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Trauma 4th leading cause of death in US
National Vital Statistics Report 2013http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf
Leading causes of accidental death
All Ages > 65 years old1. MVC2. Poisoning3. Falls4. Homicide firearm
1. Falls2. MVC3. Unspecified4. Suffocation
Falls in the elderly
• Frequent problem▫ 1/3 of people > 65 fall every year▫ ½ of institutionalized individuals fall every year▫ ½ of those that fall do so repeatedly
• 71% of falls have an associated injury▫ Femur, hip, cervical spine, arm, pelvis fractures
• Injury out of proportion to mechanism▫ Frailty, baseline health decline▫ Prolonged hospitalization (33% stay >10+ days)
High morbidity and mortality
http://www.nytimes.com/2014/11/04/science/a-tiny-stumble-a-life-upended.html
Co-morbidities
• 66% of patients over 65 years old will have co-morbidities at time of trauma• 60% HTN• 10% Respiratory
disease• 22% DM• 9% CHF
• Compared to 4.6% of those under 55 years
Bergeron J Trauma 2004NTDB, TQIP
Hip fractures
• 5-8 fold increased risk for all-cause mortality within 3 months
• Progressive decline in health, leading to persistent increasing annual mortality– 20% at 5 years vs same age, no fracture
Haentjens Ann Intern Med 2010Ioannidis CMAJ 2009
What is “elderly”?
• No consensus in the literature
– Medicare – > 65 y
– Literature ranges 45-85 yr
• Individuals have a wide range of functional status despite similar chronologic age
Central Nervous System
• 15-20% loss of brain volume from 5th-10th decade
• Elderly brain occupies less space in the skull• More potential subdural space – 3x more likely• Epidural hemorrhage less likely
• Significant tissue injury with minor trauma▫ Worse outcomes than younger patients 1 year later
Cagetti Br J Neurosurg 1992Livingston J Trauma 2005
Central Nervous System
• GCS less reliable due to chronic disease– Dementia– Hearing impairment– Fluctuating baseline– Physiologic reasons?
• GCS actually more likely to be higher with same degree of injury (head AIS) compared with younger patients
Salottolo JAMA Surg 2014Kehoe Emerg Med J 2016
Cardiovascular System
• Thickened valves and vessel walls contribute to hypertension and cardiac arrhythmias
• Coronary artery disease makes vessels and heart less responsive, and there is increased risk of demand ischemia
• Do poorly with too much or too little fluid
Cardiovascular System
• Decreased maximal heart rate, stroke volume, and cardiac output– Max heart rate (220-age)
• Increased Systolic BP and SVR at rest– “Normal” BP may be relative hypotension– Can still be in shock
Hematologic system (anticoagulants!)
• Significant head bleeds with minor trauma– Mortality doubles after first ground level fall when on oral
anticoagulants for afib (3 6%)
Inui J Trauma ACS 2014Bolt Injury 2015
Respiratory system
• Decreased alveolar surface area – 4% per decade after age 30
• Impaired gas exchange by 0.5% per year
• Pre-existing pulmonary disease, decreased pulmonary reserve
Carpo Pulm Disease & Disorders 1998
Renal system
• Progressive decrease in functioning nephrons• 1%/yr after > 40yo• Maximal concentration in 80 yo is only 70% of 30 yo
• Creatinine clearance skewed by loss of muscle mass
• Diuretics create baseline dehydration
Medication pharmacokinetics
• Absorption– Transdermal, Intramuscular, Gastrointestinal
• Clearance altered (renal, hepatic)
• Volume of distribution– Hydrophilic vs Lipophilic
Musculo-Skeletal System
• Decrease in lean body mass▫ 4% per decade after 25 yo▫ 10% per decade after 50 yo▫ Increase in adipose tissue
• Osteoporosis – loss of up to 60% of trabecular bone mass and 35% cortical bone mass
• Increased risk fractures of vertebral body, hip, humerusand forearm
Moore EE TraumaATLS manual
Cervical Spine fractures
• Osteoporosis & Degenerative changes
• C1-C2 vertebrae more frequently injured
• Younger patients injure C4-C7
Rib fractures
• Increased chest wall rigidity & osteoporosis• Multiple rib fractures (>4)
– Morbidity (Pneumonia, atelectasis, ALI, ARDS)– Mortality
• Increasing age associated with increased morbidity– 45 years
Bulger J Trauma 2000Holcomb J Am Coll Surg 2003
Abdominal injury
• More likely to sustain bowel and mesenteric injuries• May not manifest peritoneal signs on exam• Localize pain poorly• “Damage control” is not futile
Trauma, MooreNewell J Trauma 2010
Skin
• Atrophy of subcutaneous fat, 20% loss of dermal thickness– Pressure ulcers develop
within 2 hours– Skin prone to breakdown
• Microcirculation is impaired affecting medication absorption
Moore EE TraumaATLS manual
Endocrine System
• Increasing Insulin resistance– >50y: “normal” fasting Glc up 10mg/dL decade
• Adrenal function– Aldosterone levels 30% lower in 70+ yo
• Increased hypothyroidism
Immunologic System
• Immunity is altered and has an impaired ability to respond to infection
• Less able to tolerate infection and more prone to progress to multiple organ system failure
Montecino-Rodriquez J Clin Invest 2013
Thermoregulation System
• Less responsive thermoregulatory mechanisms– more likely to develop hypothermia
• Less effective compensation – shivering, cutaneous vasoconstriction
Sleep habits
• Dampened circadian rhythm amplitude– Advance sleep phase syndrome
• Low level light exposure during daytime• Inactivity• Physical and psychiatric illness
– OSA– RLS– GERD
• Meds we use to treat!
www.sleepfoundation.org
Beers Criteria
• Over 75 drugs / drug classes• List of medications to use with caution in the
elderly due to increased side effects
J Am Geriatr Soc 63:2227–2246 2015
Elderly Abuse
• Under recognized, under reported– Estimated 1 in 6 cases reported
“Any willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment
resulting in physical harm, pain, mental anguish, or other willful deprivation by a caretaker of goods or
services that are necessary to avoid physical harm, mental anguish, or mental illness”
Geriatric Trauma Patients
• Elderly are less likely to be involved in trauma, but are more likely to have fatal outcomes when injured
• The mechanism is not as impressive as the injury or the outcome– Undertriaged, underdiagnosed, undertreated
Triage Issues
• Pre-hospital– Risk for undertriage was significantly higher among those older
than 65 years (49.9 vs. 17.8%)
– Improved survival at designated Level I trauma centers• 8% vs 56% survival in 80+ year old patients• Data variable here, may not be true for all “elderly”
– Trauma centers that have a higher volume of geriatric trauma patients have better outcomes
Chang Arch Surg 2008Staudenmayer JACS 2013
Demetriades j Trauma 2001
Trauma Team Activation
• Standard activation criteria fail to identify the severely injured geriatric patient– 63% of severely injured did not meet HD criteria
• Shock Index a better predictor of mortality than traditional Vital Signs– SI = HR/SBP– Modified with >55y: Age x Shock Index
ZarZaur J Trauma 2010
ABC’s – as always
• Airway– Cervical arthritis, arthritis of TMJ, limited mobility– Dentition, Nasopharyngeal friability
• Breathing– COPD/CO2 retention: hypoxemic respiratory drive, permissive
hypercarbia– Rib fractures – higher mortality– Pulmonary contusions – poor reserve
ATLS manual
Circulation
• Decreased maximum HR (220-age)– Masks volume loss
• Decreased catecholamine response– More frequent arrhythmias
• Pre-hospital medications• Similar fluid requirements, but…
– May be volume contracted from diuretics– Baseline CHF may be exacerbated
ATLS manual
Frequent Orthopedic injuries
Treatment goals
• Least invasive, most definitive procedure
• Early mobilization
• Regional blocks for pain– Femoral nerve and fascia
ilaca blocks
– Limit systemic narcotics
– Prolonged inactivity limits functional outcome, which impacts survival
Delirium
“An acute change in cognitionnot explained by preexisting
or evolving dementia”
• Often unrecognized / under diagnosed– Affects 7-10% older patients in the ED– Affects 43% of elderly ICU patients
Han Emerg Med Clin N Am 2010
Elderly Delirium in the ICU
• Longer ICU and hospital stays
• Higher rates of mortality
• Hypoactive delirium most common: 68%
• Increased mortality @ 6mo
Robinson Arch Surg 2011
CAM-ICU RASS• Fluctuations in mental
status• Inattention• Disorganized thinking• Altered level of
consciousness (RASS)
• Agitation - sedation scale• Activity level used to
determine delirium motor subtype– 0 to -3: Hypoactive– 1 to 4: Hyperactive– Mixed – both seen
Pandharipande Intens Care Med 2007
Delirium scales/screening
Nutrition in the elderly
• Often baseline malnutrition on admission
• Decreased caloric needs with less lean body mass, but increased requirements due to inefficient utilization of calories
• Difficult to meet caloric goals– Very frequently have dysphagia
ATLS manualCahill Crit Care Med 2010
Early inpatient rehabilitation
• Weakness associated with impaired function▫ Muscle wasting highest in first 2-3 weeks of ICU
• Early exercise therapy in the ICU▫ Decreased ICU and hospital LOS▫ Improved exercise capacity, strength and perception of function
at hospital discharge▫ Reduced mortality
“Up and About gets them OUT!
Morris Crit Care Med 2008Burtin Crit Care Med 2009Killewich JACS 2006
End of life issues
• Elder patients more likely to be “DNR” at time of death• Withdrawal/withhold life support chosen in 80% of
trauma deaths > 65 yrs old• Withdrawal of care represents a significant contribution
to trauma center mortality rates– Most should not be considered failure of treatment
Sise J Trauma ACS 2012
How old is old?
• Extreme variation in functionality of individuals of the same age
• We need better functional assessments that correlate with overall health status
• Frailty is better marker• No single frailty scale validated in trauma population• Recent review
• 32 assessment tools• Very few found to be objective, feasible, and useful in trauma
population
DOI: 10.1097/TA.0000000000000981
Resources
• TQIP guidelines– https://www.facs.org/~/media/files/quality%20programs/trau
ma/tqip/geriatric%20guide%20tqip.ashx
• EAST guidelines– https://www.east.org/education/practice-management-
guidelines/geriatric-trauma,-evaluation-and-management-of
• G 60 Conference
Conclusion
• Elderly are physiologically different and have different patterns of injury
• Early and proper diagnosis and intervention, without causing of harm, yields outcomes similar to younger patients
• Early and aggressive rehabilitation improves outcomes