Abstract
An 86-year-old lady, presented with an unwitnessed fall with no obvious head injury. Her Glasgow Coma Scale (GCS) was 15 on arrival. She denied precipitating factors, taking blood thinners or seizure medication. Her examination revealed tongue biting, suprapubic tenderness, and pain in both hips and arms. An X-ray of the possible affected joints was ordered. Bloods and venous blood gas (VBG) were unremarkable. Within a few hours, she had a witnessed tonic-clonic seizure with a swollen tongue, for which lorazepam and adrenaline were administered. Repeat VBG (post-ictal) revealed a high lactate with hypoxia and hypotension. Intravenous fluids and oxygen were administered with a full body trauma series and a Contrast-Enhanced Pulmonary Angiogram. This showed a large retroperitoneal haematoma, a comminuted fracture of the superior pubic ramus and an unstable thoracic fracture. She was referred to surgeons and orthopaedics for further management.
Trauma in older patients with polymorbidities can be missed as they are poor historians with conflicting collateral histories and atypical presentations. The “Silver trauma” emphasises early diagnostics, intervention and outcome including rehabilitation, decreasing mortality and morbidity. (1) The most common trauma is a fall of less than two metres from standing. (2) They should be searched for more than one injury (2) in this case, suprapubic tenderness. They can have atypical observations compared to younger people sustaining trauma. (1) Example, a higher baseline blood pressure due to significant aortic disease. Similarly, tachycardia can be masked by medications such as beta blockers.
They should be investigated for polytrauma following an unwitnessed fall with a low threshold for a full CT trauma series.
Furthermore, early reversal of anticoagulation should be implemented with adequate pain relief hydration to prevent delirium. (2) Knowing local pathways for referral to specialist services, and considering of patient’s and relatives’ previous wishes are key for early mobilisation and discharge. (1)