Silver Trauma (+small bit of Frailty

Question 1

Why is Silver Trauma so complex

Answer 1

Trauma can be secondary to a medical event ?CVA, MI, diabetic hypo etc

Drugs will and can affect the physiological response and management

Question 2

Mechanisms of injury

Answer 2

Most common is blunt force trauma with falls <2m

Fall from standing / ‘mechanical fall’ (should be thinking as falls as a frailty syndrome!)

Question 3

Older pts have a higher mortality

Answer 3

Poor physiological reserve – decline organ function
Pre-existing medical conditions – skeleton more vulnerable to fracture
Medications / polypharmacy
Poor triage – pre-hospital and ED sample of 4534 15.1% under triaged
Low energy more likely to result in injury, high MOI more likely to result in fatality

Question 4

Cardiovascular

Answer 4

Differing response to hypovolaemia – less effective autonomic control (vasoconstrictive response is impaired)
Less ventricular compliance
Associated cardiac disease
Deranged physiological parameters may not apply in the elderly
As many as 1/3 of Silver Trauma pateints deemed clinically stable based on blood pressure and heart rate go on to have a cardiac arrest within 24hrs of hospital admission
BP below 110mmHg and or HR above 90 higher mortality in elderly trauma

Question 5

Corona mortis

Answer 5

Anastomosis between inferior epigastric artery and obturator sits behind pubic rami can be a site of bleeding

Question 6

Resp

Answer 6

Increased chest wall rigidity
Loss of muscle mass
Reduced alveolar surface for gas exchange
Reduced central responses to hypoxia and hypercapnia

Minor chest injuries (shallow breaths – development of pneumonia) each additional rib fracture mortality increases by 19% and risk of pneumonia 27% (chest injuries most commonly missed)

Question 7

CNS

Answer 7

Cerebral atrophy (decreasing brain size)
Delayed signs of cerebral hemorrhage increased space, GCS may remain high for a while
Increased vascular fragility – sheer type bleeds
Non-vit K reversible oral anticoagulants
Subdural hematomas COMMON
Delayed reflexes
Cognitive impairment
Confusion and delirium / new or old?
Elderly will likely have a higher GCS than younger patients with the same head injury

Question 8

Skeleton

Answer 8

Osteoporosis
Osteoarthritis / osteoarthosis
C-spine control
Dementia, delirium, aphasia, degenerative arthritis, stiff neck, Parkinson’s disease
High likelihood of long bone and pelvic fracutres

Question 9

Co-morbidity

Answer 9

Increases Frailty and physiological reserves

COPD, chest trauma, impaired cough, poor lung clearance = pneumonia

Question 10

Risks of c spine collars for the elderly

Answer 10

Forcing the neck into positions for the collar to fit
Increased CSF pressure
Pressure sores
Decreased tidal volumes

Overall clinical concern should be considered – consider the entire picture rather than relying on c spine tenderness in isolation
Degenerative spinal conditions
Kyphoscoliosis
Parkinsonism (rigidity, bradykinesia (slow movement))
Steroid associated ‘buffalo hump’
Minimal movement immobilization

Question 11

Red flag medications and why! – POLYPHARMACY

Answer 11

Anticoagulants – Rivaroxaban, Apixaban, Dabigatran, Enoxaparin (NOAC)
Antiplatelets - Clopidogrel, Aspirin, Ticagrelor
Adcal D3, Alendronic acid
Beta blockers
Calcium channel blockers
Steroids

Question 12

Long-lie

Answer 12

Time spend on the floor?