JEMS Clinical Review Features
This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.
Learning Objectives
>>”žReview statistics that illustrate how important it is for EMS to know how to handle geriatrics patients.”ž
>>”žExplain the effects of aging on the body and how they should change your assessment of the elderly trauma patient.
>>”žDiscuss the diseases and medications that can impact geriatric assessment and management.”ž
>>”žIdentify important EMS issues related to communication with and immobilization of geriatric patients
Glossary Terms
Kyphosis:An abnormal convex curving of the thoracic spine.
Osteoarthiritis:A group of diseases and mechanical abnormalities entailing painful degradation of joints. In the neck, it alters the structure of the spine, narrowing the diameter of the spinal canal and compressing the nerve rootlets.
Osteoporosis:A bone disorder in which bone material density is altered or disrupted.
Overtriage:A false assumption that a patient is seriously ill or injured.
Spondylosis:Degeneration of a vertebral body, causing vertebrae to become stiff and fixed.
Undertriage:A false assumption that a patient has no serious illness or injuries.”ž
It has been a typically busy Saturday when dispatch comes across the radio: “EMS 6, Rescue 2, respond to 280 Prince St., fourth floor, for a woman who fell, unknown extent of injuries.” Recognizing the address as a senior residence facility, you and your partner exchange looks that say, “Great, another little ol_ lady call.” A couple of minutes later, you arrive and enter the scene to find the crew of Rescue 2 gathered around an approximately 80-year-old female supine on the floor. Based on her position, it appears she fell from a standing position. The patient isn_t moving, but her eyes are open, and she_s following the activity of those around her. You_re not sure why the fire department EMTs seem to have made no attempt to assess, move or immobilize the patient, so you turn to the company officer and ask him what_s going on. Obviously frustrated, the lieutenant says, “We tried to do a patient assessment and get vitals, but every place we touch seems to hurt her.””ž
An Immediate Issue
When most EMS providers hear the word “trauma,” almost automatically the focus will be on the mechanism of injuryÆ’is it blunt or penetrating? Although most curricula would classify trauma this way, there_s another important criterion that needs to be considered when approaching these situations: how old is the patient? If they_re older than 65, important factors must be considered that may affect your assessment, treatment and transport.”ž
Just as we_re reminded that pediatric patients aren_t just little adults, elderly patients have their own set of differences that can make a geriatric call challenging andÆ’if not considered correctlyÆ’lead to EMS causing more harm than good. To properly handle a geriatric patient, prehospital providers need to re-evaluate and modify standard assessments and triaging techniques developed for the younger, general population of patients.
This becomes even more critical as the “baby boomer” generation ages, and advancements in technology and medication slow mortality rates, because the number of senior citizens in our society will continue to increase in the coming decades. People are living longer and remaining more active throughout their lifespan than ever before. In 2000, nearly 13% of the population was over age 65. According to the U.S. Census Bureau, by 2050, this number is expected to hit 20%, and Americans 85 and over are expected to make up 5% of the population.”ž
These individuals will certainly find their way into ambulances. Research shows that the elderly make up approximately 22à39% of”žEMSruns, which is out of proportion to their representation in the population. It_s estimated that the use of”žEMSby geriatric patients 65 years and older is twice that of younger patients. This utilization jumps by a factor of three when considering patients greater than 85 years old. When focusing on trauma as a presenting problem, geriatric patients are found to have an overall increased risk of morbidity and mortality. And although they account for just 12.5% of the general population, they account for one-third of all traumatic deaths in the U.S.
With this in mind, it_s clear new paradigms need to be embraced, but consensus is lacking. Leading physicians have stated that traumatically injured geriatric patients presenting with less than significant injuries should be transported directly to a trauma center. But physician organizations, such as the American College of Surgeons and the American Academy of Orthopaedic Surgeons, haven_t offered practical direction related to EMS response, treatment and transport. The American Geriatric Society, co-developer of Geriatric Education for EMS, has consistently described the training of EMS providers in issues related to geriatric patients as lacking.
However, at least one state, specifically Ohio, has studied the concerns surrounding geriatric trauma and issued guidelines to its EMS providers. A recent report from the Ohio Geriatric Task Force, subsequently approved by the Ohio Board of EMS, standardized the definition of a “geriatric patient” and offered direction to providers in the field.
Recommendations from the task force included giving geriatric trauma patients special consideration and sending them for evaluation at a trauma center if they have diabetes, cardiac disease, congestive heart failure (CHF), pulmonary disease, a clotting disorder, an immunosuppressive disorder or required dialysis. Ohio is now implementing these protocols statewide and has even submitted its new criteria to the Centers for Disease Control and Prevention_s (CDCs) Division of Injury Response for review and consideration for nationwide utilization.
Trauma Trends
According to the CDC, when considering mortality secondary to injury, the leading causes of traumatic geriatric deaths are due to (in order of prevalence) incidents involving motor vehicles (either as a pedestrian or vehicle occupant), firearms (typically suicides) and poisonings. Motor vehicle crashes (MVCs) kill almost as many people 65 and older as 20à24 year olds (see Figure 1). And in general, older individuals are twice as likely to die from their injuries as younger people.
Not surprisingly, given the normal effects of the aging process on strength and balance and the side effects from prescription medications, falls are the leading cause of non-fatal injuries in geriatric patients, resulting in five to 10 times more EMS calls than MVCs. The most common presenting injuries post-fall (in order of prevalence) are fractures, open wounds, superficial injuries (i.e., abrasions, contusions), sprains and strains, and traumatic brain injury (TBI). In a pedestrian-versus-motor-vehicle incident, trauma results in smaller numbers of overall injuries, but the rate and mortality in geriatrics is higher than in other age groups.”ž
Age-Based Assessment
When assessing a geriatric patient, EMS providers need to take into account several aspects of the aging process:”ž
Skin:”ž The dermis thins by up to 20% and blood supply to outer layers decreases. Smaller areas of burned skin can have a greater negative impact on an elderly patient than a similarly sized younger person. Healing of these and other insults to the skin layer, such as abrasions, lacerations and avulsions, can be delayed due to a breakdown of skin hydration and the skin replacement cycle.
Musculoskeletal system:”ž The amount of fat decreases relative to body weight, and the cartilage loses its adaptive capabilities, becoming less flexible and more likely to break when stressed. Fat pads normally found in and around bony prominences, like the pelvis, can be non-existent, leading to increased development of pressure sores if the body is left lying in one position for too long. Bones are also being robbed of calcium, especially in women, and are more prone to fracture.”ž
Pupils/eyes:”ž A high percentage of geriatric patients will present with an ophthalmic abnormality, such as cataracts or asymmetrical pupils, as well as some change in pupillary reaction from a pre-existing”ž
CNS condition or side-effect from prescription medications.”ž
Senses:“ž ltered perception of taste and/or smell, limited vision, decreased hearing, and a lower sensitivity to touch can make interacting with older patients misleading and frustrating.
Brain:”ž With age, the brain shrinks, stretching bridging vessels between the brain and skull. This causes a void; therefore, after a head injury, it may take days or weeks for internal bleeding to present signs and symptoms in elderly patients. For this reason, geriatric head injuries necessitate transportation to a medical facility. Your EMS unit may also be called out days or weeks after a fall or blow to the head to find the patient has developed an altered mental status, because enough blood has filled the void to create pressure and neuro changes.”ž
Peripheral nerves:”ž Elderly people may lose the ability to feel pain, meaning a minor complaint of “it hurts a little” may represent the only symptom of a significant fracture”ž
or other injury.”ž
Respiratory system:“žReductions in respiratory system capacity diminish the ability for the elderly to compensate during”ž
times of shock.
These changes to physiology can mislead an EMS provider. Dramatic-looking bruising and tearing of the skin that would indicate a serious underlying injury in a younger person may be of only minor concern in someone elderly. The discovery of unequal pupils (normally a red flag for TBI) may not be related to trauma at all in a geriatric patient.”ž
Conversely, an 80-year-old involved in what appears to be a low-impact MVC”žcould have fractures and dislocations a younger patient wouldn_t incur. Also, a geriatric patient with a head injury can present with a minor abrasion or hematoma on their scalp, but internally they may have significant intracranial bleeding.
As with all trauma patients, there can be issues of”ž overtriage”ž and”žundertriage. Studies have shown that both issues are extremely prevalent in geriatric trauma categorization and transport determinations. In general, many geriatrics present with only vague complaintsÆ’weakness, dizziness, diffuse painÆ’or a family member says they_re “just not acting right.” However, these complaints may be symptoms of a life-threatening injury.”ž
In addition to the actual traumatic event, underlying age-related medical problems can complicate, or have contributed to, the injury. Such conditions include diabetes, arteriosclerotic heart disease (ASHD), hypertension and CHF. For example, the elderly patient with untreated hypertension may be in shock when their blood pressure reaches the lower limits of normal.
Specific questions must be considered: Did the car accident occur because the patient failed to react in time, or is she having a transient ischemic attack? Can the sensory assessment distal to the arm fracture pre- and post-immobilization be trusted since the patient has insulin-dependent diabetes mellitus? How will you be able to appropriately package a patient who fell from a significant height when he_s complaining of exacerbation of his”žchronic obstructive pulmonary disease (COPD)“žand“ž can_t lie flat? When confronted with an elderly patient, it_s fairly safe to assume the trauma (e.g., dislocated hip, fracture, hematoma) won_t be the only medical issue a provider will deal with while transporting.”ž
Taking your findings in context is vital to treat a geriatric trauma patient appropriately. It_s your responsibility to ensure a complete exam is performed, including evaluation of motor and neurological functions.
A Note about Meds
In many systems, pain management can be provided under standing orders, but with older patients, this needs to be done judiciously. Although younger patients may tolerate common field analgesia medications, such as narcotics and nitrous oxide, the addition of these drugs to medications a patient is already taking may actually be contraindicated.”ž
The regular dosing of analgesia medications to achieve therapeutic levels may”žalso need to be adjusted. The body of a 70-year-old isn_t going to process 5 mg of morphine the same as that of a 30-year-old. Additionally, patients on blood thinners have an increased risk for intracranial bleeding from what appears to be minor head trauma.”ž
Other issues are brought on by drugs that affect heart rate. Because of atherosclerosis and arteriosclerosis, hypertension is common in the elderly, necessitating the use of drugs such as beta and calcium channel blockers. Also, because of CHF and rapid atrial fibrillation, digitalis preparations are also used. All of these drugs slow heart rate. In general, patients taking these drugs may not be able to compensate during early”ž
shock by elevating their heart rates. Don_t be fooled by a normal heart rate post trauma in patients on these meds, especially if other signs and symptoms of shock are present.
Making a Connection”ž
Communicating effectively with an elderly patient can be challenging. Depending upon underlying medical conditions, hearing and vision impairments, altered comprehension and the possibility of neurological disorders, communication may be difficult to impossible. Even if they speak the same language, your interaction may require involving others (e.g., family members, neighbors) to gain understanding and to solicit answers.”ž
Keeping the geriatric patient informed of your care plan, as well as transport determinations, is important for keeping them calm, compliant and immobile after a trauma incident. With the potential combination of acute traumatic and chronic medical factors, the majority, if not the entirety of, geriatric patients should be transported to a medical facility for evaluation and should be actively discouraged from refusing medical aid.
Packaging Points
Prior to packaging, make sure to ask about any pre-existing conditions, such asosteoporosisandosteoarthiritis.Osteoporosis and muscle weakness increase the potential for fractures, even with minor trauma. Understanding this is especially important for treating patients with musculoskeletal trauma. For example, when osteoporosis is present in the spine, basic movements (e.g., sitting down too hard in a chair, bending over, getting out of bed) can fracture the spine. The most common fracture sites in the elderly are the wrist, hip and spine, with the hip being the most commonly fractured of the three sites.”ž
In patients with osteoarthritis, sudden neck movements and even small amounts of hyperextension can easily squeeze their spinal cord, leading to injury. Thus, cord injury can occur without a fracture. It_s especially worrisome when the patient has a combination of osteoarthritis, osteoporosis andspondylosis.
So, keep the following “do_s and don_ts” in mind when packaging:
DO”ž ask about any pre-existing conditions. Finding out about conditions, such as arthritis and osteoporosis, before you begin packaging may save you from having to re-package or change your strategy mid-procedure.”ž
DO“žbe creative. When accommodating for physical deformities, use whatever materials are on hand (e.g., pillows, blankets, splints) to help make your patient”ž
more comfortable.”ž
DO”ž lightly pad pressure points. A smaller version of an air mattress sized for a backboard can be found commercially; however, a cheap alternative is sheets or”ž
thin blankets.”ž
DO NOT”ž force the patient_s head, neck, spine or extremities into a “neutral” position. Pre-existing conditions, like osteoporosis andkyphosis,can make this positioning impossible, and attempting it can lead to further injury.”ž
DO NOT”ž keep dyspneic patients supine. Remember that even a backboarded patient can be elevated by placing blankets under the head of the board while on the stretcher.
Fortunately, there are devices to help you move and immobilize geriatric patients. One of them is called the Res-Q Sling, which helps lift patients off the floor (go tojems.com/extras to find out more),and another is the “hip sling,” a device created for immobilizing hip and pelvic fractures. These devices are circumferential pelvic belts designed to provide safe and effective reduction and stabilization of open-book pelvic fractures. Research also shows that use of a pelvic sling device for an unstable pelvic fracture in the field can help prevent further injury when transferring the patient during extrication and transport. These slings are being used increasingly in the prehospital environment.
Make an Impact
Each year thousands of elderly citizens suffer traumatic injuries. EMS providers have the opportunity to positively impact their outcome with rapid, thorough assessments of injuries, as well as appropriate treatment and transport determinations. This may necessitate a combination of an in-depth medical history, physical exam”žand consultation with medical control.”ž
All EMS providers should seek to inform themselves about the specialized needs of geriatric trauma patients through continuing education, like that offered by the American Geriatric Society, and utilize that knowledge to better serve this increasing patient population.”žJEMS
Raphael M. Barishansky, MPH, is the chief of public health emergency preparedness for the Prince George_s County (Md.) Health Department and a frequent contributor to EMS publications. Contact him at”žrbarishansky@gmail.com.“ž”ž
Katherine E. O_Connor, BS, EMT-P, CIC, is an EMS systems program specialist for the Westchester County Department of Emergency Services in Valhalla, N.Y., and has been an EMS provider and educator for 18 years. Contact her at”žoconnor.ke@gmail.com.“ž”ž
References
- Centers for Disease Control: “The State of Aging and Health in America 2007 Report.””žwww.cdc.gov/aging/saha.htm“ž
- Gerson LW, Shvarch L: “Emergency medical service utilization by the elderly.” Annals of Emergency Medicine. 11(11):610à612, 1982.
- Dickinson ET, Verdile VP, Kostyun CT, et al: “Geriatric use of emergency medical services.” Annals of Emergency Medicine. 27(2):199à203, 1996.”ž
- Wofford JL, Moran WP, Heuser MD, et al: “Emergency medical transport of the elder: A population-based study.” American Journal of Emergency Medicine. 13(13):297à300, 1995.
- Hannan EL, Waller CH, Farrell LS, et al: “Elderly trauma inpatients in New York State: 1994à1998.” Journal of Trauma. 56(6):1297à1304, 2004.
- Kauder DR: The Trauma Manual. Lippincott Williams and Wilkins: Philadelphia, 2002.
- Sugimoto K, Aruga T, Hirata M, et al: “Geriatric trauma patients at a suburban level-1 trauma center in Japan.” Prehospital Disaster Medicine. 14(3):186à190, 1999.
- Demetriades D, Sava J, Alo K, et al: “Old age as a criterion for trauma team activation.” Journal of Trauma. 51(4):754à757, 2001.
- Ohio State Board of EMS Trauma Committee: “Geriatric Trauma Task Force: Report and recommendations.””žwww.ems.ohio.gov/datacenter/Geriatric%20trauma%20triage%20study.pdf“ž
- Centers for Disease Control: “The Three Leading Causes of Injury Mortality in the U.S., 1999à2005.”www.cdc.gov/nchs/products/pubs/pubd/hestats/injury99-05/injury99-05.htm“ž”ž
- Phillips S, Rond PC, Kelly SM, et al: “The failure of triage criteria to identify geriatric patients with trauma: Results from the Florida Trauma Triage Study.” Journal of Trauma. 40(2):278à283, 1996.”ž”ž”ž”ž”ž”ž”ž
New CDC GuidelinesIn January, the Centers for Disease Control and Prevention released “Guidelines for Field Triage of Injured Patients: Recommendation of the National Expert Panel on Field Triage,” in Morbidity and Mortality Weekly Report. Part of the Field Triage Decision Scheme Recommendations is to identify patients who are at risk for severe injury and may need transport to a trauma center, which includes patients over 55 years old. For more, go to”žwww.cdc.gov/fieldtriage
For more on geriatric care, visitjems.com/specialty_patients
