Geriatric TraumaGeriatric Trauma

Michele M. Fowler D.O.Michele M. Fowler D.O.

OSU Medical CenterOSU Medical Center

Emergency MedicineEmergency Medicine

BackgroundBackground

Elderly people account for 12-15% of Elderly people account for 12-15% of U.S. populationU.S. population

10-14% of all trauma victims are >6510-14% of all trauma victims are >65 33% of all trauma $ is spent on 33% of all trauma $ is spent on

elderly patientselderly patients Trauma care cost 3x as much for an Trauma care cost 3x as much for an

elderly person compared to a younger elderly person compared to a younger personperson

DefinitionsDefinitions

Elderly >65 yearsElderly >65 years Young old and Old oldYoung old and Old old Chronological age is actual # of Chronological age is actual # of

years livedyears lived Physiologic age is actual functional Physiologic age is actual functional

capacity of patient’s organ systemscapacity of patient’s organ systems

MechanismsMechanisms

FallsFalls Motor Vehicle Crashes (MVC)Motor Vehicle Crashes (MVC) Pedestrian vs. Motor VehiclePedestrian vs. Motor Vehicle BurnsBurns AssaultsAssaults

FallsFalls

Most common injury - 40% elderly Most common injury - 40% elderly traumatrauma

25% who fall sustain “serious injury” 25% who fall sustain “serious injury” Falls M=F but females are more likely Falls M=F but females are more likely

to be injuredto be injured Postural instability, vision and hearing, Postural instability, vision and hearing,

reaction time, medsreaction time, meds Syncope vs FallSyncope vs Fall Standing height fallsStanding height falls

MVCMVC

2 cars2 cars DaytimeDaytime IntersectionsIntersections Close to homeClose to home 22ndnd Highest fatal crash rate Highest fatal crash rate Time to stop drivingTime to stop driving

Auto-PedAuto-Ped

46% elderly trauma occurs at 46% elderly trauma occurs at crosswalkcrosswalk

Average crosswalk speed is 4ft/secAverage crosswalk speed is 4ft/sec Parking lotsParking lots

Pathophysiology of Pathophysiology of Geriatric TraumaGeriatric Trauma

Pre-existing diseases lead to more Pre-existing diseases lead to more severe injuriessevere injuries

Co-morbid diseases complicate Co-morbid diseases complicate recoveryrecovery

Medications alter “normal” function Medications alter “normal” function and vital signsand vital signs

Physiologic AgePhysiologic Age Less dramatic physiologic responseLess dramatic physiologic response Narrow limit of physiologic toleranceNarrow limit of physiologic tolerance

CardiovascularCardiovascular

Myocardial cells are replaced by Myocardial cells are replaced by fatty infiltration and amyloid fatty infiltration and amyloid deposits; heart becomes “stiff” deposits; heart becomes “stiff”

Decreased Beta receptor # and Decreased Beta receptor # and sensitivity to catecholamines sensitivity to catecholamines (decreases rate and contractile (decreases rate and contractile force)force)

Not able to increase cardiac output Not able to increase cardiac output at important timesat important times

CardiovascularCardiovascular

Atherosclerotic disease is prevalent in Atherosclerotic disease is prevalent in elderly and can lead to “secondary elderly and can lead to “secondary injury”injury”

Myocardial oxygen demand is increased Myocardial oxygen demand is increased during trauma and stressduring trauma and stress

Loss of elasticity of arteries decreases Loss of elasticity of arteries decreases compliance and increases resistancecompliance and increases resistance

Cardiac medicationsCardiac medications PacemakersPacemakers

PulmonaryPulmonary

Chest wall and lungs not as compliantChest wall and lungs not as compliant Respiratory muscles are weakerRespiratory muscles are weaker Loss of alveolar surface area leads to Loss of alveolar surface area leads to

impaired gas exchangeimpaired gas exchange Spinal immobilization (collar and Spinal immobilization (collar and

supine)supine) Impaired coughImpaired cough Rib fractures double mortalityRib fractures double mortality

““There are three There are three signs of old age. signs of old age. The first is your The first is your

loss of memory and loss of memory and the other two I the other two I

forget.”forget.”

UnknownUnknown

Central Nervous SystemCentral Nervous System

Subdurals - Most commonSubdurals - Most common AtrophyAtrophy

Delayed accumulation of bloodDelayed accumulation of blood Warfarin Warfarin

Pre-existing dementia or strokes Pre-existing dementia or strokes makes evaluation and recovery makes evaluation and recovery difficultdifficult

RenalRenal

By age 65 lose 40% of glomeruliBy age 65 lose 40% of glomeruli Diminished renal blood flow Diminished renal blood flow Creatinine is misleading because of Creatinine is misleading because of

decreased muscle mass (CrCl is better)decreased muscle mass (CrCl is better) Chronic dehydration Chronic dehydration Hypotension leads to ATNHypotension leads to ATN Nephrotoxic agents (IV contrast and Nephrotoxic agents (IV contrast and

NSAIDS)NSAIDS)

Metabolic, Nutrition and Metabolic, Nutrition and ImmunityImmunity

Caloric requirements decrease with Caloric requirements decrease with age but nutrient demands remain age but nutrient demands remain constant constant

Elderly have less nutritional reserveElderly have less nutritional reserve Glucose intolerance and diabetesGlucose intolerance and diabetes Catabolic response is same as with Catabolic response is same as with

young people but catabolic protein young people but catabolic protein loss is more significant with elderly loss is more significant with elderly

Increased risks of infectionIncreased risks of infection

InjuriesInjuries

SubduralsSubdurals Hip fracturesHip fractures Wrist fracturesWrist fractures Compression fracturesCompression fractures Rib fracturesRib fractures Central cord syndromeCentral cord syndrome Scalp lacerationsScalp lacerations

SubduralsSubdurals

Tear in bridging veins because of Tear in bridging veins because of atrophyatrophy

Crescent shaped clot between the Crescent shaped clot between the dura and arachnoiddura and arachnoid

Judicious use of CT for fallsJudicious use of CT for falls WarfarinWarfarin Aggressive reversal of coagulopathyAggressive reversal of coagulopathy

Central Cord SyndromeCentral Cord Syndrome

Cervical stenosis and spondylosisCervical stenosis and spondylosis Hyperextension injuriesHyperextension injuries Central corticospinal and Central corticospinal and

spinothalamic tractsspinothalamic tracts Upper extremities more commonly Upper extremities more commonly

involvedinvolved Good prognosisGood prognosis

OutcomesOutcomes

MortalityMortality Young is 4-8%Young is 4-8% Elderly is 15-30%Elderly is 15-30%

Improve survival by early invasive Improve survival by early invasive monitoringmonitoring

Prevention most importantPrevention most important Withholding CareWithholding Care

OutcomesOutcomes

Occult hypotension and early Occult hypotension and early recognitionrecognition

High RiskHigh Risk TBITBI Multiple long bone fracturesMultiple long bone fractures Auto vs. PedestrianAuto vs. Pedestrian Initial systolic BP < 130Initial systolic BP < 130

PreventionPrevention

Safe environment (rugs, cords, Safe environment (rugs, cords, lighting, etc)lighting, etc)

Home modifications (tubs, rails, etc)Home modifications (tubs, rails, etc) Medications (benzos and narcotics)Medications (benzos and narcotics) Driving SafetyDriving Safety Not drivingNot driving Strength and balance therapyStrength and balance therapy

How to Help Seniors Drive How to Help Seniors Drive Safely Longer- 8 Functional Safely Longer- 8 Functional

Areas (AAA)Areas (AAA) Leg strength and Leg strength and

flexibilityflexibility Head and neck Head and neck

flexibilityflexibility High contrast High contrast

visual acuity visual acuity (signs/marks)(signs/marks)

Low visual acuityLow visual acuity

Working Memory Working Memory (directions and (directions and traffic rules)traffic rules)

Visualization of Visualization of missing info missing info (recognize hazards)(recognize hazards)

Visual search (find Visual search (find signs)signs)

Useful field of vision Useful field of vision (peripheral threats)(peripheral threats)

““An ounce of An ounce of prevention is worth prevention is worth a pound of cure.”a pound of cure.”

Benjamin FranklinBenjamin Franklin

SummarySummary

Poor prognosis for old people with Poor prognosis for old people with traumatic injuriestraumatic injuries

Significant injuries with minor Significant injuries with minor accidentsaccidents

Warfarin is bad in traumaWarfarin is bad in trauma Judicious use of CT scansJudicious use of CT scans Early invasive monitoringEarly invasive monitoring Prevention is the keyPrevention is the key

““Age is strictly a Age is strictly a case of mind over case of mind over

matter. If you matter. If you don’t mind then it don’t mind then it doesn’t matter.”doesn’t matter.”

Jack BennyJack Benny