SimFridays - Silver Trauma

Today we looked at how we investigate older people with traumatic injury. The TARN report on major injury in older people (2017) showed differences in how these patients are looked after compared to younger trauma patients. A high number of injuries occur from falls from standing height in the home, and major injuries can be difficult to identify. 

In related news, over the next couple of months we will simulate some trauma calls to run through processes and identify any potential system errors when caring for trauma patients in the emergency department. 

The simulated case: 
A 90 year old female who had been found on the floor of her lounge by carers. She has been unable to describe the day’s events but has pain in her hip.
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​What happened?
ED assessment included a trauma survey which discovered bruising to the right side of her head and left hip with tenderness of both. Observations showed low saturations on room air, so oxygen was applied. Her next of kin was able to confirm her cognition was not at baseline.

A discussion with the ED registrar discussed the likelihood for occult injury in the thorax/abdomen between the two contralateral injuries that were apparent. A CT trauma series was requested. 

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What did we think? 
In debrief we discussed:

Imaging:
We talked about the chest examination involving a firm palpation around the sides and back of the chest if possible, to ensure we don’t miss injury around the sides of the patient. In this patient, with definite head and hip injuries on opposite sides of the body, with low saturations and pain around the side of the chest there are indications for a CT trauma scan to look for underlying injury. In other cases it may be entirely appropriate to have a CT head and a hip x-ray. Each case should be considered and discussed with someone experienced in seeing such patients.

Urine dip: (image source)
We talked about investigating a change in cognitive state in older people. Here, urine dip does not help so much in the diagnosis of UTI for those that are elderly, frail or have a catheter. Many will have bacteria present in the urinary tract without infection (asymptomatic bacteriuria) and will therefore have positive urine dip. This can in some cases lead us to miss the true cause of their confusion if we have taken a positive urine dip to mean UTI and given them antibiotics (from which there are definite risks to the patient, and the population as a whole from resistance). If someone has fever/delirium only make sure you’ve assessed for other causes before deciding to treat as UTI. 

A negative test may be a better rule out, but doesn’t totally rule out UTI in this group. Before dipping, consider the symptoms/signs they have, what your pre-test probability is, whether you would treat them regardless of results (in which case just do that), and what you will do if the test is positive. If you send a urine culture with the intention that ‘it isn’t clear yet and I’m not treating as UTI but if it becomes more apparent later then they will have sensitivities available quicker’ then make sure you put that reasoning in the ED discharge summary so that if the culture result comes back to someone else they have the context needed to decide whether the patient needs a phone call and antibiotics or if it is more likely asymptomatic bacteriuria.​

We hear older patients say they have recurrent urinary infections - and this may of course still be the case - but consider whether there is something else that is being misdiagnosed based on positive urine dip/culture. Start afresh. 

This is only about leukocytes/nitrites and infection, so if you’re using the urine dip for another purpose this doesn't apply!

Physiological considerations:
We talked about how particularly in older people it needs to be considered whether their past medical history, frailty or medication history might be affecting the clinical picture and lead to error. For instance are they taking a medication to control heart rate that affects a tachycardic response to bleeding? By definition frailty is a reduced ability to keep homeostasis after insult, so normal observations may not be reassuring, and may represent a lack of response to injury where there should be a response.


To do:

RCEM learning on silver trauma  [ ]

Have a look at the GP guidance on UTI in those over 65 years of age  [  ]

If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it   [  ]


Blog by: James Keitley ED sim fellow

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For clinical decisions please refer directly to the guidance. This blog may not be updated. All images not cited are copyright- and attribution-free in the public domain or taken by the author.