Transcript Geriatric Trauma

Geriatric Trauma
Alan Sori, MD
St. Joseph’s Regional Medical Center
Paterson, NJ
Patients

65 yo female falls on a bus – severe brain
injury
ICU – found to have a prolonged QT interval
 Echo – severe cardiomyopathy
 Needs an ICD
 In

75 yo male falls- two broken ribs.
 Multiple
medical co-morbidities
 Develops pneumonia, dies two weeks after injury
What is Geriatric Trauma?
No. 5 cause of death for age > 65.
 Mortality in most series averages 15 to 30%.

4

to 5 X mortality of younger patients.
Mortality start to increase at age 45 for males.
 ACS
- MTOS
Geriatric Trauma - Questions

What is old?
 Does
age matter and what age?
– Physiology of aging.

Triage of elderly trauma victims.
 Injury
patterns and physiologic responses.
What is the optimal resuscitation of the older
trauma patient?
 Outcomes in the elderly trauma patient?

Geriatric Bias

Documented bias in medical care:
 Rehabilitation
placement.
 Breast cancer management.
 Thrombolytics.
 Trauma triage.

“Therapeutic Nihilism”
Epidemiology

Age > 65: 12.5% population (30 million)
 2020
- 52 Million (20% population)
 At age 85 life expectancy is 5 to 7 years.
– Better health and increased activities.
 65+
are hospitalized for trauma at 2X the rate of
younger patients
– 25% of all trauma deaths
beds – 15% of all hospital beds and 30% of
hospital costs
 ICU
Epidemiology
>65 use 33% of all health care dollars and
25% of all trauma care money.
 Medicare - DRG based- grossly underpays
hospital costs for trauma, esp. in the elderly

 Avg.
reimbursement 40 to 65% of total hospital
costs.
– Increased age and ISS - worse reimbursement.
Geriatric Recidivists

Washington state Medicare population.
>
65 injured - 2X more likely to be admitted with a
new injury than uninjured person in next 24
months.
 ISS 16 to 24 - new injury risk 4x normal
population.
 Inc risk in patients with COPD, liver disease, age.
J. Trauma 1996: 41(6) p. 952
Physiology of Aging

Aging is the progressive loss of individual
organ function.
 Gradual
and continuous.
 Not directly related to age.
 Significant age related mortality differences are
apparent by age 40 in males.
 Co-morbidities: 15% at age 35, 70% at 75.
J. Trauma 1990: 30(12) p. 1476
Physiology of Aging

The extent of physiologic alterations and he
onset of those alterations are highly variable.

Most elderly well compensated for changes
in aging but have very limited physiologic
reserve that becomes evident during times of
stress or illness.
Cardiovascular

Most prominently affected.
 Myocardial
degeneration:
– Inelastic heart - decreased cardiac output.
– Diastolic dysfunction.
 Altered
conduction system
– Maximal HR decreases
 Beta
adrenergic receptor function decrease.
 Coronary artery disease.
 Hypertension - Meds
Pulmonary System
Decreased functional reserve.
 Thoracic cage - more brittle, stiff.

 Decreased
compliance
 Increased work of breathing.
 Dec. alveolar ventilation
 Inc. V/Q mismatch.
Renal System

40 to 50% nephron loss by age 65.
 RBF
decreases to 50%
 Dec. GFR, CrClr.
 Serum creatinine - poor indicator of renal function.
 Dec ADH sens, dec. thirst - chronic dehydration.
Musculoskeletal
Dec. muscle mass and strength.
 Progressive deterioration of cartilage and
ligaments

 starts
at age 30.
Age related bone loss.
 Dec. reaction times.
 Widened, unsteady gate.

Misc.
Glucose intolerance.
 Dec. LBM, BMR, need for calories.

 Need
for other nutrients unchanged.
Vit A, Vit C, Zinc deficiencies.
 Immune senescence

T
cell and B cell function.
Misc.
 Thyroid
hormone dec, tissue response decreases.
 Increased intra-cranial space - atrophy.
– Increased movement of brain during injury.
– Increased risk of subdural hematomas.
 Decreased
cognitive ability, memory and
judgment.
– Senescence of senses
Etiology of Trauma

Age 65 to 75 - MVCs - most common
 Elderly
have the highest rate of accidents / miles
driven
Age 75+ - falls number one.
 MV vs Pedestrians
 Suicide - biphasic incidence

 Increasing

incidence in males >65.
Increased incidence of penetrating trauma,
elder abuse.
Falls

Most common mechanism overall.
 65+:
30 % sustain a fall each year requiring
medical treatment
 85+: 50 % fall each year
 40% of all nursing home admissions related to
falls.
 Most falls are single level or low bilevel.
J. Am. Geriatric Soc. 1986: 34 p 119
Falls

Risk Factors
 Dementia,
visual impairments
 Lower extremity and foot diseases
 Gait and balance problems.
 Meds, med. problems, postural hypotension,
neuro- muscular disease.

Usual falls - ladders, roofs, stairs
 Injury
falls.
patterns are more severe for all levels of
Falls

Population based study:
 336
people – average age 78
– 108 (32%) fell in past year
– 48% - once, 29% - twice, 25% - three +
– 77% falls at home.
 Risk
factors:
– sedative use
– Cognitive impairment
– LE disability
- Palmomental reflex
- Foot problems
- Balance / gait
NEJM 1988: 319(26) p.1701
Falls

Falls: 159 / 333 adms- age 65+ (48%)
 83
falls age < 65 (7% total)
 ISS > 15: 50(32%) elderly, 12 (15%) young.
– Falls are 2/3 of all elderly w ISS > 15
– Same level w ISS >15 - old (30%), young (4%).
 Fall
deaths: 11 (7%), younger - 4%
– 11/20 deaths overall due to falls (55%)
J. Trauma 2001: 50(1) p. 116
MVCs

Age 75+ - second highest crash rate
 Highest
accident rate per miles driven.
– Highest fatal accident rate.
 Changes
in perception, judgment, decision
making ability and reaction times.

MV vs pedestrians:
 Most
severe of all elderly injuries.
– Highest fatalities
 Majority
occur in cross walks.
MVA- Driver Characteristics

I year period - Level 1 trauma center
 84
drivers age >60
– 67/ 84 (80%) - at fault according to police.

Running stop signs, red lights, failure to yield - most common
– 35 ( 42%) - single car crash.
– Daytime- 80%
– Good weather - 95%
– ETOH - 5%
– Low speed / intersections common
Am.Surgeon 1995: 61(5) p. 935
Elderly Abuse

Estimated 1 million cases / year.
 Physical
violence
– May not be as apparent as child abuse.
 Emotional
abuse
– Threats of abandonment or institutionalization.
 Material
exploitation.
 Neglect (may be unintentional)
– Dehydration / malnutrition, mental status changes.
Elderly Abuse

2020 elderly - 3.7 % reported abuse
 2.2%
physical, 1.1 % emotional
– 2/3 spouse, 1/3 adult child

Risk Factors
 Physical
frailty and cognitive impairment.
 Living with abuser
– Substance abusers, mental disease.
 Adult
kids who are financially dependent.
Mortality -Factors

Consistent

TS (< 7)
 SBP < 90
 Shock
 RR < 10
 Head injury
 Base deficit

Less Consistent

ISS
 Male sex
 Ped vs MV
 Non trauma center
admission
 PEC
 Pulmonary complications
J. Trauma 1998: 45(5) p 873, J. Trauma 1990: 30(12) p 1476 J. Trauma 1999: 46(4) p 702
CCM 1986: 14(8) p 681 Arch. Surg 1994: 129(4) p 448, J. Trauma 2002: 52(1) p 79
Pre Existing Conditions

Elderly patients are more likely to have
underlying medical problems that affect
survival.
 PECs
may affect survival independent of age or
injury severity.
 May be underlying cause of an injury.
 Need to be treated aggressively.
 Coumadin does not adversely effect mort.
PECs
 Hepatic*
 Renal*
– ARF as a complication is the most lethal.
 Cancer*
 CHF
 COPD
 Diabetes
 Dementia
J. Trauma 1992: 32(2) p 236
1998: 45(4) p 805
2002: 52(2) p 242
Triage

Philips - Florida- statewide
 Overtriage
7.5%, undertriage - 71%
– Triage tool identified only 103 / 355 major trauma
patients.
– < 65 - 11% / 33%.
– Triage guidelines were most sensitive to GSW and
least sensitive to falls.
J. Trauma 1996: 40(2) p 278
Triage

Compliance studies:
 MD
- statewide study
– Injury factors- high compliance
– Physiology, mechanism - poor.
– 15- 54 - 2X more likely to be triaged to a TC.
– Compliance decreases with increasing age.
 Portland
- city wide study
– Undertriage- 21% (< 65- 15%, >65- 56%)
– Non TC deaths- elderly with ISS 1- 9
J. Trauma 1995: 39(5) p 922; 1999: 46(1) p 168
Brain Injury and the Elderly

Age related mortality increases sharply at age
60+.
 Prognosis
depend on initial severity and age.
 Subdural, contusions and SAH more likely.
– Epidural, skull fractures - uncommon.
– 2 or 3 injuries common on CT scan
 High
incidence of associated injuries- chest most
common, cspine, upper extremities.
Brain Injury and the Elderly
GCS < 7 - high mortality, survivors are all
severely disabled or PVS.
 Death rate is biphasic.

 Early
from head injury, late from MSOF
Arch.Surg. 1993: 128(7) p 787
J. Trauma 1996: 41(6) p 957
Rib Fractures
 Very
common injury in elderly- due to brittle rib
cage
 Most commonly due to MV vs peds, MVCs.
 Compared to younger patients
– ISS same
– Increased mortality, ICU days, LOS, Vent days.
– Mortality increased at 5 ribs fxs. (35% vs 10%)
– Mortality decreased with epidural use.
J. Trauma 2000: 48(6) p 1040
“In younger patients, nature often
saves the day after minor surgical
errors. In the aged, every error
is a major danger in life.”
Aging and Surgery

1921: Oschner
 Herniorraphy
was not indicated in patients greater
than age 50.

Currently - age 65+ in general surgery:
 1/3
of all operative cases.
 50% of all surgical emergencies.
 75% of all operative deaths.
Surgical Risks
 148
patients for elective surgery - all cleared by
internists- had preop swan.
– 20 had normal physiology - no mortality.
– 94 had mild to moderate dysfunction - 8.5% operative
mortality.
– 34 had severe dysfunction


7 had lesser ops- survived.
8 had scheduled surgery- all died.
 Preop
evaluation did not correlate with
physiologic parameters
JAMA 1980: 243(13) p 1350
Initial Evaluation

History
 PMH
 Premorbid
functioning
 Medications
– Drug - drug interactions, cause of injury
 PMD
Initial Evaluation

Physical Exam:
 Elderly
patients have less dramatic physiologic
response to injury.
 Don't
be fooled by a patient that appears to be
stable and minimally injured.
– 80 yo female in MVA, no bleeding, poor perfusion
status but BP, HR ok. Swan- CI of < 1L/min
Resuscitation

Very little literature on trauma resuscitation in
elderly patients.
 Contradictory
 Not
very current
 Need for better studies

Avoid “therapeutic nihilism”
Preop Monitoring

70 patients with hip fractures
 randomized
to preop monitoring and optimization
with SG catheter
– Nonmonitored- 67 (40 to 89)
– Monitored - 78 ( 40 to 95)
– No difference in premorbid conditions.
 Mortality
was 2.9% vs 29%
– Cause of deaths not listed
– Operation was at 3.5 days vs 7 days
J. Trauma 1985: 25(4) p. 309
Resuscitation
60 elderly trauma patients at King’s County
- 44% mortality, 85% in high risk.
 1985-
– Ped vs MVA, SBP < 130, acidosis (pH < 7.3), head
injury, multiple fractures.
 1986
- invasive monitoring - ED to ICU was 5.5
hours - 93% mortality
 1987 - Monitoring early before diagnostic workup
- ED to ICU- 47% mortality
J. Trauma 1990: 30(2) p. 129
Resuscitation
 CI
< 3.5 L / min or MVO2sat < 60 %
– Fluids, blood, inotropes, afterload reducing agents.
– Hct- 35%
– CI > 4L / min.
 Increased
mortality
 ISS not calculated.
 No group comparisons available.
 Hayes, MA: NEJM: 1994 330(24) p 1717
J. Trauma 1990: 30(2) p. 129
Therapeutics

Imaging.
 Early
and often.
Early tracheostomy?
 Pain management

 Epidurals

?
Vena cava filters ?
Pain Management
Myth: Elderly patients experience less pain
 Realities:

 Acute
and chronic pain is common in the elderly.
 Pain in the elderly is often under diagnosed and
under treated.
 Pain is often responsible for agitation, delirium
and depression.
Pain Management
 Narcotics
- elderly are more sensitive to pain
relieving aspects.
– MSO4 - still gold standard.
– Altered pharmacodynamics - inc. half life.
– Need bowel regimen with narcotics.
– Avoid Darvon (propoxyphene), Talwin (pentazocine),
Demerol (meperidine) and long acting drugs.
 NSAIDs
- side effects more severe and common
in elderly.
Outcomes
 Oreskovich:
100 patients over 60 over a 2 year
period at a Level 1 trauma center.
– age 74
– Independent- 94%
– Home assistance- 6%
– ISS - 19
– Mortality- 15%
Falls 64%
MVC 8 %
MVC vs Ped 9 %
Burns 13%
Assaults - 4%
 Discharge:
– Independent 8 %, Home assist. 20%, NH 72%
J.Trauma 1984: 24(7) p. 565
Outcomes

vanAalst - 98 pts age 65+ with ISS >16
 48
alive 1 to 6 yrs later (49%)
 Assessed independence and functionality.
– Ind / Maintained - 8
– Ind / declined - 24
– Moderately dependent - 10
– Custodial - 6
J. Trauma 1991: 31(8) p. 1096
Outcomes
 DeMaria
- 63 patients, 97 % independent
 Discharge:
– 33% independent, 37 home but dependent
– 19 (30%) to NH
– 12/19 NH patients went to home after 3-4 months.
– Age 80 + survivors , n = 12.


4 required permanent NH
8 home independent or with assistance.
J. Trauma 1987: 27(11) p. 1200
Outcomes

Why the big difference between Oreskovich
and vanAalst / DeMaria?
 Falls-
66% falls vs <40%
– Falls are a marker of severe underlying cardiac,
pulmonary and neurologic diseases.
– Death may often be preceded by a cluster of falls.
– No 1 cause of NH admissions (40%)
Outcomes
 Battista
- 23% mortality / 93 independent
– 47% of survivors dead at 2.5 years
– 83% of those alive at home alone or with family.
– 10% retirement home, 4% at NH.
 Shapiro
- 22% mortality
– 53% home
– 14% home assistance
– 20% rehab
– 8% NH
J. Trauma 1998: 44(4) p.618, Am. Surg. 1994: 60(9) p.696
Summary / Recommendations

Advanced age is associated with increased
mortality at all injury levels.
 Elderly
have higher ISS for comparable
mechanism of injury.
 There may be fewer physiologic abnormalities
than expected for injuries.
 PEC are associated with worse outcomes for
each level of injury.
Summary / Recommendations

Elderly trauma victims should be triaged to
trauma centers
 There
should be a lower threshold for activation of
the trauma team for elderly trauma patients.
 Blood gas analysis should be obtained for any
patient with a significant injury or mechanism.
Summary / Recommendations

Aggressive hemodynamic monitoring and
resuscitation may be beneficial in the elderly
trauma patient.
 Shock,
BD < -6
 AIS > 3, high risk mechanism of injury
 Uncertain cardiac or volume status

Optimize cardiac output and O2 delivery.
Recommendations

Advanced age alone is NOT a predictor of
poor outcome and should NOT be used as a
factor to deny or limit care.
 Up
to 85% of survivors may return to independent
living.

Limiting care may be considered when:
 GCS
<8
TS < 7
RR < 10