Physiologic changes related to aging have a significant impact on how older patients respond to injury. According to Robert Barraco, MD, MPH, FACS, FCCP, these changes also affect every element of the trauma primary survey.

“The primary survey is ‘the same but different’ for geriatric trauma patients,” Dr. Barraco said. “It is the same because the ‘ABCs’ are the same and they are in the same order, but there are differences in each of the steps.”

Dr. Barraco is senior vice president and chief academic officer at Lehigh Valley Health Network in Allentown, Pennsylvania.

During the recent Virtual Summit on Geriatric Trauma, he explained how the physiologic changes of aging inform a geriatric-centered approach to the familiar ABCDE framework of trauma resuscitation.

Geriatric airway is more vulnerable

According to Dr. Barraco, aging-related changes in airway physiology include tissue redundancy (excess soft tissue in the upper respiratory tract), loss of muscle (which affects several breathing functions) and limited jaw thrust ability (complicating the physician’s ability to inspect the airway).

During the airway assessment for a geriatric trauma patient, he said, trauma teams should be aware that:

• “The airway collapses more frequently in the elderly.”
• “The elderly have dry friable mucosa, which can cause bleeding, whether it be nasogastric or orotracheal tubes.”
• “Cricothyroidotomy is more difficult in the elderly due to calcification of some of the cartilages.”

The use of airway adjuncts and second-generation supraglottic devices can help mitigate the risks of airway management in geriatric trauma patients. “And fiber-optic looks down the airway certainly help as well,” Dr. Barraco said.

When a geriatric patient undergoes rapid sequence intubation, he said, physicians should ensure safe dosing of RSI drugs to reflect the physiologic changes of the elderly.

Proceed cautiously with breathing and ventilation

Dr. Barraco noted that hypoxia and hypercarbia are more common in older trauma patients. “In addition, hyperventilation may compromise venous return and worsen hypotension,” he said.

During the breathing assessment for a geriatric trauma patient, his advice is to exercise caution:

• “For elderly patients, the goals are O2 saturations in the low 90s.”
• “Try using low ventilator volumes and pressures, say 6 ml/kg and a plateau of 30 cm H2O.”

“Of course, you start there and then you gauge your responses by your sats and your blood gases, etc.,” Dr. Barraco said.

Circulation: Restrictive protocols OK, but don’t delay

“Pitfalls in the circulation step for geriatric patients are a blunted heart rate and systolic blood pressure response,” Dr. Barraco said. “Systolic blood pressure and heart rate criteria differ for these patients, and capillary refill becomes unreliable.”

During the circulation assessment for a geriatric trauma patient, trauma teams should keep in mind that:

• “A point-of-care ultrasound of the vena cava, the heart, lungs, abdomen and aorta, so going a little beyond the usual FAST, can actually identify 80% of shock etiologies in the patient.”
• “It is recommended to get a second lactate 30 to 45 minutes after the patient arrives. So don’t just rely on the first one — get a second one about 30 to 45 minutes after arrival.”
• “If you believe the patient is in hemorrhagic shock, the mortality risk is higher if you delay transfusion beyond 4 hours. Restrictive protocols appear to be safe, and varying that towards the upper threshold should the patient have comorbidities, etc.”
• “And for non-hemorrhagic shock, again: cautious fluids, but don’t delay.”

Disabilities can complicate neurological assessment

When assessing the patient’s neurological status, trauma teams need to be aware of communication barriers that can affect elderly patients:

• “A pitfall here is removal of the patient’s hearing aid, and then the patient is unable to hear instructions, follow commands, etc. So make sure to return sensory aids as soon as possible.”
• “Glaucoma, cataract surgery and medications can alter the eye score of the patient’s Glasgow coma scale (GCS).”
• “Dementia can decrease the GCS as well.”
• Be alert to possible delirium. “This is another thing to think about, especially if a patient comes in stressed from their injury or from a sepsis. We’ve had a few patients come in as a trauma, but who were actually sepsis — they fell because they had septic shock. So don’t miss delirium from those causes.”
• Elderly patients have a higher incidence of central cord syndrome, Dr. Barraco noted, due to narrowing of the spinal canal from degenerative changes.

During exposure, be mindful of aging skin

“In the exposure step, the pitfalls here for geriatric patients are increased risk of hypothermia and skin breakdown,” Dr. Barraco said.

• “The action point is getting the patient off the backboard as soon as you can.”

In addition, he noted that pads are now available that can be placed on the patient’s sacrum shortly after arrival in the trauma bay, which can also help avoid skin breakdown.

Start with ABCDE and add F

According to Dr. Barraco, the most important addition to the ABCDE framework of the primary survey is the addition of F for frailty.

In this video excerpt of his presentation, Dr. Barraco discusses the research underpinning frailty in trauma and what it means for trauma patient care:

More issues in geriatric trauma

Dr. Barraco’s session at the Virtual Summit was entitled “5 Things You Need to Know About Geriatric Trauma”. His presentation also covered:

• The “uncommon yet common” issues of suicide and elder abuse in the older trauma population
• Why “injury masking” in the elderly makes it important to revise triage and activation criteria
• How dementia complicates patient assessment, pain management and other aspects of care
• How to recognize “quiet delirium” in injured older adults

The entire conference is now available for on-demand viewing. To learn more and access the complete program, visit Virtual Summit on Geriatric Trauma.