Myth 3: Volume Replacement in Trauma Patients with Hemorrhagic Shock Should Only Be Accomplished Utilizing Blood Products

While blood products are generally favored over crystalloid in the young trauma patient showing signs of hemorrhagic shock for volume replacement, older patients are often fluid-deplete at baseline and may be taking medications such as diuretics that further deplete their volume.¹³ In the initial resuscitation of an elderly trauma patient who may be volume-depleted at baseline, it is reasonable to give a small bolus of crystalloid (250–500 cc) followed by frequent reassessments of volume status using a combination of clinical parameters, point-of-care ultrasound, an arterial line, and urine output.

Myth 4: Isolated Pelvic Fractures Are a Rare Cause of Hemorrhagic Shock and Mortality in Trauma Patients

While young patients with isolated pelvic fractures rarely suffer from hemorrhagic shock and death, and isolated pubic ramus fractures are generally benign injuries, it is not uncommon for older trauma patients to suffer a lateral compression fracture of the pelvis leading to unrecognized retroperitoneal bleeding.¹⁴ Older trauma patients are more likely to have lateral compression fractures of the pelvis than younger patients and are more likely to suffer complications of pelvic fractures leading to death.¹⁵ These fractures in older patients carry a risk of retroperitoneal bleeding requiring angiography that cannot be detected by point-of-care ultrasound during the initial ED resuscitation. It is prudent to maintain a high level of suspicion for pelvic fractures with associated vascular injury and retroperitoneal bleeding in older trauma patients, especially if they are taking anticoagulant medications. Binding the pelvis early in the ED resuscitation of older polytrauma patients suspected of pelvic fractures should be considered.¹⁶

Myth 5: Opioid Analgesics Should Be Withheld from Older Trauma Patients Due to Potential Adverse Effects

Undertreating and overdosing analgesics in older trauma patients are common pitfalls.¹⁷ All trauma patients should have their pain treated regardless of age. Side effects from opioids are minimized in older patients by appropriately lowering the standard adult dosages. Both treating pain and proper dosing of analgesics help reduce the risk of delirium and agitation in these patients.¹⁸ Early pain control with multimodal analgesia, access to regional analgesia, and regular pain assessments are paramount in managing the older trauma patient. Goals of pain management include the ability of the patient to sit up and roll over independently.

A special thanks to Dr. Barbara Haas, Dr. Bourke Tillman, and Dr. Camilla Wong for their expert contributions to the EM Cases podcast from which this article was inspired. 