Identifying Elderly Trauma Patients
Caterino JM, Valasek T, Weman HA. Identification of an age cutoff for increased mortality in patients with elderly trauma. Am J Emerg Med. 2010;28:151–158.
Often in EMS, we discuss the need to have better trauma guidelines for the treatment of the geriatric trauma patient. However, a quick review of the literature reveals that no single age has been consistently used when discussing elderly trauma patients. Without consistent definitions, studies on these patients can’t be easily compared, and evidence-based protocols can’t be developed for the care of this patient group.
These authors evaluated all cases in a statewide trauma database that were 16 years or older. The data was grouped into five-year increments. The authors found that at age 70, there was a 5% increase in mortality for patients with an injury severity score (ISS) of less than 15 and a 20% increase in mortality for patients with an ISS of greater than 15. No other age group of patients less than 70 showed a dramatic rise in mortality.
In just 10 more years, 16% of the population will be over the age of 65. It’s important that EMS providers begin to realize that just as children aren’t small adults, patients over the age of 70 aren’t middle aged. We need to better define treatment and transport protocols that address the uniqueness of the older patient.
Hypothermia in Suffocation Resuscitation
Jehle D, Meyer M, Gemme S. Beneficial response to mild therapeutic hypothermia for comatose survivors of near-hanging. Am J Emerg Med. 2010;28:390.e1–3.
It has been well established that hypothermia is beneficial in the care of comatose cardiac arrest victims, and individuals can neurologically survive longer submersion in cold water. These authors wanted to find out if hypothermia could improve neurologic outcomes for near-hanging victims. In a near hanging, the unsuccessful attempt results in strangulation, not a fatal cervical spine injury. A near hanging is associated with global cerebral anoxia, the same type of event that occurs when someone has suffered a cardiac arrest.
The authors induced mild hypothermia, 34º F, on two patients who arrived at the hospital with spontaneous circulation but were comatose following a near hanging. Patients were maintained in mild hypothermia for 24 hours and then gradually rewarmed. Both made a full neurologic recovery.
This is only a case report; the numbers are small and can only serve to stimulate discussion about the use of mild hypothermia in other cases of cerebral anoxia. It certainly makes sense that this would work to preserve neurologic function. Now, we just need a larger study to support this hypothesis.
Alternate Delivery of Naloxone
Merlin MA, Saybolt M, Kapitanyan R, et al. Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses. Am J Emerg Med. 2010;28(3):296–303.
Giving naloxone to an opioid overdose patient can be dangerous. The traditional method requires that an IV be established in a patient population with higher than average risk of bloodborne pathogens. Once the medication has been administered, there’s a chance the patient will wake up and become combative. IV naloxone begins working in one to two minutes and lasts 30–90 minutes—depending on dose. Intranasal (IN) naloxone also has a near 100% bioavailability and a similar half-life to IV delivery.
These authors evaluated the increase in respiratory rate and GCS of patients receiving either IV or IN nalaxone. Initially, respiratory rates for both groups were 10, and GCS was 4. After IN naloxone delivery, respiratory rate increased to 16 and GCS to 12. The respiratory rate increased to 18 and the GCS to 15 in the IV naloxone group.
These results are very similar between groups, but the risk of exposure to bloodborne pathogens is nearly eliminated in the IN group. You might want to discuss this with your medical director. Several medication delivery systems that nebulize the naloxone for IN use are already on the market.
Poolside Blast Injuries
Shippert BW. Pool chemical blast injury. Am J Emerg Med. 2010;55:370–372.
When we think of pool-related incidents, the first thing that comes to mind is drowning or chemical exposure—not blast injuries. Common pool chemicals are toxic and can cause serious inhalation or dermal injuries if handled incorrectly. This is an interesting case report about a patient who lost part of a finger as a result of a blast from the interaction of calcium hypochlorite and cyanuric acid.
The patient mixed the chemicals in a nylon sock and dropped it into the pool. Several minutes later, he noticed the sock bubbling and smoking. He pulled the sock out of the pool, and it unexpectedly exploded, avulsing the distal portion of the left index finger.
This is an avoidable injury. The pool chemicals are clearly marked with warnings against mixing. You might consider including this in written material provided to patients after drowning prevention classes. It might also be useful to include information on dermal injuries from pool chemical exposure. These are just a couple of important contributions that EMS could make to keep our communities safe and healthy. JEMS