Chapter 6 – Geriatric Trauma




Abstract




While elderly patients comprise a small percentage of total major trauma patients (8–12%), they represent a disproportionate percentage of trauma mortalities and costs (15–30%, Figures 6.1 and 6.2).





Chapter 6 Geriatric Trauma



Matthew R. Levine



Importance


According to 2010 US Census data, adults >65 years old account for 14% of the population, and one in five US residents will be elderly by 2050.1, 2 Approximately one million Americans of 65 years and older are affected by trauma each year.3




  • Trauma in elders accounts for $12 billion in medical costs and $25 billion in total costs yearly.4


While elderly patients comprise a small percentage of total major trauma patients (8–12%), they represent a disproportionate percentage of trauma mortalities and costs (15–30%, Figures 6.1 and 6.2).





Figure 6.1 Proportion of all trauma patients that are elderly





Figure 6.2 Proportion of all trauma mortalities and costs that are elderly


Older age is an independent risk factor for morbidity and mortality, despite lesser severity of injuries.1, 2 The Major Trauma Outcome Study (1989), which included 3,833 patients aged >65 and 42,944 patients aged <65, showed that mortality rose sharply between 45–55 years and doubled by 75 years of age. This pattern occurred at all Injury Severity Scores (ISS), mechanisms, and body regions.5 Other literature reports various inflection points between the ages of 45 and 70 years, where trauma mortality increases.6, 7


While age has value in mortality projections for geriatric trauma patients, there is no specific age cutoff for prediction of in-hospital mortality. Furthermore, literature suggests favorable functional outcomes for those who survive to hospital discharge (Box 6.1).8 Age alone is not a sole criterion for denying or limiting care in elderly.9




Box 6.1 Limitations of Research in Geriatric Trauma




  • Few prospective randomized controlled trials



  • No uniform age cutoff criteria for elderly (45–80 years)6



  • Lack of uniform definition of an elderly trauma patient



  • Much of the literature is old



Triage of Elderly Trauma Patients



Prehospital


Under-triage is defined as a trauma patient not being transported to a state-designated trauma center. Under-triage keeps patients away from trauma centers who would benefit from trauma center care.


Per the CDC: “Under triage of the older adult population is a substantial problem.”10 Older patients were 34% less likely to die if they presented to centers treating a high vs. low proportion of elderly trauma.11


Standard adult EMS triage guidelines provide poor sensitivity for detecting older adults needing trauma center care.12 The under-triage rate is approximately 50% in patients older than 65, vs. 17.8% for those under 65.13, 14


Several sources have concluded that there should be an age threshold that mandates triage to a trauma center, with various age ranges (55–70 years) recommended.6, 9, 1517


Potential explanations for under-triage of elderly trauma patients are significant injury from low energy mechanisms and altered physiologic response to injury with aging.


The CDC recommends direct transport to a trauma center for any trauma patient age ≥65 with SBP ≤110.10 Substituting SBP <110 instead of SBP <90 for patients older than 65 reduced under-triage by 4.4% while only increasing over-triage by 4.3%.18


Although patients at level 1 trauma centers may have longer lengths of stay and higher total charges, a higher percentage of patients are discharged home.19 Elderly patients with femur fractures and those with multiple injuries benefit from trauma center care.



After Arrival at the Trauma Center


Once an elderly patient arrives at a trauma center, trauma team activation occurs significantly less often for elderly patients (14% vs. 29%), despite a similar percentage of severe injuries (defined as ISS >15).l


The Eastern Association for the Surgery of Trauma (EAST) recommends a lower threshold for trauma team activation for patients 65 and older evaluated at trauma centers (level 3 evidence).20


Some trauma centers use age as mandatory criteria for trauma team activation. This is supported by data that 63% of elderly trauma patients with ISS >15 had no standard physiologic activation criteria (Table 6.1).




Table 6.1 Triage implications for elderly trauma patients
















Location Recommendation
Prehospital Low threshold for recommending EMS transport of elderly trauma patients to a designated trauma center, especially for patients with SBP <110
After hospital arrival Low threshold for activating the trauma team after arrival at a trauma center for elderly trauma patients


Pathophysiology Concerns in the Elderly


The elderly are more susceptible to serious injury from low-energy mechanisms (particularly falls) and are less able to compensate from the stress of injury. They also are more likely to suffer complications during treatment and recovery. Key reasons for this include:




  • Less physiologic reserve



  • Occult shock/misleading picture of stability



  • Comorbid illnesses, not just age, contribute to poor prognoses in geriatric trauma (Table 6.2).




Table 6.2 Comorbidities that contribute to poor outcome in geriatric trauma

























Comorbidity Effects
Diabetes Mellitus Poor wound healing
End Stage Renal Disease Unclear fluid resuscitation goals

Platelet dysfunction
Osteoporosis Higher fracture risk
Congestive Heart Failure Medications obscure interpretation of vitals

Poor cardiac output augmentation
Dementia Poor participation in physical and occupational therapy

An important point of emphasis in elderly patients is that profound shock may be present even in the setting of “normal” vital signs. The window to intervene may be narrow, and delayed recognition of shock will delay needed resuscitation and interventions.




  • While common medications in the elderly, such as beta blockers and calcium channel blockers, may prevent typical tachycardic responses in shock, these medications do not need to be on board for an elderly patient to have “normal” vital signs in the setting of perfusion deficits.



  • The elderly myocardium has decreased sensitivity to endogenous catecholamines.



  • Blood pressures that would be considered normal in young patients may be relatively hypotensive compared to the baseline BP of an elderly patient. In fact, HR >90 and SBP <110 have been correlated with increased mortality in elderly trauma patients.18, 21



Supporting Evidence


A landmark article by Scalea et al.22 in 1990 that involved early invasive (PA catheter) monitoring in elderly trauma patients with “stable” vitals demonstrated that many of these patients have profound perfusion deficits despite “normal” vital signs.


Multiple subsequent studies have demonstrated that elevated lactate levels (>2) or abnormal base deficit (<−6) are associated with major injury and mortality both in elderly and non-elderly patients.2325


In one study, venous lactate >2.5 helped diagnose occult hypoperfusion in 20% of 1987 geriatric trauma patients.26 Lactate levels and/or base deficit should be used as an adjunct to vital signs for early identification of perfusion deficits in elderly trauma patients.


These factors have several clinical implications:




  • Avoid being falsely reassured by normal vitals



  • Consider systolic blood pressure ≤110 mm Hg to be hypotension



  • Use lactate levels or base deficit as adjuncts to detect occult shock and guide resuscitation in unclear cases



  • Use ECG to detect silent ischemia as a response to the physiologic stress of trauma



  • Have a lower threshold for admitting elderly trauma patients to an ICU



Mechanisms and Injuries That are More Concerning in the Elderly


While the elderly are at increased risk for injury from all forces compared to younger adults exposed to the same force, mechanisms that have a disproportionate burden on elderly patients are:




  • Falls from a ground level (Figure 6.3)



  • Head trauma



  • Chest wall injuries



  • Cervical spine injuries



  • Pedestrian struck by vehicle





Figure 6.3 Mechanisms of injury in elderly trauma patients


(data from Labib et al.27)


Falls




  • The most frequent cause of injury in age >65 years.27



  • The most common fatal accident in age >80 years.



  • More than one third of older adult ED fall patients had an ED revisit or died within one year!28



  • Same level falls must not be minimized, as they are 10× more likely to cause death than in a non-elderly patient (25% vs. 2.5%).29



  • Even falls that seem purely mechanical can be a sign of occult illness and require advanced assessment (Box 6.2).




Box 6.2 Elements That Must Be Assessed After an Elderly Patient Falls




  • Sudden disturbance in cardiovascular/neurologic function



  • New/progression of underlying conditions or emerging infection



  • Intoxicants/medication effects



  • Environmental safety, especially at home



  • Impact of injury on functional status/ability to care for self



  • Complete history and physical exam



Head Injury




  • Age related atrophy of the brain leads to more potential space and shearing forces of the intracranial bridging veins when exposed to trauma.



  • The risk of intracranial bleeding is markedly increased with medications common in the elderly like anticoagulants and anti-platelet agents.30, 31



  • Elderly patients are typically excluded from studies that tell us who does not need brain imaging in trauma.



Chest Wall Injuries




  • Even “minor” chest injuries impair the elderly. These are poorly tolerated due to a stiffer chest wall, loss of alveolar surface area, impaired lung defenses, and bacterial colonization.



  • A rigid cervical collar and backboard can further impair chest wall expansion (Figure 6.4).



  • The morbidity and mortality from rib fractures is much higher in geriatric populations. Studies have shown that each additional rib fracture in the elderly increases mortality by 19%!32 Elderly patients with rib fractures are at increased risk for pneumonia (31% vs. 17%, with a 16% increase per rib fractured), pulmonary contusion, and delayed hemothorax.32





Figure 6.4 A rigid cervical collar and spine board immobilization can greatly impair respiratory status in elderly patients, especially in the setting of a chest wall injury


(image by Christophe Dang Ngoc Chan, reproduced under CC BY-SA 3.0 license creativecommons.org/licenses/by-sa/3.0/)


Cervical Spine Injuries




  • The elderly spine is more vulnerable to fracture from minor mechanisms such as falls from standing.33 This is due to common conditions such as cervical stenosis, osteoporosis, and arthritis (degenerative, rheumatoid, and osteoarthritis).



  • High cervical fractures (type 2 odontoid being the most common) and central cord syndromes are more frequent in the elderly.34



Pedestrian Struck by Vehicle




  • Perhaps the most devastating common mechanism of injury to disproportionately affect this population.



  • Age >65 years accounts for 22% of pedestrian struck deaths.



  • 46% occur in crosswalks.



  • Factors that may make elderly susceptible are decreased ability to raise or turn the head from cervical arthropathy and less speed and agility (crosswalk timers often allow for a pedestrian speed of 4 ft/sec).


Box 6.3 discusses key trauma considerations in geriatric patients.




Box 6.3 Clinical Implications of Mechanisms and Injuries That Disproportionately Affect the Elderly




  • Heightened suspicion for significant injury, even from ground level falls



  • Assess for medical impairments that could have led to the fall



  • Liberal use of CT scanning for elderly head and neck trauma



  • Inquire about the use of anticoagulant and anti-platelet medication



  • Ensure adequate analgesia and oxygenation for chest wall injuries



  • Remove the cervical collar and backboard as early as safely possible



  • Lower threshold for admitting elderly patients with rib fractures (even one)



Trauma Survey Principles in the Elderly


The principles of diagnosis and management in trauma are the same regardless of age. However, certain aspects of the trauma assessment require special attention and emphasis (Table 6.3).




Table 6.3 Special trauma survey applications to elderly patients





















Airway Early airway control

Edentulous patients may be difficult to bag

Remove dentures for intubation
Breathing Avoid respiratory decompensation by use of O2, analgesia for chest injuries, suction/pulmonary toilet, clearing the cervical spine, and removing the back board as early as possible to prevent respiratory impairment
Circulation Early transfusion to minimize fluid overload from crystalloids

Recognizing that “normal” BP may be relative hypotension for an elderly patient

Recognizing that occult hypoperfusion can be present with normal vital signs

Seek anticoagulant use and consider reversal early
Disability Liberal use of head and cervical spine CT

GCS less reliable to rule in or rule out brain injury
Exposure Seek clues of comorbidities that may not have been reported (i.e. surgical scars, pacemakers, medication bottles or lists in patient belongings, medical alert tags, bruising from anticoagulants)


Elder Abuse


Elder abuse can be very difficult to detect for several reasons:




  • Patient reluctance to get a loved one in trouble.



  • Frail status makes the patient feel helpless to seek help.



  • Cognitive impairment limits the history or the ability to self-report abuse.



  • Patient dependence on the abuser.



  • Abuse in the form of neglect can mimic cachexia from comorbidities.


Steps the clinician can take to detect elder abuse:




  • When the scenario has stabilized, assess the patient’s social situation.



  • Be wary of wounds or injuries that are suspicious for abuse or do not seem to match the reported mechanism of injury.



  • Ask the patient, preferably in private.



Anticoagulants




  • Anticoagulant use is far more prevalent in the elderly population.



  • Make sure to ask the patient right away if he/she is on a blood thinner, aspirin, clopidogrel, or other anti-platelet agents. An irregular heartbeat may be a clue to chronic atrial fibrillation and suggests use of these medications.



  • Sustained reversal of warfarin is best achieved with vitamin K. More immediate reversal is achieved with prothrombin complex concentrates or fresh frozen plasma.



  • Greater numbers of elderly patients are on direct oral anticoagulants (DOACS) which are not as readily reversible as warfarin and have no universally accepted protocol for reversal.



  • Know your institution’s reversal protocol for DOACs. If your institution does not have one, then know which prothrombin complex concentrates (PCCs) are available to you. PCCs seem to be the preferred agents for DOAC reversal until definitive antidotes are readily available.



  • There are two types of DOACs: direct factor II inhibitors (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban, edoxaban).



  • Dabigatran can be removed by dialysis. In 2015, a monoclonal antibody to dabigatran, idarucizumab, was introduced for dabigatran reversal.



  • A recombinant modified decoy molecule, andexanet-alpha, is currently approved by the FDA for reversal of factor Xa inhibitors. Further clinical studies are underway evaluating efficacy.



Pitfalls




  • Withholding initial aggressive care based solely on advanced age



  • Delayed recognition of hypoperfusion because of normal vital signs



  • Giving too much crystalloid before starting blood



  • Underestimating the impact of a ground level fall



  • Not fully investigating a seemingly mechanical fall for decompensation of a comorbid condition



  • Respiratory embarrassment from prolonged spine board and cervical collar immobilization



  • Underappreciation of the impact of a rib fracture on an elderly patient



  • Under-triage of an injured elderly patient away from a trauma center



  • Not fully investigating for comorbidities and anticoagulant use



  • Missing elder abuse as a cause of injury


Jan 10, 2021 | Posted by in EMERGENCY MEDICINE | Comments Off on Chapter 6 – Geriatric Trauma
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