Trauma in the elderly and pregnancy

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Transcript Trauma in the elderly and pregnancy

Trauma in the Elderly
and Pregnant Woman
Introduction

In the pregnant trauma patient there are two patients potentially at risk

Need to consider the influence of:
-
pregnancy related anatomic changes
-
pregnancy related physiological changes
Incidence and aetiology of trauma in
pregnancy

A major contributor to maternal mortality worldwide

In NZ, Australia, UK and USA trauma is the leading cause of associated
maternal deaths

2/3’s : MVA

1/3:
- domestic violence
- assaults
- suicide

Pregnancy is a risk factor for being assaulted
Types of trauma

Penetrating (knife, foreign object)
- foetus at greater risk with enlarge uterus
- indications for laparotomy same as for non pregnant woman

Blunt ( MVA, assault)

Burns
- Foetus:
- consider fluid loss, hypoxaemia and sepsis
- Pregnant woman
- admit for smoke inhalation etc, add %5 to estimation if anterior
abdomen involved in burn
Mechanisms and Prevention

MVC:

leading cause of blunt injury
Only 46% pregnant trauma patients are restrained

Fears about seat-belt related harm to fetus

Lap belt low at the pelvic brim
Unbelted has 2x risk of premature birth and 4x
risk of fetal death
 Only 17% women counselled on appropriate use


significant cause of blunt and
penetrating injury
Violence:


ALWAYS HAVE A HIGH INDEX OF SUSPICION
Rule out domestic & sexual violence
Four groups of Trauma patients to
consider

The patient that is injured but unaware they are pregnant
- all women should be considered pregnant until proven otherwise
- Teratogenic effects

The pregnant patient where gestation < 26 weeks
- maternal resus primary goal

Where gestation >26 weeks
- two patients to consider

Perimorteum state
- early caesarean: maternal resus, fetal survival
Anatomy

Uterine enlargement
- 12 weeks, 20 weeks and 36 weeks
- at 20 weeks fundal height at umbilicus

Uterine wall thins

Amniotic fluid

Placenta

Descent of foetal head

Upward displacement of
- GIT
- Diaphragm
Estimated Foetal Age

1st trimester uterus is thick walled and intra-pelvic

Out of pelvis > 12 weeks

2nd trimester uterus contains a large amount of amniotic fluid

3rd trimester uterus is thin walled, large, fetal head engages pelvis


At 36 weeks uterus reaches costal margin
Ensure distended abdomen is 2dary
to fetus and not blood
Physiological changes in pregnancy

Cardiovascular

Respiratory

Haematological

Gastrointestinal

Neurological

Renal
Cardiovascular

Increases Cardiac output from first trimester

CO markedly increased by 20 weeks

HR increases by 15 beats/min

BP decreases by 10 mmHg, nadir @ 20 weeks, then increases to pre-pregnancy
values @ term

Decreased peripheral vascular resistance

Increased volume of distribution secondary to placenta

Maternal haemorrhage is compensated for by foetal distress ( compare to non
pregnant where the patient would become tachycardic and hypotensive
Supine Hypotension Syndrome

30 degree tilt after 20 weeks

Loss of 30% blood volume before symptomatic

Low venous return when supine ( up to 30%)
Respiratory System

By 20 weeks, decrease in FRC and an increase in tidal volume

No changes in FEV1 and respiratory rate

Respiratory Alkalosis:
- secondary to physiological hyperventilation
- resulting decrease in PaCO2, increase in PaO2 and a decrease in bicarbonate
concentration
Haematological System

Plasma volume increases by 45% (6-8 weeks)

Physiological anaemia - dilutional effect

Increased red cell mass

Haemoglobin 105/L

WCC 6,000 – 16,000 ( 1st and 2nd trimester)

WCC 20,000 – 30,000 (periparteum)

Hypercoagulable state

Fibrinogen concentration increases
Gastrointestinal System

Increased risk of gastric aspiration:
- secondary to increase in intra-abdominal pressure
- and relaxation of the lower oesophageal sphincter

Delayed gastric emptying

In a Trauma patient do early gastric decompression
Neurological

Enlarged pituitary
- result more susceptible to shock

Pre-eclampsia
- don’t forget this mimics head injury

Consider doses and which anaesthetic drugs to use
Renal System

Glomerular hyper filtration
-- therefore a reduction in normal plasma creatinine (35-40 mmol/l)
Case 1

27 year old female 8 months pregnant

Unbelted passenger involved in a high speed MVA

On arrival:

What next?


primary survey unremarkable
Obvious seat belt sign over pregnant abdomen
Seat belt
Vital Signs enroute

HR
104/min

Respiratory Rate 25/min

BP 104/54

SpO2 98% on room air
On arrival

Patient is confused, agitated and not following commands

She is breathing rapidly and shallowly

Her Vital signs are now:
- HR 120/min
- BP 90/40
- SpO2 92% on 2l Nasal Prongs
Examination

She has bruising to her abdomen

There is subcutaneous emphysema of the chest wall

What now?
? Intubation
? Fast Scan

How sensitive is a fast scan in pregnancy?

How are you going to manage her airway?
FAST SCAN

Is less sensitive for free fluid in the pregnant patient than in non-pregnant
patients

Sensitivity decreases with gestational age secondary to altered fluid flow in
the abdomen

Remember small amounts of intraperitoneal fluid normally present in
pregnancy
How do you Know she is Pregnant?

Ask her?

bhCG on all women of childbearing age
- bHCG doubles q 1.6 days early on then q 3 -4 days by 7th week
- if > 18000 can see gestational sac

Ultrasound / FAST
- 11% pregnancy diagnosed in the trauma room
Outline of Trauma in Pregnancy

Primary survey and resuscitation of mother

Foetal assessment and detecting injury

Secondary survey of mother with special considerations

Perimortem Caesarean section
- fetomaternal haemorrhage
- imaging
- medication

Critical Care concerns

Mechanism & Prevention
EARLY OB CONSULT
Trauma in Pregnancy

Hospitalization in 0.4% of pregnant women

Leading cause of non-obstetrical mortality

Causes of death
Mother head injury
foetus
- maternal shock
- placental abruption
- direct injury (GSW to fetus or pelvic fractures of mother

What do I need to do care for the unborn child?
- CARE FOR THE MOTHER
Mother - Initial Management

A : Endotracheal intubation, avoid nasal passages

B: (pre)oxygenate well ( will desaturate < 1min)

Watch potential for aspiration, watch chest tube placement

C: foetal distress first sign of maternal hypotension
- Supine Hypotensive Syndrome (SHS) (tilt to left >20 wks)

D: Eclampsia vs brain injury

E: Estimate age of foetus
Resuscitation

Call for help early
- multidisplinary team
- involve an obstetrician

Displace uterus laterally and left if above umbilicus

Assess ABC

Estimate gestational age if not known

Uterine fundus > 4 finger breaths above umbilicus at
4 months

If defibrillation, remove foetal monitoring equipment
Tilt to left
Why displace uterus laterally?

After 20 weeks gestation, uterus may compress great vessels when patient
supine

The compression causes:
- decrease in systolic BP up to 30 mmHg
- 30% decrease in stroke volume
- Result decreased uterine blood flow

Manual deflection or placement of patient in lateral decubitus position
avoids uterine compression
Mother Physiology

A: friable mucous membranes (E2), decreased LES tone, increased abdominal
pressure

B: higher diaphragm – 20% less FRC, 20% increased oxygen consumption

Increased Vt and minute ventilation (50%)

C: Elevated HR (10-15), SV (23%), CO (25 – 43%) – anaemia with
hypervolaemia

- lower SVR, BP 10 – 15 mmHg/lowest 2nd trimester

Low venous return when supine (30% C))

BLOOD > 10 weeks increasing plasma (45% at term) > increased RBC (15-30%)
- CAN MASK UP TO 30% blood loss

Hypercoagulable state
Respiratory Support

Supplemental oxygen

Anoxia develops more quickly in advanced pregnancy like this case because of the
respiratory physiology during pregnancy
- increased RR (40 to 50%)
- oxygen consumption increased by 15 to 20% at rest
- PaO2 increased
- PaCO2 decreased
- decreased bicarbonate

Aim for oxygen saturations > 95%

ABG for PaO2 and PaCO2

Placental oxygenation good when PaO2> 70 mmHg
? Chest Tube for this pregnant patient?

Yes surgical emphysema

Remember diaphragm in a higher position
- Result: place chest tube one or two interspaces higher
Cardiovascular

Signs of maternal haemorrhage?
- look for foetal distress

NOTE: significant blood loss can occur in the uterine wall or retroperitoneal
space without external bleeding

30% maternal blood loss before respiratory distress
Volume Replacement

2 large bore IV lines

Volume replacement superior to vasopressors that can reduce uterine blood
flow initially

Continue until hypovolaemia, hypoxia and foetal distress resolve

Aim to maximise uterine perfusion and oxygenation

Start blood transfusion if significant blood loss suspected or occurred
Abdominal changes in pregnant woman

Pregnant women sustain abdominal trauma more easily

The enlarged uterus
- protects against visceral injury from lower abdominal penetrating injury
- protect retroperitoneal structures

Penetrating injuries above uterus are more likely to cause bowel injuries

Rebound tenderness and guarding less prominent
Increased vascularity and blood flow

Dilated pelvic vasculature
- increased risk of retroperitoneal haemorrhage from abdominal and pelvic
trauma

Blood flow to uterus 600ml/min

Foetal oxygenation is dependent on uterine blood flow, there is no
autoregulation

Uterine blood flow also reduced by
- vasoconstriction (drugs)
- maternal hypercarbia and hypocarbia
Complications of Trauma
Often life-threatening

Uterine rupture

Placental abruption

Amniotic fluid embolism

Fetomaternal haemorrhage and alloimmunization

Preterm labour

Premature rupture of membranes

Serious pelvic injury can lead to maternal hypotension as a result of direct
injury to foetus, uterus, placenta and uterine vessels
Causes of maternal death

Most are due to head trauma or haemorrhage shock
Commonest cause of Foetal death

In severe maternal injury, it is maternal death

In “minor” injury it is placental abruption
Factors associated with increased foetal
mortality

Maternal hypotension

High maternal injury severity score

Ejection from motor vehicle

Maternal pelvic fracture

Car vs pedestrian

Maternal history of alcohol use

Motorcycle crash

Maternal smoking history

Uterine rupture

Ref American Family Physician October 2004: 70 (7) p1303
Foetal Viability by age
Beyond umbilicus is likely viable (> 24 weeks)
Foetal Assessment



Avoid fetal hypoxia at all costs

Maternal blood oxygen content

Uterine blood flow
Fetal oxygen dissociation curve is shifted to left: small change in
maternal PaO2 = large change in fetal oxygen saturation
Avoid maternal hyperventilation

Maternal alkalosis poorly tolerated

Leads to uterine vasoconstriction
How Do I manage the Foetus

Resuscitate the mother


Oxygen & blood
Monitor the fetus

cardiotocographic monitoring (CTM)
 if

>20 weeks, x 6 hrs (EAST Guidelines, 2005)
Watch for warning signs of injury to the fetus

Vaginal bleeding, fetomaternal hemorrhage, uterine
contractions, uterine rupture, placental abruption,
premature labour
 Fetal distress is often first sign of maternal hypotension
Foetal Injury

Treat maternal injuries first

Uterine rupture: rare, rapidly fatal

Placental abruption: 3-50% of trauma
- >50% fatal for foetus
- Uterine contractions, pain, bleeding 78%)
- Can lead to DIC, haemorrhagic shock, renal failure

Can bleed profusely with pelvic fracture due to dilated veins
- Foetus rarely directly injured until 3rd trimester (skull, long bones)

Kleihauer-Betke(KB) test to detect foetal blood mixed into maternal blood
Foetal Monitoring

•

A) Uterine contractions:
90% stop spontaneously
B) Fetal HR:
•
Normal HR (120-160)
•
Beat to beat variability
•
Baseline variability
•
Decelerations (esp. late)
Foetal Monitoring
Case:




She becomes hypotensive
-
how do you manage this?
She now goes into cardiac arrest in the resuscitation bay after CT
-
how do you manage this
How do you CPR in a pregnant Trauma
patient?

External chest compression more difficult
- decreased chest compliance

Hand position on sternum
-
above centre
-
need to accommodate for upward displacement of the diaphragm
by gravid uterus

May be not effective 2nd and 3rd trimester:
- aortacaval compression
- decreased cardiac output

May require a caesarean to perform effective CPR
- within 4-5 minutes
Secondary survey

Medical and Obstetric History

Head to toe physical examination

Include a pelvic examination to identify:
- vaginal bleeding
- ruptured membranes
- bulging perineum

Log roll to the left

Consider imaging

Bloods: FBC Coags, U & E’s KB test ( kleihauer – Betke test for patients in
their 2nd and 3rd trimester)
Secondary Survey and Considerations

Secondary Survey:

Pelvic examination:
◦
◦
◦
◦

Ongoing CTM:
◦
◦

Vaginal bleeding
Ruptured membranes
Bulging perineum
Prolapsed cord
Presence of contractions
Abnormal fetal heart rate and rhythm
Special considerations:
Fetomaternal hemorrhage
 Imaging
 Medications

Consider Domestic violence

Pregnancy often represents dependency and loss of autonomy and control

Abusers will take advantage of this

Think of it as a possibility

Look for signs
- emotional withdrawal, depression, self-blame
- look for signs of older injury
Imaging Concerns

Do not defer imaging as pt. is pregnant
(benefit outweighs risk)


Risk related to ionizing radiation and IV contrast





i.e. Fetal risk of harm less than risk of death/ harm
from missed injuries or delays in treatment
CXR: 0.001 rads
CT abdo/pelvis: 0.6-5.0 rads
Teratogenicity:

Fetal exposure to 10 – 50 rads in first 6 weeks of gestation

Increased risk of childhood leukemia's (RR 1.5-2.0)

Mental retardation with 5 – 15 rads at 8-15 weeks

Therefore exposure to < 5 rads is safe
Oncogenicity:
Other:
No increase in fetal anomalies or pregnancy loss if < 5 rads
exposure (American College of Obstetrics & Gynecology)
Diagnostic Imaging

Foetus most vulnerable during 1st 15 weeks of gestation

Risk of radiation is small compared to risk of missed or delayed diagnosis of
trauma

X-rays of extremities, CT scan of head and neck should be undertaken if
necessary

USS can assess solid organ injury, intraperitoneal fluid, gestational age, fetal
activity, foetal presentation, placental location and amniotic fluid volume

USS is not as reliable an indicator in recent placental abruption
CT scan
Fetomaternal haemorrhage


Mixing of fetal blood into maternal circulation
Complications:
◦
Maternal isoimmunization
◦


Mother Rh (-), fetus Rh (+)
◦
Fetal exsanguination
◦
◦
All pregnant women > 12 weeks gestation
Watch false positives with sickle cell trait
•
•
300 mg IM (72 hr. window), repeat in 12 weeks
+ 300 mg for each 30ml of fetal-maternal transfusion
KB test to detect fetal Hb in maternal
circulation
RhoGAM® if KB test positive
Medication Concerns
A) Direct risk of teratogenicity or death to
the foetus
SAFE
 Tetanus toxoid
 Fentanyl, morphine
 LMW Heparins
 Propofol
 Cephalosporins
 Penicillins
AVOID
 Benzodiazepines
 Metronidazole
 Warfarin
 Pancuronium
 Furosemide
 Prednisone
Direct risk of placenta vasoconstriction
and hypoxia

Most vasoconstrictors
Caesarean Delivery

Urgent delivery if imminent maternal death

CPR not successful within 4 minutes

Stable mother, non-reassuring CTG

During laparotomy, gravid uterus prevents adequate surgery for injuries

Perimortem Caesarean section for optimum survival of foetus an mother if
within 4 min
- irreversible brain da,mage after 4 – 6 min
- pregnant patient anoxia sooner
- Effective resuscitation with empty uterus
- Improved fetal survival with shorter time to delivery
Summary

In pregnant trauma usual ABC management principles apply BUT need to
be more vigilant



Oxygen and IV fluids for all

If mom >20 weeks, tilt left side down
Best chance for fetus is to treat mother well
 If mom Rh (–) think of Rhogam
 Don’t defer important imaging
 Give appropriate medications
Involve obstetricians early in the trauma

Estimate fetal age
References

Queensland Clinical Guidelines Trauma in pregnancy 2014

Guidelines for the management of a pregnant trauma patient by Society of
Obstetricians and Gynaecologists of Canada June 2015

Imaging of the Trauma in a pregnant patient (Seminars in USS CT and MRI
2012)

Trauma management of the pregnant patient Critical Care Clinics 32 (2016)
109-117

Blunt Trauma in Pregnancy American Family Physcian 2004 (70) 7 1303 – 1310

Trauma in the pregnant patient: an evidence based approach to management
EBMEDICINE.Net April 2013 (15) 4
Trauma in the elderly patient
What are the issues in trauma in this
group

Mechanisms of trauma

Are the injuries different than in the younger age group?

Should you use a different diagnostic approach?

Do therapeutic options differ for these patients?

Are they often under triaged because of their age?
Epidemiology

People have a longer life expectancy ( 82 years by 2050)

Rapid increase in “older” adult population

By 2030 1 in 5 people will be > 65

They are more independent and have a more active lifestyle than in previous
generations

Result: more injuries
The realities of growing old
Mobility scooter racing
Geriatric marathons
General

The elderly account for 10 to 12% of all trauma victims

They consume a significant amount of health care resources ( up to 255 of
trauma related)

They have higher mortality rates

Higher complication rates
Definitions

Elderly = over age 65 years

Young- old = 65 – 80 years

Old old = over age 80 years

ATLS Recommendations:
- all traumatized patients > 55 should be considered for evaluation in a
trauma centre
- physiological age more important than chronologic age
“Joys” of growing old:
Physical realities

Loss of hearing

Deteriorating vision

Weakening of musculoskeletal system

Breakdown of skin hydration/replacement cycle

Body becomes less efficient

Existence of multiple chronic diseases

Multiple medications
Cardiovascular

Less cardiovascular reserve

Less vascular compliance

Less cardiac compliance

Diminished catecholamine response ( less beta receptor activity)

Poor AV conduction/loss of pacemaker cells

Decline in cardiac index linearly with age ( CO(SV x HR)/BSA

Respond to hypovolaemia with increased SVR vs increased CO

Unable to tolerate and respond to fluctuations in blood volume
CVS continued

Underlying CAD increases risk of myocardial infarction ( 50% pts> 65 have
CAD)
- hypoxia
- anaemia
- hypotension

Medications affect response to trauma
- beta-blockers
- calcium channel blockers
- diuretics
CVS

Hypertension
- ? Baseline BP, may mask early shock
- 110 the new SBP not 90

CHF

Dysrhthmia

PVD
Respiratory

Lung less compliant

Increased dead space
- hypoventilation/illness/immobility

VC, FEV1, PaO2 decrease with age

Increased residual volume

Respiratory muscle weaker in the elderly

Airway management may be affected by changes in the aging

Chest wall more rigid and brittle
- result more prone to traumatic injuries
Respiratory continued
Diminished alveolar surface

-
diminishes max O2 uptake by as much as 55%

Less responsive to hypoxia

Less cilia

Chromic lung disease
- Restrictive/obstructive
- hypoxia/hypercarbia
Neurological

Dura adherent to inside of skull

Brain atrophies
- more tendency to move inside skull during trauma
- more likely to develop CNS bleeds

Spinal stenosis can complicate evaluation

Cognitive impairment increases with age

Decreased reaction times
Musculoskeletal

Osteoporosis
- more prone to fractures

Decreased joint mobility
- spinal column problematic

Vertebral compression

Kyphosis/lordosis
Medications

Anticoagulants
- increased risk of bleeding

Cardiac medications
- beta and calcium-channel blockers
- affect response to volume loss

Diuretics
- volume contraction
- potassium depletion
Predisposing factors for trauma

Diminished sight

Problems with gait/coordination
- impaired sensation/proprioception
- muscle weakness
- degenerative joint disease
- neuromuscular disorders
- dementia

Diminished hearing
Renal/urinary

Renal perfusion decreases by 10% per decade

Hormonal response decreases (vasopressin)
- impaired sodium retention

Less bladder capacity/compliance

Chronic renal failure/impairment

Nephrotoxic medications/infusions

Hydration status
Characteristics of injury in the elderly

Mores severe response to any given mechanism

Decreased ability to respond to trauma

Trauma can trigger/exacerbate pre-existing medical problems

Patterns of injury differ in the elderly
Mechanisms of Injury

What is the most common mechanism of injury in the elderly?

What is the most common LETHAL mechanism of injury in the elderly?
Mechanisms

Falls

MVA

Car vs pedestrian

Elder abuse/assault/burns

Penetrating trauma
Falls

Most common mechanism

40% of elderly trauma

3.8% of elderly have a significant fall each year

Ground falls most common

Usually occur at home

28% of falls due to an underlying medical condition

MUST determoine cause of fall
Injuries sustained from falls

Fractures
8%

Major injuries 10%

Peri-injury fatality rate from falls 12%

50% will die within one year of fall

Head injuries a significant problem
- 1 in 50 may require neurosurgery
- up to 16% will have n abnormal CT ( contusion 36%, Subdural 33%)
- highest risk fall on stairs or from height
- fall from a standing position still a significant risk
MVA second most common mechanism

28-30% of all trauma in the elderly

Fatality rate 21%
Accident Characteristics MVA

Occur in daytime

Close to home

At an intersection

Usually involve 2 cars

Frequently due to a syncopal episode

Less likely due to alcohol, excessive speed or reckless driving
Auto vs Ped

Third most common mechanism

Accounts for 9 to 25% of trauma case

Fatality rate
- 30 -55%
- most common lethal mechanism
Specific Injuries

Spinal

Head

Chest

Aortic

Abdominal

Extremity

Soft tissue
Spinal

Aging predisposes to spinal injury

Most common mechanism is falls

Requires extreme caution

Low threshold to image spine

Bony injuries
- most commonly occur C1 – C3
- type II odontoid fracture most common

Spinal cord injuries
- often from hyperextension
- central cord syndrome
Spinal

Mortality rate 26%

Thoracic and lumbar spine
- compression fractures most common
- may occur with minimal trauma
- common in osteoporotic patients
-
Head Injury

Most common mechanism is falls

Types of injury
- Cerebral contusion
- lower incidence than younger patients
- epidural haematomas
- dura adheres to inside of skull
- subdural haematomas
- more common with age
- stretching of bridging veins
- greater movement of atrophied brain
- more likely to be on anticoagulants
Head Injury

Assessment difficult
- history may be difficult to obtain
- subtle alterations in baseline mental status difficult to evaluate
- may mimic dementia

Low threshold to get head CT
- isodense SDH at 7 – 20 days after injury
- may need iv contrast
- often undertriaged
Head injury

High mortality and morbidity
- survival to discharge
21%
- favourable outcome 11%
- mortality higher still if patient over 80 ( 4x
Chest Injuries

Chest Wall injuries
- Highly morbid and mortal injuries
- predisposing factors
chest wall more rigid
osteoporosis
less pulmonary reserve
Chest Injuries

Rib Fractures
-
more common injury
-
more prone to complications ( pneumonia, hypoventilation)
- Lap-shoulder belts do not prevent these injuries
- actually may cause them
- check for rib fractures, sternal fractures, flail chest
Aortic injuries

Suspect if mediastinum > 8 cm

Low threshold to perform CT chest or aortogram
Abdominal Injuries

Seen in up to 30% of elderly trauma victims

Abdominal USS unreliable

CT if haemodynamically stable

Mortalit rte 4 – 5 times higher than in younger patients
Management of Elderly Trauma patient
Pre hospital

- rapid transportation
-
early assessment
- information from witnesses/prehospital personnel key

Watch closely for rapid deterioration
Airway/breathing

All need supplemental oxygen

Airway management maybe difficult

BMV - cachexia, edentulous

Intubation
- decreased mouth opening
- decreased neck mobility
- RSI drugs choices maybe limited by pre-existing medical conditions
Circulation

Fluid/ blood resuscitation may be complicated by pre-existing medical
conditions

Medications alter response to resuscitation
History


What happened BEFORE the trauma
Fall
- consider syncope, hypovolaemia, CV or CVA, alcohol

Single Car MVA
- consider acute medicl event
Traps

BP
- may be deceivingly normal
- many patients have underlying hypertension
- increasing SVR is response to hypovolaemia

Pulse
- maybe falsely normal
- medication effects
- decreased catecholamine response
Imaging

Spine plain plus CT

CXR

Echocardiography

FAST

Head CT
References

ACS TQIP Geriatric Trauma Management Guidelines American College of Surgeons
2014

Evaluation and management of geriatric trauma An eastern association for the
Surgery of Trauma practice management guideline J Trauma Acute Care Surg (73) 5
supplement 4 S345 –S369

The Changing face of major trauma in the UK Emerg Med J 2015;32:911-915

Polytrauma in the elderly: predictors of the cause and time of death Scandinavan
Journal of Trauma, Resuscitation and Emergency Medicine 2010 18-26

Injury in the aged: Geriatric Trauma at the crossroads Review Trauma Acute Care
Surg (78) 6 2015 1197-1209

Systolic Blood pressure criteria in the national Trauma Triage Protocol for geriatric
trauma 110 is the new 90 J Trauma Acut Care Surg 78 (2) 352-359