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Geriatric Trauma: Evolving Concepts in a Rapidly Growing Population

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


1
Geriatric Trauma Evolving Concepts in a Rapidly
Growing Population
  • Richard S. Miller, MD FACS
  • Professor of Surgery
  • Chief, Division of Trauma and Surgical Critical
    Care
  • Vanderbilt University Medical Center

2
Disclosures
  • None

3
Objectives
  • Review epidemiology of geriatric trauma (GT)
  • Discuss mechanisms and physiology unique to the
    elderly
  • Describe approach to management of GT
  • Pre-hospital
  • In-patient care
  • Discharge planning
  • Evaluate decisions
  • Advanced directives
  • Palliative care
  • End of life discussions

4
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
    years
  • 46 million - 2010
  • 81 million - 2030

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8
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
    derangement
  • Higher risk of death than younger patients with
    the same traumatic insult

9
Physiologic Reserve
  • Defined As
  • The Individual's Ability To Tolerate Injury
  • Function Of Unique Host Factors
  • Age
  • Gender
  • Preexisting Disease
  • Immuno-competence

10
Physiologic Reserve Injury Severity Determines
Slope
High ISS
Physiologic Reserve
Moderate ISS
Physiologic Exhaustion
Death
Time
11
Host Factors Define Physiologic Reserve
Young Healthy
Age
Physiologic Reserve
Underlying Disease
Host Factors
12
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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15
Falls
  • 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

16
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
17
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18
How do Geriatric trauma patients behave
differently?
  • 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
    3e3181f41af8
  • 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)

19
Geriatric trauma patientsand occult
hypo-perfusion
  • 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
    perfusion
  • Outcomes similar to patients who present in frank
    shock
  • Identifying these patients using modalities other
    than physical examination and vital signs
    critical for optimizing their resuscitation

20
Identifying geriatric patientswith occult
hypoperfusion
  • 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),
    13371341.
  • Others have even advocated for all geriatric
    trauma patients to receive the highest level
    activation
  • 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.

21
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

22
Co-morbidities
  • 80 GT patients have 1 or greater chronic
    diseases- Most Common
  • HTN
  • Arthritis
  • Heart disease
  • Pulmonary disease
  • Cancer
  • Diabetes
  • Stroke

23
Co-morbidities
  • 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

24
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

25
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
    surgeon-intensivists
  • GCS lt 8, no improvement in 72hrs, consider
    limiting additional aggressive interventions

26
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
    injuries)
  • Age 65 is an independent risk factor for
    under-triage

27
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!!

28
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

29
History
  • 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

30
Airway
  • 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
    mobility
  • RSI- medication doses adjusted in elderly
  • Age-related decline renal clearance/ hepatic
    function
  • Increase sensitivity opioids, benzos, sedatives
  • All can drop BP, Etomidate can cause adrenal
    insufficiency

31
Breathing
  • 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
    force
  • Limited ability to compensate
  • Blunted responses to hypoxia and hypercarbia and
    acidosis
  • Delay onset clinically apparent signs impending
    distress
  • Early ABG/lactate

32
Circulation/Resuscitation
  • 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

33
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
    mortality
  • Base deficit -6 mEq/L or worse ? 60 mortality

34
Disability/Exposure
  • Elderly trauma risks for hypothermia and pressure
    sores
  • 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
    coagulopathy
  • Off back board, clear cervical collar, spine ASAP

35
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

36
Rib Fractures
  • Bulger et al- 277 patients over 65 with rib
    fractures
  • 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

37
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

38
Traumatic Brain Injury(TBI)
  • Early diagnosis and treatment critical to improve
    outcome
  • 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
    dx
  • More susceptible traumatic tears, subdural
    hematoma

39
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
    outcome
  • 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

40
How should coagulation-based coagulopathy be
treated?
  • 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

41
How should coagulation-based coagulopathy be
treated?
  • 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
    hours
  • Full correction of coagulopathy within 4 hours of
    admission
  • 75 decrease in mortality

42
TBI and Direct Factor Inhibitors
  • Dabigatran- direct thrombin inhibitor
  • Rivaroxaban- direct Xa inhibitor
  • High risk bleeding even with minor injury
  • NO MEANS OF REVERSAL
  • 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

43
Geriatric Patients and Traumatic Brain Injury
  • Elderly patients with severe traumatic brain
    injury (GCS 8)
  • At least 80 mortality or long term placement
    disposition
  • Justifies discussion regarding goals of care
    after initial phase of care and withdrawal of all
    sedatives

44
Complications
  • 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

45
Delirium
  • 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

46
DELIRIUM
Acute onset fluctuating course
Inattention
AND
PLUS either or both
Disorganized thinking
Altered LOC
DELIRIUM
47
Delirium
  • Reversible Causes
  • Wake-sleep cycle disturbances and sleep
    deprivation
  • Immobilization
  • Hypoxia
  • Infection
  • Uncontrolled pain
  • Renal insufficiency, dehydration, electrolyte
    abnormalities and urinary catheter
  • Fecal impaction and constipation
  • Use of restraints

48
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
    possible

49
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

50
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
    fractures
  • Consider non-narcotics
  • NSAIDS
  • Tramadol

51
Specialized Geriatric Inpatient Care
  • Proactive geriatric consultation
  • Comprehensive Geriatric Assessment (CGA)
  • Multi-dimensional, multi-disciplinary diagnostic
    instrument
  • 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
    year
  • Fewer episodes of delirium
  • Decrease in-patient falls
  • Decreased length of stay
  • Decreased complication

52
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
53
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

54
Discharge Document
  • Discharge diagnosis
  • Medications, clear dosing instructions, possible
    reactions
  • 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

55
How can we conceptualize geriatrictrauma
outcomes?
  • 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

56
The AIG modelbailing out the geriatric trauma
patient
  • AGE gt 75
  • ISS gt 15
  • GCS lt 15

Brooks, Murkerjee et al
57
Mortality and number of AIG risk factors

p 0.009 p lt 0.0001


58
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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Summary
  • Elderly population (gt65) fastest growing age
    group
  • 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
    hypo-perfusion
  • Measure ABG/base deficit/lactate

61
Summary
  • 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
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