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