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Geriatric Trauma, Emergency Medicine

Basics

Description

- Breathing-maintain adequate and effective breathing and ventilation - Weakened respiratory muscles and degenerative changes in chest wall result in diminished effective ventilation - Blunted response to hypoxia, hypercarbia, and acidosis delays onset of clinical distress - Lower threshold to intubate elderly patients

- Circulation-ensure adequate perfusion - Vigilant hemodynamic monitoring, heart rate, and BP do not always correlate well with cardiac output - Geriatric patients often have impaired chronotropic response to hypovolemia - Cardiovascular response may be blunted by rate controlling meds (β-blockers, Calcium channel blockers) - Baseline hypertension, common in elderly, may obscure relative hypotension - Bleeding made worse by antiplatelet and anticoagulation medicines

- Disability-rapid neurologic evaluation to assess for intracranial and spinal cord injury - Brain atrophy may delay onset of clinical symptoms from compressive effects - Grave error to assume alterations in mental status due solely to underlying dementia or senility

- Exposure-patient should be undressed completely - Secondary survey - After the primary survey has been completed - Stabilization at each level - Complete physical exam from head to toe

- Airway-take into account anatomical variations when establishing an airway - Breathing - Continuous pulse oximetry and capnometry helpful - Administer supplemental oxygen to maintain oxygen saturation >95% - Serial ABGs may provide early insight to respiratory function and reserve - Timely intubation in patients with ventilatory compromise and more severe injuries - Intubation indications: Respiratory rate >40 breaths/min, PaO2 is <60 mm Hg or PaCO2 >50 mm Hg - Adequate analgesia of chest wall pain is essential for optimizing ventilation

- Circulation-severity of hemodynamic instability often underappreciated by clinicians - Serial crystalloid fluid boluses of 250-500 mL - Early invasive monitoring has been advocated, better assess need for volume loading and inotropic support - Geriatric patients can decompensate from overly aggressive volume replacement - Strong consideration for early and liberal use of red blood cell transfusion - Target hemoglobin level is controversial, but many authors recommend 10 g/dL - Recognize the harmful effects and complications of red blood cell transfusions - Blood viscosity, infection, and impairment of immune response - Serial base deficit and lactate levels provide good initial measures of shock and can guide resuscitation decisions - Creatinine clearance reduced in elderly - Kidneys more susceptible to injury from hypovolemia, medications, and nephrotoxins

- Exposure: Completely undress patient, but prevent hypothermia - Age-related changes and medications make elderly more susceptible to hypothermia - Hypothermia not attributable to shock or exposure should raise concern for sepsis, endocrinopathy, or drug ingestion

- Abdominal trauma - Similar pattern of injury as younger adults - Paramount to recognize signs of hemodynamic stability early - Nonoperative treatment of hemodynamically stable blunt hepatic and splenic injuries has emerged as the trend - Should have high index of suspicion for internal injuries with associated pelvic and lower rib cage injuries

- Orthopedic injuries-more predisposed due to osteopenia and osteoporotic changes - Uniquely susceptible to pelvic and hip fractures - Goal of orthopedic injuries is to undertake the least invasive, most definitive procedure that will permit early return to function

  • Geriatric specific considerations and approach to the elderly trauma patient
  • Should be used in conjunction with the accepted standard treatment of traumatic injuries (see trauma, multiple)
  • Advanced age is a known risk factor for adverse outcomes following trauma
  • Generally age >65, age not well defined, difficult to target due to discrepancies between physiologic and chronologic age in individuals

Epidemiology

Incidence and Prevalence Estimates

Etiology

Most common mechanisms:

  • Falls-most common cause of injury in patients of age >65, often occurs on an even, flat surface
  • Motor vehicle crashes-2nd leading cause, most common fatal etiology
  • Pedestrian-motor vehicle collisions, diminished cognitive skills, poor vision/hearing, impaired gait contribute to increased incidence
  • Burns-higher fatality rate than young adults with same extent of burn
  • Violence-less common mechanism than in younger ages, have heightened suspicion for elderly abuse, an under recognized issue
  • Elderly more susceptible to serious injury from low-energy mechanisms

Diagnosis

  • Triage to major trauma center is determined by local protocols
  • Injured patients with potential need for surgical, neurosurgical, or orthopedic intervention should be transferred to major trauma center
  • Threshold for scene triage or transfer to trauma center should be lower for elderly

Signs and Symptoms

  • The same pattern of assessment using primary survey (ABCDE) and secondary survey should be used with geriatric patients as with younger patients (see trauma, multiple)
  • Normal vital signs can lead to false sense of securityHypoperfusion often masked by inadequate physiologic response, underlying medical pathology, and medication effects

Primary survey (ABCDE)

  • Airway, cervical spine-establish and maintain a patent airway with C-spine immobilizationAnatomic variation in elderly can lead to more difficult airways (dentures, cervical arthritis, TMJ arthritis)Failure to recognize indications for early intubation is a common mistake
  • Breathing-maintain adequate and effective breathing and ventilationWeakened respiratory muscles and degenerative changes in chest wall result in diminished effective ventilationBlunted response to hypoxia, hypercarbia, and acidosis delays onset of clinical distressLower threshold to intubate elderly patients
  • Circulation-ensure adequate perfusionVigilant hemodynamic monitoring, heart rate, and BP do not always correlate well with cardiac outputGeriatric patients often have impaired chronotropic response to hypovolemiaCardiovascular response may be blunted by rate controlling meds (β-blockers, Calcium channel blockers)Baseline hypertension, common in elderly, may obscure relative hypotensionBleeding made worse by antiplatelet and anticoagulation medicines
  • Disability-rapid neurologic evaluation to assess for intracranial and spinal cord injuryBrain atrophy may delay onset of clinical symptoms from compressive effectsGrave error to assume alterations in mental status due solely to underlying dementia or senility
  • Exposure-patient should be undressed completely
  • Secondary surveyAfter the primary survey has been completedStabilization at each levelComplete physical exam from head to toe

History

  • The geriatric trauma patient should be viewed as both a trauma and a medical patient
  • Elderly patients can have significant comorbidities, past medical history, medications, and allergies are essential
  • Comorbid medical conditions may have precipitated the traumatic event
  • Consider hypoglycemia, syncope, cardiac dysrhythmia, CVA, UTI, etc.
  • Details of the mechanism, initial presentation, and treatment rendered should be elicited from EMS personnel
  • Concurrent medical conditions impede compensation, confound interpretation of severity and response, and complicate resuscitation.

Physical Exam

Should follow primary and secondary surveys

Diagnosis Tests & Interpretation

  • Primary and secondary survey
  • Cervical spine and chest imaging are mandatory for victims of major traumas
  • Pelvic radiographs should be performed with clinical suspicion of pelvic trauma or with hemodynamic instability
  • CBC, ABG, blood type
  • Electrolytes, renal function, serum glucose
  • Urine dip for blood, UA if dip shows positive result
  • Coagulation profile
  • Base deficit, lactate
  • Ethanol screen

Imaging

  • Liberal use of head CT is recommended for elderly with closed head trauma
  • Nexus criteria has been validated in ages >65; however, cervical spine imaging needed in majority of geriatric traumas. CT scan emerging as study of choice for high suspicion, high-risk mechanism or age related changes likely to limit plain films
  • Significant blunt and penetrating chest trauma requires objective evaluations of the heart and great vessels with echocardiography, CT scan, angiography, or direct visualization.
  • Blunt abdominal trauma requires objective evaluation, modality depends on patients condition
  • Hemodynamically stable patients should have an abdominal CT with IV contrast
  • Ensure adequate hydration and assess baseline renal function prior to contrast load when clinical status permits.
  • Unstable patients should have FAST exam or diagnostic peritoneal lavage
  • CT with contrast is a valuable diagnostic tool for abdominal trauma, but predispose to risk of contrast related renal impairment
  • Extremity injury:RadiographsSuspected vascular damage requires angiography or duplex ultrasound

Treatment

Pre-Hospital

  • Emphasis should be placed on airway maintenance, control of external bleeding and shock, immobilization, and immediate transfer to appropriate facility

Initial Stabilization/Therapy

  • Airway-take into account anatomical variations when establishing an airway
  • BreathingContinuous pulse oximetry and capnometry helpfulAdminister supplemental oxygen to maintain oxygen saturation >95%Serial ABGs may provide early insight to respiratory function and reserveTimely intubation in patients with ventilatory compromise and more severe injuriesIntubation indications: Respiratory rate >40 breaths/min, PaO2 is <60 mm Hg or PaCO2 >50 mm HgAdequate analgesia of chest wall pain is essential for optimizing ventilation
  • Circulation-severity of hemodynamic instability often underappreciated by cliniciansSerial crystalloid fluid boluses of 250-500 mLEarly invasive monitoring has been advocated, better assess need for volume loading and inotropic supportGeriatric patients can decompensate from overly aggressive volume replacementStrong consideration for early and liberal use of red blood cell transfusionTarget hemoglobin level is controversial, but many authors recommend 10 g/dLRecognize the harmful effects and complications of red blood cell transfusionsBlood viscosity, infection, and impairment of immune responseSerial base deficit and lactate levels provide good initial measures of shock and can guide resuscitation decisionsCreatinine clearance reduced in elderlyKidneys more susceptible to injury from hypovolemia, medications, and nephrotoxins
  • Disability:Head Injury: Age is an independent risk factor for morbidity and mortalityAge-related atrophy and mental decline may confound the evaluation of mental statusAnticoagulated patients with blunt head injury at increased risk for intracranial bleeds and delayed bleeding.Strongly consider repeat imaging to detect delayed bleeds in anticoagulated patientsWhen indicated, initiate treatment for intracranial hypertension, maintain spinal immobilization, and obtain definitive airway
  • Exposure: Completely undress patient, but prevent hypothermiaAge-related changes and medications make elderly more susceptible to hypothermiaHypothermia not attributable to shock or exposure should raise concern for sepsis, endocrinopathy, or drug ingestion
  • Common injury patterns:
  • Head injuryLess prone to epidural hematomasHigher incidence of subdural hematomas
  • Cervical spine injuriesPropensity to sustain cervical spine injuries from seemingly minor trauma (fall from standing or seated height)C1-C2 and odontoid fractures are particularly more common among elderlyUnderlying cervical spine pathology, such as arthritis may predispose to spinal cord injuriesWith hyperextension injuries, increased risk of developing a central cord syndrome
  • Vertebral injuriesMore susceptible to fractures, especially anterior wedge compression fractures
  • Chest traumaRib fracture is most common; in geriatric patients these is an increased risk of pneumonia and mortality with each additional rib fractureHemopneumothrorax, pulmonary contusion, flail chest, and cardiac contusion can quickly lead to decompensation
  • Abdominal traumaSimilar pattern of injury as younger adultsParamount to recognize signs of hemodynamic stability earlyNonoperative treatment of hemodynamically stable blunt hepatic and splenic injuries has emerged as the trendShould have high index of suspicion for internal injuries with associated pelvic and lower rib cage injuries
  • Orthopedic injuries-more predisposed due to osteopenia and osteoporotic changesUniquely susceptible to pelvic and hip fracturesGoal of orthopedic injuries is to undertake the least invasive, most definitive procedure that will permit early return to function
  • Anticoagulation-consider fresh frozen plasma, cryoprecipitate, and concentrated factor for significant bleeds depending on indicationsBeware of fluid overload and thrombotic complications

Ed Treatment/Procedures

  • Early monitoring of pulmonary and cardiovascular systems must be instituted
  • Prompt stabilization, early recognition of the need for operative intervention, and appropriate and expedient surgical consultation are paramount
  • Definitive treatment is often surgical
  • Elderly patients benefit from preferential transfer to trauma centers and aggressive, yet thoughtful care
  • No reliable age-based criteria upon which to base decisions to triage away from care
  • Good outcomes can be achieved with appropriately aggressive trauma care
  • Equally important to limit intensive treatment to injuries which are survivable and allow potentially acceptable quality of life
  • Seek existence of advance directives, living will, or similar legal document

Follow-Up

Disposition

Admission Criteria

  • Most major trauma patients should be admitted for observation, monitoring, and further evaluation
  • Lower threshold for admitting geriatric patients to ward, monitored settings, or ICU
  • Elderly patients with polytrauma, significant chest wall injuries, abnormal vital signs, evidence of hypoperfusion should be admitted to the ICU

Discharge Criteria

Patients with minor trauma and negative workup/imaging may be observed in the ED for several hours and then discharged

Issues for Referral

Follow-up should be determined by the types of injuries sustained and specialty care required.

Followup Recommendations

Follow-up and referral should be determined by the types of injuries sustained and specialty care required

Pearls and Pitfalls

  • Minor mechanisms of injury can produce serious injury and complication because of the effect of limited physiologic reserve, medication effects, and unrecognized hypoperfusion
  • Frequent use of medications, especially β-blockers and anticoagulants complicate assessment and management
  • Mistaken impression that "normal" BP and heart rate imply normovolemia.
  • Geriatric trauma patients must be treated as both trauma and medical patients.

Additional Reading

  • Legome E, Shockley LW, eds. Trauma: A Comprehensive Emergency Medicine Approach. Cambridge, UK: Cambridge University Press; 2011.
  • Heffernan DS, Thakkar RK, Monaghan SF, et al. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69:813-820.
  • Fallon WF Jr, Rader E, Zyzanski S, et al. Geriatric outcomes are improved by a geriatric trauma consultation service. J Trauma. 2006;61(5):1040-1046.
  • American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors. 8th ed. Chicago, IL: American College of Surgeons; 2008.

See Also (Topic, Algorithm, Electronic Media Element)

  • Specific anatomic injuries
  • Shock
  • Airway management
  • Multiple trauma

Codes

ICD9

  • V15.88 History of fall
  • 797 Senility without mention of psychosis
  • 995.81 Adult physical abuse

ICD10

  • R54 Age-related physical debility
  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • Z91.81 History of falling
  • R29.6 Repeated falls

SNOMED

  • 298344006 elderly fall (finding)
  • 237451000119100 Adult victim of physical abuse (finding)
  • 404904002 Frail elderly (finding)