Geriatric Trauma

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Chapter 39

Geriatric Trauma

Perspective

Demographics and Epidemiology

The U.S. population is aging, and the elderly are living more active lifestyles—which explains the dramatic rise in geriatric trauma. About one in eight Americans were aged 60 or older in 1994, whereas by 2030 one in five will be.1 In 2008, U.S. adults aged 65 and older made more than 5.8 million ED visits for injuries, accounting for 30% of all visits by older adults and almost 14% of all injury-related ED visits.2 Older trauma patients have increased morbidity and mortality owing to the severity of injury, comorbid disease, and the independent effects of age. In similar accidents, the elderly sustain more severe injuries than younger adults, a strong predictor of mortality. In 2009, unintentional injury was the ninth leading cause of death among those older than 65 years.3 Older adults are more likely to have significant underlying medical conditions that limit their physiologic response to injury and increase the risk of death after trauma, especially in less severe injuries.4,5 Age is independently predictive of morbidity and mortality even when comorbidities and Injury Severity Score (ISS) are controlled for.6,7

Age as a Triage Criterion

Age should be considered in determining criteria for transfer to a trauma center and for activation of trauma teams.8 Traditional triage criteria based on mechanism and vital signs miss many elders with major injuries.9–12 Fewer older patients are transported to trauma centers despite meeting trauma center criteria,9,13 and elders are less likely to be admitted to trauma centers than younger adults.14 In response, the Advanced Trauma Life Support (ATLS) program recommends that emergency medical services (EMS) transfer patients older than 55 years to a trauma center regardless of injury severity.15 Yet the effect of trauma center care on elders is not clear; although an early study showed that elderly patients with severe injuries have better outcomes when treated at a trauma center,16 a larger, more recent study of 69 hospitals in 14 states found no survival difference.17 At trauma centers, age is often a criterion for trauma team activation, and one study showed a trend toward decreased mortality after trauma team activation criteria were changed to include age older than 70 years.18

Mechanisms of Injury

Falls are the leading mechanism of injury and the leading cause of injury-related death in patients older than 65 years.19 In 2008, there were 2.1 million ED visits for falls among those 65 and older 10 times more common than motor vehicle collisions (MVCs).20 Up to one third of elders sustain a significant fall each year, and serious injuries occur in up to a quarter.21 Most falls are from standing and occur at the elder’s place of residence.19 Risk factors for falling include (in decreasing relative risk) weakness, balance or gait deficit, visual deficit, mobility limitation, cognitive impairment, impaired functional status, and postural hypotension.22 Fractures are the most common injuries sustained by elders during falls, occurring in 5 to 10% of falls.21 Up to 10% of fallers sustain a major injury, with head injury being most frequent.23 Although the height of the fall is associated with severity, falls from standing carry significant risk for older adults; same-level falls result in serious injury (ISS >15) 30% of the time in older patients, and peri-injury mortality from low falls is up to 10%.23–25

MVCs and pedestrians struck by a motor vehicle are the second and third most frequent causes of trauma in older adults.6,19 Elders are more likely than younger adults to be involved in daytime crashes occurring close to home.26 A detailed crash history is important, and single-vehicle crashes should raise the suspicion that a medical problem caused the crash (e.g., syncope). The mortality rate of older MVC victims is up to 21%.19,27 Elders are more likely to be struck by a motor vehicle than younger pedestrians, because of poor eyesight, limited mobility, and slower reaction time. Pedestrians struck sustain significant injury patterns and have the highest fatality rate among injuries, 30 to 55%.19

Self-injury, elder abuse, and thermal injuries are less common but important injury patterns in the elderly population. Older adults have a lower likelihood of attempting self-injury but a higher likelihood of completing suicide attempts than any other age group, with men at higher risk. Thermal injuries such as burns and smoke inhalation occur more frequently and are more severe in older adults owing to decreased mobility and physiologic skin changes.28 Elder abuse is a complex problem that can involve psychologic, social (e.g., financial), and physical abuse. Studies have identified that around 5% of elders self-report abuse in the previous month, although lower rates of physical abuse are reported to protective services.29 All older adults with injuries should be asked if they feel safe at home and if there is anyone in their life who is threatening or injuring them.

Distinguishing Principles of Disease

Older adults are more vulnerable to trauma owing to age-related changes in anatomy, physiology, and pathophysiology. Aging’s main effects on human physiology are decreased functional reserve, seen across organ systems, due to reductions in volume of viable tissue and intrinsic function of the tissues. Older adults are more likely to have comorbidities and to be taking multiple medications that affect their likelihood to get injured and their response to injury. Aging physiology, comorbid disease, and medications lead to different signs and symptoms of trauma in older adults and should inform the assessment of the geriatric trauma patient.

Effect of Medications

Medication use is common in older adults. A representative survey of community-dwelling U.S. adults (aged 57 through 85 years) showed that 81% used at least one prescription medication, and 29% used five or more prescription medications.31 Aspirin was the most common medication, used by 28% of older adults. Medications increase the likelihood of older adults getting into traumatic accidents (e.g., sedative hypnotics causing falls). Some, such as beta-blockers, affect the physiologic response to trauma. Medications’ effect on vital signs should be considered during the primary survey, and a full medication history should be taken early in the secondary survey.

Primary Assessment and Resuscitation

Airway

Establishing and maintaining a patent airway is the primary objective. As elderly patients are likely to have multiple risk factors for a difficult airway, physicians should perform a systematic airway assessment, focusing on the ability to mask ventilate, to perform endotracheal intubation, and to perform a cricothyrotomy. Early intubation is indicated for unstable patients as defined by signs of shock, altered mental status, and significant chest trauma.15 As direct laryngoscopy is more difficult in older adults because of limited cervical mobility and less mobility at the temporal mandibular joint, videolaryngoscopy is recommended.32 Cricothyrotomy is more likely to be complex in older adults as they are more likely to have had neck surgery, radiation, or tumor and are more likely to be anticoagulated.

Rapid sequence intubation (RSI) medications should be tailored to the older adult. The main risk from RSI in the older trauma patient is hypotension from medications, so dosages of induction agents should be reduced (e.g., etomidate, regular strength 0.3 mg/kg, or half strength 0.15 mg/kg; midazolam, 0.1 mg/kg in average older adults, or 0.05 mg/kg in frail elders). Older adults are more likely to have risk factors for succinylcholine-related hyperkalemia, such as recent stroke or neuromuscular disease. With a good history, succinylcholine at a regular dose (1.5 mg/kg) is safe, but in the trauma patient without clear history, it is reasonable to use a nondepolarizing neuromuscular blocker such as rocuronium (1 mg/kg).

Circulation

Elderly patients are particularly vulnerable to shock, as their blunted response to stress and limited physiologic reserve raises the risk of organ dysfunction. Assessment of circulatory status is complicated as responses to hypovolemia, such as tachycardia and hypotension, are blunted by physiologic changes and medications, such as beta-blockers and calcium channel blockers. Vital signs are insensitive, as normal blood pressure does not reliably exclude significant hemorrhage or shock. As systolic hypertension is more common among elders, normotension may indicate significant hypovolemia. Vitals signs should be frequently reassessed; in elderly trauma patients, trends are more important than specific cutoffs.

First, life-threatening bleeding is identified and stopped; this includes external bleeding, such as scalp hemorrhage, which can be significant in older adults. The focused assessment with sonography in trauma (FAST) is an important adjunct to the primary survey but has not been specifically studied in elderly patients. A urinary catheter can be placed to monitor urine output, although this is a less sensitive predictor of renal blood flow than in younger patients.

Fluid resuscitation should be initiated with defined boluses (e.g., 500 mL) of warmed isotonic crystalloid. Start resuscitation with blood in the patient with significant bleeding, signs of hemodynamic instability, or significant injuries (e.g., unstable pelvic fracture), as older adults do not tolerate large-volume resuscitation well. Hemodynamic status should be reassessed frequently after small fluid boluses to avoid causing respiratory failure from fluid overload.

Invasive hemodynamic monitoring is appropriate for severely injured elders, but routine use is not justified. In a single-center, pre-post study, Scalea and colleagues showed reduced mortality with early invasive monitoring, leading some to recommend this as standard for older trauma patients.33 Yet this has not been replicated, and multiple randomized trials of invasive monitoring in other critically ill populations have not shown a survival benefit.

Prompt reversal of anticoagulation is important, as approximately 5% of the elderly population is on warfarin and others have pathologic coagulopathy.31 Specific considerations for reversing coagulation abnormalities in elderly trauma patients are the volume of reversal agents required and the corresponding risk of fluid overload. Prothrombin complex concentrates (PCCs) require minimal volume compared with fresh frozen plasma (FFP) but are costly. To fully reverse anticoagulation, 2 to 4 L of FFP may be required, presenting a limitation to rapid reversal in older patients at risk of fluid overload.

Disability

Evaluation of the elderly for disability includes examination for traumatic brain injury (TBI), spinal cord injury (SCI), and vertebral fractures and injuries. Primary neurologic examination of older adults should focus on mental status, verbal responsiveness, pupil responsiveness, and gross motor examination. The Glasgow Coma Scale (GCS) is often used to detect mental status changes after TBI but was not designed for this purpose and lacks sensitivity for mild injuries. Any GCS score less than 15 is concerning for TBI, and a GCS below 8 is highly predictive of poor outcome.34,35 In addition to application of the GCS, other means of assessing mental status changes are useful. Subtle changes in mental status, such as confusion or decreased alertness, or symptoms such as headache may be the only signs of TBI. The mental status examination in elders is complicated by comorbidities such as previous stroke or dementia and the increasing prevalence of cognitive impairment in older adults, including dementia and delirium. Delirium can be the cause of traumatic injury, such as falls, or the result of traumatic injuries.36 Abnormal pupillary responsiveness or motor function should raise concerns for significant intracranial hemorrhage (ICH) with associated increased intracranial pressure (ICP). Ultimately, no combination of historical features and physical findings has been shown to reliably predict the absence of intracranial injuries in the elderly trauma population. Brain computed tomography (CT) is prudent in older adults with head trauma, significant multisystem trauma, and symptoms or signs of TBI.

Older adults are at higher risk of vertebral fractures, and cervical fractures in particular, and they are more likely to sustain SCI as a result of trauma. Vertebral examination can be confounded by preexisting osteoarthritis. Clinical decision rules are available for cervical spine imaging in trauma, but their use is not recommended in older adults. The Canadian C-Spine Rule (CCR) classifies all patients 65 years and older as inherently “high risk,” requiring radiography, as the derivation study found that age older than 65 had an odds ratio of 3.7 (95% confidence interval [CI] 2.4-5.6) for clinically significant cervical spine injury.37 The National Emergency X-Ray Utilization Study (NEXUS) included all ages but found that patients aged 65 and older had a relative risk of 2.1 (1.8-2.6) for clinically significant cervical spine injury.38 Although a subgroup analysis of the NEXUS study in elderly patients concluded that no clinically significant injuries were missed, there was likely selection bias, as the NEXUS study was observational and clinicians are more likely to order imaging in older adults. Other studies show that only 45% of elderly patients with cervical spine fractures had cervical spine tenderness on examination.39 Elders are also at increased risk of thoracic, lumbar, and sacral vertebral fractures, for which CT is more sensitive than the physical examination or plain radiography.40,41 Physicians should have a low threshold for CT imaging of the spine.

Elders are at higher risk for SCI without obvious radiographic abnormality (SCIWORA) owing to spinal cord stenosis and cervical kyphosis. Preexisting spinal canal stenosis increases the risk for central and anterior cord syndromes.42 Evaluation for ligamentous injury and SCI with magnetic resonance imaging (MRI) is appropriate in patients with focal neurologic deficits.

Secondary Assessment

The stable geriatric trauma patient requires a thorough secondary assessment. A complete history should be obtained from the patient or a care provider with particular emphasis on corroborating the accident history, past medical history, medications and allergies, and social history including baseline functional status and living arrangements. Screening questions for alcohol and substance abuse and elder abuse should be routinely asked. A valid screening question for elder abuse is “Has anyone close to you tried to hurt you or harm you recently?”

Specific Disorders

Traumatic Brain Injury

TBI is common in older adults, can occur with minimal head trauma, and can be asymptomatic. Increasing age is an independent predictor of disability and mortality in patients with TBI, with overall mortality rates ranging from 30 to 80%.34,45

Pathophysiology and Mechanisms of Injury

Physiologic changes of aging and the frequent use of anticoagulant medication increase the likelihood and severity of TBI in older adults. 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. Diagnosis of TBI is more difficult in elders as increased intracranial free space can allow the accumulation of blood without changes in mental status,46 and preexisting cognitive impairment is increasingly prevalent in older adults. Approximately 5% of older adults are on warfarin, and more than 30% are on an antiplatelet agent, increasing the likelihood and severity of TBI.31

Treatment

Treatment of TBI includes supportive care, rapid reversal of anticoagulation, and evaluation for decompressive surgical intervention. Supportive care aims to avoid cerebral hypoxia and hypoperfusion, which are significant predictors of adverse outcomes in patients with TBI. All patients should initially receive high-flow oxygen to maintain high oxygen saturation. Patients with hypercarbic respiratory conditions (e.g., chronic obstructive pulmonary disease [COPD]) will require an individualized determination of the appropriate oxygen saturation. Preventing cerebral hypoperfusion requires close monitoring of blood pressure, urine output, and other hemodynamic parameters, and individual patients may benefit from invasive hemodynamic monitoring. Early neurosurgical consultation is indicated to assess the need for and usefulness of surgical ICP monitoring and decompression. The current guidelines for ICP management have not been studied in older adults with TBI.34

Prompt reversal of anticoagulation with FFP or PCC is indicated in elders with TBI. The evidence supporting PCCs is from several studies of atraumatic ICH, which showed that immediate administration of PCC was associated with more rapid reversal and less hematoma growth than vitamin K and FFP, but not better outcomes. To date, there is not clinical evidence to support the use of platelet transfusion in elders taking antiplatelet agents.

Prognosis and Disposition

TBI in older adults is associated with significant morbidity and mortality, yet ED prognosis is not precise. Negative prognostic factors include increasing age, anticoagulation,49–53 use of antiplatelet medications,54 greater severity of TBI, and lower GCS. Although many patients with severe injuries, significant comorbidities, or anticoagulation may have no chance of meaningful outcome, others can return to living in the community.55 Elderly patients with TBI should undergo prompt neurosurgical consultation. This is problematic for emergency physicians at hospitals without neurosurgical coverage, as it requires transferring patients with a grave prognosis, potentially for long distances. Patients with moderate or severe TBI, or any TBI and anticoagulation, require intensive care in which frequent neurologic checks and rapid reversal of anticoagulation can be accomplished. When an elder with TBI is being transferred, reversal of anticoagulation and prevention of hypoxia and hypotension are important early management steps.

Elderly patients with isolated head trauma, a normal cranial CT, and a normal INR are safe for discharge if they have a safe environment, a responsible care provider, and reliable follow-up. Although case reports suggest that anticoagulated patients with isolated head trauma and a normal cranial CT may be at risk of a delayed bleed, one study found that routine performance of a follow-up head CT scan at 24 hours was not necessary.56 Such patients can be discharged to the care of a responsible provider who can observe them closely.

Vertebral Fractures and Spinal Cord Injuries

Vertebral fractures and SCIs show a bimodal distribution with one peak in young adults and a second peak in the geriatric population. Age-related changes to the vertebral bones, intervertebral disks, and spinal canal place patients at greater risk of vertebral fractures, result in a greater likelihood of SCI, and make physical examination and diagnostic imaging less accurate. Based on radiologic studies, approximately one quarter of patients older than 65 years have cervical stenosis, and 90% of men older than 50 years and 90% of women older than 60 years have evidence of degenerative changes in the cervical spine.57 These changes have the effect of creating leverage on the spinal column when an external force is applied, such as in a fall with impact to the head, concentrating force on weakened bone, and increasing the risk of fracture and SCI. Spinal canal stenosis and the resulting spinal cord compression are clinically manifested as a myelopathy, with impairment of coordination, gait, bowel or bladder function, and motor or sensory function or both. Geriatric patients with vertebral injuries and SCIs are more likely to sustain incomplete neurologic injuries of less severity than younger patients, largely because they have lower-force injuries. In cases of suspected vertebral fracture or SCI, continued immobilization, neurosurgical consultation, and admission are indicated.38 The majority of geriatric vertebral fractures and SCIs are represented by three types of injuries: (1) central cord syndrome, (2) cervical extension-distraction injuries (“open book” fractures), and (3) odontoid fractures.42

Thoracic Trauma

Older adults are at increased risk of rib and sternal fractures, pulmonary contusions, and their complications with low-force injuries. More than half of elderly patients admitted to hospitals with rib fractures sustained them during a fall, and a significant number occurred during low- or moderate-speed MVCs.58 The risk of pneumonia and complications increases with the number of ribs fractured.59 Pulmonary contusions are more frequent with minimal trauma and can cause significant morbidity and mortality in older adults. Chest CT is recommended for elderly patients with significant chest trauma, multiple rib fractures by plain film, or respiratory complications from trauma.

Patients with significant chest trauma require airway monitoring with consideration of early intubation to anticipate their clinical course, pulmonary therapy, and pain control. Pain control is of particular importance, as rib fractures will lead to splinting and atelectasis and increase the risk of pneumonia. Analgesia can be administered with intravenous opioids via patient-controlled analgesia or with an epidural analgesic. Geriatric trauma patients with severe pain from rib fractures often require hospitalization to allow adequate and safe pain management, and those with flail segments or larger numbers of rib fractures may require intensive care admissions.

Abdominal Trauma

Older adults are more likely to sustain intra-abdominal injuries and have higher mortality from such injuries. The general management principles are similar to those in younger adults, although there is less clinical evidence supporting nonoperative management (NOM) and angiographic embolization (AE) of solid organ injuries. The focus of the emergency physician is on the early diagnosis of intra-abdominal injuries, vigilant hemodynamic monitoring, and early resuscitation. The physical examination is unreliable for detecting intra-abdominal injury in older adults. The FAST examination is part of the initial evaluation and can be repeated as part of ongoing hemodynamic monitoring. Elderly patients with abdominal tenderness, significant multisystem trauma, or hemodynamic instability often require CT scanning to establish or eliminate dangerous diagnoses.

Although advanced age was initially an exclusion from NOM of solid organ injuries, there is more than a decade of evidence showing that carefully selected older adults are candidates for NOM. In several case series, approximately 80% of elders with splenic injuries were successfully managed nonoperatively, with the caveat that grade III injuries were more likely to fail NOM and all geriatric patients with grade IV or V injuries required an operation.60,61 There are limited data on NOM of liver injuries in older adults. As AE has been used successfully in older adults,62 angiography is a reasonable option for the elderly trauma patient with solid organ injury and a blush or extravasation on CT.

Extremities

Fractures are the most common injuries in elders with trauma. Fractures that affect mobility and the ability to live independently, such as hip fractures, are associated with significant perioperative and 1-year mortality in older adults. The most common fractures in order of frequency sustained by older adults are distal radius fractures (Colles’ fractures), proximal humerus fractures, and elbow fractures, which usually occur during a fall onto an outstretched arm. Older adults with proximal humoral fractures can have remarkably few symptoms.

The most common lower extremity fractures in older adults are ankle fractures, hip and pelvic fractures, and tibial plateau fractures. Pelvic fractures can occur with relatively little force in elders and are less likely to be classified as severe; fracture patterns are similar between the elderly and younger adults, with lateral compression fractures more common than anteroposterior fractures. In older adults, both fracture types are associated with significant hemorrhage.63 Overall pelvic fracture mortality is 9 to 30%, and up to 81% in older patients with open pelvic fractures.63,64 Emergent treatment of pelvic fractures consists of hemodynamic monitoring, resuscitation with blood, stabilization of the fracture with wrapping or external fixation, and control of bleeding with consideration of AE to address retroperitoneal hemorrhage.

Hip fractures are common in older adults, occurring in approximately 1% of men and 2% of women per year. Whereas isolated hip fractures are not associated with significant immediate hemorrhage or mortality such as seen in pelvic fractures, they are associated with an 8 to 30% 1-year mortality.65 Hip fractures are usually seen on plain x-ray films (sensitivity approximately 90%) and CT scans, but occult fractures are a well-described phenomenon in older adults. Patients with inability to ambulate or persistent pain after trauma require further evaluation; MRI and bone scan are useful imaging studies to delineate the pathology.66 Elders with fractures may have better outcomes with distinct orthogeriatric services.67,68

End-of-Life Decisions

Emergency physicians are faced with difficult decisions regarding prognosis, the usefulness of aggressive care, and end-of-life decisions in geriatric trauma. Elderly trauma patients have a uniformly worse prognosis than younger adults. Several factors that portend a grave prognosis from the ED include a GCS of 3, a GCS below 8 with anticoagulation, and hemodynamic instability from internal hemorrhage with anticoagulation. Yet initial injury in the ED does not perfectly predict an individual patient’s long-term prognosis,69 and emergency physicians have not traditionally withheld aggressive trauma care, which usually includes the involvement of trauma surgeons. Emergency physicians should discuss end-of-life decisions, such as intubation, cardiopulmonary resuscitation (CPR), transfer, and surgery, with patients, family members, and surgical consultants. Although age alone is not an indication to withhold aggressive treatment, in select cases with a grave prognosis and when the patient’s goals of care are known, comfort measures may be more appropriate than transferring patients to a trauma center.

Key Concepts

image Older adults are prone to significant injuries with low-force trauma such as falls from standing. Vigilance for occult injuries, including TBI, cervical spine injuries, hip and pelvis fractures, and solid organ injuries, should be maintained.

image Vital signs, including tachycardia and hypotension, are unreliable to detect hemodynamic instability in older adults owing to changes in physiology, comorbidities, and medications. Clinicians should expand their assessment for shock by including alterations in mental status, urine output, and skin perfusion and should have a low threshold for considering shock in elderly trauma patients.

image Elders are at significant risk from shock, yet they are also at risk from overly aggressive resuscitation. Resuscitation should be rapid but should include frequent reassessments of vitals signs, respiratory status, and other potential indicators of shock. Invasive hemodynamic monitoring may be beneficial.

image Clinical decision rules for radiographic imaging have generally excluded elderly patients. A low threshold is advised for imaging in older adults with trauma.

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