PHTLS Geriatric Trauma — Questions and Answers
Question 1: Why is tachycardia an unreliable indicator of hemorrhagic shock in many elderly trauma patients?
- Elderly patients have a higher baseline heart rate that masks changes
- Beta-blocker use and reduced chronotropic reserve blunt the heart rate response to hemorrhage (Correct answer)
- Elderly patients compensate through increased stroke volume instead
- Aging accelerates baroreceptor sensitivity, causing bradycardia instead
Correct answer: Beta-blocker use and reduced chronotropic reserve blunt the heart rate response to hemorrhage
Many elderly patients take beta-blockers, which pharmacologically prevent the compensatory tachycardia expected with hemorrhagic shock. Additionally, the aging heart has reduced chronotropic reserve. A geriatric trauma patient in Class II or III shock may present with a 'normal' heart rate of 70–80 bpm, masking the severity of hemorrhage.
Question 2: An 80-year-old woman falls from standing height. Compared to a 30-year-old with the identical fall mechanism, why does PHTLS recommend a higher index of suspicion for serious injury?
- Elderly patients have a lower center of gravity, creating more kinetic energy
- Osteoporosis, anticoagulant use, and reduced physiologic reserve amplify injury severity from the same mechanism (Correct answer)
- Risk is identical because the mechanism and kinetic energy are the same
- Elderly patients have thicker cortical bone that causes more energy transfer
Correct answer: Osteoporosis, anticoagulant use, and reduced physiologic reserve amplify injury severity from the same mechanism
The same low-energy mechanism causes disproportionately severe injury in elderly patients due to osteoporosis (fractures from minimal force), anticoagulant use (catastrophic bleeding from minor head trauma), and reduced physiologic reserve (inability to compensate). Falls from standing height are a leading cause of fatal injury in patients over 75.
Question 3: An elderly trauma patient has a blood pressure of 122/80 mmHg. Why might PHTLS consider this finding concerning even though it falls within a 'normal' range?
- Diastolic pressure above 80 is always abnormal in elderly patients
- Elderly patients' systolic pressure should exceed 160, making 122 dangerously low
- Many elderly patients have chronic hypertension, so 122/80 may represent relative hypotension from their normal baseline (Correct answer)
- The pulse pressure is too narrow, indicating tamponade
Correct answer: Many elderly patients have chronic hypertension, so 122/80 may represent relative hypotension from their normal baseline
A geriatric patient with a chronic baseline of 170/90 mmHg who presents at 122/80 has experienced a nearly 50-point systolic drop — significant hemorrhagic compromise despite a 'normal-looking' reading. PHTLS emphasizes always determining the patient's baseline BP, ideally from the patient, family, or medical history.
Question 4: Which musculoskeletal injury is MOST commonly caused by ground-level falls in elderly patients due to osteoporotic changes?
- Lumbar vertebral compression fractures
- Distal radius (Colles') fractures
- Proximal femur (hip) fractures (Correct answer)
- Calcaneal fractures
Correct answer: Proximal femur (hip) fractures
Proximal femur (hip) fractures are the most common serious musculoskeletal injury from ground-level falls in elderly patients. Osteoporotic bone at the femoral neck fails under forces that would not fracture younger bone. Hip fractures in elderly patients carry a 1-year mortality of 20–30% and are a major cause of morbidity.
Question 5: When assessing a 78-year-old trauma patient who appears confused, what is the MOST important initial step before attributing the confusion to head injury?
- Assume intoxication and proceed to physical examination
- Determine the patient's baseline mental status from available history or family (Correct answer)
- Obtain a blood glucose immediately to rule out hypoglycemia before any other assessment
- Age-related dementia makes further neurological assessment unreliable
Correct answer: Determine the patient's baseline mental status from available history or family
Altered mental status in an elderly trauma patient may reflect their baseline (pre-existing dementia) or a new change (TBI, hypoperfusion). PHTLS emphasizes establishing the baseline from family, caregivers, or medical records. A subtle decline from normal in a sharp elder may be more clinically significant than the same presentation in someone with baseline dementia.
Question 6: Which drug class is MOST critical to identify during medication history in a geriatric trauma patient because of its direct effect on hemorrhagic injury severity?
- Statins (e.g., atorvastatin)
- Proton pump inhibitors (e.g., omeprazole)
- Anticoagulants and antiplatelet agents (e.g., warfarin, clopidogrel) (Correct answer)
- ACE inhibitors (e.g., lisinopril)
Correct answer: Anticoagulants and antiplatelet agents (e.g., warfarin, clopidogrel)
Anticoagulants (warfarin, DOACs such as apixaban and rivaroxaban) and antiplatelet agents (aspirin, clopidogrel) significantly worsen hemorrhage after trauma. Even minor head trauma can cause life-threatening intracranial hemorrhage in anticoagulated elderly patients. This information must be communicated immediately to the receiving facility.
PHTLS Geriatric Trauma
Why is tachycardia an unreliable indicator of hemorrhagic shock in many elderly trauma patients?