19.1 Geriatric Trauma and Medical Care

The 82-year-old from a standing fall is a trauma patient until a capable hospital proves otherwise. Domain 5.C of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests geriatric trauma and medical care because low energy hides high injury, and because the cabin will finish any hypothermia, missed bleed, or under-triage you start on the pad. Pharmacology is section 19.2.

Why the standing fall is not "just a fall"

Under-triage is the dominant geriatric trauma error. Ground-level falls look like a medical job to a tired emergency department. The same fall in an 82-year-old with a stiff neck, warfarin, and a beta-blocker is a multi-system trauma story. Classic adult advanced trauma life support (ATLS) cues fail: heart rate may never reach 100, blood pressure may sit at a "normal" 110 after starting at 170, and a conversational patient can still harbor a subdural hematoma (SDH).

Cerebral atrophy enlarges the subdural space and stretches bridging veins. Minor head impact — a nightstand, a toilet, a single stair — can tear those veins. The hematoma has room to grow before the Glasgow Coma Scale (GCS) falls. Presentation can be delayed hours to days. Do not clear the head because the mechanism was "only a fall." Do not wait for a dilated pupil at cruise. Request a lower cabin when the head is in play (Chapter 2).

Occult injury the monitor will not announce

• Beta-blockers and some calcium-channel blockers hide tachycardia. Shock is a delta from that patient's baseline, not a heart rate of 110. Look at pulse pressure, mentation, skin, urine, and any sending lactate.
• Cervical spine injury follows low-energy falls in spondylotic, stenotic, or rheumatoid necks. Central cord can present as weak hands after a ground-level face-plant. Apply spinal motion restriction you can still manage through the aircraft door (Chapter 10). Do not sit the patient bolt-upright for comfort and call the neck cleared.
• Rib fractures kill older adults (Chapter 12). Two or three fractured ribs plus pain plus shallow tidal volumes become pneumonia, atelectasis, and respiratory failure. Treat pain so they can breathe; do not undertreat because they are old. Destination should offer multimodal analgesia, pulmonary toilet, and intensive monitoring — not a hallway chair.
• Anticoagulation turns a modest SDH or retroperitoneal bleed into a race. Note the agent (warfarin versus a direct oral anticoagulant (DOAC)), last dose, and any international normalized ratio (INR) already drawn. Do not hold the aircraft for a complete reversal you cannot finish. Fly to a hospital that can reverse and operate (section 19.2).

Medical faces that do not look like the textbook

Acute coronary syndrome (ACS) in older adults is often dyspnea, syncope, fatigue, or isolated nausea — not crushing substernal pain (Chapter 14). A "weak and dizzy" transfer can be an ST-elevation myocardial infarction (STEMI) or a rising-troponin non–ST-elevation infarct. Put pads on. Treat hypoxia. Choose a percutaneous coronary intervention (PCI)-capable door when the story is ischemic.

Sepsis may present without fever (Chapter 17). Immunosenescence blunts the pyrogenic response. Hypothermia or a "normal" temperature with a high heart rate, confusion, or falling urine output is more ominous than a 39 °C spike. Give source-aware fluids with a hard reassess, and do not wait for a white-count result on the sending fax.

Hypothermia is both a finding and a mission product. Thin skin, less muscle, and a wet nightgown on a garage floor start the cooling; rotor wash finishes it. Dry, cover, warm the cabin, and treat a 35 °C trauma patient as coagulopathic (Chapter 10).

Brain: dementia, delirium, stroke

Do not call every confused 80-year-old baseline dementia.

• Dementia is a chronic, progressive cognitive decline the family can date in months to years.
• Delirium is acute and fluctuating — infection, hypoxia, hypoglycemia, drugs, urinary retention, pain, or a new SDH.
• Stroke is a focal neurologic deficit on a clock (Chapter 14).

Ask when the patient last seemed usual. Write the family's words. Check glucose. Look for a new focal sign. A midnight "altered" from a skilled-nursing facility is a time-critical workup, not a courtesy transfer to the nearest bed.

Skin, pressure, destination, and directives

Skin tears and pressure injuries are transport injuries you can cause. Shear on a sliding board and a wrinkled sheet under a sacrum count. Pad bony prominences. Lift, do not drag. Recheck occiput, heels, and sacrum after the litter click.

Do not under-triage the standing-fall octogenarian to a hospital that cannot computed tomography (CT) a head, reverse anticoagulation, fix a hip, or admit a three-rib fracture.

Advance directives, Physician Orders for Life-Sustaining Treatment (POLST), and out-of-hospital do-not-resuscitate (DNR) forms travel with the patient (Chapter 3). Confirm the document is current, matches the name and date of birth, and is specific about intubation, cardiopulmonary resuscitation (CPR), and blood. A POLST that refuses CPR does not refuse a pelvic binder, warming, or a conversation with medical control. If family and paper conflict in cruise, treat immediately reversible threats, call medical control, and document. Do not invent a new code status because the cabin is loud.

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