CONSIDERATIONS AND PITFALLS IN

GERIATRIC TRAUMA

Carlos A. Barba, MD, FRCSC, FACS

 INTRODUCTION
• In last 30 years
– Population increase 39%
– > 65 y.o grew by 89%
– > 85 y.o grew by 232%
• 2000 = 35 million
• 2030 = 65 million
 INTRODUCTION
• Debate regarding who is consider “old”
– “young-old” = over 65
– “old-old” = over 80
• People live longer, healthier and more
active
• Activity, mechanized society and changes
with age = greater risk injury in elderly
 CONSIDERATIONS
PHYSIOLOGIC EFFECTS OF AGING

• Stiffening of myocardium
• Decrease in pulmonary compliance
– Atrophic mucosa = decrease clearance sputum
• Loss renal reserve (creatinine clearance)
• Brain atrophy
– Decrease senses: vision and hearing
• Muscle mass, immune system, glc intol.
 CONSIDERATIONS
MECHANISMS OF INJURY

• Falls are most common

– Decrease in senses, postural stability(age or
from other events)
– 70% all deaths in geriatric
– syncope as cause should be investigated
• cardiac, CVA, metabolic, anemia, psychogenic
• consultation to specialists may be necessary
 CONSIDERATIONS
MECHANISM OF INJURY

• MVA follows
– Only newest drivers higher rate
– more accidents per mile, despite less driving
– more accidents in daytime or good weather
– Decrease vision, hearing and longer reaction
• Pedestrian
– Highest mortality
– 46% in designated crossing areas
 CONSIDERATIONS
MECHANISM OF INJURY

• SW and GSW follow pedestrian

– Elderly abuse is seen more frequent
• When compared to younger population
– Worst outcome for given ISS
– In all mechanisms, all body regions
– Outcome worse by up 89%
• Physiologic scores are poor predictors
outcome except GCS
 TRAUMA AND COMORBID
DISEASE
• Prevalence 4th decade is 17%
• Sixth decade = 40% and 69% by 75 y.o.
• Presence of these have significant impact in
assessment and management
– Priorities are the same, but stressing response
present
 TRAUMA AND COMORBID
DISEASE
• Some specifics:
– B-Blockers may mask tachycardia of
hypovolemia
– Ischemic heart disease may worsen with
tachycardia
– Epidural catheters and respiratory therapy for
patient with pulmonary disease
 TRAUMA AND COMORBID
DISEASE
• Difficult to quantify the comorbid disease
and severity
• Most studies associated comorbid disease
with high mortality
• Renal and malignancy have the highest
• Also increase mortality when number of
comorbid problems increase
PITFALLS IN MANAGEMENT
• Pre-Hospital and initial resuscitation
follows PHTLS and ATLS guidelines
• When checking airway remove and check
for dental prosthesis during EMS
• Cervical spine protection indicated
• If times permit information and clues
regarding comorbid problems
 PITFALLS
• During primary survey a clinically stable
patient may be in cardiogenic shock
– Some have recommended early and aggressive
invasive monitoring in ICU setting
– Rely more in pre-hospital history and
mechanism of injury
– Overresuscitation may be as morbid as
underresuscitation
 PITFALLS
• Evidence that age 40 could be reasonable to
consider liberal use of hemodynamic
monitoring
– Especially if major injury, significant
comorbidity or conflicting results after
resuscitation
• Men have worst outcome than women
– Usually highest ISS
 SPECIFIC SITES OF INJURY
• Head injury
– Higher mortality and poorer functional
outcomes
– Because lost 10% of weight, subtle
presentations when bleed present
– Subdural more common
– Liberal use of CT scan
 Sites of Injury (Cont)
• Chest
– Minor injuries could lead to significant
complications
– Continuos use of pulse oxymetry and ABG’s
• Abdominal
– Intolerant to hypovolemia and shock
– Early surgical consider for significant
hemorrhage
 Sites of Injury (Cont)
• Spinal
– Degenerative changes makes it difficult
– Upper cervical (odontoid) are frequent
– Central cord injury is more common
• Musculoskeletal
– Most common system injured
– Humerus in 30% UE,distal radius is most
common
 Sites of Injury (Cont)
• Hip fractures are a leading cause of death
among elderly (13-30% in first year)
• Skin and soft tissues
– Atrophic, decrease protection
– Increase wound infection
– 70% tetanus
– Baux Index in burns (Mortality = Age plus %
TBSA burned)
 FUNCTIONAL OUTCOME
• Controversial reports
• Recently over 50% of discharged patients
return to independence
• Suggestion that the same for “old-old”
• More research is necessary
 COST OF TRAUMA CARE IN THE
ELDERLY
• Known that elderly consume more dollars
after injury
– >65 consumed 25% cost for injured patients but
only 12% hospitalized trauma population
• Longer hospital stays and greater need for
intensive care
– Comorbidity increases length of stay
 PITFALLS IN TRAUMA CARE FOR
THE ELDERLY
• No specific triage criteria for transport and
elderly victim to trauma center
– ACS recommend >55 consider for trauma
center triage
– In theory, outcome should be better
• Prevention seems to be very important
– Secondary prevention after injury when
cognitive impairment apparent
 ETHICAL AND SOCIAL
IMPLICATIONS
• Challenge in this population
• Communication about advance directives,
quality of life and impact of trauma in life
style are mandatory
• Withdrawal of support in over 13% and
reflects humane medical care
– Early aggressive management adequate until
clear picture evident
 CONCLUSIONS
• Incidence will increase
• Important to know effects of aging
• Mortality is higher with age, comorbid
diseases and ISS
– Triage to trauma centers those with high index
suspicion
• High index of suspicion even if stable
 CONCLUSIONS
• Early aggressive resuscitation, diagnosis
and treatment warranted
– Wait until clear clinical picture
• Humane and dignified approach if futility
• Still needed
– Functional outcome studies, more effective
resuscitation and management protocols