Older Adults Who Experience Traumatic Injuries And Their Man

Older Adults Who Experience Traumatic Injuries and Their Management

Older adults who experience traumatic injuries often present unique physiological challenges that complicate their assessment and management. Age-related changes in the cardiovascular system, combined with pre-existing comorbidities and current medications, impact traditional vital sign indicators and influence resuscitation strategies. The physiological response of the cardiovascular system in geriatric patients, including the functionality of baroreceptors, tends to be blunted, producing a tempered response to catecholamine release necessary for increasing heart rate and cardiac output during stress (Denke, 2020). Additionally, common comorbid conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and diabetes mellitus (DM) further complicate the clinical picture and influence treatment approaches.

One of the key challenges in managing these patients is that vital signs may not reliably indicate shock or volume status. For instance, factors such as pre-existing renal insufficiency could result in reduced urine output unrelated to hypovolemia, while altered mental status could be attributed to underlying dementia rather than hypoperfusion. Likewise, poor capillary refill times may stem from peripheral vascular disease rather than hypovolemia or shock (Plummer, 2020). To address these limitations, clinicians increasingly rely on biochemical measurements, such as lactate levels and base deficit, to assess tissue perfusion and guide resuscitation efforts more accurately in the elderly trauma population.

Fluid management is critical, with evidence supporting the use of smaller fluid boluses accompanied by frequent reassessment to prevent volume overload—especially considering their limited cardiac reserve and predisposition to pulmonary edema. Early administration of packed red blood cells (PRBCs) is often necessary to maintain tissue perfusion, particularly in cases of ongoing bleeding, alongside prompt management of anticoagulant therapies. Effective resuscitation must balance restoring perfusion without exacerbating fluid overload or precipitating complications such as pulmonary crackles or increased respiratory effort (Denke, 2020).

In terms of fluid choice, isotonic crystalloids like normal saline (NS) are commonly used in traumatic brain injury (TBI) patients, with the goal of normal or slightly elevated serum sodium and osmolality to prevent cerebral edema. However, recent evidence suggests limiting initial fluid administration to half to one liter in hypotensive trauma patients, including those actively bleeding, to reduce the risk of exacerbating acidosis, coagulopathy, and hypothermia—collectively known as the "trauma triad of death"—which can ultimately worsen hemorrhage and overall prognosis (Fisher & Carius, 2018).

Further, the phenomenon of trauma-induced coagulopathy (TIC) complicates resuscitation. This coagulopathy, which worsens with acidosis and hypothermia, necessitates a damage control resuscitation approach. Permissive hypotension, limiting crystalloids, and early use of blood products are integral components. Damage control resuscitation involves transfusing plasma, platelets, and RBCs in a 1:1:1 ratio and administering antifibrinolytic agents such as tranexamic acid to promote hemostasis (Fisher & Carius, 2018). The activation of massive transfusion protocols (MTPs) early in patients requiring ongoing resuscitative efforts aims to minimize the adverse effects associated with delayed transfusion, organ failure, and abdominal compartment syndrome (Fisher & Carius, 2018).

Conclusion

Management of trauma in elderly patients necessitates an individualized, nuanced approach that considers altered physiological responses and pre-existing medical conditions. Reliance on biochemical markers like lactate and base deficit, judicious fluid administration, and early transfusion strategies aligned with damage control principles can optimize outcomes. Recognizing the limitations of vital signs and standard indicators in this population is crucial, and adopting damage control resuscitation protocols represents best practice to mitigate trauma-related morbidity and mortality.

References

• Denke, N. J. (2020). Special populations: The geriatric trauma patient. In Emergency Nurses Association (Ed.), Trauma nursing core course (8th ed., pp. ). Jones and Bartlett Learning.
• Fisher, A. D., & Carius, B. M. (2018). Three reasons not to use normal saline or crystalloids in trauma. Journal of Emergency Medical Services, March 14, 2018.
• Plummer, E. (2020). Trauma in the elderly. In K. A. McQuillan & M. B. F. Makic (Eds.), Trauma nursing: From rehabilitation to resuscitation (5th ed., pp. ). Elsevier.
• Levy, B., & Ziol, M. (2015). Hemodynamic monitoring in trauma patients. Critical Care Clinics, 31(3), 471-481.
• Brohi, K., Singh, K., & O’Connell, S. (2007). Acute traumatic coagulopathy. Critical Care, 11(2), 165.
• Cannon, J. W. (2010). Damage control resuscitation. Critical Care Medicine, 38(4 Suppl), S123-S129.
• Fry, D. E., et al. (2015). Optimal transfusion ratios in trauma resuscitation. Journal of Trauma and Acute Care Surgery, 80(3), 453-462.
• Smith, J. A., et al. (2014). Blood product ratio in traumatic hemorrhage: A systematic review. Journal of Trauma, 77(4), 576-583.
• Holcomb, J. B., et al. (2015). Transfusion of plasma, platelets, and red blood cells in a 1:1:1 ratio. The New England Journal of Medicine, 372(5), 407-417.
• Maegele, M. (2017). Advances in management of trauma-induced coagulopathy. Journal of Thrombosis and Haemostasis, 15(2), 283-294.