Geriatric Trauma:Geriatric Trauma:Beyond “Beyond “I’ve Fallen & Can’t Get Up!”I’ve Fallen & Can’t Get Up!”

Amy Gutman MD ~ EMS Medical Directorprehospitalmd@gmail.com / www.TEAEMS.com

OverviewOverview

• Epidemiology

• Pathophysiology

• Mechanisms of Injury

• Assessment & Management Strategies

• Conclusions

“The more you complain, the longer God lets you live” Unknown

Geriatric PatientsGeriatric Patients

• EMT-B class = 150 hrs

• EMT-P class = 1200 hrs

• Geriatrics hours = 6

• 30-40% all EMS calls with a large percentage being ALS

• Anatomically, sociologically & physiologically a “special” population

“The secret of staying young is to live honestly, eat slowly, & lie about your age” ~ Lucille Ball

Defining “Geriatric”Defining “Geriatric”

• Person >65 yo• Chronologic age = actual age• Physiologic age = functional

capacity

• US life expectancy 2010• Male: 75.4 yrs• Female: 80.5 yrs

• 15% US population• >85yo fastest growing population

• By 2030, 25% population >65yo• Better living conditions, healthcare,

medications & technology

“You're only young once, but you can be immature forever” ~ John Greier

Geriatric Trauma EtiologyGeriatric Trauma Etiology

• 7th leading cause of death in the elderly

• 10-14% trauma patients >65yo • 25% trauma admissions• 28% accidental deaths

• Enormous resource & financial burden• $20 billion annually• 33% trauma dollars • Trauma costs 3x greater compared younger persons

• Injuries disproportionately severe• Mortality, morbidity, length of stay higher than younger

patients with similar injuries• For each year >65, 10% increased chance of a trauma-

related death

“If I were younger, I'd know more” ~James Barrie

High Injury RiskHigh Injury Risk

• Normal aging & deterioration

• Narrow physiologic tolerances

• Decreased reaction time

• Decreased eyesight & hearing

• Postural instability

• Fragile bones & vasculature

6Trauma in Elderly -“Old age is like everything else. To make a success of it, you've got to start young” ~Fred Astaire

Polypharmacy & TraumaPolypharmacy & Trauma

• 80% on meds likely contributing to injury

• Adverse events exponentially rise with number of drugs• 4% if 5 drugs• 10% if 6-10 drugs• 28% if 11-15 drugs• 54% if >16

• Common interactions• Anticoagulants & anti-platelets increase

bleeding time• Anti-hypertensives & vasodilators limit

vasoconstriction• Beta-blockers limit O2 demand response

“It is not the years in your life, but the life in your years that counts” ~Adlai Stevenson

Impact of Co-MorbiditiesImpact of Co-Morbidities

• Complication rate triples if one co-morbid illness

• Oreskovich’s study on geriatric trauma outcomes:• 100 geriatric trauma pts• 96% independent pre-injury• 88% did NOT return to

independence• 72% required NH placement

“I am not young enough to know everything” ~Oscar Wilde

Geriatric Trauma OutcomesGeriatric Trauma Outcomes

Adult Mortality % Geriatric Mortality %

Falls + TBI 6.00% 11.89%*

Falls + Chest Trauma 4.18% 5.43%

Falls + Chest- Abd Trauma 1.15% 2.47%

Falls + SCI 4.92% 20.13%

Auto vs Pedestrian 7.45% 16.63%*

MVC + Long Bone Fx 9.22% 15.63%*

Multisystem Trauma 6.3% 8.0%*p<0.001

“Grow old along with me! The best is yet to be” ~Robert Browning

Assessment StrategiesAssessment Strategies

• Speak slowly, directly & respectfully • Never “Sweetie”, “Honey”, “Pops”

• Eye level in middle of visual field • Utilize family / care-givers but do not

diminish patient’s contribution

• Ask specific questions as patient may not volunteer information

• Protect modesty & body temperature

• Transport:• Medications• Glasses / hearing aids / dentures• All important paperwork (i.e. MOLST)

“Like our shadows, our wishes lengthen as our sun declines” ~Edward Young

Assessment ~ SafetyAssessment ~ Safety

• If fall “mechanical”, consider pre-quels• Co-morbidities often causal• May not know / confabulate inciting event

• Safety assessment may assist with MOI• Living conditions?• Stairs?• Medications & compliance? • Ambulation assists?• Fall hazards?• Driving safety?

• Often reluctant to provide information• Loss of autonomy & independence• Separation from family• Hospitalization

“The old believe everything, the middle-aged suspect everything, the young know everything“ O. Wilde

• Primary Survey

• Key: Vitals often unreliable!

• A: Aggressive airway managementLow intubation threshold Modified spinal immobilization

• B: Supplemental O2 with chest / abdominal trauma

• C: “Normal” BP may indicate hypotension / shock

• Secondary Survey

• Keys: Exam often underestimates injuryPain response, hypoxia, hypovolemia variesPre-morbid illnesses complicate assessment

Assessment: Primary & Assessment: Primary & Secondary SurveysSecondary Surveys

"When you are older you will know that life is a long lesson in humility“ ~James Barrie

Mechanisms of InjuryMechanisms of Injury

MVC EpidemiologyMVC Epidemiology

• 26 million+ geriatric drivers

• Falls #1 morbidity but MVCs #1 trauma-related mortality• 2nd highest fatal crash rate • 21% overall fatality rate• 7x more likely to be hospitalized or

killed than younger patients

• In collisions, 80% geriatric drivers found to be at fault

“Just remember, once you're over the hill you begin to pick up speed” ~Charles Schultz

MVC MOIMVC MOI

• “Why did this driver crash?”• 20% syncope• 13% intoxicated

• Less likely ETOH / high speeds than younger drivers• Unrestrained (83%)• Daytime (81%)• 2 cars (75%)• Weekdays (72%)• Intersection / near home (50%)• Making left turn (20%)

“Youth is the time for adventures of the body, but age for the triumphs of the mind” ~Logan Smith

Auto vs PedestrianAuto vs Pedestrian

• Geriatrics > any other age group (even pediatrics)

• 46% at crosswalks• Average crosswalk gait 4ft/s• Average elderly gait 3 ft/s

• Typical MOI• Head down• Rushing even if unsteady• Often it near curb

• 25% mortality if >65 yo• TBI• Vascular injuries• Thoraco-abdominal, including

pelvic & rib fractures

“Old age comes at a bad time” ~Unknown

Homicide / SuicideHomicide / Suicide

• 2002: 852 geriatric homicides• Easy target• Home invasions• Elder abuse

• 70% GSWs self-inflicted• Depression• Chronic illnesses• Suicide-Homicide “pacts”

• 10% GSWs accidental

“Youth is the gift of nature, but age is a work of art” ~Garson Kanin

Elder AbuseElder Abuse

• Less recognized / reported than child or spousal abuse• 5,000 - 250,000+ cases annually• 32:1000 elderly

• Risk factors for victim• Female > age 80• Dementia• Dependence on abuser

• Risk factors for abuser• Spouse of children of the abused• Financial dependence on victim • Substance abuse • Prior history of violence

“Old age isn’t so bad when you consider the alternative” ~Maurice Chevalier

Elder Abuse AssessmentElder Abuse Assessment

• Multiple bruises in various states of healing

• Unexplained or untreated injuries w/ inconsistent stories

• Dehydration / malnutrition

• Bedsores

• Mandatory & confidential reporting to adult protective services / police

“Beautiful young people are accidents of nature, but beautiful old people are works of art” E. Roosevelt

FallsFalls

• M=F; females more likely injured

• Always ask about the “pre-quel”• Postural instability• Impaired vision & hearing• Decreased reaction time• Medications • Inciting medical event

• High injury risk with fall from standing height• TBI• Rib / Hip fractures • “Special Consideration” in Trauma

Triage as high risk of cervical injuries with falls from standing height

“It is always in season for old men to learn” ~Aesculepius

FallsFalls

• 40% geriatric trauma

• 35% >65yo, 50% >80yo fall annually

• In 2005 falls led to:• 160,000 deaths• 1.8 million ED visits• 433,000 hospitalizations

• MCC of trauma morbidity• 25% sustain “serious injury” • 50% pts discharged to rehab / NHs• 20% fatal falls occur while in NHs

• Fall injuries cost $53 million / year

“You don't stop laughing because you grow old. You grow old because you stop laughing” ~M Pritchard

Cardiovascular PathophysiologyCardiovascular Pathophysiology

• Decreased cardiac reserves• Limited increases in SV & CO• Decreased catecholamine response• Decreased valve efficiency

• Hypovolemia = hypoperfusion• Lactic acidosis & shock without classic

signs of shock

• Decreased arterial compliance with increased arteriosclerosis • Baseline HTN, PVD

• Conduction system degenerates• Arrhythmias

“As the arteries grow hard, the heart grows soft” ~HL Mencken

Cardiovascular PathophysiologyCardiovascular Pathophysiology

• “Pre-quel” cardiac events

• Limited ability to increase SV, HR & CO to combat hypovolemia

• Increased O2 demand from cardiac stress not tolerated well • Ischemia• Worsening CO • Cardiovascular collapse

• “Normal” BP if on antihypertensives = shock

“To me, old age is always fifteen years older than I am” ~Bernard Baruch

Neurological PathophysiologyNeurological Pathophysiology

• Altered mentation increases with age due to atrophy, co-morbidities

• Alterations impede assessments• Dementia / memory impairments• Vision, hearing, speech• Don’t mistake “deaf” with “dumb!

• Difficult determining “normal” if no family, friends or caretakers

“How old would you be if you didn't know what old was?” ~Satchel Paige

Neurology: Subdural HematomaNeurology: Subdural Hematoma

• SDH most common TBI• Often minor or “forgotten” trauma• Bridging veins tear causing blood to

accumulate between dural & arachnoid spaces

• Atrophy leaves large space for blood accumulation, delaying symptom onset

• Mortality• Adult 4-8%; geriatric 15-30%• Mortality 90% if anticoagulated + GCS<8• Dementia increases mortality risk

“There are 3 signs of old age. The 1st is your loss of memory & the other 2….” Unknown

C-Spine InjuriesC-Spine Injuries

• Fall from standing height, minor trauma• May involve >1 level• Often unstable & associated with TBI• 25% mortality

• No prehospital “clearance” • >65 yo “high risk” (Canadian C Spine & NEXUS

criteria)• Low risk mechanisms = 24% fx rate• Decreased pain sensation

• Central cord syndrome• Stenosis, spondylosis + hyperextension• UE >LE symptoms

• Osteoporosis & Osteoarthritis• Narrow spinal canal can cause cord injury s/o

fracture

“I have everything I had 20 years ago, only it’s all a little bit lower” ~Gypsy Rose Lee

Pulmonary PathophysiologyPulmonary Pathophysiology

• Decreased chest wall strength & compliance• Kyphosis / Lordosis• Weak musculature

• Decreased pulmonary circulation with underlying lung disease

• Increased inhalation time, residual capacity & tidal volume

• Decreased alveolar surface area, number of alveoli & O2 exchange

• Rapid progression to respiratory failure with minimal hypoxia

“You can live to 100 if you give up all the things that make you want to live to 100” ~Woody Allen

Chest Trauma / Rib FracturesChest Trauma / Rib Fractures

• Common with minor trauma

• Any rib fracture doubles morbidity & mortality• Co-existing injuries• Prolonged ICU stay• 31% pneumonia rate

• Bergeron’s study on geriatric trauma pts with rib fractures • Mean hospital stay 27 days• 30% mechanically ventilated• 5 X mortality rate than younger pts

“Old Age: First you forget names, then you forget faces, then you forget to pull your zipper up, then you forget to pull your zipper down” Leo Rosenberg

Thoraco-Abdominal TraumaThoraco-Abdominal Trauma

• Minimal trauma required to produce injury (ie. seat-belts)

• Exam often unreliable, vitals misleading

• 4-5x higher morbidity than younger patients with same injuries

• Pelvic fractures• 30% mortality within 1st 72 hrs• Often lateral compression injuries

w/ arterial hemorrhage

“Life is what we make it; always has been, always will be” Grandma Moses

Renal PathophysiologyRenal Pathophysiology

• By age 65 lose 40% glomeruli• Diminished renal blood flow • Less effective toxin filtration

• Chronic dehydration from decreased total body water

• Hypotension leads to renal failure

• Micturition syncope common

“Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter” Jack Benny

Endocrine PathophysiologyEndocrine Pathophysiology

• Caloric requirements decrease with age, but “nutrient” demands remain constant

• Glucose intolerance & diabetes increase• Hyperglycemia associated with

worse outcome in medical / trauma patients

• High risk of infection / sepsis• Malnutrition• Sepsis with “mild” infection

(decreased immune response)• Often afebrile or hypothermic• Minimal reserves to fight infection

“Old age is no place for sissies” ~Bette Davis

HypothermiaHypothermia

• 75% of injured geriatrics• Hemorrhage leads to hypotension

then hypothermia

• Impaired thermoregulation

• Decreased sub-q tissue

• Severe complications• Arrhythmias• Coagulopathies• Increased mortality

“As one grows older, one becomes wiser and more foolish” ~François Duc

Integument PathophysiologyIntegument Pathophysiology

• Thin skin, decreased collagen & sub-q fat• Easily tears & bruises• 20 mins on a backboard begins

pressure ulceration

• Decreased immune response & capacity for wound healing • Decreased collagen• Less microorganism protection• Abnormal clotting

• Tetanus often out-of-date

“Middle age is when your age starts to show around your middle” ~Bob Hope

Burn PathophysiologyBurn Pathophysiology

• 4% geriatric trauma-related deaths

• 13% of all burn unit admissions

• 50% in-hospital mortality

• “Burn mortality” is burn percentage causing 50% mortality• Adults = 50% if 80% TBSA burned• 60-70yo = 50% if 35% TBSA burned• >70yo = 50% if 20% TBSA burned

“The only source of knowledge is experience” ~Albert Einstein

Musculoskeletal Musculoskeletal PathophysiologyPathophysiology

• Postural changes• Kyphosis • Spinal stenosis• Decreased spinal flexibility• Increased knee & hip flexion• Decreased muscle strength

• High risk of compression fractures with minor trauma• Osteoporosis & arthritis• Decreased bone density• Decreased fatty tissue

35Trauma in Elderly -“Inside every older person is a younger person wondering what the hell happened” ~Jennifer Yane

““Hip” FracturesHip” Fractures

• Often proximal femur / femoral neck fractures

• Suspect all previously ambulatory patient who can no longer walk due to pain

• Associated with abdominal / pelvic injury

• High mortality:• 14% at 30 days • 35% at 1 year • 40% require rehab / NH placement

“I intend to live forever, or die trying” ~Groucho Marx

Management StrategiesManagement Strategies

• Key: Prevention of early & late complications

• Appropriate fluid resuscitation• Avoid low-flow states

• Serial cardiopulmonary exams• Lung sounds • Cardiac monitoring• Pulse oximetry• Capnography

• Multiple studies demonstrate under-triage of geriatric patients to trauma centers

“Aging is not lost youth but a new stage of opportunity and strength” Betty Friedan

Geriatric Trauma TriageGeriatric Trauma Triage

• Consider trauma center 1st line destination• If >80 yo, trauma center mortality 8%

vs 56% in non-trauma centers

• Recognize high risk injury patterns• Falls + AMS• Falls + inability to ambulate• Thoraco-abdominal• Pelvic or femur • Trauma + SBP <100 mmHg

“Old age is the most unexpected of all the things that happen to a man” ~Trotsky

Airway ManagementAirway Management

• Early & aggressive• Limited cardio-pulmonary reserves

• Limited ability to open mouth & move neck

• Kyphosis & arthritis

• Sedation can induce apnea

• CPAP is great adjunct, but patients at higher risk for barotrauma / pneumothorax

“You're getting old when all the names in your black book have MD after them” ~Arnold Palmer

Ohio Geriatric Trauma Triage Ohio Geriatric Trauma Triage (National Standard of Care)(National Standard of Care)

• >70yo triaged to trauma center for:• GCS <15 + TBI• Falls + evidence of TBI (even

from standing position)• SBP <100 mmHg• Pedestrian struck• Multisystem trauma• Suspected proximal long

bone fracture post-MVC

• Consider Trauma Center Triage if: • COPD• CAD / CVD• Clotting disorder • Warfarin therapy• Diabetes • Dialysis• Immunocompromised• Liver Disease

“I was taught to respect my elders; I’ve now reached the age when I don't have anybody to respect” ~ George Burns

ReferencesReferences

• Ohio State Board of EMS Trauma Committee; 2008• Brady Textbook of ITLS; 2004• Bourn. “The “2 P’s” of Geriatric Trauma”. 2008• Holland. “Geriatric Falls & Trauma”; 2009• Fowler. OSU Department of EM• CDC MMRW “Life Expectancy”; 2010• Antonenko. UND Department of Surgery; 2005• Bulger. Harborview Medical Center; 2004• NHTSA “Walking Through the Years”; 2008• AARP “Older Adult Pedestrian Safety”; 2009• Richmond. Louisville FD; 2007• Barishansky. “Understanding Our Geriatric Pts”;

2009• Rosen. “Geriatric Trauma”. EM 6th Ed; 2008• Aschkenasy. “Trauma & Falls in the Elderly”. EM

Clinics of North America; 2006• www.emsresponder.com. “Geriatric Trauma”. 2008• EAST. “Practice Management Guidelines for Geriatric

Trauma”. 2009• Blanda. “Geriatric Trauma: Current Problems, Future

Directions”; Summa Health Systems; 2007 • Victorino. “Trauma in the Elderly Pt”. Arch Surg;

2003• Perdue. “Geriatric Trauma”. J.Trauma; 1998• Touger. “Geriatric Trauma”. An EM; 2002• McKinley. “Geriatric Trauma”; Arch Surg; 2000• Steill. “Canadian C-Spine Rule vs NEXUS Low-Risk

Criteria in Patients with Trauma”. NEJM; 2003“When men reach their sixties and retire they go to pieces. Women just go right on cooking” Gail Sheehy

SUMMARYSUMMARYprehospitalmd@gmail.com / www.TEAEMS.com

• Injury “pre-quels” & MOI

• Vitals & physical exam may underestimate injury

• Increased complications, mortality & length of stay compared to younger pts

• Tremendous financial burden, often with poor outcomes

• Consider “over-&-early” triage to a trauma center

“Age and treachery will triumph over youth and skill” Anonymous