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Care  of  the  Injured  Patient:  A  Geriatric  Perspective

Kara  Jones  MSN,  RN,   FNP-­‐BCJenna  Kesey MSN,  RN,   FNP-­‐BC,   CWS

Disclosures

• None   to  add,  

Objectives1) Identify   differences   in  physiology   for  the  aged  

patient.2) Identify   the  significance   of  geriatric   injuries   to  

morbidity   and  mortality.3) Pinpoint   system  based  modifications   in  

management   of  the   traumatically   injured  geriatric   patient.

4) Understand   management   principles   for  caring  for  the   thermally   injured   geriatric   patient.

5) Utilize  appropriate   resources   to  maximize  outcomes   for  the  geriatric   injured   patient.

University  Medical  Center:  Service  is  Our  Passion

Why  I  Care  about  Geriatric  Trauma

Geriatric  Trauma:A  Public  Health  Issue

• Geriatric   population:   aged  >60  years.• Over  10%  of  total   population.• Most  rapidly  growing   segment  of  the   US  population.

(Administration   on  Aging,   2015)(Census   Bureau,   2010)

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The  Issue  Continues• 33%  of   trauma  health   care  expenditures.• $30  billion   per  year  in  direct  &   indirect   costs.• 4th leading  cause   of   death  in   all  age  groups• 8th leading  cause   of   death  in   those  65   years  and  older.

Dela’O,   Miller,   Rodriguez,   Dumire,   &  Zipf,  2015Avin,   Hanke,   Kirk-­‐Sanchez,   McDonough,   Shubert,   Hardage,   &  Hartley,  2015Centers   for  Disease   Control,   2015

UMC  Trauma  Admissionsvs  Geriatric  Admissions

0

500

1000

1500

2000

2500

3000

3500

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Total  Trauma

Geriatric

Geriatric  Trauma  Injuries

• Most  common   cause  of  injury:  falls.• 2nd most  common:    motor   vehicle   collisions.• Pedestrian   injuries,   suicide,   geriatric   abuse.

Kozar,   Arbabi,   Stein,   Shackford,   Barraco,   Biffl,   Brasel,   Cooper,   Fakhry,  Livingston,   Moore,   &  Luchette,   2015

UMC  Geriatric  Trauma  Injury  Data

87

MVC Fall Assault MCC Pedis trian Knife GSW Glass Biting

Geriatric  Trauma  Through  the  Ages

• Public   health   issue   dating  back   to   the  80s.  – 1984:  85%   survival   rate  BUT  88%  did   not   return   to  prior   level   of  

function.– 1986:  70%   survival   rate;  care  should   not  differ   from  other   age  groups.  – 1990:  “We  would   contend   that   the  multiply   injured   elderly   patient  

that  has   sustained   trauma   is   different.

Oreskovich,   Howard,   Copass,   &  Carrico,   1984Horst,   Obeid,   Sorensen,   &  Bivins,   1986Scalea,  Simon,   Duncan,   Atweh,   Sclafani,   Phillips,   &  Shaftan,  1990

Through  the  Ages

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Objective  1:  Identify  differences  

in  physiology  for  the  aged  patient.Decreased  vision

Decreased  hearing

Slower  reflexes

Poor  balance

Impaired  cognitive  function

Impaired  motor  function

Decreased  muscle  mass

Decreased  muscle  strength

Decreased  bone  density

Decreased  joint  flexibility

Decreased  cardiac  output

Impaired  gas  exchange Decreased  vital  capacity

Slower  expiratory  flow  rates

Creatinine  clearance  decreases

Altered  motility  patternsDecreased  skin  elasticity

Decreased  skin  tone

Decreased  lean  body  massAltered  metabolism

Decreased  testosterone  secretion

Decreased  estrogen/progesterone

Decreased  smell

Altered  cardiac  physiology

ComorbiditiesHypertension

Arthritis

Coronary  artery  diseasePulmonary  disease

Cancer

Diabetes

Stroke

Arteriosclerosis

InfectionsPneumonia

Enlarged  prostate

Urinary  incontinence

Atrophic  gastritis

Chronic  constipation

Stool  incontinence

Cholelithiasis

Osteoporosis

Degenerative  joint  disease

GERD

Dysphagia

Diverticulosis

Insomnia

AnxietyPTSD

Mental  health  disorders

Parkinson’s  disease

Atrial  Fibrillation

Malnutrition

Hyperlipidemia

Mechanisms  of  Injury

• #1  =  Falls• #2  =  Motor   Vehicle   Collisions   (MVC)• Pedestrian   injury• Abuse/assault/violence• Suicide• Thermal   injury

Falls  in  theGeriatric  Population

• 40%  of  trauma   admissions   related   to   falls.• 10%-­‐15%  of  all   emergency   department   visits.• Leading   cause   of  non  fatal   injuries.• >60%   discharged   somewhere   other   than  home.

Gelbard,   Inabe,  Okoye,  Morrell,   Saadi,   Lam,  Talving,  &  Demetriades,  2014Ayoung-­‐Chee,   Mcintyre,  Ebel,  Mack,  McCormick,  &  Maier,   2014Ambrose,   Cruz,   &  Paul,   2015

UMC  Geriatric  Trauma  Falls

0

100

200

300

400

500

600

700

800

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Chart  Title

Falls Total  Geriatric  Trauma

Objective  2:  Identify  the  significance  of  geriatric  injuries  to  morbidity  and  mortality.  

• #1  Fall:  Overall  mortality   =  6%.• Operative  intervention   =  30%.• Proximal   femur   fracture   mortality   =  20%-­‐30%.  

Gelbard,   et  al,   2014Sullivan,   Baldwin,   Donegan,   Mehta,   &  Ahn,   2014

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MVC  Mortality

• #2  MVC:  blunt   force  trauma                rib   fractures.• 3-­‐4  rib  fractures   =  19%  mortality

31%  pneumonia• >6  rib  fractures   =  33%  mortality  

51%  pneumonia• Chest   wall  pain  limits   pulmonary   function.

Bulger,   Arneson,   Mock,  &   Jurkovich,   2000

Burn  Mortality

• Top  20  non  fatal  causes  of  injury• <1940,   no  geriatric   patient   survived   >10%  TBSA• Survival  dependent   on  many  factors• Mortality=   50%  in  a  25%  TBSA  for  >70  years  old

100%  in   a  40%  TBSA  for  >80  years  • COPD  independently   associated   with  mortality

Stassen,   Lukan,  Mizuguchi,   Spain,   Carrillo,   &  Polk,   2001

Objective  3:  Pinpoint  system  based  

modifications  in  management  of  the  traumatically  injured  geriatric  patient.• EAST   guidelines:  – avoid  under   triage  – rapidly  correct   coagulopathy  – admit   to  ICU  if   base  deficit   <-­‐6mEq/L  – SBP<90   associated  with  82%  mortality  rate– GCS  <8   x  72  hours  warrants  supportive   care  discussion.

Jacobs,  Plaisier,   Barie,   Hammond,  Holevar,  Sinclair,   Scalea,  &  Wahl,   2003

Trauma  Guidelines

• American   College   of  Surgeons-­‐Committee   on  Trauma  (ACS-­‐COT)– Inclusive  trauma  system– Pre-­‐hospital  trauma  care–Multidisciplinary  approach– Rehabilitation

American   College   of  Surgeons,   2014

Trauma  Guidelines

• American   College   of  Surgeons:  Trauma  Quality  Improvement   Program  (ACS-­‐TQIP)– Trauma  team  activation– Initial  evaluation– Specialized  geriatric   inpatient  care– Decision  making  and  care  preferences– Discharge  

American   College   of  Surgeons,   2014

More  Guidelines

• Other   guidelines:– American   Association   for   Surgery  of  Trauma   (AAST)– American   Geriatrics  Society   (AGS)– American   Burn   Association   (ABA)– American   Family  Physician   (AFP)– American   College   of  Emergency   Physicians   (ACEP)– American   Association   of   Nurse   Practitioners   (AANP)– And  on,   and   on,  and   on   .  .  .  

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Neurological  System

• Insomniaorient  to  day/nightsleeping  meds

Chen,  Shi,   Liang,  Xu,  Desislava,  Wu,  &  Zhang,  2015O’Neal-­‐Moffitt,  Delic,  Bradshaw,  &  Olcese,  2015

• Delirium/Dementiaorient  to  day/nightOOB  activitesoutsidelimit  offending  drugslimit  night  time  interruptions• Alcohol/Drug  Withdrawal

give  beersvitamin  supplementationCIWA  protocol

BEERS  criteria

Nonbenzodiazepine hypnotics •

Eszopiclone• Zolpidem• Zaleplon

These medications may

not s ignificantly improve s leep and can cause many ser ious s ide effects , including confus ion, falls , and bone

fractures .

Avoid ongoing use of these drugs

(over 90 days ).

Dabigatran

This medication, used to prevent

the formation of blood clots in patients with atr ial fibr illation, increases the chance of bleeding in

adults 75 years and older more than another drug, war far in, that is

used for the same purpose. There isn’t enough evidence that dabigatran is effective and safe in

patients with kidney problems .

Use this drug with caution in adults

75 and in older adults with kidney problems .

American  Geriatrics  Society,  2012

BEERS  Criteria

Ben zod iazep in es

Short- and i ntermedi ate-acti ng: • Alp razo lam • E stazo lam • Lorazep am • Ox azep am • Temazep am • Tri azo lamLong-acti ng: • Ch lorazep ate

• Ch lord iazep ox id e • Ch lord iazep ox id e-ami trip tyl in e• Cl id in iu m-ch lord iazep ox id e • Clon azep am• Diazep am

• Flu razep am• Qu azep am

Old er ad u l ts are esp eci al l y sen si ti ve to th ese

med ication s. Th ese d ru gs may in crease ri sks o f men tal d ecl in e, d el i riu m, fal l s, fractu res, an d car accid en ts in o ld er ad u l ts. Desp i te th ese ri sks, th ey may b e ap p rop ri ate, i n certain cases, for treatin g sei zu res, certain

sleep d i sord ers, an x iety d i sord ers, wi th d rawal from b en zod iazep in e d ru gs an d al coh o l , an d en d -o f-l i fe care.

Avo id b en zod iazep in es

(al l typ es) wh en treatin g in somn ia, agi tation , or d el i riu m (seriou s con fu sion th at may h ave l astin g effects).

Insomnia

Oral deconges tants •

Pseudoephedr ine • Phenylephr ine Stimulants

• Amphetamine• Methylphenidate • Pemoline

Other medications • Theophylline

• Caffeine

These drugs make

insomnia worse. Avoid

BEERS  Criteria

Del i riu m

Al l Tri cycl i c Antid epressan ts (TCAs)Al l An ti cho linergi c drugs Benzodiazepines Ch lorp romazin e Corticosteroids H2-receptor an tagon i st Mep erid in e Sed ati ve h yp n oti cs Th iorid azin e

Th ese med ications can cau se or worsen d el i riu m in older people. Avoid these drugs in o ld er ad u lts with or at hi gh risk o f del i riu m.

Avo id

Demen ti a an d cogni ti ve/ mental impai rment An ti ch o l in ergic d rugs Ben zodiazep ines H2-recep tor an tagon ists Zolpid em An tip sych oti cs—used regu larl y or as needed

Avo id th ese dru gs in adu lts with cogni ti ve or “th in kin g” problems b ecause these med ication s may make thi s worse. An tip sych oti c drugs should not be prescribed for b eh avioral problems rel ated to d ementi a u n less n on-drug or safer dru g options are not workin g an d a p atien t i s a th reat to himsel f or oth ers. Antipsychotic d ru gs may in crease th e chance o f stroke and d eath in people with demen tia.

Avo id

Medications  in  the  Geriatric  Patient

• Restart  home  meds  appropriately  

• Follow  BEERS  criteria

• Limit  narcoticsLess  is  more

• Avoid  benzos

Polypharmacy

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What  is  CIWA?

Gonzalez,  Santolaria,  Martin,  Fernandez,  &  Quintero,  2014

UMC Health System

Patient Label Here

ALCOHOL WITHDRAWAL SYNDROME PLAN

PHYSICIAN ORDERS

Weight ____________________________________________ Allergies ________________________________________________________

Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.

ORDER ORDER DETAILS

Patient Care

Alcohol Withdrawal Prophylaxis Protocol

***See Reference Text***

Utilize the Richmond Agitation Sedation (Utilize the Richmond Agitation Sedation Scale)

q4h ***See Reference Text***

Utilize CIWA-Ar Alcohol Withdrawal Asses (Utilize CIWA-Ar Alcohol Withdrawal Assessment Tool)

q4h

Vital Signs

Per Unit Standards

Communication

Seizure Precautions

Aspiration Precautions

IV Solutions

Ethanol Dehydrated 10% 500 mL D5W

50 mL, Every Bag IV

Medications

Medication sentences are per dose. You will need to calculate a total daily dose if needed.

**Both lorazepam options should be ordered to align with the CIWA-Ar treatment protocol. If the decision is made not to order one or both of the lorazepam orders, provide clear instructions for treatment of alcohol withdrawal.**

LORazepam

1 mg, IVPush, inj, q2h, PRN agitation Give for CIWA-Ar score of 9-15. Maximum dose of 24 mg/24 hr. Reassess patient in 2 hours and treat based on CIWA-Ar Score.

LORazepam

2 mg, IVPush, inj, q1h, PRN agitation Give for CIWA-Ar score greater than 15. Maximum dose of 24 mg/24 hr. Reassess patient in 2 hours and treat based on CIWA-Ar Score.

IV Vitamins

Banana Bag (NS) Continuous

IV, mL/hr Give once every 24 hours. Hold main IVFluids while banana bag is infusing. 1 mg, Every Bag 100 mg, Every Bag

***Consider high dose thiamine in patients with diagnosis of Wernicke’s Encephalopathy***

thiamine

500 mg, IVPB, ivpb, TID, x 3 days

Oral Vitamins

folic acid

1 mg, PO, tab, Daily

TO Read Back Scanned Powerchart Scanned PharmScan

Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________

Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________

Page: 1 Alcohol Withdrawal Syndrome Plan Version: 4 Effective on: 01/05/15 1201

Page 1 of 2

UMC Health System Patient Label Here

ALCOHOL WITHDRAWAL SYNDROME PLAN

PHYSICIAN ORDERS

Place an "X" in the Orders column to designate orders of choice AND an "x" in the specific order detail box(es) where applicable.

ORDER ORDER DETAILS

multivitamin 1 tab, PO, tab, Daily

thiamine 100 mg, PO, tab, Daily

TO Read Back Scanned Powerchart Scanned PharmScan

Order Taken by Signature: _________________________________________________________________________ Date ____________________________ Time ____________________________

Physician Signature: ___________________________________________________________________________ Date ____________________________ Time ____________________________

Page: 2 Alcohol Withdrawal Syndrome Plan Version: 4 Effective on: 01/05/15 1201

Page 2 of 2

CIWA-­‐ArClinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

Patient:__________________________ Date: ________________ Time: _______________ (24 hour clock, midnight = 00:00)

Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______

NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation.0 no nausea and no vomiting1 mild nausea with no vomiting234 intermittent nausea with dry heaves567 constant nausea, frequent dry heaves and vomiting

TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation.0 none1 very mild itching, pins and needles, burning or numbness2 mild itching, pins and needles, burning or numbness3 moderate itching, pins and needles, burning or numbness4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

TREMOR -- Arms extended and fingers spread apart. Observation.0 no tremor1 not visible, but can be felt fingertip to fingertip234 moderate, with patient's arms extended567 severe, even with arms not extended

AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation.0 not present1 very mild harshness or ability to frighten2 mild harshness or ability to frighten3 moderate harshness or ability to frighten4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

PAROXYSMAL SWEATS -- Observation.0 no sweat visible1 barely perceptible sweating, palms moist234 beads of sweat obvious on forehead567 drenching sweats

VISUAL DISTURBANCES -- Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation.0 not present1 very mild sensitivity2 mild sensitivity3 moderate sensitivity4 moderately severe hallucinations5 severe hallucinations6 extremely severe hallucinations7 continuous hallucinations

ANXIETY -- Ask "Do you feel nervous?" Observation.0 no anxiety, at ease1 mild anxious234 moderately anxious, or guarded, so anxiety is inferred567 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.0 not present1 very mild2 mild3 moderate4 moderately severe5 severe6 very severe7 extremely severe

AGITATION -- Observation.0 normal activity1 somewhat more than normal activity234 moderately fidgety and restless567 paces back and forth during most of the interview, or constantly thrashes about

ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?"0 oriented and can do serial additions1 cannot do serial additions or is uncertain about date2 disoriented for date by no more than 2 calendar days3 disoriented for date by more than 2 calendar days4 disoriented for place/or person

Total CIWA-Ar Score ______Rater's Initials ______

Maximum Possible Score 67

The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.

Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989.

What  is  SBIRT

• Screening,   Brief   Intervention,   and  Referral   to  Treatment.

• Screen   patients      conduct   intervention        follow  up.

• CAGE:   Cut  down?  Annoyed?  Guilty?  Eye  opener?

American  College  of  Surgeons,  2015

Cardiovascular   System

• Atrial  Fibrillation• Myocardial  Infarction• Hypertension• Hyperlipidemia

Consult  PCP/IMEKGECHOCardiac  EnzymesRestart  home  medsBeta  BlockerStatin

• Anticoagulation?PT/INRRapidly  reverse

• Pacemaker?Check  function

• CHFGraph  I&OsWeigh  daily

Coagulopathy• Warfarin  (Coumadin)   =  INR• Dabigatran (Pradaxa)  =  minimally  increased  INR;  slightly  

prolonged  PTT;  increases  TT• Rivaroxaban (Xarelto)  =  increased  INR  at  therapeutic  levels  

(effects   are  not  equivalent  to  target  levels  of  warfarin);  mildly  increased  PTT;  does  not  prolong  TT

Ivascu,  Howells,   Junn,   Bair,   Bendick,   &   Janczyk,  2005

Coagulopathy  Algorithm

Guidelines for Management and Anticoagulation Reversal in Mild Traumatic Brain Injury

Developed 01/2015: S.E. Brooks, M.D., Jay Blasingame, MSIV

Suspicion of Head Injury and Any ONE of the Following:

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I&O  Graph Respiratory  &Gastrointestinal  System

• Pneumonia• Atelectasis• ARDS• Acute  Respiratory  Failure

appropriate  antibiotic  coverageaggressive  respiratory  interventionsISacapellajudicial  use  of  supplemental  oxygen

Helmerhorst,  Schultz,  Van  der  Vorrt,  de  Jonge,  van  Westerloo,  2015

• Chronic  ConstipationBowel  programFiberDiet  educationLimit  narcoticsElectrolyte  correction

• MalnutritionPAB/CRPmenufood  from  homenormalize  meal  times

Genitourinary  &Endocrine

• ARF/CRFIVFFENAmedication  reviewgraph  I&Oweigh  dailynephrology  consult

• DMStart  home  medicationsCheck  HbgA1cDiet  educationIM/PCP  consult

• HypothyroidStart  home  medicationsCheck  thyroid  panel

• Electrolyteskeep  in  the  “box”sneaking  medication

Hematology  &Infectious  Disease

• AnemiaTransfuse  if  necessaryCheck  under  operative  dressings

• CoagulopathyCorrectIs  anticoagulation  needed?

• LeukopeniaMyelodysplastic syndrome?

• HAP  vs  CAPTreat  with  antibiotics  appropriatelyRespiratory  consultDaily  chest  x  ray

• UTITreat  appropriatelyRemove  foley catheter

• Wound  infectionsTake  down  operative  dressingsCheck  buttocks  for  decubitus

Musculoskeletal

• FracturesEarly  mobilityOOBDischarge  planningAssistive  devices  in   roomPain  control

• OsteoporosisDiagnosticsTreatRefer  to  osteoporosis  

clinic

Progressive  Mobility  Protocol

� TO � Read back Order taken by Signature: ________________________________________Date/Time: _____________________________ Physician Signature__________________________________________ Date/Time_____________________________

Page 1 of 2- ICU Progressive Mobility Plan 05/07/2012 (#1076 R-1)

Perform each step of progressive mobility for at least 30 to 60 minutes three times a day. Repeat each step until patient demonstrates hemodynamic and physical tolerance then advance to next step at the next activity period.

Step 1: HOB elevated to 45 degrees

Step 2; HOB elevated to 45 degrees and legs in dependent position (partial chair mode)

Step 3: HOB elevated to 65 degrees and legs in full dependent position (full chair mode)

Reconsult Physical Therapy for evaluation and treatment when ready to progress to Step 4

Step 4: HOB elevated to 65 degrees plus legs in full dependent position and feet on the floor plus standing.

Step 5: Initiate stand/pivot and into chair

Step 6: Initiate stand/pivot with march stepping and into chair

ICU PROGRESSIVE MOBILITY PLAN

Patient Label Here

� TO � Read back Order taken by Signature: ________________________________________Date/Time: _____________________________ Physician Signature__________________________________________ Date/Time_____________________________

Page 2 of 2- ICU Progressive Mobility Plan 05/07/2012 (#1076 R-1)

Progressive Mobility Algorithm

ICU PROGRESSIVE MOBILITY PLAN

Patient Label Here

Is patient at risk for deconditioning due to immobility?

Assess patient for the following: Lobar collapse, atelectasis, excessive secretions, P/F ratio < 300, Hemodynamic instability with manual turning

CLRT

Initiate Progressive Mobility

Assess skin q 4 hours. Temporarily offload pressure areas as necessary for circulatory recovery. Wedges are not to be used during rotation.

Y

N

N Ambulate

Y

Reassess every shift

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Wounds/Lines/DrainsProphylaxis• Wounds• Central  lines• Drains• NGT/DHT/PEG/JP

Remove  early  as  appropriateObtain  peripheral   if  neededPromotes  mobilization

• Mechanical  prophylaxisSCDS/foot  pumps

• Chemical  prophylaxisLovenox/Heparin

• GI  prophylaxisPPI

Discharge  Planning

• Starts  on  day  1• Multidisciplinary  approach• Talk  to  family• Stop  the  “lingo”• Supportive  Care  consult

• Case  manager  to  discuss  insurance

• Document  appropriately• Advocate  for  patient• Team  rounding• Team  meetings• Monthly  M&M• Get  hospital  

administration  involved

Objective  4:  Understand  management  principles  for  caring  for  the  thermally  injured  patient

• Higher   length   of  stay• Cost  more• Loss  of  function• Loss  of  physical   freedom• Only  43%  geriatric   burn  patients  are   transferred  to  designated   burn  center

Richards,   Richards,   Miggins,   Liu,  Mozingo,   &  Ang,  2013

Burns

• Electrical,   chemical,   thermal,   flame,  scald• Intravascular   fluid   deficit  • Local   and  systemic  inflammatory   reactions• Classified   by  depth   and  size

March  &  Buckley,   2014

Rule  of  9s Burn  Pictures

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Risk  Factors  of  Burns    

• Co-­‐morbiities• Medication  

side  effects

• strength

• Impaired  protective  mechanisms

• reaction  times

• Poor  balance• Poor  vision

• postural  stability

• Mental  status  changes• Poor  motor  coordination

• mobility

• Thin  skin• Environmental  hazards

• Space  heaters;  stoves• Chemicals

March  &  Buckley,  2014

Burn  Treatment

• Stop  burning   process• Assess  airway  &  provide   oxygen• Initiate   resuscitation• Manage  pain• Transfer   to  higher   level  of  care

Discharging  Burns

• SNF   increases   risk  of  death   and  poor   long  term  physical   function

• Education,   education,   education• Manage   co-­‐morbidities   before   discharge• Involve   family   members• Utilize  community   resources

Romanowski,   Barsun,   Pamlierri,   Greenhalgh,   &  Sen,  2014Solanki,   Greenwood,  Mackie,  Kavanagh,  &  Penhall,   2011

Objective  5:  Utilize  appropriate  resources  to  maximize  outcomes  for  the  

geriatric  injured  patient• Geriatric  trauma  unit  (G-­‐60)– Contained  393  patients  (control  280)– Goals:    consult  trauma  service  <30  minutes

inpatient  room  arrival  <4  hourstime  to  OR  <36  hoursdischarge  within  5  days

– Findings:              length  of  stay;              time  to  OR;                              overall  morbidity  and  mortality  

Mangram,   Mitchell,   Shif f lett,  Lorenzo,   Truitt,   Goel,   Lyons,   Nichols,   &   Dunn,   2012

Geriatric  Trauma  Unit• Early  mobilization• Communication  • Weekly  Teaching  Rounds

• Dedicated  SS• Dedicated  CM• Commitment  to  goals

• Experienced  nurses• Availability  of  team• Low  patient  ratio• Telemetry

• Universal  documentation• Continuity  of  care• Communication  boards• Business  cards• Family  meetings• Night  nurse  leave  notes

• Anesthesia  NP• IM  consult • Head  to  toe  assessment

• Monthly  M&M• Understand  fragility  of  population

Fall  Prevention  Course

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Preoperative  Checklist Case  Studies

Summary

• Fastest  growing   age   group• Expect   increase   in   trauma   admissions  and  cost• Altered   compensation   to  stress  of  trauma• Ground   level   falls  are   not  benign• Consider   triage   to  designated   trauma   center• Concentrate   on  head   to  toe  examination• Thermally   injured   have   increased   M&M• GTU  helps  maximize   outcomes  and  help  patients  return   to  productive   lifestyle   and   independence

Contact  infoKara  Jones  MSN,  RN,  FNP-­‐BCNurse  Practitioner  Trauma/General  SurgeryFaculty  Associate  Texas  Tech  University  Health  Sciences  Center  School  of  Medicine

UMC  Health  System602  Indiana  AvenueLubbock,  TX  79413O:  807-­‐775-­‐9315Pg:  806-­‐765-­‐1300kara.jones@umchealthsystem.com

Jenna  Kesesy,  MSN,  RN,  FNP-­‐BC,  CWSNurse  Practitioner  Timothy  J.  Harnar Burn  CenterFaculty  Associate  Texas  Tech  University  Health  Sciences  Center  School  of  Medicine

O:  806-­‐775-­‐8668Pg:806-­‐721-­‐8748jennifer.kesey@umchealthsystem.com

Trauma  &  Burn  Service  Department

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References• Ambrose,  A.F.,  Cruz,  L.,  &  Paul,  G.  (2015)  “Fall  and  fractures:  A  systematic  approach  to  screening  

and  prevention.  “  Maturitis 82(1):  85-­‐93.• American  College  of  Surgeons,  Committee  on  Trauma.  Resources  for  the  Optimal  Care  of  the  

Injured  Patient:  2014.  Chicago,  IL:  2014:  1-­‐215.• American  College  of  Surgeons  Committee  on  Trauma.  ACS  TQIP  Geriatric  Trauma  Management  

Guidelines.  2014.  Chicago,  IL:  2014:1-­‐31• American  College  of  Surgeons.  (2015)  Alcohol  Screening  and  Brief  Intervention  (SBI)  for  Trauma  

Patients.  Chicago,  IL.  1-­‐15.• www.americangeriatrics.org.  Identifying  Medications  that  Older  Adults  Should  Avoid  or  Use  With  

Caution:  the  2012  American  Geriatrics  SocietyUpdated  Beers  Criteria  • Avin,  K.,  Hanke,  T.,   Kirk-­‐Sanchez,  N.,  McDonough,  C.,  Shubert,  T.,  Hardage,  J.,  &  Hartley,  G.,  (2015)  

Management  of  falls  in  community  dwelling  older  adults:  Clinical  guidance  statement  from  the  academy  of  geriatric  physical  therapy  of  the  american physical  therapy  association.  Physical  Therapy  95(6) :  815-­‐834.

• Ayoung-­‐Chee,  P.,  McIntyre,  L.,  Ebel,  B.,  Mack,  C.,   McCormick,  W.,  &  Maier,  R.  (2014).  “Long-­‐term  outcomes  of  ground-­‐level  falls  in  the  elderly.”  Journal  of  Trauma  and  Acute  Care  Surgery  76(2):  498-­‐503.

• Bulger,  E.M.,   Arneson,  M.A.,  Mock,  C.N.,  &  Jurkovich,  G.J.  (2000)  “Rib  fractures  in  the  elderly.”  The  Journal  of  Trauma:  Injury,  Infection,  and  Critical  Care.  48(6):  1040-­‐1047

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Aging.   Adminis tration   for   community   living.• www.census .gov “The   Older   Population:   2010”   2010   census   briefs .• www.cdc.gov“Leading causes  of   death”   number   of   deaths   for   leading   causes   of  death• Chen,   S.,   Shi,  L.,  Liang,   F.,  Xu,   L.,  Des is lava,   D.,   Wu,  Q.,  &  Zhang,   J.   (2015)   “Exogenous   melatonin   for  

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• Helmerhorst,   H.   J.  F.,  Schultz ,   M.   J.,   van  der   Voort,   P.   H.   J.,  de   Jonge,   E.,   &  van  Westerloo,   D.   J.  (2015).  Bench-­‐to-­‐beds ide   review:   the   effects   of   hyperoxia during   critical   illness .   Critical   Care,   19(1),   284.

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References• Jacobs ,  D.G .,  Plais ier,  B.R.,   Barie,  P.S.,   Hammond,   J.S.,  Holevar,   M.R.,   Sinclair,  K.E.,  Scalea,  T.M.,  &  Wahl,  W.  (2003)  

“Practice  management   guidelines  for   geriatric  trauma:   The  EAST  practice   management   guidelines  work   group.”  The  Journal   of  Trauma:   Injury,  Infection,   and  Critical   Care.   54:391-­‐416.

• Kozar,  R.,  Arbabi,   S.,  Stein,   D.,  Shackford,   S.,  Barraco,   R.,  Biffl,   W.,  Brasel,  K.,  Cooper,   Z.,  Fakhry,  S.,  Livingston,  D.,  Moore,   F.,  &  Luchette,  F.  (2015)   “Injury  in   aged:  Geriatric  trauma   care  at  the   crossroads .”  Journal  of   Trauma  and  Acute   Care  Surgery.   78(6):   1197-­‐1209.

• Mangram,   A.J.,   Mitchell,   C.D.,   Shifflett,V.K.,   Lorenzo,  M.,   Truitt,   M.S.,   Goel,  A.,  Lyons ,  M.A.,  N ichols ,  D.J.,   &  Dunn,  E.L.  (2012)   “Geriatric  trauma   service:  A   one-­‐year   experience.”  Journal   of  Trauma   and  Acute   Care   Surgery.  72(1):119-­‐122,   January   2012.

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alzheimer’s neuropathy   and  associated  cognitive  deficits  independent   of  antioxidant   pathways  in  ABPP/PS1  mice.”  Molecular   Neurodegeneration.   10:27.

• Oreskovich,  M.,  Howard,   J.,   Copass ,  M.,  Carrico,   C.  (1984).   “Geriatric   trauma:   injury  patterns   and  outcome.”Journalof  Trauma   24(7):   565-­‐572.

• Richards,  W.T.,  Richards,  W.A.,  Miggins,  M.,  Liu,  H.,  Mozingo,  D.W.  &  Ang,  D.N.  (2013).  “Predicting  resource  utilization  of  elderly  burn  patients  in  the  baby  boomer  era.”  The  American  Journal  of  Surgery.  2013(205):  29-­‐34.

• Romanowski,  K.S.,  Barsun,  A.,  Pamlierri,  T.L.,  Greenhalgh,  D.G.,  &  Sen,  S.  (2014)  “Frailty  score  on  admission  predicts  outcomes  in  elderly  burn  injury.”  Journal  of  Burn  Care  &  Research.  36(1):  1-­‐6.

References• Scalea,   T.,  Simon,  H.,  Duncan,  A.,  Atweh,  N.,  Sclafani,  S.,  Phillips,  T.,  &  Shaftan,  G.,  (1990).  “Geriatric  

blunt  multiple  trauma:  Improved  survival  with  early  invasive  monitoring.”  The  Journal  of  Trauma  30(2) :  129-­‐136.

• Solanki,   N.S.,   Greenwood,  J.E.,   Mackie,   I.P.,   Kavanagh,S.,   &  Penhall,   R.  (2011)  “Social  issues  prolong  elderly   burn  patient  hospitalization.”  Journal  of  Burn  Care  &  Research.  32(3) :  387-­‐391.

• Stassen,   N.A.,   Lukan,   J.K.,  Mizuguchi,   N.N.,   Spain,  D.A.,   Carrillo,   E.H.,   &   Polk,  H.C.   (2001).  “Thermal   injury  in  the  elderly:   When  is   comfort  care  the  right  choice?”  The   American  Surgeon.  67:704-­‐708.

• Sullivan,   M.P.,   Baldwin,  K.D.,  Donegan,   D.J.,   Mehta,   S.,   &   Ahn,  J.  (2014).  “Geriatric  fractures  about  the  hip:  Divergent   patterns  in  the  proximal  femur,  acetabulum,  and  pelvis.”  Orthopedics  37(3) :  151-­‐157.

Questions?