Dara BakesRiverside Methodist Hospital

Trauma Services

.... the normal, predictable, and irreversible changes of various organ systems over the passage of time that ultimately lead to death.

Average American life span has increased by almost 30 years in the past century• 1900s = 47 years old• 2000s = 76 years old

By 2050, people over age 64 will make up over 20% of the US population (today it is 12%)

Increased Life Expectancy• Improved Health

Better nutrition Better technology

• Social Supports Heightened awareness Gray Panthers AARP

Life Expectancy• 1776 -- 35 Years• 1990 -- 72 Years

Male -- 68 years Female -- 75 years

• Today Still on the rise!

Aging – What is ‘Geriatric’?• No Set Age• “Normal” Biologic Process• 65 years old is a social &

statistical parameter• Geriatric trauma patients

defined as =>70 years of age• 75 years old is a geriatrician’s

view

Cardiovascular Renal Respiratory Nervous System Musculoskeletal

Less Effective Pump Minimal Reserve Medication Effects Ischemia/Hypoxia

Functional Changes• Loss of Surface Area• Diminished Renal Blood

Flow• Progressive Decline in

filtration function

Lungs• Decreased elasticity• Decreased alveolar number and

function• Decreased baseline p02

Musculoskeletal• Kyphosis• Decreased Chest Wall Strength• Increased Chest Wall Rigidity

Infectious Risks• Increased Bacterial Colonization• Decreased Force of Cough• Decreased Clearance Rate

•Auditory•Cognition acquisition of new data memory - short and long term

•Proprioception•Visual Acuity glare intolerance color perception visual fields

Structural Changes• 10% Reduction in Brain

Weight• Loss/Degeneration of

Neurons• Cerebral Atrophy• Cerebrovascular

Changes Confounding Factors

• Brain/Skull Relationship• Cervical Spine• Altered “Baseline”

Mental Status

Structural Changes• Decreased Mass• Degeneration of

Remaining Muscle• Degeneration of

Joint Cartilage• Osteoporosis

Functional Changes• Strength• Range of Motion• Mobility• Pain• Fracture-Prone• Gait

Age Related Impairments: A Simulation Exercise

Hospitalizations of older adults for trauma-related injuries occur at twice the rate of the general population

The mortality rate of older trauma victims has been estimated at 6 times that of younger victims when statistically controlling for severity of injury

Older adults account for 33% of all healthcare resources spent on trauma and for 25% of injury fatalities

Trauma -- 5th Leading Cause of Death• Elderly account for 12% of overall traumas• But… make up 28% of ALL trauma deaths

Physiologic changes impact morbidity & mortality

2002:• 22% of our Trauma Patients > 65 years

2006:• 26% of our Trauma Patients > 65 years

2008:• 28% of our Trauma Patients > 65 years

% hasn’t changed that much… but the mechanism of injury has!

2002: 50% of all geriatric traumas were Falls

2002: 40% of all geriatric traumas were MVA

2006: 67% of all geriatric traumas were Falls

2006: 23% of all geriatric traumas were MVA

* RMH Trauma Registry

Unintentional injuries include such things as motor vehicle crashes, falls and burns.

Intentional Injuries include suicide, abuse and neglect

In just one year in Ohio, the number of deaths caused by unintentional injuries alone exceeds that of one large jet crash per month, each causing 350 fatalities.

Poor visual acuity Poor visual attention Overload of information Impaired reaction times Limited neck rotations Slower gait Medication side effects Alcohol consumption

Psychotropic Medications• Antidepressants• Sedatives

Antihypertensives• Beta-Blockers• Calcium Channel Blockers• Diuretics

Anticoagulants & Antiplatelets• Coumadin, Aspirin• Plavix

• Most Common Injury > 75 Years• Injuries to head, pelvis & lower extremities

are most common Neurosensory Changes

• altered vision, hearing & memory cause impaired obstacle avoidance

Postural Instability• prone to loss of balance

increased postural sway slowed central processing

Physiologic

DisabilitiesEnvironmental

Hazards

Behavioral

Alterations

Environmental Factors• poor lighting• new furniture• non-secured rugs• loose railings• stairs

Syncope• cerebral hypo perfusion• seizure• dysrhythmia• hypoglycemia

Orthostatic Hypotension• dehydration• medications

Gait Changes• propensity to trip or

stumble• feet not picked up as high• men

wide-based

• women narrow-based

Psychosocial Issues for Geriatric Falls

•Can the pt. function at the same level as before the fall?

•Can pt. ambulate, take care of their personal needs and manage at home?

•Will the fear of a repeat fall inhibit social and functional status?

•What additional resources may the pt. need? Primary MD Social Services Home Health

One out of every three persons over 65 years old will fall in any given year. These falls result in fractures, admissions to the hospital, loss of the ability to live alone and death.

Women are more likely then men to sustain injuries from falls because they have less muscle mass and a greater likelihood of having osteoporosis.

One half of all elderly who sustain a fall find themselves unable to return home independently

Many older adults reduce their activity after a fall and report a fear of falling again

2nd Leading cause of injury in trauma patients > 75 Years

• Nationwide and at RMH

Crashes are more likely in older versus younger drivers under normal driving conditions. The highest death rate for victims of motor vehicle crashes occurs in the lower age range of elderly (55-64 years old) followed closely by those over 74.

The most common kind of crash older drivers have is when turning left into oncoming traffic.

Close to Home Daylight Hours Good Weather Causes

• Error in Perception Pathophysiology of aging and

presence of acute and chronic medical conditions

• Altered Reaction Time

Intersection vs. Non-Intersection

Crosswalk vs. Roadway Causes

• Slow Pace• Gait/Balance• Visual & Auditory Changes • Strength/Coordination• Neurosensory Impairment• Judgment/Cognition

Fatal Injuries Include:• Severe head injury • Major vascular damage

Elderly victims sustain twice as many lower extremity injuries as younger victims of the same trauma!

Mortality is > 25%

People over 65 years old suffer 25% of all deaths that occur as a result of fire. Those over 70 years old suffer one-third of the deaths that occur after admission to burn centers

13% of All Burn Injuries• Total body surface area burned• Mortality • Hospital length of stay

Elderly Population Has the Highest Fatality Rate in Burn Victims

Treatment is the same for all victims

Scalding Most Common• Tap/Bath Water

Contact Burns• Flame• Clothing

Inciting Factors• Decreased Mobility

prolonged direct contact prolonged exposure

• Decreased Sensitivity prolonged direct contact

Older adults are more likely to be victims of abuse or maltreatment if they are dependant or demented.

Elderly persons over 65 account for more than 18% of all suicides.

Pre-disposing Factors• Easy victim

Judgement Neurosensory changes Mobility Strength

• Patterned living Income Creatures of habit Dependency Isolation

Assessment • Bruises• Fractures• Untreated Injuries• Dehydration• Malnutrition• Bedsores

Special Considerations for EMS Assessments of Older Adults

2006 

2007 

Injuries 172,196

  Injuries 173,938

General Illness 126,194

  General Illness 121,170

Cardiovascular/Circulatory

93,421   Cardiovascular/Circulatory

90,110

Respiratory 67,618   Respiratory 66,550

Musculoskeletal Injury 64,362   Musculoskeletal Injury 62,189

 

     

   

     

     

A complete interview and careful inspection of the head is essential. Also, review medications for anticoagulants and ask about the use of aspirin, vitamin E, gingko biloba or other substances that may contribute to intracranial bleeding.

Determine the Chief Complaint• Even if the patient is confused or agitated,

try to find out from him or her what is wrong. Family or neighbors may be a valuable resource if present. Determine recent behavior, eating patterns and any recent problems that are contributing factors

Determine whether there is fear of death• If so, it may help establish the intensity of

symptoms and direct attention to Acute Myocardial Infarction (AMI), pulmonary embolism or another serious problem.

Medications• Determine any new or recently discontinued

medications. Also be aware of the problem of polypharmacy with this population.

Determine baseline functional status• Baseline status can be very different from

normal but not reflect an acute change (e.g. signs of unilateral changes from an old stroke that are confused with current presenting signs and symptoms).

Simplify• Remember during the interview that older

adults need more time to respond to questions. Ask questions one at a time in simple sentences.

Personalize• Use touch, tone of voice and eye contact to

maintain attention and focus. Make allowances for likely problems with vision and hearing.

Show, not tell• Have the patient show you the site of pain

or discomfort. Ask the individual to take your hand and place it over any painful area.

Decompensation may occur rapidly and without warning• Reduce field stabilization time and perform

serial vital signs and monitoring throughout transport.

Arthritic changes increase potential complications• Protect the cervical spine

Aging tends to increase upper airway secretions - microaspiration is common.• Assist with airway secretions

Changes of aging increase the risk of compromised oxygenation• Monitor airway and ventilatory effort.

Oxygenate early and liberally in the absence of COPD.

The elderly may have “dead space” within the cranium due to loss of brain mass.• Elevate head 15 to 30 degrees.

Normal PO2 may be compromised due to normal aging.• Maintain O2 saturation >90%.

Aging changes and comorbid conditions increase risk of procedures.• Watch for complications.

Prehospital • Imperative to understand past medical

history and events leading to injury Elderly have shown to be under-triaged Comorbidities often are the inciting cause of

injury

Head and Cervical Spine• Drastically less force needed to fracture skull or

C-spine compared to younger patients who undergo

similar trauma Little or no apparent trauma can cause subdural

bleeding • Recommended to have liberal use of Head CTs

to rule out injuries Indications- multisystem injuries, +LOC, Neuro

deficit, dementia, any head trauma in face of oral anticoagulation

Cervical Spine Injuries• Just as in young trauma

Need rigid collar • Higher instance for Central Cord syndrome

Due to age related narrowing of cervical canal and vascular disease of spinal arteries Causes deficit of upper extremity strength and

sensation

Chest• Rib fractures are the most common injury• 3 point restraint belts have shown to cause

significant chest trauma• EKG remains the most sensitive method to

predict short-term cardiac complications

Abdomen/Pelvis• In face of multi-system injuries, abd exam is

unreliable Recommend liberal use of diagnostics

DPL, US, CT Pelvis

• Fractures are significant for high mortality

Extremity Trauma• Like all other fractures in elderly

Little impact necessary for fracture Overall isolated extremity injuries are tolerated

well by the elderly Liberal radiological diagnostics recommended

The physiologic, mental and psychologic effects of aging can influence how you provide trauma care. In the case of both intentional and unintentional injury, knowing the special needs of the geriatric trauma patient can help you avoid further injury and greatly increase the patient’s chance of survival.

Questions?

Dara BakesInjury Prevention Coordinator/

Performance Improvement Specialist614.566.3462

dbakes2@ohiohealth.com