Transcript Geriatric Trauma

Geriatric Trauma
Michele M. Fowler D.O.
OSU Medical Center
Emergency Medicine
Background
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Elderly people account for 12-15% of U.S.
population
10-14% of all trauma victims are >65
33% of all trauma $ is spent on elderly patients
Trauma care cost 3x as much for an elderly
person compared to a younger person
Definitions
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Elderly >65 years
Young old and Old old
Chronological age is actual # of years lived
Physiologic age is actual functional capacity of
patient’s organ systems
Mechanisms
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Falls
Motor Vehicle Crashes (MVC)
Pedestrian vs. Motor Vehicle
Burns
Assaults
Falls
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Most common injury - 40% elderly trauma
25% who fall sustain “serious injury”
Falls M=F but females are more likely to be
injured
Postural instability, vision and hearing, reaction
time, meds
Syncope vs Fall
Standing height falls
MVC
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2 cars
Daytime
Intersections
Close to home
2nd Highest fatal crash rate
Time to stop driving
Auto-Ped
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46% elderly trauma occurs at crosswalk
Average crosswalk speed is 4ft/sec
Parking lots
Pathophysiology of Geriatric Trauma
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Pre-existing diseases lead to more severe injuries
Co-morbid diseases complicate recovery
Medications alter “normal” function and vital
signs
Physiologic Age
Less dramatic physiologic response
 Narrow limit of physiologic tolerance
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Cardiovascular
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Myocardial cells are replaced by fatty infiltration
and amyloid deposits; heart becomes “stiff ”
Decreased Beta receptor # and sensitivity to
catecholamines (decreases rate and contractile
force)
Not able to increase cardiac output at important
times
Cardiovascular
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Atherosclerotic disease is prevalent in elderly
and can lead to “secondary injury”
Myocardial oxygen demand is increased during
trauma and stress
Loss of elasticity of arteries decreases
compliance and increases resistance
Cardiac medications
Pacemakers
Pulmonary
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Chest wall and lungs not as compliant
Respiratory muscles are weaker
Loss of alveolar surface area leads to impaired
gas exchange
Spinal immobilization (collar and supine)
Impaired cough
Rib fractures double mortality
“There are three signs of
old age. The first is your
loss of memory and the
other two I forget.”
Unknown
Central Nervous System
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Subdurals - Most common
Atrophy
Delayed accumulation of blood
 Warfarin
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Pre-existing dementia or strokes makes
evaluation and recovery difficult
Renal
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By age 65 lose 40% of glomeruli
Diminished renal blood flow
Creatinine is misleading because of decreased
muscle mass (CrCl is better)
Chronic dehydration
Hypotension leads to ATN
Nephrotoxic agents (IV contrast and NSAIDS)
Metabolic, Nutrition and Immunity
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Caloric requirements decrease with age but
nutrient demands remain constant
Elderly have less nutritional reserve
Glucose intolerance and diabetes
Catabolic response is same as with young people
but catabolic protein loss is more significant
with elderly
Increased risks of infection
Injuries
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Subdurals
Hip fractures
Wrist fractures
Compression fractures
Rib fractures
Central cord syndrome
Scalp lacerations
Subdurals
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Tear in bridging veins because of atrophy
Crescent shaped clot between the dura and
arachnoid
Judicious use of CT for falls
Warfarin
Aggressive reversal of coagulopathy
Central Cord Syndrome
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Cervical stenosis and spondylosis
Hyperextension injuries
Central corticospinal and spinothalamic tracts
Upper extremities more commonly involved
Good prognosis
Outcomes
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Mortality
Young is 4-8%
 Elderly is 15-30%
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Improve survival by early invasive monitoring
Prevention most important
Withholding Care
Outcomes
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Occult hypotension and early recognition
High Risk
TBI
 Multiple long bone fractures
 Auto vs. Pedestrian
 Initial systolic BP < 130
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Prevention
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Safe environment (rugs, cords, lighting, etc)
Home modifications (tubs, rails, etc)
Medications (benzos and narcotics)
Driving Safety
Not driving
Strength and balance therapy
How to Help Seniors Drive Safely
Longer- 8 Functional Areas (AAA)
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Leg strength and
flexibility
Head and neck flexibility
High contrast visual
acuity (signs/marks)
Low visual acuity
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Working Memory
(directions and traffic
rules)
Visualization of missing
info (recognize hazards)
Visual search (find signs)
Useful field of vision
(peripheral threats)
“An ounce of prevention
is worth a pound of
cure.”
Benjamin Franklin
Summary
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Poor prognosis for old people with traumatic
injuries
Significant injuries with minor accidents
Warfarin is bad in trauma
Judicious use of CT scans
Early invasive monitoring
Prevention is the key
“Age is strictly a case of
mind over matter. If you
don’t mind then it doesn’t
matter.”
Jack Benny