{"id":529,"date":"2023-10-18T14:49:34","date_gmt":"2023-10-18T11:49:34","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=529"},"modified":"2023-10-18T14:49:35","modified_gmt":"2023-10-18T11:49:35","slug":"yasli-travma-hastasi-neden-ozeldir","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-travma-hastasi-neden-ozeldir\/","title":{"rendered":"Ya\u015fl\u0131 Travma Hastas\u0131 Neden \u00d6zeldir?"},"content":{"rendered":"\n

Geli\u015fmi\u015f \u00fclkelerde azalan do\u011fum oranlar\u0131, kronik hastal\u0131k bak\u0131m\u0131ndaki ilerlemeler 60 ya\u015f ve \u00fczerindeki n\u00fcfusun g\u00f6zle g\u00f6r\u00fcn\u00fcr bir \u015fekilde art\u0131\u015f\u0131na neden olmu\u015ftur (1). \u00c7o\u011funlukla aktif ya\u015fam tarz\u0131na sahip bu bireylerin gen\u00e7lere g\u00f6re ciddi sakatl\u0131k ve \u00f6l\u00fcm riski olu\u015fturabilecek \u015fiddeti d\u00fc\u015f\u00fck yaralanmalara kar\u015f\u0131 tolerans\u0131 daha az olup, olu\u015fabilecek komplikasyon riski y\u00fckseklik g\u00f6sterebilir (2).<\/p>\n\n\n\n

Bu durum geriatrik bireylerin (yaz\u0131m\u0131zda geriatrik hasta kavram\u0131 i\u00e7in bir\u00e7ok literat\u00fcr \u00f6rne\u011findeki gibi 65 ve \u00fcst\u00fc kabul edilmi\u015ftir (3,4) ) travma durumlar\u0131nda de\u011ferlendirilmesini ve y\u00f6netimini \u00f6zel k\u0131lmaktad\u0131r. <\/p>\n\n\n\n

Travma epidemiyolojisi ve mekanizmas\u0131<\/strong><\/p>\n\n\n\n

Geriatrik hasta travmalar\u0131nda; d\u00fc\u015fmeler, motorlu ta\u015f\u0131t kazalar\u0131, yan\u0131klar, k\u00fcnt ve penetran travmalar ve daha nadir olarak fiili sald\u0131r\u0131lar \u00f6nde gelen nedenler olarak say\u0131labilir (5). Say\u0131lan nedenler aras\u0131nda d\u00fc\u015fmeler yakla\u015f\u0131k %65\u2019lik k\u0131sm\u0131 olu\u015fturup, ayn\u0131 seviyeden d\u00fc\u015fme ba\u015fta gelen neden olarak kabul edilmektedir. Bu duruma ba\u011fl\u0131 s\u0131kl\u0131kla femur gibi uzun kemik k\u0131r\u0131klar\u0131 ve pelvis k\u0131r\u0131klar\u0131yla kar\u015f\u0131la\u015f\u0131l\u0131rken, mortalite oran\u0131 %7 olarak belirlenmi\u015ftir (6). ABD \u2018de yap\u0131lan bir kohort \u00e7al\u0131\u015fmas\u0131 ise d\u00fc\u015fme ile tekrar acil servis ba\u015fvuru oranlar\u0131n\u0131 2013-2014 y\u0131l\u0131 i\u00e7in %14,4 olarak kaydetmi\u015ftir (7). Ara\u00e7 kazalar\u0131na ba\u011fl\u0131 \u00f6l\u00fcmler geriatrik hastalarda travmaya ba\u011fl\u0131 en y\u00fcksek \u00f6l\u00fcm oran\u0131na sahip olup, bunlar\u0131n \u00e7o\u011funlu\u011fu yaya olarak ge\u00e7irilen kazalard\u0131r (5). Bu durumda olu\u015fan kot k\u0131r\u0131klar\u0131, servikal vertebra yaralanmalar\u0131, pelvis ve ekstremite yaralanmalar\u0131 \u00f6nde gelen travma nedenleridir (8).<\/p>\n\n\n\n

Yan\u0131klar gen\u00e7 hastalarla kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda, geriatrik hastalarda \u00f6l\u00fcmc\u00fcl sonu\u00e7lanabilir. Bat\u0131 \u00c7in Hastanesi Yan\u0131k Merkezi’ne 2003-2009 y\u0131llar\u0131 aras\u0131nda ba\u015fvuran geriatrik hastalar\u0131n retrospektif incelemesinde alev yan\u0131klar\u0131 (%51,5), ha\u015flanma yan\u0131klar\u0131 (%37,9), elektrik yan\u0131klar\u0131 (%4,9) ve kimyasal yan\u0131klar (%2,9) d\u00fczeyinde belirlenmi\u015f olup, bu yan\u0131klar en \u00e7ok ev (mutfak) ve i\u015fyerinde meydana gelmi\u015ftir. Bu ba\u015fvurularda yan\u0131k y\u00fczdesi %0-10 aras\u0131 olanlar\u0131n oran\u0131 %52,5\u2019i iken, %50\u2019nin \u00fczerinde yan\u0131k y\u00fczdesi olanlar %11,7\u2019lik grubu olu\u015fturmu\u015ftur (9).<\/p>\n\n\n\n

Fiili sald\u0131r\u0131larda ise, yeti\u015fkin istismar\u0131 ve intihar giri\u015fimi \u00f6nde gelen nedenler aras\u0131ndad\u0131r. Ya\u015fl\u0131 istismar\u0131; fiziksel, cinsel, duygusal\/psikolojik ihmal ve mali istismar \u015feklinde olabilmektedir (10). <\/p>\n\n\n\n

Geriatrik hastalarda zamanla olu\u015fan fizyolojik de\u011fi\u015fiklikler stres durumlar\u0131nda gen\u00e7 bireylere g\u00f6re farkl\u0131 metabolik cevap olu\u015fmas\u0131na neden olmaktad\u0131r. Bu durumla ilgili olu\u015fabilecek de\u011fi\u015fiklikler tablo-1\u2019de \u00f6zetlenmi\u015ftir.<\/p>\n\n\n\n

Tablo-1: <\/strong>Geriatrik travma hastalar\u0131nda fizyolojik de\u011fi\u015fiklikler.<\/p>\n\n\n\n

Organ sistemi<\/strong><\/td>De\u011fi\u015fiklikler<\/strong><\/strong><\/td>Sonu\u00e7lar<\/strong><\/strong><\/td><\/tr>
PULMONER<\/td>Azalm\u0131\u015f vital kapasiteAzalm\u0131\u015f zorlu ekspirasyon hacmiDaha k\u00fc\u00e7\u00fck alveolar y\u00fczey alan\u0131Azalm\u0131\u015f kompliyans<\/td>Azalm\u0131\u015f solunum rezervi<\/td><\/tr>
KARD\u0130YAK<\/td>Azalm\u0131\u015f kalp debisiKatekolaminlere duyarl\u0131l\u0131\u011f\u0131n azalmas\u0131<\/td>Azalm\u0131\u015f kalp rezerviHayati belirtiler yaralanman\u0131n ciddiyetini yans\u0131tmayabilir<\/td><\/tr>
B\u00d6BREK<\/td>Azalan glomer\u00fcler filtrasyon h\u0131z\u0131Azalm\u0131\u015f b\u00f6brek k\u00fctlesi<\/td>Artan travmatik yaralanma riskiKontrasta ba\u011fl\u0131 nefropati riskinde art\u0131\u015fA\u015f\u0131r\u0131 s\u0131v\u0131 y\u00fcklenmesine kar\u015f\u0131 artan duyarl\u0131l\u0131kBaz\u0131 ila\u00e7lar\u0131n klirensinde azalma<\/td><\/tr>
HEPAT\u0130K<\/td>Azalm\u0131\u015f hepatik fonksiyon<\/td>Baz\u0131 ila\u00e7lar\u0131n klirensinde azalma<\/td><\/tr>
GASTRO\u0130NTEST\u0130NAL<\/td>Azalan a\u011fr\u0131 hissiKar\u0131n duvar\u0131 kaslar\u0131n\u0131n artan gev\u015fekli\u011fi<\/td>Peritoneal belirtiler olmadan \u00f6nemli abdominalyaralanma potansiyeli<\/td><\/tr>
BA\u011eI\u015eIKLIK<\/td>Bozulmu\u015f ba\u011f\u0131\u015f\u0131kl\u0131k tepkisi<\/td>Artan enfeksiyon riski<\/td><\/tr>
KAS-\u0130SKELET<\/td>Kas k\u00fctlesi kayb\u0131Osteoporoz<\/td>K\u0131r\u0131k riskinde art\u0131\u015f<\/td><\/tr>
N\u00d6ROLOJ\u0130K<\/td>Azalan oto-d\u00fczenleme yetene\u011fiBeyin atrofisi<\/td>Azalan serebral perf\u00fczyondan yaralanmaya kar\u015f\u0131 artan duyarl\u0131l\u0131kGizli yaralanma riskinde art\u0131\u015f<\/td><\/tr><\/tbody><\/table><\/div><\/figure>\n\n\n\n

Yukar\u0131da say\u0131lan fizyolojik de\u011fi\u015fikliklere ek olarak, hastalarda ila\u00e7 kullan\u0131m ve kronik hastal\u0131k \u00f6yk\u00fcs\u00fc ya\u015fl\u0131 travma hastalar\u0131n\u0131n y\u00f6netimini zorla\u015ft\u0131ran di\u011fer fakt\u00f6rler olarak kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r. \u00d6rne\u011fin antitrombositer ve antikoag\u00fclan ila\u00e7lar, kalsiyum kanal blok\u00f6rleri, beta blok\u00f6rler, ve glukokortikoidler kullan\u0131m\u0131 hem baz\u0131 fizyolojik cevaplar\u0131 maskelemekte hem de mortalite oranlar\u0131nda de\u011fi\u015fiklik yapmaktad\u0131r (11). Ayr\u0131ca kardiyak, renal, hepatik hastal\u0131klar travma durumlar\u0131nda mortalite oranlar\u0131n\u0131 en fazla artt\u0131ran durumlar olarak ba\u015f\u0131 \u00e7ekmektedir (12).<\/p>\n\n\n\n

T\u00fcm bunlara ba\u011fl\u0131 olarak ya\u015fl\u0131 hastalardaki zay\u0131fl\u0131klar ve travman\u0131n bu hastalardaki sonu\u00e7lar\u0131n\u0131 tahmin etmeyi ama\u00e7layan \u00e7e\u015fitli puanlama sistemi geli\u015ftirilmi\u015ftir. Travmaya \u00d6zel K\u0131r\u0131lganl\u0131k \u0130ndeksi (TSFI) olarak adland\u0131r\u0131lan \u00f6l\u00e7\u00fcm \u00f6rne\u011fi (Tablo-2) bunlardan biri olup; komorbidite, g\u00fcnl\u00fck aktivite, sa\u011fl\u0131k tutumu, fonksiyon ve beslenme gibi \u00e7e\u015fitli fakt\u00f6rlerin kombinasyonundan olu\u015fmaktad\u0131r (13).<\/p>\n\n\n\n

Tablo-2:\u00a0<\/strong>Travmaya \u00d6zg\u00fc K\u0131r\u0131lganl\u0131k \u0130ndeksi (TSFI).<\/p>\n\n\n\n

\"\"<\/figure>\n\n\n\n

TFSI \u2018n\u0131n geriatrik travma hastalar\u0131n\u0131n taburculuk d\u00fczenlemelerini planlamada klinisyenlere yard\u0131mc\u0131 olabilece\u011fine dair \u00e7al\u0131\u015fmalar bulunmaktad\u0131r (14). Ya\u015fl\u0131 travma hastalar\u0131n\u0131n travma sonras\u0131 yetersiz triyaj sorunu, do\u011fru bir \u015fekilde de\u011ferlendirilmesi noktas\u0131ndaki hatalar ve yetersiz anamnez, bu hastalar\u0131n mortalite oranlar\u0131 \u00fczerinde \u00f6nem arz eden durumlardan biridir (15). 2011 y\u0131l\u0131nda Amerika Birle\u015fik Devletleri\u2019nde ulusal uzman panelinde yay\u0131nlanan \u2018\u2019Yaral\u0131 Hastalar\u0131n Saha Triyaj\u0131na \u0130li\u015fkin K\u0131lavuzlar\u2019\u2019 isimli yaz\u0131ya ayn\u0131 y\u0131l Amerikan Travma Cerrahlar\u0131 Derne\u011fi Komitesi\u2019nin geriatrik grup i\u00e7in ek \u00f6nerileri olmu\u015ftur (16). Bu \u00f6neriler:<\/p>\n\n\n\n

– Ciddi hasar ve \u00f6l\u00fcm riski ya\u015fla beraber artar.<\/p>\n\n\n\n

– Sistolik kan bas\u0131nc\u0131n\u0131n (SKB) 110 mmHg\u2019den az olmas\u0131, \u015fok durumunu g\u00f6sterebilir ve daha k\u00f6t\u00fc sonu\u00e7larla ili\u015fkilidir.<\/p>\n\n\n\n

– D\u00fc\u015f\u00fck enerjili mekanizmalar (ayn\u0131 seviyeden d\u00fc\u015fme gibi) bile ciddi yaralanmalara yol a\u00e7abilir.<\/p>\n\n\n\n

– Travma triyaj ara\u00e7lar\u0131n\u0131n ya\u015fl\u0131 pop\u00fclasyondaki ayr\u0131m g\u00fcc\u00fc yetersizdir (16,17).<\/p>\n\n\n\n

\u00d6yleyse ya\u015fl\u0131 hastalar nas\u0131l nakledilmeli, gen\u00e7lerden fark\u0131 ne olmal\u0131? <\/strong><\/p>\n\n\n\n

Geriatrik hastalarda travma de\u011ferlendirmelerinde yap\u0131lan temel yanl\u0131\u015flardan biri ya\u015fl\u0131 eri\u015fkin hastalar\u0131n azalan fizyolojik kapasitelerinin hesaba kat\u0131larak de\u011ferlendirilmesi sorunudur. Kalp h\u0131z\u0131, nab\u0131z, g\u00f6rme, i\u015fitme sorunlar\u0131, azalm\u0131\u015f kas ve kemik yo\u011funlu\u011fu, metabolik hastal\u0131klar vb. parametreler geriatrik hasta de\u011ferlendirmesinde \u00f6nem arz etmektedir. Brooks ve ark. yapt\u0131klar\u0131 \u00e7al\u0131\u015fmada kendi seviyesinden d\u00fc\u015fmeye ba\u011fl\u0131 yaralanan ve triyaj\u0131 tam olarak yap\u0131lmam\u0131\u015f geriatrik hastalar\u0131n \u00f6l\u00fcm oran\u0131n\u0131n, daha ciddi mekanizmalarla yaralanan ve travma ekibi taraf\u0131ndan triyaj\u0131 tam olarak yap\u0131lan gen\u00e7 yeti\u015fkinlere g\u00f6re daha y\u00fcksek oldu\u011funu ortaya koymu\u015ftur (18). Bu durumda geriatrik hastalarda birincil ve ikincil bak\u0131n\u0131n \u00f6nemi bir kez daha ortaya \u00e7\u0131kmaktad\u0131r. Birincil bak\u0131da t\u00fcm hastalarda da uygulanan ABCDE (Airway- Breathing \u2013 Circulation \u2013 Disabilty – Exposure) geriatrik hastalarda da uygulanmakta olup, baz\u0131 dikkat edilmesi gereken durumlar mevcuttur. Bunlardan ilki geriatrik hastalar\u0131n res\u00fcsitatif \u00f6nlemlere iyi yan\u0131t verdi\u011fi ve buna ba\u011fl\u0131 agresif tedavinin yerinde olaca\u011f\u0131d\u0131r. Ancak hipoksi, hiperkarbi ve asidoza ya\u015fl\u0131lar taraf\u0131ndan verilen k\u00fcnt tepkilerin tedavi s\u00fcrecinde gecikmeye neden olmas\u0131 olas\u0131d\u0131r (19, 20). Di\u011fer \u00f6nemli durumlar; a\u011f\u0131z a\u00e7\u0131kl\u0131\u011f\u0131 k\u0131s\u0131tl\u0131l\u0131\u011f\u0131, takma di\u015fler, ya\u015fl\u0131larda azalan solunum rezervine ba\u011fl\u0131 y\u00fcksek ak\u0131\u015fl\u0131 oksijen verilmesinin \u00f6nemidir (21). Buna ek olarak Non invaziv mekanik ventilasyon (NIMV) kullan\u0131m\u0131n\u0131n uygun hastalarda acil ent\u00fcbasyonu geciktirmesi a\u00e7\u0131s\u0131ndan yararl\u0131l\u0131\u011f\u0131n\u0131n y\u00fcksek oldu\u011fu, ancak yine de acil ent\u00fcbasyon gereklili\u011fi olursa benzodiazepinler, barbit\u00fcratlar gibi kardivask\u00fcler depresyon olu\u015fturabilecek ila\u00e7 dozlar\u0131n\u0131n yar\u0131ya yak\u0131n dozda kullan\u0131lmas\u0131 hususudur (22).<\/p>\n\n\n\n

Geriatrik hastalardaki hemodinamik farkl\u0131l\u0131klar ayr\u0131 bir sorun te\u015fkil etmektedir. \u00d6rne\u011fin hipertansif bir hastada normotansif bir durumun hipotansif durumu maskelemesi ya da beta blok\u00f6rler gibi antihipertansif ila\u00e7lar\u0131n ta\u015fikardi yan\u0131t\u0131n\u0131 maskelemesi say\u0131labilecek nedenlerden baz\u0131lar\u0131d\u0131r (23). Ayr\u0131ca mental durum de\u011fi\u015fiklikleri, takipne, gecikmi\u015f kapiller dolum ve azalan idrar \u00e7\u0131k\u0131\u015f\u0131 gibi belirtiler hipoperf\u00fczyonu ve \u015foku yans\u0131tabilmesi a\u00e7\u0131s\u0131ndan ya\u015fl\u0131larda daha duyarl\u0131 durumlard\u0131r (24). Bu noktada hemoglobin, biyokimya, kan gaz\u0131 takibi, yatak ba\u015f\u0131 USG\u2019 ye ba\u015fvurmak \u00f6nem kazanmakta ve yan\u0131lg\u0131ya d\u00fc\u015fmemek a\u00e7\u0131s\u0131ndan yararl\u0131 olmaktad\u0131r (25, 26). Hastalarda s\u0131v\u0131 res\u00fcstasyonu dikkat edilecek ayr\u0131 bir konudur. A\u015f\u0131r\u0131 s\u0131v\u0131 verilmesinden ka\u00e7\u0131n\u0131lmal\u0131, 500-1000 ml aras\u0131nda yava\u015f inf\u00fczyonun dekompanzasyon olmamas\u0131 a\u00e7\u0131s\u0131ndan yararl\u0131 olaca\u011f\u0131 d\u00fc\u015f\u00fcn\u00fclmektedir. Ancak hipotansiyon veya hipoperf\u00fczyon belirtileri derinle\u015firse, kan \u00fcr\u00fcnlerinin transf\u00fczyonuna erken ba\u015flamak esast\u0131r. Hohle ve ark. 65 ya\u015f ve \u00fczerinde 3134 hasta \u00fczerinde yapt\u0131\u011f\u0131 \u00e7al\u0131\u015fmada eritrosit s\u00fcspansiyon (ES) ve taze donmu\u015f plazman\u0131n (TDP) 24 saatlik mortalite \u00fczerine yarar\u0131 g\u00f6sterilmi\u015ftir (27).<\/p>\n\n\n\n

A\u011fr\u0131 alg\u0131s\u0131 bozulan geriatrik hastalarda ikincil bak\u0131 \u00f6nemlidir. Bu noktada ak\u0131lda tutulmas\u0131 gereken yaralanmalar; kafa yaralanmas\u0131, servikal omurga yaralanmalar\u0131, klavikula, kot, pelvis frakt\u00fcrleri ve yan\u0131klar olarak s\u0131ralanabilir. Florio ve ark., 65 ya\u015f ve \u00fczeri 4554 hasta \u00fczerinde yapt\u0131\u011f\u0131 ara\u015ft\u0131rmaya g\u00f6re en s\u0131k kafa ve y\u00fcz travmalar\u0131 g\u00f6zlemlenirken bunlar\u0131 \u00fcst ve alt ekstremiteler izlemi\u015ftir (28). A\u011fr\u0131s\u0131 olan geriatrik hastalarda analjezinin zamanlamas\u0131 \u00f6nemlidir. Zamudio ve ark. 65 ya\u015f ve \u00fczeri 2248 hastay\u0131 inceledi\u011fi \u00e7al\u0131\u015fmada analjezinin erken ba\u015flat\u0131lmas\u0131n\u0131n geriatrik travma hastalar\u0131nda komplikasyonlar\u0131 ve kaynak kullan\u0131m\u0131n\u0131 azaltt\u0131\u011f\u0131 vurgulanm\u0131\u015ft\u0131r (29). Bunun i\u00e7in opioid grubu ila\u00e7 tercihi ilk s\u0131radad\u0131r. Bu grup ila\u00e7lar aras\u0131nda fentanil ilk tercih olarak kar\u015f\u0131m\u0131za \u00e7\u0131karken, hidromorfin ve morfin di\u011fer tercihlerdir. Ancak solunum depresyonu ve n\u00f6bet riski nedeniyle daha dikkatli kullan\u0131m ve takibi gerekmektedir. Geriatrik hastalarda bu duruma b\u00f6brek veya karaci\u011fer fonksiyonunda azalma ve v\u00fccut ya\u011f da\u011f\u0131l\u0131m\u0131ndaki de\u011fi\u015fkenlik neden olmakta, bu durumda verilen dozlar sa\u011fl\u0131kl\u0131 gen\u00e7 eri\u015fkinlere g\u00f6re %30-50 oran\u0131nda azalt\u0131lmaktad\u0131r (30).<\/p>\n\n\n\n

Geriatrik travma hastalar\u0131nda tan\u0131, takip ve mortalite tahmininde hemogram, biyokimya, kan gaz\u0131 ve laktat \u00f6nemli olsa da, gen\u00e7 yeti\u015fkinlere g\u00f6re k\u00fc\u00e7\u00fck travmalardan kaynaklanan ciddi yaralanmalara kar\u015f\u0131 daha hassas olan bu hastalarda, g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemleri komplike hastalar\u0131n te\u015fhisinde ayr\u0131 bir \u00f6neme sahiptir (31). Geriatrik hastalar\u0131n ayn\u0131 travmalardan etkilenme oran\u0131 gen\u00e7 eri\u015fkinlere g\u00f6re daha y\u00fcksektir. Ancak kafa, servikal, g\u00f6\u011f\u00fcs, abdominal, pelvis travmalar\u0131nda dikkat edilmesi gereken hususlar ya\u015fl\u0131 hastalarda daha fazla dikkat gerektirmektedir. Kafa travmas\u0131, kanama riski a\u00e7\u0131s\u0131ndan ya\u015fl\u0131 hastalarda erken tan\u0131nmas\u0131 gereken durumlar\u0131n ba\u015f\u0131nda gelmektedir. Erken konulamayan tan\u0131 hem mortalite hem de ileri d\u00f6nem palyatif bak\u0131m oran\u0131nda art\u0131\u015fa neden olur. LeBlanc ve ark. taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fmada geriatrik hastalarda min\u00f6r ya da maj\u00f6r kafa travmas\u0131na ba\u011fl\u0131 olarak ciddi sakatl\u0131k veya \u00f6l\u00fcm ile sonu\u00e7lanan durumlar %80 oran\u0131nda rapor edilmi\u015ftir (32). T\u00fcm bunlara ba\u011fl\u0131 olarak, ya\u015fl\u0131 hastalarda de\u011ferlendirme ve g\u00f6r\u00fcnt\u00fcleme say\u0131s\u0131n\u0131 azaltmak i\u00e7in New Orleans, Kanada ve NEXUS II gibi kriterler kullan\u0131lsa da bilgisayarl\u0131 tomografi (BT) hali haz\u0131rda en s\u0131k ba\u015fvurulan tetkik olarak kar\u015f\u0131m\u0131za \u00e7\u0131kmaktad\u0131r (33). Ya\u015fl\u0131 hastalarda servikal stenoz, dejeneratif romatoid ve osteoartrit gibi hastal\u0131klara ba\u011fl\u0131 olarak kar\u015f\u0131la\u015fabilece\u011fimiz bir di\u011fer yaralanma \u00e7e\u015fidi servikal omurga yaralanmalar\u0131d\u0131r. Servikal yaralanmalarda Tip 2 odontoid k\u0131r\u0131klar en s\u0131k olu\u015fan k\u0131r\u0131k tipidir. Bu tip yaralanmalarda duyarl\u0131l\u0131k a\u00e7\u0131s\u0131ndan BT yine en s\u0131k kullan\u0131lan g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemidir (34, 35). Servikal kord yaralanmalar\u0131nda ya\u015fanan hiperekstansiyon durumlar\u0131na ba\u011fl\u0131 \u00fcst ekstremitelerde orant\u0131s\u0131z olarak daha fazla motor bozuklukla kendini g\u00f6steren santral kord sendromu ak\u0131lda tutulmas\u0131 gereken bir di\u011fer husustur (36). G\u00f6\u011f\u00fcs travmal\u0131 geriatrik hastalarda kot k\u0131r\u0131klar\u0131, k\u00fcnt travmaya ba\u011fl\u0131 akci\u011fer (AC) kont\u00fczyonlar\u0131 olu\u015fmaktad\u0131r. Akci\u011fer kont\u00fczyonlar\u0131nda ve non deplese tekli kot k\u0131r\u0131klar\u0131nda hipoksi a\u00e7\u0131s\u0131ndan takip \u00f6nerilirken, 3 veya daha fazla kosta k\u0131r\u0131\u011f\u0131 olan geriatrik hastalara yo\u011fun bak\u0131m takibi \u00f6nerilmektedir (37). Geriatrik hastalarda abdominal yaralanmalarda fizik muayene \u00f6nemli olsa da, g\u00fcvenilirli\u011fi bir\u00e7ok noktada sorgulanabilir. Bu nedenle yaralanma \u015f\u00fcphesi olmasa da, ya\u015fl\u0131larda USG ile de\u011ferlendirme uygundur. Ancak stabil hastada kar\u0131n i\u00e7i \u00f6zellikle solid organ (dalak, KC gibi) ba\u015fta olmak \u00fczere organ yaralanmas\u0131 d\u00fc\u015f\u00fcn\u00fcl\u00fcyorsa BT ile inceleme \u00f6ncelikli d\u00fc\u015f\u00fcn\u00fclmelidir (38, 39). Tabi ki gen\u00e7 hastalarda oldu\u011fu gibi geriatrik hastalarda kontrast nefropatisi, hipovolemi, kronik b\u00f6brek yetmezli\u011fi (KBY) riskleri g\u00f6z \u00f6n\u00fcnde bulundurulmal\u0131d\u0131r (40). Ya\u015fl\u0131larda \u00f6zellikle kanamaya ba\u011fl\u0131 \u00f6l\u00fcm riskinin 4 kat artabildi\u011fi bir di\u011fer travma durumu pelvis k\u0131r\u0131klar\u0131d\u0131r (41). Bu nedenle aksi ispat edilene kadar pelvis k\u0131r\u0131\u011f\u0131 olan her geriatrik hasta anstabil olarak kabul edilmelidir. Ya\u015fl\u0131 hastalarda pelvis k\u0131r\u0131k tespitinde direkt grafi yeterli iken, komplike durum tespiti i\u00e7in BT ve MR kullan\u0131m\u0131 \u00f6nerilmektedir (42). Pelvis k\u0131r\u0131klar\u0131, kanama riski y\u00fcksek ve transf\u00fczyon ihtiyac\u0131 olan bir durum olarak d\u00fc\u015f\u00fcn\u00fclmekte olup hastane yat\u0131\u015f ve takibi gerekmektedir (43).<\/p>\n\n\n\n

Ya\u015fl\u0131 hastalarda antikoagulan ila\u00e7 kullan\u0131m\u0131n\u0131n yayg\u0131nl\u0131\u011f\u0131 bu tip hastalarda min\u00f6r travmaya ba\u011fl\u0131 ge\u00e7 d\u00f6nem kanamaya kar\u015f\u0131 uyan\u0131k olmam\u0131z\u0131 gerektirmektedir (44). Bu tip hastalarda 12 saatlik g\u00f6zlem s\u00fcresi \u00f6nerilmekte iken, Menditto ve ark. taraf\u0131ndan yap\u0131lan \u00e7al\u0131\u015fma ilk BT taramas\u0131 negatif olan hastalar\u0131n 24 saatlik g\u00f6zlem ve sonras\u0131nda ikinci BT taramas\u0131n\u0131n gecikmi\u015f kanama vakalar\u0131n\u0131n \u00e7o\u011funu tan\u0131mlayabilece\u011fini ortaya koymu\u015ftur (45). Hayat\u0131 tehdit eden travmal\u0131 hastalarda di\u011fer \u00f6nemli husus INR de\u011ferindeki sapmalar olup, bunun h\u0131zla d\u00fczeltilmesi \u00f6nerilmektedir. Bu ama\u00e7la taze donmu\u015f plazma (TDP), K vitamini, kriyopresipitat, protrombin kompleksi (PCC) ve fakt\u00f6r\u00fc VIIa kullan\u0131lmaktad\u0131r. \u00d6ncelikle k\u00fc\u00e7\u00fck hacimlerde TDP ve 10 mg\u2019a kadar K vitamini ilk \u00f6neridir. Daha acil kanama durumlar\u0131nda ise, PCC ve fakt\u00f6r VII ilk tercih olarak yerini almaktad\u0131r (46-48).<\/p>\n\n\n\n

Sonu\u00e7<\/strong><\/p>\n\n\n\n

65 ya\u015f ve \u00fcst\u00fc olarak kabul edilen geriatrik hasta grubu, gen\u00e7 eri\u015fkinlere g\u00f6re anatomik ve fizyolojik de\u011fi\u015fimler, kullan\u0131lan ila\u00e7 rejimlerine ba\u011fl\u0131 olarak min\u00f6r travmalar dahil olmak \u00fczere travmatik durumlara daha hassast\u0131rlar. Yaralanmalara verilen yan\u0131t kapasitesinin azalmas\u0131 ya\u015fl\u0131lar\u0131 travmatik durumlarda daha \u00f6zel hale getirmektedir. Geriatrik hastalar\u0131n de\u011ferlendirmesinde yap\u0131lan temel hatalar yetersiz triyaj ve anamnez olarak kar\u015f\u0131m\u0131za \u00e7\u0131karken bu noktada birincil ve ikincil bak\u0131n\u0131n \u00f6nemi bir kez daha anla\u015f\u0131lmaktad\u0131r. Geriatrik hastalarda ABCD de\u011ferlendirmesi, rutin kan takibi, radyolojik incelemeler, gereklilik halinde kan transf\u00fczyonu ve ila\u00e7 kullan\u0131m\u0131 iyi de\u011ferlendirilmesi gereken di\u011fer hususlard\u0131r.<\/p>\n\n\n\n

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    Geli\u015fmi\u015f \u00fclkelerde azalan do\u011fum oranlar\u0131, kronik hastal\u0131k bak\u0131m\u0131ndaki ilerlemeler 60 ya\u015f ve \u00fczerindeki n\u00fcfusun g\u00f6zle g\u00f6r\u00fcn\u00fcr bir \u015fekilde art\u0131\u015f\u0131na neden olmu\u015ftur (1).…<\/p>\n","protected":false},"author":1185,"featured_media":531,"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],"tags":[],"class_list":["post-529","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/529","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=529"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/529\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/531"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=529"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=529"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=529"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}