© Springer International Publishing Switzerland 2018Christian Nickel, Abdelouahab Bellou and Simon Conroy (eds.)Geriatric Emergency Medicinedoi.org/10.1007/978-3-319-19318-2_11
11. Trauma in Older People
Department of Emergency Medicine, University Hospital Basel, Petersgraben 2, CH-4032 Basel, Switzerland
Department of Traumatology, University Hospital Basel, Petersgraben 2, CH-4032 Basel, Switzerland
Globally, the population aged 60 or over is the fastest growing . It is expected to increase by 45% globally by the middle of the century . The increasing number of older individuals among the population is reflected by the increasing proportion of hospitalizations in this group . Older patients have a higher absolute mortality rate following traumatic injury than younger patients . Older age is associated with higher incidence rates of pre-existing comorbidities and chronic diseases . The majority of older patients suffer typically from blunt trauma; falls from low height are the leading cause . Despite existing triage tools, older people are often under-triaged [5, 6]. Delays in transfer of less-severely injured, older trauma patients to a regional trauma center can result in poor outcomes, including increased mortality . Older adults with minor injuries have different injury patterns, higher acuity, and longer length of stay and are less often discharged home compared to younger adults . The temporary loss of function of an extremity, combined with social isolation, often makes it impossible for the patient to continue an independent life. Furthermore, impaired cognition affects the capacity of older individuals to comprehend, recall, and adhere to treatment recommendations after an injury and puts them at risk for further negative health events .
Often, physiological changes exist in the cardiovascular system of older patients such as decreased beta-adrenergic responsiveness, conduction abnormalities, arrhythmias, and hypertension. The increased afterload due to stiffened walls of the arteries leads to ventricular hypertrophy, with decreased myocardial compliance and an increased reliance on Frank-Starling mechanism for cardiac output. In the non-compliant older heart, small changes in venous return will produce large changes in ventricular preload and cardiac output . The primary causes for traumatic cardiac arrest are hypovolemia, severe head injury, and hypoxia . The first monitored rhythms in cardiac arrest caused by hypovolemia are pulseless electrical activity (PEA) and asystole in the majority of cases, while ventricular fibrillation dominates the mechanisms of cardiac arrest in severe head injury . To stop the bleeding and to replace the blood loss are the most important steps in the treatment of hemorrhage leading to hypovolemia. High volume resuscitations with crystalloid solution though are associated with high mortality particularly in older trauma patients . Excessive preclinical fluid resuscitation should therefore be avoided. Registry data suggest that a restricted preclinical volume therapy is safe in older patients . However, restriction of blood transfusion on the basis of age alone cannot be supported. Survival to hospital discharge was demonstrated in older patients receiving massive transfusions post trauma, even in the presence of multiple risk factors for mortality . Venous lactate-guided therapy of occult hypoperfusion with early trauma surgeon involvement is associated with significantly lower mortality [15, 16].
11.3 Airway and Breathing
In every trauma patient, blockade of the upper airway must be ruled out. Peripheral deafferentation combined with decreased central nervous system reflex activity in older people increases the risk of aspiration [17, 18]. With increasing age, a decrease in elastic tissues and an increase in collagen in the extracellular matrix lead to a loss of elasticity . In the upper airway, this causes loss of pharyngeal support, which predisposes older people to upper airway obstruction [20, 21]. While loose objects in the mouth must be removed, intact dentures should be left in place for assisted ventilation because with teeth or dentures, the bag mask fits better to the face. Although limited mouth opening may occur, frail older patients are intubated with a higher success rate compared to younger patients . In the lower airway, the reduction in the intrinsic elastic recoil of the lung parenchyma leads to smaller airways with a higher resistance . Whereas the lung parenchyma loses elastic recoil and becomes more compliant, the chest wall becomes stiffer . Older peoples’ ribs are more prone to fracture but also to fracture in multiple places . Instability of the chest wall may compromise the respiration by pain, lung contusion, and hematothorax/pneumothorax. While the thorax enlarges with age, the diaphragm flattens. This increases the work for respiration. The reduced vital capacity, reduced functional capacity, and reduced forced expiratory volume lead to a smaller respiratory reserve in frail older patients. As a first measure for all trauma patients, additional oxygen should be applied. Because endotracheal intubation may become necessary with the signs of inadequate ventilation, the older patient must be closely monitored for altered mental status, hypercarbia, acidosis, and respiratory distress. When rapid sequence intubation is performed, the doses of the medical drugs applied, which may cause hemodynamic compromise, should be adapted. Sedative agents such as propofol, etomidate, benzodiazepines, and barbiturates as well as opioids should be decreased by up to 20–50% [24–27]. The dose for neuromuscular blocking agent remains unchanged, but rocuronium should be applied instead of succinylcholine in case of known or suspected hyperkalemia (burn injuries, prolonged immobility). While good evidence exists for safe priming with rocuronium in younger adults, there is some evidence that priming should not be applied in older people [28, 29].
There are numerous changes with age, which affect the neurological evaluation of frail older patients. Neuroanatomical changes include, among others, neuronal shrinkage and neuronal loss (loss of brain volume, increase of ventricular size), loss of synapses, decreased vascular compliance due to atherosclerosis, and reduced number of motor units in the spinal cord (resulting in decreased reflex activity) [30, 31]. Neurochemical changes, among others, are a reduction of serotonin (linked to non-cognitive changes in behavior such as depression, aggression, and sleep disturbance) and acetylcholine (associated with memory impairment) [30, 32, 33]. Physiological changes include, among others, a decrease in cerebral blood flow (more than 25% by age 80), decreased protein synthesis (resulting in neuronal cell size shrinkage), and delays in complex pathways (decreasing processing speed) [30, 34–36]. Cranial nerve alterations are functional deficits of the olfactory nerve (possible cause for nutritional deficit), presbyopia, senile miosis, decreased lacrimal secretion, presbycusis and impaired vestibulospinal reflexes, decreased number of taste buds (possible cause for nutritional deficit), and delay in swallowing . Further limitation of neurologic function in older people may occur from chronic degenerative disease, such as diabetic neuropathy, diabetic retinopathy, or macular degeneration. The prevalence of stroke is more than double in the age group of 80+ compared to the group of 60–79 . Older patients who have sustained isolated severe traumatic brain injury may present with a higher Glasgow Coma Scale (GCS) than younger patients .
Frailty is a common and important geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multi-organ systems, leading to increased vulnerability for adverse health outcomes . Older people can preserve homeostasis, when they are not stressed, but homeostatic failure occurs, when stress is induced. Frailty in older adults is associated with poor survival with a dose-responsive reduction in survival per increasing number of frailty criteria . The risk of malnutrition is more than four times higher in frail older adults compared to non-frail adults . The prevalence of malnutrition varies substantially depending on the diagnostic measure applied . Malnutrition is an independent risk factor for increased mortality in fracture patients .
11.6 Clinical Assessment
A thorough history and physical examination should direct all diagnostic and therapeutic measurements. To understand the circumstances of trauma is even more important in frail older people in the light of the higher number of underlying chronic medical conditions. In respect of the sensory changes in older people, medical personnel must assure that the patient has assistive aids, such as glasses and hearing devices. For the surgical decision making, it is crucial to assess the physical ability and demands of the patient before trauma. The knowledge of and the adherence to the recent medication are notoriously bad in older patients [44, 45]. Written reports from healthcare providers (family doctors, nursing home personnel, home care providers) should be sought out. Vital signs show age-related changes. Change from an individual reference range may indicate important warning signs and thus may require additional evaluation to understand potential underlying pathological process . Repeated clinical evaluation is therefore necessary. High suspicion for the presence of aggravating factors in terms of an increased perioperative risk or an impaired postoperative healing is indicated. Crucial basic decisions concerning resuscitation and end-of-life treatment should be addressed with the older patient at the very beginning of the hospitalization and documented in the hospital chart. The accuracy of surrogate substituted judgment even in the presence of an instructional advance directive is challenged by literature [47, 48].
Poor bone quality due to altered bone metabolism and the sequelae of degenerative bone and joint diseases make the interpretation of acute changes of the skeleton in the older patient by conventional X-ray more difficult. Painful immobilization due to undetected sacral fractures or devastating neuronal damage by undetected fractures of the cervical spine are possible consequences of insufficient imaging. Liberal use of computed tomography (CT) is therefore warranted.
11.8 Head Injury
Age is a major determinant of outcome after traumatic brain injury . Rate of fall-related fatal traumatic brain injury increases and rate of traffic accident-related fatal traumatic brain injury decreases with age . Older fall patients who are at their baseline mental status have a low incidence of intracranial injury . The best predictor of intracranial injury are physical findings of trauma to the head and history of loss of consciousness . Severe head injury in older people carries a high mortality owing to associated comorbidities . Preadmission GCS score bears a positive correlation to Glasgow Outcome Scale (GOS) . Neurosurgical management is associated with the improvement of the prognosis and a decrease in the rate of mortality in geriatric traumatic brain injury . However, surgical management was not shown to be an effective treatment in older patients with GCS scores 3–5 .
11.9 Neck and Spine
Frail older patients tend to sustain more upper C-spine fractures than non-frail older patients regardless of the mechanisms . Ground level falls or less not only can cause isolated C-spine fracture(s) but also lead to other significant injuries with intracranial pathology as the most common one in frail older patients . Extreme care is warranted in patients with advanced idiopathic skeletal hyperostosis (DISH). DISH is associated with age. The clinical outcome of patients with fractures in previously ankylosed spines, due to ankylosing spondylitis or DISH, is considerably worse compared to the general trauma population .
Due to the smaller respiratory reserve in frail older people, the control of the respiratory situation by repeated clinical evaluation and monitoring and the adequate pain management are even more important. Early mobilization and active respiratory physiotherapy should be pursued. The vast majority of rib fractures can be treated nonoperatively even in the presence of flail chest . The benefit from an epidural analgesia is controversial in literature [56–58]. Surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed . It was shown to reduce ventilation requirement and intensive care stay in a cohort of multi-trauma patients with severe flail chest injury . Meta-analyses still lack an adequate number of prospectively randomized participants . Since the myocardium is less protected in the older patient due to a decreased intercostal muscle mass and a weakened rib cage, blunt cardiac injury should be ruled out. Every frail older patient with blunt chest trauma should have routine electrocardiogram (ECG) on admission . Normal ECG and normal serum troponin-I levels have a negative predictive value of 98% for blunt cardiac injury . Advanced age is associated with higher mortality in traumatic aortic lesion . Endovascular repair for descending thoracic aortic disease was shown to reduce early death, but sustained benefits on survival have not been proven .
Occult abdominal injuries as serious consequences in falls in older patients are rare . Nonoperative management of blunt solid abdominal organ injury currently is the treatment modality of choice in hemodynamically stable patients, irrespective of patient age, with monitoring, serial clinical evaluation, and an operating room for urgent laparotomy being available [67, 68]. Early low molecular weight heparin-based anticoagulation was not associated with the development of bleeding complications in patients with blunt solid abdominal organ injuries undergoing nonoperative management .
Whereas the incidence of intertrochanteric and femoral neck fractures decline, the number of acetabular fractures and pelvic fractures increase in older people [70, 71]. Pubic rami fractures are frequently associated with concomitant posterior pelvic ring injuries, making these injuries more unstable than generally assumed . Patients with displaced inferior pubic rami fractures warrant a detailed examination of their posterior ring to identify additional injuries and instability . The clinical examination proved to be equally effective to CT in detecting posterior pelvic ring fractures . Using magnetic resonance imaging (MRI) is beneficial in cases of reduced bone density . Low-energy lesions without disruption of the pelvic ring may be treated nonoperatively. When pain management is unsatisfactory and/or early mobilization is not achieved, conservative treatment has failed. Percutaneous iliosacral screw fixation results in a better pain relief, less residual displacement, and better functional outcome than conservative treatment of unstable posterior ring injuries . The management principles for high-energy traumas should include aggressive resuscitation and medical optimization, with surgical care focusing on survival without sacrifice of skeletal stability and early mobilization . The decision for operative vs. nonoperative treatment of acetabular fractures should not be justified based upon concern for increased or decreased mortality alone . The combination of open reduction and internal fixation combined with total hip arthroplasty is a valuable option for the older patient [78, 79]. There is 28% secondary conversion rate to hip arthroplasty in the literature for primary open reduction and internal fixation of acetabular fractures in older people .
The three most common associated extremity injuries with fall in the older patient are fracture of the femur, radial fracture, and fracture of the humerus . The number of peri- and interprosthetic fractures is increasing . The rate of open fractures in patients aged ≥ 80 years is higher than the rate in the patients aged ≥ 65, and the difference is even more pronounced comparing to the patients aged < 65 . The change in mechanical properties of the skin is believed to account for this increased incidence . The pre-existing adverse conditions for wound healing in the older patient due to accompanying medical comorbidities may explain, for example, the high mortality associated with low-energy open ankle fractures . All measures applied should aim for an early functional recovery. The proximal fracture of the femur warrants an operative treatment because otherwise the patient would have to be immobilized for a long time, and it is challenging to nurse the patient without causing pain. For the treatment of the femoral neck fracture, the patient’s functional status before trauma in terms of walking capacity, tendency to fall, compliance to load removal with crutches, smoking, and degenerative diseases must be taken into consideration [85–88]. Data in the literature for the decision making of primary hip arthroplasty versus hemiarthroplasty is not conclusive . Fragility fractures of the proximal humerus and distal radius are a significant burden in terms of loss of independence, inpatient hospitalizations, and prolonged nursing home or rehabilitation needs accounting for considerable healthcare costs . Despite a small improvement of quality of life, surgical treatment for displaced proximal humeral fracture with osteosynthesis or hemiarthroplasty does not significantly improve the functional outcomes including Constant score and DASH (disabilities of the arm, shoulder, and hand) . Reverse total shoulder arthroplasty taking in account the often present degenerative changes in shoulders may change this situation both in terms of function and costs . In the treatment of intra-articular distal radius fractures in older patients, there is marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting with respect to mobility, functionality, and quality of life at 12 months . Every older patient with a fracture should be evaluated and treated for musculoskeletal frailty including osteoporosis, depending on recent status and risk factors [94, 95]. A high burden of subsequent fracture in individuals with normal bone mineral density and osteopenia and excess mortality particularly for those with osteopenia (and osteoporosis) is reflected in the literature .
11.14 Special Considerations: Abuse and Neglect
Elder abuse or mistreatment includes psychological, physical, and sexual abuse, neglect (caregiver neglect and self-neglect), and financial exploitation . Physical signs of intentional actions that cause harm or failure to satisfy the older person’s needs include decubital ulcers, skin bruises, or burns [98, 99]. Poor hygiene, bad nutritional status, delayed presentation with results from trauma (organized hematoma over fracture site), inconsistency of trauma history, or dominant behavior of accompanying persons should raise the awareness in the medical personnel about a potentially hazardous situation. Caregivers involved should have access to specialized social healthcare providers and should be familiar with the local legal regulations.
Older and frail patients have an age-associated decline in physiologic reserve and function across multi-organ systems, leading to increased vulnerability for adverse health outcomes like trauma. In the assessment of the older patient, special allowance must be made for the often impaired ability to communicate and age-related changes in vital signs. For imaging, liberal use of computed tomography is warranted. The surgical decision making should be based on patient’s needs rather than on feasibility.
World population prospects the 2012 revision, United Nations, New York, 2013
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