothorax. The cardiac silhouette was mildly prominent but stable and without evidence of failure. Dual-chamber pacer leads were in place. A previous median sternotomy was noted.
- A bilateral hip/pelvis radiograph was positive for left pelvic fracture (see Figures 1–3). There was a displaced fracture involving the left innominate bone. There was an interruption of the medial acetabulum at the level of the ischium with a medial displacement. The femoral head remained positioned within the acetabulum. The symphysis and the sacrum were grossly intact. The survey of the hip and the pelvis was somewhat limited secondary to osteopenia and overlapping materials and bone.
- A computed axial tomographic (CT) scan of the abdomen and pelvis revealed acute comminuted fracture of the left pelvis involving the acetabulum. Fracture planes involve the iliac wing extending through the superomedial acetabulum (see Figures 4–8). There was displacement in the medial wall of the acetabulum at the level of the ischium. The femoral head was in position within the acetabulum. There were chronic superior pubic ramus fractures of the left and the right. The sacrum was grossly intact. Stranding of extraperitoneal fat planes in the left hemipelvis with intermediate attenuation material was compatible with hemorrhage. The hemorrhage in the left hemipelvis had a mass effect on the central pelvic structures. The extraperitoneal hemorrhage with extension into the perivesicular space and retroperitoneum approximately measured 6 cm anterior/posterior × 13 cm transverse. There were multilevel chronic compression deformities of the spine involving all lumbar vertebrae. Lumbar changes were superimposed on chronic degenerative changes. There were deformities in the visualized lower rib cage bilaterally with chronic and subacute fractures. The urinary bladder and abdominal viscera were intact and atraumatic. The kidneys were noted to be atraumatic. Secondarily, a wide-mouth ventral abdominal hernia containing a portion of the transverse colon without obstruction was noted.
- The finding of head CT without contrast was negative for acute intracranial injury. No hemorrhage, mass lesion, or evidence of acute infarction was noted. Chronic small-vessel ischemic changes were noted.
- The finding of cervical spine CT without contrast was negative for fracture or malalignment. Multilevel cervical spondylosis and facet arthropathy were found. The canal and the foramen were narrowed, but no gross interval changes were present.
- Head injury
- Occipital scalp laceration
- Syncopal versus near-syncopal episode
- Cardiac arrhythmia
- Myocardial infarction
- Chest/abdominal/pelvic trauma
- Hip/pelvic fracture secondary to fall
- Blunt head trauma
- Left hip/pelvis fracture
- Retroperitoneal hemorrhage
- Hemorrhagic shock
- Respiratory failure
- Acute anemia
- Head concussion with occipital scalp laceration
PELVIC ANATOMY AND ALTERED PHYSIOLOGY OF THE GERIATRIC TRAUMA PATIENT WITH COMORBIDITY
With trauma patients, knowledge of the anatomy of the pelvis, mechanism, and pattern of the injury helps in making an accurate diagnosis of pelvic fracture, determine interventions, and predict patterns of associated injuries. Being aware of the patient's age and PMCs helps in predicting outcomes of trauma and what the patient can tolerate physiologically.
The pelvis is made up of the sacrum, coccyx, and two innominate bones. The two innominate bones are formed by a natural fusion by adulthood, which include the ilium, ischium, and pubic bones that form the acetabulum (Scalea, Stein, & O'Toole, 2008). The sacrum and the two innominate bones come together to form what is known as the pelvic ring. The pelvis is flexible in movement with five joints that include lumbosacral, sacroiliac (SI), sacrococcygeal, pubic symphysis, and the ball-and-socket joint of the acetabulum. The pelvis is inherently unstable without the support of ligaments. Ligaments that give stability to the pelvic ring include dorsal and ventral SI ligaments, sacrotuberous, and the sacrospinous ligament (Ghory & Sharma, 2009).
The pelvis protects the abdominal viscera, gastrointestinal, genitourinary, and vaginal tract, and prostate glands. The primary blood supply for the pelvis is from the common iliac, median sacral, and superior rectal arteries. The common iliac artery further divides into the internal and external arteries that extend through the SI joint. The internal common iliac artery is more subject to hemorrhage into the pelvis with acetebular fractures and displacement of the femoral head (Ghory & Sharma, 2009). A rich neural plexus arises from the lumbar and sacral nerve roots. Sacral injury due to trauma and fracture can lead to neurological dysfunction in 25% of the cases (Ghory & Sharma, 2009). Femoral and obturator nerves do not rise from the lumbosacral plexus, but they can be injured with pelvic fractures because of their position in the pelvic framework (Scalea et al., 2008).
PHYSIOLOGICAL CHANGES IN THE GERIATRIC PATIENT
The most common PMC in the geriatric trauma patient is cardiovascular disease. As the heart ages, there are changes in the activity of growth factor, for instance, angiotensin II (a potent vasoconstrictor in arteries and veins that causes increasing blood pressure). The geriatric heart is more predisposed to arrhythmias because of myocytes and the conductive pathway that are replaced with fat and fibrous tissue with age (Schulman, Alouidor, & McKenney, 2008). Valvular and vesicular elasticity changes occur because of a reduction in elastin and collagen and a buildup of calcium resulting in large arterial dilation and intima thickening. There is a decreased response to catecholamine, which reduces the maximum heart rate in response to stress or hypovolemia. Because of a reduction in elasticity of cardiac vasculature, there is an appreciable decreased ventricular response, ejection fraction, and cardiac output. The decreased ventricular response is with or without the presence of congestive heart failure. A PMC due to coronary artery disease decreases the geriatric trauma patient's ability to autoregulate blood to the coronary arteries, thus causing arteries to experience higher incidence of cardiac events (i.e., myocardial infarction) with trauma (Schulman et al., 2008).
Home medications of the geriatric trauma patients can potentially impede the cardiovascular response to trauma. Medications such as carvedilol (Coreg, a β-blocker with α-blocker activity and used for the treatment of hypertension and congestive heart failure) and amiodarone (Cordarone, an antiarrhythmic agent and used for the treatment of congestive heart failure) can mask shock states, as in the present case. The home medication that reduces preload (right-sided heart-filling pressure) and afterload (left-sided heart level of resistance to overcome) of the heart can alter the response to blood loss, hypotension, and pain from trauma. In what would be considered “a normal blood pressure” may be shock in the geriatric trauma patients. Therefore, early interventions to monitor cardiovascular response and vascular perfusion could produce a more optimal outcome (Schulman et al., 2008).
After 30 years of age, the pulmonary alveolar surface area reduces by 4% per decade. The reduction of alveolar surface area decreases alveolar surface tension, area for gas exchange, and forced expiratory flow (Schulman et al., 2008). Geriatric patients experiences changes: Thoracic kyphosis reduces the transverse thoracic diameter; the chest takes on a barrel shape; there is a reduction in bone density; and the chest wall becomes increasingly rigid. The chest wall muscle mass reduces, which makes the use of accessory muscles in the abdomen necessary for breathing. Because of the decreased muscle mass and the use of thoracic muscles, there is a decreased ability to cough and clear mucous, predisposing the geriatric patient to respiratory tract infections. The geriatric trauma patient is more difficult to intubate because of degenerative joint disease of the cervical spine and temporomandibular joint, which decreases their ability to flex the neck and open the mouth widely (Schulman et al., 2008). With the presence of restrictive or obstructive pulmonary disease, there is decreased baseline arterial oxygen and increased arterial carbon dioxide tension, leading to decreases in the geriatric trauma patient's respiratory reserve (Schulman et al., 2008).
A PMC of the central nervous system makes for a difficult assessment of the Glasgow Coma Scale (GCS) score. The GCS is not always a reliable neurological examination in the geriatric patient, especially when a family member or health care provider who can verbalize the patient's normal state of mentation does not accompany the patient. The geriatric brain occupies 82% of the cranial vault versus 92% in a youthful individual (Schulman et al., 2008). Because of atrophy, the brain pulls away from the skull, increasing the subdural space. Because of the increased space, there is a predisposition for subdural hemorrhages in falls. Contrarily, the epidural space is eliminated in the geriatric patient, decreasing chances of epidural hemorrhages due to trauma. Removing geriatric patients from their natural environment predisposes them to confusion, depression, delirium, and agitation in the absence of pathology. Geriatric patients can experience significant brain injury due to minor events. Minor injuries (i.e., falls from ground-level positions) should be evaluated thoroughly (Schulman et al., 2008).
A PMC of the renal system predisposes geriatric patients to acute renal failure and increased systemic volume and electrolyte abnormalities. Secondarily, medical diagnosticians should maintain a heightened awareness of contrast medium from multiple CT scans and medications that are given with regard to renal dysfunction and clearance. In light of no PMCs of the renal system, a normal aging of the glomeruli occurs after 40 years of age. There is a 10% per decade reduction in functional units of nephrons and a 20%–25% reduction in renal mass, although the renal medulla maintains its volume (Schulman et al., 2008). During 50–80 years of age, there is a progressive reduction in renal mass weight from 250 to 180 g, thus reducing the glomerular filtration rate (GFR) by 45%. The reduction in GFR decreases the ability to concentrate urine (Schulman et al., 2008).
The most overt change in geriatric patients is musculoskeletal changes. There is a reduction in lean body mass by 4% every 10 years after 25 years of age, and this increases to 10% after 50 years of age (Schulman et al., 2008). With decreased lean body mass comes decreased strength. Osteoporosis is a problem in geriatric trauma patients, putting them at risk for fractures of the vertebrae, hip, and distal forearm. A loss of elderly bone mass of 60% in the trabecular bone and 35% in the cortical bone mass is common. Geriatric patients develop degenerative cartilage and joints and experience atrophy of the fibrocartilaginous and synovial tissues. Degenerative changes lead to osteoarthritis in the hip, knees, feet, and hands (Schulman et al., 2008). This instability of joints and increasing pain due to degenerative changes lead to impaired balance and mobility.
Geriatric patients develop degenerative changes in the cervical spine as they age. The most mobile portion of the cervical spine in youthful patients is at the level of C4–C7. In the geriatric patient, the most mobile aspect of the cervical spine is at the level of C1 (atlas) and C2 (axis) due to degenerative changes (Schulman et al., 2008). The vertebra C1 sits on top of C2 to form a joint that attaches the skull and the spine. C2 is the pivotal process on which C1 can rotate. The dens or odontoid process of C2 rises from the upper surface of the vertebral body. Simple falls from standing positions in geriatric patients put them at risk for odontoid fractures of the cervical spine (Schulman et al., 2008).
MANAGEMENT OF THE GERIATRIC PATIENT WITH COMMINUTED PELVIC FRACTURE AND RETROPERITONEAL BLEED
The highest priority for an ED practitioner in treating a geriatric trauma patient is to stabilize the airway, breathing, circulation, and cervical spine during the primary survey. Second, clinicians need to ensure that the disability and neurological status of the patient are assessed and protection from hypothermia while completely undressing the patient is provided (Kaufmann, 2008). The importance of recognizing possible injuries based on the mechanism of injury with a complete history and physical assessment cannot be underestimated during the secondary survey. Ongoing revaluation should be performed to detect deteriorations in the geriatric trauma patient's condition. If the patient's condition deteriorates at any point, the airway, breathing, and circulation must be reassessed and managed (Kaufmann, 2008). These interventions can be completed initially during the primary survey, before proceeding to the secondary survey, and while waiting for laboratory and imaging studies.
A complete history includes mechanism of injury, ambulation at the scene, location of pain, bowel or bladder incontinence, numbness or weakness, and any bleeding. In the geriatric trauma patient, there may be multiple injuries to be addressed. Many times collecting additional information from the paramedic, family member, or transferring health care provider is necessary to accomplish a complete history. The additional history about allergies, medications, past medical history, last meal, and events (mnemonic: AMPLE) is necessary for good trauma care (Kaufmann, 2008).
A head-to-toe physical examination is done after the primary survey and stabilization. With pelvic trauma and suspected fractures due to fall, the inspection of the geriatric patient should include checking for external bleeding, ecchymosis, blood at the penile meatus, vaginal bleeding, and the position of the lower extremities and iliac crests. Care should be taken to inspect the back and buttocks (Kaufmann, 2008). If there are no obvious deformities noted, range of motion, palpation of the bony landmarks, and complete neurovascular assessment should be done. With a suspected pelvic fracture and hemodynamic instability, stabilization of the pelvis should be attempted. Place an external compressive device, pelvic binder, or bedsheet in an attempt to reduce the pelvic girth, stabilize pelvic fractures, and therefore assist with hemorrhage control to promote hemodynamic stability. When applying an external compressive device, pelvic binder, or bedsheet, clinicians should enlist the assistance of three people: one person on either side of the patient to apply external pressure over the greater trochanters of the hips, and a third securing the device (Schulman et al., 2008). External compressive devices should be left in place no longer than 24–36 hr to avoid skin necrosis. Also, the act of tapping the legs together in internal rotation helps in reducing pelvic volume (Davis et al., 2008).
Parameters that denote hemodynamic instability are hypotension (blood pressure less than 90 mmHg systolic) and tachycardia (heart rate 100 beats per minute); however, keeping a lower threshold for hypotension and tachycardia in geriatric patients is a must. Crystalloid solution and erythrocyte transfusion of approximately 4–6 units of PRBCs should be given with ongoing resuscitation and correction of any acidosis and coagulopathy (Davis et al., 2008). Effectiveness monitoring of the resuscitation process through heart rate, blood pressure, metabolic status, lactate levels, and tissue hemoglobin oxygen saturation is a must. The standard for giving fresh frozen plasma and PRBCs is a ratio of 1:1 and platelet pheresis pack per 5–10 units of PRBCs (Davis et al., 2008). Blood typing and crossmatching are preferred routes that usually take about 10 minutes, but in the most emergent circumstances, type O (universal donor) transfusions are acceptable. Up to 4 units of type O blood can be transfused to any blood-type recipient without transfusion reactions (Petersen & Weinberg, 2008). Ongoing assessment of the patient's body temperature is crucial, especially when transfusing banked blood. The presence of hypothermia can cause coagulopathy in geriatric trauma patients in the near future. The use of warming devices for the patient (i.e., Bair Huggers, warmed blankets, warmed fluids, and blood products) will assist in maintaining a normal body temperature. Hypothermia becomes significant at 95°F (35°C).
Plain film anterior/posterior hip and pelvis radiography is primarily recommended in hemodynamically unstable patients to rule out displaced fractures, open-book injuries (opening the pelvis like a book, disrupting the symphysis pubis), and posterior pelvis injuries. The use of plain film radiography to diagnose pelvic fracture in trauma patients is recommended by Advanced Trauma Life Support, but several recent studies question the usefulness when CT is readily available. Hilty et al. (2008) suggest that in hemodynamically stable patients, the sensitivity is 67% for plain film radiography of the pelvis. And, it may be more appropriate to omit the radiography and move straight to CT if it is available and planned in conjunction with physical assessment. A CT scan of the abdomen and pelvis is the gold standard for diagnosis of pelvic fracture in trauma patients. The 64-slice multidetector CT is very sensitive for detecting arterial bleeds, retroperitoneal hemorrhages, fractures, dislocations of the pelvis, and concomitant injuries (Mohseni et al., 2011). Patients with open fractures should receive broad-spectrum intravenous antibiotics and tetanus prophylaxis. There is a prevalence of occult hip and pelvic fractures in geriatric patients. Geriatric patients with continual hip and pelvic pain who had a negative finding on plain film radiograph should undergo a CT scan or magnetic resonance imaging to identify occult fractures (Henes et al., 2011).
There should be early consultation with the trauma, orthopedic, and vascular surgeons and interventional radiologist in the care of the geriatric traumatic patient, especially when the patient is hemodynamically unstable. Management of pelvic and acetabular fractures can be difficult when they have associated injuries. The patients with major pelvic injuries who are initially resuscitated at nontrauma centers should be transferred to trauma centers after stabilization (Davis et al., 2008).
Angiography with embolization to control arterial hemorrhage with pelvic fractures in geriatric trauma patients has been the most useful procedure. However, the majority of pelvic fractures have been found to be venous in nature, with only 3%–10% being arterial bleeds (Fang, Shih, Wong, Lin, & Hsu, 2009). The need for angiography is not based on the age of the patient, pelvic fracture pattern, or the level of shock on admission but a combination of factors. Recommendations for patients who continue to be hemodynamically unstable and who have had other causes of internal bleeding ruled out are recommended to undergo angiography. However, many patients who do undergo angiography have to have a repeated procedure and further transfusion of blood products. Angiography is considered a safe procedure, although cases of femoral artery injury, elevation of creatinine levels in geriatric patients, gluteal necrosis, and protracted hypotension have been reported (Cullinane et al., 2011).
Other procedures and radiographic tests to rule out intra-abdominal bleeding with pelvic fractures are focused assessment with sonography for trauma (FAST), diagnostic peritoneal lavage (DPL), or diagnostic peritoneal (DP) tap. For the unstable patient with a positive FAST or DPL result, Davis et al. (2008) recommend that the patient should be taken to the operating room for exploration (laparotomy), pelvic stabilization, and preperitoneal packing. In addition, in the unstable patient who has a negative FAST or DPL result, introduction of external pelvis stabilization, preperitoneal packing, and pelvic angiography is beneficial (Davis et al., 2008). The general consensus is that FAST has a decreased sensitivity and a negative predictive value for accurately diagnosing intra-abdominal hemorrhage with pelvic fracture. And, if FAST has a negative result, it does not assist in the clinical decision making to take the patient to operating room for laparotomy or angiography (Cullinane et al., 2011). When the patient is hemodynamically stable to undergo CT of the abdomen and pelvis with contrast, the study has a better predictive value for determining the best mode of care for pelvic fractures with intra-abdominal bleeding. Both DPL and DP tap are not routinely performed in the ED and have a high false-positive result. The reasons for such a high false-positive result with DPL and DP tap are thought to be disruption of the passages of blood cells through an intact vessel wall of the abdomen during the procedure (Cullinane et al., 2011).
CONTINUITY OF CARE
The prognosis of the patient was poor. The patient had persistent hypotension despite administration of intravenous fluids, PRBCs in the ED, dopamine, and eventually Levophed (norepinephrine) prior to his admission to the intensive care unit (ICU). An external compressive device was placed on the patient's pelvis in an attempt to stabilize the pelvic fracture and reduce the pelvic girth. The trauma, orthopedic, and vascular surgeons and interventional radiologist were consulted either by phone or in person. The patient was managed in an acute care hospital and not at a level I or II trauma center. The consulted physicians concluded that the patient's care could be managed without transfer to another facility. Because of the patient's PMC of heart disease, respiratory problems, renal insufficiency, and the frail condition at the time of the fall, the consulted physicians decided not to take the patient to operating room or to perform angioplasty. By the third day in the ICU, a repeat CT scan of the abdomen and pelvis revealed a significantly reduced retroperitoneal hemorrhage. The patient ultimately received 9 units of PRBCs, fresh frozen plasma, and a “four pack” of platelets. After a week in the ICU, the patient was extubated, removed from mechanical ventilation, and was off vasopressors. The patient was alert, awake, and responded appropriately. Through discussions with the patient, the patient's stepchildren, and the physician, a do-not-resuscitate order was decided that supported the patient's wishes. On the ninth day postadmission, he was discharged from the hospital to an outpatient palliative nursing care center.
The case of this geriatric patient was not unique in the sense that the events and treatments rendered do not occur every day in the ED. But as the aging patients present to the ED with falls, the practitioner should have a heightened awareness of the anatomy and the altered physiological changes in these geriatric patients. Clinicians should take into account PMCs of the geriatric patient and home medications and how both alter physiological response to trauma. On the basis of the patient's presentation, hemodynamic stability, resources available, and the practitioners' level of knowledge and expertise, all greatly affect the outcome of the geriatric trauma patient. The acute care facility treating the geriatric patient had the resources and availability of specialty physicians (i.e., trauma, orthopedic, and vascular surgeons and the interventional radiologist) to consult with, perform procedures, and evaluate tests to treat the geriatric trauma patient. Although not a level I or II trauma center as the literature recommends, it is unknown whether this particular geriatric patient's outcome would have been different had he been transferred. Many facilities throughout the nation do not have access to trauma centers, but timely treatments are needed and given regardless with varying outcomes. The patient's airway was supported by mechanical ventilation, fluids and multiple blood products were given, and eventually vasopressors were given to maintain circulation while the intra-abdominal bleed resolved by self-tampanode. The patient progressively stabilized, ultimately transferring out of the ICU, and respectfully honoring the patient and family wishes to place in palliative care after a 9-day hospital visit.