Transcript Geriatric Trauma

Geriatric Trauma:
Beyond “I’ve Fallen & Can’t Get Up!”
Amy Gutman MD ~ EMS Medical Director
[email protected] / www.TEAEMS.com
Overview
• Epidemiology
• Pathophysiology
• Mechanisms of Injury
• Assessment & Management
Strategies
• Conclusions
“The more you complain, the longer God lets you live” Unknown
Geriatric Patients
• EMT-B class = 150 hrs
• EMT-P class = 1200 hrs
• Geriatrics hours = 6
• 30-40% all EMS calls with a large
percentage being ALS
• Anatomically, sociologically &
physiologically a “special” population
“The secret of staying young is to live honestly, eat slowly, & lie about your age” ~ Lucille Ball
Defining “Geriatric”
• Person >65 yo
• Chronologic age = actual age
• Physiologic age = functional
capacity
• US life expectancy 2010
• Male: 75.4 yrs
• Female: 80.5 yrs
• 15% US population
• >85yo fastest growing population
• By 2030, 25% population >65yo
• Better living conditions, healthcare,
medications & technology
“You're only young once, but you can be immature forever” ~ John Greier
Geriatric Trauma Etiology
• 7th leading cause of death in the elderly
• 10-14% trauma patients >65yo
• 25% trauma admissions
• 28% accidental deaths
• Enormous resource & financial burden
• $20 billion annually
• 33% trauma dollars
• Trauma costs 3x greater compared younger persons
• Injuries disproportionately severe
• Mortality, morbidity, length of stay higher than younger
patients with similar injuries
• For each year >65, 10% increased chance of a traumarelated death
“If I were younger, I'd know more” ~James Barrie
High Injury Risk
• Normal aging & deterioration
• Narrow physiologic tolerances
• Decreased reaction time
• Decreased eyesight & hearing
• Postural instability
• Fragile bones & vasculature
“Old age is like everything else. To make a success of it, you've got to start young” ~Fred
Astaire
Trauma
in Elderly - 6
Polypharmacy & Trauma
• 80% on meds likely contributing to
injury
• Adverse events exponentially rise with
number of drugs
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4% if 5 drugs
10% if 6-10 drugs
28% if 11-15 drugs
54% if >16
• Common interactions
• Anticoagulants & anti-platelets increase
bleeding time
• Anti-hypertensives & vasodilators limit
vasoconstriction
• Beta-blockers limit O2 demand response
“It is not the years in your life, but the life in your years that counts” ~Adlai Stevenson
Impact of Co-Morbidities
• Complication rate triples if one
co-morbid illness
• Oreskovich’s study on geriatric
trauma outcomes:
• 100 geriatric trauma pts
• 96% independent pre-injury
• 88% did NOT return to
independence
• 72% required NH placement
“I am not young enough to know everything” ~Oscar Wilde
Geriatric Trauma Outcomes
Adult Mortality %
Geriatric Mortality %
Falls + TBI
6.00%
11.89%*
Falls + Chest Trauma
4.18%
5.43%
Falls + Chest- Abd Trauma
1.15%
2.47%
Falls + SCI
4.92%
20.13%
Auto vs Pedestrian
7.45%
16.63%*
MVC + Long Bone Fx
9.22%
15.63%*
Multisystem Trauma
6.3%
8.0%
*p<0.001
“Grow old along with me! The best is yet to be” ~Robert Browning
Assessment Strategies
• Speak slowly, directly & respectfully
• Never “Sweetie”, “Honey”, “Pops”
• Eye level in middle of visual field
• Utilize family / care-givers but do not
diminish patient’s contribution
• Ask specific questions as patient may
not volunteer information
• Protect modesty & body temperature
• Transport:
• Medications
• Glasses / hearing aids / dentures
• All important paperwork (i.e. MOLST)
“Like our shadows, our wishes lengthen as our sun declines” ~Edward Young
Assessment ~ Safety
• If fall “mechanical”, consider pre-quels
• Co-morbidities often causal
• May not know / confabulate inciting event
• Safety assessment may assist with MOI
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Living conditions?
Stairs?
Medications & compliance?
Ambulation assists?
Fall hazards?
Driving safety?
Often reluctant to provide information
• Loss of autonomy & independence
• Separation from family
• Hospitalization
“The old believe everything, the middle-aged suspect everything, the young know everything“ O. Wilde
Assessment: Primary &
Secondary Surveys
• Primary Survey
• Key:
Vitals often unreliable!
• A:
Aggressive airway management
Low intubation threshold
Modified spinal immobilization
• B:
Supplemental O2 with chest / abdominal trauma
• C:
“Normal” BP may indicate hypotension / shock
• Secondary Survey
• Keys:
Exam often underestimates injury
Pain response, hypoxia, hypovolemia varies
Pre-morbid illnesses complicate assessment
"When you are older you will know that life is a long lesson in humility“ ~James Barrie
Mechanisms of Injury
MVC Epidemiology
• 26 million+ geriatric drivers
• Falls #1 morbidity but MVCs #1
trauma-related mortality
• 2nd highest fatal crash rate
• 21% overall fatality rate
• 7x more likely to be hospitalized or
killed than younger patients
• In collisions, 80% geriatric drivers
found to be at fault
“Just remember, once you're over the hill you begin to pick up speed” ~Charles Schultz
MVC MOI
• “Why did this driver crash?”
• 20% syncope
• 13% intoxicated
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Less likely ETOH / high speeds than
younger drivers
• Unrestrained (83%)
• Daytime (81%)
• 2 cars (75%)
• Weekdays (72%)
• Intersection / near home (50%)
• Making left turn (20%)
“Youth is the time for adventures of the body, but age for the triumphs of the mind” ~Logan Smith
Auto vs Pedestrian
• Geriatrics > any other age group
(even pediatrics)
• 46% at crosswalks
• Average crosswalk gait 4ft/s
• Average elderly gait 3 ft/s
• Typical MOI
• Head down
• Rushing even if unsteady
• Often it near curb
• 25% mortality if >65 yo
• TBI
• Vascular injuries
• Thoraco-abdominal, including
pelvic & rib fractures
“Old age comes at a bad time” ~Unknown
Homicide / Suicide
• 2002: 852 geriatric homicides
• Easy target
• Home invasions
• Elder abuse
• 70% GSWs self-inflicted
• Depression
• Chronic illnesses
• Suicide-Homicide “pacts”
• 10% GSWs accidental
“Youth is the gift of nature, but age is a work of art” ~Garson Kanin
Elder Abuse
• Less recognized / reported than child
or spousal abuse
• 5,000 - 250,000+ cases annually
• 32:1000 elderly
• Risk factors for victim
• Female > age 80
• Dementia
• Dependence on abuser
• Risk factors for abuser
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Spouse of children of the abused
Financial dependence on victim
Substance abuse
Prior history of violence
“Old age isn’t so bad when you consider the alternative” ~Maurice Chevalier
Elder Abuse Assessment
• Multiple bruises in various states
of healing
• Unexplained or untreated injuries
w/ inconsistent stories
• Dehydration / malnutrition
• Bedsores
• Mandatory & confidential
reporting to adult protective
services / police
“Beautiful young people are accidents of nature, but beautiful old people are works of art” E. Roosevelt
Falls
• M=F; females more likely injured
• Always ask about the “pre-quel”
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Postural instability
Impaired vision & hearing
Decreased reaction time
Medications
Inciting medical event
• High injury risk with fall from
standing height
• TBI
• Rib / Hip fractures
• “Special Consideration” in Trauma
Triage as high risk of cervical injuries
with falls from standing height
“It is always in season for old men to learn” ~Aesculepius
Falls
• 40% geriatric trauma
• 35% >65yo, 50% >80yo fall annually
• In 2005 falls led to:
• 160,000 deaths
• 1.8 million ED visits
• 433,000 hospitalizations
• MCC of trauma morbidity
• 25% sustain “serious injury”
• 50% pts discharged to rehab / NHs
• 20% fatal falls occur while in NHs
• Fall injuries cost $53 million / year
“You don't stop laughing because you grow old. You grow old because you stop laughing” ~M Pritchard
Cardiovascular Pathophysiology
• Decreased cardiac reserves
• Limited increases in SV & CO
• Decreased catecholamine response
• Decreased valve efficiency
• Hypovolemia = hypoperfusion
• Lactic acidosis & shock without classic
signs of shock
• Decreased arterial compliance with
increased arteriosclerosis
• Baseline HTN, PVD
• Conduction system degenerates
• Arrhythmias
“As the arteries grow hard, the heart grows soft” ~HL Mencken
Cardiovascular Pathophysiology
• “Pre-quel” cardiac events
• Limited ability to increase SV, HR &
CO to combat hypovolemia
• Increased O2 demand from cardiac
stress not tolerated well
• Ischemia
• Worsening CO
• Cardiovascular collapse
• “Normal” BP if on
antihypertensives = shock
“To me, old age is always fifteen years older than I am” ~Bernard Baruch
Neurological Pathophysiology
• Altered mentation increases with age
due to atrophy, co-morbidities
• Alterations impede assessments
• Dementia / memory impairments
• Vision, hearing, speech
• Don’t mistake “deaf” with “dumb!
• Difficult determining “normal” if no
family, friends or caretakers
“How old would you be if you didn't know what old was?” ~Satchel Paige
Neurology: Subdural Hematoma
• SDH most common TBI
• Often minor or “forgotten” trauma
• Bridging veins tear causing blood to
accumulate between dural & arachnoid
spaces
• Atrophy leaves large space for blood
accumulation, delaying symptom onset
• Mortality
• Adult 4-8%; geriatric 15-30%
• Mortality 90% if anticoagulated + GCS<8
• Dementia increases mortality risk
“There are 3 signs of old age. The 1st is your loss of memory & the other 2….” Unknown
C-Spine Injuries
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Fall from standing height, minor trauma
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No prehospital “clearance”
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May involve >1 level
Often unstable & associated with TBI
25% mortality
>65 yo “high risk” (Canadian C Spine & NEXUS
criteria)
Low risk mechanisms = 24% fx rate
Decreased pain sensation
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Central cord syndrome
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Osteoporosis & Osteoarthritis
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Stenosis, spondylosis + hyperextension
UE >LE symptoms
Narrow spinal canal can cause cord injury s/o
fracture
“I have everything I had 20 years ago, only it’s all a little bit lower” ~Gypsy Rose Lee
Pulmonary Pathophysiology
• Decreased chest wall strength & compliance
• Kyphosis / Lordosis
• Weak musculature
• Decreased pulmonary circulation with
underlying lung disease
• Increased inhalation time, residual capacity
& tidal volume
• Decreased alveolar surface area, number of
alveoli & O2 exchange
• Rapid progression to respiratory failure with
minimal hypoxia
“You can live to 100 if you give up all the things that make you want to live to 100” ~Woody Allen
Chest Trauma / Rib Fractures
• Common with minor trauma
• Any rib fracture doubles morbidity
& mortality
• Co-existing injuries
• Prolonged ICU stay
• 31% pneumonia rate
• Bergeron’s study on geriatric
trauma pts with rib fractures
• Mean hospital stay 27 days
• 30% mechanically ventilated
• 5 X mortality rate than younger pts
“Old Age: First you forget names, then you forget faces, then you forget to pull your zipper up, then you
forget to pull your zipper down” Leo Rosenberg
Thoraco-Abdominal Trauma
• Minimal trauma required to
produce injury (ie. seat-belts)
• Exam often unreliable, vitals
misleading
• 4-5x higher morbidity than younger
patients with same injuries
• Pelvic fractures
• 30% mortality within 1st 72 hrs
• Often lateral compression injuries
w/ arterial hemorrhage
“Life is what we make it; always has been, always will be” Grandma Moses
Renal Pathophysiology
• By age 65 lose 40% glomeruli
• Diminished renal blood flow
• Less effective toxin filtration
• Chronic dehydration from
decreased total body water
• Hypotension leads to renal failure
• Micturition syncope common
“Age is strictly a case of mind over matter. If you don’t mind then it doesn’t matter” Jack Benny
Endocrine Pathophysiology
• Caloric requirements decrease with
age, but “nutrient” demands
remain constant
• Glucose intolerance & diabetes
increase
• Hyperglycemia associated with
worse outcome in medical / trauma
patients
• High risk of infection / sepsis
• Malnutrition
• Sepsis with “mild” infection
(decreased immune response)
• Often afebrile or hypothermic
• Minimal reserves to fight infection
“Old age is no place for sissies” ~Bette Davis
Hypothermia
• 75% of injured geriatrics
• Hemorrhage leads to hypotension
then hypothermia
• Impaired thermoregulation
• Decreased sub-q tissue
• Severe complications
• Arrhythmias
• Coagulopathies
• Increased mortality
“As one grows older, one becomes wiser and more foolish” ~François Duc
Integument Pathophysiology
• Thin skin, decreased collagen &
sub-q fat
• Easily tears & bruises
• 20 mins on a backboard begins
pressure ulceration
• Decreased immune response &
capacity for wound healing
• Decreased collagen
• Less microorganism protection
• Abnormal clotting
• Tetanus often out-of-date
“Middle age is when your age starts to show around your middle” ~Bob Hope
Burn Pathophysiology
• 4% geriatric trauma-related deaths
• 13% of all burn unit admissions
• 50% in-hospital mortality
• “Burn mortality” is burn percentage
causing 50% mortality
• Adults = 50% if 80% TBSA burned
• 60-70yo = 50% if 35% TBSA burned
• >70yo = 50% if 20% TBSA burned
“The only source of knowledge is experience” ~Albert Einstein
Musculoskeletal
Pathophysiology
• Postural changes
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Kyphosis
Spinal stenosis
Decreased spinal flexibility
Increased knee & hip flexion
Decreased muscle strength
• High risk of compression
fractures with minor trauma
• Osteoporosis & arthritis
• Decreased bone density
• Decreased fatty tissue
“Inside every older person is a younger person wondering what the hell happened” ~Jennifer
Yane- 35
Trauma in Elderly
“Hip” Fractures
• Often proximal femur / femoral neck
fractures
• Suspect all previously ambulatory
patient who can no longer walk due to
pain
• Associated with abdominal / pelvic
injury
• High mortality:
• 14% at 30 days
• 35% at 1 year
• 40% require rehab / NH placement
“I intend to live forever, or die trying” ~Groucho Marx
Management Strategies
• Key: Prevention of early & late
complications
• Appropriate fluid resuscitation
• Avoid low-flow states
• Serial cardiopulmonary exams
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Lung sounds
Cardiac monitoring
Pulse oximetry
Capnography
• Multiple studies demonstrate
under-triage of geriatric patients
to trauma centers
“Aging is not lost youth but a new stage of opportunity and strength” Betty Friedan
Geriatric Trauma Triage
• Consider trauma center 1st line
destination
• If >80 yo, trauma center mortality 8%
vs 56% in non-trauma centers
• Recognize high risk injury patterns
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Falls + AMS
Falls + inability to ambulate
Thoraco-abdominal
Pelvic or femur
Trauma + SBP <100 mmHg
“Old age is the most unexpected of all the things that happen to a man” ~Trotsky
Airway Management
• Early & aggressive
• Limited cardio-pulmonary reserves
• Limited ability to open mouth &
move neck
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Kyphosis & arthritis
• Sedation can induce apnea
• CPAP is great adjunct, but patients
at higher risk for barotrauma /
pneumothorax
“You're getting old when all the names in your black book have MD after them” ~Arnold Palmer
Ohio Geriatric Trauma Triage
(National Standard of Care)
• >70yo triaged to trauma
center for:
• GCS <15 + TBI
• Falls + evidence of TBI (even
from standing position)
• SBP <100 mmHg
• Pedestrian struck
• Multisystem trauma
• Suspected proximal long bone
fracture post-MVC
• Consider Trauma Center
Triage if:
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COPD
CAD / CVD
Clotting disorder
Warfarin therapy
Diabetes
Dialysis
Immunocompromised
Liver Disease
“I was taught to respect my elders; I’ve now reached the age when I don't have anybody to respect” ~
George Burns
References
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Ohio State Board of EMS Trauma Committee; 2008
Brady Textbook of ITLS; 2004
Bourn. “The “2 P’s” of Geriatric Trauma”. 2008
Holland. “Geriatric Falls & Trauma”; 2009
Fowler. OSU Department of EM
CDC MMRW “Life Expectancy”; 2010
Antonenko. UND Department of Surgery; 2005
Bulger. Harborview Medical Center; 2004
NHTSA “Walking Through the Years”; 2008
AARP “Older Adult Pedestrian Safety”; 2009
Richmond. Louisville FD; 2007
Barishansky. “Understanding Our Geriatric Pts”; 2009
Rosen. “Geriatric Trauma”. EM 6th Ed; 2008
Aschkenasy. “Trauma & Falls in the Elderly”. EM
Clinics of North America; 2006
www.emsresponder.com. “Geriatric Trauma”. 2008
EAST. “Practice Management Guidelines for Geriatric
Trauma”. 2009
Blanda. “Geriatric Trauma: Current Problems, Future
Directions”; Summa Health Systems; 2007
Victorino. “Trauma in the Elderly Pt”. Arch Surg; 2003
Perdue. “Geriatric Trauma”. J.Trauma; 1998
Touger. “Geriatric Trauma”. An EM; 2002
McKinley. “Geriatric Trauma”; Arch Surg; 2000
Steill. “Canadian C-Spine Rule vs NEXUS Low-Risk
Criteria in Patients with Trauma”. NEJM; 2003
“When men reach their sixties and retire they go to pieces. Women just go right on
cooking” Gail Sheehy
SUMMARY
[email protected] / www.TEAEMS.com
• Injury “pre-quels” & MOI
• Vitals & physical exam
may underestimate injury
• Increased complications,
mortality & length of stay
compared to younger pts
• Tremendous financial
burden, often with poor
outcomes
• Consider “over-&-early”
triage to a trauma center
“Age and treachery will triumph over youth and skill” Anonymous