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Can you see that? So silver trauma talk a little bit myself. A trauma. What is Silver? Former bit of pathophysiology surrounding silver trauma. Newer nears as detailed US Osama lease. Uh, superb talks. Morning talk about the primary survey assessment treatment of these patients on expectations on goals of care. So silver trauma major trauma is to find a serious and often multiple injuries where there is a strong possibility of death or disability. Mrs. Represented by injury severity score of greater than 15 Roman. The over 65 is termed silver trauma, old age eyes to find in terms of specific population and societal norms. So, you know, in certain countries or certain areas, 1 may be considered old. That's 65 compared to 75 or 80 in a different that court. Yeah, so it's a little bit subjective from that perspective, the most common injuries that old people sustain our to the head and the store ox on the commerce cause of death. This traumatic brain injury, the commonest mechanism for patients to standing an injury severity score of grill and 15 is a full from standing height or a fall from less than 2 m closely followed by full from more than 2 m on road traffic collisions that from data from the Tar Report in 2017. There's been a shift from the typical young male road traffic collision that trauma victim to the older patients with less of a male preponderance. Older patients sustaining drama are more likely to die. The dosage survive, do not have is large and incidence of disability following the drama. 2017, the Trauma Order and Research Network released this document Major Trauma and Older People, which was a 10 year report based on its Eisen's 176 patients. It's 16 of both in English. In England whales some of the themes, as well as what I've already mentioned, are that pre hospital for your systems are not as good at identifying elderly major trauma. Patients are more likely to be taken to a trauma units as a boost to the major trauma center. Lack of early recognition means less likely to be seen by a senior condition or trauma team activation, and they're less likely be transferred to specialist care of longer times taken to investigation on intervention risk and silver trauma is dictated not just purely by age, but also by frailty on other comorbidities s. So you'll see here the clinical frailty scale which Justin was talking about this morning. And there's another thing called the Charleston Co. Morbidity Index, which could be used. Teo estimate patients with allergy based on their their comorbid state and patients may cyst in trauma or be subjected trauma to two problems with cognition. Lack of awareness, for example, on the roads, what's driving or a pedestrian or inadequate supervision for those who require support. Concurrent disease such as palliative counselor or and stage COPD. Um, let cetera. It has a name packed on the feasibility off drama resuscitation on DTIC mint of some of these severe injuries folder Common multi factorial. I will be covered in more detail in another talk I ever just briefly elderly patients is Emily alluded to and her family talk Have our experience muscle wasting issues with balance both refilled and also with problems like stroke, Parkinson's disease, peripheral neuropathies probability requiring supervision, um, on the use of mobility AIDS on some people, either through the use of these or neglecting to use thumb or mobilizing without adequate revision, are subjected to the risk of false hearing in sight impairment that includes general deteriorate eyesight as well as things like glaucoma. It's related macular degeneration on indeed, patients with stiff and sore. Next, you come click over the shoulder, say, to check their blind spot when they're driving, we're trusting the roads and, uh, on hearing impairments those who needs hearing is it Centrum cognitive impairment? Maybe a manifestation of hearing or sight impairment on again route traffic collisions for traffic awareness on that, problems with the stairs to to both sites on mobility can assume that we shouldn't sure that patients have their glasses and hearing it's on day. Other is to use available to them during the hospital stay. Concurrent disease, such as politics is at cancer or, um, and stage heart failure or 70 and such kind of fact. The feasibility is a set of aggressive resuscitation on. We need to have a thing about the girls off our treatment on what the patient's wishes would be subjecting them too aggressive, uh, strenuous physiological resuscitation. Is it fair on them, or is it appropriate? Medications are important both in terms off their effect on trauma but also identifying precipitating calls off a full. For example, To begin with, the office ones are anticoagulants on the platelets, which increase your risk of bleeding on. The hypertensives on big blockers may mask the physiological effects of trauma, such as a patient not able to mind the tachycardia, UM, or issues with BP and allergies. X, including opioids, especially may complicate analgesia. Treatment on may contribute to your urine, toxicity and hospital, so it's important to look for patches and things. Whenever we're assessing these patients. Polypharmacy is harmful on the effects of both. Overdosing on under dosing or miss doses could be significant. Some specific ones again, Parkinson's disease. And there are risks both in over around on producing of anti parkinsonian drugs. Both completed falls. Anti anginal drugs, not the hypertensives, can lead to postural hypertension. Also, if patient is on a lot of cardiac drugs that just be cognizant of the risk of a type two, um, I do to lack of profusion. If and they these patients were shocked in problem and the diabetic drugs of insulin was the high board cause of collapse. Also consider that Hypo and hyper glycemia can contribute to secondary brain injury in patients who have sustained a brain injury on the depressants on the psychotic sedative medications take caution with ease in terms of cognitive impairments, delirium on drives you nuts. Then again, sir, because off a collapse or a full just remember as well that, um, well, people use drugs and alcohol, too. We have, yeah, certainly seen a significance size of the population who who use alcohol on, perhaps benzodiazepines. I just remember that the teenagers of the sixties and seventies are now in their seventies and eighties, so it's not unheard off that some of these patients may have, at least in the past, used recreational drugs from May. Still there in terms of pathophysiology, osteoporosis is common, and old people one and three women on one and five men aged over 50 will sustain a fracture in their lifetime. You've all seen this, I'm sure in talks about trauma in general, but lethal triads and coagulopathy acidosis. I'm hypothermia. Quiggle opathy. We have already talked about anticoagulation medications, um, hypothermia. These patients may have had a long lie either outside or in the host. A lot of them have reduced muscle mass reduced he production and Sometimes we resuscitated these patients with cool crystalloids should call them doughnuts. Well, acidosis that can be precipitated by chronic kidney disease with the inability to buffer certain medications. Rhabdomyolysis from a long line respiratory acidosis segment hyperventilation that can either be due to chest injuries or opioid toxicity on Do these three things were all interlinked on. They contribute. Teo kind of spiraling, um, severity off off illness, um, morbidity in patients who have a bleeding our shop from trouble. So who do we worry about? Standard three hours Tools will not capture all of these patients with an injury severity score 15 or severe injuries, for example, dutiful from standing. However, at the same time, we don't need a trauma team activation for every fall from Stanley sounding, but it's not practical. The Northern Arms Major Trauma network I have produced this safety nets, which has some objective triggers. Teo prompt early senior input based on physiology, anatomy on mechanisms of injury. And that's in May, the documentation that they have produced. There's another one that I quite like a swell from Brighton and Sussex Askew can see. It includes the clinical frailty scale. Down this side, there's a few additional elements in terms of the same things and out of the physiology. Severe pain anticoagulations triggering a senior assessment. So what a silver trauma looked like? What are we looking for? What specific injuries to these patients are? These patients, susceptible to older brands become atrophy? It's There's more space in the skull occupied by cerebral spinal fluid. Um, increased risk of deceleration injury with direct trauma. Can't contract on vascular injuries to the brain that you can see here in the subject of space between the jury matter and the arachnoid matter. The blue bridging vins on when the brain is essentially kind of floating free on rattling around in trauma, these are Franchione could be torn, and that's what causes your subdural hematoma. There's more space to fill, so it could be more insidious onset, so it might take a little bit longer for patients to become symptomatic off their blade in their heads. With age comes inevitable wear and tear, and in the neck spondylitis is osteoporosis. Canal stenosis, oral common, increased risk of fracture, but also increased risk of court injury of a high index of suspicion and heads or thorax injury for patients with a significant neck injury and typically that flexion extension mechanism. Many older people have characteristic coster associated with kyphosis that you can see here. They cannot physically lie flat, so don't try to shoehorn them into an ill fitting color or life loud on the trouble mattress. A folded blanket makes a good pillow to support their head. When I mobilization is required until I them to arrest. Naturally in there, they're neutral position. Thoracic injuries are due to similar risks. Osteoporosis again is common. Less muscle, another post tissue, um, patients. Maybe either I'm able to get their hand load in time to protect themselves or do the frailty. This may not not or may not adequately break their full long delay because you can see here is part of, uh, emphysema, this disease converted, confused with pneumothorax. Please don't try to put a test run into one of these. Like I, however, risk increased risk of sustaining you Mr. Rocks when they have these findings in their lungs, Um, a word of caution as well about the chronic lung disease, COPD patient or pulmonary fibrosis patients with Don't with low south. Don't assume that the sounds of 92 are normal because this patient's COPD um, because they more likely conclusion is that they have sustained injuries, other chest, and that's what's causing themselves and other people. Chest wall is less compliant. Chest deformity such as the barrel chest in CBD, leads to increased risk of chest wall 100. Younger people have more flexible ribs. Might sustained Long contusions I ever order ribs are more brittle. Fracture more easily, causing pneumothorax, chemotherapy, long contusions, long lacerations. I just remember about cardiac contusions in sternal injuries as well to abdominal trauma. Not all of the belly's that we see looks like this. In fact, a lot of elderly foot that we see, uh, or more of the ship with less abdominal wall musculature on adipose tissue. They can have abdominal hernias or rectus muscle differentiation, leading the weakness in the abdominal wall. Don't look traumas last common. You know the foot. However, it is still worth keeping your eyes open. Remember, liver and spleen injuries can be caused by rib fractures on our especially significant patients on anti coagulation. Hello biscuits rupture from sudden decreased or increased intradomal pressure, abruption of solo solid or hollow organs and vascular structure. Um, on the word of caution about Rachael peritoneal injuries. So the structures in the retroperitoneum are renal adrenal glands. Ureters, Sophocles, Judean um, sounding in diesel and pull on pancreas on the great vessels on the retroperitoneal space can mask quite a significant degree of bleeding and before the patients become symptomatic. So just think about, you know, similar line of into your rupture triple a patient also considered of patients for the Triple A. You know, there's a potential for traumatic rupture. We see a lot of these fractures back of fevers, typically from a full directly onto the hip. Don't assume that this is the only injury on these patients. Really Should have a trauma primary survey performed. The associated's mechanism is a, um onto the side is the same as the lateral compression pelvic fracture mechanism. So just be mindful of associated pelvic fractures as well as other injuries. Degree of my fractures are common. We see lots of these. They're easy overlooked in terms of severity. A lot of the time we see them, I think it's a pelvic pubic Ramus fracture. Get them on their feet. If you can walk, then we're Barris tolerated. We see TV. All of these patients you would see associated sacral or SSI joint injury. And think of the Parliament principal. You can't break a problem in in one place. So if you've broken the pubic area, my then the pelvis is likely opened up slightly, Um, somewhere else as well. In addition, caution with the patients on anti coagulation because the vascular bad in the pelvis can lead to significant leading even in in this relatively innocuous looking injury, we don't see too many of these. Thankfully, there last common fracture. Femoral shaft. Um, they generally denote a high impact mechanism of injury. Be mindful off pathological fracture and those patients who have presented with such an injury with a less significant mechanism on blood loss in June, injury like this could be significant. So you can lose up to a leader or a liter and a half of bugs into a closed femoral fracture, especially undercalculating. And actually, you can lose 502,000 miles of blood into a closed tibial fracture shaft fracture as well. Yeah, so these need to be treated as ah um, sort of active hemorrhage under juiced, if possible, with traction splinting, etcetera. So this is Doris Doris's How to Fold and you get a star. Michael Doris is 84. Last night she tripped coming up the box step under daughter Cold run this morning and find her lying on the kitchen floor just inside the door. She has bumped her head's. She has a respiratory rate of 24 sounds of 90 to remain. Heart rate of 77. BP of one and 1/40 it GCS of 14. She's been confused on the temperature of 35 2. She hasn't yet had any treatment, as it was a non paramedic crew policies. Just seen a message there so that people dream. I, um we talked about the femoral south fracture. Can you see the slides? And I Okay, just by that, right? So we moved on to Doris. Um, he said it all. There's the information from your stand by your observations of said Come in with a known paramedic, pre no treatment just yet. They tell you that she has a history of COPD hypertension of the atrial fibrilation. She's independent in her own home, but as you see there, she's walking with a stick. Okay, So what are your first impressions of Doris? Let's see some some answers here. Chance. Are you concerned? Should we put on a tropical? Uh, what else would you like to know? So common? You mean she has a good baseline, or does she have a good baseline? What a year? Yep. Good column. Thank you. Yeah. Yeah. Okay. Anybody else part from column? You should know the answers. Okay. Okay. So what do you think? Anybody? Trauma? Cool. Yes. New Ms. See? Okay. Right. Move on. So we'll rewind to this tree Eyes, too, that we looked at earlier. So it's over 65 mechanism full from that centimeters on them anatomy injury to body systems. Uh, we don't know that. Unable to straight leg raise. We haven't heard of it that I haven't been given any information with coughing or deep breathing. We do. I ever know that she has a systolic BP. Less than 100 and 10 on a GCS of last 15. So that really should trigger, um, the trauma call, or least any GI consultant review on arrival. Actually, if you looked on the frailty scare scale, Besides, you know We showed Doris walking with a stick, so she's gonna have a fail the scores. At least four. Although she does live in her own home. So, uh, the standby call is on red. We're gonna have her lunch. Like we'll have a think about how we might treat Doris on down. We'll come back when she arrives after without her lunch. Okay, okay.