WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.390 fast. Welcome to the emergency room. Okay, let's 00:00:47.390 --> 00:00:50.250 get into it. We're seeing, right now, one of 00:00:50.250 --> 00:00:53.270 the biggest social transformations of this century. 00:00:53.909 --> 00:00:56.990 The world is, well, it's getting older. Fast, 00:00:57.210 --> 00:00:59.890 and this isn't some abstract idea, right? Not 00:00:59.890 --> 00:01:02.630 at all. It's probably the defining challenge 00:01:02.630 --> 00:01:04.790 that's reshaping our entire healthcare system 00:01:04.790 --> 00:01:07.329 as we speak. Yeah, and the sources we're looking 00:01:07.329 --> 00:01:09.849 at today make that demographic shift. I mean, 00:01:09.989 --> 00:01:12.560 it's just... It's crystal clear. It's staggering, 00:01:12.739 --> 00:01:14.739 really. You're talking about the fastest growing 00:01:14.739 --> 00:01:17.739 part in the US population. And if you look globally, 00:01:17.879 --> 00:01:20.579 the numbers are just massive. How massive? Well, 00:01:20.640 --> 00:01:23.099 by 2050, something like half the world is going 00:01:23.099 --> 00:01:25.540 to be living in a country where one in five people 00:01:25.540 --> 00:01:28.579 is over the age of 60. One in five, wow. Yeah. 00:01:28.840 --> 00:01:32.700 I mean, that's a revolutionary shift in how we 00:01:32.700 --> 00:01:35.079 live, but also in what our trauma centers are 00:01:35.079 --> 00:01:37.579 going to be facing every single day. And that's 00:01:37.579 --> 00:01:39.519 exactly what we're here to talk about. This deep 00:01:39.519 --> 00:01:42.400 dive is all about geriatric trauma. We've designed 00:01:42.400 --> 00:01:44.620 this as a critical review guide for you, the 00:01:44.620 --> 00:01:47.939 learner, to really zero in on that crucial 20 00:01:47.939 --> 00:01:51.680 % of information that gives you 80 % of the clinical 00:01:51.680 --> 00:01:53.700 understanding you need. The Pareto principle 00:01:53.700 --> 00:01:57.019 for trauma. Exactly. We're focusing on the unique 00:01:57.019 --> 00:02:00.900 physiology, the management priorities, really 00:02:00.900 --> 00:02:03.280 hitting on the nursing implications and what 00:02:03.280 --> 00:02:05.260 you need to do in those first critical minutes. 00:02:05.659 --> 00:02:07.939 And the stakes are just. They couldn't be higher. 00:02:08.439 --> 00:02:10.879 Yeah. Injury is now the fifth leading cause of 00:02:10.879 --> 00:02:13.639 death in the elderly. The fifth. And the data. 00:02:13.949 --> 00:02:16.849 It's totally unequivocal. An older adult will 00:02:16.849 --> 00:02:19.330 have a much higher mortality rate, even when 00:02:19.330 --> 00:02:22.169 their injuries, by the standard scores, look 00:02:22.169 --> 00:02:24.949 exactly the same as a younger patient's. So if 00:02:24.949 --> 00:02:27.310 the injury itself isn't the only thing driving 00:02:27.310 --> 00:02:29.370 that mortality, we have to be looking somewhere 00:02:29.370 --> 00:02:31.569 else. It's not just the crash or the fall. That's 00:02:31.569 --> 00:02:33.250 the whole point. What's driving this? Yeah, what 00:02:33.250 --> 00:02:36.229 is it? It's this complex mix. The sources call 00:02:36.229 --> 00:02:39.919 them host factors. So the aging of their organ 00:02:39.919 --> 00:02:42.379 systems, the burden of all the diseases they 00:02:42.379 --> 00:02:45.479 already have, frailty, and this is a big one. 00:02:46.379 --> 00:02:49.520 Our failure to triage them correctly in the acute 00:02:49.520 --> 00:02:51.860 setting. So we miss the signs. We miss the subtle 00:02:51.860 --> 00:02:56.879 signs. And if we do, the outcome is just devastatingly 00:02:56.879 --> 00:02:58.460 different than it would be for a 40 -year -old 00:02:58.460 --> 00:03:00.919 with the same injury. OK. So it's a race against 00:03:00.919 --> 00:03:02.939 the patient's own body. A race against their 00:03:02.939 --> 00:03:05.159 limitations. Exactly. All right. Let's start 00:03:05.159 --> 00:03:08.340 with the absolute core concept here. The thing 00:03:08.340 --> 00:03:09.919 that explains almost everything else we're going 00:03:09.919 --> 00:03:13.259 to talk about. Decreased physiologic reserve. 00:03:14.000 --> 00:03:16.439 What does that phrase actually mean when we're 00:03:16.439 --> 00:03:19.259 standing in a loud chaotic trauma bay? It's the 00:03:19.259 --> 00:03:21.280 body's safety margin. That's the easiest way 00:03:21.280 --> 00:03:22.860 to think about it. OK. I mean, in a practical 00:03:22.860 --> 00:03:24.840 sense, aging just means that cellular function 00:03:24.840 --> 00:03:27.379 is declining everywhere in all the systems. Right. 00:03:27.659 --> 00:03:30.360 So as those cells get less efficient, the big 00:03:30.360 --> 00:03:33.699 systems, the heart, the lungs, the kidneys, they 00:03:33.699 --> 00:03:36.580 lose their ability to perform above just their 00:03:36.580 --> 00:03:38.900 normal baseline. So they have no surge capacity. 00:03:39.210 --> 00:03:41.830 Exactly. They have no surge. So when that elderly 00:03:41.830 --> 00:03:44.969 patient gets hit with a major trauma, their body's 00:03:44.969 --> 00:03:47.449 adaptive mechanisms, the very things designed 00:03:47.449 --> 00:03:49.909 to cope with massive stress like blood loss, 00:03:50.189 --> 00:03:53.030 they're just impaired. They lack that safety 00:03:53.030 --> 00:03:56.610 margin to fight back. So a younger person has 00:03:56.610 --> 00:03:59.770 this like deep reserve tank they can pull from 00:03:59.770 --> 00:04:02.009 to compensate for shock or fight off an infection 00:04:02.009 --> 00:04:06.819 for hours. But the older patient's tank is It's 00:04:06.819 --> 00:04:09.039 already running on fumes. That's a perfect analogy. 00:04:09.199 --> 00:04:11.060 The tank is almost empty to begin with. So how 00:04:11.060 --> 00:04:14.080 much warning do we actually get before they crash? 00:04:14.379 --> 00:04:16.259 Very, very little. That's the terrifying part. 00:04:16.540 --> 00:04:18.620 The sources really stress that insults that a 00:04:18.620 --> 00:04:21.120 younger patient would just tolerate. you know, 00:04:21.259 --> 00:04:22.860 a minor fracture, a little bit of blood loss. 00:04:22.860 --> 00:04:25.660 Right. That can lead to just devastating, often 00:04:25.660 --> 00:04:28.480 fatal results in an elderly patient. Their adaptive 00:04:28.480 --> 00:04:31.120 response is blunted and it's instantaneous. They 00:04:31.120 --> 00:04:33.220 start so much closer to that failure point. So 00:04:33.220 --> 00:04:35.959 once they tip over that edge into real shock. 00:04:36.399 --> 00:04:38.699 Recovery is incredibly difficult. Their mechanisms 00:04:38.699 --> 00:04:41.259 for adaptation are already exhausted or they 00:04:41.259 --> 00:04:43.319 just don't work anymore. That completely changes 00:04:43.319 --> 00:04:46.220 the urgency. It means we have to treat even what 00:04:46.220 --> 00:04:48.879 looks like mild instability as a code red event. 00:04:49.160 --> 00:04:51.180 Absolutely. And that brings us right to the next 00:04:51.180 --> 00:04:54.839 factor. Pre -existing conditions. PECs. Right. 00:04:55.079 --> 00:04:57.779 The compounders. The sources highlighted five 00:04:57.779 --> 00:05:00.660 that really, really impact outcomes. What are 00:05:00.660 --> 00:05:02.920 the five we have to be screening for immediately? 00:05:03.220 --> 00:05:06.079 OK. So the five high impact PECs from the research 00:05:06.079 --> 00:05:11.060 are cirrhosis, coagulopathy, COPD, That's chronic 00:05:11.060 --> 00:05:13.560 obstructive pulmonary disease, ischemic heart 00:05:13.560 --> 00:05:15.980 disease, and diabetes. OK, that's a big list. 00:05:16.160 --> 00:05:18.920 It is. And the presence of any one of these just 00:05:18.920 --> 00:05:22.000 tanks their already limited reserve and totally 00:05:22.000 --> 00:05:24.040 changes the patient's prognosis. Let's break 00:05:24.040 --> 00:05:26.620 down why these five are so bad in a trauma. I 00:05:26.620 --> 00:05:28.860 mean, beyond just having the diagnosis. For sure. 00:05:28.939 --> 00:05:31.980 Let's think of it as failing defenses. So cirrhosis. 00:05:32.339 --> 00:05:35.180 That compromises the liver. The liver makes clotting 00:05:35.180 --> 00:05:38.319 factors. It metabolizes waste. Post -trauma, 00:05:38.519 --> 00:05:40.540 that patient is at huge risk for just bleeding 00:05:40.540 --> 00:05:43.060 out. They can't clot. And they can't clear all 00:05:43.060 --> 00:05:44.819 the inflammatory toxins that get released during 00:05:44.819 --> 00:05:47.040 shock. OK, what about coagulopathy if they already 00:05:47.040 --> 00:05:49.259 have a bleeding problem? That's just a catastrophic 00:05:49.259 --> 00:05:52.459 risk multiplier from second one, especially with 00:05:52.459 --> 00:05:54.139 hidden bleeding in the head, which we'll get 00:05:54.139 --> 00:05:56.800 to. And COPD. That's a direct attack on their 00:05:56.800 --> 00:05:59.060 respiratory reserve. These patients already have 00:05:59.060 --> 00:06:01.709 trouble getting air out. Their lungs are stiff. 00:06:01.910 --> 00:06:03.889 Their functional reserve is tiny. So there's 00:06:03.889 --> 00:06:06.629 no wiggle room. Zero. Yeah. A little bit of pain 00:06:06.629 --> 00:06:08.850 from a rib fracture that makes them breathe shallow. 00:06:09.209 --> 00:06:11.370 That can cause a complete respiratory collapse. 00:06:11.810 --> 00:06:14.990 Fast. OK. And ischemic heart disease? That means 00:06:14.990 --> 00:06:17.430 their heart muscle is already weak. So when you 00:06:17.430 --> 00:06:20.209 hit it with the massive stress of trauma, the 00:06:20.209 --> 00:06:22.769 need for high cardiac output. It can't keep up. 00:06:22.910 --> 00:06:25.769 It can't. They're a huge risk for a heart attack 00:06:25.769 --> 00:06:28.069 right there in the trauma bay, which can just 00:06:28.069 --> 00:06:29.970 trigger the whole collapse into irreversible 00:06:29.970 --> 00:06:32.629 shock. And finally, diabetes. Diabetes messes 00:06:32.629 --> 00:06:35.629 with everything. Immune function, vascular health. 00:06:36.490 --> 00:06:38.810 They're a much higher risk for infection, for 00:06:38.810 --> 00:06:42.250 poor wound healing, and the stress of the trauma 00:06:42.250 --> 00:06:45.379 itself. sends their blood sugar into chaos, which 00:06:45.379 --> 00:06:47.540 just accelerates all the bad outcomes. That list 00:06:47.540 --> 00:06:50.180 covers a huge number of people. Do we know how 00:06:50.180 --> 00:06:52.759 common this kind of stacked risk is? The data 00:06:52.759 --> 00:06:56.639 is pretty wild. In one study, a full one -fourth 00:06:56.639 --> 00:07:00.540 of all trauma patients over 65 had at least one 00:07:00.540 --> 00:07:03.720 of these five packs. A quarter of them. And here's 00:07:03.720 --> 00:07:06.740 the real need -to -know takeaway from that. Patients 00:07:06.740 --> 00:07:09.459 with one or more of these conditions were nearly 00:07:09.459 --> 00:07:11.899 two times more likely to die after their trauma 00:07:11.899 --> 00:07:15.300 than patients who had none. Two times? Yeah. 00:07:15.620 --> 00:07:17.560 This isn't just, you know, statistical noise. 00:07:17.639 --> 00:07:20.779 This is a fundamental driver of who lives and 00:07:20.779 --> 00:07:23.279 who dies. So it's an exponential increase in 00:07:23.279 --> 00:07:25.300 risk just based on who the patient is before 00:07:25.300 --> 00:07:27.500 we even get to the injury. Exactly. Let's dig 00:07:27.500 --> 00:07:29.879 into that relationship between age, the pecs, 00:07:30.160 --> 00:07:33.689 and mortality. The data visualization and the 00:07:33.689 --> 00:07:35.790 source material really drives this home. It's 00:07:35.790 --> 00:07:37.990 not a straight line, is it? No, it's a compounding 00:07:37.990 --> 00:07:40.769 effect, a stacking effect. Your mortality risk 00:07:40.769 --> 00:07:42.529 doesn't just go up because you're old. It goes 00:07:42.529 --> 00:07:45.529 up significantly by decade 70s, 80s, 90s. Right. 00:07:45.790 --> 00:07:48.209 But then it gets compounded by how many of those 00:07:48.209 --> 00:07:50.329 pecs the patient is carrying? Zero, one to two, 00:07:50.410 --> 00:07:53.149 or three or more? So it's a multiplier. A seven 00:07:53.149 --> 00:07:55.910 -year -old with zero pecs has a manageable risk. 00:07:56.240 --> 00:07:58.819 But a 70 -year -old with three or more pecs might 00:07:58.819 --> 00:08:01.120 have a risk profile that's actually worse than 00:08:01.120 --> 00:08:03.480 someone in their late 80s with fewer conditions. 00:08:03.500 --> 00:08:05.600 That's it. Exactly. It's about their physiological 00:08:05.600 --> 00:08:08.180 age, not their chronological age. And their physiological 00:08:08.180 --> 00:08:11.300 age is defined by these conditions. Right. The 00:08:11.300 --> 00:08:14.439 expert insight here is that while the injury 00:08:14.439 --> 00:08:17.839 severity is, of course, the primary driver, a 00:08:17.839 --> 00:08:20.579 catastrophic injury is always bad. These host 00:08:20.579 --> 00:08:24.259 factors play a huge additive and often exponential 00:08:24.259 --> 00:08:28.050 role. It's a severe trauma plus zero reserve. 00:08:28.410 --> 00:08:31.050 So you have to manage the injury and the host. 00:08:31.170 --> 00:08:33.450 You have to. That vulnerability really sets the 00:08:33.450 --> 00:08:36.029 stage. But how does that fragility actually play 00:08:36.029 --> 00:08:38.549 out when they get injured? Let's talk about the 00:08:38.549 --> 00:08:40.970 mechanisms. Okay. We often think of big car crashes, 00:08:41.210 --> 00:08:43.210 but the sources point to falls as the single 00:08:43.210 --> 00:08:45.929 most common fatal mechanism. That's a really 00:08:45.929 --> 00:08:48.370 important distinction. Not just common, but the 00:08:48.370 --> 00:08:50.769 most common killer. It is. The risk of falling 00:08:50.769 --> 00:08:53.649 just goes up dramatically with age. sensory decline, 00:08:54.049 --> 00:08:56.289 balance problems, medications, and it's often 00:08:56.289 --> 00:09:00.070 a seemingly simple ground -level fall. You know, 00:09:00.190 --> 00:09:02.909 tripping on a rug. But the consequences are anything 00:09:02.909 --> 00:09:05.610 but simple. And what's the specific risk from 00:09:05.610 --> 00:09:08.149 falls we absolutely have to hammer home? Traumatic 00:09:08.149 --> 00:09:11.669 brain injury. TBI. Falls are the number one cause 00:09:11.669 --> 00:09:14.690 of TBI in the elderly. Wow. And get this, nearly 00:09:14.690 --> 00:09:16.990 half of all the deaths from ground -level falls 00:09:16.990 --> 00:09:20.549 are a direct result of a TBI. Half? Why is that? 00:09:20.789 --> 00:09:23.750 It's because of cerebral atrophy. As you age, 00:09:24.330 --> 00:09:26.269 your brain shrinks a little bit. That leaves 00:09:26.269 --> 00:09:28.549 a bigger space between the surface of the brain 00:09:28.549 --> 00:09:30.870 and the inside of the skull. Right. So during 00:09:30.870 --> 00:09:33.049 a minor fall, the brain has more room to move 00:09:33.049 --> 00:09:35.409 around and tear the tiny little bridging veins 00:09:35.409 --> 00:09:38.330 that connect it to the skull. That leads to a 00:09:38.330 --> 00:09:41.029 subdural hemorrhage. Low impact, catastrophic 00:09:41.029 --> 00:09:43.659 result. And beyond the TBI risk, there's another 00:09:43.659 --> 00:09:45.919 really devastating outcome related to falls, 00:09:46.419 --> 00:09:48.759 specifically hip fractures. This one speaks to 00:09:48.759 --> 00:09:51.179 the long term cost. This is a heartbreaking one. 00:09:51.279 --> 00:09:53.659 The loss of independence is huge. The sources 00:09:53.659 --> 00:09:55.960 say that one half of elderly patients who suffer 00:09:55.960 --> 00:09:58.240 a hip fracture will no longer be able to live 00:09:58.240 --> 00:10:00.320 independently. Half of them. That means months 00:10:00.320 --> 00:10:03.379 of rehab. And often it means a permanent move 00:10:03.379 --> 00:10:06.399 to assisted living. The focus has to be on fall 00:10:06.399 --> 00:10:08.879 prevention in the first place. OK, let's shift 00:10:08.879 --> 00:10:12.360 to motor vehicle crashes. The sources say older 00:10:12.360 --> 00:10:15.179 people are generally safer drivers. They drive 00:10:15.179 --> 00:10:18.639 less. They drive slower. Right. On familiar roads. 00:10:19.139 --> 00:10:22.379 So when fatalities do happen, what's the context? 00:10:22.620 --> 00:10:24.779 What are the clues we need to look for? It's 00:10:24.779 --> 00:10:26.779 interesting. The fatalities usually happen during 00:10:26.779 --> 00:10:29.679 the day. on weekends and they typically involve 00:10:29.679 --> 00:10:32.580 other cars. That points to issues at intersections 00:10:32.580 --> 00:10:35.539 or complex moves that need quick reaction times. 00:10:36.080 --> 00:10:38.679 And what are the underlying physical things that 00:10:38.679 --> 00:10:41.379 contribute? Slower reaction time is a huge one. 00:10:41.559 --> 00:10:44.080 Vision and hearing impairment too. But one that's 00:10:44.080 --> 00:10:47.179 really underappreciated is limited neck mobility. 00:10:47.360 --> 00:10:49.240 From arthritis. Yeah, from arthritis in the neck. 00:10:49.379 --> 00:10:51.379 If an older patient can't turn their head easily, 00:10:51.480 --> 00:10:53.779 they can't scan traffic, they end up with these 00:10:53.779 --> 00:10:55.539 huge functional blind spots, they never see the 00:10:55.539 --> 00:10:58.480 other car coming. That makes so much sense. And 00:10:58.480 --> 00:11:00.460 is there a hidden medical cause we should be 00:11:00.460 --> 00:11:03.559 thinking about? Yes. And this is critical for 00:11:03.559 --> 00:11:05.799 your differential diagnosis. You always have 00:11:05.799 --> 00:11:08.200 to consider that the crash itself might have 00:11:08.200 --> 00:11:10.759 been caused by a physiological event. Like a 00:11:10.759 --> 00:11:13.629 heart attack. Exactly. A heart attack, a stroke, 00:11:13.889 --> 00:11:16.730 a cardiac dysrhythmia. Yeah. You can't just treat 00:11:16.730 --> 00:11:18.769 the trauma from the crash. You have to look for 00:11:18.769 --> 00:11:20.909 the medical crisis that made them lose control 00:11:20.909 --> 00:11:23.190 in the first place. So assume they had a medical 00:11:23.190 --> 00:11:25.509 event until you prove otherwise. You got it. 00:11:25.590 --> 00:11:28.629 Let's talk about burns. The sources are really 00:11:28.629 --> 00:11:30.889 clear that burns are just devastating for the 00:11:30.889 --> 00:11:33.690 elderly. Why is the mortality so high here? It 00:11:33.690 --> 00:11:35.870 comes right back to that loss of physiologic 00:11:35.870 --> 00:11:38.909 reserve and the physical changes in their skin. 00:11:39.509 --> 00:11:42.690 How so? An older patient's body just can't meet 00:11:42.690 --> 00:11:46.190 the immense demands of a burn injury. The hypermetabolism, 00:11:46.330 --> 00:11:48.470 the massive fluid shifts, the constant threat 00:11:48.470 --> 00:11:50.950 of infection. It's too much for their systems. 00:11:51.649 --> 00:11:53.950 Their reaction times are also slower, so they're 00:11:53.950 --> 00:11:55.870 exposed to the heat for longer. And there is 00:11:55.870 --> 00:11:58.409 a fascinating little detail, a smallest detail, 00:11:58.490 --> 00:12:00.889 about how their skin itself changes. This is 00:12:00.889 --> 00:12:03.850 a great clinical pearl. A common mechanism is 00:12:03.850 --> 00:12:06.309 spilling hot liquid on their leg. In a younger 00:12:06.309 --> 00:12:08.629 person, that might be a partial thickness burn 00:12:08.629 --> 00:12:10.769 that can heal on its own, because they have a 00:12:10.769 --> 00:12:13.549 lot of hair follicles that act as reservoirs 00:12:13.549 --> 00:12:17.110 for new skin cells. But in older patients, because 00:12:17.110 --> 00:12:19.049 they have fewer of those follicles in their skin, 00:12:19.490 --> 00:12:22.210 that same spill often results in a full thickness 00:12:22.210 --> 00:12:24.769 burn. Which needs surgery. Exactly. Extensive 00:12:24.769 --> 00:12:28.350 surgery, grafting, a long recovery. All things 00:12:28.350 --> 00:12:31.110 that just hammer their already tiny physiologic 00:12:31.110 --> 00:12:33.669 reserve. That's a brilliant example. Finally, 00:12:33.850 --> 00:12:36.519 penetrating injuries. Blunt trauma is more common, 00:12:36.559 --> 00:12:39.139 but where does this fit in? It's the fourth most 00:12:39.139 --> 00:12:41.259 common cause of traumatic death in people over 00:12:41.259 --> 00:12:44.759 65. But the critical implication here is often 00:12:44.759 --> 00:12:47.480 psychological. How do you mean? A lot of the 00:12:47.480 --> 00:12:49.799 deaths from gunshot wounds in the elderly are 00:12:49.799 --> 00:12:52.759 related to intentional self -harm or suicide. 00:12:53.039 --> 00:12:56.059 Ah. So as clinicians, we have to recognize that 00:12:56.059 --> 00:12:58.139 hidden aspect and make sure we're getting mental 00:12:58.139 --> 00:13:00.240 health and social services involved right away 00:13:00.240 --> 00:13:02.600 if the patient survives. We've set the stage 00:13:02.600 --> 00:13:04.259 with the vulnerabilities and the mechanisms. 00:13:04.509 --> 00:13:07.289 Let's move into the acute management. The core 00:13:07.289 --> 00:13:09.990 principles are still ATLS, right? But we have 00:13:09.990 --> 00:13:12.909 to adapt them. Yeah, the structure of ABCDE is 00:13:12.909 --> 00:13:15.970 the same. But how you interpret the findings 00:13:15.970 --> 00:13:19.190 and, crucially, your threshold for intervention, 00:13:19.769 --> 00:13:22.009 that changes dramatically. So this is where we 00:13:22.009 --> 00:13:24.950 need to know what looks normal but is actually 00:13:24.950 --> 00:13:27.690 a disaster waiting to happen. Exactly. That table 00:13:27.690 --> 00:13:30.590 from the source, table 11 -1, that details the 00:13:30.590 --> 00:13:33.179 system changes. That's the Rosetta Stone for 00:13:33.179 --> 00:13:36.019 adapting ATLS to a geriatric patient. Let's start 00:13:36.019 --> 00:13:38.740 with A for airway. What are the key challenges 00:13:38.740 --> 00:13:42.200 here? It's twofold, really, anatomically. First, 00:13:42.320 --> 00:13:44.399 they lose their protective airway reflexes, so 00:13:44.399 --> 00:13:46.879 the aspiration risk is sky high. You have to 00:13:46.879 --> 00:13:49.019 make the decision to intubate much sooner. And 00:13:49.019 --> 00:13:51.019 the second part? The second is the arthritis 00:13:51.019 --> 00:13:54.169 in their jaw, in their neck. It can make just 00:13:54.169 --> 00:13:56.370 opening their mouth difficult, let alone manipulating 00:13:56.370 --> 00:13:58.649 the cervical spine for intubation. So a difficult 00:13:58.649 --> 00:14:01.610 procedure gets even harder. What's a really practical 00:14:01.610 --> 00:14:04.029 hands -on tip for managing the airway right away, 00:14:04.470 --> 00:14:06.409 especially with mask ventilation? The big one 00:14:06.409 --> 00:14:09.169 is about dentures. OK. If the dentures are not 00:14:09.169 --> 00:14:11.950 in the way, leave them in during bag mask ventilation. 00:14:12.350 --> 00:14:14.029 They provide structure and help you get a much 00:14:14.029 --> 00:14:16.129 better seal with a mask. And if they don't have 00:14:16.129 --> 00:14:20.710 any teeth? intubating might be easier, but bagging 00:14:20.710 --> 00:14:22.789 them is way harder because their cheeks just 00:14:22.789 --> 00:14:25.610 collapse in. The trick is to place some gauze 00:14:25.610 --> 00:14:27.929 between their gums and their cheek to create 00:14:27.929 --> 00:14:30.610 that seal you need. That's a great tip. What 00:14:30.610 --> 00:14:33.309 about the medications for RSI, that rapid sequence 00:14:33.309 --> 00:14:36.169 intubation? This is a huge, smallest detail. 00:14:36.330 --> 00:14:38.870 You have to reduce the doses of your sedatives, 00:14:39.049 --> 00:14:42.629 barbiturates, benzodiazepines by 20 to 40 percent. 00:14:42.750 --> 00:14:45.269 20 to 40? Why so much? Because of their reduced 00:14:45.269 --> 00:14:47.950 reserve and slower metabolism. If you give them 00:14:47.950 --> 00:14:50.629 a standard adult dose, you risk causing immediate, 00:14:50.990 --> 00:14:53.590 profound, and possibly fatal hypotension. Got 00:14:53.590 --> 00:14:56.450 it. Okay, on to B for breathing. The source talks 00:14:56.450 --> 00:14:58.990 about insidious failure here. What's going on 00:14:58.990 --> 00:15:00.889 with their respiratory mechanics? Everything 00:15:00.889 --> 00:15:03.269 is working against them. Their chest, wall, and 00:15:03.269 --> 00:15:05.309 lungs are stiffer, so it's more work to take 00:15:05.309 --> 00:15:09.090 a breath. gas exchange is less efficient. And 00:15:09.090 --> 00:15:11.509 critically, their functional residual capacity, 00:15:11.710 --> 00:15:15.370 the FRC, is much smaller. And the FRC is what, 00:15:15.370 --> 00:15:17.149 the air left in your lungs after you breathe 00:15:17.149 --> 00:15:19.629 out? Exactly. It's your buffer. When that shrinks, 00:15:19.710 --> 00:15:22.590 you have zero room for error. A small injury, 00:15:23.009 --> 00:15:25.850 pain from a rib fracture, even just lying flat 00:15:25.850 --> 00:15:29.009 for a CT scan can cause their small airways to 00:15:29.009 --> 00:15:31.429 collapse. And the hidden danger here is in the 00:15:31.429 --> 00:15:34.399 vital signs, right? Yes. This is so important. 00:15:35.039 --> 00:15:37.340 Aging suppresses the heart rate response to a 00:15:37.340 --> 00:15:39.700 lack of oxygen. So they don't get tachycardic 00:15:39.700 --> 00:15:42.259 when they're hypoxic. They might not. That critical 00:15:42.259 --> 00:15:45.039 warning sign might be completely absent. So respiratory 00:15:45.039 --> 00:15:47.700 failure can present insidiously. You look at 00:15:47.700 --> 00:15:49.840 the monitor, the heart rate is fine, but their 00:15:49.840 --> 00:15:52.440 O2 sat is plummeting. So the implication for 00:15:52.440 --> 00:15:55.250 us is... Be aggressive. Don't wait for the classic 00:15:55.250 --> 00:15:57.750 signs. Exactly. Your threshold for intubating 00:15:57.750 --> 00:16:00.250 has to be much, much lower. And you have to manage 00:16:00.250 --> 00:16:02.809 rib fractures like your hair is on fire. Older 00:16:02.809 --> 00:16:05.190 patients just do not tolerate them well at all. 00:16:05.509 --> 00:16:07.490 It's a fast track to pneumonia. OK, let's go 00:16:07.490 --> 00:16:10.649 to C for circulation. This feels like the biggest 00:16:10.649 --> 00:16:13.470 pitfall in geriatric trauma failing to recognize 00:16:13.470 --> 00:16:16.129 shock because the vitals look OK. It's probably 00:16:16.129 --> 00:16:18.440 the most common and most deadly mistake. What's 00:16:18.440 --> 00:16:21.840 the physiology behind this masked response? It's 00:16:21.840 --> 00:16:24.860 what we call the fixed response. Age -related 00:16:24.860 --> 00:16:27.259 changes mean they often have a fixed heart rate 00:16:27.259 --> 00:16:29.559 and a fixed cardiac output. They can't speed 00:16:29.559 --> 00:16:32.340 up. So unlike a younger person who gets tachycardic 00:16:32.340 --> 00:16:34.860 when they're bleeding. The older patient's response 00:16:34.860 --> 00:16:37.200 is to clamp down their peripheral blood vessels. 00:16:37.580 --> 00:16:39.940 They increase their systemic vascular resistance, 00:16:40.039 --> 00:16:42.700 or SVR, to try and maintain their blood pressure. 00:16:42.840 --> 00:16:45.179 And if they're on beta blockers? It's even worse. 00:16:45.360 --> 00:16:48.570 Up to 20 % of them are. The beta blocker just 00:16:48.570 --> 00:16:50.669 makes it physiologically impossible for the heart 00:16:50.669 --> 00:16:52.950 to speed up, even if they're bleeding to death. 00:16:53.269 --> 00:16:55.610 So if tachycardia, the classic sign of shock, 00:16:55.809 --> 00:16:58.330 is gone, how do we spot it? This is where the 00:16:58.330 --> 00:17:00.490 source flags a huge shift in our assessment. 00:17:01.129 --> 00:17:03.269 What is the new definition of hypotension for 00:17:03.269 --> 00:17:05.369 this group? This is the number you need to burn 00:17:05.369 --> 00:17:08.049 into your brain. A systolic blood pressure of 00:17:08.049 --> 00:17:11.089 110 millimeter Hg should be your threshold for 00:17:11.089 --> 00:17:14.349 identifying hypotension in anyone over 65. 110. 00:17:14.509 --> 00:17:17.269 110. Because so many of them have high blood 00:17:17.269 --> 00:17:20.529 pressure to begin with, a BP of 12 ,880 might 00:17:20.529 --> 00:17:23.150 actually be profound shock for them. If they 00:17:23.150 --> 00:17:25.730 hit 110, you have to assume they're in significant 00:17:25.730 --> 00:17:28.970 shock and act immediately. Wow. That one number 00:17:28.970 --> 00:17:32.670 changes everything. So the new mantra is, do 00:17:32.670 --> 00:17:36.529 not equate BP with shock. What's the clinical 00:17:36.529 --> 00:17:39.190 implication for managing that? If you see any 00:17:39.190 --> 00:17:41.759 evidence of circulatory failure, Even if it looks 00:17:41.759 --> 00:17:44.319 mild, you have to assume they are bleeding, period. 00:17:44.759 --> 00:17:46.660 And you need to look for definitive evidence 00:17:46.660 --> 00:17:49.759 of tissue hypoperfusion that bypasses those masked 00:17:49.759 --> 00:17:52.099 vital signs. With labs. Like labs. You have to 00:17:52.099 --> 00:17:54.059 use serum markers, like lactate and base deficit. 00:17:54.599 --> 00:17:56.660 A high lactate is a five alarm fire. It tells 00:17:56.660 --> 00:17:58.940 you that cells are starving for oxygen, no matter 00:17:58.940 --> 00:18:00.720 what the blood pressure cuff says. So what's 00:18:00.720 --> 00:18:03.119 the plan for treatment? You go fast to aggressive, 00:18:03.380 --> 00:18:05.380 balanced resuscitation. blood products early. 00:18:05.900 --> 00:18:07.720 And you need to consider advanced monitoring 00:18:07.720 --> 00:18:11.140 sooner. A central line, a focused cardiac ultrasound 00:18:11.140 --> 00:18:13.940 to guide your fluid resuscitation. You have to 00:18:13.940 --> 00:18:15.940 walk this tightrope between giving them enough 00:18:15.940 --> 00:18:18.200 fluid, but not so much that you put their already 00:18:18.200 --> 00:18:20.619 stiff heart into failure. Okay, let's move to 00:18:20.619 --> 00:18:24.599 D for disability. Neurological assessment. This 00:18:24.599 --> 00:18:26.640 is complicated by brain atrophy and, of course, 00:18:27.019 --> 00:18:30.599 medications. Right. That cerebral atrophy creates 00:18:30.599 --> 00:18:33.559 what we call the silent space. It allows a bleed 00:18:33.559 --> 00:18:36.180 in the head, like a subdural, to get pretty big 00:18:36.180 --> 00:18:38.819 before it starts causing symptoms. So a normal 00:18:38.819 --> 00:18:41.759 neuro exam, a normal GCS, it doesn't mean they're 00:18:41.759 --> 00:18:44.380 okay. It absolutely does not. It could be a deadly 00:18:44.380 --> 00:18:46.740 deception. But the number one highest priority 00:18:46.740 --> 00:18:49.380 here seems to be their coagulation status. This 00:18:49.380 --> 00:18:51.839 is the single most actionable life or death point 00:18:51.839 --> 00:18:55.039 in the D assessment. So many older patients are 00:18:55.039 --> 00:18:57.700 on anticoagulants or antiplatelets. Blood thinners. 00:18:58.200 --> 00:19:01.960 Right. Warfarin, xarelto, eliquis, plavix, aspirin. 00:19:02.299 --> 00:19:04.599 This puts them at an incredibly high risk for 00:19:04.599 --> 00:19:07.200 intracranial hemorrhage. Early identification 00:19:07.200 --> 00:19:09.900 and timely, aggressive reversal of those drugs 00:19:09.900 --> 00:19:12.019 is the single most important thing we can do 00:19:12.019 --> 00:19:14.019 to improve their outcome. Let's get into the 00:19:14.019 --> 00:19:16.420 weeds on reversal, the smallest details. What 00:19:16.420 --> 00:19:19.440 about those newer drugs, the DOACs? Okay, so 00:19:19.440 --> 00:19:21.779 for warfarin, it's pretty straightforward. You 00:19:21.779 --> 00:19:25.319 give prothrombin complex, concentrate, PCC, plasma, 00:19:25.720 --> 00:19:28.740 and vitamin K. PCC is the fastest, but here's 00:19:28.740 --> 00:19:31.279 the really scary part. With the newer drugs, 00:19:31.460 --> 00:19:34.759 the DOACs, their standard coagulation labs, like 00:19:34.759 --> 00:19:37.660 an INR, might look perfectly normal. Wait, so 00:19:37.660 --> 00:19:39.819 the lab test is normal, but they're still at 00:19:39.819 --> 00:19:42.279 high risk of bleeding. Exactly. It's a terrifying 00:19:42.279 --> 00:19:44.819 clinical moment. The lab is lying to you. There 00:19:44.819 --> 00:19:46.900 are specific reversal agents for some of these 00:19:46.900 --> 00:19:48.799 newer drugs, but they're not always available. 00:19:49.000 --> 00:19:51.099 The bottom line is you have to find out what 00:19:51.099 --> 00:19:53.420 drug they're on and start the reversal protocol 00:19:53.420 --> 00:19:55.539 immediately if you even suspect a head injury. 00:19:55.940 --> 00:19:57.980 You can't wait for a lab test that might be falsely 00:19:57.980 --> 00:20:00.500 reassuring. Okay, last one in the primary survey, 00:20:00.700 --> 00:20:03.220 E for exposure and environment. The priority 00:20:03.220 --> 00:20:05.640 here is preventing hypothermia. Why are they 00:20:05.640 --> 00:20:08.259 so at risk for getting cold? multiple reasons. 00:20:08.700 --> 00:20:11.440 They have less subcutaneous fat to insulate them, 00:20:11.720 --> 00:20:14.140 nutritional issues, chronic conditions. All of 00:20:14.140 --> 00:20:16.119 it just dramatically increases their risk for 00:20:16.119 --> 00:20:18.480 hypothermia. And hypothermia is bad in trauma 00:20:18.480 --> 00:20:21.660 because it messes up your ability to clot, creating 00:20:21.660 --> 00:20:24.599 a vicious cycle of bleeding, and it increases 00:20:24.599 --> 00:20:27.240 the risk of lethal cardiac arrhythmias. And what's 00:20:27.240 --> 00:20:29.420 the nursing priority? Balancing the need for 00:20:29.420 --> 00:20:32.220 a quick exam with preventing other problems. 00:20:32.339 --> 00:20:35.400 You have to do the exam. But the priority is 00:20:35.400 --> 00:20:38.220 early liberation from spine boards and c -collars 00:20:38.220 --> 00:20:40.619 once you've cleared the spine. To prevent pressure 00:20:40.619 --> 00:20:43.000 sores, pressure injuries, and delirium. You have 00:20:43.000 --> 00:20:45.980 to pad their bony prominences immediately and 00:20:45.980 --> 00:20:49.039 be relentless about keeping them warm with forced 00:20:49.039 --> 00:20:52.180 air warmers and warm fluids. Let's circle back 00:20:52.180 --> 00:20:54.680 and really synthesize some of the system changes 00:20:54.680 --> 00:20:57.299 from that table and the source material. Let's 00:20:57.299 --> 00:20:59.640 start with cardiac again. What does that fixed 00:20:59.640 --> 00:21:01.599 output really mean when we're trying to give 00:21:01.599 --> 00:21:04.200 fluids? It means you have a tiny, tiny therapeutic 00:21:04.200 --> 00:21:06.430 window. If you don't give enough fluid, they 00:21:06.430 --> 00:21:09.130 crash from hypovolemia. If you give too much, 00:21:09.490 --> 00:21:11.950 their stiff, weak heart can't handle the volume, 00:21:12.190 --> 00:21:14.450 and you push them into congestive heart failure 00:21:14.450 --> 00:21:18.109 and pulmonary edema. It requires exquisite, careful 00:21:18.109 --> 00:21:20.769 titration. Okay, and the renal system. You mentioned 00:21:20.769 --> 00:21:23.509 a paradox where normal labs don't mean normal 00:21:23.509 --> 00:21:25.750 function. This is a huge spot for medication 00:21:25.750 --> 00:21:29.210 errors. Kidney function goes down with age, but 00:21:29.210 --> 00:21:31.750 because they also have less muscle mass, they 00:21:31.750 --> 00:21:34.390 don't produce as much creatinine. So their serum 00:21:34.390 --> 00:21:37.410 creatinine level might look normal, but it's 00:21:37.410 --> 00:21:40.390 not reflecting their true underlying kidney dysfunction. 00:21:41.109 --> 00:21:42.910 So you have to assume their kidneys are worse 00:21:42.910 --> 00:21:45.470 than the labs say they are. Always. You have 00:21:45.470 --> 00:21:47.630 to assume renal insufficiency and adjust your 00:21:47.630 --> 00:21:49.910 drug doses accordingly, especially for drugs 00:21:49.910 --> 00:21:52.250 cleared by the kidneys. And how does the kidney 00:21:52.250 --> 00:21:55.190 also mask hypovolemia? This is another tricky 00:21:55.190 --> 00:21:58.190 one. The aging kidney doesn't respond as well 00:21:58.190 --> 00:22:00.690 to the hormone that tells it to hold on to water 00:22:00.690 --> 00:22:03.339 when the body is dehydrated. So they keep making 00:22:03.339 --> 00:22:05.720 urine even if they're in shock? They can, yeah. 00:22:06.000 --> 00:22:08.660 Urine flow might look normal or even high, despite 00:22:08.660 --> 00:22:11.680 the patient being profoundly hypovolemic. So 00:22:11.680 --> 00:22:14.039 you can't use urine output alone as a reliable 00:22:14.039 --> 00:22:17.119 guide for your resuscitation. Let's move to three 00:22:17.119 --> 00:22:19.700 specific injuries that the source's flag is being 00:22:19.700 --> 00:22:22.259 extra high -risk, starting with rib fractures. 00:22:22.599 --> 00:22:25.039 The source calls it the pneumonia trap. It's 00:22:25.039 --> 00:22:27.619 a perfect name for it. It is the single most 00:22:27.619 --> 00:22:30.900 common cause of early problems after chest trauma 00:22:30.900 --> 00:22:33.509 in this group. The incidence of pneumonia can 00:22:33.509 --> 00:22:36.890 be as high as 30%. And the mortality risk goes 00:22:36.890 --> 00:22:40.049 up with every single additional rib that's broken. 00:22:40.849 --> 00:22:43.630 So the goals are pain control and pulmonary hygiene. 00:22:44.029 --> 00:22:46.750 But the source warns about the narcotic pitfall. 00:22:47.390 --> 00:22:50.390 What's that? This is critical. You have to give 00:22:50.390 --> 00:22:52.349 them pain medicine so they can take deep breaths 00:22:52.349 --> 00:22:55.450 and cough. But if you give them too much... You 00:22:55.450 --> 00:22:57.589 cause respiratory depression and delirium. So 00:22:57.589 --> 00:22:59.869 you make the problem worse. Exactly. You get 00:22:59.869 --> 00:23:02.009 the opposite of what you want. They stop breathing 00:23:02.009 --> 00:23:04.369 deeply, and that just accelerates the collapse 00:23:04.369 --> 00:23:06.349 into pneumonia. It's a vicious cycle. So what 00:23:06.349 --> 00:23:08.710 are the strategies to avoid that? First, you 00:23:08.710 --> 00:23:10.329 have to be vigilant, watching their breathing, 00:23:10.529 --> 00:23:13.230 not just their O2 sat. Second, when you do use 00:23:13.230 --> 00:23:15.569 narcotics, use smaller doses of shorter acting 00:23:15.569 --> 00:23:18.069 ones. They clear faster. Third, and this is key, 00:23:18.650 --> 00:23:21.730 prioritize non -narcotic options, regional nerve 00:23:21.730 --> 00:23:24.589 blocks, epidurals. They provide great pain relief 00:23:24.589 --> 00:23:26.829 without the systemic side effects. Okay, next, 00:23:27.069 --> 00:23:28.769 traumatic brain injury. We know it's common in 00:23:28.769 --> 00:23:31.009 falls. What's the core challenge here? The challenge 00:23:31.009 --> 00:23:33.049 is that their high mortality isn't just because 00:23:33.049 --> 00:23:35.349 of the injury itself, but because of their inability 00:23:35.349 --> 00:23:38.769 to recover. And making the diagnosis is incredibly 00:23:38.769 --> 00:23:42.019 difficult. Why? Because of their baseline. Pre 00:23:42.019 --> 00:23:44.980 -existing dementia or delirium makes it really 00:23:44.980 --> 00:23:47.059 hard to tell if a change in their mental status 00:23:47.059 --> 00:23:49.819 is from the TBI or something else. You just can't 00:23:49.819 --> 00:23:52.099 rely on the GCS score alone. So the management 00:23:52.099 --> 00:23:54.799 priority is? Liberal use of CT scans. You just 00:23:54.799 --> 00:23:56.920 have to have a very, very low threshold to scan 00:23:56.920 --> 00:23:58.700 them, especially if they're on any kind of blood 00:23:58.700 --> 00:24:01.200 thinner. And again, if you find a bleed, the 00:24:01.200 --> 00:24:04.279 absolute priority is aggressive early reversal 00:24:04.279 --> 00:24:07.640 of that anticoagulant. Lastly, pelvic fractures. 00:24:08.160 --> 00:24:10.259 In younger people, these aren't always a huge 00:24:10.259 --> 00:24:13.220 deal unless there's major bleeding. What's different 00:24:13.220 --> 00:24:15.480 here? The risk profile just skyrockets. They're 00:24:15.480 --> 00:24:17.839 usually from ground level falls onto osteoporotic 00:24:17.839 --> 00:24:20.779 bone. And mortality from a pelvic fracture is 00:24:20.779 --> 00:24:23.220 four times higher in older patients than in younger 00:24:23.220 --> 00:24:25.900 ones. Four times? Wow. Is there a hidden risk 00:24:25.900 --> 00:24:29.140 even with stable looking fractures? Yes. The 00:24:29.140 --> 00:24:31.900 need for blood. The sources show that the need 00:24:31.900 --> 00:24:34.359 for blood transfusion is much, much higher in 00:24:34.359 --> 00:24:37.000 the elderly, even for fractures that look stable 00:24:37.000 --> 00:24:39.420 on the x -ray. You have to have a low threshold 00:24:39.420 --> 00:24:42.079 to start your massive transfusion protocol if 00:24:42.079 --> 00:24:44.519 they're unstable at all. And the long -term outcome 00:24:44.519 --> 00:24:48.019 is, again, about independence. Absolutely. They're 00:24:48.019 --> 00:24:49.980 much less likely to return to an independent 00:24:49.980 --> 00:24:52.319 lifestyle after a pelvic fracture. It really 00:24:52.319 --> 00:24:55.099 reinforces that fall prevention is the absolute 00:24:55.099 --> 00:24:57.539 mainstay of reducing the death and disability 00:24:57.539 --> 00:25:00.319 from these injuries. Let's move into a few special 00:25:00.319 --> 00:25:03.279 circumstances, starting with a revisit to medications. 00:25:03.859 --> 00:25:05.700 Beta blockers. You mentioned them, but let's 00:25:05.700 --> 00:25:08.279 just hammer this home. We have to. Up to 20 % 00:25:08.279 --> 00:25:10.970 of elderly patients are on them. They physiologically 00:25:10.970 --> 00:25:13.509 block the heart rate response to shock. It makes 00:25:13.509 --> 00:25:16.349 your standard trauma assessment totally unreliable. 00:25:16.730 --> 00:25:18.789 You have to know if they're on one, and if they 00:25:18.789 --> 00:25:20.210 are, you have to switch your brain to looking 00:25:20.210 --> 00:25:22.329 at lactate and base deficit instead of heart 00:25:22.329 --> 00:25:24.650 rate. And for anticoagulants, what's the action 00:25:24.650 --> 00:25:27.029 plan the second they roll through the door? Zero 00:25:27.029 --> 00:25:29.430 tolerance for delay. You have to immediately 00:25:29.430 --> 00:25:31.890 find out which drug they're on, talk to the family, 00:25:32.210 --> 00:25:34.990 call the pharmacy, and start the specific reversal 00:25:34.990 --> 00:25:38.680 agent immediately. Every minute you wait, especially 00:25:38.680 --> 00:25:41.160 with a head injury, is brain tissue being lost. 00:25:41.640 --> 00:25:44.220 Okay, let's talk about elder maltreatment. This 00:25:44.220 --> 00:25:46.660 is a tough topic, but one the sources say is 00:25:46.660 --> 00:25:49.940 dangerously under -recognized. It's hugely underestimated. 00:25:50.720 --> 00:25:53.420 The data suggests it might be as common as child 00:25:53.420 --> 00:25:56.579 maltreatment. but only a fraction of cases ever 00:25:56.579 --> 00:25:59.319 get reported. Physical maltreatment shows up 00:25:59.319 --> 00:26:02.480 in as many as 14 % of geriatric trauma admissions. 00:26:02.660 --> 00:26:04.720 And it's not just physical abuse, right? It's 00:26:04.720 --> 00:26:07.079 neglect, too. Right. And the signs of neglect 00:26:07.079 --> 00:26:09.119 can be really subtle. You have to look for things 00:26:09.119 --> 00:26:11.660 like poor hygiene, dehydration, malnutrition, 00:26:12.259 --> 00:26:14.380 or a caregiver who just won't leave the patient 00:26:14.380 --> 00:26:16.920 alone with the staff. And if we do suspect physical 00:26:16.920 --> 00:26:19.480 abuse, what are the specific physical findings 00:26:19.480 --> 00:26:21.079 we should be looking for? What's the checklist? 00:26:21.259 --> 00:26:22.940 Okay, so you're looking for injuries that just 00:26:22.940 --> 00:26:25.319 don't match the story of the simple fall. Things 00:26:25.319 --> 00:26:28.019 like bruises in weird places, the inner arms 00:26:28.019 --> 00:26:30.720 or thighs, the scalp behind the ears, on the 00:26:30.720 --> 00:26:33.279 buttocks, areas that don't get hit in a normal 00:26:33.279 --> 00:26:35.500 fall. Right. You're also looking for multiple 00:26:35.500 --> 00:26:38.359 bruises clustered together, or bruises shaped 00:26:38.359 --> 00:26:40.759 like an object, like a belt or a hand. What else? 00:26:41.099 --> 00:26:43.579 Abrasions from restraints, usually around the 00:26:43.579 --> 00:26:46.619 armpits or on the wrists and ankles. Untreated 00:26:46.619 --> 00:26:48.920 pressure sores in places other than their lower 00:26:48.920 --> 00:26:51.940 back. And maybe the biggest red flag is injuries 00:26:51.940 --> 00:26:54.500 in different stages of healing. that points to 00:26:54.500 --> 00:26:57.799 repeated trauma over time. That's a very clear, 00:26:57.940 --> 00:27:00.259 actionable list. So what's the bottom line, ethically, 00:27:00.759 --> 00:27:02.859 if the story and the injuries don't add up? You 00:27:02.859 --> 00:27:05.500 have to report it immediately to the appropriate 00:27:05.500 --> 00:27:08.059 authorities. And if maltreatment is confirmed 00:27:08.059 --> 00:27:10.740 or even just suspected, your primary ethical 00:27:10.740 --> 00:27:13.180 duty is the removal of that patient from the 00:27:13.180 --> 00:27:16.119 abusive situation. Which brings us to the final 00:27:16.119 --> 00:27:19.180 and maybe most important piece of this, establishing 00:27:19.180 --> 00:27:23.289 goals of care. Given the scats, They're 12 % 00:27:23.289 --> 00:27:25.609 of the population, but almost 30 % of trauma 00:27:25.609 --> 00:27:28.349 deaths. This feels like a conversation that needs 00:27:28.349 --> 00:27:31.470 to happen early. It has to happen early. The 00:27:31.470 --> 00:27:33.309 chances of them returning to their prior level 00:27:33.309 --> 00:27:37.069 of independence after a severe trauma are frankly 00:27:37.069 --> 00:27:40.740 low. So an early honest conversation with the 00:27:40.740 --> 00:27:42.640 patient, if possible, and their family about 00:27:42.640 --> 00:27:45.819 their goals is essential. It's not about giving 00:27:45.819 --> 00:27:48.359 up. It's about respecting their autonomy. So 00:27:48.359 --> 00:27:51.440 why is it so crucial to do this in the middle 00:27:51.440 --> 00:27:54.680 of a chaotic trauma resuscitation? Because the 00:27:54.680 --> 00:27:57.579 default in trauma is aggressive, maximal care. 00:27:58.039 --> 00:28:00.420 And without knowing the patient's wishes, we 00:28:00.420 --> 00:28:03.500 might start down a path of surgeries, ventilators, 00:28:04.059 --> 00:28:06.640 pressers. Things that might only prolong their 00:28:06.640 --> 00:28:08.759 suffering without actually improving their quality 00:28:08.759 --> 00:28:11.099 of life. So you bring in palliative care? You 00:28:11.099 --> 00:28:13.839 bring in palliative care early. They are the 00:28:13.839 --> 00:28:16.059 experts at navigating these conversations, at 00:28:16.059 --> 00:28:18.119 managing symptoms, and at making sure the care 00:28:18.119 --> 00:28:19.980 we provide is actually aligned with what the 00:28:19.980 --> 00:28:22.079 patient would have wanted. This has been an incredibly 00:28:22.079 --> 00:28:25.420 important deep dive. To recap, I think the central 00:28:25.420 --> 00:28:27.420 lesson for anyone listening is that geriatric 00:28:27.420 --> 00:28:29.700 trauma demands a totally different way of thinking. 00:28:29.819 --> 00:28:32.180 It really does. You cannot look for the classic 00:28:32.180 --> 00:28:34.289 signs of shock. You have to assume it's there, 00:28:34.509 --> 00:28:36.450 even with a normal heart rate. You have to look 00:28:36.450 --> 00:28:39.549 for that evidence of tissue hypoperfusion, that 00:28:39.549 --> 00:28:42.289 systolic BP of 110, the high lactate, the base 00:28:42.289 --> 00:28:45.609 deficit. And you have to reverse anticoagulation 00:28:45.609 --> 00:28:48.329 aggressively and immediately. And the focus has 00:28:48.329 --> 00:28:52.049 to be on managing the host. the pecs, the frailty, 00:28:52.470 --> 00:28:55.329 that fixed cardiac response, just as much, if 00:28:55.329 --> 00:28:57.829 not more, than the injury itself. Absolutely. 00:28:58.069 --> 00:29:00.809 All those small details, the gauze for the adential 00:29:00.809 --> 00:29:03.309 is patient. Knowing that a normal creatinine 00:29:03.309 --> 00:29:06.470 is a lie, cutting your RSI drug doses, that's 00:29:06.470 --> 00:29:08.869 what makes the difference between recovery and 00:29:08.869 --> 00:29:11.039 a catastrophic outcome. And that leads us to 00:29:11.039 --> 00:29:12.940 our final thought for you to chew on. The sources 00:29:12.940 --> 00:29:15.099 note that today's elderly are more active and 00:29:15.099 --> 00:29:17.200 mobile than ever, which puts them at higher risk. 00:29:17.259 --> 00:29:19.779 Right. So if we think about the specific vulnerabilities 00:29:19.779 --> 00:29:22.700 we've discussed, the massive TBI risk from a 00:29:22.700 --> 00:29:25.059 simple fall, the devastating mortality from small 00:29:25.059 --> 00:29:28.339 burns, what societal or infrastructure changes 00:29:28.339 --> 00:29:30.900 things outside the hospital might have the biggest 00:29:30.900 --> 00:29:33.220 public health impact here. That's a great question. 00:29:33.299 --> 00:29:36.299 I mean, Is it safer driving technology in cars 00:29:36.299 --> 00:29:38.940 that accounts for slower reaction times? Is it 00:29:38.940 --> 00:29:42.000 massive community -wide fall prevention programs 00:29:42.000 --> 00:29:44.079 that actually go into people's homes and fix 00:29:44.079 --> 00:29:46.559 the loose rugs and poor lighting? Or changing 00:29:46.559 --> 00:29:49.420 building codes to prevent the kind of minor scald 00:29:49.420 --> 00:29:52.480 burn that turns fatal? Exactly. It forces us 00:29:52.480 --> 00:29:54.759 to look beyond the trauma bay and into the world 00:29:54.759 --> 00:29:57.519 these patients are living in every day. A profound 00:29:57.519 --> 00:30:00.000 thought to end on as we close out this deep dive.