Geriatric Trauma updated Nov 2017

Geriatric Facts The fastest growing age group. Longer Life expectancy. Declining birth rate. Advances in chronic disease care.

Geriatric trauma differences Trauma leading cause of morbidity and mortality Geriatric patients have more comorbidities. Higher risk of severe disability and death. More susceptible to injury from minor events. Medications that blunt normal physiologic responses.

Epidemiology Falls and Motor Vehicle Accidents are the most common mechanism of injury amongst the elderly. Regardless of mechanism the elderly experience much higher morbidity and mortality than the younger trauma patient.

Falls Most common injury in patients over 65 Falls represent 75% of all geriatric trauma. Most falls occur while on level ground. Serious injuries sustained from simple falls.

MVC Second most common mechanism of injury Most common cause of traumatic mortality. Rib fractures are significantly related to complications, including pneumonia, and respiratory failure. Elderly are second only to children in car vs pedestrian Highest mortality however, is elderly pedestrian vs car.

Burns Mortality is significantly higher. LD50 age 60-70 is 43% age over 80 is 13%

Anatomy and physiology Impaired capacity to respond to stress and severe injury. The decrease function of the pulmonary system causes poor compensation to hypoxia, hypercarbia, and acidosis they may have acid base disturbances and appear as if they are breathing normally

Head injury Subdural hematomas common. 30% decrease in brain size from ages 30 to 70. Brain atrophy increases space for blood and delays symptoms Dementia can also complicate assessment.

History What happened…altered consciousness, difficulty breathing, change in vision and neurologic events? What medications is the patient taking? What underlying illnesses? Patient’s baseline cognitive and motor function? Advance directive?

Prehospital management Falls from standing or minor MVCs can cause significant injuries and even death in the elderly. Anyone that you are helping off the floor should be seriously considered for evaluation.

Neck injuries Common in the elder patient. Many elder patients do not tolerate rigid boards. Clinical judgment including respiratory status may mean no board and even raising the cot to 30 degrees.

Primary survey Remember that the usual clinical signs of deterioration may be absent or delayed in the elderly. So aggressive initial care is very appropriate. Assume a serious injury

Airway and breathing Dentures help you bag, but make intubation difficult. Difficult to get into a “sniffing” position. Early supplemental oxygenation is critical. Respiratory rates in the elderly of less than 10 per minute increase mortality.

Circulation Recognizing early shock may be difficult. Baseline hypertension is common. Increased mortality with heart rates above 90 and systolic pressures below 110. Look for other signs of shock - Altered mental status, Agitation, Mild tachycardia, Delayed capillary refill

Shock treatment IV boluses is a great start and then reassess Due to cardiac and renal status be careful not to fluid overload

Hemorrhage Hemorrhage remains the most important cause of shock in the elderly. Consider other causes

Disability Difficult in the setting of dementia. Reduced sensation is part of the normal aging process. Subdural presentations are frequently normal in the elder patient. As part of the primary exam a focused reevaluation in elder trauma patients should be done every 5 minutes

What to monitor ABC Pulse Ox Capnography Cardiac monitor Mental status

Secondary survey Many occult injuries are missed in the elderly as the pain perception is altered. They frequently have difficulty localizing injuries. Watch vital sign trends.

Analgesia Pain control is essential for the injured older adults. Failure to provide analgesia increases the risk of delirium. Opioids are best in the elderly with significant pain. NSAIDS in the elderly increase GI bleeds and hypertensive events.

Which opioid? Fentanyl Dilaudid Great choice because it is the most cardio-protective But it has a very short half-life and needs frequent redosing. 25-50 mcg IV/IO/IN/IM repeat once max dose = 100mcg Dilaudid Also a good choice and it lasts a considerably longer time. 0.5-1mg IV/IO/IM max dose = 2 mg (over 65 yo 0.5mg max)

Head injury studies Anyone older than 65 with a head injury requires imaging(CT). GCS<9 in the elderly has a 80% death or major disability.

Chest trauma Rib fractures are the most common Each rib fracture over 3 adds 19 percent to mortality over the age of 65. Even one rib fracture increase the risk of pneumonia and pulmonary contusion as well as pneumothorax.

Musculoskeletal injuries Hip fractures most common with a 20-25% mortality over the age of 70, within the first year after injury.. Pelvic fractures range from common pubic rami fractures, to major open book fractures.

ED Disposition We take a lot into this decision. What caused it? Safety factors. Risks of the injury. Comorbidities.

Prime Example 65 y/o fell down 3 steps Ascending newly installed stairs without a handrail when he lost his balance and fell backward down 3 stairs. +CHI, unknown LOC. He is not sure how long he laid there but thinks it was less than 30 minutes. He did not ambulate after the fall. He now complains of lower back pain.

Principal Diagnosis: Fall down 3 stairs 1.CHI, unknown LOC 2.Right Temporal lobe hemorrhagic contusion, with SAH 3.Contusion Left inferior flank 4.L5 compression fracture and T10-L2 transverse process fx, left aspect of the T5 vertebral body and 5.possibly the T4 vertebral body 6.Rib fx Right sided 5-9 and Left 10-12 posterior ribs continue 7. Left olecranon fx 8. ETOH abuse 9. Atelectasis, pulmonary contusion 10. Malnutrition 11. HTN urgency 12. Electrolytes disturbances 13. Poly drug abuse MJ and Opiates.

Summary Much higher morbidity and mortality Anyone over 65 with even minor trauma, falls and MVC, may have sustained significant injuries. Ask critical questions: What happened before the injury, what medications, comorbidities, mental and motor baseline and advanced directives. Remember that normal vitals should not make you feel that everything is OK with your geriatric trauma patient!