1. in the name of God

2. Management trauma in elderly DR. NIKSOLAT GERIATRICIAN ASSISTANT PROFESSOR, IRAN UNIVERSITY OF MEDICAL SCIENCE

3. Traumatic Brain Injury : TBI is common in older adults, can occur with minimal head trauma, can be asymptomatic. mortality rates among older patients with TBI range from 30% to 80%, increasing age is an independent predictor of disability and mortality in patients with TBI. Physiologic changes of aging and use of anticoagulant and antiplatelet medications increase the likelihood, severity of TBI in older adults.

4.  With aging, the size of the brain decreases by 10% on average, resulting in less tortuous bridging veins and increased intracranial free space.  The atrophied brain is more mobile within the skull, and trauma is more likely to shear bridging veins, leading to ICH.

5. Diagnosis of TBI is more difficult in older adults because cognitive impairment is more common and increased intracranial free space can allow the accumulation of blood without changes in mental status.

6. Management : Treatment of TBI includes: supportive care, rapid reversal of anticoagulation, evaluation for decompressive surgical intervention. Supportive care aims to avoid cerebral hypoxia, hypoperfusion, significant predictors of adverse outcomes. All patients should initially receive high-flow oxygen to maintain high oxygen saturation.

7.  Patients with hypercarbic respiratory conditions (chronic obstructive pulmonary disease) require an individualized determination of the appropriate oxygen saturation.  Preventing cerebral hypoperfusion requires close monitoring of hemodynamic parameters (blood pressure and urine output).

8. Early neurosurgical consultation is indicated to assess the need for and usefulness of surgical ICP monitoring and decompression.

9.  reversal of anticoagulation with a PCC, or FFP if PCC is unavailable, for older adults taking warfarin.  evidence supporting PCCs has shown immediate administration of PCC is associated with more rapid reversal and less hematoma growth than vitamin K, FFP.

10.  Treatment or reversal of antiplatelet agents and other anticoagulants, including low-molecular-weight heparins, novel oral anticoagulants, is based on expert opinion.  Physician should determine local practice in coordination with their trauma and neurosurgery consultants.

11. Factor Xa inhibitors Rivaroxaban, apixaban and edoxaban are factor Xa inhibitors, for which reversal agents are currently unavailable. Current consensus suggests that elderly patients(rivaroxaban, apixaban or edoxaban and have a known or suspected life threatening haemorrhage: » Administer 25–50 u/kg four-factor prothrombin complex concentrate (eg Octaplex® or Beriplex®) and 5 mg intravenous vitamin K as soon as possible after arrival at the ED. Vitamin K will not reverse the anticoagulant effect of a DOAC, but may help to correct any coagulopathy resulting from a co-existent vitamin K deficiency.

12. Dabigatran: is a direct thrombin (IIa) inhibitor which has an antidote called idarucizumab. In elderly patients received dabigatran and have a known or suspected life threatening haemorrhage idarucizumab 5g IV as soon as possible after arrival at the ED. If bleeding reoccurs and clotting times are prolonged second dose of idarucizumab 5g

13.  TBI in older adults is associated with significant morbidity, mortality. Negative prognostic factors : increasing age, anticoagulation, use of antiplatelet medications, greater severity of TBI, and lower GCS score.  Older patients with isolated head trauma, normal cranial CT, and normal INR are safe for discharge if they have a safe environment, responsible care provider, and reliable follow-up.

14. Vertebral Fractures and Spinal Cord Injuries: Age-related changes to vertebral bones, intervertebral disks, spinal canal place older adults at greater risk of vertebral fractures, result in a greater likelihood of SCI, make physical examination and diagnostic imaging results less accurate.

15. Spinal canal stenosis resulting spinal cord compression are clinically manifested as a myelopathy, impairment of coordination, gait, bowel or bladder function, and motor or sensory function, or both. Vertebral Fractures and Spinal Cord Injuries:

16. In cases of suspected vertebral fracture or SCI : immobilization, spine surgery consultation, and admission are indicated.

17. Older adults are at higher risk for SCI without obvious radiographic abnormality to spinal cord stenosis and cervical kyphosis. Evaluation for ligamentous injury and SCI in patients with focal neurologic deficits is MRI.

18. Pelvic injuries: all adult patients with blunt major trauma and suspected multiple injuries should have a whole body CT (WBCT). If a pelvic fracture is identified on X-ray after a low energy fall, then activation of the trauma team for a full trauma assessment is recommended.

19. pelvic or sacral insufficiency fracture which commonly accompanies a simple pubic ramus fracture will at least cause back pain, and may render the pelvis unstable. Urgent CT should be requested in symptomatic elderly patients (pain, reduced mobility).

20. Complex or unstable complex pelvic injuries should be referred to a pelvic surgeon, as for any adult trauma patient. Pelvic surgery (including minimally invasive techniques) may be indicated for any age group to restore mobility and function

21. Thanks For Attention