1. Geriatric trauma Care ‘A growing Concern’
Gp Capt V Kulshrestha
Department of Orthopaedics
7 Air Force Hospital

2. Geriatric Tsunami We are living Longer Need to remain active longer
Exposed to swift mechanized society
Modern health care, economic and social support system is an aging epidemic and we all are going to get it
We remain active in old age and are exposed to mechanized world
Current >6 population 8% and above 50 18% expected to double in a decade
Very high dependency ratio so need to remain active
Trauma in elderly is common and elderly trauma patient is 6 times more likely to die as compared to young
1950 > 50 3 % and > %; & o.3/ & 0.8
& 3
8 crore to 24 crore

3. We all will be there

4. Mobility is Life Life is Mobility

5. Is elderly trauma different ??
Elderly decreased physiologic reserve
More Co-morbidities
Less dramatic physiologic response
Less room for errors in judgment
Multiple medications masking symptoms
Different mechanism & pattern of injuries
70% of all deaths due to fall occur in elderly
30% of elderly fall every year and 50% of those above 80 fall every year.
Next is RTA whether inside or outside as hit by a vehicle

6. Lets look at Risk of injury Physiological changes with aging
Assessment of Geriatric Trauma
Management of Geriatric Trauma
Common Pitfalls / Do’s and Don't

7. Risk of Injury Poor visual acuity Poor visual attention
Overload of information
Impaired reaction times
Limited neck rotations
Slower gait
Muscle coordination/reflex
Medication side effects
Alcohol consumption

8. Physiological Changes

9. CARDIOVASCULAR Less Effective Pump Minimal Reserve Medication Effects
Ischemia/Hypoxia

10. RENAL Functional Changes Loss of Surface Area
Diminished Renal Blood Flow
Progressive Decline in filtration function

11. Respiratory Lungs Musculoskeletal Infectious Risks
Decreased elasticity
Decreased alveolar number and function
Decreased baseline p02
Musculoskeletal
Kyphosis
Decreased Chest Wall Strength
Increased Chest Wall Rigidity
Infectious Risks
Increased Bacterial Colonization
Decreased Force of Cough
Decreased Clearance Rate

12. Vision Changes

13. Hearing Changes

14. NERVOUS SYSTEM Structural Changes 10% Reduction in Brain Weight
Loss/Degeneration of Neurons
Cerebral Atrophy
Cerebrovascular Changes
Confounding Factors
Brain/Skull Relationship
Cervical Spine
Altered “Baseline” Mental Status

15. CENTRAL NERVOUS SYSTEM (Functional Changes)
Auditory
Cognition
acquisition of new data
memory - short and long term
Proprioception
Visual Acuity
glare intolerance
color perception
visual fields
proprioception (prō'prē-ō-sěp'shən)   The unconscious perception of movement and spatial orientation arising from stimuli within the body itself. In humans, these stimuli are detected by nerves within the body itself, as well as by the semicircular canals of the inner ear.

16. MUSCULOSKELETAL Structural Changes Functional Changes Decreased Mass
Degeneration of Remaining Muscle
Degeneration of Joint Cartilage
Osteoporosis
Functional Changes
Strength
Range of Motion
Mobility
Pain
Fracture-Prone
Gait

17. OTHER PHYSIOLOGICAL CHANGES
Thermoregulation - Hypothermia/ afebrile with infection
Immune system - Infection/Sepsis
GI - Malnutrition/medication metabolization decreased
Body water and electrolytes - dehydration / hyponatremia
Data of growing elderly population a comparison over last 5 decades

18. Assessment Symptoms ?? Poor communication Pain response; blunted
Multiple illness
Anticipate complicating factors
History and treatment details from NOK

19. Assessment Determine the Chief Complaint Medications / changes
Establish base line functional Status
Simplify questions
Personalize communication
Show not tell
Even if the patient is confused or agitated, try to find out from him or her what is wrong. Family or neighbors may be a valuable resource if present. Determine recent behavior, eating patterns and any recent problems that are contributing factors
Baseline status can be very different from normal but not reflect an acute change (e.g. signs of unilateral changes from an old stroke that are confused with current presenting signs and symptoms).
Remember during the interview that older adults need more time to respond to questions. Ask questions one at a time in simple sentences.
Use touch, tone of voice and eye contact to maintain attention and focus. Make allowances for likely problems with vision and hearing.
Have the patient show you the site of pain or discomfort. Ask the individual to take your hand and place it over any painful area.

21. Assessment Monitor fluids Frequently assess pulmonary function
Lung sounds
Cardiac monitoring
Pulse oximetry

22. Management Decompensation may occur rapidly and without warning
Reduce initial stabilization time and perform serial vital signs and monitoring throughout transport.

23. Management Arthritic changes increase potential complications
Protect the cervical spine

24. Management
Aging tends to increase upper airway secretions - micro aspiration is common.
Assist with airway secretions

25. Management
Changes of aging increase the risk of compromised oxygenation
Monitor airway and ventilatory effort. Oxygenate early and liberally in the absence of COPD.

26. Management Normal PO2 may be compromised due to normal aging.
Maintain O2 saturation >90%.

27. Management
The elderly may have “dead space” within the cranium due to loss of brain mass.
Elevate head 15 to 30 degrees.

28. Management Head and Cervical Spine
Drastically less force needed to fracture skull or C-spine
compared to younger patients who undergo similar trauma
Little or no apparent trauma can cause subdural bleeding
Recommended to have liberal use of Head CTs to rule out injuries
Indications- multisystem injuries, +LOC, Neuro deficit, dementia, any head trauma in face of oral anticoagulation

29. Management Cervical Spine Injuries Just as in young trauma
Need rigid collar
Higher instance for Central Cord syndrome
Due to age related narrowing of cervical canal and vascular disease of spinal arteries
Causes deficit of upper extremity strength and sensation

30. Management Chest Rib fractures are the most common injury
3 point restraint belts have shown to cause significant chest trauma
ECG remains the most sensitive method to predict short-term cardiac complications

31. Management Abdomen/Pelvis
In face of multi-system injuries, abd exam is unreliable
Recommend liberal use of diagnostics
DPL, US, CT
Pelvis
Fractures are significant for high mortality

32. Management Extremity Trauma Like all other fractures in elderly
Little impact necessary for fracture
Overall isolated extremity injuries are tolerated well by the elderly
Liberal radiological diagnostics recommended

34. Isolated Skeletal injury
Rapid optimization (24-48h)
Team approach
Inv which change management
Early surgery
Too old not to be operated

36. Isolated Skeletal Injury
Specialized techniques and modern implants
Immediate mobilization
Anti-resorptive treatment
Rehabilitation / fall prevention

40. Do’s Do look for medical event/ preexisting disease
Do Resuscitate early;
Do identify injury early
Do keep in mind blunted responses
Do look for right drug dose and interactions
Emergency physicians must remember that elder trauma patients may have suffered a medical event that precipitated their trauma, or vice versa, and evaluate patients accordingly.
of elder trauma patients requires oxygen supplementation, a lower threshold for advanced airway control (endotracheal intubation), and aggressive but judicious fluid and blood resuscitation with frequent re evaluation

41. DO’s Do rule out drugs masking symptoms
Do be creative in splinting extremity
Do maintain hydration
Do guard against hyponatremia
Do guard against pressure sores

42. Don’t DO NOT force the patients positioning
DO NOT keep patients supine.
DO NOT overuse narcotic.
DO NOT delay surgery unnecessarily

43. Conclusion
The physiologic, mental and psychologic effects of aging can influence how you provide trauma care.
In the case of both intentional and unintentional injury, knowing the special needs of the geriatric trauma patient can help you avoid further injury and greatly increase the patient’s chance of survival.

47. Conclusion
The role of good primary care in managing musculoskeletal injuries in the elderly cannot be overemphasized’
The first step to recovery of an injured elderly starts from the initial aid he receives.
Time is at a premium and more so in cases of elderly trauma patient when we need to impart protocol based scientific care to save lives and limbs of trauma victims.

49. Conclusion
We need to educate ourselves and our paramedical staff in management of elderly trauma victims to prevent mortality and decrease morbidity in these patients.
There appears to be a need for a standard curriculum for the orientation of medical professional in Geriatric trauma and emergency management. This is mandatory to impart highest level of medical care to elderly victims and thus prevent immobility in our elderly and its socioeconomic impact.

50. THANKS

52. Questions?
Thank you