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Geriatric Trauma. Alan Sori, MD St. Joseph’s Regional Medical Center Paterson, NJ. Patients. 65 yo female falls on a bus – severe brain injury In ICU – found to have a prolonged QT interval Echo – severe cardiomyopathy Needs an ICD 75 yo male falls- two broken ribs. - PowerPoint PPT Presentation
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Geriatric Trauma
Alan Sori, MD
St. Joseph’s Regional Medical Center
Paterson, NJ
Patients
65 yo female falls on a bus – severe brain injury In ICU – found to have a prolonged QT interval Echo – severe cardiomyopathy Needs an ICD
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
ICU beds – 15% of all hospital beds and 30% of hospital costs
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 patterns are more severe for all levels of falls.
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 - Palmomental reflex– Cognitive impairment - Foot problems– LE disability - 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 787J. 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 oftensaves the day after minor surgical errors. In the aged, every erroris 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
1985- 60 elderly trauma patients at King’s County - 44% mortality, 85% in high risk.
– 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 Falls 64%– Independent- 94% MVC 8 %– Home assistance- 6% MVC vs Ped 9 %– ISS - 19 Burns 13%– Mortality- 15% 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