Transcript Baby Boomers & Trauma: Challenges with the “Elderly

Essentials of Care for the
“Elderly” Trauma Patient
Stacy Vincent, RN
Emergency Department
Enloe Medical Center
Chico, CA
The Geriatric Tsunami
 2000- population >65= 12.4%
 2050- 20.7%
 Trauma- 5th leading cause of death
overall
 9th leading cause of death in > 65
years
 Geriatric Trauma pts. –
 More likely to be admitted
 Longer and more complicated
hospital stays
 Consume 1/3rd all health care
dollars and 25% of all trauma
care money.
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.
Physiologic changes with aging
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.
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.
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.
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.
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.
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….
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.
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.
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.
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.
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.
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.
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.
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.
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
débridement 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.
Mechanisms of Injury
 Blunt Trauma.
 Falls.
 Same level.
 Multilevel.
 MVC.
 Pedestrian Vs Car.
 Violent Crime
 Domestic Abuse
 Burns
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.
Falls

Most common mechanism of
injury in elders-40% of trauma
in patients >65 years,

Leading cause of injuryrelated 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, nearsyncope, medications, elder
abuse, and hypovolemia (e.g.,
related to gastrointestinal
bleeding, ruptured abdominal
aortic aneurysm, sepsis, or
dehydration).
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.
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 1/3rd 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.
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.
Subdural Vs Epidural Hematomas
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.
MVC
 2nd 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.
Auto vs Pedestrian
 3rd most common cause
of injury in elders- 925%
 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!
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.
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.
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.
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.
Abdominal Injuries
 Depending on the mechanism of injury, up to 30% of
elder trauma patients may suffer a significant intraabdominal injury
 Abdominal examination may be unreliable
 Mortality from abdominal injuries = X 4-5 than younger
pts.
 FAST
 CT
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.
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.
Extremity Injuries
 Upper extremity fractures are
common.
 Distal radial fractures (50%)
 Proximal humeral fractures (30%)
 Elbow injuries (radial head fractures
and elbow dislocations=15%).
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
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.
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).
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%
 Baux’s 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.
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.
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;51:754–6
 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.
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;74:245–59.
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.
THANK YOU!