Trauma & Falls in the Elderly Patient

Trauma & Falls in the Elderly Patient

Anthony J. DiPasquale, D.O.FACOEP

UMDNJ-SOM

Trauma & Falls in the Elderly Patient

This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the

New Jersey Institute for Successful Aging.This lecture series is supported by an educational

grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

Case #1

• Mr. W, 78 yo m, had a slip and fall while walking with his wife and landed on his low back.

• He presents to the ER with moderate to severe low back pain.

• X-Rays were taken.Photo: Microsoft Office Images #MP900401829 (http://office.microsoft.com/en-us/images/)

Mr. W’s X-Rays

Image Source: Kennedy Health Systems

Mr. W.’s Dispo PlanX-rays show an L3 compression fracture with greater than 50% loss of height. After implementing appropriate pain management, the next step is:A. Bone scan of spineB. Nasal Calcitonin C. WalkerD. CT of lumbar spineE. Physical Therapy Consult

Case: Mrs. M, a 79 yo woman…

• A 79-year-old woman presented to the emergency department after a ground-level fall on her left side. On emergency department presentation, she complained of left knee and hip pain, but could ambulate with moderate to significant assistance. Her left leg was neither shortened, nor externally rotated.

• Plain films were obtained:

Case:X-Rays negative, per Radiology. A walker was obtained for the patient and she was discharged to home with instructions to follow-up with her primary care practitioner if the pain did not improve over the next 5 to 7 days. She presented to her primary care physician 3 days later with worsening pain, now with the inability to weight-bear. She was sent back to the Emergency Department. Repeat plain radiographs were unchanged, per Radiology.

Case: What is required at this point?

A. Refer to Physical TherapyB. Increased pain medicationsC. MRI scan of the hipD. Orthopedics consultE. X-ray of the knee joint

Case:

Mrs. L. is an 78 year old woman who was standing on a step ladder to change a light bulb. She suddenly lost her balance and fell forward, landing directly on her face. On physical exam, she reports facial pain, headache, neck pain and is found is have a quadriparesis with significantly greater upper extremity weakness and sensory loss than lower extremities.

After immediate immobilization of the patient’s cervical spine, the next step is:

A. CT of headB. CT of facial bonesC. Transfer to trauma centerD. MRI of C-SpineE. CT of C-Spine

Summary of Topics to be Discussed

• Introduction / Scope• Physiology of the Geriatric Trauma

Patient• Major Sources of Geriatric Trauma• Triage Protocols for Geriatric

Trauma• Management of Geriatric Trauma• Review• Conclusions

Introduction

• Rapid Increase in the Elderly Population- Will continue to not only expand, but

multiply• Geriatric patients are OVER represented

in Trauma care.– Trauma is the 6th leading cause of death in the

elderly– Elderly trauma patients have significantly

worse outcomes• Not only numbers are increasing, the

health and activity of elders continue to expand

Health and Activity in the Elderly

• Meet Milos Kostic– Retired scientist and

engineer– Ironman World

Champion• 3 time winner of 65-69

age class• 2011 winner of the 70-

74 age class– Completed a 2.4 mile

swim, a 112 mile bike ride and a 26 mile marathon at the age of 68 years young

2011 Time in Ironman Canada: 11:14:24

Image Source: WikimediaPhoto by James Heilman, MD

Physiology of the Geriatric Trauma Patient

• Physiology of the geriatric trauma patient shows minimal tolerance to physiologic instability

• Frequently will have decreased physiologic reserves, due to:– Normal aging– Disease process– Poly-pharmacy


• Cardiovascular System– Decreased reserve– Hypotension poorly tolerated– Hypovolemia is common– Medication effect Beta-blocker, Ca-

Channel blockers, digoxin, diuretics, etc– Underlying coronary artery disease


• Universal Definition of Myocardial Infarction

• Presented in Circulation in 2007– TYPE 1: MI due to a spontaneous coronary

atherosclerotic event. – TYPE 2: MI secondary to ischemia, but not

related to coronary atherosclerosis. – TYPE 3: Sudden death with symptoms or signs

of ischemia (not requiring elevated biomarker confirmation).

– TYPE 4: MI associated with percutaneous coronary intervention (Subtype 4a), or stent thrombosis (Subtype 4b).

– TYPE 5: MI associated with coronary bypass surgery.


• Pulmonary System– High prevalence underlying lung

disease– Multiple physiologic changes

• Alveolar surfaces, decreased diffusion capacity, loss of lung elasticity, increased chest wall compliance, lower muscle mass, and decreased mucociliary clearance

– Decreased protective laryngeal reflexes– Increased risk of rib fractures and

pulmonary contusions


• Skeletal System– Osteoporosis

Pelvic fractures from minor trauma Hip Fractures

– Increased mortality/likely requiring long term care

– Occasionally invisible to X-ray Decreased joint mobility

– Spinal Column» increasing ankylosis of the spine,

osteoarthritis, and decreased bone density» relatively minor trauma, and can produce

devastating injury» Example: Cervical Fractures

Major Sources of Geriatric Trauma

Remember Case 1 of Mr. W, who fell while walking• Compression Fractures

- Thoracolumbar Fracture Wedge vs Burst


Occult Fractures• 3-9% of hip fractures are invisible to X-Ray• 75% of occult hip fractures occur in those who

are over the age of 65 years of age• MRI is the study of choice for confirming the

diagnosis• Missed fractures place patients at risk for

displacement of their fractures, placing them at higher risk requiring more extensive surgery, increased morbidity through unnecessary pain, avascular necrosis of the femoral head, nonunion, thromboembolic complications, and increased mortality.

• Missed fracture is the leading cause of lawsuits against the emergency physicians

Traumatic Hip Pain

Negative w/ continued clinical suspicion

Radiographs

MRI available

MRI

Rx per result

Consider CT scanAdmit to

hospital at bed rest w/ bone scan in 24-36 hours

Positive w/ appropriate Rx

MRI not available


• Central nervous system– Particular risk because of:

Atrophy – Puts bridging veins on stretch– Brain more mobile– Anticoagulated– Slowed protective reflexes– Asymptomatic expansion

– Very liberal use of CT scanning Non-Contrast vs Contrast enhanced CT


• Cord Injury– Once fractures are

ruled out, cord syndromes are still a major concern

– Central cord syndrome


• Trauma has increased from these 3 major sources:– Falls – MVC– Pedestrian vs car


• Falls– Falls account for ≈50% of trauma

injuries– Of the falls resulting in injuries, 70%

occur in the elderly– Low force mechanisms can still produce

substantial injury– High risk for repeated falling

Consider enrolling in fall prevention programs

Major Sources of Geriatric Trauma• Motor Vehicle Collisions

– 65+ years old having the 2nd highest crash rate per mile driven and those 85+ years old having the highest crash rate per mile driven

– Second-leading cause of hospitalization for multisystem trauma among elderly

– Overall fatality rate as high as 21% in the elder MVC victim (7 times that of younger patients)

– Elderly MVC’s are more often single vehicle, occur in the daytime, in good weather, and near patient’s home

– Increased risk is multi-factorial


• Pedestrian vs auto– Tragic injuries– Aged >65 years old are at

the greatest risk of being hit by a car, even greater than children

– Pedestrian vs auto accounts for 9% to 25% of trauma in elders

– Extraordinary high fatality rate of 30% to 55%.

– Crosswalks 4ft/sec

Image used by permission of Stanley Rabinowitzhttp://www.mathpropress.com/stan/crossings/

Additional Injuries in the Elderly

• Burns – Particularly devastating in the elder

patient– Very high mortality

Case

Mr. T. is a 80 year old male who tripped in his bathroom and fell hitting the right side of his chest against the bathtub and comes to the ER holding the R side of his chest.

Case: X-rays reveal 3 nondisplaced fractured ribs on the right, without any pneumothorax, pleural effusion or pulmonary contusion. Your plan for this patient should be:A. Rib binder, narcotics, incentive

spirometry and discharge homeB. Non-narcotic medication, with close

follow up with PMD.C. Hospital admission, pain control,

incentive spirometryD. 4 Hour observation in the Emergency

RoomE. Lidoderm patch and outpatient physical

therapy


• Rib Fractures– Isolated rib fx 36% of patients had

pulmonary complications, which were fatal in ≈10%.

– Multiple rib fractures Admit– Six or more rib Fractures ICU level

care– High risk for pneumonia, pulmonary

contusions, and atelectasis


• Over-triage the elderly– American College of Surgeons

recommends that trauma patients older than 55 years be taken to trauma centers

– More likely to suffer significant injuries after even relatively minor events

– Low threshold to send geriatric patients to trauma center

– Twice the rate of under-triage in the elderly


• Investigation into the cause of the trauma– Increased incidence of underlying

disease– Serious medical problems could be the

source of the trauma and may require simultaneous diagnosis and treatment in the setting of trauma and, at times, may take priority over the trauma assessment

Management of Geriatric Trauma

• Traditional ABCs• Increased Aggressive Management

– Airway: Intubate Early Anticipate problems

– Breathing– Circulation

Hypoperfusion require aggressive resuscitation in monitored setting

At risk for both hypo- and hyperperfusion

Management of Geriatric Trauma

• Vital Signs– Multiple medications may complicate

our use of vital signs– Look for Secondary Signs of cellular

perfusion and oxygenation Lactate level and/or base deficits rather than vital

signs– Hypotension

Requires rapid correction Blood transfusion may also be liberalized Decreased response to catecholamines and

vasopressor medications, because of underlying conduction defects, e.g., bundle branch block and their baseline medications

Review

• Introduction / Scope• Physiology of the Geriatric Trauma

Patient• Major Sources of Geriatric Trauma• Triage Protocols for Geriatric

Trauma• Management of Geriatric Trauma

Conclusions

• The stereotypical trauma patient is a young healthy male, and the physician’s fight is against the traumatic pathology alone.

• In geriatric trauma, the fight is two-fold, against both the traumatic pathology, but also the patients underlying physiology– Minimal margin of error– Aggressive Resuscitation– What we do matters!

Thank you

Questions?

Trauma & Falls in the Elderly Patient

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