{"id":481,"date":"2023-02-27T10:01:45","date_gmt":"2023-02-27T07:01:45","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=481"},"modified":"2023-02-27T10:01:47","modified_gmt":"2023-02-27T07:01:47","slug":"acil-servise-dusme-ile-basvuran-yasli-hastalarin-yonetimi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/acil-servise-dusme-ile-basvuran-yasli-hastalarin-yonetimi\/","title":{"rendered":"Acil Servise D\u00fc\u015fme \u0130le Ba\u015fvuran Ya\u015fl\u0131 Hastalar\u0131n Y\u00f6netimi<\/strong>"},"content":{"rendered":"\n

\u00d6ZET: <\/strong>Ya\u015fl\u0131 d\u00fc\u015fme hastalar\u0131 giderek artan oranlarda acil servise ba\u015fvurmaktad\u0131r. Ya\u015fl\u0131larda d\u00fc\u015fmeler \u00e7o\u011fu zaman d\u00fcz zeminde ve \u00e7evresel nedenlerle ger\u00e7ekle\u015fmekle birlikte t\u0131bbi durumlarda ya\u015fl\u0131 hastalarda d\u00fc\u015fmenin nedeni olabilir. Bu nedenle acil servise getirilen d\u00fc\u015fme hastalar\u0131 hem travma hem de di\u011fer t\u0131bbi medikal patolojiler a\u00e7\u0131s\u0131ndan incelenmelidir. Ya\u015fl\u0131 d\u00fc\u015fme hastalar\u0131nda laboratuvar ve g\u00f6r\u00fcnt\u00fcleme e\u015fi\u011fi d\u00fc\u015f\u00fck tutulmal\u0131, gerekirse tetkiklerin tekrar\u0131na veya ileri g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemlerine gidilmelidir. Bu hastalarda yat\u0131\u015f ve hasta takibi gen\u00e7 pop\u00fclasyona g\u00f6re daha d\u00fc\u015f\u00fck e\u015fik de\u011ferlerle yap\u0131lmal\u0131d\u0131r.<\/p>\n\n\n\n

Ya\u015fl\u0131 ki\u015filerde, ya\u015fl\u0131l\u0131\u011fa ba\u011fl\u0131 anatomik, fizyolojik ve endokrin de\u011fi\u015fiklikler nedeniyle travma riski artmaktad\u0131r(1). Ya\u015fl\u0131lar travmalara kar\u015f\u0131 hassast\u0131r, d\u00fc\u015f\u00fck enerjili olarak tan\u0131mlad\u0131\u011f\u0131m\u0131z travmalar bile ciddi problemlere neden olabilir. Bu pop\u00fclasyon travmaya ba\u011fl\u0131 durumlar\u0131n tedavisi s\u0131ras\u0131nda ya\u015fanan komplikasyonlardan da \u00f6nemli \u00f6l\u00e7\u00fcde etkilenir. Acil doktorlar\u0131 gen\u00e7 hastalara k\u0131yasla ya\u015fl\u0131 travma hastalar\u0131n\u0131 daha iyi incelemeli ve tetkik e\u015fiklerini daha d\u00fc\u015f\u00fck tutmal\u0131d\u0131r. \u00c7\u00fcnk\u00fc ya\u015f\u0131n ilerlemesiyle olan fizyolojik de\u011fi\u015fiklikler (fizyolojik ve fiziksel rezervlerin azalmas\u0131) yaralanman\u0131n de\u011ferlendirmesini zorla\u015ft\u0131rmakta ve tedavisini g\u00fc\u00e7le\u015ftirmektedir (2).<\/p>\n\n\n\n

T\u00fcrkiye \u0130statistik Kurumuna (T\u00dc\u0130K) g\u00f6re 2013 y\u0131l\u0131nda %7,7 olan 65 ya\u015f ve \u00fcst\u00fc n\u00fcfusun t\u00fcm n\u00fcfusa oran\u0131n, 2025 y\u0131l\u0131nda %11 ve 2030 y\u0131l\u0131nda %12,9 olmas\u0131 beklenmektedir (3). Bu da acil servis \u00e7al\u0131\u015fanlar\u0131n\u0131n ilerleyen zamanlarda acil servislerde daha fazla ya\u015fl\u0131 hasta g\u00f6rmelerine ve ya\u015fl\u0131 hasta bak\u0131m\u0131 konusundaki yetkinliklerini artt\u0131rma ihtiyac\u0131 duymalar\u0131na neden olacakt\u0131r.<\/p>\n\n\n\n

D\u00fc\u015fme, ya\u015fl\u0131 n\u00fcfusun maruz kald\u0131\u011f\u0131 en yayg\u0131n travma nedenidir ve acil servise ba\u015fvuran 65 ya\u015f ve \u00fczeri travma hastalar\u0131nda travman\u0131n birinci nedenidir (4). D\u00fc\u015fme oran\u0131 ilerleyen ya\u015fla artmakla birlikte her y\u0131l \u00fc\u00e7 ya\u015fl\u0131 hastadan birinin d\u00fc\u015fmeye ba\u011fl\u0131 travma ya\u015fad\u0131\u011f\u0131 bilinmektedir (2). D\u00fc\u015fme ile acil servise getirilen ya\u015fl\u0131 hastalarda en s\u0131k rastlan\u0131lan k\u0131r\u0131klar kal\u00e7a ve omurga k\u0131r\u0131klar\u0131d\u0131r (5). <\/p>\n\n\n\n

Ya\u015fl\u0131larda d\u00fc\u015fmenin nedenleri; sarkopeniye ba\u011fl\u0131 kas kitlesinde ve motor g\u00fc\u00e7te azalma, denge ve koordinasyon bozukluklar\u0131 ve reaksiyon s\u00fcresinde uzama say\u0131labilir. Bunlar\u0131n yan\u0131nda g\u00f6rme keskinli\u011finde azalma, ev ko\u015fullar\u0131n\u0131n ya\u015fl\u0131 hastalar i\u00e7in uygun olmamas\u0131 (yetersiz ayd\u0131nlatma, kayabilen\/katlanabilen hal\u0131 gibi), alkol, s\u0131cak banyo veya du\u015f, n\u00f6rolojik hastal\u0131klar (serebrovask\u00fcler atak gibi), dehidratasyon, hemoraji, n\u00f6betler ve ila\u00e7lar (beta blokerler, narkotikler) say\u0131labilir (2). Sert zemine olan veya merdivenden yuvarlanma \u015feklinde olan d\u00fc\u015fmeler yumu\u015fak ve d\u00fcz zeminde olan d\u00fc\u015fmelere g\u00f6re daha ciddi patolojiler i\u00e7erir.<\/p>\n\n\n\n

Acil serviste d\u00fc\u015fme ile getirilen hastay\u0131 de\u011ferlendirirken hastaya, yak\u0131nlar\u0131na veya hastane \u00f6ncesi sa\u011fl\u0131k ekiplerine d\u00fc\u015fmeye neden olan olaylar ayr\u0131nt\u0131l\u0131 \u015fekilde sorulmal\u0131d\u0131r. D\u00fc\u015fmenin nedenini ara\u015ft\u0131rmak hem d\u00fc\u015fmeye sebep olan t\u0131bbi nedenlerin tespitinde hem de ilerleyen zamanlarda geli\u015febilecek tekrarlayan travmalar\u0131n \u00f6nlenmesinde \u00f6nem arz eder. \u015eu unutulmamal\u0131d\u0131r ki; ya\u015fl\u0131 d\u00fc\u015fme hastalar\u0131 hem travma hastas\u0131 hem de di\u011fer medikal patolojiler a\u00e7\u0131s\u0131ndan de\u011ferlendirilmeli ve tedavi edilmelidir (2).<\/p>\n\n\n\n

B\u00fct\u00fcn travma hastalar\u0131nda oldu\u011fu gibi, ya\u015fl\u0131 travma hastalar\u0131n\u0131n da ilk de\u011ferlendirmesi vital bulgular\u0131n de\u011ferlendirilmesi ile ba\u015flar. Ta\u015fikardi<\/strong> yan\u0131t\u0131 \u00f6zellikle beta bloker alan hastalarda g\u00f6r\u00fclmeyebilir ve bu durum \u00f6nemli patolojileri (hipovolemi, a\u011fr\u0131) gizleyebilir. Yine kan bas\u0131nc\u0131<\/strong> de\u011ferleri de ta\u015fikardi gibi yan\u0131lt\u0131c\u0131 olabilir. Bu hasta gruplar\u0131nda hipertansiyon insidans\u0131n\u0131n y\u00fcksek oldu\u011fu unutulmamal\u0131 ve hipotansiyon i\u00e7in daha y\u00fcksek bir e\u015fik de\u011fer kullan\u0131lmal\u0131d\u0131r.<\/p>\n\n\n\n

Ya\u015fl\u0131 travma hastalar\u0131 tan\u0131 s\u00fcrecinde de\u011ferlendirilirken sistemlerin hepsi g\u00f6zden ge\u00e7irilmelidir. <\/p>\n\n\n\n

Kafa travmas\u0131<\/strong> sonucu olu\u015fan durumlar ya\u015fl\u0131 hastalarda mortalite ve morbiditenin \u00f6nemli nedenlerindendir. Ya\u015f grubuna ve ba\u015fl\u0131ca yaralanma mekanizmas\u0131na g\u00f6re travmatik beyin hasar\u0131 ile acil servise ba\u015fvuran hastalar incelendi\u011finde 65 ya\u015f ve \u00fczeri hastalarda travmatik beyin hasar\u0131n\u0131n olu\u015fmas\u0131nda d\u00fc\u015fmeler en s\u0131k neden olarak saptanm\u0131\u015ft\u0131r (6). Hastalar\u0131n bilin\u00e7 durumu de\u011ferlendirilirken, bilin\u00e7te olan de\u011fi\u015fiklikler ya\u015fa ba\u011fl\u0131 demans ile ili\u015fkilendirilmeden ciddi \u015fekilde ele al\u0131n\u0131p de\u011ferlendirilmelidir. Ya\u015fa ba\u011fl\u0131 beyindeki anatomik de\u011fi\u015fikler nedeniyle subdural veya intraparankimal kanamalar daha fazla g\u00f6r\u00fcl\u00fcr ve yine ya\u015fa ba\u011fl\u0131 geli\u015fen atrofi nedeniyle semptom ve bulgular ge\u00e7 d\u00f6nemde g\u00f6r\u00fclebilir. Kafa travmas\u0131n\u0131n de\u011ferlendirilmesinde planlanmas\u0131 gereken ilk tetkik kontrasts\u0131z beyin bilgisayarl\u0131 tomografi (BT) olmal\u0131d\u0131r. Antikoag\u00fclan veya antiagregan alan hastalarda (asemptomatik olsalar bile) g\u00f6r\u00fcnt\u00fcleme e\u015fi\u011fi d\u00fc\u015f\u00fck tutulmal\u0131d\u0131r.<\/p>\n\n\n\n

Spinal yaralanmalar <\/strong>(servikal,torokal-lumbal)\u2019\u0131n de\u011ferlendirilmesinde, gerek pozisyona ba\u011fl\u0131 \u00e7ekim ve de\u011ferlendirme sorunlar\u0131ndan gerekse ya\u015fa ba\u011fl\u0131 dejeneratif de\u011fi\u015fikliklerden kaynaklanan direkt grafi yorumlama problemleri ortaya \u00e7\u0131kabilir. Spinal yaralanma \u015f\u00fcphesi durumlar\u0131nda ilk g\u00f6r\u00fcnt\u00fcle y\u00f6ntemi olarak BT iyi bir tercihtir (7).<\/p>\n\n\n\n

Ya\u015fl\u0131 d\u00fc\u015fme hastalar\u0131 g\u00f6\u011f\u00fcs ve kar\u0131n yaralanmalar\u0131<\/strong> a\u00e7\u0131s\u0131ndan iyi de\u011ferlendirilmelidirler. Bu hasta gruplar\u0131nda muayene her zaman g\u00fcvenilir olmayabilir, bu nedenle ileri g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemleri (BT) i\u00e7in d\u00fc\u015f\u00fck e\u015fik de\u011ferler kullan\u0131lmal\u0131d\u0131r. Ya\u015fl\u0131 hastalarda travmaya ba\u011fl\u0131 g\u00f6r\u00fclen kot k\u0131r\u0131\u011f\u0131 say\u0131s\u0131 ve k\u00f6t\u00fc sonlan\u0131mla ili\u015fkili \u00e7al\u0131\u015fmalar mevcuttur (2,8).<\/p>\n\n\n\n

Pelvis ve kal\u00e7a k\u0131r\u0131kla<\/strong>r\u0131 ya\u015fl\u0131 hastalarda d\u00fc\u015f\u00fck enerjili travmalarda bile g\u00f6r\u00fclebilmektedir. Muayenesinde pelvis hassasiyeti olan ve direkt grafisi normal olan hastalarda BT g\u00f6r\u00fcnt\u00fclemesi yap\u0131lmal\u0131d\u0131r (9). Kal\u00e7a k\u0131r\u0131klar\u0131, d\u00fc\u015fme ile acil servise gelen ya\u015fl\u0131 hastalarda hastaneye yat\u0131\u015f\u0131n ve mortalitenin \u00f6nemli bir nedenidir (10). G\u00f6r\u00fcnt\u00fcleme planlan\u0131rken pelvis grafisine ek olarak, etkilenen ekstremitenin iki y\u00f6nl\u00fc grafileri de planlanmal\u0131d\u0131r. Ya\u015fl\u0131 hastalarda \u00fcst ekstremitenin d\u00fc\u015fmeye ba\u011fl\u0131 olu\u015fan enerjiyi tamponlayabilme \u00f6zelli\u011fi gen\u00e7 hastalara g\u00f6re olduk\u00e7a d\u00fc\u015f\u00fckt\u00fcr, bu da d\u00fc\u015f\u00fck enerjili travmalarda bile \u00fcst ekstremitelerde k\u0131r\u0131klar\u0131n olu\u015fmas\u0131 ile sonu\u00e7lan\u0131r (11). <\/p>\n\n\n\n

Ya\u015fl\u0131 travma hastalar\u0131n\u0131n laboratuvar<\/strong> planlamas\u0131 daha geni\u015f kapsaml\u0131 (ek hastal\u0131klar\u0131n ve d\u00fc\u015fmeye neden olan t\u0131bbi nedenlerin tespitinde) ve daha s\u0131k aral\u0131klarla yap\u0131lmal\u0131d\u0131r. Hastalarda antikoag\u00fclan al\u0131m\u0131 varsa ve kanama mevcut ise, antikoag\u00fclasyon tersine \u00e7evrilmelidir (12).<\/p>\n\n\n\n

Genel yakla\u015f\u0131m olarak d\u00fc\u015fme ile acil servise ba\u015fvuran ya\u015fl\u0131 hastalarda yat\u0131\u015f karar\u0131 i\u00e7in e\u015fik d\u00fc\u015f\u00fck tutulmal\u0131d\u0131r. D\u00fc\u015fme ile tedavi edilen hastalarda ama\u00e7, hastan\u0131n d\u00fc\u015fme \u00f6ncesi fonksiyonel durumuna geri d\u00f6nmesini sa\u011flamakt\u0131r. Bundan sonraki a\u015fama ise d\u00fc\u015fmeye neden olan t\u0131bbi ve \u00e7evresel fakt\u00f6rlerin (ayd\u0131nlatma, zemin, merdiven, dola\u015f\u0131m alanlar\u0131) belirlenmesi devam\u0131nda tekrar d\u00fc\u015fmenin \u00f6nlenmesi amac\u0131yla uygun d\u00fczenlemeler yap\u0131lmas\u0131 olmal\u0131d\u0131r.<\/p>\n\n\n\n

Kaynaklar<\/strong><\/p>\n\n\n\n

1.        Ferhat \u0130, Sinan B, Asliddin A, Akkan A, Haldun A, Salim S. The use of trauma scoring systems in elderly patients who are admitted to the emergency department due to falls. Turk Geriatr Derg. 2014;17(2):138\u201342. <\/p>\n\n\n\n

2.        Judith E. Tintinalli, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, et al. Tintinalli\u2019s Emergency Medicine A Comprehensive Study Guide. 2020. 1119\u20131136 p.<\/p>\n\n\n\n

3.        TU\u0130K. \u0130statistiklerle Ya\u015fl\u0131lar, 2020 [Internet]. T\u00fcrkiye \u0130statistik Kurumu. 2021 [cited 2023 Feb 19]. p. 2. Available from: https:\/\/data.tuik.gov.tr\/Bulten\/Index?p=Istatistiklerle-Yaslilar-2020-37227#<\/p>\n\n\n\n

4.        Leading Causes of Death Reports, National and Regional, 1999 – 2020, National Center for Injury Prevention and Control, US Centers for Disease Control. [Internet]. [cited 2023 Feb 19]. Available from: https:\/\/wisqars.cdc.gov\/cgi-bin\/broker.exe<\/p>\n\n\n\n

5.        Ioannidis G, Flahive J, Pickard L, Papaioannou A, Chapurlat RD, Saag KG, et al. Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW). Osteoporos Int. 2013 Jan 12;24(1):59\u201367. <\/p>\n\n\n\n

6.        Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury\u2013Related Emergency Department Visits, Hospitalizations, and Deaths \u2014 United States, 2007 and 2013. MMWR Surveill Summ. 2017 Mar 17;66(9):1\u201316. <\/p>\n\n\n\n

7.        Looby S, Flanders A. Spine Trauma. Radiol Clin North Am. 2011 Jan;49(1):129\u201363. <\/p>\n\n\n\n

8.        Shulzhenko NO, Zens TJ, Beems M V., Jung HS, O\u2019Rourke AP, Liepert AE, et al. Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma. Surgery. 2017 Apr;161(4):1083\u20139. <\/p>\n\n\n\n

9.        Bent C, Chicklore S, Newton A, Habig K, Harris T. Do emergency physicians and radiologists reliably interpret pelvic radiographs obtained as part of a trauma series? Emerg Med J. 2013 Feb;30(2):106\u201311. <\/p>\n\n\n\n

10.      Brauer CA. Incidence and Mortality of Hip Fractures in the United States. JAMA. 2009 Oct 14;302(14):1573. <\/p>\n\n\n\n

11.      Hruska K, Ruge T. The Tragically Hip. Emerg Med Clin North Am. 2018 Feb;36(1):219\u201335. <\/p>\n\n\n\n

12.      Goldstein JN, Thomas SH, Frontiero V, Joseph A, Engel C, Snider R, et al. Timing of Fresh Frozen Plasma Administration and Rapid Correction of Coagulopathy in Warfarin-Related Intracerebral Hemorrhage. Stroke. 2006 Jan;37(1):151\u20135. <\/p>\n","protected":false},"excerpt":{"rendered":"

\u00d6ZET: Ya\u015fl\u0131 d\u00fc\u015fme hastalar\u0131 giderek artan oranlarda acil servise ba\u015fvurmaktad\u0131r. Ya\u015fl\u0131larda d\u00fc\u015fmeler \u00e7o\u011fu zaman d\u00fcz zeminde ve \u00e7evresel nedenlerle ger\u00e7ekle\u015fmekle birlikte t\u0131bbi durumlarda…<\/p>\n","protected":false},"author":1185,"featured_media":483,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10020,10033,10018,10034],"class_list":["post-481","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-acil-tip","tag-dusme","tag-geriatri","tag-yasli"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/481","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=481"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/481\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/483"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=481"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=481"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=481"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}