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Geriatric Trauma: Evolving Concepts in a Rapidly Growing Population


... 10 year retrospective review in Maryland 25,565 patients Risk of under-triage in age group 65 was significantly greater than younger group 49.9% vs. 17.8 ... – PowerPoint PPT presentation

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Title: Geriatric Trauma: Evolving Concepts in a Rapidly Growing Population

Geriatric Trauma Evolving Concepts in a Rapidly
Growing Population
  • Richard S. Miller, MD FACS
  • Professor of Surgery
  • Chief, Division of Trauma and Surgical Critical
  • Vanderbilt University Medical Center

  • None

  • Review epidemiology of geriatric trauma (GT)
  • Discuss mechanisms and physiology unique to the
  • Describe approach to management of GT
  • Pre-hospital
  • In-patient care
  • Discharge planning
  • Evaluate decisions
  • Advanced directives
  • Palliative care
  • End of life discussions

Geriatric TraumaAn emerging public health issue
  • Geriatric population Age 65 and older
  • Elderly currently 1/10th general population
  • Account for 1/3rd trauma expenditures
  • 9 billion dollars for geriatric trauma per year
    in the U.S.
  • Weir S et al., Expert Rev Pharmacoecon Outcomes
    Res 2010 10(2)187-97
  • Census Bureau
  • 65 and older age group nearly double over next 20
  • 46 million - 2010
  • 81 million - 2030

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Geriatric trauma patients behave differently
  • Numerous studies describe the ways in which
    geriatric trauma patients behave differently than
    their younger counterparts
  • Normal vitals signs belie their physiologic
  • Higher risk of death than younger patients with
    the same traumatic insult

Physiologic Reserve
  • Defined As
  • The Individual's Ability To Tolerate Injury
  • Function Of Unique Host Factors
  • Age
  • Gender
  • Preexisting Disease
  • Immuno-competence

Physiologic Reserve Injury Severity Determines
High ISS
Physiologic Reserve
Moderate ISS
Physiologic Exhaustion
Host Factors Define Physiologic Reserve
Young Healthy
Physiologic Reserve
Underlying Disease
Host Factors
Age and Compensatory Responses to Trauma
  • Decreased vision and hearing
  • Slower reflexes
  • Poorer balance
  • Impaired motor/cognitive function
  • Decreased muscle mass/ strength
  • Decreased bone density
  • Less joint flexibility

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  • Most common mechanism of injury elderly
  • 5-10x more EMS calls than MVCs
  • 30 gt65 y/o fall each year
  • 6 result in fracture
  • 10-30 multi-trauma
  • Leading cause non-fatal injuries in GT
  • 7 mortality

Ground Level Falls(GLF)
  • Retrospective review NTDB
  • 32,320 elderly GLF (gt70 y/o)
  • Mortality 4.4
  • More likely to sustain
  • GCS lt15 significantly predicts mortality
  • 5x gt chance dying from GLF than younger population

Spaniolas, J.Trauma 2010 69821-825
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How do Geriatric trauma patients behave
  • Heffernan et al. demonstrated that normal
    presenting vital signs are unreliable in the
    geriatric trauma patient
  • Heffernan, D. S., Thakkar, R. K., Monaghan, S.
    F., Ravindran, R., Adams, C. A., Jr., Kozloff, M.
    S., et al. (2010). Normal Presenting Vital Signs
    Are Unreliable in Geriatric Blunt Trauma Victims.
    The Journal of Trauma Injury, Infection, and
    Critical Care, 69(4), 813820. doi10.1097/TA.0b01
  • Suggested that a heart rate greater than 90 or a
    systolic blood pressure less than 110 mmHg should
    be considered indicative of under-resuscitation
  • (Instead of heart rate greater than 100 and
    systolic blood pressure of less than 90 mmHg
    proposed from data on younger trauma patients)

Geriatric trauma patientsand occult
  • Several studies suggest that geriatric patients
    may suffer from occult hypoperfusion
  • Martin, J. T., Alkhoury, F., O'Connor, J. A.,
    Kyriakides, T. C., Bonadies, J. A. (2010).
    Normal vital signs belie occult hypoperfusion
    in geriatric trauma patients. The American
    Surgeon, 76(1), 6569.
  • Schulman, A. M., Claridge, J. A., Carr, G.,
    Diesen, D. L., Young, J. S. (2004). Predictors
    of Patients Who Will Develop Prolonged Occult
    Hypoperfusion following Blunt Trauma. The Journal
    of Trauma Injury, Infection, and Critical Care,
    57(4), 795800.
  • Normal vital signs mask inadequate tissue
  • Outcomes similar to patients who present in frank
  • Identifying these patients using modalities other
    than physical examination and vital signs
    critical for optimizing their resuscitation

Identifying geriatric patientswith occult
  • Lactate and base deficit have been identified as
    one risk stratification tool
  • Callaway, D. W., Shapiro, N. I., Donnino, M. W.,
    Baker, C., Rosen, C. L. (2009). Serum Lactate
    and Base Deficit as Predictors of Mortality in
    Normotensive Elderly Blunt Trauma Patients. The
    Journal of Trauma Injury, Infection, and
    Critical Care, 66(4), 10401044.
  • Jansen, T. C., van Bommel, J., Schoonderbeek, F.
    J., Sleeswijk Visser, S. J., van der Klooster, J.
    M., Lima, A. P., et al. (2010). Early
    Lactate-Guided Therapy in Intensive Care Unit
    Patients A Multicenter, Open-Label, Randomized
    Controlled Trial. American Journal of Respiratory
    and Critical Care Medicine, 182(6), 752761.
  • Neville, A. L., Nemtsev, D., Manasrah, R.,
    Bricker, S. D., Putnam, B. A. (2011). Mortality
    risk stratification in elderly trauma patients
    based on initial arterial lactate and base
    deficit levels. The American Surgeon, 77(10),
  • Others have even advocated for all geriatric
    trauma patients to receive the highest level
  • Full trauma resuscitation team comprised
    attending trauma surgeon, an attending emergency
    medicine physician, resident physicians in
    teaching institutions, and multiple dedicated
    nurses and technicians
  • Shifflette, V. K., Lorenzo, M., Mangram, A. J.,
    Truitt, M. S., Amos, J. D., Dunn, E. L. (2010).
    Should Age Be a Factor to Change From a Level II
    to a Level I Trauma Activation? The Journal of
    Trauma Injury, Infection, and Critical Care,
    69(1), 8892.

Geriatric Trauma Patients Designated vs.
Non-designated Trauma Center Care
  • Elderly patients
  • Less likely experience preventable adverse events
  • More likely have lower risk-adjusted mortality
  • If treated Trauma Center and/or hospitals with
    dedicated surgeon-intensivists
  • Maxwell, Miller et al. (submitted to AAST)
  • 43 of elderly patients are being admitted to
    non-designated trauma centers.
  • Non trauma centers admitting highest percentages
  • Oldest age groups/ co-morbidities
  • Falls
  • Femoral neck fractures
  • Major OR procedures

  • 80 GT patients have 1 or greater chronic
    diseases- Most Common
  • HTN
  • Arthritis
  • Heart disease
  • Pulmonary disease
  • Cancer
  • Diabetes
  • Stroke

  • Often initiating event for trauma
  • Diminished pre-injury functional status leading
    predictor of poor outcome
  • Substantially increase incidence complications
  • Probability of mortality increases as number of
    co-morbidities increase

Is advanced age a triage criteria for trauma
center referral and activation?
  • Level 1 Insufficient CLASS I and CLASS II data
  • Level 2
  • Age 65 and older, preexisting medical conditions
    should lower threshold for field triage directly
    to a designated trauma center
  • Advanced age alone should NOT be used as the sole
    predictor of poor outcome and basis for denying
    or limiting care
  • Initial approach should be aggressive unless
    experienced trauma surgeon deems injury burden
    severe or if patient seems moribund

Is advanced age a triage criterion for trauma
center referral and activation?
  • Level 3
  • Lower threshold for activation should be used for
    geriatric patients at trauma centers
  • One or more body systems with AIS 3, treated at
    designated trauma center in ICU staffed by
  • GCS lt 8, no improvement in 72hrs, consider
    limiting additional aggressive interventions

Is advanced age a triage criterion for trauma
center referral and activation?
  • Chang et al. 2008 10 year retrospective review
    in Maryland
  • 25,565 patients
  • Risk of under-triage in age group 65 was
    significantly greater than younger group
  • 49.9 vs. 17.8
  • Multivariate analysis (controlling for year, sex,
    physiology, injury, mechanism, EMS provider level
    training, presence or absence of specific
  • Age 65 is an independent risk factor for

Is advanced age a triage criterion for trauma
center referral and activation?
  • Literature supports that a large proportion of
    elderly patients return to independent living,
    and therefore
  • Age alone should not be used as the sole
    criterion for limiting care!!

Primary Survey
  • Adult / pediatric / pregnant - priorities
  • are the same!
  • A - Airway with C-spine protection
  • B - Breathing
  • C - Circulation with hemorrhage control
  • D - Disability
  • E - Exposure / Environment

  • Meds that affect initial evaluation/care
  • Anticoagulants
  • Beta blockers
  • ACE inhibitors
  • Consider common, acute, non-traumatic events that
    may have precipitated injury
  • Acute coronary syndrome
  • Hypovolemia/dehydration
  • UTI
  • Pneumonia
  • Acute renal failure
  • Cerebrovascular events
  • Syncope
  • Labs
  • BUN/Cr, lytes, blood alcohol, urine drug screen
  • Coagulation profile
  • ABG/VBG, lactate

  • Inspect oral cavity
  • Poorly fitting, loose dental appliances
  • Bag-valve mask difficult with edentulous airway
  • When in doubt- INTUBATE, especially with
  • Shock
  • Chest trauma
  • Mental status changes
  • Beware
  • Loss of kyphotic curve, spondylolysis, arthritis
  • Spinal canal stenosis, decrease cervical spine
  • RSI- medication doses adjusted in elderly
  • Age-related decline renal clearance/ hepatic
  • Increase sensitivity opioids, benzos, sedatives
  • All can drop BP, Etomidate can cause adrenal

  • Aging- myriad of effects on pulmonary function
  • Osteoporosis
  • Decreased rib durability
  • Increased incidence rib/sternal fxs
  • Pulmonary contusion even from low energy trauma
  • Weakened respiratory muscles/degenerative changes
  • Decrease CW compliance
  • Decrease pulmonary function- VC, FRC, I and E
  • Limited ability to compensate
  • Blunted responses to hypoxia and hypercarbia and
  • Delay onset clinically apparent signs impending
  • Early ABG/lactate

  • IV, 02, monitor
  • Normal BP- frank hypotension
  • Shock and Occult hypoperfusion (OH) predicts
    mortality in GT
  • Judicious fluids, blood and blood products
  • ABG/lactate/base deficit
  • Important in triage and resuscitation
  • Correlates with systemic hypoperfusion and shock
  • Early angiographic embolization playing
    increasing role in non-op management GT
  • Complex pelvic fractures
  • Splenic, liver, kidney lacerations

Use of Base Deficit in evaluating resuscitation
in Geriatric Trauma
  • Base deficit values of -6 mEq/L or worse marker
    of severe injury and significant mortality in all
    trauma patients but especially in the elderly
  • Base deficit -5 mEq/L or higher ? less than 23
  • Base deficit -6 mEq/L or worse ? 60 mortality

  • Elderly trauma risks for hypothermia and pressure
  • Poor nutrition
  • Loss of lean muscle mass
  • Microvascular changes
  • Blunted hypothalamic function
  • Rectal temperature and rewarming methods
  • Bair hugger
  • Increase ambient temperature
  • Humidifier on vent
  • Level 1 infuser
  • Reduce incidence of hypothermic-induced
  • Off back board, clear cervical collar, spine ASAP

Diagnostic Imaging
  • CXR- standard yet fails ID 50 rib fractures
  • Pelvis X-ray- rules out major pelvic fractures
  • CT scan
  • Primary mode evaluation in elderly
  • Low threshold
  • Radiation exposure not important issue
  • Contrast-induced nephropathy RFs
  • CRI, DM, dehydration, CHF
  • Management
  • Volume
  • bicarbonate/N-acetyl-cysteine (out of favor)
  • Low-osmolar, non-ionic contrast

Rib Fractures
  • Bulger et al- 277 patients over 65 with rib
  • For EACH rib fx increase risk pneumonia by 27
    and mortality by 19
  • Extensive literature describing increased
    morbidity and mortality with Chest Injury in GT
  • Pain management essential to reduce complications
    and death
  • PCA
  • Epidural
  • Comprehensive pain service

Pelvic Fractures
  • Most common after fall
  • Lateral compression fractures
  • Pubic rami
  • Acetabulum
  • Ischium
  • gt 50 multiple fxs
  • Higher rates hemorrhage
  • Binder/sheet
  • Transfusion
  • Angio-embolization
  • ICU admission
  • Look for other fracture
  • Hip with wrist/shoulder fractures

Traumatic Brain Injury(TBI)
  • Early diagnosis and treatment critical to improve
  • gt65 y/o 2-5x mortality of younger groups with
    matched GCS/intra-cranial pathology
  • Overall mortality TBI with ICH- 30-85
  • Brain weight decreases by 10 btw 30-70 y/o
  • Cerebral atrophy
  • Increase intracranial space
  • Mask ongoing bleed, subtle presentations, delay
  • More susceptible traumatic tears, subdural

TBI and Anticoagulants
  • Dramatically increase morbidity and mortality
    associated with elderly TBI
  • Coumadin
  • Independent predictor mortality TBI
  • 3-10 fold increase mortality in GT
  • Elderly more likely present with
    supra-therapeutic INR
  • Early protocol-driven reversal key to improving
  • FFP, Vitamin K
  • Prothrombin complex concentrates (PCC)
  • No good reversal strategies for anti-platelet
    agents (ASA, clopidogrel/plavix)
  • Platelet transfusion, desmopressin(DDAVP) and
    rFVIIa MAY offset some bleeding

How should coagulation-based coagulopathy be
  • Level 1 Insufficient CLASS I and CLASS II data
  • Level 2 Insufficient CLASS I and CLASS II data
  • Level 3
  • All patients on AC should have coagulation
    profile on admission
  • Suspected head injury should have immediate CT
    scan of the head
  • Patients on Warfarin with ICB should have
    correction of coagulopathy to lt 1.6x normal
    within 2hrs
  • -FFP and Vitamin K

How should coagulation-based coagulopathy be
  • Ivascu et al. Posttraumatic intracranial
    hemorrhage in elderly patients with
    Coumadin-related coagulopathy
  • Protocol
  • Rapid head computed tomography
  • Initiation of INR-correcting therapy within 1.9
  • Full correction of coagulopathy within 4 hours of
  • 75 decrease in mortality

TBI and Direct Factor Inhibitors
  • Dabigatran- direct thrombin inhibitor
  • Rivaroxaban- direct Xa inhibitor
  • High risk bleeding even with minor injury
  • Investigational studies on dialysis and PCC
  • Several case reports of mortality from GLFs and
    TBI in elderly patients with A.fib
  • Thromboelastogram(TEG) useful to ID presence of
    these drugs and platelet inhibitors

Geriatric Patients and Traumatic Brain Injury
  • Elderly patients with severe traumatic brain
    injury (GCS 8)
  • At least 80 mortality or long term placement
  • Justifies discussion regarding goals of care
    after initial phase of care and withdrawal of all

  • GT in-patient complication rate 33
  • Following most common and contribute to increase
    LOS, functional outcome and cost
  • Cardio-vascular compromise
  • Pneumonia
  • Delirium
  • Multi-organ failure
  • Preventable complication contribute to over 30
    of all GT deaths
  • Rest complications related to pre-existing
    conditions and age-related physiologic changes

  • Very common in elderly after injury
  • Associated with increase morbidity and mortality
  • Assess patients baseline cognition
  • Monitor daily- CAM-ICU, Mini Cog tools
  • Risk Factors
  • Cognitive impairment and dementia
  • Depression
  • Alcohol use
  • Poly-pharmacy and psychotropic meds
  • Poor nutrition
  • Hearing and vision impairment

Acute onset fluctuating course
PLUS either or both
Disorganized thinking
Altered LOC
  • Reversible Causes
  • Wake-sleep cycle disturbances and sleep
  • Immobilization
  • Hypoxia
  • Infection
  • Uncontrolled pain
  • Renal insufficiency, dehydration, electrolyte
    abnormalities and urinary catheter
  • Fecal impaction and constipation
  • Use of restraints

Principles in Management of GT patient toward
improved function
  • Treat individual, not just the injuries
  • Align team resources
  • Avoid AGEISM- stereotyping older patients
  • Emphasize respect/sense that GT patient viewed as
    an individual
  • Recovery highly individualized process
  • Understand unique capacities and limitations
  • Preserve as much independence and dignity as

Multi-disciplinary Treatment Plan
  • Early mobilization/ambulation
  • Standard care bundles
  • Within 24-48 hours
  • Assess fall risk
  • Aspiration precautions
  • Elevate HOB at all time with repositioning
  • Sit upright while eating and 2 hrs after
  • Evaluate for swallowing deficits
  • Chest PT- IS/deep breathing exercises
  • Early enteral nutrition
  • Pain control
  • Bowel regimen, especially with opiate use
  • Screen for presence of pressure ulcers- Braden or
    Norton scale within 24hrs
  • Assessment of cognition/sleep disturbances

Pain Management Strategies
  • Effective pain management central determinant of
    success in drive to improve
  • Pulmonary function
  • Optimize mobility
  • Mitigate delirium
  • Use elderly-appropriate meds and doses
  • Avoid benzodiazepines
  • Monitor use narcotics
  • Early implementation of PCA
  • Epidural analgesia especially with multiple rib
  • Consider non-narcotics
  • Tramadol

Specialized Geriatric Inpatient Care
  • Proactive geriatric consultation
  • Comprehensive Geriatric Assessment (CGA)
  • Multi-dimensional, multi-disciplinary diagnostic
  • Data on medical, psychological, functional
    capabilities and limitation in GT patients
  • Helps develop treatment and follow-up plans
  • 22 randomized trials/ gt 10,000 patients
  • CGA
  • Increased survival and likelihood to be home at 1
  • Fewer episodes of delirium
  • Decrease in-patient falls
  • Decreased length of stay
  • Decreased complication

Geriatric Trauma Service A one year experience
  • G-60 Geriatric Trauma Unit in Level II
  • Worked on collaboration
  • Medical hospitalist
  • Physiatrist
  • PT/OT/RT
  • Nursing supervisor with geriatric experience
  • Palliative care specialist
  • Compared before/after G-60- 280pts/393pts
  • Decreased time to OR
  • Decreased ICU and hospital LOS
  • Decreased complications
  • Decreased mortality rate

Mangram et al, J.Trauma 201272119-122
Discharge Planning
  • GT- trajectory of functional decline
  • Majority seriously injured elderly fail return to
    previous level independence and function
  • Psycho-social issues complicating care
  • Availability of caregiver
  • Home safety
  • ADL/follow-up
  • Develop plan for transition
  • Home environment, social support
  • Medical equipment and/or home health services
  • Patient acceptance/denial NH or SNF placement
  • Palliative care, comfort measures, hospice
  • Little known how to improve functional outcome of
    injured elderly

Discharge Document
  • Discharge diagnosis
  • Medications, clear dosing instructions, possible
  • Directions on wound care
  • Instructions for diet/supplements/bowel regimen
  • Mobility/home PT/OT
  • Contact information/ Follow-up appointments
  • Communicate with PCP
  • D/C summary and/or verbal communication
  • Home health visit/ phone call within 1-2 days D/C
  • Assess
  • Pain control
  • Tolerance food/liquids
  • Ability to ambulate
  • Mental status
  • Understanding of D/C instructions/medications

How can we conceptualize geriatrictrauma
  • Outcome in the geriatric trauma population has
    been conceptualized as the sum of anatomic
    injury, physiologic injury and patient reserve
  • Outcome Anatomic Injury Physiologic Injury
    Patient Reserve Error
  • Medical error might result from an inadequate
    appreciation of any of the three other factors,
    and thus lead to poorer outcomes

The AIG modelbailing out the geriatric trauma
  • AGE gt 75
  • ISS gt 15
  • GCS lt 15

Brooks, Murkerjee et al
Mortality and number of AIG risk factors

p 0.009 p lt 0.0001

EAST PMG Conclusions
  1. Elderly trauma patients should be treated at
    centers that have resources and have attained
    excellence in care
  2. In patients with ICB and Warfarin-induced
    coagulopathy, coagulation profile should be
    immediately assessed
  3. Base deficit of -6 mEq/L should be used as a
    marker for severe injury and admission to ICU
    should be considered
  4. Glascow Coma Score of 8, which remains low
    after 72 hrs warrants discussion regarding goals
    of care

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  • Elderly population (gt65) fastest growing age
  • Will account for majority of trauma admissions
    over the next 20 years
  • GT patients behave differently
  • Limited physiologic reserve
  • Ground level falls are NOT benign
  • Consider triage to designated trauma centers
  • Do not rely on normal vital signs
  • Pulse gt 90, SBPlt 110 risk of occult
  • Measure ABG/base deficit/lactate

  • Low threshold for CT scan
  • Rapid Head CT and correction of coagulopathy with
    ICH and anticoagulants
  • GCS lt 8 associated with poor outcome
  • Create multi-disciplinary team and treatment plan
    to reduce complications and improve outcome
  • GT patients eventually can return to productive
    lifestyle and independence