1. GERIATRIC TRAUMA: WHAT DO WE KNOW
GERIATRIC TRAUMA: WHAT DO WE KNOW? Kevin Biese, MD, MAT Ellen Roberts PhD, MPH Jan Busby-Whitehead, MD University of North Carolina at Chapel Hill Division of Geriatric Medicine Center for Aging and Health Department of Emergency Medicine
AGS
THE AMERICAN GERIATRICS SOCIETY
Geriatrics Health Professionals.
Leading change. Improving care for older adults.
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2. Learning Objectives
Describe the unique presentations of geriatric trauma
Identify areas of particular risk for elderly patients with traumatic injuries
Suggest care process changes that may improve the care of geriatric trauma patients
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3. Geriatric Trauma: Outline
The basics
Rib fractures
Pelvic fractures
Head trauma
Warfarin
C-spine fractures
Triage

4. Geriatric Trauma: Disclaimers
Most studies are retrospective reviews
No standard definition of “geriatric” or “elderly”

5. Geriatric Trauma: Epidemiology
Elderly are growing in numbers
Patients ≥65 years account for 10% of all traumas, but 28% of deaths!
Trauma is the 7th leading cause of death in elderly

6. Geriatric Trauma: Mechanisms
Falls — most common
Balance, strength, vision
Motor vehicle collision (MVC) — most fatal
Judgment, vision, reaction times decreased
Crash fatality rates are much higher
Burns — 1/5 of all burn unit admissions
Mortality estimate = age + % burn

7. Geriatric Trauma: Complicating Factors
Past medical history
Cardiac and pulmonary disease limit physiological response to stressors
Vital signs are difficult to interpret
Medications
Anticoagulants
Beta blockers
Cause of the event
Myocardial infarction, syncope, stroke, hypoglycemia

8. Case 1: INTRODUCTION 71-year-old woman restrained driver in MVC
“T-boned” on passenger side
Unknown rate of speed
No airbag deployment
Prolonged extrication
Not ambulatory at scene
EMS: systolic blood pressure (SBP) 100, HR 80, oxygen saturation 100% on non-re-breather mask
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9. CASE 1: Additional Information
Patient is complaining of shortness of breath, left chest wall pain, and left clavicle pain
She hit her head with reported loss of consciousness
Patient denies neck or back pain
No nausea or abdominal pain
Yellow trauma alert — no trauma team activation
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10. CASE 1: Primary Survey A  Patient speaking in complete sentences
B  Clear bilaterally, but diminished effort; significant bruising/pain left chest wall
C  Good pulses  4, 2 IVs in place
D  Glasgow Coma Scale (GCS) 14, moving all 4 extremities
E  Patient exposed, warm blankets placed

11. CASE 1: Secondary Survey
Vital signs: 103/51, 80, 18, 36.3 F, 100% NRB
General: Dyspneic, awake and alert
HEENT: 3-cm laceration on left side of scalp, PERRLA
Chest: Bruising left clavicle/left chest wall with tenderness
CV: RRR with HR 80
Abdomen: No bruising, soft, non-tender, non-distended
Pelvis stable
Neurologically intact
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12. CASE 1: Past Medical History
Hypertension
Osteoporosis
“Non-cardiac chest pain”
Medications:
Hydrochlorothiazide
Alendronate (Fosamax)
Allergies:
Penicillin

13. CASE 1: Chest x-ray

14. CASE 1: Pelvis x-ray

15. CASE 1: Chest CT
Left 1, 3, 4, 5, 6 rib fractures, left scapular fracture, left clavicle fracture, small pneumothorax

16. CASE 1: LAB RESULTS Hematocrit — 36 Potassium — 2.9 Creatinine — 1.0
INR — 1.0

17. CASE 1: Hospital Course
Day 1 – Admitted to surgical ICU, L chest tube placed
Day 2 – Rapid atrial fibrillation, amiodarone drip with conversion to sinus rhythm
Day 5 – Chest tube pulled
Day 7 – Hypoxic, hypotensive, rapid atrial fibrillation, left pleural effusion, intubated
Day 8 – Left chest tube replaced
Day 12 – Chest tube removed
Day 22 – D/C to home
5 months later – Doing well
Yellow trauma — 22-day hospital stay!

18. Rib Fractures IN THE ELDERLY (1 of 2)
Prospective cohort of 405 patients admitted with rib fractures from blunt trauma
113 patients > 65 years old
Elderly had much higher mortality (20% vs. 9%)
Isolated thoracic trauma
75% of elderly patients sustained this by fall from standing
Mortality 15% if age >65; 0% if <65
Pneumonia 34% if age >65; 11% if <65
Most geriatric deaths occurred >72 hours after trauma and resulted from sepsis or respiratory failure
Bergeron E, et al. J Trauma. 2003;54:
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19. Rib Fractures IN THE ELDERLY (2 of 2)
Age (years)
3-6 rib fractures
>6 rib fractures
<65
≅10%
≅25%
≥65
≅30%
>60%
If >65 with 3 or more rib fractures, admit;
if >6 rib fractures, ICU
Bergeron. J of Trauma 2003; 54:

20. PELVIC Fractures IN THE ELDERLY (1 of 2)
Usually associated with falls from standing & MVCs
Higher percentage of lateral compression fractures than in younger patients
Fewer “severe” fracture patterns
High rates of hemorrhage, transfusion, and ICU admission, even with “benign” fracture patterns
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21. PELVIC Fractures IN THE ELDERLY (2 of 2)
92 consecutive blunt trauma pelvic fracture patients received angiographic embolization (AE) for “liberal indications”:
Hemodynamically labile, concerning fracture pattern (open book, vertical shear, butterfly), or pelvic hematoma on CT
Patients >60 years (n=17) were compared with younger patients
No difference in injury severity score, pelvic fracture pattern, SBP, or blood requirement
>60 years: 94% chance of active bleed vs. 52% in younger patients
Consider AE before hemodynamic collapse in elderly patients with significant pelvic fractures
Kimbrell. Arch Surg
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22. CASE 2
90-year-old woman presents 3 days after fall in bathroom, when she hit her head on toilet
No symptoms for 2 days
This morning, mild headache and face pain
Medications: warfarin, oxycodone, amitriptyline
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23. Head Trauma IN ELDERLY Bridging veins travel further
More space for hematoma collection before symptoms
Age >65 have 30%85% mortality with intracranial hemorrhage (ICH)
25 higher than younger patients with matched injuries
Considered high-risk in brain imaging protocols (New Orleans, Canadian)
Webmm.ahrq.gov, retrieved June 3, 2011.
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24. Warfarin and ICH IN ELDERLY
9% of elderly patients with traumatic brain injury are on warfarin
Risk of spontaneous ICH on warfarin is 0.35.4%
Blunt head trauma on warfarin with minimal or no symptoms, 7%14% have ICH
Patients frequently have supra-therapeutic INR
11% have INR >5
Beware delayed acute subdural hematoma (DASH) — consider admission for observation even if head CT is negative
Check INR
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25. Aggressive Coumadin Protocol (1 of 2)
Emergency department initiated new protocol for patients with suspected head trauma on warfarin
Immediate evaluation
Immediate head CT
Type & cross match
Thaw 2 units AB FFP
If positive head CT
Transfuse FFP, Vitamin K IV, neurosurgery evaluation
If negative head CT
Admit for observation
Ivascu FA, et al. J Trauma. 2005;59:
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26. Aggressive Coumadin Protocol (2 of 2)
82 patients, 19 with ICH
Time to initiate warfarin reversal dropped from 4.3 hours pre-protocol to 1.9 hours
Mortality dropped from 48% to 10%
Ivascu FA, et al. J Trauma. 2005;59:
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27. CASE 3 A 97-year-old woman fell while getting out of bed
Normal activity throughout day; eventually presents with moderate neck pain
No neurological deficits on exam
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28. Geriatric C-Spine Fractures
Type II odontoid fractures are the most common
LearningRadiology.com, retrieved June 3, 2011.
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29. Odontoid Fractures
Insert image/ diagram of 3 types of odontoid fractures.
There are three types of odontoid fractures. Type I goes through the tip of the dens, type II goes through the base of the dens, and type III goes beneath the dens.

30. Geriatric C-Spine Fractures
Blunt trauma victims >65 years are 2 more likely than younger patients to have C-spine fractures
Odontoid fractures: 20% of elderly C-spine fractures vs. 5% in younger patients
Debate in literature about management of types II, III odontoid fractures
Patients >65 years included in NEXUS, identified as high risk in Canadian C-Spine Rule
X-rays frequently inadequate
Have a low threshold to use CT on geriatric C-spine
Touger. Ann Emerg Med
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31. Triage
Elderly trauma patients are under-triaged, in violation of paramedic protocols
Should the elderly be triaged more aggressively?
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32. CRITERIA for Trauma Team Activation (TTA) (1 of 3)
Review of Trauma Registry at UCLA and LA County from 19932000
Included admitted trauma patients age >70, except interhospital transfers, ground-level falls, subacute subdurals
883 patients included
25% met TTA criteria:
SBP <90 or Pulse >120
RR <10 or >29
Unresponsive to pain
Gunshot wound to trunk
Demetriades D, et al. J Trauma. 2001;51:
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33. CRITERIA for Trauma Team Activation (TTA) (2 of 3)
63% of patients with severe injuries did not meet standard TTA criteria
Among all patients who did not meet criteria, mortality was 16%
Include age 70 years as TTA criterion?
ISS = Injury Severity Score
Demetriades D, et al. J Trauma. 2001;51:
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34. CRITERIA for Trauma Team Activation (TTA) (3 of 3)
The same UCLA group added age 70 years as a TTA criterion
Data were analyzed on 336 trauma patients with ISS > 15 and age 70 years: 260 patients admitted before age became a criterion and 76 admitted afterward
Groups were similar in injury, age, gender, ISS, and Abbreviated Injury Score
Mortality was 53.8% before, 34.2% after (P=.003)
Consider early and aggressive resource mobilization for elderly trauma victims
Demetriades D, et al. Br J Surg. 2002;9:
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35. Geriatric Trauma: Take-Home Points
Elderly patients break easily — don’t minimize
Mobilize resources for elderly trauma victims
Rib fractures associated with high mortality; if patient has >2 rib fractures, admit
Consider angiographic embolization for pelvic fractures even before hypotension
Beware warfarin!
Low threshold for CT of geriatric C-spine; when (re)taking the boards, think odontoid
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36. Case 1
EMS brings in a 71-year-old woman who was “T-boned” on the passenger side while driving at an unknown rate of speed.
There was no air bag deployment, but it took several minutes to get her out of her car and she was non- ambulatory at the scene.
Upon examining her, you note that she has chest wall bruising, a tender pelvis, and vital signs significant for BP of 100/60, HR of 80, and oxygen saturation of 100% on a non re-breather oxygen mask.
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37. Case 1, Question 1
Which of the following is not true regarding the epidemiology of geriatric trauma? Select the one best answer.
Although people 65 years account for only 10% of all trauma evaluations, they account for more than 25% of all trauma mortality.
Burn mortality is estimated at percentage body surface burned plus age of patient in years.
Falls are a common cause of significant morbidity in the elderly.
Motor vehicle accidents are the most common cause of traumatic injuries in the elderly.
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38. Case 1, Question 2 True or False?
Patients aged >65 years old with 2 or more rib fractures have a higher than 30% mortality rate.
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39. Case 1, Question 3
Which of the following statements regarding triaging elderly trauma patients is not true?
Cardiac and pulmonary disease limit physiologic response to stressors.
Elderly patients involved in traumatic accidents are more likely to be triaged to trauma centers than younger patients with the same pre-hospital assessment by EMS providers.
Institutions that include age as a criterion in their trauma activation system have improved outcomes in caring for geriatric trauma patients.
Medications taken by the elderly can render vital signs more difficult to interpret.
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40. Case 2
A 90-year-old woman presents to your emergency department complaining of a headache and painful neck.
She fell 3 days ago while standing up from the toilet.
She is neurologically intact with a Glasgow Coma Scale of 15 on exam. Her medications include warfarin.
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41. Case 2, Question 1 True or False?
Both the Canadian Head CT Scan rule and the New Orleans Head CT Scan rule identify patients over the age of 65 as high risk.
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42. Case 2, Question 2
Which of the following statements regarding patients on warfarin is not true? Select the one best answer.
Delayed acute subdural hemorrhage occurs in patients on warfarin.
Eleven percent (11%) of all patients on warfarin presenting to an emergency department have an INR > 5.
In cases of blunt head trauma in patients on warfarin with no or minimal symptoms, the incidence of intracranial hemorrhage is 4%.
Nine percent (9%) of all elderly patients with traumatic brain injury are on warfarin.
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43. Case 2, Question 3
Which of the following types of cervical spine fractures is most increased in frequency in elderly patients?
a) Clay-shoveler’s fracture
b) Hangman’s fracture
c) Jones fracture
d) Odontoid fractures
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44. Answer Key Case 1 Question 1: D Question 2: False Question 3: B Case 2
Question 1: True
Question 2: C
Question 3: D
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45. Bibliography (1 of 2)
Bergeron et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54:
Callaway W. Geriatric trauma. Emerg Med Clin. 2007;25:
Demetriades et al. Old age as a criterion for trauma team activation. J Trauma 2001;51:
Demetriades et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89:
Hylek et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115:
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46. Bibliography (2 of 2)
Ivascu et al. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005;59:
Kimbrell et al. Angiographic embolization for pelvic fractures in older patients. Arch Surg. 2004;139:
Ma et al. Compliance with prehospital triage protocols for major trauma patients. J Trauma. 1999;46:
Touger et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002;40:
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47. Special thanks to Brian Downing, MD
Special Thank You
Special thanks to Brian Downing, MD
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