EMERGENCY MEDICINE
Caring for older folks can bring challenges
Sharon was a front-seat passenger in a car that was T-boned by another vehicle. The paramedics brought the 81-year-old to the emergency department and showed us a picture of Sharon’s badly crumpled car. They had to cut apart a portion to free her.
The medics had immobilized her neck in a collar. Remarkably, Sharon didn’t complain of pain, and her blood pressure and heart rate were normal.
She was quickly evaluated by our trauma team and within minutes a chest X-ray and an X-ray of her pelvis were taken. We also performed an ultrasound of her chest and torso to look for internal bleeding.
It wasn’t until things slowed down a bit that I realized Sharon seemed to have some mild confusion. She was very pleasant and cooperative, but she wasn’t answering all of our questions correctly. I wondered whether she had a touch of underlying dementia. Her confusion became more obvious as she repeatedly asked what had happened and where she was.
There are unique challenges when taking care of older trauma patients. There are normal physiological changes that occur with aging in addition to people having chronic medical problems for which they use medications that can have unintended side effects.
Aging is a progressive process that affects everyone, even those with a healthy lifestyle. With time, our physiologic reserve decreases and plays a role in how our bodies deal with the stress of traumatic events such as a car accident.
Many older patients are on numerous medications to treat such chronic conditions as high blood pressure, diabetes and atrial fibrillation. Blood pressure medications can impair the body’s normal response to stress by preventing the patient’s heart rate from increasing. Diabetes medications can cause a patient’s blood sugar to become dangerously low, causing altered mental status or unresponsiveness. Blood-thinning medications increase the risk of serious bleeding when a patient is injured.
Sharon ended up having numerous rib fractures. There also was a puncture in her right lung and a laceration to her liver that caused some internal bleeding. She suffered numerous fractures of her back. The CT scan of her brain did not show a skull fracture or bleeding in the brain, which was very fortunate.
Sharon was on a blood-thinning medication as well as a medication to keep her heart rate from getting too high. This explained why her heart rate was normal and even a little bit on the low side when we would have expected it to be more elevated due to her severe injuries and the anxiety and pain you would expect.
Her blood pressure ultimately dropped due to the internal bleeding from her liver injury, yet her heart rate did not increase as we expected. The medications that normally kept Sharon’s heart rate low were preventing her heart from increasing in this situation. We ended up giving her a blood transfusion, which helped increase her blood pressure.
At first glance, Sharon’s injuries didn’t appear to be that bad; it was hard to believe she ended up having so many. Her vital signs were normal, which was falsely reassuring. It was important for us to consider that there could be serious injuries given the severity of the crash.
Taking care of Sharon reminded me of several things. Not every patient will present the same way with the same symptoms.
Though Sharon had a pretty unremarkable physical exam, other patients with similar injuries have more pronounced findings in their exams.
There also were several complicating factors that made Sharon’s evaluation more difficult.
She was on medications that increased her risk for serious bleeding and altered her body’s normal physiological response to the stress of her trauma. She was more susceptible to injuries because of her advanced age and osteoporosis. Her dementia also made it harder for her to communicate what was bothering her.
Sharon had to stay in the hospital for several days to recover from her injuries. She didn’t require surgery, but she did have to go to a rehabilitation facility from the hospital to work on her strength and conditioning before she could go home a few weeks later.
Dr. Erika Kube is an emergency physician who works for Mid-ohio Emergency Services and Ohiohealth. drerikakubemd@gmail.com