Feb 2, 2015 · Leave a Reply

Primer on Geriatric Trauma

By Damian Baalmann, M.D. @dvb69339

Authors: Damian Baalmann, M.D., Masa Okubo M.D., Jack Kehl III, M.D.

 

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Types and Patterns of Injury in the Elderly

 

Geriatric patients (those older than 65 years) are actually less likely to be a trauma patient than those younger than them. Furthermore, trauma is only the 7th leading cause of death in the elderly, which is much less in comparison to younger patients[2]. So why place special emphasis on the geriatric trauma patient? There is a special focus on these patients because the physiological differences in the elderly make the geriatric trauma patient more likely to have a fatal outcome from their injuries. Furthermore, the elderly frequently have more pathology and more severe pathology.  One study found that the presence of cirrhosis (relative odds = 4.5), congenital coagulopathy (relative odds = 3.2), ischemic heart disease (relative odds = 1.8), chronic obstructive pulmonary disease (relative odds = 1.8), and diabetes (relative odds = 1.2) all significantly increased the risk of dying in the trauma patient.[3]

 

Falls constitute 59% of geriatric trauma and the most deadly by volume in the geriatric patient. Older people have more reasons to fall than younger people: either because of mechanical issues such as unsteady gait or because of syncopal issues brought on medical problems. The second leading cause of trauma death in the elderly are motor vehicle accidents which may be secondary to decreased reaction times and vision issues among other things. Finally, thermal injury is the third leading cause of death secondary to house fires and smoking; with a decreased ability to heal and compensate for fluid losses, even small burns can be very dangerous to the elderly patient. As far as the types of injury, closed head injury and fractures are the most frequent injuries.[4, 5]

 

Resuscitation in the Elderly

 

Resuscitation of the elderly occurs in the same sequence and with the same emphasis as resuscitation of younger individuals. This includes the primary survey consisting of airway, breathing/ventilation, circulation, disability, and exposure/environment. There are certain caveats at every step that providers must keep in mind with such resuscitations.

 

Airway

Establishing and maintaining a patent airway to provide adequate oxygenation is the first objective in geriatric trauma. Place nasal cannula with supplemental oxygen as soon as possible on the geriatric trauma patient, even in those patients with COPD (now is not the time to worry about respiratory drive: you can always turn down the oxygen, breath for them, or intubate).

 

Here are physiological factors that may directly impact the airway resuscitation in geriatric traumas:

  • Dentition
    • ATLS recommends removing broken dentures and initially leaving well-fitted dentures in place until airway is secured
    • Poor dentition affects ability to obtain adequate face mask seal
  • Nasopharyngeal fragility
    • Easy bleeding with nasal airways
  • Macroglossia
    • Big tongues lead to obstruction that can be potentially overcome by oral airways
    • Can also lead to issues with intubation
  • Microstomia
    • Small mouths because of sclerotic changes can inhibit intubation
  • Cervical arthritis
    • Increases risk of spinal cord injury with neck manipulation

 

Breathing/Ventilation

Now that the airway is secured, the resuscitation must turn to breathing and ventilation.

Here are the physiological factors of the elderly that contribute to the geriatric trauma patient:

  • Decreased respiratory vital capacity
    • This occurs in aging and can be worsened by chronic diseases
    • Results in less time before respiratory failure, prompting early intubation and mechanical ventilation
  • Rib fractures, pulmonary contusions, pneumothoraxes, and hemothoraxes are more deadly in the elderly
    • While there is no real difference in frequency of these processes in the elderly, morbidity and mortality are significantly increased
    • Increased work of breathing and decreased energy reserve can lead to respiratory failure faster than in a younger patient
    • Complications such as atelectasis, pneumonia, and pulmonary edema occur more readily and are more severe when they occur in the geriatric trauma patient
      • Pneumonia can be reduced by aggressive pain control (narcotics/epidural catheters) and pulmonary toilet
      • Pulmonary edema can be reduced by avoiding inappropriate fluid resuscitation
    • These factors prompt closer and more aggressive management in these patients. For instance, have a much lower threshold to admit a 70 y/o well-appearing male with a handful of rib fractures than a 40 y/o male with similar injuries.

 

Circulation

It is in the circulation step of resuscitation that the most significant differences in resuscitation can be observed. As people age, even the healthiest of adults have changes in their physiology. Here are some of those changes:

  • Cardiac output (SV x HR) falls linearly with age.
    • Max heart rate: 220- age (years)
    • Total blood volume decreases
      • This may be exacerbated by diuretics which can also lead to electrolyte disorders (such as hypokalemia)
    • Increasing myocardial stiffness
    • Slowed conduction through heart
    • Heart muscle mass decreases
  • Decreased ability to compensate
    • Cell membrane receptors do not respond as robustly to catecholamines
  • Kidneys are weaker (despite creatinine staying the same)
    • Can not respond as well to renin/angiotensin
    • Therefore, can not compensate flow when hypovolemia occurs
  • Increasing peripheral vascular resistance means normotensive is often hypotensive
    • This is paired by frequent lack of tachycardic response means suspicion for shock must come early in resuscitation as the vital signs may not be there
    • Relative hypotension has the same deleterious effects on end-organ damage in the elderly as the actual hypotension in the younger crowd
    • While tachycardia and hypotension may not be as reliable, evidence of metabolic acidosis has been shown to be a predictor of mortality in the elderly
  • Incidence of coagulopathies (often drug induced) are higher
    • These must be recognized earlier and reversed early when necessary

 

These are changes that can be expected in the healthy geriatric patients. Now bear in mind that these changes are often complicated and worsened by cardiovascular diseases and renal failure which are much more common factors in the elderly! Basically it all comes down to more aggressive management and monitoring with regard to circulation in the elderly patient.

 

Disability

The neurological system is not immune to change. Here are some pertinent changes with regard to resuscitation

  • Mass decreases by 10% by 70 y/o which is replaced by fluid and at the same time dura becomes more tightly adherent to the skull.
    • Increases brain movement with trauma
    • Makes bridging veins easier to tear
    • More blood can accumulate before neurological symptoms are apparent
    • Incidence of coagulopathies are higher
    • Be liberal with CT head
  • Decrease in water and protein in intervertebral disks and osteoarthritis
    • Results in increased risk of spine and spinal cord injury
    • Be liberal with CT spine and MRI if symptoms warrant

 

Exposure And Environment

Skin changes include decrease in dermis by 20%, loss of vascularity and loss of mast cells.

  • Decrease in thermal regulatory ability leading to increased incidence of hypothermia
  • Decreased barrier function and impairment in wound healing leading to increased incidence of cellulitis and abscesses.

 

 

Secondary Survey

 

The musculoskeletal system can be particularly fragile in the elderly. Osteoporosis, decrease in muscle mass, and stiffening of ligaments, tendons, cartilage, intervertebral disks, and joint capsules all contribute to this fragility.  The most common fractures in the elderly include ribs, proximal femur, hip, humerus, and wrist. Resuscitation should focus on normalizing tissue perfusion before fracture fixation and recognizing blood loss associated with fractures. The aim of treatment for musculoskeletal injuries should be to undertake the least invasive, most definitive procedure that will permit early mobilization.

 

Elderly are often malnourished at baseline. Early and adequate nutritional support of injured elderly patients is the cornerstone of successful trauma care. This ties directly into the decreased immune system response and increased rate of infections in the geriatric trauma patient. These patients may not manifest systemic signs of fever, leukocytosis, and other manifestations with infection, so keeping these high in the differential is of the upmost importance.

 

Elder Maltreatment and End of Life Decisions

With every geriatric trauma patient, the involved providers must at least consider the possibility of maltreatment. It is estimated that elder maltreatment occurs in as high has 14% of geriatric trauma admissions. Maltreatment can manifest in a variety of ways including physical/sexual/verbal abuse, neglect, financial exploitation, and violation of rights.  More than 1 in 10 elders are abused but much less than that are reported. High suspicion is required investigating unusual injury patterns or suspicious stories. In every state in the U.S., law requires mandatory reporting of elder maltreatment/abuse.[6]

 

While age does increase mortality from traumas, there is no doubt that more aggressive care has been shown to improve survival. However, in many patients’ lives, there comes a point when these patients do not want these aggressive cares. It is in these moments that the principle of patient autonomy must be respected. However, it is not always clear what the patient’s wishes are. Providers should of course consult advance directives, living wills, and next of kin when possible. However, in the heat of the moment of a crashing patient, such resources are not always available. It is in these times that providers must look to the patient’s best interests: applying therapies that both take the patient’s interests in mind as well therapies where benefits outweigh the adverse consequences.[7]

 

 References

  1. Schwab, C.W. and D.R. Kauder, Trauma in the geriatric patient. Archives of surgery, 1992. 127(6): p. 701-6.
  2. Morris, J.A., Jr., E.J. MacKenzie, and S.L. Edelstein, The effect of preexisting conditions on mortality in trauma patients. JAMA, 1990. 263(14): p. 1942-6.
  3. Oreskovich, M.R., et al., Geriatric trauma: injury patterns and outcome. The Journal of trauma, 1984. 24(7): p. 565-72.
  4. Zietlow, S.P., et al., Multisystem geriatric trauma. The Journal of trauma, 1994. 37(6): p. 985-8.
  5. Collins, K.A., Elder maltreatment: a review. Archives of pathology & laboratory medicine, 2006. 130(9): p. 1290-6.
  6. Advanced Trauma Life Support. Ninth ed2012, Chicago. 272-285.

 

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