1. Pre Hospital Recognition
Elderly Trauma
Pre Hospital Recognition
Shane Roberts  Head of Clinical Practice - Trauma Management
West Midlands Ambulance Service NHS Foundation Trust

2. Issues facing pre hospital providers

3. The West Midlands Regional Trauma Network
Network Structure

5. • older adults — risk for injury/death increases after age 55 years — SBP <110 might represent shock after age 65 years — low impact mechanisms (e.g., ground-level falls) might result in severe injury

6. Several studies suggest that differences in the physiologic response to injury and high-risk mechanisms in older adults might partly explain under triage rates in this age group.
In a retrospective chart review of 2,194 geriatric patients (aged ≥65 years) at a Level 1 trauma centre, mortality was noted to increase at a SBP of <110 mmHg.
A retrospective review of 106 patients aged >65 years at a Level II trauma centre indicated that occult hypotension (i.e., decreased perfusion that is not evident by standard vital sign criteria) was present in 42% of patients with “normal” vital signs.

7. An analysis of deaths reported by the King County Medical Examiner’s Office (King County, Washington) indicated that ground level falls accounted for 237 (34.6%) of all deaths (684) in patients aged ≥65 years.
A study of 57,302 patients with ground-level falls demonstrated higher rates of intracranial injury and in-hospital mortality among adults aged ≥70 years
The evidence reviewed suggests that the physiologic parameters used in younger patients might not apply to older adults, occult injury is likely to be greater among older adults, low-energy transfers (e.g., ground-level falls) might result in serious injuries in this population, and field identification of serious injury among older adults must be more proactive.

8. Anticoagulation and Bleeding Disorders: Patients with Head Injury Are at High Risk for Rapid Deterioration:
After reviewing this literature, the Panel elected to strengthen this criterion, underscoring the potential for anticoagulated patients who do not meet Step One, Step Two, or Step Three criteria but who have evidence of head injury to undergo rapid decompensation and deterioration.
The panel recognized that patients who meet this criterion should be transported preferentially to a hospital capable of rapid evaluation and imaging of these patients and initiation of reversal of anticoagulation if necessary.

9. Solutions?

10. Management of Elderly Trauma in Major Trauma Systems
Principles
The majority of elderly trauma patients can be managed in their local Trauma Unit.
Major Trauma Centres and Networks should support the care of elderly trauma patients at Trauma Units.
Elderly trauma patients requiring higher level of care should be rapidly transferred to Major Trauma Centres.

11. Principles - continued
Care of the Elderly clinicians should have shared responsibility for the management of elderly major trauma patients.
Elderly trauma patients should have the same standard of care as non- elderly major trauma patients.
The major trauma network should be actively engaged in the falls prevention strategy.

12. Definitions
An elderly major trauma patient is a patient sustaining serious, potentially life changing injury who is aged 65 or over.
An elderly trauma patient is a patient who sustains non-life threatening injury
Recognition
Pre-hospital and in-hospital trauma triage criteria do not accurately identify elderly major trauma patients and further work is required to address this.
Elderly major trauma patients who are recognised late or deteriorate should be discussed / referred to the MTC.

13. Clinical and Systems Governance
The Network should regularly audit the management and outcomes of elderly trauma patients managed in Trauma Units.
The MTC should regularly audit the management, outcomes and experience of all admitted elderly major trauma patients.

14. Additional Considerations
Trauma Units should activate a major trauma response for elderly trauma patients requiring transfer to MTCs, regardless of the mode of presentation or delays in identification of the injury.
Advanced directives and wishes should be discussed with elderly trauma patients and relatives as soon as possible in the clinical course.
Do Not Resuscitate directives should be considered where appropriate.
The Network should provide resources for multidisciplinary education in the immediate and on-going care of elderly trauma patients. (Includes assessment of frailty, delirium and dementia).

15. Suggested Clinical Criteria
Elderly trauma patients who can be primarily managed in trauma units:
Patients with head injury who have GCS 15 and normal CT scans
Patients with mild traumatic brain injury who are GCS on presentation and at low risk of deterioration
Patients with unilateral rib fractures without underlying lung injury
Elderly trauma patients who should be managed in the Major Trauma Centre:
Patients with moderate to severe traumatic brain injury or those with a moderate to high risk of deterioration
Patients who have an acute deterioration in their GCS after admission to the TU
Patients with rib fractures with underlying lung injury (contusion etc.) or flail segment compromising the respiratory dynamics  

16. Elderly trauma patients who should be discussed with the Major Trauma Centre:
Patients with severe, potentially non-survivable traumatic brain injury
Spinal injury other than fragility fractures
Patients with complex co-morbidities and life limiting conditions
Patients with bilateral rib fractures without underlying lung injury
Patients with traumatic brain injury on anticoagulant medication

17. Educating Pre Hospital Providers

18. 1) Cognitive impairment (acute or chronic)
2) Patient on more than 5 medications
3) If patient is difficult to assess or clinician is uncertain of condition

19. Conclusions

20. Any Questions?