Orthopedic Trauma in the Elderly

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Orthopedic Trauma in the Elderly

• Age, Injury, and Outcome
• Ellen Plummer,
• RN,MSN, MBA, CCRN

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CONFLICT OF INTEREST

• I hereby certify that, to the best of my
  knowledge, no aspect of my current personal or
  professional situation might reasonably be
  expected to affect significantly my views on the
  subject on which I am presenting.
• Ellen Plummer, RN, MSN, MBA, DL, MJ, CCRN

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Theyre Here
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Overview

• Epidemiology
• Mechanism of Injury
• Age and Injury
• The Big Three Orthopedic Injuries
• Resuscitation and Treatment
• Complications
• Rehabilitation and Prevention
• Outcomes Studies

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Epidemiology - Elderly

• Injuries are disproportionately severe
• More likely to have co-morbidities
• Suffer more complications
• Die from trauma

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Epidemiology Elderly

• Increasing focus of healthcare providers
• Limited literature available
• Trauma is 7th leading cause of death in elderly
• 25 of all trauma admissions

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Epidemiology

• Fastest growing segment of the population
• By 2050 gt 20 gt age 65
• One of the largest consumers of healthcare for
  resources and
• Less frequently injured higher mortality
• Treatment costs are higher
• Outcomes less favorable

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Factors Affecting Outcomes

• Wide variability and lack of Evidence-based
  protocols
• Less tolerate of minor derangements
• Generic decisions are inappropriate

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Factors Affecting Outcomes

• Underlying Problems (P.E.D.)
• System / Treatment Decisions
• Can affect response to trauma
• Insufficient cardiac reserves
• ?? Peripheral Oxygen Delivery
• Blood pressure unreliable
• Chronic respiratory conditions

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Mechanism of Injury

• Motor vehicle crashes
• 25 million drivers over the age of 65
• Someone is more likely to die in a collision with
  an elderly driver than in a collision involving a
  younger driver
• Belted and unbelted drivers and passengers
• Impaired drivers (medications, illness)
• High impact collisions fatal injuries

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Motor Vehicle Crashes

• More than 40 million older adults will be
  licensed drivers by 2020
• 80 of fatalities occur during the daytime
• 72 of fatalities occur on weekdays
• 75 crashes involve another vehicle
• Clear sky, no weather

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Mechanism of Injury

• FALLS
• Nearly half of those 65 and over experience falls
• Nearly 2 million seniors are treated in ER for
  fall related injuries gt1/3 hospitalized
• Cost gt 20 billion 32 billion by 2020
• Elderly have 1/3 of all hospital injury
  admissions gt80 are caused by falls

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Mechanism of Injury

• FALLS
• 23 of injury death age 65 years and older
• 34 of injury death age 85 and older
• 2/3 of falls will fall again within 6 months
• If hospitalized for a fall, risk of death in the
  year following fall is gt50
• Women more likely to fall than men

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Mechanism of Injury

• FALLS
• Elderly seek treatment for dizziness more
  frequently than for hearing loss
• 4-6 of falls in elderly result in fractures
• 1/4 are hip fractures
• Identified risk factors..

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Identified Risk Factors for Falls

• Age
• Cognitive impairment
• Medications
• Chronic disease / preexisting disease
• Vertigo
• Impairments in strength, balance, gait

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Mechanism of Injury

• Pedestrian Struck
• Exposed to hazards
• Traffic signals Crosswalks
• Road design
• Distractions
• Weather
• Vision impairments poor judgement

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Mechanism of Injury

• Elder Abuse
• National health problem 1.5 million abused every
  year
• Only 1 in 10 cases of abuse ever reported
• Physical, sexual, psychological, financial,
  neglect
• Vulnerable adults easy targets
• Physical abuse can result in orthopedic injuries

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Signs of Physical Abuse

• Sprains, dislocations, fractures
• Restrictive wounds
• Bruises
• Bilateral bruising to the arms
• wrap around bruising to arms, legs
• Multicolored bruises and injuries in various
  stages of healing

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Patterns of Injury

• Matching the story to the injuries
• Old or new?
• Obvious injuries
• Which came first? Fall or injury?
• How were they found?
• Look for everything as clues

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Age, Injury, and Preexisting Problems

• Normal Physiological changes gettin old
• Cardiac
• Respiratory
• Renal
• Neurological
• GI / GU

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Injury and Outcome

• Predictive Parameters pre injury activity level
  , previous health status
• Some of the aged do not return to their prior
  functional state (esp. with lower extremity
  fractures)
• Active aged have the best chance of returning to
  an independent functional state

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Disease Processes

• Osteoporosis most common metabolic bone
  disease significant cause of morbidity
• Epilepsy
• Cardiac arrhythmias
• Stroke
• Diabetes
• Syncope (2-15 of falls in elderly)

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Musculoskeletal Considerations

• Within limits of patients baseline
• Limited mobility, joint flexibility
• Muscle atrophy
• One fracture? ? look for other injuries
• Vertebral compression fractures gt50 are
  asymptomatic

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Medications

• Can affect response to trauma
• Beta blockers
• Anti-hypertensives
• Diuretics
• Antidepressants
• Alcohol
• Coumadin/Other anticoagulants

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Types of Injuries

• The Big Three
• Cervical Spine Fractures
• Hip Fractures
• Pelvic Fractures
• Pathological Fractures

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Cervical Spine Injuries

• 1-3 of traumatic injury survivors have a
  C-spine injury
• Most common MOI high speed MVC
• Associated with head injury
• 80 of fatalities Atlanto-occipital dislocation
  (C1-C2 fracture)

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Cervical Spine Injuries

• Severe neurological injury less common with C1-C2
  fractures (cord only occupies 1/3 of vertebral
  canal at that level)
• C2 C3 Hangmans Fractures- severe
  hyperextension 70 associated CHI
• C5-C7 fx 30-70 have neuro deficit
• Below C5 vertebral column narrow 50
  subluxations with severe SCI

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Cervical Spine Injuries

• 10-20 of fractures are delayed diagnosis or
  missed injury
• Death from injury 2-15 times that of other
  injuries
• ICU stay 1 week 2-4 weeks in hospital
• Economic burden Billions

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Cervical Spine Injuries

• Diagnosis difficult in elderly / clearance
• Osteoporosis
• Arthritis
• Difficult to obtain / read x-rays
• Differentiating between old and new injury
• Degenerative disease
• Pain / no pain deficit / no deficit

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Hip Fractures

• Falls, Motor Vehicle Crashes, Pedestrians
• Hospitalization, surgical correction
• Increased morbidity and mortality
• Reduced mobility
• 12 20 reduction in survival
• 5-20 mortality in first year

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Hip Fractures

• 350,000 per year in elderly
• 90 attributed to falls
• 90 of all hip fracture patients are older than
  65 years of age
• By age 80, 1/5 of all women will have sustained a
  hip fracture

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Hip Fractures

• Evaluation
• Initial evaluation
• Non displaced hip fractures may be asymptomatic
• Displaced severe pain, loss of function
• Unable to ambulate, extremity may be shortened
  and rotated

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Hip Fractures

• Immobilization and support of extremity
• Position of comfort
• Hare Traction Splint
• Contraindications
• Sufficient traction to reduce a fracture should
  not be used
• When sciatic nerve injury is suspected

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Hip Fractures

• Posterior Hip Fractures
• Anterior Hip Fractures
• Femoral Neck Fractures
• Intertrochanteric Fractures

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Pelvic Fractures

• Motor Vehicle Crashes / Pedestrian cause 60 of
  pelvic fractures
• 35 40 are from falls
• Small, compact cars T-bone crashes
• Associated with increased mortality (from
  hypotension)
• Survival is worse for open pelvic fractures and
  for pedestrians

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Pelvic Fractures

• Blood supply comes from iliac and hypo gastric
  arteries fed by superior gluteal artery (can be
  injured in posterior fx)
• Accurately diagnosed by PE
• High index of suspicion based on MOI
• Look for isolated rotation of LE
• Discrepancy in limb length

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Pelvic Fractures

• Tenderness over trochanter acetabular fx
• GU complications
• ¼ of pelvic fractures
• 6 of women and 11 of men have urethral injury
• Blood at meatus or high riding prostate
• 90/10 Rule

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Pelvic Fractures

• Classification Systems
• Tile Classification
• Young Burgess Classification
• Based on direction of injury, pelvic stability,
  and forces involved
• Burgess Lateral Compression, Anterior Posterior
  Compression, Vertical Shearing, Combined Mechanism

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Ramus and Acetabulum

• Low force injuries
• Stable
• 1/3 of all pelvic fractures are individual bone
  fractures and do not involve the pelvic ring
• Elderly Fall non displaced pubic rami fx
• Superior/Inferior Pubic Rami fx stable

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Ramus and Acetabulum

• 20 of pelvic fractures Acetabulum
• May involve injury of femoral head
• Posterior hip dislocations common with
  posterior acetabular fx
• Injury to sciatic nerve complicate gt 10 of
  acetabula fix

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Pelvic Ring Fractures

• High energy
• Higher transfusion requirements
• Associated injuries
• Displacement requires a break in 2 places
• A/P or L/C injuries
• Open book fractures (Head on crashes)
• Vertically stable but rotationally unstable

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Pathological Fractures

• Result from focal disease process
• Compromised bone integrity
• Fracture occurs during normal activity
• Etiology
• Malignancies
• Pagets Disease

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Pathological Fractures

• Metastatic Carcinoma most common malignancy of
  bone
• Multiple myeloma most common primary malignancy
  of bone
• Others Lymphoma, Leukemia

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Pathological Fractures

• Pagets Disease (Osteo Deformans)
• Pathological increase in bone turnover
• Common in geriatric population
• Reabsorption of normal bone and excessive
  deposition of abnormal bone
• Usually involves only one bone
• Pelvis, lumbar spine, femur

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Pathological Fractures

• Pagets Disease
• 95 of patients are asymptomatic
• Bone pain, skeletal deformity, fracture
• Diagnosis is difficult (resembles arthritis)
• Leads to significant morbidity in elderly
• Affects 3 of adults over age 40

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Resuscitation and Treatment

• Airway, Breathing ,Circulation
• Volume Crystalloid, Blood
• Immobilization
• X-rays, CT Scan
• Decision Making Process
• Damage Control

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Hypothermia

• Hypotension or Resuscitation????
• Hypothermia is present in 2/3 of severely injured
  patients
• Associated with severe complications
• Arrhythmias
• Coagulopathies
• Cardiac performance and death
• lt 32 degrees nearly 100 mortality

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Hypothermia

• Causes
• Large amounts of cold blood and IVF
• Unable to separate shock, exposure, and fluid
  resuscitation all occur simultaneously
• Hemorrhage -gt hypotension-gt hypothermia

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Pain Management

• Not That Simple
• Elderly have diminished pain receptor activity
• May have disease process (DM, renal)
• Age is most important variable to influence
  analgesic response
• Morphine generally preferred but has prolonged
  clearance rate

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Pain Management The Friends and Family Plan

• History of patient must be accurate
• Iowa study
• 72.3 meds obtained without prescription
• 14.4 women and 10.5 men take 2 or more
• 6.4 women and 11.3 men - take both Rx and non
  Rx meds
• Use of friends or relatives meds

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Pain Management

• What to use?
• Morphine, Percocet, Dilaudid, Fentanyl
  recommended
• Demerol, Methadone, Propoxyphene can be
  considered
• Patient Controlled Analgesia

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End Points of Resuscitation

• Lactate
• Correct quickly - lt2.0 within 2-4 hours
• Longer poor prognosis
• Base deficit
• Urinary Output
• May need hyper-dynamic state

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Treatment Options

• Depends on injury/severity
• Depends on type of orthopedic injury
• Depends on resources
• Depends on potential outcome ability
• Surgical
• Conservative or Aggressive?

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Operative / Non Operative Treatment

• Cervical Spine Fractures
• Ranges from immobilization in collar to surgical
  intervention
• Stable with deficit
• Maintain stability physical and physiologically
• MRI
• Cervical Traction
• Operative intervention

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Operative / Non Operative Treatment

• Cervical Spine Unstable with deficit
• Volume (1-2L)
• Pressors
• Intubation
• Cervical traction
• Operative intervention

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Operative / Non Operative Treatment

• Hip Fractures
• Pulse discrepancies, coolness, pallor, motor
  deficit suggestive of arterial injury
• Paresis, paralysis, parasthesia neurological
  compromise

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Operative / Non Operative Treatment

• Hip Fractures
• Proximal Femur surgical intervention
• Delays of over 48 hours higher mortality
• Femoral Neck Fractures surgical intervention is
  treatment of choice
• Non displaced ORIF screws and pin
• Displaced ORIF not advocated in elderly
• Decision based on age, extent of fracture

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Operative / Non Operative Treatment

• Intertrochanteric Fractures
• Operative management is advocated for virtually
  all
• Instability may necessitate fracture alignment in
  addition to fixation (hip screw, IM nail)
• Early weight bearing

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Operative / Non Operative Treatment

• Pelvic Fractures
• Goal Prevent death
• Acute bleeding management
• Damage control
• Several Options

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OPTIONS

• Pelvic Stabilization
• Invasive management (gt6 Units blood /24 hrs.)
• Early external fixator (15 minutes)
• Wrapping pelvic girdle with bed sheet
• Pelvic binder
• Angiogram embolization

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OPTIONS

• Damage Control for bleeding
• Attempts at surgical control of expanding pelvic
  hematomas are rarely successful
• If other associated injuries more severe follow
  trauma guidelines specific management

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Operative / Non Operative Treatment

• Coagulopathies CORRECT
• Hypothermia CORRECT
• Acid Base Disorders CORRECT

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Orthopedic Repair

• Non displaced stable fractures
• Analgesia
• Early mobilization
• No surgery

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Orthopedic Repair

• External fixators
• In place 6 12 weeks
• Meticulous skin / pin care
• Internal Fixators
• Complex operation
• Pfannenstiel incision

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Complications

• Systems failures (pulmonary, renal, etc.)
• Immobility
• Thromboembolic disease
• DVT 80 of patients with multi-trauma
• Infection
• Skin breakdown

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Complications

• Spinal Cord injuries
• Immobilization
• Respiratory complications pneumonia
• Paralysis prolonged rehab
• Long term care home or LTC facility
• Death ethical decisions

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Rehabilitation / Prevention

• Essential part of care
• Starts first day of injury
• PT, OT, Rehabilitation services
• Lifestyle changes
• Assistance from spouse or family may be
  impossible if spouse is elderly or debilitated

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Outcomes

• May not always be favorable
• Lifestyle changes loss of independence
• Permanent disability
• Ethical decision making as last resort
• Abuse must report

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Outcomes

• Set realistic goals
• At admission
• At 3 months 24 return for some problem
• Concerns about providing unwanted care can lead
  to suboptimal care

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Outcomes AGE

• Age is no determinate for care
• Ageism must not masquerade as ethics or cost
  effectiveness

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Treatment Decisions

• The patient may look just fine
• Remember blood can hide
• TBI can be subtle often missed
• Fixing the problem takes time
• Orthopedic injuries may be subtle at first

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Treatment Considerations

• Same principals and concepts as young
• Increased index of suspicion
• Procedures may have to be adjusted
• Intubation should be instituted rapidly
• Time is of the essence
• Treat hypothermia and shock
• Pain management

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Resuscitation

• Assessment must be rapid and efficient
• Increased ISS parallel increased mortality
• Lower ISS must assess and intervene
• Prevent low flow states
• Keep em warm
• Load em up if appropriate

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Undertriage / Overtreatment

• No clear data for care/decision making
• Under triage is common
• Under triage hurts the patient
• Over triage 7-8
• Undertriage 75-77

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Undertriage / Overtreatment

• Mental confusion is chronic
• Old people have aches and pains
• Chest pain is cardiac in nature
• probably ok if they look ok at the scene
• Time is critical often too late to recognize

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Other considerations

• Communication
• Mobility
• Nutrition
• Skin breakdown
• Modification of goals and outcomes
• Survivability / Rehabilitation Potential
• End of life care

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Outcomes Studies Over the Years

• Henry, et al (2001)
• Pelvic Fractures in Elderly
• More likely to get blood and lots of it
• LC fractures about 5X more frequent
• LC fractures minor, but require blood
• Mortality higher than young

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Outcomes Studies Over the Years

• Mosenthal, et al. (2002)
• Age as predictor of mortality in TBI
• 694 patients over 5 years
• Mortality for elder twice that of young
• Poor functional outcome
• Predominately age and GCS predicted

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Outcomes Studies Over the Years

• Grossman, et al (2003)
• Functional Outcome in Octogenarians
• Mortality rates higher than for Geriatric
• Lower functional independence

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Outcomes Studies Over the Years

• Nirula, Gentilello (2004)
• Futile resuscitation
• Head, thoracic, abdominal injuries, comorbidities
• Severe chest / abd, TBI, SBPlt90
• Near 100 mortality

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Research and Prevention

• Tremendous need for research for optimal care of
  elderly trauma patients
• Evidence based guidelines needed
• Prevention efforts for falls, MVCs, burns
• Costs are enormous, outcomes not always positive
• Evolving challenges

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Thank You

• Contact Information
• Ellen Plummer, DL, MJ, RN, CCRN
• eplummer_at_umm.edu
• Trauma Resuscitation Unit
• R Adams Cowley Shock Trauma Center
• Baltimore, Maryland

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