Trauma in Older Adults: Falls, Undertriage, and the Limits of Normal Vital Signs Practice Questions

25 multiple-choice questions on Trauma in older adults: falls, undertriage, and the limits of normal vital signs for paramedic and EMT students, from Chapter 45 (Geriatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. About what share of US adults 65 and older fall each year?

   1. A. About 1 in 50
   2. B. About 1 in 4
   3. C. About 1 in 100
   4. D. About 3 in 4
   Show answer

   Answer: B. About 1 in 4

   More than one in four adults 65 and older fall each year, and falls are the leading cause of injury death in this group; many never tell their doctor. Three in four greatly overstates the rate.

2. A frail nursing home resident with dementia is found with her head and neck wedged between the bed rail and the mattress. She is cyanotic but has a pulse. The main danger of this position is:

   1. A. A pressure injury that forms within minutes
   2. B. Aspiration of vomit from her trapped position
   3. C. Asphyxia from neck and chest compression
   4. D. A head injury from striking the rail
   Show answer

   Answer: C. Asphyxia from neck and chest compression

   Gaps between a bed rail and the mattress or headboard can trap the head, neck, or chest of a frail, confused person, compressing the airway and chest; the FDA has documented hundreds of entrapment deaths, mostly in older adults. Free her carefully, open the airway, ventilate as needed, assess for neck injury, and document the scene for reporting. Pressure injuries take hours, not minutes. Her cyanosis comes from compression of the neck and chest, not aspiration, and a blow against the rail does not explain cyanosis in a wedged neck.

3. After a long lie on the floor, an older adult should be checked for pressure injury mainly over the:

   1. A. Hips, sacrum, and heels
   2. B. Palms and fingertips
   3. C. Front of the abdomen
   4. D. Upper arms and forearms
   Show answer

   Answer: A. Hips, sacrum, and heels

   Pressure over bony prominences such as the sacrum, hips, heels, and shoulder blades reduces blood flow and can injure tissue within a few hours. Soft areas such as the abdomen bear little pressure.

4. An 84-year-old fell onto her right shoulder. She holds the arm against her chest, and bruising is spreading down her upper arm. Her hand has good pulses and sensation. The most likely injury and splint are:

   1. A. Clavicle fracture; a long rigid board splint
   2. B. Proximal humerus fracture; sling and swathe
   3. C. Shoulder dislocation; straighten it to splint
   4. D. Rotator cuff tear; no splint is needed
   Show answer

   Answer: B. Proximal humerus fracture; sling and swathe

   Proximal humerus fractures are among the most common osteoporotic fractures in older adults after a fall onto the shoulder or outstretched arm; pain at the shoulder, guarding of the arm against the chest, and bruising that tracks down the arm over a day are typical. Support the arm in a sling and swathe in the position of comfort, pad it, and recheck distal circulation and sensation. A clavicle fracture causes pain and deformity over the collarbone and is also managed with a sling, not a rigid board. A dislocated shoulder is splinted in the position found rather than forced straight. Spreading bruising points to a fracture rather than a rotator cuff tear, and either injury benefits from a sling.

5. Older trauma patients are frequently undertriaged mainly because:

   1. A. They have fewer injuries per fall than adults
   2. B. Their vital signs change early and dramatically
   3. C. Serious injuries occur from minor mechanisms
   4. D. Trauma centers do not accept older adults
   Show answer

   Answer: C. Serious injuries occur from minor mechanisms

   Ground-level falls and low-speed crashes can cause major injury in older adults, and their vital signs may look reassuring, so they are less often sent to trauma centers. Vital signs often change late, not early, because of medications and reduced reserve.

6. An 87-year-old fell and has a shortened, externally rotated leg. An hour later she is pale and tachycardic, with no other injuries found. You should recognize that a hip fracture:

   1. A. Can lose enough blood to cause shock
   2. B. Rarely bleeds since the hip is small
   3. C. Causes pallor from pain, not blood loss
   4. D. Bleeds little unless the skin is broken
   Show answer

   Answer: A. Can lose enough blood to cause shock

   Proximal femur fractures, especially intertrochanteric fractures, can bleed a liter or more into the thigh, and older adults with little reserve and on anticoagulants may become hypovolemic; treat for shock, splint to limit motion, and reassess often. The hip and thigh hold a large volume of blood. Pain can cause pallor, but tachycardia and pallor after an hour should be treated as blood loss until proven otherwise. Closed fractures bleed internally without broken skin.

7. An 84-year-old with a pacemaker has a pelvic fracture after a fall. Her pulse is 70 and regular. This heart rate:

   1. A. Proves that she has not lost blood
   2. B. Means her pacemaker is malfunctioning
   3. C. Indicates cardiogenic shock is present
   4. D. May not rise in response to blood loss
   Show answer

   Answer: D. May not rise in response to blood loss

   Many pacemakers hold a set rate, so a patient may bleed significantly without tachycardia; look for other signs of shock such as altered mentation, cool skin, and falling BP. A normal rate does not exclude hemorrhage.

8. An 83-year-old on warfarin has a scalp laceration that keeps bleeding steadily after a fall. The best initial bleeding control is:

   1. A. Loose gauze with frequent peeks
   2. B. A cold pack without any pressure
   3. C. Leaving it open to clot on its own
   4. D. Firm, sustained direct pressure
   Show answer

   Answer: D. Firm, sustained direct pressure

   Anticoagulated scalp wounds can bleed heavily, so hold firm, uninterrupted pressure and apply a pressure dressing; repeatedly lifting the gauze breaks up forming clot. A cold pack alone does not control active bleeding.

9. An 82-year-old fell against a counter and has three right rib fractures. Compared with a younger adult, she is at greater risk of:

   1. A. Flail chest from a single fracture
   2. B. Faster healing with fewer complications
   3. C. Pneumonia and respiratory failure
   4. D. Rib fractures that need no pain control
   Show answer

   Answer: C. Pneumonia and respiratory failure

   In older adults each additional rib fracture raises mortality, largely from splinting, hypoventilation, pneumonia, and respiratory failure, so pain control and close monitoring of ventilation are vital. Flail chest requires two or more ribs each broken in two places.

10. A 76-year-old on clopidogrel was struck by a car at 20 mph. He is alert with stable vital signs and leg pain. Per field triage guidance, he should:

    1. A. Be considered for a trauma center
    2. B. Go to a nearby clinic for x-rays
    3. C. Be released if he can bear weight
    4. D. Be driven by family to urgent care
    Show answer

    Answer: A. Be considered for a trauma center

    A pedestrian struck by a vehicle, older age, and antiplatelet or anticoagulant use are each reasons to consider trauma center care even when the patient looks stable. Releasing a struck pedestrian because he can bear weight misses occult injuries.

11. Older adults are at higher risk of dying in house fires mainly because of:

    1. A. Greater lung capacity for smoke
    2. B. Slower escape and impaired senses
    3. C. Thicker skin that resists flames
    4. D. Faster response to smoke alarms
    Show answer

    Answer: B. Slower escape and impaired senses

    Impaired hearing, vision, smell, mobility, and cognition delay recognition of a fire and escape from it, so older adults have among the highest fire death rates. Their response to alarms is slower, not faster.

12. An 80-year-old with diabetes fell asleep with a heating pad on her lower back and now has a deep burn there. She says it 'never felt hot.' This injury mostly reflects:

    1. A. Thicker skin that holds heat in for longer
    2. B. Less heat sensation from age and neuropathy
    3. C. A normal sign of the skin aging well
    4. D. Increased pain sensitivity to heat with age
    Show answer

    Answer: B. Less heat sensation from age and neuropathy

    Older adults, especially those with diabetic neuropathy, sense heat and pain less well, and their thin skin burns at lower temperatures and with shorter contact, so heating pads, hot water bottles, and bath water cause deep burns; cool the burn, cover it, and advise against prolonged heat use. Aging skin is thinner, not thicker. A deep burn is not a sign of healthy aging. Pain sensitivity to heat decreases rather than increases.

13. An 89-year-old has a suspected hip fracture after a fall. When packaging her for transport, the best approach is to:

    1. A. Apply a traction splint to the injured leg
    2. B. Have her stand and pivot to the stretcher
    3. C. Straighten and rotate the leg into line
    4. D. Pad between the legs and support the hip
    Show answer

    Answer: D. Pad between the legs and support the hip

    Move her with a scoop stretcher or vacuum mattress, place padding between the legs and under the knees, and secure the legs together in a position of comfort, with analgesia titrated cautiously. Traction splints are designed for midshaft femur fractures and are generally not used for hip fractures, where traction can worsen pain and displacement. Standing and pivoting loads the fracture. Forcing the leg straight or rotating it into line can displace the fracture and injure vessels.

14. When an older driver has a minor crash, you should consider that:

    1. A. Older drivers rarely have medical problems
    2. B. The crash speed rules out serious injury
    3. C. A medical event may have caused the crash
    4. D. Airbags prevent chest wall injury
    Show answer

    Answer: C. A medical event may have caused the crash

    Syncope, hypoglycemia, stroke, dysrhythmia, or MI can cause a crash, so assess for a medical cause along with injuries. Low speed does not rule out serious injury in older adults.

15. Which factor most increases an older adult's risk of falling?

    1. A. Taking four or more medications
    2. B. Wearing well-fitting shoes
    3. C. Regular tai chi or balance exercise
    4. D. Using night-lights at home
    Show answer

    Answer: A. Taking four or more medications

    Polypharmacy, especially sedatives, antihypertensives, and psychoactive drugs, is a major modifiable fall risk, along with weakness, poor vision, and home hazards. Balance exercise such as tai chi reduces falls.

16. You are called for the third 'lift assist' this month for an 84-year-old man who has no injuries today. The best practice is to:

    1. A. Lift him and leave if his vital signs are normal
    2. B. Look for a cause and arrange follow-up
    3. C. Lift him and advise an alert pendant
    4. D. Advise him to stay in bed to avoid falls
    Show answer

    Answer: B. Look for a cause and arrange follow-up

    Repeated falls signal illness, weakness, medication effects, or unsafe conditions and predict future injury, so do a full assessment and use referral or community paramedicine programs. Normal vital signs do not explain repeated falls, and a medical alert pendant speeds the next call for help without addressing why he keeps falling. Bed rest causes deconditioning and increases fall risk.

17. Compared with a younger adult with the same injuries, an older trauma patient has:

    1. A. A higher risk of death
    2. B. A lower risk of death
    3. C. The same risk of death
    4. D. A lower risk of infection
    Show answer

    Answer: A. A higher risk of death

    Reduced physiologic reserve, comorbidities, and medications mean older adults die at higher rates from the same injury severity. Infection and other complications are also more common, not less.

18. An 85-year-old fell and has a shortened, externally rotated right leg with groin pain. Your partner wants to apply a traction splint. You should:

    1. A. Apply the traction splint as he suggests
    2. B. Straighten the leg forcefully before splinting
    3. C. Use padding and pillows instead of traction
    4. D. Tie both legs together with no padding
    Show answer

    Answer: C. Use padding and pillows instead of traction

    Traction splints are designed for midshaft femur fractures. They do not help, and may harm, a fracture of the hip or femoral neck. Support the leg in a position of comfort with padding between the legs and pillows or blankets, and move her carefully on a scoop or vacuum mattress.

19. An 82-year-old fell from standing and has groin pain on one side and pain over the front of the pelvis. She can walk slowly with help. The most likely injury is:

    1. A. A torn tendon in the calf muscle
    2. B. A dislocated knee joint
    3. C. A sprained ankle ligament
    4. D. A fracture of the pubic rami
    Show answer

    Answer: D. A fracture of the pubic rami

    Pubic rami fractures are common osteoporotic fractures after ground-level falls in older adults; they cause groin and anterior pelvic pain, and many patients can still walk, which delays care. Most are stable, but they can bleed, especially on anticoagulants, so assess for shock and transport. Calf, knee, and ankle injuries do not cause groin and anterior pelvic pain. Being able to walk does not rule out a pelvic or hip fracture.

20. Permissive hypotension in an older trauma patient with chronic hypertension is risky because:

    1. A. Their kidneys tolerate low pressure better
    2. B. They bleed less at any blood pressure
    3. C. Their brains autoregulate well at lower pressures
    4. D. Their organs need higher pressure for perfusion
    Show answer

    Answer: D. Their organs need higher pressure for perfusion

    Chronic hypertension shifts cerebral and renal autoregulation upward, so a 'permissive' systolic pressure of 80 to 90 mm Hg may cause ischemia in an older adult. Their kidneys are more, not less, vulnerable to hypoperfusion.

21. Advanced airway placement may be harder in older trauma patients mainly because of:

    1. A. Larger, more mobile tongues
    2. B. Arthritis that limits neck movement
    3. C. A more anterior larynx than children
    4. D. Stronger gag reflexes with age
    Show answer

    Answer: B. Arthritis that limits neck movement

    Cervical arthritis, kyphosis, and poor dentition make positioning and laryngoscopy difficult, and forced extension can injure a stiff neck. Gag reflexes weaken, not strengthen, with age.

22. A 78-year-old fell down four stairs and has a GCS of 15, a BP of 142/80 mm Hg, and a pulse of 84. Which statement about her triage is most accurate?

    1. A. Normal vital signs exclude significant internal bleeding
    2. B. A GCS of 15 rules out any brain injury
    3. C. Normal findings do not exclude serious injury
    4. D. She needs no assessment beyond vital signs
    Show answer

    Answer: C. Normal findings do not exclude serious injury

    Older adults can have serious injuries with normal initial vital signs and mental status, so a thorough exam and a low threshold for trauma center care are needed. A GCS of 15 does not rule out a developing intracranial bleed.

23. A 79-year-old cut her hand on a rusty garden tool. She cannot remember her last tetanus shot. Compared with younger adults, older adults are:

    1. A. Less often current on tetanus vaccine
    2. B. Protected for life by childhood shots
    3. C. Unable to receive a tetanus booster
    4. D. At no risk from tetanus after age 65
    Show answer

    Answer: A. Less often current on tetanus vaccine

    Many older adults never completed a primary series or have not had a booster in decades, and adults 65 and older have the lowest Td/Tdap coverage and the highest tetanus death rate, so ask about tetanus status and report it so the hospital can give a booster (and immune globulin if needed). Childhood vaccination does not give lifelong protection; boosters are needed every 10 years, or after 5 years for dirty wounds. Age is not a contraindication to a booster. Older adults are at higher, not lower, risk.

24. For an injured older adult taking apixaban, which detail is most useful to report to the receiving hospital?

    1. A. The time of her last dose
    2. B. Her most recent INR value
    3. C. Whether she takes it with food
    4. D. How long she has had the bottle
    Show answer

    Answer: A. The time of her last dose

    The timing of the last DOAC dose helps the hospital judge how much anticoagulant effect remains and whether reversal is needed. The INR does not reliably measure apixaban's effect, so a recent INR value is not a useful guide. Apixaban can be taken with or without food, so that detail does not change the reversal decision. How long she has had the bottle says nothing about her current drug level.

25. In older adults who are injured, which factor best predicts complications and death after the injury?

    1. A. His or her age in years, considered by itself
    2. B. Frailty and function before the injury
    3. C. Whether the injury happened in the home
    4. D. The time of day when the injury occurred
    Show answer

    Answer: B. Frailty and function before the injury

    Frailty, meaning reduced physiologic reserve, weight loss, weakness, and dependence in daily activities, predicts complications and death after trauma better than age alone. A fit 85-year-old may do better than a frail 70-year-old. Ask about baseline mobility and independence and report it.