Basics
Description
- 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 security
- Hypoperfusion 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 immobilization
- Anatomic 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 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
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:
- Radiographs
- Suspected 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
- 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
- Disability:
- Head Injury: Age is an independent risk factor for morbidity and mortality
- Age-related atrophy and mental decline may confound the evaluation of mental status
- Anticoagulated patients with blunt head injury at increased risk for intracranial bleeds and delayed bleeding.
- Strongly consider repeat imaging to detect delayed bleeds in anticoagulated patients
- When indicated, initiate treatment for intracranial hypertension, maintain spinal immobilization, and obtain definitive airway
- 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
- Common injury patterns:
- Head injury
- Less prone to epidural hematomas
- Higher incidence of subdural hematomas
- Cervical spine injuries
- Propensity 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 elderly
- Underlying cervical spine pathology, such as arthritis may predispose to spinal cord injuries
- With hyperextension injuries, increased risk of developing a central cord syndrome
- Vertebral injuries
- More susceptible to fractures, especially anterior wedge compression fractures
- Chest trauma
- Rib fracture is most common; in geriatric patients these is an increased risk of pneumonia and mortality with each additional rib fracture
- Hemopneumothrorax, pulmonary contusion, flail chest, and cardiac contusion can quickly lead to decompensation
- 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
- Anticoagulation-consider fresh frozen plasma, cryoprecipitate, and concentrated factor for significant bleeds depending on indications
- Beware 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)