Kevin Biese MD MAT Ellen Roberts PhD MPH Jan BusbyWhitehead MD University of North Carolina at Chapel Hill Division of Geriatric Medicine Center for Aging and Health Department of Emergency Medicine ID: 910982
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GERIATRIC TRAUMA:
WHAT DO WE KNOW?Kevin Biese, MD, MATEllen Roberts PhD, MPH Jan Busby-Whitehead, MDUniversity of North Carolina at Chapel HillDivision of Geriatric MedicineCenter for Aging and Health Department of Emergency Medicine
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.Leading change. Improving care for older adults.
AGS
Slide2Learning ObjectivesDescribe the unique presentations of geriatric traumaIdentify areas of particular risk for elderly patients with traumatic injuriesSuggest care process changes that may improve the care of geriatric trauma patientsSlide 2
Slide3Geriatric Trauma: OutlineThe basicsRib fracturesPelvic fracturesHead traumaWarfarinC-spine fractures Triage
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Slide4Geriatric Trauma: Disclaimers Most studies are retrospective reviews No standard definition of “geriatric” or “elderly”Slide 4
Slide5Geriatric Trauma: EpidemiologyElderly are growing in numbersPatients ≥65 years account for 10% of all traumas, but 28% of deaths!Trauma is the 7th leading cause of death in elderlySlide 5
Slide6Geriatric Trauma: MechanismsFalls — most commonBalance, strength, visionMotor vehicle collision (MVC) — most fatalJudgment, vision, reaction times decreasedCrash fatality rates are much higher
Burns — 1/5 of all burn unit admissionsMortality estimate = age + % burnSlide 6
Slide7Geriatric Trauma:Complicating FactorsPast medical historyCardiac and pulmonary disease limit physiological response to stressorsVital signs are difficult to interpretMedicationsAnticoagulantsBeta blockers
Cause of the eventMyocardial infarction, syncope, stroke, hypoglycemiaSlide 7
Slide8Case 1: INTRODUCTION71-year-old woman restrained driver in MVC “T-boned” on passenger side Unknown rate of speedNo airbag deploymentProlonged extricationNot ambulatory at sceneEMS: systolic blood pressure (SBP) 100, HR 80, oxygen saturation 100% on non-re-breather mask
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Slide9CASE 1:Additional InformationPatient is complaining of shortness of breath, left chest wall pain, and left clavicle painShe hit her head with reported loss of consciousness Patient denies neck or back painNo nausea or abdominal painYellow trauma alert — no trauma team activation
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Slide10CASE 1:Primary SurveyA Patient speaking in complete sentencesB Clear bilaterally, but diminished effort; significant bruising/pain left chest wallC Good pulses 4, 2 IVs in place
D Glasgow Coma Scale (GCS) 14, moving all 4 extremitiesE Patient exposed, warm blankets placedSlide 10
Slide11CASE 1:Secondary SurveyVital signs: 103/51, 80, 18, 36.3 F, 100% NRBGeneral: Dyspneic, awake and alertHEENT: 3-cm laceration on left side of scalp, PERRLAChest: Bruising left clavicle/left chest wall with tendernessCV: RRR with HR 80Abdomen: No bruising, soft, non-tender, non-distendedPelvis stable
Neurologically intactSlide 11
Slide12CASE 1:Past Medical HistoryHypertensionOsteoporosis“Non-cardiac chest pain”Medications:HydrochlorothiazideAlendronate (Fosamax)
Allergies: PenicillinSlide 12
Slide13CASE 1: Chest x-raySlide 13
Slide14CASE 1: Pelvis x-raySlide 14
Slide15CASE 1: Chest CTLeft 1, 3, 4, 5, 6 rib fractures, left scapular fracture, left clavicle fracture, small pneumothorax Slide
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Slide16CASE 1: LAB RESULTSHematocrit — 36Potassium — 2.9Creatinine — 1.0
INR — 1.0Slide 16
Slide17CASE 1: Hospital CourseDay 1 – Admitted to surgical ICU, L chest tube placedDay 2 – Rapid atrial fibrillation, amiodarone drip with conversion to sinus rhythmDay 5 – Chest tube pulledDay 7 – Hypoxic, hypotensive, rapid atrial fibrillation, left pleural effusion, intubated
Day 8 – Left chest tube replacedDay 12 – Chest tube removedDay 22 – D/C to home5 months later – Doing wellYellow trauma — 22-day hospital stay!Slide 17
Slide18Rib FracturesIN THE ELDERLY (1 of 2)Prospective cohort of 405 patients admitted with rib fractures from blunt trauma113 patients > 65 years oldElderly had much higher mortality (20% vs. 9%)Isolated thoracic trauma75% of elderly patients sustained this by fall from standingMortality 15% if age >65; 0% if <65Pneumonia 34% if age >65; 11% if <65
Most geriatric deaths occurred >72 hours after trauma and resulted from sepsis or respiratory failureBergeron E, et al. J Trauma. 2003;54:478-485.Slide 18
Slide19Age (years)3-6 rib fractures>6 rib fractures<65≅10%≅25%≥65
≅30%>60%If >65 with 3 or more rib fractures, admit; if >6 rib fractures, ICUBergeron. J of Trauma 2003; 54: 478-85.Rib FracturesIN THE ELDERLY (2 of 2)
Slide20PELVIC FracturesIN THE ELDERLY (1 of 2)Usually associated with falls from standing & MVCsHigher percentage of lateral compression fractures than in younger patientsFewer “severe” fracture patterns High rates of hemorrhage, transfusion, and ICU admission, even with “benign” fracture patterns
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Slide21PELVIC FracturesIN THE ELDERLY (2 of 2)92 consecutive blunt trauma pelvic fracture patients received angiographic embolization (AE) for “liberal indications”:Hemodynamically labile, concerning fracture pattern (open book, vertical shear, butterfly), or pelvic hematoma on CTPatients >60 years (n=17) were compared with younger patientsNo difference in injury severity score, pelvic fracture pattern, SBP, or blood requirement
>60 years: 94% chance of active bleed vs. 52% in younger patientsConsider AE before hemodynamic collapse in elderly patients with significant pelvic fracturesKimbrell. Arch Surg. 2004.Slide 21
Slide22CASE 290-year-old woman presents 3 days after fall in bathroom, when she hit her head on toiletNo symptoms for 2 daysThis morning, mild headache and face painMedications: warfarin, oxycodone, amitriptylineSlide 22
Slide23Head Trauma IN ELDERLYBridging veins travel furtherMore space for hematoma collection before symptomsAge >65 have 30%85% mortality with intracranial hemorrhage (ICH)25 higher than younger patients with matched injuries
Considered high-risk in brain imaging protocols (New Orleans, Canadian)Webmm.ahrq.gov, retrieved June 3, 2011.Slide 23
Slide24Warfarin and ICH IN ELDERLY9% of elderly patients with traumatic brain injury are on warfarinRisk of spontaneous ICH on warfarin is 0.35.4%Blunt head trauma on warfarin with minimal or no symptoms, 7%14% have ICHPatients frequently have supra-therapeutic INR11% have INR >5Beware delayed acute subdural hematoma (DASH) —
consider admission for observation even if head CT is negativeCheck INRSlide 24
Slide25AggressiveCoumadin Protocol (1 of 2)Emergency department initiated new protocol for patients with suspected head trauma on warfarinImmediate evaluationImmediate head CTType & cross matchThaw 2 units AB FFP If positive head CTTransfuse FFP, Vitamin K IV, neurosurgery evaluationIf negative head CT
Admit for observationSlide 25Ivascu FA, et al. J Trauma. 2005;59:1131-1139.
Slide26AggressiveCoumadin Protocol (2 of 2)82 patients, 19 with ICHTime to initiate warfarin reversal dropped from 4.3 hours pre-protocol to 1.9 hoursMortality dropped from 48% to 10%Slide
26Ivascu FA, et al. J Trauma. 2005;59:1131-1139.
Slide27CASE 3A 97-year-old woman fell while getting out of bedNormal activity throughout day; eventually presents with moderate neck painNo neurological deficits on exam Slide 27
Slide28Geriatric C-Spine FracturesType II odontoid fractures are the most common LearningRadiology.com, retrieved June 3, 2011.
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Slide29Odontoid FracturesInsert image/ diagram of 3 types of odontoid fractures.
Slide30Geriatric C-Spine FracturesBlunt trauma victims >65 years are 2 more likely than younger patients to have C-spine fracturesOdontoid fractures: 20% of elderly C-spine fractures vs. 5% in younger patientsDebate in literature about management of types II, III odontoid fracturesPatients >65 years included in NEXUS, identified as high risk in Canadian C-Spine Rule
X-rays frequently inadequateHave a low threshold to use CT on geriatric C-spineTouger. Ann Emerg Med. 2002.Slide 30
Slide31TriageElderly trauma patients are under-triaged, in violation of paramedic protocolsShould the elderly be triaged more aggressively?Slide 31
Slide32CRITERIA for TraumaTeam Activation (TTA) (1 of 3)Review of Trauma Registry at UCLA and LA County from 19932000
Included admitted trauma patients age >70, except interhospital transfers, ground-level falls, subacute subdurals883 patients included25% met TTA criteria:SBP <90 or Pulse >120RR <10 or >29Unresponsive to painGunshot wound to trunk
Slide 32Demetriades D, et al. J Trauma.
2001;51:754-756.
Slide33CRITERIA for TraumaTeam Activation (TTA) (2 of 3)63% of patients with severe injuries did not meet standard TTA criteriaAmong all patients who did not meet criteria, mortality was 16%
Include age 70 years as TTA criterion?Slide 33Demetriades D, et al. J Trauma. 2001;51:754-756.ISS = Injury Severity Score
Slide34CRITERIA for TraumaTeam Activation (TTA) (3 of 3)The same UCLA group added age 70 years as a TTA criterion
Data were analyzed on 336 trauma patients with ISS > 15 and age 70 years: 260 patients admitted before age became a criterion and 76 admitted afterwardGroups were similar in injury, age, gender, ISS, and Abbreviated Injury Score Mortality was 53.8% before, 34.2% after (P=.003)Consider early and aggressive resource mobilization for elderly trauma victimsSlide 34Demetriades D, et al. Br J Surg. 2002;9:1319-1322.
Slide35Geriatric Trauma:Take-Home PointsElderly patients break easily — don’t minimizeMobilize resources for elderly trauma victimsRib fractures associated with high mortality; if patient has >2 rib fractures, admitConsider angiographic embolization for pelvic fractures even before hypotension
Beware warfarin!Low threshold for CT of geriatric C-spine; when (re)taking the boards, think odontoidSlide 35
Slide36Case 1EMS brings in a 71-year-old woman who was “T-boned” on the passenger side while driving at an unknown rate of speed.There was no air bag deployment, but it took several minutes to get her out of her car and she was non- ambulatory at the scene.Upon examining her, you note that she has chest wall bruising, a tender pelvis, and vital signs significant for BP of 100/60, HR of 80, and oxygen saturation of 100% on a non re-breather oxygen mask. Slide
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Slide37Case 1, Question 1Which of the following is not true regarding the epidemiology of geriatric trauma? Select the one best answer.Although people 65 years account for only 10% of all trauma evaluations, they account for more than 25% of all trauma mortality.Burn mortality is estimated at percentage body surface burned plus age of patient in years.
Falls are a common cause of significant morbidity in the elderly. Motor vehicle accidents are the most common cause of traumatic injuries in the elderly.Slide 37
Slide38Case 1, Question 2True or False?Patients aged >65 years old with 2 or more rib fractures have a higher than 30% mortality rate.Slide 38
Slide39Case 1, Question 3Which of the following statements regarding triaging elderly trauma patients is not true?Cardiac and pulmonary disease limit physiologic response to stressors.Elderly patients involved in traumatic accidents are more likely to be triaged to trauma centers than younger patients with the same pre-hospital assessment by EMS providers. Institutions that include age as a criterion in their trauma activation system have improved outcomes in caring for geriatric trauma patients.
Medications taken by the elderly can render vital signs more difficult to interpret.Slide 39
Slide40Case 2A 90-year-old woman presents to your emergency department complaining of a headache and painful neck.She fell 3 days ago while standing up from the toilet.She is neurologically intact with a Glasgow Coma Scale of 15 on exam. Her medications include warfarin.Slide 40
Slide41Case 2, Question 1True or False? Both the Canadian Head CT Scan rule and the New Orleans Head CT Scan rule identify patients over the age of 65 as high risk.Slide 41
Slide42Case 2, Question 2Which of the following statements regarding patients on warfarin is not true? Select the one best answer.Delayed acute subdural hemorrhage occurs in patients on warfarin. Eleven percent (11%) of all patients on warfarin presenting to an emergency department have an INR > 5.
In cases of blunt head trauma in patients on warfarin with no or minimal symptoms, the incidence of intracranial hemorrhage is 4%. Nine percent (9%) of all elderly patients with traumatic brain injury are on warfarin.Slide 42
Slide43Case 2, Question 3Which of the following types of cervical spine fractures is most increased in frequency in elderly patients?a) Clay-shoveler’s fractureb) Hangman’s fracturec) Jones fractured) Odontoid fracturesSlide 43
Slide44Answer KeyCase 1Question 1: DQuestion 2: FalseQuestion 3: BCase 2Question 1: TrueQuestion 2: C
Question 3: DSlide 44
Slide45Bibliography (1 of 2)Bergeron et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54:478-485.
Callaway W. Geriatric trauma. Emerg Med Clin. 2007;25:837-860.Demetriades et al. Old age as a criterion for trauma team activation. J Trauma 2001;51:754-757.Demetriades et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89:1319-1322.Hylek et al. Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation. Circulation. 2007;115:2689-2696. Slide 45
Slide46Bibliography (2 of 2)Ivascu et al. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. 2005;59:1131-1139.Kimbrell et al. Angiographic embolization for pelvic fractures in older patients. Arch Surg. 2004;139:728-733.Ma et al. Compliance with prehospital triage protocols for major trauma patients. J Trauma. 1999;46:168-175.Touger et al. Validity of a decision rule to reduce cervical spine radiography in elderly patients with blunt trauma. Ann Emerg Med. 2002;40:287-293.
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Slide47Special Thank YouSpecial thanks to Brian Downing, MDSlide 47
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