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HECTOR

The Heartlands’ Elderly Care Trauma & Ongoing Recovery Programme

Course Manual

Author Dr David Raven MBChB FRCEM

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Foreword

The Heartlands’ Elderly Care Trauma & Ongoing Recovery Programme (HECTOR) started with Paul. Paul was 89 years old when he presented to the Emergency Department with pain in his neck following a fall down five steps on the previous day. Holding his head, he was asked to sit in the waiting room to be called two hours later into a Minors cubicle. On assessment his neck was immediately immobilised and a CT cervical spine requested for a suspected fracture of his odontoid peg.

Paul had no history of: loss of consciousness; amnesia; vomiting; nor did he have any neurological abnormalities on examination. In consideration of such findings, and also due to the fact that Paul wasn’t taking anticoagulant medication, there was felt to be no need for a CT Head scan.

The CT scan of Paul’s cervical spine revealed a type II fracture of his odontoid peg and following discussion with the regional Neurosurgery team, he was admitted under the local Trauma & Orthopaedic team. Paul died nearly 11 days after his admission. During this time, it was noted that he had an isolated episode of acute confusion and blood tests had shown falling levels in his serum sodium concentration.

Neither of these features were acted upon and a CT scan performed a few hours before his death revealed the presence of large bilateral subdural haematomas. Paul would not have been a candidate for surgery even if such a diagnosis had been made earlier, but nevertheless, the care he received could have been much better.

The HECTOR Programme was established in an attempt to highlight such issues and develop a training programme for clinicians and independent practitioners who are responsible for looking after older people with injuries. The injuries that an individual sustains often plays second-fiddle to the complex co-morbidities, frailty and challenge of being cared for within ever pressured urgent and emergency systems.

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The HECTOR symbol is a helmet which represents a protective mechanism against direct trauma. It is designed to highlight the fact that most elderly people sustain their injuries following same-level falls, especially with damage to the head and neck.

The symbol’s colour represents vibrancy and the fact that the negative stereotypes that accompany advancing age are outdated – some people continue to lead full, active lifestyles well into their 80s and negative assumptions about quality of life should not be made based on age alone.

This manual has been written for people like Paul in an attempt to ensure that patients of advancing age receive safe and high quality trauma care. This care should focus on them as individuals and be directed towards the following theme:

“To treat patients with injuries and not injuries on patients”

Dr David Raven

This work is dedicated to Jaq, Fin and Henry – the foundations upon which HECTOR was built and the greatest support of all.

HECTOR is registered with the UK Copyright Service Reg No. 284686535

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AN INTRODUCTION TO HECTOR

Chapter 1: Important Considerations for the Injured Elderly Patient Page 8

PART I: THE IMMEDIATE ASSESSMENT AND TRAUMA SURVEYS

Chapter 2: Initial Assessment & Triage Page 18

Chapter 3: The Primary Survey Page 25

Chapter 4: Imaging After the Primary Survey Page 39

Chapter 5: The Secondary Survey Page 46

Chapter 6: The Silver Survey Page 54

PART II: MANAGEMENT OF SPECIFIC INJURIES IN ELDERLY PATIENTS

Chapter 7: Head Injuries Page 66

Chapter 8: Cervical Spine Injuries Page 78

Chapter 9: Thoracic and Lumbar Spine Injuries Page 90

Chapter 10: Thoracic Injuries Page 98

Chapter 11: Abdominal Trauma Page 111

Chapter 12: Extremity Trauma & Burns Page 124

PART III: MEDICAL ILLNESS AND CO-MORBIDITIES IN THE INJURED ELDERLY PATIENT

Chapter 13: Falls Page 136

Chapter 14: ECG Interpretation and Management Page 142

Chapter 15: Management of Illness Page 151

Chapter 16: Pharmacological Considerations Page 160

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PART IV: ONGOING CARE AND RECOVERY

Chapter 17: The HECTOR Daily Assessment Page 170

Chapter 18: Elderly Abuse & Vulnerable Adults Page 186

Chapter 19: End of Life Care and Do Not Resuscitate Decisions Page194

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AN INTRODUCTION TO HECTOR

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Chapter 1 – Important when caring for the injured elderly patient. Considerations for the Injured Elderly Patient In order to develop a deeper understanding of the difference in the Introduction delivery of trauma care for older patients compared to younger individuals, it is Traditional teaching in trauma care, from important to take the following into ATLS to ETC, remains very injury-focussed. account: Students are taught how to diagnose and treat life-threatening injuries. For A. Patient Considerations example, they are given the skills needed B. Triage Considerations to insert chest drains into haemothoraces C. Training Considerations and how best to reduce fractures and D. Recovery dislocations. Such concepts are a crucial part of trauma care and are fundamental A. Patient Considerations for delivering a safe service. Outward Appearance However, this also relies on a “one size fits As human beings, we are continuously all approach”. For example, the Shock analysing information placed in front of us Classification Tool assumes that all and making assumptions and judgements individuals will have the same based on that information. The outwardly physiological response to blood loss and appearance of individuals may affect how exhibit specific parameters that define the we interpret their state of health. This different degrees of shock1. Such evidence could lead to assumptions being made is useful as a guide but in practice, may about how we might expect a person to not reflect how ageing physiology respond to injury. manifests itself under different states of stress. For example, an 80-year-old gentleman who has no significant past medical The philosophy for the care of the injured history may look older, but be healthier elderly patient should be to treat a than a 65-year old individual with a patient with injuries and not injuries on a history of myocardial infarction, diabetes patient. This philosophy is based on the and COPD. Their response to injury may fact that a combination of: ageing be completely different to that of the anatomy and physiology; co-morbidities; younger individual. and polypharmacy; mean that an individual patient-centred approach is In some circumstances, outward key. All of these factors will affect how an appearance is helpful. For example, a individual responds to trauma both in the clinician can assume that a patient who is acute setting, and in the later stages of observed to have profound hemiplegia, is their recovery. bed-bound and has rolled out of bed sustaining a femoral shaft fracture This manual aims to introduce concepts of presents a high risk for pressure sores and holistic trauma care for older patients and venous thrombo-embolism. Such highlight some of the challenges faced observations should be balanced against the risk of negative stereotyping.

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In the acute setting, it is safer to forgo mechanisms are more likely to lead to assumptions made on the basis of significant and possibly life-threatening outwardly physical appearance and begin multi-system injury. to gather more information about the individual (e.g. past medical history, social With an increased likelihood of history). This information can then be osteoarthritis with advancing age, used to form a global picture to prevent degenerative change and osteophyte inaccurate assumptions. Accurate history- formation can lead to fixed flexion taking, in combination with thorough deformities in the joints, especially the examination, is an essential and cervical spine. Kinetic energy applied to fundamental concept to preventing these more rigid structures is more likely unnecessary error and avoiding negative to result in fracture than when applied to stereotyping that can occur with age. flexible structures that can freely flex and extend and thus absorb some of this Anatomy & Physiology energy. Trauma is a sudden and acute insult to a person’s body. When this body is in a Bone-related disease isn’t the only issue prime state of health and functioning at that can lead to musculoskeletal rigidity. A 100%, the individual may respond better patient with Parkinsonism may have to a particular insult. Trauma applied to hypertonia of the neck muscles producing an ageing body may have a more rigidity of the cervical spine. Direct kinetic significant impact. energy applied to the head of such individuals (e.g. following a fall) may not The ageing process involves the be absorbed by flexion of the cervical replacement of active parenchymal cells spine without fracture or excessive with inactive interstitial cells. This abnormal movement. invariably leads to a loss of functional reserve and a decline in organ function. It Respiratory System is important to understand how such The ageing lungs undergo changes which processes affect different body systems. will affect their underlying function:

Musculoskeletal System a. Increased chest wall rigidity The ageing skeleton is more vulnerable to traumatic insult than younger bones. The b. Loss of muscle mass of respiratory presence of osteoporosis and reduced muscles mineral density makes bones more susceptible to fracture with a given force. c. Reduced alveolar gas exchange surface Seemingly minor mechanisms of injury area that may have had no impact on the younger skeleton, for example a fall from d. Reduced central responses to hypoxia standing, could result in significant and hypercapnia fractures in the older individual. Overall, elderly patients will have a less It is therefore important to appreciate compliant chest wall and will need to that “low energy” mechanisms are more work harder with each inspiration to open likely to lead to injury in older collapsed airways. This may be individuals, and “high energy” exacerbated by injury to the chest wall or

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lungs, and worsened further by pre- The presence of atherosclerosis can existing lung disease. impair blood flow to vital organs. This in combination with hypovolaemia A loss of muscle mass will lead to an secondary to traumatic blood loss can increased risk of fatigue with lung or chest have a major effect on auto-regulation wall injury. This may produce hypercapnic and lead to the development of severe (Type II) respiratory failure at a much organ injury even with a moderate degree earlier stage and such patients maybe of hypotension. more likely to need supported ventilation. Taking all of these features into Cardiovascular System consideration, standard “abnormal” Taking the cardiovascular system into parameters of physiology that are used consideration, a young patient can to define states of shock and cardio- respond to hypotension by respiratory distress are not always vasoconstriction and increasing their applicable to the elderly patient. cardiac output. The cardiac output (CO) can be increased by increasing stroke volume (SV) or the heart rate (HR). Co-morbidity In addition to the ageing process, genetics CO = HR x SV and/or habits and behaviours acquired over the course of an individual’s lifetime The ageing myocardium is replaced by may predispose them to illness and collagen and fat, leading to stiffer walls deteriorating function, e.g. the smoker and less ventricular compliance. This can with COPD. limit the heart’s contractile ability and lead to a decreased cardiac reserve. Taking a patient who has fallen and Stiffening of blood vessels, desensitisation sustained a head injury as an example, the of baroceptors and impaired autonomic ageing brain undergoes a degree of function limits this reserve even further. cerebral atrophy, shrinking in the process. This “shrinking effect” pulls the subdural An age-related reduction in atrial veins taut and leaves them at greater risk pacemaker cells can lower the resting of tearing following a fall. A younger heart rate and place a limit on the individual is extremely unlikely to have maximum attainable heart rate. This in such a degree of atrophy so the veins turn can place a limit on the cardiac aren’t under as much pressure and are output. thus less likely to tear.

Disease processes affecting the A young patient with rib fractures may cardiovascular system may further affect fare better than an older patient with its performance when faced by the COPD. The young patient may be sent physiological challenges of traumatic home with simple analgesia and chest injury. Infiltration by amyloid deposits or exercises but the older patient may pre-existing myocardial damage may require admission for oxygen therapy and impair conduction pathways, predisposing formal chest physiotherapy to prevent individuals to arrhythmias such as atrial collapse and consolidation. fibrillation.

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If the patient has COPD, the delivery of Beta-blockers are one of the commonest oxygen is determined in terms of whether prescribed medicines. They cause a they retain CO2 and need targeted O2 blockade of B-adrenoceptors, leading to saturations. This contradicts standard blunting of the contractile and inotropic principles of trauma care which cardiac response. This coupled with age- recommend the delivery of high flow related densitisation of receptors to oxygen to all patients. sympathetic outflow may conceal an obvious physiological response to injury. All individuals are unique and need a bespoke approach to their care. HECTOR Warfarin and novel oral anticoagulant believes that all clinicians responsible for medications are often prescribed to providing acute trauma care should have patients with a risk of thrombo-embolism a basic understanding of managing acute (e.g. patients with metallic prosthetic medical illness. Without such knowledge, heart valves, concurrent or previous elderly patients are unlikely to receive DVT/PE or atrial fibrillation). Any patient high-quality care and more likely to be at who has sustained an injury whilst taking risk of developing unnecessary warfarin or one of the novel complications. anticoagulants should be deemed as being at high risk of catastrophic Certain co-morbidities are associated with haemorrhage. a higher level of mortality than others. One retrospective review found that previous CVA (p=0.003), a history of CCF B. Triage Considerations (p=0.0009) and a higher number of co- morbidities (p=0.0273) were significantly Pre-hospital triage tools often refer to 2 associated with mortality . Other studies features such as: abnormal physiology; have identified that the presence of abnormal anatomy; and mechanism of hepatic, renal disease or active cancer injury as part of the decision-making significantly increase mortality. process about whether a patient warrants Level I Major Trauma Centre transfer or HECTOR believes that all elderly patients can be managed in a local unit. being admitted to hospital should have a formal review of their past medical Such tools often use mechanism of injury history and drug history during the initial as a factor but fail to take into account an stages of resuscitation. All co-morbidities individual’s age. Taking normal should be documented in the patient’s physiological and anatomical ageing records and this may involve reviewing processes into consideration, an older old clinic letters, discharge summaries or person struck by a car is more likely to speaking to family members to gain as suffer significant injuries than a younger much information as possible. person. High mechanisms of injury in older individuals therefore warrant a Polypharmacy higher degree of suspicion for severe Elderly patients with underlying illness traumatic injuries than in younger may be taking a myriad of medicines that patients. can alter their physiology and response to injury.

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There are particular mechanisms of injury Such low-energy mechanisms may not that cause concern, irrespective of age alert pre-hospital or in-hospital triage group: teams to the possibility of severe underlying injury. This could lead to  High speed Road Traffic Collisions under-triage and delayed care. A 2003 (high speed rollover; ejection; death in retrospective Pennsylvania-based study3 same compartment; prolonged found that only 36.6% of patients over the entrapment) age of 65 were treated in a level 1 centre compared to 47% of those under 65  Pedestrian Traffic Accidents; (p<0.001), when adjusted for AIS and ISS.

 Falls from height or down a full flight Another study of the Maryland 4 of stairs; Ambulance system found that the rate of under-triage (patients not taken to Level I  Penetrating torso trauma. centres despite having significant injuries), was higher for patients over the age of 65 One mechanism of injury that is often years (49.9% vs 17.8%, p<0.001). ignored is a simple fall from standing. Fall from standing is by far the commonest Under-triage means that patients are not mechanism of injury in the elderly age taken to the most appropriate centre to group. A local survey of 195 patients with deal with their injuries. The Maryland TARN-qualifying injuries presenting to the paper identified a lack of training, HECTOR site found that simple falls were by unfamiliarity with protocol and age bias as far the commonest mechanism of injury, factors that led to under-triage of elderly (see below). patients. HECTOR believes all sites need to be aware of the risks of under-triage and develop internal triage systems which can cater for such issues.

Mechanism By Age Group 50

40

30

20

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0 65-70 71-75 76-80 81-85 86-90 91-95

Total Fall Height RTC Other

Fig 1. A retrospective survey of injury mechanism for patients over 65 at the HECTOR site

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Suggested Adaptation to Pre-Hospital Triage Guidelines

EAST GUIDELINE5 OHIO REGISTRY REVIEW6

Age >65 and co-morbidity should lower the GCS <14 with suspected head injury threshold for Level I Trauma Centre Care Systolic Blood Pressure < 100mmHg Fall from any height with head injury Severe anatomic injury (AIS >3) in more than Multi-system injuries one body region should warrant Level I Patient struck by moving vehicle Trauma Centre Care Long bone fracture after RTC

C. Training Considerations Excellence (NICE), European Society of Cardiology (ESC), British Thoracic Society UK-based trauma training relies heavily on (BTS), Royal College, and Local Hospital the (ETC) European Trauma Course and practice. ATLS (Advanced Trauma Life Support). Both are unique but both tend to focus on Specific guidance can be found in the injuries as opposed to the underlying 2012 Silver Book which recommends patient with those injuries. advanced approaches for the delivery of 7 care to injured elderly patients . Up to HECTOR acknowledges the skill-set and date evidence will be used throughout knowledge that both courses teach and this manual to introduce key concepts in recognises the importance of core the care of elderly patients. principles in the management of any patient with traumatic injuries. HECTOR believes that trauma care should be patient-centred, holistic and “total”. There is very little coverage of trauma Assessment and management should not care for the injured elderly patient in cease once primary, secondary and even these manuals, and population-based tertiary surveys have been completed. surveys have shown that this Assessment is an ongoing process and demographic has been increasing over the information obtained in the acute stages last few years. of presentation can have a major impact on later care. It is just as important to know how to treat complications of injuries as it is the D. Considerations for Recovery injuries themselves. This is even more relevant if a patient has underlying illness Patient-Centred Recovery that could leave them vulnerable to future Injury-focussed care will look at an complications, (e.g. diabetes mellitus and individual as having femoral shaft fracture infection). Guidance may be taken from in isolation. Once a patient has been the National Institute of Clinical admitted, plans will be taken to fix the

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fracture and get the patient mobilising 20-80% of patients. It can increase when it is safe to do so. mortality by 2-5x and lead to prolonged length of stay, increased morbidity and For the elderly patient, such practice is increased discharge to care settings8. still required, but requires a higher level of patient-centred care to prevent It is a syndrome characterised by complications and promote quicker fluctuating levels of consciousness which recovery. For example, if this patient can lead to a hyperactive or hypoactive receives high levels of opiate analgesia, state in comparison to the patient’s this may depress their respiratory level, baseline status. It can be due to almost leaving them at higher risk of basal any underlying illness but in general atelectasis, especially if they are bed- terms, a simple mnemonic can be used to bound or unable to expectorate properly. screen for the root cause:

This may predispose them to developing a P Pain hospital acquired infection with the In Infection possibility of developing delirium. All of C Constipation these factors would contribute to an H Hydration increased length of stay and increased Me Medications recovery time in the hospital. Taking this into consideration, an elderly Further delays in taking the patient to patient with rib fractures and a femoral theatre with prolonged periods spent Nil shaft fracture may be in pain without By Mouth could predispose them to appropriate analgesia. They might have dehydration and renal impairment, which basal atelectasis from: supine positioning; would need medical treatment and lead reduced cough; and chest wall discomfort to a prolonged patient journey. thus predisposing them to developing lower respiratory tract infections. Individualised, patient-centred care should be adopted to take all co- Furthermore, the opiate analgesia given morbidities into consideration and focus to them in the Emergency Department on preventing complications that may could leave them vulnerable to result from the injury or as a constipation. Abdominal bloating and consequence of the management of that distension from constipation would then injury. discourage them from eating and drinking leading to dehydration and poor nutrition. Multiple elements of care are needed in the day-to-day management of elderly All of these features could be prevented patients with injuries and HECTOR by first recognising the effects that introduces a structured tool that tailors injuries have on patients, and by secondly daily ward-based assessment to recognising how our treatments and individualised needs. management can also affect an individual.

Preventing Delirium Any patient with changes in their baseline Delirium is a common cause of mortality state at admission should have a formal and morbidity for any elderly patient top-to-toe reassessment, looking admitted to hospital, affecting between specifically for root causes of delirium.

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HECTOR will introduce such assessments in responsible for managing such later chapters with a view to patients should possess a core implementing this in practice background knowledge of trauma care and acute medical care. Falls Prevention & Risk Assessment The majority of elderly patients with  Standard “abnormal” parameters of injuries present following a simple fall. physiology used to define states of Just as important as getting patients back shock and cardiorespiratory distress on their feet, is ensuring that they are may not always be applicable to the fully assessed for future risk of falls and elderly patient. Underlying disease, preventative measures are put in place. the ageing process and polypharmacy all contribute to varying physiological This could involve confidence-building responses to injury. therapy on the wards, adjusted use of mobility aids or changes to the home  It is important to be aware that “low environment before discharge. energy” mechanisms such as simple falls are more likely to lead to injury in All of these factors need to be taken into older patients. Furthermore, “High consideration at the earliest possible energy” mechanisms are more likely stage and implemented sooner rather to lead to significant and possibly life- than later to prevent unnecessary delays threatening multi-system injury. once a patient is fit for discharge.  All sites managing elderly trauma Equally important is to address issues that patients need to be aware of the risks may make elderly patients vulnerable of under-triage and age-related bias once they are discharged. Addiction to for pre-hospital conveyance and alcohol should be addressed and dealt develop internal triage systems to with during admission by appropriate manage this risk liaison teams. If maltreatment is considered or suspected in the context of  Assessment of the trauma patient this patient group, early safeguarding does not stop after the acute phase of referrals should be made to local teams to care. It is an ongoing process and investigate further essential for preventing delirium which will delay an individual’s recovery.

Summary References  The main philosophy of HECTOR is the treatment of a patient with injuries 1. American College of Surgeons Committee on and not the treatment of injuries on a Trauma. Advanced Trauma Life Support for Doctors. Eighth Edition. 2008 Page 60-61 patient 2. Fox ED, Heffernan DS, Adams CA et al. Not all  Accurate history-taking, in comorbidities are the same: The impact of combination with thorough scientific comorbidities on mortality in critically ill examination is a fundamental aspect geriatric trauma patients. J Am Coll Surg 2013; 217(3) Supp 1 (S59) of trauma care. All clinicians

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3. Lane P, Sorondo B, Kelly J. Geriatric trauma patients – are they receiving trauma center care? Acad Emerg Med 2003; 10(3); 244-250.

4. Chang DC, Bass RR, Cornwell EE et al. Undertriage of elderly trauma patients to state- designated trauma centers. Arch Surg 2008; 143(8): 776-81.

5. Calland JF, Ingraham AM, Martin N. Evaluation and management of geriatric trauma. An Eastern Association for the Surgery of Trauma management guideline. J Acute Trauma Care 2012; 73(5) Suppl 4: S345-S350

6. Werman HA, Erskine T, Caterino J. Development of statewide geriatric patients trauma triage criteria. PreHosp & Disaster Med 2011; 26(3): 170- 179.

7. British Geriatrics Society. Quality Care for Older People with Urgent & Emergency Care Needs “The Silver Book” 2012.

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PART I: THE IMMEDIATE ASSESSMENT AND TRAUMA SURVEYS

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Chapter 2 – Triage Irrespective of how patients present, the quality of in-hospital triage is crucial in initiating the appropriate hospital Introduction response.

Existing trauma courses focus on a vertical Patients with significant mechanisms of or horizontal approach to the ABCDE injury or severe anatomical and/or assessment of an injured patient: physiological derangement are more likely to need a trauma team approach than the A - Airway patient who presents in a stable condition B - Breathing following a simple fall. C - Circulation D - Disability The Trauma Team E - Exposure Most trauma networks will have a pre- This remains the standard of care, with hospital triage tool that Emergency adjustments made to give greater priority Response Teams use to determine to the assessment of circulation and the whether patients should be taken to a cervical-spine on the assessment ladder. Major Trauma Centre or Trauma Unit.

The horizontal approach favours the An example of such a tool is illustrated concurrent assessment of ABCDE normally below and trauma teams will be activated performed by a team of practitioners. The (or not) on the basis of abnormal vertical approach ensures that an physiological signs, abnormal anatomy or assessment of each area occurs in mechanism of injury. sequence and is usually performed by a sole clinician. Such tools allow a measured response from hospital teams in the form of In the Emergency Department, elderly mobilising a trauma team. The teams will patients may present in one of two ways – often consist of: a trauma team leader they might be alerted in whereby the (usually ED staff); anaesthetists to manage paramedic team forewarn the ED about the airway, disability assessment and c- their imminent arrival, allowing the spine; speciality or ED staff to perform department to mobilise a trauma team if BCE assessments; and members of the required. Nursing team or advanced practitioners for additional support. Alternatively, elderly patients may be under-triaged, arriving to wait in the same This triage system is useful for patients in queue as other patients. In this situation, extremis or with high mechanisms of they might be assessed by a single injury. In-hospital teams should not clinician. This circumstance may also arise question the decision or judgement of if a hospital inpatient falls on the ward pre-hospital teams until they have and sustains an injury – it is more likely assessed the patients themselves. In that one practitioner will assess the short, it is far safer to mobilise the trauma patient and a vertical ABCDE approach is team once requested, assess the patient, used. and review performance and decisions once patient care has been delivered.

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There is a risk of under-triage with tools were the injury mechanism in 48% of the that are insensitive to age-based older group and only 7% of the younger differences in physiology and anatomy. group (p<0.05)1. Elderly patients may be in hypovolaemic shock with a systolic blood pressure of This same study identified that 32% of all 110mmHg and yet would not trigger falls resulted in serious injury (ISS > 15) for direct transit to a Level I centre. older patients compared to 15% in the younger group (p<0.05). Similarly same- Understanding Under-Triage level falls led to serious injury 30% of the time in the older group compared to 4% in It is important for the triage team to have the younger group (p<0.05). The following an understanding about why elderly injury types were also recognised patients might be under-triaged. This between groups: normally occurs as a result of different physiological responses to any given injury >65 65 or years less hence patients may not activate the pre- Head/Neck 47% 22% P<0.05 hospital triage tools, but can also be due Chest 23% 9% P<0.05 to age-related bias and perceptions in the Pelvic/Extremity 27% 15% P<0.05 pre-hospital setting that a patient may not be suitable for MTC/Level I Trauma Care. In light of such evidence, it is important that triage teams are aware that same- A US Study reviewed all patients admitted level falls in elderly patients are COMMON to a trauma service over a ten-year period and CAN RESULT IN SERIOUS INJURY. and defined under-triage as having an ISS > 15 but not having formal trauma team Physiology & Under-Triage activation by pre-hospital or in-hospital 1 teams . Of 4534 elderly patients, 15.1% If pre-existing triage tools list hypotension were under-triaged and the study (systolic blood pressure < 90mmHg) and identified that these patients were more low GCS (<14) as markers of compromise, likely to die when corrected for GCS, this may lead to under-triage of elderly Revised Trauma Score (RTS), the patients. occurrence of >1=complication and whether they were taking warfarin. If an individual suffers from hypertension, they may have a significant drop from Such studies demonstrate the risks of their baseline measurement due to under-triage and highlight the need to haemorrhagic shock, but present with a understand why it occurs in order to systolic blood pressure above 90mmHg. It develop mechanisms to manage this risk. is important in patients with hypertension to evaluate the initial blood pressure Falls & Under-Triage measurements in accordance with previous blood pressure (if available from Same-level falls are often perceived to be hospital records). a low mechanism of injury and unlikely to cause significant trauma. One study A US Level 1 trauma centre retrospective looked at trauma data and compared review identified that mortality increased patients aged 65 years or less to patients in elderly trauma patients with a systolic aged over 65 years and found that falls blood pressure of <110mmHg. This same

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association was not seen in younger injuries (16.1% vs 54.1% in younger group; patients until the blood pressure dropped p< 0.001), yet had a higher ISS (26.6 vs below 95mmHg3. 21.3; p<0.001). Furthermore, the older group had a fourfold increase in mortality A separate study demonstrated that following vascular injuries (OR 3.9; 95% CI elderly patients appeared less likely to 3.32-4.58), with a higher incidence of tolerate relative hypotension with higher injury to the thoracic aorta than in mortality at initial systolic blood pressures younger patients6. of 90 - 130mmHg4. However, this study suggested that if such criteria were to be Such studies highlight the fact that older used as predictors of injury severity, they patients may be under-triaged to units would need to be adjusted for different without appropriate specialist provision age groups. for vascular trauma because they are more likely to be a result of blunt trauma Both studies highlight the fact that pre- than penetrating injury. In these existing triage tools with a systolic blood circumstances, the triage team need to pressure cut-off of <90mmHg will fail to consider high mechanisms of injury (e.g. identify elderly patients with significant road traffic collisions, falls from height), as injuries who have a higher SBP. It is being mechanisms that could precipitate important for in-hospital teams to be such devastating injuries. aware of this fact and incorporate a higher index of suspicion for injury at Patients with suspected pelvic fractures higher SBP levels. are deemed as needing MTC-Level care according to most triage tools. A small US A 2014 UK-based study5 found that study reviewed 87 patients with severe presenting GCS was higher in elderly pelvic injuries and identified that 39% patients than younger patients for each were initially taken to a non-tertiary level of AIS-related head injury. This centre7. Of these patients, the two-week difference was noted to be more apparent incidence of complications was 54% in the presence of the most severe injury higher in the group of patients who were types (AIS 5). From this study, it is possible transferred later to the level I trauma to extrapolate that older patients may center. have a significant head injury and not trigger the triage tool because they will Elderly patients with injuries to the pelvic have a higher initial GCS than younger or groin region are most likely to suffer patients. from pubic rami or neck of femur fractures. Such injuries are extremely Anatomy of Injury & Under-Triage common and may lead pre-hospital teams to consider such diagnoses before more Patients with penetrating torso trauma significant pelvic injuries. The triage team are likely to be transferred directly to a should manage this risk by evaluating the Major Trauma Centre unless they require exact mechanism of injury, with higher immediate resuscitation at a Trauma Unit mechanisms (e.g. fall downstairs, road or prior to transfer. One study reviewed pedestrian traffic collisions), being more 29,736 patients with vascular injury and likely to cause significant injury. identified 2268 elderly patients. This group were less likely to have penetrating

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The Triage Team HECTOR believes that mechanism of injury plays a pivotal role in determining The maximum time any patient should the correct in-hospital response. wait to be triaged is 15 minutes and there Assessment teams can use this in is an expectation on Emergency combination with adjusted parameters of Departments to tailor their assessment physiology and anatomical injury to systems accordingly. determine the best course of action.

Some departments will have an After the initial assessment, patients will assessment team comprising of: a senior either be assessed by the Trauma Team or clinician; Nursing staff; and phlebotomists, by an individual clinician. Irrespective of whereas others will have a Triage desk. the individual pathway, all patients should Whatever system is in place, there is a have ABCDE assessed and documented need to have a “secondary” filter to appropriately. manage the risk of under-triaged patients.

Patient Arrives via Ambulance or Self-Presents – Assessment within 15 minutes

MECHANISM OF INJURY PHYSIOLOGY Systolic BP < 110mmHg

1. Fall downstairs Heart Rate > 90 bpm 2. Fall from any height other than GCS < 15

standing 3. Pedestrian / Cyclist struck by ANATOMY OF INJURY vehicle Injury to >/= 2 Body regions Suspected head / spinal injury 4. Road Traffic Collision (anything

other than simple rear-end shunt or speed >30mph) OTHER 5. Penetrating or crush injury to Patient on anticoagulant medication or has a bleeding disorder torso

MOBILISE TRAUMA TEAM IMMEDIATE SENIOR NURSE / CLINICIAN REVIEW

If any concerns

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Using Pre-Hospital Information  Underlying knowledge of the reasons for under-triage is an essential Most trauma teams will receive direct component in managing this risk. The handover by Paramedic crews. This isn’t team that is aware of the causes of possible if elderly patients are under- under-triage is more likely to be able triaged and the crews have already stood to identify the severely injured patient down. Attempts should be made to obtain at the point of their arrival. information about the pre-hospital assessment using tools such as the  Robust triage mechanisms are “ATMIST” mnemonic. essential in Emergency Departments to counteract the effects of under- ATMIST Handover triage from pre-hospital teams – assessment of vital signs, suspected A Age anatomy of injury and consideration T Time of Incident of mechanism of injury are key factors M Mechanism of Injury in this process. I Injuries suspected S Symptoms & Signs T Treatment References

This information can be obtained from 1. Rogers A, Rogers F, Bradburn E et al. Old ambulance records if ambulance crews and undertriaged: A lethal combination. Am have already stood down. It is vital to Surgeon 2012; 78(6): 711-15. have a grasp on what occurred to the patient between the point of injury and 2. Sterling DA, O’Connor JA, Bonadies J. arrival in hospital. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma

2001; 50(1): 116-119. Even before the primary survey, assessment should be focussed on looking 3. Heffernan DS, Thakkar RK, Monaghan SF et at the “complete picture”. For elderly al. Normal presenting vital signs are unreliable patients, the commonest mechanism is a in geriatric blunt trauma victims. J Trauma simple fall – it is important to know why 2010; 69(4): 813-820. such falls may have occurred and bring this into the primary survey. 4. Hranjee T, Sawyer RG, Young JS et al. Mortality factors in geriatric blunt trauma patients: Creation of a highly predictive statistical model for mortality using 50,765 Summary consecutive elderly trauma admissions from the national sample project. Am Surgeon  Individual assessment of patients will 2012; 78(12): 1369-75. either merit a formal trauma-team or individual clinician-led response. As 5. Kehoe A, Rennie S, Smith JE. Glasgow Coma elderly patients are likely to present Scale is unreliable for the prediction of severe following low mechanisms of injury, head injury in elderly trauma patients. Emerg Med J 2014; 31(9): 775-7. trauma team activations are less likely

to occur. 6. Konstantinidis A, Inaba K, Dubose J et al. Vascular trauma in geriatric patients: a

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national trauma databank review. J Trauma 2011; 71(4): 909-16.

7. Garwe T, Roberts ZV, Albrecht RM. Direct transport of geriatric trauma patients with pelvic fractures to a level I trauma center within an organised trauma system: Impact of a two-week incidence of in-hospital complications. Am J Surg 2012; 204(6): 921-6.

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Chapter 3: The Primary Survey liaison for the patient and establish a continuous dialogue with them where The role of the primary survey is to possible. identify immediate life-threatening problems and intervene accordingly. This If a patient is unresponsive or fails to is one aspect of care that should remain respond appropriately, the airway should “injury-focussed”, but requires tailoring to be assessed formally: the elderly demographic.  Look – any signs of obstruction from It consists of the following steps: dentures, foreign bodies, facial fractures  Airway and cervical spine control  Listen – snoring, stridor, hoarseness  Breathing and ventilation  Feel – is there any air movement?  Circulation and haemorrhage control  Move – if concerns arise, attempt jaw  Dysfunction of the CNS thrust in the first instance and  Exposure and environmental control consider airway adjuncts (nasopharyngeal, oropharyngeal Specific aspects of primary survey airways) management are taught well on traditional courses and won’t be covered Advanced Airway Management in full detail. Focus will be placed on the adjustments needed in primary survey Elderly patients may present a greater assessment when caring for elderly challenge in terms of rapid sequence patients. induction and intubation. Lifelong development of obesity, altered dentition, reduced neck movement are all predictors Airway and Cervical Spine of difficult intubation and may develop Control with advancing age. Once a decision has been made to intubate an elderly patient, Initial Airway Assessment it is important that this process is not rushed. Correct procedure should be Talking to a patient will quickly allow a followed and each patient assessed in clinician to establish rapport whilst at the terms of predicted difficulty: same time allowing them to assess airway patency. Hospitals are unfamiliar environments and patients with dementia LEMON Predictors for The Difficult may become distressed by such Airway surroundings, especially if they have their neck immobilised. LOOK – facial trauma, large incisors, beard or moustache, dentition, large tongue Clinicians should introduce themselves to patients at the first point of contact and constantly offer explanation and EVALUATE – 3-3-2 rule (3 fingerbreadths reassurance about what is happening. between open incisors; 3 fingerbreadths When a trauma team has been mobilised, between chin and hyoid; 2 fingerbreadths the clinician allocated to airway between thyroid notch and floor of management should be the point of mouth)

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A 2015 study compared pre-hospital rapid sequence induction of patients using MALLAMPATI SCORE – see below etomidate and suxamethonium against fentanyl, ketamine and rocuronium1. Patients in the ketamine group were OBSTRUCTION – presence of any found to have a higher first pass condition that could cause an obstructing intubation success (100% vs 95%, airway p=0.007) and a less frequent hypertensive response to laryngoscopy.

NECK MOBILITY – fixed deformity, Despite being conducted in the pre- immobilisation hospital setting, this study suggests that a simple and standardised RSI protocol may Equipment should be prepared to ensure improve the safety of the procedure and that rescue devices (e.g. LMA, quicktrach) should be considered to facilitate are available and senior assistance sought definitive airway support. It used a 3:2:1 earChoice of induction and paralysing regime for stable patients and a 1:1:1 agents will depend on user experience regime for patients with haemodynamic and preference. One of the real concerns compromise (see below) for elderly patients is the risk of hyperkalaemia following burns or prolonged immobilisation after a fall. 3:2:1 1:1:1 Tissue and muscle damage leading to Fentanyl 3mcg/kg 1mcg/kg rhabdomyolysis can elevate the plasma Ketamine 2mg/kg 1mg/kg [K+] which can be made worse by pre- Rocuronium 1mg/kg 1mg/kg existing renal impairment or dehydration.

Use of suxamethonium in these patients may cause the potassium concentration to increase by up to 0.5 mmol L-1. Elderly patients should have a venous blood gas performed to estimate the [K+] prior to using suxamethonium or consideration should be given to using a different muscle relaxant like rocuronium.

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Approach to the Cervical Spine “Minimal Movement” Whilst managing the airway, care must be taken to ensure that the cervical spine is  When a cervical spine injury is properly assessed. Any patient over the suspected and application of a hard age of 65 years with head / facial injury collar is not practical, attempts should following trauma must be considered as be made to support the neck in its being at high risk of having a cervical current position spine injury.  AP Control: Blankets can be rolled to The presence or absence of neck pain will be inserted behind a patient’s neck if vary for different individuals. Some the occiput can not lie flat on the patients may not be able to communicate trolley. (e.g. dementia, delirium, aphasia post CVA), in which case the presence of any  Lateral Control: blocks, fluid bags or type of injury above the clavicles should blankets may be used either side of alert the clinician to the possibility of c- the patient’s head, to maintain its spine trauma. current position and be secured with trauma tape. Degenerative arthritic disease, kypho- scoliosis, Parkinsonism with increased  Log-rolling should be restricted (i.e to rigidity and steroid-associated “buffalo prevent aspiration in the vomiting hump” are all examples of conditions that patient, to change soiled bed sheets). can make cervical spine immobilisation difficult. In the elderly patient, it is not always possible or practical to apply a Clearance of the Cervical Spine hard collar. There are case reports of patients being harmed from the forced Irrespective of the method of cervical application of collars2. spine control, clearance should be performed by an appropriately trained Cervical collars may have the effect of: clinician. increasing cerebrospinal fluid pressure; causing pressure sores; reducing tidal The Canadian Cervical Spine criteria3 volume and affecting breathing; and categorises age >65 years as a high risk limiting an individual’s ability to swallow. feature and advocates imaging for any Such complications need to be balanced elderly patient where there is clinical against the risks of not applying a collar concern of injury. By contrast, the NEXUS and this need to be assessed on an criterion4 does not include age but individualised basis. stipulates that if patients meet all of the following low-risk criteria then they do HECTOR encourages teams to use collar not need imaging: and block immobilisation if safe to do so and if tolerated by the patient, but if NEXUS Low Risk Criteria: resistance is met by trying to apply such a. No posterior midline cervical spine measures. If this is not possible, HECTOR tenderness encourages a practice of “minimal b. No evidence of intoxication movement”. c. Normal level of alertness

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d. No focal neurological deficit e. No painful distracting injuries C. CT-Cervical Spine is the imaging modality of choice in the first instance Clinical acumen is important as distracting when injury is suspected or can’t be injuries, altered conscious levels, previous excluded. stroke and neurological deficit can all cloud the decision-making process. D. Imaging should be acquired within 60 minutes of request to prevent prolonged HECTOR advises the following rules be lie, immobilisation and distress and be applied for the initial management of reported within 60 minutes of image cervical spine injury: acquisition.

1. Assessment of Risk:

A. Any elderly patient with head or facial Breathing and Ventilation injury following a fall should be considered at risk of cervical spine injury Life-Threatening Injuries

B. Any elderly patient with new-onset When breathing is assessed in the primary neck pain following a fall or other survey, examination should be focussed mechanism of injury should be considered on looking for the presence of the at risk of cervical spine injury following life-threatening chest injuries:

C. Any elderly patient with a high  Tension pneumothorax mechanism of injury (fall from height  Massive haemothorax greater than standing; pedestrian / cyclist  Open sucking chest wound vs vehicle collision; road traffic collision)  Flail chest should be considered at risk of cervical  Cardiac tamponade spine injury Such serious conditions should be treated as they are identified with the use of 2. Clearance of the Cervical Spine: thoracostomy / tube thoracostomy for tension pneumothoraces and A. If a patient has: a decreased level haemothoraces; and 3-sided dressings or of consciousness; is intoxicated or Ashermann seals for open wounds. confused; has any focal neurological signs or symptoms; or has distracting injuries and has been deemed as being at risk of Respiratory Rate and Ventilation injury, the cervical spine should not be cleared without imaging Respiratory rate and effort of breathing are valuable signs for detecting the B. Patients without any of these presence of serious injury: abnormal features should be asked about the presence of neck pain – movement  A raised respiratory rate (>20) should may be assessed in the absence of pain. alert the examiner to possible injury or Restrictions of movement or pain on illness. movement should trigger imaging.

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 Slow rates (<12) may uncover fatigue,  Bronchiectasis exhaustion and the possibility of  Previously unrecognised COPD – lifelong opiate toxicity from drugs smoker, chronic breathlessness on minimal exertion administered in the pre-hospital

setting.

HECTOR encourages the initial Arterial blood gas analysis is a prescription of high flow oxygen to fundamental component for assessing patients with major trauma (multi- ventilation and should be used to guide system injuries; high mechanisms), until oxygen delivery. High flow oxygen an ABG can be performed to deliver (15L/min) should be delivered with targeted therapy. caution in the presence of chronic lung disease as it may be more appropriate to In the absence of COPD and risk of aim for a lower target oxygen saturation hypercapnic failure, oxygen should be level (88-92%) for such patients. then prescribed to achieve saturations of

94 – 98%. The vast majority of elderly patients are not admitted following high energy For patients with injuries following mechanisms and instead attend following simple falls and low energy mechanisms, simple falls. In these latter and more high flow oxygen therapy should be common circumstances, high flow oxygen stopped completely on arrival to the therapy will not be appropriate for every emergency department and adjusted to patient. according to the presence of chronic lung

disease. Initial oxygen saturations should be targeted to 94-98% for cases of major trauma and adjusted following formal arterial blood gas (ABG) analysis. Addition Circulation & Haemorrhage Control of supplemental oxygen to patients with COPD has been thought to reduce the “hypoxic drive”, thus slowing their Traditional trauma courses like ATLS make respiration and leading to increasing reference to the American College of Surgeons classification of shock in terms PaCO2. of clearly defined parameters associated If a patient is deemed as being at risk of with increasing volumes of blood loss. hypercapnic respiratory failure, (see below), oxygen saturations should be The descriptors for Class I, II, III and IV targeted to 88-92%. shock are based on an average 70kg patient and are not specific for age. Risks Factors for Type 2 Respiratory Failure Furthermore, they don’t take into account ageing physiology, underlying disease  Severe / moderate COPD such as hypertension or polypharmacy –  Previous respiratory failure all of which can alter cardiovascular  Long term oxygen therapy physiology.  Severe chest wall disease  Severe spinal disease (e.g. kyphoscoliosis) Existing evidence has suggested that  Neuromuscular disease  Severe obesity mortality increases in elderly patients

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when their heart rate increases above 90 as falls from height; road traffic collisions beats per minute, an association not seen and penetrating trauma may lead the in younger patients until the rate examiner to be more vigilant for the increases above 130 bpm. possibility of major injury and hence have a lower threshold for suspecting shock. Similarly, mortality in elderly patients increases when the systolic blood Again, the global picture is essential to pressure drops below 110mmHg, determine the underlying state. although this relationship is seen in younger patients when the blood pressure Mechanisms of Injury That Cause falls below 90 mmHg. Concern

What this means is that, what in a  Fall from height younger person may be considered as  Fall downstairs being normal, is abnormal in an older  Vehicular collision >30mph person, and this may lead to a failure to  Pedestrian vs Vehicle accurately diagnosis shock.  Ejection from Vehicle  Penetrating trauma chest / HECTOR believes in a systematic approach abdomen for the diagnosis of shock which uses all of the following information: B. Regional Assessment A. Mechanism of injury B. Regional clinical assessment A set of observations must be taken to C. Occult hypoperfusion ensure that baseline heart rate, blood D. Assessment of coagulation status pressure, respiratory rate and Glasgow Coma Score are documented.

A. Mechanism of Injury Abnormal vital signs might be difficult to distinguish in the elderly patient. The majority of injured elderly patients Increases in heart rate may be limited by a sustain their injuries from same-level falls. lack of sympathetic tone or the For the vast majority of cases, such prescription of beta blockers. Such mechanisms of injury would not alert the patients may not mount a tachycardic assessing clinician to the possibility of response to blood loss and a seemingly major haemorrhage. normal heart rate could conceal overt blood loss. Taken in isolation, this may be the case, but if you consider a patient with a In terms of blood pressure, if an elderly fractured shaft of femur who is on patient suffers from hypertension and has warfarin, haemorrhagic shock can develop a resting systolic blood pressure of quickly. Looking at any of these factors in 180mmHg for example, a drop in pressure isolation is meaningless – the global to 150mmHg may not be interpreted as picture is important in assessing the significant yet there could be underlying possibility of hypovolaemic shock. blood loss.

Higher energy mechanisms of injury such HECTOR advocates that a lower limit of

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heart rate and a higher level of systolic As soon as overt bleeding is identified, blood pressure be used to highlight measures should be taken to halt the concern to the examining clinician: bleeding, (i.e. splintage of limbs, suturing of wounds, cautious nasal packing).

Consider the Possibility of Overt / Occult Patients with bleeding into the chest, Blood Loss if: abdomen, pelvis and retroperitoneum might be harder to identify. Ultrasound Heart Rate > 90 bpm can be used to assess for free fluid in the chest or abdomen and also to quantify and / or abdominal aortic calibre. HECTOR recommends the visualisation and Systolic Blood Pressure <110mmHg assessment of the abdominal aorta by trained personnel if FAST is being used.

Extended FAST scanning has high In isolation, abnormal observations may specificity but a low sensitivity which is be due to trauma but could equally be a user dependent. It should only be used as consequence of underlying illness which a mode of “rule in” for significant injury may have precipitated the incident in the and not used for its exclusion. first place. This stresses the importance of a global view in the diagnosis of shock and Retroperitoneal bleeding should be an assessment of its severity. considered if hypovolaemic shock is suspected and no obvious cause is Other features such as skin colour, identified. In such circumstances, CT clamminess, sweating, and capillary refill imaging would be appropriate to identify time should be considered during an the source of bleeding. assessment of circulation.

Having performed routine observations, the assessing clinician should perform a head-to-toe assessment of circulation, looking at specific areas of the body.

Overt bleeding is relatively straightforward to identify on external examination – this could be from scalp lacerations, deformed limbs or facial injuries (e.g. epistaxis).

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SCALP – lacerations, arterial bleeds MIDFACE/JAW – epistaxis, dental injury, jaw fracture

THORAX – rib fracture / flail, haemothorax, lacerations

ABDOMEN – rigidity / guarding; bruising to flanks / abdomen; PELVIS & RETROPERITONEUM – lacerations; aortic calibre (USS); obvious deformity, leg rotation, FAST scan retroperitoneum suspected if concerns about shock with no obvious source on exam

LIMBS (upper / lower) – obvious deformity, leg rotation, lacerations, bleeding varicose veins, compound fractures

Areas to Assess for Circulation

C. Occult Hypoperfusion (OR 1.71; p = 0.21 and OR 1.18; p = 0.78 respectively)5 Occult hypoperfusion can be defined as the presence of reduced organ perfusion A venous lactate > 2.5 equates to a two- in the absence of abnormal vital signs. In fold increase in mortality compared to the context of trauma, this reduced patients with normal vital signs and a perfusion should be suspected as resulting normal lactate. from haemorrhagic shock until proven otherwise. HECTOR proposes that all injured elderly patients have blood gas analysis to assess A raised venous lactate could predict lactate. If this is above 2.5, then the mortality (OR 2.62; p<0.001) whereas initial response should be to seek sources abnormal vital signs (HR >120; SBP <90) of haemorrhage. and a shock index (HR/SBP) > 1 may not

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If no sources of haemorrhage are Warfarin is a coumarin that is commonly identified, the assessing team should prescribed for: stroke prevention in review the patient and assess for the patients with atrial fibrillation; patients possibility of sepsis, dehydration, and with metallic heart valves; and for polypharmacy (e.g. metformin), and the patients with a history of DVT / PE. patient treated with intravenous fluid Warfarin inhibits the vitamin K-dependent rehydration as appropriate. synthesis of clotting factors II, VII, IX and X. The International Normalised Ratio (INR), is used to measure dose adequacy D. Assessment of Coagulopathy with high levels corresponding to risk of bleeding and low levels increasing the risk Iatrogenic Coagulopathy of thrombosis.

One of the first questions to ask any Warfarin may be reversed through the use injured elderly patient should be: IS THIS of intravenous vitamin K, Fresh Frozen PATIENT ON WARFARIN OR OTHER NOVEL Plasma or Prothrombin Complex ANTICOAGULANT AGENTS? Relatively Concentrate (beriplex, octaplex). In the minor trauma can have a profound effect context of acute trauma with major or if a patient has been prescribed warfarin. life-threatening bleeding identified, a Any such patient should be deemed as target INR < 1.5 should be maintained. being at high risk for occult and overt The risk of acute bleeding should haemorrhage and vigilance taken for supersede the risk of thromboembolism in assessing all regional areas. acute situations as this risk can be mitigated later.

Anticoagulant Indication Monitoring Reversal Agent Warfarin

Stroke Prevention in Life-Threatening Bleed (e.g. Vitamin K recycling INR antagonist Atrial Fibrillation; intracranial, intra- abdominal/thoracic): Metallic heart valves; - Vitamin K 5mg iv Affects Vitamin K- dependent factors II, VII, - Prothrombin complex IX, X History of DVT / PE concentrate (as per INR): e.g. beriplex

Half-life 20-60 hours INR 2- 3.9 25 u/kg INR 4- 5.9 35 u/kg INR >/= 6 50 u/kg

Major Bleed - Vitamin K 5mg iv - Fresh Frozen Plasma (15mls/kg)

Dabigatran

Direct Thrombin Factor Recent Acute Coronary None available No reversal agent but consider PCC IIa inhibitor Syndrome

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Half-Life 12-17 hours Stroke Prevention in Atrial Fibrillation

Thromboprophylaxis in Total Hip / Knee Replacement

Rivaroxaban

Direct factor Xa inhibitor Stroke Prevention in None available No reversal agent Atrial Fibrillation; Effects last 8-12hrs Thromboprophylaxis in Xa levels normalise Total Hip / Knee within 24 hours Replacement Enoxaparin

Binds to antithrombin III, Thromboprophylaxis and Anti-Factor Xa Protamine can cause ~60% of thus inhibiting factors Xa Treatment of Thrombo- not usually antithrombin III effect and IIa embolism; recorded

Half-life 4.5 hours Acute Coronary Syndrome;

Abdominal Surgery

Acute Traumatic Coagulopathy A. Rapidly identify any haemorrhagic focus and control this appropriately; A high proportion of patients present to major trauma centres with established B. Warm the patient by removing wet coagulopathy on their arrival. Trauma clothes, using Bair huggers / blankets leads to tissue factor exposure and a and using warm intravenous fluids; subsequent cascade of coagulopathy. Different models exist but essentially C. Correcting acidosis whether due to comprise a mixture of clot formation, respiratory or metabolic causes clotting factor consumption and hyper- fibrinolysis. All elderly patients should have a temperature recorded in the primary Coagulopathy is worsened in the presence survey with the aim of targeting an ideal of the “lethal triad” of: temperature range of 35 – 37OC. Some elderly patients may present following a  hypothermia, long-lie and may have become  acidosis and hypothermic due to immobility or  worsening coagulopathy. underlying conditions such as hypothyroidism. In such circumstances, Attempts should be made to limit the clinical staff must ensure that warming detrimental effects of this “lethal triad” by occurs as soon as possible. a combination of the following actions:

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Diagnosis of Coagulopathy ensuring adequate resuscitation. Haemodynamic instability and/or occult In order to recognise the possibility of hypoperfusion with evidence or suspicion acute traumatic coagulopathy, all patients of major bleeding should merit massive should have standardised tests performed transfusion activation. with the aim of targeting specific levels. All patients needing blood transfusion Parameter Target following trauma should be given 1g tranexamic acid iv, (unless contra- Haemoglobin > 80 g/L indicated), within 3 hours of the injury. This initial bolus may need to be followed by a further infusion over 8 hours. Platelets >100 x 109/L Blood products should be given as per regional guidelines, with some centres INR < 1.5 offering a ratio 1 PRC: 1 FFP: 1 Platelets and some offering 1.5 PRC: 1 FFP with platelet infusion dependent on initial Fibrinogen >2.0 g/L levels. Such processes may be stood down or altered in light of haematological parameters and the patient’s underlying Patients with blood results outside these status. parameters should be discussed with the on-call haematologist. If massive Methods of stemming sources of bleeding transfusion protocols are not being include anything from: simple pressure to activated, targeted transfusion regimes tourniquets to sutures for external may lessen the impact of coagulopathy. wounds; splinting of long limb fractures; pelvic splintage; interventional radiology Responding to Hypovolaemic Shock for internal bleeding; and damage control surgery. If haemorrhagic shock has been identified, immediate action should be taken to arrest the source of bleeding whilst

Primary Survey Assessment of Circulation in the Injured Elderly Patient

Assessment of circulation must take into account the following features in combination

A. MECHANISM OF INJURY

 Higher mechanisms of injury should warrant higher levels of vigilance for the possibility of major haemorrhage  Low mechanisms of injury may be significant if the individual has coagulopathy (e.g. warfarin, anticoagulant use)

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B. REGIONAL ASSESSMENT:

 Baseline observations should be performed for all patients as soon as possible  Heart Rate > 90 bpm should be considered significant  Systolic Blood Pressure < 110 mmHg should be considered significant  An ECG must be performed if any arrhythmias are identified  All body regions should be examined for occult and overt haemorrhage and any bleeding source controlled as soon as it is identified  A suspicion of haemorrhagic shock and no obvious source should raise concerns about retroperitoneal and/or pelvic bleeding

C. OCCULT HYPOPERFUSION:

 A raised lactate (>2.5) in the presence of trauma should alert the examiner to the possibility of haemorrhage  After thorough assessment and imaging, if haemorrhage is not identified, alternative causes for raised lactate should be sought – sepsis, dehydration, pharmacy (metformin)

D. COAGULOPATHY:

 The following question must be asked “Is The Patient On Anticoagulant medication?”  All patients to have Hb, Platelets, INR and Fibrinogen levels assessed and acted on appropriately.

Disability & Environmental Control A gross neurological examination should be conducted to look for any signs of In the primary survey, the clinician weakness, with the caveat of questioning responsible for airway assessment should for the presence of existing weakness and record pupil size, reactivity and Glasgow previous stroke / degenerative conditions. Coma Score. Attempts should be made to clarify if there are any pre-existing disease All patients should be placed in hospital states that have affected pupillary size / gowns and have wet clothes removed. response, (e.g. cataracts). Temperature control is vital at this point and all elderly patients should have blankets to maintain an adequate

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temperature. patient requiring urgent or immediate intubation. A significant proportion of elderly patients may have been exposed to low ambient Cervical Spine temperatures after a fall, or their level of  Cervical spine injuries may arise from activity may have been significantly relatively low mechanisms of injury. reduced causing a drop in their core Patients with new onset neck pain; temperature. Hypothyroidism and midline tenderness; facial / head myxoedema coma are diagnoses that trauma; and high mechanisms of should be considered if patients present injury should be considered as being following a fall with a low core at risk of cervical spine injury. temperature.  CT-cervical spine is the imaging Efforts taken to raise the core modality of choice for elderly patients temperature above 35oC, (ideally 36oC – with suspected neck injury. 37.4oC) should start early during the primary survey. Blankets and Bair Huggers  Cervical spine immobilisation may be may be used and efforts taken to ensure impractical in patients with underlying that patients are not left exposed on a disease causing musculoskeletal hospital trolley for longer than is rigidity. Patients should never be necessary. forced into movements just to position a cervical collar. Summary  The process of “Minimal Movement”  The Primary Survey is conducted to should be adopted to prevent identify any immediately life- unnecessary collar application whilst threatening conditions and to manage ensuring attempts are made to limit them as they are found. movement of the cervical spine.

Airway Breathing  Patients needing definitive airway  High flow oxygen is appropriate in the management should be managed in a early stages of care for patients with controlled manner. Recent pre- the potential for major multi-system hospital evidence suggests that trauma (e.g. following a road traffic standardised RSI protocols (fentanyl, collision), but may not be appropriate ketamine, rocuronium), can help to for all patients following same-level provide safe and effective care. falls.

 Elderly patients with injuries in need  Oxygen delivery should be adjusted to of RSI are likely to have multi-system take into account the risk of type II or head and neck trauma. They should respiratory failure. Oxygen saturations be assumed to have a cervical injury should be targeted to 88-92% in such until proven otherwise and care circumstances should be taken to minimise neck movement during the intubation Circulation process. Difficult airway equipment  Assessment of circulation requires a should be at hand for any elderly global oversight into features that

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could herald underlying haemorrhagic effectiveness of pre-hospital trauma shock. anaesthesia. Critical Care 2015; 19: 134

 A systematic approach that assesses 2. Papadosopoulus MC, Chakraborty A, Waldron G et al. Exacerbating cervical spine the following areas should be adopted injury by applying a hard collar. BMJ 1999; for all patients, irrespective of 319(7203): 171-2. mechanism of injury: 3. Stiell IG, Wells GA, Vandemheen KL et al. A. MECHANISM OF INJURY The Canadian C-Spine rule for radiography in B. REGIONAL ASSESSMENT (& VITAL alert and stable trauma patients. JAMA 2001; SIGNS) 286(15): 1841-8 C. OCCULT HYPOPERFUSION D. COAGULOPATHY 4. Hoffman JR, Mower WR, Wolfson AB. Validity of a set of clinical criteria to rule out  All four categories should be injury to the cervical spine in patients with blunt trauma. N Engl J Med 2000; 343:94-99 considered concurrently, and not in

isolation. 5. Salottolo KM, Mains CW, Offner PJ. A retrospective analysis of geriatric trauma  Crystalloid infusions should be patients: venous lactate is a better predictor restricted and if volume replacement of mortality than traditional vital signs. Scand is needed for acute haemorrhage, J Trauma, Resus & Emerg Med 2013; 21(7). blood products should be used in the first instance.

Disability & Environmental Control  In addition to recording GCS and blood glucose, attempts should be made to correct core temperature to between 35-37oC as soon as possible

 Patients may present in a hypothermic state due to a long lie, underlying disease (e.g. myxoedema coma), or external environmental conditions and the assessing team should be aware that they will be at risk of trauma coagulopathy. Such patients should be actively rewarmed as soon as possible and not be left exposed on the hospital trolley.

References

1. Lyon RM, Perkins ZB, Chatterjee D et al. Significant modification of traditional rapid sequence induction improves safety and

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Chapter 4: Imaging after the Cervical Spine X-Ray Primary Survey Interpretation of the plain-film cervical The approach to requesting specific spine X-Ray can be complicated by pre- imaging after the primary survey will vary existing bone disease, osteophyte according to the mode of presentation formation and previous neck surgery. and mechanism of injury for the elderly Clinicians must judge the likelihood of patient. obtaining adequate views on plain films against the risks of double radiation Traditional ATLS teaching has taught that exposure if plain films are insufficient and plain film radiography of the cervical the patient then requires a CT scan. spine, chest and pelvis are suitable first- line imaging modalities for patients with The 2014 NICE Guidance for investigating acute injuries. cervical spine injuries advocates the use of CT imaging as opposed to plain film radiography for patients aged 65 years Whilst important, this “one size fits all” 3 approach to imaging is not suitable for all and over . HECTOR suggests that this is patients. The plain film cervical spine has the most appropriate policy. Where low sensitivity in the elderly patient with access to CT imaging is difficult, local degenerative bone disease1; and the discussion is warranted to prioritise CT supine chest X-Ray has a low sensitivity imaging over plain film radiography. for small pneumothoraces and rib fractures2. Chest X-Ray

Advances in ultrasound imaging and Plain Film Chest radiography has its uses easier access to CT scan in Emergency in determining the presence of additional Departments mean that different centres pathology (e.g. consolidation with may have different policies about imaging pneumonia), and in needing to make elderly patients. quick decisions about the presence of large pneumothoraces / haemothoraces HECTOR believes that such variations in which will determine the appropriateness practice can be avoided by implementing of thoracostomy. a standardised and structured approach to CT requesting. With a more widespread use of ultrasonography in emergency Role of Plain Film Radiography departments, pneumothoraces and haemothoraces can be relatively

straightforward to identify depending on The majority of elderly patients present the expertise of the examiner. Ultrasound following a simple fall and in a lot of may yield a higher sensitivity than the cases, plain film radiography may be supine chest X-Ray for such diagnoses but appropriate as a first-line imaging it will depend on the skills and experience modality. If a patient if suspected of of the examiner4. having a fractured neck of femur or femoral shaft fracture following a fall, Clinical suspicion of multiple rib fractures then plain film imaging of those areas will is better identified with CT imaging, as this normally suffice in obtaining a diagnosis. can determine the presence of flail

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segments, underlying contusion and immediate senior surgical review: associated haemo/pneumothoraces in a more appropriate manner.  Haemodynamic instability;

Pelvis X-Ray  Significant mechanism of injury;

At times, Pelvis X-Rays may be insufficient  Suspicion of bleeding in the in diagnosing injuries such as a neck of absence of haemodynamic femur fracture, pubic rami fractures and instability (lactate >2.5; Base subtle sacroiliac injuries. Where clinical Deficit >5) concern remains high, (for example, in the patient with ongoing pain and an inability Standard FAST scans acquire images in the or difficulty in weight bearing), CT or MRI 5 right and left upper quadrants (Morrison’s imaging of the pelvis may be required . pouch and lienorenal angle respectively); the pelvis (transverse and longitudinal views of the bladder); and subxiphoid Role of Ultrasound area (pericardial sac). Extended imaging to include the lung bases can be used to The Extended FAST Scan identify pleural effusions.

In the context of trauma, FAST scans Pleural effusions may be present for a (Focussed Assessment Sonography in number of reasons, commonly including Trauma), can be used to identify the infection and malignancy and may not presence of intra-thoracic and intra- represent blood, (haemothorax). If there abdominal free fluid. With advancing age, is doubt about the nature of an effusion, the likelihood of liver failure, congestive an ultrasound-guided pleural tap could be cardiac failure, and malignancy increases, performed. If blood is evacuated, then the as does the possibility that free fluid on examiner should proceed to performing a FAST scanning may represent ascites. tube thoracostomy. In the absence of False positive results are likely to increase blood, progression to tube thoracostomy with advancing age. should cease and the patient re- evaluated. FAST results have to be taken into clinical context. A patient with gross The Aortascan and Bladder Scan haemodynamic instability with a positive FAST scan and a significant mechanism of When elderly patients present following a injury should trigger immediate senior fall, the clinician should also think about surgical review. what led up to the patient falling in the first instance. Sudden onset back pain A patient with haemodynamic stability, a followed by collapse may herald the lesser mechanism of injury and FAST presence of an underlying ruptured positive scan with a history of malignancy abdominal aortic aneurysm. may or may not need a CT scan for further clarification. These patients may have injured themselves during the collapse and it As a rule, the following patients with free would be very easy for the clinician to fluid identified on FAST scan merit focus on injuries and ignore underlying

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pathology. should be analysed to detect the presence of pneumothoraces. HECTOR advises that if FAST scanning is being used for elderly patients with injuries, or if the presenting history and patient details (e.g. white, male, smoker, peripheral vascular disease) make the diagnosis of AAA a possibility, FAST scanning should include an assessment of aortic calibre.

The aorta should be visualised down its length from the superior mesenteric artery to the iliac bifurcation. Two transverse measurements and one longitudinal measurement should be used to assess aortic calibre.

Ultrasound may also be of use in assessing bladder volume. If a patient suffers from dementia and has been collared and boarded, they may become increasingly agitated if they have a full bladder. Some Pneumothoraces can be detected by the patients may not be able to communicate following signs6: the need to pass urine. Ultrasound may be used in such circumstances to determine  The absence of pleural sliding; the need to assist the patient in voiding  Prominent A-lines; urine, or if a urinary catheterisation is  The presence of a lung point (the appropriate. interface between moving and non-

moving lung); Chest Ultrasonography  Stratosphere sign on M-mode,

(commonly described as the “tide The use of ultrasound in the assessment coming in”). of chest injuries could be considered as being like a “visual stethoscope”. Traditional stethoscopes transmit sound- waves from the chest to the ear of the examiner. Ultrasound uses sound waves to create a visual image that can be interpreted by the examiner looking at the pictures, hence the “visual stethoscope”.

Chest ultrasound can be structured by drawing a horizontal line between the a. Normal Lung nipple and scapula and two vertical lines b. Stratosphere sign (pneumothorax) on the anterior and posterior axillary borders. This creates six segments that

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Computerised Tomography highest exposure to contrast.

Acquisition of CT scans following trauma The WBCT serves to identify all possible has become commonplace over the last major injuries that would need immediate few years. CT scans offer higher resolution intervention or management, whilst at the images than plain film radiography and same time highlighting injuries that could multi-slice scans improve sensitivity have an impact following admission. further7. HECTOR advocates the following CT scans allow the trauma team to indications for WBCT: establish diagnoses quickly and with a high degree of confidence, whilst also 1. Obvious severe injury on clinical providing a means to structure future assessment – e.g. > 2 long limb fractures; management plans (i.e. surgery, pelvic fracture; amputation interventional radiology, conservative approach). 2. Haemodynamic instability or the presence of occult hypoperfusion with For the elderly patient with injuries, CT high mechanism of injury scans can help identify subtle injuries (e.g. transverse process fractures, rib 3. Suspicion of severe injury to more than fractures), that may not warrant any one body region immediate intervention, but which could lead to uncontrolled pain and the onset of 4. Significant mechanism of injury: delirium after admission. a. Vehicular collision: It is important to take a rational approach to CT acquisition and not utilise i. Ejection from vehicle a blanket approach of scanning every ii. Entrapment in vehicle > 30 mins individual who presents with traumatic iii. Fatality at scene of vehicular injuries. Even though there is little collision evidence to demonstrate a high iv. High speed rollover prevalence of renal failure, the use of contrast in CT scans can in theory worsen b. Fall from >3M (10 foot) a patient’s underlying renal function. The risks of this occurring must be balanced c. Pedestrian hit by car against the perceived benefits of performing a CT scan. d. Fall downstairs

Whole Body CT Scanning (WBCT) Focussed CT Scanning This approach to imaging should be reserved for patients with suspected If patients don’t fulfil the above criteria major injuries and with major mechanisms for WBCT, they may still need focussed CT of injury. It involves acquiring images from scans to identify the exact nature of their the vertex (top of skull) down to the pelvis injuries. or mid-femoral region and as a result, involves the highest dose of radiation and Regional scanning includes head, neck,

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chest, abdomen and pelvis, either in Patients taking clopidogrel had a relative combination or as an isolated scan. risk for traumatic intracranial haemorrhage of 2.31 (95% CI 1.48-3.63, CT Head Scan p<0.001) compared to patients taking warfarin9. Such findings suggest that The National Institute of Clinical patients taking clopidogrel and not just Excellence in the United Kingdom has those on anticoagulants may benefit from highlighted the following as indications for CT Head Scan in the context of trauma. performing a CT Head scan for suspicion of traumatic injury: Once the need to perform a CT Head scan has been identified, efforts should be taken to ensure that this occurs within 1. GCS < 13 on initial assessment one hour.

2. GCS < 15 after 2 hours of observation CT Cervical Spine 3. Open or depressed skull fracture If there is a suspicion that an elderly 4. Signs suggestive of basal skull fracture patient has injured their neck following trauma, NICE recommends the use of CT 5. Post-traumatic seizure imaging to detect underlying fracture.

6. Focal neurological deficit CT Thorax

7. >1 episode of vomiting Focussed scans of the thoracic cavity can be performed to assess for the presence 8. Loss of consciousness or amnesia (>65 of flail segments or haemo- years old) pneumothoraces. If there is no suspicion of arterial injury and the only question is 9. Any patient on anticoagulant about the bony skeleton or lung tissue medication following blunt trauma, then a contrast- enhanced scan may not be required.

Any patient aged 65 years and over with Contrast-enhanced scans may be of use if loss of consciousness or amnesia after there is a suspicion of pulmonary head injury should have a CT Head scan. embolism as a precipitant for a fall, or Furthermore, any patient on warfarin, any where there is a suspicion of mediastinal other anticoagulants or with bleeding injury or penetrating trauma. disorders like haemophilia should also have a CT Head scan. Non-contrast scans will identify bony injury including multiple rib fractures A 2012 study8 observed different cohorts and/or flail segments. Such scans may be of patients for the risk of traumatic indicated following a fall whereby the intracranial haemorrhage and found that chest wall has made contact with a hard higher proportion of patients on object and the patient has ongoing pain clopidogrel (12%) had an abnormal CT and difficulty in breathing. This will aid in scan than patients taking warfarin (5%). the decision-making process about the

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indications for epidural analgesia. rendered the traditional method of “Primary Survey” films (chest, pelvis, CT Abdomen cervical spine), less relevant

Isolated scans of the abdomen may help  When requesting any CT scan, the identify the presence of solid organ and trauma team leader / assessing bowel injury. The use of contrast is clinician should make a judgement of recommended to ensure that minor or risk based on exposure to radiation major vessel leaks are identified and can and contrast, against the perceived be managed accordingly. benefit of the scan

Patients on warfarin with blunt abdominal  WBCT scans should be reserved for trauma are particularly susceptible to patients with high mechanisms of significant injury (e.g. retroperitoneal injury, or where there is a suspicion of bleeding, soft tissue bleed), so the severe injury. threshold for scanning such patients  Focussed CT scans may be of use for should be lowered. patients with simple falls provided the assessing clinician has a specific CT Pelvis question in mind about what they hope the CT scan will reveal. Focussed pelvic scans may be useful if a patient has had an apparently normal Pelvis X-ray but continues to have pain in References the pelvic area or is unable to weight bear. This may help to identify minimally 1. Gale SC, Gracias VH, Reilly PM et al. The displaced fractures of the femoral neck. inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. J Patients with pubic rami fractures with Trauma 2005; 59(5): 1121-5 persistent hypotension or falling Hb levels 2. Blaivas M, Lyon M, Duggal S. A prospective may benefit from a contrast-enhanced CT comparison of supine chest radiography and of the pelvis to identify the presence of bedside ultrasound for the diagnosis of local haematomas are actively bleeding traumatic pneumothorax. Acad Emerg Med vessels. This is particularly relevant for 2005; 12(9): 844-9 patients taking warfarin who present with these injuries. 3. National Institute of Clinical Excellence (NICE). Head Injury CG176, 2014. London: National Clinical Guideline Centre Summary 4. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine  The majority of elderly patients with anteroposterior chest radiographs for the traumatic injuries present following a identification of pneumothorax after blunt simple fall and plain film radiography trauma. Acad Emerg Med 2010; 17(1): 11-17. may be sufficient to diagnose their injuries 5. National Institute of Clinical Excellence (NICE). Hip fracture: The management of hip  Advances in ultrasound and access to fracture in adults. CG124, 2011. London: National Clinical Guideline Centre computerised tomography has

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6. Husain LF, Hagopian L, Wayman D. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 2012; 5(1): 76-81.

7. Royal College of Radiologists. Standards of practice and guidance for trauma radiology in severely injured patients. London 2011

8. Nishijima D, Offerman S, Ballard D et al. Immediate and delayed traumatic intracranial haemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use. Annals of Emerg Med 2012; 59(6): 460-468.

9. Nishijima D, Offerman S, Ballard D et al. Risk of traumatic intracranial haemorrhage in patients with head injury and pre-injury warfarin or clopidogrel use. Acad Emerg Med 2013; 20: 140-145.

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Chapter 5: The Secondary Survey conducted as part of the primary survey.

Following the primary survey and Injuries should be treated as they are associated imaging, a top-to-toe found with lacerations being closed assessment should be performed to through appropriate techniques, (sutures, identify additional injuries and illness wound glue, staples). Actively bleeding that could have precipitated the traumatic vessels should be treated with greater event. urgency and the following techniques may be used to manage arterial vessels: The Structured Approach a. Local pressure with adrenaline-soaked The assessing clinician should adopt a gauze structured approach to the secondary survey covering the following areas: b. Injection of combined local anaesthetic and adrenaline 1. Scalp, Eyes, Face, Jaw c. Vicryl suture to achieve haemostasis to 2. Upper Limb – sternoclavicular bleeding vessel joint to distal phalanges, (including formal neuro- d. Use of haemostatic agents (e.g. Celox) vascular status) in the patient with agitation or delirium if formal closure is impractical 3. Chest – Formal cardio-respiratory assessment with ECG. e. Formal wound closure with subsequent compression bandage 4. Abdomen & Pelvis – formal gastrointestinal examination Eyes (including rectal examination) and Assessment of pupillary reflexes and size urinalysis should have occurred during the primary survey and should be repeated again. 5. Lower limb – greater trochanters Unilateral irregularities of pupil size to distal phalanges (including and/or reactivity may not be related to formal neurovascular status) trauma and may have resulted from previous eye surgery, (e.g. cataracts), or underlying disease.

Each area should be assessed externally Aniscoria is when one pupil is different in with any deformities or skin abnormalities size to the other. In the context of trauma, being documented in the notes and then a this could herald severe brain injury. It more detailed examination conducted. may also be caused by hypoglycaemia,

acoustic neuromas and other diseases

such as optic neuritis. 1. Scalp, Eyes, Face, Jaw

Small pupils may follow excessive opioid Scalp administration especially if high doses At this point, efforts should be made to have been given to elderly patients who examine the entire scalp for obvious may not have the same capacity for renal lacerations and bleeding points, if not

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clearance. If such findings are associated administration of 400mcg naloxone iv/im. with bradypnoea and/or reduced GCS, consideration should be given to the

Abnormality Causes (non-exhaustive)

Unilateral dilated pupil  Congenital, post Cataracts surgery  Intracerebral haemorrhage; Raised ICP  Giant cell arteritis  Myasthenia gravis  Thyroid eye disease  Inter-nuclear ophthalmoplegia

Bilateral constricted pupils  Opioid toxicity  Organophosphates

Horner’s Syndrome  Trauma to base of neck Partial ptosis  Carotid artery dissection Anhidrosis  Thoracic aortic aneurysm & dissection Miosis (small pupil)  Bronchogenic carcinoma Enophthalmos

Acutely Red, Painful Eye  Corneal foreign body / abrasion  Retrobulbar haemorrhage (severe eye pain, progressive visual loss, ophthalmoplegia, proptosis).  Penetrating eye injury (irregular pupil, hyphaema)  Acute glaucoma from blunt trauma and ciliary body injury

Abnormalities on Eye Examination

If significant injury to the eye is suspected, any focal tenderness and crepitus. The a formal ophthalmogical examination examiner should palpate around both should be performed at the earliest and orbital rims and along the zygomatic safest opportunity. This should include arches. Any bruising below the eyes measurement of visual acuity and should warrant formal assessment of eye fundoscopy. movements and consideration of imaging to assess for the presence of an orbital floor fracture. Such plain film imaging may Face have to be delayed until the patient can The face should be examined from the sit upright, or can be expedited if forehead to the maxillary region. All bony performed using CT imaging. prominences should be felt to assess for

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Careful attention should be paid to any The Jaw & Teeth injury to the mid-face region as this may The jaw should be palpated from both point to underlying cervical spine injury temporo-mandibular joints medially. Any (see earlier). tenderness should raise suspicion of underlying injury and a bimanual oral Significant epistaxis should be controlled examination should be performed to as per any overt haemorrhage. Care must assess for any loose or missing be taken prior to the insertion of nasal teeth/dentures, and any obvious gingival packing, especially if there is a suspicion lacerations. of basal skull fracture, (see below). In such circumstances, the assessing clinician should balance the risk of causing damage 2. The Upper Limb against the benefits of controlling haemorrhage. Examination of the upper limb should start at the sternoclavicular joint working Methods to control epistaxis are not distally, and should only be considered as confined to Merocel or Rapid Rhino Packs. complete once the distal phalanges have Posterior nasal packing with urethral been assessed. catheters secured in position with umbilical clips and BIPP ribbon packing In general terms, the assessment should may be of use but require expertise to comprise a basic examination consisting insert. of:

Signs of Basal Skull Fracture - INSPECTION - PALPATION 1. Haemotympanum - MOVEMENT 2. CSF Otorrhoea - ASSESSMENT OF NEUROVASCULAR 3. CSF Rhinorrhoea STATUS 4. Racoon eyes 5. Battle’s sign (mastoid bruising) The clinician should inspect the limb for any obvious anatomical deformity, obvious skin lesions and lacerations/abrasions, and ensure any findings are documented.

Obvious anatomical deformity should prompt the assessor to review the administration of analgesia and whether limb splintage should occur before or after correction of the deformity.

If there is a suspicion of fracture of the With most mechanisms of injury being nasal bones, the nose should be examined simple falls, attention should be paid to for the presence of septal haematoma the nature of the fall and how the patient and if identified, should prompt urgent landed. ENT referral. Falls onto the shoulder may result in

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clavicle, neck of humerus fractures or presence of lower motor neurone lesions glenohumeral dislocation. Falls onto the (e.g. spinal injury), but in elderly patients, outstretched hand may lead to scaphoid, may be increased as a result of previous distal radius (Colles’/Smith’s), and head of upper motor neurone lesions (e.g. stroke), radius fractures. or Parkinson’s disease. Cog-wheel rigidity may be present in association with Each MCPJ, phalanx and inter-phalangeal increased rigidity and underlying tremor. joint should be assessed in turn, and attention paid to the presence of b. POWER & REFLEXES flexor/extensor tendon involvement that could lead to Mallet and Boutonniere’s Upper limb power should be tested in a deformity. The presence of existing symmetrical fashion and measured using osteoarthritis may make deformities more the MRC scale: likely, and in these circumstances the patient should be asked whether any 0 No muscle contraction visible anomaly is new or old. 1 Flicker of contraction but no movement Assessment of Upper Limb Neurology 2 Joint movement when effect of gravity eliminated Each upper limb should be assessed for 3 Movement against gravity but not central and peripheral neurological signs against examiner’s resistance and symptoms. The examiner should be 4 Movement against resistance but mindful of the patient’s normal level of weaker than normal function as a history of previous stroke 5 Normal power may lead to asymmetrical findings. As a minimum, the following movements a. GENERAL INSPECTION & TONE should be assessed:

Upper limb muscles should be inspected C4,C5 Shoulder Abduction for symmetry, looking for wasting, C5,C6 Elbow Flexion fasciculations and involuntary C7,C8 Elbow Extension movements: C6,C7 Wrist Flexion (volar) C8 Finger flexion Involuntary Movements T1 Finger Abduction i. Tremor – oscillatory movement around Following assessment of power, the a joint (e.g. “pill-rolling” tremor of biceps, triceps and supinator reflexes Parkinson’s disease; intention tremor of should be assessed and both sides cerebellar damage) compared to each other. ii. Myoclonic jerks – sudden, shock like c. SENSATION & COORDINATION contractions in muscles By assessing a gentle pain sensation, the iii. Chorea – irregular, brief writhing examiner can assess the function of the movement spinothalamic tracts. Examination of proprioception can aid in the assessment Muscle tone may be decreased in the of the dorsal columns. Each of these

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modalities should be assessed for each Assessment of Cerebellar Function dermatome (see below): i. Disdiadochokinesis ii. Ataxia iii. Nystagmus iv. Intention Tremor v. Speech disturbance vi. Hyper-reflexia

d. PERIPHERAL NERVES

The peripheral nerves of the upper limb should be assessed as part of the secondary survey. If it is not possible to assess each peripheral nerve at this stage, then it may be delayed until later.

Each nerve should be assessed in terms of inspection of the relevant muscles, Assessment of coordination can aid in the assessment of power and sensation. A diagnosis of underlying cerebellar basic knowledge of anatomy is needed to dysfunction and prompt the examiner to conduct a formal assessment. complete a formal examination of cerebellar dysfunction, (see below).

Axillary INSPECT: MOTOR: SENSORY: SITES AFFECTED: Deltoid wasting Shoulder abduction Regimental badge area Glenohumeral dislocation Radial INSPECT: MOTOR: SENSORY: SITES AFFECTED: Wrist drop Supinator (supinate hand Dorsal aspect of hand Axilla against resistance with Dorsal forearm Mid-humeral fracture elbow in extension) Elbow dislocation Brachioradialis (flex elbow against resistance with forearm in mid- prone position) Triceps (extend elbow against resistance) Ulnar INSPECT: MOTOR: SENSORY: SITES AFFECTED: Claw hand (flexion of PIPJ Interossei (adduction of Volar and dorsal aspect Medial epicondyle of little finger) ring and little finger) of little finger Forearm fracture Adductor Pollicis Wrist laceration (Froment’s test) Flexor carpi ulnaris (resist attempted dorsiflexion of wrist held in volarflexion)

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Median INSPECT: MOTOR: SENSORY: SITES AFFECTED: Nil acute Flexor carpi radialis Thenar eminence Supracondylar fracture (place hand on flat Deep wrist laceration surface palm up. Hold fingers and ask to flex wrist) Flexor pollicis longus (flexion of thumb DIPJ) Abductor pollicis longus (thumb abduction)

3. Chest Wheeze in the presence of known COPD or asthma may prompt the examiner to Assessment of life-threatening chest prescribe nebulisers such as short acting injuries would already have been or long-acting beta-agonists (5mg performed during the primary survey. The salbutamol, 500mcg ipratropium secondary survey should be used to bromide). assess for the presence signs that may suggest cardio-respiratory illness. The presence of added breathing sounds on secondary survey should prompt the Only a formal respiratory examination will examiner to review observations and be helpful in detecting the presence of investigation findings. Suspicion of lower underlying illness. This includes respiratory tract infection should lead the assessment of chest expansion, examiner to consider the prescription of percussion, auscultation of breath sounds, antibiotics for example. and vocal resonance. Attention should be paid to the presence of added sounds and Assessment of the cardiovascular system at which phase they occur in the should include listening to the heart respiratory cycle. sounds for murmurs. In the context of trauma and the elderly patient, members Cause of Crackles of the trauma team should have a basic Phase of Cause knowledge of ECG interpretation and be Inspiration able to manage common anomalies. This Early Small airway disease will be covered in Chapter 14. (bronchiolitis) Middle Pulmonary oedema 4. Abdomen Late Pulmonary fibrosis Secretions in COPD, During the secondary survey, the Pneumonia etc.. examiner should inspect the abdomen Biphasic Bronchiectasis and document the presence of any scars, abrasions / lacerations, and distension. Wheeze commonly occurs during the expiratory phase as airways narrow on Examination should include an breathing out. Inspiratory wheeze may be assessment of the bladder to look for the indicative of severe airway narrowing, but presence of urine retention, and a rectal in general, wheeze is a poor indicator of examination to assess for constipation. the severity of airflow obstruction. Both of these features may lead to acute or delayed delirium and lead to worsening

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outcomes. Pain and deformity over the shin should The examiner should review baseline prompt further imaging of the affected blood tests that were sent during the area to assess for underlying fracture. primary survey and pay close attention to Compound fractures should be assessed the underlying renal function. Acute for size and depth of wound, as per kidney injury may be precipitated by Gustilo grading and if found, be dehydration and/or a long lie on the floor immobilised after application of a saline with associated rhabdomyolysis and soaked gauze and the patient be raised creatine kinase. Early institution of prescribed intravenous antibiotics. intravenous rehydration should commence early with the aim of Grade Description maintaining urine output (>0.5ml/kg/hr). I Wound <1cm and clean II Wound >1cm without extensive soft tissue damage The assessing clinician should have a low IIIA Adequate soft tissue coverage in spite of threshold for CT imaging in the presence soft tissue damage or high energy trauma of abdominal / back pain for any patient IIIB Contamination; extensive soft tissue loss; on warfarin or anticoagulation. Risks of periosteal stripping; bone exposure scanning should be balanced against the IIIC Associated arterial injury risks of spontaneous bleeding (retroperitoneal or intra-abdominal) in Assessment of the neurological status of such patients. the lower limb should follow similar principles to those used in the assessment of the upper limb. After inspection, tone, 5. Lower Limb power, reflexes and sensation should be examined to identify underlying Secondary survey assessment of the lower abnormalities. limbs should aim to identify any obvious anatomical deformity before moving onto a. TONE a formal neurological assessment. As per upper limb assessment Shortening or rotation of the legs may indicate the presence of underlying b. POWER & REFLEXES fracture. Patients with fractures of the femoral neck may present with groin pain Power should be graded as per the MRC and shortened, rotated lower limbs. scale and as a minimum, the following Review of primary survey films may muscle groups should be examined: identify such injuries, or may reveal L2, L3 Hip Flexion injuries such as pubic rami fractures. L3,L4 Knee extension L4, L5 Knee flexion Patients with gross swelling and deformity S1 Ankle plantarflexion to the mid-thigh may have underlying shaft of femur fractures and in such The knee and ankle jerk reflexes should be circumstances will need plain film examined and compared with each other, radiography to assess for these injuries. followed by assessment of the plantar On diagnosis, traction should be applied response. for bony realignment and pain relief.

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c. SENSATION  The assessing clinician should always keep in mind the presence of pre- The lower limbs should be assessed for existing disease states that may nociception and proprioception as per the contribute to abnormal findings on specific dermatomes (see below). The clinical examination and be able to examiner should consider the presence of treat findings appropriately diabetes and peripheral vascular disease when assessing neurovascular status as  Specific injuries should be treated as both can contribute to abnormal findings. they are identified (e.g. lacerations, fractures), and consideration given to Lower limb pulses (femoral, popliteal, pain relief and additional therapy (e.g. dorsalis pedis, posterior tibial), should all antibiotics) be palpated and any asymmetrical findings or absence of pulsation should be documented in the notes.

Summary

 A secondary survey assessment should be performed for all elderly patients with traumatic injuries

 A structured approach to this process will allow the examiner to identify any significant injuries and/or fractures in each body region

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Chapter 6: The Silver Survey

Established trauma courses will cover PINCHME trauma care up until the point when decisions are made about definitive P Pain management strategies for patients and their injuries. In Infection – chest, wound, urine, skin This is inappropriate for elderly trauma patients as the very nature of their C Constipation & urinary retention injuries predisposes them to developing delirium. H Hydration (i.e. dehydration)

Delirium may be defined as a clinical M Medication (prescribed or illicit; syndrome characterised by disturbed alcohol / benzodiazepine consciousness, cognitive function, or withdrawal; opiates; sedatives; perception, which has an acute onset and anticholinergics a fluctuating course1. It is important to prevent the onset of delirium as it is an E Electrolytes (hypo-hyperglycaemia; independent risk factor for increased hyponatraemia; hypercalcaemia; mortality and length of stay2. hyper-or hypothyroidism)

Causes of Delirium Management and prevention of delirium requires a multifactorial, patient-centred assessment. HECTOR introduces the During the Silver Survey, it is important “Silver Survey” as a means of identifying for the lead clinician to be able to step risk factors for the development of back from the acute aspects of trauma delirium (see opposite) care that can feel rushed or pressured, and adopt an individualised focus towards the patient. The Silver Survey It may not be possible to conduct such an The purpose of the Silver Survey is to assessment in the Emergency consolidate the findings of the primary Department, especially if the patient is and secondary surveys as well as due to be transferred to theatre or critical identifying any individual risk factors for care. However it should be completed as the development of delirium. soon as it is safe to do so.

This aims to ensure that anything that The Silver Survey involves obtaining as could precipitate the onset of delirium is accurate a history as possible from the managed early and in an appropriate patient, or from members of their family manner. It also ensures that ward-based or carers to establish their pre-injury teams have a greater understanding of status from a medical and societal the patient’s presenting state and can perspective, (see below) assess for any subtle changes that may occur following admission.

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The Silver Survey

A  Missing or Broken Teeth / Dentures □

 Swallowing difficulties that could limit nutrition □

 Is SALT assessment needed before oral hydration / feeding □

B  Underlying respiratory disease (e.g. COPD; Asthma; UIP; TB) □ Baseline ABG and correct hypoxia If risk of CO2 retention, aim sats 88-92% or >94% if normal CO2/HCO3- Review CXR for presence of consolidation, pulmonary oedema and treat

 >2 rib fractures or undrained pneumo/haemothoraces Ensure patient has adequate pain-relief prescribed □

C  Review blood results and clotting profile □

 Prescribe TED stockings □

 Prescribe 40mg enoxaparin (or 20mg if renal impairment), unless any of □ the following are present: Patient Related Admission Related Active bleeding; acquired bleeding Intracranial haemorrhage or spinal surgery disorder; use of anticoagulants with INR>2; planned; procedure planned with high risk acute stroke; platelets <75; uncontrolled of bleeding systolic BP >230mmHg; untreated inherited bleeding disorder

D  Patient has visual aids □ Document if broken or not present

 Patient has auditory aids □ Document if broken or not present

 Calculate 4-point abbreviated mental test score (1 point each) /4 A. YEAR B. PLACE C. AGE D. BIRTHDAY

 Assess pain and offer analgesia if in discomfort □

 Perform baseline RASS assessment

E  Reassess temperature and aim >36OC □

 Assess continence status □ Continent; catheterised; incontinent of faeces; urinary incontinent; doubly incontinent

 Assess skin integrity / tissue viability of pressure areas □ Healthy; tissue-paper like; clammy; grade 1 erythema; grade 2 or above

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HISTORY OF INJURY:

PAST MEDICAL HISTORY: Hypertension CVA / TIA / SAH Cancer Peripheral vascular disease DVT / PE Dementia Ischaemic heart disease / MI Renal Impairment Parkinsonism CCF / LVF COPD Mental Health Atrial fibrillation / flutter Asthma Drug / Alcohol Abuse Pacemaker / ICD Diabetes

Other:

DRUG HISTORY:

ON WARFARIN OR OTHER ANTICOAGULANTS? Y / N

CVS: (HTN, IHD, statins etc..) RS: (COPD, Asthma etc..) NEURO: (Parkinson’s, epilepsy etc..) ENDOCRINE: (diabetes, thyroid etc..) ALLERGIES:

SOCIAL CIRCUMSTANCE: Accommodation Own Home Sheltered / Warden Controlled Residential Home Nursing Home Level of Dependency Independent Mobile with carer assistance Walks with one aid Chair Bound Walks with two aids or a frame Bed Bound

Pre-Injury Walking Distance

metres

FAMILY / PATIENT CONCERNS:

Any increasing confusion or illness that has been a concern? Y / N

Any underlying diagnosis of dementia or interactions with GP for this diagnosis? Y / N

Any other falls in the last twelve months? Y / N

Any pre-existing documentation or discussion about end-of-life status Y / N

Any concerns with current accommodation status? Y / N

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Components of the Silver Survey target oxygen saturation of 88-92%. Those patients without such risks may have A – AIRWAY oxygen prescribed to target saturations above 94%. Airway is formally assessed during the primary survey. For the Silver Survey, the Elderly patients with >2 rib fractures assessment requires review of dentitions should be identified as being at risk of and swallowing function that could delirium from pain and possible hypoxia otherwise hinder adequate nutrition. due to under-ventilation. Careful pain management can promote adequate The assessing clinician should document ventilation and prevent underlying the presence of any missing / broken atelectasis due to a poor cough or teeth and whether or not the patient uses hypoventilation. dentures. Following this, the patient should be asked about swallowing These patients should be alerted to problems or pre-existing use of PEG- inpatient teams as being at risk of feeding etc.. progressive respiratory failure, and be seen by a Respiratory Physiotherapist Patients with injuries may have had a soon after admission. Pain management stroke that precipitated the event and may involve epidural analgesia or patient- may require formal SALT assessment controlled analgesia (PCA), and such before oral hydration and nutrition can be requirements should be flagged up as commenced – failure to do so may lead to soon as possible on the patient’s journey. aspiration. A simple trial of oral liquid could be instituted in the Emergency C – CARDIOVASCULAR Department, provided the patient is not being kept Nil by Mouth for definitive The Silver Survey aims to review surgical care. Inability to swallow or coagulation status and prevent venous coughing at this point may trigger formal thromboembolism. SALT assessment. All patients should have their blood tests B – BREATHING & RESPIRATION reviewed to assess for baseline haemoglobin, platelets and INR. The Silver Survey should be used to Traumatic coagulopathy may be a establish an accurate goal for oxygen continuing process in the event of saturations. This takes into account BTS undiagnosed injuries and the assessing guidance on management of COPD and team should ensure that haematological guidance on oxygen delivery3. All oxygen parameters are within acceptable limits. should be prescribed as per any other drug. Injuries that appear to be of low significance (e.g. pubic rami fractures) The ABG taken during primary / secondary could be significant for patients taking survey should be analysed to assess the oral anti-coagulants or for those with patient’s risk of type II respiratory failure. established coagulopathy. Again, - Those with high CO2 levels or high HCO3 admitting teams should be alerted to the (a marker of chronic renal compensation possibility of clinical deterioration in the for respiratory acidosis), should have a presence of such injuries.

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Patients with falling blood pressure or a scale of four, (i.e. one point per rising heart rate in the presence of injury question). and abnormal clotting, (Hb <8; Platelets <100; INR > 1.5), should be reassessed i. What year is it? and considered for further CT Imaging. ii. Where are you now? iii. How old are you? The prescription of TED stockings and iv. When is your birthday? subcutaneous heparin is standard practice for patients being admitted to hospital. A score of less than four may be normal The Silver Survey allows the assessing for that patient, especially if there is a clinician to review patient-related and background history of dementia. What injury-related contra-indications for remains important is whether this score chemical thromboprophylaxis in deteriorates following admission. If so, accordance with NICE guidelines4. this should prompt a formal reassessment of risk factors for delirium. D – DISABILITY & NEUROLOGICAL STATUS Alternative measurements include the 4- The Silver Survey is used to assess for the AT score and CAM-ICU assessment tool. presence, absence or damage of The 4-AT is an assessment test for audiovisual aids. Without such devices, delirium and cognitive impairment which patients who rely on them could become looks at four separate components: quickly disorientated or confused. Attempts should be made to ask family A Alertness members or carers to bring these devices A AMT4 to hospital if not present. A Attention A Acute change or fluctuating course Following this, the assessing clinician should document: The 4-AT tool has been found to have a 89.7% sensitivity and 84.1% specificity for  A Four Point AMT score delirium from a previous study5.  Assess pain and manage appropriately  Perform a RASS (Richmond Agitation The CAM-ICU assessment tool suggests Sedation Scale) assessment. that a patient may have delirium if they have two core features and one of two By assessing each of these areas in turn, other features: the clinician can establish the patient’s baseline level on admission and document CORE COMPONENT (both must be this in the notes. If the patient were to present): deteriorate further, the team responsible 1. Acute Onset of Change or Fluctuating for their ongoing care will have this as a Course reference point. 2. Inattention

The Four-Point AMT Score OTHER COMPONENT (one of the following): This assessment is quick to perform and easily reproducible. The examiner asks the 1. Disorganised thinking patient four questions and marks them on 2. Altered level of consciousness

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This method of assessment was created in The clinician should reassess the patient 1990 and intended to be used as a whenever their pain score increases in a bedside assessment tool by non- subjective manner and act accordingly. psychiatrists to assess for delirium, This may involve prescribing analgesia, or (Confusion Assessment Method, CAM). it could also involve splinting undiagnosed The CAM-ICU tool was created as an fractures or treating previously adaptation of the CAM tool for use in ICU undiagnosed illness. patients and studies have shown it to have a high sensitivity and specificity (93- The prescription of analgesia should 100% and 98-100% respectively)6. follow standard practice of “climbing the analgesic step-ladder”7. Simple analgesics For the purposes of the HECTOR Course, such as paracetamol are prescribed in the the AMT-4 tool has been utilised for its first instance, followed by non-steroidal ease of use and practical application. anti-inflammatory agents and then HECTOR does support the use of other opioids / opiates. assessment tools but acknowledges the difficulties in implementing their effect Care must be shown in elderly patients, as through wider training and education. NSAIDs may cause renal impairment and worsen peptic ulcer disease. Similarly, Assessment of Pain opioids prescribed to opioid-naive patients could have a significant effect on There are many different tools for cardiorespiratory systems, especially in assessing a patient’s degree of pain. If a the presence of underlying renal patient is fully coherent, the ideal method impairment leading to reduced clearance. is whichever one can be used consistently and with which the patient becomes Drugs such as codeine phosphate can lead familiar. Asking a patient to score their to increased confusion or constipation, level of pain from 0 to 10 (with 0 being no both potentially leading to acute delirium. pain and 10 being the most severe pain), allows patients to describe their Where possible, regional nerve blockade experience in a subjective manner and for with local anaesthetic agents can limit clinicians to assess this objectively. these side-effects or lead to lower dosages of opioids / opiates. Fluctuations in pain scores may be useful in detecting progression of illness (e.g. In the situations where patients are developing hospital acquired lower unable to verbalise their levels of pain, respiratory tract infection, pulmonary the Abbey Pain Scale should be used to embolus), but also progression of injury, determine the need for additional (e.g. expanding pelvic haematoma from analgesia8. pubic rami fractures).

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The Richmond Agitation Sedation Scale Patients are scored on a linear scale with The RASS Score can be used to assess 0 representing an alert and calm state and whether a patient is alert, agitated or scores above this reflecting increasing hypoactive8. It is easily reproducible and agitation, and those below it reflecting can be used to assess for rapid increasing sedation. deteriorations in behaviour.

The RASS score requires the examiner to patient’s with dementia may be restless in establish a baseline level of alertness for unfamiliar environments and this may be patients that can be used to assess for unlikely to improve until they are restored improvements or deteriorations following to their normal accommodation. admission. The linear scoring system allows clinicians It has the advantage of determining the to identify subtle changes in a patient’s presence of hypoactive states as well as underlying state that could pre-empt the hyperactive, agitated states that are more onset of established delirium and trigger a obvious to the assessing clinician. formal review for underlying risk factors / Furthermore, it can be used to describe a causes of delirium. patient’s normal resting state, (i.e.

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E. ENVIRONMENTAL / EXPOSURE All patients should have a formal history of injury documented in the notes. It is All patients should have their important for the assessing clinician to temperature, continence status and skin document the precise nature of any falls – integrity recorded during the Silver including mechanism of injury, footwear / Survey. Hypothermia contributes to the lighting at the time of fall, pre-injury lethal triad and if not treated, can worsen weakness or illness, chest pain / coagulopathy. A core temperature above palpitations. 36OC should be targeted and measures taken to ensure patients are not left It is crucial to determine the exact nature exposed to the cold conditions of of the injury mechanism and be able to Emergency Department trolleys. make a judgement on any underlying disease process that could have Persistent hypothermia may exist in contributed to the injury. extreme states of hypothyroidism and myxoedema coma. Similarly, ingestion of Past medical history should be alcohol or other toxic substances can documented in a formal manner so that lower temperature through inactivity. All pre-existing conditions such as atrial measures should be taken to ensure any fibrillation, chronic obstructive pulmonary reversible causes are treated (including disease etc.. can be taken into account sepsis), and that patients are warmed to when treating specific injuries. appropriate temperatures as soon as possible. A documentation of drug history (including allergies), is useful in Continence status is an important step in determining whether a patient is taking the assessment process. Patients who are medication that could predispose them to incontinent, or who have trouble passing sudden drops in blood pressure, (i.e. anti- urine / faeces, are at increased risk of falls hypertensives). It is important to and delirium. Unnecessary urethral document doses of medications catheterisation should be avoided but in accurately as drugs such as co-beneldopa patients with injuries that limit rolling, and levodopa should be prescribed at (e.g. unstable vertebral body fractures), consistent times to prevent worsening of catheterisation of patients with urinary Parkinsonian symptoms. incontinence may help prevent skin complications. Social history is necessary to determine a patient’s pre-injury status. This combined Skin integrity is important to assess as the with carer / family concerns can be used presence of pre-existing pressure sores / to target specific outcomes for the ulcers must be documented. These can be patient. For example, if the family or made worse by poor nutrition or infection patient believes that they are not coping so a documentation of baseline status can and need additional / new carer support, help assess what type of mattress a this should be coordinated at as early a patient needs, and whether or not such stage as possible in the patient’s journey areas have progressed after admission. to ensure that delays do not occur once the patient is deemed fit for discharge. F. STANDARD HISTORY

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End of Life / Do Not Attempt  Baseline AMT, Pain and RASS scores Resuscitation Decisions are the most useful systems for establishing objective and subjective Patients and their families should be parameters for injured patients involved in any discussion that centres on the futility of treatment in the presence of  A formal history as per standard overwhelming injuries. medical practice should be conducted as part of the Silver Survey to ensure Such discussions need to be as honest as that any pre-existing illnesses or possible and respect a patient’s wishes. features that may contribute to Some patients may have pre-existing delirium can be addressed as early as DNAR orders or may refuse further possible. intervention in the wake of perceived poor outcomes.  Assessment of social circumstances and consideration of family / carer HECTOR believes that such discussions concerns can help establish early should occur as early as possible in the targets of therapy and discharge patient journey to minimise distress and planning as opposed to creating delays unnecessary and / or unwanted later on in the patient journey that resuscitation following admission. leaves patients vulnerable to hospital acquired illness.

Summary  Frank and open discussions should be made with the patient and family  The purpose of the Silver Survey is to about realistic outcomes in the event consolidate the findings of the primary of patients sustaining significant, life- and secondary surveys as well as threatening injuries. Specialist advice identifying any individual risk factors should be sought about the for the development of delirium. appropriateness of escalation in care.

 It is important for the lead clinician to References be able to step back from the acute aspects of trauma care and adopt an 1. Francis J, Martin D, Kapoor WN. A individualised focus of care towards prospective study of delirium in hospitalised the patient. elderly. JAMA 1990; 263: 1097-1101.

2. Inouye SK, Rushing JT, Foreman MD et al.  The Silver Survey follows a structured Does delirium contribute to poor hospital approach, ABCDE, and established outcomes? A three-site epidemiologic study. J baseline and pre-injury status for Gen Intern Med 1998; 13: 234-242. injured patients 3. O’Driscoll BR, Howard LS, Davison AG.  This baseline status can be used to Guideline for emergency oxygen use in adult identify early improvements or patients. Thorax 2008; 63 (suppl VI). deteriorations in patients following admission so that admitting teams can 4.National Institute of Clinical Excellence reassess and act according to findings. (NICE). Venous thromboembolism in adults admitted to hospital: reducing the risk CG92,

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2010. London: National Clinical Guideline Centre

5. Bellelli G, Morandi A, Davis DHJ. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age and Ageing 2014; 0: 1-7.

6. Wesley E, Inouye SK, Bernard GR et al. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). JAMA 2001; 286 (21): 2703- 2710.

7. Vargas-Schaffer, G. Is the WHO analgesic ladder still valid? Twenty-four years of experience. Can Fam Physician 2010; 56(6): 514-517.

8. Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. The Abbey Pain Scale. Funded by the JH & JD Gunn Medical Research Foundation. 1998-2002.

9. Tadrisi SD, Madani SJ, Farmand F. Richmond agitation-sedation scale validity and reliability in intensive care unit adult patients; Persian edition. Iranian J Crit Care Nursing 2009: 2(1): 15-21.

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PART II: MANAGEMENT OF SPECIFIC INJURIES IN ELDERLY PATIENTS

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Chapter 7: Head Injuries responders to the possibility of serious injury. Furthermore, patients with Introduction memory impairment may not recall why, how or when they have fallen, thus making assessment even more difficult. Same level falls represent the commonest mechanism of injury for elderly patients A UK-based study1 found that for any and these falls can have a devastating given AIS score related to a head injury, impact on the individual if associated with older patients had a higher presenting a traumatic brain injury. GCS than their younger counterparts. This would leave them more vulnerable to Traumatic brain injury can be a challenge under-triage as they would not present to diagnose and manage in the elderly with the reduced GCS that mandates patient, especially if they have: declining direct MTC transfer. cognitive function; pre-existing neurological signs; or where in normal As nearly all neurosurgical centres in the circumstances, they have a reduced level UK are based within major trauma of consciousness. centres, this patient group not only face the risk of delayed diagnosis because of a The management of elderly patients with higher presenting GCS, but also face the traumatic brain injury often follows risk of being managed in non-specialist conservative pathways. As age increases, centres despite having significant injury. a dichotomy exists whereby patients are managed with comfort measures on a A Canadian-based study2 identified that “wait and see basis”, or are managed for patients with severe brain injury in a aggressively with surgical intervention but level II trauma unit, 81% of young patients may be left living with serious compared to 71% of those aged 65 years neurological impairment. and over were transferred to a specialist centre (p<0.0001). When “time is brain” Taking all of this into account, it is and time to definitive care can affect important to have a basic understanding outcome, such issues may deprive elderly of the different types of brain injury, the patients from being given the option of cause and acute and prolonged response aggressive intervention. to injury, and prognosis. It is important for the trauma clinician to Head Injuries in the Elderly be aware of such evidence to appreciate that an elderly patient with significant With current trauma training, a trauma brain injury may present in a stable, fully moulage for the head-injured patient is conscious state. If extra vigilance is not often taught whereby they will present used at this time and if a diagnosis is not with a clear mechanism of injury, a made, the management needed to reduced GCS and additional injuries that prevent secondary brain injury may not be require management. implemented, leading to further deterioration. By this stage, treatment In practice, elderly patients often sustain options will be even more limited. head injuries following simple falls or trips. Such mechanisms may not alert first

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Types of Brain Injury i. Hypoxia (PaO2 <10kPA)

It is important for the trauma clinician to ii. Hypotension (SBP <90mmHg) have a basic understanding of primary and secondary brain injury in order to iii. Delayed diagnosis prevent deterioration. iv. Raised intracranial pressure (ICP) PRIMARY – This is the damage sustained at the time of injury. Elderly patients are The skull should be regarded as a rigid box particular vulnerable to subdural that contains brain, blood and haematomas owing to greater tension on cerebrospinal fluid (CSF). In a normal the bridging veins connecting the subdural state, these components fill the skull to surface to the ageing brain with cerebral produce a small positive pressure, known atrophy. Low mechanisms of injury can as the ICP which is between 5-13mmHg. tear these taut veins leading to slow The presence of additional contents (e.g. venous bleeding and the development of haematoma), would cause the intracranial a subdural haematoma. pressure to increase were it not for the displacement of blood and CSF. This Subdural haematomas may also be principle is known as the Monroe-Kellie associated with additional injuries such as doctrine3. cerebral contusions / intraparenchymal haemorrhage. Extradural haematomas are The ageing brain undergoes cerebral often associated with arterial injury and atrophy, thus resulting in it occupying a tend to be confined to younger patients lower volume within the skull. This may following high mechanisms of blunt explain why older patients with the same trauma or penetrating injury. intracranial injury as younger patients present with a higher GCS – the brain Irrespective of the type of injury, this may does not occupy as much volume so any not be obvious at the time of first additional increase can be accommodated presentation because the speed of to a point, without pressure on the progression and development of volume reticular system. expansion within the cranium is slow. An altered level of consciousness or drop in As pressure within the intracranial GCS may take days to develop – such compartment increases, blood and CSF patients may therefore benefit from are displaced, resulting in reduced prolonged periods of observation and / or cerebral perfusion and hypoxia of brain careful discharge advice about tissue. With further expansion of progression of symptoms. pressure, patients develop ipselateral IIIrd nerve palsy manifested as a unilateral SECONDARY – This damage occurs after fixed, dilated pupil. This can be the initial traumatic insult and is often the accompanied by contralateral hemiparesis result of the following physiological due to compression of corticospinal tracts states: crossing at the midbrain.

If bleeding continues and pressure rises, the patient may develop the Cushing’s reflex (bradycardia and hypertension).

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Further volume expansion results in brainstem herniation or “coning”.

Cerebral Perfusion Pressure Approach to the Patient with Suspected Head Injury The cerebral perfusion pressure represents a careful balance between the As a guide, HECTOR suggests that a head blood flowing into the brain (mean injury be suspected for any patient above arterial pressure, MAP) and the pressure 65 years with any one of the following opposing the flow of this blood into the features: brain (ICP).

CPP = MAP – ICP THINK HEAD INJURY

If CPP falls, delivery of oxygen and glucose 1. Bruising above the neck / chin to neuronal axons diminishes and these 2. Traumatic epistaxis neurones start to fail. The ideal CPP 3. Fall and altered GCS or new onset should be >70mmHg. Falls in blood headache pressure will lead to reduced MAP and a 4. Loss of consciousness and amnesia smaller difference between MAP and ICP, (irrespective of history of dementia) thus leading to reduced CPP. In the 5. High mechanisms of injury (fall presence of a raised ICP, CPP can be downstairs, fall from height, road managed by raising the MAP, although traffic incident) this should be in a high dependency 6. Any possibility of trauma to the head setting. in a patient on anti-coagulant medication ..AND IF YOU THINK HEAD, THINK NECK!

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Triage Any abnormalities in the observations should prompt a quick review for Most elderly patients with traumatic head concurrent illness and injury. injuries will present following a simple fall from standing. As discussed already, if Summary of Priorities for Triage these patients are brought to hospital via ambulance, they may not trigger pre-  Careful documentation of mechanism hospital trauma triage tools on the basis of injury of mechanism or physiology. Such patients could also self-present or attend  Review of possible causes for any falls hospitals via GP referral. (include full set of obs and ECG)

It is important that the first steps of  Any bruising above the neck to assessment and triage are performed prompt clinical assessment for properly. Any elderly patient who attends intracranial injury after a fall or with any other injury to the head region (e.g. assault) should be  Any neck pain, restricted range of examined for bruising / haematoma movement, reduced GCS or distracting above the neck and also have a formal injury to necessitate immediate assessment of their cervical spine. Ideally clinical review for immobilisation this should be done by a senior clinician. (“Minimal Movement” philosophy), and imaging Any bruising above the level of the neck should immediately raise concern about  Prioritise clinical review for any the possibility of intracranial injury. patient with abnormal observations Similarly any neck pain, limited range of (GCS <15; HR >100; Altered movement of the cervical spine, reduced Temperature) GCS or presence of distracting injury should warrant formal radiological Primary Survey investigation as cervical injuries can be difficult to detect in such groups. Clinical assessment should follow a formal ABCDE. Any elderly patient with reduced The process of triage should include a GCS or bruising above the neck following review of the following as a minimum: a road traffic collision or a fall downstairs / from height should warrant full trauma  Mechanism of injury; team activation and standard CT protocols should be followed, (ideally a WBCT).

- If high energy, move to Resuscitation Room and consider trauma team High energy mechanisms should warrant activation. formal trauma team activation as per local guidance with the trauma team leader  The recording of a full set of managing the operational oversight of the observations (HR; BP; O2 sats; RR; team and instructing on immediate GCS; BM) therapy / imaging as soon as possible.  A 12-lead ECG.  Brief assessment for major injury In these situations, patients who have a (head, neck, pelvis, long limbs) reduced GCS (8 or less) or who are

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agitated should be intubated to facilitate e. Traumatic epistaxis* the acquisition of CT imaging. Decisions about whether a patient is suitable for *in the context of an unprotected fall onto the intubation / critical care management are face inappropriate in this hyperacute setting. This will delay care. Such decisions can be If not already identified during the made later following discussion with the primary survey, the following criteria patient’s family. should be used to determine the need for CT Head scan: The practice of using sedation to keep a patient still for CT imaging should be i. GCS < 13 avoided in patients with high energy ii. GCS <14 2 hours after injury mechanisms. Agitation or reduced GCS iii. Signs of basal skull fracture often occurs for a reason and the use of iv. Post-traumatic seizure benzodiazepines could lower blood v. Focal neurological signs* pressure, lead to a fall in GCS and an vi. Loss of consciousness increased risk of aspiration of stomach vii. Amnesia contents. viii. Patient taking anticoagulants (consider use of clopidogrel) For patients with normal physiological ix. Suspected skull fracture parameters and a low mechanism of *Patients who are known to have pre-existing injury, a full trauma team response will abnormal neurological signs may still benefit from not be required. Assessment of these CT scan if there is a clear history of trauma patients should follow the same principles of the Primary Survey (Chapter 3) but also Patients with pre-existing dementia or aim to identify any underlying illness or previous stroke may be difficult to assess precipitating factor that could have as their baseline GCS might be less than caused the injury. 15, and they could have pre-existing focal neurological signs. A senior clinician The ABCDE approach remains should review these patients and fundamental to assessment to identify determine the need for immediate additional injuries and illness and be able imaging or observant management with a to treat them as they are found (e.g. decision to scan based on clinical associated cervical spine trauma; cardiac deterioration. arrhythmias etc..).

Secondary Survey Preventing Secondary Brain Injury and Neurosurgical Referral The assessing clinician should perform a formal neurological examination at this Following the diagnosis of intracranial point and look for any signs suggestive of haemorrhage, efforts should be made to a basal skull fracture: prevent secondary brain injury through a combination of the following actions: a. Racoon Eyes b. Battle’s sign  Ensure adequate oxygenation (aim c. Haemotympanum PaO2 >10 kPa unless patient has COPD d. CSF otorrhoea / rhinorrhoea with Type II Respiratory failure in

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which case tolerate Pa02 >8 kPA or O2 bleeding with dark grey signal (primarily sats 88-92%) around the edges)

 Head Up tilt (15-30o) C – Contour / Cortex – cortical tissue abnormalities; contour of bleeding around  Remove or reduce tightness of cervical rim of brain to differentiate between neck collar extradural and subdural

 Avoid dextrose-containing infusions D – Deviation – midline shift and / or blood in ventricles At this point, the need for intubation for patients with reduced GCS will be E – Extracranial – bony skull for any influenced by decisions about fractures / deformity; inspect for large neurosurgical intervention. One could extra-cranial haematoma / foreign body. argue that endotracheal intubation for a patient with a low GCS <8 who is not for A – Adequacy neurosurgical intervention is Before attempting to interpret any form inappropriate. of imaging, the clinician should ensure that the images relate to the right patient Each patient should have this decision from the right period of time. Elderly reviewed on a case-by-case basis patients may have had previous CT scans following discussion with senior decision and it is important to ensure that the makers involved in the patient’s ongoing most recent image is the one being care and the patient’s family. interpreted.

The clinician should check the patient’s Imaging details and date / time of the scan. Following this, the images should be NICE guidance provides clear criteria for viewed for any rotation or movement which patients require a CT Head Scan artefact that could affect the accurate following trauma. This imaging modality interpretation of films. Additional artefact has become increasingly common in may be witnessed from metallic fillings / modern Emergency Departments and as dentures or previous surgery. such, HECTOR believes that clinicians should be able to identify significant B – Blood abnormalities prior to an official report The clinician should assess the rim of the being available. cerebral cortex and cortical tissue for any white (acute) or dark grey (chronic / The following system could be used to oedema) discolouration. This should be structure a review of CT Head scans: relatively straightforward to assess although calcification within the brain A – Adequacy: check patient details; date may lead to a false interpretation as being of scan; rotation; movement artefact an acute bleed.

B – Blood: areas of acute bleeding in the form of bright white signal; chronic

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Image – acute subdural (bright white hyperdensity) i. Hyperdense artery (dense MCA sign)

Image – chronic subdural (dark grey discolouration)

C – Cortex ii. Obscuration of the lenticular nucleus The cerebral cortex should be examined for any gross asymmetry and likely haemorrhage. Cerebral tumours may be difficult to identify on non-contrasted CT Head scans and if such anomalies are suspected, the clinician should take the advice of the radiologist if any further imaging is warranted.

Some patients may present with focal neurology or reduced GCS in the absence of gross intracranial haemorrhage. This could represent the presence of an acute ischaemic stroke (CVA), in which case CT iii. Loss of grey-white interfaces (insular findings may be normal in 50-60% of ribbon signs) cases4. In the absence of any obvious bleeding but with a patient with focal C-Contour neurological signs, subtle changes to The contour of any suspected bleeding suggest CVA may be seen on a CT: can aid the clinician in determining whether a patient has a subdural or extradural haemorrhage. Subdural

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haemorrhage is most likely to adopt a For ease of use, the clinician should draw crescent-shaped appearance compared to an imaginary line between the falx cerebri a biconvex appearance of an extradural (anterior) and middle of the occiput. haemorrhage (see below): Midline shift will be demonstrated by divergence of the midline structures away from this imaginary line.

E – Extracranial Having assessed the brain tissue, the clinician should view the bony windows of the CT Images and assess for any obvious pneumo-cranium (air underneath the skull). Clinical findings (i.e. scalp lacerations; point tenderness) should be used to direct focus towards specific areas of the cranium to assess for the presence of fractures.

HECTOR advises that protocols for CT Head scanning in the elderly include the Subdural Haemorrhage – crescent-shaped odontoid peg and base of C2 vertebral body as a minimum. This ensures that any injury to this region is identified and used to direct any further imaging requests.

Monitoring of Elderly Patients with Head Injury

The following group of patients should be admitted to hospital following head injury5:

- Patients with new, clinical significant abnormalities on imaging Extradural haemorrhage – biconvex-shaped - Patients whose GCS has not returned D – Deviation to their normal GCS, irrespective of In the presence of any suspected the CT result haemorrhage the clinicians should look for midline shift – a sign of increased - Continuing worrying signs (persistent pressure within the brain. Structures of vomiting, severe headache) or illness the midline include the septum pellucidum, the third ventricle and the After admission, patients need to have pineal gland. minimum acceptable documented observations which include: GCS; pupil size and reactivity; limb movements;

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respiratory rate; heart rate; blood Prognosis and Traumatic Brain pressure; temperature and blood oxygen Injury saturation. Prognostication may be difficult for These observations should be recorded on patients aged 65 years and over – pre- a half-hourly basis until the patient has existing co-morbidity and frailty, returned to their normal GCS level. After concomitant use of anti-coagulants and this point, observations should be limits of daily functioning will all aid in the recorded along the following schedule: decision-making process. In many circumstances, decisions about how to  Half-hourly for 2 hours manage an injury (and not the patient  Hourly for 4 hours with the injury) are made with the  Two-hourly thereafter neurosurgical teams via a remote process.

Any deterioration in GCS during this This relies on the provision of accurate period mandates a return to half-hourly and detailed information from the observations and urgent clinical referrer. Omission of important reassessment. information such as pre-morbid status may influence the decision about whether A repeat CT scan is indicated if any of the or not a patient is considered for following are observed (unless there has aggressive intervention. already been an agreement that escalation of care and resuscitation in the Each patient with a severe head injury event of cardiorespiratory arrest is should be managed on an individualised inappropriate): basis. Having an understanding of some elements of the evidence for prognosis Indications for Repeat CT Head Scan may prove to be useful in the decision- making process. 1. Development of agitation or abnormal behaviour Prognosis and Advancing Age

2. Any drop of 3 points in eye-opening or In a prospective study of the Traumatic verbal response scores, or 2 or more Coma Data Bank (TCDB), there was a points in the motor response score significantly increased percentage of poor outcomes (death and vegetative) in 3. Development of severe or increasing patients with pre-existing co-morbidity in headache or persistent vomiting ages above 56 (86% vs 50%)6.

4. New or evolving neurological symptoms The same study identified that a poor or signs outcome was associated with patients who had: intra- or extra-cerebral haematomas greater than 15cc, subarachnoid haemorrhage; midline shift or compressed cisterns.

The Brain Trauma Foundation identified Class I studies which demonstrated a

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mortality of greater than 75% in severely For elderly patients with severe brain brain injured patients older than 60 7. injury, a further trajectory has been proposed that describes either a rapid A study of 11,772 patients compared decline (early death after a decision to patients aged 65 years and over with withdraw life sustaining treatments), or a similar brain injuries to younger patients chronic stage of survival with a high (<65 years). Mortality was 24% in the degree of disability.13 This latter stage elderly population compared to 12.8% in may enter a trajectory of chronic illness, the younger population. The elderly non- with repeated exacerbations of worsening survivors were statistically older, with health until eventual death. (see below) mortality rate increasing with age8.

Prognosis and Type of Injury

A 2015 meta-analysis9 looking at patients with bilateral fixed dilated pupils identified that mortality rates were different for patients with extradural haematoma compared to subdural haematoma (29.7% vs 66.4%). This same Taken from Creutzfeldt et al “Predicting decline study also found that of the survivors with and survival in severe acute brain injury: the fourth 13 subdural haemorrhage, only 6.6% had a trajectory” good functional recovery. With severe brain injury, the patients

themselves are often too impaired to For patients with cerebral contusions, a express the preference for their review of the TARN database was treatment, with decisions often falling conducted in 2013 which assessed upon clinicians and the patient’s family. outcomes for patients with cerebral These decisions often focus on measures contusions (AIS 3 or more).10 Of 4387 to maintain comfort, or for aggressive patients, mortality was found to increase intervention (with life-saving intervention with increasing age. The study also being offered but at the compromise of identified that the likelihood of not being quality of life). transferred to a neurosciences centre also increased with advancing age. In the emergency setting, these decisions

are often made rapidly, in contrast to Prognosis and Trajectory of Illness after patients with chronic illness where Traumatic Brain Injury management options can be discussed,

absorbed and decided upon over a longer Three main illness trajectories exist that period of time. attempt to describe how function declines as life-limiting diseases advance a patient For the majority of patients over 65 years towards death. These trajectories include of age, neurosurgical intervention will not a rapid decline in function (as observed in be an option or may not be offered by cancer); an episodic decline (e.g. heart regional teams. In such circumstances, it is failure); and a prolonged decline (e.g. vital that the clinical team responsible for dementia).11, 12 ongoing care have an honest discussion

with the patient and their family as soon

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as possible. These discussions need to  All patients should be assessed with a continue on a periodic basis as the high degree of vigilance, especially if patient’s trajectory of illness progresses. they have evidence of any injury above the clavicles and are taking Patients may recover or deteriorate anticoagulant medication. Assessment unexpectedly and their family need to be should follow Primary Survey guidance made aware of this fluctuating course. in previous chapters, either through a The lack of information may lead to trauma team response (high-energy conflict or confusion about management mechanism), or lone assessor (low- goals, but such issues can have their energy mechanism) impact lessened with clear, open and honest communication.  Clear indications for CT imaging exist and clinicians should have a basic Some patients will die whilst staying in understanding of these rules and how hospital, whilst others will make some to interpret CT films for gross recovery with a possible impact on their abnormalities. activities of daily living. This will require family members and/or carers to adapt  Prognostication should occur on an changing roles and this will require time individual basis and referrals to to occur. neurosurgical teams should provide core information on a patient’s pre- HECTOR believes that elderly patients morbid level of functioning to aid with conservatively-managed traumatic decision-making. brain injury should be managed jointly by specialists who can monitor for acute  The trajectory of illness may be rapid deteriorations and elderly care physicians with death within a few days, or enter who can take responsibility for ongoing a prolonged trajectory of recovery and care if patients enter a chronic stage of episodic ill health. After the acute survival and recovery. phase, patients will benefit by being cared for by specialists in elderly care. Summary

 Elderly patients with serious head References injury are at higher risk of under-triage 1. Kehoe A, Rennie S, Smith JE. Glasgow coma than younger patients. This occurs for scale is unreliable for the prediction of severe different reasons but mainly because head injury in elderly trauma patients. EMJ they will have a lower energy 2015; 32: 613-5.

mechanism of injury (e.g. simple fall), 2. Moore L, Turgeon AF, Sirois MJ et al. and will have a higher GCS for any Trauma centre outcome performance: A given injury. comparison of young adults and geriatric patients in an inclusive trauma system. Injury  Clinicians should have an 2012; 43(9): 1580-85. understanding of basic neuroanatomy and the relevance of primary brain 3. Mokri B. The Monro-Kellie hypothesis: injury and the importance of applications in CSF volume depletion. preventing secondary brain injury. Neurology 2001; 56(12):1746-8.

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4. Kase CS, Wolf PA, Eliot H. Prevalence of brain injury: the fourth trajectory. BMJ 2015; silent stroke in patients presenting with initial 351: 14-16. stroke: The Framingham Study. Stroke 1989; 20: 850-852

5. National Institute for Health & Care Excellence. Head Injury: Triage, assessment, investigation and early management of head injury in children, young people and adults (CG176). NICE Jan 2014

6. Chestnut RM, Ghajar J, Maas AIR et al. Early indicators of prognosis in severe traumatic brain injury. Brain Trauma Foundation https://www.braintrauma.org/pdf/protected/ prognosis_guidelines.pdf (Last Accessed Aug 15)

7. Lavati A, Farina ML, Vecchi G et al. Prognosis of severe head injuries. J Neurosurg 1982: 57: 779-83.

8. Susman M, DiRusso SM, Sullivan T et al. Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 2002; 53: 219-23

9. Scotter J, Hendrickson S, Marcus HJ et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. EMJ 2015; 32: 654-9.

10. Kirkman MA, Jenks T, Bouamra O et al. Increased mortality associated with cerebral contusions following trauma in the elderly: bad patients or bad management? J Neurotrauma 2013; 30: 1385-90

11. Murray SA, Kendall M, Boyd K et al. Illness trajectories and palliative care. BMJ 2005; 330: 1007-11

12. Lynn J, Adamson DM. Living well at the end of life. Adapting health care to serious chronic illness on old age. Rand Health, 2003.

13. Creutzfeldt CJ, Holloway RG et al. Predicting decline and survival in severe acute

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Chapter 8 Cervical Spine patients over 70, primarily due to how the axis (C2) articulates with the atlas (C1). Injuries The peg (axis) forms the pivot upon which the atlas rotates. The odontoid peg is held Introduction in position by the transverse atlantal ligament and alar ligaments which Approximately 5% of unconscious patients connect the peg to the occipital bone. who present to the ED following trauma have an injury to the cervical spine. Most fractures occur at two levels with 33% occurring at the level of C2 and 50% affecting C6 or C71.

Elderly patients with pre-existing joint disease (e.g. osteoarthritis, ankylosing spondylitis), or reduced movement in the 2 neck (e.g. Parkinson’s disease), are The atlas particularly vulnerable to fractures of the The atlantoaxial joint is responsible for cervical spine following relatively low 50% of all cervical rotation, with the mechanisms of injury (see below). atlanto-occipital joint being responsible for 50% of all rotation. With such a degree The main principles of management rely of movement permitted across these on having a lower index of suspicion for joints, the kinetic energy generated by injury than in younger patients. High direct trauma to the head will be mechanisms of injury such as fall from transmitted to these areas. height (including downstairs), road traffic collisions and pedestrian traffic accidents Mechanism of Injury should all warrant careful assessment for injury. Any patient with a history of fall Restricted neck movements that have and bruising / injury above the neck or been caused by underlying disease neck pain should be considered as being processes make elderly patients at high risk for having a cervical spine particularly vulnerable to injuries to the injury. odontoid peg. A lack of movement in flexion / extension that occurs following Cervical Spine Anatomy falls with a direct blow to the head will place a greater strain on the ascending odontoid peg, thus rendering it more The cervical spine consists of seven vulnerable to the forces involved. (see vertebra (C1-C7), with the first two called below). the atlas and axis, respectively. C3-C7 all have a body, pedicles, laminae, facet Consideration should also be given to the joints and spinous processes. The cervical risk of injuries to the stabilising ligaments, spine provides stability and mobility to spinal cord and intervertebral discs. the head whilst connecting it to the more Decreasing nutrition of the central disc fixed thoracic spine. that occurs with age can make prolapse

highly likely with consequential effects on Odontoid peg fractures represent the the spinal cord. most common cervical spine fracture in

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Mechanism of Injury and the Cervical Spine – Energy Transfer in the Rigid and Flexible Skeleton

Triage decisions to clear the patient’s cervical spine at triage without imaging should The initial triage of any elderly patient is only be made by the skilled and trained the most important step for picking up clinician. concerns about underlying neck injury. A low index of suspicion is needed for any Elderly patients with a history of a fall / elderly patient who has presented collapse and injury above the clavicles following a fall. As soon as direct trauma should be considered as being at risk of to the head has been identified, the cervical spine injury. cervical spine should be assessed for injury. If a cervical spine injury can not be excluded and if the patient has not Elderly patients with high mechanisms of already been immobilised, the triage team injury (pedestrian vs car; high speed RTC; should consider the best methods of fall from height; fall downstairs) should immobilisation at this stage, (i.e. using the have formal imaging of the neck to “Minimal Movement” Philosophy). If exclude injury. In these circumstances, collars and head blocks can be applied this

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should be done. If this is not possible (i.e. instillation or consideration should be an agitated patient; significant given to the use of haemostatic agents kyphoscoliosis), pillows or rolled blankets like Celox with direct pressure as a can be applied behind the head / neck and temporary measure. on either side. Traumatic nasal injuries can lead to Semi-rigid cervical collars should never catastrophic haemorrhage if not be forcibly applied to patients. If a collar controlled. Friable blood vessels, can not be found that fits, the triage team hypertension and concomitant used of should use methods as described above anticoagulant therapy will make control prior to formal imaging. even more pertinent.

Initial Assessment & Primary Patients kept lying flat will also be at risk Survey of aspiration from posterior haemorrhage so the decision to provide nasal packing should be weighed up against the risks of A structured ABC approach should be aggravating any high cervical spine injury used for the assessment of all elderly or basal skull fracture. trauma patients with suspicion of cervical spine injury. The following techniques can be used to

provide haemostasis of epistaxis: Catastrophic Haemorrhage – Scalp

Lacerations and Epistaxis

Neck injuries can often be associated with direct trauma to the mid-face and/or scalp. Seemingly minor injuries can have devastating consequences if they are not identified and managed immediately. Patients may develop haemorrhagic shock if scalp lacerations continue to bleed whilst a patient waits for a CT scan, and continues to wait in an immobilised state, Insertion and inflation of Rapid Rhino device3 until results are available.

Management of catastrophic haemorrhage may include immediate control of epistaxis as well as scalp lacerations and if required, the clinician should aim to preserve alignment of the cervical spine whilst this is being done. This may require manual in-line stabilisation provided by an assistant. 4 Merocel Nasal Tampon

Haemorrhage from lacerations may be difficult to control if located in the occiput. These can either be sutured during a log-roll after local anaesthetic

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close attention paid to the chest wall and groin / pelvic area in the event of a fall.

Disability

The assessing clinician should document pupillary size and presenting GCS. Every patient should have a formal neurological examination incorporating all myotomes and dermatomes. In the event that a patient has any back pain or is unable to communicate such symptoms, a log-roll should be performed (if safe to do so), to Foley catheter insertion and BIPP (bismuth palpate for any spinal tenderness. subnitrate – iodoform) packing5 Spinal tenderness or abnormal Airway and Cervical Spine neurological signs / symptoms should lead the examiner to coordinate additional Management of the airway should occur spinal imaging. in tandem with management of the cervical spine. Any concerns about airway Imaging of the Cervical Spine patency should warrant formal assessment and consideration of the need The following criteria can be used to for definitive care. determine which patients will require radiological clearance: If a patient is being intubated, manual in- line stabilisation should be used to a. Fall from standing and neck pain prevent excessive neck movement. Such b. High mechanism of injury (high patients should be considered as being at speed RTC – rollover, ejection, high risk of difficult intubation (due to death in same passenger their restricted neck movement). The compartment; fall downstairs; fall clinical team should ensure that rescue from height) devices and difficult airway equipment are c. Injury above the clavicles if GCS < available for any intubation attempt. 15 d. Injury above the clavicles if GCS > 15 and patient complains of neck Breathing & Circulation pain e. Distracting injury All patients should have their respiratory f. New-onset focal neurological signs rate, oxygen saturations, heart rate and blood pressure recorded as a minimum. If CT-Cervical Spine is the imaging modality there is a history of fall, patients should of choice as it will help differentiate have a blood glucose checked and a 12- between degenerative change (e.g. Lead ECG performed. osteophytes) and acute injury. In centres where CT is not readily available, plain The chest and abdomen should be film radiography should be performed as a examined for any additional injury with

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minimum (AP, lateral, Open-Mouth Peg AAABCS view). A Accuracy Interpretation of Plain Film Cervical Spine A Adequacy X-Rays A Alignment B Bones HECTOR makes the recommendation that C Cartilages and Joints CT-scanning is the imaging modality of S Soft Tissues choice for injury to the cervical spine. Although MRI has a higher sensitivity and specificity, it is less accessible than CT Accuracy: imaging and may not be tolerated by the  Are the patient details correct? Check agitated or confused patient. the patient’s name, PID, date of birth to ensure that the correct patient is HECTOR also believes that clinicians being reviewed. should possess the skills needed for  Were the images taken today? Elderly interpretation of plain film imaging of the patients may have more historical cervical spine. These skills are partially imaging studies than younger patients transferable to a gross review of sagittal and it is important that the right and coronal CT slices to identify obvious images are being reviewed. (but not subtle) injury. Adequacy: Inadequacy of cervical spine plain films  Have AP / Lateral / PEG views been and incorrect interpretation are key taken? All three views need to have causes for error in the assessment of the been performed and all need to be patient with suspected spinal injury. The adequate. additional presence of degenerative  Is the odontoid PEG in the middle of skeletal change (e.g. osteophytes), and the image and is it clearly visible? chronic injuries can make adequate Check this by drawing an imaginary assessment even more difficult. line between the upper and lower middle teeth and the middle of the It is important to have a system for peg should pass through this line. If interpreting plain film imaging that is the entirety of the PEG is not visible, structured, reproducible and covers the image is inadequate. enough depth of assessment to ensure  Has the lateral c-spine been imaged that common injury patterns can be down to the C7-T1 junction? If not the identified. spine can’t be cleared with this view.

HECTOR recommends using a system Alignment: similar to the one outlined below: There are four longitudinal contours present on the lateral cervical spine film – by ensuring that all contours are smooth and don’t have any obvious steps, one can comment on the alignment.

If there appears to be a step in any of these contours, this should be discussed

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immediately with a senior clinician and Bones plans made to perform CT imaging. Trace around all the bones of the cervical spine to include vertebral bodies, facets Steps in the anterior or posterior and spinous processes at each level, to longitudinal line may be due to facet ensure there are no fractures or dislocation. Simple unifacet dislocation is deformities. often a stable injury – it may be evidenced by anterior subluxation of one vertebral Unless each bone is traced individually, body on top of another by less than half there is a high risk of missing fractures. the antero-posterior length of that Careful attention should be paid to the vertebral body. odontoid PEG during this part of the interpretation.

Cartilages & Joints Having assessed each bone, it is important to assess each intervertebral space, (space between each vertebrae) the interspinous gaps (space between each spinous process) and the C1-odontoid gap. This is the space between the anterior aspect of the odontoid process and C1.

The C1-odontoid gap should be less than three millimetres. Steele’s Rule of Thirds6 comments that in this area, 1/3rd of space is spinal canal, 1/3rd is odontoid peg and 1/3rd is space. Any increase in this space could jeopardise the spinal cord at this level.

Soft Tissues In some situations, this will be the only marker of acute injury. It is a similar concept to the recognition of the anterior Anterior Longitudinal Line: fat pad sign of the elbow, i.e. acute -A line drawn over the anterior aspect fractures will bleed and will result in soft of the vertebral bodies tissue swelling.

Posterior Longitudinal Line There are three distinct areas in which to -A line drawn over the posterior look at the soft tissues – the level of the aspect of the vertebral bodies odontoid peg; C2-C3; and C4-C7. Any

enhanced swelling of the soft tissues Spinolaminar Line: anterior to the PEG with suspicion of -A line drawn along the laminae and injury at this level should lead the clinician anterior aspect of spinous process to consider other imaging, CT or MRI.

Spinous Processes: -A line drawn along the most posterior aspect of the spinous processes 83

Anterior to the vertebral body of C2 and  Is the tip of the peg visible? The whole C3, the distance between the anterior of the odontoid process should be border of the vertebral body and the soft visible on this image. Without it, type I tissue shadow directly in front of it should fractures could be missed. be <7mm, or roughly half the antero-  Are all the lateral masses visible? posterior length of the vertebral body Assessment of this image requires itself. review of the alignment of the lateral masses. Without these being present At the levels below C4, this distance on this image, interpretation will be (anterior border of vertebral body to soft compromised. tissue shadow), is slightly longer and  Is the odontoid peg central on the equivalent to the entire A-P length of the image? If it is not central (see before), corresponding vertebral body, or less than the film is likely to be rotated and 21mm. interpretation of alignment will be inaccurate. Interpretation of the Open Mouth Odontoid Peg View Alignment:  Are the lateral masses aligned? This view can only be obtained when the  Is there symmetry between the peg patient is able to follow instructions. It and the lateral masses? Ensure that may not be possible to obtain such images the lateral masses of C1 do not for patients with dementia or in overhang the most lateral aspects of hypoactive or hyperactive states of the C2 vertebral body. delirium. In such circumstances, CT cervical spine should be the imaging Bones: Check the peg to ensure there is modality of choice. no fracture through it.

Cartilage & Soft Tissues: Check for any gross abnormalities in the soft tissues.

Classification of Fractures of the Odontoid Process

Injuries at this level can be classified using the Anderson – D’Alonso system7:

The Open Mouth Odontoid Peg View TYPE I: Extends through the tip of the peg A similar AAABC approach can be used for (usually stable) interpreting this view: TYPE II: Extends through the base of the Accuracy: Is this the right film for the right peg (unstable) patient? (see above) TYPE III: Extends through the vertebral Adequacy: body of C2 and may be stable or unstable.

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Anderson – D’Alonso Classification of Odontoid Peg Fractures8

General Management of Patients with Cervical Spine Injuries

Most elderly patients with injuries to the cervical spine will be treated with a semi- rigid collar. The most commonly-utilised collars are the Aspen, Philadelphia and Miami-J collars (see below):

The Philadelphia Collar11

Collar application will be dependent on local availability but studies have shown that the Miami J and Philadelphia collars generate the lowest pressure on occipital and mandibular areas and may be of benefit to elderly patients with fragile The Miami J Collar9 skin12. Most collars are worn for between 6-8 weeks following the injury. Patients with unstable injuries may require up to two weeks hospital admission before discharge.

Once an injury to the cervical spine has been identified, clinicians should discuss the most appropriate management with their local spinal service, (commonly neurosurgeons). Most specialists will request MRI prior to definitive management planning and this may prove The Aspen Collar10 to be a challenge in the agitated patient.

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Consideration should be given to the risks  Delayed start of treatment (>4 days). of MRI against its possible benefit. If a patient is unlikely to be fit for surgery and Management of these types of injury in likely to not tolerate an MRI, this becomes elderly patients remains controversial. an unnecessary investigation in the Elderly patients demonstrate poor long- patient with no abnormal neurological term functional outcomes, and high rates signs / symptoms. of morbidity and mortality with non- operative management. Many elderly MRI is appropriate if a patient has patients will also have non-union of their developed new neurological injuries but at the same time can achieve signs/symptoms in the presence or an asymptomatic stable fibrous union absence of cervical spine fracture. MRI (non-bony). will aid in the diagnosis of acute cord injury (e.g. central cord syndrome), and Surgical intervention includes anterior intervertebral disc prolapse. odontoid screw fixation and posterior C1- C2 fusion and is often reserved for patients with neurological deficit, Management of Specific Fractures symptomatic non-union and unstable of the Cervical Spine non-union. In the event of surgery being considered, factors to take into account Type I Odontoid Peg Fracture will be an individual’s pre-morbid functioning and co-morbid state. It is This fracture occurs at the tip of the likely that these decisions will be made on odontoid peg, is rare, and is often caused an individual basis. by an avulsion of the alar ligament. Most of these injuries are stable but they can be Type III Odontoid Peg Fracture an unstable injury if associated with occipito-atlantal dissociation which may These fractures involve the C2 vertebral be present on CT or dynamic flexion / body. Like Type I fractures, semi-rigid extension views of the cervical spine. collars have been shown to be the most appropriate form of management for Patients can be treated with a semi-rigid elderly patients with these injuries. These collar (e.g. Miami J or Philadelphia) for 6-8 patients require frequent follow-up and weeks. Unstable injuries should be most heal by bony union within 12 weeks discussed with neurosurgical specialists. of immobilisation.

Type II Odontoid Peg Fracture Hangman’s Fracture

These fractures occur at the base of the This type of fracture involves a fracture of dens and the blood supply is often the pars interarticularis of C2 and results compromised. The rate of non-union is in the disruption of the C2-C3 junction. It 30-50%, and related to the following usually results from forced factors13: hyperextension (i.e. forced extension such as a blow to the head on an already  Older age groups; extended neck). They are often associated  >5mm displacement; with facial injuries.  Angulation >10O;

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These injuries are classified according to with vascular cord compromise and a the degree of translation and angulation. poor prognosis. Most require some form of neurosurgical input (e.g. cervicothoracic brace; halo Bifacet dislocations are inherently vest; fixation), but are not tolerated unstable and have associated disruptions particularly well by elderly patients, of the middle and posterior ligamentous especially with pre-existing respiratory structures. Up to 10% of patients may conditions. All patients should be have associated disc herniation which can discussed with the specialist teams to plan cause catastrophic compression of the the most appropriate form of spinal cord. management. Once these types of injury have been identified on imaging, MRI should be performed to assess for cord involvement/oedema. Patients with this type of injury can be treated in a semi- rigid collar with neurosurgical referral to discuss the need for operative intervention.

Jefferson Fracture

The Jefferson fracture is a burst fracture of the atlas (C1) and most commonly occurs after axial compression. In the elderly population, this is most likely to occur following a significant fall (i.e. downstairs) with direct trauma to the skull vertex.

14 Hangman’s Fracture It is important to note that 50% of these injuries are associated with other injuries Cervical Spine Facet Dislocation to the cervical spine and that 33% are associated with fractures to C2. Cervical dislocation may be present in patients with minimal or no neck pain, following seemingly minor trauma (e.g. same-level falls). It rarely occurs without subsequent insult to the spinal cord but at the time of the original injury, pain in the neck may be minor and occurs due to impingement on cervical nerves or joints.

A progressive development of paralysis can occur within 48 hours due to ongoing oedema of the cord within the narrowed Jefferson Fracture16 canal15. This oedema can be associated

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The Odontoid PEG view on plain film a. Autonomic dysreflexia – nifedipine may imaging is likely to reveal displacement of be used to control hypertension resulting the lateral masses and a more accurate from generalised sympathetic activity. classification of injury will be apparent on transverse CT sections. Patients should be b. Neurogenic bladder – urethral treated in semi-rigid collars for 6-8 weeks. catheterisation should be performed and bladder function usually returns within 6 Vertebral Body Injuries months.

These type of injuries will most likely be c. Spasticity – proper bed positioning and related to anterior tear-drop fractures or a regular stretching programme can fractures from osteophytes. The majority reduce spasticity and the development of will be stable but MRI may be required to contractures. Baclofen may be of use if asses for ligamentous injury or disc spasticity develops. prolapse. d. Pressure Ulcers (Decubitus) - If patients Patients can be treated in semi-rigid develop sensory loss, they may have a collars and if the injury is deemed stable, reduced awareness of continued forces on should be mobilised early to prevent the skin, leaving them prone to pressure further complications. ulcers. Special pressure-relieving mattresses and regular turning should be Central Cord Syndrome and Cord Injury employed to eliminate the risk of such ulcers. Central cord syndrome usually presents in patients over 50 with pre-existing cervical e. Neurogenic Bowel – patients should be spondylosis who have sustained a started on a regular bowel programme to hyperextension injury to the neck. The avoid incontinence and have adequate spinal cord may be pinched between a intake to avoid constipation. thickened ligamentum flavum located behind the cord and a protruding osteophyte or disc. Summary  All elderly patients with either a high Most patients will present with: mechanism of injury or history of fall with injury to the head/above the  Incomplete quadriplegia affecting the clavicles should be considered as upper more than the lower limbs; being at risk of having a cervical spine  Variable sensory impairment injury  Bladder dysfunction.  One of the most vital steps in a MRI imaging will reveal high signal change patient’s journey is in their initial in the centre of the spinal cord and most assessment and triage. If cervical spine patients can be treated with a semi-rigid injury is not suspected or considered collar with management of possible at this stage, it may be missed later. complications:  All patients with suspicion of injury should have a formal primary survey and management of significant

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haemorrhage should be addressed as 6. Wheeless CR. Atlantoaxial subluxation. early as possible. Wheeless’ Textbook of Orthopaedics, Dec 2011  CT imaging is the modality of choice 7. Anderson LD, D’Alonzo RT. Fractures of the although clinicians should have a basic odontoid process of the axis. J Bone Joint Surg knowledge of plain film interpretation Am 1974; 56(8): 1663-74. for when CT is not readily available 8. OrthopaedicsOne. Fractures of the dens (odontoid) – Anderson and D Alonzo  Most patients will be treated classification. conservatively in a semi-rigid collar http://www.orthopaedicsone.com/display/M (Miami J or Philadelphia) for 6-8 ain/Fractures+of+the+dens+(odontoid)+- weeks, and many will require an MRI +Anderson+and+D+Alonzo+classification Last to investigate for associated disc, cord accessed Aug 2015 and ligamentous injury. 9. Image from www.medline.com. Last accessed August 2015  Early mobilisation whilst wearing a collar is important but patients with 10. Image from www.chaneco.co.uk. Last unstable fractures or cord accessed August 2015 involvement may require a prolonged period of bedrest (1-2 weeks) before 11. Image from www.healthandcare.co.uk. this occurs. Last accessed August 2015

References 12. Tescher AN, Rindfleisch AB, Youdas JW et al. Range-of-motion restriction and 1. Boyarsky I. C2 Fractures. Dec 2014 craniofacial tissue-interface pressure from http://emedicine.medscape.com/article/1267 four cervical collars. J Trauma Injury, Infection 150-overview Last accessed Aug 2015 & Crit Care 2007; 63(5): 1120-26

2. Gray H. Anatomy of the Human Body 13. Koivikko MP et al. Factors associated with 1918.Fig 88 non-union in conservatively treated type II fractures of the odontoid process. J Bone Joint 3. Fauquier ENT. How does nasal packing stop Surg 2004; 85; 1146-1151 nosebleeds? ENTBlog 2012 http://fauquierent.blogspot.co.uk/2012/05/h 14. Radiology Picture of the Day. Hangman’s ow-does-nasal-packing-stop-nosebleeds.html Fracture. Last accessed Aug 2015 http://www.radpod.org/2007/11/09/hangma ns-fracture Last accessed Aug 2015 4. Unidentified Source. Image of Nasal Packing Google images. Last accessed Aug 2015 15. Mahale YJ, Silver JR. Progressive paralysis after bilateral facet dislocation of the cervical 5. From the collection of Randall DA, spine. J Bone Joint Surg 1994; 74: 219-223 Springfield Ear Nose Throat and Facial Plastic Surgery, MO. 16. LearningRadiology – Jefferson Fracture http://bestpractice.bmj.com/best- http://www.learningradiology.com/archives0 practice/monograph/421/treatment/step-by- 6/COW%20188- step.html Last Accessed Aug 2015 Jeffersons%20Fx/jeffersonfxcorrect.htm Last accessed Aug 2015

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Chapter 9 – Injuries to the injury and as such, may arrive via emergency ambulance or could self- Thoracic and Lumbar Spine present to the emergency department. At initial assessment or triage, it is important Introduction to assess an individual in the context of their mechanism of injury. Patients with Patients with simple falls may be simple falls and no focal neurology may be vulnerable to fractures of the thoracic and managed alongside other Majors / Minors lumbar spine, especially in the presence of patients, whereas patients with back pain osteoporosis. Osteoporosis may only and/or neurological symptoms following become evident when a fracture occurs RTC / falls from height or downstairs may after relatively trivial mechanisms of merit formal trauma team activation. injury. In general terms, osteoporosis is a systemic skeletal disease characterised by Primary Survey low bone mass, deterioration of bone tissue and increased bone fragility. The primary survey should follow an individual ABCDE approach where systems Osteoporosis can be divided into different are assessed successively, or a horizontal classifications according to its aetiology. approach whereby the trauma team, led Primary osteoporosis occurs when a by the team leader, assesses each area secondary cause is not identified (e.g. concurrently. juvenile; idiopathic; postemenopausal; age-associated). Secondary osteoporosis Airway & Cervical Spine occurs when an underlying disease, drug or deficiency causes osteoporosis (e.g. Patients with a history of trauma and pain porphyria; panhypopituitarism; diabetes; to the thoracic or lumbar areas should pregnancy; calcium deficiency; also be considered as being at risk of inflammatory bowel disease; cervical spine injury – injuries to the anticonvulsants; furosemide; alcoholism). thoracic and lumbar areas could distract attention away from the cervical spine. Most fractures of the thoracic and lumbar spine in elderly patients will result from B – Breathing simple falls and be a consequence of underlying osteoporosis and bone In the context of thoracic pain, clinicians fragility. should pay close attention to the possibility of additional thoracic trauma. Patients who present following higher Elderly patients who have fallen against mechanisms of injury should be treated hard objects should be examined for the carefully – these injuries are more likely to possibility of rib fractures, flail segments be unstable and possibly associated with and associated haemothoraces, involvement of the spinal cord. pneumothoraces and lung contusions.

Initial Assessment The anterior and posterior aspects of the thoracic wall should be examined for any Elderly patients with injuries to the focal tenderness, crepitus and surgical thoracic / lumbar spine may present emphysema. This may have to be done following low or high mechanisms of when it is safe to perform a log-roll.

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C – Circulation entrapment), are best imaged using WBCT or focussed CT. Blood pressure, heart rate and skin colour / warmth should all be documented. Patients with injuries to the thoracic cage Patients with neurogenic shock will and/or spine are best imaged using CT develop hypotension, bradycardia and thorax imaging but plain film CXR and peripheral vasodilatation in response to a plain film thoracic AP/Lat views may be loss of sympathetic vascular tone with appropriate in some centres without early traumatic lesions higher than the level of access to CT. T6. Patients who present following: simple For elderly patients with a history of fall / falls; with thoracic spine or lumbar spine collapse, thoracolumbar pain could also tenderness, (in isolation or combined), be attributed to vascular events such as could be imaged using AP/Lat plain film ruptured AAA or thoracic artery dissection radiography in the first instance. Any / aneurysm. The assessing clinician should abnormality on plain films should warrant take into account these possible further CT / MRI imaging if the fractures diagnoses and examine the patient look unstable (see below) and represent accordingly. more than simple osteoporotic crush injuries. Formal assessment for abdominal and pelvic injuries should be completed in the When interpreting plain films, it is often context of mechanism of injury. useful to access old images for comparison – osteoporotic fractures may D – Disability be longstanding and patients may have acute pain on the background of chronic All patients should have GCS and pupillary injuries. size and reaction documented. A formal neurological assessment will be required Assessment of Thoracic and but this can be conducted within the Lumbar Spine Stability secondary survey. When interpreting X-Rays, it’s important Imaging of the Thoracic and to consider the spinal column as having Lumbar Spine three separate sections:

If there is a suspicion of injury to the ANTERIOR COLUMN – anterior thoracic and / or lumbar spine, the most longitudinal ligament and anterior half of appropriate imaging modality will depend the vertebral body on mechanism of injury and any suspected associated injuries. MIDDLE COLUMN – posterior half of vertebral body, disc, annulus and Patients with high energy mechanisms posterior longitudinal ligament such as falls from height / downstairs or high-speed road traffic collisions POSTERIOR COLUMN – facet joints, (pedestrian vs car; rollover; ejection; ligamentum flavum and the posterior death in same compartment; prolonged elements.

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A fracture is generally considered stable if brace (thoracolumbar spinal orthosis) in only the anterior column is involved, (e.g. extension. most wedge fractures). However, if there is loss of >50% vertebral body height, this Burst Fractures could be a marker of instability. Other fractures that involve two or more Burst fractures occur when the vertebral columns are considered unstable and body is crushed in all directions, merit further imaging, preferably MRI to potentially causing bony fragments to assess cord integrity. undergo retropulsion into the spinal canal. Types of Fracture & Management If any disruption to alignment exists, or if Wedge Fractures there is reduction in the height of the posterior margin of the vertebral body, Wedge fractures occur when the anterior focussed CT imaging or MRI should be aspect of the vertebral body is crushed, performed assess stability and forming a wedge shape. X-Ray findings encroachment into the spinal canal. will demonstrate a loss of height in the anterior margin of the vertebral body in Any patient with an unstable injury should comparison to the posterior margin. be discussed with local spinal / neurosurgical specialists to determine The amount of wedging should be appropriate management. assessed and the fracture could be considered stable if the following are With both types of fracture, elderly present: patients are often nursed in a supine, bed- bound state. They will be at increased risk a. Height of the anterior margin of the of pressure sores, thrombo-embolic vertebral body is two-thirds or more of events and noscomial infections. High the posterior margin. levels of vigilance and daily monitoring will be needed to ensure that b. The degree of wedging is less than 15o preventative measures can be utilised to prevent such events. c. The depth of the vertebral body divided by the difference in the heights of the Secondary Survey & Cord Injury anterior and posterior margins is greater than 3.75. All patients should have a formal neurological examination completed as Patients with stable injuries should be part of the secondary survey (see Chapter managed with analgesia and complete 5). Any abnormal neurological signs / bed rest in recumbency for one week or symptoms should lead the clinician to until the symptoms have settled. consider the possibility of spinal cord Thereafter, extension exercises will injury. promote a better functional outcome. The American Spinal Injury Association Patients with unstable injuries should has published international standards for have further imaging (CT or MRI), and be neurological and functional classification managed in recumbency or with a TLSO of such injuries and it is important for

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admitting teams to have a basic Elements of Sensory Assessment understanding of these concepts. Sensation should be examined at 28 key Definitions points on the left and right hand side of the body. Sensitivity to light-touch and Tetraplegia refers to impairment or loss of pinprick should be assessed and graded as motor and/or sensory function in the follows: cervical segments of the spinal cord due to damage of neural elements within the 0 Absent spinal canal. It results in impairment in the 1 Impaired (includes hyperaesthesia) arms, legs, trunk and pelvic organs. 2 Normal NT Not testable (e.g injury present) Paraplegia refers to impairment or loss of motor and/or sensory function in the The following 28 key points should be thoracic, lumbar or sacral (but not assessed and examination completed with cervical) segments of the spinal cord. Arm perceived sensation at the external anal functioning will be spared. sphincter, graded as present or absent:

Neurological Level refers to the most C2 Occipital protuberance caudal segment of the spinal cord with C3 Supraclavicular fossa normal sensory and motor function on C4 Top of acromioclavicular joint both sides of the body. C5 Lateral side of antecubital fossa C6 Thumb C7 Middle Finger Sensory Level refers to the most caudal C8 Little Finger segment of the spinal cord with normal T1 Medial side of antecubital fossa sensory function on both sides of the T2 Apex of axilla body. T3 Third intercostal space (IS) T4 Fourth IS (nipple line) T5 Fifth IS Motor Level refers to the most caudal T6 Sixth IS (level of xiphisternum) segment of the spinal cord with normal T7 Seventh IS motor function on both sides of the body. T8 Eighth IS T9 Ninth IS Definitions of Injury T10 Tenth IS (umbilicus) T11 Eleventh IS Incomplete Injury occurs if partial T12 Inguinal ligament at mid-point L1 Half the distance between T12 and L2 preservation of sensory and/or motor L2 Mid-anterior thigh function is found below the neurological L3 Medial femoral condyle level AND includes the lowest sacral L4 Medial malleolus segment (anal sensation and tone) L5 Dorsum of foot at third metatarsal- phalangeal joint Complete Injury occurs when there is S1 Lateral heel S2 Popliteal fossa in midline absence of sensory and motor function in S3 Ischial tuberosity the lowest sacral segment. S4-5 Perianal area

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Elements of Motor Assessment The ASIA Impairment Scale

Motor examination is performed by The ASIA classification system should be assessing a key muscle in each of the 10 used for grading the degree of paired myotomes, with strength being impairment: graded on a six-point scale: A Complete No sensory or motor 0 Total paralysis function is preserved 1 Palpable or visible contraction in sacral segments 2 Active movement, full range of S4-S5 motion with gravity eliminated B Incomplete Sensory but not 3 Active movement, full range of motor function is motion against gravity preserved below the 4 Active movement, full range of neurological level movement against moderate and includes S4-S5 resistance C Incomplete Motor function is 5 Active movement, full range of preserved below the movement against full resistance neurological level NT Not testable and more than half of key muscles The following muscle groups should be below the level have tested: a muscle grade of less than 3 C5 Elbow flexors (biceps, brachialis) D Incomplete Motor function is C6 Wrist extensors (extensor carpi radialis preserved below the longus and brevis) neurological level C7 Elbow extensors (triceps) and at least half of C8 Finger flexors (flexor digitorum profundus) to the middle finger key muscles below T1 Small finger abductors (abductor digiti the level have a minimi) muscle level greater L2 Hip flexors (iliopsoas) than or equal to 3 L3 Knee extensors (quadriceps) Normal Normal sensory and L4 Ankle dorsiflexors (tibialis anterior) E motor function L5 Long toe extensors (extensor hallucis ASIA Classification System longus) S1 Ankle plantarflexors (gastrocnemius, soleus) Clinical Syndromes

When assessing power, the examiner Central Cord Syndrome occurs when a needs to be aware that the motor level lesion occurs in the cervical region and will be defined by the lowest key muscle produces sacral sensory sparing and that has a power grade of at least 3, greater weakness in the upper limbs than providing that the key muscles in the lower limbs. represented by segments above that level are judged to be normal. Brown-Sequard Syndrome occurs when a lesion produces greater ipselateral proprioceptive and motor loss and contralateral loss of sensitivity to pain and

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temperature. This is extremely rare in the their pre-morbid status and level of elderly population and is most often due functioning being used to target ongoing to penetrating trauma (e.g. stabbing) with treatment schedules. resultant hemisection of the spinal cord. In order to fully appreciate the impact of Anterior cord syndrome occurs when a spinal cord injury on patients and evaluate lesion produces variable loss of motor their progress / deterioration, the function and sensitivity to pain and Functional Independence Measure (FIM) temperature whilst proprioception (dorsal could be used. The FIM focuses on six columns) is preserved. It can occur when areas of functioning and evaluates specific blood flow is reduced or interrupted in items using a seven-point scale (see the artery that runs along the anterior below): portion of the spinal cord. Core Themes Conus medullaris syndrome is when injury Self-Care to the sacral cord (conus) and lumbar Sphincter Control Mobility nerve roots within the spinal canal results Locomotion in an areflexic bladder, bowel and lower Communication limbs. Social cognition Grade Description Neurogenic Shock 7 Complete independence 6 Modified independence – activity being assessed requires assistive device; more This state can occur following injury to the time and/or is not performed safely spinal cord above T6 and is defined as 5 Supervision or setup – no physical vascular hypotension with bradycardia. assistance is needed but cuing, coxing or This is mainly due to a loss of sympathetic setup is required 4 Minimal contact assistance – subject outflow and is associated with reduced requires no more than touching and central venous return to the heart which expends 75% or more of the effort may not be well tolerated by elderly needed for the activity patients with pre-existing cardiac 3 Moderate assistance – subject requires conditions. more touching and expends 50-75% of the effort required in the activity 2 Maximal assistance – subject expends Inotropic support of the circulation will be 25-50% of the effort required in the required at an early stage and intensive activity monitoring will depend on the patient’s 1 Total assistance – subject expends 0- pre-morbid status. Invasive fluid balance 25% of the effort required in the activity monitoring may be required to prevent Functional Independence Measure (FIM) pulmonary congestion. Continence

Spinal Cord Injury in the Older Elderly patients with spinal cord injury will Patient need careful evaluation of their continence status and consideration given Older patients should still have the same towards urethral catheterisation and level of access to specialist services (e.g. bowel management strategies following inpatient rehabilitation, outreach services admission. etc..) as younger patients. Each patient should be managed as an individual with

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Whatever management method is used, Prognosis patients should be included in all decisions and plans should be acceptable Once damage to the spinal cord has to the patient and be transferable to the occurred, prognosis is generally good if community setting after discharge. recovery is evident during the first 24 hours. Functional recovery is poor if no Some patients may benefit from signs of sacral sensation to pinprick or suprapubic catheterisation as opposed to temperature are present after 24 hours. intermittent urethral catheterisation but each patient should be managed on an In these instances, patients will require individual basis. formal care bundles for spinal injury to manage pressure ulcers, neurogenic Nutrition and Toileting bowel etc... Early referral to specialist spinal rehabilitation teams will help guide Patients should be toileted using low- the most appropriate management of impact transfer techniques and this may patients. involve a plan for bowel opening on the bed as opposed to on the Summary toilet/commode.

Depending on the neurological level,  Elderly patients with thoracolumbar some patients will be at risk of paralytic pain may have pre-existing, chronic ileus and aspiration pneumonitis and may back problems and it is important to benefit from early nasogastric tube establish whether an injury is new or insertion. not. Patients should be considered as having a new injury if they have a new In the later stages of recovery, some onset of symptoms following trauma. patients with good degrees of cognitive functioning may benefit from surgical  Clinicians should be aware of the review to consider the risks versus markers of instability on plain film benefits of colostomy. This will depend on radiography and be able to determine the individual and may be more socially which patients warrant further acceptable to some patients more than imaging (CT/MRI). others.  Assessment of spinal cord injury Skin Hygiene and Pressure Sores should follow a standardised process that examines motor and sensory All patients should have a regular function and referrals should be made assessment of pressure areas to include as soon as possible to specialist units. the sacrum, heels, buttocks and occipital areas. Regular turning should be  The ongoing care of elderly patients instituted provided any unstable injuries with spinal cord injuries will depend are being managed appropriately. on the individual and is best served with specialist input which can be delivered on an outreach basis.

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References

1. McRae R. Pocketbook of Orthopaedics and Fractures (1999) Churchill Livingstone: London p368-79.

2. Maynard FM, Bracken MB, Creasey G et al. International Standards for Neurological and Functional Classification of Spinal Cord Injury. Spinal Cord 1997; 35: 268-274

3. MASCIP. Management of the older person with a new spinal cord injury: Good practice guidance 2010.

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Chapter 10 – Thoracic Injuries starts at the point of initial assessment and continues until discharge. Introduction Ageing of the Respiratory System

Thoracic injuries in elderly patients are mainly due to blunt trauma with same- The respiratory system comprises the level falls being the most common thoracic cage, lungs and diaphragm. It mechanism. They comprise a wide undergoes structural and physiological spectrum of injury ranging from simple changes with age but there are large bruising to multiple fractures and differences between individuals, underlying lung injury. especially in the presence of co-existing disease. Rib fractures have been documented in up to two thirds of cases of chest trauma. It is important to appreciate how this There exists an increasing incidence of system changes with advancing age as isolated or multiple rib fractures with patients will respond differently to increasing age1. Such injuries may be thoracic injury. With declining associated with pulmonary complications physiological reserve and anatomical in more than one-third of patients, and changes, patients may deteriorate rapidly pneumonia in up to 30% of cases. hence the need to have higher levels of vigilance when managing patients with One 2009 study2 identified the following these injuries. criterion as having 100% sensitivity to developing complications after thoracic Mechanics of the Respiratory System trauma (95%CI 79.4 - 100%): Compliance refers to the change in  Age >85 years; volume in relation to a change in pressure. Lung compliance determines the  Initial systolic blood pressure <90mmHg; Haemothorax; rate and force of expiration whilst chest wall compliance determines the elastic  Pneumothorax; load that builds within the chest during  Three or more unilateral rib fractures; inspiration.  Pulmonary contusion.

Chest wall compliance is lessened by the Thoracic trauma is common in the elderly following changes that can occur with and associated with high morbidity. It is age3: important for the assessing clinician to be able to correctly diagnose injury and  Osteoporosis of vertebral bodies and institute appropriate management to loss of height of thoracic vertebrae. prevent future complications.  Kyphosis in the ageing skeleton

 Furthermore, injuries that could be Calcification of the rib cage causing stiffening and reduced range of treated in a conservative manner in younger patients, (e.g. rib fractures), may motion. need more aggressive intervention in the Reduced compliance means that the chest elderly population. Getting things right wall is effectively “stiff” and more effort is needed to generate a given volume of

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inhaled air. This would put extra pressure onset of fatigue when extra load is place on the diaphragm. on the respiratory system. Respiratory failure will ensue and patients can Studies have shown that people with low deteriorate rapidly without appropriate chest wall compliance will have a higher intervention and possibly mechanical residual volume (RV)4. This is the volume ventilation. remaining in the lungs at the end of expiration and the stiffened chest wall Lung Function acts as an obstacle to complete emptying of the lungs. Dynamic flow rates such as forced expiratory volume (FEV1) and forced vital Changes in Anatomy capacity (FVC) are dependent on lung volumes. FEV1 refers to the forced With lifelong non-smokers, autopsy expiratory volume in one second whereas specimens have demonstrated an FVC is the total forced volume on increase in airspace size with increasing expiration. age5. This has been thought to be related to degeneration of elastic fibres around the alveoli. It is thought that this leads to premature closure of the small airways during normal breathing, leading to hyper-inflation. This can impede gaseous exchange and lead to higher levels of

PaCO2. The normal response would be to increase the respiratory rate, leading to higher levels of fatigue and eventual exhaustion.

As mentioned previously, changes to the ERV, expiratory reserve volume; FRC, functional residual capacity; RV, residual volume; VC, vital capacity; TV, tidal thoracic vertebrae, calcification in the volume; TLC, total lung capacity costal cartilages and arthritic changes reduce the efficiency of breathing. In the There is a huge degree of variability in context of injury, ribs with lower mineral lung function amongst older individuals density and osteoporosis will be at greater but overall, there is a decline in FEV1 that risk of fracture to increasing levels of occurs with age. Functional residual kinetic energy. Older patients are volume and residual volume increase with therefore at greater risk of multiple rib age, leading to a lower vital capacity. fractures and injuries such as flail chest. When looking at the FEV1:FVC ratio, Respiratory Muscle Function which refers to the proportion of a person’s vital capacity that they are able With increasing age there is an age- to expire in the first second of forced related decrease in fast twitch fibres of expiration, this will be reduced when the diaphragm and overall muscle there is an obstruction to air escaping the atrophy. Such changes also exist within lungs (e.g. COPD, asthma). intercostal musculature. This can predispose individuals to a more rapid

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In the individual with normal lungs, FEV1 Primary Survey and FVC are likely to both decline with advancing age, leading to a relatively A – Airway & C-Spine constant FEV1:FVC ratio. Such a pattern is seen in restrictive lung disease but also Close attention should be paid to the serves to augment the effects of reduced presence of surgical emphysema that chest wall compliance as discussed earlier. extends from the chest into the soft tissues of the neck and face. Initial Assessment & Triage

As with most elderly patients, injuries may present in a relatively innocuous manner and only become clear after clinical assessment. Patients involved in high energy mechanisms merit a formal trauma team response whereas other patients arriving by ambulance or those who self-present warrant a more detailed assessment at triage.

Surgical emphysema to the face Observations should be recorded for all patients at initial assessment and any Air in the soft tissues of the neck can patient with a history of chest pain that quickly cause compression of vital starts after a fall should be deemed to be structures so the source for any air leak at risk of thoracic wall / intra-thoracic needs rapid identification and if suspected injury. as coming from the chest, thoracostomy should be performed as a priority. Where possible, all elderly patients presenting with chest pain should have a Any injury above the clavicles, or where 12-lead ECG recorded during the initial clavicular fractures are noted with high assessment process. mechanisms of injury, should lead the examiner to consider cervical spine Features of concern at the point of initial immobilisation and formal imaging (see assessment would be any of the following: before).

 Low oxygen saturations (<92%) Whilst assessing a patient’s airway, the  Raised respiratory rate (RR>25) neck should be examined for any midline  Reduced respiratory rate (RR<12) shift of the trachea and the presence of  Reduced GCS distended neck veins. Both signs could  High mechanism of injury (road traffic herald the presence of tension within the collision; pedestrian vs car; fall from chest (either caused by pneumothorax, height or downstairs) haemothorax or pericardial effusion).  Same-level fall but with blunt trauma between chest wall and a hard object B – Breathing and Ventilation (e.g. concrete kerb; furniture) Observations should be performed for all patients as soon as they arrive to include

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respiratory rate, heart rate, blood Where the percussion note is not obvious pressure, oxygen saturations and GCS as a to interpret, attention should be paid to minimum. In the presence of suspected any asymmetry between left and right thoracic trauma, an arterial blood gas lung fields. Any abnormality should should be performed immediately to warrant further investigation for the assess the patient’s underlying ventilatory presence of injury. performance. AUSCULTATION: auscultation of all lung Supplemental oxygen should be delivered fields should be performed, comparing if oxygen saturations fall below 94%, but left to right. In the context of trauma, patients with a history of COPD and crackles may be interpreted as saturations of 88-92% without obvious contusions; absent breath sounds as respiratory distress may not benefit from pneumothoraces and reduced breath oxygen therapy. sounds as effusions. Auscultation of heart sounds should be performed to assess for The chest requires formal assessment in muffled heart sounds or bruits / murmurs. terms of inspection, palpation, percussion and auscultation. With elderly patients, abnormal signs on respiratory examination may represent INSPECTION: inspect for any of the more than just findings secondary to following signs: acute traumatic injury. Fine crepitations  asymmetry of chest wall from congestive cardiac failure could be movement; previous sternotomy / misinterpreted as lung contusions; a silent thoracotomy scars; obvious chest in severe COPD could be bruising or deformity; misinterpreted as a pneumothorax; and a  paradoxical chest wall movements; dull percussion note from malignant  open wounds effusions could be misinterpreted as a haemothorax. PALPATE: formally assess for the following: HECTOR advises that a cautionary  tracheal deviation with apical shift; approach is taken for elderly patients with  surgical emphysema or localised chest injury, especially if such patients tenderness; have pre-existing lung and/or cardiac  AP and lateral palpation of the disease. History-taking is key with history chest wall to elicit pain that could of injury and symptom-onset, and past signal underlying bony thoracic medical history playing vital roles in the injury. decision-making process.  sternal injury If any life-threatening injuries are found PERCUSS: percussion should be during the primary survey (e.g. tension performed in all lung fields, paying close pneumothorax, open pneumothorax, attention to the lung apices and bases massive haemothorax), these should be (including the axillae). Any dullness to treated as soon as they are identified, percussion should raise suspicion of an usually with chest decompression and/or effusion and any hyper-resonance should tube thoracostomy. raise the possibility of a pneumothorax (or emphysematous bulla).

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The examiner should also be vigilant to possibility of intracranial injury, and in the the possibility of concurrent illness that context of chest injuries, the effects of may have precipitated the trauma. diminished ventilation / oxygenation. A Underlying sepsis and pneumonia should blood glucose should also be performed. be managed according to local findings if identified on primary survey. Any elderly patient with a significant chest wall / intra-thoracic injury and declining Similarly, any evidence of myocardial GCS should have a repeat arterial blood insult (e.g. ACS), should warrant formal gas. Declining Pa02 or increasing PaCO2 medical review at an early stage to should lead the assessing clinician to determine the appropriate next stages of reassess pain management, and consider care. whether early mechanical ventilation may be appropriate to prevent further C – Circulation & Haemorrhage Control deterioration. These decisions should not Any physiological abnormality to blood be made in isolation but should be made pressure or heart rate should lead the between senior team members and take examiner to consider the possibility of into account the patient’s underlying pre- diminished venous return caused by morbid condition. tension pneumothorax, massive haemothorax or pericardial tamponade. Imaging Similarly, it may represent a peri-arrest state if caused by haemorrhagic shock. Plain Film Radiography The assessing clinician should employ a Such states warrant immediate action and structured method for interpreting Chest consideration should be given for the X-Rays to ensure that key features are not decompression of any tension or missed. tamponade whilst also considering the role of massive transfusion and correction A – Accuracy of coagulopathy. A – Adequacy A - Airway Large haemothoraces may be B – Breathing unaccompanied by physiological C – Cardiac & Costal cartilages derangement, in which case signs D – Diaphragm suggestive of occult hypoperfusion should S – Soft Tissues be noted. A – Accuracy: Is this the right film for the If there are no obvious sources for altered right patient? Are there any old films for physiological states within the chest, comparison? attention should be paid to other others (e.g. abdomen, scalp, pelvis, long limbs, A – Adequacy: Are both lung apices and retroperitoneum), especially in the costo-phrenic angles clearly visible on the context of high mechanisms of injury. image? Is there any rotational element to the image? (observe any overlap or D – Disability discontinuity of clavicular heads at GCS should be repeated following the sternoclavicular joint or alignment of initial recording at triage and any changes spinous processes of thoracic spine) Is the should lead the examiner to consider the image AP or PA, erect or supine?

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A – Airway: Observe the trachea down to the left and right main bronchi – is there any obvious narrowing? Is there any deviation or flattening of the trachea / bronchi?

B – Breathing: View both lung fields and compare for any obvious symmetry. Look at the lung markings and ensure they meet the edge of the chest wall – if not consider the possibility of a pneumothorax. Look for radio-opacity and collapse for possibility of lung contusions / Absence of left sided lung markings suggestive of pneumothorax pneumonia. C – Cardiac & Costal Cartilages: observe the cardiac shadow and mediastinum – ts there any widening or unfolding of the mediastinum? Are the heart borders distinct? Trace each anterior / posterior rib in turn and note any obvious fractures / irregularities. Observe the clavicles, humeral heads and scapulae for obvious injury.

D – Diaphragm: view the costophrenic

Right sided pulmonary contusion angles and note the presence of any obvious effusion. Note any elevation of either hemidiaphragm and herniation of abdominal contents into the thoracic cavity.

S – Soft Tissues: look at the soft tissues and surrounding structures for the presence of surgical emphysema. Note any medical equipment (e.g. endotracheal tube, oxygen tubing) appearing on the

Right middle lobe pneumonia Xray.

If there is any suspicion of sternal fracture (anterior chest wall pain following RTC; focal tenderness over the sternum), dedicated sternal views should be requested.

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Ultrasound findings include:

i. Loss of pleural sliding ii. Loss of comet tail artefacts iii. Clearly defined lung point – point at which pleural sliding appears and disappears (anterior in small pneumothoraces; lateral in larger pneumothoraces)

CT Imaging

Sternal Fracture on Sternal Xray In most emergency departments, CT scanning will be the most appropriate Ultrasonography method for identifying specific thoracic injuries. In the absence of multi-system In experienced hands, chest trauma, focussed CT imaging of the thorax ultrasonography may be used to assess will be sufficient to detect significant for the presence of: abnormalities.  occult pneumothoraces;  pleural effusions; If there is no suspicion of great vessel  sternal fractures; injury and no history of penetrating  pulmonary oedema. trauma, a non-contrasted CT scan will be appropriate to detect pulmonary Extended FAST views of the lienorenal contusions, haemopneumothoraces and angle and Morrison’s pouch through bony injuries and will avoid the superior migration of the probe, will nephrotoxic effect of intravenous contrast elucidate the diaphragm and lung bases. agents. Fluid is anechoic and will be demonstrated by a dark appearance: Contrast-enhanced CT and angiography should be considered in cases of penetrating trauma or where there is suspicion of great vessel injury.

Management of Different Types of Injury

Rib Fractures & Flail Chest

Simple rib fractures account for more

than 50% of thoracic injuries due to blunt Supine plain film radiography only has a trauma. The most common mechanism of 50%-76% sensitivity for small injury in elderly persons is a fall from pneumothoraces. Sensitivity of ultrasound height or standing. Close attention should is between 86-100% and hence may be of be paid to the exact mechanics of the fall more use in excluding pneumothoraces6. – if the patient has fallen with their chest

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striking a blunt object, the risk for rib mortality and morbidity and should all be fractures is increased. considered for epidural analgesia unless contra-indicated. A combination of a Pain from rib fractures can compromise narcotic (e.g. fentanyl) and a local ventilation by causing respiratory anaesthetic (bupivicaine) is considered to splinting, resulting in atelectasis and be the most effective form of epidural pneumonia. Multiple successive rib analgesia. fractures, (>3 successive rib fractures) can increase the risk of a patient developing Epidural analgesia has been demonstrated respiratory insufficiency and pneumonia if to result in an increased functional not managed appropriately. residual capacity (FRC), lung compliance and vital capacity. Tidal volume increases Flail chest describes the paradoxical and the paradoxical movements of flail movement of a segment of chest wall that segments are reduced. arises when two or more consecutive ribs are fractured in two or more places. For In a hospital setting, epidural analgesia elderly patients with osteoporosis, the may result in hypotension, especially blunt force needed to create such an when associated with hypovolaemia and injury is lessened, thus rendering elderly may be technically demanding in patients patients more vulnerable to such injuries with confusion or dementia. with lower mechanisms of trauma. Surgical Fixation Respiratory insufficiency is likely to result The National Institute of Clinical if a flail chest or rib fractures are Excellence (NICE) have published guidance associated with underlying pulmonary for the surgical fixation of patients with contusion, especially in the presence of flail segments7. Other evidence includes a underlying lung disease. The management randomised control trial of 40 patients of these types of injury focuses on with 3 or more rib fractures allocated to optimising pulmonary mechanics through surgical stabilisation or conservative adequate analgesia and chest treatment. This discovered that patients physiotherapy. in the surgical group had fewer days in hospital, fewer days on mechanical Management of Pain ventilation and fewer days in critical care. Intravenous opiates are commonly used (p<0.001)8 for severe pain but have the adverse effects of causing: At present, HECTOR neither supports nor dismisses such practice. Surgical  cough suppression; management of rib fractures will vary  respiratory depression; according to specialist centres and patient  hypoxia. selection for such a procedure has yet to be defined in a clear manner. These side-effects may render opiates counter-intuitive to recovery in patients Ongoing Care with significant chest wall injury. All elderly patients with rib fractures should be given optimum pain relief, Patients with four or more rib fractures or oxygenation as needed and receive a flail segment are at significant risk of

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elements of chest physiotherapy (either develop over a period of 24 hours so all as an inpatient or as outpatient advice). elderly patients should be admitted for Patients with severe pain should be close observation. admitted for close observation and any clinical deterioration should warrant Patients with exacerbations of COPD / further arterial blood gas analysis, repeat asthma should be managed with chest radiography and formal clinical controlled oxygen therapy and nebulised assessment. Antibiotics should be given Beta – agonists. Baseline arterial blood for suspected pneumonia and the gases taken at admission can be used as a development of any effusions should guide to determine whether an merit ultrasound guided or video-assisted individual’s condition is improving or thoracoscopic drainage. becoming gradually worse.

Pulmonary Contusions Traditional practice has been to place patients with pulmonary contusions under Pulmonary contusions occur when the strict fluid restriction regimes. Contrary to lung parenchyma is damaged, resulting in this practice, patients should be blood and oedema collecting in alveolar resuscitated with crystalloid to maintain spaces. This interrupts normal respiratory adequate tissue perfusion and thereafter, function and most progress over a 24 unnecessary fluid administration should hour period. be avoided.

Such injuries tend to follow blunt trauma The main complications of pulmonary and may be evidenced by crackles heard contusions are ARDS and pneumonia. At on auscultation or increased radio-opacity molecular level, a mediator-driven on a plain film Chest X-Ray. inflammatory process (e.g. interleukin-6, tumour necrosis factor etc...), can cause The combination of pain from associated further insult after the initial injury and injuries (e.g. rib fractures) with lead to ARDS. parenchymal damage, limits ventilation, worsens alveolar gas exchange and can Pneumothorax – Simple, Open & Tension lead to progressive respiratory distress. These features are exaggerated if an Pneumothorax is the presence of air individual suffers from underlying lung between the parietal and visceral pleura. disease (e.g. COPD; UIP), in which case Management will depend on the degree careful management of pain, oxygenation of symptoms, size of pneumothorax and and ventilation is often required. Blood in level of cardiorespiratory impairment. the alveolar spaces is an excellent culture medium for bacteria with pneumonia Elderly patients with COPD may have being a common complication of such underlying lung disease that mimics the injuries. presence of pneumothoraces on clinical and radiological evaluation. These The mainstay of treatment for patients patients may have long-standing with contusions rests with optimal emphysematous bullae. Careful analgesia, chest physiotherapy and evaluation of past medical history, vigilance for declining respiratory medical records and previous X-Rays may function. Pulmonary contusions may be required to ensure that chronic

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problems are not associated with the preferable to Seldinger drains as they are acute consequences of trauma. less likely to become blocked by blood clots. Open and tension pneumothoraces are medical emergencies and need treating as An occult pneumothorax is one which is soon as they are identified. Such injuries evident on computed tomography but not can cause severe cardiorespiratory on plain film radiography. In the absence distress and should be prioritised as they of respiratory distress, such injuries can are for younger patients. be treated conservatively without tube thoracostomy. If mechanical ventilation is Specific Management required, this is not an absolute indication Tension pneumothorax should be for tube thoracostomy. managed by immediate chest decompression and followed by formal Ongoing Care tube thoracostomy. The decompression A persistent leak and failed resolution of can occur via needle thoracocentesis or pneumothorax at 3 days following injury thoracostomy. may be an indication for VATS assessment. If a pneumothorax persists Standard peripheral venous cannulae may beyond 3 days, patients with this injury not be long enough to penetrate the chest should be referred to the Thoracic wall tissue. Furthermore, the presence of specialists for ongoing management soft tissue swelling and/or surgical decisions. emphysema would increase the distance between the skin and pneumothorax even Haemothorax more. Thoracostomy is a more effective means of decompression but may not be Traumatic haemothoraces may result tolerated particularly well in confused, from either blunt or penetrating trauma. agitated patients. Multiple rib fractures, lung lacerations or thoracic spinal fractures may be the HECTOR recommends that either underlying cause for accumulation of technique can be used and will depend on blood in the chest. the state of the individual patient and urgency of procedure. The absence of abnormal physiological signs that would otherwise correlate with With the open pneumothorax, clinical hypovolaemic shock, bear less relevance teams should apply a three-way dressing in the elderly population. Closer attention over the wound site and proceed to should be paid to occult hypoperfusion perform tube thoracostomy. Chest drains (I.e. raised lactate, base deficit), in the should not be inserted through the wound presence of finding an effusion on which is often caused by penetrating examination or imaging. trauma and can be associated with underlying visceral injury. Management All patients with a haemothorax, Large, simple pneumothoraces (>2cm irrespective of size, should be considered between pleural edge and lateral chest for drainage via tube thoracostomy. In wall) are best managed with tube circumstances where physiology is thoracostomy. Trauma drains are abnormal and suggestive of shock (i.e. low

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blood pressure, raised heart rate), thoracostomy is indicated. If the aspirated especially if accompanied by low O2 sats fluid is not blood, management will or rising ETCO2, attempts should be made depend on the suspected underlying to drain any effusion / haemothorax cause of the effusion. immediately. Thoracic Great Vessel Injuries Surgical exploration should be considered in the presence of: The thoracic aorta may be injured by a sudden change in velocity, with the  drainage exceeding 1500mL in any 24- commonest mechanisms being road hour period; traffic collisions and falls from height. The  patients with grossly abnormal aortic arch is fixed by great vessels with physiology; the ascending and descending thoracic  evidence of uncontrolled intrathoracic aorta being more mobile and stopping at haemorrhage demonstrated by the a later point of deceleration causing stress need for ongoing transfusion to on the aortic root and isthmus. maintain tissue perfusion. Full thickness injury will result in Patients with a persistent retained catastrophic haemorrhage with most haemothorax on plain film radiography patients dying on scene. Other injuries should be managed with VATS within the include minimal intimal flaps through to first 3 to 7 days of hospitalisation to extensive pseudoaneurysm formation. decrease the risk of infection and conversion to thoracotomy. Elderly patients may sustain such injuries with lower level impacts than in younger Haemothorax or Effusion? patients. This patient group therefore Pleural effusions may be long-standing warrants a higher level of awareness in and can have multiple causes. Deciding on the event that they present following whether to treat an effusion with formal deceleration injuries. CT angiography will drainage will depend on the be the imaging modality of choice in most cardiorespiratory state of the patient and centres to identify such injuries. the likelihood that the effusion represents a collection of blood. Traumatic Aortic Dissection Patients may present with an abrupt A clear history of trauma with associated onset of chest pain that is felt worst at its rib fractures may point towards the latter onset and at the impact of trauma, and is but if there is any doubt a CT scan will tearing in nature. It can be associated define blood as having a density of +30 to with a combination of early neurological +45 Hounsfield Units (HUs), and and cardiovascular complications that demonstrate any associated injury. include:

If there is still concern about whether an  Cerebrovascular accident (CVA) effusion represents blood, an experienced  Syncope clinician could attempt an ultrasound-  Congestive cardiac failure guided diagnostic pleural tap to sample  Ischaemic limb the fluid. If at this point it is clearly blood  Progressive paraplegia that has been aspirated, tube

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Examination may reveal transient pulse myocardial infarction), will require cardiac deficits, signs suggestive of cardiac monitoring and/or serial ECGs in the tamponade, raised JVP, and new onset presence of myocardial / pericardial aortic regurgitation. injury.

Plain film radiography may reveal the Emergency Thoracotomy following findings: The indications for Emergency Widening of superior mediastinum thoracotomy continue to be discussed Dilatation of aortic arch within the trauma fraternity. Most of Obliteration of aortic knob these discussions do not take into account Double density of aorta Trachea/NG tube deviated to right a patient’s age and there are limited Flattening if left mainstem bronchus studies to pass comment on the survival Left pleural effusion of elderly patients undergoing this Cardiomegaly procedure.

Strategies should be taken to control Emergency thoracotomy is often done in blood pressure, with the aim of a systolic the context of penetrating thoracic blood pressure between 100-120mmHg. trauma where there has been a traumatic arrest with previously witnessed cardiac Pericardial Tamponade & Myocardial activity or with unresponsive hypotension Contusion (BP<70mmHg).

Sternal fractures occur in approximately In blunt thoracic injury, indications may 3% of blunt chest trauma and are usually include unresponsive hypotension a result of road traffic collisions caused by (BP<70mmHg) or rapid exsanguinations the seat belt or steering column. The from a chest drain (>1500mL). It is contra- prevalence is higher in patients over 50, indicated in the context of: blunt with simple falls whereby the anterior traumatic injuries with no witnessed aspect of the chest strikes a hard object cardiac activity; multiple blunt trauma; being a likely mechanism. Approximately and severe head injury. 6-12% of patients with sternal fractures will develop a myocardial contusion. The purpose of thoracotomy is to perform one or more of the following life-saving If any of the following are present, interventions: patients will require admission and further investigation: a) Release of pericardial tamponade b) Control of intrathoracic haemorrhage  abnormal ECG; c) Control of massive air embolism or  elevated cardiac enzymes (Troponin, bronchopleural fistula CK); inadequate pain control; d) Open cardiac massage  cardiorespiratory compromise. e) Cross-clamping the descending aorta.

Elderly patients with pre-existing cardiac Irrespective of the indication, emergency co-morbidity (i.e. ischaemic heart disease; thoracotomy is a traumatic procedure in congestive cardiac failure; previous itself and any chance of survival will also depend on the patient’s reserve for

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ongoing recovery and ability to cope with  Clinicians should have a lower the procedure. REBOA (retrograde balloon threshold for admitting elderly occlusion of the aorta) may be a more patients with thoracic injury due to appropriate life-saving procedure in the the higher comparative rate of elderly patient, but again there is complications such as pneumonia, insufficient evidence to pass further empyema and ARDS. comment. References Summary 1. Gyun JH, Young Kim H. Factors affecting  Elderly patients with thoracic injuries pneumonia occurring to patients with may present following simple falls or multiple rib fractures. Korean J Thorac Cardiovasc Surg. 2013; 46(2):130-134 following higher mechanism of injury.

Following a fall, a history of blunt 2. Lotfipour S, Kaku SK, Vaca FE et al. Factors trauma to the chest against a hard associated with complications in older adults object (e.g. furniture, concrete kerb), with isolated blunt chest trauma. West J should raise concerns with the Emerg Med 2009; 10(2): 79-84. assessing team. 3. Sharma G, Goodwin J. Effect of ageing on  Clinicians should have a basic respiratory system physiology and understanding of the effects of ageing immunology. Clinical Interventions in Ageing on the respiratory system which all 2006; 1(3):253-260

contribute towards declining 4. Mittman C, Edelman NH, Norris AH et al. respiratory function and a reduced Relationship between chest wall and tolerance to any given injury. pulmonary compliance with age. J Apply Physiol 1965; 20; 1211-16.  All patients should have a thorough examination of the chest performed 5. Gillooly M, Lamb D. Airspace size in lungs of on primary survey and have this lifelong non-smokers: effect of age and sex. augmented with arterial blood gas Thorax 48: 39-43. analysis. A knowledge of the baseline PaO2 and PaCO2 will help direct 6. Ball CG, Ranson K, Dente CJ et al. Clinical predictors of occult pneumothoraces in ongoing care and guide oxygen severely injured blunt polytrauma patients: A prescription. prospective observational study. Injury 2009; 40:44-7.  Life-threatening thoracic injuries should be treated as they are found 7. National Institute for Health and Clinical and most involve thoracostomy. Excellence (NICE). Insertion of metal rib reinforcements to stabilise a flail chest wall  Ongoing care will be focussed on (IPG361). Oct 2010. providing optimum analgesia, and epidural analgesia for patients with 8. Granetzny A, Abd El-Aal M, Emam E et al. Surgical versus conservative treatment of flail multiple rib fractures if appropriate, chest. Evaluation of the pulmonary status. adequate oxygenation and chest Interact Cardiovasc Thorac Surg 2005; 4: 583- physiotherapy. 7.

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Chapter 11 – Abdominal & Abdominal examination in elderly patients Pelvic Injuries has a low sensitivity for diagnosing injury. Concomitant use of opiate analgesia Introduction and/or steroids can mask signs of peritoneal involvement and limit the Abdominal Trauma effectiveness of clinical examination.

Patients with blunt abdominal trauma can In this context, abdominal examination present with: pain; tenderness on should not be considered as a reliable palpation; gastrointestinal haemorrhage; means of excluding serious injury in or evidence of peritoneal irritation, (e.g. elderly age groups. Factors such as rebound tenderness). Features to suggest dangerous mechanisms of injury, significant trauma may include: associated chest wall/pelvic injury and evidence of occult hypoperfusion should  lap belt marks; be used in combination to raise the level  steering wheel shaped contusions; of suspicion for abdominal injury. abdominal distension;  instability of the lower thoracic cage; Pelvic Trauma  Grey Turner (ecchymosis in flanks)  Cullen sign (ecchymosis around Osteoporosis in the elderly age groups umbilicus). leaves individuals vulnerable to pelvic trauma with relatively low mechanisms of Intra-abdominal injury following blunt injury. The most common injuries include trauma may occur for one of the following fractures of the femoral neck and/or reasons: pubic rami after same-level falls. a. Crushing of solid viscera between the No injury to this area should be regarded anterior abdominal wall and vertebral as trivial and seemingly minor injuries like column or posterior thoracic cage; pubic rami fractures can cause catastrophic haemorrhage, especially in b. Rapid deceleration causing solid or patients taking anticoagulant medication. hollow organs and vascular pedicles to tear at fixed points of their attachment; Patients sustaining significant pelvic disruption (e.g. open book or vertical shear injuries), often do so following high- c. External compression resulting in a rapid increase in intra-abdominal pressure energy trauma mechanisms. The risk of causing the rupture of a hollow organ. associated injury is great and formal trauma team review is merited if such Elderly patients may be particular injuries are discovered. vulnerable to these types of force as they have: reduced muscle mass and therefore In order to gain a greater appreciation of reduced protection of internal organs; the different types of injury to these body bone fragility resulting in fractures that regions, it is important to understand the can damage solid organs; and age-related basic anatomy of each area. organ atrophy placing more tension on vascular pedicles.

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The Abdomen pain. Progressive haemorrhage leads to clinical signs of early shock and/or raised The abdomen is the space between the lactate. thorax and pelvis, formed by the diaphragm at its upper surface and pelvic Elderly patients with lower left-sided brim at its lower surface. The anterior chest wall tenderness or left upper layers of the abdomen are the: quadrant pain following trauma should be considered as being at risk of splenic  External oblique; injury and arrangements made for  Internal oblique; appropriate imaging to confirm / refute  Transverse abdominis which merge in the diagnosis. the midline to form the rectus abdominis. The Liver

Solid organs such as the liver and spleen The liver is divided into two lobes (right are contained within the upper aspect of and left) and divided further according to the abdomen and are particularly its vascular and bile duct distribution. It vulnerable to injuries that involve the may be injured during blunt abdominal lower thoracic cage. trauma, especially when there is associated injury to the right lower thoracic cage.

Elderly patients with any of the following features should be considered at risk of injury and warrant further assessment:

 Injury to the right lower chest wall;  Pain in the right upper quadrant after a traumatic injury;  Significant ecchymoses over the right upper quadrant The Spleen The Retroperitoneal Space The spleen is the most commonly affected organ in blunt injury to the abdomen for The retroperitoneal space exists behind all age groups. It weighs approximately the peritoneum and contains organs that 75-150g and filters 10-15% of the total are covered by peritoneum on their blood volume every minute. Nearly 25% anterior aspect only. of the human body’s circulating platelets are held in reserve in the spleen. The following structures are retroperitoneal: Direct blows to the spleen or rapid deceleration during road traffic collisions Urinary or falls from height can lead to injury.  Adrenal glands Most patients with minor injury will  Kidney complain of left upper quadrant  Ureter tenderness and possibly left shoulder-tip

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Circulatory Injuries to the sacroiliac joints can cause  Abdominal aorta injuries to the veins of the pelvic venous  Inferior vena cava plexus and branches of the iliac arteries, Gastrointestinal / Abdominal leading to catastrophic haemorrhage.  Rectum  Head, neck and body of pancreas Any suspicion of pelvic fracture in the  Duodenum (except proximal segment) elderly age group should lead to a high index of suspicion for vascular injury and  Ascending and descending colon ongoing haemorrhage until it can be

The retroperitoneum is an area that can excluded by appropriate contrast- enhanced imaging. conceal ongoing haemorrhage. A high index of suspicion is needed to consider a retroperitoneal bleed and may only arise when patients fail to respond to resuscitation and there being no overt signs of injury.

Early diagnosis and management of bleeding is crucial to prevent rapid deterioration. Contrast-enhanced imaging will be needed to confirm the diagnosis and patients may then be candidates for Pelvic veins interventional radiology to arrest the haemorrhage. Initial Assessment & Triage

The Pelvis All patients should have routine observations at the point of initial The bony pelvis consists of: two assessment (HR, BP, O2 sats, RR, Blood innominate bones; the sacrum and the Glucose). High mechanisms of injury such coccyx. as: pedestrian traffic collisions; high speed road traffic collisions; or falls from height The sacroiliac joints connect the ilium of / downstairs warrant formal trauma team the innominate bones to the sacrum. The activation. sacrococcygeal symphysis connects the sacrum to the coccyx and the pubic Patients with lower mechanism of injury symphysis connects the pubic bodies: may be at risk of intra-abdominal trauma if they are suspected to have sustained injuries to the lower chest wall. Other features that should concern the triage team include the use of anticoagulant medication.

The initial triage of patients should include an assessment for signs that may suggest:

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 Pelvic injury - shortening and concerned about the possibility of injury. rotational asymmetry of the lower All patients should have bloods sent for limbs; lower abdominal bruising; FBC, U&E, LFT, Amylase, Clotting, Group & blood around external genitalia Save and Fibrinogen. Venous lactate on blood gas analysis may raise concern of  Lower chest wall injury – crepitus, occult injury if >2.5. bruising, raised respiratory rate Urine samples should be obtained to  Abdominal injury – bruising over the assess for the presence of haematuria. If a flanks or over the anterior aspect of patient has frank, macroscopic the abdomen. haematuria, injury to the renal tract should be suspected and imaging performed (ultrasound or CT Primary Survey abdomen/pelvis).

A – Airway & Cervical Spine Control Patients with any shortening or rotational deformity of the lower limbs should have Careful attention should be paid to a pelvis X-Ray for low mechanisms of mechanisms of injury that could result in injury. For high mechanism of injury, the cervical injury, (e.g. fall with head trauma; team should consider the application of a high mechanisms of injury) pelvic splint and perform WBCT.

B – Breathing & Ventilation Features that may suggest pelvic fracture on primary survey examination include: If pain is elicited in the lower chest wall or the examining clinician feels any lower  Blood around the tip of the urethral crepitus, surgical emphysema or meatus; witnesses paradoxical chest wall  Bruising above the inguinal ligament; movement, this should raise suspicion of  Scrotal haematoma. the possibility of hepatic and/or splenic injury. Patients with any of these findings should have a CT scan of the pelvis as a If bowel sounds are heard on auscultation minimum. over the chest, the examining clinician should also consider the possibility of Depending on expertise, FAST scan may diaphragmatic rupture. be performed to assess for the possibility of intra-abdominal haemorrhage. Elderly C- Circulation & Haemorrhage Control patients with ascites or who have ambulatory peritoneal dialysis will give a Physical examination of the abdomen may false positive result on FAST scanning. In yield little useful information in these circumstances, CT imaging is likely determining the presence or absence of to be required to confirm the extent of intra-abdominal injury. injury before operative intervention is considered. Any pain in the right or left upper quadrant or bruising over these areas or Abdominal ultrasound can also be in the flanks should make the clinician performed to assess the calibre of the

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abdominal aorta. The scan can be used to head continued along the inferior aspect assess aortic calibre on two transverse of the superior pubic ramus). views and one longitudinal view but it will not demonstrate small tears, B – Bones: inspect the following: the haemorrhage or aneurysmal rupture. femoral head and neck for any obvious deformity and breaks in trabeculae D – Disability pattern; the iliac crests; and the pubic rami All patients should have a temperature recorded in addition to blood glucose and C – Contours: review the sacroiliac joints a GCS. for widening; review any widening of the pubic symphysis. Imaging Common injury patterns will involve Ultrasound and CT scanning are ideal fractures of the pubic rami (superior, imaging modalities for intra-abdominal inferior or both), and the neck of the injuries. Contrast-enhanced scanning with femur (intratrochanteric, subtrochanteric arterial and porto-venous phase imaging or subcapital). will be needed to identify small areas of bleeding and contrast extravasation.

Pelvis X-Ray & Pelvic Injuries

Plain film radiography of the pelvis can be used to identify any obvious bony abnormality:

A – Accuracy A – Adequacy A – Alignment Subtrochanteric Neck of Femur fracture B – Bones C- Contours

A – Accuracy: is this the right film for the right patient?

A – Adequacy: if prostheses are present, have they been imaged in their entirety? Are both iliac crests visible?

A – Alignment: trace around the following Widening of pubic symphysis and assess for any obvious steps: the inner pelvic rim; around the inferior aspect of the superior pubic ramus and superior aspect of the inferior pubic ramus; Shenton’s line (a line drawn along the medial border of the femoral neck and

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secondary trauma caused by the laparotomy.

For stable patients with splenic injury, (i.e. those neither in need of immediate theatre nor radiological intervention), the need for operative intervention will depend on:

Fracture of right iliac crest i. Presence of intraperitoneal blood Management of Intra-Abdominal ii. Contrast blush on CT scan iii. Calculated risk of rebleeding Injuries iv. Presence and severity of associated injuries / illness Splenic Injury v. Grade of Injury vi. Options regarding blood transfusion Patients with splenic injury will vary in their states of presentation – some Patients on anticoagulant medication may patients may be haemodynamically stable have a more pressing need for definitive whereas others could be in a state of intervention and the threshold for haemorrhagic shock in need for urgent removal might be lowered. If observant definitive care. management is planned, any signs of persistent bleeding or haemodynamic Any patient with suspicion of splenic instability would be indications for injury who is hypotensive has a surgical surgery. emergency and should be taken to the Grade of Splenic Injury1 operating theatre or interventional Grade Type Description radiology suite as soon as possible. Haematoma Subcapsular <10% surface I area Laceration Capsular tear, <1cm In simple terms, a patient who has parenchymal depth sustained blunt trauma with Haematoma Subcapsular, 10-50% surface area, <5cm haemodynamic instability which is II diameter unresponsive to fluid challenge / transfusion and no other signs of obvious Laceration 1-3cm parenchymal depth, not involving a vessel haemorrhage should be considered as Haematoma Subcapsular, >50% surface having a life-threatening injury until area or expanding, proven otherwise. ruptured subcapsular or III parenchymal haematoma Patients who have a transient response to >5cm Laceration >3cm parenchymal depth resuscitation or with a blood pressure or involving trabecular >110mmHg, heart rate <90 bpm may be vessels suitable for imaging in the first instance to Laceration Laceration of segmental or hilar vessels producing assess whether interventional radiology is IV a more appropriate step than laparotomy. major devascularisation (>25% of spleen) Laceration Completely shattered Elderly patients may benefit from a less V spleen invasive approach as it will prevent them Vascular Hilar vascular injury with from having to recover from the devascularised spleen

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Hepatic Injury active bleed Laceration Parenchymal disruption involving 25-75% hepatic Patients who are haemodynamically lobe or 1-3 Couinaud unstable or who have diffuse abdominal segments (within one peritonitis after blunt abdominal trauma lobe) should be considered for laparotomy. V Laceration Parenchymal disruption involving >75% of hepatic Stable patients without peritonitis should lobe or >3 Couinaud segments (within one have a contrast-enhanced abdominal CT lobe) scan to identify and assess the severity of Vascular Juxtahepatic venous any injury to the liver. injuries (IVC, major hepatic vein) Patients with active contrast VI Vascular Hepatic avulsion extravasation or who are transient responders to resuscitation should be Renal Injury referred to Interventional Radiologists for consideration of embolisation. Most renal trauma occurs as a result of blunt trauma and most injuries can be Non-operative management in stable divided into the following groups: patients should be safe provided that laceration; contusion and vascular injury. facilities are available to monitor such Any patient presenting with macroscopic patients, perform serial clinical haematuria following injury should have assessments and are available to take a immediate imaging to assess the severity patient to theatre in the event of of injury. deterioration. 2 Grade of Renal Injury Grade Type Description The severity of hepatic injury, increasing I Contusion Simple contusion or non- age and the presence of associated enlarging subcapsular injuries should not act as contra- haematoma without indications to non-operative care. laceration II Superficial <1cm depth and not 1 Laceration involving the collecting Grade of Hepatic Injury system Grade Type Description Contusion Non expanding perirenal I Haematoma Subcapsular, <10% surface haematoma area III Laceration >1cm, without extension Laceration Capsular tear <1cm depth into the renal pelvis or II Haematoma Subcapsular, 10-50% collecting system and no surface area; evidence of urine intraparencyhmal < 10cm extravasation diameter IV Laceration Extends to renal pelvis or Laceration Capsular tear, 1-3cm urinary extravasation depth, <10cm length Vascular Injury to main renal artery III Haematoma Subcapsular, >50% surface Injury or vein with contained area pr ruptured with haemorrhage active bleeding; V Shattered Avulsion of renal hilum intraparenchymal > 10cm Kidney with devascularisation of diameter kidney Laceration Capsular tear > 3cm depth IV Haematoma Ruptured intraparenchymal with

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The kidney lends itself to non-operative Management of Pelvic Injuries management with the closed retroperitoneal space promoting the Fractured Neck of Femur tamponade of any bleeding, and the availability of high levels of tissue factor Since the launch of the National Hip which activates the coagulation cascade Fracture Database (NHFD) in 2007, over helps to prevent further bleeding. 250,000 cases have been recorded. The NHFD reviews standards of care for Surgical management should be reviewed patients with these injuries which include: on an individual basis at senior consultant level. Patients with persistent renal  Surgery within 36 hours bleeding as demonstrated by a pulsatile,  Shared care by surgeon and expanding retroperitoneal haematoma or geriatrician with avulsion of the main renal artery or  Assessed by geriatrician within 72 vein should be considered for surgery. hours  Pre-and post-operative mental test Decisions about definitive care should score assessment take into account concurrent injuries and  Geriatrician-led multi-disciplinary co-morbidities – if a patient is unlikely to rehabilitation survive, this should be discussed with the patient and their family in a collaborative Patients presenting following a fall with manner and as soon as possible. groin/hip pain and leg shortening / rotation should be assessed for a Traumatic Pancreatitis fractured neck of femur. Hip fracture is the commonest reason for admission to Pancreatic injury is uncommon and more an orthopaedic trauma ward. likely to be associated with penetrating trauma than high-mechanism blunt All patients with moderate or severe pain trauma. With the force needed to injure should be offered analgesia within 15-30 the pancreas being severe, such injuries minutes of arrival to an Emergency rarely occur in isolation and other injuries Department and have a Pelvis X-Ray should be sought. within one hour.

Bruising to the flanks, seatbelt marks and All patients should have routine bloods penetrating injuries should raise the and an assessment completed which suspicion for pancreatic injury. Symptoms includes the following (as covered in the and signs are most likely to be related to HECTOR assessment): other injuries and pancreatic trauma may not become evident until a few days into  Pressure sore risk a person’s care.  Hydration and nutrition  Fluid balance If CT findings are inconclusive, further  Pain investigation with MRCP may be useful,  Continence especially in patients who are not  Co-morbidities  Cognitive state recovering as well as expected.  Previous mobility  Functional ability

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After admission, patients should be co- iliacus muscle posteriorly which contains managed by orthopaedic and the femoral, obturator and lateral femoral orthogeriatric teams and have their cutaneous nerves. It is an ideal space for surgery within 36 hours. allowing the instillation of local anaesthetic to block these nerves.

Fascia Iliaca Compartment Block (FICB) FICB can be used for patients with a fractured neck or shaft of femur except in Adequate analgesia is a vital part of the the following circumstances: fractured neck of femur pathway. Over- use of opiates can lead to respiratory a. Anticoagulation depression and increase the risk of b. Previous femoral bypass surgery atelectasis and noscomial illness. An c. Inflammation or infection over injection alternative to opiate analgesia is the fascia site iliaca compartment block. d. Refusal by patient e. Allergy to local anaesthetic agent. The FICB is an effective method of providing pre-operative analgesia for Informed consent should be obtained patients with injuries to the hip and thigh. which involves informing the patient of It limits the need for opiate analgesia and the following complications: thus reduces the side-effects associated with such medication.  Intravascular injection; Anatomy The femoral nerve, obturator nerve and  Local anaesthetic toxicity; lateral femoral cutaneous nerve all arise from the lumbar plexus and provide part  Temporary or permanent nerve of the nerve supply to the legs. damage;

Femoral Nerve – sensory supply to  Infection; anteromedial surface of thigh  Block failure; Obturator Nerve – sensory supply to medial aspect of the thigh  Perioperative injury secondary to

numbness or weakness Lateral Femoral Cutaneous Nerve (LFCN) – sensory supply to lateral aspect of thigh to the knee. Close monitoring is essential within the

first 15 minutes after injection. The fascia iliaca compartment is a space between the fascia iliaca anteriorly and

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needle attached, pierce the skin at The fascia iliaca compartment3 right angles to its surface.

Equipment 6. Once through the skin, adjust the  Blunted or short-bevelled needle angle to 60O and aim cranially  Antiseptic skin solution  1-2mL 1% Lidocaine for skin infiltration in the awake patient  Long-acting local anaesthetic: 2mg/kg 0.25% bupivacaine or 2.5-3mg/kg levobupivicaine  Ultrasound machine and needle if being used

Landmark Technique 1. Draw an imaginary line between the anterior superior iliac spine and pubic tubercle

2. Divide this line into thirds and mark a point 1cm caudal from the junction of the lateral and middle third

3. Palpate the femoral pulse at the level Anatomical Landmarks for Fascia Iliaca Compartment Block3

of the planned injection site (should 7. Advance the needle through two be 1.5-2 cm medial to site) distinct “pops” which represent the fascia lata and fascia iliaca.

4. Prepare the skin and infiltrate skin and deep tissues with 1% lidocaine 8. Aspirate before injection and after

every 5mL injected – there should be

5. Using a syringe of long-acting local no resistance to injection. anaesthetic with a short-bevelled

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Large volumes of local anaesthetic (30mL) Patients with unstable and/or displaced are required to achieve good spread of pelvic ring disruptions on plain film the agent and a better chance of radiography should undergo contrast- providing block to the three nerves. If enhanced CT imaging to assess for active possible, reduce the concentration of the extravasation and haemorrhage. If local anaesthetic agent to achieve higher required, the assistance of an instillation volumes. interventional radiologist should be sought at the earliest opportunity. Unstable Pelvic Fractures When the pubic symphysis is disrupted, Patients with unstable pelvic fractures are there is often injury to the posterior most likely to sustain such trauma after osseous ligamentous complex, high-energy mechanisms. As such, head, represented by disruption to the sacroiliac chest and abdominal injuries are likely to joint or fracture. occur at the same time.

Most elderly patients present following low-energy mechanisms and are thus more likely to sustain injuries to the pubic rami or neck of femur than have significant disruption to the pelvic ring.

Types of Pelvic Ring Injury

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Widening of symphysis pubis with disruption of right sacroiliac joint following antero- posterior compression

Patients with unstable pelvic fractures can bleed from one of the following sources: observation. Any evidence of haemodynamic instability, occult a. Fractured bone surface hypoperfusion or pain not controlled b. Pelvic venous plexus despite adequate analgesia should c. Pelvic arterial injury warrant formal CT imaging to assess for d. Extra-pelvic sources the presence of haematoma or ongoing haemorrhage. Massive transfusion protocol should be activated for patients with haemodynamic Summary instability and unstable pelvic injuries.  Blunt abdominal trauma is often CT and angiography may fulfil an essential associated with high mechanism of role for unstable patients prior to theatre injury but can also accompany injuries and external fixation. Such decisions to the lower chest wall following should be made by the Consultant team same-level falls. responsible for damage control surgery.  Abdominal examination is an Pubic Rami Fractures unreliable method for excluding intra- abdominal injury and cues taken from Such injuries are common in the elderly the primary survey (occult population following simple falls. Patients hypoperfusion, FAST findings, injury may present with groin pain and an mechanism), should be used to inability to weight bear. Adequate determine the need for further analgesia should be prescribed and if imaging. necessary, patients may require admission.  Intra-abdominal injuries to solid viscera can often be managed in a Patients taking anticoagulant medication conservative manner with close should be considered for admission and

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observation. Vascular injuries and injuries to hollow viscera are more likely to need definitive damage- control management.

 Consideration should be given for the role of interventional radiology in the elderly patient with intra-abdominal injury. The invasiveness of laparotomy may not be appropriate for all patients, especially those with high levels of frailty and co-morbidity.

 Pain management plays a large role in the management of patients with fractured neck of femur. Fascia iliaca compartment block can be used as an alternative to opiate analgesia and can prevent the side effect profile of the latter.

 The identification of severe pelvic injury warrants high levels of vigilance towards haemorrhage control and the existence of other injuries. Patients should have a WBCT as soon as such injuries have been identified.

References

1. Moore EE, Cogbill TH, Jurkovich et al. Organ injury scaling V: Spleen and liver (1994 revision). J Trauma 1995; 38:323

2. Moore EE, Shackford SR, Pachter HL et al. Organ injury scaling: spleen, liver and kidney. J Trauma 1989; 29: 1664-6

3. Range C, Egeler C. Fascia Iliaca Compartment Block: Landmark and Ultrasound Approach. Anaesthesia Tutorial of the Week 193 Aug 2010. http://www.frca.co.uk/Documents/193%20Fa scia%20Iliaca%20compartment%20block.pdf (last accessed Aug 2015)

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Chapter 12: Extremity Trauma to poor wound healing and skin breakdown. Compound fractures and Burns especially may not heal well and need high levels of input from tissue viability Introduction teams, with longer hospital stays.

The secondary survey is performed to In addition to blunt trauma, burn injuries identify any significant injuries that may are particularly troublesome in the elderly have been missed during the primary population with the vast majority survey. Elderly patients who present occurring in a domestic setting. Flame and following simple falls may be at risk of scald injuries are the most common cause extremity trauma (i.e. injuries distal to the of major burns, although patients may elbow and knee). present following a fall and direct contact with a hot surface (e.g. a radiator), These injuries can affect the skin, muscle especially if they are unable to move due and tendon structures, bony skeleton, to associated injuries. neurovascular structures or all of the above. What is important to consider is Different injury types and patterns are too how such injuries are likely to impact on numerous to include in their entirety. an individual’s recovery. A patient who is HECTOR will review the commonest types reliant on a zimmer-frame for mobility will of injuries that present to Emergency be unable to use such a device if their arm Departments and offer advice on is in plaster. appropriate management.

Seemingly minor injuries can impair Upper Limb Injuries recovery, and with that can lead to prolonged hospital stays, increased risk of Colles’ Fracture noscomial illness and a high rate of complications. This injury was first described by Abraham Colles in 1814 and was originally Patients of increasing age are more likely described as a “low energy extra-articular to suffer from delayed wound healing, fracture of the distal radius occurring in especially if initial management is elderly individuals”. It is more common in suboptimal. Skin morphology changes elderly women and often associated with with age and is due to the following: an underlying history of osteoporosis.

 Reduction in dermal thickness; Patients may present following a simple  Reduced number of cells; fall onto a hand that they have stretched  Disrupted microcirculation; out to protect themselves and may have a  Altered collagen/elastin content; “dinner-fork deformity” of the distal  Changes to physical properties of forearm. collagen With these injuries the dorsal surface When combined with conditions such as undergoes compression whilst the volar diabetes or medications that impair surface undergoes tension. healing (immunosupressants, corticosteroids), these changes can lead

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C. Displacement of the ulnar styloid or ulnar angulation of the distal fragment, (indicates serious disruption of the inferior radioulnar joint)

The decision to perform a manipulation should be reviewed on a case-by-case basis. The discomfort caused by such a procedure may be unnecessary for Dinner-Fork Deformity in Colles’ Fracture patients who have limited functional ability. X-Ray Findings Attempts at reduction of such injuries should only be done with the provision of adequate analgesia, sedation or methods such as the Bier’s Block. Irrespective of whether a patient undergoes manipulation, a below elbow backslab should be applied as soon as possible to splint the injury and alleviate pain.

Complications

Aside from complications such as non- union and arthritis, patients may develop a. Dorsally angulated fracture of distal the following complications after radius metaphysis sustaining a Colles’ fracture: b. Fracture is 2.5cm proximal to the

radiocarpal joint  Rupture of extensor pollicis longus c. Radial displacement of distal fragment O tendon d. Loss of normal 5 forward tilt of the  joint surface Median nerve compression e. Impaction  Distal radioulnar joint injury leading to weak grip, localised pain and loss of

supination Management of Patient with Colles’  Fracture Sudek’s atrophy – swollen fingers and In addition to providing adequate restriction of finger flexion analgesia and excluding other serious injuries, patients should have an X-Ray Smith’s Fracture wrist AP/Lateral to determine whether or not manipulation is required. This injury occurs around the distal radius and involves volar angulation in contrast The following list summarises the to the dorsal angulation of a Colles’ situations in which manipulation may be fracture. Individuals tend to fall onto the palm behind them. required:

A. Gross displacement Type I and II injuries are extra-articular B. Appreciable deformity to the naked eye whilst Type III injuries (Barton’s fracture), enter the radiocarpal joint and involve

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volar dislocation of carpus with the distal Type III fractures occur when there is radius fragment. complete comminution of the radial head and significant displacement. Patients Such injuries are commonly unstable and with these injuries should be referred it may be difficult to obtain adequate immediately for Orthopaedic review and reduction in an Emergency Department consideration of ORIF or radial head setting. If a patient is likely to be delayed excision / implant. getting to theatre for reduction, a single attempt to correct obvious deformity Shaft of Humerus Fracture could be attempted within the ED, followed by application of a volar slab Patients with fractures to the midshaft of with the wrist in extension. the humerus will sustain the injury by either: Radial Head Fracture  Torsion force (spiral fracture); Fractures of the radial head normally  Bending force (transverse fracture); occur following a fall onto the  Combination of torsion and bending outstretched hand, with the impact of the (oblique fracture with/out butterfly fall driving the head of the radius onto the fragment) capitulum of the humerus. Up to 18% of patients with fractures of Patients may complain of pain and the humeral shaft will have an associated swelling around the elbow and the radial nerve palsy. Most of the time these assessing clinician will find pain on direct injuries are due to neuropraxia, and pressure over the radial head. Elbow X- patients will recover within 3-4months. Rays may be inconclusive for minimally displaced injuries, but more obvious for Wrist extension, dorsal hand sesnation displaced or intra-articular fractures. and assessment of extensor carpi radialis longus/brevis and extensor pollicis longus Management should be used to identify this Type I fractures may be difficult to identify complication. on elbow X-ray but anterior fat pads may be visible anterior to the coronoid fossa. Management Patients can be treated in a broad-arm Patients with these type of injuries will sling and be encouraged to mobilise the need good levels of analgesia and elbow early to avoid stiffness. Non-union application of a hanging cast which will occur in 5% of these types of injury extends from at least 1cm proximal to the and in the event that it becomes fracture site to the wrist. symptomatic, may warrant resection.

Type II injuries involve fractures with less than 30% articular involvement and more than 2mm of displacement. Conservative treatment can be used in the acute setting with follow-up review determining the need for operative intervention. The assessing clinician should assess for

the presence of additional injuries and be

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aware of the indications for operative Via Dislocation of shoulder with greater intervention: tuberosity fracture VIb Dislocation with two-part fracture through

the surgical neck 1. Unacceptable fracture position after Vic Three and four-part injuries where the closed reduction humeral head is completely detached and 2. New onset radial nerve palsy after displaced, or split closed reduction 3. Multi-trauma patients Most injuries can be treated with simple 4. Open fractures analgesia and a collar and cuff sling in the 5. Segmental humerus fractures first instance. Patients with Type III 6. Floating elbow or ipselateral arm injuries or greater should be discussed injuries with the Orthopaedic team to plan future 7. Suspicion of pathological fracture management. This will depend on a variety of factors and should remain Fractures of the Proximal Humerus patient-focussed.

Fractures to the neck of the humerus are Lower Limb Injuries a common injury in elderly patients and are often sustained following a fall onto Shaft of Femur Fractures the affected side. Patients with fractures to the shaft of Injuries can be classified using Neer’s femur can lose between 0.5 – 1.0L blood classification which is based on the into the surrounding tissues. This volume anatomical position of injury and degree may increase in the presence of of displacement / comminution: anticoagulant therapy. With this in mind, if such injuries are suspected in elderly patients, a formal ABCDE approach should be used for the initial assessment followed by appropriate resuscitation.

Underlying bone disease such as osteoporosis or metastatic deposits should be considered and looked for if patients present with relatively low mechanisms of injury.

1 = anatomical neck; 2 = surgical neck; 3 = greater tuberosity; Patients may present with a leg which is 4=lesser tuberosity. Type Description externally rotated, shortened and I All fractures where there is minimal abducted. The gluteus medius and displacement or angulation (1-part) minimus abduct the proximal fragment II All fractures of the anatomical neck through their attachments to the greater displaced by more than 1cm trochanter and the iliopsoas causes III All fractures of the surgical neck with severe displacement or angulation flexion as it inserts onto the lesser IV All displaced fractures of the greater trochanter. tuberosity (2 part or more) V Fractures of the lesser tuberosity (2 part or more)

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Management Patients with X-Rays which demonstrate a AP and lateral X-rays of the femur will displaced horizontal fracture will need confirm the anatomy of injury and skin intervention such as tension-band wiring. traction with the use of a Thomas Splint will provide comfort and restore elements Tibial Plateau Fracture of anatomical alignment prior to any further intervention. This can be applied Fractures to the tibial plateau are often following femoral nerve blockade, fascia sustained following severe valgus stress, iliaca compartment block, or with the use (lateral to medial compression). This is of strong opiate analgesia and/or often due to the weight of the lateral sedation. femoral condyle sliding downwards and laterally from the tibial spine. Complications Patients with these injuries are at risk of The Schatzker classification system can be ongoing haemorrhage if not treated used to classify these types of injury and properly. Other significant complications reflects increasing energy imparted to the include fat embolism which may present bone and an increasingly worse diagnosis. 1-3 days after injury with shortness of breath, hypoxia and a degree of agitation I Wedge-shaped fracture of the lateral tibial or delirium. Patients may develop a plateau with less than 4mm depression / displacement petechial rash and develop II Split and depression of lateral tibial plateau thrombocytopaenia. IIIa Lateral depression of the lateral tibial plateau The most effective measure to prevent fat IIIb Central depression of the lateral tibial embolism is to reduce fractures as soon as plateau possible after injury. Patients should not IV Depression of the medial tibial plateau, without a fracture fragment be left waiting in Emergency Departments V Fractures of lateral and medial tibial plateau for porters to take them to X-ray. Imaging VI Fracture through the metadiaphysis of the should be performed as soon as the tibia diagnosis is suspected in order to facilitate Schatzker Classification of Tibial Plateau Fractures rapid reduction. Patients with these types of injury are Fracture of the Patella likely to need formal CT imaging to assess the depth of depression of the fracture Fractures of the patella may occur fragment. If the articular surface is following a direct fall onto the knee, or depressed by more than 10mm, the from direct trauma (e.g. from the success of conservative management is dashboard in road traffic collisions). unlikely. For this reason, patients should Patients will be unable to extend the knee be discussed with the Orthopaedic team and will be unable to perform adequate to determine the appropriateness of straight leg raise. Additional signs will further imaging and intervention. include point tenderness and crepitus over the patella. Compound Fractures of the Tibia / Fibula Patients with undisplaced fractures or fractures in a vertical orientation may be Open lower limb fractures are often treated conservatively in a cylinder cast. associated with high-energy trauma in

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younger patients, but may follow simple falls in elderly age-groups. If a patient FRACTURE PATTERNS presents to an emergency department with such an injury, the following steps  Transverse or short oblique tibial should be taken: fractures with fibular fractures at a similar level a. Formal primary survey (vertical if lone clinician or horizontal if team-based  Tibial fractures with approach) comminution/butterfly fragments with fibular fractures at a similar level b. Stop external haemorrhage by direct pressure or application of a CAT  Segmental tibial fractures tourniquet (last resort)  Fractures with bone loss, either from c. Provide appropriate analgesia and extrusion at the time of injury or after perform neurovascular examination of debridement the limb SOFT TISSUE INJURY PATTERNS d. Straighten and align the limb (ensuring that adequate analgesia and/or  Skin loss such that direct tension-free sedation is used) closure is not possible following wound excision e. Repeat neurovascular examination  Degloving f. Remove gross contaminants, photograph wound if possible and if  Injury to the muscles which requires the patient provides consent, and excision of devitalised muscle via cover the wound with saline-soaked wound extensions gauze.

 Injury to one or more of the major g. Splint the fracture, repeat arteries of the leg neurovascular examination

The Trauma & Orthopaedic team may h. Give 1.2 g intravenous co-amoxiclav or decide that certain groups of elderly clindamycin 600mg if the patient is patients warrant referral to specialist allergic to penicllin centres with Ortho-Plastic cover

irrespective of whether they meet any of i. Check tetanus status and administer the above criteria. Specialist teams should prophylaxis if required. review such decisions on an individual

basis. j. Obtain full length AP and lateral X-

Rays.

The characteristics of injuries that should prompt referral to a specialist centre are based on the following domains:

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Burns Airway Assessment The supraglottic airway is vulnerable to Elderly patients constitute between 13 oedema and progressive obstruction and 20% of admissions to burns units but caused by heat exposure. Features of have the highest death rate of the overall inhalational injury may not be burn population1. immediately apparent, but patients can deteriorate rapidly so features that may Sensory and cognitive impairment may herald such progression should be sought: prevent patients from recognising imminent dangers. For example, patients  Burns to the face / neck with peripheral neuropathy secondary to  Singeing of the eyebrows and nasal diabetes may not feel the burning process hair if their feet are being kept close to a  Carbon deposits and inflammatory heater. changes in the oropharynx  Carbonaceous sputum Risk Factors  Hoarse voice (new onset)  HbCO >10% with history of being Mortality associated with all burns is involved in a fire. linked to total body surface area (TBSA) affected, percentage of full thickness The presence of these features should 2 burns, and smoke inhalation injury . warrant formal anaesthetic assessment with a low threshold for endotracheal Feature Odd ratio (95% intubation and transfer to a burns unit. confidence interval) New onset stridor in a patient with burns Inhalation Injury 2.58 (2.03-3.29) Full thickness burn size 1.10 (1.09-1.11) should be considered as an immediate Partial-thickness burn 1.06 (1.06-1.07) indication for intubation. size Age 1.05 (1.05-1.06) Stop the Burning Process Independent predictors of mortality All affected clothing should be removed, and if possible, extremities ran under tap For older patients, other predictors of water to promote cooling. Such mortality include: the severity and techniques should be used cautiously and number of comorbid illnesses; pre-existing temperature checked regularly to prevent malnutrition; post-burn complications; the onset of hypothermia. Warm, clean and increasing age. and dry blankets should be used to prevent hypothermia. Initial Assessment History Patients with burns injuries should be All patients presenting with burns injuries assessed using a structured ABCDE should have a thorough history taken, approach with modifications to conduct a especially in the context of flame or thorough assessment for the possibility of inhalational injuries. inhalational injury, and immediate efforts to stop the burning process. Relevant information includes:

 Exposure to a closed space fire;  Duration of the exposure;

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 Mode of extrication from smoke-filled spaces; Superficial Partial Thickness – involves  History of loss of consciousness; upper layer of dermis and the skin is pink  Cause for fire (cigarette; chip-pan); and blistered Burning materials (e.g. sofas, electrical components).

Patients with direct contact or splash injuries should be asked about: duration of exposure; temperature of appliance; whether splashed fluids had been boiled and if so how recently; history of falls and associated injuries and symptoms.

All patients should be asked about past medical history, paying close attention to Superficial Partial Thickness Burn diabetes and peripheral vascular disease. An enquiry should be made into tetanus Deep Dermal – deeper dermal burn with status and dates of last immunisation. fixed staining of the skin and a dry-looking wound

Breathing & Ventilation Having assessed airway, patients should be examined for circumferential chest wall injuries and given high flow oxygen, (initially 100% but lowered in accordance with ABG and risk of type II respiratory failure). Deep Dermal Burn

Blood pressure and heart rate should be Full Thickness – destruction of the assessed and intravenous access obtained epidermis and dermis manifested as a for burns more than 10% of total body dense white, waxy or charred appearance, surface area. Arterial or venous blood gas without sensation. Eschars appear as analysis should be performed to monitor coagulated dead skin which is leathery in HbCO. appearance

Evaluating Burns – Depth & Body Surface Area

Burns should be classified in terms of depth and body surface area affected. The depth of burns can be graded as follows: The percentage of total body surface area Superficial Erythema – erythema, pain and (TBSA) involvement can be calculated the absence of blisters. Should not be using Wallace’s Rule of Nines or Lund and included in measurements for body Browder Charts. surface area

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Wallace’s Rule of Nines hypovolaemic shock, renal impairment Body Region % BSA and organ dysfunction but over- Head and Neck 9% resuscitation can lead to pulmonary Upper Limbs (each) 9% oedema, especially in patients with Torso anterior and posterior 18% impaired cardiac function. (each) Lower Limbs (each) 18% Elderly patients needing fluid Perineum 1% resuscitation are likely to have burns of more than 10% total body surface area, and should therefore be managed in specialised burns units. Early discussion should occur with the regional Burns team for such patients as aggressive, early excision (24-72 hours) of deeply burned tissues and early skin grafting will limit subsequent infections and provide a greater chance of a quicker return to function.

Other criteria for referral to specialist Burns Units include:

a. All full thickness burns b. All circumferential burns c. Any burns to hands, feet, face, genitalia Fluid Resuscitation and perineum. d. Cold Injury (e.g. frostbite) Patients with burns > 10% TBSA will e. Chemical, electrical or friction burns. require fluid resuscitation. The Parkland Formula is commonly used to calculate One study has shown that early excision fluid requirements in a 24 hour period and 24-72 hours after injury and early skin is given below: grafting provides a greater chance of a return to function, fewer complications 3 PARKLAND: and a shorter hospital stay . However, survival has not been shown to improve 4 4mL/kg X TBSA % with patients managed in this way .

½ total volume should be given in the first Prognosis 8hrs from time of burn Remaining volume to be given in the next The Baux score5 (age + %TBSA = 16 hrs %mortality) is often cited in trauma training as a tool for prognostication but Adequacy of fluid resuscitation can be fails to address associated medical factors measured by maintaining a mean arterial and does not correlate well with very old pressure above 60mmHg and ensuring an patients. hourly urine output of 0.5-1.0mL/kg. Under-resuscitation can lead to

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A score developed by Ryan et al6 used three objective clinical criteria to predict  Elderly patients with extremity trauma different rates of mortality (see below): need to have prompt diagnosis and management to prevent injury-specific Clinical Criteria complications. Age > 60 years More than 40% TBSA Inhalation Injury  Patients who have sustained a shaft of No Risk Factors = 0.3% mortality femur fracture should not have the 1 Risk Factor = 3% mortality 2 Risk Factors = 33% mortality reduction of their injury delayed. Plain 3 Risk Factors = 90% mortality film radiography should be prioritised Ryan et al Criteria for predicting survival after burns as urgent to ensure rapid injury management to lessen the likelihood of fat embolism. The problem with the above scoring tool is that a patient could have 100% TBSA burns as the only risk factor and only have  Older patients with burn injuries a 3% risk of death. should be managed as a priority, with clinical teams looking for any evidence The Abbreviated Burn Severity Index7 was of inhalational injury or other features first published in 1982 and uses five that predict early mortality (e.g. full- variables and an adjusted scoring system thickness and partial-thickness burn to predict mortality. This has been shown size). Clinicians should have a low to be more accurate and specific in threshold for early referral to determining outcomes after burn injury. specialist burns units in an attempt to minimise complications. Abbreviated Burn Severity Index Parameter Score TBSA Score References Male 0 1-10% 1 1. Huang SB, Chang WH, Huang CH et al. Female 1 11-20% 2 Management of elderly burn patients. Int J Age 0-20 1 21-30% 3 Gerontol 2008; 2: 91-97. Age 21-40 2 31-40% 4 Age 41-60 3 41-50% 5 2. Suzuki M, Aikawa N, Kobayashi K et al. Age 61-80 4 51-60% 6 Prognostic implications of inhalation injury in Age >80 years 5 61-70% 7 burn patients in Tokyo. Burns 2005; 31: 331-6. Inhalation Injury 1 71-80% 8

Full thickness 1 81-90% 9 3. Kara M, Peters WJ, Douglas LG et al. An burn 91-100% 10 early surgical approach to burns in the elderly. Predicted mortality with ABSI J Trauma 1990; 30: 430-2 ABSI Score Mortality 2-3 <1% 4. Deitch EA. A policy of early excision and 4-5 2% grafting in the elderly burn patients shortens 6-7 10-20% the hospital stay and improves the survival. 8-9 30-50% Burns Incl Therm Inj 1985; 12: 109-14. 10-11 60-80% Abbreviated Burn Severity Index 5. Wibbenmeyer LA, Amelon MJ, Morgan LJ et al. Predicting survival in an elderly burn patient population. Burns 2001; 27: 583-90.

Summary

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6. Ryan CM, Schoenfeld DA, Thorpe WP et al. 7. Tobiasen J, Hiebert JH, Edlich RF. Prediction Objective estimates of the probability of of burn mortality Surg Gynecol Obstet 1982; death from burn injuries. N Engl J Med 1998; 23: 711-4. 338: 362-6.

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PART III: MEDICAL ILLNESS AND CO- MORBIDITIES IN THE INJURED ELDERLY PATIENT.

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Chapter 13: Falls or location of their fall. More details have to be gathered from pre-hospital teams, families, neighbours etc.. in order to paint Falls represent the commonest cause of a clearer picture of events. injury-related mortality in the elderly population. In the space of 12 months, The injuries sustained following a fall may 30% of people over 65 years and 50% of be significant, but they may take second people over 80 years would have had at 1 place to underlying medical conditions least one fall. that precipitated the fall. The assessing clinician must bear this fact in mind and Falls place a dangerous burden on the aim to address both sets of problems at individual. In addition to possible injury, the same time, and manage medical patients may suffer from psychological illness as well as acute injury. distress, loss of independence, loss of mobility and loss of confidence. Falls History

There are many reasons why an individual The First Question may fall and accurate history taking is essential in determining why the fall The very first and most important occurred. HECTOR rejects the term question to ask any patient who has had a “mechanical fall” that is often quoted in fall is: patient records yet does not provide any useful information about why a patient “Do you remember hitting the ground?” fell.

This will give a clearer indication if there The term “mechanical fall” is often are likely to be any neurological or documented in clinical records but means cardiovascular events that caused a nothing. It may refer to the fact that a collapse. Patients who trip or slip are patient has fallen without a precipitating more likely to remember hitting the floor medical cause (e.g. stroke, postural (depending on underlying cognitive state / hypotension). However, it fails to state memory). certain causes for a fall, (e.g. patient tripped over a rug etc..). History of Presenting Complaint

In terms of individual patient assessment, It is important for the assessing clinician one of two scenarios may occur when to ascertain the following: trying to take a history:

 Why did the patient fall? 1. Patient is able to provide a history and  can be assessed in a routine manner. When did the patient fall?  Where did the patient fall? 2. Patient is unable to provide a history so  How did the patient fall? corroborative history and screening investigations are essential. Knowing why a patient fell will involve asking about any underlying illness, Patients with dementia or acute delirium mobility issues and environmental / may not remember the exact cause, time behavioural factors that could have led to the fall. It will involve a formal systemic

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enquiry to gather information about chest Some of these questions include the pain, dizziness, neurological symptoms following: (e.g. slurring of speech, limb weakness), before the fall. Delving into social history  What was the patient doing? will allow the clinician to formulate a  Was the patient carrying anything that picture of the patient’s home could have affected their balance? environment and use of mobility aids etc..  What was the patient wearing for Drug history is also important at this stage footwear? to look for medications that could affect  Were any walking aids being used? If blood pressure (e.g. anti-hypertensives, so, what type? beta-blockers etc..)  What was the ambient lighting like at the time of the fall? Knowing when a patient fell will allow the  What kind of flooring was the patient clinician to gather information such as: standing on? what was the patient doing at the time; how long could they have been lying on Risk Assessment for Falls the floor for; and the length of time between presentation to hospital and any acute medical event (e.g. stroke) The National Institute for Health and Care Excellence (NICE) recommends that a

Knowing where a patient fell will give multi-factorial risk assessment is carried out for any patient presenting to some indication as to what time they fell 1 and what they might have been doing. emergency services following a fall. Patients falling in bedrooms could have An example of such a risk assessment been getting ready for bed, or getting up to get dressed / go to the toilet etc.. would include the following topics:

- Falls History Finally, knowing how a patient fell will - Gait, balance, mobility, muscle weakness allow the clinician to assess the likely - Osteoporosis risk injuries that they could have sustained. - Perceived functional ability and fear of For example, if a patient fell whilst falling twisting their leg, this could lead to a - Visual impairment femoral shaft fracture. Likewise, if a - Cognitive impairment patient fell and banged the back of their - Urinary incontinence head, they could have sustained - Cardiovascular examination intracranial and / or cervical spine injuries. - Medication review

Important Questions to Ask The falls history should also encompass the frequency, context and characteristics If a patient is able to provide a clear and of falls. It is important to know if there are accurate depiction of events, other useful any recurring themes that occur. information will help determine the exact nature of the patient’s fall. By gaining as Whilst considering individual risk factors much detail as possible, one can try and for falls, it is important to note that they ascertain what type of intervention may may not occur in isolation and an be needed to prevent further falls from individual may have a number of happening. modifiable risk factors for falls. The only

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way of managing these preventable into descriptions about what happened causes is by identifying them in the first before, during and after the attack: instance, (see below)2. Before Attack Risk Factor Adjusted OR Position of the patient Sedative use 28.3 Activity of patient Cognitive impairment 5.0 Predisposing features – cold, warm, Disability of lower 3.8 extremities stressors, coughing etc.. Palmomental reflex 3.0 Presence of aura / sweating Abnormalities of 1.9 Palpitations or chest pain balance and gait Headache Foot problems 1.8 During Attack Nature of fall Transient Loss of Consciousness & Skin colour Syncope Length of unconsciousness Snoring Syncope may be defined as: Abnormal movements “..a transient loss of consciousness and Tongue biting loss of postural tone which is of rapid Incontinence of urine / faeces onset and spontaneous with a quick After Attack recovery” Time to full recovery Residual weakness Syncope is different from comatose states Speech disturbance which lead to a more persistent altered Headache loss of consciousness. Pain / Injuries sustained

In general terms, causes for syncope can Taking vasovagal or situational syncope as be divided under the following headings: an example, the individual will normally Reflex Syncope experience an abrupt sense of light- - Vasovagal – fear; distress; pain headedness or flushing in response to a - Situational – cough, sneeze, micturition particular stimulus. This will be followed

- Carotid sinus syncope by a fall and transient loss of - Atypical consciousness with rapid recovery to Orthostatic Syncope normal when in a horizontal position. - Primary autonomic failure – Parkinson’s disease; Lewy body dementia - Secondary autonomic failure – diabetes; Cardiac syncope may be preceded by uraemia; spinal cord injury sudden palpitations, chest pain or be - Volume depletion – haemorrhage; evidenced by a sudden drop attack with dehydration; diuretics no preceding symptoms. Cardiac Syncope - Arrhythmias Epileptiform seizures may be heralded by - Heart block – Mobitz II; complete heart an aura and result in collapse with seizure block activity, tongue biting and/or - Altered QT interval incontinence with a protracted recovery Like falls, syncope warrants a specific form period. of history taking to clarify the possible diagnoses. This history should be divided

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Clinical Scoring Tools for Collapse diagnosing injuries. This should not be overlooked as some medical problems From a medical perspective, clinicians will need immediate attention. often use scoring systems to determine the risk of an adverse event from Alcohol History occurring. For patients suffering from a collapse and transient loss of It is wrong to assume that consumption of consciousness, the following scoring alcohol is confined to younger age groups. systems may be of use: Alcohol use disorders in elderly people are often described as being “hidden” and San Francisco Score3 may not be detected by clinicians. This Increased risk of adverse outcomes if 1 or may be a result of people being: ashamed more of the following are present: of their drinking habits; under-reporting Abnormal ECG or under-estimating their consumption; Congestive heart failure and/or professionals being reluctant to Shortness of breath ask an older person about drinking. Systolic blood pressure < 90mmHg Haematocrit < 30% Alcohol can affect balance, decision- OESIL Score4 making processes and reflexes. This can Increased risk if two or more of the precipitate falls and subsequent injury. It following are present: is important in any assessment to ask Abnormal ECG about alcohol consumption, and habitual Age > 65 years drinking. Lack of prodrome History of cardiovascular disease Alcohol problems may arise in the elderly EGSYS Score5 population for various reasons (see Increased risk with any of the following: below), and it is important to consider Palpitations pre-syncopal episode why someone might be drinking alcohol in Abnormal ECG a non-judgemental manner. Syncope during effort Syncope whilst supine Emotional Medical Practical -Bereavement -Disability -Reduced -Loss of -Chronic pain coping skills NICE guidance also provides the main risk Friends -Insomnia -Altered factors for transient loss of consciousness -Loss of social -Sensory finances which help identify the subsequent need status deficit -Impaired self- for formal medical / cardiology review6. -Loss of -Reduced care occupation mobility -Family conflict -Cognitive 1. ECG abnormality -Reduced self impairment 2. Heart failure esteem -Depression 3. Collapse during exertion 4. New or unexplained Alcohol screening has proven to be breathlessness effective through the use of the Michigan 5. Heart murmur Alcohol Screening Tool – Geriatric Version 6. Lack of prodromal symptoms (MAST-G). This consists of 24 questions In the context of trauma, it is just as about alcohol with 5 “Yes” responses to important to develop a list of differential questions such as “Does having a drink diagnoses for the cause of the fall as it is

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help you sleep”, being indicative of an to an increased risk of rhabodmyolysis. alcohol problem. This may be manifested by a raised creatine kinase on blood tests. Such tools may not be practical to use in the acute setting but may have a role on It is important to ascertain the length of the wards. For the purposes of acute time an individual has been lying on the assessment, all elderly patients who floor, or could potentially have been lying present following a fall should be asked on the floor. If a “long lie” is associated about recent alcohol consumption and to with a raised creatine kinase, intravenous quantify the amount of alcohol drank in a fluid rehydration should commence and seven day period. adjusted according to urine output, (aim minimum of 0.5mls/kg/hr). Approach to the Patient who is Unable to Provide a History Summary

For patients with dementia, delirium, or  Same level falls represent the those with head injury and altered loss of commonest mechanism of injury for consciousness, it may not be possible to elderly patient with injuries ascertain an accurate falls history. In these circumstances, the clinician should use  All clinicians should be mindful of the whatever corroborative information is need to address acute medical available. problems as well as manage any injuries that have been sustained. Pre-Hospital information in terms of how and where the patient was found, what  Accurate history taking is vital to they were wearing and what injuries they ascertain medical conditions, injuries are suspected to have sustained can give and also to clarify an individual’s vital clues to the puzzle. This can be modifiable risk factors for future falls. combined with history from neighbours or Only when all of these features have the next of kin about when they last saw been considered will interventions the patient and if they had noticed designed to promote recovery and anything different. prevent further falls be effective.

Each patient should have a formal primary  Transient loss of consciousness should and secondary survey followed by a prompt the clinician to perform formal searching of available resources to specific investigations and ask specific clarify their past medical history, drugs questions to clarify the cause for history and social history. collapse.

The “Long Lie” References

Following a fall, an elderly patient may 1.National Institute of Health and Care have lost the ability to move due to injury Excellence (NICE). Falls: assessment and and hence remain in the same position prevention of falls in older people. CG161 until help arrives. In such circumstances, June 2013 UK. skeletal muscle necrosis can occur, leading

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2. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1998; 319:1701-1707.

3. Quinn J, McDermott D, Stiell I et al. Prospective validation of the San Francisco Syncope Rule to predict patients with serious adverse outcomes. Ann Emerg Med 2006; 47(5): 448-54.

4.Colivicchi F, Ammirati F, Melina D et al. OESIL (Osservatorio Epidemiologico sulla Sincope nel Lazio) Study Investigators. Development and prospective validation of a risk stratification system for patients with syncope in the emergency department: the OESIL risk score. Eur Heart J 2003; 24(9): 811-891.

5.Del Rosso A, Ungar A, Maggi R et al. Clinical predictors of cardiac syncope at initial evaluation in patients referred urgently to general hospital: the EGSYS score. Heart 2008; 94: 1620-1626

6. National Institute of Health and Care Excellence (NICE) Transient loss of consciousness (“blackouts”) management in adults and young people. CG109. Aug 2010 UK.

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Chapter 14: ECG Interpretation  Is this the right ECG for the patient? Ensure that the patient’s name and and Management hospital number have been clearly

documented on the ECG All elderly patients presenting with traumatic injuries should have a 12-Lead  Is this the relevant ECG for the ECG performed. All clinicians managing patient? Check the date and time patients with traumatic injuries must when the ECG was recorded to ensure possess the relevant skills needed to it is the most relevant one to current interpret these ECGs. This competency practice. forms part of basic clinical training for independent practitioners and is a skill Rate that can be lost due to non-use.

The ECG has thick lines which are 5mm HECTOR appreciates that whilst acquisition apart. This equates to 0.20 seconds. The of such skills occurs in medical school and thin lines are closer together, measure foundation training, maintenance of skills 1mm, and correspond to 0.04 seconds of may vary between specialities. This time. chapter aims to reintroduce the key concepts of ECG interpretation and To calculate rate, the following provide an over-arching structure for calculations can be done: recurrent practice.

a. Count the number of large squares Systematic Approach to the ECG between successive R-waves and divide into 300. Accurate interpretation of ECGs is reliant on a structured method of assessment. b. Count the number of small squares Without such a structure, subtle changes between successive R-waves and divide and abnormal findings may be missed. into 1500 - useful if the heart rate is very HECTOR recommends the following fast. structure for ECG interpretation: c. Count the number of cardiac cycles in 6  Patient Identifiers seconds (30 large squares) and multiply by  Rate ten – useful if the rate is irregular.  Rhythm  Axis Rhythm  PR Interval  QRS Complexes The cardiac rhythm can be classified into  ST Segments and T waves the following broad categories:  QT interval Regular By reviewing each feature in order, the Consistent interval between R-R waves clinician is less likely to miss specific Regularly Irregular features. Generally consistent interval between R-R waves Patient Identifiers May be interrupted by ectopic beats or change during the respiratory cycle

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Irregularly Irregular electrical axis that lies somewhere Inconsistent interval between R-R waves between lead aVL and aVF. In such Absent p-waves denote atrial fibrillation circumstances, one is likely to see positive deflection of the QRS complex in leads I If it is unclear as to whether a rhythm is and aVF. regular or irregular, the position of two or more adjacent R-waves can be marked on Left Axis Deviation a separate piece of paper. This paper and these markings are then moved along the Left axis deviation occurs when the QRS ECG to judge whether the R-R interval is vector falls between -30 and -90 degrees. consistent, (i.e. the spaces between R- This will be represented by a positive waves should match the markings on the deflection in leads I and negative paper throughout the whole ECG). deflections in leads III and aVF.

Cardiac Axis Right Axis Deviation

The cardiac axis is often poorly For right axis deviation, the QRS vector understood and missed during ECG lies between +90 and +180 degrees. The interpretation. It represents the direction ECG will demonstrate a positive QRS of the overall electrical activity of the deflection in leads III and aVF but a heart and can be used to identify negative deflection in lead I. underlying disease. The Importance of Determining Cardiac The axis can be determined by reviewing Axis the limb leads (I, II, III, aVL, aVF, aVR) and NOT the praecordial leads (V1-V6). In When a patient presents following a order to understand this process, one collapse, it is essential to determine must be fully aware of the placement of whether a patient has any underlying ECG leads: condition that could have precipitated the fall. Conditions such as pulmonary embolism, bifascicular and trifascicular heart block may be suspected in the presence of an abnormal axis.

The Normal Axis

The normal cardiac axis lies between -30 and +90 degrees. This corresponds to an

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Normal Cardiac Axis

Leads I and aVF are both positive, inferring that the QRS vector lies between them.

This represents a normal cardiac axis

Left Axis Deviation

Lead I is positive whilst leads aVF and III are negative

This represents left axis deviation

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Right Axis Deviation

Lead I is negative whilst leads III and aVF are positive

This represents right axis deviation

The PR Interval Mobitz Type I (Wenkebach)  PR interval gets bigger and bigger after The PR interval should be between 0.12 – each p-wave, eventually leading to a 0.20 seconds and represents the time dropped QRS complex: between the onset of the p-wave and the start of the QRS complex.

First degree heart block is common and represents a delay in conduction through the atrioventricular junction. It is noted Mobitz Type II when the PR interval is longer than 0.20  Constant PR interval between seconds, (equivalent to five small conducted beats but some of the p- squares). waves are not followed by a QRS complex Second degree heart block occurs when  Patients with this pattern of block are some but not all of the p-waves are at risk of developing complete heart conducted to the ventricles. This can lead block or asystole. to the absence of QRS complexes after some p-waves. There are two types of Third degree or, complete heart block, second degree heart block: exists where there is no relationship between p-waves and QRS complexes. This means that there is no

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synchronisation between atrial and ventricular activity.

The QRS Complex

The QRS complex should be less than 0.12 seconds (= three small squares). If it is wider than this, it should be described as Fascicular Block being broad complex. Broad complexes In left anterior fascicular block, the can occur in relation to ventricular electrical impulse will be conducted by ectopics, ventricular tachycardia and/or in the left posterior fascicle, resulting in a bundle branch block. predominant leftward axis with small R-

waves and deep S-waves in the inferior Bundle Branch Block leads: In the cardiac cycle, electrical activity is transmitted to the right ventricle via the right bundle branch and to the left ventricle by the left anterior and posterior fascicles. Altered conduction down these branches will change the morphology of the QRS complex and could point to the underlying disease process.

Right bundle branch block may be In left posterior fascicular block, the demonstrated by an additional R-wave in impulse is carried by the left anterior the anterior chest leads (V1-V3), due to fascicle and results in a rightward axis slow conduction down the right ventricle. with small Q-waves and tall R-Waves in There will also be a slurred s-wave in the the inferior leads lateral leads (see below):

Left bundle branch block will be The T-Wave and ST-Segments demonstrated by an additional R-wave in the lateral chest leads and a dominant s- The T wave follows the S-wave and may wave in V1. There will also be an absence be normal or be peaked, flattened or of Q-waves in leads V5 and V6 (see inverted during different disease states. below): Peaked T-waves may be indicative of hyperkalaemia or hyperacute ischaemia in the presence of acute chest pain.

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Flattened T-waves may be present with to enquire further about these symptoms hypokalaemia and can be inverted with and risk factors for coronary artery established myocardial infarction. disease.

The ST-segment is usually isoelectric but If ACS is a possible diagnosis, the TIMI can be elevated or depressed in acute scoring system1 can be used to identify myocardial infarction. Drugs such as patients in low and high-risk groups. If digoxin can also cause ST depression to be present, the following features are evident on an ECG. Biphasic ST segments awarded 1 point each: may be indicative of Wellen’s syndrome whereby a critical stenosis has formed in TIMI Score the left main coronary artery. Age 65 years or older? Three or more risk factors for coronary The QT Interval artery disease? Prior coronary stenosis 50% or more? The QT interval is measured from the start ST segment deviation >0.5mm? of the QRS complex to the end of the T- Use of aspirin in last 7 days? wave. In normal circumstances, the QT Two angina events in last 24 hours? interval shortens as the heart rate Elevated serum cardiac markers? increases, so corrections need to be made for this. Having calculated the TIMI score, the risk The QTc (corrected QT interval) can be of all-cause mortality, new or recurrent calculated using the following equation, MI or ischaemia is given below: but is also calculated electronically on most modern ECG machines: Risk Score TIMI Risk 0-1 4.7% QTc = QT / √R-R 2 8.3% 3 13.2% Range 0.39 +/- 0.04 seconds 4 19.9% 5 26.2% A prolonged QTc has many causes and can 6-7 40.9% predispose an individual to torsades de pointes and collapse. A shorted QTc can In addition to the above, the following be seen in digoxin treatment and with ECG findings may be indicative of an acute hypercalcaemia. coronary syndrome:

Management and Diagnosis of 1. ST depression or elevation Patients with Specific ECG Abnormalities & Cardiac Conditions 2. T-wave inversion in chest leads or II, III, aVF

Acute Coronary Syndrome (ACS) 3. New onset left bundle branch block

In the context of trauma and falls / collapse, sudden onset severe chest pain If a patient with injuries has ongoing chest pain and any of the above ECG changes, preceding a fall should lead the examiner urgent cardiology review is indicated.

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Such patients may need immediate analgesia – GTN and/or opiates, high-flow primary coronary intervention. oxygen).

In the absence of such findings but a Atrial Fibrillation (AF) degree of suspicion of ACS, serial high sensitivity troponin I levels taken at 0 and AF is a common arrhythmia occurring in 5- 3 hours can be used to identify this 10% of patients aged 65 years and over. diagnosis. Any elevations above the upper Most patients with AF tolerate their limit of normal or increases or decreases rhythm and are controlled with beta from the initial baseline level should blockers or digoxin and either antiplatelet warrant cardiology review. or anticoagulants to reduced thrombotic risk of stroke, PE etc.. Some patients may have had previous cardiac disease and if any abnormalities Atrial fibrillation in trauma may be due to are identified on ECG, it would be useful the following: to review previous records and compare findings. If it is unclear whether a patient  blunt thoracic injury; with chest pain has new or old left bundle  be pre-existing; 2 branch block, the Sgarbossa criteria have  be a precedent or consequence of the a specificity of 90% for detecting new traumatic event. acute coronary events: Some of the causes of AF are listed below: Sgarbossa Criteria (>/= 3 points = 90% specificity): Cardiac Disease Ischaemic heart disease a. Concordant ST elevation >1mm in leads Mitral valve disease with positive QRS complex (score 5) Hypertension b. Concordant ST depression >1mm in V1- Heart Failure / Cardiomyopathy V3 (score 3) Post cardiac surgery / CABG c. Excessively disconcordant ST elevation Intrathoracic Pathology >5mm in leads with a negative QRS Pneumonia complex (score 2) Malignancy Pulmonary embolus Trauma Metabolic Disturbance Renal impairment Acidosis / dehydration Thyrotoxicosis Drugs (alcohol, sympathomimetics)

Key principles of care rest on how well the atrial fibrillation is tolerated by the patient, and its duration since onset.

If ACS is a possible diagnosis standard If a patient has fast atrial fibrillation, treatment should be given (aspirin 300mg, (defined as a heart rate over 150 beats per minute), and either shock, syncope,

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myocardial ischaemia or heart failure, the UK Resuscitation Council advocates Patients with collapse and Type II Mobitz synchronised dc cardioversion if block are at risk of asystole and treatment has been given for underlying progression to complete heart block. reversible causes. Similarly patients with collapse and bifascicular or trifascicular heart block In the context of trauma, if an individual require monitoring. All such patients has extensive traumatic injuries and / or should have cardiology review to massive blood loss, these factors should determine whether pacemaker insertion be controlled in the first instance before is appropriate. resorting to synchronised dc shock. Bifascicular Block on ECG: On a similar level, if a patient has  Right bundle branch block sustained injuries following a collapse  Right or left axis deviation brought on by an underlying septic condition, fluid resuscitation and Incomplete Trifascicular Block on ECG: management of sepsis may be sufficient  Bifascicular block to control an unstable tachyarrhythmia.  1st or 2nd degree AV block

In the event where reversible factors have Complete Trifascicular Block on ECG: been controlled, management of atrial  Bifascicular Block fibrillation is conducted through either  3rd degree AV block (complete rate or rhythm control, depending on its dissociation) duration since onset. If a patient is known to have atrial fibrillation and is not anti- Patients with bradycardia (resting heart coagulated, cardioversion may result in rate < 60bpm) should have any reversible thrombo-embolic events such as stroke or features treated (e.g. digoxin or beta PE. blocker toxicity). After treating such causes, atropine may be given 500mcg iv Rate control with either beta-blockers up to a maximum of 3mg or external such as bisoprolol (2.5-5mg) or digoxin pacing delivered. (500mcg loading iv or oral), would be the recommended approach. Compromised patients with bradycardia and any of the following on ECG are at risk For patients where the atrial fibrillation of asystole and need immediate has a duration of less than 48 hours the management of the bradycardia: quicker they are cardioverted back to sinus rhythm the more likely they are to a. Recent asystole remain in this state. b. Mobitz II AV block c. Complete heart block and broad QRS Atrio-ventricular Block d. Ventricular pause 3 seconds.

First degree heart block is often well Causes of Prolonged QT Interval and tolerated and does not need immediate Management intervention. Second degree and third degree atrioventricular blocks necessitate A Prolonged QT interval can predispose an formal medical review. individual to torsades de pointes and lead

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to syncope. If identified on an ECG, (QTc > consequence of the traumatic event. 450ms), consideration should be given to treating any electrolyte abnormalities,  Attention to ECG details to diagnose and reviewing a patient’s drug history. acute illness should warrant the same amount of vigilance as the attention It may be sufficient to stop drugs that given to imaging to diagnose cause a prolonged QT interval but other traumatic injuries causes (e.g. hypokalaemia, hypomagnesaemia) need more specific  Underlying causes for arrhythmias and therapy. A single dose of magnesium ECG abnormalities need to be sulphate (8mmol) may be appropriate first understood in order to provide the line treatment for patients with a best possible treatment prolonged QT interval (>500ms) and a history of syncope.  Management of reversible causes and the patient should take precedence before offering specific treatment for Anti-arrhythmics cardiac arrhythmias. Amiodarone, sotalol Anti-psychotics / Anti-depressants References Chlopromazine, amitryptiline Anti-histamines 1.Elliott M, Antman MD, Cohen M et al. The Terfenadine TIMI Risk Score for unstable angina/non ST- Antibiotics elevation MI. JAMA 2000;284(7): 835-842.

Erythromycin and macrolides 2. Sgarbossa EB, Pinski SL, Barbagelata A et al. Electrolyte abnormalities Electrocardiographic diagnosis of evolving Hypokalaemia acute myocardial infarction in the presence of Hypocalcaemia left bundle branch block. N Engl J Med 1996; Hypomagnesaemia 334(8): 481-487 Congenital / Other Romano-Ward syndrome Myocardial infarction Mitral valve prolapsed Causes of QT prolongation

Summary

 Skills in ECG interpretation and assessment of basic concepts of rate, rhythm, axis are essential for the assessment of the elderly trauma patient

 ECG abnormalities may represent long-standing conditions or be acute, as a preceding issue or as a

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Chapter 15 – Management of significant drop. The untrained individual may be falsely reassured by such readings. Illness This stresses the importance of looking for other signs of shock such as cold clammy This Chapter will aim to look at common skin, reduced urine output and raised conditions that may affect individuals as lactate. they get older and assess how such illnesses may influence management in Hypertension is treated in individuals with trauma care. It is important for the high or very high cardiovascular disease assessing clinician to have a broad risk. In elderly patients, the thresholds for understanding of such illnesses and know therapy are lowered so that a systolic the common treatment regimes. blood pressure of >160mmHg in those over 80 years and systolic of >140mmHg Cardiovascular Disease between 60 and 79 years may warrant treatment. Such standards mean that Hypertension elderly patients are more likely to take antihypertensive medication. Hypertension is defined as: Common drugs that are used to manage “...a systolic blood pressure of >140mmHg hypertension include: and diastolic pressure of 90mmHg or more”  Diuretics (bendroflumethiazide, furosemide); Alternatively, it can relate to people  Beta-blockers (bisoprolol, atenolol); taking anti-hypertensive medication but  Calcium antagonists (amlodipine, with normal blood pressure due to their nifedipine); treatment.  ACE-inhibitors (ramipril, enalapril);  Angiotensin receptor blockers Hypertension is a major risk factor for (candesartan, losartan). stroke, myocardial infarction, vascular disease and chronic kidney disease. In They can all be used in isolation or in most developed countries, over 50% of combination. people aged 60 years and over will have hypertension. Diuretics Diuretics promote dieresis and micturition In the context of trauma, hypertension which may predispose an individual to may predispose an individual to a higher volume depletion, hypokalaemia and an blood pressure reading than expected in increased risk of falls from postural comparison to a younger individual with hypotension. features of Class III/IV shock. Beta-Blockers Knowledge of a patient’s baseline blood Beta-blockers may inhibit the tachycardic pressure is crucial – if an individual has a response to volume loss and reduced resting systolic blood pressure of preload, thus masking such signs in the 170mmHg but attends after high energy face of major haemorrhage. trauma with a blood pressure of 120mmHg, this could represent a

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Calcium Channel Blockers Elderly patients taking diltiazem or HECTOR advocates that any patient over verapamil may have a greater level of the age of 65 years with a history of fall / heart rate suppression than younger collapse leading to traumatic injury, and individuals on the same medicines. who presented with chest pain prior to the fall or who has ECG changes ACE-Inhibitors suggestive of ischaemia, should have ACE-Inhibitors are used in individuals for blood tests taken for high sensitivity control of hypertension following troponin. myocardial infarction. They have fewer renal and cardiovascular complications The initial blood test should be repeated than other antihypertensive agents. after 3 or 6 hours depending on the local troponin assay, and cardiology review be In general, the assessing clinician needs to sought immediately if a patient has a be mindful of the effects of raised level or who has features of ST- antihypertensive medications on an elevation MI (see below): individual’s response to trauma (e.g volume depletion, blunting of sympathetic i. ST elevation of >2mm in two consecutive chest response), but they should also be leads ii. ST elevation of >1mm in two consecutive limb mindful of not relying on “seemingly leads normal” physiological parameters to iii. New onset Left bundle branch block exclude major haemorrhage. iv. Posterior MI – ST depression V1-V3 v. ST elevation >1mm in avR with depression in Ischaemic Heart Disease & Myocardial eight or more surface leads may hint at multivessel disease or left mainstem lesions Infarction

Patients with features suggestive of an Coronary heart disease is the leading cause of death in the UK and results from acute STEMI should have primary coronary intervention within 90 minutes. a build up of fatty atheroma in the There is no place for chemical fibrinolysis coronary vessels, leading to gradual stenosis and predisposing an individual to in trauma due to the risk of bleeding from associated injuries. thrombo-embolic events (myocardial infarction). Acute events could lead to an The lead clinician should be able to make individual collapsing or falling over, whereby any resulting injury may shift a a judgement about whether the clinician’s focus away from the actual treatment of a patient’s injuries or the STEMI should take priority, and discuss cause for the fall/collapse. this accordingly with a cardiology specialist. All patients with a fall or collapse should have a 12-lead ECG recorded to assess for Arrhythmias the presence of ischaemic changes.

Patients may have an associated history of central chest pain, nausea or sudden Patients presenting following a fall or collapse should always have an ECG onset breathlessness, or they may have no history of chest pain, especially if they performed. If an arrhythmia is identified, it is important for the clinician to establish are diabetic or have had previous bypass surgery. two things:

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a. Is this arrhythmia new or old? known as Bricanyl), and a combination of b. Is the patient stable or not? maintenance therapy depending on their FEV1: If the arrhythmia is old and the patient was known to suffer from this before the If FEV1 >/= 50% Predicted: traumatic event, the examiner should Long acting beta agonist (salmeterol, enquire about drug history and any known as Serevent) or long acting medications that may have been used to muscarinic antagonist (ipratropium control the arrhythmia. bromide known as Atrovent, tiotropium known as Spiriva) If the arrhythmia is new-onset, the examiner should ask whether or not it If FEV1 <50% Predicted: may have led to a collapse that caused the Long acting beta agonist combined with injury, or whether it may have been a an inhaled corticosteroid or a long acting consequence of the injury itself. muscarinic antagonist

In order to answer these questions, the Patients may also be using inhaled examiner should review the patient’s past corticosteroid therapy (e.g. fluticasone medical history and perform a full known as Flixotide, beclomethasone examination to look for any potential known as Clenil, or budesonide known as causes of sepsis that may lead to Pulmicort). arrhythmias such as AF. A baseline venous blood gas should be performed to look for The table below outlines the inhalers that any hypo or hyperkalaemia that can be are in common use in the UK and how treated urgently. they can be identified.

Respiratory Disease Short acting beta agonist Salbutamol Ventolin Blue colour Chronic Obstructive Pulmonary Disease / Terbutaline Bricanyl White & Blue Asthma Long acting beta agonist Salmeterol Serevent Green colour Muscarinic antagonist A diagnosis of COPD is considered when a Ipratropium Atrovent patient over 35 years of age with a risk Tiotropium Spiriva factor (e.g. smoking) develops: Inhaled corticosteroid Beclomethasone Clenil Brown / red  exertional breathlessness, Fluticasone Flixotide Yellow/orange  chronic cough, Budesonide Pulmicort  regular sputum production Combination steroid & beta agonist  frequent wheeze. Salmeterol & Seretide Purple Fluticasone Airflow obstruction is then confirmed by performing post bronchodilator Formoterol & Symbicort Budesonide spirometry.

If a patient with COPD presents to the Most patients with COPD will be using Emergency Department following a short acting bronchodilators (e.g. traumatic injury, the assessing clinician salbutamol known as Ventolin; terbutaline

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should try and establish whether or not injuries such as the following will limit its they need immediate therapy for their use: respiratory condition.  Intracranial bleeds; Acute breathlessness and wheeze on  Significant facial trauma; clinical examination should lead the  Untreated pneumothoraces clinician to prescribe inhaled or nebulised salbutamol in conjunction with oral or Discussion should be had with critical care parenteral corticosteroids. teams as early as possible about the need for intubation and mechanical ventilation All patients should have an arterial blood and whether or not this is a pragmatic gas, ECG and Chest X-ray performed and approach. Studies have shown that oxygen therapy should be administered patients with COPD who require and prescribed to target specific oxygen mechanical ventilation have a mortality saturations. rate above 50%.

If a patient is known to be vulnerable to HECTOR believes that rush decisions to CO2 retention, saturations should be intubate patients with significant injuries targeted at 88-92%, otherwise, they can may not be in the patient’s best interests be targeted above 94%. if they have significant co-morbidity and a reduced quality of life. All attempts should Patients with a hypercapnic respiratory be made to see if a patient’s normal failure (high PaCO2 >6kPa), in the respiratory physician or GP has had a presence of acidosis pH <7.35 should be discussion with the patient about the use considered for NIV therapy if this picture of mechanical ventilation for their COPD. persists after one hour of standard Patients may have advanced directives or medical therapy. do not resuscitate orders contained within their records. Some patients use NIV at home or only require its use during extreme acute Diffuse parenchymal lung disease exacerbations. The following table lists contra-indications to its use: Elderly patients may suffer from lung disease other than COPD as a result of Contra-Indications to NIV wider systemic illness. The term “diffuse  Facial burns / trauma / recent facial or upper parenchymal lung disease” incorporates airway surgery  Vomiting granulomatous disease (e.g. sarcoidosis),  Fixed upper airway obstruction disease of known cause (e.g. drug-related,  Undrained pneumothorax collagen vascular disease-associated), and  Upper gastrointestinal surgery idiopathic interstitial pneumonias (IIPs).  Inability to protect the airway  Copious respiratory secretions Idiopathic pulmonary fibrosis is a form of  Haemodynamically unstable patient IIP that has an unknown cause or  Confusion / agitation  Bowel obstruction association and is characterised by slowly  Patient declines therapy progressive breathlessness, crackles on In the context of trauma, if a patient with chest auscultation in individuals aged >50 COPD develops Type 2 respiratory failure years. The long term survival is poor with and has an indication for NIV therapy, 20-30% of patients surviving 5 years after

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the time of diagnosis. of 27.8% and should be considered for high dependency care. Other forms of IIP have different prognoses, but most are characterised by Diabetes progressive scarring of lung tissue. Most patients will develop progressive Hypoglycaemia respiratory failure and the presence of these diseases should also prompt a All elderly patients with a history of discussion about pragmatic limits of diabetes should have a blood glucose therapy for patients with significant evaluated as soon as possible after arrival. traumatic injuries. Symptoms of hypoglycaemia such as drowsiness, agitation, seizures and Idiopathic pulmonary fibrosis has a 5-year reduced GCS can mimic the symptoms of prognosis which is slightly better than significant head injury. A blood glucose gastric carcinoma but worse than level should be checked in all patients as leukaemia or ovarian carcinoma. It is soon as possible after arrival to hospital. important for the assessing clinician to be mindful of such conditions when it comes Elderly patients are more vulnerable to to decision making in the same way that hypoglycaemic attacks, and when these underlying malignancy may affect occur, are at increased risk of falls leading treatment decisions. to traumatic injuries. Patients with diabetes who have suffered a long lie may Lower Respiratory Tract Infection / be particularly vulnerable to Pneumonia hypoglycaemia and extreme vigilance should be taken with this patient group. Elderly patients are vulnerable to community acquired pneumonia and Diabetes UK recommends a practical underlying infections may affect balance, policy of “make four the floor”, whereby mobility and predispose an individual to any blood glucose level less than falls and subsequent trauma. 4.0mmol/L warrants treatment.

The presence of consolidation on an X-Ray If possible, a patient should be given 15- or fever with associated breathlessness 20g quick acting carbohydrate (e.g. 90- and/or a productive cough should warrant 120ml lucozade, or 3-4 heaped teaspoons a course of antibiotics in accordance with of sugar in water), to treat hypoglycaemia. 1 local policy. The CURB-65 rule is of use in Capillary blood glucose can then be determining an individual’s risk: repeated 10-15 minutes later and further CURB-65 carbohydrate given if the glucose level Confusion of new onset remains below 4mmol/L. Urea > 7mmol/L Respiratory Rate >30 breaths/min Patients with traumatic injuries may be Blood Pressure (systolic <90mmHg; diastolic immobilised, unable to swallow or are <60mmHg) Age 65 or older being treated under a “nil by mouth” Score 1 for each point (maximum 5) policy. A quick acting carbohydrate might The risk of death at 30 days increases as be impractical to administer to treat the score increases. Patients with a score hypoglycaemia. In such circumstances, of 4 or more have a 30-day mortality rate 1mg glucagon im or 10% Dextrose iv

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(100ml/hr) may be given. 3. Ensure that the rate of fall of plasma sodium does not exceed 10mmol/L in 24 Patients may also present with hours (due to risk of central pontine hypoglycaemia following Addisonian myolysis) crises. If this is suspected, intravenous hydrocortisone should be administered in 4. Low dose intravenous insulin (0.05 addition to controlling the blood glucose. units/kg/hr) should only be commenced once the blood glucose fails to fall with iv Hyperosmolar Hyperglycaemia State fluids alone, or if there is significant (HHS) ketonaemia.

A precise definition of HHS does not exist The clinical team should aim to consult a but its characteristic features are: specialist with expertise in diabetes for ongoing management. If a patient has significant haemorrhage from underlying a. Hypovolaemia injury, the large volumes of fluid needed to correct HHS may interfere with b. Hyperglycaemia (>30mmol/L) without coagulation. In these instances, definitive significant ketonaemia (<3mmol/L) or control of bleeding should take - acidosis (pH >7.3, HCO3 >15mmol/L). precedence over additional disease states. c. Osmolality 320 mosmol/kg or more Diabetic Ketoacidosis

Diabetic ketoacidosis is a complex HHS may affect elderly patients with type disordered metabolic state characterised 2 diabetes and develops over many days. by hyperglycaemia, acidosis and The principles of treatment are to: ketonaemia. It is more likely to affect patients with Type 1 diabetes mellitus, but  Normalise serum osmolality; increasingly there are cases of ketone-  Replace fluid and electrolyte losses; prone type 2 diabetes being recognised.  Normalise blood glucose. A diagnosis of DKA is made when the A diagnosis should be suspected for any following occurs: elderly patient with diabetes who presents with evidence of hypovolaemia Diabetic Ketoacidosis and hyperglycaemia without acidosis or significantly raised ketones. 1. Ketonaemia >3mmol/L or ketonuria (>2+ on standard urine sticks) Once diagnosed, the principles of therapy are to take the following actions: 2. Blood glucose > 11.0mmol/L or known diabetes mellitus 1. Measure or calculate osmolality to measure the response to treatment: 3. Bicarbonate <15.0mmol/L and/or (2Na+ + Glucose + Urea) venous pH <7.3 2. Use intravenous 0.9% sodium chloride solution to reverse dehydration In the first instance, patients require IV 0.9% sodium chloride solution to be

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started followed by fixed rate insulin patient remains adequately hydrated. infusion therapy adjusted for weight (0.1unit/kg/hr). Once this has been started, hourly blood glucose and hourly Neurological Disease ketone measurement should suffice but this should be adjusted according to the Cerebro-vascular Accident (CVA) individual. More often than not, patients who have In the context of trauma, the suffered a stroke may be alerted to management of DKA can occur alongside hospitals with the prime emphasis being the management of traumatic injuries. placed on their neurological state. In such Expert advice should be sought for any circumstances, pre-hospital teams may elderly patient with features of DKA and not consider additional injuries that a significant traumatic injuries. patient may have sustained if the event had caused them to collapse. Renal disease and Haemodialysis Pre-Hospital teams in the United Kingdom Patients with end-stage renal disease will use the “FAST” mnemonic to assess have a complication and mortality rate for the risk of stroke (see below): approximately three times greater than those in the general trauma population. F Face – face dropped to one side Patients on dialysis who suffer significant A Arms – unable to lift arms traumatic injuries should be cared for in S Speech – slurring of speech centres with dialysis capability. T Time – time to access help

Outcomes are generally worse in elderly Such a mnemonic is useful if a patient has patients with traumatic injuries who have suffered a stroke and might be a end-stage renal disease and a patient- candidate for thrombolysis. centred, pragmatic approach should be taken for any definitive care being The following list contains examples of considered for this patient group. when thrombolysis might be considered for individuals following ischaemic stroke: Elderly patients with pre-existing renal disease are particularly vulnerable to the 1. No upper age limit if presenting within nephrotoxic contrast agents used in CT 3 hours of symptom onset scanning. If a contrast-enhanced CT scan is deemed necessary for such patients, the 2. Patients aged 18-80 years can be clinician responsible for overall patient treated up to 4.5 hours after symptom care should make an assessment on the onset risk-benefits of the scan. 3. Patients on warfarin can be lysed if INR A discussion should be had with the is 1.7 or less radiologist to determine if the relevant answers to clinical questions can be Patients who have been alerted by pre- obtained without the use of contrast, and hospital teams as being “FAST Positive” if not, then steps should be taken after should be assessed for the possibility of CT-image acquisition to ensure that the associated fall and/or collapse. If this is

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not present, then the patient can be sepsis. Elderly patients are particularly treated as per standard practice. vulnerable to infection and the physiological response to trauma can be If a patient is found to have an acute similar to that seen with infection. thrombo-embolic stroke on CT scan but they have additional injuries (e.g. a The two can co-exist and any elderly femoral shaft fracture), thrombolysis patient with traumatic injuries and should not be given and specialist advice underlying fever or hypothermia should sought about most appropriate therapy. be considered as being at risk.

Transient Ischaemic Attacks (TIA) If infection is suspected, a screening tool should be used to clarify the need for Patients with injuries may present antimicrobial therapy. The “Survive following a fall associated with a TIA. Sepsis” campaign has generated a These episodes occur when a person screening tool that ensures early suffers a transient episode of neurologic recognition of sepsis and appropriate dysfunction caused by ischaemia but therapy. without associated infarction. Any two of the following present? Patients suffering from these events may Temperature < 36 or >38oC still be at risk of stroke after admission Heart rate > 90 bpm WCC >12 or <4 x 109/L and the admitting team may focus on an Respiratory rate > 20/min injury as opposed to the TIA itself. As a Acutely altered mental state simple rule, any patient suspected of Hyperglycaemia without diabetes having had a TIA should be risk-assessed using the ABCD2 algorithm (see below)2. If yes, patient has SSI Does patient have history or signs suggestive of infection? Patients with a score of 4 or more have a Cough / sputum / chest pain 4-8% risk of stroke within 2 days. These Abdo pain / distension / diarrhoea patients should all be seen by a specialist Line infection team as soon as possible after admission. Endocarditis Dysuria Headache and neck stiffness ABCD2 Algorithm Cellulitis / septic arthritis Feature Score Age (>60 years) 1 If yes, patient has Sepsis Blood Pressure >140/90mmHg 1 Any signs of organ dysfunction Clinical Features SBP < 90mmHg pr MAP < 65mmHg Unilateral weakness 2 Urine output < 0.5ml/kg/hr for 2 hrs INR > 1.5 Speech disturbance (no weakness) 1 Lactate > 2 Duration New need for oxygen to keep SpO2 >90% >60 mins 2 Platelets < 100 10-59 mins 1 Creatinine > 177 mmol/L Diabetes 1 If yes, patient has Severe Sepsis Infection & Sepsis General Principles On diagnosis of sepsis, the patient should receive the following: Any patient of any age can present with

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 High-flow oxygen; 1. Lim WS, van der Eerden MM et al. Defining  Intravenous antibiotic therapy in community acquired pneumonia severity on accordance with local policy; presentation to hospital: an international derivation and validation study. Thorax 2003;  Fluid therapy (0.9% sodium chloride or 58: 377-382. Hartmann’s solution 20ml/kg- 60ml/kg). 2. Galvin R, Geraghty C, Motterlini N et al. Prognostic balue of the ABCD2 clinical Summary prediction rule: a systematic review and meta-analysis. Fam Pract 2011; 28(4): 366-76.  Elderly patients may suffer from multiple complex co-morbidities that can affect either be affected or contribute to the acute traumatic event

 All clinicians responsible for the management of these patients should have a general understanding of common acute conditions and how these should be treated.

 Optimising an individual’s illnesses, and/or exacerbation of them, may be required to optimise their overall condition following acute traumatic insults.

 Multidisciplinary input may be required for patients with specialised conditions such as COPD or those with end-stage renal failure on dialysis

 A pragmatic approach should be taken for each individual patient in light of their underlying co-morbidities, quality of life, and expected outcome from their injuries. Definitive care may not be in the patient’s best interests for some injuries and in such circumstances, early discussion should be had with the family and their relatives about agreeing the ceilings of care.

References

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Chapter 16: Pharmacological its site of administration into the plasma. The commonest route of administration in Considerations trauma is through intravenous or intraosseous access. Both routes can Poly-pharmacy is common in the elderly deliver a very high concentration of drug population. With advancing age comes a that travels to the right heart, lungs and higher risk of illness and a higher need for systemic circulation. medicines to prevent worsening of established conditions. The more Distribution medicines a patient takes, the greater the chance of drugs interacting with each The major compartments in which drugs other and the greater the effect on an are distributed are: individual’s physiology.  Plasma (5% body weight) Drugs can affect the elderly patient but  Interstitial fluid (16% body weight) the elderly patient can also affect how the  Intracellular fluid (35% body weight) drugs work. Drug metabolism and renal  Transcellular fluid (2% body weight) function are less efficient with advancing  Fat (20% body weight but varies) age, thus resulting in drugs having a greater and more prolonged effect in the Within each compartment, drug elderly age group. molecules exist in both free solution and bound form and rest in equilibrium across This Chapter aims to cover the concepts compartments depending on: of pharmacokinetics in an attempt to provide a greater appreciation of how i. Permeability across tissue barriers drugs that may be given in the acute ii. Binding within compartments trauma setting can affect patients. iii. pH partition iv. Fat:Water partition Pharmacokinetics Drugs that are protein-bound stay mainly Pharmacokinetics relates to what the in the plasma, as do lipid-insoluble drugs human body does to a drug, whereas (which can also enter interstitial fluid). pharmacodynamics is concerned with Lipid soluble drugs can reach all what the drug does to the body. compartments and can accumulate in fat, (e.g. thiopentone, phenytoin, ethanol, The stages of pharmacokinetics are as diazepam) follows: Accumulation of drugs in fatty tissue can A. Absorption from the site of prolong drug action as the tissues release administration the drug as the plasma concentration B. Distribution within the body decreases. Body composition changes C. Metabolic alteration with age with fat contributing a greater D. Excretion proportion to body mass in the elderly. Such groups may therefore experience Absorption prolonged effects with drugs such as benzodiazepines or alcohol. Absorption is the passage of a drug from

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Metabolism effect on the individual in higher doses.

Modification of drug molecules usually Frailty and Drug Metabolism diminishes their pharmacological activity and typically occurs via a two stage A wide variation of health / illness exists in process. Phase I reactions consist of the elderly population with different oxidation, hydrolysis or reduction with the levels of disease and function affecting resulting product sometimes being more older people. There is a large difference toxic or reactive than the parent drug. between a “fit” elderly patient and a “frail” elderly patient. Phase II reactions involve conjugation and often result in a compound that is inactive Many studies refer to frailty in terms of and has less lipid solubility so is more function rather than disease: likely to remain in the plasma and be cleared by the kidneys. “Persons over 65 years who are not independently mobile and are dependent These Phase I and Phase II reactions on others for activities of daily living” mainly take place in the liver by microsomal enzymes. The activity of these Studies have demonstrated a decline in enzymes declines slowly with age, thus the metabolic activity of plasma aspirin slowing the metabolism of many drugs. In esterase with frailty. Esterases are Phase I addition to reduced enzymatic activity, enzymes which are located in the liver, blood flow to the liver and the number of plasma and brain. Other studies have hepatic cells is in decline, thus making the shown that plasma aspirin esterase levels liver less efficient at metabolising are reduced in patients with neck of medications. femur fractures.

Excretion Trauma in itself, combined with frailty may thus impair the metabolism of drugs The main routes from which drugs are like aspirin, thus potentiating its effects removed from the body are the kidneys, and leading to a greater antiplatelet the hepato-biliary system and the lungs. effect. In the context of trauma and traumatic coagulopathy, this may increase Most drugs can cross the renal glomerulus an individual’s risk of bleeding. freely, although large molecules such as heparin, or those highly bound to plasma Specific Pharmacological protein (e.g. warfarin), can not pass. Many Considerations in Acute Trauma drugs are actively secreted into the renal tubule and are thus excreted rapidly. Management

Several important drugs are removed Morphine & Opioids predominantly by renal excretion and elderly patients with reduced renal The pure opioid agonists (morphine, function may be particularly vulnerable to codeine, pethidine etc..) act on different their side effects. Furosemide, atenolol receptors, (μ-, δ-, κ-, σ-), with most having and digoxin are cleared in this way and if high affinity for μ-receptors. They provide not used carefully, can have a profound analgesia, euphoria – although the latter

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is less pronounced in patients with becomes sluggish. chronic pain. Non-Steroidal Anti-Inflammatory Drugs Unwanted effects of morphine include: NSAIDs include a variety of different  Respiratory depression; agents from different chemical groups.  Depression of the cough reflex; Most have three specific types of effect:  Nausea and vomiting;  Reduced gastrointestinal motility &  Analgesia constipation;  Anti-inflammatory  Urinary retention.  Antipyretic

Extreme care should be exercised when Most NSAIDs act by inhibiting arachidonic administering opioids to elderly patients acid cyclo-oxygenase and reduced who are opioid-naive or who have prostanoid synthesis. Nearly 25% of all reduced renal function. HECTOR reported adverse drug reactions in the UK recommends slow injection of morphine are due to NSAIDs, with agents causing (1mg/min) and monitoring the response side effects in the gastro-intestinal tract, to avoid high plasma concentrations that liver, kidney and spleen. can lead to greater risk of side effects. If used for elderly patients with acute Any development of reduced respiratory traumatic injuries, NSAIDs can cause rate, low blood pressure, reduced GCS or dyspepsia, and lead to an increased risk of development of pinpoint pupils following GI bleeding. NSAIDs inhibit the synthesis opioid administration should warrant of prostaglandins that normally reduce consideration of reversal. This can be gastric acid secretion, and modulate achieved by giving intravenous doses of gastric mucosa blood flow. Proton pump naloxone (400mcg), until a response is inhibitors (omeprazole, lansoprazole), are seen. good agents to limit these unwanted effects by reducing gastric acid secretion. Elderly patients with a reduced cough reflex who have pre-existing lung disease, NSAIDs reduce prostacyclin production who are bed bound, or who are lying thereby depressing renal and aldosterone supine due to spinal trauma, may be more secretion, which may cause the following prone to developing basal atelectasis and to occur: subsequent lower respiratory tract infection. Opioids should be avoided a. Acute ischaemic renal failure where possible in these patients and b. Sodium retention replaced with alternative analgesics. c. Water retention d. Hyperkalaemia Patients given high doses of opioids or regular prescriptions of drugs like Patients on long-term NSAIDs who are codeine, may become constipated and be admitted to hospital following an acute at greater risk of delirium. If opioids are traumatic event should have their renal prescribed, patients should be asked on a function monitored on a regular basis to daily basis about bowel opening and detect any acute deterioration in function. laxatives prescribed if bowel habit

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Benzodiazepines than reverse the benzodiazepine. These patients may be at an increased risk of Benzodiazepines may be used for delirium once the drug effects have worn procedural sedation (midazolam), or off so should be monitored closely in high taken by patients with acute anxiety or visibility areas. agitation (oral lorazepam, diazepam). They are lipophillic compounds and are β-Blockers distributed throughout all body components. Benzodiazepines cause These drugs are commonly used in elderly reduced anxiety and aggression; sedation; patients and their main unwanted effects muscle relaxation; and suppression of are a consequence of their action on β1 convulsions. and β2 receptors. They can cause effects such as: With advancing age and a higher proportion of body fat to muscle mass,  Unwanted bronchoconstriction; benzodiazepines may be stored in fatty  Physical fatigue leaving an individual tissue and slowly released as plasma prone to falls; levels fall. This may prolong the effects of  Concealing the sympathetic warning these agents and lead to increased levels signs of hypoglycaemia. of sedation. Careful attention should be paid to the Benzodiazepines should be used with elderly patient who presents following a extreme caution in the elderly population fall and has a history of diabetes and is and if given intravenously, should be given taking medications such as atenolol or very slowly, administering subsequent bisoprolol. All these patients need close boluses to reach the desired effect. It may monitoring of blood glucose to detect be advisable to wait a few minutes falling levels. between successive 1mg boluses of midazolam for fear of causing unwanted By blocking the β1 receptor, these drugs toxic effects. lead to a reduced resting heart rate. In the context of trauma and major Flumazenil is a reversal agent which is haemorrhage, elderly patients on β- available but HECTOR recommends that blockers may not exhibit the associated this should not be given unless in a life- tachycardia that accompanies fluid loss, saving situation. Flumazenil lowers the thus rendering vital signs on unreliable seizure threshold and may predispose an indicator of shock. individual to convulsions – furthermore, its action only lasts two hours so Elderly patients who take beta-blocker drowsiness can return in acute medication warrant close observation and benzodiazepine overdose. careful assessment for the possibility of occult injury. In such patients, a raised In excessive benzodiazepine-induced lactate (>2.5) or base deficit may be one sedation, supportive cardio-respiratory of the only indicators of haemorrhage in measures should be initiated prior to the trauma so close attention should be paid administration of flumazenil. It may be to these patients with high mechanisms of preferable to manage patients injury and a low threshold be taken for conservatively or with ventilator support Whole Body CT.

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Warfarin and Novel Anticoagulants Unwanted effects of steroids include Warfarin and other anticoagulants have thinning of the skin, leaving it vulnerable been covered in Chapter 3. Any patient to injury and poor healing. If a patient has with a history of trauma on these been taking steroids and has them medications is at high risk of bleeding, suddenly withdrawn, this can result in especially if clotting profiles are deranged. adrenal insufficiency. Patients on long- Low-energy mechanisms such as fall from term steroids should continue these standing can have a profound effect on where possible following acute traumatic internal organs and a low threshold injury. should be taken for CT-image acquisition. Long-term steroid use can also predispose Patients are particularly at risk of an individual to osteoporosis and muscle intracranial haemorrhage, splenic injury, weakness/wasting, rendering them at retroperitoneal bleeding and increased risk of fragility fractures haemorrhage from fracture sites. Any following simple falls. patient with a raised INR / clotting and any of these injuries should have their Specific Illnesses and Important clotting reversed as soon as possible Drug Considerations whilst definitive treatment is being coordinated. Parkinson’s Disease

Steroids Missing doses of Parkinson’s medication can cause serious complications, such as Elderly patients may be taking mineralo- the neuroleptic-like malignant syndrome. or gluco-corticoids (fludrocortisone, Any patient who presents with an acute prednisolone) as part of their regular traumatic injury and takes regular medications. These drugs are commonly Parkinson’s medications should have prescribed for anti-inflammatory or these delivered at the same dose and at immunosuppressive purposes (see the same time where possible. below), and may suppress the body’s response to illness or injury. Neuroleptic malignant syndrome is characterised by altered consciousness, Anti-Inflammatory / Immunosuppression fever, autonomic instability, elevated Asthma or COPD creatine kinase and extrapyramidal signs. Hypersensitivity states Autoimmune and inflammatory diseases (e.g. Withdrawal of levodopa therapy can rheumatoid arthritis; inflammatory bowel precipitate this syndrome. It is thought to disease etc..) occur by central D2 receptor blockade or Post organ transplantation dopamine depletion. In addition to Replacement Therapy withdrawal of levodopa, the For patients with adrenal insufficiency or administration of drugs like: haloperidol; failure prochlorperazine; and metoclopramide Neoplastic Disease can precipitate this syndrome by blockade To reduce cerebral oedema in patients with of dopamine / serotonin pathways. metastatic or primary brain tumours In combination with cytotoxic agents for ALL / If patients are unable to take their anti- Hodgkin’s disease Parkinsonian medication orally, levodopa

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can be administered via NG feeding as it is Polypharmacy is the use of multiple absorbed by the jejunum. Co-beneldopa medications by a patient, and normally (madopar) is available in dispersible form consists of a patient taking four or more and can be used as an alternative to co- different medicines. Polypharmacy can be careldopa +/- entacapone where oral appropriate for some patients and feeding is not possible. For patients taking inappropriate for others, leaving them at oral dopamine agonists (e.g. ropinirole, risk of falls and subsequent injury. pramipexole), rotigotine patches are available and if needed, advice should be It may be a result of ill-considered sought from a specialist before prescribing or multiple prescribers for the administration. same patient working independently of each other. The more drugs a person Addison’s Disease takes, the greater the risk of interactions and unwanted side effects. Trauma may precipitate an Addisonian crisis in patients with an underlying The agents most commonly associated adrenocortical insufficiency. The trauma with adverse reactions include itself can lead to adrenal failure and/or cardiovascular agents, antibiotics, adrenal haemorrhage. Patients may diuretics, anticoagulants and present with any of the following features hypoglycaemics amongst others. below as a cause of the trauma or a consequence of it, (e.g. a patient collapses Elderly patients should ideally have their with postural hypotension and sustains a medications reviewed by a pharmacist or cervical spine injury). elderly care physician soon after hospital admission. Different strategies exist for 1. Hypotension and CVS collapse managing polypharmacy such as the 2. Postural Hypotension Beer’s Criteria and STOPP/START criteria1. 3. Nausea and vomiting 4. Hyponatraemia Beer’s Criteria for Potentially 5. Diarrhoea Inappropriate Medication Use in Older 6. Confusion Adults 7. Hyperkalaemia 8. Hypoglycaemia The Beers Criteria from the American 9. Metabolic acidosis Geriatrics Society lists the types of drugs to avoid or use in specific circumstances Treatment is often required before the against the class of drug and underlying diagnosis is confirmed and involves the disease or syndrome. administration of iv dextrose for hypoglycaemia, iv fluid resuscitation for It is of use as a reference guide for teams shock and either iv dexamethasone or to decide if certain medications can be hydrocortisone for the adrenal stopped in light of the clinical insufficiency. presentation and underlying state of the patient. Table 1 lists some of the Polypharmacy and Review of recommendations given for specific Medications disease states / syndromes

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Disease or Drug(s) Recommendation Syndrome Syncope ACEIs Avoid Alpha blockers (doxazosin) Increases risk of orthostatic hypotension Chlorpromazine, olanzapine Delirium All TCAs Avoid Anticholinergics Avoid in older adults with or at risk of Benzodiazepines delirium; if discontinuing drugs used Corticosteroids chronically, taper to avoid withdrawal H2-receptor antagonist symptoms Dementia Anticholinergics Avoid Benzodiazepines Avoid antipsychotics for behavioural Antipsychotics problems of dementia unless non- pharmacological options have failed. Antipsychotics are associated with increased risk of stroke and mortality History of falls Anticonvulsants Avoid unless safer alternatives are not or fractures Antipsychotics available; avoid anticonvulsants except for Benzodiazepines seizures TCAs/SSRIs Ability to produce ataxiq, impaired psychomotor function, syncope Parkinson’s All antipsychotics Avoid disease Metoclopramide Dopamine receptor antagonists with Prochlorperazine potential to worsen parkinsonian symptoms Chronic kidney NSAIDS Avoid disease stage IV Drug Recommendation Aspirin Use with caution in adults >80 years old Lack of evidence of benefit vs risk in patients > 80 Dabigatran Use with caution in adults > 75 years old or with GFR < 30 mL/min Increased risk of bleeding when compared to warfarin Prasugel Use with caution in adults > 75 years old Antipsychotics Use with caution Carbamazepine Can precipitate SIADH or hyponatraemia SSRIs TCAs

The STOPP / START Toolkit recommendations on adjustments. This toolkit serves as a guide to ensure appropriate medications are prescribed STOPP (Screening Tool of Older People’s and inappropriate ones are stopped for Potentially Inappropriate Prescriptions) elderly patients. It reviews specific and START (Screening Tool to Alert systems and the medications acting on Doctors to Right Treatments) can be those systems, and makes performed by clinicians or pharmacists.

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STOPP (Potentially Inappropriate) START (For Consideration) Gastrointestinal System Loperamide, codeine phosphate Proton Pump Inhibitor -For diarrhoea of unknown cause With severe GORD or peptic stricture needing dilatation -For treatment of severe infective gastroenteritis Fibre supplement Prochlorperazine or Metoclopramide For chronic, symptomatic diverticular disease with -With Parkinsonism constipation Proton pump inhibitor at treatment dose -For peptic ulcer disease for > 8 weeks Anticholinergic antispasmodic drugs -With chronic constipation Cardiovascular System Digoxin Warfarin -At long term dose of >125mcg/day with GFR < 50ml/min -in the presence of chronic atrial fibrillation Loop diuretic Aspirin -For dependent ankle oedema only and no other signs of -in presence of chronic atrial fibrillation where warfarin is heart failure contra-indicated -As first line therapy for hypertension -atherosclerotic coronary disease in patients with sinus Thiazide diuretic rhythm -With a history of gout Clopidogrel Beta-blocker -documented history of ischaemic stroke or peripheral -In combination with verapamil vascular disease -With COPD Antihypertensives Calcium channel blocker -where systolic blood pressure is > 160mmHg -With chronic constipation Statins -Use of diltiazem or verapamil with NYHA Class III or IV -History of coronary, cerebral or peripheral vascular disease failure where functional status is independent for activities of daily -Fall in last three months living and life expectancy is > 5 years Aspirin ACE-Inhibitors -history of peptic ulcer disease without PPI or H2 receptor -following acute myocardial infarction antagonist -at dose > 150mg/day Beta-Blockers -no history of coronary, cerebral or arterial symptoms -with chronic stable angina -with concurrent bleeding disorder Warfarin -for first uncomplicated DVT of longer than 6 months duration -for first uncomplicated PE > 12months duration -with concurrent bleeding disorder -use of aspirin and warfarin without gastroprotection Clopidogrel -with concurrent bleeding disorder Dipyridamole -as monotherapy for secondary cardiovascular prevention -with concurrent bleeding disorder general principles behind drug distribution, metabolism and Summary clearance that may affect how drugs prescribed in the acute setting impact  Elderly patients with acute traumatic on an elderly patient injuries may be taking a large variety of medications for underlying illness  Drugs such as morphine and benzodiazepines should be used with  It is important to understand the caution, especially in patients with

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reduced renal function and those who are naive to these groups of medication

 Beta-blockade may inhibit the cardiovascular response to haemorrhagic shock so additional signs of occult hypoperfusion should be sought in high-energy mechanisms

 Patients with Parkinson’s disease should continue their dopaminergic medications as soon as possible after injury to prevent neuroleptic malignant syndrome

 After admission, all elderly patients should have their medicines reviewed to manage unnecessary polypharmacy and associated unwanted effects that could precipitate delirium

References 1. Hamilton H, Gallagher P, Ryan C et al. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalised patients. Arch Int Med 2011; 171(11): 1013-1019.

With special thanks to a main contributor of this chapter, Dr Niall Fergusson Elderly Care Consultant Heart of England NHS Foundation Trust.

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PART IV – ONGOING CARE AND RECOVERY

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Chapter 17: The HECTOR Daily It is important that all members of staff have an appreciation in managing Assessment common frailty syndromes such as confusion, falls and polypharmacy as well Introduction as issues like safeguarding in older A patient’s journey to recovery does not patients. finish when they leave the Emergency Department, Theatre or Critical Care Unit. The “Silver Book” or “Quality Care for The provision of ongoing, quality care is Older People with Urgent & Emergency essential to prevent the complications Care Needs” document2 defines the associated with injury and hospital underpinning principles for acute care in admission itself. elderly patients. Part of these principles involves the routine assessment of the If patients’ are labelled as suffering from following: specific injuries such as, “Mrs Smith has a peg fracture and is on bed rest”, this Issue to Address neglects the basic elements of care upon  Pain which the foundations of recovery need  Depression to be built.  Skin Integrity  Falls and mobility The Constitution of the World Health  Continence  Safeguarding issues Organisation (WHO) states that good  Delirium and dementia health is:  Nutrition and hydration  Sensory loss “...a state of complete physical, social and  Activities of daily living mental well-being and not merely the  Vital signs absence of disease or infirmity.”1  End of life care issues

Elderly patients may suffer from co- These issues are covered in the primary, morbidities and the acquisition of injuries secondary and silver surveys conducted in places a greater burden on health. These the acute stages of care, and are assessed patients will need basic, fundamental on a daily basis via the HECTOR Daily aspects of health care provision to Assessment Tool. prevent a worsening state of health. HECTOR Daily Assessment Tool These basic fundamentals of care include: Concept & Design  Adequate hydration and access to water / The HECTOR Daily Assessment tool is fluids; designed to be included in the patient’s  Proper nutrition;  Comfortable mattresses and clean, dry records with the sheet being completed blankets and bed-sheets; every day by the Clinical and Nursing  Pain relief and regular assessment of the teams. It requires multidisciplinary causes of discomfort; collaboration to ensure that all fields of  Appropriate facilities or support for toileting; concern are addressed. The tool ensures  Regular clinical assessment to review progress that areas which would be considered as or deterioration. being “Nursing” in the traditional sense

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are held in equal importance to areas considered “Medical”.

The HECTOR Daily Assessment Tool

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Structure Urine output is an indicator of perfusion The tool ensures that the fields of care of the vital organs. Reduced urine output that could lead to the development of could be a feature of pre-renal, renal or complications are addressed on a daily obstructive “post-renal” disease. Patients basis. It requires collaboration between on bed-rest who have been given opioid Medical and Nursing staff to identify analgesia and develop constipation could issues and act upon them as they are be at risk of acute retention of urine and found. be in need of urethral catheterisation.

Some centres may have access to Ortho- If urine output is less than 0.5mls/kg/hr, geriatricians who could be used to the team should ask the following “troubleshoot” issues and advise on questions: management strategies. Alternatively, the tool can be used as a guide and a way of 1. Is the patient having enough fluid? developing teams’ experience in the provision of elderly care. 2. Are there any sources of fluid loss / hypovolaemia (e.g. ongoing bleeding, sepsis)? H – HYDRATION 3. Are there any signs or symptoms Monitoring of Input / Output suggestive of acute retention of urine?

This section ensures that teams keep a Patients with acute retention of urine and note of a patient’s urine output, fluid delirium / dementia may not be able to intake and renal function. Measurement communicate about levels of discomfort. of urea and electrolytes need not be Clinical examination of the abdomen may taken each day, but the team need to be reveal a tense mass in the suprapubic area aware of when the last measurements which is dull to percussion. were taken to assess for change. The presence of a large, distended If patients have injuries that require bladder may be confirmed by ultrasound operative fixation, they may be kept on or the use of a bladder scanner, but if not strict nil by mouth regimes. Cancellations available, urinary catheterisation should to theatre or excessive delays could lead be performed to decompress the bladder. to prolonged periods without hydration and subsequent renal impairment. This In such circumstances, urine should be can be pre-empted by reviewing daily tested for evidence of infection (dipstick input. and/or MC&S), residual volume of urine drainage should be documented and the Fluid input may follow the enteral or cause for retention should be sought (e.g. intravenous route and be determined by rectal examination for faecal loading, the underlying state of the individual. review of drug chart for opioid analgesia Patients who have suffered from stroke etc..) may have failed a SALT assessment and be in need of NG or intravenous fluid input.

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Urea & Electrolytes Elderly patients with traumatic injuries may be at risk of developing acute renal It is not necessary to check the urea and impairment, especially if they have any of electrolyte levels each day, but the the following risk factors: following situations may prompt testing:  History of diabetes i. Oliguria (urine output less than  History of heart failure 0.5ml/kg/hour)  Liver disease

 Use of drugs with nephrotoxic ii. Hypovolaemia potential in the per-operative period iii. Symptoms or history of urological (e.g. NSAIDs after surgery) obstruction  Use of iodinated contrast with pre- existing chronic kidney disease (eGFR iv. Sepsis < 40) or in patients aged over 75 years, or those with a renal transplant v. Severe diarrhoea Patients with risk factors for acute kidney vi. Deteriorating early warning score injury and who have been given iodinated vii. Hypotension contrast agents (see above), should be given intravenous crystalloid volume viii. Recent Use of iodinated contrast expansion and the clinician should agents consider stopping any nephrotoxic agents on a temporary basis. ix. Use of drugs with nephrotoxic potential (e.g. NSAIDs, Symptoms / Signs that May Suggest Acute aminoglycosides, ACE-I, diuretics) Kidney Injury  Malaise Results should be compared to baseline  Confusion levels for urea and creatinine, (as taken on  Seizures admission), and also compared to any  Coma historical results that may suggest the  Nausea presence of chronic renal impairment.  Vomiting  Anorexia Acute Kidney Injury Acute kidney injury can be defined by Management of Patients with Acute using any of the following criteria: Kidney Injury

 A rise in serum creatinine of Identify and Manage the Cause: 26micromol/litre or greater within 48 There are multiple reasons why patients hours develop acute kidney injury after hospital admission. Pre-renal causes such as  A 50% or greater rise in serum hypotension and shock should be creatinine within the past seven days managed in accordance with the exact cause (e.g. antibiotics and iv fluids for  A fall in urine output <0.5ml/kg/hour sepsis; transfusion for ongoing for more than 6 hours haemorrhage).

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Post-renal or obstructive causes should be with the patient and their family and may managed by relieving the obstruction. not be appropriate for some patients. Renal causes may be harder to diagnose and may require early input from a Hyperkalaemia nephrologist (e.g. acute tubular necrosis secondary to: ischaemia from Extracellular potassium is regulated hypotension; sepsis; myoglobin excess / between 3.5 – 5.0 mmol/L. As potassium rhabdomyolysis; nephrotoxic agents). concentration increases, the risk of serious consequences increases and Relieving Urological Obstruction: urgent treatment is needed. Levels above If patients develop fever, loin pain and >5.5mmol/L should be treated. rigors, pyonephrosis should be suspected. In such circumstances, CT or ultrasound Other than blood tests, hyperkalaemia imaging should be performed as soon as may be recognised on an ECG with the possible to identify any source of following changes: obstruction. ECG Changes with Hyperkalaemia Patients with acute kidney injury  First degree heart block secondary to urine retention or  Flattening of p-waves nephrolithiasis should be referred to  Tall, tented T-waves Urology teams for urgent review.  ST-segment depression  Widened QRS (>0.12s) Pharmacological Management:  Bradycardia Loop diuretics (e.g. furosemide) should be  Ventricular tachycardia considered for treating fluid overload or  S and T wave merging oedema. Patients with pulmonary oedema may need additional oxygen Management of hyperkalaemia should therapy and if either medication is focus on reverting potassium needed, urgent review by the Nephrology concentration back to acceptable levels team should be arranged. and treating the underlying cause. The following table provides treatment Referral for Renal Replacement Therapy: recommendations for different levels of Patients should be referred to the severity: nephrology and critical care specialists if Mild Elevation (5.5 – 5.9 mmol/L) any of the following complications are not  Potassium exchange resins (calcium resonium responding to medical management: 15-30g)  Diuretics (slow IV furosemide 1mg/kg) a. Hyperkalaemia Moderate Elevation (6 - 6.4 mmol/L) b. Metabolic acidosis  Use strategies for mild elevation c. Complications of uraemia (e.g  10 - 15 units insulin actrapid in 50mls 50% encephalopathy) dextrose over 15 – 30 mins Severe Elevation (>6.5 mmol/L) d. Fluid overload / pulmonary  Use strategies for moderate elevation oedema  Salbutamol 5mg nebulised  50mL 8.4% sodium bicarbonate if metabolic Any decision to initiate renal replacement acidosis is present (contact critical care / therapy should be taken in conjunction nephrology teams) Severe Elevation with Toxic ECG Changes  Use strategies for severe elevation

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 10mL 10% calcium chloride over 2-5 mins Patients with volume depletion will  Critical Care & Nephrology Review benefit from intravenous fluids, but those Immediately with SIADH (syndrome of inappropriate ADH secretion), are likely to need fluid Hyponatraemia restriction 800-1000mL/24hrs

Hyponatraemia can be common in the Causes of Hyponatraemia elderly population, especially in those Hyponatraemia may be caused by patients taking diuretic medication. It is reduced extracellular volume, or may usually asymptomatic but in the context occur with normal to increased of trauma, may signify underlying occult extracellular volume in certain injury. Changes in sodium concentration circumstances. In the context of trauma are likely to be detected after measuring and head injury, a low Na+ may be a urea and electrolytes and it is important consequence of SIADH secondary to an for the relevant clinician to know how to expanding intracranial haematoma that manage any change. was not identified on admission. In these

+ situations, investigations such as CT Head Patients with a serum Na

Drugs  Is the JVP elevated or low? Opiates; haloperidol; amitryptiline; carbamazepine  Check supine and sitting or standing Increased Extracellular Volume blood pressure to look for orthostatic Congestive Cardiac Failure hypotension Severe renal impairment Cirrhosis and ascites  Look for signs of excessive Nephrotic syndrome extracellular fluid (ascites, pulmonary oedema; sacral / lower limb oedema) Correction of hyponatraemia should be gradual and avoid volume overload as  Increased skin turgor with tenting for rapid correction could cause central >1sec after pinching is indicative of pontine myelinolysis. low extra-cellular volume. Patients with increased extracellular volume caused by cirrhosis and ascites

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should be treated with water-restriction also to monitor for signs of malnutrition in before considering diuretic medication. order to identify underlying illness or the need for expert advice from a nutritionist. If there is any doubt about the underlying cause for hyponatraemia, help should be Conditions Associated with Energy sought by an endocrinology specialist or Malnutrition orthogeriatrician to guide future management. In circumstances of low dietary intake, the body is dependent on the breakdown of E – EATING & TOILETING hepatic glycogen to glucose for energy. Once these stores are depleted, With the assessment of a patient’s gluconeogenesis occurs from lactate, hydration status, clinicians aim to identify pyruvate, glycerol and amino acids. that input is good enough to maintain an adequate urine output. In a similar sense, Patients with underlying disease may be nutritional input can be considered at the vulnerable to malnutrition from: same time as faecal output.  Increased catabolism (e.g. sepsis); Elderly patients have similar nutritional  Tumour necrosis factor (e.g requirements to younger patients, malignancy); although their energy expenditure is less.  Anorexia associated with disease The basal metabolic rate (BMR) in older states; patients is generally reduced owing to a  Malabsorption. fall in the fat-free mass, although the reverse may also be true for the BMR in Patients with traumatic injuries have a patients with underlying malignancy. rise in glucocorticoid and catecholamine levels and an increased release of On arrival to hospital, some patients may cytokines. have problems with nutrition due to many factors such as: All of these contribute towards stimulating the ubiquitin - proteasome  Dental problems; pathway which leads to enhanced  Lack of cooking skills (particularly proteolysis in skeletal muscle. This in widowers); increases the rate of muscle breakdown  Depression; and can lead to reduced strength and the  Financial restraints; need for longer periods of rehabilitation.  Lack of motivation. Disease States / Causes of Malnutrition Malnutrition may be worsened by Sepsis; Trauma; prolonged periods of being “nil by mouth” GI Tract Surgery; GI disease; caused by delayed or cancelled Malignancy; Dementia; operations. Depression; Anorexia

It is important for clinical teams to ensure Vitamin Deficiency that patients are not only having regular meals on the wards (which includes Elderly patients may suffer from assistance to eat meals if required), but deficiency of important vitamins. Patients

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with alcohol dependency will be prone to Toileting thiamine deficiency, institutionalised patients (e.g. from Nursing Homes), or The daily assessment should address the those with a poor diet may suffer from patient’s bowel habits in order to identify vitamin D deficiency. any significant changes. Clinical teams should aim to assess what is normal for Thiamine – an essential co-factor in the patient at the point of admission, and carbohydrate metabolism. Patients with observe for any change. deficiency can present with polyneuropathy or Wernicke-Korsakoff Nursing staff should keep stool charts that syndrome. Either state can be a document stool frequency and the nature precipitant for a fall and subsequent of stool production, such as described by traumatic injury. Patients should receive the Bristol Stool Chart3. supplementation with iv Pabrinex or an equivalent. Constipation Constipation will take different forms for Vitamin D - this is produced in the skin by different people. Some consider the sunlight photoactivation of 7- passage of hard, painful pellets as being dehysrocholesterol. Deficiency usually indicative of constipation others will results from lack of sunlight as opposed to perceive constipation as being unable to dietary insufficiency. Vitamin D is needed open the bowels for a few days. to increase calcium absorption from the gastrointestinal tract. Elderly patients are particularly vulnerable, especially in the presence of Assessment of Dietary Intake reduced mobility, altered diet, depression, and opiate use. It can lead to delirium in During the daily assessment, clinical this age group, thus leading to increased teams should work alongside Nursing staff mortality and morbidity. to document an individual’s daily dietary intake. In addition to asking the patients If a patient has failed to open their bowels about their intake, the team should aim to for a few days, or they pass hard, pellet- look for features that may hinder input. like stool, they should be examined for Poor dentition, oral candidiasis, increasing abdominal discomfort and a rectal levels of confusion or evolving illness examination should be performed. should be considered. Absolute constipation, defined as an If there are any concerns that a patient is inability to pass faeces or flatus, may be losing weight, Nursing teams should an early feature of large bowel endeavour to record the patient’s weight obstruction or a late feature of small on a regular basis. Ongoing weight loss bowel obstruction. Patients with such a should trigger the need for clinical history in the presence of abdominal assessment and review by a nutritionist. distension and / or vomiting should have Patients may be in need of dietary an abdominal X-Ray to assess for acute supplementation (e.g. Fortijuice, Fortisips obstruction. etc..)

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Hard faeces or a full rectum on digital rectal examination may respond to treatment such as glycerine suppositories or enemas, (e.g. Microlax – sodium citrate and sodium lauryl sulphoacetate).

Diarrhoea Diarrhoea occurs when there is an increase in stool weight to greater than 300g per day, although it commonly is referred to as representing increased bowel opening and/or the passage of loose, watery stool.

Patients developing diarrhoea should have urea and electrolyte levels checked to monitor its impact on renal function and electrolytes such as potassium. Stool cultures should be sent for MC+S and

patients should be isolated in side rooms Drug charts should be reviewed to assess with full reverse barrier nursing. for any medications that may contribute towards constipation and which may be Recent use of antibiotics can lead to stopped. Opiate and opioid analgesia diarrhoea and abdominal cramps caused (including codeine phosphate and its by pseudomembranous colitis. In the preparation with paracetamol), should be hospital setting, screening is needed for avoided where possible, or if needed, Clostridium difficile and its associated used at its lowest dose and titrated to toxins. All antibiotics should be stopped pain. and if C. difficile is confirmed, advice

should be sought from the duty Medications Associated with Constipation microbiologist about the need to  Anticholinergics  Antidepressants prescribe metronidazole or intravenous  Antihistamines vancomycin.  Calcium channel blockers  Diuretics C – COMFORT & CONFUSION  Iron / Ferrous sulphate  Opioids All patients should be asked about levels  Sympathomimetics of comfort or discomfort on a regular  Levodopa (should not be stopped) basis. Patients being admitted for management of traumatic injuries are Osmotic laxatives (polyethylene glycol, likely to suffer from pain and therefore be lactulose), have the strongest supporting at risk of delirium. data for managing constipation in elderly populations, although sodium docusate is Patients with pre-existing dementia or commonly used as a stool softener. confusional states may not be able to communicate their experience of pain with teams. In these circumstances, the

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Abbey Pain Scale may be used and should The use of intravenous opioids should be be accessible to all ward staff4. restricted and controlled by slowly titrating as low a dose as possible to Management of Pain achieve the desired response. Pre-existing renal impairment may lead to a toxic Chronic pain affects between 20-50% of accumulation and subsequent respiratory elderly people and some patients will be and depression. on long-term analgesic regimes before they arrive at hospital (e.g. MST, fentanyl Patients needing repeated doses of patch). morphine may benefit from the prescription of fentanyl patches as an Additional injuries may require greater alternative agent. In these situations, the levels of analgesia and upset this regime. following patches can be used against In these circumstances, the clinician needs daily morphine requirements: to be aware of the practicalities of making changes to long-term pain management Morphine Salt / 24hr Fentanyl Patch strategies. 45mg 12 90mg 25 In general terms, management of pain 180mg 50 starts with an appropriate assessment of 270mg 75 new injuries, (including the diagnosis of all 360mg 100 injuries on secondary survey) and an assessment of long-standing conditions Elderly patients should avoid being given (e.g. back pain). Clinicians should aim to NSAIDs where possible. Patients being identify previous / current analgesic use admitted with traumatic injuries may be and any adverse effects from medications. at risk of contrast-induced nephropathy; hypovolaemic states etc.. all of which may Patients should be prescribed regular contribute to worsening renal function in analgesia, rather than waiting for pain to the presence of NSAIDs. break through. Paracetamol is an effective analgesic agent in most cases and is used Confusion as a starting point for the “analgesic stepladder”. On admission to hospital, patients may or may not have pre-existing levels of Care should be taken for elderly patients confusion or dementia. The Silver Survey with low body mass index and uses a shortened version of the paracetamol dosing may need to be Abbreviated Mental Test (AMT4) as a reduced to prevent toxic hepatic injury. means of establishing a baseline level of confusion / orientation. Opioids are effective agents for nociceptive pain, with low-dose codeine This has been suggested as a means of being an acceptable starting point. providing an easy-to-use and pragmatic Consideration should be given to method of measuring cognition at the prescribing concomitant laxatives to time of initial attendance. prevent constipation.

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AMT4 T – THROMBO-EMBOLISM 1. Age 2. Date of Birth Part of the daily assessment should 3. Place include a check for mechanical and 4. Year chemical thromboprophylaxis and a review for the presence of venous This is easy to use but is a non-validated thromboembolism. In 2005 the House of way of assessing for delirium after Commons Health Committee reported admission. The daily HECTOR assessment that an estimated 25,000 people in the UK also uses this tool and if there is any die every year from hospital-acquired deviation away from baseline, should lead venous thromboembolism (VTE). the team to consider the possibility of occult injury or illness. If AMT4 score has A UK survey suggested that 71% of changed from the one recorded on arrival, patients assessed as being at medium- the clinical team should use the CAM-ICU high risk of developing VTE did not receive screening tool to detect delirium. any form of prophylaxis. All patients should be assessed on admission for their The CAM-ICU tool incorporates the risk of VTE and those at highest risk will Richmond Agitated Sedation Scale (RASS) meet one of the following criteria6: 5 and is divided into four parts :  Surgical procedure with a total 1. acute onset or fluctuating course; anaesthetic and surgical time of more 2. inattention; than 90 minutes, or 60 minutes if the 3. altered level of consciousness; surgery involves the pelvis or lower 4. disorganised thinking. limb  Acute surgical admission with an intra- Patients are deemed CAM-ICU positive, abdominal condition meaning that delirium is present, if  Expected significant reduction in features 1. and 2. and either 3. or 4. are mobility present. The onset of delirium should  One or more of the following risk trigger a formal head-to-toe assessment factors: looking at all systems, observations and investigations to determine any Risk Factors for VTE underlying organic cause. If delirium Active cancer or cancer treatment persists despite managing supposed Critical care admission causes, the opinion of an elderly care Dehydration Thrombophilias specialist should be sought to determine BMI > 30 the presence of dementia or unrecognised Personal history or 1st degree relative with VTE illness. Use of HRT Varicose veins with phlebitis Other screening tools for dementia exist >/=1 Medical comorbidities (heart disease; metabolic; endocrine; respiratory) such as the 6 Item Cognitive Impairment Age > 60 years Test (6CIT) and Mini-Mental State

Examination (MMSE), although the former All elderly patients with traumatic injuries is validated for a primary care setting. needing admission will therefore be at risk and need thromboprophylaxis.

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Mechanical Thromboprophylaxis traumatic intracerebral haemorrhage should not receive chemical Mechanical prophylaxis takes the forms thromboprophylaxis until the lesion had of: TEDs or other anti-embolism stockings; either been secured surgically or the foot impulse devices; and intermittent patient’s condition is deemed stable. This pneumatic compression devices. They may require further discussion with should not be offered to patients who Neurosurgery specialists. have: Different forms of prophylaxis exist, with a. Suspected or proven peripheral arterial fondaparinux sodium being used 6 hours disease after surgical closure of patients undergoing hip fracture surgery. b. Peripheral arterial bypass grafting Alternatively, enoxaparin may be used on c. Peripheral neuropathy or other causes admission and stopped 12 hours before of sensory impairment surgery, and restarted 6-12 hours post- operatively. d. Fragile “tissue paper” skin, dermatitis or recent skin graft Risk Factors For Bleeding  Active bleeding e. Allergy to material  Acquired bleeding disorders  Concurrent use of anticoagulants (INR > 2)  Lumbar puncture or epidural expected within f. Cardiac failure - severe leg oedema or the next 12 hours pulmonary oedema  Acute stroke  Thrombocytopaenia (platelets < 75x109/L) g. Unusual leg size or shape  Uncontrolled hypertension (>230/120mmHg)  Untreated inherited bleeding disorders h. Major limb deformity Assessment for Deep Venous Thrombosis Anti-embolism stockings provide graduated compression and a calf Following admission for acute traumatic pressure of 14-15mmHg. Patients should injuries, elderly patients who develop any be encouraged to wear them day and signs or symptoms suggestive of a DVT night until they are able to mobilise. should have Doppler Ultrasound Imaging to confirm or refute this diagnosis. The The HECTOR daily assessment provides modified Wells score or d-dimer test the opportune moment to assess would not be relevant as most patients compliance with anti-embolism stockings with unilateral leg swelling and calf pain and also to examine the underlying skin are likely to fall under the high-risk group. condition. O – OCCULT INJURY & ILLNESS Chemical Thromboprophylaxis Having assessed Hydration, Eating & Chemical prophylaxis (e.g. enoxaparin), Toileting, Comfort and Confusion, and should not be prescribed until an Thrombo-embolism, the clinical team assessment has been undertaken for risk should aim to complete a quick systems- factors for bleeding. Patients with acute based review of the patient as well as

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taking recent observations into Failure to identify the reasons behind consideration. abnormal observations or examination findings warrants escalation to senior Most issues with the genito-urinary or personnel and other specialist teams, (e.g. gastro-intestinal systems would have general medicine, nephrology, respiratory been identified at earlier stages of the etc.). assessment tool. Therefore, focus should be centred on looking for any features to This stage of the daily assessment uses suggest cardiovascular, respiratory or basic medical history and examination neurological compromise, whilst techniques that all doctors registered with examining any post-operative or the GMC should possess. Some clinicians traumatic wounds and injuries. may have more acute skills than others and in such situations, a team-based Abnormalities in the early warning score approach helps – those with technical (parameters dependent on the local surgical skills may rely on those with more hospital), should lead to a triggered acute skills to determine the most assessment of a specific system. appropriate management strategy.

For example, any symptoms of chest pain or changes in heart rate should warrant R – RECOVERY 12-lead ECG to detect any abnormalities. Low oxygen saturations or a raised The final part of the daily assessment respiratory rate should lead the team to centres on a formal multi-disciplinary examine the chest and consider plain film approach. It should start with a general radiography for underlying infection. question:

Respiratory Illness “How are things since yesterday?”

In the context of chest trauma, If the answer is that the situation has deteriorating respiratory function could worsened, then the reason for this should be a marker of conditions such as: be identified, acted upon and documented in the medical records. If the  Worsening contusion; situation remains the same, the team should also consider why care isn’t  Lower respiratory tract infection; Empyema; progressing.

 Pneumo-haemothorax. In some circumstances, progression will

not be expected on a day-to-day basis Neurological Considerations (e.g. a patient with a thoracic vertebral

body fracture on a regime of bed rest is If a patient has suffered from an likely to remain in a state of stasis for intracerebral bleed, a falling GCS or prolonged periods). However, other episodic confusion should make the team situations may arise whereby an issue consider whether a repeat CT Head is such as constipation has been identified, appropriate to detect expansion of the treatment has been given, and yet the lesion. patient remains constipated. In these

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situations, alternative laxatives may be acknowledge the complexity in dealing required. with frail elderly patients.

Progression of the care pathway is reliant  The HECTOR Daily assessment tool on addressing social and psychological provides the means of ensuring that factors as well as the management of basic care standards are being physical injury and illness. delivered on a consistent basis, and that any complications are identified Physiotherapy and Occupational Therapy early and can be acted on in a prompt teams have the ability to mobilise patients manner. and address any concerns about falling or returning home. Once these concerns are  During the daily assessment, the raised, teams can develop targeted following areas of patient care are strategies to improve confidence and addressed: Hydration (including reduce the risk of further falls etc.. review of input/output and urea and electrolytes); Eating and Toileting; Ward-based teams should involve a Comfort and Confusion; patient’s family in decisions about Thromboembolism (detection and discharge as early as possible. A patient prevention); Occult injury and Illness; attending following a fall may lead their and Recovery. family to believe that they are no longer safe to look after themselves at home.  It requires high levels of collaboration and communication between the Communication with family members multidisciplinary team to ensure that should be open, honest and occur as early any shortcomings or issues are as possible. If it is clear that a patient is addressed and acted on by the most unlikely to return to their own home after appropriate people. injury, a referral to social services should be made as soon as possible. References This early communication is likely to 1. The World Health Organisation. The prevent any later conflict that may arise Constitution of WHO (1946) when a patient is deemed medically fit for http://www.who.int/trade/glossary/story046/ discharge. It allows families to express en/ (Last accessed Aug 2015) their concerns whilst also allowing the clinical teams to outline the practicalities 2. British Geriatrics Society. Quality Care for Older People with Urgent & Emergency Care Needs “The of ongoing care and recovery outside the Silver Book” 2012. hospital. 3. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Summary Gastroenterol 1997; 32(9): 920-4

 All patients require basic levels of care 4. Abbey J, De Bellis A, Piller N, Esterman A, Giles L, Parker D, Lowcay B. Abbey Pain Scale. and attention to be provided following Funded by the JH & JD Gunn Medical admission. Failure to deliver such Research Foundation 1998-2002 standards may result from low staffing levels, poor training and / or failure to

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5. Ely EW. Confusion Assessment Method for the ICU (CAM – ICU): The Complete Training Manual ICU Delirium 2014; 1-32.

6. National Institute of Health and Care Excellence (NICE) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. CG92, Jan 2010.

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Chapter 18: Elder Abuse there are other forms which elderly people may suffer from: A vulnerable person is anyone aged 18 years and over who: Physical  Hitting;  Slapping;  Pushing;  Needs community care services  Misuse of medication; because of mental or other disability, Restraint age, or illness; Financial Using a person’s money  Is unable to take care of themselves; bank account, pension  Is unable to protect themselves book, property or any against significant harm or other belongings without exploitation. their consent Neglect Depriving a person of help Many elderly adults who have been leading to harm or abused have suffered in their own homes, suffering their relatives’ homes, or in institutions Sexual  Rape; such as hospitals and Nursing Homes.  Unwanted touching; With increasing frailty comes an  Kissing or sexual activity without a increasing inability to stand up for oneself person’s consent leaving people vulnerable and open for Emotional  Shouting; unscrupulous individuals to take  Swearing; advantage.  Threats of harm; Intimidation; Cognitive impairment and changes to  Humiliation; behaviour may make people difficult to  Controlling behaviour; live with and may push others to forms of  Deprivation of contacts abuse. Similarly, those caring for such Discriminatory Abuse based on race, individuals could be at risk of abuse and gender, disability, age, caring professionals should remain open religion to the possibility that the vulnerable adult Institutional Mistreatment by a group of may not be the person they are treating. staff or individual within an institution Abuse UK Study of Abuse and Neglect of Elder abuse may be defined as: Older People

“A single or repeated act or lack of A 2007 Joint Study between King’s College appropriate action, occurring within any London and the National Centre for Social relationship where there is an expectation Research1 was commissioned to provide of trust, which causes harm or distress to nationally representative prevalence an older person” estimates of elder abuse and neglect in the community. Abuse may be a single or recurrent act or failure to act, which results in harm or The study was conducted by interviewing distress to an individual. The most widely 2111 individuals over 65 years of age who publicised form of abuse is physical but lived in the community, (excluding institutions).

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The study identified that 2.6% of people The study suggested that reports of living in private households had neglect may not necessarily be experienced mistreatment involving a intentional, but may be a consequence of family member, friend or care worker in two people with increasing disabilities the last year. This equates to one in forty trying to help and support each other. people or 227,000 people aged 66 and over experiencing mistreatment. Barriers to Identifying Abuse

The predominant form of mistreatment Most perpetrators of mistreatment are in was reported as neglect (1.1%) followed close relationships with the victim. Such by financial abuse (0.7%). Mistreatment closeness may have an impact on the was influenced by some of the following victim’s willingness to come forwards for factors: fear of getting a loved-one into trouble or through fear of further mistreatment. a. Sex - women more likely to experience What remains troubling about this mistreatment than men information is the likelihood that the victim is commonly discharged back to the b. Marital status - 9.4% of those who care of the perpetrator and continues to were separated or divorced to 1.4% of “suffer in silence”. those who were widowed Cognitive impairment and physical illness c. Socio-economic position such as vascular dementia and Alzheimer’s disease may impair memory d. Tenure - those in rented housing had and may prevent the victim or perpetrator higher prevalence rates than owner- from volunteering the underlying cause of occupiers injury. Similarly, speech and language impairment caused by CVA may limit an e. Health - increased likelihood of individual’s ability to provide an accurate mistreatment with declining health history. f. Loneliness, depression and quality of Deficiencies in the training of healthcare life – all of these features increased staff may limit the ability to identify prevalence rates mistreatment. Elder abuse does not have the same profile in the media or training Partners and other family members were programmes that are seen with most commonly reported as being the safeguarding of children and adolescents perpetrators of mistreatment. The age so is commonly overlooked. Furthermore, pattern for neglect rose sharply for those a lack of understanding of the correct aged 85 and over. The study proposed a reporting procedures may hinder its hypothesis of the “Partner Effect”. identification.

This proposed that the effect of having a Practitioners may fear the response of supportive partner is protective up until family members or carers if concerns are the moment when disability in the partner raised about abuse. This may be sets in – either physical, mental or both – heightened further by having a suspicion and neglect increases. with a victim who is unable or unwilling to

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clarify the details about their cognitive impairment and their carer mistreatment. provides the majority of the history. Clinical acumen and a heightened index of Risk Factors for Elder Abuse suspicion to specific signs and symptoms may prevent abuse from being dismissed. Among carers and relatives, risk factors for abuse include: Features of Physical Abuse  Broken bones without reasonable A. Inability to cope with stress explanation or where injuries occur which don’t match a mechanism of B. Depression injury and the patient’s physical state  Signs of being restrained, such as C. Lack of support ligature marks on the wrists  Carer’s refusal to allow the patient to D. Substance abuse (alcohol / drugs) be left alone  Unexplained, symmetrical injuries – E. Inadequate training bruises, welts or scars

F. Intensity and demands of an elderly Features of Emotional Abuse person’s illness or dementia  Behaviour that mimics dementia – rocking, sucking or mumbling to G. Social isolation oneself  Witnessed threatening or controlling H. Elder’s role as an abusive parent or behaviour by the carer spouse at an earlier time of life  Destructive criticism and verbal abuse – shouting, mocking, accusing, name- I. History of domestic violence in the calling household  New-onset depression, anxiety, panic attacks J. Elder’s tendency towards verbal or physical aggression Features of Sexual Abuse  Bruises around the breasts or genitals In addition to the above risk factors, older  Unexplained vaginal or anal bleeding women are at risk of mistreatment if they with associated traumatic laceration / are the carer of an abusive partner. Such injury individuals are also more likely to  Torn, stained or bloody underclothing experience abuse from a son and they more be reluctant to report abuse. Neglect or Self-Neglect  Malnutrition, dehydration Signs and Symptoms of Elder Abuse  Untreated physical problems or failure to seek medical advice for bedsores Many of the signs and symptoms of elder  Unsanitary living conditions abuse overlap with symptoms of mental  Dirty / unbathed appearance deterioration, as explained by a patient’s  Unsuitable clothing and covering for carers or relatives. It is easy to dismiss the weather certain features if a patient suffers from  Desertion at a public place

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Features of Financial Abuse  Absolute confidentiality can not be  Spending of an older person’s money promised – the individual should be on oneself when shopping for the informed that information about the older person, without their expressed mistreatment will need to be shared consent.  Refusal to allow an older person to  If risk is great, the individual should be decide on how to spend their money aware that information may have to  Moving into an older person’s home be shared to protect them uninvited  Pressure to change a will  Try and establish what the individual  Pressure to sign property over feels they need to ensure their safety  Disconnecting the phone  Make an accurate, factual and Aiding Disclosure contemporaneous record of the disclosure If any form of mistreatment is suspected, subsequent interviews with relatives or Responding to Concerns of carers should be undertaken in a Mistreatment supportive environment away from the alleged perpetrator. The victim may not Clinicians should be aware of the be the patient in hospital and teams need reporting process for adult safeguarding to be aware of the risk to vulnerable at their own place of work. These carers. guidelines should be made available to all staff for quick reference and training It is important to ask direct questions programmes should be delivered around rather than let improbable explanations the reporting process. occur without challenge. Some carers / patients will be reluctant to disclose Concerns about mistreatment may be information that could get their partner made by the assessing clinician, members into trouble so everything should be of the multi-disciplinary team in the asked in a sensitive and non-judgemental Emergency Department or on the wards, manner. or by the patient and/or their carers themselves. When taking a disclosure, individuals should be empowered to give an accurate When a concern is raised, the responsible account of what has happened or what clinician should aim to establish the level may happen in the future. In such a of harm caused by the mistreatment. The circumstance, the individual should be following questions could be asked to given reassurance that their concerns are ascertain whether a safeguarding referral being taken seriously and action will be is required: taken if needed to minimise future risk and increase safety. 1. How serious was the harm or abuse or what was the potential consequence? When speaking to an individual, it is important to be honest and remember the following facts:

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2. How often has the actual / risk of abuse addition to providing written occurred documentation using local proformas which are sent via fax or email. 3. What is the likelihood of abuse or harm recurring? As a collaborative and multi-agency action is the normal response to safeguarding How serious was the harm or abuse or concerns, the adult at risk should be made what was the potential consequence? aware of the need to share information. If no harm has befallen an individual and They should be asked if they are willing to no criminal act has been committed, then give consent for this sharing of a safeguarding referral may not be information. indicated. Further discussions and history should be sought to ascertain any level of If it is not possible for a person to consent intended harm and the actions adjusted to sharing information through illness and accordingly. / or cognitive impairment, the clinician should act within the best interests of the If some harm has come to an individual alleged victim. (e.g. fractured ribs from assault), or if a criminal act has been committed, this Family members should be consulted in should trigger a safeguarding referral to this instance, unless they are the the local social services adult team. perpetrators of the alleged mistreatment. In such cases, appropriate action should How often has the actual or risk of abuse be taken in the interests of protecting the or harm occurred? patient from further mistreatment. If an incident has occurred once, led to no harm and re-occurrence is considered as If an individual refuses to provide consent being minimal, then safeguarding is not for their information to be shared, required. However, a pattern of repetitive disclosure can be made if there is a mistreatment or risk of mistreatment legitimate purpose to do so, which should warrant formal referral. includes:

What is the likelihood of the abuse or  Preventing serious harm to an adult at harm recurring? risk If there is a high likelihood that mistreatment will continue, then a  Providing urgent medical treatment safeguarding referral should be made. Evidence of this can be sought by looking  Implementing the Department of at past attendances to the Emergency Health’s “No Secrets” agenda of Department to identify recurring themes protecting adults. to suggest mistreatment. After a safeguarding referral is made, it is Making a Safeguarding Referral vital that this is documented in the medical records and handover is given to Local policies will dictate the exact the appropriate teams to ensure referral conduct of such referrals. In the majority is met with necessary action. of cases, this will involve a telephone call to the local Adult Safeguarding team in

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Capacity  Identify all the relevant circumstances – try and identify the things that the The 2005 Mental Capacity Act2 was individual would take into account if established to protect those individuals they had capacity who lack the mental capacity to make decisions about their own care. The Act  Find out the individual’s past views ensures that everyone has the right to and feelings from appropriate family make their own decisions, irrespective of members whether such decisions are deemed “unwise”.  Assess whether capacity might be regained (e.g. low GCS due to subdural The essence of the Mental Capacity Act haemorrhage) identifies the need to perform a capacity assessment if “unwise” decisions about  Consult with those closest to the care are made. If a person lacks capacity, individual and enquire about any then decisions can be made for individuals appointees of a Lasting Power of in their best interests. Attorney.

The Mental Capacity Act has designed a Deprivation of Liberty two-stage test of capacity: In certain circumstances, a “deprivation of liberty” may be required to ensure that an 1. Does the individual have an impairment individual receives care in their best of, or a disturbance in the functioning of, interests. Where individuals lack the their mind or brain, whether as a result of capacity to make decisions, but the a condition, illness, or other external provision of treatment is challenging (e.g. factors such as alcohol or drug use? an agitated or non-cooperative patient), legal authorisation may have to be sought 2. Does the impairment or disturbance from the local authority to provide care. mean the individual is unable to make a specific decision when they need to? Applications for this legal authorisation will follow local policy but can be provided An individual is unable to make a on an “urgent” or “standard” basis. decision if they cannot: Application for urgent authorisation is a. Understand the information done when it is necessary to prevent a b. Retain that information level of harm that is proportionate to the c. Weigh up that information to make a deprivation of their liberty. It is unlikely to decision be granted if it conflicts with a valid d. Communicate their decision back decision made by a person named under the Lasting Power of Attorney. If an individual lacks the capacity to make a decision, any further decisions about Self-Neglect treatment must be made in their best interests. In such instances, the following Self-neglect may be defined as: checklist may be used to guide what is in an individual’s best interests:

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“The inability (intentional or non- the date and time; any identified risks; intentional) to maintain a socially and communication with other agencies and culturally accepted standard of self-care proposed actions to minimise risk. with the potential for serious consequences to the health and well-being Engaging with Patients and Families of the individual and sometimes to their community” When self-neglect is suspected, families / friends / carers should be consulted to The lifestyle choices that an individual understand if the behaviour is new or a makes may conflict with what is perceived long-standing way of living and what may to be common sense. These choices may have initiated the behaviour, (e.g. also have a negative impact on an depression, isolation, pain). individual’s health, wellbeing or safety. Some families / individuals may refuse However, any challenge to an individual help and if this occurs, it may be due to: about perceived risk of self-neglect must be balanced against their rights of self-  cognitive processing (weighing up determination – everyone has a risks/costs); fundamental right to live the way they choose.  established habits or beliefs about having external help; Clinicians should be aware of the possible indicators for self-neglect:  experience of receiving help in the past;  Living in unclean circumstances  Poor self-care and personal hygiene  self-esteem and a fear of intrusion  Poor nutrition into one’s environment.  Pressure sores  Poorly maintained clothing Refusal of help may also be indicative of  Long toenails underlying abuse / mistreatment by  Social isolation others and alarm should be raised if a  Non-compliance with medication family refuse help against an individual’s  Hoarding large numbers of pets expressed consent to receive this help.  Neglecting household maintenance  Unpaid bills / no electricity or gas Managing Self-Neglect

i. Individual with capacity to make their When self-neglect is suspected, the own decisions clinical team should aim to establish whether or not an individual has capacity If concerns about self-neglect have been to make decisions about their safety and raised, the first step should be to assess well-being. an individual’s capacity to make decisions.

It is essential to ensure that the clinical If an individual has capacity this should be teams document: all factual observations recorded in the notes. A Carers which describe risk factors of self-neglect; Assessment could still be offered to the all mental capacity assessments to include individual but if this is refused, an adult

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safeguarding referral could be made if be provided in the best interests of the there is evidence that the neglect is patient. causing significant harm to the individual. This must be made in the patient’s best interests with the intent of activating a Summary multi-agency assessment.  Many elderly adults who have been ii. Individual has fluctuating capacity to abused have suffered in their own make decisions homes and often have close relationships with the perpetrator of In these circumstances, an adult the abuse. safeguarding referral should be made. The individual should be informed of this  All clinicians managing older patients necessity and steps taken to look at with injuries should be aware of the renegotiating options for delivery of care / different forms of abuse and risk ongoing treatment. factors that will predispose individuals to certain types of abuse. iii. Individual lacks capacity to make decisions  Barriers to detecting abuse are mainly due to it not being considered through When an individual lacks capacity and poor training, or a failure of the evidence of self-neglect has been individual to disclose, or be able to demonstrated, the clinical team should disclose the abuse. complete an adult safeguarding referral and may even need to apply for  Clinicians should follow their own local Deprivation of Liberty Safeguard authority safeguarding policies if they are if a person is non-compliant with considering whether or not a person’s treatment plans. injuries are a direct result of abuse.

Once an adult safeguarding referral has  Open and honest communication with been made, the following agencies may the patient and different family also be important to engage: members is an essential part of the safeguarding process. Clinicians may  Mental Health services discover that the patient they are  Domiciliary care providers treating is not actually the person  CPN Counselling or therapy services being abused.  Advocacy Voluntary organisations  Environmental health References  Age UK  Debt advice 1. National Centre for Social Research & King’s College London. UK Study of Abuse and A multi-agency assessment of risk should Neglect of Older People. London 2007 be performed and if a patient is deemed to have capacity, a multi-agency meeting 2. Department of Health. Mental Capacity Act 2005, UK. should be held to create, monitor and review a support plan for the individual. If a patient lacks capacity, intervention may

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Chapter 19: End of Life Care a. Organ or systems failure, where and Do Not Resuscitate patients are likely to die as a result of an acute crisis Decisions b. Life threatening acute conditions In the context of trauma care, older caused by catastrophic events (e.g. severe patients may be at risk of death from: head injury)

 The direct effect of their injuries; c. Progressive conditions such as cancer or  As a consequence of their injuries (e.g. dementia noscomial infections), and/or;  From pre-existing co-morbidities. d. Permanent vegetative state

Treatment options will vary for older Making a Clinical Judgement patients as the risks of definitive interventions are balanced against the risk The starting point for decision-making lies of death from anaesthesia etc.. in the consideration of an individual’s clinical situation. This should be done on a Whereas a younger patient with a case-by-case basis. In multi-system subdural haemorrhage may be taken to trauma, a high Injury Severity Score or low theatre for clot evacuation, an older GCS without recovery may be indicative of patient from a Nursing Home is less likely poor prognosis. to benefit from such invasive surgery. Help should be sought from specialists A simple truth exists – age is related to with the expertise to prognosticate the mortality and older patients are at an likelihood of survival against the entire increased risk of death from traumatic clinical picture (e.g. age, co-morbidities, injuries. prognosis of an isolated injury in the context of multi-system injuries). The GMC states that: Such a task is rendered near-impossible “Good end of life care helps patients with without good collection of data and life-limiting conditions to live as well as information from patients and their possible until they die, and to die with families. The wishes of the patient should dignity”. be considered whether it be a contemporaneous or historical expression This is based on doctors’ obligations to of these wishes. show respect for human life and to make the care of their patients their first For example, a patient with widespread concern. malignancy may not wish to have definitive treatment of traumatic injuries The term “life-limiting conditions” if they are on a palliative treatment includes: course. However, one should not assume that patients on end-of-life pathways would refuse operative intervention. For example, the same patient with widespread malignancy may benefit from

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fracture fixation to manage pain and nausea) whilst providing other support should not be denied access to such (e.g. psychological, social). intervention because of their underlying disease. End-of-life care should be delivered with certain standards which are described Explaining the Clinical Issues below:

All treatment options should be explored 1. People approaching the end of life are with patients and their families. This identified in a timely way should focus on goals of therapy and with the added explanation of the likely 2. People and their families and carers benefits, burdens and risks. are communicated with and offered information, in an accessible and Elderly patients in a Trauma Unit with a sensitive way in response to their severe head injury should still be needs and preferences informed of all the forms of intervention and be offered an explanation as to why 3. People are offered comprehensive the risks of surgery outweigh the possible holistic assessments in response to benefits. changing needs

Such discussion is necessary for patients 4. People have their physical and and their families to understand the psychological needs met at any time decision making process. Open and of day or night honest communication about clinical issues will help to build trust and reduce 5. People are offered timely personalised the potential for conflict. support (including religious and spiritual support) If an individual is inexperienced or does not have the clinical expertise to lead such Dying individuals with catastrophic discussions, this should be handed over to injuries should not be left without the an appropriately-trained senior clinician. If levels of support as described above. patients are likely to die as a result of Involvement of palliative care specialists their injuries, early involvement of a may help to control symptoms such as senior clinician or team with experience of pain or anxiety and make an individual’s end-of-life care is recommended to final days more comfortable. support the patient and their families. DNAR (Do Not Attempt End of Life Care Resuscitation) Decisions

End of life care refers to the support given A DNAR order consists of formal, written to patients who are approaching death to documentation that an individual is not enable them to live as well as possible for cardio-respiratory resuscitation (CPR) until they die. It includes palliative care in the event of a cardiac or respiratory which aims to make people as arrest. It is good quality practice to discuss comfortable as possible by controlling such orders with patients who are at risk symptoms (e.g. pain, breathlessness, of cardiac or respiratory arrest.

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The following steps will aid in the they do not want their family to know, decision-making process: these wishes must be respected under the duty of confidentiality. Is there a realistic chance that CPR could be successful? All DNAR forms should be counter-signed If a DNAR decision is made on clinical by the Consultant responsible for the grounds that CPR would not be successful, individual’s ongoing care. Such orders the patient should be informed of the must not be made without discussion with decision and be offered an explanation of the patient, or if they lack capacity, with these reasons. If a patient lacks capacity, a their family / closest relative. welfare attorney, court-appointed deputy or family member should be informed of Organ Donation this decision. Although organ donation occurs after If the decision is not accepted by the death, clinicians should be aware of local patient or those closest to them, a second policy for identifying suitable donors opinion should be offered and explanation before death. Organ donation should be given for these reasons. considered as a usual part in end-of-life planning and clinicians should attempt to Does the patient lack capacity AND have have discussions with patients and their an advance decision specifically refusing families to ascertain an individual’s wishes CPR OR an appointed attorney, deputy or to be a donor. guardian? If an individual has made an advance Patients with a catastrophic brain injury decision refusing CPR, this should be and the absence of one or more cranial respected provided that the criteria for nerve reflexes and a GCS of 4 or less applicability and validity are met. (which is not explained by sedation), should be considered as potential donors. Some advanced decisions are made in relation to underlying physical illness and The following are currently listed as may not be specific enough to reference absolute contra-indications to deceased an individual’s wishes in response to acute donation: traumatic injuries. In such situations, attempts should be made to discuss DNAR  Age 85 years or above with the patient and their family.  Primary intra-cerebral lymphoma  All secondary intracerebral tumours Does the patient lack capacity?  Any active cancer with evidence of If a patient is unable to demonstrate spread outside affected organ within 3 capacity to make their own decisions, years of donation discussion with those closest to the  Melanoma patient must be used as a guide to the  Active haematological malignancy patient’s best interests.  Definite, probable or possible cases of

human transmissible spongiform Is the patient willing to discuss their encephalopathy wishes regarding CPR?  TB – active and untreated A patient’s wishes must be respected. If  West Nile Virus they do not wish to be resuscitated and

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 HIV disease (but not with HIV It also stated that a person’s capacity infection) must not be judged on the basis of:

In addition to the above, the following “..age, appearance, condition or an aspect contraindications exist for organ-specific of their behaviour” donation: Elderly patients with cognitive problems Liver including dementia may at times have Acute hepatitis / Cirrhosis decisions made about their treatment Portal vein thrombosis based upon preconceived ideas of age or Kidney negative stereotyping. This should be Chronic kidney disease / Long-term avoided at all costs. dialysis Renal malignancy If an individual is unable to express their Previous kidney transplant preferences for care as they approach the Pancreas end of their life, the views on their care Insulin-dependent diabetes should be represented by an independent Non-Insulin dependent diabetes advocate. Pancreatic malignancy BMI >40 Hospital chaplains or an appropriate Heart person through a voluntary organisation Age > 65 years will be suitable candidates to ensure that Documented coronary artery disease / a patient’s holistic needs as they approach LVEF < 30% death are delivered in a compassionate Median sternotomy for cardiac surgery and caring manner. Lungs Intra-thoracic malignancy References

Chronic destructive or suppurative lung 1. Department of Health. Independent Review disease of the Liverpool Care Pathway. More Care, Major pulmonary consolidation on Chest Less Pathway: A Review of the Liverpool Care Xray Pathway. UK 2015

The Final Word

Care of dying older people is not always done well. Age is a “protected characteristic” under the Equality Act 2010 and older people should not be discriminated against just because of their age. A 2015 review of the Liverpool Care Pathway recommended that:

“The starting assumption must always be that a person has the capacity to make a decision, unless it can be established that they don’t have capacity”.

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