GERIATRIC TRAUMA

By

Dr. HARDY, SpB

PENGERTIAN LANSIA

Proses menua merupakan suatu keadaan yang fisiologis, pasti akan dialami oleh setiap orang.

Menurut UU No 13 tahun 1998 orang dikatakan lanjut usia → usia > 60 tahun.

Menurut WHO lanjut usia meliputi:

1. Usia pertengahan (middle age) ialah kelompok usia 45 sampai 59 tahun.

2. Lanjut usia (elderly) antara 60 - 74 tahun

3. Lanjut usia tua (old) antara 75 - 90 tahun

4. Usia sangat tua (very old) di atas 90 tahun

Geriatri : cabang ilmu kedokteran yang mempelajari masalah kesehatan pada lansia.

Aspek Geriatri :

1. Promotion (penyuluhan)

2. Preventif

3. Kuratif

4. Rehabilitasi

5. Aspek psikososial lansia.

PENDAHULUAN

Angka harapan hidup bangsa meningkat :

1. Kemajuan ilmu pengetahuan dan teknologi

2. Perbaikan lingkungan hidup

3. Kemajuan ekonomi

4. Pembangunan nasional

MENINGKATNYA POPULASI LANSIA

Jumlah lansia bertambah secara pesat

terutama di negara berkembang pada

dekade pertama abad Millennium ini.

DI INDONESIA

- Tahun 2000 proporsi penduduk

lanjut usia (lanjut usia)  adalah 7,18

%

- Tahun 2010 meningkat sekitar 9,77

%,

- Tahun 2010 : proporsi penduduk lanjut usia

hampir menyamai proporsi penduduk balita.

- Thn 2020 : diperkirakan proporsi lanjut usia

dari total penduduk Indonesa dapat sampai

11,34 %

- Pada saat ini penduduk lanjut usia berjumlah

sekitar 24 juta dan tahun 2020 diperkirakan

sekitar 30-40 juta jiwa.

DI USA

- Thn 2000 : usia ≥ 65 thn mencapai 35 juta jiwa

- Thn 2030 : usia ≥ 65 thn kemungkinan

mencapai 70,3 juta jiwa atau ± 20 % dari total

populasi

- Dari 12 % populasi : 36 % memerlukan

transportasi ambulans, 25 % memerlukan

perawatan di RS

What the Elderly say???

“Pada Saat Kita berusia lanjut, mungkin Kita mulai menyadari

bahwa Kita tidak sekuat, setangkas atau gesit seperti dahulu. Mungkin

Kita akan terkejut akan menurunnya kemampuan atau kekuatan Kita”

WHAT THE ELDERLY SAY ???

POPULASI LANSIA ↑

TRAUMA PADA LANSIA ± 10 – 12 % DARI KORBAN TRAUMA

± 25 % MEMERLUKAN PERAWATAN

MORBIDITAS ↑ MORTALITAS ↑ LAMA PERAWATAN ↑ BIAYA KESEHATAN ↑

Trauma pd lansia

Penyebab kematian ke-5

↓ Fungsi fisiologi

Comorbid : penyakit/medication

Outcome : tergantung pd penanganan

dini/awal dan agresif

POLA TRAUMA

- FALLS (TERJATUH)

- PEJALAN KAKI VS SEPEDA MOTOR

- PENGEMUDI MOBIL

- LUKA BAKAR

- ATTEMP SUICIDE

BEBERAPA ALASAN TERJADINYA TRAUMA

- Impaired balance and gait

- Postural hypotension

- Increased reaction time

- Syncope

- Cognitive dysfunction

- Visual loss

Orang usia lanjut saat ini mempunyai resiko yg meningkat untuk terjadinya trauma (injuri) o.k meningkatnya aktifitas sehari-hari dan penurunan dari fungsi indra dan kognitif.

Thirty percent of persons over 65 years of age fall each year; of these falls, 6 percent result in fractures, 10 to 30 percent result in significant trauma, and 7 percent lead to mortality. Falls from a standing position account for half of all rib fractures in the elderly population.

Geriatric Considerations

Pada pasien usia lanjut yang mengalami trauma dalam penanganannya harus dipertimbangkan adanya perubahan fisiologis sistem organ dan adanya penyakit yg menyertainya, seperti pada :

Cardiovascular considerations Respiratory considerations Renal considerations

EFFECTS ON THE ELDERLY

Mortality is increased across all phases of the death curve in the elderly: prehospital, early, and late. Early mortality can be reduced by aggressive resuscitation, liberal radiographic evaluation, early monitoring, and surgery. Late mortality is reduced by meticulous attention to changes in patient status.

Complication rates of 33 percent are reported in the elderly, compared with 19 percent in younger patients. Cardiovascular events (23 percent) and pneumonia (22 percent) are the most common and significant complications.

In the emergency department, the two most useful scores are the Trauma Score (TS) and Revised Trauma Score (RTS).

The TS assesses blood pressure, respiratory rate, respiratory effort, Glasgow Coma Score (GCS), and

capillary refill to produce a minimum score of zero and maximum score of 16.

The RTS is similar, but does not account for respiratory effort or capillary refill (scores 0–8).

Trauma Considerations

Beberapa faktor yang dapat mempengaruhi mortaliti pada usia tua :- Osteoporosis- Reduced cardiac reserve- Decreased respiratory function- Impaired renal function- Decreased elasticity in the peripheral blood vessels

Management

The elderly have increased mortality across all categories of the trimodal death curve: immediate (ie, at the scene), early (ie, within the first 24–48

hours), and delayed (ie, after 48–72 hours).

Head Injury

• Dapat terjadi hanya dengan trauma yang ringan• Peningkatan ICP terjadi secara perlahan• Pasien sering lupa dengan trauma yang menimpanya

Cervical Injury

OSTEOPOROSIS

• Mudah terjadi fraktur hanya dengan trauma yang kecil

Arthritic changes• Kanalis spinalis menyempit• Resiko injury meningkat

• Hanya dengan gerakan yang tiba-tiba dapat menyebabkan cedera spinal kord tanpa adanya fraktur

• Penurunan sensasi nyeri dapat mengaburkan adanya fraktur

Orthopedic Injuries—Common Fractures in the Elderly

• Hip or pelvis fractures• Proximal humerus• Distal radius• Proximal tibia• Thoracic and lumbar bodies

BurnsFaktor-faktor yang mempengaruhi tingginya angka

kematian pada luka bakar : Higher mortality than any group except infants Preexisting disease Thin skin Poor immune response Reduction in organ system reserve Inability to meet metabolic demands of burn injury Increased risk of shock Fluid administration critical to prevent renal failure

Priorities of trauma care for older patients are similar to those for all trauma patients

Special consideration should be given to the older patient’s:

Transport strategies should be given special consideration

Management Considerations

How would you backboard?

Modifications in positioning, immobilization, and packaging may be necessary in the elderly patient.

BASIC PRINCIPLES

TRAUMA

DEATH MORBIDITY

PRE HOSPITAL

- Transport guidelines/protocolsOn-line

medical direction

- Mobilization of resources

- Periodic review of care

PHASES OF TRAUMA CARE

INHOSPITAL

- TRIAGE

- PRIMARY SURVEY

- RESUSCITATION

- SECONDARY SURVEY

- CONTINUED MONITORING

- DEFENITIVE TREATMENT

PHASES OF TRAUMA CARE

CHILDREN YOUNGER

ADULT ELDERLY

PREGNANT WOMEN

PRIORITIES ARE THE SAME

TRAUMA IN

OBJECTIVE

Identifikasi prioritas managemen

Aplikasi prinsip2 primary dan secondary survey

Lakukan resusitasi & monitoring

Perhatikan riwayat kejadian & biomekanik

injury

Antisipasi bahaya/kesulitan2 yang tersembunyi

TRAUMA TRIAGE

INITIAL CARE EVALUATION

BASED ON

ANATOMIC INJURY PHYSIOLOGIC STABILITY

PRIMARY SURVEYElderly, adult, younger, children, pregnant women : Priorities are the same

A : Airway + C-spine protectionB : BreathingC : Circulation + hemorrhage controlD : DisabilityE : Exposure/Environment

TERIMA KASIH

PRIMARY SURVEY

A = AIRWAY / C – SPINE ≈ JALAN NAFAS /TL BELAKANG CERVIKAL PASTIKAN BAHWA JALAN NAFAS

BERSIH - BENDA ASING- MANUVER

KASUS SPESIAL IN LINE TRACTION = TRAKSI SEGARIS RESIKO TINGGI CEDERANYA C – SPINE PITFALLS (HAL2 YG TERSEMBUNYI)

PRIMARY SURVEY

B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASIBERSIHNYA JALAN NAFAS SAJA TDK MENJAMIN VENTILASI YANG ADEKUAT

PASIEN TRAUMA MEMBUTUHKAN PERTUKARAN GAS YANG ADEKUAT

EVALUASI DINDING DADAAUSKULTASI PARU-PARUPERKUSI ADANYA CAIRAN / DARAH

PRIMARY SURVEY

B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASIMAJOR INJURIES :

TENSION PNEUMOTHORAXFLAIL CHESTMASSIVE HAEMOTHORAXOPEN PNEUMOTHORAX

MINOR INJURIES : RIB FRACTURES

SIMPLE HAEMO / PNEUMOTHORAXPULMONARY CONTUSION

PRIMARY SURVEY

B = BREATHING AND VENTILATION≈ BERNAFAS DAN VENTILASI

THE PATIENT IS DYSPNOE, TACHYPNOE RR = 35 X/i

YOU DECIDE TO INTUBATE / VENTILATE

PRIMARY SURVEY

C = CIRCULATION AND CONTROL OF BLOOD LOSS≈ SIRKULASI DAN KONTROL PERDARAHAN

STATUS HAEMODYNAMIC PENDERITA DI ASSESS SECARA CEPAT

HYPOTENSION YG MENYERTAI TRAUMA ADALAH HYPOVOLEMIC KECUALI KENYATAAN SEBALIKNYA

HAEMORRHAGE ADALAH PENYEBAB KEMATIAN KE-2 PASCA TRAUMA

PRIMARY SURVEY

C = CIRCULATION AND CONTROL OF BLOOD LOSS

CLINICALLY, ASSESS

1. LEVEL OF CONSCIOUSNESSBLOOD LOSS

C.V.P.

2. SKIN COLOUR

3. PULSE

PRIMARY SURVEY

CONTROL BLEEDING

DIRECT PRESSURE BEFORE

USING TOURNIQUETS

BEFORE USING CLAMPS

PRIMARY SURVEY

CONTROL BLEEDING≈ KONTROL PERDARAHAN

THINK OF THE SITE THORAX

ABDOMEN

RETROPERITONEUM

FRACTURE SITE

PENETRATING THORAX

PRIMARY SURVEY

PITFALLS REGARDING BLOOD LOSS

BEWARE OF THE ELDERLY AND CILDREN

BEWARE THOSE ON BETA – BLOCKERS

BEWARE FIT MALES (ATLIT)

The Lethal Triad SHOCK Prolonged hypotension

Coagulopathy

Metabolic Acidosis

Hypothermia

DEATH

Rotondo MF, Zonies DH. Surg Clin North Am 1997; 77(4): 761-777

PRIMARY SURVEY

D = DISABILITY → NEUROLOGICAL EVALUATIONDONE AT THE END OF THE PRIMARY SURVEY

DROP IN LVL. OF CONSCIOUSNESSRE – EVALUATE OXYGENATION, VENTILATION, AND PERFUSIONIS IT A DIRECT CEREBRAL INJURY ?ARE THERE ALCOHOL OR DRUGS INVOLVED ?

AVPU GCS

PRIMARY SURVEY

E = EXPOSURE / ENVIRONMENT

EXPOSURE IS IMPORTANT

LOGROLL THE PATIENT

MAINTAIN THE CORE TEMPERATURE

THE RESUSCITATION PHASE

AGGRESSIVELY RESUSCITATE PATIENTS TO INCREASE SURVIVAL

AIRWAY BERSIHKAN, BEBASKAN, LINDUNGI IF THE PATIENT CAN’T MAINTAIN AIRWAY INTEGRITY

PLACE A DEFINITIVE AIRWAYINTUBATE WITH CONTINUOUS C – SPINE PROTECTION !!!

THE RESUSCITATION PHASE

BERIKAN CAIRAN – CRYSTALLOID OR COLLOID ??

ATASI HYPOVOLEMIA DAN HAEMORRHAGE !!!

HAMPIR SEMUA SHOCK PD TRAUMA ADALAH HYPOVOLEMIC !!!!

HENTIKAN PERDARAHAN, BUKAN BERIKAN CAIRAN

PULIHKAN VOLUME INTRAVASCULAR

MONITORING DURING RESUSCITATION

ECG MONITORING SINUS TACHYCARDIAST CHANGESATRIAL FIBRILLATIONPEA (Pulseless Electrical

Activity) BRADYCARDIA

TUBESURINARY CATHETERSNASOGASTRIC DECOMPRESSION

MONITORING DURING RESUSCITATION

TUBES

INSTRUMENT THE UNCONSCIOUS PATIENT CAREFULLY

BEWARE OF URETHRAL TRANSECTION

MONITORING DURING RESUSCITATION

MONITORINGRESUSITASI YG ADEKUAT DI ASSESS DENGAN PARAMETER FISIOLOGIS- HR- BP- PULSE PRESSURE- RR- ABG ANALYSIS- URINE OUTPUT

MONITORING DURING RESUSCITATION

RE – EVALUATE ALL PARAMETERS

ALL THE TIME

SECONDARY SURVEY

JANGAN DIMULAI SAMPAI ABCDE’s (PRIMARY SURVEY) TERSELESAIKAN

JANGAN DIMULAI SAMPAI KEADAAN PASIEN MEMBAIK

JANGAN DIMULAI SAMPAI FASE RESUSITASI MEMBAIK

SECONDARY SURVEY

HISTORY AMPLEMECHANISM OF INJURY

FULL EXAMINATIONHEAD AND FACENECKCHESTABDOMENMUSCULOKELETALNEUROLOGICAL

IMAGING

IMPORTANT POINTS IN TRAUMA

FULL ASSESSMENT

EVALUASI BERKELANJUTAN DAN

SELALU DIULANGI

MULTIDISCIPLINARY APPROACH

IMPORTANT EXAM POINTS IN TRAUMA

BERPEGANG PD BASIC PRINCIPLES

SETIAP PERMASAALAHAN TRAUMA SECARA GLOBAL DI ASSESSMENT DENGAN MENGGUNAKAN ATLS / ACLS PROTOCOLS

TERIMA KASIH