Topic 11-12 D

Q-1

Fractures are the most common serious injury or trauma resulting from falls in older persons. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Several common chronic medical conditions, including arthritis, dementia of the Alzheimer's type, stroke, cataracts, and urinary incontinence, as well as such uncommon conditions as Parkinson's disease, are associated with falls. In healthy, active older persons, situational and extrinsic factors may be the predominant determinants of risk. Compared with frail and impaired elderly persons, falls among the individuals in this group are thought more often to involve overt environmental hazards, risk-taking activities like climbing ladders, hurrying, or running; in addition, they are more often likely to occur away from home. Exposure to fall risks is spread over a wide range of physical environments and activities. In contrast, falls in health-impaired older persons are thought to occur during routine ambulation and transfer maneuvers, usually without an overt environmental hazard, and to occur at home. Among the functionally impaired elderly, fall risks are focused on activities required for basic mobility within a familiar environment (Bergen & Stevens, 2019).

Prevention is key to avoid trauma and fracture in the older adults. Providers should address this in her assessments of older patient. All persons older than 65 years should be asked annually about whether they have fallen, the number of falls they have had and if they caused injury, and whether they have difficulty with walking or balance. The CDC STEADI initiative encourages providers to screen for fall risk by asking these questions and about fear of falling, or by administering the Stay Independent self–risk assessment brochure. A gait, strength, and balance evaluation should be performed if a patient answers positively to any of the screening questions. The Timed Up and Go (TUG) test, 30-Second Chair Stand test, and 4-Stage Balance test are quick and easy to administer. The TUG test is recommended as the primary measure of functional assessment. It involves timing the patient as he or she rises from a chair with armrests, walks 10 feet (with an assistive device if applicable), turns, walks back to the chair, and sits (CDD, 2018)

Centers for Disease Control and Prevention. (CDC) (2018). National Center for Injury Prevention and Control (WISQARS).Retrieved from: http://www.cdc.gov/injury/wisqars/0-900

Bergen, G. & Stevens, M. R. (2019) Falls and fall injuries among adults aged ≥65 Years. Morbidly and Mortality Weekly Report. 65(37):993–998. Retrieved from http://wwwmmr.org/injury/2019.9008

Q-2

In trauma patients, fluid resuscitation remains a discussed topic due to the availability of multiple agents to use such as crystalloids or colloids, packed red cells, or any combination of them to be successful (Wise, Faurie, Malbrain, & Hodgson, 2017). Some contributing factors that limit discussions are availability of resources, time, and the type of initial injury (Wise, Faurie, Malbrain, & Hodgson, 2017). The fluids that are most discussed are NS 0.9%, Balanced crystalloids such as Plasmalyte, and colloids such as Albumin (Wise, Faurie, Malbrain, & Hodgson, 2017);(Yoo, Bridewell, & Long, 2021).

In trauma patients who have signs of hemorrhage, clear fluid resuscitation is indicated with lower blood pressure targets until the operating room is available, then once the bleeding has been controlled, blood product resuscitation is indicated with higher blood pressure targets (Wise, Faurie, Malbrain, & Hodgson, 2017). For those that are having trauma to the brain, isotonic would be most favorable and balanced crystalloids would be favorable in other traumatic situations (Yoo, Bridewell, & Long, 2021). Otherwise, in most trauma patients, NS is the resuscitation fluid of choice, as it promotes the most benefit versus risk to the patient as well as being readily available (Wise, Faurie, Malbrain, & Hodgson, 2017). However, NS should be used only up to maintaining organ perfusion, then once achieved, the bleeding has been controlled, and blood products are available, it is then indicated to use a blood product for resuscitation (Wise, Faurie, Malbrain, & Hodgson, 2017).

The ultimate choice of type of fluid comes down to cost, and it happens to be that 0.9% NS is cheaper and more readily available to use in trauma situations despite the possible associated risks using 0.9% NS (Wise, Faurie, Malbrain, & Hodgson, 2017). The use of Ringer's Lactate shows more benefits to use as it is closer to similarity of blood plasma, but remains hypotonic, so that can induce or exacerbate cerebral edema (Wise, Faurie, Malbrain, & Hodgson, 2017). Studies have shown that when using albumin, there is either no benefit, or that there are actually worse outcomes, which has ultimately led to the recent recommendation of not using colloids particularly Albumin (Wise, Faurie, Malbrain, & Hodgson, 2017). One thing to remember is that in patients requiring resuscitation, when using 0.9% ns there is a higher incidence of hyperchloremic metabolic acidosis and subsequent AKI (Wise, Faurie, Malbrain, & Hodgson, 2017).

Overall the use of NS 0.9% has its scientific backing and role in trauma, for multiple reasons, and the resuscitation of traumatic patients blood should also be used but when it is appropriate (Wise, Faurie, Malbrain, & Hodgson, 2017);(Yoo, Bridewell, & Long, 2021). References:

Wise, R., Faurie, M., Malbrain, M., & Hodgson, E. (2017). Strategies for Intravenous Fluid Resuscitation in Trauma Patients. World journal of surgery, 41(5), 1170–1183. https://doi.org/10.1007/s00268-016-3865-7 Yoo, M. J., Bridwell, R. E., & Long, B. (2021). What Is the Optimal Resuscitation Fluid for Patients With Sepsis, Trauma, or Traumatic Brain Injury? Annals of Emergency Medicine, 78(2), 303–305. https://doi-org.lopes.idm.oclc.org/10.1016/j.annemergmed.2021.02.012

Q-3

Significant risk factors for trauma in adult and geriatric populations include polypharmacy, environmental factors, accidents, motor vehicle accidents, and medical events. Geriatric traumas are different than adult ones because of the physiological changes with aging, medications, and comorbidities that may be present. The injuries they sustain can be devastating because of the response to injury, bleeding, and shock that can occur (Gioffre-Florio, 2018). Age-related changes can include decreased muscle tone, weakness, reduced reaction times, unsteady gait, and cognitive changes. The body loses ability to respond to mechanisms of compensation throughout the body such as cardiovascular system with reduced elasticity of vessels and atherosclerosis. The responses are diminished, and tachycardia can be masked missing the signs of shock as versus the younger adults.

Prevention in the geriatric population can be doing more frequent med reconciliations, asking about home safety, physical therapy for stability, recommending exercise, monitoring blood pressure to assess for orthostatic hypotension, and making sure they have the right DME that is needed to maintain safety (Brooks & Peetz, 2017). As providers we need to make sure that patients have autonomy and are able to make decisions for themselves. Houses can be evaluated for fall hazards and physical therapy can see patients and make recommendations to help improve safety of the patient.

We had an instance that this 84-year-old woman seemed feisty and completely with it but when you ask her simple questions such as orientation ones, she couldn’t do it. She had a documented history for 2 years at different places that she should not be living alone and we recognized the deficits within a physical assessment and psychology and neurology came to see her and deemed her not safe to go home. We received collateral information from family that she had been leaving burners on, forgetting to do daily tasks, and ended up with recurrent cellulitis from her cats. We had to intervene and make sure this patient would have a safe discharge to prevent further injuries. With adult’s prevention is talking to them about medical history, importance of taking medication, wearing seatbelts, and no hold my beer moments. Polypharmacy is seen a lot as people get older and we need to recognize interactions and make sure all medications are appropriate and needed.

 

Brooks, S. E., & Peetz, A. B. (2017). Evidence-based care of geriatric trauma patients. Surgical Clinics of North America, 97(5), 1157–1174. https://doi.org/10.1016/j.suc.2017.06.006

Gioffrè-Florio, M., Murabito, L. M., Visalli, C., Pergolizzi, F. P., & Famà, F. (2018). Trauma in elderly patients: a study of prevalence, comorbidities and gender differences. Il Giornale di chirurgia, 39(1), 35–40. https://doi.org/10.11138/gchir/2018.39.1.035