Essentials of Care for the Elderly Trauma Patient Stacy
Vincent, RN Emergency Department Enloe Medical Center Chico,
CA
Slide 2
The Geriatric Tsunami 2000- population >65= 12.4% 2050-
20.7% Trauma- 5 th leading cause of death overall 9 th leading
cause of death in > 65 years Geriatric Trauma pts. More likely
to be admitted Longer and more complicated hospital stays Consume
1/3 rd all health care dollars and 25% of all trauma care
money.
Slide 3
Physiologic changes with aging Progressive loss of functional
reserve in each organ system. Diminished reserve + concomitant
disease ability of the elderly trauma patient to absorb physical
insult and subsequently recover.
Slide 4
Physiologic changes with aging
Slide 5
Predictors of morbidity and mortality Age Age morbidity and
mortality rates after trauma. Co-morbidities 80% of age>65 at
least one chronic medical condition 50% have at least two. Severity
of injury Elderly patients tend to sustain more severe injuries,
and ISS is one of the strongest predictors of mortality.
Slide 6
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "Trauma is not really my major problem."
Stroke, myocardial infarction, and seizures may result from falls
or motor vehicle crashes and delayed diagnosis of the principal
underlying problem.
Slide 7
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "Major trauma? Heck, I wouldn't even
tolerate a brisk haircut..." Underestimating and undermanaging
comorbidities (eg, chronic obstructive pulmonary disease, coronary
artery disease, smoking, ethyl alcohol [ETOH] consumption) may
result in preventable morbidity/mortality.
Slide 8
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "A little medication goes a long way with
me..." Failure to adjust medication dosage, particularly
sedative-hypnotics and analgesics, may result in serious
complications.
Slide 9
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "I just haven't been eating so well
lately." Chronic malnutrition is common and often undiagnosed.
Slide 10
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) I pee all the time and I never make any
pee.
Slide 11
Renal Changes Cortical Mass Loss Hypertension, diabetes
mellitus, and atherosclerosis accelerate these processes. GFR (
After the age of 40 years, the GFR decreases 1 ml/min/year)
capacity to reabsorb sodium and to secrete potassium and hydrogen
ions. ADH response Thirst response Watch fluid balance and
acid-base status carefully especially those requiring surgery,
during which massive fluid shifts are expected.
Slide 12
Measurement of Renal Function in the elderly BUN/Cr Kidney
Function muscle mass normal serum creatinine despite a reduced
creatinine clearance. Age-adjusted formulas for creatinine
clearance are much better estimates of renal function in the
elderly patient than serum creatinine levels. Potentially
nephrotoxins eg. IV contrast dye, should be used with extreme
caution even if serum creatinine levels appear within normal
limits.
Slide 13
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "I get demand ischemia if I have too much
pain or my hematocrit drops below 29." Myocardial (demand) ischemia
may result from severe or prolonged pain or from transfusion
thresholds that have not been appropriately liberalized in the
setting of coronary artery disease. "I can't stand even a little
shock or hypoxia...and neither can my myocardium." Even minor
perturbations in perfusion, oxygenation, or vasoconstriction may
lead to major cardiac complications.
Slide 14
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "I can go from normotensive to hypotensive
in a heartbeat. Profound, life-threatening hypovolemia may occur in
the setting of normal blood pressure. Physiologic reserve is
minimal, and hemodynamic decompensation can occur quickly.
Slide 15
Cardiovascular Changes LVH myocardial stiffening diastolic
relaxation and slowed ventricular filling Stroke volume. Heart
extremely sensitive to both hypovolemia and hypervolemia very
narrow therapeutic window. inotropic and chronotropic response to
both internal and external beta-adrenergic stimulation Progressive
deterioration of the conducting system by cell atrophy, fibrosis,
and calcification.
Slide 16
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "I only look like I have adequate
ventilatory reserve." Ventilatory failure and respiratory arrest
may occur suddenly in conjunction with chest or abdominal injuries
despite a benign outward clinical appearance.
Slide 17
Pulmonary Changes Calcified Costal cartilage chest wall
rigidity lung compliance. Respiratory muscle atrophy reliance on
diaphragm function and abdominal musculature for breathing. Forced
vital capacity and FEV1. Fusion of adjacent alveoli surface tension
forces pulmonary elastic recoil. Thickening of the alveolar
basement membrane gas-diffusing capability V/Q mismatch +
alveolar-arterial oxygen gradients. airway sensitivity and
efficiency of the mucociliary clearance mechanism.
Slide 18
Musculoskeletal Changes muscle mass and strength. DJD in
weight-bearing joints chronic pain. Postural compensation altered
weight-bearing mechanics injury. Osteoporosis fractures esp. hip,
pelvis, wrist, and ribs. Vertebral collapse progressive kyphosis
altered center of gravity balance disturbances. Women> Men.
Women lose up to 35% of cortical bone mass and 50% of trabecular
bone mass over their lifetime; men lose about one third less.
Progressive limitation of movement risk of injury + complicated
recovery.
Slide 19
Skin changes Skin trauma is common. Thin skin tears and
lacerations even with relatively minor trauma. May be very
difficult to repair and often require dbridement of devitalized
tissue. Prolonged immobilization on a backboard or in a C-collar
decubitus ulcers of the back, buttock, or occiput. Tetanus prone
due to lapses in immunization.
Slide 20
Mechanisms of Injury Blunt Trauma. Falls. Same level.
Multilevel. MVC. Pedestrian Vs Car. Violent Crime Domestic Abuse
Burns
Slide 21
CNS Changes Cortical atrophy volume of the subdural space
allows for greater movement of the brain during traumatic impact.
Relatively minor mechanisms of injury subdural and subarachnoid
hemorrhage secondary to greater shearing forces on parasagittal
bridging veins. Large volumes of blood may accumulate
intracranially before symptoms of intracranial hypertension
develop. + anticoagulant and/or antiplatelet medications.
predisposition to injury Vision, auditory function, reflex timing
pain perception. cognitive ability, memory, and information Also
may obscure post-traumatic evaluation.
Slide 22
Falls Most common mechanism of injury in elders-40% of trauma
in patients >65 years, Leading cause of injury- related death.
Risk factors medications (sedatives) cognitive and visual
impairment, history of stroke arthritis. Most falls occur at home
and are same-level falls. 25% - due to underlying medical problem.
Need appropriate medical screening. Eg. strokes, syncope, near-
syncope, medications, elder abuse, and hypovolemia (e.g., related
to gastrointestinal bleeding, ruptured abdominal aortic aneurysm,
sepsis, or dehydration).
Slide 23
Falls Fractures- most common injuries ..in 5 to 10% of fall
victims. 10% of patients -major injury esp. head injury. +
anticoagulants susceptibility to significant head injury. + Head CT
in 16%, 1 in 50 require neurosurgery. The greater the height of the
fall, the more likely the patient is to have an abnormal CT scan,
Serious head injuries may also be seen in patients who suffer a
same-level fall. Peri-injury mortality =12%, 50% die within 1 year
of the fall, often related to either recurrent falls or significant
medical complications.
Slide 24
Head Injuries Head injuries -most common cause of mortality
directly related to trauma. Most common mechanism -falls. Epidural
hematomas Rare because of the adherence of the dura mater to the
inside of the skull. Cerebral contusions up to 1/3 rd head-injured
elder patients Subdural hematomas more common with age. Atrophied
brain is more mobile within the skull, and head trauma may result
in shearing of bridging veins. Variable Clinical Presentation- ALOC
Vs Normal Neuro status.
Slide 25
Head Injuries Mortality = 2X that of younger patients Mortality
from subdural hematoma = 4 X than in younger patients. Often need
Rehab. Head CT -diagnostic test of choice for brain injury +
contrast study - if the injury is 7 to 20 days old and an isodense
subdural hematoma is suspected. Magnetic resonance imaging
(MRI-alternative in these patients when the injury is subacute and
an isodense lesion is suspected.
Slide 26
Subdural Vs Epidural Hematomas
Slide 27
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "My subdural hematoma hasn't expanded
enough yet to really affect my level of consciousness." Cortical
atrophy, common in the elderly, may act to delay the clinical
manifestations of serious intracranial hemorrhage. This hemorrhage
may be clinically occult.
Slide 28
MVC 2 nd most common cause of trauma - 20 to 59% Mortality =
21%. Risks Cognitive impairment, hearing and vision, and slower
reaction. Most are daytime crashes occurring close to home.
Single-vehicle crash suspect medical problem. Less likely to
involve alcohol, excessive speeds, or reckless driving than younger
patients.
Slide 29
Auto vs Pedestrian 3 rd most common cause of injury in elders-
9- 25% Risk Factors poor eyesight and hearing decreased mobility
and longer reaction times Fatality rate-30 to 55%. Standard time
allotted for most crosswalks in the United States assumes a walking
speed of 4 feet per second!
Slide 30
Violent Crime 10% of all geriatric trauma admissions. 6% of all
assault victims in US 5 X more likely to die Attacks primarily
involve blunt instruments. Penetrating injuries via knife or
firearm are increasing in frequency - recently reported by the CDC
to account for over 50% of assault related fatal injuries in the
elderly.
Slide 31
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "My injuries weren't accidental." Elder
abuse is common and often unreported and undiagnosed.
Slide 32
Domestic abuse True magnitude clouded by variances in legal
definitions and reporting accuracy. The National Aging Resource
Center on Elder Abuse estimated in 1998 that only 1 in 15 cases of
geriatric abuse is reported. Often a result of denial -victim as
well as the abuser. >2 million cases per year in the US
involving up to 6% of the elderly population. Reasons Longer life
expectancy Altered family dynamics Financial difficulties Females
> males > 80 = 2-3 X than those between 65 and 80. Similar to
child abuse, detection mandates a high degree of suspicion,
especially when there are signs of physical injury or neglect that
are inconsistent with the mechanism described.
Slide 33
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "The sensitivity of my abdominal
examination is better than flipping a coin...but not much."
Clinical manifestations of serious abdominal injury in elderly
patients are often minimal. Reliance on the abdominal examination
often leads to missed abdominal injuries.
Slide 34
Abdominal Injuries Depending on the mechanism of injury, up to
30% of elder trauma patients may suffer a significant intra-
abdominal injury Abdominal examination may be unreliable Mortality
from abdominal injuries = X 4-5 than younger pts. FAST CT
Slide 35
Pitfalls In Geriatric Trauma What the injured elderly would
tell you (if they could) "My bones are brittle...my hip bone, my
shin bone, and my aortic bone!" Blunt Aortic Injury may occur in
the elderly in the absence of conventional signs or symptoms. A low
threshold for CT imaging should exist.
Slide 36
Extremity Injuries Musculoskeletal system - most commonly
injured organ system By the age of 75 years, 30 to 70% of patients
with osteoporosis - + fracture. daily activities May need admission
Pain control Home support or rehabilitation.
Slide 37
Extremity Injuries Upper extremity fractures are common. Distal
radial fractures (50%) Proximal humeral fractures (30%) Elbow
injuries (radial head fractures and elbow dislocations=15%).
Slide 38
Extremity Injuries Hip fractures most frequent lower extremity
fractures most common cause of admission in elder trauma patients.
Early mortality rate = 5% Mortality for 1 yr. after hip fx. =
13-30% MRI for occult hip fractures
Slide 39
Extremity Injuries Tibial plateau fractures fall or MVC and
most commonly involve the lateral tibial plateau. Patellar
fractures fall directly onto the kneecap sunrise views of the
patella may be the only way to visualize these injuries. Ankle
fractures 25% of all lower extremity fractures most commonly
involve the lateral malleolus treatment often a walking cast.
Slide 40
Soft Tissue Injuries Skin tears Treatment difficult, and
debridement of devitalized tissue and careful local care are often
necessary. Elder pts frequently are not up to date with their
tetanus immunizations. Treatment - active + passive immunization
(tDAP + TIG).
Slide 41
Burns >90% of burns occur at home Living alone + decreased
reaction times deeper and more extensive burns Flame burns -50% of
all burns + 20% of burn-related deaths. Some are cooking related;
Scalds = 19% Flammable liquid burns = 10%. mortality = 30% Bauxs
formula (risk of mortality = age in years + % body surface area
burned). Prognosis better since 1980s immunocompetence Exacerbation
of underlying medical conditions precipitated by the stress of an
extensive burn injury and its treatment.
Slide 42
Triage Current guidelines suggest that age alone, in the
absence of any diagnosable injury, is insufficient for activation
of the trauma team. However, the threshold for activation should be
lower in patients who show hemodynamic instability or any
potentially life-threatening injuries, such as severe fractures,
abdominal trauma, or chest trauma.
Slide 43
Age as a trauma center triage criterion One possible cause of
the under triage of elderly trauma patients is the late
presentation of physical findings indicating hypovolemia.
Demetriades D, Sava J, Alo K, et al. Old age as a criterion for
trauma team activation. J Trauma 2001;51:7546 63% did not meet the
standard hemodynamic criteria for trauma team activation
Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome
of early intensive management of geriatric trauma patients. Br J
Surg 2002;89:1319 22. mortality rate when age >70 was added as a
criterion for trauma team activation.
Slide 44
Withdrawal of care Withholding and withdrawing life support in
hopelessly ill geriatric trauma patients is a necessity. The
challenge is identification of the hopelessly ill patients.
Decisions to limit ICU care should be based on the following
principles : 1. Every patient deserves a precise diagnosis. 2. The
prognosis often is uncertain. 3. Each decision should be based on a
risk-benefit analysis for patients. 4. Patient autonomy is
paramount. 5. Due deliberation prior to decision. 6. Communicating
with patients, families, and professional colleagues. 7. Framing
the discussion within families cultural context. 8. Achieving
consensus before a final decision. Schecter WP. Withdrawing and
withholding life support in geriatric surgical patients. Ethical
considerations. Surg Clin North Am 1994;74:24559.
Slide 45
Conclusions Elder patients are more susceptible to injuries
than younger patients and have a higher mortality rate for any
given injury. Mechanisms of injury are different in elders than in
younger patients. Elder patients are more likely to sustain their
injury from a fall, an MVC, or an auto versus pedestrian incident
than from an assault. Physiologic changes that occur with aging
alter the way in which these patients may manifest significant
injuries as well as how they tolerate these injuries. Emergency
providers must remember that elder trauma patients may have
suffered a medical event that precipitated their trauma, or vice
versa, and evaluate patients accordingly. Resuscitation of elder
trauma patients requires oxygen supplementation, a lower threshold
for advanced airway control (endotracheal intubation), and
aggressive but judicious fluid and blood resuscitation with
frequent reevaluation.