Geriatric Trauma

Published on 08/04/2015 by admin

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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.912 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%.2325

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.

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